www.jpnim.com Open Access eISSN: 2281-0692 Journal of Pediatric and Neonatal Individualized Medicine 2013;2(1):55-62 doi: 10.7363/020117 Original article Breastfeeding practice in Bosnia and Herzegovina Darinka Šumanović-Glamuzina Clinic for Child Diseases Mostar, University Hospital Mostar, Mostar, Bosnia and Herzegovina Abstract Bosnia and Herzegovina is one of the new countries established after the break up of the former Yugoslavia. One of the unfortunate legacies of this country due to the 1992-1994 war is the destruction of human and material resources. Despite many negative events, steady progress can be seen in social, technological and cultural aspects of life. According to the global public health recommendation, infants should be breastfed for the first six months of life to achieve optimal growth, health and development. Therefore, to meet their evolving nutritional requirements, infants should receive nutritionally adequate and safe food, with Breastfeeding (BF) extended up to and beyond two years of age. In Bosnia and Herzegovina (B&H) majority of mothers (estimated at 95%) have initiated breastfeeding. However, Exclusive Breastfeeding (EBF) is not commonly practiced, and BF ceases by the age of five months. After 1995, a number of programs were introduced by WHO and UNICEF in B&H with a primary goal to ensure that babies were given a healthy start in life. Through implementation of Baby- Friendly Hospital Initiative (BFHI), enabling exact public health survey – the Multiple Indicator Cluster Survey (MICS), it would be possible to create comparable health indicators and make a step forward to promote and support breastfeeding practice as the best option for infants. Keywords Breastfeeding, survey, prevalence, duration, postwar health situation. Corresponding author Darinka Šumanović-Glamuzina, MD, PhD, Clinic for Child Diseases, Neonatal Intensive Care Unit, University Hospital Mostar, 88 000 Mostar, Bijeli Brijeg, Bosnia and Herzegovina; Tel.+ 387 36 341 978; e-mail: [email protected]. How to cite Šumanović-Glamuzina D. Breastfeeding practice in Bosnia and Herzegovina. J Pediatr Neonat Individual Med. 2013;2(1):55-62. doi: 10.7363/020117. 55 www.jpnim.com Open Access Journal of Pediatric and Neonatal Individualized Medicine • vol. 2 • n. 1 • 2013 Introduction After an initiation of Global Initiative for Breastfeeding by UNICEF and WHO [2], Bosnia and Herzegovina, country formed after Initiative for Implementing of International Code the break up of the former Yugoslavia, is situated of Marketing of Breast Milk Substitutes in 1981 in the southeastern part of Europe, i.e. in the [3], Innocenti Declaration in 1990 [4], Bosnia and western part of the Balkans peninsula. Its present Herzegovina also started changing the perception of establishment is a result of 1995 Dayton Accords, breastfeeding as an optimal form of infant feeding following the 1992-1995 war. War and postwar not only for children, but for women’s health too periods were marked with significant demographic [5, 6]. Despite the fact that the damage is already movements. Prewar health care was relatively well done, there is positive experience of generations of organized: free health insurance for all segments of pediatricians who have, since the 1980s, been slowly population, with children specially protected as the increasing a breastfeeding rate in the whole of the most vulnerable group in society. former Yugoslavia. Even in the country devastated Such good practices have been used up to and discouraged in the terrible war, health care date, despite the country’s unsafe socioeconomic professionals advised mothers and promoted breast development, and severe political, economic milk as optimal infant food. This was, however, and socio-cultural transition. Former Republic provided in a voluntary and enthusiastic manner, of Bosnia and Herzegovina, as a part of ex neither systematically, nor as a national and global Yugoslavia, has been transformed into the State strategy. of Bosnia and Herzegovina, consisting of two During the war some surveys on child health entities: Federation of Bosnia and Herzegovina and nutrition were carried out by UNICEF and (F B&H) and Republika Srpska (RS), with a total WHO in Sarajevo, Mostar, Tuzla, Zenica and area of 51,197 km2. Administrative structure is very Bihać. Consequently, certain data on breastfeeding complex, comprising ten Cantons and District of rates and practice were available early in the war Brčko. Health services are legally guaranteed by and were widely disseminated to government and the entity forms of insurance. Demographic profile international agencies, including Non Government reports on the total population of 3,760,000 (2010 Organizations (NGOs) [7]. Since 1993 UNICEF and est.), 49% being urban population, 8.47/1,000 WHO in cooperation with Ministries of Health have infant mortality rate (2012 est.), 8/100,000 (2010) encouraged health professionals to an action for maternal mortality rate. Birth rate is estimated at the promotion of breastfeeding throughout Bosnia 8.89 births/1,000 population (2012). Population and Herzegovina. A number of training seminars growth rate is -0.003% (2011 est.) [1]. have been arranged and implemented throughout Percentage of population using improved a campaign which resulted in the increase of drinking water sources was 99% (2008). Coverage breastfeeding rates [8]. of antenatal care (by doctor, nurse or midwife) is A 1995 Baby Friendly Hospitals Initiative (BFHI) high, with all women receiving antenatal care at least in B&H, supported by UNICEF and WHO turned once during the pregnancy (99%). Overall, 99% into a national program to support, promote and help of births were delivered by skilled personnel and breastfeeding practice [9]. International Baby-Food almost all were delivered in health care institutions. Action Network (IBFAN) supported “Association 99% percent of newborns were weighted at birth; for breastfeeding promotion” as a Non Government around 5% estimated to have been born with birth Organization (NGO). This Organization initiated a weight below 2,500 grams [1]. survey in 1997 to investigate the breastfeeding rate in six cities of the Federation of B&H (Sarajevo, Survey on breastfeeding practice Zenica, Mostar, Livno, Bihać, Goražde) [10]. In cooperation with UNICEF and Institute for In B&H back in the 1980s, before the war, a Public Health F B&H a Project “Breastfeeding in F tendency of abandoning breastfeeding practice and a B&H” was initiated and performed according to the “silent” introduction of milk food supplements were methodology and health indicators adopted from noted. At the same time, an easy adoption of milk WHO and UNICEF [11]. formula by mothers and remarkable conformity of In accordance with the Millennium Declaration health care professionals were rather emphasized. (2000) [12] and the Plan of Action of World Fit for Aggressive promotion of infant formula producers Children (2002) [13], a Program for monitoring was a constant practice during last decades. the situation of children and women in Bosnia and 56 Šumanović-Glamuzina Journal of Pediatric and Neonatal Individualized Medicine • vol. 2 • n. 1 • 2013 www.jpnim.com Open Access Herzegovina was started. The Multiple Indicator First Nutritional Study (partial) was done by Survey (MICS) was originally developed in WHO during 1994 as a pilot project. It showed that response to the World Summit for Children to only 5% infants under 4 months were exclusively measure progress towards an internationally breastfed. There was a common practice in B&H agreed set of mid-decade goals. The sample of giving tea, sugar-water and juice early in first for the F B&H MICS was designated as part of months, with bottle (42%); at that time, 25% state level MICS, to provide estimates of health mothers did not practice breastfeeding [10]. indicators at the entity level. The first round was Second comprehensive analysis was taken in conducted around 1995 in more than 60 countries. F B&H in 1997 [10]. It was organized by NGO It has been a state source for monitoring the (Association for breastfeeding promotion) in six Millennium Development Goals (MDG) with 21 cities in F B&H on 892 infants at the age 12-18 MDG indicators (particularly related to health, months. Main results were the following: education and mortalities). From February 2013 there is available data on the MICS 4 (Multiple • 9.7% infants less than 6 months of age were Indicator Cluster Survey-4) [14]. exclusively breastfed; Also, big effort was made with Baby Friendly • 64.3% were predominantly breastfed; Hospital Initiative (BFHI). It began in 1995 and • 8.5% infants were continuously breastfed for 12- out of a total of 40 maternity wards in B&H, 18 months. Tea and sugar water were given to 55% of them (22 wards) were certified as “Baby almost all infants (90.3%) up to three months of Friendly” [15]. age. To 28% of infants substitution food (milk At that time, appropriate definitions were formula) was given up to three months, and to adopted from WHO [16]: 15% of them up to six months of age. 6% of Exclusive Breastfeeding (EBF): The practice infants up to three months, and 27% of infants of feeding breast milk only, including expressed up to six months were given cow milk. breast milk, excluding water, other liquids, breast milk substitutes and solid foods. Vitamin drops, Third comprehensive analysis (1999) [11] in F minerals, oral rehydrating solution (ORS) and B&H was performed on 469 mother-infant pairs medicines may be given. under 5 years of age: Predominant Breastfeeding (PBF): The practice of feeding breast milk only as predominant • 8.1% infants below the age of 4 months were milk source. Water, sugar water, juices, ritual fluids, exclusively breastfed; vitamin drops, ORS and medicines may be given. • 5.5% of infants below the age of 6 months were Partial Breastfeeding (PaBF): Practice of exclusively breastfed; breastfeeding only in addition to food or liquids • 77.3% infants were predominantly breastfed including non-human milk and formula.