May 5, 2009

“Give me formula, feed me for a week; encourage me to breast-feed, feed me for…”

Tuesday is the baby clinic day in Itipini. That means mothers (almost exclusively) bring their newborns into the clinic for immunizations and check-ups. As an enticement, we distribute baby food and infant formula. That way the mothers keep coming back every week and we can check on not only the health of their babies but also of the mothers themselves and their other children who might tag along. It should be pretty straightforward, if always verging on completely chaotic. Why then have I found myself dreading Tuesdays?

The main problem is the infant formula. The idea is to give formula only to children of HIV-positive mothers. Those mothers shouldn’t be breast-feeding because of the risk of transmitting the virus to their children. (And even then the South African health guidelines recommend exclusive breast-feeding for the first six months even for HIV-positive mothers for a variety of reasons I won’t discuss here.) That makes sense to me.

But there seems to be this view among a number of the young mothers that infant formula is better than breast-feeding, that somehow some powder concocted in some lab someplace could do better than what thousands of generations have survived on. Even if formula is equivalent to breast milk, there is still a tremendous cost associated with formula feeding in a place like Itipini. The water is more or less clean but the bottles aren’t always sterilized, for instance. What’s the point of preventing babies from getting HIV if they’re just going to die of diarrhoea?

But these young women are insistent on formula. I don’t quite know why. Perhaps they worry about how breast-feeding will make them look. Maybe they think that things you have to pay for (and formula is expensive!) are automatically better than things your body produces for free. And so they concoct some story - I have a wound on my breast, I’m not producing, etc., etc. - to explain why they’re not breast-feeding. It is particularly galling when I see them breast-feed as they are waiting in line to be seen and then sit down in front of me and begin to spin me a tale.

Today, for instance, a woman who gave birth less than a month ago, came in complaining she wasn’t producing any milk. She’s been breast-feeding and we’ve been giving her vitamins and a nutritional supplement. I checked to see that she had those. She did. I made to send her on her way but she protested, quite vigorously, in front of the entire clinic. “Nothing’s coming out! The baby is hungry!” and on and on and on. As she has a history of this sort of behaviour, I told her to wait outside a few minutes to calm down. Not thirty seconds later, I looked out the door and this is what I saw.
(Note that she's smiling!)

The question all this raises for me is the difference between the short term and the long term. Sure, I could have given that woman today formula to shut her up and get her out of my hair. It was a tempting thought. But breast milk works on a supply and demand model. If the baby needed more milk, the mother would eventually produce more. If I filled that demand gap with formula, the mother would not produce more and the child would end up in some mixed feeding purgatory. My seeming “help” in the short-term would actually exact a long-term cost on the health of the baby.

The difficulty is convincing the mothers that breast-feeding now will pay dividends in the future. Most people come into the clinic with an attitude of “I want my problems fixed right now.” Telling them that what they can do for themselves over time is better than what I can do for them now is a difficult message. Anyway, people here work on a different timeline than I’m used to. They’re thinking about getting through the next day or week not, primarily, the long-term health of their baby.

The obvious answer is education, teaching mothers about the importance of breast-feeding and its benefits. But that takes time and can be difficult to do in a meaningful way. Plus, how do you have an extended chat about the importance of breast-feeding with a young mother when there are scores of babies and mothers waiting in line behind her? The end result is that we end up giving more formula out than I believe we should and that always frustrates me.

The larger question of short-term versus long-term assistance continues to bedevil me. Everyone knows the “give me a fish, feed me for a day; teach me to fish, feed me for a lifetime” saying. The trouble is what to do before they’ve learned to fish on their own. Doesn’t on some level giving people fish reduce the will to learn to fish on their own?


Naoko said...

Agh! Just reading this makes me want to tear my hair out. What a complex issue.