The babies arrive small and skinny. To a health worker's eye, it's clear they're not growing well, though it's often only a health crisis like a fever or severe diarrhea that leads their mothers to make what is almost always a long trek to the Al Salam Hospital in Khamir, Yemen.
"By then, the babies are too weak to breastfeed," says Fiona Bay, a nurse with Medecins Sans Frontieres (Doctors Without Borders) at the hospital.
The neonatal unit of Al Salam in the war-torn country is seeing an increasing number of malnourished infants, and providers say that mothers are reporting that they cannot breastfeed their babies. Studies on breastfeeding in a conflict zone are scarce, but a few suggest that war and violence are tremendous obstacles to a mother's ability to breastfeed her baby.
In war-torn countries, there are lots of reasons why mothers don't breastfeed their infants. Often, the grandmothers and aunties who would have passed on the wisdom and skills of breastfeeding are absent or distracted by war. The information on how to breastfeed has been lost, says Bay. "Most of the mothers are very young, and they haven't had any education about breastfeeding. Some replace breast milk with goat's milk or cow's milk. Or they use donated powdered formula but dilute it too much. I saw one woman giving her infant juice. I have no idea what made her think this would be good."
Just as conflict and violence can take a toll on health, they can also lead to a reduction in breastfeeding, says Michael Malcolm, professor of economics at West Chester University in Pennsylvania. He, along with co-authors Vidya Diwakar of the Overseas Development Institute in London and George Naufal of the Public Policy Research Institute at Texas A & M University, wrote a paper the topic: Violent Conflict and Breastfeeding: The Case of Iraq.
The authors compared breastfeeding rates among women who lived in high-conflict areas of Iraq with those who lived in lower-conflict areas, determined by a database counting war casualties, in the years 2006 and 2011. They found that in high-conflict areas, there approximately a 60% rate of breastfeeding compared to 68% in lower conflict areas.
Malcolm and his co-authors found only three other studies of the effect of conflict and violence on breastfeeding: a 2000 study of breastfeeding in Croatia during the war years of 1991 to 1996; a 2018 study of breastfeeding among women displaced in 2015 by conflict in Ukraine; and a 2009 study of breastfeeding among mothers in Iraq in 2003.
"Our results, an 8.5 percent decline, was in line with the other studies which found a decline of between 4 percent and 7 percent," says Malcolm.
Countless other studies have shown the benefits of breastfeeding for infants. The World Health Organization estimates that exclusive breastfeeding for six months, and then continued breastfeeding for two years as other foods are introduced, would save the lives of 800,000 children because of the naturally protective effects of breast milk. "It's pretty well-established that declines in breastfeeding rates are associated with increases in [infant] deaths," says Malcolm.
Even if women are educated about breastfeeding, there are other reasons for a decrease in breastfeeding in countries at war or otherwise in turmoil. "When women are under stress, there's both a decrease in the amount of milk and also the nutritional content of the milk," he says.
"Breastfeeding is about emotions as well," says Jane Hancock in a YouTube presentation. She is a nurse with MSF at the Al Salam Hospital in Yemen. "When you are living in a stressful environment, you are not going to produce breast milk. And this is a very stressful environment."
In addition, women displaced by conflict might not have the privacy or a suitable place to breastfeed. And health professionals might have fled a war-torn country, leaving women without the benefit of professional advice on how to overcome obstacles to breastfeeding, says Malcolm.
At Al Salam hospital, says Bay, when women come in with a malnourished infant, health professionals teach them how to increase their milk supply and breastfeed effectively. "We tell them they have to drink a lot of water in order to produce enough milk," she says, suggesting 1.5 to 2 liters per day — about 2 quarts a day, depending on the woman's weight. "But one mother told me that access to water is a very long walk, and she can't bring enough home to drink all the water she needs," says Bay.
The undernourished and sickly infants who make it to the hospital in Yemen can almost always be stabilized in a few days, says Bay, and their mothers are sent home better educated about breastfeeding. But no one has looked at how many infants in war zones who never get to the hospital have health problems, or even die, because of inadequate breastfeeding.
Some women in conflict zones try to supplement with formula, which they buy or might receive as part of international aid packages, says Malcolm. But it needs to be mixed with water, and water can be scarce and impure.
Women also skimp on water themselves so their family members can have more to drink. One woman who came into Al Salam this summer was typical. "Her baby was six months old and born at home. She only had enough milk to breastfeed three times a day, the family had no money to buy supplementary formula, and the baby was always hungry. The baby was not gaining weight," says Bay. Water was so scarce that the woman told Bay she only drinks a few sips a day — hardly enough to sustain an ample supply of milk.
New mothers around the world in areas of conflict have fled their homes, fled violence, and their lives are falling apart, Bay says. They don't have enough to eat or drink, and their levels of stress are high. Women need education to better understand how to breastfeed, Bay says. They need food. They need water.
Maybe most of all, she says, they need peace.
Susan Brink is a freelance writer who covers health and medicine. She is the author of The Fourth Trimester, and co-author of A Change of Heart.