Comparison of the Breastfeeding Practices of Refugee
Syrian Mothers and Native Turkish Mothers
Vasfiye Bayram Deg˘er,1Meliksxah Ertem,2and Sema Cxifc¸i1
Abstract
Background: The World Health Organization recommends that babies be breastfed within the first hour of
delivery and that they should exclusively be given breast milk in the first 6 months. The aim of this study was to
ascertain the breastfeeding behaviors of refugee Syrian women and to compare their practices with those of the
native mothers of the local community.
Materials and Methods: This study is a cross-sectional study. The study was conducted in a Southern city in
Turkey. The questionnaire was filled by face-to-face interviews. A total of 381 refugee Syrian mothers were
compared with 381 native women living in the same community.
Results: A significant difference was found between the two groups regarding breastfeeding. The rate of those
who initiated breastfeeding within 1 hour after delivery was 61.4% for the Syrians and 71.1% for the Turkish
mothers. In addition, the rates of exclusive breastfeeding (28.1 versus 34.1) and continuing breastfeeding for
12 months (55.0 versus 63.8) were lower in the Syrian refugee mothers. Maternal age and educational level
were not correlated to the breastfeeding rates.
Conclusions: This study is a rare study in which refugee mothers and local mothers were compared. Forced
migration and refugee status are negatively associated with breastfeeding behavior.
Keywords:
breast milk, breastfeeding, immigration, Syria, Turkey
Introduction
T
he World Health Organization (WHO) recom-mends that babies be breastfed within the first hour after delivery, they are fed exclusively with breast milk during the first 6 months, and breastfeeding should be continued for at least 2 years to facilitate ideal infant growth and develop-ment.1,2In Turkey, the rate of breastfeeding within the first hour after delivery is 50%, the rate of feeding exclusively with breast milk during the first 6 months is 30% and the rate of continuing breastfeeding for 2 years is 34%.3 Turkey promotes policies that encourage mothers to breastfeed. Ninety-two percent of the births in Turkey are delivered in baby-friendly hospitals.3WHO has raised the concern that forced migration may adversely affect the breastfeeding behaviors of mothers.4 Breastfeeding behaviors of migratory communities should be examined with due care and be followed up continuously, and the necessary interventions should be carried out.
An intense and challenging migration flow from Syria to Turkey took place from 2011 onward. According to the of-ficial data of Turkey’s Directorate General of Migration
Management, the number of migrants has reached 3,623,192 people as of end of 2018.5Given this new reality. it is of utmost urgency that the breastfeeding behaviors of refugee Syrian women compared to the native local population be determined so as to provide a basic data set to develop ap-propriate supportive strategies for this refugee population.
Study site
The province of Mardin, the approximate population of which is 829,000, is located in the Southeastern Anatolia. According to official records, there are 89,000 Syrian refu-gees in the province, which make up 10% of the population. In Mardin, intense counseling and training are carried out on breastfeeding. All of the hospitals in the province serve as baby-friendly hospitals. The fact that local health service providers in Mardin can speak Arabic minimizes communi-cation problems for the Syrian refugees.
The aim of this study was to ascertain the breastfeeding behaviors of Syrian refugee women who incurred forced migration, and to determine the differences in their behaviors compared to the native mothers.
1
Faculty of Health Sciences, Artuklu University, Mardin, Turkey. 2
Faculty of Medicine, Dicle University, Diyarbakir, Turkey. ª Mary Ann Liebert, Inc.
DOI: 10.1089/bfm.2019.0233
170
Methodology
This study is a cross-sectional study and the eligibility criteria for the study were having a baby between 6 and 72 months and being a Syrian refugee. To examine the breast-feeding behaviors of the women, a questionnaire was pre-pared by the researchers and completed through face-to-face interviews. The questionnaire was applied to the same number of native women with the same characteristics as the Syrian refugees. The filling of questionnaires was conducted by senior nursing faculty students who were fluent in both Turkish and Arabic.
The study was conducted in Mardin Artuklu district center. Due to the fact that the Syrian population was relatively mobile, their addresses were not accurate and the exact number of their population was only predictive; the proba-bilistic sampling method could not be used. Instead, a ques-tionnaire was applied until the calculated sample volume was reached. The sample population, the prevalence of which was the Syrian population, was taken with probable prevalence as 50% and the confidence interval (CI) as 95%, and was cal-culated as 380 people. Home visits were carried out in the Mardin Artuklu district until 381 women were reached. In addition, to compare the breastfeeding behaviors of the Syrian refugees with the local community, 381 native women who live in the same community were selected. The demo-graphic features of both groups of women, their status of benefiting from safe motherhood services, and their breast-feeding behaviors were compared. A chi-square analysis was performed and the crude odds ratios and respective 95% CIs were calculated. In addition, logistic regression analysis, adjusted odds ratios, and respective 95% CIs were calculated to examine the factors affecting breastfeeding behaviors during the first 6 months after birth.
Definitions
Exclusive breastfeeding: feeding only with breast milk for the first 6 months without giving even water; intensive breastfeeding: feeding with breast milk, along with water and supplementary food; feeding with supplementary food: breastfeeding along with supplementary food.
Before starting this study, the approval of the ethics committee was obtained (2017/1,1). Written consent forms were obtained from the individuals who agreed to participate in the study, and they were informed that they could leave the study at any time and they would not benefit in any financial way by participating in the study. All interviewers were trained in compliance with ethical issues and supervised throughout the field study. Four Syrian women and seven Turkish women, who were eligible for the study criteria, did not accept to participate in the study, and therefore were not included in the study. In addition, the necessary legal permits were obtained from provincial health administrators and the local authority.
Results
The demographic features of the women included in the study are shown in Table 1. Around 44.6% of the Syrian ref-ugees and 59.6% of the Turkish women were in the age group of 25–34. However, it was observed that there was a difference between the two groups based on the distribution by age
groups ( p= 0.002). There was also a difference in terms of educational background between the women ( p< 0.0001). The ratio of illiterates was 42.8% for refugees and 28.6% for the natives. Furthermore, differences in terms of financial incomes were found among both groups ( p< 0.0001). Among the Syrian refugees, the rate of those who reported having less income than their expenditures was 49.3%, while this rate of disparity was 23.4% for the native women.
Table 2 shows the first gestational age of the women and the number of births they had. Accordingly, the risk of first gestational age at or before 18 and was 3.26 (1.52–7.02) times higher in the Syrian refugee women ( p= 0.002). Further-more, the percentage of the refugee women who had four or more currently alive children was 23.1%, while this ratio was 16.5% for the Turkish women ( p= 0.024).
The findings related to safe motherhood, including pre-natal care, birth aid, and breastfeeding counseling, are shown in Table 3. As can be seen, there was a significant difference between the two groups in terms of postnatal follow-up pe-riod by health personnel ( p< 0.001). Ten percent of the Syrian refugee women stated that they visited the doctor three or more times during the pregnancy, while this ratio was 49.3% for the native women. The odds ratio and the re-spective 95% CI were found as 1.76 (1.48–2.09). The like-lihood of the refugee women giving birth at home was found be higher than the native women (16.3% versus 6.3%) ( p< 0.001). No difference was found between the two groups in terms of receiving breastfeeding counseling ( p= 0.21).
Table1. Comparison of the Demographic Features of381 Syrian Refugee Women
and 381 Native Women
Syrian Turkish Age group 18 and under 4 (1.1) 3 (0.8) 19–24 103 (27.0) 66 (17.3) 25–34 208 (54.6) 227 (59.6) 35–44 60 (15.7) 84 (22.0) 45 and above 6 (1.6) 1 (0.3) v2= 16.64; p= 0.002 Educational background Illiterate 163 (42.8) 109 (28.6)
Literate and primary school graduate
82 (21.5) 61 (16.0)
Secondary school graduate or above 136 (35.7) 211 (55.4) v2= 30.01; p< 0.0001 Financial status Disparity of income and expenses 188 (49.3) 89 (23.4) Balance of income and expenses 193 (50.7) 292 (76.6) v2= 55.59; p< 0.0001 Status of working in an income-generating job
Yes 54 (14.2) 56 (14.7)
No 327 (85.8) 325 (85.3)
v2= 0.04; p= 0.4
The breastfeeding behaviors of the refugee and native women are shown in Table 4. The rate of women who achieved exclusive breastfeeding in the first 6 months was 52.8% in the refugees and 64.8% in the natives ( p< 0.001). The behavior of not giving colostrum was higher in refugees (4.5%) compared to the natives (0.5%) ( p< 0.001). There was a significant difference between the two groups in terms of starting breastfeeding less than 1 hour after birth ( p= 0.003). The rate of those who started breastfeeding after the first hour after birth was 38.6% in Syrians (ratio= 1.34; 95% Cl= 1.092–1.636).
Exclusive breastfeeding in the first 6 months was consid-ered a significant indicator. The logistic regression model was applied and results are shown in Table 5. One of the most important factors affecting intensive breastfeeding during the first 6 months was found to be refugee status (adjusted odds ratio= 0.65; 95% CI = 0.43–0.98). While age and educa-tional backgrounds were not significant factors affecting the intensive breastfeeding behavior in the first 6 months ( p= 0.680 and p = 0.69), prenatal care and hospitalized birth were found to be significant factors in this regard ( p= 0.007 and p < 0.001).
Discussion
The benefits of breast milk and exclusive breastfeeding during the first 6 months are well documented and have special importance.6,7Especially, in developing societies and disadvantaged groups, the importance of breastfeeding is increasing due to its contribution in protection against in-fectious diseases and guarantee of facilitating the healthy growth of infants. Syrians who have been displaced due to war and who had to migrate constitute a prime example of such a high-risk group. Developing breastfeeding support programs can significantly contribute to the children of this community. This study provides the required information regarding the breastfeeding behaviors of Syrian refugee mothers to assist in developing such programs.
The striking finding of this study was that, despite their lower education and economic status, the prevalence and duration of breastfeeding among the Syrian mothers were lower than those of the native mothers. This unexpected finding may be attributed to the fact that most of the Syrian women witnessed war and experienced traumatic events. Prevailing conditions of conflict that contribute to a mother’s anxiety and insecurity may interfere with a mother’s ‘‘let down’’ reflex and lactation.8In addition to this, breastfeeding for refugee mothers is not easy as they face immense chal-lenges. There may be some obstacles regarding breastfeed-ing, which may cause a decrease in breastfeeding initiation or continuity. It was reported that, in Croatia, after the war, the breastfeeding behaviors of mothers changed and, in particu-lar, continuing breastfeeding for more than 1 year decreased.9 In another study conducted in Iraq, it was reported that conflict intensity was negatively associated with breastfeed-ing incidence.10 The breastfeeding behaviors of migrant mothers were found to be different from those of the host community mothers. The findings of this study also supported that the breastfeeding behaviors of mothers who migrated due to war were not at the desired level.11
Adolescent mothers may be more prone to discontinuing breastfeeding before their infants reach 6 months of age. An important reproductive health problem for refugee women is reported to be early age marriages and early age pregnan-cies.12 It has been emphasized by the UNFPA (United Nations Population Fund) reports that the rates of early marriage among young Syrian refugee children continue to Table2. Comparison of First Gestational Age
and Number of Currently Alive Children of381 Syrian Refugees and 381 Native Women
Syrian Turkish
Odds ratio (95% CI) First gestational age
18 years and younger 28 (7.3) 9 (2.4) 19 years and older 353 (92.7) 372 (97.6) 3.26 (1.52–7.02) p= 0.002 Number of living children
1–3 children 293 (76.9) 318 (83.5) 4 or more children 88 (23.1) 63 (16.5) 1.51 (1.05–2.17) p= 0.024 Total 381 (100.0) 381 (100.0)
CI, confidence interval.
Table 3. Comparison of the Status of Benefiting from Safe Motherhood Services
Syrian Turkish Odds ratio (95% CI)
Status of taking prenatal care
Never 210 (55.1) 153 (40.2) 1.83 (1.16–1.53)
1–2 times 91 (23.9) 40 (10.5) 1.76 (1.48–2.09)
3 or more times 80 (10.0) 188 (49.3)
v2= 72.32; p < 0.001 Place of delivery
At home and other 62 (16.3) 24 (6.3) 2.583 (1.648–4.049)
v2= 18.92; p < 0.001 Status of receiving breastfeeding counseling
Not received 189 (49.6) 201 (52.8) 1.067 (0.922–1.234)
v2= 0.75; p = 0.21
CI, confidence interval.
increase.13Feeling insecure in their new environments urges families to marry their children at early ages. In this study, early age pregnancies were found to be 3.26 times higher in the refugee women. Similar results were found in terms of the number of children. In addition to trauma caused by experi-encing war and obligatory migration, the refugee women faced trauma caused by early age marriages, which contrib-uted to bad breastfeeding behaviors.
Prenatal and postnatal care services have a positive effect on breastfeeding behaviors. Refugee mothers may have less
of a chance to reach prenatal and postnatal care services. In a study conducted by Bayram Deg˘er et al. in Mardin,14the ratio of women receiving sufficient prenatal care was found to be 46% in the Syrian refugee women. In this study, the ratio of sufficient prenatal health care for those who fled from the conflict environment was not at a covetable level. High levels of maternal mortality and insufficient health services have been reported, especially among women who are exposed to local conflicts and the war environment, which depicts the need for more intensive delivery of safe motherhood Table4. Comparison of the Breastfeeding Behaviors of the Refugee and Native Women
Syrian Turkish Odds ratio (95% CI)
Breastfeeding at least once 375 (98.4) 377 (99.0) 0.66 (0.18–2.36)
v2= 0.63; p = 0.52
Exclusively breastfeeding in the first 6 months (only breast milk) 107 (28.1) 130 (34.1) 0.75 (0.55–1.02) v2= 1.79; p = 0.07
Intensive breastfeeding (breast milk+water+occasional supplementary food) 201 (52.8) 247 (64.8) 0.65 (0.43–0.98) v2= 28.00; p < 0.001
Not giving colostrum 17 (4.5) 2 (0.5) 8.50 (1.97–36.53)
v2= 12.14; p < 0.001
Interruption of breastfeeding before 12 months 168 (44.1) 138 (36.2) 1.21 (1.022–1.450) v2= 4.91; p = 0.02
Starting breastfeeding more than 1 hour after birth 147 (38.6) 110 (28.9) 1.34 (1.092–1.636) v2= 8.03; p = 0.003
Total 381 (100) 381 (100)
CI, confidence interval.
Table5. Analysis of the Factors Affecting the Full Breastfeeding Behaviors of 762 Participant Women
Factors
Intensive breastfeeding, n (%)
Crude odds ratio and 95% CIs
Adjusted odds ratio and 95% CIs Nationality Syrian 201 (52.8) 0.60 (0.45–0.81) 0.65 (0.43–0.98) Turkish 247 (64.8) p< 0.001 Age group 18 and younger 3 (42.9) 19–24 97 (57.4) 0.55 (0.12–2.56) 0.58 (0.31–1.09) 25–34 263 (60.5) 0.49 (0.10–2.21) 0.589 (0.29–1.18) 35–44 82 (56.9) 0.56 (0.12–2.62) 0.907 (0.16–4.95) 45 and older 3 (42.9) 1 (0.12–8.30) 1.25 (0.22–6.94) p= 0.680 Educational background Illiterate 164 (60.3)
Literate and primary school graduate 80 (55.9) 1.19 (0.79–1.81) 1.17 (0.69–1.90) Secondary school graduate or above 204 (58.8) 1.06 (0.77–1.47) 1.26 (0.84–1.91)
p= 0.69 Receiving prenatal care
Never 192 (52.9)
1–2 times 85 (64.9) 0.60 (0.40–0.91) 0.59 (0.41–0.87)
3 or more times 171 (63.8) 0.63 (0.46–0.88) 0.55 (0.33–0.93)
p= 0.007 Place of delivery
Home delivery or other 35 (40.7)
Hospital delivery 413 (61.1) 0.48 (0.32–0.72) 0.55 (0.30–0.99)
p< 0.001
CI, confidence interval.
programs to refugee women.15,16The breastfeeding rates of the refugee mothers may also be attributable to insufficient prenatal or postnatal care.
The mothers’ approach to breastfeeding is understood to be very positive as can be seen from the very high rate of breastfeeding at least once. As a matter of fact, the rate of women breastfeeding at least once was reported to be over 95% in the studies conducted in the same region.17,18 How-ever, the ratio of exclusive breastfeeding behavior in the first 6 months was not at the desired levels in either group. Ex-clusive breastfeeding behavior during the first 6 months was found to be between 40% and 50% in studies conducted in Turkey.19 When the breastfeeding behaviors of mothers in Middle Eastern countries were examined, the exclusive breastfeeding rates in the first 6 months were found to be 55% in Iran, 2% in Kuwait, and 20% in general.20In this study, the principal research matter was the comparison of refugee and native women. While 1/4 of the refugee women stated that they had exclusively breastfed in the first 6 months, this ratio increased to 1/3 among the Turkish mothers. It was clear that the refugee Syrian mothers required training for breastfeed-ing durbreastfeed-ing the first 6 months. Although the Turkish mothers appeared to be much better in this regard, they were not at the most desired level.
Starting breastfeeding within the first hour after birth is important for sustaining breastfeeding. Mothers should be encouraged to breastfeed immediately after birth.21 Accord-ing to studies, the frequency of startAccord-ing breastfeedAccord-ing within the first hour after birth in Turkey was found to be 45.5%.22 Turkey’s Demographic and Health Survey (2013) showed that the percentage of people who started breastfeeding within the first hour after birth was 50%.23In this study, the rate of starting breastfeeding within the first hour after birth was found to be much higher (70% for Turkish mothers and 60% for Syrian refugee mothers). Refugee status was found to be an important factor affecting breastfeeding initiation rate. Furthermore, the fact that the province in which the study was carried out was a baby-friendly province, and that all of the hospitals serving in the province supported breastfeeding within the first hour after the birth, may have caused these higher rates. Baby-friendly hospitals have been reported to have an early effect on breastfeeding.24In addi-tion, the communication problems between Syrian refugee mothers and health service providers may have an effect on breastfeeding rates.
Limitations
The most substantial limitation of this study was the in-ability to use probabilistic samples because of the lack of definite addresses of the refugee Syrian mothers and the continuous change in their residential addresses.
Conclusions
This study is a rare study that compared the breastfeeding behaviors of refugee women and native women living in the same community. In this context, despite the fact that their cultures were seemingly akin to each other, the breastfeeding behaviors of the disadvantaged Syrian refugee mothers were much poorer. These findings highlight the urgent need for developing specific programs for such mothers.
Despite their lower education status and socioeconomic level, one might have expected that Syrian refugee women’s breastfeeding behaviors would be better reflecting the prac-tices and culture of a traditional nonindustrialized society. Given the fact that the results showed the opposite confirms the negative and disruptive force of war and traumatic mi-gration life has on the health status of mothers and children.
Acknowledgment
The author would like to thank the nursing students who helped collect information for the study.
Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received.
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Address correspondence to: Vasfiye Bayram Deg˘er, PhD Faculty of Health Sciences Artuklu University Mardin 47100 Turkey
E-mail: vasfiyedeg@gmail.com
