This post was most recently updated on April 6th, 2017
There is a French translation of this article below.
This article edited 11/3/17 to add – we are not accusing the midwves of GSF of not supporting breastfeeding or believing that breastmilk is the safest manner to feed babies. We are, however, concerned that mothers who are using formula are not being appropriately supported. The comments from GSF under this article prove that they are struggling to understand the particular hygiene challenges mothers in camp face every day.
At the end of January 2017, after many attempts by the Breastfeeding Counsellors of Calais and Dunkirk Infant Feeding Team to encourage safe infant feeding practices in the Grande Synthe refugee camp, the midwives of Gynecologie Sans Frontieres finally shared their infant feeding guidance document. Strangely, it was not sent to the British Infant Feeding Team who had spent nearly a year and a half trying to support them, but to an English volunteer not involved with infant feeding, who instantly shared it with us. What follows are some quotes from this guidance and short explanations of why it is inappropriate.
“GSF recommends the use of bottles (either glass or polycarbonate) and silicone or rubber teats with variable flow. Start with a low flow so as not to overwhelm the infant by the sudden arrival of a large quantity of milk; and ensure that the teat is always full of milk, and not air. Thus we do not recomend [sic] the use of cup feeding which risks choking the infant.”
This directly contravenes accepted best practice in emergency conditions. (see page 39 of this UNHCR manual for staff working in emergency situations http://www.unhcr.org/45f6cb1f2.pdf )
The women in camp live in shelters with no running water, without readily available access to sterilisation facilities. This paragraph does not take into account how difficult it is to keep equipment like teats clean and bacteria-free in such conditions of privation. It also does not take into account evidence based practice and proven research that has found cup feeding to be a safe and appropriate way to feed infants, especially if they have to be artificially fed in conditions that are damp and dirty. Cups, with fewer nooks and crannies, are much easier to wash up effectively and thus harbour fewer bugs.
“Sterilisation is not recommended”
We understand this is mainstream advice in France, unlike in the UK where the Dept of Health recommend sterilising all baby feeding equipment. However, French advice for parents living in safe, clean homes cannot apply to mothers living in tiny, damp wooden sheds with no running water, electricity or often even anywhere to keep equipment off the floor. This is far from appropriate advice for a refugee/transit situation.
“The recommended drying method is leaving to dry upside-down in the atmosphere : a purpose-made stand is recommended.”
So where is this equipment then? And where are these facilities? They were not available in the old woman’s centre, which was burned down in January 2017. We are not aware that communal, secure, clean washing up facilities are being built into the new Woman’s Centre. Will the midwives be welcoming mothers into their clinic to wash up and air dry bottles? Even if that were the case, are mothers going to walk, possibly in the rain, after every single feed, perhaps for 10 mins from one end of the camp to the other? If we give each mother enough clean bottles to last a day, they are given away, swapped or sold.
“Bottled water can be used if it is clearly labelled ‘convient pour la préparation des aliments pour nourrisson’ (‘suitable for the preparation of infant milk formula’)
So, contrary to ALL safety guidelines all over the world, these midwives are telling mothers it is acceptable to make up powdered formula with cold water? In a meeting in January 2017, the idea was actually mooted that British formula may contain bacteria, which therefore needs to be killed by the addition of very hot (more than 70 degrees) water but that French formula was not so affected. (Actually all European formula comes from the same sources – most made in manufacturing plants in Ireland. All of it is potentially contaminated).
“In order to make up feed, tap-water is permissible, letting the tap run for a time (from 3 seconds to 2 minutes depending on the frequency of its use)”
Even in clean, middle-class homes in the UK, our mothers are told to boil the water! The running water in camp is most easily accessed in the toilet blocks. Toilets that are dirty, without good electric light and dangerous places at night. In fact women and children wear nappies at night to avoid having to go to the toilets and risk being attacked.
“Once opened, the water bottle should be reclosed and kept in a refrigerator for a maximum of 24 hours”
Again, we ask: where are these fridges? These refugees are living in shelters that are not much more than garden sheds.
“The preferred method of heating is to use a bain marie (placing the bottle in a pan of warm water).”
So, a non-sterilised bottle, containing formula that probably contains bacteria, sitting in a bowl of warm water for some time, while those bacteria multiply? Nice. While the baby cries in hunger waiting for the feed to warm up. We have had no answer to our question: why can’t donors be asked to provide ready-made up formula? It has been pasteurized, can be stored at room temperature and can be provided in small cartons that means the packaging is not open for long before it’s empty. Crucially, it can be fed to the child straight from the carton, making feeding quicker and easier.
“Follow-up milks are enriched with iron, essential fatty acids and vitamin D and the calcium:potassium ratio is more suitable for bone growth.”
Our calls for the midwives to provide the evidence for this statement have been ignored. In fact, the World Health Organisation has maintained that these milks are nutritionally unnecessary and, in some instances, risky:
“In 1986, the World Health Assembly stated that “the practice being introduced in some countries of providing infants with specially formulated milks (so-called ‘follow-up milks’) is not necessary” 4 . The Organization further maintains that as well as being unnecessary, followup formula is unsuitable when used as a breast-milk replacement from six months of age onwards. Current formulations lead to higher protein intake and lower intake of essential fatty acids, iron, zinc and B vitamins than those recommended by WHO for adequate growth and development of infants and young children” http://www.who.int/nutrition/topics/WHO_brief_fufandcode_post_17July.pdf
All quotes from GSF Infant Feeding Guidance document sent to a volunteer on 30th Jan 2017.
In February 2017, the Calais and Dunkirk Infant Feeding Team received a reply from Gynecologie Sans Frontieres to our open letter calling for them to follow established, evidence-based Infant and Child Feeding in Emergencies protocols; guidelines that are followed by all established NGOs, Unicef and the World Health Organisation. The reply did not address any of our concerns or questions and included this worrying comment:
“Breastfeeding and artificial breast-feeding protocols were written by breastfeeding and infant nutrition specialists, certified IBCLC (International Board Certified Lactation Consultant).
What IBCLC, following her own ethics and Code of Conduct, could be involved in such inappropriate and potentially dangerous infant feeding guidance?
It is clear the midwives have no real idea of the conditions these families are living in. We wonder why they refuse to even look at the evidence we have provided them and we are aghast at their resistance to learning about Infant Feeding in Emergencies, leaving babies at risk on a daily basis.
We call on GSF to answer our concerns and justify their practices – practices that are in direct contradiction to absolutely every large NGO, governmental and health authority in the world. We also ask that they welcome support and help from infant feeding specialists who are happy to volunteer our time, skill and knowledge to support refugee mothers in Northern France.
We want to know why a small, almost unknown NGO has sole responsibility for women’s health in this refugee camp and why no one appears to be holding them accountable or auditing their work.
We want to know why the French government appears uninterested in this crisis or why they do not allow non-French NGOs to operate in camp.
Most of all, we want to know how anyone, whatever their nationality or job description, cannot try to put assumptions and bias aside and concentrate on the health and safety of the most fragile and vulnerable members of the human race; babies.
Calais and Dunkirk Infant Feeding Team, 1st March 2017
Can you help? By raising awareness or talking to someone who might be able to advocate for the mothers and babies in this camp? Or by helping with admin tasks, letter writing, or do you have experience working with NGOs? Perhaps you are a French breastfeeding supporter who could speak with GSF? If you have any ideas of where we can go from here, please do not hesitate to get in touch.