Comparison of the Breastfeeding Practices of Refugee Syrian Mothers and Native Turkish Mothers

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.

Introduction

The World Health Organization (WHO) recommends 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 development.^1,2 In 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.³

WHO 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 official data of Turkey's Directorate General of Migration Management, the number of migrants has reached 3,623,192 people as of end of 2018.⁵ Given 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 appropriate 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 refugees 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 communication 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.

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 breastfeeding behaviors of the women, a questionnaire was prepared 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 probabilistic sampling method could not be used. Instead, a questionnaire 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 calculated 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 demographic features of both groups of women, their status of benefiting from safe motherhood services, and their breastfeeding 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 refugees 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 1.

Comparison of the Demographic Features of 381 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)
		χ² = 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)
		χ² = 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)
		χ² = 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)
		χ² = 0.04; p = 0.4

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). Furthermore, 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).

Table 2.

Comparison of First Gestational Age and Number of Currently Alive Children of 381 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.

The findings related to safe motherhood, including prenatal 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 period 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 respective 95% CI were found as 1.76 (1.48–2.09). The likelihood 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).

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)
			χ² = 72.32; p < 0.001
Place of delivery
At home and other	62 (16.3)	24 (6.3)	2.583 (1.648–4.049)
			χ² = 18.92; p < 0.001
Status of receiving breastfeeding counseling
Not received	189 (49.6)	201 (52.8)	1.067 (0.922–1.234)
			χ² = 0.75; p = 0.21

CI, confidence interval.

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).

Table 4.

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)
	χ² = 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)
	χ² = 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)
	χ² = 28.00; p < 0.001
Not giving colostrum	17 (4.5)	2 (0.5)	8.50 (1.97–36.53)
	χ² = 12.14; p < 0.001
Interruption of breastfeeding before 12 months	168 (44.1)	138 (36.2)	1.21 (1.022–1.450)
	χ² = 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)
	χ² = 8.03; p = 0.003
Total	381 (100)	381 (100)

CI, confidence interval.

Exclusive breastfeeding in the first 6 months was considered 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 educational 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).

Table 5.

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.

Discussion

The benefits of breast milk and exclusive breastfeeding during the first 6 months are well documented and have special importance.^6,7 Especially, in developing societies and disadvantaged groups, the importance of breastfeeding is increasing due to its contribution in protection against infectious 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.⁸ In addition to this, breastfeeding for refugee mothers is not easy as they face immense challenges. There may be some obstacles regarding breastfeeding, 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 particular, 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 breastfeeding 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 pregnancies.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 increase.¹³ Feeling 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 experiencing war and obligatory migration, the refugee women faced trauma caused by early age marriages, which contributed 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 Değer et al. in Mardin,¹⁴ the 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 programs to refugee women.^15,16 The 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 However, the ratio of exclusive breastfeeding behavior in the first 6 months was not at the desired levels in either group. Exclusive 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.²⁰ In 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 breastfeeding during 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 According to studies, the frequency of starting breastfeeding 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%.²³ In 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.²⁴ In addition, 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 inability 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 practices 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 migration life has on the health status of mothers and children.

Footnotes

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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