Lactation Newsmakers: Documenting our History-The Current State of Breastfeeding in Ukraine: An Interview With Lidiia Romanenko and Olha Shlemkevych.

In this issue, we are featuring an interview with two medical doctors from Ukraine, who are specialists in breastfeeding, and work with the implementation of the Baby-Friendly Hospital Initiative (BFHI) in Ukraine. The authors met during the Eleventh BFHI Network Meeting of Country Coordinators from Industrialized Countries, Eastern Europe, and the Commonwealth of Independent States, in Brussels in June 2022 (Hernández-Aguilar, M. T., 2022). Ukrainian citizens have lived in a war situation since February 24, 2022, when Russia first attacked; this has had a huge impact on infant feeding issues.

Keywords: breastfeeding; breastfeeding difficulties; breastfeeding support; complementary feeding; infant and young children feeding; mental health; refugees; Ukraine; wartime emergencies

Olha Shlemkevych is a Ukrainian MD and PhD trained at the Department of Paediatrics at Lviv State Medical University. Olha's activities to support breastfeeding started in 1998, when she attended the Certificate course "Breastfeeding and Policy" at the Institute of Child Health, London, UK. She is a member of the National BFHI Committee. Since 1991, she has worked as a neonatologist at the Maternity Department of Lviv Regional Clinical Perinatal Centre. She is the author of a popular book and co-author of two scientific-popular books.

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Olha Shlemkevych, MD, PhD

Lidiia Romanenko is a Ukrainian medical doctor and pediatrician trained at the Horkyy Medical Institute. Since 2007 she has been the Head of the Methodological Monitoring Centre at the National Children's Specialized Hospital "OXMATDYT" and BFHI National Coordinator in Ukraine. As a trainer she has experience in youth and Baby-Friendly medical care. She is co-author of five methodical recommendations, and six manuals on medical care for adolescents and young people, youth friendly care, and Baby-Friendly Hospital assessment and reassessment. (This is a verbatim interview that has been edited for readability; LR: Lidiia Romanenko, OS: Olga Shlemkevych, MA: Maryse Arendt)

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Lidiia Romanenko, MD

MA:

When did you first come in contact with breastfeeding issues?

LR:

My meeting with the Breastfeeding Support Initiative began in 1996, when the first breastfeeding support program was approved in Ukraine with the support of UNICEF [the United Nations Children's Fund]. At that time, I worked in the Department of Health Care of Kyiv and managed health care facilities that provided assistance to mothers and children. In the capital of Ukraine, we were the first to start holding events for the training of coaching teams, the training of medical workers, [and] the introduction of modern perinatal technologies. The first maternity hospital in Ukraine to receive the status of "Child-Friendly Hospital" became maternity hospital Number 1 in Kyiv.

My personal experience with breastfeeding was not entirely successful. I breastfed my eldest son only up to 4 months [and] the youngest son up to 7 months, but it was not exclusively breastfeeding. Later, I became a breastfeeding coach, a certified expert.

In 2006, I gladly accepted the offer of the Ministry of Health and headed the Monitoring Center, which was created with the support of the UNICEF field office in Ukraine within the structure of the National Children's Specialized Hospital "Okhmatdyt" of the Ukranian Ministry of Health BFHI [The Baby-Friendly Hospital Initiative] National Methodological and Monitoring Centre operates and manages the implementation of the BFHI in Ukraine. I really wanted to do everything in my power to change the existing practices of health care facilities that did not support breastfeeding.

OS:

My first meeting with breastfeeding took place a long time ago, at the end of 1994, when I attended a Lactation Management Educational Program at Wellstart International, San-Diego, California, USA, as part of a delegation from Ukraine (eight medical workers from the central, western, and eastern parts of Ukraine and two representatives of the Ministry of Health). Upon our return, we started to introduce new approaches to protect and support breastfeeding in the medical institutions of our regions.

MA:

The Ukraine was attacked on the 24th of February, 2022, by Russia, and since then the life of Ukrainian people has dramatically changed. Please tell us about this.

OS:

Before the start of the war, as of January 1, 2022, the population of Ukraine was 41,167.3 million ([12]). Sociologists predicted that as a result of the war with Russia, Ukrainians will decrease by millions. Among the reasons are migration, an increased mortality rate, a decreased birth rate, and a general deterioration in the state of health of the population. By 2030, the country's population may decrease to 30–35 million ([18]) According to State Statistics, in 2019, an average of 25,700 babies were born every month; in 2021, 22,000 children, and at the beginning of 2022, 18,000 newborns. In January 2022, 18,062 babies were born in Ukraine, which is 18% less than in the same month of the previous year, when 21,931 children were born ([11]). The Ministry of Justice in Ukraine published data according to which 102,575 babies were born in Ukraine in the first half of 2022. The largest number of them are in Lviv (9,079 children), Dnipropetrovsk (8,397 children), Kyiv (7,591 children), Odesa (7,530 children), Zakarpattia (5,495 children), and Vinnitsa (5,273 children) regions. However, active military operations had not been conducted in these regions ([10]).

MA:

Could you describe the status of BFHI in Ukraine before the war?

LR:

The implementation of the BFHI, based on The Ten Steps of Successful Breastfeeding started in Ukraine in 1996. The BFHI has been actively implemented in maternal and child health facilities since 2001. Expanded-BFHI in Ukraine covers all types of mother and child health care (MCH) institutions: maternity hospitals, children's hospitals, children's outpatient departments, and antenatal clinics. Breastfeeding support centers were established and operated in all 24 regions of Ukraine until 2014, when Crimea was annexed, and part of the Eastern Oblasts were separated.

The provisions of the Expanded Initiative to Support Breastfeeding were included, as an integral component, in more than 15 orders of the Ministry of Health of Ukraine on obstetrics, neonatology, pediatrics, and sanitary services. National BFHI criteria were adopted by respective Orders of the [14]. This Order has been operating until now. Two more steps to "10 Steps of successful breastfeeding" have been adopted by the Order: the 11th step (i.e., evaluation of compliance with the International Code of the Marketing of Breast Milk Substitutes) and the 12th step (i.e., evaluation of compliance with effective perinatal care practices according to WHO [2009] Mother Friendly care). With the support of the UNICEF representative office in Ukraine, the Ministry of Health (2002) issued the educational manual Modern Management of Lactation and Breastfeeding ([7]).

In 2008, with the support of UNICEF, the training manual International Summary of Marketing Rules for Breast Milk Substitutes was published and in 2013 the Ministry of Health of Ukraine developed and approved the new Guidelines for the Assessment and Reassessment of Health Care Institutions for Compliance With the Status of "Child- Friendly Hospital.

As of January 1, 2022, there were 128 national and regional coaches, 103 evaluation specialists, and 18 revaluation specialists trained. This is sufficient for the effective continuation of the implementation of the WHO BFHI.

MA:

How many hospitals and mother and child health facilities have been designated as Baby-Friendly following the 10 Steps and the WHO criteria?

LR:

From 2001 to 2021, about 30% of all health care facilities for mothers and children in Ukraine were accredited in accordance with WHO criteria. This means 92% of all maternity hospitals, 66.0% of children's hospitals, and only 6.5% of primary medical care centers. For BFHI certification, we have appropriate methodological recommendations and a sufficient number of trained specialists.

In all certified obstetric hospitals, individual and family delivery rooms have been created for births with the partner. This means that 2-hour skin-to-skin contact, the start of breastfeeding within the 1st hour of life, the observance of the "warm chain," and family participation in the care of mother and child, have been implemented.

MA:

Could you explain more the concept of the observance of the "warm chain"?

LR:

The heat chain is a sequence of actions during childbirth and in the first days of life to reduce heat loss from the baby. It is one of the most important factors in the soft adaptation of the baby to external conditions after a cozy and safe mother's womb, and the loss of one of the actions can seriously threaten the future health of the child.

In Ukraine, the recommendations of WHO international experts are used. In the clinical protocols for the provision of neonatal care, obstetric, and gynecological care, the main steps are formulated to ensure conditions in the maternity hospital for the normal adaptation of the newborn in the first minutes of life, the so-called "heat chain" ([13]). To ensure thermal protection immediately after the birth of a child in maternity hospitals, and later in the departments for nursing very premature babies, the 10 Steps of the thermal chain are observed (see Table 1). It is important that during all procedures the child is not taken away from mom or dad under any circumstances, except those that threaten life. In critical cases, resuscitation is organized so that parents can contact the baby for the maximum amount of time. Such support is sometimes vital for the tiniest babies.

The kangaroo method has been introduced in Ukrainian hospitals for more than 8 years, when the baby is [placed] on the mother's chest, and the temperature is regulated in this way by the mother's body itself. Other members of the family (dad, grandmother) also take part in caring for small children using the kangaroo method.

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Table 1. The 10 Steps of the Thermal Chain.

1 Source. Ukraine Ministry of Health (2005).

MA:

Could you present any statistics about breastfeeding initiation, duration, and exclusiveness in Ukraine before the war?

LR:

Before the war, we achieved quite good breastfeeding rates, namely 92% of newborns start breastfeeding in the 1st hour after birth. According to national statistics, exclusive breastfeeding before 6 months of age is 56%, and 25% of children receive breastmilk up to a year or more.

Unfortunately, the last multi-indicator cluster study was conducted 10 years ago—in 2012 (Government Statistics Service of Ukraine, 2013). According to these data, the rate of exclusive breastfeeding up to 6 months in Ukraine was 19.7%. Today, this indicator does not correspond to state statistics and the results of the survey of mothers, which is regularly conducted by the national center. It would be good to conduct an independent study after the war.

MA:

When babies are no longer exclusively breastfed, what will they receive? Is there a recommended time to introduce complimentary food, solids, or semi-solids?

LR:

In 2008, the Order No. 149 of the Ukrainian Ministry of Health approved the medical Clinical Protocol "Care for a healthy child under 3 years of age." It was updated in 2018 ([15]). In one of the sections of this Protocol, "Rational feeding and nutrition of a child under 3 years of age," the scheme of the introduction of supplementary food to children after the end of exclusive breastfeeding was approved. All family doctors and pediatricians adhere to this Clinical Protocol in their work. Family doctors explain to parents how to properly introduce complementary foods (see Table 2).

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Table 2. The following order of introduction of products is recommended.

2 Source. Ukrainian Ministry of Health (2018).

MA:

Since the beginning of the war the situation has dramatically changed, and a lot of persons have fled the war zones and became internal refugees or have left to neighboring countries or even further away. How has birthing and infant nutrition been impacted by the war? Could you give some examples of how the situation is in the most impacted war zones?

OS:

In the 6 months since the start of the war, 9,136,006 border crossings out of Ukraine were recorded, but about 2.5 million returned to Ukraine. At the same time, 8 million Ukrainians became internally displaced. The majority of migrants and internally displaced persons were women. Women who remained in their places of residence received medical care in relation to the war situation. In order for you to better understand how the organization of medical care and breastfeeding for mothers was carried out, I will tell you about the experience of regional perinatal centers in five different parts of Ukraine.

In cities where active hostilities are taking place or [where there] may be air strikes, or air alarms, hospitals are forced to use basements to protect mothers with newborns. The babies are breastfed in basements. Kharkiv Perinatal Center is in the eastern Ukraine and Chernihiv Perinatal Center in the northern part of Ukraine. At the beginning of the war there were active military actions (Community News, 2022). Doctors in the bomb shelters delivered babies and performed Caesarean sections (UNICEF, 2022).

Odessa Perinatal Center is in the south part of Ukraine. There was no active military action, but regular risk of missile strikes. During the missile strikes, when the sirens sound, mothers with children were forced to hide in bomb shelters or basements. Sometimes mothers with children listened to a lecture on breastfeeding in this terrible time.

Kyiv Perinatal Center is in the center of Ukraine, [where] there were no active military actions, but regular risk of missile strikes. The first breastmilk bank in Ukraine was established in this Center in 2019. In the difficult conditions of wartime, all equipment of the perinatal center worked regularly. Breastmilk received from a small number of donors was used for children in the intensive care unit, and for premature infants in the Perinatal Center and other maternity hospitals in Kyiv. At the same time, the mothers received support with initiation of lactation.

Lviv Perinatal Centre is in the west part of Ukraine with no risk of active military action, [and] without regular risk of missile strikes. A great part of the internally displaced people are in the western part of Ukraine. When there are no sirens, despite the martial law and the disturbing atmosphere, the perinatal center operates as usual for locals and refugees or displaced persons. Antenatal classes on breastfeeding for pregnant women are conducted. Partners can attend the births. Mothers are counseled on breastfeeding. Babies are breastfed.

MA:

How was breastfeeding counseling organized before the war?

OS:

In accordance with the order of Ministry of Health of Ukraine ([14]) on the counseling of women on breastfeeding before and after childbirth, counseling can be obtained at maternity hospitals. Most maternity hospitals are Baby-Friendly Hospitals (BFH). Each BFH facility has trained health professionals who can provide qualified breastfeeding advice. Many maternity hospitals have lactation consultants. There are also Breastfeeding Support Centers, organized in each region of Ukraine. Breastfeeding counseling can be obtained in private clinics where there are breastfeeding consultants. In some large regional centers, a powerful network of mother-to-mother support groups has been created, which conduct informational and advisory activities on breastfeeding.

In recent years, online counseling for women on breastfeeding issues has developed in Ukraine. Many Internet sites supporting breastfeeding were created and operate in Ukraine. There are many educational videos on various breastfeeding issues on YouTube channels. In addition, maternal and child health facilities have their own websites where it is possible to find information on breastfeeding. Breastfeeding mother-to-mother support groups also have their own web pages with information about breastfeeding and the telephone numbers of breastfeeding counselors who can provide online help. In the online mode mothers can ask questions and receive consultation with breastfeeding professionals. Since the beginning of the war, in areas of active hostilities breastfeeding counseling can be obtained from medical facilities, if they are open or online.

MA:

How is breastfeeding counseling operated now? You mentioned online tools. Could you give us some, as those might be of importance for those Ukrainian mothers going through this now.

OS:

In the first days of the war, the Lithuanian Association of Lactation and Breastfeeding Consultants (https://lalak.lt/pagalba-ukrainieciu-mamoms/) and La Leche League Lithuania approached us with a proposal to provide assistance. They provided the address of a site where you can get answers to a variety of breastfeeding questions and support in Ukrainian and Russian ([8]).

In Ukraine, there are also several large Internet sites, where you can find information about breastfeeding, get answers to relevant questions, and consult a specialist (Breastfeeding Specialists in the Ukraine, 2022). In particular, there is the National Movement in Support of Breastfeeding "Milk Rivers of Ukraine" (https://www.facebook.com/MolochnieReki/), and the [9]

A group, Breastfeeding Specialists in Ukraine has been created on Facebook. It includes 439 participants; some of them are medical specialists who are engaged in breastfeeding, others are breastfeeding consultants. On the page of one of the participants of this group, there is a list of breastfeeding supporters outside of the country who can counsel Ukranian immigrants or find health professionnals in the host countries who can speak in their language. Find them at: https://www.facebook.com/groups/1683622991924542/permalink/3240840936202732/?app=fbl

MA:

How are the infant nutrition experiences of mothers who have not initiated or who have stopped breastfeeding? Does the war have any impact on mothers' decisions on infant feeding?

LR:

The value of breastmilk and breastfeeding is well known. In the emergency of the military conflict in Ukraine, mothers particularly appreciated breastfeeding. Breastmilk was the only available food, when moms were in bomb shelters, or basements. When fleeing shelling, when moving to safe places by train; in conditions where there is no water and electricity, breastmilk is always clean, warm, and nutritious.

If breastfeeding is not possible, especially for children under 6 months old, ready-to-use liquid milk formula, or powdered infant formula should be available. During emergency situations, the planning and management of artificial feeding is very important. Today, UNICEF and the nutrition cluster are helping Ukraine in this.

OS:

The value of breastmilk and breastfeeding is well known. But the importance and the life-saving protection of breastfeeding in emergencies, during hostilities, is growing considerably. Breastmilk is the only possible food for a baby if the house is destroyed by bombing.

MA:

Yes, it is very important to support breastfeeding in those difficult circumstances. Recently a new Guidance Note was published on infant and young child feeding in the first 3 days after a nuclear power plant accident (Infant Feeding in Emergency [IFE] Core Group, 2022), to provide clear and accurate information, reassurance, and guidance to ensure appropriate infant and young child feeding in a nuclear emergency, and especially to ensure that breastfeeding is not unnecessarily interrupted. But it still awaits translation into Ukrainian language. Do you have experiences of uncontrolled donations and distributions of infant formula to mothers?

OS:

Baby food, as a part of humanitarian aid, is provided by Ukrainian and international charities from around the world. Maternity and children's hospitals receive breastmilk substitutes and medical nutrition for non-breastfed infants. Medical facilities are also provided by age—appropriate feeding for infants and young children aged 6 to 23 months. In cities where hostilities are taking place, mothers or caregivers can receive the baby food in humanitarian aid headquarters.

Preference is given to supplying liquid formula to places [where there are] active hostilities. The problem is the lack of proper control over compliance with the requirements of the International Code of Marketing of Breast Milk Substitutes and the relevant Presidential Decree in all medical institutions of Ukraine.

LR:

This is an extremely difficult question. Before the war, these were isolated cases, as the National Center monitored compliance with the Code by health care institutions that provided assistance to mothers and children and were certified according to WHO BFHI criteria.

At the beginning of the war, uncontrolled donations, and distribution of infant formula to mothers became a frequent phenomenon. UNICEF, the Global Nutrition Cluster, and partners, have developed a Joint Statement on Protecting Maternal and Child Nutrition in Ukraine's Conflict and Refugee Crisis (UNICEF et al., 2022) this is based on the Operational Guidance on Infant Feeding in Emergencies (IFE Core Group, 2017). We jointly try to control the situation and influence it.

MA:

What is the impact of the war on complementary feeding of infants and young children?

OS:

Mothers who are in a war zone may face difficulties in organizing complementary feeding. Sometimes this encourages mothers to continue exclusive breastfeeding. Organizations such as UNICEF, the Global Nutrition Cluster, the Center for Social Leadership, and other NGOs involved in organizing humanitarian aid carry out various activities for the most vulnerable sections of the population—including infants and young children—aimed at ensuring safe and appropriate methods for feeding them, including complementary feeding.

MA:

Is there psychological support for traumatized mothers who are birthing or living with their babies in the bombed cities?

OS:

It is well known that hostilities, explosions, shootings, and bad news can cause stress in the mother and impact the milk flow. Psychological support is extremely important in times of war! It can be obtained in medical institutions and psychosocial support centers, and special NGOs provide free psychological counseling by phone. Telephone hotlines operate 24 hours a day throughout Ukraine.

A psychologist works with every internally displaced person in the perinatal center where I work. The mothers who fled from Kharkiv experienced a highly depressive condition after witnessing active hostilities. One of my patients would always start crying when she heard the siren. A psychologist works in such conditions, the patients receive help from all medical staff. We have some success stories of mothers discharged home with the ability to breastfeed.

MA:

In your presentation in Brussels, you mentioned a Ukrainian singer that created and sings songs dedicated to children and breastfeeding.

OS:

Despite all the difficulties of wartime, breastfeeding does not lose its value. The Ukrainian singer, MamaRika, has created and sings songs dedicated to child and breastfeeding during the war. Her song "Synu" ("My Sun") is the cry of the soul of every Ukrainian mother who protects her child from war. Maternal love is the strongest, which is why every mother is ready to stand under bullets without hesitation to protect her child from harm. On the YouTube page (https://www.youtube.com/watch?v=KAGj8PXjdHY https://fanlink.to/MamaRikaSon), where you can listen to the song and read the lyrics, the singer wrote:

"I will never forget the way I hugged my son David to my chest when rockets flew over our houses. At that moment, you are ready to give your life, if only your most precious treasure would live and never see war again."

The song is available for listening on many music platforms (see, too, https://www.instagram.com/mamarika%5fof https://vm.tiktok.com/@mamarika%5fofficial; https://fanlink.to/MamaRikaSon https://www.facebook.com/MamaRikaOff).

MA:

From your work, what has had the largest impact on breastfeeding in the Ukraine?

LR:

The WHO and UNICEF initiative "Child Friendly Hospital" in Ukraine is 25 years old. During this time, health care practices have changed—they have become family-friendly, and the system of training medical workers to support breastfeeding has changed. [For example,] it is prestigious for health care institutions to have the status of "Child-Friendly Hospital." Not only medical workers are involved in breastfeeding support, but also public organizations that unite breastfeeding consultants in all regions of Ukraine. Today, women go to the maternity hospital to give birth together with their partner and they want to breastfeed! All this became possible thanks to teamwork. I am happy to be a member of this team.

Graph: Supplemental material, sj-docx-1-jhl-10.1177_08903344221136477 for The Current State of Breastfeeding in Ukraine: An Interview With Lidiia Romanenko and Olha Shlemkevych by Lidiia Romanenko, Olha Shlemkevych and Maryse Arendt in Journal of Human Lactation

Graph: Supplemental material, sj-docx-2-jhl-10.1177_08903344221136477 for The Current State of Breastfeeding in Ukraine: An Interview With Lidiia Romanenko and Olha Shlemkevych by Lidiia Romanenko, Olha Shlemkevych and Maryse Arendt in Journal of Human Lactation