CAIRO – In the corner of a government-run health center in downtown Cairo, Shaymaa Mohamed, 31, held her 10-month-old baby as she waited to receive her monthly share of subsidized milk formula.
Mohamed had to go through an extensive process, including a breast examination, to establish that she could not produce enough milk to feed her daughter and qualified for the government’s milk substitute program.
“The process was never easy,” she said of getting into the scheme. For the Egyptian government, that is exactly the point. Officials say limiting access to subsidized formula is the best way to achieve their twin goals of improving early child health by boosting exclusive breastfeeding, while reducing the demand for costly subsidized formula.
The program has drawn criticism from some nutritionists, though, who say the government has gone too far. They worry that essentially forcing mothers to breastfeed might actually do more harm than good.
A Difficult Balance
Egyptian officials have long been grappling with how to assist mothers who needed milk substitutes, while encouraging those who can exclusively breastfeed to do so. It was clear the previous system of making government-subsidized formula available to anyone who wanted it was not succeeding.
While the World Health Organization recommends mothers exclusively breastfeed for the first six months after a child is born, in Egypt less than 15 percent of children are exclusively breastfed by the time they reach four months old, according to the 2014 Egypt Demographic and Health Survey.
“The old system had to stop because it paved the way for many mothers who are able to breastfeed their children to get subsidized milk formula,” said Khaled el-Oteify, who directs Egypt’s motherhood and childhood centers, where subsidized formula is distributed. “That prevented their children from benefiting from breast milk, which is much healthier and more useful.”
Under the new system, which began to roll out in 2016, subsidized milk formula only goes to mothers who can prove they have specific diseases, including cancer, high blood pressure and diabetes, or who have mental disabilities. Mothers with low milk supply or who stopped breastfeeding for more than a month also qualify for the program, which is why the government mandates a breast examination.
“This is the main target of the scheme: To prompt mothers to breastfeed,” Dr. Mona el-Naqaa, who heads the basic healthcare department at Egypt’s health ministry, told News Deeply.
At the same time, the government needed to restrict the heavy demand for the subsidized formula. In 2016, there was actually a shortage, prompting mothers to demonstrate in front of the Egyptian Pharmaceutical Trading Company, which was then the major body for distributing the product. Officials said these shortages posed a significant risk for those mothers who genuinely needed the product.
The new scheme appears to have resolved that concern. The country now has a surplus of milk formula for the first time ever, according to a February ministry of health statement.
It has also introduced worries among some experts who think the government has gone too far in its efforts to encourage exclusive breastfeeding.
For women who cannot afford the formula at full price, the government’s program means they have little choice but to exclusively breastfeed. It has sparked outrage in Egypt, where some women have called the policy insulting and say it does not account for the non-medical conditions that might cause them to seek out subsidized formula, like jobs that do not offer maternity leave or social stigma against public breastfeeding.
“Strict rules do not work,” said Amira Ibrahim, a Cairo-based gynecologist. She warned that the new policy may actually lead to some infants not getting enough food and becoming dehydrated and jaundiced. “Tightening the grip on giving easy access to milk formula may negatively affect the very aim that you are trying to achieve.”
It is not possible yet to say who is right, because the government is still gathering data on exclusive breastfeeding rates and the nutritional status of infants since the policy was introduced.
A Broader Debate
The situation reflects a broader dilemma for breastfeeding advocates, who are looking to encourage exclusive breastfeeding, but respect a woman’s right to make a decision.
The United Nations Children’s Fund (UNICEF), for instance, says, “the reinforcement of a ‘breastfeeding culture’ and its vigorous defense against incursions of a ‘formula-feeding culture’ is imperative.” The agency stops well short of advocating any policies that force women to breastfeed, lobbying instead for proactive legislation, like maternity leave and designated breastfeeding spaces, that makes it easier for mothers to make that choice – policies that critics of Egypt’s new scheme say the government should focus on instead of restricting access to subsidized formula.
UNICEF also calls for greater education about the importance of exclusive breastfeeding – something the Egyptian scheme is trying to encourage. Women who do not meet the requirements for subsidized formula are given extensive information on breastfeeding, said Hanan Abu Zeid, the head of el-Fagala Healthcare Center in downtown Cairo.
“If the applying mother has turned out to be not eligible for the program, we tell her how instrumental breastfeeding is and we give her data on the benefits of breastfeeding,” she said. “We also give her tips on how to breastfeed the baby, advise her to eat certain food and tell her exactly how many times she should breastfeed her child per day.”
She told News Deeply she hopes that additional information might help some mothers overcome any reticence about breastfeeding and develop strategies to make breastfeeding work within busy schedules.
Essam Abdel Hamid, undersecretary of the Egyptian Pharmacists’ Syndicate, initially criticized the scheme for establishing conditions that are “hard to meet.” But now he is supportive, telling News Deeply the government appears to be supporting mothers as it guides them toward exclusive breastfeeding, while also reducing demand for formula.
“The government has succeeded in putting things under control,” he said.