Public Health Nutrition: 13(12), 2097–2104 doi:10.1017/S1368980010001667 Breast-feeding in a complex emergency: four linked cross-sectional studies during the Bosnian conflict Neil Andersson 1 , Sergio Paredes-Solı ´s 1 , Jose ´ Legorreta-Soberanis 1 , Anne Cockcroft 2, * and Lorraine Sherr 3 1 Centro de Investigacio ´n de Enfermedades Tropicales, Universidad Auto ´ noma de Guerrero, Acapulco, Mexico: 2 CIET Trust, 71 Oxford Road, Saxonwold, Johannesburg 2196, South Africa: 3 Research Department of Infection & Population Health, Royal Free and UC Medical School, University College London, London, UK Submitted 29 August 2009: Accepted 27 April 2010: First published online 25 June 2010 Abstract Objective: To examine changes in breast-feeding and impacts on child health during the Bosnian conflict. Design: Four linked representative cross-sectional household surveys, 1994 to 1997. Setting: The countries of former Yugoslavia largely missed the international wave of enthusiasm for breast-feeding of the 1980s and early 1990s. The concern is that breast- feeding deteriorates during humanitarian emergencies, when children need it most. Subjects: The four surveys visited a random sample of clusters from population registers in the Federation of Bosnia and Herzegovina (BiH) and the Republica Srpska (RS). Interviewers asked about breast-feeding and other factors related to child health, and measured mid upper-arm circumference in 1123 infants aged 1–12 months. Results: One-fifth of infants were not breast-fed at all (220/1087). Muslim and dis- placed children were less likely to breast-feed; 59 % of Muslim displaced children never breast-fed. Among infants in sites visited by all four surveys, there was no change in the proportion ever breast-fed and a significant increase in duration of breast-feeding and exclusive breast-feeding between 1994 and 1997. Children were breast-fed for shorter durations in male absent households, in frontline communities, the RS, and households that did not receive remittances from abroad. Non-breast-fed children and those who breast-fed for less than 4 months were more likely to be malnourished, as were those with complementary foods added either before or after their sixth month of life. Conclusions: If relief agencies had promoted and supported breast-feeding, this might have avoided some of the increased malnutrition that occurred during the conflict. Keywords Breast-feeding Complex emergencies Malnutrition A literature on breast-feeding in emergencies has grown up in the last decade; across the settings studied, a con- sistent concern is that women stop breast-feeding in times of crisis (1–5) . Such settings, and the increased risks asso- ciated with not breast-feeding at these times, may alert the public to the need for breast-feeding in general (6) but there are also concerns specific to emergencies. Women may stop earlier or be less likely to initiate breast-feeding when it is most needed, in the face of reduced alternatives and the special need for mother–infant bonding. The reasons why women stop breast-feeding in emer- gencies are not completely understood. Unsolicited for- mula donations might discourage breast-feeding in conflict areas where bottle-feeding was already widespread before the emergency (7) ; this may have occurred in the 1999 Kosovo conflict (8) . According to Cogill, very few mothers have milk insufficiency, and lactating mothers are less prone to stress (9) . In emergencies, there may be a selection out of breast-feeding of those women who are stressed. Interrupted breast-feeding could be an actionable deter- minant of infant morbidity and mortality in humanitarian crises (1,10) . Yip suggested that some of the excess morbidity in the 1991 Kurdish refugee crisis may have been due to inadequate methods of infant feeding (11) , but this is speculative as it is difficult to measure breast-feeding and mortality under such conditions. Cultural norms and traditions affect breast-feeding and, out of context in emergencies, can be inappropriate (12–15) . The countries of the former Yugoslavia mostly did not benefit from the international wave of support and pro- gramming for breast-feeding of the 1980s and early 1990s. The limited evidence suggests that breast-feeding practices were poor prior to the conflict. Small studies in Sarajevo showed low levels of breast-feeding and very short periods of exclusive breast-feeding (16,17) . Studies from other parts of Bosnia reported similar findings (18–20) . The studies described in the present paper provide information about breast-feeding practices in the Federation of Bosnia and *Corresponding author: Email acockcroft@ciet.org r The Authors 2010