Retrospective qualitative analysis of an infant and young child feeding intervention among refugees in Europe
Summary of MSc thesis
By Alexandra Svoboda
Alexandra Svoboda is a student on the MSc Nutrition for Global Health course at the London School of Hygiene and Tropical Medicine (LSHTM). She has five years humanitarian experience, including working in the Philippines and Nepal alongside an international relief organisation based in Switzerland.
The author acknowledges the support of supervisors Claudine Prudhon, IYCF-E Researcher at Save the Children and Phil James, Research student at LSHTM.
Location: Greece, Serbia and Croatia
What we know: The European migrant crisis involved a rapidly transiting, multicultural, multilingual population that challenged the humanitarian response.
What this article adds: A retrospective qualitative analysis was carried out to evaluate Save the Children’s infant and young child feeding (IYCF) intervention in Greece, Serbia and Croatia. Fourteen IYCF programme staff were interviewed. Key activities were provision of breastfeeding counselling and support, and targeted provision of breastmilk substitutes to non-breastfed infants. Rapid transit, low contact time, varied IYCF practices and multiple languages greatly complicated response. Untargeted distribution of infant formula and poor provision of complementary foods were common. Supply chain for ready-to-use infant formula took time to establish. Poor IYCF coordination improved with time. Early regional assessment and establishment of IYCF working groups at the outset may have benefited the response.
The European migrant crisis began in 2015 when, exacerbated by the Syrian war, rising numbers of people migrated to the European Union, travelling across the Mediterranean Sea and overland through Southeast Europe. A Save the Children (SC) team arrived in Greece in June 2015 to launch a multisector assessment in response. The initial investigation found no visible signs of malnutrition, such as thinness/wasting or bilateral oedema, in children under two years old arriving on the Greek islands (Save the Children, 2015). However, women reported reducing breastfeeding due to stress and lack of time or privacy. SC also found that non-governmental organisations (NGOs) were freely handing out feeding bottles with mainly powdered infant formula (Save the Children, 2015). These observations prompted a preventative intervention to minimise risks associated with infant and young child feeding (IYCF) practices in migrating populations in Greece, Serbia and Croatia.
Aims and objectives
A retrospective qualitative analysis was carried out to evaluate the SC IYCF in emergencies (IYCF-E) intervention in three countries. It aimed to assess the challenges of responding to IYCF needs in a transiting, multicultural, multilingual population in a high-income European setting. A second objective was to evaluate the SC IYCF-E interventions in Greece, Serbia and Croatia against relevant guidelines and standar operating procedures (UNICEF et al, 2015; IFE Core Group, 2017; WHO, 2004; UNHCR, 2015) to inform future programming in similar contexts.
This investigation involved interviews with humanitarian aid workers involved in the IYCF response among European refugees in Greece, Croatia and Serbia and an analysis of secondary information, including previous assessments and SC country situation reports. Findings were interpreted against existing IYCF-E guidelines. The study report was guided by the checklist of Consolidated Criteria for Reporting Qualitative Research (COREQ).1
A total of 31 organisations, including local and national NGOs, volunteer associations and United Nations (UN) agencies operating across the three countries, were invited to participate in interviews; 14 individuals took part in interviews with nutrition and IYCF-E counsellors and advisors, breastfeeding counsellors, field workers and coordinators, and technical advisers. Most were employed by SC (including five from the SC Croatia programme and five from SC Greece), followed by UNICEF (one from UNICEF Croatia and two from UNICEF Serbia) and one independent (with experience of the Greece response).
Key IYCF-E activities
In Greece and Croatia, SC integrated mother-baby areas (MBAs) with an existing child protection programme run by local partners. In faster-paced transit camps in Serbia, SC worked alongside UNICEF in UNICEF-operated ‘mother baby corners’. MBAs provided a private place to rest and breastfeed for caregivers with children under two years of age. IYCF-E counsellors were available to speak with caregivers about feeding practices, provide breastfeeding support and counsel caregivers on safe feeding practices and/or relactation if using infant formula. Kits with infant formula and instructions for its safe use were targeted at mothers who were not breastfeeding, out of sight of breastfeeding mothers. Baby and hygiene kits, including nappies or wipes, were also distributed. A total of 4,091 (Greece), 1,495 (Serbia) and 1,575 (Croatia) children under two years old visited MBAs between August 2015 (when MBAs became operational) and March 2016 (Save the Children, 2016a-c). In addition, SC undertook advocacy and training sessions for humanitarian and non-humanitarian actors on the importance of IYCF-E and the need for careful, targeted distribution of BMS.
Context and challenges of the IYCF-E interventions
An SC IYCF-E assessment undertaken in February 2016 in Greece revealed that individuals from many different countries were involved in this migration. Among those assessed, women from Syria were less likely to breastfeed compared to those from other countries, such as Afghanistan or Iraq (Prudhon, 2016). The multitude of different feeding practices across many refugee nationalities was a challenge for IYCF counsellors. Some mothers, particularly those from Syria, had never breastfed at all. Other mothers stopped breastfeeding whilst in transit due to the perception that they could no longer produce enough milk. The main reason cited by mothers for cessation was stress, for reasons such as trauma, dehydration, separation from family members, or arduous weather conditions that made breastfeeding outdoors difficult. An emerging theme throughout all country programmes was that ease of access to BMS within camps encouraged women to stop breastfeeding.
Interviewees reported adapting health messages to suit the specific needs and priorities of women in this setting. One breastfeeding counsellor in the Greece programme explained to women the practical benefits of breastfeeding in a way that appealed to them; for example avoiding carrying heavy tins of infant formula and avoiding lost time on the road searching for baby food. Women who had previously breastfed were generally receptive to the concept of relactation counselling, but usually time was lacking to action this in fast-transit countries like Croatia or Serbia.
Breastmilk substitutes (BMS)
Current global operational guidance on IYCF-E (IFE Core Group, 2007) and interim guidance issued for the feeding support of infants and young children in transit during the Europe migrant crisis (UNICEF et al, 2015) recommend no untargeted distribution of BMS, bottles and teats. However, many responders (often volunteers unfamiliar with the humanitarian response) were unaware of these recommendations. This led to large-scale distributions of infant formula within all of the country programmes and challenges with multisector coordination around this. A recurring challenge with the use of powdered infant formula distribution was foreign-language labelling. As a result, mothers were unsure if the infant formula was culturally appropriate (e.g. halal) and were uncertain how to dilute the formula correctly.
To minimise hygiene risks, ready-to-use infant formula (RUIF) was identified by staff as the preferred product for mothers unable or unwilling to breastfeed. However, interviewees reported that RUIF was not available in the early stages of the emergency response. This compromised messaging to organisations to avoid distribution of powdered formula when no better alternative was available. Also, it was not known how long the migration period would last, which made estimating RUIF needs very difficult.
Interviews revealed the lack of a coordinated response on complementary feeding. Refugees received food from volunteers or NGOs for infants under two years of age in camps and transit locations; however most of these independent distributions were undertaken without the use of selection criteria. Interviewees reported the dissatisfaction of caregivers with the unaccustomed complementary foods provided. Interviewees across the different countries reported that coordination between agencies on complementary feeding was absent.
Water, sanitation and hygiene
There was general agreement among interviewees that feeding bottles used by mothers and caregivers were below minimum hygiene standards in all countries. There was a lack of facilities to clean bottles, both on the road and in transit camps, in all three countries. Most IYCF-E staff explained to caregivers how to initiate cup feeding if the concept was new to them; however interviewees reported that many caregivers did not feel that they had the time required to cup feed if they had to move on quickly. Exchanging new bottles for old was not mentioned by staff in the interviews.
The most difficult aspect of this humanitarian intervention cited by interviewees was a lack of contact time with mothers, further complicated by unknown refugee arrivals and departures. Insufficient availability of interpreters, especially females in a gender-sensitive sector such as IYCF, was also a challenge. Referral systems with the child protection group were in place, as well as coopration to send ill children to medical NGOs. However, there was a lack of coordination by nutrition agencies with water, sanitation and hygiene (WASH) sector staff from other organisations; a critical gap given the hygiene issues around feeding.
In a refugee crisis such as this, UNHCR implements the Refugee Coordination Model (RCM) to coordinate the response for all actors from UN and non-UN agencies (UNHCR, 2016). However, feedback suggests a lack of global coordination in this emergency, particularly in the handling of donations of BMS at the beginning of the crisis. The unpredictability of the movements and numbers of refugees seems to have been an important constraint on creating an efficient coordination system. However, interviewees did report that, regarding IYCF, coordination became much better with time; for example, after an IYCF working group was established in January 2016 in Greece by SC, and subsequently in Croatia and Serbia, with ongoing advice and support from UNHCR.
Conclusions and recommendations
The fluctuating presence of volunteer associations and the high turnover of staff from other organisations meant that maintaining IYCF awareness in all three country programmes was a challenge. Establishing an IYCF working group earlier on in the crisis and improving coordination and communication to uphold best practice might have helped prevent some of the issues around BMS management and enabled a much stronger, sensitive response regarding complementary feeding.
In a context such as this (bottle feeding, rapid transit, low contact time), it may be more realistic to make clean bottles readily available for mothers who are unwilling or unable to breastfeed, rather than relying solely on the promotion of cup feeding, which mothers were reluctant to uptake. The lack of sanitation facilities greatly compromised feeding with infant formula; the health impact of feeding infants with unhygienic bottles in this setting is unknown. Establishing advance procurement agreements with international RUIF suppliers may help organisations cope more quickly with a first wave of supplies in this kind of response.
With varying nationalities came multiple languages and cultural backgrounds. Leaflets and flyers with pictures were often available to assist in introducing important messages. A short training for key aid workers to learn essential phrases in different languages could facilitate better relationships with anxious mothers and lead to better uptake of positive health messages.
The response would have benefited from an earlier regional IYCF-E assessment to aid the coordination of refugees migrating between countries. Country assessments were undertaken in Greece and Croatia in June to July 2015; however no regional assessment was undertaken. An early cross-country tracking system for vulnerable beneficiaries could have helped cooperating partners in onward transit locations to follow up on support. Taking advantage of the high use of mobile phones among the refugee population might be an area to explore further for this purpose.
For more information, contact: Alexandra.email@example.com
1A 32-item checklist for interviews and focus groups originally published by Tong A, Sainsbury A and Craig J in Int J Qual Health Care. 2007 Dec;19(6):349-57.
Prudhon, C. Assessment of infant and young child feeding practices among refugees on Lesvos Island, Greece. London, UK: Save the Children; 2016.
IFE Core Group (2017). Operational guidance on infant and young child feeding in emergencies, v 2.1.
Save the Children. Multi-sector needs assessment of migrants and refugees in Greece. Athens, Lesvos, Chios, Kos July 5-18 2015. London, UK: Save the Children 2015.
UNICEF, UNHCR, Save the Children, ENN and reviewers (2015). Interim operational considerations for the feeding support of infants and young children under 2 years of age in refugee and migrant transit settings in Europe.
Save the Children (2016a). Situation Report Serbia March 2016. London, UK: Save the Children, 2016.
Save the Children (2016b). Situation Report Croatia March 2016. London, UK: Save the Children, 2016.
Save the Children (2016c). Situation Report Greece March 2016. London, UK: Save the Children, 2016.
UNHCR (2016) United Nations High Commissioner for Refugees. Refugee Coordination Model (RCM). Geneva, Switzerland: United Nations High Commissioner for Refugees; 2016.
UNHCR (2015) Infant and young child feeding practices Standard Operating Procedures for the Handling of Breastmilk Substitutes (BMS) in Refugee Situations for children 0-23 months, August 2015 (version 1.1).
WHO (2004) Guiding principles for feeding infants and young children during emergencies.
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Reference this page
Alexandra Svoboda (2017). Retrospective qualitative analysis of an infant and young child feeding intervention among refugees in Europe. Field Exchange 55, July 2017. p85. www.ennonline.net/fex/55/ifyerefugeeseurope