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Barriers to infant feeding in emergencies programming in middle and high-income countries

By Mija Ververs and Cindy Hwang

Mija Ververs is a Senior Associate for the Center for Humanitarian Health at Johns Hopkins Bloomberg School of Public Health in Baltimore, USA. She has over 35 years of experience with over 15 organisations across 25 countries in nutrition, public health, food security and livelihoods programming.

Cindy Hwang is a registered dietitian who studied at the Johns Hopkins Bloomberg School of Public Health and obtained a Masters of Science in Public Health. She began her professional career as a clinical dietitian at the Johns Hopkins Hospital in Baltimore earlier this year.

The authors would like to acknowledge the following IFE Core Group members for their participation in the interviews and for their time and insight: Christine Fernandes, Karleen Gribble, Michelle Branco, Aunchalee Palmquist, Maaike Aarts, Isabelle Modigell, Suzanne Brinkmann, Sarah Butler, Alessandro Iellamo, Andi Kendle, Zita Weise Prinzo, Marie McGrath, Julie Tanaka and Colleen Emary.

Location: Middle- and high-income countries (MICs/HICs)

What we know: In every emergency it is necessary to assess and act to protect and support the nutrition needs and care of all infants and young children.

What this article adds: Interviews were conducted with 14 global experts with experience of working on infant feeding in emergencies (IFE) in recent disasters in MICs and HICs to identify barriers to effective IFE programming. Findings demonstrate a lack of understanding among disaster responders and healthcare professionals of the impact of disasters on infant feeding patterns and risk profiles of infants dependent on breast milk substitutes (BMS), the vulnerability of infants, and the nature of and need for supportive infant feeding interventions to manage new risks. Lack of experience and training among disaster responders and perceptions that IFE is a food rather than a health issue were common findings. Global guidelines on IFE are considered ‘inapplicable’ in MICs/HICs; maternal choice in infant feeding decisions carries great weight, with little consideration of public health and resource implications. Advocacy and preparedness action is urgently needed among disaster responders, healthcare professionals and decision-makers in MICs/HICs on context-specific IFE programming.

Introduction

The IFE Core Group document Operational Guidance on Infant and Young Child Feeding in Emergencies provides concise guidance on how to ensure appropriate infant and young child feeding in emergencies for all children under two years of age (IFE Core Group, 2017). While attention often centres on low-income contexts, experiences from recent disasters in middle- and high-income countries (MICs/HICs) have demonstrated considerable challenges related to infant feeding practices and response. Publications in 2017 and 2018 alone show that problems in infant feeding in emergencies (IFE) have been encountered in Canada (DeYoung et al, 2018), Iraq (Haidar et al, 2017; Ververs et al, 2018), Lebanon (Akik et al, 2017; Shaker-Berbari et al, 2018), Pakistan (Maheen and Hoban, 2017), Puerto Rico (Santaballa, 2018), Ukraine (Summers and Bilukha, 2018) and the migrant crises in Europe (Svoboda, 2017). This study aimed to describe the internal and external barriers that humanitarian organisations and government agencies faced in addressing infant feeding problems during emergencies in MICs/HICs as perceived by various members of the IFE Core Group.1

Methodology

Between November 2017 and March 2019, key informants (KIs) were selected based on their active membership in the IFE Core Group, experience working in IFE programming and active engagement on IFE in MICs/HICs in the past five years. Semi-structured interviews were held, during which the KIs were asked to describe barriers within their own organisations and other organisations and government agencies when addressing IFE in MICs/HICs. Notes were taken during the interview; colour-coded, analysed and categorised by theme. Informed consent was sought through a verbal consent process prior to the KI interview. The data was de-identified to assure privacy of the participants.

Results

Fourteen key informant interviews were conducted. At the time of the interviews, the KIs worked for non-governmental organisations (NGOs) (8), United Nations (UN) agencies (3), in academia (2), or as an independent consultant (1). Interviews lasted on average between 30 to 60 minutes. Table 1 illustrates the main barriers related to infant feeding in disasters in MICs/HICs that emerged, described in more detail below.

Table 1. Barriers to optimal IFE in disasters in middle- and high-income countries (MICs/HICs) as expressed by key informants

A. Lack of understanding of a changing risk profile in disaster contexts

All KIs agreed that, in a disaster context, infant feeding patterns change. Some infants who were breastfed before the disaster no longer received breast milk, either because they were separated (temporarily or permanently) from their mothers (due to death, illness, injury or absence), or because mothers believed they were no longer able to breastfeed. Infants dependent on breast milk substitutes (BMS) before the disaster likely remain so during it, but their risk profile changes dramatically. Caregivers providing for BMS-dependent infants may find themselves without electricity, gas, access to safe water and boiling facilities, with few means to hygienically prepare BMS or access necessary infant-feeding supplies. KIs reported that many caregivers in recent crises were preparing BMS in bathrooms of schools, sports facilities and train stations as these were often the only places where water was available. KIs reported a lack of understanding among disaster responders of the changing risk profile of infants during disasters in MICs/HICs and a belief among healthcare professionals that there was no need for specific programmes for their support2 as caregivers already knew how to prepare and use BMS.

B. Lack of awareness that infants are a vulnerable group

KIs stated that disaster responders in MICs/HICs often only recognise “classic” vulnerability groups, such as the elderly, people who are ill or immunocompromised, and people who are institutionalised. They are unaware that infants are also a vulnerable group in disasters, especially with regard to their feeding. Additionally, some KIs stated that decision-makers in disaster response programming were often “middle-aged men” who did not identify infants as specifically vulnerable, which explained the absence of infant-feeding preparedness plans.

C. Infant feeding not seen as lifesaving in disaster settings

KIs stated that infant feeding was not seen as lifesaving by healthcare professionals and others, but as an issue relevant for later stages of emergency response after access to shelter, curative care, water and food had been provided. Many disaster responders did not understand that infants need immediate access to either breast milk or safely prepared BMS and that no other food options are suitable. KIs mentioned that responders often believed survival needs to be more or less the same for every group of people and that, if the prevalence of acute malnutrition was relatively low in the disaster area, a nutrition response was low priority. This sometimes led to tension within organisations that worked on health and nutrition in disasters among individuals who saw no need for an IFE response and others who understood the need.

D. Lack of experience of IFE

KIs indicated that many organisations lacked IFE experience at programme-manager level or above. Many disaster responders and healthcare professionals have limited experience in nutrition or in emergency settings specifically in MICs/HICs. Even if some NGO staff had experience in low-income settings where breastfeeding is the norm, this did not adequately prepare them to deal with more complex IFE issues in contexts where breastfeeding is not the norm. KIs also specified that the emergency response training curricula in MICs/HICs often inadequately address nutrition.

E. Lack of understanding of the response needed for IFE

KIs agreed that there was a lack of understanding on what IFE programming entails and how labour intensive it is, with little understanding of the need for individual infant-feeding assessments and counselling. Disaster responders in MICs/HICs were likely to view the response as a commodity-driven exercise and distribute BMS as they would food; it was reported that sometimes medical staff are paid incentives to prescribe BMS for new mothers. BMS was occasionally included in blanket distributions to all caregivers, which disincentivised breastfeeding mothers. Distributions sometimes only included a one-week supply of BMS, and rarely included water, detergent, brushes and fuel to clean or sterilise feeding bottles and boil water to prepare the BMS safely.

F. Lack of knowledge on risks of BMS use in disasters

KIs reported that, when the need for IFE programming was raised (including individual assessments and counselling prior to blanket distribution of BMS), disaster responders asked for scientific evidence showing the risks of BMS distribution. One KI reported that healthcare professionals wanted to use free distribution of BMS in a conflict-affected MIC as an incentive for other interventions and asked the KI to provide evidence of how distribution of BMS would harm infants, if at all.

G. Perception that global guidelines on infant feeding are not necessarily applicable to MICs/HICs

Many KIs noted that, in MICs/HICs, local disaster responders, including Ministry of Health staff, believed that globally established guidelines and evidence did not necessarily apply to their countries or contexts when affected by disasters. This included guidance established by the World Health Organization; notably the International Code of Marketing of Breast-milk Substitutes (WHO, 1981). This was also seen in countries where paediatricians and other healthcare professionals were part of the incentive-driven distribution system of BMS. Many humanitarian organisations were aware of the guidance and best practices, but were conflicted on how to implement the guidance and consequently did not address IFE out of fear of making mistakes or breaking the rules, leading to inaction.

H. Perception that maternal choice and autonomy supersede increased public health risks

There was a consensus among KIs that when a mother of an infant less than six months of age is absent, ill or deceased in a disaster, BMS and additional resources need to be mobilised and provided. However, organisations were little prepared on how to address situations where mothers expressed that they no longer desired to breastfeed. Many KIs noted that healthcare professionals put great emphasis on maternal choice. Often there was no discussion when a mother decided to stop breastfeeding during a disaster and no information was shared about the risks of BMS. Healthcare professionals felt that the disaster context was not the right context to question the mothers’ decisions, not realising the significant public health consequences – particularly for infants – of this autonomy. Once the choice was made to use BMS, it was rarely discussed or agreed upon which organisation(s) would provide the additional resources needed for the length it was required.

I. Lack of clear indicators to show impact of IFE programming

Several KIs acknowledged that IFE programming lacked clear impact indicators. Some remarked that, unlike community-based management of acute malnutrition (CMAM) programming, IFE programmes were unable to show the number of deaths or diarrhoea episodes averted, or impact on nutrition outcomes.

J. Lack of understanding that infant feeding is not (just) a food issue

KIs expressed concern about how IFE was perceived. They stated that as long as professionals working in sexual and reproductive health, paediatricians and disaster responders perceived IFE as merely a food issue (rather than a public health and child development issue), response in disasters would be inadequate.

Discussion

The analysis of the interviews confirms findings from other recently published articles from MICs/HICs of a lack of understanding among healthcare workers on the risks, challenges and necessary support needed for safe BMS use in emergencies, lack of experience among disaster responders on IFE, and an overall lack of understanding of what constitutes an adequate IFE disaster response (Modigell et al, 2016; Prudhon, 2016). Findings reveal that, at times, a tension exists between IFE experts and co-workers within the same organisation due to differing opinions on IFE programming. There also appears to be a drive within organisations to support maternal choice to use BMS, without factoring in the substantial resource and public health implications for mothers and infants. Findings suggest that, as long as disaster responders continue to regard infant feeding during a disaster as a food issue and not as a significant health concern, IFE programming will remain under-delivered as a necessary intervention to protect infant and child health and nutrition.

Findings of this study demonstrate a significant need for advocacy and awareness-raising on what good (and bad) IFE programming entails within humanitarian organisations and governments, as well as among healthcare professionals and disaster managers in MICs/HICs. Addressing these barriers will ultimately contribute to a reduction in morbidity and mortality among infants in disaster settings.

For more information, please contact Mija Ververs.


Endnotes

1 The IFE Core Group is a global collaboration of agencies and individuals that address policy guidance and training resource gaps hampering programming on infant and young child feeding support in emergencies. www.ennonline.net/ifecoregroup

2Recommendations on the necessary supplies and support to manage artificial feeding in emergencies are outlined in the Operational Guidance on IFE.


References

Akik C, Ghattas H, Filteau S, Knai C. Barriers to breastfeeding in Lebanon: A policy analysis. J Public Health Policy. 2017;38(3):314-326. doi:10.1057/s41271-017-0077-9

DeYoung SE, Chase J, Branco MP, Park B. The Effect of Mass Evacuation on Infant Feeding: The Case of the 2016 Fort McMurray Wildfire. Matern Child Health J. 2018;22(12):1826-1833. doi:10.1007/s10995-018-2585-z

Haidar MK, Farhat J Ben, Saim M, Morton N, Defourny I. Severe malnutrition in infants displaced from Mosul, Iraq. Lancet Glob Heal. 2017;5(12):e1188. doi:10.1016/s2214-109x(17)30417-5

IFE Core Group. Infant and Young Child Feeding in Emergencies: Operational Guidance for Emergency Relief Staff and Programme Managers. Oxford; 2017.

Maheen H, Hoban E. Rural Women’s Experience of Living and Giving Birth in Relief Camps in Pakistan. PLoS Curr. January 2017.

Modigell I, Fernandes C, Gayford M. Save the Children’s IYCF-E Rapid Response in Croatia. Field Exchange. 2016;(56):102.

Prudhon C. Assessment of Infant and Young Child Feeding Practices among Refugees on Lesvos Island, Greece. London; 2016.

Santaballa Mora LM. Challenges of Infant and Child Feeding in Emergencies: The Puerto Rico Experience. Breastfeed Med. 2018;13(8):539-540. doi:10.1089/bfm.2018.0128

Shaker-Berbari L, Ghattas H, Symon AG, Anderson AS. Infant and young child feeding in emergencies: Organisational policies and activities during the refugee crisis in Lebanon. Matern Child Nutr. 2018;14(3). doi:10.1111/mcn.12576

Summers A, Bilukha OO. Suboptimal infant and young child feeding practices among internally displaced persons during conflict in eastern Ukraine. Public Health Nutr. 2018;21(5):917-926. doi:10.1017/S1368980017003421

Svoboda A. Retrospective qualitative analysis of an infant and young child feeding intervention among refugees in Europe. Field Exchange. 2017;(55):85.

Ververs M, McGrath M, Gribble K, Fernandes C, Kerac M, Stewart RC. Infant formula in Iraq: part of the problem and not a simple solution. Lancet Glob Heal. 2018;6(3):e251. doi:10.1016/s2214-109x(18)30038-x

World Health Organization. The International Code of Marketing of Breast-milk Substitutes. Geneva; 1981.

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Mija Ververs and Cindy Hwang (2019). Barriers to infant feeding in emergencies programming in middle and high-income countries. Field Exchange 61, November 2019. p24. www.ennonline.net/fex/61/barrierstoinfantfeeding

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