Infant feeding in the South Asia earthquake aftermath

By Maaike Arts

Maaike Arts was seconded to UNICEF Pakistan in November 2005, until January 2006. Formerly she was Project Officer in Nutrition/Early Childhood Care with UNICEF Vietnam. This article is written as a personal account and does not necessarily reflect the position of UNICEF.

The author would like to acknowledge the work of the MOH Pakistan, UNICEF Pakistan, national staff and local and international NGOs and UN agencies that have contributed to the experiences outlined here.

Maaike Arts was seconded to UNICEF Pakistan in November 2005, until January 2006. Formerly she was Project Officer in Nutrition/Early Childhood Care with UNICEF Vietnam. This article is written as a personal account and does not necessarily reflect the position of UNICEF.

This article describes the infant feeding situation and the initial interventions to protect, promote and support appropriate infant feeding practices during the relief efforts in Pakistan following the 8 October 2005 earthquake.

On 8 October 2005, Pakistan's North West Frontier Province and Pakistan administered Kashmir were struck by an earthquake measuring 7.6 on the Richter scale. More than 70,000 people were killed, a similar number injured, and about three million people left homeless¹.

Old University camp Muz

The WFP and UNICEF carried out a rapid assessment of the food and nutrition situation in 700 households at the end of October². The assessment found that a total of 20 per cent of children under two years of age were no longer breastfeeding, 2 per cent because their mothers had passed away and 18 per cent because their mothers had stopped breastfeeding. The reasons given for ceasing breastfeeding were sickness of the mother and insufficient breastmilk.

From the rapid assessment and feedback of Ministry of Health (MOH) staff, non-governmental organisations (NGOs) and international organisations, it became clear that in the area of infant feeding, three issues required attention: support for breastfeeding, feeding of orphans and dealing with donations of inappropriate milk products.

Mother with her four month old infant in IDP camp Jalabad Park,Muzaffarabad. This mother was told that if she breastfed while she was nervous or upset, it would affect her child.

Support for breastfeeding

Compared to many countries, Pakistan has a strong breastfeeding culture. The National Nutrition Survey 2001-2002 found that 96.3 per cent of one month old infants were breastfed. Exclusive breastfeeding rates, however, were not optimal, with rates of 52.2 per cent at four months and 50 per cent at six months. Among children older than 13 months, 60.7 per cent were still breastfed.

The rapid assessment showed how the emergency situation had created a number of challenges for breastfeeding. It was apparent that there were many misunderstandings about breastfeeding, like "once breastfeeding is stopped, it can not be re-established", and "tired and malnourished mothers cannot breastfeed", and the perception that some women do not produce enough milk and that nothing can be done to improve the situation. I also heard "if you breastfeed when you are nervous or upset, you pass this on to the baby".

Another potentially damaging myth is "all women breastfeed", which I heard some health workers say. In other words there is a ubiquitous assumption that all mothers breastfeed and that breastfeeding does not require effort to be maintained. This was also apparent from the fact that few interventions to protect, promote and support breastfeeding were undertaken in the initial period after the earthquake.

The mother of this seven month old said that he stopped breastfeeding after the earthquake as he 'did not feel well'.

Gender segregation is very strong in Pakistan, often even within the household and the extended family. After the earthquake, women frequently shared a shelter with more distant male relatives or even non-related males. It was reported that many women felt uncomfortable to breastfeed in these circumstances.

Feeding of orphans

Field visits and reports indicated when a young infant had lost its mother, a female relative was sought to wet nurse the baby. When no female relative was available, the infant would often be fed inappropriate Breast Milk Substitutes (BMS), like diluted cow's milk and rice water. It became clear that many health workers and relief organisations lacked both the experience to deal with this situation or a budget for the procurement of suitable BMS.

Bottled water for sale in Mansehra town

It appeared that while international and local criteria and guidelines for the use and procurement of suitable BMS exist (see the information on the Director General Health's letter below), they were not well known. It also seemed that relief organisations were hesitant to enter into the procurement of BMS for fear of stoking up controversy.

Donations of inappropriate milk products

In Pakistan, milk is traditionally used for example in 'milk tea' (black tea with milk). Many national and international NGOs and local charities included either liquid or powdered whole milk in their food aid basket, or had received donations from individuals or companies. These milk products were passed out to all families and little attention or consideration was paid to the potential use of these milks for infants who could otherwise be breastfed.

There were anecdotal reports of small scale donations of BMS, mostly by individuals, and it was observed that some relief groups included BMS in their medical supplies. These groups did not provide counselling on either breastfeeding or relactation or on the proper use of BMS.

Interventions

Breastfeeding

Immediately after the earthquake, UNICEF distributed posters and leaflets about the importance of breastfeeding.

On 10 November, the Director General of Health issued Guidelines for 'Promoting and Protecting Infant and Young Child Feeding' and 'Prevention and Control of Watery Diarrhoea' during recent Earthquake Response and Other Emergencies in Pakistan. The guidelines were addressed to all Government officials and MOH staff in the affected areas, NGOs and international organisations and provided an important framework for all interventions.

At the end of November, the Nutrition Wing of the MOH convened a two-day workshop with national nutrition and infant feeding experts and relevant international organisations. The aim of the workshop was to agree on the additional or refresher training required for different categories of health workers in the area of nutrition in general and infant feeding in particular, and on the establishment of therapeutic feeding centres. The Infant Feeding in Emergencies (IFE) training modules were used as resource materials and reviewed as potential briefing and training documents (see box). The modules were found very useful. For the Pakistan situation, some parts could be taken out because they were already covered in the breastfeeding counselling and lactation management manuals developed in Pakistan. Module 1, in particular, was found useful since most issues were not covered in the existing materials. To improve the cultural appropriateness, it was necessary to replace pictures of African subjects with pictures from Pakistan (see slide examples in postscript).

The outcome of the workshop was a list of trainees on nutrition and infant feeding (Lady Health Workers, Community Health Workers and medical staff of First Level Care Facilities) and a list of topics and related training materials for refresher/additional training. It was agreed that camp managers would only need to receive an orientation on nutrition and infant feeding in emergencies. The protocol and training plan for therapeutic feeding centres were also agreed upon.

To overcome the problems related to a lack of privacy and support, the concept of 'mothers corners' was created and promoted. These were separate tents where women can meet to breastfeed, provide mutual support and exchange information and receive support and information from a Lady Health Worker or other community health worker. It was suggested that these corners could be combined with the child protection corners, which were already established in some IDP camps and were intended only for (vulnerable) children and their female caregivers.

Orphans

It was agreed that an inventory of the actual number of maternal orphans and their feeding practices needed to be undertaken so that the situation can be understood fully and appropriate measures taken.

Donations of inappropriate milk products

The MOH Guidelines distributed in November provided all guidance necessary (i.e. breastmilk substitutes or powdered milks should never be part of a general distribution, act to prevent donations of BMS and powdered milks, the limited amounts of BMS required should be purchased locally). It proved necessary to carry out more information, education and communication activities on this issue.

Reflection

The infant feeding activities in the context of the emergency were facilitated by the commitment of the MOH, the existence of legislation on the marketing of breastmilk substitutes in Pakistan, the presence of a group of highly qualified national infant feeding experts, and the fact that breastfeeding counselling and promotion are integrated into the work of community health workers. This created a solid basis on which the emergency interventions could be built.

A mother and child cooking in the camp

Interagency coordination and sharing of information was facilitated through the Food and Nutrition Clusters, which were established in Islamabad as well as in Bagh, Muzaffarabad and Battagram and co-chaired by WFP and UNICEF. These were attended by international NGOs, local NGOs, the Pakistan army and also MoH. In practice, participation varied a lot - some organisations had field staff with no time to attend meetings, while others always made an effort to be present. Outside Islamabad, attendance was often low and limited to groups who distribute food aid. The discussions at these meetings mostly revolved around distribution of food aid and related operational challenges. Issues around infant feeding were considered to only be of interest to specialists and not a subject for more mainstream nutrition programming.

The lack of awareness of internationally agreed guidelines in this area, including the Operational Guidelines on infant and young child feeding in emergencies, among many actors in the earthquake relief operation, created a substantial challenge for the protection, promotion and support of optimal infant feeding practices in this emergency.

View the postscript that this article relates to

¹United Nations Information Centre, Weekly Newsletter No. 5/2006 (31 January 2006)

²Joint WFP/UNICEF Emergency Food Security and Nutrition assessment (with the support of Oxfam), October 2005