Infant Feeding in Emergencies: Experiences from Indonesia and Lebanon

By Ali Maclaine and Mary Corbett

Ali Maclaine has a MSc in Human Nutrition from the London School of Hygiene and Tropical Medicine. She has been involved in infant feeding and International Code issues since the mid 1990s. As well as consultancy work, she is a lactation counsellor.

Ali would like to thank all individuals and agencies in Lebanon that provided information but especially ACF and the Lebanese Association for Early Childhood Development for their help and support.

Mary Corbett is an independent food security and nutrition consultant working on short contracts with NGOs, UN agencies and donors in Africa and Asia mainly. She has been involved in IFE issues since the nineties, including development of IFE Core Group training materials (Module 2).

Mary extends thanks to the Save the Children team in Jakarta and Yogyakarta Province and to UNICEF for sharing their initial survey findings.

Women washing utensils by the well in an earthquake destroyed village

On the 27th May 2006 a strong earthquake had a devastating impact on two provinces on Java Island in Indonesia killing 5,778 people. Major infrastructural damage left 3.2 million people affected. One third of them had their homes completely destroyed¹. Water and sanitation structures were particularly heavily affected. The deterioration in living conditions and in the general environment posed a considerable threat to the population, in particular for infants and young children.

On 12th July 2006, a major military offensive started between Hizbollah combatants and Israeli troops resulting in heavy bombing of southern Beirut and towns in East and South Lebanon, followed by an Israeli ground assault. During the conflict up to 900,000 people were internally displaced (IDP)² - a quarter of the population - fleeing further north to shelter in schools or in the homes of relatives or friends. A ceasefire was declared on 14th August and most of the IDPs immediately returned to their home areas. However, over 30,000 houses had been completely or partially destroyed so that many returnees had to live in the ruins of their houses, stay with friends/relatives, or rent rooms. In the affected villages, there was a lack of water (quantity and quality), poor sanitation (the sewerage system had been destroyed and there was uncollected rubbish), no electricity, lack of cooking gas and cooking facilities.

SC UK and IFE

Save the Children (SC) has played a significant role in infant feeding since the mid-1990s, as an establishing member of the Interagency Group on Breastfeeding Monitoring that conducted research³ on compliance to the International Code of the Marketing of Breastmilk Substitutes (see box), and more recently in Code advocacy work. Field research⁴ to assess the impact of the humanitarian intervention on infant feeding during the 1999 Kosovo Crisis by SC UK and the Institute of Child Health (London) was a key influence in the development of the Operational Guidance on Infant and Young Child Feeding in Emergencies⁵ (Ops Guidance) first produced in 2001.

Due to SC's interest, expertise and knowledge of the issues involved, following the crises in Indonesia and Lebanon, a consultant was sent to each country to monitor compliance with the Code and to develop programmes to ensure that the best infant feeding practices were being followed. Mary Corbett visited Indonesia and Ali Maclaine visited Lebanon.

The feeding practice context

Pre-crisis infant feeding practices in both contexts were less than ideal⁶. In Java, exclusive breastfeeding rates were low, with only 5% of mothers exclusively breastfeeding by five months⁷. Local sources described introduction of complementary foods, in particular commercial porridge, as early as two months of age, often under pressure from grandmothers. However, many Indonesian mothers did continue to breastfeed their young children until two years of age. In general, mothers reported that they did not use formula milks as they were too expensive, but did if their financial means improved.

In Lebanon, national pre-crisis figures estimated that 27% of mothers exclusively breastfed for 4 months⁸, however any regional variations were hard to establish. In a SC Alliance assessment involving 20 mothers, 42.6% of mothers reported that their older infants had been exclusively or predominantly⁹ breastfed. (A more indepth assessment was not possible due to security and access constraints). An Action Contre La Faim (ACF) assessment determined that 52% of infants <6 months were exclusively breastfed pre-crisis. These figures are hard to interpret due to variation in how indicators were measured, different sample sizes and potential recall bias amongst mothers, as well as possible regional versus national differences. Probably more telling, local sources described how mixed feeding (breastfeed and formula milk) was increasingly common particularly amongst young mothers either from birth or after a couple of months, but most continued to breastfeed for a year or more. The perceived 'ease' of bottle-feeding, the 'glamour' attached to it, the resultant 'fatter' babies and encouraging advice from health care staff were the reasons given for opting for infant formula feeding. Feeding bottles were commonly used to feed infant formula, water and diluted complementary porridges. Bottles were preferred to cups well into childhood. Bottled water was used for formula milk preparation, which carries risks due to the high solute levels (especially sodium), in some bottled waters.

Violations of the Code and Ops Guidance

During the early humanitarian response in Indonesia and Lebanon, relief goods flooded the affected area including potable bottled water, and food aid including infant formulas and commercial infant complementary foods. In Java, all types of milk formulas for different age groups, commercial porridges, soft drinks for older children, and snack foods were received in the aid response. Villagers did not always know where these gifts came from. Sources identified by community leaders and health workers in Java included private donations from well wishers and adjacent communities, and donations from organisations, institutions, and companies. Some infant foods were channelled through the Ministry of Health (MoH) at district and provincial levels and delivered to the communities through the community health workers and midwives. Numerous violations of the Code were documented by UNICEF that included violations by manufacturers, foreign governments and international NGOs (see box 1).

In Lebanon, field visits also identified many violations of the Code and violations¹⁰ of the Ops Guidance (see also box 1). Contrary to the Ops Guidance, there was distribution of commercial baby foods, distribution of bottles and teats by local and international NGOs, and distribution of dried milk powder without pre-mixing. Of serious concern were instances where mothers were being provided with the wrong type of formula for the age of her infant (see case study 2).

Failure to undertake certain support activities also constitute violations of the Code and Ops Guidance. For example, in Lebanon, local and international NGOs that distributed infant formula did not undertake training on safe preparation of formula, home follow up, and regular monitoring of infant weights, as required under Article 6.5 of the Code and the Ops Guidance 6.2.3. There were no systems or programmes designed to protect, promote and support breastfeeding (Violation 1994 and Ops Guidance 5.2.3) and infant formula was distributed without an undertaking that the supplies would continue for as long as the infant concerned needed it (Violation Article 6.7 and Ops Guidance 6.3.5)

None of the NGO staff questioned were aware of the Ops Guidance and only one was aware of the Code. None of the international staff questioned were aware if their organisation had a policy on infant feeding in emergencies or what that policy was.

Impact

In Lebanon, a rapid (purposive) survey of 20 mothers by the SC Alliance found that the conflict had negatively affected breastfeeding practices: five mothers stopped breastfeeding completely, and eight mothers started mixed feeding and/or reduced breastfeeding. The main reasons given for the change were stress and lack of quality food reducing their breastmilk. Other reasons included being too busy, recommendations from medical staff when on medication for stress, embarrassment of breastfeeding in public and refusal of the infant. This trend of a change in feeding habits was confirmed by other mothers, interviews with doctors, clinic nurses, pharmacies (exclusive sale of infant formula) and findings from other NGOs. While mothers did not articulate the lack of breastfeeding promotion or the increased availability of formula as a reason to stop lactating, the authors feel that this was another significant factor. In Indonesia, due to the lack of control of distribution of breastmilk substitute products in Java, rapid assessments were indicating that some mothers were converting to formula feeding post-earthquake¹².

Box 1 Violations of the Code and Ops Guidance in Indonesia and Lebanon

A box of donated 'baby' foods that a village woman had received in Java

By companies:

• In Yogyakarta Province, Java donations had been received by the Provincial Health Office directly from the manufacturer (a total of 30 cartons, with 12 cans per carton). (Violation Code Article 5.2).

By foreign governments:

• In Java, a foreign government donated six cartons (12 tins per carton) of formula for 6-12 month olds, labelled only in a foreign language (Violation Code Article 9.2 and Ops Guidance 6.3.6. Also possible violation of 9.4 although not possible to ascertain at the time as label in a foreign language).
• In Java, as of 15th June, the Bantul emergency co-ordinator had received donations from local companies, private organisations and other regional provinces: - 265 cartons and 1,567 packs of infant formula - 945 boxes, 260 bottles, 180 cartons and 1240 cans of powdered milk
• Foreign governments donated formula to the Lebanese government's aid organisation the Higher Relief Commission (HRC) that was not in Arabic. (Violation Code Article 9.2 and Ops Guidance 6.3.6).

Example 2. The labels are in English and/or Greek, not Arabic.

By NGOs:

• In the sub-district Jedis in Bantul, Indonesia, an international NGO distributed 7,200 boxes each of porridge, biscuits and formula through the local health cadres. (Violation Code WHA 47.5(1994) and Violation Ops Guidance 6.2.1 and 6.2.3)
• In Pundong sub-district, Indonesia, boxes of food supplies including infant formula for 0-6 months were widely distributed to communities, even families with no young children (as part of the general ration). (Violation Code Article 6.6 and Violation Ops Guidance 6.2.1 and 6.2.3)
• In Jedis, infant formula was distributed as incentive/reward for partaking in a measles & tetanus vaccination campaign¹¹. (Violation Code Article 6.2).
• In Lebanon, one INGO distributed 1500 'baby kits' including formula and bottles to hospitals, municipalities (local councils) and directly to IDP households. Postconflict, the same INGO gave each village muncipality 'village kits' containing infant formula (25 boxes x 24 cans) and baby food (80 units) amongst other items (Violation Code Article 6.1 and Violation Ops Guidance 6.4.1 and 6.4.3)
• Formula distributed by one local NGO vio lated the labeling requirements of the Code in that they idealised the BMS and did not mention the use of the advice of a health worker (see picture example 1). (Violation Code Article 9.2 and Ops Guidance 6.3.6).
• Many health workers distributed single tins or samples of formula milk to mothers. (Violation Code Article 7.7).
• Tins of formula milk donated and imported by NGOs were in a foreign language (see picture example 2). (Violation Code Article 9.2 and Ops Guidance 6.3.6).

Major issues

The under two year old population group is at highest risk of malnutrition, morbidity and mortality and their vulnerability increases dramatically in a disaster affected environment. However during an emergency, they become a silent and often invisible minority, particularly small infants who are kept indoors and may be rarely seen. This group is rarely assessed in early needs assessment which we consider a major oversight within the emergency humanitarian sector.

Infant feeding practices must be addressed at the earliest possible stages of an emergency to promote and support appropriate practices in often very difficult circumstances. Acting to prevent violations of the Code will help achieve this. Decisions to intervene should not depend on first seeing rises in acute malnutrition or be postponed until everything has 'settled down'.

A co-ordinated response to IFE is essential. In both Indonesia and Lebanon, UNICEF was the designated co-ordinating agency on IFE, within the UN interagency standing committee (IASC) cluster approach to humanitarian response. In Indonesia, UNICEF's leadership immediately after the earthquake was significantly stronger than their leadership in Lebanon and this made a considerable difference to how IFE issues were managed on the ground.

As an agency, these experiences have highlighted to Save the Children that we need to work to improve awareness and capacity internally within our own organisation. Within the SC Alliance there was initially a resistance to even look at infant feeding issues in Lebanon and Indonesia. It then took much work by the SC nutrition advisors to convince programme staff of the need to address infant feeding issues in the initial weeks.

In both crises, there were any number of ways in which BMS and other items were distributed and the Code violated. The increasing trend for INGOs to work with national partners creates the potential for the INGO to distance itself from direct accountability for its actions. However, we would argue that accountability for violations of the Code, whether manifesting from financial contributions or donations of goods, must reside both with the donor agency and the implementing agency.

Monitoring for Code violations in the field by both consultants positively helped to raise the profile of IFE in the field. Documenting violations has raised the issue of how we, as an agency, should constructively deal with the Code violations we have observed by donors, governments, and NGOs, in order to promote agency and sectoral learning and to prevent violations in future emergencies.

Recommendations

UNICEF, as the IASC nutrition cluster lead, needs to take the lead on the ground in supporting infant and young child feeding best practices, monitoring adherence to the Code, supporting implementation of the Ops Guidance and building the capacity of their field emergency staff in emergencies. If UNICEF cannot take on these responsibilities in a given emergency, then they should relinquish these early in a crisis to another agency that can.

Humanitarian agencies involved in health and nutrition in emergencies should assess infant feeding practices in the initial phase of an emergency and develop appropriate programmes around identified needs. Linked with this, there is a need for a standardised assessment tool for IFE for different stakeholders e.g. mothers, health workers, NGOs, local authorities.

An advocacy and awareness campaign on the Code and the Ops Guidance is required for NGOs, particularly those who tend to be on the ground early during emergencies. The Code and Ops Guidance should be part of the orientation package for operational, logistic and technical staff that could, for example, be presented as an extension of the IFE component of the Sphere standards.

Donor NGOs (whether funding or donating BMS) must maintain their responsibilities and moral obligations to ensure that the Code and Ops Guidance are followed by their partner organisations.

The IFE training modules developed by the IFE Core Group should include an extra section on IFE adapted to developed countries or in cases where the majority of infants are formula or bottle fed pre-crisis. It should include an explanation about why infant feeding issues and the promotion of breastfeeding is essential in an emergency situation rather than waiting for the development phase of the programming.

Humanitarian agencies and NGOs need to develop or endorse a policy on infant feeding in emergencies (Key point 2 Ops Guidance). When partnering with national or community-based organisations, agencies should advocate for and monitor adherence to the Code and Ops Guidance.

SC will commit to addressing internal communication/ advocacy and work towards improving how we, as an agency, respond to support IFE. It is only by mainstreaming infant and young child nutrition in government and humanitarian agencies' responses that we can hope to offer best practices to this very vulnerable group during emergencies.

For further information, contact: Frances Mason, Nutrition Advisor, SC UK, email: F.Mason@savethechildren.org.uk

Case Study 2

Lebanon: This baby pictured is two and a half months old. After birth, her mother breastfed her for 10 days but then gave up due to lack of breastmilk, so she was already only formula feeding before the conflict. While she was in an IDP school, she was given (by a local NGO) a tin of Fabimilk 2 (she should have been given 1 as the child was too young for 2) - as she read the tin she didn't give it to her baby. The tin also only had a month to go before it expired. She was also donated a bottle and normal powdered milk.

The baby had had diarrhoea in the past 7 days and was unwell.

Case Study 3

Lebanon: Fatima Balhass is a 29 year old mother of 6 children. Married at 14 years she has lived in Saddiqine her whole life. She exclusively breastfed all of her previous five children for 5 months. However, her latest boy Abed Al Hussein (pictured), now 3 months old, was born just before the conflict started on 12th July 2006. They fled to Saida and stayed in an IDP camp in a school run by the Hariri foundation. She found that when she put her boy to her breast her milk had suddenly stopped. She did not know what to do, or who to get advice from, about breastfeeding. By chance, hidden amongst other items she had brought, she found the tin of formula given to her as a present by the hospital when the baby was born so she used that initially as well as other formula that was donated in the school. However, the baby became sick with diarrhoea and vomiting and so she had to buy special formula for him. She has not breastfed since. Since the end of the conflict she returned back to Saddiqine only to find her house destroyed, so she is now renting in a nearby village. She buys water and has a little gas to sterilise the feeding bottle. The baby is often sick. She says that she liked breastfeeding and would like to start again but did not know that this was possible, never mind how to do it.

¹CRED Crunch, CRED Brussels, October 2006

²Lebanon Crisis 2006. Interim Report. Humanitarian Response in Lebanon. 12 July to 30 Aug 2006. United Nations

³Detailed in the report, Cracking the Code

⁴Meeting the nutritional needs of infants during emergencies: recent experiences & dilemmas. Report of an International Workshop, Institute of Child Health, London, November 1999. http://www.ennonline.net/docs/IFEWorkshopReport1999.pdf

⁵Operational Guidance for Emergency Relief Staff and Programme Managers on Infant and Young Child Feeding in Emergencies, Version 2.0. IFE Core Group, May 2006. Available online at www.ennonline.net and in print from ENN.

⁶WHO guidelines recommend exclusive breastfeeding (where an infant receives breastmilk and essential medicines only) for six months, with introduction of appropriate complementary foods at six months of age and continued breastfeeding for two years and beyond.

⁷National Health and Nutrition Surveillance System (NSS), Helen Keller International and Ministry of Indonesia, 2002

⁸The State of the World's Children 2006 - Excluded and Invisible. UNICEF.

⁹Predominant breastfeeding is where an infant receives only breastmilk and water-based fluids. Exclusive breastfeeding is where an infant receives only breastmilk and essential medicines.

¹⁰The term 'violation' of the Ops Guidance was used by the assessment team in this context to demonstrate failure to adhere to or implement the recommendations.

¹¹Situation update. Infant and Young Chid feeding in Yogyakarta and Central Java, June 2006, UNICEF.

¹²Breastfeeding Assessment Report, Java - Indonesia - June 2006, ACF