Breastfeeding support in the refugee camps of North Western Tanzania

By Lucas Kulwa Machibya

Lucas Machibya has been working for UNHCR since June 1994 in the north-western Tanzania refugee operation as National Public Health Nutrition Officer. His scope of work has included the promotion and protection of breastfeeding, infant and young child feeding in the context of HIV/ AIDS and management of both moderately and severely malnourished children in the refugee camps.

The author would like to acknowledge the contributions of the following organisations to the work reflected in this article: Tanzanian Red Cross Society, Norwegian People's Aid, International Rescue, The International Baby Food Action Network (IBFAN) - Africa, UNICEF and WFP Northwestern Tanzania, ENN, CARE International and UNHCR Headquarters.

This article describes UNHCR's experiences of supporting breastfeeding in a refugee camp setting, and how the 'breastfeeding corners' initially established evolved into community based support approach.

A breastfeeding corner in one of the camps in Tanzania

The refugee operation of north-western Tanzania has been ongoing for 12 years. Burundian refugees were displaced by political and ethnic turmoil sparked by the assassination of the Hutu President Melchoir Ndadaye, followed by massacres in 1993, and a coup in 1996. Intensification of the conflict in some provinces and the policy of re-grouping the community in Burundi generated subsequent waves of refugee influx into Tanzania from 1996 to 2004. With regards to the Democratic Republic of Congo (DRC), three main rebel groups and numerous militia began fighting over a complex mix of economic, ethnic, state and factional interests, leading the country into a devastating humanitarian crisis in 1996.

In December 2006, the North Western Tanzania refugee operation was managing a total of 282,389 refugees, from Burundi (154,412) and DRC (127,967). The refugees are located in 11 refugee camps in four districts; Ngara district (Lukole camp), Kibondo district (Mtendeli, Kanembwa, Nduta and Mkugwa camps), Kasulu district (Nyarugusu, Muyovosi, Mtabila I and II) and Kigoma rural district (Lugufu I and II). In June 2006, UNHCR launched a repatriation programme for Burundian refugees, currently implemented in Kasulu, Kibondo and Ngara refugee camps. A repatriation scheme for Congolese refugees in Kigoma rural and Kasulu districts is ongoing. By December 2006, a total of 16,503 Congolese refugees and 41,908 Burundians refugees had been repatriated to their countries of origin.

UNHCR's position on infant and young child feeding UNHCR seeks to protect and support optimal infant and young child feeding practice in its operations, which includes establishing exclusive breastfeeding among newborn infants, protecting and supporting exclusive breastfeeding for the first six months, timely and appropriate complementary feeding, and continued breastfeeding for at least the first 2 years of life. This is reflected in UNHCR's policy on the acceptance, distribution and use of milk products in refugee settings¹, which was updated in 2006 in close collaboration with the IFE Core Group². This article focuses on UNHCR's experiences in protecting and supporting breastfeeding in a refugee setting³.

The camp context

Breastfeeding was considered 'natural' among the Rwandans and Burundian women who gave birth in the refugee camps. However, some mothers of newborn infants were reporting diffi- culties that were heightened during emergency situations, when mothers often presented to the camps devastated and dehydrated (see box 1). Initially, systematic breastfeeding counselling was not carried out as part of the refugee operation. However in 1998, the camps experienced a severe epidemic of malaria, leading to severe anaemia among pregnant women and resulting in a high prevalence of low birth weight infants reaching as high as 35 per 1000 live births. The foetal death rate was estimated at 45.6/1,000 births, neonatal mortality was 29.3/1,000 live births and both neonatal and maternal deaths accounted for 16% of all deaths. This situation highlighted the urgent need for breastfeeding support targeted particularly at newborn infants.

Breastfeeding corners

A programme was established to protect, support and promote breastfeeding of newborn babies in accordance with WHO and other stakeholders⁴. This took the form of 'breastfeeding corners' that were established by humanitarian agencies working in the camps. These comprised rooms/ areas located around the health facilities where breastfeeding women with feeding difficulties could come for support. At these facilities, the women were given breastfeeding assistance, and taught about infant feeding, personal hygiene, and ways to cook for themselves and their families. Babies were monitored to exclude any medical conditions that might affect breastfeeding. Attending women were given one family meal and one cup of porridge that was prepared at the kitchen in the health facilities. By February 2000, all health facilities in the camps in North Western Tanzania had implemented breastfeeding corners.

At the camp reception centres, 'at risk' groups were identified, including breastfeeding mothers who arrived in a poor condition - many presented dehydrated due to walking long distances without water or food. Medical screening was undertaken by humanitarian agencies. Mothers who delivered on the way were immediately registered for the breastfeeding corners, along with prima gravida (first-time mothers) and other women with lactation problems.

At the breastfeeding corners, newly arrived mothers who showed a lack of confidence in breastfeeding were supported through counselling and encouragement (see box 2). The counselling was geared towards restoring lost competencies and building psychological morale. In the camps, prima gravida were the most common group to have low confidence in breastfeeding. As well as breastfeeding support, mothers were advised on the importance of eating adequate food and drinking safe and clean water. They were also encouraged to use the improved cooking stoves, as fuel was not easily available and collecting wood involved walking long distances and was risky. This was conducted in conjunction with the agencies working on the environment, camp management and in community services. Mothers mostly attended the corners for three to four weeks.

Through health screening, babies or women who were ill were identified and treated according to the Ministry of Health case definition and protocol treatment. Most mothers and babies were found to have malaria and related fever; and mothers suffering from tiredness, lost confi- dence and stress. The breastfeeding corners were also used to capture all postnatal women to ensure that they had postnatal checkups, that the infant was vaccinated and to establish growth monitoring. Vitamin A was given to those women who had not received it immediately after delivery. Women with a Body Mass Index (BMI) < 18.5 were admitted to the supplementary feeding programme (SFP). However this was discontinued at the end of 2001 due to a reduction in resources.

Family disintegration is a common problem in emergencies. Women are left with several children to take care of, making it difficult to juggle breastfeeding a baby and look for food for the older children. The value of maintaining good family relationships was emphasised.

Babies whose mothers could not breastfeed

Where an infant could not be breastfed by his/ her mother (based on established criteria), the implementing agencies worked together with the community to identify a "wet nurse" to breastfeed the baby - an approach that was already traditionally practiced. Where a wet nurse could not be identified or in the interim, infant formula or diluted therapeutic milk (F-100) were given to the infants. This necessitated admission of the infant together with his/ her caregiver to phase 1 of a therapeutic feeding programme. Using diluted F100 was not ideal as it was not designed for this purpose and it was a challenge to decide on the most appropriate dilution.

The use of breast milk substitutes in this refugee programme requires close monitoring and a careful procurement system is in place among the health and nutrition agencies in the refugee camps. Within the camps, infant formula is part of the pharmacy items with a small budget line, and is procured in line with drugs and other medical consumables. The nutritionist is responsible for providing the specifications, which includes labelling in the appropriate language (English or Swahili). Careful estimation of the projected quantity is based on various reporting indicators including the rate of maternal deaths, early pregnancies from teenagers, prevention of mother to child transmission of HIV/AIDS to babies, the number of women opting not to exclusively breastfeeding their babies and the capacity of the agency to adhere to acceptable, feasible, affordable, sustainable and safe criteria (AFASS)⁵. In this regard, the National Breastfeeding Policy is also respected and followed accordingly.

Review of the breastfeeding corners

In early 2001, the breastfeeding corner approach at the health facility level was reviewed in consultation with beneficiaries and humanitarian workers involved in the health and nutrition programme, including WFP and UNICEF. The following concerns were raised:

• The majority of lactating women admitted to the breastfeeding corners were having a baby for the first time. This suggested that inadequate advice and support on successful breastfeeding was being offered during pregnancy.
• While the beneficiaries found that the service was beneficial to them, they expressed their concerns about time pressure to attend daily while leaving other small siblings at home without care.
• Staff responsible had inadequate time to spend with mothers to provide the required support and advice they needed.
• There may be enough capacity for support in the community rather than at the health facility to support lactating mothers, especially for those delivering for the first time.
• Increased number of admission to breast feeding corners due to increased early pregnancies meant that staff felt overwhelmed by the situation.
• There was a risk of cross infection while attending daily breastfeeding corners.

To address these, a workshop was called in March 2001, in Kibondo that brought together Medical Coordinators, Medical Doctors, Nutritionists, Reproductive Health Managers / Officers and Community Services Coordinators. The following recommendations were made:

• A strategy to be developed to incorporate support to breastfeeding mothers in the community through mothers support groups and outreach activities.
• UNHCR and IP's medical and nutrition teams to identify specific activities and plans of action to successfully implement a community based approach to support breastfeeding of infants and feeding young children.
• Collaboration to be strengthened between Maternal and Child Health (MCH) services, community services, health information teams, traditional birth attendants (TBAs), nutritionists and medical staff in order to provide holistic support through the cycle of the pregnancy and through the period of continued breastfeeding (i.e. up to 24 months of age).
• UNICEF to provide additional in-service training, including health education and breastfeeding management.
• Given the benefits of the current SFP for pregnant women, WFP were requested to extend supplementary feeding to all lactating women until six months post delivery, but this has yet to happen (see box 3).
• Breastfeeding corners for the majority should not continue at the health facility but should gradually be integrated into the current MCH activities and the community. Only those few mothers with medical problems and low birth weight babies who cannot be managed at home should be admitted to the health facility for breastfeeding management.

A mother breastfeeding her young baby supported in a breastfeeding corner

Community based approach to support breastfeeding

The community based approach that was adopted following the workshop recommendations focused particularly on the protection, support and promotion of exclusive breastfeeding in infants under six months of age. The following steps were followed:

• There was a gradual phasing out of the breastfeeding corners from the health facilities in tandem with training of communitybased workers on infant and young child feeding. Those trained, in turn, trained their colleagues in the community. Collectively considered as 'breastfeeding promoting agents', they included community health workers/health information teams, traditional birth attendants, women representative groups, home based care service providers, traditional healers and religious leaders.
• The breastfeeding promoting agents were key to the community based approach. They advocated and supported exclusive breastfeeding and proper practices during breastfeeding, and appropriate and timely complementary feeding. They also addressed psychological and moral support, including the importance of family unity in relation to breastfeeding and care of the infant and young child in general. They were also assigned various streets/blocks/villages in each camp to assist and support women who were breastfeeding.
• Existing women's income generation groups such as weaving groups, basket making groups, kitchen gardening groups, and restaurants groups along with groups involved in artisan activities were targeted by breastfeeding promoting agents. New mothers were encouraged to join these groups, so that they could benefit both from the income generated and receive breast feeding support.
• Cooking demonstrations were conducted to encourage preservation of nutrients during preparation and cooking. Mothers were taught about food preservation techniques and the importance of kitchen gardening activities that would support and supplement their household food security.
• Related topics included the importance of family hygiene and promotion of good health in the family, how to clothe and bathe the baby, and how to access safe and clean water in the camps for drinking and when preparing and cooking of their family foods. The community based staff also promoted proper disposal of babies/children excreta (in this population, children's excreta were considered safe not harmful) and educated on the importance of family latrines and their proper maintenances and use.

Capacity building

From 2001, both the UN and non-governmental agencies implementing the health and nutrition projects in the refugee camps began coordinating their approaches to infant and young child feeding in emergencies training, based on key training materials (see box 4).

National facilitators from the Tanzania Food and Nutrition Centre in Dar es Salaam are used for training of trainers (TOTs). The use of national facilitators is crucial because it ensures that new developments are recognised by the government in the sphere of infant and young child feeding, including breastfeeding. The local trainers continue to train on the ground. They collaborate and agree on a common work plan to follow when rolling out training in their MCH centres, outpatient departments, inpatient departments, SFPs, TFCs, paediatric wards and at large in the 'villages' within the camps.

Humanitarian workers who are trained in these courses includes Medical Doctors, Nutritionists, Clinical Officers, Nurse midwives, Nurse Officers, Reproductive Health Managers /Officers, and all nurses working in MCH programmes, in feeding centres, and paediatric and maternity/delivery wards.

One of the key challenges faced is adequate coverage of the camp because of frequent turnover of trained personnel exacerbated by the ongoing repatriation. For example, in one camp there are only 40 breastfeeding promoting agents, which is not sufficient to cover all villages - there are 52 villages in the camp. Ongoing training of newly recruited TBAs and community health workers is therefore paramount. It is also important to expand the skills and knowledge base regarding breastfeeding to other cadres of the staff in the camps, to ensure that the programme reaches the majority of the breastfeeding women in the camp's villages/ zones or blocks.

A mother supported to breastfeed her twins.

Conclusions and recommendations

Breastfeeding corners built around health facilities are a valuable intervention during the acute phase of an emergency where a population is displaced, as most families will have been dislocated from normal support structures. Once the acute emergency period is over, other services in the camps are set up and functioning properly, and the community has re-established some level of support structures, breastfeeding support is best implemented as a community based approach.

For further information, contact: Lucas K. Machibya, Associate Nutrition Officer, email: machibya@unhcr.org, Ms. Fathia Abdala, Senior Nutritionist, UNHCR Geneva, email: abdala@unhcr.org, Dr. Raoufou Makou, email: makou@unhrc.org

¹Policy on the acceptance, distribution and use of milk products in refugee settings (2006). Available in English and French. Download from http:///www.unhcr.org or http://www.ennonline.net Contact: ABDALLAF@unhcr.org or HQTS01@unhcr.org

²An interagency collaboration developing policy guidance and capacity building on infant and young child feeding in emergencies since 1999. See online at www.ennnonline.net/ife

³More detailed coverage of UNHCR and partners' experiences in managing artificial feeding in refugee settings, largely in the context of HIV/AIDS, will be shared in a later issue of Field Exchange.

⁴Breastfeeding and healthy eating in pregnancy and lactation: Report on a WHO workshop; Arkhangelsk, Russia Federation, 5 - 8 October 1998. WHO Regional Office for Europe.

⁵WHO HIV and Infant Feeding Technical Consultation Consensus Statement. Held on behalf of the Inter-agency Task Team (IATT) on Prevention of HIV Infections in Pregnant Women, Mothers and their Infants. Geneva, October 25-27, 2006. Available at: http://www.who.int/child-adolescent-health/publications/NUTRITION/consensus_statement.htm