Increased diarrhoea following infant formula distribution in 2006 earthquake response in Indonesia: evidence and actions

By Fitsum Assefa, Sri Sukotjo (Ninik), Anna Winoto and David Hipgrave

Fitsum Assefa is a nutritionist with over 15 years experience working on public nutrition in various countries in Asia and Africa. She has wide experience in emergencies as well as development settings. She led the UNICEF Indonesia nutrition team during 2006/7.

Anna Winoto is a Nutrition Specialist at UNICEF Indonesia. She has been working on advocacy, technical guidance, implementation and evaluation of public nutrition programmes, including infant young child feeding, for the last ten years, mostly in Indonesia. She holds a Masters in International Health from the Johns Hopkins School of Public Health.

David Hipgrave is an Australian paediatrician with a special interest in international child health and infectious diseases. He joined UNICEF in October 2004 as the Chief of Health and Nutrition at UNICEF Indonesia where he oversaw the responses to a number of disasters, including the Asian tsunami. In February 2007 he joined UNICEF China, where he heads the Health, Nutrition and Water and Enviornmental Sanitation (WES) Section.

Natural disasters are common in Indonesia. While still recovering from a series of such events¹, a severe earthquake struck Yogyakarta² and Central Java provinces during the morning hours of May 27, 2006. The earthquake took about 6,000 lives, injured 40,000 - 60,000 people, and robbed hundreds of thousands of their homes and livelihood. Around the same time, volcanic activity of nearby Mount Merapi increased dramatically, prompting the evacuation of tens of thousands of people. The epicentre of the earthquake was Bantul district in the south of Yogyakarta, while parts of Klaten district in Central Java were also seriously affected (see map).

The context

Child undernutrition remains a significant and deteriorating public health problem in Indonesia. The percentage of underweight children under five years of age rose from 24.7% in 2000³ to 28% in 2005⁴. Disparities are sharp across the nation, with malnutrition being more prevalent in the eastern provinces. National data on stunting and wasting is lacking, but localised assessments have found that stunting exceeds 40 percent in the eastern islands⁵ and in Aceh province⁶. Acute malnutrition (wasting and nutritional oedema) was a significant concern in these and other areas during 2005 and 2006, but again, population incidence estimates are lacking. However, economic, health and nutrition indicators for the earthquake-affected areas of Yogyakarta and Central Java are amongst the best in the country, and primary health care systems function relatively well in both provinces.

Epicentre of the 2006 Indonesian earthquake

Infant and young child feeding (IYCF) practices are also far from optimal in Indonesia. Though virtually all Indonesian women breastfeed, the most recent data found that only 17.8%⁷ of them breastfeed exclusively at 4 - 5 months of age. Promotion of breastmilk substitutes (BMS) is common and formula feeding is widespread. Complementary feeding practices vary widely; major concerns include poor nutrient density, low frequency and early introduction of complementary foods, and the poor sanitation and hygiene environment within which they are prepared. National efforts/investment to protect, promote and support breastfeeding have been inadequate for years, not evidence based and ineffective in improving feeding practices, although committed efforts have improved recently.

Early aid to support infants and young children

The overall emergency response to the 2006 earthquake was rapid, involving civil society, private sector, individuals, United Nations (UN) agencies, non-governmental organisations (NGOs) and Indonesian and foreign military personnel. Literally a few hours after the earthquake, supplies of food and drinks started flowing into the affected region from many different sources. These included large quantities of BMS such as infant formula, powdered milk (Dried Skimmed Milk (DSM)), and various commercial complementary foods. Contrary to key international guidance⁸, many local and international agencies quickly proceeded to distribute commercial infant formula and commercial porridge to infants and young children. Furthermore, there was a strong perception amongst benefactors that as BMS were already widely used in Indonesia, such blanket distribution was just maintaining the status quo. However, there was no hard evidence to support or refute this perception. Also, in the crisis zone, some of the pre-earthquake 'nutrition rehabilitation' programmes of the government included distribution of BMS, and infant formula companies had been promoting their products through local health care providers, further legitimising this form of assistance in the eyes of relief workers and beneficiaries.

Challenges in cluster coordination

Having learned from experiences in other recent disasters in Indonesia, UNICEF health and nutrition staff advocated for support for appropriate infant and young child feeding during the emergency (IFE) from the first day of the emergency. However, the initial UN assessment and subsequent assignment of roles and responsibilities of the various agencies to Clusters/sub-Clusters did not consider nutrition as a specific issue. In fact, according to minutes of the coordination meeting during the first week of the crisis,, some agencies used the UN coordination mechanism to request more BMS. Furthermore, a number of donor government representatives in Jakarta pledged BMS as part of the emergency response. In general, there was very little awareness within the UN, NGOs (both national and international), donors, communities and local government about IFE, despite similar experiences after the 2004 tsunami.

Within a week of the disaster, BMS had been widely distributed to almost every affected household. Major distributors included national and international NGOs, civil society, the army and infant formula companies⁹. There were multiple brands (imported and locally manufactured), distribution was not coordinated and the amount distributed per child varied from place to place. Avenues for distribution included through the general ration, at temporary and fixed health care facilities and at temporary shelters.

Based on field observations, the UNICEF nutrition team alerted partners to the potential negative consequences of universal distribution of BMS and other milk powders, and challenged the opinion that families were familiar with the use of BMS. The team soon suspected that many infants and young children were suffering from diarrhoea as a result of consuming BMS in poor sanitary conditions. However, these observations were challenged as anecdotal and comments such as "the people and the health care providers request it" or "the population is already dependent on it" were heard.

Reluctance was noted amongst senior managers of the emergency to add another Cluster/sub-Cluster, so nutrition issues were referred to the Food Cluster, led by the World Food Programme (WFP). UNICEF actively participated in this Cluster (later named the Food and Nutrition Cluster), and advocacy on appropriate IFE and mapping of who was distributing BMS and/or other powdered milk was one of the first activities initiated through this forum. However, it was evident that participant agencies were mainly concerned with the logistics of food distribution and not IFE. The Food and Nutrition Cluster did review the composition and adequacy of the general food basket and assisted inclusion of multiple micronutrient sprinkles (supported by Helen Keller International), as a means to improve the nutrient density of available foods for children.

UNICEF also actively participated in the various sub-Clusters on Health, led by WHO (injury, EPI, infectious diseases, reproductive health, mental health, etc.) and continued to report field observations and advocate for appropriate IYCF at every opportunity. However, the issue continued to be minimised, with coordination meeting minutes simply reporting that "UNICEF is concerned about formula feeding and potential risks".

The emergency was overwhelmed with the management of casualties and cases of tetanus. Given the overall lack of interest in nutrition matters, UNICEF successfully advocated and transformed the Reproductive Health sub- Cluster into a Maternal and Child Health and Nutrition (MCHN) sub-Cluster. This created more opportunities to document evidence and start addressing various nutrition issues, including IFE.

One of the priorities of the Reproductive Health sub-Cluster, led by UNFPA and WHO, was to identify and interview all pregnant women in the 7 most affected sub-districts of Bantul. The expansion of this sub-Cluster to MCHN facilitated the addition of critical nutrition interventions for pregnant mothers (specifically, distribution of prenatal multiple micronutrients during the registration process). In addition, this enumeration process was considered an opportunity to acquire populationbased data and hard evidence to support further advocacy and intervention on IFE.

Assessment of IYCF practices

From 18-24 June 2006, an IYCF assessment was conducted in tandem with registration of pregnancies, involving 831 primary caretakers of children 0-23 months of age. Assuming the occurrence of pregnancy and location of a pregnant woman were 'random', the registration process was used to also 'randomly' identify children under two years of age and to interview their primary caregivers on feeding practices. This sampling method provided a rapid solution to what would otherwise have been a time consuming and expensive selection process.

For every other pregnant woman interviewed, the child aged less than 2 years who slept nearest to where she slept was identified. This could be the child of the pregnant woman or of a neighbour. If there was more than one child under 2 years old in the pregnant woman's household/shelter/tent (or her neighbour's household/shelter/tent), the interviewer randomly selected one of the children for the interview. The primary caretaker (mother, grandmother, etc.) of this child was then interviewed. Standard questions based on standard indicators were used, after pilot testing¹⁰.

Coverage of BMS and/or other milk products

Data on 831 children under 2 years of age (296 children < 6 months old and 535 children 6-24 months old) were included for analysis of coverage of BMS distribution. The data showed that 80% of children under the age of two years received infant formula, while 'follow-on' formula¹¹ or commercial porridge was distributed to 76% of these children. Half (49%) received 'other' milk powder (DSM type) and 31% received locally produced blended/fortified food (see Figure 1). Baby feeding bottles were distributed to 14% of these children.

The issue for infants under the age of six months was not just the uncontrolled supply of infant formula, but also unnecessary distribution of other products, including 'follow-on' formula and complementary foods. Amongst such infants, 75% received BMS, 72% received commercial porridge, 46% received other powdered milk and 28% received complementary food. The labels of the products violated many aspects of the International Code of Marketing of Breastmilk Substitutes¹². Some were labelled in a foreign language, and distributors provided no instruction on preparation or the intended target of the product.

Impact of donations on the use of BMS by infants < 6 months after the earthquake

As can be seen in Figure 2, less than one-third of the infants (32%) under the age of 6 months old had ever consumed infant formula before the earthquake, as compared to at least 43% of those who consumed BMS during the emergency response. The figure of 43% might be an underestimation of current consumption of BMS, as data were based on 24 hour recall only. Considering the fact that 75% of infants under the age of 6 months (and over 82% of all children under 2 years) had received donations, it is highly likely that more infants and young children did or would consume these products. The 32% pre-hoc consumption amongst young infants strongly challenges the perception that artificial feeding was the 'status quo' in Indonesia. The consumption of BMS was significantly higher in those who received donations, regardless of age (Figure 3).

To try and communicate the potential risks of artificial feeding, cases of those infants and young children who suffered from diarrhoea following change in feeding habit were followed up and widely reported in local and international media¹³. Though lacking supporting evidence, anecdotal information suggests some of those who received infant formula were not consuming it because of these advocacy and communication efforts by UNICEF and other NGOs soon after the earthquake.

Prevalence of diarrhoea

The data also suggested a significant increase in the prevalence of diarrhoea post earthquake (29%) compared to 1% - 7 % prior to the earthquake¹⁴. Furthermore, diarrhoea prevalence was double amongst those who received donations of infant formula (25.4%) as compared to those who did not (11.5%) (Figure 4). We associated this rise with the changing feeding practices and artificial feeding in conditions of poor sanitation and hygiene following the disaster. The much higher prevalence among BMS recipients as compared to non recipients was regardless of consumption in the previous 24 hours - this suggests that some those who had not consumed it within the 24 hour recall period may have consumed it earlier.

Advocacy and Promotion

The data presented above, available a month after the earthquake, facilitated advocacy and promotion of appropriate IFE in Yogyakarta and Central Java. A press release on the problem was issued urgently by the Ministry of Health (MOH)/UNICEF. The MOH also circulated (in English and Bahasa Indonesia) the Operational Guidance on Infant and Young Child Feeding in Emergencies (ENN/IFE Core Group)¹⁵ to all health workers and partners working in the earthquake areas. Intensive communication on IFE was conducted through local media, with at least one TV and radio station and newspaper (including headline news and popular talk shows) covering these issues at least once a week. A UNICEF video news release, featuring infants hospitalised with diarrhoea following consumption of BMS and showing the poor hygiene conditions in affected areas, was broadcast widely by most national media and on CNN weekly review.

Journalists were provided with a half-day orientation on major IFE issues - and specifically on the related challenges (and solutions) during emergencies, and were encouraged to continue reporting. They were also briefed on the results of the survey from Yogyakarta.

TV and radio were not widely available among the earthquake-affected population. Thus many agencies used flyers and leaflets to communicate various issues. Traditional arts and entertainment, such as the famous Indonesian shadow puppet show (Wayang kulit), were utilised to communicate breastfeeding messages for affected communities. Involving the community in creating the 'story' (using real-case examples of mothers who had received donated formula and mothers who have changed infant feeding practices) was also one of the key approaches.

 

In conjunction with the UNICEF communication team, the 'CREATE (Communication Resources Essentials and Tools for Emergencies) methodology¹⁶ was used to develop posters and radio/TV spots using community focus groups (see picture). Among all messages and illustrations, highest scores were awarded by the community to those that emphasised the cost of artificial feeding (see example in Picture 1) as mothers realised their reliance on the donation made their breastmilk stop and that they would need to buy more formula once donated supplies were used up. Surprisingly, mothers gave a low score for conventional posters showing a mother and child well attached and happily breastfeeding. They said they have seen such posters all their life, including on packets of infant formula, and that such posters don't really make an impression, especially as they don't demonstrate the potential harmful effects of infant formula.

Breastfeeding support: an intervention

It was clear, however, that advocacy and promotion alone were not enough to change the situation. Even when mothers were aware of the benefits of breastfeeding and the potentially harmful effects of artificial feeding, this did not result in them successfully reverting to breastfeeding, or protect newborns from similar practices. An active intervention was needed and a 'cascade' method of breastfeeding support was developed to do just that.

UNICEF/ MOH-Indonesia aimed to reach large numbers of mothers with breastfeeding counselling and to demonstrate its effectiveness. In Indonesia at the time, there were only a few trained breastfeeding counsellors who are able to provide skilled counselling (40 - 50, at most), spread over a vast country. Even if they were all available to work in the crisis area, they wouldn't have been able to meet the needs for counselling thousands of mothers affected by the earthquake and the blanket distribution of donated BMS. It was also not feasible to bring counsellors from abroad, given language issues and the scale of support that was required, so a 'cascade' method of breastfeeding support using community volunteers was devised.

At its core, the scheme needed frontline counsellors who lived in the communities and possessed adequate skills and knowledge to train local lactation counsellors to counsel mothers effectively, and to demonstrate results. Realising that the most effective and proven training is the WHO/UNICEF 40 hours breastfeeding counselling course¹⁷, a mechanism to deliver the course at the community level was needed, with an approach sensitive to the context. Major considerations were:

• Competing needs of health care providers and community volunteers, themselves victims of the disaster and already involved in response activities, who could not afford to spend a full week/40 hrs on breastfeeding training alone.
• The setting for training needed to be 'on the job' coaching/demonstration and using cases from the disaster affected community for clinical practice (immediate response).
• Constrained movement, as people did not want to leave their home area for various reasons, including fear of losing their valuables buried under the rubble, lack of local transport, not wanting to leave their family members, especially children, without appropriate shelter, etc.
• People were busy cleaning up the damage and searching for their valuables.
• Only a few trained counsellors could be deployed to the earthquake affected area for extended periods of time.

Training

UNICEF contracted the Indonesian Breast feeding Centre (Sentra Laktasi Indonesia) to design and implement the training programme with the aim of ensuring the highest possible coverage, quality, and sustainability (e.g. through the selection of appropriate participants). Training participants were community workers/volunteers and village midwives. After discussions with them on their availability, it was decided to deliver the training on a twice weekly basis, 3 - 4 hours at a time, depending on the session. This way the full WHO/UNICEF 40 hours training course with practical skills could be delivered in a six week period. Pictorial based flip-charts were developed to use with mothers. For clinical practice sessions, breastfeeding and pregnant mothers were brought into the training sessions. Facilitators met every evening to evaluate the process of the training on that day. Every Sunday, the facilitators and course coordinators discussed any difficulties with the trainees and visited breastfeeding mothers.

'Cascade' system of support

A target of supporting at least 5,000 mothers was initially established. To address the challenge of how to reach such a large number of mothers rapidly, a 'cascade' system of support was used (see Figure 5):

• Twelve¹⁸ frontline counsellors/trainers were placed in the community covering 12 villages. Each village was divided into about six sub-villages (dusun) for which the frontline counsellor was responsible.
• Each frontline counsellor recruited six 'local lactation counsellors' (LLC) from each of their six sub-villages. Thus each frontline counsellor was responsible for coaching a total of 36 LLC on a twice weekly basis.
• These 'local lactation counsellors' were able to provide help and support to pregnant women and breastfeeding mothers to practice early initiation and exclusive breast feeding and to improve their breastfeeding technique. They were also able to identify common breastfeeding problems in their communities such as sore nipples, poor positioning of the baby, mastitis and support mothers reporting that they had "not enough breastmilk".
• In turn, each LLC was to identify and counsel a minimum of 5 mothers with lactation prob lems. This brought the number of mothers directly receiving counselling as part of the training practice by each frontline counsellor /trainer to about 180.
• In turn, these counselled mothers were recruited to become peer educators (PE). Each PE had to refer at least two other mothers with counselling needs to a LLC. This established the 'trickle' effect of one frontline counsellor reaching up to 360 families.

Impact of active breastfeeding support

Using this cascade approach, 4,260 families were accessed and benefited. (Figure 6). MOH/UNICEF devised a quick monitoring exercise in order to determine any change in breastfeeding practices as the result of this intervention. Fifty-four mothers from 30 subvillages in the most affected areas in Bantul district who gave birth after the earthquake were assessed (17-31 October, 2006). The monitoring exercise revealed that almost all of these mothers initiated breastfeeding in the first hour after birth as a result of support from breastfeeding counsellors. Of the 54 mothers assessed, 63% were exclusively breastfeeding regardless of access to free BMS - mainly due to the counselling/ support they received from trained breast feeding counsellors, who were health workers or volunteers.

In order to investigate the impact of the intervention more closely, a rapid survey was conducted by UNICEF in November 2006 (three months after the training had concluded). The survey was conducted in the earthquake affected area in Bantul (7 sub-districts, 7 villages where there are counsellors in place). A total of 247 mothers with babies born after the earthquake were assessed on their breastfeeding practices. All babies were under six months of age (Figure 7). Follow-up interviews were also conducted with 136 LLC in the areas.

Feeding patterns in infants

Amongst the mothers surveyed, the rate of exclusive breastfeeding rate was 49.8% (see Figure 8). On further questioning, 39% of the mothers of these infants had previously been giving other liquid and/or food in addition to breastmilk, but reported moving to exclusive breastfeeding after being counselled. However, over one-quarter (28.3%) of mothers surveyed continued to give infant formula in addition to breastmilk and 16.6% were giving foods in addition to breastmilk.

Over half (54.6%) of mothers had received counselling - from the cadre - community volunteer (69.6%), midwife (21.5%) and both midwife and cadre (8.1%). Those who received counselling had better knowledge than those who did not receive counselling: 90% of counselled mothers correctly defined exclusive breastfeeding compared to 55% who had not been counselled.

When asked how they planned to feed their baby up to the age of six months, 53.3% of counselled mothers answered "breastmilk only" compared to 35% of mothers who did not receive counselling. However, 20% of counselled mothers planned to give infant formula in addition to breastmilk and 22% to give food to their infant before they reached six months of age (Figure 9).

LLC follow-up

Follow-up visits were made with 136 LLC in November 2006. Most (98.5%, n=134) of the LLCs provided counselling after their training through home visits (92%), at village health posts (posyandu) (86%), at village health centres (polindes) (2.2%), and during women's group discussions/ koran recital (44%). Over half (58%) had counselled 1-5 mothers since being trained and nearly one quarter had counselled 6-10 mothers (see Figure 10).

These findings indicate a positive impact on exclusive breastfeeding rates and infant feeding knowledge amongst mothers of young infants born after the earthquake. Despite the widespread distribution of BMS to the population, the findings suggest that the intervention limited the negative impact this had, since the reported use of BMS amongst those surveyed are similar to pre-earthquake levels. However, this survey was undertaken only three months after the training was completed, probably too soon to see a behaviour change that represents a change to established complementary feeding practices and infant formula use.

Experiences from implementing 'cascade' training

There were a number of challenges to implementing the cascade training:

• Many community workers and health workers were, themselves, affected by the earthquake so it was difficult to find community workers who could commit to participating in the training.
• Variable levels of education also provided training challenges. In some instances, oneto- one training was conducted where workers could not come to the scheduled training. There was minimal support from the local health office, which was more focused on building new premises, manning the health system, and other health issues.
• It took a couple of weeks to develop the idea/proposal and secure the implementing partner (Sentra Laktasi). In the absence of already developed capacity, the process is not sufficiently rapid to provide the critical breastfeeding support needed in the hours, days and immediate weeks after the acute onset of an emergency
• The cost of the training is approximately $255 per LLC, due to the very limited number of trainers available and the need to bring them to the site, usually from central level. However, this cost should be reduced once the programme was established and trainers are available at district level.

Ongoing support for counsellors has increased their confidence to assist breastfeeding mothers even though most did not have any health background. The 'cascade' system using community based volunteers/peer support appears a sustainable breastfeeding service, and continued after the acute stage of the emergency situation subsided.

The 'cascade' model has since been replicated by the MOH. The WHO/UNICEF 40 hours breastfeeding counselling training course has been translated into Bahasa Indonesia and the MOH has used the 'cascade' model in all of their 40 hours trainings. At the end of each training session, facilitators ask the participants to counsel a minimum of five pregnant and/or lactating mothers. In turn, the mothers should provide information on breastfeeding to their community and refer identified mothers for breastfeeding counselling. There are now around 1500 counsellors across the country.

Discussion and conclusions

Despite a similar experience with donations of BMS during the 2004 tsunami emergency, it was not possible to prevent unsolicited donations and manage the establishment of centralised/ controlled BMS distribution system following the Yogyakarta earthquake. However, UNICEF Indonesia had a stronger in-country nutrition capacity by the time of this crisis and was already advocating for and addressing national IYCF issues in close collaboration with the government. Involvement of the government from the outset was key in placing IYCF issues on the highest level of the humanitarian agenda through evidence-based advocacy, awarenessraising and subsequent interventions. Since 2006, more national commitment has been expressed and demonstrated in addressing IYCF issues.

Awareness on issues around IFE was very poor amongst the humanitarian actors, including those working on health and nutrition, and amongst the general public. Some of the international NGOs, with competencies in responding to nutrition in emergencies, failed to understand the IFE situation and to identify their role in supporting the government and the community in this area. Having a history of relatively better socio-economic status and good access to food following the emergency, the affected communities may have been misrepresented as 'not being nutritionally vulnerable', with a consequent lack of interest and commitment from agencies to address nutrition matters.

Understandably, there was much more pre-occupation with injuries and other issues. It was very difficult to find implementing partners to address the prevailing problems in IFE. Informal networking with key individuals of various agencies was very important to mobilise interest, as many actors were not working through the official coordination mechanism.

Our experience also showed that, without hard evidence, advocacy, awareness raising and subsequent interventions are very challenging. However, conducting a 'stand alone' IYCF survey was not practical - as it would have been both resource intensive and probably poorly accepted by a community already responding to extensive surveys from various agencies and sectors. Devising a cost effective and opportunistic method was necessary to acquire the 'evidence', in this case integrating the survey with exhaustive registration of pregnant women. Working closely with all the clusters and transforming the Reproductive Health Cluster to formally include nutrition as an MCHN Cluster gave access to/pooled resources, and opened up opportunities to document evidence and start addressing nutrition issues, such as through the distribution of antenatal micronutrient supplements. However, there was significant resistance from various partners to integrate IYCF in the registration process of pregnant women. Persistence and full time technical representation was key to convincing partners, enable adequate training of enumerators and ensure rigorous pre-testing and supervision of the data collection.

Conventional IEC (Information, Education, and Communication) using print and electronics media was not very effective in changing feeding practices. Messages that expressed the negative consequences of artificial feeding were more effective than those expressing the benefits of breastfeeding. Knowing the potential danger of BMS distribution was not enough to enable mothers to revert to breastfeeding when BMS were being widely distributed and recommended by health workers and international agencies. Furthermore, mothers had lost their communication assets like radio and TV, and were preoccupied with the wide-reaching impact of the crisis on their lives, as well as lack of privacy. Therefore, creativity and using context sensitive ideas, low technology and entertaining methods were needed. In addition, raising the awareness and educating politicians and journalists/ media producers helped ensure continuous coverage of the IFE issue at prime time news and other programmes, even months after the earthquake. We found that evidence based advocacy, coupled with context specific IEC to the public and counselling services, minimised the harmful effect of widespread BMS distribution.

This experience has demonstrated how the WHO/UNICEF 40 hours breastfeeding counselling training module can be adapted to suit the context and deliver frontline breastfeeding support and counselling. From our experience we believe that volunteers with modest formal education can be successfully trained in breastfeeding counselling in an emergency. An important task for the trainers/training director is to adapt the UNICEF/WHO 40 hour module for these counsellors and to tailor the course delivery mechanism based on prevailing need. Providing hands-on practice, above and beyond the recommended numbers of practices in the WHO/UNICEF guidelines, was a key strategy in training volunteers with no prior health/ nutrition training and experience. Using community volunteers was the best choice in this setting, as they were well accepted by their communities to help and support the pregnant and lactating mothers. Creative adaptation of the training was made possible by using a local implementing agency, Sentra Laktasi Indonesia/Indonesian Breastfeeding Centre, whose mandate is to train and counsel on breastfeeding. Through this exercise, the capacity of Sentra Laktasi itself was substantially developed, which is an asset for the country.

Within less than two months of starting the training, an impact of the intervention was quickly demonstrated on the mothers of newborn infants - a critical target group in an emergency. Further assessments suggested that early initiation and exclusive breastfeeding rates have improved significantly as the result of this intervention. We recommend that the impact of this intervention should be studied further and properly documented to support similar future interventions both nationally and globally.

The focus and effort on breastfeeding as part of the earthquake response has actually strengthened national IYCF programming. Efforts are ongoing to further replicate the cascade training method in other districts/ provinces. This demonstrates how IYCF programmes in an emergency can evolve into regular programming and in this case, have proved an opportunity to invest in improving the awareness and behaviour of the community and key stakeholders with regard to breastfeeding and artificial feeding.

Finally, commitment to IYCF and related capacity of government, UN, international and local agencies in 'normal' times is the key to more timely and appropriate interventions during emergencies. Strengthening this is an essential 'emergency preparedness' initiative in any disaster prone country, regardless of its socio-economic status.

For more information, contact: Sri Sukotjo (Ninik), email: ssukotjo@unicef.org

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¹The December 2004 Indian ocean Tsunami, the March 2005 north Sumatra earthquake, and many other smaller disasters of flooding, land slides etc.

²Yogyakarta is a centre for Javanese traditional arts and culture and is home to a royal family whose lineage goes back to the Mataram era in the 16th century. It is also a centre of higher education in Indonesia.

³National Socioeconomic Survey, 2000

⁴National Socioeconomic Survey, 2005

⁵SEAMEO and World Food Programme, July-August, 2005. Survey in NTT and NTB. Indonesia

⁶CARE and UNICEF, July-August 2005. Survey Data in Aceh. Indonesia

⁷Badan Pusat Statistik-Statistics Indonesia (BPS), 2008. Indonesia Demographic and Health Survey 2007. Preliminary Report.

⁸Operational Guidance on IFE for Emergency Relief Staff and Programme Managers, v2.1, February 2007. Developed by the IFE Core Group and supported by UN agencies (including UNHCR), NGOs and donors. Available at: http://www.ennonline.net/ife

⁹There are three infant formula producing companies in Yogyakarta province.

¹⁰The questionnaire is available on the ENN website, www.ennonline.net/ife and search Resource Library.

¹¹These are specifically formulated milk products defined as "a food intended for use as a liquid part of the weaning diet for the infant from the sixth month on and for young children" (Codex Alimentarius Standard 156-19871). Providing infants with a follow-on/follow-up formula is not necessary (See WHA Resolution 39.28 (1986) (para 3 (2)). In practice, follow-on formulae may be considered a BMS depending on how they are marketed or represented for infants and children under 2 years, and fall under the remit of the International Code (see footnote 12). Source: Operational Guidance on IFE, V2.1, Feb 2007.

¹²The International Code of Marketing of Breast-milk Substitutes. WHO,1981. Full Code and relevant World Health Assembly (WHA) resolutions are at: http://www.ibfan.org/English/resource/who/fullcode.html http://www.who.int/nut/documents/code_english.PDF

¹³ UNICEF video release, 26 July 2006

¹⁴GOI/HKI, Nutrition and Health Surveillance in rural Central Java. Key results for the period: Dec 1999-Sep 2003. Yr. 5, Iss 10, Jan 2004

¹⁵See footnote 8. Bahasa (Indonesia) version is available online at www.ennonline.net

¹⁶The CREATE method aims to develop and bring together materials for communication in emergencies. These materials can then be rapidly adapted according to local circumstances, as has been done for avian flu in the region. See at http://www.createforchildren.org

¹⁷Available online at: http://www.who.int/child_adolescent_health/documents/who_cdr_93_3/en/

¹⁸The original proposal aimed to place a pair of facilitators per village. In reality, one facilitator was placed per village.