Assessing the intervention on infant feeding in Gaza 2008

By Susan Thurstans and Vicky Sibson

Susan Thurstans has been part of the emergency response team for nutrition with Save the Children UK since January 2009 and previously worked for ACF for 6 years. She is also the focal point for nutrition on the current revision of Sphere.

Victoria Sibson has been the emergency nutrition adviser for Save the Children UK since April 2007, with a focus on treatment of acute malnutrition and infant and young child feeding in emergencies.

Thanks to all staff who participated in the survey particularly the tireless support of Mahasen Abu Hassan and Rania Muhana in the design and implementation of the survey and the distance support from Ribka Amsula. Thanks also to Kirk Dearden and Mary Lung'aho for their support during the planning and analysis of the survey

The two field articles that follow share different experiences of working in Gaza during the 2008/09 conflict. Both deal with the area of infant and young child feeding especially. It is important to note that the Save the Children assessment is not a critique of the programme described by NECCCRW; both agencies operated in different areas and were submitted independently to Field Exchange. Also, while the Save the Children programme was part of an emergency response, the NECCCRW programme happened to coincide -rather than directly respond to - the emergency.

The production of these articles has opened up constructive and considerable discussion between both sets of authors and with the ENN editorial team. We invite the Field Exchange readership to share experiences and observations around these articles on the online forum, en-net, where a discussion thread has been set up in the 'Infant and young child feeding interventions' area (eds)

On the 27th of December 2008, Israel launched a three week military operation in the Gaza Strip (referred to as Gaza here on)¹ during which 1,417 Palestinians were killed, including 313 children and 116 women². Over 5,380 people were injured, 1,872 of whom were children. The severe bombing and incursions caused devastating damage. During the military operation, over 15,000 homes were totally or partially destroyed, as well as schools, kindergartens, hospitals and emergency service stations. An estimated 26,000 people lost their homes and a further 75,000 people were left displaced or living in difficult conditions³.

The effects of the crisis were exacerbated by the blockade imposed by Israel since the 2006 elections. Since June 2006 (and prior to this military operation), the context of Gaza was characterised by increasing restrictions on movement of people, means of transport, building materials, medical supplies and equipment and other goods into and out of Gaza. The economic situation had already been on a downward trend since the second intifada⁴ in 2000. Water and sanitation conditions are chronically poor. Prior to the military operation, 80% of the water supplied in Gaza did not meet WHO standards for drinking.

The crisis also presented a unique conflict situation; during the military operation the population of Gaza was not allowed to flee from the military attack zones which covered the whole of the Gaza strip. Furthermore, the crisis does not follow the usual crisis 'relief - early recovery - development' cycle as the ongoing blockade restricts recovery efforts.

Health and nutritional situation pre-crisis

Political instability, economic deterioration, destruction of infrastructure and lack of resources are factors negatively affecting the health and nutritional status of the Gazan population. The nutrition situation among children prior to the recent hostilities was characterised by rising stunting levels (13.2% in 2006), a high rate of low birth weight (7% in 2006) and 'alert level' micronutrient deficiency rates (iron deficiency anaemia >40% and vitamin A deficiency >20% in certain age groups and a rickets prevalence of 4.1% in 6- 36 months olds)⁵.

The blockade has led to severe deterioration from a population with a health status typical of a middle income country to stagnated life expectancy. The infant mortality rate in Gaza is 25.3/1000 for 2004-2005⁶, with little decline since the 1990s. Between 1995 and 2005, Gaza has seen the smallest reduction in mortality in children under 5 years compared with surrounding Arab countries.

Before the current crisis, 74% of people in Gaza were living below the poverty line of US$3-15 per person per day in 2007⁷. The ongoing blockade on Gaza impacts greatly on access to food and livelihoods for the population, in particular those relying on farming and fishing. Due to poverty and the siege, both the quality and quantity of food intake has been reduced. Over half (56%) of households are food insecure and following the military offensive, 88% of the population were registered to receive food aid from either UNRWA (United Nations Relief and Works Agency for Palestine Refugees in the Near East) or the World Food Programme (WFP).⁸

IYCF concerns in the Gaza humanitarian response

The vital role of optimal infant and young child feeding in the nutrition and survival of children is well recognised, particularly so in emergencies. Protection and support of optimal IYCF was a key concern of Save the Children in the Gaza emergency response, especially given the prevailing poor feeding practices pre-crisis. While most infants were breastfed (97%), less than 25% of women exclusively breastfed for six months⁹ and early introduction of liquids such as teas, water, herbs, infant formula, and complementary foods was common. Furthermore, anecdotal evidence and reports during and following the 2008 hostilities suggested that large influxes of donated breastmilk substitutes (BMS) to Gaza were exacerbating the situation. The lack of appropriate complementary foods for children 6-24 months was also a cause for concern, as a result of increasing poverty due to the blockade and reduced dietary diversity. While the food needs of the population were mostly met according to WFP and UNRWA (as reported to the Food and Nutrition Cluster on February 3rd), suitable nutrient and energy dense foods for small children were not thought to be widely available.

Assessment

Save the Children and its three existing local partners (Ard El Insan, Palestinian Medical Relief Services and the Union of Health Workers Committee) undertook an assessment to examine current IYCF practices, nutritional status and morbidity, key elements of the overall humanitarian response, and the impact of this response.

Objectives

The main objectives of the assessment were:

• To obtain quantitative data on IYCF practices
• To obtain an understanding of current IYCF practices, beliefs, barriers and challenges
• To determine the prevalence of anaemia in children 0-23.9 months and their mothers
• To determine the prevalence of morbidity (diarrhoea, fever, and cough) in children 0-23.9 months of age.
• To look at the impact of the conflict on infant and young child feeding and the humanitarian response to this.

A secondary objective was to pilot the use 'Infant and Young Child Feeding Practices: A Step-by-Step Guide to Measuring and Using IYCF Data¹⁰ manual under development at the time by Care USA. Specific considerations in this regard are not reported here but are available from the authors.

Methodology

The assessment collected data on IYCF practices as an independent survey. Systematic random sampling was adopted in 12 communities with a total population of 66,400 (about 4% of the total population). The majority were still classified as refugees since their displacement during the 1948 Arab-Israeli war.

Sampling

The sampling procedure and size were guided by the 'Infant and Young Child Feeding Practices: A Step-by-Step Guide to Measuring and Using IYCF Data' manual. The sample was calculated based on the 0-23.9 month age group, using the software prevalence sample size calculations with finite population correction¹¹. The population of children aged from 0-23.9 months was calculated with information from municipalities and partner non-governmental organisations (NGOs) active in those areas, considering that this age range represents 8% of the population.

Estimates were made on the percentage of mothers practicing each of 10 main IYCF 'behaviours' under assessment. The 10 variables used were based on the WHO 2008 agreed eight core indicators and two additional optional indicators for assessing infant and young child feeding. An estimated 5,312 children in the population were aged 0-23.9 months. Factoring in a 10% dropout/refusal rate, the sample size required was a total of 994 children 0-23 months of age¹².

A group of 377 infants and mothers were sampled for anaemia (using haemacue). Anthropometric data (not presented here) were also collected by Ard El Insan through exhaustive screening of all children under 5 years in 3 neighbourhoods (Al Attatra, Al Moqrega and Beit Hanoun), in April and May 2008. This built on routine surveillance.

The data were entered into ENA/SMART for anthropometric data analysis. Infant and young child feeding core indicators were analysed in excel following the IYCF manual. Other analysis was done using Stata® and EPI info.

Survey teams

IYCF data were collected by a team of 12 enumerators divided into six teams. Each team was supervised by Save the Children staff through regular field visits. The same enumerators conducted focus group discussions in the areas for which they were responsible, again with supervision from the Save the Children health team. A total of 15 focus group discussions were held in 12 neighbourhoods with a total of 146 participants. All enumerators participated in four days of training.

Results

A total of 998 questionnaires were completed and 965 children were included in this analysis. Overall, 49% (n=473) of the sample were male and 51% female (n=492). 73.8% of respondents were refugees and 25.8% non-refugees. Haemoglobin levels were taken for 318 children and 337 mothers. This was slightly short of the estimated required sample for mothers due to logistical challenges¹³.

IYCF practices

Nearly two-thirds of children under 2 years (64%) initiated breastfeeding within the recommended one hour of birth. The exclusive breastfeeding rate (2.7%) - using 24 hour recall method - was very low and less than pre-crisis rate of 25% reported in 2007 (see Table 1). Only 40% of infants were breastfed at 1 year of age. One third (35.6%) of infants were bottle fed. By 6 months, nearly half (48%) of infants had already been introduced to solid foods.

During and after the conflict, nearly half (49.3%, n=254) of mothers reported reduced frequency of breastfeeding 5.1% (n=26) of mothers stopped breastfeeding and 2.1% (n=11) of mothers restarted breastfeeding. The remaining mothers (43.6%, n=237) reported no change in breastfeeding practice. The main reasons for stopping or reducing breastfeeding were mothers perception that their own diet was insufficient (89.6%) and/or that they were unable to produce any or enough milk as a result of breast problems, stress or fear (99%) (see Table 2).

Regarding complementary feeding, half of mothers (50.9%, n=406) reported giving their child less variety of foods during or since the conflict, 15.6% (n=124) of mothers reported feeding children less and 12.2% (n=97) reported increased complementary feeding. The remaining 21.3% (n=170) of mothers reported no change. Nearly three-quarters of children under 2 years surveyed reported meeting the minimum acceptable diet (see Table 1, Indicator 7).

The assessment investigated what commodities related to infant and young child feeding mothers had received as part of the humanitarian response. Over one quarter of mothers (27.6%, n=265) received infant formula during or immediately after the conflict, including mothers who were breastfeeding. Nearly half of mothers (47.6%, n=453) received other breast milk substitutes and 5.3% (n=50) of mothers received baby bottles.

Table 1: Results for standard indicators measured on IYCF practices
Indicators		Total number	Sample size	Percent (CI)
1	Timely initiation of breastfeeding (within 1 hour)	619	965	64.1% (CI 95% 61.0-67.2)
2	Exclusive breastfeeding	7	268	2.7% (CI 95% .00.7-04.5)
3	Introduction of solid, semi-solid or soft foods	99	119	83.1% (CI 95% 70.7-88.3)
4	Continued breastfeeding at one year	50	95	40.3% (CI 95% 31.5-49.1)
5	Minimum dietary diversity	542	697	77.7% (CI 95% 74.7-80.9)
6	Minimum meal frequency	567	697	81.3% (CI 95% 78.4-84.2)
7	Minimum acceptable diet	515	697	73.8% (CI 95% 70.6-77.2)
8	Consumption of iron-rich or iron-fortified foods	697	697	N/A14
9	Children ever breastfed	944	965	97.8%
10	Bottle feeding	344	965	35.6% (CI 95% 35.6-38.7)

 

Table 2: Reasons given by mothers for stopping or reducing breastfeeding
Response	%	(n) (n=280)
Own diet was insufficient	89.6%	(251)
Too busy to breastfeed	8.2%	(23)
Unable to produce any or enough milk as a result of breast problems, stress or fear	99.0%	(276)
There was availability of breastmilk substitutes	3.2%	(9)
No suitable place to breastfeed	5.7%	(16)
Other (e.g. due to pregnancy)	4.6%	(13)

Note: Mothers could give more than one response

Morbidity

The incidence of diarrhoea was high amongst the children surveyed; 45.7% reported diarrhoea in the previous two weeks. According to UNRWA data, the time of data collection has a higher diarrhoea incidence than other seasons. After correcting for seasonal variation, this percentage drops to 38.2%. In terms of other morbidity, fever (39.5% n=381) and cough (24.6% n=237) were amongst the most common.

Morbidity The incidence of diarrhoea was high amongst the children surveyed; 45.7% reported diarrhoea in the previous two weeks. According to UNRWA data, the time of data collection has a higher diarrhoea incidence than other seasons. After correcting for seasonal variation, this percentage drops to 38.2%. In terms of other morbidity, fever (39.5% n=381) and cough (24.6% n=237) were amongst the most common.

There was no significant correlation between bottle use, receipt of infant formula on diarrhoea in the children 0-23.9 months (p=0.179).

Antenatal care

While all women surveyed had access to antenatal care, there were very low levels of post natal follow up (6.7% follow up within 3 days of delivery), which is consistent with prevalent practices. Discharge within two hours of delivery is common among maternity services (much less than the WHO recommended 12 hours). Low birth weight rate (<2500g) was 8.7%.

The humanitarian response on IFE

The humanitarian community has a responsibility to protect, promote and support IYCF in emergencies. This is reflected in Sphere Standard indicators and detailed in the provisions of the Operational Guidance on IFE, that includes early needs assessment, basic interventions (targeted shelter, water, food, security), avoidance and management of donations of BMS, bottles and teats, controlled use of BMS when indicated as a last resort, and skilled IYCF counselling and support, that includes breastfeeding and complementary feeding.

In the Gaza situation, poor and risky IYCF practices were common pre-conflict. It is hard to say whether the conflict situation had an impact on feeding practices, given the deteriorating situation that already existed through the blockade. The assessment suggests that these practices probably deteriorated since the blockade, with very low exclusive breastfeeding rates and over half of mothers reporting stopping or reducing breastfeeding. Mothers did not report BMS availability as a reason for breastfeeding decline, this may reflect that such products were in common use pre-crisis. Rather, the reasons given were 'breast problems', lack of food, stress and fear. The decline in breastfeeding practices may therefore partly reflect failure of the humanitarian effort to intervene in other ways - such as basic food provision to mothers and skilled support to address stress in breastfeeding mothers, and warranted in these circumstances.

As stated, appropriate management of breast milk substitutes in emergencies is part of the protection and support of infant and young child feeding in an emergency¹⁵. In Gaza, the distribution of BMS was the dominant IYCF intervention. Provision was often in general distributions, not based on needs assessment and not accompanied by additional supports or monitoring. The uncontrolled distribution of breastmilk substitutes, especially where breastfeeding mothers are included in the target group, in all likelihood reinforced prevailing poor feeding practices. Distribution of breastmilk substitutes without additional support that addresses water source, fuel, preparation and child monitoring, exposes both breastfed and non-breastfed infants to increased risks, especially given the prevailing poor water and sanitation condition in Gaza, While the incidence of diarrhoea was high in young children, no specific reasons were identified.

The concerns that complementary feeding needs were not being met during the emergency response were not substantiated in the assessment. Although mothers reported giving less food variety to their children, surveyed children did meet minimum food standards. Household food was provided by many agencies and though not specifically targeted at complementary food needs, appears to have been adequate for such a purpose. Despite widespread coverage of iron supplementation, non compliance with iron syrup was common and levels of both maternal and child anaemia were very high.

There was a general lack of knowledge amongst local partners and some international NGOs of the provisions of key policy guidance on IFE. This contributed to the uncontrolled distribution of breastmilk substitutes during and immediately after the December 08/January 09 military operation, and a lack of appropriate response in handling them. Though IYCF was identified as an issue during the emergency, the absence of expertise or commitment to follow through on this resulted in it not being pursued as a priority. Lack of policy guidance awareness most likely contributed to a failure to deliver a more comprehensive and informed package of protection and support on IFE. Even when IYCF issues were identified during the emergency these were not prioritised.

Acute response in a chronic situation

This assessment undertaken during the acute emergency response highlighted the significant and chronic problems around IYCF and the nutritional status of children and mothers. There were - and continue to be - huge constraints to mounting an emergency response in Gaza, with the ongoing blockade and prevailing poor situation. Whilst acute malnutrition rates have remained low, a long term nutrition strategy and response plan to address chronic undernutrition in the Gaza Strip should be a priority concern, especially considering short birth spacing, the blockades, increasing poverty, deterioration in food quality and quantity, rising prices, political conditions, poor water and sanitation conditions, and food insecurity. Anaemia remains a significant problem in mothers and children.

Many of the problems identified in antenatal care during the assessment - highly medicalised health systems with poor linkages between maternity units and primary health care, almost absent post-natal follow-up, limited midwifery/nurse capacity to offer practical support - are chronic problems spotlighted in the emergency context.

A key challenge in the emergency response was how to practically implement the provisions of policy guidance and standards in a population in which infant formula is widely used and certain feeding practices well established.

A number of actions were identified by Save the Children that could be taken to improve the coordination and nature of the emergency response to the situation in Gaza:

• Clarify leadership on infant and young child feeding in the current and ongoing response and terms of reference for this role. This role should include advocating and supporting implementation of all the provisions of the Operational Guidance on IFE by humanitarian actors, monitoring and reporting of any violations of the Code, and dealing with untargeted distribution of breast milk substitutes.
• Collaborative development of an emergency preparedness and response plan across sectors and between local, national and international partners. These should look to integrate the provisions of the International Code of the Marketing of Breast Milk Substitutes and the Operational Guidance on IFE.
• Cross-sectoral collaboration on IFE, involving heath/nutrition cluster to lead on IFE as lead sectors, and with water, sanitation and hygiene (WASH), shelter and logistics participation.

Specific actions to address concerns highlighted in the assessment include:

• Prioritisation of a more detailed assessment into the causes of childhood diarrhoea, combined with effective prevention and treatment. This could build upon on going WASH cluster studies at household level.
• Pilots of new approaches to prevent and treat anaemia at both facility and community level are needed. One option is use of multiple micronutrient powders for home fortification as part of comprehensive complementary feeding interventions. Special attention should be paid to the 6-24 month old group who are not targeted by many nutrition based interventions in Gaza. Given the chronic nutrition problems in Gaza, iron status is not the only concern and more in-depth micronutrient assessment should be considered to investigate further other micronutrient deficiencies in Gaza.
• Donor advocacy for longer term programming that allows root causes and behaviours associated with poor IYCF practices to be addressed. Newborn and child survival is a priority focus,

Continued short term funding in the Gaza Strip is not conducive to the required behaviour change, planning and resource inputs needed at all levels. Critically, participatory development of a comprehensive IYCF policy and strategy that considers the implementation of international policy guidance on IFE in the context of Gaza and involving local, national and international partners is needed. Appointment of a national coordinator with appropriate authority would greatly facilitate leading multi-sectoral stakeholders to develop and deliver such a strategy.

For more information, contact: Victoria Sibson, email: v.sibson@savethechildren.org.uk or Susan Thurstans, email: S.Thurstans@savethechildren.org.uk

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¹The Gaza Strip is a coastal area of land along the Mediterranean Sea bordered by Egypt and Israel, about 41 km long, and between 6 and 12 km wide, with a total area of 360 square km. It is home to about 1.5 million Palestinians. The area is recognized internationally as part of the occupied Palestinian territories.

²PCHR (2009) Confirmed figures reveal the true extent of the destruction inflicted upon the Gaza Strip, Palestinian Centre for Human rights, Ramallah

³Palestinian Authority (2009) The Palestinian national early recovery and reconstruction plan for Gaza 2009- 1010, launched by the Palestinian national Authority at the international conference in support of the Palestinian economy for the reconstruction of Gaza in Sharm El- Sheikh, Egypt, 2 March 2009

⁴Refers to the second Palestinian uprising, a period of intensified Palestinian-Israeli violence, which began in late September 2000

⁵Rahim. H, Wick. L, Sahar Hassan-Bitar L, Chekir H, Watt. G, Khawaja M (2009) Maternal and child health in the occupied Palestinian territory, Lancet 2009; 373: 967-77

⁶Save the Children UK, child rights fact sheet, October 2007

⁷Giacaman R, Khatib R, Shabaneh L, Ramlawi A, Sabri B, Sabatinelli G, Khawaja M, Laurance T, (2009), Health status and health services in the occupied Palestinian territory, Health in the occupied Palestinian territory, Lancet 373:837-49

⁸UNRWA factsheet

⁹Data for Palestine Central Bureau for Statistics (PCBS), 2007

¹⁰Infant and young child feeding practices. Collecting and Using Data: A Step-by-Step Guide. Care USA, Jan 2010.

¹¹http://sampsize.sourceforge.net/iface/index.html#prev

¹²The indicator that drove sample size was exclusive breastfeeding. The sample therefore required 226 children 0-5 months of age, 226 children 6-11 months of age, 226 children 12-17 months of age and 226 children 18-23 months of age.

¹³Based on 58% prevalence in this population size, a sample size of 370 would be required to achieve 95% confidence for mothers. A sample of 287 is required to gain 95% confidence for this level of anaemia amongst children meaning the sample size was sufficient.

¹⁴Because calculation of this indicator according to the international guidelines produced misleading results in light of the extreme prevalence of anaemia, the estimation has been omitted

¹⁵Save the Children UK (2008). Fast tracking improvements to infant feeding in emergencies.