Postscript: Commentary on experiences of IYCF support in the Jordan response

By Ann Burton, Senior Public Health Officer UNHCR Jordan 

These two articles highlight the challenges in protecting and promoting sound infant and young child feeding (IYCF) practices in a humanitarian emergency. Much of the guidance on IYCF has been developed for resource poor settings. Infants in these settings who are not breastfed have a much higher risk of dying.  This risk is exacerbated by the upheaval generated by emergency settings. There have been few articles published on experiences of IYCF in emergencies in low to middle income countries, such as Jordan. Acute malnutrition prevalence amongst Syrian refugees in Jordan is low and not considered a public health problem, and mortality rates are low and stable; regardless there is always an important need to promote sound IYCF practices for optimal infant and young child health outcomes.  

Alsamman and Flanders et al highlight the poor IYCF practices both in Syria and in the refugee hosting country, Jordan, prior to the refugee influx. Though it is critical to try and protect breastfeeding throughout all stages of the refugee programming, this has been made much harder by the poor practices pre-conflict, the low level of knowledge amongst many humanitarian actors, including medical and nursing staff, and the misconceptions around breastfeeding. There were many non-traditional actors involved in the response most of whom had not been exposed to the Code or the Operational Guidance on IYCF in Emergencies (IYCF-E). Though health and nutrition programme managers from international organisations were well-versed in the current recommendations about the use of breastmilk substitutes (BMS), doctors and midwives providing services were not generally very supportive of breastfeeding or easily succumbed to pressure from mothers and family members to provide infant formula. Practices surrounding delivery were also not conducive to early initiation, with the infant often separated from the mother and started on other liquids. This highlights the need to not only target humanitarian service providers with training in key beneficial IYCF practices but also, in the medium to longer term, to strengthen the IYCF component of medical and nursing school curricula and revitalise the Baby Friendly Hospital Initiative.  

Unsolicited donations of BMS continue at the time of writing.  Fortunately, the Standard Operating Procedures on Distribution and Procurement of Infant Formula and Infant Feeding Equipment¹ put in place in November 2012 by the Nutrition Sub-working Group (and updated in May 2014) meant that many donations came to the attention of the nutrition actors and measures could be taken to minimise the risks associated with such donations.  However, as pointed out by Flanders et al, this was very time consuming at a time when there were many other pressing priorities.  Furthermore, if the NWG had been consulted prior to the donation, a request would have been made for other food or non-food items, such as age appropriate complementary food in place of infant formula.  

There were many donations and distributions of BMS outside of the health system demonstrating that advocacy and training needs to also target other sectoral actors in addition to those working in health and nutrition. Non-traditional actors, especially the military and emerging humanitarian actors, also need to be made aware. As these actors expand their geographical scope into other crisis-affected parts of the world - many of which have considerably higher malnutrition rates and poorer hygiene and sanitation situations - the effects of indiscriminate use of BMS on infant morbidity and mortality would be much more severe.  

Another key challenge in the Syrian situation and detailed by these two articles is how to support non-breastfed infants and their mothers to ensure optimal growth and wellbeing but without undermining key messages in support of breastfeeding.  Much of the focus of IYCF programming has been support to breastfeeding mothers or relactation. Alsamman has outlined the support in camp settings in Jordan to non-breastfed infants. In non-camp settings, this has been very difficult to put in place. Most refugees access Ministry of Health services  and apart from ad hoc support to some women,  non-governmental organisation (NGO) service providers are not in a position to meet the demand for infant formula which would entail assessment of  women for their ability to breastfeed, prescription and dispensing when indicated and support to non–breastfed infants.  Their reluctance to get involved has also been influenced by security concerns based on the experiences in Zaatri Camp outlined by Alsamman.  In Jordan, infant formula is only available through pharmacies and is therefore not available through the WFP-supported food voucher schemes, which has also limited formula use in out-of-camp settings. Recognising that there are mothers who will not be able to breastfeed and who will have difficulties affording formula, the Nutrition Working Group is exploring the option of referring mothers who are unable to breastfeed (after assessment by a midwife trained in IYCF) for cash assistance so that they can purchase formula themselves.  This would be combined with the additional support and follow up needed for non-breastfed infants but will reduce the likelihood of the potential problems associated with actual formula distribution. The different approaches in the camp and non-camp settings in Jordan have resulted in formula feeding being considerably more common in out-of-camp infant refugees compared to those living in the camp (16.1 % of those 23 months and under had received formula in the preceding 24 hours versus 9.8% respectively²).   Though the more restricted access in the camp to BMS and the IYCF programming are no doubt significant factors, more research is needed on the determinants of infant feeding choices in displaced populations.  Are displaced women choosing to breastfeed because of economic necessity as well as convenience and if so how can these factors be used to promote breastfeeding in similar situations?

Lastly, more consideration needs to be given to the question of informed choice in infant feeding practices and to what extent humanitarian actors should withhold support for formula feeding in women who have made a truly informed choice.  Are humanitarian actors prepared to support this approach in settings where the choice to formula feed - though not optimal - does not carry the same health consequences as in other settings?  Even though the Operational Guidance on IYCF-E promotes the minimisation of the risks of artificial feeding, this is not always given the attention it needs in IYCF programming. Furthermore, the tendency is to focus on mothers who cannot breastfeed and not those who choose to not breastfeed. The economic considerations of an informed choice approach are also considerable. Infant formula is an expensive commodity and it is unlikely that limited humanitarian funds could be used to support provision of formula in a situation where a woman has chosen to formula feed.  Indiscriminate distribution of BMS and unsolicited donations should still be managed as per the Operational Guidance on IYCF-E but should a harm minimisation approach be considered in some settings? The Syrian refugee situation, with most refugees fleeing to low - middle income countries, has raised these questions and is challenging actors to review thinking on this issue. 

For more information, contact: Ann Burton, email:burton@unhcr.org

¹ Available at the UNHCR Syria response, portal: visit http://data.unhcr.org/syrianrefugees/regional.php?

² Preliminary findings Interagency Nutrition Survey  of Refugees in Zaatri and Out-of-Camp settings, May 2014 (unpublished)