Reviewing the FHI 360 mother-to-mother support experience in Yemen

What we know: Mother-to-mother support groups (MtMSGs) provide a peer support environment where women come together to discuss infant and young child feeding (IYCF) issues and share their experiences overcoming problems. These groups can effectively improve IYCF practices, including in emergency contexts.

What this adds: This FHI 360 experience illustrates the importance of peer support groups, especially in crisis contexts, reaffirming their potential to provide benefits in terms of IYCF practices, mutual support, health and wellbeing, and cost savings from reduced purchase of commercial milk formula and medication. We identify strategies to enhance support for lead mothers and to strengthen mothers’ engagement in support groups, for additional benefits.

After 10 devastating years of war, with thousands of civilian casualties and over four million internally displaced people, violence and insecurity remain endemic in Yemen. A profound economic crisis threatens the government's ability to sustain vital public services. Multiple domestic and external shocks are exacerbating the situation, including extreme weather events, the financial repercussions of the COVID-19 pandemic, and the wars in Ukraine and Gaza. A recent Humanitarian Needs Overview from the UN Office for the Coordination of Humanitarian Affairs (OCHA, 2024) reported that 7.7 million people require nutrition services: 2.7 million women and 5 million children.

According to data from the Nutrition cluster, 8/21 Yemeni governorates have wasting rates that exceed the 15% WHO emergency threshold: Al Hudaydah, Lahj, Taiz, Hajjah, Abyan, Mahawit, Sa’ada, and Dhamar (IPC, 2023). These governorates include 76 districts, accounting for 36% of the national wasting caseload. In the districts served by FHI 360 (figure 1), the level of nutrition severity is 5 (the highest), with a wasting rate of 28.9% in Hudaydah (Hays) and Taiz (Dhubab, Mawza and AlMokha (Al Makha)). Poor IYCF practices are a key factor contributing to the high wasting rates in the country.

Figure 1: FHI 360’s areas of intervention

MtMSGs are active in the Al Makha and Dhubab districts

MtMSGs are among the strategies implemented by FHI 360 to support communities to redress the dire situation. These groups complement and link with community health volunteers’ (CHVs) work. FHI 360 has implemented the MtMSG approach in five locations since 2023: Al Ghaded, Al Kadaha, Al Roa’a, Al Gharaffi, and Al Shatheliah. FHI 360 adopted the guidance and recommendations from the Yemen Ministry of Public Health and Population, while also drawing from the organisation’s experience in similar contexts such as north-east Nigeria and Ethiopia.

Evidence suggests that MtMSGs can be effective in emergency contexts. In the Dadaab Refugee camp (Kenya), there were 713 MtMSGs across three different camps, with 581 facilitators being trained over one year. Despite an increasing programme size due to refugee influxes, IYCF behaviours continually improved (World Alliance on Breastfeeding Action, 2024). 

What are mother-to-mother support groups?

There are important considerations when deciding to establish MtMSGs. In Yemen, FHI 360 looks for the following conditions: some stability in the context of operations (e.g. no major security threats in terms of fighting or social unrest), that people are likely to continue residing in the area for some time (at least six months), and that there is a sense of community. If the population is mobile and/or living in an unstable context, other strategies such as home visits and community discussions by community health and nutrition volunteers may be more effective.

To target the window of opportunity of the first 1,000 days of life, the recommended members of MtMSGs are pregnant women and mothers (primary caregivers) of children aged 0–2 years. In Yemen, where men must be informed and approve when women leave the house, it is very important for a mother to have the agreement of her family to join a MtMSG. As this is a new activity for FHI 360 and the community, it is important that the lead mothers and group members ensure that their husbands agree to and support their participation.

Lead mothers are selected from among the MtMSG members based on various criteria, including community knowledge, successful IYCF practice, communication skills, and time to dedicate to the initiative. They generally host group meetings in their homes. They are provided with two training days in IYCF facilitation and communication, as well as basic information, education, and communication materials to support group discussions and exchanges. The lead mothers also link with the health facility and the CHVs, sharing their group's updates, issues, and challenges. 

FHI 360 MtMSGs are set up so that group members do not need to walk more than 30 minutes to attend. Each MtMSG has between eight and 15 members. MtMSGs must be supervised and supported by trained CHVs and the health and nutrition staff of the nearest health facility.

MtMSG activities

The lead mother follows the proposed programme of thematic sessions on maternal, infant, and young child feeding, preparing each session in advance.

At the start of each session, the lead mother presents a visual counselling card (Figure 2) that describes the session's topic. She facilitates the group to share their knowledge and engage in discussion. The lead mother then suggests what they “would” do to help others practice what is recommended or “what they will do to try to practice it themselves.” Members then review and agree on recommendations to action themselves and promote to their communities.

Figure 2: Visual counselling card examples

Members commit to attend the sessions and participate by sharing experiences or ideas, trying out (and hopefully sustaining) recommended practices, and supporting the learning of other mothers living in their area. Members also refer mothers who may need additional support. A member will be asked to share their experiences of helping other mothers during the group sharing activity. Lead mothers also visit members’ homes to discuss how the support to other women is going.

After more than one year of implementation and anecdotal success, FHI 360 conducted a rapid assessment of the experience to learn from and inform the subsequent phases of the work. This assessment collected qualitative information on how IYCF practices among participants in the MtMSGs have changed after 16 months. The primary assessment outcomes were self-reported changes in knowledge about IYCF, self-reported changes in IYCF practices, and preferred topics discussed during support groups. Other benefits of participation in MtMSGs were assessed, as well as challenges or negative aspects, the level of engagement with other community members, and recommendations to improve the groups.

The study was conducted on the west coast in south Yemen, where FHI 360 is implementing an emergency response project. Five areas in Taiz were selected based on FHI 360’s extended presence in the area and the associated trust that has been built with communities. The assessment was conducted in December 2023 using focus group discussions (FGDs) and in-depth interviews to elicit the experiences of mothers and lead mothers in MtMSGs. Fifteen FGDs were conducted, with a total of 79 participants. Each FGD took between 60 and 90 minutes and included two note takers. Thirteen in-depth interviews were conducted with lead mothers, representing half of all lead mothers in the assessment area. Each interview took up to 60 minutes, with either the interviewer or a notetaker taking notes. Purposive sampling was used to identify and select the participants for the FGDs and the interviews. 

A compressed timeline limited the assessment team’s ability to pre-test the interview and FGD guides and limited the time for in-depth data analysis. Mothers did not feel comfortable with audio recording, so the assessment data consisted of notes taken by the team. These notes highlighted key themes and quotes from participants. In the results below, when frequencies are reported, these refer to the number of FGDs in which a particular theme emerged. While images would have been helpful, many participants did not want to be photographed (a traditional value on the west coast of Yemen). 

FGDs with participant mothers

Most women attended between 40 and 50 MtMSG sessions and noted that the location was easy to access, comfortable, and safe. Participants in all FGDs emphasised optimal breastfeeding and complementary feeding when asked what they had learned. The importance of exclusive breastfeeding in the first six months emerged as a critical learning across all FGDs (n=15). In addition, participants mentioned breastfeeding attachment (n=4), breastfeeding positioning (n=8), and hygiene, including personal and child hygiene (n=12). When asked about the benefits of these practices to the child and mother, they noted that their children are healthier and experienced a reduced incidence of disease, especially diarrhoea. Mothers credited the knowledge gained for their children’s improved nutrition/freedom from malnutrition, body growth, weight gain, development, and sleep, as well as comfort and confidence for mother and child (n=12). Mothers shared additional benefits, such as a reduction in the cost of purchasing both commercial infant formula and medications/medical care. Mothers in all FGDs associated increased immunity and improved health with changes they made due to their participation in MtMSGs. 

“It affected my comfort because my child’s comfort is my comfort” – FGD participant

When mothers were asked what they perceived to be the most significant change that resulted from their participation in MtMSGs, the key themes highlighted in the FGDs were improved breastfeeding (n=13) and complementary feeding (n=5), alongside cost savings (n=4) and improved family and home situations (n=3). 

Mutual support emerged as an important element of MtMSGs. Mothers valued the exchange of opinions and experiences with each other and, subsequently, their families and communities. Women from all but one FGD had invited neighbours or other women to join their MtMSG. The FGD facilitators asked participants about opportunities for MtMSGs to provide additional support and possible MtMSG adaptations. Mothers in more than half of the FGDs identified the provision of incentives and assistance, citing hygiene kits, nutritional support, and cash support as options that support groups are well placed to provide. Suggested adaptations ranged from varying the topics of the sessions and changing the leaflets and posters to providing snacks/meals, mats, and more materials for sessions. Participants noted that more groups could be created to benefit more women, children, and families. 

“Breastfeeding has been a challenge because… mothers believed that breastfeeding alone was insufficient to satisfy the child's hunger and that using formula feeding and introducing solid foods would contribute to faster growth. There was a misconception that breastfed children might be more susceptible to illnesses due to their slender and weak bodies” – lead mother, Taiz

Interviews with lead mothers

Reflecting on sessions they facilitated, lead mothers found the sessions that addressed breastfeeding, complementary feeding, and personal hygiene to be most impactful (in line with participant views). In terms of the successes of the MtMSGs, all lead mothers noted that, by successfully conveying information to members, they saw mothers make more positive choices. These included avoiding complementary feeding until the seventh month and prioritising vaccination (after initially fearing them). Anecdotally, lead mothers also reported seeing an overall reduction in disease and malnutrition among members’ children. 

Nine out of thirteen (69%) lead mothers shared that the most challenging part of their role was managing misconceptions related to breastfeeding and complementary feeding, as these made it difficult for mothers to accept the information being given. Other reported challenges included difficulty motivating members and the need to adapt information to suit members’ education/literacy levels. In addition, mothers had concerns about their own nutrition. Some mothers were unable to consume regular meals and they feared that this would affect their breastfeeding. Other challenges cited by lead mothers focused on logistical challenges (n=6) such as the distance between homes, lack of transportation, challenging roads, high winds, and presence of dogs.

Lead mothers mentioned educating (n=12) and building relationships with/respecting mothers and the community (n=3) as their favourite part of being a leader. When asked how one might improve upon MtMSGs, lead mothers suggested additional training for leaders (n=3) to be able to discuss new topics and providing cash incentives (n=5) for participating mothers.

“MtMSGs are a vehicle for behavioural change, valuing each member's experiences, views, and opinions. It provides a learning opportunity, receiving support, and supporting others without being judged or shamed.” – Lead mother

The findings of the qualitative assessment provide several recommendations on ways to strengthen MtMSGs that could lead to greater effects. The provision of joint session review meetings for lead mothers would support them to understand and agree on strategies that work to make MtMSG sessions more engaging. These session review meetings would also give the lead mothers a chance to share experiences with each other. Communication materials need to be adapted for specific contexts to address local misconceptions and myths. The possibility of supporting MtMSG members with basic in-kind materials (e.g. hygiene kits or cooking utensils,) or linking members with other local programmes for additional support (e.g. food security and livelihoods programmes), needs to be explored. Practical solutions to address issues of distance and transportation need to be identified (e.g. rotating venues to vary transit time among different group members and reducing session frequency from twice to once per week). Motivation and engagement can be improved by providing recognition to MtMSG members and the lead mothers for what they do, through certificates or a simple ceremony, or more simply through refreshments provided during the sessions.

The recommendations and suggestions from lead mothers and members are very valuable. Mothers feel they are not just part of the initiative but leading it. All the recommendations are practical and feasible in the medium to long term, but FHI 360 will need to network and link with other partners and programmes to respond successfully to each of them.

Despite some challenges in methodology within this setting, this qualitative assessment has shown the value of MtMSGs in this context in regard to improving the understanding of optimal IYCF and mutual support generated between mothers. Notably, the evaluation has identified key areas that can be enhanced to support the lead mothers and strengthen mothers’ engagement for future benefits. Following this, FHI 360 will continue supporting the MtMSGs and expanding the interventions in other villages. At the same time, thanks to the initial encouraging feedback and experiences, FHI 360 will also start supporting father-to-father support groups in recognition of men's critical role in Yemen in the improvement and care of the health and wellbeing of their families.

For more information, please contact Alessandro Iellamo at AIellamo@fhi360.org

IPC (2023) Yemen: Acute malnutrition situation October 2022 – May 2023 and projected June – September 2023 (partial analysis). ipcinfo.org

OCHA (2024) Yemen humanitarian needs overview 2024 (January 2024). reliefweb.int

World Alliance on Breastfeeding Action (2024) Mother-to-mother support groups in the Dabaab refugee camps. waba.org