Teresa Welsh :
In the aftermath of the 2010 earthquake in Haiti, the international aid community worked to respond to immediate needs of millions of people lacking access to food, shelter, and health care. One need was infant nutrition.
"There was some real concern after the earthquake about how babies were being fed," recalled Sarah Butler, director of emergency nutrition at Save the Children USA.
Despite studying public health, before joining Save the Children Butler remembers feeling like she had not received enough training to enable her and other aid workers to assist mothers who needed support breastfeeding after the quake, as the country struggled with recovery efforts.
"We knew that infants in Haiti were at high risk, and that breastfeeding could protect them from illness and death. We had standard guidance on feeding infants and young children in emergencies, and lessons learned from previous responses, but we were still learning how best to support mothers - both those who were breastfeeding and those who were not," Butler said.
"We brainstormed and developed new ways to offer parents support during emergencies. Looking back, we learned a lot from the Haiti response."
Save the Children began "investing heavily" in breastfeeding during emergency responses following the Haiti earthquake, Butler said, and now breastfeeding is incorporated into every response plan.
One of the organization's key responses is currently taking place in Cox's Bazar in Bangladesh, in Rohingya refugee camps where breastfeeding is considered a life-saving intervention. In such situations, the team works to identify where children and mothers are and how Save the Children and other partners can help address their needs.
They work to educate mothers on the basics of breastfeeding - that women who have already had infants may not have been taught when the baby was born. They also target mothers who have given birth after an emergency is underway, such as in a refugee camp. Lessons include how to attach a baby to the breast and position them for feeding. NGOs also work to create safe spaces where women can come to breastfeed their children in privacy and also have access to experts who can help address any concerns they have.
"Many mothers have doubts and questions all over the world in all kinds of settings, including on this issue of breastfeeding," said Maaike Arts, United Nations Children's Fund's nutrition specialist. "We're talking about very stressful situations where … people are stressed out in general, so it's another reason to make sure this important aspect gets a lot of support."
UNICEF is the global cluster lead for nutrition in emergency situations, and along with the Emergency Nutrition Network, co-led an update to the operational guidance of Infant and Young Child Feeding in Emergencies, which was first developed by the Interagency Working Group on Infant and Young Child Feeding in Emergencies in 2001.
After updates in 2006 and 2007, the most recent version was released in October 2017. The document aims to help decision-makers, planners, and donors to meet responsibilities set out in the UNICEF and WHO Global Strategy on Infant and Young Child Feeding, which is in the Convention of the Rights of the Child. It includes guidance on how to develop policies to support breastfeeding in emergencies and then how to train staff to implement them. UNICEF and the World Health Organization also lead the Global Breastfeeding Collective, which focuses on advocacy.
World Health Assembly targets set in 2012 call for at least a 50 percent rate of exclusive breastfeeding by 2025, from a 37 percent baseline at the time. Currently, no country meets the minimum recommendations for breastfeeding recommended by UNICEF and WHO.
UNICEF's programming includes establishing mother-to-mother networks so women can share information and experiences, as well as giving women access to skilled counselors who can assist them.
World Health Assembly targets set in 2012 call for at least a 50 percent rate of exclusive breastfeeding by 2025, from a 37 percent baseline at the time. Currently, no country meets the minimum recommendations.
These counselors and other aid workers work to battle misinformation about breastfeeding that can proliferate in developing countries and in stressful situations. Often, this revolves around breast milk substitutes that are sometimes encouraged by governments and local health facilities.
Najwa Rizkallah, nutrition sector coordinator in Damascus, Syria for UNICEF, who previously worked in Baghdad, said the Iraqi government provided bottles and infant formula to women after they delivered their babies. In addition, often, delivery attendants did not provide women with the right information on early attachment - to start breastfeeding within the first hour of birth - and at times, pediatricians receive incentives from formula companies to recommend it instead of breastfeeding.
All of this posed a challenge for UNICEF during the Iraq War as it worked with internally displaced women and vulnerable populations.
"Most of them, they are coming traumatized," Rizkallah said. "We were trying to find a safe haven for these women to come and talk and discuss their problems, and at the same time encourage them to breastfeed. This was really done in IDP [internally displaced person] camps and in Syrian refugee camps also we managed to do that. But it's required a lot of patience and also it's required a lot of commitment and discussion and raising awareness of these women."
Another major obstacle in emergency situations is that mothers think that when they are malnourished themselves, their bodies cannot provide appropriate nutrition for their infants via breast milk.
This often leads to situations where the mother or other family members start supplementing a baby's food with formula or other foods, moving both mother and baby away from the habit of breastfeeding.
"Even if a mother is malnourished, she can produce enough milk to breastfeed her child. That said, it can be very difficult for mother who hasn't eaten or doesn't have enough water or has been walking from country to country for X number of days to believe she can and that she has sufficient supply," Butler said.
"Even if a mother is malnourished, she can produce enough milk to breastfeed her child. That said, it can be very difficult for mother who hasn't eaten or doesn't have enough water … to believe she can and that she has sufficient supply."
"It's something that we're really conscious of, that even if the science says that ... her body will prioritize the food for the baby, the woman cannot be forgotten in this situation."
Butler emphasized the importance of involving other sectors that may be present in an emergency response to ensure that the care mothers and families receive is holistic. The Operational Guidance on Infant and Young Child Feeding in Emergencies encourages organizations to train staff that come into contact with mothers and children under age two on nutrition screening, and how to help parents and refer at-risk families to specialists.
"Breastfeeding isn't easy for everybody. Under the best of circumstances, it can be challenging. So when you're facing an emergency we need to make sure that mothers have access to the people who know how to support breastfeeding," Butler said.
"Many breastfeeding challenges are just in attachment, or how the baby latches, so that's something that you can train a frontline health worker to support a mom and just altering one thing that they're doing to help that attachment. Beyond that, working with other colleagues to make sure basic needs are met and prioritized can make a real difference to support a mother to breastfeed."
In protracted emergencies, such as refugee camps, NGOs work to spread institutional knowledge about the importance of breastfeeding and how it can be successful in stressful situations that see families out of their homes for years.
"If an emergency continues, of course you have a chance maybe to build capacity of local organizations and local governments in particular, and among the affected population," Arts said. "You get a better understanding of situation so you are better able to cater to the need."
NGOs involved in breastfeeding education also emphasize the importance of preparedness in ensuring that infant feeding doesn't fall by the wayside in emergency situations. In areas prone to natural disasters, UNICEF and its partners work with governments and local NGOs on risk-informed programming.
"One important aspect of our regular programming is to make sure that the relevant policies are in place, for example the marketing of breast milk substitutes, but also in general that the general policies on breastfeeding are in line with WHO and UNICEF recommendations," Arts said. "Preferably we don't start at the moment that there is an earthquake or other emergency."
(Teresa Welsh is a reporter with Devex based in Washington, D.C. Prior to joining Devex, Teresa wrote about Latin America from McClatchy's Washington Bureau and covered foreign affairs for U.S).