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Shela Hirani,¹ Solina Richter² and Bukola Salami²

¹Faculty of Nursing, University of Regina, Regina, Saskatchewan, Canada. ²Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada. (Correspondence to: Shela Hirani: This e-mail address is being protected from spambots. You need JavaScript enabled to view it ).

Abstract

Background: During disasters and displacement, affected families often receive humanitarian aid from governmental and nongovernmental organizations and donor agencies. Little information is available on the effects of humanitarian aid on the breastfeeding practices of mothers affected by disaster and displacement.

Aims: The aim of this study was to explore the effects of humanitarian aid on the breastfeeding practices of displaced mothers affected by natural disasters in Chitral, Pakistan.

Methods: This was qualitative study of residents of four villages of Chitral who had experienced a recent flood and later an earthquake. Data were collected through field observations, analysis of various documents (e.g. aid-agency documents, published reports and newspaper articles) and in-depth interviews with 18 internally displaced mothers living in disaster relief camps in Chitral.

Results: Three main themes developed from the data: humanitarian aid as a life saver, insufficient humanitarian aid affecting breastfeeding, and systemic injustices in the distribution of humanitarian aid.

Conclusion: Although humanitarian aid facilitated the survival, health and well-being of the displaced mothers and their family members, there were various problems with the humanitarian aid that increased the vulnerability of the displaced mothers and negatively affected their breastfeeding practices. Humanitarian aid must be gender-sensitive, thoughtful, timely, needs-based, equitable and context-specific. A systematic process of aid allocation and restricted donation of formula milk or any other form of breast-milk substitute is recommended during disasters.

Keywords: natural disasters, relief work, mothers, breastfeeding, Pakistan

Citation: Hirani S; Richter S; Salami B. Humanitarian aid and breastfeeding practices of displaced mothers: a qualitative study in disaster relief camps. East Mediterr Health J. 2021;27(12):1197–1202. https://doi.org/10.26719/emhj.20.087
Received: 03/10/19; accepted: 09/02/20

Copyright © World Health Organization (WHO) 2021. Open Access. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

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Introduction

Globally, malnutrition is reported to cause the deaths of 2.7 million children a year. Optimal breastfeeding could save the lives of over 820 000 children under the age of 5 years each year (1). Breast milk completely meets the nutritional needs of infants under the age of 6 months, promotes growth, fosters brain development, reduces the risks of malnutrition and infectious disease, and minimizes the risk of noncommunicable diseases (2). Considering the health, nutritional, developmental, psychological, environmental, and economic benefits of breastfeeding (3), it is particularly recommended during humanitarian emergencies, mainly natural disasters, to save the lives of young children (4). Despite the benefits of breastfeeding, suboptimal infant feeding practices and subsequent increases in infant mortality are reported during disasters, displacement and settlement of displaced communities in disaster relief camps (4). Although challenges associated with breastfeeding during natural disasters are global, they are particularly problematic in low- and middle-income countries such as Pakistan. Pakistan has the second-highest under-5 child mortality rate (86 per 1000 live births) in South Asia as a result of suboptimal breastfeeding practices and malnutrition (5). During disasters, child mortality in Pakistan often increases by about 10% because of a further decline in breastfeeding prevalence, subsequent rise of childhood malnutrition and outbreaks of communicable and infectious diseases such as diarrhoea and dysentery (5).

Chitral is a mountainous region in northern Pakistan with a population of 470 000. It is underserved and affected by natural disasters. About 47% of the population are females and 12% are children aged 0–5 years. The region has a limited number of educational institutions, accessible health facilities and programmes on breastfeeding. Although the overall adult literacy rate is 54%, the female literacy rate is only 37%. Maternal and under-5 mortality rates are quite high at 275 per 100 000 live births and 75 per 1000 live births, respectively.

Chitral has had recurrent disasters, including earthquakes, landslides, avalanches and flooding. Many villages in Chitral experienced flooding on 29 July 2015 as a result of a glacial lake outburst, which lasted for a month. The flooding killed about 32 people and injured more in Chitraland. It wiped out and damaged many villages and cut them off from other parts of the district for more than 3 weeks. The flood caused the water and electricity supply to be cut off in many villages, and damaged many health centres and basic health units, hence interrupting delivery of health care services to the area. About 3 months after the flood, a major earthquake (magnitude 7.5) occurred on 26 October 2015, which killed 221 people, and left many more injured and homeless. Many families affected by these disasters are temporarily resettled in disaster relief camps (mainly tents, transitional shelters and mud-brick houses). The recurrent disasters have led to long stays in disaster relief camps and forced affected communities, mainly women and young children, to live in unsafe housing that lacks basic facilities such as sanitation, clean drinking-water, proper ventilation, electricity, waste disposal, and health care (5).

During disasters, affected families often receive humanitarian aid from a variety of governmental and nongovernmental organizations and donor agencies. Although humanitarian aid is provided in order to save the lives of the displaced population, it is important to understand how this aid shapes breastfeeding practices of displaced mothers with young children. In the disaster relief camps in Chitral, there are currently no standardized national or regional programmes or policies to support breastfeeding. Therefore, it is even more important to fill this gap in knowledge so that health care professionals, relief workers and other stakeholders can develop context-specific supportive interventions that may improve breastfeeding practices.

We aimed to explore the effects of humanitarian aid on the breastfeeding practices of displaced mothers living in the disaster relief camps of Chitral, Pakistan.

Methods

This was a qualitative study undertaken from March to May 2018 in the disaster relief camps of Chitral, Pakistan. We collected on residents from four villages of Chitral that had been affected by the glacial lake outburst flood and subsequent earthquake. We accessed the relief camps with the support of a humanitarian relief agency based in Pakistan.

We collected data through field observation, document analysis and in-depth interviews with 18 internally displaced mothers living in the disaster relief camps who had young children aged 1 day to 36 months. We invited mothers to participate in this study through a community mobilizer. We used a semi-structured interview guide for the in-depth interviews. Participation in this study was voluntary and participants had the option to withdraw from the study at any time. We maintained anonymity and confidentiality of the participants during data collection, analysis and reporting of the findings.

The process of data analysis included derivation of codes, categories and themes from the data gathered from multiple sources.

We received ethical approval to conduct this study from the University of Alberta Research Ethics Board.

Results

Demographic characteristics of participants

The ages of the 18 mothers ranged from 18 to 40 years. The education level of participants varied from illiterate to university education. Participants had been living in a variety of temporary housing for more than 2.5 years, including transitional shelters, damaged houses and tents donated by the humanitarian relief agencies. Most of the participants lived within an extended family. The number of family members living in temporary housing ranged from four to 15. The number of children per participant ranged from one to seven. The age of the youngest children ranged from 3 months to 3 years. Three of the mothers were exclusively breastfeeding their infants, 11 were breastfeeding and using cow’s milk, solids and/or formula milk, and four mothers were using only breast-milk substitutes (cow’s milk, formula milk and/or solids) to meet the nutritional needs of their youngest child.

Effects of humanitarian aid

Three main themes evolved from the data: (i) humanitarian aid as life saver; (ii) insufficient aid affected breastfeeding and (iii) systemic injustices in distribution of humanitarian aid. Each of these are discussed below:

Humanitarian aid as life saver

Participants viewed humanitarian aid as life saver. Most of the mothers acknowledged that the contribution of humanitarian aid from the government, relief agencies, volunteers and neighbouring villagers enabled them to survive during the disaster and helped them to sustain breastfeeding. The aid provided included food items (rice, sugar, cooking oil, powdered milk, flour, lentils, tea, salt), non-food items (tents, tarpaulin sheets, clothes, blankets, hygiene kits, mattresses utensils, water coolers), insulated shelters and financial assistance While acknowledging the insulated shelters allocated by the relief agency as a humanitarian aid, one of the participants who was continuing her breastfeeding while living in a shelter said:

When I am feeding her [child] it’s much better if we sit inside the shelter because the shelter is an enclosed warm space and the child won’t feel cold inside, and nor would I, during that time [breastfeeding].

While acknowledging the role of humanitarian aid in supporting the nutritional needs of breastfeeding mothers, another mother who was able to resume breastfeeding noted:

At first, my breastmilk stopped because of the lower food intake, but as I started to eat again the breastmilk supply resumed. We received some support and items as help: oil, blankets, flour, and a lot of other things. We also received some clothes. I am thankful that we had that at least. In our homes [before the disaster] we had lands and lots of food. Comparatively, this was much less than that, but I am thankful that we got this much at least.

Insufficient aid affecting breastfeeding

The mothers highlighted insufficient and inadequate aid as a barrier to breastfeeding. A review of records and documents maintained by the humanitarian relief agency confirmed that during the two disasters in Chitral, most of the accessible villages and displaced families were provided food and non-food items only for 2–4 weeks. The documents maintained by one of the relief agencies showed that after each of these disasters, the families affected received food and non-food items only once.

Breastfeeding mothers affected by disaster shared various challenges with humanitarian aid, including: inadequacy of the aid, delayed allocation of aid, delays in getting a shelter or tent, inadequate assistance for the real victims as opposed to those who were not affected, inadequate duration of aid, no donations of items needed at the time, and distribution of aid (especially powdered milk and infant formula) without proper instructions about its use and contraindications.

People who came from the relief agency did provide us with some expenses. I got mine. I got it for a month only and after that it stopped. We [breastfeeding mothers] didn’t eat proper meals and all these reasons were a contributing factor to it [insufficient breastmilk].

My breastmilk was not sufficient, and my child cried. I was worried and I was not comfortable in the way we lived. We got the tent at that time [after the earthquake]. Once it rained so much that the tent collapsed on the ground. After the rains we had to reconstruct it and live in the same again… If a person is not comfortable, how will he or she be able to survive in this life? The mother will always be under stress and surviving in such conditions [cramped and uncomfortable disaster relief camps] will be difficult. In such circumstances, mothers may commit suicide as a last resort.

Another mother could not sustain her breastfeeding practices because of a prolonged period of hunger as a result of not receiving humanitarian aid on a timely basis.

During and after the disaster there wasn’t anything available for us to eat. The problem was that all the roads were destroyed on the way out of here. We got the aid after almost a month.

One mother shared the challenges associated with the delayed allocation of aid that negatively affected the health of children and the breastfeeding practices of mothers affected by disaster.

If we had been given a house or tent sooner and proper food then it would have been helpful for us and the children. Lots of children from other families were sick because of not having a proper diet. We didn’t get the tents on time.

Although the transitional insulated shelters provided were better than tents, there were delays in the allotment of the shelters that affected the health and wellbeing of breastfeeding mothers and young children. Due to this delay, many breastfeeding mothers faced the stress of breastfeeding in public and they spent the winter season in a tent, their damaged house, open spaces with no privacy, or at a relative’s place where there were several challenges to maintaining their breastfeeding practices.

When the floods came in, we [breastfeeding mother] were left without shelter from view and became unveiled. We didn’t have shelter at that time, we lived in a tent for a month. The men would live outside the tent, whereas women lived inside the tent. Mothers and children were also living inside the tent. There were no clothes for the children. They only had what they were wearing. Whenever I had to breastfeed my child, there was no privacy. We couldn’t breastfeed them [children] comfortably like a mother does in her own house. These were difficult times.

A few of the participants said that they received formula milk and powdered milk without any instructions on whether it was for children or adults. They either used it to prepare tea, feed older children, or passed it on to the mothers who had insufficient breastmilk or hungry infants.

We [breastfeeding mothers] did get some powdered milk for tea. We [mothers] weren’t told that the powdered milk was for tea. We added it to the tea ourselves. No one told us anything; we did all of it ourselves.

Injustices in aid distribution

Many of the mothers talked about systemic injustices in aid distribution that increased their stress, and hence affected their health and breastfeeding practices. They mentioned favouritism, inequitable distribution of humanitarian aid, inadequate needs assessment before allocation of humanitarian aid (including shelter), lack of governmental support, corruption by the influential people in the village, non-supportive relief authorities and a lack of a participatory approach by relief authorities (consultation with the affected communities) to understand their needs and provide them with context-specific need-based services.

We don’t get the relief funds properly because the people who are in charge of the distribution get hold of it first.

Another mother who could not sustain her breastfeeding practices, elaborated on the multiple forms of systemic injustices (favouritism, corruption by influential people of the village and inadequate needs assessment of the victims) that affected her health and breastfeeding practices.

Some of them got the relief items while the others didn’t get anything…if the influential people who were distributing all these items [aid and donated items] knew you then a person could readily get those items…The external donors don’t know who the victims are and who are not. They look for victims by asking local influential people about the affected families. The people of the village only share names of people who they know [on a personal basis regardless of if they are a victim or not]. The donors are absolutely unaware of the real victims actually affected by this [disaster]. Those who were not really affected got everything for themselves and their relatives, but no one came to us and gave anything for me [breastfeeding mother] or my children.

Discussion

Although humanitarian aid facilitated the survival, health and wellbeing of the displaced mothers and their family members, various problems with the humanitarian aid increased the vulnerability of the displaced mothers and negatively affected their breastfeeding practices. Although various relief agencies distributed aid in the form of temporary housing, food and non-food items, this aid was not available to many displaced mothers due to systemic injustices and gender insensitivities. The literature supports the existence of such injustice as it is reported that humanitarian aid often neglects the notion of cultural and gender-sensitive services, does not always reach the intended communities and is often not equitable (6), which further increases the vulnerability of displaced women and children (7,8). In our study, some families received support from multiple relief and donor agencies and others did not receive any aid as they were not in direct contact with the donor agencies or held less powerful positions in their communities.

Families that were not allocated a transitional shelter or tent on a timely basis had to live in damaged houses with limited privacy and safety. This further increased the vulnerability of displaced mothers and affected their breastfeeding practices. Moreover, the process of distribution of humanitarian aid did not provide equal opportunities for the breastfeeding mothers to receive humanitarian aid, services or assistance. Research underscores that injustices and gender insensitivity in distribution of aid increases women’s vulnerability as a result of disasters and negatively affects their preparedness and capacity to look after their child care responsibilities, including breastfeeding (9–13).

The short-term nature of the humanitarian aid (food and non-food items) led to food insecurity, mental distress and other challenges among the displaced mothers, including the negative effect on the breastfeeding of displaced mothers who wished to sustain these practices. In Chitral, where recurrent disasters are prevalent, humanitarian aid lacked interventions and need-based support specific for the disaster-affected families, especially for mothers and young children. Again research highlights that traditional humanitarian responses that lack need-based services and interventions relevant to the specific community increase vulnerability and jeopardize the wellbeing and safety of displaced women and children (14–16). A narrow scope of interventions and inadequate attention to the long-term development of the displaced people are also reported as major drawbacks of humanitarian assistance (11,17,18).

Another concern about the humanitarian aid was the unmonitored distribution of powdered milk without proper instruction or guidance on its use, which further increased the vulnerability of mothers and children, and negatively affected the mothers’ ability to provide for their children. Although displaced mothers mainly used the powdered milk to prepare tea, they sometimes fed this milk to their infants as a breast-milk substitute. Limited knowledge of how to prepare and use powdered milk may lead to waterborne diseases in infants and subsequently increase the economic and emotional burden of caring for a sick child during disaster and displacement. Previous studies have also highlighted similar issues on the distribution of free formula milk to displaced mothers that negatively affect the health and wellbeing of mothers and children (4,19–24).

Our analysis of the situation suggests the importance of a collaborative approach among local, national and international relief agencies in undertaking proper planning on the scope, design and distribution of humanitarian aid. Moreover, strategies to ensure proper monitoring and evaluation of the process of aid distribution are essential to overcome systemic injustices and gender insensitivities of humanitarian aid. Responding to the needs of a community during a disaster and emergency evacuation by government and humanitarian relief agencies is important to ensure the humanitarian aid is thoughtful, equitable and context-specific. Involving the disaster-affected community (both men and women of different villages in Chitral) is needed to identify the supplies needed during the disaster, displacement and settlement in the disaster relief camps. This approach will ensure that the aid is timely, needs-based, gender-sensitive and culturally appropriate.

A systematic process of aid allocation to the displaced families is also necessary. This will ensure that the aid is distributed in an equitable manner and there are no systematic injustices. Collaboration between the relief agencies (both national and international) is essential to design an efficient process of aid allocation in view of the needs of the displaced community. Various processes can be undertaken in collaboration with the key stakeholders to ensure allocation of aid to displaced families (both accessible and inaccessible families) on a timely basis to ensure their survival and wellbeing. Monitoring and evaluation of the distributed aid must be done collaboratively by the national and international relief agencies. Moreover, restricted donation of formula milk or any other form of breast-milk substitute, including powdered milk, is recommended during disasters.

Acknowledgement

We acknowledge the support of Aga Khan Agency for Habitat (AKAH), Pakistan (humanitarian relief agency based in Pakistan) before and during fieldwork in Chitral, Pakistan. We thank the study participants for their time and agreement to share their breastfeeding experiences.

Funding: International Development Research Center, Canada and Sigma Theta Tau International, United States of America.

Competing interests: None declared.

Aide humanitaire et pratiques d'allaitement au sein des mères déplacées : une étude qualitative dans les camps de secours en cas de catastrophe

Résumé

Contexte : Lors des catastrophes et des déplacements de populations, les familles touchées reçoivent souvent une aide humanitaire de la part d'organisations gouvernementales et non gouvernementales ainsi que d'organismes donateurs. Peu d'informations sont disponibles en ce qui concerne les effets de l'aide humanitaire sur les pratiques d'allaitement au sein des mères touchées par des catastrophes et déplacées.

Objectifs : L'objectif de la présente étude était d'examiner les effets de l'aide humanitaire sur les pratiques d'allaitement au sein des mères déplacées touchées par des catastrophes naturelles dans le district de Chitral (Pakistan).

Méthodes : Il s'agissait d'une étude qualitative menée auprès de résidents de quatre villages du district de Chitral qui avaient récemment subi une inondation, puis un tremblement de terre. Les données ont été recueillies par le biais d'observations sur le terrain, de l'analyse de divers documents (par exemple des documents des organismes d'aide, des rapports publiés et des articles de journaux) et d'entretiens approfondis avec 18 mères déplacées internes vivant dans des camps de secours en cas de catastrophe dans le district de Chitral.

Résultats : Trois thèmes principaux sont ressortis des données : l'aide humanitaire en tant que moyen de préserver des vies, l'impact de l'insuffisance de l'aide humanitaire concernant l'allaitement au sein, et les injustices systémiques dans la distribution de l'aide.

Conclusion : Même si l'aide humanitaire a facilité la survie, et favorisé la santé et le bien-être des mères déplacées et des membres de leurs familles, divers problèmes liés à cette aide ont augmenté la vulnérabilité des mères déplacées et ont eu un impact négatif sur leurs pratiques d'allaitement au sein. L'aide humanitaire doit intégrer les questions de genre, être judicieuse, accordée en temps utile, fondée sur les besoins, équitable et adaptée au contexte. Un processus systématique d'allocation d'aide et de don restreint de lait maternisé ou de toute autre forme de substitut du lait maternel est recommandé pendant les catastrophes.

المساعدات الإنسانية وممارسات الرضاعة الطبيعية لدى الأمهات النازحات: دراسة كيفية في مخيمات الإغاثة في حالات الكوارث

شيلا هيراني، سولينا ريختر، بوكولا سلامي

الخلاصة

الخلفية: غالبًا ما تتلقى الأُسر المتضررة من الكوارث والنزوح مساعدات إنسانية من المنظمات الحكومية وغير الحكومية والوكالات المانحة. ولا تتوفر سوى معلومات قليلة عن آثار المساعدات الإنسانية على ممارسات الرضاعة الطبيعية لدى الأمهات المتضررات من الكوارث والنزوح.

الأهداف: هدفت هذه الدراسة إلى استكشاف آثار المساعدات الإنسانية على ممارسات الرضاعة الطبيعية لدى الأمهات النازحات المتضررات من الكوارث الطبيعية في شيترال، باكستان.

طُرق البحث: أُجريت هذه الدراسة الكيفية على سكان أربع قرى في شيترال، كانوا قد تعرضوا لفيضان حدث مؤخرًا ثم تبعه زلزال. وجُمعت البيانات من خلال الملاحظات الميدانية، وتحليل مختلف الوثائق (مثل الوثائق الصادرة عن وكالات تقديم المساعدات، والتقارير المنشورة ومقالات الصحف)، وإجراء مقابلات متعمقة مع 18 من الأمهات النازحات داخليًا اللاتي يعشن في مخيمات الإغاثة في حالات الكوارث في شيترال.

النتائج: أبرزت البيانات ثلاثة مواضيع رئيسية، هي: المساعدات الإنسانية بوصفها منقذة للحياة، وتأثير عدم كفاية المساعدات الإنسانية على الرضاعة الطبيعية، والإجحافات المنهجية في توزيع المساعدات الإنسانية.

الاستنتاجات: على الرغم من أن المساعدات الإنسانية يسَّرت فرص بقاء الأمهات النازحات وأفراد أسرهن على قيد الحياة والحفاظ على صحتهم وعافيتهم، فإن هناك مشاكل عديدة تتعلق بالمساعدات الإنسانية تزيد من ضعف الأمهات النازحات وتؤثر سلبًا على ممارساتهن في الرضاعة الطبيعية. ويجب أن تكون المساعدات الإنسانية مراعية للاعتبارات الجنسانية، ومدروسة، وملائمة من حيث التوقيت، وقائمة على الاحتياجات، ومنصفة، ومحددة السياق. ويوصى أثناء الكوارث باتباع أسلوب منهجي في تخصيص المساعدات والحد من التبرع بمستحضرات الحليب أو بأي شكل آخر من بدائل لبن الأم.

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