Opeds

Without proper education on sanitation and their use, milk substitutes do more harm than good, especially in disaster-hit areas

Manoj Suji
The Kathmandu Post
14 January 2018

Every developing country faces challenges when it comes to saving the lives of infants and children. Maintaining standard health and nutrition during emergency situations such as earthquakes or severe flooding is made even more difficult because the intensity of challenges increases. It is important to understand the relationship between humanitarian organisations and their impact on mothers, infants, and children. Nepal suffered a devastating earthquake and many other natural disasters, including severe floods and landslides, in 2015, 2016, and 2017.  Many mothers, babies, and pregnant women were thrust into a state of severe vulnerability after these devastating events. These occurrences exacerbated issues relating to child health and nutrition as well as feeding practices.  

I recently co-authored a study with two other researchers on infant feeding during emergencies. In this project, our findings suggest that women who were displaced after the earthquake continued breastfeeding their babies. However, these women also encountered humanitarian groups that were distributing powdered infant formula (PIF) without proper assessment or lactation support. I had a series of conversations with many of the lactating mothers in the different shelters in and out of the Kathmandu Valley, and they shared their experiences of how the humanitarian organisations provided support. A woman from the Chuchepati shelter said that she had been feeding PIF to her five month old baby when she was only three months old, since her milk was insufficient. 

According to a post-disaster need assessment (PDNA) report, approximately 250,000 children between the ages of six months to 59 months, and 135,000 lactating women were adversely affected across 14 districts. Similarly, Save the Children stated that 29,332 babies were born after the earthquake in the 14 districts; Care Nepal and UNICEF also estimated that 126,000 pregnant women and 18,000 babies were severely affected. Despite the inconsistency of the data, there were commonalities on the extensive vulnerabilities experienced by many lactating mothers and pregnant women, as most had lost their houses, food, sources of livelihood, and often loved ones. After disasters and displacement, families live in unsafe and poorly managed shelters that lack adequate food and sanitation. 

Moreover, humanitarian organisations and individuals provide support by organising shelters for health care and psychosocial counselling, and also for distributing food for mothers and babies. However, this assistance is often inadequate or potentially detrimental; for instance, in Laprak, Gorkha, the World Food Program (WFP) provided expired packets of infant formula and power milk for the babies and inedible rice for the survivors. 

Nothing beats mother’s milk
Scholarly research on feeding infants and young children conducted globally in post-disaster contexts mostly in developing countries, show that pregnant women, lactating mothers, and children are severely vulnerable and require additional support. The studies suggest that the supply and use of breast-milk substitutes and formula distribution is dangerous for infants and children as they may cause several kinds of disease, diarrhoea, and even death. Furthermore, infant and child mortality is higher in post-disaster scenarios and more likely to occur in developing countries due to the badly managed distribution of formula and breast-milk substitutes, and the lack of promotion and teaching of appropriate alternative feeding practices. In addition, the studies also suggest that the distribution of formula discourages mothers in exclusively breastfeeding, and also the lack of availability of clean water and knowledge on how to prepare formula has a negative impact on child health. In many relocation camps, or areas in which displaced families are housed, it is extremely difficult, if not impossible, to properly clean and sterilise bottles, teats, and supplies for feeding. Therefore, breastfeeding is much safer than bottle feeding, especially in low resource settings. 

Following World Health Organisation (WHO) code, the International code for the Marketing of Breast-milk Substitutes 1981, the Ministry of Health and Population, and UNICEF released a joint statement on April 30, 2015, five days after the earthquake, to act as a guideline. It aimed to prohibit the unsolicited distribution of breast-milk substitutes in order to avoid the potentially dangerous and unintended consequences to infants and children. However, there was a lack of monitoring and implementation to prevent the distribution of breast milk substitutes and other inappropriate food items. 

When it’s all about output, not outcome
The flow of support was structured more by the political and economic interest of aid organisations, as they appeared to be more focused on the providing any type of support without following the guideline. Moreover, distributors at the ground level did not engage in proper assessments or provide clear instructions for safe infant feeding.  There were also many local Nepali NGO’s calling for donations of infant formula in response to the monsoon floods. These groups are well intentioned; however, gathering and distributing infant formula can cause great harm, including malnutrition, illness, and even death. 

During emergencies, the role of humanitarian organisations is indispensable for countries like Nepal, where the state cannot immediately access all levels of society due to economic and institutional restrictions. However, serious questions can be raised about the effectiveness and ethics of the support system that is provided, what the quality of distributed food items is, and how will it impact the health and nutrition of infants and children. The case of Laprak in Gorkha is just one example of how the aid was distributed during the disaster, but similar issues likely occurred throughout the country after the earthquake and recent floods. 

A recently published Nepal Demographic and Health Survey (NDHS 2016) suggests that although the nutrition status of children has improved over the last 20 years, from 1996 to 2016, breastfeeding exclusively is crucial for a child’s health and nutrition, which has declined by 4 percent from 2011 to 2016. There might be several other reasons for the decline in the practice of exclusively breastfeeding; however, natural disasters and the role of humanitarian aid agencies, the supply of breast-milk substitutes and inappropriate food items may also adversely affect the generational and cultural importance of breastfeeding. If aid organisations distribute breast-milk substitutes, there is a danger that mothers may perceive bottle feeding as ‘modern’ and healthier, even though breastfeeding is safer, provides protection against infection, and should be encouraged and supported.    

Government agencies should control these negative and potentially harmful practices and humanitarian aid organisations should also follow the guidelines outlined in the International Code of Marketing Breast-milk Substitutes. In addition, lactating mothers and pregnant women should be given additional support through education programs that provide information about infant feeding practices. Families and organisations should encourage mothers to continue breastfeeding during emergencies, and the media, especially community based radio, can play a very useful and significant role in disseminating knowledge and information in local languages to the mothers at individual and household level. These practices will be extremely effective in the Tarai region as frequent floods occur every year that displace many families and put thousands of mothers and children at risk.  

Suji is a researcher at Social Science Baha and holds a Master’s in Anthropology from Tribhuvan University

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