Every year, hundreds of thousands of people worldwide are affected by natural or humanitarian disasters. A disaster is defined as a catastrophic event that results in loss of life, severe human suffering and distress, and significant material damage.Reference Giusti, Marchetti and Zambri 1
Disasters of all types significantly affect public health. Post-disaster conditions and changes in living standards lead to mental, emotional, and physical stress, resulting in a decline in overall health.Reference Benevolenza and DeRigne 2
The 7.4 magnitude earthquake that struck the center of Kahramanmaras, Turkey, on February 6, described as the disaster of the century, directly affected the lives of more than 9 million people living in the region. Women and children were most affected by the disaster in the Pazarcık district, which affected 11 provinces. 3
It is crucial to respond effectively to the health needs of society, particularly women and their infants, who are especially vulnerable in such situations. Beyond immediate needs such as safety, shelter, and clean water, infants (0-12 months) have specific feeding requirements that necessitate an immediate and adequate response, particularly in the critical hours and days following a disaster, before aid arrives. In this context, breastfeeding becomes vital, as breast milk provides all the essential nutrients an infant needs, ensuring proper nutrition even when food supplies are limited or disrupted. Additionally, breast milk contains antibodies and immune-boosting properties that protect infants from infections and diseases, which can be prevalent in disaster-stricken areas.Reference Benevolenza and DeRigne 2 , 4 – 5 Breastfeeding offers protection against numerous health conditions, including asthma, obesity, type 1 diabetes mellitus, severe lower respiratory tract infections, acute otitis media, sudden infant death syndrome, gastrointestinal infections (such as diarrhea and vomiting), and necrotizing enterocolitis in preterm infants. 5 , 6 According to a 2016 report by the Lancet, breastfeeding can save 820 000 lives each year and prevent 13% of deaths in children under 5. In low- and middle-income countries, breastfeeding reduces respiratory infections by one-third and diarrhea by half.Reference Lancet 7 The report also indicates that longer durations of breastfeeding are associated with higher intelligence levels, a benefit observed across all economic classes.Reference Victora, Horta, Loret de Mola, Quevedo, Pinheiro and Gigante 8 Following natural disasters, there is often a marked increase in morbidity and mortality rates. Common health issues that arise in the aftermath include malnutrition, dehydration, and a heightened prevalence of infectious diseases, such as gastrointestinal and respiratory infections.Reference Mavrouli, Mavroulis, Lekkas and Tsakris 9 In situations such as earthquakes, where access to clean water and sanitation is severely restricted, breastfeeding serves a crucial role in mitigating the risks associated with the use of contaminated water for formula preparation. Furthermore, breastfeeding fosters a strong emotional bond between mother and child, providing comfort and alleviating stress during tumultuous times. It also represents a cost-free source of nutrition, making it an invaluable option for families facing crisis conditions.Reference Benevolenza and DeRigne 2 , 3 , 10
The Convention on the Rights of the Child (2nd, 3rd, 6th, etc.) emphasizes the priority of the child’s benefit and well-being under equal conditions in all circumstances, including in times of crisis. In this context, breastfeeding and lactation should be assessed and supported, especially during extraordinary situations such as earthquakes. The experiences of breastfeeding mothers after disasters can provide valuable guidance for mothers, health professionals, and other relevant institutions and authorities. Also, this information can help inform the precautions and actions required to support and sustain breastfeeding in any post-disaster scenario. This study aimed to investigate the experiences of breastfeeding mothers living in temporary shelters in the earthquake epicenter region referred to as the disaster of the century. A research question guided our work:
1) What are the experiences of breastfeeding mothers living in temporary shelters in the earthquake zone?
Methods
Study Design
This study utilized a descriptive qualitative design to explore the experiences of mothers residing in temporary shelters in the center of Kahramanmaraş between May and June 2023. Qualitative research methods, including observation, interviews, and document analysis, were employed to provide a realistic and comprehensive understanding of participants’ perspectives, perceptions, and experiences within their natural environments. Various qualitative approaches, such as narrative research, grounded theory, ethnography, case study, and phenomenology, are encompassed within this research methodology. Specifically, phenomenology seeks to understand human experiences by concentrating on the essence of shared experiences. Its key feature is the assumption that “shared experiences” have an underlying essence. Building on this assumption, phenomenology explores the fundamental meanings and essences of experiences derived from shared phenomena. 10 Consequently, this study employed a phenomenological approach. Additionally, the research adhered to the guidelines outlined in the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.
Informed consent was obtained by providing participants with clear explanations of how their data would be collected, used, stored, and protected. To maintain anonymity, pseudonymization was employed, and any identifying information was removed from the data. Access to the audio recordings was restricted to the researchers ET, MG, and AK. Participants were informed of their right to withdraw from the study at any time and to request the deletion of their data.Reference Speziale, Streubert and Carpenter 11
Research Population and Sample
The study population consisted of breastfeeding mothers living in temporary shelters within the city center of Kahramanmaraş. Following the earthquake, affected individuals in the region were registered with the Disaster Management Center and initially accommodated in tent cities, subsequently relocating to container cities as temporary shelters. At the outset of the study, a comprehensive review of the information lists for all individuals residing in the largest tent city in the city center was conducted, enabling the identification and contact with breastfeeding mothers in these shelters. Using a purposeful sampling method, midwifery researcher MG conducted interviews by visiting mothers in these temporary accommodations. MG interviewed those breastfeeding mothers who met the study’s criteria and consented to participate.
In qualitative research, sample size is influenced by the chosen research approach, the diversity within the sample, and the depth of information each participant provides. Typically, sample size is determined based on the concept of saturation—reached when additional interviews yield no new information and responses start to repeat, reflecting no novel insights. Thus, sample size cannot be precisely determined beforehand, as it must be large enough to reach this saturation point.Reference Yıldırım and Simsek 12 , Reference Fusch and Ness 13 Saturation occurs when participant responses become repetitive and no new insights are obtained.Reference Fusch and Ness 13 The expressions of the participants become identical (recurring); that is, they are not different from previous data.Reference Fusch and Ness 13 In this study, researchers reviewed the transcripts multiple times to thoroughly understand the mothers’ statements. Significant statements were then formulated into themes and further integrated into comprehensive descriptions. In this study, saturation was achieved with 14 mothers and, thus, the study sample consisted of these participants.
In the study area, mothers initially lived in tents for the first 5 months before transitioning to container shelters. As damaged buildings continued to be demolished, there remained ongoing needs for drinking water, domestic water, toilets, showers, and infrastructure services. 10 Access to hot and clean water was a challenge for those affected. Temporary shelters faced difficulties with wastewater management due to inadequate drainage systems, leading to the open flow of contaminated wastewater in areas lacking underground drainage. This situation increased the risk of infectious diseases and pest infestations near living containers. To address hygiene needs, mobile toilet-shower units and laundry facilities were provided, while water requirements were met through water tanks and treatment devices. 14
About 2.4 million people are living in temporary shelters in earthquake zones in Turkey, including 1.6 million in irregular tent sites and 800 000 in state-owned tent cities. 15 In temporary housing, inadequate food supply, difficulty in accessing clean water, and lack of personal hygiene items lead to malnutrition and poor hygiene conditions in the area. 3 , Reference Mavrouli, Mavroulis, Lekkas and Tsakris 9 The lack of toilet and hygiene facilities is a constant source of distress. 16 UNFPA reported 3 months after the earthquake that there were approximately 130 000 pregnant women and women who had recently given birth in temporary housing in the earthquake zone, and that they continued to need access to basic care services. 16
The inclusion criteria for the study were: (1) volunteering to participate, (2) being an earthquake survivor living in a temporary shelter city, and (3) currently breastfeeding a baby. The exclusion criteria were: (1) the baby not being breastfed, (2) the mother having communication issues (such as hearing or speech problems), and (3) the baby has reached 6 months of age (according to WHO recommendations, exclusive breastfeeding should continue for the first 6 months, and supplementary feeding typically should begin after that period; therefore, the study aimed to determine the experiences of mothers who were exclusively breastfeeding post-disaster).
In the study, 1 woman was excluded due to an interruption during the conversation, and 3 women declined to participate, citing a lack of psychological readiness to engage in the discussion.
Data Collection
“A semi-structured interview form” was used in the interview.
Semi-structured interview form
The form consists of socio-demographic and obstetric questions (8 questions), such as age, education, occupation, pregnancy, number of children born, medication use, and smoking status, and disaster-related questions (3 questions), such as duration of stay in the temporary shelters, loss of life in the earthquake, and individual interview questions (6 questions) that can more clearly identify and clarify the breastfeeding difficulties experienced in this process. Individual interview questions are as follows:
-
1. What were your experiences with breastfeeding after the earthquake?
-
2. What kind of changes did you encounter about breastfeeding, and what did you do?
-
3. What were your basic life needs after the earthquake?
-
4. What are your current needs for breastfeeding?
-
5. How did you cope with the changes related to breastfeeding and your baby after the earthquake?
-
6. What and who helped you in these situations?
The questions were developed by the researchers by reviewing the literature.Reference Giusti, Marchetti and Zambri 1 Expert opinion was obtained from 5 people for the appropriateness of the questions, and the form was finalized after the expert opinion suggestions. A pilot study was conducted with 3 mothers to determine the appropriateness of the questions and these mothers were not included in the study.
The in-depth individual interview process continued until the point where the participant began to repeat concepts and no new information emerged. Although this period varies according to the interviews, it lasted 30-45 minutes on average in this study. The interviews were conducted in a suitable area within the tent city environment. During each interview, the mother’s responses were recorded. The interviews were carried out by a researcher (Researcher-2) working in the temporary shelters.
Voice recorder
A Kingboss HS-27 brand voice recorder was used to record the interviews. The voice recorder has a capacity of 8 GB and can record for 24 hours.
Ethical Considerations
Permission was obtained from the Scientific Research and Publication Ethics Committee of a university (Date:29/03/2023, Decision no:2023/23) to conduct the study. Participation in the study was voluntary, and mothers were informed about the study’s purpose and the intention to make voice recordings prior to their involvement. Informed consent was obtained from all participants. In the transcription of the data collected from the study, the mothers were coded as M1, M2, M3….
Data Analysis
Descriptive data were analyzed using number, percentage, and mean statistical tests in Statistical Package for Social Sciences (SPSS) 21.0. Colaizzi’s 7-step method was used to analyze the qualitative data. The first step involved recording the audio interviews. Next, the interviews were transcribed using MAXQDA software, and each transcript was thoroughly reviewed multiple times by each author. In the second step, significant statements about the challenges faced by the mothers were identified from the transcripts. The third step involved formulating these significant statements. In the fourth step, the formulated meanings that reflected the mothers’ difficulties were grouped into clusters, resulting in 19 codes grouped into 4 themes. The fifth step defined the fundamental structure of the difficulties experienced by the mothers. In the final step, the results were validated by re-contacting the mothers.Reference Valle and King 17 The relationship between the codes and sub-codes was analyzed during the coding and theme development process using MAXQDA.
Trustworthiness
In qualitative research, the criteria used to ensure the reliability of the results include credibility, dependability, confirmability, and transferability.Reference Speziale, Streubert and Carpenter 11 (a) Credibility was ensured by the researcher actively conducting interviews with breastfeeding mothers and allocating adequate time for each interview. (b) Dependability was achieved by consulting experts in the relevant field during the preparation and finalization of the semi-structured interview form and the data analysis process. (c) Confirmability was maintained by consulting 2 experts in qualitative research to verify the appropriateness of the main themes and subthemes. (d) Transferability was addressed by employing a purposive sampling method during visits to the tents and container city, allowing for data collection from a suitable and diverse sample of breastfeeding mothers. After each interview, the accuracy of the transcribed data was confirmed with the participants. Informed consent was obtained from all mothers at the beginning of each interview.
Results
The descriptive characteristics of the mothers who participated in the study are presented in Table 1. The mothers’ ages ranged from 31-37 years. The youngest baby was 10 days old, while the oldest was 6 months old. Most of the mothers had completed secondary school. Two of the mothers had lost a relative in the earthquake, with 1 mother losing both her uncle and aunt. The duration of their stay in the temporary shelters ranged from a minimum of 14 days to a maximum of 120 days. (Table 1).
The descriptive characteristics of the mothers
In line with the data obtained from the interviews of the mothers within the scope of the study, 4 themes were identified: basic life needs, emotional difficulties, difficulties in caring, and difficulties in breastfeeding.
Theme 1. Basic Life Needs
This theme includes the statements regarding the difficulties experienced by breastfeeding mothers regarding basic life needs in the post-earthquake period. This theme consists of sub-codes for housing, warming, nutrition, hygiene/sanitation, sleep, and dressing sub-codes (Figure 1). The hierarchical map of the main codes and sub-codes of basic life needs is shown in Figure 1.
Hierarchical map of main themes and sub-themes of breastfeeding mothers’ experiences during the earthquake.
All the participants stated that they had problems with housing and warming after the earthquake.
“We stayed in the car to keep ourselves safe. We waited in an empty spot inside the car while the earthquake passed. We were in the car for about a week because we had no other choice. Eventually, my husband’s family had a barn where we could stay. Right now, we’re living in a tent.” (Mother 1) Another mother shared, “When we were in the car, it was really cold, and we couldn’t warm it up. My child was cold, and that was a big problem. The baby was freezing, like ice, and didn’t want to breastfeed because he was so cold. This made it hard for me to breastfeed him. I would try to keep him warm, but then he would start to sweat and still not want to feed.” (M5).
Nearly all mothers experienced difficulties accessing nutritional food. “We could not eat because there was no open place, we had difficulties in feeding, so we ate dry bread, let’s say dry bread” (M4).
Mothers also had problems accessing clean water and experienced hygiene problems. “Water was the thing I needed the most at that time, we put the rain under the glass for a sip of water and waited to drink it in the rain, so it was one of the things I needed the most. We needed so much water that we put the glass under the rain so that we could drink.” (M14). Another mother said, “My baby didn’t have any problems either; he just had a little mansion in his head because of the lack of water. I guess it happened inevitably when he could not take a shower for a while” (M5). Another mother said, “I faced a lot of water shortages; there just wasn’t enough water. Living in a tent without access to water, not being able to take a shower, and not having a toilet really affected my mental health. I couldn’t keep up with my hygiene at all.” (M3). In addition to these, with the cold weather conditions and inadequate housing, mothers had difficulties with clothing. “We did not have our clothing needs met in any way, we slept in the car for a week, and then we were given tents and clothes” (M12).
One mother shared, “The tent was really crowded, which made breastfeeding tough. On one hand, I felt hesitant and embarrassed to do it. On the other hand, I still felt shy about it. I tried to cover myself while breastfeeding, but it was really difficult for me.”” (M4). Another mother mentioned, “My milk supply decreased because I couldn’t eat for the first 3 days” (M2).
Theme 2. Emotional Difficulties
This theme includes expressions about the emotional difficulties experienced by breastfeeding mothers in the post-earthquake period and consists of the subcodes shock, fear, stress, and crying (Figure 1). The hierarchical map of the emotional distress main code and subcodes is shown in Figure 1.
Because the earthquake occurred at night and many buildings collapsed, most mothers stated that they experienced shock, fear, and stress.
“I could not leave the house when the moment the earthquake struck. I was sleeping in the same place with my baby. I picked up my child and screamed. We were in shock; it was a very stressful environment. My husband and my other child were in the hospital. When they said the hospital collapsed, I thought they were dead. I couldn’t get out myself at first, thanks to my neighbor, and when I got out, they took my baby in their arms. I didn’t realize it anyway.” (M5). Another mother said, “I was breastfeeding at that moment. I stopped immediately when it shook. I took my child in my arms. I wrapped him in his blanket and went outside to the car. That’s when I woke up my husband and my child, and we immediately went out in front of the door. We went outside and got into the car. We waited in the car for a while until it stopped. It was scary; I didn’t know what to do.” (M1). Another mother said, “I felt panicked after the earthquake; I went out in a panic; I was in pain. We thought a lot about whether we could go out. We couldn’t go out anyway; the door was locked. Thank God, God helped us, and then the door opened, and we went out. The moment the earthquake started to stop slightly, we went out. We went out without shoes and wearing sweatpants when there was nothing.” (M4). In addition, almost half of the mothers stated that they cried during this process. “My children and we lived in constant fear of an earthquake, even when the electricity went off, we were afraid that an earthquake had happened, I cried all the time” (M6).
Another mother also mentioned, “My baby was crying a lot, was restless, and wasn’t sleeping at all. I cried out of frustration and ended up giving my baby formula” (M3).
Theme 3. Difficulties in Care
This theme includes expressions regarding the difficulties experienced by breastfeeding mothers in the care of their babies in the post-earthquake period. It consists of the sub-codes of difficulty in accessing medication, constipation, diarrhea, decrease in urine output, and decrease in comfort (Figure 1). The hierarchical map of the main difficulty in care main code and subcodes is shown in Figure 1.
One of the mothers reported having difficulty accessing her baby’s medicine because she was trapped under the rubble. “My baby has goiter. He was taking thyroid medication for that. But he couldn’t use that medicine either. There was no medicine; we couldn’t find it.” (M12).
One mother shared that her baby had constipation problems. “My baby did not poop for 3 days. He was always crying and moody. Then it was sick for 3 weeks. I had difficulties” (M6).
Two mothers reported that their babies had diarrhea and weren’t peeing as much. One mother said, “We drank water from the fountain. It was fine for us, but my baby got diarrhea and wasn’t peeing as much. The diarrhea was the hardest part for us. People told me about an herb that helps with diarrhea, so I found it, drank some, and gave some to my baby too” (M1).
Almost all the mothers said their comfort was affected, and they had trouble taking care of their babies. One mother said, “I couldn’t move around freely because there were always people around. I can’t eat properly in this crowd, and I can’t take care of my baby or myself” (M12).
Another mother shared, “It was cold where we stayed, and I found it hard to breastfeed; I couldn’t feed my baby comfortably” (M1).
Theme 4. Breastfeeding Difficulties
Theme 4 includes expressions about the difficulties experienced by mothers in the post-earthquake period regarding breastfeeding. The theme consists of breast rejection, breast engorgement, decreased/interrupted milk, privacy, and infant feeding problems (Figure 1). The hierarchical map of breastfeeding difficulties code subcodes is shown in Figure 1.
Some mothers stated that their babies did not want to suckle. “My baby never latched on; he just didn’t want to breastfeed.” (M6). Most mothers reported having breast engorgement. One mother shared, “I didn’t know what to do. My eyes were swollen, and milk wasn’t coming from 1 breast, but then it eventually started. I was too scared to breastfeed because I didn’t know what to do. There was debris everywhere, and my husband had gone to help because he’s in the military. I was left alone with 2 kids. I tried breastfeeding with 1 side, but it hurt. I don’t even remember stopping. I didn’t use one of my breasts for 2-3 days because it was swollen and painful” (M9).
Most mothers stated that their milk had decreased or stopped. “My milk supply went down a bit because of the fear, and the baby was cranky, so everything was hard” (M1). “The period after the earthquake stressed me out, and my milk supply went down because of the stress” (M4). Another mother said, “When my milk stopped for the first 3-4 days, I was really stressed. I kept thinking, What will I do? How will I feed my baby? I worried that if my milk didn’t come back, I wouldn’t be able to find any formula. I read the Qur’an, blamed myself, and felt like there was nothing else I could do. I prayed a lot, asking Allah for the best and hoping I would never have to go through this again. I was so happy when my milk came back” (M6).
All the mothers said they had trouble with privacy while breastfeeding because it was so crowded in the temporary shelters. One mother explained, “It was really crowded in the tent. We stayed with my mother-in-law and my young brother-in-law, so breastfeeding was hard. I felt embarrassed and awkward. I had to breastfeed while covering myself and the baby. It was difficult to do it like that” (M4). Another mother added, “At home, you can lie down and breastfeed easily, but in the tent, it was hard to take care of my baby” (M9).
Some mothers also mentioned that they had to give their babies formula because they were having trouble breastfeeding, which led to feeding issues for their babies. One mother said, “My milk supply went down. When that happened, I gave the baby formula, but when the formula wasn’t enough, I started giving the baby animal milk” (M7).
Discussion
In the literature, it is noted that temporary housing, food, and non-food aid are essential following natural disasters, but these resources often reach breastfeeding women with delays.Reference Giusti, Marchetti and Zambri 1 , Reference Hirani, Richter and Salami 18 , Reference Dörnemann and Kelly 19 Meeting the needs of breastfeeding women for food, shelter, water, and basic health services after an earthquake is reported to facilitate infant care and support breastfeeding.Reference Giusti, Marchetti and Zambri 1 , Reference Hirani, Richter and Salami 18 –Reference Hwang, Iellamo and Ververs 20 Conversely, in middle- and high-income countries, inadequate nutrition and fluid intake have led women to stop breastfeeding after disasters.Reference Hwang, Iellamo and Ververs 20 For example, after the Haiti earthquake, malnourished women perceived their breastmilk supply as insufficient and ceased breastfeeding.Reference Dörnemann and Kelly 19 Similarly, a study by Hirani et al. (2021) highlighted that breastfeeding mothers often faced nutritional deficiencies and insufficient milk production due to inadequate food intake.Reference Hirani, Richter and Salami 18 The study also found that mothers struggled with essential needs related to housing, warmth, nutrition, hygiene, sleep, and clothing. Prioritizing safe spaces for breastfeeding women, access to basic needs like water and food, and keeping families together is crucial. Temporary housing centers play a vital role in ensuring that mothers and babies remain together during natural disasters,Reference Giusti, Marchetti and Zambri 1 , Reference Dörnemann and Kelly 19 and these shelters should be secure and warm.Reference Hirani, Richter and Salami 18
Inadequate toilet facilities in temporary shelters, leading to poor hygiene, significantly discomfort breastfeeding women.Reference Giusti, Marchetti and Zambri 1 In this study, mothers faced challenges accessing clean water and encountered hygiene issues. The earthquake’s damage to infrastructure also resulted in the contamination of existing water sources, increasing the risk of gastrointestinal and infectious diseases.Reference Mavrouli, Mavroulis, Lekkas and Tsakris 9
Living in temporary shelters, coupled with the breakdown of social support systems, disruption of daily routines, loss of family members, and difficulties meeting basic needs such as food, water, and hygiene, negatively impacts mental health.Reference Hwang, Iellamo and Ververs 20 –Reference Vilar-Compte, Pérez Navarro, Burrola-Méndez, Sachse-Aguilera and Veliz 24 Breastfeeding mothers reported experiencing emotional challenges such as shock, fear, stress, and crying after the earthquake. Literature suggests that these stressors can affect breastfeeding.Reference Mavrouli, Mavroulis, Lekkas and Tsakris 9 , Reference Hirani, Richter and Salami 18 Mental, emotional, and physical stress following a natural disaster have been shown to contribute to the discontinuation of breastfeeding,Reference Giusti, Marchetti and Zambri 1 even in middle- and high-income countries, and mothers who experience stress and fatigue after a natural disaster discontinue breastfeeding.Reference Hwang, Iellamo and Ververs 20 For example, after the Haiti earthquake, breastfeeding mothers experienced stress and perceived their milk supply as inadequate due to the loss of family members, living conditions in tents, and poor nutrition.Reference Dörnemann and Kelly 19 Health professionals must assist mothers in overcoming the emotional challenges they face due to the disaster, with particular attention to managing stress.
Child mortality rates in disaster situations can be 2-70 times higher than those associated with infectious disease outbreaks, such as diarrhea, respiratory diseases, and dehydration caused by malnutrition and gastrointestinal or respiratory infections.Reference Mavrouli, Mavroulis, Lekkas and Tsakris 9 , 25 This highlights the importance of considering the needs of breastfeeding women and recognizing that breastfeeding is an urgent health priority that should not be delayed. 25
The study found that mothers faced challenges in caring for their babies, including difficulty accessing medication, constipation, diarrhea, reduced urination, and overall discomfort. To address these issues, it is important to ensure proper hygiene conditions in temporary shelters. Health professionals, especially midwives, should reach out to breastfeeding women to provide the necessary information and support regarding infant care.
In emergency and disaster situations, breastfeeding mothers face challenges related to breastfeeding in addition to their basic needs. 3 These challenges include a lack of privacy while breastfeeding in temporary shelters, inadequate breastfeeding support, early cessation of breastfeeding, cultural beliefs, insufficient milk supply due to inadequate maternal nutrition and stress, and the distribution of infant formula after the earthquake.Reference Giusti, Marchetti and Zambri 1 , 16 , Reference Hirani, Richter and Salami 18 , Reference Dörnemann and Kelly 19 , Reference Hookway, Brown, Grant and Nutrition 22 , Reference Thorne-Lyman, K, Manohar, Shrestha, Nonyane and Neupane 26 Similarly, our study identified several difficulties faced by breastfeeding mothers in the post-earthquake period, including breast rejection, breast engorgement, decreased or interrupted milk supply, lack of privacy, and feeding difficulties. A study by Sarimin et al. (2020) also highlighted that one of the challenges for breastfeeding mothers after an earthquake was breastfeeding their babies in the presence of strangers or open areas within temporary housing.Reference Sarimin, Ponidjan and Wanda 27 Additionally, it was reported that the lack of privacy in temporary accommodations, such as cars, caravans, and tents, caused significant discomfort for breastfeeding women after the earthquake in Abruzzo, Italy.Reference Giusti, Marchetti and Zambri 1 In middle- and high-income countries, it has also been noted that these mothers often struggle to find private spaces for breastfeeding after natural disasters.Reference Hwang, Iellamo and Ververs 20 A systematic review found that ensuring privacy significantly facilitated breastfeeding.Reference Mudiyanselage, Davis, Kurz and Atchan 23 Moreover, the UNFPA (United Nations Population Fund) 2023 report on Kahramanmaraş stated that 3 months after the earthquake, there was still a shortage of safe, private spaces to promote and support breastfeeding. 16 Our study, conducted within the first 4 months after the earthquake, similarly found that women struggled with privacy issues while breastfeeding in tents or containers, citing these concerns as a significant barrier to breastfeeding. To address these challenges, it is crucial to establish temporary shelters that ensure privacy for breastfeeding mothers immediately following natural disasters. Additionally, creating designated breastfeeding areas within temporary housing and distributing breastfeeding aprons as part of relief efforts can help alleviate these difficulties and better support breastfeeding mothers.
The IYCF guidelines say that during disasters, it is important to help breastfeeding mothers by giving them safe and private places to breastfeed. If there aren’t any designated areas, we should offer alternatives like curtains, scarves, slings, or aprons to help maintain privacy. We also need to respect women’s cultural and religious beliefs. Professional breastfeeding support should fit the local culture, and it’s important to work with community leaders to provide care that is both evidence-based and culturally sensitive. 5
Enhancing women’s health literacy about the impact of stress on breast milk production is also essential, reassuring them of their ability to produce adequate milk. Education on the importance of breastfeeding during emergencies should be provided to both women and their families. Establishing breastfeeding support groups and dedicated areas, improving training for those providing support, and prioritizing access to nutritious food are key steps. Developing evidence-based, region-specific guidelines can further improve effective breastfeeding practices during disasters (IYCF guidelines). 5
In our study, some mothers reported having to use formula because they faced difficulties breastfeeding their babies. Following the earthquake, formula milk was among the aid supplies provided by public and private sources and was distributed to mothers who requested it. A study on breastfeeding promotion after the earthquakes in Mexico highlighted that distributing infant formula in temporary shelters could lead to the misconception that formula is as good as breast milk.Reference Vilar-Compte, Pérez Navarro, Burrola-Méndez, Sachse-Aguilera and Veliz 24 Additionally, the lack of protocols around formula distribution has been associated with food safety issues.Reference Vilar-Compte, Pérez Navarro, Burrola-Méndez, Sachse-Aguilera and Veliz 24 One of the biggest challenges in health facilities in emergencies is the acceptance and uncontrolled distribution of infant formula,Reference Hwang, Iellamo and Ververs 20 which can cause more harm than good. 25 Given that child mortality in disasters can increase due to diarrhea, respiratory diseases, and malnutrition, it is crucial to remember that breastfeeding is the preferred infant feeding method in all challenging situations. 25 According to the IYCF guide, when formula feeding is necessary during natural disasters, it is essential to provide proper feeding supplies, areas for cleaning them, and clear instructions for the safe preparation of formula. Evidence-based guidelines should be developed to identify which infants require formula. 5 Health personnel should also educate and counsel mothers on how breastfeeding can sufficiently nourish infants when other foods are unavailable. In disaster settings, breastfeeding support should be provided promptly and continuously by experienced health professionals.
In the study, breastfeeding difficulties reported by mothers included decreased or interrupted milk supply, breast rejection, and breast engorgement. During the Canadian forest fires, breastfeeding women experienced stress that led to a reduced milk supply and increased formula use.Reference DeYoung, Chase, Branco and Park 28 Similarly, Hookway et al. (2023) found that breastfeeding women under high stress produced less milk.Reference Hookway, Brown, Grant and Nutrition 22 After an earthquake, breast milk production may decrease or even stop due to unmet basic needs such as nutrition and shelter, along with emotional challenges like stress. However, it is important to note that even if a mother’s milk supply diminishes under stress, regular breastfeeding can help restore milk production, as the hormones released during breastfeeding can also help reduce stress. 25 Therefore, it is vital for midwives and health professionals experienced in breastfeeding support to provide counseling in disaster areas and assist mothers in resuming breastfeeding if they have stopped.
Limitations
The study’s limitations include that the data were collected within the first 4 months after the earthquake, so the findings only provide insights into this initial period. Also, the study is limited to the experiences of breastfeeding mothers (breastfeeding should continue for the first 6 months) living in temporary shelters in the earthquake epicenter region.
Conclusions
From the first moments following the earthquake, mothers faced considerable challenges in breastfeeding their infants. To enhance support for breastfeeding in the aftermath of a disaster, the following recommendations are proposed:
-
• Safe spaces should be established for breastfeeding women, and special areas should be created in temporary shelters to facilitate breastfeeding.
-
• In emergencies and disaster situations, breastfeeding practice should not stop or be delayed, and experienced health personnel should provide necessary information and support promptly.
-
• It is recommended that specialized lactation consultants and midwives receive appropriate knowledge and skills about the provision of breastfeeding support following disasters.
Supplementary material
The supplementary material for this article can be found at http://doi.org/10.1017/dmp.2025.10080.
Data availability statement
Data cannot be publicly shared due to confidentiality. However, upon request, voice recordings and written texts are available for scientific purposes.
Author contribution
ET: contributed to the conception and design of this study, performed the statistical analysis, drafted the manuscript, and supervised the whole study process. MGK: contributed to the conception and design of this study, collected the data, and drafted the manuscript. AK: contributed to the conception and design of this study, performed the statistical analysis, critically reviewed the manuscript, and supervised the whole study process.
Acknowledgments
The authors would like to thank all the mothers for participating in the study. This study was presented at the 6th International 7th National Midwifery Congress held in Ankara-Turkey between September 25-27, 2023 as an oral presentation.
Funding statement
The authors received no financial support for writing or publishing this article.
Competing interests
None.
Ethical standard
Permission was obtained from the Non-Interventional Clinical Research Ethics Committee of Tarsus University (Date:29/03/2023, Decision no:2023/23) to conduct the study. Participation in the study was voluntary, and mothers were informed of the purpose of the study and that voice recordings would be made prior to the study, and their consent was obtained.
