Introduction
Natural or man-made disasters can cause serious damage to the health and well-being of communities. 1 Disaster-affected people need food, safe water, shelter, clothing, and medicine, which are difficult to provide after a disaster.Reference Tsuboyama-Kasaoka and Purba 2 Among the affected population, women and children account for more than three-quarters of injured people.Reference Sohrabizadeh 3 , Reference Pyone, Dickinson, Kerr, Boschi-Pinto, Mathai and Broek 4 However, literature shows that relief organizations focus on general population needs, rather than vulnerable groups such as pregnant women and infants.Reference Pfeiffer, Avery and Benbenek 5
Protecting women’s breastfeeding rights in emergency situations is associated with improved maternal and neonatal outcomes.Reference Gribble, McGrath, MacLaine and Lhotska 6 Infants are one of the most vulnerable groups in disasters, with a higher mortality rate than diarrhea. Therefore, the World Health Organization (WHO; Geneva, Switzerland) has recommended that infants are fed exclusively using breast milk for up to six months, and then breast milk and supplements can last for up to two years.Reference Lawrence 7 Approximately 20% of children under the age of five die in the world if they do not breastfeed. Breast milk can prevent infections resulted from pathogenic microorganisms and help strengthen the immune system.Reference Lawrence 7 , Reference Carothers and Gribble 8 Accordingly, it is recommended that the infant should be fed with breast milk at an early hour after birth.Reference Pfeiffer, Avery and Benbenek 5 , Reference Davanzo 9 , 10
The results of research on children who were fed with infant formula in emergencies and disasters reported a higher mortality rate.Reference Adhisivam, Srinivasan, Soudarssanane, Deepak Amalnath and Nirmal Kumar 11 – Reference Hipgrave, Assefa, Winoto and Sukotjo 13 Due to inappropriate conditions for the preparation of dry milk, such as the lack of an oven for boiling water and disinfection of the milk glass, this method of feeding can cause the transmission of infection to the child. 10 Children who are fed with formula are at an increased risk for gastrointestinal diseases, diarrhea, and pneumonia. For example, during the flood in Botswana (2005-2006), a diarrheal outbreak caused more than 500 children to die, which was 30-times higher in children who used formula.Reference Arvelo, Kim and Creek 12 , Reference Creek, Luo and Quick 14 , Reference Creek, Arvelo and Kim 15 In addition, during the Kelantan flood in Malaysia (2014), a 40% increase in diarrheal diseases was reported in comparison to the same period prior to the flood.Reference Sulaiman, Mohamad, Ismail, Johari and Hussain 16 Therefore, there must be support for breastfeeding mothers in critical situations so that they can feed their infants. Feeding a child with dry milk in an emergency situation is very dangerous and requires significant resources.Reference Creek, Kim and Lu 17
Despite the fact that breast milk is more than a simple food for infants and young children, the distribution of formula in disaster-affected regions is still very high, which can cause serious problems for the health of infants and young children.Reference Davanzo 9 , Reference Adhisivam, Srinivasan, Soudarssanane, Deepak Amalnath and Nirmal Kumar 11 – Reference Hipgrave, Assefa, Winoto and Sukotjo 13
Since midwives have a unique position to support breastfeeding during disasters and increase the health of children in emergencies, 18 the present study aimed to explore factors affecting the nutrition of infants after disasters, as well as barriers to breastfeeding in disasters using midwives’ experiences.
Methods
Design
A qualitative approach using content analysis was applied for this study. Data were collected directly and without any pre-suppositions. Codes, sub-categories, and categories were extracted using the deductive process.Reference Elo and Kyngäs 19 , Reference Graneheim and Lundman 20
Setting
Iran is located in the Middle East region and is known as a disaster-prone country frequently affected by natural disasters such as earthquakes, floods, and droughts.Reference Sohrabizadeh 3 , Reference Mehrdad 21 – Reference Taghizadeh 23 Earthquakes and floods took place in the provinces of East Azerbaijan, Bushehr, Mazandaran, and Kermanshah (2012-2017) and killed more than 980 people and injured approximately 10,000 citizens living in these regions.Reference Sohrabizadeh, Jahangiri, Jazani, Babaie, Moradian and Rastegarfar 24 , Reference Greshko 25 Women and children accounted for over 70% of victims in these disasters. 26
Participants
A total of 19 midwives were approached for interviews using a purposive sampling method. Of these, 15 midwives were volunteers who provided reproductive health services in the recent disaster, and four midwives were instructors who had the experiences of teaching post-disaster reproductive health to midwives. The number of participants was determined based on the saturation principles. Data saturation was reached after 18 interviews, but one additional interview was conducted to make certain that no new concepts developed.
Data Collection
Data were collected through semi-structured, in-depth, face-to-face interviews conducted by the first author (MM). Accordingly, the participants were asked open-ended questions, including: “Explain your experiences on the breastfeeding issues when you provided health services in the disaster-affected regions.” Each interview lasted between 50 and 90 minutes. Probing was done to encourage the interviewees to describe their experiences and feelings completely. All interviews were performed, recorded, and transcribed verbatim in Farsi and confirmed by the participants. Each interview was reviewed and analyzed by two researchers (MM and SS), and the retrieved information became a guide for further data collection. Furthermore, a memo was written out whenever the researcher encountered interesting subjects which could be helpful for analysis.
Data Analysis
Data collection and data analysis were conducted simultaneously. The Graneheim approach was used for data analysis.Reference Graneheim and Lundman 20 According to this approach, several steps were conducted for analyzing data. First, the interviews were read several times to obtain a sense of the whole. Second, the entire material was elicited and brought together into a single text which formed the unit of the analysis. In the third stage, the text was divided into meaningful units. Fourth, the condensed meaningful units were summarized and labeled with a code. At this stage, peer checking was applied for quality control of coding. Finally, all codes were compared based on the differences and similarities and classified into four categories. Furthermore, the temporary categories were discussed by two researchers and revised for exploring the final concepts. Word-processing software was used to type the transcribed interviews.
Trustworthiness
Four strategies of credibility, dependency, confirmability, and transferability were used for data trustworthiness.Reference Holloway and Freshwater 27 – Reference Speziale, Streubert and Carpenter 29 Member and expert checking were applied for achieving the criteria of credibility and dependency. In member checking, the main researcher asked the respondents about possible misunderstandings, and for expert checking, the research team discussed the emerging concepts. Confirmability and transferability of data were obtained by the personal interest of the researchers as well as a comprehensive explanation of all the study’s process given to the participants. In addition, the main researcher tried to discard her potential biases through peer evaluation before interviews. Accordingly, the first author played the role of a participant, and colleagues performed the interview. Feedback of colleagues helped the researcher recognize and manage her potential biases.
Ethical Considerations
This study was approved by the ethics committee of Shahid Beheshti University of Medical Sciences, Tehran, Iran (IR.SBMU.RETECH.REC.1396.273). The consent form was approved by the ethics committee as well. Accordingly, all participants were informed about the confidentiality of their names and other private information in the related reports. Furthermore, the participants were provided the possibility of leaving their own interview session at any time.
Results
The participants had five to 35 years work experience and were aged between 26 and 61 years. They had an educational level of bachelor’s degree (79%) and PhD in reproductive health (21%).
Data analysis led to the extraction of the main categories, which demonstrated the participants’ perspectives of barriers to breastfeeding in disasters. Categories included maternal factors, neonatal factors, management factors, and factors related to the socio-cultural context (context-based factors). Categories are described as follows.
Maternal Factors
It was found that maternal factors included mental and physical health. The maternal mental health factors that could negatively influence the child’s nutrition included numerous items; the most important one was maternal depression caused by the loss or damage to loved ones in the disaster. This could be seen in most people in the affected area. Observing those who are mourning their loved ones causes depression in others. The next factor was the fear of an aftershock, and because of frequent after-quakes, they all feared that more severe earthquakes happened. One of the midwives said:
Some mothers complained of a shortage or even a loss of milk that was caused by stress or fear after the earthquake, but before the incident they had enough milk to feed the child (P11).
One of the other barriers to feeding the child was the lack of self-efficacy to feed and care for the child. Mothers’ knowledge played an important role in their self-efficacy. When the mother was not aware of the correct method of breastfeeding, or was unaware of the adequacy of breastfeeding, the child’s cry made the mother think that she did not have enough feeding capacities. One of the midwives said:
The serious problem I faced was the mother’s ignorance, especially primiparous women. They did not know if their milk was enough for the child. When the child cried, most mothers thought that the child was still hungry, but the cry of a child can have many reasons. In general, some mothers felt that they could not take care of their children (P10).
The maternal physical health factors that influenced breastfeeding included a lack of proper nutrition by the mother and maternal illness or injury resulted from disasters. Access to proper nutrition for pregnant women and nursing mothers in post-disaster situations was an issue that should be taken into consideration. They needed more diet, which should be taken into consideration by regional authorities. One of the participants said:
Some mothers believed that when they did not have enough to eat, they could not breastfeed the child (P12).
Damages to mothers, such as a fracture or injuries due to trauma, were also a barrier to breastfeeding. In this case, one midwife said:
One of the mothers had a hand fracture and could not hug the child to breastfeed (P3).
Infant Factors
A series of issues that prevented breastfeeding rooted in the child itself, which made it possible to feed using formula milk, such as the illness and injury of the child during disasters, and the mental and emotional effects of the disaster on the child. It included the crying and restlessness of the child and the child preference for sucking milk from the bottle with broad holes, and sometimes confusion in identifying the nipple. Children that used both breast milk and the glass to feed became confused to identify the nipple and refrained from sucking the mother’s nipple. One of the midwives said:
I remember a mother that used glass to feed the child, so the child could not get her nipple anymore (P7).
Management Factors
Other barriers to feeding the child in disasters were management factors such as human resources. For example, some managers were not familiar with the field of reproductive health in disasters, and educated volunteers of reproductive health services were absent in disaster-affected fields.
One of the midwives, regarding the reasons for not paying attention to mothers and children in disasters, said:
Perhaps, it is due to special circumstances such as earthquake devastation, many injured people in the region and prioritize other health issues, they do not pay attention to these mothers (P9).
The next important finding, according to the participants’ experience, was the lack of proper oversight by relevant organizations on the distribution and the quality of formula in the affected area. Formula is mostly distributed without any supervision in the disaster-stricken regions. In this regard, one midwife said:
Unsupervised distribution of formula caused the mother to use it for infant feeding. I witnessed that sometimes due to the abundance of formula milk in affected areas, mothers arbitrarily used formula, even when there was not enough water to wash and clean (P17).
It should be noted that some factories or drug distribution companies donated formula to the relief organizations for the use of people in affected areas only with the purpose of advertisement. One of the midwives said:
It is noteworthy that among the donated milk boxes, there were also a number of expired formula boxes that we were fortunate enough to understand and dispose them before use (P13).
The next issue was education, meaning that aid forces had not received any special education in reproductive and nutritional health, and even some of them had false beliefs about children’s nutrition. Therefore, they were unable to provide mothers with necessary education and provided inappropriate education. Lack of qualified people such as midwives and nurses to educate mothers about lactation was one of the important obstacles. One of the midwives said:
Of course, everyone is unaware of the importance of breastfeeding. There are plenty of people that want to help, but because of ignorance or misconceptions such as mother’s mourning or lack of enough food to eat, they encourage mothers to use dry milk (P3).
Factors Related to the Socio-Cultural Context
In this research, context-based factors could also affect the infant. The lack of a safe and private environment for feeding, the traditional role of women’s support and care in the home, and inadequate family and social support for women were mentioned as reasons.
One of the serious cultural-belief barriers to breastfeeding was the lack of a safe and private environment for infants’ feeding. In Iran, this is a cultural and religious belief for most women to protect their privacy when they are breastfeeding. One participant said:
Immediately after the earthquake, people were living in tents, which usually do not provide the mothers with the right to breastfeed, so they cannot easily breastfeed (P8).
Another cultural and social issue was the traditional role of women in caring for other family members, including children, elderly, and injured people. In addition to managing affairs of the home, it led to double physical and mental pressure. One participant said:
I saw a woman who had lost her son in an earthquake and her husband suffered a severe injury, and provided care to her old mother alone. She was carrying a little child when working. The workload was so heavy that she was brought to the health care clinic and she could not take care of herself and her little child (P7).
Other barriers preventing breastfeeding were a lack of support from the spouse, family, and community. One of the participants said:
I saw a lot of husbands that urged their wives to use formula; because they thought she could not breastfeed the child. They did not give extra food to the mother that was breastfeeding the child (P15).
Discussion
The present study was the first one focused on barriers to breastfeeding during natural disasters in Iran. The findings showed that factors such as maternal, infant, management, and context-based factors affected breastfeeding practices in the destructed regions. Probably, one of the most important findings of this study was the massive distribution of formula without the supervision of related organizations in disaster-affected areas in Iran. Women’s breastfeeding rights in emergency situations can be managed through controlling the distribution of breastfeeding materials and providing a supportive environment for breastfeeding.Reference Gribble, McGrath, MacLaine and Lhotska 6 Donors, relevant organizations, and health care staff should be informed that unplanned distribution of dry milk to the affected regions is more harmful to children.Reference Gribble, McGrath, MacLaine and Lhotska 6 , Reference Sulaiman, Mohamad, Ismail, Johari and Hussain 16 During the Balkan crisis in 1990s, more than 40% of 3,500 tons of aid sent by the North Atlantic Treaty Organization (NATO; Brussels, Belgium) during the first week of the disaster in Macedonia was children’s food.Reference Borrel, Taylor and McGrath 30 In disastrous situations, access to drinking water and facilities, such as the stove to boil the water and disinfect the milk bottle, is impossible; thus, milk provided in such condition is unhealthy and acts as a disease vector to the child.Reference Sulaiman, Mohamad, Ismail, Johari and Hussain 16 , Reference Kelly 31 On the other hand, the massive distribution of formula can have a reverse effect on the mother’s decision to breastfeed the child.Reference Gribble, McGrath, MacLaine and Lhotska 6 , Reference Dobson and Murtaugh 32
Needs assessment is critical in disaster management. In the aftermath of any disaster condition, having accurate information about needs is a key point for providing the essential requirements in the region.Reference Tatham 33 A monitoring system is also required to prevent mistakes in the amount of dry milk for feeding. Public health organizations conduct monitoring to identify and prioritize health issues and evaluate interventions.Reference Chretien, Tomich, Gaydos and Kelley 34 Along with international recommendations, the donation of milk should be prevented and all donated formula to the region should be subject to the supervision of governmental or non-governmental organizations. 35
Another key challenge with the continuation of breastfeeding in disasters was the mental and emotional problems of mothers in disasters. There is little information about the relationship between mental health and the mother’s nutritional status. It is not true that mothers in a painful condition due to mental stress or moderate malnutrition cannot breastfeed their children, and they will not be able to produce enough milk. Through enough support and guidance, stress will not reduce the amount of milk. 10 Moderate malnutrition has either no effect on milk production or has less impact. 10 , Reference Sulaiman, Mohamad, Ismail, Johari and Hussain 16 This presumption can serve as an excuse for health care providers not to promote breastfeeding.Reference Gribble, McGrath, MacLaine and Lhotska 6 , Reference Davanzo 9 , Reference Sulaiman, Mohamad, Ismail, Johari and Hussain 16
A number of recent studies have shown that depression in women who use infant formula to feed the infant is higher than that of the women who breastfeed the child.Reference O’Hara, Schlechte, Lewis and Wright 36 , Reference Pope and Mazmanian 37 Depression is not only an obstacle to breastfeeding, but breastfeeding also can reduce depression.Reference Henderson, Evans, Straton, Priest and Hagan 38
Self-efficacy is the ability to understand an individual to perform a particular task or behavior that can be rectified.Reference Kingston, Dennis and Sword 39 Bandura believes that the most powerful effect on self-efficacy is an active mastery of experience that enables a person to behave in a particular way and observe its consequences.Reference Bandura 40 Mothers may stop breastfeeding early due to their lack of confidence in breastfeeding.Reference Mitra, Khoury, Hinton and Carothers 41 There is a negative relationship between the receipt of professional assistance from health care providers and self-efficacy.Reference Kingston, Dennis and Sword 39
Another concern is wrong perceptions of family members, community members, health care personnel, and volunteer staff about breastfeeding. Some people believe that when the child suffers from diarrhea, breastfeeding should be discontinued.Reference Kendall and Cathy 42 In this case, the child needs more breast milk, because breast milk contains enough water, minerals, vitamins, and antibodies that can prevent dehydration.Reference Sulaiman, Mohamad, Ismail, Johari and Hussain 16 The early discontinuation of breastfeeding is related to the child’s confusion in identification of the nipple.Reference Greshko 25 The term “nipple confusion” refers to an infant’s difficulty in achieving the correct oral configuration and suckling pattern necessary for successful breastfeeding after bottle feeding or other exposure to an artificial nipple.Reference Neifert, Lawrence and Seacat 43 For this reason, the WHO has strongly advised that breastfeeding infants should never be given artificial nipples.Reference Zimmerman and Thompson 44
Lack of knowledge about breastfeeding among health care staff may lead to mothers receiving inappropriate information about breastfeeding.Reference Radzyminski and Callister 45 The lack of guidelines for following up breastfeeding issues by health care providers can lead to inefficient administration of malnutrition problems.Reference Heidari, Keshvari and Kohan 46 Health care providers that do not have enough knowledge about breastfeeding may provide inappropriate information and lead them to use formula.Reference Dobson and Murtaugh 32 Mothers often receive free dry milk from health care providers, despite their willingness to breastfeed.Reference Clark 47 So both health care providers and disaster victims need special training on breastfeeding issues in the post-disaster phase.
Social support is described as a facility or resources prepared by others, and is thought to be one of the mechanisms that affect health.Reference Datta, Graham and Wellings 48 Another barrier to breastfeeding in disasters is the lack of social support networks for mothers and their children. Social support is one of the key indicators for the mother’s decision to feed the infant, and research has shown that it can have a direct positive effect on breastfeeding.Reference Mitra, Khoury, Hinton and Carothers 41 , Reference Heidari, Keshvari and Kohan 46 Husbands are often the first source of support for new mothers.Reference Heidari, Keshvari and Kohan 46 , Reference Clark 47 , Reference Raj and Plichta 49 Nutritional comments from fathers and grandmothers have the strongest impact on mothers’ decisions for breastfeeding.Reference Clark 47
Another serious obstacle to breastfeeding was the lack of access to a private environment. During a disaster, mothers usually live in shelters or temporary camps. These places do not provide the necessary privacy for mothers, which may hinder breastfeeding. Appropriate places to preserve the privacy of mothers should be prepared.Reference Gribble, McGrath, MacLaine and Lhotska 6 , Reference Sulaiman, Mohamad, Ismail, Johari and Hussain 16 They should protect the privacy, security, water, and food for mothers. 10 Evidence indicates that providing facilities for breastfeeding in a safe and supporting place, counseling from health care professionals, and communicating with other mothers on breastfeeding helps maintain breastfeeding in disasters.Reference Binns, Lee, Tang, Yu, Hokama and Lee 50
The results showed that some contextual factors affected breastfeeding. In emergencies, women are often responsible for caring for infants, children, and elderlies, as well as victims while still performing their routine tasks. Providing necessary supplies for women with a priority of access to food and water enables them to pay more attention to others and have the opportunity to breastfeed their child.
Limitations
The experiences of midwives who provided reproductive health services in the affected regions in Iran may not be representative of breastfeeding issues in all disaster-stricken regions. Thus, the results may not be generalizable and comparable to other breastfeeding studies.
Conclusion
Protecting breastfeeding in disasters can save infant life post-disasters. Breastfeeding rights can be protected by supervising the distribution of breast milk substitutes and providing supportive environments for mothers in disaster-affected regions. In addition, the establishment of a surveillance system is recommended to estimate the amount of dry milk needed in disaster-stricken areas. Furthermore, it is highly recommended to provide a safe and secure environment for breastfeeding to feed infants after disasters. The mother’s self-efficacy and support plays an important role in promoting breastfeeding. To overcome barriers to breastfeeding, support and training programs should be provided for all those who are involved in breastfeeding, including mothers, families, and health care workers.
