“A Vulnerable Time To Be a Young Family in an Emergency”: Qualitative Findings From an Exploration of an Emergency Perinatal and Infant Feeding Hotline in Louisiana

Abstract

Background:

Birthmark Doula Collective, a cooperative that provides doula and lactation services in the Greater New Orleans area, mounted an emergency response after two Category 4 storms: Hurricane Laura (2020) and Hurricane Ida (2021). The response included activating a no-cost emergency perinatal and infant feeding hotline. Both disasters coincided with a resurgence of COVID-19 infections in Louisiana.

Research Aim:

The aim of this study is to understand how an emergency perinatal and infant feeding hotline supported infant and young child feeding in emergencies during hurricanes in Louisiana.

Method:

This study used a cross-sectional, retrospective qualitative design in a population with low breastfeeding rates. We conducted a content analysis of 97 hotline call logs from Hurricanes Laura and Ida, focus groups with lactation support providers who staffed the hotline during either storm (n = 5), and interviews with mothers who called during Hurricane Ida (n = 2). Focus groups and interviews lasted 30 and 60 minutes, respectively. Transcripts were analyzed using thematic analysis techniques.

Results:

Call logs revealed infant feeding needs (e.g., mastitis, low milk supply, relactation, and infant formula requests) and non-infant feeding needs (e.g., infant supplies, perinatal and infant care referrals, shelter information). Infant formula was the most requested supply during both hurricanes. Maternal participants discussed family vulnerabilities during Hurricane Ida. Staff described training and strategies to provide support while maintaining their own well-being.

Conclusion:

Providing a free emergency hotline service is one way to support pregnant and postpartum people and their families seeking infant feeding advice, supplies, and support in the immediate aftermath of a disaster.

Background

In emergencies (e.g., natural disasters, public health emergencies), infants and young children are at high risk for malnutrition, infection, and death (Carothers & Gribble, 2014). According to the World Health Organization (WHO), lack of food, unsafe water, poor sanitation, and overburdened health systems increase the vulnerability of infants and young children (WHO, 2020). Health agencies including the United Nations International Children’s Fund (UNICEF), the WHO, and the United States Centers for Disease Control & Prevention (U.S. CDC) assert that breastfeeding is the cleanest, safest infant feeding option during emergencies (U.S. CDC, 2022b; UNICEF & WHO, 2018). The WHO defines breastfeeding as an infant receiving breast milk (including milk expressed or from a wet nurse) and solid or semi-solid foods (Noel-Weiss et al., 2012). Alternatively, not breastfeeding in an emergency makes infants more vulnerable to illness and death (Gribble, 2018; WHO, 2004)). Safe formula feeding requires a steady supply of infant formula, clean drinking water, and supplies to clean and sanitize feeding equipment. These necessary items are not guaranteed in an emergency (Infant Feeding in Emergencies [IFE] Core Group, 2017; U.S. CDC, 2022a).

Mothers and young children are particularly vulnerable to climate change and resulting emergencies, especially those in poverty and from disadvantaged racial/ethnic backgrounds (Wheeler et al., 2022). In Louisiana, a state located in the Southeastern United States, poverty levels are greater than the national average (United States Department of Agriculture [USDA], 2023b) and the state ranks lowest in breastfeeding rates (U.S. CDC, 2022a). Only 22.2% of infants in Louisiana are breastfeeding exclusively at 6 months and, in rural areas, breastfeeding rates are generally lower than in the larger population (U.S. CDC, 2022a). Louisiana is also prone to hurricanes and flooding (Shao et al., 2020). That being so, residents of Louisiana face two vulnerabilities: low breastfeeding rates and high disaster risk (Grubesic & Durbin, 2022).

The literature on infant and young child feeding in emergencies (IYCF-E) is largely framed around the experiences of low- and middle-income countries and assumes high breastfeeding rates in a population before an emergency event. This may be true in many parts of the world, but not in the United States, and especially not in Southern Louisiana. In 2021, Birthmark Doula Collective (Birthmark) received a pilot grant to conduct research exploring how to support IYCF-E in populations with low breastfeeding rates. The purpose of this qualitative study was to determine the usefulness of an emergency perinatal and infant feeding hotline in a setting with low breastfeeding rates during hurricanes in Louisiana. These data from Louisiana can help to inform emergency response strategies in natural disasters in similar contexts. The aim of this study was to understand how an emergency perinatal and infant feeding hotline supported IYCF-E during hurricanes in Louisiana.

Methods

Research Design

This study used a cross-sectional, retrospective qualitative design. This study was also designed and implemented using a Community-Based Participatory Research (CBPR) approach. CBPR fostered a collaborative relationship between the academic researchers and community researchers from Birthmark, allowing for respect and integration of each organization’s cultural values and practices into every aspect of the research process (Wallerstein & Duran, 2017). All study plans and documents—including plans and implementation for recruitment, consent, retention, qualitative interviews, and focus group guides—were developed in partnership between Xavier University of Louisiana and Birthmark. Ethics approval was granted by Xavier University of Louisiana’s Institutional Review Board (ID: #844).

Setting and Relevant Context

The study took place in New Orleans, Louisiana, in the United States. Among its programs for pregnant and parenting families, Birthmark provides infant feeding support through virtual consultations, home visits, and clinic visits in the Greater New Orleans area, as well as breastfeeding support circles in five cities in the state of Louisiana. Birthmark also has an emergency preparedness project called Infant Ready^™, which promotes breastfeeding as the safest feeding option during emergencies through training, educational materials, and distribution of emergency infant feeding kits.

Louisiana experienced two Category 4 hurricanes during the COVID-19 pandemic. Hurricane Laura made landfall on August 27, 2020, near Cameron, Louisiana, about 245 miles west of New Orleans. This storm occurred around the same time as a second wave of COVID-19 infections in Louisiana. Birthmark mounted an emergency response to support pregnant women and caregivers of children under 2 years old who evacuated to New Orleans (O’Connor, 2020). One novel response strategy was activating a free 24-hour emergency perinatal and infant feeding hotline. The hotline number was created via a Google Voice^™ number, a free and easily accessible online platform to make and receive calls and send SMS messages. The hotline was launched the night before the storm and was staffed remotely by Birthmark’s doulas and lactation support providers. Birthmark also collaborated with a local language justice collective to offer interpretation for Spanish speaking individuals calling the hotline. The hotline was shared via email to Birthmark’s email listserv (consisting of current and former clients, recipients of continuing education and training, and community partners), the Louisiana Breastfeeding Coalition, State Hospitals, city and state emergency response contacts, the New Orleans Maternal and Child Health Coalition, and community birth workers and lactation professionals. A hotline flyer was also posted on social media. The hotline provided 24/7 support for 3 weeks before gradually decreasing to daytime hours the following week. Birthmark staff reduced hours of operation once it was clear that the volume of calls was decreasing. The hotline supported 62 callers during Hurricane Laura.

One year later, on August 29, 2021, Hurricane Ida struck near Port Fourchon, nearly 100 miles from New Orleans, Louisiana. New Orleans was hit with strong winds and experienced extensive power outages (Kasakove, 2021). Birthmark partnered with the Global Military Lactation Community (formerly Mom2Mom Global) to staff the hotline so that Birthmark staff and their families could evacuate to safety or shelter in place. Members of Global Military Lactation Community were instructed on how to log into the hotline Google Voice^™ account, how to sign up for 12-hour shifts, and how to keep a record of incoming calls. Standardized record keeping included name and phone number of the lactation support provider, name and phone number of the Spanish speaking interpreter (where applicable), general topics covered on each call, the name and phone number of each caller (where follow up was needed), and the total number of calls received during each shift. Four of the hotline staff from Global Military Lactation Community were Spanish speakers and thus able to provide interpretation where needed. Due to the high volume of calls in the first week, coordinators from Birthmark and Global Military Lactation Community created a quick resource guide with the most up-to-date information on food and supply distribution, sheltering sites, and other information for volunteers staffing the hotline. The hotline was launched one night before the storm made landfall and provided 24/7 support for 1 week, before decreasing to daytime hours for a second week in response to reduced demand. The decrease in calls by the end of the first week post-hurricane may have been due to the fact that the city of New Orleans had set up eight cooling stations, where hot meals, ice, diapers, and other supplies were available. The hotline supported 35 callers during Hurricane Ida.

Sample

We obtained call logs of all 62 calls from Hurricane Laura and all 35 calls from Hurricane Ida from Birthmark’s database. Inclusion criteria included all call logs from Category 4 Hurricanes between 2020 and 2021. The total number of calls on the call logs was 97. Call log notes were formatted in Google Sheets, a spreadsheet application. Call logs notes included date, time, general topics covered on each call, any follow up support provided, and number of callers per day. During its operation, hotline staff did not collect demographic information about callers or their children, which means the demographic information is not included in the data set.

To set up focus groups, we sent recruitment emails to all hotline staff, eight employees of Birthmark and eight employees of Global Military Lactation Community who staffed the hotline. Inclusion criteria included staffing the hotline for one of the two Category 4 hurricanes of interest, and availability to participate in a virtual focus group. Three staff from Birthmark and two staff from Global Military Lactation Community agreed to participate.

To supplement lessons learned from the call logs and staff focus groups, we interviewed mothers who called our hotline for support. We reviewed hotline call logs to identify mothers who were either pregnant or who had specifically sought out support for infant feeding-related issues. Fifteen potential participants were identified for whom we could accurately match telephone numbers, five from Hurricane Laura and 10 from Hurricane Ida. We sent a recruitment text and a nudge text to each of these 15 participants. Two mothers responded, both of whom called the hotline after Hurricane Ida. Both mothers were residing in New Orleans and had children less than 1 year old at the time of Hurricane Ida. All participants, including those who participated in the interviews and focus groups, were offered a $50 gift card for their participation. The sample size was adequate for the scope of this qualitative research project.

Data Collection

Data collection occurred from May to September 2022. We conducted individual interviews with mothers and focus groups with hotline staff, which lasted approximately 30 and 60 minutes in duration, respectively. Prior to the interviews (n = 2) and two focus groups (n = 5), participants were given information about the study and had the opportunity to ask questions before providing verbal consent. Interviews and focus groups were audio recorded with each participant’s permission. Our research team consisted of three Black women, all with graduate degrees in public health and research or practitioner experience with breastfeeding: an academic faculty co-principal investigator (PI), a community co-PI, and a postdoctoral fellow collaborator. The research team developed and pilot tested the interview guide for mothers, and a focus group guide for hotline staff (see the online Supplemental Materials). To establish cultural appropriateness, each guide underwent four iterations to refine questions. This time was also used to train the research team on conducting interviews and focus groups, allowing them to assess any challenges with cultural nuance and comprehension of study materials. For mothers, the guide content included: emergency preparedness plans, property damage, evacuation experience, and support and resources needed during emergencies. For hotline staff, the guide content included: training process, training recommendations, provider/caregiver experiences during disasters, nature of calls, challenging and rewarding calls, and past, current, and future natural disaster concerns.

The interview protocol was guided by the qualitative interview method described by Rubin and Rubin (2005), which structures research guides around main questions, follow-up questions, and probes for clarification. This ensured that similar data were collected from each participant, yet allowed them the flexibility to tell their stories in their own way (Davis & Craven, 2016). All data collected from interviews and focus groups were stored on a shared drive with access restricted only to the research team members involved in the study.

Data Analysis

Call logs were exported from Google Sheets into Microsoft Excel. Personal identifiers were removed from call logs prior to content analysis (Cavanagh, 1997). Two researchers categorized the 97 calls as infant feeding-related versus non-infant feeding-related within Microsoft Excel and quantified the types of requests and referrals made. Several call logs were not mutually exclusive as individual calls contained both infant feeding and non-infant feeding requests.

Audio recordings were transcribed verbatim, and data were de-identified using pseudonyms. Our research team cross-checked transcripts for accuracy then imported transcripts into Microsoft Excel for data management and analysis. Our team performed a reflective thematic analysis of interview and focus group transcripts to gain insight on our research question using the process provided by Braun and Clarke (2006). First, our team familiarized ourselves with the interview and focus group data. We read transcripts multiple times prior to coding to gain greater familiarity with the participants’ perspectives. Then, codes were generated inductively by reviewing transcripts line by line. Lastly, these codes were categorized into broader themes. Specific procedures were used to achieve trustworthiness, which included member checking, peer debriefing, audit trails, and triangulation of data between call logs, interviews, and focus groups (Lincoln & Guba, 1985; Sandelowski, 1993). Member checking occurred at the end of each interview and focus group and participants confirmed the findings. The audit trail includes call log files, audio recordings, transcripts, and interview and focus group notes.

Results

For the call log content analysis, findings were grouped into two categories: “Infant Feeding Needs” and “Non-Infant Feeding Needs.” For the thematic analysis of data from interviews with mothers and focus group discussions with hotline staff, four themes emerged: “Family Vulnerabilities,” “Social Networking Works,” “Brief Staff Training,” and “The Helper Versus the Helped.” Each theme is presented with example quotes.

Characteristics of Sample From Interviews and Focus Groups

All Birthmark staff who participated in the study were Black women who were Certified Lactation Counselors (CLC) residing in New Orleans. Global Military Lactation Community staff included one Black IBCLC residing in Florida and one Latina CLC residing in Georgia.

One mother (Lexi) identified as Black, resided in New Orleans, had four children, sheltered in place during Hurricane Ida, and was formula feeding her youngest child (2 months old). At the time of the hurricane, she was living with her four children. The other mother (Audrey) identified as White, resided in New Orleans, evacuated to Baton Rouge, Louisiana, and had one child (10 days old) at the time of Hurricane Ida. She was breastfeeding, bottle feeding expressed human milk, and supplementing with pasteurized donor milk before and during Hurricane Ida. At the time of the storm, she was living with her spouse and parents-in-law.

Call Log Analysis

We estimate 94% (n = 91/97) of callers were the caregiver of an infant or young child, and 3% of callers (n = 3/97) were caregivers who were native Spanish speakers. In all, 6% of callers (n = 6/97) were emergency response personnel and local nurses. Five percent of calls (n = 5/97) were related to enrollment, benefits, and access to The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Table 1 provides a comparative summary of basic characteristics of Hurricanes Laura and Ida, as well as descriptions of the hotline duration, number of staff, number of calls received, and the general nature of calls made to the hotline.

Table I.

Findings From Analysis of Perinatal Emergency Hotline Call Logs.^a

	Hurricane Laura	Hurricane Ida
Area Impacted	Southwest Louisiana	Southeast Louisiana
Evacuation Location(s)	Centralized to Greater New Orleans Area	Louisiana (New Orleans shelter sites. Baton Rouge, Ascension Parish) Texas (Houston) Mississippi Florida (Pensacola)
Date of Hurricane Landfall	Thursday, August 27, 2020	Sunday, August 29, 2021
Hurricane Category	4	4
Length of Hotline	24hr/day, 7 days/week for 3 weeks; 9 hr/day 5 days/week for 1 week	24hr 7days for 1 week; 9 hr 5 days for 1 week
Dates of Hotline Operationb	August 26 to September 20, 2020	August 28, to September 12, 2021
Organization Staffing Hotline	Birthmark Doula Collective	Global Lactation Military Community (formerly Mom2Mom)
Total # of Hotline Staff	9	9
Data Collection Tool	Google Sheets	Google Sheets
Calls (N = 97)	62 (64%)	35 (36%)
Calls Per Site Related to Infant Feeding	16 (26%)	15 (46%)
Sample Infant Feeding Needs	Managing breastfeeding challenges including nipple pain, plugged ducts, and switching for formula to human milk. Introducing solid food. Seeking formula. Seeking a breast pump. Enrolling in WICc program.	Managing milk supply, pumping, colostrum, mastitis. Seeking advice on relactation. Seeking formula (both in New Orleans and in evacuation locations). Accessing WIC program benefits across state lines.
Sample Non-Infant Feeding Needs	Seeking information on what the hotline provides. Seeking diapers and clothing. Seeking transportation to Evacuee Resource Center.c Seeking stroller. Seeking bassinet. Seeking hospital nurse hotline. Seeking mental health crisis referral. Seeking missing family member. Seeking dentist referrals. Seeking booster seat. Seeking cane.	Seeking information on what the hotline provides. Seeking evacuation sites. Seeking diapers, clothing, and baby items. Seeking referrals for pregnancy care. Seeking list of hotel shelters. Seeking mutual aid resources. Seeking food distribution centers. Seeking services for the elderly. Seeking transportation. Seeking mental health support and housing. Seeking urgent care facility for newborn.

Note. WIC = The Special Supplemental Nutrition Program for Women, Infants, and Children.

^aContent analysis of 97 total call logs divided calls into two broad categories: Infant feeding needs versus non-infant feeding needs.

^bDates of hotline operation are the dates for data collection.

^cCity of New Orleans resource center for Hurricane Laura evacuees.

For Hurricane Laura, the hotline received the highest volume of calls (n = 13/62, 21%) on August 31, 2020. On that day, all callers were referred to the Evacuee Resource Center in downtown New Orleans to get basic supplies, medical care, and other direct support. Due to the novel implementation of the hotline, there were gaps in details from 11 calls (18%) made on various days following Hurricane Laura.

Exactly a year later, during Hurricane Ida, the hotline received the highest volume of calls (n = 12/35, 34%) on August 31, 2021. On that day, calls came from New Orleans, but also from other parts of Louisiana, Mississippi, Florida, and Texas. Callers needed resources wherever they were located; 29% (n = 10/35) of callers were looking for infant formula or food distribution sites. The note taking process for hotline staff during Hurricane Ida was more detailed.

Infant Feeding Concerns

Of the 97 calls recorded between both storms, 31 out of 97 (32%) were related to infant feeding concerns. More specifically, during Hurricane Laura, 16 of 62 (26%) calls were related to infant feeding concerns, compared to 15 of 35 (43%) calls during Hurricane Ida. Thirteen of the 97 calls (13%) were related to breastfeeding support, with callers specifically seeking support for managing challenges such as latching, plugged ducts, nipple pain, mastitis, and milk supply.

In addition to these general breastfeeding challenges, two other calls (2%) specifically discussed relactation, and another call (1%) explored tips on how to gradually switch from formula feeding to breastfeeding. One call (1%) was on how to obtain a breast pump and five calls (5%) inquired about WIC enrollment and/or accessing benefits during evacuation in other cities and states. A total of 17 of the 97 calls (18%) were requests for infant formula, which was the most frequently requested supply for both storms.

Non-Infant Feeding Needs

During and immediately after natural disasters, the needs of families with young children were multi-faceted and not solely related to infant feeding. Needs ranged from shelter, electricity, and cooling, to infant supplies and healthcare. Of the 97 calls, 13 (13%) included requests for items such as strollers, bassinets, diapers, and clothing. In all, 29% of calls for Hurricane Laura included referral to the resource center for various types of support. Overall, four calls (4%) included mothers needing information for pregnancy support, prenatal care, or labor/delivery referral. Hotline staff referred seven calls (7%) for other services including dental care, mental health care, and urgent care. Call logs did not denote any COVID-specific needs for either storm. Fourteen percent of calls for Hurricane Ida related to shelter or housing.

Thematic Analysis

The following themes (Table 2) emerged from interviews with two maternal participants who called the hotline during Hurricane Ida and from focus groups with five hotline staff participants who provided remote support across two hurricanes. Table 3 includes select supporting quotes for these themes. The Birthmark staff quoted were Kenya, Valerie, and Isabelle (Hurricane Laura, 2020) and The Global Military Action Community staff quoted were Kaitlyn and Sophia (Hurricane Ida, 2021). The two maternal participants were Audrey, mother of one, who breastfed, and Lexi, mother of four, who fed her baby with infant formula.

Table 2.

Data Analysis Structure for Thematic Analysis.

Theme	Theme Definition	Codes
Family Vulnerabilities	Maternal participants’ familial context during and after Hurricane Ida in terms of infant feeding and non-infant feeding needs.	1. Evacuation Plan 2. Home Damage 3. Breastfeeding Support 4. Infant Formula 5. Other needs
Social Networking Works	Communication channels for promoting the emergency perinatal hotline to families in need.	1. Social Media 2. Word of Mouth 3. Email
Brief Training	Staff experiences with the brief hotline training received compared with actual experiences implementing the hotline.	1. Hotline training 2. Previous remote support experience 3. Local knowledge 4. Resource information 5. Staff self-care 6. Trauma responsiveness 7. Language support
The Helper Versus the Helped	Staff experiences partnering with another organization to implement the hotline for Hurricane Ida.	1. Partnership benefits 2. Partnership concerns 3. Recommendations for partners

Table 3.

Quotes From Thematic Analysis of Interviews with Mothers (n = 2) and From Focus Groups with Hotline Staff (n = 3).

Themes	Selected Quotes
Family Vulnerabilities	“Our donor milk supplies were dwindling because we were only able to purchase for 1 week. It was about to be finished so I called you guys.” – Audrey, mother of one “I was running out of formula … because at the time, the stores was still closed and the stores that was open, they didn’t have no formula … and I was on the last can of formula for my son, and I’m like, I don’t know where I’m gonna get formula from…. And, I was asking people and then my friend gave me the hotline number.” – Lexi, mother of four “I feel that it was such a vulnerable time to be as a young family in a emergency situation…. I feel very lucky to have so many resources in place. By resources I mean human resources, supplies, information, a car to evacuate, family and friends who were checking with us constantly…. I was afraid that so much stress impact us, or me. All those resources in our lives work great together, we feel very protected inside this bubble.” – Audrey, mother of one “We was out of lights for 2 whole weeks. So, I have a son who has seizures and between me having a new baby and just with me having all my children here, I was thinking about keeping them hydrated and trying not to let them get overheated by us being without lights for 2 weeks.” – Lexi, mother of four “They [hotline staff] gave me formula, water…. They was asking me some other stuff like did I need anything else … and they also told me where I can get hot meals from.” – Lexi, mother of foura
Social Networking Works	“We posted it [hotline information] on social media. I think the health department and stuff shared it, and then it was pretty much word of mouth…. A lot of people were staying in the same hotels [for Hurricane Laura] and they were saying, ‘Here, text this number if you need help.’” – Kenya, CLC,b Birthmark “Somebody on social media had posted it and was giving it out and I had contacted y’all. It was a friend through Instagram.” – Lexi, mother of four
Brief Staff Training	“We had different numbers and websites and links that we could give out to people who needed things that we didn’t have. Answering any questions that they had about breastfeeding because we did have a lot of pregnant moms and a lot of moms who were breastfeeding. And for those who weren’t breastfeeding … where they could get formula, where they could get water for formula, how they could heat up the water to make the formula with the resources that they did have available to them, but also encouraging them to use the liquid formula because it didn’t need to be sterilized. Talking points on relactation if the moms are interested. And we even had to go as far as like giving directions to shelters because we didn’t realize that a lot of people didn’t know where to go.” – Isabelle, CLC, Birthmark “We had more than one about WIC benefits transferring to other states…. We all learned something new about that process and like how that works for emergencies in short term so that would be a really great resource to have more prominent because … even on the WIC site we were like ‘where’s the information for this so that we can tell them like where to call and who to contact to be able to get those things that they needed.’” – Sophia, CLC, Global Military Lactation Community “We did create a buddy system during that time. So you would check in with your buddy during the hurricane season and it’s an ongoing conversation that we have…. It’s, it’s a lot. It’s a disaster. They say it disrupts, it disrupts a lot of things” – Valerie, CLC, Birthmark “The ability to take a step back, compartmentalize almost the emotional part of it, and then think through, and then use your brain and the systems in place and be able to research and stay calm…. Someone who can think on their feet.” – Kaitlyn, IBCLC, Global Military Lactation Community “Those who are on the hotlines to try [to be as] trauma informed as possible, and so I always think about the four R’s of like trauma informed care, realizing that this person is going through a trauma. And then we want to help them realize that this is a trauma. We want to recognize it. I can’t remember all of them. We’re going to respond to their trauma by something and then make sure that we’re not retraumatizing that person, well, by hearing your personal experience and like something so simple, but like, this, the idea of like retraumatizing because that can happen accidentally.” – Valerie, CLC, Birthmark “As far as having people, Spanish language and translation, having the capacity to be able to manage all of that at the same time very quickly was helpful for us.” – Sophia, CLC, Global Military Lactation Community
The Helper Versus the Helped	“We’re all just clueless. We just had the clothes on our back. Nobody knew what their houses looked like or anything [for Ida], so it was hard to even show up for them [clients] because we weren’t even showing up for ourselves. Everybody was just lost. For Laura, it was different. I think we were able to help out a lot more because we weren’t really impacted … but I definitely think when a disaster hits home, self-care goes out the window.” – Kenya, CLC, Birthmark “A lot of [hotline] questions [are] around “What does the city offer?” It was a weird situation because New Orleans became the headquarters [for Hurricane Laura]…. But then for [Hurricane] Ida, we had our own damage, so things were all scattered and all over the place…. In person after Laura, I was able to assist and have conversations around relactating, and well, why did you stop breastfeeding. I was able to have those conversations in person. But when you’re calling the hotline, they are looking for like quick [answers], ‘Where’s my stuff? Where can I get it?’” – Valerie, CLC, Birthmark “Preparedness, supply shortages, whether or not I’ll be able to actually help people or be in the midst of it. Especially after Ida, it’s like the focus is changing from being the helper to being the one who needs the help.” – Isabelle, CLC, Birthmark “It felt good and a relief since we had to take care of our own families and evacuate (I don’t think we could have been any help), but had some reservations/worries that Mom2Mom would not be as familiar with being able to help people since they are not from New Orleans or the surrounding areas … it’s a culture thing.” – Kenya, CLC, Birthmark “It would be useful to have a general info on the geographic location of New Orleans and you know how in New Orleans everything’s referred to by neighborhood and different locations … maybe a general terminology of how things are described in the area.” – Kaitlyn, IBCLC, Global Military Lactation Community

Note.

^aBirthmark Doula Collective partnered with Community Organized Relief Effort (CORE New Orleans), a crisis response organization, to deliver diapers and water to a few families that called the hotline who expressed transportation barriers in the aftermath of Hurricane Ida.

^bCLC = Certified Lactation Counselor, IBCLC-Internationally Board Certified Lactation Consultant.

Family Vulnerabilities

Audrey and Lexi provided context on their vulnerable situations during Hurricane Ida. Before Hurricane Ida hit, Audrey was having issues with her milk supply. To supplement feedings, she bought donor milk from a local hospital milk bank before the storm, when her baby was just 5 days old. When Hurricane Ida made landfall, Audrey’s “donor milk supplies were dwindling” and she had questions about where to purchase more milk. She also had questions about latching and increasing her milk supply.

Audrey was breastfeeding her 2-week-old baby when she evacuated to Baton Rouge, Louisiana. She already had a general evacuation plan in place before the storm hit. Although it was a “vulnerable time,” Audrey was grateful to have the “many resources” to safely evacuate. Conversely, Lexi was formula feeding her 2-month-old baby at the time of Hurricane Ida. She was on her “last can of [infant] formula.” Lexi did not have an evacuation plan because she did not think the storm would be severe. As Hurricane Ida drew nearer, she considered evacuating but instead had to shelter in place with her four children when her car malfunctioned. Lexi suffered minor damage to her home and was “without lights for 2 weeks.”

Both Audrey and Lexi expressed that the emergency hotline was very helpful in meeting other general needs. Even though they initially called about their baby’s needs, they found hotline staff shared other helpful information “about anything else” for their families.

Social Networking Works

For Hurricane Laura, hotline staff stated that the hotline was promoted via several different avenues, including “social media,” “word of mouth,” “the Health Department,” and the convention center. During Hurricane Ida, a health provider referred Audrey to the emergency hotline. Lexi found out about the emergency hotline from “a friend through Instagram.”

Brief Staff Training

Since the hotline was launched in the wake of each storm, staff received brief training. Staff had experienced providing remote support due to the COVID-19 pandemic and were able to build upon that experience. Hotline staff expressed needing to be prepared for “a broad range of questions” related to breastfeeding challenges, as well as where to find infant formula, where to find clothes, where to go to get paperwork to make sure the family unit is safe, and links to organizations providing disaster assistance. Sophia mentioned “we all learned something new” when helping callers understand how to access WIC services while evacuated out of state.

In addition to needing to be resourceful, the importance of “trauma informed” care emerged. Staff said anyone staffing the hotline should be calm, level-headed, and able to provide the support needed, even under stress. Staff also remarked about the importance of working as a team, and taking breaks as staffing the hotline was both rewarding and challenging. Additionally, being able to communicate with non-English speakers (either by knowing the language or having an interpreter) is extremely important during emergency situations.

The Helper Versus the Helped

Birthmark staff described the difference between serving families during Hurricane Laura in 2020 versus being personally impacted by Hurricane Ida in 2021. Thus, it was important to have a partnership with the Global Military Lactation Community. Birthmark staff voiced appreciation for having another organization assist with operating the disaster hotline because their staff shifted “from being the helper to being the one who needs the help.” They stated that making themselves available to assist other families during Hurricane Ida was challenging because they had to prioritize their own families’ well-being.

Although grateful, Birthmark staff also voiced “reservations/worries” about an organization based in a different location staffing the hotline. Local residents make geographic and cultural references that outside staff “would not be as familiar with,” thus possibly creating a barrier for support.

One of the Global Military Lactation Community staff previously resided in New Orleans and was able to relate. Kaitlyn described the importance of having local knowledge and suggested resources to aid partner organizations supporting the hotline. However, also being knowledgeable about how to access national resources, like WIC, was essential to supporting families calling for assistance out-of-state.

Discussion

To our knowledge, this is one of the first pieces of research to highlight service-based efforts to protect IYCF-E in the context of the United States. The work presented here suggests that there are opportunities to support IYCF-E remotely using a hotline, including in locations with low breastfeeding rates. As hotline staff suggest, this IYCF-E support could be included as part of a larger emergency resource hotline such as 2-1-1 (Landis et al., 2023). While overall call volume was low—considering the number of people affected by both Hurricanes Laura and Ida—this may be due to a lack of awareness of the hotline during the storms and a lack of understanding of what type of support the hotline provided. This could be addressed by heavily promoting the hotline to pregnant and parenting families well ahead of hurricane season. Our other novel findings include relactation, family vulnerabilities during disaster, the role of the WIC program in disaster response, and infant formula shortages.

Remote Lactation Support

Remote lactation support is critical for families, especially during disasters. For example, Landis et al. (2023) reported a higher use of a 2-1-1 call line by women specifically during Hurricane Irma and COVID-19. During the pandemic, several of the breastfeeding topics that increased significantly on breastfeeding support mobile applications (i.e., LactApp), and breastfeeding helplines overlap with the breastfeeding challenges highlighted in our study, namely breast pain, mastitis, and relactation (Hull et al, 2020; Quifer-Rada et al., 2022). Unlike disease outbreaks such as COVID-19, natural disasters like hurricanes often lead to limited-to-no electricity and limited use of phone and internet services, thus restricting the use of mobile apps and increasingly popular telehealth services. This limitation must be acknowledged. Future research could explore the advantages and disadvantages of various types of phone support interventions for IYCF-E, and also assess the quality of support received.

The success of the IYCF-E hotline in Louisiana was enhanced by partnerships with both a language justice collective and another lactation support organization outside the state. We see this as a form of mutual aid, or community-based disaster responses built on principles like solidarity and reciprocity (Loh et al., 2023). Mutual aid networks have increased in visibility during the Covid-19 pandemic (Landau, 2022). These same networks can be leveraged to support IYCF-E following natural disasters. Future research can explore how mutual aid and other community-level responses can offer lactation support in disaster situations.

Relactation

For both Hurricanes Laura and Ida, the hotline received calls regarding relactation. For mothers who have stopped breastfeeding, relactation can provide a safe way to feed an infant during a period of uncertainty (U.S. CDC, 2020). The U.S. CDC’s IYCF-E toolkit has information for stakeholders on how to support families in reestablishing lactation after having ceased for some time (U.S. CDC, 2022b). While information on relactation is available from health authorities and health agencies, there is a shortage of literature on how to implement relactation support during emergencies. Future research can explore the experiences of women who are successful at establishing relactation following disasters such as a hurricane, as well as the resources and strategies that providers can utilize to facilitate relactation support. Emergency preparedness messaging should promote breastfeeding as providing food security for infants.

Family Vulnerabilities During Disasters

The two mothers in our study represent opposite ends of the spectrum in terms of socioeconomic and social vulnerability during emergencies. These two women followed the typical pattern for infant feeding practices, whereby the mother with greater access to resources and support was breastfeeding, and the mother with less access to resources and support was not. There is mounting evidence suggesting that climate-related crises are harming the most those with the least resources to protect themselves and their families (Human Rights Watch, 2020). Mothers who are poorer, have fewer resources, are less able to avoid or escape emergencies, and are more likely to be living in locations or housing where they will be more affected by emergencies are also more likely to be formula feeding. There is an imperative to increase support to assist more disadvantaged mothers to breastfeed, as they are at greater risk in an emergency.

Role of WIC

WIC serves about half of all infants born in the United States, including infants and children up to age 5 who are at nutrition risk (Kessler et al., 2023). WIC can play an important role in disaster response to promote resilience in socioeconomically disadvantaged families with young children. The WIC program found several ways to be flexible in service provision during the Covid-19 pandemic (Morris et al., 2022; Ventura et al., 2022). These pivots could also be useful during natural disasters. Wemette et al. (2018) found that WIC program staff identified several recommendations to improve preparedness for continuity of services following Superstorm Sandy in 2012 in the New York area. Recommendations included having better information-sharing with state and local health departments, and having mobile and/or temporary WIC sites to reach impacted families. The USDA (2023a) has official guidance for WIC program sites during disasters. Birthworkers and lactation providers should provide education during hurricane season about accessing WIC benefits in times of disaster. Future studies can uplift the importance of WIC during disaster response.

Infant Formula Shortages

Louisiana has some of the lowest breastfeeding rates in the United States, leaving families—especially socioeconomically disadvantaged families—particularly vulnerable to accessing infant formula and safely preparing it during emergencies. Unless single-serve, ready-to-feed infant formula is available, caregivers also need water for reconstitution and/or washing, as well as gas or electricity for boiling water (U.S. CDC, 2022b). Communities of color who are vulnerable to natural disasters are also vulnerable to poor municipal water infrastructure.

The challenges in obtaining infant formula during Hurricanes Laura and Ida foreshadowed the 2022 infant formula recall, which resulted in a national infant formula shortage (Tomori, 2023). Supply shortages may lead families to dilute infant formula or try to make alternatives (Abrams & Duggan, 2022). Birthworkers, healthcare providers and emergency personnel should provide messaging on safe infant formula preparation during emergencies and also provide resources on where to access infant formula and water.

Limitations

This study is limited by the incomplete and inconsistent data available in the call logs due to the novel nature of the perinatal emergency hotline. For example, some staff did not include notes, while others did not clearly distinguish the needs of each caller. However, since our analysis was done retrospectively, these inconsistencies provide implications for practice for Birthmark and other organizations launching perinatal disaster support hotlines in the future. After immediate disaster responses, call log documentation can be reviewed to identify ongoing needs of perinatal populations during disaster recovery, as well as to increase preparedness for future emergencies. Additionally, we were only able to recruit two mothers for interviews, both from Hurricane Ida, which limits generalizability.

Conclusion

Infant and young child feeding is an often-overlooked component of emergency preparedness (Talley & Boyd, 2013). This is problematic, as climate related disasters are predicted to occur more frequently and with greater intensity. The protection and promotion of breastfeeding in emergencies has health benefits for infants, parents, and entire communities, particularly those that are at a socioeconomic disadvantage, and thus more vulnerable during emergencies. A hotline is a unique strategy to promote IYCF-E in contexts with low breastfeeding rates that are prone to natural disasters and emergencies. This research highlights the importance of incorporating perinatal health and family-centered support services into emergency preparedness planning and policies.

Supplementary Material

Supplementary Material may be found in the “Supplemental material” tab in the online version of this article.

Key Messages.

• There are gaps in the literature regarding infant and young child feeding in emergencies (IYCF-E) in populations with low breastfeeding rates in the United States.

• During Hurricanes Laura and Ida, families who called an emergency perinatal and infant feeding hotline operated by a cooperative that provides doula and lactation services in the Greater New Orleans area had needs beyond infant feeding.

• Hotline staff providing IYCF-E support during natural disasters need basic training and disaster response plans. Previous experience providing remote lactation support during emergencies, such as the COVID-19 pandemic, is also beneficial.

• Hotline staff should be located outside of the area impacted by the emergency to ensure emotional and technological capacity to staff the hotline.