Protecting and improving breastfeeding practices during a major emergency: lessons learnt from the baby tents in Haiti

Abstract

Problem

The 2010 earthquake in Haiti displaced about 1.5 million people, many of them into camps for internally displaced persons. It was expected that disruption of breastfeeding practices would lead to increased infant morbidity, malnutrition and mortality.

Approach

Haiti’s health ministry and the United Nations Children’s Fund, in collaboration with local and international nongovernmental organizations, established baby tents in the areas affected by the earthquake. The tents provided a safe place for mothers to breastfeed and for non-breastfed infants to receive ready-to-use infant formula. Such a large and coordinated baby tent response in an emergency context had never been mounted before anywhere in the world.

Local setting

Baby tents were set up in five cities but mainly in Port-au-Prince, where the majority of Haiti’s 1555 camps for displaced persons had been established.

Relevant changes

Between February 2010 and June 2012, 193 baby tents were set up; 180 499 mother–infant pairs and 52 503 pregnant women were registered in the baby tent programme. Of infants younger than 6 months, 70% were reported to be exclusively breastfed and 10% of the “mixed feeders” moved to exclusive breastfeeding while enrolled. In 2010, 13.5% of registered infants could not be breastfed. These infants received ready-to-use infant formula.

Lessons learnt

Thanks to rapid programme scale-up, breastfeeding practices remained undisrupted. However, better evaluation methods and comprehensive guidance on the implementation and monitoring of baby tents are needed for future emergencies, along with a clear strategy for transitioning baby tent activities into facility and community programmes.

Background

On 12 January 2010, an earthquake measuring 7.3 on the Richter scale hit Haiti. Its epicentre was close to Port-au-Prince, the capital city. Overall, about 3 million people, or 30% of the country’s population, were affected – half of them children. Approximately 300 000 people were killed and another 300 000 were injured.¹ The earthquake destroyed homes and forced 1.5 million people into displacement.² Many of these people took up residence in one of the country’s 1555 crowded camps for internally displaced persons.³ Port-au-Prince, where the majority of the camps were established, was already home to a poor population with little access to basic social services. The rate of exclusive breastfeeding (21.7%) in the city was the lowest in the country even before the earthquake and there was fear that breastfeeding practices would be further jeopardized during the emergency.⁴

The humanitarian response to the crisis was fast and multifaceted. In collaboration with local and international nongovernmental organizations (NGOs), the Haitian health ministry and the United Nations Children’s Fund (UNICEF) established baby tents (points de conseils en nutrition pour bébés [infant nutrition counselling units]) throughout the areas affected by the earthquake (the cities of Port-au-Prince, Jacmel, Leogane, Petit Goave and Gonaive). Similar smaller initiatives, described elsewhere, had been launched in Bosnia, Kenya, the Philippines and the United Republic of Tanzania in response to various types of emergencies.^5,6 These initiatives helped to inform Haiti’s response, but Haiti’s baby tent programme was the world’s largest coordinated response of its kind in an emergency context.

In this article we describe Haiti’s baby tent strategy, the results achieved, the challenges encountered and some potential ways to address these challenges. We also discuss certain recommended features of future emergency programmes in support of infant and young child feeding.

Context

Before the earthquake

According to empirical evidence, 19% of all deaths among children younger than 5 years in the developing world could be prevented through appropriate infant and young child feeding practices.⁷ In Haiti, implementation of the infant and young child feeding practices recommended by the World Health Organization (WHO) and UNICEF was hindered by certain circumstances and beliefs.^8–10 For example, infants were often separated from their working mothers during the day and some people felt that the first milk was “dirty” and harmful to neonates. According to the 2005–2006 Demographic and Health Survey, 44% of Haitian mothers initiated breastfeeding immediately after birth and 41% of infants less than 6 months old were exclusively breastfed. Of infants in this age group, another 23.7% were prematurely given liquid, semi-solid and solid foods of suboptimal quality.¹¹

After the earthquake

Haiti’s health ministry and nutrition partners (UNICEF, WHO, the United Nations World Food Programme and various NGOs) feared that harsh living conditions in the camps for displaced persons would lead to the abandonment of appropriate infant and child feeding practices. They also realized that infants whose mothers had died or were missing would need to be fed and cared for. There were also fears that a flood of donated infant formula and milk products would lead to the uncontrolled distribution of these products and to increased rates of diarrhoea and death among infants as a result of unhygienic bottle feeding practices. Haiti had been a recipient of donations of all kinds from the United States of America for decades. In the weeks immediately after the earthquake, Haiti received infant feeding products from different countries in enormous quantities, in violation of the International Code on the Marketing of Breast Milk Substitutes, which restricts the marketing of breast-milk substitutes to protect breastfeeding.¹²

It became clear that infant feeding had to be facilitated through the creation of spaces where mothers could receive antenatal and postnatal counselling and safely breastfeed their infants, and where infants who could not be breastfed (e.g. orphans and infants separated from their mothers) could be given ready-to-use infant formula. This led to the establishment of the baby tent programme.

The baby tents

The goal of the baby tent programme was to promote and sustain optimal infant feeding practices while reducing the health risks associated with the unregulated use of infant formula. Baby tents were relaxed, friendly and stimulating spaces where mothers could breastfeed comfortably and be supported by a trained counsellor and their own peers. The tents were spacious, light, clean, attractive and, in places with electric power, equipped with fans. Safe drinking water was available and there were mats and mattresses for sitting and relaxing. The tents were often decorated with child feeding balloons and posters and children’s songs were played in some of them between other activities.

The tents operated 6 to 7 days a week, as prescribed by the national guidelines developed by the health ministry and Haiti’s nutrition cluster partners. Activities included registration and assessment of the feeding and nutritional status of new mother–infant pairs and pregnant women; individual nutrition counselling of pregnant and breastfeeding women; counselling of caretakers of non-breastfeeding infants on ready-to-use infant formula; infant growth monitoring; and group education sessions on health and nutrition, childcare and the caretaker–child relationship. Children with acute malnutrition were transferred to the closest government-run or NGO-run nutrition programme, as appropriate; those with other severe medical conditions, such as dehydration or pneumonia, were transferred to the closest health centre.

In some baby tents, pregnant women were given iron and folate tablets to prevent anaemia and birth defects; children received vitamin A, deworming tablets, zinc and oral rehydration salts for non-life-threatening dehydration resulting from diarrhoea. In addition, psychosocial support services were provided and caregivers with major psychosocial problems were referred to specialized psychiatric services.

The staff of a baby tent included a social worker, a guard and a nurse in charge. The nurse had overall responsibility for the tent, performed all the nutritional and health assessments and saw to it that all reports were written and correct. Tents providing psychosocial support had a psychologist on the staff. One individual routinely supervised four baby tents.

Women came and went with their children throughout the day. Every morning and sometimes in the early afternoons, nutrition staff members conducted community awareness and participation activities in the camps with the use of megaphones. They also paid home visits, sometimes assisted by the psychologist. Home visits were conducted to encourage absentee mothers or caretakers to return to the tents; to counsel mothers experiencing breastfeeding difficulties; to see if the caretakers of infants who could not be breastfed were using ready-to-use infant formula and to investigate why some infants were losing weight.

Baby tent activities were recorded in a register and updated daily. Admission, discharge and transfer data were collected and managed using a standardized form and an information system. Such data were shared monthly. The data presented here were therefore obtained from the nutrition cluster database. Breastfeeding data are cumulative (February 2010 to June 2012) and data on infants receiving ready-to-use infant formula are for 2010 only, as this component of the programme ended in February 2011.

Programme results

Table 1 outlines key programme results. Overall, 193 baby tents were established after the earthquake: 108 in 2010 and 85 in 2011. They were attended by 180 499 infant–mother pairs and 52 503 pregnant women over a period of 29 months. Of the 180 499 infants enrolled, 54% (97 469) were less than 6 months old – the age group for which exclusive breastfeeding is the international recommendation. Of these younger infants, 70% (67 759) were exclusively breastfed as recommended; of the other 30% – those who reportedly received “mixed feeding” (i.e. breast milk plus other foods or liquids) – 10% moved to exclusive breastfeeding before the end of their participation in the baby tent programme. In 2010, 13.5% of all infants less than 12 months old who participated in the programme (i.e. 8787) had no possibility of being breastfed and hence were given ready-to-use infant formula for up to 6 months. The main lessons learnt from this programme are summarized in Box 1.

Table 1. Number of baby tents and their beneficiaries in terms of enrolment and fraction of infants who received ready-to-use infant formula or exclusive breastfeeding.

Year	No. of baby tentsa established	No. of mother–infant pairs enrolled	No. of pregnant women enrolled	No. of infants enrolled	No. of infants < 12 months old on ready-to-use infant formulab	No. of infants < 6 months old with possibility of being breastfedc	No. of children < 6 months old who were exclusively breastfed
2010	108	65 216	10 040	65 216	8787	31 677	22 319
2011	85	80 021	29 300	80 021	–	45 238	31 396
2012d	0	35 262	13 163	35 262	–	19 971	14 044
Total	193	180 499	52 503	180 499	8787	96 886	67 759

^a Officially known as points de conseils en nutrition pour bébés.

^b Ready-to-use infant formula was given in 2010 only.

^c Infants receiving ready-to-use infant formula were, by definition, excluded from this category.

^d January to June only.

Box 1. Summary of main lessons learnt.

• It is important to promote optimal infant and young child feeding practices through people with effective counselling skills during times of normality, before disaster strikes.

• There is a need for clear and easily adaptable infant feeding guidelines for emergencies that include a set of minimum implementation and reporting standards and monitoring tools for use at the individual and project levels.

• Involvement of community leaders and caregivers in the design and implementation of baby tent programmes are essential to ensure community awareness, participation and follow-up.

Challenges and potential solutions

Establishing the baby tent programme proved challenging in several respects. Before the earthquake breastfeeding practices and guidelines were generally poor. Training materials for workers and programme monitoring tools on optimal infant feeding practices appropriate for the Haitian context, particularly on the use of ready-to-use infant formula, did not exist. Following the earthquake, the health ministry was severely weakened and there arose an urgent need for trained health workers who could provide counselling and for qualified psychologists, which were very few. The displacement of large numbers of people and the lack of social cohesion made it difficult to ensure community participation in baby tent programmes and to follow up some of those mothers and infants who participated. Maintaining confidentiality while integrating infant and young child feeding practices and providing psychosocial support to mothers was also very difficult. Equally challenging was determining how many infants needed ready-to-use infant formula and how much formula would be needed; setting criteria for determining when an infant could never be breastfed; procuring enough infant formula in generic, uniform units of a single serving, and managing formula stocks. Because of space constraints, ready-to-use infant formula was distributed in the same tents where breastfeeding counselling was conducted and this may discourage mothers who could breastfeed. Urban mothers often worked or had to procure food outside their home and had to leave their children with others. The impact of the earthquake on the environment was not negligible either: larger tins containing ready-to-use infant formula led to spoilage; smaller tins generated more plastic debris. The forms used initially to monitor and report programme activities went through several revisions because they contained too many variables. Finally, transitioning from baby tents to infant and young child feeding practices sustainable over the longer term proved to be an arduous process. The same was true of efforts to integrate these practices within health centres.

To overcome these challenges, optimal infant and young child feeding practices were intensely promoted within baby tents and in the community using culturally appropriate messages and materials. Counsellors and health professionals were trained in counselling techniques and in infant and young child feeding practices; community leaders and caregivers became involved in baby tent programme activities and were empowered from the beginning and throughout; national guidelines, monitoring tools and training materials and job aids on infant and young child feeding were developed in Haitian Creole and a central database was established.

Other important measures might be applied in future catastrophes. Psychologists can be identified before the emergency. Confidential space for psychosocial support can be created. Before ordering ready-to-use infant formula, a census can be conducted to find out how many infants will need it. Flexibility should be exercised in setting and adhering to criteria for identifying infants who have no possibility of being breastfed. Ready-to-use infant formula should be procured in generic, uniform units of a single serving with identical instructions and should comply with labelling codes. It will also be essential to establish a robust mechanism for managing ready-to-use infant formula stocks and waste; to spatially separate the distribution of infant formula from the provision of breastfeeding counselling; to ensure a post-emergency baby tent exit strategy in which “model mothers” continue to receive support in their role as counsellors on infant feeding practices in each community and in which the population is informed about the reintegration of baby tent activities into existing health and community structures. Finally, UNICEF and WHO should consider issuing a joint statement or developing a global policy on baby tents as a component of any response to emergencies that could jeopardize infant feeding practices.