3.1 Humanitarian Context
In the Gaza Strip, ten years of blockade imposed by Israel after the takeover of Gaza by Hamas, and further recurrent outbreaks of hostilities have eroded basic infrastructure, service delivery, livelihoods and coping mechanisms. In 2019, the United Nations Office for the Coordination of Humanitarian Affairs (UNOCHA) suggested that issues affecting vulnerability in occupied Palestinian territory (oPt) include: the risk of and/or exposure to violence; the policies and restrictions imposed on geographic locations; and the specific contextual vulnerabilities that arise as a result.(1) The chronic electricity deficit has severely affected the availability of essential services, particularly health, water and sanitation services, and undermined Gaza’s fragile economy, particularly the manufacturing and agriculture sectors.(1) Palestinians in the Gaza Strip without access to safe water or sanitation have been identified among the most vulnerable groups in need of humanitarian assistance. (1) Instability, repeated and unpredictable escalation of conflict and limitation of movement for international and sometimes national experts, poses significant challenges to the ability of national and international agencies to conduct quality and consistent research.
The health sector has been heavily disrupted by years of conflict, sanctions and socio-economic decline. (3) Healthcare services are understaffed and lack basic resources, with frequent power cuts and stock-outs of essential drugs and equipment. (4) Over 90% of the water is unsuitable for human consumption.(3) Psychological trauma and poverty have severely affected the population’s mental health, with many people, including children and pregnant and lactating women, suffering from anxiety and depression.(3) Less than 50 percent of infants under six months are exclusively breastfeeding. (5). The level of micronutrient deficiency is high; 75 percent of children under 1 year are anaemic and more than 30 percent of pregnant and lactating women suffering from anaemia as well. (6)
3.2 Research Study
This case analysis highlights a component of a larger nutrition multisectoral assessment conducted in the Gaza strip and focuses on the following questions:
1) How does the protracted crisis in Gaza affect the breastfeeding practices of the most vulnerable population; and (2) What is the potential role that midwives can play in improving breastfeeding practices?
Data was collected using a mixed method approach with both quantitative and qualitative methods. This included a household survey comprised of anthropometric measurements, a Knowledge, Attitude and Practices (KAP) and an household infant and young child feeding (IYCF) survey, focus group discussions with primary caregivers and key informant interviews with stakeholders.
The assessment took place across all five governorates of Gaza; poverty data from 2018 was only available at the governorate and not at the locality level. (7). Proxy indicators correlated with for poverty from the 2018 census were identified as household size and highest educational attainment. (7)
In order to collect the sample sizes for the household survey a two-pronged approach to sampling was used. The sample size was calculated a design effect of 1.5 and a 10 percent estimate of non-response. The sample size was calculated based on achieving statistical confidence for the breastfeeding indicators.
Systematic random sampling was carried out by beginning at the administrative edge of the selected area and counting every 10 households to screen for eligibility criteria. If a household was found to have multiple eligible women, a maximum of two women were sampled per household. For each woman, a maximum of two children were eligible for sampling. Purposeful selection of women and children was conducted utilising eligibility and prioritisation criteria.
The household questionnaire was developed in Excel and uploaded onto mobile data collection tool (Kobo) for testing and shared with relevant stakeholders for testing and review.
The approval for the conduct of the assessment was provided by the Ministry of Interior in the Gaza strip, that reviewed, commented and requested changes in the questionnaire and in the design, no other approval was needed by the local authorities to conduct the study.
All the respondents were asked if they agreed to participate in the survey. Their verbal answer was recorded in the Kobo survey tool. The Ministry of Interior reviewed the questionnaire and the methodology including the verbal approval by the respondents to participate in the study.
During the actual implementation of the study, two (2) initially selected areas could not be accessed due to rapid deterioration in the security situation and associated risks of conflict escalation with aerial attacks from both parties involved. Data collection was therefore stopped for 2 days due to the imminent risk of escalation between the parties. Clearance was provided by the security officer prior to the re-start of data collection.
The findings illustrate the level of breastfeeding knowledge and practices of mothers living in poor communities, suggesting an opportunity to increase the ability of the midwives in the Gaza strip to promote, protect, and support breastfeeding during ante-natal, intra-partum and the post-natal period. A total of 1476 respondents (mothers) of children (0–59 months) were covered by the assessment, and all (100%) delivered in a health facility. 1172 (80.7%) delivered vaginally, while 284 (19.2%) delivered via a Caesarean-section (CS). A total of 1044 had a child less than 24 months (70.7%) while the remaining had children 2 to less than 5 years of age.
Findings show that in the context of the Gaza strip, 88% of women know that breastfeeding should be initiated within the first hour of birth (Table 1).
Table 1
Knowledge on when to start breastfeeding
When should you start breastfeeding? | No | (%) |
Immediately/within one hour | 919 | 87.77 |
Within one day | 87 | 8.31 |
Within two days | 23 | 2.20 |
When the mother is ready | 12 | 1.15 |
When the baby wants | 3 | 0.29 |
Don't know | 2 | 0.19 |
After three days | 1 | 0.10 |
More than 50% of women said that they received most breastfeeding information during antenatal care visits. Only 18% of women said that they received breastfeeding information during contact with health professionals throughout labour, delivery and subsequent post-natal care visits.
However, despite women’s knowledge, this study revealed that 6.3% of mothers with children less than 24 months stated that they never breastfed their children. When asked about the reasons for never breastfeeding their children, the top five (5) reasons given were: 1) maternal illness (40.3%); 2) new-born illness (26.9%); 3) baby’s refusal to breastfeed (16%); 4) perceived no/insufficient breast milk (9%); and 5) preterm baby (4.5%) or CS delivery (4.5%).
Early initiation of breastfeeding (breastfeeding within the 1st hour of birth) was practiced by 62.75% of mothers of children aged 0–23 months; 42% of the respondents confirmed that their new-borns were given liquids other than breast milk during the first three days of life.
Mothers were asked about the way that they addressed breastfeeding complications, such as perceived breast milk insufficiency. More than 50% answered that they rely on drinking additional fluids, 40% started to use breast milk substitutes such as infant formula, 21% of women increased the frequency of breastfeeding and 3% sought counselling support (Table 2).
Focus group discussions conducted with women affected by the conflict confirm quantitative findings. Qualitative findings show a very high awareness of recommended breastfeeding practices, but the concerns and worries about the current economic situation, coupled with misinformation currently affect the breastfeeding practices in these communities.
Table 2
Respondents’ solutions to perceived breast milk insufficiency
What should you do if you have insufficient breast milk?) | No. | (%) |
Drink more fluids | 533 | 51% |
Top up each breastfeed with a bottle of formula | 431 | 41% |
Increase frequency of breastfeeding | 220 | 21% |
Unsure / Don’t know | 141 | 13.5% |
Seek advice/assistance with positioning and attachment | 37 | 3.5% |