The role of midwives in improving breastfeeding practices in protracted crises: The Gaza Strip example

Background: The protection, promotion and support of breastfeeding is the most effective intervention to prevent child morbidity and mortality in all contexts. During the Palestine-Israel conict that started in the middle of the 20 th century, healthcare services are understaffed and lack basic resources, with frequent power cuts and stock-outs of essential drugs and equipment. This case study seeks to answer the questions: (1) How does the protracted crisis in Gaza affect the breastfeeding practices of the most vulnerable population; and (2) What is the role that midwives can play in improving breastfeeding practices? A mixed method (qualitative and quantitative) study was used to collect data. A total of 1044 respondents had a child less than 24 months at the time of the study. A total of 62.75 percent practice early initiation of breastfeeding and 42 percent conrmed that their new-borns were given liquids other than breast milk during the rst three days of life. Fifty percent of mothers addressed breast milk insuciency by drinking additional uids and 40 percent by using infant formula. to operational in the pre-service and in-service for For in included and with international organizations on and allocation of and geographical areas and in-country and remote assistance to data collection teams Implementing partners must address this gap in knowledge and skill as a matter of urgency. The role of midwives in supporting women to improve their breastfeeding practices has several important effects on maternal health and wellbeing and proven positive effects for children. In humanitarian contexts such as the Gaza strip, the initiation and continuation of effective breastfeeding has lifesaving impacts. This study raises alerts humanitarian agencies on the importance of the need to invest more in evidence-based interventions and the capacity of midwives in humanitarian contexts. If this need is met, midwives’ effective support of improved breastfeeding practices will contribute to reducing pressure on Gaza’s public health system, currently stretched in a fragile and constant crisis setting.


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 O ce 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 speci c contextual vulnerabilities that arise as a result.(1) The chronic electricity de cit 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 identi ed among the most vulnerable groups in need of humanitarian assistance. (1) Instability, repeated and unpredictable escalation of con ict and limitation of movement for international and sometimes national experts, poses signi cant 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 con ict, 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 de ciency 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)

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 ve 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 identi ed 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 con dence 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 con ict 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 o cer prior to the re-start of data collection.
The ndings 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 rst hour of birth (Table 1). 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.
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 con rmed that their new-borns were given liquids other than breast milk during the rst three days of life.
Mothers were asked about the way that they addressed breastfeeding complications, such as perceived breast milk insu ciency. More than 50% answered that they rely on drinking additional uids, 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 con ict con rm quantitative ndings. Qualitative ndings 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. Breastfeeding save lives in all contexts -even more so in humanitarian and fragile contexts. The protection, promotion and support of breastfeeding are among the most effective interventions to prevent child morbidity and mortality in humanitarian contexts. (10). Exclusive breastfeeding for the rst six months and continued breastfeeding, thereafter, may prevent 13% of under-ve deaths, primarily from infections resulting in diarrhoea, pneumonia, and neonatal sepsis. (10) Non breastfed infants have a 14 times higher risk of dying from any cause compared to exclusively breastfed infants, a 15 times higher risk pneumonia and a 10 times higher risk of diarrhoea. (11) Furthermore, the global impact of breastfeeding on maternal health is signi cant, with a reduction in the risk of breast cancer and potential to prevent 20,000 deaths (12). In environments where access to safe water is limited and food insecurity is a signi cant issue for families, exclusive breastfeeding for new-borns and infants is a lifesaving public health intervention. It is important to ensure that additional studies are conducted in similar contexts, to ensure that ndings are re ected in practical measures to protect the lives of the youngest and most vulnerable in humanitarian settings, whilst providing the needed support for pregnant women and mothers.
This assessment provided new, updated information on the breastfeeding practices of the most vulnerable communities in the Gaza strip. Prior to this study the most recent data was the Multiple Indicator Cluster Survey of 2014 (9).
This study's ndings highlight the potential role that midwives in humanitarian contexts, who have an integral role in the initiation, protection promotion and support of breastfeeding practices. This is particularly relevant in con ict settings, where the need for psychosocial and mental support for pregnant and postnatal women with babies is signi cant, given the continuous challenge of giving birth and raising children in such a di cult and unsafe environment.
The ndings con rm the need to: a) ensure a concerted effort to fully adapt and implement the recommendations of the IYCF-E operational guidance (24); b) review and possibly improve the pre-service training for midwives and other health professionals who provide antenatal, intrapartum and post-natal care in relation to the protection, promotion and support of breastfeeding using recommended WHO modules (25); and scale up and exert efforts to ensure hospital and health facilities providing maternity services fully comply with the WHO/UNICEF Baby Friendly hospital (26).
For the vulnerable population of the Gaza strip, it is imperative to support midwives to provide skilled support at birth (both vaginal and caesarean) thus ensuring breastfeeding initiation. If breastfeeding is practiced in the Gaza strip as per recommendations, there will be increased protection for common childhood diseases such as diarrhoea and ARI, whilst ensuring that the available resources are used by the household to increase access to a diverse and appropriate diet for the mother and the other members of the family. Having skilled midwives providing lactation support and counselling is certainly recommended in all contexts, particularly humanitarian settings and fragile environments like the Gaza strip.
The ndings of the study were disseminated and validated by the members of the Nutrition Working Group and were presented to national and international organizations working in the Gaza strip during a workshop in May 2019. Additional ad hoc presentations were provided to different sectors including Health, WASH, Food Security, Livelihoods and Protection from June to August 2019.
Finally, study ndings illustrating the immediate need to focus on practical, focussed interventions aiming at the most vulnerable were shared and presented with the Humanitarian Country Team (lead by UN OCHA), UN agencies and the organizations and donors contributing and supporting the humanitarian response. This guided strategic discussion and initial direction with UN OCHA and relevant UN partners. The study ndings ensure that the protection, promotion and support of breastfeeding focusing on the most vulnerable populations in the Gaza strip, will receive more attention, including nancial resources. At the same time the ndings of the study were used to inform the revision and update of the Humanitarian Needs Overview for 2020 and the Humanitarian Response Plan 2019-2020 providing additional windows of opportunity for resources for an integrated solution to the issues presented.

Security
The security situation in the Gaza strip is unpredictable and escalation of con icts is always a possibility. This was a major consideration during the design and planning phase of the study, and plans were made to ensure successful completion, even in the event of potential security situations. Contingency plans included the identi cation of back up areas to be covered and/or the reduction of the sample size requirements were also included.
The current political situation in the Gaza strip, exempli ed by a strict set of requirements limiting study coverage and information to be collected by the Ministry of Interior in Gaza, was a critical challenge faced during the study. The Ministry of Interior reviewed the proposed questionnaire, as per local policy and requested that questions on socio-economic status and mental health be removed. This did not allow for an analysis of the results linking infant feeding practices and psychological condition of the caregiver, which, in a context like the Gaza strip, could be remarkable.

Capacity
Due to the con ict and travel restrictions within the Gaza strip, many professionals and health workers (including midwives) are not able to access regular trainings and capacity building opportunities. This is clearly identi ed as a major gap and highlighted the need to strengthen local capacity in relation to nutrition assessments and implementation using local capacities and resources. This is relevant to this study's ndings, with associated challenges when nalising study design and methodology, data collection and the quality of some aspects of the study.

Research Strategies
The following strategies and actions were deployed to address most of the challenges encountered: Integration and linkage with security o cers of leading organizations was essential, during the design, planning and execution of all the activities. During the data collection phase, it was continuous and provided valuable information that lead to the temporary interruption of the data collection due to a rapid escalation of the con ict affecting the selected areas. In a volatile and unpredictable context like the Gaza strip, daily movements of teams and large groups must be cleared by relevant o cers, mostly considering the locations of destination.
Coordination with authorities and communities; a requirement for the issuance of the needed formal endorsements and clearances by the governing authorities as well ensuring full engagement and support from the participating communities. The Ministry of Interior in Gaza (under the Hamas leadership) required the review and clearance of the design and questionnaires. Several questions were removed as per their recommendations, that called for a revision of the questionnaire and of the objectives of the study.
Supportive supervision was provided during the whole data collection with daily debrie ng with teams, with the support of the leading organizations and to the extent possible international consultant. However, considering the escalation of the hostility during this period, this was reduced drastically and limited to Phone SMS based follow ups and updates. Teams were asked to communicate locations, challenges and progress, regularly during the day, to ensure their safe and smooth progress in the data collection.
Allocation of buffer days and geographical areas in lieu of days lost. Having a contingency plan for similar exercises in the context of the Gaza strip is crucial. Due to the potential for escalation of con ict in selected areas, this extra allocation in relation to logistical support and timeframe mitigated any major impact on the actual timely conclusion of the assessment. Data collection was halted for 2 days due to the escalation of the con ict that affected the selected areas, and the buffer days were used to complete the data collection. Allocation of extra days meant ensuring that budget, cars, and other logistical support was available in a timely manner and did not require extra approvals and procedures.
In country and remote assistance to the data collection teams were provided by all the agencies involved during the data collection but mostly during data processing and analysis. The lead researcher could not visit all the areas and during the potential escalation of the con ict could not visit the eld and support the data collection teams

Conclusions
The study in Gaza highlights the importance of supporting research in protracted crisis settings. It proves that it is possible to conduct research in complex humanitarian environments. The value of this study is linked to its context and the living conditions of the most vulnerable communities in the Gaza strip. Lessons learned in this research include the importance of a) allocating additional research time, to account for potential interruption, due to the volatile situation b) daily coordination with security o cers to ensure safe access to target localities c) identi cation of extra sites, in case escalation of con icts do not allow for access to pre-selected localities and d) training of additional enumerators to ll up for potential gaps due to the con ict escalation and e) negotiation with the authorities to ensure compliance with the requirements. Finally, it was observed that there is a general need for health and nutrition workers to increase their knowledge and skills on nutrition assessments.
Despite the documented challenges, this research has highlighted the urgent need to review midwives' current skills and availability to provide breastfeeding support, including the timely initiation of breastfeeding and lactation support. Indeed, the protracted emergency settings may have limited midwives' ability to access professional updates and on the job capacity building opportunities. Implementing partners must address this gap in knowledge and skill as a matter of urgency.
The role of midwives in supporting women to improve their breastfeeding practices has several important effects on maternal health and wellbeing and proven positive effects for children. In humanitarian contexts such as the Gaza strip, the initiation and continuation of effective breastfeeding has lifesaving impacts. This study raises alerts humanitarian agencies on the importance of the need to invest more in evidence-based interventions and the capacity of midwives in humanitarian contexts. If this need is met, midwives' effective support of improved breastfeeding practices will contribute to reducing pressure on Gaza's public health system, currently stretched in a fragile and constant crisis setting. The study was part of a larger assessment and was agreed by the Nutrition Working Group, a sub working group of the Health Cluster in the Gaza strip. All assessments and data collection exercises require the approval of the Ministry of Interior (MOI) in the Gaza strip. The MOI is the clearing house and approving agencies for all data collection and assessments in the Gaza strip. The MOI reviewed, commented and approved the conduct of the study, with some modi cations in the questionnaire and in the design. No other ethical reviews were sought by the Nutrition Working Group and its members. Additional ethical reviews were waived because the MOI approved the conduct of the assessment, and the assessment was endorsed by the members of the Health Cluster, like the MOH, UN agencies and national and international partners. The assessment was implemented also to inform the development of the the Humanitarian Needs Overview and the Humanitarian Response Plan for the Gaza strip.
The nal approval was given verbally after the changes were done accordingly. The Ministry of Interior reviewed the questionnaire and the methodology including the verbal approval by the respondents to participate in the study.
All the respondents, after explaining the purpose of the study were asked if they agreed to participate in the survey. Their verbal consent was recorded in the Kobo survey tool.

Consent for publication
Not applicable Availability of data and materials The datasets generated and/or analysed during the current study are not publicly available due to the speci c operational context but are available from the corresponding author on reasonable request and upon approval from the leading agencies.