3.1 Humanitarian Context
Sub-optimal breastfeeding is associated with more than 800,000 deaths annually worldwide (1). Exclusive breastfeeding for the first six months and continual breastfeeding may prevent 13% of under-five deaths, primarily from infections resulting in diarrhoea, pneumonia, and neonatal sepsis (2). Early initiation of breastfeeding may help prevent 22% of newborn deaths (3,4).Beyond the first years of life, breastfeeding has been found to improve children’s quality of life by preventing various diseases such as leukaemia, asthma, ear infections, allergies, and diabetes (5,6). Recent systematic reviews have highlighted the role that midwives have in the protection, promotion and support of breastfeeding, from the midwife's perspective (7). The findings show that midwives value breast feeding education and breastfeeding support but the way they provide it varies across contexts (7). The same review suggests that the hospital-based midwives face more challenges like time constraints (7), A Cochrane review, confirms that providing women breastfeeding support, helps ensure longer breastfeeding 8). The same review suggest that the breastfeeding support is more effective when the support is predictable, scheduled, and includes regular visits to health professionals like midwives (8)
During emergencies and displacements, the protection, promotion, and support of breastfeeding is a priority lifesaving and food security intervention (5,6).
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 (9). The health sector has been heavily disrupted by years of conflict, sanctions and socio-economic decline (10). Healthcare services are understaffed and lack basic resources, with frequent power cuts and stock-outs of essential drugs and equipment (11,12,13). Over 90% of the water is unsuitable for human consumption (10,11,12). 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 (11,12). In 2014 the prevalence of early initiation dropped drastically from 66% to 41% (11); MICS 2014, revealed very low level of exclusive breastfeeding (36.5%) (64th of 133 countries), and that only less than 60% of children are breastfed up to 1 year and the same drops to a 10% of children are breastfed up to 2 years (12). 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 (13). As a part of a larger multisectoral assessment, this paper considers how the protracted crisis in Gaza has affected breastfeeding practices of the most disadvantaged women. It investigates 1) What were women's infant feeding practices and 2) What are their beliefs and knowledge concerning breastfeeding
3.2 Research Study
3.2.1 Methods
The assessment took place across all five governorates of Gaza, covering nine of the most vulnerable localities; 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. (14)
The study was conducted 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 a household infant and young child feeding (IYCF) survey, focus group discussions with primary caregivers and key informant interviews with stakeholders.
Sample:
The sample size was calculated with a design effect of 1.5 and a 10 percent estimate of non-response and was calculated based on achieving statistical confidence for the breastfeeding indicators.
Data Collection
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.
Relevant questions related to breastfeeding were asked to each of the respondents with children less than 2 years of age at the time of the interview. The questions focus on the respondent breastfeeding practices, including time of initiation, current breastfeeding practices, and some of the questions were related to understand how the respondent was accessing breastfeeding information, and where the respondent would get support when experiencing breastfeeding problems.
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. The Ministry of Interior reviewed the questionnaire and the methodology including the verbal approval by the respondents to participate in the study.
A group of 22 all-female Gaza-based enumerators were selected as data collectors from a pool of a local organization and contract staff. All enumerators had previous experience with nutrition programmes. Enumerators were organised in 11 team of 2 persons each. Staff underwent 3 days of training, conducted by Save the Children, WFP, and UNICEF.
During the data collection, the teams used systematic random sampling 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.
All the respondents were asked if they agreed to participate in the survey. Their verbal answer was recorded in the Kobo survey tool.
During the data collection phase, 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.
Focus groups discussions (FGDS) were conducted to gather additional information on belief systems and other socio-cultural factors that can contribute or inhibit behaviours identified by the assessment A total of four focus group discussions were held with women on the 22nd and 23rd October 2018; two FGDs in the Gaza Governorate and two in the Middle Area (Dier-el-Balah) Governorate. The two FGDs hosted in the Northern Area were for women from localities in the North Gaza and Gaza city Governorates, whilst the two FGDs hosted in the Middle Area were for women from The Middle Area, Khan Younis and Rafah Governorates. The all-women FGDs were held in private meeting rooms at two separate clinics in Gaza City and Khan Yunis which were familiar to many of the women Between 4 and 5 women were selected from each locality and invited to attend the nearest FGD discussion. Women were invited to the FGD based on their responses to breastfeeding knowledge and practices in the household questionnaire. Half of women invited had good breastfeeding knowledge and practices and half had poor breastfeeding knowledge and practices. This was done to encourage a difference in opinion which would drive debate and to provide insight into inhibiting and enabling beliefs.
Data analysis
The surveys are uploaded onto the kobo cloud every evening during data collection where Save the Children staff conducted plausibility checks.
Data was downloaded onto Excel for cleaning and translation of text entries and exported into ENA Smart Software for plausibility analysis and calculation of anthropometric data. The other data were entered into SPSS for further analysis. Data on Food Consumption Scores and Coping strategies were analysed by WFP Jerusalem office.
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.
The study revealed that 6.3% of mothers with children less than 24 months stated that they never breastfed their children. 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.
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.
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%).
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. Some of the mothers of infants less than six months attending the FGDs said that they are exclusive breastfeeding.
“It is better to commit to exclusive breastfeeding rather than supplementary food we cannot afford”, one woman said.
Other women said that “they do not have enough breastmilk, so they have to resort to infant formula, yogurt or cerelac to help the child feeding beside the not enough breastfeeding”. One woman said that she gives child formula because she has twins and another one because her health is not good to give enough breastfeeding for child.
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%
|