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Fitsum Assefa is a nutritionist with over 15 years experience working on public nutrition in various countries in Asia and Africa. She has wide experience in emergencies as well as development settings. She has been working on advocacy, technical guidance, implementation and evaluation of public nutrition programmes, including infant young child feeding, for the last ten years, mostly in Indonesia.
David Hipgrave is an Australian paediatrician with a special interest in international child health and infectious diseases. Natural disasters are common in Indonesia. While still recovering from a series of such events 1a severe earthquake struck Yogyakarta 2 and Central Java provinces during the morning hours of May 27, The earthquake took about 6, lives, injured 40, - 60, people, and robbed hundreds of thousands of their homes and livelihood.
Baby bottle cleaner liquid philippines earthquake the same time, volcanic activity of nearby Mount Merapi increased dramatically, prompting the evacuation of tens of thousands of people.
The epicentre of the earthquake was Bantul district in the south of Yogyakarta, while parts of Klaten district in Central Java were also seriously affected see map. Child undernutrition remains a significant and deteriorating public health problem in Indonesia. The percentage of underweight children under five years of age rose from Disparities are sharp across the nation, with malnutrition being more prevalent in the eastern provinces. National data on stunting and wasting is lacking, but localised assessments have found that stunting exceeds 40 percent in the eastern islands 5 and in Aceh province 6.
Acute malnutrition wasting and nutritional oedema was a significant concern in these and other areas during andbut again, population incidence estimates are lacking.
However, economic, health and nutrition indicators for the earthquake-affected areas of Yogyakarta and Central Java are amongst the best in the country, and primary health care systems function relatively well in both provinces.
Though virtually all Indonesian women breastfeed, the most recent data found that only Promotion of breastmilk substitutes BMS is common and formula feeding is widespread. Complementary feeding practices vary widely; major concerns include poor nutrient density, low frequency and early introduction of complementary foods, and the poor sanitation and hygiene environment within which they are prepared.
The overall emergency response to the earthquake was rapid, involving civil society, private sector, individuals, United Nations UN agencies, non-governmental organisations NGOs and Indonesian and foreign military personnel. Literally a few hours after the earthquake, supplies of food and drinks started flowing into the affected region from many different sources. Contrary to key international guidance 8many local and international agencies quickly proceeded to distribute commercial infant formula and commercial porridge to infants and young children.
Furthermore, there was a strong perception amongst benefactors that as BMS were already widely used in Indonesia, such baby bottle cleaner liquid philippines earthquake distribution was just maintaining the status quo. However, there was no hard evidence to support or refute this perception. Also, in the crisis zone, some of the pre-earthquake 'nutrition rehabilitation' programmes of the government included distribution of BMS, and infant formula companies had been promoting their products through local health care providers, further legitimising this form of assistance in the eyes of relief workers and beneficiaries.
Having learned from experiences in other recent disasters in Indonesia, UNICEF health and nutrition staff advocated for support for appropriate infant and young child feeding during the emergency IFE from the first day of the emergency. In fact, according to minutes baby bottle cleaner liquid philippines earthquake the coordination meeting during the first week of the crisis, some agencies used the UN coordination mechanism to request more BMS. Furthermore, a number of donor government representatives in Jakarta pledged BMS as part of the emergency response.
In general, there was very little awareness within the UN, NGOs both national and internationaldonors, communities and local government about IFE, despite similar experiences after the tsunami. Within a week of the disaster, BMS had been widely distributed to almost every affected household.
Major distributors included national and international NGOs, civil society, the army and infant formula companies 9. There were multiple brands imported and locally manufactureddistribution was not coordinated and the amount distributed per child varied from place to place. Avenues for distribution included through the general ration, at temporary and fixed health care facilities and at temporary shelters. Based on field observations, the UNICEF nutrition team alerted partners to the potential negative baby bottle cleaner liquid philippines earthquake of universal distribution of BMS and other milk powders, and challenged the opinion that families were familiar with the use of BMS.
The team soon suspected that many infants and young children were suffering from diarrhoea as a result of consuming BMS in poor sanitary conditions.
However, these observations were challenged as anecdotal and comments such as "the people and the health care providers request it" or "the population is already dependent on it" were heard. However, it was evident baby bottle cleaner liquid philippines earthquake participant agencies were mainly concerned with the logistics of food distribution and not IFE. The Food and Nutrition Cluster did review the composition and adequacy of the general food basket and assisted inclusion of multiple micronutrient sprinkles supported by Baby bottle cleaner liquid philippines earthquake Keller Internationalas a means to improve the nutrient density of available foods for children.
However, the issue continued to be minimised, with coordination meeting minutes simply reporting that "UNICEF is concerned about formula feeding and potential risks". The emergency was overwhelmed with the management of casualties and cases of tetanus. This created more opportunities to document evidence and start addressing various nutrition issues, including IFE.
The expansion of this sub-Cluster to MCHN facilitated the addition of critical nutrition interventions for pregnant mothers specifically, distribution of prenatal multiple micronutrients during the registration process.
In addition, this enumeration process was considered an opportunity to acquire populationbased data and hard evidence to support further advocacy and intervention on IFE.
From Junean IYCF assessment was conducted in tandem with registration of pregnancies, involving primary caretakers of children months of age. Assuming the occurrence baby bottle cleaner liquid philippines earthquake pregnancy and location of a pregnant woman were 'random', the registration process was used to also 'randomly' identify children under two years of age and to interview their primary caregivers on feeding practices.
This sampling method provided a rapid solution to what would otherwise have been a time consuming and expensive selection process. For every other pregnant woman interviewed, the child aged less than 2 years baby bottle cleaner liquid philippines earthquake slept nearest to where she slept was identified.
This could be baby bottle cleaner liquid philippines earthquake child of the pregnant woman or of a neighbour. The primary caretaker mother, grandmother, etc. Standard questions based on standard indicators were used, after baby bottle cleaner liquid philippines earthquake testing The issue for infants under the age of six months was not just the uncontrolled supply of infant formula, but also unnecessary distribution of other products, including 'follow-on' formula and complementary foods.
The labels of the products violated many aspects of the International Code of Marketing of Breastmilk Substitutes Some were labelled in a foreign language, and distributors provided no instruction on preparation or the intended target of the product. The consumption of BMS was significantly higher in those who received donations, regardless of age Figure 3. To try and communicate the potential risks of artificial feeding, cases of those infants and young children who suffered from diarrhoea following change in feeding habit were followed up and widely reported in local and international media Though lacking supporting evidence, anecdotal information suggests some of those who received infant formula were not consuming it because of these advocacy and communication efforts by UNICEF and other NGOs soon after the earthquake.
Furthermore, diarrhoea prevalence was double amongst those who received donations of infant formula We associated this rise with the changing feeding practices and artificial feeding in conditions of poor sanitation and hygiene following the disaster. The much higher prevalence among BMS recipients as compared to non recipients was regardless of consumption in the previous 24 hours - this suggests that some those who had not consumed it within the 24 hour recall period may have consumed it earlier.
The data presented above, available a month after the earthquake, facilitated advocacy and promotion of appropriate IFE in Yogyakarta and Central Java. Intensive communication on IFE was conducted through local media, with at least one TV and radio station baby bottle cleaner liquid philippines earthquake newspaper including headline news and popular talk shows covering these issues at least once a week. A UNICEF video news release, featuring infants hospitalised with diarrhoea following consumption of BMS and showing the poor hygiene conditions in affected areas, was broadcast widely by most national media and on CNN weekly review.
Journalists were provided with a half-day orientation on major IFE issues - and specifically on the related challenges and solutions during emergencies, and were encouraged to continue reporting. They were also baby bottle cleaner liquid philippines earthquake on the results of the survey from Yogyakarta. TV and radio were not widely available among the earthquake-affected population.
Thus many agencies used flyers and leaflets to communicate various issues. Traditional arts and entertainment, such as the famous Indonesian shadow puppet show Wayang kulitwere utilised to communicate breastfeeding messages for affected baby bottle cleaner liquid philippines earthquake. Involving the community in creating the 'story' using real-case examples of mothers who had received donated formula and mothers who have changed infant feeding practices was also one of the key approaches.
Among all messages and baby bottle cleaner liquid philippines earthquake, highest scores were awarded by the community to those that emphasised the cost of artificial feeding see example in Picture 1 as baby bottle cleaner liquid philippines earthquake realised their reliance on the donation made their breastmilk stop and that they would need to buy more formula once donated supplies were used up.
Surprisingly, mothers gave a low score for conventional posters showing a mother and child well attached and happily breastfeeding. They said they have seen such posters all their life, including on packets of infant formula, and that such posters don't really make an impression, especially as they don't demonstrate the potential harmful effects of infant formula.
The text in Bahasa says "Breastmilk is the best and it's free, so why would you want to spend money on an expensive substitute? The focus group reported that they liked it because it was funny, attention grabbing and was relevant to their current situation. It was clear, however, that advocacy and promotion alone were not enough to change the situation. Even when mothers were aware of the benefits of breastfeeding and the potentially harmful effects of artificial feeding, this did not result in them successfully reverting to breastfeeding, or protect newborns from similar practices.
An active intervention was needed and a 'cascade' method of breastfeeding support was developed to do just that. In Indonesia at the time, there were only a few trained breastfeeding counsellors who are able to provide skilled counselling 40 - 50, at mostspread over a vast country. Even if they were all available to work in the crisis area, they wouldn't have been able to meet the needs for counselling thousands of mothers affected by the earthquake and the blanket distribution of donated BMS.
It was also not feasible to bring counsellors from abroad, given language issues and the scale of support that was required, so a 'cascade' method of breastfeeding support using community volunteers was devised. At its baby bottle cleaner liquid philippines earthquake, the scheme needed frontline counsellors who lived in the communities and possessed adequate skills and knowledge to train local lactation counsellors to counsel mothers effectively, and to demonstrate results.
UNICEF contracted the Indonesian Breast feeding Centre Sentra Laktasi Indonesia to design and implement the training programme with the aim of ensuring the highest possible coverage, quality, and sustainability e. After discussions with them on their availability, it was decided to deliver the training on a twice weekly basis, 3 - 4 hours at a time, depending on the session.
Pictorial based flip-charts were developed to use with mothers. For clinical practice sessions, breastfeeding and pregnant mothers were brought into the training baby bottle cleaner liquid philippines earthquake. Facilitators met every evening to evaluate the process of the training on that day.
Every Sunday, the facilitators and course coordinators discussed any difficulties with the trainees and visited breastfeeding mothers. Baby bottle cleaner liquid philippines earthquake target of supporting at least 5, mothers was initially established.
To address the challenge of how to reach such a large number of mothers rapidly, a 'cascade' system of support was used see Figure Using this cascade approach, 4, families were accessed and benefited. Fifty-four mothers from 30 subvillages in the most affected areas in Bantul district who gave birth after the earthquake were assessed October, The monitoring exercise revealed that almost all of these mothers initiated breastfeeding in the first hour after birth as a result of support from breastfeeding counsellors.
In order to investigate the impact of the intervention more closely, a rapid survey was conducted by UNICEF in November three months after the training had concluded. The survey was conducted in the earthquake affected area in Bantul 7 sub-districts, 7 villages where there are counsellors in place.
A total of mothers with babies born after the earthquake were assessed on their breastfeeding practices. All babies were under six months of age Figure 7. Follow-up interviews were also conducted with LLC in the areas. Amongst the mothers surveyed, the rate of exclusive breastfeeding rate was However, over one-quarter Those who received counselling had better knowledge than those who did not receive counselling: When asked how they planned to feed their baby up to the age of six months,
