21 November 2006 1

Action Contre La Faim (ACF) is a Non- Governmental Organisation that was created in France in 1979. ACF has been active in Afghanistan in the Medical, nutrition, food security, and water and sanitation feilds since 1995.

ACF is working in collaboration with the ministry of Public Health of Afghanistan, Public nutrition department.

ACF together with the Ministry of Public Health runs the structures treating severe acute malnutrition, hospital based therapeutic feeding units in the city of Kabul and previously has runs day care nutrition centers as well.

21 November 2006 2

The children treated in the nutrition centers are mainly less than 5 years old, amongst whom very high rates are infants less than 6 months.

It has traditionally been assumed that below six months, infants are protected from malnutrition by breast milk. However in Kabul many mothers are complaining of a lack of breast milk, which highlights the role of care practices in the etiology of severe malnutrition of those infants.

In most of therapeutic feeding centres, in other countries, the rate of infants admitted is low. The 6-29 months age group is usually observed to be more vulnerable than the older children, as it is the weaning period.

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In all of feeding centres, the number of infants below 6 months is surprisingly high, as it is shown in the following table:

2000 2001 2002 2003 2004 2005 Jan- May

Total nb of admissions 1480 1327 1555 1184 1011 297 Total number of <6mo old admissions

231 234 254 399 260 129 TFCs

Rate of <6mo old admitted - %

15.6 17.6 16.0 33.7 25.7 43.4

Total nb of admissions 2478 2329 1724 872 699 253 Total number of <6mo old admissions

422 631 542 422 249 99 Day cares Rate of <6mo old

admitted - % 17.0 28.7 31.4 48.4 35.6 39.1

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Therefore, a nutrition and care practices survey has been conducted in Kabul city in may 2004, in order to establish a prevalence of this problem, and try to find out some factors that may lead to unsatisfactory nutritional status of babies.

Hence, objectives of this survey were: To assess the nutritional status of the infants below six

months in Kabul City. To assess care practices, especially feeding practices

(breastfeeding and weaning) concerning this age group. To assess the extent of the problem of mother milk

insufficiency in Kabul, and strategies developed to compensate this insufficiency (positive deviance).

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1. Acute Malnutrition expressed in Z-score

Acute Malnutrition rates in Z score, for infants below 6 months – Kabul, May 2004

Global acute malnutrition: 0.4% [95% CI : 0.0 – 2.6] Severe acute malnutrition: 0.0% [95% CI : 0.0 – 0.0]

Malnutrition rates are very low, and most of the infants surveyed had a satisfactory nutrition status, even though feeding practices were not always adequate.

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2. Feeding practices

a- Breast feeding practices 44.1% of all infants surveyed are exclusively breast fed 20.2 % are predominantly breast fed (receiving mainly

breast milk, and other liquids in addition, such as tea, water, juices, and/or powder milk)

34.2% are introduced to complementary feeding (other kinds of solid food)

1.5% (8 infants) are not breastfed at all at the time of the survey. Among them, half never received breast milk, and for the other half, the mother had stopped breastfeeding.

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Initiation of breastfeeding Most mothers (88%) initiate breastfeeding within 24 hours

after delivery, sometimes as early as 2 or 3 hours after.11% of babies receive breast milk after 2 or 3 days, and 1% later.

Majority of mothers knows that colostrums is good for the child.

Most of the mothers breastfeed their baby many times a day, for a short time

Feeding practices

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Feeding practices

Bottle feeding and powder milks Almost ¼ of the infants surveyed have ever been fed with

feeding bottles Most of the time, bottles are used for powder milk.

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b- Complementary feeding practices

Different reasons to start complementary food can be highlighted:

Breast milk is not enough in quantity: this is the main reason for the huge majority of the mothers.

Breast milk is not sufficient to cover the infant’s nutritional needs for growing.

The mother has to go to work, so the child must be partially weaned.

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c - Breastfeeding mothers

Mothers’ feelings about breastfeeding

96.4% of the mothers answered positively when they were asked whether they like breastfeeding or not. Only 18 of them did not like breastfeeding, including complaints of not having enough milk and pain.

In general, 54.6% had no particular complaints about breastfeeding. For the other ones, the main complaint is “not enough breast milk”

(most of mothers come to this conclusion because “the child is crying”, the others linked it with their diet, sickness, or psychological state of mind”).

Not having enough breast milk does not always appear as a problem for the surveyed mothers, but something almost “normal” and widely accepted.

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d - Other care practice: Swaddling of babies

97.2% of the infants visited were swaddled, according to the mothers:

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3- Conclusion

This survey gives us a picture of the caring and feeding practices in the general population. Data on breastfeeding are encouraging, with a high rate of breastfeeding (98.4%) and most of the infants receiving colostrums, but is also emphasised how much quality and quantity of breast milk are a concern for the afghan women (40% of mothers are complaining of lactation difficulties).

Even if breastfeeding is widely spread, rate of exclusive one is a bit low and it appears there is a very early introduction of inappropriate complementary food at the same time as breast milk, since the very first days after birth. On the other hand, mother feeling like they have a lack of milk or a bad quality one usually start complementary feeding because of this reason, which may highlight complementary feeding for less than 6 months as being a coping strategy rather than a tradition in feeding practices for some of these mothers.

The use of bottle-feeding, even if the rate is not very high (1 baby out of 4 is bottle-fed when 56% of the infants receive complementary food), remains an issue with a hygiene environment usually quite poor, as well as the lack of psycho-social stimulation observed.

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ACF decided to conduct another survey

But this survey was quite descriptive and doesn’t give information on the causes for a mother to have MMI and another not. To better understand breastfeeding problematic among general population, other survey has been done, not only to assess the extent of MMI’s problem, but to understand what is influencing or leading to it.

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To do so ACF decided to assess three different groups:

Mothers with lactation difficulties and a severely malnourished child (group A),

Mothers with lactation difficulties and a well-nourished child (group B),

Mothers without lactation difficulties and a well nourished child (group C).

Then the differences between these groups were compared, in the aim of defining risks or protective factors for lactation difficulties, mainly in the form of mother milk insufficiency (MMI).

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Results and analysis:

Social acceptability and acknowledgement Among the general population, 40 % of mothers with

an infant of less than 6 months old complained about lactation difficulties, mainly in the form milk insufficiency.

A huge majority of mothers with milk insufficiency talked freely about this difficulty.

Afghan people are usually saying that milk insufficiency isn’t a particular difficulty, as powdered milk and animal milk are available on the market.

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The child’s ability to suckle

About half the children whose mother complained of lactation difficulties were low birth weight, compared to 20% of children whose mothers did not complain. The weakness of these children may lead to mother milk insufficiency (absence of stimulation of lactation, loss of the mother’s confidence in her ability to breastfeed, use of the bottle to feed the infants who may then refuse the breast...).

The low birth weight might be the result of intra-uterine malnutrition resulting notably from nutritional deficiencies of the mother or may be due to prematurity.

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Breastfeeding: a social and religious code?

Even in case of mother's milk insufficiency, the complete abandon of breastfeeding is rare before at least six months.

The decision to breastfeed or not, isn’t the decision of the mother: a mother is expected to breastfeed her baby, except in some very specific situations (decision of husband or Mullahs)

Mothers hardly ask for advice regarding MMI, which may be due to the wish of the mother not to breastfeed, and to enhance herself as a mother with lactation difficulties.

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The crucial family support

Appetite during pregnancy and the mother milk insufficiency are linked, probably through the low birth weight child. Special attention given to the pregnant woman within the family is essential, but it depends on the relationships and organisation of the family. Mothers-in-law reign supreme in the household, and women often talk about the family violence of which they are victims; from their husbands but also their mothers and sisters in law.

Having time to breastfeed is a major issue for the success of lactation, as too few or too short breastfeeding episodes lead to decrease of the mother’s milk production. Feeling supported, having time to rest, to spend time with their babies are also factors that interfere with lactation and which rely on what the family will put in place for the young mothers.

About 39 % of the women didn’t receive any advice regarding breastfeeding for their first-born and even less received any advice for their following children.

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The breastfeeding practices

Children are first breastfed either immediately or up to three days after birth. Most of the women give colostrums, and say that breastfeeding should last until 2 years. They report however, that it is highly recommended for a woman to interrupt the breastfeeding in case of new pregnancy.

Giving butter, zouf or liquid food to the child in addition to the breast milk is a very common practice and is not considered, by the families, as being complementary food.

Basically mothers propose the breast to their child when the child cries, and they stop when the infant refuses.

The position during breastfeeding is not satisfactory in 90% to 95% of the mother-child dyads.

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Health, stress, psychological suffering of the mother

If the general family situation has improved, breastfeeding is more a success, as well as if the mother is receiving a special support from someone when she needs it. Of course the mother’s mental health doesn’t have only to do with that, her own individual story, as well as her self confidence in her ability to breastfeed her baby is part of this process.

The mothers with lactation difficulties, whether they have malnourished children or not, are those who complain of feeling depressed and who are declaring more chronic diseases (68.3% against 51.4%). Milk insufficiency might be interpreted as one of the symptoms of ill being of the woman.

These psychic troubles can cause mother milk insufficiency, on two levels: either directly (a mother, who feels sad or depressed, does not wish to breastfeed her child), or indirectly (depression may considerably limit or hinder the care, and thus the mother’s ability to satisfactorily breastfeed her baby).

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What makes mother milk insufficiency leads to malnutrition?

The surveys showed few differences between the groups of lactating mothers in difficulty, with malnourished children and without, which leads us to question whether the main variable interfering in the constitution of these two groups isn’t the knowledge of the mother in the preparation of food, hygiene and needs of infants.

All the women apply the same coping strategies when confronted with milk insufficiency: no advice seeking and the introduction of, or increase in quantity of other milks and complementary foods.

The level of hygiene of the family (is the bottle and teat clean, is the water boiled...) and their knowledge (how many spoons of powder to how much water to add...) are determinant factors for malnutrition. The fact that many mothers in nutrition centres have already lost children under one year of age can be an indicator of the low level of these factors among group A.

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Recommendations:

Recommendations specific to the Afghan context and possibilities for the infants of Kabul are formulated and have been grouped around several themes of; Prevention, Psychological support and the continuum of treatment from admission to follow up after discharge. Other recommendations on a more international level are also formulated.

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Prevention

To challenge and correct misconceptions and beliefs about breastfeeding

To improve care for pregnant and lactating mothers To communicate on the care for Low Birth Weight or

premature babies To transmit these messages to the mother, but also

to all the reference persons and to the whole family. To increase the knowledge on infants’ capacities

and needs To reinforce the delivery of these messages.

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Psychological support

To work on the family solidarity system around mothers. To develop counselling for pregnant and lactating mothers in order

to prepare for the arrival of the baby and to increase the mother’s capacity to give adequate feeding and care practices to their child.

To develop counselling and support activities for mothers who complain about milk insufficiency

To give mothers tips to breastfeed as comfortably as possible. To propose a longer follow up for children discharged as cured

from the nutrition centres. To spread health and nutrition message to a wide range

population. To organise breastfeeding counselling courses for health staff. Improve nutritional follow up within the centres To reinforce activities in the existing health facilities To improve and to complement the Systematic screening

component of the programme

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On a Global Scale

Need for establishment of standardised guidelines for the identification and treatment of severely malnourished infants

Wide diffusion and use of the information and training documents developed to date by Infant feeding in Emergencies Group

Recognition of the vulnerability of children under 6 months old.

To evaluate the supplementary suckling Technique for Relactation.

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Thank you