CDC/UNICEFIYCF Assessment

in IDPs in Kharkiv, Dnipropetrovsk, and Zaporizhia oblasts

July 10, 2016

Introduction• Focused on oblasts with highest numbers of IDPs outside of conflict

Zone• 169,800 IDPs in Kharkiv• 82,986 IDPs in Dnipropetrovsk• 63,434 IDPs in Zaporizhia

• Nutrition sub-cluster strategy• IYCF Education Counseling• Complementary baby baskets

• Goal: Collect information to inform key issues for Nutrition sub-cluster

Methods• Obtained lists of registered IDPs in each oblast• Randomly selected households for calling

• Child <2 in household, still living in oblast, agree to interview

• Survey conducted from June 8 until June 19, 2015• Sample size based on proportion of IDPs in each oblast

• 230 Kharkiv• 130 Dnipropetrovsk• 117 Zaporizhia• 477 Total

• Good representation• 492 children 0-23 months interviewed for MICS 2012 survey in Eastern Region

Methods• 2 Focus Group Discussions with IDP mothers of children 0-23 months

in each oblast (6 total):• IDPs living in rented housing (more educated, urban, better SES)

• 7 mothers in Kharkiv• 9 mothers in Dnipropetrovsk• 3 mothers in Zaporizhia

• IDPs living in collective center (less educated, more rural, poor SES)• 10 mothers in Kharkiv• 9 mothers in Dnipropetrovsk• 5 mothers in Zaporizhia

Methods• 2 Key Informant interviews in each oblast (6 total)• Kharkiv: • Postnatal Interview: Pediatrician• Postnatal Interview: Pediatrician

• Dnipropetrovsk:• Prenatal Interview: Ob/Gyn• Postnatal Interview: Pediatrician

• Zaporizhia:• Birth Clinic Interview: Midwife• Postnatal Interview: Pediatrician

Child Characteristics Child Characteristics Total

(N=477)

Gender (n, %)

     Male  247 (51.8)

     Female 230 (48.2)

Age (months) (n,%)

     0-5 66 (13.8)

     6-11 163 (34.2)

     12-17 152 (31.9)

     18-23 96 (20.1)

     Mean (SD) 12.8 (5.8)

Maternal CharacteristicsMaternal Characteristics Total (N=458)

Age, years (n, %)      < 25 years 64 (14.0)     25-29 years 157 (34.3)     30-34 years 151 (33.0)     >=35 years 86 (18.8)     Mean (SD) 30.1 (5.3)Education level (n, %)      Incomplete secondary school 7 (1.5)     Complete secondary school 20 (4.4)     Professional secondary education 139 (30.4)     Incomplete higher education 19 (4.1)     Complete higher education or above 273 (59.6)Total # of children born to mother (n, %)      1 197 (43.0)     2-3 244 (53.3)     >= 4 17 (3.7)

Household Characteristics Household Characteristics Total

(N=458)Household location (n, %)      Oblast Center  347 (75.8)     Other City 92 (20.1)     Village 19 (4.1)Living situation (n, %)      Living w/ relatives or friends (no fee) 78 (17.0)     Renting an apartment or house (for fee) 348 (76.0)     Collective center  31 (6.8)     Other 1 (0.2)Permanent Address Left From (n, %)      Donetsk 289 (63.1)     Luhansk 162 (35.4)     Other 7 (1.5)Length of displacement, months (n, %)      <6 months 42 (9.2)     6-11 months 289 (63.1)     >= 12 months 127 (27.7)

WHO Indicator IYCF Survey% (95% CI)

MICS 2012Eastern Region (%)

Ever breastfed (N=children 0-23 mo) 93.3 (90.7-95.2) 96.7

Early Initiation of Breastfeeding (within 1 hour of birth)(N=children 0-23 mo)

63.7 (59.2-68.1) 61.5

Exclusive breastfeeding <6 mo  (N=children 0-5 mo) 25.8 (16.5-37.9) 21.3

Predominant breastfeeding <6 mo (N=children 0-5 mo) 45.5 (33.1-58.2) 47.5Continued breastfeeding at 1 year (N=children 12-15 mo) 53.5 (43.2-63.6) 33.4

Continued breastfeeding at 2 years (N=children 20-23 mo) 20.6 (11.5-32.7) 31.1

Age-appropriate breastfeeding (N=children 0-23 mo) 42.3 (37.9-46.9) 22.3

Introduction of solid, semi-solid, or soft foods (N=children 6-8 mo)

98.6 (92.5-99.9) 43.2

Bottle Feeding (N=children 0-23 mo) 68.1 (63.7-72.3) 51.1

Minimum Meal Frequency (N=children 6-23 mo) 

     Breastfeeding 96.2 (92.4-98.5) 32.1

     Non-Breastfeeding 98.7 (96.1-99.7) 89.3

     Total 97.6 (95.6-98.8) 67.2

WHO Indicators

WHO Indicators  Age (months)Indicator 6-11 mo

(N=163)(n, %, (95%CI))

12-17 mo(N=152)

(n, %, (95%CI))

18-23 mo(N=96)

(n, %, (95%CI))

6-23 mo(N=411)

(n, %, (95%CI))

Dietary Diversity* <3 Food groups given yesterday

2213.5 (8.6-19.7)

42.6 (0.72-6.6)

22.1 (0.25-7.3)

286.8 (4.6-9.7)

3 Food groups given yesterday

5332.5 (25.4-40.3)

2516.4 (10.9-23.3)

1414.6 (8.2-23.3)

9222.4 (18.4-26.7

>= 4 Food groups given yesterday

8854.0 (46.0-61.8)

12380.9 (73.8-86.6)

8083.3 (74.4-90.1)

29170.8 (66.1-75.2)

Consumption of iron-rich foods given yesterday** 

13884.7 (78.2-89.8)

13488.2 (81.9-92.8)

9598.9 (94.3-99.9)

36783.4 (80.0-86.9)

*Includes 6 Foods Groups: Grains, roots, and tubers; Legumes and nuts; Dairy products (milk, yogurt, and cheese); Flesh foods (meat, fish, poultry, and liver/organ meats); Eggs; Fruits and vegetables**Includes meat, eggs, and formula

Breastfeeding Beliefs and PracticesIndicator n (%)Reason stopped breastfeeding among mothers who ever breastfed (N=210)

     Stress related to conflict 63 (30)     Stress unrelated to conflict 7 (3.3)     Not enough food for mother 14 (6.7)     Work schedule 1 (0.5)     Problems with attachment 23 (11.0)     Use of bottle for feeding 4 (1.9)     Other 89 (42.4)     Don’t know 9 (4.3)Mother’s opinion of age child should stop breastfeeding  (N=458)

     < 6 months 1 (0.2)     6-11 months 16 (3.5)     12 months 198 (43.2)     13-17 months 33 (7.2)     18-23 months 71 (15.5)     24 months 114 (24.9)     > 24 months 21 (4.6)     Don’t know 4 (0.9)

Reason stopped breastfeeding among mothers who ever breastfed

All Mothers(N=210)

Mothers who stopped when baby was <6 mo

(N=105)

     Stress related to conflict 63 (30) 48 (45.7)     Stress unrelated to conflict 7 (3.3) 3 (2.9)     Not enough food for mother 14 (6.7) 10 (9.5)     Work schedule 1 (0.5) 0 (0)     Problems with attachment 23 (11.0) 10 (9.5)     Use of bottle for feeding 4 (1.9) 1 (1.0)     Other 89 (42.4) 29 (27.6)     Don’t know 9 (4.3) 4 (3.8)

Foods Given Yesterday to Children <6 months not exclusively breastfed

  BF PracticesType of Food Not Currently Breastfeeding

n (%)(N=17)

Currently Breastfeedingn (%)

(N=32)

Water 14 (82.4) 28 (87.5)Tea or herbal tea 8 (47.1) 5 (15.6)Fruit or vegetable juice 3 (17.7) 1 (3.1)Soda drinks or other sweetened drinks 2 (11.8) 2 (6.3)

Infant formula 17 (100) 15 (46.9)Animal milk 1 (5.9) 1 (3.1)Sour milk drinks 0 (0) 0 (0)Cottage cheese or cheese 0 (0) 0 (0)

Infant commercial porridge 4 (23.5) 4 (12.5)

Semolina homemade 2 (11.8) 0 (0)Buckwheat porridge homemade 0 (0) 1 (3.1)

Other homemade porridge 0 (0) 1 (3.1)

Mashed potato 2 (11.8) 3 (9.4)Commercial baby fruit or vegetable puree 3 (29.4) 2 (6.3)

Fruits 4 (23.5) 1 (3.1)Vegetables 1 (5.9) 1 (2.3)Peas or beans 0 (0) 0 (0)Meat homemade 0 (0) 0 (0)Commercial meat puree 1 (5.9) 0 (0)

Eggs 0 (0) 0 (0)Bread or pasta 3 (17.7) 2 (6.3)Fats 0 (0) 0 (0)Sweets 0 (0) 0 (0)

Foods Given Yesterday to Children 6-23 months  Age (months)Type of Food 6-11 (n, %)

(N=163)12-17 (n, %)

(N=152)18-23 (n, %)

(N=96)Total Including children <6 months

(n, %) (N=477)

Water 153 (93.9) 136 (89.5) 92 (95.8) 423 (88.7)Tea or herbal tea 48 (29.4) 69 (45.4) 65 (67.7) 195 (40.9)Fruit or vegetable juice 49 (30.1) 60 (39.5) 43 (44.8) 156 (32.7)Soda drinks or other sweetened drinks

41 (25.2) 63 (41.4) 46 (47.9) 154 (32.3)

Infant formula 70 (42.9) 39 (25.7) 16 (16.7) 157 (32.9)Animal milk 31 (19.0) 65 (42.8) 49 (51.0) 147 (30.8)Sour milk drinks 55 (33.7) 94 (61.8) 47 (49.0) 196 (41.1)Cottage cheese or cheese 78 (47.9) 96 (63.2) 51 (53.1) 225 (47.2)

Infant commercial porridge 103 (63.2) 67 (44.1) 19 (19.8) 197 (41.3)

Semolina homemade 26 (16.0) 33 (21.7) 33 (34.4) 94 (19.7)Buckwheat porridge homemade

22 (13.5) 42 (27.6) 32 (33.3) 97 (20.3)

Other homemade porridge 33 (20.2) 64 (42.1) 44 (45.8) 142 (29.8)

Mashed potato 81 (49.7) 64 (42.1) 38 (39.6) 188 (39.4)Commercial baby fruit or vegetable puree

80 (49.1) 45 (29.6) 13 (13.5) 145 (30.4)

Fruits 107 (65.6) 116 (76.3) 81 (84.4) 309 (64.8)Vegetables 106 (65.0) 129 (84.9) 88 (91.7) 325 (68.1)Peas or beans 4 (2.5) 6 (3.9) 15 (15.6) 25 (5.2)Meat homemade 82 (50.3) 115 (75.7) 85 (88.5) 282 (59.1)Commercial meat puree 22 (13.5) 10 (6.6) 4 (4.2) 37 (7.8)

Eggs 32 (19.6) 52 (34.2) 36 (37.5) 120 (25.2)Bread or pasta 108 (66.3) 136 (89.5) 91 (94.8) 340 (71.3)Fats 63 (38.7) 85 (55.9) 65 (67.7) 213 (44.7)Sweets 16 (9.8) 32 (21.1) 53 (55.2) 101 (21.2)

Iron and Protein Containing FoodsNumber of Days Given in Past Week

Age 6-11 Months(N=163)

Age 12-23 Months(N=248)

# of Days Meat (n, %)

     0 Days 45 (27.6) 8 (3.2)

     1-2 Days 20 (12.3) 21 (8.5)

     >=3 Days 98 (60.1) 219 (88.3)

# of Days Eggs (n, %)

     0 Days 72 (44.2) 52 (21.0)

     1-2 Days 46 (28.2) 90 (36.3)

     >=3 Days 45 (27.6) 106 (42.7)

Children 6-11 mo Given Commercial Foods Yesterday

SES Indicator Formula CommercialPorridge

Meat Puree

Fruit/Veg Puree

Head of household Male (N=84) 37 (44.0) 57 (67.9) 16 (19.0) 42 (50.0)Female (N=73) 28 (38.4) 42 (57.5) 5 (6.8) 34 (46.6)Resident of household currently earning money 

No (N=76) 33 (43.4) 48 (63.2) 5 (6.6) 34 (44.7)Yes (N=81) 32 (39.5) 51 (63.0) 16 (19.8) 42 (51.9)Living situation  Living w/ relatives or friends (no fee) (N=25)

10 (40.0) 11 (44.0) 2 (8.0) 8 (32.0)

Renting an apartment or house (for fee) (N=122)

51 (41.8) 85 (69.7) 19 (15.6) 65 (53.3)

Collective center (N=10) 4 (40.0) 3 (30.0) 0 (0) 3 (30.0)

Mother Education Did not complete higher education (N=60)

30 (50.0) 36 (60.0) 5 (8.3) 34 (56.7)

Completed higher education (N=97)

35 (36.1) 63 (64.9) 16 (16.5) 42 (43.4)

0-5 Months 6-11 Months 12-17 Months 18-23 Months0

10

20

30

40

50

60

70

Types of Porridge Given Yesterday

Commercial Porridge SemolinaBuckwheat Other Homemade Porridge

Age Groups

Perc

ent

MUAC Children <2 Years  Age (months)MUAC (mm) 6-11

N=163(n, %, 95%CI)

12-23 N=248

(n, %, 95%CI)     <115 0 (0) 0 (0)     115-125 1

0.6 (0.02-3.4)1

0.4 (0.01-2.2)     >125 162

99.4 (96.6-99.9)247

99.6 (97.8-99.9)

MUAC Children 2-4 YearsMUAC (mm) (n, %)

      <115 0 (0)

     115-125 0 (0)

     >125 57 (100)

Access to ServicesAccess to Services (n,%)Attempted to register child at clinic(N=477)

     No 28 (5.9)     Yes 448 (93.9)     Don’t know 1 (0.2)Child registered at clinic (N=448)      No 4 (0.9)     Yes 444 (99.1)Difficulties registering child at clinic (N=448)

     No 434 (96.9)     Yes 14 (3.1)Difficulties faced during registration at clinic (N=14)

     Required unavailable documents 3 (21.4)     Required registration as IDP 6 (42.9)     Required payment 0 (0)     Other 8 (57.1)

Humanitarian AssistanceHumanitarian Assistance Total  (N=458)

Cash or voucher assistance received (n, %) 353 (77.1)

Food assistance received (n, %) 399 (87.1)

Non-food assistance received (n, %) 397 (86.7)

Baby food assistance received (n, %) 323 (70.5)

     Number of Times          1 130 (27.3)          2-3 125 (26.2)          >3 68 (14.3)Items included in baby food assistance package (n, %) (N=323)

     Infant formula 143 (44.3)     Fruit or vegetable puree 159 (49.2)     Meat puree 9 (2.8)     Commercial baby porridge 182 (56.4)     Semolina 17 (5.3)     Other porridge 33 (10.2)     Other 34 (10.5)

Water and SanitationSafe Water and Hand Washing Total (N=454)

Running water in home (n, %)      No 16 (3.5)     Yes 438 (96.5)Main source of water for drinking/cooking (n, %)

     Bottled 280 (61.7)     Tap 106 (23.3)     Well 43 (9.5)     Water pump 7 (1.5)     Other 18 (4.0)Ability to boil water (n, %) 454 (100)Times used soap in last 2 days (n, %)

     0-4 times 7 (1.5)     5-10 times 35 (7.6)     >10 times 415 (90.6)     Don’t know 1 (0.2)

Key Message From Focus Groups and Key Informant Interviews

Information and services in health system• Mandatory home visits post-partum by doctor and nurse in 1st

month, then monthly visits to polyclinic• Test Hb at 9 months• Generally no difficulties for IDPs to register for medical

services• Courses for future mothers exist both pre-natal and post-

natal, but may not be communicated to all• Pediatricians are used and trusted by more educated• Medical staff in some areas seem to provide incorrect advice

(early intro of water, early complementary feeding)

Information and services in health system• Rural mothers seem to have less access and use of medical staff and

courses/services• Mothers with prior children rely on own prior experiences• Less educated seem to rely more on grandmother’s advice• Many mothers also rely on advice from friends with children• Educated mothers often rely on internet for advice

Breastfeeding• Initiation – almost universal• Early introduction of water• “Babies need water when it is hot out”

• Some health workers seem to advise to introduce water and teas very early• If breast milk perceived as “not enough” introduce formula• Many mothers were offered to buy formula in hospital

Breastfeeding problems• Stress – major problem, many perceive to lose milk because of

stress of war and displacement• Support BF in birth clinic in the first few days – major problem

(esp. for first mothers)• More educated – difficulties of adhering to “hypoallergenic

diet” (expensive)• Maternal nutrition is not perceived as a major problem,

although mentioned• Working schedule of the mother – not a major problem since

IDP mothers rarely work

Complementary feeding• Early introduction of complementary feeding (at 3-4 mo) in some in less

educated, rural mothers• Standard MoH advice – from 6 months, table for portion sizes and intro

schedule for food groups• Most common foods currently used: mashed potatoes, baby porridges,

semolina, buckwheat, fruit/vegetable purees • Many mothers making homemade purees now instead of purchasing

purees in cans because of cost• Some mothers boiling water and using animal’s milk because can’t

afford formula

Complementary feeding• No problems with introducing meats, liver, yolk at 6 mo• Meat well liked and accepted by children• Some mothers prefer milk-free, some with-milk porridges• Semolina is less preferred by some mothers, but generally common,

buckwheat is also common and well liked, many consider buckwheat most useful porridge, but also most expensive

Complementary feeding problems • Mothers try hard not to impact child’s diet due to lack of money,

prioritize the child• Use less preferred meats (chicken)• Some mothers can only afford meat once per week• Lack of access to milk and milk products and fresh fruits/vegetables in

collective center• No way to make homemade fruit/veg/meat purees in collective

centers• Try to give the same products to children but less frequently

Assistance• Mostly sporadic one-time assistance depending on ad hoc donations,

no systematic consistent assistance packages• Organizations giving assistance dependent on Oblast• No information materials on BF/CF• No counseling on BF/CF at (or linked to) the point of distribution • No comprehensive list of organizations mothers can go to for

assistance• Some assistance packages not age appropriate

Conclusions and Recommendations

Conclusions• Non-exclusive breastfeeding for infants <6 months is a major issue• Water, tea, juice, and formula are the most common liquids given to babies

<6 months who are not exclusively breastfed• Beliefs on early water introduction a major challenge• Some health care workers recommend early introduction of water• Commercial porridges, mashed potatoes, and fruit/vegetable puree are the

most common foods given to babies <6 months not exclusively breastfed

• Stress related to the conflict is the most common reason mothers stopped breastfeeding

Conclusions• Malnutrition is not a major problem in this population

• No child with severe acute malnutrition (MUAC <115)• 2 children with moderate malnutrition (MUAC 115-125)

• Commercial porridges are the most common porridges given when children are <12 months• Buckwheat and semolina are both well accepted, but semolina may be less preferred

by some• In general, meat is perceived valuable and well accepted, including commercial

purees (although most women cannot afford)• Many children 6-11 months receive iron and protein containing foods <3 days per

week• Mothers may believe that children in this age group should not be eating these foods often

Conclusions• Most IDP families have not had problems registering their children at

health clinics, treated the same as other children• Most mothers trust pediatrician for advice• Some pediatricians/midwives giving incorrect information on feeding practices

(early introduction of water, advising mother to give formula, etc.)

• Many mothers now use the internet for advice• Although a high proportion of families have received humanitarian

assistance, very few receive baby food assistance regularly• A high proportion of families received formula in their most recent

baby food assistance package

Recommendations• Educate and train health care workers on providing the correct

information to mothers• No early introduction of liquids• Advocate for timely (at 6 mo) introduction of complementary foods, no

complementary foods in <6 mo

• Increase resources for breastfeeding education for mothers in polyclinics, points of assistance distribution, collective centers, etc.• Information on the effects of stress on breastfeeding, problems with

attachment, effects of bottle feeding, etc.• Provide information to mothers before birth so they are prepared• Additional counseling capacity (outside of polyclinics), especially in collective

centers and at the point of assistance distribution• Availability of skilled consultants for on-the phone advice (free hotline)

Recommendations• Educate humanitarian and volunteer organizations on age appropriate

distribution of formula• Provide targeted assistance packages for different age groups

• Provide to beneficiaries a list of humanitarian and volunteer organizations who are providing baby food assistance• Perhaps in polyclinics, social service offices, etc.

• Include key educational messages on infant and young child feeding (as leaflets) in complementary baby baskets• Create a nutrition website women can access for correct information

on breastfeeding/complementary feeding