Scoop situation - Field Exchange - Emergency Nutrition Network

This article shares the practical realities ofidentifying wet nurses for young orphanswhere artificial feeding was not considered anacceptable, feasible, affordable, sustainableand safe option.UNHCR started working inBangladesh in 1992 upon the invitationof the Government ofBangladesh to assist in the repatriationof more than 250,000 Rohingya refugees.These people had fled from Myanmar duringthe same year due to socio-economic and politicalreasons. UNHCR has since assisted in therepatriation of around 230,000 refugees, equivalentto 95% of the original registered refugeecaseload.As of end December 2007, there were some27,400 refugees residing in the two camps ofKutupalong and Nayapara situated along theBangladesh-Myanmar border. UNHCR providescare and maintenance while activelypursuing durable solutions for the remainingrefugees 1 . The Ministry of Health along withone local non-governmental organisation(NGO), Technical Assistant Inc (TAI), were theonly two UNHCR implementing partners untilrecently. In November 2007, Research TrainingManagement International and HandicapInternational began working in the two camps.In both camps 2 , Medecins Sans Frontieres-Holland has been present and is planning toclose down its operation in 2008.In the Rohingya refugee camps of Nayaparaand Kutupalong in Bangladesh, three types ofnutrition programmes are operating, in additionto the World Food Programme (WFP)general food distribution.• A Blanket Feeding Programme (BFP) for allchildren between 6 and 24 months residingin the camps• A Supplementary Feeding Programme(SFP) for pregnant or lactating mothers andmoderately malnourished children between6 to 59 months. A total of three SFPs areoperating between the two camps.• A Therapeutic Feeding Centre (TFC) forseverely malnourished children from 6 to59 months. One TFC is present in eachcamp, run by the MOH.The challengeIn October 2007, Ministry of Health staff workingin the TFC alerted the UNHCR teammanaging the camps that five orphans belowsix months of age had been brought by caretakersto the TFC but were sent home again sinceno guidelines were set for their care. No infantformula is provided in the camps and the caretakerswere feeding the infants with cereals. Atfirst the UNHCR team thought about providinginfant formula for the orphans. However,after consulting the ‘UNHCR Policy Related tothe Acceptance, Distribution and Use of Milkproducts in Refugee settings (2006) 3 , anddiscussions with the UNHCR HeadquartersNutrition Unit, the challenges of introducinginfant formula to such an unhygienic settingwere recognised. Furthermore, the caretakerswere illiterate and unable to read writtenguidelines. Another fear was that all motherswould start requesting infant formula for theirinfants, as it was common practice for distributedfood to be sold in the camps.The optionsWe therefore opted to find a ‘wet nurse’ – awoman who is not the mother who wouldbreastfeed the infant. This strategy is includedin the options outlined in the OperationalGuidance on Infant and Young Child Feedingin Emergencies (2007) 4 produced by the IFECore Group, of which UNHCR is a member.We realised that the HIV status of the wetnurse should be considered. However, in theNayapara and Kutupalong camps the risk ofHIV was considered to be low 5 , therefore thewet nurses were not offered Voluntary andConfidential Counselling and Testing forHIV 6 .In the Nayapara camp there was a motherwho was already breastfeeding one orphanwho was not a relative. She was also breastfeedingher one year old child at the sametime. Since this seemed to be an accepted practicein the community, we asked theCommunity Health Worker (CHW) and theTFC and SFP staff, as well as the caretaker, toactively look for wet nurses amongst the relativesof orphans. In the event that no relativewas lactating, we urged them to extend theirsearch to the wider community. As an incentive,we agreed to offer the wet nurses foodfrom the SFP. After a few days, one wet nursewas found for one orphan: she was theorphan’s aunt. It had not occurred to her thatshe could also breastfeed her orphan nephew.“It is an honour to breastfeed my nephew”said the aunt smiling, hugging the baby andcuddling him. This positive experienceencouraged us further.The CHW and selective feedingprogramme staff informed us that no otherwet nurse could be found so we decided toreach out to the community. One of the waysin which we did this was to talk with groupsof pregnant and lactating women when theycame to the SFP for food. We told them, “Weare the team responsible for nutrition in thecamps. We are facing a problem. We need yourhelp. We have orphans in our camps that aretoo small to be given food. They should onlybe breastfed. We don’t want to give thempowdered formula because if the water in theformula is not clean, they will be sick and havediarrhoea. Would you or someone you knowbe able to breastfeed the orphan?” Weexplained that the baby already has a caretakerand that their role would only be tobreastfeed the baby several times a day. Wealso explained that the wet nurse wouldreceive an extra food ration from the SFP (anegg, a banana and some porridge) every day.Two lactating mothers agreed on the spot. Oneof them was hesitant but when we took her tosee the orphan her doubts disappeared. Weasked the wet nurses to come to the centreevery day. The TFC staff and the caretakerwould make sure the wet nurse was breastfeedingthe infant 8 times a day and that shealso received her extra ration. In theKutupalong camp, a wet nurse was easilylocated for one orphan and she breastfed himmore than 6 times a day, in the morning andthe afternoon. This was also a very encouragingoutcome.However, a number of difficulties did arise.One wet nurse was not allowed by herhusband to breastfeed an unknown child, sowe had to actively locate and recruit anotherField Articlewoman for this child. Luckily, we were able tofind another willing wet nurse, although shefound it difficult to breastfeed 8 times a daysince she lived far from the centre. Since theTFC closes at 2pm, we asked the caretaker totake the infant to the wet nurse every afternoon.This seemed to work well for all theorphans. However, another problem soonarose. As refugee women do not feel safe travellingat night, the caretakers were asking forinfant formula for night-feeds. During a trainingon breastfeeding organised by UNHCR, asolution was found through discussion andbrainstorming led by a trainer from theBangladesh Breastfeeding Foundation. Thewet nurse would hand over expressed breastmilkto the caretaker who would keep it in acontainer. If the milk needed to be kept formore than 6 to 8 hours, then a box of ice wouldbe given to the caretaker for storing theexpressed milk. The milk could then be heatedand given to the infant by cup. This practice isnow adopted in the camps.Of course, a number of challenges remain.For example, there was an occasion when acaretaker decided that when her orphan had about of diarrhoea that this was due to the wetnurse’s breastmilk. She therefore boughtpowdered milk. On showing it to us it wasclear that she was unable to read the warningthat clearly stated “not suitable for infantsbelow 1 year”! We discussed the issues aroundthis with her and offered advice. However, sheseemed uninterested and never came back tothe TFC. Challenges like these are, of course,to be expected but in my opinion, the advantagesof wet nursing outweigh the problemsfaced. The best results for malnourishedorphans have so far consistently been whenthe caretaker is also the wet nurse.For more information, contact: Yara, Sfeir,email: SFEIR@unhcr.orgAn UNHCR Guidance on Infant feeding and HIVin Emergencies for Refugees and Displaced populationsis being finalised. The purpose of the guidanceis to assist UNHCR, its implementing andoperational partners and governments on policiesand decision-making strategies on infant feedingand HIV in emergency situations. For furtherinformation, contact: Fathia Abdallah, UNHCR,email: Abdallah@unhcr.org1As per the memorandum of understanding between theGovernment of Bangladesh and UNHCR, a third camp (Tal),present on the banks of the Naf river, is not supported byUNHCR.2MSF-H is also operating in Tal camp where UNHCR is notpresent.3Policy on the acceptance, distribution and use of milkproducts in refugee settings (2006). Available in English andFrench. Download from http:///www.unhcr.org orhttp://www.ennonline.net Contact: ABDALLAF@unhcr.org orHQTS01@unhcr.org4Operational Guidance for Emergency Relief Staff andProgramme Managers on Infant and Young Child Feeding inEmergencies. Version 2.1. February 2007. Available athttp://www.ennonline.net5Bangladesh is deemed a low HIV/AIDS prevalent country -it is estimated that the HIV prevalence in the adult populationis less than 0.01%. However vulnerability is consideredhigh for reasons that include low awareness of HIV/AIDS andlow condom use. (http://www.whoban.org/hiv_aids.htmlUpdated 7 Jan 2008. Accessed 7 Jan 2008). When dealingwith refugee populations, the HIV prevalence of the countryof origin and associated knowledge and practices, shouldalso be considered for more recent arrivals (eds).6In the context of wet nursing where the risk of HIV transmissionis considered very low because of an overall lowprevalence and incidence, and voluntary and confidential HIVcounselling and testing is thus deemed unnecessary, apotential wet nurse should still be counselled about how toavoid HIV exposure during breastfeeding. The refugeewomen in the TFCs are counselled regularly on HIV as agroup and individually on a number of health related topics.A major campaign on HIV was ongoing in the camps inNovember and December 2007.26