Infant-feeding, Maternal Vulnerability, and Well-being

The Case of Nepal Earthquake Recovery

Abstract

This project focuses on women with infants in temporary housing who were relocated due to the April 2015, Nepal earthquake. Data collection took place in the month of November of 2015. Qualitative data gathering using a semi-inductive approach was used to find patterns of challenges and perceptions of experiences of 14 women with infants, with a focus on decisions about feeding, nursing, and infant care. More broadly, the research questions focused on decision-making for infant-feeding and perceptions of sense of community and recovery. The data collection also took place during a fuel crisis fomented by political tension between India and Nepal following the promulgation of Nepal’s new constitution and during the approach of the winter season. The crisis was caused by the halting of fuel and other raw materials that normally flow from India into Nepal, which exacerbated concerns about the speed for recovery and preparations for winter among those affect by the earthquake. In the current study, respondents expressed concern over the impending winter season combined with concerns about the on-going fuel crisis. Respondents were also concerned about a lack of sheltering options and sustainable earthquake recovery processes. Findings about decisions for infant feeding revealed that knowledge about feeding was intergenerational and complex.

Overview

This fieldwork project was a part of a broader, long-term research endeavor. The principal investigator originally deployed to Nepal four weeks after the April 25th, 2015 earthquake. The first deployment was conducted as reconnaissance fieldwork deployment of a small team of social science researchers (from the Disaster Research Center at the University of Delaware) with the objective of capturing the broader social impacts of the disaster in Nepal. Based on observations during reconnaissance deployment, the principal investigator (PI) formed specific research questions for the second fieldwork deployment (work for the current report) regarding the maternal well-being, decision-making of infant feeding, and recovery of Nepalese mothers residing in temporary shelters. The second fieldwork deployment took place over the span of two weeks in November of 2015. The research and logistics of the fieldwork were complicated by international tensions between Nepal and India, which resulted in an economic blockade of fuel and other raw materials into Nepal from India. Several main findings emerged from the fieldwork concerning 1) intergenerational cultural knowledge of lactation, infant feeding and weaning, 2) the impact of the fuel crisis on micro-level and family functions, 3) evidence of bottle-feeding and wet-nursing, 4) sense of community and support in relocation communities, 5) perceptions of low milk supply in nursing mothers. These data are still being analyzed for results in a journal and will be discussed in more detail. Other findings that were also interesting but not related to the specific research questions was the disparate outcomes for earthquake victims who had land versus those without land, perceptions of relief materials among different castes, and activities occurring in temporary tent camps related to the annual Tihar festival. The Tihar holiday celebration, despite the destruction caused by the earthquake earlier in the year, suggests that an overall sense of community, celebration, and return to normalcy is in some ways on-going in the Kathmandu Valley. There were some interesting emerging findings in terms of sense of community and solidarity within the tent camps but there was also some evidence of inter-group conflict within the tent camps. There was also evidence of growing tensions between the communities hosting the tent camps and the tent camp residents. These issues will also be explored more thoroughly in a manuscript to follow this initial report.

Method for Current Project

A total of 14 respondents (13 mothers and one grandmother) were interviewed using a semi-scripted interview guide which contained questions on feeding choices, perceptions about urgency of needs, psychological well-being, sense of community in the tent camps (or village), and some demographic information (natal village, caste, occupation, birth and delivery location and method and occupation of the infants’ fathers). The respondent caregivers ranged in age from 19 to 67, however the majority of the respondents/mothers were in their 20’s. Research questions were constructed based on initial findings from reconnaissance fieldwork and then semi-scripted items for an open-ended questionnaire were piloted at the beginning of the second round of fieldwork. Most of the data were collected in the Kathmandu Valley, but two respondents were interviewed in the district of Sindhupalchowk (Northeast of Kathmandu) and one respondent was interviewed from the rural village of Ramkot, just Northeast of Kathmandu. Some of the respondents in the rural areas were not residing in tents but temporary shelters of corrugated tin and bamboo. In the urban area of Kathmandu the respondents were from two main tent camps, the Harsiddhi and Chuchepati. Three of the women we interviewed were not living in a tent camp but residing in temporary housing in their village/land, and one woman was living in a tent camp that had been transformed into a temporary housing site. We also spoke with people residing in the Tahli tent camp (located between Kathmandu and Bhotechaur) about their general perceptions after the earthquake, but no mothers of infants were available for interviews at that particular camp. Informed consent and questions for the interviews were translated to Nepali and interviews were conducted in Nepali. We also held informal interviews with two staff members from Save the Children (in Kathmandu) and a medical doctor from a children’s hospital (in Bhaktapur) to gather contextual information about programs implementing nutrition and maternal outreach projects.

Forming the Research Questions (Initial Fieldwork)

During the first trip to Nepal, the researcher met with several program officers, community health workers, and earthquake victims and had a series of informal conversations about the perception of the earthquake relief. Observation of damaged areas and tent camps was also a key part of informing the research questions. Specifically, the observation of the major tent camp, Tundikhel, in the military ground in central Kathmandu led to conversations with program leaders in the women’s advocacy groups that provided tent space for mothers and babies. Some women in the tent camps appeared to be helping one another with childcare and other activities, although it was not clear if these activities were coordinated within or across families. It was also unclear if women from the same villages were “sticking together” to support one another for childcare, cooking, infant-feeding, and social support. Some research suggests that the space of temporary living is an inherently different community and therefore operates uniquely and is perceived as such by its inhabitants (Bulley, 20141; Saltzman, 20112). This sense of community aspect of the tents and temporary housing became an important part of the research questions for the follow-up work, especially since infant care and feeding may be a communal activity (Ghosh, Gidwani, Mittal, and Verma, 19763; McIntyre, Hiller and Turnbull, 20014; Rose, Warrington, Linder, and Williams, 20045).

Also during the initial fieldwork in a suburban neighborhood of Kathmandu, the PI had conversations with one of the main “inventors” of Sarbottam Pitho, or “super flour” (Krantz, 19836). Sarbottam Pitho is now marketed and mass produced as a weaning food for infants or first complimentary food, but was originally created as a malnutrition intervention. Before the advent of “super flour” soy was being fed to small children in rural parts of Nepal as whole kernels, and the children were unable to digest the soy. Once the super flour was implemented as a major malnutrition intervention, it became common practice not only for health and humanitarian workers to use in interventions, but also for most families to use as an introductory food beginning around age five to six months. Now it is considered traditional practice to make pitho or litho (cooked pitho) for the infants and toddlers as their first and main source of solid foods.

Quite different than implementing the preparation and use of traditional Sarbottam Pitho, the common approach for combatting malnourishment in Nepal by some INGO’s has been through the distribution of ready-to-use prepackaged foods (Porter & Shafritz, 19997). One well-known ready to eat food that is distributed by various INGO’s is the Plump’y Nut, developed by a French-based company known as Nutriset, and is a common Ready-to-Use Therapeutic Food. Similar ready to use foods have been developed Nutriset for younger children (Defourny et al. 20098). Although some researchers (Dibari et al. 2012) suggest that locally based ingredients may be an alternative solution for ready-to-use foods as malnutrition interventions, this issue has not been extensively explored from a sociological or anthropological perspective. Bourdier (2009) assessed the acceptability of Pump’y Nut in the Cambodia, but this assessment was not linked to academic theories of decision-making about infant feeding and nutrition preparation as a form of protective action.

Another key issue that the PI was looking for upon the initial fieldwork was to find evidence or instances of 1) formula distribution and 2) wet-nursing of infants following the earthquake. Although there were instances of infants whose parents or mother were killed after the earthquake, it was unclear how many of these infants were nursed by relatives, friends, or other mothers. Nursing an infant after the death of a mother caused by a disaster could be viewed both as protective action and improvised behavior. Although improvisation during and after disasters has been studied broadly (e.g. Wachtendorf and Kendra, 20049), it has not been studied in the context of wet-nursing or milk-sharing after disasters. Breastfeeding after disasters and in low resource settings can dramatically increase the chances of infants surviving and thriving because breastfeeding reduces vulnerability to infections and communicable diseases (Binns et al, 2012; Carothers and Gribble, 201410). Through word of mouth the PI found out about a woman who was running a nonprofit program for prisoners in Nepal who was caring for an infant whose mother had died in the earthquake. From conversations with journalists who met this woman, it seemed as though she was feeding the baby formula. Evidence of wet-nursing among mothers was scarce, but implied because of the cultural norm of breastfeeding in Nepal (Karkee, Lee, Khanal & Binns, 2014[^Karkee, Lee, Khanal & Binns, 2014]; Khanal, Sauer, and Zhao, 201311; Pandey et al, 201012; Panter-Brick, 199213; Subba et al, 200714). What was unclear is if instances of wet-nursing increased after the earthquake. Cases of wet-nursing in other countries after earthquakes has been indicated through anecdotal stories (Gribble, 2013) but has not been documented and explored with systematic research. In some of the tent camps, program officers indicated that mothers were most likely nursing babies of other women who were feeling depressed or stressed after the earthquake.

For evidence of distribution of formula, similarly there were instances in which second-hand accounts were shared with the PI of formula that was distributed in the days and weeks following the earthquake. Most of the groups that were engaged in formula distribution were small emergent groups made up of students and community members. Donations and other supplies flowing into a disaster-affected area can be very problematic not only because the flow of goods and people into the area can slow down response and reduce efficiency of logistics operations (Holguin-Veras, et al., 201415), but because the donations may be unneeded or even harmful. Although formula donation is not unusual after disasters (Gribble, McGrath, MacLaine & Lhotska, 2011), there has been a lack of fieldwork on studying groups who distribute breastmilk substitutes, motives for distribution, and perceptions of this distribution among women in the disaster affected area. In the case of Nepal, the flow of formula and other relief supplies was monitored by the Nepali government. This may have partly been associated with the increased customs monitoring in the days and weeks after the earthquake- specifically the flow of goods into the airport in Kathmandu. This effect may have may have combined with rigorous efforts of INGO’s to prevent widespread distribution of formula. For example, five days after the earthquake, a document was distributed through social media released by the Child Health Division, Ministry of Health and Population of UNICEF (2015) with guidelines for aid workers and the general public about distribution of breastmilk substitutes. This document listed common myths about nursing after disasters (such as stress causing lactation to stop or be greatly reduced) and also indicated that distribution of breastmilk substitutes (formula) should be prohibited and that Nepal should “refuse any unsolicited donations of these products” (p. 1).

Broad Findings

Of the 14 respondents we interviewed about infant feeding, all had been directly impacted by the earthquake, and 13 women had homes that were completely collapsed or uninhabitable following the earthquake (one woman tried to return to her rented room after the earthquake but was unable to afford the rent). All of the respondents expressed concern for the on-going fuel crisis and the approaching winter season. Although most of the women did not express that they had psychological trauma after the earthquake, many of the tent camp residents made statements such as “It would be better if we had died in the earthquake” without shelter and a way to make an income. Many tent camp residents also indicated that they felt that “the government of Nepal has forgotten about us” and “The politicians came for our votes during elections, but they didn’t come help us after the earthquake”. These statements were interesting because at the time of data collection, Nepali-based newspapers were dedicating many articles and stories to explain how India was forcing Nepal into a humanitarian crisis because of the fuel blockade.

When asked about their most urgent needs, most of the respondents indicated that they were worried about fuel for cooking. Because of the fuel crisis, the oil for cooking was unavailable so most families that were living in the tent camps and temporary shelters were cooking with firewood. Many of the mothers expressed concern for the colder temperatures at night time in the tents because the infants were not warm enough. In two of the urban tent camps (Harsiddhi and Chuchepati), respondents indicated that they had recently received blankets from nonprofit organizations.

Findings on infant feeding reflected the cultural norm of breastfeeding as a primary choice in Nepal. Although while many of the women chose to nurse/breastfeeding their babies, many of the women also expressed perceptions that their milk supply was “not enough” after approximately 4 months of breastfeeding. The mothers frequently said that their milk was “not enough” or that it was “bad”. Upon further questioning of what they meant by “bad”, the respondents indicated that there was not enough milk for the baby. Many of the mothers decided to feed Lactogen or infant formula to the babies to supplement breastfeeding. However, there were instances of women indicating that humanitarian groups distributed formula but the mothers continued breastfeeding without using the distributions of formula. In other words, the presence of formula did not specifically sway women away from their nursing activities. It us unclear though, if and when the perception of insufficient milk supply corresponded with the timing of these formula distributions. Also, many of the mothers stated that they were feeding complementary foods to the babies in the form of litho or pitho. Data are still being analyzed to determine the relationship between these perceptions and the earthquake. Low perceived supply has been studied outside of the disaster context (Gatti, 200816; McCarter-Spaulding and Kearney, 200117, Perez-Escamilla, 199418) but also within the contexts of disasters (Dörnemann, & Kelly, 2013). Another interesting finding was that many of the women we interviewed indicated that they learned about infant feeding practices from their mothers and grandmothers. These practices included the consumption of the Jwano spice to increase lactation as well as preparing homemade Sarbottam Pitho for the infants as the first complementary foods after breastmilk (and breastmilk substitutes such as Lactogen).

Much of what we found was gathered through second-hand information or narratives about general practices related to infant feeding in Nepal. For example, through conversations with hospital researchers and other native Nepalese women, the practice of giving tea or water to infant under the age of six months appears to be somewhat common. This can be problematic because it can cause a variety of problems for the infant such as water intoxication (Keating, Schears, and Dodge, 199119) and may also reduce the supply of breastmilk in the nursing mom (Daly and Hartmann, 199520). We feel that this topic requires more research and documentation so that possible interventions and educational programs could be designed and implemented.

Implications and Future Research

Infant feeding from a cultural perspective is quite different in the United States than in Nepal. In the United States, bottle-feeding is more common (Scott and Mostyn, 200321), although there has arguably been recent movements of breastfeeding advocacy in the United States (Ryan, 199722). For our research purposes, it is important to consider how cultural and national differences influence perspectives and practices of infant feeding and breastfeeding (Callen and Pinelli, 200423; Ghaemi-Ahmadi, 199224; Williamson, 198925). Furthermore, the hazard cycle, systems of governance, social systems, and cultural expectations are different in the United States than in Nepal. However, despite these differences there are similarities and possible lessons to be learned. The most obvious and substantial lesson that could be applied from Nepal to the United States would be the tremendous acceptance and established normalization of breastfeeding. In other words, women in Nepal see breastfeeding as normal, expected, and traditional. Nursing in public is a common practice, whereas women in the United States face many barriers in this front (Li et al, 200426; Trocola, 200527). The normalization of breastfeeding in the United States would mean that more women would be nursing when a catastrophic hazard or disaster strikes, thus increasing the chances of infant survival. Problems with access to clean water may be one main reason for why women in Nepal have been largely “immune” to marketing by formula companies. The United States has had recent incidents in which lead poisoning in water supplies (Wang, 201528) may engender policies and public opinions to shift about trust in clean water, which may ultimately spill into perceptions about formula-feeding as a safe option.

Other major areas that can be applied from the Nepali to the United States context would be the exploration on the sense of community among people who are relocated after disasters. Although the current study focused on the intersection of child and maternal well-being with relocation, it would be useful and interesting to see how specific variations occur in both the perceptions and behaviors related to a “sense of community” among people relocated after disasters. Although this issue has been studied with regards to Hurricane Katrina (Airriess et al., 200829; Chamlee‐wright and Storr, 200930) and in other areas of the world (Bulley, 20141; Davidson et al, 200631), longer term tent communities in Nepal have not been systematically studied. The on-going blockade and fuel crisis that began after the earthquake may also have unique effects on how sense of community is perceived and “acted out” among Nepalese earthquake victims. All of these areas require further research to build upon theoretical work and to begin to understand how these findings can be applied in community interventions to bolster the well-being of those affected by disasters in Nepal and the United States.

Acknowledgements and Notes

In addition to the Quick Response Grant from the University of Colorado Boulder, the salary for the PI during fieldwork was supported by NSF grant # 1331269. The Society for Community Action and Research (American Psychological Association, Division 27) also provided funds for translation during data collection. Master’s student Manoj Suji of Tribhuvan University (Department of Anthropology and Sociology) collected data with the principal investigator and will be included as a co-author for corresponding manuscripts for this project.


  1. Bulley, D. (2014). Inside the tent: Community and government in refugee camps. Security Dialogue, 45(1), 63-80. 

  2. Saltzman, A. (2011). Beyond the Tents: Community Spaces in Post-disaster Temporary Settlements (Doctoral dissertation, University of Cincinnati) 

  3. Ghosh, S., Gidwani, S., Mittal, S. K., & Verma, R. K. (1976). Socio-cultural factors affecting breast feeding and other infant feeding practices in an urban community. Indian pediatrics, 13(11), 827-32. 

  4. McIntyre, E., Hiller, J. E., & Turnbull, D. (2001). Attitudes towards infant feeding among adults in a low socioeconomic community: what social support is there for breastfeeding?. Breastfeeding Review, 9(1), 13. 

  5. Rose, V. A., Warrington, V. O., Linder, R., & Williams, C. S. (2004). Factors influencing infant feeding method in an urban community. Journal of the national medical association, 96(3), 325. 

  6. Krantz, M. E. (1983). Sarbottam pitho: A home-processed weaning food for Nepal. International Food and Nutrition Program, Massachusetts Institute of Technology. 

  7. Porter, R., & Shafritz, L. (1999). Packaged foods for complementary feeding: marketing challenges and opportunities. Washington, DC: Linkages Project, Academy for Educational Development. 

  8. Defourny, I., Minetti, A., Harczi, G., Doyon, S., Shepherd, S., Tectonidis, M. & Golden, M. (2009). A large-scale distribution of milk-based fortified spreads: evidence for a new approach in regions with high burden of acute malnutrition. PLoS One, 4(5), e5455. 

  9. Wachtendorf, T. & Kendra, J.M. 2005. Improvising Disaster in the City of Jazz: Organizational Response to Hurricane Katrina, Understanding Katrina: Perspectives from the Social Sciences. Social Science Research Council. 

  10. Carothers, C., & Gribble, K. (2014). Infant and Young Child Feeding in Emergencies. Journal of Human Lactation, 0890334414537118. 

  11. Khanal, V., Sauer, K., & Zhao, Y. (2013). Exclusive breastfeeding practices in relation to social and health determinants: a comparison of the 2006 and 2011 Nepal Demographic and Health Surveys. BMC public health, 13(1), 958. 

  12. Pandey, S., Tiwari, K., Senarath, U., Agho, K. E., & Dibley, M. J. (2010). Determinants of infant and young child feeding practices in Nepal: secondary data analysis of Demographic and Health Survey 2006. Food & Nutrition Bulletin, 31(2), 334-351. 

  13. Panter‐Brick, C. (1992). Women's work and child nutrition: the food intake of 0–4 year old children in rural Nepal. Ecology of food and nutrition, 29(1), 11-24. 

  14. Subba, S. H., Chandrashekhar, T. S., Binu, V. S., Joshi, H. S., Rana, M. S., & Dixit, S. B. (2007). Infant feeding practices of mothers in an urban area in Nepal. 

  15. Holguin-Veras, J., Jaller, M., Van Wassenhove, L. N., Perez, N., & Wachtendorf, T. (2014). Material convergence: Important and understudied disaster phenomenon. Natural Hazards Review, 15(1), 1-12. doi:10.1061/(ASCE)NH.1527-6996.0000113 

  16. Gatti, L. (2008). Maternal perceptions of insufficient milk supply in breastfeeding. Journal of Nursing Scholarship, 40(4), 355-363. 

  17. McCarter-Spaulding, D. E., & Kearney, M. H. (2001). Parenting self-efficacy and perception of insufficient breast milk. JOGNN, 30(5), 515-522. 

  18. Perez-Escamilla, R. (1994). Factors Associated with Perceived Insufficient Milk in a Low-Income urban Population in Mexico1'2. 

  19. Keating, J. P., Schears, G. J., & Dodge, P. R. (1991). Oral water intoxication in infants: an American epidemic. American Journal of Diseases of Children,145 (9), 985-990. 

  20. Daly, S. E., & Hartmann, P. E. (1995). Infant demand and milk supply. Part 1: Infant demand and milk production in lactating women. Journal of Human Lactation, 11(1), 21-26. 

  21. Scott, J. A., & Mostyn, T. (2003). Women's experiences of breastfeeding in a bottle-feeding culture. Journal of Human Lactation, 19(3), 270-277. 

  22. Ryan, A. S. (1997). The resurgence of breastfeeding in the United States. Pediatrics, 99(4), e12-e12. 

  23. Callen, J., & Pinelli, J. (2004). Incidence and duration of breastfeeding for term infants in Canada, United States, Europe, and Australia: a literature review. Birth, 31(4), 285-292. 

  24. Ghaemi-Ahmadi, S. (1992). Attitudes toward breast-feeding and infant feeding among Iranian Afghan and Southeast Asian immigrant women in the United States: implications for health and nutrition education. Journal of the American Dietetic Association, 92(3), 354-5. 

  25. Williamson, N. E. (1989). Breastfeeding trends and patterns. International Journal of Gynaecology and Obstetrics, (1), 145-52. 

  26. Li, R., Hsia, J., Fridinger, F., Hussain, A., Benton-Davis, S., & Grummer-Strawn, L. (2004). Public beliefs about breastfeeding policies in various settings. Journal of the American Dietetic Association, 104(7), 1162-1168. 

  27. Trocola, M. G. (2005). Breastfeeding in Public. New Beginnings, 22, 238-243. 

  28. Wang, Y. (December, 2015). In Flint, Mich., there’s so much lead in children’s blood that a state of emergency is declared. Washington Post. Retrieved from https://www.washingtonpost.com/news/morning-mix/wp/2015/12/15/toxic-water-soaring-lead-levels-in-childrens-blood-create-state-of-emergency-in-flint-mich/ 

  29. Airriess, C. A., Li, W., Leong, K. J., Chen, A. C. C., & Keith, V. M. (2008). Church-based social capital, networks and geographical scale: Katrina evacuation, relocation, and recovery in a New Orleans Vietnamese American community. Geoforum, 39(3), 1333-1346. 

  30. Chamlee‐wright, E., & Storr, V. H. (2009). “There's no place like New Orleans”: Sense of place and community recovery in the Ninth Ward after Hurricane Katrina. Journal of Urban Affairs, 31(5), 615-634. 

  31. Davidson, C. H., Johnson, C., Lizarralde, G., Dikmen, N., & Sliwinski, A. (2006). Truths and myths about community participation in post-disaster housing projects. Habitat International, 31(1), 100-115.