Scientific importance of this research
The findings illustrate the level of breastfeeding knowledge and practices of mothers living in poor communities, suggesting an opportunity to increase the ability of the midwives in the Gaza strip to promote, protect, and support breastfeeding during ante-natal, intra-partum and the post-natal period. This assessment provided new, updated information on the breastfeeding practices of the most vulnerable communities in the Gaza strip. Prior to this study the most recent data was the Multiple Indicator Cluster Survey of 2014 [
11].
Breastfeeding saves lives in all contexts - even more so in humanitarian and fragile contexts. The protection, promotion and support of breastfeeding are among the most effective interventions to prevent child morbidity and mortality in humanitarian contexts [
2]. Exclusive breastfeeding for the first 6 months and continued breastfeeding, thereafter, may prevent 13% of under-five deaths, primarily from infections resulting in diarrhoea, pneumonia, and neonatal sepsis [
2]. Non breastfed infants have a 14 times higher risk of dying from any cause compared to exclusively breastfed infants, a 15 times higher risk pneumonia and a 10 times higher risk of diarrhoea [
14,
15]. Furthermore, the global impact of breastfeeding on maternal health is significant, with a reduction in the risk of breast cancer and potential to prevent 20,000 deaths [
1]. In environments where access to safe water is limited and food insecurity is a significant issue for families, exclusive breastfeeding for new-borns and infants is a lifesaving public health intervention [
14‐
21]. It is important to ensure that additional studies are conducted in similar contexts, to ensure that findings are reflected in practical measures to protect the lives of the youngest and most vulnerable in humanitarian settings, whilst providing the needed support for pregnant women and mothers.
This study’s findings highlight the potential role that midwives in humanitarian contexts, who have an integral role in the initiation, protection promotion and support of breastfeeding practices. The findings were disseminated and validated by the members of the Nutrition Working Group and were presented to national and international organizations working in the Gaza strip during a workshop in May 2019.
The same were also presented to the different sector’s coordination mechanism including Health, WASH, Food Security, Livelihoods and Protection from June to August 2019.
The findings illustrate the immediate need to focus on practical, focussed interventions aiming at the most vulnerable were shared and presented with the Humanitarian Country Team (lead by UN OCHA), UN agencies and the organizations and donors contributing and supporting the humanitarian response. This guided strategic discussion and initial direction with UN OCHA and relevant UN partners. The study suggests that the protection, promotion, and support of breastfeeding focusing on the most vulnerable populations in the Gaza strip, will receive more attention, including financial resources. The findings of the study were used to inform the revision and update of the Humanitarian Needs Overview for 2020 and the Humanitarian Response Plan 2019–2020 providing additional windows of opportunity for resources for an integrated solution to the issues presented.
Evidence shows that when breastfeeding support is offered to women, the duration of exclusive breastfeeding is increased [
6]. Studies have confirmed the benefits that individual breastfeeding support provided by midwives have on women and their practices [
16,
22,
23]. This is particularly relevant in conflict settings, where the need for psychosocial and mental support for pregnant and postnatal women with babies is significant, given the continuous challenge of giving birth and raising children in such a difficult and unsafe environment.
The findings confirm the need to: a) ensure a concerted effort to fully adapt and implement the recommendations of the IYCF-E operational guidance [
24]; b) review and possibly improve the pre-service training for midwives and other health professionals who provide antenatal, intrapartum and post-natal care in relation to the protection, promotion and support of breastfeeding using recommended WHO modules [
25]; and scale up and exert efforts to ensure hospital and health facilities providing maternity services fully comply with the WHO/UNICEF Baby Friendly Hospital Initiative [
26].
For the vulnerable population of the Gaza strip, it is imperative to support the midwives to provide skilled support at birth (both vaginal and caesarean) thus ensuring breastfeeding initiation. If breastfeeding is practiced in the Gaza strip as per recommendations, there will be increased protection for common childhood diseases such as diarrhoea and ARI, whilst ensuring that the available resources are used by the household to increase access to a diverse and appropriate diet for the mother and the other members of the family. Having skilled midwives providing lactation support and counselling is certainly recommended in all contexts, particularly humanitarian settings, and fragile environments like the Gaza strip.
Challenges to research
Security
The security situation in the Gaza strip is unpredictable and escalation of conflicts is always a possibility. This was a major consideration during the design and planning phase of the study, and plans were made to ensure successful completion, even in the event of potential security situations. Contingency plans included the identification of back up areas to be covered and/or the reduction of the sample size requirements were also included.
Political situation
The current political situation in the Gaza strip, exemplified by a strict set of requirements limiting study coverage and information to be collected by the Ministry of Interior in Gaza, was a critical challenge faced during the study. The Ministry of Interior reviewed the proposed questionnaire, as per local policy and requested that questions on socio-economic status and mental health be removed. This did not allow for an analysis of the results linking infant feeding practices and psychological condition of the caregiver, which, in a context like the Gaza strip, could be remarkable.
Capacity
Due to the conflict and travel restrictions within the Gaza strip, many professionals and health workers (including midwives) are not able to access regular trainings and capacity building opportunities. This is clearly identified as a major gap and highlighted the need to strengthen local capacity in relation to nutrition assessments and implementation using local capacities and resources. This is relevant to this study’s findings, with associated challenges when finalising study design and methodology, data collection and the quality of some aspects of the study.
Research strategies
The following strategies and actions were deployed to address most of the challenges encountered:
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Integration and linkage with security officers of leading organizations was essential, during the design, planning and execution of all the activities. During the data collection phase, it was continuous and provided valuable information that led to the temporary interruption of the data collection due to a rapid escalation of the conflict affecting the selected areas. In a volatile and unpredictable context like the Gaza strip, daily movements of teams and large groups must be cleared by relevant officers, mostly considering the locations of destination.
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Coordination with authorities and communities; a requirement for the issuance of the needed formal endorsements and clearances by the governing authorities as well ensuring full engagement and support from the participating communities. The Ministry of Interior in Gaza (under the Hamas leadership) required the review and clearance of the design and questionnaires. Several questions were removed as per their recommendations, that called for a revision of the questionnaire and of the objectives of the study.
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Supportive supervision was provided during the whole data collection with daily debriefing with teams, with the support of the leading organizations and to the extent possible international consultant. However, considering the escalation of the hostility during this period, this was reduced drastically and limited to Phone SMS based follow ups and updates. Teams were asked to communicate locations, challenges, and progress, regularly during the day, to ensure their safe and smooth progress in the data collection.
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Allocation of buffer days and geographical areas in lieu of days lost. Having a contingency plan for similar exercises in the context of the Gaza strip is crucial. Due to the potential for escalation of conflict in selected areas, this extra allocation in relation to logistical support and timeframe mitigated any major impact on the actual timely conclusion of the assessment. Data collection was halted for 2 days due to the escalation of the conflict that affected the selected areas, and the buffer days were used to complete the data collection. Allocation of extra days meant ensuring that budget, cars, and other logistical support was available in a timely manner and did not require extra approvals and procedures.
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In country and remote assistance to the data collection teams were provided by all the agencies involved during the data collection but mostly during data processing and analysis. The lead researcher could not visit all the areas and during the potential escalation of the conflict could not visit the field and support the data collection teams