CDC/UNICEF IYCF 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 Dnipropetrovsk: Prenatal Interview: Ob/Gyn Postnatal Interview: Pediatrician Zaporizhia: Birth Clinic Interview: Midwife Postnatal Interview: Pediatrician

Child Characteristics Total (N=477) Gender (n, %) Male247 (51.8) Female230 (48.2) Age (months) (n,%) (13.8) (34.2) (31.9) (20.1) Mean (SD)12.8 (5.8)

Maternal Characteristics Total (N=458) Age, years (n, %) < 25 years64 (14.0) years157 (34.3) years151 (33.0) >=35 years86 (18.8) Mean (SD)30.1 (5.3) Education level (n, %) Incomplete secondary school7 (1.5) Complete secondary school20 (4.4) Professional secondary education139 (30.4) Incomplete higher education19 (4.1) Complete higher education or above273 (59.6) Total # of children born to mother (n, %) 1197 (43.0) (53.3) >= 417 (3.7)

Household Characteristics Total (N=458) Household location (n, %) Oblast Center347 (75.8) Other City92 (20.1) Village19 (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 center31 (6.8) Other1 (0.2) Permanent Address Left From (n, %) Donetsk289 (63.1) Luhansk162 (35.4) Other7 (1.5) Length of displacement, months (n, %) <6 months42 (9.2) 6-11 months289 (63.1) >= 12 months127 (27.7)

WHO Indicator IYCF Survey % (95% CI) MICS 2012 Eastern Region (%) Ever breastfed (N=children 0-23 mo)93.3 ( )96.7 Early Initiation of Breastfeeding (within 1 hour of birth) (N=children 0-23 mo) 63.7 ( )61.5 Exclusive breastfeeding <6 mo (N=children 0-5 mo)25.8 ( )21.3 Predominant breastfeeding <6 mo (N=children 0-5 mo)45.5 ( )47.5 Continued breastfeeding at 1 year (N=children mo)53.5 ( )33.4 Continued breastfeeding at 2 years (N=children mo)20.6 ( )31.1 Age-appropriate breastfeeding (N=children 0-23 mo)42.3 ( )22.3 Introduction of solid, semi-solid, or soft foods (N=children 6-8 mo) 98.6 ( )43.2 Bottle Feeding (N=children 0-23 mo)68.1 ( )51.1 Minimum Meal Frequency (N=children 6-23 mo) Breastfeeding96.2 ( )32.1 Non-Breastfeeding98.7 ( )89.3 Total97.6 ( )67.2 WHO Indicators

Age (months) Indicator 6-11 mo (N=163) (n, %, (95%CI)) mo (N=152) (n, %, (95%CI)) mo (N=96) (n, %, (95%CI)) 6-23 mo (N=411) (n, %, (95%CI)) Dietary Diversity* <3 Food groups given yesterday ( ) ( ) ( ) ( ) 3 Food groups given yesterday ( ) ( ) ( ) ( >= 4 Food groups given yesterday ( ) ( ) ( ) ( ) Consumption of iron- rich foods given yesterday** ( ) ( ) ( ) ( ) *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 Practices Indicatorn (%) Reason stopped breastfeeding among mothers who ever breastfed (N=210) Stress related to conflict63 (30) Stress unrelated to conflict7 (3.3) Not enough food for mother14 (6.7) Work schedule1 (0.5) Problems with attachment23 (11.0) Use of bottle for feeding4 (1.9) Other89 (42.4) Don’t know9 (4.3) Mother’s opinion of age child should stop breastfeeding (N=458) < 6 months1 (0.2) 6-11 months16 (3.5) 12 months198 (43.2) months33 (7.2) months71 (15.5) 24 months114 (24.9) > 24 months21 (4.6) Don’t know4 (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 conflict63 (30)48 (45.7) Stress unrelated to conflict7 (3.3)3 (2.9) Not enough food for mother14 (6.7)10 (9.5) Work schedule1 (0.5)0 (0) Problems with attachment23 (11.0)10 (9.5) Use of bottle for feeding4 (1.9)1 (1.0) Other89 (42.4)29 (27.6) Don’t know9 (4.3)4 (3.8)

Foods Given Yesterday to Children <6 months not exclusively breastfed BF Practices Type of Food Not Currently Breastfeeding n (%) (N=17) Currently Breastfeeding n (%) (N=32) Water14 (82.4)28 (87.5) Tea or herbal tea8 (47.1)5 (15.6) Fruit or vegetable juice3 (17.7)1 (3.1) Soda drinks or other sweetened drinks2 (11.8)2 (6.3) Infant formula17 (100)15 (46.9) Animal milk1 (5.9)1 (3.1) Sour milk drinks0 (0) Cottage cheese or cheese0 (0) Infant commercial porridge4 (23.5)4 (12.5) Semolina homemade2 (11.8)0 (0) Buckwheat porridge homemade0 (0)1 (3.1) Other homemade porridge0 (0)1 (3.1) Mashed potato2 (11.8)3 (9.4) Commercial baby fruit or vegetable puree3 (29.4)2 (6.3) Fruits4 (23.5)1 (3.1) Vegetables1 (5.9)1 (2.3) Peas or beans0 (0) Meat homemade0 (0) Commercial meat puree1 (5.9)0 (0) Eggs0 (0) Bread or pasta3 (17.7)2 (6.3) Fats0 (0) Sweets0 (0)

Foods Given Yesterday to Children 6-23 months Age (months) Type of Food 6-11 (n, %) (N=163) (n, %) (N=152) (n, %) (N=96) Total Including children <6 months (n, %) (N=477) Water153 (93.9)136 (89.5)92 (95.8)423 (88.7) Tea or herbal tea48 (29.4)69 (45.4)65 (67.7)195 (40.9) Fruit or vegetable juice49 (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 formula70 (42.9)39 (25.7)16 (16.7)157 (32.9) Animal milk31 (19.0)65 (42.8)49 (51.0)147 (30.8) Sour milk drinks55 (33.7)94 (61.8)47 (49.0)196 (41.1) Cottage cheese or cheese78 (47.9)96 (63.2)51 (53.1)225 (47.2) Infant commercial porridge103 (63.2)67 (44.1)19 (19.8)197 (41.3) Semolina homemade26 (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 porridge33 (20.2)64 (42.1)44 (45.8)142 (29.8) Mashed potato81 (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) Fruits107 (65.6)116 (76.3)81 (84.4)309 (64.8) Vegetables106 (65.0)129 (84.9)88 (91.7)325 (68.1) Peas or beans4 (2.5)6 (3.9)15 (15.6)25 (5.2) Meat homemade82 (50.3)115 (75.7)85 (88.5)282 (59.1) Commercial meat puree22 (13.5)10 (6.6)4 (4.2)37 (7.8) Eggs32 (19.6)52 (34.2)36 (37.5)120 (25.2) Bread or pasta108 (66.3)136 (89.5)91 (94.8)340 (71.3) Fats63 (38.7)85 (55.9)65 (67.7)213 (44.7) Sweets16 (9.8)32 (21.1)53 (55.2)101 (21.2)

Iron and Protein Containing Foods Number of Days Given in Past Week Age 6-11 Months (N=163) Age Months (N=248) # of Days Meat (n, %) 0 Days45 (27.6)8 (3.2) 1-2 Days20 (12.3)21 (8.5) >=3 Days98 (60.1)219 (88.3) # of Days Eggs (n, %) 0 Days72 (44.2)52 (21.0) 1-2 Days46 (28.2)90 (36.3) >=3 Days45 (27.6)106 (42.7)

Children 6-11 mo Given Commercial Foods Yesterday SES IndicatorFormula Commercial Porridge 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)

MUAC Children <2 Years Age (months) MUAC (mm) 6-11 N=163 (n, %, 95%CI) N=248 (n, %, 95%CI) <1150 (0) ( ) ( ) > ( ) ( )

MUAC Children 2-4 Years MUAC (mm) (n, %) <1150 (0) (0) >12557 (100)

Access to Services (n,%) Attempted to register child at clinic (N=477) No28 (5.9) Yes448 (93.9) Don’t know1 (0.2) Child registered at clinic (N=448) No4 (0.9) Yes444 (99.1) Difficulties registering child at clinic (N=448) No434 (96.9) Yes14 (3.1) Difficulties faced during registration at clinic (N=14) Required unavailable documents3 (21.4) Required registration as IDP6 (42.9) Required payment0 (0) Other8 (57.1)

Humanitarian 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 1130 (27.3) (26.2) >368 (14.3) Items included in baby food assistance package (n, %) (N=323) Infant formula143 (44.3) Fruit or vegetable puree159 (49.2) Meat puree9 (2.8) Commercial baby porridge182 (56.4) Semolina17 (5.3) Other porridge33 (10.2) Other34 (10.5)

Water and Sanitation Safe Water and Hand WashingTotal (N=454) Running water in home (n, %) No16 (3.5) Yes438 (96.5) Main source of water for drinking/cooking (n, %) Bottled280 (61.7) Tap106 (23.3) Well43 (9.5) Water pump7 (1.5) Other18 (4.0) Ability to boil water (n, %)454 (100) Times used soap in last 2 days (n, %) 0-4 times7 (1.5) 5-10 times35 (7.6) >10 times415 (90.6) Don’t know1 (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 1 st 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 ) 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