|Year : 2020 | Volume
| Issue : 1 | Page : 78-84
Baby friendly spaces: an intervention for pregnant and lactating women and their infants in Cameroon
Elisabetta Dozio1, Karine Le Roch2, Cécile Bizouerne3
1 Clinical Psychologist, Mental Health and Care Practices Advisor, Action Contre la Faim, France
2 Research Project Coordinator for Mental Health and Care Practices Sector, Action Contre la Faim, France
3 Senior Advisor for Mental Health and Care Practices Sector, Action Contre la Faim, Paris, France
|Date of Submission||04-Sep-2018|
|Date of Decision||05-Mar-2019|
|Date of Acceptance||29-Aug-2019|
|Date of Web Publication||28-Jan-2020|
PhD Elisabetta Dozio
14/16 Boulevard de Douaumont, 75854 Paris
Source of Support: None, Conflict of Interest: None
In complex humanitarian emergencies, infants and young children are exposed to a higher risk of malnutrition, morbidity, delayed development and mortality. As shown by earlier research, maternal mental health and capacity for nurturing are of fundamental importance in child health and development. Since 2006, the international nongovernmental organisation, Action Contre la Faim, has been implementing a holistic approach to interventions for pregnant and lactating women and their young children to prevent child mortality and developmental delay in contexts affected by war and natural disasters. The experience presented here of ‘Baby Friendly Spaces’ refers to a programme in Cameroon, implemented with Central African refugees. The activities comprised in this model are focused on maternal mental health, parental skills, early child stimulation and infant and young child feeding practices. Results show a positive and significant (p < 0.01) impact on maternal wellbeing, breastfeeding practices and mother–child relationships. These findings reinforce previous evidence highlighting the necessity of implementing programmes, within complex humanitarian contexts, to reinforce the mother’s psychological wellbeing and increase capacity to provide nurturing care to guarantee the child’s health status and development.
Keywords: baby friendly spaces, breastfeeding, holistic approach, maternal mental health
|How to cite this article:|
Dozio E, Le Roch K, Bizouerne C. Baby friendly spaces: an intervention for pregnant and lactating women and their infants in Cameroon. Intervention 2020;18:78-84
| Introduction|| |
In September 2013, fighting between two self-defence groups called ‘Anti-balaka’ and ‘former Seleka’ broke out in numerous villages and in the capital of Central Africa, forcing thousands of people to seek refuge and protection in bordering countries. Continuing violence has forced many into internally displaced persons camps within the borders since. Refugees exposed to atrocities and forced migration showed significant signs of psychological trauma (Ventevogel, 2014). A preliminary psychosocial assessment done by Action Contre la Faim (ACF) in East Cameroon showed a strong degradation of childcare practices leading to a high risk of infant mortality or negligence (ACF, 2014). Mothers who were not able to breastfeed or take care of their infants also showed signs of deep depression and loss of engagement in their parental role (ACF, 2014). Fathers were absent in most cases.
Pregnant women in complex, humanitarian emergencies
In complex humanitarian emergencies, whether man-made or natural disasters, people are affected by traumatising experiences, including forced displacement and bereavement, causing high levels of stress. Additionally, pregnancy is potentially a period of increased vulnerabilities with regard to both physical and psychological or emotional components. These may include health, nutrition and wellbeing of the pregnant women, the foetus’ health and survival and the health and nutritional status of infants and mothers after birth. These risks are increased within emergency contexts, with women facing elevated risks of maternal morbidity and mortality (Haar & Rubenstein, 2012; Swatzyna & Pillai, 2013).
Pregnancy and birth reactivate the break with the culture of origin created by traumatic experiences. Migration and exile also modify the creation of a ‘cultural cradle’ (Moro, 1994), which are the set of cultural and collective expectations that parents have of their baby. The importance of the cultural cradle and the consequent expectations are structured before birth and increase in significance after the birth and during early relationships. Migration can lead to a break in the transmission of this cultural cradle with the consequent risk of difficulties in adopting cultural adapted childcare practices.
This effect is more evident in women who are pregnant for the first time and away from their families and communities, who would under normal circumstances have a support function. For these young women, it would be very difficult becoming mothers for the first time in a foreign environment without social and cultural support.
Studies conducted within more general contexts have shown that depression and anxiety in women double during pregnancy and can even reach a higher peak during the year following delivery (World Health Organization, 2008). Maternal depression and anxiety, expressed through symptoms like appetite disorder, lack of energy to care for herself and the baby, apathetic behaviour etc., can further increase risks of creating a non-optimal, mother–child relationship, potentially leading to a strong negative impact on child wellbeing.
Lactating women and their infants within emergency contexts
Within emergency contexts, improving breastfeeding support has the potential to save millions of children’s lives and disability-adjusted life years (Black et al., 2013). Unfortunately, health services or community outreach systems that deliver essential care and support services to women and their infants have often deteriorated or fragmented during emergencies.
Women who have lost a child or children may have difficulties providing child care, as being pregnant again could bring back painful emotions linked to the deceased child (Moro, Neuman, & Réal, 2008). The imperative of finding solutions to survival as well as increased changes in the environment and its resources can all drastically affect a caregiver’s ability to provide essential care practices to children, in both quantity (time spent on care) and quality (responsiveness, sensitivity, maintaining attention and affection and the encouragement of autonomy and exploration). Lactating women, specifically, can also face difficulties in breastfeeding practices due to stress, displacement, lack of time available or lack of availability of a confidential and quiet space for breastfeeding. Cultural habits and beliefs are other aspects to be considered in terms of misconceptions surrounding the impact of stress on the quality and production of mothers’ milk: ‘trauma and stress dries the milk up’, ‘if you stop breastfeeding, you can never start again’, ‘if the mother is not well-fed, she cannot breastfeed’. Within such contexts, if breastfeeding is stopped, infants and young children are often exposed to a higher risk of malnutrition, morbidity, delayed development and mortality.
Furthermore, there is strong epidemiological evidence that highlights the importance of maternal mental health, mother–child attachment (Tol, Song, & Jordans, 2013) and nutrition (Black et al., 2013) on child mortality and morbidity within complex humanitarian settings. These results are in line with the recent Lancet series, Early Childhood Development, that show the importance of nurturing care for favourable child development in infancy (Britto et al., 2017).
Additionally, there is substantial evidence that maternal depression often accompanies suboptimal rates of immunisation, minimal hospital visits and lower rates of exclusive breastfeeding (defined as being given no other food or drink for the first six months of life). These, in turn, can contribute to higher rates of child diarrheal and febrile illnesses (Guo et al., 2013), as well as having a negative effect on cognitive, motor, and socio-emotional child development indicators. According to Black et al. (2013), regardless of the fact that maternal mental health is considered a key factor for child growth, it is rarely taken into consideration in global health programming (Ruel & Alderman, 2013; Surkan, Kennedy, Hurley, & Black, 2011), highlighting the importance of integrating these factors into programming.
Description of the Baby Friendly Space programme
In order to improve mother and child survival and health and address the lack of support services, ACF developed the ‘Baby Friendly Space’ (BFS) model of intervention (ACF, 2014). Since 2006, ACF has implemented this kind of intervention in many different contexts, including Pakistan in 2006, Haiti in 2010, Myanmar in 2011, in Ethiopia (in Somaliland in 2011 and the Gambella in 2014), the Philippines in 2013, Nepal in 2014, Chad in 2014, Cameroon in 2014, and in the Central African Republic and Bangladesh up to the present day. These BFSs aim to enhance the health status and wellbeing of mothers and children less than two years of age. They also seek to reduce morbidity for both women and children by providing comprehensive support, which integrates various evidence-based activities, including breastfeeding and feeding practices, counselling, maternal psychosocial support, group discussions on parenting skills, play sessions and child stimulation. Admission criteria included pregnant women (admitted as soon as they knew about their pregnancy), lactating mothers and children aged less than two. The exit criteria, except for dropout and death, were due to the age of the child. However, despite former and current BFS programmes, there is little evidence of the impact of such interventions because of a lack of assessment so far. Notwithstanding, relevant changes have been observed in breastfeeding practices in a BFS in Haiti (Ayoya et al., 2013). This field report therefore aims to highlight the impact of the BSF approach on pregnant and lactating women and young children through a practical case study where it has been possible to measure the results of the psychosocial intervention. It refers to the ACF experience in Cameroon, covering a period of eighteen months, from October 2014 to April 2016.
| The Case Study in Cameroon|| |
Safe spaces were built in three refugee camps in East Cameroon. These spaces were small shelters of 6 m2 each, with a separate space for individual consultation and a special area for group activities. These shelters were located close to the women shelters, in strategic points inside the refugee camps, to make their access easier.
Activities were focused on strengthening/enhancing parental skills, psychomotor development for babies and emotional wellbeing for both women and babies and were planned weekly. This planning remained flexible in order to adapt according to the evolution of the context, caregivers’ availability, attendance and observed needs. The aim was not only to guarantee a framework for the teams but also to give an overall view of the activities suggested to the participants, providing the opportunity to decide whether to participate or not. This is very important in emergency situations as women frequently lack time to dedicate to themselves or to their children. Additionally, providing a clear structure is essential, especially in the first phase of the emergency, when the environment is chaotic and can be difficult to understand.
Main activities suggested included care for women during pregnancy and after delivery, breastfeeding counselling, counselling on complementary feeding, baby massage, mother and child play sessions, relaxation exercises, psychosocial support, group discussion around child care practices, home visits and community awareness activities.
The BFS’s team was composed of Cameroonian trained professionals, paraprofessionals, psychologists and psychosocial workers. An expatriate psychologist, specialised in early child development and child feeding, ran the programme and supervised the team. This ensured both close guidance and support but also continual training. A system of referral was also set up through networking and partnerships with other agencies to assess the coverage level of the population’s needs and to improve coordination to increase services.
Methods and measures
Different indicators were used to evaluate the impact of the intervention, improvement in childcare practices and psychological wellbeing. The level of psychological distress and perceived social support were evaluated for both pregnant and lactating women. The quality of interactions and difficulties in breastfeeding were also assessed for mothers and their infants. These indicators were measured initially when the participants joined the programme and again when they left the programme.
To measure psychological distress and perceived social support, a self-reporting scale from 0 to 10 points was administered. The ‘suffering scale’ [Figure 1] and ‘social support scale’ [Figure 2] were designed using pictograms to facilitate understanding and obtain a more accurate estimation of the degree of suffering and perceived social support.
Seven BFS were built in three refugee camps in East Cameroon (Timangolo, Lolo and M’bilé), with 3345 pregnant or lactating women (PLW) and their infants participating. Data were collected from 1022 participants (203 pregnant women, 819 lactating women and 819 infants). The age of participants is shown in [Table 1]. During the programme, 150 PLW were less than 18 years of age, with 27.6% of PLW admitted into the programme for their first child.
On their admission to the programme, both pregnant and lactating women were welcomed by a psychosocial worker and participated in a clinical evaluation of their psychological status to provide tailored support through the psychosocial sessions.
The quality of mother and baby interactions were assessed using an observation grid, developed by ACF in the ‘Manual for the integration of childcare practices and mental health into nutrition programmes’ (ACF, 2013) focusing on mother and child cross-modal behaviours: vocal, touch and visual. The maximum score is 76. A higher score indicates a healthier relationship.
The quality of breastfeeding was checked through the B.R.E.A.S.T. observation form (Armstrong, 1990). This tool is composed of 53 items, corresponding to indicators showing that breastfeeding is going well and others depicting potential difficulties. The assessment of difficulties in breastfeeding enables the team to gather important information to provide appropriate counselling to the mother. It is expected that the negative indicators would decrease after psychosocial intervention and increased support to the mother.
| Results|| |
‘I am very comfortable in the BFS and very well received. The advice I received is very useful for practice and so the baby is different from other babies of the same age. My husband supports me a lot. We are both very happy and thank you very much.’ (25-year-old mother of two young children, one admitted into the programme after birth where the baby received exclusive breastfeeding for six months)
Weekly sessions of analysis of practice, as well as a workshop organised at the end of the project by the team, allowed a qualitative glimpse of the impact of BFSs, as described in the programme final report (ACF, 2016). 1552 support groups were animated as spaces of exchange of practice and experiences, where the women shared difficulties and sometimes solutions. By sharing these different elements, the women realised that they were not alone in encountering problems or feeling apprehensions and anxieties, but that they were widely shared among them. This had a reassuring function, and moreover through support and mutual encouragement, the women supported in this way found a new network of social support.
The theme of pregnancy was complex to address at first, as traditionally it is not a subject of discussion or exchange; conception and pregnancy belong to a more intimate sphere. However, women gradually got used to exchanges around this theme and were enabled to share emotions and personal difficulties, thus relieving their isolation.
Primiparous women (i.e. women who are pregnant for the first time or have only given birth once before) often had the most difficulties in speaking, because conventionally it is the oldest women who would lead a discussion. Two strategies were adopted to cope with this: the first consisted of temporarily separating the primiparous group of women to stimulate an exchange between them, before joining the rest of the group. Second, the more experienced women were requested to encourage the youngest to express themselves.
2061 workshop sessions were conducted on the following themes:
- Appropriate breastfeeding practices such as positioning the baby, attachment to the breast, attention to the baby and techniques to cope with breastfeeding problems.
- Stimulation methods for young children, adapted to the stage of development of the baby.
- Bath massage, making it possible to work on the practice of hygiene.
The women were able to see concrete and immediate results of the practices implemented: a clean smelling and relaxed baby, who falls asleep during a massage, or a baby who laughs and interacts with his mother during a play session. The massage also proved to be a privileged moment between the child and the mother, a moment of skin-to-skin sharing, the reciprocal knowledge between the two elements of the dyad, muscular and emotional relaxation and, therefore, the wellbeing of the child. The successful learning of an adapted practice, coupled with the positive emotions that resulted from it (e.g., satisfaction, pride, joy, etc.), facilitated the reproduction of home behaviour.
As the project progressed, the workshops were given new impetus: the psychosocial workers, under the guidance of the psychologists, started to animate sessions with a therapeutic objective. The gradual implementation of therapeutic mediation activities found a very positive echo among refugee women because of the originality of the activities such as making traditional toys, creating dolls, decorative brooms, storytelling workshops, producing a group fresco, etc. The women were very enthusiastic and actively participated, which recreated a social bond.
Personalised psychosocial support took many forms, both individual and group. Women were offered individual support for serious milk expression problems, mother–child relational dysfunction, abandonment or neglect of young children, failure to meet nutritional standards for their children, anxiety and depressive disorders, perinatal distress and/or pathological grief. In addition to this, specific support was initiated after observing symptoms such as sleep disorders, somatic complaints, isolation and appetite disorders.
For all pregnant women, a tailored and systematic follow-up allowed them to be accompanied and supported to return to BFS after delivery. For many of them, it was a question of rebuilding the link to the health centre they had left behind, due to conditions in the hospital of long waits and male doctors. Pregnant women were sensitised on perinatality in terms of physical changes, mood changes, risks related to unhealthy diet and workload, the importance of prenatal consultations and the early mother–child relationship from conception. The follow-up also focused on deconstruction of any anxiety related to the birth of a ‘big baby’ that caused some pregnant women to starve themselves. At the end of the follow-up, women often saw a change in their relationship to ‘the child of exile’, born after migration in a country that was not theirs. This is a different child, a child of renewal and bearer of hope.
For lactating women, the psychosocial support focused on strengthening the mother–child relationship, restoring family links and managing the psychoemotional stressors that influence good lactation. The team observed a steady improvement in breastfeeding practices and decreased complaints of milk deficiency.
Specific counselling was also implemented about the perception of control of events that affect people’s lives. Indeed, within the culture of Central African refugees who had migrated to Cameroon, life events are often attributed to external causes which people do not think they have any control over. For example, persistent illnesses, psychic disorders and even chronic malnutrition will be attributed frequently to mystical causes such as bewitchment, bad luck or the will of God.
The work of re-focussing the locus of control from external to internal gave women the feeling of control over external events and enabled them to re-mobilise appropriate health behaviours and the use of health services. Among women attending BFSs, there was a clear shift in the causal explanation of disease, including malnutrition. It was less often attributed to external causes beyond their control but now possible to counteract through prevention and adequate care.
Since the opening of BFSs, there has been a significant increase in the participation and arrival of new participants in different groups. Women were certain to find an ear to listen to their needs, opportunities for mediation and advocacy and support in referral to other partners, including health services. Thanks to the availability and benevolence of psychosocial workers, a relationship of trust with women was developed. This made it possible to lessen the very present fears concerning referral to health centres for medical issues, for pregnancy monitoring and for the child growth monitoring. Births at the health centre increased significantly.
[Figure 3] shows the main psychological symptoms expressed by pregnant and lactating women on the first day of the programme. Women and their infants came to BFS for a period of (maximum) six months (M 6.35, SD 4.61) and during this period they participated in psychosocial activities 11.9 times on average (minimum once, maximum 52 times). [Table 2] and [Table 3], show how women improved their wellbeing, reduced their psychosocial suffering (pregnant women t = 9.43, p = 0.000; lactating women t = 23.37, p = 0.000) and increased perceived social support (pregnant women t = −7.41, p = 0.000; lactation women t = −16.11, p = 0.000). Mothers and their infants improved interactions and, consequently, relationships (t = −32.24, p = 0.000). Lactating women reduced their difficulties with breastfeeding practices (t = 37.23, p = 0.000). The Pearson correlation between these variables and the length of time spent in the programme show a positive correlation − in particular, the reduction of psychosocial suffering (r = 0.213, p < 0.01) and the improvement of mother and child relationships (r = 0.299, p < 0.01). Even improved social support can be correlated with the length of time spent in the programme (r = 0.074, p < 0.05), as well as a reduction in signs of difficulties with breastfeeding practices (r = 0.079, p < 0.05).
|Figure 3 Clinical evaluation of pregnant and lactating women on admission to the programme|
Click here to view
| Discussion|| |
BFSs aimed to support pregnant and lactating women and their infants in refugee camps through provision of psychosocial support and reinforcing parenting skills. These spaces were well accepted by the community and easily identified as ‘safe places’ where women could feel protected and dedicate moments to themselves and to their children. This physical and psychic space allowed them to rest from extremely heavy daily tasks and from difficult conditions due to a new life in a foreign country.
The activities focused on child stimulation helped mothers to improve their knowledge of child development and to acquire better recognition of signs of distress expressed by the child. They also learned how to encourage the child to explore their environment and to develop new abilities according to their developmental stage. Even in breastfeeding practices, mothers showed fewer difficulties after counselling and support by the psychosocial team.
The most significant improvements assessed were mother–child interactions and breastfeeding practices. Although psychological wellbeing and perceived social support also showed significant improvements after the intervention, the degree of this improvement was lower. This may be due to the fact that, at the time of admission into the BFS programme, the level of psychological suffering was not extremely high and the level of perceived social support was quite good. This can be attributed to the fact that the programme had been implemented some months after the arrival of refugees and, therefore, they had time to go through their grief process and to create links with new neighbours. This may have reduced the level of emotional suffering induced by their new living conditions, their traumatic journey and the memories of traumatic experiences from their country of origin. Moreover, the level of perception of social support was already rated high at the beginning of the intervention. This may indicate the presence of social support based on specific cultural determinants where in distressing situations, people support each other and can rely on others that have the same cultural background or shared experiences.
| Limitations and challenges|| |
Despite the fact that this form of intervention has been used in the field for over a decade, this article shows some of the first data collected. Data collecting remains a real challenge in the humanitarian field, because its accuracy can be affected by several factors such as the professional background of the team, logistic difficulties with security and access, data storage, etc. In this programme, we were able to collect precise data for only one third of participants. These data measure the impact based on pre- and post-intervention evaluations, but there is no comparison with a control group. Future programmes should improve the monitoring and evaluation measures to provide more evidence on the efficacy of this kind of intervention.
| Conclusion|| |
The psychosocial model of BFSs addresses maternal mental health, as well as childcare practices and early child development. Pregnant women, mothers and their babies showed a real improvement in parent–child bonding and psychosocial wellbeing. The improvement of mothers’ mental health and psychic and physical availability to their infants, as well as improvement in childcare skills, suggests that they will be more capable of responding to their own needs and, consequently, to the specific needs of their infants. These results are encouraging and seem to highlight the accuracy of this multi-sectoral approach in an emergency context, focused on providing a stable and protective environment that can promote children’s health and nutritional needs, as well as children’s emotional support and stimulation.
Financial support and sponsorship
The BFSs in Cameroon were funded by UNICEF and UNHCR.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]