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BFS+: Process evaluation of an integrative health

approach for lactating women and their babies in humanitarian emergencies, Nguenyyiel refugee camp, Gambella, Ethiopia Key words: lactating woman, babies, breastfeeding, Baby Friendly Spaces, maternal mental health, emergencies, Ethiopia

Study rationale • During humanitarian emergencies, pregnant and lactating women experience heightened risk of maternal morbidity and mortality. The problem is even worse for infants and young children. Evidence from Low and Middle Income Countries shows that environmental stressors such as poverty and exposure to violence place children at a high risk for cognitive and psychological delays and general mental health disorders. • Approximately 30% of women in developing countries suffer from depression during pregnancy or following childbirth; these rates increase during emergencies. • A systematic review of maternal depression and child development in developing countries revealed that children of mothers with depression or symptoms of depression are found to have 1.5 times greater probability of being underweight or stunded. • Maternal depression has also been demonstrated to have a link with suboptimal rates of immunization, hospital visits, and exclusive breastfeeding; higher rates of diarrheal and fever related illnesses; and negatively affects cognitive, motor, and socio-emotional child development indicators. • Even though maternal mental health has been demonstrated as a key factor for child growth, this component is still too rarely taken into consideration in global health programming. • Although Baby Friendly Spaces (BFS) programs are implemented globally, there has been a lack of formal research to date to evidence their impact on the lives of the beneficiaries. Thus, it is necessary to conduct this research to evidence its effectiveness and strengthen program implementation.

Objective of the Research

© Léa Vollet for Aciton Against Hunger - Ethiopia 2017

• The study is conducted with the goal of evaluating the current effectiveness of an integrated health approach, as well as strengthening the implementation and acceptability of the Baby Friendly Spaces intervention programs delivered to lactating women and their babies in humanitarian emergencies.

Where we work • The fieldwork takes place in Nguenyyiel refugee camp in Gambella, Western Ethiopia. The camp currently hosts around 74,000 South Sudanese refugees who have fled conflict and hunger. About 88% of the refugees in the camp are women and children and 5% of the camp population constitutes under-two children. The physical and psychosocial wellbeing of arriving refugees are poor and the prevalence of malnutrition in the camp is alarmingly high (14.3% SENS survey 2018).

The methodology • We use mixed-methods triangulation design that draws on new data collection and analysis of routine monitoring data collected through a strengthened and streamlined system. We plan to recruit 248 respondents from three categories; Group 1: BFS completed, Group 2: BFS dropped out and Group 3: non-attendant groups of women.

What we do ? Literature review: all relevant documents, research evidences, and survey results will be reviewed as we analyse the results and write the findings of our research.

Qualitative in-depth interviews: are used to explore the uptake, acceptability and participation of women residing in Nguenyyiel refugee camps using the Baby Friendly Spaces program and to identify the perceived needs of mothers of young children (under age 2) in the BFS catchment area. The needs and experiences of staff delivering the BFS program will also be included in this research. Prospective quantitative survey: we want to assess whether and how participation in BFS activities is associated with improved maternal (mental health, breastfeeding practices, mother-child interactions) and child (morbidity and growth) outcomes. More specifically, we want to understand: a) what the overall pattern of health and well-being is among women, and b) how these outcomes vary by participation in activities and/or participant characteristics (demographics, baseline problems, etc.). Dissemination and training: at local level, female stakeholders are involved in the project and their contributive role will facilitate the uptake of the findings. Participants in the research receive detailed information on research goals, process, and findings shared through local leaders and community groups. At international level, Action Against Hunger will disseminate the results through scientific articles and non-technical policy briefs. This is Bubble Chart Timeline aimed at a wider humanitarian audience including presenting the findings at relevant global, regional, and national working groups (Child protection working group, health cluster, IASC MHPSS working group, Infant Feeding in Emergencies Group) and conferences.

Timeline Start grants


Trainings Preparation

dec 17

mar 18

IRBs' approval





apr 18

may 18

Data analysis

sep 18

oct 18

oct 18

jan 19

mar 19

may 19

Contacts Collaboration/ Consortium For the successful implementation of the BFS+ research project, Action Against Hunger is working in collaboration with John Hopkins University (USA), Jimma University, ARRA, and UNHCR (Ethiopia).

Reference/ important links South Sudan Situation / Refugee population in Gambella region GambellaEthiopiaasof31January2018.pdf ACF Policy on Mental Health and Child Care Practices ACF-International_ Manual of Baby Friendly Spaces

Karine Le Roch: MHCP Research project coordinator, AAH HQ France. Sarah M. Murray, PhD, MSPH: Assistant Professor, Johns Hopkins University (USA).

Molly Lasater, PhD, MPH. Johns Hopkins University (USA). Getachew Mekonen: BFS+ Research Project Manager, AAH Ethiopia.

Andy Solomon-Osborne: Head of MHCP department, AAH Ethiopia. Endale Dlasso: Deputy Head of MHCP department, AAH Ethiopia.