The experiences of pregnant and lactating women during the earthquake emergency in Abruzzo: ten years later, what have we learned?


 Background

Emergencies have a great impact on infant and young child feeding. Although the evidence, the recommended feeding practices are still not implemented in the emergency response, undermining infant and maternal health. The aim of this study was to explore the experiences of pregnant and lactating women during the earthquake emergency that occurred in L’Aquila on April 6, 2009.
Methods

The study design was qualitative descriptive. Data were collected by individual semi-structured interviews, investigating the mother’s experiences of pregnancy, childbirth, breastfeeding, infant formula or complementary feeding during the emergency and the post emergency phase. Data analysis was categorical and was performed by using N-Vivo software.
Results

Six women who were pregnant at the time of the earthquake were interviewed in January 2010. In addition to the essential needs of pregnant and lactating women, such as those related to the emergency shelters conditions, the main findings emerged from this study were: the reconfiguration of relationships and the central role of partners and family support; the need of spaces for sharing experiences and practices with other mothers; the lack of breastfeeding support after the hospital discharge; the inappropriate donations and distribution of Breast Milk Substitutes.
Conclusions

During and after L’Aquila earthquake, several aspects of infant and young child feeding did not comply with standard practices and recommendations. The response system appeared not always able to address the specific needs of pregnant and lactating women. It is urgent to develop management plans, policies and procedures and provide communication, sensitization, and training on infant and young child feeding at all levels and sectors of the emergency response.

This study was conducted after the earthquake that struck L'Aquila and the surrounding areas in 2009. In its primary intention, the research was designed to inform local action on mothers and infants' care. Given the limited availability of studies exploring the emergency responses from the mothers' perspective (22), and the ongoing obstacles and challenges affecting IYCF-E worldwide (e.g. untargeted donations of BMS, uncoordinated infant feeding interventions, lack of programs and policies) (23)(24)(25), ten years later the authors decided to re-analyze the collected data with a focus on the recommended practices for breastfeeding protection, promotion and support. Therefore, the aim of this study was to explore women's experiences of pregnancy, childbirth, and infant feeding during and after L'Aquila earthquake emergency. Moreover, we examined how health care system and emergency response system were able to address their expressed needs.

Methods
The study design was qualitative descriptive, according to the COREQ checklist (26). The purposeful sampling included women who were pregnant and lived in the affected area at the time of the earthquake. The women were contacted through the health care services provided in the camps and the emergency network; all accepted to participate and gave their informed consent. The data collection was performed by individual semi-structured interview (30-60 minutes); this methodology was chosen due to the precariousness of housing and the geographical dispersion of women.
The interviews were conducted by a study researcher and included a general question on the mother's experience of pregnancy, childbirth, breastfeeding, infant formula or complementary feeding during the emergency and the post emergency phase. In-depth information was sought through probing, with regard to essential needs (e.g. housing, food, safety), everyday life and health care provision, exploring the areas of strength, the challenges and the current needs (Table 1). Table 1 Semi-structured interview questions.
What has been your maternity experience (pregnancy, childbirth and infant feeding) during the emergency? Probes: -What di culties did you encountered?
-What helped you in these situations? -How do you feel now? What are your current needs?
-What are your suggestions to improve the well-being of mothers, babies and families in emergency situation?
Each participant reported socio-demographic data on an anonymous, self-administered form. The interviews were conducted at the women's home or in their temporary accomodation, on their invitation. All the interviews were digitally audio-recorded and fully transcribed.
Data analysis was categorical: categories were developed both deductively, based on the research question, and inductively, based on emerging contents. The analysis was performed coding all the transcripts by using N-Vivo software.
The emerging women's need and care provided were classi ed in main themes, according to the Guidelines on Mental Health and Psychosocial Support in Emergency Settings (27), adapted to maternal and infant care (Fig. 2).

Results
Six women who were pregnant at the time of the earthquake (6 April 2009) were contacted in January 2010, 8-9 months after the emergency. They all lived in one of the municipalities of L'Aquila province; they were affected by the earthquake and were forced to leave their homes.
At the time of the interview, three women had returned to their homes, scarcely compromised by the earthquake, and declared safe. The others were still hosted in hotels, waiting for a more stable accommodation assignment. The babies had an age ranging from one to nine months of life.

Essential needs, basic services and security
Concerning the direct experience of the earthquake and the response to essential needs, the trauma and the fear of seismic shocks were common to all the interviews and constant over time, in the immediacy of the events and at the time of the interview: On the night of the earthquake we woke up with a big rumbling sound inside the house, the walls swaying ... my husband went to the children's room, took them and went out, I took the blanket from our bed and followed them. We were very scared." Some pregnant women have also reported that the safety of their fetus was the main concern at the time of the seismic event: "The earthquake was a trauma, everything was shaking and I was just thinking: I hope it will end soon! We rushed away immediately, me, my husband and my mother-in-law, who lives with us. It was terrible: half of the house collapsed. But the thing that scared me the most was to know if the baby was okay." Living in temporary housing was very hard for many women. Their accommodation initially consisted of makeshift housing (e.g. cars, caravans), then emergency camp tents. Only two of them moved away from the earthquake-stricken areas immediately after the earthquake, while the other four spent between one and three days in their car before moving into the tents, reporting a considerable discomfort.
"… then in the evening, at a certain time, we went to the farmyard […] with the car turned on all night. Well, it was quite a bit uncomfortable, because with my belly ... she [3-years-old daughter] was sleeping behind: we couldn't lay down all the seats. Anyway, at night, I had to get up four or ve times to pee, go out, and it was so cold in the yard! What could we do? And after four or ve days they came to set up the tents." In the weeks after the earthquake, the accommodation varied according to the availability, i.e. their homes (when considered safe), local hotels, dislocated hotels, or hosting by relatives. In some cases, a better accommodation option has been offered, but was declined, as it would have involved separating the family. The time spent in the tents was variable, from a few days to a month and a half. These temporary shelters caused considerable discomfort to the pregnant women, determined by the cold climate inside the tents and the impossibility to rest, especially in case of threat of preterm labour, and, above all, by the absence of dedicated or adequate toilets (poor hygiene, lack of privacy, location outside the tents): "And then the worst thing: the toilets. Staying in that space where everyone goes and so you can't even lean on, because obviously they were lthy. My husband had to hold my hands like that, because I couldn't stand it anymore. How many times did I hold back the pee to not wake him! Because it was raining outside… but I could not go alone. I think there was a need for a bathroom only for pregnant women." "I couldn't get in because I had such a big belly that I couldn't get into it." "I always had a sore throat, in short, always a little cold ... because it was cold, the tent was damp, the heating was not enough." During the rst days of emergency, in the temporary housing, the interviewees suffered deprivation of privacy and di culties related to living with many other people, sometimes strangers. In some areas pregnant women got private tents, and they highly appreciated it.
Because of the discomfort caused by the everyday life in the camps, some of the women and their partners took action to nd another accommodation that was suitable for their needs.
In general, the time taken by the institutions to allocate housing other than tents was not adequate to promptly meet women's need to reprogram the place of birth and nd an accommodation close to it.
Therefore, most couples tried to nd a solution that could meet at least two main needs: to keep the woman close to her partner, who had resumed work immediately after the earthquake, and to beclose enough to a maternity facility, safe from the seismic shocks. This resulted in repeated moving that, for some women, were added to other temporary moving determined by the hospital admission or other health care checks.
"So, in mid-May, they sent us to the hotel. But we moved twice. The rst to P. [a town where there were some hotels that had been made available for the earthquake victims], but I was a bit far from S. [the municipality of the hospital where the woman had decided to give birth]. So I asked for another hotel closer to S. […]." "In May I went to P. and I stayed there for a month. Then, from May to October [...] I was on the coast. In November I returned to L.. My husband bought a caravan, to stay closer to the hospital: I had to do medical checks and I wanted to give birth in L.." "So I went rst to my sister-in-law's house and then, at the end of May, I went to the coast. My husband was not always with me, he came and went. [...] My husband worked, so he settled in some friends' house [in the earthquake area] and I was on the coast with my mother-in-law. He used to come every now and then." They also needed a place and a space to conciliate the baby's and the siblings' needs, close to their families, where they could care for the newborn and other children at the same time.
After childbirth, the women who were forced to change the accommodation several times, expressed a strong need for stability and "return to normality". This referred to more stable place, next to their village, their house, their belongings, affection, relationships, social life and memories and the opportunity to return to work.
"Normality. Here we feel very ne, it's a lovely village, because I love it, I didn't expect it, we really feel good. But it's not your village, you do not have your home." "A stable place, from which we no longer have to move [...]. Something we can say, for now: -This is home! -. Because here we live with our suitcases, the suitcases must be enough for everything. Because you never know when you'll have to leave, you don't have all your stuff. My clothes are limited, all limited, all limited." Community, partner and family support During the emergency, the women experienced a noticeable recon guration of relations, characterized by a reduction in the time spent daily with their partner, and by an increase, in some cases, of relationships with other family members or forced cohabitation with people not belonging to the family. Being displaced far from their homes or villages, many of them suffered the absence of the belonging community and the consequent lack of support from their relatives and friends, especially after childbirth and for the care of the baby and the siblings.
Again, the separation from partners was reported as the greatest effort: "The hardest thing for me was being away from my husband. [...] Whatever could have happened, and he was not there: I was always alone. Of course, with my mother, my sister ... but not him! We haven't lived the experience together…" "We didn't have any deaths in the family, but we felt really alone: me on one side and my husband on the other. We used to cry so much by phone, I think the child has suffered, I was really sad!" "For a while he was with me (...) then he had to come back: he was traveling back and forth, returning on Friday or Saturday. But for me it was horrible, because ... alone with the two of them ... [the baby and the older sister]." For some women, the support from the family was signi cant, as was the relationship with their baby, which represented an important element of well-being: "Back at the hotel, my mother-in-law helped me a lot, she made me eat even if, often, I didn't want to. She said to me: "You have to try hard." And then I saw that the baby was ne. The pediatrician said: "He grows well, keep it up!" And so, I'm doing it this way ... I always keep him next to me, even at night… he stays with me and my husband, when he comes back ... I feel safer having him [the baby] next to me. Besides, I really like that baby smell..." On the other hand, a mother told how negative the social pressure focused on child care and breastfeeding was, in a moment of intense vulnerability and emotional shock in which she needed to focus on her own needs and resources: "He ... I had the refusal to breastfeed him, to take care of him, to hold him in my arms. Not because I didn't want, but because it was a burden to me. It was an extra burden. I couldn't even manage her… [eldest daughter] who, after all…. she eats by herself […]. I don't know, it was a bad thing, I didn't enjoy the baby as I should have. The milk? The people and even my mother-in-law [they said]: -No, you have to breastfeed, you have to force yourself, you have to believe in it, you have to do it. -That fact... that made me feel even guilty, do you understand? Okay, I didn't feel like doing it! For me it was easier to give him the bottle. Even at night, I couldn't even wake up. Although, fortunately, he always slept: he woke up to eat, I put him back to sleep and he slept. He woke up two or three times ... for me it was a burden... I couldn't do it ... Apart from sleep, I just refused it ... but then ... You know that breast milk is good, and so you had that contrast of thinking: -No, it's necessary! -…But I wanted to give him the bottle, even to try to make him sleep longer at night!" The women reported the feeling of having been abandoned by the institutions. They felt that the Municipality failed to address their housing needs: "It was bad (…) we went to the Mayor, but we had no answer. They still didn't handle the situation" "We received more from strangers than from ... you see… we felt a little abandoned, [..] we thought the Municipality would be closer to us." Furthermore, women had the perception that, in the post-emergency management, families with pregnant women, babies or young children were considered a burden: "We were a burden, because one who says to you -Don't make me think about it too, go to the coast! [the accommodation provided on the coast]-It means that you are a burden!" Mother-Infant focused, non-specialized support The rst aid personnel were reported with gratitude as being the "angels in uniform". The health and psychosocial professionals were a relevant presence for the psychological well-being of mothers, as well as the services aimed to family support (i.e. campus for children). Instead, the professional's turnover and the consequent loss of meaningful nodes within the emerging support network has been reported as highly frustrating. The meeting areas for mothers and children were considered useful, despite their discontinuous availability in the post-emergency. This was due both to the population's dispersion and to the staff turnover: "Perhaps, now that everyone will settle down… it would be nice and helpful for us: having a meeting point with other mothers." Several initiatives aimed to promote the psycho-social health of women and parents with young children were reported, as the implementation of dedicated spaces for older children. On the other side, the system failed in providing occasions for group support (peer-to-peer support, mutual aid, shared time, care or activities). Some women reported that it would have been useful to provide a baby-sitting service to support mothers in managing care and everyday life.

Specialized Maternal and Infant health care
For some women, the birth of their baby compensated for the lack of housing, relationships and social support. The positive experience of childbirth was more evident in those hospitals that provided a welcoming care to women and their partners, acknowledging their speci c needs related to the earthquake experience. In these cases the hospital was perceived as a safe, protected and clean place where women could take refuge after months of unsatis ed basic needs. During the hospitalization, some women felt, for the rst time since the earthquake, the feeling of being taken in charge together with their family.
Hospitality and emotional-psychological support provided by the healthcare personnel, together with the opportunity to share with other pregnant women and new mothers, have made childbirth a moment of reassurance and reconciliation.
In some cases, women reported the support they have received for the positioning and attachment of their babies to the breast after birth: "They attached him immediately [at my breast], more or less not even a couple of hours".
"Already in the hospital they made me attach him [at breast] often." Speci cally, a woman whose daughter was hospitalized a week after birth, told about the support she received in the hospital on breastfeeding: "They helped me, they helped me a lot, because I wasn't so skilled. [ On the other hand, two mothers were advised to use infant formula during the hospital stay and, in one case, a speci c brand was prescribed: The support to breastfeeding provided after discharge was insu cient both by local health services and emergency staff, with some variability related to speci c services or professionals. "The pediatrician has always been there. And even though she was also a victim of the earthquake, she was never absent in [name of the municipality], she works in several Municipalities ... The Health District almost immediately restarted its activity, in short, the doctor was there too, so let's say that it was ne, if we needed anything there was no problem." Infant's products, included infant formula, were actively distributed into the camps to pregnant and lactating women, even without a speci c clinic indication: "When [the relief workers] brought us all that stuff. It was really a godsend. For everything: infant formula, diapers (…), baby food, ointments that I still have, baby wipes… therefore, it was money saving." "I did not use much infant formula, I mean that we tried the different infant formula brands that they gave to me. I brought the surplus to the pediatrician, and she gave it to other babies, so I didn't waste anything. Jarred baby food too, I brought everything [to the pediatrician]: teats, bottles, paci ers… in short, I received a lot of things, but… how many paci ers do I need? How many bottles? And so I brought everything to the pediatrician." "There was a man, he took special care of us (…). And he brought me a lot of stuff, always from the [reference Agency of the area]: infant formula, stuffed toys, bottles, paci ers, everything, everything, everything! I didn't even know where to put it! We had to come and put it here in the garage! But, besides me, they went to the tents: they brought [these goods] to the other pregnant women too. So, I mean, for that [aspect] the care was great, immediate, they said -If you need something, come down and ask us." It appears, from mothers' narratives, that support and education on the correct use and reconstitution of BMS were not provided to the parents that had received donations of infant formula or undertaken for other reasons this type of feeding for their babies. The supplies of infant formula have not been granted throughout the emergency phase, especially when the infant formula prescribed by the pediatrician was not available in the donation stock. One mother that was discharged from hospital with her healthy newborn on ready-to-use infant formula, referred major supplying di culties, as it was not available in the local shops: "I'm going to [main town, distance 100 km] to buy it, because the shops that are here… despite the fact that they have it… given how much he [the baby] used to eat, I needed higher volumes, and they don't want to bring it to me." The two women who had interrupted breastfeeding were asked if anyone ever proposed them the relactation, but both answered negatively. Women reported di culties in feeding and caring for their baby. In some cases breastfeeding was perceived as a burden, and consequently interrupted and substituted with infant formula feeding; in others, infant formula was prescribed and this was perceived as frustrating by those mothers that would have otherwise preferred to breastfeed. One woman expressed a great unease in caring for her newborn and young child and a great sense of isolation, highlighting the lack of support services.

Discussion
Although the essential needs of pregnant and breastfeeding women are similar to those of the general population (food, shelter, water, basic healthcare, infection control, and safety), they have some speci city that must be taken into account when addressing an emergency. The available literature highlights how natural disasters impact psychologically on pregnant women, which can develop short and long term traumas, often resulting in increased levels of stress and anxiety (27,28). During the emergency, one of the main concerns of pregnant women, as con rmed by our study, is the safety and the well-being of their unborn baby (22,(29)(30)(31). Other main concerns are the challenges related to the loss of one's home, the displacement, and the move to other temporary housing solutions. In these situations, pregnant and lactating women face di culties that relate speci cally to their condition (30). The emergency shelters do not always guarantee spaces suitable for physical needs (dedicated toilets, warm environments) and the need for privacy and intimacy of women and families. All of this can lead to a further increase in psychological distress, as resulting also for the general population (32).
In addition to the physical environment, natural disasters deeply impact on relationships (33). Our study shows the strong need to protect meaningful relationships and social networks (partner, relatives, friends, neighborhood, and community). The social support plays a key role in traumatic and emergency situation to promote the well-being, quality of life, and resilience of the affected population (27,(33)(34)(35) and are considered a potential resource for relieving depression in pregnant women (36). Over the L'Aquila earthquake experience, family was an extremely important support system for emergency and postemergency everyday life, and women clearly expressed the need to be close to their partners. Therefore, emergency response has to support this social unit (33), as a mean to promote people's health and wellbeing, e.g. by designing emergency systems that allow parental nuclei to remain united (27).
This study also highlights the importance of offering services that encourage the encounter with other mothers and children, in peer groups. As reported by Sezgin & Punamäki (2016), peer and neighbor relations can represent a valid aid in sharing the disaster experience, as well as in the practical management of children. Moreover, providing opportunities for interaction between families could relieve the sense of isolation and mitigate the loss of the belonging community. On this concern, it could be opportune to identify and involve mother-to-mother breastfeeding support organizations, such as La Leche League (17).
One of our interviewees reported great di culties, highlighting the burden of taking care alone of her young children, the sense of inadequacy, and the perception of social pressure and judgment. In emergencies, traumatic experiences and challenges, included the separations from partners and relatives, add up to the new mother's post-partum peculiar di culties, increasing the risk of adverse mental health effects (37), such as postpartum depression and Post Traumatic Stress Disorder (38). As recommended by IASC guidelines (27), in the emergency response it is necessary to individuate people who require more focused psychosocial interventions.
As for specialized maternal and infant care, most of the women interviewed in this study reported a positive childbirth experience and the feeling of being welcomed by the maternity services. Greater obstacles emerged, instead, regarding infant feeding during the hospital stay. The hospital practices described by women (e.g. infant formula prescription in the absence of clinical indications, no rooming in, newborns fed on a schedule) were not in line with the recommended standards (12,17). Some women perceived that health personnel had adequately supported them during their hospital stay, especially in the very rst hours after birth. In this regard, more than one of them reported how the health personnel "attached the baby to the breast". This approach was widespread in Italy in the last decades, when "positioning a baby at the breast" was considered a professional competence, according to the educational programs available at that time (39). More recently, in light of the evolving evidence, a different paradigm has been proposed, considering the newborn and the mother's competencies and relationship as the core for breastfeeding success (40)(41)(42). In this vision, the mother-newborn dyad should be supported in "doing themselves", creating and protecting the surrounding environment for let them express their primitives re ections and skills without interferences (43).
Appropriate, evidence-based, and timely support of IYCF-E saves lives and protects child health and bene ts mothers and families (15,17). As stated by Gribble et al. (2019), in emergency conditions targeted support for the caregivers of both breastfed and formula fed infants is crucial for continuing breastfeeding despite the challenges or to access the resources needed to safe formula fed. In our study, breastfeeding support after discharge appeared to be insu cient or absent, despite standard healthcare was often available. Mothers' narratives revealed a lack of breastfeeding support, resulting, in some cases, in di cult experiences, inappropriate infant formula prescription, or early disruption of breastfeeding. In emergencies, infant formula should be limited to speci c conditions, including the mother's decision, following an individual assessment performed by skilled professionals. This has to consider other cultural appropriate strategies (e.g. relactation, wet nursing and use of donor human milk), and include continuous support and educational strategies for mothers and caregivers (17). When properly prescribed or used, infant formula should be provided for as long as the baby needs it (17); our study highlighted the importance of preserve, when possible, the type or brand previously used, to support the psychological continuity with pre-emergency life. Despite the recommendations (17,44), the mothers in our study did not receive education or demonstrations on formula safe use and reconstitution, nor information or proposals for relactation.
Among the factors that explain the lack of infant feeding support after the hospital discharge, in the aftermath of earthquake, several organizational di culties affected the healthcare provision at community as well as emergency response system level, e.g. the missed involvement of skilled professionals and experts in IYCF-E, mother-to-mother groups and peer support associations (17).
Dealing effectively with infant feeding in emergency means acting in preparedness. In order to guarantee an appropriate and timely support to mothers, families, infants and young children during the emergency response (17), it is critical to develop in ordinary time a structured and multisectoral planning involving IYCF support strategies (18) and to implement speci c professional training (15,17,23).
From this study emerged the theme of inappropriate donations during the emergency response. As happened in other contexts and emergencies (24), infant's products, infant formula and commercially produced complementary foods were actively and widely distributed to mothers and pregnant women after the earthquake, without any prior needs assessment. This lack of prevention or management of donations was in contrast with international recommendations (15,17,45). It was associated to a lack of awareness about the risks of this practice both by the mothers (that perceived it as part of an e cient care) and by the emergency volunteers, camp managers and operators. It cannot be excluded that, in some cases, uncontrolled distribution of infant products undermined recommended IYCF-E practices and breastfeeding continuation during L'Aquila earthquake emergency, although the extent of its impact was not quanti ed, as infant feeding variables are not included in the emergency monitoring or surveillance systems.
In the last decade several emergencies occurred in Italy, including earthquakes (Emilia-Romagna Region, Central Italy), oods, other disasters (Genoa Morandi bridge collapse), refugee and migration crisis (e.g. Balcanic route, Mediterranean Sea) and, in recent times, the COVID-19 pandemic. While the Civil Protection and the emergency systems at regional and local level (e.g. Red Cross, Non-Governmental Organizations [NGOs]) have signi cantly improved their response capacity (46), little or nothing has changed in regards to protection, promotion and support of IYCF-E. During the Covid-19 emergency the Italian National Institute of Health has received reports of Food Aids targeting pregnant women, mothers and babies containing infant formula as a standard provision.
Despite the attempts to raise the priority of IYCF-E into the agenda of emergency preparedness, including speci c communication and training for decision makers, health professionals, camp managers, NGOs volunteers and lay support personnel and other relevant stakeholders (47)(48)(49), there is a urgent need of a coordinated action targeting this population group.
Among the limitation of this study, the small sample size was due to the precarious conditions of the emergency context and the geographical dispersion and isolation of the mothers.

Conclusions
This descriptive study contributes to draw attention to the speci c needs of mothers, infant, and young children in emergencies. During and after L'Aquila earthquake, the response system appeared not always able to address the speci c needs of this population groups. These results con rm that, if breastfeeding protection, promotion and support practices are adequate in ordinary conditions, this appropriateness re ects in the whole emergency management. On the contrary, where obsolete practices, unsupported by scienti c evidence, prevails, this negatively impact IYCF-E. Donations of baby food, feeding equipment and BMS require a strict management at all levels of the emergency response and is a great issue, potentially undermining safety and health of infants and mothers. To meet mothers' and infant's needs in the emergencies it is urgent to develop management plans, policies and procedures and provide communication, sensitization, and training at all levels and sectors, to support IYCF-E. It is therefore vital acting in preparedness and ensuring the awareness of policy and decision-makers, and programmers.

Declarations
Ethics approval and consent to participate All participants were voluntary, they were informed of the purpose of the study and gave their written informed consent. According to the Italian legislation, there is no legal obligation regarding the evaluation of descriptive qualitative studies by an ethics committee. This obligation is envisaged only for experimental clinical studies (50,51).

Consent for publication
Not applicable.
Availability of data and materials Not applicable.