Abstract

Background

To explore the breastfeeding status of mothers with children aged 0鈥�2听years after the major earthquake disaster in Kahramanmara艧, to reveal the obstacles to the sustainability of breastfeeding, and to reveal the problems and experiences they have in breastfeeding, preparing formula, and feeding their infants.

Methods

This study used a qualitative, exploratory research design with a phenomenological approach. Data were collected between September and November 2023 by face-to-face interviews using a Personal Information Form and a semi-structured interview form. A total of 21 participants who breastfed their babies before the earthquake and experienced the earthquake were included in the study, which was conducted using purposive sampling technique. Data were methodologically analysed using inductive coding and thematic analysis procedures. Max Qualitative Data Analysis Analytics Pro2020 software was used to code data.

Results

The results revealed four primary themes and twenty-two subcategories. The four main themes were; (i) Expectations from Health Personnel, (ii) Suggestions of Mothers, (iii) Difficulties Experienced and (iv) Experiences in Breastfeeding and Infant Feeding.

Conclusion

The results obtained in this study showed that mothers had problems in terms of information, support, equipment, appropriate area, and food supply related to infant feeding especially in the early post-disaster period. Insights into mothers鈥� perspectives can help healthcare professionals understand the challenges faced by mothers during disasters and emergencies. In this way, nurses can take the lead in implementing programs designed to support continued breastfeeding and appropriate nutrition for children during disasters.

Introduction

Nutritional characteristics of the infant, especially in the first two years of life, determine the health of the individual in childhood and adulthood [1]. Breast milk is the optimal nourishment for infants as it contains bioactive components that protect against infections, promotes growth and development, lowers rates of illness and death, is cost-effective, and offers numerous other benefits [2,3,4]. The World Health Organisation (WHO) advises are to initiate breastfeeding immediately after birth for 60听min and that infants should be exclusively breastfed for the first six months, with no other food or liquids, including water, introduced during this period [5]. From the sixth month onwards, additional nutrients can be introduced alongside breastfeeding, and breastfeeding should continue until the child reaches two years of age and beyond [6]. Reduction or discontinuation of breastfeeding is linked to an increased risk of infant sickness, such as acute infections, chronic disorders, and infant death. Whereas, breast milk consumption promotes healthy growth and development, including cognitive and neurological development, which increases social production [3, 6, 7].

Global evidence emphasises that the protective effect of breastfeeding on infant health in natural disaster situations is particularly important [8, 9]. Due to its ability to tailor its composition to fulfil the specific nutritional requirements of infants and offer enhanced protection against infection-related agents, breastfeeding is especially crucial during emergency situations [8, 10]. In this regard, national and international organisations recommend that care be taken to protect, encourage and promote breastfeeding of infants [11,12,13,14]. At the same time, they emphasise the necessity of providing counselling support to mothers in emergency and disaster situations due to the fact that breastfeeding is hygienic, healthy content, free of charge, constantly available and effective in reducing the psychological effects of such processes [7, 15, 16].

On February 6, 2023, a series of catastrophic earthquakes have struck southeastern T眉rkiye, with the epicentre located in Kahramanmara艧 and affecting a total of 11 provinces. It is stated that newborn and infant mortality rates rise significantly during disasters and emergencies [17, 18]. Infants are a vulnerable population, especially in emergencies; therefore, it is vital to ensure compliance with recommended infant and young child feeding practices. When the literature is analysed, it is emphasised that as a result of the disaster, it may not be possible to prepare infant formula safely due to insufficient access to clean drinking water and lack of training and materials in this field, and this situation may pose significant risks for the health of infants [8, 19, 20].

Developing comprehensive management plans, policies, and procedures is crucial to effectively support infant feeding during emergency reaction scenarios, such as earthquakes. These measures are necessary to satisfy the specific needs of both mothers and infants, and to promote effective communication, awareness, and education across all levels and sectors [15, 21]. Therefore, the studies to be carried out on the subject have a strategic importance in terms of being prepared for the current situation and raising awareness of policy and decision makers. Although the importance of maintaining breastfeeding and infant feeding in disaster situations is emphasised in guidelines and studies [11,12,13,14,15, 19, 21], there are a limited number of studies in the literature with mothers who experience this situation [7, 8, 10, 20]. In the literature, systematic review addressing country policies on the subject and analysis of newspapers and documentaries on this subject have been made. Unlike the studies in the literature, our study addressed the mothers' individual and cultural contexts and their experiences during the earthquake process using a qualitative research methodology. The experiences, needs and difficulties experienced by mothers during this process were addressed by creating themes in our article. Most of the themes and categories (sustainability of breastfeeding, obstacles to this, mothers' food preparation needs during this process, use of formula, food preparation material needs, supplementary feeding process and provision of nutrients, diarrhea and allergy seen in children) are different from the limited studies in the literature. Unlike other studies in the literature, the experiences of mothers of babies in the 0鈥�24-month lactation period were taken. The aim of this study is to determine the experiences of mothers with children aged 0鈥�2 who experienced the major earthquake disaster in Kahramanmara艧 regarding breastfeeding and infant feeding, to create data for health professionals in providing early intervention in similar situations by making inferences from the infant feeding experiences and needs, to examine the sustainability of breastfeeding in case of disaster and to reveal the obstacles to the sustainability of breastfeeding, and contribute to the field of breastfeeding and infant feeding in the national disaster prevention and response action plan.

Methods

Design

The study used a phenomenological design to analyse the experiences of breastfeeding mothers before and after the earthquake through in-depth interviews. Phenomenology is a methodology that evaluates experiences and reveals meanings and perceptions of phenomena, presenting the phenomenon as an accessible and recognisable human experience [22].

Sample

The study data was collected from mothers with infants aged 0鈥�2听years who experienced an earthquake in a container city in Kahramanmara艧 between September and November 2023. Kahramanmara艧 is a city located in the southeast of Turkey. The 2023 earthquake centered in Kahramanmara艧 and is one of the cities most affected by the earthquake. The population of the study group consisted of all mothers living in the relevant container city (N: 38), and the sample consisted of earthquake survivor mothers who experienced the moment and aftermath of the earthquake in accordance with the inclusion criteria (n: 21).

The purposive sampling method was used to gather the sampling that is 鈥渕others who breastfed their babies in the pre-earthquake period or continued breastfeeding with complementary feeding鈥�. Purposive sampling allows in-depth research to be carried out by selecting cases where more information can be obtained in parallel with the purpose of the study [23]. Criterion sampling is based on the study of situations meeting the criteria determined by the researcher [24].

Within the scope of this study, semi-structured, open-ended interviews were conducted with 21 mothers and data collection process was stopped after reaching data saturation. Inclusion criteria: Being 19听years of age or older, volunteering to participate in the study, being literate, having experienced the earthquake that took place in February 2023 in Kahramanmara艧, mother and baby living in the same environment, living in a tent/container, and having no physiological and psychological barriers to communication. Exclusion criteria; Mothers who had to live separately from their babies for a while after the earthquake, who had a condition that prevented them from continuing the care of the baby, who had special health problems, who had more than one infant (twins, triplets, etc.).

Qualitative data collection

Data were collected through face-to-face in-depth interviews using a semi-structured interview form in order to reveal the experiences, perceptions, opinions, feelings, and thoughts of the participants. The interviews lasted between 45鈥�60听min on average.

In the study, a form consisting of two parts was used by the researchers. The first section included 21 questions about the sociodemographic characteristics of mothers and infants. A semi-structured interview form consisting of a total of 11 questions was utilised. The draft semi-structured interview form was prepared in line with the literature and the experiences of the researchers [12, 14, 19, 25]. The opinions of experts in the field (5 people who are experts in the field and qualitative data experts working in the Department of Pediatric Nursing, Midwifery, Child Health and Diseases Specialist, Nutrition and Dietetics Specialist) were taken and the final version was given after the necessary arrangements. Final version of the semi-structured interview form is provided in Table S1.

Audio and video recording

In qualitative research, qualitative data collection techniques such as observation, interview, document, and discourse analysis are generally used. In addition, this type of research is based on in-depth analyses of human perceptions and events in social reality and natural environment [26]. In qualitative research, data collection process can be in the form of writing the conversations during face-to-face interviews, or it can be transcribed later by creating audio-visual materials that strengthen data such as audio and video recordings, and the analysis process can be completed with videography (video analysis) [27]. The qualitative interviews were recorded in both audio and video formats to enhance the validity of the study and facilitate thematic analysis.

Measurements

Firstly, a pilot interview was conducted to determine the comprehensibility of the semi-structured questions. The pilot and all other interviews were conducted by two researchers (PhD, ST ve SY脟) who are experts in the field of paediatric nursing. It was checked whether there were any obstacles that prevented the mother from understanding the questions in the form and giving clear answers, the answering time was measured and her opinion was obtained about the general comprehensibility and usefulness of the form. The pilot interview was conducted with two mothers and was not included in data analysis. The pilot study and subsequent interviews were conducted by sitting at the same level and guided by active listening through questionnaire forms. The interviews were conducted by ST while SY脟 observed the interviews and took audio and video recordings. N脟, ST, and 脰KS transcribed the audio recordings after the interview and provided appropriate documentation for the analysis.

Ethical considerations

This research was approved by Sakarya University Non-Interventional Research Ethics Committee (Date: 28.07.2023 and Number: E-71522473鈥�050.01.04鈥�267880-234). The rationale of the study and the purpose for which the results would be used were explained to the mothers participating in the study. All participants were informed and verbal informed consent from the participants themselves were assured before data collection. No individual identifying information was collected to protect participants. This study was conducted according to the Declaration of Helsinki.

Data analysis

In this research report, the Consolidated Criteria for Reporting Qualitative Research guidelines were used for guidance [28]. The study data were evaluated with the support of IBM SPSS Statistics 23 and Max Qualitative Data Analysis (MAXQDA) Analytics Pro2020 programs. The participants' descriptive features were examined using frequency n (%) for categorical variables. The qualitative component of the study included thematic analysis to assess mothers' experiences about nursing and infant nutrition following the earthquake. Data analysis is an essential phase in qualitative research, involving the identification and classification of occurrences, along with the clarification of links between ideas [26]. Following the first speech recording, coding commenced and was reiterated with expert input, leading to a consensus, after which the thematic analysis process. Thematic analysis was conducted according to Braun and Clarke (2006) to identify, analyze and report themes in data [29]. Data was analyzed in four stages: (1) Coding data, (2) Finding the codes, categories and themes, (3) Organizing and defining data according to the codes and themes, (4) Interpreting the findings and creating recommendations for the breastfeeding and infant nutrition area of 鈥嬧�媡he national disaster prevention and intervention action plan to be prepared according to the analysis results of the views of the earthquake victim mothers. All recorded focus group interviews were transcribed verbatim after their completion by one researcher (脰KS). The analysis was an iterative and non-linear process whereby the research team (N脟, 脰KS, SY脟, ST) moved back and forth between steps in analysis to refine data. During the coding process of the data, open and complete coding was done by two independent researchers. Data were inductively coded, line by line, independently by the research team. In order to increase the consistency between the codes, regular comparisons were made between the coders. During all phases of the analysis, codes and themes were discussed by the research team until consensus was reached. Consensus was reached on the codes. The researchers generated initial codes on relevance to the phenomenon of interest which were sorted into potential themes. The constant comparison method was used to verify the consistency of the themes with the data. In the coding and theme creation process, original quotes obtained from the participants were used and participant verification (member checking) was done to prevent meaning shifts. Thereafter, themes were reviewed by the research team, some themes were excluded, while others were combined or split into separate themes.

The MAXQDA software facilitates the comparison of extensive sample data, the aggregation of codes under certain themes, the rapid repetition of operations as needed, the continuous access to findings, and the organization and presentation of acquired data in models, graphs, or reports. First, the MAXQDA program was used to code data. By merging the codes that were categorized into subcategories and related categories, relationships between the underlying concepts were discovered and themes were created. Following the program's classification of the codes, the researchers identified, analyzed, and reported on pertinent themes. The survey numbers of the participants (P1, P2, P3, etc.) were used to code data.

Reflexivity

The researchers employed reflexivity throughout the study. In qualitative research, reflexivity is important for the researcher to manage their influence as a data collection tool [30]. Throughout the process, the researchers were transparent with the participants about their careers as nurses. The interviewers recorded their experiences and feelings in a journal to avoid insider bias and unintentional manipulation or influence of the study鈥檚 results. This helped them approach subsequent interviews with greater reflexivity.

Trustworthiness

To ensure consistency and to avoid potential problems arising from differences in interviewer role, all interviews were conducted by the same researchers (ST and SY脟). The researchers have a PhD degree in pediatric nursing and have conducted studies with qualitative research methodology. In addition, ST, one of the researchers, resides in Kahramanmara艧 province, knows the internal dynamics of the region, experienced the earthquake and took part in the post-earthquake processes. For this study, the strategies suggested by Lincoln and Guba (2011) for trustworthiness were used [31]. These strategies are credibility, consistency, confirmability and transferability. To ensure research ethics, the researchers obtained verbal and informed consent from the participants before each interview. Participants were also informed about confidentiality, anonymity and the opportunity to withdraw from the study at any stage. To increase the reliability of data, participants were not addressed by name during the interviews.

Validity, reliability, and rigor: For the reliability of this study, the components of qualitative rigor, namely credibility, transferability, dependability, and confirmability were considered [32].

Credibility: The interview transcripts were transcribed separately. An online meeting was organized for the interview recordings and similarities/differences were evaluated. To ensure the credibility of the study, data were translated from Turkish to English by a team of translators independent of the research. The Turkish and English texts were compared and the study was finalized.

Transferability: Demographic characteristics of families and children are given. This gives readers the opportunity to assess whether the study is applicable to their own studies or populations.

Dependability: Expert opinion was obtained about the interview questions and their content. A pre-application was conducted to ensure reliability. Due to the nature of qualitative research, the sample size is completed when data reaches saturation. To examine the saturation of data, attention was paid to code and meaning saturation [33]. Code development and iterative evaluation of codes continued separately for each interview until all 21 interviews were reviewed and code documents were completed.

Confirmability: At the end of each interview, a summary was given to each mother and her confirmation was awaited. The reader needs to be able to analyze data to confirm that the results or author interpretations accurately represent data. Written documentation, code files and data collection tools were all documented and recorded for this reason.

Results

Sociodemographic characteristics

Table 1 presents the sociodemographic data of mothers and infants in detail. Of the mothers; mean age was 30.28鈥壜扁��5.49听years, 66.7% are high school graduates, all are unemployed, 85.7% have a nuclear family type, 57.1% have two or more children, and 71.4 have had a cesarean section. The mean age of the infants was 13.42鈥壜扁��5.18听months and the mean birth weight was 3080.95鈥壜扁��256.64听g. 66.7% of the mothers were secondary school graduates, 100% were housewives, 38.1% had low income, 85.7% had nuclear family structure and 57.1% had 2 or more children. 71.4% of the infants were delivered by caesarean section, 66.7% had a gestational week of 39 and above and 52.4% of the mothers held their babies immediately after birth.

Table听1 The mothers鈥� and infants鈥� demographic information (n鈥�=鈥�21)

Themes and sub-themes

In the analysis of data, inductive coding was followed methodologically. As a result of coding, four themes and 22 codes related to the experiences of mothers in the sustainability of breastfeeding and infant feeding in the earthquake region are provide in Fig.听1.

Fig.听1

Themes and codes representation

Main theme 1. Expectations from health personnel

The theme of expectations from health personnel includes three categories: (1) information/guidance: Participants expressed that they wanted more support in the post-earthquake period, that guidance was lacking, and that information on infant care and nutrition should be provided; (2) psychological support: Mothers stated that they felt bad when they could not breastfeed their babies, that their milk decreased after this feeling, that they could not get enough support, and that they needed psychological support in their current situation; (3) health check of infants: The need for regular examination of infants with condition-related health problems was emphasized (Table听2).

Table听2 Themes, codes and mothers' statements

Main theme 2. Mothers' suggestions

The theme of mothers' suggestions includes six categories. These categories include (1) having a distribution plan for infant nutrition products: Mothers emphasized the need to distribute infant care products in a way that is accessible to all infants and appropriate to their needs. In addition, health staff identified a list of infants in tents and made suggestions to facilitate distribution. They expressed the importance of distributing formula according to the age/month of the babies; (2) insisting on breastfeeding the infant: mothers should insist on breastfeeding their babies; (3) remaining cool and strong: mothers should not be caught up in negative emotions and should remain strong; (4) making infant food products available for earthquake risk: earthquake emergency kit should be prepared according to the needs of babies; (5) nutrition of nursing mothers: attention should be paid to the nutrition of breastfeeding mothers; (6) breastfeeding and supplementary foods: attention should be paid to the nutrition of babies and supplementary foods (Table听2).

Main theme 3. Difficulties experienced

The theme of Difficulties Experienced includes nine categories. These categories are (1) difficulties in accessing food/formula: not being able to access formula in container cities; (2) diarrhoea/allergy: experiencing health problems after the formula provided to the baby; (3) difficulties with safe food preparation: living conditions are not suitable for preparing hygienic and hot food for babies; (4) difficulties related to the family/mother's situation: financial means of the family and the health status of the mother are effective factors in feeding babies; (5) access to heater/hot water: not being able to prepare hot water and having difficulties in accessing hot water due to the lack of heaters and electricity; (6) not being able to feed the infant: difficulty in feeding the baby and the baby being hungry from time to time; (7) difficulties in formula adaptation in an infant who has stopped sucking: difficulties in accepting formula and showing selectivity in a midwife who breastfeeds; (8) psychological difficulty: psychological wear and tear and fighting; (9) other difficulties: tent city conditions are not suitable for infant care, lack of electricity and hygiene conditions (Table听2).

Main theme 4. Breastfeeding and infant feeding

The theme of needs related to experiences in breastfeeding and infant feeding includes three categories. These categories are (1) reduction/interruption of breastfeeding: reduction of breastfeeding due to stress and adverse conditions; (2) experiences in the supplementary food period: initiation of supplementary feeding under inappropriate conditions in tent cities; (3) breastfeeding in non-privacy areas: inability to provide breastfeeding privacy in crowded environments; (4) appropriate space/equipment and materials: Participants stated that there were no infant care products and infant area (Table听2).

The codes frequently mentioned by the participants are shown in Fig.听2. The map shows the relationships between the codes and which codes are frequently mentioned together. The lines are shown wider to reflect the relationship between codes that are mentioned together and those that are mentioned more frequently. Accordingly, the participants who mentioned the code of decreased/interrupted breastfeeding also mentioned the codes of psychological difficulties, breastfeeding in areas where there is no privacy, not being able to feed the infant, difficulties due to the situation of the family/mother, difficulties in accessing formula/food, other difficulties and appropriate space/equipment and materials.

Fig.听2

Code map

When the results of the study are examined, the experiences of disaster survivor mothers regarding breastfeeding and infant feeding were determined in accordance with our objectives, barriers related to the sustainability of breastfeeding were revealed, inferences were made, and contributions were made to health professionals and national disaster prevention and response action plans in the field of breastfeeding and infant feeding in similar situations.

Discussion

This study aimed to assess the long-term viability of breastfeeding and child feeding practices in the earthquake-affected area, drawing on the firsthand accounts of mothers who experienced the Kahramanmara艧 earthquake in T眉rkiye in early 2023. As a result of the interviews conducted with the mothers, the themes of expectations from health personnel, requirements related to infant feeding, experiences in breastfeeding and infant feeding, difficulties experienced and suggestions of mothers were determined. The themes and codes of this study suggest that it is important to develop management plans, policies, and procedures to support infant feeding to meet the needs of mothers and infants in emergency response situations such as earthquakes, and to ensure communication, sensitisation and education at all levels and sectors.

Main theme 1: Expectations from health personnel

Several participants in the study reported experiencing negative emotions when they were unable to breastfeed their infants. They also noted a decrease in their milk supply as a result of these emotions. Additionally, they expressed a lack of sufficient support and emphasised the need for psychological assistance in their particular circumstances. The literature suggests that disasters increase psychological burden and individuals often experience post-traumatic stress symptoms [34]. Losing a loved one, feeling hopeless about the future and losing memorable objects and places due to disasters can lead to psychological problems among women [35]. Oz et al. (2024) in their study with 173 mothers after the earthquake, they found that 49.7% of the mothers showed post-traumatic stress symptoms [36]. Assuming new roles and responsibilities in the recovery period after the disaster may positively affect women's psychological health. Health practitioners can assist by offering information on strategies to enhance the mental well-being of mothers and by providing advice on seeking support when needed. The participants in our study conveyed a desire for further information and guidance from healthcare professionals throughout the post-earthquake period. In some studies, women reported that access to health services was prevented due to the destruction caused by the earthquake and that guidance was incomplete [35, 37]. Evidence in the literature demonstrates the importance of professional support for breastfeeding mothers. Professional support in the form of one-on-one counseling supports mothers by encouraging breastfeeding and infant feeding practices [20,听38].

Our study concluded that most mothers expect support for the regular examination of babies with health problems. During natural disasters, the health status of infants is particularly threatened [39]. In the study conducted by Akkaya et al. (2024), it was reported that forty-two (5.8%) children applied for health check-ups after the earthquake [40]. According to the study of Felix et al., (2020), when the health problems of children affected by the earthquake were analysed, it was stated that they had musculoskeletal system problems, they were at risk in terms of developing respiratory problems, digestive system disorders and sleep problems [41]. Routine post-disaster health screenings are important in terms of prevention and early detection of physical and mental diseases.

Main theme 2: Theme of mothers' suggestions

Mothers are advised not to distribute infant food uncontrolled and to check whether it is suitable for the age of the infant. One of the most frequently identified challenges during disasters and emergencies is access to formula in the right form and characteristics in disaster-affected areas. In disasters, it may take time to find formula suitable for the infant. The use of inappropriate formula is harmful to the infant's health [40]. Giusti et al. (2023) found that there were inappropriate distributions and donations during the emergency response and that infant products, infant formula and commercially produced supplementary nutrition were actively and widely distributed to mothers after the earthquake without any prior needs assessment [25]. This lack of prevention or management of donations contradicts international recommendations [42, 43]. There are a number of guidelines for infant feeding after natural disasters [11,12,13,14, 42,43,44,45,46]. All guidelines prioritise the significance of safeguarding and advancing breastfeeding. They also outline safeguards that should be taken while distributing infant formula in the aftermath of a disaster. It is important to acknowledge that the unregulated distribution of infant feeding products during disasters can have a negative impact on the continuation of breastfeeding. Therefore, it is crucial to pre-determine how supplies will be transported to the affected region and to plan for alternative modes of transportation [47]. The impact of the distribution of large quantities of infant formula in aid areas on current and future breastfeeding rates is unknown. Therefore, there may be a need to monitor the nutritional impact on affected mothers and children to protect breastfeeding and ensure that these public health measures are successful.

Breastfeeding is the recommended and safest available way to feed babies after disasters [19]. In our study, mothers suggested that mothers should insist on breastfeeding their babies after the disaster. Due to the rich content of breast milk, all the nutrients needed for the infant are provided [48]. It is easily available and improves the infant's immune response [12]. Breastfeeding is an effective way to protect the infant from hypothermia. During and after a disaster, if the mother cannot reach sufficient food and water, breast milk is the best food for the infant until help arrives [48]. According to Article 24 of the United Nations Convention on the Rights of the Child, 鈥淭o combat disease and malnutrition, including within the framework of primary health care, though, inter alia, the application of readily available technology and through the provision of adequate nutritious foods and clean drinking-water, taking into consideration the dangers and risks of environmental pollution鈥� is stated. These statements emphasise the importance of promoting health and nutrition for all children and state that this should be achieved, where possible, through continued breastfeeding [49].

In our study, mothers suggested that infant food products should be kept ready for the risk of earthquake. According to the Final Report of the Panel and Workshop on Emergency Nutrition Needs and Coordination after Disasters (2023), "Emergency Kits for Infants" should be prepared [48, 50]. Emergency Kits" are designed for the first 72听h. These kits contain ready-to-eat nutritional foods. Emergency feeding algorithm for infants can be a guideline in disaster situations.

In our study, mothers suggested that attention should be paid to the nutrition of breastfeeding mothers after the disaster. Although the basic needs of breastfeeding women are similar to those of the general population, there are some specificities that must be taken into account when responding to an emergency [25]. The daily energy requirement of nursing mothers is increased by 500听kcal. A minimum of 1800听kcal/25听g of additional protein/25听g of pulp should be provided [50, 51]. Adequate fluid intake in nursing mothers is very important in terms of increasing breast milk. According to the Final Report of Post-Disaster Emergency Nutrition Needs and Coordination Panel and Workshop (2023), nursing mothers should be recommended to consume two changes of milk and milk products in addition to daily nutrition [50]. Although mild to moderate malnutrition does not affect breastmilk supply, milk production is likely to decrease if the mother is severely malnourished [51]. In this case, the woman needs emergency feeding and extra food while continuing to breastfeed [52,听53].

In our study, the mothers suggested that mothers should not hesitate to continue breastfeeding and supplementary foods after the disaster. To enhance the mother's psychological well-being and foster a trusting environment for her infant, it is advisable to explicitly recommend and provide support for breastfeeding [54]. There are ready-to-use therapeutic foods that meet the nutritional needs of babies and children, which are defined as lifesaving in disasters, wars and epidemics [55, 56]. It is very important to obtain this therapeutic food from Turkey and store it in appropriate places.

Main theme 3: Difficulties experienced

Appropriate, evidence-based, and timely support of infant and young child feeding in emergencies saves lives (IYCF-E), protects child health and benefits mothers [14, 56]. According to our study, moms reported encountering challenges in obtaining food and formula for their infants. Additionally, they expressed difficulty in transitioning their babies from breastfeeding to formula feeding, and occasionally struggled to provide consistent nourishment for their infants. Studies emphasise that in order to become stronger and more protected against natural disasters, it is necessary to expand the pre-disaster supply area and take proactive measures [50, 57, 58].

One of the most frequently identified challenges during disasters and emergencies is access to formula in the right form and characteristics in disaster-affected areas. According to our study, mothers reported encountering challenges in obtaining formula suitable for their kids' specific age. Giusti et al. emphasised the importance of preserving, to the extent possible, the type or brand of infant formula previously used to support the psychological continuity of pre-emergency life [25]. The risk of contamination is high due to limitations in the preparation, storage, and cleaning of formula milks. According to our study, women reported encountering challenges in the process of preparing food for their infants. Difficulties in accessing clean water and food sources, use of formula under inadequate hygienic conditions may increase the risk of disease due to contamination of infants [19]. In our study, mothers stated that their babies had diarrhoea\allergy problems caused by food. During natural disasters, the incidence of foodborne diseases increases as a result of early cessation of breastfeeding and the use of unsafe water in food or formula. WHO data indicates 600 million suffer from foodborne illnesses annually, with children under 5 bearing 30% of foodborne fatalities [59]. Following the 2004 tsunami in Southeast Asia, children who were fed formula had a diarrhoea rate that was three times greater than that of children who were nursed. Similarly, after the 2006 earthquake in Yogyakarta and Central Java, there was a significant correlation between the consumption of infant formula and the occurrence of infant diarrhoea [60]. The UNICEF survey found that 80 per cent of all households with infants aged 0鈥�5听months received donated infant formula. The incidence of one-week diarrhoea was higher among people who received donated infant formula (25.4%) than among those who did not (11.5%) [60]. Uncontrolled distribution of infant formula is thought to increase the risk of diarrhoea among infants and young children in emergencies.

Main theme 4: Theme of experiences in breastfeeding and infant feeding

In our study, mothers stated that their milk decreased due to stress conditions and that they started to give supplementary food even though it was not suitable for the month of their infants. Mothers in the earthquake zone may have reduced milk supply due to "stress, injury, preoccupation with property damage and loss of privacy". Regular breastfeeding should be maintained even if breast milk decreases due to this acute stress experienced by mothers after the disaster [61]. M谋zrak Sahin et al. (2024) study, participants who breastfed their babies during the earthquake mentioned many sources of stress, such as the effect of the earthquake鈥檚 severity, death of family members, hunger, and housing problems, which decreased or stopped their breastfeeding [52]. Nevertheless, breastfeeding practices may be interrupted during and after a disaster, access to donor breast milk may not be available, or hygienic preparation and storage of formula may be difficult [20]. The World Health Organisation's operating guide on child and adolescent health in humanitarian circumstances emphasises the importance of providing timely, safe, sufficient, and suitable supplementary nutrition during disasters and emergencies [44]. Clean and safe supplementary nutrition along with breast milk should be appropriately included in the infant's diet after the 6th month [62]. Following the disasters, it is crucial to organise nutritional aid for children to resume their regular diet. It is imperative to promptly provide the required formula or additional meals that are appropriate for the diet of the infants.

In our study, the participants stated that breastfeeding privacy could not be provided in crowded environments and they needed appropriate space/equipment and materials for infant feeding. Mudiyanselage et al. draw attention to "privacy" (e.g. infant tents, curtains, shawls, and private areas) as a facilitator of breastfeeding during disasters [20]. M谋zrak Sahin et al. (2024) sutudies, the lack of privacy was a major barrier to the continuation of breastfeeding [52]. Safe and private places should be created for the continuity of breastfeeding after the disaster [15]. International studies examining women鈥檚 experiences of breastfeeding in the community have determined the factors that contribute to the role of privacy in breastfeeding, such as attracting attention, sexualizing the breasts, being aware of the discomfort of others, and making efforts not to be seen [63]. According to the results of a systematic review conducted on infant and young child feeding in natural disasters, it is emphasised that feeding materials, areas for cleaning these materials and instructions for the correct preparation of infant formula should be provided to the mothers of disaster victims [20]. In accordance with the systematically prepared disaster plan after the disaster, fast and safe care environments should be provided to ensure the care and feeding of newborns and infants requiring special care. In addition, appropriate materials and equipment for newborns and infants should be delivered to the disaster area as soon as possible [15]. Women in disaster tents face challenges in nursing as they lack privacy, lack of baby feeding tools and are unable to establish an appropriate atmosphere for breastfeeding and infants feeding.

Lack of privacy prevents breastfeeding women from breastfeeding their children comfortably, causing them to experience stress and this may negatively affect the breastfeeding process [60, 64]. Our findings underline the need to prioritise Infant and young child feeding in emergencies on the emergency preparedness agenda. There is an urgent need for coordinated action targeting managers, health professionals and other relevant stakeholders. Training sessions on sustaining breastfeeding and feeding infants in emergencies should be actively offered to this population group.

Strengths and limitations

This study was conducted after the earthquake, when the event was still remembered and the mothers' memories were fresh. Therefore, the strength of this study in terms of recall of events and impairments in memory is that the mothers remembered their experiences very well and shared them with the researchers. Another strength is that although the mothers experienced severe trauma due to the earthquake itself and its consequences, the fact that their opinions were taken and the idea that they could help other mothers and babies motivated them to participate in the study and share their experiences. Even though emotional situations were experienced from time to time, the mothers' willingness and motivation to participate in the study during the interviews were significantly reflected in the results of this study. One limitation/difficulty of this study is that emotional moments were experienced during the interview due to the events, physical conditions, and material/moral losses experienced after the earthquake. In this study, which was conducted with the in-depth interview method, the intense emotionality experienced made the interview difficult to the detriment of the researcher. Another limitation is that the researchers experienced difficulties due to problems with transportation and accommodation to the place where the study was conducted in the post-earthquake region, and differences occurred in the planned hours and days. Another limitation is that in this study, the purposive sampling method was used. This technique allowed us to better explore the experiences of the mothers and to select participants who were suitable for the purpose of the study. However, the purposive sampling technique has some limitations in terms of generalizability. In qualitative studies, instead of statistical generalization, it is important to evaluate the findings in similar contexts. Therefore, the findings of our study are valid only in the specific context and cultural framework where the participants are located.

Conclusion

Since this study was conducted very soon after the earthquake, it is a unique study whose results can be utilized in disaster management strategies to encourage the dissemination of experiences and conclusions about breastfeeding in communities living in earthquake geography. As a result of this study, it was seen that mothers who specifically mentioned the sub-theme related to the reduction/interruption of breastfeeding also drew attention to issues related to psychological difficulties, breastfeeding in areas where there is no privacy, inability to feed the baby, difficulties arising from the family/mother's situation, difficulties in accessing formula/food, and lack of appropriate space/equipment and materials. All these data underline the urgency of transitioning earthquake survivors from tents to permanent housing to improve the well-being of mothers and infants in the aftermath of the earthquake. Local and regional action plans should also be developed to protect the privacy of breastfeeding mothers in this process. As part of this policy, mothers who wish to continue breastfeeding while staying in their shelters should be provided with a special space (breastfeeding room/cabinet/ mobile food kitchens) with feeding equipment. In addition, baby-friendly areas should be structured for mothers who want to continue breastfeeding. These areas in disaster areas should also be visited by experts to provide breastfeeding support. In addition, written policies for breastfeeding mothers should be created before disasters, personnel should be trained for these situations and should be mobilized to the region immediately in an emergency.

Nurses working in the clinic and in the field during the disaster process can create a vision for the implementation of programmes to be designed to support the mother to maintain and initiate breastfeeding, to provide the necessary privacy for breastfeeding after the disaster, to distribute nutrients appropriately, to provide psychological support, to provide appropriate equipment and environment for feeding, and to provide the necessary nutrients for the infant and mother. Therefore, it is crucial to address the risk factors associated with breastfeeding and nutrition that may arise due to adverse circumstances experienced by children who are breastfed and/or receive additional food during disasters. It is also important to plan interventions that can be implemented beforehand. In addition, destructive disasters such as earthquakes can lead to psychological problems such as post-traumatic stress disorder in mothers. In order to prevent this, breastfeeding can also help to maintain the continuity of mother-infant attachment, maintain the well-being of mothers, and reduce stress in mother and infant. It is important to address these factors in studies.