Original Articles
Original Article

Lead mother, explaining to mothers
how to express breastmilk. Yemen

What we know:

Mother-to-mother support groups (MtMSGs) provide a peer support environment
where women come together to discuss infant and young child feeding (IYCF) issues
and share their experiences overcoming problems. These groups can effectively improve
IYCF practices, including in emergency contexts.

What this adds:© Crisis Response FHI 360 Yemen

This FHI 360 experience illustrates the importance of peer support groups, especiallyin crisis contexts, reaffirming their potential to provide benefits in terms of IYCF
practices, mutual support, health and wellbeing, and cost savings from reduced
purchase of commercial milk formula and medication. We identify strategies
to enhance support for lead mothers and to strengthen mothers’ engagement insupport groups, for additional benefits.

Reviewing
the FHI 360
motherto-mothersupportexperiencein YemenA

fter 10 devastating years of war, withthousands of civilian casualties andover four million internally displaced people, violence and insecurity remain endemic in Yemen. A profound economic crisis threatens the government's ability
to sustain vital public services. Multiple domestic and external shocks are exacerbating the situation, including extreme weather events, thefinancial repercussions of the COVID-19 pandemic, and the wars in Ukraine and Gaza. A recent Humanitarian Needs Overview from theUN Office for the Coordination of Humanitarian Affairs (OCHA, 2024) reported that 7.7 million people require nutrition services: 2.7 million women and 5 million children.
According to data from the Nutrition cluster,
8/21 Yemeni governorates have wasting rates thatexceed the 15% WHO emergency threshold: Al
Hudaydah, Lahj, Taiz, Hajjah, Abyan, Mahawit, Sa’ada, and Dhamar (IPC, 2023). These gover-Figure 1

norates include 76 districts, accounting for 36%
of the national wasting caseload. In the districts
served by FHI 360 (figure 1), the level of nutrition severity is 5 (the highest), with a wasting rateof 28.9% in Hudaydah (Hays) and Taiz (Dhubab,Mawza and AlMokha (Al Makha)). Poor IYCF
practices are a key factor contributing to the highwasting rates in the country.

The intervention

MtMSGs are among the strategies implemented
by FHI 360 to support communities to redress
the dire situation. These groups complement andlink with community health volunteers’ (CHVs)
work. FHI 360 has implemented the MtMSG approach in five locations since 2023: Al Ghaded,Al Kadaha, Al Roa’a, Al Gharaffi, and Al Shatheliah. FHI 360 adopted the guidance and recommendations from the Yemen Ministry of Public
Health and Population, while also drawing fromthe organisation’s experience in similar contexts
such as north-east Nigeria and Ethiopia.

FHI 360’s areas of intervention

Mohannad Ibrahim
Community Health Officer, WAMERO, SUIHAY,FHI 360
Lina Muhammad Al-Khatri
Community Health Officer, WAMERO, SUIHAY,FHI 360
Hazem Samra
Health and Nutrition Coordinator, WAMERO,SUIHAY, FHI 360
Mohammed Helmi
Meal Manager, WAMERO, SUIHAY, FHI 360
Kelly Thayer
Deputy Crisis Response Coordinator, WAMERO,SUIHAY, FHI 360
Alessandro Iellamo
Senior Emergency Nutrition Adviser at FHI
360
Sarah Brittingham
Technical Advisor, Research Utilization at FHI
360
Gina Etheredge
Senior Technical Advisor, Strategic
Information at FHI 360
MtMSGs are active in the Al Makha and Dhubab districts

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Figure 2 Visual counselling card examples

Original Article
Evidence suggests that MtMSGs canbe effective in emergency contexts. In
the Dadaab Refugee camp (Kenya), there
were 713 MtMSGs across three different
camps, with 581 facilitators being trained
over one year. Despite an increasing programme size due to refugee influxes, IYCF
behaviours continually improved (WorldAlliance on Breastfeeding Action, 2024).

ic. She facilitates the group to share theirknowledge and engage in discussion.
The lead mother then suggests what they“would” do to help others practice what isrecommended or “what they will do to try
to practice it themselves.” Members thenreview and agree on recommendations toaction themselves and promote to theircommunities.

What are mother-to-mothersupport groups?

Members commit to attend the sessions
and participate by sharing experiences orideas, trying out (and hopefully sustaining)recommended practices, and supporting
the learning of other mothers living in theirarea. Members also refer mothers who mayneed additional support. A member will be
asked to share their experiences of helping
other mothers during the group sharing
activity. Lead mothers also visit members’
homes to discuss how the support to otherwomen is going.

There are important considerations when
deciding to establish MtMSGs. In Yemen, FHI 360 looks for the following conditions: some stability in the context ofoperations (e.g. no major security threats
in terms of fighting or social unrest),
that people are likely to continue residing in the area for some time (at least sixmonths), and that there is a sense of community. If the population is mobile and/orliving in an unstable context, other strategies such as home visits and community
discussions by community health and nutrition volunteers may be more effective.
To target the window of opportunityof the first 1,000 days of life, the recommended members of MtMSGs are pregnant women and mothers (primary caregivers) of children aged 0–2 years. In
Yemen, where men must be informed andapprove when women leave the house, itis very important for a mother to have theagreement of her family to join a MtMSG.
As this is a new activity for FHI 360 andthe community, it is important that thelead mothers and group members ensurethat their husbands agree to and support
their participation.
Lead mothers are selected from among
the MtMSG members based on various criteria, including community knowledge,
successful IYCF practice, communication
skills, and time to dedicate to the initiative.
They generally host group meetings in theirhomes. They are provided with two training
days in IYCF facilitation and communication, as well as basic information, education,and communication materials to support
group discussions and exchanges. The leadmothers also link with the health facility andthe CHVs, sharing their group's updates, issues, and challenges.
FHI 360 MtMSGs are set up so thatgroup members do not need to walk morethan 30 minutes to attend. Each MtMSG has
between eight and 15 members. MtMSGs
must be supervised and supported bytrained CHVs and the health and nutrition
staff of the nearest health facility.

MtMSG activities

The lead mother follows the proposed programme of thematic sessions on maternal,
infant, and young child feeding, preparing
each session in advance.
At the start of each session, the leadmother presents a visual counselling card
(Figure 2) that describes the session's top-16

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Assessing success

After more than one year of implementation and anecdotal success, FHI 360
conducted a rapid assessment of the experience to learn from and inform thesubsequent phases of the work. This assessment collected qualitative information on how IYCF practices among participants in the MtMSGs have changed
after 16 months. The primary assessment outcomes were self-reported changes in knowledge about IYCF, self-reportedchanges in IYCF practices, and preferred
topics discussed during support groups.
Other benefits of participation in MtMSGs
were assessed, as well as challenges or negative aspects, the level of engagement withother community members, and recommendations to improve the groups.
The study was conducted on the west
coast in south Yemen, where FHI 360 is
implementing an emergency response
project. Five areas in Taiz were selectedbased on FHI 360’s extended presence inthe area and the associated trust that has
been built with communities. The assessment was conducted in December 2023
using focus group discussions (FGDs)
and in-depth interviews to elicit the experiences of mothers and lead mothersin MtMSGs. Fifteen FGDs were conducted, with a total of 79 participants. Each
FGD took between 60 and 90 minutes
and included two note takers. Thirteen
in-depth interviews were conducted withlead mothers, representing half of all leadmothers in the assessment area. Each interview took up to 60 minutes, with either the interviewer or a notetaker taking notes. Purposive sampling was used
to identify and select the participants for
the FGDs and the interviews.

Study limitations

A compressed timeline limited the assessment team’s ability to pre-test the interview and FGD guides and limited the time
for in-depth data analysis. Mothers did
not feel comfortable with audio recording,Original Article
so the assessment data consisted of notes takenby the team. These notes highlighted key themes
and quotes from participants. In the results below, when frequencies are reported, these refer to the number of FGDs in which a particular theme emerged. While images would havebeen helpful, many participants did not want tobe photographed (a traditional value on the west
coast of Yemen).

Results

FGDs with participant mothers

Most women attended between 40 and 50
MtMSG sessions and noted that the location was easy to access, comfortable, and safe.
Participants in all FGDs emphasised optimal breastfeeding and complementary feeding when asked what they had learned. The
importance of exclusive breastfeeding in thefirst six months emerged as a critical learning across all FGDs (n=15). In addition, participants mentioned breastfeeding attachment (n=4), breastfeeding positioning (n=8),
and hygiene, including personal and child hygiene (n=12). When asked about the benefits of these practices to the child and mother, they noted that their children are healthierand experienced a reduced incidence of disease, especially diarrhoea. Mothers credited the knowledge gained for their children’simproved nutrition/freedom from malnutrition, body growth, weight gain, development,and sleep, as well as comfort and confidence
for mother and child (n=12). Mothers sharedadditional benefits, such as a reduction in thecost of purchasing both commercial infant
formula and medications/medical care. Mothers in all FGDs associated increased immunity
and improved health with changes they madedue to their participation in MtMSGs.

“It affected my comfort because
my child’s comfort is my comfort.”– FGD participant

When mothers were asked what they perceived to be the most significant change that resulted from their participation in MtMSGs, thekey themes highlighted in the FGDs were improved breastfeeding (n=13) and complementary feeding (n=5), alongside cost savings (n=4)
and improved family and home situations (n=3).
Mutual support emerged as an important element of MtMSGs. Mothers valued the exchangeof opinions and experiences with each other and,subsequently, their families and communities.
Women from all but one FGD had invited neighbours or other women to join their MtMSG. The
FGD facilitators asked participants about opportunities for MtMSGs to provide additional support and possible MtMSG adaptations. Mothers in more than half of the FGDs identified theprovision of incentives and assistance, citing hygiene kits, nutritional support, and cash support
as options that support groups are well placed toprovide. Suggested adaptations ranged from varying the topics of the sessions and changing theleaflets and posters to providing snacks/meals,
mats, and more materials for sessions. Participants noted that more groups could be created
to benefit more women, children, and families.

“Breastfeeding has been achallenge because… mothers
believed that breastfeedingalone was insufficient to satisfy
the child's hunger and thatusing formula feeding andintroducing solid foods would
contribute to faster growth.
There was a misconception thatbreastfed children might be more
susceptible to illnesses due totheir slender and weak bodies.”– Lead mother, TaizInterviews with lead mothers

Reflecting on sessions they facilitated, leadmothers found the sessions that addressedbreastfeeding, complementary feeding, and personal hygiene to be most impactful (in line withparticipant views). In terms of the successes ofthe MtMSGs, all lead mothers noted that, bysuccessfully conveying information to members,
they saw mothers make more positive choices.
These included avoiding complementary feeding
until the seventh month and prioritising vaccination (after initially fearing them). Anecdotally, lead mothers also reported seeing an overall
reduction in disease and malnutrition among
members’ children.
Nine out of thirteen (69%) lead mothers
shared that the most challenging part of theirrole was managing misconceptions related tobreastfeeding and complementary feeding, as
these made it difficult for mothers to accept theinformation being given. Other reported challenges included difficulty motivating members and the need to adapt information to suitmembers’ education/literacy levels. In addition, mothers had concerns about their own nutrition. Some mothers were unable to consume
regular meals and they feared that this would affect their breastfeeding. Other challenges citedby lead mothers focused on logistical challenges(n=6) such as the distance between homes, lackof transportation, challenging roads, high winds,and presence of dogs.
Lead mothers mentioned educating (n=12)
and building relationships with/respecting
mothers and the community (n=3) as theirfavourite part of being a leader. When asked
how one might improve upon MtMSGs, leadmothers suggested additional training forleaders (n=3) to be able to discuss new topics
and providing cash incentives (n=5) for participating mothers.

“MtMSGs are a vehicle forbehavioural change, valuing eachmember's experiences, views, andopinions. It provides a learning
opportunity, receiving support,
and supporting others without
being judged or shamed.”– Lead mother

Recommendations for support
group implementation

The findings of the qualitative assessment provide several recommendations on ways tostrengthen MtMSGs that could lead to greater effects. The provision of joint session review meetings for lead mothers would support
them to understand and agree on strategies
that work to make MtMSG sessions more engaging. These session review meetings would
also give the lead mothers a chance to shareexperiences with each other. Communicationmaterials need to be adapted for specific contexts to address local misconceptions and myths.
The possibility of supporting MtMSG memberswith basic in-kind materials (e.g. hygiene kits
or cooking utensils,) or linking members withother local programmes for additional support(e.g. food security and livelihoods programmes),needs to be explored. Practical solutions to address issues of distance and transportation need
to be identified (e.g. rotating venues to vary transit time among different group members and reducing session frequency from twice to once perweek). Motivation and engagement can be improved by providing recognition to MtMSG
members and the lead mothers for what they
do, through certificates or a simple ceremony,or more simply through refreshments provided
during the sessions.
The recommendations and suggestions fromlead mothers and members are very valuable.
Mothers feel they are not just part of the initiative but leading it. All the recommendations
are practical and feasible in the medium to longterm, but FHI 360 will need to network and linkwith other partners and programmes to respondsuccessfully to each of them.

Conclusion

Despite some challenges in methodology within this setting, this qualitative assessment has
shown the value of MtMSGs in this context in regard to improving the understanding of optimal
IYCF and mutual support generated between
mothers. Notably, the evaluation has identified
key areas that can be enhanced to support thelead mothers and strengthen mothers’ engagement for future benefits. Following this, FHI 360
will continue supporting the MtMSGs and expanding the interventions in other villages. At
the same time, thanks to the initial encouraging
feedback and experiences, FHI 360 will also start
supporting father-to-father support groups inrecognition of men's critical role in Yemen in theimprovement and care of the health and wellbeing of their families.
For more information, please contact
Alessandro Iellamo at
AIellamo@fhi360.org

References
IPC (2023) Yemen: Acute malnutrition situation October
2022 – May 2023 and projected June – September
2023 (partial analysis). ipcinfo.org
OCHA (2024) Yemen humanitarian needs overview
2024 (January 2024). reliefweb.int
World Alliance on Breastfeeding Action (2024) Mother-to-mother support groups in the Dabaab refugee
camps. waba.org

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