When Hurricane Laura hit Louisiana in August 2020, over 10,000 residents from the southwestern part of the state fled their homes for New Orleans. A central evacuation resource hub where evacuees could go to find basic necessities like food, water and clothing was set up downtown.
Malaika Ludman, a doula and certified lactation consultant, along with others from the Birthmark Doula Collective, had been planning for a moment like this — they had weathered hurricane season with their clients for years. The New Orleans Breastfeeding Center, a program run by the collective, had previously created emergency infant feeding kits tailored to nursing parents, yellow drawstring backpacks filled with things like ice packs to keep milk cold, nursing covers, water and sanitizer that Ludman and others were prepared to distribute.
But at the evacuation center, Ludman, who is also the program coordinator for the collective’s emergency preparedness program, realized the situation would be more complex than handing out supplies: The large majority of families they spoke with were feeding their babies with formula, and cans of powdered formula donated to the center were being handed out without any other supplies, like a way to sterilize or clean baby bottles. Bottles can harbor bacteria if they aren’t cleaned properly, so without dish soap or a bottle brush it can be dangerous.
“For the baby, it can mean diarrhea – that’s the biggest problem – and dehydration,” Ludman said. “It can be especially scary for a baby that’s born prematurely or who has a weak immune system.”
As the climate crisis worsens, leading to more dangerous hurricanes and longer wildfire seasons, more mothers and breastfeeding parents — who are already considered uniquely vulnerable to the climate crisis — will need assistance to feed their babies in shelter settings. States are increasingly starting to recognize this problem and are turning to grassroots groups like the Birthmark Doula Collective to help skirt deadly consequences.
Seeing the lack of resources and general guidance for parents, the doulas pivoted in the aftermath of Hurricane Laura. They began conducting feeding assessments — a quick interview with parents to figure out how they fed their babies prior to the disaster — and within a few weeks had created a new set of kits to distribute. This time they were buckets instead of bags, which were filled with dish soap, bottle brushes and liquid 2-ounce bottles of ready-to-feed formula — the safest kind of formula in emergency situations since it does not require water or electricity.
They also launched a 24-hour emergency parent-infant hotline that they activated the night before the hurricane hit and that ran for four weeks. It was staffed with doulas and lactation counselors and a local organization that helped interpret for those who spoke Spanish. Sixty people called in needing information on where to find things like diapers and clothing or advice on breastfeeding their infants through a disaster.
The grassroots response led by the doula collective points to a major gap in emergency planning in the United States. In 2005, in the days after Hurricane Katrina, several babies died of dehydration when food and water ran out due to a poor emergency response. And, in 2016, the World Breastfeeding Trends Initiative gave the United States its lowest score for emergency preparedness for safe infant and child feeding in an analysis of 84 countries.
The Federal Emergency Management Agency (FEMA) has a series of guidelines it follows to prepare and respond to disasters including one detailing “mass care,” or the deployment of shelter and food in times of emergency or disaster. Sarah DeYoung, an assistant professor at the University of Delaware and disaster researcher, notes there are hardly any references to infant feeding needs. There is more information in emergency planning documents on preparing for companion animals rather than infants or babies, she said.
“There’s kind of vague statements about anticipating that families may be arriving in shelters, (but) nothing about saying, make sure there’s a breastfeeding space with a sink for washing hands or a place to plug in a breast pump or all these other provisions. There’s nothing specific to safe infant feedings. … So that’s really lacking in guidance.”
There are many things the country could be doing to improve how it accommodates people with infants, DeYoung said, starting with encouraging breastfeeding, which is considered the healthiest way to feed an infant.
If someone is already breastfeeding, they sometimes need support in continuing that practice through an event like a hurricane.
“Breastfeeding parents are in a very stressful and traumatic situation. And a lot of times they think that it affects their milk supply, or even the quality of their milk. That’s one of the big myths,” Ludman said. “Stress doesn’t actually lower your milk supply. But it can delay the flow of the milk.
However, there are barriers, as the doulas witnessed in New Orleans. Historically, low-income people breastfeed at lower rates. That’s for a few reasons, including lack of support and care postpartum, and working in jobs that don’t give paid parental leave. But feeding babies with formula is usually more expensive and becomes more complicated when evacuating to a shelter.
“When a disaster hits, that divide becomes even greater,” Ludman said. “Those families become dependent on the state or the city for food and for resources.” If there is no formula available “then what do those families do?”
Multiple studies show that babies in disasters are more likely to be malnourished, to get sick or even die if they are formula fed.
“So thinking about it as a human rights issue is really critical,” DeYoung said. “And in the United States, it’s a racial justice issue as well, because minority populations are more likely to be exposed to disasters.”
One step the United States could take is adhering to a set of guidelines created by the World Health Organization (WHO) aimed at regulating the marketing of formula, DeYoung said. The code was originally created in the 1980s after formula companies like Nestlé had been aggressively targeting mothers in developing countries using a variety of misleading tactics, including having employees dressed in nurse uniforms extoll the benefits of their product to new parents.
The WHO code more broadly is used to help countries develop plans to encourage breastfeeding. “It comes in handy in disasters if providers and organizations know about the WHO code, because then they can safely provide guidelines for infant feeding and disasters,” DeYoung said.
In the case of Hurricane Laura, it would have laid out guidance over how to provide formula to mothers without inadvertently advertising it to those who might not need it. Most professionals like DeYoung say handing out formula should be more akin to the ways emergency response professionals distribute medicine. Instead, formula comes in as donations from well meaning community members and is distributed ad hoc.
The United States is the only country out of 195 member states in the World Health Assembly, the decision-making body of the WHO, that has not formally signed on to the code. “That’s probably the biggest barrier at the policy level,” DeYoung said.
After Hurricane Laura, the doulas participated in a stakeholder meeting with others involved in the city’s disaster response to unpack what they had documented at the evacuation resource center. In that meeting they detailed the lack of safe formula distribution and gaps in assistance for nursing parents. Shortly after, they saw their first win. A nutritionist from the WIC program, which provides assistance for low-income people with infants and children, had heard their concerns about liquid formula being a safer option during emergencies.
“So she went to WIC and advocated to update their emergency preparedness policy, and made it so that WIC moving forward, will be able to issue liquid ready to feed formula to families in an emergency,” Ludman said. This is crucial, because only 14 percent of WIC recipients breastfeed their babies.
After Hurricane Laura, the collective also partnered with the Bureau of Family Services, who collaborated with them on a grant from the National Association of County and City Health Officials, to train over 440 emergency response professionals in the state on the basic principles of safe infant feeding in emergencies.
Those who’ve gone through the training include people who staff shelters, social workers, food bank workers, responders involved in evacuations, and representatives from the Bureau of Community Preparedness, among other groups. The courses are conducted by Ludman and Latona Giwa, the cofounder of the collective, in a series of live online training and pre-recorded webinars.
“I think the training is super helpful in helping leaders and staff understand why and how breastfeeding can be protected and supported, really as the safest feeding option,” said Marci Brewer, the neonatal initiatives manager with the Bureau of Family Health. “And that everybody, including families, and emergency responders, and health professionals really also understand how to safely and appropriately use infant formula.”
An effort to better serve parents and infants in emergency response is beginning to take hold in other states as well. In Colorado, where wildfire season is becoming more destructive, Allison Wilson, a strategic initiatives coordinator for Jefferson County’s public health department, developed a program to train 30 safe-infant feeding volunteers in disaster response. They can be deployed to shelters, or someone’s house, or can assist someone virtually both in the Denver-metro area and statewide.
The volunteers already come from infant feeding backgrounds, like as a lactation counselor for example, and their training helps them apply that skillset in a disaster setting, Wilson said.
“It is a lot about understanding emergency preparedness and then understanding how you would be called on and deployed to support a family,” Wilson said. “Things could have been going great at home but then you had to evacuate. You forgot your pump, now one side is engorged, and the baby is upset because it’s a new setting. It’s just all those things can happen so quickly. … How can we support the family because everything else has changed?”
Wilson, who has swapped strategies and solutions with Ludman, has also ordered 450 of the safe infant kits to distribute both prior and during emergencies. Wilson’s been working with the Medical Reserve Corps, a national volunteer program, as a partner who could distribute these kits to families when disaster hits.
Back in Louisiana, Brewer, with the Bureau of Family Services, said the county will be more prepared this hurricane season. Over 300 responders have now been trained by the doula collective and several agencies like the Red Cross are working to update their intake forms to better identify people who might need safe infant feeding support after being evacuated. They’ve also more widely distributed the information for the parent-infant hotline that the doula collective built.
Ludman would like to see some of these projects eventually be taken over by other agencies. Frankly, the doulas’ resources are stretched thin. “It’s figuring out how we can make our hotline a sustainable thing,” she said. “We staff it as Birthmark, but we’re not that many people, we don’t have that much money.”
In September, the work of the collective was honored by the New Orleans City Council for their assistance during yet another hurricane, this time Ida, which hit the city center. At the time of the storm, many of the doulas from the collective had to evacuate. Months prior they had worked out a collaboration with a group of lactation counselors in Florida to staff the hotline from afar in the likely event they themselves would have to escape the city.
The doulas’ work has proved crucial, Brewer said. “They’ve really been an expert and the elite leader in this space. And really it’s my goal to build on their expertise and knowledge and make sure that we’re really using that to change and improve our system in Louisiana.” She added: “They’ve served as a catalyst for this work. And I’m just really thankful to be a partner with them.”