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 earthquake, the women’s mean age was 33.6 years (28-46). Four women were primigravidae, one was secundigravidae and one tertigravidae. The gestational age was 6 to 40 weeks. Three women had a spontaneous vaginal birth, while three had a cesarean section. Three infants were exclusively breastfed, while three were using/had used infant formula.
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 1 to 9 months of life.
The following themes, categories and codes (Table 3) were identified with the categorical analysis of the data.
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 1 and 3 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 five times to pee, go out, and it was so cold in the yard! What could we do? And after four or five 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, hotels in a different location, 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 filthy. 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 first days of emergency, in the temporary housing, the interviewees suffered deprivation of privacy and difficulties related to living with many other people, sometimes strangers. In some areas, pregnant women and their relatives were provided with private tents. One woman experienced the family tent and reported high satisfaction. Because of the discomfort caused by the everyday life in the camps, some of the women and their partners took action to find 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 find an accommodation close to it. Therefore, most couples tried to find 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 be close 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 first 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 first 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.”
Women also expressed a need for a place and space close to their families to care at the same time for the baby and their older children.
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 fine, 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 reconfiguration 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 community they belong to 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 challenge:
“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 significant, 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 fine. 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:
“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 first 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 was reported as highly frustrating. Due both to the population’s displacement and to the staff turnover, the meeting areas for mothers and children were available in very rare cases but, where present, they were considered useful:
“They wanted to organize meetings with mothers and children, even just mothers to do activities together a few times a week. Having a chance to hang out would have been nice, I think.”
Some 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 welcoming care to women and their partners, acknowledging their specific 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 unsatisfied basic needs. During the hospitalization, some women felt, for the first time since the earthquake, the feeling of being taken care of 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, made childbirth a moment of reassurance and reconciliation.
In some cases, women reported the support they 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.”
Specifically a woman whose daughter was hospitalized a week after birth spoke about the breastfeeding support she received in the hospital:
“They helped me, they helped me a lot, because I wasn’t so skilled. [...] [Latching on required] a lot of patience and they helped me. They expressed my milk, considering that at midnight they sent me away [from the Neonatal Intensive Care Unit], they gave it [to the baby] and showed me how I should do [...]: - Insist, attach her, even if you feel that she doesn't suck. And in fact now, at eight months, she takes only my milk.”
On the other hand, two mothers were advised to use infant formula during the hospital stay and, in one case, a specific brand was prescribed:
“No, I was not able, I had very little breastmilk. I was expressing it all, but the maximum I expressed was 20 ml. And so ... he had an excess of hunger. [...] He started with [brand of the infant formula], [...] [while] to the premature babies they gave [brand of infant formula].”
“The hospital… [recommended me infant formula] my breastmilk was not enough for him. [...] He wanted to eat every hour, he was always attached.”
In some hospitals there was no rooming-in:
“He seemed quieter, they told me he was resting [...]. Then when he woke up they brought it back to me.”
The support to breastfeeding provided after discharge was insufficient both by local health services and emergency staff, with some variability related to specific services or professionals.
“I left the hospital on Thursday, and on Saturday he didn’t pee or wake up to eat. [...] He was weakening, I immediately called the pediatrician and she told me: - Give him the infant formula -. And… nothing [...] I don’t know if he was not able to suckle at the breast anymore. For half a month I tried both [breastmilk and infant formula], but at the breast he got little or nothing.”
“Alone. I did it alone [once discharged from the hospital].”
“No, [they didn’t give me information on breastfeeding], [the pediatrician at the clinic] saw that I was breastfeeding and that he was growing well. [...] [She told me] only: - Don’t eat legumes. [...] Eat everything but not the beans, otherwise the abdominal cramps can come - but otherwise she didn’t tell me anything at all.”
Standard health care was perceived as present and efficient:
“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 fine, 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 specific 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, pacifiers… in short, I received a lot of things, but… how many pacifiers 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, pacifiers, 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 initial assessment of need for infant formula, 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 difficulties, 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 difficulties 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.