Prioritizing earthquake-prone countries for implementing the operational guidance on infant and young child feeding in emergencies (OG-IFE): a descriptive risk mapping and prioritization analysis

Introduction

Ensuring safe and appropriate infant feeding practices support optimal growth, development, and positive health outcomes in young children, particularly during natural disasters such as earthquakes. The World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) recommend exclusive breastfeeding for the first six months of life, followed by the introduction of safe and nutritionally adequate complementary foods while continuing breastfeeding for up to two years or more (1).

Exclusive breastfeeding (EBF) is critical for an infant's health and survival, even more so in disaster settings (2, 7). Breastmilk is safe and readily available. It provides essential nutrients and antibodies to protect infants from common illnesses like diarrhea and respiratory illnesses, which are significant causes of child mortality (1, 3). Preparedness activities that preserve breastfeeding and promote appropriate infant and young child feeding (IYCF) practices are essential for protecting population health.

In situations where maternal breastfeeding cannot happen because of death, absence, or serious illness, preparedness plans informed by global guidance are needed to ensure the safe and rapid provision of alternatives such as breastfeeding by another healthy woman or donor human milk (4, 5).

In situations where a mother is partially breastfeeding her infant or where the infant is not breastfed, and no alternate source of human milk is available, supply chain identification and advance procurement arrangements for appropriate breastmilk substitutes (BMS) and complementary foods are important preparedness activities. These arrangements can help ensure safer access to BMS for dependent infants under six months of age while avoiding common response problems that increase morbidity and mortality or undermine breastfeeding, including unsolicited BMS donations, unsafe preparation, weak targeting, and poor follow-up (4, 6, 7). Earthquakes pose significant operational challenges for safe infant feeding practices, regardless of feeding method. The Operational Guidance for Infant and Young Child Feeding in Emergencies (OG-IFE) offers a global preparedness framework for governments, NGOs, UN agencies, and others, and should be incorporated into preparedness plans to address these challenges.

Unlike the availability of the OG-IFE, implementation readiness is inconsistent across countries and often weak in earthquake preparedness. Common gaps include limited institutionalization of OG-IFE within national disaster management plans and coordination structures, insufficient pre-event (before the impact) training and role designation for IYCF-E response, and operational weaknesses in planning for controlled BMS management and breastfeeding support during displacement. Accessibility barriers, particularly the absence of OG-IFE in relevant national languages, can further delay the response and hinder standardized decision-making in the critical early response period. This study therefore situates earthquake risk alongside preparedness accessibility to support targeted OG-IFE implementation before major seismic events.

Three pathways link earthquake exposure to disruptions in infant and young child feeding. First, caregiver mortality and separation may interrupt breastfeeding directly, requiring immediate access to lactation support, wet nursing, donor human milk, or safely managed breastmilk substitute provision. Second, destruction of infrastructure reduces access to clean water, fuel, sanitation, and healthcare, increasing the risks associated with BMS preparation and use. Third, low pre-disaster EBF rates reflect a larger population of infants already dependent on BMS, so that infrastructure disruptions affect a greater number of infants directly. These pathways are distinct but may compound one another, and the indicators used in this study are intended to reflect each one.

For example, during earthquakes, mothers who practice EBF may die, be trapped, be injured, become separated from their infants, or have other reasons preventing breastfeeding. In these circumstances, immediate alternatives need to be sought. The destruction of infrastructure creates a challenging environment that is magnified in countries with low EBF rates and many non-breastfed infants. The risk of contamination and incorrect preparation of infant formulas is extremely high in these contexts (7). Powdered infant formula is the riskiest feeding method in such disaster settings due to the extensive resources required for its safe preparation, including clean water, proper utensils, and fuel for heating water for safe preparation as well as sterilizing utensils. Despite being bulkier and pricier, ready-to-use infant formula (RUIF) is preferred as it requires significantly less preparation and minimizes the risk of contamination (4, 6). However, context-appropriate BMS, especially RUIF, might not be available or accessible in an earthquake setting because of the destruction of infrastructure. Each of these challenges has been anticipated in the OG-IFE to support risk reduction and improve outcomes.

Studies have documented infant feeding challenges during post-earthquake responses in Russia, New Zealand, Indonesia, Türkiye, and Italy (8–12). Reported gaps include limited availability or utilization of infant feeding experts and insufficient support, contributing to increased post-disaster morbidity and mortality from malnutrition and infectious diseases. Research following the 2011 Great East Japan Earthquake further demonstrated that clear operational guidance is critical to protecting breastfeeding exclusivity and preventing unnecessary replacement feeding with BMS (13). These adverse outcomes reflect not only disaster severity, but also deficiencies in preparedness and implementation of established infant feeding guidance. Evidence from recent emergencies in high-income countries also demonstrates persistent gaps in preparedness for infant and young child feeding, with poor integration into emergency planning (14). These findings reinforce the need for systematic integration of IYCF-E guidance into national disaster preparedness frameworks across all settings. In response to such gaps, the OG-IFE was affirmed through World Health Assembly Resolutions 63.23 (2010) and 71.9 (2018), which call on Member States to align national preparedness plans with global IYCF standards (4, 15, 16).

This study aims to identify and prioritize earthquake-prone countries where IYCF disruptions are most likely to happen (due to a relatively large number of fatalities and/or destroyed infrastructures), and to assess preparedness gaps relevant to implementing the OG-IFE, including gaps in guidance accessibility. Altogether, these risk-informed indicators are intended to support strategic preparedness planning and targeted actions before major seismic events occur.

Methods

This study used a descriptive, implementation-informed approach to identify earthquake-prone countries where infant and young child feeding practices may be most vulnerable to disruption and where gaps in OG-IFE preparedness may be most consequential. The three indicators used, Average Annual Fatalities (AAF), Average Annual Area Damaged (AAA), and exclusive breastfeeding (EBF) rates, were examined separately and were not combined into a composite score. The study does not seek to establish a causal relationship between seismic exposure and infant feeding outcomes; rather, it identifies countries where the conditions associated with post-earthquake IYCF disruption overlap, to support targeted preparedness planning before major seismic events occur.

The Global Seismic Risk Model (GSRM), developed and maintained by the Global Earthquake Model (GEM) Foundation (17), uses a probabilistic method to evaluate seismic risk and estimate the potential impacts of earthquakes on buildings and people. It has three components: (1) a seismic hazard model (18), which predicts the ground shaking for specific earthquakes; (2) an exposure model (19), which maps the locations and key features of buildings; and (3) a vulnerability model (20), which estimates how likely buildings are to be damaged by shaking. These components are analyzed using the OpenQuake engine (21) developed by the GEM Foundation.

The model simulates potential earthquakes over a long period and calculates each earthquake's impact by combining ground shaking intensity, building exposure, and vulnerability. Metrics such as economic loss, fatalities, and damaged/collapsed buildings are averaged over time to give annualized results, which can then be used to compare seismic risks across regions. We obtained data on Average Annual Fatalities (AAF) and Average Annual Area Damaged (AAA) from the country-level outputs of the 2023 GSRM report (22) database, which comprises 198 countries or territories. The AAF reflects the estimated yearly human deaths from earthquake-induced building collapses, including maternal/caregiver deaths. Countries with the highest AAFs were considered more likely to face challenges for infant feeding, in any form, post-earthquake.

The AAA reflects the estimated annual area of buildings in square kilometers that need repair or replacement, caused by the impact of earthquakes, and is used herein as a proxy measure for the overall potential of earthquake-related destruction. Countries/territories with high AAA values were considered to face challenges for safe feeding of non-breastfed infants, given the potential reduction in access to essential resources like clean water, sanitation, BMS, and healthcare services, which could impact safe and hygienic infant feeding practices.

Additionally, EBF rates for each country were analyzed to identify further risks to infant feeding post-earthquake. We assumed that countries with EBF rates lower than 50%, which was the global nutrition target for exclusive breastfeeding endorsed by World Health Assembly Resolution 65.6 for 2025, would likely face more significant challenges for safe infant feeding of non-breastfed infants (23). The target has since been raised to at least 60% by 2030 (24), and both values are examined in the sensitivity analysis reported in Supplementary Table 1.

The selection of AAF, AAA, and EBF was based on three considerations: relevance to the OG-IFE framework, availability in comparable global datasets, and their ability to represent different pathways of post-earthquake infant feeding disruption. AAF was used to identify countries where earthquake-related mortality may increase the risk of caregiver loss. AAA was used to identify countries where damage to buildings and infrastructure may reduce access to clean water, sanitation, fuel, healthcare, and infant feeding supplies. EBF rates were used to identify countries where a larger share of infants may already depend on breastmilk substitutes before an earthquake occurs. These indicators were therefore selected because they reflect distinct but potentially compounding challenges for IYCF preparedness in earthquake-prone settings, consistent with the operational risks described in the OG-IFE and in post-earthquake IYCF literature (7, 10, 25).

Other indicators, such as sex-disaggregated earthquake mortality, health system capacity, caregiver-specific mortality risk, or urban population density, would also be relevant to post-earthquake IYCF planning. However, comparable global data for these measures were not available across all 198 countries and territories included in the GSRM database. AAF and AAA were available as country-level GSRM outputs, while EBF rates were available from UNICEF and country-specific sources with sufficient coverage for this analysis (17, 22, 26). The use of these three indicators should therefore be interpreted as a practical and transparent approach within the limits of available secondary data, not as a claim that they capture all dimensions of earthquake-related IYCF risk.

The indicators were not combined into a weighted score. Instead, they were applied sequentially to identify countries where multiple conditions associated with post-earthquake infant feeding disruption overlap. Countries appearing in both the top-20 AAF and top-20 AAA lists were considered most likely to face both caregiver-related and infrastructure-related challenges. EBF rates were then reviewed to identify settings where baseline reliance on BMS may further increase the need for controlled BMS management, breastfeeding support, and other OG-IFE preparedness actions. This approach reflects a descriptive prioritization logic rather than a validated predictive model.

Each indicator reflects a distinct pathway through which earthquakes can disrupt IYCF. High AAF values indicate substantial potential loss of life among mothers and caregivers, which may require rapid activation of lactation support, wet nursing or donor human milk pathways, and/or targeted support for non-breastfed infants. The AAF metric is used as a proxy for caregiver loss and separation risk. As noted in the Limitations, AAF reflects total fatalities and is not disaggregated by sex or household role; the inference that high-AAF countries face elevated caregiver mortality risk is supported by evidence from specific post-earthquake settings rather than by the GSRM data directly. High AAA values indicate the likely scale of infrastructure disruption, including reduced access to clean water, sanitation, fuel, healthcare services, and supply chains, which increases the operational requirements and safety risks associated with BMS use. Low EBF rates indicate greater baseline reliance on BMS and a larger number of infants who may require controlled, well-supported artificial feeding interventions under OG-IFE. Countries were selected through a stepwise process. In the first step, the 20 countries with the highest AAF values were identified. In the second step, the 20 countries with the highest AAA values were identified from the same dataset. These steps were conducted independently. In the third step, the 16 countries appearing in both lists were identified as the core group most likely to face compounding challenges for safe infant feeding following an earthquake. The remaining eight countries, each appearing in only one top 20 list, were also retained, giving a total of 24 countries for analysis. In the fourth step, EBF rates for all 24 countries were reviewed to identify those with greater dependency on breastmilk substitutes. Countries are listed alphabetically in Table 1; no composite ranking or weighting was applied across indicators.

Table 1. High-Risk earthquake countries falling in the top 20 with the highest AAF values and/or AAA values listed with EBF rates and the absence or presence of operational guidance in their respective national languages.

(26).

(27).

(28).

(29).

(30).

Subsequently, we evaluated the availability of the OG-IFE in the corresponding national languages of the top 20 AAF and AAA countries (4). The absence of guidance in the local language was used as a proxy for one specific aspect of preparedness accessibility: the accessibility of guidance documents to national and subnational responders. This indicator reflects document availability only and should not be interpreted as a measure of overall implementation readiness, which would additionally require trained personnel, institutionalized protocols, coordination mechanisms, and pre-positioned resources. The absence of translated guidance represents a specific and addressable barrier; its presence confirms only that this particular barrier has been addressed. Availability in widely used national languages was nonetheless treated as a practical starting point for identifying preparedness gaps, recognizing that translation is necessary but not sufficient for full implementation.

Results

The study analyzed data on the risk of infant feeding disruptions due to earthquakes by examining indicators separately: Average Annual Fatalities (AAF), Average Annual Area Damaged (AAA), Exclusive Breastfeeding (EBF) rates, and the availability of Operational Guidance in national languages. Table 1 presents each indicator and its respective values. Twenty-four countries ranked in the top 20 for either AAF or AAA values, with sixteen of these appearing on both lists: Afghanistan, Algeria, Bangladesh, China, Guatemala, India, Indonesia, Iran, Italy, Mexico, Pakistan, Peru, the Philippines, Romania, Taiwan, and Türkiye. These countries show the greatest overlap of indicator conditions associated with post-earthquake infant feeding disruption, and they may require further national and subnational OG-IFE preparedness assessment. Additionally, El Salvador, Haiti, Nepal, and Uzbekistan were in the top 20 for AAF but not AAA, while Colombia, Ecuador, Japan, and the USA ranked in the top 20 for AAA but not AAF. These two groups differ in the nature rather than the degree of the challenge they present. Colombia, Ecuador, Japan, and the USA appear in the top 20 for AAA but not AAF, reflecting large built-up area combined with comparatively lower estimated fatality burden. El Salvador, Haiti, Nepal, and Uzbekistan appear in the top 20 for AAF but not AAA, reflecting higher estimated fatality burden relative to a smaller total built-up area. The first group may therefore face predominantly infrastructure- and supply-chain-related challenges to safe feeding, while the second may face predominantly caregiver-related challenges, and preparedness planning may need to be weighted differently in each case.

As shown in Figure 1, China (AAF 3,979), Pakistan (AAF 2,615), Türkiye (AAF 2,237), India (AAF 1,940), and Iran (AAF 1,900) exhibited the highest AAF values, indicating significant human losses, including caregivers. Afghanistan (AAF 1,418), Bangladesh (AAF 477), and Peru (AAF 543) also reported high AAF values, which could disrupt breastfeeding continuity due to maternal fatalities. In contrast, Colombia (AAF 176), Taiwan (AAF 182), and Italy (AAF 181) ranked lower but remain at risk due to infrastructure damage and varying EBF rates.

The highest AAA values were observed in China (13.79 km²), Pakistan (8.73 km²), India (8.57 km²), Türkiye (8.27 km²), and Iran (6.35 km²), highlighting the potential for widespread destruction of infrastructure essential for safe infant feeding practices (Figure 1). Japan (AAA 7.00 km²), Mexico (AAA 3.45 km²), and the USA (AAA 3.85 km²) also exhibited significant infrastructure damage, which could hinder access to clean water and infant feeding supplies. Countries such as Colombia (AAA 2.87 km²) and Taiwan (AAA 2.95 km²) had moderate AAA values, but their reliance on non-breastmilk alternatives could still present challenges in emergency settings.

EBF rates varied across high-risk countries. Afghanistan (EBF 63.3%), Bangladesh (EBF 62.6%), India (EBF 64%), and Peru (EBF 66.9%) demonstrated relatively high EBF rates, suggesting a stronger baseline for sustaining breastfeeding post-disaster. In contrast, China (EBF 35.1%), Japan (EBF 37.4%), Italy (EBF 30.0%), and Algeria (EBF 28.6%) reported lower EBF rates, indicating greater reliance on BMS and heightened vulnerability to unsafe infant feeding practices and supply chain disruptions. Romania (EBF 15.8%) and the USA (EBF 25.8%) also had low EBF rates, necessitating contingency plans for artificial feeding.

The 50% EBF threshold was used because it corresponds to the World Health Assembly Global Nutrition Target for exclusive breastfeeding in the first six months of life, while the 60% threshold reflects the updated global target for 2030 (24). To assess whether the 50% cutoff affected the interpretation of EBF-related vulnerability, country groupings were also examined using lower and higher sensitivity thresholds of 35% and 60%, as presented in Supplementary Table 1.

Several countries in the high-risk group fall close to the 50% threshold, including Guatemala (53.2%), Indonesia (50.7%), Uzbekistan (49.5%), Pakistan (47.8%), Iran (47.4%), and El Salvador (46.7%). Under the lower 35% threshold, all six countries exceed the cutoff; under the higher 60% threshold, all six fall below it. These countries should therefore be interpreted as near-threshold cases rather than as categorically distinct high- or low-EBF settings.

The countries with the lowest EBF rates were less sensitive to the primary 50% cutoff. Romania (15.8%), the USA (25.8%), Algeria (28.6%), Italy (30.0%), and Taiwan (30.9%) remained below both the 35% and 50% thresholds. China (35.1%) remained below the primary 50% threshold and the higher 60% threshold but was just above the lower 35% sensitivity threshold. These findings indicate that the EBF threshold affects interpretation mainly for countries near the cutoff, while the identification of countries with overlapping AAF and AAA risk is unchanged because those indicators were derived independently from the GSRM data. EBF classifications should therefore be treated as descriptive profiles of baseline BMS dependency, not as validated risk categories or as a composite ranking of preparedness priority.

The OG-IFE is available in the national language of several of the 24 high-risk countries, including Algeria, Bangladesh, Colombia, Ecuador, Guatemala, India, Indonesia, Italy, Mexico, Peru, and Türkiye. Afghanistan, China, Iran, Nepal, Pakistan, the Philippines, Romania, Taiwan, and Uzbekistan currently lacked translated guidance, indicating a specific gap in document accessibility for national and subnational responders. Document availability alone does not confirm implementation readiness, which would additionally require trained personnel, institutionalized protocols, and operational coordination structures.

These findings highlight the varying risks faced by high-exposure countries. Some countries face greater caregiver losses, others face significant infrastructure damage, and many struggle with low EBF rates. The combination of these factors influences the overall risk of infant feeding disruptions in the aftermath of earthquakes.

Discussion

This study examined three indicators relevant to post-earthquake infant and young child feeding, including Average Annual Fatalities, Average Annual Area Damaged, and exclusive breastfeeding rates, to identify countries where preparedness gaps may be most consequential. The associations described are grounded in the operational pathways described above rather than tested statistically in this dataset. The study does not demonstrate that high AAF causes breastfeeding disruption, but rather identifies countries where conditions associated with caregiver loss, infrastructure damage, and baseline breastmilk substitute dependency may create operational challenges for safe infant feeding. The findings are intended as a prioritization tool for preparedness planning and should not be interpreted as statistical evidence of causation.

Caregiver loss and AAF

High AAF values indicate substantial loss of human life, particularly among mothers and caregivers which can significantly disrupt breastfeeding continuity and infant nutrition. Evidence from earthquakes in Afghanistan and Italy indicates that maternal mortality and morbidity can compromise IYCF by interrupting breastfeeding and increasing reliance on artificial feeding under resource-constrained conditions (31, 32). In Afghanistan, the 2023 earthquake resulted in disproportionately high female and child fatalities, exacerbating the risks associated with infant feeding (33). Similar patterns have been observed elsewhere, with mortality among women of reproductive age elevated in some earthquake settings due to household occupancy trends and physical structural vulnerabilities (8, 34). Infants depend entirely on their caregivers for nutrition and care and will deteriorate rapidly without many foods over a 24-hour period, making them particularly vulnerable in these circumstances. These findings suggest that caregiver loss is critical in shaping IYCF challenges in disaster settings and underscore the need for contingency planning informed by the OG-IFE including ensuring alternative feeding support, rapid deployment of trained staff, and maintaining breastfeeding support and counselling services in disaster response strategies.

The potential disruption in feeding practices can have consequences that extend beyond the acute disaster phase, as inadequate nutrition in early infancy is associated with increased risks of malnutrition, stunted growth, and weakened immune function (1).

Infrastructure damage and AAA

Countries with high AAA values present a distinct challenge, as destruction of buildings and infrastructure can limit access to clean water, sanitation, healthcare and infant feeding resources. Non-breastfed infants in these settings may be vulnerable to malnutrition and increased infection due to lack of immune protection from breastfeeding, coupled with unsafe preparation of BMS. Violations of international codes and challenges in ensuring safe infant nutrition have been documented with critical impact on infant feeding practices (10, 35, 36). In middle- and high-income countries, where BMS dependence among infants is often higher, earthquakes can disrupt supply chains and healthcare services. For instance, during the 2011 Christchurch earthquake in New Zealand, infrastructure disruptions affected the distribution of essential supplies and access to healthcare support for infant feeding (9). Similarly, in the aftermath of the 2011 Great East Japan Earthquake, evacuation shelters faced significant challenges in providing adequate nutrition, particularly for formula-fed infants. A study analyzing dietary conditions in these shelters found that many lacked the facilities and resources necessary for preparing balanced meals, including infant formula. The absence of cooking equipment and disruptions to gas supplies further impeded the ability to provide appropriate nutrition for evacuees (37). Identical challenges were identified in the 2023 Türkiye earthquake, where mothers reported problems regarding information, support, equipment, appropriate space, and food supply related to infant feeding. A lack of attention to the post-disaster nutritional needs of breastfeeding mothers was also identified (12). The 2010 Haiti earthquake demonstrated that structured feeding support interventions, including lactation counseling and controlled BMS distribution, can mitigate post-disaster nutrition risks (38). The destruction of critical infrastructure also affects food distribution channels, reducing access to both maternal nutrition and infant feeding supplies. Countries where infrastructure fragility is already a concern before an earthquake may experience prolonged disruptions in essential services, further exacerbating health and nutrition disparities among vulnerable populations (6). Delays in access to nutritional support can have cascading effects on infant survival and development (1).

These findings reinforce the importance of integrating maternal and infant nutrition services into disaster preparedness, especially in regions with fragile infrastructure.

Exclusive breastfeeding and BMS dependence

EBF rates varied across countries at high risk which impacts vulnerability to post-earthquake feeding disruptions. Afghanistan, Bangladesh, India and Peru's higher EBF rates provide a stronger baseline for sustaining breastfeeding post-disaster. Conversely, low EBF rates in China, Japan, Italy, Algeria, Romania, and the US indicate an increased risk of unsafe feeding practices during infrastructure disruptions due to their higher reliance on BMS. These patterns offer an opportunity for targeted, tailored preparedness intervention including provision of a full package of supports to ensure safer BMS use.

Operational guidance and implementation

The availability of OG-IFE guidance in a country's national language represents one addressable barrier to rapid, standardized emergency response. Among the 24 high-risk countries identified, nine currently lack translations in their primary official languages: Afghanistan, China, Iran, Nepal, Pakistan, the Philippines, Romania, Taiwan, and Uzbekistan. Addressing this gap is a concrete preparedness action that can be taken before a seismic event occurs. However, translation alone is not sufficient. Research has identified structural, socio-economic, and cultural barriers that hinder the effective implementation of IYCF-E policies even where translated guidance is available (39). Effective implementation also requires that guidance be integrated into national disaster management plans, supported by pre-event training and role designation, and coordinated across agencies (4, 15). The language availability data presented here indicate a specific document accessibility gap and should not be interpreted as a broader measure of preparedness capacity.

Implications for OG-IFE implementation

The study findings highlight key IYCF preparedness priorities for earthquake-prone countries. These priorities focus on feeding-related preparedness under the OG-IFE framework, including protection, promotion, and support for breastfeeding, controlled BMS management, and support for non-breastfed infants when breastfeeding is reduced or not possible (5, 25). Caregiver death, incapacity, or separation may also create psychosocial and developmental risks for surviving infants and young children, particularly when the loss or disruption involves a primary caregiver (40). Preparedness planning should therefore address caregiver loss as both a feeding continuity issue and an infant protection concern. OG-IFE-aligned interventions for caregiver loss or separation should be understood as more than nutritional interventions. Measures such as breastfeeding support, relactation, skin-to-skin contact, wet nursing where appropriate and safe, donor human milk where available, and controlled BMS management can help restore safe feeding while also supporting caregiver-infant contact and infant regulation (4, 5, 42). This is particularly important in the first months of life, when feeding, physical contact, comfort, and caregiver responsiveness are closely connected. Preparedness planning organized around the OG-IFE framework may therefore have psychosocial protective value for infants, even when specialized mental health and psychosocial support is coordinated through separate emergency response mechanisms (43).

• Prioritization of high-risk countries by focusing on those with high AAF and AAA values, low EBF rates and without translated guidance
• Preparedness investments through implementing the OG-IFE to improve access to maternal and infant supports including access to safer options when breastfeeding is reduced or not possible (5, 25).
• Translation and dissemination of the OG-IFE in all relevant national languages to facilitate preparedness and response. Priority should be given to translations in the official languages in Afghanistan, China, Iran, Nepal, Pakistan, the Philippines, Romania, Taiwan, and Uzbekistan.
• Incorporation of preparedness protocols for caregiver or maternal death, incapacity, and separation. These protocols should include pathways for breastfeeding support, relactation, wet nursing where appropriate and safe, donor human milk where available, and controlled BMS management when no human milk option is feasible (5, 25). They should also include mother-to-mother support, mother-baby or baby-friendly spaces, breastfeeding counseling, and referral pathways for psychosocial support when infants are separated from or bereaved of primary caregivers (40, 41).

For surviving caregivers, separation, injury, bereavement, or other earthquake-related disruptions may lead to involuntary interruption or cessation of breastfeeding. This experience should not be treated only as a feeding problem. When breastfeeding had been desired, established, or central to the caregiver-infant relationship, inability to continue may be experienced as a significant loss and may be accompanied by sadness, guilt, shame, anxiety, or depressive symptoms (44–47). Post-disaster support planning should therefore acknowledge the emotional consequences of disrupted breastfeeding and ensure access to lactation support, relactation counseling, and psychosocial referral pathways when needed.

Together, these preparedness measures can reduce post-earthquake disruptions to infant feeding, enhance resilience across the population, and align national preparedness strategies with the global OG-IFE.

Future research

This study contributes to the broader understanding of the interplay between caregiver loss, infrastructure damage, and IYCF preparedness in earthquake-prone regions. The findings align with existing literature on disaster nutrition and risk mitigation strategies by identifying patterns across AAF, AAA, EBF rates, and policy implementation gaps. The results suggest that further research into the relationships between gendered mortality patterns, infrastructure resilience, and emergency feeding strategies may provide additional perspectives on improving infant nutrition outcomes in post-earthquake settings. Expanding these analyses across diverse geographic contexts will be valuable in strengthening IYCF resilience in high-risk regions. Future research should evaluate how different support models can be adapted for earthquake preparedness and response. This includes telelactation and remote breastfeeding counseling after earthquakes (48). It also includes culturally and socially appropriate IYCF support strategies during natural disasters (49). Mother-baby or baby-friendly spaces should also be examined, particularly when they combine infant feeding support with maternal mental health, caregiving, and early child development services in humanitarian settings (38, 50). Further research should also examine how policy, community engagement, preparedness systems, and response capacity interact to strengthen IYCF frameworks in earthquake-prone regions.

These findings require a substantive qualification about how country-level prioritization should be interpreted for operational use. The framework provides a first-level screen for identifying countries where aggregate conditions associated with post-earthquake IYCF disruption are present. It does not identify where within those countries risk is concentrated, nor does it distinguish the subnational configurations most relevant to response planning. India illustrates this limitation. India appears in the core overlap group for both AAF and AAA and has a high national EBF rate, but a major earthquake affecting the National Capital Region would present a different operational profile from one affecting rural or mountainous districts in Assam or Uttarakhand, where seismic exposure, population density, infrastructure conditions, health service access, and infant feeding practices may differ substantially (51, 52). A single national EBF estimate, and aggregate seismic risk values cannot capture this variation.

The same qualification applies to other large and geographically diverse countries in the analysis, including China, Pakistan, Indonesia, and the United States. These countries contain substantial internal variation in seismic exposure, urbanization, infrastructure resilience, health system access, and infant feeding practices that country-level indicators may mask. Therefore, the country rankings presented here should be interpreted as indicators of where national preparedness investment may be warranted, not as evidence identifying the specific sub-populations, districts, or provinces most likely to experience post-earthquake IYCF disruption. Operational planning would require subnational seismic exposure data, localized EBF estimates, infrastructure mapping, and response capacity assessments that were beyond the scope of the present analysis.

Subnational and event-based operational illustrations: India and Türkiye

India: subnational variation in seismic exposure and EBF

India illustrates why country-level prioritization should be interpreted as a first-stage screen rather than as an operational map. India appears in the core overlap group for both AAF and AAA and has a high national EBF rate in Table 1, but these national values can conceal important subnational differences. India's official seismic zoning places the Himalayan and north-eastern belts, including Assam and Uttarakhand, among higher-seismic-risk settings, while the National Capital Region represents a dense urban exposure with different infrastructure, displacement, and service-access constraints (51). NFHS-5 also reports infant feeding indicators below the national level, allowing EBF and related IYCF preparedness conditions to be assessed by state/union territory and residence rather than only as a national average (52).

Operationally, an earthquake affecting Delhi/NCR would require planning for dense displacement sites, disrupted urban supply chains, and rapid identification of infants dependent on BMS, whereas an event affecting rural or mountainous districts in Uttarakhand or Assam would place greater emphasis on terrain, transport interruption, decentralized service access, and community-based breastfeeding support. This example shows that a country can be correctly identified as a national preparedness priority while still requiring subnational seismic exposure data, localized EBF estimates, infrastructure mapping, and response-capacity assessments to decide where and how OG-IFE investments should be implemented.

Türkiye: recent earthquake evidence of IYCF disruption

Türkiye provides an event-based illustration of why country-level prioritization should be supplemented with disaster-specific and subnational evidence. Türkiye appears in the core overlap group for both AAF and AAA and has an EBF rate below the 50% threshold in Table 1, indicating both seismic exposure and greater baseline reliance on BMS. Unlike most countries in this analysis, Türkiye also has recent post-earthquake IYCF evidence from the 2023 Kahramanmaraş earthquakes. Mothers in the earthquake-affected region described disruptions in breastfeeding and infant feeding related to access to formula, safe food preparation, hot water, electricity, hygiene, suitable spaces for infant care, maternal health, and psychological distress (12). A separate observational study documented infant formula donations and International Code violations during the earthquake relief effort, including untargeted formula-related donations and practices that could undermine breastfeeding and safe BMS management (35). This case illustrates how a high-risk country can move from preparedness risk to observed post-earthquake operational challenges, and it reinforces the need for pre-event translation, responder training, controlled BMS protocols, breastfeeding counseling, and mother-baby spaces tailored to affected provinces rather than relying on national averages alone.

Limitations

This study has several limitations. First, the country-level unit of analysis is a meaningful constraint on the precision of the findings. Earthquake impact, breastfeeding prevalence, infrastructure resilience, and OG-IFE implementation capacity may vary substantially across urban and rural areas within the same country, and country-level indicators cannot capture this variation. The India and Türkiye illustrations show why national prioritization is useful for identifying countries where preparedness investment may be warranted, but insufficient for operational response planning. Operational planning would require subnational seismic exposure data, localized IYCF and EBF estimates, infrastructure mapping, health service access information, and response-capacity assessments. This limitation applies across all 24 countries in the analysis and is particularly relevant for large, geographically diverse countries such as China, Pakistan, Indonesia, India, Türkiye, and the United States.

Second, the study relies on secondary data, which may not capture all nuances of local conditions or recent changes in infrastructure and health practices. We assumed that average EBF rates applied equally throughout each country; however, EBF rates may differ across the areas within a country most likely to be affected by a given earthquake.

Third, the EBF data used in this study are drawn from sources that vary in reference year and methodology. The majority come from UNICEF 2021 estimates, which are derived primarily from Demographic and Health Surveys and Multiple Indicator Cluster Surveys using standardized protocols across countries. However, country-specific sources were used for India (2024), Taiwan (2024), Italy (2025), and Japan (2021), each drawing on national surveillance data, hospital-based studies, or birth cohort studies with different sampling frames, reference populations, and definitions of exclusive breastfeeding. Differences between countries in Table 1 may therefore partly reflect methodological variation rather than true differences in breastfeeding prevalence. EBF rates also change over time due to policy shifts, urbanization, and infant formula marketing, and countries such as China and Romania may have experienced meaningful changes since the reference data were collected. The EBF values in Table 1 should therefore be interpreted as reflecting conditions at the time of data collection rather than as current figures, and these profiles should be updated as more recent comparable estimates become available. Additionally, the 50% EBF threshold used to distinguish countries with greater versus lower dependency on BMS introduces classification imprecision at the margin. Several countries cluster close to this cutoff, including Indonesia at 50.7%, El Salvador at 46.7%, and Uzbekistan at 49.5%, and the classification of these countries should be treated as approximate.

Fourth, the AAF and AAA data do not account for differentiation by sex or age in the estimates of earthquake impact. The inference that high-AAF countries face elevated risk to breastfeeding continuity, because maternal and caregiver mortality may interrupt infant feeding, is supported by evidence from specific post-earthquake settings in Afghanistan, Italy, Japan, and Pakistan, where women of reproductive age faced disproportionate mortality (8, 33, 34). This inference does not derive from the GSRM dataset itself, which reflects total fatalities only. Countries with different household occupancy patterns or structural vulnerability profiles may present different actual risks to caregivers specifically.

Fifth, although this study acknowledges the psychosocial consequences of caregiver loss and disrupted breastfeeding for surviving infants and caregivers, it does not provide a full analysis of how OG-IFE preparedness intersects mental health and psychosocial support (MHPSS) frameworks. Such an analysis lies beyond the scope of the present study. Future research examining how OG-IFE implementation can be coordinated with MHPSS mechanisms in post-earthquake settings would strengthen the evidence base for comprehensive infant protection planning (43).

Future applications of this framework would benefit from sex-disaggregated seismic mortality estimates as these become available. Finally, the study does not account for a country's resilience to earthquakes, such as emergency preparedness measures, healthcare system strength, or community support networks, as these factors are difficult to measure comprehensively.

Conclusion

Countries with high earthquake fatalities (AAF), high annualized infrastructure damage (AAA), and low exclusive breastfeeding (EBF) rates show the greatest concentration of conditions associated with infant and young child feeding disruption during seismic disasters, and they may require further national and subnational OG-IFE preparedness assessment. Strengthening breastfeeding protection and support, while embedding the Operational Guidance on Infant and Young Child Feeding in Emergencies (OG-IFE) into national disaster preparedness and response systems, is a critical strategy to mitigate these compounded vulnerabilities.

Generative AI statement

The author(s) declared that generative AI was used in the creation of this manuscript. Grammarly was used for language editing, and Claude (Anthropic) was used to clarify editorial queries and to assist in drafting proposed revisions. The authors independently reviewed and verified all changes, references, numerical values, and interpretations, and take full responsibility for the final content. Neither tool was used to generate data, conduct the analysis, or formulate the study's findings or conclusions.

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Footnotes

Edited by: Alessandro Iellamo, FHI 360, United States

Reviewed by: Tamorish Kole, University of South Wales, United Kingdom

Ahmet Gülsoy, Kastamonu University, Türkiye