Early nutrition practices and access to food and nutrition services for young malnourished children attending MSF-supported facilities in Herat, Afghanistan: a mixed-methods study

Afghanistan’s protracted humanitarian crisis has intensified food insecurity and child malnutrition. In 2022, Medecins Sans Frontieres (MSF) reported that 45% of malnourished children admitted to Khadestan hospital were under 6 months, yet evidence on feeding practices and access barriers for infants < 12 months in Herat is limited. To describe breastfeeding and complementary feeding among infants aged 0–11 months attending MSF-supported services in Herat and to examine caregivers’ needs and barriers to food and nutrition services using the demand-side domains of Levesque’s access-to-care framework. Explanatory mixed methods in two MSF-supported facilities (Herat Regional Hospital; Khadestan clinic). Phase 1 analysed routine programme data (August–September 2022), including infant feeding practices, maternal and child food insufficiency and related coping strategies, health-seeking behaviour, and barriers to accessing health and nutrition services for all infants 0–11 months admitted with acute malnutrition (including severe acute malnutrition, SAM). Phase 2 comprised 38 in-depth interviews with caregivers of malnourished and non-malnourished infants and key informants (Jan–Jun 2023). Participatory approaches included training community peer researchers, informed tool refinement, data collection, and interpretation. Phase 1- Sixty-seven% of the children accompanied by the mother to the MSF health facilities ( N = 236) were currently breastfed, but only 17.8% of the children aged 0–5 months received breast milk without other foods or liquids according to their mother. Women frequently cited perceived low milk supply and limited breastfeeding support. Among infants ≥ 6 months, the majority ate ≥ 3 times/day, but diets were mainly cereals with frequent sweets. Although 92.3% of mothers ate ≥ 3 times/day, 63.5% reported ≥ 1 day of food insufficiency in the prior week; coping strategies included portion reduction mostly and meal skipping. For child illness episodes, 75.0% sought facility care first, yet 62.3% reported access barriers (distance, transport costs, poor roads, seasonal constraints). Phase 2- Interviews identified constraints across Levesque domains: low female literacy and reliance on informal advice (perceive); restricted autonomy, gender norms, and language-related stigma (seek); long travel times and harsh climatic/road conditions (reach); poverty and costs of transport/medicines (pay); and reduced self-efficacy, suboptimal feeding, and maternal stress/mental health challenges (engage). Early infant feeding among infants accessing MSF-supported health facilities in Herat is shaped by socio-cultural, geographic, and economic barriers. According to the study participants, programmes may pair facility nutrition care with community-led education, early counselling and peer support, targeted food assistance during antenatal/postnatal contacts, affordable transport solutions, and integrated maternal mental health support to improve access and outcomes for infants aged 0–11 months.