|Breastfeeding: from Biology to Policy (UNSSCN, 1998, 28 p.)|
I will now give an example of attempts we have made in The Gambia to break some of these barriers through a Baby-Friendly Community Initiative (BFCI) project. Breastfeeding is a universal practice in The Gambia but exclusive breastfeeding is rare and weaning foods are introduced by the age of three months. In 1993, the Nutrition Unit of the Department of State for Health initiated a pilot project - the Baby-Friendly Community Initiative. The concept of a community initiative was derived from the global UNICEF/WHO Baby-Friendly Hospital Initiative (BFHI) of 1991. This involved 12 rural communities in the Lower River Division of The Gambia.
The rationale behind the community initiative was that most deliveries in the Gambia occurred at home, and those women who delivered at health facilities only stayed there for a day or less with a normal delivery. The way mothers fed their infants was therefore influenced to a greater extent by the traditional beliefs and practices in their home environment.
The aim of the BFCI was to improve infant feeding practices in rural Gambia. Among the objectives were:
à to get 25% of mothers to practice exclusive breastfeeding for at least 4 months;
à to get 90% of mothers with normal delivery to initiate breastfeeding within an hour of delivery.
A baseline study was carried out using quantitative and qualitative methods. The aim was to identify current infant feeding practices, including the traditional beliefs and practices influencing them. All mothers with infants 0-12 months were included in the study (n = 324). Results from this baseline study indicated sub-optimal feeding practices.
A methodology using an integrated approach was developed for the intervention. This included '10 steps to successful infant feeding', based on the Baby-Friendly Hospital Initiative '10 steps' (WHO, 1989). However, the community initiative went beyond breastfeeding to include maternal nutrition (using locally available foods), weaning, environmental sanitation and personal hygiene. This integrated approach was important so as to emphasize the linkages between maternal and infant nutrition, and a clean environment. It was expected that this approach would also create the opportunity for maximum community participation in the project.
The 10th step of the Baby-Friendly Hospital Initiative was used as a basis for the creation of village support groups. In this instance, mother-to-mother support groups (Kyenkya-Isabirye and Magalhaes, 1990) took on a new meaning with the inclusion of men in the groups. A village support group consisted of five women and two men - identified by their communities - to be trained to implement and monitor the initiative. Among them was the traditional birth attendant whose role in the project was crucial because she delivered babies in her community. Support group members were aware from the outset that they were voluntary and did not expect any remuneration.
A guide was developed for training the village support groups. It was divided into sessions ranging from maternal and infant nutrition, to environmental sanitation and personal hygiene, using material from WHO, UNICEF and Wellstart International. In the training, the participants were viewed from a dual perspective: first as a target for attitudinal change, and second as educators for their communities. In this regard therefore, the training had a dual objective: to influence the attitude of the participants, and to equip them with relevant and adequate information for their role as educators.
How does one attempt to influence the attitude of a target person within a limited period? First of all, it is by acknowledging that the targets have their own local knowledge, which would most probably differ from our knowledge. To disregard this local knowledge could be detrimental to the achievement of the project objectives.
This meant that participants were given the opportunity to discuss a topic e.g., colostrum, based first on their local traditional knowledge. The trainer using modern scientific knowledge then presented the topic. Finally, participants were again given the opportunity to question, argue and gradually understand the topic from their own perspective. This gave us the following equation:
Modern/Scientific Knowledge + Local/Traditional Knowledge = Credible Knowledge
One example of how this equation worked, is the understanding of the concept of exclusive breastfeeding by the participants. Giving prelacteal feeds as well as water and other liquids throughout the breastfeeding duration was considered the norm. Therefore exclusive breastfeeding was a modern concept which participants could not accept. However, through discussions, participants recalled that their newborn animals (livestock)3 breastfed only without drinking any water for an unspecified period, yet they did not die. Based on this reasoning, the practice of exclusive breastfeeding seemed credible for human babies.
3 The Gambia is predominantly an agricultural society.
Apart from theoretical information, the training emphasized practical solutions to simple problems which breastfeeding mothers may encounter. These included cracked or sore nipples and engorged breasts for which avoidable causes and simple solutions were identified. It was expected that such practical information would make the support groups more persuasive and credible in their communities.
The support groups were also taught about breastmilk expression for mothers who had to be away from their infants for short periods. There was some reluctance to this based on local belief that breastmilk can turn sour if not utilized for several hours. Even mothers who are away from their babies for a few hours were, according to local tradition, expected to express and throw away the first milk before breastfeeding.
Men are important actors in infant feeding decisions but are not usually targeted by breastfeeding intervention programmes. Their involvement in this initiative as both information providers and information recipients, was a formal acknowledgement of the important role they play. It was also one step further to achieving the objectives of the BFCI. Mothers alone may find it difficult to take a decision on exclusive breastfeeding without the support of their husbands. With men as members of the support group, it was also assumed that it would be easier to convince their fellow men as well as to support their wives.
Almost all the participants were non-literate, but a graduation ceremony after the training with certificates issued to all the participants proved to be highly motivating. The ceremony, involving senior officials from the Health Ministry and other government institutions as well as NGOs, was a sign of government support and acknowledgement of their participation in the project.
There was regular monitoring and retraining of the support groups by the Nutrition Unit. According to the group members, these activities not only strengthened the groups; they also served to motivate them.
Target groups were specified by the project as being pregnant and lactating women and their spouses. How information was disseminated in the communities was left entirely to the village support groups. The support groups were very innovative. They used house-to-house visits, village gatherings, ceremonies, songs, dances and role-plays to disseminate information. The '10 steps' were made into songs and were sung at every opportunity thereby enabling even small children to learn about breastfeeding and its importance. Some communities expanded their target groups to include schools, where they gave talks and choreographed plays by the pupils.
Impact - 'susundiri timaringo'
The practice of exclusive breastfeeding became universal as a result of the project. This was somewhat unexpected, given the scepticism voiced by some individuals in the communities. Breastfeeding was initiated within one hour of delivery by 87% of mothers after the intervention. A full 99.8% initiated within 24 hours of delivery. This can be compared to 40% initiation later than 24 hours following delivery prior to the intervention. The duration of exclusive breastfeeding also increased considerably. After the intervention 99.5% of mothers (n = 413) fed only breastmilk at four months of age as opposed to only 1.3% before the intervention (n = 324).
Attitudinal change was evident from the way in which colostrum was described. Before the intervention, colostrum was referred to as bad milk, dark milk or hot milk. After the intervention, colostrum was referred to as the protective milk. Furthermore, exclusive breastfeeding did not have a local name before the intervention and was regarded as a foreign concept. During the intervention, a new term in Mandinka was coined - susundiri timaringo - which translates literally as the 'complete breastfeeding', and this became a password in the communities.
The unifying effect of the project on community members was another unexpected outcome of the BFCI. Optimal breastfeeding became the concern of both mother and father, while adequate maternal nutrition became the concern of wife and husband. Environmental sanitation involved the whole community resulting in regular village clean-up.
Awareness of the importance of an enabling environment for breastfeeding mothers was raised through this initiative. This is defined as any activity that enhances the mother's capacity to practice optimal breastfeeding, specifically exclusive breastfeeding. Rural women farmers however, may face similar constraints as their counterparts in the formal sector (Saadeh et al, 1993) with regards to inadequate day care facilities at the workplace. During discussions with the communities, it was learnt that the mothers in this project were no exception. Traditional shelters at the fields, which had been used to protect infants from various weather conditions no longer existed in most of these communities. Consequently, the concept of a 'Baby Friendly Rest House' at the field, was born as a by-product of the traditional shelters and the modern cres. Eight communities opted for them and mobilized both men and women to construct them.
A 'community maternity leave' concept was also derived from the example of a 12-week government maternity leave and the traditional 40 days rest for new mothers. This involved community assistance for the breastfeeding mother at her farm and while she stayed home with her infant, for a period of up to six months or more. It was adopted unilaterally by one community while the remaining communities chose to have it as an option for individual households.
Expressing and storing breastmilk for the infant - previously considered an undesirable practice - was now done by mothers who had been convinced by support group members that this was a safe and practical method of infant feeding. This practice was widely adopted by mothers who had to be away from their infants. The expressed milk was often stored at the foot of their clay water jars, which was believed to be the coolest place in the house.
All the above contributed to an enabling environment for rural mothers to practice exclusive breastfeeding for up to six months.