More than 200 stakeholders from across West Africa learned how the Stronger With Breastmilk Only initiative is supporting health officials to increase rates of exclusive breastfeeding during webinars in French and English in early December.
The webinar presented the regional initiative, including its objectives, tools and resources, and support for national programs. During a question and answer session of the webinar, participants sought more background on the key messages, the initiative’s design, monitoring and evaluation and sustainability. The discussion is summarized here and includes links to a variety of resources and further information.
The webinar also highlighted the initiative’s new WhatsApp group and invited stakeholders to join.
Addressing the problem of exclusive breastfeeding in West and Central Africa called for a new approach – “business as usual” would not suffice, UNICEF West and Central Africa Nutrition Advisor Simeon Nanama told participants at the 11th Africa Food and Nutrition Security Day global webinar event in October. The new approach is Stronger With Breastmilk Only.
“Thirty per cent of babies are exclusively breastfed (in the West and Central Africa region),” Nanama said. “That is 20 percentage points away from the 50 per cent World Health Assembly 2025 target. And doing business as usual will not get us to meeting that goal.
“So, because of that, we decided to be very systematic trying to understand how we can reimagine the breastfeeding programming…. Building on these these two analyses of quantitative and qualitative data, a regional programme was designed (Stronger With Breastmilk Only).
“The objective is really to focus on advocacy to change social norms and behaviors. It is a large regional campaign and right now 19 countries have subscribed to the campaign.”
Watch Mr. Nanama’s presentation below.
Before I get into how we went systematically on the use of data, I would like to give you an overview of the UNICEF West and Central Africa region. It is a region with 24 countries. Together, those countries are home to 11 percent of the world’s under five children. However they are also home to 20 of the world’s stunted children and 35 percent of the world’s under five death. It means that there is a big discrepancy between population size and all the burden of child-related issues in this particular region. We all know that breastfeeding is important and adequate child feeding – and breastfeeding in particular – is critical for survival development and growth of children and there is a lot of evidence on that. But when we look at the data in this region only 3 out of 10 children are exclusively breastfed and the remaining seven children who are not exclusively breastfed are not exclusively breastfed for different reasons because they are receiving other food in addition to breastmilk.
Breastfeeding is a priority in the UNICEF regional plan for the period 2018-2021 and we really wanted to make sure that we focus and work on this aspect, which is the first line of defense and the first line of prevention when we are talking about malnutrition. But because the situation has not been improving for many years, we thought that we needed to really be innovative, thinking out of the box and trying to be a bit more focused and going to scale to make sure that we make a difference when it comes to improving breastfeeding. Because 30 percent of the babies who are exclusively breastfed that is 20 percentage point away from the 50 of the world health assembly 2025 targets and doing business as usual will definitely would not get us to meeting that that goal.
So because of that, we decided to be very systematic in looking at the data and trying to understand how we can re-imagine the breastfeeding programming. We started by looking at the first step – looking at quantitative data and this is illustrated by the first graph that you see on the upper side of upper left side of the of the slide where the yellow bars are showing the proportion of babies age less than six months that are exclusively breastfed in a number of countries in the region. And the blue part of the bars are the proportion of the children who are fed breast milk plus water. The blue presents those breastfed with receiving water in addition to breast milk and clearly if we are able to remove or reduce the proportion of babies who have fed water we would bring the rate of exclusive breastfeeding to in most of the countries, except maybe two, to the level of 50 which is the 2025 target. So this analysis, the quantitative data has helped us to identify a critical bottleneck which is really water being the problem in most of the countries of the region.
Then we went ahead in a second step to try to understand what are the social cultural barriers to child feeding in general and to breastfeeding in particular: What are the influences of child feeding in the community in the families and what are the enabling factors that we can leverage on to improve breastfeeding? We did that work together with Alive & Thrive and that has helped us to really understand where are, who are the people in the community we need to target if we need to make a difference in in breastfeeding. We also identified the factors that can enable us to make a difference at the community level and in families. And that qualitative study led also to programmatic recommendations. Now building on these two analyses of quantitative and qualitative data, an original program was designed which is called Stronger With Breast Milk Only and you can see the logo on the right hand side of the slide.
The objective is really to focus on advocacy to change social norms and behaviors. It is a large regional campaign and right now 19 countries have subscribed to the campaign. The campaign was launched in Cote d’Ivoire last year and it is being now rolled out. And the idea through this program is really to support, promote and protect adequate child feeding practices, breastfeeding practices and to support the families to engage the community systems in this initiative, to also strengthen this health care system and improve the norms, and to engage the business sector as well and to improve the perception and the social environment around child feeding and strengthening the national policy and regulation related to breastfeeding especially some regulations like the code of marketing of breast milk substitute.
The overall outcome we are aiming at is really to push most of the countries engaged in this initiative to be able to remove water from the feeding of children and to be able to achieve the 2025 uh world health assembly target for exclusive breastfeeding which is 20 to 50 percent at minimum of the of the children being exclusively breastfed. Now the program was launched and it’s being rolled out now we are in a stage where we are working on the next steps which is really to work on the monitoring framework and be able to monitor the countries and see how they are progressing and see what are the bottlenecks they are facing in the implementation of the campaign and help them readjust the program. We also need to engage in knowledge generation and knowledge management to document best practices in countries that are making progress so that the other countries could use that and also speed up the process toward achieving the objective and do the adjustment of the program as we go. This is an example that we are just taking to share with you on how we use data to design a program aiming to reduce malnutrition. We often hear that we are lacking data in many sectors and this is true but it is also true that we can do a lot with the data that we already have in hand.
Separated by quarantines and travel restrictions, nutrition stakeholders have turned to virtual events to connect, share information and discuss issues. Below is a selection of upcoming webinars and virtual events of interest – a list we will update weekly (so check back regularly!). The list includes three sections, Webinars, Conferences, and Useful Online Resources.
Please share your webinar or other virtual activities of interest: Send us an email with the details (be sure to include date, time and a link) or share the information on social media using the hashtag #OnlineMIYCN!
How and why do people make food choices?
Jan. 14, 13:00-14:30 GMT (8 a.m. EST)
The first in a series on “Drivers of food choice in low- and middle-income countries: a synthesis of evidence,” organized by Agriculture, Nutrition & Health Academy. This webinar will include three presentations about selected projects to illustrate key findings on drivers of food choice at the individual and household levels with an emphasis on the dynamic and reciprocal relationship with the food environment. Speakers include Christine E Blake, Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina; Mirriam Matita, Lilongwe University of Agriculture and Natural Resources (LUANAR), Department of Economics, University of Malawi; Helen Walls, London School of Hygiene and Tropical Medicine; and Sigrid Wertheim-Heck, Environmental Policy, Wageningen University. Moderated by Edward A Frongillo, Professor & Director, Global Health Initiatives at Arnold School of Public Health, University of South Carolina, and a member of the Alive & Thrive Strategic and Technical Advisory Group.
Food choice involves the processes by which people consider, acquire, prepare, distribute, and consume foods and beverages. Viewing nutrition and health outcomes through the lens of food choice ties individual perceptions and behaviors to food environments and food systems. People are the key element of any food system, and their interaction with the food environment is a focal point for understanding what, how, and why people eat. The food environment both shapes and is shaped by individual food choices. The DFC portfolio has generated key insights into the drivers of food choice behaviors across diverse settings in LMICs, along with compelling new directions for research focused on understanding the relationships between food environments, food choice, and health outcomes.
Unlocking Potential: Prioritizing Child & Adolescent Health and Well-Being in the New Decade (Global Health Practitioners Conference)
Jan. 27-28, 2021
Implementers, academics, governments, donors, UN, private sector, and other community health advocates convene in this multi-day, content rich meeting that features knowledge sharing and skills building sessions, recent evidence on cross-sectoral technical areas, dialogues on community health, and professional networking. Learn more at https://conference.coregroup.org/theme/
Useful Online Resources
Investing in Child Nutrition: E-learning Course on Infant and Young Child Feeding from A&T, UNICEF, Global Health Media Project, & Raising Children Network
Working with UNICEF and a global network of experts, Alive & Thrive developed an e-learning course based on the World Health Organization (WHO) Combined Course on Growth Assessment and IYCF Counselling as a free online resource to address gaps in training for those working in child health and nutrition in developing countries, especially in primary healthcare and community settings. Available in English and French, the self-paced coursecan be used as a solid introduction or a refresher course; modules include counselling skills, breastfeeding, complementary feeding, and growth assessment. Resources on COVID-19 and breastfeeding have been recently added to the platform.
Online training courses on nutrition from Tufts University Friedman School of Nutrition Science and Policy
Tufts University Friedman School of Nutrition Science and Policy has created free online certificate courses as part of the Feed the Future Ethiopia Growth through Nutrition Activity. The intended audience for these courses includes those who are engaged in designing, implementing, funding and evaluating multisectoral programs and policies in Ethiopia and other LMIC countries. Each module involves an online lecture and completion of a quiz. Additional courses are added as they become available. Recently added: COVID-19 and Nutrition.
Popular music animates life everywhere and West Africa is no exception. Artists tell all types of stories in their songs and tackle all sorts of issues. The “Stronger with breastmilk only” campaign recently got a boost when Safiath, a popular artist in Niger, produced a song to support its awareness raising efforts, joining other artists who also produced songs. Born in Khartoum to a Nigerienne father and a Sudanese mother, Safiath’s first forays into music came as a university student in Rabat, Morocco. She took a few minutes recently to speak by phone from Niamey.
Listen to Safiath’s latest album, Point Final ! Read more about exclusive breastfeeding across West Africa in this series of Le Monde Afrique articles.
A&T: Tell us about your start in music. I read you were studying economics in Morocco when you got started.
Safiath: Yes, I started singing in Morocco, with a group that was playing Latino-American music. I did covers of songs by groups like Buena Vista Social Club and Santana. When I graduated, I returned to Niger and started making personal music. I joined Kaidan Gaskiya 2, a hip-hop group. That’s really when my career started. The group was a big success. We were three – myself and two men. In Niger, female rappers are rare. I stayed with the group for 10 years and now it’s been three years since I’ve been solo.
A&T: How would you describe your music today?
Safiath: I do a mix, a little of everything. In 2018, I did a lot of urban music – hip hop, R&B, ragga dance hall – and I also do songs inspired by traditional music with a rock foundation. People love music here but not always Niger music. [Editor’s note: Safiath has been a strong supporter of Nigerienne music, promoting it both within the country and around the world.]
A&T: Tell us about the song “Nono uwa.”
Safiath: I made the song specifically for the campaign. The chorus says (in Hausa) “nono uwa” – breastmilk; “Banda ruwa” – without water; “aba jariri nono tsantsa daga an ayhoshi zuwa wata shidda” – exclusive breastfeeding to six months. It’s a good thing, particularly in a situation where hygiene is not adequately controlled. It’s difficult because clean water is not available all the time, so moms might give whatever water, which can cause the baby to fall ill. It’s very difficult to manage compared to exclusive breastmilk.
A&T: Was it unusual for you to write a song calling attention to an issue like this?
Safiath: No, not at all. I am a big proponent of engaged hip hop – we don’t sing just to sing: we sing to address the social and political problems. It was a habit i already had. In 2007, I did a whole album on the rights of the child with a group of African artists.
A&T: And do you think it makes a difference when a popular artist sings such a song?
Safiath: Music has the power to teach people, to reach people. I know there are people who prefer songs that don’t say anything, but there are people who appreciate music that says something important. And it changes mentality.
A&T: Do you think it changes behavior?
Safiath: Yes, music can change behavior. There is a proverb in Niger that says, “Music soothes the soul.” When we are very musical, it’s easier to receive a message. I’m not saying it will change the world but it will change the behavior of certain people. Of course, I want to see that with this song. I had a song on forced marriage, and I met a young girl who told me when her mother tried to force her to marry, she thought of this song. She played the music so her mother could hear its message and it influenced her mother – her mother changed her mind.
At a recent virtual meeting of stakeholders in Southeast Asia discussing a new agenda for maternal, infant and young child nutrition, the moderator came prepared: She segued between topics with quotes about change.
“We’ve been challenged to do things differently and this workshop is no different,” said Jane Badham, the moderator and a nutritionist who has worked with Alive & Thrive on a number of initiatives.
One segue was, “The art of life is a constant readjustment to our surroundings – and boy in 2020 have we all had to make constant adaptions to how we live, work, play and connect with people!” In another she quoted the entrepreneur Richard Branson: “Every success story is a tale of constant adaption, revision and change.”
The point was clear: the COVID-19 pandemic has forced nutrition programs to adapt to the dramatic changes the disease has wrought, disrupting critical aspects of life that in turn affect nutrition: livelihoods and food systems, health systems and government programs.
Social distancing measures to prevent the spread of the coronavirus halted in-person events and activities of every kind – from workshops and conferences to visits to health clinics and markets (and every place in between). The need to respond led governments and other institutions to shift budgets. The airborne nature of the virus’s transmission led to new behavior change guidance – generally, for everyone going out into public spaces, and specifically for mothers nursing newborns, among others.
“The impact of COVID-19 on MIYCN is very context specific,” said Roger Mathisen, regional director of the Alive & Thrive program in Southeast Asia. “We have countries like Viet Nam and Cambodia in our region with no new cases for weeks or months and things going on as usual more or less, and countries like Indonesia, Philippines, and Myanmar with high numbers of cases and massive restrictions or even widespread stay-at-home orders (Myanmar).”
In West Africa, Burkina Faso and Senegal saw a sharp increase in the number of COVID-19 cases in March and April and cases quickly spread to all 17 countries in the region. However, by early April many West African governments had closed airports and borders; implemented social distancing measures, including curfews; and adopted mandatory mask wearing policies.
The region has been much less impacted for reasons that are as yet unclear; however this needs to be interpreted with caution as testing data may be incomplete, noted Manisha Tharaney, Program Director of the A&T office for the region.
“Many West African governments opened up for business in May and June,” she said. “They have been following social distancing protocols during meetings and workshops and working remotely wherever possible, but in a few countries it is business as usual.”
However, the virus has impacted the daily lives of people across the region and livelihoods, particularly in urban areas where business activity has dropped significantly, have suffered.
Beyond immediate response, COVID-19 will have long-term multi-sectoral impacts, a USAID global review, “Over the Horizon,” concluded. The review concluded that the pandemic is “a health crisis of enormous scale: COVID-19 is overwhelming health care providers, facilities, and supply chains. Beyond the direct impact of the virus, the burden of other disease may grow. For example, nearly 120 million children risk missing measles vaccines this year.” Additionally, more than 132 million people are expected to experience chronic food insecurity.
Mobile service delivery. In Kaduna State, Nigeria, the use of mobile platforms allowed health workers to provide dietary diversity messages to participants in a program to improve dietary diversity among children 6-23 months old by targeting fathers and religious leaders. The messages were delivered via SMS text messages and in WhatsApp groups. Teams in Bangladesh similarly adapted an initiative that had relied on in-person visits by developing a “mobile MIYCN” service for participants. The significant growth of cell phone ownership and cell phone communication coverage over the past decade have made these innovations possible. Community radio, which reaches millions in many rural areas across the globe, could similarly serve as a platform, teams noted.
Virtual meetings. Shortly after social distancing policies and interventions went into effect globally, in-person meetings became impossible – organizers simply canceled in-person events. But although nutrition stakeholders were grounded, webinars allowed them to continue meeting colleagues worldwide to share information and knowledge. Because of the important role they are playing to help people connect, A&T has introduced a calendar of webinars of interest to stakeholders. Alert us to a webinar of interest: Send us an email or share on social media using the hashtag #OnlineMIYCN.
e-learning. In 2019, Alive & Thrive launched an IYCF e-learning hub, featuring a course on infant and young child feeding practices called “Investing in Child Nutrition.” This comprehensive course now includes the latest guidance for breastfeeding with COVID-19. Though access is limited by connectivity, e-learning courses allow for training to continue in a time when in-person training workshops are impossible or at least severely limited. Enrollments in the course has increased since the pandemic. It is based on the World Health Organization (WHO) Combined Course on Growth Assessment and Infant and Young Child Feeding Counselling with supplemental content from WHO, UNICEF, the Global Health Media Project, and the Raising Children Network (Australia).
Similar courses allow people to access information and knowledge that would otherwise be unavailable. But the courses do require internet connectivity, which is a significant barrier for millions of people particularly in low and middle income countries. Some courses have been updated to reflect COVID-19 guidance, while others, like the Tufts University Friedman School of Nutrition Science and Policy series, has introduced specific online trainings on the topic.
Using social media. Twitter, Facebook, Instagram, TikTok, Snapchat and other social media platforms offer numerous opportunities to deliver MIYCN messages. In honor of World Food Day 2020, A&T partnered with popular Vietnamese influencer Quang Dang to launch a dance challenge on Tiktok to raise awareness of the importance and benefits of breastfeeding. Programs can use digital platforms to reach audiences with key information, eliciting engagement that portends changes in behavior (although much more research is needed to clarify the role, if any, social media can play in achieving such changes).
As COVID-19 continues to affect lives worldwide, adapting to the pandemic means different things for different contexts. More research will help to clarify what modifications are most effective. Indeed, A&T and partners have modified some implementation research activities to learn what those adaptations might be.
More than 500 stakeholders participated in the first-ever regional human milk bank webinar with A&T support. The Regional Human Milk Bank (HMB) Network for Southeast Asia and Beyond hosted the webinar “Human Milk Banking during the COVID-19 Pandemic,” which drew participants from around the world.
The webinar discussed the role of HMBs in the protection, promotion, and support of breastfeeding in the context of COVID-19, and shared on-the-ground experiences dealing with the effects of COVID-19 on the HMB establishment and operations including human milk donor mobilization and screening.
A&T, in coordination with the HMB network and other experts, drafted regional minimum standards and ethical considerations for HMBs, which were also disseminated during the webinar. The draft standards are being revised based on discussions during the webinar and will be undergo final reviews by the end of the year.
For Alive & Thrive’s portfolio of implementation research activities, the pandemic has required adjustments. But it has also allowed researchers to adapt studies to investigate the impacts of the disease.
A summary of implementation research studies indicates delays due to COVID-19, which were inevitable as lockdowns prevented research activities and the program activities that were the focus of study. In India and Bangladesh, however, modifications and additions have allowed researchers to consider the impact of the pandemic.
In India, a qualitative study building on maternal nutrition implementation research has been completed in the states of Bihar, Gujarat, Jharkhand, and Uttar Pradesh to understand the effect of COVID-19 on health and nutrition service delivery, especially the positive adaptations to service delivery.
The survey of frontline workers and households seeks to identify solutions to strengthen the delivery and uptake of essential health and nutrition interventions in the context of COVID-19 and beyond.
Secondarily, the survey explores the effect of COVID-19 on households’ exposure to health and nutrition services and communications, their nutrition practices, food security, and other aspects of their lives.
In Bangladesh, researchers have started a phone survey with FLWs and their clients in urban areas, which, in conjunction with on-going implementation research, seeks to understand the effect of COVID-19 on health and nutrition services, with a focus on positive adaptations. The qualitative study aims to elicit feasible solutions to strengthen the delivery and uptake of essential health and nutrition interventions in the context of COVID-19.
Secondarily, the survey explored the effect of COVID-19 on households’ access to health and nutrition services and communications, their nutrition practices, food security, and other aspects of their livelihoods.
Analysis of data from these studies will shed light on the extent of the pandemic’s impacts and help identify ways to mitigate those impacts.
A series of articles published in Le Monde Afrique highlights the importance of exclusive breastfeeding across West Africa and discusses the obstacles to achieving the target of 50% exclusive breastfeeding by 2025. Lack of information for Burkinabé mothers, difficulties in combining work and full breastfeeding in Dakar, fear of seeing their breasts sag for some Cameroonian mothers… The reasons are multifold.
At a time when 5 million African children die every year before their fifth birthday, the series emphasizes the importance of the “Stronger With Breastmilk Only” campaign, which is led jointly by UNICEF, WHO and Alive & Thrive. The campaign highlights the virtues of breastfeeding on demand, day and night, and no supplementing with water, other liquids or foods, even in hot and dry climates such as West Africa.
The series was produced by Le Monde Afrique in collaboration with the Fonds Français Muskoka. Translated and reprinted by permission. For rights reasons, photos below are from Alive & Thrive archives and not the original Le Monde Afrique articles.
The series includes the following “episodes,” reproduced below in order. The original articles, in French, are available at Le Monde Afrique here.
Episode 1 Exclusive breastfeeding, a public health priority in Africa
Episode 2 “It’s natural, safe and free”: in Burkina Faso, the many benefits of breastfeeding
Episode 3 Reconciling work and breastfeeding, a challenge for mothers in Senegal
Episode 4 In Cameroon, the benefits of mother’s milk make it hard to forget social pressure
Episode 5 “The child does not need water in addition to milk”: in Nigeria, exclusive breastfeeding up against preconceived ideas
1 Exclusive breastfeeding, a public health priority in Africa
According to WHO and UNICEF, breastfeeding on demand, day and night, with no water or other food supplements, would make it possible to curb neonatal and infant mortality.
By Raoul Mbog
In Africa, 5 million children die each year before they celebrate their 5th birthday. Diarrhea, pneumonia, malaria, malnutrition, infectious diseases … On this continent, death is stalking the baby at every corner. So much so that an infant is fourteen times more likely to die in its first month of life than in a Western country.
Yet, there is a life elixir available to every baby, regardless of its family’s social, cultural and financial status. A baby food that is available to all mothers and which offers all the health and nutritional guarantees, without recourse to development aid or additional expenses for the States or families: breast milk.
According to experts from the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF), the generalization of exclusive breastfeeding during the first six months of a baby’s life would make it possible to curb neonatal and infant mortality and save 200,000 lives each year in the West Africa region alone.
Based on various scientific studies, the two UN agencies recommend that all infants be put on this unique diet. To help mothers become better informed on this subject, they have launched a campaign called “Stronger with breast milk only” during World Breastfeeding Week, from August 1st to 7th.
Led jointly by UNICEF, WHO and Alive & Thrive (a global nutrition initiative), the campaign highlights the virtues of breastfeeding on demand, day and night, with no water, other liquids or food supplements, even in hot and dry climates such as West Africa.
“Breast milk is 88% water. It contains all the nutrients and antibodies essential for the health and development of infants,” reminds Adelheid Onyango, nutrition advisor at the WHO Regional Office for Africa. She adds that if strictly enforced, early and exclusive breastfeeding could prevent one-third of respiratory infections, half of diarrheal episodes and even reduce the risk of obesity and high blood pressure later in adult life.
In addition, “healthy nutrition combined with adequate stimulation and appropriate care are essential for the development of babies’ brains during the first 1,000 days of life,” says Anne-Sophie Le Dain, a nutrition specialist at UNICEF’s regional office for West and Central Africa, who is very committed to the subject. And contrary to popular belief, mothers also benefit from it, since breastfeeding speeds up their recovery after childbirth and reduces their risk of breast and uterine cancer.
Although breastfeeding has always had a privileged place in infant and young child feeding in Africa, its practice is still considered far too confidential. Today, only four out of ten newborns are put to the breast within the hour after birth and only three out of ten babies are exclusively breastfed until the age of six months. This is too little.
Very often, “maternity wards are too small to receive several women coming for delivery at the same time and the large number of deliveries makes it impossible to offer breastfeeding assistance from the first minutes of a newborn’s life,” explains Marie-Thérèse Arcens Somé, a health sociologist and author of a study on “the challenge of adopting exclusive breastfeeding in Burkina Faso”, published in February in the journal Santé publique. For her, “the attention of midwives is focused on the technical gestures and very little on the information to be transmitted and applied for the baby’s survival”.
The young mothers therefore go back home without having been guided on the importance of the nurturing gesture in terms of their child’s health and development. And without having been shown the right gestures. This is all the more unfortunate since, as specialists remind us, breastfeeding is not “natural”. It is a skill that needs to be learned.
The Infant formula lobby
Among the other factors that prevent exclusive breastfeeding from becoming part of mothers’ habits, the researcher mentions certain social and cultural practices, such as the traditional rites of giving decoctions and administering ointments to newborns. This tradition is observed in the 24 countries of West and Central Africa and can be partly responsible for the severe acute malnutrition suffered by some 4.9 million children in these regions.
In addition to this, you have the messages conveyed by the infant formula manufacturers. The latter, who have understood that Africa is a promising territory at a time when demographic forecasts are betting on a doubling of the population by 2050, are making their voice heard in a market that already represented some 71 billion dollars in 2019 (about 63 billion euros), according to the NGO Action Contre la Faim. Yet all the specialists have been saying it since the 1960s: breast-milk substitutes are one of the major obstacles to the expansion of breastfeeding on the continent.
These messages promoting infant formula, which are based on a certain notion of “modernity,” are all the more harmful because breastfeeding a baby remains “one of the most effective ways to preserve its health, its growth and also to ensure the development of the country,” says Aita Cissé, from Alive and Thrive. For her, breastfeeding is not only a public health issue; it is also “an emergency for human and economic development in sub-Saharan Africa.”
Indeed, if this method of infant nutrition became widespread, it would generate an economic gain of 42 billion dollars per year, thanks in particular to the reduction of health expenses, according to the specialist. Anne-Sophie Le Dain reminds us that “each dollar invested in breastfeeding support generates an economic return of 35 US dollars.” One of the most profitable investments, therefore. All the more so as the UNICEF nutrition manager, who has also taken an interest in the cost generated by the lack of breastfeeding in sub-Saharan Africa, observes that the economic loss incurred today due to the weakness of this practice is 2.57% of the region’s gross national income.
Awareness of the multiple benefits of breastfeeding is beginning to spread and, despite the aggressive marketing of infant formula products, significant advances are being made. According to the latest World Nutrition Report, published in May, eleven countries in West and Central Africa are on track to achieving the 50 percent exclusive breastfeeding rate that the United Nations has set for 2025. Burkina Faso, Cameroon, Mauritania, and the Democratic Republic of Congo (DRC) are among them, although they still face many other challenges to ensure that all newborns get a good start in life.
2 “It’s natural, safe and free”: in Burkina Faso, the numerous benefits of breastfeeding
At the maternity center of Bangrin, mothers are advised to feed their babies only with their own milk for the first six months – and especially no water.
By Sophie Douce
The baby doesn’t have a name yet but already wears a colorful bracelet on her left wrist. At the maternity center of Bangrin, about twenty kilometers from Ouagadougou, Noélie Sawadogo considers this little adornment as a protective amulet and never fails to consult it while she watches her 4-day-old daughter, asleep with closed fists. This is indeed where her baby’s weight is being recorded; this monitoring reassures the young mother.
With her 3 kg weight, the girl is slightly below average, but the midwife Maïmounata Nikiéma is serene in her pink dress.
“A newborn baby always loses a little weight in the first few days, but it will quickly put on weight with your milk,” continues the twelve-year strong practitioner whom everybody calls affectionately “Aunt Maïmouna.”
Like many mothers giving birth in this rural health center in Burkina Faso, Noélie Sawadogo has chosen exclusive breastfeeding for her first child.
“I want my baby to be strong and healthy,” the 25-year-old mom explains shyly. As recommended by the World Health Organization (WHO), the practice of “100% breast milk and nothing else,” from birth to six months of age, helps prevent malnutrition and diarrheal diseases, the main causes of child mortality in West Africa.
Though breastfeeding is practiced by a large number of Burkinabe mothers (about 80% breastfeed until their baby is 24 months old), many of them still give liquids other than breast milk to their babies. Four out of ten infants in Burkina Faso are given water or other beverages, according to the United Nations Children’s Fund (UNICEF). In this landlocked Sahelian country where temperatures hover around 40°C during the hot season, it may seem counterintuitive to some parents not to give water to their infants.
“Yet breast milk is enough,” insists Maïmounata Nikiéma. Made up of 88% water, rich in lactose but also in proteins, fats and mineral salts, it contains all the nutrients that the baby needs.
“It’s the best food and drink we can offer a baby, it’s natural, safe and free,” says this fervent advocate of exclusive breastfeeding, who tries to explain the benefits of breastfeeding to each of her patients in Mooré language and with the help of simplified images. And these benefits are many.
Colostrum, the first thick, yellowish milk secreted at the time of delivery, and rich in antibodies, thus serves as the newborn’s “first vaccine.” Breast milk then contributes to the child’s physical and cognitive development, while protecting him or her from respiratory infections and diarrhea. In Burkina Faso, where the under-five mortality rate is 82 per 1,000 births, nearly 3,500 children could be saved each year through breastfeeding, according to a study by the U.S. based Alive & Thrive initiative.
Finally, breastfeeding accelerates the mother’s recovery after delivery, reduces the risk of cancer and allows birth spacing.
Force-feeding herbal teas
In less than two generations, Fati Zangré, Noélie Sawadogo’s mother-in-law, has seen the difference in the village of Bangrin.
“Today our children are healthy!” This 75-year-old grandmother is delighted. “In my time, we had to give birth at home; we didn’t know not to give water. A lot of children were getting sick,” she regrets, looking at her granddaughter, whose hair was already thick and full.
In the villages, water, which is assimilated to life, is central to customs. Herbal decoctions, “welcome water,” purging and even “force-feeding” herbal teas… are common practices. It is sometimes difficult for some women to oppose these practices perpetuated from generation to generation. While awareness campaigns have succeeded in reducing the proportion of infants fed herbal tea from 21% in 2012 to 8% in 2018, some preconceived ideas are still alive and well.
“Some nurses and midwives continue to convey false beliefs, for example by advising to make the infant drink to hydrate him/her,” fustigates Mediator Touré Kiburente, nutrition specialist at Unicef, who knows well the damage caused by this practice.
The water quickly fills the baby’s stomach without feeding him, then he loses his appetite for breast milk, which increases the risk of malnutrition. The liquid or utensils used can also be contaminated and cause diarrhea.
“And the less the baby suckles, the less milk the mother produces,” emphasizes the specialist.
This virtuous cycle remains fragile, she knows it. This is also why she does not hesitate to repeat again and again how much these first months are decisive for the growth of the child and the rest of his life. Noélie Sawadogo, for her part, has got the message. Her baby will benefit from it.
3 Reconciling work and breastfeeding, a challenge for mothers in Senegal
With the increase in women’s employment, the practice of exclusive breastfeeding is on the decline, especially in urban areas.
By Théa Ollivier
With her rounded belly under her long green dress, Aïssatou, 24 years old, enters the gynecological consultation room of the health center of Grand Medine, a working class neighborhood in Dakar. After the routine checks, Ramatoulaye Diouf Samb, the senior midwife, asks the young mother if she has heard of exclusive breastfeeding, with no water, for the infant’s first six months.
“I practiced it with my first child because I was taking him with me to my workplace. He is now in very good health. I hope to be able to do the same with my second, if my current employer allows me to,” says Aïssatou, who works as a domestic servant.
In Senegal, where six out of ten children suffer from anemia and one third of neonatal deaths are related to undernutrition, 99% of women breastfeed their babies, but only 42% do so without adding water, as recommended by the World Health Organization (WHO).
In charge of the nutrition and food division of the Ministry of Health, Dr. Maty Diagne Camara is fighting to change unhealthy practices and reminds how “exclusive breastfeeding ensures a good start to a child’s growth.”
The benefits of breast milk are multiple for the mother, who rapidly expels the placenta, enjoys natural contraception for six months and sees a reduced risk of uterine cancer. For the child, this milk contains easily digestible nutrients and helps the child fight infectious and respiratory diseases. But if this discourse flies well, it clashes with some lifestyles.
“With the progress of women’s employment, the practice of exclusive breastfeeding is on the decline, especially in urban areas,” notes Maty Diagne Camara.
In her health center in Grand Médine, dressed in her pink striped blouse and a mask over her nose, Ramatoulaye Diouf Samb tries to sensitize as many mothers as possible.
“I was triggered when I saw a grandmother giving porridge to a two-month-old baby while the mother was at work,” recalls the midwife, who points out that giving water or porridge weakens the baby’s digestive system.
She advises women who work to take their child with them to their workplace, strapped on their back. This is generally already a habit for those who work in the informal sector or in rural areas.
“Housewives and small tradeswomen are obliged to do so, as they often have no one to look after their child,” notes Ramatoulaye Diouf Samb. On the other hand, this option is more complicated to implement when women have a job in the formal sector.
Cécile Constantine Time, a mother of four, managed to take the last two to her office to breastfeed them for the first six months.
“I asked my employer to set up a breastfeeding corner. The baby was either in her crib or on my back, even during meetings with colleagues,” she said smiling, her head full of good memories.
While everything went well on the employer’s side, it was at home that things got complicated: ” My mother-in-law was upset that I was taking my children to work “… until she saw for herself that the babies were growing better, with less diarrhea and vomiting than the two older children, with whom Cécile was unable to practice exclusive breastfeeding.
The young woman regrets that the legislation is not more stringent on requiring a breastfeeding space at the workplace or the possibility of coming to work with a nanny. According to the labor code, mothers are entitled to eight weeks of maternity leave after childbirth. Breastfeeding mothers can also take one hour off work per day, paid as actually worked hours.
“The legislation is there, but the difficulty lies in its enforcement,” concludes anthropologist Sokhna Boye, author of a thesis on breastfeeding in Senegal.
Raising awareness among the mothers’ entourage
A mother of three, Rhokaya Bâ tried to breastfeed all of them exclusively.
“But it was very difficult to combine work and breastfeeding, because the daily hour to express my milk was not enough,” she says.
Faced with this time constraint, it was her mother-in-law and other women in her family who were responsible for feeding her children, thanks to the bottles of breast milk she left in the fridge in the morning.
“From their fifth month, I knew they had been fed porridge and given water to drink when I was not there,” regrets, disappointed, this call center employee.
This situation does not surprise Sokhna Boye: “The institutional norms that encourage exclusive breastfeeding do not correlate with, or even contradict social and cultural norms. It is in fact frowned upon to not give water to one’s infant, especially when it is hot,” she explains.
The challenge is therefore not only to raise awareness among mothers, but also among mothers-in-law, aunts and all the women around them.
“They are the ones who look after the child when the mother goes to work, so they must know and follow the instructions for giving breast milk that has been drawn and reheated after being kept cool.,” says Ramatoulaye Diouf Samb. For her part, the midwife of Grand Médine relies on the “marraines de quartier” (neighborhood mentors) to combat socio-cultural barriers. It’s an everyday battle that has not yet been won, but is on the right track.
4 In Cameroon, the benefits of breast milk have a hard time overcoming social pressure
Poverty, work constraints and body image concerns explain why many women give up exclusive breastfeeding.
By Josiane Kouagheu
Ayo is bursting with life. Just 2 years old and she never stops. Hardly climbed onto the sofa, she has already come down from it to go to the television, where she points at the animals strolling by. Is it the exclusive breastfeeding that fed her for the first six months of her life, without giving her any water, that gives her so much energy?
Her mother is convinced that “her diet has something to do with it.” As a matter of fact, Marylène Owona, 34, says she sees the difference between her two children.
She had her first daughter, Alys, at the age of 19, while she was a student in France. She had tried to breastfeed her 100%, despite a painful first week, because the baby’s suckling was “shredding” her nipples. But she had quickly stopped, introducing small pots of baby food into her little girl’s diet as early as at 2.5 months of age.
Then, to make matters worse, Marylène was forbidden to breastfeed, as the practice was incompatible with the medication she had to take. So she reluctantly switched to bottle-feeding.
The young woman knew from the beginning of her second pregnancy that she would breastfeed this child exclusively. Back in Cameroon, she hoped that it would be easier. And indeed, being self-employed – she runs a communications agency – made it easier for her.
For her, putting the baby to the breast is a natural gesture.
“A pleasure, a privileged moment,” she says. “And also the child likes to connect with her mother, to suckle this milk which contains vital nutrients for her.”
For six months, she exclusively breastfeeds her little girl, though not without constraints because the feeding is at the child’s demand.
“There is no programmed feeding. No matter what time it is, you have to be there.”
Between the ages of 6 and 12 months of the baby, she gently introduces purées and small meals, while maintaining more and more spaced out breastfeeding, leading to a complete weaning of Ayo at 1 year old.
With hindsight, Marylène Owona can see that “the older one was sicker than the little one”. She believes that “breastfeeding, with its antibodies and micro-nutrients, made Ayo stronger.”
According to Professor Anne Esther Njom Nlend, President of the Cameroonian Society of Perinatal Medicine (SCMP) and Director of the National Social Security Fund (CNPS) Medical Center in Yaoundé, breastmilk provides the child with anti-infectious and immunological components, many antibodies, prevents obesity and promotes good growth. And for the mother, breastfeeding helps prevent certain cancers.
Yet, according to the 2018 Demographic and Health Survey in Cameroon, only 40% of the babies under 5 months of age are exclusively breastfed. A rate that is too low, which puts the others “at risk of allergies, infections and malnutrition,” stresses Anne Esther Njom Nlend, who, with other doctors, is stepping up awareness-raising campaigns on the importance of exclusive breastfeeding and provides advice to women.
But alas, many women still refuse her help. From poverty, to complications due to returning to work, to fears of body deformation, the reasons for such reluctance are numerous.
No, your breasts won’t sag.
Jacqueline Souffo is 47 years old, a mother of six children and a three times grandmother. In twenty-seven years of maternity, this “bayam-sellam” (buyer-seller) has never exclusively breastfed for six months.
“To breastfeed all the time, you have to eat well. But I don’t have much to eat and I was dizzy from breastfeeding. So from the first month, I gave my children corn porridge, soy and peanut,” she recalls.
As for Mireille, a pretty employee of an insurance company who came to a beauty salon for body care, she says she “stopped after three weeks of breastfeeding” and “continued with artificial milk”.
“I just didn’t feel like it and I didn’t want my breasts to sag,” the young woman admits.
According to sociologist Bertrand Magloire Ndongmo, breastfeeding is “very limited and little encouraged” in certain Cameroonian working-class circles because it has “a strong impact on the body” and many women believe, despite the denials of experts, that their breasts will sag if they breastfeed.
“We are in a society that is very demanding of women,” he says. “And a mother who wants to be desired after giving birth will sacrifice her offspring. In the huge and competitive love market, women with firm breasts are more in demand. That’s why we’re experiencing a breastfeeding crisis. The woman who chooses not to breastfeed is a rational being who tells herself that it is cheaper for her.” Especially as cosmetic surgery is out of reach for the majority of Cameroonian women.
To create a forum for discussion, to help pregnant or breastfeeding women and break the “fake news” impact, Marylène Owana launched the magazine Ma Famille.
“There are a lot of popular misconceptions and not necessarily true that are circulating,” reminds the communication expert, looking at little Ayo. To channel her boundless energy, the young woman has just started making organic modeling clay for children, which she is beginning to market throughout Cameroon.
5 “The child does not need water in addition to milk”: in Nigeria, exclusive breastfeeding vs. misconceptions
Though the urban middle class is well informed, the practice remains limited despite its many health benefits.
By Liza Fabbian
The plastic chairs in the waiting room were installed all the way to the parking lot of the Ogudu health center to respect the physical distancing measures related to the Covid-19 epidemic. In the shade of a cashew tree, about twenty women, with their children on their knees, are waiting at a good distance from each other for a nurse to call them in to vaccinate the little ones.
Every day, nearly 150 patients pass through the door of this small, run-down clinic in a working-class neighborhood of Lagos, the economic capital of Nigeria. To all of them, the same message is delivered and they are advised to practice exclusive breastfeeding until the children are six months old.
“Immediately after delivery, we encourage women to breastfeed their babies and explain to them the benefits of exclusive breastfeeding for the growth and health of their children,” explains Dr. Akintola, half his face hidden behind his mask.
The advice is well received by the women visiting that day. In this country where the infant mortality rate is still 120 per 1,000 (compared to 3 per 1,000 in France), everyone knows some bereaved parents.
Agnes Edward lifts her 9-month-old son, King David, a baby with rounded cheeks. Like her two older children, the child was exclusively breastfed for the first six months.
“It was easy for me to breastfeed,” says their mother, “because I was fortunate to have the support of my sister and my husband, both of whom were very supportive. ”
Agnes lost her job four years ago when the family she worked for as a domestic servant moved to Brazil. With her salary at the time, she was able to buy a breast pump, which she still uses today when she leaves her children with a friend. A luxury that most Nigerian women cannot afford.
In this country, the most populous of Africa with 200 million inhabitants, not all mothers are yet convinced of the benefits of breastfeeding. In fact, Nigeria has one of the lowest rates of exclusive breastfeeding in sub-Saharan Africa. According to a 2018 study, only 29% of babies are breastfed.
A situation that “is changing very slowly, but we hope to raise this rate to 50% by 2025,” promises Ijeoma Onuoha-Ogwe, who works for UNICEF. The stakes are high, because “when a child is not exclusively breastfed, it means that he or she ingests water or even solid foods; this weakens the immune system, promotes malnutrition and increases the risk of diarrhea, one of the leading causes of infant mortality. ”
Ijeoma Onuoha-Ogwe recalls seeing women giving their infants “pap,” cassava flour diluted in water: “Sometimes it is hard for them to understand that the child does not need to drink water in addition to milk. They also think that it will be difficult for the child to diversify his diet if they do not get him used to solid food at a young age. This is completely false.”
Misconceptions about breastfeeding circulate among all segments of the population, from remote provinces to large cities.
Victoria Akuidolo, a 27-year-old stylist, remembers having to defend this choice in front of her mother.
“When she realized that I was exclusively giving breast milk to my little girl, she asked me if I didn’t have enough money to buy powdered milk,” the young woman recalls, drawing her 3-year-old daughter towards her.
The dress designer says she had no trouble breastfeeding her, neither her 9-month-old baby boy.
“It’s pretty easy to find a place to breastfeed here. Even at church there is a room for that,” she explains, admitting that her self-employment work has made things easier for her: “If I had to go out to work, it would have been much more complicated for me to organize myself to ensure exclusive breastfeeding.”
Involving fathers and the community
In 2018, Nigeria officially extended maternity leave from three to four months. While Victoria is not affected, Chiboza Tony-Nze has been able to benefit from this progress, which only concerns women employed in the formal sector. This analyst at an insurance company in Lagos was able to leave her job to take care of Daniel, her firstborn child.
Although she breastfed him for the first few months, Chiboza was unable to maintain exclusive breastfeeding for the child’s first six months.
“Daniel was born by caesarean section and I quickly ran out of milk,” she regrets. “I found him a little thin, and other people’s children seemed chubbier and healthier to me.”
The young mother had received nutritional counseling for herself and her baby at the Ogudu clinic. This outreach service is more difficult to provide in rural areas, where health workers try to involve fathers and the community at large to break down the barriers of misconceptions and promote the benefits of breastfeeding. This message is slow to spread, even if the practice is gradually taking hold in the country.
The scope of the decree includes infant formula as well as follow-on formula, “growing-up” milks, and “toddler formula” for children up to 36 months of age, following the recommendations of World Health Assembly Resolution 69.9.
The decree also includes guidance on labelling breastmilk substitutes, prohibitions on actions that create conflicts of interest with health workers, as well as other safeguards based on the International Code, similar legal measures in the ASEAN region, and the country’s own experience with harmful BMS marketing.
Around the world, COVID-19 has radically affected public health delivery, placing unprecedented stress on health systems that in many countries are under-resourced and ill-equipped.
As the pandemic has upended daily life, Alive & Thrive has worked with government and other partners to design effective responses, providing technical assistance regarding breastfeeding and the maintenance of essential MIYCN services.
As the pandemic unfolded, guidance evolved regarding breastfeeding. The first guidance, issued in February, came from the China Consensus and called for separating mothers and their infants due to the risk of infection.
But by mid-March, experts agreed that breastfeeding did not pose a significant risk of transmission. The fast-evolving situation called for concerted efforts to ensure governments and their partners were providing consistent, accurate information.
An A&T review of guidance documents from around the world confirmed that guidance varied. Results were shared with stakeholders, including during a global webinar.
A&T’s participation in bodies that advise governments in the countries where it works facilitated the rapid sharing of the latest WHO guidance. And in one case – that of human milk banking – A&T supported the forming of a global online network of HMB stakeholders that is now leading efforts to promote the use of human milk banks, including issuing a call to action.
“The strengthening of human milk bank systems is required to ensure that safe provision of donor milk remains an essential component of early and essential newborn care during routine care or emergency scenarios, such as natural disasters and pandemics” – From the Call to Action of the Virtual Communication Network of milk bank leaders
In Niger, the Technical Group on Nutrition, an advisory body comprising nutrition partners including A&T, supported the development of IYCF guidance documents that emphasized the importance of early initiation of breastfeeding, exclusive breastfeeding, appropriate foods for complementary feeding and breastfeeding to the age of 2 years.
The group also supported a joint statement on child nutrition with UNICEF and the Directorate of Nutrition, calling for concerted efforts across the health system and the private and public sectors to share the latest COVID-19-related breastfeeding guidance. It also included alerts regarding the marketing of breastmilk substitutes which, anecdotally, appears to have increased during the pandemic across A&T’s program countries.
At the same time, the A&T Southeast Asia office provided supportive evidence and updated references for breastfeeding to the National Nutrition Cluster in the Philippines, the Scaling-Up Nutrition Civil Society Alliance in Viet Nam and to partner hospitals. And in Nigeria, A&T supported the National Agency for Food and Drug Administration and Control (NAFDAC) to raise awareness via the media of the WHO guidance and the BMS Code.
In Madagascar, A&T also provided guidance regarding BMS Code enforcement and assisted in the planning of activities to enforce the Code. In India, A&T supported national professional associations to disseminate information on breastfeeding through a three-day webinar that reached over 700 medical professionals on breastfeeding and COVID-19, focusing similarly on BMS Code violations, referred to in the country as the Infant Milk Substitutes (IMS) Act.
Health system response and MIYCN program maintenance
Technical assistance also helped health systems respond and supported governments to maintain MIYCN services, a critical need in light of an expected spike in malnutrition globally, particularly in West Africa.
After it became clear that COVID-19 led to significant declines in people seeking services at health facilities, the Government of Ethiopia established a national task force. As members, A&T’s experts devised and then supported the government to conduct rapid assessment checklists to assess MIYCN service delivery status and provide guidance for frontline workers to continue non-COVID-19 services.
“Most health facilities’ services were significantly disrupted,” said Dr. Abdulaziz Oumer, A&T Country Director. “Some facilities had closed due to lack of personal protective equipment and mothers stopped coming for services due to the panic.”
The assessments provided insights on the scope of the problem and led to a concerted media campaign and delivery of personal protective equipment. The effort also led to the development of a focused action plan to strengthen antenatal care, post-natal care, delivery, and child health and nutrition services.
Swift response in Southeast Asia helped hospitals maintain early and essential newborn care despite the surge in COVID-19 cases, which initially filled hospitals to capacity. In a presentation during a WHO webinar, A&T Southeast Asia’s team discussed the technical assistance it provided to the hospitals to set up separate areas to treat suspected COVID-19 cases, implement measures to manage admissions, and adopt social distancing, among other strategies.
In India and Bangladesh technical support to government and partners on MIYCN during COVID-19, in close collaboration with UNICEF, USAID, the World Health Organization and the World Bank included, disseminating materials on breastfeeding; information on safely initiating complementary feeding, and and guidance on continuing nutrition services during COVID-19.
In Burkina Faso, A&T worked directly with the Ministry of Health to develop materials and radio advertisements on IYCF and COVID-19 and collaborated with community radios to discuss COVID-19 and IYCF in six health regions, sharing knowledge and information and answering listeners’ questions during live call-in shows.