Exclusive breastfeeding in West Africa: Series focuses on the realities for mothers, infants and communities in Burkina Faso, Cameroon, Nigeria and Senegal

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.

Resource: The Cost of Not Breastfeeding for West Africa

Reducing the risk of cancer

“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.

Resource: The online Cost of Not Breastfeeding tool allows users to explore the data on breastfeeding in more than 30 countries

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

Burkina Faso mother-in-law
The social norm to “obey one’s mother-in-law” is powerful around the world, including West Africa.

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.

Resource: The Cost of Not Breastfeeding in Burkina Faso

“First Vaccine”

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

mother breastfeeding her child
Stronger With Breastmilk Only raises awareness of the importance of exclusive breastfeeding. Across West Africa, infants often receive water during the important first six months of life, which is not as beneficial as breastmilk.

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.

Resource: The Cost of Not Breastfeeding in Senegal

Water weakens the baby’s digestive system

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

A mother laughing with her baby
Research shows that babies who are exclusively breastfed are less likely to suffer illness.

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.

Resource: the Cameroon Cost of Not Breastfeeding in Cameroon

“The child likes to connect with her mother”.

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

billboard in Nigeria
The Start Strong/Zero Water campaign in Nigeria, supported by A&T, has raised awareness of the importance of exclusive breastfeeding. The campaign messages are featured on billboards and widely aired on TV and radio.

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.

Resource: The Cost of Not Breastfeeding in Nigeria

“Even at church, there’s a room for that.”

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.