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Mali: promoting exclusive breastfeeding in "baby-friendly" maternities

© UNICEF/WCARO/2008/Pirozzi

SAHEL: Percentage of infants under 6 months who are exclusively breastfed: 17%

Clearly exhausted after a difficult delivery, Aminata Lea rests under a bednet in the maternity ward of the health centre in Djenné, 380 km northeast of Bamako, the capital of Mali. She has just given birth to a girl who is sleeping peacefully, nestled against her mother.

Aminata, a 20-year-old mother of two, does not want her daughter to undergo the same experience as her son, who was given date juice at birth. Her voice is weak, but she makes herself understood: “If my mother says we should give her date juice, I will tell her that date juice contains water and that you should not give water to babies younger than six months. In any case, breast milk already contains water.” At the Djenné health centre, which was named a Baby Friendly Hospital in 2005, Aminata has repeatedly been told about the importance of exclusive breastfeeding for an infant. A list of breastfeeding guidelines is posted on the door to the midwife’s office. One rule bans feeding bottles from health centre premises.

In Mali, exclusive breastfeeding during a child's first six months of life is slowly gaining ground. The proportion of mothers following this practice rose from 12% to 38%, according to the latest Demographic and Health Survey. But much remains to be done. Breastfeeding itself is not a problem – Malian mothers often breastfeed their children up to the age of two years and beyond – but exclusive breastfeeding is a stumbling block. Mothers and grandmothers traditionally give plain water, date juice diluted with water or herbal teas to infants. 

Deeply entrenched traditions
In some villages, this is still the first food that newborns are given. Take Boro, for example, a village in the Dogon region of eastern Mali, where this traditional practice is widespread. Besides date juice, lemon juice is also given to newborn babies in the belief that it cleans their mouths. Local women usually think of babies as tiny adults rather than as persons with specific nutritional needs. That is why they are frequently tempted, given the hot climate, to give their babies water. Hawa Tapily readily admits she gave date juice to her eight children and to her recently born grandson. Her daughter-in-law did not object. Such customs, Hawa Tapily says, are still widely followed in Boro. “You don’t know what individual women are doing in their own homes, but I don’t know a single one who did things differently from me,” she says. Exclusive breastfeeding is gaining ground in Mali, particularly in "baby-friendly" maternities. But much remains to be done.
Most mothers mistakenly believe that women can only breastfeed on the third day after delivery. Women who have just given birth manually extract from their breasts the colostrum, the yellowish milk they first produce, and throw it out. Yet experts regard nutrient-rich colostrum as a “vaccine” that boosts the newborn's immune system. Colostrum is also known as beestings or first milk or "immune milk".

It is a different story in the Djenné health centre, the Baby Friendly facility. According to Fatoumata Tolo Togo, one of the centre midwives, health agents urge mothers to put their baby to the breast in the first hour after birth. “In the maternity ward, mothers used to express their colostrum, even though the first milk is the best,” she says. “They don’t do it any more.” When mothers note that they themselves drank water as infants, Mrs. Togo explains that breast milk already contains water. This usually comes as a surprise. This midwife wastes no time in telling them that they need to change their ways. “Things move on,” she says. “The olden days are over. We have to change our old ways. The water our grandparents gave children was not safe to drink. That is why infants died.”

Supporting mothers to promote breastfeeding
To raise awareness about exclusive breastfeeding, the health centre turned to religious leaders who recorded radio messages in Mali’s three national languages (Bambara, Songhai and Fulani). The challenge is to reach out not just to mothers but to all those who may be in a position to give water to babies, especially grandmothers. Mrs. Togo believes that lots of people have taken the message on board, including older women. Social mobilization teams, which regularly organize talks on breastfeeding, particularly when babies are being baptized, play a particularly important role. Besides public health messages, economic considerations weigh heavily: exclusive breastfeeding is free, a major detail in a region where so many households live under the poverty line. But, even wealthier mothers, which until fairly recently considered infant formula as a status symbol, have switched to breastfeeding.

At the Djenné health centre, the medical staff – made up of three midwives, two matrons and four doctors – are trying to tackle other bad habits, including the practice of feeding babies from both breasts in a single feeding. The mothers are told that they must feed from only one breast at each feeding and make sure it is quite empty to ensure that their infant gets the maximum benefit. It is no small matter, as switching breasts without properly emptying each one can have serious consequences, such as malnutrition, a condition that traditional healers might then aggravate by prescribing leaves, roots or herbs.

To convey the importance of feeding their babies from only one breast at each feeding, the health centre staff draws a comparison with cow’s milk. “At first, it is water, then it is milk, finally it is cream,” Mrs. Togo says. It is a colorful way of explaining that, when breastfeeding is done properly, breast milk is the only food an infant needs in the first six months of life.

by Michel Arseneault





Malnutrition in the Sahel


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