The main challenge mothers in Africa are facing in relation to exclusive breastfeeding is traditional cultural practices on infant feeding which call for mixed feeding earlier in an infant's life. This means that there is lack of social support from those around them to exclusively breastfeed for 6 months. Other challenges include HIV, poverty as in lack of enough nutritious diet for the breastfeeding mothers that might affect the ilk flow, gender role inequalities meaning mothers may not have enough time for exclusively breastfeed for 6 months.

In addition to Martha's comment, I also think that mothers in third world countries are ignorant about the positive health outcomes of breast milk, exclusive breast feeding and introducing the child to breast milk within the first few hours after delivery. For example, they lack knowledge about the importance of colostrum and believe the yellowish colour of colostrum is unpleasant and infectious, so they prefer to express it out for several days before introducing the child to breast milk.

In a formative research recently conducted in northern Uganda, it discovered that actually the mothers know the principals of infant feeding ie EBF for 6 months and optimal complementary feeding, however, there were six factors that influenced the practical aspect of the principles. 1) Teenage pregnancies and frequent pregnancies- young children giving birth to children lack the knowledge, are stigmatised culturally, lack support etc while too many children and the assumption that breastmilk form pregnant women makes the baby sick; 2) Alcoholism and gender based violence- such households were identified as those most likely to have malnutrition, food insecurity, poor child care practices; 3) women's time/workload- the roles of the woman include gardening to provide food; care for the sick, infant feeding, water and firewood collection, food preparation, and all nutrition/livelihood interventions target women and call for meetings often thus they take shortcuts ie breastfeed only when child cries; leave children with younger siblings all day, give one meal a day etc; 5) traditions and beliefs- from disposal of colostrum during the "thorn removal ceremony" to unblock the breastpores to naming ceremonies with 3 or 4 days of birth to denying the mother the right to breastfeed her child if she spends a night outside her home without the baby among others; 6) lack of livelihood. This is aggravated by the general lack of a condusive policy environment to support EBF and the growing norm of adoption of everything from the western countries whether good or bad especially among the urban corporates!

Dear Brenda, This is a very interesting piece of work. Is the report available to share? If so, send it to me at ENN and we can post it in our resource library. Many thanks, Marie

From Ann Burgess: Brenda - a very interesting study. Do you think the results are likely to apply to some extent in South Sudan? If so, we might like to put a small item on this in the Southern Sudan Medical Journal (see [url]www.southernsudanmedicaljournal.com[/url] ) - with your permission of course.

Reply to Sibida Noella George: I am very sorry, but this comment is a slap in the face to everybody who takes BCC serious. I do not like expressions such as "ignorance" when discussing feeding or eating patterns. Maybe my interpretation of the word "ignorance" is wrong as I am not a native English speaker. However, I understand ignorance as an act of denial or carelessness. Looking at the plight of mothers especially in rural areas in Africa and the level of literacy, workload, frequency of deliveries, access to assistance ect., I think there are more reasons behind than just "ignorance". One of the major problems with regard to exclusive breastfeeding is the fact that so many deliveries are taking place without professional support, this also includes assisting mothers in coming to an informed decisison which feeding practice will be best for the newborn. If you ask TBAs in rural areas what are the important steps to do after delivery, you will most likely hear that "giving water to the child" is one of these important actions. And they will give you reasons for this and they will never recognize this act of giving water to the child as a major obstacle for a good start for the child. You will not succeed to hammer knowledge in a TBA or a mother as their actions are deep rooted in beliefs and traditions. In my opinion, our problem to combat undernutrition is not (only) that the mother don't know but that nutrition and health workers don't realize how essential it is to understand first why people doing what they are doing and to engage in a dialogue with caregivers. Showing empathy is a basic skill for a nutrition promoter.

Reply to Martha's comments submitted 19th August: Refering to the statement on the "milk flow" I would like to mention that the major stimulant for milk flow is actually the suckling of the baby and not so much a nutritious diet. Unless a mother is severly undernourished she will be able to breastfeed.

Reply to Juliane Juliane, thanks for your contribution I do understand from the perspective you are writing. Basically, I used the word 'ignorance' in this context as referring to lack of knowledge, uninformed and unawareness of standard breastfeeding practices and health benefits to the infant by majority of mothers in developing countries. Would you like to check out the word 'ignorance' on World English dictionary on http://dictionary.reference.com/browse/ignorance ? I absolutely do agree that cultural practices are a major challenge in breastfeeding practices but there are researches that have identified lack of knowledge as a barrier to breastfeeding practices among mothers in developing countries. The most recent review of IYCF program in six countries ( Bangladesh, Srilanka, Phillippines, Uganda, Uzbekistan and Benin) published in April 2010 revealed that one of the major challenge or obstacles in infant feeding is the lack of feeding knowledge and skills among care givers which includes; Lack of knowledge of benefits of breastfeeding and the importance of Exclusive Breastfeeding, assumption that breast milk is not enough to nourish infants, Lack of infant feeding management skills, such as proper positioning and attachment, Lack of understanding that insufficient milk is due to poor suckling techniques etc. Detailed consolidated report can be found on http://www.unicef.org/nutrition/files/IYCF_Booklet_April_2010_Web.pdf In addition, some other researches have also identified the lack of knowledge as a barrier to breastfeeding. A cross-sectional study on the barriers to EBF among infants aged 0-6 months and involving 384 mother-infant pair visiting Huruma and West maternal and child health (MCH) clinics in Eldoret municipality, Kenya reported that 64.4% of the respondents indicated breast milk is unsatisfying to the infant. This is basically ignorance of the correct information. This report can be found on East African Journal of public health web page on, ajol.info/index.php/eajph/article/view Another interesting research finding worth mentioning is the one carried out in Edo state Nigeria about factors influencing breast feeding practices. This can be found on http://www.ajfand.net/Issue-XI-files/PDFs/SALAMI_1680.pdf This research finding also mentioned the lack of knowledge as a factor influencing breastfeeding practices My recent experience in a baseline assessment of knowledge and practices of 600 women of reproductive age in an IDP settlement in South Darfur, Sudan on IYCF revealed 20% knowledge on benefits of breast feeding which obviously affected the practice of breastfeeding. A review of the nutrition education project after six months of project implementation reported a 30% increase in knowledge of standard breastfeeding practices. The end of project evaluation will reveal if knowledge gained also contributed to an increase in standard breastfeeding practices among these targets, which I am quite optimistic about.

Hi Sidiba It sounds like you are doing amazing work - blazing a trail for IYCF. "A cross-sectional study on the barriers to EBF among infants aged 0-6 months and involving 384 mother-infant pair visiting Huruma and West maternal and child health (MCH) clinics in Eldoret municipality, Kenya reported that 64.4% of the respondents indicated breast milk is unsatisfying to the infant. This is basically ignorance of the correct information." I think these result would be similar in the developed world. What we are finding is that education alone is insufficient to change behaviour. I hope that your current work is able to report that increased knowledge about the importance of breastfeeding - and especially the importance of exclusive breastfeeding - translates into better practice but I am not terribly optimistic. The idea that babies are not satisfied by breastmilk alone is well studied (search using the term "PIMS" or "perceived insufficient milk supply"). Even the most educated mothers seem to (mis)interpret normal newborn behaviours (like cluster-feeding, like feeding 'frequently' - and the meaning of 'frequent' seems to vary across cultures and socio-economic groups, like crying, like waking) as hunger. The question of how to address this issue has not been well studied BUT establishing trained peer counselling services and professionally mediated mother-to-mother support seems to be the most promising intervention. This must be coupled with attention to the problem of the marketing of breastmilk substitutes, which undermine women's confidence in their bodies and make outrageous claims for their product. Research out of the Philippines (it is old now but there not really anything newer) shows that exposure to advertising for formula milk increases the use of all breastmilk substitutes - not just formula - including animal milks, porridges, water and the like. Working with local authorities to ensure that this advertising does not reach mothers is one way to address the problem; teaching mothers that advertising is usually misleading (I prefer the 'tells lies' but there are sometimes legal issues to consider on public discussion boards) is another. I would also add that when promoting exclusive breastfeeding, the important message is actually risk-based rather than benefit-based. Telling mothers that breastfeeding is best (or has certain benefits) is not the same as informing them that feeding their babies ANYTHING other that breastmilk in the first six months WILL make their babies sick. Mothers need to know that feeding babies anything other than breastmilk in those first six months causes diarrhoea, pnuemonia, ear infections .... cheers Nina

One of the most important challenges to exclusive breast feeding (EBF) in the developing world, particularly in Africa is the HIV epidemic. In general terms, mothers are highly reluctant to breastfeed in fear of exposing their babies to infection. The problem arises where alternative feeding does not meet AFASS requirements (Acceptable, Feasible, Affordable, Safe Sustainable) and lead to an increase in infant mortality. The reality of the situation is there will always be mothers who choose not to breastfeed within the first six months of their child's life, whatever the reason may be. Hence it becomes more of a development issue, as access to safe and effective alternatives to breatfeeding should be prioritized, rather than exclusively trying to change the mindset of millions of women. The issue of providing access to clean water to prepare infant formula, and research into formula preparations that meet nutrient requirements as well as combat diseases definitely warrants further investigation and insight.

Hi Keiron, I think that the situation that you are describing (where mothers fear breastfeeding due to the risk of HIV transmission) is a serious issue. Why is there the belief that breastfeeding is riskier than artificial feeding?? Because governments and NGOs have promoted this for years. We now know that the risk of transmission of HIV via breastfeeding can be decreased to an extremely low level (less than 0.5%) and that in most situations the risk of artificial feeding is greater than the risk of transmission of HIV. Artificial feeding cannot be made safe- even in the most developed of contexts babies who are not breastfed are 4-5x more likely to be hospitalised with infections than babies that are fully breastfed. Even in the most developed contexts health authorities recognise that for the well-being of mothers and children assisting mothers to breastfeed (which does not mean telling them what to do, it means creating environments within which it is easy and normal to exclusively breastfeed) is the most effective way of promoting health.

Reply to Karleen Talking of conducive environments for EBF and health authorities.... Most countries do not have elaborate policies on breastfeeding, what exists are some guidelines which have no support mechanisms to implement. This is a big setback to all the efforts of encouraging EBF. How are mothers expected to exclusively breastfeed if they are required back to work by the employers before six months and in some cases just 3 months are given. Shouldn't the governments be setting example to private institutions by establishing breastfeeding friendly environments? Shouldn't the health authorities be giving a helping hand by training mothers on how to express and preserve the milk for babies when the are away at work?

This discussion is getting as good as it should.Thanks to all the contributors for your time and sharing. Yes, Breast feeding is important for child survival, literate or illiterate we all know these facts. However, the biggest problem here is our cultures. In a study done in Uganda's Bunyoro region in 2009, we found that culture was a barrier to EBF. There is no clear cut line between native and western cultures. Some health workers too are left in this confusion not clearly knowing which sound practices to promote. Worth noting is that not all our native practices on breast feeding are bad. Therefore most of our efforts should be geared towards BCC. It may take forever, but it is possible. Thanks.