Gaurav Garg
07/16/2010
Exclusive Breastfeeding for improving child health in Sierra Leone
Background
Despite some recent progress, Sierra Leone continues to have extremely high rates of infant
and child mortality.1 In the 2009 Human Development Report (HDR), Sierra Leone was
ranked 180 out of 182 countries. Recently, the Government of Sierra Leone (GoSL) with the
help of development partners has taken steps to strengthen health systems and improve access
to and quality of curative care through the launch of the Free Health Care services for
pregnant women, lactating mothers and children under five years on April 27, 2010. The
preventive side of public health is equally if not more important.
Figure 1: Map of Sierra Leone
Evidence has shown that exclusive breastfeeding (EBF) for the first six months is one of the
most effective interventions to reduce child malnutrition and morbidity. This is because
1
The Lancet (Vol 375, Issue 9730, pg. 1988-2008, 5 June 2010) reported Sierra Leone was one of the
34 countries in which between 2000-10 rates of decline in child mortality have increased by more
than 1%. According to the SLDHS 2008, infant mortality and child mortality stood at 89 and 140 per
1000 live birth, a reduction from corresponding figures of158 and 267 according to MICS 2005.
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breastfeeding is a low cost and high impact intervention (as are handwashing and use of bed
nets) that can improve nutrition and immunological status of children and also reduce
incidence of diarrhoea, which is the second leading causes of child mortality worldwide.2
Although breastfeeding is very common in Sierra Leone with 95% of children ever breastfed,
EBF is only 11% (DHS 2008). The UNICEF Sierra Leone Country Programme objective is
that by 2012, 60% of the lactating mothers are aware of the benefits and practice EBF.
Identifying the script
Within Sierra Leonean society and across all ethno-tribal groups (Krio, Mende, Limba,
Temne, Kono, Madingo and others) grandmothers, mothers-in-law, Traditional Birth
Attendants (TBAs) and community elders are held as custodians of traditions, knowledge and
best practices on child care. For this, they are accorded a high degree of respect in the
community. In Sierra Leone, credible information about healthcare and childcare information
is minimal across all demographic groups and this is further compounded by the women’s
low literacy levels – only 43% of the women aged between 15-24 years are literate according
to SLDHS 2008. In this scenario, new and/or young mothers are often thought of as being
inexperienced, “dumb”, unaware and largely incapable of making decisions about child
feeding and care. The social structure within the communities and the power hierarchy within
women systematically marginalise young mothers. The high incidence of teenage pregnancy
and early marriage in Sierra Leone has further entrenched these attitudes in the country. 3
According to Bicchieri (2006), social norms are embedded in scripts, and thus are part of a
2
WHO, Learning from Large-scale Community-based Programmes to Improve Breastfeeding
Practices, 2008, pg 47.
3
According to the SLDHS 2008, 25% of women (15-49 years) are married before age 15, and 69% of
women (20-49 years) are married before age 18.
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complex network of values, practices etc”.4 In this paper, I focus on precisely this, the “young
mother” script which is activated in issues of EBF in Sierra Leone.
A recent qualitative study undertaken by UNICEF Sierra Leone shows that there exist several
social norm influenced barriers to the adoption of exclusive breastfeeding practices. These
barriers include limited autonomy on the part of the woman/mother (subject to the directives
of her husband, her mother-in-law, and even some ill-informed health advisors); mistrust of
the information source; fear of violence or embarrassment; cost of adoption of the new
practice; and the distance to acquire the information, skills, or materials to undertake it. The
study also highlights the issue of work overload which blocks women from taking on new,
recommended practices is another key barrier to exclusive breastfeeding. However,
“women’s workload” can be understood as another script in the EBF and broader nutrition
scenario (across the world and not only in Sierra Leone), and a detailed discussion on its
complexities is beyond the scope of this paper.
Traditional practice and customs on EBF, under the custodianship of older women,
grandmothers and community elders, often outweigh the perceived positive benefits of
changing behaviour. Some of the traditional practices, customs and beliefs around EBF in
Sierra Leone include - child given salt mixed with palm oil and kola nut because this is what
the relatives eat and the child should learn right way how to eat like adults; water is the
child's first meal in the world, and colostrums is discoloured so should be discarded; water
promotes growth and cleans the stomach; wife discouraged by husband to breastfeed because
of the belief that sexual intercourse with the wife/mother while she is breastfeeding will
4
Bicchieri, C. (2006), The Grammer of Society: The Nature and Dynamics of Social Norms,
Cambridge; Cambridge University Press pg. 57
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poison the breastmilk (sexual intercourse ranks above EBF of child in the preference
ordering).
Social norm analysis – expectations and payoffs
Using Bicchieri’s social norm framework to explore and analyse the “young mother” script
reveals useful details. There exist conditional preferences for a social norm to exist which are
a combination of empirical expectations (young mothers believe that a sufficiently large part
of the relevant population conforms to non-exclusive breastfeeding behaviours) and
normative expectations (young mothers believe that a sufficiently large part of the relevant
population expect them to conform to non-exclusive breastfeeding behaviours).5 The
normative expectations of young mothers are managed and enforced by the respect
relationship and power hierarchy among women and elders in the community. Nonconformity with the norm could lead to ostracisation, loss of respect and standing and also to
domestic violence. Changing these expectations is the key to enhancing young mothers’
decision making about EBF and for them to adopt the favourable EBF behaviours. For this to
happen, the collective empirical expectations of the reference group need to be changed, in a
participatory manner with the full participation and involvement of the community members
to ensure that the change is socialised and sustainable.
This is not to say that positive deviants for exclusive breastfeeding do not exist in
communities. UNICEF Sierra Leone’s monitoring of community nutrition activities has
revealed that in certain communities pregnant and lactating women’s understand, adopt and
maintain favourable exclusive breastfeeding practices. This “change” has been largely
5
Bicchieri, C. (2006)
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attributed to regular counselling and outreach by a long serving health worker who over a
period of time has been able to convince community members and mothers about the value of
EBF and importantly, make mothers believe that it is indeed possible to practice EBF and
support them in the adoption and maintenance of the practice. Within the social norms
framework, it can thus be said that these positive deviants have strong personal normative
beliefs which clash with the normative expectations, which means that mothers practice EBF
without worrying about the sanctions (ostracisation, rejection, shame etc).
This EBF scenario in Sierra Leone presented in the “young mothers” script represents a pure
coordination game with two Nash equilibria, which implies that if a young mother “knows a
cooperative norm exists and expects a sizeable part of the population to follow it, then
provided she also believes she is expected to follow such a norm, she will have a preference
to conform to the norm in a situation in which she has the choice to cooperate or to defect”.6
In the figure below, conforming to EBF when everyone else also does so, is represented by a
payoff of 10 for the young mother with 10, 10 representing the ideal/desired situation where
due to existing collective empirical expectations everyone exclusively breastfeeds.
Conforming to the traditional practices reinforced by elders would result in a payoff of 5 to
the young mother. This is less desirable than 10, 10 state but conforming would save the
young mother from sanctions and punishments so she is likely to adopt unfavourable EBF
practices. When others in the reference group are practicing EBF and there exist empirical
and normative expectations for the young mother to do so as well, not doing it would mean
that the infant would miss out on the health benefits of the practice which is represented by
0,3. The -1, 0 state represents the young mother practicing EBF (3) but in the absence of
6
Bicchieri, C. (2006), pg. 26.
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empirical and normative expectations for her to do so which means that sanctions would be
imposed on her (-4).
Figure 1: Coordination game with young mother
The figure below represents the case of the positive deviance in practicing EBF. All other
figures being the same as in the figure above, since the young mother does not worry for the
sanctions and has enough belief in her own capacity to practice EBF and is also supported by
some key influencers in the community ( combination of health worker, maybe some health
volunteers, religious leaders etc), her payoff is 3.
EBF
EBF
O
T
H
E
R
Non-EBF
10,10
3,0
0,3
5,5
SELF
Non-EBF
Figure 2: Coordination game with positive deviance
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Strategies to promote EBF in Sierra Leone
Since the end of the war in 2002, Sierra Leone has taken small but assured steps in moving
from an emergency to a more structured development phase. In the past, health promotion
strategies have been limited to one-way information dissemination campaigns. Other
problems exist. For example, while radio is the most popular source of information in the country,
social customs and informal asset ownership rules dictate that radios be owned by men. Also as recent
Sierra Leone polio communication evaluation has confirmed, information heard on the radio by men
is not always shared with their wives, mothers and sisters. UNICEF Sierra Leone studies have
shown that women’s access to credible information remains limited and information when
received, does not translate into desired behaviour due to the lack of support from community
members and the overwhelming importance of customs and traditional practices and low
levels of education. Following the qualitative baseline study on barriers to infant and young
child feeding practices in 2009, a detailed network analysis was undertaken to understand the
flow of information - who talks to whom in a typical community in Sierra Leone.
In the figure below the young mother (blue) receives information from her peers (green) and
the health worker (black), grandmothers and older women (yellow) and the TBA (orange).
Older women’s and TBA’s experience and position in society heavily mediate this
relationship. The young mother’s peers receive information from/talk to grandmothers and
the health worker. As mentioned earlier, in cases of the positive deviance in Sierra Leonean
communities the tie between the young mother and the health worker is very strong and the
health worker’s influence in the community is able to override the traditional practices and
marginalization of young mothers. The husband (pink) in the community receives
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information from the religious leader and also from the grandmothers but has there is little
transfer of information between the husband and the young mother.
Figure 3: Network Analysis on flow of information on EBF to a young mother in a typical
community
Based on the network analysis and qualitative data available, since 2009, UNICEF Sierra
Leone has put in place a two pronged strategy which aims to support a collective
transformation within communities not only on EBF but on child health (with EBF and
nutrition being a core component of it). The first step in this approach is to share (learn and
provide) with communities knowledge about EBF within the broader framework of child
health. A broader discussion on child health is a useful tool to trigger the aspirations of the
community members for their respective communities and identify their role in supporting
positive health outcomes in their community. This is done with a wide variety of community
members and stakeholders – women and men, women leaders, religious and traditional
leaders, youth groups, farming groups, market women leaders.
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The second step is the setting up of We Pikin (Our Children in Krio) mother to mother
support groups across the country. We Pikin groups are constituted by pregnant women,
lactating mothers and other women members of the community. If there are cases of positive
deviance in the respective communities, these mothers also form part of the group as agents
of change. Each group has a democratically elected leader and We Pikin groups use dialogue
and deliberation to identify barriers to exclusive breastfeeding and young child feeding
practices, and also other health issues (immunisation, handwashing, malaria prevention).
Partner NGO facilitators introduce counselling techniques and the We Pikin group members
are encouraged to use these techniques to discuss EBF issues and suggest supportive actions
and measures. Recently in some communities men have also started attending the meetings
out of curiosity and due to advocacy from key influencers in the community. The groups are
free to meet anywhere they want, under a mango tree in the village, in the veranda of the
mosque or church or by the water point or any other location. The design of the group
meetings is flexible and participants are free to talk about anything they want, with the NGO
facilitator’s role being to bring up and direct the conversation towards EBF and health issues.
Apart from this the NGO facilitator is largely non-visible in the discussions.
A supporting component is UNICEF led advocacy with religious leaders, town and village
chiefs to ensure their support and leverage their authority to mobilise the community
(especially elders and men). Recently UNICEF Sierra Leone has signed a MoU with the Inter
Religious Council of Sierra Leone to promote EBF and other essential practices for child
survival and development. Towards this end chiefdom level consultation meetings are being
organised with imams and pastors, so they can carry the messages to their congregations and
also organise, take part in and lead discussion sessions on their premises and during outreach
visits. UNICEF Sierra Leone is also planning to restart the Chiefs as Champions programme,
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so Paramount Chiefs of chiefdoms in the country can take on the leadership roles in
improving the child survival and education outcomes and enhancing the protective
environment for children.
The well documented success of the Community Led Total Sanitation (CLTS) intervention in
many communities in Sierra Leone and their being declared open defecation free (ODF) has
provided UNICEF Sierra Leone with a “foot in the door” to engage the same communities on
other child health issues. In the next stage of expansion of the We Pikin groups, new groups
will be set up in the ODF communities where community deliberation and action is at an
advanced stage and propensity for collective transformation is high.
Positive incentives and sanctions
Programme activities do not provide monetary incentives for social transformation and
behaviour change, rather the focus is on incentivising and regulating action through social
recognition, leadership and moral obligation (especially with religious leaders) around EBF
and child health issues. In its next scale of expansion, We Pikin will be expanded to also
include UNICEF Sierra Leone’s education supported mothers groups (called Mothers Clubs)
in order to scale up, consolidate gains and establish a stronger presence at the community
level with a shared identity (concept of imagined communities by Benedict Anderson). Better
health of children through exclusive breastfeeding ceteris paribus (made visible through Baby
Shows), a shared sense of identity of a nationwide and growing women’s network and greater
participation and mobilisation are some of the positive incentives to advance behaviour and
social change.
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Another positive incentive is linking up We Pikin groups the community radio which will
give them an opportunity to have their voices and discussions heard beyond their villages and
hamlets, a step towards advancing common knowledge on EBF and child health. These
positive incentives are not only limited to the pregnant women and lactating mothers but also
to the older women, grandmothers and the community elders and represents a step towards
the re-categorisation of their role from being obstacles to being enablers and leaders in the
development of the country and its children. In a recent consultation meeting with religious
leaders for example, some of them said that being able to talk about EBF and take health
related information to the communities (many admitted that information about the benefits of
EBF was new to them) would make them “aware” and “champion” leaders. Sierra Leone yet
being a centralised state, with ongoing decentralisation being a slow and tedious process,
there exists a real hunger for information and willingness to assume leadership at the
community level. This needs to be built on.
Going forward – the need for attention to detail
As the programme moves ahead, special attention needs to be given to ensure that We Pikin
group discussions do not become one way information transfer sessions relying solely on
message delivery through the partner NGO. Not all NGOs have the capacity to adopt and
undertake a dialogue based pedagogy to the work, so this area will require capacity
strengthening. The discussion between traditions and new information can be potentially
fraught, so greater attention needs to be paid to how the rights based discourse is linked to
people’s everyday lives (as in Tostan and also in the case of Mockus-Bogota). Also solely
addressing EBF might limit the scope and the potential impact of the intervention, so this
needs to be placed within the larger framework of child health and wellbeing therefore other
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key health, protection and education issues need to be linked in, but without being forced on
the communities. It needs to be a process of constant development and iteration. Links needs
to be made between community radios, religious and traditional leaders and folk theatre
groups, and the We Pikin groups and participants so each and everyone in the community has
a potential stake in the collective transformation and this can be communicated even to
external audiences.
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