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Hunger, health, and the society
Infant feeding in the Ivory Coast
Issues in evaluating food crisis warning systems
Application of incremental growth standards
Nutrition education: lack of success in teaching papua new guinea mothers to distinguish "good" from "not good" weight development charts
Field guide for the study of health-seeking behaviour at the household LEVEL
Infant feeding in the Ivory Coast
D. Clayton and S. Orwell, M.l.L. Research, London, UK
A. E. Dugdale, Human Nutrition Research Group, University of Queensland, St. Lucia, Queensland, Australia
The Food and Nutrition Bulletin does not ordinarily publish surveys that pertain to a single country, but an exception is made in this case because the Ivory Coast is one of the most developed and prosperous countries in Africa. It is frequently asserted that breast-feeding is rapidly declining in Africa under the pressure of modernization and the commercial promotion of weaning foods. The I vory Coast might be expected to have moved furthest in this direction. The evidence that even in urban areas 97 per cent of infants are initially breast-fed and that 80 per cent are still being breast-fed at 12 months is heartening.
In traditional societies breast-feeding, either by the mother or a wet nurse, is essential for the survival of the infants, but infant mortality is often high (1). The changes in education, pattern of living, and expectations of women, particularly in urban areas, have all led to changing practices in child-rearing. In rapidly developing countries like the Ivory Coast, where many urban mothers seek work to maintain reasonable nutrition and standards of living for their whole family, the solution of the immediate economic problem often takes precedence over custom and long-term goals (2-4). Even in rural areas, cash cropping is replacing subsistence farming (5), with new demands upon mothers (6). There has been concern that the health and well-being of infants in the Ivory Coast may be surffering in this process. Studies of the traditional patterns of child care (7-9) show that most infants in the Ivory Coast are breast-fed until they can walk. Many preschool children have had considerable growth deficits by Western standards (10). The Ivory Coast is one of the most prosperous countries in West Africa and is rapidly developing a cash economy. In 1977 it was the world's largest producer of palm oil (5), and the poultry industry is expanding (1). It is therefore desirable at this time to review current practices of infant feeding and to examine the factors that influence the choices made by mothers.
MATERIAL AND METHODS
Early in 1981 a nation-wide survey was undertaken in the Ivory Coast to investigate infant-feeding practices and the reasons for the choices made. The sampling of the families was designed to cover children from birth to two years living in urban and rural areas and including all main ethnic, socioeconomic, and religious groups. The sample consisted of 1,845 children from urban areas and 329 from rural areas, with an over-representation of those under one year. For the purposes of this study, an "urban area " was defined as a town with than 20,000 people in the most recent census. "Rural areas" were villages with no nearby hospital, school, or industry, whose main occupation was agriculture.
A cluster sampling method was used, with 60 sampling points covering all main geographical and religious divisions. There was random selection within each target area. The data source was a questionnaire. When a home was visited, the information was always obtained from the person who fed the child. Most often this was the mother (98 per cent of those questioned), but only mothers aged 16 years or older were included (table 1).
The questions fell into five groups:
1. The present milk feeding of the child, including age of the child, the duration and frequency of breast-feeding, the age when other milks were introduced, the type of milk used, and the frequency of such milk feeding. If the mother was giving milk other than breast-milk, she was asked the reason for introducing it and the methods of preparation. In these questions, the interviewer did not prompt the mother.
2. If the child was receiving non-milk foods, the age at which the food was started, the reason for starting, the type of food, the method of preparation, and the frequency of use.
3. Whether the child was born at home or in hospital, where the mother got information about infant feeding, and when the child was last seen by a health worker. The mother was also asked how many children she had and how many had died.
4. The mother's attitudes toward breast-feeding and the use of other milks and foods.
5. Household information (table 2). Also, the religion of the mother and father was determined. No questions were asked about the health, growth, or development of the child.
TABLE 1. Socio-demographic Profile of the Sample (Percentages)
(N = 1,845)
(N = 239)
|Age of mother with first child|
|30 and older||29||27|
|Subjects' ability to read|
|35 and older||10|
|Education of mother|
|Education of father|
|Working status of mother|
|Can take child to work||21||51|
|Cannot take child to work||14||5|
TABLE 2. Household Facilities of the Population Sampled (Percentages)
|Piped water, internal or external||66||9|
|Water carrier||26||26 13|
|Listened to radio in last 7 days||52||35|
|Watched TV in last 7 days||61||11|
The interviewers were trained, and a pilot study was done before the main data collection. Ten per cent of the interviews were repeated by a supervisor to test the reliability of the data. The data were entered into a computer file for analysis, with 100 per cent checking of all entries. Some groups had been oversampled to get statistically significant numbers, and these were weighted back in the analysis to their true proportions in the population. In the following section, statements about "urban," "rural," and other groups are derived entirely from these sample results.
Only those facts and associations of medical and health significance are given here. As the majority of mothers interviewed were in urban areas, these larger numbers allow a detailed analysis. The smaller number in rural areas permits only broader generalizations to be made. The results of the socio-demographic section of the questionnaire are summarized in tables 1 and 2.
Use of Health Services
In urban areas, 92 per cent of infants were born in hospitals or maternity units. Only 6 per cent were born at home with no qualified assistance. In rural areas, 50 per cent of infants were delivered in maternity units, and 17 per cent were delivered with no trained assistance. In the towns, 64 per cent of the infants has been seen by a health worker within the last three months; in rural areas only 46 per cent had been seen in this time.
Feeding of Milk and Other Fluids
The feeding patterns in urban areas are shown in figure 1. During the first three months of life, 97 per cent of infants were breast-fed. The main reasons given for a mother not to breast-feed were maternal illness of lack of milk. About 80 per cent of the infants were still breast-fed at 12 months, but this level dropped to 23 per cent by two years. Water was given to half the infants in the first month, but this level declined later in infancy. Infant formula was started in the first month by 19 per cent of infants and reached a peak of 35 per cent in the third month. Other milk products, usually evaporated milk, sweetened condensed milk, or yoghurt, were given to some infants after the third month and reached a later plateau of about 25 per cent.
Fig. 1. The Pattern of Milk and Other Fluid Use by Urban Mothers
FIG. 2. The Pattern of Milk and Other Fluid Use by Rural Mothers
TABLE 3. Reasons for Breast-feeding and for Stopping Breast-feeding (Percentages)
|Reasons for breast-feeding|
|(babies 0-3 months)||(N-258)||(N=214)|
|Natural, obvious thing to do||30||49|
|Nourishing, healthy for infant||30||23|
|Mother had plenty of milk||25||19|
|Reasons for stopping||(N=371)||(N=4)*|
|Breast-milk no longer necessary||16|
|Baby refused breast||15|
|Mother pregnant again||19|
|Mother had to go away||7|
* As only four mothers in the rural sample had stopped breast-feeding, no analysis was possible.
TABLE 4. Reasons for Starting Infant Milk Formula and Methods of Preparation (Percentages)
|Reasons for starting formula|
|Mother works; not at home||21|
|Received advice from hospital||14|
|Mother's opinion on virtues of formula||13|
|Formula given at hospital||4|
|Add powder until right consistency**||74|
|Boil bottle or bowl||66|
*Only 10 of the rural mothers had used formula, and so no
analysis was possible for the rural areas.
** The overlap indicates that adding powder to the "right consistency" do. not preclude measuring.
In rural areas there was a different pattern of infant feeding, as shown in figure 2. As in the urban sample, almost all infants were breast-fed for the first eight months, but in the rural group most infants were still breast-fed at 24 months. Water was commonly given to infants in the first
Reasons for Starting and Stopping Breast-Feeding
Only 4 per cent of the rural woman did not breast-feed their own infants. The reasons for breast-feeding are shown in table 3. Among mothers of young infants (0-3 months), none gave contraception as a reason for breast-feeding, although it was mentioned by 4 per cent of mothers of older infants ( 12-24 months). The reasons for urban mothers stopping breastfeeding are also shown in table 3. Most reasons related to the infant and what mothers perceived as its needs, but in 19 per cent of the cases the mother was pregnant again, and in 7 per cent the mother had to go away from the child.
Use of Infant Formulas
The reasons for starting infant formulas are shown in table 4. The commonest reason given was that the baby appeared to need more milk than the mother could supply (34 per cent). The next commonest was the mother's absence from home (21 per cent); following this were advice from health personnel (14 per cent) and the mother's opinions about the virtues of these products ( 13 per cent).
The procedures used in preparation were asked about by the interviewer, who was not allowed to prompt answers. Consequently, the results shown in table 4 are probably underestimates of the actual practices. Most urban mothers reported that they boiled the water, but fewer said they boiled the bottle and teat. A large number did not measure the powder but added it to the bottle until the mixture appeared to have the correct consistency. The protocol did not allow the interiewer to clarify the meaning of this statement, and it is obvious from table 4 that adding powder to the right consistency does not preclude measuring.
Use of Non-milk Supplements
The pattern of use of other foods is shown in figures 3 and 4. In urban areas some mothers gave cereals as early as the first month of life. There was a slight predominance of brand-name cereals for the first months, but in later infancy traditional cereals were more commonly used.
In rural areas the overall usage of cereals was much lower. Use of brand-name cereals reached a peak at four months and then dropped, while the use of traditional cereals increased to a level of about 28 per cent. It is likely that many infants were also fed family food. In both urban and rural areas, brand-name cereals were considered expensive, suitable for small infants, but difficult to find in shops.
This study gives a cross-section of a society in transition.
As in many other developing countries (12), city living is associated with a shorter duration of breast-feeding. Unfortunately, few studies show the impact of this "urban package" on the growth and health of infants. But it is not enough to examine the growth and welfare of infants in isolation. When making decisions, a mother must consider the well-being of her whole family and not just her new infant (13). Such decisions are made in the light of background knowledge, the resources currently available to the family, and an assessment of the risks involved in different courses of action (2-4). The complexity of the decision-making process has been demonstrated in computer models (14), while Galbraith (15) has suggested that stable village communities can optimize their welfare without outside assistance.
FIG. 3. The Pattern of Use of Cereal Products by Urban Mothers
FIG. 4. The Pattern of Use of Cereal Products by Rural Mothers
There are major methodological difficulties in obtaining data on methods of preparing food for infants. The method used in this study, where the interviewer could not prompt or interrogate the mother, runs the risk that important steps may be omitted. However, prompting and interrogation will inevitably tend to produce the answers that the interviewer desires.
This study has suggested possible dangers in the methods of preparing infant formulas and probably also other foods consumed by infants. But equally, the reported use of water and other foods carries with it risks of infection.
The widespread and early use of supplementary foods in the developing world (16, 17) suggests that they may meet a real biological or sociological need (2, 4, 18). Our knowledge of these biosocial interactions is very sparse (19). Rather than attempting to forbid these potentially dangerous practices when we know so little about their causes, we would gain much more by educating mothers about the benefits and risks of different methods of child care. Mothers in the developing world have every reason to weigh actions carefully because the consequences of a mistaken decision are more likely to be serious in a developing country where there are few back-up facilities.
The choices made by mothers about the feeding of infants are likely to be rational within their value system and within the resources and commitments of the whole family. The Director General of WHO has reported that "the multiplicity of causal and contributing factors . . . and extreme variations between and within countries preclude any uniform approach to the problem. Data collected on a longitudinal basis are required" (20).
It appears that breast-feeding and supplementary feeding are not exclusive alternatives (12, 18) and that many mothers give both. While further data are being collected, the dissemination of useful information through public media and the health services would be both economical and beneficial to mothers and infants (21).
M.l.L. Research is an independent market research organization. The survey was commissioned by Nestle S.A., who gave the authors complete freedom in reporting and interpreting their data.
1. S. L. Huffman, A. Chowdhury, J. Chakraborty, and N. I. Simpson, "Breast-feeding Patterns in Rural Bangladesh," Amer. J. Clin. Nutr., 33: 144 (1980).
2. N. S. Scrimshaw and B. A. Underwood, "Timely and Appropriate Complementary Feeding of the Breast-fed Infant - An Overview, " Food and Nutr. Bull., 2 (2): 19 (1980).
3. G. H. Pelto, "Perspectives on Infant Feeding: Decision-Making and Ecology," Food and Nutr. Bull., 3 (3): 16 (1981).
4. B. A. Underwood and Y. Hofvander, "Appropriate Timing for Complementary Feeding of the Breast-Fed Infant: A Review," Acta Paediat. Scand., Suppl. 294 (1982), p. 12.
5. W. F. Brooks, "Ivory Coast Trying to Match Palm Oil Success with Copra," Foreign Agric., 21 Mar. 1977, p. 11.
6. J. Fauchon, ''Without Losing its Soul," Ceres, 9 (3): 30 (1976).
7. E. Lauber and M. Reinhardt, "Studies on the Quality of Breast Milk during 23 Months of Lactation in a Rural Community of the Ivory Coast," Amer. J. Clin. Nutr., 32: 1159 (1979).
8. M. C. Reinhardt and E. Lauber, "Etudes sur l'allaitement au sein dans une region rurale de Côte d'lvoire," Med. Afr. Noire, 27: 273 (1980).
9. E. Lauber and M. C. Reinhardt, "Prolonged Lactation Performance in a Rural Community of the Ivory Coast," J. Trop Pediat., 27: 74 (1981).
10. A. de Muralt, "Le problème de la malnutrition en Afrique - Experiences faites en Côte d'lvoire," Bull. Acad. Med. Belg., 128: 781 (1973).
11. K. Murray, "Ivory Coast to Expand Poultry Industry," Foreign Agric., 16 Oct. 1978, p. 5.
12. Report on the WHO Collaborative Study on Breast Feeding: "Contemporary Patterns of Breast Feeding" (World Health Organization, Geneva,1981).
13. B. M. Popkin, F. S. Solon, l. Fernandez, and M. C. Latham, "Benefit-Cost Analysis in the Nutrition Area - A Project in the Philippines, "Soc. Sci. Mad., 14: 217 (1980).
14. A. E. Dugdale and D. P. Doessel, "A Simulation Model of Infant Feeding and Family Economics in Developing Countries," J. Policy Modelling, 2: 345 ( 1980).
15. J. K. Galbraith, The Nature of Mass Poverty (Penguin Books, Harmondsworth, Middlesex, UK, 1979).
16. D. B. Jelliffe, Infant Nutrition in the Subtropics and Tropics, WHO Monograph Series, no. 29 (World Health Organization, Geneva, 1968).
17. J. D. Gussier and L. H. Briesemeister, "The Insufficient Milk Syndrome: A Biocultural Explanation," Med. Anthro., 4: 1 (1980).
18. J. E. Brown and R. C. Brown, "Finding the Causes of Protein Calorie Malnutrition in a Community," J. Trop. Pediat., 23: 248 (1977).
19. M. Carballo, "Social and Behavioural Aspects of Breast Feeding, "J. Biosoc. Sci. Suppl. 4 (1977), p. 57.
20. Report by Director General to World Health Organization, 36th World Health Assembly, 15 Mar. 1983.
21. Food and Agriculture Organization, Programme d'Alimentation Ecolaire et d'Education Nutritionelle, report to the Government of the Ivory Coast, no. AT2813 (1970).
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