Mother’s Milk, Not Bananas, Key to Infant Health in Aceh
Zahira beamed. It wasn’t just the proud-parent smile that spreads across a mother’s face when strangers fawn over her child. And it wasn’t because her baby lay so quietly in her bassinette amid the commotion. Zahira grinned with a sense of accomplishment as she stood in her living room rhythmically rocking Zafira.
When asked how she fed her baby, Zahira replied that she exclusively breastfed for the first six months, and then introduced other foods and liquids later on.
“Then I rephrased the question,” said Nurdanlia Lairing, a behavior change specialist in Unicef’s Aceh field office. “I asked her how old Zafira was the first time she was given a banana, and Zahira said one month.”
Nurdanlia constantly meets mothers like Zahira in Aceh — mothers who understand the importance of nursing their babies, but don’t grasp the concept of exclusive breastfeeding, or the dangers of complementary feeding too early. And now she’s working to fight these misconceptions, because the health of Aceh’s next generation depends on it.
Aceh has some of the highest stunting rates for children under five in the entire country, which is why health organizations like Unicef aggressively promote exclusive breastfeeding. Nothing but breast milk during a baby’s first six months is one of the most effective ways to prevent stunting, but studies show that exclusive breastfeeding rates have dropped over the past decade.
“Breastfeeding is a major intervention that contributes to reducing stunting — it’s probably the most major intervention,” said Edward Carwardine, Unicef’s chief of communication. “[But right now] there are a lot of cultural practices that prevent optimal breastfeeding practices.”
Indonesia has been struggling with nutrition for decades. Although there’s been a steady decline in acute malnutrition — wasting, which results from food deprivation over a short period of time — the archipelago still sees some of the highest stunting rates in the world.
More than one in three Indonesian children under five suffer from stunting, says Unicef, and Aceh is the country’s fourth most impacted province, with about 45 percent of children suffering from the condition.
Stunting, or stunted growth, is a low weight-to-height ratio that results from chronic malnutrition.
According to Unicef, stunted children look healthy, but grow to be about four to six inches shorter than average, which makes them more susceptible to physical illnesses like diarrheal diseases and parasitic infections, and also impairs their cognitive development.
Stunting becomes irreversible after a certain age, and part of the reason that it’s so difficult to fight is because of its cyclical nature.
“Stunting is indicative of much deeper rooted problems. It basically goes across generations,” said Robin Nandy, Unicef’s chief of child survival development.
“If, for example, the mother is malnourished, and gets pregnant, this can get transmitted to the child, so the child will be stunted as well,” Nandy added.
Medical experts identify the first 1,000 days — the time from pregnancy through the child’s second birthday — as the most critical period in terms of nutrition. Mothers must maintain healthy diets while carrying their child, and after giving birth they need to provide the right nutrients and vitamins for their babies — an endeavor that’s relatively simple and cheap.
A Simple Solution
Breastfeeding provides unparalleled benefits for both mother and child. According to the World Health Organization, breast milk contains not only key vitamins, but provides babies with antibodies that fight common childhood diseases. Studies also show that for mothers, nursing reduces the risk of certain types of cancer and acts as a natural form of birth control.
Health officials and organizations across the board promote exclusive breastfeeding for at least the first six months. Realizing its importance, the government jumped on the bandwagon as well when it passed a law promoting exclusive breastfeeding in 2009.
Yet despite this unanimous support, exclusive breastfeeding rates have been on the decline. About 40 percent of Indonesian mothers exclusively breastfed in 2002, according to Unicef, compared to 32 percent in 2007. Experts cite a rise in formula use as a leading culprit, but also explain that cultural practices play a large part, particularly in Indonesia’s rural areas.
“In Brebes, for example, there is a traditional belief that when a baby is born, it has to be given a banana,” explains midwife Rahayu Pujiastuti.
Rahayu has worked in Jakarta for nearly two decades, but travels to rural provinces like Brebes in Central Java to train midwives. In these areas, she finds that traditions usually lead family members to feed babies solid food far too early, sometimes just a few days after birth.
Similar beliefs prevail in Aceh. It’s not that women don’t nurse their children. In fact, it might be difficult to find a mother who doesn’t. It’s just that they don’t exclusively breastfeed, and that is where the problem lies.
After a decade of rigorous educational campaigning, mostly supported by non-governmental organizations, perceptions of breastfeeding are changing.
In rural areas, midwives and posyandus, or community health centers, are particularly crucial in communicating these messages, and luckily Aceh seems to have its fair share of dedicated messengers.
Posters splashed across health center walls show mothers gazing lovingly at their infants as they nurse. Midwives repeatedly stress the importance during routine check-ups. And in one posyandu hallway hangs a map, which marks the homes of pregnant mothers or newborns, so the midwife can better keep tabs on each baby’s feeding regiment. So far, the effort appears to be working.
“In the old days, I gave my daughter bananas, starting when she was three months,” recalled Husnaini, 46, who often watches her 3-month-old granddaughter, Kanza Putri.
Now she says she only feeds Kanza her daughter’s breast milk.
“My mindset changed because of what I learned at the posyandu,” Kanza said.
Many mothers and grandmothers throughout Aceh echo Husnaini’s attitudes. Either from the posyandu or information online, mothers today not only know the importance of nursing, but they regularly pass the knowledge on to older generations.
Despite this progress, officials still face the challenge of defining what “exclusive” means exactly. Husnaini, for example, explained that her granddaughter only drank breast milk, but then said that she sometimes fed the baby water when there wasn’t enough.
Setting the Message Straight
To facilitate this change, Unicef is developing a new communications campaign. Because most women nurse their babies in some capacity, officials plan to stress that poor feeding habits can have harmful consequences, such as stunting.
“We will not be [promoting] the benefits of breastfeeding, because that has become the norm,” explained Nurdanila. “We will emphasize our measures on the dangers of giving additional food and bottle feeding.”
The communications strategy began with a four-month study aimed at pinpointing misconceptions. In addition to beliefs that solid foods at an early age are beneficial, Nurdanlia and her team found that many families believe formula milk can increase intelligence and improve health.
Now, Unicef is strategizing how to best deliver the correct information. They plan on asking religious leaders for help, as well as facilitating support groups.
“Instead of using the media, our studies show that the most effective method is to go through interpersonal communication,” Nurdanlia said.
The strategy should be finished this September and from there officials will help the community implement the new plan. In addition to breastfeeding education, Unicef will stress the importance of health during pregnancy and hand-washing with soap. And although it will be tough to foster behavior change on such a large scale, Nurdanlia remains optimistic.
“Once you succeed in one step, the others will follow.”
Before the plan rolls out this fall, Nurdanlia will join officials around the globe in promoting World Breastfeeding Week, which is hosted annually by the World Alliance for Breastfeeding Action. The event kicks off on Wednesday, and activities will include lectures, workshops and photo contests.