Julie Hurt and Dr. Kirk Dearden, Health Science

A variety of elements influence infant feeding practice in Ghana. These include the public advertising of breast milk substitutes, cultural traditions, educational opportunities, accessibility of educational information, time available, and several perceived options of breastfeeding.1 The World Health Organization (WHO) adopted the International Code of Marketing of Breast Milk Substitutes in 1981 to ensure the proper use and marketing of breast milk substitutes. The Code also emphasizes the importance of exclusive breastfeeding for an infant’s first six months. Studies show that closer adherence to the Code correlates with smaller family size, increased maternal education, and higher breastfeeding promotion in health facilities.2

Ghanaian legislation implemented the Code in 2000 as Breastfeeding Promotion Regulations. According to the law in Ghana, manufacturers cannot advertise breast milk substitutes to the public, labels on infant formula must not idealize the use of breast milk substitutes, and labels on condensed milk must contain information that they are not to be used as a breast milk substitute. Regulations concerning the marketing of breast milk substitutes are needed in Ghana so that mothers’ and health providers’ attitudes toward breastfeeding are based on scientific knowledge rather than the power of advertising.3

In 1992, WHO launched the Baby Friendly Hospital Initiative to achieve the goals set forth in the Code. This program focuses on the health of both infants and mothers in promoting breastfeeding in an environment free of commercial influences of breast milk substitutes. Baby Friendly hospitals provide the structure for educating both health providers and mothers in the benefits of exclusive breastfeeding. In the Sekyere West District, only 2 of the 15 health facilities surveyed were certified as Baby Friendly-the two district hospitals. One of the sub-district health centers is due to become certified in 2005.

My research is based on Victor Aguayo’s study in Burkina Faso and Togo.4 West African countries have high infant mortality rates. “Every year, sub-optimal breastfeeding is the underlying cause of an estimated 3,300 infant deaths in Togo and over 6,200 deaths in Burkina Faso.” Aguayo concluded that legislative action is necessary to monitor violations of the Code in the onslaught of the aggressive marketing of breast milk substitutes and western influence that encourage bottle-feeding.4 The implementation of the Code has increased the exclusive breastfeeding rates and provided for improved infant nutrition. For this reason, the Breastfeeding Promotion Regulations need to be monitored for any violations that may be occurring in health facilities, among health providers and manufacturers, and in advertisements.

I found that none of the surveyed health facilities promoted breast milk substitutes. In the district, there were no violations of marketing in advertisements; however, I noted 4 violations in the larger cities where most market women or businessmen carry on their trade. In the Sekyere West district, it is difficult to find breast milk substitutes. When they are available, the mother must be willing to pay the high price for infant formula. This lack of packaged formula lends itself to mothers using sweetened condensed milk or evaporated milk in porridge for their infants. One water company advertised its water as being “suitable for babies and all ages.” It is no wonder that at least 14 % of the women surveyed also gave water to their infants.

In order to monitor the health providers’ knowledge of the Code, I surveyed 15 health facilities, interviewed 47 health providers, and 124 mothers. Statistics show that 56% of mothers exclusively breastfeed their children, 81% of mothers received breastfeeding counsel at the time of their antenatal consultation, and 70% of mothers elected to follow the counsel of their health provider. Exclusive breastfeeding dominates in the district, but 44% of infants less than 7 months old do not receive optimal nutrition (Fig. 1).

Aguayo reported high levels (90%) of health provider ignorance of the Code and a relatively high level (63%) of women who had never received counseling on breastfeeding from their health provider. In contrast, in Ghana there were high levels (87%) of health provider knowledge and a high level (81%) of women who had received breastfeeding counsel from a health provider (Fig. 2). I assessed that this high level of education on the part of the health provider and the mother correlates positively with an increase in the exclusive breastfeeding rate.

The district hospital only serves 30% of the population. For this reason, it is important that health providers in rural health centers receive training on the Code so as to reach the remaining 70% of the district. I would recommend refresher courses on exclusive breastfeeding and the Code for all health providers. Authorities should continue monitoring to prevent further Code violations. I am convinced that, if continued maternal education and support throughout infancy is provided, malnutrition rates and infant mortality rates should decrease, and mothers will have a desire to breastfeed their children exclusively for their optimal growth and health.5

References

1. World Health Organization. Infant formula and related trade issues in the context of the international code of marketing of breast milk substitutes. Geneva: World Health Organization, June 2001.
2. Shirima R, Gebre-Medhin M, Greiner T. Information and socioeconomic factors associated with early breastfeeding practices in rural and urban Morogoro, Tanzania. Acta Pædiatr 2001;90:936-942.
3. Perera T. National code of marketing of formula milks is not properly enforced in Sri Lanka. BMJ 1999;318:1140.
4. Aguayo VM, Ross JS, Kanon S, Ouedraogo AN. Monitoring compliance with the international code of marketing of breast milk substitutes in west Africa: multisite cross sectional survey in Togo and Burkina Faso. BMJ 2003;326:1-6.
5. I would like to acknowledge ORCA and IRB for funding, Dearden for the idea, and Ghana for its hospitality.