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As part of Madagascar's breastfeeding program, health care workers practice breastfeeding counseling using counseling cards, flipcharts, and posters. Here, a midwife role-plays with a traditional birth attendant to show how a mother correctly holds and latches her infant. Photo: © 2001 Lisa Folda, Courtesy of Photoshare
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Spotlight: Madagascar's Comprehensive Approach Improves Breastfeeding
In 1997 the Madagascar Ministry of Health launched a major program to improve breastfeeding practices. The program's approach can serve as a model for other countries. It combines policy-level approaches with improved health care services and community support. Health teams from the Ministry of Health, two USAID-funded projects with expertise in breastfeeding promotion-the LINKAGES Project and the Jereo Salama Isika (Look, We Are Healthy) Project-as well as other local and national organizations within Madagascar collaborated to carry out the program.
Policies and Partnerships Developed
During the first two years of the program, the national government developed policies on breastfeeding and infant nutrition. They also set up and coordinated a nationwide nutrition coalition of about 50 organizations. The organizations in this coalition agreed on nutrition guidelines, breastfeeding messages, communication materials, and behavior-change efforts to support better infant nutrition.
The government program promoted breastfeeding by focusing on essential actions for good infant nutrition: exclusive breastfeeding for the first six months, breastfeeding to complement other foods at six months and beyond, feeding sick children, improving women's nutrition, and managing vitamin A deficiency, anemia, and iodine deficiency.
Health Care Services Strengthen Support
The Ministry of Health promoted the essentials of good nutrition at clients' key points of contact with-in the health care system. These points included consultations for antenatal, delivery, and immediate postpartum care, as well as for family planning, immunization, growth monitoring, and treatment of children's illnesses. To provide services at these contact points, health care workers, community volunteers, and members of women's groups were trained in counseling and supporting mothers' infant feeding practices. Health care workers and community members practiced using communication materials such as counseling cards, flipcharts, and posters through role playing.
Community Approaches Inform and Encourage
A combination of community activities sought to influence breastfeeding practices. They addressed both mothers and their families. During postnatal follow-up in health facilities and women's homes, health care workers and community volunteers encouraged and helped mothers to try optimal breastfeeding practices.
Nutrition promoters also encouraged mothers to consider optimal breastfeeding practices and showed how family members can support mothers' decisions. Radio and television spots, traditional and popular singers, and village theater portrayed optimal breastfeeding behavior and conveyed the importance of family support.
Positive Results: More and Better Breastfeeding
The program reached more than 6 million people in rural and urban communities in two highland provinces. In 2000, 68% of children under six months old in the program area were being exclusively breastfed compared with 46% before the program began. In 2001 this percentage rose to a peak of 83%. In 2002 it fell to 75% after a political crisis put a temporary stop to the program's field activities.
More infants were exclusively breastfeeding into the fourth and fifth months after the program than beforehand. Among infants four and five months old, levels of exclusive breastfeeding rose from 12% before the program to 58% in 2002. Also, the percentage of infants beginning breastfeeding soon after birth rose from 34% before the program to 73% in 2000 and increased further to 76% in 2002.
Sources: Quinn 2005 (185) and WHO 2003 (257)
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