Comment form the Reviewer

Coming from someone who says she is not an expert, Isatou Jallow Semega-Janneh's Lecture has an unusually clear vision, unusually innovative contributions to make, and is a welcome addition to the breastfeeding literature. She rightly emphasizes the fact that exclusive breastfeeding without even additional water is necessary if the benefits of breastfeeding are to be fully realized. As the ACC/SCN has earlier emphasized - it is not being stunted but the act of becoming stunted that is harmful, and yet it starts throughout the developing world almost from birth. Little relevant research has been done yet, but one could hypothesize that if too much water and other fluids are given, breast milk will be displaced to the point where protein and/or mineral levels in the infant diet will be inadequate to achieve ideal increases in stature, even in the absence of frank illness and malnutrition.

She is equally correct to point out that exclusive breastfeeding for about six months cannot be achieved unless the newborn baby and mother receive more support than we have recognized in the past was necessary and important. She mentions economic arguments for longer maternity leave but one could also view it from a human rights perspective. If we now agree that the life of school age children should be protected from harm done by child labor, is it any more acceptable for a baby's life to be harmed through unreasonable work demands placed on the mother in the early months of life? We have an historic opportunity now to rethink this issue, as the ILO will reconsider Convention 103 on Maternity Protection at its next annual meeting in June, 1999.

Given how rare it is that one comes across really new and creative ways of approaching breastfeeding promotion, it was a pleasure to read the amazing number of fresh ideas Isatou Jallow Semega-Janneh had both at international and national level.

Even more refreshing was how the Gambian Baby Friendly Community Initiative ignored all the usual limitations that keep breastfeeding promotion limited to the health care system, and moved out to the villages. The inclusion of men in the village groups was also a crucial innovation. Only if everyone realizes the importance of maternal-infant proximity will it be possible to mobilize the necessary support. The idea of setting up baby-friendly rest houses in the fields where the mothers worked was also truly ingenious. Though less widely adopted in the trial, the "community maternity leave" concept sounds like the kind of long-term solution we would already have everywhere in the world if we had built up social systems that had taken into account the importance of exclusive breastfeeding.

It was also a pleasure to see that some kind of evaluation research was linked to the initiative from the beginning. The results, as the author herself says, were of an unexpected magnitude. While there was no control group, one can be fairly certain that such a large secular change in breastfeeding practices do not occur.

Is this approach reproducible elsewhere? Like all innovative projects, there is a risk that a dynamic person or small group was responsible for much of the impact. But one hopes that The Gambia will move ahead with its plans for national implementation and lead the way for the rest of the world!

One wonders what kinds of innovative efforts would be tried now if [the author] had been running a global effort to cope with the problem of HIV transmission through breastmilk. Presumably she would soon have determined how and where heat treatment of expressed milk, use of wet nurses, and milk banking might be used as first priority approaches for reducing the risk of mother to child transmission of HIV without risking so many infant lives and damaging public confidence in this most irreplaceable of human functions.

Information on ACC/SCN Nutrition Policy papers, as well as additional copies of papers, can be obtained from the ACC/SCN Secretariat.

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