Socio-cultural determinants of infant

malnutrition in Cameroon Ngambouk VitalisPemunta

Centre for Concurrences in Colonial and Postcolonial Studies, Linnaeus University, 35195 Växjö, Sweden.

Email.vitalispemunta@gmail.com

Mathias Alubafi Fubah Research Associate, Visual Identities in Arts andDesign(VIAD), University of Johannesburg, SouthAfrica

AbstractAim of study: This paper seeks to explore and explain the socio-cultural factors responsible for the incidence of infantmalnutrition in Cameroon with particular emphasis on northernCameroon where it is most accentuated.

Method: The paper combines quantitative data drawn from the1991, 1998, 2004 and 2011 Cameroon Demographic and HealthSurveys, (CDHs) as well as a literature review of publicationsby the World Health Organisation (WHO) and The United NationsChildren's Fund (UNICEF). This is further complemented withqualitative data adduced from various regions of Cameroon,partly from a national ethnographic study on the ethnomedicalcauses of infertility in Cameroon conducted between 1999 and2000.Findings: Whereas, socio-cultural factors related to childfeeding and maternal health- breastfeeding, food taboos andrepresentations of the colostrum as dangerous for infants iswidespread through out Cameroon, poverty related factors - lackof education for mothers; natural disaster, unprecedented influx

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of refugees, inaccessibility and inequity in the distribution ofhealthcare services are pervasive in northern Cameroon. Thisconjunction of factors accounts for the higher incidence ofinfant malnutrition and mortality in northern Cameroon.Policy implications: The study suggests among others, the needfor women’s empowerment and for healthcare personnel intranscultural situations to understand local cultural beliefs,practices and sentiments before initiating change efforts ininfant feeding practices and maternal health.

The practical implication of this paper is to tailorbiomedical services to the social and cultural needs of thetarget population-particularly women since beliefs and practicesunderpin therapeutic recourse. Whereas, infant diarrhoea might bebelieved to be the result of sexual contact, in reality, it iscaused by unhygienic conditions. Similarly, weaning foods aimedat transmitting ethnic identity might not meet a child’s age-specific food needs and might instead give rise to malnutrition.

Key words: infant mortality, malnutrition, women’s health,maternal and child health, food taboos, food insecurity, feedingpractices, ethno-physiology, Women’s empowerment, humandevelopment.

Introduction

Infant malnutrition is a global public health problem associatedwith a heavy burden of disease. Malnutrition is a significantunderlying factor of child mortality accounting for approximately50 percent of deaths among under-five children. In developingcountries, approximately 25 percent of children are moderately orseverely malnourished (underweight and/or stunted). With over 9.2million under-five child deaths in 2007 worldwide, malnutritionaccounts for a significant degree of this burden of childhoodmortality (WHO, 2009). Globally, malnutrition causes over one-third of infant mortality mostly from increased severity ofdisease. Cameroon ranks 153 out of 182 countries on the HumanDevelopment Index. Life expectancy at birth is 51 years, while

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the lifetime risk of maternal death is 1 in 24. Under-fivemortality is 131 per 1,000 live births. Additionally, the countryis ranked the 43rd highest in terms of stunting out of 136countries. In Cameroon at least 45,000 children die annually dueto malnutrition (UNICEF, 2012, Human Development Index, 2012).Undernourished children between conception and age two are athigh risk for impaired cognitive development, which adverselyaffects the country’s productivity and growth (UNICEF, 2009). InCameroon, 36% of children under the age of 5 are stunted, 16% areunderweight, and 7% are wasted (UNICEF, 2009), 45% of those aged15 and above are overweight or obese (WHO, 2009), and 11 % ofchildren are born with a low birth weight (WHO, 2009, UNICEF,2009). This middle income country with an estimated population of20,129,878 clearly-‘‘falls short of the Millennium DevelopmentGoals (halving 1990 rates of child underweight by 2015), withbusiness as usual” (UNICEF, 2008). The aim of MillenniumDevelopment Goal number 4 is to reduce child mortality by twothirds by 2015 (UN Millennuim Development Goals, 2005).

This study is a review of secondary qualitative andquantitative data to explain differences in the incidence ofinfant malnutrition and mortality in Cameroon. Acute malnutritionof infants and under-five children is accentuated in the northernregion of the country- home to one-third of Cameroon’s childrenwhere an estimated 55,000 children suffer from acute malnutrition(about 70 percent) (UNICEF, 2012). Most of the 5 millioninhabitants of this enclaved region lack access to safe water andsanitation. The region is further lagging behind in terms ofvarious national level nutrition-related indicators suggestingthat it has a huge incidence of malnutrition as demonstrated intable 1.

Table1: Comparison of National Nutrition-relatedIndicators with the Northern RegionNutrition indicators National Rate (%)North Region (%)Poverty incidence 39.9 67.3Prevalence of under Nutrition/underweight

19.30 35.7

Prevalence of under 6.1 14.1

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Nutrition/ wastingPrevalence of underNutrition/stunting

30.4 43.3

Children <5 mortality rate 144 205Children <Severe Acute malnutrition

1.2 2.9

Zinc Deficiency amongchildren

30.4 43.3

Vitamin A Deficiencies 38.8 63Anaemia among Children 57 61.2Primary school Completionrate

72.6 63.5

Expressed per 1000 live births, not percentages Source: Counterpart International (2012)

Relying on the WHO/CDC/NCHS reference population as a benchmark,table 1 shows that whereas 19.30 % of children ages 0-59 months arechronically malnourished in Cameroon, an even higher rate of 35.7 %are found in Northern Cameroon. Stated otherwise, they are too shortfor their age, or stunted (height-for-age Z-score that is below -2SD). The proportion of children who are stunted is 16 times thelevel expected in a healthy, well-nourished population. Table 1further suggests that the rate of wasting-evidence of acutemalnutrition stands at 6.1% nationally against 14.1% for the North.According to the WHO/CDC/NCHS reference population, a weight-for-height of Z-score that is below -2 SD as these figures suggests-results in a child being too thin for his or her height. It affects6.1% nationally against 14.1% of children in North Cameroon. This issome 2.5 times the level expected in a healthy population. Nineteenpercent (19.30%) of children under five years are underweight(weight-for-age Z score that is below -2 SD). In Northern Cameroon,35.7 percent of children suffer the same fate compared to their age.This is an estimated 9.5 times the level expected in a healthy,well-nourished population.

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Five percent of children under five are overweight (weight-for-height Z-score that is above +2 SD based on the WHO/CDC/NCHSreference population). This is equivalent to 2.5 times of what isexpected in a healthy, well-nourished population. Stunting rangesfrom 10 to 45 percent among children in the 10 regions of Cameroon.Stunting rates are lowest in Yaoundé (10 percent) and highest inNorth region (43.3 %). Wasting ranges from 1 to 9 percent amongchildren in the 10 regions with a national prevalence rate of 6.1 %that contrasts sharply with 14.1 % in the North. Wasting rates arelowest in West region (1 percent) and highest in Northern region(14.1%).The same negative trends and contrasts are reflected forzinc and vitamin A deficiency (30.4% and 38.4%) against 43.3% and63% respectively and for anaemia (57%) against 61.2% nationally andfor the North respectively. Whereas, the national primary schoolcompletion rate stands at 72.6%, it is 63.5% for the North. Anincrease in the level of maternal education is correlated with adecrease in the level of stunting and wasting. Maternal education isfurther related to knowledge of good child care practices and tohousehold wealth (Reisma, 2008:10). These statistical figurescompellingly suggest that more children in Cameroon suffer fromchronic malnutrition as compared to acute malnutrition and that thisugly trend is accentuated in the Northern region of the country asevidenced by its higher under five malnutrition rate of 205% against144% nationally. Children that suffer from acute malnutrition livein the Extreme North and Northwest regions (see also Reisma,2008:10).

Background

From the late 1980s, Cameroon was sweating under a chronic andinternecine economic crisis. Structural adjustment andprivatisation led to rigorous cutbacks in social services,including health care, making access the sole property of the richfew. In the mid-1990s, there was the stabilisation of the economyand the decentralisation of the health care system and in 2006,Cameroon met the requirements for reaching the completion pointunder the enhanced Heavily Indebted Poor Countries (HIPC)

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Initiative. Completion point triggers met included satisfactoryimplementation of the poverty reduction strategy, maintenance ofmacroeconomic stability, social sector and structural reforms, andactions to improve governance and reduce corruption (Charlier andN’Cho-Oguie, 2009). Although this led to debt relief and seemingeconomic progress, infant malnutrition and mortality that isaccentuated in northern Cameroon has continued unabated.

Over time, under-nutrition and infant mortality havesignificantly remained higher in the Northern region (Adamawa,North and Far North) and in the Eastern region than in the Westernregion of Cameroon. How do we account for this higher rate ofmalnutrition in northern Cameroon?This paper combines a review of available secondary quantitativedata, and qualitative data in an attempt to (1) explore the socialand cultural factors related to child-feeding practices and (2) toexplain the regional differentials for the worrying reverse trendin the incidence of infant mortality in Cameroon. This articleargues that an adequate account of infant malnutrition and infantmortality will need to address both its statistical patterns, aswell as the socially meaningful processes that underlie it.Demographic statistics are of course the residuals of socialpractice, and to understand them, we must direct our attention totheir social causes (see Greenhalgh, 1995, Bledsoe, 2002, Johnson-Hanks, 2003).

Method of study

This article relies primarily on data from three sources: anextrapolation of secondary data from the 1991, 1998, 2004 and 2011Cameroon DHS to capture trends over time, and ethnographic sources,both primary and published for possible explanation of theunderlying social and cultural factors regarding maternal and childfeeding practices. The DHS, a nationally representative sample,covered 10,462 households, 10,656 women age 15-49 and 5,280 men age15-59 in 1991. A total of 5, 227 women and 5,125 men were testedfor HIV. In 1998 it consisted of 5501 women aged 15-49 and 2562 menaged 15-59 years. The 2004 DHS targeted 10,462 households, 10,656

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women age 15-49 and 5, 280 men age 15-59. A total of 5, 227 womenand 5,125 men were tested for HIV. It is carried out by MacroInternational in conjunction with the Bureau Central des Recensements etdes Études de Population of Cameroon. (For a discussion of sampling,translation, and interview methods, see Fotso et al., 1999). TheseDHS data are complemented by a literature review of publications bythe World Health Organisation (WHO), UNICEF and the World Bank.

The ethnographic materials we analyze include our own eldfinotes from research among various tribes, particularly a nationalethnographic study on the ethnomedical causes of infertility inCameroon (1999-2000), and published and archival sources fromvarious regions of Cameroon. Although on each occasion our studieswere approved by the Independent Ethics Review Board of theCameroon Ministry of Scientific Research, participants furthersigned ethics forms or gave oral approval. In order to provideunderstanding for perceptions and beliefs regarding infant feedingpractices, we used purposive sampling and semi-structuredinterviews with healthcare workers, mothers and grandmothers aswell as participant observation to collect data. We thereforecombine qualitative and quantitative data to explain the regionaldifferentials in the incidence of infant malnutrition and mortalityin Cameroon.

The usefulness of well-designed mixed method studies has beenwell documented (Miles & Huberman, 1994:40, Gherardi & Turner,1987: 208, Guba & Lincoln, 1998). In fact, ‘… numbers and words areboth needed for us to understand the world’ (Miles & Huberman,1994:40). Simple analyses of various DHS data was undertaken andcompared to expose trends over time so as to gauge the magnitude ofthe problem of infant malnutrition. The results of both thequantitative and qualitative data have been compared andcomplemented after independent analysis of both datasets so as toenhance understanding of infant malnutrition. Our analytic methodis in line with standard anthropological practice, which seeks toexplore the social causes underpinning patterns that are observablein demographic statistics. This resonates with Kreager’s(1982)model of “demography in situ” (see also Johnson-Hanks, 2003).

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RESULTSThe figures that follow show nutrition-related indicators from fournationally representative surveys (DHS) conducted in 1991, 1998,2004 and 2011 in Cameroon.

Chronic malnutrition.

Fig 2: Chronic malnutrition.Years Percentage1991 23%1998 29%2004 32%2011 33%Source: Compiled from DHS Data: 1991-2011

The table above depicts an increasing rate of moderate chronicmalnutrition or stunting (height-for-age) among children under fiveyears over time. In 2011, 14 percent of children aged 3 to 59months suffered from severe stunting (included in the 33 percentstated above) (Counterpart International, 2012) reminiscent of1991(DHS, 1991), but the percentage was as high as 29 percent in1998 (DHS, 1998) and has since continued to rise. This suggests amore than 50 percent increase in the rate of chronic under-nutrition over time. Negative trends are observable in the threemain indicators of malnutrition-stunting, wasting and underweight.Although the 2004 DHS showed some improvement with 14.6 percentunderweight, 32.5 percent stunting and 5.6 percent wasting(Charlier and N’Cho-Oguie, 2009:40), it revealed that 32 percentof infants under 5 years old (1 out of three) suffered from chronicmalnutrition, and 13 percent from severe malnutrition. Stuntinggoes beyond poverty in Cameroon as 12% of children in the richestquintile are stunted, suggesting that this is not an issue of foodaccess, but of caring practices and diseases (UNICEF, 2009). The2011 DHS indicates that one out of three children in Cameroonsuffer from malnutrition. It therefore shows an increase ofchronically malnourished children from 32 percent to 33 percent in2011 and from 13 to 14 percent between children who are victims of

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severe malnutrition. UNICEF estimates that malnutrition kills atleast 105.000 children less than 5 years old in Cameroon annually.Furthermore, some 210, 000 children less than 5 years suffer fromchronic malnutrition, with 120, 000 of them living in the north andextreme north of the country (UNICEF, 2012).

Slower decline in infant and child mortality

Fig 3: Decline in infant and child mortality andregional variations

Year Infant deaths(per 1,000)

Infantmortality(per 1,000)

<5 mortalityrate(per 1,000)

1998 77 77 1512004 62 74 144 Regional Variations inunder-five mortality1998 and 2004 Douala(Littoral) 48

Northern Region 205Centre/South/East 146Adamawa/North/Far North

203

Source: compiled from Population Council data(Population Council, 2009) Although Fig 3 shows a significant decline (15 percent) per 1000live infant deaths below age 1 however, the decline in child deathrate, (ages 1 to 4) demonstrates a slower trend than for infantmortality- 63 deaths per 1,000 live births in 1998(PopulationCouncil, 2009).Cameroon shows higher infant and maternal mortalityrates compared to Sub-Saharan Africa. According to a recent WorldBank sponsored report, the country actually has the worse healthindicators when compared to other middle income countries in theregion. The country has the highest incidence of under-fivemortality: for every 1000 live births, Cameroon counts 122 deathslargely attributed to malaria, pneumonia and diarrhoea. Regionally,

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the average number of deaths in this age bracket is 108. The reportfurther notes that in the course of the last two decades, Cameroonhas been one of the countries in the world where the rate of under-five mortality has decreased minimally. Only 16 infants for every1000 live births live above five years in Cameroon whereas on theaverage, 65 more infants survive in Sub-Saharan Africa. Infantmortality remains extremely high in the poorest regions of thecountry such as the Northern and the Adamawa/North/Far NorthRegions, where an estimated 20 percent of infants do not attend theage of five. Recent estimates further suggest that the North counts191 deaths per 1000 live births. On the contrary, the East region(90 deaths per 1000 live births) and South (50 deaths per 1000 livebirths) show the highest reductions in the rate of infantmortality. Among poor and rural communities, women and new-bornbabies are exposed to higher risk of death, and the risk ofpremature births are higher (young girls and women in the 10-24years age bracket have a 33% rate of pregnancy(Campos et al.2013)(see also Population Council, 2009).

Underutilisation of prenatal care and assisted delivery services.The 2004 DHS suggests modest improvements in the coverage of bothmeasures. Prenatal care rose by an estimated 4.6 percent between1998 and 2004, with important increments in the relativelydisadvantaged regions of Adamawa, the Far North and the North. Atthe same time, the incidence of assisted deliveries witnessed a 7.8percent increase (Charlier and N’Cho-Oguie, 2009). Between 2004 and2011, 85 percent of Cameroonian women consulted a health careprofessional for prenatal care-a 1 percent increase from 2004(83percent). Simultaneously, 20 percent more urban than rural womenconsulted a health professional for prenatal care. The Extreme Northand North distinguished themselves with the lowest rates of prenatalconsultations. The Adamawa, and East recorded intermediate levels ofprenatal consultations, whereas, in other regions, 90 and as high as99 percent in the Western region consulted a health careprofessional for prenatal care (DHS, 2011). These figures compareunfavourably with the national total of 61 percent, and the highpercentage scores for Yaounde and Douala respectively and depicts

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an urban monopoly of health care facilities and personnel as well asinequality in the sharing of these resources(Campo et al.2013).

These disparities are represented in the fig 4.

Birth in healthcare facility. Fig 4: Birth in healthcare facility and regional variations (%)Years Facility

birthProfessionalcare

Home birth

1991 63 64 -1998 54 58 -2004 59 62 40% Regionalvariations1991-1998 Adamawa/

North/Far North

25 -

2004 59 -North 22 -Yaounde area 97 -

2011 Adamawa 45.8 -Extreme North22.7 -North 30.2 -Yaounde 90.9 -Douala 97.8 -Total Nationalcover

61 -

Source: compiled from 2004, DHS

Late initiation to breastfeeding. Fig 5: Late initiation to breastfeeding (%).Years Breastfeeding1991 151998 202004 242011 20

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Source: compiled from various DHS

The table above shows a 5 percent increase in the number ofexclusively breastfed infants for the first 6-7 months between1991-1998 which has however not been sustained (DHS, 1991,1998,2004). Since 2004, there has instead been a 4 percent decrease inthe percentage of exclusively breastfed infants. Presently, fourout of five infants are not exclusively breastfed. This is insharp contrast to the WHO recommendations to supplementbreastfeeding with solid/mushy food at the child’s six months ofage. In 77 percent of cases, infants receive water (37 percent),liquids (6 percent), other milks 8 percent while 26 percentreceived solids/semi-solid foods. The level of severe malnutritionvaries according to the region of residence. In the Extreme Northand North regions, the prevalence of acute malnutrition is morethan 10 percent whereas it is estimated at only 1 percent in theLittoral (excluding Douala) and West regions (DHS, 2011). InCameroon, only 20% of all newborns receive breast milk within onehour of birth, and four out of five infants under six months arenot exclusively breastfed. During the important transition periodto a mix of breast milk and solid foods between six and nine monthsof age, more than one-third of infants are not fed appropriatelywith both breast milk and other foods (UNICEF, 2009).

Childhood stunting and underweight

Fig 6: Childhood stunting and underweight (%) Years Stunting & underweight1991 231998 292004 35.82011 57.7

Source: compiled from 1991-2011 DHS and Pongou et al. (2006)

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The prevalence of childhood stunting accompanied by underweightwitnessed a 6 percent increase between 1991 and 1998. This wasreminiscent of the rising trends in under-5-mortality, within thesame period (Pongou et al. 2006). These indicators of children’shealth situation rather became accentuated as evidenced by a 21.9percent increase between 2004 and 2011 (DHS, 2011). Of childrenunder age 5, 57.7 percent were stunted (height-for age) and 27.7percent severely stunted (inclusive of the 57.7 percent), quitehigh values for this measure; 28.8 percent were underweight(weight-for-age) (DHS, 2011, Haul, 2012).

Inappropriate feeding of infants and young children. Most often,infants are given supplemental foods either too early (basicallywater, liquids and solid foods) or too late. This is furthercompounded by the potential dangers of early, latter and/orinappropriate supplementation or appropriate feeding duringepisodes of illness of the mother and/or the child exists.

Cultural beliefs about colostrums. A concatenation of culturalbeliefs and lack of knowledge regarding the advantages of givingcolostrums to babies tends to hamper maternal and child health andwell-being.

Food insecurity. Twenty three percent of households are reportedlyfood insecure, according to a measure of per capita access tocalories. Many more households likely lack access to diverse dietsyear round, particularly in the North and Extreme North Regions(FAO, 2009).

The Causes of Malnutrition in Northern Cameroon

The factors responsible for infant malnutrition in Cameroon are manyand varied and include lack of basic healthcare, food insecurity,poor access to essential child-survival services and poor infantfeeding practices. Although these factors work in conjunction, theyare however accentuated in the Northern unlike Western and other

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regions of the country. The higher malnutrition rate in the northernregion- the hardest hit, according to UNICEF is attributed to lackof essential healthcare treatment, lack of mother education,insufficient exclusive feeding practices and poverty. In their studyof the cultural acceptability of biomedical services in NorthCameroon, Gervais Beninguisse and Vincent De Brouwere(2004) maintainthat biomedical services are culturallly inacceptable because of tooearly first prenatal visits, use in common of delivery rooms, wardsand obstetrical tools, the absence of massage as a form oftraditional healing, the medical staff’s refusal to hand over theplacenta and umbilical cord to the family, and restrictions on thepresence of family members during childbirth. They call for atransition from a normative medical system to an efficient andflexible medical system related to the expectations of the tragetgroup established in collaboration with them- what is calledpatient-centered care.

Women and children in the predominantly northern region facemultiple protection risks and as part of their survival strategies,vulnerable households often force children to drop out of school inorder to work. High rates of premature marriages and the fear ofpregnancy before marriage usually lead to school dropouts coupledwith the belief that educated girls have less respect for eldersand men, and are less subservient, are other factors contributingto under-scolarisation which is accentuated among women. As rightlyarticulated by UNICEF:

Despite some progress, schooling is still perceived to be incompatible withcultural and religious customs in certain regions of Cameroon. Traditions ofteninhibit the participation of women in social life, and the education of girls is notconsidered a priority for many parents in some areas, especially in theNorthern provinces, who often keep their female children at home for domesticchores and prepare them for early marriage (http://www.unicef.org/infobycountry/cameroon)

Although the government decreed free and compulsory primary schoolattendance in 2000/01, the public educational system is bedecked bylack of infrastructure and droves of desertion due to poor pay andworking conditions. Primary school teachers in the Northern region

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are often away from their schools undertaking other, more lucrativeeconomic activities in the name of chasing integration files in thepublic service in Yaounde.

In the 1998/1999, academic year 82 percent of children inCameroon including the Northern region were enrolled in primaryschool while the total enrolment rate in the Northern region wasonly 53 percent. By gender, only, 74 percent of girls against 88percent boys went to school in the whole country, while in the threenorthern regions the rate was 38 percent for girls against 68percent of boys. In Adamawa- the province situated closest to thesouthern provinces, the situation is better than in the two othernorthern regions, the North and the Extreme North. In Adamawa, therate of girls was 43 against 62 percent boys (Anonymous, 2001).

Poverty is gendered and includes low purchasing power offamilies particularly women and inequitable income distribution. Itshould however be pointed out that malnutrition is not solelyrelated to poverty-children even from the richest quantile sufferfrom malnutrition. Adequate nutrition requires much more than accessto food. It requires adequate knowledge of how to prepare it, thenutritional needs of children and how often feeding is required.Additionally, it needs someone present with adequate time to feedchildren (Wodon and Zaman, 2010).

Furthermore, the region is prone to drought and foodsupplements provided by UNICEF often arrive community distributioncentres already expired because of enclavement and lack of means oftransport (UNICEF, 2011). The enclavement and isolation of thenorthern region is further compounded by the interplay betweendifficult living conditions and influxes of refugees from theCentral African Republic and Chad. Since 2003, there has been anunprecedented influx of refugees fleeing instability into theEastern and the three Northern regions. They number up to a quarterof a million, with 82,000 refugees from the Central African Republicin the Adamawa and East regions and 3,500 Chadian refugees in Northregion. In the Adamawa and East regions, the global acutemalnutrition rate among refugees from the Central African Republicis about 12.1 per cent, which is considered critical, particularlyin East Province. In northern Cameroon, malnutrition is widespread:the global acute malnutrition rate of 14.5 per cent is close to the

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emergency threshold of 15 per cent. The pervasive condition is dueprimarily to a lack of access to age-appropriate foods and feedingpractices, essential health services, and safe water and hygienepractices (UNICEF, 2011).

Additionally, the northern region further suffers from a conspiracybetween nomadism, a combination of drought and extensive flooding-consequently crop failure, which is exacerbated by poorinfrastructure. About 4,000 people, including more than 600children, were affected in 2010 by the flooding, although no long-term displacement was caused because these individuals wereeventually resettled. In May 2010, the country’s worst choleraoutbreak in more than 40 years affected 74 health districts in theAdamawa, Centre, Extreme-North, Littoral, North, South-west and Westregions, leading to 10,965 reported cholera cases and 658 deaths –an extremely high fatality rate of almost 6.03 per cent (UNICEF,2011). Alongside poor infrastructure, the situation is furthercompounded by lower rates of female education as well asinequalities in the distribution of health care facilities andpersonnel. In 1999 for instance, only 40 percent of the populationof the Adamawa, 51 percent of northerners, 50 percent of people inthe Far North, and 40 percent in the East region lived within fivekilometres of a health centre. These regions constantly witness theaccentuated desertion of rural Integrated Health Centres(IHC),District Health Centres(DHC) and some District Hospitals are asconsidered ’’difficult areas” by healthcare staff. ’’Difficultareas” are remote or landlocked health areas, subdivisions andhealth districts underserved by modern amenities where healthservices are provided by low-skilled professionals and poorlyequipped in health technology”. They are mostly located between 80and 400km or between 1-4 hour drive in good weather from the firstreferral hospital and these delays make it impossible to guarantee acontinuity of care (Centre for the Development of Best Practices inHealth, (CDBPH), 2011:2). This bleak picture is contrary to 78percent, 75 percent and 65 percent of people for the Littoral, Westand Southwest regions who live within five kilometres of a healthcentre (Charlier and N’Cho-Oguie, 2009:42). While the quantitativeand qualitative shortages alongside unequal distribution of health

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workers at the expense of rural areas characterizes sub-SaharanAfrican countries, in Cameroon the population/caregiver ratios -9.245/medical doctor and 1.806/nurse – deemed acceptable mask anuneven regional distribution: 3.657/MD are found in the Centre vs61.873/MD in the Far North; 2.036/nurse in the West vs 7700 /nursein the Far North. Moreover, 59.75% of the healthcare workforce isconcentrated in the richest regions - Central, Littoral and West –and serves 42.14% of the population. The high urban concentration ofhealthworkers contrasts with the severe shortage in rural areas,exacerbating unequal access of citizens to a basic public service:25% of doctors and 38% of nurses serving 46% of the population andfuelling the vicious circle of poverty.

Despite concerted efforts by the Cameroon Government and developmentpartners since 2006 in a priority recruitment of 2331 fix termstaff in most deprived areas under the HIPC funding opportunity and150 additional staff under C2D funding in 2007 with contracts towork in targeted districts of Adamawa, East, Far North and Northfollowed by further recruitment in 2009 and 2011, the decentralizedmanagement of contract staff and retaining them in their recruitmentworkplace has not always been efficient with over 12 month-delay forthe first salary, irregular wage payments, regional devolution ofmanagement not extended to the payroll, as well as multiplemigrations.This has undermined and compromised Cameroon's chances ofachieving the health MDGs related to maternal and child health aswell as endemic diseases control thus impoverishing the ruralpopulations (CDBPH, 2011:2).

These regions are the poorest and most deprived in human resources account formore than three quarters of 4500 maternal deaths recorded annually. The skilledbirth attendance rate is on average 29.3% in the three northern regions against71.9% in the Centre Region. The rates of maternal morbidity and mortality areinversely proportional to health workforce. The same applies to the appropriatetreatment of diarrhea, cholera respiratory infections and malaria in children. Interms of access to free vaccination, 64% of children aged 12-23 months living in theurban areas against 52% in rural areas have received all eight routine vaccines ofthe Expanded Programme on Immunization (CDBPH, 2011:3).

In 10 health centres in Kousseri city, moderate and severemalnutrition cases jumped from 75 in May to 166 in July, while 6

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children died from malnutrition in Kousseri hospital in July, 2012.Only 20 of the 43 health districts in the North and Far Northregions have the trained staff, equipment, and means to provide freemalnutrition treatment (AGenzia Fedes, 31/08/2012, IRIN NEWS, 2012).In September, 2012, 40 people died in the wake of tropical downpoursand the breaching of a dam in the Far North Region. The inundationaffected more than 26,000, and in neighbouring Nigeria at least 15deaths were blamed on waters rushing into the country fromCameroon's compromised Lagdo Dam on the Benoue River wiping outhomes, farms and livestock. In 2010, flooding in northern Cameroontriggered an outbreak of cholera that claimed nearly 6,000 lives.Thousands of children suffered from respiratory problems brought onby the flooding, and malaria infections among pregnant women ranhigh. Food supplies have largely been low, boosting worries aboutmalnutrition, and tent shelters are inadequate for the tens ofthousands of displaced flood victims. Ironically, assistance is toosmall and thousands of families are sidelined (Tanko, 2012) becauseof bribery and corruption. Ngatchou et al. (1993:1287), observed a higher rate of infantmortality in isolated sub divisions of the Extreme North withdifficult access. These sub divisions include those found around theMandara Mountains, bordering Nigeria, the Tcholliré sub division atPoli around the frontier with the Central African Republic, andaround Amban in the border with Gabon. However, other isolated areaswith difficult access such as Lomie and Messaména sub divisions inthe East region had and continue to have a lower rate of infantmortality, which is difficult to explain.

In Cameroon, infant mortality differs by region (urban andrural or by administrative units), depending on the cause of death.Generally, it is higher in rural than in urban areas partly due todifferences in the concentration of healthcare services. The Centre-South has the lowest mortality unlike the northern region. Theformer region however has a higher incidence of diarrhoea, malaria,and tuberculosis. But it also has the most equipped healthcareinfrastructure with some 7,852 inhabitants per doctor, against13,000 at the national scale. Seventy two (72) percent of women fromthis region are without education, 71 percent give birth unattended

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to by medical personnel and only 52 percent of the population haveaccess to potable water.The north is a high-risk zone for infant mortality. Only 7 percentof the population have access to potable water, 89 percent of womenhave no formal education, 79 percent give birth at home, without anymedical assistance and there is acute malnutrition (CDHS, 2011).This low female socio-economic status is compounded by poor weaningand infant feeding practices and the reticence to acknowledgemalnutrition (‘to say a child is malnourished”) which is furtherexacerbated by lack of access to treatment (IRIN, 2012). Heavyannual flooding leading to the contamination of water sources andcholera outbreak in the area are also exacerbating the nutritionproblem, as crops have been destroyed (AGenzia Fides, 31/08/2012).Additionally, certain customary practices are directly linked toinfant mortality in the region. For example, the coating of theumbilical cord of new born babies with cow dung and soil causestetanus. Children here further suffer from pneumonia, bronchitis,measles and malaria.

Socio-cultural factors

There is an intricate relationship between culture, foodavailability, infant feeding practices and maternal nutrition. Ethnicgroups are characterized by specific models and practices relating topregnancy and childbirth that explain conception, the evolution ofpregnancy and childbirth in line with the life representations of theethnic group. These cultural conceptions and representations informthe protection of pregnancy through the observation of alimentary andbehavioural prohibitions and prescriptions. Most of these culturalpractices are more entrenched in the Northern unlike Western part ofCameroon. This might most probably be one of the outcomes of lowlevels of female education. Local ideas about ethno-physiology withparticular reference to lactation and the perception of infantdiseases like diarrhoea must be borne in mind in the analysis ofinfant mortality. These local concepts and beliefs about the body andits functioning are most often, contrary to ‘standard’ medicalbeliefs based on germ theory that explain illness causation from abiomedical perspective. Feeding is both a biological and cultural

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phenomenon and food is good to be eaten but at the same time, we musttake care of what we eat. Various customs further represent colostrumas dangerous for children as shown in table 9 below. Additionally,the failure to comply with the postpartum abstinence period iscorrelated with diseases such as diarrhoea and determines (non)-recourse to therapy. In a review article, Mortajemi and colleagues(1993) maintain that after respiratory infections, diarrhoealdiseases are the commonest illnesses and have the greatest negativeimpact upon the growth of infants and young children. While thecauses of diarrhoeal diseases they concede have traditionally beenascribed to water supply and sanitation, in attempting to preventsuch diseases, efforts by governments and nongovernmentalorganizations have been focused on and sometimes limited to improvingwater supply and sanitation as well as promoting and protectingbreast-feeding. They demonstrate that weaning foods prepared underunhygienic conditions are frequently heavily contaminated withpathogens and thus are a major factor in the cause of diarrhoealdiseases and associated malnutrition.

Inappropriate weaning foods given to children with the aim oftransmitting ethnic identity is a bane on their health. The firstsolid food and the most popular weaning food in the northern Cameroonregion is a thin cereal gruel made from millet pap and soya beans.Most mothers use the traditional forced hand-feeding method (seeOsuhor,1980). Like in most of West Africa, the problems inherent inthe traditional weaning foods and feeding practices predispose theinfant to malnutrition, growth retardation, infection, and highmortality. Guiro et al. rightly observed that one major cause ofweaning-age malnutrition is complementation of breastmilk with cerealgruels that are of low energy density (1987). Thus, protein - energymalnutrition is a common problem among infants and children in thepoor socio-economic groups of developing countries.The inadequategrowth or stunting produced as a result of poor supplementation isbest described as hidden malnutrition. This is because the child mayhowever appear healthy while being severely malnourished (Gopalan andSrikantia,1973). Writing on malnutrition in the Nigerien sahel,Casiday et al.(2010:166) have noted that “cultural practices of eatingtogether and sharing food equally between children make it difficult

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for parents to single out a child for special treatment”. In the samevein, Claxton (2008:1) observes that “food establishes the culturalidentity of an ethnic group’’ and that children are usually socialisedearly in life through weaning food into this cultural identity bybeing made to consume it because [Food] “is always imbued with meaning,which is understood and communicated in various symbolic ways” .However,these ethnic foods may not meet children’s age-specific food needs.However, research findings from Nigeria shows that a high proportionof the nursing mothers utilized local food ingredients to formulateweaning foods for their babies. While the nutritional composition ofthese foods is of high quality, they are also suitable as weaningfoods, particularly for infants from low socioeconomic level familieswho do not have access to commercial weaning foods (Ijarotimi andOgunsemore 2006).

In what follows, we explore child feeding practices with particularreference to representations of the colostrum, the gendering of food(Division of food by gender and age of the consumer), food taboos,infantile diseases, local therapy and their impact on infant health.Some recommendations will be made.

Breastfeeding beliefs and practices

Decision-making relating to the initiation of breastfeeding or to itsnon-initiation is reached in the light of socio-culturalconsiderations. Socio-cultural factors underpin infant feedingpractices by determining what is and what is not food, when and whoshould consume what and at what time of the life cycle. All overCameroon, there is late initiation to breastfeeding. The discardingof colostrums deprives some infants of its immunological andnutritional benefits. Barriers to breastfeeding show great variationin their cause, but include ethnic and cultural association, genderissues as well as the accessibility and availability of education. Inmany developing countries, public health education is both widelyunavailable and inaccessible and familial, cultural or religioustraditions often dictate the practices of mothers (USAID, 2001,cf.Schwartz, 2008:8). A study conducted in the Western region of

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Cameroon found that cultural beliefs about breastfeeding were themost significant barriers in preventing optimal infant feedingpractices which resulted in mothers giving food and water to theirinfants at too early an age. The decision to introduce foods otherthan breast milk to their babies at a very early age were largelycultural and included- pressures by village elders and families to dothis because it is a traditional practice, belief that breast milk isan incomplete food that does not increase the infant’s weight, beliefthat all family members should receive the benefit of food grown inthe family farm, and the taboo of prohibiting sexual contact duringbreastfeeding (Kakute et al., 2005, see also Chwartz, 2008:8-9).

Breastfeeding is rooted in social norms, beliefs and prohibitions.Among the Bakweris of Southwest Cameroon for instance, a lactatingwoman is prohibited from consuming palm oil during the first monthafter giving birth because “It will spoil the child’s stomach”. Thismeans that it will cause the child to suffer from diarrhea.Ironically, palm oil contains both proteins and vitamins. All overCameroon, various representations of colostrum that prevents it frombeing given to children have been formulated. It is mostly discardedas the table that follows shows.

Table 6. Cultural Representations of Colostrum inCameroonRegion of Cameroon

Name Perception Treatment

Grand North / murla/ Evil spirits Massage breast withherbal mixture to get rid of it

Adamaoua /vaanome/ Poison Take traditional medicine

North West Differently called

Black milk Press breast with hand to get rid of it

West Differently called

Illness that makes breast to enlarge, likewise the veins and nipples

Press breast milk using the hand to get rid of it

Rest of National Territory

Yellow Liquid Contains sexual Germs (sperm particles of a

Squeezed and thrownaway

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man) Source: Adopted and translated from Tamba (1997)

There is however, a reduction in the postpartum abstinence period aswell as an almost non-compliance to the lactation taboo in most ofCameroon. This is attributed to modernism, the drop in the number oflegally married wives due to economic hard times and the improvededucational status of women today unlike in the past. The fall inthe number of polygynous unions has meant bed sharing by partners somuch so that they instinctively start intercourse a few weeks afterthe woman has just put to birth. This might equally be attributed toa more Western orientation in both beliefs and practices todayunlike in the past. The Western idea of one-man one woman has beenbought like hot cake by the new generation of educated Africanwomen. The masculine need for sex at any time fostered theinstitution of polygyny whereas women were expected to stay withoutsex until they are rostered for intercourse by their collectivehusband one at a time. In his analysis of World Fertility data fromCameroon (8219), Ivory Coast (5764), 6125 from Ghana, and 9727respondents from Nigeria to evaluate the dependence of breastfeedingand postpartum sexual abstinence on norms that vary by ethnicgrouping, and to evaluate the extent to which modernizing factors,like education and urbanization, are modifying these 2 variables,while producing new cultural models of fertility, Ofosu (1998:10)maintains that ethnicity is a significant determinant of bothbreastfeeding and postpartum abstinence, and that variousethnicities have followed and continue to follow different culturalpatterns, but new cultural patterns are evolving. He furtherconcedes that these transformations, associated with the majoragents of social change: education, urbanization, and religion,“neatly always take the form of reductions in postpartum duration,and consist of a movement away from tradition toward some sort ofhomogeneity. The most significant changes occur with respect totraditionally long durations, and among those groupings that haveundergone the most social change. When the durations havetraditionally been short, little change has occurred”. Similarly,Benefo (1995) maintains that modernization and female status isassociated with declines in abstinence, which could lead to an

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increase in fertility and deterioration in maternal and childhealth.

Body image, sexuality and disease

From the standpoint of ethno-physiology, it is held that spermchanges the body chemistry of a lactating woman, affects thequality of the breast milk and endangers the health of the child.Any violation of the sex prohibition taboo during breast-feeding isbelieved to be evidenced by the development of red hair,kwashiorkor, and generally the child looks weak. Pamela Feldman-Savelsberg who studied the Bangangtes of the western region ofCameroon noted that:

While the “official” reason for abstinence during lactation was to protectthe quality of the breast milk, sexual abstinence also prevented mothers ofinfants from becoming caught up in fights among co-wives regardingsexual access to the husband (Feldman-Savelsberg, 1995:499).

This taboo, which is under serious contestation from young femalestoday, was functional for reproductive health. It encouragedprolonged breastfeeding, gave the woman respite from sex andreproduction. Sexual intercourse in traditional African society wasnot meant for pleasure but rather for procreation and taboospermitted a woman’s reproductive organs to rest. In the northernregion of Cameroon where syncretic Islam is practised, birthspacing is more a function of lactational amenorrhea. That is, non-susceptibility to conception due to breastfeeding. From informalchats with several young females, it was recorded thatbreastfeeding leads to physiological changes particularly the factthat the breasts falls and the male partner vanishes into thin airfor firmer breasts elsewhere. Considerations as to the shape of thebreasts and the zeal to preserve it or not- seem therefore to playa preponderant role as to whether a woman breastfeeds or not.Additionally, there are also the social costs of breastfeeding.This includes interference with social roles such as working out ofthe home in a country where neither the government nor privateemployers provide breastfeeding or childcare facilities.

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Taboos, Infantile diseases and therapy

The perception of the cause of infant diarrhoea is determined bycultural beliefs. There is teething diarrhoea and diarrhoeabelieved to be induced by sexual intercourse. The former isconsidered natural and part of the child’s growth cycle. Sexualabstinence is resorted to for the later as a therapeutic regimen.The child is subjected to an enema leading to dehydration insteadof to oral dehydration therapy (ORT). In Messaména village in theEast Province of Cameroon, where one of the co-authors didfieldwork in July and August 1997, this diarrhoea aetiology ispartly held. Children are purged (given enema) using the freshleaves of the tobacco plant against diarrhoea and malaria. Theyalso hold that malaria and diarrhoea are caused by “dirty stomach”.Despite cross-country variations in the median durations ofpostpartum abstinence, women in polygynous unions in Cameroon andGhana report abstaining 2 to 3 months longer than wives inmonogamous marriages. At the same time, there is the weakening oftraditional patterns of child-spacing (Lesthaeghe, 1989). InCameroon and Ghana, the gap between the minimum and the maximumduration of abstinence by region is 10.6 and 23.5 monthsrespectively. The reasons include ensuring adequate birth spacingand the child’s health and are often framed in symbolic terms suchas semen being capable of “spoiling” the breast milk and leading todiarrhoea (van de Walle and van de Walle, 1989). In Sub-SaharanAfrica widespread pollution beliefs often use “heat’’ to designatea form of pollution originating from certain types of sexualintercourse, including extramarital sex and violations of thepostpartum abstinence period (van de Walle and van deWalle,1993).This is what Mary Douglas (1992/1966:123, 206)describes as “sex pollution”. Douglas points out that the “sextaboo” as a danger-belief is a mechanism of influencing behaviour.Sexual fluid is accordingly presented as dangerous(Douglas1966/84:3) to the health and wellbeing of an infant. In herown words: ‘‘What goes for sex pollution also goes for bodilypollution”. Among the Wagogo of Tanzania most serious cases of

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childhood diarrhoea are associated with violations of thepostpartum sex taboos by the parents of a child (Mabilia, 2005). Astudy of the likely barriers to exclusive breastfeeding with 320women in Cameroon found that sexual contact is proscribed duringthe postpartum period, as it is believed to spoil the breast milkand harm the child. Infant diarrhoea is often linked to theresumption of sexual intercourse (Kakute et al. 2005, see alsoLiamputtong, 2011).

Gender and food segregation

Infant nutrition involves not only the availability of food.Quality food is needed at all stages of infant upbringing. A well-fed mother gives birth to a healthy offspring. Traditional societyhowever tolerates certain foods and behavioural patterns for awoman during pregnancy- the consumption of citron, unripe mangoes,charcoal, soil and “kalaba chalk” among others. Although these onesare tolerated, a pregnant woman is forbidden from consuming othercategories of food. They are considered to be the root causes ofdeformation of the foetus and eventually of the new-born baby if itsurvives. It is believed that the child will manifest certainphysiological characteristics on its body as well as behaviouralpatterns.

Kouinche et al (1997) using Focus Group Discussion Sessionsconducted nation-wide in Cameroon with 600 respondents (45% men and55% women respectively) on food taboos during pregnancy concludedamong others that: (1) When foods that are rich in protein such asegg are consumed, the child will have a bald head or become a thiefdepending on the tribe (South West: thief). The Kirdis of northernCameroon hold that egg consumption causes diarrhoea. (2.) Theconsumption of wild animals such as lions and tigers is believed tolead to the malformation of the foetus. However, in other regionsof Cameroon, it is believed that the child will be as strong andpowerful as these animals. The consumption of gorilla, chimpanzeeand antelope meat among others leads to haemorrhage (bleeding)during pregnancy and subsequently abortion. Certain species of fishare held to cause epilepsy. (3) Some forbidden foods are those that

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are rich in sugar: fruits, sugar cane. There is the risk of oedemafor the mother and she can give birth to a large baby, which attimes may necessitate a surgical operation.

Food and commodities are used as symbolic expressions of maledominance within the context of every day social interaction(Bourdieu, 1977: 177-179). The chicken gizzard in the WesternGrassfields of Cameroon is a patriarchal symbol of honour andprestige. Its consumption is forbidden for women. The deviant womanwho breaches this injunction loses her fertility (Simo, 1995:90).In consonant with Achebe (1966), he further notes that when a manfails to find it in his dish, he can beat his wife without anysanction from society. When a mature man who opens his dish andsaved with chicken fails to find the gizzard in the dish, he willrefuse to eat it on grounds that ‘‘some other person”(in this case,his wife’s lover) has already eaten the dish.If a woman is single, a widow or separated, she is supposed to givethe gizzard to a man irrespective of the latter’s age. But he mustbe a close relative or somebody she admires and respects (Simo,1995: 90).

In an ethnographic study on reproductive health practices inTiben Village, Temah Timah (1998) catalogued “forbidden foods” forfemales. Following him, monkeys are forbidden for pregnant womenfor fear that the child will resemble the monkey, cobra on groundsthat the child will be heady and will be persistently crying- asituation that is incompatible with farm work. Chicken and eggconsumption is held to confiscate the reproductive prowess of awoman and render her infertile. In the same vein, a menstruatingwoman is forbidden from giving food to a wine taper or even passingby the calabash because she will spoil the wine. In most instancesof prohibition, taboos are invoked as justification. In MaryDouglas’ (1966) analysis of beliefs in ritual pollution, shesuggests that societies are likely to see things as "taboo" whenthey are anomalous, when they do not fit neatly into a society'sclassification of the world. Sometimes ritual taboos apply to awhole community at all times (like the rule against Jews andMuslims eating pork), sometimes only to part of a community, or aparticular time period (e.g. many cultures make certain foods taboo

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to pregnant women, or isolate menstruating women from the rest ofthe community).

Consumable food categories for pregnant women and children

Although gendered food segregation is increasingly losing its valueand currency in Tiben village and in most of Cameroon, this doesnot apply to certain categories of food. Edible foods for pregnantwomen include viper meat. The belief is that its consumption willmake the child sleepy and therefore untroublesome once delivered.This, of course is compatible with farm work. Large quantities ofpalm wine are equally consumed to increase and induce the flow ofbreast milk. Ironically, ‘the first dark milk’, (colostrum) whichcontains hormones and antibodies for protection against diseases isdiscarded. The fear, as we saw above is to avoid contaminating thechild because it is presumed to contain sperm particles which cancause disease. Preventive health personnel, nurses and othermembers of the Medical Corp must raise a voice of warning againstthis as well as the giving of enema to a pregnant woman to removedirt and to clean the child.

Among the Oban clan of the Ejaghams of Southwest Cameroon, apregnant woman is given a knife to carry along for protection. Thewoman subsequently abstains from the consumption of certain foodsand from undertaking certain activities believed to be harmful tothe foetus. For example, she is not supposed to eat eggs. If shedoes, the child will develop a bald head. If she drinks water whilestanding up, during labour, the baby’s movement will be upwardsinstead of downwards. She will encounter difficulties duringdelivery. The woman does not also wear a necklace. It is thoughtthat it will strangle the baby. Failure to comply with these ruleswill result in difficult and prolonged labour. For her to give birthsafely in such a situation, traditional rites must be performed.

Local beliefs, practices and ideas also tend to influenceaccess to healthcare with regards to particular diseases. Theypartly underpin the underutilisation of the few existing maternaland child health infrastructure in Northern Cameroon. They have

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effects on the feeding practices and nutritional status of pregnantwomen. Food taboos for instance, frequently deprive a woman ofnutritional elements necessary for the proper development of herpregnancy. Adherence to traditional beliefs and food taboos maylead to the malnutrition of the mother. This calls for theintensification of nutrition education with focus on healthy foods-selection and the importance of nutrition during pregnancy. Researchfrom the Nwangele Local Government Area of Imo State, Nigeriasuggests that 15 Percent of pregnant women adhere to food taboos andthat 38 percent were malnourished. Pregnancy imposes greater energyneed in the body, hence when all the easily available sources ofenergy food are forbidden, the woman would find little to selectfood from, and hence, monotonous feeding will set in (Maduforo,2010).

Child weaning practices

Child weaning practices and the web of prohibitions in which theyare embedded are part and parcel of the process of socialisation.Experience shows that weaning foods may be inappropriateconsidering the age of the child. In the East, Centre and Southernregions of Cameroon, cassava leaf juice (mpeme) is part of theweaning menu whereas among the kirdis of the north, millet derivedproducts are used. What is given to the baby, as weaning food isthe symbol of an identity, an element of cohesion and unity. Thesymbolic meaning of food sometimes has little to do with the fooditself, as in the use of rice to shower newly-weds in certaincultures, and eating socially has less to do with nutrition thanwith communication and relationships (Claxton, N.D:1). Variousrespondents opined that ‘‘it is meant to prepare the child for themeal s/he has to take in the future.’’ Once a woman becomesexpectant in the Northern region of Cameroon, she is supposed tostop breastfeeding the last child. Breast milk at this time isbelieved to cause diarrhoea because the woman’s body chemistry haschanged.

The key issue at stake is that a meaningful maternal andchildcare requires much more than just delivering a baby. Pre andpostnatal care of the mother through the provision of appropriate

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nutrients “to repair worn out tissues, promote growth, reproductionand regulate body processes”, and to provide heat and energy toperform its daily functions are required (Kate, 1982:88). Thenewborn baby must be given the same treatment. Other components ofmaternal health care include: family planning, immunisation,nutritional guidance and careful follow up of both infants andchild under five years old (Coreil et al.1996:63).

Global acute malnutrition (GAM)-weight deficit for height- is12.6 percent, affecting 115,000 children under five in northernCameroon. Additionally, nearly 40 percent of children-approximately350,000-suffer chronic malnutrition. The World Health Organizationclassifies a GAM between 10 percent and 14.9 percent as “serious”,warranting supplementary feeding, 15 percent and above constitutesan emergency. The north and extreme make up 4.9 million ofCameroon’s 20 million people (WHO 2010). Female Empowerment and the behavioural determinants of mortalityreduction

Governments, planners, and social scientists alike neglect women.Unlike men, they have differential access to education, health careand employment (Anker et al. 1982, Hammer, 1982, Dastildar, 1984).Unfortunately, the female literacy rate for Cameroon is only 54.8%(UNICEF, 2008) and the Northern region of the country has thehighest number of “never-been-to-school”. A woman’s educationexerts an influence on infant and child mortality that isindependent of the rate of both the available medical technology ina given society and of the family’s access to it (Orubuloye &Caldwell,1975). Survey data analysis from Ibadan, Nigeria showedthat mother’s education was a more decisive determinant of childsurvivorship than more family economic characteristics likehusband’s occupation (Caldwell, 1979).

Female education impacts on mortality and morbidity rates. Itempowers a woman to make better use of existing healthcare servicesfor both preventive and curative health purposes, to accept medicaladvice and to make timely recourse to modern healthcare facility,greater identification with the outside world, more socialconfidence at handling officials and the willingness to go out of

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the home for services. Maternal education is correlated with theuse of modern health care services in West Africa (Brown et al.1982). There is a high probability for better-educated women to getmarried to similarly economically advantaged men and to enjoyrelatively high standards of living. A 15 country comparative studyundertaken by the United Nations in 1985 aimed at re-evaluating theimpact of maternal education confirmed this point of view. Althoughdata for household income were fragmentary and only available forthree countries, on water supply for six, on toilet facility forfive, other residential facilities four countries, data on place ofresidence and husband’s education, occupation and status, permitteda reasonable evaluation of the net effects of education. Theoverwhelming conclusion was that almost half of the gross effectsof mother’s education could be attributed to economic advantage (cfDeasi and Alva, 1998).

Policy recommendations

The high rate of infant mortality in Cameroon, which ispartly due to socio-cultural factors, suggests the need forculturally sensitive health education so as to change infant andmaternal food habits and practices. To achieve this loftyambition, culture must be borne in mind and taken intoconsideration instead of being labelled merely as superstitionand ignorance. A national nutrition policy must above all beholistic and comprehensive: interventions that cut acrosssectoral boundaries-need for improved food security, changes ininfant feeding behaviours and knowledge regarding dietarydiversity, child care and health care. A woman’s overall healthand nutritional status, pregnancy outcomes and other reproductivehealth problems are considered to be the major biological causesof maternal mortality; therefore, the overall nutritional statusof a pregnant woman is principally determined by the feedingpractices and care facilities available to her (Saba, 1996). Abroad maternal and child nutritional policy should ideallyinclude broad interventions that cut across multiple sectors such

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as food and agriculture, water and sanitation, education andhealth.

Discourage negative practices including: the throwingaway of the first breast milk which contains colostrum,the excessive use of other liquids other than breastmilk, the use of feeding bottles, massaging of thefemale abdomen with hot water after birth, food chewingusing the mouth for infants, food segregation formothers and infants.

Encourage (i) lengthy lactation for at least six months(ii) the immediate initiation of breastfeeding afterbirth.

Empower women through education since a ‘mother’ssocioeconomic characteristics particularly mother’seducation remain the fundamental factors of childmalnutrition in Cameroon’ (Emina, ND). This could beachieved partly by increasing their purchasing power andgranting them access to formal education.

• Increase the broadcasting of developmental andreproductive health programmes over the mass media.Radio health programmes already attract many femalelisteners. Information should also be disseminated inlocal languages. Town criers, school teachers, communityleaders, female organisations and NGOs must lead theway. This is more the case because women’s resources aremostly geared towards the care and welfare of theirchildren.

• The content of prenatal and postnatal health care shouldlay emphasis on household hygiene, infant immunisationthrough vaccination whose rural outreach must beameliorated upon.

• Publication and distribution of a maternal and infantnutrition handbook with tables on nutritional groups aswell as the nutrient content of the various classes offood for both mother and child.

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• Need to balance the regional distribution of health carefacilities so as to avoid existing disequilibria interms of the quality and quantity of health careinfrastructure and personnel as well as undertakebalanced regional development. Reproductive healthfacilities must be given top priority in terms of bothquantity and quality.

Conclusion

This article has argued that an adequate account of infantmalnutrition and infant mortality will need to address not onlyits statistical patterns, but also the socially meaningfulprocesses that underlie it. The relationship between socialprocesses and demographic indices undergirds recent work incultural demography and the anthropology of population (seeespecially Bledsoe, 2002; Greenhalgh, 1995; Hertrich, 1996,Johnson-Hanks, 2003). Ultimately, demographic statistics are theresiduals of social practice, and to understand them, we mustdirect our attention to their social causes (Johnson-Hanks,2003).

This study has shown that local beliefs, practices and ideasdetermine what a pregnant or lactating woman is supposed toconsume. Conformity is held to lead to the enhancement of thehealth and well-being of the foetus whereas non-conformity isheld to negatively affect the health and well-being of theinfant. Taboos whose violation usually relates to children’shealth have been formulated so as to control the behaviour ofwomen in matters of sexuality by attributing particular illnessepisodes to the mother’s misbehaviour- such as involvement insexual intercourse during breastfeeding which is said to spoilthe quality of the breast milk leading to diarrhoea. Certain foodcategories are attributed physical and social characteristics andare either (dis)qualifed for both children and their mothers. Mentoo are not spared. It is held for instance that ‘sweet fooditems’ weaken the virility of a man and is therefore not good for

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consumption because it will weaken a man’s sexual performance.‘Bitter foods’ are therefore held to enhance sexual performance.Weaning foods reflect ethnicity and ethnic identity. What isgiven to children as food is not considered in terms of their ageor nutritional value but rather in terms of what they will eatwhen they eventually grow up. Local beliefs and practices may notalways hold up to the rationality of scientific reason asexpressed in germ theory and biology. This does not mean thatthey should be disqualified as ‘superstition’. Rather, healthcarepersonnel, particularly those practising in transculturalsituations, should try to understand local cultural beliefs andsentiments before initiating change efforts. The reduction ofinfant mortality trends is only possible throughinterdisciplinary collaboration by multiple actors.

Practically, this paper articulate the need to adoptbiomedical services to the social and cultural needs of thetarget population-particularly women as well as the fact thatbeliefs and practices underpin therapeutic recourse. In thespecific case of diarrhoea believed to be caused by sexualcontact, non-recourse to therapy might be resorted to, whereas inreality, it is caused by unhygienic conditions. Similarly,weaning foods meant to transmit ethnic identity might not meet achild’s age-specific food needs. Acknowledgement

We wish to acknowledge the research assistance and in putsfrom Tabe Geneva Nkongho and Dr.Tatah Peter Ntaimah. Dr.Mathias Alubafi Fubah is grateful for comments as well ascritical and useful feedback from various individuals atthe Centre for African Studies, University of Cambridgewhere he was a Research Fellow in 2012.

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