In this article, I describe my work as a Qualitative Research Consultant for a USAID-funded study that explored ways to strengthen nutrition services in integrated community case management (iCCM) in the Democratic Republic of Congo (DRC).
“We live in the flicker - may it last as long as the old earth keeps rolling! But darkness was here yesterday.” – Joseph Conrad, author of Heart of Darkness
Many of you know that I love coffee shops. What many of you may not know is that a substantial chunk of my hours in coffee shops last year were spent pouring over French-language interview transcripts from a study based in DRC. Although I was an ocean away from this magical land, my eyes were opened wide to the layers of complexity in gender norms that I read in the interview transcripts.
The research that I spent most of my hours working on was a USAID-funded study to evaluate ways to strengthen nutrition services in integrated community case management (iCCM) in four Tshopo District of Democratic Republic of Congo (DRC). iCCM is a strategy that trains and empowers community health workers with the knowledge to diagnose and treat pneumonia, diarrhea, malaria, and acute severe malnutrition, among other illnesses and conditions. This specific project was founded with the hope that community health workers could also be trained to help mothers in the community to better feed and breastfeed their children. Last year, I also worked as an ethnography report writer for a church-based DRC study that was designed to reshaping masculinity (also eye-opening, but more on that later).
For the iCCM study, local researchers performed 135 interviews or focus groups with members in four “health zones” of Tshopo District. Interviewees included mothers, fathers, and grandmothers of children under 5 years old; and community health workers, physicians, and traditional healers. I worked with the research team to design a codebook for the study, and then I analyzed nearly all of these transcripts with the guidance of a Senior Qualitative Research Consultant.
Before I became involved with this research, the few things that I knew about DRC were that it is a former colony of Belgium (and thus French is still a predominant language), that Anthony Bourdain filmed an episode of Parts Unknown in the country (which I didn’t watch until the consultancy), and that it is the setting for the book Heart of Darkness by Joseph Conrad. This book is based on the author's experience in the 1890’s voyaging down the Congo River on a boat called the River Thames. One of the central ideas in the book is that there is little difference between the “civilized” colonizing people and the “savage” colonized people – a notion that shocked many in the age of imperialism.
What has changed since then? According to the research, not much. The finding from the research that was most striking to me was the level of poverty experienced by the families interview for the study. Although I had only the lens of the transcripts to peer into the lives of these farming communities, the impact of poverty on the lives of these families is crystal clear. The second most striking finding for me is that the legacy of colonialism is alive and well in the medical system – but more on that soon to come in another research paper. The third finding that struck me is the ways in which gender norms in these farming districts of DRC run parallel to gender norms in urban environments of the United States.
The primary reason that mothers in this study reported introducing foods to their newborns before they were 6 months old (the age that WHO recommends frequent, exclusive breastfeeding) was that their socio-economic conditions forced them to return to their work in the fields. Members of extended families or older siblings were reported to feed young children if mothers were at work, but some mothers only had the option of leaving their children at home without caretakers when they went out to work. Mothers were stigmatized if they brought their children to work in the fields because, as community members said, it would expose their children to the “sweat of the fields”. Working in the fields for long durations (some reported 12 hour stretches or more) was also said to cause mothers to experience difficulty in breastfeeding upon their return home. Yet on the flipside, mothers who did not return to work in the fields risked being unable to feed their families. Either way, mothers were perceived by community members to be responsible for the nourishment (or malnourishment) of their children. Best case scenario was when mothers had social support networks to contribute to the family’s work while she stayed home to nurse her newborn children.
Although there are numerous differences between farming communities of DRC and urban environments of USA, there are several notable similarities in gender norms experienced by mothers in the two geographic locations. Just as in DRC, mothers in the U.S. are less likely to stay home to nurse their children if their socioeconomic conditions to not allow them to do so. Breastfeeding is made easier if mothers have the financial ability to take time off to breastfeed newborns, if their work environment facilitates rather than stigmatizes breastfeeding (e.g. through attitudes of others in the workplace or by granting maternity leave), and if they have the caretaking support from family members.
How important is breastfeeding to the long-term health of newborns? It’s instrumental. Breastfeeding exclusively for 6 months and with complementary foods for 2 years or more is linked to lower levels of asthma, allergies, diarrhea, malnutrition, and obesity, among other conditions. It is also linked to improved IQ scores in later childhood and improved bonding through skin-to-skin touch.
So what is the main factor preventing these health benefits from being transmitted to future generations in both DRC and USA? As much as global health interventions to provide improved knowledge and literacy of breastfeeding to new mothers, it’s often the socioeconomic environment that truly needs to be reshaped. Whether it’s through de-stigmatizing attitudes toward breastfeeding in workplaces, in granting maternity leave, or in forming social support groups to aid mothers of newborns in caretaking, it’s essential that mothers throughout the world feel socially supported rather than stigmatized in providing for their children.