Chapter 17

Breastfeeding, Vertical Disease Transmission

and the Volition of Medicines in Malawi

Robert Pool, Christopher Pell, Blessings Nyasilia Kaunda, Don Mathanga,

and Marjolein Gysels

Contents

17.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277

17.2 The Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278
17.3 Breastfeeding and Health . . . . . . . . . . . . . . . . . . . . . . . . . . 279
17.4 Disease Transmission Through Breastfeeding . . . . . . . . . . . . . . . . . 280
17.5 The Quality of Breast Milk . . . . . . . . . . . . . . . . . . . . . . . . . 281
17.6 Medication and Breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . 282
17.7 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286

17.1 Background

The data on which this paper is based were collected as part of a multi-country
anthropological study of the acceptability of intermittent preventing treatment of
malaria in infants (IPTi) (Gysels et al. 2009). Intermittent preventive treatment (IPT)
of malaria involves the administration of treatment doses of an anti-malarial drug
at predetermined intervals, regardless of parasitaemia or symptoms. Compared to
continuous chemoprophylaxis, IPT reduces the number of times an individual has
to be given the antimalarial, and can avoid the problem of delivery if it is given
at routine health visits: IPT during pregnancy (IPTp) is linked to ongoing routine
antenatal care, and IPT for infants (IPTi) is delivered through the expanded pro-
gramme of immunisation (EPI) (Egan, Crawley, & Schellenberg 2005). At the time
of the acceptability study, IPTi with sulfadoxine-pyrimethamine (SP) was being
implemented in two districts in central Malawi (Lilongwe and Salima). The SP

R. Pool (B)
CRESIB (Barcelona Centre for International Health Research), Hospital Clinic University of
Barcelona, Rossell 132, sobretico 1a., 08036, Barcelona, Spain; Centre for Global Health and
Inequality, University of Amsterdam, Spui 21, 1012WX Amsterdam, The Netherlands
e-mail: robert.pool@cresib.cat

P. Liamputtong (ed.), Infant Feeding Practices, DOI 10.1007/978-1-4419-6873-9_17, 277


C Springer Science+Business Media, LLC 2011
278 R. Pool et al.

was administered at the time of DPT2 (10 weeks), DPT3 (14 weeks) and measles
vaccinations (9 months).
During interviews and focus group discussions for the acceptability study, there
was evidence that some women thought that malaria could be transmitted from
mother to child through breastfeeding. Given the attention devoted to preventing the
vertical transmission of HIV during health education given to breastfeeding women
everywhere, and given reports in the literature of beliefs about breast milks capac-
ity to transmit other diseases (Mull 1992; Nielsen, Konradsen, Mudasser, & van
der Hoek 2001; Hofmann, De Allegri, Sarker, Sanon, & Bohler 2009), it did not
seem surprising that mothers should believe that they could transmit various dis-
eases to their infant through breastfeeding. However, we had not encountered the
notion of vertical transmission of malaria before, either during our own research
on socio-cultural issues relating to malaria or in the literature, and we considered
that it warranted further investigation, particularly because such beliefs could have
implications for malaria prevention.
Related to this, we were also interested in finding out whether women thought
that malaria medication taken by a mother could be passed on to her infant through
breastfeeding and have an effect on the infants illness, and whether this might influ-
ence their attitudes towards malaria prevention interventions aimed at infants. In
order to investigate these questions, eight supplementary focus group discussions
(FGDs) were carried out in Malawi, one of the five research sites.

17.2 The Study

The study was carried out in Lilongwe and Salima districts in central Malawi.
Malawi is one of the worlds poorest countries, with a Human Development Index
that places it 162 out of 179 countries (United Nations Development Programme
2008). Malawis infant mortality rate is high at 76 per 1000 live births and around
half of Malawian children are chronically malnourished (National Statistical Office
(NSO) [Malawi] & ORC Macro 2005). Infant feeding typically involves short peri-
ods of exclusive breastfeeding (around two months) and extended complementary
breastfeeding (over 23 months). It is estimated that HIV prevalence in Malawi
has stabilised at between 16 and 17 percent (Joint United Nations Programme
on HIV/AIDS (UNAIDS) & World Health Organization (WHO) 2008). Although
malaria transmission in Malawi varies locally, in Lilongwe it is described as
endemic, perennial, and in Salima endemic-prone seasonal (www.mara.org.za).
The initial data on malaria and breastfeeding were gleaned from 57 in-depth
interviews, 137 questionnaires and 18 focus group discussions (FDGs) with women
participating in the IPTi acceptability study in Malawi. These were part of the
main data set which also included interviews and FGDs with men, opinion lead-
ers, health workers and traditional healers (Gysels et al. 2009). Women were not
asked specifically about breastfeeding in these interviews, but the topic did arise
spontaneously during discussions about malaria prevention, transmission and diag-
nosis. The data presented below, which are more focused on womens views on the
17 Breastfeeding, Disease Transmission and the Volition of Medicines in Malawi 279

vertical transmission of malaria and the effects of malaria medication taken by the
mother on her infant, were taken from both the main study and the eight supplemen-
tary FGDs carried out after the end of the main data collection phase. These FGDs
were held in the villages surrounding the health centres (Mitundu and Mchoka) and
outreach clinic (Chimoga) where the main study had been carried out.
During the supplementary FGDs, women were asked about their views on the
role of breastfeeding in infant health and how it affected the infants susceptibility
to illness in general and malaria in particular. Ethical clearance for the study was
obtained from the ethics committees of the Malawi College of Medicine, Blantyre,
and the Hospital Clinic of the University of Barcelona.

17.3 Breastfeeding and Health

With the single exception of one woman, who said that she thought bottle-fed babies
were healthier, the women who participated in the supplementary FGDs were unan-
imous that breastfed babies were healthier and less susceptible to disease: Giving
breast milk helps the baby to fight off many diseases was a common comment. This
view of the importance of breastfeeding was based partly on their own experience
(they claimed they could easily see the difference between breastfed and bottle-fed
babies) and on the fact that this was what they were repeatedly told to do at the
clinic. Related to the latter, a few women said that they breastfed longer to please
clinic staff who had told them to do so. In both the supplementary FGDs and in the
main data where breastfeeding was discussed, women all claimed that they breastfed
for at least two years.
Although they all agreed that breastfeeding was good, the women did not think
that it prevented disease, because disease was something that was unavoidable
infants get sick whatever mothers do to prevent it but that it reduced the chance
of them getting sick and it reduced the severity when they did fall ill. These views
were repeated in the context of discussions specifically about malaria. Women knew
that malaria was transmitted by mosquitoes and that the best protection was to avoid
being bitten, by sleeping under bednets for example; but if the child did get bitten,
the illness would be less severe if they were breastfeeding.
R3: The one who gets malaria frequently is the one who is not breastfed. The baby becomes
very weak in the knees because of lack of breast milk, and becomes susceptible to
malaria, while the one breastfeeding has all the energies from the milk, from the first
time, that they start taking the yellowish milk, and that milk energises the knees.
R4: A child who is not breastfed is a weakling and will get more severe malaria, and suffer
from malaria more often, while the breastfed do not get malaria that often.

This protection was sometimes linked to vitamins:

The ones who are not breastfed get more malaria, since they do not have any vitamins in
their body, there is no prevention in the body, and thus they suffer from more malaria.

These views were very similar to those about the way in which both child-
hood vaccination and intermittent preventive treatment of malaria worked; it did not
280 R. Pool et al.

prevent disease i.e. stop its occurrence entirely but rather reduced its incidence
and attenuated its severity.
Women agreed that the longer they breastfed, the longer their infant was pro-
tected. Some women also linked longer breastfeeding to their own health; because it
entailed longer sexual abstinence and greater birth spacing, it reduced the negative
impact on womens bodies of giving birth. One woman expressed this clearly by
arguing that it was obvious from the physical difference between urban women who
practice family planning and rural women with many children. Another one said:
If you are on family planning, your body gets stronger, you look more beautiful and you
gain more strength as compared to a woman who gives birth year after year. That woman
who gives birth year after year does not look good, and the other child does not get enough
breast milk and the father too is never there to help with the babies and that causes you to
overwork, some fathers are only available when they want to make you pregnant again.

Women sometimes linked birth spacing back again to infant health. For example,
in a FGD in the main dataset, one woman argued that:
Another advantage is that the children grow up healthy because you dont have other young
ones to breastfeed or look after. . .and if you have a few children, you have more time to
take good care of them. . .not bearing children like sasakawa [referring to a method of maize
planting where by one seed is planted per hole but the holes are close together].

17.4 Disease Transmission Through Breastfeeding

All the women in the supplementary FGDs said that diseases could be transmitted
to their infants through breastfeeding, and that they would not allow other women
to breastfeed their infants for this reason.
R8: There are some who do breastfeed for other women.
R6: Yes there are, such as a mother and a daughter breastfeeding for each other, but it is not
allowed.
R7: It is because of the blood, some diseases are transmitted through the blood and that is
dangerous for the baby. Nowadays there are diseases out there, AIDS, and for someone
to just breastfeed your child is not good.

They all knew that HIV could be transmitted through breastfeeding, though var-
ious other diseases were also spontaneously mentioned, including TB, flu, asthma,
tetanus and cholera.
Almost all the women were also aware of the need to breastfeed exclusively, and
in one FGD they protested loudly when one woman said that she gave her newborn
baby some water.
R: When a baby is born, I take water on a spoon and give a few drops to the baby, because
my breasts are still dry and the milk is not coming out.
R2: No, no, no, a baby is not supposed to be given any water, just the breast milk [unanimous
response].

However, in the main dataset, mention was often made of older relatives (in par-
ticular mothers-in-law) who were keen to give the infant water and other foods.
17 Breastfeeding, Disease Transmission and the Volition of Medicines in Malawi 281

Also, when the discussion was not explicitly about exclusive breastfeeding, some
women did mention giving water when the infant refused to take the breast or there
was insufficient milk.
Malaria was not mentioned spontaneously in connection with the vertical trans-
mission of disease, but when asked, women tended to have mixed views about this.
In two FGDs, women were unanimous that only mosquitoes transmitted malaria.
However, in two FGDs they were unanimous that malaria could be transmitted
through breast milk. And in the remaining four, there were mixed views. In the
mixed opinion FGDs, there was lively discussion:
R2: Yes, because the malaria stays in the blood, and when my baby is breastfeeding, the
milk is coming from my body, thus through my blood, the baby can get malaria from
my breast.
R3: No, it cannot happen, the baby cannot get my malaria like that. . .
R5: I got really sick with malaria, but my baby has not been sick, so my baby cant get my
malaria.
R6: The baby can get my malaria; it depends on how serious it is. The more severe malaria
will attack the baby. . . thats what I think. . .
R7: I dont think the malaria can be passed from mother to baby because malaria is not
passed from one person to the other through blood.

Women were aware that malaria is in the blood and those who claimed
that it could be transmitted through breastfeeding thought that the mechanism of
transmission was the blood circulating in the breasts rather than the breast milk
as such:
The baby can get the malaria from the mother, through the blood, since breast milk comes
from the body whose blood is circulating with malaria, and so the baby can get the
malaria too.

They were unable to articulate the precise mechanism, however.

17.5 The Quality of Breast Milk

All the women agreed that disease (particularly HIV) could be transmitted from
mother to infant through breastfeeding, and some thought that malaria could also be
transmitted in this way. They mostly thought that this transmission occurred through
the blood of the mother circulating in the breasts rather than through the milk itself
and that the actual quality of the breast milk would not be affected by the mothers
illness. This was expressed in terms of it having been made by God. The women
did think that the amount of milk could be reduced as a result of the mothers lack of
appetite during illness. However, when women have malaria, they do not eat much
and that causes the milk not come out. However, there was a parallel and somewhat
contradictory discourse in which they talked about breast milk becoming bad due
to various factors. First, breast milk can turn bad as a result of the mother being ill.
When I am sick, my whole body is affected, thus the milk too will be infected, the milk too
has a disease, and that is why children become malnourished because they have drunk milk
that is infected from their mother. That means as a mother I have a bad body, a sick body,
that causes my child to be malnourished.
282 R. Pool et al.

When I have malaria, the milk becomes bad, the milk becomes hot because of the fever that
I have and becomes bad for the child to suck, and thus I wait for my body to cool down so
that the milk can cool down too for the baby.

Second, breast milk can become bad if the woman becomes pregnant again while
still breastfeeding. Some mothers, however, contested the belief that breast milk
becomes tainted during pregnancy and contrasted it with what they are taught at the
clinic:
R4: Some babies, when they drink the milk from their pregnant mother, they get diarrhoea
and the mother has to stop breastfeeding.
R5: Yes, but from what we have learnt from the clinic. . .even if a woman finds herself
pregnant, she should not stop breastfeeding, because when she stops, the baby will lose
the protection from the breast milk.

Third, breast milk could become bad if one of the parents had an extramarital
affair while the mother was breastfeeding. Women said that the locally defined dis-
ease kusempha was caused by the infidelity committed by one of the parents and
passed to the child through breastfeeding:
When the mother or the father goes and sleeps with another person and the mother
breastfeeds the child, or the father carries the child, the child reacts by becoming ill.

Hence, while women claimed that a mothers illness would not generally affect
the quality of her breast milk, they did think that some illness could affect the child
through breastfeeding, and that breast milk could become bad as a result of the
breastfeeding mother becoming pregnant or one of the parents committing adultery.

17.6 Medication and Breastfeeding

Women, being aware of the possibility of vertical HIV transmission, talked about the
role of blood circulation through the breasts enabling HIV transmission. We wanted
to know whether they thought that medication that they had taken for malaria could
be transmitted to their infant through their breast milk, and whether they thought
that this medication would have an effect on their infants illness. Their views on
this varied: in two of the supplementary FGDs women were unanimous that this
happened; in three of the FGDs they were unanimous that it was not possible; and
in the remaining three there were mixed views.
Women who thought that the vertical transmission of medication was possible
used the same reasoning they had used for the vertical transmission of illness:
The baby gets the medication from the mothers breast because of the blood that passes
through the breast, and when the baby sucks from the breast, the medication too gets sucked
in the process.
It can happen, because these things are interconnected, when a woman eats more food,
she has more milk, and if she takes medicine into her body, then the medicine can also be
found in her breast and her milk.

The women who disagreed with this seemed to think that there was some sort of
barrier that prevented medication travelling from their body to that of their infant.
17 Breastfeeding, Disease Transmission and the Volition of Medicines in Malawi 283

R1: No, the baby cannot get my medication, because I am the one who has taken the drugs,
they cannot be passed to the baby.
R7: But the food that you eat is turned into milk, so cannot the medication also be passed
from the breast milk to the baby?
R3: Oh no, food is one thing and medication is another. Medication meant for me works in
my body and nowhere else. For my baby I have to get her own medication.
R4: My baby cannot get any of the medication I take. For example if I take Fansidar
[sulfadoxine-pyrimethamine an anti-malarial], it just works on the parasites that are
in my body, and when it gets to the breast, it kills the parasites that cause malaria only,
it does not influence my breast milk nor the baby.

After further discussion, however, it turned out that the reasons that medication
taken by the mother did not affect the breastfeeding infant; it was not so much
because the breast prevented the transmission of the medication to the infant in some
way, but because of characteristics of the medicine itself; medicine that is meant for
the mother only has an effect on the mother, whether or not it is passed on to the
infant.
The medication I take is for me and me alone, not for my baby, so I dont think it passes
through my breasts.
I think that, when I take drugs that are meant for me, they are only for me. If my baby
is ill, I have to go to the clinic and get medicine for his illness. There is no way that my
medication can pass through my breast to work in my childs body. It [medicine] can be
passed, but it only affects the milk itself [not the infants illness].
Drugs do not pass through the breast milk because my babys body is a different body;
the child needs its own medication for it to be well.
The baby cannot get my medication. If I take Panadol, it is for my body and mine alone.

This was also clear in the wider dataset, where people spoke about medicines,
vaccination and IPTi as though they were active agents. They worked because they
received, liked or accepted the child. Similarly, the drug could also reject the
child, and following perceived side effects of IPTi, mothers talked about the drug
refusing the child. It was, therefore, the drug that either accepted or rejected the
child, not the other way round.

17.7 Conclusion

Women were generally knowledgeable about the benefits of breastfeeding and aware
of the importance of long-term breastfeeding and of exclusive breastfeeding during
the first months. They thought, as do women in most societies, that breast milk is the
most valuable food for newborn infants (Liamputtong 2007; see also other Chapters
in this volume). They all claimed to breastfeed for at least two years with some
claiming that they did this exclusively for the first six months. However, this might
have been subject to desirability bias due to the clinic setting of the study. Indeed,
Bezner Kerr, Dakishoni, Shumba, Msachi, and Chirwa (2008) report, in northern
Malawi, that mothers fear health workers disapproval if they discover that they have
not exclusively breastfed (see also Chapter 13 in this volume). Moreover, the fre-
quent mention of older relatives giving infants water during the first months suggests
that this was more frequent than the women cared to admit. Furthermore, elsewhere
284 R. Pool et al.

in Malawi (Bezner Kerr et al. 2008; see also Chapters 14 and 13 in this volume) and
more widely in sub-Saharan Africa, older relatives play an important role in breast-
feeding decision-making and tend to discourage exclusive breastfeeding (Leshabari,
Koniz-Booher, Astrom, de Paoli, & Moland 2006; De Allegri, Sarker, Hofmann,
Sanon, & Bohler 2007; Fjeld et al. 2008). And breastfeeding practices of Malawian
mothers have been described as far from optimal (Piwoz et al. 2006).
Women generally associated breastfeeding with health. It had a positive effect
on themselves as well as on their infants, reducing the incidence and severity of
illness in their infants and enabling birth spacing that enhanced their own health,
which also indirectly benefited the health of their children. But, they also talked
about it in terms of danger. They were aware of the risk of vertical transmission of
HIV and, similarly to what has been reported in the wider literature (Mull 1992;
Hofmann et al. 2009), they thought that other diseases could be passed to infants
through breastfeeding. However, they seemed to keep these two aspects separate
and formulate them as two distinct discourses: a positive one in which their own
breastfeeding practices were good and a negative one, which they did not see as
applying to themselves but to other women who might be HIV-positive or have
other illnesses, and who were seen as a potential threat to their own infants through
shared breastfeeding. However, there was some ambiguity here, as the general claim
that they were committed to exclusive breastfeeding (whatever they really did in
practice) suggests that at some level they were well aware of the possibility that they
themselves might be a potential source of HIV infection for their own infants.
The women did not spontaneously mention malaria when we asked about the
vertical transmission of disease, and when we asked them explicitly about this, their
views were very mixed, giving the impression that it was something that they had
not really thought about. This is surprising, as we had expected them to be more
unanimous about the possibility of vertical transmission of malaria given that they
generally thought that various diseases could be transmitted in this way, that they
saw this transmission as taking place through the blood rather than through breast
milk1 , that they were knowledgeable about malaria parasites being in the blood, and
given that the focus of the project was malaria. Perhaps it was because they were so
knowledgeable about malaria that so many of them did not associate malaria with
vertical transmission. Data from the main study show that although some women
thought that malaria could be caused by hard work in the hot sun or exposure to
cold winds, most knew that it was transmitted by mosquitoes, and some even named
the anopheles vector. There is not much literature on this, and we have only found
an odd reference to the belief that malaria could be transmitted through breast-
feeding (in Yemen) (Al-Taiar, Jaffar et al. 2008; Al-Taiar, Chandler, Al Eryani, &
Whitty 2009).
Women saw the vertical transmission of disease as occurring through the blood
in the breasts rather than breast milk, thus suggesting that they thought that the

1 InBurkina Faso, women thought that disease was transmitted through breast milk, which was
seen as having the same potential as blood to transmit disease (Hofmann et al. 2009)
17 Breastfeeding, Disease Transmission and the Volition of Medicines in Malawi 285

milk itself is always good. This is not the case, however, and there was also much
ambiguity relating to the perceived quality of breast milk. On one hand, participants
argued that a mothers illness would not generally affect the quality of her breast
milk, which was God given and, therefore, good by definition. But on the other
hand, they claimed that breast milk could become bad for various reasons: if the
mother is sick, then this can make her milk bad, which in turn causes illness in the
child (i.e. rather than her simply passing on the disease through her breast), and if
she becomes pregnant and continues breastfeeding or if either of the parents commit
adultery. This is very similar to what has been reported in the vast literature on bad
breast milk from all over the world, where it is also often related to the mothers own
ill health or bodily constitution (Mull 1992; Fjeld et al. 2008), to witchcraft or other
supernatural causes (Mull 1992; Pool 1994; Mabilia 2005;) or, most commonly, to
the behaviour of the parents: either the mother getting pregnant again while she is
still breastfeeding or to adultery by one of the parents (Fernandez & Guthrie 1984;
Mull 1992; Vong-Ek 1993; Liamputtong-Rice 2000; Nielsen et al. 2001; Mabilia
2005; Fjeld et al. 2008).
Given womens awareness of the possibility of vertical HIV transmission, how
they talked about the role of blood circulation through the breasts enabling HIV
transmission, and their statements on how food eaten by the mother is transformed
into breast milk, one might assume that they would also accept that medication con-
sumed by the mother would be passed to the infant in a similar way. Their views on
this were mixed: about half of the women in the supplementary FGDs thought that
this was possible, while the other half insisted that this was not possible.2 However,
all the women, including those who thought that medication could be passed to the
infant, agreed that medication taken by the mother and intended to treat illness in the
mother would have no effect on illness in the infant. Women were adamant that if
they and their infant both had malaria, then the infant would need its own medicine
in order to be cured.
The underlying assumption here seems to be that medicines are not just chem-
ical substances that act equally on all human bodies and that those bodies react in
a uniform way, however, the medication was introduced. It is as though medicines
have volition the power to choose, to exercise will; as though they act on an indi-
vidual level and know which individual body, they are supposed to have an effect
on. Perhaps this idea has been stimulated by the distinction between adult and infant
doses as prescribed in clinics (and in this particular setting perhaps also by the pres-
ence of intermittent preventive treatment for pregnant women (IPTp) and for infants
(IPTi), both using the same drug). Whether or not this is the case, the notion of
medicine being the active agent, of having volition, clearly resonates with the broad
concept of medicine in traditional African aetiology and cosmology as substances
with the power to influence people, events and outcomes i.e. as substances with
volition (Pool 1994).

2 Nichter and Nichter (1996) have reported women deliberately consuming medicines intended for
their babies as a means of transferring the qualities of the medicine to their baby.
286 R. Pool et al.

The points above all have implications for health-seeking behaviour for infants.
First, the distancing of vertical transmission of disease to more distant others
could lead to women underestimating the chances of themselves being HIV-positive
and, thus, delay their seeking voluntary counselling and testing (VCT).
Second, the idea that malaria can be transmitted vertically is clearly present; and,
even though this is a relatively small and perhaps not widely representative group, it
does suggest that this belief may be more widespread. As a result, women may tend
to be fatalistic about the use of malaria prevention interventions such as IPT and
the use of bednets, thinking that their infants are still likely to get malaria anyway
through breastfeeding, which women admit they cannot avoid.
Third, the notion of the volition of medicines, while potentially detrimental to
health interventions, could be adapted and used to support messages relating to the
proper use of medication, thus ensuring better adherence. For example, IPTi with
drugs requiring multiple doses (as opposed to the single dose of SP administered
in the clinic in the study reported above) would have to be partly administered at
home. Given that the infants getting this treatment are not actually sick, parents may
be tempted to use the additional doses for themselves or sell them on to neighbours
(and indeed there is evidence of this from our data in other countries using a three-
dose regimen see Pool et al. 2008 and Gysels et al. 2009). Emphasising that the
drugs are for that child only will resonate with existing beliefs, thus enhancing
adherence.
Acknowledgments The authors would like to thank the mothers and other community members
who gave up their time to participate in this study. The project was funded by a grant from the Bill
and Melinda Gates Foundation through the IPTi Consortium.

References
Al-Taiar, A., Jaffar, S., Assabri, A., Al-Habori, M., Azazy, A., Al-Gabri, A., et al. (2008). Who
develops severe malaria? Impact of access to healthcare, socio-economic and environmen-
tal factors on children in Yemen: A case-control study. Tropical Medicine and International
Health, 13(6), 762770.
Al-Taiar, A., Chandler, C., Al Eryani, S., & Whitty, C. J. (2009). Knowledge and practices for pre-
venting severe malaria in Yemen: The importance of gender in planning policy. Health Policy
Plan [Advance Access published online on September 2, 2009].
Bezner Kerr, R., Dakishoni, L., Shumba, L., Msachi, R., & Chirwa, M. (2008). We grand-
mothers know plenty: Breastfeeding, complementary feeding and the multifaceted role of
grandmothers in Malawi. Social Science and Medicine, 66(5), 10951105.
De Allegri, M., Sarker, M., Hofmann, J., Sanon, M., & Bohler, T. (2007). A qualitative investiga-
tion into knowledge, beliefs, and practices surrounding mastitis in sub-Saharan Africa: What
implications for vertical transmission of HIV? BMC Public Health, 7, 22. Retrieved 6 July
2009, from http://www.biomedcentral.com/1471-2458/7/22
Egan, A., Crawley, J., & Schellenberg, D. (2005). Intermittent preventive treatment for malaria
control in infants: Moving towards evidence-based policy and public health action. Tropical
Medicine and International Health, 10(9), 815817.
Fernandez, E. L., & Guthrie, G. M. (1984). Belief systems and breast feeding among Filipino urban
poor. Social Science and Medicine, 19(9), 991995.
Fjeld, E., Siziya, S., Katepa-Bwalya, M., Kankasa, C., Moland, K. M., & Tylleskar, T.
(2008). No sister, the breast alone is not enough for my baby a qualitative assessment
17 Breastfeeding, Disease Transmission and the Volition of Medicines in Malawi 287

of potentials and barriers in the promotion of exclusive breastfeeding in southern Zambia.

International Breastfeeding Journal, 3, 26. Retrieved 6 July 2009, from http://www.
internationalbreastfeedingjournal.com/content/3/1/26
Gysels, M., Pell, C., Mathanga, D. P., Adongo, P., Odhiambo, F., Gosling, R., et al. (2009).
Community response to intermittent preventive treatment of malaria in infants (IPTi) delivered
through the expanded programme of immunization in five African settings. Malaria Journal,
8, 191.
Hofmann, J., De Allegri, M., Sarker, M., Sanon, M., & Bohler, T. (2009). Breast milk as the water
that supports and preserves life socio-cultural constructions of breastfeeding and their impli-
cations for the prevention of mother to child transmission of HIV in sub-Saharan Africa. Health
Policy, 89(3), 322328.
Joint United Nations Programme on HIV/AIDS (UNAIDS), & World Health Organization (WHO)
(2008). Sub-Saharan Africa AIDS epidemic update regional summary (UNAIDS/08.08E/
JC1526E) Geneva: Joint United Nations Programme on HIV/AIDS (UNAIDS) and
World Health Organization (WHO). Retrieved 6 July 2009, from http://data.unaids.org/
pub/Report/2008/JC1526_epibriefs_subsaharanafrica_en.pdf
Leshabari, S. C., Koniz-Booher, P., Astrom, A. N., de Paoli, M. M., & Moland, K. M. (2006).
Translating global recommendations on HIV and infant feeding to the local context: The
development of culturally sensitive counselling tools in the Kilimanjaro Region, Tanzania.
Implement Science, 1, 22.
Liamputtong, P. (2007). On childrearing and infant care: A cross-cultural perspective. In
P. Liamputtong (Ed.), Childrearing and infant care issues: A cross-cultural perspective
(pp. 329). New York: Nova Science.
Liamputtong-Rice, P. (2000). Hmong women and reproduction. Westport, CT: Bergin and Garvey.
Mabilia, M. (2005). Breast feeding and sexuality: Behaviour, beliefs and taboos among the Gogo
mothers in Tanzania. New York: Berghahn Books.
Mull, D. S. (1992). Mothers milk and pseudoscientific breastmilk testing in Pakistan. Social
Science and Medicine, 34(11), 12771290.
National Statistical Office (NSO) [Malawi], & ORC Macro (2005). Malawi demographic and
health survey 2004. Calverton: National Statistical Office (NSO) [Malawi] and ORC Macro.
Nichter, M., & Nichter, M. (1996). Anthropology and international health: Asian case studies.
Amsterdam: Gordon and Breach.
Nielsen M. H. A., Konradsen, F., Mudasser, M., & van der Hoek, W. (2001). Childhood diarrhea
and hygiene: Mothers perceptions and practices in the Punjab, Pakistan. IWMI Working Paper
25. Colombo, Sri Lanka: International Water Management Institute (IWMI).
Piwoz, E. G., Ferguson, Y. O., Bentley, M. E., Corneli, A. L., Moses, A., Nkhoma, J., et al.
(2006). Differences between international recommendations on breastfeeding in the pres-
ence of HIV and the attitudes and counselling messages of health workers in Lilongwe,
Malawi. Internatinal Breastfeeding Journal, 1(1), 2. Retrieved 6 July 2009, from http://www.
internationalbreastfeedingjournal.com/content/1/1/2
Pool, R. (1994). Dialogue and the interpretation of illness: Conversations in a Cameroon village.
Oxford: Berg.
Pool, R., Mushi, A., Schellenberg, J. A., Mrisho, M., Alonso, P., Montgomery, C., et al. (2008). The
acceptability of intermittent preventive treatment of malaria in infants (IPTi) delivered through
the expanded programme of immunization in southern Tanzania. Malaria Journal, 7, 213.
United Nations Development Programme (2008). Human Development Reports: Malawi. 2008
Statistical Update. Retrieved 6 July 2009, from http://hdrstats.undp.org/en/2008/countries/
country_fact_sheets/cty_fs_MWI.html
Vong-Ek, P. (1993). How popular beliefs influence breastfeeding practices in northeast and central
Thailand. Journal of Primary Health Care and Development, 6, 6176.