TABLE 4.

Formative research findings on MCN beliefs and practices with illustrative quotes and their translation into the Grandmother-Inclusive Approach¹

Current practices and beliefs to reinforce	Current practices and beliefs to dialogue for change
Maternal nutrition during pregnancy and lactation
Grandmothers encourage attendance to prenatal visits at health facilities	Some grandmothers advise home deliveries and many mothers prefer grandmothers or older experienced TBAs rather than younger midwives:
Grandmothers encourage rest and reduction in workload during pregnancy, to protect the fetus (e.g., avoid carrying heavy loads)	“The midwives are trained but the grandmothers have more experience.” —Mother, Sogballeh Community
Grandmothers promote a wide variety of foods during pregnancy and lactation, including animal-source foods such as eggs, meat, and fish	“…the traditional birth attendant here does more work during delivery than even the young nurse/midwife. I feel more comfortable with the TBA than the nurse, whom I am far older than.…” —Mother, Tangahun Community
Grandmothers and mothers understand and communicate that mother's food intake is transferred to baby through breast milk	Grandmothers discourage a few foods, especially during pregnancy, for a variety of reasons (e.g., rats, snakes, lizards) for example, [If a pregnant woman eats snake, then] “her baby will crawl like a snake” —Grandmother, Boi Pieh Community
Grandmothers advise which foods increase milk production (e.g., cassava leaves with sesame, beans, groundnuts, fish, meat)	Most grandmothers encourage pregnant women to eat less, especially during the last trimester of pregnancy, so that the baby is smaller and the delivery is easier. Most mothers also prefer a “small belly” for ease of walking and delivery.
	Only a few noted: “I prefer her to give birth to a bigger baby as people will love to carry her baby.” —Grandmother, Sogballeh Community
	Increasing fluids by nursing mothers is not recommended
New practices to promote
• Deliver at health facility with support of grandmothers, in case of difficult pregnancy
• Increased food intake of pregnant woman by 1 additional meal per day, including last trimester, results in a healthy baby
• Give extra food and liquids to lactating mothers
Breastfeeding practices
Grandmothers provide constant support of mothers during delivery and with newborns: “The nurse is like someone passing by in a vehicle and you ask that person to hold your baby so you can get in. When you get in the vehicle you get your baby back. The nurse helps deliver the baby and then the baby goes home with the grandmother who washes, feeds, and cares for the baby.” —Grandmother, Boi Pieh Community	Water and herbs are commonly given in first days of newborn's life, sometimes discarding colostrum. Herbs are said to have medicinal purposes (e.g., “to clean out the stomach”) or spiritual purposes (e.g., holy water containing verses of the Koran in Muslim communities)
“Grandmothers sleep less to monitor the baby, to change the nappy and to wake up the mother to tell her to breastfeed.” —Grandmother, Boi Pieh Community	Warm water is given at birth and afterwards, as it is believed that there is no water in breast milk; water's benefits include to quench the child's thirst, to help the child sleep or stop them from crying, and to replace breast milk when it is “contaminated” (e.g., mother is sick)
All mothers breastfeed	“Exclusive breastfeeding is what we were told to do, but we have never tried it. All the children are not satisfied with breast milk alone, so we give water. How can a mother that has not eaten since morning breastfeed?” —Mother, Victoria Community
Some mothers feed colostrum	Most stated: “Babies, like all human beings, need to drink water.”
	All introduce traditional rice water (ngoh bayei), referred to as the “food of the gods” at 2 to 3 mo of age to prepare the child for rice (a staple cultural food in Sierra Leone) and to prevent dehydration
	“We are afraid to say that we give ngoh bayei because we were told not to give it…[but] ngoh bayei must be given to children otherwise they can cry a lot and even at the hospital they won't know what the problem is or what to do about it. When it is given the baby sleeps and that gives the mother time to rest.” —Grandmother, Boi Pieh Community
New practices to promote
• Emphasize the value of giving only colostrum after birth—including protection from infection and disease
• Breast milk contains all the nutrients and water the infant needs for the first 6 mo of life; additional water is not needed
• All mothers can produce enough milk if they nurse frequently; more nursing, more breast milk
• Breast milk best meets the infant's needs for 6 mo
Complementary feeding, responsive feeding, and feeding the sick child
Grandmothers teach first-time mothers how to prepare first foods for children: “Grandmothers have vast experience preparing first paps because she has been doing it for a long time. Even the nurse will send us to the grandmother to know how to make the first pap” —Mother, Boi Pieh Community	Most grandmothers and mothers introduce first complementary foods at 3 to 5 months of age, and some earlier, as reflected in this quote: “When the child cries too much, the first pap can be given at 2 months, with warm water and herbs before the pap.” —Grandmother, Toma Town
Some porridge recipes include protein-source foods and vegetables	Grandmothers teach and promote thin porridges for “easy digestibility,” which are most often made of water, rice flour, palm oil and salt: “[The] grandmother prepares the first pap. It should be thin, easy to swallow when light, and doesn't make the child constipated.” —Mother, Boi Pieh Community
Grandmothers actively encourage children to eat using the following approaches: patiently taking more time with the child; not showing their frustration; delaying the normal feeding time until the child asks for food; identifying foods that the child prefers; never forcing the child to eat; and promising small rewards for eating (e.g., going for a walk or carrying him or her on her back)	Mothers are less patient than grandmothers when a child is unwilling to eat and use approaches such as threats; forcing food into the child's mouth by holding the nose; beating the child; or leaving the child alone
Mothers and grandmothers actively encourage children to eat more after an illness	Mothers and grandmothers feed children usual or less food during illness
Grandmothers feed children during illness and when the mother or elder daughters are absent
New practices to promote
• Wait until 6 mo to introduce foods
• From 6 mo, infants can digest thick porridge; it should be soft but not watery
• Include a wide variety of foods in the porridge (animal-source foods, protein, fruits, and vegetables)
• Use grandmothers’ active feeding practices of encouragement
• Feed small, frequent meals throughout the day because of infants’ small stomachs
• Sick children need extra food and fluids to fight and heal from illness

¹MCN, maternal and child nutrition; TBA, traditional birth attendant.