ABSTRACT

Optimal infant and young child feeding (IYCF) is the World Health Organization (WHO) recommended way of feeding children. There is a lot that has been done on IYCF but there still remains a dearth of information in areas related to the application of IYCF recommendations in various regions. In the nations all around the globe, national IYCF recommendations and programs are in place. However, various studies reveal low incidences of exclusive breastfeeding (EBF); a major indicator of IYCF. It implies non- compliance to the national guidelines on IYCF amongst the mothers. This study was designed to assess the mothers „compliance with IYCF recommendations amongst mothers with infants aged 0-24 months in Nakuru Municipality. The study was carried out in five health facilities. The objectives were to establish the demographic and socio-economic characteristics of mothers, to establish the mothers‟ level of knowledge on IYCF recommendations, to establish the mothers‟ prior plan, sources of information, popular culture, prior teenage exposure to breastfeeding mother and support for IYCF, to establish the mothers‟ IYCF practices and to establish the mothers‟ level of compliance with IYCF recommendations. The study involved the administration of interview questionnaire adopted from the WHO questionnaire on the 24 hour recall food diversity. Nine research assistants were trained prior the exercise to collect data from 377 mothers with children aged 0-24 months. The findings indicated that 37.9% of the mothers were 25-29 years, 86% were married, 37% had attained secondary education and 40.6% were housewives. Over half (57%) of the children in the mother-child pair were aged 7-24 months while 62.1% were subsequent birth (second to seventh) with only 37.9% being firstborn. Mothers‟ knowledge on IYCF recommendation was good (66%) and indicated areas requiring strengthening as the insufficient breast milk management and the frequency of complementary meals during the transition period from breast milk to solids, semi-solid and soft food. Mothers‟ IYCF practice was predominantly early introduction of solids, semi-solid and soft food as early as 2 months. Almost half (49.6%) of mothers‟ had prior plan for exclusive breastfeeding for six months, however only 14.2% carried through their plan. The main sources of IYCF information was the media (radio and television) by 39.3%, a large majority (95.5%) of the mothers had prior teenage breastfeeding exposure to witnessing a mother frequently breastfeed. The popular culture of IYCF was early (0-3 months) introduction of solids, semi-solids and soft foods (39%). The main sources of reassurance (support) on mothers‟ IYCF practice was by the community health nurse (46.4%). The mothers‟ level of compliance with IYCF recommendation was 55%. The study recommends that; IYCF information should be targeted to all mothers irrespective of neither demographic nor socioeconomic variables at HF by the CHN. Dissemination of information by health workers should emphasize on IYCF aspect of complementary feeding and continued breastfeeding up to two years and beyond when giving IYCF information to mothers. The policy makers should come up with strategies of building capacity to increase the community health nurse efforts of supporting IYCF. The policy makers need to come up with IYCF policies that would reach the mothers in the community with practical IYCF intervention. County Health System to ensure the CHEW monitor and evaluate of IYCF compliance at family level. 1

CHAPTER ONE: INTRODUCTION

1.1 Background information

Infant and young child feeding (IYCF) in the first two years of life is a key determinant of growth and development in children (Lamberti et al., 2011; Lahariya, 2008). Children below 2 years old grow rapidly and are vulnerable to illness (Senarath and Dibley, 2012; WABA, 2010). While under-nutrition usually spikes at the age of 3-18 months making the child‟s first two years of life are considered „a critical window of opportunity‟ for the prevention of growth faultering and under-nutrition (Victora et al., 2010). Prudence therefore calls for capturing of children at this period in life with appropriate interventions to ensure children reach their full growth potential and help prevent irreversible stunting and acute under nutrition (Dewel and Adu-Afarwuah, 2008). In order to engage effective measures to control and eliminate child malnutrition, there is need for mothers‟ compliance with optimal IYCF recommendations (Arabi et al., 2012). Indicators for monitoring IYCF that are utilized in this study on the basis of literature review on WHO IYCF indicators include; initiating breastfeeding (BF) within one hour of delivery, exclusive breastfeeding (EBF) for the first six months, introduction of solid, semi-solid and soft foods in 6-8 months of age, minimum dietary diversity, minimum meal frequency and continued breastfeeding for 2 years (Senarath and Dibley, 2012; GOK, 2007). Globally about 8.8 million children under five years die each year mostly due to preventable causes such as under-nutrition, diarrhoea, pneumonia, measles, malaria and HIV/AIDS (UNICEF, 2009a; Black et al., 2003). Globally, the disease burden can be attributed to under-nutrition whereas malnutrition has been responsible, directly or indirectly, for 60% of the 10.9 million deaths annually amongst children under five year (Lahariya, 2008). Over two-thirds of these deaths are associated with inappropriate feeding practices and occur during the first year of life (WHO, 2009a; WHO, 2003). Sub-optimal breastfeeding especially non-exclusive breastfeeding in the first six months results in 1.4 million deaths and 10% of disease burden in children younger than five years (WHO, 2009a). Worldwide the exclusive breast fed children rates are 34.8% (WHO, 2009a). Malnutrition in sub-Saharan Africa contributes to high rates of childhood morbidity and mortality (Olack et al., 2011). Fortunately, the EBF rate in sub-Saharan Africa has increased from 22% to 30% (UNICEF, 2007). However, these rates are still low.

In the developing countries like Kenya, poor IYCF practices raise threat to child development causing growth faultering (WHO, 2007). More so, in the urban setting, where households are faced with the challenges of broken extended family support systems, and have to engage in rigorous activities to ensure household food security, the mothers must decide how to feed their young children within contexts that constrain them (KNBS and ICF macro, 2010). The resultant choices may be reflected in less than 3% of Kenyan infants being exclusively breast fed for the first six months of life (MOPHS, 2008). It may cause the Kenyan children to be at risk of food contamination due to exposure to ingestion of contaminated foods and drinks when these are introduced too early. Contamination of dairy products was found by a study done in Dagoretti, Nairobi which revealed Escherichia coli in dairy products (Kang'ethe et al., 2007). This was associated with milking hygiene, sources and treatment of water. Furthermore, lack of EBF arising from inappropriate optimal BF also causes risks of infection due to lack of immunity commonly found in breast milk (Lamberti et al., 2011). In kenya, the IYCF recommendations states that mothers should initiation breastfeeding within one hour of birth, EBF for six months, continue breastfeeding for two years and beyond meanwhile introduce solids, semi-solids and soft food at six months. Meals frequency and food diversity be done as for appropriate age. Assessment of mothers‟ compliance to this recommendation has not been done in Nakuru as it was revealed in a study done by Kamau-Mbuthia et al., (2008). However, a study done in Eldoret (Cherop et al., 2009) showed that mothers do not EBF due to inadequate breastfeeding knowledge. In Nakuru Municipality, within the first half of the year (2012), 16% of the children aged 0-11months old were recorded as underweight in the category of nutritional status with the highest proportion of children followed by faultering weight (2%) (DHIS Nakuru 2012).

1.2 Statement of the Problem

Infant Young Child Feeding (IYCF) recommendations in Kenya are given to ensure child survival through interventions that are cost effective. Child malnutrition, morbidity and mortality are reduced when mothers comply with the national IYCF recommendations (Nduati, 2012). Compliance with national IYCF recommendations is in the mothers‟ domain as they make decisions as to how their children will be fed in terms of types of foods in a meal, frequency as well as timing of when to commence and stop breastfeeding. Mothers‟ non-compliance is manifested in outcomes of children health. No study has addressed the most current mothers‟ compliance with IYCF recommendations in Nakuru Municipality. Therefore, this study sought to fill the gap by assessing the current situation in mothers‟ compliance to national IYCF recommendations. There is need to be in touch with current IYCF practice status frequently so as to be aware of the current trends and make interventions in good time to ensure achievement of reduction of child mortality by two thirds by 2015 (World Bank, 2006).

1.3 Research Questions

The study sought to answer the following research questions:

1. What are the demographic and socio-economic characteristics of mothers?

2. What is the mothers‟ level of knowledge on the national IYCF recommendations?

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3. What are the mothers‟ prior plan, sources of IYCF information, popular culture, past teenage exposure to a breastfeeding mother and sources of support for IYCF?

4. What are the current mothers‟ IYCF practices?

5. What is the level of mothers‟ IYCF compliance with national recommendations?

1.4 Broad objective

To assess the mothers‟ compliance with National IYCF recommendations amongst children aged 0-24 months in Nakuru Municipality, Kenya.

1.5 Specific Objectives

i. To establish the demographic and socio-economic characteristics of mothers with infants 0-24 months in Nakuru Municipality, Kenya.

ii. To establish mothers‟ level of knowledge on National IYCF recommendations amongst mothers with infants 0-24 months in Nakuru Municipality, Kenya.

iii. To establish mothers‟ prior plan, sources of information, popular culture, past teenage exposure to a breastfeeding mother and support for IYCF practices in Nakuru Municipality, Kenya.

iv. To determine the mothers‟ IYCF practices amongst mothers with infants 0-24 months in Nakuru Municipality, Kenya.

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v. To establish the level of mothers‟ compliance with IYCF recommendations amongst mothers with infants 0-24 months in Nakuru Municipality, Kenya

1.6 Null Hypothesis

There is no difference in mothers‟ compliance with IYCF recommendations and IYCF factors. 1.7 Justification

Majority (35%) of children globally die before they celebrate their 5th birthday due to, amongst other causes under-nutrition (WHO, 2010). Under-nutrition culminates from poor IYCF practices. Initiation of breastfeeding within one hour and pre-lacteal feeds percentages are 56% and 47% respectively in Egypt, 52% and 36% in Ghana (DHS 2008-2009) while in Kenya, rates are 58% and 42% (KNBS-KDHS survey 2008-2009). EBF rates in Kenya are 32% (KNBS and ICF Macro, 2010). During the ante-natal period, 92% of the mothers visited a health worker at least once (KNBS and ICF macro, 2010). These health workers have a mandate to prepare the mothers during the antenatal period for IYCF especially breastfeeding. However, not all the mothers receive information on IYCF. According to KNBS and ICF macro (2010), rates of mothers in urban setting who receive information on breastfeeding are 65.8% while in the rural areas the rates are at 49%. Within the Rift Valley Province (RVP) about 52.2% mothers received IYCF information from health facilities (KNBS and ICF Macro, 2010). The IYCF practices depicted were; initiation of breastfeeding 7

within 1 hour of birth done by 58% of the mothers and gave something before breastfeeding (pre lacteal feeds) were 52%. EBF rates were at 24% for children less than 2 month old. All this prevalence rate of one of the key IYCF indicators is below the satisfactory rates requirement by WHO to move the MDG number 4 of decreasing infant and child mortality rate by two thirds by the year 2015 (World Bank, 2006). Barriers that may cause the gap between the mothers‟ IYCF knowledge and the compliance with the recommended guidelines may be in the approaches of the IYCF information dissemination. The new knowledge generated by this study will help identify mothers‟ current IYCF practice; support accorded to mothers for IYCF and their IYCF compliance levels. Study in the area of IYCF has been done in Nakuru and this current study brings in the aspect of assessing the mothers‟ level of knowledge on National IYCF recommendation and mothers‟ current IYCF compliance with recommendations as also cited as a recommendation for further study by Kamau et al., (2008).

1.8 Significance of the Study

v1.9 Delimitation and Limitation

The limitations of this study were that only mother-child pairs attending the Child welfare clinic (CWC), mother child health and reproductive health (MCH/RH) clinics and sick children clinics were captured. Children who were not presented at the HF were omitted. These children would have been a special interest group. These limitations were dealt with by including both healthy and sick children of mothers who were attending the health facility as well as including children in the outreach services carried out by the HF.

1.10 Conceptual framework for infant and young child feeding

Infant and young child feeding behaviors are influenced by the choices mothers make. Other factors playing a role in the behavior of IYCF are information and support given to the mothers before infants are born, at birth and afterwards. Family and mothers‟ norms also play a role on mothers‟ choices and practice of IYCF. Other 9

factors include demographic, economic and policy factors. The researcher conceptualized that these interrelated factors influence the mothers‟ choice of infants and young child feeding as first theoritized by Lutter (2000). Hence, compliance with the recommended IYCF practices is obtained in attempting to establish factors influencing specific geographical areas and changing intervention measures to curb barriers identified as conceptualized by the researcher (Figure 1.1).

Intervening variables:

 Culture: Teenage exposure, popular culture and support from community members.

 National IYCF policy.

Dependent variables Mothers‟ IYCF practice, Mothers‟ compliance to IYCF recommendations

Independent Variables

 Mothers‟ knowledge of infant feeding guidelines

Maternal characteristics

 Age

 Level of education

 Prior plan to EBF

 Employment

 Attendance of AN and PN clinic

 Support for BF

Figure 1.1: Conceptual Frame Work of Determinant Factors of IYCF.

(Mordified from Lutter, 2000)

Figure 1.1 Conceptual Frame work of determinant factors of IYCF (Mordified from Lutter, 2000) 10

The mothers‟ level of education, level of knowledge of IYCF recommendations and the mother‟s characteristics such as age, level of education, prior plan to EBF, mothers‟ past teenage exposure to a mother breastfeeding regularly, popular culture and past IYCF experience which is captured as infants‟ birth order are conceptualized as factors influencing IYCF practice. The culture upheld by the mothers and the economic background of the mother may influence them to comply with the national IYCF recommendations or not. Employed mothers may not exclusively breast feed as per national IYCF recommendations due to returning to work before the EBF period is over. A national policy gives recommendation of how to feed infants and young children as per the Ministry of Public Health and Sanitation (MOPHS) directives. Mothers‟ awareness of National IYCF recommendations influences their IYCF practices. These factors were conceptualized as interacting and influencing the issue of IYCF in Nakuru Municipality. The National IYCF strategy recommends that infants should be exclusively breast fed for the first six month of life. Optimal infant feeding means the infant should be initiated with breastfeeding within one hour of birth; continue to be breastfed exclusively for the first six months and receive adequate quantities of and safely prepared nutritious complementary foods while breastfeeding is continued for at least two years (WHO/UNICEF, 2007) 

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