Factors affecting actualisation of the WHO breastfeeding recommendations in urban poor settings in Kenya

Strengthening counseling on barriers to exclusive breastfeeding through use of job aids in Nampula, Mozambique

Introduction

While the Government of Mozambique has galvanized action around exclusive breastfeeding (EBF) as a national priority, only 43% of Mozambican children under six months of age are exclusively breastfed. In the absence of skilled lactation support, challenges mothers experience with breastfeeding may inhibit initiation, exclusivity and duration. There is insufficient evidence on how to strengthen health providers’ competencies to address breastfeeding challenges in low- and middle-income countries. The objectives of this study were to 1) assess EBF challenges, from the perspectives of health providers and mothers; 2) ascertain the quality of health provider counseling to address EBF challenges; and 3) gain an understanding of the usefulness of job aids to improve counseling within routine health contact points in Nampula, Mozambique.

Methods

This implementation science study was conducted in Meconta and Mogovolas districts, Nampula province, Mozambique from July-November 2018. In Phase 1, 46 in-depth interviews with mothers and providers, and 11 observations of counseling sessions were conducted. In Phase 2, health providers were trained to use three job aids (i.e., facility, community or maternity contacts) to identify and address EBF problems during routine health services. In Phase 3, 30 in-depth interviews with mothers and providers were conducted to assess the experience with job aid use. In both Phase 1 and 3, we conducted a thematic analysis using a grounded theory approach involving a step-wise coding process.

Results

Poor latch and positioning, perceived insufficient breastmilk and breast engorgement emerged as barriers to EBF. Providers often lacked the knowledge, skillset, and self-efficacy to manage EBF problems, with little counseling provided at community or facility levels. Following job aid rollout, providers reported improved assessment of breastfeeding technique, and increased self-efficacy and motivation to identify and resolve EBF problems.

Conclusions

Integration of job aids, with clear lactation management guidance, into maternal and child health training curricula and supportive supervision is critical to building providers’ skillsets and competencies to provide quality lactation counseling and support.

Changes in rates of early exclusive breast feeding in South Africa from 2010 to 2013: data from three national surveys before and during implementation of a change in national breastfeeding policy

OBJECTIVE

Between 1998 and 2009 reported exclusive breastfeeding (EBF) rates in South African infants, aged 0-6 months, ranged from 6.2% to 25.7%. In 2011, the National Minister of Health shifted policy to promote 'exclusive' breast feeding for all women in South Africa irrespective of HIV status (Tshwane Declaration of Support for Breastfeeding in South Africa). This analysis examines early EBF prior to and through implementation of the declaration.

SETTING

Data from the three South Africa national, cross-sectional, facility-based surveys, conducted in 2010, 2011-12 and 2012-13, were analysed. Primary health facilities (n=580) were randomly selected after a stratified multistage probability proportional-to-size sampling to provide valid national and provincial estimates.

PARTICIPANTS

A national sample of all infants attending their 6 weeks vaccination at selected facilities. The number of caregiver-infant pairs enrolled were 10 182, 10 106 and 9120 in 2010, 2011-12, and 2012-13, respectively.

PRIMARY OUTCOME MEASURE

Exclusive breast feeding as measured using structured 24 hours recall plus prior 7 days (8 days inclusive prior to day interview) and WHO definition.

RESULTS

The adjusted OR comparing EBF prevalence in 2011-12 and 2012-13 with 2010 were 2.08 and 5.51, respectively. Mothers with generally higher socioeconomic status, HIV-positive, unplanned pregnancy, primipara, postcaesarean delivery, resided in certain provinces and women who did not receive breastfeeding counselling had significantly lower odds of EBF.

CONCLUSION

With what seemed to be an intransigently low EBF rate since 1998, South Africa saw an increase in early EBF for infants aged 4-8 weeks from 2010 to 2013, coinciding with a major national breastfeeding policy change. These increases were seen across all provinces and subgroups, suggesting a population-wide effect, rather than an increase in certain subgroups or locations. While these increases in EBF were significant, the 59.1% prevalence is still below desired levels of early EBF. Further improvements in EBF programmes are needed.

Strengthening nutrition services within integrated community case management (iCCM) of childhood illnesses in the Democratic Republic of Congo: Evidence to guide implementation

In the Democratic Republic of Congo, 43% of children under 5 years of age suffer from stunting, and the majority (60%) of children, 6–59 months of age, are anaemic. Malaria, acute respiratory infections, and diarrheal diseases are common among children less than 5 years of age, with 31% of children 6–59 months affected by malaria. This qualitative implementation science study aimed to identify gaps and opportunities available to strengthen service delivery of nutrition within integrated community case management (iCCM) at the health facility and community level in Tshopo Province, Democratic Republic of Congo, through the following objectives: (a) examine cultural beliefs and perceptions of infant and young child feeding (IYCF) and child illness, (b) explore the perspectives and knowledge of facility‐based and community‐based health providers on nutrition and iCCM, and (c) gain an understanding of the influence of key family and community members on IYCF and care‐seeking practices. This study involved in‐depth interviews with mothers of children under 5 years of age (n = 48), grandmothers (n = 20), fathers (n = 21), facility‐based providers (n = 18), and traditional healers (n = 20) and eight focus group discussions with community health workers. Study findings reveal most mothers reported diminished quantity and quality of breastmilk linked to child/maternal illness, inadequate maternal diet, and feedings spaced too far apart. Mothers' return to work in the field led to early introduction of foods prior to 6 months of age, impeding exclusive breastfeeding. Moreover, children's diets are largely limited in frequency and diversity with small quantities of foods fed. Most families seek modern and traditional medicine to remedy child illness, dependent on type of disease, its severity, and cost. Traditional healers are the preferred source of information for families on certain child illnesses and breastmilk insufficiency. Community health workers often refer and accompany families to the health centre, yet are underutilized for nutrition counselling, which is infrequently given. Programme recommendations are to strengthen health provider capacity to counsel on IYCF and iCCM while equipping health workers with updated social and behavior change communication (SBCC) materials and continued supportive supervision. In addition, targeting key influencers to encourage optimal IYCF practices is needed through community and mother support groups. Finally, exploring innovative ways to work with traditional healers, to facilitate referrals for sick/malnourished children and provide simple nutrition advice for certain practices (i.e., breastfeeding), would aid in strengthening nutrition within iCCM.

Family influences on child nutritional outcomes in Nairobi's informal settlements

BACKGROUND

Improving child nutritional status is an important step towards achieving the Sustainable Development Goals 2 and 3 in developing countries. Most child nutrition interventions in these countries remain variably effective because the strategies often target the child's mother/caregiver and give limited attention to other household members. Quantitative studies have identified individual level factors, such as mother and child attributes, influencing child nutritional outcomes.

METHODS

We used a qualitative approach to explore the influence of household members on child feeding, in particular, the roles of grandmothers and fathers, in two Nairobi informal settlements. Using in-depth interviews, we collected data from mothers of under-five children, grandmothers, and fathers from the same households.

RESULTS

Our findings illustrate that poverty is a root cause of poor nutrition. We found that mothers are not the sole decision makers within the household regarding the feeding of their children, as grandmothers appear to play key roles. Even in urban informal settlements, three-generation households exist and must be taken into account. Fathers, however, are described as providers of food and are rarely involved in decision making around child feeding. Lastly, we illustrate that promotion of exclusive breastfeeding for 6 months, as recommended by the World Health Organization, is hard to achieve in this community.

CONCLUSIONS

These findings call for a more holistic and inclusive approach for tackling suboptimal feeding in these communities by addressing poverty, targeting both mothers and grandmothers in child nutrition strategies, and promoting environments that support improved feeding practices such as home-based support for breastfeeding and other baby-friendly initiatives.

Are stage-based health information messages effective and good value for money in improving maternal newborn and child health outcomes in India? Protocol for an individually randomized controlled trial

Background

Evidence is limited on the effectiveness of mobile health programs which provide stage-based health information messages to pregnant and postpartum women. Kilkari is an outbound service that delivers weekly, stage-based audio messages about pregnancy, childbirth, and childcare directly to families in 13 states across India on their mobile phones. In this protocol we outline methods for measuring the effectiveness and cost-effectiveness of Kilkari.

Methods

The study is an individually randomized controlled trial (iRCT) with a parallel, partially concurrent, and unblinded design. Five thousand pregnant women will be enrolled from four districts of Madhya Pradesh and randomized to an intervention or control arm. The women in the intervention arm will receive Kilkari messages while the control group will not receive any Kilkari messages as part of the study. Women in both arms will be followed from enrollment in the second and early third trimesters of pregnancy until one year after delivery. Differences in primary outcomes across study arms including early and exclusive breastfeeding and the adoption of modern contraception at 1 year postpartum will be assessed using intention to treat methodology. Surveys will be administered at baseline and endline containing modules on phone ownership, geographical and demographic characteristics, knowledge, practices, respectful maternity care, and coverage for antenatal care, delivery, and postnatal care. In-depth interviews and focus group discussions will be carried out to understand user perceptions of Kilkari, and more broadly, experiences providing phone numbers and personal health information to health care providers. Costs and consequences will be estimated from a societal perspective for the 2018–2019 analytic time horizon.

Discussion

Kilkari is the largest maternal messaging program, in terms of absolute numbers, currently being implemented globally. Evaluations of similar initiatives elsewhere have been small in scale and focused on summative outcomes, presenting limited evidence on individual exposure to content. Drawing upon system-generated data, we explore linkages between successful receipt of calls, user engagement with calls, and reported outcomes. This is the first study of its kind in India and is anticipated to provide the most robust and comprehensive evidence to date on maternal messaging programs globally.

Trial registration

Clinicaltrials.gov, 90075552, NCT03576157. Registered on 22 June 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3369-5) contains supplementary material, which is available to authorized users.

Analysing child linear growth trajectories among under-5 children in two Nairobi informal settlements

OBJECTIVE

We sought to identify factors associated with linear growth among under-5 children in two urban informal settlements in Nairobi.

DESIGN

We used longitudinal data for the period 2007-2012 from under-5 children recruited in the two sites between birth and 23 months and followed up until they reached 5 years of age. We fitted a generalized linear model on height-for-age Z-scores using the generalized estimating equations method to model linear growth trajectories among under-5 children. Known for its flexibility, the model provides strong parameter estimates and accounts for correlated observations on the same child.

SETTING

Two urban informal settlements in Nairobi, Kenya.ParticipantsUnder-5 children (n 1917) and their mothers (n 1679).

RESULTS

The findings show that child weight at birth, exclusive breast-feeding and immunization status were key determinants of linear growth among under-5 children. Additionally, maternal characteristics (mother's age, marital status) and household-level factors (socio-economic status, size of household) were significantly associated with child linear growth. There were biological differences in linear growth, as female children were more likely to grow faster than males. Finally, the model captured significant household-level effects to investigate further.

CONCLUSIONS

Findings from the study point to the need to improve the targeting of child health programmes directed at the urban poor population in Nairobi. Specific modifiable determinants of child linear growth, particularly child weight at birth, exclusive breast-feeding, immunization status and mother's background characteristics, should be considered when designing interventions aiming at addressing child health inequities in these settings.

Herbal medicine use during breastfeeding: a cross-sectional study among mothers visiting public health facilities in the Western area of Sierra Leone

BACKGROUND

The use of medications, including herbal medicines during breastfeeding is always a concern among women. Currently, there is no published evidence on whether Sierra Leonean women use herbal medicine during breastfeeding. This study investigates the prevalence, correlates and pattern of herbal medicine use during breastfeeding.

METHODOLOGY

We conducted a cross-sectional study among 378 current breastfeeding mothers visiting public healthcare facilities within the Western area of Sierra Leone. Descriptive statistics and logistic regression analysis were used for data analysis.

RESULTS

Over a third of mothers (n = 140, 37.0%) used herbal medicine during breastfeeding. However, very few herbal medicine users (2.1%, n = 3) used herbal medicine to augment breastfeeding. Dietary changes were the most common method used to increase breast milk supply (93.9%, n = 355) with cassava leaves sauce and tubers being the most common dietary addition. Mothers with children more than six months old were more likely to use herbal medicine than mothers with younger children (OR:1.8; CI:1.13-2.85,p = 0.013). Among herbal medicine users, only 11.4% (n = 16) disclosed their herbal medicine use to their conventional healthcare providers.

CONCLUSION

The use of herbal medicine among breastfeeding mothers attending public health facilities in the Western area of Sierra Leone is common. Whilst this use is not usually specific to increasing breast milk supply, our study indicates that herbal medicines may be used to 'cleanse' initial breast milk.

"Everybody breastfeeds if they have milk": factors that shape exclusive breastfeeding practices in informal settlements of Mumbai, India

Background

In India, though breastfeeding is universally practiced, exclusive breastfeeding (EBF) rates in urban informal settlements are low; and health programs face several challenges in promoting EBF. In this study, ensconced in one program area of a non-government organization, we focused on "positive deviant"- mothers who were able to practice EBF for six months and attempted to delineate factors that shaped their EBF practices. Typically, qualitative research from Lower and Middle Income countries on EBF has focused on understanding why women do not practice EBF; the converse perspective taken in this study has been less explored.

Methods

We employed the positive deviance approach which contends that important programmatic learnings can be attained from persons who adopt positive behaviours. We conducted twenty-five diverse, purposively sampled case-studies of "positive deviant" mothers from two urban informal settlements in Mumbai; and analysed these using a framework approach. The results were summarised using a socioecological framework (consisting of individual, interpersonal, organizational and environment levels).

Results

We found that mothers typically construed EBF as not giving breastmilk substitutes. Giving the infant minor supplements (water, honey) was not considered a violation of the EBF practice. The main themes that emerged as influencers of EBF included: at individual level, perceptions of having adequate milk; at interpersonal level, having role models who practiced EBF and having family support; at organizational level, advice from health workers (which was purported to play a secondary role); and at environmental level, financial constraints that limited access to supplements. One important finding was that women who practiced EBF could not always do it optimally; we encountered several instances of "poor EBF" practices, where mothers had breastfed infants inconsistently, allowing for long gaps between feeds, and had continued EBF even after six months.

Conclusions

There is an urgent need for health programs to clarify the meaning of EBF and counsel against "poor EBF" practices. Messages received by women from immediate family on EBF were powerful and families play an important role in the actualization of optimal EBF practices. Hence, it is imperative to counsel entire families on EBF rather than women alone.

Exploring the Experiences of Middle Income Mothers in Practicing Exclusive Breastfeeding in Nairobi, Kenya

Objectives To establish exclusive breastfeeding (EBF) practice, women are encouraged to initiate breastfeeding of their newborns within one hour of delivery and breastfeed exclusively for the first 6 months of the infant's life. Research in Kenya has shown evidence of a reduced rate of EBF with an increase in socio-economic class (SES). This study explores the experiences of middle-income women so as to understand their attitudes and practices of EBF and to contribute toward the Baby Friendly Hospital (BFHI) and Baby Friendly Community Initiatives (BFCI) programs in Kenya. Methods A qualitative study using nine in-depth interviews and two focus group discussions were conducted with middle-income women with a child < 2 years. Thematic content analysis was used to analyze the data. Results The majority of the women interviewed did not achieve EBF and this was attributed to many challenges that they encountered such as; inadequate workplace support including short maternity leave, lack of designated breast feeding facilities flexible hours and breastfeeding breaks. Support structures were highlighted as either inadequate or lacking while the internet was preferred by most of the women for breastfeeding information. Mass media was seen as more credible, though some women indicated that there was lack of depth in the information it provided. Conclusion The study showed that majority of women were unable to EBF for the first 6 months. Women experienced inadequate social, healthcare and workplace support and preferred online sites for information on breastfeeding than the healthcare professionals or mass media. Recommendation There is need to implement policies at the workplace that promote a breastfeeding friendly environment. There is also a need for more research on role of mass media in promotion of optimal breastfeeding practices, especially how to reach this population. There is a need for continued advocacy on social support including spousal, relatives, and other community members at the community level.

Facilitators and Barriers to Breastfeeding and Exclusive Breastfeeding in Kilimanjaro Region, Tanzania: A Qualitative Study

Background

Breastfeeding is the best way to feed infants. It is a simple intervention to improve child health and development. Despite its advantages, there is a low global rate of exclusive breastfeeding (EBF) and, in Kilimanjaro region, Tanzania, EBF is rarely practiced. The aim of this paper is to explore social and cultural factors that might influence the practice of breastfeeding and exclusive breastfeeding in Kilimanjaro region.

Methods

A qualitative design was used. Three districts in Kilimanjaro region, namely, Same, Moshi Municipal Council, and Rombo, were selected. In each district three focus group discussions (FGDs) were conducted with mothers with infants aged 0-12 months.

Results

A total of 78 mothers participated in the focus group discussions. A majority of the mothers were positive towards breastfeeding. They believed that it prevents child sickness, creates happiness, and is good for family economy. Despite the positive attitudes, the mothers revealed many perceptions that interfered with breastfeeding and exclusive breastfeeding. These included the following: breast milk is very light and has bad odor, breastfeeding may affect mothers appearance, chango (abdominal pain) has to be treated, there is fear of the evil eye when breastfeeding in public places, breast milk may become unclean, and there is a need of pauses in breastfeeding after the child has burped on the breast.

Conclusion

There are beliefs that promote the practice of breastfeeding in this setting; these local beliefs could be used to develop breastfeeding messages to improve breastfeeding practices. However, there is also a need to address beliefs that interfere with the practice of exclusive breastfeeding in this setting.

Assessing the level of knowledge and practice of breastfeeding among factory working mothers in Kathmandu, Nepal

Purpose

The purpose of this paper is to assess the level of knowledge and practice of breastfeeding among factory working mothers in Kathmandu who had a minimum of one child of less than two years of age.

Design/methodology/approach

A cross-sectional survey, with the help of a semi-structured questionnaire, was completed. χ2 or Fisher exact tests were applied for analysis using the SPSS program.

Findings

In total, 36.0 percent of the mothers had adequate knowledge, and 40.0 percent had an appropriate practice of breastfeeding (BF). Also, 30 percent of them were supplementing their BF with additional milk and 54.0 percent began to give additional food at less than six months of age, mainly due to insufficient breast milk. However, 40.0 percent of mothers practiced exclusive BF; 34.0 percent of mothers continued BF until their child reached two years of age. BF was initiated within an hour by 64.0 percent of mothers. Regarding knowledge, the majority of them (82 percent) knew about initiation time of the feed, 64.0 percent of mothers knew that breast milk had positive effects on a child’s health while 48.0 percent knew that it also had good effects on the mothers’ health. There was a positive association between available facilities and BF knowledge levels (p-value<0.00, χ2=4.25, df=1). The associations of knowledge levels against the education status of mothers (p-value=0.11, χ2=2.59, df=1) and practice level of initiation of breast milk (p-value=0.96, χ2=0.02, df=1) were not significant.

Originality/value

The knowledge and practices of BF among factory working mothers are not satisfactory. Hence, an effective way to encourage BF is to increase the availability of facilities for the practice of BF at a mother’s workplace.

Getting schooled: teachers' views on school-based breastfeeding education in Lebanon

Background

School-based breastfeeding education (SBBE) may help improve breastfeeding rates in the long term by instilling in young people a base of evidence-informed knowledge, skills, and attitudes that primes them to make informed decisions about infant feeding and to become positive change agents. Breastfeeding rates in Lebanon remain suboptimal, and breastfeeding misconceptions along with social pressures to use infant formula are known contributing barriers. We conducted this study with pre-K-12 teachers to understand the SBBE landscape as well as the supports and constraints for SBBE at two large Lebanese schools.

Methods

We conducted a survey with 193 teachers during the 2017-2018 academic school year to collect information about demographics, breastfeeding history, breastfeeding teaching practices, attitudes towards SBBE such as attitude towards educating both boys and girls about breastfeeding, and views on potential constraints to successful SBBE implementation. Descriptive statistics and thematic analysis were used. Binary multiple logistic regression was used to ascertain the effects of teacher characteristics on likelihood to support SBBE.

Results

While limited SBBE is currently taking place with only eight (4%) teachers reporting teaching about breastfeeding, 133 (69%) reported students should learn about breastfeeding in school. A multiple regression model [χ2(4) = 19.71, p = 0.001] showed teachers were more likely to support SBBE if they/their partners had ever breastfed, if they taught biology, or if they believed that schools should educate both boys and girls about breastfeeding in a society where discussing breastfeeding in public is a taboo. One hundred and ten (60%) teachers reported several concerns to SBBE implementation which included limited uptake by students who might not find SBBE valuable to them and resistance from parents due to cultural barriers. In order to effectively expand SBBE in these schools, 71 SBBE supporters (59.2% of respondents; 13 with missing data) suggested supporting local teachers to deliver SBBE, and 48 (40%) suggested mandating SBBE.

Conclusions

Teachers held generally positive views on SBBE, which provides a fertile ground for growing SBBE in their schools. Future steps need to include engaging parents, students, and school principals to further understand the social constrains to SBBE before program design.

The care, stimulation and nutrition of children from 0-2 in Malawi-Perspectives from caregivers; "Who's holding the baby?"

Introduction

Universal access to quality early childhood development and care is a fundamental part of Sustainable Development Goal 4.2.1. Research from diverse settings, including that in low and middle income countries, now demonstrates the positive impact that interventions to promote play, stimulation, early communication and responsiveness can have, not just on child development, but on long term gains in education and economic growth. International agencies have recently produced the Nurturing Care Framework for Early Child Development in order to promote this and to encourage countries to move the focus from child survival to child thrival. Research on the best methods of integration of these programmes into present care practices, particularly in African settings is still very limited.

Methods

We used qualitative methods to gain an understanding of care practices (play, developmental stimulation, early communication and responsive feeding) for children 0–2 years. We conducted 18 focus groups (FGDs), six PFGDs (Participatory Research focus groups), 18 in depth interviews (IDIs) and 20 observations with caregivers in rural and urban settings of Malawi. We used a topic guide, audio-recorded the FGDs and IDIS and transcribed them in Chichewa or Yao and then into English. We coded data using an inductive approach to thematic analysis. We placed the data within a framework with the emerging major and minor themes. We conducted quality assurance for translations and coding frameworks through cross comparison of data and used respondent validation to check our results.

Results

Malawian caregivers see children’s play as a consequence of good health and wellbeing, less an interaction that a parent undertakes to promote wellbeing and learning. Non-verbal communication and responsiveness with infants is clearly present and caregivers have many one-on-one interactions with young infants. Furthermore, many caregivers have good knowledge of feeding recommendations but cannot always follow these due to constraints on money. When children become mobile (toddlers), play is an activity done more often between children or with other caregivers such as siblings or grandparents.

Community members consider that caring for children from 0–2 years is a woman’s domain. Despite this, both men and women acknowledge the importance of maternal wellbeing in enabling good care of children. The present socioeconomic situation of most families in our study means that income generation and food security come first. Many mothers spend most of their time managing the responsibilities of daily living and have limited time to dedicate to children’s play, responsiveness and communication with their children.

Discussion

Programmes promoted as part of the Nurturing Care Framework which provide advice on developmental stimulation, play, early communication and responsive feeding should ensure that topics within these programmes are culturally appropriate for the setting. Furthermore, programmes must not be an added burden to parents but be supportive to parents managing many responsibilities of daily living. Multi-sectorial approaches where both men and women are provided with knowledge but are also supported through programmes which address family finances, safe spaces for children whilst families are working, and family mental health and relationships may enable programmes to work more effectively.

Knowledge of, and attitudes to giving expressed breastmilk to infants in rural coastal Kenya; focus group discussions of first time mothers and their advisers

Background

The World Health Organization (WHO)/UNICEF Baby-Friendly Hospital Initiative step number five of the “Ten steps to successful breastfeeding” states “Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants.” Urban mothers in Nairobi have low rates of exclusive breastfeeding after returning to work but there are no published data on rural Kenya mothers’ infant feeding practices when working or schooling away from home.

Methods

We explored knowledge of, and attitudes to, the practice of giving expressed breastmilk in a mixed methods observational study of breastfeeding in rural Kenyan mothers. Fifty mothers with newborns, identified by nurses and community health workers, were asked questions about their experiences of breastfeeding and who they had sought or received advice from on breastfeeding. Focus group discussions, one with community health workers, and four each with mothers and their named advisers were held. Recordings were analyzed using a thematic framework approach.

Results

The main themes were: the baby’s right to feed from the breast, lack of knowledge about expressing and giving breastmilk, negative attitudes towards expressed breastmilk, and traditional customs for disposing of expressed breast milk. Most participants did not have any experience of giving expressed breastmilk to infants. They described practices of expressing and discarding milk when the mother or baby was ill, to relieve discomfort from engorgement or after the baby had died.

Conclusions

Feeding expressed breastmilk to infants is a new concept in this context. Promotion of, and training in this practice would help mothers to maintain their milk supply when away from their babies and benefit the infants of working and schoolgirl mothers.

Social value of a nutritional counselling and support program for breastfeeding in urban poor settings, Nairobi

Background

In Kenya, poor maternal nutrition, suboptimal infant and young child feeding practices and high levels of malnutrition have been shown among the urban poor. An intervention aimed at promoting optimal maternal infant and young child nutrition (MIYCN) practices in urban poor settings in Nairobi, Kenya was implemented. The intervention involved home-based counselling of pregnant and breastfeeding women and mothers of young children by community health volunteers (CHVs) on optimal MIYCN practices. This study assesses the social impact of the intervention using a Social Return on Investment (SROI) approach.

Methods

Data collection was based on SROI methods and used a mixed methods approach (focus group discussions, key informant interviews, in-depth interviews, quantitative stakeholder surveys, and revealed preference approach for outcomes using value games).

Results

The SROI analysis revealed that the MIYCN intervention was assessed to be highly effective and created social value, particularly for mothers and their children. Positive changes that participants experienced included mothers being more confident in child care and children and mothers being healthier. Overall, the intervention had a negative social impact on daycare centers and on health care providers, by putting too much pressure on them to provide care without providing extra support. The study calculated that, after accounting for discounting factors, the input ($USD 419,716) generated $USD 8 million of social value at the end of the project. The net present value created by the project was estimated at $USD 29.5 million. $USD 1 invested in the project was estimated to bring USD$ 71 (sensitivity analysis: USD$ 34–136) of social value for the stakeholders.

Conclusion

The MIYCN intervention showed an important social impact in which mothers and children benefited the most. The intervention resulted in better perceived health of mothers and children and increased confidence of mothers to provide care for their children, while it resulted in negative impacts for day care center owners and health care providers.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5334-8) contains supplementary material, which is available to authorized users.

The Association Between Pregnancy Intention and Breastfeeding

BACKGROUND

Although breastfeeding is associated with proven benefits to both mother and child, there are many factors that influence a mother's decision to breastfeed. Pregnancy intentionality at the time of conception is associated with postpartum maternal behavior including breastfeeding. Research aim: We sought to understand how maternal and paternal pregnancy intentions were associated with breastfeeding initiation and duration in a nationally representative sample.

METHODS

We used a cross-sectional, retrospective study of the CDC National Survey of Family Growth data to examine the link between pregnancy intentionality and breastfeeding initiation and duration among women ages 15 to 44 years.

RESULTS

We found that whereas the mother's intention to have a child was a factor in how long she breastfed, the paternal intention to have a child predicted whether the mother breastfed at all. Additionally, Hispanic mothers were most likely to breastfeed and breastfed the longest of any other group. Age and education were also positive predictors of ever breastfeeding.

CONCLUSION

Understanding the father's and mother's attitudes toward the pregnancy and influence on breastfeeding intention is important for intervention planning.

Infant and Young Child Feeding Decision Making and Practices: Malawian Mothers' and Fathers' Roles in the Context of HIV

BACKGROUND

Few studies in low- and middle-income countries have examined the roles of couples in infant and young child feeding decision making and practices, and there is no corresponding data in the context of human immunodeficiency virus (HIV). Research aim: This study aimed to explore mothers' and fathers' perceptions of their roles in feeding decision making and practices.

METHODS

The authors conducted in-depth interviews with 15 mothers and their male partners, recruited from the catchment areas of two urban and two rural government clinics in Lilongwe District, Malawi. The mothers were ≥ 18 years of age, were HIV positive, and had a child < 24 months of age. Twelve of the 15 fathers were also HIV positive. The interviews were analyzed using content analysis.

RESULTS

Mothers were responsible for child care, including breastfeeding and complementary feeding. Fathers provided monetary support for purchasing food and offered verbal support to encourage mothers to implement recommended feeding practices. Many fathers found it difficult to support adequate complementary feeding because of household food insecurity. Mothers were advised on child feeding during prevention of mother-to-child transmission clinic visits. No fathers in this study accompanied women to clinic appointments, so they were less well-informed about feeding than mothers. Fathers usually deferred to mothers in feeding decision making. One-third of mothers wanted fathers to be more involved in child feeding.

CONCLUSION

Malawian mothers' and fathers' roles in feeding decision making in the context of HIV align with local gender norms. Strategies are needed to improve fathers' knowledge of and involvement in child feeding, as desired by mothers.

Association between household food security and infant feeding practices in urban informal settlements in Nairobi, Kenya

Studies in urban informal settlements show widespread inappropriate infant and young child feeding (IYCF) practices and high rates of food insecurity. This study assessed the association between household food security and IYCF practices in two urban informal settlements in Nairobi, Kenya. The study adopted a longitudinal design that involved a census sample of 1110 children less than 12 months of age and their mothers aged between 12 and 49 years. A questionnaire was used to collect information on: IYCF practices and household food security. Logistic regression was used to determine the association between food insecurity and IYFC practices. The findings showed high household food insecurity; only 19.5% of the households were food secure based on Household Insecurity Access Score. Infant feeding practices were inappropriate: 76% attained minimum meal frequency; 41% of the children attained a minimum dietary diversity; and 27% attained minimum acceptable diet. With the exception of the minimum meal frequency, infants living in food secure households were significantly more likely to achieve appropriate infant feeding practices than those in food insecure households: minimum meal frequency (adjusted odds ratio (AOR)=1.26, P=0.530); minimum dietary diversity (AOR=1.84, P=0.046) and minimum acceptable diet (AOR=2.35, P=0.008). The study adds to the existing body of knowledge by demonstrating an association between household food security and infant feeding practices in low-income settings. The findings imply that interventions aimed at improving infant feeding practices and ultimately nutritional status need to also focus on improving household food security.

Measuring exclusive breastfeeding social support: Scale development and validation in Uganda

The World Health Organization recommends exclusive breastfeeding (EBF) for 6 months and continued breastfeeding for at least 2 years. Social support has been widely recognized to influence breastfeeding practices. However, existing scales do not measure exclusive breastfeeding social support (EBFSS), rather they assess social support for any breastfeeding. Further, they are tailored towards high-income settings. Therefore, our objectives were to develop and validate a tool to measure EBFSS in low-income settings. To develop the scale, local and international breastfeeding experts were consulted on modifications to the Hughes' Breastfeeding Social Support Scale. It was then implemented in an observational cohort in Gulu, Uganda, at 1 (n = 238) and 3 (n = 237) months post-partum (NCT02925429). We performed polychoric and polyserial correlations to remove redundant items and exploratory factor analysis at 1 month post-partum to determine the latent factor structure of EBFSS. We further applied confirmatory factor analysis to assess dimensionality of the scale at 3 months post-partum. We then conducted tests of predictive, convergent, and discriminant validity against EBF, self-efficacy, general social support, and depression. The modification of the Hughes' scale resulted in 18 items, which were reduced to 16 after examining variances and factor loadings. Three dimensions of support emerged: Instrumental, Emotional, and Informational, with alpha coefficients of 0.79, 0.85, and 0.83, respectively. Predictive, convergent, and discriminant validity of the resultant EBFSS scale was supported. The EBFSS scale is valid and reliable for measuring EBFSS in northern Uganda and may be of use in other low-income settings to assess determinants of EBF.

Intimate Partner Violence Against HIV-Positive Women is Associated with Sub-Optimal Infant Feeding Practices in Lusaka, Zambia

Objectives The aim of this study is to determine how intimate partner violence against HIV-positive women affects safe infant feeding practices in Lusaka, Zambia. Methods A cross-sectional face-to-face survey was conducted with 320 married postpartum women at a large public health center in Lusaka, Zambia, in 2014. Variables were measured using previously validated instruments from the Demographic and Health Survey. Data were analyzed using simple and multivariate logistic regression in Stata 12. Results Thirty-seven percent of women report early mixed infant feeding prior to six months. Women who experienced intimate partner violence have 2.8 higher adjusted odds of early mixed infant feeding (p < 0.001). Women who experienced emotional violence, specifically, have 1.9 higher adjusted odds of early mixed infant feeding (p < 0.05), while women who experienced sexual violence have 2.3 higher adjusted odds (p < 0.01). There is also a dose-response relationship between IPV and early mixed infant feeding (p < 0.05). Lastly, disclosing one's HIV-positive status to the husband is associated with at least 67 % lower adjusted odds of early mixed feeding (p < 0.05). Conclusions Intimate partner violence against HIV-positive women, in particular emotional and sexual violence, increases the likelihood of early mixed infant feeding, putting infants at greater risk for both mother-to-child transmission of HIV and other infant morbidities. Intimate partner violence should thus be given increased attention within the context of infant feeding and HIV in sub-Saharan Africa.

Factors Associated with Exclusive Breastfeeding Practice among Nursing Mothers in rural areas of Enugu State and its Implications for Social Work Practice in Nigeria

This study investigates factors that influence exclusive breastfeeding practice. Focus group discussions involving 60 nursing mothers from selected rural areas of Enugu State, Nigeria, was adopted. Thematic analysis was adopted in analyzing data collected. Findings show that nursing mothers in the study area are yet to fully accept the 6 months' practice of exclusive breastfeeding. Issues relating to culture, economic hardship, and support networks were revealed to exercise gross influence on practice of exclusive breastfeeding. The study concluded that professional support from social workers is very vital to achieving conformity to the practice. This can be done through awareness creation that would accommodate support networks, while adopting exclusive breastfeeding campaign models that have proven successful in other African nations.

Effectiveness of home-based nutritional counselling and support on exclusive breastfeeding in urban poor settings in Nairobi: a cluster randomized controlled trial

BACKGROUND

Exclusive breastfeeding (EBF) improves infant health and survival. We tested the effectiveness of a home-based intervention using Community Health Workers (CHWs) on EBF for six months in urban poor settings in Kenya.

METHODS

We conducted a cluster-randomized controlled trial in Korogocho and Viwandani slums in Nairobi. We recruited pregnant women and followed them until the infant's first birthday. Fourteen community clusters were randomized to intervention or control arm. The intervention arm received home-based nutritional counselling during scheduled visits by CHWs trained to provide specific maternal infant and young child nutrition (MIYCN) messages and standard care. The control arm was visited by CHWs who were not trained in MIYCN and they provided standard care (which included aspects of ante-natal and post-natal care, family planning, water, sanitation and hygiene, delivery with skilled attendance, immunization and community nutrition). CHWs in both groups distributed similar information materials on MIYCN. Differences in EBF by intervention status were tested using chi square and logistic regression, employing intention-to-treat analysis.

RESULTS

A total of 1110 mother-child pairs were involved, about half in each arm. At baseline, demographic and socioeconomic factors were similar between the two arms. The rates of EBF for 6 months increased from 2% pre-intervention to 55.2% (95% CI 50.4-59.9) in the intervention group and 54.6% (95% CI 50.0-59.1) in the control group. The adjusted odds of EBF (after adjusting for baseline characteristics) were slightly higher in the intervention arm compared to the control arm but not significantly different: for 0-2 months (OR 1.27, 95% CI 0.55 to 2.96; p = 0.550); 0-4 months (OR 1.15; 95% CI 0.54 to 2.42; p = 0.696), and 0-6 months (OR 1.11, 95% CI 0.61 to 2.02; p = 0.718).

CONCLUSIONS

EBF for six months significantly increased in both arms indicating potential effectiveness of using CHWs to provide home-based counselling to mothers. The lack of any difference in EBF rates in the two groups suggests potential contamination of the control arm by information reserved for the intervention arm. Nevertheless, this study indicates a great potential for use of CHWs when they are incentivized and monitored as an effective model of promotion of EBF, particularly in urban poor settings. Given the equivalence of the results in both arms, the study suggests that the basic nutritional training given to CHWs in the basic primary health care training, and/or provision of information materials may be adequate in improving EBF rates in communities. However, further investigations on this may be needed. One contribution of these findings to implementation science is the difficulty in finding an appropriate counterfactual for community-based educational interventions.

TRIAL REGISTRATION

ISRCTN ISRCTN83692672 . Registered 11 November 2012. Retrospectively registered.

Economic determinants of breastfeeding in Haiti: The effects of poverty, food insecurity, and employment on exclusive breastfeeding in an urban population

There is limited and inconsistent empirical evidence regarding the role of economic factors in breastfeeding practices, globally. Studies have found both negative and positive associations between low income and exclusive breastfeeding (EBF). Employment, which should improve household income, may reduce EBF due to separation of mother and infant. In the context of a randomized controlled study of lipid-based complementary feeding in an urban slum in Cap Haitien, Haiti, we examined the economic factors influencing breastfeeding practices using mixed methods. Findings demonstrate relationships between urban context, economic factors, and breastfeeding practices. Poverty, food insecurity, time constraints, and limited social support create challenges for EBF. Maternal employment is associated with lower rates of EBF and less frequent breastfeeding. Extreme food insecurity sometimes leads to increased exclusive breastfeeding among Haitian mothers, what we call "last resort EBF." In this case, women practice EBF because they have no alternative food source for the infant. Suggested policies and programs to address economic constraints and promote EBF in this population include maternal and child allowances, quality child care options, and small-scale household urban food production.

Addressing barriers to exclusive breast-feeding in low- and middle-income countries: a systematic review and programmatic implications

OBJECTIVE

Despite numerous global initiatives on breast-feeding, trend data show exclusive breast-feeding (EBF) rates have stagnated over the last two decades. The purpose of the present systematic review was to determine barriers to exclusive breast-feeding in twenty-five low- and middle-income countries and discuss implications for programmes.

DESIGN

A search of Scopus, MEDLINE, CINAHL and PsychINFO was conducted to retrieve studies from January 2000 to October 2015. Using inclusion criteria, we selected both qualitative and quantitative studies that described barriers to EBF.

SETTING

Low- and middle-income countries.

SUBJECTS

Following application of systematic review criteria, forty-eight articles from fourteen countries were included in the review.

RESULTS

Sixteen barriers to EBF were identified in the review. There is moderate evidence of a negative association between maternal employment and EBF practices. Studies that examined EBF barriers at childbirth and the initial 24 h post-delivery found strong evidence that caesarean section can impede EBF. There is moderate evidence for early initiation of breast-feeding and likelihood of practising EBF. Breast-feeding problems were commonly reported from cross-sectional or observational studies. Counselling on EBF and the presence of family and/or community support have demonstrated improvements in EBF.

CONCLUSIONS

Improving the counselling skills of health workers to address breast-feeding problems and increasing community support for breast-feeding are critical components of infant and young child feeding programming, which will aid in attaining the 2025 World Health Assembly EBF targets. Legislation and regulations on marketing of breast-milk substitutes, paid maternity leave and breast-feeding breaks for working mothers require attention in low- and middle-income countries.

Is competence enough to enable Kenyan mothers to make good infant and young child feeding decisions?

The aim of this study was to explore factors associated with maternal infant and young child feeding motivation in urban and rural Kenya. We conducted 18 focus group discussions with mothers of children 0 to 23 months of age and healthcare workers. The data were transcribed, translated, and explored following the principles of content analysis. We first explored and coded the data inductively and categorized it according to emerging themes representing the most relevant topics for young child feeding. After this, these themes were theorized into an explanatory framework. Finally, the results yielded seven themes integrated into self-determination theory's three basic motivation-building pillars: autonomy, competence, and relatedness. We found that maternal intrahousehold autonomy on child feeding was substantial. However, this autonomy was lost for a period of time while in close contact with the healthcare staff. The authority of the healthcare workers was at its peak when the child was born and faded gradually as the child grew. Building maternal competence is important for child-feeding outcomes, but our data showed that the health education methods used by the healthcare workers were inadequate to improve maternal to improve the motivation. The competence of Kenyan healthcare workers should be improved in the area of complementary feeding counseling, and they should be trained to provide practical and emotional support as a way of increasing maternal motivation on infant and child feeding.

Duration of exclusive breastfeeding is a positive predictor of iron status in 6- to 10-month-old infants in rural Kenya

The prevalence of iron-deficiency anemia (IDA) is high in infants in Sub-Saharan Africa. Exclusive breastfeeding of infants to 6 months of age is recommended by the World Health Organization, but breast milk is low in iron. Some studies suggest exclusive breastfeeding, although beneficial for the infant, may increase risk for IDA in resource-limited settings. The objective of this study was to determine if duration of exclusive breastfeeding is associated with anemia and iron deficiency in rural Kenyan infants. This was a cross-sectional study of 6-10-month-old infants (n = 134) in southern coastal Kenya. Anthropometrics, hemoglobin (Hb), plasma ferritin (PF), soluble transferrin receptor (sTfR), and C-reactive protein were measured. Body iron stores were calculated from the sTfR/PF ratio. Socioeconomic factors, duration of exclusive breastfeeding, nature of complementary diet, and demographic characteristics were determined using a questionnaire. Mean ± SD age of the infants was 7.7 ± 0.8 months. Prevalence of anemia, ID, and IDA were 74.6%, 82.1%, and 64.9%, respectively. Months of exclusive breastfeeding correlated positively with Hb (r = 0.187; p < .05) and negatively with sTfR (r = -0.246; p < .05). sTfR concentrations were lower in infants exclusively breastfed at least 6 months compared with those exclusively breastfed for less than 6 months (7.6 (6.3, 9) vs. 8.9 (6.7, 13.4); p < .05). Controlling for gender, birth weight, and inflammation, months spent exclusively breastfeeding was a significant negative predictor of sTfR and a positive predictor of Hb (p < .05). The IDA prevalence in rural Kenyan infants is high, and greater duration of exclusive breastfeeding predicts better iron status and higher Hb in this age group.

Mental health predictors of breastfeeding initiation and continuation among HIV infected and uninfected women in a South African birth cohort study

Breastfeeding is a cost-effective, yet underutilized strategy to promote maternal and infant health in low and middle income countries (LMICs). Breastfeeding remains challenging for mothers living with HIV in LMICs, yet few studies have examined mental health predictors of breastfeeding initiation and continuation. We investigated breastfeeding among mothers by HIV status in South Africa, evaluating predictors of breastfeeding initiation and continuation to identify intervention-targets. Breastfeeding patterns were investigated in a subsample of 899 breastfeeding mothers from the Drakenstein Child Health Study; a prospective birth cohort of 1225 pregnant women, between March 2012 and March 2015 in a peri-urban area. Breastfeeding was assessed at 5 time-points between 6weeks and 24months' infant age. Cox proportional hazard models evaluated breastfeeding initiation and duration. Logistic regression models with breastfeeding non-initiation as the outcome parameter were performed to determine associations with maternal sociodemographic, psychosocial factors and gestational outcomes. More HIV-uninfected mothers initiated breastfeeding (n=685, 97%) than HIV-infected mothers (n=87, 45%). Median duration of exclusive breastfeeding was short (2months), but HIV-infected mothers engaged in exclusive breastfeeding for longer duration than uninfected mothers (3 vs 2months). Despite concerning high rates, mental disorders were not significant predictors of breastfeeding behaviour. Employment and HIV diagnosis during pregnancy predicted a lower likelihood of breastfeeding initiation among HIV-infected mothers, while employment was associated with earlier breastfeeding-discontinuation in HIV-uninfected mothers. Findings indicate that future interventions should target sub-populations such as HIV-infected women because of distinct needs. Workplace interventions appear particularly key for mothers in our study.

What influences feeding decisions for HIV-exposed infants in rural Kenya?

BACKGROUND

Infant feeding in the context of human immunodeficiency virus (HIV) poses unique challenges to mothers and healthcare workers in balancing the perceived risks of HIV transmission and nutritional requirements. We aimed to describe the decision-making processes around infant feeding at a rural HIV clinic in Kenya.

METHODS

We used a qualitative study design. Between March and August 2011, we conducted in-depth interviews (n = 9) and focus group discussions (n = 10) with purposively selected hospital and community respondents at Kilifi County Hospital, Kenya. These respondents had all experienced of infant feeding in the context of HIV. These interviews were informed by prior structured observations of health care worker interactions with carers during infant feeding counselling sessions.

RESULTS

Overall, women living with HIV found it difficult to adhere to the HIV infant feeding guidance. There were three dominant factors that influenced decision making processes: 1) Exclusive breastfeeding was not the cultural norm, therefore practising it raised questions within the family and community about a mother's parenting capabilities and HIV status. 2) Women living with HIV lacked autonomy in decision-making on infant feeding due to socio-cultural factors. 3) Non-disclosure of HIV status to close members due to the stigma.

CONCLUSION

Infant feeding decision-making by women living with HIV in rural Kenya is constrained by a lack of autonomy, stigma and poverty. There is an urgent need to address these challenges through scaling up psycho-social and gender empowerment strategies for women, and introducing initiatives that promote the integration of HIV infant feeding strategies into other child health services.

Intention, magnitude and factors associated with bottle feeding among mothers of 0-23 months old children in Holeta town, Central Ethiopia: a cross sectional study

Background

World Health Organization (WHO) recommends that bottle feeding should be avoided for infant and young child feeding since it has an impact on optimal breastfeeding, appropriate complementary feeding and bottles with a nipple are prone to contamination. The objectives of this study were to determine intention, magnitude and factors associated with bottle feeding among mothers of 0–23 months infants and children.

Methods

Community based cross sectional study was conducted from February to May 2016. A total of 422 mothers who had children 0–23 months were included in the study. Systematic random sampling was used to select the study subjects. Data were collected using a pre-tested interviewer administered structured questionnaire. The data were cleaned, coded, entered in to EPI-INFO version 3.5.4, and transferred and analyzed using SPSS. Odds ratio was calculated with 95% CI to identify factors associated with bottle feeding practice. P-values less than 0.05 were considered as statistically significant.

Results

The prevalence of bottle-feeding in this study was 19.6% and another 27.6% mothers have intention of bottle feeding. Being infant age of 0–5 months [AOR = 0.27;95% CI:(0.12,0.62)] and being a housewife [AOR = 0.37;95% CI:(0.21,0.67)] were negatively associated while having three under five children [AOR = 2.77;95% CI:(1.07,7.14)], not attending PNC follow-up [AOR = 2.13;95% CI:(1.19,4.97)], lower age of mothers [AOR = 3.38;95% CI:(1.48,7.73)] and not counseled on bottle feeding [AOR = 2.18;95% CI:(1.24,3.83)] were positively associated with bottle feeding.

Conclusion

The prevalence of bottle feeding in the study area was high compared to the national prevalence of bottle feeding. Working outside home, lower maternal age, older age of children, having more than one under five children in the household, not attending PNC follow-up and not counseled on bottle feeding were found to be risk factors associated with bottle feeding practice in the study area.

Maternal Psychological Distress and Perceived Impact on Child Feeding Practices in South Kivu, DR Congo

BACKGROUND

Maternal mental health problems are associated with poor child growth and suboptimal child feeding practices, yet little qualitative research has been conducted to understand mothers' perceptions about how maternal mental ill health and child nutrition are related.

OBJECTIVE

The objective of the study was to understand maternal perceptions on sources of psychological distress, and how distress impacts functioning, especially related to childcare and feeding practices among mothers of young children in South Kivu, DR Congo.

METHODS

Mothers of young children who were participating in a larger study were eligible. Using purposive sampling, participants were selected if they had high or low levels of psychological distress, based on their mean item score on measures of symptoms of depression, anxiety, and post-traumatic stress. Twenty in-depth interviews and 2 focus group discussions were conducted, with a total of 35 mothers. Key informant interviews were conducted with 5 local health workers. Audio recordings were transcribed and coded, and the analysis was guided by Grounded Theory methodology.

RESULTS

Major themes to emerge were that women's husbands were a significant source of distress, with husbands' infidelity, abandonment, and lack of financial support mentioned by participants. Psychological distress resulted in appetite and weight loss, and poor nutritional status made it difficult to breastfeed. Participants perceived psychological distress caused milk insufficiency and difficulty breastfeeding.

CONCLUSION

Mothers experiencing psychological distress may need greater support for maternal nutrition and breastfeeding, and engaging fathers through responsible parenting interventions may reduce psychological distress and have a positive impact on child health.

The history, geography, and sociology of slums and the health problems of people who live in slums

Massive slums have become major features of cities in many low-income and middle-income countries. Here, in the first in a Series of two papers, we discuss why slums are unhealthy places with especially high risks of infection and injury. We show that children are especially vulnerable, and that the combination of malnutrition and recurrent diarrhoea leads to stunted growth and longer-term effects on cognitive development. We find that the scientific literature on slum health is underdeveloped in comparison to urban health, and poverty and health. This shortcoming is important because health is affected by factors arising from the shared physical and social environment, which have effects beyond those of poverty alone. In the second paper we will consider what can be done to improve health and make recommendations for the development of slum health as a field of study.

Sociocultural factors influencing breastfeeding practices in two slums in Nairobi, Kenya

BACKGROUND

Despite numerous interventions promoting optimal breastfeeding practices in Kenya, pockets of suboptimal breastfeeding practices are documented in Kenya's urban slums. This paper describes cultural and social beliefs and practices that influence breastfeeding in two urban slums in Nairobi, Kenya.

METHODS

Qualitative data were collected in Korogocho and Viwandani slums through 10 focus group discussions and 19 in-depth interviews with pregnant, breastfeeding women and community health volunteers and 11 key-informant interviews with community leaders. Interviews were audiotaped, transcribed verbatim, coded in NVIVO and analyzed thematically.

RESULTS

Social and cultural beliefs and practices that result to suboptimal breastfeeding practices were highlighted including; considering colostrum as 'dirty' or 'curdled milk', a curse 'bad omen' associated with breastfeeding while engaging in extra marital affairs, a fear of the 'evil eye' (malevolent glare which is believed to be a curse associated with witchcraft) when breastfeeding in public and breastfeeding being associated with sagging breasts. Positive social and cultural beliefs were also identified including the association of breast milk with intellectual development and good child health. The beliefs and practices were learnt mainly from spouses, close relatives and peers.

CONCLUSION

Interventions promoting behavior change with regards to breastfeeding should focus on dispelling the beliefs and practices that result to suboptimal breastfeeding practices and to build on the positive ones, while involving spouses and other family members as they are important sources of information on breastfeeding.

TRIAL REGISTRATION

ISRCTN83692672: December 2013 (retrospectively registered).

How does poverty affect children's nutritional status in Nairobi slums? A qualitative study of the root causes of undernutrition

Objective

Children in slums are at high risk of undernutrition, which has long-term negative consequences on their physical growth and cognitive development. Severe undernutrition can lead to the child’s death. The present paper aimed to understand the causes of undernutrition in children as perceived by various groups of community members in Nairobi slums, Kenya.

Design

Analysis of ten focus group discussions and ten individual interviews with key informants. The main topic discussed was the root causes of child undernutrition in the slums. The focus group discussions and key informant interviews were recorded and transcribed verbatim. The transcripts were coded in NVivo by extracting concepts and using a constant comparison of data across the different categories of respondents to draw out themes to enable a thematic analysis.

Setting

Two slum communities in Nairobi, Kenya.

Subjects

Women of childbearing age, community health workers, elders, leaders and other knowledgeable people in the two slum communities (n 90).

Results

Participants demonstrated an understanding of undernutrition in children.

Conclusions

Findings inform target criteria at community and household level that can be used to identify children at risk of undernutrition. To tackle the immediate and underlying causes of undernutrition, interventions recommended should aim to: (i) improve maternal health and nutrition; (ii) promote optimal infant and young children feeding practices; (iii) support mothers in their working role; (iv) increase access to family planning; (v) improve water, sanitation and hygiene (WASH); (vi) address alcohol problems at all levels; and (vii) address street food issues with infant feeding counselling.

Eating soup with nails of pig: thematic synthesis of the qualitative literature on cultural practices and beliefs influencing perinatal nutrition in low and middle income countries

BACKGROUND

The perinatal period, i.e. pregnancy, childbirth and early infancy, is a significant transition period where the biological and the social strongly intersect. In low and middle-income countries the disease burden arising from the perinatal period, is still substantial. The perinatal period is also a crucial window of opportunity for reducing undernutrition and its long term adverse effects.

METHODS

We explored qualitative research conducted in low resource settings around the perinatal continuum over the past two decades, with a particular focus on the 'cultural' realm, to identify common themes influencing maternal and infant nutrition. We systematically searched electronic databases from 1990 to 2014, including MEDLINE, EMBASE, PsycINFO, Scopus and Cumulative Index to Nursing and Allied Health Literature, using relevant search terms including traditional beliefs, practices, pregnancy, childbirth, developing countries etc. Adapted Consolidated Criteria for Reporting Qualitative Health Research and Critical Appraisal Skills Programme criteria were used to determine quality of studies. We synthesised the literature thematically, enabled by NVivo 10 software.

RESULTS

Most studies showed cultural support for breastfeeding, although most traditional societies delayed breastfeeding due to colostrum being considered 'dirty'. A range of restrictive practices through pregnancy and the post- partum period were revealed in Asia, Latin America and Africa. There was a strong cultural understanding of the healing power of everyday foods. A wide range of good foods and bad foods continued to have currency through the perinatal continuum, with little consensus between groups of what was beneficial versus harmful. Cross-cutting themes that emerged were 1) the role of the woman/mother/wife as strong and good; 2) poverty restricting women's nutrition choices; 3) change being constant, but the direction of change unpredictable.

CONCLUSIONS

A rich and diverse repertoire of cultural practices and beliefs influenced perinatal nutrition. Results from this synthesis should influence public health policymakers and practitioners, to tailor contextually specific, culturally responsive perinatal nutrition interventions to optimise health and wellbeing of mother-infant dyads. Ideally these interventions should build on culturally sanctioned life affirming behaviours such as breastfeeding, promoting post-partum rest and recovery, while modifying the potentially harmful aspects of other cultural practices in the perinatal period.

Predictors of early breastfeeding cessation among HIV-infected women in Botswana

OBJECTIVE

Infants born to HIV-infected women receiving antiretroviral treatment (ART) can be breastfed through at least 6 months with very low risk of HIV acquisition. We aimed to identify demographic and cultural factors that may influence mothers' willingness to breastfeed for the recommended duration.

METHODS

We evaluated factors associated with early cessation of breastfeeding (i.e. before 5 months post-partum) in a randomized clinical trial evaluating different ART regimens used for prevention of mother-to-child transmission during breastfeeding in Botswana. Univariate and multivariable Cox regressions were used to describe predictors of early exclusive BF cessation.

RESULTS

Among 677 women who started breastfeeding, the median time to breastfeeding cessation was 178 days (IQR 150-181) and 25.1% weaned early. In multivariable analysis, urban location (aHR = 1.86 95%CI 1.27-2.73; P = 0.002), salaried employment or being a student (aHR = 2.78 95% CI 1.63-4.75; P < 0.001) and infant hospitalisation before weaning (aHR = 2.04 95% CI 1.21-3.45; P = 0.008) were independently and significantly associated with early BF cessation.

CONCLUSIONS

Improved support for breastfeeding among employed mothers, especially in urban settings, may allow HIV-infected women who are receiving ART prophylaxis to breastfeed longer.

"When you give birth you will not be without your mother" A mixed methods study of advice on breastfeeding for first-time mothers in rural coastal Kenya

Background

Exclusive breastfeeding for the first 6 months of life is currently recommended by the World Health Organization, but mixed feeding earlier than this commonly occurs in rural coastal Kenya. Mothers may receive conflicting advice on breastfeeding from various sources including health workers, relatives and community members. We aimed to find out how first-time mothers learn to breastfeed, who advises them on infant feeding and what advice they obtain in case of any breastfeeding problems.

Methods

To identify advisers, a questionnaire on socio-demographic status, place of delivery, household members, education and help received on breastfeeding, breastfeeding problems, name of advisers and their relationship to the mothers was administered to 50 new first-time mothers in Jaribuni, Kilifi (population approximately 18,000). Summary statistics were obtained using frequencies, medians and interquartile ranges (IQR). Focus group discussions (FGDs) were held amongst 4 groups of mothers who had answered questionnaires; 4 groups of their named advisers; and 1 group of community health workers in order to explore breastfeeding practices, problems and advice given. FGDs were analysed by thematic framework analysis.

Results

First-time mothers were young (median age 18, IQR 17–21, range 14–26 years) and 42 % were single. Living in extended families was the norm and married women lived with their husband’s family. All had a female family member or neighbour helping with childcare in the perinatal period. The main advisers on breastfeeding were their mother or older female members of their husband’s family. Married first-time mothers felt obliged to follow their mother-in-law’s advice to maintain good relationships and show respect within the household. Breastfeeding problems were reported by 80 % of respondents. Nipple pain (56 %) was the most reported problem, then breast engorgement (48 %) and insufficient milk supply (38 %). Most problems were treated at home without consultation with health workers. Concerns were raised about co-sleeping, breastfeeding whilst lying down, and insufficient milk supply. Advisers would like more information on breastfeeding in order to help mothers.

Conclusions

Interventions to increase knowledge of, and facilitate optimal breastfeeding practices in first-time mothers should include those family members who advise and assist with childcare around the time of delivery.

Electronic supplementary material

The online version of this article (doi:10.1186/s13006-016-0069-6) contains supplementary material, which is available to authorized users.

Potential effectiveness of Community Health Strategy to promote exclusive breastfeeding in urban poor settings in Nairobi, Kenya: a quasi-experimental study

Early nutrition is critical for later health and sustainable development. We determined potential effectiveness of the Kenyan Community Health Strategy in promoting exclusive breastfeeding (EBF) in urban poor settings in Nairobi, Kenya. We used a quasi-experimental study design, based on three studies [Pre-intervention (2007-2011; n=5824), Intervention (2012-2015; n=1110) and Comparison (2012-2014; n=487)], which followed mother-child pairs longitudinally to establish EBF rates from 0 to 6 months. The Maternal, Infant and Young Child Nutrition (MIYCN) study was a cluster randomized trial; the control arm (MIYCN-Control) received standard care involving community health workers (CHWs) visits for counselling on antenatal and postnatal care. The intervention arm (MIYCN-Intervention) received standard care and regular MIYCN counselling by trained CHWs. Both groups received MIYCN information materials. We tested differences in EBF rates from 0 to 6 months among four study groups (Pre-intervention, MIYCN-Intervention, MIYCN-Control and Comparison) using a χ(2) test and logistic regression. At 6 months, the prevalence of EBF was 2% in the Pre-intervention group compared with 55% in the MIYCN-Intervention group, 55% in the MIYCN-Control group and 3% in the Comparison group (P<0.05). After adjusting for baseline characteristics, the odds ratio for EBF from birth to 6 months was 66.9 (95% CI 45.4-96.4), 84.3 (95% CI 40.7-174.6) and 3.9 (95% CI 1.8-8.4) for the MIYCN-Intervention, MIYCN-Control and Comparison group, respectively, compared with the Pre-intervention group. There is potential effectiveness of the Kenya national Community Health Strategy in promoting EBF in urban poor settings where health care access is limited.

Evidence of a Double Burden of Malnutrition in Urban Poor Settings in Nairobi, Kenya

Background

Many low- and middle-income countries are undergoing a nutrition transition associated with rapid social and economic transitions. We explore the coexistence of over and under- nutrition at the neighborhood and household level, in an urban poor setting in Nairobi, Kenya.

Methods

Data were collected in 2010 on a cohort of children aged under five years born between 2006 and 2010. Anthropometric measurements of the children and their mothers were taken. Additionally, dietary intake, physical activity, and anthropometric measurements were collected from a stratified random sample of adults aged 18 years and older through a separate cross-sectional study conducted between 2008 and 2009 in the same setting. Proportions of stunting, underweight, wasting and overweight/obesity were dettermined in children, while proportions of underweight and overweight/obesity were determined in adults.

Results

Of the 3335 children included in the analyses with a total of 6750 visits, 46% (51% boys, 40% girls) were stunted, 11% (13% boys, 9% girls) were underweight, 2.5% (3% boys, 2% girls) were wasted, while 9% of boys and girls were overweight/obese respectively. Among their mothers, 7.5% were underweight while 32% were overweight/obese. A large proportion (43% and 37%%) of overweight and obese mothers respectively had stunted children. Among the 5190 adults included in the analyses, 9% (6% female, 11% male) were underweight, and 22% (35% female, 13% male) were overweight/obese.

Conclusion

The findings confirm an existing double burden of malnutrition in this setting, characterized by a high prevalence of undernutrition particularly stunting early in life, with high levels of overweight/obesity in adulthood, particularly among women. In the context of a rapid increase in urban population, particularly in urban poor settings, this calls for urgent action. Multisectoral action may work best given the complex nature of prevailing circumstances in urban poor settings. Further research is needed to understand the pathways to this coexistence, and to test feasibility and effectiveness of context-specific interventions to curb associated health risks.