LITERATURE REVIEW

2.1 Introduction

Chapter two entails review of relevant literature on exclusive breast feeding. A general overview of breastfeeding is given. The chapter then describes the global situation of breast feeding in general and narrows down to exclusive breast feeding.

2.2 Overview of breastfeeding and exclusive breast feeding practices

There is a universal consensus about the fundamental importance of breastfeeding for children`s adequate growth and development and for their physical and mental health (WHO, 2002). Breastfeeding, particularly exclusive breastfeeding, and appropriate complementary feeding practices are universally accepted as essential elements for the satisfactory growth and development of infants as well as for prevention of childhood illness. This has culminated in a publication by the World Health Organization (WHO) recommending that infants up to 6 months of age should be exclusively breastfed (WHO, 1998).

Benefits of breastfeeding like a decrease in the incidence, severity of infectious diseases such as diarrhea, respiratory tract infections, otitis media and urinary tract infection; decreased incidence of types 1 and 2 diabetes mellitus, overweight, obesity and asthma were reported (Gartner LM, Morton J, Lawrence RA, et al, 2005). Too early introduction of breast milk substitutes and too late introduction of semi solid complementary feeds are common and are responsible for rapid increase in the prevalence of under nutrition between 6-24 months (Ramachandran, 2005). Exclusive breastfeeding defined by World Health Organization (WHO) as practice of feeding only breast milk (including expressed breast milk) and allows the baby to receive vitamins, minerals or medicines and water, breast milk substitutes, other liquids and solid foods are excluded.

Some studies (Aidam et al, 2005) reveal factors, positively associated with exclusive breastfeeding, such as higher maternal educational level, gestational age greater than 37 weeks and mothers with previous experience of breastfeeding. There are also studies that relate factors leading to interruption of exclusive breastfeeding such as low family income, low maternal age, primiparity and mothers returning to work (Mascarenhas et al, 2006). Several studies intended to define determinant variables in the success or failure of breastfeeding (Losch et al, 1995), which could ease the planning of promotional strategies. Nevertheless, it is always prudent to consider that, as an eating habit, breastfeeding is intrinsically related to social, cultural and traditional patterns of a given population. This fact justifies need for regional studies that allows more efficient action in regard to measures for intervention, based on knowledge of local reality (WHO, 2002).

Based on WHO guiding principles for feeding breast fed and non breastfed children, the IYCF practices indicators is comprised of all the following three components: continued breastfeeding or feeding with appropriate calcium rich foods if not breastfed; feeding (solid/semisolid food) a minimum number of times per day according to age and breastfeeding status and feeding a minimum number of food groups per day according to breastfeeding status. The promotion and support of optimal breastfeeding and complementary feeding practices (IYCF) is a global priority. WHO and UNICEF have for many years emphasized the importance of maintaining the practice of breastfeeding and reviving the practice where it is in decline. The twenty seventh world assembly in 1974 noted the general decline in breastfeeding in many parts of the world and in May 1981, the world health assembly adopted the /international code of marketing of breast milk substitutes (WHO, 1981).

This was to protect breastfeeding and to regulate the advertising and promotional techniques used to encourage artificial feeding. In Scientific evidence demonstrates lower infant mortality and morbidity rates, reduced prevalence of overweight among young children and reduced risk of breast and ovarian cancers among women (Jones and Steketee, 2003). WHO recommends exclusive breastfeeding for six months since from that age breast milk is no longer sufficient to meet all the nutritional needs of the growing infant (WHO, 2002). The period from birth to two years of age is widely recognized as a critical window for the promotion of optimal growth, health and development.

In Kenya and in much of Sub Sahara Africa, poor breast feeding and poor complementary feeding practices coupled with high rates of childhood illnesses are the principal causes of malnutrition during the first two years of life (UNICEF ESARO, 2007). Globally, exclusive breastfeeding of children less than six months of age has been increasing annually (UNICEF, 2009). The current prevalence is 37 percent (UNICEF, 2011). UNICEF has further documented this improvement in the developing world as 33 percent in 1995 and 37 percent in 2008. South Asia registers the highest rate at 44 percent (UNICEF 2011). The exclusive breastfeeding indicator is the proportion of infants 0-6 months of age who are fed exclusively breast milk based on 24-hour recall. The national rate (both urban and rural) is 32.0 percent (KDHS 2008-09). The rate is yet to reach the WHO target of 90 percent. There are several factors that hinder proper IYCF practices among women in Kenya. Study findings show a poor knowledge of recommended breastfeeding practices among mothers (Ochola et al, 2008).

Early breastfeeding practices determine the successful establishment and duration of breastfeeding. It is recommended that children be put to the breast immediately or within one hour after birth. When a mother initiates breastfeeding immediately after birth, breast milk production is stimulated. During the first few days after delivery, colostrum, an important source of nutrition and antibody protection for the newborn, is produced and should be fed to the newborn while awaiting the production of regular breast milk. Prelacteal feeding, giving liquids or foods other than breast milk prior to the establishment of regular breastfeeding, deprives the child of the valuable nutrients and protection of colostrum and exposes the newborn to the risk of infection.

2.3 Socioeconomic factors and exclusive breastfeeding

On maternal education level, evidence of the association between a mother’s level of education and the duration of breastfeeding varies (Pascale 2007). In a study by Kimani, 2011 lower than secondary level education was associated with earlier cessation of breastfeeding. While it is not very clear why this is the case, higher education may be associated with higher knowledge and practice of positive health behavior. Higher HIV prevalence among those with less than secondary level education; especially those with no education at all in our setting (Ziraba et al., 2011) may be associated with early cessation of breastfeeding.

The socioeconomic status influences the mothers’ choice to introduce formula milk.

This was indicated in a study by Rejesh, 2011 in South Gujarat region of India. Mothers who worked away from home were more likely to introduce formula milk and start complementary feeding before the infant attained six months of age. A mother returning to work was reported to have led to early complementary feeding (Mascarenhas et al, 2006). Mothers also cited challenges to exclusive breastfeeding to include return to work after maternity leave forcing them to introduce complementary feeds before the children are six months of age (Ochola et al, 2008), and caregivers left with the child while the mother goes to work introducing these foods when they perceive that the babies are hungry, (Kimani, 2011). In Tanzania according to Shirima, Gabre-Medhin and Greiner (2001) duration of exclusive breastfeeding is mainly associated with information and knowledge about breastfeeding.

Urban settings present unique challenges with regards to breastfeeding and infant and young child feeding practices due to their physical and socio-economic characteristics. In these settings, basic government services including health care services are limited and this may be coupled with financial constraints and lead to a substantial proportion of women in these giving birth at home or at informal private health facilities (Fotso et al, 2009). This means that most of these women are systematically excluded from government initiatives such as those aimed at promoting optimal breastfeeding and infant feeding practices, based at health facilities such as the BFHI which involves counseling of mothers on infant and young child feeding around the time of delivery. A potential intervention to counteract the systematic exclusion from basic government services may include, home-based counseling of mothers on infant and young child feeding by community based health workers and/or supporting the (informal) private service providers for instance through training programs to offer services according to established government guidelines such as those on breastfeeding. The effectiveness of such interventions in health care delivery, including promotion of optimal infant feeding practices in resource-constrained settings has been indicated (Haider et al, 2000).

2.4 Socio- cultural factors and exclusive breastfeeding

A range of factors have been reported to hinder exclusive breastfeeding; a study reports cultural norms of giving infants concoctions and customs such as giving water to every stranger entering the house including newborn (de Paoli, 2001) . Study from West Africa reported cultural practice of giving infants herbal mixture for their protection and also that breast milk does not contain adequate nutrients for the growth of the young infant which make it necessary to give infant extra food before the recommended age (Adejuyigbe, 2008). Another study reports that family members and social pressure to introduce other liquids and to mixed feed to infant has been known to have a strong influence on infant-feeding practices, particularly for young mothers (Petri et al, 2007). In Tanzania studies reveal that the use of pre lacteal feeds is a norm in both rural and urban settings with belief that it calms the crying baby (Shirima et al, 2001). A study in Ethiopia indicated that apart from close family members, influence like that of husband and neighbors imposition have also been reported to pressure mothers to practice mixed feeding, whereas mothers reported increasing pressure from family members to introduce other liquids, and most importantly the fear of being uncovered as HIV positive as reasons for non adherence to exclusive breastfeeding (Maru,2009).

In a study using data from Botswana which examined the association between breastfeeding, morbidity, and malnutrition, it was found that children aged four months or younger who had been weaned had more than eleven times the odds of having diarrhea compared with those who were still being breastfed (Chikusa, 1991). The main reason cited for introducing complementary food early was the mother’s perception of insufficient breast milk. This finding is in line with other studies from other settings which have shown that the perceived lack of sufficient breast milk is a main reason for early breastfeeding cessation or early introduction of complementary foods (Roy, 2009). Furthermore according to the Kenya Urban Comprehensive Food Security & Vulnerability Analysis (KU-CFSVA) and Nutrition Assessment (2010), the main reason given for the children not breastfed was the mothers’ perception that they had no milk. To enhance adequacy of milk produced by the mothers, potential interventions may be to enhance maternal nourishment through ensuring food security. This may be through appropriate income generating activities to enhance livelihoods. Food supplementation has also been found to enhance breast milk volume Jelliffe, 1978). Additionally, interventions that empower the new mother by demonstrating correct breastfeeding techniques, ways of stimulating breast milk production, and counselling on proper nutrition may improve breastfeeding practices (Mellin et al,). Predictors of early introduction of complementary foods include the child’s sex; the mother’s marital status, her ethnicity, and her level of education; the desirability of the pregnancy of the index child, the place of delivery and the slum setting. Boys are more likely to be introduced to complementary feeding early compared with girls. Anecdotal evidence indicates that boys are introduced to complementary foods early because breast milk alone does not meet their feeding demands (Kimani, 2011).

2.5 Maternal characteristics and exclusive breastfeeding

Mothers who get pregnant while breastfeeding are more likely to stop but, also mothers who breastfeed for longer period have lower chances of getting pregnant (Kennedy, 1998). The association between birth size and the duration of breastfeeding has not been studied in depth. The study by Kennedy, 2008 found that children who were perceived to be larger at birth were less likely to be stopped from breastfeeding earlier.

The association between marital status and early cessation of breastfeeding has been reported in many studies with conflicting results (Thulier, 2009). In a study by Alemayehu et al. in Ethiopia in 2005 exclusive breastfeeding was associated significantly with, current marital status, and economical status (Alemayehu et al., 2009). In a study by Kimani, 2011 in urban informal settlement in Nairobi, women who were not in union, particularly those who were formerly married were more likely to stop breastfeeding their infants than women who were in union. It has been suggested that the association between marital status and breastfeeding cessation may be due to the presence or absence of social, emotional and economic support of a partner (Giugliani, 1994). Having never been in union/married was associated with higher risk of early introduction of complementary foods.

A positive association between being married and exclusive breastfeeding has been documented in a study by Lande, 2003. As in the case of the duration of breastfeeding, this may be associated with social, emotional and economic support of a partner (Giuglian, 1994). A more plausible reason in Kenya, where HIV is high, is that a disproportionately large number of formerly married women are HIV positive and many women in this situation were until recently advised to exclusively breastfeed their infant for six months and then to rapidly wean (MoH,2006).

Studies have reported mode of delivery as one of the predictors of exclusive breastfeeding. In a study by Coovadia et al, on mother to child transmission of HIV infection during exclusive breastfeeding in the first six months of life, among other factors vaginal delivery was a predictor of exclusive breastfeeding. Furthermore, in a study done by Zanardo et al, to determine whether elective caesarean delivery has negative effect on breastfeeding they report that, emergency and elective caesarean deliveries are similarly associated with a decreased rate of exclusive breastfeeding compared with vaginal delivery.

In addition, Maru and Haidaru report in their study that mothers who delivered by caesarean section were 80% times less likely to practice exclusive breastfeeding. In a study done in Guatemala, it is reported that, place of delivery is associated with early initiation of breast feeding; that is mothers who gave birth at health facility initiate breast feeding early (Dearden et al, 2002) Moreover; the role of Baby Friendly Hospital Initiation (BFHI) was assessed in a study conducted in Nigeria and it was found that there was increased duration of exclusive breastfeeding of up to 75% from mothers who deliver at BFHI facility as compared to 35% from non BFHI facility(Laar AS and Govender V, 2011). Another study which was done in Ghana by Aidam et al reports further that delivery in maternity homes, private clinics, at home, or with Traditional Birth Attendant (TBA) or spiritual leaders poses a risk for not practicing exclusively breastfeeding within the first six months of life as opposed to delivering in government health facilities (Aidam et al, 2005).

2.6 Theoretical review

According to WHO, 2007, indicators of Infant and Young Child Feeding are as follows; Early initiation of breastfeeding: Proportion of children born in the last 24 months who were put to the breast within one hour of birth, Exclusive breastfeeding of infants under six months of age: Proportion of infants 0–6 months of age who are fed exclusively with breast milk, Continued breastfeeding at 1 year: Proportion of children 12–15 months of age who are fed breast milk, Introduction of solid, semisolid or soft foods: Proportion of infants 6–8 months of age who receive solid, semisolid or soft foods, Minimum dietary diversity: Proportion of children 6–23 months of age who receive foods from four or more food groups, Minimum meal frequency: Proportion of breastfed and non-breastfed children 6–23 months of age who receive solid, semi-solid, or soft foods (but also including milk feeds for non-breastfed children), Minimum acceptable diet: Proportion of children 6–23 months of age who receive a minimum acceptable diet (apart from breast milk) and Consumption of ironrich or iron-fortified foods: Proportion of children 6–23 months of age who receive an iron-rich food or iron-fortified food that is specially designed for infants and young children, or that is fortified in the home.

Optional indicators include, Children ever breastfed: Proportion of children born in the last 24 months who were ever breastfed, Continued breastfeeding at 2 years: Proportion of children 20–23 months of age who are fed breast milk, Age-appropriate breastfeeding: Proportion of children 0–23 months of age who are appropriately breastfed, Predominant breastfeeding under 6 months: Proportion of infants 0–6 months of age who are predominantly breastfed, Duration of breastfeeding: Median duration of breastfeeding among children less than 36 months of age, Bottle feeding: Proportion of children 0–23 months of age who are fed with a bottle and Milk feeding frequency for non-breastfed children: Proportion of non-breastfed children 6–23 months of age who receive at least two milk feedings

Of these indicators, this study focused on exclusive breastfeeding of children less than six months of age. Several factors have been documented to influence the practice or non practice of exclusive breast feeding. Socioeconomic characteristics, socio-cultural factors and maternal characteristics directly influence the practice.