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Patterns and determinants of breastfeeding and complementary feeding practices in urban informal settlements, Nairobi Kenya

Patterns and determinants of breastfeeding and complementary feeding practices in urban informal... Background: The World Health Organisation (WHO) recommends exclusive breastfeeding during the first six months of life for optimal growth, development and health. Breastfeeding should continue up to two years or more and nutritionally adequate, safe, and appropriately-fed complementary foods should be introduced at the age of six months to meet the evolving needs of the growing infant. Little evidence exists on breastfeeding and infant feeding practices in urban slums in sub-Saharan Africa. Our aim was to assess breastfeeding and infant feeding practices in Nairobi slums with reference to WHO recommendations. Methods: Data from a longitudinal study conducted in two Nairobi slums are used. The study used information on the first year of life of 4299 children born between September 2006 and January 2010. All women who gave birth during this period were interviewed on breastfeeding and complementary feeding practices at recruitment and this information was updated twice, at four-monthly intervals. Cox proportional hazard analysis was used to determine factors associated with cessation of breastfeeding in infancy and early introduction of complementary foods. Results: There was universal breastfeeding with almost all children (99%) having ever been breastfed. However, more than a third (37%) were not breastfed in the first hour following delivery, and 40% were given something to drink other than the mothers’ breast milk within 3 days after delivery. About 85% of infants were still breastfeeding th by the end of the 11 month. Exclusive breastfeeding for the first six months was rare as only about 2% of infants were exclusively breastfed for six months. Factors associated with sub-optimal infant breastfeeding and feeding practices in these settings include child’s sex; perceived size at birth; mother’s marital status, ethnicity; education level; family planning (pregnancy desirability); health seeking behaviour (place of delivery) and; neighbourhood (slum of residence). Conclusions: The study indicates poor adherence to WHO recommendations for breastfeeding and infant feeding practices. Interventions and further research should pay attention to factors such as cultural practices, access to and utilization of health care facilities, child feeding education, and family planning. Background together with high rates of morbidity from infectious dis- The first two years of life are critical stages for a child’s eases are the prime proximate causes of malnutrition in growth and development. Any damage caused by nutri- the first two years of life. Breastfeeding confers both tional deficiencies during this period could lead to short-term and long-term benefits to the child. It reduces impaired cognitive development, compromised educa- infections and mortality among infants, improves mental tional achievement and low economic productivity [1-3]. and motor development, and protects against obesity and Poor breastfeeding and complementary feeding practices, metabolic diseases later in the life course [3-7]. The WHO recommends exclusive breastfeeding in the first six months, beginning from the first hour of life, to * Correspondence: [email protected] 1 meet the infant’s nutritional requirements and achieve African Population and Health Research Center (APHRC), Nairobi, Kenya Full list of author information is available at the end of the article © 2011 Kimani-Murage et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Kimani-Murage et al. BMC Public Health 2011, 11:396 Page 2 of 11 http://www.biomedcentral.com/1471-2458/11/396 optimal growth, development and health. The mother is health education and media exposure; socio-economic advised to continue breastfeeding up to two years of age status and area of residence; and the child’s characteris- or more and begin nutritionally adequate, safe, and tics including birth weight, method of delivery, birth appropriately-fed complementary foods at the age of six order, and the use of pacifiers [19-21]. However, there months in order to meet the evolving needs of the are conflicting findings with regards to the consistency growing infant [6]. The WHO/UNICEF global strategy of the associations and the magnitude of the effects [20,22-25], suggesting that the context may be impor- on infant and young child feeding practices aims to pro- tant when trying to isolate characteristics and practices mote optimal breastfeeding and complementary feeding that may be amenable to interventions. There is limited practices, through various initiatives for example the Baby Friendly Hospital Initiative (BFHI) and the Interna- evidence on breastfeeding and infant feeding practices tional Breastfeeding Code [8]. Interventions promoting in urban slums in sub-Saharan Africa since few studies optimal breastfeeding could prevent 13%, while those have focused on urban slums. Although there is national promoting optimal complementary feeding could pre- level evidence on breastfeeding and infant feeding prac- vent another 6% of deaths in countries with high mor- tices, the data for urban areas is not disaggregated, and tality rates [5]. hence, the dearth of evidence on practices in urban Poor breastfeeding and complementary feeding prac- slums. In this study, we have collected longitudinal data tices have been widely documented in the developing and assessed infant feeding practices with reference to countries. Only about 39% of infants in the developing WHO recommendations, in two slums in Nairobi, countries, 25% in Africa are exclusively breastfed for the Kenya, and their determinants. first six months. Additionally, 6% of infants in develop- ing countries are never breastfed [9]. In Kenya, accord- Methodology ing to Kenya Demographic and Health Survey 2008- Study setting and data source 2009 [10], 32% of children under the age of six months The study was carried out in two urban slums of Nair- are exclusively breastfed, improving from only 13% in obi Kenya (Korogocho and Viwandani) where the Afri- 2003 [11]. As a result, substantial levels of child malnu- can Population and Health Research Center (APHRC) trition and poor child health and survival have been runs a health and demographic surveillance system; the documented in Kenya [11]. Deriving from the broad Nairobi Urban Health and Demographic Surveillance principles of the joint WHO and UNICEF’s Global System (NUHDSS). The two slum areas are densely Strategy for infant and young child feeding developed in populated (63,318 and 52,583 inhabitants per square 2002 [8], the government of Kenya is implementing a km, respectively), and are characterized by poor housing, strategy aimed at improving infant and young child lack of basic infrastructure, violence, insecurity, high feeding practices in Kenya. The strategy is actualized unemployment rates, and poor health indicators through revitalization of the BFHI [12]. [14,15,17]. The socio-economic status of the two slums Urban poor settlements or slums present unique chal- differs slightly: Viwandani has relatively higher levels of lenges with regards to child health and survival. Slums education and employment as being located in the in sub-Saharan Africa are expanding at a fast rate, and industrial area, it attracts migrant workers. On the other the majority of urban residents now live in slum settle- hand, the population of Korogocho is more stable since ments, [13]. These slums are characterized by poor on average, residents in the area have lived the area for environmental sanitation and livelihood conditions a longer period than Viwandani residents. Approxi- [14-16]. Contrary to the long-held belief that urban resi- mately two thirds of married men live with their spouses dents are advantaged with regards to health outcomes, in Korogocho, compared with half in Viwandani. urban slum dwellers tend to have very poor health indi- The NUHDSS involves a systematic recording (every cators [14,17,18]. For example, in Kenya, slum children four months) of vital demographic events including are reported to be sicker and to have higher mortality births, deaths and migrations occurring among residents rates than any other sub-group in Kenya including the of all households in the NUHDSS area, since 2003. rural areas [14]. In line with this, infants born to Other data that are collected regularly include house- mothers that reside in the urban slums may be exposed hold assets, morbidity, and highest educational attain- to sub-optimal breastfeeding and complementary feed- ment. This paper is based on data from a maternal and ing practices. child health component of a broader longitudinal study Various factors associated with sub-optimal breast- entitled “Urbanization, Poverty and Health Dynamics in feeding and complementary feeding practices have been sub-Saharan Africa” that was nested within the identified in various settings. These include maternal NUHDSS. The study started in February 2007 and characteristics such as age, marital status, occupation, ended in December 2010. All women who gave birth and education level; antenatal and maternity health care; since September 2006 and their children were enrolled Kimani-Murage et al. BMC Public Health 2011, 11:396 Page 3 of 11 http://www.biomedcentral.com/1471-2458/11/396 in the study and were followed up every four months to ethnicity of the mother (Kikuyu, Luhya, Luo, Kamba, obtain data including self-reported health status, breast- and other tribes); the highest level of education (none, feeding, complementary feeding practices, vaccination primary, secondary or higher); and parity (1, 2, 3+); and health care. Data on socio-economic status was pregnancy desirability of the index child (wanted at the extracted from the NUHDSS database and linked to the time of conception, wanted later and never wanted,); the study participants through their household identifier. place of delivery (health facility, home or traditional Data collection & sample birth attendant [TBA]); the mother’s perception of the The data presented in this paper were collected at base- child’s size at birth (normal, smaller than normal, larger than normal); the socio-economic status of the house- line and during the first two updates, four months apart, for each child recruited between February 2007 and May hold; and the slum of residence (Viwandani or Korogo- 2009. Therefore, the follow-up period for each child was cho). The household socioeconomic status was defined on average nine months and the average age of the chil- using the household monthly expenditure per capita, dren at the second update was 15 months. However, we taking a child to be the equivalent of half an adult. The restrict our analyses to the first year of life for all 4,299 expenditure data used was obtained from the poverty children who were enrolled in the study. Table 1 pre- component of the Urbanization, Poverty and Health sents the sample size for the children involved in the Dynamics study, and was collected in the same year as studyand thedatacollection dates. Six cohorts of chil- the data for the dependent variables above. This variable dren enrolled during the study period are included. was recoded as tertiles of “poorest”, “middle” and “least Variables poor”. a. Dependent variables The two dependent variables Data Analysis are cessation of breastfeeding and introduction of com- The survival analysis of the duration of breastfeeding plementary foods (liquids and solids). Cessation of and the time to introduction of complementary foods is breastfeeding is a time-dependent variable indicating the presented using Kaplan-Meier survival curves. Cox age when breastfeeding was stopped. Introduction of regression analysis was performed to determine factors complementary foods is also a time-dependent variable associated with breastfeeding cessation during infancy indicating the age at which complementary foods (either and early introduction of complementary foods. Some liquids or solids other than breastmilk) were introduced. independent variables had missing values, mainly mater- Children who entered the study after the events (breast- nal level variables such as the mother’s age, ethnicity, feeding cessation or initiation of complementary foods) the highest level of education; and the household’s had occurred had their information updated retrospec- socio-economic status. A missing category was created tively. About 1% of children were never breastfed and in the multivariate analysis to keep all cases in the ana- were excluded from survival analysis. Children who did lysis (though results for missing category are not not have their information updated due to loss to fol- shown). In all cases, except the household expenditure low-up were excluded from the study. variable, the number of cases with missing information b. Independent variables The independent variables was less than 10%. About one-third of the participants were: the child’s sex; the mother’s age (< 25 years, 25-34 were missing data on household expenditure, therefore years, 35+ years); the marital status of the mother (in imputation using a linear interpolation computation union i.e. currently married or living with someone; procedure was used. A p-value of less than 0.05 was previously in union; and never married/in union); the used as the cut-off for statistical significance. Table 1 Sample Size, Nairobi informal settlements, Kenya Survey 1 Survey 2 Survey 3 Survey 4 Survey 5 Survey 6 Survey 7 Survey 8 Number of observation Survey Feb-Apr Jul-Aug Oct-Dec 2007&Mar- May-Aug Sep 2008-Jan Feb-May Jun-Sep Oct-Jan Feb 2007-Sept period ==> 2007 2007 Apr 2008 2008 2009 2009 2009 2010 2009 Panel 1 615 507 378 * * * * * 1,500 Panel 2 458 359 323 * * * * 1,140 Panel 3 948 727 645 * * * 2,320 Panel 4 968 814 696 * * 2,478 Panel 5 479 398 333 * 1,210 Panel 6 831 689 498 2,018 Total 615 965 1,685 2,018 1,938 1,925 1,022 498 10,666 * Censored. Note: The total number of children enrolled across all six panels is 4299. Kimani-Murage et al. BMC Public Health 2011, 11:396 Page 4 of 11 http://www.biomedcentral.com/1471-2458/11/396 Ethical Considerations The Urbanization, Poverty and Health Dynamics study was approved by the Ethical Review Board of the Kenya Medical Research Institute (KEMRI). The field workers were trained in research ethics and obtained informed consent from all respondents. The NUHDSS has also been approved by KEMRI’s Ethical Review Board. Verbal consent is routinely obtained from all the NUHDSS respondents. Results Sample Characteristics Almost all the children (99%) were ever breastfed; how- ever, more than a third (37%) were not breastfed in the 0 1 2 3 4 5 6 7 8 9 10 11 12 Months first hour following delivery. The main reasons given for Figure 1 Probability of continuing breastfeeding for specific not initiating breastfeeding immediately were: little or ages, Nairobi informal settlements, Kenya. no breastmilk (35%); baby being asleep/tired (23%); baby being sick (13%); and mother being sick (9%). Two in five of the children were given something to drink other than the mothers’ breast milk within 3 days following introduced to complementary foods (either liquids or delivery. The main reasons given were that the mother solids) by the age of 6 months. Liquids were introduced had little or no breast milk (42%) or that the child had much earlier than solids; the mean age of introduction an upset stomach (32%). During each data collection of liquids was one month while that for solids was three round, mothers and other caregivers were asked if the and a half months. child was being given any liquid or solid food to com- Proportional Hazards Regression plement breastfeeding, with the recall period being the In the multivariate analysis, the factors significantly last three days. The most common complementary associated with cessation of breastfeeding during infancy foods being given to children before the age of six were the mother’s marital status, her ethnicity, and her months were: plain water (56%), with most children on highest level of education and the perceived size of the it having been given within the first month (69%); por- child at birth (p < 0.05, respectively). The mother’sage ridge (54%), with most children on it having been intro- was marginally associated (p > 0.05 < 0.1) with the dura- duced between the second and third months (64.7%); tion of breastfeeding. When other factors were con- fresh or powdered milk (45%) with most children on it trolled for, mothers who were previously in union and also having been introduced between second and third those never in union had close to 3 and 2 fold higher months of life (57%); and sweetened/flavoured water hazards of stopping breastfeeding before the age of 12 (41%), with most of children on it having been intro- months respectively compared to mothers in union. duced within the first month of life (78%). The main Luhya, Luo and mothers of other ethnic groups were reason given for introducing complementary foods to more likely to stop breastfeeding early (Hazard Ratios: children below six months was that the mother had no 1.6, 1.8. and 2.1, respectively), compared to Kikuyu or little breast milk (approx 40%). About two-thirds mothers; mothers with secondary or tertiary education knew that complementary feeding should be started at level had 40% lower hazards of stopping breastfeeding 6monthswhile about30% indicatedtheyshouldbe compared to those with less than secondary level educa- started before six months. tion; and children who were perceived as larger than normal were 40% less likely to stop breastfeeding before Survival Analysis the age of 12 months (Table 2). Cessation of breastfeeding and introduction of Factors associated with early introduction of comple- complementary foods mentary foods (before the age of six months) at multi- Figure 1 shows Kaplan-Meier survival curves for prob- variate level include child’ssex;mother’s marital status, ability of continuing breastfeeding at specific ages. ethnicity, and education level; pregnancy desirability; Nearly all of the infants were started on breastfeeding, place of delivery; and slum of residence (p < 0.05, and about 85% of the infants were still breastfeeding by respectively). Boys were more likely to be introduced to the end of the 11th month. Figure 2 illustrates Kaplan- foods early; mothers never in union had 23% higher Meier survival curves for time to introduction of com- hazards of introducing complementary foods before 6 plementary foods. Nearly all (98%) of children had been months of age; Luos, Luhyas and other ethnic groups 0.80 0.90 0.75 0.85 0.95 1.00 Kimani-Murage et al. BMC Public Health 2011, 11:396 Page 5 of 11 http://www.biomedcentral.com/1471-2458/11/396 Liquids Solids Liquids & Solids 0 2 4 6 8 10 12 0 2 4 6 8 10 12 0 2 4 6 8 10 12 Months Months Months Figure 2 Probability of initiating complementary foods for specific ages, Nairobi informal settlements, Kenya. were more likely to introduce foods early; mothers with picture masks the unwelcome finding that the WHO at least secondary level education had 10% lower recommendations with regards to breastfeeding and hazards of introducing foods early; children who were introduction of complementary food were largely not not wanted at conception but wanted later had 7% adhered to. Early initiation of breastfeeding following lower hazards of being introduced early; and mothers in delivery, as recommended by the WHO is not univer- Viwandani had 10% lower hazards of introducing com- sally being practiced in developing countries, despite the plementary foods early compared to mothers in Korogo- importance of colostrum in providing the baby with rich cho (Table 3). nutrients. The findings that close to 40% of the infants were not breastfed within one hour following delivery Discussion are in agreement with findings from studies in other This study has documented breastfeeding and infant developing countries including Uganda, India and Ban- feeding practices in two slum settings in sub-Saharan gladesh [20,26,27]. In our setting, the main reasons sta- Africa. It has also identified the factors associated with ted for failure to introduce babies to breast milk sub-optimal breastfeeding and infant feeding practices in immediately after birth were health-related including the these two slum settings. The study finds that though mother having insufficient milk. This has also been there is almost universal breastfeeding, exclusive breast- documented in other studies [22]. Other cultural factors feeding is rare. Complementary foods are initiated too have been noted in other settings such as Nigeria, for early; only two percent of children were exclusively example the belief that colostrum is dirty milk, hence breastfed before the age of six months and the mean age harmful to the baby, a belief that the mother should rest of introduction of complementary foods was one month. and clean up first, and performance of rituals and In our study, we see an overall picture of universal prayers before the baby starts breastfeeding [28]. In our breastfeeding with the majority of infants breastfed for study though, cultural factors did not feature in the at least 12 months. These findings are similar to find- responses from the women, supposedly because our ings in other developing countries [9,26]. However, this study was a quantitative, rather than qualitative study. 0.00 0.20 0.40 0.60 0.80 1.00 Probability of initiating foods 0.00 0.20 0.40 0.60 0.80 1.00 0.00 0.20 0.40 0.60 0.80 1.00 Kimani-Murage et al. BMC Public Health 2011, 11:396 Page 6 of 11 http://www.biomedcentral.com/1471-2458/11/396 Table 2 Characteristics of study participants, Nairobi In this study complementary foods were initiated too informal settlements, Kenya early, despite two thirds of the women in our study Category (%) being aware of the WHO recommended time to initiate complementary feeding. This is in line with previous Sex studies conducted in rural Kenya, Malawi and Uganda Girls 50.5 [26,29,30], and in some other slum settings in the devel- Boys 49.6 oping world [31,32]. In a study conducted in the late Mother’s age 1990s on the determinants of child nutritional status in < 25 years 53.6 six African countries, Madise et al. reported very low 25-34 years 32.5 levels of exclusive breastfeeding among infants under 35+ years 6.4 the age of 4 months with percentages ranging from two Missing 7.5 percent in Nigeria to about 34% in Tanzania [33]. The Mother’s Marital Status few studies that have looked at slum settings particularly In union currently 83.3 in Asia paint a similar picture [31,32]. The finding Ever in union 7.2 showing the persistence of early introduction of comple- Never in union 9.2 mentary feeding in the region is critical given the Missing 0.3 importance of exclusive breastfeeding to child health. Mother’s ethnicity Exclusive breastfeeding protects against infections such Kikuyu 24.1 as gastrointestinal and respiratory infections, and Luhya 16.0 enhances motor development in the child [4,34,35]. In a Luo 18.0 study using data from Botswana which examined the Kamba 18.8 association between breastfeeding, morbidity, and mal- Other 15.7 nourishment, Chikusa (1991) found that children aged 4 Missing 7.5 months or younger who had been weaned had more Mother’s education level than 11 times the odds of having diarrhea compared < Secondary 70.7 with those who were still being breastfed [36]. The main Secondary+ 21.9 reason cited for introducing complementary food early Missing 7.5 was the mother’s perception of insufficient breast milk. Mother’s Parity This finding is in line with other studies from other set- One (ref) 33.0 tings which have shown that the perceived lack of suffi- Two 27.8 cient breast milk is a main reason for early Three+ 39.0 breastfeeding cessation or early introduction of comple- Missing 0.3 mentary foods [31,37,38]. Pregnancy desirability* The variables associated with the cessation of breast- Wanted at conception 49.8 feeding during the first year of the child’slifeinclude Wanted later 37.2 the mother’s marital status, her ethnicity, and her level Never wanted 12.4 of education, and perceived size at birth. The association Missing 0.5 between marital status and early cessation of breastfeed- Delivery place* ing has been reported in many studies with conflicting Health Facility 71.4 results [22,23]. In this study, women who were not in Home 28.3 union, particularly those who were formerly married Missing 0.3 were more likely to stop breastfeeding their infants than Perceived size at birth* women who were in union. It has been suggested that Normal 69.5 the association between marital status and breastfeeding Smaller 14.2 cessation may be due to the presence or absence of Larger 15.6 social, emotional and economic support of a partner Missing 0.7 [39]; however, these factors were not assessed in our SES (Expenditure) Category study. A more plausible reason in Kenya, where HIV is Poorest 55.0 high, is that a disproportionately large number of for- Middle 29.0 merly married women are HIV positive and many Least Poor 7.3 women in this situation were until recently advised to Missing 8.6 exclusively breastfeed their infant for 6 months and then Slum of residence to rapidly wean [40]. Korogocho 52 The evidence of the association between a mother’s Viwandani 48 level of education and the duration of breastfeeding also *Refers to the index child. Kimani-Murage et al. BMC Public Health 2011, 11:396 Page 7 of 11 http://www.biomedcentral.com/1471-2458/11/396 Table 3 Cox regression for cessation of breastfeeding and introduction of complementary foods, Nairobi informal settlements, Kenya Variable Cessation of Breastfeeding Initiation of Complementary Foods Univariate Multivariate Univariate Multivariate HR 95%CI HR 95%CI HR 95%CI HR 95%CI Sex Girls Ref Ref Ref Ref Boys 0.98 [0.80, 1.21] 0.88 [0.71, 1.10] 1.03 [0.99, 1.08] 1.05* [1.00, 1.09] Mother’s age < 25 years Ref Ref Ref Ref 25-34 years 1.18 [0.94, 1.48] 1.22 [0.92, 1.62] 0.99 [0.95, 1.04] 1.01 [0.95, 1.06] 35+ years 1.40# [0.95, 2.05] 1.52# [0.96, 2.40] 1.02 [0.94, 1.11] 1.01 [0.92, 1.12] Mother’s Marital Status In union Ref Ref Ref Ref Ever in union 2.52*** [1.87, 3.40] 2.76*** [1.97, 3.88] 1.10* [1.02, 1.19] 1.07 [0.98, 1.16] Never in union 1.31 [0.93, 1.84] 1.73** [1.17, 2.55] 1.16*** [1.08, 1.24] 1.23*** [1.13, 1.34] Mothers ethnicity Kikuyu Ref Ref Ref Ref Luhya 1.20 [0.86, 1.69] 1.54* [1.06, 2.23] 1.21*** [1.13, 1.29] 1.19*** [1.12, 1.28] Luo 1.28 [0.93, 1.77] 1.83*** [1.28, 2.62] 1.16*** [1.09, 1.23] 1.12** [1.04, 1.19] Kamba 0.91 [0.64, 1.28] 1.16 [0.79, 1.71] 0.98 [0.92, 1.04] 1.02 [0.95, 1.09] Other 1.49* [1.09, 2.03] 2.08*** [1.48, 2.92] 1.07* [1.00, 1.14] 1.09* [1.02, 1.17] Mother’s education level < Secondary Ref Ref Ref Ref Secondary+ 0.61*** [0.45, 0.81] 0.58*** [0.43, 0.80] 0.88*** [0.84, 0.92] 0.92** [0.87, 0.97] Mother’s Parity One Ref Ref Ref Ref Two 1.41* [1.08, 1.83] 1.23 [0.91, 1.66] 1.04 [0.99, 1.10] 1.04 [0.98, 1.10] Three+ 1.20 [0.93, 1.55] 0.91 [0.64, 1.30] 1.03 [0.99, 1.08] 1.01 [0.94, 1.07] Pregnancy desirability Wanted at Ref Ref Ref Ref conception Wanted later 0.95 [0.76, 1.20] 0.90 [0.69, 1.17] 1.01 [0.96, 1.05] 0.93** [0.89, 0.98] Never wanted 1.45* [1.09, 1.94] 1.08 [0.76, 1.54] 1.15*** [1.08, 1.22] 1.05 [0.98, 1.13] Delivery place Health Facility Ref Ref Ref Ref Home 0.93 [0.73, 1.17] 0.89 [0.69, 1.15] 1.19*** [1.14, 1.25] 1.19*** [1.14, 1.25] Perceived size at birth Normal Ref Ref Ref Ref Smaller 1.20 [0.91, 1.59] 0.95 [0.70, 1.30] 1.03 [0.97, 1.09] 1.03 [0.97, 1.10] Larger 0.61** [0.43, 0.87] 0.55** [0.38, 0.81] 0.96 [0.91, 1.01] 0.97 [0.92, 1.04] SES Category Poorest Ref Ref Ref Ref Middle 0.89 [0.70, 1.13] 0.97 [0.75, 1.25] 0.95* [0.91, 0.99] 1.01 [0.97, 1.06] Least Poor 1.03 [0.69, 1.54] 1.10 [0.71, 1.68] 0.90* [0.84, 0.98] 0.96 [0.89, 1.05] Slum Korogocho Ref Ref Ref Ref Viwandani 0.86 [0.70, 1.06] 1.20 [0.92, 1.55] 0.85*** [0.82, 0.89] 0.89*** [0.85, 0.94] HR = Hazard Ratio; # = p < 0.1; * p < 0.05; ** = p < 0.01; *** = p < 0.001. varies [20,24,25]. In this study, lower than secondary Higher HIV prevalence among those with less than sec- level education was associated with earlier cessation of ondary level education, especially those with no educa- breastfeeding. While it is not very clear why this is the tion at all in our setting [41] may be associated with early case, higher education may be associated with higher cessation of breastfeeding. We also observed an asso- knowledge and practice of positive health behaviour. ciation between ethnicity and breastfeeding cessation. Kimani-Murage et al. BMC Public Health 2011, 11:396 Page 8 of 11 http://www.biomedcentral.com/1471-2458/11/396 All other ethnic groups apart from the Kamba were more of a mother’s low education on early introduction of likely to stop breastfeeding their infants compared to complementary foods has been observed in many stu- Kikuyu women. There is no established reason for this dies in other settings, suggesting a need for education but it could be multi-factorial, including cultural prac- and health promotion to change these harmful feeding tices related to breastfeeding and child rearing. Further, practices [21,45,46]. HIV prevalence, which may affect breastfeeding practices, Slum of residence, was associated with the timing of introduction of complementary foods. Mothers from has also been documented as higher amongst the Luo Viwandani, were at lower risk of introducing comple- and Luhya ethnic groups in this slum setting compared mentary foods before six months. This may be because to the Kikuyu ethnic group [41]. Additionally, evidence from the study areas indicates that Kikuyus have lower Viwandani, being in the industrial area and attracting fertility compared to other ethnic groups. Prolonged labourers to the industries is likely to have more edu- breastfeeding may explain or be explained by lower ferti- cated people (other than the mother) for example the lity. Mothers who get pregnant while breastfeeding are father and other household members, who may affect more likely to stop but, also mothers who breastfeed for infant feeding practices. Mothers who delivered at home longer period have lower chances of getting pregnant were more likely to introduce complementary foods ear- [42]. Additionally, better child health outcomes have also lier than those who delivered in a health facility. been documented among the Kikuyu’scomparedto Mothers who deliver in a health facility in most cases other ethnic groups in this study setting [14] and our receive breastfeeding counselling, especially with the findings may indicate that the Kikuyus have better revitalisation of the Baby Friendly Hospital Initiative health-related behaviours and practices than most of the (BFHI) from 2007 aimed at promoting optimal breast- other ethnic groups in the study area. The association feeding practices. The BFHI has been found to be effec- between birth size and the duration of breastfeeding has tive in several settings in the developing world [47]. not been studied in depth. Our study found that children BFHI, is being revitalized in Kenya in the National Strat- who were perceived to be larger at birth were less likely egy on Infant and Young Child feeding [12], and it may to be stopped from breastfeeding earlier. This is similar be playing a role in encouraging mothers to exclusive to a US study, infants who were breast-fed for less than 4 breastfeeding their infants in the first 6 months of life. months were smaller at birth than those who were Since the BFHI initiative was introduced, there has been breast-fed for 4 months or more [43]. The factors behind potential improvement in the proportion of children exclusively breastfed from 13% in 2003 to 32% in 2008 this association in our study setting need further [10]. The positive association between pregnancy desir- investigation. Predictors of early introduction of complementary ability and complementary feeding has barely been pre- foods include the child’s sex; the mother’s marital status, viously studied. In our study, infants who were her ethnicity, and her level of education; the desirability unwanted at conception but were wanted later were less of the pregnancy of the index child, the place of delivery likely to be introduced to complementary foods early. and the slum setting. Boys were more likely to be intro- The association between pregnancy desirability and duced to complementary feeding early compared with breastfeeding and complementary feeding practices girls. Anecdotal evidence indicates that boys are intro- needs further investigation. duced to complementary foods early because breast Urban slum settings present unique challenges with milk alone does not meet their feeding demands. Having regards to breastfeeding and infant and young child never been in union/married was associated with higher feeding practices due to their physical and socio-eco- risk of early introduction of complementary foods. A nomic characteristics. In these informal settings, basic positive association between being married and exclusive government services including health care services are breastfeeding has been documented in other studies limited and this, coupled with financial constraints, [44]. As in the case of the duration of breastfeeding, this leads to a substantial proportion of women in these may be associated with social, emotional and economic slums giving birth at home or at informal private health support of a partner [39]. Similar to the finding related facilities [48,49]. This means that most of these slum to the duration of breastfeeding, all other ethnic groups women are systematically excluded from government apart from the Kamba group, were more likely to initi- initiatives such as those aimed at promoting optimal ate complementary foods earlier than the Kikuyus. This breastfeeding and infant feeding practices, based at health facilities such as the BFHI mentioned above, may be related to cultural practices and other factors which involves counselling of mothers on infant and such as HIV status as described for duration of breast- young child feeding around the time of delivery. feeding. Whileafew studieshavelinkedthemother’s education with early introduction of complementary Another unique characteristic of slum settings is limited foods [27], similar to our study, the negative influence livelihood opportunities [15] hence food insecurity. Kimani-Murage et al. BMC Public Health 2011, 11:396 Page 9 of 11 http://www.biomedcentral.com/1471-2458/11/396 As indicated in this study and in other slums such as in follow-up period, reducing bias due to loss to follow-up. India [31], one key reason for initiating complementary The study involved a census of all children born to foods too early is due to the mother having inadequate mothers in two defined geographical areas; hence there breast milk. While the important role of hormones and was minimal bias due to sampling error. the psychosocial status of the mother in lactation is well established, though limited evidence exists, volume of Conclusion milk produced may also be related to maternal nourish- This study presents important findings on breastfeeding ment. A review of breastmilk volumes and composition and infant feeding practices and determinants of sub- among poorly nourished communities indicated that optimal practices in informal settings in sub-Saharan milk volumes were lowest in communities with poor Africa. This is timely and critical as such evidence is levels of nutrition and poor living conditions [50]. currently rare. The study finds that despite universal Potential interventions to address the unique chal- breastfeeding in this population, WHO breastfeeding lenges in the slum settings should address both access and infant feeding recommendations are rarely adhered issues and the socio-economic limitations. A potential to. It is important therefore to develop interventions tar- intervention to counteract the systematic exclusion from geting women, health care workers and policy makers basic government services may include, home-based aimed at bridging the gap between current breastfeeding counselling of mothers on infant and young child feed- and infant feeding practices in the informal settings and ing by community based health workers and/or support- WHO recommendations. It is evident from this study ing the (informal) private service providers for instance that breastfeeding and infant feeding patterns are asso- through training programs to offer services according to ciated with child, maternal and household level factors established government guidelines such as those on and it is crucial to understand and reduce the inequal- breastfeeding. The effectiveness of such interventions in ities. Interventions and further research should address health care delivery, including promotion of optimal inequalities including gender, ethnicity, access to and infant feeding practices in resource-constrained settings utilization of health care facilities, socio-economic status has been indicated [51]. To enhance adequacy of milk and family planning. This study only looked at early produced by the mothers, potential interventions may introduction of complementary food; further investiga- be to enhance maternal nourishment through ensuring tion on late introduction of the same is needed. food security. This may be through appropriate income generating activities to enhance livelihoods. Food sup- List of abbreviations plementation has also been found to enhance breastmilk APHRC: African Population and Health Research Center; BFHI: Baby Friendly volume [50]. Additionally, interventions that empower Hospital Initiative; HIV: Human Immuno-deficiency Virus; NUHDSS: Nairobi the new mother by demonstrating correct breastfeeding Urban Health and Demographic Surveillance System; HR: Hazard Ratio; TBA: techniques, ways of stimulating breast milk production, Traditional Birth Attendant; UNICEF: United Nations Children’s Education Fund; US: United States; WHO: World Health Organization. and counselling on proper nutrition may improve breastfeeding practices [52]. Acknowledgements Limitations in this study relate to missing values in This study was funded by the Wellcome Trust (Grant No. 078530/Z/05/Z). We also acknowledge funding for the NUHDSS from the Rockefeller some of the variables particularly the socio-economic Foundation and core support for APHRC from the Rockefeller Foundation, status variables. Appropriate measures were taken in the the William and the Flora Hewlett Foundation. We would like to thank Dr. analysis to minimize bias as indicated above. It would Alex Ezeh, Dr. Eliya Zulu, Prof. John Cleland, Prof Jane Falkingham and Prof Philippe Bocquier for their contribution in the design of the study from have been important to follow-up the children for a which data for this article was derived. We thank Dr. George Mgomella, Ms longer period to establish complete duration of breast- Hilda Essendi, Ms Teresa Saliku and Mr. Peter Muriuki for project feeding in line with the WHO recommendation that coordination. We are also grateful to the data collection team and the data processing and management team at APHRC. We are highly indebted to the breastfeeding should continue for two years or beyond. study participants. This was however not done and children were only fol- lowed up till they were slightly more than one year old. Author details African Population and Health Research Center (APHRC), Nairobi, Kenya. Despite these limitations, this studyhas keystrengths University of Southampton, Centre for Global Health, Population, Poverty, that are worth mentioning. The study provides impor- and Policy, Faculty of Social and Human Science, Southampton, UK. University of the Witwatersrand, MRC Mineral Metabolism Research Unit, tant information on infant breastfeeding and feeding Department of Paediatrics, Faculty of Health Sciences, Johannesburg, South practices in informal settings in sub-Saharan Africa, for Africa. which there is a dearth. A key strength of this study lies Authors’ contributions in its longitudinal nature, minimising recall bias that EWK-M:Design of the study, project management, data analysis, writing of maybeassociatedwithcross-sectional studies. The the manuscript and approval for submission; NJM: Principal Investigator of study involved rigorous follow-up hence information for the project, design of the study, analytic guidance, reviewing of the most of the children was updated by the end of the manuscript and approval for submission; J-CF: Design of the study, overall Kimani-Murage et al. BMC Public Health 2011, 11:396 Page 10 of 11 http://www.biomedcentral.com/1471-2458/11/396 project co-ordination, reviewing of the manuscript and approval for 18. Fotso JC: Urban-rural differentials in child malnutrition: trends and submission; CK: Design of the study, project management, review of the socioeconomic correlates in sub-Saharan Africa. Health Place 2007, manuscript and approval for submission; MK: Data management and 13(1):205-223. analysis, review of the manuscript and approval for submission; TG: Writing 19. Patel A, Badhoniya N, Khadse S, Senarath U, Agho KE, Dibley MJ: Infant and of the manuscript and approval for submission; NY: Writing of the young child feeding indicators and determinants of poor feeding manuscript and approval for submission. All authors read and approved the practices in India: secondary data analysis of National Family Health final manuscript. Survey 2005-06. Food Nutr Bull 31(2):314-333. 20. Roig AO, Martinez MR, Garcia JC, Hoyos SP, Navidad GL, Alvarez JC, Pujalte Competing interests Mdel M, De Leon Gonzalez RG: Factors associated to breastfeeding The authors declare that they have no competing interests. cessation before 6 months. Rev Lat Am Enfermagem 18(3):373-380. 21. Kristiansen AL, Lande B, Overby NC, Andersen LF: Factors associated with Received: 25 January 2011 Accepted: 26 May 2011 exclusive breast-feeding and breast-feeding in Norway. Public Health Nutr Published: 26 May 2011 1-10. 22. Thulier D, Mercer J: Variables associated with breastfeeding duration. J Obstet Gynecol Neonatal Nurs 2009, 38(3):259-268. References 23. Scott JA, Binns CW: Factors associated with the initiation and duration 1. Victora CG, Adair L, Fall C, Hallal PC, Martorell R, Richter L, Sachdev HS, of breastfeeding: a review of the literature. Breastfeed Rev 1999, Maternal and Child Undernutrition Study G: Maternal and child 7(1):5-16. undernutrition: consequences for adult health and human capital. Lancet 24. Pascale KNA, Laure NJ, Enyong OJ: Factors Associated with Breast feeding 2008, 371:340-357. as Well as the Nutritional Status of Infants (0-12) Months: An 2. Grantham-McGregor S, Cheung YB, Cueto S, Glewwe P, Richter L, Strupp B: Epidemiological Study in Yaounde, Cameroon. Pakistan J Nutr 2007, Developmental potential in the first 5 years for children in developing 6(3):259-263. countries. Lancet 2007, 369(9555):60-70. 25. Akter S, Rahman MM: The determinants of early cessation of 3. 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Madise NJ, Matthews Z, Margetts B: Heterogeneity of child nutritional 2009 [http://www.measuredhs.com/pubs/pdf/FR229/FR229.pdf], Accessed status between households: A comparison of six sub-Saharan African January 2011. countries. Population Stud 1999, 53(3):331-343. 11. Central Bureau of Statistics (CBS) Kenya, Ministry of Health (MoH), Kenya, 34. Dewey KG: Nutrition, growth, and complementary feeding of the ORC Macro: Kenya Demographic and Health Survey 2003: Key Findings. breastfed infant. Pediatr Clin North Am 2001, 48(1):87-104. Calverton, Maryland, USA: CBS, MOH and ORC Macro; 2004 [http://www. 35. Arifeen S, Black R, Antelman G, Baqui A, Caulfield L, Becker S: Exclusive measuredhs.com/pubs/pdf/SR104/SR104KE03.pdf], Accessed January 2011. breastfeeding reduces acute respiratory infection and diarrhea deaths 12. Ministry of Public Health and Sanitation: National Strategy on Infant and among infants in Dhaka slums. Pediatrics 2001, 108:E67. Young Child Feeding Strategy 2007-2010. Nairobi: Ministry of Public 36. Chikusa Madise NJ: Effects of breastfeeding on infant and child morbidity Health and Sanitation, Kenya; 2007 [http://www.hennet.or.ke], Accessed and malnourishment [in Botswana] using the multinomial logistic January 2011. model. In Biometry for Development, Proceedings of the First Scientific 13. UNHABITAT: Slums of the World. The Face of Urban Poverty in the New Meeting of the Biometric Society, Nairobi, Kenya 2-6 April 1990. Edited by: Millennium? Global Urban Observatory. Nairobi: UNHABITAT; 2003 [http:// Patel MS, Nokoe S. Nairobi: ICIPE Science Press; 1991:187-193. www.unhabitat.org/pmss/listItemDetails.aspx?publicationID=1124], Accessed 37. Haider R, Rasheed S, Sanghvi TG, Hassan N, Pachon H, Islam S, Jalal CS: January 2011. Breastfeeding in infancy: identifying the program-relevant issues in 14. African Population and Health Research Center: Population and Health Bangladesh. Int Breastfeed J 5:21. Dynamics in Nairobi Informal Settlements. 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Am J Clin Nutr 2000, 72(1):159-167. 44. Lande B, Andersen LF, Baerug A, Trygg KU, Lund-Larsen K, Veierod MB, Bjorneboe GE: Infant feeding practices and associated factors in the first six months of life: the Norwegian infant nutrition survey. Acta Paediatr 2003, 92(2):152-161. 45. Wijndaele K, Lakshman R, Landsbaugh JR, Ong KK, Ogilvie D: Determinants of early weaning and use of unmodified cow’s milk in infants: a systematic review. J Am Diet Assoc 2009, 109(12):2017-2028. 46. Ku CM, Chow SK: Factors influencing the practice of exclusive breastfeeding among Hong Kong Chinese women: a questionnaire survey. J Clin Nurs 19(17-18):2434-2445. 47. Braun ML, Giugliani ER, Soares ME, Giugliani C, de Oliveira AP, Danelon CM: Evaluation of the impact of the baby-friendly hospital initiative on rates of breastfeeding. Am J Public Health 2003, 93(8):1277-1279. 48. Fotso J-C, Ezeh A, Madise N, Ziraba A, Ogollah R: What does access to maternal care mean among the urban poor? 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Pre-publication history The pre-publication history for this paper can be accessed here: http://www.biomedcentral.com/1471-2458/11/396/prepub doi:10.1186/1471-2458-11-396 Cite this article as: Kimani-Murage et al.: Patterns and determinants of breastfeeding and complementary feeding practices in urban informal settlements, Nairobi Kenya. BMC Public Health 2011 11:396. Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Public Health Springer Journals

Patterns and determinants of breastfeeding and complementary feeding practices in urban informal settlements, Nairobi Kenya

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Springer Journals
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Copyright © 2011 by Kimani-Murage et al; licensee BioMed Central Ltd.
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Medicine & Public Health; Public Health; Medicine/Public Health, general; Epidemiology; Environmental Health; Biostatistics; Vaccine
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10.1186/1471-2458-11-396
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21615957
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Abstract

Background: The World Health Organisation (WHO) recommends exclusive breastfeeding during the first six months of life for optimal growth, development and health. Breastfeeding should continue up to two years or more and nutritionally adequate, safe, and appropriately-fed complementary foods should be introduced at the age of six months to meet the evolving needs of the growing infant. Little evidence exists on breastfeeding and infant feeding practices in urban slums in sub-Saharan Africa. Our aim was to assess breastfeeding and infant feeding practices in Nairobi slums with reference to WHO recommendations. Methods: Data from a longitudinal study conducted in two Nairobi slums are used. The study used information on the first year of life of 4299 children born between September 2006 and January 2010. All women who gave birth during this period were interviewed on breastfeeding and complementary feeding practices at recruitment and this information was updated twice, at four-monthly intervals. Cox proportional hazard analysis was used to determine factors associated with cessation of breastfeeding in infancy and early introduction of complementary foods. Results: There was universal breastfeeding with almost all children (99%) having ever been breastfed. However, more than a third (37%) were not breastfed in the first hour following delivery, and 40% were given something to drink other than the mothers’ breast milk within 3 days after delivery. About 85% of infants were still breastfeeding th by the end of the 11 month. Exclusive breastfeeding for the first six months was rare as only about 2% of infants were exclusively breastfed for six months. Factors associated with sub-optimal infant breastfeeding and feeding practices in these settings include child’s sex; perceived size at birth; mother’s marital status, ethnicity; education level; family planning (pregnancy desirability); health seeking behaviour (place of delivery) and; neighbourhood (slum of residence). Conclusions: The study indicates poor adherence to WHO recommendations for breastfeeding and infant feeding practices. Interventions and further research should pay attention to factors such as cultural practices, access to and utilization of health care facilities, child feeding education, and family planning. Background together with high rates of morbidity from infectious dis- The first two years of life are critical stages for a child’s eases are the prime proximate causes of malnutrition in growth and development. Any damage caused by nutri- the first two years of life. Breastfeeding confers both tional deficiencies during this period could lead to short-term and long-term benefits to the child. It reduces impaired cognitive development, compromised educa- infections and mortality among infants, improves mental tional achievement and low economic productivity [1-3]. and motor development, and protects against obesity and Poor breastfeeding and complementary feeding practices, metabolic diseases later in the life course [3-7]. The WHO recommends exclusive breastfeeding in the first six months, beginning from the first hour of life, to * Correspondence: [email protected] 1 meet the infant’s nutritional requirements and achieve African Population and Health Research Center (APHRC), Nairobi, Kenya Full list of author information is available at the end of the article © 2011 Kimani-Murage et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Kimani-Murage et al. BMC Public Health 2011, 11:396 Page 2 of 11 http://www.biomedcentral.com/1471-2458/11/396 optimal growth, development and health. The mother is health education and media exposure; socio-economic advised to continue breastfeeding up to two years of age status and area of residence; and the child’s characteris- or more and begin nutritionally adequate, safe, and tics including birth weight, method of delivery, birth appropriately-fed complementary foods at the age of six order, and the use of pacifiers [19-21]. However, there months in order to meet the evolving needs of the are conflicting findings with regards to the consistency growing infant [6]. The WHO/UNICEF global strategy of the associations and the magnitude of the effects [20,22-25], suggesting that the context may be impor- on infant and young child feeding practices aims to pro- tant when trying to isolate characteristics and practices mote optimal breastfeeding and complementary feeding that may be amenable to interventions. There is limited practices, through various initiatives for example the Baby Friendly Hospital Initiative (BFHI) and the Interna- evidence on breastfeeding and infant feeding practices tional Breastfeeding Code [8]. Interventions promoting in urban slums in sub-Saharan Africa since few studies optimal breastfeeding could prevent 13%, while those have focused on urban slums. Although there is national promoting optimal complementary feeding could pre- level evidence on breastfeeding and infant feeding prac- vent another 6% of deaths in countries with high mor- tices, the data for urban areas is not disaggregated, and tality rates [5]. hence, the dearth of evidence on practices in urban Poor breastfeeding and complementary feeding prac- slums. In this study, we have collected longitudinal data tices have been widely documented in the developing and assessed infant feeding practices with reference to countries. Only about 39% of infants in the developing WHO recommendations, in two slums in Nairobi, countries, 25% in Africa are exclusively breastfed for the Kenya, and their determinants. first six months. Additionally, 6% of infants in develop- ing countries are never breastfed [9]. In Kenya, accord- Methodology ing to Kenya Demographic and Health Survey 2008- Study setting and data source 2009 [10], 32% of children under the age of six months The study was carried out in two urban slums of Nair- are exclusively breastfed, improving from only 13% in obi Kenya (Korogocho and Viwandani) where the Afri- 2003 [11]. As a result, substantial levels of child malnu- can Population and Health Research Center (APHRC) trition and poor child health and survival have been runs a health and demographic surveillance system; the documented in Kenya [11]. Deriving from the broad Nairobi Urban Health and Demographic Surveillance principles of the joint WHO and UNICEF’s Global System (NUHDSS). The two slum areas are densely Strategy for infant and young child feeding developed in populated (63,318 and 52,583 inhabitants per square 2002 [8], the government of Kenya is implementing a km, respectively), and are characterized by poor housing, strategy aimed at improving infant and young child lack of basic infrastructure, violence, insecurity, high feeding practices in Kenya. The strategy is actualized unemployment rates, and poor health indicators through revitalization of the BFHI [12]. [14,15,17]. The socio-economic status of the two slums Urban poor settlements or slums present unique chal- differs slightly: Viwandani has relatively higher levels of lenges with regards to child health and survival. Slums education and employment as being located in the in sub-Saharan Africa are expanding at a fast rate, and industrial area, it attracts migrant workers. On the other the majority of urban residents now live in slum settle- hand, the population of Korogocho is more stable since ments, [13]. These slums are characterized by poor on average, residents in the area have lived the area for environmental sanitation and livelihood conditions a longer period than Viwandani residents. Approxi- [14-16]. Contrary to the long-held belief that urban resi- mately two thirds of married men live with their spouses dents are advantaged with regards to health outcomes, in Korogocho, compared with half in Viwandani. urban slum dwellers tend to have very poor health indi- The NUHDSS involves a systematic recording (every cators [14,17,18]. For example, in Kenya, slum children four months) of vital demographic events including are reported to be sicker and to have higher mortality births, deaths and migrations occurring among residents rates than any other sub-group in Kenya including the of all households in the NUHDSS area, since 2003. rural areas [14]. In line with this, infants born to Other data that are collected regularly include house- mothers that reside in the urban slums may be exposed hold assets, morbidity, and highest educational attain- to sub-optimal breastfeeding and complementary feed- ment. This paper is based on data from a maternal and ing practices. child health component of a broader longitudinal study Various factors associated with sub-optimal breast- entitled “Urbanization, Poverty and Health Dynamics in feeding and complementary feeding practices have been sub-Saharan Africa” that was nested within the identified in various settings. These include maternal NUHDSS. The study started in February 2007 and characteristics such as age, marital status, occupation, ended in December 2010. All women who gave birth and education level; antenatal and maternity health care; since September 2006 and their children were enrolled Kimani-Murage et al. BMC Public Health 2011, 11:396 Page 3 of 11 http://www.biomedcentral.com/1471-2458/11/396 in the study and were followed up every four months to ethnicity of the mother (Kikuyu, Luhya, Luo, Kamba, obtain data including self-reported health status, breast- and other tribes); the highest level of education (none, feeding, complementary feeding practices, vaccination primary, secondary or higher); and parity (1, 2, 3+); and health care. Data on socio-economic status was pregnancy desirability of the index child (wanted at the extracted from the NUHDSS database and linked to the time of conception, wanted later and never wanted,); the study participants through their household identifier. place of delivery (health facility, home or traditional Data collection & sample birth attendant [TBA]); the mother’s perception of the The data presented in this paper were collected at base- child’s size at birth (normal, smaller than normal, larger than normal); the socio-economic status of the house- line and during the first two updates, four months apart, for each child recruited between February 2007 and May hold; and the slum of residence (Viwandani or Korogo- 2009. Therefore, the follow-up period for each child was cho). The household socioeconomic status was defined on average nine months and the average age of the chil- using the household monthly expenditure per capita, dren at the second update was 15 months. However, we taking a child to be the equivalent of half an adult. The restrict our analyses to the first year of life for all 4,299 expenditure data used was obtained from the poverty children who were enrolled in the study. Table 1 pre- component of the Urbanization, Poverty and Health sents the sample size for the children involved in the Dynamics study, and was collected in the same year as studyand thedatacollection dates. Six cohorts of chil- the data for the dependent variables above. This variable dren enrolled during the study period are included. was recoded as tertiles of “poorest”, “middle” and “least Variables poor”. a. Dependent variables The two dependent variables Data Analysis are cessation of breastfeeding and introduction of com- The survival analysis of the duration of breastfeeding plementary foods (liquids and solids). Cessation of and the time to introduction of complementary foods is breastfeeding is a time-dependent variable indicating the presented using Kaplan-Meier survival curves. Cox age when breastfeeding was stopped. Introduction of regression analysis was performed to determine factors complementary foods is also a time-dependent variable associated with breastfeeding cessation during infancy indicating the age at which complementary foods (either and early introduction of complementary foods. Some liquids or solids other than breastmilk) were introduced. independent variables had missing values, mainly mater- Children who entered the study after the events (breast- nal level variables such as the mother’s age, ethnicity, feeding cessation or initiation of complementary foods) the highest level of education; and the household’s had occurred had their information updated retrospec- socio-economic status. A missing category was created tively. About 1% of children were never breastfed and in the multivariate analysis to keep all cases in the ana- were excluded from survival analysis. Children who did lysis (though results for missing category are not not have their information updated due to loss to fol- shown). In all cases, except the household expenditure low-up were excluded from the study. variable, the number of cases with missing information b. Independent variables The independent variables was less than 10%. About one-third of the participants were: the child’s sex; the mother’s age (< 25 years, 25-34 were missing data on household expenditure, therefore years, 35+ years); the marital status of the mother (in imputation using a linear interpolation computation union i.e. currently married or living with someone; procedure was used. A p-value of less than 0.05 was previously in union; and never married/in union); the used as the cut-off for statistical significance. Table 1 Sample Size, Nairobi informal settlements, Kenya Survey 1 Survey 2 Survey 3 Survey 4 Survey 5 Survey 6 Survey 7 Survey 8 Number of observation Survey Feb-Apr Jul-Aug Oct-Dec 2007&Mar- May-Aug Sep 2008-Jan Feb-May Jun-Sep Oct-Jan Feb 2007-Sept period ==> 2007 2007 Apr 2008 2008 2009 2009 2009 2010 2009 Panel 1 615 507 378 * * * * * 1,500 Panel 2 458 359 323 * * * * 1,140 Panel 3 948 727 645 * * * 2,320 Panel 4 968 814 696 * * 2,478 Panel 5 479 398 333 * 1,210 Panel 6 831 689 498 2,018 Total 615 965 1,685 2,018 1,938 1,925 1,022 498 10,666 * Censored. Note: The total number of children enrolled across all six panels is 4299. Kimani-Murage et al. BMC Public Health 2011, 11:396 Page 4 of 11 http://www.biomedcentral.com/1471-2458/11/396 Ethical Considerations The Urbanization, Poverty and Health Dynamics study was approved by the Ethical Review Board of the Kenya Medical Research Institute (KEMRI). The field workers were trained in research ethics and obtained informed consent from all respondents. The NUHDSS has also been approved by KEMRI’s Ethical Review Board. Verbal consent is routinely obtained from all the NUHDSS respondents. Results Sample Characteristics Almost all the children (99%) were ever breastfed; how- ever, more than a third (37%) were not breastfed in the 0 1 2 3 4 5 6 7 8 9 10 11 12 Months first hour following delivery. The main reasons given for Figure 1 Probability of continuing breastfeeding for specific not initiating breastfeeding immediately were: little or ages, Nairobi informal settlements, Kenya. no breastmilk (35%); baby being asleep/tired (23%); baby being sick (13%); and mother being sick (9%). Two in five of the children were given something to drink other than the mothers’ breast milk within 3 days following introduced to complementary foods (either liquids or delivery. The main reasons given were that the mother solids) by the age of 6 months. Liquids were introduced had little or no breast milk (42%) or that the child had much earlier than solids; the mean age of introduction an upset stomach (32%). During each data collection of liquids was one month while that for solids was three round, mothers and other caregivers were asked if the and a half months. child was being given any liquid or solid food to com- Proportional Hazards Regression plement breastfeeding, with the recall period being the In the multivariate analysis, the factors significantly last three days. The most common complementary associated with cessation of breastfeeding during infancy foods being given to children before the age of six were the mother’s marital status, her ethnicity, and her months were: plain water (56%), with most children on highest level of education and the perceived size of the it having been given within the first month (69%); por- child at birth (p < 0.05, respectively). The mother’sage ridge (54%), with most children on it having been intro- was marginally associated (p > 0.05 < 0.1) with the dura- duced between the second and third months (64.7%); tion of breastfeeding. When other factors were con- fresh or powdered milk (45%) with most children on it trolled for, mothers who were previously in union and also having been introduced between second and third those never in union had close to 3 and 2 fold higher months of life (57%); and sweetened/flavoured water hazards of stopping breastfeeding before the age of 12 (41%), with most of children on it having been intro- months respectively compared to mothers in union. duced within the first month of life (78%). The main Luhya, Luo and mothers of other ethnic groups were reason given for introducing complementary foods to more likely to stop breastfeeding early (Hazard Ratios: children below six months was that the mother had no 1.6, 1.8. and 2.1, respectively), compared to Kikuyu or little breast milk (approx 40%). About two-thirds mothers; mothers with secondary or tertiary education knew that complementary feeding should be started at level had 40% lower hazards of stopping breastfeeding 6monthswhile about30% indicatedtheyshouldbe compared to those with less than secondary level educa- started before six months. tion; and children who were perceived as larger than normal were 40% less likely to stop breastfeeding before Survival Analysis the age of 12 months (Table 2). Cessation of breastfeeding and introduction of Factors associated with early introduction of comple- complementary foods mentary foods (before the age of six months) at multi- Figure 1 shows Kaplan-Meier survival curves for prob- variate level include child’ssex;mother’s marital status, ability of continuing breastfeeding at specific ages. ethnicity, and education level; pregnancy desirability; Nearly all of the infants were started on breastfeeding, place of delivery; and slum of residence (p < 0.05, and about 85% of the infants were still breastfeeding by respectively). Boys were more likely to be introduced to the end of the 11th month. Figure 2 illustrates Kaplan- foods early; mothers never in union had 23% higher Meier survival curves for time to introduction of com- hazards of introducing complementary foods before 6 plementary foods. Nearly all (98%) of children had been months of age; Luos, Luhyas and other ethnic groups 0.80 0.90 0.75 0.85 0.95 1.00 Kimani-Murage et al. BMC Public Health 2011, 11:396 Page 5 of 11 http://www.biomedcentral.com/1471-2458/11/396 Liquids Solids Liquids & Solids 0 2 4 6 8 10 12 0 2 4 6 8 10 12 0 2 4 6 8 10 12 Months Months Months Figure 2 Probability of initiating complementary foods for specific ages, Nairobi informal settlements, Kenya. were more likely to introduce foods early; mothers with picture masks the unwelcome finding that the WHO at least secondary level education had 10% lower recommendations with regards to breastfeeding and hazards of introducing foods early; children who were introduction of complementary food were largely not not wanted at conception but wanted later had 7% adhered to. Early initiation of breastfeeding following lower hazards of being introduced early; and mothers in delivery, as recommended by the WHO is not univer- Viwandani had 10% lower hazards of introducing com- sally being practiced in developing countries, despite the plementary foods early compared to mothers in Korogo- importance of colostrum in providing the baby with rich cho (Table 3). nutrients. The findings that close to 40% of the infants were not breastfed within one hour following delivery Discussion are in agreement with findings from studies in other This study has documented breastfeeding and infant developing countries including Uganda, India and Ban- feeding practices in two slum settings in sub-Saharan gladesh [20,26,27]. In our setting, the main reasons sta- Africa. It has also identified the factors associated with ted for failure to introduce babies to breast milk sub-optimal breastfeeding and infant feeding practices in immediately after birth were health-related including the these two slum settings. The study finds that though mother having insufficient milk. This has also been there is almost universal breastfeeding, exclusive breast- documented in other studies [22]. Other cultural factors feeding is rare. Complementary foods are initiated too have been noted in other settings such as Nigeria, for early; only two percent of children were exclusively example the belief that colostrum is dirty milk, hence breastfed before the age of six months and the mean age harmful to the baby, a belief that the mother should rest of introduction of complementary foods was one month. and clean up first, and performance of rituals and In our study, we see an overall picture of universal prayers before the baby starts breastfeeding [28]. In our breastfeeding with the majority of infants breastfed for study though, cultural factors did not feature in the at least 12 months. These findings are similar to find- responses from the women, supposedly because our ings in other developing countries [9,26]. However, this study was a quantitative, rather than qualitative study. 0.00 0.20 0.40 0.60 0.80 1.00 Probability of initiating foods 0.00 0.20 0.40 0.60 0.80 1.00 0.00 0.20 0.40 0.60 0.80 1.00 Kimani-Murage et al. BMC Public Health 2011, 11:396 Page 6 of 11 http://www.biomedcentral.com/1471-2458/11/396 Table 2 Characteristics of study participants, Nairobi In this study complementary foods were initiated too informal settlements, Kenya early, despite two thirds of the women in our study Category (%) being aware of the WHO recommended time to initiate complementary feeding. This is in line with previous Sex studies conducted in rural Kenya, Malawi and Uganda Girls 50.5 [26,29,30], and in some other slum settings in the devel- Boys 49.6 oping world [31,32]. In a study conducted in the late Mother’s age 1990s on the determinants of child nutritional status in < 25 years 53.6 six African countries, Madise et al. reported very low 25-34 years 32.5 levels of exclusive breastfeeding among infants under 35+ years 6.4 the age of 4 months with percentages ranging from two Missing 7.5 percent in Nigeria to about 34% in Tanzania [33]. The Mother’s Marital Status few studies that have looked at slum settings particularly In union currently 83.3 in Asia paint a similar picture [31,32]. The finding Ever in union 7.2 showing the persistence of early introduction of comple- Never in union 9.2 mentary feeding in the region is critical given the Missing 0.3 importance of exclusive breastfeeding to child health. Mother’s ethnicity Exclusive breastfeeding protects against infections such Kikuyu 24.1 as gastrointestinal and respiratory infections, and Luhya 16.0 enhances motor development in the child [4,34,35]. In a Luo 18.0 study using data from Botswana which examined the Kamba 18.8 association between breastfeeding, morbidity, and mal- Other 15.7 nourishment, Chikusa (1991) found that children aged 4 Missing 7.5 months or younger who had been weaned had more Mother’s education level than 11 times the odds of having diarrhea compared < Secondary 70.7 with those who were still being breastfed [36]. The main Secondary+ 21.9 reason cited for introducing complementary food early Missing 7.5 was the mother’s perception of insufficient breast milk. Mother’s Parity This finding is in line with other studies from other set- One (ref) 33.0 tings which have shown that the perceived lack of suffi- Two 27.8 cient breast milk is a main reason for early Three+ 39.0 breastfeeding cessation or early introduction of comple- Missing 0.3 mentary foods [31,37,38]. Pregnancy desirability* The variables associated with the cessation of breast- Wanted at conception 49.8 feeding during the first year of the child’slifeinclude Wanted later 37.2 the mother’s marital status, her ethnicity, and her level Never wanted 12.4 of education, and perceived size at birth. The association Missing 0.5 between marital status and early cessation of breastfeed- Delivery place* ing has been reported in many studies with conflicting Health Facility 71.4 results [22,23]. In this study, women who were not in Home 28.3 union, particularly those who were formerly married Missing 0.3 were more likely to stop breastfeeding their infants than Perceived size at birth* women who were in union. It has been suggested that Normal 69.5 the association between marital status and breastfeeding Smaller 14.2 cessation may be due to the presence or absence of Larger 15.6 social, emotional and economic support of a partner Missing 0.7 [39]; however, these factors were not assessed in our SES (Expenditure) Category study. A more plausible reason in Kenya, where HIV is Poorest 55.0 high, is that a disproportionately large number of for- Middle 29.0 merly married women are HIV positive and many Least Poor 7.3 women in this situation were until recently advised to Missing 8.6 exclusively breastfeed their infant for 6 months and then Slum of residence to rapidly wean [40]. Korogocho 52 The evidence of the association between a mother’s Viwandani 48 level of education and the duration of breastfeeding also *Refers to the index child. Kimani-Murage et al. BMC Public Health 2011, 11:396 Page 7 of 11 http://www.biomedcentral.com/1471-2458/11/396 Table 3 Cox regression for cessation of breastfeeding and introduction of complementary foods, Nairobi informal settlements, Kenya Variable Cessation of Breastfeeding Initiation of Complementary Foods Univariate Multivariate Univariate Multivariate HR 95%CI HR 95%CI HR 95%CI HR 95%CI Sex Girls Ref Ref Ref Ref Boys 0.98 [0.80, 1.21] 0.88 [0.71, 1.10] 1.03 [0.99, 1.08] 1.05* [1.00, 1.09] Mother’s age < 25 years Ref Ref Ref Ref 25-34 years 1.18 [0.94, 1.48] 1.22 [0.92, 1.62] 0.99 [0.95, 1.04] 1.01 [0.95, 1.06] 35+ years 1.40# [0.95, 2.05] 1.52# [0.96, 2.40] 1.02 [0.94, 1.11] 1.01 [0.92, 1.12] Mother’s Marital Status In union Ref Ref Ref Ref Ever in union 2.52*** [1.87, 3.40] 2.76*** [1.97, 3.88] 1.10* [1.02, 1.19] 1.07 [0.98, 1.16] Never in union 1.31 [0.93, 1.84] 1.73** [1.17, 2.55] 1.16*** [1.08, 1.24] 1.23*** [1.13, 1.34] Mothers ethnicity Kikuyu Ref Ref Ref Ref Luhya 1.20 [0.86, 1.69] 1.54* [1.06, 2.23] 1.21*** [1.13, 1.29] 1.19*** [1.12, 1.28] Luo 1.28 [0.93, 1.77] 1.83*** [1.28, 2.62] 1.16*** [1.09, 1.23] 1.12** [1.04, 1.19] Kamba 0.91 [0.64, 1.28] 1.16 [0.79, 1.71] 0.98 [0.92, 1.04] 1.02 [0.95, 1.09] Other 1.49* [1.09, 2.03] 2.08*** [1.48, 2.92] 1.07* [1.00, 1.14] 1.09* [1.02, 1.17] Mother’s education level < Secondary Ref Ref Ref Ref Secondary+ 0.61*** [0.45, 0.81] 0.58*** [0.43, 0.80] 0.88*** [0.84, 0.92] 0.92** [0.87, 0.97] Mother’s Parity One Ref Ref Ref Ref Two 1.41* [1.08, 1.83] 1.23 [0.91, 1.66] 1.04 [0.99, 1.10] 1.04 [0.98, 1.10] Three+ 1.20 [0.93, 1.55] 0.91 [0.64, 1.30] 1.03 [0.99, 1.08] 1.01 [0.94, 1.07] Pregnancy desirability Wanted at Ref Ref Ref Ref conception Wanted later 0.95 [0.76, 1.20] 0.90 [0.69, 1.17] 1.01 [0.96, 1.05] 0.93** [0.89, 0.98] Never wanted 1.45* [1.09, 1.94] 1.08 [0.76, 1.54] 1.15*** [1.08, 1.22] 1.05 [0.98, 1.13] Delivery place Health Facility Ref Ref Ref Ref Home 0.93 [0.73, 1.17] 0.89 [0.69, 1.15] 1.19*** [1.14, 1.25] 1.19*** [1.14, 1.25] Perceived size at birth Normal Ref Ref Ref Ref Smaller 1.20 [0.91, 1.59] 0.95 [0.70, 1.30] 1.03 [0.97, 1.09] 1.03 [0.97, 1.10] Larger 0.61** [0.43, 0.87] 0.55** [0.38, 0.81] 0.96 [0.91, 1.01] 0.97 [0.92, 1.04] SES Category Poorest Ref Ref Ref Ref Middle 0.89 [0.70, 1.13] 0.97 [0.75, 1.25] 0.95* [0.91, 0.99] 1.01 [0.97, 1.06] Least Poor 1.03 [0.69, 1.54] 1.10 [0.71, 1.68] 0.90* [0.84, 0.98] 0.96 [0.89, 1.05] Slum Korogocho Ref Ref Ref Ref Viwandani 0.86 [0.70, 1.06] 1.20 [0.92, 1.55] 0.85*** [0.82, 0.89] 0.89*** [0.85, 0.94] HR = Hazard Ratio; # = p < 0.1; * p < 0.05; ** = p < 0.01; *** = p < 0.001. varies [20,24,25]. In this study, lower than secondary Higher HIV prevalence among those with less than sec- level education was associated with earlier cessation of ondary level education, especially those with no educa- breastfeeding. While it is not very clear why this is the tion at all in our setting [41] may be associated with early case, higher education may be associated with higher cessation of breastfeeding. We also observed an asso- knowledge and practice of positive health behaviour. ciation between ethnicity and breastfeeding cessation. Kimani-Murage et al. BMC Public Health 2011, 11:396 Page 8 of 11 http://www.biomedcentral.com/1471-2458/11/396 All other ethnic groups apart from the Kamba were more of a mother’s low education on early introduction of likely to stop breastfeeding their infants compared to complementary foods has been observed in many stu- Kikuyu women. There is no established reason for this dies in other settings, suggesting a need for education but it could be multi-factorial, including cultural prac- and health promotion to change these harmful feeding tices related to breastfeeding and child rearing. Further, practices [21,45,46]. HIV prevalence, which may affect breastfeeding practices, Slum of residence, was associated with the timing of introduction of complementary foods. Mothers from has also been documented as higher amongst the Luo Viwandani, were at lower risk of introducing comple- and Luhya ethnic groups in this slum setting compared mentary foods before six months. This may be because to the Kikuyu ethnic group [41]. Additionally, evidence from the study areas indicates that Kikuyus have lower Viwandani, being in the industrial area and attracting fertility compared to other ethnic groups. Prolonged labourers to the industries is likely to have more edu- breastfeeding may explain or be explained by lower ferti- cated people (other than the mother) for example the lity. Mothers who get pregnant while breastfeeding are father and other household members, who may affect more likely to stop but, also mothers who breastfeed for infant feeding practices. Mothers who delivered at home longer period have lower chances of getting pregnant were more likely to introduce complementary foods ear- [42]. Additionally, better child health outcomes have also lier than those who delivered in a health facility. been documented among the Kikuyu’scomparedto Mothers who deliver in a health facility in most cases other ethnic groups in this study setting [14] and our receive breastfeeding counselling, especially with the findings may indicate that the Kikuyus have better revitalisation of the Baby Friendly Hospital Initiative health-related behaviours and practices than most of the (BFHI) from 2007 aimed at promoting optimal breast- other ethnic groups in the study area. The association feeding practices. The BFHI has been found to be effec- between birth size and the duration of breastfeeding has tive in several settings in the developing world [47]. not been studied in depth. Our study found that children BFHI, is being revitalized in Kenya in the National Strat- who were perceived to be larger at birth were less likely egy on Infant and Young Child feeding [12], and it may to be stopped from breastfeeding earlier. This is similar be playing a role in encouraging mothers to exclusive to a US study, infants who were breast-fed for less than 4 breastfeeding their infants in the first 6 months of life. months were smaller at birth than those who were Since the BFHI initiative was introduced, there has been breast-fed for 4 months or more [43]. The factors behind potential improvement in the proportion of children exclusively breastfed from 13% in 2003 to 32% in 2008 this association in our study setting need further [10]. The positive association between pregnancy desir- investigation. Predictors of early introduction of complementary ability and complementary feeding has barely been pre- foods include the child’s sex; the mother’s marital status, viously studied. In our study, infants who were her ethnicity, and her level of education; the desirability unwanted at conception but were wanted later were less of the pregnancy of the index child, the place of delivery likely to be introduced to complementary foods early. and the slum setting. Boys were more likely to be intro- The association between pregnancy desirability and duced to complementary feeding early compared with breastfeeding and complementary feeding practices girls. Anecdotal evidence indicates that boys are intro- needs further investigation. duced to complementary foods early because breast Urban slum settings present unique challenges with milk alone does not meet their feeding demands. Having regards to breastfeeding and infant and young child never been in union/married was associated with higher feeding practices due to their physical and socio-eco- risk of early introduction of complementary foods. A nomic characteristics. In these informal settings, basic positive association between being married and exclusive government services including health care services are breastfeeding has been documented in other studies limited and this, coupled with financial constraints, [44]. As in the case of the duration of breastfeeding, this leads to a substantial proportion of women in these may be associated with social, emotional and economic slums giving birth at home or at informal private health support of a partner [39]. Similar to the finding related facilities [48,49]. This means that most of these slum to the duration of breastfeeding, all other ethnic groups women are systematically excluded from government apart from the Kamba group, were more likely to initi- initiatives such as those aimed at promoting optimal ate complementary foods earlier than the Kikuyus. This breastfeeding and infant feeding practices, based at health facilities such as the BFHI mentioned above, may be related to cultural practices and other factors which involves counselling of mothers on infant and such as HIV status as described for duration of breast- young child feeding around the time of delivery. feeding. Whileafew studieshavelinkedthemother’s education with early introduction of complementary Another unique characteristic of slum settings is limited foods [27], similar to our study, the negative influence livelihood opportunities [15] hence food insecurity. Kimani-Murage et al. BMC Public Health 2011, 11:396 Page 9 of 11 http://www.biomedcentral.com/1471-2458/11/396 As indicated in this study and in other slums such as in follow-up period, reducing bias due to loss to follow-up. India [31], one key reason for initiating complementary The study involved a census of all children born to foods too early is due to the mother having inadequate mothers in two defined geographical areas; hence there breast milk. While the important role of hormones and was minimal bias due to sampling error. the psychosocial status of the mother in lactation is well established, though limited evidence exists, volume of Conclusion milk produced may also be related to maternal nourish- This study presents important findings on breastfeeding ment. A review of breastmilk volumes and composition and infant feeding practices and determinants of sub- among poorly nourished communities indicated that optimal practices in informal settings in sub-Saharan milk volumes were lowest in communities with poor Africa. This is timely and critical as such evidence is levels of nutrition and poor living conditions [50]. currently rare. The study finds that despite universal Potential interventions to address the unique chal- breastfeeding in this population, WHO breastfeeding lenges in the slum settings should address both access and infant feeding recommendations are rarely adhered issues and the socio-economic limitations. A potential to. It is important therefore to develop interventions tar- intervention to counteract the systematic exclusion from geting women, health care workers and policy makers basic government services may include, home-based aimed at bridging the gap between current breastfeeding counselling of mothers on infant and young child feed- and infant feeding practices in the informal settings and ing by community based health workers and/or support- WHO recommendations. It is evident from this study ing the (informal) private service providers for instance that breastfeeding and infant feeding patterns are asso- through training programs to offer services according to ciated with child, maternal and household level factors established government guidelines such as those on and it is crucial to understand and reduce the inequal- breastfeeding. The effectiveness of such interventions in ities. Interventions and further research should address health care delivery, including promotion of optimal inequalities including gender, ethnicity, access to and infant feeding practices in resource-constrained settings utilization of health care facilities, socio-economic status has been indicated [51]. To enhance adequacy of milk and family planning. This study only looked at early produced by the mothers, potential interventions may introduction of complementary food; further investiga- be to enhance maternal nourishment through ensuring tion on late introduction of the same is needed. food security. This may be through appropriate income generating activities to enhance livelihoods. Food sup- List of abbreviations plementation has also been found to enhance breastmilk APHRC: African Population and Health Research Center; BFHI: Baby Friendly volume [50]. Additionally, interventions that empower Hospital Initiative; HIV: Human Immuno-deficiency Virus; NUHDSS: Nairobi the new mother by demonstrating correct breastfeeding Urban Health and Demographic Surveillance System; HR: Hazard Ratio; TBA: techniques, ways of stimulating breast milk production, Traditional Birth Attendant; UNICEF: United Nations Children’s Education Fund; US: United States; WHO: World Health Organization. and counselling on proper nutrition may improve breastfeeding practices [52]. Acknowledgements Limitations in this study relate to missing values in This study was funded by the Wellcome Trust (Grant No. 078530/Z/05/Z). We also acknowledge funding for the NUHDSS from the Rockefeller some of the variables particularly the socio-economic Foundation and core support for APHRC from the Rockefeller Foundation, status variables. Appropriate measures were taken in the the William and the Flora Hewlett Foundation. We would like to thank Dr. analysis to minimize bias as indicated above. It would Alex Ezeh, Dr. Eliya Zulu, Prof. John Cleland, Prof Jane Falkingham and Prof Philippe Bocquier for their contribution in the design of the study from have been important to follow-up the children for a which data for this article was derived. We thank Dr. George Mgomella, Ms longer period to establish complete duration of breast- Hilda Essendi, Ms Teresa Saliku and Mr. Peter Muriuki for project feeding in line with the WHO recommendation that coordination. We are also grateful to the data collection team and the data processing and management team at APHRC. We are highly indebted to the breastfeeding should continue for two years or beyond. study participants. This was however not done and children were only fol- lowed up till they were slightly more than one year old. Author details African Population and Health Research Center (APHRC), Nairobi, Kenya. Despite these limitations, this studyhas keystrengths University of Southampton, Centre for Global Health, Population, Poverty, that are worth mentioning. The study provides impor- and Policy, Faculty of Social and Human Science, Southampton, UK. University of the Witwatersrand, MRC Mineral Metabolism Research Unit, tant information on infant breastfeeding and feeding Department of Paediatrics, Faculty of Health Sciences, Johannesburg, South practices in informal settings in sub-Saharan Africa, for Africa. which there is a dearth. A key strength of this study lies Authors’ contributions in its longitudinal nature, minimising recall bias that EWK-M:Design of the study, project management, data analysis, writing of maybeassociatedwithcross-sectional studies. The the manuscript and approval for submission; NJM: Principal Investigator of study involved rigorous follow-up hence information for the project, design of the study, analytic guidance, reviewing of the most of the children was updated by the end of the manuscript and approval for submission; J-CF: Design of the study, overall Kimani-Murage et al. BMC Public Health 2011, 11:396 Page 10 of 11 http://www.biomedcentral.com/1471-2458/11/396 project co-ordination, reviewing of the manuscript and approval for 18. Fotso JC: Urban-rural differentials in child malnutrition: trends and submission; CK: Design of the study, project management, review of the socioeconomic correlates in sub-Saharan Africa. Health Place 2007, manuscript and approval for submission; MK: Data management and 13(1):205-223. analysis, review of the manuscript and approval for submission; TG: Writing 19. Patel A, Badhoniya N, Khadse S, Senarath U, Agho KE, Dibley MJ: Infant and of the manuscript and approval for submission; NY: Writing of the young child feeding indicators and determinants of poor feeding manuscript and approval for submission. All authors read and approved the practices in India: secondary data analysis of National Family Health final manuscript. Survey 2005-06. Food Nutr Bull 31(2):314-333. 20. Roig AO, Martinez MR, Garcia JC, Hoyos SP, Navidad GL, Alvarez JC, Pujalte Competing interests Mdel M, De Leon Gonzalez RG: Factors associated to breastfeeding The authors declare that they have no competing interests. cessation before 6 months. Rev Lat Am Enfermagem 18(3):373-380. 21. Kristiansen AL, Lande B, Overby NC, Andersen LF: Factors associated with Received: 25 January 2011 Accepted: 26 May 2011 exclusive breast-feeding and breast-feeding in Norway. Public Health Nutr Published: 26 May 2011 1-10. 22. 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Pre-publication history The pre-publication history for this paper can be accessed here: http://www.biomedcentral.com/1471-2458/11/396/prepub doi:10.1186/1471-2458-11-396 Cite this article as: Kimani-Murage et al.: Patterns and determinants of breastfeeding and complementary feeding practices in urban informal settlements, Nairobi Kenya. BMC Public Health 2011 11:396. Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit

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BMC Public HealthSpringer Journals

Published: May 26, 2011

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