1. family and parenting
2. babies and toddlers

African Population and
Health Research Center
Breastfeeding Briefing #1 | October 2013
How Can I Exclusively
Breastfeed My Baby
In Kenya, according to
the Kenya Demographic
and Health Survey
(KDHS) 2008-2009,
What’s so Great about Exclusive
Breastfeeding?
Breastfeeding is the most natural way to feed
newborn babies, yet millions of babies are
not breastfed adequately. UNICEF and WHO
recommendations for infant feeding during the
first two years of life include (WHO 2003):
only 32% of children
⁍⁍
under the age of six
⁍⁍
months are exclusively
⁍⁍
breastfed.
Immediate initiation of breastfeeding
after birth
Exclusive breastfeeding for first six
months
Sustained breastfeeding for two
years or beyond with appropriate
complementary feeding from six
months
This breastfeeding practice is critical for child
growth, development and survival. It reduces
infections and mortality in children, improves
mental and motor development, and protects
against obesity and metabolic diseases and
premature deaths later in the life course (Black
et al 2013, Lanigan and Singal 2009, Black et al.
2008, Victora et al. 2008, Grantham-McGregor
et al 2007).
...In urban slums in
Nairobi, Kenya, only 2%
of infants are breastfed
exclusively for the first
six months according
to research by APHRC
(Kimani-Murage 2011).
But how does Breastfeeding
Provide all these Benefits?
Human breast milk uniquely benefits the baby.
It contains various components including
bioactive proteins that are lacking or are in
lower quantities in other milk substitutes
such as cow milk. These components offer
various benefits to the baby including enzyme
activities, antimicrobial effects, enhanced
nutrient absorption and growth stimulation.
It also contains milk fat globule membranes
Practical Concerns In Realizing
The WHO Recommendations
For Breastfeeding In Urban Poor
Settings In Nairobi
(MFGM), which may explain the difference in
infection levels and cognitive development
between breastfed and formula fed children.
While some studies have found no consistent
difference in adiposity between formula-fed
and breastfed infants in the first six months of
life, others have found that breastfed infants
may gain more fat in the first six months of life
but gain more fat-free mass after six months,
which reduces the risk of obesity later in life
(Ziegler 2006, Lonnerdal 2010).
The Global Nutrition Target
The 65th Session of the World Health Assembly
(WHA), Geneva, May 21-26, 2012 endorsed six
nutrition targets, including increasing exclusive
breastfeeding rates in the first six months up
to at least 50% by 2025. This is an ambitious
target, given the current situation globally
of sub-optimal breastfeeding practices,
where only 39% of children are exclusively
breastfed for the first six months (UNICEF
global databases 2012 - www.childinfo.org/
breastfeeding_status.html).
In Kenya, according to the Kenya Demographic
and Health Survey (KDHS) 2008-2009, only
32% of children under the age of six months
are exclusively breastfed. Even fewer children
in the urban slums, where majority of urban
residents in Kenya live, are adequately
breastfed. Only 2% of children are exclusively
breastfed for the first six months, and 15% of
children stop breastfeeding by the end of one
year (Kimani-Murage 2011).
1
To improve breastfeeding practices,
and achieve the WHA target of a 50%
increase in exclusive breastfeeding for
six months by 2025, context-specific
interventions are needed.
Breastfeeding in Kenyan Slum Settings
In April 2013, the African Population and Health Research
Center (APHRC) carried out a study to establish the
factors that influence breastfeeding practices among
the urban poor in Nairobi, Kenya. The study found that
though the urban poor highly esteem the WHO guidelines
for breastfeeding, these recommendations are impractical
in the urban slum settings due to several factors affecting
breastfeeding in these settings. In this briefing paper, we
outline the root causes of poor breastfeeding practices among
the urban poor.
Five socio-economic and structural
barriers to exclusive breastfeeding in slum
settings
1
Due to limited livelihood opportunities in the slums,
most people work for a daily wage. Most working
women are casual laborers in neighboring factories or
domestic workers in nearby middle income estates, and
these work environments are not conducive for breastfeeding.
They are therefore said to be hustlers, struggling to make ends
meet. With no option for maternity leave, most resume work
weeks, sometimes even days, after delivery.
Sometimes it is because of the many
problems they encounter. For example, a
mother cannot sit, caring for the young baby
when she has 5 children to take care of. The
other children will suffer. She has to go out
and hustle for what they will eat. In most
cases she will stop to breastfeed since she
cannot carry the baby to work
(FGD, Village Elders)
2
Food insecurity due to chronic poverty is a major
deterrent to optimal breastfeeding, as lack of food
means inadequate breast milk for the baby.
… if you ask her she will ask you how she
will breastfeed and she hasn’t eaten. And if
you look at the breasts, they have flattened
and are sagging to the side and she is a girl,
she hasn’t eaten… So even if you tell her to
breastfeed, first of all that milk is not there
because there is no food in that house
Here in Korogocho, there are many girls who
get children out of wedlock so after delivery
they start the baby on bottle feeding because
their parents tell them not to breastfeed so
that they go back to school”.
(FGD: Mothers)
(FGD, Village Elders)
5
Poor professional and social support was considered
an important factor. Many mothers give birth at home
so no professional counseling, many have no domestic
help so resume household chores immediately, while
for married women, husbands were also hustlers and often
drunkards, offering little support.
Now you’ll find the problem which is here, is that
the child is born and after one month it is given
these adults’ foods. That is one problem and it
is as if the mother doesn’t know… Most children
are born just here at home ... The mother didn’t
even go to the clinic, she was not taught about
to take care of the child, she doesn’t know if she
is (HIV) positive or negative”.
(FGD, Village Elders)
Recommendation:
Recommendation:
There is need for social protection measures such as cash
transfers for vulnerable breastfeeding mothers in urban poor
settings and baby friendly income generating activities and
work environments. Additionally, counseling of mothers on
birth planning should encourage saving to cater for the first
six months after birth. Further, maternal, Infant and Young
Child Nutrition (MIYCN) interventions must be carried out hand
in hand with reproductive health provisions addressing the
number of and spacing of children.
though the urban poor highly esteem the
WHO guidelines for breastfeeding, these
recommendations are impractical in the
urban slum settings due to several factors
affecting breastfeeding in these settings.
2
3
Teenage pregnancy and single motherhood are key
factors because many mothers are young and single.
They have concerns of body image (aging and breasts
sagging), they are still in school and they are still busy
with their lives, often working as commercial sex workers to
make ends meet, not conducive for breastfeeding
Adolescent reproductive health interventions including sex
education in schools are required in these settings
4
HIV in an area with high prevalence, twice the national
level is also considered a key factor. There is mixed
understanding regarding breastfeeding for HIV positive
women, which affects practice for HIV victims and other
uninfected women.
Some people believe those who breastfeed
(exclusively) for six months are HIV positive.
(FGD, mothers)
Recommendation:
There is need to ensure correct and consistent messaging on
breastfeeding for HIV positive women. Additionally, there is
need for creation of awareness at the community level on the
importance of exclusive breastfeeding amongst all mothers
and not just for HIV-positive ones to reduce HIV-related stigma
associated with exclusive breastfeeding.
Recommendation:
There is need for creation of awareness on the need for
support for breastfeeding mothers including on the need
for spousal support. Additionally, baby friendly community
initiatives such as providing breastfeeding counselling and
support at the community level may make a change.
Conclusion
To improve breastfeeding practices, and achieve the WHA target
of a 50% increase in exclusive breastfeeding for six months by
2025, context-specific interventions are needed. For example
in the urban slum settings, approaches aimed at improving
breastfeeding practices must consider the wider ecological
setting in order to be successful. Interventions should also
target empowerment such as with income generating activities
that offer conducive environment for breastfeeding and social
protection measures such as cash transfers for the first few
months after delivery.
3
...A mother cannot sit,
caring for the young baby
when she has 5 children
to take care of. The other
children will suffer. She has
to go out and hustle for
what they will eat...
Because Urban Poor Mothers Are Hustlers!
APHRC carried out a study to establish the factors that influence breastfeeding practices among the urban poor in Nairobi,
Kenya.
Research Methods
⁍⁍
⁍⁍
Data collection period: April 2012
Qualitative interviews – IDIs, KIIs & FGDs (n=40) with mothers; health care workers, community leaders and traditional birth
attendants
Study Context
⁍⁍
⁍⁍
⁍⁍
⁍⁍
⁍⁍
⁍⁍
⁍⁍
⁍⁍
⁍⁍
⁍⁍
Two slums of Nairobi: Korogocho & Viwandani
Densely populated areas 63,318 and 52,583 inhabitants/km2
Fourth largest informal settlement in Nairobi
Located 12km northeast of Nairobi’s Central Business District
Inhabited by stable long-term residents
In existence since 1972
Total area: 0.97 sq. kilometers
Population density: 46, 961
Poor housing, livelihood opportunities (low average monthly wage of approx. USD 70), water and sanitation
Poor health conditions: high level of early sexual debut (10% of adolescents <15 years sexually active); high levels of under
five malnutrition at 40%; high HIV prevalence at 12%; high prevalence of severe food insecurity (50% of households)
Contributors
Kimani-Murage, E ., Wekesah F., Kyobutungi, C ., Wanjohi
M1., Muriuki P1., Ezeh A1., Musoke R2., Norris S3., Madise, N4.,
Griffiths P5.,
1
1
African Population and Health Research Center (APHRC); P.O. 10787, 00100,
Nairobi Kenya; [email protected];
University of Nairobi, Kenya;
3
University of the Witwatersrand, Johannesburg, South Africa,
4
University of Southampton, UK;
5
Loughborough University, UK;
1
2
Sources
Black, R.E., et al., Maternal and child undernutrition and
overweight in low-income and middle-income
countries. Lancet, 2013. 382(9890): p. 427-51.
Black, R.E., et al., Maternal and child undernutrition: global and
regional exposures and health consequences. Lancet,
2008. 371(9608): p. 243-60.
Kenya National Bureau of Statistics (KNBS) and ICF Macro,
Kenya Demographic and Health Survey 2008-09. 2009:
Calverton, Maryland: KNBS and ICF Macro.
Kimani-Murage, E., et al., Patterns and determinants of
breastfeeding and complementary feeding practices
in urban informal settlements, Nairobi Kenya. BMC
Public Health, 2011. 11(396).
Lonnerdal, B., Bioactive proteins in human milk: mechanisms
of action. J Pediatr, 2010. 156(2 Suppl): p. S26-30.
Victora, C.G., et al., Maternal and child undernutrition:
consequences for adult health and human capital.
Lancet, 2008. 371(9609): p. 340-357.
WHO, Global strategy for infant and young child feeding. 2003,
WHO Geneva.
Ziegler, E.E., Growth of breast-fed and formula-fed infants.
Nestle Nutr Workshop Ser Pediatr Program, 2006. 58:
p. 51-9; discussion 59-63
*IDIs=Indepth interviews | KII=Key Informant Interview | TBA=Traditional Birth Attendant | FGD=Focus Group Discussion | CHWs=Community Health Workers
African Population and Health Research Center, APHRC Campus | 2nd Floor, Manga Close, Off Kirawa Road |
P.O. Box 10787-00100, Nairobi, Kenya | [email protected] | www.aphrc.org