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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 by the end of the 11th 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. © 2011 Kimani-Murage et al; licensee BioMed Central Ltd.
The study was carried out in two urban slums of Nairobi Kenya (Korogocho and Viwandani) where the African Population and Health Research Center (APHRC) runs a health and demographic surveillance system; the Nairobi Urban Health and Demographic Surveillance System (NUHDSS). The two slum areas are densely populated (63,318 and 52,583 inhabitants per square km, respectively), and are characterized by poor housing, lack of basic infrastructure, violence, insecurity, high unemployment rates, and poor health indicators [14,15,17]. The socio-economic status of the two slums differs slightly: Viwandani has relatively higher levels of education and employment as being located in the industrial area, it attracts migrant workers. On the other hand, the population of Korogocho is more stable since on average, residents in the area have lived the area for a longer period than Viwandani residents. Approximately two thirds of married men live with their spouses in Korogocho, compared with half in Viwandani. The NUHDSS involves a systematic recording (every four months) of vital demographic events including births, deaths and migrations occurring among residents of all households in the NUHDSS area, since 2003. Other data that are collected regularly include household assets, morbidity, and highest educational attainment. This paper is based on data from a maternal and child health component of a broader longitudinal study entitled “Urbanization, Poverty and Health Dynamics in sub-Saharan Africa” that was nested within the NUHDSS. The study started in February 2007 and ended in December 2010. All women who gave birth since September 2006 and their children were enrolled in the study and were followed up every four months to obtain data including self-reported health status, breastfeeding, complementary feeding practices, vaccination and health care. Data on socio-economic status was extracted from the NUHDSS database and linked to the study participants through their household identifier. The data presented in this paper were collected at baseline and during the first two updates, four months apart, for each child recruited between February 2007 and May 2009. Therefore, the follow-up period for each child was on average nine months and the average age of the children at the second update was 15 months. However, we restrict our analyses to the first year of life for all 4,299 children who were enrolled in the study. Table Table11 presents the sample size for the children involved in the study and the data collection dates. Six cohorts of children enrolled during the study period are included. Sample Size, Nairobi informal settlements, Kenya * Censored Note: The total number of children enrolled across all six panels is 4299 The two dependent variables are cessation of breastfeeding and introduction of complementary foods (liquids and solids). Cessation of breastfeeding is a time-dependent variable indicating the age when breastfeeding was stopped. Introduction of complementary foods is also a time-dependent variable indicating the age at which complementary foods (either liquids or solids other than breastmilk) were introduced. Children who entered the study after the events (breastfeeding cessation or initiation of complementary foods) had occurred had their information updated retrospectively. About 1% of children were never breastfed and were excluded from survival analysis. Children who did not have their information updated due to loss to follow-up were excluded from the study. The independent variables were: the child’s sex; the mother’s age (< 25 years, 25-34 years, 35+ years); the marital status of the mother (in union i.e. currently married or living with someone; previously in union; and never married/in union); the ethnicity of the mother (Kikuyu, Luhya, Luo, Kamba, and other tribes); the highest level of education (none, primary, secondary or higher); and parity (1, 2, 3+); pregnancy desirability of the index child (wanted at the time of conception, wanted later and never wanted,); the place of delivery (health facility, home or traditional birth attendant [TBA]); the mother's perception of the child's size at birth (normal, smaller than normal, larger than normal); the socio-economic status of the household; and the slum of residence (Viwandani or Korogocho). The household socioeconomic status was defined using the household monthly expenditure per capita, taking a child to be the equivalent of half an adult. The expenditure data used was obtained from the poverty component of the Urbanization, Poverty and Health Dynamics study, and was collected in the same year as the data for the dependent variables above. This variable was recoded as tertiles of "poorest", "middle" and "least poor". The survival analysis of the duration of breastfeeding and the time to introduction of complementary foods is presented using Kaplan-Meier survival curves. Cox regression analysis was performed to determine factors associated with breastfeeding cessation during infancy and early introduction of complementary foods. Some independent variables had missing values, mainly maternal level variables such as the mother's age, ethnicity, the highest level of education; and the household's socio-economic status. A missing category was created in the multivariate analysis to keep all cases in the analysis (though results for missing category are not shown). In all cases, except the household expenditure variable, the number of cases with missing information was less than 10%. About one-third of the participants were missing data on household expenditure, therefore imputation using a linear interpolation computation procedure was used. A p-value of less than 0.05 was used as the cut-off for statistical significance. 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.
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