1

JOMO KENYATTA UNIVERSITY OF AGRICUTURE AND TECHNOLOGY.

NAME: IRENE MWENDWA

REG NO: ENC 211-0044/2017

UNIT: RESEARCH METHODOOGY.

TASK: RESEARCH PROPOSAL.

BREASTFEEDING PRACTICES AND MORBIDITY AMONG CHILDREN AGED 0-24

MONTHS IN KAHAWA SOWETO, NAIROBI COUNTY.

A RESEARCH PROPOSAL SUBMITTED IN PARTIAL FULFILLMENT OF BACHELOR

OF SCIENCE DEGREE IN CIVIL ENGINEERING.

DECEMBER 2021

DECLARATION

This Research proposal is my original work and has not been presented for a degree in any other

University.

1) Signature Date

Name: IRENE MWENDWA ENC211-0044/2017

 2

Table of Contents ........................................................................................................................................ 1

ABBREVATIONS AND ACRONYMS .................................................................................................... 2
OPERATIONAL DEFINITION OF TERMS .......................................................................................... 3
ABSTRACT ................................................................................................................................................. 4
INTRODUCTION....................................................................................................................................... 5
1.1 BACKGROUND TO THE STUDY................................................................................................. 6
1.2 STATEMENT OF THE PROBLEM .............................................................................................. 7
1.4 OBJECTIVES OF THE STUDY ..................................................................................................... 8
1.4.1 MAIN OBJECTIVE .................................................................................................................. 9
1.4.2 SPECIFIC OBJECTIVE .......................................................... Error! Bookmark not defined.0
1.4.3 RESEARCH QUESTIONS ........................................................ Error! Bookmark not defined.
1.5 LIMITATIONS OF THE STUDY.................................................... Error! Bookmark not defined.
1.6 CONCEPTUAL FRAMEWORK ..................................................... Error! Bookmark not defined.
CHAPTER TWO: LITERATURE REVIEW ........................................... Error! Bookmark not defined.
2.1 BREAST MILK AND ITS IMPORTANCE .................................... Error! Bookmark not defined.
2.2 BREASTFEEDING PRACTICES ................................................... Error! Bookmark not defined.
2.2.1 COMPLEMENTARY FEEDING ............................................. Error! Bookmark not defined.
2.3: SOCIO-ECONOMIC FACTORS IN URBAN SETTLEMENTS Error! Bookmark not defined.
2.4: MORBIDITY STATUS .................................................................... Error! Bookmark not defined.
2.5: NUTRITIONAL STATUS ............................................................... Error! Bookmark not defined.
CHAPTER 3: METHODOLOGY .............................................................. Error! Bookmark not defined.
3.1 RESEARCH DESIGN ....................................................................... Error! Bookmark not defined.
3.2 STUDY AREA .................................................................................... Error! Bookmark not defined.
3.3 TARGET POPULATION ................................................................. Error! Bookmark not defined.
3.4 SAMPLING ........................................................................................ Error! Bookmark not defined.
3.4.1 SAMPLE SIZE DETERMINATION ........................................ Error! Bookmark not defined.
3.4.2 DATA COLLECTION TOOLS ................................................ Error! Bookmark not defined.
3.4.DATA ANALYSIS ............................................................................. Error! Bookmark not defined.
3.5 BREASTFEEDING PERFORMANCE INDEX (BPI) ................... Error! Bookmark not defined.
References ..................................................................................................... Error! Bookmark not defined.
 3

ABBREVATIONS AND ACRONYMS

WFH Weight For Height

WHO World Health Organization

UNICEF United Nations Children’s Fund

LMICs Low and Middle Income Countries

APHRC African Population and Health Research Centre

DALY Disability Adjusted Life Years

IYCF Infant and Young Child Feeding

 4

OPERATIONAL DEFINITION OF TERMS

Weight for age: is an indicator of nutritional status that is used to monitor growth of children

and indicate chronic or acute malnutrition.

Height for age: is an indicator of nutrition status that gives information on the nutritional

situation in the past and indicates whether a person suffers from chronic malnutrition.

Weight for height: is a nutritional indicator that gives information on the present nutritional

status and indicates whether a child suffers from acute malnutrition. The weight of a child is

taken and compared against the weight of a standard child of the same height.

Recommended breastfeeding practice: is the breastfeeding pattern that ensure optima; growth,

development and health of infants. It include exclusive breastfeeding for the first six months, the

introduction of complimentary feeding with continued breastfeeding for up to two years

(WHO/UNICEF, 2003).

Exclusive breastfeeding: is the feeding of the infants with breast milk only.

Attitude: the individual feelings, opinions or thoughts about something.

Breastfeeding: is the action of feeding a baby with milk from the breast.
 5

ABSTRACT

Child health is a prime concern to any country. Poor child health has a far reaching consequence

on the future of a developing country. Malnutrition is the leading causes of morbidity among

infants. It increases the vulnerability to diseases due to immunological deterioration. It includes

cases of stunting and wasting. Infants residing in urban settlements are at a greater risk of

malnutrition due the vulnerabilities offered by their biophysical, demographic and socioeconomic

environment. Inappropriate breastfeeding practices like bottle-feeding irregular patterns of

breastfeeding and pre lacteal feeds within one hour after birth are also key contributors to

morbidity and mortality among infants. The duration of breastfeeding below the recommended

duration will leave the infant vulnerable to disease. This study focused on breastfeeding practices

and morbidity among children aged 0-24 months in Kahawa Soweto. A descriptive cross sectional

survey was carried out. The study tools included an open-ended questionnaire, which focused on

assessing the mothers’ level of knowledge on recommended breastfeeding practices, social

demographic characteristics of the mothers and their families and morbidity status among the

children aged 0-24 months.

This study showed that majority of the householdheads were men (94.3%). Out of those household

heads, (51.9%) were employed. Majority of the mothers and caregivers were below the age of 30

and among them, 69.8% were housewives. Only 5.7% of the mothers` were employed. 53.8% of

the children were breastfed before one hour after birth. 53.8% of the mothers’ did not practice pre

lacteal feeding. Bottle feeding was slightly common in the area with 42.5% of the mothers’

practicing it. During the time of the study, 78.3% of the infants were still being breastfed. Only

24.5% of the mothers’ expressed breast milk. Majority of the mothers’ knew that a child should

be breastfed on demand (74.5%). A large number of the mothers’ obtained information about
 6

breastfeeding from clinics in the area. 70.8% of the mothers knew that colostrum should be given

to a child.

43.4% of the children were moderately wasted while 34.91% were underweight. 59.4% of the

children had a history of previous illness. In a period of 14 days, 24.5% of the targeted population

had been ill. Common cases were; fever, cough, meningitis and jaundice.

Majority of the mothers had knowledge on the recommended breastfeeding practices. Exclusive

breastfeeding was not practiced fully as there were cases of inappropriate breastfeeding practices.

It was also realized that majority of the mothers were unemployed.

From the study, there should be an emphasis on the benefits of breastfeeding, expression of breast

milk and its benefits and breastfeeding and other feeding options for infants older 6 months. There

is also the need to encourage women to be employed and guidance of first time mothers’.
 7

INTRODUCTION

1.1 BACKGROUND.

Breast milk is the global standard meal for optimal infant nutrition and health. It’s a natural

resource that has a major impact on child health, growth and development. Breastfeeding

promotion is a key in newborn and child survival. Optimal breastfeeding practices include

exclusive breastfeeding (breast milk with no other foods or liquids) for the first six months of

life, followed by breast milk and complementary foods (solid or semi-solid foods) from about six

months of age on, and continued breastfeeding for up to at least two years of age at beyond,

while receiving appropriate complementary foods. WHO recommends introduction of

complimentary feeding after six months with continued breastfeeding for up to 24 months or

beyond according to WHO. Sub-optimal breastfeeding results in over 800000 deaths of under 5

children annually including 250000 due to morbidity. Morbidity is defined as the rate of disease

in a population. Studies by UNICEF in low income countries and middle income countries

indicate increased rates of morbidity among infants due to the practice of suboptimal

breastfeeding practices. . For example, a study by Kerac (2011)using data from Demographic and

Health Surveys indicated that among 21 developing countries, prevalence of wasting for children

under 6 months may be as high as 34%. .In Kenya, high levels of undernutrition has been

documented. At the national level, 35% of children under 5 years are stunted, 16% are

underweight, and 7% are wasted (Kenya National Bureau of Statistics & ICF Macro 2009).The

problem of under nutrition is even worse in urban poor settings with stunting prevalence of over

40% (Olack, 2011; Abuya ,2012).

 8

1.2 STATEMENT OF THE PROBLEM

Lack of support and inadequate knowledge on recommended breastfeeding practices affect the

breastfeeding practices and the required breastfeeding duration rates (WHO 2017). Poor care

practices during the first 1000 days of life have been widely documented in the Low-and Middle

Income Countries (LMICs). For example, about 40% of infants in LMICs are exclusively

breastfed for the first 6 months (Lauer 2004).In Kenya, a third of children living in urban

settlements(slums) are exclusively breastfed for the first 6 months while about 40% of children in

Kenya aged 6–23 months are fed according to IYCN guidelines (World Health Organization

2005). According to KDHS 2014, just over 60% infants were breastfed before one hour after

birth in the whole country. However in urban poor settings in Kenya, poor infant feeding

practices have been identified. While close to 40% of the infants are not breastfed within 1 h

following delivery, 15% stop breastfeeding by the end of 1 year (Kiman - Murage. 2011). High

levels of malnutrition have been documented among urban settlements with a stunting

prevalence of 40% ( Abuya 2012) due to poor infant feeding practices among other potential

causes such as poor water and environmental sanitation and access to health services (African

Population and Health Research Center 2002a,b; Kimani-Murage & Ngindu 2007).The factors

that are associated with suboptimal breastfeeding and complementary feeding practices include

maternal characteristics such as age, marital status, occupation and education level; antenatal and

maternity health care seeking; health education and socio-economic status; and the child’s

characteristics including birth weight (Setegn 2012).In addition, social-cultural factors including

food insecurity, lack of knowledge or competence, socio-cultural myths and health status of the

mother are also related to sub-optimal breastfeeding practices. These factors lead to
 9

undernutrition which may be short term effect or a long term effect on child’s health and

survival. They are also associated with increased morbidity (World Health Organization 2009).

The urban settlements have poor housing, no basic infrastructure such as potable water and waste

disposal, and are characterized by high levels of violence and insecurity, unemployment and

poor health indicators (Fotso 2012). Being malnourished leaves an infant susceptible to Acute

respiratory infection, fever and diarrhea. According to KDHS 2014, diarrhea caused by use of

contaminated water and improper practices in food preparation, causes dehydration which leads

to cases of morbidity and mortality.

 10

1.4 OBJECTIVES OF THE STUDY

1.4.1 MAIN OBJECTIVE

To determine breastfeeding practices and morbidity among children aged 0-24 months in

Kahawa Soweto

1.4.2 SPECIFIC OBJECTIVE

1. To establish the social-demographic factors of mothers and its relation to morbidity

2. To assess mothers level of knowledge on recommended breastfeeding practices

3. To determine the frequency of breastfeeding.

4. To assess the nutritional status of children aged 0-24 months

5. To assess the morbidity status of the children aged 0-24 months

1.4.3 RESEARCH QUESTIONS

1. Does the social-demographic factors of the mothers relate to morbidity among the

children?

2. Are the mothers or the caregivers well informed on the recommended breastfeeding

practices?

3. How frequent are infants breastfed in the area?

4. What’s the level of nutritional status among infants in the area?

5. What are the common cases of illnesses?

 11

CHAPTER TWO: LITERATURE REVIEW

2.1 BREAST MILK AND ITS IMPORTANCE

Breast milk is produced by mammary glands of a human female to feed child. It’s the primary

source of nutrition for newborns before they are able to eat and digest other foods. Breastfeeding

offers health benefits to mother and child even after infancy. Few examples of importance of

breast milk include:

1. There is increased intelligence. Nucleotides found in high concentrations in breast milk

are involved in increase in head size in early infancy reflecting an increase in brain

volume during a critical period in development and is related to higher cognitive function

later in life (Bredow M ;The influence of head growth in fetal life, in-fancy and childhood

on intelligence at the age of 4. 2006)

2. It provides cold and flu resistance. Immunoglobulin A found in breast milk is important

because it coats and seals the infant’s respiratory and intestinal tract to prevent germs

from entering his/her body and his/her bloodstream. The IgA antibodies protect the

infant from a variety of illnesses including those caused by bacteria, viruses, fungi, and

parasites (Steinhoff, M. C. (2018). Breast Milk; Immunoglobulin G as a Correlate of

Protection against Respiratory Syncytial Virus Acute Respiratory Illness).

3. Presence of Leukocytes which primarily provide active immunity and promote the

development of immunocompetence in the infant

4. It also reduces the risk of developing psychological disorders. Breast milk contains health

promoting anaerobic bacteria including bacteriodes. These individual species aid in early

development of mucosal immune system which appears to provide lifelong protection

 12

against expression of disease (Kaplan JL The role of microbes in developmental

immunologic programming. 2011)

Universally, there is no commercial formula that can equal breast milk. Breast milk has

appropriate amounts of carbohydrates, protein, and fat. In addition, it provides vitamins, minerals

digestive enzymes and hormones. It also contains antibodies and lymphocytes from the mother

that help the baby resist infections (Le-Doare, K. M. 2015. Human breast milk: A review on its

composition and bioactivity). The immune function of breast milk is individualized as the mother

through her touching and taking care of the baby, comes into contact with pathogens that

colonize the baby and as a consequence her body makes the appropriate antibodies and immune

cells.

Breast milk is produced under the influence of the hormones prolactin and oxytocin. The initial

milk to be produced after giving birth is referred to as colostrum. Its high in immunoglobulin. Its

responsible for protecting the newborn until its own immune system is functioning properly

(Blumberg, R. S. (2016). How colonization by microbiota in early life shapes the immune

system). According to Becker GE “Methods of milk expression for lactating women”, a greater

volume of milk is expressed while listening to relaxing audio during breastfeeding, along with

warming and massaging of the breast prior to and during feeding. A greater volume is expressed

can also be attributed to instances where the mother starts to pumping milk sooner, even if the

infant is unable to breastfeed.

2.2 BREASTFEEDING PRACTICES

According to WHO, breastfeeding is an unequalled way of providing ideal food for the healthy

growth and development of infants. To enable mothers to establish and sustain exclusive

breastfeeding for 6 months, WHO and UNICEF recommend;

 13

 Initial breastfeeding within the first hour of life.

 Exclusive breastfeeding- refers to the type of infant feeding in which the infant only

receives breastmilk without any additional food or drink not even water.

 Breastfeeding on demand – that is as often as the child wants, day and night

 No use of bottles, teats or pacifiers

Breastmilk promotes sensory and cognitive development, and protects the infant against

infectious and chronic diseases. Exclusive breastfeeding reduces infant mortality due to common

childhood illnesses such as diarrhea or pneumonia, and helps for a quicker recovery during

illness. Breastfeeding contributes to the health and well-being of mothers; it helps to space

children, reduces the risk of ovarian cancer and breast cancer, increases family and national

resources is a secure way of feeding and is safe for environment. While breastfeeding is a natural

act, it’s also a learned behavior. An extensive body of research of WHO and UNICEF, it

demonstrated that mothers and other caregivers requires require active support for establishing

and sustaining appropriate breastfeeding practices. However, various social and structural

barriers influence breastfeeding practices, hence making it impractical to actualize WHO

recommendations for breastfeeding in urban settlement. There is high level of poverty, poor

livelihood and poor living conditions. This is due to unemployment, alcoholism and undefined

living arrangements (Muindi K., Elung’ata P. (2011) Monitoring of health and demographic

outcomes in poor urban settlements). Others include: poor social and professional support, poor

knowledge, myths and misconception, HIV and unintended pregnancies.

 14

2.2.1 COMPLEMENTARY FEEDING

Complementary foods are often of lesser nutritional quality than breast milk. In addition, they are

often given in insufficient amounts and, if given too early or too frequently, they displace breast

milk (WHO 2002 COPLEMENTARY FEEDING). Gastric capacity limits the amount of food

that a young child can consume during each meal. Repeated infections reduce appetite and

increase the risk of inadequate intakes. Infants and young children need a caring adult or other

responsible person who not only selects and offers appropriate foods but assists and encourages

them to consume these foods in sufficient quantity. Global recommendations for appropriate

feeding of infants and young children are: Breastfeeding should start early, within one hour after

birth. Breastfeeding should be exclusive for six months. Appropriate complementary feeding

should start from the age of six months with continued breastfeeding up to two years or beyond.

Appropriate complementary feeding is:

1. Timely – meaning that foods are introduced when the need for energy and nutrients exceeds

what can be provided through exclusive and frequent breastfeeding.

2. Adequate – meaning that foods provide sufficient energy, protein, and micro nutrients to meet

a growing child nutritional needs.

3. Safe – meaning that foods are hygienically stored and prepared, and fed with clean hands

using clean utensils and not bottles and teats.

4. Properly fed – meaning that foods are given consistent with a child’s signals of appetite and

satiety,
 15

2.3: SOCIO-ECONOMIC FACTORS IN URBAN SETTLEMENTS

Socio-economic status shows individuals living standards, life style and all over development

and progress. The education, occupation are the most important elements in the study of socio-

economic status of population. Besides these elements age, caste are also taken into

consideration. Slum is considered unhygienic place for human settlements. It’s the human

settlement in divert condition or situation (UNHABITAT 2003; Slums of the world). The urban

settlements have poor housing, no basic infrastructure such as potable water and waste disposal,

and are characterized by high levels of violence and insecurity, unemployment and poor health

indicators (African Population and Health Research Center Fotso 2009) It’s the adjustment with

nature and compromise with life’s needs for survival in worst conditions. This happens due to

poverty affecting the people who reside in the area. Hence the population is backward socially

and economically. Poverty affects the health, nutrition, education, birth and death ratio. Due to

poverty economic status is lower, so education level is low, unskilled or low skills, so the socio-

economic status of people in the slum is low. Some of this houses are headed by Women. They

are lower educated unskilled, have poor economic condition so they perform the work as per

capacity which has impact on their children.

Human settlement is a term used to refer to slums as they are known in Brazil, Egypt, Turkey

and Kenya. These human settlements have local native words like favelas or kijiji. The United

Nations Expert Group characterizes human settlements as a place with inadequate access to clean

and safe water, low level of sanitation, poor structural quality of housing, a congested location,

there is high rate of unemployment and high rate of communicable diseases. According to KDHS

2014, for child survival, health and development there is need to focus on a healthy start of life.
 16

However this turns to be a challenge in the human settlements. The socioeconomic differences

have an impact on infant and child mortality. A study by the UN also shows that children in

Nairobi slums are two and half times more likely to die before their fifth birthday due to the

existence of young mothers who have little knowledge on the recommended breastfeeding

practices and can hardly afford to feed their children, Few resources and poor sanitation is a

challenge during the initiation of complimentary feeding. This leaves a risk of contracting a

disease due to lack of clean water which is also expensive in these type of areas

There exists a need to work on morbidity of children in human settlements to aid in the reduction

of mortality of children to help to reduce the negative effect on the development of the country

2.4: MORBIDITY STATUS

Morbidity is defined as the rate of disease among a population. A large global disease burden is

attributed to sub-optimal breastfeeding practices accounting for 77% and 85% of the under- five

deaths and disability-adjusted life years (DALYs), respectively (Black, 2008). According to

(Black 2008), sub-optimal breastfeeding, especially non- exclusive breastfeeding in the first six

months of life, results in 1.4 million deaths and 10% of disease burden among children younger

than five years. In developing countries, sub-optimal breastfeeding practices during the first

months of life are an important risk factor for infant and childhood mortality, especially resulting

from diarrhea and acute respiratory infection (WHO 2011). Kenya is rated among 22 countries in

Africa with poor infant and young child feeding (IYCF) practices with a resultant high burden of

under nutrition among the under-fives (UNICEF 2011).The latest Kenya Demographic and

Health Survey (KDHS) showed that nutritional status of children under five in Kenya is poor

with 26% stunted, 4% wasted and 11% underweight. Cases of diseases among infants include:
 17

1. Acute respiratory infection (ARI) which is a leading cause of childhood morbidity and

mortality throughout the world (Pan American Health Organization (PAHO) and World

Health Organization (WHO). 2003. Guiding Principles for Complementary Feeding of

the Breastfed Child).

2. Fever which is a major symptom of malaria and other acute infections in children.

3. Diarrhoea causes dehydration among infants which is a major cause of morbidity and

mortality infants (, N. Gour; Morbidity of under 5 children in urban slums).

2.5: NUTRITIONAL STATUS

.High levels of malnutrition have been documented in low-income countries despite many global

strategies, declarations and policies aimed at combating it (World Health Organization 2007)

Wasting, including severe wasting with implications on child survival, is also prevalent in low-

income countries. For example, a study by Keral.(2011) using data from Demographic and

Health Surveys indicated that among 21 developing countries, prevalence of wasting for children

under 6 months may be as high as 34%.In Kenya, high levels of undernutrition have been

documented. At the national level, 35% of children under 5 years are stunted, 16% are

underweight, and 7% are wasted (Kenya National Bureau of Statistics & ICF Macro 2009).The

problem of undernutrition is even worse in urban poor settings with stunting prevalence of over

40% (Olack 2011). .The global strategy on infant and young child nutrition (IYCN) highlights

the notion that inadequate knowledge about proper foods and feeding practices is often a more

important determinant of malnutrition than the availability of food (World Health

Organization2003). While close to 40% of the infants are not breastfed within 1 h following

delivery, only 2% are exclusively breastfed for the first 6 months, and 15% stop breastfeeding by

the end of 1 year (Kimani-Murage 2011).As a possible consequence of poor infant feeding
 18

practices high levels of malnutrition have been documented among urban poor residents with

stunting prevalence of over 40% (Abuya 2012). Stunting reflects a failure to reach linear growth

potential. Stunting is a key indicator for chronic malnutrition. Globally between 171 million and

314 children are classified as stunted (WHO database on child growth and malnutrition). 90%

of this burden occurs in 36 African countries.

CHAPTER 3: METHODOLOGY
3.1 STUDY DESIGN

The research was conducted using a descriptive cross-sectional design.

3.2 STUDY AREA

This study will be conducted in Kahawa Soweto, an informal settlement found in Nairobi

constituency. The study area is located in between the Kenyatta university hospital and Kahawa

West and borders the Farmers choice company.

3.3 TARGET POPULATION

The study targets mothers’ and children of 0-24 months of age attending public outpatient health

center in Kahawa Soweto and lactating mothers in the area. The estimated targeted population in

this study of caregivers of the children was 106 (n).

3.4 SAMPLING

3.4.1 SAMPLE SIZE DETERMINATION

The Fischer’s formula will be used for sample size for sample size calculation (Lwanga,

Lemeshow & World Health Organization, 1991).

 19

N=Z2*pq / d2

Where n= the desired sample size

Z= standard normal deviation set at 95% confidence level (1.96)

d= desired precision set at (0.09)

P= estimated prevalence of morbidity and suboptimal breastfeeding practices among

children aged 0-24 months (0.34)

q= 1-p (children under optimal breastfeeding practices and not affected by morbidity)

N = 1.962 X 0.34 X 0.66 / 0.092

N= 106 respondents will participate in the interview by responding to questionnaires

3.4.2 DATA COLLECTION TECHNIQUE

Structured questionnaires will be used for data collection in the area. The questionnaire comprise

a section assessing the social economic status of the caregivers and a section of morbidity that

will be used to assess the morbidity status of the infants in the area. It also comprises of a section

that will assess the level of breastfeeding practices and the level of knowledge on the

recommended breastfeeding practices.

3.5 DATA ANALYSIS

The data will be collected and entered in statistical package for social sciences (SPSSv16) for

analysis purposes. Data from open-ended questions will be pre-coded before entry. Various

forms of presentations will be used i.e. frequency’s, frequency tables, percentages, graphs

,charts and pie charts.

3.6 Study Limitations.

 20

The study will be carried out in a public health setting hence the findings are void of the users of

private health facilities.

21