Are WHO Breastfeeding Recommendations Practical in Urban Poor Settings in Kenya?

There are numerous short and long-term benefits associated with breastfeeding. 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 (Lanigan and Singal 2009, Victora et al. 2008, Grantham-McGregor et al 2007).

But how does Breastfeeding provide all these benefits?

This question was answered at the IUNS 20^th International Congress of Nutrition (ICN), Granada Spain, September 15-20^th 2013. 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 (MFGM), which may explain the difference in infection levels and cognitive development between breastfed and formula fed children. It is now known that breastfed infants may gain more fat in the first six months of life compared to formula fed children but gain more fat-free mass after six months, which reduces the risk of obesity later in life.

The global nutrition target

The 65^th 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). In Kenya, according to the Kenya Demographic and Health Survey (KDHS) 2008-2009, only a third of children under the age of six months are exclusively breastfed. The worst situation seems to be in the urban slums where most urban residents in Kenya work. Only two per cent 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).

Factors affecting Breastfeeding practices in Kenya

I presented results of a recent study conducted by the African Population and Health Research Center (APHRC) explaining the poor practices in the Kenyan urban slums at the IUNS 20^thInternational Congress of Nutrition. While urban poor residents recognize the WHO recommendations for breastfeeding, actualizing these recommendations is seen as impractical due to factors related to the ecological setting including socio-economic and structural barriers. These context specific factors include:

• Livelihood issues where women have to resume casual labor shortly after birth in the cash-based economic setting;
• High levels of teenage pregnancy where young mothers worry about body image related to faster aging and sagging of breasts due to breastfeeding and also worry about the child getting used to breastfeeding while they (mothers) need to go back to school;
• High levels of food insecurity while many people believe that lack of adequate food leads to inadequate breast milk, thus affecting breastfeeding practices;
• High levels of HIV, twice the national level, while there is mixed understanding regarding breastfeeding and HIV, with exclusive breastfeeding often being thought to be a reserve of HIV positive women which affects breastfeeding practices overall due to HIV stigma;
• Poor professional and social support in a setting where many mothers deliver at home so no professional counseling on breastfeeding is offered around the time of birth like happens with hospital delivery, many have no domestic help so resume household chores immediately after delivery, while for married women, husbands are often drunkards, offering little financial and psychosocial support.

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 without considering the wider ecological setting are unlikely to be successful.

This is an excerpt from Dr. Kimani’s presentation at the IUNS 20^th International Congress of Nutrition in Granada, Spain (15-20^th September 2013).