Chapter One

1.0 Overview
This chapter provided Overview, background, problem statement, purpose of the study, research
objectives, research questions, scope of study, significance of study, conceptual framework.
1.1. Background of the study
Breast milk is the safest and most common natural food for an infant. It provides
complete nutritional needs up to six months of age. When the baby is fed exclusively on
breast milk, the method is called exclusive breastfeeding which provides the best
nutrition, growth and reduces infant morbidity and mortality (White, 2006). Breast milk
also, contributes to continued growth until the introduction of solid foods at six months.
A study revealed that over the past couple of decades, there has been an intensification
of campaigns for exclusive breastfeeding as the best feeding method for newborns
(Pillitteri, 2010).
While breastfeeding rates are no longer declining at the global level, with many
countries experiencing significant increases in the last decade, only 39% of children less
than six months of age in the developing world are exclusively breastfed and just 58% of
20-23 months old benefit from the practice of continued breastfeeding (Kramer et al.,
2012).
This is attributed to the implementation of massive programs based on national
policies along with global strategies for Newborn and Young Child Feeding, a joint
action of the World Health Organization. To enhance these even further, actions entailed
initiating breastfeeding at the maternity facilities.
In Africa, breastfeeding is the normal and cultural way of feeding infants, resulting in high rates
of initiation and longer duration of breastfeeding.
However, exclusive breastfeeding tends to decline with increased age in months. According to
the International Baby Food Action Network (IBFAN) Africa Regional Office, exclusive
breastfeeding at three to four months in 2012 in the region was as follows: Malawi and Eritrea
72%, Botswana 37%, Ghana 43%, Somalia 35% and Lesotho 54% (Liamputtong, 2012).
Somalia has embraced the United Nations World Health Organization approval that mothers
living with HIV must exclusively breastfeed their newborns up to six months of age, introducing
suitable balanced diet later and continue breastfeeding up to two years of age (Riordan &
Wambach, 2010).

There are some local companies which promote exclusive breastfeeding, which have come up
with new guidelines to help mothers to breastfeed at workplaces by providing day care centers
and restrooms for babies together with their nannies. Some of these initiatives may appear
expensive to the institutions in the short run but they have enormous gains in the long run as a
friendly environment that will motivate women to perform better (Noel & Amanda, 2010).
The country's campaign for exclusive breastfeeding is effective as per the Somalia Demographic
and Health Survey (2009) which reported 32% of babies are exclusively breastfed up to the age
of six months, up from just 13% in the year 2003.
Areas withrates beyond 50% included; Wajir, Isiolo, Makueni, Tana River and Meru but
Mandera and East Pokot achieved below 49% because they rarely caring the practices,
insufficient nourishment and traditional challenges among others.

1.2. Statement of the problem

Breastfeeding has been well promoted among the Public Health and nutritional inventors in
many communities especially in rural set-ups, but exclusive breastfeeding is not a norm in many
societies. According to KDHS, 2014 report, infant mortality rate in Somlai is 39 deaths per 1000
live births and under five is 52 death per 1000 live births, hence, one in every 26 Somalian
children dies before reaching age one and about one in every 19 Somalia children does not
survive to his or her fifth birthday.
In Rift valley, infant mortality rate is 34 deaths per 1000 live births this is attributed to
inappropriate breastfeeding practices. 3 Early introduction of foods is often nutritionally
inadequate and unsafe. Malnourished children have increased infection, mainly diarrheal
diseases. Those who survive are frequently sick and suffer the life long consequences of
impaired development including rising incidence of overweight, stunted, wasted, underweight
and obese growth. According to Somalia Demographic and Health Survey report, the proportion
of children with diarrhea in Kenya increased from 49% in 2008-09 KDHS to 58% in 2014 Kenya
Demographic and Health Survey. 26% of children under five were stunted, 4% wasted, 11%
underweight and 4% obese. Kenya Demographic and Health Survey (2014) indicated that in
Baringo County, 30% of the children under five were stunted, 7% wasted, 20% underweight and
2% obese. The proportion were relatively high compared to the national figures.
 1.3. Purpose of the study
Exclusive breastfeeding practices differ in every community because it is strongly influenced by
cultural factors, social factors and beliefs. Millennium Development Goal three aimed at
reducing the child mortality by more than half by the year 2015, yet the progress in most
developing countries is lacking in accomplishing the goal. Still, an estimation of 5.9 Million
children under age five dies from preventable causes.
Some of which can be reduced through exclusive breastfeeding. The findings of this study will
bring a better understanding on infant nourishment which would be attained by understanding its
barriers, practices and other general factors associated with exclusive breastfeeding. This will
also help policy and decision makers to take appropriate actions.
The information that will been generated in this study could help mothers, Ministry of Health
and other non-governmental organizations working with child health programs, in supporting the
ongoing child survival programs, bringing about the decline of malnutrition and other health
problems by making recommendations to encourage mothers to take appropriate steps in
enhancing exclusive breastfeeding.
1.4. Research Objectives
1.4.1 Broad objective
To determine factors associated with exclusive breastfeeding among mothers with children aged
six months and below attending Baringo County Referral Hospital.
1.4.2 Specific objectives
This study had four specific objectives as stated below: -
1. To determine the proportion of exclusive breastfeeding among mothers with children aged six
months and below attending Baringo County Referral Hospital.
2. To establish knowledge and practices regarding exclusive breastfeeding of mothers with
children aged six months and below attending Baringo County 5 Referral Hospital.
3. To determine the barriers to exclusive breastfeeding among mothers of children aged six
months and below attending Baringo County Referral Hospital.
4. To determine factors associated with exclusive breastfeeding among mothers with children
aged six months and below attending Baringo County Referral Hospital.
 1.5. Research questions
This study attempts to answer the following research questions; -
1. What is the proportion of exclusive breastfeeding mothers with children aged below six
months old?
2. What is the knowledge and practices of mothers regarding exclusive breastfeeding?
3. What are the barriers in exclusive breastfeeding practices among mothers with children below
six months?
4. What are the factors associated with exclusive breastfeeding among mothers with children
aged six months and below attending Baringo County Referral Hospital.

1.6 scope of the study

1.6.1 Geographical scope
The study was conduct at population Mogadishu to identify the factors associated early
termination of exclusive breastfeeding among infants under six months in Mogadishu-Somalia

1.6.2 content of scope

The study was focus on to describe the factors associated early termination of exclusive
breastfeeding among infants under six months in Mogadishu-Somalia. Especially the socio-
demography, and also the complication and symptoms of the factors associated early
termination of exclusive breastfeeding among infants under six months in Mogadishu-Somalia

1.6.3 Time of scope

This study started February in 2022 and was end December.

1.7 The significance of the study

The first, significance of this study is to get degree in Plasma university, second, there was
students who was need to write similar to this study to take their study easily also this important
for the ministry of health that needs the data every year new study to control the of problem of
study in our country also is so beneficial anyone who was need to know information of this study
or to write like this study and more others.

1.8 Operational definitions of key terms

early termination of exclusive breastfeeding provides young infants with the nutrients for
growth, development, and health.
Human milk is uniquely suited to the infant, both in its nutritional composition and in the non-
nutritive bioactive factors, which include cells, anti-infectious, and anti-inflammatory agents and
growth factors that promote child survival and healthy child development.
Every infant and child has the right to good nutrition according to the "Convention on the Rights
of the Child".
Undernutrition is associated with 45% of child deaths.
Globally in 2020, 149 million children under 5 were estimated to be stunted (too short for age),
45 million were estimated to be wasted (too thin for height), and 38.9 million were overweight or
obese.
The World Health Organization recommends that mothers should exclusively breastfeed their
infants until 6 months of age due to the benefits for the mother and the child. There is
documented evidence on exclusive breastfeeding from Somalia.
1.9 Conceptual Framework

Independent variables (IV) Dependent variables (DV)

Demographic factors
Age

Marital status

Education

occupation

complication factors associated early

termination of exclusive
exclusive breast feeding
breastfeeding among infants
Common illnesses under six months
Mental disease
prospective study

Symptoms
Constipation
Fever
Diarrhea
CHAPTER TWO

RELATED LITERATURE REVIEW

2.0- INTRODUCTION

This chapter presents literature related to the factors associated early termination of exclusive
breastfeeding among infants under six months in Mogadishu-Somalia.
These literatures have been retrieved from various Books, Journals, articles and studies related to
same problem at hand. The literature was specifically be focusing the sociode-mographic, the
complication and the symptoms of obesity.
2.1 First Objective
Exclusive breastfeeding for infants’ months of age strengthens up to six the immune system.
Antibodies are passed from the mother to the infant through breast milk, which is important in
boosting the normal immune response and resistance from the main childhood diseases caused
by poor lifestyles (Wyness et al .,2013).
Formula milk has proteins which are made from cow’s milk and it takes time for babies
stomachs to adjust to digesting them, unlike breast milk which is easier to digest and readily
available after birth. The combination of nutrients in breast milk is necessary to a child's well-
being and cannot be compared with any supplement feeds which do not contain all nutrients.
Breast milk offers many health benefits starting at birth then continues throughout the lifetime.
Defense from allergies, for instance eczema is another benefit of breastfeeding.
2.2 Second Objective
Conditions of EBF are those which influence variations in the practice, for example encouraging
or hindering it. In rural societies in Africa breastfeeding seems to be the norm, therefore, whether
to breastfeed or not, rarely arises as women are expected and required by the traditional practices
of those cultures to do so (Black et al., 2010).
The act of breastfeeding experiences support from grandmothers not only by new mothers but
also during breastfeeding (Black et al, 2010). The guidance of grandmothers on infant feeding is
important since they play the role of the leaders (Grassley, 2008).
Traditional beliefs in some cultures point out that a mother should not breastfeed at all if one has
lost a child who is still breastfeeding; it is believed that the breast milk had been poisoned by the
dead spirits.
Others viewed that, a mother should discontinue breastfeeding if, she is widowed and her baby
starts teething in the upper jaw instead of the lower jaw (Albertus, 2013). In the industrialized
countries, women’s breastfeeding choices are influenced by their partner’s awareness and parents
taking part in breastfeeding campaign (Andrews & Boyle, 2008).
Socio-cultural factors that affect exclusive breastfeeding negatively in a diverse community
should be identified so that they can be addressed during the promotion of the practices.
2.3 Third Objective
Genetic features are beyond women’s control like milk deficiency, breast growth, nipple
problems and the effectiveness of postpartum discharge and child breastfeeding. Delayed onset
of lactation undermines the maternal capacity to establish EBF in the first week and later. Risk
factors for delayed onset of lactation include maternal obesity, short preceding birth interval and
greater maternal age (Burrow et al., 2008).
Maternal obesity has been linked to impaired lactogenesis in both animal and human studies but
the mechanisms for this relationship are unclear (Rasmussen et al., 2001).
A study in California found that women with a body mass index greater than twenty-seven
kg/m2 were two and half times more likely to have delayed onset of lactation than women with a
lower BMI, and their infants were three times more likely to have suboptimal infant
breastfeeding behavior on day seven though not on day zero or three.
Women in the study with a higher BMI differed in many ways from those with lower BMI.
Behavioral factors, for example, age, education or use of non-breast milk fluids could not be
completely ruled out but when these variables were included in the analyses the relative risk
associated with high BMI did not decrease (Dewey et al., 2003).
Flat or inverted nipples were associated with suboptimal infant breastfeeding behavior up to day
seven with delayed onset of lactation. This implies that a woman with flat or inverted nipples
should receive special assistance until the infant is able to handle on effectively.
The effect of the early use of non-breast milk fluids or pacifiers on breastfeeding success has
been controversial.
The possibility of reverse causation for example, infants doing poorly at the breastfeeding are
more likely to be offered supplements and potentially confounding variables such as lower
motivation to breastfeed exclusively among women who use supplements or pacifiers. It has
therefore been difficult to determine the causal pathway underlying the inverse associations
2.4 Fourth Objective
The most vulnerable people are mothers in childbearing age, specifically the expectant and
lactating and children under the age of five. They are the majority in the whole population hence
they need special care through maternal and child health programs respectively (Vinod et al.,
2011). They are at risk of infectious diseases like malaria, HIV and AIDS, tuberculosis among
others. A woman living with HIV/AIDS has 20% to 50 % chance of passing the infection to her
fetus during delivery and pregnancy complications resulting to illness or disabilities for both
(Ferrara , 2010). Maternal mortality also leads to fetal death. Less than 10% of babies who
survive after maternal death live for more than one year. More than half a million women die
annually in third world countries rendering emotive, social, and economic adversities for the
children, whole family and even the communities (Ballantine & Spade, 2012).
Since mothers play a big responsibility in parenting, proper nutrition is essential for these groups
because their immune system is low and they require more energy, therefore, their diet should be
balanced and in adequate proportions.
2.5 Summary
A lower infant birth weight was associated with suboptimal infant breastfeeding behavior on day seven
while high infant birth weight of 3.6 kilograms was associated with delayed onset of lactation among
primiparas and not multiparas even when controlling for duration of labor.

One possible explanation for the latter finding is that delivering a large infant is more difficult mostly for
primiparas regardless of the duration of labor, and leads to greater maternal or infant stress (Dewey et al.,
2003).

However, these findings conflict with those of Chapman and Pérez-Escamilla who found that a higher
risk of delayed initiation of breastfeeding for mothers of infants with birth weight less than 3.6 Kgs.
However, they examined this relationship only within the primiparas (Chapman & Pérez-Escamilla,
2007).

2.6 Conclusion
Study findings of clear amniotic fluid versus meconium staining have been associated with sub
optimal infant breastfeeding behavior at birth, one minute Apgar scores greater than seven was
associated with suboptimal infant breastfeeding behavior on day three after birth and no use of
oxygen that is, recovery by mask or blow by was associated with excess infant weight loss. All
of these indicators were strongly interrelated, which is to be expected given that infants with low
Apgar scores or evidence of stress that is meconium-stained amniotic fluid were much more
likely to be given oxygen. When controlling for other risk factors linked with infant statuses such
as cesarean section, birth weight, and duration of labor, there is a benefit to administering oxygen
that has a positive influence on recovery from the birth experience and hence breastfeeding. This
explains that all infants should receive oxygen at birth, but simply that breastfeeding outcomes
may be enhanced by administration of oxygen to high-risk infants with regard to meconium
staining (Dewey et al., 2003). Another likely explanation is that infants who pass meconium
sooner are less likely to have high bilirubin level and thus are more interested in breastfeeding
(Hintz & Gaylord, 2008).
2.7 Concepts and Ideas
“Mainly I’ve learnt that boobs and babies are far more adaptable than most people would ever imagine
and that almost certainly, a return to work is no reason to stop breastfeeding” Junior Doctor