World Health Organization recommends the formation of Mother-to-Mother Support Groups (MtMSGs) to improve nutrition information for mothers. This strategy has been implemented in Turkana since 2008. With limited research on its contribution to improved complementary feeding practices, this study sought to ascertain if there were significant differences in complementary feeding practices and nutrition status of children 6-23 months of MtMSGs participants and MtMSGs non-participants. The study targeted mothers of children 6 to 23 months of age and their children in 3 locations in Kakuma Division. Systematic random sampling was used to select the 177 MtMSGs participants from Kakuma location and 179 MtMSGs non-participants from Pelekech and Nakalale locations. A structured questionnaire was used to collect socio-economic, demographic, and complementary feeding practices data. Anthropometric tools were used to measure the length and weight of the children 6-23 months. Focused Group Discussions (FGDs) involving fathers, grandmothers, and traditional birth attendants (TBAs) were also carried out. The data obtained from this study was analyzed using SPSS version 20. Anthropometric data was analyzed using ENA for SMART 2015. Data was presented in figures and tables. Pearson correlation (r), T-test, chi-square, and odds ratio were used to measure associations, relationships, comparisons, and risk associated with being or not being MtMSGs participants, respectively. With a response rate of 94.1% (MtMSGs participant) and 95.2% (MtMSGs non-participants), the results showed 61.0% and 51.4% of the children of MtMSGs participants and MtMSGs non-participants respectively, were still breastfeeding. The results further showed that MtMSGs participants were 1.8 times more likely to introduce complementary foods at 6 months while MtMSGs non-participants introduced foods earlier than 6 months. The odds ratio showed that MtMSGs participants were 1.3 times more likely to continue breastfeeding up to 23 months than MtMSGs non-participants who had an early stoppage (OR= 1.32; P=0.024 CI, 0.97 to 3.938). The mean dietary diversity score was 3.7±1.6 with the majority (61.6%) being in the lower tercile (<3) for the MtMSGs participants and a bigger proportion (73.2%) of the MtMSGs non-participants. Children belonging to MtMSGs participants were twice more likely to feed on a diversified diet compared to their counterparts. Global acute malnutrition was significantly higher (25.7%) in the MtMSGs non-participants as compared to the 16.9% in the MtMSGs participants. In conclusion, being in MtMSGS group led to a higher likelihood of the introduction of foods at 6 months and continued breastfeeding up to 2 years. More children in the comparison group were malnourished than in the MtMSGs group. This study, therefore, recommends more sensitization of mothers on exclusive breastfeeding, continued breastfeeding, and optimal complementary feeding.
CHAPTER ONE: INTRODUCTION
Background of the Study
Infants and young children have rights as defined by the Convention on the Rights of the child. One of those rights is a right to good food and thus, good nutrition (United Nations Children Emergency Fund [UNICEF], 2003). During infancy and childhood, good nutrition promotes optimal growth, development, health, and nutrition status (World Health Organization [WHO] & UNICEF, 2003). Poor infant and young child feeding practices such as poor breastfeeding practices and sub-optimal complementary feeding practices threaten a child’s health and survival (WHO, 2003).
Optimal infant feeding has been shown to reduce child mortality by 19% with exclusive breastfeeding contributing the highest reduction in child mortality by 13% while poor nutrition causing 45% of deaths in children under five worldwide. Insufficient quantity of complementary foods, poor quality of complementary foods, poor feeding practices, and increased rates of infection during the 6-23 months period are risk factors for stunting (Jones et al., 2003; Black et al., 2013; Danaei et al., 2016). Globally, only 41% of infants are exclusively breastfed up to 6 months. This is below the 2030 target of 70% (WHO, 2018). Complementary feeding is inadequate and is started too early or too late in most countries (White et al., 2017). Complementary foods are mostly inadequate in nutrition content and are prepared under poor hygienic conditions rendering them unsafe (WHO, 2003).
In Kenya, the introduction of complementary feeding is early with 15% of infants given complementary feeds at the age of 2-3 months (KNBS & ICF Macro, 2015). 21% of children 6-23 months are fed on nutritionally inadequate diets. A study in Kitui found out that dietary diversity was poor at 2.4 with more consumption of cereals compared to proteins (Kimiywe & Chege, 2015). Nearly half of the children 6 to 23 months in Kenya consume a diet inadequate in nutrients hence do not meet their nutrition needs (KNBS & IFC Macro, 2010). Kimiywe and Chege (2015), found out that meal frequency and dietary diversity significantly correlated with child nutrition status. Many scientific studies have shown that inappropriate feeding practices can have profound consequences on the growth, development, and survival of infants and children (Saha et al., 2008). Kimwele & Ochola (2017) in a study conducted in Kahawa West (Nairobi) found out that dietary diversity and meal frequency were associated with wasting, stunting, and underweight. Similar findings were reported in another study in Korogocho slums which showed that lack of minimum acceptable diet was a predictor of wasting (Korir, 2014).
The government of Kenya is committed to improving child health and nutrition in line with the Big 4 Agenda. The National Nutrition Action Plan (Ministry of Health, 2012) has set complementary feeding targets to improve “proportion of children 6 to 23 months consuming 3+ or 4+ food groups in a day (dietary diversity) from 39% (2008) to 67% in 2017. The National Strategy for Maternal Infant and Young Child Nutrition (MIYCN; 2012–2017), highlights timely, appropriate, adequate and safe complementary feeding for children 6–23 months (MoH, 2012). The Government of Kenya in collaboration with
other organizations has put up initiatives to improve infant and young child feeding (IYCF) practices. One such program was rolled out in 2012 by International Rescue Committee to support Mother-to-Mother Support Groups (MtMSGs) dubbed Enhancing Nutrition preparedness, Surveillance, and Resilience in Kenya’s arid and semi-arid lands (ENSURE) project. The project was implemented in Mandera, Wajir, and Turkana Counties giving support to the implementation of the High Impact Nutrition Interventions (HINI) package and fortifying the capacity of Sub-County and county health management teams to coordinate, supervise and monitor nutrition activities. The program was central to the project. The 3-year project funded by the UK Department for International Development (DFID) commenced in November 2012 and ended in January 2016. The project was implemented by a consortium of four partners: International Rescue Committee (IRC), Islamic Relief Kenya (IRK), Save the Children International Kenya (SCI), and World Vision Kenya (WVK).
The government further developed the Baby Friendly Community Initiative (BFCI) guidelines in 2016. The BFCI guideline states the formation of mother-to-mother support groups (MtMSGs) as an intervention to improve child nutrition and health information at the community level (Kenya Ministry of Health, 2016). Mother-to-mother support group is a peer support group composed of breastfeeding or pregnant mothers who meet on regular basis to ‘provide emotional, appraisal, and informational assistance by a created social network of members who possess experiential knowledge of a specific behavior or stressor and has similar characteristics as the target population’ (Mother Support Group
Discussion Guide, 2011). Mother-to-mother support groups provide individual counseling, information, and support group discussions to enable women to practice breastfeeding and child care well (Mother Support Group Discussion Guide, 2011). These groups have a special role, different from, but complementary to, the role of health services and health professionals. The MtMSGs aimed to increase maternal, infant, and young child feeding knowledge, attitude, and practices and to improve the livelihood of the mothers. MtMSGs give more detailed information to mothers (Mother Support Group Discussion Guide, 2011). The support groups also build confidence in the women who may fear to express their challenges at the facility but can willingly share breastfeeding challenges with their peers (Mother Support Group Discussion Guide, 2011). Although the government of Kenya has put much effort to improve child health and nutrition, nutrition indicators are still poor. Turkana County still ranks the highest in stunting, underweight and wasting. Global Acute Malnutrition (GAM) is critical at 18.1%. Turkana West reported the poorest indicators with a GAM of 19.1% and a SAM of 5.5% (Turkana Nutrition SMART Surveys, 2018).
World Health Organization recommends information sharing and skilled support to mothers through community-based mother support groups (WHO, 2003). The MtMSGs involve mothers who have infants and young children and others who may be pregnant. They come together to learn about maternal and child nutrition (Mother to Mother Support Groups Trainers’ Manual, 2011). With the formation of MtMSGs, it is expected
the complementary feeding practices will be improved. This is because MtMSGs are aimed at improving mothers’ knowledge regarding IYCF, which is presumed to improve IYCF practices. However, increased knowledge may not necessarily lead to the desired practice. There are a number of factors that influence IYCF practices. Grandmothers play a key role in influencing how their grandchildren are fed. Available resources determine the kinds of food given to a child. Other factors include the availability of time, peer influence, maternal age, maternal education level, cultural beliefs, and practices. Forming MtMSGs while other influencing factors are not addressed may not necessarily improve the complementary feeding practices (UNICEF, 2008).
MtMSGs were introduced in Turkana in 2008 (UNICEF, 2008). Mothers join when pregnant and leave when the child turns two years. Since the inception of MtMSGs in Turkana, the county still reports poor complementary feeding indicators. KNBS (2015) showed that in Turkana, minimum meal frequency, minimum dietary diversity, and minimum acceptable diet remain poor at 18.1%, 9.5%, and 3.7%, respectively. This is far below the national indicators. Few studies have been carried out to ascertain the impact MtMSGs on complementary feeding practices and nutrition status of children 6-23 months in Turkana. In order to ascertain the association of MtMSGs on breastfeeding, complementary feeding practices and nutrition status of children 6-23 months, this study was conducted to fill this information gap by comparing the complementary feeding practices between mothers in MtMSGs groups and those who are not in the MtMSGs in the proposed study area.
Purpose of the Study
The aim of this study was to compare complementary feeding practices and nutrition status of children 6-23 months of mothers who were attending MtMSGs and those who were not in Kakuma Division, Turkana West Sub County, Kenya.
Objectives of the Study
The objectives of this study were to:
- Assess the demographic and socio-economic status of mothers attending and those not attending MtMSGs in Kakuma Division.
- Determine complementary feeding practices of children 6-23 months of mothers attending and those not attending MtMSGs in Kakuma Division.
- Establish the nutrition status of children aged 6 to 23 months of mothers attending and mothers not attending MtMSGs in Kakuma Division.
- Compare breastfeeding and complementary feeding practices and the nutrition status of children aged 6 to 23 months of mothers attending and mothers not attending MtMSGs in Kakuma Division
- Assess the relationship between demographic and socio-economic status and complementary feeding practices and the nutrition status of children aged 6 to 23 months of mothers attending and mothers not attending MtMSGs in Kakuma Division.
Hypothesis of the Study
H01: There is no significant difference in demographic and socio-economic characteristics between mothers attending and mothers not attending MtMSGs in Kakuma Division.
H02: There is no significant difference in breastfeeding and complementary feeding practices between mothers attending and mothers not attending MtMSGs in Kakuma Division.
H03: There is no significant relationship between breastfeeding and complementary practices and the nutrition status of children aged 6 to 23 months of mothers attending and mothers not attending MtMSGs in Kakuma Division.
Significance of the Study
This study generated information that may be useful in policy formulation and advocacy aimed at improving the MtMSGs strategy as an intervention towards improving complementary feeding practices in Turkana West. The study recommendations will be useful to the Turkana County Ministry of Health when developing county-specific infant and young child feeding (IYCF) guidelines. This study will also form a baseline for future IYCF studies in Turkana West.
Delimitations of the Study
This study was carried out in Kakuma Division in villages that have MtMSGs. Besides, the study did focus on mothers who have children 6 to 23 months of age attending or not attending MtMSGs. The study population did not include the Kakuma refugee camp.
Limitations of the Study
The results obtained in this study cannot be generalized to apply to all mothers due to different cultural beliefs and practices, the diversified social demographic status of women in Kenya, and differences in literacy levels across different communities in Kenya. The results obtained can only be applicable within Turkana because the populations have similar characteristics.