Factors enabling the practice of EBF
The mothers had high knowledge of breastfeeding. Most had a good understanding of the concept of exclusive breastfeeding and indicated that it meant giving the baby only breast milk without even water for six months. Almost all the mothers had a good understanding of the benefits of EBF for the child and the mother. One primiparous mother who exclusively breastfed her infant said, “
Breastmilk has all the nutrients an infant requires, it is not contaminated and will make the child grow well as required”. The same sentiment was echoed by almost all the mothers who practiced, and those who did not practice EBF. One multiparous mother reported, “
Breastmilk does not cause diarrhea and vomiting as animal milk sometimes does. Furthermore, breastfeeding prevents pregnancy especially when actively breastfeeding”. The high level of maternal knowledge on EBF reported by most mothers indicated they had adequate information to choose whether to practice EBF and this was an important influence on their feeding decision (Table
3).
Most mothers held positive attitudes towards EBF and acknowledged that breast milk is irreplaceable and should be fed to babies as a priority. One mother pointed out, “Breastmilk is superior to all other feeds and is a gift from God that all mothers should not forget to utilize”. Others acknowledged that breastfeeding is prescribed in the Holy Quran and failure to breastfeed had spiritual consequences. Since almost all the study participants were Muslims, this belief encouraged mothers to breastfeed, although it may not necessarily have influenced all the mothers to practice EBF. Nevertheless, this unanimous view was indicated through comments such as “I believe a mother can exclusively breastfeed her child for six months without any supplement including water. I have done it for the third time now”. These positive attitudes encouraged others to practice EBF. Health care providers also positively influenced the practice of EBF amongst the mothers who regularly sought services at the Ante Natal Care and Maternal Health Care on a regular basis, and those who delivered their babies at a health facility. Some husbands were very supportive and encouraged their wives to breastfeed exclusively. Furthermore, children of the mothers who practiced exclusive breastfeeding grew healthily and had a much lower morbidity rate which encouraged others to breastfeed their children.
Factors hindering the practice of EBF
Socio-cultural factors were reported to hinder the practice of EBF. Such factors are deeply rooted in the Somali community and play a major role in encouraging mothers not to practice exclusive breastfeeding. For instance, when asked whether she believed a baby can survive on breast milk alone, without even water, for the first six months, one multiparous mother stated, “Because of the hot harsh weather conditions in Wajir County, a child needs some water to quench thirst. Some mothers do not produce enough breast milk and this trend is prevalent in some families.” Other mothers held similar views. One primiparous mother stated, “On delivery the child needs some water to dilute the colostrum and clear the system.” Similarly, a mother of four indicated that a “Majority of the mothers believe that if a woman breastfeeds while pregnant, her milk will be toxic and can make the baby ill and can even kill.”
Other barriers to EBF included a mother becoming pregnant while breastfeeding and having to wean. The mothers indicated that culturally, breastfeeding during pregnancy is not acceptable and ceases when a woman conceives another child. Many cultural barriers were propagated by TBAs, grandmothers and community members. For example, the belief that baby’s first feed should be animal milk and that babies should be given water to quench thirst and to dilute colostrum which they viewed as harmful to the baby because it is too strong. Consequently, the mothers experienced immense pressure from grandmothers and TBAs to give pre-lacteals and animal milk to infants aged under six months. For example, one mother who dropped out school at Standard eight said, “I had immense pressure from my mum-in-law and my husband to introduce water and cow’s milk as early as the first week to my first child. I resisted this having understood the importance of EBF. Luckily my child grew well with no hospital visits compared to my neighbour’s child who was given cow’s milk and water early. My husband and mother-in-law are now convinced that EBF has health benefits for the baby and I… did not have a tussle of war on how to feed my subsequent children”.
Most of the mothers who delivered at home assisted by TBAs reported being pressured to administer pre-lacteal feeds such as cow’s milk, water, honey, cow/goats’ milk and sugar/glucose to their babies as early as the first day after delivery [
16]. Additionally, grandmothers and mothers-in-law greatly influenced the introduction of pre-lacteals. In a region where majority of mothers opt for home delivery assisted by TBAs, cultural factors override the knowledge received from health professionals on EBF. Most mothers preferred to deliver their babies at home for reasons such as unfriendly health care providers and inaccessible health facilities. One primiparous mother who delivered her a baby in Wajir County hospital and routinely took her child to the Maternal Health Clinic, reported several unpleasant experiences with healthcare providers: “
The nurses and clinicians are not friendly and are always in a hurry. If you ask them questions, they get irritated and put you off. If only I had on option of having my child immunized elsewhere with free government vaccines, I would not go to the health facility at all.”
The mothers who preferred home delivery confirmed their familiarity with the TBAs and their understanding of their circumstances and culture. One mother said, “I delivered all my three children at home under the care of an experienced TBA, as advised by my grandmother. Since then, the experience has been good, my daughters and those of my sisters will follow the same.”
Mothers who delivered through cesarean section at health facilities reported initiating pre-lacteals early. One multiparous mother who delivered her two sons in hospital by cesarean section said, “In the hospital, after my delivery… the nurses started feeding the child with water and glucose and/or powder milk, making the child refuse the breastmilk/breast attachment, and this reduced my milk production.” These sentiments were overwhelmingly supported by majority of the mothers who delivered through cesarean section. Nonetheless, these mothers represented the small percentage (less than 2%) who delivered through cesarean section and were not a major factor influencing the practice of EBF. Nonetheless, it was reported that the majority of those who practice EBF delivered their babies at the health facility where they were encouraged by the health workers.