Cultural Beliefs and Practices Around Maternal and Child Nutrition Among the Urban Poor in Nairobi Milka Wanjohi1*, Paula Griffiths2, 3, Frederick Wekesah1, Peter Muriuki1, Nelson Muhia1, Rachel N Musoke4, Hillary N Fouts5, Nyovani J Madise6, Elizabeth W Kimani-Murage1 1. African Population and Health Research Center, 2. Loughborough University, 3 University of the Witwatersrand, 4.University of Nairobi, 5. University of Tennessee, 6.University of Southampton, Southampton.

Background WHO IYCF recommendations - Early initiation and Exclusive breastfeeding (EBF) for 6 months, timely and appropriate complementary feeding (CF), continued breastfeeding for at least 2 years (WHO., 2002) Kenya – 40% are not exclusively breastfed, about 60% are started on complementary feeding at age 4-5 (ICF macro., 2014) Nairobi slums - 2% are EBF, mean age of CF -1 month ,while 15% are not breastfed beyond one year (Kimani Murage., 2011) (WHO 2002 ,Victora et al., 2008 Dewey et al., 2011) (Butta et al., 208) ( ICF macro ,. 2010) ( kimani – murage et al.,2011)

Background cont.. Cultural beliefs among the major challenges to optimal BF practices in Kenya, and probable causes of poor IYCN practices in urban slums (IFPRI, 2014) Cultural beliefs and norms have a powerful influence on human nutrition including maternal and child nutrition (Lancet, 2014) Paucity of data on specific cultural beliefs and practices around breastfeeding in urban slums. -.( ICF macro., 2010 , Olack et al 2011, ( Gotsken 2002., samega janeh ., 2001 et al) (zweber et al ., 2002)

Objectives Main Objective : To determine the effectiveness of personalised home-based counselling on infant feeding practices and consequently morbidity and nutritional outcomes in two Nairobi slums. Specific objective: To understand the cultural beliefs and practices around maternal and child feeding practices among the urban poor in Nairobi, Kenya.

Methods Data collection period: April 2012. Korogocho and viwandani slums : Residents from over 15 ethnic backgrounds : Kikuyu(28%), Luhya (24%), Kamba (21%) and Luo (15%). Data collection period: April 2012. Qualitative interviews - using interview guides. FGDs (10)- young mothers, older mothers, CHWs. KIIs (11) - community Leaders, TBA , healthcare providers IDI (19) – pregnant women, breastfeeding women Interviews recorded, Transcribed verbatim , Code in NVIVO for analysis. high level of early sexual debut (10% of adolescents <15 years sexually active); high levels of under five malnutrition at 40%; poor livelihood opportunities: low average monthly wage of approx. USD 70. high HIV prevalence at 12%; high prevalence of severe food insecurity (50% of household);

Result 1 : Immediate Initiation A common practice in the community ( normal hospital deliveries) Associated with severe stomach cramps in some communities ‘ It is believed that if you breastfeed immediately you give birth, it makes the baby’s stomach ache. I do not know how it is called in Swahili but Kikuyu calls it ‘Kirumati’ FGD with CHWs .

Result 2: Prelacteal Feeds Reason for giving. Crying babies No milk in the first few days Cultural cleansing’ ( manyasi) The child may refuse to breastfeed until it is named correctly, or the child may cry until it is named (KII with a TBA) What will you do? Like Luhya children are always hungry right from birth so you give it. So even if the baby doesn’t have milk, you will be forced to prepare some light porridge and give it…FGD with CHWs.

Result 3 : Colostrum (i) ‘ watery milk…. yellowish thick milk’ Considered medicinal , healthy and protective in some communities. “In some communities, colostrum used to be expressed and discarded, they believed that this was dirty milk due to its yellow color, this however has changed in most communities and children are fed on colostrum. It is believed to be medicine , a balanced diet which makes the baby very strong and important for baby’s brain development. It improves baby immunity and helps the womb contract back to original shape ”FGD religious leaders’’

Colostrum (ii) Feeding Colostrum is a taboo in other communities. Curdled and fermented Dirty Even us we express out so that fresh milk can come yet the first one is the one which is important. But we see its thick, dirty, it has fermented on the mothers’ breast, that’s why people express and don’t give the baby first. (FGD with religious) “ For example, Sukuma people from Tanzania dubbed ‘mapenga’ in this community, do not breastfeed on colostrums , even if the mother doesn’t have fingers she would rather ask for assistance to express colostrums for the first 2 days ” (FGD with village elders )

Result 4: Exclusive Breastfeeding Vast knowledge on exclusive breastfeeding however, does not translate into practice. Most mothers introduce food at 2 to 4 months. If breastfed for six months they become very clever (whistles)…..First class, Maranda high school (laughter) ‘FGD with young mothers

Result 5 : Reason for not EBF perceived size of the baby ( too small/ too big) ‘Breast milk not enough’ Breasts will sag’ belief Breastfeeding is a taboo. They say it’s like a taboo. If you are prostituting a lot, it affects the baby. So if you are a woman and you know you are doing this then you stop breastfeeding the baby so that it doesn’t affect the baby ……. I support her because even us we have a lady who has a four month old baby. She leaves the baby with her daughter and she goes to Koinange (prostitution) and she comes with milk. They say ‘chira’ (cultural disease/curse) will affect the baby ((FGD with community health workers)

Result 6 : Duration of breastfeeding Most mothers breastfeed for more than a year ( majority less than 2 years) Shorter duration for boys than girls Religion plays an important role Longer duration of breastfeeding is counteractive R: I think breastfeeding up to 2 years is even biblical. Also, Muslims believe a baby should be breast fed for 2 yrs, after which it is a sin. Why we breastfeed for about one or one and half years in Korogocho is because most mothers are hustlers-we don’t have time for prolonged breastfeeding. For example, I may be called for a seminar and told not to go with children, now see I have to stop the baby from breastfeeding’ FGD with older mothers.

Result 7 : Expressing breast milk A taboo in most communities . Expressing the mother’s milk like us Luhya’s, when you have a child you are not supposed to milk and it goes down, the child should just breastfeed. They say if the child is dead, you express the milk but if the child is alive you should not. So we don’t express. If you are going far like for work, you will have to go and come back to breast feed or you go with it’ In-depth Interview with a mother of a child under5 yrs.

Conclusion & Recommendations Cultural practices/beliefs in the community influence breastfeeding positively or negatively Need to promote positive cultural practices/beliefs. Dispel negative cultural practices through community education/awareness on optimal breastfeeding practices and provide necessary. Support mothers to translate MIYCN knowledge into practice.

ACKOWLEDGEMENTS Ministry of Health, Nutrition and Dietetics Unit (Kenya) University of Nairobi, Kenya Loughborough University, UK University of the Witwatersrand, SA University of Southampton, UK Korogocho and viwandani slums