DECLARATION

To the best of my knowledge, I do declare that this proposal is my original work and has never been presented to any other institution for academic purpose or any other award whatsoever.

Name…………………………………………………………..

Signature……………………………….

Date……………………………………….

SUPERVISORS APPROVAL

I do certify that this research work was presented for this award with my approval as the academic supervisor.

Supervisor’s name…………………………………………………

Signature……………………………………………………………..

Date…………………………………………………………………….

ACKNOWLEDGEMENT.

My sincere gratitude to almighty God by whose power I have been able to complete this work. My indebted thanks to my supervisor by whose relentless guidance, corrections and efforts have enabled me accomplish this work.

To my familyand fellow classmates, thank you for your unwavering and dedicated support you accorded me throughout the development of this academic proposal. May the almighty God bless you in abundance?

DEDICATION

I do dedicate this research work to my immediate family for their daily strives in seeing me through my education. I also dedicate it to all Nursing students and qualified nursing staffs in Kenya as well as outside Kenya, mayyou find pleasure as well as grow in knowledge in reading this piece of work. I salute you all.

 LIST OF ABBREVIATIONS

WHO-World Health Organizations.

ANC-Antenatal clinic.

CDC-Centers for disease control

MTC-Mother -to- child transmission of HIV.

UNICEF-United nation’s children education fund.

HIV-Human Immunodeficiency Virus.

AIDS-Acquired Immune-deficiency Syndrome.

KNH-Kenyatta National Hospital.

Contents

DECLARATION.. 2

SUPERVISORS APPROVAL. 3

ACKNOWLEDGEMENT. 4

DEDICATION.. 5

LIST OF ABBREVIATIONS. 6

CHAPTER 1: INTRODUCTION. 9

1.1BACKGROUND INFORMATION.. 9

1.2 PROBLEM STATEMENT. 11

1.3 JUSTIFICATION.. 12

1.4 RESEARCH OBJECTIVES. 13

1.4.1 BROAD OBJECTIVE. 13

1.4.2 SPECIFIC OBJECTIVES. 13

1.5 VARIABLES. 13

1.5.1 INDEPENDENT VARIABLE. 13

1.5.2 DEPENDENT VARIABLE. 13

1.5.3 CONFOUNDING VARIABLES. 13

1.5.4 CONCEPTUAL FRAMEWORK. 14

1.6 RESEARCH QUESTIONS. 15

1.7 HYPOTHESES. 15

CHAPTER 2: LITERATURE REVIEW. 16

2.1 BENEFITS OF EARLY CHOICE OF EXCLUSIVE BREASTFEEDING.. 16

2.2 ADVANTAGES OF EXCLUSIVE BREASTFEEDING AMONG HIV EXPOSED INFANTS. 16

2.3 HIV TRANSMISSION DURING BREASTFEEDING.. 16

2.4 FACTORS AFFECTING THE PRACTICE OF EXCLUSIVE BREASTFEEDING.. 17

2.4.1 PERSONAL FACTORS. 17

2.4.2 SOCIO-DEMOGRAPHIC FACTORS. 17

CHAPTER 1: INTRODUCTION.

1.1BACKGROUND INFORMATION

Breast feeding is an ancient practice and refers to the feeding of an infant with milk from the human female breast as opposed to formula method of feeding that utilizes other types of feeds rather than breast milk[1].Exclusive breastfeeding means that the infant receives only breast milk. No other liquids or solids are given – not even water – with the exception of oral rehydration solution, or drops/syrups of vitamins, minerals or medicines.[2]. It has received endorsement and backed up by research including from different organizations including UNICEF, WHO, American Academy of Pediatrics among others [1, 2]

Making a decision on the mode of feeding for an infant prenatally remains an important step to achieving adequate nutrition after delivery, [3]. Though mother to child transmission of HIV can occur during breastfeeding, available research has indicated that children who are exclusively breast fed have a lower risk of acquiring it as opposed to children on combined feeding [4].

Breastfeeding is considered a complete nutrition due to the components of breast milk which include carbohydrates, proteins, water and essential fatty acids the promote child growth. It also contains antibodies that boost the child’s immunity by acting as a first immunization. The vitamins in it are vital, one being Vitamin K which protects the neonate from bleeding disorders [5]

Children who are exclusively breastfed have reduced chances of acquiring infections such as diarrhea as well as respiratory infections [6]. A reduced childhood infection reduces the cost of treating sick children and reduces their mortality and morbidity.

Based on data from 37 countries with trend data available (covering 60% of the developing world’s population), the rate of exclusive breastfeeding for the first six months of life increased from 34% to 41% across the developing world between 1990 and 2004. Significant improvements were made in sub-Saharan Africa, where rates more than doubled from 15% to 32% during this same time period. Exclusive breastfeeding rates in South Asia and the Middle- East/North Africa also increased from 43% to 47% and from 30% to 38% between 1990 and 2004, respectively. Western and Central Africa, in particular, experienced significant improvements with rates rising from 4% to 22%, and Eastern and Southern Africa also showed improvements with exclusive breastfeeding rates increasing from 34% to 48%. Rates remained roughly constant in East Asia and the Pacific during this time (8). It is also worth noting that each year under nutrition is implicated in about 40% of the 11 million deaths of children under five in developing countries, and lack of immediate and exclusive breastfeeding in infancy causes an additional 1.5 million of these deaths (9).

Kenya as a country has been the fore front in promoting breastfeeding. This has been done through the adoption of policies to policies to promote exclusive breastfeeding, which has included the baby friendly hospital initiative which involves the ten (10) steps to successful breastfeeding and establishment of breastfeeding rooms in hospitals. The country’s push for exclusive breastfeeding has significantly worked and according to the 2009 Kenya Demographic and Health Survey, 32 percent of babies are exclusively breastfed up to the age of six months, up from just 13 percent in 2003 [10].

1.2 PROBLEM STATEMENT

Despite indications by research that about 95% of all children born are started on breastfeeding within the first hour, the average age of breast feeding remains low at 2.4 months [4]. This means that a high number of newborns are introduced to mix feeding at a very tender age, which poses a great risk of malnutrition, newborn infections as well as increasing the chances of HIV transmission from mother to child (MTC) through breastfeeding.

Exclusive breastfeeding has shown to have positive impacts on the health of the child; the mother as well as promoting the economy since much of the funds spends in treating a sick child from diseases that can be prevented by breastfeeding can be directed to other developmental projects related to mother and child [6]. Without it being practiced, the country suffers greatly economically.

Exclusive breastfeeding is known to reduce childhood mortality and morbidity [7]. If well practiced, it can contribute to the achievement of millennium development goal touching on children and their mothers by promoting optimal health [8]

Despite the big steps made by the Kenyan government in promoting exclusive breastfeeding in both HIV infected as well as the non infected mothers, which include adoption of a policy on breastfeeding, establishment of baby friendly hospital environment for breastfeeding, the percentage of mothers breastfeeding exclusively has remained relatively low rated at 31.9% by the Kenya demographic and health survey, 2009 [12]. This is far much below as proposed by WHO as well as other worldwide health organizations such as UNICEF and CDC.

1.3 JUSTIFICATION

Majority of the studies done on exclusive breastfeeding mostly focused on the mothers who are already breastfeeding hence little documentation on choice of exclusive breastfeeding among mothers in their prenatal period.

Making an early choice on infant feeding can greatly influence the nutritional outcome as well as well development of child during breastfeeding. Findings of this study will fill the knowledge gap identified as well as add to the body of knowledge on exclusive breastfeeding in the context of HIV infection.

Prevention is better than cure. The treatment of sick children from childhood infections that can be prevented through breastfeeding is costly economically. Exploring the knowledge, attitude and practice of exclusive breastfeeding can help in averting this crisis by highlighting the necessary interventions that can be done and can only be done through evidence based research.

The recommendations from this study will be forwarded to the relevant bodies and authorities for implementation hence making a positive impact to the society at large.

1.4 RESEARCH OBJECTIVES.

The objectives for this study will be classified as follows.

1.4.1 BROAD OBJECTIVE

The aim of this research is to establish the knowledge, attitude and practice of exclusive breastfeeding among HIV infected mothers attending ANC at KNH.

1.4.2 SPECIFIC OBJECTIVES

The specific objectives for this study are as follows;

1. To determine the level of knowledge on exclusive breastfeeding among HIV infected mothers attending ANC at KNH.
2. To explore the attitudes of HIV infected mothers attending ANC at KNH towards exclusive breastfeeding.

• To determine the factors influencing exclusive breastfeeding among HIV infected mothers attending ANC at KNH.

1. To explore the practices towards exclusive breastfeeding among HIV infected mothers attending ANC at KNH.

1.5 VARIABLES

The study will have the independent variable, dependent variables and the confounding variables.

1.5.1 INDEPENDENT VARIABLE

1. Knowledge
2. Attitude

• Practice

1.5.2 DEPENDENT VARIABLE

Exclusive breastfeeding

1.5.3 CONFOUNDING VARIABLES

1. time
2. level of education

• personal decisions

1. Cultural beliefs.

1.5.4 CONCEPTUAL FRAMEWORK

Key

Direction of influence.

1.6 RESEARCH QUESTIONS.

For the achievement of the set objectives, the study will be guided by the following research questions;

1. What is the level of knowledge on exclusive breastfeeding among HIV infected mothers attending ANC in Kenyatta National Hospital?
2. What are the factors influencing exclusive breastfeeding among HIV infected mothers attending ANC at KNH?

• What are the attitudes of HIV infected mothers attending ANC at KNH towards exclusive breastfeeding?

1. What are the practices towards exclusive breastfeeding among HIV infected mothers attending ANC at KNH.

1.7 HYPOTHESES.

1. There is a relationship between HIV infected pregnant women’s knowledge on breastfeeding and its practice.
2. There is a relationship between HIV infected pregnant women’s attitude towards exclusive breastfeeding and its practice.

 

CHAPTER 2: LITERATURE REVIEW.

Due to the transmissibility of HIV from mother to child (MTC) through breast milk, the feeding of HIV-exposed infants remains a significant challenge in controlling the spread of HIV/AIDS. The dilemma concerning feeding infants of HIV-positive mothers is how to balance the risk of HIV transmission through breastfeeding with the risk of death from causes other than HIV such as respiratory diseases, diarrheal diseases and malnutrition among formula-fed infants.

Exclusive breastfeeding (EBF) plays a critical role in the overall health of infants. It is estimated that 3% of all under-5 mortalities in low-income countries could be prevented through optimal breastfeeding during the crucial first year of life [3]. Optimal breastfeeding is considered to be EBF for the first 6?months of life, followed by continued breastfeeding combined with safe and nutritionally adequate complementary feeding up to 24?months of age [4]. According to WHO, complementally feeds should only be introduced when affordable, feasible, available, safe and sustainable. Despite these conditions, most mothers introduce them in early ages of child feeding affecting exclusive breastfeeding.

EBF is regarded as a global health goal given its strong association with reduced morbidity and mortality, particularly in low-income countries where safe water and sanitation are often lacking [6]

Researches done in various regions of this world have identified various factors that influence choice feeding for young ones among mothers, exclusive breastfeeding being one of them. The literature available on exclusive breastfeeding is summarized under the following subtopics;

2.1 BENEFITS OF EARLY CHOICE OF EXCLUSIVE BREASTFEEDING

Early choice of breastfeeding among pregnant mothers has been shown to positively influence mother’s initiation and sustaining of breastfeeding for the required period time. Mothers who choose breastfeeding before delivery are likely to sustain it compared to their counterparts [4, 5, 12].

2.2 ADVANTAGES OF EXCLUSIVE BREASTFEEDING AMONG HIV EXPOSED INFANTS.

Exclusive breastfeeding has been shown to have advantages among HIV exposed infants which include; adequate nutrition and prevention of malnutrition, prevention diseases such as diarrhea and respiratory diseases. It also acts as first immunization to children protecting them from other infections. It also serves as a bonding part between the mother and the young one [3].

2.3 HIV TRANSMISSION DURING BREASTFEEDING

Though HIV transmission is known to occur from mother to child transmission, the risk is higher in children who are exclusively breastfed than those with mixed feeding [7, 9]

 

2.4 FACTORS AFFECTING THE PRACTICE OF EXCLUSIVE BREASTFEEDING

Various factors have been known to influence exclusive breastfeeding both in HIV infected as well as mothers not infected by HIV. These can be grouped into;

2.4.1 PERSONAL FACTORS.

Personal factors included mother’s intention to breast feed. Mothers who had the intention to breastfeed for a long time were found to have a likelihood of complying to the guidelines on exclusive breastfeeding compared to mothers who indented to breastfeed for a shorter period according to a research done in Ontario [1, 5].

Mothers who receive maternal support from relatives such as in-laws and spouses were likely to exclusively breastfeed compared to mothers who were not supported [5]

Mothers who had Knowledge on breastfeeding were likely to exclusively breastfeed compared to mothers who had no knowledge on breastfeeding [1, 5]

 

2.4.2 SOCIO-DEMOGRAPHIC FACTORS.

Maternal age has likelihood of influencing exclusive breastfeeding. Younger mothers are less likely to follow the WHO recommendations for infant feeding and are more likely than older mothers to introduce mixed feeding.. Maternal level of education also appears to influence when exclusive breastfeeding is terminated; mothers with higher levels of education are more likely to follow feeding recommendations and less likely to introduce other foods early compared to mothers with lower education levels. Studies have also found that maternal income levels affect exclusive breastfeeding. Mothers with higher income levels are more likely to follow infant feeding recommendations and less likely to introduce other feeds early compared to mothers with lower income levels [5, 13]. Mothers who were employed and working on relatively tight schedules were likely not to adhere to exclusive breastfeeding compared to mothers who were working on relatively free schedules.

2.4.3 ENVIROMENTAL FACTORS.

Mothers’ healthcare providers appear to influence when solid foods are introduced; studies have reported that mothers introduce solid foods based on their doctor’s advice [5,13]

The cultural practices and the influence from the people a mother is interacting with could influence when to stop breastfeeding. Stigma from people around the HIV positive mother could influence exclusive breastfeeding.

References.

1. Wikipedia, the free encyclopedia, breastfeeding. Available at,http://en.wikipedia.org/wiki/Breastfeeding, accessed 2/4/2014
2. UNICEF-Nutrition and infant feeding.Available athttp://www.unicef.org/nutrition/index_24827.html,accessed, 5/4/2014.
3. WHO-Exclusive Breastfeeding .Available at,http://www.who.int/topics/breastfeeding/en/accessed 5^th April, 2014.
4. UNICEF- Progress for children: A report card on Nutrition: Number 4, May 2006.

http://www.unicef.org/progressforchildren/2006n4/index_breastfeeding.html (site

visited on 4/4/2014

5.      WHO-Breast is always best, even for HIV-positive mothers. Available athttp://www.who.int/bulletin/volumes/88/1/10-030110/en/, accessed 4^thApril, 2014.

6. Matji JN, Wittenberg DF, Makin JD, Jeffery B, macIntyre UE, Forsyth WC: Factors affecting HIV- infected mothers’ ability to adhere to antenatally intended infant

Feeding choice in Tshwane. South Africa Journal of Child Health 2009, 3 (1):21, 23

 

• Susan Swarts¹, Salome Kruger¹ Robin C. ,Dolman^{1 .}Factors affecting mothers’ choice of breastfeeding vs. formula feeding in the lower Umfolozi district war memorial hospital, KwaZulu-Natal.

6        Motovu A, et al; Factors influencing adherence to exclusive breast feeding among HIV positive mothers in Kabarole district, Uganda.

7        Homsy J, et al; Breastfeeding, mother-to-child HIV transmission, and mortality among infants born to HIV-Infected women on highly active antiretroviral therapy in rural Uganda.

• Global data bank on breastfeeding: (http://apps.who.int/nut/db_bfd.htm ).site visited on 4/4/2013
• De Cock, K., Fowler, M., Mercier, E., De Vincenzi, I., Saba, J., Hoft, E.,et al.;

Prevention of Mother-To Child HIV Transmission in Resource-Poor countries.

JAMA, 2000, 283(9): 1178- 1182.

• World Health Organization UNAIDS, UNFPA, UNICEF: Guidelines on HIV and

infant feeding. Principles and recommendations for infant feeding in the context of

HIV and a summary of evidence. Geneva, 2010.

http://whqlibdoc.who.int/publications/2010/9789241599535_eng.pdf .

• Kiarie JN, Richardson BA, Mbori-Ngacha D. Infant feeding practices of women in

a perinatal HIV-1 prevention study in Nairobi, Kenya. Acta Paediatric 2005,

           94(3)359-363.

• Kenya Demographic and Health Survey 2008-2009, pdf. Available at,https://www.opendata.go.ke/Population/Kenya-Demographic-and-Health-Surveys/s9cb-ewv4 , accessed 31/3/2014.

13    Sarah Earle; Factors affecting the initiation of breastfeeding: implications for breastfeeding promotion, Available athttp://heapro.oxfordjournals.org/content/17/3/205.full ,accessed 1/4/2014.