Initiation of Breast Feeding Practices
Results from in-depth interviews with sixty mothers with children of less than 2 years showed that breastfeeding practices are less than optimal. It was recommended that infants needs to began nursing within the first hour after birth to take advantage of the strong sucking reflex that is usually at its peak at this time, to ensure that infants receive colostrums and to help stimulate milk production (Victoria et al 1999). Fifty nine (98%) of mothers in all the six wards reported having nursed their newborns within the first hour after child birth, 9 (15%) nursed after 2nd hour after birth while 40% did not remember the exact time of nursing but mentioned it to be within the first twenty four hours. Whilst 24 (49%) reported having nursed their infants within one hour of delivery [see Table 1]. Only one mother from Kibondemaji did not nurse at all because she is HIV positive and was advised not to breastfeed but bottle-feed her baby with milk formulae.
Table 1
Initiation of Breastfeeding [N=60]
| Mitaa | Nursed 1st hour after Birth [n = 60] | Nursed 2nd hour after Birth [n = 60] | Nursed within 24 hours after Birth Between (1st & 24th) hour [n = 60] | Did not nurse at all [n = 60] |
| Bora | 8 | 2 | 10 | 0 |
| Temeke | 6 | 3 | 10 | 0 |
| Sabasaba | 4 | 2 | 10 | 0 |
| Mzinga | 2 | 0 | 10 | 0 |
| Makuka | 3 | 1 | 10 | 0 |
| Kibondemaji | 1 | 1 | 9 | 1 |
| Total | 24 | 9 | 59 | 1 |
| Total in % | 40% | 15% | 98% | 2% |
Among the reasons for women not exclusively breast feeding their children, mothers at Kibondemaji pointed out that they sometimes do not have enough milk and they cannot afford milk formulae, therefore they decided to prepare maize porridge to feed their children. Others reported that when they are in the fields or working areas, their children are given water to stop them from crying. Exclusive breastfeeding means that babies are given only breast milk and nothing else – no other milk, food, drinks and not even water (UNICEF: 1995).
4.1.1 Actual Feeding Practices
During the first months exclusive breastfeeding should be practiced. Breast milk provides best and complete nourishment to the baby during the first six months. Exclusive breastfeeding means that babies are given only breast milk and nothing else – no other milk, food, drinks and not even water(UNICEF: 1995b). Babies who are exclusively breastfed do not require anything else namely additional foods or fluid, herbal water, glucose water, fruit drinks or water during the first six months. Breast milk alone is adequate to meet the hydration requirements even under the extremely hot and dry summer conditions prevailing in the country (USAID: 2000).
Among the reasons for women not exclusively breastfeeding their children, mothers at Kibondemaji pointed out that they sometimes mothers do not have enough milk and they can not afford milk formulae, therefore they decide to prepare maize porridge to feed their children. Others reported that when they are in the fields their children are given water to stop them from crying. Mothers at Makuka mentioned that when they are busy preparing food for their husbands, they do not breastfeed until husband authorizes and babies are given porridge instead. For early infancy (from birth to about six months of age), the focus is on achieving exclusive breastfeeding with adequate frequency (Victoria et al 1999)
Mothers Breastfeeding Experiences
[Focus Group Discussions, September 2006]
- “Babies are sometimes thirsty, that’s why at times they cry a lot; therefore it is necessary to give them some drinking water.” [Old Woman, Mzinga – Toangoma Ward]
- “After delivery, my breasts could not provide enough milk to satisfy the baby, so for the first month; I prepared some local herbs to feed the baby. In the second month I was forced to introduce soft porridge from maize flour so that my baby could not be hungry for longer times.”[Mother, Sabasaba – Mtoni Ward]
- “When a mother does not get enough to eat, she cannot produce enough milk. Already at 3 months my breast milk was gone”. [Mother, Bora – Chang’ombe Ward]
- “Nursing is a problem. Most mothers who are employed can not exclusively breastfeed their children especially after maternity leave which is only three months before mother resumes to her normal work.” [Mother, Temeke – Temeke Ward]
- “When I go to the field, I take my baby with me and my older daughter or son comes with me to stay with the baby. When the baby cries, I give her water so that I am not disturbed.” [Mother, Kibondemaji – Charambe ward]
- “When mothers are preparing food for their husbands, they can’t really take good care of their children. Even if your child cries, you must wait until your husband authorizes you
Frequency of Feeding
Infants and young children need to be fed 5 – 6 times a day in addition to breastfeeding. It must be remembered that adequate feeding of infants and young children during the first two years is the main cause of malnutrition. However findings from in depth interviews with sixty mothers with children of less than two years showed that among the six researched areas, the higher income areas had fed their children more frequently than the low income areas. Due to higher income levels, mothers from Bora and Temeke could afford more feeds. Their babies are fed with fruit juices, vegetable soup, beef soup, milk formulae, cereal, power porridge (lishe) and other foods while those from lower income areas could not afford many feeds (See Table 4.2).
Table 2
Frequency of Feeding [N = 60]
 Researched Area | Bora [n = 10] | Temeke [n = 10] | Mzinga [n =10] | Sabasaba [n = 10] | Makuka [n = 10] | Kibondemaji [n = 10] |
 Incidence of malnutrition | Low incidence areas [N = 20] | Middle incidence areas [N = 20] | High incidence areas [N = 20] | |||
| Less than twice a day | | | | ü | | ü |
| 3-4 times a day | | | ü | | ü | |
| 5-6 times a day | | | | | | |
| 6-7 times a day | | | | | | |
| More than 7 times a day | ü | ü | | | | |
In some studies it has been found out that low energy density of complementary foods given to young children and low frequency of feeding result in inadequate calorie intake and thus malnutrition (Arroyaye et al 1999). Most of the foods are bulky and a child cannot eat more at a time. Hence it has been recommended to give small energy intake dense feeds at frequent intervals to the child with a view to ensure adequate energy intake by the child.
Types of Food given to Children soon after Birth
Colostrum is all the food and fluid needed soon after birth with no supplements of other food necessary, not even water. It is essential, therefore, that the baby gets the first breast milk called Colostrum which is thicker and yellowish than later milk and comes only in small amounts in the first few days (Bentley: 1992). During this period and later, the new born infant should not be given any other fluid or food like honey, tea, powdered milk, water or glucose water, since these are potentially harmful. The mother especially with the first birth may need help in proper positioning for breastfeeding (AED: 2001). Breastfeeds should be given as often as the baby desires and each feed should continue for as long as the infant want to suckle. During focus group discussions, mothers with children less than two years were asked to mention types of food they give to children soon after birth, responses were as follows in Table 3).
Table 3
Types of food given to Children soon after Birth [N = 75]
| Researched Area | Bora [n = 10] | Temeke [n = 15] | Mzinga [n =13] | Sabasaba [n =12 ] | Makuka [n = 15] | Kibondemaji [n = 10] |
| Incidence of malnutrition | Low incidence areas | Middle incidence areas | High incidence areas | |||
| Breast milk | ü | ü | ü | ü | ü | ü |
| Milk Formulae | ü | ü | | | | |
| Water | | | ü | ü | | ü |
| Vaccines | | | | ü | | |
| Soft Maize Porridge | | | | | ü | ü |
| Local Herbs | | | | ü | | |
Most of the respondents replied that they breastfed their children immediately after birth. While mothers in low incidence areas gave their infants, milk formulae. In Mzinga, Sabasaba and Kibondemaji, mothers replied that they gave water to their infants (see table 2). In the high incidence areas of Makuka and Kibondemaji, said that they gave their infants soft maize porridge. During structured and unstructured observations it was observed that the majority of infants at Makuka and Kibondemaji wards had protruding stomachs, this could possibly be explained that infants are being fed on maize porridge at an earlier age when their digestive systems are still immature and cannot digest such foods. Several reasons were pointed out for giving infants such foods but variations were observed according to economic status and level of education. Mothers with high income levels in Bora and Temeke wards had higher education level compared to those with low income level of Kibondemaji and Makuka wards. Table 4.16 illustrates variation in education levels in the six researched areas.
When inquired as to why infants are provided with each of such liquids and food items mentioned, women of Bora revealed the following: firstly, breast milk because it was the best food for the baby, secondly, tinned powdered milk because sometimes breast milk does not come out and also in addition to breast milk because sometimes breast milk was not enough when the baby was hungry. For Temeke, breast milk was given to stop the baby from crying and also because they believed that breast milk was good for the baby. Women at Mzinga ward pointed out that they provided such foods because they want their children to grow well and continue to survive; also they said that some of children were not satisfied with breast milk so they aimed at building and strengthening bodies of their children. Warm water was given to cleanse and activate the digestive systems of babies and vaccines to prevent diseases.
Women at Sabasaba ward cited that they gave breast milk because a child does not have teeth, hence can not eat anything. S/he needs to be breastfed so that s/he could survive. They also declared that they gave their children such foods [breast milk] because it was important for human body and it was the only food for infants. Mothers at Kibondemaji ward said they gave their children warm water to cleanse their babies’ digestive system. Makuka women gave their children other foods because they were sometimes busy and could not breastfeed.
Early Initiation of Breastfeeding
Various research studies since early 90s have brought out the beneficial effects of exclusive breastfeeding for the first six months on the growth, development and nutrition and health status of the infant and also for the mother (Waldman: 2003). It was revealed that exclusive breastfeeding not only prevented infections particularly the diarrhea infections in the child but also helped in preventing anaemia in child as breast milk has the best bioavailability of iron. The appearance of enzyme amylase in the seventh month of the infant was suggestive of desirability of introducing cereal based foods in the diet of infant after the age of six months.
Mothers at Sabasaba when asked the same question they revealed that, traditionally when mothers do not produce enough milk after delivery, a baby is given tea made of local plants and soft porridge. It was interesting to find that mothers at Mzinga believe that babies are sometimes thirsty therefore they decide to give them water. It was also noted that infants are given water immediately after birth to cleanse their digestive system because it is dirty. Reasons given by mothers at Bora for not exclusively breastfeeding their children were that most mothers do not have knowledge and skills on breastfeeding. [See Box 1
Exclusive Breastfeeding
Table 4
Exclusive Breastfeeding [N = 60]
| Mitaa | Exclusively Breastfed for the 1st three months [n = 60] | Exclusively Breastfed for the 1st five Months [n = 60] | Exclusively Breastfed for the 1st six months [n = 60] | Had already introduced water in the 2nd month [n = 60] |
| Bora | 2 | 1 | 7 | 0 |
| Temeke | 4 | 2 | 3 | 1 |
| Sabasaba | 1 | 0 | 5 | 4 |
| Mzinga | 2 | 1 | 2 | 5 |
| Makuka | 1 | 0 | 2 | 7 |
| Kibondemaji | 0 | 0 | 0 | 10 |
| Total | 10 | 4 | 19 | 27 |
| Total in % | 17% | 7% | 31% | 45% |
When mothers were asked about the time their children had they been exclusively breastfed of the infants, they had different answers, 27 (45%) of the respondents say had introduced water in the first two months. While 19 (31%) had exclusively breast fed their infants for the first six months. 10 (17%) mothers breast fed for the first three months [see Table 4].
Introduction of Complimentary Food
The type of complimentary foods and the timing of their introduction to infants differ from place to place. Thus the question was asked, “What type of fluid that is given to the infant immediately after birth?” From four to six months, it was recommended that children start to receive energy and nutrient rich complementary foods (Van de Perre et al: 2002). Research results as shown in Table 5 revealed that only 15 (25 %) of mothers introduced foods to their child at the recommended time of 4 to 6 months, while 19 (32%) respondents had not introduced solid foods until after 10 months. However, it was also noticed that majority of the mothers in the lower income areas could not follow WHO guidelines (WHO: 2001).
Table 5
Introduction of Complementary Foods [N = 60]
| Mitaa | Introduced solid foods at the 2nd to 3rd months [n = 60] | Introduced solid foods at the 4th to 6th months [n = 60] | Did not introduce solid foods until after 10 months [n = 60] |
| Bora | 3 | 6 | 1 |
| Temeke | 5 | 4 | 1 |
| Sabasaba | 7 | 1 | 2 |
| Mzinga | 4 | 1 | 5 |
| Makuka | 5 | 2 | 3 |
| Kibondemaji | 2 | 1 | 7 |
| Total | 26 | 15 | 19 |
| Total in % | 43% | 25% | 32% |
The delay in introducing food is a second factor potentially explaining the rapid acceleration in the prevalence of wasting and stunting observed in the sample children between 6 and 18 months researched, a time at which children are vulnerable during the transition between breast milk and adult diet. An examination of complementary feeding practices broken down by mothers’ economic levels shows that 50% of children in the low incidence areas (Bora and Temeke) began feeding their children complementary food between 4 to 6 months period, significantly higher than the 10 and 15% level for children of mothers in the higher incidence areas. These results suggest a relationship between women’s economic status and complementary feeding practices. There is considerable variation across areas in the percentage of children who receive complementary foods between 4 and 6 months of age, ranging from 10% to 15 % in the Mzinga, Sabasaba, Kibondemaji and Makuka areas with higher incidence of malnutrition up to 50% at Bora and Temeke with lower incidence of malnutrition.
Table 6
Introduction of Solid Foods in the 4th to 6th months [N = 60]
| Researched Area | Bora [n = 10] | Temeke [n = 10] | Mzinga [n =10] | Sabasaba [n = 10] | Makuka [n = 10] | Kibondemaji [n = 10] |
| Incidence of malnutrition | Low incidence areas [N = 20] | Middle incidence areas [N = 20] | High incidence areas [N = 20] | |||
| Responses | 6 | 4 | 1 | 1 | 2 | 1 |
| Total | 10 | 2 | 3 | |||
| Total in % | 50% | 10% | 15% | |||
The focus groups discussion with mothers of children of two years of age, have reported the different types of food given to their children as complementary foods. Continuing breastfeeding while giving adequate complementary foods to the baby provides all the benefits of breast feeding to the baby (Whitehead 2000). In other words, the child gets energy, high quality protein, vitamin A, anti – infective properties and other nutrients besides achieving emotional satisfaction from the breastfeeding much needed for optimal development of the child. Breastfeeding especially at night ensures sustained lactation. Quotes in Box 2
Complementary Feeding Practices
- “It is best to start introducing food to children at 6 months. Porridge added with groundnuts flour or sardines has been added is the best. If you give food to children too early your child could become sick.” [Mother, Temeke – Temeke Ward]
- “Health attendants have told us that we should not give any food to our children before they are 6 months old. I started giving food to my child at 7 months.”[Mother, Sabasaba – Mtoni Ward]
- “At 12 months we offer our children porridge and when she is used to that we provide ugali or rice. At 5 months food will cause diarrhea and that in turn will cause all types of illnesses”. [Mother, Makuka – Mbagala Kuu Ward]
- “As long as my breasts are full of milk, I will not give my child any other foods.” [Mother, Mzinga – Toangoma Ward]
- “Because of certain constraints, some children eat before 4 months, if not a child should start eating at 4 months. If you give solid food to children before 4 months, they will not walk at an early age and you will get pregnant again and that too will cause your child to lose weight” [Old woman, Kibondemaji – Charambe ward]
- “Already at 4 to 5 months, mothers leave the child with an elder sibling, because they have too much work to do. Now when the mother distances herself from the child, the child will not have the quantity of breast milk s/he needs and is used to getting, and the type of food to eat is not available. In the end, the person caring for mother child is obliged to give the child food from the family meal, which is not appropriate for the child. This is why children do not grow and develop at the rate they should”. [Extension worker, Bora – Chang’ombe Ward]
Food and Feeding Practices
Optimal infant and young child feeding practices – especially early initiation and exclusive breastfeeding for the first six months of life – help ensure young children the best possible start of life. Breastfeeding is a natural way of nurturing the child, creating a strong bond between the mother and the child. It provides development and learning opportunities to the infant, stimulating all five senses of the child – sight, smell, hearing, taste and touch. Breastfeeding fosters emotional security and affection, with a life long impact on psychosocial development. Special fatty acids in breast milk lead to increased intelligence quotients (IQs) and better visual acuity. A breastfed baby is likely to have an IQ of around 8 points higher than a non – breastfed baby (Levin et al 2003).
Ingredients added in Infant Food
When asked about foods introduced to children in addition to breast milk, mothers at Mzinga ward mentioned maize porridge and mashed potatoes while at Sabasaba they give soft ugali and mashed bananas. At Makuka ward children were offered porridge, mashed potatoes, bananas, soft stiff porridge, fruits, fish and sardines whereas at Temeke ward, children were given porridge, dairy cow milk, mashed bananas and Lactogen. Other food as mentioned by Bora women includes tinned milk, porridge and water. Those of Kibondemaji ward said they provide them power porridge (Lishe) at three months, as well as finger millet at four months and also bananas, Irish potatoes, all these mixed with meat soup and mashed.
Ingredients added to the infants were grounds nuts, sugar or ghee or oil to the food increases the energy value of the food. The following sub-sections would explore more on the ingredients that are added to the infant’s food. In most cases, mothers would blame poverty as the main factor which hindered them buying and using them for their infants. The ingredients in Temeke are mostly obtained from the market and the shops which are situated in the area. For the high income areas, it was observed that they use groundnuts, margarine, and sardines as the main ingredients added to infant’s food.
Ingredients added in Maize Porridge
Types of ingredients added in maize porridge prepared at Kibondemaji are slightly different to that of Bora. Table 7 illustrates the types of ingredients added in Maize porridge in the study areas. Such findings were reported through structured and unstructured observations at the households of mothers with children less than two years of age.
Table 7
Types of Ingredients added in Maize Porridge [N = 60]
| Researched Area | Bora [n = 10] | Temeke [n = 10] | Mzinga [n =10] | Sabasaba [n =10 ] | Makuka [n = 10] | Kibondemaji [n = 10] |
| Incidence of malnutrition | Low incidence areas | Middle incidence areas | High incidence areas | |||
| Water | ü | ü | ü | ü | ü | ü |
| Maize flour | ü | ü | ü | ü | ü | ü |
| Salt | | | ü | ü | ü | ü |
| Sugar | ü | ü | ü | | | |
| Margarine | ü | ü | | | | |
| Milk | ü | ü | | | | |
| Groundnuts flour | ü | | ü | | | |
| Sardines flour | | | ü | | ü | ü |
| Lemon | | | | ü | ü | ü |
The high incidence areas which have lower income levels could not afford adding sugar to their babies’ porridge while those with higher income and low incidence of malnutrition added sugar to the porridge. According to WHO (Beaton et al: 2003). Children need more energy and hence adequate amounts of sugar or jiggery should be added to child’s food. Sardine flour is nutritious but reduces the taste of porridge and makes it smell unpleasant. This contributes to babies’ refusal of eating, hence become malnourished.
As Table 7 shows, the children who were fed porridge added with sardine flour were from the high incidence areas and their mothers could not afford adding margarine or milk to their porridge. As suggested by Bentley (2000), by adding a teaspoon of oil or ghee in every feed substantially increases energy content of food without increasing bulk. While, high incidence areas lacked sugar, margarine, milk, and groundnuts, was not used in the baby’s food. As pointed out earlier that low income earners can not afford them.
Ingredients added in Cooked Mashed Bananas
According to Singh (2004), baby needs foods from six months namely cereals, pulses, vegetables particularly green leafy vegetables, milk and milk products, egg, meat and fish if non – vegetarian, oil/ghee and iodized salt in addition to breastfeeding. A diversified diet of the infant along with breastfeeding will also improve the micronutrients’ status of the child.
Table 8
Types of Ingredients added in Cooked Mashed Bananas [N = 60]
| Researched Area | Bora [n = 10] | Temeke [n = 10] | Mzinga [n =10] | Sabasaba [n =10 ] | Makuka [n = 10] | Kibondemaji [n = 10] |
| Incidence of malnutrition | Low incidence areas | Middle incidence areas | High incidence areas | |||
| Bananas | ü | ü | ü | ü | ü | ü |
| Water | ü | ü | ü | ü | ü | ü |
| Salt | ü | ü | ü | ü | ü | ü |
| Tomatoes | ü | ü | ü | ü | | |
| Cooking Oil | ü | ü | | | | |
| Onions | ü | ü | ü | ü | | |
| Milk | ü | ü | | | | |
| Beef | ü | ü | | | | |
| Beef Soup | ü | ü | ü | ü | ü | ü |
| Fish | ü | ü | | | | |
| Fish Soup | ü | ü | ü | ü | ü | ü |
| Vegetables | ü | ü | | | | |
As regards Table 7, bananas were cooked and mashed before giving to young children below two years. This was observed through structured and unstructured observations in all the six wards at the households of mothers with children less than two years of age. The difference that was observed was; mothers in the low incidence areas could afford to add all the ingredients mentioned in Table 7. While mothers in the high incidence areas were not adding tomatoes, onions, cooking oil, milk and beef, in the baby’s food. Despite the fact that they added beef and fish soup to their child’s bananas, they did not add vegetables.
Ingredients added in Mashed Irish Potatoes
Preparation of Irish potatoes was only observed at Bora, Temeke, Sabasaba and Makuka wards. Mothers at the low incidence areas added carrots, margarine and milk to the potatoes while those of the middle (Sabasaba ward) and the high (Makuka ward) incidence areas boiled their potatoes, added salt and mashed (see Table 9). The mothers in these areas could afford to buy the ingredients, as they have more income than the mothers in high incident areas.
Table 9
Types of Ingredients added in Mashed Irish Potatoes [N =60]
| Researched Area | Bora [n = 10] | Temeke [n = 10] | Mzinga [n =10] | Sabasaba [n =10 ] | Makuka [n = 10] | Kibondemaji [n = 10] |
| Incidence of malnutrition | Low incidence areas | Middle incidence areas | High incidence areas | |||
| Irish potatoes | ü | ü | | ü | ü | |
| Water | ü | ü | | ü | ü | |
| Carrots | ü | ü | | | | |
| Salt | ü | ü | | ü | ü | |
| Margarine | ü | ü | | | | |
| Milk | ü | ü | | | | |
Active Feeding
Feeding children requires the active participation of the care giver to make sure that the child is consuming sufficient amounts of what is being offered. When asked what mothers do when children refuse to eat, only 19 (32%) respondents reported that they actively encourage the child to eat. Others 19 (32%) respondents reported that they let the child eat as he or she wished; or if the child refused to eat, whilst 22 (36%) respondents said they would nurse the child in place of the feeding (see Table 10). Active feeding during feeding like talking to the child, playing with the child stimulates appetite and development one to two year old child should be given food on a separate plate and encouraged to eat on his/her own. Eating at the same time and at the same place also helps in improving appetite and avoids distractions.
Table 10
Reactions of Mother when Child Refuse to Eat [N = 60]
| Mitaa | Actively encourage the child to eat [n = 60] | Let the child eat as he/She wished [n = 60] | Breastfeed the child in place of feeding [n = 60] |
| Bora | 4 | 3 | 3 |
| Temeke | 6 | 4 | 2 |
| Sabasaba | 4 | 5 | 2 |
| Mzinga | 1 | 2 | 5 |
| Makuka | 2 | 1 | 2 |
| Kibondemaji | 2 | 4 | 7 |
| Total | 19 | 19 | 22 |
| Total in % | 32% | 32% | 36% |
Ensuring Safety of Complementary Foods
Careful hygienic preparation and storage of complementary foods is crucial to prevent contamination. Personal hygiene plays an important role in feeding infants. Table 11 illustrates some of the important issues to be considered while preparing foods for infants were observed in different households of the researched areas. Good hygienic practices were observed among majority of mothers of Bora and Temeke ward, who also have higher income levels and low levels of malnutrition compared to practices observed among mothers of Makuka and Kibondemaji wards who were worse than mothers of Mzinga and Sabasaba wards [Table 11]. Hygiene of the child and the cleanliness of the child’s physical environment can affect the incidence of diarrhea. Diarrhea is the second most common illness of all episodes of illness - affecting children as reported by extension workers at Temeke Municipality
Table 11
Considerations while preparing foods for Infants [N = 60]
| Mitaa | Hands washed with soap and water before handling food [n = 60] | Utensils washed well, dried and kept covered [n = 60] | Keeping the food in a covered container [n = 60] |
| Bora | 8 | 10 | 10 |
| Temeke | 9 | 10 | 10 |
| Sabasaba | 5 | 8 | 10 |
| Mzinga | 5 | 6 | 4 |
| Makuka | 0 | 0 | 0 |
| Kibondemaji | 0 | 0 | 1 |
| Total | 27 | 34 | 35 |
| Total in % | 45% | 56% | 58% |
Seven (12%) of all respondents disposed properly of a child’s waste in a latrine or wash their hands with soap after child’s defecation. Although it is common to rinse children's hands in a shared water dish before a meal as was observed from 58 (96%) of mothers who washed their children's hands before eating with the use of soap or rinsing with fresh water is rare.
Table 12
Unhygienic Practices Observed at Households [N = 60]
| Mitaa | Disposing properly child’s waste in a latrine [n = 60] | Washing hands with soap after child’s defecation [n = 60] | Rinse children’s hands in a shared water dish before meal [n = 60] |
| Bora | 3 | 3 | 10 |
| Temeke | 4 | 3 | 8 |
| Sabasaba | 0 | 0 | 10 |
| Mzinga | 0 | 0 | 10 |
| Makuka | 0 | 0 | 10 |
| Kibondemaji | 0 | 0 | 10 |
| Total | 7 | 6 | 58 |
| Total in % | 12% | 10% | 96% |
Inaccessibility to water services is detrimental to the survival and growth of children. Presence of portable water close to the homesteads has close association with better nutrition among the under-fives since it facilitates better hygiene and secondly as a result of the reduced workload on the part of women since they do not have to walk far in search of water. Poor water and sanitation facilitate the occurrence of the most common infectious and morbidities among women and children. Based on government data, clean and safe water is available to 53% of the rural and 73% of the urban population, but disruptions of supply do occur (UNICEF/WHO: 1999).
Table 13
Availability of Water Services in the Household [N = 60]
| Researched Area | Bora [n = 0] | Temeke [n = 10] | Mzinga [n =10] | Sabasaba [n =10 ] | Makuka [n = 10] | Kibondemaji [n = 10] | Total | Total in % |
| incidence of malnutrition | Low incidence areas | Middle incidence areas | High incidence areas | |||||
| Tap | 9 | 1 | 2 | 6 | 3 | 0 | 21 | 35% |
| Shallow wells | 1 | 7 | 7 | 4 | 7 | 8 | 34 | 57% |
| River | 0 | 0 | 1 | 0 | 0 | 1 | 2 | 3% |
| Bought | 0 | 2 | 0 | 0 | 0 | 1 | 3 | 5% |
The availability of water in Temeke Municipal was inadequate both in terms of quality and quantity. Besides, the majority of municipal residents have no access to piped water and, as a result, rely mostly on bore holes and shallow wells which are unfortunately untreated and thus, unsafe (Temeke Profile: 2005). Results from Formative research conducted in September 2006 in six streets of Temeke municipality had the following results, as can be seen in Table 13. During structured and un-structured observation, research participants were required to observe the accessibility to clean and safe water for domestic use, and the results were as follows, majority of respondents 34 (57%) had access to water from wells for domestic use. While 21 (35%) of the respondents got clean water from the tap, 2 (3%) of the respondents got from the rivers whereas 3 (5%) bought water for their domestic use.
Maternal Care
Prenatal care will help reduce many of the factors that lead to low birth weight babies and safe delivery procedures reduce complications of child birth which can cause disability and death of women and their children. 35 (59%) of mothers interviewed, reported having had at least one prenatal visit at a health centre during their most recent pregnancy, whilst 15 (43%) had four or more visits. Twenty five (41%) of the respondents said that they had not attended to prenatal visit to the health centre (as shown in Table 14). Providing women with prenatal, postpartum, and delivery care by qualified health care providers is associated with positive nutritional and health outcomes for children (WHO, 2004).
For the 41% of respondents who did not attend prenatal visits, 32% stated that they lacked financial resources to pay for the resources while 28% stated that the health centre was too far away and they had neither the time nor the means of transportation to go there. Another 12% of women reported that their husbands did not want them to go to the centre.
Table 14
Prenatal Visits at a Health Centre [N = 60]
| Mitaa | At least one prenatal visit at a health centre [n = 60] | Four or more visits [n =35] | Did not attend prenatal visits [n = 60] |
| Bora | 8 | 7 | 2 |
| Temeke | 5 | 6 | 5 |
| Sabasaba | 6 | 2 | 4 |
| Mzinga | 7 | 0 | 3 |
| Makuka | 7 | 0 | 3 |
| Kibondemaji | 2 | 0 | 8 |
| Total | 35 | 15 | 25 |
| Total in % | 59% | 43% | 41% |
When respondents were asked for the reasons for not attending prenatal visits, they responded differently according to the incidence area. Each household had different source of income, thus the answers were mainly on the ability of having resources that could make mothers attend to the prenatal care.
Table 15
Mothers not giving Birth at a Health Facility [N =60]
| Mitaa | Went to traditional midwives [n = 25 ] | Number of Mothers not giving Birth at a Health Facility [n = 60] |
| Bora | 0 | 0 |
| Temeke | 0 | 1 |
| Sabasaba | 1 | 1 |
| Mzinga | 0 | 0 |
| Makuka | 4 | 3 |
| Kibondemaji | 2 | 2 |
| Total | 7 | 7 |
| Total in % | 28% | 12% |
Responses among elderly men at Bora ward suggested relatively widespread support for some type of prenatal care or related expenditures as majority of the grand fathers of children with less than two years, when interviewed reported having paid for either prenatal visits or other pregnancy – related medical costs for the most recent pregnancy of their daughters or grand daughters. This finding suggests that majority of grand fathers at Bora Ward were well off in terms of economical status, their support to pregnant women contributed to most mothers at Bora ward who attended Prenatal Health Centres more frequently.
Despite the number of mothers benefiting from prenatal care, not all mothers reported giving birth at a health facility with the assistance of a qualified provider. Seven (12%) mothers reported that they did not give birth at a health facility; referring to Table 4.15, the same number of respondents 7 (28%) went to traditional midwives. These findings suggested a strong relationship between Table 14 and 15. Those mothers who did not attend prenatal visits (shown in Table 4.14), and went to traditional midwives (see Table (15) are the ones who did not give birth at a health facility. The difference was that, only one mother from Temeke neither gave birth at a health facility nor did she visited traditional midwives. She gave birth at home. Also one mother at Makuka went to traditional midwife but gave birth at a health facility.
In addition to the physical constraints of transporting a woman in labor to a health centre (which may be some distance from the village, and may not be staffed at the time of need) and considerations, socio-cultural and psychological barriers (example; delivering away from home or with the assistance of a male health provider, spending time away from home for child birth) also keep women from delivering from a health centre.
4.6.1 Care to Mothers and Infant Support Systems
Work resumes soon after child birth because women have few avenues of assistance with household tasks, child care or to replace their labor inputs on communal fields. Most women also cannot risk losing income and resources by reducing the time spent on income generating activities or their own crop production. Support provided to mothers after child birth was an important factor affecting both the mother's and child's health and nutrition. Within four weeks after child birth, 22 (37%) of mothers said they resumed to their normal work while only 24 (40%) waited at least 40 weeks.
Most women from higher income areas of Bora and Temeke wards resumed their normal work, three weeks after child birth while women at lower income areas of Makuka and Kibondemaji wards waited longer at least nine weeks after child birth. Reasons could be majority of women at Bora and Temeke wards are employed and have a three week maternity leave while most women from the lower income areas are housewives and farmers, hence have much time to rest after child birth. Although very few women mentioned any specific tasks performed by their husbands in their place, majority of women recognized the importance of their spouses' financial contributions during and after pregnancy. Family members appear to be a more significant source of support for household and other tasks than their spouses.
Table 16
Work Resumption after Child Birth [N =60]
| Mitaa | Resumed their normal work three weeks after child birth [ n = 60] | Resumed their normal work six weeks after child birth [n = 60] | Waited at least nine weeks after child birth [n = 60] |
| Bora | 7 | 2 | 1 |
| Temeke | 8 | 1 | 1 |
| Sabasaba | 1 | 8 | 1 |
| Mzinga | 3 | 7 | 0 |
| Makuka | 1 | 1 | 8 |
| Kibondemaji | 4 | 3 | 3 |
| Total | 24 | 22 | 14 |
| Total in % | 40% | 37% | 23% |
Beyond the immediate six-week period following child birth, the availability of competent, alternate child care is one important type of social support that was limited for many mothers. Among the sixty mothers interviewed, 31 (51%) reported to have left their infants in the care of house girl while 6 (10%) left their infants under the care of another child (See Table 4.16). Only one mother did not leave her infant in the care of others because she did not have any source of reliable child care.
Table 17
Alternate Child Care Practices [N =60]
| Mitaa | Leave infant in the care of house girl [n = 60] | Leave infant in the care of another child [n = 60] | Did not have any source of reliable child care [n = 23] |
| Bora | 10 | 0 | 0 |
| Temeke | 8 | 1 | 1 |
| Sabasaba | 5 | 2 | 0 |
| Mzinga | 6 | 1 | 0 |
| Makuka | 1 | 0 | 0 |
| Kibondemaji | 1 | 2 | 0 |
| Total | 31 | 6 | 1 |
| Total in % | 51% | 10% | 4% |
Majority of mothers at Bora and Temeke wards reported that they regularly leave their infants in the care of house girls for periods exceeding four hours because they were employed and could not go to work with their infants. Among women who did not leave their child in the care of others, 1 (4%) respondent stated that she did not have any source of reliable child care available to her.
Care Seeking and Management of Child Illness
Feeding During and After Illness
During the weaning period, those six months to two years of age, young children often suffer from infections like diarrhea, measles, cold or cough. If their diet had been adequate, their symptoms are usually less severe than those of an undernourished child. A sick child needs more nourishment so that he/she could fight infections without using up nutrient reserves of his/her body. However, a child may loose appetite and may refuse to eat, but the child needs adequate nutrition to get better from illness. Appropriate feeding during and after illness was important to avoid weight loss and other nutrient deficiencies. The cycle of infection and malnutrition can be broken if appropriate feeding of infants was ensured.
Table 18
Types of Food given to a Sick Child [N =60]
 Researched Area | Bora [n = 10] | Temeke [n = 10] | Mzinga [n =10] | Sabasaba [n =10 ] | Makuka [n = 10] | Kibondemaji [n = 10] |
 Incidence of malnutrition | Low incidence areas | Middle incidence areas | High incidence areas | |||
| Thin maize porridge | ü | ü | ü | ü | ü | ü |
| Stiff Porridge | | | | | ü | ü |
| Fruit juice | ü | ü | | | | |
| Beef Soup | ü | ü | | | | |
| Vegetable Soup | ü | ü | ü | ü | | |
| Beans Soup | | | ü | | ü | |
| Pilau | | | | | ü | ü |
| Mashed potatoes | ü | | ü | | | |
| Mashed bananas | ü | | ü | | | |
| Water | ü | ü | | ü | | |
| Fruits | ü | ü | | ü | | |
Breastfed babies have lesser illness and are better nourished. A breastfed baby should be given breastfeeding more frequently during illness. For infants older than six months, both breastfeeding and complementary feeding should continue during illness. Restriction or dilution of food should be discouraged. Time and care must be taken to help an ill child eat enough food. The infant can be discouraged to eat small quantities of food but more frequently and by offering foods the child likes to eat.
As regards Table 18 above, when mothers were asked to mention the types of food given to sick children, those mothers from the low incidence areas mentioned more nutritious foods than those from the high incidence areas. For example; fruit juice and beef soup were only mentioned by mothers from low incidence areas who also have higher income than those of the high incidence areas.
The child with measles, diarrhea and respiratory infections should eat plenty of vitamin A rich foods. A massive dose of vitamin A could also be given to such children in consultation with the medical officer. After illness when the child is recovering, a nutritious diet with sufficient energy, protein and other nutrients is necessary to enable him to catch up growth and replacement of nutrient stores. The nutrient intake of child after illness can be easily increased by increasing one or two meals in the daily diet for a period of about a month or so.
Child Illness and Medical Treatment
The Ministry of Health, in accordance with WHO guidelines, recommends that parents use oral dehydration therapy (ORT), which consists of continued feeding and increasing fluids (including water, breast milk, juice, and/or oral dehydration salts) for early home treatment of diarrhea, thus preventing the occurrence of dehydration, reducing the nutritional impact of diarrhea and also shortening its duration. Parents must also recognize when children need medical treatment and provide it (Victoria et al. 2000). In Table 3.18, has been indicated that 51 (85%) of women in the research reported that their children had at least one episode of diarrhea in their first two years of life. While, 22 (43%) women respondents were treated at a health center for their last episode of diarrhea (Table 3.19).
Table 19
Child Illness and Medical Treatment [N = 60]
| Mtaa | Had at least one episode of diarrhea [N = 60] | Treated at health center [N = 51] |
| Bora | 7 | 7 |
| Temeke | 8 | 7 |
| Sabasaba | 8 | 2 |
| Mzinga | 9 | 1 |
| Makuka | 10 | 3 |
| Kibondemaji | 9 | 2 |
| Total | 51 | 22 |
| Total in % | 85% | 43% |
Care giving Practices during Diarrhea
When asked about care giving practices during the child’s last episode of diarrhea, 43 (73%) of women reported to have increased the amount of water given to children during their illness. However, nearly half of the women reported that they reduced the amount of breast milk given during the last episode of diarrhea. For children who had already begun to eat complementary foods, 16 (66%) of mothers reported decreasing the amount of food given.
Table 20
Care giving Practices during Diarrhoea [N = 60]
| Mtaa | Increased amount of water given to child [ N = 60] | Reduced amount of Breast milk [N = 36] | Decreased amount of food given [N =24] |
| Bora | 7 | 1 | 0 |
| Temeke | 8 | 2 | 1 |
| Sabasaba | 9 | 4 | 4 |
| Mzinga | 8 | 4 | 6 |
| Makuka | 5 | 3 | 7 |
| Kibondemaji | 6 | 4 | 7 |
| Total | 43 | 18 | 16 |
| Total in % | 73% | 50% | 66% |
Roles, Responsibilities and Capacity Concerns
Father’s role in child care: Both elderly men, elderly women and mothers focus group discussions confirmed that fathers’ role in child care is for the most part limited to providing food for family meals and financial support to women and children for health care. Fathers have minimal involvement in day-to-day care and management of children. Food provision was the responsibilities of the father, which are traditionally shared between male and female members of the family unit who produce and eat together. Mothers frequently cited lack of access to food as a major constraint in feeding children. The research revealed that over 20% of fathers never or rarely furnish condiments for family meals. It was also interesting to note that over 40% of mothers reported that their husbands regularly ate outside the home (one or more times per week) over the last 12 months (17% more than three times per week).
Heavy Workloads and Limited Time
The ability of families to adopt recommended practices and behaviors will depend on having knowledge of the benefits of a particular practice and the know-how to adapt that practice to their daily lives. However, knowledge alone will not assure their sustainable adoption. Care provided to children, in all its manifestations, is directly affected by the workload and time constraints of the attending caregiver. Since children less than 4 years of age are cared for primarily by their mother, a women’s workload plays a major role in shaping the care given to a child.
In addition to the time spent caring or managing the care of their children, sample women reported that women are responsible (to varying degrees depending on the region) for key household tasks (gathering wood, fetching/carrying water, preparing food), agricultural labor on both family and individual fields as well as for many other productive and remunerative activities. Information from the research and focus groups yields several interesting insights about the relationship between women’s workload and child care:
i) Twenty-nine percent of mothers at Makuka Street
ii) Referring solely to feeding practices, 10% of mothers at Bora Street
iii) Majority of men extension workers at Temeke Street
iv) In focus group discussions at Bora Street
v) When asked about ways to help mothers so that they have more time to nurture their children, both old men and old women at Mzinga Street
vi) Forty-three percent of mothers at Sabasaba stated that mothers’ illness is a major constraint preventing proper child care.
These insights illustrate how every household member's contribution is needed to surmount the low productivity of household enterprises - including agriculture. Women often have no choice but to work in the fields and perform daily household tasks, even if the demands on their time threaten the health and nutrition of their children. If productivity was higher for agriculture and women’s daily tasks, households would be in a better position to invest in child care (example, freeing up mothers' time or hiring household help).
Factors and Determinants that influence Child Care and Feeding Practices
There is strong evidence that parents', caregivers' and communities' knowledge remains a major constraint to the adoption of practices that would have a positive impact on children's health and well-being. Only 19% of mothers know that mosquitoes cause malaria, only 16% of mothers exclusively breastfed their child during the first 3 months and only 32% of children received complementary foods between 4 to 6 months of age. Effective communication strategies need to be developed at the district and community levels with clear objectives and involvement of partners from all sectors. Interventions will have a greater chance of success if they are based on an evaluation of past programs to identify what strategies have been successful, what were the specific conditions for their success and at what cost. The impact of these strategies will depend largely on their close monitoring and evaluation, and systematic documentation and dissemination of experiences.
Communication strategies can not overlook the importance of establishing effective community mechanisms to support positive nutrition and health behaviors. Behavior change is not; however, simply an issue of providing caregivers with correct information. Certain conditions and enabling factors that cut across sectors must exist for change to be effective and sustainable. They include social support systems, reduced workloads and time savings from higher labor productivity and access to financial and productive resources. There is strong evidence that work and child care demands compete for women's time. Innovative strategies to increase adequate child care options for women need to be tested. Actions may include community day care centers, increasing men's role in child care and work sharing groups. It will be important to learn from experiences of communities in other countries. Cereal mills and potable water sources in good working order are a priority for women to reduce their workloads, yet we found a high percentage of wards where they did not function due to ineffective management structures and lack of maintenance. The lessons and methods used by successful projects to develop effective, transparent management structures in community organizations must be documented and disseminated so that they can be replicated in village and community development programs.
Recommendations from Respondents on Current Child Feeding Practice
Mothers of Children under Two Years Old
i) Special programme should be initiated so that women could get loans as capital for income generating activities to rise income for their household, hence covering all costs accrued for child feeding and care;
ii) Knowledge on how to improve feeding to children, specifically on how to identify and prepare food rich in required nutrient. This was reported to be important because majority of mothers interviewed have low levels of education;
iii) Clinic services should be free, no payment should be made to the clients;
iv) Donors to support and or provide people with nutritious baby food so that those not able to purchase and prepare required food for their children would get support. The consideration should be made to children under difficult environment;
v) Women without income generating activities should join others and participate in women entrepreneurship groups.
vi) On roles and responsibilities mother have the following comments: mothers should get enough support from their husbands and other family members to ensure that children get nutritious foods;
vii) Plus, women should be exempted from other activities so that they can get more time for care and feeding children. At the same time pregnant mothers should get enough care and support from their families.
Recommendations from Old Men
i) People should get quality treatment so that their health could be improved i.e. body will be active and resistance to communicable diseases;
ii) Health services should be improved in case of child feeding care should be taken on: quality immunization and vaccination services to all children under four years old;
iii) Donors help people to acquire mosquito nets so that grand children are protected from malaria which kill a considerable number of young children. At the same time at Mzinga the promise was made by the some organisation and no positive results to date;
iv) Government should support poor people with small and infant children by providing them with milk formula;
v) Community health workers should be motivated so that they can perform their tasks effectively this includes working gears like bicycles, groves, monitoring cards and weighing scales;
vi) The government should provide support together with donor agents which will enhance training through seminars and workshops to mothers. Contents of this training should include preparation of nutritious food and knowledge and understanding on family planning measures. In addition reading material in various forms should be provided, i.e. brochures, leaflets the contents of which should be on how to feed and take care of a child.
Recommendations from Village Government Council [VGC], Village Health Workers [VHW], Extension Workers and Communities Workers
i) The government should provide training to health workers, specifically on nutrition and child caring;
ii) Community Health Workers should be supported by the government when implementing their activities. For example they have to be given motivation [allowance], when they conduct seminars to women at grassroots level and attend them;
iii) Village government leaders should be educated about nutrition so that they can solve some nutrition problems at their levels. This knowledge will enable them determine some nutrition problems indicators;
Recommendations by Municipality Officials
i) There is a need to have Nutritionist at ward level who will provide nutrition education to women health workers and extension workers;
ii) Village government leaders should be educated about nutrition issues so that they can be able to identify or determine the nutrition problems indicators in their areas;
iii) Working gears should be provided for communities health and extension workers;
iv) It is important that each ward should have health facility in any form, such as health post, dispensary or health centre. This will counter the problem of inadequate facilities and hence accelerate improvement of child care and practice;
v) Financial support to women is very relevant at this moment to make them able to access financial resources to cover costs emanating from child feeding and care practices.
Recommendations from Key Informants
i) Parents should contribute money so that their children could get lunch at school;
ii) At Kibondemaji UNICEF is requested to support recognized NGOs which serve the community there, to make them capable of implementing programmes related to child feeding and care. The support should be in various forms, such as construction of dispensary at ward level.
Conclusion
Throughout the course of this research, men and women have repeatedly alluded to the pervasive effect of poverty on their lives. Poverty and the lack of resources condition the actions of parents in all they do. Focus group discussions reveal how poverty manifests itself at many levels, from the mother working in the field who does not stop to nurse her child, to the pregnant woman who does not have money for prenatal care or the young mother who is unable to produce enough breast milk because she, herself, is hungry. It also affects the family who does not have the means to buy mosquito nets, pay for health care and often eats one meal per day with neither the time nor the resources to prepare the multiple, nutrient-rich meals that children need.
This research has examined household and community practices for improving child health and nutrition. It has highlighted the importance of improving parents’ knowledge of key practices and creating the conditions that foster their adoption. Improved health and nutrition outcomes will also depend on the existence of a coordinated set of policies and programs across sectors and at all levels. Subsequent reports will present results of discussions with village and district health center personnel, village chiefs and newly elected commune officials on the constraints and challenges to developing sustainable multi-sector interventions.
[Extracted from a Report titled "Formative Research on Nutrition and Child Care Practices in Temeke Municipality." UNICEF’s ECD Programme. Reported by GAD Consult – January 2007]
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