Child Physical Growth and Care Practices in Kenya: Evidence from Demographic and Health Surveys
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Background: The aims of this dissertation were to describe trends in child undernutrition in Kenya manifest as poor physical growth, along with trends in feeding care practices, and to examine socio-demographic correlates of child feeding practices. The dissertation also examined the reliability of socio-demographic variables in predicting initiation of breastfeeding within an hour of birth. Globally, millions of children under the age of five die of conditions associated with undernutrition. The effects of undernutrition do not end at child mortality but have pervasive effects on surviving victims. Undernutrition alters normal brain development, reduces energy levels and limits the rate of motor development in children. The aforementioned biological impairments have been linked to over 200 million children in the developing world not achieving their development potential and perpetuating intergenerational poverty. Feeding is, of course, a key child care practice. The pattern of infant and young child feeding that provides most benefit is being put to the breast within an hour of birth, exclusive breastfeeding for six months, continued breastfeeding along with complementary foods up to two years of age or beyond, and avoidance of any bottlefeeding. The data show that many children across the world, and particularly in Kenya, are not fed optimally. Consequently, it was estimated in 2011 that globally, about 804,000 children die annually due to sub-optimal breastfeeding and a further 44 million disability-adjusted life years are lost. It is perplexing that the world is still grappling with such loss of life and yet the benefits of optimal breastfeeding to the health and development of the child are enormous. The benefits range from physical, motor, cognitive and psychosocial development of the child to a boosted natural immunity against infection and thus scaling down undernutrition. Breastfeeding also has health benefits for the mother and cumulative benefits to the child in its later years, as it is protective against obesity, diabetes and hypertension. Despite knowledge of the pervasive effects of undernutrition and the potential effect of optimal infant and young child feeding practices, little is known about their trends, especially within countries in the global south. Research on trends in child growth and care practices has been hindered by the challenges of changing criteria for classifying child undernutrition and optimal care practices. There has also been an emphasis in the literature on international comparisons of countries’ situations with little attention to within-country trend analyses. There is need for detailed analyses of child growth and care practices over time. In addition, little is known about the reliability of socio-demographic variables in predicting (in statistical terms) child health care outcomes such as initiation of breastfeeding within an hour of birth. Researchers and policy-makers need reliable statistical models that describe the relationship of possible risk and protective factors to child feeding endpoints such as early initiation of breastfeeding. The development of reliable models in which the early initiation of child breastfeeding is in focus is imperative, because this feeding behaviour has such profound consequences for mother and child health. Methods: The study used data from the Kenya Demographic and Health Surveys (KDHS) collected in 1993, 1998, 2003 and 2008-09. Analyses in Papers I, II and III were conducted using IBM SPSS version 19. Due to the multi-stage sampling design used by KDHS, the design effect parameters ‘sampling weight’, ‘sample domain’ and ‘sample cluster’ were incorporated in all analyses using SPSS’ Complex Samples Module. Logistic regression was used in data analysis in all the three papers. Child undernutrition was estimated by classifying children as stunted or not (height for age and sex), wasted or not (weight for age and sex) and underweight or not (weight for age and sex) using the most recent recommended WHO growth standards of 2006. To assess child feeding practices, children of ages 0-23 months were considered to have been: breastfed early if they were put to breast within one hour after birth, exclusively breastfed if they were fed on nothing else other than breast milk in the last 24 hours prior to the KDHS interview, complementary fed and breastfed if they were given breast milk as well as any solid, semi-solid or soft foods in the last 24 hours, and bottle-fed if a bottle was used for at least part of their feeding in the 24 hours prior to the KDHS interview. Results: Results in paper I showed that the national trends in the prevalence of child underweight declined, while the trends in wasting and stunting were stagnant. Analyses disaggregated by demographic and socio-economic sub-groups revealed some departures from the overall trends. Wasting trends declined more among girls than among boys, and the opposite was true for stunting, with boys posting a greater decline in the prevalence of stunting compared to girls.</p<In paper II, trends in exclusive breastfeeding showed significant improvement in most of socio-demographic sub-groups. Conversely, the trends in early initiation of breastfeeding, complementary feeding and breastfeeding, and bottle-feeding were stagnant or slightly worsening in most socio-demographic sub-groups. Multivariate analysis using the 2008-09 data showed that accounting for other variables, the province where the mother resided was the most significant predictor of early initiation of breastfeeding, exclusive breastfeeding and bottle-feeding. The main finding in Paper III was that the socio-demographic variables that were significantly related to early initiation of breastfeeding in the multivariate analysis using 1998 data were weakly related in analyses using the 2003 and 2008-09 data. Only mode of birth and province of residence reliably predicted early initiation of breastfeeding across the three surveys. Discussion: Results of paper I and II showed stagnating trends in child growth and feeding practices in Kenya but also important departures in the sub-group analyses. The sex differences in child growth were consistent with previous studies from sub-Saharan Africa where growth patterns showed slightly lower prevalence in wasting, stunting and underweight for girls as compared to boys. The evidence on reasons for the gender difference is conflicting. The contribution of this dissertation is to suggest that differences in the early feeding of Kenyan boys and girls are insignificant as a factor in child growth differences, but this requires detailed exploration in further research. Another important finding on trends in paper I and II relates to differences by age in child growth and feeding practices. There was a consistently low prevalence and stable trend in wasting and stunting among youngest children aged 0-5 months from 1993 to 2009 and an increasing trend in exclusively breastfed children at the same age. In the older age groups however, trends were not generally improving. It is possible that some aspect of quality of feeding after age 5 months plays a role in this pattern, and further research is desirable on this aspect of child care in Kenya. Consistent in the three papers, trends in child growth and care practices differed by province of residence, highlighting the importance of province as a contextual/distal factor in analyses of child growth and feeding practices trends. An analysis in paper III of the reliability of the association between socio-economic and demographic variables and child feeding confirmed that province of residence was a reliable predictor of timing of initiation of breastfeeding over time, but this was not true for other socio-economic and demographic variables. This calls for detailed research at the intra-province level, to illuminate the aspects of provincial living that impact child growth and care. This is a central conclusion of this dissertation: if we can better understand how ‘place’ affects child growth and care, we might be able to fine tune health promotion interventions to make them more sensitive to features of various places – with place referring to province-of-residence, but perhaps also levels of locality much nearer the household.
Has partsPaper I: Matanda, D. J., Mittelmark, M. B., & Kigaru, D. M. (2014). Child undernutrition in Kenya: trend analyses from 1993 to 2008-09. BMC Pediatrics, 14(1), 5. http://hdl.handle.net/1956/7798
Paper II: Matanda, D. J., Mittelmark, M. B., & Kigaru, D. M. (2014). Breast-, complementary and bottle-feeding practices in Kenya: stagnant trends were experienced from 1998 to 2009. Nutrition Research, 34(6), 507–517. http://hdl.handle.net/1956/9009
Paper III: Matanda, D. J., Mittelmark, M. B., Urke, H. B., & Amugsi, D. A. (2014). Reliability of demographic and socioeconomic variables in predicting early initiation of breastfeeding: a replication analysis using the Kenya Demographic and Health Survey data. BMJ Open, 4(6), e005194. http://hdl.handle.net/1956/9011