Somali KAP Study on Infant and Young Child Feeding and Health Seeking Practices

By Waweru Joseph Mwaura and Grainne Moloney

Joseph Waweru has worked as Nutrition Project Officer with the FAO Food Security Analysis Unit (FSAU) Nutrition Surveillance Project in Somalia for the last two years. He has coordinated and supervised several nutrition assessments and trainings and reviewed/piloted technical guidelines and methodologies. Previously he worked as a Research Assistant at Kenyatta University.

Grainne Moloney is the Nutrition Project Manager of the FAO/FSAU Nutrition Surveillance Project, where she has worked for the last 18 months. Previously, Grainne worked with UNICEF in Darfur, also on nutritional surveillance, and with Oxfam and Action Against Hunger UK on nutrition and food security in many different contexts.

The authors would like to acknowledge the great effort of Professor Wambui Kogi-Makau and Ms Rose Opiyo for leading the study. The authors also express sincere thanks to the FSAU nutrition team. The contribution of UNICEF, World Vision and Gedo Health Consortium in the study is acknowledged. The study was financed by the Swedish International Development Agency.

Since the collapse of the Somali Central Government in 1991, the country has faced a series of disasters, both natural (floods and droughts) and man-made (poor governance, armed conflict, and collapse of institution/infrastructure). These have led to disruption of livelihood systems, poor provision of basic services and erosion/loss of social care network.

The Food and Agriculture Organisation's (FAO) Food Security Analysis Unit (FSAU) has been conducting nutrition assessments in Somalia for the last eight years. Together with past surveys conducted across South and Central Somalia since the1980s, these have consistently recorded high levels of acute malnutrition and under five mortality rates, even in years with improved food production. Median rates of global acute malnutrition in 2007, based on 36 surveys, were 15.2% global acute malnutrition (GAM) and 2.7% severe acute malnutrition (SAM), illustrating the severity of the crisis. Potential contributing factors¹ include lack of safe water (only 15% of the population have access), lack of sanitation facilities (25% of the population have access), lack of a functional health system for basic services (measles coverage estimated at 35%) and chronic food insecurity.

Humanitarian agencies' efforts to address these services deficiencies are hampered by recurrent insecurity. Available data on care practices of young children indicate an alarming situation with regard to breastfeeding, complementary feeding and treatment of childhood illness. Based on the hypothesis that the role of child care, feeding and health practices are a significant contributing factor to chronically high rates of acute malnutrition, the FSAU commissioned a Knowledge Attitudes and Practices (KAP) study in September 2007² to learn more and come up with recommendations to address identified problems.

The study assessed the key livelihood systems³ of Somalia in seven major regions. Data collection methods were both quantitative and qualitative including literature review, focus group discussions, rapid profiles, key informant interviews and case studies. Respondents included elderly, pregnant women and women of child bearing age, men, traditional birth attendants, traditional healers, community health workers, health professionals, community/ religious leaders, women groups and international/ local NGOs.

Not surprisingly, the study found that pregnant/ lactating women do not have access to formal nutrition education and mainly rely on social networks including grandmothers, traditional healers and sheikhs for advice on child feeding and health seeking behaviours. There is no special diet for pregnant women. However, food intake is reduced in the 3rd trimester to control the size of the baby and thereby ease its delivery. Some of the foods prohibited (though in negligible levels) include honey, lamb meat and ghee. The traditional post-natal care for 40-days after delivery is routinely implemented in all but the pure pastoralists' households. This encourages mothers to eat nourishing food and to focus on breastfeeding in the initial weeks after delivery, however mother often cite lack of resources to purchase the necessary foods.

Breastfeeding is mainly influenced by social environment, especially by maternal grandmothers and other elderly women in the community. Although breastfeeding is acceptable to all, infants are first introduced to sugary water after birth around the 3rd or 4th day after delivery. This is to avoid the colostrum (first milk) that is generally discarded by the mother as considered heavy, thick, coarse, dirty, toxic, and harmful to children's health. Exclusive breastfeeding is not practiced, as breastmilk alone is considered inadequate and water essential to cool the baby and quench their thirst. On a positive note, the agreed and acceptable duration of breastfeeding is 24 months, based on the Koran,Sural Al-Baqrah, Juz 2:233 and is consistent with recommended standards. However, this is rarely implemented for two main reasons - very close birth spacing, since once a women discovers she is pregnant she stops breastfeeding, and an increasing trend of mothers working outside the home, resulting in early separation from the infant.

A breastfeeding mother from Berbera

The study also found that there is a lack of or inappropriate knowledge of proper complementary feeding practices across all livelihood groups. Early introduction of complementary foods (from birth to three months) is common, mainly as cow's/goat's milk (involving no special preparation or storage), tea and porridge. The poorer households report limited access to milk, which they replace with tea/porridge after 3 months. Lack of dietary variety is typical among the riverine and, to a lesser extent, the agropastoral community, where children are mainly fed a cereal-based diet. Tea is often given to children as a snack before meals, which reduces stomach capacity and appetite and interferes with nutrient absorption. During illness, special diets for quick recovery include avoiding animal protein-based foods, which are believed to aggravate illnesses. Knowledge on the use of Oral Rehydration Salts (ORS) for diarrhoea was good, with local adaptations using lemon or water melon juice.

Access to safe water is of major concern, with most households relying on unprotected sources. Water treatment at household level rarely happens. Unsafe water and childhood diarrhoea are the strongest associated factor with childhood malnutrition in Somalia. Sanitation/waterrelated diseases including diarrhoea, acute respiratory infection (ARI), intestinal parasitic infestations and skin/eye infections are the main reported illnesses. Access to formal health services is limited or unavailable, especially among the rural population. Responses to illnesses tend to follow a generalised pattern of: Prayer - Traditional home health practice - Traditional healer -Buy medicine - Get Sheikh to pray -Health facility.

This clearly shows the lack of knowledge of, or confidence in, more modern health care practices. Many of the traditional practices are harmful, such as burning of the feet for nutritional oedema, and often result in the child becoming sicker before they are finally taken for conventional treatment.

In conclusion, the study revealed glaring evidences that child feeding and care practices are below the acceptable standards. Much of this can be attributed to poor knowledge, with poor practices exacerbated by the collapse of the basic infrastructure resulting from the war in the early 90's. The study recommends participatory dissemination of the study findings, training, advocacy and active involvement of key community change agents (religious/traditional and professionals) and caregivers in generating solutions for the challenges highlighted. Parallel campaigns and interventions are needed that focus on basic health care, hygiene, sanitation, safe water and child feeding practices. The importance of Islam in imparting positive messages relating to child care and hygiene is very evident, highlighting a clear entry point for community sensitisation and future behaviour change.

For further information or a copy of the full report, please contact Grainne Moloney, P.O. Box 1230- 00621, Nairobi, Kenya. Tel: 254-20-3745734/1299; Fax: 254-20-3740598; email: grainne.moloney@fsau.or.ke or Joseph.waweru@fsau.or.ke

¹Source: FSAU nutrition surveys database (n=105) from 2000 to 2007

²Somali Knowledge Attitudes and Practices (KAP) study. Infant and Young Child Feeding and Health Seeking Practices. FAO/FSAU. December 2007. Available at: http://www.fsausomali.org/rss_article_id_245.php

³Agro-pastorals, Pastoral, Riverine, Urban and Coastal Communities.