“There Is No Other Food Besides the Breast”: Challenges of Infant and Young Child Feeding in Rural Sierra Leone

Abstract

Background: Optimal breastfeeding and complementary feeding of children under the age of two years has been found to have significant consequences for child survival. However, current rates of optimal infant and young child feeding (IYCF) practices in Sierra Leone are suboptimal and little research has been conducted about this issue, particularly in rural communities. This thesis aims to address this knowledge gap by assessing IYCF practices and barriers to optimal feeding experienced by women living in Kono District, a rural area of eastern Sierra Leone. Methods: A mixed-methods approach with simultaneous administration of a quantitative questionnaire and semi-structured interview questions was used to investigate IYCF practices in villages located in four chiefdoms of Kono District. This methodology was chosen to broadly characterize IYCF practices and test for significant predictors of these practices, while elaborating on key determinants of maternal decision-making processes that might not be identified by a strictly quantitative analysis. Fifty-six women chosen by random selection participated in both components of the survey. Results: Thirty-eight percent of women had initiated breastfeeding within one hour after delivery and seventy-two percent of surveyed children were exclusively breastfed at five months. Multivariable logistic regression analysis found that primary or greater maternal education, membership in the highest wealth quartile, and a shorter birth interval were significant predictors of timely breastfeeding initiation. Women who had received IYCF information from health care workers were more likely to exclusively breastfeed for at least six months than women who had received information from family members or media. Qualitative interviews revealed that low socioeconomic status and financial instability caused some mothers to stop exclusive breastfeeding before six months, delay weaning due to lack of appropriate weaning provisions, and provide a low-diversity diet to children who had been introduced to family foods. Although the majority of women received information about exclusive breastfeeding from a health care worker and appeared to have retained this knowledge, IYCF education regarding early complementary feeding and introduction of nutritious family foods was suboptimal. Conclusions: Four objectives for improving IYCF practices among rural, low-income women in Sierra Leone require greater attention by policymakers and health care providers: 1) more comprehensive and locally appropriate IYCF education by health care workers, 2) involvement of traditional birth attendants in IYCF promotion, 3) availability of multiple complementary food options, and 4) scaling back on initiatives that prioritize discouraging infant formula in hospitals and clinics. Additionally, the WHO and other international institutions should engage in an ongoing evaluation of the guideline of exclusive breastfeeding for six months to take into account the practical limitations that frequently arise in very low-income settings.