Breast milk is the safest and most common natural food for an infant. It provides complete nutritional needs up to six months of age. When the baby is fed exclusively on breast milk, the method is called exclusive breastfeeding which provides the best nutrition, growth and reduces infant morbidity and mortality [2]. Breast milk also, contributes to continued growth until the introduction of solid foods at six months. A study revealed that over the past couple of decades, there has been an intensification of campaigns for exclusive breastfeeding as the best feeding method for newborns [3]. While breastfeeding rates are no longer declining at the global level, with many countries experiencing significant increases in the last decade, only 39% of children less than six months of age in the developing world are exclusively breastfed and just 58% of 20-23 months old benefit from the practice of continued breastfeeding [4]. This is attributed to the implementation of massive programs based on national policies along with global strategies for Newborn and Young Child Feeding, a joint action of the WHO [5]. To enhance these even further, actions entailed initiating breastfeeding at the maternity facilities. In Africa, breastfeeding is the normal and cultural way of feeding infants, resulting in high rates of initiation and longer duration of breastfeeding. However, exclusive breastfeeding tends to decline with increased age in months. According to the International Baby Food Action Network [IBFAN] Africa Regional Office, exclusive breastfeeding at three to four months in 2012 in the region was as follows: Malawi and Eritrea 72%, Botswana 37%, Ghana 43%, Kenya 35% and Lesotho 54% [6].

Breastfeeding reduces the mother's risk of fatal postpartum hemorrhage, the risk of breast and ovarian cancer and of anemia and by spacing births, breastfeeding allows the mother to recuperate before she conceives again [7]. In many Sub-Saharan Africa societies, exclusive breastfeeding is considered by far the best feeding option for women of unknown HIV status and for most HIV positive mothers, although it is challenged by low acceptability and feasibility [8]. The rates of exclusive breastfeeding have improved over the recent past, with the global rate at 37% [9]. However, in all regions the percentage of infants under six months receiving the benefits of exclusive breastfeeding is less than 50%. In the developing world, less than 40 % of infants under 6 months old receive the benefits of exclusive breastfeeding. The rate is particularly low in Africa, where less than one third of infants under 6 months old are exclusively breastfed. There has been a major increase in exclusive breastfeeding in 19 African countries including Rwanda (88%), Tanzania (41%) and Malawi (57%) among others [10]. 

In Kenya however, rates of exclusive breastfeeding remain low with only 32% of infants below six months being exclusively breastfed [11]. Studies have identified various factors that influence breastfeeding practices such as inadequate knowledge of the health benefits of breastfeeding, inadequate antenatal counseling on breastfeeding and belief that breast milk is insufficient. A range of maternal and child health attributes such as marital status, economical status and child age also influence the practice of exclusive breastfeeding. To make better feeding choices, mothers need specific, culturally appropriate, information that responds to their constraints and concerns.

Breastfeeding is very widespread in Arabic and Islamic culture, in which Islam carries encouragement for Muslim women to breastfeed their babies for a full two years. This encouragement of breastfeeding by the Islamic religion supports the great importance of breastfeeding to the health of humanity. In Jordan, 94% of mothers initiated breastfeeding and 27% of mothers initiated breastfeeding immediately within the first hour after delivery [12]. Yet introducing supplements other than breast milk, such as water, juice, herbal tea, is very common practice in Arabic culture. A study in United Arab Emirates (UAE) of 221 mothers showed that at one-month follow-up, only 43% of mothers practiced exclusive breastfeeding and others used extensive amount of fluids such as water, tea and herbal combinations. At six-month follow up, only 13.3% of the sample exclusively breastfed their babies [13]. This percentage falls below the WHO‟s recommendations of exclusive breastfeeding. 

Attitude is defined as a bipolar concept that has a cognitive, affective and behavioral component and is a response to a stimulus [14]. Scott [15], indicates that a woman’s decision to initiate and continue breastfeeding is influenced by her attitude towards breastfeeding as well as the breastfeeding attitudes of significant referent people (e.g. partner, family and friends) and society in general. If she perceives that her breast milk will adequately nourish her infant and that breastfeeding is convenient and better for the health of her infant, then she will have positive attitudes towards breastfeeding. The reasons for low breastfeeding rates among the Somali women include the influence of society and cultural norms, the lack of continuity of care in the health services, clinical problems and the lack of preparation of health professionals and others to support breastfeeding effectively. Mothers ability to prefer to breastfeed is therefore hindered by barriers and afar from a matter of ‘informed choice’, breastfeeding is a behavior that is simply not available for most mothers and babies, notably among Low socio-economic groups [16].

The Ministry of Health in Kenya has implemented the Baby Friendly Hospital Initiative (BFHI), developed by the WHO and UNICEF in order to address poor breastfeeding practices [17]. Despite this and other numerous interventions promoting optimal breastfeeding practices in Kenya, pockets of suboptimal breastfeeding practices. Sub-optimal breastfeeding practices are still prevalent which has contributed to high rates of under nutrition [18]. Kimani-Murage et al. [19], add that poor breastfeeding practices are widely documented in Kenya, where only a third of children are exclusively breastfed for 6 months and only 2% in urban poor settings.

Despite efforts by the county and national government as well as non-governmental organizations, breastfeeding uptake in Garissa County was low. A survey by the county government of Garissa showed low levels of breastfeeding initiation, high use of pre-lacteals, exclusive breastfeeding was low and appropriate introduction of complementary was low. Currently, there exist little information and studies done in line with breastfeeding among the Somali Community and thus there is need to assess the attitudes towards breastfeeding among the Somali and knowledge on breastfeeding This study therefore assessed attitudes towards breastfeeding and the relationship between women’s attitudes and breastfeeding practice.

The study adopted a descriptive cross-sectional survey design. According to Setia [20], a descriptive cross-sectional study inspects the prevalence of a disease or condition in a defined population at a specific point or period in time without attempting to draw any inferences or offer any causes for the prevalence. The target population for the study included mothers in Garissa County, the total number of lactating mothers in Bulla Adaan was estimated to be around 7671 and thus a representative sample was drawn from this. For this study, the sample was obtained by calculating the sample size from the target population by applying a Yamane [1], formula:

Where, 

n: Sample size

N: Population size

e: Level of Precision at 95% level of confidence

P: 5

n = 7671÷ (1+7671×0.0025)

n = 373.34 respondents 

n= 373

Thus a sample size of 373 respondents was required. 

A structured researcher-administered questionnaire was used to collect data. To test the validity, the researcher conducted a pilot study using 6 participants from the camp and were not part of the study. The split half method was used to establish instrument reliability. The researcher administered the questionnaires to the same group of persons after one week. Computation of the correlation between the scores was done by first splitting the tests into two halves. Data was collected through actual administration of questionnaires and interviews by the researcher. The participants were assured of confidentiality of their identity. The researcher waited for the questionnaire to be filled in and then collect them once completed. Data was analyzed both qualitatively and quantitatively. Quantitative data was analyzed by use of descriptive statistics such as frequency distribution and percentages with the aid of computer software. Qualitative data was analyzed by the use of content analysis which is the categorizing and indexing of responses and other field notes into common themes. Chi-square tests were conducted to test for relationships. Results were presented in form of tables and figures.

The study targeted 373 breastfeeding/lactating mothers to assess them in breastfeeding practices among Somali women of reproductive age in Bulla Aadan, Garissa County. A total of 373 women filled and returned the questionnaire and this made a response rate of 100%which was excellent.

Demographic Characteristics of the Respondents

It was determined that majority (188, 50.4%) of the respondents were aged between 21-30 years, followed by those aged between 31-40 years, 77[20.6%]16.6% were more than 41 years. On the highest level of education of the respondents, the findings indicated that majority of the respondents had secondary education [149,39.9%], followed by those who had primary education [120,32.2%], while 62[16.6%] had college education and a mere 42 [11.3%] had no education and this was in contrary to my expectations as this region is characterized with high illiteracy rates. On their marital status, majority were married in a polygamous union at [185,49.6%], 137 [36.7%] were married in a monogamous union while 13.7% were divorced/separated (Table 1).

Table 1: Demographic Characteristics of the Respondent

The study also sought to determine the age of the child. It was determined majority [192,51.5%] were between 6-12 months, 53,14.2% indicated that their children were between 12-18 months,128[34.3%] were less than six months On the gender of the children, the respondents indicated that 61.4% were female while 38.6% were males (Table 2).

Table 2: Demographic Characteristics of Children

Breastfeeding Practices

It was established that 40% of the respondents had breastfed their children less than 6 months, compared to 23.9% who had breasted their children for one and half months while a mere 19.3% and 15.5% had breastfed their children for between for 12 months and 24 months respectively. On the factor that influenced the respondents decision to breastfeed, 145[38.9%] indicated it was from their Islamic religion encourages breastfeeding compared to 143 [38.3%] that indicated that they knew that Breastfeeding has health benefits for the baby while 21[5.6%] indicated that they breastfed as a result of Advice from a health care professional or nurse. 

Querying the first time the respondents put their infants to breast, majority [n = 186,49.9%, indicated that they put them within first day compared to 135 (36.2%) who indicated they put them within the hour of birth, while a mere 52 [13.9%] indicated within the second day. This implied that the respondents had the knowledge on the importance of putting the infant on breast immediately. Further, the study sought to determine if the respondents gave their neonates/infants the child anything else after three days after delivery. It was determined that majority of the respondents (232, 62.2%) had not provided their infants with anything else after three days after delivery compared to 141 [37.8] who had given them other foods/drinks. This implied that the respondents knew the importance of abstaining from giving their neonates other baby foods. Assessing the various reasons for weaning /stop breastfeeding child, the study established that 107 [28.7%] cited that they become pregnant, 105 [28.2%] indicated that breastfeeding was too tiring and this necessitated them to wean their children while 71[19%] argued that Baby continued to be hungry after feeding (Table 3).

Table 3: Breastfeeding Practices

Majority 271 (72.7%) of the respondents had poor breastfeeding practices as shown in Figure 1. This is in agreement with findings of Taha et al. [21], that breastfeeding practices were suboptimal in several aspects with a low proportion of children being exclusively breastfed, short breastfeeding duration and early introduction of complementary feeding, despite high socioeconomic status. It is also similar to findings of Swigart et al. [22], where women reported supplementing breast milk with water and teas soon after birth, as well as introducing small bites of solid food a few months after birth. Asare et al. [23], also found that exclusive breastfeeding and timely complementary feeding practices are suboptimal.

Figure 1: Breastfeeding Practices

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Attitudes towards Breastfeeding among Respondents

The study also sought to establish attitudes towards breastfeeding among respondents. The results are presented in Table 4. Results show that 291(78%) disagreed that they did not like breastfeeding. Results show that 267 (71.6%) agreed that women should not breast‐feed in public places such as restaurants. Similarly, 315 (84.5%) agreed that they would feel embarrassed if someone saw me breastfeeding. Majority 312 (83.7%) felt that breastfeeding is old fashioned. Similarly, 294 (78.8%) agreed that breastfeeding will make mothers’ breasts sag. These results point to negative attitudes among respondents. This is similar to findings of Westmar and Johansson [24], where majority of the women had a poor attitude towards breastfeeding. In Ketbi et al. [25], study, 90 (26.2%) had a poor attitude. Dukuzumuremyi et al. [26], also found that only few mothers had a positive attitude towards exclusive breastfeeding.

Table 4: Attitudes Towards Breastfeeding

Findings in Figure 2 show that majority 266 (71.3%) of the respondents had negative attitudes towards breastfeeding. This is similar to findings of Orabi et al. [27], whereby only a minority of respondents had a positive attitude toward breastfeeding. However, the finding differs from findings of Zhou et al. [28], Mogre et al. [29], Alamirew et al. [30], Mohamed et al. [31] and Kitiyo et al. [32], where majority of the mothers had positive attitude towards breastfeeding.

Chi-square tests were conducted to find out the effect of attitudes towards breastfeeding on breastfeeding practices. Results in Table 5 show that there is a significant relationship (χ² = 25.020, df = 8, p = 0.002) between attitudes towards breastfeeding on breastfeeding practices. This means that attitudes influence breastfeeding practices. Khresheh [33], also found that participants who intended to breastfeed had significantly higher breastfeeding knowledge and positive attitudes. However, Al Ketbi [25], found that there was no statistically significant relationship between mothers’ breastfeeding attitudes and practices.

Table 5: Effect of Attitudes on Breastfeeding Practices

Figure 2: Attitudes Towards Breastfeeding

The study concludes that majority of women had negative attitudes towards breastfeeding. Majority of respondents did not believe breast‐feed in public places such as restaurants. Majority indicated that they would feel embarrassed if someone saw me breastfeeding. A high number of respondents felt that breastfeeding was old fashioned and it made mothers’ breasts sag. Analysis showed that knowledge and attitude were related whereby low knowledge resulted in negative attitudes. Similarly, respondents’ attitudes affected their breastfeeding practices whereby respondents with negative attitudes were highly likely to have poor breastfeeding practices. The government and other private institution in the health sector should carry out mass education particularly the women on the importance of breastfeeding to the infants as this has more benefits to both the mother and the infant as well as the society.

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