DECLARATION

This thesis has been presented to University Of Somalia for the award Degree Bachelor of Public
Health. This is my original work and to the best of my knowledge has never been presented for
any other award.

Student

Hassan abdulahi shire

Signature: .........................

Date: ……./………./ 2018

I
 APPROVAL

I confirm that the candidate under my supervision carried out the work respondent in this thesis.

Supervisor:

Mr. Omar Abdi Farah

Signature: ......................... Date: ...../...../20118

Dean of the Faculty of Health Sciences

Mr. Yasin Ahmed Nor

Signature: ......................... Date: ...../...../2018

II
 DEDICATION

This work is dedicated to my family for their love, encouragement and support throughout my
study.

III
 AKNOWLEDGEMENT

First and for most, I owe my gratitude to the almighty Allah for granting me good health and
strength throughout my period of study.

Secondly, I am most grateful to my supervisor Mr. Omar Abdi Farahfor his sincere
encouragement and guidance to me. His remark made this work what is it.

Thirdly, my appreciation is extended to the study participants for their participation and the time
they scarified for this study which could otherwise been used for their other duties.

Finally my heartfelt thank goes to my family members and my friends for their inspiration and
encouragement.

IV
 ABBREVITIONS

ABBREVIATIONS term description

IMR Infant Mortality Rate

SIDS Sudden Infant Death Syndrome

WHO World Health Organization

WHA World Health Assembly

UNICEF United Nations International Children Education Fund

V
 ABSTRACT

Bottle feeding is the popular alternative method to breast feeding for babies. Formula milk
cannot be made identical to human milk and the bottle fed babies are deprived of many valuable
antibodies present in the mother's milk. Scientific evidence shows that formula is inherently
inferior to breast milk unable to replicate the immunological or living cells necessary to protect
infants from an infectious environment far greater consequential harm is inflicted when formula
is used under sub-optimal environmental conditions. Commercial formulas generally meet
minimal safety standards under international law, notwithstanding recurring product recalls.
However, due to the dangers of mixing formula with unclean water, high bacterial
contamination of bottles and teats, and improper dilution from inadequate educational and
financial resources, the process of bottle-feeding has unnecessarily harmful consequences in
parts of the developing world. Pervasive throughout the developing world, 20% of mothers who
used formula were found to have diluted the formula over 40% more than recommended. As an
indicator of health complications, infants fed over-diluted formula are at a serious risk of not
absorbing adequate levels of calories and nutrients so exacerbating the harms of unhygienic
bottle conditions and crippling an infant's defenses against starvation, disease, and ,ultimately,
death.
Objective: This study is aimed to describe effect of bottle feeding and also to determine mothers
knowledge about exclusive breastfeeding as well as to identify risk factors associated with bottle
feeding Hodan district in Mogadishu.
Methodology: Descriptive cross-sectional survey was carried out in Hodan district. every one of
respondents are randomly selected by using structured questionnaire. The ethical consideration
of the study focused primary on the rights of the participants who were questioned for the
purpose of gathering data. The Study sample will be 50 participants from Hodan district.

Result: The study included fifty participants. 68% of the participants identified health effects of
bottle feeding. Despite majority of the participants indicate that health risks of bottle feeding the
is preventable, and also they improve the best way to prevent is to rise community awareness
and health education and also to make breastfeeding policy.

Conclusion: Community mobilization, health education and making breastfeeding policy are the
best ways to reduce effects of bottle feeding among infants in Hodan district.

VI
 TABLE OF CONTENTS

Contents
DECLARATION ........................................................................................................................................... I
APPROVAL ................................................................................................................................................. II
DEDICATION ............................................................................................................................................. III
AKNOWLEDGEMENT .............................................................................................................................. IV
ABBREVITIONS ......................................................................................................................................... V
ABSTRACT................................................................................................................................................... VI
TABLE OF CONTENTS ............................................................................................................................ VII
LIST OF TABLE ......................................................................................................................................... XI
CHAPTER ONE ......................................................................................................................................... 1
INTRODUCTION....................................................................................................................................... 1
1.1 BACKGROUND ................................................................................................................................... 1
1.2 PROBLEM STATEMENT ..................................................................................................................... 3
1.3 JUSTIFICATION OF THE RESEARCH ............................................................................................... 3
1.4 OBJECTIVES ......................................................................................................................................... 4
1.4.1 GENERAL OBJECTIVE ..................................................................................................................... 4
1.4.2 SPECIFIC OBJECTIVE .................................................................................................................... 4
1.5 RESEARCH QUESTIONS..................................................................................................................... 4
1.6 RESEARCH HYPOTHESIS .................................................................................................................. 4
1.6.1 ALTERNATIVE HYPOTHESIS ........................................................................................................ 4
1.7 SIGNIFICANT OF THE STUDY ........................................................................................................ 4
1.10 OPERATIONAL DEFINITIONS ......................................................................................................... 5
CHAPTER TWO ........................................................................................................................................ 6
LITERATURE REVIEW .......................................................................................................................... 6
2.1 Bottle Feeding ......................................................................................................................................... 6
2.3.3 EDUCATION .................................................................................................................................... 10
2.3.6 EMPLOYMENT ................................................................................................................................ 10
CHAPTER THREE .................................................................................................................................... 15
MATERIALS ANDMETHODOLGY ........................................................................................................ 15
3.0 STUDY AREA ..................................................................................................................................... 15

VII
3.1.1HODAN DISTRICT ........................................................................................................................... 15
3.1.1.1 SUBDIVISIONS OF HODAN DISTRICT .................................................................................... 15
3.1.1.2WADAJIR HEALTH STANDARD ................................................................................................ 15
3.2 STUDY DESIGN.................................................................................................................................. 16
3.3 STUDY POPULATION ....................................................................................................................... 16
3.3.1 INCLUSION CRITERIA ................................................................................................................... 16
3.3.2 EXCLUSION CRITERIA.................................................................................................................. 16
3.4 SAMPLE SIZE DETERMINATION ................................................................................................... 16
3.5 SAMPLING PROCEDURE ................................................................................................................. 16
3.6 RESEARCH INSTRUMENT ............................................................................................................... 16
3.7 DATA ANALYSIS ............................................................................................................................... 17
3.8 ETHICAL CONSIDERATIONS .......................................................................................................... 17
3.9 SCOPE OF THE STUDY ..................................................................................................................... 17
Place of the study ........................................................................................................................................ 17
Time of the study ........................................................................................................................................ 17
3.10 RESEARCH LIMITATION ............................................................................................................... 17
CHAPTERFOUR........................................................................................................................................ 18
DATA ANALYSISAND RESULTS .......................................................................................................... 18
4.1 RESPONDENTS BY AGE................................................................................................................... 18
4.2 sex respondents ..................................................................................................................................... 19
4.3 marital status respondents ..................................................................................................................... 20
4.4 educational respondents ........................................................................................................................ 21
4.5 occupational respondents ...................................................................................................................... 22
4.6 respondents of do you know bottle feeding?......................................................................................... 23
4.7 respondents food .................................................................................................................................. 24
4.9 respondents of If you answered ‘Yes’ Have you seen infants suffering diseases resulted from bottle
feeding? ....................................................................................................................................................... 26
4.10 Respondents of factors influencing mother’s bottle feeding practice is ............................................. 27
4.11 Respondentsdoes bottle feeding diseases only occur infants? ............................................................ 29
4.12 Respondent of bottle feeding related disease is .................................................................................. 31
4.13 Respondent of does bottle feeding increases infant mortality rate...................................................... 32
4.14 respondents of prognosis of bottle feeding is...................................................................................... 33

VIII
4.15.Respondents of malnutrition is most common in a bottle fed infants ................................................. 34
4.16 respondents of effects of belief and attitude of mother on exclusive breastfeeding is ........................ 35
4.17 Respondent of do you believe that health risks of bottle feeding can be preventable ........................ 36
4.18 Respondents of If yes, which interventions can be used to preventhealth risks of bottle feeding. ..... 37
CHAPTER FIVE ........................................................................................................................................ 38
CONCLUSION AND RECOMMENDATION .......................................................................................... 38
5.1 CONCLUSION ..................................................................................................................................... 38
5.2 RECOMMENDATIONS .................................................................................................................... 40
REFERENCE.............................................................................................................................................. 41
APPENDIX I .............................................................................................................................................. 42
QUESTIONNAIRE .................................................................................................................................... 42
APPENDIX II ............................................................................................................................................. 46
BOTTLE FEEDING IMAGES ................................................................................................................... 46
APPENDIX III ............................................................................................................................................ 47
WADAJIR MAP ......................................................................................................................................... 47
APPENDIX IV: MAP OF MOGADISHU ................................................................................................ 48
APPENDIXV: MAPOF SOMALIA ........................................................................................................... 49
APPENDIX VI: LETTERTO THE ETHICAL COMMITTEE .................................................................. 50

IX
 LIST OF FIGURES

Table 4.1 respondents of age ...................................................................................................................... 18

Table4.3 marital status respondents ............................................................................................................ 19
Table4.3 marital status respondents ............................................................................................................ 20
Table4.4 educational respondents ............................................................................................................... 21
Table 4.5 occupational respondents ............................................................................................................ 22
Table 4.6 respondents do you know bottle feeding..................................................................................... 23
Table 4.7 food or drink given to infants before breast milk follow is......................................................... 24
Table 4.8 respondents do you know the health effects of bottle feeding among infants ............................ 25
Table 4.10 respondents of factors influencing mothers bottle feeding practice is ...................................... 27
Table 4.13 Respondent of does bottle feeding increases infant mortality rate. .......................................... 32
Table 4.14 prognosis of bottle feeding........................................................................................................ 33
Table 4.15.Respondents of malnutrition is most common in a bottle fed infants ....................................... 34
Table 4.16 respondents of effects of belief and attitude of mother on exclusive breastfeeding is.............. 35
Table 4.17Respondent of do you believe that health risks of bottle feeding can be preventable. .............. 36
Table 4.18 respondents of If yes, which interventions can be used to prevent health risks of bottle feeding.
.................................................................................................................................................................... 37

X
 LIST OF TABLE

Figure 4.1 respondents of age ..................................................................................................................... 18

Figure4.2:sex respondents........................................................................................................................... 19
Figure 4.3 marital status respondents .......................................................................................................... 20
Figure4.4 educational respondents .............................................................................................................. 21
Figure 4.5 occupational respondents ........................................................................................................... 23
Figure 4.7 food or drink given to infants before breast milk follow is ....................................................... 24
Figure 4.8 respondents do you know the health effects of bottle feeding among infants ........................... 25
Figure 4.9 If you answered ‘Yes’ Have you seen infants suffering diseases resulted from bottle feeding?
.................................................................................................................................................................... 26
Figure 4.10 respondents of factors influencing mothers bottle feeding practice is..................................... 27
Figure 4.11 Does bottle feeding diseases only occur infants ...................................................................... 29
Figure 12: bottle feeding related disease..................................................................................................... 31
Figure 4.13 Respondent of does bottle feeding increases infant mortality rate. ......................................... 32
Figure 4.14 prognosis of bottle feeding ...................................................................................................... 33
Figure 4.15.Respondents ofmalnutrition is most common in a bottle fed infants ...................................... 34
Figure 4.16 respondents of effects of belief and attitude of mother on exclusive breastfeeding is ............ 35
Figure4.17Respondent of do you believe that health risks of bottle feeding can be preventable. .............. 36
Figure 4.18 respondents of If yes, which interventions can be used to prevent health risks of bottle
feeding. ....................................................................................................................................................... 37

XI
 CHAPTER ONE
INTRODUCTION
1.1 BACKGROUND
Bottle feeding is the popular alternative method to breast feeding for babies. Formula milk
cannot be made identical to human milk and the bottle fed babies are deprived of many valuable
antibodies present in the mother's milk. The risks of contamination of the feed are also greater
with bottle than with breast feeding (WHO, 2013).

According to globally there is documented evidence of increased risk of infant mortality in

formula fed infants versus breast fed infants. The hazards of bottle use for infant feeding,
especially in underprivileged communities, are also well known. As the issue of bottle use is
directly related to childhood survival and mortality, there is legislation against propagation of
bottle feeding in developing countries. The tendency to use the bottle increased in relation to
child’s increasing age .The attributes associated with increased bottle use were mother’s
illiteracy and increased parity. Bottle use is a public health issue in poor and illiterate mothers of
developing countries. While, feeding the infant with bottle, the milk which has no disinfectant
factor may be polluted with micro-organism which causes infant morbidity so, we need
community-based strategies to bring about a socio-cultural shift in the growing prevalence of
bottle use. Infant feeding in developing countries, bottle use and breast milk substitute resulted
great risk to infants health. The hazards of bottle feeding include over dilution of milk with
resultant of malnutrition and consequently retardation in infant growth. There is increased
susceptibly to diarrhea and other GIT infections, ear infections, allergic tendency, mental
retardation and dental caries. Recently a detailed comprehensive report, using data both from
developed and developing countries highlighted the increased relative risk of infant mortality
amongst formula fed versus breast-fed infants. In developing countries, the risk of IMR is higher
in bottle fed babies as compared to breast-fed. The report also highlights that the extent, severity
and frequency of childhood illnesses is more in bottle fed infants as compared to breast fed
babies. Many studies on infant feeding practices have found the declining trend and decreased
duration of exclusive breast-feeding. However no study has particularly focused on determinants
of bottle-feeding amongst low-income urban communities (Abbottabad ,2006).

1
According to regionally, during the last few decades an increase in the use of bottle with a
Nipple for infant feeding has been observed in developing countries. This use has been shown to
interfere with breast feeding. The replacement of breast with bottle feeding has health
consequences for the infant. Increased infant mortality and infant morbidity rate risks have been
reported. The adverse health effects of bottle feeding and the effects on the household resources
of the use of bottle milk substitutes have prompted an international complain against the use of
bottle feeding in developing countries. the success of this bottle battle has been measured largely
by the establishment of an international code for the marketing of breast milk substitutes adopted
by the world health assembly in1981 by influencing infant formula promotion and by reversing
of the decline of breast feeding such as was shown for Malaysia, Kenya. (Pediatrics 1991)

According to nationally by discouraging bottle feeding, exclusive breastfeeding for at least the
first six months of life is recommended by UNICEF and the World Health Organization. Breast
milk provides all the nutrients newborns need for healthy development and also provides
important antibodies against common childhood illnesses resulted bottle feeding practices.
Exclusive breastfeeding also prevents babies from ingesting contaminated water that could be
mixed with infant formula. The difference between breastfeeding and formula feeding is
tremendous: Breastfed infants have at least a six-fold greater chance of survival in the early
months than bottle fed infants. Still, many Somali women do not exclusively breastfeed; instead
feeding their infants camel’s milk, tea or water in addition to breast milk. In Somalia, most
mothers do breastfeed their infants, however the common practice is to also feed babies other
infant formulas. In rural areas, women often return to strenuous work in the fields within days
after giving birth, so it is especially difficult for mothers to follow recommendations regarding
breastfeeding. Many of the women from the countryside usually do breastfeed, even up to one
year, even if the lactating mother is malnourished. But when these women come to Mogadishu,
they see the women here bottle-feeding with formula, and believe it is better. Then they start
changing their ways. Making matters worse is the abundance of infant formula in camps for the
displaced, much of it donated by people around the world who believe malnourished mothers are
unable to breastfeed (UNICEF,2003)

2
1.2 PROBLEM STATEMENT

Recent studies have shown that bottle fed infants are more sensitive to childhood widespread
diseases like gastroenteritis and a lot of rebellious diseases even in their adulthood such diseases
include allergy, diabetes and lymphoma. Bottle fed infants are more likely to be exposed to
pathogens which contaminate bottle, formula given to the infants leading an increased incidence
of infectious morbidity such as otitis media, pneumonia as well as (SIDS) .Health outcome in
developing countries differ substantially for infants who are bottle fed .Infants who are not breast
fed are at great risk for early childhood dental carries. Feeding bottle results baby bottle tooth
decay. ( Pediatric ,1991)

In developing countries any products unacceptable in the Western market are on sale there. In the
absence of strong governmental controls, consumer pressure and professional vigilance, bottle
feeding is taken lightly with disastrous results. Currently the (UNICEF) estimates that 1.5
million infant deaths occur annually in the developing countries on account of bottle feeding
(UNICEF, 2003).

Studies have shown that high percentage of bottle feeding 82% in parts of developing world are
contaminated with common pathogens such as Escherichia coli, Salmonella and other major
contributors to infant illnesses ( Bekele and Berhane, 1999).

In Somalia being one of the developing countries , the effects of bottle feeding is high as many
mothers practice bottle feeding without knowing the importance of exclusive breast feeding.

1.3 JUSTIFICATION OF THE RESEARCH

 Pediatric research estimates that 250 to 300 infants die each year from diarrheal
infections as a result of bottle feeding.
 In developing countries such as Pakistan, the risk of infant mortality rate was
estimated to be 4.5 times higher in bottle fed infants compared breast fed infants.
 In Somalia most mothers bottle feed their infants resulting many diseases and death
of young infants due to lack of knowledge about important of exclusive breast
feeding.

3
1.4 OBJECTIVES

1.4.1 GENERAL OBJECTIVE

 To evaluate effects of bottle feeding among infants in Hodan district

1.4.2 SPECIFIC OBJECTIVE

 To describe socioeconomic and demographic factors on effects of bottle feeding

infants in Hodan district.
 To determine mothers knowledge and belief about exclusive breast feeding.

 To identify risk factors associated with bottle feeding.

 To establish level of awareness with regards risk associated bottle feeding.

1.5 RESEARCH QUESTIONS

What are the effects of bottle feeding and infants in Hodan district?

1.6 RESEARCH HYPOTHESIS

1.6.1 ALTERNATIVE HYPOTHESIS

Bottle feeding can contribute health effects among infants in Hodan district.

1.7 SIGNIFICANT OF THE STUDY

This study will be great significance to the community who live in Hodan district. And to be
guideline for care givers, clinical instructors, MOH, policy makers and the scholar researchers
who always want to know more about effects of bottle feeding among infants. This study will
provide health information and support to mothers whose infants have malnutrition, diarrhea, and
pneumonia by giving good consultation in order to receive health promotion and to be more
aware the effect of bottle feeding towards the health of their infants.

4
1.10 OPERATIONAL DEFINITIONS

Excusive breast feeding: is when a baby receives only breast milk, without any additional food
or drinks, including water, until 6 months of age.

Bottle feeding: is the popular alternative method to breast feeding for babies.

Mental retardation: is a condition in which people have below average intelligence that limits
their ability to function normally.

Poor growth: is generally describes child whose current weight, or rate of weight gain, is
significantly below that expected for similar children of the same age of sex.

Diarrhea: Are abnormally frequent intestinal evacuations with more or less fluid stools.

Pneumonia: is a serious disease that affects the lungs and makes it difficult to breathe.

Otitis media: an infection involving the middle ear that is common among infants but is not
limited to them.

Infant: a child during earliest period of life, especially before he or she can walk.

Infant formula: a manufactured food designed and marketed for feeding infants, usually
prepared for bottle feeding.

Malnutrition: is a condition which occurs when there is deficiency of certain vital nutrients in
persons diet.

5
 CHAPTER TWO
LITERATURE REVIEW

2.1 Bottle Feeding

Bottle feeding is the popular alternative method to breast feeding for babies. Formula milk
cannot be made identical to human milk and the bottle fed babies are deprived of many valuable
antibodies present in the mother's milk. The risks of contamination of the feed are also greater
with bottle than with breast feeding. Early introduction of other foods is of public health concern
because it exposes infants to increased infection, particularly diarrheal diseases. It may also lead
to poorer infant nutrition and adversely affect growth rates. The fifty- ninth (WHA) projected
that by 2015 the relative contribution to the global prevalence of childhood under nutrition was
expected to increase from 16% to 38% for Africa (WHO, 20013).

Many mothers neither exclusively breastfeed for the first six months of the baby’s life nor
continue breastfeeding for the recommended two years or more, and instead replace breast milk
with commercial breast milk substitutes or other milks. Bottle-feeding poses many practical
challenges for mothers in developing countries, including ensuring the formula is mixed with
clean water, that dilution is correct, that sufficient quantities of formula can continually be
acquired and that the feeding utensils, especially if bottles are used can be adequately cleaned.
Formula is not an acceptable substitute for breast milk because formula, at its best, only replaces
most of the nutritional components of breast milk: it is just a food, whereas breast milk is a
complex living nutritional fluid containing anti-bodies, enzymes, long chain fatty acids and
hormones, many of which simply cannot be included in formula. Furthermore, in the first few
months, it is hard for the baby’s gut to absorb anything other than breast milk. Even one feeding
of formula or other foods can cause injuries to the gut, taking weeks for the baby to recover. The
major problems are the societal and commercial pressure to stop breastfeeding, including
aggressive marketing and promotion by formula producers. These pressures are too often
worsened by inaccurate medical advice from health workers who lack proper skills and training
in breastfeeding support. In addition, many women have to return to work soon after delivery,
and they face a number of challenges and pressures which often lead them to stop exclusive
breastfeeding early. Working mothers need support, including legislative measures, to enable
them to continue breastfeeding. (UNICEF, 2015)

6
Scientific evidence shows that formula is inherently inferior to breast milk unable to replicate the
immunological or living cells necessary to protect infants from an infectious environment far
greater consequential harm is inflicted when formula is used under sub-optimal environmental
conditions. Commercial formulas generally meet minimal safety standards under international
law, notwithstanding recurring product recalls. However, due to the dangers of mixing formula
with unclean water, high bacterial contamination of bottles and teats, and improper dilution from
inadequate educational and financial resources, the process of bottle-feeding has unnecessarily
harmful consequences in parts of the developing world. Because formula may be the only source
of nutrition for the infants, whose immune system is already compromised without the support of
breast milk, undetected outbreaks in the developing world have proven especially dangerous for
entire generations. Mixing formula with unsanitary water dangerously elevates the infant's risk
for diarrheal and other diseases. With more than 1.1billion people lacking access to safe drinking
water, more than three million children under the age of five die annually from combination of
water-borne disease, under-nutrition, and indoor air pollution. WHO has found widespread fecal
contamination in rural water supplies in the developing world, with this contamination posing
acute risk to infants, who are generally at greater risk of infection, particularly when they lack
the immunological benefits of breastfeeding ,as impoverished mothers are more likely to lack
access to clean water and facilities, these factors put infants in poverty at greater risk of bottle
bacterial contamination and unsafe water consumption, leading to infant illness, long-term
under-nutrition, and death. (Meier, 2010)

Compounding the risk of water-borne illness, dangers of bottle-feeding contamination occur

during formula preparation and increase the infant's exposure to infectious disease. Studies have
shown that a high percentage of feeding bottles (82%)and teats (64%) in parts of the developing
world are contaminated with common pathogens such as Escherichia coli, Salmonella, and other
major contributors to childhood illnesses. High contamination rates are often attributed to
improper bottle washing, but even bottles that are washed and disinfected in poor environmental
settings have been found to possess a high level of contamination. Contamination also stems
from the powdered formula itself, which, when stored under the suboptimal conditions present in
the developing world, is often susceptible to bacterial contamination even before it is mixed with
water. Whereas recalls of contaminated formula have occurred in the United States and Europe,
the spread of food-borne illness outbreaks are difficult to identify and control in the developing

7
world, especially for environmentally sensitive food products like baby formula, due to a lack of
surveillance infrastructures for product safety. And even if the water, bottle, and product could
be freed from contamination, formula continues to pose great risk to infant health due to
improper formula dilution. Over-dilution of formula occurs with high frequency, leading to
under-nutrition and exacerbating the consequences of water-borne contamination. Few
commercial formula containers provide proper mixing instructions in local languages, much less
for illiterate or semi-literate users. Without an understanding of the harms of inaccurately
diluting formula, many mothers in the developing world over-dilute when they cannot afford the
necessary amount of formula powder. With women given free samples of formula at the time of
birth-leading them to become dependent on formula and to stop producing breast milk-many of
these mothers cannot afford additional formula and are forced to extend their sample product
through dilution. Pervasive throughout the developing world, 20% of mothers who used formula
were found to have diluted the formula over 40% more than recommended. As an indicator of
health complications, infants fed over-diluted formula are at a serious risk of not absorbing
adequate levels of calories and nutrients so exacerbating the harms of unhygienic bottle
conditions and crippling an infant's defenses against starvation, disease, and ,ultimately, death.
Yet despite these unrivaled harms from manufactured breast milk substitutes-harms that can be
avoided through the protection, promotion, and support of natural breastfeeding processes-the
rapacious marketing of these substitutes by recalcitrant formula industry has stymied national
efforts to regulate these products and prevent health harms. (Meier, 2010)

In many places, mothers regard breastfeeding as normal, but they have other ideas that can
interfere with it. Sometimes mothers approve of breastfeeding but believe that it is not enough by
itself and that infants need something else as well. Many mothers decide to feed their infants
artificially either partially or completely because they believe that they do not have enough
breast milk. Mothers perception of insufficient breast milk production is a barrier to exclusive
breastfeeding as found in South Africa. Some mothers give infants bottle feeds as well to make
them fatter, because they believe that it is healthier. For Asian families, formula feeding is seen
as a way to ensure that babies will grow to be physically larger and to have harder bones
(Morrow, 1996).

8
Some women do not want to stay with the baby all the time to breastfeed, they want to be free to
go out with friends or go to work. They believe that breastfeeding will not suit their ways of life.
The findings of a study among Hong Kong women showed that women tended to consider
breastfeeding as socially limiting and thought that women should not be tied to the baby and
family (Kong et al., 2004).

Colostrum has traditionally been viewed as “bad milk” The colostrum is discarded because of the
general belief that it is heavy or not good for the child‟. Turkish migrant mothers believe that
colostrum, causes stomachache and infants dislike this milk. Mothers squeeze their breasts to get
rid of this milk. In many developing countries, mothers do not give that first milk because they
fear it to be “pus” or “poison” (Ergenekonet al., 2006).

Having inadequate information about breastfeeding and experiencing problems during

breastfeeding period are found to influence mothers to bottle feed their infants. One of the
elements that makes woman to bottle feed is that she has insufficient knowledge to make
decision. Bottle feeding choice usually associated with lower knowledge on important of
breastfeeding (Vogel et al.,1999).

The literature on the determinants of bottle feeding has consistently identified lower maternal
age as predictors of higher bottle feeding rates. A young mother with her first child may find it
difficult to believe that she can breast feed successfully and instead bottle feed her young infant.
Breastfeeding fails easily in a young school girl who has a baby that she really did not want to
breastfeed and prefer to bottle feed. Age above 25 years has been repeatedly associated with a
longer duration of breastfeeding. It is probable that older women know more about the benefits
of breastfeeding and have more realistic outcome expectations and this make them not to bottle
feed their infants at young age (King et al., 1993).

9
2.3.3 EDUCATION

A woman’s educational and social class affects her motivation to breastfeed but the way it
affects is different in different parts of the world. In many industrialized countries in the west,
bottle feeding is less common among the educated and upper class women. On the other hand, in
third world countries the educated and upper class women are more likely to bottle feed their
infant. Generally educated women tend to breastfeed less and are likely to introduce
supplementary feeding earlier than those with little or no education. This is attributed to the fact
that a better educated woman is more likely to work away from home which makes breastfeeding
difficult (King et al., 1993).

Single mothers have great difficulty supporting themselves and caring for the baby especially if
they are young. Single mothers have less family support. Without this support, activities outside
the home such as having to work might lead practice of bottle feeding. It is often best if the
mother and the baby can stay together and be supported as a family. They can breastfeed at least
partially (Ergenekon et al, 2006).

The decision to breastfeed is very often influenced more by socio-cultural factors than by health
consideration, cultural beliefs have a significant influence on breastfeeding practices. When
perceived primarily as sex symbols, the breasts must be decently hidden which makes
breastfeeding in public places difficult. Breastfeeding in a public place or in the presence of
friends is an activity that is extremely sensitive to cultural norms. Findings of the study done
among women in Hong Kong showed that majority of the women agreed that it was
unacceptable to breastfeed in front of others except the husband and the health care workers and
this makes them to bottle feed their infants. (Kong et al., 2004).

2.3.6 EMPLOYMENT

A woman may choose to bottle feed because she plans to go back to work outside home soon
after the baby is born and feels it is too difficult to work and also breastfeed. Other women find
it hard to maintain their milk supply when separated from their babies and may be forced to stop
breastfeeding. Maternal employment outside the home is often cited as a major factor in long-
term bottle feeding patterns seen throughout the world(Fisher et al., 1990).

10
There are a number of ways in which the use of infant formula makes babies vulnerable to
developing diarrhea. Infant formula and feeding implements can be contaminated with
pathogens. In emergency situations, water supplies are often contaminated with fecal material
containing diarrhea-causing pathogens. Contamination happens in different ways depending on
the type of emergency. Earthquakes can rupture sewage pipes resulting in the flow of sewage
into water supplies. Storms, tsunamis and flooding similarly can wash human and animal fecal
material into water supplies. Water supply systems can also be damaged by events such as
earthquakes and floods resulting in the necessity of obtaining water from poor quality and
potentially contaminated sources. In addition, when large numbers of people are homeless,
sanitary services may be makeshift and inadequate which creates an environment where water
supplies are easily contaminated. Since the use of infant formula requires water to both make up
the formula and to clean feeding implements, formula feeding is often a direct source of infection
(Pediatric, 1991).

The association between infant feeding habits and infant mortality from diarrhea was
investigated in a population-based case-control study in two urban areas in southern Brazil
during 1985. Each of 170 infants who died due to diarrhea was compared with two neighborhood
controls. After allowance was made for confounding variables, infants who received powdered
milk or cow's milk, in addition to breast milk, were at 4.2 times confidence interval, the risk of
death from diarrhea compared with infants who did not receive artificial milk, while the risk for
infants who did not receive any breast milk was 14.2 times higher. Similar results were obtained
when infants who died from diarrhea were compared with infants who died from diseases that
were presumed to be due to noninfectious causes. Each additional daily breast feed reduced the
risk of diarrhea death but the increase in risk associated with each bottle feed was not significant
after allowance was made for the number of breast feeds. The only other consumption variable
associated with diarrhea mortality was the frequency with which tea, water, or juices were drunk
with each feed increase in risk. The odds ratios associated with no breast milk were highest in the
first two months of life. Around the world diarrhea remains one of the most common illnesses
among children although diarrhea kills about 4 million people in developing countries each year,
it remains a problem in developed countries as well. Diarrhea is common in all age groups but
more common in infants. Annually at least 1500 million episodes of diarrhea occur in children
under age of 5 years (Jason et al., 1984).

11
To measure the impact of bottle-feeding on nutrition, study was done 510 consecutive mothers
and their infants under 3 attending an urban health center in North Yemen. Infants were weighed
and their mothers interviewed on use of cow's milk and other foods and on demographic,
educational and economic status, of those who bottle-fed, most (74 per cent) used powdered
whole-milk products and not special infant formulas. Bottle-fed infants under 6 months had a
markedly increased risk of severe malnutrition over those fully breast-fed (16.2 per cent vs. 2.2
per cent, P<0.01). Despite the inadequacy of local weaning foods, a regression model suggested
nutritional advantage from early introduction of solids for bottle fed but not for fully breast-fed
infants. Milk tended to be made dilute and feedings small. Only 21 per cent of all bottle-fed
infants (27 per cent of those aged 3 to 9 months) received >60 kcal/kg body weight daily from
milk. Use of dilute milk (<50 kcal/dl) appeared to double the risk of severe malnutrition in
bottle-fed infants. Milk concentration was correlated with size of the measuring scoop supplied
in the tin. Concentration and daily intake were both related more strongly to family income than
to parental literacy or other socio-demographic measures. Interim strategies to prevent the
syndrome of the ‘bottle-starved’ infant should focus on early provision of additional calories
from all possible sources, particularly breast milk and suitable solids. To affect feeding patterns,
regulation of the infant-formula industry must control producers of other milk products as
well(Chantry and Robert, 2009).

Otitis media is the medical name for an infection of the middle ear. While it affects people of all
ages, it is far more common in young infants in fact, it is the number one reason that children
under one year old are taken to the doctor. Despite advances in drugs and other treatments, the
percentage of infants who develop otitis media has remained quite steady over time. About half
of all infants will come down with an ear infection before their first birthday; and those who do
will have an increased risk of further attacks, as well as a higher risk of developing repeated
infections later in childhood. When a child uses a typical feeding bottle, lack of ventilation or
inadequate ventilation causes a vacuum to form, and this can cause problems inside the ear. It
works like this: the non-vented bottle is simply a solid walled vessel with a nipple held in place
with a cap. The cap holds the enlarged flange end, or base of the nipple, firmly against the top of
the bottle forming a tight seal. This arrangement does not permit any air entry, resulting in the
creation of a vacuum (negative pressure) during sucking. Fluid may only be removed by the
infant in small amounts by overcoming the stiffness of the wall of the nipple or bottle. The

12
vacuum created by bottle feeding can play havoc with the ear's inner auditory tube. Negative
pressure generated in the mouth is transmitted up the tube and into the middle ear where, as a
result, fluid can build up. The increased fluid can cause hearing difficulties and infections.
Interestingly, none of this occurs with breast feeding, which does not create any kind of vacuum
and which actually creates positive pressure within the ear. Not only does negative middle ear
pressure increase a child's risk for otitis media, but severe cases of otitis media can have even
worse long-term consequences. Studies have shown a definite relationship between this kind of
negative pressure in the ear and development of more serious ear disease. It may lead to a
condition known as secretory otitis, which can cause permanent hearing loss, along with delayed
speech development. It may also contribute to the development of other, irreversible kinds of
middle ear disease (Pediatrics 1991).

Pneumonia remains the leading cause of childhood morbidity and mortality and is one of the
most common reasons for hospital admission infant in low resource countries. It is estimated that
156 million childhood clinical pneumonia cases occur annually, resulting in approximately 2
million deaths in children during the first 5 years of life .The burden of pneumonia is highest in
South- East Asia and Africa, with the highest incidence seen in poor and marginalized groups.
Recurrent infection and hospitalization in early life can lead to poor growth and development in
childhood, and can impose substantial economic burden on the population and healthcare system
(WHO, 20013).

To determine the modifiable risk factors for acute lower respiratory infection in young children,
Indian hospital-based study compared 201 cases to 311 controls. Bottle feeding was one of the
key modifiable risk factors for lower respiratory infection in children under five years of age. A
number of sources were used to examine the relationship between breastfeeding and risk of
hospitalization for lower respiratory tract disease in healthy full-term infants with access to
adequate health facilities. Analysis of the data concluded that in developed countries, infants
who were formula-fed experienced more than three times the severity of respiratory tract illness
and required more frequent hospitalization compared to infants who had been breastfed
exclusively for four months or more. Breastfeeding and the risk of hospitalization for respiratory
disease in infancy increases (Aeudry M. et al.,1995).

13
The use of infant formula directly impacts the intestine of infants so that they are more
vulnerable to infection and illness. This includes creating an environment that retards the growth
of beneficial Lactobacillus and Bifidobacteria and encourages the growth of bacteria that may be
pathogenic. Standard infant formula lacks the oligosaccharides that Lactobacillus and
Bifidobacteria use as a food hindering their growth and ability to compete for colonization of the
intestine with pathogens. The lower population of these beneficial bacteria results in a higher pH
in the intestine of formula-fed babies which encourages the growth of pathogenic bacteria.
Formula fed babies have about one tenth of the population of Lactobacillus and Bifidobacteria
having larger populations of potentially pathogenic enterobacteriaand enterococci as compared to
exclusively breastfed infants.Components of infant formula can also damage the protective
mucous barrier in the small intestine. The mucosal membrane of a baby’s developing intestine is
very delicate. Ingestion of “foreign” protein such as cows’ milk protein in infant formula can
damage the mucous membrane of the intestine. The mucous membrane helps to protect the
intestine from colonization by pathogens and so damage to the membrane facilitates colonization
by pathogenic organisms. The intestine of newborn babies is quite permeable and vulnerable to
infection. Over time the intestine becomes less permeable, however the use of infant formula
delays this process, the more permeable intestine makes formula fed infants more vulnerable to
colonization by diarrhea causing pathogens (Pediatrics, 1991).

14
 CHAPTER THREE

MATERIALS ANDMETHODOLGY
3.0 STUDY AREA

3.1.1HODAN DISTRICT

Hodan district is 1 of the 17 districts in Banadir Region (Mogadishu City). It is the 2nd largest
district in Mogadishu City. Geographically, it lies in the south-western part of Mogadishu. The
district was established in 1970s.

It has borders with many districts (lower Shabelle) to the west direction and Daynile district to
the north, wadajir district in the south, and Howlwadag district to the East direction. The
population live in Hodan district is estimated around 280,000. The population is an a three levels
according to social lives high level , middle level and low level, most of them are un
employment , but small number of them goes for work.Hodan district has a lot of roads which
facilitate the communication.

3.1.1.1 SUBDIVISIONS OF HODAN DISTRICT

 Tarabuunka

 shiirkole

 siigaale

 banadir

 saybiyaano

 Taleex

 Galmudug

3.1.1.2WADAJIR HEALTH STANDARD

The sanitation and environmental health of the district is not good, because there is no local
government which controls that. The people do not get clean water, because most of the branches
get water from uncontrolled sources, so it delivers many diseases. The health problems are very

15
common and the most of the people suffer from many diseases such as malaria, hypertension,
typhoid, cholera, gonorrhea, diarrhea, skin disease and many others that result from fighting and
conflicts between Somali people, poor sanitations and many other reasons. It has many important
hospitals including Madina and Banadir hospitals.

3.2 STUDY DESIGN

A descriptive correlation research design was used in the study, to find the relationship between
effects of bottle feeding on children under five years ; also an ex-post facto design was used to
access information on the existing facts, respondents were asked to recall what has already
existed in addition to document analysis.

3.3 STUDY POPULATION

3.3.1 INCLUSION CRITERIA

Mothers with infants who are residents of Hodan district and are capable of responding to the
research questionnaire.

3.3.2 EXCLUSION CRITERIA

Mothers with infants who are nonresidents of Hodan district are excluded from the study.

3.4 SAMPLE SIZE DETERMINATION

The study sample size consist 50 respondents only; this number is chosen according to the
capacity of the researcher.

3.5 SAMPLING PROCEDURE

The non-probability-convenient-sampling method was used for the selection of the study sample
from the sampling population

3.6 RESEARCH INSTRUMENT

The research employed questionnaire as tool for data collections for this research because of
questionnaire have advantages over some other type of survey in that they are cheap, do not
require as much effort from the questionnaire as verbal or telephone surveys, and often have
standardized answer that make it simple data, also have the advantage of being cheaper,
especially when large samples are used.

16
3.7 DATA ANALYSIS

When the data was collected, the incomplete questionnaires were eliminated. Data entry was
made using Microsoft Excel.

3.8 ETHICAL CONSIDERATIONS

During the study period:

 Every respondent was asked about permission to complete the questionnaire.

 Good explanations of the questionnaire were given to the respondent before requesting to
fill the questionnaire.
 Privacy and confidentiality was maintained by keeping the respondents nameless
 Choice/freedom to participate the study or on were given to every respondent.

3.9 SCOPE OF THE STUDY

This study determines effects of bottle feeding among infants in Hodan district.

Place of the study

This study is conducted in Hodan district Mogadishu, Somalia.

Time of the study

The study was conducted on time frame between started November 2017 to April 2018.

3.10 RESEARCH LIMITATION

The following were expected limitations:

 Lack of sufficient cost to run the study.

 Many data have lost by virus

 Misunderstanding of respondents

Difficult to design data analysis

17
 CHAPTERFOUR

DATA ANALYSISAND RESULTS

4.1 RESPONDENTS BY AGE

The below table and graph indicates the majority of respondent 26(52% ) were 29-38, 12(24%)
were 18-28, 8(16% ) were 39-48,while 4(8% ) were above 49.
Age Frequency Percentage

18-28 12 24%

29-38 26 52%

39-48 8 16%

Above 49 4 8%

Total 50 100.0

Table 4.1 respondents of age

Figure 4.1 respondents of age

18
4.2 sex respondents

Marital status Frequency Percentage

Female 50 100%

Male 0 0%

Total 50 100.0

Table4.3 marital status respondents

All the respondents were female

Figure4.2:sex respondents

19
4.3 marital status respondents

The table below and graph indicate that the majority of respondents 34(68%) of the respondents
were married, while 9(18%) of the respondents were widowed and 7(14 %) of respondents were
divorced.

Marital status Frequency Percentage

Married 34 68%

Widowed 9 18%

Divorced 7 14%

Total 50 100.0

Table4.3 marital status respondents

Figure 4.3 marital status respondents

20
4.4 educational respondents

The table below and graphIndicates that the majority of respondents 14 (28%) were secondary
,12 (24%), of the respondents were informal, 10(20%) were other respondents, 8(16%) were
primary respondent and 6(12%) were university respondents.

Educational respondents Frequency Percentage

secondary 14 28%
informal 12 24%
primary 10 20%
other 8 16%

university 6 12%

Total 50 100.0

Table4.4 educational respondents

Figure4.4 educational respondents

21
4.5 occupational respondents

The table below and graph indicates that the majority of respondents 34(68 %) of the
respondents were housewives, while10 (20%) of the respondents unemployed,6(12%) of
respondents were employed.

Occupation Frequency Percent

Housewife 34 68%

Unemployed 10 20%

Employed 6 12%

Total 50 100

Table 4.5 occupational respondents

22
Figure 4.5 occupational respondents

4.6 respondents of do you know bottle feeding?

The table below and chart indicates the majority of respondent 43(86%) said yes, while 7(14%)
said no.
Do you know bottle feeding?
Frequency Percent
Yes 43 86%
No 7 14%
Total 50 100

Table 4.6 respondents do you know bottle feeding

yes no

86%
14%

yes

no

Figure 4.6 respondents do you know bottle feeding

23
4.7 respondents food

or drink given to infants before breast milk follow is

The table below and graph indicates that the Majority of the respondents 20(40%) said infant
formula, 16(32%) said only breast milk, 8(16%) said water alone and 6(12%) of the respondents
said sugar water.

Food or drink given to infants before breast milk follow is

Frequency Percent

infant formula 20 40%

only breast milk 16 32%

water alone 8 16%

sugar water 6 12%

Total 50 100

Table 4.7 food or drink given to infants before breast milk follow is

Figure 4.7 food or drink given to infants before breast milk follow is

24
4.8 respondents do you know the health effects of bottle feeding among infants
The table below and chart indicates the majority of respondent 34(68%) said yes, while 16 (32%)
said no.
Do you know the health effects of bottle feeding among infants?

Frequency Percent

Yes 34 68%

No 16 32%

Total 50 100

Table 4.8 respondents do you know the health effects of bottle feeding among infants

Figure 4.8 respondents do you know the health effects of bottle feeding among infants

25
4.9 respondents of If you answered ‘Yes’ Have you seen infants suffering diseases resulted
from bottle feeding?

The table below andchart indicates the majority of respondent 26(52%) said yes, while 24 (48%)
said no.

If you answered ‘Yes’ Have you seen infants suffering diseases resulted from bottle
feeding?

Frequency Percent

Yes 26 52%

No 24 48%

Total 50 100

Table 4.9 If you answered ‘Yes’ Have you seen infants suffering diseases resulted from bottle
feeding?

Figure 4.9 If you answered ‘Yes’ Have you seen infants suffering diseases resulted from
bottle feeding?

26
4.10 Respondents of factors influencing mother’s bottle feeding practice is

The table below and graph indicate that the Majority of the respondents 25(50%) said factors
influencing mothers bottle feeding practice is level of knowledge on breastfeeding, and 15(30%)
said education while the least number 6(12%) and 4(8%) responded age and employment
respectively.

Factors influencing mothers bottle feeding practice Frequency Percent

Level of knowledge on breastfeeding 25 50%

Age 6 12%

Education 15 30%

Employment 4 8%

Total 50 100

Table 4.10 respondents of factors influencing mothers bottle feeding practice is

Figure 4.10 respondents of factors influencing mothers bottle feeding practice is

27
28
4.11 Respondentsdoes bottle feeding diseases only occur infants?

The table below and graph indicates most respondent 43 (86%) answered yes, 7 (14%) said no.

Do bottle feeding diseases only occur infants?

Frequency Percent

Yes 43 86%

No 7 14%

Total 50 100

Table 4.11 Does bottle feeding diseases only occur infants

14%

yes
no

86%

Figure 4.11 Does bottle feeding diseases only occur infants

29
30
4.12 Respondent of bottle feeding related disease is

The table below and graph show that the majority of respondent 26(52%) said diarrhea, while 13
(26%) said malnutrition, 7(13%) of the respondents said otitis media while 4(8%) said
pneumonia.
Bottle feeding Frequency Percent
related disease

Diarrhea 26 52%

Otitis media 7 14%

Malnutrition 13 26%

pneumonia 4 8%

Total 50 100

Table4.12: bottle feeding related disease

Figure 12: bottle feeding related disease

31
4.13 Respondent of does bottle feeding increases infant mortality rate.

The Table below and graph showthat the majority of respondent 31(62%) said yes, while 19
(38%) said no.
Does bottle feeding increases infant mortality rate?

Frequency Percent

Yes 31 62%

No 19 38%

Total 50 100

Table 4.13 Respondent of does bottle feeding increases infant mortality rate.

38%
Yes
No
62%

Figure 4.13 Respondent of does bottle feeding increases infant mortality rate.

32
4.14 respondents of prognosis of bottle feeding is

The table below and graph indicates that the majority of respondent 35(70%) said good
prognosis, while 15 (30%) said bad prognosis.
prognosis of bottle feeding

Frequency Percent

Good 35 70%

Bad 15 30%

Total 50 100

Table 4.14 prognosis of bottle feeding

30%

Good
Bad

70%

Figure 4.14 prognosis of bottle feeding

33
4.15.Respondents of malnutrition is most common in a bottle fed infants

The table below and chart indicates the majority of respondent 33(66%) said yes, while 17 (34%)
said no
malnutrition is most common in a bottle fed infants

Frequency Percent

Yes 33 66%

No 17 34%

Total 50 100

Table 4.15.Respondents of malnutrition is most common in a bottle fed infants

17
YES
NO
33

Figure 4.15.Respondents ofmalnutrition is most common in a bottle fed infants

34
4.16 respondents of effects of belief and attitude of mother on exclusive breastfeeding is

The table below and graph show that the majority of respondent 29 (58%) said insufficient breast
milk production, 14(28%) said colostrum viewed as bad milk and 7(14%) said mother returns to
work.
Belief and attitude of Frequency Percent
exclusive breastfeeding

Insufficient breast milk 29 58%

production

Colostrum viewed as bad 14 28%

milk

Mother returns to work 7 14%

Total 50 100.0

Table 4.16 respondents of effects of belief and attitude of mother on exclusive breastfeeding
is

Figure 4.16 respondents of effects of belief and attitude of mother on exclusive

breastfeeding is

35
4.17 Respondent of do you believe that health risks of bottle feeding can be preventable

The Table below and chart indicates the majority of respondent 38(76%) said yes, while 12
(24%) said no.
Do you believe that health risks of bottle feeding can be preventable?

Frequency Percent

Yes 38 76%

No 12 24%

Total 50 100

Table 4.17Respondent of do you believe that health risks of bottle feeding can be
preventable.

yes no

76%

24%

Figure4.17Respondent of do you believe that health risks of bottle feeding can be

preventable.

36
4.18 Respondents of If yes, which interventions can be used to preventhealth risks of bottle
feeding.

The below table and graph indicates that the majority of respondent20 (40%) said community
awareness, 17(34%) said Health education, 13(26%) said to make breastfeeding policy.
If yes, which interventions can be used to preventhealth risks of bottle feeding?

Frequency Percent

community awareness 20 40%

Health education 17 34%

to make breastfeeding policy 13 26%

Total 50 100

Table 4.18 respondents of If yes, which interventions can be used to prevent health risks of
bottle feeding.

26%
40%
community awareness
health education
to make breast feeding policy
34%

Figure 4.18 respondents of If yes, which interventions can be used to prevent health risks of
bottle feeding.

37
 CHAPTER FIVE

CONCLUSION AND RECOMMENDATION

5.1 CONCLUSION

This result shows that most of the respondents in the research aged between 29-38, while the
other ages were little, such as those aged between18-28,39-48 and above 49.This result also
expresses that female were the only respondents.

The result indicates the majority of the respondents were married while the divorced and
widowed were so little than married respondents.

The most respondents were secondary, while other respondents such as primary and university
werethe least in the research.

Majority of the respondents were housewives, while unemployed and employed respondents
were the minority.

The majority of the respondents know bottle feeding while least number of the respondents do
not know bottle feeding.

This result indicates that majority of the respondents said food or drink given to infants before
breast milk flow is infant formula other respondents said breast milk while the respondents said
water alone and sugar water were the minority.

This result shows that majority of the respondents know the health effects of bottle feeding
among infants.

Majority of the respondents have seen infants suffering diseases resulted from bottle feeding
while least number have not seen.

This result explores majority of the respondents said factors influencing mothers bottle feeding
practice is level of knowledge on breastfeeding and education while the least number responded
age and employment.

38
Majority of the respondents said bottle feeding diseases only occur infants and stated that
diarrhea and malnutrition are the most bottle feeding related diseases while otitis media and
pneumonia are the least.

This result reveals that the highest number of the respondents said bottle feeding increases infant
mortality rate while few respondents said no.

This results shows that majority of the respondents said prognosis of bottle feeding is good while
minority of the respondents said bad prognosis.

Majority of the respondents said effects of belief and attitude of mother on exclusive
breastfeeding is insufficient breast milk production while the minority said colostrum viewed as
bad milk and mother returns to work.

This result shows that majority of the respondents said malnutrition is the most common in bottle
fed infants while least number said no.

This result explore that majority of the respondents said that health risks of bottle feeding can be
preventable while respondents said no were little.

This result indicates that majority of respondents said the appropriate interventions can be used
to prevent bottle feeding practice were community awareness while respondents said Health
education and making breastfeeding policy were the minority.

39
5.2 RECOMMENDATIONS

1. All mothers, irrespective of their age, marital status, education level and employment
status should be encouraged to exclusively breastfeed their infants. Public forums should
be used as a channel to promote EBF.
2. There is a great need for health education to explain to mothers the importance of
breastfeeding the child on demand to sustain the quantity of breast milk production. This
should be done in both antenatal and postnatal clinics in health facilities. Mothers need
counseling if they doubt their milk is inadequate or if going back to work.
3. It should be made clear to the mothers the meaning of exclusive breastfeeding, its
recommended period and its health benefits both for the mother and infant.
4. To reduce cases of malnutrition, early introduction of complementary foods to infants by
mothers should be discouraged
5. Mothers should be clearly explained health risks of bottle feeding and diseases resulted
by encouraging to breastfeed instead of bottle feeding the infants putting their health in
risk.

40
REFERENCE

1. Aeudry M.et al. (1995).Relation between infant feeding and infections during first 6
months of life.
2. Bekele, A., and Berhane, Y., (1999).Magnitude and determinants of bottle feeding in
rural communities. East Africa Medical Journal; 76; 516-9.
3. Boema JT., Rustein SO, Sommerfelt AE, Bicego GT. Bottle use for infant feeding
in developing countries: data from the demographic and health surveys. Has the bottle
been lost J Tropical Pediatric. 1991;37:116-20.
4. Ergenekon, P., Elmaci, N., and Erten, M. (2006). Breastfeeding beliefs and
practices among migrant mothers in slums of Diyarbakir, Turkey 2001. European
Journal of Public Health, 16(2): 143 – 148.
5. Fisher, C. Mary, R. and Suzanne, A. (1990). Best feeding: Getting Breastfeeding
Right for you. Celestial Arts publishers.
6. J Ayub Med Coll Abbottabad 2006; Determinants of Bottle use Amongest
Economically Disadvantaged Mothers.
7. J.M. Jason, Niebugr P., Marks J.S. Mortality and infectious disease associated with
infant feeding practices in developing countries. Pediatrics 1984;74:702–27.
8. King, F.S. and Ann, B. (1993). Nutrition for Developing Countries.2nd ed. Oxford
Medical Publications.
9. Kong, S.K.F. and Leed, T. F. (2004).Breastfeeding Practices. Breastfeeding Journal
of Advanced Nursing, 46(4), 369-379.
10. Chantry, A. and Robert, S. (2009). American Academy of Pediatrics, Center for
Child Health Research.Retrieved January 7, 2017, http://www.ucdavis.edu/teens.http.
11. Meier-Labbok-210-From the Bottle to Grave.
12. Morais T.B, Sigulam D.M, Maranhao H.S. and MoraisM.B.Bacterial
contamination and nutrient content from home prepared milk bottles. J.Trop.Pediat
2005:0;841.
13. UNICEF (2003).Global Strategy for Infant and Young Child Feeding. Geneva.
14. Vogel, A., Hutchison, B.L., and Michelle, E.A. (1999). Factors associated with the
duration of bottle feeding. Act on Paediatrica 88: 1320-1326
15. WHO (2013).Infant and Young Child Nutrition. Geneva

41
 APPENDIX I

QUESTIONNAIRE

Effects of bottle feeding among infants in Hodan district.

INSTRUCTION

 Don’t write your name on the questionnaire.

 This research is only for academic purpose and not for money.

 All information will be private.

 Please fill or insert check sign in the space provided to the best of your knowledge.

 You are free choosing not to fill it.

SECTION A: SOCIO-DEMOGRAPHIC DATA

1. Age

a) 18---28 ( )

b) 29---38 ( )

c) 39---48 ( )

d) above 49 ( )

2. Gender

a) Female ( )

3. Marital status

a) Married ( )

b) Divorced ( )

42
 c) Widow ( )

4 .Level of education:

a) Informal ( )

b) Primary ( )

c) Secondary ( )

d) University ( )

e) Other ( )

5. Occupational status:

a) Employed ( )

b) Students ( )

c) House wife ( )

SECTION B: KNOWLEDGE

6.Do you know bottle feeding?

a) Yes ( )

b) NO ( )

7. Food or drink given to infants before breast milk flow is

a) Water alone ( )

b) Sugar water ( )

c) Infant formula ( )

d) Only breast milk ( )

43
8.Do you know the health effect of bottle feeding among infants?

a) Yes ( )

b) No ( )

9. If you answered yes, have you seen infants suffering diseases resulted from bottle
feeding?

a) Yes ( )

b) No ( )

10. Factors influencing mother’s bottle feeding practice is

a) Level of knowledge on breastfeeding ( )

b) Age ( )

c) Education ( )

d) Employment ( )

11. Does bottle feeding diseases only occur infants?

a) Yes ( )

b) No ( )

12. Bottle feeding related disease is

a) Diarrhea ( )

b) Otitis media ( )

c) Malnutrition ( )

d) Pneumonia ( )

44
13. Does bottle feeding increases infant mortality rate?

a) Yes ( )

b) No ( )

14. Prognosis of bottle feeding is

a) Good ( )

b) Bad ( )

15. Malnutrition most common in a bottle fed infants

a) ( )

b) No ( )

16. Effects of belief and attitude of mother on exclusive breastfeeding is

a) Insufficient breast milk production ( )

b) Colostrum viewed as bad milk ( )

c) Poor infant growth ( )

17. Do you belief that health risks of bottle feeding practice can be preventable?

a) Yes ( )

b) No ( )

18. IF yes, which intervention can be used to prevent bottle feeding practice?

a) Health education ( )

b) Community awareness ( )

c) To make breast feeding policy

Thanks

45
 APPENDIX II

BOTTLE FEEDING IMAGES

46
APPENDIX III

WADAJIR MAP

47
APPENDIX IV: MAP OF MOGADISHU

48
APPENDIXV: MAPOF SOMALIA

49
APPENDIX VI: LETTERTO THE ETHICAL COMMITTEE

From: Hassan Abdullahi Shire

University of Somalia
Faculty of Health Sciences
Department of Public Health
E-mail: drshire10@gmail.com
Tell: +252 615772144
To: Ethical Committee

SUBJECT: Application To Be Allowed To Undertake Research In Wadajir District

I am a student at University of Somalia, Faculty of Health Sciences, Department of

Public Health; I am doing research on effect of bottle feeding among infants in Hodan
district and I will make sure that all the ethical considerations have been followed.
Therefore, I kindly request to be allowed to undertake research in Hodan district.

Ethical Committee Your’s faithfully

------------------------------ ----------------------------

Thanks

50