Breastfeeding is a process whereby the infant receives breast milk from the maternal breast (Kong, 2004). Exclusive breastfeeding has been defined as feeding of an infant with breast milk only without giving any other foods, not even water (Jolly, 2008). The definition allows for prescribed medicines, immunizations, vitamins and mineral supplements. Breastfeeding as a practice was recommended by WHO (2001), for optimal feeding (i.e. exclusive breast feeding for the first 6 months and continued breastfeeding for up to 2 years, with the introduction of other foods). A nationwide survey conducted in Pakistan on breastfeeding practice revealed that fewer mothers breastfed their children and these mothers often supplemented breast milk unnecessarily and / or stopped breastfeeding early (Morisky, 1991). Study findings from a UK based research indicated that reasons for low breastfeeding rates included cultural attitudes, limited knowledge of the benefits of breastfeeding and heavy media promotion of bottle-feeding (Mitch, 2006). According to Kong et al. (2004), undesirable breastfeeding practices were found to be associated with urban residence, younger mother’s age and higher educational attainment. Data on the prevalence of exclusive breastfeeding vary widely in African countries and rates for exclusive breastfeeding under 4 months of age are very low. For example, Zimbabwe, 17%, Zambia, 23%, (WHO, 2003), South Africa, 29%, (Bland et al., 2002), Tanzania 19%, Uganda 48% (Coutsoudis, 2001).
According to UNICEF (2006), one out of every three children is exclusively breastfed for the first six months of life in the developing world. East Asia / Pacific and Eastern / Southern Africa are the regions with the highest levels of exclusive breastfeeding in the first six months of life (43 %), while west and central Africa have the lowest levels (20 %). Globally, available figures show few babies are exclusively breastfed to 3 months (UNICEF, 1994). In Denmark, 4 % of babies were exclusively breastfed to 4 months (Lanting, 2005). Only 25% of Dutch mothers feed their children mainly on breast milk during the first 6 months (Lanting , 2005).
Problem statement
Despite the extensive available information on the benefits of exclusive breastfeeding both for the mother and the infant, in Kenya only 13% of children below six months are exclusively breastfed (UNICEF, 2006). More so UNICEF (1996), reported a prevalence of 2.3% of exclusive breastfeeding in Uasin Gishu District. The mean duration in months of EBF was 1.5 in 1998, 1.6 in 2003 and 1.7 in 2008 in Rift Valley Province (KDHS 1998, 2003 and 2008).
High infant mortality rates associated with diarrhea, acute respiratory infections and poor responses to vaccinations result from lack of exclusive breastfeeding. Acute respiratory infections and diarrheal diseases are two of the major causes of infant mortality in the developing world (UNICEF, 2006). Infant mortality rate in Kenya was 77 deaths per 1,000 live births and 61 deaths per 1,000 live births in the Rift Valley Province, (KDHS, 2003).
While almost all Kenyan mothers initiate breastfeeding, 85% to 90% of them offer water and other liquids to their babies in the first month. This increases the babies‟ risk to infection, poor nutrition and diarrhea (Bureau of Statistics, 1993). Based on Bureau of Statistics (1993), 46% and 30% of children under 5 years experienced Acute Respiratory Infections (ARI) and diarrhea respectively. Of these, 41% of ARI and 26% of diarrhea cases were from the Rift Valley Province under which Eldoret Municipality is found.
According to KDHS (2003) the under fives who were underweight, stunted and wasted were 20%, 30% and 6% respectively. In the Rift Valley Province 24%, 32% and 8 % were underweight, stunted and wasted respectively. A third (33 %) of bed occupants in pediatrics’ wards in hospitals in Kenya are diarrhea cases. Prevalence of diarrhea among infants aged 0-6 months is 14% in Kenya (CBS, 2004). Early introduction of other foods is of public health concern because it exposes infants to increased infection, particularly diarrhea diseases. It may also lead to poorer infant nutrition and adversely affect growth rates. The fifty- ninth World Health Assembly 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, 2006).
In this era of HIV/AIDS, exclusive breastfeeding faces a great challenge as mothers who are HIV/AIDS positive are advised to formula feed their infants to minimize transmission of the virus to the infant. Feeds introduced to infants may have too much fat and carbohydrates leading to obesity, poor muscle development and low resistance to infections. For HIV- positive mothers, infants risk of death from infectious diseases is high in the absence of breastfeeding (WHO, 2000). Poor infant diet hampers cell division (Drane, 1997). The low prevalence and short duration of exclusive breastfeeding in previous studies have highlighted the need for more investigation into the problem (Kong, 2004).
Justification
High infant mortality rates associated with diarrhea, acute respiratory infections and poor responses to vaccinations that result from lack of exclusive breastfeeding (UNICEF, 2006) can greatly be reduced if exclusive breastfeeding of infants is encouraged. This is because human milk is the ideal nourishment for infant’s survival, growth and development as it contains all the nutrients, antibodies, hormones, immune factors and anti-oxidants an infant needs to thrive. It has been estimated that exclusive breastfeeding for the first six months of life could reduce infant mortality by a remarkable 13% (Jolly, 2008) and by an additional 2% were it not for the fact that breastfeeding may transmit HIV (Jones, 2003). Exclusive breastfeeding has to be practiced in order to contribute to achieving Millennium Development Goal number which is to reduce child mortality by two thirds by 2015 (UNSD, 2005).
Other studies have shown that full breastfeeding for at least six months has large beneficial effects on child survival regardless of socio economic status. However, the beneficial effects of breastfeeding are dose dependent (Raisler, 1999); therefore increasing the rate of exclusive breastfeeding should be a major target for breastfeeding promotion programmers (Simondon, 1998). It is argued that promotion of exclusive breastfeeding promotion is the most effective child health intervention currently feasible for implementation at population – level in low income countries (Jones, 2003).This is because exclusive breastfeeding reduces infant deaths in developing countries by reducing diarrhea and infectious diseases (Oddy, 2003).
The low frequency of exclusive breastfeeding during the first months of life found in the previous studies underline the necessity to promote exclusive breastfeeding if infant feeding recommendations are to be realized. Breastfeeding is an important determinant of the nutritional status of the child which in turn influences growth and development (EL-Zanaty et al., 1992). Good nutrition protects fetus, infant and young children from permanent physical and intellectual stunting. Globally, the promotion of breastfeeding is a major public health concern. Breastfeeding reduces the risk of both under nutrition and overweight later in childhood. Breastfed children are healthier and have fewer hospitalizations than non-breastfed children (Drane, 1997, Weimer, 2001).
Although the WHO recommendation on EBF has been in effect for more than two decades, majority of women do not comply with it. This discrepancy has necessitated the need to explore factors that hinder women to practice EBF. It is worthy carrying out this study to understand factors hindering the exclusive breastfeeding practice in Eldoret Municipality. Given the set up of the study location, mothers have very varied socioeconomic backgrounds. This will show how different socioeconomic characteristics can either promote or hinder the practice of exclusive breastfeeding. The varied representation of the study population (heterogeneous), will minimize on the biasness of the findings than if the study was done among mothers with a similar background.
Specific objectives
To identify factors that hinder exclusive breastfeeding practice.

2) To establish the mothers‟ level of knowledge of exclusive breastfeeding.

3) To assess the nutritional status of non – exclusively breastfed infants.

4) To determine the relationship between mothers socio-demographic characteristics and exclusive breastfeeding practice.
Research questions

What are the factors that hinder exclusive breastfeeding practice?

2) What is the mothers‟ level of knowledge of exclusive breastfeeding?

3) What is the nutritional status of non – exclusively breastfed infants ?

4) What is the influence of mothers‟ socio-demographic characteristics on exclusive breastfeeding practice ?
Null hypothesis

There are no factors that hinder exclusive breastfeeding practice.

Significance of the study
There is need for greater efforts to promote and support the healthy practice of exclusive breastfeeding. The planning of public health interventions to promote longer and more exclusive breastfeeding practice requires an understanding of the factors that hinder the practice. More efforts are needed to promote exclusive breastfeeding among mothers in order to realize international feeding practices of the infants. Health education on breastfeeding should be improved in order to eliminate barriers to exclusive breastfeeding. The findings can be used in designing appropriate and effective breastfeeding intervention programmers aimed at improving infant and young children feeding practices.
Limitations
The study was not inclusive of mothers who do not attend child welfare clinics. The study did not include HIV positive infants Therefore results may not be generalized to the entire population of mothers with infants aged 0-6 months. Data on infant feeds and diseases were reported during the survey and were not based on observation. Language was another limitation. Most mothers could not understand English and therefore questions were asked verbally in Kiswahili. The translation may to some extent have altered the meaning of the question.