Investigating factors that influence the practice of exclusive breastfeeding among mothers in an urban general hospital in Ghana: a cross-sectional study

The World Health Organization recommends that mothers exclusively breastfeed their babies for the first 6 months after birth [1]. EBF is defined as providing infants with only breast milk as their sole source of nutrition, with the exception of necessary oral rehydration solution, drops, and syrups of vitamins, minerals or medications [2, 3]. The benefits associated with EBF include: healthier eating habits, a shorter hospital stay, more favourable weight gain, a lower body mass index, less adiposity, lower total cholesterol values, better cognitive and behavioural development, and metabolic level stability in children with metabolic disorders [4]. EBF plays a significant role in reducing infant morbidity and mortality as well as certain illnesses such as type II diabetes [4‐7]. The American Academy of Paediatrics considers breastfeeding as the ideal and optimal source of nutrition in the first year of life, most importantly the first half, and recommends that mothers and caregivers exclusively breastfeed for the first 6 months after a baby is born, followed by complementary feeding with solid foods [8].

According to the United Nations International Children’s Emergency Fund (UNICEF), the infant mortality rate in Ghana as of 2019 stood at 34 deaths per 1000 live births and the under 5 mortality rate stood at 46 deaths per 1000 live births [9]. In 2008, infections and malnutrition accounted for a huge proportion of the causes of infant mortality of which a reasonable number could have been prevented with EBF [10]. The Ghana Demographic and Health Survey conducted in 2008 showed that 63% of infants below 6 months were being exclusively breastfed [10]. The survey re-conducted in 2014 however showed a decrease in this number, as only 52% of infants below 6 months were exclusively breastfed [11]. This represents an 11% decrease in the EBF rate from 2008 to 2014.

In order to achieve Sustainable Development Goals 3.2 which tackles preventable deaths in neonates and children under five, efforts need to put in place globally, and even more specifically in developing countries like Ghana, in the area of EBF as it contributes enormously to reducing mortality in infants. Knowing the wide array of benefits EBF provides, it is of relevance to decipher ways and means to achieve maximum numbers in terms of EBF among mothers. This will help reduce drastically the infant mortality rates, infectious illnesses that could have been otherwise prevented by EBF as well as malnutrition in their children.

Despite extensive research and the advantages associated with EBF, the practice remains low globally, with rates declining fastest in developing nations due to the significant influence by contextual and environmental factors [4, 5]. Evidence shows a significant difference in EBF between urban and rural areas. For example, Astika et al. [12] discovered that mothers who reside in urban areas were more likely to commence early breastfeeding and breastfeed exclusively than those in rural areas. Also, low patronage were attributed largely to sociodemographic and cultural practices in Ghana and other Sub-Saharan African countries, as well as low levels of knowledge, misconceptions, maternal age and health conditions, antenatal care services, the economic situation of the family, access to information, and employment issues [13‐18]. In order to maximize positive perception and attitude toward the practice of EBF in these areas, educational interventions to help women better understand the benefits of EBF is required. While studies on exclusive breastfeeding in Ghana have focused on the knowledge level, socioeconomic and cultural practices as being the major factors affecting the practice of EBF [13, 16‐19], information on the effect of family support from parents, spouse and healthcare professionals on the practice of EBF has remained inadequate.

According to the theory of planned behaviour, the intention to carry out a specific behaviour is said to be the primary motivator behind an individual's particular behaviour. These intentions are presumptively intended to capture the driving forces behind motivation, including attitude, subjective norm (perceived expectations from others and how they value them), and perceived behaviour control (individual's level of knowledge or competences) [20]. This has the power to affect how decisions are made. As a result, motivational factors like a maternal knowledge, attitude, and perceived expectations from others, such as family support, may affect her intentions or willingness to exclusively breastfeed her infants. This study intends to provide additional information by assessing the factors including level of support from family members influencing the practice of EBF among mothers in an urban general hospital in Ghana. This crucial information has not been captured in the studies conducted so far in Ghana creating a knowledge gap that this study seeks to fill. It will also contribute to scientific knowledge and enable formulation of relevant, attainable and realistic policies aimed at increasing the rates of EBF.

The purpose of this study was to determine the factors that influence exclusive breastfeeding among mothers who visited the Tema General Hospital. This was done to identify additional factors (e.g. mothers’ level of knowledge, practice of EBF and level of support from family and spouse) that influenced the practice of EBF among mothers who visited the child welfare clinic. In previous studies, significant determinants of exclusive breastfeeding (EBF) have been identified to include maternal attitude and knowledge, as well as socio-demographic and cultural factors [17, 18]. In order to reduce infant morbidity and mortality in settings with limited resources, mothers should be encouraged to breastfeed exclusively for the first 6 months [31, 32]. Also, EBF is well known to play a critical role in fostering infant development, immunity, and illness prevention [33, 34]. Key findings of this study were as follows:

Our study demonstrated that over 95% of the women had good knowledge of EBF before their last delivery. The mothers viewed that prevention of neonatal sepsis, provision of adequate nutrition, enhancement of brain development; family planning, reducing the financial burden, time saving and enhancing bonding between mother and baby were some of the benefits that could be derived from EBF. Almost 66% of the mothers practiced EBF for the first 6 months and of those who failed to adhere to EBF, 65% were due to insufficient breast milk. One-third of the mothers had complaints about EBF from either their spouse or parents although about 58% of support was from their spouse, parents, extended family members or health personnel when they had difficulties with EBF. Again, 76.13% of the mothers had a good attitude toward EBF.

It is important to note that good knowledge (perceived behavior control) about the benefits of EBF according to the theory of planned behaviour may influence positive attitude and the intention or desire to exclusively breastfeed [20]. This study demonstrated significant maternal knowledge and positive attitude of the mothers toward EBF. This good knowledge on EBF is reflected in their view that water and other complementary foods should be initiated after 6 months of EBF and that colostrum is ideal for initiating breastfeeding in infants. As several studies have shown, about 94.14% of the mothers had good knowledge on EBF among mothers vising the Tema General Hospital with a large percentage (98.64%) of them obtaining the information on EBF from hospitals [21, 35, 36]. The child welfare and antenatal clinics of the facility carry out educational talks to clients every morning on various topics including EBF and this could have played a role in the high level of knowledge these mothers had. Out of every five mothers interviewed, four thought breast milk alone was enough for the first 6 months which certainly plays a role in determining whether or not a mother introduces supplementary feeds before the 6 months is completed. Our findings also agree with Dukuzumuremyi et al. [1] in East Africa who reported that almost 96.2% of mothers knew about EBF with an awareness rate of 84.4% and 49.2% knew that EBF should be done for the first 6 months only. In their study, maternal attitude toward EBF was good [1]. In Zimbabwe, although the practice was low, Mundagowa et al. [37] found a significant good maternal knowledge and positive attitude toward breastfeeding. Both good maternal knowledge and positive attitude were also demonstrated by Hoseini et al. [38] in a cross-sectional study in Mashhad. In contrast, Haghighi and Varzandeh [39] in Iran found a low level of maternal knowledge although they had a good attitude toward breastfeeding. Ekambaram et al. [40] also found poor maternal knowledge, especially regarding the time of initiation of breastfeeding, colostrum feeding, and duration of EBF, expressed breast milk and continuation of breastfeeding while the baby is sick. However, significant correlations were found between higher maternal age, better maternal education, higher socioeconomic status and having received antenatal care from tertiary care centers and private practitioners. There is still a need for a programme, which support and encourage breastfeeding particularly at a primary care level, focusing more on younger, less well-educated women and those from lower socioeconomic class.

Again, the 76.0% positive attitude recorded in this study was significantly associated with adequate maternal knowledge, the attitude of the mother and whether or not the spouse complained about EBF. Also, mothers who have good knowledge had increased odds to exclusively breastfeed their children and those who had positive attitudes towards EBF were 4 times likely to exclusively breastfeed, while mothers whose spouses complained about EBF were 3 times likely not to adhere to EBF.

It is worth noting that having a good understanding of the benefits of breastfeeding has a bigger impact on EBF compliance. The mothers' high knowledge and positive attitude toward EBF, as in the current study, could be linked to their strong belief that exclusive breastfeeding is associated with significant benefits. Our findings were not different from Smith and Forrester [41] where EBF was said to minimize public health costs. Similarly, Allen and Hector [42] reported that EBF is associated with several health benefits similar to those reported by Couto et al. [4]. As a result, emphasizing the maternal benefits of EBF could encourage mothers to breastfeed their infants exclusively.

According to Oche et al. breastfeeding continues to be the most straightforward, healthiest, and affordable feeding method for almost all infants [43]. In their study, although the practice of EBF was found to be low (31%) in Sokoto state, Nigeria, the proportion of mothers who practiced EBF for the recommended 6 months was almost 66%, with one in every four women who start EBF stopping before the 6 months is up. This proportion is similar to the 64% recorded in 2013 across Ghana [44]. It was 14.2% higher than the estimated 52% by the Ghana Demographic and Health Survey in 2014 [11] but lower than the study by Boakye-Yiadom et al. in Mamprusi West by 18.5% which could be attributed to the mother-to-mother support group created in the area by non-governmental organizations. Those who failed to practice EBF, 65% were due to insufficient breast milk. The increased desire and willingness to comply with EBF practices among our study participants may be largely due to the good knowledge and understanding about the numerous advantages associated with EBF. Our finding on mothers’ practice of EBF was a little higher than those reported by Dukuzumuremyi et al.

The theory of planned behavior states according to Ajzen [20], intentions are what drive individual behaviors and are influenced by things like attitudes, subjective norms, and perceived behavioral controls. Therefore, depending on how accurately perceived behavior control represents actual behavior control; external factors such as level of support or expectations from family and healthcare professionals (subjective norm) may directly affect behavior regardless of the intention [20]. Our study also identified that mothers had about 58% supports from spouses, parents, close relations and healthcare professionals. Although few complaints from close relations were reported, support from immediate family members contributed enormously to building a strong mental and positive attitude, serving as a major determinant of the high patronage toward EBF among the mothers. On the other hand, studies in Ethiopia, Nigeria and Ghana reported that the major determinants of EBF were directly linked to maternal sociodemographic and economic status such as maternal age, maternal monthly earnings, level of education, employment status, mothers who delivered at a healthcare facility, antenatal attendance [34, 45, 46]. Even though 95.5% of the mothers who participated in this study were financially supported by their spouses, only two in every five of them were assisted by their spouse in taking care of the child. Two again out of the five mothers interviewed was assisted by other people besides their spouse implying that one out of every five of them did not receive any assistance in the care of the infants. However, there was no association between 6 months of EBF and mothers receiving support when they faced challenges EBF (p = 0.881). Again, there was no association between EBF and mothers whose parents complained about EBF (p = 0.090) unlike parts of the Greater Accra Region where grandmothers of the baby were the most powerful influencers [46]. However, spouses seemed to influence the practice of EBF the most in this study evidenced by a significant association between the practice of EBF and mothers whose spouses complained about EBF. Mothers whose spouses complained about EBF had 79.5% decreased odds of EBF. This could be due to poor knowledge on EBF of the spouses causing them to not appreciate the importance of this practice. Also, up to three out of five of the mothers did not receive help from their spouses when they had difficulties with EBF. This could mean that more than half of these spouses are not actively involved in the care of their babies and as such may not be able to make positive contributions towards the practice of EBF.

In conclusion, a high rate of EBF was observed among mothers who visited the child welfare clinic at Tema General Hospital. The increased rate of practice and a positive attitude toward EBF was as a result of their significant knowledge of the advantages associated with EBF. Also, whether or not mothers should exclusively breastfeed their babies was highly influenced by support from their spouse, parents, and healthcare professionals. Therefore, midwives, nutritionists, and public health nurses should continuously educate mothers about EBF both before and after delivery at both antenatal and child welfare clinics. In order to identify knowledge gaps, particularly with regard to EBF, mothers must be thoroughly evaluated during antenatal visits and at child welfare clinics. This will allow for the delivery of more thorough education. Male participation in the care of their infants should be encouraged, and these educational sessions should be expanded to include spouses.