Breastfeeding practices and determinants of exclusive breastfeeding in a cross-sectional study at a child welfare clinic in Tema Manhean, Ghana

Optimal breastfeeding practice decreases child death and contribute significantly to the long term health of children [1]. In 2016, a Lancet series estimated that 823,000 deaths of children under five years could be prevented every year through optimal breastfeeding practices [2]. Optimal breastfeeding practices reduce hospitalization among children from diarrhoea, respiratory infections, and otitis media illnesses [2].

In view of the benefits of breastfeeding, starting breastfeeding in the first hour of delivery, exclusive breastfeeding (EBF) for the first 6 months of life and continued breastfeeding together with suitable complementary foods for up to 2 years or beyond are recommended as the best infant feeding plan for optimal growth, development and health [1]. Yet just about half of the 80% of neonates who are given breast milk worldwide initiated breastfeeding in the first hour of birth, and late initiation of breastfeeding is still a challenge in developing countries [2]. The rates of continued breastfeeding also appear to be declining among poor mothers [2]. Exclusive breastfeeding is reportedly low in many countries [3‐7]. Globally, just 38% of infants less than 6 months are exclusively breastfed [8]. The trend of exclusive breastfeeding among infants less than 6 months in developing countries has taken over a decade to increase from 33% in 1995 to 39% in 2010 [9].

In Ghana, breastfeeding is common with nearly all children being breastfed. However, the Ghana Demographic Health Survey in 2014 has reported an exclusive breastfeeding rate of 52% at 6 months [10], which is below the optimal EBF rate of 90% in infants less than 6 months set by the WHO/UNICEF for developing countries [11].

Among factors identified to influence breastfeeding practices in both developing and developed countries are sociodemographic factors [4, 12‐15]. Findings from a number of studies have emphasized maternal education [5, 16] and in the study by Vieria and colleagues, mothers who had an education for 8 years or less were at 34% higher risk of stopping exclusive breastfeeding [16]. A study in Nigeria has found that mothers who visited the antenatal clinics were positively associated with EBF and mothers who resided in rural areas were less likely to practice exclusive breastfeeding [17]. Seid et al. have reported in Ethiopia that being a housewife, having prenatal EBF plan, giving birth vaginally and receiving infant feeding counseling was associated with the practice of exclusive breastfeeding [18]. Findings from another study in Ethiopia has observed that mothers with less income status are positively associated with practice of exclusive breastfeeding [19]. Mothers who are unemployed are also positively associated with the practice of exclusive breastfeeding [20]. Furthermore, mothers living in their own homes and the place of delivery have also been documented to predict the practice of exclusive breastfeeding [21]. In Ghana, a study has highlighted that mothers who delivered at the government hospitals were at a higher odd of practicing exclusive breastfeeding [22]. Child factors such as the age and sex of child have also been indicated to predict the practice of exclusive breastfeeding [20, 23]. In Nigeria, Agho and colleagues have reported that female infants are more likely to be exclusively breastfed than their male counterparts and also infants aged less than 2 months are more likely to be exclusively breastfed [17].

There are enormous benefits of breastfeeding to both mothers and infants, yet the levels of breastfeeding practices particularly in developing countries including Ghana continue to be suboptimal. Therefore, understanding the breastfeeding practices and the factors that predict them is important in designing and carrying out successful interventions. This study aimed at determining the breastfeeding practices and to examine the sociodemographic factors associated with exclusive breastfeeding among mothers attending child welfare clinic at Manhean Health Center in the Tema Metropolitan area of the Greater Accra region in Ghana.

Recognizing the important health benefits of breastfeeding based on the adequate evidence available, this study was aimed at assessing maternal knowledge about exclusive breastfeeding, the breastfeeding practices among mothers and the sociodemographic factors that influence exclusive breastfeeding.

There was a universal awareness about EBF and majority of mothers were knowledgeable about exclusive breastfeeding. Similar high awareness and knowledge on EBF has also been reported in Nigeria where 95.3% of mothers had heard about EBF and 82.0% of them correctly defined exclusive breastfeeding [29]. In contrast, a similar study in Nigeria has reported low knowledge about EBF where only 30% (n = 179) of the mothers were adequately informed [30]. The high level seen in our study could be due to the effectiveness of the health education and awareness programmes run by the Ministry of Health and Ghana Health Service, and their partners on exclusive breastfeeding. In relation to accessing help and information on breastfeeding, this current study found that mothers tend to go to the health facilities and rely on midwives/nurses for information on breastfeeding. This result is in agreement with the findings of another study in Ghana where all the mothers received information on breastfeeding from health professionals on their visit to health facilities [31]. Oche et al. have on the other hand reported that younger (newer) mothers also mostly rely on their older experienced mothers for information on exclusive breastfeeding [30]. Our current finding stresses the trust and confidence mothers have in the health professionals and the importance of health education to be carried out at the antenatal and postnatal care centres.

Although there was a universal awareness and high level of knowledge about exclusive breastfeeding, only 66.0% of infants less than 6 months were exclusively breastfed. This finding is similar to EBF rate (64.0%) documented by another study in Ghana among infants aged 0–5 months [22] and in Ethiopia where a EBF rate of 60.8% has been reported [32]. However, lower EBF rates of 16.4% and 31.0% have also been reported in similar studies in Nigeria [14, 30]. The discordance between high knowledge and the suboptimal practice of EBF observed in the current study has also been reported by Onah et al. [29]. As stipulated by Onah et al., awareness and knowledge do not necessary translate into practice, probably due to mothers’ lack of appreciation of the vital benefits of EBF, and to address this, strategies should for now focus on practically assisting mothers to addressing the identified challenges to practice of EBF rather than just giving out information on exclusive breastfeeding [29].

This study found factors such as mother’s age, educational status and ethnicity to be associated with exclusive breastfeeding among mothers. The odds of exclusive breastfeeding were high when mothers were older than 20 years. A similar finding has also been reported by Asemahagn where mothers aged 30 years and above were more likely to engage in exclusive breastfeeding [33]. This could be explained as argued by Asemahagn that mothers gain experience in child management as they increase in age, and in the quest of younger mothers to maintain their breast size and beauty, EBF will not practiced for a longer time and introduce early supplementary feeding [33].

In relation to education as a factor of EBF, mothers in our current study who had a tertiary education were less likely to exclusively breastfeed their infants. This finding is in contrast to what has been documented in other similar studies where mothers who had informal education and/or with lower education were all less likely to exclusively breastfeed their infants [29, 33]. Our results could be explained by the fact that in Ghana mothers with higher education tend to engage in formal employment and as observed by Safari et al., mothers who are engaged in formal employment are less likely to exclusive breastfeed [34].

The ethnic affiliation of the mother was found to influence their practice of exclusive breastfeeding. A similar finding has been reported in a similar study by Jacdonmi et al. in Nigeria [35]. The influence of ethnicity on exclusive breastfeeding could be explained by the influence of cultural beliefs and practices of the various ethnic groups in Ghana on breastfeeding practices. For instance, Tawiah-Agyemang and colleagues have postulated that mothers mostly from the Northern ethnic groups in Ghana held the belief that the breast is filled with breast milk on the third day after birth which delays the initiation of breastfeeding [36].

This study also found an early initiation of breastfeeding rate of 63.4% similar to other published study where 57.0% of mothers started breastfeeding within the first hour after birth [6]. This is higher than what has been documented by other studies in Ghana [37], in Ethiopia [38] and in India [39] where timely initiation breastfeeding rates were 39.9%, 52.4% and 23.5% respectively. However, the study found that about 81% of all mothers fed their babies with the first breast milk (colostrum). This is supported by other studies reporting 91.0% in Nepal [6] and 83.3% in Ethiopia [18]. The high rates recorded in our current study could be as a result of the fact that most of the mothers delivered at the health facility, where mothers are encouraged by health personnel to breastfeed just after delivery.

There is widespread and long duration of breastfeeding noted in Ghana [10]. Our study found current breastfeeding and continuous breastfeeding at 1 year of age rates of 74.1% and 76.2% respectively. However, higher rates for current breastfeeding (89.8%) and continuous breastfeeding (89.4%) have been reported elsewhere in Asia [39]. The observed difference could be due to the study design and the sample size differences.

Our study further found that, only 33.7% of infants aged between 6 and 8 months were receiving timely complementary feeding. In contrast to this finding, high timely complementary feeding rates have been documented in Ghana (72.6%) by Issaka et al. [40] and in Ethiopia (60.5%) [41]. As observed by a study in Bangladesh, where mothers with low education were less likely to timely introduce complementary feeding among infant aged 6–8 months [42], the low educational background of most of the mothers in our study could explain the lower rate of timely complementary feeding. This suggests the need for an intense education on the importance of complementary feeding among mothers.

Even though bottle feeding is reportedly not widespread in Ghana [10], bottle feeding among infants less than 24 months was 30.1%. This was higher than what has been reported elsewhere (14.8%) [39]. As found by Petal et al. where high bottle feeding was found among urban and wealthier mothers [39], the high rate of bottle feeding reported in the current study could be explained by the fact that the study was done in a peri-urban community with characteristics similar or close to urban counterparts. These current findings suggest the need for an intense campaign on the importance of timely, adequate and safe complementary feeding and interventions necessary to bring down the high rates of bottle feeding among mothers.

The results of this study are limited. The findings of the study cannot be generalized for Greater Accra Region and other similar setting as the study respondents were recruited from a single health centre in the Tema East Sub-Metropolitan area of the Greater Accra Region but could be considered indicative of the context considered.

Mothers were adequately informed about exclusive breastfeeding. The practice of exclusive breastfeeding among infants less than six months old in the previous 24 h and complementary feeding among infants aged 6–8 months were suboptimal. Exclusive breastfeeding among mothers was influenced by mother’s age, ethnicity and educational status. Interventions emphasizing practical education should therefore be targeted at addressing factors that influence exclusive breastfeeding.