Study area and participants
The study was conducted from July to November, 2015 in Effutu Municipality in the Central Region of Ghana. Effutu municipality is one of the twenty districts in the Central Region, and is about 66 km way from the capital city of Ghana (Accra). It has a projected population of 75,117 from the 2010 population census with a growth rate of 2.3% per annum and a population of women in fertility age and children aged less than one year at 17,844 and 3,103 respectively [
22]. Administratively, the municipality is divided into four sub-areas called sub-municipalities; namely, South-East Winneba, South-West Winneba, Essuekyr-Gyahadze and Kojo-Bedu North/Low Cost Sub-Municipalities.
The municipal health system is organized at the municipality, sub-municipality and community levels. Each sub-municipality is further divided into communities for purposes of organizing Child Welfare Services (CWS) and other health related activities. The administrative division actually enabled the author to randomly select communities for the purpose of the study. It also ensured that the sample selected was a true representation of the entire municipality thereby avoiding bias.
Child Welfare Services are organized once every month in each of the communities. The services are part of the interventions under the Reproductive and Child Health Program in Ghana.
This study is a community based cross-sectional study which employs quantitative and qualitative method of data collection. The study involved 260 mother-infant pairs attending the community-based Child Welfare Clinic organized by the Municipal Reproductive and Child Health (RCH) Unit during the study period. Out of the 260 mother-infant pairs who participated in the study, 225 mother-infant pairs with infant up to seven months of age attending child welfare clinics within the communities were selected for the quantitative aspect of the study. The remaining 35 mother-infant pairs were selected and used for the qualitative aspect of the study.
Two communities were selected at random from each of the four sub-municipalities. This was done by writing the name of each sub-municipality on a box. Sheets of papers labeled with the names of communities within each sub-municipality were folded and put in their respective boxes. Community Health Nurses (CHN’S) were asked to pick two communities from each box. To ensure that each community has equal chance of being selected, the first paper (community) that was selected was replaced and reshuffled before selecting the second community. This step was repeated until the author was able to select two communities each from the four sub-municipalities.
Universal sampling technique was used in selecting the eligible mother-infant pairs who attended the Child Welfare Clinic during the study period. Data for the study was collected according to the CWC schedule. This was obtained from the health facilities within the various sub-municipalities.
After obtaining verbal consent from eligible mothers, face-to-face structured interviews were conducted using a pretested questionnaire during mothers visit to CWC within the study period. The questionnaire was pretested among 15 mother-infant pairs from a health facility (RCH unit) within the municipality. A 24 h self-recall method was used for assessing exclusive breastfeeding and breastfeeding frequency of mothers. Two volunteer CHN’s were trained on the administration of the questionnaire to assist the author in the data collection. Data were collected by Community Health Nurses were done under the supervision of a Registered Nurse.
Data on maternal sociodemographic variables (maternal age, education, religion, place of residence, sex and age of infant) and maternal work features (sector of employment, type of occupation, work location, risks of mother’s work on infant health, going to work with the infant, number of hours worked and distance from home to workplace) were collected. Data were collected once from each CWC to avoid interviewing the same mother-infant pair more than once during the study period. Mothers who visited the CWC with children of their relatives were excluded from the study.
The qualitative data were collected through the use of field notes. Focus group discussions were organized to discuss the results of the quantitative data collected at CWC in the communities. One CWC was selected for the focus group discussions because it has the highest attendance within the municipality. The clinic appointment gave author the opportunity to meet the same mother-infant pairs who participated in the face-to-face interview. Interviews and discussions were conducted in Fante, a dialect of Akan, since that is the Lingua-franca of the people of Effutu. Questions were prepared in English but were translated into Fante for mothers during the discussion.
The focus group discussion was facilitated by the author. Verbal consent was obtained from all mothers who participated in the discussion. This was done by explaining to mothers the aims of the focus group discussion and requesting individual mothers who wished to participate in the discussion to meet with the author after they have been attended to by nurses at the clinic. The 35 mother-infant pairs selected for the discussion were divided into three groups. The average number of mother-infant pair in each group was 12. The rules of the discussion were explained to mothers before the discussion and individual participants were not allowed to dominate the discussions. Answers to questions and contributions were taken in turns by mothers.
Discussions centered on the following: 1) How mothers managed to exclusively breastfeed their infants irrespective of demands of their work. 2) Reasons that accounted for mothers’ ability to breastfeed many times in a day. 3) Features of the mothers’ work that encourage or discourage breastfeeding in the manner taught by health professionals. 4) General issues within mothers’ environment that negatively or positively affect exclusive breastfeeding.
Data in the questionnaires were coded and entered into Statistical Package for Social Science (SPSS) version 20.0. The dependent variables were exclusive breastfeeding and breastfeeding frequency. Frequencies and cross-tabulations were run and a Chi-square test, specifically Fisher’s Exact Test, was used to identify strength of association between features of maternal work and exclusive breastfeeding practice. A p - value < 0.05 was used as the criterion for statistical significance.
The qualitative data were transcribed from Fante into English language. The field notes were taken by a research assistant proficient in both the English and Fante languages. The field notes were transcribed into English text by the same research assistant at the end of the discussion. The transcribed data from the focus group discussions were perused, categorized and summarized by the author and triangulated with the quantitative data.
Definition of variables
Exclusive breastfeeding: This is defined as infant 0 to 6 months who were fed with breast milk without any other liquid or solid except drops and syrups (vitamin, minerals and medicines) in the previous 24 h.
Breastfeeding frequency: This is defined as the number of times infants were breastfed in the previous 24 h. This was coded based on the recommended number of times infants should be nursed per day [
4,
5]. This is coded ‘1’ if a mother nursed 8 + times per day and ‘0’ if she nursed below 8 times per day.
Timely initiation of breastfeeding: This is defined as putting the newborn baby to the breast within the first hour of birth.
Maternal work: This refers to economic activities of mothers either on full-time or part-time to earn a living or support the home. In this study, mothers were given the option to indicate the actual economic activities they under take to earn a living or to support their homes.
Features of maternal work: This refers to the characteristics of mother’s work and includes the type of occupation, the sector of employment, place of work, conditions at work place, risks posed by mother’s work to infant health (examples of risks include smoke, heat from the sun, harmful objects and substances), mother working with her infant, distance from home to work place and the work location.
Formal employment: This refers to paid jobs and/or situations where mothers work in formal organizations such as schools, hospitals, banks, factories and supermarkets.
Informal employment: This refers to mothers who are self-employed; usually in small enterprise such as, subsistence farming, dress making, hair dressing, trading, catering and other forms of self-employment.