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Background. Exclusive breastfeeding (EBF) for the first six months after birth has been recommended by the WHO as the best infant feeding strategy. Data on EBF rates among twin infants in Ghana remain limited and for that matter hypothesized to be low. Aim. The study sought to measure the prevalence of EBF and identify associated factors among twins in the Tamale metropolis. Methods. A cross-sectional survey involving 185 mother-twin pairs was conducted in four health facilities in the Tamale metropolis providing Child welfare Clinic (CWC) services. Socio-demographics data on both mother and twin were taken. Biomedical (e.g. perceived onset of lactation, confidence of producing enough milk, parity, delivery place, delivery type, time of breastfeeding initiation) and bio cultural factors (e.g. family cooperation for current infant feeding, breastfeeding counselling) were also obtained. In-depth interviews were also conducted with a sub sample of mothers (30) who were purposively selected to generate qualitative data on breastfeeding and associated cultural factors in twins as this data was necessary to aid in the explanation of the quantitative results. Results. Only 17% of twin infants were exclusively breastfed for six months. Women who were not confident that they could produce enough breast milk were about 83% less likely to practice exclusive breast-feeding (EBF) compared to those who were confident that they could produce enough breast milk (AOR = 0.17; CI = 0.04, 0.73; p-value = 0.017). Moreover, mothers who had no access to radio were about 87% less likely to practice EBF (AOR = 0.13; CI = 0.02, 0.79; p-value = 0.027). The qualitative analysis also revealed that babies are frequently breastfed because according to the mothers, breastmilk was the only food for the baby. It was also found that begging when you have twins had spiritual underpinnings in the study area. Conclusions. The study shows that, ownership of radio, confidence of producing enough breast milk and admission of the children into NICU were identified as the most important factors affecting exclusive breastfeeding of twins. Beyond Educating, encouraging and assuring twin mothers of their abilities to produce enough breast milk to satisfy their children, healthcare professionals should pay more attention on providing appropriate information on breastfeeding to mothers and caregivers.
This study was conducted at the Tamale Teaching hospital, Tamale West Hospital, Seventh Day Adventist Hospital and Central Reproductive and Child Health Center in the Tamale metropolis. Tamale Metropolis is the Regional capital of the Northern Region of Ghana. The Metropolis is boarded to the South by Central and East Gonja Districts, North by the Savelugu-Nanton District, East by the Mion District and West by Sagnerigu District. The 2012 and 2013 projected population of the Metropolis was 383205 and 404609 respectively [17]. The study design was a mixed method, convergent design where both quantitative and qualitative data were collected simultaneously. The study was a facility based cross-sectional survey, which was conducted among mothers with twins 6–23 months in the Tamale Metropolis. A required sample size of 185 mothers of twins was calculated from 14% [18] prevalence of exclusive breastfeeding among twins in Greater Accra Region of Ghana using a 95% confidence interval and 5% margin of error. One hundred and eighty five mothers of twins between the ages of 6–23 months were selected for this study. They were drawn from the six Health facilities in the metropolis providing Child welfare Clinic (CWC) services on predetermined day(s) of the week. It was during these CWC services that the mothers of children age 6–23 months were selected using consecutive sampling, a non-probability sampling technique, as it was difficult to obtain large numbers of twins at a session, therefore in every visit we made to a selected facility on every child welfare session day, all mothers with twins who met the selection criteria were approached and when agreed to be part of the survey, were interviewed. This procedure continued in all selected facilities until the required sample size was achieved. This is because the mothers with twins at every child welfare session was small because twin delivery is not a very common occurrence hence random sampling was inappropriate. More so, the six (6) health facilities in each of the six sub-districts were selected on the basis of those that have very high numbers of mothers attending CWCs. The 185 mother and child pairs were distributed among all the hospitals as a proportion of their respective CWCs daily attendance. Mothers with twins aged 6–23 months were interviewed in the present study. Mothers who were not breastfeeding at all due to personal choice or medical condition that interferes with breastfeeding such as mastitis were excluded as well as babies with any condition that made breastfeeding difficult (e.g. cleft palate). The qualitative data was also generated from a sub sample of 30 mothers with twins who were purposively (based on educational status, ethnicity, etc.) selected to participate in the in-depth interviews. The sample aimed at a diversity of the participants’ background (heterogeneous sampling). Five (5) mothers were selected from each of the six health facilities for this study. Mothers were interviewed using a semi-structured questionnaire. Data on maternal socio-demographics (e.g. age, marital status, occupation, income and highest educational level attained), biomedical (e.g. perceived onset of lactation, confidence of producing enough milk, parity, delivery place, delivery type, time of breastfeeding initiation) as well as health service and cultural factors (e.g. family cooperation for current infant feeding, breastfeeding counselling) were obtained. Additionally, data on the infants’ background characteristics (e.g. age in completed months, gestational age, Neonatal Intensive Care Unit admission and birth weight) were collected. The interviews were conducted using the most dominant local language (Dagbani) in the study area on breastfeeding messages given by nurses after delivery, perception of inadequate milk production to satisfy their children for the first 6 months of life and cultural factors associated with breastfeeding in twins as this data was necessary to aid in the explanation of the quantitative results. The interviews were tape recorded. Before the interviews were conducted a research assistant explained the nature of the study to each woman in a separate room at the facility, read the consent form and obtained her verbal consent. Additionally, notes were taken for backup purposes and in order to ensure completeness of records. SPSS version 22.0 software (SPSS Inc. Chicago, IL, USA) was used for data entry and analysis. Responses on whether or not the children were given any feed aside breast milk in the first 6 months of life and the age (in months) at which water or other liquids was given were used to measure the prevalence of exclusive breastfeeding. Marital status, educational level, employment status, delivery type, decision to exclusively breastfeed, perceived onset of lactation, initiation of breastfeeding, confident of producing enough breast milk and breastfeeding counselling were crosstab with the prevalence of exclusive breastfeeding. Descriptive statistics (frequencies and proportions) were used to summarize the demographic characteristics of participants. Chi-square was used to establish whether or not there were significant relationships between exclusive breastfeeding and maternal and infant factors. Logistic regression model was also estimated to determine predictors of exclusive breastfeeding among twins. We examined effect sizes of exposure variables as well as p-values of bivariate analysis before including the variables in the multivariate logistic regression model. Given the size of our study, variables that had p-values of 0.3 showed that the most effective and improved multivariable models were included. Even though marital status met the p ≤ 0.3 criteria, we did not include it in the multivariable modelling because they had poor distribution with exclusive breastfeeding and did not improve the models. For example, none of the mothers who were cohabiting practiced exclusive breastfeeding. The qualitative data was analyzed using computer assisted qualitative data analysis software NVivo (version 10) (QSR international Pty Ltd, Doncaster, Victoria, Australia). The field notes and audio recordings were translated verbatim. A thematic analysis was performed. The analysis started by reading, coding, and then categorizing the qualitative transcripts. Coding nodes were generated based on the study objectives and the main themes of the interview guide. Specifically, the coding was done by finding references to different ideas, concepts or categories in the form of sentences, phrases and paragraphs within the sources (transcript), which represented them. When a meaningful segment of the text was found, a code was assigned or category named to signify that particular segment. This continued until all the text was segmented. The process was repeated several times to make sure that all the relevant segments important to the study objectives were identified and coded. Queries were used to find document content coded by a specific combination of nodes, or combination of nodes and attributes. They were made purposefully to identify content in the transcript with particular text so that they could be used as a basis for further analysis.
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