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Background: In Ghana, only 52% of mothers exclusively breastfeed their babies and the rate of increase has been steadily slow across all geographical areas of Ghana. The purpose of this study was to determine the various factors that influence exclusive breastfeeding (EBF) among mothers who visited the child welfare clinic at the Tema General Hospital, Accra, Ghana. Methodology: This descriptive cross-sectional study was carried out at the Child Welfare Clinic of the Tema General Hospital, Accra, Ghana. A random sampling technique was used to recruit mothers with children between the ages of 6 months and 24 months attending the Child Welfare Clinic. Mothers were interviewed with the aid of a structured questionnaire. Results: Out of the 222 of mothers interviewed, 68.8% of them exclusively breastfed their infants up to 6 months. Mothers who have good knowledge were more than 3 times (AOR = 3.484, 95% CI 1.200, 10.122, P = 0.022) likely to breastfeed their children exclusively. Those who had positive attitudes towards EBF were about 4 times (COR: 4.018, 95% = 1.444, 11.181, P = 0.008) more likely to exclusively breastfeed than those who had poor attitudes towards EBF. Also, mothers whose spouses complained about EBF were about 3 times (AOR: 2.655, 95% CI 0.620, 11.365, P = 0.018) at increased odds of not exclusively breastfeeding their babies. Conclusions: High rate of EBF among mothers who visited the child welfare clinic was found. The mothers’ level of knowledge and attitude towards EBF significantly influenced the 6 months of EBF. Spouses also showed a high influence on whether or not mothers should exclusively breastfeed their babies.
A retrospective quantitative cross-sectional study design using researcher administered questionnaire was employed to describe the factors that influence EBF among mothers visiting the Tema General Hospital, Ghana. This study adopted the theory of planned behaviour [20] as its conceptual framework. This allowed access to information on the practice of exclusive breastfeeding among the study population, knowledge, level of support provided as well as the attitude of these mothers toward EBF. The study was conducted at the Child Welfare Clinic of the Tema General Hospital, a highly patronized district hospital located in the Greater Accra Region of Ghana. This healthcare facility is equipped with the necessary infrastructure to deliver both primary and specialist health care to all clients within the region and its environs. The Child Welfare Clinic undertakes activities such as growth monitoring of children, vaccinations and other services including birth registry. Most children visit this facility from birth to 5 years when vaccinations are completed. The inclusion criteria were made up of mothers who visited the Child Welfare Clinic of the Tema General Hospital. All registered postnatal mothers and parent/legal guardian with children aged between 6 and 24 months who were of sound mind and competent enough to give assent/consent were included in the study. This was done to obtain information from those who had completed the recommended 6 months of EBF and was limited to mothers with babies under 24 months in order to reduce recall errors and biases. We excluded all mothers with conditions which do not support breastfeeding such as babies with an established diagnosis of galactosemia, babies of deceased mothers, mothers who had mastectomy, those actively receiving cancer treatment, taking drugs (e.g. amphetamines, statins and antidepressants), those with active TB and mothers with Human T-lymphotropic virus as well as all eligible mothers who declined to participate in this study. Mothers with babies less than 6 months were exempted because EBF is recommended for the first 6 months and it cannot be ascertained as to whether they would practice EBF for the period until their babies turned 6 months. Using a simple random sampling technique, all eligible mothers who had their written informed consent taken were required to randomly pick confidentially prepared slips that had either a YES or NO inscribed. Only qualified participants who met the selection criteria and picked a slip with YES inscribed were enrolled for the study. The sample size for the study was estimated using the Cochran formula below; where N = sample size to be determined, Z = Z score (reliability coefficient) of 1.96 at 95% confidence level, P = the estimated proportion of the population who practiced exclusive breastfeeding. This was determined using a single population proportion from a study by Boakye-Yiadom et al., 2016 [21] to be 84.3% = 0.85, and D = margin of error of 5% = 0.05. The sample size calculated was 202. Assuming a non-response rate of 10%, the total sample size required for the study was 222. The total time used for this study was 9 weeks, starting from 21st of June to 20th of August, 2021. The first 5 weeks were used for data collection and the subsequent four for analysis. After obtaining ethical approval from the Research Ethics Committee of the University of Health and Allied Sciences (UHAS-RECA.12 [171] 21-21), permission to commence data collection was sought from the clinical coordinator and the in-charge of the Child Welfare Clinic of the Tema General Hospital, Ghana. Written informed consent was also obtained from the individual mothers who met the selection criteria after providing them with adequate explanations regarding the aims of the study. For participants who were below 18 years, informed consent was sought from their parents/legal guardians who accompanied them. Following informed consent and recruitment, study participants were interviewed using a standard structured self-administered questionnaire which was developed and validated by the authors for this study. The validity of the questionnaire was determined by the adoption of the checklist/guideline by the Centers for Disease Control and Prevention (CDCP), 2014 [22], Global Opinion Panels [23] and the breastfeeding self-efficacy scale [24] and was pre-tested on five participants which served as a pilot study and the reliability determined through a review with two public health physicians and a paediatrician. The study participants were approached and assessed for their eligibility to participate in the study following the determination of the age of their children between 6 to 24 months. In all, a total of 222 eligible mothers were enrolled in the study. The questionnaire was prepared in English and had it translated and explained to mothers in their local language where necessary. Questionnaires were numbered and coded prior to data collection. The questionnaires sought to provide information on the various factors that influence EBF among mothers. This was done by assessing the practice of EBF among the study population, knowledge of EBF, the attitude of mothers toward EBF as well as the level of support received from spouses. Age of mother and baby, sex of the baby as well as the level of education of the mother, marital status of the mother, religion, occupation, place of residence and the number of children she had were defined as independent variables. The occupation of the mothers was then defined as formal, informal or unemployed with those being unemployed including students. The place of residence was also categorised into various districts. Also, questions were asked on what hospital the mothers attended for antenatal care, where they delivered and the gestational age at which they delivered. The hospitals mothers attended for antenatal care were categorised into either a government facility or a private facility. For the birth weight, all babies born with birth weight from 2.5 to 4.5 kg were noted to have normal weight whereas all those less than 2.5 kg or more than 4.5 kg were considered to have a low birth weight and a high birth weight respectively. The current weight of the children was assessed using the weight for age chart for the various sexes and all those between the -2 standard deviation and + 2 standard deviation were considered to have normal weight. Those above + 2 standard deviation and those below -2 standard deviation were evaluated to be overweight and underweight respectively. The WHO criteria or indicators for assessing infant feeding practices, Geneva, 2021, were used to assess EBF [25]. The main dependent variable was mothers’ practice of EBF. EBF was defined as the babies receiving only breast milk as a source of nutrition. The first type of feed was also asked together with whether they fed the first yellowish breast milk or not and if they fed their babies with other foods or fluids. Mothers were also asked when they stopped breastfeeding and if they were still breastfeeding at the time of the study. To measure mothers’ level of knowledge on EBF, they were asked about whether or not they had heard of EBF and subsequently about where they heard about it from and also when they heard about it. The respondents were asked when one should initiate breastfeeding after delivery and when one should start giving water and then food to their children. They were also asked if breast milk alone was enough for the babies in the first 6 months and what one should do with the first breast milk. Knowledge about the benefits of EBF was assessed. The overall level of knowledge of mothers was considered to either be good or poor. The criteria for assessing knowledge on EBF was used based on literature [23, 25–28]. A score from zero to four implied you had poor knowledge of EBF whereas a score of more than four implied a good knowledge of exclusive breastfeeding. The level of support obtained from the family, community and health professionals was ascertained. This was done by finding out whom they stayed with, then who helps take care of the baby followed by who provides money to take care of the baby. Further questions were asked about whether the spouse or the parents of the respondents complained about EBF. Finally, attitude of the mothers towards exclusive breastfeeding was determined. The questions required answers using the 3-point Likert scale. The questions began with asking the mothers if they found it difficult exclusively breastfeeding for 6 months and continued by asking if they felt it was okay to give their children formula if they were not producing enough breast milk. They were also asked if it was okay to give complementary feeds before 6 months if the baby was not satisfied after feeds or if it was okay to give water to their babies before 6 months if the babies were thirsty. Again, they were asked if they found it difficult to breastfeed in public and if they felt confident expressing breast milk to be given to their children in their absence. To evaluate mothers as having a good or poor attitude towards EBF, choosing disagree scored one point while disagree or unsure scored zero point. Cumulatively, mothers could score from zero to seven. A mother with a score less than four was deemed to have a poor attitude towards EBF and one who scored four through to seven was noted to have a good attitude towards EBF. Data were double entered into Microsoft excel, validated for entry errors and exported onto Statistical Package for Social Sciences Software (SPSS) version 20.01 (IBM Corporation, Armonk, NY, USA) for statistical analysis [29, 30]. The results were presented as means, frequencies and tables. The confidence interval was 95% and considered statistically significant at P < 0.05. The frequency distribution was done for all variables. The Pearson chi-square test was used to test the significance of the association between the practice of EBF and knowledge, attitude, support received and complaints of relatives. Factors found to have significant associations were analyzed using a multiple logistic regression model which was used to calculate the odds ratio and confidence interval. P-values of variables in the chi-square table with only significant terms as predictors of EBF was the criteria for variable selection to fit the multiple logistic regression model. Socioeconomic indicators such as income level, maternal health condition or mental state relation, parity, maternal age, gestational age, educational level, occupation and employment issues were perceived as major confounders to the multiple logistic regression model. These were chosen because many previous studies [14, 17–20] have reported the influence of socio-economic and cultural factors on the practice of EBF. Missing data was managed using a listwise or case deletion. To address data bias, multiple people were used to code the data; results were reviewed and were verified from other data sources and compared with other studies’ results.
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