Maternal challenges of exclusive breastfeeding and complementary feeding in Ghana

Mothers are recommended to exclusively breastfeed their infants for the first six months of their lives. Also, after the sixth month, breastfeeding should continue with added complementary foods to the diets of children. Studies designed to sought the views of mothers on breastfeeding practices are limited. The aim of this study was to explore challenges to breastfeeding practices by considering spatial, societal and maternal characteristics in Ghana. Twenty mothers aged 15–49 years were interviewed purposively in selected communities within two regions of the country. Thematic content analytical procedures were applied to interpret and present findings. Challenges (to both exclusive breastfeeding and complementary feeding) spanned across spatial (home and work places), societal, and maternal characteristics. Key themes identified were in relation to household chores, work schedules, family influence, low breast milk production, swollen breasts or sore nipples, access to food items and preparation or giving foods. Addressing these challenges would require co-creation of supportive environments between couples and significant others as well as tackling institutional barriers that obstruct adequate breastfeeding among mothers. On complementary feeding, there is the need to form community health volunteers help educate mothers more on how to appropriately use local foods to feed their children. The study was conducted in two regions–Upper West and Western. We purposively selected these regions due to the level of exclusive breastfeeding prevalence for children age 0–23 months in each region following a secondary analysis of data from 2014 Ghana Demographic and Health Survey (GDHS). Comparatively, Upper West Region had the highest prevalence rate (33.08%) while Western Region had the lowest prevalence rate (9.60%) of exclusive breastfeeding. Convenience sampling was subsequently applied to select urban and rural settings within each of the regions. In Upper West Region, Kambali (urban) and Siriyiri (rural) were selected whiles Kojokrom (urban) and Inchaban Nkwanta (rural) were selected in Western Region. Upper West Region is located in the north-western part of Ghana. It is predominantly inhibited by the Dagaaba and Sissala ethnic groups. It lies in the Guinea Savannah vegetation belt and it is a place commonly associated with the shea (Vitellaria paradoxa), baobab (Adansonia), dawadawa (Parkia biglobosa), and neem (Azadirachta indica) trees. Main economic activities in the region are agricultural related and key crops grown are maize, millet, and peanuts (groundnuts). Animal husbandry (for example sheep, goats, pigs, and cattle) is also common in the region. Tuo-zafi (a stable food made from maize or millet flour, eaten commonly in the northern part of Ghana),accompanied with soups made of green vegetable leaves is the commonest food among households in the region. On the other hand, the Western Region is located in the south-western part of the country with the Fante being the largest group of inhabitants. About 75 per cent of the region is dense forest vegetation. The key economic activities include cocoa, rubber, oil palm and coffee farming. Food crops mostly cultivated in this region are plantain, cassava, and cocoyam. Fufu (pounded cassava with plantain, yam or cocoyam) with soup prepared from palm nut is a stable food in the region. An interpretive case study design was adopted to explore challenges of breastfeeding practices (exclusive breastfeeding and complementary feeding) among mothers in selected regions in Ghana. The application of interpretive case study design facilitated in discovering deeper and social meanings attached to breastfeeding practices. Data were collected through unstructured in-depth interviews. The interview guide was designed in English language. It was subsequently translated to Fante (for participants in the Western Region) and Dagaare/Waale (for participants in Upper West Region) and then translated back into English Language to ensure reliability of the data collection instrument. Interviews were conducted using any of the languages (English, Fante, or Dagaare/Waale) that a mother was conversant with, understood and spoke fluently. The interview guide was structured in three main portions. The first portions contained questions on the background characteristics (age, education, marital status, occupation, age of child, sex of child) of participants. The second part had questions on challenges to exclusive breastfeeding, and the third part included questions on challenges to complementary feeding. These questions were in areas of individual, household, health, and food items. In order to get in-depth explanations and exhaust each of the issues under discussion, probes followed the questions in the second and third sections. The interview guide was developed based on a wider assessment of the data and questionnaire of the Ghana Demographic and Health Survey 2014. Criteria for the selection of mothers were that a mother should have had a singleton birth, be aged 15–49 years old and have an infant or a child of aged 0–23 months. Also, mothers had to be residents of the selected sites. The data collection tool was pretested in a rural setting community. Pretesting was done in two waves. The first wave consisted of one participant and the second wave involved two participants. This afforded the research team the opportunity to revise the tool for clarity. The purposive sampling technique was used to select mothers. Interviews were conducted according to the date, time and place agreed upon with each mother. Some mothers allowed the interviewers to interview them only after we had introduced ourselves and requested for their consent (in either a signature or thumb print mark on the informed consent form). Those who were willing but could not afford the time for a prompt interview, a time and place were agreed upon. Interviews took place at either their homes or work places. In both instances, interviews were conducted without the presence of a third-party. This was done to avoid split attention on the side of mothers during the interviews and also to have clear audio recordings of the discussions. No initial sample size was set for the study. Twenty-two participants were contacted but two mothers in Western Region declined to be interviewed because they were busy and were not ready. In all, 20 mothers (10 each from Upper West and Western regions) participated in the study. The other team members, who are experienced in qualitative studies tutored the interviewer (corresponding author) who then canvassed through the selected communities to recruit participants until data saturation was attained. This was attained when no new themes were emerging from the data collected [26]. All interviews were conducted between August 19, 2017 and September 17, 2017; and each interview lasted about 35–45 minutes. Prior to the data collection, no relationship was established with the participants. Informed consent was obtained from each participant and confidentiality of discussions was assured before the commencement of each interview. Unique numbers were then assigned to each participant to ensure anonymity. Participants were informed of their rights to respond or not respond to any question they might deem sensitive and could pull out from the interview at any time. The interviews were audio recorded and field notes were written in a hand book. The field notes included issues such as date, time, exact location and phone number of mothers, and health status of mother-child pairs. Using the field notes and transcribed data from each interview, where necessary, interview questions were modified accordingly. The researchers obtained ethical clearance, with reference number UCCIRB/CHLS/2016/22, from the Institutional Review Board (IRB) of the University of Cape Coast, Ghana. Thematic analysis was applied using the inductive approach to analyze the data [27–28]. Preliminary data analysis started immediately with the first two interviews and transcription of data was done manually. Each transcript was critically read in order to become familiar with the data. These transcripts were verified by the research team with reference to the field notes where necessary. Some participants in both localities were subsequently contacted to clarify and validate issues in the transcribed data. On the transcripts, identified emerged themes were marked with letters. For instance, the letter ‘A’ was used for exclusive breastfeeding challenges at home and ‘B’ for exclusive breastfeeding challenges at work place. Similarly, numerals were used to specifically identify sub-themes. For example, the number ‘1’ was used for household chores; and ‘2’ for formal and informal work schedules. Further, to enable easy identification of individual transcripts, unique codes (consisting of a number, place of residence, and region) were assigned to selected quotations. Further, each researcher independently reviewed the transcripts and outlined themes. The research team met to discuss the identified themes. After the meeting, again, each researcher was tasked to review the initial themes that were put together by critically comparing them to the transcribed data. This iterative process was necessary to comprehensively identify further themes and categories that might have been omitted. Inconsistencies, where identified, were reconciled. Also, quotations used to support views expressed by mothers were mutually agreed upon by all researchers. Interpretations of views were done to reflect salient and subtle meanings as expressed by participants. Also, as the analysis of themes continued, each identified theme was interpreted coherently to show the meanings participants attached to challenges of breastfeeding practices noting their spatial and societal characteristics. The lead researcher wrote up the findings and the other team members, who are well vest in qualitative research, reviewed the presentation. Comments were presented accordingly and then a neutral qualitative researcher was called upon to peer review the presentation. In all, sixteen categories emerged from the challenges of exclusive breastfeeding, and five categories from challenges of complementary feeding (Fig 1). To ensure mutual exclusiveness of the categories, some categories were merged. This reduced the number of themes to seven. Due to the merger of categories, newly constructed typologies that were not indicated by the participants were used to label the themes where necessary. For instance, ‘formal and informal work schedules’ was used to represent both ‘running office errands’, ‘working in office’ and ‘farm works’. The themes identified were used as main headings in the results sections. The themes presented at the results section are: household chores; formal and informal work schedules; family influence on exclusive breastfeeding; low breast milk production; swollen breasts or sore nipples; access to complementary food items; and preparing and giving complementary foods to children. Exclusive breastfeeding challenges consisting of household chores, work schedules, family influence, low breast milk production, and swollen breast or sore nipples. Complementary feeding challenges consisting of access to food items, and preparing and giving foods.