DUN-DERY, Laar (2016) PDF
DUN-DERY, Laar (2016) PDF
DUN-DERY, Laar (2016) PDF
DOI 10.1186/s13006-016-0083-8
Abstract
Background: In Ghana, periodic national surveys report the practice of exclusive breastfeeding (EBF) in the general
population to be over 50 %. However, little is known about EBF among professional working mothers, particularly
its duration after maternity leave. Female workers are entitled to 12 weeks (84 days) of maternity leave with full pay
in Ghana, and this can be extended by two additional weeks in case of a caesarean or abnormal delivery. This study
assessed the prevalence of EBF, as well as factors associated with the practice among professional working mothers
in one of the ten regional capitals of Ghana.
Methods: The study was descriptive cross-sectional in design and employed a multi-stage sampling technique to
sample 369 professional working mothers. The study was planned and implemented between January to July 2015.
Study-specific structured questionnaires were used in the data collection over a period of one month. Some factors
including demographic characteristics, types of facilities available at workplace to support breastfeeding, challenges
to exclusive breastfeeding at the workplace and mother’s knowledge base on EBF, were assessed. Exclusive
breastfeeding is defined as feeding infants with only breast milk, without supplemental liquids or solids except for
liquid medicine and vitamin or mineral supplements.
Results: There was a near universal awareness of exclusive breastfeeding among respondents (99 %). Even though
most mothers initiated breastfeeding within an hour of delivery (91 %), the EBF rate at six months was low (10.3 %).
The study identified three elements as determinants of EBF; Those who did not receive infant feeding
recommendation from health workers were less likely to practice exclusive breastfeeding (Adjusted Odds Ratio
[AOR] 0.45; 95 % Confidence Interval [CI] 0.27, 0.77), mothers who had shorter duration of maternity leave were less
likely to practice exclusive breastfeeding (AOR 0.09; 95 % CI 0.02, 0.45), and those who had a normal delivery were
almost 10 times as likely to practice exclusive breastfeeding (AOR 9.02; 95 % CI 2.85, 28.53).
Conclusion: Given the high breastfeeding initiation, but low EBF continuation rate among professional working
mothers, improved policies around maternity leave and breastfeeding friendly work environments are needed.
Keywords: Exclusive breastfeeding, Breastfeeding practice, Professional working mothers, Ghana
Abbreviations: AOR, Adjusted odds ratio; EBF, Exclusive breastfeeding; OR, Odds ratio; CI, Confidence interval;
ERC, Ethics Review Committee; GDHS, Ghana Demographic and Health Survey; GHS, Ghana Health Service;
IBM, International Business Machines; SPSS, Statistical Package for Service Solutions
* Correspondence: [email protected]
Department of Population, Family and Reproductive Health, School of Public
Health, College of Health Sciences, University of Ghana, Accra, Ghana
© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Dun-Dery and Laar International Breastfeeding Journal (2016) 11:23 Page 2 of 9
are employed in the formal sector. They were eligible to orally, to participate in the interview. Of 375 mothers
partake in the study if they had infants/children between deemed eligible to participate in the study, 369 con-
the ages of six (6) and 24 months. As indicated within sented. This gives a 98 % response rate.
this paper, the researcher’s choice of professional work-
ing mothers for the study was determined by the limited Data collection tools and procedures
data on exclusive breastfeeding among this group of Before the start of the data collection, research assistants
women [21]. were recruited and orientated. They were guided on the
purpose of the research, the focus of the research, the
Sampling technique and sample size administration of completing questionnaires without any
A systematic random sampling technique was used with form of coercion, and handling of unresponsive inter-
the register of females employed in the formal sector viewees during the process. The structured question-
(18,021) in the Municipality as the sampling frame. This naires were then distributed to the research assistants
sampling frame was gained from all institutions under for administration over a period of one month. The
the formal sector, comprising both public and private questionnaires consisted of five sections. The first part
sectors. Formal sector as defined by this study, encom- included questions on participants’ socio-demographic
passes all jobs with usual hours (8 am to 5 pm) attract- characteristics and breastfeeding; the second section
ing regular wages, and are recognized as income assessed mothers’ awareness of exclusive breastfeeding.
sources, on which income taxes is paid. The third and fourth sections included the exclusive
The sample size for the study was calculated based on breastfeeding practices of mothers and employment re-
the prevalence of EBF in the general population and lated factors influencing exclusive breastfeeding respect-
others. The sample size for this study was calculated as ively. The last section sampled the views of mothers
follows: regarding the health workers recommendations pertain-
n = Z2 × PQ/d2, where n represents the desired sample ing to exclusive breastfeeding. All variables presented
size, Z is the normal standard deviate, whose value at were coded with numeric values.
95.0 % confidence level is 1.96, P = current EBF rate; 0.6
[16, 22], Q = 1-P = 0.4, and d = the set margin of error; Data analysis
0.05. Thus minimum sample size, n = 368.7936 or n = The data entry and analysis were performed using the
369. The figure was upwardly adjusted by 5 % to cater International Business Machines Statistical Package and
for possible non-respondents or recording errors. The Service Solutions, IBM SPSS version 20 data processing
resultant sample size was 387. software. Administered questionnaires were collated at
The total population (18,021) was divided by the esti- the end of each day. All necessary differences and errors
mated sample size (387). A number between 1 and 46 were rectified before the processing. The data were then
was randomly generated using a random integer gener- processed afterwards into tables to show the frequency
ator at www.random.org [23] to serve as the random and percentages of the distribution of the data. Uni-
start point. After a random start, every 46th person was variate analysis was used to generate frequencies. The
picked, her corresponding institution identified and she main outcome, the exclusive breastfeeding rate, was
was interviewed. This was repeated until the sample size measured using three standard questions. First, mothers
of 387 was reached. It is worthy of note that the up- answered a question on what age of the child they
wardly adjusted sample size of 387 could not be met. started giving other foods and drinks to their infants,
The single most important determinant of our inability secondly, they were asked how many months they
to interview the 387 was time. As a time-bound graduate breastfed baby with only breast milk, and thirdly,
work, when the data collection period was exceeded by whether they (mothers) have ever given anything to the
some weeks without the desired numbered, a decision child to eat or drink apart from breast milk before the
was taken to conclude the data collection when the child was six months old.
minimum sample size of 369 was met. The 5 % adjust- Simple logistic regression analysis was done to further
ment to address potential non-response and recording test the strength and direction of the association be-
errors was deemed inconsequential. tween several independent variables and the outcome
variable. In a multiple logistic regression model, adjusted
Data collection odds ratios (AOR) were calculated to control for con-
The researchers interacted with the mothers using a founders. Variables with p < 0.25, at the simple logistic
structured interviewer administered questionnaire. The regression analysis were selected into the multiple re-
consent of the mothers was sought prior to the com- gression models as per [24, 25]. Several factors were
mencement of the questionnaire administration. Once considered potential factor including the type of delivery
mothers were identified to be eligible, they were invited mothers had, feeding method most difficult to practice,
Dun-Dery and Laar International Breastfeeding Journal (2016) 11:23 Page 4 of 9
infant feeding recommendation by health workers at Table 1 Background attributes of respondents (n = 369)
birth and duration of maternity leave. Adjusted odds ra- Attribute Frequency Percent
tios were used to control confounders in a multiple lo- Age of respondent (in years)
gistic regression model. Confounders assessed included 24–30 177 48.0
but not limited to educational background, type of deliv-
31–35 158 42.8
ery, duration of maternity leave, and advice from
mothers’ support persons. P < 0.05 denotes statistical 36 or older 34 9.2
significance. Age of child (in months)
6–8 72 19.5
Ethical approval and consent to participate 9–11 68 18.4
Ethical clearance was obtained from the Ethics Commit- 12–17 96 26.0
tee of the Ghana Health Service (Ethical Approval ID #
18–24 133 36.0
for the study is GHS-ERC:91/02/15). Permission was ob-
tained from the Wa Municipal Health Director of Health Marital Status
Services, and from the various heads and representatives Married 343 93
of the working establishments in Wa Central. Informed Not married 26 7
consent was obtained from all participants after the ob- Highest level of schooling completed
jectives and the methodology of the study was explained Voc/Technical 26 7
to them. Participation in the study was completely vol-
Tertiary 343 93
untary, no financial or material benefits were given. The
privacy and confidentiality of every participant was en- Mother tongue of respondents
sured throughout the study period. Southern Languages 56 15.2
Northern Languages 313 84.8
Results Religious denomination of respondents
Descriptive results Christian 235 63.7
There were 369 study participants, consisting of profes-
Muslim 134 36.3
sional working mothers who had children aged between
6 and 24 months. Most (48 %) of the respondents were Place of work of respondents
between the ages 24 and 30 years; about 10 % were Outside home 359 97.3
36 years or older. Overall, one in every three of the chil- Home 10 2.7
dren was aged between 18 months and 24 months; 18 % Type of employment
between 9 months and 11 months. More than 90 % of Full time 360 97.6
the participants had attained tertiary education. The
Part time 9 2.4
Northern ethnic groups (Dagaari, Waali, Sissali, Dagbani,
Frafra, Kassin and Mamprusi) formed the majority Gestation at birth
(85 %) of the respondents as compared to Southern eth- Premature (less than 9 months) 11 3
nic groups (Ezema, Ewe, and Akan). Other details are in- Full-term (9 months) 358 97
dicated in Table 1. Type of delivery
Normal delivery 352 95.4
Mothers’ awareness of exclusive breastfeeding and
Caesarean/section 17 4.6
feeding practices
The study reveals a near universal awareness on exclu-
sive breastfeeding; 99 % of them knew that a child
should be breastfed for the first six months. Almost all Exclusive breastfeeding and health workers’
mothers (94 %) were aware that infants are healthier on recommendations and mothers’ work environment
only breast milk for the first six months than they do on Almost all (98 %) of the responses indicated that
other milks. Although awareness about EBF was very health workers recommended breast milk to mothers
high, its practice was low. Only 10.3 % had exclusively as the best food for children for the first six months.
breastfed their infants for six months. Of note however, The study also explored the mothers’ work environ-
is the fact that most (91 %) of the respondents initiated ment in relation to exclusive breastfeeding. Most
breastfeeding within the first hour after delivery. A little (81 %) of the mothers had three months maternity
above half (52 %) of the respondents gave water to their leave. Beyond this, many mothers (69 %) did not re-
infants before they were six months old. Other details ceive any support from their employers to help them
are supplied in Table 2. continue breastfeeding (Table 2).
Dun-Dery and Laar International Breastfeeding Journal (2016) 11:23 Page 5 of 9
Table 2 Mothers’ awareness of exclusive breastfeeding Table 2 Mothers’ awareness of exclusive breastfeeding
Attributes Frequency Percent (Continued)
Awareness that babies need to be breastfed for 366 99.2 Mothers allowed to have their children at the work 176 47.7
the first six months place
Believes that infants do better on only breast milk 346 93.8 Mothers who had breastfeeding rooms at their 16 4.3
for the first six months. work place
Sources of education on exclusive breastfeeding Mothers given special break for breastfeeding 81 22.0
Nurses/health worker 275 74.5 Mothers on shift duties 38 10.3
Media/Other sources 94 25.5
Initiation of breastfeeding
Factors associated with exclusive breastfeeding
Within the first one hour 336 91.1 (unadjusted associations)
After one hour 31 8.4 Odds ratios (OR) were calculated to determine the
Ever breastfed baby 364 98.6 strength of association between independent variables
Introduction of child to other foods/milks and EBF (Table 2). The results indicate that, age of the
Less than six months 311 89.7
respondents, marital status, level of education, and re-
spondents’ language were not associated with mothers’
From six months 38 10.3
practice of exclusive breastfeeding. Mothers who were
Foods given to infants before six months pregnant for less than nine months (OR 0.11; 95 % CI
Water 191 51.8 0.02, 0.80) as compared to mothers who had a full time
Porridge 106 28.7 pregnancy were less likely to practice exclusive breast-
Lactogen 34 9.2 feeding. Mothers who went through a normal delivery
Milk products usually used for feeding
compared to caesarian delivery, were almost ten times as
likely to practice exclusive breastfeeding (OR 9.54; 95 %
Tin milk (lactogen infant formula) 95 25.7
CI 3.43, 26.54). The odds of practicing EBF were high
Breast milk 213 57.7 among mothers who were aware that infants need to be
Cerelac infant formula 17 4.6 exclusively breastfed for the first six months (OR 14.10;
SMA 8 2.2 CI 2.28, 87.27). The mothers who were advised by their
None 22 6.0 support persons to include formula feeding were less
Others (Ideal milk, Carnation, cowbell) 14 3.8
likely to engage in the practice of exclusive breastfeeding
(OR 0.19; CI 0.05, 0.79). Mothers who considered for-
Feeding method most convenient for mothers
mula feeding as the most difficult to practice were more
Breastfeeding 353 95.7 likely to adopt exclusive breastfeeding (OR 2.27; CI 1.03,
Formula feeding 16 4.3 4.99).
Feeding method most difficult for mothers to practice Recommendations given at birth by health workers
Breastfeeding 55 14.9 were also assessed. The odds of practicing exclusive
Formula feeding 314 85.1
breastfeeding among mothers who were advised to use
formula feeding was low (OR 0.18; CI 0.07, 0.45). Three
Health workers recommendation on infant feeding from birth
months or longer durations of maternity leave was also
Breast milk 346 93.8 significantly associated with a mother’s practice of exclu-
Formula foods 23 6.2 sive breastfeeding. Respondents who were on maternity
No recommendation 5 1.4 leave for less than three months were less likely to have
Nurses’ recommendations on infant feeding beyond six months. exclusively breastfed (OR 0.14; CI 0.03, 0.66). Of note,
Breast milk 15 4.1
however, is the fact that all other variables did not have
any association with mothers’ practice of EBF.
Complementary feeding (semi-solid, porridge, 340 92.1
family foods)
Factors associated with exclusive breastfeeding
Formula feeding 3 .8
(multivariate analyses)
No recommendation 11 3.0
In a multiple logistic regression model, adjusted odds ra-
Mothers had maternity leave with pay 356 96.5 tios (AOR) were calculated to control for confounders.
Support from worksite to continue breastfeeding after maternity leave Variables with p < 0.25, at the simple logistic regression
Not at all 263 71.3 analysis were selected into the multiple regression
Some support 106 28.7 models. After controlling for a number of covariates,
normal delivery (AOR 9.02; CI 2.85, 28.53), the type of
Dun-Dery and Laar International Breastfeeding Journal (2016) 11:23 Page 6 of 9
infant feeding recommendation by health workers at breastfeeding is ideal [36]. This results in reduced prac-
birth (AOR 0.01, CI 0.27, 0.77), three months or longer tice of EBF among working mothers within the first six
duration of maternity leave (AOR 0.09; CI 0.02, 0.45), months. Possible hindrances to the sustained practice of
and feeding method most convenient to mothers (AOR exclusive breastfeeding among professional working
3.13; CI 0.96, 10.23) were all independently associated mothers as indicated by this study include conflict of
with exclusive breastfeeding (Table 3). commitment, limited workplace support, lack of breast-
feeding facilities and short or lack of official breaks.
Discussion Thus, the demand to perform official duties is difficult
Data from this study show that although awareness on with the obligation to breastfeed at the same time. This
exclusive breastfeeding among professional working finding is similar to other studies where infants of work-
mothers is almost universal (99 %), the practice of EBF ing mothers failed to attain their full breastfeeding and
at six months is low (10.3 %). Elsewhere, Al-binali [26] health potential because they were denied the option to
found 89 % of mothers had a good knowledge about ex- breastfeed while at work [37]. Considering these chal-
clusive breastfeeding but only a small percentage (8.3 %) lenges, several studies have cited paid extended mater-
engaged in the practice for the first six months. The nity leave, appropriate institutional policies and lactation
work of Afrose et al. in Dhaka City among working breaks as proven to be the most effective interventions
mothers reported findings contrary to those of this study in promoting breastfeeding among working mothers [36,
[27]. Afrose et al. showed that most working mothers 38, 39]. In other studies done in Ghana, maternity leave
who received their main source of information from was cited as having a positive breastfeeding duration
nurses and other health workers (75 %) were not EBF. among working mothers [8]. It is worthy of note that, in
Data from work done by Anyanwu and Maduforo in Ghana, this period is limited to only three months by
2004 [28] in a neighboring country, and others [29] con- law, which is far too short for a working mother to prac-
cur that the main source of education about breastfeed- tice exclusive breastfeeding to six months, making the
ing provided to working mothers is the health worker, practice a challenge. In Western Pacific settings, mater-
although determinants of EBF among working mothers nity leave extends to sixteen weeks [2] but other studies
include the women’s educational status and working in Taiwan cited that most companies provide only eight
conditions [30, 31]. Februhartanty and colleagues pre- weeks of maternity leave [40].
sented data similar to those of the current study [30]. With limited flexibility and workplace support indi-
They found that all working mothers knew about exclu- cated by this study, formula supplementation seems
sive breastfeeding and the need to breastfeed infants for unavoidable for many working mothers, even though
the first six months. Others have suggested that the en- their preference may still be to exclusively breastfeed.
hancement of education and knowledge among working Similarly, included among experiences in Ireland,
mothers can improve workplace lactation [32] working mothers experienced negative attention or a
The importance of early initiation of breastfeedingis lack of support due to their continued breastfeeding
well recognised [2, 30, 33]. In the current study, nearly while being back to work [41]. The practice most
all working mothers (91 %) initiated breastfeeding within convenient for mothers in this study was breastfeed-
the first one hour of delivery. This concurs with the re- ing. Contrary to this recommended practice, profes-
sults of Heck's study where a high rate 95.2 % of work- sional working mothers elsewhere failed to adhere to
ing mothers had initiated breastfeeding within one hour breastfeeding recommendations, with the impression
after birth [34], but Liben & Yesuf, in Ethiopia observed that the practice is not welcomed within workplaces
only 39.6 % breastfeeding initiation rate among working [42]. Those who said breastfeeding practice was the
mothers [35]. In Ghana, 56 % started breastfeeding most difficult to combine with work were twice as
within the first one hour of birth [30]. This figure is ra- likely to practice formula feeding (OR 2.27; 95 % CI
ther low as compared to the finding of this study (91 %) 1.03, 4.99). In the same perspective, other evidence
and that of the general population in the Upper West suggests that breastfeeding is more likely compro-
Region which recorded 60 % [16]. This disparity in the mised among professional working [6].
prevalence of early breastfeeding initiation could be at- An earlier study by Adeyinka et al. showed that mater-
tributed to the potentially high level of exposure of EBF nity ward practices and the health professionals' advice
among the current group of relatively highly educated were associated with exclusive breastfeeding [7]. How-
women, in comparison to their counterparts in the gen- ever, advice given by nurses on how to practice EBF did
eral population. not influence exclusive breastfeeding (OR 1.40; 95 % CI
Even though breastfeeding initiation is high, more than 0.63, 3.12) in the current study. Support and counseling
50 % of women of child bearing age are employed, and from health care providers can tremendously improve
most return to work at a time when exclusive breastfeeding practices [43].
Dun-Dery and Laar International Breastfeeding Journal (2016) 11:23 Page 7 of 9
95 % CI: Confidence Interval, * p < 0.05, ** p < 0.001, Ref: Reference, shaded sections are not included in multivariable regression analysis
Dun-Dery and Laar International Breastfeeding Journal (2016) 11:23 Page 8 of 9
The most important factor that determines EBF prac- Authors’ contributions
tice among professional working mothers is maternity DEJ conceived the study and discussed with AL for inputs. Both authors
equally contributed to the design of the study. AL supervised study tools
leave (OR 0.14; 95 % CI 0.03, 0.66). Using a multivariable development, as well as data analysis. DEJ drafted the first version of the
regression analysis, the duration of maternity leave was manuscript. AL critically reviewed it for intellectual content. Both authors
an independent predictor of exclusive breastfeeding read and approve the final manuscript.
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