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A JCESSION1 NO. 0 8 B a  1 OBO B a S f  a
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PERCEPTION OF THE "SIGNIFICANT OTHERS"
ON THE PRACTICE OF EXCLUSIVE BREASTFEEDING OF NURSING 
MOTHERS WITH INFANTS AGED 6-12 MONTHS IN THE 
DANGME WEST DISTRICT
BY
ABIGAIL AMA A'SANTEWA GYAMFI
A DISSERTATION SUBMITTED TO THE UNIVERSITY 
OF GHANA, SCHOOL OF PUBLIC HEALTH, IN PARTIAL 
FULFILLMENT FOR THE AWARD OF MASTERS 
IN PUBLIC HEALTH DEGREE
SEPTEMBER 1998
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Page
Dedication.............................................................................. .....................................lv
Declaration.................................................................................................................. v
Acknowledgement.....................................................................................................V1
Abbreviation..............................................................................................................vii
List of Tables.......................................................................................................... viii
Map of the District................................................................................................ ix
Abstract...................................................................................................................... x
Key Findings............................................................................................................xi
Key Recommendations.......................................................................................... xii
Chapter One: Introducing the Study area,
the people and the problem....................................................................... 1
1.1 Background information...............■............................................................. 1
1.2 Introduction................................................................................................. 3
1.3 Rationale....................................................................................................... 8
1.4 Study Area.................................................................................................... 9
Chapter Two: Literature Review
Objectives of the Study........................................................................... 11
2.1 Literature Review......................................................................................11
2.2 Main Objective.......................................................................................... 19
2.3 Specific obj ectives.................................................................................... 19
Chapter Three: Methods and Procedure........................................................... 21
3.1 Study Type and its Justification.............................................................21
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3.2 Study Population............................................................................................22
3.3 Selection Procedure......................................................................................22
3.4 Variables......................................................................................................... 23
3.5 Preparation towards Data Collection........................................................ 24
3.6 Training of Research Assistants................................................................. 24
3.7 Data Collection............................................................................................. 25
3.7.1 Focus Group Discussion.............................................................................25
3.7.2 Survey Questionnaire................................................................................. 26
3.7.3 Checklist for health Workers.................................................................... 26
3.8 Data Analysis................................................................................................ 26
3.8.1 FGD Data Analysis.................................................................................... 26
3.8.2 Survey Questionnaire Analysis................................................................. 27
3.9 Limitation of the Study.............................................................................. 27
Chapeter Four: Findings and Discussion........................................................... 28
4.1 Findings from FGD’s................................................................................. 28
4.2 Findings from the Health Workers..........................................................37
4.3 Findings from the Questionnaire Study.................................................. 39
Chapter Five: Conclusions and Recommendations...........................................47
5.1 Summary and Conclusions........................................................................ 47
5.2 Recommendations....................................................................................... 49
References.................................................................................................... 51
6.0 Appendices...................................................................................................55
6.1 Appendix I: Indepth interview schedule
for nursing mothers...................................................................................55
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6.2 Appendix II: Focus Group Discussion Guides.................................................. 61
6.3 Appendix III: Interview Guide for Health
Personnel................................................................................................................... 66
6.4 Appendix IV: Information on FGD Group
members................................................................................................................... 69
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DEDICATION
Dedicated to my loving husband Yaw and my lovely children 
Nelly and Doris. This is to say THANK YOU for the patience, 
the understanding and the support, and for enduring my long 
absences from home.
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DECLARATION
This dissertation has been submitted in partial fulfillment of the requirements 
for the award of the degree of Master of Public Health. This is original work 
based on data I collected in die field. The supervisors can neither be held 
responsible for the views expressed nor the factual accuracy of the contents.
Academic Supervisors: 
Dr. John Gyapong
0 \j v
Dr. .&,A. Koram
-
Field Supervisor 
Sister Narh Dometey 
Principal Nursing Officer 
Public Health ^
........
Resident:
Mrs. Abigail A.A. Gyamfi 
......
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A CKNOWLEDGEMENTS
My sincere gratitude goes to Dr. Irene Agyepong, my field supervisor, Dr. 
Koram and Dr. Gyapong my Academic supervisors for the immense support 
and advice accorded me during my field residency programme. I also wish 
to thank the following persons who have contributed in diverse ways to 
assisting me throughout the course:
1. Mr. & Mrs. J. K. Agyemang and family
2. Director and Staff, School of Public Health, Legon
3. District Health Management Team Dangme West District
4. Mr. & Mrs. Kofi Wellington
5. Prof. & Mrs. S. I. K. Odoom and family
6. Registrar, Staff and Members of Pharmacy Council
7. Pastors & Congregation, Living Word Assemblies International
8. Miss Esther Binah
9. Staff of Danpong Pharmacy, Accra
10. Mr. & Mrs. E. Asiamah
11. Mr. & Mrs. Eric Nartey and family
12. Miss Lydia Kwadjo & Miss Delali Osei
Last but not the least, my gratitude goes to God Almighty, whose 
abundant grace saw me through the year.
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ABBREVIATIONS
DHMT District Health Management Team
TBA Traditional Birth Attendant
IEC Information Education and Communication
MCH/FP Maternal and Child Health/Family Planning
FGD Focus Group Discussion
MOH Ministry of Health
GDHS Ghana Demographic and Health Survey
BFHI Baby Friendly Hospital Initiative
ARI Acute Respiratory Infection
ORT Oral Rehydration Therapy
UNICEF United Nations Children’s Fund
DDHS District Director of Health Services
SDHMT Sub-district Health Management Team
NM Nursing Mother
GM Grandmother of the infant
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LIST OF TABLES
TABLE TITLE PAGE
1. Percentage distribution of Respondents........................................ 39
2. Marital Status of Respondents.........................................................40
3. Educational level of Respondents...............’...................................41
4. Occupation of Respondents............................................................. 42
5. Sources of Advice on Breast-feeding........................................... 42
6. Distribution of women who have received
advice on breast-feeding................................................................ 43
7. Proportion of women who have ever practised
exclusive breast-feeding..................................................................44
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ABSTRACT
The general objective of the study was to describe the perceptions of the nursing 
mothers and of "significant others" that is the peers, husbands, grandmother of 
the infants, and health workers in relation to the practice of exclusive breast­
feeding in the Dangme West District.
Specific Objectives:
To describe the perceptions of nursing mothers with infants aged 6-12 months, 
and that of their husbands, peers, mothers on the practice of exclusive 
breastfeeding and to describe the kind of support and advice available to nursing 
mothers, so as to incorporate their perceptions in Health Education Programmes.
To achieve the objective of the study, the Focus Group Discussions (FGD’s) were 
chosen as the major technique to collect qualitative data.
The FGD’s were conducted in five (5) communities in the Dodowa sub-district 
namely, Doryemu, Ayikuma, New Town, Lower and Zongo.
A survey questionnaire was administered to 100 nursing mothers with infants aged 
6-12 months. The nursing mothers were recruited from MCH clinic records and 
immunization returns and visiting their homes to request an interview with the 
mothers. These served as index cases to identify the husbands, grandmothers and 
peers. A checklist was used with the Health workers. The pretesting of the FGD 
guides and the questionnaires for both the nursing mothers were done in the Salem 
Community of the Dodowa Sub-district.
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Findings
The proportion of women who do not practice exclusive breastfeeding in 
the district is high. Out of the 100 nursing mothers interviewed, 47 did 
not practice exclusive breastfeeding.
The groups know about and have a positive attitude towards exclusive 
breasfeeding in general.
Nursing mothers are receiving some advice on exclusive breastfeeding. 
Out of the 100 modiers interviewed, 82 had received some advice on 
exclusive breastfeeding either from a health worker, a mother, mother-in- 
law, a husband or a friend (peer).
There was a general agreement that exclusive breastfeeding is good for the 
baby.
All groups agreed that they need more public education on the practice of 
exclusive breastfeeding.
There are a few cultural misconceptions on the practice of exclusive 
breastfeeding.
Some nursing mothers who had received advice on exclusive breastfeeding 
did not practice it because they were not allowed to do so by either a 
mother or a mother-in-law.
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•  Out of the 100 nursing mothers interviewed, 51 were "living together", as 
common law wives.
Key Recommendations
It is strongly recommended that the District Health Management Team (DHMT)
should:
•  Organise training sessions on the terms and concepts of the practice of 
exclusive breastfeeding to health workers in the district.
•  Strengthen and expand their Information, Education and Communication 
(IEC) programme to include an intensified health education campaign on 
the benefits of exclusive breastfeeding through methods like folk media 
and drama, to reduce the negative fears and rumours.
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1.0 CHAPTER ONE 
INTRODUCING THE STUDY AREA, THE PEOPLE 
AND THE PROBLEM
1.1 Background Information
Studies have been carried out in Ghana on infant feeding practices by social 
scientists, health professionals, scientists and students, covering areas such as:
•  prevalence, duration and differential in breastfeeding
•  weaning practices in Ghana1
•  relationship between breastfeeding and child spacing/diarrhoea/nutritional 
status of the infant1.
Ninety-seven percent (97.1%) of all children born in the past three years were 
breastfed for some time19. Eleven percent (11.7%) of children under age 2 years 
within this same period were exclusively breastfed. The proportion of children 
exclusively breastfed is low in relation to awareness. The Baby Friendly Hospital 
Initiative (BFHI) has been developed to address the need for improved 
breastfeeding practices globally. The main causes of child deaths in the country 
are known to be parasitic and infectious diseases notably malaria, diarrhoea and 
measles which normally combine with malnutrition to become fatal.
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There is the need to promote exclusive breastfeeding with the aim of reducing 
mortality. The essence of the study is to describe the perceptions of nursing 
mothers and their "significant others" to the practice of exclusive breastfeeding 
in a bid to promote exclusive breastfeeding in the Dangme West District.
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Introduction
Exclusive breast-feeding is defined as feeding the baby with breast milk only, with 
nursing beginning within an hour of birth, feeding on demand; giving the baby 
colostrum, frequent feeding in 24 hours and of a duration of 4 to 6 months.14
Exclusive breast-feeding in the first 4-6 months is vital to child survival and the 
most effective available means of child spacing.13 With the knowledge that 
declining breast-feeding trends can be reversed, it has become imperative to 
promote and support it.13
Although nearly all women breast-feed their infants, initial breast- feeding 
practices are far from optimal.19 Only 16% of infants are put to the breast 
immediately after birth; over half wait 24 hours or more after birth. About 30% 
are put to the breast sometime within the first 24 hours.19
Both cultural practices and information provided by health workers influence the 
timing of the first breast-feed.19
The proportion of Ghanaian children who are not breast-fed for 24 hours after 
delivery and do not receive colostrum, is unacceptably high2. There is a negative 
attitude toward feeding colostrum to infants in Ghana especially in the north 
where colostrum is believed to be harmful to the baby.19 Some Ghanaians believe 
that anyone who advises a mother to give colostrum wishes the baby ill.19
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In some areas in the north, colostrum is given to a newborn only after a test is 
performed to show that it is not bitter and that it is healthy. In the forest and 
coastal regions, many mothers delay breast- feeding until their full milk flow is 
established, not because they are against feeding colostrum but because they do 
not want the child to suck air. Misinformed health workers sometimes reinforce 
these practices.
The proportion of children who are exclusively breast-fed is estimated to be 19% 
and this is very low as compared to the proportion of children ever breast-fed 
which is 99.8%.19' 18' 6
Exclusively breast-fed infants are protected against death from diarrhoea, acute 
respiratory infection and other infectious diseases.
Unfortunately, in many countries relatively few women breast-feed their babies 
exclusively for the first 4-6 months14. Many problems contribute to this erosion 
of breast-feeding practices. Breast-milk is best for babies and, it reduces the 
incidence of allergies eg. asthma, it is economical, there is no wastage.15
Breast milk contains antibodies and offers greater immunity against infectious 
diseases. It makes stool in-offensive. The temperature of the breast milk is 
always ideal. Breast milk is always fresh and never goes off even when exposed 
to micro-organisms15.
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Breast-feeding enhances emotional bonding, it is ecologically sound, digested 
easily, within 2 or 3 hours, it is immediately available, is nutritionally optimal 
and gastroenteritis is greatly reduced.
Even with the most willing mother and contended baby, problems may arise 
during breast-feeding. It is useful to know what might happen and how to prevent 
or cope with problems. Cracked or sore nipples usually is the result of having 
the baby in a poor position for breast-feeding. It may happen when the baby does 
not have the aveola as well as the nipple itself in the mouth, or when the baby 
sucks for a very long time in the same position, when the breasts are too full or 
when there is friction against tight and ill fitting brassieres or if the mother uses 
irritating soaps or other substances on the nipples.17
Breast engorgement occurs when the breasts get too full because the baby does 
not feed often enough or does not thoroughly empty all parts of the breasts. 
Engorged breasts can be quite painful and cause fever. To prevent breast 
engorgement, the woman should breast-feed the baby often and be sure that at 
each feeding, both breasts are emptied. Changing positions during breast-feeding 
will also help empty the breast.17
Sometimes breasts become infected and cause pain and fever. Infection usually 
follows breast engorgement or cracked nipples. The mother may need medical 
treatment but she should continue to breast-feed on both breasts.17 The baby 
cannot catch the infection and breast feeding will help relieve the problem.
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Breast abscess is an infection that forms a collection of white pus. Breast 
abscesses are rare but serious and will need medical attention where the abscess 
can be cut open and drained. The woman will have to stop breast-feeding her 
baby for a while. Flat or inverted nipples are “pulled out” by the sucking of the 
baby 17,
There are not enough support systems in the country for new or young mothers. 
Some organizations have shown an interest in the promotion and support of 
Breast-feeding namely, Ministry of Social Welfare and Mobilization, National 
Council on Women and Development (NCWD), Ghana National Commission on 
Children, Ghana Infant Nutrition Action Network (GINAN), Nutrition Division 
and Maternal and Child Health/Family Planning Division of the Ministry of 
Health.
The family of new or young women play a very crucial role in the initiation of 
breast-feeding. The family and community support is needed and die nutrition of 
the mother needs to be taken care of. The roles of fathers and other family 
members and health workers are very important.
Other family members, including the baby’s grandparents, "aunties" and 
especially the father can help the woman by making sure the woman stays 
healthy by having a proper diet and rest; helping with work in die home and in 
the fields, especially work that is physically demanding or tiring; providing
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emotional support and understanding and working together to talk about and solve 
any problems associated with breast-feeding and helping to care for and raise the 
children.17
To encourage fathers and other family members as well as health workers to 
perform these roles effectively, their perceptions on the practice of exclusive 
breast-feeding need to be explored and the findings incorporated in health 
education campaigns.
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1.3 RATIONALE
Feeding practices of infants aged between 0-3 months indicate that breast-feeding 
is universal and given on demand, but exclusive breast feeding is not widely 
practiced. Mothers give water before and after breast-feeding due to the hot 
tropical climate and the belief that babies also feel thirsty.1
Most mothers give water, glucose water or infant formula before the first breast 
milk. Some health professionals advise that before the initiation of breast-feeding 
the baby is hungry and needs to drink something.2
According to Boeurna et al. (1991), 1.9% of children covered in a Demographic 
and Health Survey (GDHS) (1988), were exclusively breast-fed. A national study 
carried out by the nutrition division of the Ministry of Health (MOH) in 1989 
supports the GDHS findings where almost all babies involved in the survey were 
given water several times a day.1
Colostrum is often discarded by mothers believing that it is not good for the baby. 
Only 50% of mothers fed their babies with colostrum in the 1989 survey 
conducted by the Nutrition Division of the MOH.2
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The Greater Accra Regional launching of Exclusive breast-feeding was carried out 
in the Dangme West District on the 7th August 1997. Review of records in the 
district show that diarrhoea is quite common in children up to age one year. The 
essence of the study is to find out what is going on in the Dodowa sub-district 
since the regional launching, that is Has the launching of exclusive breast­
feeding in the Dodowa sub-district done anything to promote exclusive breast­
feeding? Sources of information on breast-feeding are families, Health workers, 
School and the media.2
The focus of this study is on the perceptions of husbands, peers,mothers and/or 
mothers-in-law of nursing mothers on the practice of exclusive breast-feeding in the 
Dodowa sub-district, the kind of support and advise they and health workers offer to 
these mothers.
1.4 Study Area
The Dangme West district is one of the two purely rural districts in the Greater 
Accra region which have not been caught up by the rapid urbanization of the 
peripheral areas surrounding the city of Accra.
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It covers an area of about 1,700 sq. Km and has an estimated mid year population 
of 103.210 (1997) The district is divided into 4 sub-districts namely:
•  Dodowa (Shai)
• Prampram
• Great Ningo (formerly Old Ningo)
• Osudoku
The respective population according to the 1984 Census were 25,326; 25,326; 
18,379 and 34,179. The study will be conducted at Dodowa. The Dodowa Sub­
district is made up of Doryemu, Ayikum, Salem, New Town, Lower and Zongo.
There are 4 health posts which are situated at Dodowa, Prampram, Osudoku and 
Great Ningo. There are 4 community clinics at Dawa, Lekpogunor, Ayetepa and 
Awhiam. There are 5 Community Clinic/Maternal and Child Health Services at 
Kordiabe, Duffor, Agomeda, Osuwem and Nyigbenya.
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CHAPTER TWO
2.0 LITERATURE REVIEW AND OBJECTIVES OF THE STUDY
2.1 Literature Review
"Imagine that the world had invented a new dream product" to feed and immunize 
everyone born on earth. Imagine also that it was available everywhere, required 
no storage or delivery - and helped mothers to plan their families and reduce the 
risk of cancer. Then imagine that the world refused to use it. The ‘dream 
product’ is human breast-milk available to us all at birth and yet we are not using 
it.3
Every year over one million infants die and millions of others are 
impaired, because they are not adequately breastfed.4 In all parts of the world 
babies are being born into unfriendly environments, victims of widespread 
poverty, rapid urbanization and relentless marketing of breast milk substitutes.4
This is happening despite over whelming scientific evidence that 
human breast milk is vastly superior to anything available from our most 
sophisticated technologies. Science is rediscovering what our great- grandparents 
already knew; that breast-feeding is Nature’s perfect ‘room service’ for 
newborns, no matter where they are born. With rapid urbanization, in many 
countries, hospitals are also under increasing pressure to serve larger numbers of
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poorer and less educated people who are the most vulnerable to the forces which 
inhibit breast-feeding.
The Baby Friendly Hospital Initiative (BFHI) has been developed to address the 
need for improved breast-feeding practices globally. It is in response to the 
“Innocenti Declaration” , the Convention on the Rights of the Child and the World 
Summit for Children which all called for the promotion protection and support of 
breast-feeding worldwide7
The 1997 State of the World’s Children report states that in Ghana between 1990 
and 1996, 19% of infants aged between 0-3 months were exclusively breast-fed; 
63 % of infants aged between 6 - 9 months were breast-fed with complementary 
food and 48 % of babies aged 20 - 23 months were still breast-feeding. In Uganda 
during the same period, 70% of infants aged 0 3 months were exclusively 
breast-fed and in Rwanda, 90% of infants aged 0 3 months were exclusively 
breast-fed.5
Most women in developing countries breast-feed their infants. However in many 
countries relatively few women breast-feed exclusively for the first four to six 
months and many do not continue breast-feeding throughout the first year of life. 
Child survival interventions to prevent deaths from diarrhoea and acute respiratory 
infections primarily have centred on the use of oral rehydration therapy (ORT) to 
prevent deaths due to dehydration caused by diarrhoea, treatment of acute 
respiratory infections (ARI) and vaccines against major childhood illnesses which
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often lead to diarrhoea and ARI. While these interventions are important, breast­
feeding has an equal or greater impact on infant health.
Breast-feeding currently saves over 6 million lives of infants (agesO -12 months) 
UNICEF estimates that ORT has the potential to save an additional one million 
childrens lives. Breast-feeding has the potential to save an additional 2 million 
infants lives13
The benefits of breast-feeding are so great and the act itself is so 
natural and well accepted that one might expect all mothers to breast- feed their 
babies15 Ideally breast-feeding should begin within an hour after birth and all 
babies should have only breast-milk for the first 4 -6 months of their lives. But 
mothers who need to work and care for many other children often feel it is easier 
and more “modern” to use breast-milk substitutes4
Ideally breast-feeding should be “on demand”. But this can mean breast-feeding 
12 to 14 times a day or more in the early months making it hard for a mother to 
leave her infant long enough to fulfill other household responsibilities. Breast­
feeding should continue for a year or longer but many women perceive their milk 
as “insufficient” much sooner than that. Optimal breast-feeding is relatively rare.
Growing numbers of women in developing countries do not breast-feed at all or 
breast-feed in ways that lose some of its potential benefits.
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Younger mothers and women having their first children also tend to breast-feed 
less due in part to a lack of confidence in their ability to breast-feed successfully 
and lack of support and role models at home. If these trends continue, they could 
lead to increased infant mortality and also have a pronounced effect on would be 
fertility patterns 3
The percentage of women who choose not to breast-feed while small, is growing, 
especially in urban areas. The problem is more pronounced in the Latin 
America/Caribbean region and in some of the more economically advanced 
countries of Asia, but the trend is moving away from breast-feeding almost 
everywhere.
In the Philippines, for example, data from 1983 indicate that 10% of rural infants 
and 21% of urban infants were never breast-fed15. Many women stop breast­
feeding after a month or so. Thus, while the average duration of breast-feeding 
in South East Asia is fourteen months, many mothers stop before then, some as 
early as three months. In general, urban infants are breast-fed for shorter periods 
than rural infants, but the drop off in the first three months is pronounced for both 
groups in all societies15.
In El Salvador, for example, rural women under the age of 30 are 
breast-feeding for only three months on average15.
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Among those who do breast-feed the norm is for partial, not exclusive breast­
feeding. Siblings give babies bottles while mothers are busy with other 
responsibilities. Relatives give babies “tastes” of food out of affection10
Mothers often add infant formula to their baby’s diet in the mistaken belief that 
it is a “tonic”10'
Failure to use colostrum, the first milk is a particularly serious 
problem. In country after country colostrum is discarded and 
replaced by sugared water or other prelacteal feeds 15
In Cameroon, for example, virtually all mothers think colostrum is “heavy and 
yellow” and “bad” for the child. In Pakistan large percentages of both mothers 
and traditional birth attendants (TBA’s) say colostrum is “dirty” or “bad”15
In Jordan even though most mothers breast-feed, 75 % of infants are given breast- 
milk substitutes in their first day or two of life. Even after being exposed to 
educational messages at Indonesian integrated health posts, only 19% of Balinese 
village women agreed that colostrum should be given to a newborn. These beliefs 
are reinforced when doctors and nurses, trained in outmoded Western theories, 
offer prelacteal feeds, which inhibit initiation of breast-feeding15
Breast-milk is uniquely suited to the human infant’s immature 
digestive system.
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No breast-milk substitute is the nutritional or immunological equivalent of human 
milk which alone provides all the nutrients a child needs through 4 - 6  months of 
age. It has over 100 known components and a singular ability to adapt overtime 
to match the infant’s changing nutritional and immunological needs.
It is an extremely valuable food even for premature low birth weight
infants because of its easy digestibility and the growth enhancing proteins it
contains.15
A 10-year experiment at Kenyatta Hospital in Nairobi, Kenya on the use of human 
milk for low birth-weight babies, has shown that, with help from a well-trained 
staff and manual expression of breast-milk to maintain lactation, it is possible to 
feed these infants exclusively on milk from their own mothers, thus retaining 
breast-milks many benefits. Even after weaning foods are introduced, breast-milk 
continues to be a critical source of calories, high quality protein and 
micronutrients well into a child’s second year of life13
Breast-milk is the infant’s first immunization. It is rich in the 
immunoglobulins and antibodies produced and transmitted by the 
mother. Breast-milk contains substances that protect infants against measles and 
a variety of other ailments. One study in Brazil found that children who were not 
breast-fed had more than three times the risk of dying from respiratory infections 
before their first birthday than children who were fed only breast-milk 12
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A study in Peru found that infants who continued to breast-feed had fewer skin 
infections that those who did not. One study in Indonesia and others in the 
United States have documented lower rates of middle ear infection.
Recent research also shows that colostrum enhances an infant’s immune response 
to the BCG tuberculosis vaccine given at birth15
The WHO recommends continuation of breast-feeding even for 
infants of HIV-positive mothers, despite some indications that the 
AIDS-producing HIV virus can, in rare instances, be transmitted 
through breast-milk10
The contraceptive effect of breast-feeding (lactational amenorrhea) which comes 
from frequent suckling, is a health measure of far-reaching importance. Research 
suggests that if all births were at least two years apart, infant mortality rates 
would drop by 10%. Surviving children would also benefit. An older sibling is 
one-and-a-half times more likely to die if another child is born within two years 
of his or her birth11.
Because suckling hastens contraction of the uterus, women who 
breast-feed their babies at birth are less likely to haemorrhage.
Breast-feeding may also lower the lifetime risk of breast and ovarian cancer9
By inhibiting the return of menstruation, breast-feeding also allows women to 
build up their stores of iron and alleviate anaemia9
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Women’s roles and experiences in the protection and promotion of breast-feeding 
are unique. It is extremely important that women gain greater control of actions 
affecting this aspect of their lives8 Information and attitudes about breast-feeding 
are transmitted through many channels, there has been a lot of criticism of health 
workers (including nurses and midwives) who have condoned or even promoted 
bottle feeding and have even given incorrect information about breast-feeding. 
Much of the well-intentioned breast-feeding ‘education’ may be technical or 
scientific; other messages may be moralistic or guilt-including, and have negative 
results, the importance of women having access to complete, accurate and 
unbiased information about breast-feeding cannot be over­
emphasized10
Sources of information on breast-feeding are mainly:2 
Families (54.8%)
Health Workers (36.9%)
School and media (8.3%)
Families (54.8%) constitute the "significant others" and this group do influence 
the choices made by a mother on whether to practice exclusive breastfeeding or 
not.
Investigating their perceptions is necessary to promote the declining trends of 
breastfeeding by incorporting their preceptions in Health Education Programmes.
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Through an “SIP” commitment, a lot can be achieved to stop the 
decline in breast-feeding and make it again the norm13.
S Support- of mothers and health workers
I Information - accurate and specific Investigation of Current
Situation Integration
P Promotion Protection Programs.
Support for exclusive breastfeeding and appropriate young child feeding, must 
come from the community at large. Unless the community is aware of the 
importance of this problem and sensitized to the ways in which it can help 
families and complement the work of educators, health workers and workers in 
other sectors, progress will be slow25.
2.2 Main Objective
To describe the perceptions of the nursing mothers and of the “significant others” 
that is the peers, husbands, grandmothers of the infants, and health workers in 
relation to the practice of exclusive breast-feeding in the Dangme West district.
2.3 Specific Objectives
1. To describe the perceptions of nursing mothers with infants aged 6-12
months to the practice of exclusive breast-feeding.
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2. To describe the perceptions of fathers, grandmothers and peers of the 
mothers of infants aged 6-12 months to the practice of exclusive breast­
feeding.
3. To describe the kind of support and advice which are available to breast­
feeding women from their husbands,health workers, peers and grand­
mothers of their infants.
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CHAPTER THREE 
3.0 METHODS AND PROCEDURES
3.1 Study Type and its Justification
The study was a descriptive cross-sectional one. The intention of the study was 
to illustrate the effects of the family particularly husbands, peers mothers, and 
mothers in law of nursing mothers and health workers on the practice of exclusive 
breast-feeding of nursing mothers in the Dodowa sub-district.
It was felt that a qualitative study design would be best in describing the 
perceptions of the study population. The questionnaire survey was to supplement 
findings of the qualitative study.
3.2 Study Population
The study population was made up of mothers with infants aged 6-12 months in the 
Dodowa sub-district, their husbands, peers, grandmothers of the infants and health 
workers in the sub-district.
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3.3 Selection Procedure
Selection of the study population in the Dodowa sub-district was by 
recruiting mothers with infants aged 6-12 months from MCH Clinic 
records and immunization returns and visiting their homes to request an 
interview with the mothers. The mothers served as index cases to identify 
husbands, grandmothers and peers. The sample size, was calculated using 
the total estimated mid-year population for 1997 of Dodowa (25,336) and 
the proportion of women who practice exclusive breast-feeding in Ghana 
(19%)
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3.4 VARIABLES
Variable Name Definition Variable Measurement
1. Knowledge about breast­ Knowledge of benefits of Ability to enumerate 5 benefits of 
feeding exclusive breast-feeding exclusive breast-feeding.
2. Significant others Husbands, Grandmother 
of the infant, Health 
workers, Peers.
3. Husband Male partner of the 
mother of the infant 
whether legally married 
(civil or customarily) or 
not married.
Grandmother of the 
4. Grandmother infant. That is the 
mother or mother-in-law 
of the infant’s mother.
5. Support/Advice of Knowledge of ten steps 
Health Worker of the “Baby Friendly 
Hospital Initiative” and 
the ability to enumerate 
ten benefits of exclusive 
breast-feeding from any 
health worker, TBA or 
Private maternity home.
Friends or women of 
6. Peers similar age group of the 
nursing mothers who 
have ever had children.
The variables measured are defined in the above table.
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3.5 Preparation towards Data Collection
The sub-district was selected by the Director of District Health (DDHS) 
and the Study Communities were selected by the District Health 
Management Team (DHMT) with the help of the Community leaders and 
members of the sub-district Health Management Team.
The Community leaders and some members of the DHMT recruited the 
participants for the focus group discussions.
The resident and two members of the DHMT visited the communities and 
held discussions on the forth coming study with the community leaders.
The DHMT helped to identify the research assistants (facilitator and note 
taker) for the focus group discussions. The facilitator and the Note Taker 
were trained per focus discussions.
3.6 Training of Research Assistants
A plan was developed to train the research assistants and especially the 
facilitator. The training dealt with communication skills and how to 
conduct focus group discussions, especially the probing, seeking 
clarification and paraphrasing responses of participants.
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A pre-testing of the focus group discussion guide was done at Salem 
Community. The questionnaire needed no revision.
3.7 Data Collection
3.7.1 Focus Group Discussion
Data collection through the FGD lasted from July 21 until July 24, 1998. 
The note taker and the facilitator organised and co-ordinated all the 
discussion. At the end of the discussion, the facilitator confirmed and 
summarised issues that had arisen. Participants were given a cake of soap 
each. After the discussions, participants had time to interact with the 
research team. All group discussions were taped after obtaining 
permission from the participants for use in the final document.
Although the FGD guide was in English, the discussion was in the 
Dangme language. Through long discussions, consensus was established 
regarding the issues covered by the FGD guide.
The resident and the facilitator developed a common understanding of the 
issues, prior to the dates for the FGDs.
Present at the discussions were:
•  The recorder who recorded all discussions in English
•  The facilitator who organised and coordinated all the discussions.
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Recording was done manually and data stored on cassettes prior to 
transcription.
3.7.2 Survey Questionnaire
A survey questionnaire was conducted to serve as support for the 
qualitative study. The questionnaire was administered to a group of 
nursing mothers identified from MCH/FP and immunization record. The 
questionnaire was administered by the resident and research assistants at 
the homes of the nursing mothers.
3.7.3 Checklist for health Workers
The structured questionnaire was administered to health workers including 
TBAs and a private midwife. This helped to get information on the kind 
of advice and support available to nursing mothers from health workers.
3.8 Data Analysis
3.8.1 FGD Data Analysis
The tapes were transcribed and data compared and cross checked with 
information recorded verbatim by the note taker.
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Participants were made to feel at ease and comfortable to discuss issues. 
Being in group of same sex made the information required obtainable. 
Periodic summary by the facilitator validated the information obtained and 
this was confirmed each time by the participants.
3.8.2 Survey Questionnaire Analysis
Sorting of data and verification were done daily for each data set. 
Analysis was done using Epi Info 6.
3.9 Limitation of the Study
Much of the study went well. As anticipated, the language barrier was a 
major constraint. As a result, most of the discussions were missed by the 
resident as she had to depend on an interpreter who happened to be one 
of the research assistants to translate the contents of the discussions.
In some groups one or two participants did not participate actively in the 
discussion but concurred with other speakers without adding any different 
views.
The restricted sample size was due to time constraint. The sample was 
obtained from MCH/FP and immunization records, hence the sample 
consisted of only those attending clinics and had contact with a 
government health worker.
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CHAPTER FOUR
4.0 FINDINGS AND DISCUSSION
4.1 Findings from FGD’s
The major purpose of focus group discussions was to describe the perception of 
the nursing mothers, their husbands, peers or friends and their mothers/or mother- 
in-law to die practice of exclusive breast-feeding in the Dodowa sub-district.
A total of five (5) group discussions were conducted with men and women in the 
community between July 21 and July 24, 1998. Forty (40) women and Ten (10) 
men participated in the study.
Many of the participants had little or no formal education and came from different 
backgrounds. The majority of the participants were petty traders, drivers and 
farmers. There were a few civil servants, mechanics, hairdressers, seamstresses 
and housewives.
The focus group data show that all the participants knew about and had a positive 
attitude towards breast-feeding in general.
These sentiments are reflected in the following statements expressed by 
participants when asked what they know about breast-feeding.
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"Breast-feeding makes children grow and it opens the mind" (NM) 
"Breast-feeding gives energy to the children" (NM)
"Breast-feeding gives energy and blood to children" (GM)
"Earlier removal from  the breast may bring about Kwashiokor" (GM)
"It’s natures food  which contains all nutrients and when a child is breast-fed the 
child gets energy to grow w ell." (Husbands)
When the participants were asked if in their opinion, the public know enough 
about breast-feeding in general, the following sentiments were expressed:
"No, because more often than not they ask that we give the children water because 
our mothers gave water" (NM)
"Sometimes they tell us the nurses are cheating us, breast-feeding is not enough 
fo r  the child so koko should be added. (NM)
"No, because some believe breast-feeding brings about sagging breast and it also 
makes a woman grow old in no tim e." (peers)
"Some women take advice from  their friends and they believe breast-feeding does 
not make children strong so it’s better when water and other foods are added." 
(peers)
"Yes, they know breast-milk is good fo r  the children." (NM)
"They also know it develops the brain and makes them perform well in class." 
(NM)
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"No, because some mothers do not bother washing their hands and the breast 
before feeding their children when they return from  the farm. This affects the 
children so education to the public is very necessary." (Husbands)
"Some women feed  their children on bottle, implying they leave the children at 
home in the care o f people with the expectation that the children would be bottle 
fed. I  think more education is desirable".
(Husbands)
A discussion on colostrum (the first yellowish milk that flows out of the breast 
when about to start breastfeeding) yielded the following responses:
"/ don’t know what brings about that yellowish milk and I  would be glad if  some 
education is g iven." (Husbands)
"As can be seen in an egg, we have the white and the yellow so I  believe nature 
made it so and it is good fo r  the baby" (Husbands)
"That has more energy '. (NM)
"At first we thought it was not good but at the health facility we were educated 
on its importance. We were told it contains a lot o f energy." (NM)
"I don’t know anything about tha t." (peers)
"I know that comes first and it gives energy and it also contains protein necessary 
fo r  the child ." (peers)
"I think that allows much flow  o f breast m ilk ." (GM).
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There was general consensus among the group of nursing mothers that they had 
received some form of advice/talk on breast-feeding from a health centre and also 
that their husbands/male partners encourage them to breast-feed their babies which 
were expressed as follows:
"They (husbands) think or know it is good".
"They also believe since the children are not old enough to e a t , they must be on 
breast on ly."
There was also a general consensus on the average duration of breast-feeding in 
the Dodowa Sub-district. The participants stated an average duration of two (2) 
years. Some reasons for stopping were given as:
"They are stopped because at that time they do not get enough breast milk to 
support growth so they need to be fed  on other meals. * (NM)
"Sometimes it affects the mothers as it is believed that the child sucks the mothers 
blood, so at 2 years they must be given other meals. "(NM)
"Stopping them after 2 years helps strengthen their legs." (NM)
"At 6 months some mothers stop breast-feeding to enable them to do their w ork." 
(NM).
"Some stop at 6 months due to too much thinking, leading to lack o f breast milk 
fo r  the child" (peers)
"Some at 1 year because they have to go to work and they do not have time to 
breast-feed." (peers)
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"There is no fixed time but some mothers are not able to breast-feed up to even 
one year from  6-7 months they stop breast-feeding." (Husbands).
"From our fore-fathers we know children are to be breast-fed fo r  3-4 years but 
presently due to immoral life o f the women they do not breast-feed fo r  long". 
(Husbands)
"Also current economic hardship making both men and women to go out in order 
to make ends meet does not allow breast-feeding fo r  long. " (Husbands)
It emerged from the discussions that there were a few rumours on breast-feeding 
in the areas.
The husbands argued that the nursing mothers felt shy to breast-feed their babies 
in public especially when travelling in vehicles, to the extent that even when the 
baby is crying they would not breast-feed.
This encourages early supplementary feeding to overcome the shyness of exposing 
their breasts in public.
The nursing mothers argued that when a woman is pregnant whilst breast-feeding, 
the woman has to stop breast-feeding since it is believed that the child, being 
breast-fed could fall ill or be malnourished. They also argued that there is the 
belief that a woman does not have to sleep with another man who is not the father 
of the child being breast-fed as this may cause the death of die child. This is 
regardless of the fact that the relationship between the nursing mother and the 
baby’s father has broken up.
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Other sentiments concerning cultural rumours were expressed in the following 
statements.
"They ask if  the nurses who say the child should not be given water do not drink 
water themselves. "(NM)
"When a child breast-feeds fo r  long, people say the child is sucking the mother’s 
blood implying that the child should be stopped." (GM)
"You are not to insult or speak against the child whilst breast-feeding. "(GM) 
"Some say the breast is to be held whiles breast-feeding other than the child’s 
mouth would be enlarged", (peers)
"It is said that resting the chin in the palm while breast-feeding may lead to the 
death o f the child, "(peers)
"Yes, people say when the children are put on breast-milk only fo r  six (6) months 
it does not make them healthy. They also get thirsty so they need to be given 
water and other meals latest by three (3) months. (NM)
"It is also said that the husband should not suck breast when breast-feeding." 
(peers)
"Also saying bad things or insulting or being angry whiles breast-feeding would 
lead to the child’s refusal to take breast leading to Kwashiokor." (peers)
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On the issue of whether or not, they would practice exclusive breast-feeding, the 
nursing mothers had this to say:
"Yes, because breast-feeding without water and other foods would make the 
children grow w ell."
"No because breast-feeding without water would make the child so thirsty. "
"An addition o f koko to breast-feed would make them look n ice."
"Giving o f water could bring about infections that is why we are not suppose to 
give w ater."
"Yes, only breast-feeding would make the children grow because we are told by 
the nurses that breast-milk contains more water so water given would occupy 
space."
"Our mothers gave water in addition to breast-feeding and we can also do that 
provided the water is clean."
On the issue of the whether or not they would advice a friend/colleague to 
practice exclusive breast-feeding, the peer group had this to say:
"Yes, in the past there was no canned foods, so I  would advice that my 
friends/colleague breast-feed fo r  at least 6 months before adding other fo o d s ." 
"No, some people do not have breast-milk flowing fo r  the first 3 days and they 
give water from  coconut to their children, so I  cannot advise in such 
circumstances since the child may go hungry."
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On whether they would allow their wives to practice exclusive breast-feeding, the 
husbands had these to say:
"No, mothers from  generation to generation gave water in addition to breast-milk 
because the children get thirsty so there is nothing wrong if  water is given." 
"Also one could have a disease which could prevent breast-feeding and hence the 
introduction o f other meals and water."
"Yes, because i t ’s nature’s food  which makes them grow well. This is better than 
canned foods which sometimes give problems. "
The grandmothers of the infants said they would encourage their 
daughters/daughters-in-law to practice exclusive breast-feeding.
"so that the children would be strong and also grow well" and also "be able to 
walk w ell."
During a discussion on whether or not they had ever practiced exclusive breast­
feeding, the grandmothers and peers had these to say:
"No, I  gave water in addition to breast-milk till I  stopped breast-feeding." (GM) 
"No, some children would not eat especially the males so you have to give breast- 
milk with other fo o d s ." (GM)
"No, I  breast-fed with water fo r  3 months and then added other foods like koko." 
(GM)
"No, the child should be on breast-milk only fo r  some time about 6 weeks before 
other foods would be added, (peers)
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"No, after a month, the child may not get enough breast-milk so other foods could 
be added, (peers)
"No, one may be working and would need to add other foods so that in the 
absence o f the mother, the child could still be fed  at home. " (peers)
All participants agreed that a lot should be done to promote exclusive breast­
feeding. Some suggestions given by participants on what can be done to promote 
exclusive breast-feeding include:
"We can tell our friends the importance o f breast-feeding. We only need to eat 
well by taking in more soup as nursing mothers. " (NM)
"If a sister or friend delivers, I  would advise and encourage breast-feeding 
exclusively because i t ’s the best. "(NM)
"/ think this is the work o f health personnel, you need to go house to house and 
educate our women since most o f them are illiterates. " (Husbands)
"As husbands too, we can educate our wives. Public address systems on hospital 
vehicles too could be used to educate the public. "(Husbands)
"Durbars could be held at all communities and the educational programme passed 
on to the people. This would work better than ju st the Public address system since 
it would be a forum fo r  people to ask question as well as express their views. " 
(Husbands).
"Religious groups like churches can do a lot by dissemination o f such 
information." (Husbands)
"The media/radio could also be used fo r  the promotion. " (Husbands)
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"It would be good if  the radio is used to educate people in different languages. " 
(peers)
"I never bought feeding bottles but I  gave water using my fingers." (GM)
"We need to be educated well on why water should not be given. " (GM)
"Some children are always thirsty and they need to be given water before being 
breast-fed. Would there be a problem if  they are not given water?" (GM)
From the FGD’s it is clear that the participants want and need more education on 
the practice of exclusive breast-feeding.
Most education on this practice has been on nursing mothers whilst neglecting 
their "Significant Others" - their husbands, peers, mothers and /or mother-in-law 
who play a very crucial role in the feeding practices of their infants.
4.2 Findings from the health Workers
The checklist for the health workers provided information to supplement data 
collected from the FGDs and questionnaire survey.
The checklist was also a way of finding out what the health workers know about 
exclusive breast-feeding since this would give an idea of what they are teaching 
the nursing mothers.
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A total of eleven (11) health workers were interviewed.
3 Traditional Birth Attendants 
1 Midwife from a private maternity home
7 Government health centre workers.
From the health workers’ study, it came out that, only three out of the eleven 
health workers understood the term "Rooming in". One out of the these three 
was a TBA. The other two were health workers of the health centre.
All the health workers had some knowledge about breast-feeding, the "Baby 
Friendly Hospital Initiative (BFHT) the advantanges of breast-feeding. Ten health 
workers understood the term. "Exclusive breast-feeding." All the health workers 
stated that they would advice mothers to practice exclusive breast-feeding.
The health workers stated that there were some cultural taboos or rumours on 
breast-feeding in the sub-district and these include:
•  If a child is exclusively breast-fed, the child will not eat any food after 
sometime.
•  Exclusive breast-feeding will lead to "charlie wote" breasts.
•  When someone is suffering from asthma she should not breast-feed the 
baby for the first three days after delivery."
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One health worker stated that the grandmothers discouraged nursing mothers from 
practicing exclusive breast-feeding.
The health workers from the government health centre however stated that they 
have had no formal training on how to impart breast-feeding knowledge. They 
are teaching the nursing mothers what they have learnt on their own. They 
expressed the desire for formal training from the Ministry of Health or any other 
interested organization and education for the community members as well.
4.3. Findings from the Questionnaire Study
The questionnaire was administered to one hundred (100) nursing mothers with 
infants aged 6-12 months, recruited from MCH clinic records and immunization 
returns. The questionnaires were administered by two trained research assistants 
and the resident.
The study was meant to determine the characteristics of the nursing mothers and 
whether or not they ever practiced exclusive breast-feeding on their recent child 
birth.
Table 1: Percentage Distribution of Respondents
Age Frequency Percentage (%)
15-30 79 79
31-45 19 19
Don’t know 2 2
Total 100 100
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Table 1: shows the summary age distribution of respondents. Seventy-nine percent (79) 
of respondents were nursing motiiers aged 15-30 years and nineteen percent (19) were 
aged 31-45 years. Two percent (2) of women did not know their ages. The fact that 
79% of women fell between the ages of 15 and 30 years indicates a potential for many 
more births and hence health personnel must direct their education activities on exclusive 
breast-feeding to this age group and their "Significant Others".
Table 2: Marital Status of Respondents
Marital Status Respondents Percentage (%)
Married (Civil) 3 3
Married (customary rite) 38 38
Living together 51 51
Divorced 0 0
Separated 1 1
Widowed 1 1
Other 6 6
Total 100 100
Table 2 shows the marital status of respondents. The majority of the respondents fifty 
one percent (51) were just living together. This is not too encouraging as it may make 
the men shirk their responsibilities as fathers resulting in the women having to work to 
support the child. There is the likelihood that such mothers would find it difficult under 
such circumstances to practice exclusive breast-feeding.
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The District assembly should try and encourage the men and women to have their 
marriages legalized. A unit can be set up to see to the registration of marriages and 
when health workers are doing home visits they can encourage such couples to legalize 
their unions.
Among the respondents, thirty-eight percent (38) were married through the performing 
of customary rites, three percent (3) through the civil method, one percent (1) separated, 
1% widowed and the "other" group which includes those whose male partners refused 
to accept responsibility for the pregnancies and singles form 6% (6).
Table 3: Educational level of Respondents
Educational Level Frequency Percentage (%)
Primary 36 36
JSS/SSS 24 24
Middle School 23 23
Secondary 3 3
Tertiary 1 1
None 13 13
Total 100 100
Table 3 shows the educational attainment of respondents. Among the women, thirteen 
percent (13) had no education, eighty seven percent (87) of them received either Primary, 
Middle, Secondary, or Tertiary School eduction. The higher educational level of the sample, 
may explain their presence at MCH/FP and Child Welfare clinics. From the FGD’s it was 
realized that participants wanted education on exclusive breast-feeding. This high education 
level should serve as a incentive to health workers.
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Table 4: Occupation of Respondents
Occupation Frequency Percentage (%)
Teacher 1 1
Farmer 12 12
Unemployed 23 23
Professional 1 1
Trader 47 47
Other (Apprentice,
Civil Servant Seamstress, 16 16
Hairdresser
Total 100 100
Table 4 gives the distribution of respondents by their occupations. It was observed that 
forty seven percent (47) of respondents were traders, twenty three (23) were 
unemployed, sixteen percent (16) were either seamstresses, civil servants, hairdressers 
or apprentices, twelve percent (12) were farmers, one percent (1) a professional and one 
percent (1) a teacher.
Table 5 : Sources of Advice on Breast-Feeding
Sources o f Advice Frequency Percentage (%)
Mother 6 6
Mother-in-law 3 3
Husband/male partner 1 1
Health worker 92 92
Friend 3 3
* Total 105 105
* Multiple responses
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Table 5 shows who had ever given the nursing mothers advice on breast-feeding. Ninety 
two percent (92) received advice on breast-feeding from a health worker including TBA; 
six percent (6) from a mother, three percent (3) from a mother-in-law; three percent (3) 
from a friend and one percent (1) from a husband. Five (5) respondents stated that they 
received advice from both health worker and either a mother or a mother-in-law.
Eighty-two percent (82%) of the women interviewed had received advice on breast­
feeding when they had their most recent baby. Eighteen percent (18%) of the women 
interviewed had not received advice on breast-feeding when they had their recent baby. 
This can be seen from Table 6.
However, fifty-three percent (53 %) of the women interviewed practiced exclusive breast­
feeding on their most recent baby and forty-seven percent (47%) did not practice 
exclusive breast-feeding on their most recent baby. This can be seen from table 7. Out 
of the 100 women interviewed, one percent (1) stopped breast-feeding her most recent 
baby at 3 months, one percent (1) stopped because of supplementary feeding and one 
percent (1%) stopped because of insufficient milk production.
Table 6: Distribution of women who have received advice exclusive breast-feeding.
Frequency Percentage (%)
Received Advice 82 82
Did not receive advice 18 18
Total 100 100
'fable 6 shows distribution of women who have or have not received advice on breast­
feeding with their most recent baby.
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Table 7: Proportion of Women who have ever practiced exclusive breast-feeding
Frequency Percentage (%)
Ever Practiced exclusive breast­
feeding 53 53
Did not practice exclusive breast­
feeding 47 47
Total 100 100
Table 7 shows proportion of women who have ever practiced exclusive breast-feeding 
with their last or most recent baby.
Even though a high proportion of women eighty-two percent (82) had received advice on 
breast-feeding with their most recent baby, only fifty-three percent (53) ever practiced 
exclusive breast-feeding. The proportion of women receiving advice eighty-two percent 
(82) compares favourably with those who received advice from the health worker ninety- 
two percent (92). From the questionnaire, when asked if they had anything to say about 
exclusive breast-feeding, some women had this to say:
1. "I fee l it is a good idea, but my mother-in-law did not allow me. "
2. "The public should be educated more on it because it was my mother-in-law who 
discouraged me from  practicing i t ."
3. "I don’t understand why I  am to give only breast-milk to my child"
4. "I don’t understand why I  have to breast-feed my baby exclusively though I  did 
it. "
5. "I thought they would suffer without water, but I  was made to understand that it 
prevents diarrhoea and other stomach problem ."
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6. "I seem not to understand what we are being told now because earlier on we 
never attend clinic and we were giving water yet the children didn’t have 
problems. Infact they get thirsty and need to be given water."
7. "How do you fee l when you do not drink water ? I t ’s the same way the children 
also feel, so they need to be given water."
8. "I fee l it is not good but once it is the doctors who said it, I  obeyed."
9. "The milk is not enough, they are twins so I  could not practice i t ."
10. "I fee l it is good but my mother did not allow me to practice it.
11. I  fee l my child is not satisfied when I  give my breast milk alone so koko should be 
added to i t . "
4.4 The linkages between demographic factors (age, marital status, educational 
status and occupation) and the practice of exclusive breastfeeding.
From Table One, Seventy nine percent (79) of the nursing mothers fell between 
the ages of 15 and 30 years indicating a potential for many births.
Ninety two percent (92) of the women interviewed were living with their male 
partners. This can enhance emotional support during breastfeeding. The high 
educational level of the sample (eighty seven percent) compares favourably with 
the high level of those in employment (seventy seven percent). The high 
educational level will enhance educational systems for exclusive breastfeeding 
which plays an important part in the achievement of improving health.
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Eighty two percent (82) of the women interviewed had received advice on 
exclusive breastfeeding and ninety two percent (92) had received advice from a 
health worker and thirteen percent (13) from a family member and/or friend.
Health professionals should be well prepared to advise mothers and the public on 
the benefits of exclusive breasfeeding. The family as the unit most intimately 
involved in supporting exclusive breastfeeding, is of primary importance. The 
information developed for various audience groups may possibly differ in level 
and type of content, but it must be consistent.
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CHAPTER FIVE 
5.0 CONCLUSIONS AND RECOMMENDATIONS
5.1 Summary and Conclusions
The study attempted to describe the perceptions of the "significant others" on the 
practice of exclusive breastfeeding in the Dangme West District.
The "significant others" in this study referred to the husbands or male partners, 
peers, mothers and mothers-in-law of nursing mothers with infants aged 6-12 
months and Health workers including a midwife home and TBA's.
Since the Regional launching of Exclusive breast-feeding was done at Dodowa and 
with a high prevalence of diarrhoea in the sub district21, it was expected that a 
very high proportion of nursing mothers in the district would practice exclusive 
breast-feeding with the support of their husbands, peers, mothers and/or mother- 
in-law who persumably were witnesses to the launching.
The findings of this study show that these "significant others" do play a role in 
whether a nursing mother will practice exclusive breastfeeding or not.
It confirms the existence of "gate keepers" in society and the need to identify the 
"gatekeepers" to prepare them to give support to the primary group.
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Most of the nursing mothers interviewed had received advice on breastfeeding 
from a health worker. However, most healthworkers interviewed did not 
understand the term "rooming in". Some nursing mothers just practice exclusive 
breastfeeding even though they did not really understand why, but because a 
doctor said so.
The nursing mothers felt their babies would feel thirsty hence the need to, add 
water to breastmilk and in order for their babies to look "nice" they need to add 
Koko to the breastmilk.
Others wished to practice it but were not allowed to do so either by a friend, a 
mother or a mother-in-law.
There was a general consensus amongst all groups for the need for more public 
education.
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RECOMMENDATIONS
The study findings do show that the "significant others" influence the decision of 
a nursing mother to practice exclusive breast-feeding. The following 
recommedations are made:
•  Information, Education and Communication (IE&C) programme should 
be widely promoted and intensified, particularly in the following areas:
a. Training healthworkers in communication skills and to understand the 
terms and concepts in relation to exclusive breastfeeding.
b. Discuss the benefits of exclusive breastfeeding through the use of folk 
media and drama.
c. Reduce negative rumours through appropriate communication methods.
d. Raise awareness on the benefits of exclusive breastfeeding through the 
distribution of pamphlets and brochures among the literate population.
e. Education should not only be restricted to nursing mothers when they call 
at the health facility, it should extend to the other community members to 
promote exclusive breastfeeding.
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f. Communities are made up of different groups with different needs. These 
differences should be recognised and messages adapted to the 
characteristics and needs of these groups.
Until this is done, the level or proportion of women who practice exclusive 
breastfeeding will remain low and children in the district will continue to suffer 
from preventable diseases and deaths.
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REFERENCES 
Gomez V. (July 1992).
Breast-feeding Practices. Support anri Status. Baseline Survey Report-Ghana
Odoi-Agyarko, H.; Gomez V. (February 1993). Report on the National 
Seminar on Breast-feeding Practices. Support Support and Status in Ghana.
Centre to prevent childhood Malnutrition USA (July 1991).
Breast-feeding Saves Lives. The Impact of breast-feeding on Infant Survival. 
Policy Series Volume 2 (1): 1-12.
United Nations Childrens Fund/WHO (1993). Breast-feeding Management 
and Promotion in a Babv-friendlv Hospital.
UN Plaza, New York, USA
King, Felicity, Burgess. (1996).Nutrition for Developing Countries 
2nd edition Oxford University Press
United Nations Childrens Fund (1997). The State of the World’s Children. 
Oxford University Press.
The Baby-Friendly Hospital Initiative Newsletter.
BFHI News. (July/August 1993) UNICEF. Geneva
University of Ghana          http://ugspace.ug.edu.gh
8. Van Esterik, Penny. World Alliance for Breast-feeding Action (WABAh  
WABA Activity Sheet -4. WABA Secretariat, Malaysia.
9. Gibbons, Yee, (1993). Mothers and Children. Bulletin on Infant Feeding and 
Maternal Nutrition. Volume 12 (2) 1-8.
10. World Health Organization. (1993) Women and Breast-feeding. WHO, 
Geneva.
11. Simpson-Herbert, M; Huffman, L. (1981). Breast-feeding
Program. Policy and Research Issues. The Contraceptive Effect of Breast­
feeding. Volume 12 (4) 120-132.
12. Belsey, Mark; Boohene Esther, et al; Breast-feeding Protecting 
NaturalResource. (1988) IMPACT.
13. Baumslag, Naomi (1989). Breast-feeding: the Passport to Life. UNICEF.
14. World Health Organization (1993). Breast-feeding. The Technical Basis and 
Recommendations for Action. WHO Geneva.
15. United States Agency for International Development (1989).
Breast-feeding: A Report on A-I-D Program s. USAID, United States of 
America.
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16. Arbor, A. flQQffl. Components of infant and childhood mortality in West 
A frica: a study of health care practices, breast-feeding behaviour and its 
interaction with diarrhoea in Ghana an d  Nigeria. UMI Dissertation Services 
1996 (2). XIV, 240P. UMI No. 96 24870. Michigan.
17. Arkutu Ananie, A. Dr. Healthy women. Healthy Mothers.
Family Care International Inc. 2nd ed. 1995.
18. Ghana Demographic and Health (GDHS) Survey 1998. Ghana 
Statistical Service, Accra. Demographic and Health Surveys Maryland USA
19. Ghana Demographic and Health Survey. 1993. Ghana Statistical Service, 
Accra Ghana. Demographic and Health Surveys Maryland USA.
20. The World Bank: Better Health in Africa Experience and Lesson Learned. 
The World Bank 1994 Washington DC
21. District Health Management Team Dangme West District 1997 Annual 
Report.
22. WHO/UNICEF (June 1990) Technical Meeting Breastfeeding in 1990. 
Breastfeeding and the Control of diarrhoel diseases
Geneva.
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23. Ebrahim, G.J., (1993) Breastfeeding the biological option 
2nd edition, Hong Kong.
24. Protecting Infant Health (June 1993) A health workers guide to the 
international Code of marketing of breastmilk Substitutes 7th
edition. Malaysia.
25. Joint WHO/UNICEF meeting on infant and young child feeding. Part II. 
FHE/ICF 79.3 Geneva.
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6-0. APPENDICES
6.1. Appendix I: Indepth interview schedule (for nursing mothers with infants aged 
6-12 months)
TITLE: Perceptions of the “Significant Others”
on the practice of exclusive breast-feeding in the Dangme West District.
INTRODUCTION
I am a student with the School of Public Health, University of Ghana, Legon. I 
am conducting a survey on the above-mentioned subject. The study is in partial 
fulfilment of my course study. I would be very grateful if you could answer the 
following questions and I assure you that the answers you give would be kept 
confidential.
Thank you.
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IN DEPTH INTERVIEW SCHEDULE (FOR NURSING MOTHERS) 
DISTRICT: NUMBER:
1. ID:
2. Age (Last b ir th d ay ):_________________________________
3. Date of birth: < d d /m m /y y > ___________________________________
4. Marital status (current):
1. Married (civil) [ ]
2. (Customary rite) [ ]
3. Living together [ ]
4. Divorced [ ]
5. Separated [ ]
6. Widowed [ ]
7. Other (please specify) [ ]
5. W h e n  w a s  y o u r  m o s t  r e c e n t  c h i l d b i r t h ?
6. How old is this child?
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7. Have you ever attended School?
Yes [ ] 2. No [ ]
If No, go to No. 9.
8 Level of \Education
Primary [ ]
JSS/SSS [ ]
Middle School [ ]
Secondary [ ]
Tertiary [ ]
Other (specify) [ ]
9. Occupation:
1. Teacher [ ]
2. Farmer [ ]
3. Blnemployed [ ]
4. Professional [ ]
5. Trader [ ]
6. Other (Specify) [ ]
10. Did your husband ever attend School?
!• Yes [ ] 2. No [ ] 
If No, go to No. 12
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11. Level of education of husband:
1. Primary
2. JSS/SSS
3. Middle School
4. Secondary
5. Tertiary
6. Other (specify)
12. Occupation of Husband:
1. Teacher [ ]
2. Farmer [ ]
3. Unemployed [ ]
4. Professional [ ]
5. Trader [ ]
6. Other (specify) [ ]
13. Were you given any advice on breast-feeding when you had your baby? 
1. Yes [ ] 2. No [ ]
14. Who gave you the advice?
1. Mother [ ]
2. Mother-in-law [ ]
3. Husband/male partner [ ]
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4. Health worker [ ] 
5. Friend [ ]
15. Did you ever practice exclusive breast-feeding i.e. giving breast milk only
with your last or most recent baby (name)?
1. Yes [ ] 2. No [ ]
16. Are you still breast-feeding (name)?
1. Yes [ ] 2. No [ ]
If Yes, go to No. 19.
17. How old was your baby (name) when you stopped breast-feeding
him/her?
1. One month
2. Two months
3. Three months
4. Four months
5. Five months
6. Six months
7. Seven months
8. Other (specify)
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18. Why did you stop breast-feeding (name)?
1. Supplementary feeding [ ]
2. Illness of mother [ ]
3. Illness of baby [ ]
4. Insufficient milk production [ ]
5. Sore nipples [ ]
6. Advice by husband [ ]
7. Advice by mother [ ]
8. Advice by mother-in-law [ I
9. Other (specify)
19. Is there anything you would want to say about exclusive breast-feeding?
That is, giving the baby breast milk only. No other food or drink?
THANK YOU FOR ANSWERING THESE QUESTIONS.
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6.2 Appendix H: Focus Group Discussion Guides
GROUP:
A: Nursing Mothers Age 15-30 years 
B: Nursing Mothers Age 31-45 years 
C: Grandmothers of Infants 
D: Husbands of Nursing mothers 
E: Peers of Nursing mothers
Members of each group: 12 including a facilitator and a Note 
Taker.
Introduction Narrative welcoming the participants, describing the
reasons for the discussion and setting up the general ground rules for the session.
Ground Rules 60 minutes (Tape recorded)
Speak clearly/one at a time 
Conversation/All participate 
Want everyone’s opinion 
No right/wrong answers.
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Introduction by participants to the group.
A: Guide for Nursing Mothers. All Ages.
First, I would like to obtain some ideas from you about breast­
feeding.
^  What do you know about breast-feeding?
♦  Would you practice exclusive breast-feeding? i.e. giving the baby only breast 
milk, no other food or drink.
♦  Why or why not
♦  Do you think the public knows enough about breast-feeding in general ? Why or 
why not?
♦  Have you had any talk on breast-feeding from a hospital or health centre about 
breast-feeding?
♦  What do you think about the first yellowish milk that flows out of the breast when 
about to start breast-feeding?
♦  For how long do women in this area breast-feed their babies?
♦  Why do they stop?
♦  When did you introduce other foods to your baby?
♦  Are there any cultural taboos or rumours on breast-feeding?
♦  What do your husbands/male partners think about breast-feeding?
♦  What do you think can be done to promote exclusive breast-feeding?
Thank you.
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Guide for Grandmothers of Infants.
First, I w ould  lik e  to obtain som e ideas from  you about breast-feeding.
♦  What do you know about breast-feeding?
♦  What do you dunk about the first yellowish milk that flows out of the breast when about
to start breast-feeding?
♦  For how long do women in this area breast-feed their babies?
♦  Why do they stop?
♦  Are there any cultural taboos or rumours on breast-feeding?
♦  Would you encourage your daughter/daughter-in-law to breast-feed her baby?
♦ Why or why not?
♦  Did you ever practice exclusive breast-feeding?
♦  What do you think can be done to promote exclusive breast-feeding?
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C: Guide for Husbands:
First, I would like to obtain some ideas from you about breast-feeding.
♦  What do you know about breast-feeding?
♦  Do you think the public knows enough about breast-feeding in general?
♦  Why or why not?
♦  What do you think about the first yellowish milk that flows out of the breast when about 
to start breast-feeding?
♦ For how long do women in this area breast-feed their babies?
♦  Why do they stop?
♦  Are there any cultural taboos or rumours on breast-feeding?
♦  Would you allow your wife to practice exclusive breast-feeding?
♦ What do you think can be done to promote exclusive breast-feeding?
Thank you.
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D: Guide for Peers of the Nursing Mothers
First, I would like to obtain some ideas from you about breast-feeding
♦  Do you think the public knows enough about breast-feeding in general?
♦  Why or why not?
♦  What do you think about the first yellowish milk that flows out of the breast when about 
to start breast-feeding?
♦  Would you advice a friend/colleague to practice exclusive breast-feeding?
♦  Why or why not?
♦  For how long do women in this area breast-feed their babies?
♦  Why do they stop?
♦  When did you introduce other foods to your baby?
♦  Are there any cultural taboos or rumours on breast-feeding?
♦  Would you practice exclusive breast-feeding i.e. giving the baby only breast milk, no 
other food or drink?
♦  What do you think can be done to promote exclusive breast-feeding?
Thank you.
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^  Appendix III: Interview Guide for Health Personnel
Perceptions of the “Significant Others” on the Practice of exclusive breast-feeding 
in the Dangme West District.
INTRODUCTION:
1 am a student with the School of Public Health, University of Ghana,
Legon. I am conducting a survey on the above mentioned subject. The 
study is in partial fulfilment of my course study. I would be very grateful if you could 
answer the following questions and I assure you that the answers you give would be kept 
confidential. Thank you.
District:
Number:
Rank of Health Personnel:
Date:
1. ID:.......................
2. What do you know about breast-feeding?
Short description.......................................
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What are the advantages of breast-feeding?
Short description.......................................
What do you understand by exclusive breast-feeding?
Short description...............................................................................
Would you advise mothers to practice exclusive breast-feeding?
1- Yes [] 2. No []
Please give reasons for your answer
What information do you give to mothers before they are discharged 
from the health facility?
Short description........................................................................
Do you think the public knows enough about breast-feeding in general? 
1. Yes [ ] 2. No []
Please give reasons for your answer
What do you understand by “rooming-in”?
Short description .....................................................
Do you practice “rooming-in” at your institution?
1. Yes [] No [] 
please give reasons for your answer .......................
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10. Do you know of any cultural taboos or rumours on breast-feeding?
1. Yes [] No []
If “Yes” what are these? (Short description) ...................................
11. What general comments would you like to make about exclusive breast-feeding?
Short description....................................................................
Thank You
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6 4 Appendix IV: Information on FGD group members
District: .......................... Facilitator: .
Date: ................................  Note Taker:
Venue: .............................. Group: ......
ID “  Names Age Occupation No. of Marital
Children Status
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