SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA CHALLENGES OF EXCLUSIVE BREASTFEEDING AMONG FEMALE HEALTH WORKERS IN TWO HOSPITALS IN ACCRA BY NOUFFAN DANIELLE GLADZAH (10364132) THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PUBLIC HEALTH DEGREE JULY, 2013 University of Ghana http://ugspace.ug.edu.gh i DECLARATION This dissertation “Challenges of Exclusive Breastfeeding among female health workers in two hospitals in Accra” consist entirely of my own work, produced under supervision, with the exception of specified quotations duly acknowledged. I declare therefore that this work has not been accepted in substance for any other degree, nor is concurrently being submitted in candidature for any academic reward. …………………………………. Nouffan Danielle GLADZAH STUDENT …………………………………… Dr Augustine Ankomah ACADEMIC SUPERVISOR University of Ghana http://ugspace.ug.edu.gh ii ABSTRACT The recent decades have seen a sharp increase in the labor force participation of mothers with young children throughout their childrearing. The World Health Organization (WHO) recommends 6 months of exclusive breastfeeding starting from birth with establishment of early breastfeeding within 30 minutes after delivery. The benefits of exclusive breastfeeding are shown by numerous studies and include both the maternal and infant outcomes. Health workers are in general the first advocate of health benefits and subsequently are regarded as role models in whatever they teach and therefore in the practice of exclusive breastfeeding. This study sought to determine the proportion of female health workers practicing exclusive breastfeeding and to describe the reasons for the non practice of exclusive breastfeeding as described by female health workers in two hospital in Accra- La general and Ridge. It was a cross-sectional study involving 163 female health workers of reproductive age (15-49 years old) with a child aged between 6 months and 10 years at the time of working with both institutions. A structured Questionnaire was administered following informed consent to obtain information on their socio-demographic background characteristics as well as factors influencing the non practice of exclusive breastfeeding in their place of delivery, at work and at home. SPSS 16.0 was used for the analysis of the data and Pearson Chi-square test and logistic regression the tools to determine the association and significance of exclusive breastfeeding and the factors associated with the non practice of exclusive breastfeeding at work and at home and at the place of delivery. Sixty height percent (68%) of the female health workers interviewed reported practicing Exclusive breastfeeding for 6 months with their children. Two background variables - high level of education and moderate monthly income were found to influence positively the practice of Exclusive breastfeeding with a p- value of 0.009 and 0.019 respectively. Childbirth through assisted surgery and an income of more than 1000 Ghana cedi were associated with the likelihood of non exclusive University of Ghana http://ugspace.ug.edu.gh iii breastfeeding with a p-value of less than 0.001 and 0.045 respectively. Female Health workers who are nursing mothers are faced with challenges at the venue of delivery and at their work places in the practice of exclusive breastfeeding despite their exposure on the benefits of the practice of Exclusive Breastfeeding. These findings suggest to the policies makers that health education programmes alone are not sufficient to improve the practice of exclusive breastfeeding among the population. Policies which address adequate hours work upon return to maternity leave and mandatory availability of nursing room at workplace as well as emulation of more baby friendly hospital with emphasis on the practical training of both health workers and clients in the establishment and sustainability of Exclusive Breastfeeding are necessary. These measures will improve the rate of exclusive breastfeeding among female health workers and eventually the rate of exclusive breastfeeding among all nursing mothers who are looking up to female health workers as role models in the practice of health recommendations in general and exclusive breastfeeding in particular. University of Ghana http://ugspace.ug.edu.gh iv DEDICATION This piece of academic work is dedicated to my dear husband Constant Koku Gladzah, my parents Amon Marcel Tiemele and Yaba Claudine Elloh, and all working nursing mothers worldwide. University of Ghana http://ugspace.ug.edu.gh v ACKNOWLEDGEMENTS My sincere gratitude goes to a number of personalities who contributed in diverse ways to the completion of this academic work. I thankfully acknowledge the School of Public Health, College of Health Sciences, University of Ghana, the Department of Population, Family and Reproductive Health, the Ministry of Health, La General and Ridge Hospital. Mention should be made of my supervisor, Dr Augustine Ankomah for his guidance, criticism, encouragements and suggestions. University of Ghana http://ugspace.ug.edu.gh vi TABLE OF CONTENTS DECLARATION………………………………………………………………………………i ABSTRACT………………………………………………………………………...…………ii DEDICATION…………………………………………………………………………..……iv ACKNOWLEDGEMENTS………………………………………………………………..….v TABLE OF CONTENTS…………………………………….…………………………….....vi LIST OF FIGURES……………………………………………………...……………………ix LIST OF TABLES…………………………………………………………………….....……x LIST OF ABREVIATIONS…………………………………………………………..…..…..xi CHAPTER ONE…………………………………………………………………….……..…1 1.0 INTRODUCTION………………………………………………………………………....1 1.1 Background………………………………………………………………………….…….1 1.2 Statement of the problem…………………………………………………………...……..4 1.3 Objectives of the Study…………………………………………………………..………..6 1.3.1 General Objective……………………………………………………..……………6 1.3.2 Specifics Objectives……………………………………………………….……..…6 1.4 Study Hypotheses………………………………………………………………..…………6 CHAPTER TWO……………………………………………………………………………..7 2.0 LITERATURE REVIEW…………………………………………………………...……..7 2.1 Benefits of Breastfeeding………………………………………………………....……….7 2.2 Breastfeeding Epidemiology…………………………………………………..…………..8 2.3 Factors affecting Exclusive Breastfeeding………………………………………………...9 University of Ghana http://ugspace.ug.edu.gh vii 2.3.1 Individual (mother) Factors…………………………………….…………….…..10 2.3.2 Group Factors (Work and/or home)…………………………..…………….……11 2.3.3 Societal Factors (Policy Planning)………………………………...……..………12 CHAPTER THREE………………………………………….……………………………..16 3.0 METHODS……………………………………………………………….………………16 3.1 Type of study and study design………………………………………………...…..…….16 3.2 Study Location………………………………………………………………….…….….16 3.3 Variables………………………………………………………………………….………16 3.4 Study Population………………………………………………………………..………...17 3.5 Sampling Procedure…………………………………………………………….....……..18 3.6 Sampling Size ………………………………………………………..……….………….18 3.7 Sampling Method …………………………………………………………..……………19 3.8 Data Collection techniques/Methods & Tools ……………………………………..……20 3.9 Quality Control……………………………………………………………..…………….20 3.10 Data Processing and analysis…………………………………………..…………...…..21 3.11 Ethics……………………………………………………………………...…………….21 3.12 Pretest and Pilot Study……………………………………………...………………......22 3.13 Limitation of the study…………………………………………..……………………...22 CHAPTER FOUR………………………………………………………………………..…23 4.0RESULTS……………………………………………………………………………....…23 4.1 Socio-demographic Characteristics……………..………………………………………..23 4.2 Exclusive Breastfeeding……………………………………………………………..…...25 4.2.1 Proportion of female health workers who practice exclusive breastfeeding…………………………………………………………..…………..…26 4.3. Individual Factors influencing respondents inability to exclusively breastfeed……...…27 University of Ghana http://ugspace.ug.edu.gh viii 4. 4 Hospital Factors influencing Exclusive Breastfeeding Practice……………….………...28 4.4.1 Venue of Delivery …………………………………………………….……….28 4.4.2 Type of Delivery……………………………………………………………….29 4.5 Factors at work affecting Exclusive breastfeeding…………………………...…………..30 4.5.1 Breastfeeding hour break at work within 6 months post delivery……...……....30 4.5.2 Work hours after Delivery…………………………………………………...…30 4.5.3 Work/Duty Resumption…………………………………………..……………31 4.6 Factors at home affecting exclusive breastfeeding………………………….......………..31 4.7 Tests of Hypothesis……………………………………………………….………….….33 4.8 Logistics Regression of Exclusive Breastfeeding on Various Independent Variable .......34 CHAPTER FIVE…………………………………………………………………………….37 5.0 DISCUSSION……………………………………………………………………………37 5.1 Background information and Characteristics of the study population …………………..37 5.2 Logistics regression of EBF on various independent variables…………….……………46 CHAPTER SIX……………………………………………………………………………...47 6.0 CONCLUSION AND RECOMMENDATIONS…………………………………......….47 6.1 Conclusion……………………………………………………………………….……….47 6.2 Recommendations………………………………………………………………..……....48 REFERENCES………………………………………………………………………...50 APPENDICES…………………………………………………………………….……54 APPENDIX 1 QUESTIONNAIRE…………………………………………………………54 APPENDIX 2 INFORMED CONSENT FORM……………………………………………..58 University of Ghana http://ugspace.ug.edu.gh ix LIST OF FIGURES Figure 1 Conceptual framework of f actors affecting EBF…………………………………...3 Figure 2 Individual Factors influencing respondents‟ inability to exclusively breastfeed…..28 Figure 3 Venue of delivery…………………………………………………………………..29 Figure 4 Type of delivery……………………………………………………………………30 Figure 5 Work hours per day…………………………………………………………….......31 University of Ghana http://ugspace.ug.edu.gh x LIST OF TABLES Table 1 Background Characteristics of Female Health workers…………...…………….....24 Table 2 Exclusive Breastfeeding according to Background Characteristics…………….….26 Table 3 Sources of help at home after childbirth………………………………………...…32 Table 4 EBF by selected independent variables ……………………………………………33 Table 5 Logistic regression on EBF and independent variables…………………………....35 University of Ghana http://ugspace.ug.edu.gh xi LIST OF ABREVIATIONS BFHI: - Baby Friendly Hospital Initiative EBF: - Exclusive Breastfeeding GDHS: - Ghana Demographic Health Survey WHO: - World Health Organization University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE 1.0 INTRODUCTION 1.1 Background In the last decade, a growing number of women have remained in the labor force throughout their childbearing and childrearing years (Bromberg, 1998). In 2001, the World Health Organization (WHO) changed its recommendation for exclusive breastfeeding from four to six months of age for optimal growth, development and health of the infant. How have these changes affected the adherence of exclusive breastfeeding by nursing working mothers? Although seventy two percent (72%) of women living in US initiated breastfeeding for at least the first six months of life as recommended by the World Health in 2002, by six months, the rate dropped to thirty five percent (35%) substantially lower than Healthy People 2010 objectives of fifty percent (50%)(Kramer et al., 2003). This recommendation of six months of exclusive breastfeeding is evidence-based and adherence to it improves infant‟s outcomes (Kramer et al., 2003). The prevalence of exclusive breastfeeding rates for all women varies worldwide. Industrialized countries like Australia and the U.S, fifty four (54) and forty one (41) percent of women exclusively breastfeed for three months. The exclusive breastfeeding rate of Australia and the U.S was thirty two (32) and fourteen (14) percent for six months, respectively (ABS, 2004). In developing countries such as Kenya, Bangladesh, Vietnam and Turkey, the exclusive breastfeeding rate for three months by working mothers ranges from thirteen (13) percent to fifty nine (59) percent (Haider, 2000). In Ghana, it is sixty three percent (63%), a rate far higher than other neighboring countries in the region like republic of Benin (43.1%), Cameroon (23.5 %) (Abdulwadud & Snow, 2008). University of Ghana http://ugspace.ug.edu.gh 2 CONCEPTUAL FRAMEWORK The conceptual framework for this study utilizes three levels of factors influencing exclusive breastfeeding. These levels are: individual factors, group of individuals‟ factors in a society and society‟s factors as a whole. The framework can be used to generate findings about factors affecting breastfeeding and the types of interventions that might be used to address them. Individual level factors relate directly to the mother, infant, and the „mother-infant dyad‟. These factors include the mother‟s knowledge, skills and childcare experience. The health status of mothers and/or infants can be included among individual factors. Each of these factors can directly influence the initiation and duration of breastfeeding. A sick mother may not be able to breastfeed her child and a very sick child might not be able to suck his/her mother breasts. Group level factors and societal factors are the attributes of the environment in which mothers and infants find themselves, the attributes that enable mothers to breastfeed. Environments with a direct influence on mothers and infants include: the hospital and health facility environment, in which practices procedures such as infants routinely rooming-in with mothers, post delivery skin-to-skin contact and providing professional support with breastfeeding technique influence the early feeding experience and the follow-up care and support. The home and peer environment, where physical and social factors such as size of household, parity, family circumstances, partner attitudes and support, and peer support affect the time, energy and resolve that nursing mother share for breastfeeding. The work environment, in which policies, practices and facilities such as work hours and flexibility, place and type of work that enable on-site expressing and storing of breast milk influence mother‟s ability to combine work and breastfeeding .Our emphasis in this study is University of Ghana http://ugspace.ug.edu.gh 3 on the group support at work and at the place of delivery where changes can be made in the life of the individuals if the issues are conveyed to the specific authorities. Societal level factors are policies, beliefs of a larger group of individual for example in a country which can influence the practice of exclusive breastfeeding. In this study societal factors are restrained to policies planning like length of maternity leave in Ghana, Exclusive Breastfeeding policies to promote EBF in Ghana. More over Conceptual Framework of factors affecting exclusive breastfeeding Figure 1: Conceptual framework of factors affecting exclusive breastfeeding Exclusive breastfeeding Individual Cosmetic reason Health Status/ skills skills Skills Group Home Support Hospital/Work Environment Hospital environment Work Support Hospital Support Society Maternity Leave Policies University of Ghana http://ugspace.ug.edu.gh 4 1.2 Statement of the problem Numerous studies have shown the benefits of exclusive breastfeeding (EBF) and its relevance in maternal and infants outcomes. There is evidence for delayed return of menses with an additional two months of exclusive breastfeeding (Kramer et al., 2003) from the previous four months of EBF. The benefits of prolonged amenorrhea (no menses) include increase birth spacing and reduced blood loss during delivery, resulting in reduced iron requirements for lactating mother (Dewey et al., 2001). There is also good evidence that six months comparing to four months of exclusive breastfeeding provide infants with additional protection against gastro intestinal infections (Kramer et al., 2003). Research has consistently shown that low educational attainment, young age, being single, being black, and for multiparous (mother of more than one child) having no previous breastfeeding experience are risk factors for early breastfeeding cessation (Guendelman et al., 2009). For working mothers, the challenge of balancing breastfeeding and paid work is an important reason for breastfeeding cessation in the first six months and therefore failure to achieve exclusive breastfeeding for six months. Recent studies by Guendelman et al (2009) suggest that inflexible work schedule is associated with breastfeeding cessation. WHO and UNICEF recommend that babies should be exclusively breastfed from birth until 6 months of age(WHO, 2003). Such long period of EBF may be difficult for women to achieve unless they receive greater support from employers, family, friends indeed from social norms in general, as well as from health care professionals and lactation specialists when needed (Rea et al., 1999). Despite the many benefits of EBF, it has been shown that numerous factors hinder its optimal practice. Some of these barriers include mother‟s employment, unfriendly hospital practices, advertisement of breast milk substitutes, ignorance, family pressure, and mother‟s ill health among other factors (Utoo et al., 2012). University of Ghana http://ugspace.ug.edu.gh 5 In a survey conducted in Nigeria by Utoo et al (2012) 97.2% of participating health workers identified breastfeeding to be the preferred mode of feeding for an infant, versus artificial milk. The same study showed that as high as 83.4% of the respondents knew the correct duration of EBF revealing that at least as far as EBF duration is concerned, health workers are knowledgeable. Similarly the breastfeeding experience of 36 female doctors in Nigeria in a study by Sadoh et al (2011) showed that all respondents knew that babies should be exclusively breastfed for the first 6 months of life however the exclusive breastfeeding rate for the studied doctors was 11.1%. Very few studies have been done on female health workers in Ghana and the challenges they face when going through the practice of exclusive breastfeeding despite their exposure on the need to practice EBF. And fewer studies are available in Africa, West Africa and in Ghana. The intention of this study is to help improve the rate of exclusive breastfeeding among nursing mothers in general notwithstanding the profession having in mind that women will be encouraged in their practice of exclusive breastfeeding if the very female health workers who advice them in the practice of EBF are practicing what they teach. So by identifying the reasons for the non practice of exclusive breastfeeding as described by the female health workers the first recipient in the training and promotion of EBF policy, one could reach meaningful conclusions to ensure the success of the EBF among female health workers and therefore promoting the practice of EBF more than before among patients attending health facilities or in contact in one way or another with female health workers. University of Ghana http://ugspace.ug.edu.gh 6 1.3 Objectives of the Study 1.3.1 General Objective To identify the factors associated with exclusive breastfeeding among female health workers 1.3.2 Specifics Objectives 1. To determine the proportion of female health workers practicing exclusive breastfeeding 2. To describe the reasons for the non practice of exclusive breastfeeding as described by female health workers. 1.4 Study Hypotheses Some hypotheses (at home, in health facilities and at workplace) have been associated with the practice of exclusive breastfeeding. They are: Maternity leave less than 17 weeks, women who undergo surgery during childbirth and availability of help at home. A test of those hypotheses will determine the significance of these difficulties in the practice of EBF among the participants of this survey. Other factors like maternal health, child health, peer influence as well as social norms were not tested in this study. Hypotheses related to work .Maternity leave in Ghana is 12 weeks and maternity leave less than 17 weeks has been identified to be associated with cessation of breastfeeding. Hypothesis: Exclusive breastfeeding is related to duration of maternity leave Hypotheses related to health facilities. Surgery during childbirth has been identified with non practice of exclusive breastfeeding. Hypothesis: Exclusive breastfeeding is related to the type of delivery Hypotheses related to home Availability of help at home has been identified with the practice of exclusive breastfeeding. Hypothesis: Exclusive breastfeeding is related to the availability of help at home. University of Ghana http://ugspace.ug.edu.gh 7 CHAPTER TWO 2.0 LITERATURE REVIEW 2.1 Benefits of Breastfeeding Breastfeeding has been recognized for many years as superior to bottle feeding in a variety of respects. Studies show that breastfeeding benefits infant, mother and society (Yimyam & Morrow, 1999). The first two years of life are critical stages for a child‟s growth and development. Any damage caused by nutritional deficiencies during this period could lead to impaired cognitive development, compromised educational achievement and low economic productivity (Kimani-Murage et al., 2011). Breastfeeding confers both short-term and long- term benefits to the child. It reduces risk of infections and mortality among infants, improves mental and motor development, and protects against obesity and metabolic diseases later in the life course (Kimani-Murage et al., 2011). Early initiation of breastfeeding is encouraged for a number of reasons. Mothers benefits from early suckling because it stimulates breast milk production and facilitates the release of hormone which helps the contraction of the uterus and reduce postpartum blood loss (Stuebe & Bonuck, 2008). Among mothers, not breastfeeding is associated with an increased risk of type 2 diabetes, breast and ovarian cancer, and myocardial infection (Stuebe & Bonuck, 2008).Infants who are not breastfed face increased risks of lower respiratory tract infections, obesity, diabetes, childhood leukemia, and sudden infant death syndrome (Stuebe & Bonuck, 2008) The first breast milk contains colostrums, which is highly nutritious and has antibodies that protect the newborn from diseases. Early initiation of breastfeeding also fosters bonding between mother and child (Health Canada, 2004). University of Ghana http://ugspace.ug.edu.gh 8 UNICEF and WHO recommend children to be exclusively breastfed during the first 6 months of life because breast milk is usually uncontaminated and contains all the nutrients necessary for children in the first few months of life (WHO, 2003). Breast milk protects the infant from pathogens and decreases their risk of infection, especially diarrheal diseases and in low resource settings, supplementary food is often nutritionally inferior and detrimental to the infant‟s nutritional status (Chudassama et al., 2009). 2.2 Breastfeeding Epidemiology In Ghana, over 98 percent of children born between 2003 and 2008 are ever breastfed. The results from the Ghana Demographic Health Survey 2008 show that there is no difference in early initiation of breastfeeding by sex of child. Children in urban areas (55 %) are slightly more likely to receive breast milk during the first hour after birth than children in rural areas (50 %). Similarly, children of women who gave birth in a health facility (56%) are more likely to initiate breastfeeding early than women who deliver at home (47 %)(GDHS, 2008). The survey results indicate that children whose births were assisted by someone other than a health professional or a traditional attendant, and children born at home, are more likely to receive a prelacteal feed (something other than breast milk) during the first three days of life than children whose births were assisted by a health provider, and children born in a health facility(GDHS, 2008). Recent trends from the GDHS indicate that the percentage of children ever breastfed has remained stable at 97-98%,on the other hand, the percentage of children who started breastfeeding within one hour of birth has increased from 46 to 52 % and the proportion of children who received prelacteal feeds decreased slightly from 20 percent to 18 percent between 2003 and 2008(GDHS, 2008). Promotion of exclusive breastfeeding for the first 6 months of life has been estimated to be the most effective preventive strategy for saving the University of Ghana http://ugspace.ug.edu.gh 9 lives of young children in low-income settings, and could contribute towards the Millennium Development Goal 4 of reducing child mortality (Tylleskar et al, 2011). In Ghana, breastfeeding extends to 20 months, while exclusive breastfeeding has short duration, with overall 63 percent of children under 6 months exclusively breastfed. In addition to breast milk children less than 6 months are given non breast milk (3 %), water (17 %), non-milk liquids or juice (less than 1 %) and solid food (17 %)(GDHS, 2008). Poor breastfeeding and complementary feeding practices have been widely documented in the developing countries. Only about thirty nine (39) percent of infants in the developing countries, twenty five (25) percent in Africa are exclusively breastfed for the first 6 months. Additionally, six (6) percent of infants in developing countries are never breastfed (Kimani- .Murage et al, 2011). Internationally, the relationship between employment and breastfeeding is far from established. Differences exist both among and within countries. Employment does not seem to influence breastfeeding initiation in either developed or developing countries (Yimyam & Morrow, 1999). Research on Exclusive breastfeeding by employment status is rarely available; however employed mothers are less likely to practice Exclusive Breastfeeding (Seteqn et al., 2012). 2.3 Factors affecting Exclusive Breastfeeding Exclusive breastfeeding is now the hallmark for breastfeeding during the first 6 months of life especially for the past decade. Despite its benefits, EBF is not always practiced. University of Ghana http://ugspace.ug.edu.gh 10 2.3.1 Individual (mother) Factors Some of the reasons for not practicing EBF are personal. Some women believe that they can lose their beauty and especially the firmness of their body and their breast in particular (Lindberg, 1996). And most of them claimed not to have enough breast milk for their baby or that their breasts or nipples are painful (Lindberg, 1996). Maternal knowledge and comfort (acceptance) with the practice of breastfeeding affect prenatal feeding intentions, and these intentions are strong predictors of feeding outcomes (Stuebe & Bonuck, 2008). The main reason given for introducing complementary foods to children below six months was that the mother had no or little breast milk (about forty percent) (Kimani-Murage et al., 2011). This reason according to Lindberg (1996) may not be the actual reason because women are often unable to articulate in survey responses and/or are uncomfortable reporting, less socially acceptable or mother-driven‟ reasons (such as fear or loss of breast shape) for not breastfeeding or stopping breastfeeding early. They tend to report more child-centered reasons such as “child did not want the breast” or reasons beyond the mother‟s control, notably, insufficient milk (Lindberg, 1996). Insufficient milk is said to be one of the commonest reasons women give for stopping breastfeeding, yet evidence indicates that less than five (5) percent of women are physiologically incapable of producing an adequate supply of milk. The explanation of insufficient milk therefore masks a range of underlying factors that undermine breastfeeding (Lindberg, 1996). Other personal reasons for common breastfeeding problems are inability to breastfeed due to sore nipples, inverted nipples, and breast engorgement. These problems are usually overcome when the right positioning, timing and techniques is applied in the practice of breastfeeding (Nankunda et al., 2006). The knowledge and skills of the mother in the practice of breastfeeding is therefore important and lack of knowledge and skills can prevent mothers to breastfeed their children. University of Ghana http://ugspace.ug.edu.gh 11 Various factors associated with sub-optimal breastfeeding have been identified in various settings. These include maternal characteristics such as age, marital status, occupation, and education level; antenatal and maternity health care; health education and media exposure; as well as method of delivery, birth order, and the use of pacifier (Kimani-Murage et al, 2011). 2.3.2 Group Factors (Work and/or home) Very few studies mentioned the lack of support at home as a factor preventing mothers to breastfeed their infants. This can be explained by the fact that women are reluctant to accuse people they love being the husband, the older children or close relatives for not giving the needed support at home for a successful breastfeeding practice. A lot of studies on the other hand address the role of workplace environment in the promotion of breastfeeding. In recent years, there has been a rise in the participation rate of women in employment. Some may become pregnant while in employment and subsequently deliver their babies. Most may decide to return early to work after giving birth for various reasons. Unless these mothers get support from their employers and fellow employees, they might give up breastfeeding when they return to work. As a result the duration and exclusivity of breastfeeding to the recommended age of the babies would be affected (Abdulwadud & Snow, 2008). Employers hold a range of attitudes about nursing working mothers, and they offer varying degrees of support for breastfeeding in the workplace. They express concerns about the difficulties of providing formal breastfeeding support, including monetary constraints, challenges of providing breaks, and limited space. Even when generally positive, employers‟ attitudes about breastfeeding have not translated into practices supporting breastfeeding mother in the workplace (Stratton & Henry, 2011). University of Ghana http://ugspace.ug.edu.gh 12 Workplace programs could help women to continue breastfeeding, and some programs may help women to initiate breastfeeding. By promoting and supporting the programs, employers may be able to influence the duration of exclusive breastfeeding and so improve the health of mother and baby, but also benefit from less work absenteeism, high productivity and increased employee morale and retention. A study from Abdulwadud & Snow showed that among working mothers enrolled in an employer-sponsored lactation program; breastfeeding was initiated by 97.5 percent of the women (Abdulwadud & Snow, 2008). Breastfeeding at the work place challenge the myth of separate worlds in which employment and family exist separately. It erases boundaries between women‟s private roles as mothers and public roles as worker (Lindberg, 2006). However if there are nursery breaks and child care provisions at the workplace, even formal urban employment can be compatible with breastfeeding (Yimyam & Morrow, 1999). 2.3.3 Societal Factors (Policy Planning) Efforts towards promoting the practice of breastfeeding led to the 1990 Innocenti Declaration which states that “all governments should create an environment enabling women to practice EBF for the first 6 months of life (Uchendu et al., 2009). The Labor Law provisions in the constitution and other statutes set up the legal framework for “labor” for the citizens of the country. In Ghana, there are Labor law provisions related to Exclusive breastfeeding and working mothers. Mothers feeding options have been influenced by both the existence of the regulation and the strong breastfeeding policy together with the Baby Friendly Hospital Initiative (BFHI). LI 1667 regulate the advertisement of infant formula by Manufacturers both in the Media and in the Heath facilities University of Ghana http://ugspace.ug.edu.gh 13 PNDC 305B section 3 on Deception of consumers stipulate that : a person who manufactures, labels, packages, sells or advertises a food in a manner that is false, misleading or deceptive as regards its characters, nature, value, additives, substance, quality, composition or safety commit an offence. PNDC 305B and LI 1667 were implemented to restrain manufacturers to deceive the public about the benefits of infant formula versus Exclusive Breastfeeding. Labor law in Ghana seeks to protect working mothers and some of them are: Act 55(1) unless with her consent, an employer shall not Assign or employ a pregnant woman worker to do any night work between the hours of 10.00 in the evening and 7.00 in the morning. Engage for overtime a pregnant worker or a mother of a child less than eight months old. Maternity, annual and sick leave Act 57(1) A woman worker, on production of a medical certificate issued by a medical practitioner or a midwife indicating the expected date of her confinement is entitled to a period of maternity leave of at least twelve weeks in addition to any period of annual leave she is entitled after her period of confinement. Act 57(2) a woman worker on maternity leave is entitled to be paid her full remuneration and other benefits to which she is otherwise entitled. Act 57(3) the period of maternity leave may be extended for at least 2 additional weeks where the confinement is abnormal or where in the course of the same confinement 2 or more babies are born Act 57(6) a nursing mother is entitled to interrupt her work for an hour during her working hours to nurse her baby. Act 57(7) this shall be treated as working hours and paid accordingly. University of Ghana http://ugspace.ug.edu.gh 14 In general, to achieve high rates of breastfeeding and women‟s employment, socio-cultural support and labor market, health and early childhood policies are vital (Abdulwadud & Snow, 2008). The WHO and UNICEF have initiated the Global Strategy for Infant and Young Child Feeding. The strategy highlights the priority actions, duties and responsibilities of various organizations and calls for governments to pass imaginative legislation to protect the rights of working women to breastfeed, and to establish the means to enforce these policies, which are consistent with international labor standard (Abdulwadud & Snow, 2008). WHO/UNICEF encourage the ten steps of successful breastfeeding for BFHI which are:1 have a written breastfeeding policy that is routinely communicate to all health care staff, 2 train all health care staff in skills necessary to implement this policy, 3 inform all pregnant women about the benefits and management of breastfeeding, 4 help mothers initiate breastfeeding within a half-hour of birth, 5show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants, 6 give newborn infants no food or drink other than breast milk, 7practice rooming-in-allow mothers and infants to remain together 24 hours, 8 encourage breastfeeding on demand, 9 give no artificial teats or pacifiers to breastfeeding infants, 10 foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic. In most industrialized countries, there is workplace-related legislation or regulation, or both, to support women employees to continue breastfeeding when they return to work. Legislation has been passed to have an effect on breastfeeding (Abdulwadud & Snow, 2008). Some developing countries are also making some efforts in the promotion of EBF. For instance, Agho et al (2011) report that the Nigerian government supported the Baby Friendly Hospital Initiative (BFHI) with the aim of providing mothers and their infants a supportive University of Ghana http://ugspace.ug.edu.gh 15 environment for breastfeeding. BFHI promotes appropriate breastfeeding practices thus helping to reduce infant morbidity and mortality rates. Some working nursing mothers commended the federal government (In Nigeria) for increasing the maternity leave from 12 to 16 weeks, calling for more baby-friendly policies to help nursing mothers to devote more time to their babies at the very crucial stage of the babies‟ lives (Sheyin, 2012).Some Health facilities in Ghana like the Mamprobi Polyclinic in Accra have provided a nursing room for nursing mothers to promote the practice of breastfeeding in infants less than 2 years. The purpose of BFHI is to actively protect, promote, encourage and support breastfeeding through education of health care workers in maternity and neonatal services. It also accredits those meeting the WHO/UNICEF criteria as a BFHI. (Nankunda et al., 2006) University of Ghana http://ugspace.ug.edu.gh 16 CHAPTER THREE 3.0 METHODS 3.1 Type of study and study design This was a cross-sectional study involving 163 mothers working in a health facility with a child of at least 6 months but less than 10 years at the time of working in the health facility. A quantitative study was conducted for a period of six weeks from15th May to 30th June 2012 at two health facilities in the greater Accra region in Accra, the capital of Ghana. 3.2 Study Location The study locations were La General Hospital and Ridge Regional Hospital. La General Hospital was established in 1963 and accredited to a district hospital status in 2004. It is the only government heath institution overseeing the work of both private and quasi government hospitals in the La Sub- Metropolis. La General Hospital has a catchment population of 243,471 and a bed complement of 105. Ridge Regional Hospital which was once known as the European Hospital was established in 1920 by the British to take care of the health needs of the European merchants and missionaries. The Hospital became the Greater Accra Regional Hospital in 1997. The Hospital is located in the OSU Clottey sub-district. The bed capacity at Ridge hospital is 348. Ridge Hospital receives referrals from other districts and clinics in the Greater Accra Region. 3.3 Variables The dependent variable is Exclusive Breastfeeding. The independent variables were the factors affecting Exclusive Breastfeeding. University of Ghana http://ugspace.ug.edu.gh 17 Independent Variables Background variables: Profession Age Marital status Level of education Number of children Income Skills of the mother in the practice of breastfeeding Sickness of the mother and/or the baby Mother desire to conserve the firmness of her breast Baby unfriendly atmosphere at work Nursing mother unfriendly atmosphere at work Nursing mother unfriendly atmosphere at home 3.4 Study Population This study involves women of reproductive age from 15 to 49 years working in the health Institutions of La General Hospital and Ridge Hospital as health workers, with a child of at least six months and at most ten years at the time of working in those health facilities. The health workers the study focus on are: Female Doctors of Medicine, Pharmacist, Nurses and Health care Assistants and allied health workers and administrators who have worked at La General Hospital and Ridge Hospital during the first six months of the life of the baby involved in the study. University of Ghana http://ugspace.ug.edu.gh 18 3.5 Sampling Procedure The Sampling frame of La General Hospital Workers obtained from the general Administration is 278 and include 13 Public Health nurses, 118 General Nurse‟s midwives, 6 Psychiatric nurses so at least 137 female health workers. Ridge Hospital total health workers are 872 including 203 professional nurses, 60 midwives, 79 enrolled nurses, 13 community health nurses, and 9 health assistants so at least 161 female health workers. The Sampling method chosen was purposive and convenient. Female health workers who fit the study population were taken from each department of both hospitals (La General and Ridge). The female health workers were Doctors, Pharmacist, Nurses, and Health care Assistant as well as allied Health workers and administrators in this Study who fitted the study population. 3.6 Sampling Size 163 female Health workers were involved in this study. The sample size for this quantitative survey was determined using a formula for estimation of single population proportion assuming an expected prevalence for exclusive breastfeeding of 11% using the prevalence of EBF in the female health workers in a similar study in Nigeria by Sadoh et al (2011) with 95% confidence level, 5% margin of error. Z2 P (100-P) N = ………………………. ε2 N = the required minimum sample size ε= margin error set at 5 P= prevalence of EBF among health workers- Z=95% confidence interval (1.96) University of Ghana http://ugspace.ug.edu.gh 19 N= 150 rounded to 163 for 10% missing data 3.7 Sampling Method The survey was carried out in selected health facilities which are La general Hospital and Ridge Hospital. These health facilities were selected on the basis of the assumption of having a large number of female heath workers in their institutions. Selection of the participants was done by using purposive and convenience sampling technique. Inclusion criteria were mothers who were workers at La General and Ridge Hospital with a child aged between 6 months and 10 years while working at those facilities at the time of the study. Exclusion criteria were mothers of child aged less than 6 months or more than 10 years and child with congenital malformations or born preterm and unable to suck. A structured survey questionnaire was administered by trainee interviewers to mothers of reproductive age from 15 to 49 years working in both health institutions of La General and Ridge. La General Hospital was first screened following by Ridge Hospital. Female health workers were approached department by department in each Hospital starting from the wards to the administration block and finally the allied health care centers like radiology, physiotherapy. The interviewer first introduce himself/herself, then introduce the topic of the survey and the permission to interview the female workers when she answered being a mother of a child aged between six months and ten years at the time of working in the selected health facilities. The usual age of six to five years used to assess EBF in most studies could not be achieved in this study due to the poor number of participants with a child age between six and five years during the pilot study and has to be extended to ten years despite the risk of recall-bias. . Exclusive Breastfeeding were assessed by referring to the Ten Steps to Successful Breastfeeding (WHO, 2002) by Bulle et al and a participant‟s answer to “Do you practice EBF” was filled YES when: 1 She has initiated breastfeeding within a half hour of delivery. 2 University of Ghana http://ugspace.ug.edu.gh 20 She was given the newborn infants no food or drink other than breast milk unless medically indicated. 3 No artificial teats or pacifiers were given to the breastfeeding infants .4 she was given Breast milk on demand as and when the child wanted 3.8 Data Collection techniques/Methods & Tools Data collection occurred between May and June 2012. Data collected include socio- demographic characteristics like marital status, level of education, number of children exclusively breastfeed and income. Some of the characteristics included exclusive breastfeeding status and this was assessed using the WHO recommendation for establishment and sustenance of breastfeeding. Mothers who have not given any liquid or semi-solid or solids food except breastmilk before the child was 6 months were said to have exclusively breastfed their children in the first 6 months of life. The data for the study was collected through a questionnaire. Interviewers administered questionnaire and a face-to-face interview was used to gather data from 163 participants. The researchers conducted all the interviews and the language of the interview was English. Participants with a busy schedule were given two options: the flexibility to fill the form within three days or an attachment to their email address given previously to the researcher and to be sent back within three days. All participants filled the forms; none of the participants gave their email address. 3.9 Quality Control Researchers assistant were given one day training on the administration of the questionnaires and introduction to the various departments of the two selected Hospitals were done on the day training. Three assistant researchers were responsible for the follow up of the University of Ghana http://ugspace.ug.edu.gh 21 Questionnaire. Collection of the forms was done every day at closing official hour (5pm).The forms were reexamined at the end of the day and cross-examined by the researcher. 3.10 Data Processing and analysis Field data were entered by the researcher using the Statistical Package for Social Sciences (SPSS) Version 16.0. The data was then cleaned thoroughly to ensure that all inconsistencies and recording errors were eliminated. Data analysis was done with the same software. Frequency distributions were obtained and these were summarized in tables and charts. The charts were drawn with Microsoft Excel. For all statistical tests, α = 0.05 was used to determine statistical significance. Logistic regression was performed to determine the strongest determinant of exclusive breastfeeding using stata8. 3.11 Ethics The following measures were taken to ensure that participants‟ rights were protected and their safety was guaranteed: Ethical clearance was obtained from the Ghana Health Service Ethical Review Committee. Participants were assured of privacy and confidentiality. They were informed about their rights to withdraw from the study at any point of time. Informed consent was obtained from all participants after the study had been explained to them. Permission was obtained from the authorities of La General and Ridge Regional Hospitals. University of Ghana http://ugspace.ug.edu.gh 22 3.12 Pretest and Pilot Study The study questionnaire was pre-tested among 10 female health workers sampled from a different hospital which is the Legon Hospital in Accra at the premises of the University of Ghana, Legon. Feedbacks from the pre-test were noted and the necessary modifications were made to the questionnaire for readability and comprehension. 3.13 Limitation of the study The age of the child involved in the study should have been ideally less than 5 years to avoid the risk of recall-bias unfortunately the pretesting at the pilot study site revealed that the number of participants for the survey would have drastically reduced so the age of 6 months to 10 years was finally chosen. Female Health workers was first thought to be only female medical doctors for this study but the poor number of female doctors available in these institutions forced to expand the female health workers to any female working in those health institutions ( Ridge and La General). University of Ghana http://ugspace.ug.edu.gh 23 CHAPTER FOUR 4.0 RESULTS 4.1 Socio-demographic Characteristics The 163 respondents surveyed for this study were females with each having a child aged between six months and 10 years. A cross-section of the female health workers at the La General Hospital as well as Ridge Hospital had their opinions represented in this survey. The study sought the age, marital status, level of education, number of children, number of children exclusively breastfed, profession, and income level. Details summarized in the Table 1. The majority of respondents interviewed were from the Ridge Hospital- a total of 103 and representing 63.2% of the respondents while the remaining 60 (36.8%) were health workers at the La General Hospital. The majority of the respondents were Nurses. These made up 57.1% of the total respondents. Allied Health Workers interviewed (Lab Technicians, Radiologists, Physiotherapists) numbered 36 out of the 163 (22.1%) health professionals interviewed. Nineteen (11.7%) of the professionals interviewed were Hospital Administrators, 11 (6.7%) were Healthcare Assistants, and only 4 (2.4%) were Medical Doctors. There were 77 (47.2%) of the respondents interviewed who fell within the 31-40 years age bracket, 64 respondents representing 39.3% were aged between 20-30 years, and 22 (13.5%) were above 40 years old. The majority (153 respondents) reported being married and made up 93.9% of total respondents surveyed. Six (3.7%) were single and 4 (2.5%) were either divorced or widowed. Only one respondent did not go beyond primary level education. Thirty five respondents (21.5%) had up to secondary school education. The majority (127 respondents) however had tertiary education, and this represented 77.9% of the total respondents. The majority of University of Ghana http://ugspace.ug.edu.gh 24 female health workers (84 and representing 51.5% of respondents) had more than one child. Female health workers who earned a monthly income of 500 Ghana cedi or less numbered 54 (33.1%). Those who earned between 501–1000 Ghana cedi were 79 (48.1%) in total and representing the majority. Twenty eight (17.2%) of the female health workers interviewed earned between 1001 and 2000 Ghana cedi. Only 2(1.2%) of the respondents reported earnings of more than 2000 Ghana cedi. Table 1: Background Characteristics of Female Health workers (N=163) Name of Health facility Frequency Percent La Hospital 60 36.8 Ridge Hospital 103 63.2 Profession Doctors 4 2.4 Nurses 93 57.1 Health Care Assistants 11 6.7 Allied Health Workers 36 22.1 Administrators 19 11.7 Age group 20 – 30 64 39.3 31 – 40 77 47.2 Above 40 years 22 13.5 Marital status Married 153 93.9 Single 6 3.7 Divorced/Widow 4 2.5 Level of Education Primary 1 0.6 Secondary 35 21.5 Tertiary 127 77.9 Number of children One 79 48.5 More than one 84 51.5 Monthly income(Ghana Cedi) 500 or less 54 33.1 501 – 1000 79 48.5 1001 – 2000 28 17.2 More than 2000 2 1.2 University of Ghana http://ugspace.ug.edu.gh 25 4.2 Exclusive Breastfeeding Background variables such as respondents profession, age group, marital status, level of education, and income level were matched against their responses that they exclusively breastfeed or not. The purpose was to explore the existence of any association or otherwise between the dependent variable (exclusive breastfeeding), and the background variables. The reported exclusive Breastfeeding (for 6 months) rate among the participants were sixty height (68) percent representing 111 female health workers. Table 2 shows that exclusive breastfeeding is not significantly associated with most of the background variables including profession, age, marital status, and number of children. There is no significant difference among the categories of health workers in their practice of exclusive breastfeeding (Nurses are not more likely to exclusively breastfeed compared to the other professionals). Similarly, there is no significant difference in the age group of respondents to exclusive breastfeeding, no difference in marital status to exclusive breastfeeding, and no significant difference in the number of children one has given birth to and their practice of exclusive breastfeeding. However, significant effects or differences were discovered among respondents‟ level of education vis a vis exclusive breastfeeding. Health workers with a tertiary education as per this study are more likely to exclusively breastfeed their child/children than female health professional with a secondary or a primary education. Similarly significant differences were observed with respondents‟ monthly income and their practice of exclusive breastfeeding. Female health workers with a monthly income of less than 1000 Ghana cedi are more likely to practice exclusive breastfeeding than their counterpart with a monthly income of more than 1000 Ghana cedi. University of Ghana http://ugspace.ug.edu.gh 26 Table 2: Exclusive Breastfeeding According to Background Characteristics of Respondents Exclusively breastfed child No Yes Total Pearson Chi- Square p-value Profession Nurses 36 (38.7%) 57(61.3%) 93(100.0%) 7.68 0.104 Health Care Assistants 5(38.5%) 8(61.5%) 13(100.0%) Allied Health Workers 5(15.2%) 28(84.8%) 33(100.0%) Administrators 4(21.1%) 15(78.9%) 19(100.0%) Pharmacies/Doctors 2(40.0%) 3(60.0%) 5(100.0%) Age group 20 – 30 21(32.8%) 43(67.2%) 64(100.0%) 1.24 0.538 31 – 40 22(28.6%) 55(71.4%) 77(100.0%) Above 40 years 9(40.9%) 13(59.1%) 22(100.0%) Marital Status Married 48(31.4%) 105(68.6%) 153(100.0%) 0.322 0.571 Not married 4(40.0%) 6(60.0%) 10(100.0%) Level of education Secondary 5(13.9%) 31(86.1%) 36(100.0%) 6.901 0.009 Tertiary 47(37.0%) 80(63.0%) 127(100.0%) Number of children One 25(31.6%) 54(68.4%) 79(100.0%) 0.005 .946 More than one 27(32.1%) 57(67.9%) 84(100.0%) Income Less than 1000 37(27.8%) 96(72.2%) 133(100.0%) 5.543 0.019 More than 1000 15(50.0%) 15(50.0%) 30(100.0%) TOTAL 52(32%) 111(68%) 163(100%) 4.2.1 Proportion of female health workers who practice exclusive breastfeeding The question asked was “did you exclusively breastfeed your child”, question 10 in the questionnaire? The participants were told prior to the question the meaning of EBF in our study and as recommended by WHO/UNICEF and GHS.EBF was initiating breastfeeding within half hour delivery, giving newborn infant no food or drink other than breast milk, University of Ghana http://ugspace.ug.edu.gh 27 unless medically indicated, giving no artificial teats or pacifiers to breastfeeding infants and giving breastfeeding on demand. One hundred and eleven respondents representing 68% of the female health workers interviewed (the majority) said that they did practice exclusive breastfeeding with their child/children for 6 months as recommended by WHO/ GHS. 32% responded that they did not practice exclusive breastfeeding and those numbered 52. 4.3. Individual Factors influencing respondents inability to exclusively breastfeed Exclusive breastfeeding can be influenced by a number of factors. One of them is the individual personal reasons for not practicing exclusive breastfeeding. Cosmetic reasons like flat breasts, poor health status of the mother or the infant, poor skills in the practice of exclusive breastfeeding, poor knowledge of the benefits of exclusive breastfeeding were some of the personals reasons for not practicing exclusive breastfeeding. Most respondents mentioned multiple reasons and responses were analyzed separately as shown in Figure2. Figure 2 show that 3.8% of the 52 respondents who did not practice exclusive breastfeeding said „they wanted to preserve the firmness of their breasts/body‟. Out of the 52 who did not exclusively breastfeed 5.8% reported that either they or their baby was sick and resulted in their inability to exclusively breastfeed. The majority of the respondents (55.8% of the 52 who did not exclusively breastfeed) reported incompatible work hours with the practice of exclusive breastfeeding as their reasons for not practicing exclusive breastfeeding. Some 17.3% out of the 52 did not exclusively breastfeed because co-workers became antagonist of their having to close earlier than others in order to exclusively breastfeed their babies. 34.6% out of the 52 who did not practice exclusive breastfeeding could not do so because of the unavailability of private rooms for breastfeeding at work places. Finally 40.4% respondents selected their having to resume work as a factor that caused them to break their practice of exclusive breastfeeding. University of Ghana http://ugspace.ug.edu.gh 28 Figure 2: Individual Factors influencing respondents inability to exclusively breastfeed 4. 4 Hospital Factors influencing Exclusive Breastfeeding Practice 4.4.1 Venue of Delivery The structure of a Health facility, adequate drugs provision and equipments in a Health center as well as the human resources especially the skilled professionals make a huge difference in the outcome of health service delivery. The venue of delivery can influence the practice of exclusive breastfeeding especially the information given to the pregnant women and more importantly in this study the counseling given and the guidance given in the practice of exclusive breastfeeding just after delivery (the positioning of the baby on the breast, the timing of early breastfeeding and other practical short steps to ensure successful exclusive breastfeeding). The majority of the respondents representing 61.4% had their child delivery at the Regional Hospitals. Thirty eight (23.3%) female health workers delivered in a University of Ghana http://ugspace.ug.edu.gh 29 Teaching Hospital and the remaining 25(15.3%) respondents delivered in Private Hospitals. (Refer to Figure3). Figure 3. Venue of Delivery 4.4.2 Type of Delivery With respect to the delivery type, 56.4 % of the female health workers interviewed delivered through a spontaneous vaginal delivery, 36.2 % through a Caesarean section, and 12 (7.4%) said they delivered via assisted vaginal delivery (Figure 4). 0 10 20 30 40 50 60 70 80 90 100 Teaching Hospital Regional Hospital Private Hospital 23.31% 61.35% 15.34% University of Ghana http://ugspace.ug.edu.gh 30 Figure 4: Type of Delivery 4.5 Factors at work affecting Exclusive breastfeeding 4.5.1 Breastfeeding hour break at work within 6 months post delivery The majority of the respondents (115; 70.6%) said they did not have any hour break for breastfeeding during the day at their workplace. The remaining 48 (29.4%) said they did have one hour break for breastfeeding their babies during work hours. 4.5.2 Work hours after Delivery In the majority of developed countries, the labor law has statutory decrees to protect the right of the working nursing mother and one of them is the working hours of a nursing mother which ideally should be maximum 4 hours a day especially the first 6 months after delivery. With respect to the duration of hours of work after resumption of work following Delivery, 6.1% of the respondents said they worked for less than four hours a day, 88.9% said they did so for between 4 – 8 hours a day and 4.9% said they worked for a period longer than 8 hours a day (Figure5). Caesarian Section Spontaneous Vaginal Delivery Assisted Vaginal Delivery 56.4% 7.4% 36.2% University of Ghana http://ugspace.ug.edu.gh 31 Figure 5. Work Hours per day 4.5.3 Work/Duty Resumption Data collated indicates that 67.5% of the sampled female health workers from La General Hospital and Ridge Hospital resumed work between 3 and 6 months after delivery. Twenty seven % (27%) resumed work within 1 to 3 months postpartum, 4 (2.5%) resumed work in less than one month postpartum. There were 5 (3.1%) of the respondents who resumed work after 6 months for various reasons including being on cumulated leave or on leave without pay. 4.6 Factors at home affecting exclusive breastfeeding A respondent‟s receipt of home assistance in catering to basic chores such as washing/cleaning, cooking, bathing the baby, etc is very important to their ability to exclusively breastfeed their baby. Over 90% (152) of the respondents received help at home after giving birth. Only 11 (6.7%) of the respondents said they did not receive any help at home after their having delivered a child. 6.13 88.96 4.9 0 10 20 30 40 50 60 70 80 90 100 Less than 4h0urs Between 4and 8 hours More than 8 hours Hours work Per Day University of Ghana http://ugspace.ug.edu.gh 32 For the 152 female health workers who received help at home following their delivery, a multiple response set was used to capture the source of help received. (Refer to table 3). Table 3: Sources of Help At Home after Child Birth Source of Help N=152 (100%) Husband 26.9% Older Children 0.5% Close relative (Mother, Aunt) 59.4% Friends 2.4% Help maid 10.8% The multiple response from table 3 indicates that out of the 152 respondents who indicated that they got help at home after their child birth, (26.9%) obtained the assistance from their husbands, only one person said she obtained help from her older child/children, 59.4% said they got help from close relatives such as their respective mothers/older aunties, cousins or nieces/nephews. Two point four (2.4%) got help from their friends and (10.8%) got help from their housemaids. An individual help could have come from several persons at the same time (example husband, mother and older children or husband and help maid). University of Ghana http://ugspace.ug.edu.gh 33 4.7 Tests of Hypothesis Table 4 EBF by selected independent variables VARIABLE EXCLUSIVE BREASTFEEDING FOR 6 MONTHS (df) P-value Resumption at work YES NO Three months or less 30 (27.0%) 17 (32.7%) 1.699 0.428 More than three months but less than six months 78 (70.3%) 32 (61.5%) Six months and more 3 (2.7%) 3 (5.8%) Type of delivery 21.2 <0.001 SpontaneousVaginal Delivery 75 (67.5%) 17 (32.7%) Assisted Vaginal Delivery 8 (8.1%) 5 (8.3%) Caesarean Section 27 (24.3%) 32 (61.5%) Help at home 1.02 0.312 Yes 102 (91.9%) 9 (8.1%) No 50 (96.2%) 2 (3.8%) Test of hypothesis one: Exclusive Breastfeeding is related to duration of maternity leave. The p value of 0.428 is greater than 0.05 our chosen level of significance so the null hypothesis is rejected and therefore the practice of EBF is not significantly associated with the resumption at work after the maternity leave (before six months as per this study).The practice of EBF among Female health workers who resumed work before six months is not different from their counterpart who did not resume work. University of Ghana http://ugspace.ug.edu.gh 34 Test of hypothesis two: Exclusive breastfeeding is related to the type of delivery The chi square test of EBF with the type of delivery female workers experienced shows a p value of 0.000 a value lower than our significance level, the null hypothesis is therefore not rejected. Female health workers who delivered spontaneously are twenty one time more likely to practice EBF than the female mother who delivered through surgery/caesarean section. Test of hypothesis three: Exclusive breastfeeding is related to the availability of help at home The p value for this test is 0.312 and it is greater than 0.05 so therefore the null hypothesis is rejected and the availability of help at home do not influence the practice of EBF. Female workers who get help at home do no practice EBF more than those who do not get help at home. 4.8 Logistics Regression of Exclusive Breastfeeding on Various Independent Variables Direct logistic regression was performed to assess the impact of a number of factors on the likelihood that female health workers (respondents) would exclusively breastfeed their child/children. The model contains seven independent variables (level of education, income, type of delivery, hour break for breastfeeding, hours of work per day, resumption of work, help at home,). University of Ghana http://ugspace.ug.edu.gh 35 Table 5 logistic regression table on EBF and independent variables Variable Odds Ratio (95% CI) P-value Level of education 0.187 Secondary 1 (ref) Tertiary 0.50 (0.15-1.44) Income 0.045 Less than 1000.00 Ghana cedi 1 (ref) More than 1000.00 Ghana cedi 0.38 (0.14-0.98) Type of Delivery < 0.001 Assisted Delivery 1 (ref) Spontaneous vaginal Delivery 4.9 (2.23-10.62) Help at home 0.323 No 1 (ref) Yes 0.38 (0.06-2.5) Hours break for breastfeeding per day 0.976 No 1 (ref) Yes 1.0 (0.42-2.42) Hours per day 6 months post delivery Less than 4 hours 1 (ref) Between 4 and 8 hours 1.67 (034-8.27) 0.526 More than 8 hours 4.74 (0.27-83.39) 0.287 Resumption of work Less than one month 1 (ref) Between 1-3 months 5.63 (0.41-76.66) 0.194 More than 3 months but less than 6 months 7.24 (0.55-94.88) 0.131 0ther 1.31 (0.06-32.42) 0.829 As shown in table 5, only two of the independent variables made a statistically significant contribution to the model (Income and type of delivery).One of the strongest predictor of factors influencing health workers to practice exclusive breastfeeding is income, recording an odd ratio of 0.38 and 95% confidence interval (014-0.98) with a p value of 0.045. This University of Ghana http://ugspace.ug.edu.gh 36 indicated that respondents who get more income are less likely to exclusively breastfeed. The other strongest predictor of factor influencing health workers practice of EBF is type of delivery. The odd ration is 4.9 with 95% confidence interval (2.23-10.62) with a p value of 0.000 thus indicating that respondents who deliver spontaneously have almost five times the likelihood of practicing EBF compare to those who delivered through assisted delivery including surgery (caesarean section). University of Ghana http://ugspace.ug.edu.gh 37 CHAPTER FIVE 5.0 DISCUSSION 5.1 Background information and Characteristics of the study population Exclusive breastfeeding (EBF) has been defined as feeding an infant with breast milk only without given any other foods, not even water. The definition allows for prescribed medicine, immunizations, vitamins and minerals supplements (WHO, 2001). There is a wealth of information on the benefits of Exclusive Breastfeeding for the first 6 months of life for the mother and infant (Okolo et al, 2002), some of them are adequate growth, anti-infective properties and increase intellect quotient and is one of the most natural and best forms of preventive medicine (WHO, 1991; WHO, 2008). It has been estimated that EBF reduces infant mortality rates by up to 13% in low income countries (Jones et al, 2003). The importance of supporting breastfeeding stands in the spotlight for health promotion (Stratton et al, 2011). This study was carried out in two hospitals- La General Hospital and Ridge Hospital both in the Greater Accra Region. The respondents were female health workers from those two institutions. This study considered Health workers as professionals working in a health institution and included Health professionals like doctors, pharmacists, nurses, healthcare assistants but also workers from allied health field like laboratory technicians, and finally administrators including secretary, accountant etc... There were 163 respondents for this study with each of them having a child aged between 6 months and 10 years at the time of working for those institutions. The range for the age of the child was important since the assessment was on the practice of EBF by the female Health workers. Six months was the minimum time to assess EBF since the mother would have just completed the recommended duration of time for EBF; 10 years was the maximum time to University of Ghana http://ugspace.ug.edu.gh 38 assess EBF in order to avoid recall bias from the respondents. The majority of respondents interviewed were from the Ridge Hospital- a total of 103 representing 63.2 % of the respondents while the remaining represented 36.8%. Ridge Hospital is a regional hospital and its human resources are far greater than the staff at La General Hospital and explain the greater percentage of female health workers found at Ridge Hospital compared to La General Hospital. Doctors represented the least percentage of female Health workers (2.4%) while the nurses represented the majority (57.1%). A look at the Ghana Health Services information on Health workforce status show big disparities between categories of Health workers in Ghana (example Total of General medical practitioners- 1945 with 545 women and 1362 in Urban area, 538 in rural area, 1400 in Public institutions and 545 in Private Health institution compared to Nursing Professionals- 8938 with 6882 women and 2459 in urban area, 5738 in rural area, 3302 in Public institutions, 1627 in private Health institutions). The respondents who fell within the 31-40 age brackets were 47.2%, 39.3% were aged between 20-30 years and13.5% were above 40 years. The majority of the respondents representing 77.9% of the total study population had tertiary education, and this result could be explained by making a parallelism with the majority of category of health workers presents in this study meaning the nurses whose education level is tertiary education for the majority. Female Health workers reported being married at 93.9% of the total respondents surveyed. The criteria of having a child in a setting where single mothers are seen as failure may have had an influence of mothers who were not married to report being married and therefore bloating the percentage of married female health workers. The influence of Religion in the decrease of premarital sex could also explain those values. The proportion of female health workers who practice EBF is 68% an encouraging number which is slightly higher than the Ghana Demographic Heath Survey (2008) value where the percentage of children at 6 months exclusively breastfed is 63%. University of Ghana http://ugspace.ug.edu.gh 39 This report is similar to the study “Breastfeeding practices of mothers in the Legon hospital catchment area” by Sartie, K. (2010) where 47.6% of mothers did practice EBF. However the Female Health workers reported rate of practicing EBF in this study is higher. The higher percentage of EBF among female health professionals may be due to bias-answer since a health professional is expected to promote EBF. The participants may also have a better knowledge of the benefits of the practice of EBF although some studies like a study by Utoo et al (2012) showed otherwise. In Utoo et al survey, 36 health workers were screened for their breastfeeding knowledge and the study revealed that there is unacceptable knowledge gaps among frontline cadres of health workers. Female health workers who earned a monthly income of 501-1000 Ghana cedi were the majority of the respondents interviewed with 48.1% of them, followed by those who earned less than 500 Ghana cedi and 17.2% for those earning between 1001 and 2000 Ghana cedi. Female health workers of La Hospital and Ridge hospital were more likely to earn an income of less than 1000 Ghana cedi since the majority of the respondents were nurses and the income of less than 1000 Ghana cedi correspond to the income of majority of the nurse in Ghana at the time of the study. Exclusive breastfeeding is not significantly associated with most of the background variable including profession, age, marital status, number of children. There is no significant difference among the different categories of health workers in the practice of EBF. No particular age group among the respondents in this study does influence the practice of EBF. Similarly there is no significant difference in the number of children one has given birth to and the practice of EBF as per this study. These findings do not compare favorably with some studies published earlier on this issue and among them Guendelman et al (2009) where the author states that low educational attainment, young age, being single and for multiparous ( University of Ghana http://ugspace.ug.edu.gh 40 giving birth more than once) having no previous breastfeeding experience is a risk factor for early breastfeeding cessation”. This observation may have several possible explanations. First, the women in the sample are 94% married so that the effect of being single and not practicing EBF is not felt. Secondly, the category of health workers did not significantly influence the practice of EBF and this finding correlate with a survey by Sadoh et al (2011) in which 30 medical doctors in Nigeria were interviewed about their breastfeeding knowledge and experience. The study by Sadoh et al showed that the female health workers knew all the duration of EBF but only 11% did practice EBF for the 6 months. The practice of EBF lay on different factors than the category of the female health workers. Beside the information can be easily acquired and does not need a particular hierarchy position to be understood. Thirdly, the number of children did not significantly influence the practice of EBF because a female health worker choice of EBF is not influenced by her knowledge but by different factors imposed on her, consequently the mother of one who did not practice EBF will not practice EBF when she is mother of two if the challenges forcing her first choice are still present. In the other way significant differences were observed with respondents‟ monthly income and their practice of EBF. Respondents with a monthly income of less than 1000 Ghana cedi are more likely to practice EBF than female health workers with a monthly income of more than 1000 Ghana cedi. This report go against a study by Stratton and Henry (2011) in “What employers and Health care providers can do to support breastfeeding in the workplace: aiming to match positive attitudes with action” stated that “mother from low income are less likely to breastfeed than women of higher socioeconomic status due to mixed factors including lack of education, confidence, and social support, in addition to perceived difficulties associated with return to work. These moms may return to work earlier than higher income groups for financial reasons” The difference with Stratton and Beverly work is University of Ghana http://ugspace.ug.edu.gh 41 that among female health workers in this study who earned more than 1000 Ghana cedi in Ghana, the flexibility of work is poorly available compare to those who earn less than 1000 Ghana cedi making the latter group more likely to have time for the practice of EBF and explaining the findings. In addition the female health workers as per this study have the same length of maternity leave making less likely for one to return from work before the expected length of maternity leave because of financial constraints. The relation between income level and the practice of EBF is that the higher the income level, the weaker the practice of EBF and this can be explained by the fact that high income earners usually hold managerial position which may lack job flexibility and these can lead to non practice of EBF. Similarly significant differences were discovered among respondents ‟level of education and their practice of EBF. Health workers with a tertiary education as per this study are more likely to exclusively breastfeed their child/children. Then the significant association between higher education and the practice of EBF in this study may follow the high percentage of tertiary education holder in this study. The reported percentage of respondents who reported practicing EBF is 68% (111 respondents) suggesting that 52 female health workers (32% precisely) reported not practicing EBF. This findings show the determination of the female health workers at La General Hospital and Ridge to practice EBF contrary of Sadoh et al (2011) study in which only 11% health workers did practice EBF for 6 months. Cosmetic reason is one of the individual reason for not practicing EBF and represented 3.8% of the reasons Health workers did not practice EBF in this study. Agunbiade & Opeyemi (2012) in their work on breastfeeding in Southwest Nigeria explained that some of the University of Ghana http://ugspace.ug.edu.gh 42 obstacles prevalent in some African communities include the perception that by continually breastfeeding the child, the breast becomes floppy and unappealing for their husband who preferred well shaped breasts. They also explained that one reason why breastfeeding is discontinued is due to the breast aches and pain experienced by mothers during breastfeeding. These concerns are similar to the study findings and can be addressed by more information on the role of pregnancy on the body of the mother which has nothing to do with EBF. Pregnancy plays more than EBF an important role in the change of shape of mother‟s body. The schedule at work as well as poor cooperation with colleagues and non availability of nursing office room are all challenges from the work place. Incompatibility of duration of maternity leave and EBF is a policy planning setting imposed on the individual. A greater percentage of the respondents (61.4%) delivered in a Regional hospital and this can be explained by the greater percentage of respondents from Ridge hospital which is a regional hospital.. Only 6% of the female health workers interviewed worked for less than 4 hours after resumption of work following delivery; 89% work between 4-8 hours and 5% more than 8 hours. Less than one-third (29%) of the respondents did have an hour break at work while 71% did not have an hour break. The labor law of the Republic of Ghana Act 57 section 6 stipulates that “a nursing mother is entitled to an hour break during working hours” but unfortunately most of the health workers concentrate on their work and have few knowledge about their right. Consequently few of them were entitled to an hour break during working hours. The majority of the female health workers (68%) resumed work 3-6 months following delivery while 27% resumed work 1-3 months after delivery and 5% less than a month after delivery. Yimyam & Morrow (1999) in “breastfeeding among employed Thai women in Chiang Mai” revealed that women who were working outside the home for a long period or University of Ghana http://ugspace.ug.edu.gh 43 had shift jobs encountered many obstacles to maintain breastfeeding, and most gave it up within 1 month after resuming employment. ” The chi square testing Exclusive breastfeeding and resumption at work (before six months as per this study) in table 4 showed a p value of 0.428. Therefore the hypothesis related to resumption of work (less than 6 months) is not accepted and Resumption at work is not associated with the practice of Exclusive breastfeeding. The explanation of this finding can come from the fact that in Ghana the resumption at work following delivery is usually between three to five months. The maternity leave is three months and female workers usually add their annual leave which is approximately two months to get five months off work. However the practice of exclusive breastfeeding is done during the first six months of life of the infant and the duration of maternity leave is less than six months so one can think of the difficulties female workers go through to maintain the exclusive breastfeeding especially the last month of EBF. Female health workers are usually left with a month to complete the 6 months EBF when they resumed work. They have the choice of expressing their breast milk during that period for the infant at home. This finding correlate with the work of Yimyam and Morrow (1999) in “Breastfeeding practices among employed Thai women in Chiang Mai” which stated that “women who were working outside the home for long period or had shift jobs encountered many obstacles to maintaining breastfeeding, and most give up within one month after resuming employment”. And those difficulties are accentuated when the place of work is far from home and Yimyam and Morrow acknowledge in their work that “rural occupations are usually more compatible with child-care activities, including breastfeeding because work in or around the home is usually flexible”. Abdulwadud and Snow (2008) in “Interventions in the work place to support breastfeeding for women in employment” stated that “most women may decide to return to work and unless they get support from their employers and fellow employees, they might give up University of Ghana http://ugspace.ug.edu.gh 44 breastfeeding when they return to work”. The return from work is then a problem for the success of the practice of exclusive breastfeeding and unless the return from work is done after the duration of exclusive breastfeeding so after six months, the risk for the mother to interrupt the breastfeeding and not achieve exclusive breastfeeding is still present. And Guendelman et al (2008) said in their study in “Juggling work and Breastfeeding: effects of maternity leave and occupational characteristics” where they examine the relationship between breastfeeding and maternity leave before and after delivery among working mothers in \southern California that “ a maternity leave of less than six weeks or six to twelve weeks after delivery was associated respectively, with a fourfold and twofold higher odds of failure to establish breastfeeding and an increase probability of cessation after successful establishment, relative to women not returning to work“. In our study, female health workers who resumed work before six months did not practice exclusive breastfeeding more than those who did not resume work. Nursing mothers working in most Health institutions in Ghana resumed work in general 5 months following delivery (12weeks of maternity leave added to 2 months of annual leave) and close work before 2pm when they resumed work These schedule probably allow flexibility to express and keep breastmilk at home and continuing breastfeeding when returning home . The majority of the respondents (56.4%) delivered by spontaneous vaginal delivery while an important number (36.2%) delivered by Caesarean section and 7.4% by assisted vaginal delivery The chi square test show a strong relation between Exclusive breastfeeding and the type of delivery and this relation is significant (p