Agyekum et al. 
International Breastfeeding Journal           (2022) 17:21  
https://doi.org/10.1186/s13006-022-00462-z
RESEARCH Open Access
Enablers and inhibitors of exclusive 
breastfeeding: perspectives from mothers 
and health workers in Accra, Ghana
Martin Wiredu Agyekum1,2* , Samuel N. A. Codjoe2, Fidelia A. A. Dake2 and Mumuni Abu2 
Abstract 
Background: Despite the health and economic benefits of exclusive breastfeeding, there is evidence of a decline 
globally and in Ghana. Previous studies addressing this problem are mostly quantitative with only a few of such 
studies using qualitative or mixed methods to examine the predictors, benefits, ways of improving and managing 
exclusive breastfeeding, and the challenges associated with exclusive breastfeeding from the perspective of exclusive 
and nonexclusive breastfeeding mothers, and health workers. This study employs the health belief model to examine 
the experiences of mothers and health workers regarding exclusive breastfeeding to fill this gap in the literature.
Methods: A cross-sectional qualitative study involving in-depth interviews was conducted among health workers 
and mothers attending child welfare clinic at two polyclinics in Madina, Accra-Ghana in 2019. Purposive sampling was 
used to select health facilities and participants for the study. Twenty participants comprising ten exclusive breastfeed-
ing mothers, six non-exclusive breastfeeding mothers and four health workers were interviewed for the study. The 
data were analyzed based on emerging themes from inductive and deductive coding.
Results: The decision to practice exclusive breastfeeding was based on mothers’ work, advertisement on exclusive 
breastfeeding and education on breastfeeding provided by health workers. Insufficient flow of breast milk, pressure 
from family and friends, and insufficient breast milk for infants were among the reasons for discontinuing exclusive 
breastfeeding. The factors that help improve exclusive breastfeeding include eating healthy food and breastfeeding 
on demand, while  counselling and monitoring, restricting advertisement on infant formula and granting maternity 
leave for breastfeeding mothers were identified as factors that can  facilitate the practice of exclusive breastfeeding.
Conclusion: Different levels of experience affect and shape exclusive breastfeeding practice in Ghana. The decision 
to practice exclusive breastfeeding, as well as the challenges and strategies employed in managing exclusive breast-
feeding, emanates from mothers’ personal experiences and interactions with institutional factors. In view of this, there 
should be counselling on the management of challenges associated with exclusive breastfeeding and provision of 
accurate information on  exclusive breastfeeding to enable mothers practice exclusive breastfeeding.
Keywords: Exclusive breastfeeding, Decision making, Discontinuation, Enablers and inhibitors, Ghana
Background
Exclusive breastfeeding (EBF) is a public health inter-
vention that provides optimal feeding as well as eco-
nomic, social and health benefits for the reduction of 
*Correspondence:  mwagyekum@uew.edu.gh
1 Institute for Educational Research and Innovation Studies, University morbidity and mortality among infants and moth-
of Education, Winneba, P. O. Box 25, Winneba, Ghana ers [1, 2]. Globally, empirical evidence shows that the 
Full list of author information is available at the end of the article prevalence of initiation of  exclusive breastfeeding 
© The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which 
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the 
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Agyekum et al. International Breastfeeding Journal           (2022) 17:21 Page 2 of 15
initiation is very high, but few mothers continue exclu- improvement of exclusive breastfeeding could thus help 
sive breastfeeding up to six months [3]. Early discon- mothers understand exclusive breastfeeding better and 
tinuation of exclusive breastfeeding could be attributed enable them to overcome the challenges associated with 
to challenges of EBF and mothers’ inability to manage exclusive breastfeeding [17].
these challenges [4–9]. While on the one hand, factors In Ghana, according to the 2014 Ghana Demographic 
such as insufficient milk production, lack of support for and Health Survey, there has been a decline in the preva-
mothers, low confidence of mothers and pressure from lence of exclusive breastfeeding as  measured using the 
family and friends have been identified as barriers to 24-h recall method. The prevalence of exclusive breast-
the practice of exclusive breastfeeding and thereby con- feeding has been observed to have declined from 63% in 
tributing to the low prevalence in Ghana and other sub- 2008 to 52% in 2014 [18]. Among several factors, condi-
Saharan countries [10–13], on the other hand, other tions in the home and work environments, maternal and 
factors such as support for mothers, the flow of breast paternal characteristics and societal influence contribute 
milk, benefits of exclusive breastfeeding, demand to this decline in EBF [10, 19, 20]. For example, moth-
breastfeeding and interaction between mothers and ers who work in formal settings are unable to practice 
health workers have been noted to contribute to the EBF due to an  unfriendly breastfeeding  environment at 
practice of exclusive breastfeeding [10–12]. the workplace [10]. Hence, there have been discussions 
The theoretical underpinnings of this study hinges on extending the current three (3) months maternity 
on the Health Belief Model (HBM), on the premise leave policy in Ghana to six (6) months to help especially 
that the decision of mothers to practice EBF depends working mothers’ practice exclusive breastfeeding. Such 
on their knowledge of exclusive breastfeeding, the per- policy revisions are critical because of the benefits of 
ceived benefits of exclusive breastfeeding, the perceived EBF for the health of infants, mothers and the nation at 
threats to exclusive breastfeeding and the  cues to large. Revising this policy will help women to spend more 
action for breastfeeding [14, 15]. This means that, if the time with their children after delivery and offer them the 
perceived benefit of exclusive breastfeeding  is greater opportunity to practice exclusive breastfeeding.
than the perceived threat, a mother is  likely to prac- Several studies have been conducted on exclusive 
tice exclusive breastfeeding while the reverse may be breastfeeding, however, existing studies in Ghana and 
true. However, there are cues to action that could facili- sub-Saharan Africa are mostly quantitative with few 
tate exclusive breastfeeding. For example, strong  sup- studies using qualitative or mixed methods [10, 12, 19, 
port systems from family members, friends, and health 21–23]. There is thus a paucity of qualitative studies that 
workers could facilitate the practice of EBF  and this focus on challenges, benefits and cultural factors affect-
could help to reduce discontinuation and the risk of ing exclusive breastfeeding [11, 13, 24]. Again, only a few 
non-exclusive breastfeeding. studies have examined the experiences of exclusive and 
Additionally,  the practice of exclusive breastfeeding non-exclusive breastfeeding mothers, and health workers 
depends on the understanding and the ability of moth- to understand the complexities and nuances surround-
ers to overcome the associated challenges. This,  includes ing decision making, challenges and management of the 
creating an enabling environment at home, at work and challenges associated with practicing EBF in Ghana. Fur-
in health facilities that support mothers to practice exclu- thermore, previous studies have focused largely on moth-
sive breastfeeding [1, 4, 10, 16]. Evidence from research ers but health workers are the first point of contact with 
shows that the experience of mothers is shaped by their mothers especially at birth and health workers  serve as 
interaction with other women most especially health advocates for exclusive breastfeeding [5]. It is therefore 
workers [5]. Health workers play a significant role in important to study the perspectives of health work-
women’s decision-making process regarding EBF as well ers on exclusive breastfeeding, as the information pro-
as in the management  of exclusive breastfeeding. Nieu- vided by health workers could offer the needed support 
woudt and Manderson [5] argue that mothers rely mostly for mothers to overcome the challenges associated with 
on the advice of health workers to decide to exclusively exclusive breastfeeding [7].
breastfeed  and manage EBF. Hence, providing informa- Against the foregoing,  the objective of this study is to 
tion to mothers on the challenges and management of examine experiences of practicing exclusive breastfeed-
EBF could lead to the continuation of EBF for the rec- ing, from the perspective of exclusive and non-exclusive 
ommended  six months. However, many mothers are breastfeeding mothers. The study also explores the per-
not provided information on EBF and they  do not have spectives of health workers who interact often with peri-
knowledge on the management of exclusive breastfeed- partum women.
ing, thus inhibiting their ability to practice EBF. Consist-
ent provision of information on the management and 
A gyekum et al. International Breastfeeding Journal           (2022) 17:21 Page 3 of 15
Methods study (with the help of health workers) based on the fol-
Study design lowing criteria;
This was study designed as  a cross-sectional qualita-
tive study. In-depth interviews were  conducted  among •  The mother must be within the reproductive age of 
mothers in their reproductive age (15–49  years) and 15–49 years,
health workers in the  La Nkwantanang  Municipality • Must have an infant who is less than 6 months old,
(Madina) in Accra, Ghana. This study was embedded • Must be practicing exclusive breastfeeding (Feeding 
within a cross-sectional mixed-methods study under the infants aged 0 to 5 months with only breast milk and 
“Willows Impact Evaluation” project conducted in Ghana no other liquids, solids or water except for oral rehy-
and  implemented by the Regional Institute for Popula- dration solution, drops) or not practicing exclusive 
tion Studies at the University of Ghana. The larger study breastfeeding (mothers who fed their infants with 
explored reproductive behaviours of contraceptive use breast milk and or any other food;  classified as non-
among urban poor women along selected coastal towns exclusive breastfeeding)
(Osu klottey, La, Teshie and Nungua) and inland areas 
(La Nkwantanang, Abogba and Old Ashongman) in Health workers were also purposively selected for in-
Accra, Ghana [25]. depth interviews based on the following criteria;
Setting • Should be a permanent staff of the health facility.
The study was conducted in two health facilities at Mad- • Provides services to pregnant women and breastfeed-
ina-Accra, Ghana. Madina is the municipal capital of the ing mothers.
La-Nkwantanang Municipal Assembly. It is located in 
the northern part of the Greater Accra Region and cov- In all, twenty (20) participants were interviewed for 
ers 70.887 square kilometres. The Municipality shares the study. This includes ten mothers who were practicing 
boundaries in the west with Ga East Municipal, the east exclusive breastfeeding, six mothers who were not prac-
with Adenta Municipal, the south with Accra Metropoli- ticing exclusive breastfeeding and four health workers. 
tan Assembly and the north with Akuapim South District In each health facility, five mothers who were exclusively 
[26]. According to the 2010 Ghana Population and Hous- breastfeeding, three mothers who were not exclusively 
ing Census report, the population of the La-Nkwantan- breastfeeding and two health workers were interviewed.
ang Municipality is youthful (38.7%) with a small (5.0%) 
proportion of older adults [26]. The indigenous people 
of the municipality are Ga-Dangbes. However, most of Data collection
the current residents are migrants with the majority of Data collection  for the study was carried out in June 
in-migrants coming from the Eastern and Volta regions. 2019 using a semi-structured interview guide that was 
The main economic activities are commerce, agriculture, developed and pilot-tested for the study. The inter-
services and manufacturing. The Madina market serves view guides consisted of sub-section on the demo-
as the main trading centre in the municipality [26]. In graphic  characters of mothers, child’s characteristics, 
terms of health facilities, Madina has both private and decision to exclusively breastfeed or not, as well as 
public health facilities. The public health facilities include the  management, challenges and benefits of exclusive 
two polyclinics (Kekeli Polyclinic and Rawlings Circle breastfeeding (An English version of the questionnaire 
Polyclinic), health centres, and Community-Based Health has been uploaded as Additional file 1, Additional file 2 
Planning and Service (CHPS) compounds. and Additional file  3). The participants were selected 
for interview through the following process. Upon 
Selection of participants entering the hospitals, permission was sought from 
Purposive sampling was used to select the health facili- the management to use the facility for the study. Per-
ties and the participants for this study. The two polyclin- mission was then sought from the participants (moth-
ics in the La-Nkwatanang Municipality,  namely; Kekeli ers and health workers) to be included in the study. 
Polyclinic and Rawlings Circle Polyclinic were purpo- The purpose of the study including the general objec-
sively selected based on the fact that they focus more on tives, benefits, and risk of taking part in the study were 
providing  maternal and child health services to a wide explained to the participants. After that, the respond-
population in Madina and its neighboring environment. ent, if literate, signed an informed consent form and, 
Breastfeeding mothers attending child welfare clinic if they could not read or write, provided a thumbprint 
in the two polyclinics  were purposively selected for the or verbal consent to participate in the study. Partici-
pants were also  informed about strict confidentiality 
Agyekum et al. International Breastfeeding Journal           (2022) 17:21 Page 4 of 15
and anonymity of their responses. Lastly, they were Pseudo names were used in reporting quotes  from the 
informed about their right to stop participating in the transcripts.
study at any point if they desired to do so. The health 
workers were interviewed in an office while the inter-
views with mothers  were conducted at a quiet loca- Ethical approval
tion within the health facility without interference or The present qualitative study was conducted as part of 
the presence of other people.  In recruiting respond- the Willows Impact Evaluation Study. Ethical approval for 
ents, Not all the mothers who were approached agreed the Willows International Evaluation Project was granted 
to be part of the study. Those who refused to be inter- by the Ethics Review Committee of Ghana Health Service 
viewed  cited work and husband approval as their rea- (GHS-ERC #005/08/2017) and the University of Ghana 
sons for not being part of the study. Only those who Ethics Committee for the Humanities (ERC #020/17–18). 
agreed to be part of the study were interviewed. All The ethical clearance was further used to obtain adminis-
the interviews were carried out by the lead author. The trative permission from the two polyclinics and from the 
interviews were conducted in a preferred language of study participants, i.e. mothers and health workers.
the participants, mainly English and Twi. The inter-
views were audio-recorded with the permission of the Results
participants. Characteristics of study participants
As shown in Table  1, ten of the sixteen mothers inter-
viewed practiced exclusive breastfeeding while the 
Data analysis remaining six were not practicing exclusive breastfeed-
The data were analyzed thematically using Atlas.ti. The ing. The age range for the mothers and health workers 
thematic analysis approach involves searching across a was 25 to 40  years. About 7 of the mothers and health 
range of text or transcripts to find a repeated pattern workers had Junior High School level of education and 
of meaning and organising these into various levels of a total of sixteen (16) of the mothers and health workers 
themes such as basic, organising and global themes were Christians. With regards to marital status, 16 of the 
[27]. According to Braun and Clarke [27] there are six participants were married. The health workers who were 
steps in the analyses of qualitative data and these are; interviewed as part of this study included a community 
familiarizing yourself with the data, generating initial health nurse, a nutritionist, a midwife and a registered 
codes, searching for themes, reviewing themes, defining community nurse.
and naming themes and producing a report. The initial 
stage involves reading through the transcripts repeat- Thematic analyses
edly to gain familiarity with the text as well as noting Five major organising themes that are related to the 
initial ideas. This was followed by assigning codes to the global theme (exclusive breastfeeding practice) were 
appropriate segment of the transcripts. The assigned identified. These are (i) decision to practice exclusive 
codes are organized to generate cross-cutting themes breastfeeding, (ii) challenges of exclusive breastfeeding, 
from all the transcripts. At this stage, different codes (iii) reasons for discontinuation of EBF, (iv) management 
from the transcripts are sorted into potential themes, of EBF and (v) improvement of exclusive breastfeeding.
as all relevant codes are collated within the identified 
themes [27]. The various codes are searched, reviewed Decision to practice exclusive breastfeeding
and named for the production of a report. The results reveal that the decision of mothers to prac-
In analyzing the data, all the authors read through the tice exclusive breastfeeding was based on advertisement, 
transcripts to gain familiarity with the text. Inductive type of work, the ability of mothers to produce enough 
coding and deductive coding  approaches  were used in breast milk, health workers advocacy and support from 
the data analysis. The first author read through all the partners (Fig. 1).
transcripts to identify the deductive codes and themes. 
The co-authors provided feedback on the identified Advertisement for exclusive breastfeeding
codes and themes after each of them had gone through Advertisement was identified as an important factor 
the transcripts. The lead author and one co-author coded in the decision  regarding  exclusive breastfeeding as it 
all the responses and generated the various themes. The informs and provides mothers with the needed informa-
other two co-authors validated the codes and the vari- tion on the importance of exclusive breastfeeding thereby 
ous themes. Thematic networks  maps were constructed influencing their decision to practice EBF. This was high-
to show the relationship between the various themes lighted by Abena, an exclusive breastfeeding mother;
at the three levels: basic, organising and global themes. 
A gyekum et al. International Breastfeeding Journal           (2022) 17:21 Page 5 of 15
Table 1 Characteristics of exclusive and non-exclusive mothers and health workers interviewed for the study
Characteristics Exclusive breastfeeding Non-exclusive breastfeeding Health workers Total Number 
mothers (N = 10) mothers (N = 6) (N = 4) of Participants 
(N = 20)
Age of mother
 25–30 3 4 1 8
 31–35 5 2 2 9
 36–40 2 0 1 3
Level of education of mother
 Primary 1 0 0 1
 JHS 6 1 0 7
 SHS 1 4 0 5
 Tertiary 2 1 4 7
Ethnicity
 Akan 1 3 3 7
 Dagomba 2 1 0 3
 Gonja 2 1 0 3
 Ewe 4 0 1 5
 Ga 1 0 0 1
 Other (Nigerian) 0 1 0 1
Religious affiliation
 Muslim 3 1 0 4
 Christian 7 5 4 16
Marital Status
 Never married 2 1 1 4
 Married 8 5 3 16
Employment status
 Employed 8 5 4 17
 Unemployed 2 1 1 3
Category of health worker
 Nutritionist - - 1 1
 Midwife - - 1 1
 Community Health Nurse - - 1 1
 Registered Community Nurse - - 1 1
Fig. 1 Decision to practice exclusive breastfeeding
Agyekum et al. International Breastfeeding Journal           (2022) 17:21 Page 6 of 15
“I have seen an advertisement that says that if you Health workers advocacy
give the baby only breast milk, it develops her brains. Health advocacy including talks on exclusive breast-
That is why I planned to give her only breast milk” feeding by health workers at the health facilities during 
(Exclusive breastfeeding mother, 36 years). antenatal and postnatal clinics played a critical role in 
mothers’ decision-making. For instance, some mothers 
mentioned that during post-natal and antenatal clin-
Type of work ics, health workers taught them how to breastfeed their 
Type of work facilitates or hinders the decision of moth- babies. Sometimes they use a doll to demonstrate how to 
ers to practice exclusive breastfeeding. Mothers work- hold the baby and breastfeed. They are also taken through 
ing in formal settings are unable to practice exclusive nutrition lessons including exclusive breastfeeding man-
breastfeeding for long compared to mothers working in agement, benefits, and challenges. This helped them to 
informal settings. This is due to unfavourable working understand exclusive breastfeeding practice and thereby 
conditions in the formal sectors such as separation of the influence their decision to practice exclusive breastfeed-
child from the mother and lack of private room/space ing. In addition, the health workers indicated that when 
for breastfeeding. Most of these mothers leave their chil- mothers understand the education received at the health 
dren at home when they resume work from their three facilities on exclusive breastfeeding, they are encouraged 
months maternity leave, thus making it difficult for them to practice exclusive breastfeeding. One of the health 
to breastfeed on demand. However, mothers working in workers mentioned that;
informal settings are always with their children and they 
are able to breastfeed and practice exclusive breastfeed- “We normally explain exclusive breastfeeding to 
ing much longer. This, therefore, influences the mother’s them for their understanding. If they understand 
decision on exclusive breastfeeding. The quote below the benefits of breastfeeding, then there is a need for 
from Edna highlights this point. them to start” (Midwife, 40 years).
“Because of the nature of my work (trading), I think Similarly, a 34-year-old mother, Esther, reported that.
that’s a factor which made me practice exclusive 
breastfeeding. Those in the government sector such “Yes, they really teach us how to breastfeed. They 
as banks, if you want to practice exclusive breast- sometimes bring a doll and teach us how we should 
feeding, it would be quite difficult. Even if you pump hold the breast, how you should feed the baby, the 
breast milk and place it in the fridge for the child, kind of food you can give it and how to keep yourself 
I don’t think it would be healthy for the child. The neat. This, therefore, influenced my decision to prac-
nature of my work also helps me practice exclusive tice exclusive breastfeeding” (Exclusive breastfeeding 
breastfeeding because my child is with me always mother, 34 years).
and I can take her everywhere, I go” (Exclusive 
breastfeeding mother, 30 years). Partner support
Another factor that was found to promote the decision 
on exclusive breastfeeding was partner support. Partner 
Production of breast milk
The ability of mothers to produce enough breast milk support is very important in women’s decision to prac-
also influences their decision to practice exclusive breast- tice exclusive breastfeeding. All exclusive breastfeed-
feeding. For example, Agnes reported that; ing mothers indicated that they had support from their partners  regarding  their decision to practice exclu-
“I have a lot of breast milk so I do not see why I sive breastfeeding. Some mentioned that their partners 
should add any other thing when the breast milk is wanted them to practice exclusive breastfeeding for a 
there. I always give and she is always satisfied after year. For example, Mavis, an exclusive breastfeeding 
taking it. So, I don’t have to add anything” (Exclusive mother reported that.
breastfeeding mother, 40 years). “I did exclusive breastfeeding because my husband 
Additionally, one of the health workers, a midwife, understands and supported me to practice exclu-
indicated that. sive breastfeeding” (Exclusive breastfeeding mother, 
30 years)
“You can easily access breast milk when the baby 
is crying, it is available, and you do not prepare or Similarly, Sandra, a breastfeeding mother indicated 
have to go to the kitchen. It is available and brings that her husband provided the needed support to ensure 
love. That also influence their decision to practice that she gives only breast milk to the infant. She men-
exclusive breastfeeding” (Midwife, 40 years). tioned  that;
 Agyekum et al. International Breastfeeding Journal           (2022) 17:21 Page 7 of 15
Fig. 2 Challenges of exclusive breastfeeding
“I discuss with my husband to give her only breast to take her everywhere you go. You cannot tell some-
milk... he agreed and wouldn’t even allow me to give body to take care of your child” (Exclusive breast-
her any other food. He provided security to ensure feeding mother, 30 years).
that I don’t give the child any food apart from 
breastmilk” (Exclusive breastfeeding mother, 35 
years). Weight of motherAdditionally, some mothers indicated that they put on 
weight because they eat more food to enable them pro-
Challenges of exclusive breastfeeding duce breast milk. Some of the mothers were uncomfort-
Five sub-themes including, dizziness among mothers, able with this situation as their appearance changes. For 
inconvenience of mothers, mothers’ weight, breast sag example, Edna reported that;
and pressure from caregivers were identified by health 
workers and mothers as challenges of exclusive breast- “Because of exclusive breastfeeding you put on 
feeding (Fig. 2). weight even when you do not want to, you have to eat so the baby can also benefit. Due to this, you 
put on weight by so doing” (Exclusive breastfeeding 
Dizziness
Exclusive breastfeeding mothers indicated that after mother, 30 years).
breastfeeding, they become dizzy and are unable to per-
form any other activity. This makes them restless for Breast sag
some time before gaining strength to perform normal There was a perception by the mothers that practic-
activities. One participant, Mary, indicated that; ing exclusive breastfeeding is associated with breast sag. 
“There are times when you breastfeed your baby, you As a result of this, they shorten the practice of exclusive 
will feel dizzy and you will have to lie down because breastfeeding. However, a midwife explained that this is a 
you will not be able to do anything” (Exclusive misconception and ignorance on the part of the mothers. 
breastfeeding mother, 32 years). The midwife emphasized that breast sag is not as a result 
of exclusive breastfeeding or prolonged breastfeeding. 
She reiterated,
Mothers’ inconvenience
Another challenge mentioned by exclusive breastfeeding “…. that is ignorance because whether you breast-
mothers was inconvenience. The mothers indicated that feed or not your breast will sag. They do not know 
because they breastfeed on demand, the child is always because if they knew they wouldn’t say that. Because 
with them wherever they go and this sometimes incon- if you have a small breast that cannot come down, 
veniences or limits their movement. For instance, Bernice it will not come down… It is the weight that sags the 
reported that. breast. What about those who haven’t delivered, and 
their breasts are sagging? Will the men that suck 
“Because of her (the child) feeding, you would have their breast sag their breast or not? I think those who 
Agyekum et al. International Breastfeeding Journal           (2022) 17:21 Page 8 of 15
are educated are the problem” (Midwife, 40 years). “Some of my friends told me to give him food, while 
others said no, but I had decided to practice exclu-
sive breastfeeding. When they ask me to give the 
Pressure from caregivers baby food, I only said yes knowing that I would not 
Also, both health workers and mothers mentioned that do it” (Exclusive breastfeeding mother, 30 years).
pressure from family and friends, mostly caregivers, are 
challenges associated with exclusive breastfeeding. A 
health worker indicated that caregivers, mostly mothers- Reasons to discontinue exclusive breastfeeding
in-law who are not in support of exclusive breastfeeding, Some mothers started with exclusive breastfeeding but 
sometimes give water and food to the children without discontinued because of advice from family members, 
the knowledge of the child’s mother. This sometimes insufficient breast milk for the child and insufficient flow 
leads to the child developing infectious diseases because of breast milk (Fig. 3).
of the contamination of food that they feed the children. 
One of the health workers attested to this and she indi- Insufficient breast milk production
cated that; Insufficient breast milk production is when the mother 
“Our challenge is the caregivers; the caregivers are may not produce enough breast milk to feed the infant. 
mothers-in-law who are their own mothers. They The lack of production of breast milk could lead to a situ-
are old and did not practice exclusive breastfeeding, ation where the mother does not exclusively breastfeed 
so they don’t want to believe that what we are say- at all or discontinues exclusive breastfeeding early. Some 
ing is right. At times they even hide to give water to mothers mentioned that they wanted to practice exclu-
the child. When they see that the mother insists that sive breastfeeding but when they realised that they were 
they do not have to give water, during bathing they not producing enough breast milk, they introduced other 
will give water to the child” (Midwife, 40 years). supplementary foods to the child. Akua, for example, 
reported that;
Similarly, one of the mothers mentioned that she was 
pressurised by her friends to give her baby food. “I planned practicing exclusive breastfeeding when I 
give birth. There are some people who do not have 
“My friends told me he will not have an appetite for breast milk naturally, when I gave birth the breast 
food when he grows up and I told them I will start milk wasn’t flowing so we added other foods” (Non-
giving him beans, maize and rice when he is six Exclusive breastfeeding mother, 27 years)
months. I believe he will have an appetite for food 
when he turns 6 months” (Exclusive breastfeeding 
mother, 28 years). Breast milk not sufficient to satisfy the child
According to the account of the respondents, the situ-
Aside from mothers-in-law, some friends discouraged ation where  breast milk is  not sufficient to satisfy the 
mothers from practicing exclusive breastfeeding. They child arises  where the mother produces enough breast-
explain to mothers that exclusively breastfed children do milk but perceives that breast milk alone is not enough 
not eat well after six months of exclusive breastfeeding. or sufficient to satisfy the child, hence there is the need 
One of the mothers reported that; to give the child other supplementary foods. Some of the 
Fig. 3 Factors contributing to discontinuation of exclusive breastfeeding
A gyekum et al. International Breastfeeding Journal           (2022) 17:21 Page 9 of 15
respondents indicated that breast milk was not enough start when he is six months, and he will get used to it 
for their children. They attributed this to the fact that in the eighth or ninth month. So I should start giving 
their children were not able to sleep well at night and they him small, so he knows this is water” (Non-Exclusive 
had to introduce other foods such as coconut water and breastfeeding mother, 26 years).
SMA to enable them to sleep. One mother indicated that; Aside mothers who discouraged their daughters from 
“When I gave birth, I was giving her only breast practicing EBF, mothers-in-law also discouraged breast-
milk, but she was not sleeping, she kept crying at feeding mothers to discontinue EBF. Ernestina reported 
night. So, I thought it was because of what she ate, that.
so I first gave her coconut water and after drinking 
it she slept throughout the night. I could not give her “My mother-in-law was not in support. Anytime 
coconut water all the time because the peel of the the baby cries she thinks the baby is hungry, so she 
coconut might be in the water... So, I gave her SMA will  ask me to give the baby porridge or something 
for a month and then I stopped” (Non-Exclusive else” (Non-Exclusive breastfeeding mother, 27 years).
breastfeeding mother, 26 years).
Also, a health worker expressed that most mothers add Management of exclusive breastfeeding
food supplements because they feel that breast milk is Despite the challenges associated with exclusive breast-
not enough. She reiterated that; feeding, there appeared to be ways exclusive breastfeed-ing is managed by mothers. According to Fig.  4, these 
“Some mothers say breast milk is not enough for include eating healthy food and feeding on demand.
their children. All the time when  they are eating, 
their children also feels like eating. They think it’s not Eating healthy food
enough, so they have to add some food supplements Eating healthy foods was identified as one of the ways of 
to it” (Nutritionist, 31 years). managing exclusive breastfeeding practice. Majority of 
the exclusive breastfeeding mothers indicated that there 
are specific healthy meals such as groundnut soup, palm 
Advice from family members nut soup, mashed kenkey, and fruits that help in the pro-
Advice from family members’ especially biological moth- duction of breast milk. Mothers eat these foods regularly 
ers of breastfeeding mothers and mothers-in-law con- to enable them to produce enough breast milk. Abena a 
tribute to the discontinuation of exclusive breastfeeding. 36  years old exclusive breastfeeding mother explained 
A mother expressed that she wanted to practice exclusive that;
breastfeeding up to six months, but her mother advised “You must eat well. You must drink more soup-like 
her to give water and food to the child, and this discon- palm nut soup and groundnut soup. That will give 
tinued the practice of exclusive breastfeeding. She indi- you more milk. Also, mashed Fante kenkey with 
cated that; groundnut also helps to produce more milk for the 
“He will be six months next month so I started the baby” (Exclusive breastfeeding mother, 36 years).
water last week because my mum said there are Another participant, Esther also indicated that;
some things if he doesn’t get used to , he wouldn’t 
like   them. He should be taking water, to get him “I only have to eat healthy foods. I must eat to my 
going, so if he is not used to it now, he is now going to satisfaction because they normally say the breast 
Fig. 4 Management of exclusive breastfeeding
Agyekum et al. International Breastfeeding Journal           (2022) 17:21 Page 10 of 15
milk is dependent on the food you eat. They also say 36 years).
if the mother eats healthy foods, she will produce 
healthy milk for the baby. I can prepare “tuo zaafi 
with ayoyo” (maize dish) in the morning. We drink Improvement in exclusive breastfeeding
“agushi soup” and I eat fruits. After every meal, I eat Health workers identified several strategies through 
fruits” (Exclusive breastfeeding mother, 34 years). which exclusive breastfeeding could be improved. This 
includes education on EBF, counselling and monitoring 
mothers, restricting advertisement on infant formula and 
Feeding on demand maternity leave (Fig. 5).
Also, breastfeeding on demand was identified as one of 
the ways of managing exclusive breastfeeding. Exclusive 
breastfeeding mothers mentioned that they keep an eye Education on EBF
on their children in order to breastfeed when needed. Narrations of the health workers showed that education 
Mothers breastfeed at regular intervals and do not wait on exclusive breastfeeding at antenatal and postnatal 
for the child to cry for food. Some mothers indicated that clinics, provides mothers with the necessary knowledge 
in their absence, they express breast milk for caregivers about EBF  and creates awareness on exclusive breast-
to breastfeed their children. For instance, Bertha indi- feeding practice. The health workers also mentioned that, 
cated that. education on exclusive breastfeeding should not target only mothers but others including grandmothers, part-
“You must keep an eye on him so that you can ners, and in-laws. One of the health workers reported 
breastfeed him regularly. You should not wait for a that;
long period before you breastfeed him. You should 
be feeding him regularly so that he will not cry and “It can be improved through health education during 
disturb. He doesn’t cry and disturb me” (Exclusive antenatal services, postnatal services, child welfare 
breastfeeding mother, 28 years). clinic even including those at the OPDs… when we give talks, they are not excluded. It’s not only preg-
Similarly, time management is very important in exclu- nant women that we must talk to, but we also have 
sive breastfeeding. Some participants expressed that men as partners who are also involved because it’is 
having time for the baby enables them to monitor the not only mothers. Sometimes those at the OPDs like 
wellbeing of the child as well as breastfeeding well. This grandmothers, caregivers are also part. So, when we 
includes prioritising the baby over any other thing as give talks like that, it is also extend to them” (Nutri-
Abena indicated; tionist, 31 years).
“I have to make time for the baby. If I don’t have time Another health worker supported the intensification of 
for the baby, he will worry me, and I will be tempted education and mentioned that.
to add other foods when he is not 6 months old. I 
have to make time for the baby and prioritize the “We must intensify our education at our antenatal 
baby over my work” (Exclusive breastfeeding mother, clinics, child welfare clinics, and the communities. It is more of the education” (Registered Community 
Fig. 5 Improving exclusive breastfeeding
A gyekum et al. International Breastfeeding Journal           (2022) 17:21 Page 11 of 15
Nurse, 35 years). 25 years).
Also, the health workers indicated that sometimes 
mothers find it easy to understand their own peers than Maternity leave
the health professionals. In such situations, the health In addition, the health workers mentioned that work-
workers use mothers who have been successful in prac- ing mothers do not get to have enough time to prac-
ticing exclusive breastfeeding to talk to their fellow tice exclusive breastfeeding due to the short duration of 
mothers about misconceptions and benefits of exclusive maternity leave. The working environment does not allow 
breastfeeding practice. This motivates and encourages mothers to go to work with their children to breastfeed 
others to practice exclusive breastfeeding. A registered on demand. This therefore limits their ability to exclu-
community health nurse indicated that; sively breastfeed for six months. For instance, a midwife 
“They tell them the baby will be thirsty if you don’t gave an account of a colleague nurse who closed at work 
give him water, but we explain to them that breast early to take care of the child at home.
milk contains water and they understand it. But if “We said mothers should take leave up to 6 months 
you want them to understand, then you use a col- so they can breastfeed their babies. Like the lady 
league who has done exclusive breastfeeding and (nurse) who closed from work to go home and breast-
has been successful like I said. That is the best way feed. The child is 3 months so if she has maternity 
to teach a mother” (35 years, Registered Community leave for 6 months she would not have come to work, 
Nurse). she would have stayed at home to breastfeed, but 
the challenges are there. I think that will be the only 
way that can help to make exclusive breastfeeding 
Counselling and monitoring
Furthermore, counselling and monitoring of women effective. Mothers should be with their  babies for 
were mentioned as one of the strategies for improving 6 months. The sixth month you introduce the solid 
exclusive breastfeeding. A health worker indicated that foods then you start work” (Midwife, 40 years).
due to the misconceptions about exclusive breastfeed-
ing, most mothers were put on counselling programs and Enablers and inhibitors of EBF
then monitored. Through this, mothers have understood Figure 6 provides a summary of the results of the study. It 
the benefits, misconceptions and challenges associated captures the enablers and inhibitors of exclusive breast-
with exclusive breastfeeding and they are now encour- feeding practice. The enabling factors are presented first, 
aged to practice exclusive breastfeeding. A health worker on the left side in the diagram while the inhibiting fac-
expressed that counselling has helped women to under- tors are also presented on the right side of the diagram. 
stand the benefit of exclusive breastfeeding and this Among some enablers of exclusive breastfeeding are 
should continue; advertisement for exclusive breastfeeding, type of work, 
“With much counselling and monitoring, they are production of breast milk, health workers advocacy, 
now understanding the main reason(s) why you support from partners, eating healthy food, feeding on 
should exclusively breastfeed your baby” (Commu- demand, education on exclusive breastfeeding, counsel-
nity Health Nurse, 25 years). ling and monitoring, maternity leave and controlling 
advertisement on infant formula. On the other hand, the 
factors that inhibit the practice of exclusive breastfeed-
Controlling advertisement on infant formula ing include the type of work, pressure from caregivers, 
Controlling advertisement on infant formula feeding was breast sag, mothers’ weight, dizziness, mothers’ incon-
identified in the narrative to enhance exclusive breast- venience, insufficient breast milk production, breast milk 
feeding. Restrictions on advertisement of infant for- not being sufficient to satisfy the child and advice from 
mula could help to reduce the patronage of these foods, family members.
which consequently, could help to improve the practice 
of exclusive breastfeeding. A community health worker 
mentioned that; Discussion
Previous studies have highlighted the benefits, challenges 
“If the advertisement of infant formula food can go and cultural practices affecting exclusive breastfeeding 
down, most people will love to breastfeed because practice in Ghana and SSA [10, 13, 16, 28, 29]. However, 
if you don’t know of a formula that you can give to there is scarce literature on the decision to practice EBF, 
your baby, you will definitely breastfeed because you reasons for discontinuation of EBF, management and 
want your baby to live” (Community Health Nurse, 
Agyekum et al. International Breastfeeding Journal           (2022) 17:21 Page 12 of 15
Fig. 6 Framework showing the enablers and inhibitors of EBF in Ghana
ways of improving EBF. This study contributes to the Previous studies have reported the influence of educa-
exclusive breastfeeding debate by highlighting experi- tion by health professionals on mothers’ decision making 
ences of exclusive breastfeeding mothers, non-exclusive regarding exclusive breastfeeding [11, 16, 30, 31]. In this 
breastfeeding mothers and health workers in relation to study, the plausible reason could be that health work-
factors that contribute to women’s decision to practice ers communicate clearly to mothers by demonstrating 
EBF, reasons for discontinuing EBF, challenges associ- how to breastfeed using objects such as dolls and other 
ated with EBF, management and ways of improving EBF. relevant materials. In addition, observations made  by 
Additionally, by, using the health belief model, this study the lead author during data collection show that health 
triangulates the experiences of mothers and health work- talks are given almost every morning at child welfare 
ers to understand the complexity of exclusive breastfeed- clinics using simple English and local languages. These 
ing in Ghana. The results of the study suggest that there talks sometimes take the form of an interactive section 
are individual, interpersonal, and organizational factors where mothers are allowed to ask questions and health 
that explain the complexity of exclusive breastfeeding workers respond to the various questions. This prob-
in Ghana. These factors are shaped by the experiences ably increased mother’s self-confidence and offered them 
of  mothers and their interaction with family members, security in their decision to practice exclusive breastfeed-
friends, and other stakeholders including health workers. ing [31]. Such approaches could be leveraged  as a way 
The findings indicate that  decision making on exclu- of reaching out to mothers with, exclusive breastfeeding 
sive breastfeeding is influenced by multiple factors. programs designed to reach women through social media 
From the results, the dominant themes among these outlets such as television and radio.
factors are education by health workers and mothers’ The results also suggest that the  work schedules 
work. The findings underscore the relevance of accurate of mothers play a significant role in their decision to 
information on  exclusive breastfeeding and therefore practice exclusive breastfeeding. Informal work such 
places an emphasise on education by health workers. as trading enables mothers to be in contact with their 
A gyekum et al. International Breastfeeding Journal           (2022) 17:21 Page 13 of 15
children always, unlike formal work which separates (mashed banana with sour milk) are prepared for women 
mothers from their children. Also,  unfriendly work- to produce enough breastmilk. The probable reason 
ing facilities in formal workplaces   limits the ability could be that soup, mashed kenkey and sour milk have 
of mothers  to continue exclusive breastfeeding after nutritional value which helps breastfeeding mothers to 
resuming work  from  their maternity leave. In Ghana, produce enough breast milk. It is therefore  important to 
there are not enough enabling or supportive environ- have  nutritionists based  at health facilities especially, in 
ments at the various work places to accommodate the rural areas to provide advice to mothers on the spe-
mothers and their babies [10]. There is lack of privacy cific type of food to eat in order to produce breast milk.
for breastfeeding, and most mothers are not allowed to The results of the study show that restrictions on 
go to work with their babies. This limits the ability of advertisement is very vital and serve as a way of improv-
mothers to continue practicing exclusive breastfeeding ing exclusive breastfeeding practice. This is because in 
after going back to work and therefore affects the bond- Ghana there is an influx of advertisement on infant for-
ing between the mother and the child at the early form- mula which restraints women from practicing exclusive 
ative stages. The findings, therefore, have implications breastfeeding. Women use these infant formulae feeds as 
for policies at the  work place  on exclusive breastfeed- a  supplement or complement to breastfeed their infants 
ing, i.e. encouraging organisations to provide support- [33–35]. But  if there are restrictions on infant formula, 
ive working environment for breastfeeding mothers. mothers will have no alternative and will be motivated to 
Provision should also be made for mothers to take their practice exclusive breastfeeding. Moreover, health work-
children to work or there should be flexible working ers mentioned that there was the need to use women who 
terms for breastfeeding mothers such as working from have been successful in practicing exclusive breastfeeding 
home if there is the need. to educate and create awareness on exclusive breastfeed-
This study identified several challenges associated with ing. This is because women tend to learn and understand 
exclusive breastfeeding and these challenges have impli- the language of their own colleagues than health work-
cations for policy for the consideration of health practi- ers. Also, when women are allowed to share their experi-
tioners. For example, there were complaints of dizziness ences, other women understand their experiences better 
after exclusive breastfeeding by mothers as they indicated than the health workers explaining to them.
that it makes them inactive for some time. Similar health In terms of addressing challenges associated with 
challenges have been reported in Australia where exclu- exclusive breastfeeding, counselling and monitoring were 
sive breastfeeding mothers experience health problems identified as another strategy for improving exclusive 
after breastfeeding [32]. The implication is that when breastfeeding. Health workers adopted this method in 
such challenges are not addressed, mothers may discon- identifying challenges associated with exclusive breast-
tinue exclusive breastfeeding. feeding and helping mothers to overcome these chal-
Other  reasons for discontinuation of exclusive breast- lenges. It was realized that, counselling and monitoring 
feeding focused on insufficient production of breastmilk, has an impact on improving exclusive breastfeeding in 
pressure from family members and breastmilk not being Ghana. It is therefore very important that breastfeeding 
sufficient to satisfy the child. Some participants expressed counselling is performed during antenatal care sessions 
that naturally, they are unable to produce enough breast and after delivery during the mother’s stay at the hospi-
milk to feed their children. Insufficient breast milk pro- tal. In addition, there should be follow up counselling at 
duction could be as a result of a medical or non-medical postnatal clinics and home visits to help improve exclu-
problem that disrupts the practice of exclusive breast- sive breastfeeding practice.
feeding. This underscores the relevance of counselling Lastly, the short maternity leave of three months lim-
and education to identify the cause of insufficient flow of its the ability of mothers working in formal settings to 
breast milk to help mothers in managing breastfeeding practice exclusive breastfeeding for six months. Several 
challenges. studies have reported that mothers working in formal 
Also, eating healthy food, and breastfeeding on environments discontinue exclusive breastfeeding when 
demand were strategies adopted for managing exclusive they resume work after the  three months of maternity 
breastfeeding. Breastfeeding mothers’ believe that eating leave [10, 28, 33].  In view of this, there is the need for the 
such foods will help them to produce enough breastfeed- Government of Ghana to revise the three months policy 
ing. Mothers indicated that they needed to eat healthy to six months to help mothers’ practice exclusive breast-
food in order for them to produce enough breast milk. feeding for six months.
These foods include mashed kenkey and soups. Con- The findings of this study support the position of 
sistent with other studies in Tanzaina, Mgongo et  al., Health Belief Model. The findings give indication that 
[24] reported that special food such as soup and kitawa breastfeeding mothers have a favorable understanding of 
Agyekum et al. International Breastfeeding Journal           (2022) 17:21 Page 14 of 15
the perceived benefits of practicing exclusive breastfeed- Authors’ contributions
ing as well as the dangers associated with non-exclusive MWA, SNAC, FAAD and MA conceptualized the study. MWA analysed and 
interpreted the data, wrote and revised manuscript. SNAC, FAAD and MA 
breastfeeding practices (perceived severity). This, there- contributed in the data analyses, interpretation of the data, reviewed and 
fore, enforces the desire of mothers to practice exclu- revised the final manuscript. All authors read and approved the final version of 
sive breastfeeding. However, a perceived threat, that is the manuscript for submission.
discontinuation of exclusive breastfeeding as a result of Funding
insufficient production of breastmilk and breastmilk not Not applicable.
being enough to satisfy the child leads to discontinua-
Availability of data and materials
tion of exclusive breastfeeding practice. In addition, other The dataset used for the study is available and can be requested from the cor-
threats such as inconvenience, mothers’ weight, breast responding author on reasonable request.
sag and dizziness were identified as challenges associated 
with exclusive breastfeeding. Furthermore, external fac- Declarations
tors such as friends, relatives and health workers served 
Ethics approval approval and consent to participate
as cues to action that encouraged mothers to continue Ethical clearance for the qualitative study was obtained from the Ethics 
practicing  exclusive breastfeeding. Information from Review Committee of Ghana Health Service (GHS-ERC #005/08/2017) and the 
health professionals and advertisement also support the University of Ghana Ethics Committee for the Humanities (ERC #020/17–18).
practice of exclusive breastfeeding. Consent for publication
Not applicable for this study.
Conclusion
Competing interests
This study sought to examine the experience of exclu- The authors declare that they have no competing interest.
sive and non-exclusive breastfeeding mothers and 
health workers in Ghana. The findings revealed differ- Author details1 Institute for Educational Research and Innovation Studies, University of Edu-
ent levels of experiences that affect and shape the prac- cation, Winneba, P. O. Box 25, Winneba, Ghana. 2 Regional Institute for Popula-
tice of exclusive breastfeeding. The decision to practice tion Studies, University of Ghana, P. O. Box LG 96, Legon-Accra, Ghana. 
exclusive breastfeeding and the challenges of exclusive 
Received: 1 April 2021   Accepted: 22 February 2022
breastfeeding emanates from mothers’ personal experi-
ences and institutional interactions. Based on the find-
ings of the study, it is recommended that mothers who 
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