Nkrumah et al. BMC Public Health         (2021) 21:1647 
https://doi.org/10.1186/s12889-021-11652-5
RESEARCH ARTICLE Open Access
Towards a comprehensive breastfeeding-
friendly workplace environment: insight
from selected healthcare facilities in the
central region of Ghana
Jacqueline Nkrumah1* , Aaron Asibi Abuosi2 and Rodney Buadi Nkrumah3
Abstract
Background: In the last three decades, Ghana has championed the objectives of Baby-Friendly Hospital Initiatives
to provide pregnant women and nursing mothers with the skills and support systems necessary for attaining
optimal breastfeeding. Yet, little is known in literature on how these intervention regimes practically promote
breastfeeding-friendly work environment in healthcare facilities and their level of effectiveness. This study explores
the extent to which healthcare facilities in Ghana’s Effutu Municipality provide breastfeeding-friendly workplace
environment to breastfeeding frontline health workers.
Methods: A descriptive mixed-method approach was employed to collect data from fifty-four participants,
comprising healthcare facility representatives and breastfeeding frontline health workers. A self-administered
questionnaire with structured responses was administered to frontline health workers, followed by interview guides
for representatives of hospital management. Thematic analysis was used to analyze interview responses. Responses
to questionnaires were processed with SPSS version 23.0 and presented using frequencies and percentages.
Results: Three main themes emerged, namely, Standpoints on workplace breastfeeding support; Breastfeeding support,
and Suggested future directions. Beyond this, six sub-themes emerged, including backings for workplace breastfeeding
support; perceived benefits of breastfeeding support; factors of poor breastfeeding workplace support; maternity
protection benefits; workplace support gaps, and awareness creation on benefits. Breastfeeding frontline health workers
held that their hospitals have no breastfeeding policy (96%), no breastfeeding facility (96%), they do not go to work with
baby (96%), but had 12weeks maternity leave (96%) and worked half-day upon return to work (70%).
Conclusion: Health facilities in the study do not provide a breastfeeding-friendly work environment except for the
privileges provided by the Labor Act and conditions of service. Continuous advocacy on breastfeeding workplace support
and stakeholder engagement to build consensus on the mix of strategies suitable to cushion breastfeeding frontline
health workers is recommended for optimal breastfeeding and improved productivity.
Keywords: Optimal breastfeeding, Frontline health workers, Breastfeeding workplace environment, Work challenges,
Coping strategies
* Correspondence: acquiankrumah@gmail.com; jnkrumah@uew.edu.gh
1Faculty of Science Education, Department of Health Administration and
Education, University of Education, P.O Box 25, Central Region, Winneba,
West African, Ghana
Full list of author information is available at the end of the article
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Nkrumah et al. BMC Public Health         (2021) 21:1647 Page 2 of 12
Background main questions: 1). To what extent do healthcare facil-
Optimal breastfeeding practice is known to improve ities in the Effutu Municipality provide a breastfeeding-
infant and child health and enhance cognitive ability in friendly workplace environment for BFHWs? 2). What
children [1]. In Ghana, breastfeeding practice is universal views do BFHWs in the Effutu Municipality share on
among mothers and fifty-two (52%) percent of all breastfeeding workplace support? 3). What coping
infants, aged 0–6 months are exclusively breastfed [2]. strategies do BFHWs employ to balance work and
However, the country’s effort to improve optimal breast- breastfeeding challenges in the Effutu Municipality? By
feeding is hampered by several factors including rapid BFHWs, we refer to breastfeeding clinical and non-
urbanization and its associated formalization of women’s clinical health staff in health facilities.
work [3]. Exclusive breastfeeding takes a dip during the
third month of infants’ life because women return to Work, breastfeeding, and workplace support in Ghana
work after 3 months of maternity leave [1]. This situ- Maternal work and breastfeeding incompatibility have
ation is partly driven by insufficient organizational-level received growing interest from infant feeding researchers
support systems and individual mother’s attitudes and in Ghana. It is suggested that women in self-
values [4]. While some employee mothers believe that employment and paid work experience tension between
extension of maternity leave would do the magic, others work and breastfeeding and are unable to practice exclu-
believe that prioritizing home and workplace support sive breastfeeding. However, work-breastfeeding tension
systems for breastfeeding should be the approach to pro- is experienced differently depending on the type of work
tect and promote optimal breastfeeding [5]. Strategies a mother does. In some cases, the conflict between work
for scaling up optimal breastfeeding practices, therefore, and breastfeeding has led some mothers to withdraw
demand appropriate harmonization of home and work- from work or spend less time with babies [8, 9]. Also, it
place factors that promote and protect, breastfeeding has been found that poor recommendations of exclusive
appropriately. breastfeeding from health workers and shorter duration
Ghana’s strategy towards promoting optimal breast- of maternity leave contribute to the decline in exclusive
feeding practice begun with the implementation of the breastfeeding at 6 months [10]. This has led some
Innocenti Declaration of 1990, 5 years after it has been scholars to explore the availability and effectiveness of
launched. This involved the implementation of a “Ten breastfeeding support mechanisms in workplaces. For
Step” successful breastfeeding code, and a Baby-Friendly instance, Mensah [11] studied the role of social support
Hospital Initiative (BFHI), both aimed at socializing mid- in improving breastfeeding and employee commitment
wives to become aware of information and skills for and found that breastfeeding mothers who received sup-
breastfeeding as well as providing nursing mothers with port from relatives, spouses, and colleagues appeared
the skill set to practice optimal breastfeeding. Becoming more satisfied and committed to their jobs compared to
Breastfeeding Friendly (BBF) assessments conducted in those with no or less social support.
Ghana showed that the country has a moderate breast- Recent studies have also investigated the lived experi-
feeding scale-up environment [4, 6, 7]. Consequently, ences and views of breastfeeding mothers in paid work
the BFHI has been revived and relaunched to achieve its and tertiary institutions and have identified individual
aim. The initiative is perceived by stakeholders as one of and organizational-level factors that affect optimal
the surest ways to protect and promote breastfeeding. breastfeeding practice. Abekah-Nkrumah and colleagues
Yet, maternal work, particularly paid work is limiting opti- [12], found factors such as lack of knowledge and
mal breastfeeding practice in emerging industrial econ- understanding of exclusive breastfeeding, negative lived
omies such as Ghana, making breastfeeding and childcare experiences of working mothers, and unsupportive
support intervention necessary. If BFHI is a vital element organizational environment as adversely affecting exclu-
of breastfeeding promotion and support in Ghana, then sive breastfeeding. A study of institutional-level support
the extension of this initiative to the workplace cannot be for breastfeeding among tertiary students also found a
overemphasized. Today, most Ghanaian health facilities stern conflict between breastfeeding and academic work
are accredited as baby-friendly. Yet, there is little empirical due to lack of breastfeeding support for student mothers.
evidence on how these protocols and policies translate In this study, student mothers used unapproved and un-
into a breastfeeding-friendly workplace environment for safe places as breastfeeding facilities [8].
Breastfeeding Frontline Health Workers (BFHWs). We Even though the above studies suggest a general lack
test this assertion by exploring the extent to which health- of breastfeeding workplace support, other studies also
care facilities at the sub-national level (i.e., Effutu Munici- identify maternity leave, peer support, and breastfeeding
pality) provide a breastfeeding-friendly workplace break as basic workplace breastfeeding support available
environment for BFHWs using a descriptive mixed- in tertiary institutions and healthcare facilities that
method approach. To achieve this aim, we asked three support working mothers to breastfeed [13]. While the
Nkrumah et al. BMC Public Health         (2021) 21:1647 Page 3 of 12
above studies provide evidence of inadequate workplace health cannot be considered without recourse to the rela-
breastfeeding support in Ghana and breastfeeding tional process that accompanies support [19]. The stress
mothers’ lived experience of work-breastfeeding ten- and coping perspective of the SST has principles useful in
sions, they only present workplace breastfeeding support emphasizing the importance of breastfeeding workplace
from employees’ perspective and do not bring to bear support to optimal breastfeeding practice.
the views of employers on breastfeeding workplace sup- The values of the modern-day workplace are at variance
port. The concept of breastfeeding workplace support with those of breastfeeding, often resulting in work-
has economic implications for employers. For this rea- breastfeeding tension, which compromises optimal breast-
son, limiting the discussion to the lived experiences of feeding. Breastfeeding support practices such as a
employees clouds our ability to appreciate the differenti- breastfeeding-friendly work environment, maternity leave,
ated interests at stake and may result in biased policy breastfeeding breaks, and organizational breastfeeding
initiatives. Vilar-Compte and colleagues [14] estimated policy can act as buffers to reduce the stressfulness of
the cost of maternity leave extension and found that the mothering and the discrepancies between work and
mean cost of extending maternity leave for 2 weeks in breastfeeding. Providing such support would promote op-
formal employment in Ghana was $109 purchasing timal breastfeeding among working mothers. Evidence
power parity. Given the cost associated with maternity shows that the provision of breastfeeding rooms, breaks,
leave extension, the perspective of employers on any reduced workloads, and encouragement for breastfeeding
proposed extension of maternity leave is crucial in bal- mothers promote continuous breastfeeding on return to
ancing the interest of all stakeholders. work [24]. In a community-based cohort study in Taiwan,
it was found that mothers with extended maternity leave
Theoretical framework breastfed longer than those with shorter maternity leave.
Workplace breastfeeding support may facilitate optimal Lower breastfeeding initiation was also found among
breastfeeding and protect employee mothers from the mothers returning to work after 1 month [25]. A longitu-
stress of work and family responsibilities. This assess- dinal birth cohort study in the US also found that mothers
ment of breastfeeding support in healthcare facilities in with a longer duration of maternity leave had higher odds
the Effutu Municipality illuminates further, our under- of breastfeeding initiation and continuous breastfeeding
standing of organizational-level factors that impede beyond 6 months [26]. Just as social support contributes
breastfeeding practice in Ghana. Several theoretical and to health and wellbeing, These pieces of evidence beacon
conceptual frameworks, including the maternal role- to us the buffering effect of breastfeeding workplace
incompatibility hypothesis [15], social-ecological theory support in minimizing the negative impact of work-
[12]; work-family conflict framework [16] have been breastfeeding stress on optimal breastfeeding practice.
used in studies on work-childcare conflict. This study is
predicated on the Social Support Theory (SST). Al- Methods
though the social support theory is mostly used in health Study area
and well-being studies [17–19]. This study draws on the The study was rolled out in Effutu Municipality of
stress and coping perspective of the SST as explained by the Central Region of Ghana. The municipality has a
Lakey and Cohen [19] to argue that breastfeeding work- population of 79,411 projected from the 2010 popula-
place support can act as stress buffer to support mothers tion census and a growth rate of 3.2% per annum
to balance breastfeeding, work stress, and burnout while [27]. Administratively, Effutu is divided into four sub-
improving optimal breastfeeding among mothers in paid municipalities, namely, South-East Winneba, South-West
work. Winneba, Essuekyir-Gyahadze, and Kojo-Bedu North
The social support theory is a broad construct with Low-Cost. The municipal health system is organized at
several definitions [20–23]. It highlights the different the municipal, sub-municipal, and community levels. Each
forms of aid and assistance provided by family members, sub-municipality is further divided into communities for
friends, neighbors, among others, and often involves a purposes of organizing public health services and other
myriad of social interactions [22]. SST is grounded in health-related services activities. Winneba is the municipal
three different theoretical perspectives, namely, the capital and the only urban settlement among the four sub-
stress and coping perspective, which states that social municipalities.
support contributes to health by protecting people from
the dangers of stress. The second perspective is grounded Study design and sampling
in social constructionism and proposes a direct relation- We used exploratory research design and a mixed-
ship between support and health without consideration method approach to explore and describe verbal reports
for stress. The third is the relational perspective, which of representatives of hospital management and responses
predicts that the relationship between social support and of BFHWs on breastfeeding-friendly workplace environment.
Nkrumah et al. BMC Public Health         (2021) 21:1647 Page 4 of 12
The study population included all heads of health facilities tendencies. On the other hand, verbal reports of repre-
and bBFHWs in the Effutu Municipality. The selection sentatives of hospital management were thematically an-
of the Effutu Municipality proved convenient for two alyzed. Audiotapes were manually transcribed verbatim
key reasons. First, the municipality was selected based and validated to guarantee the accuracy of the tran-
on anecdotal accounts of BFHWs’ challenges of keeping scribed data with the audiotapes. Codes were developed
up with the demands of work and mothering. Second, manually from the transcribed data to describe their
it was selected based on proximity and cost. The lead content. Coding was done independently by the first and
researcher was introduced to managers of participating the second authors and was later compared and recon-
health facilities by her affiliated institution. Lists of ciled into a single codebook. Common patterns were
BFHWs were obtained from participating hospitals. identified among the codes and selected themes were
Sampling was done in two stages. In the first stage, four established based on developed codes. Relevant sen-
healthcare facilities were purposefully selected based on tences and phrases were identified and highlighted from
the number of female employees (20 or more female the transcript to support the established themes. Satur-
employees). Selected healthcare facilities included two ation was reached when no new themes were identified
public healthcare facilities, one private for-profit, and from the final codes developed by the authors. To en-
one mission-based healthcare facility. Each facility sure that the established themes were representative of
appointed one representative to respond to our in- the data, the themes were compared against the data set
depth interviews. The second stage involved a purpose- and necessary revisions were made to the initial themes.
ful selection of BFHWs with babies between 3 and 23 The themes were redefined to make them useful and
months. Mothers in this category were selected because coherent.
the authors believed they would have fresh lived experi-
ences of work and breastfeeding. In all, a list of sixty-
two (62) BFHWs were obtained, and 50 mothers con- Results
sented to participate in the study. Characteristics of participants
Table 1 presents the characteristics of the study partici-
Data collection pants. All 50 questionnaires were completed and
Both secondary and primary data were used for the returned giving a response rate of 100%. Fifty-four (54)
study. Secondary data were sourced mainly from reports, respondents participated in the study. Four out of the 54
handbooks, and published articles. Primary data were respondents were representatives of healthcare facilities
gathered through in-depth interviews and self- in the study, were all females, and heads of nursing ser-
administered questionnaires with close-ended and Likert- vices. The mean age of participants was 32 years. All
type questions. Questionnaires were used to gather data participants were females, the majority of whom were
from BFHWs and in-depth interviews were used to glean married with children between the ages of 4-21 months.
data from representatives of hospital management with The mean age of babies of mothers in the study was 11
the aid of an interview guide. The interview guide and months with almost a third (30%) of the babies at 4
questionnaires were both developed by authors based on months. Sixty-one percent (61%) of BFHWs interviewed
the literature reviewed [8, 14, 16, 28–30], (see supple- were clinical staff and 39% were support staff. Informa-
mentary file 1 for details). After obtaining written tion on parity, work experience, and age in Table 1 re-
consent from the BFHWs, questionnaires were given lates to BFHWs and babies.
to participants to complete. Questionnaires were Three main themes emerged from the interviews
picked up after 1 week, followed by interviews con- with representatives of health facility management. 1).
ducted by the lead researcher and assisted by a re- Standpoints on workplace breastfeeding support. 2).
search assistant. All interviews were conducted in the Breastfeeding support. 3). Suggested future directions.
English language and were recorded using field notes Standpoints on workplace breastfeeding support had
and an audio recorder. Each interview lasted between three sub-themes, namely, Backing for workplace
40 and 45 minutes. Data for the study were collected breastfeeding support, Perceived benefits of breast-
between April and May 2018. feeding support, and factors of poor breastfeeding
workplace support. Breastfeeding support also had
Data analysis three sub-themes, including maternity protection ben-
Self-reported questionnaires from BFHWs were proc- efits, workplace support gaps, and awareness creation
essed using Statistical Package for Social Science (SPSS, on benefits. Verbatim quotations were used to sup-
version 23.0) and analyzed using descriptive statistics. port the themes and to provide evidence. Details of
Results on the one hand were presented based on the main themes and sub-themes are discussed
frequencies/percentages and measures of central followed by the quantitative results.
Nkrumah et al. BMC Public Health         (2021) 21:1647 Page 5 of 12
Table 1 Demographic characteristics of respondents
Description Freq. % Description Freq. %
Age Respondents parity
Mean age 32 ± 5 1 17 34
24–28 14 26 2 13 26
29–33 17 31 3 12 24
34–38 9 17 4 6 12
39–43 9 17 5 2 4
44+ 5 9 Total 50 100
Total 54 100 Work experience
Marital Status 1–4 30 60
Married 43 79 5–8 14 28
Single 8 15 9+ 6 12
Divorced 2 3 Age of Baby (in Months)
Widowed 2 3 Mean age of babies 11 ± 5
Total 54 100 4–6 15 30
Religion 7–9 6 12
Christian 32 58 10–12 11 22
Muslim 23 42 13–15 7 14
Total 54 100 16–18 5 10
Staff Category 19–21 6 12
Clinical staff 33 61 Total 50 100
Support staff 21 39
Total 54 100
Source: constructed by authors using data from the field
Standpoints on workplace support for breastfeeding Workplaces must have very very well-equipped
Representatives of health facility management inter- places for breastfeeding. For instance, in this
viewed shared their facilities’ perceived positions on hospital, there should be a place where working
workplace breastfeeding support and accentuated the mothers can go and breastfeed. Possibly, there should
importance of providing such support for frontline be a nurse at the place to take care of the babies so
health workers. The three sub-themes that follow that even if the mother is not visiting … and there is
present the details. bottle feeding, it would be expressed breast milk. It
should be a very hygienic place that can take care of
Backings for workplace breastfeeding support babies.
Respondents in this study had extensive knowledge of
workplace support for breastfeeding and shared some The perceived benefits of breastfeeding workplace support
views on workplace support for breastfeeding. Breast- The representative of hospital 4 shared the benefits em-
feeding workplace support such as the creation of ployers stand to gain when they implement breastfeeding
breastfeeding rooms where breastfeeding frontline workplace support and said:
health workers can keep their babies while working
was emphasized by all the respondents. The need for If we have healthy children … . I mean, if a mother
a national policy on a breastfeeding-friendly work- can breastfeed so that the child does not have
place was also mentioned. Respondents believed this diarrhea and other illnesses, then the mother will
would help provide a standardized workplace support not lose working days to go and take care of a
culture across industries and workplaces. The repre- sick baby. Once a child is healthy on breast milk,
sentative of hospital 3 shared her views on the need the employee saves money and time for work. So,
for a breastfeeding-friendly work environment in the it is good for mothers in employment and
following statement: employers as well.
Nkrumah et al. BMC Public Health         (2021) 21:1647 Page 6 of 12
It is clear from the above statement that creating a Maternity Protection benefits
breastfeeding-friendly workplace can be thought of as a As part of the conditions of service of BFHWs, breastfeed-
good business or an aspect of hospitals’ corporate social ing mothers are granted 12 weeks paid maternity leave in
responsibility. Most respondents were of the view that the case of spontaneous vagina delivery (SVD) and 24
breastfeeding workplace support has triple benefits that weeks for those with assisted delivery, such as cesarean
may outweigh the cost involved in providing the sup- section. BFHWs also enjoy paid breastfeeding breaks. Re-
port, particularly, loss of man-hours that may arise from spondents from both private and public hospitals men-
the indisposition of infants because of inappropriate tioned that the conditions of service of BFHWs capture all
feeding practices. The representative of hospital 2 shared the maternity protection provisions provided in the labor
this with us. laws of Ghana. Further, BFHWs are first put on morning
shifts only until the baby is 26 weeks, followed by morning
Breast milk has nutrients that protect the child from and afternoon shifts until the baby is 52 weeks old. They
illness, so employers must support it. In this way, can also apply for casual leave where necessary.
working mothers will not need to take days off work
to care for their babies because of illness. Mothers Workplace support gaps
will always be present at work to discharge their The gaps in breastfeeding workplace support identi-
duties. I believe employers stand to benefit if their fied in the health facilities are summed up in the
employees are always present at work. statements of the representatives of hospital 1 and 3
as follows:
Factors of poor breastfeeding workplace support
Our clients breastfeed in the wards … …… … . I
In this study, a range of factors was outlined by re-
mean our postnatal inpatients are entitled to
spondents to limit efforts in providing breastfeeding
breastfeed in the ward. For our staff, we do not have
support for BFHWs. They included a lack of funding
a lactating site. A breastfeeding staff must leave her
to create a breastfeeding-friendly workplace environ-
baby at home and when it is time to breastfeed, she
ment, limited office space, and inadequate staff. Two
goes home to breastfeed. If they are fortunate to have
of the respondents retorted that it is difficult to
a babysitter who will come to work with them, then
promote breastfeeding supportive work culture,
they can bring their babies along to breastfeed at
particularly when more frontline health workers
work … … maybe sit under the tree if they would be
must be provided with such support at the same
comfortable over there. But as to getting a place that
time. The representative of hospital 2 shared her
is so conducive for breastfeeding, no, not at all.
experience and said:
(Representative of hospital 1).
Hmm … it is quite difficult. Sometimes we have
When they come to work, depending on the
issues with limited staff. Supposing you are on a
workload for the day … you know, there are days
ward that requires ten (10) staff but only eight (8)
that the workplace is very busy and there are
are on duty and you have some of the staff taking
days that the workplace is less busy. On our busy
two (2) hours off to breastfeed. … . this situation puts
days, when we monitor and realize that the
pressure on the other remaining staff if the
tension has reduced, we give them the time to go
workplace is busy. They are forced to do the work of
and breastfeed. Sometimes, when the workplace is
those breastfeeding in addition to theirs, especially
busy, they communicate with their babysitters and
when the breastfeeding mothers decide to take some
ask, ‘is the baby in need of breast milk?’, ‘is it
time off their schedules to breastfeed. Other times
time for breastfeeding?’ ‘is baby showing any signs
too, you may have situations where more than three
of lactating?’ If it comes out like that then the
mothers would be on maternity leave at the same
person goes and then breastfeeds. (Representative
time in a unit. This gives more work and stress to
of hospital 3).
the other staff who may be at work.
These statements highlights the plight of BFHWs
Breastfeeding support and the work-breastfeeding discrepancies that are
All health facilities in the study had some form of likely to result from it. Almost all hospitals in the
breastfeeding support in place for BFHWs. Predomin- study did not have breastfeeding facilities or an on-
antly, they are those guaranteed in the maternity protec- site creche for kids of BFHWs. Only one out of the
tion provision of the Labor Act of Ghana. The details four hospitals was constructing an onsite creche at
are discussed in the sub-themes below. the time of the study.
Nkrumah et al. BMC Public Health         (2021) 21:1647 Page 7 of 12
Awareness creation on breastfeeding workplace support facilities or creche in the hospitals. However, reasons of-
Even though healthcare facilities in the study did not fered for not going to work with baby were, no place to
have most of the essentials of a breastfeeding-friendly keep the baby (28%) and concentration at work (16%). A
workplace environment, those provided in the condition little above half of the participants failed to provide rea-
of services of BFHWs, such as maternity leave, casual sons. All (100%) BFHWs in the study knew the benefits
leave, working half-day, and other staff welfare packages of breastfeeding and did initiate breastfeeding. However,
were disseminated among BFHWs through staff orienta- about 34% of them supplemented breastfeeding with
tion, memos, website, and staff meetings. It was also as- artificial milk (4%), water (18%), and porridge and water
sumed that BFHWs are well informed of issues related (12%). Averagely, participants indicated that they re-
to optimal breastfeeding practice, given that breastfeed- ported to work at 8:00 am and closed at 3:00 pm each
ing education is integrated into maternity services. day. Feeding strategies upon returning to work included
breast milk expression (34%), breastfeeding when at
Suggested future direction home (40%), and breastmilk and porridge (26%). Twenty
Respondents were united in their views regarding the percent of the participants indicated that their closing
way forward. They called for a revision of the Labor Act, and reporting time affected breastfeeding and 96% said
Act 651 of 2003 to define the essentials of the workplace they will prioritize work over breastfeeding in circum-
breastfeeding policy. On the flipside, representatives of stances of work-breastfeeding conflict. About a third
the mission-based and private hospitals expressed a pref- (34%) of the respondents indicated they would wean
erence for a policy guideline that would leave details of their babies earlier than planned due to the separation
action for promoting a breastfeeding-friendly workplace between them and their babies occasioned by the de-
environment to employers to formulate and implement mands of work.
based on organization-specific circumstances. The repre- Table 3 presents mothers’ evaluation of coping strategies
sentative of hospital 4 explained further in the statement adopted to manage breastfeeding-work tension. The results
below: show social support such as support from husbands and
relatives (median = 3) as highly supportive in mitigating the
A national policy would be helpful. Yes, it would inconsistencies between work and childcare. Flexible work
guide the hospitals to formulate their action plans. I arrangement (median = 2) and support from coworkers
think a policy framework must come from the top (median = 2) were believed to be moderately supportive for
and then translated down to all healthcare facilities. coping with the challenges arising from work, breastfeeding,
Individual hospitals can have their strategic plans and childcare. Regarding the challenges of work and breast-
which will have considerations for specific needs feeding, undue stress resulting from the conflict between
related to breastfeeding mothers. work and breastfeeding (median = 3) was considered ex-
tremely challenging. Insufficient breast milk arising from
To obtain balanced views on the extent of support for the separation between mother and baby (median = 2),
workplace breastfeeding, BFHWs were interviewed. difficulties in expressing milk (median = 2), work overload
Table 2 presents BFHWs’ views of breastfeeding work- (median = 2), and work duration (median = 2) were consid-
place support and breastfeeding practice. Participants’ ered moderately challenging.
views on breastfeeding workplace support were consist-
ent with responses from the interviews. Ninty-6 % (96%) Discussion
of the participants said they went on 12 weeks maternity In this study, we assessed the extent to which health facil-
leave, had breastfeeding break (80%), and 70% indicated ities in the Effutu Municipality provide a breastfeeding-
that they enjoyed five-day 20-h workweek (5/20) (i.e., friendly workplace environment for BFHWs, their views
half-day) after returning to work instead of the usual on the breastfeeding support they receive, and the coping
five-day 40-h workweek (5/40). Participants mentioned strategies used in managing work-breastfeeding chal-
staff orientation (44%) and workshops (16%) as the main lenges. Out of the list of 62 BFHWs obtained, only 50 con-
sources of maternity protection benefits information. sented to participate in the study. Consequently, the views
The results also established several shortfalls in the expressed in this study are the views of BFHWs who actu-
breastfeeding workplace support of the hospitals. ally participated in the study. Even though the study re-
Ninety-six percent (96%) of breastfeeding frontline corded a 100% response rate, it must be noted that some
health workers indicated a lack of breastfeeding policy of the questionnaire items recorded non-response possibly
and breastfeeding facilities (94%) in their hospitals. Even because participants had limited time to complete the
though 90% said their workplace policy allows them to questionnaires. The results are likely to have some
go to work along with baby, only 14% go to work with amount of nonresponse bias. The results established that
their babies, possibly due to the lack of breastfeeding hospital leaders have a positive standpoint on
Nkrumah et al. BMC Public Health         (2021) 21:1647 Page 8 of 12
Table 2 Mothers’ Views on Workplace Support
Freq. %
Breastfeeding policy at workplace Mothers’ feeding strategies %
Yes 0 0 Expressed breast milk 17 34
No. 48 96 Breastfeed when at home 20 40
No response 2 4 Breast milk and porridge 13 26
Paid maternity leave Feeding trategy below 6months
Yes 48 96 Expressed breast milk 18 36
No. 2 4 Artificial milk 2 4
Paid breastfeeding Break Breast milk and water 9 18
Yes 40 80 porridge, water, and breast milk 6 12
No. 10 20 No response 15 30
Worked half-bay Had breastfeeding education when pregnant
Yes 35 70 Yes 47 94
No 5 10 No 3 6
No response 10 20 Aware of breastfeeding benefits
Sources of maternity benefits information Yes 50 100
HR handbook 3 6 No. 0 0
Facility’s website 3 6 Initiated breastfeeding
Orientation 22 44 Yes 50 100
Workshop 8 16 No 0 0
Memos/circulars 4 8 Reporting/closing time affected breastfeeding
No. response 10 20 Yes 20 40
Policy allows oing to work withbBaby No 30 60
Yes 45 90 Would sacrifice work to breastfeed
No 5 10 Yes 48 96
Go to Work long with baby No 2 4
Yes 7 14 The possible effect of separation on breastfeeding
No. 43 86 Insufficient breast milk 8 16
Breastfeeding facility at workplace Early winning 17 34
Yes 3 6 Decision not to breastfeed 4 8
No. 47 96 No response 21 42
Reasons for leaving baby at home Common breastfeeding challenges
To concentrate at work 8 16 Work overload 19 38
No place to keep baby 14 28 Insufficient breastmilk 11 22
wanted the baby to be at creche 2 4 Breast milk contamination 10 20
No response 26 52 Breast milk expression 10 20
Mean reporting time to work 8:00 am Common coping strategies
Mean closing time from work 3:00 pm Husband/relatives support 35 70
Colleagues’ support 9 18
Closing at unapproved times 7 12
Source: constructed by authors using field data
breastfeeding workplace support that has practical value. places for babies. The challenge with this situation is that
However, effort at implementing the standpoints appeared babies do not have a fully developed immune system, ex-
restrained by systemic challenges. BFHWs who go to work posing them to the hospital environment has the potential
along with their babies had no access to demarcated to compromise their health. Breastfeeding sites and onsite
Nkrumah et al. BMC Public Health         (2021) 21:1647 Page 9 of 12
Table 3 Mothers’ Evaluation of Coping Strategies of Childcare, Work, and Challenges
Description Frequency
Challenges Least Challenging (1) Most Challenging (2) Highly Challenging (3) NR Total Median
Difficulties in expressing milk 12 17 5 16 50 2.0
Inadequate breast milk due 9 16 10 15 50 2.0
to infrequent feeding
Breastmilk contamination 14 10 9 17 50 2.0
Work overload 7 15 21 7 50 2.0
Work duration 12 15 9 14 50 2.0
Conflicting responsibilities 11 12 15 12 50 2.0
Stress and burnout 5 15 21 9 50 3.0
Poor concentration at work 6 14 17 13 50 2.0
Difficulties in meeting timelines 10 12 11 17 50 2.0
Copping Strategies Least Supportive (1) Moderately Support (2) Highly Supportive (3) No Response Total Median
Avoiding workplace responsibilities 18 13 2 17 50 1.0
Reporting to work late 15 10 4 21 50 1.0
Leaving workplace before approved 17 8 4 21 50 1.0
closing time
Support from husband and relatives 3 7 34 6 50 3.0
Flexible work arrangement 6 22 9 13 50 2.0
Breast milk expression 7 10 19 14 50 3.0
Support from colleagues 2 18 11 19 50 2.0
Source: constructed by authors using field data
creches in hospitals could be a haven for preventing provisions are not enough to support and protect opti-
infants and kids of BFHWs from hospital-acquired mal breastfeeding on return to work.
infections. Other gaps included a lack of education on A notable gap identified was the lack of breastfeeding
strategies for returning to work and balancing childcare policy in the hospitals. This circumstance can markedly
and work. affect breastfeeding upon return to work. Though some
The findings show that the most reliable workplace institutions in Ghana have systems in place to support
breastfeeding support available to BFHWs for breast- women to balance the demands of work, learning, and
feeding/childcare were maternity leave, spousal, and co- childcare, Ghana has no policy framework that guaran-
worker support. Even though family support was tees a minimum package of workplace breastfeeding/
prominent, it is at best appropriate for childcare com- childcare support for working mothers. In the US for in-
pared to breastfeeding. Family support exists outside of stance, the Patient Protection and Affordable Care Act
the workplace and may not represent adequate social (ACA) oblige employers with 50 or more employees to
support for improving optimal breastfeeding on return allow reasonable break time and provide designated
to work. It also demonstrates a lack of workplace sup- rooms for breast milk expression [30, 31]. Even though
port systems for breastfeeding mothers to cope with the there is a dearth of empirical literature on the effective-
stress and burnout arising from work and breastfeeding ness of national policies on workplace breastfeeding pro-
in the health facilities studied. Systems at the workplace tection in improving breastfeeding initiation and
to promote optimal breastfeeding among mothers duration [32], Kogan et al. [33], have found a relation-
returning to work are an important aspect of the Inter- ship between state adopted breastfeeding support laws
national Labor Organization’s (ILO) recommendation and breastfeeding initiation and duration in developed
for maternity protection benefits [29]. Women have the economies. Likewise, Kim et al. [34], conducted a sys-
right to work, and children have the right to appropriate tematic review on the effectiveness of workplace lacta-
feeding and nutrition. It is therefore important that tion interventions on breastfeeding in the US and found
pragmatic steps are taken to promote breastfeeding a significant association between interventions such as
workplace environment in Ghana. Even though the con- the provision of a breast pump, return-to-work consult-
ditions of service of BFHWs subscribe to the maternity ation, telephone support, and exclusive breastfeeding
protection benefits enshrined in the Labor Act, the duration. While we do not seek to create economic and
Nkrumah et al. BMC Public Health         (2021) 21:1647 Page 10 of 12
institutional equivalence between Ghana and the US, the exclusive breastfeeding. Evidence from Durban, USA,
above evidence shows that effective national policies shows that women in workplaces that had supportive
that enforce provisions of basic lactation support in work culture exclusively breastfed 4 months and longer
the workplace, particularly, in health facilities would than those in workplaces with poor supportive work cul-
help create employee value and make breastfeeding- ture [40].
friendly accredited hospitals worth their names. The results of this study and the literature in Ghana
Health facility representatives interviewed blamed their seem to suggest that breastfeeding break and maternity
inability to provide such an environment on lack of re- leave are the common forms of breastfeeding support
sources. They believe that if their hospitals were to have culture of organizations in Ghana.
adequate resources and implementation guidelines, they BFHWs’ access to maternity leave and breastfeeding
could undertake such initiatives for staff. It stands to break corroborate research findings from the USA and
reason that employers are unlikely to provide breastfeed- Ghana [13, 41]. Due to the lack of a breastfeeding facility
ing support at the workplace in the absence of a policy and the desire to concentrate at work, most BFHWs
directive that obliges them to do so. On this basis, a na- breastfeed when they are at home. This practice was also
tional policy in this regard can help promote a breast- found in some universities in Nigeria where most breast-
feeding workplace culture in healthcare institutions. The feeding employee-mothers breastfeed before and after
views of respondents on the triple benefits of providing work only [42].
breastfeeding workplace support corroborates the argu- Almost all participants indicated receiving breastfeed-
ment that breastfeeding workplace support is cost- ing education during pregnancy, which presupposes that
effective compared to the extension of maternity leave. BFHWs are aware of the benefits of exclusive breastfeed-
It reduces absenteeism, improves employee retention, ing. Yet, 34% supplemented breastfeeding with water,
and increases employee morale and loyalty [35–37]. artificial milk, and porridge on return to work, when the
Workplace breastfeeding support has mutual bene- baby was below 6months. This situation could be attrib-
fits to both employers and employees. On this basis, uted to the negative effect of maternal work on breast-
partnership between industry and policymakers can feeding and accentuates the need for intervention in the
be explored for improving workplace breastfeeding in workplace to minimize the effect of work-related factors
Ghana. Such a partnership can yield positive out- on optimal breastfeeding. The findings of this study also
comes for both employers and employees. Available emphasize frontline health workers’ desire for economic
evidence indicates that workplace lactation interven- independence and how this quest can influence infant
tions are related to better outcomes such as lower ab- feeding practice. Most women are eager to work in re-
senteeism, lower turnover, higher job satisfaction, and turn for economic benefit. As evident in this study, 70%
positive organizational reputation [38, 39]. The ab- of the participants indicated that they would not
sence of such interventions may lead to poor work sacrifice work for breastfeeding in situations where
outcomes. The situation in Ghana puts employers in breastfeeding interferes needlessly with work, which is
a disadvantaged position in the absence of such a consistent with earlier research in Ghana [15]. In this re-
partnership. Breastfeeding mothers would accept to search, it was found that maternal work affected breast-
work given the financial benefit they stand to earn, feeding in situations where income from maternal work
coupled with the lack of jobs that guarantee job se- was needed to supplement the family budget. It is even
curity. Yet, breastfeeding mothers may lack the level possible to assume that net income of BFHWs who par-
of morale and job satisfaction needed for improved ticipated in this study formed a significant proportion of
productivity. their family’s budget.
Poor breastfeeding workplace environment in this Averagely, the participants spent 6–7 h in the work-
study may well be the bane of optimal breastfeeding place, and others (40%) believed that time spent in the
practice as BFHWs find it an enormous task to continue workplace affected breastfeeding. This makes BFHWs the
breastfeeding upon return to work [40]. Smith and col- most affected in the absence of workplace breastfeeding
leagues in their study found a significant association be- policy. They have a dual duty to fulfill their gendered role
tween awareness of breastfeeding support policy and of infant nursing and work to support their families.
higher rates of exclusive breastfeeding among Australian Breastfeeding and childcare support at the workplace are
working mothers. Supportive work culture such as a aspects of employee welfare. Under this circumstance, the
flexible work arrangement for breastfeeding mothers Ghana Registered Nurses and Midwives Association, the
varied across hospitals in this study. The arrangements Health Service workers Union and the Ghana Medical As-
were unofficial and were granted based on exigencies at sociation can play a vital role in pressing home the urgent
the workplace and at the discretion of unit heads and need for breastfeeding support policy in hospitals. Support
managers. Such an arrangement is unlikely to support from husbands and relatives in this study is consistent
Nkrumah et al. BMC Public Health         (2021) 21:1647 Page 11 of 12
with research findings in Ghana, where family support productivity is recommended. Sensitization of employers
aided exclusive breastfeeding practice among working on the benefit of workplace lactation interventions to
mothers [8]. improved productivity is also recommended.
The proposed future directions provided by respondents
point to the need for extensive stakeholder consultation in Abbreviations
WHO: World Health Organization; BFHI: Baby-Friendly Hospital Initiative;
arriving at a national workplace breastfeeding and childcare SST: Social Support Theory
support policy. For instance, there were divergent views on
the extension of maternity leave from 3 to 6months further Supplementary Information
to WHO’s push for an increase in maternity leave. While The online version contains supplementary material available at https://doi.
the Ghana Medical Association, Nutritionists, and some org/10.1186/s12889-021-11652-5.
mothers were in favor of such a policy, other women in
paid employment were more interested in the Additional file 1. Research instrument file. Questionnaire and interview
guide. The file contains the questionnaire and interview guide used to
institutionalization of baby-friendly workplace environ- glean data for the study.
ments to enable them to return to work for fear of losing
their jobs [5]. The opinions shared by stakeholders in the
Acknowledgments
literature and in this study provide deeper insights into The authors acknowledge the management of hospitals in the study and
what should be the content of future policy on workplace breastfeeding frontline health workers for their maximum cooperation
breastfeeding policy. Most importantly, the process for such during the data collection.
a policy should entail extensive stakeholder engagement to Authors’ contributions
ensure that workplace support policies provide equitable We declare that we are the sole authors of this manuscript. The study was
benefits to employers and employees. conceptualized together with a literature review and instrument
development by all authors. Research instruments were developed by the
first author (J.N.) in addition to data collection. Analysis of data and
Limitations of the study manuscript preparation were done by the first and third authors (J.N. and
The results of this study have limited generalizability R.B.N) Review and editing of the manuscript were done by the first authors
owing to the use of non-probability sampling and (A.A.A. and J.N.). All authors have read and approved the manuscript.
descriptive data analysis. It is also possible that the back- Funding
ground of respondents interviewed might have intro- The research was funded by the authors.
duced some level of bias in the verbal responses. Given
that respondents were females and members of manage- Availability of data and materials
The datasets used and/or analyzed during the current study are available
ment of their respective hospitals. The data collected from the corresponding author on reasonable request.
only allowed for the description of mothers’ views on
workplace breastfeeding support and did not capture Declarations
mothers’ lived experiences of navigating the difficult
Ethics approval and consent to participate
terrine of modern employment and child nursing. Ethics approval for this study was waived by the Faculty Science Education,
Similarly, the study did not explore workplace lactation Univerisity of Education,Winneba (letter number: FSE/DO/D5/VoL.3/101.
interventions and their significance for BFHWs’ work Dated 10th April, 2018). Management of participating health facilities were
formally informed about the purpose and details of the study and a writtren
output and optimal breastfeeding. This can be consid- approval was obtained before the commencement of the study. All
ered for further studies. participants were briefed about the purpose of the study and those who
consented for participation in writing were included in the study.
Participation was voluntary and data were anonymously analyzed such that
Conclusion results were untraceable to participants.
We conclude based on the analysis of the interviews and
questionnaire responses that breastfeeding support pro- Consent for publication
vided to BFHWs in the Effutu Municipality is limited to Not applicable.
those enshrined in the Labor Act. Health facilities in the Competing interests
study do not provide a breastfeeding-friendly work en- The authors declare that the work contained in this article is their original
vironment for BFHWs. The BFHI has no significance for work and there is no conflict of interest concerning authorship and
publication of the article. The manuscript is currently not under review by
the workplace environment of staff in the frontline of any journal.
implementation of the BFHI. Consistent with the social
support theory, support from relatives was perceived as Author details1Faculty of Science Education, Department of Health Administration and
the most effective buffer against work-breastfeeding Education, University of Education, P.O Box 25, Central Region, Winneba,
stress and tension. Continuous advocacy on breastfeed- West African, Ghana. 2Department of Public Administration and Health
ing workplace support and stakeholder engagement to Services Management, University of Ghana Business School, P. O. Box 75,
Greater Accra Region, Accra-Legon, West Africa, Ghana. 3Center for Research
build consensus on the mix of strategies appropriate to on Children and Families, McGill University|3506 University Street, Suite 106,
cushion BFHWs for optimal breastfeeding and improved Montreal, QC H3A 2A7, Canada.
Nkrumah et al. BMC Public Health         (2021) 21:1647 Page 12 of 12
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