University of Ghana http://ugspace.ug.edu.gh SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA FACTORS ASSOCIATED WITH EXCLUSIVE BREASTFEEDING AMONG BREASTFEEDING MOTHERS IN KOFORIDUA MUNICIPALITY BY ABIGAIL DODUWAH SACKEY (STUDENT ID-10874772) A DISSERTATION SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF MASTER OF PUBLIC HEALTH (MPH) DEGREE i University of Ghana http://ugspace.ug.edu.gh MARCH, 2022 DECLARATION I, Abigail Doduwah Sackey, hereby declare that this thesis is almost entirely my own work except other people's investigations which have been indicated and acknowledged. This dissertation has not been submitted elsewhere for another degree either in whole or part. Abigail Doduwah Sackey Signature: (MPH candidate) Date: 20/06/2022 Dr. Juliana Enos Signature: (Supervisor) Date: 20/06/2022 ii University of Ghana http://ugspace.ug.edu.gh DEDICATION This project is dedicated to my mother, Mrs. Lucy Sackey and my father, Mr. Francis Quabu Sackey for their immense support throughout this phase of my life. iii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT First and foremost, I wish to express my sincere gratitude to Jehovah I Am that I Am for being my constant help in all things. To my supervisor, Dr. Juliana Enos, for her guidance and patience through this project. Also, to the management, staff and patients of Eastern Regional Hospital who gave me their permission to collect data at their facility. Finally, to my parents, brothers, husband and friends for their financial, physical and emotional support which have brought me this far. Not forgetting my children, Boahemaa Lyubov and Ekuban Slava for being my driving force to be a better health worker. May God bless and sustain you! iv University of Ghana http://ugspace.ug.edu.gh ABSTRACT About 595,379 children die globally as a result of not being breastfed every year. The prevalence of exclusive breastfeeding of babies is low worldwide. Globally 43% of infants are breastfed exclusively whereas 37% and 36% in developing countries and sub-Sahara Africa, respectively. In Ghana, the prevalence of exclusive breastfeeding has declined from 52% in 2014 to 43% in 2018. Understanding the factors influencing the practice of exclusive breastfeeding is critical to developing appropriate strategies to promote the practice. Hence, this study aims to determine the factors associated with exclusive breastfeeding among mothers in Koforidua municipality since there are no recorded documents on this. A descriptive cross-sectional study design was used in this study. A total of 348 mothers with at least 6 months old babies were recruited for this study from May to June 2022, and interviewed using a structured questionnaire. The data was analyzed using descriptive statistics and multiple logistic regression model with statistical significance set at p<0.05. Analysis of the results showed that 93.4% of mothers were aware of exclusive breastfeeding. Yet, only 42.2% of them practiced exclusive breastfeeding. The factors associated with compliance of exclusive breastfeeding in Koforidua were educational level, monthly income and the place of birth of the youngest child. Mothers who earned above 500 Ghana cedis monthly had reduced odds of exclusive breastfeeding (AOR=0.28; 95% Cl=0.08 - 0.92; p= 0.035). Mothers who disagreed that expressed breastmilk maintained its health benefits were 96% less likely to practice exclusive breastfeeding (AOR=0.04; 95% Cl = 0.01 - 0.22; p < 0.001). Furthermore, mothers who v University of Ghana http://ugspace.ug.edu.gh recommend exclusive breastfeeding to their colleagues were 42.92 times more likely to practice it (AOR = 42.92; 95% cl = 4.32 - 426.31; p= 0.001). Also, respondents who did not know where to get help for breastfeeding issues had 74% less likelihood of practicing exclusive breastfeeding (AOR =0.26; 95% Cl = 0.11 - 0.62; p = 0.002). The factors which showed significant association with exclusive breastfeeding include; income (p = 0.005), educational level (p < 0.001) and place of birth of youngest child, i.e., institutional delivery (p = 0.006). Conclusion of the study was that less than half of breastfeeding mothers in Koforidua practiced exclusive breastfeeding even though almost all of them were aware of it. Since the adherence to exclusive breastfeeding is low in Koforidua (42.2%), the health professionals in the municipality need to intensify their education of mothers on the importance of exclusive breastfeeding, especially at ANC and pediatric department in all hospitals. This can be done through videos, music and fliers on exclusive breastfeeding. The municipality can partner with stakeholders such as chiefs, assembly men, pastors and imams to use their platform as an information medium and also to make public places such as churches and mosques baby friendly to encourage mothers to practice exclusive breastfeeding. Community centers can be created where mothers can easily have access to health professionals for all their questions surrounding breastfeeding. Support groups for working class women who are breastfeeding must be created to encourage each other. vi University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENT DECLARATION ........................................................................................................................................ ii DEDICATION ........................................................................................................................................... iii ACKNOWLEDGEMENT .......................................................................................................................... iv ABSTRACT................................................................................................................................................ v LIST OF TABLES ...................................................................................................................................... 3 LIST OF FIGURES ..................................................................................................................................... 4 LIST OF ABBREVIATION ........................................................................................................................ 5 CHAPTER ONE ......................................................................................................................................... 6 1.1 Background to the Study ................................................................................................................. 6 1.2 Problem Statement .......................................................................................................................... 7 1.3 Research Questions ......................................................................................................................... 8 1.4 Objectives of the study .................................................................................................................... 8 1.5 Conceptual framework .................................................................................................................... 9 1.5.1 Narrative of Conceptual Framework ..........................................................................................10 CHAPTER TWO .......................................................................................................................................11 2.1 Introduction ....................................................................................................................................11 2.2 Importance of Exclusive Breastfeeding .........................................................................................11 2.3. Factors Associated with Exclusive Breastfeeding .........................................................................12 CHAPTER THREE ....................................................................................................................................20 METHODS ................................................................................................................................................20 3.1 Introduction ....................................................................................................................................20 3.2 Study Design ...................................................................................................................................20 3.3 Study Location ................................................................................................................................20 3.4 Study Population ............................................................................................................................21 3.4.1 Inclusion criteria: .........................................................................................................................21 3.4.2 Exclusion criteria: ........................................................................................................................21 3.5 Sampling Size Determination and Sampling method....................................................................21 3.6 Sampling Technique .......................................................................................................................23 3.7 Study Variables ..............................................................................................................................23 1 University of Ghana http://ugspace.ug.edu.gh 3.7.2 Independent variables: .................................................................................................................23 3.8 Data Collection ...............................................................................................................................24 3.8.1 Pretesting ......................................................................................................................................24 3.8.2 Quality Control ............................................................................................................................24 3.9 Data Analysis ..................................................................................................................................24 3.10 Ethical Consideration ....................................................................................................................25 CHAPTER FOUR ......................................................................................................................................22 4.1 Demographic characteristics of respondents .................................................................................22 4.2 Prevalence of exclusive breastfeeding ............................................................................................24 4.3 Knowledge about exclusive breastfeeding ......................................................................................24 4.4 Attitude towards exclusive breastfeeding .......................................................................................29 4.5 Practice of exclusive breastfeeding .................................................................................................31 4.6 Breastfeeding support .....................................................................................................................33 4.7 Supportive workplace policies towards exclusive breastfeeding ...................................................34 4.8 Bivariate analysis of demographic characteristics associated with exclusive breastfeeding ........36 4.9 Supportive workplace policies associated with practice of exclusive breastfeeding .....................38 4.10 Breastfeeding support factors associated with practice of exclusive breastfeeding ....................39 4.11 Association between attitude towards exclusive breastfeeding and practice of exclusive breastfeeding .........................................................................................................................................39 4.12 Factors associated with practice of exclusive breastfeeding ........................................................42 CHAPTER 5 ..............................................................................................................................................46 5.1 Introduction ....................................................................................................................................46 5.2 Prevalence of Exclusive Breastfeeding ...........................................................................................46 5.3 Factors associated with compliance to Exclusive Breastfeeding ...................................................47 5.4 Limitations of the study ..................................................................................................................49 CHAPTER SIX ..........................................................................................................................................50 6.1 Conclusions......................................................................................................................................50 6.2 Recommendations ...........................................................................................................................51 REFERENCES ..........................................................................................................................................53 APPENDIX I: PARTICIPANT INFORMATION SHEET .........................................................................64 APPENDIX II: CONSENT FORM ............................................................................................................68 2 University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES 4.1 Demographic characteristics of respondents ........................................................................................................22 4.2 Knowledge about exclusive breastfeeding ...........................................................................................................25 4.3 Attitude towards exclusive breastfeeding .............................................................................................................29 4.4 Practice of exclusive breastfeeding .......................................................................................................................31 4.5 Breastfeeding support.............................................................................................................................................33 4.6 Supportive workplace policies towards exclusive breastfeeding ..........................................................……….….34 4.7 Bivariate analysis of demographic characteristics associated with exclusive breastfeeding………………….…35 4.8 Supportive workplace policies associated with practice of exclusive breastfeeding ............................................38 4.9 Breastfeeding support factors associated with practice of exclusive breastfeeding ............................................ . 39 4.10 Association between attitude towards exclusive breastfeeding and practice of exclusive breastfeeding ..........40 4.11 Factors associated with practice of exclusive breastfeeding ..............................................................................42 3 University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 1 Conceptual framework …………………………………………….……...…………………...10 Figure 2 Prevalence of exclusive breastfeeding among mothers …………………………….………... 23 4 University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATION ANC - Antenatal Clinic AAP - American Academy of Pediatrics CWC - Child Welfare Clinic EBF - Exclusive breastfeeding GDHS - Ghana Demographic and Health Survey GHS - Ghana Health Service UNICEF - United Nations Children's Fund WHO - World Health Organization 5 University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE 1.0 INTRODUCTION 1.1 Background to the Study Breastfeeding is a unique and natural way of providing food for healthy growth and development of babies (Motee & Jeewon, 2014). It is a vital area in public health because of its direct influence on the wider population’s overall quality of health and mortality levels (Alzaheb, 2017). In 1990, the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) established the Innocenti Declaration - a global initiative on the protection, promotion and support of breastfeeding. According to the declaration, mothers were encouraged to initiate breastfeeding within one hour of birth. Mothers were advised to exclusively feed their babies breastmilk for the first six months and to continue breastfeeding up to two years of age or beyond. Similarly, the American Academy of Paediatrics (AAP) also recommends that infants should be exclusively breastfed for the first six months of life. Breastmilk is the best source of nutrients for babies (Martin, Ling & Blackburn, 2016) as it enhances the infant’s immunity, lowering the risk of mortality and infectious diseases and protecting the baby against respiratory and gastrointestinal infections, as well as offering long-term protection against noncommunicable diseases such as obesity and diabetes (Kelishadi & Farajian, 2014). Breastfed infants have a lower chance of contracting allergic diseases and a lower risk of suffering sudden infant death syndrome (Alzaheb, 2017). Breastfeeding 6 University of Ghana http://ugspace.ug.edu.gh also protects mothers against the risk of breast and ovarian cancers (Centers for Disease Control and Prevention, 2019). In spite of its numerous benefits, statistics in various countries show breastfeeding trends in terms of prevalence and duration to be lower than that of international recommendations (Alemayehu, Haidar & Habte, 2009). Globally, only 43% of infants are exclusively breastfed while 37% and 36% of infants are exclusively breastfed in developing countries around the world and in Sub Saharan Africa respectively (Mgongo et al., 2018). This study seeks to assess the factors associated with adherence to exclusive breastfeeding among mothers in the Koforidua. 1.2 Problem Statement In a systematic review conducted by Sankar et al. (2015), risk of all-cause and infection-related mortality was higher in partially and non-breastfed infants compared to exclusively breastfed infants aged 0–5 months. Globally, 595,379 children die as a result of not being breastfed every year (Walters, Phan & Mathisen 2019). Optimal breastfeeding can save 98,243 mothers from dying of cancers and type II diabetes every year. The world suffers an economic loss estimated to be between US$257 billion and US$341 billion or between 0.37% and 0.70% of global gross national income yearly (Walters, Phan & Mathisen 2019). The Lancet Series on breastfeeding, estimates that over 800,000 children lose their lives and suffer cognitive losses globally (Rollins et al., 2016; Victora et al., 2016). This amounts to US$302 billion financial loss yearly due to infant exposure to breastmilk substitute (Rollins et al., 2016; Victora et al., 2016). The global health system spends an estimated US$1.1 billion annually on treatment to decrease infant morbidity and mortality rate (Walters, Phan & Mathisen 2019). In Africa, about 1.24 million (approximately 96%) babies die during the first six months of life due to failure of mothers to 7 University of Ghana http://ugspace.ug.edu.gh breastfed exclusively (Alebel et al., 2018). According to the 2003 Ghana Demographic and Health Survey (GDHS), the prevalence of exclusive breastfeeding was 39.2% which increased to 63% in the 2008 (GDHS, 2008) and declined to 52% in 2014 (Ghana Statistical Service, Ghana Health Service, 2014). The current prevalence of exclusive breastfeeding documented in 2021 was 43% which shows a decline in the 52% reported in the 2014 GDHS. According to the Director-General of the Ghana Health Service (GHS), Dr Kuma-Aboagye noted poor traditional practices such as giving water and foods and the uncontrolled advertisement and sale of breast milk substitute as factors that may have influence the fall in rate of exclusive breastfeeding in 2021 (WHO, 2021). A number of studies also noted maternal age, marital status, level of education, occupation and the child’s characteristics such as birth order and method of delivery to have an influence on the practice of exclusive breastfeeding (Bhandari et al., 2019; John et al.,2019 & Seidu et al., 2020). Kimani‐Murage et al. (2015) also identified employment, early and single motherhood, poor social and professional support, lack of information or education on breastfeeding, cultural and religious belief as factors affecting exclusive breastfeeding. Despite the factors listed above, the factors influencing the adherence of EBF in Koforidua is not documented . Thus, this study seeks to identify the factors associated with exclusive breastfeeding in Koforidua. 1.3 Research Questions 1. What is the prevalence of exclusive breastfeeding among mothers in Koforidua? 2. What are the factors associated with exclusive breastfeeding among mothers in Koforidua? 1.4 Objectives of the study 1.4.1 General Objective The overarching objective of the study is to assess the factors associated with exclusive breastfeeding among mothers in Koforidua 8 University of Ghana http://ugspace.ug.edu.gh 1.4.2 Specific Objectives The specific objectives of this study are: 1. To determine the prevalence of exclusive breastfeeding among mothers in Koforidua. 2. To determine the factors associated with exclusive breastfeeding among mothers in Koforidua. 1.5 Conceptual framework Figure 1 Conceptual framework for the study (adapted from the WHO, 2015) 9 University of Ghana http://ugspace.ug.edu.gh 1.5.1 Narrative of Conceptual Framework Several factors influence the practice of exclusive breastfeeding and these factors can be categorized into sociodemographic, social, supportive workplace policies and information or educational factors. Sociodemographic factors such as maternal age (Kitano et al., 2016; Asare et al., 2018; Agho et al., 2019), marital status (Odindo et al., 2014; Bich et al., 2019; Mamo et al., 2020), level of education (Diji et al., 2016; Asare et al., 2018; Laksono et al., 2021) and occupation and employment (Taddele et al., 2014; Chekol et al., 2017; Chhetri et al., 2018) can affect the practice of exclusive breastfeeding. Social factors such as cultural and religious attitudes and beliefs (Issaka et al., 2014; Diji et al., 2016; Bernard, Cohen & Kramer 2016), spousal, family and community support (Ratnasari et al., 2017; Coomson &Aryeetey 2018; Ogbo et al., 2020) affects exclusive breastfeeding. Supportive workplace policies such as maternity leave and flexible working hours (Buccini et al., 2016; Altamimi et al., 2017; Rimes, Oliveira & Boccolini, 2019) and breastfeeding breaks, breastfeeding corners and expression rooms (Osibogun et al.,2018; McCardel & Padilla 2020; Nkrumah, Abuosi & Nkrumah, 2021) also affects exclusive breastfeeding. Information or education received from the media, health workers, family and friends (Yang et al., 2018; Hamze et al., 2019; Ebrahimi, 2021) influence the practice of exclusive breastfeeding. 10 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO 2.0 LITERATURE REVIEW 2.1 Introduction This chapter examines current and historical literature on exclusive breastfeeding among women in order to improve understanding of the topic and increase the amount of evidence available to support it. Exclusive breastfeeding is defined as giving no other foods not even water apart from only breastmilk to infants in the first six months of their life (WHO,2015). However, the infant can be given medications such as oral rehydration salt, vitamins and minerals. 2.2 Importance of Exclusive Breastfeeding The World Health Organization (2013) advocates for optimal breastfeeding practices to promote a child's healthy growth and development. Breastfeeding should begin within one hour of birth, be exclusive for the first six months of the infant's life, and then be supplemented with adequate nutritious foods and continued for the next two years. Accordingly, (Hannula, Kaunonen and Tarkka, 2014; WHO, 2019) revealed that exclusive breastfeeding during the first few months of life and continued breastfeeding for at least the first two years of life is associated with a significant reduction in the load of infections. In addition, UNICEF (2018) indicated that, breastfeeding new-borns within the first hour of life protects them from illnesses and saves lives. Infants who are only partially breastfed or not nursed at all are at a higher risk of dying from diarrhoea and other diseases (UNICEF, 2018). Breastfeeding does not interfere with infant’s response to any vaccine, but rather improves it (Anderson, 2019). 11 University of Ghana http://ugspace.ug.edu.gh Breastfed infants are less likely than non-breastfed infants to have fever, anorexia, and reduced energy intake following routine childhood immunization (Anderson, 2019). Breastfeeding benefits mothers' health and well-being; it helps to space children, reduces the risk of breast and ovarian cancer, increases family and national resources, is a secure method of feeding, and is environmentally safe (WHO, 2018). 2.3. Factors Associated with Exclusive Breastfeeding 2.3.1 Demographic Factors 2.3.1.1 Maternal Age The relationship between maternal age and exclusive breastfeeding has yielded inconclusive results over time. A study done in Japan (Kitano et al., 2016) revealed that mothers under the age of 35 were more likely than older women to practice exclusive breastfeeding. They discovered that younger mothers had higher rates of success in practicing exclusive breastfeeding at discharge (88.5 percent) and one month (76.9 percent) after delivery, with maternal age greater than 35 being identified as a negative factor in initiating and sustaining exclusive breastfeeding (Kitano et al., 2016). In line with this finding, Asare et al. (2018) conducted a study in Tema Manhean, Ghana and discovered that among the study’s participants, mothers between the ages of 20 and 34 were more likely to practice exclusive breastfeeding. In contrast, several research (Agho et al., 2019; Fisher et al., 2013) found that older mothers aged 35 years or older were more likely than younger mothers to practice exclusive breastfeeding. In a study conducted by Diji et al. (2016) in Ghana indicated that, despite the fact that the mean age of the participants was 27.72, women who practiced exclusive breastfeeding were substantially older than their counterparts who did not practice exclusive breastfeeding, indicating a significant connection between the practice and maternal age. 12 University of Ghana http://ugspace.ug.edu.gh 2.3.1.2 Educational Level In the literature, a mother's level of education has been identified as a related factor in the practice of exclusive breastfeeding. In a Ghanaian study conducted by Diji et al. (2016) noted a significant association between exclusive breastfeeding and maternal education. According to the study they identified that mothers who were educated were more likely to exclusively breastfeed their infants arguing that such mothers may be relatively more confident and committed to breastfeeding than their less educated counterparts due to the infant care experiences and education they have acquired over time. This report is in line with previous studies done in Nigeria (Onah et al., 2014), Tanzania (Maonga et al., 2016) and Ethiopia (Asemahagn, 2016) indicating mothers with informal or no education were less likely to practice exclusive breastfeeding. In a study conducted in Kano, Nigeria, by Aliyu & Shehu (2016) found that the majority (69.2 percent) of mothers had university education, while 21.6 percent had secondary school education, 2 percent had basic school education, and 7.2 percent had informal education. They also found a positive relationship between education and exclusive breastfeeding, noting that the more educated the mothers are, the more likely they are to engage in the practice of effective breastfeeding, which is similar with studies by Glassman et al. (2014), Danso (2014) and Laksono et al. (2021). Danso (2014) found that 37% of respondents had a bachelor's degree, 32% had various diplomas, and 18.5 percent had professional certifications, with 12.5 percent having a master's or higher degrees, suggesting that respondents' educational level gives in-depth information about the practice of exclusive breastfeeding. In contradiction, a study conducted in Ghana by Asare et al. (2018) noted that mothers with university education were less likely to practice exclusive breastfeeding than those with no education, stating that Ghanaian mothers with higher education work in formal jobs, making exclusive breastfeeding challenging and less likely. 13 University of Ghana http://ugspace.ug.edu.gh 2.3.1.3 Marital Status In the practice of exclusive breastfeeding, marital status has been linked as a contributing factor. A study in Oromia, Ethiopia by Mamo et al. (2020) revealed that marital status has an association with exclusive breastfeeding. According to Odindo et al. (2014), a positive association was found between marital status and exclusive breastfeeding. According to their findings, mothers in polygamous marriages accounted for 33 percent were more likely to practice breastfeeding than the 29.7 percent in the monogamous marriage. Despite these findings, single mothers reported the highest percentage of exclusive breast feeding at 36%, which is slightly higher than the rate reported by polygamous married women. Polygamous mothers have a high rate of exclusive breastfeeding because of the social network with co-wives who might have successfully practised exclusive breastfeeding in the past (Odindo et al., 2014). In a study conducted by Bich et al. (2019) provided evidence that educating and encouraging fathers to actively participate in exclusive breastfeeding have significantly improved the rate of early initiation and practice of exclusive breastfeeding. Hence, indicating the importance of paternal influences on breastfeeding (Bich et al., 2019). However, Hunegnaw, Gezie, & Teferra (2017) found no link between marital status and exclusive breastfeeding in Ethiopia. 2.3.1.4 Occupation/Employment The impact of occupation and employment on exclusive breastfeeding practice have also been inconsistent. According to Diji et al. (2016), women who work in the public sector had a greater rate of exclusive breastfeeding. In contrast to the above finding several studies in Ethiopia (Setegn et al., 2012; Taddele et al., 2014 and Chekol et al., 2017) reported, that unemployed mothers were more likely than employed mothers to practice exclusive breastfeeding. 14 University of Ghana http://ugspace.ug.edu.gh According to an Indian survey, 43.8 percent of breastfeeding mothers were technical managers, 16.8 percent were administrative staff, 13.1 percent were salespersons and petty traders, 1.5 percent were agricultural workers, another 13.1 percent worked in service, and 11.7 percent conducted manual labour (Chhetri et al., 2018). In addition, 21.1 percent of these mothers worked part-time, while 16.9 percent worked full-time. Despite this, no significant association between exclusive breastfeeding and occupation or kind of job was discovered (Chhetri et al., 2018). 2.3.2 Sources of Information / Education on Breastfeeding The source and veracity of a mother's education or knowledge about exclusive breastfeeding has been found to be a significant predictor of practicing exclusive breastfeeding. According to a study conducted by Osibogun, Olufunlayo & Oyibo (2018) in Lagos, Nigeria found that 86.5 percent of mothers get breastfeeding information or advice from the hospital, 41.5 percent of them from their friends, 32.0 percent from their family members and 35.5 percent from the media. A study conducted by Yang et al. (2018). showed that healthcare professionals do not receive adequate education on breastfeeding to effectively support mothers in how to practice exclusive breastfeeding properly. Ebrahimi, (2021) found that lactation consultants work to refute common breastfeeding myths and communicate accurate information in order to increase the likelihood of practicing exclusive breastfeeding. Mothers usually seek information, support and encouragement on exclusive breastfeeding from communities, relatives and health system (Hamze et al., 2019). Due to the information, they got from health experts during their visit, women who had at least one antenatal care visit were more likely to practice EBF than their peers who did not. (Tariku et al., 2017). 15 University of Ghana http://ugspace.ug.edu.gh 2.3.3 Supportive Workplace Policies 2.3.3.1 Maternity Leaves and Flexible Working Hours Policies at workplace is a significant predictor in the mother’s ability to practice exclusive breastfeeding. Even when compared to mothers who did not work, mothers on maternity leave had a higher rate of exclusive breastfeeding, indicating that maternal work is not a hinderance to exclusive breastfeeding, but rather the lack of maternity leave is (Rimes, Oliveira & Boccolini, 2019). Working mothers on maternity leave were found to have a lower likelihood of ceasing EBF in the first four months of their child's life according to Buccini et al., (2016) and Vieira et al., (2014). Brown et al. (2014) found that the lack of maternity leave is linked to the decision not to start or cease breastfeeding. Altamimi et al. (2017) discovered that work-related variables were the reason of premature discontinuation of breastfeeding for 30% of the participants in a study conducted in Jordan, implying that working mothers have a lower prevalence of practicing exclusive breastfeeding. This is unsurprising, given that most organizations, including those in Ghana, provide a three-month leave after which the mother is expected to return to work. In Ghana, mothers who work in the formal sector are unable to exclusively breastfeed following maternity leave since the facilities and working circumstances at their workplaces do not encourage exclusive breastfeeding and they are not permitted to bring their babies to work. (Nkrumah, 2016). 2.3.3.2 Breastfeeding Breaks, Breastfeeding Corners and Expression Rooms Workplace support for exclusive breastfeeding is also a significant predictor of practicing EBF. Exclusive breastfeeding becomes difficult for working mothers who return to work without workplace support (Osibogun et al.,2018). Chekol et al. (2017) discovered that, while work status had no effect on 16 University of Ghana http://ugspace.ug.edu.gh breastfeeding initiation, it did have an effect on breastfeeding length in Northwest Ethiopia. Working mothers were more likely than nonworking mothers to discontinue breastfeeding (Chekol et al., 2017). In a study conducted in Kenya by Ickes et al. (2021), flexible work schedules and reduced hours while returning to work helped mothers' ability to breastfeed exclusively for 6 months. Women have the right to work, and children have the right to adequate nutrition and feeding (Nkrumah, Abuosi & Nkrumah, 2021). As a result, it is critical that practical actions are implemented to foster a breastfeeding-friendly workplace environment in Ghana (Nkrumah et al., 2021). In an American study conducted by McCardel & Padilla (2020), approximately 78.8 percent of participants had access to break periods for expressing breast milk, and 65.4 percent had access to venues other than a lavatory to express breast milk. 2.3.4 Social Factors 2.3.4.1 Cultural/ Religious Beliefs According to Watson (2013), cultural and religious beliefs is a major predictor of breastfeeding duration. Breastfeeding women are frequently urged by their culture to supplement their infants' nutrition with water and artificial feeds (Diji et al., 2016). A study conducted in Ghana on the determinants of inadequate complementary feeding practices among children aged 6–23 months in Ghana by Issaka et al. (2014) stated that, many Ghanaian mothers believe that breastmilk alone is insufficient to meet the nutrients needed by their kids. They typically introduce complementary foods to their infants in their early year of life (Issaka et al., 2014). In an ecological study, Bernard, Cohen and Kramer (2016) found that the larger the Catholic share in the population, the lower the breastfeeding initiation rates in that population. Mothers who do not attend religious services are less prevalent to practice exclusive breastfeeding as compared to mothers who attend religious services (Burdette & 17 University of Ghana http://ugspace.ug.edu.gh Pilkauskas, 2012). According to the findings of the preceding studies, religion can improve the likelihood of practicing exclusive breastfeeding. 2.3.4.2 Spousal/ Family/Community Support Spousal, family and community support is also a significant predictor of exclusive breastfeed and can increase the prevalent of its practice. Appropriate spousal support was discovered to be vital and can impact new mothers' decision to begin, maintain, or discontinue nursing in the early postnatal period (Ogbo et al., 2020). This assistance can take the form of aiding in the prevention and management of breastfeeding challenges, assisting with home chores, assisting with infant care duties, and providing verbal encouragement (Ogbo et al., 2020). According to Ratnasari et al. (2017), practicing exclusive breastfeeding was substantially connected with sufficient family support. According to their findings, family support can boost the likelihood of achieving exclusive breastfeeding. Family members can encourage exclusive breastfeeding by emphasizing that breast milk is the best source of nutrition for infants. To help working women, husbands and grandmothers can help with childcare by babysitting, buying or cooking food, and feeding the babies (Ratnasari et al., 2017). In a study, Coomson and Aryeetey (2018) found that public breastfeeding is a prevalent behaviour among breastfeeding women in Ghana. However, when breastfeeding in public, women exhibit signs of shyness, embarrassment, discomfort, or stigmatization. Because women are increasingly involved in work outside the home, these beliefs about nursing in public can reduce the prevalence and have a detrimental impact on their decision to practice exclusive breastfeeding (Coomson & Aryeetey, 2018). To cope with the discomfort and shame they experience when breastfeeding in public, they develop coping mechanisms such as covering the breast and infant (Amir, 2014). The coping strategy technique limits eye-to-eye bonding 18 University of Ghana http://ugspace.ug.edu.gh between the mother and child, as well as making the baby hot and uncomfortable while breastfeeding (Amir, 2014). 19 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METHODS 3.1 Introduction The methods section gives details how data were obtained, how research questions and objectives were investigated, how the sampling processes, the information and data was analyzed. This chapter also discusses the study design, study location, study population, sampling technique, sample size, types and sources of data, research instrument, administering of research instrument, data handling and ethical considerations. 3.2 Study Design The study design used was a descriptive cross-sectional study to determine the factors associated with adhering to exclusive breastfeeding. A cross-sectional study design is appropriate for this research because the study is interested in assessing the possible relationship between the factors influencing adherence to exclusive breastfeeding. 3.3 Study Location The study was conducted at the Eastern Regional Hospital located in the New Juaben Municipality, Koforidua in the Eastern Region. The municipality has a population of 183,727 of which 51.7% are females (GSS, 2014). The Eastern Region is bordered to the east by the Lake Volta, to the north by Brong-Ahafo Region and Ashanti Region, to the west by Ashanti Region, to the south by Central Region and Greater Accra Region. Akans are the dominant inhabitants and natives of the Eastern Region. Akan and Krobo are the main spoken languages. Eastern Regional Hospital, Koforidua (ERHK) is a Ghana Health Service facility which is a non-profit 20 University of Ghana http://ugspace.ug.edu.gh healthcare organization. It was established in 1926 and is a secondary level referral facility for the entire Eastern Region. The hospital offers the following services: Obstetrics and Gynecology, Internal Medicine including Anti-retroviral therapy, Paediatrics, Surgery, Dental, Ophthalmology, Physiotherapy, Ear, Nose and Throat, Laundry, Mortuary and Primary Healthcare Services. 3.4 Study Population All women in Koforidua attending postnatal clinic and CWC at the Eastern Regional Hospital. 3.4.1 Inclusion criteria: Mothers whose recent child are at least six months old were included in this study if they consented to participate. 3.4.2 Exclusion criteria: Those who were ill were excluded from the study. 3.5 Sampling Size Determination and Sampling method 3.5.1 Sample size calculation Proportion of mothers who exclusively breastfed their children for six months in a study conducted by Manyeh et al., (2021) in Ningo-Prampram and Shai Osu-doku were used to calculate the sample size. The study reported that 71% of mothers exclusively breastfed their children for six months (Manyeh et al., 2021). Thus, the sample size of this study was calculated at 95% confidence interval using a formula by Cochran. The formula is given by: 𝑧2𝑝𝑞 n0= 2 (Cochran, 1977) 𝑒 21 University of Ghana http://ugspace.ug.edu.gh Where: • n= required sample size • Z2 = standard normal deviate for two tailed-test based on 95% confidence level = 1.96 • p= proportion of postpartum women using contraception = 71%= 0.71 (Morhe et al., 2017) • q=1-p= proportion of postpartum women not using contraception = 1-0.71 = 0.29 • e= margin of error = 5% = 0.05 • Therefore, the sample size will be calculated as follows • N = 3.8416 ×0.71 ×0.29 • N = 0.0025 0.79099 • N = 0.0025 • 316.39 = 316 participants • However, to cater for non-response rate, an attrition rate of 10% was used to upwardly adjust the sample size. Thus, 1.1 × 316 = 348. Therefore, 348 mothers were surveyed in this study. 22 University of Ghana http://ugspace.ug.edu.gh 3.6 Sampling Technique Consecutive sampling method was used to select participants for this study. To do this, eligible participants were first identified based on the inclusion and exclusion criteria. Then, those who consented to partake in the study were enrolled into the study. All consecutive mothers who attended CWC every Wednesday were approached to seek consent to partake in the study. This was done by dividing the determined sample size into four Wednesdays since the data collection was done in one month. On each day the daily specific sample size was achieved by enrolling participants who met the inclusion criteria and gave consent to participate in the study. Enrolment was done on a first come first serve basis and continued until the overall sample size was achieved. Each participant was engaged, to answer the questionnaire, at least, within a period of 30mins. 3.7 Study Variables 3.7.1 Dependent variables: Exclusive breastfeeding 3.7.2 Independent variables: Demographic Factors: Maternal Age, Marital Status, Educational Level, Occupation Supportive Workplace Policies: Breastfeeding Breaks, Flexible Working Hours, Maternity Leaves, Breastfeeding Corners and Expression Rooms Social Factors: Cultural/Religious attitudes and beliefs, Spousal Support, Family Support, Community Support. Information/Education /Environmental Factors: Media, Family and Friends, Health Workers 23 University of Ghana http://ugspace.ug.edu.gh 3.8 Data Collection Data was collected from the study participants using a structured questionnaire. The questionnaire had five sections which included the individual characteristics of participants, information on supportive workplace policies, knowledge on breastfeeding, attitude on exclusive breastfeeding and practices on exclusive breastfeeding. Participants were made aware of the aim of the study to prevent ambiguity and ensure full comprehension, prior to the administering of the questionnaire. The questionnaires were administered by the principal investigator with support from two trained research assistants on a one-on-one basis. The filling of the questionnaire for each participant lasted an average of 20 minutes. 3.8.1 Pretesting Pretesting was done at the St. Joseph Hospital by the principal investigator for a week but did not lead to any changes to the questionnaire. 3.8.2 Quality Control Field workers were trained to administer the questionnaire. The data collected after administering the questionnaires were sorted, coded and entered into Microsoft excel. The spreadsheet was cross- checked for missing data and replaced to ensure accuracy of the data entered. The clean database was imported into Stata version 16.0 file (Stata Corporation, Texas, USA) before analysis was done. 3.9 Data Analysis Data was imported from Microsoft excel into STATA 16 for analysis. Frequencies and percentages were used to report descriptive statistics. Continuous variables were reported using means and standard deviations. The prevalence of exclusive breastfeeding was reported using graphs and percentages. 24 University of Ghana http://ugspace.ug.edu.gh Furthermore, Pearson Chi-Square was used to determine the factors associated with exclusive breastfeeding at the bivariate level. Variables found to be statistically significant were fitted into a multiple logistic regression table with significance set at p<0.05. 3.10 Ethical Consideration Ethical Clearance: Ethical approval for this research was obtained from the Ghana Health Service Ethics Review Committee, approval number GHS-ERC: 073/03/22 Permission was sought from the management of the Eastern Regional Hospital, Koforidua to allow the study to be conducted at the facility. Risks: This research comes with no risk that borders on physical damage to the participant except the risk of having to share information which may seem personal. Benefit: Participants had an opportunity to gain some knowledge and awareness on exclusive breastfeeding since each participant was educated after the data collection. Privacy and Confidentiality: To ensure privacy and confidentiality, participants were identified with codes and numbers and were allowed to answer the questionnaires at convenient places of choice. No information regarding participants’ name or any other information that traces the data collected to the participants was taken. Participants information were kept on a computer with a secured password. Filled questionnaires were kept under lock and key, with only the principal investigator having access. Voluntary Consent/Withdrawal: Participants were made to understand that participation in the study is voluntary, that they have the right to either be or not be part of the study; and that they can withdraw at any time during the study. 25 University of Ghana http://ugspace.ug.edu.gh Data Storage and Usage: All hard copies of the data obtained from the field were transformed into an electronic data using Microsoft Excel which was password encrypted. Data collected were stored in both electronic and hard copies for at least five (5) years. The participants were assured that the data collected were used for academic purposes and were inform about the policy which they stand to benefit from. Compensation There were no compensation for study participants. 26 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR RESULTS 4.1 Demographic characteristics of respondents Table 4.1 shows the demographic characteristics of respondents. The mean age of respondents was 32.5 years ± 5.8SD. Majority of the mothers (75.9%) were married. Nearly 87% of the respondents were Christians. About 55.8% of the respondents were formally employed with only 12.6% earning above GH₵ 2000. Ninety- seven percent of the respondents were educated at various levels with 46.3%, 19.5%, 23.0% and 8.3% having tertiary, vocational, secondary and primary education respectively. Almost all mothers (99.4%) attended ANC when they were pregnant and 81.6% had their youngest child in a hospital setting, which shows that most of them have been educated on the benefits of exclusive breastfeeding during ANC. Table 4.1 Demographic characteristics of respondents (N = 348) Frequency Percentage Variables ( n ) ( %) Marital status Married 264 75.9 Cohabiting 36 10.3 Single 44 12.6 Divorced 4 1.2 Religion Christian 302 86.8 Muslim 31 8.9 Traditional religion 15 4.3 22 University of Ghana http://ugspace.ug.edu.gh Employment status Unemployed 47 13.5 Informal workers 107 30.7 Formal workers 194 55.8 Income (GHC) < 500 85 28.2 500 – 1000 99 32.9 1001 – 2000 79 26.3 > 2000 38 12.6 Educational level None 10 2.9 Tertiary 161 46.3 Vocational 68 19.5 Secondary 80 23.0 Primary 29 8.3 Place of birth of youngest child Home 50 14.4 Health facility 284 81.6 Other 14 4.0 ANC attendance No 2 0.6 Yes 346 99.4 23 University of Ghana http://ugspace.ug.edu.gh 4.2 Prevalence of exclusive breastfeeding Figure 4.1 below shows the results after mothers had answered the questionnaire. Out of the 348 mothers, 42.2% practiced exclusive breastfeeding (proportion = 0.42; 95% CI = 0.37 – 0.48). Figure 2 Prevalence of exclusive breastfeeding among mothers 4.3 Knowledge about exclusive breastfeeding Table 4.3 shows respondents’ knowledge on exclusive breastfeeding. Majority of the respondents (93.4%) had heard of exclusive breastfeeding with 89.9% stating health facilities as their source of information. Nearly 34.8% of respondents defined exclusive breastfeeding as “a type of breastfeeding where the infant receives only breast milk and no other liquids or solids – not even water – with the exception of prescribed oral rehydration solution, or drops/syrups of vitamins, minerals or medicines”. Majority of the respondents’ (72.6%) indicated that babies less than 6 months should be given only breast milk. Also, most of the respondents (46.8%) stated the “sense of love and attachment” as the benefit of exclusive breastfeeding to the mother whilst 40.9% stated “resistance to infections” as the benefit of exclusive breastfeeding to the child. In addition, majority of the mothers (74.8%) agreed that breast 24 University of Ghana http://ugspace.ug.edu.gh milk fulfils a child’s dietary requirement better than formula milk with a further 77.5% indicating that breast milk alone is sufficient during the first six months of a babies’ life. Most of the respondents (46.5%) also stored their breast milk in a refrigerator. Out of the 348 respondents, 229 (70.5%) indicated that exclusive breastfeeding should only last for 6 months. Table 4.2 Knowledge about exclusive breastfeeding Frequency Percentage Variables ( n) ( %) Ever heard of exclusive breastfeeding No 23 6.6 Yes 325 93.4 Source of information Health facility 292 89.9 Family 111 34.2 Market 10 3.1 Friends 76 23.4 Media 91 28.0 Others 5 1.5 Definition of exclusive breastfeeding: A type of breastfeeding where the infant receives only breast milk 189 58.2 only breast milk and herbal formulations 2 0.6 only breast milk, water and other liquids or solids 6 1.8 breast milk, water, other liquids or solids as well as prescribed medicines 12 3.7 only breast milk, no other liquids or solids – with the exception of prescribed oral rehydration solution, or syrups of vitamins, minerals or prescribed medications 113 34.8 25 University of Ghana http://ugspace.ug.edu.gh I do not know 3 0.9 Awareness of the benefits of exclusive breastfeeding Yes 314 96.6 No 6 1.9 Don’t know 5 1.5 Source of information of benefits of exclusive breastfeeding Health facility 295 84.8 School 60 17.2 Market 9 2.6 Friends 78 22.4 Media 79 22.7 Others 15 4.4 Babies less than 6 months be given any other food apart from breastmilk Yes 89 27.4 No 236 72.6 Benefits of exclusive breastfeeding to the mother Weight control 130 37.4* Uterus returns to regular size 95 27.3* Reduce postpartum bleeding 83 24.1* Sense of love and attachment 161 46.8* Natural contraception 130 37.4* Don’t know 56 17.0* 26 University of Ghana http://ugspace.ug.edu.gh Benefits of exclusive breastfeeding to child (multiple responses) Resistance to infections 133 40.9 Protects against diarrhea 74 22.8 Protects against childhood illness 74 22.8 Prevents obesity 44 13.5 Importance of colostrum to the baby (multiple responses) Nutrient rich fluid 106 32.6 Helps immunity 85 26.2 Provides hydration and protein 36 11.1 Don’t know 98 30.1 Waiting time for breastfeeding after delivery (practically) Immediately 144 44.3 30 minutes 87 26.8 1 hour 29 8.9 1 day 49 45.1 More than one day 16 4.9 Duration for nursing mother to empty each breast (practically) 5 minutes 28 8.6 10-15 minutes 94 28.9 15-20 minutes 126 38.8 Don’t know 77 26.7 Breast milk fulfils the child's dietary requirements better than formula milk 27 University of Ghana http://ugspace.ug.edu.gh Yes 243 74.8 No 82 25.2 Breast milk alone sufficient during the first 6 months of life Yes 252 77.5 No 73 22.5 Expressed breast milk loses its benefits Yes 106 32.6 No 219 67.4 Storage mode of breast milk At room temperature 94 28.9 In a refrigerator 151 46.5 Anywhere 43 13.2 Freezer 37 11.4 Duration for exclusive breastfeeding after birth 1 month to less than 2 months 10 3.1 3 months to less than 5 months 26 8.0 5 months to less than 6 months 35 10.8 6 months 229 70.5 More than 6 months 18 5.5 Don’t know 7 2.1 *Multiple response 28 University of Ghana http://ugspace.ug.edu.gh 4.4 Attitude towards exclusive breastfeeding Most of the women (74.1%) agreed that the attitude towards breastfeeding of society and the people around them was good. In addition, 75.6% of the women indicated that their family was supportive towards breastfeeding the child exclusively. Majority of the respondents (87.1%) stated that they took the decision to practice exclusive breastfeeding on their own with 99.1% happy to be breastfeeding their child. Eighty nine percent of the respondents revealed that they felt confident about breastfeeding their child after birth with 94.5% also revealing their intention to breastfeed future children. The proportion of women who indicated they will recommend exclusive breastfeeding to their colleagues was 80.5% and a further 78.8% disagreeing with the statement “breastfeeding the child for 6 months or more is a waste of time” as shown in table 4.5. Table 4.3 Attitude towards exclusive breastfeeding Frequency Percentage Variables ( n) (% ) Society and people around me think breastfeeding is good Agree 258 74.1 Not sure 80 23 Disagree 10 2.9 Family reaction towards exclusive breastfeeding Supportive 263 75.6 Unsupportive 54 15.5 Don’t know 31 8.9 Mother’s sole decision to breastfeed child Yes 303 87.1 No 45 12.9 Happy with breastfeeding baby 29 University of Ghana http://ugspace.ug.edu.gh Yes 345 99.1 No 3 0.9 Support for women to exclusively breastfeed their children No 50 14.4 Yes 298 85.6 Expressed breast milk maintains its health benefits Agree 204 58.6 Not sure 103 29.6 Disagree 41 11.8 Confidence to breastfeed child after birth Yes 311 89.4 No 37 10.6 Intention to breastfeed future children Yes 307 94.5 No 18 5.5 Recommend exclusive breastfeeding to colleagues No 68 19.5 Yes 280 80.5 Breastfeeding the child for 6 months or more is a waste of time No 256 78.8 Yes 69 21.2 30 University of Ghana http://ugspace.ug.edu.gh 4.5 Practice of exclusive breastfeeding Most of the respondents (68.3%) in this study had ever practiced exclusive breastfeeding. Among the 222 respondents who had practiced exclusive breastfeeding, 95.0% had practiced with their current child. Forty one percent of the respondents (41.1%) introduced other foods to their child at 6 months and 36.8% stopped breastfeeding of their child after 24 months. After delivery, 39.7% of the respondents had introduced their child to breast milk within 30 minutes of birth. 28% of the mothers breastfed exclusively for less than 6 months, 60% breastfed exclusively for 6 months and 12% breastfed exclusively for more than 6 months. About 34.8% of mothers introduced new foods at less than 6 months, 41.1% at 6 months and 24.1% after 6 months. The study also showed that 16.7% stopped breastfeeding at less than 6 months, 5.5% at 6 months, 41.1% between 6 months and 2 years and 36.8% above 2 years. Also 13.2% of the babies who were less than 2 days were given formula at the hospital since mothers had not started lactating and 86.8% were not. Table 4.4 Practice of exclusive breastfeeding Variables Frequency (n) Percentage (%) Ever practiced exclusive breastfeeding No 103 31.7 Yes 222 68.3 If yes, practiced exclusive breastfeeding with current child (n = 222) No 11 5.0 Yes 211 95.0 Duration of exclusive breastfeeding for current child < 6 months 91 28.0 6 months 195 60.0 > 6 months 39 12.0 31 University of Ghana http://ugspace.ug.edu.gh Age at which other foods were introduced < 6 months 121 34.8 At 6 months 143 41.1 6 to 24 months 84 24.1 Age at which breastfeeding of the child was stopped < 6 months 58 16.7 At 6 months 19 5.5 Between 6 months and 2 years 143 41.1 After 24 months 128 36.8 Time of initiating breastfeeding after delivery Within 30 minutes 138 39.7 30 minutes - 1 hour 41 11.8 1 - 24 hours 94 27.0 After 24 hours 75 21.5 Child given milk formula in the hospital Yes 46 13.2 No 302 86.8 32 University of Ghana http://ugspace.ug.edu.gh 4.6 Breastfeeding support Twenty nine percent of the mothers indicated that they spoke to their doctors about breastfeeding. However, 85.6% of the mothers indicated that talking about breastfeeding was challenging. Most of the respondents (80.8%) mentioned that they had a challenge talking about breastfeeding. Moreover, forty three percent of the respondents indicated that their partners provided support during breastfeeding. Majority of the mothers (77.3%) knew where to obtain help if any breastfeeding-related issues occur as illustrated in table 4.7 below. Table 4.5 Breastfeeding support Variables Frequency (n) Percentage (%) Individual(s) consulted about breastfeeding (multiple responses) Partner 87 25.0 Friends 52 14.9 Family 67 19.3 Employer/co-workers 17 4.9 Doctor 100 28.7 Childcare provider 11 3.2 Community group 7 2.0 Other 7 2.0 Ease of talking to individuals about breastfeeding Difficult 298 85.6 Easy 50 14.4 Challenges faced when talking about breastfeeding No 67 19.2 Yes 281 80.8 Support system for breastfeeding Partner 151 43.4 Friends 56 10.3 Family 100 28.7 Doctor 41 11.8 33 University of Ghana http://ugspace.ug.edu.gh Know where to get help if any breastfeeding issues occur Yes 269 77.3 No 79 22.7 4.7 Supportive workplace policies towards exclusive breastfeeding The table below shows the workplace policies available to support the practice of exclusive breastfeeding. Majority of the respondents (68.1%) indicated that their workplace grants them paid maternity leave for 3 months ±1.0SD on average. Out of the 111 respondents who stated that their workplace did not grant paid maternity leave, only 9.0% have ever had a maternity leave. More than half of the respondents (53.5%) stated that their workplace offered flexible working hours for nursing mothers. Most of the respondents’ (63.0%) workplaces did not allow nursing mothers to bring their children to work. However, among nursing mothers who were allowed to bring their children to work (37.0%), majority of them (79.7%) indicated they were allowed to take breaks of an hour or 30 minutes. Twenty three percent of the nursing mothers indicated that their workplaces have a breastfeeding or milk expression room with chairs indicated by most of the respondents (43.7%) as the equipment available to aid in breastfeeding. Table 4.6 Supportive workplace policies towards exclusive breastfeeding Variables Frequency ( n ) Percentage (% ) Paid maternity leave No 111 31.9 Yes 237 68.1 If yes, average duration of maternity leave (months) 3.0 ± 1.0 , If no, ever had a maternity leave (n = 111) No 101 91.0 Yes 10 9.0 34 University of Ghana http://ugspace.ug.edu.gh Flexible working hours for nursing mothers No 162 46.5 Yes 186 53.5 Nursing mothers allowed to bring children to work No 218 63.0 Yes 128 37.0 If yes, breastfeeding breaks at workplace No 26 20.3 Yes 102 79.7 Length of breastfeeding breaks 1 hour 51 50.0 30 minutes 41 40.2 15 minutes 10 9.8 If no, other arrangements made to support nursing mothers No 190 87.2 Yes 28 12.8 Availability of breastfeeding/milk expression room No 268 77.0 Yes 80 23.0 If yes, equipment available to aid breastfeeding Refrigerator 9 11.3 Chairs 35 43.7 Tables 20 25.0 Breast milk pumps 3 3.8 Footstools 5 6.2 Baby/toddler lay area 5 6.2 Others 3 3.8 35 University of Ghana http://ugspace.ug.edu.gh 4.8 Bivariate analysis of demographic characteristics associated with exclusive breastfeeding Table 4.7 shows the results of bivariate analysis (chi-square) of demographic factors associated with practice of exclusive breastfeeding. The factors which showed significant association with exclusive breastfeeding include; income (p = 0.005), educational level (p < 0.001) and place of birth of youngest child (p = 0.006). The age of respondents, employment status, marital status and religion were not associated with exclusive breastfeeding. Table 4.7 Socio-demographic factors associated with exclusive breastfeeding Variables Exclusive breastfeeding p-value Practiced EBF Not practiced EBF (n = 147) (n = 201) Age of respondents 32.2 ± 4.3 32.7 ± 6.7 0.464 + Marital status 0.109 Married 121(45.8) 143(4.2) Cohabiting 12(33.3) 24(66.7) Single 13(29.5) 31(70.5) Divorced 1(25.0) 3(75.0) Religion 0.145 Christian 133(44.0) 169(56.0) Muslim 8(25.8) 23(74.2) Traditional religion 6(40.0) 9(60.0) Employment status 0.086 Unemployed 16(34.0) 31(66.0) Informal workers 39(36.5) 68(63.5) Formal workers 92(47.4) 102(52.6) 36 University of Gha n a http://ugspa ce.ug.edu.gh Income (GH₵) 0.014* < 500 28(32.9) 57(67.1) 500 – 1000 41(41.4) 58(58.6) 1001 – 2000 38(48.1) 41(51.9) > 2000 24(63.2) 14(36.8) Educational level 0.000* None 3(30.0) 7(70.0) Tertiary 86(43.4) 75(46.6) Vocational 15(22.1) 53(77.9) Secondary 26(32.5) 54(67.5) Primary 17(58.6) 12(41.4) Place of birth of youngest child 0.006* Home 12(24.0) 38(76.0) Hospital 126(44.4) 158(55.6) Other 9(64.3) 5(35.7) + ANC attendance 0.511 No 0(0.0) 2(100.0) Yes 147(42.5) 199(57.5) + Statistically significant (p<0.05) Fisher’s exact 37 University of Ghana http://ugspace.ug.edu.gh 4.9 Supportive workplace policies associated with practice of exclusive breastfeeding The table shows the supportive workplace policies associated with practice of exclusive breastfeeding. These factors include; workplace grants paid maternity leave (p = 0.011) and workplace offers flexible working hours for nursing mothers (p < 0.001). This shows that if mothers have more time with their babies at work, then they will be encouraged to practice exclusive breastfeeding. Table 4.8 Supportive workplace policies associated with practical of exclusive breastfeeding Variables Exclusive breastfeeding p-value Practiced EBF Not practiced EBF (n=147) (n=201) Paid maternity leave 0.001* No 36(32.4) 75(67.6) Yes 111(46.8) 126(53.2) Flexible working hours for nursing 0.000* No 50(30.9) 112(69.1) Yes 97(52.2) 89(47.8) Nursing mothers allowed to bring children to work 0.059 No 83(38.1) 135(61.9) Yes 62(48.4) 66(51.6) Availability of breastfeeding or milk expression room 0.569 No 111(41.4) 157(58.6) Yes 36(45.0) 44(55.0) + *Statistically significant (p<0.05) Fisher’s exact 38 University of Ghana http://ugspace.ug.edu.gh 4.10 Breastfeeding support factors associated with practice of exclusive breastfeeding From the chi-square analysis, support system for breastfeeding (p < 0.001) and knowing where to get help if any breastfeeding issues occur (p = 0.001) were significantly associated with practice of exclusive breastfeeding (Table 4.9). Table 4.9 Support factors associated with practice of exclusive breastfeeding Variables Exclusive breastfeeding p-value Practiced EBF Not practiced EBF (n = 147) (n = 201) Support system for breastfeeding 0.000* Partner 52(34.4) 99(65.6) Friends 23(41.1) 33(58.9) Family 42(42.0) 58(58.0) Doctor 30(73.2) 11(26.8) Know where to get help if any breastfeeding issues occur 0.001* Yes 127(47.2) 142(52.8) No 20(25.3) 59(74.7) *Statistically significant (p<0.05) 4.11 Association between attitude towards exclusive breastfeeding and practice of exclusive breastfeeding Society and people around nursing mothers’ perception regarding the practice of exclusive breastfeeding was significantly associated with practice of exclusive breastfeeding (p < 0.001) (Table 4.10). Family’s reaction towards exclusive breastfeeding (p < 0.001), support for women to exclusively breastfeed their children (p < 0.001), breast milk maintains its health benefits when it is expressed (p < 0.001), confidence to breastfeed child after birth (p = 0.002), intention to breastfeed future children (p = 0.001) and recommendation of exclusive 39 University of Ghana http://ugspace.ug.edu.gh breastfeeding to colleagues (p < 0.001) were all found to be significantly associated with exclusive breastfeeding after a chi-square analysis. Table 4.10 Association between Attitude towards exclusive breastfeeding and practice of exclusive breastfeeding Variables Exclusive breastfeeding p-value Practiced EBF Not practiced EBF (n = 147) (n = 201) Society and people around me think breastfeeding is good 0.000* Agree 10(83.3) 2(16.7) Not sure 9(11.5) 69(88.5) Disagree 128(49.6) 130(50.4) Family reaction towards exclusive breastfeeding 0.000* Supportive 128(48.7) 135(51.3) Unsupportive 9(16.7) 45(83.3) Don’t know 10(32.3) 21(67.7) Mother’s sole decision to breastfeed child 0.516 Yes 130(42.9) 173(57.1) No 17(37.8) 28(62.2) + Happy with breastfeeding baby 0.266 Yes 147(42.6) 198(57.4) 40 University of Gh ana http://ugsp ace.ug.edu.gh Expressed breast milk maintains its health benefits 0.000* Agree 112(54.9) 92(45.1) Not sure 33(32.0) 70(68.0) Disagree 2(4.9) 39(95.1) Confidence to breastfeed child after birth 0.002* Yes 140(45.0) 171(55.0) No 7(18.9) 30(81.1) Intention to breastfeed future children 0.001* Yes 141(46.4) 163(53.6) No 2(9.5) 19(90.5) Recommend exclusive breastfeeding to colleagues 0.000* No 1(1.5) 68(98.5) Yes 146(52.3) 133(47.7) Breastfeeding the child for 6 months or more is a waste of time 0.143 No 118(46.1) 138(53.9) Yes 25(36.2) 44(63.8) No 0(0.0) 3(100.0) Support for women to exclusively breastfeed their children 0.000* No 8(16.0) 42(84.0) Yes 139(46.6) 159(53.4) *Statistically significant (p<0.5) *Fisher’s exact 41 University of Ghana http://ugspace.ug.edu.gh 4.12 Factors associated with practice of exclusive breastfeeding The table below shows the results from a multiple logistic regression of factors associated with practice of exclusive breastfeeding. After adjusting for all other variables (income (GH₵), educational level, place of birth of youngest child, paid maternity leave, flexible working hours for nursing mothers, attitude and support towards exclusive breastfeeding, expressed breast milk maintains its health benefits, decision to breastfeed current child and future children, recommend exclusive breastfeeding to colleagues, support system for breastfeeding and know where to get help if any breastfeeding issues occur), the odds of practicing EBF was significantly reduced by 72%, among respondents who earned from GH₵ 1001 to GH₵ 2000 respectively as compared to those who earned below GH₵ 500 (AOR = 0.28; 95% CI = 0.08 – 0.92; p = 0.035). The odds of practicing EBF was significantly reduced among respondents who were not sure whether society and the people around them thought breastfeeding was good thing as compared to those who indicated that society and the people around them agreed breastfeeding was a good thing (AOR = 0.001; 95% CI = 0.00 – 0.31; p = 0.017). Furthermore, respondents who disagreed that expressed breast milk maintained its health benefits had a 96% significant reduction in their odds of practicing EBF as compared to those who agreed that expressed breast milk maintained its health benefits (AOR = 0.04; 95% CI = 0.01 – 0.22; p < 0.001). Mothers who recommended EBF to their colleagues were significantly 42.92 times more likely to practice EBF as compared to those who will not recommend EBF to their colleagues (AOR = 42.92; 95% CI = 4.32 – 426.31; p = 0.001). Respondents who did not know where to get help if any breastfeeding issues occur had a 74% significant reduction in their odds of practicing EBF as compared to those who know where to get help if any breastfeeding issues occur (aOR = 0.26; 95% CI = 0.11 – 0.62; p = 0.002). 42 University of Ghana http://ugspace.ug.edu.gh Table 4.11 Factors associated with practice of exclusive breastfeeding Variables cOR (95% CI) p-value aOR (95% CI) p-value Income (GH₵) < 500 1.00 1.00 500 - 1000 1.44 (0.79 – 2.63) 0.652 0.56 (0.22 – 1.45) 0.236 1001 - 2000 1.89 (1.003 – 3.55) 0.049* 0.28 (0.08 – 0.92) 0.035* > 2000 3.49 (1.57 – 7.76) 0.002* 0.30 (0.07 – 1.24) 0.096 Educational level None 1.00 1.00 Tertiary 2.68(0.67-10.72) 0.164 2.28 (0.12 – 45.29) 0.588 Vocational 0.66(0.15-2.87) 0.580 0.37 (0.02 – 7.33) 0.515 Secondary 1.12(0.27-4.70) 0.873 0.23 (0.01 – 4.29) 0.326 Primary 3.31(0.71-15.44) 0.128 0.73 (0.03 – 15.77) 0.842 Place of birth of youngest child Home 1.00 1.00 Hospital 2.53(1.27-5.03) 0.008* 1.41 (0.41 – 4.81) 0.583 Other 5.70(1.60-20.32) 0.007* 0.76 (0.12 – 4.76) 0.770 Paid maternity leave No 1.00 1.00 Yes 1.84(1.14-2.94) 0.012* 1.03 (0.42 – 2.54) 0.943 Flexible working hours for nursing mothers No 1.00 1.00 Yes 2.44(1.57-3.79) 0.000* 1.02 (0.47 – 2.22) 0.958 43 University of Ghana http://ugspace.ug.edu.gh Society and people around me think breastfeeding is good Agree 1.00 1.00 Not sure 0.03(0.00-0.14) 0.000* 0.001(0.00 – 0.31) 0.017* Disagree 0.20(0.04-0.92) 0.038* 0.01(0.00 – 2.32) 0.101* Family reaction towards exclusive breastfeeding Supportive 1.00 1.00 Unsupportive 0.21(0.10-0.45) 0.000* 0.97 (0.25 – 3.69) 0.964 Don’t know 0.50(0.23-1.11) 0.088 7.99 (0.57 – 111.89) 0.123 Support for women to exclusively breastfeed their children No 1.00 1.00 Yes 4.59(2.08-10.11) 0.000* 0.67 (0.16 – 2.75) 0.581 Expressed breast milk maintains its health benefits Agree 1.00 1.00 Not sure 0.39(0.24-0.64) 0.000* 0.57 (0.22 – 1.50) 0.257 Disagree 0.04(0.01-0.18) 0.000* 0.04 (0.01 - 0.22) 0.000* Confidence to breastfeed child after birth Yes 1.00 1.00 No 0.29(0.12-0.67) 0.004* 1.55 (0.18 – 13.48) 0.693 Intention to breastfeed future children Yes 1.00 1.00 44 University of Ghana http://ugspace.ug.edu.gh No 0.12(0.03-0.53) 0.005* 0.30 (0.02 – 4.47) 0.383 Recommend exclusive breastfeeding to colleagues No 1.00 1.00 Yes 74.65(10.22-545.13) 0.000* 42.92(4.32 – 426.31) 0.001* Support system for breastfeeding Partner 1.00 1.00 Friends 1.33(0.71-2.49) 0.378 0.93 (0.32 – 2.75) 0.891 Family 1.38(0.82-2.32) 0.226 0.59(0.27-1.30) 0.192 Doctor 5.19(2.41-11.19) 0.000* 0.67 (0.21 - 2.16) 0.505 Know where to get help if any breastfeeding issues occur Yes 1.00 1.00 No 0.38(0.22-0.66) 0.001* 0.26(0.11 – 0.62) 0.002* *Statistically significant (p<0.05) 45 University of Ghana http://ugspace.ug.edu.gh CHAPTER 5 5.0 DISCUSSION 5.1 Introduction This section discusses the results of the study according to the objectives taking into consideration relevant literature. This current study focuses on assessing the prevalence and factors associated with adherence to exclusive breastfeeding among mothers in Koforidua. 5.2 Prevalence of Exclusive Breastfeeding Analysis of the results attained from this contemporary study showed that 93.4% of mothers had knowledge of exclusive breastfeeding with almost 90% stating health facilities as the primary source of information. Despite this high number, the proportion of mothers in Koforidua who adhered to exclusive breastfeeding was found to be 42%. This observation is lower than that of Asare et al. (2018) who recorded a figure of 66% among mothers attending child welfare clinic in Tema Manhean. A descriptive cross-sectional survey conducted in Wa in the Upper West Region of Ghana recorded a much lower prevalence of 10.3% among 369 professional working mothers (Dun-Dery & Laar, 2016). Among 393 mothers attending CWC in three health facilities in Tamale, only 27.7% practiced exclusive breastfeeding for the first six months (Nukpezah et al., 2018). On the contrary, a much higher prevalence of 84.3% was documented in the Mamprusi West district of the Northern region of Ghana by Boakye-Yiadom et al. (2016). Manyeh et al. (2020) also recorded a high prevalence of 71% in the Dodowa district. In Tuna, a district in the Northern region also recorded a high prevalence of 56% among rural women who were lactating (Mogre et al., 2016). Despite the variations, these observations are generally lower than the WHO recommendation of 90% which is worrying. Also, the difference between knowledge and practice shows a huge gap which needs to be aggressively tackled by health professionals through appropriate education. 46 University of Ghana http://ugspace.ug.edu.gh 5.3 Factors associated with compliance to Exclusive Breastfeeding The results in this study showed that the factors associated with compliance of breastfeeding are educational level, monthly income and the place of birth of the youngest child. Mothers who earned above GH₵ 500 had reduced odds of breastfeeding their children exclusively. Comparably, mothers in Southwest Ethiopia who earned a high income of ≥3000 Ethiopian Birr (ETB) (equivalent to GH₵ 400) were less likely to breastfeed their babies exclusively as compared to mothers who earned a monthly income of 890 ETB an equivalent of GH₵ 134 (Awoke & Mulatu, 2021). Similarly, lactating mothers in another Ethiopian study who earned more than 1000 ETB were less likely to exclusively breastfeed than those who earn less than 1000 ETB (Shifraw et al., 2015). Awoke & Mulatu (2021) argue that women who earn higher incomes are most likely have highly demanding jobs that makes it difficult to for them to stay at home and breastfeed exclusively. Workplaces which pay high wages in the Ghanaian society should be encouraged to provide flexible schedules as well as lactational facilities to buoy up lactating mothers to practice exclusive breastfeeding. In this study, mothers who had their youngest child at the hospital were more likely to practice exclusive breastfeeding as compared to those who birthed at home. Similarly, Arage & Gedamu (2016) noted that mothers in Northwest Ethiopia who birthed their babies at the health facilities were more likely to practice exclusive breastfeeding compared to those who were born at home. In contrast, adolescent mothers in rural Bangladesh were more likely to breastfeed their babies exclusively for the first six months compared to those who gave birth at health facilities (Rahman et al., 2020). Again, Seid et al. (2013) also noted the place of delivery to be significant in the practice of exclusive breastfeeding as mothers who gave birth at the health facilities were three times more likely to breastfeed their babies exclusively compared to those who delivered their babies at home. Arage & Gedamu (2016) reason that mothers who give birth at the health facilities are most likely to be educated and encouraged to practice exclusive breastfeeding hence their willingness to exclusively breastfeed their babies. 47 University of Ghana http://ugspace.ug.edu.gh Breastfeeding mothers who were not sure of or disagreed with society’s perceptions that practicing breastfeeding was a good thing were less likely to practice exclusive breastfeeding. Also, mothers who were not sure of or disagreed with the notion that expressed breast milk maintained its health benefits had significant reduction in their odds of practicing exclusive breastfeeding as compared to those who agreed that expressed breast milk maintained its health benefits. Societal perceptions including cultural and religious ones concerning exclusive breastfeeding has posed as a huge challenge to mothers over the years (Boateng, 2018; Burdette & Pilkauskas, 2012; Watson, 2013). Studies in Ghana have shown that societal perceptions have a way of coercing mothers to introduce complementary feeds at very early stages with the misconception that breastmilk alone is insufficient to meet the nutritional needs of the babies (Adda et al., 2020; Diji et al., 2016; Issaka et al., 2014). Both findings in this current study points to the need to attain and disseminate the right information to the general public. Hence health professionals need to introduce effective ways of educating mothers and the public on issues of exclusive breastfeeding. Mothers who recommended exclusive breastfeeding to their colleagues had higher odds of exclusive breastfeeding as compared to those who will not recommend exclusive breastfeeding to their colleagues. Lactating mothers who did not know where to get help if any breastfeeding issues occur had significant reduction in their odds of practicing exclusive breastfeeding as compared to those who know where to get help if any issues with breastfeeding occur. This is similar to observations made by Diji et al. (2017) which suggest that lactating mothers are not able to get appropriate help when challenges arise during the practice of exclusive breastfeeding hence their reluctance to continue with the practice. They noted that majority of women faced with the challenges in practicing exclusive breastfeeding reported a lack of support from healthcare professionals in how to properly practice exclusive breastfeeding (Diji et al., 2017). In such cases, mothers’ resort to friends, colleagues, family and neighbours for advice. Even though information from this group of people may be right, there is the possibility of misinformation, distortion, falsehoods and misconception (Egede et al., 2015). 48 University of Ghana http://ugspace.ug.edu.gh 5.4 Limitations of the study The findings of this study cannot be generalized for all of the Koforidua or Ghana. Due to the cross-sectional nature of this contemporary study, the associations found in the study are not temporal and therefore causality cannot be explained. Since mothers were asked if they exclusively breastfed their children, the nature of the question is likely to have yielded over estimated outcomes. That notwithstanding, the analytical methods used in this study are statistically sound to give reasonable estimation of odds ratios within a 95% confidence interval. 49 University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX 6.0 CONCLUSIONS AND RECOMMENDATIONS 6.1 Conclusions The prevalence of exclusive breastfeeding for women visiting the Koforidua hospital is 42% even though 93.4% of mothers were aware of exclusive breastfeeding. The factors which showed significant association with exclusive breastfeeding include; income, educational level and place of birth of youngest child. The age of respondents, employment status, marital status and religion were not associated with exclusive breastfeeding as observed in other studies. In relation to income, mothers who earned more than GH₵ 500 were less likely to exclusively breastfeed because they could afford to buy formula to feed their children. Therefore, the employment of mothers outside the home enables them to earn more income but prevents them from exclusively breastfeeding their babies without adequate support and provisions. Other factors included mothers with their youngest child born at the hospital were more likely to exclusively breastfeed because early initiation of breastfeeding is started at the hospitals. Mothers who were not sure of or disagreed with society’s perceptions that breastfeeding was good were less likely to exclusively breastfeed and mothers who were not sure of or disagreed with the notion that expressed breast milk maintained its health benefits were less likely to exclusively breastfeed. In conclusion, since educated mothers with high incomes to support formula feeding were less likely to breastfeed exclusively, efforts at promoting exclusive breastfeeding might not target such mothers and promote supportive workplace policies for educated working mothers to enable the practice exclusive breastfeeding successfully. 50 University of Ghana http://ugspace.ug.edu.gh 6.2 Recommendations 1. Health professionals especially those in the obstetrics, gynecology and pediatrics departments must constantly have educational materials at their out-patient-departments. Materials such as videos, music, fliers on exclusive breastfeeding will reinforce the education at ANC. 2. Employers in Ghana should be motivated more by the Ghana Health Service and the Ministry of health as well as other stakeholders to provide flexible schedules and lactational facilities to encourage the practice of exclusive breastfeeding among working mothers. 3. A support group for high earning and working-class women who can easily afford formula and hence are less likely to exclusive breastfeed should be formed to encourage each other, share their struggles and success 4. The whole community must be educated on the benefits of exclusive breastfeeding since the family and the society serve as the direct support system for breastfeeding mothers. 5. Lactational support groups must be set up in every community. This will serve as easy to access places for such mothers who have questions instead of joining the general hospital queues. 6. Every hospital in Ghana must have a baby friendly environment to encourage exclusive breastfeeding. Also, community leaders such as chiefs and assembly men must work with all stakeholders to make public places such as the churches and mosques baby friendly as well. 7. The ministries of Gender, Education, Trade, Youth and Sports, must work with corporate bodies who employ women of high educational level and high income to hold seminars about the importance of breastfeeding and encourage such women to desist from only formula feeding their children 51 University of Ghana http://ugspace.ug.edu.gh 8. Regular attendance of ANC must be encouraged strongly, and also mothers must be encouraged and supported to deliver in hospital settings where early initiation of breastfeeding will be done. 52 University of Ghana http://ugspace.ug.edu.gh REFERENCES Adda, L., Opoku-Mensah, K., & Dako-Gyeke, P. (2020). “Once the child is delivered, he is no more your baby,” Exclusive Breastfeeding experiences of first-time mothers in Kassena-Nankana Municipality, Ghana-a qualitative study. BMC pregnancy and childbirth, 20(1), 1-9. Arage G., & Gedamu H. Exclusive breastfeeding practice and its associated factors among mothers of infants less than six months of age in Debre Tabor town, Northwest Ethiopia: A cross-sectional study. Adv. Public Health. 2016 doi: 10.1155/2016/3426249. Asare, B. Y. A., Preko, J. V., Baafi, D., & Dwumfour-Asare, B. (2018). Breastfeeding practices and determinants of exclusive breastfeeding in a cross-sectional study at a child welfare clinic in Tema Manhean, Ghana. International breastfeeding journal, 13(1), 1-9. Awoke, S., & Mulatu, B. (2021). Determinants of exclusive breastfeeding practice among mothers in Sheka Zone, Southwest Ethiopia: A cross-sectional study. Public Health in Practice, 2, 100108. Boakye-Yiadom, A., Yidana, A., Sam, N. B., Kolog, B., & Abotsi, A. (2016). Factors associated with exclusive breastfeeding practices among women in the west Mamprusi District in northern Ghana: a cross-sectional study. Public Health Research, 6(3), 91-98. Boateng, M. (2018). Knowledge, attitude and practice of exclusive breastfeeding among mothers in Techiman, Ghana (Master's thesis, Itä-Suomen yliopisto). Dun-Dery, E. J., & Laar, A. K. (2016). Exclusive breastfeeding among city-dwelling professional working mothers in Ghana. International breastfeeding journal, 11(1), 1-9. Joshi, P. C., Angdembe, M. R., Das, S. K., Ahmed, S., Faruque, A. S. G., & Ahmed, T. (2014). Prevalence of exclusive breastfeeding and associated factors among mothers in rural Bangladesh: a cross-sectional study. International breastfeeding journal, 9(1), 1-8. Yang, S. F., Salamonson, Y., Burns, E., & Schmied, V. (2018). Breastfeeding knowledge and attitudes of health professional students: a systematic review. International breastfeeding journal, 13(1), 1-11 53 University of Ghana http://ugspace.ug.edu.gh Manyeh, A. K., Amu, A., Akpakli, D. E., Williams, J. E., & Gyapong, M. (2020). Estimating the rate and determinants of exclusive breastfeeding practices among rural mothers in Southern Ghana. International Breastfeeding Journal, 15(1), 1-9. Mogre, V., Dery, M., & Gaa, P. K. (2016). Knowledge, attitudes and determinants of exclusive breastfeeding practice among Ghanaian rural lactating mothers. International breastfeeding journal, 11(1), 1-8. Nukpezah, R. N., Nuvor, S. V., & Ninnoni, J. (2018). Knowledge and practice of exclusive breastfeeding among mothers in the tamale metropolis of Ghana. Reproductive health, 15(1), 1-9. Rahman, A., Nomani, D., & Taneepanichskul, S. (2020). Trends and Determinants of EBF among Adolescent Children Born to Adolescent Mothers in Rural Bangladesh. International Journal of Environmental Research and Public Health, 17(24), 9315. Seid, A. M., Yesuf, M. E., & Koye, D. N. (2013). Prevalence of Exclusive Breastfeeding Practices and associated factors among mothers in Bahir Dar city, Northwest Ethiopia: a community based crosssectional study. International breastfeeding journal, 8(1), 1-8. Shifraw, T., Worku, A., & Berhane, Y. (2015). Factors associated exclusive breastfeeding practices of urban women in Addis Ababa public health centers, Ethiopia: a cross sectional study. International breastfeeding journal, 10(1), 1-6. Agho, K. E., Ezeh, O. K., Ghimire, P. R., Uchechukwu, O. L., Stevens, G. J., Tannous, W. K., ... & Maternal, G. (2019). Exclusive breastfeeding rates and associated factors in 13 “Eco nomic Community of West African States” (ECOWAS) countries. Nutrients, 11(12), 3007. Alebel, A., Tesma, C., Temesgen, B., Ferede, A., & Kibret, G. D. (2018). Exclusive breastfeeding practice in Ethiopia and its association with antenatal care and 54 University of Ghana http://ugspace.ug.edu.gh institutional delivery: a systematic review and meta-analysis. International breastfeeding journal, 13(1), 1-12. Alemayehu, T., Haidar, J., & Habte, D. (2009). Determinants of exclusive breastfeeding practices in Ethiopia. Ethiopian Journal of Health Development, 23(1). Aliyu, A. M., & Shehu, M. (2016). Knowledge attitude and practice of exclusive breastfeeding among multigravid women attending antenatal clinic in Aminu Kano University Teaching Hospital. IOSR J Nurs Health Sci, 5(6), 59-74. Altamimi, E., Al Nsour, R., Al Dalaen, D., & Almajali, N. (2017). Knowledge, attitude, and practice of breastfeeding among working mothers in South Jordan. Workplace health & safety, 65(5), 210-218. Alzaheb, R. A. (2017). A review of the factors associated with the timely initiation of breastfeeding and exclusive breastfeeding in the Middle East. Clinical medicine insights: pediatrics, 11, 1179556517748912. Amir, L. H. (2014). Breastfeeding in public: “You can do it?”. International breastfeeding journal, 9(1), 1-3. Anderson, P. O. (2019). Maternal vaccination and breastfeeding. Breastfeeding Medicine, 14(4), 215- 217. Asare, B. Y. A., Preko, J. V., Baafi, D., & Dwumfour-Asare, B. (2018). Breastfeeding practices and determinants of exclusive breastfeeding in a cross-sectional study at a child welfare clinic in Tema Manhean, Ghana. International breastfeeding journal, 13(1), 1-9. 55 University of Ghana http://ugspace.ug.edu.gh Asemahagn, M. A. (2016). Determinants of exclusive breastfeeding practices among mothers in a zezo district, northwest Ethiopia. International breastfeeding journal, 11(1), 1- 7. Bernard, J. Y., Cohen, E., & Kramer, M. S. (2016). Breast feeding initiation rate across Western countries: does religion matter? An ecological study. BMJ global health, 1(4), e000151. Bhandari, S., Thorne-Lyman, A. L., Shrestha, B., Neupane, S., Nonyane, B. A. S., Manohar, S., ... & West, K. P. (2019). Determinants of infant breastfeeding practices in Nepal: a national study. International breastfeeding journal, 14(1), 1-17. Bich, T. H., Long, T. K., & Hoa, D. P. (2019). Community‐based father education intervention on breastfeeding practice—Results of a quasi‐experimental study. Maternal & child nutrition, 15, e12705. Brown, C. R., Dodds, L., Legge, A., Bryanton, J., & Semenic, S. (2014). Factors influencing the reasons why mothers stop breastfeeding. Canadian Journal of Public Health, 105(3), e179- e185. Buccini, G. D. S., Pérez-Escamilla, R., & Venancio, S. I. (2016). Pacifier use and exclusive breastfeeding in Brazil. Journal of Human Lactation, 32(3), NP52-NP60. Burdette, A. M., & Pilkauskas, N. V. (2012). Maternal religious involvement and breastfeeding initiation and duration. American journal of public health, 102(10), 1865-1868. Centers for Disease Control and Prevention (2019). Breastfeeding for Cancer Prevention. 56 University of Ghana http://ugspace.ug.edu.gh Retrieved from: https://blogs.cdc.gov/ Chekol, D. A., Biks, G. A., Gelaw, Y. A., & Melsew, Y. A. (2017). Exclusive breastfeeding and mothers’ employment status in Gondar town, Northwest Ethiopia: a comparative cross- sectional study. International breastfeeding journal, 12(1), 1-9. Chhetri, S., Rao, A. P., & Guddattu, V. (2018). Factors affecting exclusive breastfeeding (EBF) among working mothers in Udupi taluk, Karnataka. Clinical Epidemiology and Global Health, 6(4), 216-219. Coomson, J. B., & Aryeetey, R. (2018). Perception and practice of breastfeeding in public in an urban community in Accra, Ghana. International breastfeeding journal, 13(1), 1-10. Danso, J. (2014). Examining the practice of exclusive breastfeeding among professional working mothers in Kumasi metropolis of Ghana. International journal of nursing, 1(1), 11-24. Diji, A. K. A., Bam, V., Asante, E., Lomotey, A. Y., Yeboah, S., & Owusu, H. A. (2016). Challenges and predictors of exclusive breastfeeding among mothers attending the child welfare clinic at a regional hospital in Ghana: a descriptive cross-sectional study. International breastfeeding journal, 12(1), 1-7. Ebrahimi, A. (2021). Breastfeeding in Refugee Camps: A Child and Maternal Right? Human Rights Law Review. Fisher, J., Hammarberg, K., Wynter, K., McBain, J., Gibson, F., Boivin, J., & McMahon, C. (2013). Assisted conception, maternal age and breastfeeding: an Australian cohort study. Acta 57 University of Ghana http://ugspace.ug.edu.gh Paediatrica, 102(10), 970-976. Ghana Statistical Service & Ghana Health Service. (2014). Ghana Demographic and Health Survey 2014. Retrieved from: https://dhsprogram.com/ Glassman, M. E., McKearney, K., Saslaw, M., & Sirota, D. R. (2014). Impact of breastfeeding self- efficacy and sociocultural factors on early breastfeeding in an urban, predominantly Dominican community. Breastfeeding Medicine, 9(6), 301-307. Hamze, L., Mao, J., & Reifsnider, E. (2019). Knowledge and attitudes towards breastfeeding practices: a cross-sectional survey of postnatal mothers in China. Midwifery, 74, 68- 75 Hunegnaw, M. T., Gezie, L. D., & Teferra, A. S. (2017). Exclusive breastfeeding and associated factors among mothers in Gozamin district, northwest Ethiopia: a community based cross- sectional study. International breastfeeding journal, 12(1), 1-8. Ickes, S. B., Sanders, H., Denno, D. M., Myhre, J. A., Kinyua, J., Singa, B., ... & Nduati, R. (2021). Exclusive breastfeeding among working mothers in Kenya: Perspectives from women, families and employers. Maternal & Child Nutrition, e13194. Issaka, A. I., Agho, K. E., Burns, P., Page, A., & Dibley, M. J. (2014). Determinants of inadequate complementary feeding practices among children aged 6–23 months in 58 University of Ghana http://ugspace.ug.edu.gh Ghana. 18 (4), 669– 678. John, J. R., Mistry, S. K., Kebede, G., Manohar, N., & Arora, A. (2019). Determinants of early initiation of breastfeeding in Ethiopia: a population-based study using the 2016 demographic and health survey data. BMC pregnancy and childbirth, 19(1), 1- 10. Kelishadi, R., & Farajian, S. (2014). The protective effects of breastfeeding on chronic non- communicable diseases in adulthood: A review of evidence. Advanced biomedical research, 3. Kimani‐Murage, E. W., Wekesah, F., Wanjohi, M., Kyobutungi, C., Ezeh, A. C., Musoke, R. N., & Griffiths, P. (2015). Factors affecting actualisation of the WHO breastfeeding recommendations in urban poor settings in Kenya. Maternal & child nutrition, 11(3), 314- 332. Kitano, N., Nomura, K., Kido, M., Murakami, K., Ohkubo, T., Ueno, M., & Sugimoto, M. (2016). Combined effects of maternal age and parity on successful initiation of exclusive breastfeeding. Preventive medicine reports, 3, 121-126. Laksono, A. D., Wulandari, R. D., Ibad, M., & Kusrini, I. (2021). The effects of mother’s education on achieving exclusive breastfeeding in Indonesia. BMC Public Health, 21(1), 1-6. Mamo, K., Dengia, T., Abubeker, A., & Girmaye, E. (2020). Assessment of Exclusive 59 University of Ghana http://ugspace.ug.edu.gh Breastfeeding Practice and Associated Factors among Mothers in West Shoa Zone, Oromia, Ethiopia. Obstetrics and gynecology international, 2020. Maonga, A. R., Mahande, M. J., Damian, D. J., & Msuya, S. E. (2016). Factors affecting exclusive breastfeeding among women in Muheza District Tanga northeastern Tanzania: a mixed method community-based study. Maternal and child health journal, 20(1), 77-87. Martin, C. R., Ling, P. R., & Blackburn, G. L. (2016). Review of infant feeding: key features of breast milk and infant formula. Nutrients, 8(5), 279. McCardel, R. E., & Padilla, H. M. (2020). Assessing workplace breastfeeding support among working mothers in the United States. Workplace health & safety, 68(4), 182189. Mgongo, M., Hussein, T. H., Stray-Pedersen, B., Vangen, S., Msuya, S. E., & Wandel, M. (2018). “We give water or porridge, but we don’t really know what the child wants:” a qualitative study on women’s perceptions and practises regarding exclusive breastfeeding in Kilimanjaro region, Tanzania. BMC pregnancy and childbirth, 18(1), 1-9. Motee, A., & Jeewon, R. (2014). Importance of exclusive breastfeeding and complementary feeding among infants. Current Research in Nutrition and Food Science Journal, 2(2), 56- 72. Nkrumah, J. (2016). Maternal work and exclusive breastfeeding practice: a community based cross- sectional study in Efutu Municipal, Ghana. International breastfeeding journal, 12(1), 1-9. 60 University of Ghana http://ugspace.ug.edu.gh Nkrumah, J., Abuosi, A. A., & Nkrumah, R. B. (2021). Towards a comprehensive breastfeeding- friendly workplace environment: insight from selected healthcare facilities in the central region of Ghana. BMC public health, 21(1), 1-12. Odindo, S. J., Loum, C., Alwar, J., Olayo, R., Mwayi, A., & Oyugi, H. (2014). Assessment of Association between Socieconomic Status and Breast-Feeding Practices among Lactating Mothers in Siaya County. Universal J Med Sci, 2(4), 51-4. Ogbo, F. A., Akombi, B. J., Ahmed, K. Y., Rwabilimbo, A. G., Ogbo, A. O., Uwaibi, N. E., ... & Agho, K. E. (2020). Breastfeeding in the community—how can partners/fathers help? A systematic review. International journal of environmental research and public health, 17(2), 413. Onah, S., Osuorah, D. I. C., Ebenebe, J., Ezechukwu, C., Ekwochi, U., & Ndukwu, I. (2014). Infant feeding practices and maternal socio-demographic factors that influence practice of exclusive breastfeeding among mothers in Nnewi South-East Nigeria: a cross-sectional and analytical study. International breastfeeding journal, 9(1), 1-10. Osibogun, O. O., Olufunlayo, T. F., & Oyibo, S. O. (2018). Knowledge, attitude and support for exclusive breastfeeding among bankers in Mainland Local Government in Lagos State, Nigeria. International breastfeeding journal, 13(1), 1-7. Ratnasari, D., Paramashanti, B. A., Hadi, H., Yugistyowati, A., Astiti, D., & Nurhayati, E. (2017). Family support and exclusive breastfeeding among Yogyakarta mothers in employment. Asia Pacific journal of clinical nutrition, 26(Supplement). 61 University of Ghana http://ugspace.ug.edu.gh Rollins, N. C., Bhandari, N., Hajeebhoy, N., Horton, S., Lutter, C. K., Martines, J. C., ... & Group, T. L. B. S. (2016). Why invest, and what it will take to improve breastfeeding practices? The lancet, 387(10017), 491-504. Sankar, M. J., Sinha, B., Chowdhury, R., Bhandari, N., Taneja, S., Martines, J., & Bahl, R. (2015). Optimal breastfeeding practices and infant and child mortality: a systematic review and meta‐analysis. Acta paediatrica, 104, 3-13. Seidu, A. A., Ameyaw, E. K., Ahinkorah, B. O., & Bonsu, F. (2020). Determinants of early initiation of breastfeeding in Ghana: a population-based cross-sectional study using the 2014 Demographic and Health Survey data. BMC pregnancy and childbirth, 20(1), 1-11. Setegn, T., Belachew, T., Gerbaba, M., Deribe, K., Deribew, A., & Biadgilign, S. (2012). Factors associated with exclusive breastfeeding practices among mothers in Goba district, south east Ethiopia: a cross-sectional study. International breastfeeding journal, 7(1), 1-8. Taddele, M., Abebe, L., & Fentahun, N. (2014). Exclusive breastfeeding and maternal employment in Ethiopia: a comparative cross-sectional study. Int J Nutr Food Sci, 3(6), 497-503. Tariku, A., Alemu, K., Gizaw, Z., Muchie, K. F., Derso, T., Abebe, S. M., ... & Biks, G. A. 62 University of Ghana http://ugspace.ug.edu.gh (2017). Mothers' education and ANC visit improved exclusive breastfeeding in Dabat Health and Demographic Surveillance System Site, northwest Ethiopia. PloS one, 12(6), e0179056. The United Nations Children's Fund (2018). WHO and UNICEF issue new guidance to promote breastfeeding in health facilities globally? Retrieved From: https://www.unicef.org/ Victora, C. G., Bahl, R., Barros, A. J., França, G. V., Horton, S., Krasevec, J., ... & Group, T. L. B. S. (2016). Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. The Lancet, 387(10017), 475-490. Vieira, T. O., Vieira, G. O., de Oliveira, N. F., Mendes, C. M., Giugliani, E. R. J., & Silva, L. R. (2014). Duration of exclusive breastfeeding in a Brazilian population: new determinants in a cohort study. BMC pregnancy and childbirth, 14(1), 1-9. Walters, D. D., Phan, L. T., & Mathisen, R. (2019). The cost of not breastfeeding: global results from a new tool. Health policy and planning, 34(6), 407-417. Watson, B. M. (2013). Ethnicity and breastfeeding in Kenya. World Health Organization (2018). Breastfeeding – Nutrition. Retrieved from: https://apps.who.int/ World Health Organization (2019). Exclusive breastfeeding for optimal growth, development and health of infants. Retrieved from: https://www.who.int/ 63 University of Ghana http://ugspace.ug.edu.gh World Health Organization (2021). Ghana launches National Breastfeeding Week. Retrieved from: https://www.afro.who.int/ APPENDIX I: PARTICIPANT INFORMATION SHEET Study Title: Factors Affecting adherence to Exclusive Breastfeeding Practices Among Breastfeeding Mothers in Koforidua Municipality Introduction: This study is being conducted by Abigail Doduwah Sackey (Principal Investigator) a Master of Public Health (MPH) student of School of Public Health, University of Ghana. Address: Eastern Regional Hospital, P.O.Box 201.Koforidua. Tel: 0542211099 Background and Purpose of Research: This study is seeking to identify the factors affecting the adherence to exclusive breastfeeding in Koforidua. A lot of factors which interferes with breastfeeding exclusively 64 University of Ghana http://ugspace.ug.edu.gh have been identified through literature review. However, the rate of adherence is not well known within Koforidua Municipality. It is therefore important to have a clear idea of these interferences, in order for health workers to ensure optimum growth of babies and this will also decrease the rate of infant mortalities Safety Protocol: The principal investigator will conduct interviews directly. With that, all Covid-19 protocols will be adhered to during the interviews in the facility. The principal investigator will ensure that interviewees are in their face mask before the start of the study. Possible Risk and Discomfort: This study poses no risk and discomfort to you as a participant in this study. You will spend about 15 minutes in answering the questionnaires. You will be required to sign a consent form before we start the interview. You will be considered as volunteers and can opt out of the study or decline to answer any question. Possible Benefits: There is direct benefit to you as a participant, since you will gain in-depth understanding of the importance of exclusive breastfeeding Confidentiality: 65 University of Ghana http://ugspace.ug.edu.gh All the information collected from you will be kept strictly confidential and will be used for the intended purpose only. You will not be identified by name in any dissemination reports or publications resulting from this study. Data Security and Record Keeping: Study materials (questionnaires and informed consent) will be stored in a locked file cabinet in the office of the principal investigator. Study materials will be labelled according to codes and will not be identified by names. The data storage will be done by the principal investigator. My right to refuse or withdraw: I have the right to take part in this research or not without losing any benefit. I may stop participating in this research at any time I wish. I have read the above information and well understood it. I have had the opportunity to ask questions about it and any questions that I have asked has been answered to my satisfaction. I consent voluntary to participate as a subject in this study and understand that I have the right to withdraw from the study at any time. Signed by: ................................................... Name: ........................................................ Date: ........................................... Place: ......................................................... Contact information: Do you have any questions or clarifications? 66 University of Ghana http://ugspace.ug.edu.gh If any of your questions were not satisfactorily answered by me, or you have further questions regarding this study, you may contact: Abigail Doduwah Sackey Tel: 0542211099 Email: abigaildoduwahsackey@gmail. com Or Dr Juliana Enos College Of Health Sciences Department of Epidemiology Tel: 0504229909 If you have any concerns or need clarifications regarding ethical issues, please contact Nana Abena Kwaa Ansah Apatu (Administrator) Ghana Health Service, Ethics Review Committee, Accra. Tel: 0503539896. 67 University of Ghana http://ugspace.ug.edu.gh APPENDIX II: CONSENT FORM Study Title: Factors Affecting adherence to Exclusive Breastfeeding Practices Among Breastfeeding Mothers in Koforidua Municipality INTERPRETERS’ STATEMENT I interpreted the purpose and contents of the Participants’ Information Sheet to the afore named participant to the best of my ability in English/ Twi (underline the language) language to his proper understanding. All questions, appropriate clarifications sort by the participant and answers were also duly interpreted to his/her satisfaction. Name of Interpreter: …………………………… Signature of Interpreter………………………... OR Thumb Print ………............................ Date: ……………………… Contact Details ………………………... 68 University of Ghana http://ugspace.ug.edu.gh STATEMENT OF WITNESS I was present when the purpose and contents of the Participant Information Sheet was read and explained satisfactorily to the participant in the language, he/she understood (….name of language) I confirm that he/she was given the opportunity to ask questions/seek clarifications and same were duly answered to his/her satisfaction before voluntarily agreeing to be part of the research. Name: ………………………… Signature…………………………... OR Thumb Print ………............................ Date: …………………………… 69 University of Ghana http://ugspace.ug.edu.gh PARTICIPANTS’ STATEMENT I acknowledge that I have read or have had the purpose and contents of the Participants’ Information Sheet read and all questions satisfactorily explained to me in a language I Understand, English/ Twi (underline the language). I fully understand the contents and any potential implications as well as my right to change my mind (i.e., withdraw from the research) even after I have signed this form. I voluntarily agree to be part of this research. Name of Participant: …………………………... Participants’ Signature: ……………………... OR Thumb Print: …………………………… Date: …………………………………. 70 University of Ghana http://ugspace.ug.edu.gh INVESTIGATOR STATEMENT AND SIGNATURE I certify that the participant has been given ample time to read and learn about the study. All questions and clarifications raised by the participant have been addressed. Researcher’s name: …………………………………………... Signature: …………………………………………………. Date: …………………………………………………………. Appendix III (QUESTIONNAIRE) QUESTIONNAIRE ON KNOWLEDGE, ATTITUDES AND PRACTICES OF EXCLUSIVE BREASTFEEDING AMONG WORKERS IN CORPORATE ORGANIZATIONS 71 University of Ghana http://ugspace.ug.edu.gh This is research on Knowledge, Attitudes and Practices of Exclusive Breastfeeding among women in Koforidua, the Eastern Region of Ghana. The study is aimed at assessing the level of Knowledge, Attitudes and Practices of Exclusive Breastfeeding as well as the factors that influence its practice. Kindly share your experiences to help achieve this aim by responding to the following questions. QUESTIONS CODING CATEGORIES SKIP CODES TO 1. INDIVIDUAL FACTORS 1a Maternal Age (State your Please state Date of age last birthday age) Birth: ……………… Age state………… 1b Marital Status Married ..................................1 mstat (Circle applicable number) Cohabiting… ......................... 2 Unmarried/Single .................. 3 Divorced ................................. 4 Widowed ................................ 5 72 University of Ghana http://ugspace.ug.edu.gh 1c Religious Denomination Christian ................................. 1 religion (Circle applicable number) Muslim .................................... 2 Traditional Religion ............... 3 Others (Specify)… ................. 4 1d Cultural ethnic Affiliation/Ethnicity? Please state…………………… 1e Employment Health worker ........................... 1 employ Civil /Public Servant .................... 2 Education/Teacher ................. 3 Trader ....................................... .4 Unemployed .............................. 5 Other/specify… .......................... 6 1f How much do you earn No salary…………………………1 earnings monthly? Below GH¢400… ........................... 2 GH¢401 - GH¢1000… ..................... 3 GH¢1001 – GH¢2000......................4 GH¢2000 and above ..................... 5 73 University of Ghana http://ugspace.ug.edu.gh 1g What is the highest level of Tertiary… ....................................1 educ education attained? (Educational level) Vocational ....................................2 Secondary… ................................ 3 Primary… ....................................4 None .............................................. 0 1h Where did you give birth to a. Home pbirth your youngest baby? b. Hospital/Health Facility c. Other (Specify)....................................... 1i Did you attend ANC clinic Yes ............................... 1 anc when you were pregnant No… ............................. 0 with this child? How many times ………………………….. 2. SUPPORTIVE WORKPLACE POLICIES 74 University of Ghana http://ugspace.ug.edu.gh 2a Does your workplace Yes ............................................ 1 mat_leave grant paid maternity No… .......................................... 0 leave? (Formal sector) or Does your work allow you to get days off after delivery? (Informal sector) 2b If yes in (a), how long is howlongmat_l the leave? (Formal sector) Please state…………………… or How many days off? (Informal sector) 2c If no on a) have you ever Yes ............................................ 1 everhad_mat Had a maternity leave? No… .......................................... 0 _l (Formal sector) or Have you ever had days off from your work after delivery? (Informal sector) 75 University of Ghana http://ugspace.ug.edu.gh 2d If yes in c), how long was How Your maternity Please state…………………… long_ever leave? (Formal sector) or How long did you rest without working? (Informal sector) 2e Does your work place Yes ............................................ 1 flexi_work_hr have flexible working No… .......................................... 0 hours for nursing mothers? (Formal and informal sectors) 2f Describe/state the State: provisions in the flexible working ……………………………………… hours (both formal and informal) ……………………………………… ………………………………………. 2g Does your workplace Yes ............................................ 1 lactM_atwork allow nursing mothers to bring their children to No… .......................................... 0 76 University of Ghana http://ugspace.ug.edu.gh work? (Formal sector) or are you able to send your children to work? (Informal sector) 2h If yes in (2g), does Yes ............................................ 1 breast_breaks your workplace No… .......................................... 0 encourage breastfeeding breaks? (Formal sector) or are you able to take break from work to breastfeed? (Informal sector) 2i If yes in (2h) please, 1 hour ......................................... 1 how long are these breaks? (Both formal 30 mins ........................................ 2 and informal sectors) 15 mins ........................................ 3 77 University of Ghana http://ugspace.ug.edu.gh 2j If your workplace does Yes ............................................ 1 other_support not allow nursing No… .......................................... 0 mothers to bring their if yes Please state children to work, are there other arrangements to support nursing mothers to continue breastfeeding? (Both formal and informal sectors) 2k Does your workplace have Yes ............................................ 1 a breastfeeding or milk? expression room? (Formal No… .......................................... 0 sector) or do you have a place that you can comfortably express breastmilk at your workplace? (Informal sector) 78 University of Ghana http://ugspace.ug.edu.gh 2l If yes in (k), can you Refrigerator ................................. 1 identify any equipment that can be found there to Chairs ........................................... 2 aid in breastfeeding or expression? (Both formal Tables ........................................... 3 and informal sectors) Breast milk Pumps ...................... 4 Footstools .................................... 5 Sink .............................................. 6 Baby/toddler lay area ................ 7 Toys ............................................. 8 Others, Specify… ........................ 9 3. KNOWLEDGE ON EXCLUSIVE BREASTFEEDING 3a 3b 3a Have you heard of Yes ........................................ 1 exclusive breastfeeding? No… ..................................... 0 3b If yes in (3c), where did 1. Health Facility [ ] you hear it from? (Tick as many as apply) 2. Family [ ] 3. Market [ ] 4. Friends [ ] 79 University of Ghana http://ugspace.ug.edu.gh 5. Media [ ] 6. Other (Specify) 3c If yes in (3c) what is 1. A type of breastfeeding where the exclusive breastfeeding? infant receives only breastmilk [ ] (Tick only one) 2. A type of breastfeeding where the infant receives only breast milk and herbal formulations [ ] 3. A type of breastfeeding where the infant receives only breast milk, water and other liquids or solids [ ] 4. A type of breastfeeding where the infant receives breast milk, water, other liquids or solids as well as prescribed medicines [ ] 5. A type of breastfeeding where the infant receives only breast milk no other liquids or solids are given – not even water – with the exception of prescribed oral rehydration solution, or drops/syrups of vitamins, minerals 80 University of Ghana http://ugspace.ug.edu.gh or medicines [ ] [ ] 6. All the above 7. I do not know [ ] 3d Do you know the benefits 1. Yes [ ] of exclusive breastfeeding? 2. No [ ] 3. I do not know [ ] 81 University of Ghana http://ugspace.ug.edu.gh 3e If yes in (f), where did 1. Health Facility [ ] you hear it from? (Tick as many as apply) 2. School [ ] 3. Market [ ] 4. Friends [ ] 5. Media [ ] 6. Other (specify) 3f What should be the food 1. Water [ ] for a baby who is less than 2. Breastmilk [ ] 6 months old? 3. Formula Milk [ ] 4. Porridge [ ] 5. All the above [ ] 3g Do you think babies who 1. Yes [ ] are less than 6 months should be given any other (Which other food) and state reasons food during breastfeeding? ……………………………………….. 2. If No State reasons…………………. 82 University of Ghana http://ugspace.ug.edu.gh 3h What are some of the 1. Weight control [ ] benefits of exclusive breastfeeding to mother? 2. Uterus returns to regular size [ (Allow multiple answers ] 3. Reduce postpartum bleeding [ ] 4. sense of love and attachment [ ] 5. Natural contraception 6. Don’t know 3i What are some benefits of 1. resistance to infections [ ] exclusive breastfeeding to the child? 2. protects against diarrhoea 3. protects against childhood illness 4. prevents overweight, obesity 3j What is the importance of 1. Nutrient rich fluid colostrum (thick, yellowish milk produced 2. Helps immunity usually from days 2 to 5 after delivery) to the 3. Provides hydration and protein baby? 4. I don’t know 3k How long after delivery 1. immediately [ ] should breastfeed starts? 2. 30 minutes [ ] 3. 1 hour [ ] 83 University of Ghana http://ugspace.ug.edu.gh 4. 1 day [ ] 5. more than one day [ ] 3l How long should a 1. 5mins nursing mother take in emptying each breast? in 2. 10-15mins minutes 3. 15-20mins 4. I don’t know 3m What is the minimum age at which the child should continue to receive breast milk? ……………………………………….. 3n Is breast milk alone better 1. Yes [ ] than formula milk to fulfil the child’s necessary 2. No [ ] dietary requirements? 30 Is breast milk alone 1. Yes [ ] sufficient during the first 2. No [ ] 6 months of life? Does breast milk lose its 1. Yes [ ] benefits when it is 3p expressed/pumped? 2. No [ ] 84 University of Ghana http://ugspace.ug.edu.gh 3q How should breast milk 1. At room temperature [ ] be stored? 2. In a refrigerator [ ] 3. Anywhere [ ] 4. Freezer [ ] 3r How long should a baby 1. Less than 1 week [ ] be breastfed exclusively after birth? 2. 1 week to less than 1 month [ ] 3. 1 month to less than 2 months [ ] 4. 3 months to less than 5 months [ ] 5. 5 months to less than 6 months [ ] 6. 6 months 7. More than 6 months [ ] 8. Don’t know 85 University of Ghana http://ugspace.ug.edu.gh 4. ATTITUDE ON EXCLUSIVE BREASTFEEDING 4a Society and people around me 1. Agree [ ] think breastfeeding my child is good thing. 2. Not sure [ ] 3. Disagree [ ] 4b How do your spouse’s family/your family react towards breast feeding your child exclusively? 1. Supportive [ ] 2. Unsupportive [ ] 3. Do not know [ ] 86 University of Ghana http://ugspace.ug.edu.gh 4c Was it your own decision to 1. Yes [ ] breast feed your child? 2. No [ ] (Specify)..................................... 4d Are you happy with breast 1. Yes [ ] feeding your baby? 2. No [ ] State reasons 4e Do you think all women should Yes .......................................... 1 be supported to exclusively breastfeed their children? No… ....................................... 0 4f If yes in (4e) state reasons If no in (4e) state reasons ……………………………………………………………… ……………………………………………………………… ……………………………………………………………… ……………………………………………………………… 87 University of Ghana http://ugspace.ug.edu.gh 4g Breastmilk maintains its 1. Agree [ ] health benefits when it is expressed/ pumped 2. Not sure [ ] 3. Disagree [ ] 4h After the birth of your baby, did 1. Yes [ ] you have the confidence to breastfeed? 2. No [ ] 4i Do you have intention to 1. Yes [ ] breastfeed future children? 2. No [ ] 4j Will you recommend exclusive Yes ......................................... 1 breast feeding to colleagues? And/or family members? No… ...................................... 0 4k Breastfeeding the child for 6 Yes ......................................... 1 months or more is waste of time No… ...................................... 0 5. PRACTICES ON EXCLUSIVE BREASTFEEDING 88 University of Ghana http://ugspace.ug.edu.gh 5a Have you ever practiced Yes ......................................... 1 exclusive breastfeeding No… ...................................... 0 5b If yes in (a), do you or did Yes ......................................... 1 you do so with your current child? No… ...................................... 0 If No then Why? ................. 5c For how long did you Below 6months ............................. 1 6months ........................................... 2 exclusively breastfeed (Giving your child only 6months and above ........................ 3 breast milk, no formula milk or food) your last child after birth? 5d At what age did you Below 6 months ............................. 1 introduce other foods to the child? At 6 months ........................... 2 Between 6months – 2years ......... 3 After 2 years ................................ 4 89 University of Ghana http://ugspace.ug.edu.gh 5e At what age did you stop Below 6months ............................. 1 breastfeeding this child? At 6 months ........................... 2 between 6months – 2years ......... 3 After 2 years ................................ 4 5f What was the main reasons for stopping breastfeeding before the child reached 2 years of age? …………………………………………………………………… …………………………………………………………………… …………………………………………………………………… …………………………………………………………………… 5g When did you initiate 1. within 30 mins [ ] breastfeeding after delivery? 2. 30-1hr [ ] 3. 1hr- 24hr [ ] 4 after 24 hours [ ] 90 University of Ghana http://ugspace.ug.edu.gh 5h Was the child given ready- 1. Yes [ ] made liquid formula in the hospital 2. No [ ] 6. BREASTFEEDING SUPPORT 6a Who do you talk to about 1. Partner [ ] breastfeeding? 2. Friends [ ] 3. Family [ ] 4. Employer/ Co-workers [ ] [ ] 5. Doctor/Midwife/Nurse [ ] 6. Childcare Provider [ ] 7. Community group 8. Other (specify) 6b Is it easy to talk to them 1. Yes [ ] about breastfeeding? 2. No [ ] 91 University of Ghana http://ugspace.ug.edu.gh 6c Is there any problem in 1. Yes [ ] talking about breastfeeding? What is the problem? 2. No [ ] ……………………………………… ……………………………………… ……………………………………… ……………………………….......... 6d Who supports your 1. Partner [ ] breastfeeding? Please tick the ones which 2. Friends [ ] are applicable. 3. Family [ ] 4. Employer/ Co-workers [ ] 5. Doctor/Midwife/Nurse [ ] 92 University of Ghana http://ugspace.ug.edu.gh [ ] 6. Childcare Provider 7. Community group [ ] 8. Other (specify) 93 University of Ghana http://ugspace.ug.edu.gh 6e Have you been told where 1. Yes [ ] to get help if any breastfeeding issues occur? 2. No [ ] What have you been told? Please specify…………………… Thank you for participating in the study \ GHANA HEALTH SERVICE ETHICS REVIEW COMMITTEE [n case ofreply theResearch & Des, elopment l)tviston number and date ofthisGhana lealth Service Letter should be quoted.P O. Box MB 190 Accra 1)i2ital Address: GA-OSO-3 303 Mob: +233-50-3539896 Gils ERC App I Eel: - +233- 302-68 1 109 Your Ref. No. l' mail: eth ics.researchca ghsmail.org Abigail D. Sack-ey University of Ghana School of Public Health The Ghana Health Service Ethics Review Committee has iewed and given approval the implementation of our Stud Protocol. GHS-ERC Number GHS-ERC: 073/03/22 94 University of Ghana http://ugspace.ug.edu.gh Study Title "Factors Affecting Adherence to Exclusive Breastfeeding Practices among Breastfeedino Mothers in Koforidua Munici alit A roval Date 24th Mav, 2022 Ex i Date 23 rd Ma , 2023 GHS-ERC Decision A roved This approval requires the following from the Principal Ins estigator Submission of a yearly progress reporl of the study to the Ethics Committee (l' IRC) Renewal of ethical approval if the study lasts for more than 12 months, Reporting of all serious adverse events related to this study to the 1• RC within three days verbally and seven days in writing. Submission of a final report after completion of the study Informing ERC if study cannot be implemented or is discontinued and reasons vs hy Informing the ERC and your sponsor (where applicable) before any publication 01 the research findings. You are kindly advised to adhere to the national guidelines or protocols on the prevention or ('OVID -19 Please note that any modification of the study without ERC approval of the amendment is invalid. The ERC may observe or cause to be observed procedures and records of the study during and after implementation Kindly quote the protocol identification number in all future correspondence in relation to this approved protocol SIGNED... Mr. Kofi Wellington (Gl IS ERC Vice Chairperson) Cc: The Director, Research & Development Division, Ghana Health Service, Accra 95 University of Ghana http://ugspace.ug.edu.gh UNIVERSITY OF GHANA DEPARTMENT OF POPULATION, FAMILY AND REPRODUCTIVE HEALTH SCHOOL OF PUBLIC HEALTH Ref No.: ……………………… 9th August, 2021 The Medical Director Eastern Regional Hospital Koforidua Dear Sir/Madam, LETTER OF INTRODUCTION ABIGAIL DODUWAH SACKEY I write to introduce to you Abigail Doduwah Sackey, an MPH Student with the Department of Population, Family and Reproductive Health, School of Public Health, University of Ghana, Legon. As part of her academic requirement, she is undertaking research on the topic “Factors affecting Adherence to Exclusive Breastfeeding Practices among Breastfeeding Mothers in Koforidua Municipality’’. She would need assistance on pertinent information in your facility to enable her carry out her research work successfully. Your cooperation would be very much appreciated. Thank you. Yours faithfully, Prof Kwasi Torpey (Head of Department) 96 University of Ghana http://ugspace.ug.edu.gh COLLEGE OF HEALTH SCIENCES P.O. Box LG 13, Legon, Accra, Ghana. · Telephone: +233 (0)28 910 9021/22 · Email: pfrh@ug.edu.gh · Website: www.publichealth.ug.edu.gh 97