PLOS ONE
RESEARCH ARTICLE
The association between paternal
characteristics and exclusive breastfeeding in
Ghana
Frank Kyei-Arthur ¤*☯, Martin Wiredu Agyekum☯, Grace Frempong Afrifa-Anane¤☯ID
Regional Institute for Population Studies, University of Ghana, Legon, Accra, Ghana
☯ These authors contributed equally to this work.
a1111111111 ¤ Current address: Department of Environment and Public Health, University of Environment and
a1111111111 Sustainable Development, Somanya, Eastern Region, Ghana
* fkyei-arthur@uesd.edu.gh
a1111111111
a1111111111
a1111111111
Abstract
Background
OPEN ACCESS
Studies have shown that partners play an influential role in exclusive breastfeeding practice
Citation: Kyei-Arthur F, Agyekum MW, Afrifa-
and that they can act as either deterrents or supporters to breastfeeding. However, there
Anane GF (2021) The association between paternal
characteristics and exclusive breastfeeding in are limited studies on the influence of partners’ characteristics on exclusive breastfeeding in
Ghana. PLoS ONE 16(6): e0252517. https://doi. Ghana. This study examined the association between partners’ characteristics and exclu-
org/10.1371/journal.pone.0252517
sive breastfeeding in Ghana.
Editor: Joann M. McDermid, University of Virginia,
UNITED STATES
Methods
Received: November 19, 2020
This cross-sectional study used data from the 2014 Ghana Demographic and Health Sur-
Accepted: May 17, 2021
vey. Infants less than 6 months old (exclusively breastfed or not) with maternal and paternal
Published: June 3, 2021 characteristics were included in the study. A total of 180 participants were used for the
Peer Review History: PLOS recognizes the study. A binary logistic regression was used to examine the influence of partners’ character-
benefits of transparency in the peer review istics on exclusive breastfeeding.
process; therefore, we enable the publication of
all of the content of peer review and author
responses alongside final, published articles. The Results
editorial history of this article is available here:
Partners’ characteristics such as education, desire for children, religion, and children ever
https://doi.org/10.1371/journal.pone.0252517
born were associated with exclusive breastfeeding. Mothers whose partners had primary
Copyright: © 2021 Kyei-Arthur et al. This is an
education (AOR = 0.12; CI 95%: 0.02–0.93; p = 0.04) were less likely to practice exclusive
open access article distributed under the terms of
the Creative Commons Attribution License, which breastfeeding compared to those whose partners had no formal education. Also, mothers
permits unrestricted use, distribution, and whose partners desired more children (AOR = 0.20; CI 95%: 0.06–0.70; p = 0.01) were less
reproduction in any medium, provided the original likely to practice exclusive breastfeeding compared to those whose partners desire fewer
author and source are credited.
children.
Data Availability Statement: All relevant data are
within the manuscript and its Supporting
Information files. Conclusion
Funding: The authors received no specific funding Improving EBF requires the involvement of partners in exclusive breastfeeding campaigns/
for this work. programmes. A more couple-oriented approach is required by health practitioners to
PLOS ONE | https://doi.org/10.1371/journal.pone.0252517 June 3, 2021 1 / 15
PLOS ONE The association between paternal characteristics and exclusive breastfeeding in Ghana
Competing interests: The authors have declared educate and counsel both mothers and partners on the importance of exclusive breastfeed-
that no competing interests exist. ing in Ghana.
Introduction
Exclusive breastfeeding (EBF) has been identified as an essential practice to enhance the nutri-
tional status and growth of infants aged under 6 months [1]. EBF is the practice of giving
infants only breast-milk and no liquids or solids with the exceptions of drops or syrups consist-
ing of vitamins, mineral supplements, or medicines [2]. The World Health Organisation
(WHO) and United Nations Children’s Fund (UNICEF) recommend EBF for the first six
months of an infant’s life since breastmilk contains all the essential nutrients required by an
infant to attain optimal growth and health [1]. Exclusive breastfeeding has enormous benefits
for mothers and their infants. It reduces neonatal and infant mortality and morbidity, enables
infants to crawl early, enhances growth and cognitive development, and reduces the risk of
childhood obesity [3–7]. In addition, it helps mothers to lose weight after birth, reduces their
risk of pregnancy in the first 6 months after birth, and reduces their risk of breast and ovarian
cancers [3, 8, 9]. It is estimated that increasing breastfeeding could annually help avert 823,000
child deaths and 20,000 breast cancer deaths [10].
Despite these benefits, the practice of EBF is generally low [11]. In 2019, two-fifth (41%) of
infants aged under 6 months were exclusively breastfed worldwide. The WHO estimates that
at least 50% and 70% of infants aged under 6 months globally should be exclusively breastfed
by 2025 and 2030 respectively [12, 13]. Ghana’s EBF rate rose steadily from 53% in 2003 to
63% in 2008. The increase in Ghana’s EBF rate can be attributed to the implementation of poli-
cies and programmes such as the Breastfeeding Promotion Regulations 2000 [14], Imagine
Ghana Free of Malnutrition [15], and Infant and Young Child Feeding Strategy [16]. These
policies and programmes highlighted the importance of practicing exclusive breastfeeding. For
instance, the Breastfeeding Promotion Regulations 2000 prohibits the sale and promotion of
infant formula or any other product marketed as appropriate for feeding infants less than six
months of age in health facilities or public places [14]. It is worth noting that these policies and
programmes placed less emphasis on couple-oriented approaches to enhance exclusive
breastfeeding.
However, a total of 52% of infants below 6 months were breastfed exclusively in 2014 [17].
This is a reduction upon the 2008 rate of 63%, and thus, calls for further investigation. The
decline in exclusive breastfeeding can be attributed to factors such as violation of the Ghana
Breastfeeding Promotion Regulation, selective implementation of funded breastfeeding initia-
tives at the district and regional levels, and increased participation of women in the labour
market [18, 19]. Participation of women in the labour market, especially formal employment
has been linked with a decline in the practice of exclusive breastfeeding since their workplace
and working conditions do not support the practice of exclusive breastfeeding [20, 21].
Previous studies in Ghana have established that mothers breastfeeding practices are influ-
enced by interpersonal and community factors including pressure from family members and
cultural beliefs and practices [22, 23]. For instance, Diji et al.’s [24] study among mothers at a
public health facility in Kumasi South Hospital revealed that the belief that breastmilk is inade-
quate to meet the nutritional needs of infants and pressure from family members to give water
and food to infant hindered the practice of exclusive breastfeeding. Studies have also docu-
mented the traditional practice of giving herbal concoctions to infants to drink after birth,
especially in the Northern part of Ghana. It is perceived that herbal concoctions make the
infants strong and healthy [25–27].
PLOS ONE | https://doi.org/10.1371/journal.pone.0252517 June 3, 2021 2 / 15
PLOS ONE The association between paternal characteristics and exclusive breastfeeding in Ghana
Evidence suggests that a partner (a man who is either currently married or living with a
woman) is one of the most influential persons to the mother and that he can act as either a
deterrent or supporter to breastfeeding [28–31]. For instance, a father can provide the practical
and emotional support needed for successful breastfeeding, contribute to maternal breastfeed-
ing confidence, and influence decisions on the duration of breastfeeding [32, 33]. In addition,
studies in Brazil and Sweden have found that paternal age and education influence the practice
of exclusive breastfeeding [34, 35].
However, studies on EBF in sub-Saharan Africa, particularly Ghana, have mainly focused
on maternal characteristics, child characteristics, household characteristic (such as household
size), family influence (grandmothers and in-laws), health-related factors (such as place of
delivery), and spatial characteristics (such as place of work) [20, 24, 36–39]. There is a dearth
of information on the influence of partners on EBF. In light of the limited literature and reduc-
tion in exclusive breastfeeding rate in Ghana, this study seeks to examine the influence of part-
ners’ characteristics on EBF in Ghana using a nationally representative sample. Understanding
the influence of partners’ characteristics on EBF in addition to other factors will provide a
holistic understanding to help develop appropriate interventions to promote exclusive breast-
feeding among mothers in Ghana.
Materials and methods
Data and study population
This study used data from the 2014 Ghana Demographic and Health Survey (GDHS). The
GDHS is a nationally representative sample survey that is conducted every five years and the
2014 GDHS is the sixth round in the series. A two-stage sample design was employed to select
participants for the interview. The 2014 GDHS sampling procedure and methodology have
been described in detail in the Ghana Demographic and Health Survey manual [18]. The 2014
Ghana Demographic and Health Survey had a sample of 5,884 infants. However, the analysis
of the current study was based on a sample size of 180 infants less than six months (exclusively
breastfed or not) who had both maternal and paternal characteristics.
Variables
Dependent variable. The dependent variable for the study was exclusive breastfeeding.
Exclusive breastfeeding was defined based on the World Health Organisation 24-hour recall
method. This was measured as a binary variable using several food items such as breastmilk,
water, liquids, milk, and solid food. Infants who were fed only on breast milk 24 hours preced-
ing the survey were coded as “1” for exclusive breastfeeding while infants who were fed on
breastmilk and any other food 24 hours preceding the survey were coded as “0” and classified
as non-exclusive breastfeeding.
Independent variables. Partners’ characteristics such as age, education, occupation, reli-
gion, ethnicity, place of residence, partners’ attitude towards wife beating, desire for children,
and number of children by partner were the independent variables for the study. These vari-
ables were selected based on literature review. Partners’ age was categorized as 15–24 years,
25–34 years, and 35 years and above. The level of education of a partner was re-categorized as
no education, primary, and secondary, and above. The proportion of partners with higher edu-
cation was few so they were added to partners who had secondary education. Partners’ main
occupation was categorized as professionals, sales and service, agriculture, skilled manual, and
unskilled manual. In addition, partners’ religion was classified as Christians, Muslims, and
Other comprising Traditionalist, Buddhist, and Hinduism. Partners’ ethnicity was categorized
as Ewe, Ga/Dangme, Akan, Mole-Dagbani, Gurma, and other including Grussi and Mande.
PLOS ONE | https://doi.org/10.1371/journal.pone.0252517 June 3, 2021 3 / 15
PLOS ONE The association between paternal characteristics and exclusive breastfeeding in Ghana
Partner’s place of residence was categorized as urban and rural areas while attitude towards
wife beating was classified as favourable and unfavourable. Moreover, a partner’s desire for
having children was classified as a partner desiring for fewer children than the mother, a part-
ner desiring for more children than the mother, both the partner desire for the same number
of children. Lastly, children ever born was measured as the total number of children born by
the partner.
Control variables. The study controlled for other variables that may influence exclusive
breastfeeding based on the review of the literature. The control variables were mother’s age
(15–24, 25–34, and 35 years and above), mother’s education (no education, primary, and sec-
ondary and above), mother’s marital status (married and living with a partner), mother’s chil-
dren ever born (single child mothers and multiparous mothers), decision on health (woman
alone, partner alone, and both partner and woman), mother’s ethnicity (Akan, Ewe, Mole-
Dagbani, Gurma and other groups comprising Ga/Dangme, Guan, and Grusi), frequency of
antenatal clinic, maternity leave (No, and Yes), postnatal (Yes and No), mother’s attitude
towards wife beating (favourable and unfavourable), sex of the child (male and female), age of
infant (less than one month, 1 month, 2 months, 3 months, 4 months and 5 months) and birth
order. All variables and their categories used in this study align with the standards for Ghana.
Data analysis. The data was analyzed using Stata version 15. The data were weighted to
make it representative and to provide a better statistical estimate. The proportion of each vari-
able was described using tables and percentages. A binary logistic regression model was used
to examine the relationship between partners’ characteristics, and exclusive breastfeeding, con-
trolling for other variables. A binary logistic regression was used because the dependent vari-
able (exclusive breastfeeding) is a dichotomous variable “with responses “yes” and “no”. All
associations were tested at a significance level of 0.05.
Results
Characteristics of partners
Table 1 shows the exclusive breastfeeding practice and partner’s characteristics. More than half
(58.33%) of the infants were exclusively breastfed 24 hours preceding the survey. About six out
of ten (58.33%) partners were aged 35 years and older, and about 58% of the partners had at
least secondary or higher education. Also, about 32% of partners had no formal education.
The highest proportion (48.9%) of partners were engaged in agricultural work and a few
(8.3%) were into sales and services. In addition, more than half (53.89%) of the partners were
Christians and about three out of ten (31.11%) partners belonged to the Mole-Dagbani ethnic
group. Most partners were living in rural areas (56.67%) and had favourable attitude towards
wife beating (82.78%). With regards to partner desire for children, about 46% of both mothers
and their partners wanted the same number of children. Additional socio-demographic char-
acteristics of the partners are presented in Table 1.
Characteristics of mothers and infants
The results indicate that more than two-fifths (43.89%) of the mothers were within the age
group 25–34 years and the highest proportion (40.6%) of the mothers had no formal education
(Table 2). Also, seven out of ten mothers (76.11%) were married and the majority (89.44%) of
the mothers were multiparous mothers. Regarding decision on health, more than half
(56.11%) of the mothers made a joint decision with their partner. Furthermore, the majority
(86.7%) of the mothers had no maternity leave and 68.89% of them attended postnatal clinics.
Regarding the infants, more than half (53.89%) were males and the highest proportion
PLOS ONE | https://doi.org/10.1371/journal.pone.0252517 June 3, 2021 4 / 15
PLOS ONE The association between paternal characteristics and exclusive breastfeeding in Ghana
Table 1. Description of exclusive breastfeeding and partner’s characteristics.
Variables Frequency Percentage
Exclusive breastfeeding
No 75 41.67
Yes 105 58.33
Partner’s age
15–24 9 5.00
25–34 66 36.67
35+ 105 58.33
Partner’s educational level
No education 57 31.67
Primary 18 10.00
Secondary/higher 105 58.33
Partner’s occupation
Professionals 22 12.22
Sales and service 15 8.33
Agriculture 88 48.89
skilled manual 30 16.67
Unskilled manual 25 13.89
Partner’s religion
Christian 97 53.89
Muslims 45 25.00
Other 38 21.11
Partner’s ethnicity
Ewe 22 12.22
Ga/Dangme 11 6.11
Akan 46 25.56
Mole-Dagbani 56 31.11
Gurma 26 14.44
Other 19 10.56
Partner’s place of residence
Urban 78 43.33
Rural 102 56.67
Partner’s attitude towards wife beating
Unfavourable 149 82.78
Favourable 31 17.22
Partner’s desire for children
Partner wants fewer 47 26.11
Partner wants more 51 28.33
Both want same 82 45.56
Min, Max Mean, std
Partner’s children ever born 1, 21 4.71, 3.60
https://doi.org/10.1371/journal.pone.0252517.t001
(22.78%) of the infants were aged five months old. Additional socio-demographic characteris-
tics of the mothers and infants are presented in Table 2.
Predictors of exclusive breastfeeding
Table 3 illustrates factors associated with exclusive breastfeeding in Ghana. The model shows
the effects of partner, mother, and infant characteristics on exclusive breastfeeding. The
PLOS ONE | https://doi.org/10.1371/journal.pone.0252517 June 3, 2021 5 / 15
PLOS ONE The association between paternal characteristics and exclusive breastfeeding in Ghana
Table 2. Description of mother and infant characteristics.
Variables Frequency Percentage
Age of mother
15–24 47 26.11
25–34 79 43.89
35+ 54 30.00
Education of mother
No education 73 40.56
Primary 40 22.22
Secondary and higher 67 37.22
Marital status of mother
Married 137 76.11
Living with partner 43 23.89
Mother’s children ever born
Single 19 10.56
Multiparous 161 89.44
Decision on health
Respondent alone 22 12.22
Respondent and partner 101 56.11
Partner alone 57 31.67
Mother’s ethnicity
Ewe 23 12.78
Akan 43 23.89
Mole Dagbani 66 36.67
Other 48 26.67
Maternity leave
No 156 86.67
Yes 24 13.33
Postnatal
No 56 31.11
Yes 124 68.89
Mother’s attitude towards wife beating
Unfavourable 116 64.44
Favourable 64 35.56
Sex of infant
Male 97 53.89
Female 83 46.11
Age of infant
0 13 7.22
1 33 18.33
2 36 20.00
3 27 15.00
4 30 16.67
5 41 22.78
Min, Max Mean, std
Partner’s children ever born 1, 21 4.71, 3.60
Frequency of ANC 0, 98 7.14, 10.13
Birth order 1, 10 3.74, 2.10
https://doi.org/10.1371/journal.pone.0252517.t002
PLOS ONE | https://doi.org/10.1371/journal.pone.0252517 June 3, 2021 6 / 15
PLOS ONE The association between paternal characteristics and exclusive breastfeeding in Ghana
Table 3. Binary logistic regression showing the factors associated with exclusive breastfeeding.
Exclusive breastfeeding (EBF)
Variables Adjusted Odds Ratio (AOR) 95% CI P-value
Partner’s educational level
No education (RC)
Primary 0.12 0.02–0.93 0.04
Secondary/higher 0.50 0.10–2.55 0.40
Partner’s occupation
Professionals (RC)
Sales and service 0.38 0.05–3.05 0.36
Agriculture 3.52 0.51–24.49 0.20
Skilled manual 2.53 0.49–13.09 0.27
Unskilled manual 0.48 0.10–2.43 0.38
Partner’s age
15–24 (RC)
25–34 1.09 0.12–9.97 0.94
35+ 0.97 0.09–10.63 0.98
Partner’s desire for children
Partner wants fewer (RC)
Partner wants more 0.20 0.06–0.70 0.01
Both wants same 0.33 0.10–1.13 0.08
Partner’s religion
Christian (RC)
Muslims 0.20 0.05–0.76 0.02
Other 2.59 0.64–10.56 0.18
Partner’s ethnicity
Ewe (RC)
Ga/Dangme 2.17 0.22–21.96 0.51
Akan 1.29 0.18–9.40 0.80
Mole-Dagbani 2.36 0.15–37.74 0.55
Gurma 0.39 0.02–6.61 0.51
Other 4.12 0.32–53.06 0.28
Partner’s place of residence
Urban (RC)
Rural 0.75 0.19–3.03 0.69
Partner’s children ever born 1.38 1.08–1.77 0.01
Partner’s attitude towards wife beating
Unfavourable (RC)
Favourable 0.44 0.14–1.39 0.16
Age of mother
15–24 (RC)
25–34 0.97 0.27–3.48 0.97
35+ 0.20 0.03–1.21 0.08
Education of mother
No education (RC)
Primary 1.79 0.39–8.18 0.45
Secondary and higher 5.14 0.95–27.91 0.06
Marital status of mother
Married (RC)
(Continued)
PLOS ONE | https://doi.org/10.1371/journal.pone.0252517 June 3, 2021 7 / 15
PLOS ONE The association between paternal characteristics and exclusive breastfeeding in Ghana
Table 3. (Continued)
Exclusive breastfeeding (EBF)
Variables Adjusted Odds Ratio (AOR) 95% CI P-value
Living with partner 1.49 0.45–4.93 0.51
Mother’s ethnicity
Ewe (RC)
Akan 0.15 0.02–1.10 0.06
Mole Dagbani 0.50 0.04–6.65 0.60
Other 0.55 0.06–5.14 0.60
Mother’s children ever born
Single (RC)
Multiparous 1.30 0.23–7.17 0.77
Decision on health
Respondent alone (RC)
Respondent and partner 2.63 0.63–10.96 0.18
Partner alone 0.99 0.21–4.63 0.99
Frequency of antenatal visits 1.08 1.00–1.16 0.04
Maternity leave
No (RC)
Yes 2.02 0.43–9.43 0.37
Postnatal
No (RC)
Yes 0.71 0.24–2.09 0.54
Mother’s attitude towards wife beating
No (RC)
Yes 1.14 0.36–3.65 0.82
Sex of child
Male (RC)
Female 0.69 0.28–1.71 0.42
Age of child
Less than 1 (RC)
1 0.07 0.00–1.19 0.07
2 0.03 0.00–0.41 0.01
3 0.01 0.00–0.23 0.00
4 0.01 0.00–0.18 0.00
5 0.01 0.00–0.12 0.00
Birth order 0.95 0.64–1.42 0.82
RC: Reference category; R square = 0.3460.
https://doi.org/10.1371/journal.pone.0252517.t003
R-square of the model (0.3460) shows that about 34.60% of the partner, maternal and infant
characteristics explain variations in EBF practice in Ghana.
The results of the adjusted regression model indicate that partner’s education, partner’s
desire for children, partner’s religion, and partner’s children ever born were significantly asso-
ciated with EBF.
Mothers whose partners had primary education were less likely to practice EBF compared
to those whose partners had no formal education (AOR = 0.12; CI 95%: 0.02–0.93; p = 0.04).
Also, mothers whose partners desire more children were less likely to practice EBF compared
to those whose partners desire fewer children (AOR = 0.20; CI 95%: 0.06–0.70; p = 0.01). In
PLOS ONE | https://doi.org/10.1371/journal.pone.0252517 June 3, 2021 8 / 15
PLOS ONE The association between paternal characteristics and exclusive breastfeeding in Ghana
addition, mothers whose partners were Muslims were less likely to practice EBF compared to
mothers whose partners were Christians (AOR = 0.20; CI 95%: 0.05–0.76; p = 0.02). Moreover,
as the number of children by a partner increases, the odds of a mother practicing EBF increases
(AOR = 1.38; CI 95%: 1.08–1.77; p = 0.01).
Other factors that were found to predict EBF include frequency of antenatal visits and age
of infant. Regarding frequency of antenatal care visits, an increase in antenatal care visits
increases the practice of exclusive breastfeeding by mothers (AOR = 1.08; CI 95%: 1.00–1.16;
p = 0.04).
Lastly, infants who were two months old were less likely to be exclusively breastfed com-
pared to infants less than one month old (AOR = 0.03; CI 95%: 0.00–0.41; p = 0.01). Also,
infants who were three months old were less likely to be exclusively breastfed compared to
infants less than one year old (AOR = 0.01; CI 95%: 0.00–0.23; p = 0.00). Furthermore, infants
who were four months old were less likely to be exclusively breastfed compared to infants less
than one year old (AOR = 0.01; CI 95%: 0.00–0.18; p = 0.000).
Discussion
Considering the reduction of EBF practice in Ghana, identifying partner characteristics that
influence EBF would help develop policies and other interventions to increase EBF prevalence
in Ghana. In the light of scant literature on significant role partners’ play in EBF, we examined
the influence of partner’s characteristics on exclusive breastfeeding (EBF) in Ghana. Our find-
ings unearth the relevance of partner’s education, desire for children, religion, and children
ever born in the practice of EBF which have implications for policy and research. In addition,
the results of the study show that mother’s antenatal visits and age of child explain mothers’
exclusive breastfeeding behaviour in Ghana.
We found that EBF was practiced by more than half (58.33%) of mothers in this study. The
results indicated that more than half of the mothers practiced EBF in Ghana. However, the
proportion of mothers practicing EBF is below the recommended rate of 90% by WHO [40].
This, therefore, has implications for the welfare of children in relation to morbidity and mor-
tality. Comparing the prevalence of EBF (58.33%) in this study to the 2008 Ghana Demo-
graphic and Health Survey EBF prevalence (63.00%), there is a decline in the practice of EBF.
Despite the decline in the practice of EBF in Ghana, other child nutrition indicators (such as
stunting, wasting, and underweight) have improved over time. Since 1988, the prevalence of
stunting, wasting, and underweight has reduced from about 34%, 9%, and 23% to 19%, 5%,
and 11% respectively [17].
The reduction of EBF practice could therefore explain the slight decline of neonatal mortal-
ity from 43 per 1000 live births in 2003 to 29 per 1000 live births in 2014 [17]. There is a need
for measures and policies to be strengthened to promote the practice of EBF. For instance,
Tsai [41] reported that encouragement of mothers to use lactation rooms and milk expression
breaks programme increased breastfeeding in Taiwan. Similarly, the involvement of men in
breastfeeding programmes in Brazil led to an increase in exclusive breastfeeding practice [42].
In addition, assistance with preventing and managing lactation difficulties among couples in
Italy improved exclusive breastfeeding [43].
Although formal education has been recognized to have a positive effect on attitude and
health-related behaviours [44, 45], findings from the present study indicate otherwise. The
likelihood to practice EBF was lower among mothers whose partners had primary education
compared to those whose partners had no formal education. The finding is consistent with
previous studies in Sweden and India which found that partners with low education are less
likely to practice exclusive breastfeeding compared to those with no education [34, 46]. A
PLOS ONE | https://doi.org/10.1371/journal.pone.0252517 June 3, 2021 9 / 15
PLOS ONE The association between paternal characteristics and exclusive breastfeeding in Ghana
probable reason is that having knowledge about behaviour does not always translate into an
attitude or behavioural change [47]. Therefore, mothers whose partners have acquired some
level of formal education may not necessarily be empowered to practice EBF.
Furthermore, the findings revealed that the likelihood to practice EBF was lower among
mothers whose partners desired more children than those whose partners desired fewer chil-
dren. The practice of EBF reduces mothers’ risk of pregnancy in the first 6 months after birth.
This is because it serves as a family planning method and could delay mothers in conceiving
and having children [3, 9].
It was also evident in the findings that the likelihood to exclusively breastfeed was lower
among mothers whose partners were Muslims compared to those whose partners were Chris-
tians. This finding is consistent with previous studies [23]. The Holy Quran encourages breast-
feeding among Muslims [48]. However, the reasons why mothers whose partners were
Muslims are less likely to exclusively breastfeed compared to those whose partners are Chris-
tians could not be explained in the present study and therefore further studies using qualitative
approaches could explore the probable reasons.
The findings also indicated a positive association between partner’s number of children
ever born and practice of EBF. The reasons underlying this finding could not be explained in
the present study due to data limitation and therefore needs further exploration using qualita-
tive approaches.
Importantly, partner characteristics such as age, occupation, place of residence, and attitude
towards wife beating, were not significantly associated with the practice of EBF. This finding is
similar to other studies in Malaysia [49] and Brazil [50] which found that paternal age is not
significantly associated with exclusive breastfeeding. Despite the non-significant association
between occupation and EBF, mothers whose partners were engaged in agriculture were more
likely to practice EBF than those whose partners were professionals. A plausible explanation is
that in Ghana, agricultural extension officers, (for example, Women in Agricultural Develop-
ment (WIAD) officers) provide health and nutrition education to farmers during the provision
of extension services to enhance the wellbeing of their households, including the practice of
exclusive breastfeeding [51].
Furthermore, there was a positive association between antenatal care visits and the practice
of EBF. Previous studies have established that antenatal clinics provide an opportunity for
health care workers (midwives, community health nurses) to interact and educate mothers on
infant feeding, the nutritional value of EBF, and challenges associated with EBF. The health
education provided by health care workers during antenatal care visits increases knowledge on
infant feeding and thus, enhances the practice of exclusive breastfeeding [52–54].
Finally, the findings showed that the likelihood to exclusively breastfeed decreased as the
age of an infant increased. Similar findings have been reported in Nigeria [55, 56] and India
[57]. It is explained that most mothers perceive that as an infant’s age increases, he/she does
not get satisfied when exclusively breastfed. This leads to persistent crying and sleeplessness.
The introduction of complementary foods, therefore, reduces hunger and calms the infants
[58]. In addition, Ghanaian women working in the formal sector are entitled to three-month
maternity leave after delivery. Therefore, the early return to work tends to affect exclusive
breastfeeding especially when the infant is aged three months or above [59]. The introduction
of complementary foods as infants get older enables the mothers to attend to other activities
particularly work [56, 60]. This calls for the need for the Ministry of Health and other govern-
ment agencies to advocate for a longer duration of maternity leave since exclusive breastfeed-
ing is beneficial to the mother and infant.
Results of this study provide an understanding of the influence of partners in the practice of
EBF. This study is very relevant towards the inclusion of partners in exclusive breastfeeding
PLOS ONE | https://doi.org/10.1371/journal.pone.0252517 June 3, 2021 10 / 15
PLOS ONE The association between paternal characteristics and exclusive breastfeeding in Ghana
campaigns. Countries (such as Brazil and Taiwan) that have included men in breastfeeding-
specific interventions have succeeded in improving exclusive breastfeeding practice [42, 43].
In Ghana, there are no direct policies or measures targeting partners in breastfeeding practices.
Programmes involving partners and women such as partners offering assistance with prevent-
ing and managing lactation difficulties, partners helping with household tasks and child care,
partners encouraging their women to use lactation room and milk expression breaks could
help improve exclusive breastfeeding practice in Ghana. Findings from this study could inform
policy makers to encourage men to follow women to antenatal clinics. Through this, they will
be educated on the importance of exclusive breastfeeding and on how to manage the chal-
lenges associated with it. In addition, there could be breastfeeding schools for partners to help
them understand breastfeeding, other maternal and child issues as well as addressing concerns
of partners related to exclusive breastfeeding.
Limitations
This study had some limitations that are worth noting. First, due to the cross-sectional nature
of the study, we cannot infer causality. Second, the sample size for the study was small
(n = 180) because some data on partners of mothers with an infant less than six months were
missing. Third, exclusive breastfeeding was limited to 24 hours preceding the survey. This
does not accurately measure the exclusive breastfeeding of infants less than six months.
Despite these limitations, this study is one of the few to examine the influence of partners’
characteristics on exclusive breastfeeding. The findings, therefore, contribute to exclusive
breastfeeding literature in sub-Saharan Africa.
Conclusions
Findings from this study indicate an association between partners’ characteristics and EBF. As
found in this study, partner’s education, religion, desire for more children, and children ever
born significantly predicted the practice of EBF. This is an indication that partners play a cru-
cial role in the practice of EBF in Ghana. The Global Strategy for Infant and Young Child
Feeding emphasizes the need for those involved in promoting breastfeeding to understand the
benefits and importance of exclusive breastfeeding. Therefore, health policy makers should
provide incentives to partners to promote their involvement in attaining optimal nutrition and
breastfeeding. To achieve the full benefit of partners’ involvement, future research should
encompass qualitative approaches to help understand and explain the association between the
partners’ characteristics and exclusive breastfeeding.
Supporting information
S1 Data.
(XLSX)
S2 Data.
(XLSX)
Acknowledgments
The authors acknowledge the Measure Demographic and Health Survey programme for mak-
ing the 2014 Ghana Demographic and Health Survey data set available for this study. The
authors are grateful to the academic editor and reviewers for their constructive comments and
suggestions.
PLOS ONE | https://doi.org/10.1371/journal.pone.0252517 June 3, 2021 11 / 15
PLOS ONE The association between paternal characteristics and exclusive breastfeeding in Ghana
Author Contributions
Conceptualization: Frank Kyei-Arthur, Grace Frempong Afrifa-Anane.
Formal analysis: Martin Wiredu Agyekum.
Supervision: Frank Kyei-Arthur, Martin Wiredu Agyekum, Grace Frempong Afrifa-Anane.
Validation: Frank Kyei-Arthur, Martin Wiredu Agyekum, Grace Frempong Afrifa-Anane.
Writing – original draft: Frank Kyei-Arthur, Martin Wiredu Agyekum, Grace Frempong
Afrifa-Anane.
Writing – review & editing: Frank Kyei-Arthur, Martin Wiredu Agyekum, Grace Frempong
Afrifa-Anane.
References
1. World Health Organization (WHO). Essential nutrition actions: Improving maternal, newborn, infant
and young child health and nutrition. Geneva: WHO; 2013.
2. World Health Organization (WHO). Indicators for assessing breastfeeding practices. Geneva: WHO;
1991.
3. Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane Database of Systematic
Reviews. 2012(8):CD003517. https://doi.org/10.1002/14651858.CD003517.pub2 PMID: 22895934
4. Edmond KM, Zandoh C, Quigley MA, Amenga-Etego S, Owusu-Agyei S, Kirkwood BR. Delayed breast-
feeding initiation increases risk of neonatal mortality. Pediatrics. 2006; 117(3):e380–e6. https://doi.org/
10.1542/peds.2005-1496 PMID: 16510618
5. Arifeen S, Black RE, Antelman G, Baqui A, Caulfield L, Becker S. Exclusive breastfeeding reduces
acute respiratory infection and diarrhea deaths among infants in Dhaka slums. Pediatrics. 2001; 108(4):
e67–e. https://doi.org/10.1542/peds.108.4.e67 PMID: 11581475
6. Agrasada GV, Ewald U, Kylberg E, Gustafsson J. Exclusive breastfeeding of low birth weight infants for
the first six months: Infant morbidity and maternal and infant anthropometry. Asia Pacific Journal of Clin-
ical Nutrition. 2011; 20(1):62. PMID: 21393112
7. Horta BL, Loret de Mola C, Victora CG. Long-term consequences of breastfeeding on cholesterol, obe-
sity, systolic blood pressure and type 2 diabetes: A systematic review and meta-analysis. Acta Paedia-
trica. 2015; 104(S467):30–7.
8. Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer and breastfeeding: Collabo-
rative reanalysis of individual data from 47 epidemiological studies in 30 countries, including 50 302
women with breast cancer and 96 973 women without the disease. The Lancet. 2002; 360(9328):187–
95.
9. Chowdhury R, Sinha B, Sankar MJ, Taneja S, Bhandari N, Rollins N, et al. Breastfeeding and maternal
health outcomes: A systematic review and meta-analysis. Acta Paediatrica. 2015; 104(S467):96–113.
10. Victora CG, Bahl R, Barros AJ, França GV, Horton S, Krasevec J, et al. Breastfeeding in the 21st cen-
tury: Epidemiology, mechanisms, and lifelong effect. The Lancet. 2016; 387(10017):475–90.
11. Olufunlayo TF, Roberts AA, MacArthur C, Thomas N, Odeyemi KA, Price M, et al. Improving exclusive
breastfeeding in low and middle-income countries: A systematic review. Maternal & Child Nutrition.
2019; 15(3):e12788. https://doi.org/10.1111/mcn.12788 PMID: 30665273
12. World Health Organization (WHO), United Nations Children’s Fund (UNICEF). Global breastfeeding
scorecard, 2019: Increasing commitment to breastfeeding through funding and improved policies and
programmes. WHO/NMH/NHD/19.22. Geneva, New York: WHO and UNICEF; 2019.
13. Nurturing the Health, Wealth of Nations. The Investment case for breastfeeding. New York, Geneva:
UNICEF and WHO; 2017.
14. Ministry of Health. Ghana, Breastfeeding Promotion Regulations, 2000. Accra: Ministry of Health;
2000.
15. Ghana Health Service. Imagine Ghana Free of Malnutrition: A Concept Paper for Addressing Malnutri-
tion in Ghana as a Development Problem Using Health as an Entry Point. Accra: Ghana Health Ser-
vice; 2005.
16. Ghana Health Service. National Infant and Young Child Feeding for Ghana Strategy Document. Accra:
Ghana Health Service; 2007.
PLOS ONE | https://doi.org/10.1371/journal.pone.0252517 June 3, 2021 12 / 15
PLOS ONE The association between paternal characteristics and exclusive breastfeeding in Ghana
17. Ghana Statistical Service (GSS), Ghana Health Service (GHS), ICF International. Ghana demographic
and health survey 2014. Rockville, Maryland: GSS, GHS, and ICF International; 2015.
18. Tawiah-Agyemang C, Kirkwood BR, Edmond K, Bazzano A, Hill Z. Early initiation of breast-feeding in
Ghana: barriers and facilitators. Journal of Perinatology. 2008; 28(2):S46–S52. https://doi.org/10.1038/
jp.2008.173 PMID: 19057568
19. Ghana News Agency. FDB blames unsuccessful breastfeeding to violation of law [Internet]. 2006 Jan
16. [Available from: https://www.ghanaweb.com/GhanaHomePage/health/artikel.php?ID=97651.
20. Nkrumah J. Maternal work and exclusive breastfeeding practice: a community based cross-sectional
study in Efutu Municipal, Ghana. International breastfeeding journal. 2017; 12(1):10. https://doi.org/10.
1186/s13006-017-0100-6 PMID: 28203267
21. Dun-Dery EJ, Laar AK. Exclusive breastfeeding among city-dwelling professional working mothers in
Ghana. International breastfeeding journal. 2016; 11(1):23. https://doi.org/10.1186/s13006-016-0083-8
PMID: 27602050
22. Mogre V, Dery M, Gaa PK. Knowledge, attitudes and determinants of exclusive breastfeeding practice
among Ghanaian rural lactating mothers. International breastfeeding journal. 2016; 11(1):12. https://
doi.org/10.1186/s13006-016-0071-z PMID: 27190546
23. Agyekum MW. Birth weight, birth size and exclusive breastfeeding in Ghana [dissertation]. citty: Uni-
versity of Ghana; 2019.
24. Diji AK-A, Bam V, Asante E, Lomotey AY, Yeboah S, Owusu HA. Challenges and predictors of exclu-
sive breastfeeding among mothers attending the child welfare clinic at a regional hospital in Ghana: A
descriptive cross-sectional study. International breastfeeding journal. 2016; 12(1):13.
25. Aborigo RA, Moyer CA, Rominski S, Adongo P, Williams J, Logonia G, et al. Infant nutrition in the first
seven days of life in rural northern Ghana. BMC Pregnancy and Childbirth. 2012; 12(1):76. https://doi.
org/10.1186/1471-2393-12-76 PMID: 22857600
26. Adda L, Opoku-Mensah K, Dako-Gyeke P. “Once the child is delivered, he is no more your baby,” Exclu-
sive Breastfeeding experiences of first-time mothers in Kassena-Nankana Municipality, Ghana-a quali-
tative study. BMC Pregnancy and Childbirth. 2020; 20(1):1–9.
27. Nsiah-Asamoah C, Doku DT, Agblorti S. Mothers’ and Grandmothers’ misconceptions and socio-cul-
tural factors as barriers to exclusive breastfeeding: A qualitative study involving Health Workers in two
rural districts of Ghana. PloS one. 2020; 15(9):e0239278. https://doi.org/10.1371/journal.pone.0239278
PMID: 32941500
28. Sherriff N, Hall V, Pickin M. Fathers’ perspectives on breastfeeding: ideas for intervention. British Jour-
nal of Midwifery. 2009; 17(4):223–7.
29. Operto E. Knowledge, attitudes, and practices regarding exclusive breastfeeding among HIV-positive
mothers in Uganda: A qualitative study. The International Journal of Health Planning and Management.
2020; 35(4):888–96. https://doi.org/10.1002/hpm.2966 PMID: 31849114
30. Mahesh PKB, Gunathunga MW, Arnold SM, Jayasinghe C, Pathirana S, Makarim MF, et al. Effective-
ness of targeting fathers for breastfeeding promotion: Systematic review and meta-analysis. BMC Pub-
lic Health. 2018; 18(1):1140. https://doi.org/10.1186/s12889-018-6037-x PMID: 30249216
31. Ogbo FA, Akombi BJ, Ahmed KY, Rwabilimbo AG, Ogbo AO, Uwaibi NE, et al. Breastfeeding in the
Community—How Can Partners/Fathers Help? A Systematic Review. International Journal of Environ-
mental Research and Public Health. 2020; 17(2):413. https://doi.org/10.3390/ijerph17020413 PMID:
31936302
32. Tohotoa J, Maycock B, Hauck YL, Howat P, Burns S, Binns CW. Dads make a difference: an explor-
atory study of paternal support for breastfeeding in Perth, Western Australia. International Breastfeed-
ing Journal. 2009; 4(1):1–9. https://doi.org/10.1186/1746-4358-4-15 PMID: 19943958
33. Rempel LA, Rempel JK. The breastfeeding team: The role of involved fathers in the breastfeeding fam-
ily. Journal of Human Lactation. 2011; 27(2):115–21. https://doi.org/10.1177/0890334410390045
PMID: 21173422
34. Ludvigsson JF, Ludvigsson J. Socio-economic determinants, maternal smoking and coffee consump-
tion, and exclusive breastfeeding in 10 205 children. Acta Paediatrica. 2005; 94(9):1310–9. https://doi.
org/10.1111/j.1651-2227.2005.tb02093.x PMID: 16278998
35. Mascarenhas MLW, Albernaz EP, da Silva MB, da Silvera RB. Prevalence of exclusive breastfeeding in
the first 3 months of life and its determinants in southern Brazil. Jornal de Pediatria. 2006:289–94.
https://doi.org/10.2223/JPED.1506 PMID: 16881009
36. Tampah-Naah AM, Kumi-Kyereme A. Determinants of exclusive breastfeeding among mothers in
Ghana: A cross-sectional study. International Breastfeeding Journal. 2013; 8(1):13. https://doi.org/10.
1186/1746-4358-8-13 PMID: 24119727
PLOS ONE | https://doi.org/10.1371/journal.pone.0252517 June 3, 2021 13 / 15
PLOS ONE The association between paternal characteristics and exclusive breastfeeding in Ghana
37. Tampah-Naah AM, Kumi-Kyereme A, Amo-Adjei J. Maternal challenges of exclusive breastfeeding and
complementary feeding in Ghana. PloS ONE. 2019; 14(5). https://doi.org/10.1371/journal.pone.
0215285 PMID: 31048865
38. Asare BY-A, Preko JV, Baafi D, Dwumfour-Asare B. Breastfeeding practices and determinants of exclu-
sive breastfeeding in a crosssectional study at a child welfare clinic in Tema Manhean, Ghana. Interna-
tional Breastfeeding Journal. 2018; 13(1):12.
39. Manyeh AK, Amu A, Akpakli DE, Williams JE, Gyapong M. Estimating the rate and determinants of
exclusive breastfeeding practices among rural mothers in Southern Ghana. International Breastfeeding
Journal. 2020; 15(1):7. https://doi.org/10.1186/s13006-020-0253-6 PMID: 32033567
40. World Health Organization, United Nation Children’s Fund. Global action plan for prevention and control
of pneumonia (GAPP). Geneva: WHO; 2009.
41. Tsai SY. Influence of partner support on an employed mother’s intention to breastfeed after returning to
work. Breastfeeding Medicine. 2014; 9(4):222–30. https://doi.org/10.1089/bfm.2013.0127 PMID:
24650363
42. Susin LRO, Giugliani ERJ. Inclusion of fathers in an intervention to promote breastfeeding: Impact on
breastfeeding rates. Journal of Human Lactation. 2008; 24(4):386–92. https://doi.org/10.1177/
0890334408323545 PMID: 18784322
43. Pisacane A, Continisio GI, Aldinucci M, D’Amora S, Continisio P. A controlled trial of the father’s role in
breastfeeding promotion. Pediatrics. 2005; 116(4):e494–e8. https://doi.org/10.1542/peds.2005-0479
PMID: 16199676
44. Caldwell JC. Mass education as a determinant of the timing of fertility decline. Population and Develop-
ment Review. 1980:225–55.
45. Frempong GA, Codjoe SNA. Sex preferences for children in Ghana: the influence of educational attain-
ment. Journal of Population Research. 2017; 34(4):313–25.
46. Chudasama RK, Patel PC, Kavishwar AB. Determinants of exclusive breastfeeding in south Gujarat
region of India. Journal of Clinical Medicine Research. 2009; 1(2):102. https://doi.org/10.4021/
jocmr2009.06.1242 PMID: 22505975
47. Baranowski T, Cullen KW, Nicklas T, Thompson D, Baranowski J. Are current health behavioral change
models helpful in guiding prevention of weight gain efforts? Obesity Research. 2003; 11(S10):23S–
43S. https://doi.org/10.1038/oby.2003.222 PMID: 14569036
48. Amosa IA. FIGH of fasting. 2019. Available from https://fiqhclassorg.files.wordpress.com/2019/08/fiqh-
of-fasting-ibraheem-abubakr-amosa.pdf.
49. Tan KL. Factors associated with non-exclusive breastfeeding among 4-week post-partum mothers in
Klang district, Peninsular Malaysia. Malaysian Journal of Nutrition. 2009; 15(1):11–8. PMID: 22691800
50. Muelbert M, Giugliani ER. Factors associated with the maintenance of breastfeeding for 6, 12, and 24
months in adolescent mothers. BMC Public Health. 2018; 18(1):1–11.
51. SPRING. Opportunities for integrating nutrition into agricultural information systems in Northern Ghana.
Arlington, VA: USAID/Strengthening Partnerships, Results, and Innovations in Nutrition Globally
(SPRING) Project; 2017.
52. Acheampong AK, Ganga-Limando M, Aziato L, Ganga-Limando M. Perceived enablers of exclusive
breastfeeding by teenage mothers in Ghana. South African Family Practice. 2020; 62(1):a5108. https://
doi.org/10.4102/safp.v62i1.5108 PMID: 33054255
53. Kavle JA, LaCroix E, Dau H, Engmann C. Addressing barriers to exclusive breast-feeding in low-and
middle-income countries: a systematic review and programmatic implications. Public Health Nutrition.
2017; 20(17):3120–34. https://doi.org/10.1017/S1368980017002531 PMID: 28965508
54. Apanga PA. Infant and young child feeding in children under-5 years in Ghana: Key strategy to child-
hood development. British Journal of Medicine & Medical Research. 2015; 8(4):343–7.
55. Jacdonmi I, Suhainizam MS, Suriani IB, Zoakah AI, Jacdonmi GR. Determinants of Exclusive breast-
feeding continuity among mothers of infants under six months in Plateau State, Nigeria. International
Journal of Health Sciences and Research. 2016; 6(4).
56. Onah S, Osuorah DIC, Ebenebe J, Ezechukwu C, Ekwochi U, Ndukwu I. 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 Jour-
nal. 2014; 9(1):6. https://doi.org/10.1186/1746-4358-9-6 PMID: 24860612
57. Ogbo FA, Dhami MV, Ude EM, Senanayake P, Osuagwu UL, Awosemo AO, et al. Enablers and barriers
to the utilization of antenatal care services in India. International Journal of Environmental Research
and Public Health. 2019; 16(17):3152. https://doi.org/10.3390/ijerph16173152 PMID: 31470550
58. Talbert A, Jones C, Mataza C, Berkley JA, Mwangome M. Exclusive breastfeeding in first-time mothers
in rural Kenya: a longitudinal observational study of feeding patterns in the first six months of life.
PLOS ONE | https://doi.org/10.1371/journal.pone.0252517 June 3, 2021 14 / 15
PLOS ONE The association between paternal characteristics and exclusive breastfeeding in Ghana
International Breastfeeding Journal. 2020; 15(1):1–9. https://doi.org/10.1186/s13006-020-00260-5
PMID: 32138727
59. Abekah-Nkrumah G, Antwi MY, Nkrumah J, Gbagbo FY. Examining working mothers’ experience of
exclusive breastfeeding in Ghana. International breastfeeding journal. 2020; 15(1):1–10. https://doi.org/
10.1186/s13006-020-00300-0 PMID: 32552899
60. Mgongo M, Hussein TH, Stray-Pedersen B, Vangen S, Msuya SE, Wandel M. “We give water or por-
ridge, 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. 2018; 18(1):323. https://doi.org/10.1186/s12884-018-1962-3 PMID: 30089449
PLOS ONE | https://doi.org/10.1371/journal.pone.0252517 June 3, 2021 15 / 15