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SCHOOL OF PUBLIC HEALTH 
 COLLEGE OF HEALTH SCIENCES  
UNIVERSITY OF GHANA 
LEGON 
 
 
 
 
 
 
 
EXCLUSIVE BREASTFEEDING PRACTICES AMONG WOMEN IN THE 
FORMAL SECTOR OF THE GREATER ACCRA REGION AND IMPLICATIONS 
FOR THE LACTATIONAL ROOM POLICY. 
 
BY 
 
JOAN ESE MORNY (10637263) 
 
THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA 
LEGON, IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE 
AWARD OF MASTER OF PUBLIC HEALTH DEGREE 
 
JULY, 2018 
 
 
 
 
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DECLARATION 
I, Joan Ese Morny, do hereby declare that, apart from references made to the work done 
in relation to this subject area which have been duly acknowledged, this work was 
independently done by me under supervision. I further declare that this work has not 
been submitted for the award of any degree in this University or elsewhere. 
 
 
JOAN ESE MORNY          
(STUDENT)    SIGNATURE    DATE  
 
 
DR. PATRICIA AKWEONGO        
(SUPERVISOR)   SIGNATURE    DATE  
 
 
 
 
 
 
  
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ABSTRACT 
BACKGROUND: In Ghana, even though the knowledge of the practice and benefits of 
exclusive breast feeding amongst women is very high, only 52% of babies are breastfed 
up to 6 months of life.  In Ghana 49.52% of the work force are females, also 40.1% of 
workers are within the formal sector. Better educated women participate more in the 
formal sector and earn higher incomes. This study sought to examine exclusive 
breastfeeding practices amongst women in the formal sector in the Greater Accra region 
and the implication for the breastfeeding room policy in Ghana. 
METHODS: The study was a cross sectional analytical study and it employed a 
quantitative approach. The study was conducted at the Greater Accra Regional 
Hospital, Police Hospital, Narh-Bita Hospital and Port Medical Centre. All consecutive 
formal sector working mothers who reported to the immunization clinic of these 
hospitals were recruited (359 mothers). They were interviewed using a structured 
questionnaire. The data collection for the study covered a period of 4 weeks (June to 
July 2018). The data was analysed using Stata 15.0, frequency tables and percentages 
were used to describe the distribution of variables and cross tabulations with Chi-square 
tests were also used to establish bivariate associations between exclusive breastfeeding 
and independent variables. Logistic regression was then used to investigate if the 
independent variables were jointly associated with the practice of exclusive 
breastfeeding. 
RESULTS: The results showed that 191(52.3%) of mothers in the formal sector 
exclusively breastfeed their babies. The average number of months spent on practicing 
exclusive breastfeeding was 5.2 months. The higher the income of the less likely a 
woman was to exclusively breastfeed. 
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Knowledge of EBF is high 111 (68%) among mothers working in the formal sector. 
About 227 (93%) of formal sector working mothers had accurate knowledge of 
exclusive breastfeeding but only 103 (45.4%) of them actually practiced exclusive 
breastfeeding. Only mothers who received information about EBF from their partners 
had the highest 60.6% EBF practice. Fifty three (14.8%) of mothers described their 
workplace as very supportive for breastfeeding and out of that 29(54.7%) of them 
practiced EBF. 
CONCLUSION: Slightly over fifty percent of women in the formal sector practices 
EBF. Despite the non-availability of organizational structures in place a breastfeeding 
supportive workplace also increases the likelihood of a woman exclusively 
breastfeeding her baby. Male involvement and partner support in EBF increases a 
woman’s likelihood to practice EBF. 
 
 
 
 
 
 
 
 
 
 
 
 
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DEDICATION 
Dedicated to my dear mummy, Mrs Elizabeth Morny and to all hardworking women 
trying to balance motherhood and career. 
 
 
  
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ACKNOWLEDGEMENT 
I would like to thank my Lord and Saviour Jesus Christ for his overwhelming love 
towards me. I would also like to thank my family and friends for their immense support. 
To my supervisor, Dr Patricia Akweongo, thanks for your extraordinary patience.  To 
Mr. Tony Godi and Bernad Fiador I say a big thank you for the assistance. God bless 
you. 
 
 
 
  
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TABLE OF CONTENTS 
DECLARATION ............................................................................................................ i 
ABSTRACT ................................................................................................................... ii 
DEDICATION .............................................................................................................. iv 
ACKNOWLEDGEMENT ............................................................................................. v 
LIST OF FIGURES ...................................................................................................... ix 
LIST OF TABLES ......................................................................................................... x 
LIST OF ABBREVIATIONS ....................................................................................... xi 
DEFINITION OF TERMS .......................................................................................... xii 
CHAPTER ONE ............................................................................................................ 1 
INTRODUCTION ......................................................................................................... 1 
1.1 Background .............................................................................................................. 1 
1.2 Problem Statement ................................................................................................... 4 
1.3 Justification of the Study ......................................................................................... 5 
1.4 General Objective .................................................................................................... 6 
1.5 Specific Objectives .................................................................................................. 6 
1.6 Research Questions .................................................................................................. 6 
1.7 Conceptual Framework ............................................................................................ 7 
CHAPTER TWO ........................................................................................................... 9 
LITERATURE REVIEW .............................................................................................. 9 
2.1 Exclusive Breastfeeding........................................................................................... 9 
2.2 The Health Belief Model ......................................................................................... 9 
2.2.1 Theoretical Perspective of the study ................................................................... 10 
2.3 Trends in  Exclusive Breastfeeding Practices ........................................................ 11 
2.4 Benefits of Exclusive Breastfeeding ...................................................................... 12 
2.5 Determinants of Exclusive Breastfeeding .............................................................. 13 
2.4.3 Behavioural Factors ............................................................................................ 16 
2.6 Exclusive Breastfeeding among Women in the Formal Sector ............................. 17 
2.7 The Breastfeeding Room Policy ............................................................................ 17 
2.8 Benefits of the Breastfeeding Room ...................................................................... 18 
2.9 Conclusion ............................................................................................................. 19 
CHAPTER THREE ..................................................................................................... 20 
METHODOLOGY ...................................................................................................... 20 
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3.1 Introduction ............................................................................................................ 20 
3.2 Study Design .......................................................................................................... 20 
3.3 Study Sites ............................................................................................................. 20 
3.4 Study Population .................................................................................................... 21 
3.5 Sampling ................................................................................................................ 21 
3.5.1 Sample Size Determination................................................................................. 21 
3.6 Sampling Technique .............................................................................................. 22 
3.7 Inclusion Criteria ................................................................................................... 23 
3.8 Exclusion Criteria .................................................................................................. 24 
3.9 Study Variables ...................................................................................................... 24 
3.10 Data Collection Techniques and Tools ................................................................ 26 
3.10.1 Pretesting........................................................................................................... 26 
3.10.2 Quality Control ................................................................................................. 26 
3.11 Data Analysis ....................................................................................................... 27 
3.12 Ethical Consideration ........................................................................................... 27 
3.13 Participant Consent .............................................................................................. 27 
3.14 Privacy and Confidentiality ................................................................................. 28 
3.15 Risk and Benefit ................................................................................................... 28 
3.16 Permission for Study ............................................................................................ 28 
3.17 Description of Subjects Involved In the Study .................................................... 28 
3.18 Informed Consent Process ................................................................................... 28 
3.19 Voluntary Consent/Withdrawal ........................................................................... 29 
3.20 Data Storage and Usage ....................................................................................... 29 
3.21 Compensation ...................................................................................................... 29 
3.22 Proposal and Funding Information ...................................................................... 29 
CHAPTER FOUR ........................................................................................................ 30 
RESULTS .................................................................................................................... 30 
4.1 Background Characteristics ................................................................................... 30 
4.2 Mode of feeding ..................................................................................................... 33 
4.3 Knowledge and Perception of Exclusive Breastfeeding ........................................ 33 
4.4 Breastfeeding in the course of Work ..................................................................... 35 
4.5 Organizational Support for Breastfeeding ............................................................. 39 
4.6 Predictors of Exclusive Breastfeeding among formal sector working mothers ..... 41 
CHAPTER FIVE ......................................................................................................... 45 
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DISCUSSION .............................................................................................................. 45 
CHAPTER SIX ............................................................................................................ 49 
CONCLUSIONS AND RECOMMENDATIONS ...................................................... 49 
REFERENCES ............................................................................................................ 51 
APPENDIX .................................................................................................................. 57 
CONSENT FORM ....................................................................................................... 57 
 
 
 
 
 
 
  
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LIST OF FIGURES 
Figure 1: Conceptual framework of behavioural and organizational factors affecting on 
exclusive breastfeeding Practices in formal sector workplace ...................................... 7 
Figure 2: The Health Belief Model .............................................................................. 10 
Figure 3 Mode of feeding ............................................................................................ 33 
Figure 4: Reasons why a woman should Exclusively Breastfeed ................................ 35 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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LIST OF TABLES 
Table 1: Sociodemographic characteristics and breastfeeding .................................... 31 
Table 2: Knowledge and Perception about Exclusive Breastfeeding .......................... 34 
Table 3: Breastfeeding and Work ................................................................................ 36 
Table 4: Experiences with Breastfeeding at Work ...................................................... 38 
Table 5: Organizational Support for Breastfeeding ..................................................... 40 
Table 6: Organizational support and lactation policy .................................................. 41 
Table 7: Logistic Regression of EBF on Sociodemographic and Organizational factors
...................................................................................................................................... 43 
 
 
  
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LIST OF ABBREVIATIONS 
EBF  Exclusive Breastfeeding 
GHS-ERC Ghana Health Service Ethics Review Committee 
GSS  Ghana Statistical Service 
ILO  International Labour Organization 
O&A     Ordinary and Advanced Level Certificate 
SDG  Sustainable Development Goals 
SHS                 Senior High School 
UN  United Nations 
UNICEF United Nations International Children’s Fund 
WHO  World Health Organization 
 
 
 
 
 
  
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DEFINITION OF TERMS 
 
Formal sector worker: Formal sector worker is any worker whose job is within 
usual hours (8am to 5 pm) who earn regular wages, and 
are on a recognize income source, on which income 
taxes is paid. 
 
Exclusive breastfeeding: Feeding baby with only breast milk and not food and 
water for up to 6 months of life  
 
Lactation Room: A private room in an institution where a nursing mother 
can pump breast milk or nurse her baby. Also known as 
the Breastfeeding room 
 
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CHAPTER ONE 
INTRODUCTION 
1.1 Background 
Prior to the industrial revolution which spanned from the 18th to 20th century, the sole 
role of a woman was defined by her household roles,  that is to raise children and keep 
the home. The industrial revolution required that more and more women were 
incorporated into the labour force which allowed them to receive wages and which gave 
them little time for household roles which included breastfeeding their babies 
(Pinchbeck, 1930; Revolution, Clark, Hutchins, & George, 1991). This period 
coincided with the era of the proliferation of breast milk substitutes as it seemed the 
most convenient way of feeding an infant (Wolf, 2001). Also, researchers of that era 
positioned infant formula as a better alternative to human breast milk (Stevens, Patrick, 
& Pickler, 2009). This was corroborated by breast milk substitute key industry players 
who through the adoption of effective promotional strategies managed to get a large 
segment of the working population especially those in the formal sector to adapt to the 
infant formula(Stevens et al., 2009). 
 
Previously it was a status symbol in Ghana  and worldwide to feed babies with infant 
formula hence most young couples including those who were in the informal sector 
resorted to the use of various brands of breast milk substitutes.  
However, after some recorded adverse effects of breast milk substitutes on the health 
of babies such as summertime milk spoilage where there was milk spoilage due to the 
heat and inappropriate preservation of cow milk deeper research into human breast milk 
was conducted, which resulted in a paradigm shift to human breast milk as the optimum 
source of infant nutrition. In the 1970s  breastfeeding support movements were formed 
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and the association between  infant formula  and diseases such as diarrhoea, diabetes 
and allergy was established(Castilho & Filho, 2010). In the year 1990, the Innocenti 
Declaration on the protecting, promotion and supporting of breastfeeding was made 
(WHO & UNICEF, 1990). Over the last two decades, there has been a growing attention 
in the endorsement of exclusive breastfeeding as the recommended feeding practice for 
newly born babies(Castilho & Filho, 2010) This, to a great extent, has been encouraged 
by increasing scientific research, discoveries and substantiation on the significance of 
exclusive breastfeeding in reducing infant morbidity and mortality. 
 
More than 100 years after the industrial revolution more women today find themselves 
in the formal sector where they rub shoulders with their male counterparts despite the 
need to still combine this with their traditional role as home keepers and nurturers of 
children. In this highly competitive global marketing environment, employers have 
become very sensitive to the returns on their investments hence time spent by an 
individual employee in carrying out a task and the revenue generated through the act 
has become very important(Saks, 2015). This situation has a heavy toll on breastfeeding 
mothers who are faced with the decision as to the safest, most convenient, healthy and 
sustainable ways of providing nutrition to their infants. Maternity leave periods are 
short with the average period in Ghana being 12 weeks  or 3 months according to the 
Ghana labour act and a survey done by ILO as there is the need to resume full time 
work (Centres & Agencies, 2003; ILO, n.d.). 
 
 Finding solution to the gaps created during the absence of the   mothers  whilst at work 
has generated a lot of advocacy and debate as to how to find innovative ways of 
providing human breastmilk while the nursing mother is at work. In recent times 
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governments and international bodies have encouraged workplace breastfeeding 
support through policies and interventions.(Government, Government, & Government, 
2010; Lyell, 2012; National Breastfeeding Policy And Action Plan, 2015)  
 
The International Labour Organization (ILO) in partnership with the World Health 
Organization (WHO) came out with conventions to ensure breastfeeding in nursing 
mothers as a way of encouraging high breastfeeding rates amongst women in labour 
organisations especially in the formal sector worldwide. These conventions and 
recommendations are embodied in the ILO convention number 183 and 
recommendation 191. ILO Recommendation convention number 183 and 
recommendation 191 emphasize that nursing facilities are to be provided at the 
workplace with one or more breastfeeding breaks to enable the mother express breast 
milk for continual breastfeeding. Convention number  183 article 10 states that “the 
period during which nursing breaks or the reduction of daily hours of work are allowed, 
their number, the duration of nursing breaks and the procedures for the reduction of 
daily hours of work shall be determined by national law and practice.”(ILO, 2017). This 
gives room for the nation to design its own national breastfeeding policy as well as 
workplace breastfeeding policy. 
 
The global breastfeeding initiative which was an initiative set up  by WHO and 
UNICEF  set up the Global Breastfeeding Scorecard,  as a bench mark for the evaluation 
of breastfeeding practices worldwide (UNICEF, 2017).  The   scorecard  number 3 was 
based on the availability of paid maternity leave as well as a workplace breastfeeding 
policy (WHO, 2017). The ILO, WHO and UNICEF have come together to put down 
laid down procedures for breastfeeding amongst working mothers globally. This was 
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done to ensure that mothers who had to return to work during the course of the exclusive 
breastfeeding period could do so despite the need to return to work (UNICEF, 2017). 
In Ghana the median breastfeeding period is 3 months which coincides with the period 
when most mothers have to return to work (Aryeetey & Goh, 2013). 
 
1.2 Problem Statement 
According to the 2017 WHO report no single country globally has been able to reach 
the estimated WHO breastfeeding rates of  90% (Mogre, Dery, & Gaa, 2016; UNICEF, 
2017). The Global Breastfeeding Initiative Scorecard, which is a joint collective by 
WHO and UNICEF indicated that globally the rate of exclusive breastfeeding for 
infants for up to six months is 40%. Out of 194 countries they assessed that only 23 of 
them have at least 60% rate of exclusive breast feeding among babies less than six 
months. The Collective has established a target to increase the rate of exclusive 
breastfeeding to at least 60% by 2030 (UNICEF, 2017). 
 
Even though exclusive breastfeeding rates in Africa is high, West Africa records one of 
the lowest breastfeeding rates in the world (Sokol, Aquago, & Clark, 2007). West 
Africa also has the highest rates of childhood malnutrition in the world and 
breastfeeding is one major factor to end malnutrition globally (Sokol et al., 2007). In 
West Africa, there is inappropriate use of breast milk substitutes due to the literate level 
of the population. Infants are left home with house helps and grandparents who at times 
have challenges handling these breast milk substitutes.(Sokol et al., 2007). Breast milk 
substitutes are used by most women in the formal sector as there is a need to return to 
work as soon as possible.  Breast milk substitutes have however  been found to expose 
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children to diarrhoeal, pneumococcal, diabetes and allergic conditions later in life and 
as such should not be encouraged.  
 
 
In Ghana even though the knowledge of the practice and benefits of exclusive breast 
feeding amongst women is very high, only 52% of babies are breastfed up to 6 months 
of life.(UNICEF, 2016). For most women in the formal sector the return to work ends 
the period of exclusive breastfeeding or breastfeeding in its entirety (Aryeetey & Goh, 
2013) which means measures have to be taken to ensure the sustainability and practice 
of exclusive breastfeeding amongst women in the formal sector. In the 2015 to the 
World Bank in 2017, 49.52% of the work force in Ghana are females, also 40.1% of 
workers in Ghana are within the formal sector (Ghana Statistical Service, 2015). Better 
educated women participate more in the formal sector and earn higher incomes (World 
Bank, 2017). However studies have shown that educated and wealthier women tend to 
less likely breastfeed their babies (Shifraw et al., 2015; Tewabe et al., 2017). Despite 
educational programmes and advocacy efforts by health and governmental bodies and 
women advocacy groups, exclusive breastfeeding among working mothers is still poor.  
This study seeks to investigate the practice of exclusive breastfeeding among formal 
working mothers and possible implication for the lactational room policy.  
 
1.3 Justification of the Study 
In Ghana the median breastfeeding period is 3 months which coincides with the period 
when most mothers working in the formal sector  have to return to work (Aryeetey & 
Goh, 2013). This suggests a need to look at breastfeeding in the workplace and the 
workplace support by employers to ensure that Ghana reaches its 90% breastfeeding 
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rate. This research examines exclusive breastfeeding practices among women in the 
formal sector in Ghana, the workplace support and its implication for the full 
implementation of the breastfeeding policy. The findings may highlight the factors 
affecting mothers in the formal sectors decision to exclusively feed the child which may 
in turn affect the full implementation of the lactation room policy in Ghana to enable 
the country conform to international policies and set goals. 
 
1.4 General Objective 
To examine the practice of exclusive breastfeeding amongst women in the formal sector 
and its implication for the Lactation Room Policy  
1.5 Specific Objectives  
1. To determine the proportion of formal female workers who exclusively breastfeed 
2. To determine the knowledge and perception of working mothers on exclusive 
breastfeeding.  
3. To examine factors that influence exclusive breastfeeding amongst women in the 
formal sector.  
 
1.6 Research Questions 
1. What proportion of formal female workers exclusively breastfeed their babies? 
2. What is the level of knowledge of Exclusive breastfeeding amongst mothers in the 
formal sector. 
3. What are the factors that promote exclusive breastfeeding practices in formal sector 
workplace? 
 
 
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1.7 Conceptual Framework 
 Socio-demographic Organizational factors 
factors Working hours per  day 
 Age Availability of lactation 
Marital status rooms 
 Educational background Number of breaks for 
 Current profession Milk expression 
Level of income Availability of lactation 
 Working sector room policy 
Number of children 
  
 
 
 Exclusive Breastfeeding 
 
 
 
 
 Behavioural factors 
 Knowledge of Exclusive Breastfeeding (EBF) 
 
 Sources of knowledge  
 Knowledge of benefits of EBF 
 
 Perception about EBF 
 
  
 Figure 1: Conceptual framework of behavioural and organizational factors 
 affecting on exclusive breastfeeding Practices in formal sector workplace 
 
 
 
This conceptual framework as drawn in with underpinnings of the health belief model 
gives an overview of the factors that affect the practice of Exclusive breastfeeding in 
mothers in the formal sector in Ghana. From the diagram, socio-demographic factors 
(Age, Marital status, Educational level, Profession, Income, Working sector), 
Organizational factors such as Working hours per day, Availability of lactation Rooms, 
Number of breaks for Milk expression, Availability of lactation room policy and 
behavioural factors (Knowledge of the of Exclusive, Breastfeeding (EBF), Sources of 
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knowledge, Knowledge of benefits of EBF) independently can affect the practice of 
Exclusive breastfeeding.  Although these factors individually influence EBF, there is 
some interaction between socio-demographic factors, organizational factors and 
behavioural factors. Older women may likely breastfeed their babies exclusively. On 
the other hand, older women may have more responsibilities at work and that could 
reduce the effect of age on EBF. Marital status, Educational level may influence the 
organization they work for, amount of time spent at work and whether or not they enjoy 
breaks at the workplace. Educational level, age and profession may influence one’s 
knowledge and perception on breastfeeding. Increase in educational status may lead to 
an increase in knowledge on exclusive breastfeeding Also the organization one works 
for can influence the income level. Individuals’ knowledge on benefits of breastfeeding 
and their perceptions on EBF may influence the need for formal sectors workers to 
make use of lactation Breaks, lactation rooms at work place. With the availability of a 
lactation room and lactation room policy, the mother may positive perception about 
EBF and could increase her likelihood of practicing exclusive breastfeeding. 
 
 
 
  
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CHAPTER TWO 
LITERATURE REVIEW 
2.1 Exclusive Breastfeeding 
According to WHO "Exclusive breastfeeding" is the practice of giving only breastmilk 
including milk expressed or from a wet nurse and no other food or drink, not even water, 
for 6 months of life, but allows the infant to receive ORS, drops and syrups (vitamins, 
minerals and medicines (WHO, 2015). 
 
Breastfeeding is the best way of providing healthy, natural and ideal food for the 
growing infant. It provides all the nutrients and a balanced diet for a baby’s needs for 
the first six months of life. 
 
It also provides more than half of the babies nutritional needs for from 6months going 
on and one third of the babies nutritional needs during the second year of life (WHO, 
2017). 
 
To enable mothers to establish and sustain exclusive breastfeeding for 6 months, WHO 
and UNICEF recommend: “Initiation of breastfeeding within the first hour of life; the 
infant only receives breast milk without any additional food or drink, not even water; 
breastfeeding on demand – that is as often as the child wants, day and night and no use 
of bottles, teats or pacifiers (WHO, 2017)”. 
 
2.2 The Health Belief Model 
 The Health Belief Model is used to inform behaviour change interventions and assess 
behaviour change. Originally, the Health Belief Model had four constructs: perceived 
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susceptibility, perceived severity, perceived benefits, and perceived barriers. 
Subsequently, a number of other constructs were added to the model including cues to 
action and self-efficacy (Sweeney & Gulino, 1987) These constructs are concepts that 
combine to make the theory  
 
Figure 2: The Health Belief Model 
   
2.2.1 Theoretical Perspective of the study 
This study is underpinned by the Health Belief Model (HBM), on the basis that 
successful breastfeeding practice requires that target audience are knowledgeable of the 
benefits to be derived if adopted and the potential risks involved. Mojaye (2008) stated 
that the HBM is based on the fundamental understanding that an individual will only 
take a health-related action if the person feels that the threatening condition can be 
evaded and is left with no doubt that partaking in the suggested action would lead to 
positive outcomes. Against this backdrop, formal sector working mothers will only 
carry out exclusive breastfeeding if they are truly aware of the benefits and also when 
they are sure it will not affect their job security. Health behaviours are triggered by 
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one’s desire to prevent illness (perceived susceptibility) or to live in a state of wellness.  
The assumption is that, understanding the advantages of exclusive breastfeeding 
(perceived benefits) and having a clear knowledge of the dangers of not exclusively 
breastfeeding the child (perceived severity), mothers’ confidence will be activated to 
overcome the challenges and that can improve the practice of exclusively breastfeeding 
their babies. Providing information improves knowledge which affects perception and 
this promotes acceptance (Ogwezzy-Ndisika, 2012). Sensitization and education of 
mothers on the advantages of exclusive breastfeeding; and provision of adequate 
information on how to deal with the challenges of breastfeeding in the workplace will 
help mothers adopt the desired behaviour. Certain factors such as working hours, non-
availability of lactation room at work place, no/inadequate break time at work as 
perceived by the individual may serve as barriers to the desired behaviour (perceived 
barriers). For example, a mother might not breast-feed the baby for fear of the breast-
milk not being adequate for the infant due to hours spent at the work place and not  
breastfeeding. External factors also influence the desired behaviour, serving as cues to 
action. For exclusive breastfeeding, information from health professionals, radio and 
television as well as support and encouragement from partner and other relatives may 
influence mother to exclusively breastfeed their babies (Ogwezzy-ndisika, 2016) 
2.3 Trends in  Exclusive Breastfeeding Practices  
In the United States, a national survey found that only 16.8% of infants had been 
exclusively breastfed for six months(Jones & Kogan, 2011). Dop &Benbouzid (1999) 
reported a mean rate of 24% of infants exclusively breastfed at the age of 4months after 
they combined data from Lebanon (7%), Yemen (15%), Pakistan (16%), Jordan (32%), 
and Iran (48%). In a study by Ong et al  in Singapore 20% of working  mothers 
exclusively breastfed for up to 6 months of life(Ong, Yap, Li, & Choo, 2018) 
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In Ethiopia, a study conducted to assess factors associated with exclusive breastfeeding 
practices in Debre Berhan District by Asfaw, Argaw, & Kefene, (2015)  reported  a 
prevalence 68.6 % mothers who exclusively breastfed their babies. In another study in 
Ethiopia, 188 (74%) of the children were fed breast milk exclusively for the first 6 
months of life (Gizaw, Woldu, & Bitew, 2017). 
 
In Ghana, periodic national surveys report the practice of exclusive breastfeeding (EBF) 
in the general population to be over 50 %. However a study conducted by Dun-Dery & 
Laar, (2016)  among 389 professional working mothers revealed a low rate of EBF at 
six months of 10.3%. 
 
2.4 Benefits of Exclusive Breastfeeding 
Breast milk promotes healthy growth and development of infants as it promotes sensory 
and cognitive development (Kramer et al., 2008; León-Cava, Ross, Lutter, & Martin, 
2002). It protects and reduces the risk of certain infectious diseases such as otitis media, 
diarrhoeal diseases, pneumonias or lower respiratory tract infections and meningitis as 
well as chronic disease such as asthma and diabetes(Allen & Hector, 2005; Bachrach, 
Schwarz, & Bachrach, 2003). Breastfed infants have a lower risks of developing atopic 
diseases such as asthma(Greer, Sicherer, & Burks, 2008). Breastfed infants have a 
reduced risk of sudden death syndrome, Hodgkin’s lymphoma and leukaemia (Allen & 
Hector, 2005). 
 
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Breast milk does this by building the babies immune system thereby helping to fight 
against diseases.  Breast feeding promotes gastrointestinal development. Breast fed 
infants have a lower risk of obesity compared to formula fed infant. 
 
Breastfeeding delays ovulation which has benefits such as lactation amenorrhoea and 
the prevention of certain diseases such as breast, ovarian and endometrial 
cancers(WHO, 2002). Breast feeding also promotes the bond between the mother and 
the baby. Breastfeeding, especially immediately after delivery helps in the involution 
of the uterus and helps to prevent postpartum haemorrhage(Negishi et al., 1999). In the 
long term breastfeeding helps to shed off the excessive weight gained by most women 
during pregnancy which is a desirable effect in most cases. 
 
Socioeconomic benefits of exclusive breastfeeding includes the fact it is freely 
produced by the body so the mother would not have to spend money on baby formula 
which is quite expensive (UNICEF, 2003). The child is healthier and less prone to 
sicknesses thereby reducing the cost of drugs and hospitalization. According to 
UNICEF in 2003, breastmilk substitutes are diluted in an excessive amount of water or 
if the water is impure leaves the child susceptible to growth deficiency or illness. 
2.5 Determinants of Exclusive Breastfeeding   
2.5.1 Socio-demographic factors associated with EBF 
Age  
Gizaw, Woldu, & Bitew, (2017) conducted community based cross-sectional study to 
assess EBF of children aged between 6 and 24 months during the first 6 months of life  
and reported that exclusive breastfeeding was significantly associated with mothers 
aged above 35 years. Age was also reported to be statistically associated with EBF in 
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another study conducted to assess factors associated with exclusive breastfeeding 
practices in Debre Berhan District, Central Ethiopia. The odds of mothers aged 25 to 
35 years to practice EBF was found to be nearly 9 times more than mothers whose ages 
were less than 25 years (Asfaw et al., 2015). 
Marital status  
Adugna, Tadele, Reta, & Berhan, (2017) in a study to assess prevalence and 
determinants of EBF practice among infants less than six months age in Hawassa city, 
Ethiopia reported that married mothers practiced EBF more likely than single mothers. 
Educational status 
Some studies have found positive significant association between maternal educational 
status and exclusive breastfeeding. They reported increased odds of EBF among 
mothers with higher education(Dashti, Scott, Edwards, & Al-sughayer, 2010; Dorgham 
& Hafez, 2018). Other studies have reported that mothers with lower educational status 
have had significantly higher odds of EBF (Amin, 2014; Batal, Boulghourjian, 
Abdallah, & Afifi, 2006; Radwan, 2013). Some other studies assessed association 
between educational status of the mothers and EBF but found no association(Adugna 
et al., 2017; Al-Kohji, Said,& Selim, 2012; Gizaw et al., 2017; Shifraw, Worku, & 
Berhane, 2015; Tewabe et al., 2017)  
Income 
A facility based cross-sectional study with internal comparison was  conducted among 
mothers attending immunization sessions in all public health centres in Addis Ababa, 
Ethiopia, This study  revealed that mothers with lower monthly income were more 
likely to exclusively breastfeed than their counterparts who earned more(Shifraw et al., 
2015).  Another study which was a community-based cross-sectional study was 
conducted among local health extension workers of each Kebele with total of 423 
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mothers also indicated that low income mothers had significantly three times the odds 
of breastfeeding their children compared those who earned more(Tewabe et al., 2017). 
Number of children 
Three different studies in Egypt (Mohamed, El, & Labib, 2016), Lebanon, (Batal et al., 
2006)and Saudi Arabia(Amin, 2014) have found significant association between 
number of children born by mothers and EBF. Two of these studies reported significant 
reduction in odds of exclusive breastfeeding among multiparous women(Amin, 2014; 
Mohamed et al., 2016). Batal M, Boulghourjian, Abdallah, & Afifi, (2006) reported 
that increased number of children significantly increased the odds of EBF. 
 
2.5.2 Organizational factors associated with EBF 
Work hours 
It is a known fact that about 98% of mothers initiate Breast feeding within the first 
hours of life but  at 6 months the number of mothers still exclusively breastfeeding 
drops significantly as low as 2.8% in a Kinshasa study(Babakazo, Donnen, Akilimali, 
Ali, & Okitolonda, 2015). This goes to show that very few women in Sub-Saharan 
Africa exclusively breast feed for up to 6 months even though the initiation rate is high. 
One reason for discontinuing breastfeeding was due to the problems encountered during 
the first days after childbirth i.e. problems with lack of breast milk production, improper 
positioning of mother and baby, the frustration that the baby couldn’t be fed enough. 
This could explain the high rate of exclusive breastfeeding discontinuation during the 
first month of life. Another factor in discontinuation of  exclusive breastfeeding during 
the fourth month was probably due to the resumption of income-generating activities 
(Babakazo et al., 2015). As such postnatal breastfeeding support in a form of workplace 
support is needed to aid mothers to surmount breastfeeding challenges 
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The contribution of the mother’s employment on exclusive breastfeeding depends on 
the job flexibility. It has been noted that full- time workers stop breastfeeding earlier 
than unemployed mothers. However, it is good to note that the exclusive breastfeeding 
practice of self-employed mothers did not vary significantly from unemployed mothers 
(Babakazo et al., 2015). 
2.4.3 Behavioural Factors 
Knowledge and Practice of Exclusive Breast Feeding 
In a study by Tadele et al. carried out in Ethiopia, up to 93.6% of mothers had 
knowledge on what exclusive breast feeding was and 59.3% thought breast milk alone 
was enough for the child for up to 6 months of life even though 89.5% did practice 
exclusive breastfeeding for up to 6 months of life mostly due to recommendations and 
enforcement by health workers (Tadele, Habta, Akmel, & Deges, 2016). 
 
In a study by Nkrumah done in  the Effutu Municipal  of Ghana it showed that 
breastfeeding initiation is high  and women in the informal sector are 8 times more 
likely to practice exclusive breastfeeding than their counterparts in the formal 
sector(Nkrumah, 2017).  
A prospective study conducted in Kinshasa, Democratic Republic of the Congo to 
determine factors that significantly predict discontinuing exclusive breast feeding 
revealed  that  mothers with low level of breastfeeding knowledge  had  52% increase 
in their hazard of discontinuing breastfeeding compared to mothers with high level of 
knowledge on breastfeeding (Babakazo et al., 2015) 
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Other studies in Egypt, Saudi Arabia, and North East of Iran have found associations 
between mothers knowledge on breastfeeding and EBF (Alzaheb, 2017; El Shafei & 
Labib JR, 2014; Vafaee , Khabazkhoob, Moradi,& Najafpoor ,2010). 
 
2.6 Exclusive Breastfeeding among Women in the Formal Sector 
In a study by Dun-Dery et al., it was noted that awareness of exclusive breastfeeding 
(EBF) amongst mothers in the formal sector is universal about 99% with the actual 
practice of EBF as low as 10.3% (Dun-Dery & Laar, 2016). This same study indicated 
that lack of commitment, limited workplace support and the unavailability of work 
place breastfeeding facilities, lack of breastfeeding breaks as some of the barriers to the 
continual practice of exclusive breastfeeding among professional working mothers 
(Dun-Dery & Laar, 2016). 
 
2.7 The Breastfeeding Room Policy 
The exclusive breastfeeding room policy stems from the International Labour 
Organization to support working mothers have concessions at work when they are 
breastfeeding. In the ILO Convention number 183 article 10: “A woman shall be 
provided with the right to one or more daily breaks or a daily reduction of hours of 
work to breastfeed her child”.
Secondly, “the period during which nursing breaks or the reduction of daily hours of 
work are allowed, their number, the duration of nursing breaks and the procedures for 
the reduction of daily hours of work shall be determined by national law and practice. 
These breaks or the reduction of daily hours of work shall be counted as working time 
and remunerated accordingly” (ILO, 2017). 
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Where practicable and with the agreement of the employer and the woman concerned, 
it should be possible to combine the time allotted for daily nursing breaks to allow a 
reduction of hours of work at the beginning or at the end of the working day.”  
ILO Recommendation, 2000 (No. 191)  Paragraph 8 (ILO, 2017) 
 
“Where practicable, provision should be made for the establishment of facilities for 
nursing under adequate hygienic conditions at or near the workplace.”  
ILO Recommendation, 2000 (No. 191)  Paragraph 9 (ILO, 2017) 

The Ghana Labour Act 651 entitles a breastfeeding mother of at least one hour during 
her normal working period to nurse her baby. The one hour is within her normal 
working period and should be fully paid for (Centres & Agencies, 2003).
A study done by Aryeetey and Goh showed that the median age in Ghana for 
breastfeeding  for working mothers is 3 months and that the proportion of exclusively 
breastfed (EBF) infants declines rapidly after 3 months (Aryeetey & Goh, 2013).  This 
decline in EBF coincides with the period most mothers return to work. As such there is 
a need for the implementation of the breastfeeding room policy as most maternity leave 
end before the stipulated time for exclusive breastfeeding which is 6 months as such 
policies have to be put in place to ensure continual exclusive breastfeeding of the baby 
even whilst the mother is at work. 
 
2.8 Benefits of the Breastfeeding Room 
A study done at the Los Angeles Department of Power and Water, which provides a 
comprehensive breastfeeding programme to support workers, including on-site 
lactation rooms and flexible scheduling showed that a few years after the programme 
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was introduced, health-care claims were 35 per cent lower, 33 per cent of new mothers 
returned to work sooner than anticipated, absenteeism rates were 27 per cent lower 
among both men and women, and 67 per cent of all employees said they planned to stay 
with the company in the long run (“Breastfeeding in the workplace: Good for the 
mother, child, business and society,” n.d.). 
 
2.9 Conclusion 
In summary, prevalence of exclusive breastfeeding have varied across different 
geographical locations of the world. Particularly, among formal sector workers, these 
have been influenced by several factors ranging from those that have to do with the 
individual (socio-demographic, perceptions and knowledge) to organisational/ 
workplace factors. The ILO has put in place measures to increase the prevalence of 
EBF amongst women in the formal sector with the passing of the maternity protection 
convention of which the implementation of lactation rooms at workplaces is required. 
The study was guided by this literature and underpinned by the health belief model. 
  
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CHAPTER THREE 
METHODOLOGY 
3.1 Introduction 
This chapter discusses the research design, target and study population, sampling 
technique and calculation of sample size, types and sources of data, research instrument, 
administering of research instrument, data handling and ethical considerations. 
 
 
3.2 Study Design 
The study was an analytical cross-sectional study by design and employed quantitative 
methods to give an insight into Exclusive Breastfeeding practices among women in the 
formal sector and the implication for the lactational room policy. The study was carried 
out on nursing mothers who presented to the immunization clinic of some selected 
hospitals in the Greater Accra region.  
 
3.3 Study Sites 
The Greater Accra Region is the regional and administrative capital of Ghana and 
contains the main and largest metropolitan areas i.e. Accra and Tema which are the 
countries major industrial and administrative areas, The region is the smallest of the 10 
administrative regions with a land surface area of 3,245 square kilometres which is 1.4 
per cent of the total land area of Ghana. It is also the second most populated region, 
after the Ashanti Region, with a population of 4,010,054 in 2010, accounting for 15.4 
per cent of Ghana’s total population. 
 
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The administrative areas within the region are as follows: Accra Metropolitan Area 
(AMA) Accra, Tema Municipal Area Tema, Ga East District, Ga West District, 
Dangme West District, Dodowa and Dangme East District, Ada-Foah. Since the region 
is the centre of Ghana’s politico administrative and industrial hub, the region has a 
higher concentration of professional and technical workers (10.8%) compared to the 
national figure of 6.5 percent (GOVERNMENT OF GHANA OFFICE PORTAL, n.d.). 
 
The study locations were in the two major industrial and commercial areas in the region 
namely; Tema and Accra. The study was done in 2 public Hospitals and 2 private 
hospitals with the public ones being Ghana Police Hospital, The Greater Accra 
Regional Hospital, and the private ones being Port Clinic Tema and Narh Bita Hospital. 
The above named private hospitals were chosen on the basis that the serve a large 
population of professional or formal workers based on the fact that both have contracts 
to treat and serve the staff  of  a number of companies in the Tema district. 
 
3.4 Study Population 
The study population was all nursing mothers who attended postnatal clinic in the above 
mentioned hospitals and who work in the formal sector. 
 
 
 
3.5 Sampling 
3.5.1 Sample Size Determination 
In a similar study in Ghana by Dun-Dery and Laar , 69% of  professional  working 
breastfeeding mothers did not receive work place breastfeeding support (Dun-Dery & 
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Laar, 2016). Using 69% as the sample proportion, the sample size of this current study 
was computed using Cochran’s formula (1965) as follows: Where 
 
 
n= Sample size 
z = Confidence interval at 95% which is 1.96 
p = estimated proportion of the outcome of interest 
d = Maximum error allowed 
 
For the purposes of the study, the following assumptions were made in calculating the 
sample size: 
95% confidence level (standard value 1.96), and 
Maximum margin of error of 5% 
Substituting into the formula, the sample size was computed as follows: 
n = (z2pq)/d2 
 
Thus, sample size n = 1.96² × 0.69 (1-0.69) 
                                                         0.05² 
n = 329 approximately 330 
A 10% non-response rate will be applied. The total sample will therefore be 365. 
 
3.6 Sampling Technique 
The calculated sample size was divided into the selected facilities by using 
proportionate to size sampling (PSS). Information on total number of mothers who 
attended postnatal care at the selected facilities the previous year was sought from the 
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facilities. Also information on average daily attendance to the facilities’ immunization 
centres was obtained from the various facilities. Average daily attendance was 70, 50, 
45 and 30 for the Greater Accra Regional Hospital, Police Hospital, Narh-Bita Hospital, 
Port  Medical Centre respectively. This was used as basis for the PSS to arrive at 
facility-specific sample sizes of 130, 94, 84, 56 for Greater Accra Regional Hospital, 
Police Hospital, Narh-Bita Hospital, Port Medical Centre respectively. These facility-
specific samples were further divided by the 4 clinic days for data collection for each 
facility to arrive at daily targets.  On each day, all consecutive mothers who met the 
inclusion criteria were recruited into the study until the daily targets were met.  On 
clinic days mothers typically queued up for services early in the morning. Just before 
the clinic began, mothers present were approached with to find out whether or not they 
were formal sector workers per the study definition of formal sector workers and the 
other inclusion citeria. The study was explained to those who met the criteria, only 
mothers who gave informed consent were recruited. This was done on one clinical day 
per week until the quota for the facility was met. For the facilities that had more than 
one clinical day per week, one of the days was randomly selected weekly. Participants 
were recruited simultaneously in all four facilities to achieve the overall sample size of 
365. However a total of 359 formal sector working mothers participated in the study. 
 
 
 
3.7 Inclusion Criteria 
All nursing mothers who attended the immunization clinic who were working in the 
formal sector. Dun Dery and Laar in their study defined the formal sector as all jobs 
with usual hours (8 am to 5 pm) who earn regular wages, and are on  a recognized  
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income source, on which income taxes is paid (Dun-Dery & Laar, 2016). This was 
established through interaction with the mothers. 
 
3.8 Exclusion Criteria 
Nursing mothers in the formal sector who attended the postnatal clinic but did not 
consent to the interview. Mothers with twins or multiple babies as well as mothers with 
babies with special needs were excluded because according to the Ghana Labour Act 
these category of nursing mothers are entitled to up to 2 weeks extra on the stipulated 
maternity leave or as per the medical practitioners assessment and discretion (Centres 
& Agencies, 2003). 
 
3.9 Study Variables 
Dependent Description Operational Definition Scale of 
Variable Measurement 
Exclusive  Feeding with only breastmilk Binary 
Breastfeeding and not food and water for Yes 
up to 6 months of life No 
 
 
 
 
 
 
 
 
 
 
Independent Description Operational Description Scale of 
Variable Measurement 
 
Age in years 20-29 Years Age Categories of Categorical 
30-35 Years Respondents 
35-40 Years 
 
Marital Status Single  Marital Status of Nominal 
Widowed Respondents 
Divorced 
Married 
Separated 
 
Educational Level Basic Educational Levels of Ordinal 
SHS/ O&A Respondents 
LEVEL 
Tertiary 
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Independent Description Operational Description Scale of 
Variable Measurement 
 
Number Of 1 Total number of children Categorical  
Children 2 the respondents have. 
3 
4+ 
 
Working Sector 1.Healthcare Working sector in which the Nominal 
2.Engineering respondents belong to. 
3.Banking and 
Finance 
4.Business 
Consulting and 
Management 
 
 
Average time to Less than 15 mins How many minutes it takes Categorical 
work 15 to 30 mins from respondent to move to 
30 mins to 1 hr and from work including 
1hr to 2 hrs hours spent in traffic 
More than 2 hrs 
 
 
Independent Description Operational Description Scale of 
Variable Measurement 
 
 
Current Mode of Exclusive Mode of feeding babies by Categorical      
feeding child. breastfeeding respondents who presented 
Mixed feeding to the Child welfare clinic. 
Formula feeding 
only 
 
 
Duration of Never Duration for which Categorical         
Breastfeeding 1 Month Or Less respondent exclusively 
2 Months breastfed babies 
3 Months 
4 Months 
5 Months 
6 Months 
 
Workhours Per  Hours Duration of time spent in Continuous 
day workplace in hours from 
time work starts to close by 
mother.      
 
 
 
 
Independent Description Operational Description Scale of 
Variable Measurement 
 
Knowledge of Correct knowledge Acurate knowledge of the Binary 
EBF Incorrect definition of Exclusive 
Knowledge breastfeeding. 
 
 
Availability of Yes Whether or not there is/are Nominal       
Lactation Rooms No breastfeeding or lactation 
at work room(s) at respondents 
work place 
 
 
Number Of None The number of breaks the Categorical       
Breaks For Milk 1 respondents have during 
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Expression 2 or more working hours for milk 
during working expression 
hours excluding 
lunch breaks 
 
 
Number of 15 min or less The duration of breaks for Categorical       
minutes per 15- 30 mins milk expression during 
breastfeeding 30 mins or more working hours that 
break respondents have at their 
workplace. 
 
 
 
3.10 Data Collection Techniques and Tools 
Data was collected with the aid of a semi-structured questionnaire which was adapted 
from CDC questionnaire on breastfeeding. The questionnaire was self-administered as 
well as face to face interview depending on the literacy level of the mothers. Assistance 
to filling the questionnaire was provided by the research assistants. 
 
3.10.1 Pretesting 
The developed questionnaire was pretested at the Tema General Hospital. This facility 
was used because it shares similar characteristics with the hospitals to be used for the 
research. Tema General Hospital is a Sub-Metropolitan hospital based in Tema which 
also serves a wide range of patients in the formal sector due to its location in Tema. The 
pretesting gave a fair idea on what needed to change on the questionnaire. The aim was 
to test for validity and reliability of the instruments. Errors in the questionnaire were 
corrected before the final data collection. 
 
3.10.2 Quality Control 
To ensure quality control, I trained the data collectors to understand the questions and 
to ask the questions appropriately. All questionnaires submitted by data collectors were 
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previewed to ensure completeness and consistency of responses. The data was double 
entered to ensure consistency and validity. 
 
3.11 Data Analysis 
Data were analysed using the Stata software version 15. Descriptive analysis was 
employed that generated frequencies and percentages for categorical variables. Chi 
square analysis and logistic regression was used in the study to compare the 
independent variables with exclusive breastfeeding which was the dependent variable. 
A significance level of 5% was used for all tests. Results have been presented in tables 
and figures. 
 
3.12 Ethical Consideration 
Approval of the study was obtained from Ghana Health Service Ethics Review 
Committee (GHS-ERC). Permission letters were sent to the various hospitals involved 
in the study and granted before the study was carried out. 
 
3.13 Participant Consent 
Consent forms were issued out to every prospective participant for prior approval 
before the study was carried out. Approval was in the form of thumb print or signatures 
and with the background of women in the formal sector there was  assumption that most 
of them can read and write those  unable understand the issues involved in the 
questionnaire explanation was provided  by the data collectors. 
 
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3.14 Privacy and Confidentiality 
Respondent privacy was assured as the questionnaires did not require them to provide 
their names, numbers were used. Also as part of the consent form they were assured of 
privacy and also given the assurance that the information given is for academic 
purposes only. 
 
3.15 Risk and Benefit 
The purpose of this study is to inform a policy on a breastfeeding room and as such the 
risk element was minimal. The participants of the study were assured that they are only 
adding to academic knowledge and also getting involved in a policy that when instituted 
would benefit future generations and the country as a whole. 
 
3.16 Permission for Study 
Permission to conduct the study letters were sent to the Medical Directors of the above 
named hospitals. This ensured the necessary support needed to make the study 
successful. 
 
3.17 Description of Subjects Involved In the Study 
In this cost-effective study, data was collected from nursing mothers who presented to 
the immunization clinic. 
 
3.18 Informed Consent Process 
Individual written consent was sought from all the nursing mothers who presented to 
the immunization clinic and are in the formal sector health. The nature of the data 
collection process as well as the reason for carrying out the research was explained to 
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the participants and written consent was signed before the start of the activity. Consent 
forms were approved by the ethical review committee of the Ghana Health Service. 
3.19 Voluntary Consent/Withdrawal 
Participation in the study was voluntary and no coercion or inducement was applied to 
get subjects to participate. Moreover, those who decided not to participate were given 
the right to withdraw from the study at any point without justifying or explaining to the 
researcher their reason for exit. Their withdrawal did not in any way attract any sanction 
or their access to health care. 
3.20 Data Storage and Usage 
The data collection materials in the form of questionnaires had identifiers which were 
anonymous codes. There were no personal identifiers to link subjects’ personal 
information to the data. The answered questionnaires were collated  with limited access 
by only the principal investigator. Even though the study had minimal risk and data are 
not sensitive in nature, no personal identifiers were included in the electronic database. 
All data that was collected was strictly used for the purpose of this study and nothing 
more. The original dataset is being kept by the principal investigator and will be 
destroyed after 5 years. 
3.21 Compensation 
No payments was made to survey respondents. 
3.22 Proposal and Funding Information 
This project was self-funded by the researcher. 
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CHAPTER FOUR  
 RESULTS 
4.1 Background Characteristics 
A total of 359 nursing mothers participated in this study. Of this, 191 nursing mothers 
representing 53.2% of nursing mothers practiced exclusive breastfeeding for the first 6 
months after birth. 
The nursing mothers were aged between 22 and 46 with the average age being 32 years. 
Most of the mothers 267 (74.4%) had a tertiary educational level degree. 
Two hundred and eighty one (79.2%) of the nursing mothers were married and only 5 
(1.4%) were divorced. One hundred and twenty seven women (35.4%) had one child 
and 41 (11.4%) mothers had 4 or more children. One hundred and seventy three (48.1%) 
of these mothers earned between 1,000 to 1,999 Cedis monthly with only 25 (7%) of 
them earning 3000 Cedis or more. Seventy four nursing mothers interviewed 
representing 23% worked in the educational sector, 26 (8.1%) in the health sector, 27 
(8.4%) in administrative and managerial positions, 52 (16.2%) in the financial sector 
and 53 (16.5) in lower level administrative sectors. 
The average time spent to work per nursing mother was 61.4 minutes and the average 
age of the babies of the nursing mothers studied was 5.5 months. Also for mothers with 
multiple children, the average age of their previous child was 3 years and duration of 
EBF practice for the previous children was 5.1 months. 
 
Sociodemographic characteristics and breastfeeding  
There were significant differences in the practice of EBF across age with the highest 
level being 74 (63.3%) out of the 117 mothers aged 20-29 years and the least being 18 
(40.0%) out of the 45 mothers aged 40-49 years (Table 1). 
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Table 1: Sociodemographic characteristics and breastfeeding 
 N (%) of Exclusive breastfeeding (% within N) 
mothers Do not practice Practice P-value 
Age    0.012 
20-29 117 (32.6) 43 (36.8) 74 (63.3) 
30-39 186 (51.8) 94 (50.5) 92 (49.5) 
40-49 45 (12.5) 27 (60.0) 18 (40.0) 
Education    <0.001 
Basic 21 (5.8) 8 (38.1) 13 (61.9) 
SHS/O&A level 65 (18.1) 14 (21.5) 51 (78.5) 
Tertiary 267 (74.4) 140 (52.4) 127 (47.6) 
Marital status    0.002 
Single 44 (12.4) 12 (27.3) 32 (72.7) 
Married 281 (79.2) 133 (47.3) 148 (52.7) 
Widowed 14 (3.9) 11 (78.6) 3 (21.4) 
Divorced 5 (1.4) 2 (40.0) 3 (60.0) 
Separated 11 (3.1) 8 (72.7) 3 (27.3) 
No of living children    <0.001 
1 127 (35.4) 44 (34.7) 83 (65.4) 
2 125 (34.8) 65 (52.0) 60 (48.0) 
3 57 (15.9) 36 (63.2) 21 (36.8) 
4+ 41 (11.4) 23 (56.1) 18 (43.9) 
Monthly income    <0.001 
<1,000 84 (23.4) 20 (23.8) 64 (76.2) 
1,000 – 1,999 173 (48.1) 81 (46.8) 92 (53.2) 
2,000 – 2,999 63 (17.6) 44 (69.8) 19 (30.2) 
3,000+ 25 (7.0) 19 (76.0) 6 (24.0) 
Total 359 (100.0) 168 (46.8) 191 (53.2)  
 Mean (SD)    
Average time to work 
(mins) 61.4 (31.9) 63.5 (31.7) 59.6 (32.0) 0.252 
Age of baby (months) 5.5 (4.3) 7.6 (4.1) 3.6 (3.4) <0.001 
Age of previous child 
(years) 3.0 (1.3) 3.1 (1.5) 2.8 (0.8) 0.094 
Duration of  EBF for 
previous child (months) 5.1 (1.1) 5.2 (1.1) 4.9 (1.1) 0.040 
 
 
 
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Practice of EBF was significantly lowest among the women with tertiary education, 
followed by those with basic education and highest among the women whose highest 
education was SHS/O&A level as shown in Table 1. There was a significant association 
marital status and educational level were significantly associated practice of EBF. Of 
the 44 (12%) who were single 32 (72.7%) of were practicing EBF. Also amongst the 
281 who  
 
Mothers with only one child practiced EBF the most followed by mothers with 2 
children, although those with four or more children did so more than those with three 
with the differences being highly significant (p<0.001). The 84 women who earned less 
than 1,000 Cedis practiced EBF the most with 64 (76.2%) of them doing so compared 
with their counterparts who earned much higher. 
 
There were no significant differences in terms of average commuting time to work 
between women who practiced EBF (61.4 ± 31.9 minutes) and those who didn’t (63.5 
± 31.7 minutes). There were significant differences with regards to the average age of 
the babies of mothers who practised EBF and those who did not, with those doing so 
having much lower ages. The average age of the previous child for mothers who 
practiced EBF (3.1 ± 1.5 years) was also not too different from those who did not (2.8 
± 0.8 years). 
Mothers who practiced EBF for the current child surprisingly had done same for a 
shorter period for their previous child compared to the mothers who did not practice 
EBF for the current baby but this difference was not too strong (p=0.040). 
 
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4.2 Mode of feeding 
Most of the women practiced exclusive breastfeeding with 191 (53.2%) of them doing 
so followed by baby formula only, infant formula only and other household foods only 
as seen in Figure 3. 
60.0
53.2
50.0
40.0
(%) 30.0
20.0
10.0
10.0 6.4
3.1
0.0
Exclusive Infant formula only Baby food only Household food
breastfeeding only
Mode of feeding
 
Figure 3 Mode of feeding 
  
4.3 Knowledge and Perception of Exclusive Breastfeeding 
Two hundred and forty four mothers (68%) said they had knowledge of the 
recommended number of months for EBF whilst 227 (93.0%) out of those who said this  
had accurate or correct knowledge of EBF. The majority of nursing mothers 287 (80%) 
mentioned health personnel as their source of knowledge on EBF with the 31 mothers 
(8.6%) receiving such information from friends as seen in out of 33 (9.2%) of mothers 
who received information from partners, 20(60.6%) were practicing EBF (Table 2).  
 
Eighty three mothers (90.2%) stated pain, discomfort and annoyance as the top most 
reason why they did not like breastfeeding. Other reasons stated where the fact that 
their babies could not suck well, 2 (2.2%) and that it was time consuming, 4 (4.4%). 
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Out of the 183 mother mothers who said they liked breastfeeding, 54 (29.5%) mothers 
stated they liked exclusive breastfeeding because it promoted healthy growth and 
development of the child. Other reasons for liking EBF were cost effectiveness for 16 
(11.7%) mothers, disease prevention for 13 (9.5%) mothers, source of nourishment for 
11 (8.1%) mothers, and baby-mother bonding for 11 (8.1%) mothers. 
 
Table 2: Knowledge and Perception about Exclusive Breastfeeding 
 N (%) of Exclusive breastfeeding (% within N) 
mothers Do not practice Practice P-value 
Self-reported     
knowledge of     <0.001 
recommended EBF    
months    
No knowledge 111 (30.9) 32 (28.8) 79 (71.2) 
Have knowledge 244 (68.0) 135 (55.3) 109 (44.7) 
Correct knowledge of     
recommended EBF    0.540 
months    
Incorrect 17 (7.0) 10 (62.5) 6 (37.5) 
Correct 227 (93.0) 124 (54.6) 103 (45.4) 
Source of Knowledge     
of Breastfeeding*    0.026 
Health Personnel 287 (80.0) 145 (50.5) 142 (49.5) 
Partner 33 (9.2) 13 (39.4) 20 (60.6) 
Family 105 (29.3) 53 (50.5) 52 (49.5) 
Friends 31 (8.6) 25 (80.7) 6 (19.4) 
Media 83 (23.1) 50 (60.2) 33 (39.8) 
School 37 (10.3) 23 (62.2) 14 (37.8) 
Total 359 (100.0) 168 (46.8) 191 (53.2)  
      * Multiple responses allowed 
 
Women who claimed they did not have knowledge of recommended months for EBF 
rather practiced it more compared those who claimed to have such knowledge, however 
those who had correct knowledge of the duration for EBF practiced it more than those 
without but this was not statistically (Table 2).  
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There were significant differences in the practice of EBF by the source of information 
on the practice with the highest practice by mothers who received their breastfeeding 
information from their partners and the least by those who got theirs from friends as 
shown in Table 2. 
 
From Figure 4, the major reason which most women gave as to why a woman should 
exclusively breastfeed is the fact that it promotes healthy growth and development with 
167 (46.5%) of the child, cost nothing in monetary outlay, it boost the babies’ immune 
system and prevents diseases, bonds mother and baby and served as a family planning 
measure. 
 
50.0 46.5
40.0 37.3
30.0
(%)
20.0
10.0
4.2 3.1 1.7
0.0
Promotes For nutrition, Less expensive Bonds mother Family planning
growth and health & disease and child measure
development prevention
Reasons for exclusive breastfeeding
 
Figure 4: Reasons why a woman should Exclusively Breastfeed 
 
4.4 Breastfeeding in the course of Work 
Majority of them, 166 (94.3%) did not have a breastfeeding room present at their 
workplace, with the average age of their babies on resumption of work being 5.3 
months. The average time spent at work whilst the child was less than 6 months was 
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5.9 hours. Nearly 51% (179) of the mothers had not resumed work out of whom 138 
(77.1%) were practicing EBF. Of the 176 mothers who had resumed work, 50 (28.4%) 
were practicing EBF. Only 9 (5.1%) of the mothers worked for companies that had a 
breastfeeding room. For these 9 mothers, 5 of them had someone to relieve them of 
their tasks when breastfeeding at work (Table 3). 
The average age of the babies on resumption of work was 5.3 months. The average 
work hours per day when child was less than 6months was 5.9 hours and was   not 
significantly different from those who practiced and for those who did not. 
Breastfeeding breaks on the average was 24minutes and average duration of such 
breaks was also not significantly different among the two groups as seen from Table 3. 
Table 3: Breastfeeding and Work 
 N (%) of Exclusive breastfeeding (% within N) 
mothers Do not practice Practice P-value 
Have you resumed work    <0.001 
Not resumed 179 (50.9) 41 (22.9) 138 (77.1) 
Resumed work 176 (49.1) 126 (71.6) 50 (28.4) 
Breastfeeding room at     
work    1.000 
No breastfeeding room 166 (94.3) 119 (71.7) 47 (28.3) 
Breastfeeding room 9 (5.1) 7 (77.8) 2 (22.2) 
Total 359 (100.0) 168 (46.8) 191 (53.2)  
 Mean (SD)    
Age of baby on resumption 
of work (months) 5.3 (1.6) 5.3 (1.6) 5.3 (1.6) 0.941 
Work hours per day when 
child < 6months 5.9 (1.0) 6.0 (0.9) 5.8 (1.2) 0.229 
Number of Breastfeeding 
Breaks 1.9 (0.7) 1.9 (0.7) 1.8 (0.7) 0.526 
Average duration of each 
break (mins) 24.0 (7.4) 24.4 (7.7) 24.7 (6.6) 0.847 
For women who had resumed work, 111 (30.9%) had a family member taking care of 
their child when they went to work while 31 (8.6%) of them had a non-family caretaker 
doing so. Ninety eight (27.3%) of them said their baby depended solely on infant milk 
whilst they went to work while 17 (4.7%) said they neither breastfed nor pumped milk 
for their child during working hours. Eighty (22.3%) of these working mother indicated 
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difficulties with equipment for expressing milk and its storage for their children while 
at work and only 7 (2.0%) had experienced negative comments from their colleagues 
and superiors regarding breastfeeding while at work.  
Six of the women stated that work prevented exclusive breastfeeding, while four stated 
that EBF slowed down productivity at their workplace. 
 
Effect of work on breastfeeding choice in first 6 months 
There were no significant differences (p=0.543) in the practice of EBF depending on 
who took care of the babies while their mothers were at work as seen from Table 4. 
EBF practice across lactation and other feeding circumstances of the children did not 
also vary significantly. The mothers’ work experiences whilst breastfeeding/expressing 
milk also did not significantly affect the practice of EBF as seen from Table 4. 
 
 
 
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Table 4: Experiences with Breastfeeding at Work 
 N (%) of Exclusive breastfeeding (% within N) 
mothers Do not practice Practice P-value 
Who takes care of baby whilst at work*    0.543 
Family member 111 (30.9) 81 (73.0) 30 (27.0) 
Baby stays with me at the work place 38 (10.6) 30 (79.0) 8 (21.1) 
Non-family caretaker 31 (8.6) 28 (90.3) 3 (9.7) 
Crèche 48 (13.4) 34 (70.8) 14 (29.2) 
Which circumstances describe your situation*    0.132 
Pump breastmilk during work and save for breastfeeding 45 (12.5) 29 (64.4) 16 (35.6) 
I go to breastfeed during working hours 18 (5.0) 12 (66.7) 6 (33.3) 
Baby is brought to work place 45 (12.5) 32 (71.1) 13 (28.9) 
Neither breastfeeds nor pumps during working hours 17 (4.7) 13 (76.5) 4 (23.5) 
Baby depends solely on infant milk whilst at work 98 (27.3) 79 (80.6) 19 (19.4) 
Work experiences whilst breastfeeding/expressing*    0.470 
Colleagues and superiors make negative comments 7 (2.0) 7 (100.0) 0 (0.0) 
Difficult to arrange time and place 34 (9.5) 22 (64.7) 12 (35.3) 
Difficulty with equipment and storage 80 (22.3) 60 (75.0) 20 (25.0) 
Worried about keeping job 59 (16.4) 44 (74.6) 15 (25.4) 
Worried about continuing to breastfeed because of job 39 (10.9) 33 (84.6) 6 (15.4) 
Felt embarrassed among co-workers or superiors 23 (6.4) 20 (87.0) 3 (13.0) 
Total 359 (100.0) 168 (46.8) 191 (53.2)  
* Multiple responses allowed 
 
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4.5 Organizational Support for Breastfeeding 
One hundred and fifty six (43.5%) of mothers said they had an organizational policy on 
breastfeeding whilst 76 (21.2%) said they did not know if their workplace had such a 
policy. Most of the mothers, 238 (66.3%) stated that their workplace offered work 
schedule flexibility with 202 (56.3%) claiming their organizations allowed scheduled 
breaks for nursing babies. 
One hundred and eighty seven (52.1%) worked with institutions that allowed bringing 
breastfed infants to work while 143 (39.8%) of mothers said their organization was 
supportive for EBF and 93 (25.9%) claiming their organization was not supportive for 
this. 
EBF was significantly highest among women who worked for companies with a policy 
on breastfeeding and lowest among those who worked for companies without such a 
policy as seen from Table 5 although the details of such policies were not obtained for 
analysis. It was also significantly higher among women whose work schedules were 
flexible. Surprisingly, EBF was much lower for mothers who worked for organizations 
that had scheduled breaks for nursing and significantly higher where women were not 
allowed to bring their breastfed infants to work as seen from Table 5. 
Ironically mothers who described their workplace as not supportive for EBF practiced it 
the most compared to those who described their workplace as providing some level of 
support with significant differences in the level of EBF across the various levels of 
support as seen from the Table 5. 
 
 
 
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Table 5: Organizational Support for Breastfeeding 
 N (%) of Exclusive breastfeeding (% within N) 
mothers Do not practice Practice P-value 
Organizational policy on    <0.001 
breastfeeding    
No policy 124 (34.5) 75 (60.5) 49 (39.5) 
Policy exists 156 (43.5) 60 (38.5) 96 (61.5) 
Don’t know 76 (21.2)  31 (40.8) 45 (59.2) 
Organizational work    <0.001 
schedule    
Not flexible 94 (26.2) 64 (68.1) 30 (31.9) 
Flexible 238 (66.3)  89 (37.4) 149 (62.6) 
Organizational scheduled    <0.001 
breaks for nursing    
No breaks 153 (42.6) 47 (30.7) 106 (69.3) 
Breaks exist 202 (56.3) 119 (58.9) 83 (41.1) 
Workers bringing    <0.001 
breastfeeding infants to    
work    
Not allowed 167 (46.5) 56 (33.5) 111 (66.5) 
Allowed 187 (52.1) 108 (57.8) 79 (42.3) 
Organizational support  for    <0.001 
breastfeeding    
Not at all 93 (25.9) 22 (23.7) 71 (76.3) 
Somewhat 64 (17.8) 30 (46.9) 34 (53.1) 
Supportive 143 (39.8) 89 (62.2) 54 (37.8) 
Very supportive 53 (14.8) 24 (45.3) 29 (54.7) 
Total 359 (100.0) 168 (46.8) 191 (53.2)  
 
Out of the 238 mothers who claimed their work schedule was flexible, 137 (57.6%) of 
them had a lactation policy at their workplace compared to only 12 (12.8%) of the 94 
women whose work schedule was not flexible and this difference was highly significant 
(p<0.001). There were significant differences in the existence of a lactation policy across 
the various levels of organizational support for breastfeeding (p<0.01). Nearly 40% of the 
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143(39.8%) claimed their organizations were supportive.  Among these 143 mothers, 47 
(32.9%) stated the existence of such a policy, as seen from Table 6. 
 
Table 6: Organizational support and lactation policy 
 N (%) of Lactation policy at work (% within N) 
mothers No policy/ Policy Don’t know exists P-value 
Organizational work    <0.001 
schedule    
Not flexible 94 (26.2) 82 (87.2) 12 (12.8) 
Flexible 238 (66.3)  101 (42.4) 137 (57.6) 
Organizational support  for    0.003 
breastfeeding    
Not at all 93 (25.9) 46 (49.5) 47 (50.5) 
Somewhat 64 (17.8) 27 (42.2) 37 (57.8) 
Supportive 143 (39.8) 96 (67.1) 47 (32.9) 
Very supportive 53 (1.67) 28 (52.8) 25 (47.2) 
Total 359 (100.0) 197 (55.8) 156 (44.2)  
 
 
4.6 Predictors of Exclusive Breastfeeding among formal sector working mothers  
The socio-economic variables Age, Education, Marital status and Income as well as 
organizational variables on policy, work schedule and support were individually strongly 
associated with the practice of EBF, however after adjusting for each them to remove the 
effect of potential confounders only monthly income, organizational work flexibility and 
organizational support for breastfeeding remained significantly associated with the 
practice of EBF. 
An increase in age resulted in reduced odds of practicing EBF but after adjusting for the 
other factors, the 30-39 year olds had about 1.25 times the odds and the 40-49 year olds 
having a lower odds of EBF compared to the 20-29 year olds as shown in Table 7. Higher 
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education beyond the SHS/O&A level also led to a reduced odds of the practice but after 
adjustment, those with SHS/O&A and tertiary education had about twice the odds of 
practicing EBF compared to those with basic education. 
Compared to single women, all the other women had a reduced odds of practicing EBF 
as well but after adjusting, only the divorced women had a higher odds of about 1.34. 
Women whose organizations did “not at all” have organisational support for breast 
feeding had three times higher odds of EBF as compared women who worked in 
“supportive” work places.  Women who claimed their work schedule was flexible also 
had a higher odds of practicing EBF compared to the women without such flexibility at 
work. Support for breastfeeding also led to a reduced odds of practicing EBF surprisingly. 
 
 
  
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Table 7: Logistic Regression of EBF on Sociodemographic and Organizational 
factors 
 Unadjusted  Adjusted 
 OR (95% CI) P-value  OR (95% CI) P-value 
Age (years)  0.011   0.605 
20 – 29 Ref Ref 
30 – 39 0.57 (0.35, 0.91) 1.25 (0.62, 2.52) 
40 – 49 0.39 (0.19, 0.78) 0.85 (0.30, 2.41) 
Education  <0.001   0.518 
Basic Ref Ref  
SHS/O&A level 2.24 (0.78, 6.48) 2.29 (0.53, 9.90) 
Tertiary 0.56 (0.22, 1.39) 2.10 (0.48, 9.18) 
Marital status  0.003   0.329 
Single Ref Ref 
Married 0.47 (0.21, 0.84) 0.62 (0.23, 1.66) 
Widowed 0.10 (0.02, 0.43) 1* 
Divorced 0.56 (0.08, 3.79) 1.34 (0.08, 21.62) 
Separated 0.14 (0.03, 0.62)  0.18 (0.03, 1.21) 
Monthly income  <0.001   0.022 
<1,000 Ref Ref 
1,000 – 1,999 0.35 (0.20, 0.64) 0.32 (0.10, 0.99) 
2,000 – 2,999 0.13 (0.06, 0.28) 0.19 (0.05, 0.70) 
3,000+ 0.10 (0.03, 0.28) 0.08 (0.01, 0.44) 
Organizational policy      
on breastfeeding     
No policy Ref 0.001 Ref 0.454 
Policy exists 2.45 (1.51, 3.97) 1.39 (0.68, 2.85) 
Don’t know 2.22 (1.24, 3.98) 1.67 (0.72, 3.86) 
Organizational work      
schedule  <0.001  0.005 
Not flexible Ref Ref 
Flexible 3.57 (2.15, 5.93) 2.81 (1.37, 5.76) 
Organizational      
support for     
breastfeeding  <0.001  0.044 
Supportive Ref Ref 
Not at all 5.32 (2.96, 9.55) 3.2 (1.50, 6.67) 
Somewhat 1.87 (1.03, 3.39) 1.68 (0.78, 3.59) 
Very supportive 1.99 (1.05, 3.77) 1.49 (0.67, 3.33) 
*All mothers in category did not practice EBF for the adjusted model 
 
 
 
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Perceived benefits of Workplace lactation room 
Some of the perceived benefits of   a workplace lactation room stated by mothers was that 
it enhanced productivity, prevent infections in children, and promoted EBF. One of the 
mothers stated that “I know that having a place at my workplace to breastfeed my child 
will give me piece of mind to work well and be productive”. 
Another respondent stated that  “ the presence of a place to breastfeed my child at work 
will encourage me to breastfeed up to six months before introducing any food”. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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CHAPTER FIVE 
DISCUSSION 
The aim of this study was to examine the Exclusive breastfeeding practices of women in 
the formal sector and its implication on the workplace breastfeeding room policy.  
 
In this study, 53.2% of the mothers in the study practiced Exclusive Breastfeeding and 
this is consistent with the national exclusive breastfeeding rate of 52% in Ghana. 
Similarly, Tewabe et al., (2017) reported a prevalence of 50.1% among  formal sector 
workers who were health extension officers.  The comparability of the results may be in 
design and characteristics of study participants as these studies included formal sector 
workers. However this finding is in contrast with what was reported in other studies in 
Ethiopia that found higher prevalence of 68.9% (Asfaw et al., 2015) and  74.0% (Gizaw 
et al., 2017). Other studies in the USA have reported lower prevalence of EBF of 16.8%  
 
In this study, monthly income, organizational work flexibility and organizational support 
for breastfeeding were significantly associated with the practice of EBF. 
An increase in age resulted in reduced odds of practicing EBF but after adjusting for the 
other factors, the 30-39 year olds had about a 25% higher odds and the 40-49 year olds 
having about 15% lower odds of EBF compared to the 20-29 year olds. These may be 
perhaps the result of mothers aged 40-49 having previous children thereby decreasing 
their likelihood of practicing EBF. Formal sector working mothers may have climbed the 
career ladder and may have more responsibilities at the work side and thus decrease their 
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odds of EBF.  These findings are in consistent with what was reported by Gizaw, Woldu, 
& Bitew, (2017)  who reported that that exclusive breastfeeding was significantly higher 
among  mothers aged above 35 years. However this findings overlap the findings of  
Asfaw et al., (2015) which found significantly  higher odds EBF practice among mothers 
aged 25 to 35 years as compared to mothers whose ages were less than 25 years. 
 
Higher education beyond the SHS/O&A level also led to a reduced odds of the practice 
but after adjustment, those with SHS/O&A level and tertiary education had about twice 
the odds of practicing EBF compared to those with basic education. This finding agrees 
with some studies who found positive significant association between maternal 
educational status and exclusive breastfeeding. They reported increased odds of EBF 
among mothers with higher education (Dashti et al., 2010; Dorgham & Hafez, 2018). 
However, some others found that mothers with lower educational status have had 
significantly higher odds of EBF (Amin, 2014; Batal et al., 2006; Radwan, 2013).  Some 
other studies assessed association between educational status of the mothers and EBF but 
found no association (Adugna et al., 2017; Al-Kohji, Said,& Selim, 2012; Gizaw et al., 
2017; Shifraw, Worku, & Berhane, 2015; Tewabe et al., 2017). The educational status of 
formal sector working mothers was generally high and perhaps these highly educated 
mothers were in a better position to comprehend the benefits of breast feeding and accept 
the practice than the less educated mothers.  
 
 
With high monthly income the numbers of mothers practicing EBF also decrease. The 
lower the monthly income the more likely the mother was to practice EBF. This finding 
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is consistent with what was reported in other studies that mothers with lower monthly 
income were more likely to exclusively breastfeed than their counterparts who earned 
more (Shifraw et al., 2015;Tewabe et al., 2017). This is probably because those women 
with lower income cannot afford breastmilk substitutes or infant formula and are left with 
no choice than breastfeed their babies to save cost.  
 
Compared to single women, all the other women had a reduced odds of practicing EBF 
as well but after adjusting, only the divorced women had a higher odds of about 34%. 
This increase in odds may be as a result of divorced women being more attached to their 
babies. This finding is in sharp contrast to what  Adugna, Tadele, Reta, & Berhan, (2017)  
found in a study while assessing prevalence and determinants of EBF practice. They 
reported that married mothers practiced EBF more likely than single mothers.  
 
 
Women who reported their work schedule was flexible also had a higher odds of 
practicing EBF compared to the women without such flexibility at work. Support for 
breastfeeding also led to a reduced odds of practicing EBF surprisingly. Some work places 
already have this flexibility for such mothers to be able to breastfeed. This finding may 
create need for some more work places to allow such flexibility to be created for lactating 
mothers to be able to enhance breastfeeding. 
 
Knowledge of exclusive breastfeeding is high amongst women in the formal sector with 
68% reporting the accurate number of months recommended for EBF, but 93% of them 
accurately gave 6 months as the recommended number of months a mother should 
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exclusively breastfeed her baby.  This finding is higher than a study done in Nigeria which 
showed a 60% knowledge of the duration of EBF  and 30 had accurate knowledge of the 
recommended duration with 31% of them practicing Exclusive breastfeeding (Oche, 
Umar, & Ahmed, 2011).  
 A study also done by Tadele  et al  in Ethiopia found that 93.6% of mothers had 
knowledge of EBF (Tadele et al., 2016). Even though in this current study the knowledge 
was high (93%) only 45.4% of women who had this correct knowledge of EBF actually 
practiced it.  This did not tally with a study done by Tadele et al in Ethiopia which found 
that 89.5% practiced EBF. 
Pain, discomfort, annoyance and time consuming were the major reasons why mothers 
did not like EBF. 
 
EBF was significantly highest among mothers who worked for companies with a policy 
on breastfeeding and lowest among those who worked for companies without such a 
policy although the details of such policies were not obtained for analysis. It was also 
significantly higher among women whose work schedules were flexible. Surprisingly, it 
was much lower for women who worked for organizations that had scheduled breaks for 
nursing and significantly higher where women were not allowed to bring their breastfed 
infants to work. Ironically mothers who described their workplace as not-at-all supportive 
for EBF practiced it the most compared to those who described their workplace as 
providing some level of support with significant differences in the level of EBF across 
the various levels of support. The supportiveness of the work environment does not appear 
to have an influence on EBF when the mother is very willing.  
  
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CHAPTER SIX 
CONCLUSIONS AND RECOMMENDATIONS 
This study sought to examine exclusive breastfeeding practices among women in the 
formal sector and its implications for the lactation room policy. The study found that high 
socioeconomic status such as high income and high educational status negatively impacts 
a nursing mother in the formal sectors decision to practice exclusive breastfeeding.  Those 
with low income are more likely to practice EBF probably due to its cost effectiveness. 
 
Although knowledge of EBF is high amongst mothers in the formal sector only half of 
them actually practice it. Exclusive Breastfeeding rates are high when the source of 
knowledge of exclusive breastfeeding is from the partner thus involving males in 
breastfeeding offer support for mothers. 
 
Exclusive breastfeeding rates drops drastically when a mother resumes work at an average 
age of baby being 5.3 months which extends their stay at home beyond the stipulated 12 
weeks or 3 month leave period, thus indicating that the maternity leave is short. Hence 
making a policy of 6 months maternity leave will encourage women not to take days off 
unofficially in addition to their annual and maternity leave. Half of the mothers who 
resumed work fed babies solely on infant formula thus affecting the effectiveness of the 
exclusive breastfeeding policy of 6 months. 
 
Also women who have a workplace support are likely to practice Exclusive breastfeeding 
as women who do not. This is because women with time have adapted ways of exclusively 
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breastfeeding their children. Even so more should be done in terms of organizational 
support for breastfeeding women.  
 
RECOMMENDATIONS 
 The Government of Ghana under the Ministry of Health, Ministry of Employment 
and Labour Relations, Ministry of Gender, Children and Social protection should 
come out with a National Breastfeeding Policy as well as a National Workplace 
Breastfeeding policy  
 
 Further studies on male involvement in breast feeding support as well a partner 
education to strengthen community action on exclusive breastfeeding should be 
explored. 
 
 Ministry of Health, Ministry of Gender and Ministry of Employment and Labour 
relations should extend the maternity leave period to 6 months to enable working 
mothers fully practice exclusive breastfeeding. 
 
 
 
 
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Negishi, H., Kishida, T., Yamada, H., Hirayama, E., Mikuni, M., & Fujimoto, S. (1999). 
Changes in uterine size after vaginal delivery and cesarean section determined by 
vaginal sonography in the puerperium. Archives of Gynaecology & Obstetrics, 263, 13–
16. https://doi.org/10.1007/s004040050253 
Nkrumah, J. (2017). Maternal work and exclusive breastfeeding practice: A community 
based cross-sectional study in Efutu Municipal, Ghana. International Breastfeeding 
Journal, 12(1), 1–9. https://doi.org/10.1186/s13006-017-0100-6 
Oche, M. O., Umar, A. S., & Ahmed, H. (2011). Knowledge and practice of exclusive 
breastfeeding in Kware, Nigeria. African Health Sciences, 11(3), 518–523. 
https://doi.org/10.4314/tjmr.v15i2. 
Ogwezzy-ndisika, A. O. (2016). Application of the Health Belief Model to the Practice of 
Exclusive Breastfeeding Application of the Health Belief Model to the Practice of 
Exclusive Breastfeeding among Women in Lagos State , Nigeria, (March 2017). 
Ong, G., Yap, M., Li, F. L., & Choo, T. B. (2018). Impact of working status on breastfeeding 
in Singapore Evidence from the National Breastfeeding Survey 2001, 15(4), 424–430. 
https://doi.org/10.1093/eurpub/cki030 
Pinchbeck, I. (1930). Women Workers in the Industrial Revolution 1750-1850. 
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Radwan, H. (2013). Patterns and determinants of breastfeeding and complementary feeding 
practices of Emirati Mothers in the United Arab Emirates. 
Revolution, T. I., Clark, A., Hutchins, B. L., & George, D. (1991). Spring 1991 Recent 
Findings of Research in Economic &amp; Social History. Retrieved from 
http://www.ehs.org.uk/dotAsset/03e09441-1fde-4aac-812a-79f18507fcc4.pdf 
Saks, A. M. (2015). Antecedents and consequences of employee engagement, (June). 
https://doi.org/10.1108/02683940610690169 
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, 4–9. 
https://doi.org/10.1186/s13006-015-0047-4 
Sokol, E., Aquago, V., & Clark, D. (2007). Breastfeeding in West and Central Africa; 25 
years of implementing the International Code of Marketing Breastmilk Substitutes. 
UNICEF Regional Office for West and Central Africa, June 18, 2009. Retrieved from 
http://www.unicef.org/wcaro/WCAR_Protecting_Breasfeeding_Code_of_Marketing_
En.pdf 
Stevens, E. E., Patrick, T. E., & Pickler, R. (2009). A History of Infant Feeding. Journal of 
Perinatal Education, 18(2), 32–39. https://doi.org/10.1624/105812409X426314 
Tadele, N., Habta, F., Akmel, D., & Deges, E. (2016). Knowledge, attitude and practice 
towards exclusive breastfeeding among lactating mothers in Mizan Aman town, 
Southwestern Ethiopia: descriptive cross-sectional study. International Breastfeeding 
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breastfeeding practice and associated factors among mothers in Motta town , East 
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Gojjam zone , Amhara Regional State , Ethiopia , 2015 : a cross-sectional study, 1–7. 
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percent. Retrieved from https://www.unicef.org/ghana/media_10519.html 
UNICEF, W. (2017). Tracking Progress for Breastfeeding Policies and Programmes, 7. 
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Wolf, J. H. (2001). Don’t kill your Baby. 
 
 
 
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APPENDIX 
CONSENT FORM 
RESPONDENT INFORMATION SHEET 
General information  
I, Dr. Joan Ese Morny, a student of Health Policy Planning and Management in the School of Public Health, 
University of Ghana, Legon pursuing a Master of Public Health Degree Programme. I am here with my 
research assistants to carry out a survey on mothers attending your postnatal clinic on the Topic: Exclusive 
Breastfeeding Practices amongst women in the formal sector and its implication for the Breastfeeding Room 
Policy. This is purely for academic purposes and forms part of the requirement for the award of Master of 
Public Health Degree. I, the researcher has no conflict of interest in this study. 
Confidentiality 
No name will be recorded. Your name and identity are not needed in the study. However the information 
you are going to provide will be coded and will be treated strictly confidential. You are assured of total 
confidentiality to the information you will give. Apart from the researcher and supervisor of this research, 
no one else will have access to information provided whether in part or whole. Data collected will be stored 
under lock and key then destroyed after a minimum of three years as per research protocol.  
Right to refuse  
Participation in this study is voluntary. You are free to answer part or the entire questionnaire. You can 
choose to withdraw from the study or stop the interview at any time you want. You can also choose not to 
answer any question(s) you find uncomfortable about. Should you choose not to participate, it will not 
affect you or your clinic in any way. However you are encouraged to participate fully in this study to help 
in determining exclusive breastfeeding practices amongst women in the formal sector and its implication 
for the breastfeeding room policy in Ghana and beyond.  
 
If yes, please indicate any questions below 
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If you have any question(s) or further clarification concerning this study and/or the conduct of the researcher 
and research assistants, please do not hesitate to contact the following; Dr. Joan Ese Morny, School of 
Public Health, University of Ghana, Legon esemorny@live.com/esemorny@gmail.com Tel:0206739260; 
Dr. Patricia Akweongo, School of Public Health, University of Ghana, Legon, akweongo@gmail.com Tel: 
0243138376 and; Mrs. Hannah Frimpong (Administrator), Ghana Health Service Ethical Review 
Committee Secretariat, Accra. Tel: 0507041223/0243235225. 
 
INFORMED CONSENT 
I have read the information given above, and I understand. I have been given a chance to ask questions 
concerning this study and questions have been answered to my satisfaction. I now voluntarily agree to 
participate in this study knowing that I have the right to withdraw at any time without it affecting my current 
or future use of health care services. 
 
Signature/Thumb print: …………………………………………… Date: ……………………….. 
 
I, the undersigned, have explained this consent to the respondent in English and that she/he understands 
the purpose of the study, procedures to be followed as well as the risks and benefits of the study. The 
participant has fully agreed to participate in the study. 
 
Signature of interviewer:……………………………………….… Date: ………………………… 
 
 
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QUESTIONNAIRE 
SECTION A: DEMOGRAPHIC CHARACTERISTICS 
 
1. Age (years):   
 
2. Educational Level: 
[0] None  [2] JHS/Middle School  [4] Undergraduate 
 
[1] Primary  [3] SHS/O’ & A’ Level  [5] Graduate 
 
[6]Postgraduate  
Other:             
 
3. Marital Status 
[1] Single  [3] Widowed  [5] Separated 
[2] Married [4] Divorced  [6] Co-habiting 
 
4. Number of living children:   
 
5. Level of  monthly income in Ghana Cedis  
[1] Less than 1,000  [3] 2,000 – 2,999 [5] 4,000 – 4,999 
[2] 1,000 – 1,999  [4] 3,000 – 3,999 [6] 5,000+ 
 
6. Where do you work?           
 
7. What is your job title/position?        
  
 
8. Average time it takes you to move from work to home:  hours,  
 minutes 
 
9. How old is your baby?  years,   months,  weeks,  days 
 
10. How old is your youngest child before this baby?   years,   months   
 
11. How long did you exclusively breastfeed the child before this baby?     months, 
 weeks,         days 
 
12. What do you currently feed your baby with ? (Tick all applicable) *** 
[1] Breast milk  [1] Infant formula [1] Baby food  ****** 
 
Other:            
 
 
 
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SECTION B: KNOWLEDGE AND PERCEPTION ON EXCLUSIVE BREASTFEEDING 
 
13. Do you have an idea about the recommended number of months to exclusively breastfeed 
a baby? 
 
[0] No  [1] Yes, how many months?   
 
 
 
14. Where did you obtain knowledge about breast feeding from? (Tick all applicable) 
[1] Health personnel [1] Family 
[1] Partner  [1] Friends [1] Media [1] School 
 
Other:            
 
15. In your opinion, which statement best describes the preference of the following people 
about feeding your baby within the first 6 months? 
 No Exclusive Formula Mixed Don’t 
preference breastfeeding Feeding Feeding know 
[0] [1] [2] [3] [4] 
Family      
Partner      
Friends      
Health personnel      
 
16. Why do you think a mother should exclusively breastfeed her child?   
            
            
  
 
17. What was your impression about the concept of breastfeeding in your first few 
days/weeks/months of doing so? 
[1] Disliked very much [2] Disliked [3] Indifferent [4] Liked [5] Liked very 
much 
 
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18. Give reasons for your answer:        
            
            
SECTION C: BREASTFEEDING AND WORK 
 
19. Have you resumed work? [0] No (go to Section D) [1] Yes (continue) 
 
20. How old was your baby when you resumed work after maternity leave or how old would 
the baby be when you are expected to resume work? (If you are not sure, give your best 
time estimate) 
 
  years,   months,  weeks,  days 
 
21. Does your company have a breastfeeding room?   [0] No  [1] Yes 
22. If yes how does it operate              
23. How does it affect your work, do you have a reliever whilst breastfeeding. [0] No 
 [1] Yes 
24. What do you have in your workplace place breastfeeding room    
       
 
25. How many hours per day do/did you usually work at your job during the time when your 
child is/was less than 6 months?   hours 
 
26. Who takes care of your baby whilst at work? (Tick all applicable) 
[1] My baby is cared for by a family member  
[1] I keep my baby with me at the work place 
[1] My baby is cared for by a non-family caretaker 
[1] My baby is cared for by a crèche 
[1] I house a house help who takes care of my baby 
 
27. Which of the following circumstances describe your situation? (Tick all applicable) 
[1] I pump breastmilk during my work day and save it for breastfeeding during my work 
day 
[1] I pump breastmilk during my working day and save it for my baby to drink later 
[1] I go to my baby and breastfeed him during working hours 
[1] My baby is brought to me to breastfeed at my work place 
[1] I breastfeed my baby during break time 
[1] I neither pump breastmilk nor breastfeed during my working hours   
[1] My baby depends solely on infant milk whilst I am at work 
[1] My baby depends on infant milk whilst I am at work and I continue with breastfeeding 
after work  
 
28. Assuming you breastfeed or express breastmilk at work, have you had any of the following 
experiences during of workplace breastfeeding? (Tick all applicable) 
[1] A co-worker made negative comments or complained to me about breastfeeding or 
expressing breastmilk 
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[1] My employer or my supervisor made negative comments or complained to me about  
time spent on breastfeeding  or breastmilk expression. 
[1] It was hard for me to arrange break time for breastfeeding or pumping milk 
[1] It was hard for me to find a place to breastfeed or pump milk 
[1] It was hard for me to arrange a place to store pumped breast milk 
[1] It was hard for me to carry the equipment I needed to pump milk at work 
[1] I felt worried about keeping my job because of breastfeeding 
[1] I felt worried about continuing to breastfeed because of my job 
[1] I felt embarrassed among co-workers, my supervisor, or my employer because of 
breastfeeding 
 
29. How many breaks do you get within work hours for breastfeeding or breastmilk expression 
each work  day?   
 
30. What is the average duration of each break?  minutes 
 
31. Would you consider your workplace a breastfeeding friendly workplace? [0] No 
 [1] Yes 
 
32. How does/did your work affect the choice of the mode of feeding your baby within the first 
6 months?            
            
             
 
 
  
SECTION D: ORGANIZATIONAL/WORKPLACE FACTORS 
 
33. Does your organization have a policy outlining organizational support for breastfeeding 
employees? [0] No  [1] Yes [2] Don’t know 
 
34. Does your organization offer work schedule flexibility? [0] No  [1] Yes 
 
35. Does your organization allow nursing mothers to schedule breaks and work patterns to 
provide time to breastfeed their babies or to express or pump breastmilk during the 
workday?  
[0] No  [1] Yes 
 
36. Does your organization allow employees to routinely bring breastfeeding infants to work 
with them? [0] No  [1] Yes 
 
37. In your opinion, how supportive of breastfeeding is your place of employment? 
[0] Not at all [1] Somewhat  [2] Supportive [3] Very supportive 
 
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SECTION E: PERCEIVED BENEFITS OF WORKPLACE BREASTFEEDING ROOM 
 
How do you think the implementation of a breastfeeding room policy in your organization would 
affect your breastfeeding behaviour?         
             
              
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