exclusive breastfeeding practices among women in the

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

University of Ghana http://ugspace.ug.edu.gh

i

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


ii

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.


iii

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.


iv

DEDICATION

Dedicated to my dear mummy, Mrs Elizabeth Morny and to all hardworking women

trying to balance motherhood and career.


v

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.


vi

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


vii

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


viii

DISCUSSION .............................................................................................................. 45

CHAPTER SIX ............................................................................................................ 49

CONCLUSIONS AND RECOMMENDATIONS ...................................................... 49

REFERENCES ............................................................................................................ 51

APPENDIX .................................................................................................................. 57

CONSENT FORM ....................................................................................................... 57


ix

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


file:///C:/Users/JOAN%20MORNY/Desktop/JOAN%20DISSERTATION%20FOR%20GRADUATION.docx%23_Toc527653786

file:///C:/Users/JOAN%20MORNY/Desktop/JOAN%20DISSERTATION%20FOR%20GRADUATION.docx%23_Toc527653786

x

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


xi

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


xii

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


1

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


2

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


3

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


4

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


5

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


6

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?


7

1.7 Conceptual Framework

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

Socio-demographic

factors

Age Marital status Educational background Current profession Level of income Working sector Number of children

Organizational factors

Working hours per day Availability of lactation rooms Number of breaks for Milk expression Availability of lactation room policy

Behavioural factors

Knowledge of Exclusive Breastfeeding (EBF) Sources of knowledge Knowledge of benefits of EBF Perception about EBF

Exclusive Breastfeeding

Figure 1: Conceptual framework of behavioural and organizational factors

affecting on exclusive breastfeeding Practices in formal sector workplace


8

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.


9

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


10

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


11

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)


12

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).


13

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


14

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


15

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


16

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)


17

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).


18

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


https://www.ilo.org/global/standards/WCMS_186339/lang--en/index.htm

https://www.ilo.org/global/standards/WCMS_186339/lang--en/index.htm

19

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.


20

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.


21

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 &


22

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


23

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


24

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

Variable

Description Operational Definition Scale of

Measurement

Exclusive Breastfeeding

Feeding with only breastmilk and not food and water for up to 6 months of life

Binary Yes No

Independent

Variable

Description Operational Description Scale of

Measurement

Age in years 20-29 Years 30-35 Years 35-40 Years

Age Categories of Respondents

Categorical

Marital Status Single Widowed Divorced Married Separated

Marital Status of Respondents

Nominal

Educational Level Basic SHS/ O&A LEVEL Tertiary

Educational Levels of Respondents

Ordinal


25

Independent

Variable


Measurement

Number Of Children

1 2 3 4+

Total number of children the respondents have.

Categorical

Working Sector 1.Healthcare 2.Engineering 3.Banking and Finance 4.Business Consulting and Management

Working sector in which the respondents belong to.

Nominal

Average time to work

Less than 15 mins 15 to 30 mins 30 mins to 1 hr 1hr to 2 hrs More than 2 hrs

How many minutes it takes from respondent to move to and from work including hours spent in traffic

Categorical

Independent

Variable


Measurement

Current Mode of feeding child.

Exclusive breastfeeding Mixed feeding Formula feeding only

Mode of feeding babies by respondents who presented to the Child welfare clinic.

Categorical

Duration of Breastfeeding

Never 1 Month Or Less 2 Months 3 Months 4 Months 5 Months 6 Months

Duration for which respondent exclusively breastfed babies

Categorical

Workhours Per day

Hours Duration of time spent in workplace in hours from time work starts to close by mother.

Continuous

Independent

Variable


Measurement

Knowledge of EBF

Correct knowledge Incorrect Knowledge

Acurate knowledge of the definition of Exclusive breastfeeding.

Binary

Availability of Lactation Rooms at work

Yes No

Whether or not there is/are breastfeeding or lactation room(s) at respondents work place

Nominal

Number Of Breaks For Milk

None 1

The number of breaks the respondents have during

Categorical


26

Expression during working hours excluding lunch breaks

2 or more working hours for milk expression

Number of minutes per breastfeeding break

15 min or less 15- 30 mins 30 mins or more

The duration of breaks for milk expression during working hours that respondents have at their workplace.

Categorical

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


27

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.


28

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


29

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.


30

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).


31

Table 1: Sociodemographic characteristics and breastfeeding

N (%) of mothers

Exclusive breastfeeding (% within N) Do not

practice Practice P-value

Age

20-29 30-39 40-49

117 (32.6) 186 (51.8) 45 (12.5)

43 (36.8) 94 (50.5) 27 (60.0)

74 (63.3) 92 (49.5) 18 (40.0)

0.012

Education

Basic SHS/O&A level Tertiary

21 (5.8)

65 (18.1) 267 (74.4)

8 (38.1)

14 (21.5) 140 (52.4)

13 (61.9) 51 (78.5)

127 (47.6)

<0.001

Marital status

Single Married Widowed Divorced Separated

44 (12.4)

281 (79.2) 14 (3.9) 5 (1.4)

11 (3.1)

12 (27.3)

133 (47.3) 11 (78.6) 2 (40.0) 8 (72.7)

32 (72.7)

148 (52.7) 3 (21.4) 3 (60.0) 3 (27.3)

0.002

No of living children

1 2 3 4+

127 (35.4) 125 (34.8) 57 (15.9) 41 (11.4)

44 (34.7) 65 (52.0) 36 (63.2) 23 (56.1)

83 (65.4) 60 (48.0) 21 (36.8) 18 (43.9)

<0.001

Monthly income

<1,000 1,000 – 1,999 2,000 – 2,999 3,000+

84 (23.4)

173 (48.1) 63 (17.6) 25 (7.0)

20 (23.8) 81 (46.8) 44 (69.8) 19 (76.0)

64 (76.2) 92 (53.2) 19 (30.2) 6 (24.0)

<0.001

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


32

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).


33

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.

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%).

53.2

6.410.0

3.1

0.0

10.0

20.0

30.0

40.0

50.0

60.0

Exclusivebreastfeeding

Infant formula only Baby food only Household foodonly

(%)

Mode of feeding


34

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 mothers



Self-reported

knowledge of

recommended EBF

months

No knowledge Have knowledge

111 (30.9) 244 (68.0)

32 (28.8) 135 (55.3)

79 (71.2) 109 (44.7)

<0.001

Correct knowledge of

recommended EBF

months

Incorrect Correct

17 (7.0) 227 (93.0)

10 (62.5) 124 (54.6)

6 (37.5) 103 (45.4)

0.540

Source of Knowledge

of Breastfeeding*

Health Personnel Partner Family Friends Media School

287 (80.0) 33 (9.2)

105 (29.3) 31 (8.6)

83 (23.1) 37 (10.3)

145 (50.5) 13 (39.4) 53 (50.5) 25 (80.7) 50 (60.2) 23 (62.2)

142 (49.5) 20 (60.6) 52 (49.5) 6 (19.4)

33 (39.8) 14 (37.8)

0.026

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).


35

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.

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

46.5

37.3

4.2 3.1 1.7

0.0

10.0

20.0

30.0

40.0

50.0

Promotesgrowth and

development

For nutrition,health & disease

prevention

Less expensive Bonds motherand child

Family planningmeasure

(%)

Reasons for exclusive breastfeeding


36

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 mothers



Have you resumed work

Not resumed Resumed work

179 (50.9) 176 (49.1)

41 (22.9)

126 (71.6)

138 (77.1)

50 (28.4)

<0.001

Breastfeeding room at

work

No breastfeeding room Breastfeeding room

166 (94.3) 9 (5.1)

119 (71.7) 7 (77.8)

47 (28.3) 2 (22.2)

1.000

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


37

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.


38

Table 4: Experiences with Breastfeeding at Work

N (%) of mothers



Who takes care of baby whilst at work*

Family member Baby stays with me at the work place Non-family caretaker Crèche

111 (30.9) 38 (10.6) 31 (8.6)

48 (13.4)

81 (73.0) 30 (79.0) 28 (90.3) 34 (70.8)

30 (27.0) 8 (21.1)

3 (9.7) 14 (29.2)

0.543

Which circumstances describe your situation*

Pump breastmilk during work and save for breastfeeding I go to breastfeed during working hours Baby is brought to work place Neither breastfeeds nor pumps during working hours Baby depends solely on infant milk whilst at work

45 (12.5) 18 (5.0)

45 (12.5) 17 (4.7)

98 (27.3)

29 (64.4) 12 (66.7) 32 (71.1) 13 (76.5) 79 (80.6)

16 (35.6) 6 (33.3)

13 (28.9) 4 (23.5)

19 (19.4)

0.132

Work experiences whilst breastfeeding/expressing*

Colleagues and superiors make negative comments Difficult to arrange time and place Difficulty with equipment and storage Worried about keeping job Worried about continuing to breastfeed because of job Felt embarrassed among co-workers or superiors

7 (2.0)

34 (9.5) 80 (22.3) 59 (16.4) 39 (10.9) 23 (6.4)

7 (100.0) 22 (64.7) 60 (75.0) 44 (74.6) 33 (84.6) 20 (87.0)

0 (0.0)

12 (35.3) 20 (25.0) 15 (25.4) 6 (15.4) 3 (13.0)

0.470

Total 359 (100.0) 168 (46.8) 191 (53.2) * Multiple responses allowed


39

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.


40

Table 5: Organizational Support for Breastfeeding

N (%) of mothers



Organizational policy on

breastfeeding

No policy Policy exists Don’t know

124 (34.5) 156 (43.5)

76 (21.2)

75 (60.5) 60 (38.5) 31 (40.8)

49 (39.5) 96 (61.5) 45 (59.2)

<0.001

Organizational work

schedule

Not flexible Flexible

94 (26.2) 238 (66.3)

64 (68.1) 89 (37.4)

30 (31.9) 149 (62.6)

<0.001

Organizational scheduled

breaks for nursing

No breaks Breaks exist

153 (42.6) 202 (56.3)

47 (30.7) 119 (58.9)

106 (69.3) 83 (41.1)

<0.001

Workers bringing

breastfeeding infants to

work

Not allowed Allowed

167 (46.5) 187 (52.1)

56 (33.5) 108 (57.8)

111 (66.5) 79 (42.3)

<0.001

Organizational support for

breastfeeding

Not at all Somewhat Supportive Very supportive

93 (25.9) 64 (17.8)

143 (39.8) 53 (14.8)

22 (23.7) 30 (46.9) 89 (62.2) 24 (45.3)

71 (76.3) 34 (53.1) 54 (37.8) 29 (54.7)

<0.001

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


41

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 mothers

Lactation policy at work (% within N) No policy/

Don’t know Policy exists P-value

Organizational work

schedule


94 (26.2) 238 (66.3)

82 (87.2) 101 (42.4)

12 (12.8) 137 (57.6)

<0.001

Organizational support for

breastfeeding

Not at all Somewhat Supportive Very supportive

93 (25.9) 64 (17.8)

143 (39.8) 53 (1.67)

46 (49.5) 27 (42.2) 96 (67.1) 28 (52.8)

47 (50.5) 37 (57.8) 47 (32.9) 25 (47.2)

0.003

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


42

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.


43

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)

20 – 29 30 – 39 40 – 49

Ref 0.57 (0.35, 0.91) 0.39 (0.19, 0.78)

0.011 Ref 1.25 (0.62, 2.52) 0.85 (0.30, 2.41)

0.605

Education

Basic SHS/O&A level Tertiary

Ref 2.24 (0.78, 6.48) 0.56 (0.22, 1.39)

<0.001 Ref 2.29 (0.53, 9.90) 2.10 (0.48, 9.18)

0.518

Marital status

Single Married Widowed Divorced Separated

Ref 0.47 (0.21, 0.84) 0.10 (0.02, 0.43) 0.56 (0.08, 3.79) 0.14 (0.03, 0.62)

0.003 Ref 0.62 (0.23, 1.66) 1* 1.34 (0.08, 21.62) 0.18 (0.03, 1.21)

0.329

Monthly income

<1,000 1,000 – 1,999 2,000 – 2,999 3,000+

Ref 0.35 (0.20, 0.64) 0.13 (0.06, 0.28) 0.10 (0.03, 0.28)

<0.001 Ref 0.32 (0.10, 0.99) 0.19 (0.05, 0.70) 0.08 (0.01, 0.44)

0.022

Organizational policy

on breastfeeding

No policy Policy exists Don’t know

Ref 2.45 (1.51, 3.97) 2.22 (1.24, 3.98)

0.001

Ref 1.39 (0.68, 2.85) 1.67 (0.72, 3.86)

0.454

Organizational work

schedule


Ref 3.57 (2.15, 5.93)

<0.001

Ref 2.81 (1.37, 5.76)

0.005

Organizational

support for

breastfeeding

Supportive Not at all Somewhat Very supportive

Ref 5.32 (2.96, 9.55) 1.87 (1.03, 3.39) 1.99 (1.05, 3.77)

<0.001

Ref 3.2 (1.50, 6.67) 1.68 (0.78, 3.59) 1.49 (0.67, 3.33)

0.044

*All mothers in category did not practice EBF for the adjusted model


44

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”.


45

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


46

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


47

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


48

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.


49

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


50

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.


51

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57

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 [email protected]/[email protected] Tel:0206739260;

Dr. Patricia Akweongo, School of Public Health, University of Ghana, Legon, [email protected] 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: …………………………


mailto:[email protected]/[email protected]

tel:0206739260

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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

preference

[0]

Exclusive

breastfeeding

[1]

Formula

Feeding

[2]

Mixed

Feeding

[3]

Don’t

know

[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?


exclusive breastfeeding practices among women in the

Documents