Disparities in 6 Month Exclusive Breastfeeding in Ghana,Africa: A Scoping Review

Abstract

Background:

Exclusive breastfeeding practice for 6 months is a critical global public health goal. In 2020, only 44% of infants globally, 31% in Central and West Africa, and 43% in Ghana, were exclusively breastfed for the first 6 months of life.

Research Aim:

To critically evaluate disparities in exclusive breastfeeding practice for 6 months in Ghana.

Methods:

The scoping review was guided by Arksey and O’Malley’s (2005) six-stage scoping review process. The online databases of American Psychological Association PsychInfo (APA PsychInfo), Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, and Scopus were searched with keywords inclusive of Ghana, exclusive breastfeeding, breastfeeding, infant feeding, lactation, lactating, and exclusive. Eligibility criteria included full-text, peer-reviewed research articles written in the English language without limitation to specific years. Data were analyzed thematically.

Results:

Initially, 317 records were identified, and 15 full-text articles were eligible for the scoping review. Four main themes emerged as disparities in exclusive breastfeeding practice in Ghana. The themes were healthcare (prenatal clinic visits, delivery place, exclusive breastfeeding knowledge), personal (maternal age, Human Immunodeficiency Virus status, parity, type of delivery, breast problem), employment (unemployed, formal, or informal sector worker), and sociocultural (ethnicity/region, family support, religious beliefs, cultural practices).

Conclusion:

Disparities in exclusive breastfeeding in Ghana warrant the collaborative efforts of stakeholders for successful mitigation. Future researchers should explore the role of religion and sociocultural practices to protect, promote, and support 6 months of exclusive breastfeeding in Ghana.

Keywords

breastfeeding breastfeeding experience breastfeeding promotion breastfeeding support cultural norms disparities exclusive breastfeeding Ghana scoping review West Africa

Key Messages

Exclusive breastfeeding practice for 6 months is suboptimal in Ghana.

Key disparities of maternal exclusive breastfeeding practice for 6 months in Ghana are related to healthcare, employment, personal, and sociocultural factors.

In Ghana, health professionals, families, the community of residence, religious leaders, and employers are the key influencers to favorably provide the breastfeeding social support necessary for the promotion of 6 months exclusive breastfeeding practice.

Background

Exclusive breastfeeding (EBF) practice is defined as the feeding of an infant with only human milk (inclusive of childbearing parent’s own milk; milk expressed from a wet nurse; or milk fed directly from the breast) and the exclusion of other foods or drinks, even water, except for the administration of oral rehydration salt, drops, and syrups when the infant is ill during the first 6 months of life (World Health Organization [WHO], 2021a). Infants in lower- and middle-income countries who experience EBF for 6 months are less likely to suffer gastrointestinal diseases, excessive weight loss, dehydration, physiological jaundice, kernicterus, sudden infant death syndrome, recurrent hospital admission, obesity, or diabetes (Victora et al., 2016; WHO & United Nations Children’s Fund [UNICEF], 2021). Mothers who practice 6 months of EBF have improved emotional wellness; attain well-spaced birthing and pre-pregnancy body-shape; and experience declines in obesity, diabetes, hypertension, breast, and ovarian cancers (Ganju et al., 2018; Ross-Cowder et al., 2017; Schalla et al., 2017). Annually, there is a global economic saving of $341.3 billion to the healthcare system because of breastfeeding (Walters et al., 2019). Although the benefits of breastfeeding are well established, disparities in EBF for the first 6 months of life remain a critical global public health burden.

Only 44% of infants in the world experience EBF for the first 6 months of life (UNICEF, 2021; WHO, 2021b). In high-income countries, for example, the United States, EBF is associated with race (Beauregard et al., 2019). African American infants are least likely to benefit from 6 months of EBF primarily because of inadequate maternal social support for EBF initiation and continuation from relatives, healthcare professionals, the public, and employers (Gyamfi et al., 2021; Merewood et al., 2019). In lower- and middle-income countries, for example, Nigeria, Nepal, and Pakistan, infants experience suboptimal EBF during the first 180 days of life (Kavle et al., 2017). Mothers who are least likely to practice EBF in these regions have breastfeeding problems, are engaged in full-time work, lack breastfeeding counseling and support from the family and community, and have misconceptions about breastfeeding (Kavle et al., 2017).

In East and Central Africa, EBF practice for 6 months is highly differentiated. For instance, in East Africa, Ethiopian and Kenyan mothers who adhered to EBF regularly patronized prenatal and postnatal services, had in-depth knowledge about breastfeeding, delivered vaginally, initiated breastfeeding soon after birth, and either earned a low income or had no jobs (Tadesse et al., 2019). Central African mothers from Rwanda mainly breastfed (UNICEF, 2021); those who resided in the rural areas, had no education, earned low or middle income, and birthed male infants who were mostly breastfed as compared to female infants, mostly practiced EBF (National Institute of Statistics of Rwanda et al., 2016). Mothers who received breastfeeding counseling from health professionals in the Democratic Republic of Congo usually breastfed their infants (Burns et al., 2016). However, Congolese mothers who were poor, worked extensively in farms, experienced painful breastfeeding, and were malnourished, perceived human milk alone to be inadequate to satisfy their infant or had ill infants and were least likely to breastfeed their infants (Burns et al., 2016).

West African mothers from Nigeria with advanced maternal age, regular antenatal attendance, and ethnicity from Igala, Tiv, or Yoruba mostly practiced EBF (Benova et al., 2020; Joseph & Earland, 2019). Breastfeeding misconceptions (e.g., human milk alone was insufficient to satisfy infant) after early initiation resulted in irregular breastfeeding, inadequate family support and uvulectomy of infants (Benova et al., 2020; Joseph & Earland, 2019). Infants’ infections were treated with oral traditional medicines which halted exclusive breastfeeding (Joseph & Earland, 2019).

Ghana, the focus of this paper, is in West Africa, with a population of 31.7 million, 57% urban residency, and birth and infant mortality rates of 28.99 per 1000 people and 33.90 per 1000 live births, respectively (O’Neill, 2022a, 2022b; Worldometer, n.d.). Maternal efforts to practice EBF in Ghana are favorably supported at the national level. This is evident in the Ghanaian Labor Law, which mandates 3 months paid maternity leave and an hour of break time daily for all formal and informal sector breastfeeding mothers, the existence of Baby-Friendly Hospital Initiatives (BFHI), access to breastfeeding counseling in health facilities, the practice of public breastfeeding, and a legislative Act instituted in 2009 that controls the commercialization of human milk substitutes (Coomson & Aryeetey, 2018). The regulations promot adherence to the International Code of Marketing of Breast-milk Substitutes (IC; WHO, 1981) and prohibit the sale of other designated products (i.e., feeding bottles and pacifiers and teats) in any health care facility (Iddrisu, 2000). The BFHI allows accredited health facilities to support maternal efforts to initiate breastfeeding within an hour of birth and supports lactation throughout the postnatal period. Additionally, the BFHI and prevalent control of the sale of human milk substitutes restricts introduction of most infants in Ghana to human milk substitutes (Ghana Health Service, 2016). Further gains in breastfeeding promotion have been achieved through the positive attitude of the Ghanaian culture towards public breastfeeding (Coomson & Aryeetey, 2018).

However, Ghanaian mothers experience a suboptimal rate of 6 months of EBF because of prevailing barriers. These barriers include breast problems (e.g., pain, maternal human immunodeficiency virus [HIV] positive status, misconceptions about breastfeeding, physical impairments, lack of family support to EBF, maternal employment, negative sociocultural practices, and inadequate adherence to BFHI and the IC (Acheampong et al., 2020; Agbozo et al., 2020; Nsiah-Asamoah et al., 2020). These barriers exist despite national efforts to support breastfeeding. The aim of this scoping review was to critically evaluate the disparities in EBF practice for 6 months in Ghana.

Methods

Research Design

The study was a scoping review. Through the scoping review, disparities in EBF practice in Ghana were explored and recommendations provided for practice and future research to promote, protect, and support 6 months of EBF practice in Ghana.

Sample: Defining the Articles Reviewed

Records from databases and registers (i.e., organization specific documents, inclusive of government institutions) were identified, retrieved, and screened for full-text, peer-reviewed articles (quantitative and qualitative studies) written in the English language in 2012–2020. All duplicates were removed. Records that were not related to EBF practice for 6 months in Ghana were excluded and the remainder assessed for eligibility. Additional full-text literature was excluded if the focus was only on barriers and/or facilitators of breastfeeding and or/EBF below 6 months; complementary feeding; study target population involved other countries; breastfeeding initiation; policy document, or report or other breastfeeding issues. A final sample size of 15 full-text peer reviewed articles was used for the scoping review (Figure 1). Ten of the studies were quantitative, four were qualitative, and one study had a mixed methods design.

Data Collection: The Search Strategy and Process

The scoping review process was conducted between December 15, 2020 and June 10, 2021. The scoping review was guided by Arksey and O’Malley’s (2005) six-stage framework: (a) identifying the research question; (b) identifying relevant studies; (c) study selection; (d) charting the data; (e) collating, summarizing, and reporting results; and (f) consultation. The review was further guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR; Peters et al., 2020) and the critical appraisal tools for qualitative and quantitative studies (Joanna Briggs Institute, 2020). To identify relevant studies, the online databases of APA PsychInfo, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, and Scopus were searched. Keywords included the following: PsychInfo – Ghana AND EBF; CINHAL – Ghana AND breastfeeding or lactating or infant feeding or lactation AND exclusive; PubMed – Ghana AND EBF; and Scopus – Ghana AND EBF. In addition, a preliminary search of the databases of the Campbell Library (Rowan University Libraries, Campbell Library, n.d.), Joanna Briggs Institute Evidence Synthesis (Joanna Briggs Institute, n.d.) and The Cochrane Database for Systematic Reviews (Cochrane Library, n.d.) was conducted to search for previous scoping and systematic reviews about breastfeeding disparities in Ghana, but none were found.

Measurement

In the analysis process for this scoping review, disparities in EBF for 6 months in Ghana were identified and measured based on findings from the reviewed literature. The definitions for the identified disparities are provided in the results section. The variables measured by authors of the reviewed articles focused on:

EBF (knowledge, perceptions, experience, practices, initiation, facilitators, coping strategies, breastfeeding frequency, barriers, discontinuation, workplace factors and challenges that influence EBF decisions and practices, prevalent cultural practices concerning breastfeeding, and supplementation);

Maternal variables (age, timing of antenatal clinic initiation, number of antenatal care visits, reception of EBF counseling/education at antenatal clinic, mode and place of delivery, gestational age of infant at birth, parity, EBF support from family, exposure to advertisement of formula milk, pressure to give the baby other foods or liquids, disability status, sore nipples, past illness and obstetric history, and education);

Maternal work (experience, type, rank, location, risks to infant health, going to work with the infant, hours worked, and distance from home to workplace);

Socio-demographics (marital status, religion, mother tongue, area or district of residence, ethnicity, educational level of household head, monthly income, household socioeconomic status, social capital, anthropometric measurements, age of last baby);

Infant (age, sex, anthropometric measurements, complementary feeding) and food insecurity (determined based on an adapted version of the 16-item Latin American and Caribbean Household Food Security Scale [Woldeghebriel et al., 2016]). This instrument was open access (Pérez-Escamilla et al., 2009).

EBF for 6 months was defined as feeding infants with only human milk, without supplemental liquids or solids except for liquid medicine and vitamin or mineral supplements for the first 6 months of life based on UNICEF and WHO recommendations (WHO, 2021a). EBF history was based on maternal recall. Breastfeeding practice was based on the WHO indicators for assessing infant and young child feeding practices. Household socioeconomic status was defined as a proxy measure of a household’s long-term standard of living.

Data Analysis

The identified eligible full-text articles were read iteratively to identify disparities in EBF for 6 months in Ghana. Subsequently, defined data fields were tabulated for each article based on the author, year of publication, study site, study aim, study design, sample, variables, instruments, trustworthiness or reliability, and validity (Tables 1 and 2). The details from each article included in the tabulated data fields facilitated appreciation of each study’s methodological congruence and possible bias. Each of the articles was evaluated with the critical appraisal tools for qualitative and quantitative studies (Joanna Briggs Institute, 2020) and found to be appropriate for the scoping review process.

Table 1.

Methodology Characteristics of Qualitative Reviewed Studies (N = 4).

1st Author (year) Location	Study Aim	Sample	Data Sources	Data Collection	Trustworthiness
Abekah-Nkrumah (2020) Accra, Ghana	To examine EBF experience of working mothers with an emphasis on the influence of workplace factors on decision EBF.	N = 20 professionals > 6 mos. pre- birth child < 5 yrs. > 18 yrs.	Interviews	Unstructured Audio taped	Point of saturation verbatim transcriptions
Adda (2020) Kassena-Nankana Municipality, Ghana	To explore of EBF knowledge, perceptions, prevailing social & cultural norms that influence EBF	Purposive & snowball primipara < 20 years 21-26 yrs. with infant 7-12 mo.	Interviews TBA (n = 4) HCW (n=4) FGD (n = 4).	audio recording thick description	Pilot test Verbatim transcription Audit trail reflexibility member checking
Tampah-Naah (2019) Upper West & Western Regions, Ghana	To explore the challenges of BF practice with consideration on spatial, societal, and maternal characteristics	Purposive sampling mothers (N = 20) 15-49 yrs. single infants 0-23 mo.	Interpretive case study & interviews.	audio recorded interviews, verbatim transcription	Pretesting saturation field notes peer review.
Aborigo (2012) Kasena-Nankana District, Ghana	To explore infant feeding practices in a resource-poor setting & assess the implications for future interventions	Random sampling of study zone purposive sampling BF mothers (n = 35) infant 4-8 wks. Community leaders (n = 16) HCW (n = 13) TBA (n = 8)	Interviews (n = 72) FGD (n = 18).	Audio tapes transcribed verbatim	Pretesting of instruments, field notes co-investigators audited data

Note. BF = breastfeeding; exclusive breastfeeding = EBF; focus group discussions = FDG; TBA = traditional birth attendants; HCW = health care workers.

Table 2.

Characteristics of the Quantitative and Mixed Methods Studies (N = 11).

1st Author (yr.) Site	Study aim	Sample	Design	Variables	Instruments	Reliability & validity
Ganle (2020) Shai-Osudoku, Ghana.	Determine EBF discontinuation & examine associated factors.	Convenance mothers 15-49 yrs. (N = 322) single, term NSVD	Longitudinal one group observation study	EBF demographics EBF support exposure to adverting of formula, pressure to give other foods, EBF education	Author created structured questionnaires	Pretested instrument, Cronbach’s alpha = 0.89.
Manyeh (2020) Shai-Osudoku & Ningo-Prampram, Ghana.	To estimate the rate & investigate the demographic and socio-economic determinants of EBF for 6 mo.	Purposive BF mothers (N = 1870) infant > 6 mo.	Secondary data analysis	BF Maternal demographics	Dodowa Health & Demographic Surveillance System	Validity not addressed Established survey
Yeboah (2019) Kumasi Metropolis, Ghana	The prevalence & factors associated with EBF	Simple random sampling mothers (N = 170) infant 6-24 mos. from five health centers	Cross-sectional survey	EBF Maternal & infant demographics BF complications,	Structured closed-ended questionnaires	Simple random sampling pretesting
Nukpezah (2018)	To assess the knowledge & practice of EBF	Purposive, quota & simple random	Cross-sectional survey.	EBF demographics	Questionnaire	none mentioned
Asare (2018) Tema East Sub-Metropolis, Ghana	To determine BF practices and examine sociodemographic characteristics that influence EBF	Simple random sampling 355 mothers (N = 355) 15-49 ys. Infant 0-24 mos.	Cross-sectional survey.	BF practice, demographics Delivery data Infant data	Structured questionnaire	Pretest
Nkrumah (2017) Effutu Municipality, Ghana	To identify the features of maternal work associated with EBF	Simple random & universal sampling mothers (N = 260) Infant 0-7 mos.	Cross-sectional survey face-to-face structured interviews FGD (n = 3)	EBF BF frequency maternal socio-demographics maternal work characteristics	Questionnaire	Pretest
Dun-Dery (2016) Wa, Ghana.	To assess the prevalence of EBF, and factors associated with professional working mothers	Random sampling mothers (N = 369) >24 yrs. Infant 6-24 mos.	Descriptive cross-sectional survey	EBF Influencing employment factors HCW recommendations socio-demographics	Questionnaire (structured)	Random sampling
Marquis (2016) Yilo Krobo & Manya Krobo, Ghana	To examine if maternal HIV status was associated with EBF and other infant feeding practices	Pregnant women 18-50 yrs/ HIV+ = 150, HIV- = 170 HIV unknown = 162	12 mos. PP prospective	Household SES Demographic data, obstetric history (depression) Infant’s birth wgt. daily feeding log	Author adapted from existing surveys	Surveys used to create authors' survey were established & validated
Mogre (2016) Tuna Health Center, Ghana	To assess the EBF knowledge, attitudes, and practices & factors associated EBF	Rural lactating mothers (N = 200) Infants 0–6 mos.	Cross-sectional survey.	EBF knowledge Attitudes Feeding practices Socio-demographics	Author adapted Questionnaire.	Reviewed by expert panel Pretested
Woldeghebriel (2016) Buduburam Refugee Settlement & Awutu, Ghana	To explore the association between the amount of time living in Ghana & EBF practices among Liberian refugees & Ghanaians	Random sampling female non-pregnant caretakers (N = 480) biological child 6-59 mos.	Cross-sectional survey.	Maternal demographics maternal BMI social capital health status anthropometric measurements child food insecurity.	Author adapted Survey	pretest
Tampah-Naah (2013) Ghana.	To examine factors that predict the practice of EBF	412 clusters systematic sampling (30 households in each cluster) 15-49 yrs/ Secondary data analysis sample mothers (N = 316) infant 0-5 mos.	Secondary data analysis of the 2008 Ghana Demographic and Health Survey	EBF Demographics Birth variables Infant demographics	Ghana Demographic and Health Survey (2008).	Validated established instrument

Note. NSVD = normal vaginal delivery; BF = breastfeeding; EBF = exclusive breastfeeding; focus group discussions (FGD), HIV = Human Immunodeficiency Virus; PP = postpartum; SES = socioeconomic.

Data fields were further categorized into themes guided by Krippendorff’s (2019) content analysis, which is best suited for databases from both qualitative and quantitative research. Using Krippendorff’s content analysis, two researchers iteratively read all articles and obtained an in-depth understanding of the contents to facilitate analysis. Two researchers independently completed the analysis, themes were compared and discussed until consensus was reached between the two researchers. In this iterative process, a dendrogram was created by the first author to illustrate the development of themes. A dendrogram is a treelike diagrammatic representation used to illustrate how the themes were developed from the databases (Krippendorff, 2019). Key phrases and words from the result sections of the articles were identified, clustered in the dendrogram, and labeled by themes. An illustration of the dendrogram for the theme “healthcare disparities” is provided (Figure 2).

The dendrograms and themes were verified by co-authors with expertise in human milk and lactation to promote trustworthiness. Additionally, a detailed audit trail about the analysis was kept. Subsequently, key phrases and words were pulled from the results section of each article, similar phrases were grouped together, and themes were identified (Table 3). Four main themes emerged from the dendrograms which represented the 6 months of EBF practice disparity in Ghana.

Table 3.

Descriptive Main Themes of the Disparities in Breastfeeding Exclusivity Practice in Ghana.

1st Author (date)	Healthcare Disparities	Personal Disparities	Employment Disparities	Socio-Cultural Disparities
Abekah-Nkrumah (2020)	EBF was highly practiced when mothers had adequate knowledge & understanding about it.		Maternity leave < 6 mos.absence of BF breaks organization-specific maternity polices	Inadequate family support limited 6 mos. EBF practice.
Aborigo et al., 2012	Mothers who delivered at the hospital were most likely to practice EBF.	EBF was least practiced by mothers with cracked or sore nipples. Younger mothers less likely to BF due to the desire to maintain their prepregnant body shape.		Christian religion encouraged EBFTraditional believers endured 3-4 days of cultural cleansing and sacrifices to determine if maternal human milk was wholesome for EBF Grandmothers influenced maternal EBF decisions.
Adda (2020)	EBF high among 1st mothers who had adequate knowledge of benefits of EBF practice	EBF was less likely in primiparous women with misconceptions about EBF practice	maternal employment limited EBF practice	Challenges from key influencersprevailing socio-cultural practices household chores
Ganle (2020)	EBF practice was low among mothers who made < 4 prenatal visits during pregnancy.			EBF low among urban residents, lack of family support, & had pressure to introduce complementary food before 6 mos.
Manyeh (2020)	EBF was less practiced among mothers who delivered outside a health facility.	EBF was practiced in mothers > 20 years or with household size >5	EBF practiced by unemployed mothers Least often by Artisans, civil servants, farmers, students, and traders
Marquis et al., 2016		EBF rates highest in maternal households with more children < 5 HIV+ mothers were least likely EBF.		Mothers from Ga/Adange and Ewe ethnicities mostly practiced EBF.
Mogre et al., 2016	EBF rates highest among mothers with increased knowledge on EBF.	EBF rates were highest among highly educated mothers.
Nkrumah, 2017			EBF practice was significantly higher among informal sector working mothers because of flexible work schedules.	EBF was positively impacted by adequate family support. Cultural beliefs were noted to negatively affect EBF rates.
Nukpezah et al., 2018	The mothers most likely to EBF had knowledge on the benefits of EBF	The mothers most likely to EBF had female infants.
Tampah-Naah et al. (2019)		EBF rates low due to sore breasts or nipples and low human milk production	Low EBF rates among mothers with unfavorable work schedules.	Low EBF rates were reposted in mothers who spent much time in household chores & mothers whose close relatives, co-tenants fed solid food before 6 months.
Tampah-Naah & Kumi-Kyereme, 2013	Infants born at government health facilities were most likely to be EBF	EBF rates were highest among mothers who perceived their infants to be of average size at birth.		EBF rates were highest among mothers from the Volta Region.
Woldeghebriel et al., 2016		EBF was common among primiparous women.		EBF rates were highest among Liberian refugees who had lived in Ghana for 8 yrs and borrowed money from neighbors /family in past year.

Note. EBF = exclusive breastfeeding; BF = breastfeeding.

Results

Characteristics of the Sample

Thirteen of the articles were based on primary research and two on secondary analysis of national surveys. Study participants for all the studies were women in the reproductive ages (15–49 years; pregnant, breastfeeding mothers, or cared for infants aged 0–59 months, healthcare providers, grandmothers, community leaders, traditional birth attendants, herbalists, compound heads, or heads of households).

Healthcare Disparities Themes

Four main themes emerged as the basis for disparities in EBF for 6 months in Ghana. The four themes were (1) healthcare, which covered the number of prenatal clinic visits, delivery place, and EBF knowledge; (2) personal, which focused on maternal age, HIV status, parity, type of delivery, and breast problems (breast and nipple pain); (3) employment, for which maternal work status was categorized as unemployed, formal, or informal sector worker; (4) sociocultural, which included the significant impact of family support, maternal ethnicity, cultural practices, religious beliefs, and maternal region of residence on EBF practice for 6 months in Ghana. Summaries of the themes are described below and illustrated in Table 3.

EBF varied among mothers because of access to healthcare services. More mothers who patronized prenatal clinic sessions on four or more occasions practiced EBF for 6 months as compared to mothers who made fewer prenatal clinic visits (Ganle & Bedwei-Majdoub, 2020). From health professionals, mothers gained adequate knowledge about EBF and in-depth understanding of the benefits of 6 months EBF practice (Abekah-Nkrumah et al., 2020; Nukpezah et al., 2018; Mogre et al., 2016). Additionally, pregnant women who delivered at government health facilities compared to pregnant women who delivered outside health facilities were most likely to adhere to the 6 months EBF practice (Aborigo et al., 2012; Manyeh et al., 2020; Tampah-Naah & Kumi-Kyereme, 2013). This is because government healthcare workers were observed to recommend EBF to mothers during the birth of the infants (Dun-Dery & Laar, 2016).

Personal Disparities

Mothers’ EBF practices differed based on individual differences. Older mothers (above 20 years), irrespective of the educational status, with parities of one or more than three, household size of more than five and more children under the age of 5 mostly practiced 6 months EBF (Aborigo et al., 2012; Adda et al., 2020; Asare et al., 2018; Manyeh et al., 2020; Marquis et al., 2016; Mogre et al., 2016; Yeboah et al., 2019). Mothers with an HIV negative status who delivered by spontaneous vaginal delivery, birthed female infants, and perceived the infants to be of average size usually exclusively breastfed the infants for the first 6 months of life as compared to other mothers with infants (Dun-Dery & Laar, 2016; Marquis et al., 2016; Nukpezah et al., 2018; Tampah-Naah & Kumi-Kyereme, 2013; Yeboah et al., 2019). The aforementioned categories of mothers who practiced EBF for 6 months also adhered to bedsharing and scheduled feeding of the infants (Nkrumah, 2017). Interestingly, young mothers (below 20 years) who desired an immediate return to the pre-pregnant body shape, experienced pain as a result of cracked or sore nipples and other mothers who reported low human milk production irrespective of the educational status did not practice EBF for 6 months (Aborigo et al., 2012; Asare et al., 2018; Manyeh et al., 2020; Mogre et al., 2016; Tampah-Naah et al., 2019; Yeboah et al., 2019).

Employment Disparities

Maternal work status influenced the practice of EBF for 6 months. EBF for 6 months was predominant among mothers who were unemployed or worked in the informal sector (self-employed or worked in the private sector; Abekah-Nkrumah et al., 2020; Asare et al., 2018; Manyeh et al., 2020; Nkrumah, 2017). Maternal engagement in the informal sector jobs provided flexible work schedules supportive of EBF practice for 6 months (Manyeh et al., 2020; Nkrumah, 2017; Tampah-Naah et al., 2019). Meanwhile, the 6 months EBF practice was unattainable by formal sector (working in the government sector) or other full-time professionals who were entitled to only 3 months of paid maternity leave (Abekah-Nkrumah et al., 2020; Dun-Dery & Laar, 2016; Manyeh et al., 2020). Besides, formal sector mothers lacked organization specific policies favorable to breastfeeding, for example, nursing breaks (Abekah-Nkrumah et al., 2020). Similarly, student mothers in the university lacked convenient breastfeeding space which compromised their ability to practice EBF for 6 months (Manyeh et al., 2020).

Sociocultural Disparities

Prevalent maternal sociocultural factors impacted EBF practice for 6 months. Maternal EBF support from significant individuals, for example, grandmothers, mothers-in-law, aunts, cousins, co-tenants, traditional birth attendants, herbalists, and older women in the communities of residence positively affected EBF practice for 6 months (Aborigo et al., 2012; Adda et al., 2020; Ganle & Bedwei-Majdoub, 2020; Nkrumah, 2017; Tampah-Naah et al., 2019; Woldeghebriel et al., 2016). The lack of breastfeeding support from the aforementioned key influencers resulted in the enforcement of certain birth rites, traditional beliefs, and cultural practices, which were unfavorable to EBF practice (Aborigo et al., 2012; Adda et al., 2020; Ganle & Bedwei-Majdoub, 2020; Nkrumah, 2017; Tampah-Naah et al., 2019). The cultural practices included 3–4 days of sacrifice (i.e., administration of herbal concoction to infants, human milk purification, and cultural cleansing to determine the wholesomeness of human milk for EBF; Aborigo et al., 2012; Adda et al., 2020; Ganle & Bedwei-Majdoub, 2020; Nkrumah, 2017; Tampah-Naah et al., 2019). Mothers who followed Christian teachings, however, reported high EBF rates because of lack of conformity to traditional beliefs and cultural practices (Aborigo et al., 2012).

Maternal ethnicity and place of residence influenced the practice of 6 months EBF. EBF for 6 months was commonest among urban residents in the Volta and Greater Accra regions (Asare et al., 2018; Ganle & Bedwei-Majdoub, 2020; Marquis et al., 2016; Tampah-Naah et al., 2019; Tampah-Naah & Kumi-Kyereme, 2013). Similarly, Liberian refugees in the Buduburam Refugee Camp with more than 8 years of acculturation in Ghana mostly practiced EBF for 6 months (Woldeghebriel et al., 2016). EBF was least practiced by mothers with ethnicity or regional locations in the rural parts of Akan, Northern, Upper West or Western (Adda et al., 2020; Asare et al., 2018; Marquis et al., 2016; Tampah-Naah et al., 2019; Tampah-Naah & Kumi-Kyereme, 2013).

Discussion

Access to formal health care services was identified in Ghana, as well as in Central, East, and West Africa as promoting EBF for 6 months (Benova et al., 2020; Burns et al., 2016; Joseph & Earland, 2019; Tadesse et al., 2019). The Ghanaian mothers who frequently attended prenatal and postnatal clinics gained in-depth breastfeeding knowledge, understanding, and adequate support from health professionals, which empowered them to practice EBF for 6 months (Benova et al., 2020). This suggested that health education about the benefit of EBF for 6 months during these visits should be regular, concise, and easy to understand throughout pregnancy, and continue through to delivery and during the birthing process and puerperium to enhance maternal practice. We also learned that health professionals at government health facilities who recommended EBF at birth were a key influence for maternal EBF practice. This highlights the need to provide health professionals in these roles with the tools and resources they need to educate women on EBF.

There were also Ghanian women’s personal factors that positively influenced infants’ EBF for 6 months. Some of these factors were shared by women in Central and East Africa. Namely, mothers of advanced age (above 20 years), who had either completed above secondary level education or not; had higher parity, spontaneous vaginal delivery, and birthed female infants, practiced EBF for 6 months (Tadesse et al., 2019). We also observed additional personal factors that increased EBF for which limited literature existed. These were maternal parity of one, household size of more than five, more children under 5 years, maternal perception of average size of infant, practicing bedsharing with the infant, and scheduled feeding of an infant. Furthermore, the identified low EBF rates among Ghanian mothers with breastfeeding problems aligns with research outcomes in Central and West Africa (Benova et al., 2020; Burns et al., 2016; Joseph & Earland, 2019). The above disparities suggested the need to individualize breastfeeding support to meet the unique needs of each pregnant, birthing, or breastfeeding mother to promote exclusive human milk feeding during the first 6 months of the infant’s life.

Employment and education are also important considerations in EBF. As in East Africa, unemployed mothers in Ghana have higher rates of EBF (Tadesse et al., 2019). A possible explanation is that the women have time to be with their infants and are not restricted by work and school. While low rates of EBF practice are predominant among students and formal and full-time workers in Ghana, this is also the case in high-income, and lower- and middle-income countries (Beauregard et al., 2019; Kavle et al., 2017; Merewood et al., 2019). These disparities suggested that there should be further investigation into the institutionalization of organization-specific policies favorable to the 6 months maternal EBF practice. These provisions may include convenient breastfeeding spaces, a refrigerator to store human milk, and flexibility in work schedules. Moreover, working mothers should be taught how to express and safely store human milk to be fed to their infants in their absence.

The positive influence of adequate social support from relatives and community members on maternal EBF practice for 6 months reported in this study confirms researchers’ earlier outcomes in high-income, and lower- and middle-income countries (Burns et al., 2016; Gyamfi et al., 2021). Additionally, urban residents and Liberian refugees with 8 or more years of acculturation in Ghana mostly practiced EBF for 6 months, contrary to earlier studies where rural dwellers in Central Africa readily practiced EBF for 6 months (National Institute of Statistics of Rwanda et al., 2016). The positive influence of Christianity and the negative effect of the enforcement of traditional and cultural practices by key influencers on maternal EBF practice for 6 months emerged as new disparities in this study. The identified sociocultural disparities suggested the need for proactive collaboration with significant individuals in the family and community to support, protect, and promote maternal EBF practice for 6 months. Some of the collaborative initiatives could include regularized community-based health intervention programs for EBF.

The scoping review helped to underscore the importance of education in support of EBF in specific populations. Regular EBF education in simple and concise language targeted to meet the unique needs of pregnant, birthing, and nursing mothers at health facilities—especially in the rural areas of Akan, Northern, Upper West, and Western ethnicities in Ghana—helps to facilitate EBF. Mothers living with HIV and on treatment in a resource-poor setting benefit from being coached on EBF best practices and should be encouraged to practice EBF (WHO & UNICEF, 2016). Young, first-time mothers have concerns about changes in their body image and therefore benefit from learning how to manage the changes in their breasts and bodies so they can return to pre-pregnant body shape (Schalla et al., 2017). Furthermore, maternal efforts toward EBF should be adequately supported and integrated into the birth plan irrespective of parity, type of delivery, perceived size of the infant, educational status, household size, or number of children under 5 years.

Healthcare providers are well respected and are in a good position to share their breastfeeding knowledge and expertise in every encounter with their patients. They must collaborate with key influencers of maternal EBF practice in the community (grandmothers, mothers-in-law, aunts, cousins, co-tenants, community leaders, traditional birth attendants, herbalists, compound heads, heads of households, and any other significant others inclusive of fathers) to encourage social support of breastfeeding. Additionally, healthcare providers must begin dialogues with religious leaders to educate them on the benefits of breastfeeding so they can help address any misconceptions and discourage traditional beliefs and cultural practices unsupportive of EBF practice (Kamoun & Spatz, 2018). Furthermore, healthcare providers should advocate for the establishment of organizational policies favorable to EBF for 6 months among working mothers, including lactation rooms to allow space for human milk expression during lactation breaks.

The role of Christian practices and beliefs in the promotion, protection, and support of EBF for 6 months in Ghana should be explored further. Moreover, future intervention studies may focus on the institutionalization of new workplace policies supportive of maternal EBF efforts for 6 months. Finally, the complexity of EBF in Ghana warrants the exploration of familial support (based on household size and influential persons e.g., fathers and grandmothers), the influence of traditional practices and women’s control in breastfeeding.

Limitations

The limitations of the study were the dearth of literature directly related to disparities in EBF for 6 months in Ghana and the absence of a previously published protocol for the scoping review process. Additionally, this scoping review was limited to published articles discoverable by database searches which may have omitted relevant sources of unpublished and/or virtually unavailable information. Researcher bias in conducting this study is always a possibility.

Conclusions

Ghana’s suboptimal EBF at 6 months is influenced by maternal disparities in access to healthcare services, personal characteristics, employment status, and sociocultural practices. A pragmatic approach to mitigate EBF disparities requires collaboration with various stakeholders inclusive of significant others, birthing, and nursing mothers; formal and informal healthcare providers; traditional and religious leaders; labor unions; and government officials. Future investigators might consider using mixed methods approaches to assess the disparities in EBF practice in Ghana.

Footnotes

Author contribution(s)

Adwoa Gyamfi: Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Visualization; Writing – original draft; Writing – review & editing.

Urmeka T. Jefferson: Methodology; Writing – review & editing.

Barbara O’Neill: Methodology; Writing – review & editing.

Ruth Lucas: Methodology; Writing – review & editing.

Diane Lynn Spatz: Methodology; Writing – review & editing.

Wendy A. Henderson: Conceptualization; Methodology; Validation; Writing – review & editing.

Disclosures and Conflicts of Interest

Adwoa Gyamfi, completed the student research. Drs. Jefferson, O’Neill, Lucas, Spatz, and Henderson were advisors. The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: PEO International Peace Scholarship, 2020/2021 Academic year and predoctoral scholarship from the University of Connecticut School of Nursing.

ORCID iDs

Adwoa Gyamfi

Ruth Lucas

Diane Lynn Spatz

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