Details of the study findings are structured under the following sub-headings; characteristics of participants, knowledge and perception of EBF practices, cultural perspectives on breastfeeding practices, socio-economic influencing factors for breastfeeding practices as well as changing perceptions on breastfeeding practices.
Characteristics of participants
In all, 37 participants were involved in this study. This consisted of 29 first-time mothers who participated in the FGDs as well as TBAs (4) and health workers (4) who were a part of the in-depth interviews. Majority of the participants for the FGDs were married (28), had children aged between 7 and 9 months (19) and professed the Christian faith (27). These individuals in the majority were among the category of first-time mothers with junior high school as their highest level of education (14) and they resorted to farming as their major economic activity (15). In addition, only a few of the respondents (2) had ethnic backgrounds other than Kassena and Nankana (native groups within the study area). Table 1 provides details of the socio-demographic characteristics of the primary participants (first-time mothers). In the case of the socio-demographic characteristics of health workers interviewed, all were females, consisting of three community health nurses and one midwife who was the only one married among the four. Their years of working experience ranged between two and six years. Likewise, all the TBA’s interviewed (4) were females, married and occupied with farming as their major source of income. Two of the TBAs aged 42 and 58 years had middle school and primary level of education respectively whereas the other two had no formal education.
Table 1
Socio-Demographic Characteristics of First-time Mothers
Characteristics of FGD Participants | Number of participants |
Ethnic Background Kassena Nankana Others | 13 14 2 |
Age of mother 20 years and below 21–26 years | 14 15 |
Religion Christian Traditionalist | 27 2 |
Level of education No formal education | 2 |
Primary | 7 |
JHS | 14 |
SHS | 6 |
Occupation Artisan | 3 |
Farmer | 15 |
Trader | 4 |
Unemployed | 7 |
Age of child 7–9 months | 19 |
10–13 months | 10 |
Marital status Single Married | 1 28 |
Knowledge on EBF
We explored knowledge on EBF and its practices from the perspectives of health workers, TBAs and first-time mothers. The major source of knowledge on EBF among the mothers was health facilities where information was usually obtained after delivery. For instance, a participant made mention that, “It was when I delivered, they [health care providers] told me about EBF practice in Navrongo, the big hospital.” (Mother, FGD, Community 1). On few occasions, family members who had practiced EBF were also in the position to introduce first-time mothers to the practice as indicated by another mother, who stated that: “I heard it [EBF] from my house women who had delivered before I got pregnant and delivered. (Mother, FGD, Community 2). Furthermore, TBAs recommended infant feeding practice, since they were another source of information on EBF to mothers who came to them for care.
Again, health workers, TBAs and the first time mothers also had knowledge of the benefits in practicing EBF. They perceived the practice as the initial immunity for babies against childhood diseases and infections. For instance according to one of the mothers, “If you give your baby only breast milk for six months, he does not fall sick frequently and he will be strong” (Mother, FGD, Community 4). Interviews with the health care providers highlighted some developmental benefits of EBF. One of the health workers stated that “… to the child too it [EBF] helps in especially the brain development of the child and it also helps to prevent diseases especially diarrhea in children” (Health worker, IDI, Community 1).
EBF was also found to have a substantial advantage to women, especially because it is an effective and less costly method for family planning for nursing mothers, as observed below:
“…it serves as a natural family planning for the woman if she practices it very well... Also if the woman doesn’t practice EBF, she’ll need to use back up methods like condoms during sex because if she doesn’t, she might get pregnant since she doesn’t breastfeed exclusively” ( Health worker, IDI, Community 3).
Perceptions and misconceptions about breastfeeding practices
Despite the fact that first time-mothers saw the practice of EBF as vital to a child’s health and an effective practice for birth spacing and personal wellbeing of mothers, some few respondents misinterpreted the practice. To such mothers, EBF was perceived to have several disadvantages to both mother and baby, and we found such information to contrast with some earlier responses on knowledge of EBF. Several personal and cultural reasons accounted for the early introduction of babies to substitute foods and liquids. Women held the assumption on the irreplaceable nature of water required to wet the throat of babies and subsequently ease the pains associated with breast sucking. One woman expressed her worries pertaining to the comfortability of EBF saying that,
“to be only breastfeeding the baby for six months with breast milk brings a lot of disadvantages to the mother. For instance, because you do not give the baby water and food to wet the throat, it is always dry and he sacks the breasts vigorously, which creates pains for the mother. But if you give the water, it will soften the throat and he will suck the breasts slowly” (Mother, FGD, Community 2).
In the same regard, some mothers believed a baby could die from thirst, if exclusively breastfed. Thus, the need to quench the thirst of babies with water was seen as a mechanism against such threat to the baby’s life. The narratives below suggest that it was not only breast milk that enhanced the health and development of babies.
“In my opinion, it is not only breast milk that makes children grow well. We did that giving them water, they get well and become adults ( Mother, FGD, Community 2).
In understanding how the participants perceived EBF in terms of duration and content of the practice, we found consistency in the description of the EBF information they shared. In their explanation, the first-time mothers emphasized the duration for the practice. One woman, for example, mentioned, “Exclusive breastfeeding means, when a woman delivers, she should breastfeed the baby for six months….” (Mother, FGD, Community 2). This response was similar to that of the other mothers indicating that almost all the respondents knew the duration for EBF as determined by international standards. In addition to understanding the content of EBF practice from the perspective of first-time mothers, another mother added, “She [the mother] should not give the baby food nor water until he attains six months” (Mother, FGD, Community 2).
We further explored participants’ perceptions on the frequency of EBF. However, our findings show a few discrepancies pertaining to the acceptable number of times a child needed to be breastfed. Some of the first time mothers were of the view that a baby must suckle an uncountable number of times in a day while to others breastfeeding their infants for not less than 10 times in a day was seen as ideal.
Cultural practices which inform decisions to breastfeed
The findings revealed interesting cultural complexities regarding decision making on breastfeeding practices. To a large extent, decisions on composition of infant feeds and onset and duration of breastfeeding were all culturally predetermined by existing norms within Kassena-Nankana. Although the mothers involved in the study admitted to have been taken through some form of EBF counselling and education, not all the mothers were able to strictly adhere. This was due to the existence of certain cultural structures that hindered the practice of EBF. Focus group discussions in community one for instance, revealed the culturally tainted perception on colostrum, which restricted a mother’s ability to breastfeed right after delivery. One mother mentioned the following:
“When a woman delivered they would not allow the baby to breastfed, saying that the first breast milk was dirty. They would rather look around for a woman who had delivered some days before to come and breastfeed the newborn baby.” ( Mother, FGD, community 1).
Also, certain rituals are often performed with the intention to test the quality of the breast milk and to purify it. It is only after these rituals are performed that a decision to breastfeed the baby was taken. This practice performed for first-time mothers and their babies is referred to as “Kacheeri” in Kasem and “pog-saare” in Nankani. The FGD in community two revealed that the practice involved expressing the breast milk of a mother who had just delivered into a calabash often done by the elderly women in the house, which usually includes the mother-in-law. This is to determine whether breast milk is good for consumption by the baby or not. Live ants are then put into the calabash of breast milk if the ants survive and are able to crawl out then the milk is graded as good for the baby. Otherwise, help from the herbalist is sought to purify the breastmilk and the baby is fed on other foods such as cow milk, millet flour, water and other herbal concoctions while awaiting the mother’s breast milk to be purified. Duration for the purification process was also dependent on the promptness of the herbalist’s judgement. Thus, the herbalist is a key figure in the determination of breastfeeding practices in Kassena-Nankana. During the purification period, the mother’s breast milk will always be expressed and discarded.
Furthermore, the study revealed other cultural practices intended to keep the baby strong and healthy. More specifically, herbal concoctions were given to babies to prevent certain deformities that can affect the baby’s head (fontanels) or hinder their ability to walk. Such practices according to first-time mothers in community two, started immediately one delivers and was discharged from the hospital to the house, as older women were quick to commence feeding the baby their herbal concoctions. Concoctions may be given for four or three days to the baby girl or boy, respectively. Some of these beliefs were known by health care providers:
“I think it’s their belief; especially they are concerned with their fontanels, that if you don’t give medicine to the child, his/her head would divide” ( Health worker, IDI, Community 4).
“They [mothers who just delivered] are however allowed to breastfeed the baby on the first day but they [mother in-laws and other elderly women] still introduce the concoctions/herbs.” (Heath worker, IDI, Community 2).
Relational influences on EBF decision-making
Furthermore, the desire of a mother to exclusively breastfeed her baby could only materialize when significant family members, especially mothers-in-law consented to that decision. Thus, mother-in-laws also exerted much influence on the newborn baby and the mother. The findings indicate that mothers-in-law were the major enforcers of certain cultural formalities performed for first-time mothers and their babies upon reaching home after delivery. The study participants invariably described some mechanisms through which mothers-in-law and elderly women compelled first-time mothers to feed their babies with herbal concoctions believed for spiritual and sedative advantages. To support this assertion, one of the primary respondents highlighted that:
“The old ladies [referring to mothers-in-law and other older women] always say that if you don’t allow them to give the baby the herbal concoctions and water to drink and the baby is crying in the night, they won’t come to your aid. They will leave you alone to take care of your baby and that, it is the herbal concoctions and water that put the baby to sleep without worrying the mother.” ( Mother, FGD, Community 3).
Similarly, as peculiar to collective cultures, first-time mothers in Kassena Nankana did not have much control over their babies. Due to their inexperience and dependence the older women in taking care of their babies, they often become vulnerable and are at the mercy of the community gatekeepers for prevailing cultural norms. In addition, women were culturally expected not to act contrary to the dictates of in-laws, especially mother-in-law and other elderly women in the household. Therefore elderly women and mother in laws capitalized on this norm and restrictions on women, serving as a formalized structure to resist the practice of EBF. As was stated by one first-time mother:
“The old ladies don’t agree at all because they bath the baby and do everything so when you want to complain [against the use of herbal concoctions], they will tell you that once the child is delivered, he is no more your baby so you cannot control them. What they want was what they will do” (Mother, FGG, Community 2).
The contribution of the key informants also confirmed how family influence played an important role in the decision-making process for EBF. Therefore, a mother’s decision to exclusively breastfeed her baby for six months depends on the approval of key family members. A health care provider, for instance, expressed the difficulty with obtaining approval to exclusively breastfeed that,
“It’s not easy at all. For most of the mothers, their families and partners always complain because they think that the child is not only supposed to take breast milk” ( Health worker, IDI, Community 3).
In the same regard, a TBA also emphasized the resistance to EBF indicating,
“They [first-time mothers’ family] do not accept it at all; unless the young woman tells them she must follow what the nurses have told her to do. However, her mother-in-law will grumble saying they do not have any good food to eat, how can the baby feed only on breast milk? If she goes out and leaves her baby behind, they will give it water to drink” (TBA, IDI, Community 4).
Socio-economic factors influencing breastfeeding practices
Undoubtedly, mothers described EBF as economical, accessible, nutritious, as well as a means for promoting good health. Most women in the Kassena-Nankana Municipality engaged in productive roles simultaneously with the usual reproductive roles of childbearing and housekeeping. Thus, majority of the mothers interviewed were farmers, artisans and traders who could not afford to stay home all day to breastfeed their infants at the expense of these productive roles. In such cases, the need for supplementary food was necessary, leading to a rise in the demand for alternative milk for the child’s feeding in the absence of the mother. This assertion can be supported by a mother’s statement below:
“You know we have two types of milk, powdered milk and liquid milk. So, in my opinion, you should buy the liquid milk and keep so that when you are not around, they can feed the baby with that one” ( Mother, FGD, Community 3).
Similarly, the performance of other reproductive roles including house chores could render mothers unavailable to breastfeed always and this supports the argument made by one mother that “If you leave your baby behind and go to fetch water and he/she cries, the throat will dry and he/she may die.” (Mother, FGD, Community 4). This presupposes that EBF was seen as a threat to the baby’s life, making the utilization of alternative milk or water a preferred choice for infant feeding in the mothers’ absence.