This study sought to describe the food items and herbs used to enhance breastmilk production and the beliefs of their usage effectiveness in two regions of Ghana. The results show that special foods and selected herbs are widely used to enhance breastmilk production in Ghana and constitute an important part of the diet of lactating mothers. These special herbs and selected foods have been categorized into 3 groups; groundnut related lactogogues, herb related lactogogues and hot related/consumed lactogogues. There were few reported problems with breastmilk production and use of lactogogues in pregnancy.
Awareness of the use of selected foods and herbs to aid in breastmilk production was high in both regions, this is consistent with studies conducted in Malaysia and Australia [16, 21] where high knowledge on breastmilk production aids were reported. A study in the United States also reported high awareness on the use of special aids especially fenugreek to promote breastmilk production . People with high knowledge would have been aware of substances used to help in breastmilk production, in most cases awareness increases curiosity and the urge to learn more about these substances and hence the high level of knowledge reported.
The current study showed that most lactating women obtained information on selected foods and special herbs from the home mostly parents and grandparents. Contrary to the findings of the current study, some studies have reported the internet as a major source  , for other studies, friends and family  and health service providers [22, 23] were the main sources of information on breastmilk production aids. Our results are consistent with the study by Budzynska et al  in which most cultures transfer knowledge of breastmilk productions aids from generation to generation.
The high prevalence of lactogogue use among lactating women in both regions is consistent with earlier studies [25-27] but a little higher than reported in studies from some developed countries [11, 23, 28]. Wealth inequality could play a role in healthcare access and delivery, respondents in the current study (a developing country setting) where healthcare access is relatively low may be less likely to seek professional advice from healthcare professionals – resorting to information from the family on which foods and special herbs could be used to support breastmilk production. It is expected that access to professional advise might have increased the options available for respondents from developed countries and, therefore, the low usage of breastmilk production aids especially herbs that may have little scientific evidence of efficacy and less likely to be recommended by professionals. A few mothers reported having breastmilk production problems but the majority still used lactogogues, this finding may suggests that these foods and herbs are used largely for prophylactic purposes or as part of usual post-partum diet rather than as a lactogogue or for curative purposes. However, we are unable to determine how many mothers are reporting no breastmilk problems because they had used lactogogues as a prophylaxis.
The current study showed that almost all respondents from both regions reported experiencing the effect of lactogogues within 24 hours of use. Similarly, other studies reported effectiveness of lactogogues within 24-72 hours [12, 29] . However, some studies have reported increased breastmilk production following lactogogue intake without indication of the duration for which effectiveness was felt [21, 30]. This highlights that breastmilk production aids such as the selected foods and special foods are highly perceived to be effective irrespective of the time taken for their effects to be felt but this finding does not indicate scientifically proven efficacy because they are participant perception of effectiveness.
The high use of groundnut/peanut in most of the lactogogues preparations, especially in the Brong-Ahafo region have been reported in other settings. The most popular lactogogue, fenugreek, used mostly in Europe and Asian countries [12, 31, 32] is from the pea family which includes groundnuts. Differences in which sub-type of the pea family is used may be geographically dependent on availability. Groundnuts are abundant in Ghana as opposed to fenugreek. There have been reports in the literature about their use and potential to increase breastmilk production . They are protein rich foods which is believed to explain the lactogenic effect. The exact mechanisms are yet unknown but proposed to be through the action of special amino acids which are absorbed into the blood stream and synthesized to milk proteins, such as whey and casein in the mammary glands . They could also exert a lactogenic effect by providing a source of fatty acids for breastmilk production .
Lactogogues taken hot (hot-related) were also widely used in the enhancement of breastmilk production mostly in the Northern region of Ghana especially hot black tea. This finding is in line with a study which identified black tea (Camellia sinensis) as a lactogogue even though caution was indicated due to the presence of caffeine in most commonly used brands in our setting which could cause irritability in the child if taken in excess . The women particularly emphasized that the tea needed to be hot to be effective. Taking into consideration the temperature of the tea and the components of the tea, there are two schools of thought on the mechanism of action to promote breastmilk production in lactating women. The first been: Tea contains polyphenols and flavonoids which are important components that promote breastmilk production through an interaction with dopamine receptors  and the second explanation been that, the hot temperature of the tea might cause a rapid increase in blood circulation or stimulate circulation for faster let down of milk. Mothers also said the hot tea ‘melts’ the contents of the breast for more milk production.
Herb and selected local vegetables were also a major lactogogue in this Ghanaian population. Their use was, however, relatively low compared to the other lactogogue types. The common herb used in the Brong-Ahafo region was Abemudro (a polyherbal formulation) mostly used to improve lactation, an earlier study in the eastern region of Ghana also reported its usage . The use of lactogogues during pregnancy, though it was low, it was believed to prepare the breast for more milk production after birth.
Our results could be useful in targeted education for lactating women. Knowledge about the food items, herbs and beliefs of efficacy could also help healthcare professionals plan contents of educational programmes targeted at lactating mothers. This is important given the high belief of efficacy in these products without established scientific evidence of any effect. We can only reasonably speculate that because the herbs and foods identified in this study are commonly used in Ghana without apparent health harms may indicate some level of safety. However, as we show in this study, usage frequency and modes of preparation of these products may be different when they are destined for lactogogues than for normal usage. Therefore, there is the need for further research to determine their level of safety and efficacy as lactogogues in Ghana. In addition, high beliefs in the efficacy of local herbs and selected food items in promoting breastmilk production could mean that lactating women who have breastmilk production problems may not or will delay in seeking professional care – affecting effective breastfeeding. Therefore, it is important for healthcare professionals engaged in breastfeeding promotion to be aware of these practices and beliefs in order to identify and encourage those with problems to seek professional help.
This study has a number of strengths such as the use of FGDs to enhance a comprehensive profile of lactotogues used in the study areas. The use of two regions, chosen to represent the northern and southern parts of Ghana has enabled documentation of the different lactogogue use and practices. However, the study has some limitations worth noting. The exclusion of non-breastfeeding women likely introduced some bias in the lactogogue practices as experiences of current lactating women and non-lactating women may be different. However, inclusion of current lactating women possibly improved recall of lactogogue practices and beliefs. It is also possible that women who are more interested in using some foods and herbs as lactogogues during breastfeeding may recall their practices differently. In spite of these limitations, this study has provided ample light on the practices and beliefs of efficacy of special foods and local herbs used in promoting lactation in Ghana.