Breastfeeding-Friendly Policies And Programs In Selected Public Universities In Ghana


 Background The United Nations through its Sustainable Development Goals 3 and 5 has championed Women empowerment for exclusive breastfeeding through various action plans and expected the concept to be decentralized through locally mandatory implementation of various institutional policies and programs in member Countries. Using Kabeer’s empowerment concept, the authors in this paper assessed the availability and implementation of breastfeeding policies and programs in selected public universities in Ghana. MethodsThe study design was an integration of descriptive, exploratory, and case study using an unstructured interview guide developed by the authors for qualitative data collection. Thematic analysis of data on breastfeeding experiences was done yielding three main categories (breastfeeding policy and programs, support, and views on breastfeeding) emerged during data analysis. The in-depth interviews of respondents lasted 60 minutes. The University of Cape-Coast Ethics Review Board gave ethical approval for the study. ResultsAlthough Ghana has ascribed to various international conventions on childcare and developed policies enshrined in its labour law to support breastfeeding, none of the universities in this study has a formal breastfeeding/childcare policy/program and there are no future policy plans for on-campus facilities to enhance breastfeeding. Financial cost emerged as a major challenge hindering the universities from implementing a policy/program in this regard, hence nursing mothers continue to make personal but challenging arrangements for breastfeeding on university campuses.Conclusions The finding that formal breastfeeding-friendly policy/program was unavailable in the various universities in Ghana reflects negative implications for childcare, hence achieving the Sustainable Development Goals 3 and 5 in Ghana. The authors recommend formal breastfeeding-friendly policies/programs as a criterion for accreditation of universities in Ghana to enhance childcare.


Abstract Background
The United Nations through its Sustainable Development Goals 3 and 5 has championed Women empowerment for exclusive breastfeeding through various action plans and expected the concept to be decentralized through locally mandatory implementation of various institutional policies and programs in member Countries. Using Kabeer's empowerment concept, the authors in this paper assessed the availability and implementation of breastfeeding policies and programs in selected public universities in Ghana.

Methods
The study design was an integration of descriptive, exploratory, and case study using an unstructured interview guide developed by the authors for qualitative data collection. Thematic analysis of data on breastfeeding experiences was done yielding three main categories (breastfeeding policy and programs, support, and views on breastfeeding) emerged during data analysis. The in-depth interviews of respondents lasted 60 minutes. The University of Cape-Coast Ethics Review Board gave ethical approval for the study.

Results
Although Ghana has ascribed to various international conventions on childcare and developed policies enshrined in its labour law to support breastfeeding, none of the universities in this study has a formal breastfeeding/childcare policy/program and there are no future policy plans for on-campus facilities to enhance breastfeeding. Financial cost emerged as a major challenge hindering the universities from implementing a policy/program in this regard, hence nursing mothers continue to make personal but challenging arrangements for breastfeeding on university campuses.

Conclusions
The nding that formal breastfeeding-friendly policy/program was unavailable in the various universities in Ghana re ects negative implications for childcare, hence achieving the Sustainable Development Goals 3 and 5 in Ghana. The authors recommend formal breastfeeding-friendly policies/programs as a criterion for accreditation of universities in Ghana to enhance childcare.

Background
Women's empowerment has remained a focal part of the United Nations (UN) declarations on women's issues since 1975 because of its importance in global development (Mandal, 2013). In various international development frameworks such as the UN Sustainable Development Goals 3 and 5; the UN conventions on child care/rights, women empowerment is considered an intrinsic goal for national development because of its pivotal roles in child health, care, growth and development (Chant & McIlwaine, 2009, p.206;Malhotra & Schuler, 2005;Desai, 2010). These initiatives have stimulated women's increasing engagement in various social spheres of life across diverse settings as women are increasingly bridging huge gender gaps with men in various social domains (Millazo & Goldstein, 2017).
Gender gaps in basic, secondary, and tertiary education have shrunk substantially in many countries over the past three decades (UNESCO, 2015). These improvements in the educational status of women are paving way for more women to participate in politics, governance, formal labor market, and public life (Sackey, 2005 . The entry of more women of childbearing age into job markets and tertiary institutions have made it increasingly imperative that support for breastfeeding and childcare are provided at workplaces and academic institutions. This study adopted an existing concept of empowerment from Kabeer (1999) and explored critical roles played in promoting the development and rights of women in paid employment and educational opportunities linking it to the support offered to students and employee mothers in public universities in Ghana. Kabeer (1999)  In terms of pressure from civil society, institutional actors, such as bilateral agencies and nongovernmental organizations also in uence policy and discuss issues related to women's rights and continued empowerment (Anyidoho & Manuh, 2010).
Ghana being a member of UN and a liate organizations like the International Labor Organization (ILO), has responsibilities to conventions and recommendations of UN a liates. Yet, apart from the Labor Act (Act 651of 2003) which guarantee twelve weeks paid maternity leave and a further extension in the case of multiple births or intrapartum and postpartum complications, and the Breastfeeding Promotion Regulation Act of 2000 (LI 667), regulating the marketing of breastmilk substitute, it appears Ghana has not fully implemented the ILO's conventions (No. 103 of 1952;No. 3, 1999;No, 156 of 1981;No. 183, 2000) and recommendations (No. 95, 1952;165, 1981;191, 2000) which seeks to broaden the scope and entitlement of maternity protection at work (ILO, 2012). It is important to build national consensus through research and advocacy to support women in balancing a formal job and academic responsibilities with optimum breastfeeding practices when required.
Over the past three decades, international development scholars have used the concept of empowerment as a guiding framework in championing women's development (Kabeer 1999;King & Mason 2001;Mandal 2013). According to Kabeer (2005), access to resources (economic, human and social) confer on individuals and groups ability (referred to as agency) to de ne and achieve their life's goals or the capacity to dominate the abilities of other individuals and groups through the exercise of authority or coercion. Resources together with an agency are the instruments of individual and group potentials for making choices in life (referred to as achievement). However, access to resources depends on rules and norms governing distribution and exchange in social institutions (Kabeer, 1999).
Based on Kabeer's concept of empowerment, the authors argue that without institutional arrangements and norms that are supportive of childcare in the formal labor market and higher institutions of learning, many women of childbearing age would be denied access to higher education and opportunities to participate in the formal labor market. Based on this perspective, the concept of empowerment, as emphasized by Ranjula (2007), can be seen as transcending beyond mere economic betterment and wellbeing of women to exclusive breastfeeding which forms one of the strategic gender issues discussed in this paper.
Exclusive breastfeeding in Ghana usually declines during the third month of infants' life; a situation which is attributed to the practice of women returning to work after maternity leave at which time the infant will be three months old (Ghana Statistical Service, 2014). Studies have shown that the multiple roles of women con ict with their ability to perform optimum breastfeeding responsibilities, especially in cases where remunerated work is crucial to supplement the family budget (DeRose, 2003; Amoah, 2018).
Further, the maternity protection provision of the Labor Act in Ghana does not extend to female students of higher institutions of learning who become pregnant and deliver in the course of study.
Even though some studies have reported the plight of employee and student mothers on university campuses (Esia-Donkoh, 2014), there is limited evidence of actions taken by university authorities to provide support for students and employee mothers (i.e. paid maternity leave for working mothers and provision for student mothers to differ a program after childbirth if required). Additionally, apart from exibilities in allowing nursing mothers on the various university campuses for breastfeeding, there is no further support given to working and/or student mothers within the general framework of promoting the development and rights of women to equal opportunities in society. The few studies that have explored institutions provide for women to effectively combine their formal job or academic responsibilities with their day-to-day duties of providing optimum breastfeeding practice and childcare? The aim is to obtain answers to this question for lling these pockets of grey spaces identi ed in the current literature on women's development and the current national effort in empowering women in Ghana by exploring public universities' support for breastfeeding and childcare among students and employee mothers.

Design
The authors used an integrated descriptive, case study, and exploratory research design with a qualitative approach for data collection and analysis. The COREQ checklist (https://www.equatornetwork.org/reporting-guidelines/coreq/) provided additional guidance for reporting the study. The choice of this integrated design aligns with the study objective to examine the policies and programs available in public universities to support breastfeeding and childcare practices for employee and student mothers.

Target population
The target population for this study comprised employees, the management of the universities, and student mothers in public universities in Ghana. The target institutions (KNUST, UCC, and UEW) and respondents for the study were purposively selected. The unique characteristics of these universities make them suitable for this study. In the case of UEW, which has four satellite campuses, three out of its four campuses including the main campus were selected at random as per the study inclusion criteria.

Inclusion and Exclusion criteria
Participants in the study were senior staff members from key divisions of the respective universities whose activities have a direct bearing on the research topic (i.e Human Resource Division, Quality Assurance Division, Academic Planning Division, O ce of the Dean of students and the University Teachers Association (Local Branch).

Data Collection
Author developed an unstructured interview guide was used to collect data from respondents in the identi ed institutions. The interview guide was adapted from the ILO's maternity resource package (ILO, 2012), which spells out conditions for embarking on paid maternity leave. Additionally, an interview guide developed for a previous study by Nkrumah and Gbagbo, (2018) was also used as a guide. Interviews commenced after formal approvals were obtained from the three universities and respondents. Data was collected using author developed interview guides and eld notes. The interviews lasted between 40 to 60 minutes and discussions continued until saturation was reached when no new related issue and views no longer came. Data were collected between April and July 2018 using the research instruments and eld notes. All interviews were conducted in English. The Institutional Review Board (IRB) for research Ethics at the University of Cape-Coast gave ethical approval for the study.

Data Analysis
Data Analysis was done manually. In the manual analysis, the data collected were transcribed immediately after each interview and analyzed using a thematic analysis approach. The transcribed data was tabulated with two columns (A and B). Column 'A' contained the transcribed data and column 'B' the eld notes. This rough tabulation was done to compare the transcribed data and eld notes so as to ensure that no relevant information was omitted. The synchronization of the transcribed audio and eld notes constituted the nal results from the eld work. Table 1 presents the distributions of respondents. Twenty-four respondents from 5 o ces in the respective universities participated in the study. The distribution includes the Human Resource Division (6), Quality Assurance Division (6), Academic Planning Division (6), the o ce of the Dean of students (3), and three respondents from the University Teachers Association (Local Branches). Three main themes (breastfeeding policy and programs, institutional support, and views on Breastfeeding/Childcare Support) emerged during data analysis. The breastfeeding policy and program had 3 sub-themes; institutional support on the other hand has 1 sub-theme and views on breastfeeding/childcare support have 2 sub-themes (Table 2).  This sub-theme exhibited o cial policies and programs of the university on breastfeeding and childcare related supports. It is concerned with the various policy and programs provided by the universities to help student and employee mothers cope with breastfeeding and childcare. It was observed that, although the various universities had some exible and informal arrangements to support breastfeeding mothers (i.e taking short breaks to breastfeed, closing earlier than o cial working hours, and in some cases bringing nannies around the work/school environment to prompt mothers when their babies require breastfeeding). There were however no o cial policies and programs binding these exibilities. A respondent explained that '--we are humans, for that matter, we ensure some exibility in these issues to ensure our nursing mothers don't unnecessarily deprive their babies of breastfeeding when required…' (Human Resource Manager, University 1).

Conditions of Work (CW)
Despite comprehensive policies on the conditions of work with respect to childbirth in the various universities involved in this study, there were no explicit formal policy documents for breastfeeding and childcare in the three participating universities. The closest available document to childcare policy was the condition of work (CW) of the three universities which guarantee maternity protection for employee mothers in line with the Labour Laws of Ghana. The content of this document is explained to employees during orientations and copies are made available in faculties and department o ces, online, and in libraries of the universities.
In addition to the CW of the universities, two of the universities had provisions in their strategic plans to provide childcare related support to both students and employee mothers. Even though one of the universities has a directorate that champions gender issues, speci c policies, and programs to support childcare and breastfeeding were not available. Heads of some key units in two of the universities indicated that the strategic plan of their university has strategic goals towards promoting infants and child care at the university. One university had plans to provide on-site crèche for both student and employee mothers. An o cer from the planning unit in one of the universities outlined some provisions in their strategic plan as follows. 'This issue has never crossed our mind as an institution, but it's worth considering for our future plans since it's a relevant issue for our females'. (Local UTAG executive, University 3)

Maternity Protection Privileges
All o cials interviewed in the three universities reported that 'employee mothers are entitled to the statutory maternity leave but no such provision for student mothers. Some o cers indicated that: '…….where a mother encounter complication, the case then moves beyond pregnancy.....the employee will have to follow the procedure for that......once this is done, we extend the maternity leave'. (HR representative of university 3).
'……we have provisions for paid maternity leaves for our employee mothers but there is nothing like maternity leave for student mothers….. At best a student mother is allowed to defer the course either on health grounds or upon a reasonable request to nurse a newborn baby.' (O ce of Dean of students, University 2).
Additionally, employee mothers were found to have the privilege of taking casual leave or leave of absence where necessary. It was also noted that employee mothers are allowed to arrange for their annual leave at the expiration of their maternity leave. On resumption from maternity leave, mothers are made to work ve days weekly or 20-hours per week (5/20) for nine consecutive months instead of the usual ve-days, 40-hour work per week (5/40).
A review of student handbooks of the universities revealed the existence of procedures that partially support academic work and childcare. The universities provide counseling services for academic, social, and personal issues affecting students. They also have in place procedures for deferment of programs and examinations. However, deferment of programs has some limitations. As part of the policy, a student cannot defer his/her program in the rst year of admission. Where applicable, deferment is limited to two semesters. Only one university had a maximum period of four semesters on grounds that the deferment period would not exceed the maximum period allowed for completion of the program.
In terms of housing or on-campus accommodation policies, none of the universities had speci c accommodation arrangements for nursing mothers. This was explained that pregnancy among students is usually not predictable for the university to invest in such a policy/program.
'…….we are concern with academic work and not childbearing issues….. A woman who opts to be pregnant in school is expected to make her own arrangements to nurse her baby…' (Quality Assurance Directorate, University 1).
'…….the University has plans to build mother and child hostel with facilities convenient to accommodate nursing student and employee mothers in future but not now.…..'(Academic Planning Division, University 3) Institutional breastfeeding Support All three universities did not have designated facilities for breastfeeding. In one of the universities, o cials indicated that by convention, employee mothers are not expected to come to work with babies. The workplace is considered not conducive for nursing babies and breastfeeding break is not practiced.
An o cial indicated that: '.... employees are not allowed to be at work with their babies. Though this is not a policy. I think the work environment could be hazardous to the child'. (HR representative of university 2) '.....no, we don't have breastfeeding facilities or a lactation room. There is a kitchenette but since employees are not supposed to come to work with babies, I don't think the kitchenette will serve that purpose'. (HR representative of university 3) In another university, an o cial said that the university does not regulate workplace nursing, hence have no ceiling on the number of breaks available to a mother in a day. Despite this exible work environment aimed to enhance child care, most employee mothers choose not to come to work with babies so as to avoid interfering breastfeeding with their work.
'Breastfeeding staff can break anytime to breastfeed their babies provided there is no pressure or workload on them'. (HR representative of university 1).
Likewise, there is no policy in any of the Universities that prevents student mothers from nursing their babies on campus.
'Although this is an academic environment, people have their rights to childbirth and childcare hence, the university does not prevent student and employee mothers from nursing their babies in any of these university campuses…. What we discourage however is for babies to be left to loiter around unattended to and disturbing o cial work and lectures as usually seen during our sandwich and weekend programs…..'(HR representative of university 2).
Only one of the universities has a purposefully built but privately managed on-site crèche situated in close proximity to lecture halls and administrative o ces. The remaining two universities didn't have onsite crèche for employees and student mothers.
Childcare related support The practice of ve-day 20-hour work per week (5/20) "half-day" was found to be substitutive to breastfeeding break. As part of exible work schedule practices, employee mothers can arrange with their immediate boss on which time of the day to report to and close from work for their 4-hour work per day. A human resource o cer explained further: 'There is no breastfeeding break because of the half-day........but there is exibility, for instance, if a staff is supposed to report at 8 am and close at 12 pm, she can arrange with her head so she can come at 9 am and close at 1 pm'. (HR representative of university 3) O cials interviewed indicated that they resort to the various internal arrangement because the universities have no standard procedures on exible work schedules. In one of the universities, an o cial mentioned that the Vice-Chancellor is supportive of women's welfare and that housing arrangements for students are made to favor female students. There was however no future plans for on-campus accommodation for student mothers. Rather, the universities have breastfeeding promotion and education programs for employee mothers at the universities' hospitals as part of maternity services.
'......at the university hospital, we have a complete area for pregnant women...... the staff is aware of it and they go there for antenatal, weighing and receive breastfeeding education'.
(HR representative of university 1) 'I don't think we have such programs, but we have breastfeeding awareness creation in the departments annually'. (HR representative of university 2) Views on Breastfeeding/Childcare Support This category provides information on university management perception about the workplace and oncampus support for breastfeeding and childcare. Management perception of support and perceived challenges are the sub-categories.

Management Perception of Support
In one of the universities, it was mentioned that management considers breastfeeding as an important element of infant care due to its immense bene t to mothers and infants. An o cial from another university said providing support for breastfeeding and childcare is about the welfare of employees and their children, as such the university will support it. Another o cial also mention some health bene ts of breastfeeding and suggested that it is important to support employee mothers. However, no mention was made of support for student mothers to help them combined childcare and academic work effectively.

Perceived institutional challenges
Financial cost emerged as a major challenge hindering universities' support for breastfeeding and childcare. All o cials interviewed concluded that maternity leave is expensive in terms of loss of manhours. Cost of relieving duties, di culties in nding a replacement for staff going on maternity leave, Human resource representatives interviewed suggested that future review of the maternity protection provision of the Labor Act should consider extending the period of the "half-day" currently enjoyed by mothers instead of the maternity leave duration. They also proposed the implementation of baby and child-friendly work environment initiatives such as the provision of breastfeeding rooms and on-site crèche in place of extension of the maternity leave period. Initiatives such as allowing employee mothers take maternity leave in addition to current and ensuing year's annual leave were proposed.

Discussion
The ndings suggest gaps in breastfeeding and childcare provisions in public universities in Ghana, which have a policy and program implications as the present arrangement is discriminatory and nurtures gender inequality. In the works of Sholkamy (2010) on women empowerment within the Arab world, advocating for women's right to work in the formal labor market, acquire property, and freedom to speak on issues relating to their safety and sexuality goes beyond providing access to micro-credit and sewing machines. This shows that efforts to promote women's empowerment and rights to equal opportunities, especially in the Ghanaian context, also need to transcend mere livelihood empowerment and social assistance programs to genuine initiatives that weaken social and institutional barriers to equality. collaborations, and funding support to be done to move this idea, which might not be a top priority for most of the universities in the short term.
Flexible work arrangement is not standardized across units and is left to the discretions of the various heads of departments and units. This has the potential to deny employee mothers the exibility required to combine work and optimum breastfeeding and childcare in circumstances where the predisposition of ahead of unit or department is not supportive of nursing and childcare. Only one out of the three universities studied was found as an exemplar in childcare arrangements. This university has a purposefully built crèche. However, the location of the facility is quite distant from some departments; a situation that can challenges mothers' ability to provide optimum breastfeeding. It must be noted that the maternity protection provision of the labor act and by extension, CW of the universities do not extend to student mothers. The only privilege available to students and/or expectant mothers in the course of their study program is the option for one-year deferral, in cases of pregnancy or childbirth. Yet, the deferment policies of public universities are subjected to certain limitations and exclude rst and nal year students from enjoying such privileges. Therefore, students who are not sure of readmission prefer combing these two incompatible roles (Nkrumah & Gbagbo, 2017).
Although the study did not assess university management knowledge on the bene t they stand to gain from providing breastfeeding support at the workplace, it was evident that they are aware of these bene ts. Yet, no remarks were made regarding breastfeeding and childcare support for student mothers. O cials rather pointed out likely challenges such as Cost and work overload to come their way should there be an extension of maternity leave beyond the current period. It was also noted that making provisions to support student mothers to provide the necessary care for their babies whilst pursuing academic programs on the various university campuses is not one of the immediate priorities of these universities. Although it was observed that such provision is desirable, it is not mandatory nor an urgent need considering the population of students faced with such challenges.
The observation that Universities in the study do not have adequate policies, programs, and facilities to support breastfeeding and childcare for employee and student mothers, to a large extent discriminate against women's right to equal opportunities for work, education and their ability to freely exhibit their fundament human rights of childbirth by choice in an academic environment. The absence of a formal breastfeeding/childcare policy and program in the various universities could have negative implications for achieving the Sustainable Development Goals 3 and 5 in Ghana. This de ciency has the potential to also negatively affect women's development and rights to equal opportunities in Ghana.

Limitations
The study design had a limitation because of its scope which excludes data from student mothers to ascertain their challenges relating to childcare on campus. The study was also silent on work performance appraisal reports and academic performance of employees and student mothers to critically establish the effects of on-campus childcare on performance for decision making.

Conclusion
Assessing the availability and implementation of breastfeeding policies and programs in the selected public Universities in Ghana shows a lack of formal breastfeeding policy/program in the various universities. These observations could have negative implications for achieving Sustainable Development Goals 3 and 5 in Ghana. The author, recommends that the national accreditation board for tertiary institutions should incorporate childcare modalities as part of the requirements for the accreditation of universities in Ghana to enforce the law. This when done, will enhance on-campus facilities for breastfeeding and childcare which will empower women of reproductive age to combine their reproductive intentions with academic pursuits at the tertiary level. Additionally, a national qualitative survey is also recommended to assess the current status of breastfeeding and childcare support from the perspectives of employers, employees, and students in the various tertiary institutions in Ghana to guide policy and program decisions/interventions. We declare no con ict of interest in this study.

Funding
There was no funding for this study

Authors' contributions
Author one (F. Y. G) reviewed the literature, participated in data collection, data analysis, interpretation of results and drafted the manuscript. Author two (J. N.) conceptualized the study, took part in the literature review, data collection, data analysis and interpretation of results. Both authors reviewed and approved the nal manuscript before submission.