Introduction

According to the United Nations Children’s Fund (UNICEF), with respect to breastfeeding, every second counts in an infant’s life. Hence, the time at which it is initiated and its exclusivity for the first six months of life can make a whole lot of difference between life and death [1]. Early initiation of breastfeeding, that is, putting newborns to the breast within the first hour of their lives safeguards their survival and considerably reduces the risk of death during the critical neonatal period of life [2]. In addition, early initiation of breastfeeding has been described as an effective intervention that helps to establish exclusive breastfeeding (EBF) [3]. Exclusive breastfeeding for the first six months of life is a recommended intervention, in view of its established benefits of reducing the risks of morbidity and mortality in infants [3]. There is also evidence that EBF protects against pneumonia and diarrhoea–the two leading killers of children under five [1].

While breastfeeding is common in most parts of the world, EBF is not the norm. The situation is not different in Ghana where, according to the latest Ghana Demographic and Health Survey (GDHS) report of 2014, almost all children in Ghana (98 percent) are breastfed at some point in their life [4]. However, only 52 percent of children less than 6 months of age are exclusively breastfed; and the median duration of EBF is approximately four months instead of the recommended six months. A cursory study of previous GDHS reports reveals that, with regard to EBF, the prevalence increased considerably from 53% in 2003 to 63% in 2008, but declined to 52% in 2014 [4–6]. Therefore, according to the 2014 GDHS, the percentage of children aged between 0 and 5 months who were exclusively breastfed has decreased by approximately 17% between 2008 and 2014. It is important to acknowledge that the findings in the 2014 GDHS, which was the only available information representative of Ghana at the time of the study (in 2018), may not be an updated information. However, these figures suggest that the practice of EBF might be gradually declining among mothers and requires much effort to assess the factors leading to this occurrence. In addition, the prevalence of EBF reported in these demographic and health surveys obviously falls far below the widely accepted “universal coverage” target of 90% coverage [7].

The barriers which have been identified as preventing EBF are generally maternal, child and socially or environmentally-related. Maternal-related barriers to EBF include low educational level of mothers, working mothers, difficulties in obtaining maternity leave, increase in mother’s workload, less number of antenatal visits and lack of knowledge about EBF [8]. Child-related factors such as being a male and having been delivered by cesarean section have been reported to reduce the likelihood of being exclusively breastfed [9]. Social and environmental barriers to EBF which include lack of spousal support with chores, controversial health messages on EBF delivered at health facilities and unsupported environments for EBF in public places have been identified as discouraging EBF [10, 11].

It has been indicated that most infants are not exclusively breastfed but are given other foods or liquids throughout the first six months, due to cultural practices and beliefs and some misconceptions held by mothers [12]. These cultural practices, myths, misconceptions and beliefs influence the ability of most mothers to initiate breastfeeding within one hour after birth, practice EBF and prolong the duration of breastfeeding, particularly in low-income countries [13]. In Ghana, Tampah-Naah and Kumi-Kyereme [14] assert that the limited practice of EBF in all regions of the country can be attributed to cultural beliefs. However, there is little information regarding these cultural practices and misconceptions which are barriers to the practice of exclusive breastfeeding for the first six months in a developing country like Ghana. Most studies undertaken in the past to investigate cultural practices influencing optimal EBF practices were conducted among mothers [12–16] and grandmothers [16, 17]. For example, in the study of Thet et al. [16] which was undertaken in the Ayeyarwaddy Region of Myanmar (formerly Burma), the barriers to EBF were assessed qualitatively from the views of mothers, grandmothers, and husbands. Clearly, there has been less focus on context, norms and cultural practices influencing EBF from the viewpoints of health workers (HWs). However, recommendations from studies suggest the need for health professionals in various settings to understand and be well-informed about these cultural practices and misconceptions that act as barriers to appropriate breastfeeding practices [18, 19].

In Ghana, there is a dearth of information on barriers to EBF practices of mothers from the perspectives of Community Health Workers (CHWs) and Community Health Volunteers (CHVs) who play a major role in providing care to breastfeeding women, neonates and young infants when they undertake both home visits and community outreach programmes. We seek to fill this gap by assessing the perceptions of these group of HWs regarding socio-cultural influences and mothers’ misconceptions about EBF. Although, other key health professionals like midwives and nurses play significant roles in promoting child health and nutrition, the study focused on only CHWs and CHVs because of some reasons. The study concentrated on only CHWs and CHVs because they play an important role in the delivery of health care services particularly in rural settings where there are shortages of trained health care workers. Both CHWs and CHVs have been described as agents of behaviour change promotion as they interact with community members in their allocated catchment areas [20]. They are regarded as being in a better position to deliver crucial health messages, empower community members to enable them make informed decisions and therefore increase local access to health preventive measures [21].

Therefore, a better understanding of cultural practices and misconceptions that negatively imparts EBF practices of mothers can particularly guide CHWs and CHVs in developing interventions such as health talks which are culturally sensitive to help disabuse the minds of caregivers on issues regarding EBF. In addition, the findings can play a role in the development and implementation of some intervention activities by the HWs on the basis of the Motivational theory of role modeling [22] which highlights the power of role models (in this study, HWs) to serve as sources of inspiration and agents of behavioural change to their clients (in this study, lactating mothers). Therefore, this study assessed the cultural practices and misconceptions of mothers that influence EBF practices from reports of CHWs and CHVs (collectively referred to as HWs for the purpose of this study) working in two rural districts in Ghana.

Subjects and methods

Results

The demographic information of the HWs who participated in the study is presented in Table 1.

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Table 1. Demographic information of study participants.

https://doi.org/10.1371/journal.pone.0239278.t001

The findings that emerged from the FGDs are presented under three main themes: perceptions of mothers that prevent them from practicing EBF, misconceptions of mothers with regard to EBF and cultural practices in the community that prevent mothers from exclusively breastfeeding their babies. Most of the participants reported that they learnt about these misconceptions and beliefs from mothers they had come into contact with at their Child Welfare Clinics (CWCs). It is important to note that all the statements and reports presented in this study are perceptions of the HWs based on their interactions with mothers, grandmothers and observations made during their outreach programmes and home visits within their communities of operation.

Discussion

The perceptions and reports of Community Health Workers (CHWs) and Community Health Volunteers (CHVs) regarding the cultural practices and misconceptions of mothers that inhibit 6-months of EBF were explored through FGDs. According to the health workers, some misconceptions held on to by mothers prevented them from exclusively breastfeeding their babies.

The findings revealed HWs report that some mothers had the misconception that HWs themselves do not practice EBF. The statements from the HWs imply some mothers had the perception that nurses who advised them to exclusively breastfeed their babies were unfortunately going contrary to their own advice, which resulted in not encouraging some mothers to practice EBF. Although, the HWs did not confirm or refute this misconception and as to whether this perception is the real case, this report from the HWs has implications on the services that they provide to help mothers care for their babies. However, in support of the reports by mothers to this effect, studies that were conducted in Brazil [29] and Northwest Ethiopia [30] also found out that some health professionals were not adhering to the recommended period of exclusive breastfeeding.

In the study that was carried out in Northwest Ethiopia [30] which assessed EBF practices of nurses and midwives, it was found that though they had adequate knowledge on breastfeeding, their high knowledge level was not translated into their practice of EBF. The exclusive breastfeeding rate among the nurses was found to be 35.9%; and almost half (49.4%) of them exclusively breastfed their babies for only three months or less. Likewise, a study undertaken among health professionals in an accredited baby friendly hospital in Brazil revealed that only 28.3% sustained exclusive breastfeeding for the first six months of their babies’ lives [29].

Some of the common reasons mentioned by the nurses and midwives for their failure to exclusively breastfeed their babies included work-related problems, for instance, short three(3)-months duration of maternity leave, lack of nearby child care facilities and inflexible work schedules that prevented them from taking nursing breaks [29, 30]. It is important to note that these past studies [29, 30] were quantitative studies which were aimed at assessing the prevalence of EBF among health professionals and no information was obtained with respect to socio-cultural factors influencing EBF practices.

These reports however may suggest the need for HWs to act as "role-models" in order to encourage mothers to heed their advice as most mothers greatly rely on health workers’ advice on infant feeding, and consult HWs whenever they experience breastfeeding challenges. The recommendation on the need for HWs to act as role-models is based on the Motivational theory of role modeling [22] which has implications on the findings of this study. Role models through their exemplary deeds are often described as motivating others to set and achieve ambitious goals to follow their examples. The Motivational Theory of Role Modeling, highlights ways in which the influence of role models can be employed to improve role aspirants’ motivation, strengthen their existing goals, and facilitate their acceptance of new goals [22]. With regard to the applicability of the motivational theory to this study, the role modelling responsibility of nurses can be harnessed to increase the motivational level and facilitate the adoption of new practices (EBF) by role aspirants’ (in this study, lactating mothers).

Another misconception is based on the perception of mothers that their grandmothers and great grandmothers did not practice EBF, but their children survived and grew as expected. The responses of the HWs suggest that mothers in these rural settings are likely to tap into the experiences of grandmothers who may influence the breastfeeding practices of their daughters when they bring their own infant feeding beliefs and practices to support their daughters to enable them care for newborns. In a related study that was undertaken in rural areas in Kenya, mothers indicated that their parents advised them to give sugary water and other pre-lacteal foods to their babies, and it was difficult to ignore their advice. This was because their parents had gone through it before. They did not exclusively breastfeed their children. Yet, they grew as expected and were healthy [31].

An interpretation that can be given to the finding that mothers are likely not to practice EBF as a result of advices that are given by grandmothers can be based on the theory of planned behaviour. The theory explains the relationship between the intention to exclusively breastfeed, and the factors that affect a women’s final decision regarding exclusive breastfeeding. The theory explains how significant persons (in this case grandmothers) can determine and influence behavioural change and the adoption of new health behaviours. In this case, grandmothers might be perceived by mothers as good advisers, because of their knowledge of existing social norms, past experiences and this may influence their infant feeding choices. The implication of this finding emphasizes the need for HWs to also target grandmothers when planning and conducting health education programmes on child nutrition.

The responses of the HWs suggested that some mothers had wrong perceptions about the water content of breast milk perhaps because they do not have adequate knowledge about the water and nutrient composition of breastmilk. Similar to the reports of the health workers, other related studies reported that mothers had the perception that breastmilk alone was insufficient for their babies. Rather, mother believed that water in addition to breast milk was necessary to hydrate infants and to quench their thirst [32, 33]. The findings suggest that if HWs are able to address this knowledge gap of mothers using evidence to support their assertions; it may reassure mothers that the water and nutrient needs of their babies can be met by practicing EBF.

According to the HWs, some mothers also had the perception that gestures and actions by babies suggested their readiness to start eating other family foods. This finding is consistent with other studies that were carried out in Australia which explored why mothers introduced solid foods early [34, 35]. A major reason cited for the commencement of complementary feeding prior to six months of age was gestures and cues exhibited by infants, suggesting their readiness to start eating food [34, 35]. In these studies, mothers explained that these signals indicated that infants "wanted" or "were ready" for solid foods, regardless of their age. These findings imply that mothers have to learn and understand infant’s cues, gestures and behaviours regarding specific needs. This is especially important during the first few months of infancy when they are familiarizing themselves with a newborn baby. These reports by HWs suggest that the interpretations given to infant gestures and behaviours influence early introduction of foods and the inability of mothers to exclusively breastfeed their babies. This finding suggests the need to include in the health education of expectant mothers’ and “first-time” mothers’ interventions that focus on accurate interpretation of infant cues, gestures and behaviours as putative weaning signs.

There were reports that some mothers with male babies are unable to exclusively breastfeed them. Their argument is that since boys eat a lot as compared with girls, it is doubtful whether they are satisfied when fed solely on breastmilk for the first six months of their lives. In support of this assertion by some mothers, it was found out in some previous studies in Zimbabwe [36] and Denmark [37] that girls were introduced to complementary foods later than boys when they were less than six months old. In a related study conducted in Kenya, it was reported that mothers with male children complained that they breastfed often which sometimes made them feel dizzy after suckling. As a result, there was a greater propensity to an earlier introduction to other foods and shorter breastfeeding duration with boys than girls [13]. This misconception of some mothers that have male babies may be as a result of low or lack of knowledge about the potential capacity of breastmilk to optimally support growth and prevent malnutrition in infants regardless of the sex of the child [38]. Another reason that can be attributed to this misconception is perhaps the lack of guidance and encouragement given by HWs to mothers to enable them practice EBF. This misconception perhaps suggests the need for HWs to use scientific evidence to support the information shared with mothers. Alternatively, with the permission of mothers who have exclusively breastfed their male babies, HWs can use their children as examples during CWC sessions to encourage other mothers to also practice EBF.

This finding has implications for the need to intensify nutrition counseling services by HWs to boost the confidence of mothers that when they eat healthy foods, they will be in a better position to produce more nutritious breastmilk as reported in a systematic review paper by Bravi et al. [39] to satisfy their babies, regardless of their sex, while remaining healthy and strong as well. This misconception perhaps also suggests the need for HWs to use scientific evidence to support child feeding and nutrition information or recommendations that are shared with mothers. Alternatively, with the permission of mothers who have exclusively breastfed their male babies, HWs can use their children as examples during CWC sessions to encourage other mothers to also practice EBF.

The Health workers also reported the practice of giving new-born babies some herbal concoctions believed to confer protection and give some powers that fights against wicked spirits before they appear at public places such as at CWCs. The giving of herbal concoctions which is an example of pre-lacteal feeding have been shown to delay the initiation of breastfeeding [40], interfere with exclusive breastfeeding and makes it difficult for breastfeeding to be established in newborns. The use of herbal concoctions has been found to make newborns more prone to early risk of severe gastrointestinal infections [41] which can result in loss of appetite and consequently reduce their intake of breastmilk. These reports by the HWs have health and safety implications given that there are grave concerns with respect to the dosage and safety of herbal preparations. There is also the possibility that infants with their immature digestive system may have difficulty digesting, absorbing and utilizing these herbal preparations.

Another misconception of mothers reported by HWs is that babies who are not exclusively breastfed gain weight faster and grow better. This misconception is perhaps as a result of the perception that breastmilk alone does not satisfy babies and therefore might not support the attainment of any substantial weight gain in infants. In support of these assertions by mothers, some studies have revealed that longer duration of exclusive breastfeeding is negatively related to infant weight gain [38, 42]. In a systematic review report [42], it was concluded that duration of more than 4 months of exclusive breastfeeding may be associated with a reduction in weight gain in late infancy.

An explanation that can be given for the rapid weight gain in children who are not exclusively breastfed for six months but are quickly introduced to infant formula and other foods is their higher protein intake [42]. Hence, it is assumed that exclusively breastfeeding for the recommended period of six months may result in slower weight gain in later infancy. These findings suggest that HWs must emphasize more on the future or long-term benefits of EBF, such as its being protective against overweight and obesity and Type 1 Diabetes especially during the adulthood stages of life [43]. Regarding Type 1 Diabetes, the human milk contains substances that promote maturation of the immune system, conferring protection against its onset later in life [43].

The reports by the HWs also suggest that certain traditions and rituals that are performed for newborns, sometimes before a mother can start breastfeeding, could delay early initiation of breastfeeding, prevent EBF and lead to prelacteal feeding practices. An example is the practice of mixing corn flour and water which is given to newborns in most African countries [44]. Similarly, in a related study in slums in Nairobi, Kenya, light porridge was given to newborns because of the belief that children from the ethnic group, Luhya, are always hungry right from birth [13]. Another possible explanation that can be given to this practice is that corn is one of the major staple foods in Ghana. Hence, giving corn to infants can be a way of introducing them to a common food item that they are likely to eat for the entire period of their lives. These misconceptions and cultural practices that hinder EBF practices can prevent infants from reaping the benefits of EBF such as a lowered risk of gastrointestinal infection, pneumonia, otitis media and urinary tract infections [45].

Conclusions

Our results show that misconceptions of mothers and grandmothers and some cultural practices as reported by the HWs continue to hinder EBF practices in the study area. The findings reveal that long-standing cultural norms that encourage mothers to give their babies water and other herbal concoctions, even immediately after birth, still persist in the study area. Generally, as reported by the HWs, grandmothers did not support EBF and they influenced the breastfeeding practices of their daughters. The revelations made by the HWs also suggests a gap in the knowledge levels of mothers regarding the adequacy of only breastmilk in satisfying the hunger and thirsty needs of babies for the first six months of life. The findings also have implications for the need to engage grandmothers, mothers-in-law and other influential community leaders like queen mothers as stakeholders in the development and implementation of interventions to promote exclusive breastfeeding practices in the districts.

Acknowledgments

The authors highly acknowledge the data collection and management team made up of Mr. David Kwame Tsotorvor, Mrs. Victoria Parkoo, Mr Fabrics Asinyo, Mr Frank Kwasi Arthur and Mr Isaac Manford. The authors appreciate the study participants for providing a receptive environment for the study to be conducted. We also acknowledge all the support, technical advice and assistance in many ways given by the District Health Directors, Mr. Robert Kweku Bio and Mrs. Joana Amankwah, during the data collection period in the districts.