Early Initiation of Breastfeeding in Ghana: Barriers and Facilitators Charlotte Tawiah-Agyemang1, Zelee Hill2, Alessandra Bazzano2, Karen Edmond1, 2, Betty Kirkwood2 1 Kintampo Health Research Centre, Ghana. 2 London School of Hygiene and Tropical

1
Early Initiation of Breastfeeding in Ghana
Barriers and Facilitators Charlotte
Tawiah-Agyemang1, Zelee Hill2, Alessandra
Bazzano2, Karen Edmond1, 2, Betty Kirkwood2 1
Kintampo Health Research Centre, Ghana. 2 London
School of Hygiene and Tropical Medicine

• 1. Introduction
• There has been little change in neonatal
  mortality in developing countries1,2 and feasible
  home-based interventions are urgently needed.
• A recent Ghanaian study found 30 of infants did
  not initiate breastfeeding on the day of birth
  and that these infants had a 2 times higher risk
  of neonatal death than those who initiated on day
  one3.
• Programs targeting early infant feeding could
  have a significant impact on neonatal mortality
  but designing effective interventions requires
  understanding the barriers and facilitators for
  early breastfeeding.

3. Sample Characteristics
References 1. Lawn J. Cousens S, Zupan J. 4
million neonatal deaths When? Where? Why? Lancet
2005 Published online Mar 3 2005. 2. Save the
children. State of the world's newborns 2001. A
report from Saving Newborn Lives. Washington DC
Save The Children, 20011-49 3.Karen M Edmond,
Charles Zandoh, Maria A Quigley,
SeebaAmenga-Etego, Seth Owusu-Agyei, Betty R
Kirkwood. Paper in press in Pediatrics Delayed
breastfeeding initiation increases risk of
neonatal mortality.

• 4. Results
• 15/21 women who initiated late reported that they
  did not have enough breast milk (see box 1)
  saying that there was no point, or that it was
  unfair, to give a child an empty breast.
• Beliefs about first milk were mixed. A belief
  that it was harmful sometimes resulted in delayed
  feeding as women waited for the good milk to
  come, however, some women squeezed the milk out
  and fed on day one.
• Other reasons for late initiation were that the
  baby did not cry (indicating it was not hungry)
  or because the mother or baby needed rest after a
  long or difficult birth
• Babies who were breastfed on day two were given
  nothing at all or water and those breastfed
  later, a variety of liquids including water,
  evaporated milk, bead or shea butter dissolved
  in water, coconut water or Milo (malted chocolate
  drink).
• Advice was an important reason for early
  initiation and was most often given at a health
  facility by the midwife. This is reflected by the
  fact that only 3/21 women who initiated late gave
  birth at a health facility compared with
  18/31women who initiated early.
• Advice on initiation was occasionally given at
  ANC (attended by all but two women) or by family
  and friends. This was usually to first time
  mothers.
• Some women (mostly from the Bono tribes) had
  beliefs that encouraged early initiation such as
  giving the baby the breast to pull to encourage
  milk to come.

Study area

• I dont give the first breast milk to the baby.
  I gave the breast milk to the baby the next day
  after birth when the first milk has mixed with
  the second breast milk.
• I start feeding when the baby begins to cry.
• It took a long time for me to push the baby out
  and the child was weak and slept the whole day.
• The nurse brought me the baby and told me to
  start breastfeeding, I wanted to have some rest
  but she insistedthere was no milk as I could not
  feel anything coming out when the baby was
  sucking. I told the nurse but she said I should
  put it in its mouth and through that the milk
  will come
• I didnt get any advice because I was old enough
  to know what to do with my baby. 
• There is no breast milk but you have to give the
  breast to him to suck the red one and the proper
  one will come.

• 2. The study
• Aim Explore why women initiate breastfeeding
  early or late, who gives advice about initiation
  and what food or fluids are given when initiation
  is late.
• Study site Kintampo district is predominantly
  rural, with little electrification, one hospital
  and seven health posts. The district is part of
  the ObaapaVitA Vitamin A and maternal mortality
  trial area.
• Data Collection

• Women who had given birth in the last two months
  were identified from the ObaapaVitA surveillance
  system.
• Qualitative case histories were collected from 52
  women selected to capture a range of initiation
  timing and factors associated with timing.
• Information collected included a description of
  when, what and why infants were first fed and
  where women got advice about feeding.
• Fieldnotes were taken during the interview and
  converted to fairnotes manual coding and content
  analysis was then conducted.

Box 1 What does not having enough milk mean?
  No milk at all I didnt give breast milk
because there was none in my breast- I squeezed
and realized that nothing at all was coming out
  The breast was flat and nothing came out of
it   No milk sometimes means no white milk I
had no milk in my breast I squeezed and nothing
came out when probed about first milk, I did
have a little red milk at birth but I squeezed it
out because it isnt good for the child   The
breast milk was coming but it wasnt thick and
the breast was very light  

• 5. Conclusions/implications
• Having no, or the wrong kind of milk, is the main
  reason breastfeeding was not initiated within the
  first day of life.
• Women are willing to change their initiation
  behaviour if given advice and some women have
  beliefs that facilitate early initiation.
• Currently advice is mainly provided by midwives
  at the time of birth, but many women deliver at
  home and do not receive any advice. Most women
  attended antenatal clinics during pregnancy,
  which may offer a good educational channel.