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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
3. Sample Characteristics
1. Introduction

Characteristic
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.
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, 2001:1-49
3.Karen M Edmond, Charles Zandoh, Maria A Quigley, Seeba
Amenga-Etego, Seth Owusu-Agyei, Betty R Kirkwood. Paper in press in
Pediatrics: Delayed breastfeeding initiation increases risk of neonatal mortality.
Study area
4. Results
 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

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.
<20
21-30
31-45
Residence
Urban
Rural
Education
None
Primary
> Primary
Ethnicity
Akan
Northern
13 (25)
17 (33)
22 (42)
9 (17)
43 (83)
24 (46)
10 (19)
18 (35)
27 (52)
25 (48)
 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.
2. The study
n (%)
Age
 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.
‘I don’t 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 insisted…there 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’
 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.
‘I didn’t get any advice because I was old
enough to know what to do with my baby’.
 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.
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’.
Box 1: What does not having enough milk mean?
No milk at all:
‘I didn’t 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 isn’t good for the child’
‘The breast milk was coming but it wasn’t 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.