Knowledge and Perception of Appropriate Breastfeeding Practices

Sciknow Publications Ltd.
International Journal of Maternal and Child Health
©Attribution 3.0 Unported (CC BY 3.0)
IJMCH 2015, 3(2):56-64
DOI: 10.12966/ijmch.05.01.2015
Knowledge and Perception of Appropriate Breastfeeding Practices
among Grandmothers in Northern Ghana
Sixtus Aguree1,*, Victor Mogre2, Juventus B. Ziem3, Yahya Mohammed1, and Sulemana Issah1
1
Department of Community Nutrition, School of Medicine and Health Sciences, University for Development Studies, P.O.Box L 1883, Tamale,
Northern Region, Ghana, West Africa
2
Deaprtment of Human Biology, School of Medicine and Health science, University for Development Studies, Tamale
3
Department of Clinical Laboratory Sciences, University for Development Studies, Tamale
*Corresponding author (Email:[email protected])
Abstract- Support offered by grandmothers to new mothers greatly influences their breastfeeding habits. This study was
conducted in Tamale, Ghana, to assess the knowledge and perception of grandmothers on breastfeeding. It involved 400
grandmothers purposively selected from the study area between January and April, 2014. Data were analyzed using SPSS
(version 19.0), with a Chi-square (X2) test performed at a P<0.05 considered significant. The results showed that: 76% of
respondents were aware of appropriate breastfeeding practices; 88.2% were aware of exclusive breastfeeding practice; 55% gave
advice to mothers on exclusive breastfeeding; 61.5% believed that exclusive breastfeeding helped promote the health of both
baby and mother; and 69.5% said children should be breastfed on demand during the exclusive breastfeeding period. On early
initiation of exclusive breastfeeding, only 42.2% knew that the child should be latched to the breast within 1-hour after delivery.
Concerning colostrum, two-thirds of grandmothers believed that it had a protective effect on infants, with 78.2% of them
believing that it should be given to the baby whiles the remaining 21.8% believes that it should be discarded. Strong correlations
were established between: awareness and knowledge of appropriate breastfeeding practices; and grandmothers‟ knowledge and
likelihood of giving advice to mothers. Grandmothers that were aware of appropriate breastfeeding practices were more likely to
perceive it as good than those that were unaware of it (X²=65.506, P<0.001). Knowledge level of breastfeeding practices among
grandmothers was high, and they were more likely to have good perception of appropriate breastfeeding practices and gave
advice on it to mothers.
Key words-Tamale, Grandmothers‟ Knowledge, Grandmothers‟ Perception, Breastfeeding Practices
1. Introduction
Breastfeeding has always been acknowledged as the optimal
way to feed an infant and is recommended by the World
Health Organization (WHO) for all mothers unless medically
contraindicated. Timely initiation of breastfeeding is critical
and exclusive breastfeeding for the first 6 months of life is
recommended (WHO/UNICEF, 2002). Appropriate breastfee
ding is known to confer several benefits on the child and
mother, but this sometimes could be influenced by the family
(Beznerkerr et al. 2008). Grandmothers, are particularly
known to influence child feeding practices (Davies-Adetugbo,
1997; Sear et al., 2000 Aubel et al., 2004; Macharia et al.,
2004; Bezner Kerr et al., 2008; Aubel, 2012) and could
negatively influence mother‟s decision on breastfeeding
(Susin et al., 2005). Breastfeeding practices in Ghana are
sub-optimal (GDHS, 2008; ICF Macro 2010; MICS, 2011).
In Ghana, grandmothers spend a lot of time with their
grandchildren, maternal grandmothers particularly, usually
stay with their daughters during the first weeks and sometimes
months after birth. They usually bath the baby and spend a
great deal of time with these new mothers teaching them the
skills of motherhood and including child care. Unfortunately,
these grandmothers are left out of the maternal and child
health education programs in most parts of sub-Saharan
Africa including Ghana; the focus is usually on the mother of
the young child (Aubel et al., 2004; Lee and Garvin, 2003;
Waisbord, 2001) done by nurses (in Ghana) for pregnant and
lactating mothers during pre-natal and post-natal care
respectively. Considering the influential role these grandmo
thers play in child care (Bezner Kerr et al. 2008; Aubel, 2012)
and decision making regarding child‟s nutrition (Aubel, 2012;
Brown et al.2014), it is important that we know their
knowledge and perception of breastfeeding practices, as they
are sometimes seen as a barrier to breastfeeding practices
(Bezner Kerret al. 2007;Bezner Kerr et al., 2008). It reported
International Journal of Maternal and Child Health (2015) 56-64
that sometimes mothers only indicate that they practice
exclusive breastfeeding for instance, „to avoid being chastised
by hospital staff‟ though in real practice they do not practice
proper exclusive breastfeeding (BerzerKerr et al., 2008),
partially due to the influence of these grandmothers. An
understanding of the knowledge level and perception of
grandmothers would be helpful in our effort at improving
optimal exclusive breastfeeding practices, particularly in
Ghana. There is however, scarcity of information on
grandmother‟s knowledge and perception of breastfeeding
practices in Ghana.
This present study assessed grandmothers‟ knowledge and
perception of breastfeeding practices, including timely
initiation of breastfeeding and exclusive breastfeeding, and as
well as complimentary feeding practices within the Tamale
Metropolis, Northern Region, Ghana.
2. Subjects and Methods
A cross-sectional study design was used to assess the
knowledge and perception of grandmothers on appropriate
breastfeeding practices in the Tamale Metropolis. Tamale is
the Northern Regional capital, Ghana. The metropolis which
is the major urban area in the region occupies an area of about
70,384 km2 and consists of the Tamale Township and 30
surrounding towns and villages. Dagombas are the main
inhabitants and are predominantly Muslims. Most women in
this area are into farming and/or trading.
Using the Snedecor and Cochran (1989) formula, with
confidence interval of 95%( at a z-score of 1.96) and an
assumed prevalence (awareness of appropriate breastfeeding
practices among grandmothers in Ghana) of 50% and an error
level set at 5% we arrived at 384 as the required sample size.
But to cater for incomplete and missing questions, we
increased the sample size to 400.The 400 grandmothers were
purposively selected through house-to-house visit across the
metropolis. Grandmothers were included in this study if the
consented to participate.
A structured semi-closed ended questionnaire was used to
gather the information. The local language (Dagbani) was
used in administering the questionnaire since most of the
participants were more familiar with it. This was done by one
of the authors. The questionnaire was made up of three
57
sections, section „A‟, the socio-demographic characteristics of
the respondent, containing variables like age, religion, marital
status, ethnicity, occupation and educational level. Section „B‟
assessed the awareness and knowledge level of the
respondents on appropriate breastfeeding practices and
section „C‟ assessed the perception of the respondents on
appropriate breastfeeding practices.
The questionnaire was pretested, finalized and then used
for the final data collection. All participating women
consented to participate in the study.
Microsoft excels and Statistical Package for Social
Sciences (SPSS version 19.0) was used in analyzing the data.
The results from the analysis were displayed as frequency
tables for easy understanding. To find out the knowledge level
of grandmothers on WHO recommended breastfeeding
practices, a score of 1 was given for each correct answer to
each closed-ended question and 2 points given for very
correct and clear explanatory answers to opened-ended
questions. A total of 20 points were allocated for the
awareness and knowledge levels of the respondents; a score
of up to half (10) of the total points was considered low
knowledge and a score of more than half (greater 10 point)
was considered as high knowledge of breastfeeding practices.
Also, a total of five points were allocated for grandmothers
perception of which of three point and or below was
considered a negative perception of breastfeeding practices
and a score greater than three considered a positive perception
of breastfeeding practices.
A Chi- square(X²) analysis was carried out to determine
the association between the socio-demographic characteristics
and the knowledge and perception levels of the respondents.
Descriptive analysis of means and the standard deviations
were also obtained. A p-value of <0.05 was considered
statistically significant.
3. Results
Presented in Table 1 are the background characteristics of the
respondents. The respondents were less frequently to be
younger than 40 years (2.2%), frequently followed the Islamic
religion (85.8%), were married (61.8%) and had no formal
education (61.5%)
Table1. Background information of respondents (N=400)
Variable
Age(completed years)
<40
40-60
61-80
81-100
Religion
Islam
Christianity
ATR
N
%
9
213
133
45
2.2
53.2
33.2
11.2
343
47
9
85.8
11.8
2.2
58
International Journal of Maternal and Child Health (2015) 56-64
Others
Marital status
Single
Married
Separated
Widow
Divorce
Ethnicity
Dagomba
Gonja
Frafra
Mamprusi
Others
Occupation
Farmer
Civil servant
Service worker
Education/research
Health care provider
Trader
Others
Educational level
No formal education
Primary
Middle/JHS
SHS/vocational/technical
Tertiary
Respondents‟ knowledge and awareness level on breastfe
eding practices are as presented in Table 2. Majority (76.2%)
of the respondents reported having awareness on appropriate
breastfeeding practices. Thirty-two percent of the respondents
reported appropriate breastfeeding practice as giving water to
1
0.2
8
247
19
113
13
2.0
61.8
4.8
28.2
3.2
276
30
16
12
66
69
7.5
4.0
3.0
16.5
46
23
19
7
32
184
89
11.5
5.8
4.8
1.8
8.0
46.0
22.2
246
52
35
12
55
61.5
13.0
8.8
3.0
13.8
the child before the age of 6 months. Even though over 70% of
the respondents reported breastfeeding children less than 6
months with only breast milk, another 20.8% lack of
knowledge on exclusive breastfeeding.
Table 2. Awareness and knowledge of respondents (N=400)
Variable
Are you aware of appropriate
breastfeeding practices?
Yes
No
The appropriate breastfeeding
practice in the following
Exclusive breastfeeding
Giving water to children under 6 months
Discarding the colostrum
Timely initiation
Are you awareness of
exclusive breastfeeding (EBF)
recommendations?
Yes
No
Knowledge on EBF
Breastfeeding children under 6 months
with only Brest milk without water
I don’t know
Is it allowed to take prescribed
N
%
305
95
76.2
23.8
247
129
23
1
61.8
32.2
5.8
0.2
353
47
88.2
11.8
317
79.2
83
20.8
International Journal of Maternal and Child Health (2015) 56-64
Medicines EBF period?
Yes
No
Do you give advice and practice of
EBF to mothers?
Yes
No
What is the appropriate time to stop
exclusive breastfeeding?
before 6 months
at the beginning of the 6 months
after 6 months
I don’t know
Number of times to breastfeed in a day
during the first 6 months
0-3
4-7
8-12
on demand
Importance of exclusive breastfeeding
improves the health status of the child
it has no use
I don’t know
When to latch the child to the breast after
birth
within the first hour
within the first day
within the second day
within the third day
Awareness of the change in breast milk
Yes
No
Importance of colostrum
Protectant
it has no use
I don’t know
what is done to the colostrum
give to the baby
discard it
Period of breastfeeding (months)
<18
>=18 <=24
>24<=30
>30<=36
Others
Time to introduce complementary foods
<6
>=6<=9
>9<=12
>12
Suitable complementary foods
Porridge
Tz
Yam
Others
357
43
89.2
10.8
222
178
55.5
44.5
248
68
22
62
62.0
17.0
5.5
15.5
27
61
34
278
6.8
15.2
8.5
69.5
246
66
88
61.5
16.5
22.0
169
180
37
14
42.2
45
9.2
3.5
374
26
93.5
6.5
264
40
96
66.0
10.0
24.0
313
87
78.2
21.8
29
141
157
54
19
7.2
35.2
39.2
13.5
4.8
149
196
48
7
37.2
49.0
12.0
1.8
294
39
3
64
73.5
9.8
0.8
16.0
59
60
International Journal of Maternal and Child Health (2015) 56-64
Thickness of semi-solid foods
flows from the spoon
drops from the spoon
Others
Given fruits as snacks
Yes
No
Shown in Table 3 are respondents‟ perceptions on approp
riate breastfeeding practices. About 39.8% said appropriate
breastfeeding practices are very good practices and 29.8%
thought that, it is a good practices. Only 8% of them did not
258
82
60
64.5
20.5
15
277
123
69.2
30.8
know about appropriate breastfeeding practices. Grandmothe
rs give varying levels of support to young mothers; about 57%
said they demonstrate to young mothers how to breast their
young child.
Table 3. Perceptions on appropriate breastfeeding practices (N=400)
Variable
What is your thought about
appropriate breastfeeding practices?
very good
Good
Bad
I don’t know
Awareness of a role play by grandmothers
Yes
No
What role do you play in breastfeeding of
grandchildren?
I demonstrate to mothers how to
breastfeed
I give financial support
I gives emotional support
I give more than one of the above options
Others
Total
Missing
Why don‟t you play any role in
breastfeeding
Nothing
not my duty
Others
Total
Missing
The knowledge score as depicted in Table 4 below
indicates that 69.2% had a high knowledge level with regards
to appropriate breastfeeding practices. Higher knowledge
levels were seen in the older age women, who more likely to
N
%
159
119
90
32
39.8
29.8
22.5
8.0
368
32
92.0
8.0
228
57.0
12
91
12
26
369
31
3.0
22.8
3.0
6.5
92.2
7.8
7
6
18
31
369
1.8
1.5
4.5
7.8
92.2
be windowed. Those working in the education sector/research
sector all had higher knowledge of appropriate breastfeeding
practices.
Table 4. Knowledge score of the study population and associations with SDF (N=400)
Knowledge score
0 to 10
11 to 20
SDF
N
n (%)
123 (30.8)
277 (69.2)
Low Knowledge
n (%)
Age(complete years)
Mean (SD)
8.407 (1.644)
13.744 (1.914)
High Knowledge
Statistical test
n (%)
International Journal of Maternal and Child Health (2015) 56-64
<40
40-60
61-80
81-100
Religion
Islam
Christianity
ATR
Others
marital status
Single
Married
Separated
Widow
Divorce
Ethnicity
Dagomba
Gonja
Frafra
Mamprusi
Others
Occupation
Farmer
Civil servant
Service worker
Education/research
Health care provider
Trader
Others
Educational level
No formal education
Primary
Middle/JHS
SHS/vocational/tech
Tertiary
61
9
213
133
45
2(22.2)
53(24.9)
44(33.1)
24(53.3)
7(77.8)
160(75.1)
89(66.9)
21(46.7)
X²= 14.868
p=0.002
343
47
9
1
109(31.8)
10(21.3)
4(44.4)
0(0)
234(68.2)
37(78.7)
5(55.6)
1(100)
X²= 3.388
p=0.336
8
247
19
113
13
2(25.0)
62(25.1)
7(36.8)
49(36.8)
3(23.1)
6(75.0)
185(74.9)
12(63.2)
64(63.2)
10(76.9)
X²= 12.958
p=0.011
276
30
16
12
66
98(35.5)
7(23.3)
2(12.5)
2(16.7)
14(21.2)
178(64.5)
23(76.7)
14(87.5)
10(83.3)
52(78.8)
X²= 10.742
p=0.057
46
23
19
7
32
184
89
18(39.1)
3(13.1)
2(10.5)
0(0)
1(3.1)
55(29.9)
44(49.4)
28(60.9)
20(86.9)
17(89.5)
7(100)
31(95.9)
129(70.1)
45(50.6)
X²= 37.790
p<0.001
246
52
35
12
55
95(38.6)
18(34.6)
6(17.1)
1(8.3)
3(5.5)
151(61.4)
34(65.4)
29(82.9)
11(91.7)
52(94.5)
X²= 29.918
p<0.001
Table 5 presents the perception of grandmothers and how
that is associated with socio-demographic characteristics.
About 64.5% had poor/negative perception of appropriate
breastfeeding practices. Older age groups were more likely to
have negative perception of the appropriate breastfeeding
practices. Those who work in the health sector or the educati
on/research sector appear to have a positive perception of
appropriate breastfeeding practices. The knowledge and
perception scores were also correlated as shown in Table 6
below.
Table 5. Perception score of the study population and associations with socio-demographic factors (N=400)
Perception score
0 to 3 (Negative)
4 to 5 (positive)
Socio-Demographic
Factors
Age(completed years)
<40
40-60
61-80
81-100
Religion
N
9
213
133
45
n(%)
258 (64.5)
142 (35.5)
perception n %
5(55.6)
127(59.6)
91(68.4)
35(77.8)
Mean(SD)
2.29 (0.822)
4.020 (0.155)
positive
Statistical test
Perception
n (%)
4(44.4)
86(40.4)
42(31.6)
10(22.2)
X²= 6.884
p=0.076
62
International Journal of Maternal and Child Health (2015) 56-64
Islam
Christianity
ATR
Others
Marital status
Single
Married
Separated
Widow
Divorce
Ethnicity
Dagomba
Gonja
Frafra
Mamprusi
Others
Occupation
Farmer
Civil servant
Service worker
Education/research
Health care provider
Trader
Others
Educational level
No formal education
Primary
middle/JHS
SHS/vocational/tech
Tertiary
343
47
9
1
213(62.1)
22(46.8)
5(55.6)
0(0)
112(37.9)
25(53.2)
4(44.4)
1(100)
X²= 9.770
p=0.021
8
247
19
113
13
3(37.5)
147(59.5)
14(73.7)
89(78.8)
5(38.5)
5(62.5)
247(40.5)
5(26.3)
24(21.2)
8(61.5)
X²= 19.815
p=0.001
276
30
16
12
66
195(70.7)
15(50)
16(50)
6(50)
34(51.5)
81(29.3)
15(50)
16(50)
6(50)
32(48.5)
X²= 15.125
p=0.010
46
23
19
7
32
184
89
28(60.9)
11(47.8)
9(47.4)
3(42.9)
7(21.9)
124(67.4)
76(85.4)
18(39.1)
12(52.2)
10(52.6)
4(57.1)
25(78.1)
60(32.6)
13(14.6)
X²= 49.956
p<0.001
246
52
35
12
55
183(74.4)
33(63.5)
21(60)
5(41.7)
16(29.1)
63(25.6)
19(36.6)
14(40)
7(58.3)
39(70.9)
X²= 43.692
p<0.001
Table 6.knowledge and perception association
Knowledge
Low
High
rank on perception
Negative (%)
Positive(%)
104(84.6)
19(15.4)
154(55.6)
123(44.4)
4. Discussion
More than half(53%) of the respondents were within the age
range of 40 to 60years, which is normal given that the median
age of married women within 25-49 years is about 20years
(GDHS,2008) and so could have grandchildren on or before
40years. Nearly all participants were ever-married (Table 1)
with seven in 10 participants being Dogombas (native
inhabitants). Nearly half (46) of the respondents were traders.
More than three-quarters said they are aware of what
appropriate breastfeeding practices are (in this case, timely
initiation of breastfeeding and exclusive breastfeeding and
timely introduction of complimentary feeding). Nearly 9 in 10
have heard of EBF though only 8 in 10 could explain what the
meaning of EBF was. There was generally low knowledge of
timely initiation of breastfeeding with only a little over 4 in 10
knowing that it should be started within the first one hour after
statistical test
X²=31.192 p<0.001
birth, with six in 10 indicating that exclusive breastfeeding
should stop before the 6th month after birth whiles nearly 2 in
ten indicating that EBF has no use (is not important). Also
nearly 2 in 10 did not know the importance of colostrum to the
child with a similar number of respondents indicating that
colostrum should be discarded and not given to the child
(Table 2).This is consistent with the findings of Das et
al.(2013) findings, where more than one in five mothers
indicated that they discarded colostrum.
This practice maybe due to their lack of understanding of
the usefulness of colostrum as captured here by some
comments made during the interview by respondents; the first
breast milk[colostrum] is dirty and it should not be given to
the child, the baby ran [had diarrhea] when given the
colostrum. However, some local practices are carried out to
sustain both the mother and the child as noted here; the
mother is given local medicine (concoction) to facilitate the
letdown of the second breast milk. The new born baby is either
International Journal of Maternal and Child Health (2015) 56-64
given to a breast feeding mother to be breastfed or a mixture
of sheabutter with warm water is used as a feed whenever the
baby cries till thesecond breast milk of the mother start to
flow, the mother is also advised to take ‘zeizeri’ (light soup
with plenty dawadawa) in other to facilitate the letdown of the
second breast milk, to heal the wounds after delivery and to
replenish the blood loss during delivery (Participant,
Tamale).
More than 9 in 10 of the grandmothers indicated that they
play a role in the breastfeeding of their grandchildren with
about 2 in 10 having a bad (negative) perception of
appropriate breastfeeding practices in general. More than 9 in
ten indicated that they give some form of support to young
mothers (their daughters or daughters-in-law) in different
forms, including but not limited to financial, emotional
support and demonstration on how to breastfeed their
children(Table 3). This is consistent with the several studies
in different parts of the world, where grandmothers or elderly
women were seen to play significant roles in child nutrition
and health (Sear et al., 2000; Waisbord, 2001;Aubel, 2004;
Beznerkerr et al. 2008;Lee and Garvin, 2003;Aubel,
2012;Brown et al., 2014).
Close to seven in 10 of the respondentshad high
knowledge score (Mean, SD; 13.7, 1.9 out of a total score of
20) (Table 4) and nearly two-thirds had negative perception of
appropriate breastfeeding practices. A number of
demographic characteristics were seen to be associated with
knowledge and perception scores. There were significant
differences in knowledge and perception scores with respect
to respondents‟ marital status, occupation and educational
levels (P< 0.05; Table 4 and Table 5). However, knowledge
score but not perception score was significantly different for
age whiles perception score was significantly different with
respect to one‟s religious group (P<0.05; Table 4 and Table 5).
Associated between knowledge score and perception score
statistically significant (X2= 31.192, p< 0.001; Table 6).
What was also apparent from this study was the perception
that some of these grandmothers had; that, they were not
exclusively breastfed but they grew up well and also that their
children (mothers of the young children) were not exclusively
breastfed but they too are healthy and so, why should they
exclusively breastfeed their grandchildren. They further
argued that they did not see any differences in the nutritional
status between the mothers who claim they are breastfeeding
their children exclusively compared to those who do not
exclusive breastfed their grandchildren. This is captured in the
following statement “I was not given water but I grew well,
when you practice exclusive breastfeeding some of the
children tend to behave strangely” (study participant Tamale).
This was echoed by several other grandmothers in the study.
This could help explain why we have high knowledge level of
the appropriate breastfeeding practices but a considerably low
level of positive perception of breastfeeding practices among
grandmothers. This means that even as the knowledge level
increase, we cannot conclude that some mothers will not
practice the exclusive breastfeeding either because they have
63
negative perception about it or they will be influenced by the
grandmothers, not to follow what they are told at the antenatal
centers. This call for a concerted effort at improving the
capacity of these mothers and other grandmothers on
exclusive breastfeeding during the antenatal care or child
nutrition education programs. This could be done by
involving grandmothers and allowing them to share their
experiences with the health staff whiles addressing their
concerns. This will likely lead to an active participation of the
grandmothers in the breastfeeding of their grandchildren
breastfeeding and could result in a likely increase in the
practice of breastfeeding practices as reported in a study by
Aubel (2004). According to that study the involvement of
grandmothers in nutrition education programs resulted in an
increase in the number of grandmothers willing to encourage
exclusive breastfeeding for their grandchildren.
In conclusion, grandmothers have some knowledge and
experiences in appropriate breastfeeding practices that need to
be tabbed. These grandmothers were generally helpful to the
young women beyond teaching them how to properly
breastfeed their young children, but offer psychosocial and
financial supports as well. We believe that the negative
perception that they have about some expect of appropriate
breastfeeding practices, could be improved by sharing
knowledge with them even as we learn from their
experiences.
Acknowledgment
We sincerely thank all the grandmothers that took part in this
study.
Conflicts of interest: none
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