Introduction

The importance of breastfeeding practices for a healthy growth and development of infants and young children have been presented in numerous policy documents [1–2]. Breastfeeding practices are categorized into two broad aspects; exclusive breastfeeding and complementary feeding [3]. For each of these aspects, guidelines are stipulated as to how to appropriately practice each of them to yield maximum outcomes for the good health of children. For instance, mothers are encouraged to exclusively breastfeed their infants for the first six months of their lives. It is worth mentioning that breastfeeding is much more than giving infants and young children breast milk. Breastfeeding is a complex adaptive process that bonds a mother and her child. During this process, physical, biochemical, hormonal, and psychological exchanges occur to facilitate the transfer of needed essential nutrients between the mother and her child [4]. After six months of exclusive breastfeeding, breastfeeding should still continue with added complementary foods as recommended by World Health Organization [5].

The introduction of complementary foods is necessary since after the sixth month, breast milk alone is no longer enough to meet the nutritional requirements of infants [5]. At this stage, it is a transitional period when infants are introduced gradually to family foods. Also, it is recommended that the feeding process should start with other milks and non-milk liquids; and as the children grow older, then other semi-solid or soft foods could be given to them [6]. Mothers in their quest to feed their children, as recommended, are sometimes confronted with both personal and external challenges [7].

Research indicates that mothers are sometimes negatively influenced by significant others as to how to practice breastfeeding [7]. Other challenges documented include the belief that breast milk alone is not sufficient in meeting nutritional needs of infants; short maternity leave period; and socio-cultural pressure to introduce water and artificial feeds [8–9]. Again, breastfeeding mothers who return to work often feel exhausted–since they feed-on-demand and attend to family and employment responsibilities–leading to concerns for their personal health [10]. Also, Nankumbi and Muliira [11] observed that challenges in relation to appropriate infant and young child-feeding practices are mothers' knowledge about complimentary feeding, influence of culture custodians on mothers, and patterns and burden of other responsibilities the mothers have in the household.

For mothers to practice appropriate complementary feeding, they need to have suitable and enough foods, and ensure that there is diversity in the diets they give to their children. However, in many resource poor contexts, foods that are available are predominantly cereal-based with low nutrient density and poor mineral bioavailability, posing substantial low nutrient consumption for breastfeeding mothers and their children [12]. Even in some environments, commercial fortified foods are often beyond the reach of financially-challenged-mothers; therefore, homemade complementary foods remain commonly used [13]. These homemade foods are mostly unfortified or unenriched plant-based complementary foods hence providing insufficient key micronutrients especially among children aged 6–23 months [14].

To promote infants and young children feeding issues, the Ministry of Health (in Ghana), has implemented a number of related policies including the Baby-Friendly Hospital Initiative, the National Child Health Policy and the National Nutrition Policy. The Baby-Friendly Hospital Initiative was adopted and implemented in qualified health facilities in the country to promote breastfeeding initiation and improvements of exclusive breastfeeding among neonates and infants less than six months respectively [15]. The National Child Policy was equally implemented to promote the survival, growth and development of all children [16]. Also, the National Nutrition Policy, as contained in one of its measures, was to promote optimal nutrition among infants and young children in the areas of appropriate breastfeeding and complementary feeding practices [17]. All these policies, as part of their purposes, were intended to guide stakeholders in the country to effectively and properly ensure the healthy growth and development of infants and young children. Notwithstanding the well-articulated aims of the of the aforementioned policies, infants and young children feeding practices are still low in Ghana [18].

Prior studies have documented the determinants, predictors, or risk factors of breastfeeding practices [19–21]; primarily skewed towards the positivist paradigm. This suggests that there is paucity of literature on exploring challenges mothers encounter in their quest to practice exclusive breastfeeding and complementary feeding. We, therefore, sought to explore views of mothers on challenges of breastfeeding practices in the areas of exclusive breastfeeding, and complementary feeding, drawing on an interpretivist approach. The study primarily focused on mother-child dyads. Findings from this study would highlight issues that impede the practice of these feeding practices among mother-child dyads. Salient views from the mothers might pin-point to how to improve infants and young children feeding practices in Ghana.

Methods

Data analysis

Thematic analysis was applied using the inductive approach to analyze the data [27–28]. Preliminary data analysis started immediately with the first two interviews and transcription of data was done manually. Each transcript was critically read in order to become familiar with the data. These transcripts were verified by the research team with reference to the field notes where necessary. Some participants in both localities were subsequently contacted to clarify and validate issues in the transcribed data.

On the transcripts, identified emerged themes were marked with letters. For instance, the letter ‘A’ was used for exclusive breastfeeding challenges at home and ‘B’ for exclusive breastfeeding challenges at work place. Similarly, numerals were used to specifically identify sub-themes. For example, the number ‘1’ was used for household chores; and ‘2’ for formal and informal work schedules. Further, to enable easy identification of individual transcripts, unique codes (consisting of a number, place of residence, and region) were assigned to selected quotations.

Further, each researcher independently reviewed the transcripts and outlined themes. The research team met to discuss the identified themes. After the meeting, again, each researcher was tasked to review the initial themes that were put together by critically comparing them to the transcribed data. This iterative process was necessary to comprehensively identify further themes and categories that might have been omitted. Inconsistencies, where identified, were reconciled. Also, quotations used to support views expressed by mothers were mutually agreed upon by all researchers. Interpretations of views were done to reflect salient and subtle meanings as expressed by participants. Also, as the analysis of themes continued, each identified theme was interpreted coherently to show the meanings participants attached to challenges of breastfeeding practices noting their spatial and societal characteristics. The lead researcher wrote up the findings and the other team members, who are well vest in qualitative research, reviewed the presentation. Comments were presented accordingly and then a neutral qualitative researcher was called upon to peer review the presentation.

In all, sixteen categories emerged from the challenges of exclusive breastfeeding, and five categories from challenges of complementary feeding (Fig 1). To ensure mutual exclusiveness of the categories, some categories were merged. This reduced the number of themes to seven. Due to the merger of categories, newly constructed typologies that were not indicated by the participants were used to label the themes where necessary. For instance, ‘formal and informal work schedules’ was used to represent both ‘running office errands’, ‘working in office’ and ‘farm works’. The themes identified were used as main headings in the results sections. The themes presented at the results section are: household chores; formal and informal work schedules; family influence on exclusive breastfeeding; low breast milk production; swollen breasts or sore nipples; access to complementary food items; and preparing and giving complementary foods to children.

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Fig 1. Description of coding tree showing themes.

Exclusive breastfeeding challenges consisting of household chores, work schedules, family influence, low breast milk production, and swollen breast or sore nipples. Complementary feeding challenges consisting of access to food items, and preparing and giving foods.

https://doi.org/10.1371/journal.pone.0215285.g001

Results

Background characteristics of participants

Results from the qualitative study indicated that 14 mothers were within the age group of 21–30 years (Table 1). Nine of them attained primary education. Eighteen mothers were married. Seven of the mothers were traders including one each as a teacher, a hair stylist, and a Pito brewer (a type of alcoholic beverage made from millet or sorghum in northern parts of Ghana, parts of Nigeria, and other parts of West Africa). An equal number of their children were within the age brackets of 6–11 months and 12–23 months. Female children were 12. There was an equal number of mothers from the regions (Western and Upper West), and place of residence (urban, and rural) within each region.

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Table 1. Background characteristics of participants (N = 20).

https://doi.org/10.1371/journal.pone.0215285.t001

Discussion

The interviews conducted provided insight into the views of breastfeeding mothers in relation to challenges they encounter in their bid to exclusively breastfeed as well as complementarily feed their children. This study identified nursing mothers’ engagement in performing household chores (especially cooking and fetching water) as challenges to practicing optimum exclusive breastfeeding. Nursing mothers being overwhelmed at combining exclusive breastfeeding and household chores can be attributed to weak social support systems. This in the light of increasing urbanization is leading to the rise of nuclear families compared to larger family systems (extended families) that use to offer needed social support for nursing mothers in Ghana [29]. The disintegration of larger families into smaller ones sometimes poses constraints that tend to hinder the practice of exclusive breastfeeding. In the Ghanaian context, extended families accommodate several relatives (aunties, cousins, nieces) who are mostly willing to offer assistance to nursing mothers. As communities get urbanized, supports from these relatives diminish or are unavailable. On the other hand, by tradition, husbands are not supposed to take part or assist in household chores since these activities are highly gendered towards females. Where necessary, some husbands offer minimal assistance in household chores that may not be enough to relief the burden on mothers. The absence or limited assistance nursing mothers get in performing household chores in most contemporary Ghanaian homes tend to negatively influence how their infants are exclusively breastfed including those who are complementarily fed.

Further, the findings revealed that at work schedules of mothers equally hinder the practice of exclusive breastfeeding. The early return to work by breastfeeding mothers in civil and public services—after three months of maternity leave—tend to compound exclusive breastfeeding challenges for mothers [30–32]. Aside the early return to work, most institutions or organizations in Ghana do not have breastfeeding cubicles or rooms as required by law. Again, the location of crèches and where most mothers work are distant. In such circumstances, mothers may be required to express breast milk to be given to children while they are at work [33]. Although this approach would be more useful elsewhere, the certainty that children might be given the expressed breast milk in a good condition in the context of Ghana is questionable. Likewise, in busy informal sectors such as trading and farming, mothers encounter challenges that impede the practice of exclusive breastfeeding. Mothers in their hustle and bustle at local trading centers would have to combine uncoordinated activities by attending to clients and at the same time trying to optimally breastfeed their children. As a result, exclusive breastfeeding is breached with early weaning inevitable [34–35]. Hence, mothers have no choice than to introduce complementary foods to their infants.

In addition, within societies, mothers may be challenged in their quest to practice exclusive breastfeeding. Grandmothers were commonly mentioned as individuals who have much influence on how mothers, particularly young mothers, should breastfeed. Particularly in Ghana, grandmothers (mother-in-laws) have much say in relation to health care of their grandchildren [36]. Grandmothers tend to act as advisors and sometimes authorize what kinds of foods to be given to children. The practices of giving infants herbs, water, and concoctions are common habits of grandmothers in some communities in Ghana [37] and elsewhere [38–39]. Nursing mothers (who are mostly daughter-in-laws) staying with the grandmothers, due to respect, may not be able to oppose to all actions grandmothers take even when that contravenes with the practice of exclusive breastfeeding. On the contrary, Aguree et al. [40] in their study observed that grandmothers with appropriated knowledge on the importance of breastfeeding rather tend to encourage mothers to practice exclusive breastfeeding. In addition to grandmothers, other family members sometimes introduce foods or liquids to infants who are supposed to be exclusively breastfeeding; such family members act without the knowledge of mothers. This finding collaborates with what Nduna et al. [41] found in Zimbabwe. They noted that even trusted individuals such as aunties who are supposed to act as co-mothers intentionally give liquid foods to children (less than six months) without the knowledge of mothers.

Again, in this study, low breast milk production was another challenge encountered by mothers. Low breast milk production is linked to medical and non-medical conditions [42]. Most often, it is the non-medical conditions (such as less sucking time, and delaying feeds) that contribute to low breast milk production among mothers [43]. For instance, less sucking time probably could be due to sore nipples resulting in low breast milk production. Also, while mothers may intend to exclusively breastfeed children, physical conditions may inhibit such intentions. For instance, breast abnormalities such as sore nipples [44] could lead to less breastfeeding and consequently low breast milk production. Mothers in this study pointed to all these as shortcomings that thwart their willingness to practice or continue with exclusive breastfeeding. Agunbiade and Ogunleye [45] documented similar findings in a study conducted in Nigeria. They identified constraints such as swollen breast, nipple problems, and perceived milk insufficiency among breastfeeding mothers.

Moreover, it was found that mothers had challenges accessing complementary food items or ingredients. Insufficient financial endowment poses challenges to some mothers in purchasing complementary foods. This is a common challenge for mothers in rural areas, as compared to their urban counterparts, where mothers are usually not economically endowed to afford children’s foods. Zahiruddin et al. [46] also found similar issues in their qualitative study which explored challenges and patterns of complementary feeding in India. Also, not having the requisite knowledge on where to acquire quality complementary foods for children was a related challenge for mothers. With the influx of so many low-quality complementary foods in markets, mothers need to be knowledgeable enough to buy appropriate foods for their children to ensure healthy growth and development [47]. Therefore, mothers not having enough money to buy food or without the required knowledge on the best choice of food, they may tend to feed their children to be satisfied with less regard to nutritional gains.

Preparing and giving complementary foods to children while at work was a challenge for mothers. Mothers are supposed to adhere to diversifying—adequate nutrient—rich foods and hygienic practices when preparing complementary foods for children [2]. Weaned children also need to eat frequently and consistently. This requires mothers to always prepare foods to ensure that their children are healthy. Aside this, foods prepared for children are supposed to be kept warm to avoid food contamination. Working mothers who may not have effective food storage containers to keep their children’s food warm are likely to give them cold foods. In instances where children are not fed because foods are cold, then the expected frequency and consistency in the feeding cycle of children would be breached. Children may even be exposed to consuming cold foods when other caregivers are to feed them in the absence of their mothers [46].

Findings of this study emanated from small sample of mothers within two regions, and views expressed by mothers are unique to their own observations and knowledge. The views may not represent those of other mothers in the same communities.

Conclusion and implications

Findings suggest that mothers encountered exclusive breastfeeding challenges at home, with work schedules within their societies, and in relation to their health status. In order to address these challenges, we suggest the creation of awareness through especially radio for family members and other significant others to enable them provide adequate support for exclusive breastfeeding mothers. Also, increasing maternity leave to at least four months for expectant and nursing mothers by authorities in the country would reduce challenges nursing mothers have at work places. On complementary feeding, a platform should be created for midwives and community health nurses to provide further education on how to adequately and appropriately use local foods to feed their children. Besides, the provision of suitable feeding cubicles for breastfeeding or feeding children at work places by authorities would be a positive measure to ensuring mothers feed their children with ease.

Supporting information

Acknowledgments

We would like to thank mothers in both Upper West and Western regions who participated in this study.