Background

Optimal breastfeeding of infants and young children is a public health priority in sub-Saharan Africa because of the numerous benefits it affords newborns, both in short and long term [1, 2]. It is well documented that exclusive breastfeeding boosts a newborn’s immune system, guards against gastrointestinal and lower and upper respiratory tract infections, including pneumonia and asthma, and decreases the frequency of otitis media episodes and hospitalisation [1, 3,4,5]. Breastfed children also have a lower risk of obesity, diabetes mellitus, hypertension, and childhood leukaemia [2, 6]. As a result, the World Health Organization (WHO) recommend the initiation of breastfeeding within one hour after birth and the practice of exclusive breastfeeding for the first six months of a newborn’s life. Mothers are encouraged to introduce safe and sufficient complementary foods after the first six months, while breastfeeding is continued for up to two years and beyond [7].

Despite the benefits and recommendations for exclusive breastfeeding, the global prevalence is suboptimal [8]. Even in sub-Saharan Africa, where nearly all mothers breastfeed, only a small proportion of mothers practise exclusive breastfeeding for the first six months after giving birth. For example, a geospatial analysis in 2019 revealed that only 18 of the 46 countries in sub-Saharan Africa are on track to achieving the World Health Assembly 2030 target of 70% prevalence of exclusive breastfeeding in the six months after birth [9]. In Ghana, the prevalence of exclusive breastfeeding has declined drastically from 63% in 2008 to 43% in 2018 [10]. The decline has been attributed to several factors, including traditional practices such as the introduction of water and other homemade preparations to newborns and the indiscriminate advertisement of breastmilk substitutes [11]. In addition, many studies in Ghana have reported on several maternal and child factors and family sociodemographic characteristics that influence the practice of exclusive breastfeeding, including antenatal and postnatal attendance, infant birthweight, place of delivery, mode of delivery, maternal education, occupation, misconceptions about exclusive breastfeeding, and pressure from mothers-in-law, traditional birth attendants or grandmothers [10, 12,13,14,15,16,17,18].

A preliminary search of the literature revealed that no systematic reviews or meta-analyses have been conducted to summarise the prevalence and determinants of exclusive breastfeeding among infants younger than six months in Ghana. A review will highlight current trends in the prevalence of exclusive breastfeeding and the factors that promote or hinder the practice to inform healthcare policies and design pragmatic interventions to tackle the declining exclusive breastfeeding rate. Annually, malnutrition costs the Ghanaian economy about $2.6 billion or 6.4% of the gross domestic product [19]. Such expenditure is significant given Ghana’s low-income level and resource-constrained economy. Policies to scale up breastfeeding can mitigate this cost and reduce the incidence of malnutrition, especially in the first six months of life, since exclusive breastfeeding provides children with complete and adequate nutrition needed for optimal growth and development [20]. This study, therefore, aimed to conduct a systematic review and meta-analysis of the prevalence and factors associated with exclusive breastfeeding in the first six months of an infant’s life in Ghana.

Methods

The protocol for this systematic review was registered with PROSPERO (Number CRD42021278019) [21] and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [22].

Search strategy

We searched Embase, Medline, and Africa-Wide Information using a combination of subject headings and free text terms from the databases’ inception until February 2021. The database searches were carried out using the following terms: exclusive breastfeeding; exclusive breast feeding; exclusively breastfed; breastfed exclusively; breastmilk only; breastmilk alone. The breastfeeding terms were combined with terms for Ghana and the sixteen regions of the country. The search was initially created in the Medline database (see supplementary Table 1 for the search plan) before being translated for the other databases using subject headings suitable for each database’s thesaurus. Boolean and proximity operators were used to combine synonyms and keywords describing the main concepts, which were then searched as free-text terms. To include various variations of the terms, truncations and wildcards were used. In addition, we searched for additional studies in the references of studies that met the inclusion criteria and articles that cited them.

Eligibility criteria

The outcome investigated was exclusive breastfeeding, defined as feeding an infant with only breastmilk and no other liquids or solids except for oral rehydration salt, drops, and syrups (vitamins, mineral supplements, or medicines) in the first six months after birth [7]. We included quantitative observational and experimental studies that assessed the prevalence, predictors, determinants, and factors associated with exclusive breastfeeding in the first six months of an infant’s life in Ghana. However, studies that pooled data from several countries, including Ghana but did not present Ghana-specific estimates were excluded. Studies that investigated the effects of exclusive breastfeeding on mortality, morbidity, nutrition status, and health-related outcomes were excluded, except where the prevalence of exclusive breastfeeding in Ghana was estimated. In addition, we excluded studies that assessed the factors associated with exclusive breastfeeding in children older than six months and those that were not conducted in Ghana. Dissertations, systematic reviews, meta-analyses, and conference papers with no adequate information on the study’s methods were excluded. Because we aimed to conduct a meta-analysis of the prevalence of exclusive breastfeeding, we included qualitative studies that reported the prevalence of exclusive breastfeeding in Ghana. Studies were not excluded based on the language or date of publication. A summary of the inclusion and exclusion criteria is presented in Supplementary Table 2.

Selection and data extraction

The Mendeley citation manager was used to combine articles from the databases before they were exported and deduplicated using Rayyan QCRI systematic review management software [23]. The titles and abstracts of the retrieved studies were screened by authors SM and IY for relevance, and SM then obtained the full texts of any studies that passed the initial screening. SM and IY read the full text of the articles to establish their eligibility using the same criteria. Studies that met the predefined inclusion criteria were retained for critical appraisal and data extraction. Authors SM and IY extracted information on the author’s name (s), study location, study design, sample size, sampling technique, description of study participants, data source and measurement of exclusive breastfeeding, and factors associated with exclusive breastfeeding. Disagreements during the screening and data extraction were resolved through discussions.

Critical appraisal of studies

The methodological quality of the included studies was evaluated using the Joanna Briggs Institute’s (JBI) critical appraisal tools. The JBI appraisal tools are intended to comprehensively evaluate the methodological quality of included studies and ascertain the extent to which each study has addressed the potential for bias in its design, conduct, and analysis. This information is then used to synthesise and interpret the findings of the studies [27]. A variety of JBI appraisal tools are available for the quality assessment of different studies. We used appraisal tools for analytical cross-sectional studies [24], cohort studies [25], and randomised controlled trials (RCTs) [26]. The cross-sectional appraisal tool has eight items, while the tools for cohort studies and randomised controlled trials consist of 11 and 13 items, respectively. In this study, the original tools were applied without modification. “Yes” or “No” were used to indicate whether a criterion was present or absent, respectively, while “unclear” was used when authors did not provide sufficient details to allow for criterion evaluation. The appraisal tool has no distinct cut-off points. It is recommended that authors use cut-off values appropriate for their study to determine whether a study is of low, moderate, or high quality. However, cut-off scores are generally discouraged because items of the critical appraisal tool are not equally weighted [28]. As a result, we did not exclude articles based on the results of the quality appraisal. Nonetheless, cross-sectional studies with scores of eight or seven, six to four, and three or less were considered to have a low, moderate, or high risk of bias, respectively. Scores of eleven or ten, five to nine, and four or less were considered low, moderate, and high risk of bias in cohort studies, respectively. In a randomised controlled trial, the risk of bias was considered high for scores less than six, moderate for scores six to eleven, and low for scores twelve or thirteen.

Data analysis

A random-effects meta-analysis was used to pool the prevalence of exclusive breastfeeding across the included studies to estimate the overall prevalence in Ghana. The pooled prevalence and corresponding 95% confidence intervals were presented in a forest plot. The proportion of total variability that was due to between study heterogeneity was estimated using Higgins and Thompson’s I2 statistic [29]. The presence of publication bias was assessed through Egger’s test and visual examination of funnel plot. We performed sub-group analysis by locality (rural-urban residence), administrative regions, and geographical zone (coastal-middle belt [Greater Accra, Central, Western, Volta, Ashanti, Brong-Ahafo and Eastern Regions] and savannah/northern belt [Northern, Upper East and Upper West Regions] [30]) to investigate potential sources of heterogeneity. Were it was not clear whether a study setting was a rural or urban locality, we referred to the Ghana statistical services report for the region for guidance. To determine the factors associated with exclusive breastfeeding, data from the studies were summarised in tables, and the summarised data were synthesised and integrated to produce summary statements. Stata version 17 was used for all statistical analysis.

Results

Characteristics of included studies

The PRISMA flow chart in Fig. 1 illustrates the study selection procedure. The database searches yielded 247 potential articles, and the hand search turned up 11 additional articles. In total, 42 articles were eligible for full-text screening after removing duplicates (n = 113) and screening titles and abstracts of 145 articles. Of the 42 articles that underwent full-text screening, 24 were included in the systematic review. Table 1 summarises the characteristics and summary findings of the included studies. Twenty-one of the included studies were cross-sectional, two were prospective cohort studies, and one was a randomised controlled trial. The sample sizes of the quantitative studies varied between 108 and 1870, with a total sample size of 8740 participants included in this review. Most study participants were recruited from healthcare facilities. The 24 included studies were published between 2005 and 2021, with 92% (n = 22) published in the last decade. Overall, the included studies were conducted in seven of the ten former regions of Ghana: Greater Accra region (n = 6), Northern region (n = 5), Ashanti region (n = 5), Central region (n = 2), Eastern region (n = 1), Upper West region (n = 1), and Volta region (n = 1). Three studies were nationally representative using data from the Ghana Demographic and Health Survey [12, 31, 32].

Fig. 1
figure 1

Flow diagram showing study selection

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Critical appraisal of included studies

We used descriptive statistics (counts and percentages) to summarise the scores of each study on the JBI tools. Of the 21 cross-sectional studies (Supplementary Table 3), ten (47.6%) had a low risk of bias, while 11 (52.4%) had a moderate risk of bias. None had a high risk of bias. All the cross-sectional studies appropriately measured the exposures and outcome, and nearly all employed an appropriate statistical method. The two cohort studies each scored 10 on the 11-item JBI tool indicating a low risk of bias (Supplementary Table 4). Nonetheless, the cohort studies lacked a detailed explanation of the methods used to address incomplete follow-up. The risk of bias in the randomised controlled trial was moderate, as measured by a score of 11 on the 13-item JBI tool (Supplementary Table 5). Outcome assessors were not blinded to the allocation of interventions in the randomised controlled trial.

Prevalence of exclusive breastfeeding in Ghana

Of the 24 included studies, 23 had suitable data for a meta-analysis. Based on the random-effects meta-analysis of the 23 studies (Fig. 2), the pooled prevalence of exclusive breastfeeding in the first six months of life in Ghana was 50% (95%CI 41.0–60.0%; I2 = 98.5%). There was no evidence of publication bias after examining the funnel plot (Supplementary Fig. 1) and based on Egger’s test (p-value = 0.56). Sub-group analysis by urban-rural residence showed that the prevalence of exclusive breastfeeding in the first six months after birth was 44% (95%CI 32.0–57.0%; I2 = 97.9%) in urban areas and 54% (95%CI 37.0–70.0%; I2 = 98.9%) in rural areas (Fig. 3). Figure 4 shows that the pooled prevalence of exclusive breastfeeding at the level of the administrative regions was 62% (95%CI 54.0–70.0%; I2 = 93.3%) in the Greater Accra region, 55% (95%CI 43.0–67.0%; I2 = 0%) in the Ashanti region, 51% (95%CI 24.0–77.0%; I2 = 98.9%) in the Northern region, and 44% (95%CI 38.0–50.0%; I2 = 0%) in the Central region. Heterogeneity in prevalence estimates was lower among studies conducted in the Greater Accra region than those from the other regions. The pooled prevalence based on geographic zone sub-group analysis indicated that the prevalence of exclusive breastfeeding was higher (51%; 95%CI 41.0–61.0%; I2 = 98.1%) in the coastal-middle belt than in the northern/savannah belt (43%; 95%CI 18.0–70.0%; I2 = 99.2) (Fig. 5).

Fig. 2
figure 2

Forest plot of the prevalence of exclusive breastfeeding among children younger than six months in Ghana

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Fig. 3
figure 3

Forest plot of the prevalence of exclusive breastfeeding by rural and urban residence of Ghana

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Fig. 4
figure 4

Forest plot of the prevalence of exclusive breastfeeding by administrative regions of Ghana

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Fig. 5
figure 5

Forest plot of the prevalence of exclusive breastfeeding by geographical zones of Ghana

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Determinants of exclusive breastfeeding in Ghana

Of the 24 included studies, 21 had suitable data for narrative synthesis. The determinants of exclusive breastfeeding identified in the 21 studies were grouped into maternal and paternal factors and infant factors (Table 2).

Maternal and paternal factors

The maternal and paternal factors associated with exclusive breastfeeding in the first six months were categorised into (1) sociodemographic factors, (2) workplace-related factors and influences, (3) obstetric and healthcare factors, and (4) feeding practices or decisions.

Sociodemographic factors

We found that exclusive breastfeeding in the first six months after birth was more likely among women aged 20 or older [33,34,35], women who lived in a large household or with many children [32, 33, 36], self-employed women [37], unemployed women [35] rural women with higher education [38], women from the Volta region [39], and women who owned a house [40].

However, exclusive breastfeeding in the first six months was less likely among unmarried women [41], women residing in urban areas [17], urban women with higher education [34], women living in fishing districts [33], women of the Akan or northern ethnic groups [34, 36], women who have experienced intimate partner violence [31], those without access to radio [42], women with a partner who had primary education [32], and women with a partner who desired more children [32].

Workplace related factors

In the first six months after giving birth, women who worked as artisans [33] and those given less than three months of maternity leave [43] were less likely to practice exclusive breastfeeding.

Obstetric and healthcare factors

Three studies reported that women who delivered in health facilities were more likely to practice exclusive breastfeeding in the first six months than those who delivered outside a health facility [39, 40, 44]. In two studies, an increase in antenatal care visits was positively associated with exclusive breastfeeding in the first six months after birth [44] [32]. Two studies found that women who had normal delivery were more likely to practice exclusive breastfeeding than those delivered through caesarean Section. [35, 43]. Also, mothers who had healthy nipples were more likely to exclusively breastfeed for a longer duration than those who had sore nipples [35]. On the other hand, women who made less than four antenatal care visits [17] and those who were HIV positive [36] were less likely to practice exclusive breastfeeding. In one study, women who had 3–4 previous deliveries were less likely to practice exclusive breastfeeding [35].

Feeding practices, decisions, and support

In two studies, women with higher knowledge of exclusive breastfeeding were more likely to practice exclusive breastfeeding than those with inadequate knowledge [38, 44]. Likewise, women who received counselling on breastfeeding were more likely to exclusively breastfeed their children in the first six months after birth [13, 45]. Also, women who participated in mother-to-mother support groups were more likely to practice exclusive breastfeeding [44]. One study reported that women who planned to exclusively breastfeed on delivery or had positive attitudes towards exclusive breastfeeding were more likely to exclusively breastfeed in the first six months after birth [40]. Not knowing when to start complementary feeding or believing it is appropriate to introduce complementary feeds at six months was positively associated with exclusive breastfeeding in the first six months [13].

On the other hand, counselling on complementary feeding [13], formula feeding recommendations from health workers [43], non-awareness of exclusive breastfeeding [13], short duration of breastfeeding [13, 41], perceived inability to produce enough breastmilk [42], lack of support from family [17], advise from support person to formula feed [43], and outside pressure to introduce other foods [17] were associated with a lower likelihood of exclusive breastfeeding in the first six months after birth.

Infant factors

We found in two studies that a child’s average size at birth or lower weight-for-age-z score was associated with an increased likelihood of exclusive breastfeeding [36, 39]. Infants younger than three months [38] and those who never fed from a bottle [13] were more likely to breastfeed exclusively in the first six months after birth. In contrast, two studies found that older infants were less likely to be exclusively breastfed than younger infants [32, 37]. In addition, one study [42] reported that children admitted to Neonatal Intensive Care Units (NICU) were less likely to exclusively breastfeed in the first six months.

Table 1 Characteristics and summary of findings of included studies
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Table 2 Determinants of exclusive breastfeeding in the first six months after birth in Ghana
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Discussion

We reviewed the current evidence on the prevalence and determinants of exclusive breastfeeding in the first six months of life. To our knowledge, this is the first systematic review and meta-analysis on this subject in Ghana. Overall, the prevalence of exclusive breastfeeding in the first six months of life in Ghana was 50%. Subgroup analysis revealed that the prevalence is higher in rural areas than in urban areas. Our estimated prevalence of exclusive breastfeeding in Ghana is comparable to the reported prevalence in most West and Central African countries [52]. However, it is lower compared to prevalence in most East and Southern African countries [52]. These variations in exclusive breastfeeding rates are likely a result of regional and cultural variations in breastfeeding policies, practices, and expectations across sub-Saharan Africa. Furthermore, although our estimated prevalence for Ghana is lower than the World Health Assembly’s target of 70% prevalence of exclusive breastfeeding by 2030 [9], it is higher than the current global prevalence (44%) of exclusive breastfeeding [53] and the overall prevalence of exclusive breastfeeding (41%) for sub-Saharan Africa [52].

In contrast to our findings, a systematic review of 25 studies from nineteen developing countries found that older women were less likely to practise exclusive breastfeeding [54]. Unlike the current review, the earlier review included studies from diverse cultures and compared older women to younger non-adolescent women, which may explain the contradictory findings. Nevertheless, in line with our findings, a Brazilian systematic review of 27 studies found that teenage mothers were less likely to practise exclusive breastfeeding [55]. Younger mothers may have a lower exclusive breastfeeding rate due to a possible lack of awareness of the benefits of exclusive breastfeeding, inadequate breastfeeding skills, and unpleasant and painful breastfeeding experiences [56,57,58,59]. Young mothers often introduce complementary foods earlier than recommended to avoid the unpleasant experiences and perceived physical changes associated with exclusive breastfeeding [60, 61].

Consistent with our findings, previous studies have identified self-employment, higher maternal education, and house ownership as facilitators for exclusive breastfeeding [54, 57, 62, 63]. These factors empower women, increase their self-efficacy, and promote health-seeking behaviour, including the ability to address the challenges of exclusive breastfeeding [38, 64]. Healthcare professionals must become familiar with these enabling factors to identify at-risk mothers during prenatal and postpartum care and provide prompt intervention and counselling. Additionally, several previous systematic reviews have reported on the positive influence of antenatal attendance, facility delivery, and normal vaginal delivery on exclusive breastfeeding in line with our findings [54, 55, 57, 65]. In a mixed-methods systematic review, Patil et al., found that caesarean delivery was associated with a 1.6 times higher risk of exclusive breastfeeding cessation than normal vaginal delivery [57]. Antenatal attendance improves pregnant women’s knowledge of the nutritional value of breastmilk as well as their attitude toward exclusive breastfeeding. This explains why this study found a higher likelihood of exclusive breastfeeding among women who attended more antenatal visits and had good knowledge of exclusive breastfeeding.

Unsurprisingly, several previous studies have reported positive associations between exclusive breastfeeding and adequate maternal knowledge of the benefits of exclusive breastfeeding, positive attitude toward breastfeeding [54], social support from friends and family [52, 56, 57], and peer counselling on exclusive breastfeeding [54, 57], which is consistent with our results. For example, in 2018, a meta-analysis of 27 randomised controlled trials found that mothers with breastfeeding support were more likely to practice exclusive breastfeeding than those without support [63]. The positive impact of family support may explain why women in larger households were more likely to practise exclusive breastfeeding in this study. In Ghanaian society, a large household generally includes other family members who may support and encourage breastfeeding.

Births out-of-wedlock are generally regarded as morally inappropriate in Ghanaian society, and mothers who are not married receive little assistance from their families and community [66, 67]. It is possible that insufficient family and community support contributed to the lower likelihood of exclusive breastfeeding among unmarried women in this study. Indeed, a lack of family support was identified as a major barrier to the practice of exclusive breastfeeding in the current review. Furthermore, we found that intimate partner violence was negatively associated with exclusive breastfeeding, which is consistent with the findings of Normann et al. [68]. Women exposed to intimate partner violence in any form and at any stage are at significant risk of terminating exclusive breastfeeding before the recommended duration of six months [68].

Exclusive breastfeeding practices are impacted by mothers return to work [26, 38]. When returning to work, mothers frequently leave their infants with family members, spend less time with them, and introduce complementary foods earlier than is ideal [71]. Therefore, it is not surprising that in the present review, exclusive breastfeeding was less likely among women who returned to work within three months of giving birth. Several earlier studies have reported similar results [54, 72, 73]. There is a need for institutions to improve their support of breastfeeding in the workplace. For instance, policies extending paid maternity leave might increase exclusive breastfeeding duration among working mothers. In line with our findings, a prior systematic review found that women in urban areas were more likely to terminate exclusive breastfeeding before six months than those in rural areas [57]. This can be attributed to urban dwellers early return to work, busy work schedules, and infant illness from expressed breastmilk [74].

Maternal HIV-positive status as a barrier to exclusive breastfeeding, as found in this review, can be attributed to poor policy dissemination, inadequate counselling, and mothers’ fear of passing the infection to their children through breastmilk [75]. Even though there is some risk of transmitting HIV through breastmilk [76], there is evidence suggesting a reduced viral load in women who adhere to antiretroviral drugs [77]. For instance, a Cochrane review reported a 29% reduction in HIV transmission through breastmilk within 18 months of breastfeeding [78].

When health professionals recommend infant feeding, mother’s and child’s best interest are considered. Therefore, it is surprising and unclear why health professionals in one of the studies under review [43] suggested complementary and formula feeding for infants younger than six months. It will be useful for future studies to investigate this practice. In agreement with our findings, a previous study found that women’s perceptions of insufficient breastmilk are linked to a lower likelihood of exclusive breastfeeding [54].

Our findings have implications for public health and clinical practice. A holistic approach is required to increase the prevalence of exclusive breastfeeding in the first six months of life and interventions should be multi-dimensional. For example, some inequalities derive the low prevalence of exclusive breastfeeding as demonstrated in this review and this may be addressed through the promotion of exclusive breastfeeding in all socioeconomic strata, localities, traditions, and languages. Guidelines should be culturally sensitive to provide a multicultural approach to breastfeeding counselling and education during antenatal and postnatal care and to ensure adherence. Accurate prenatal, perinatal, and postnatal educational interventions on exclusive breastfeeding, both within and outside health facilities, could correct misinformation on when to introduce complementary foods and discourage formula use in the first six months after birth. Family members and healthcare professionals can help adolescent mothers breastfeed exclusively for longer by providing breastfeeding support, encouragement, and guidance. Healthcare professionals must also provide adolescent mothers with adequate health education on the relevance and practice of exclusive breastfeeding. HIV-positive mothers need tailored counselling, education and support to promote exclusive breastfeeding. Public health authorities need to engage relevant stakeholders, including government and policymakers, to review the labour law to allow working mothers paid maternity leave for a minimum of six months. Policies should also be directed towards minimising the advertisements of breastmilk substitutes. Future reviews should focus on qualitative studies as evidence from these studies will likely uncover new understanding or perspectives on the factors that influence exclusive breastfeeding in Ghana.

Our study has several strengths. One major strength is that our findings are nationally representative as it includes studies from rural and urban areas of Ghana and across almost all the country’s administrative regions. In addition, the criteria for the search were not limited by region, language, or publication date. Despite the strengths, some limitations should be recognised when interpreting the findings of this study. One major limitation is that most of the studies were cross-sectional with the possibility of recall bias and measurement error due to the retrospective collection of breastfeeding data. In addition, some studies did not adequately control for known confounding variables. Another limitation of this study is that compared with an annual crude birth rate of 2.8, we report findings from 0.8% of babies born in Ghana annually. Even though most of the included studies adopted the WHO criteria for exclusive breastfeeding, the assessment and categorisation of exclusive breastfeeding varied across included studies. Three studies that analysed national surveys were not included in the subgroup analysis because it was not specific to a locality or administrative region. The regional subgroup analysis included only regions with at least two included studies.

Conclusions

The prevalence of exclusive breastfeeding in Ghana is lower than the global target, though it is higher than the rates reported in most sub-Saharan African countries. We found that the determinants of exclusive breastfeeding in the first six months after birth included a range of sociodemographic, workplace-related, obstetric, and healthcare-related factors and feeding decisions and breastfeeding support available to mothers. Several infant characteristics were also identified as determinants of exclusive breastfeeding in the first six months after birth.