FRENCH EMBASSY . SMALL GRANTS PROGRAMME IN THE HUMANITIES AND SOCIAL SCIENCES. ACCRA 2010.

Socio-cultural factors influencing infant feeding practicies of mothers attending welfare clinic in Cape Coast
Solomon SIKA-BRIGHT, Department of Sociology and Anthropology University of Cape Coast, Ghana January 2010

Abstract Infant feeding behaviour has undergone a number of changes and this has generated a lot of debates all over the world. Infants worldwide are fed breastmilk exclusively, complementary food exclusively, or a combination of both. The study sought to investigate socio-cultural factors that influence the infant feeding practices of mothers attending welfare clinic in Cape Coast. A cross-sectional survey design was employed to examine socio-cultural factors influencing infant feeding practices of a randomly selected sample of mothers in Cape Coast Metropolis. A survey questionnaire was completed through semistructured interviews with mothers with a baby not older than six months. Among the respondents, the majority were Akan, married, over 27 years of age, and held at least junior high school certificate. Respondents who reported having primary education were significantly more likely to exclusively breastfeed than were respondents who reported having higher levels of schooling. Mothers marital status, mothers employment status, friends way of feeding their babies, social support and babys age were also influential in infant feeding practices. The finding of the study indicates that infant feeding practices in Metropolis are still far from ideal can be bettered if the problem is tackled from the sociological point of view. It is therefore suggested that Health workers carrying out infant feeding education need to be aware of the infant feeding practices applicable to their target group as well as the socio-cultural beliefs held by that target group.

Keywords
Breastfeeding, formula feeding/complementary feeding, sociocultural

1 Introduction
The change in the infant feeding practices of society has generated much debate throughout the world. The debate has to do with what to give to the child at what time and for what duration. Infants are fed with breast-milk and complementary foods. Mothers of today have to decide either to breastfeed or bottle-feed their young infants, meanwhile until recent times there was not thought to be a safe, effective alternative to human milk for providing an infant nutrition. The decision of what infant feeding practice to adopt is influenced by a wide range of factors. Many research studies had been conducted on this subject matter. Despite many years of research and policy initiatives, on infant feeding in subSaharan Africa, rates of infant malnutrition and under-nutrition have remained consistently high (ACC/SCN 2000). This is hugely due to the fact that most of these infant feeding campaigns are almost always directed to the mother and are based on the assumption that women are free to make their own decisions on feeding their infants. But in all cultures there are a number of factors that affect women's decisions on how to feed their children (Matusiak, 2005).

The socio-cultural influences on acceptable infant feeding practices are varied and complex, thus they vary greatly from one society to another. As a result of some of these practices, a large number of children especially in the developing world never experience proper feeding routines. In Ghana, the situation is not different, for instance, in a recent poster publication from the US Population Reference Bureau, on studies made in sub-Saharan Africa, proportion of those breastfeeding exclusively up to 6 months in Ghana was below 32% (Population Reference Bureau, 1999). This figure is woefully below the WHO/UNICEFs aim of achieving 75% and above exclusive breastfeeding in subSaharan Africa. However, Ghanaian mothers do not hesitate at all in giving their infants complementary foods. For instance, Davis, Tagoe-Darko & Munkuria (2003), reported that, water and glucose solutions are widely given to infants, beginning in the first few months of life with the explanation that water should be given to infants immediately after birth because they are thirsty after the exhaustion of the birth process or as a cultural gesture to welcome the child into the world. They go ahead to report that, most mothers in Ghana give koko, a maize-based fermented porridge, to their infants as early as the first month of life (Davis, Tagoe-Darko & Munkuria 2003), a stage where the child is supposed to be exclusively breastfed. No wonder, the Ghana Statistical Service reports that an estimated 17 percent of children in Ghana under age five are moderately stunted while another 9 percent are severely stunted (Ghana Demographic and Health Survey, 1999). The above discussions point to one fact, and that is, the high incidence of infant malnutrition and mortality experienced in developing countries is mainly due to poor infant feeding practices. However, most infant feeding research is not done by sociologists but by researchers in the areas of health education, international nutrition, clinical nursing, or public health; fields that have had the most influence on policy (Van Esterik, 2002). As a result, infant feeding has not always been seen as a complex process shaped by social and cultural forces interacting with local environmental and political conditions. Also such studies often ignore the abstract theoretical framing perceived to be of less relevance to policy makers. This study therefore attempts filling in that gap of bringing out the sociocultural factors that influence infant feeding practices through the lenses of sociological theories in a developing nation like Ghana. The study was therefore undertaken to identify the socio-cultural factors influencing infant feeding practices of mothers attending welfare clinic. To facilitate this investigation, the study described local knowledge, attitudes, perceptions and beliefs regarding infant feeding practices in the Metropolis, assess the level of mixed feeding and exclusive breastfeeding/ formula feeding and society's response to both forms and identify and describe socio-cultural factors influencing infant feeding in the Metropolis; specifically; the influence of family, friends and clinic based health workers in shaping current infant feeding practices, and the availability of resources that could influence infant feeding practices.

2 Review of Literature
The study utilizes both empirical and theoretical literature. The empirical literature consists of results of research done on related topics whereas the theoretical review looks at some sociological theories that could be explain the phenomenon under study.

2.1 Review of Research

2.1.1 History of Infant Feeding Breastfeeding has been the natural and normal means of feeding infants. In fact, it is one of the defining characteristic of being a mammal. The importance of breastfeeding before civilization was so pronounced that, wet nurses were contracted for infants of the wealthy and the royal families who were not able to lactate successfully (Wickes, 1953). Wet nursing has been in continual existence from earliest times although its popularity has been inconsistent. In England and Europe in the fifteenth and sixteenth centuries, the middle classes began employing wet nurses, a luxury formerly afforded only to the elite. By the latter part of the 1700s wet nursing was on the decline in North America and England, largely due to increased public concern regarding the moral character of wet nurses and the care they provided (Golden, 1996). Before the last few hundred years, alternatives to breastfeeding were rare. Attempts in 15th century Europe to use cow or goat's milk were not very positive. In the 18th century, flour or cereal mixed with broth was introduced as substitutes for breastfeeding, but this did not have any favourable outcome, either. True commercial infant formula appeared on the market in the mid-19th Century but their use did not become wide spread until after World War II. This was the period when the working pattern of women was rapidly changing; a resultant effect of the industrialization process. This was the beginning of artificial feeding for infants (Wickes, 1953). As the superior qualities of breast-milk became betterestablished in medical literature, breastfeeding rates have increased and countries have enacted measures to protect the rights of infants and mothers to breastfeed. 2.1.2 Breastfeeding and its Benefits Extensive researches using improved epidemiological methods and modern laboratory techniques document diverse and compelling advantages for infants, mothers, families, and society from breastfeeding as a source of infant feeding (Guise and Freed, 2000). Baumslag and Michels, (1995) announced in their book Milk, Money, and Madness: The Culture and Politics of Breastfeeding that, Breastfed babies are healthier, have fewer hospitalizations, and have lower mortality rates than formula-fed infants (p. xxiii). Nutrition and medical journals have added to the body of research that states simply and emphatically that breast-milks health and developmental benefits far surpasses any artificial infant formula. There are numerous studies demonstrating breastfeedings contribution to saving childrens lives, for instance, an infant who is breastfed has a reduced risk of developing diarrhea. Breastfeeding also helps protect infants against acute respiratory illnesses (ARI). A study in Peru showed that infants under 6 months of age who were not breastfed had a fourfold greater risk of developing acute respiratory infections compared with exclusively breastfed babies (Brown et al., 1989). 4

Other developmental benefits of breastfeeding are that, it enhances brain development and learning readiness. Breastfeeding protects babies from illnesses that can cause malnutrition, hearing problems, and learning difficulties (USAID, 2001). Breast-milks vitamin A component reduces the risk of eye problems, growth failure, illness, and death. Breastfeeding provides frequent interaction between mother and infant, fostering bonding, a sense of security, and stimulus to the babys developing brain. A meta-analysis of 20 controlled studies showed that breastfeeding was associated with a 3.2-point higher cognitive development score than formula feeding, after adjusting for key cofactors (Anderson, Johnstone, & Remley, 1999). Breastfeeding benefits are not only limited to the child, mothers also benefits from breastfeeding. In the short term, breastfeeding increases oxytocin levels. Oxytocin, the love or bonding hormone, also contributes to maternal child bonding. The long term benefits of breastfeeding for women who breastfeed are that, they have lower their risk of developing uterine cancer, osteoporosis, type 2 diabetes, and breast cancer (Rosenblatt & Thomas, 1995). For the family and society as a whole, breastfeeding has some benefits. Breastfeeding delays the resumption of ovulation and the return of a womans menstrual cycle, thus serving as the physiological basis of Lactational Amenorrhea Method (LAM). Data from the Demographic and Health Surveys (DHS) show that the duration of lactational amenorrhea (absence of a menstrual period due to breastfeeding) was strongly associated with the duration of breastfeeding (Perez-Escamilla, Hight-Laukaran, Peterson, and Labbok, 1997). In addition to its benefit in decreasing fertility, breastfeeding also contributes to improved child survival by increasing the interval between the births of children. 2.1.3 Infant Feeding in Ghana Like in many of the sub-Saharan African countries, the practice of breastfeeding in Ghana has been a major aspect of infant feeding. The available data on infant feeding behaviour of Ghanaian women portray that, about 90% of them practice breastfeeding. In fact, for many years, the situation has not changed. The percentage of mothers initiating breastfeeding ranges between 98% in 1979 and 99.7% in 1989 and was still 99% in 2003 (MOH, 1989; LLLI/CBI, 2003). Like the initiation rate, duration rate has also remained high over the last decade. In 1979/80 for instance, mothers in Ghana breastfed averagely for as long as 15 months. The duration rose to 20.4 months in1988 and then to 21.6 months in 1993 (Ministry of Health, 1989). Looking at the percentage of mothers practicing breastfeeding and for that duration of time, malnutrition and it associated infant mortality should have been a history in Ghana. However Ghana is still saddled with the problem of malnutrition among infants. At a time when infants are supposed to be fed exclusively with breast-milk, they are fed alongside with complementary foods. For instance in a study conducted by Davis et al. (2003) on complementary feeding practices in Ghana, it was reported that, water and glucose solutions are widely given to infants, beginning in the first few months of life. In Ghana, and in most African countries, the traditional complementary food fed to infants is a fermented maize porridge called koko. Koko is generally perceived by mothers as easy to digest and is often the first food introduced to infants and the food of choice during illness (Mensah, Ndiokwelu, Uwaegbute, 1995). 5

2.1.4 Factors influencing Infant feeding Behaviour Demographic and socioeconomic factors affect infant feeding practices. Research studies addressing the influence of maternal age on breastfeeding initiation and duration have varying results (Ford & Labbok, 1990). Investigators have found a strong, positive correlation between maternal age and education level and breastfeeding initiation and duration. Specifically, older, and more educated women are the subgroup most likely to choose breastfeeding as their preferred infant feeding method, and generally they breastfeed their children longer than other groups (AAP, 1997; Scott & Binns, 1999). Older women are more likely to breastfeed exclusively (Arora, McJunkin, Wehrer, & Kuhn, 2000, p. 4). Multiple studies addressing the factors associated with the infant feeding practices have identified adolescent mothers as one group that is unlikely to breastfeed (Volpe & Bear, 2000, p. 196). Generally, families in rural areas are less educated and are more likely to be living in poverty than their urban colleagues. The relationship between breastfeeding and pre-pregnancy employment, enrollment in school and intention to return to work are reported inconsistently in research findings (Littman et al., 1994). However, most investigators agree that full-time employment and school enrollment are associated with decreased breastfeeding duration as the result of environmental barriers at both work and school (Spisak & Gross, 1991). Married women breastfeed their infants exclusively more often than single women (Arora et al., 2000). In a study by De La Mora et al. (1999), the attitudes of married women concerning breastfeeding were more positive than were the attitudes of single mothers (p. 2366). Familial factor have a profound impact on infant feeding practices (Arora et al., 2000). Having been breastfed as an infant or having a sibling who was breastfed establishes breastfeeding as a norm for an individual and her household (Meyerink & Marquis, 2002). Mothers are more likely to feed their infants in the same manner in which they themselves were fed (Hawthorne, 1994; Meyerink & Marquis, 2002). Hospital practices may also affect infant feeding practices, with regards to the initiation and duration of breastfeeding, and the introduction of infant formulas (Ford & Labbok, 1990). The role of the healthcare professional can be very critical in providing women with the information they need to make the decision on how to feed their babies. Negative attitudes and lack of knowledge on the part of healthcare providers can be barriers to successful infant feeding practices (Black et al., 1990). 2.1.5 Social Support and Infant Feeding Infant feeding can be a difficult behaviour to practice and, as such, is best practiced just as any other social behaviour, in a supportive environment. Lack of social support, therefore, has emerged as a key constraining factor on infant choices. A link between social support and breastfeeding initiation and duration has been supported in multiple studies. Having friends who successfully breastfeed and seeing family and friends breastfeed increases the likelihood of a mother breastfeeding (Meyerink & Marquis, 2002). 2.1.6 Work and Infant Feeding Notwithstanding home and support networks, nursing mothers struggle with the difficulty of combining infant feeding with employment or work. Socialist feminism emphasizes how the social system of

capitalist patriarchy limits options available to women economically and politically (Abramovitz, 1988). Infant feeding is a time-consuming behaviour characteristic of the domestic arena. The primary empirical finding concerning working mothers and infant feeding is that the intention to return to a job does not hinder initiation of breastfeeding but does hinder duration of breastfeeding (Auerbach & Guss, 1984). A secondary finding is that the sooner a mother returns to work the less likely she is to maintain breastfeeding (Bick, Macarthur, & Lancashire, 1998; Lindberg, 1996). Galtry (1997), in line with socialist feminist perspectives, argued that infant feeding methods are as much a function of structural conditions expanding or limiting womens options as they are a function of womens attitudes.

2.2 Theoretical Viewpoints of the Study

The study is based on two theories: socialist feminism and symbolic interaction. Socialist feminism is chosen because of it is useful in identifying what may explain aspects of infant feeding behaviours at both macro and micro social levels. Symbolic interaction is also selected because it describes how humans perceive, choose lines of action, and make sense of their social worlds. 2.2.1 Socialist Feminism and Infant Feeding Practices Socialist feminism brings together materialist class analyses and feminist social protest to explain womens oppression. The theory argues that the economically invisible labour of women subsidizes the economy by disguising real costs. These insights are applicable to infant feeding practices. Infant feeding is a form of domestic labour that costs mothers time and energy without producing income. The infant feeding choices available to women are to formula feed, breastfeed exclusively, or offer the infant a combination of formula and breast milk. As such, mothers who do not breastfeed because of workrelated constrains must buy formula, representing a large, sought after, capitalist market. The intensive formula marketing that mothers are exposed to is another influence on infant feeding, in that it serves as a barrier to successful breastfeeding. Mothers who intend to breastfeed successfully are persuaded by such media portrayals of formula feeding to switch to Infant feeding in a capitalist patriarchy has far-reaching macro level economic and political implications. The baby formula industry has been estimated to generate between 5 and 6 billion dollars in profits annually (Tamaro, 1998). These powerful companies have an economic interest in continued low breastfeeding rates. Infant feeding is tied intimately to micro structures of daily life including: the human body and its involvement in childbearing; home maintenance, with its unpaid, invisible domestic tasks; and emotional sustenance of self and others (Lengermann & Neibrugge-Brantley, 2000). Fatigue with the energy demands required of nursing a baby in addition to domestic and workforce labour may partly explain poor infant feeding practices. 2.2.2 Symbolic Interactionism and Infant Feeding While socialist feminist theory provides a framework for considering structural implications for infant feeding; symbolic interactionism provides a theory for considering the subjective inner processes that mothers use in making their choices and deciding on the significance of their actions. The development of the self is central to symbolic interactionism. This happens as an individual imaginatively constructs the attitudes of the other about a particular role, and thus anticipates the behaviour of the other. Not all 7

others are equally influential in this construction process. The generalized other, in the most abstract sense, is the view of relevant rules and roles of society as a whole. In the case of infant feeding, marketing and media portrayals of infant care are influential (Newman & Pittman, 2002). Reference groups are social groups with which people identify that are capable of influencing them. Family, friends, peers, neighborhood, and workplace groups may become such reference groups for mothers who are feeding their infants (Scott & Mostyn, 2003). Significant others are considered the most influential person or group of persons with whom an individual interacts. Infant feeding choices can be framed in symbolic interaction terms. Individual mothers must decide whether they will take on the roles of breastfeeding or formula feeding, or even both. A mother whose family has a tradition of formula feeding already has a reference group that may encourage continued formula feeding. However, a key significant other, like a husband who supports or encourages breastfeeding, may prompt a behavioural change. A mothers identity may therefore become profoundly shaped by the symbolically charged behaviour of infant feeding in view of others. Infant feeding practice is therefore that can be explained in symbolic interactionists terms.

3. Subjects and Methods

3.1 Research Design
A descriptive cross-sectional survey design utilizing mixed methods was used. A descriptive study was chosen because it is designed to gain more information about characteristics within a particular field of study with the purpose of providing a picture of situations as they naturally happen (Burns & Grove, 1995).

3.2 Area of Study

Cape Coast, the Capital town of Central Region was used for the study, principally because of its heterogeneous inhabitants.

3.3 Sampling and Sampling technique

Purposefully, the Central Regional Hospital was selected as the site for the selection of lactating mothers for the study. 147 mothers of children aged 0-6 months, visiting welfare clinic at the Central Regional Hospital were selected to participate in the study. The following inclusion criteria were defined for participation: The respondent

1) Has to be the infants mother 2) Has to be a resident in Cape Coast Metropolis 3) Should not have twins (index child) 4) Should have an infant not older than 6 months of age at the time of the study.
8

154 mothers were checked against the inclusion criteria, and seven were dropped because they did not meet the selection criteria. After obtaining the informed verbal consent of the 147 qualified mothers, the mothers were visited at their respective homes for the administration of the instrument. Seven mothers (4.8%) declined participation because they did not have time. Two mothers (1.2%) also declined participation for some other reasons. As a result, one hundred and thirty-eight (94%) mothers participated in the study.

3.4 Research Instrument

A 52-item standardized and pre-tested interview guide was developed based on the literature review. The interview protocols were assessed by experts in the field to evaluate the appropriateness and coverage thereof, especially in terms of content. The interview protocols were also pretested. The interview protocol for the lactating mothers was tested in a pilot study representing 10% of the total sample size (n=15) prior to implementation on the field. The mothers for the pilot study were selected from the Metropolitan Hospital. Few changes to the questions on the interview guides were required after the pilot testing exercise.

3.5 Data collection and Statistical Analysis

The researcher with the aid of one trained field assistant administered and collected data from the respondents. All the 147 mothers were visited in their homes on an agreed date with the mothers, where the interviews were completed and returned. The average interview duration per respondent was 45 minutes to 1hour. Follow-ups were done to clarify vague responses with the respondents. The data collected were edited, coded and analyzed for common themes. All the data that were generated by this study was analyzed using the Statistical Product for Service Solution (SPSS) computer software package (version 16.0 for Microsoft Windows). Data values were checked against the field records to ensure that no data entry errors were made. Findings from the analysis were presented in contingency tables with summary statistics including multi-variants chi-square and proportions to look at the various relationships that exist among variables of interest.

4. Results
4.1 Characteristics of Respondents
The demographic characteristics of the respondents are presented in Table1. The mothers ranged in age from 20 to 39 years with an average age of 29 years. With respect to age, participation was highest amongst mothers aged between 30 and 34 years. Approximately 75% (n=103) of the participants were married, 41% (n=57) had at least some tertiary education, and 75% (n=103) were employed.

Table 1: Respondents Socio-Demographic Characteristics Characteristic Frequency (N =138) Percent Age 20-24 12 8.7 25-29 15 10.9 30-34 98 71.0 35-39 13 9.4
9

Marital Status Married Cohabitation Never married Education Primary Junior high Senior high Voc/Technical Tertiary Employment Yes No Source: Fieldwork, 2009.

103 23 12 24 33 12 12 57 103 35

74.6 16.7 8.7 17.4 23.9 8.7 8.7 41.3 74.6 25.4

4.2 Infant feeding practices among respondents

Table 2 shows the type of infant feeding practice respondents were practicing at the time of the study. Breast-feeding and formula/porridge feeding were practiced exclusively by 12% (n=17) and 28% (n=39) of mothers respectively, while 59.4% (n=82) of the mothers practiced mixed feeding at the time of the study. Forty-five percent (n=62) of the mothers reported to have introduced their babies to other foods aside breast-milk within the ages of three to four months. Fifty-two (37.7%) mothers introduced other foods within the fifth and sixth months of their infants life. Also, seventeen mothers have not yet introduced their babies to any food apart from breast milk.

Table 2: Current Infant Feeding Practices and Age at which other foods were introduced Variables Frequency (n = 138) Percentage Current Feeding Practice Exclusively breastfeed 17 12.3 Formula/ feeding 39 28.3 Mixed feeding 82 59.4 Age at which other food supplements were introduced No Introduction 17 2 months and below 7 Between 3-4 months 62 5-6 months 52
Source: Fieldwork 2009.

12.3 5.1 44.9 37.7

4.3 Factors influencing Infant feeding Practices

Possible factors that may have influence infant feeding practices were reported in Table 3 and 4. The variables of interest were mothers demographic characteristics and socio-cultural factors; specifically the influence of family, friends and clinic based health workers in shaping current infant feeding practices. The age of mothers and their current feeding practices (Table 3) reveals an interesting trend. 10

The percentage of mothers exclusively breastfeeding and formula feeding tend to increase as the age of mothers increase. However, that of mixed feeding decreases as mothers age increases. There seems therefore to be a relationship between maternal age and feeding practice as older mothers are more likely to exclusively breastfeed whiles younger mothers are more likely to mixed feed. Looking at the distribution of current feeding methods by mothers marital status (Table 3), a significant relationship was observed between marital status and exclusive breastfeeding. Out of the 17 exclusively breastfeeding mothers, 14 were living together with their partners but were not married. The remaining three were married. None of the never-married respondents was exclusively breastfeeding. A distribution of feeding method by mothers level of schooling is also presented in Table 3. Respondents who reported having primary schooling were more likely to breastfeed exclusively than respondents of the other levels of schooling. Meanwhile respondents with tertiary schooling were practicing formula feeding more than other respondents. Mothers employment status was found to be strongly associated with how they were feeding their babies. As portrayed in Table 3, of the seventeen mothers practicing exclusively breastfeeding, 14 were mothers who reported that they were unemployed. However 65 of 82 mothers practicing mixed feeding were employed.

Table 3: Current Infant Feeding Practices by Demographic Characteristics Feeding Practice Variable Total Exclusively Formula Mixed breastfeed feeding feeding n=138(%) n=17(%) n=39(%) n=82(%) Age of 20-24 0 (0%) 2 (16.7%) 10 (83.3%) 12 (100%) mother 25-29 1 (6.7%) 4 (26.7%) 10 (66.7%) 15 (100%) 30-34 14 (14.3%) 27 (27.6%) 57 (58.2%) 98 (100%) 35-39 2 (15.4%) 6 (46.2%) 5 (38.5%) 13 (100%) Marital Status Married Living together but not married Never married Primary Junior High Senior High Voc/technical Tertiary Yes No 3 (2.9%) 14 (60.9%) 35 (34.0%) 2 (8.7%) 65 (63.1%) 7 (30.4%) 103 (100%) 23 (100%)

pValue 0.357

0.000

0 (0%)

2 (16.7%)

10 (83.3%)

12 (100%)

Mothers Level of Schooling

13 (54.2%) 0 (0%) 2 (16.7%) 0 (0%) 2 (3.5%) 4(3.9%) 13(37.1%)

2 (8.3%) 8 (24.2%) 3 (25.0%) 2 (16.7%) 24 (42.1%) 34 (33.0%) 5 (14.3%)

9 (37.5%) 25 (75.8%) 7 (58.3%) 10 (83.3%) 31 (54.4%) 65 (63.1%) 17 (48.6%)

24 (100%) 33 (100%) 12 (100%) 12 (100%) 57 (100%) 103 (100%) 35 (100%)

0.000

Employment

0.000

Source: Fieldwork, 2009.

11

The study also found out that, families, friends and health workers exert some amount of influence on mothers choices of infant feeding practices. As portrayed in Table 4, seventy-one out of the 138 mothers interviewed were advised by clinical nurses on how to feed their infants. Of this number, 16.9% were exclusively breastfeeding, 26.8% were formula feeding, and 56.3% were mixed feeding. However only one out of the 17 exclusively breastfeeding mothers received advise on how to feed her baby from friends. It was also observed that 66% of mothers who received advice from their family members on infant feeding were mixed feeding. This shows that the families of the mothers were more likely to support mixed feeding than the other types of feeding. One young woman reported: My mother wish the baby eats, they like to see the baby eating every always, and they believe if the baby is crying then he must eat something. The Table 4 also portrays to a very large extent that mothers are more likely to be influenced by what their friends do. Majority (68 out of 138) of the mothers have friends who formula feed. Here, it was observed that 16 of 17 mothers exclusively breastfeeding had friends who also breastfeed, however only one out of the 17 exclusively breastfeeding mothers had a friend who formula feed. Likewise, 95.6% of mothers mixed feeding have friends who mixed feed.It was also realized that parents (of the mothers) assisted majority (76 (55.1%) of the mothers interviewed compared to fiances who assisted 13 (9.4%) and husbands who assisted 15 (10.9%) mothers, while 34 (24.6%) mothers were assisted by no one. Table 4 further portrays that majority of the exclusively breastfeeding mothers were assisted by parents. This shows the importance of grandparents in the lives of children born in the study area. However, the proportion of exclusively breastfeeding mothers out of the mothers assisted by their husbands was greater than those of the other subgroups looking at the row percentages. This therefore implies that mothers who have their husbands supporting them are more likely to exclusively breastfeed. Interestingly, mothers who have nobody to assist them were not exclusively breastfeeding, likewise those who were assisted by their fiances.

Table 4: Influence of Family, Friends and Health Workers Feeding Practice Variable Exclusively Formula breastfeed feeding n=17 (%) Who advised you on what to feed baby with? Nurse Friends Family 12 (16.9%) 1 (7.1%) 4 (7.5%) n=39 (%) 19 (26.8%) 6 (42.9%) 14 (26.4%)

Total Mixed feeding n=82 (%) 40 (56.3%) 7 (50.0%) 35 (66.0%) n=138 (%) 71 (100%) 14 (100%) 53 (100%) pValue 0.357

12

What friends feed their babies with

Formula only Breast-milk only Mixed Feeding

1 (2.8%) 16 (47.1%) 0 (0%)

26 (72.2%) 10 (29.4%) 3 (4.4%)

9 (25.0%) 8 (23.5%) 65 (95.6%)

36 (100%) 34 (100%) 68 (100%)

0.000

Who assist you most in caring for your baby?

Husband Fiance Parents No one (self)

3 (20.0%) 0 (0.0%) 14 (18.4%) 0 (0%)

4 (26.7%) 1 (7.7%) 22 (28.9%) 12 (35.3%)

8 (53.3%) 12 (92.3%) 40 (52.6%) 22 (64.7%)

15 (100%) 13 (100%) 76 (100%) 34 (100%)

0.024

Source: Fieldwork, 2009.

5 Discussion
This study provides the level and socio-cultural factors influencing infant feeding practices of women in Cape Coast Metropolis. Mothers attending the Central Regional Hospital Welfare clinic were participants of this study. The results of this study therefore may not be generalized to represent the whole of Ghana, because of the limited coverage. A review of the literature on current infant feeding practices showed the effects of demographic characteristics on infant feeding practices (Ford & Labbok, 1990). In this study it was observed that all the demographic characteristics except the age of mother affected the way infants are fed. Young mothers below 22 years of age were less likely to exclusively breastfeed, likewise mothers who were never married. Exclusive breastfeeding was high among mothers aged between 28-32 years, among mothers living together with their partners, unemployed, less educated mothers and Christian mothers. Scott & Binns (1999) and Arora et al. (2000) reported that, older women were more likely to exclusively breastfeed. Volpe & Bear (2000) had also identified that young mothers are unlikely to breastfeed. This study agrees with these claims, though the relationship between the two variables was not statistically significant (p=0.357) (Table 5). Mothers level of education and employment status were found to be significantly related (p=0.000) to infant feeding practices. Mothers with higher educational degrees were not exclusively breastfeeding likewise mothers who were employed. Bick et al. (1998) made it clear that working mothers are less likely to maintain breastfeeding. It follows therefore that, educated mothers are mostly employed and are more likely to mixed feed than exclusively breastfeed in the first six months of their childs life. A banker, mother of a three-and-a-half-month old baby reported that: my leave has expired and my job too is very demanding, so I have to mixed feed, even that, Im still stressed up each day, when she was 13

asked a follow up question on why she was not practicing exclusive breastfeeding. Work therefore plays a major role in conditioning mothers infant feeding practices. Bick, et al. (1988) found a return to work within 3 months of birth predictive of early mixed feeding. These mothers therefore would have to start buying formula during the first six months of the childs life. The socialist feminism perspective informing this study makes it clear that mothers are being exploited by the capital market when short maternity leaves are given to them, moreover, when such mothers have to buy formula during the early stages their infants life, the capitalist market again exploits such mothers (Bentley et al., 2003). Galtry (1997), in line with socialist feminist perspectives, argued that infant feeding methods are as much a function of structural conditions expanding or limiting womens options as to what to give to the child. This finding supports Galtrys argument and the socialist feminist position that informs this study that women nursing a baby alongside domestic and workforce labour partly explain poor infant feeding practices (Bick, Macarthur & Lancashire, 1998). The fact that clinic based nursing staff are the most important source of infant feeding information underlines the important role that clinic based staff can play in shaping appropriate infant feeding decisions. Of all the sources of advice, those who consulted the clinical nurses were more likely to exclusively breastfeed than the other subgroups. Black et al. (1990) emphasise the enormous role health workers play in shaping infant feeding practices of mothers. Though in this study, the relationship between sources of mothers advice and current infant feeding practices is not statistically significant (p=0.357), certain trends were noticed. Literature has also shown that mothers are more likely to feed their infants the way their friends do (Hawthorne, 1994, p. 27; Meyerink & Marquis, 2002, p. 38). This study tends to portray this trend. Mothers to a considerable extent were practicing what their friends were doing (p=0.000). Majority of exclusively breastfeeding mothers had friends who breastfeed, likewise those of the other subgroups. Looking again at this trend from the symbolic interactions perspective, it is realized that, friends had become the mothers reference points as friends form integral part mothers reference groups. Such associations with the reference groups enable mothers to develop the self which is very central to symbolic Interactionism (Bailey, 2001). The literature also makes it clear that, mothers whether employed or unemployed, are mostly engaged in domestic chores and thus keeping them away from proper infant feeding routines (Sullivan, Leathers, & Kelley, 2004; Bick, Macarthur & Lancashire, 1998). The results portrays that mothers assisted by their husbands were more likely to exclusively breastfeed.

6 Summary
Mothers were not exclusively breastfeeding as they should, instead, majority of them were mixed feeding. Current infant feeding practice was found to be associated (p<0.05) with the following demographic variables: age of last baby, marital status of mother, level of education and employment status of mother. Mothers were also more likely to feed their babies the way their friends feed their 14

babies. Who assists the mother in taking care of their baby was also found to influence mothers choice of infant feeding practice. It is thus recommended that mothers who choose to formula feed, they should be provided with the necessary counselling and advice in order to implement formula feeding effectively and safely. Continuous in-service trainings and refresher courses for health workers in the areas of appropriate infant feeding practice was also recommended.

7 Conclusions
The conclusions based on the findings of the study are presented in this section. Based on the statistical analysis of the data, a primary conclusion is that the infant feeding practice is affected by certain demographic and socio-cultural factors. The relationship between maternal age and current feeding practices is not statistically significant, though the percentage of respondents who chose to exclusively breastfeed increased with age. Generally, research studies addressing the influence of maternal age on breastfeeding initiation and duration have reported varying results. Alexy & Martin (1994) and Scott & Binns (1999) led studies which addressed the relationship between maternal age and infant feeding practices. Both studies concluded that older women are more likely to choose breastfeeding as their preferred infant feeding method. The conclusion of this study as far as maternal age is concerned, confirms these earlier works. A significant relationship was however observed between marital status and whether the youngest child was exclusively breastfed (p<0.000). None of the single/never-married respondents reported feeding their youngest child breast-milk exclusively, compared with 3% of married respondents and 61% of respondents living together but not married. Maternal education was negatively associated with breastfeeding exclusivity. Mothers who have completed primary education exclusively breastfed at significantly higher rates than mothers who had higher educational experience. On the other hand, respondents who reported having some higher education were more likely to mixed feed than were respondents who reported having primary education. Work was readily identified by mothers as a reason for not breastfeeding exclusively. Thirteen out of the 17 exclusively breastfeeding mothers were unemployed. Postnatal clinic based nurses were reported as the most important source of infant feeding information. Surprisingly however, majority of the mothers who cited nurses as their source of infant feeding information were mixed feeding. This shows that infant feeding practices were still not ideal in the Cape Coast Metropolis. Study respondents were more likely to feed their infants in the same manner in which friends fed their infants. Although a quarter of mothers indicated that they had no infant care support, the majority indicated the availability of resources such as social support from fiances and significant others like the husband and infants grandmother.

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7 Recommendations
7.1 Recommendation to Health workers and authorities
Symbolic Interaction, one of the theories informing this study, emphasizes the influence of reference groups and significant others opinions as shaping the Selfs choice of meaningful lines of action. This study to a very large extent confirms this theory as mothers were influenced by such groups in their choice of infant feeding practice. Health workers and health authorities therefore are called upon to not only target the mother as the sole recipient of infant feeding education, but also the general public, since anyone could be a reference point or a significant other for a lactating mother. Also nursing staff and counselors involved in infant feeding education should be properly trained in order to advice and counsel mothers and the general public on appropriate infant feeding practices and related issues. Lastly there is the need for the re-assessment of Cape Coast Regional Hospital and other hospitals in the metropolis by the Ghana Health Service for baby and mother friendliness and use the result of reassessments to improve infant feeding practices in heath facilities.

7.2 Recommendations to mothers

It is recommended that mothers begin infant feeding education as soon as they get pregnant, so that they can make well informed decisions on how to feed their babies Mothers should also visit the postnatal clinic very early in order to curb the initiation of any inappropriate infant feeding practice. Where mothers opt to formula feed, they should seek necessary practical advice in order to implement formula feeding effectively and safely.

7.3 Recommendations for further research

The study should be replicated by other researchers in order to strengthen the foundation for interpreting results. A replication of the study with samples drawn from all the hospitals in the metropolis would provide additional insights into the factors affecting the infant feeding practice. Researchers investigating the factors influencing mothers infant feeding practices should conduct such studies among mothers who do not attend any hospital. This would limit the level of bias that the research environment could have on the data being generated. Also such studies must cover fathers roles, recognition and support for infant feeding practices.

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