This qualitative study among more than 250 individuals in rural northern Ghana suggests that community members are knowledgeable about the importance of breastfeeding, and most women with newborn infants do attempt to breastfeed. However, data suggests that traditional practices related to breastfeeding and infant nutrition continue, despite knowledge of clinical guidelines. Such traditional practices include feeding newborn infants water, gripe water, local herbs, or traditionally meaningful foods such as water from the flour of guinea corn(yara’na). These findings are similar to existing literature that suggests the introduction of foods other than breastmilk in the first 6 months is a common practice in sub-Saharan Africa [19, 20].
In this district of Ghana, there are significant cultural traditions associated with breastfeeding – including testing the breastmilk for bitterness before allowing a woman to breastfeed. Such a test – in which an ant is dropped into breastmilk and its demise is seen as an indication of the toxicity of the milk– is performed by grandmothers and other influential community members. Given the community hierarchy, such a tradition is likely to be challenging for a young mother with a newborn to overcome. Traditionally, breastfeeding is delayed by three days for male and four days for female infants by first time mothers if a test of the mother’s milk shows that it is toxic. Also, prelacteal feeds are given or a wet nurse is used while the mother goes through the traditional process of purifying the breast. Changing such community-rooted traditions will require the engagement of the community hierarchy in breastfeeding campaigns.
Generally, there was a perception that most traditional ways of feeding infants are giving way to current recommendations. This transition is positive and appeared to be associated with religion. Individuals, who practice religions, such as Christianity, that prohibit the offering of sacrifices, consulting of sooth-sayers and performing rituals such as testing colostrum by putting ants in it, are more likely to promote and support appropriate infant feeding practices. Religious leaders could therefore, play a crucial role in shaping societal conduct towards breastfeeding.
Our data also indicate that grandmothers – typically the mother-in-laws – wield an enormous amount of power in these communities. These results are similar to other studies both in Ghana and beyond. In Eastern Ghana, Otoo et al. found that one major barrier to breastfeeding cited by women was pressure from family, specifically, the grandmother . The authors report women becoming confused by the mixed messages they receive and often defaulting to adding water or other supplemental foods . Similarly, a study in Mozambique found that while mothers had heard the recommendation to exclusively breastfeed, other family decision makers had not and expressed skepticism about its feasibility .
Infant feeding is viewed traditionally as a gender role for women . However, it was evident from our study that males also play a crucial role in influencing breastfeeding behavior. In the KND, compound and household heads are the gender roles of males and these groups demonstrated good knowledge of breastfeeding recommendations. Being a patriarchal society, men generally dictate the ways of life of the people. Men prepare the herbal teas, pour the libations and consult the sooth-sayers and these activities were reported to influence breastfeeding behavior. This finding corroborates with the study by Littman et al who found that a strong approval of breastfeeding by fathers was associated with a high incidence of breastfeeding (98.1%), compared to only 26.9% breastfeeding when the father was indifferent to feeding choice (P < 0.001) .
Finally, our findings caution that conclusions about breastfeeding and supplemental feeding may be highly contingent upon where women delivered their babies. Babies delivered in a healthcare facility may be more likely to initiate breastfeeding early and maintain exclusive breastfeeding. In addition, our data suggest that women delivering in a facility may be more likely to give their babies colostrum than women delivering outside the facility. These findings are similar to those of Tawiah-Agyemang et al. (2008)  in the middle belt of Ghana. Negative perceptions of colostrum have been well documented elsewhere and strategies to disabuse the minds of mothers and grandmothers have been developed by Linkages, Ghana [25, 26]. However, aggressive campaigns and creation of community platforms to guide mothers to breastfeed appropriately have not been vigorously pursued.
Despite its strengths, there are limitations to this study. First, interviews were conducted by undergraduate- and graduate-student interviewers. It is possible that results might have been different if the community members perceived the interviewers to be more similar to themselves. It is also possible, on the other hand, that community members were less guarded among students than they might have been with local peers. Given the volume of information readily volunteered and the 20-year history of the Navrongo Health Research Center conducting interviews in the community with interviewers very similar to those used in this study, we believe respondents were not inhibited by the student status of interviewers.
Second, this study relied upon self-reported data and does not include, for example, independent assessments of infant feeding practices. Nonetheless, the consistency of the findings and the wide variety of respondents who reported similar occurrences suggest that self-reported data in this case is valid. Finally, qualitative data were translated from the local language into English for analysis. It is possible that nuances of meaning were lost in the translation process, despite our efforts to maintain the integrity of the data by retaining local words when no English translation was sufficient.
The results presented here have enormous implications for improving infant nutrition in rural Ghana. Perhaps most critically, our results suggest that while most women have heard and absorbed messages regarding exclusive breastfeeding, their family members may not. In a setting where decisions are often made by grandmothers and husbands and community leaders rather than individual women, this suggests that public health interventions would be well served to target the broader community, specifically grandmothers, fathers and local healers when trying to increase appropriate breastfeeding rates. There is a precedent for this: One study in Senegal successfully utilized grandmothers to encourage pregnant women to reduce their workload during pregnancy , while the Health Hut system also in Senegal has reported similar improvements in health care process indicators since the incorporation of grandmothers and fathers . We propose a similar intervention in northern Ghana, in the realm of optimal newborn health practices, specifically nutrition.
Our results also suggest that religious leaders may be an important target in improving early onset of breastfeeding, exclusive breastfeeding, and maintenance of breastfeeding. Religious practices, especially among those who practice traditional religion, appear to favor supplemental feeding from a very early age. Integrating religious leaders into future public health interventions has the potential to significantly alter community attitudes, beliefs, and norms with regard to what is appropriate newborn nutrition.