Abstract
Introduction
Breastfeeding has proven over the years to be one of the most effective means to ensure child survival. The advocators and myth busters of breastfeeding myths are supposed to be health professionals. However very little is known about myths surrounding breastfeeding as expressed by these health professionals (nurses and midwives). Hence this study.
Objective
The study aimed at exploring the myths about breastfeeding as voiced by lactating nurses and midwives.
Method
Qualitative exploratory descriptive design was used to investigate the subject matter. Twenty-five nurses and midwives were purposely selected to participate in the study after they had voluntarily opted to be part of the study. Data was audiotaped, transcribed verbatim and inductively analyzed.
Results
It was evident that participants believed in myths about breastfeeding. The main themes discovered were breastfeeding myth beliefs and sociocultural myth influences. Six sub-themes identified were green stools/diarrhoea, childhood disease, teeth discoloration, child becoming stupid, culture and close relatives.
Conclusion
Health professionals believe in unfounded myths about breastfeeding. Steps should be taken for them to get better lactation support. The outcomes of this study underscore the need for health professionals to address breastfeeding myths, understand the sociocultural context, and support evidence-based practice. Improving lactation support and education for nurses and midwives can lead to better clinical practice and, as a result, help to promote successful and healthy breastfeeding in Ghana.
Introduction
There is no doubt that breastfeeding is valuable to the survival of infants due to the many documented benefits associated with its practice (Bar et al., 2016; Binns et al., 2016; Brahm & Valdes, 2017; Jiang et al., 2018; Lowson et al., 2015; Muniz et al., 2015; Rollins et al., 2016; Victora et al., 2015, 2016; Yan et al., 2014). The World Health Organization (WHO) asserts that, if practiced, it has the single most effective benefit of ensuring child survival and reducing under five deaths by eight hundred thousand (800,000) annually (WHO, 2016). Despite its benefit, global exclusive breastfeeding rate at 6 months stands at 38% with West and Central Africa collectively recording a rate of 31% (UNICEF, 2019). In Ghana, exclusive breastfeeding rate has reduced from 63% in 2008 to 43% in 2018 (Mohammed et al., 2022). Meanwhile, the WHO recommends strongly that, breastfeeding should be practiced for at least 2 years in each infant's life with the first 6 months being exclusive (WHO, 2009).
Review of Literature
Myths surrounding breastfeeding practices have been extensively documented to negatively affect the rate of breastfeeding across different cultures and continents in the world (Akram et al., 2017; Eram, 2017; García-Magdaleno & Laureano-Eugenio, 2019; Isytiaroh, 2018; Koura, 2019; Lajuna et al., 2020; Martins et al., 2020; Muggaga et al., 2017; Prado et al., 2016; Rahadini & Rahmat, 2018; Sámano et al., 2020; Tsegaye et al., 2019; Wanjohi et al., 2016; Yurtsal et al., 2016). One of the myths expressed about breastfeeding included insufficient milk production and this myth leads most mothers to wean their infants earlier than recommended (Isytiaroh, 2018; Prado et al., 2016; Sandhi et al., 2020; Tsegaye et al., 2019; Vargas-Zarate et al., 2020; Zakar et al., 2018). Some mothers are influenced by myths about the quality of breast milk and referred to breast milk as weak, dirty or not of high quality (Koura, 2019; Prado et al., 2016; Vargas-Zarate et al., 2020; Wagner et al., 2020; Wanjohi et al., 2016). Others associate breastfeeding with causing gastrointestinal problems and fever (Koura, 2019; Prado et al., 2016). Some lactating mothers hold unsubstantiated views about avoiding certain foods when breastfeeding (Akram et al., 2017; Koura, 2019; Rahadini & Rahmat, 2018) which may deny the infants of certain required nutrients. Others are fixed on vague ideas that, formula is as good as breast milk and the amount of formula given to infants determines the rate at which those infants demand for breast milk (Koura, 2019; Yurtsal et al., 2016).
Most of the above documented myths surrounding breastfeeding have no scientific basis but they are mostly handed over between generations in different cultural settings (Vargas-Zarate et al., 2020). Cultural norms in parts of Africa and Asia that encourage traditional practices where opinion leaders feed newborns with foods other than breast milk have impacted negatively on breastfeeding practices and fueled baseless myths about breastfeeding (Alianmoghaddam et al., 2018; Martins et al., 2020; Tsegaye et al., 2019; Zakar et al., 2018). In other cultures where breastfeeding in public is considered strange thereby making it embarrassing for women to breastfeed in public may fuel such myths (Leahy-Warren et al., 2012).
The opinions of significant people in the lives of breastfeeding mothers may have lasting impacts on their breastfeeding practices since they are influencers who may perpetuate breastfeeding myths or debunk myths and therefore, lack of support from such people has negative influence on breastfeeding practices (Alianmoghaddam et al., 2018; Eram, 2017; Ferreira et al., 2018; Leahy-Warren et al., 2012; Tsegaye et al., 2019; Wanjohi et al., 2016).
Nurses and midwives form the majority of health workers who care for breastfeeding clients. Therefore, the myths about breastfeeding expressed by lactating nurses and midwives may affect their breastfeeding practices and advocacy techniques. In a health application, questions about myths surrounding breastfeeding were among the most frequently asked (Padró-Arocas et al., 2020). Breastfeeding myth busters have been identified to be primarily nurses (Martins et al., 2020) which means that, nurses are expected to be the ones debunking breastfeeding myths and not perpetuate them. But, very little is known about myths held by nurses and midwives concerning breastfeeding.
In Ghana, there is no current documented paper on myths and misconceptions about breastfeeding as voiced by lactating nurses and midwives. Meanwhile, their unfounded myths and misconceptions about breastfeeding practices may affect their breastfeeding advocacy behaviors. There is, therefore, the need to explore their own misconceptions about breastfeeding in order to give them the much needed support.
The findings of this study may fill part of the research gap by explaining the misconceptions nurses and midwives themselves hold about breastfeeding. Findings may assist healthcare workers who provide lactation support to provide psychological, physical and social support for lactating health care professionals. This is because it may be assumed that, once postnatal health professionals have knowledge about lactation, they may not need much support. This intervention that may be given to postnatal health professionals due to the study's findings may improve their breastfeeding practices and advocacy techniques. The study's findings may add to knowledge on breastfeeding myths and misconceptions.
Methods
Study Design
The study used qualitative descriptive exploratory design to elicit responses from participants. This design allows the researcher to explore in-depth participants’ perspectives on a phenomenon where little is known. (Creswell, 2014). The study relied on the qualitative method of data collection to explore participant’ views on myths about breastfeeding. The findings were analyzed inductively for themes and sub-themes to emerge.
Population, Sample and Setting
The population was made up of all professional nurses and midwives within the Greater Accra Region of Ghana who had given birth and were breastfeeding at the time of data collection. Although, thirty-three (33) prospective clients responded to the call for recruitment into the study, twenty-five (25) lactating nurses and midwives were purposely sampled according to the inclusion criteria of the study. In this study, the inclusion criteria were; breastfeeding nurses and midwives (practicing either exclusive or complementary breastfeeding) with infants below the age of 2 years and voluntarily willing to participate in the study. Participants were asked to provide their postnatal books as proof of breastfeeding before recruitment into the study. All breastfeeding nurses and midwives who chose not to respond to the call to participate in the study were excluded. Participants were aggregated into groups of five in no particular order for group discussions to be conducted. The sample size was determined by data saturation where no new information was obtained from participants. The data saturated on the fifth group and each group had five participants. The rest of the prospective participants were politely excused from participation in the study after data saturation. The study's setting was the Greater Accra Region of Ghana. This is the Region that hosts the capital of Ghana. Among the sixteen Regions, it is the most populated Region in the country. Interested participants voluntarily contacted the researchers after the study had been advertised and they were scheduled into groups for data collection. Therefore, data was collected from participants who work in different health facilities in the Greater Accra Region of Ghana as nurses or midwives. Two public hospitals were selected by the participants as the settings for the interviews.
Data Collection
Data were collected through focus group discussions. Participants were put into five groups, each with five members. Soft copies of the information sheets containing synopsis of the study and what it intended to achieve had already been posted on the various social media platforms before participants decided to participate in the study. These were the WhatsApp and Telegram pages for nurses and Midwives within the Greater Accra Region. They were then aggregated into groups of fives. The focus group discussions were conducted face to face after participants chose their preferred venues. Participants were to choose one of the selected public hospitals that had been earmarked for data collection. Group discussions were conducted by the researchers with an interview guide developed purposely for this study based on the study's aim. The interview guide was piloted among a separate group with similar characteristics and although results from the pilot study were not added to the data, feedback from it was used to correct all ambiguous questions in the interview guide. The days, times and venues for data collection were determined by the participants. Participants spoke English with few phrases in Twi (the most popular Ghanaian language) during the interviews with open ended questions that elicited in-depth discussions among group members. Discussions were conducted in safe, confidential and noise-free environments that allowed participants to express themselves freely since the authorities of both hospitals allocated such rooms for the data collection exercise. Discussions started with group rules which laid the foundation for a respectful, safe space encouraging active participation from all. The group rules were; there were no right or wrong answers, group members were to respect the opinions of each other, group members were to avoid interfering in the middle of each other's submissions, all participants were to keep all discussions confidential and all phones and electronic devices were to be kept on silent. Participants were given consent forms to sign before data was collected. They were made aware that, participation in the study was voluntary and they could withdraw from the study at any stage without any repercussions. Confidentiality was ensured by identifying participants with alpha-numeric codes and all data was kept by only the researchers on locked electronic devices.
Data Analysis
Data analysis and transcription were done concurrently to allow the researchers to probe emerging themes and sub-themes in subsequent interviews. Data were content analyzed inductively with processes described by Padgett (Padgett, 2011). First, data were cleaned by removing any identifiable data. After that, it was read several times to make meaning out of the data. Words and phrases that depicted the meanings of individual sentences were attached to them (coding). After that, codes were aggregated to form sub-themes and sub-themes were then aggregated to form major themes.
A few of the participants were contacted for clarification in order to keep participants’ perspectives intact and this ensured member checking. Member checking was done individually after individual transcriptions. It was done to clarify the perspective of clients if the researchers noticed that, some of the responses were ambiguous. Field notes which were taken during data collection were used to confirm participants’ perspectives. The same interview guide was used to conduct all the focus group discussions. Data were transcribed verbatim and some of the quotes have been used to back participants’ opinions. The research team finally met and agreed that the data represented the participants’ perspectives.
Credibility, Rigor, and Trustworthiness of the Study
The study's credibility was ensured by recruiting participants who met the study's inclusion criteria and voluntarily opted to participate. Concurrent data collection and transcription also ensured that both verbal and non-verbal clues were captured. Both field notes and transcripts were compared in order to ensure data triangulation and this ensured that participants’ perspectives were fully captured. Detailed descriptions of the study's methodology ensured transferability of the study. Therefore, the study can be replicated by other researchers at different settings. A few of the participants were contacted again to re-iterate some of their responses and this ensured that, member checking was done to capture the true essence of participants’ responses. During data collection, the researchers avoided leading questions in order to get participants’ own perspectives without any biases.
Ethical Consideration
All ethical processes and principles regarding social and health research (autonomy, right to privacy, confidentiality, justice, and protection from risk and harm) were followed. The Institutional Review Board of 37 Military Hospital (37MH-IRB/NF/IPN/418/2020) gave ethical approval for the study to be done. The researchers sought permission from participants before their voices were audio taped and they were made aware that, participation was voluntary and that, they could withdraw at any time without any consequences. Alpha-numeric codes were used to replace participants’ names in order to ensure confidentiality. The informed consent stated clearly that, the findings would be made public once confidentiality was ensured.
Results
Demographic Characteristics
A total of twenty-five (25) participants were enrolled in the study of which five (5) were midwives (RM), sixteen (16) were general nurses (RGN) and four (4) were community health nurses (RCN). Their ages ranged between 26 years and 35 years. Their work experience extended between one (1) year and ten (10) years. Seven (7) of the participants were multiparous, and the remaining participants were breastfeeding their first children. Seven (7) of the participants were able to practice exclusive breastfeeding till the recommended period of six months. Out of these seven (7), three (3) were midwives, two (2) were general nurses and the last two (2) were community health nurses. Four (4) of the participants who were able to practice exclusive breastfeeding for six (6) months were multiparous whereas the rest of the three (3) were primiparous. Please refer to Table 1 below for summary of the socio-demographic characteristics.
Socio-demographic Characteristics.
Source: Transcribe data
Themes and Sub-Themes
Two main themes and six sub-themes emerged from the data. The main themes discovered were breastfeeding myth beliefs and sociocultural myth influences. Table 2 below depicts the themes and sub-themes that emerged after data analysis.
Themes and Sub-Themes.
Source: Transcribed data
Theme 1: Breastfeeding Myth Beliefs
When participants were asked whether they knew about breastfeeding myths, it was interesting to note that, despite their health background, most of them believed in all kinds of myths surrounding breastfeeding. Four sub-themes were aggregated to constitute this main theme and they were Green stools/diarrhea, childhood disease, teeth discoloration and child becoming stupid.
Green Stools/Diarrhea
Some participants expressed that, infants passed out green stools and sometimes developed diarrhea if a lactating mother goes out in the evening after 5pm without covering her hair and her breasts. Here are some verbatim quotes: “I have also heard that, in the evening the breastfeeding woman shouldn't be standing outside because the evening dew shouldn't touch the mother's hair and breasts. If not the baby will pass green stools after breastfeeding. I experienced some of these myths though it was not severe so anytime I’m going out in the evening, I have to cover my head and breasts with a cloth” “One myth that they say, and I realized that it was true was going into dew around 6pm. …I realized that baby's stool color changes to green. It has happened to me a couple of times, I realized that if I stay outside for long without covering my hair, the stool color changes to green. I used to tell my father that there is no scientific basis but observed it for long and I realized that whenever I stayed in the room, the stool is normal but when I stay out till late, the baby's stool changes into green” “After I had my baby, I went out without covering my hair. My mom was telling me to hurry and cover my hair with head gear if not the baby will have frequent stools. It is true too because I observed the baby actually passing frequent stools with some white phlegm for that particular day when I exposed myself”
“I think it is not true that if you do not cover your hair it will cause lose stools in the baby. Because, I had to leave the baby after bathing to go and buy food at the nearest market. But the baby did not pass any loose stool”
Childhood Disease
Some participants were of the view that there is a myth that insinuates that exposing one's breast in public to breastfeed could cause a situation whereby diseases can be spiritually ‘injected’ into the breast. Therefore, leading to the child contracting that disease. “Sometimes, if you expose your breast and breastfeed at the wrong place and at the wrong time, someone can spiritually inject your child with ‘asram’ (A spiritual disease that causes a child to be sick frequently) through the breast milk” “As for me, although I am a health worker, I believe that, if you are a breastfeeding mother and you expose your breast in public, then you can catch certain diseases spiritually through breastfeeding for the child”
Teeth Discoloration
Participants informed the researchers that they have also heard about a myth that talks about teeth discoloration and that, children who breastfeed for long periods may have their teeth discolored. With regards to this myth, participants were of the view that, although they believe in it, they were prepared to take the chance to breastfeed till the recommended period and when it happens, they would rectify it by cleaning their children's teeth. “I have heard and believe that, after two years of breastfeeding, the child's teeth discolors. But that is not much of a problem since I can clean the teeth for her after she stops breastfeeding” “For me I only heard their teeth will get rotten if they are breastfed for a long time. But I have told myself that, I will still continue to breastfeed and if the teeth discoloration happens, then I will buy him a toothbrush”
Child Becoming Unwise
Three of the participants mentioned that, they had heard about myths that suggests that male children who are breastfed for up to two years grow up becoming unwise. Out of the three, two of them were first time mothers and although they were health professionals, they sometimes wondered if their children would not be affected. Here is one of their quotes: “Yes, although I am a health worker, I believe that, if I breastfeed my male child for a long time, he will be ‘Gymi Gymi’ (unwise). So when he was one year old, I was afraid to continue with the breast milk because I didn’t want him to be ‘Gymi Gymi’ (unwise)”
“I have heard those myths about male children becoming stupid if breastfed for a long period but as a health professional I don’t believe it. Moreover, this is not the first time I have breastfed a male child for two years”
Theme 2: Sociocultural Myth Influences
The second major theme that emerged from the data was sociocultural myth influences. This theme refers to whatever influences such myths in the communities of the participants. Two sub-themes were merged to form this theme and they include culture and close relatives.
Culture
Almost all the participants were of the view that, such breastfeeding myths were part of their way of life and they were born into it. Therefore, it becomes difficult to debunk such ideas although they are health professionals. “Ooo No, it has nothing to do with being a health worker, my culture also has its influence on me” “Yes
Close Relatives
All the participants were of the view that, the myths about breastfeeding were influenced by their close relatives. These relatives keep handing such information from generations to generations without giving any scientific based explanations to such myths. “My mom always tells me that one breast has sugar and the other has salt so when I keep giving one breast, I am depriving the baby of the nutrients they need. My mother has a lot of influence on what I believe about these myths. They have been handed down from generation to generation” “My grandmother has been telling me a lot about these myths and initially, I didn’t believe them because of my background as a health worker but after a few experiences, I think I believe some of them”
“My grandmother said that, as a breastfeeding mother, I am not supposed to eat mango because the baby will have diarrhea but I didn't experience that when I ate mango so I don’t believe it”
Discussion
In this current study, participants reported beliefs about breastfeeding myths which ranged from their children getting sick, becoming stupid and their teeth becoming discolored if breastfeeding was not practiced in a particular way or at a particular time. Literature supporting the breastfeeding myth which asserts that breast milk can cause gastro-intestinal conditions is rare (Koura, 2019; Prado et al., 2016), although other breastfeeding myths have been widely reported in other studies (Koura, 2019; Prado et al., 2016; Tsegaye et al., 2019; Vargas-Zarate et al., 2020; Wagner et al., 2020; Wanjohi et al., 2016). Perhaps being health workers and knowing the facts about health-related issues may not necessarily translate into disbelief in scientifically baseless myths in our communities. Therefore, all lactating health professionals deserve to be supported during breastfeeding by their fellow colleagues without the assumption that, they would follow the scientifically proven guidelines.
On the other hand, there were other health professionals who were skeptical about some of the myths and therefore did not believe such myths about breastfeeding. Perhaps formal education at the tertiary level has been able to erase beliefs in unfounded myths. Nevertheless, all breastfeeding health professionals should be given support to ensure that, they practice breastfeeding as recommended by the WHO. This is because sometimes, they may have some of the information concerning breastfeeding distorted as reported in a study to find out the knowledge of nurses and doctors about breastfeeding (Shaw & Devgan, 2018).
It was reported by some participants in this study that, their culture had a lot of influence on them. To them, being health workers alone was not enough to debunk breastfeeding myths due to the strong influences their cultures had on them. This finding is similar to reports from other studies where breastfeeding mothers were strongly influenced by their cultural practices (Alianmoghaddam et al., 2018; Martins et al., 2020; Tsegaye et al., 2019; Zakar et al., 2018). Conceivably, the culture of a group of people has massive influence on their wellbeing. Therefore, all public health directives and recommendations should be adapted to address each myth and misinformation with corrected information. Because, in this current study, being a health worker did not stop participants from believing in obviously doubtful myths surrounding breastfeeding.
It has been established that, myths are baseless opinions that are handed from generation to generation without any scientific foundations (Vargas-Zarate et al., 2020). These myths are propagated by significant members of the family. In this study, participants pointed close relatives as their sources of information about breastfeeding myths although some believed them, others did not. Meanwhile, breastfeeding myths have been reported to be propagated by significant family members (Alianmoghaddam et al., 2018; Eram, 2017; Ferreira et al., 2018; Leahy-Warren et al., 2012; Tsegaye et al., 2019) which is similar to these current findings. This emphasizes the fact that, breastfeeding is a public health issue, and its optimal practice can only be achieved through collective efforts.
Limitations
This study involved only lactating nurses and midwives without the inputs of other health care workers, and this limits the generalization of the results to all lactating health care workers, non-lactating health care workers working with pregnant populations as well as supportive health care workers. It was also qualitative in nature and there may be the need for replication of the study using the quantitative method for generalization sake.
Implications for Practice
The clinical implications of this study include the necessity of myth awareness, cultural competency, evidence-based practice, and improved lactation support among healthcare professionals. Clinical practice can better fulfill the needs of breastfeeding mothers and their infants by addressing these implications, encouraging successful breastfeeding, and improving maternal and child health outcomes in Ghana. Therefore, education on correct breastfeeding practices should be tailored for all practicing nurses and midwives. This may ensure that the unfounded myths about breastfeeding are debunked. In so doing, mothers will be guaranteed proper education and support on the subject matter at the various healthcare facilities.
Conclusion
It is apparent that most of the participants in this study believed in baseless scientifically unproven myths about breastfeeding ingrained in influences of culture and significant relatives. Meanwhile, only seven (7) out of the twenty-five (25) were able to practice exclusive breastfeeding till the recommended six months period. Although this may be attributable to a host of other factors, such myths may have influences. Such findings may be of significant concern since it is expected that, nurses and midwives are supposed to be the myth busters and advocates for breastfeeding. This, then calls for further investigations.
Footnotes
Acknowledgements
We acknowledged the contribution of the lactating health professionals who participated in this study.
Author Contributions
AKA conceived and designed the study with inputs from ASA. Data collection and analysis were performed by both authors. The manuscript was drafted by AKA and reviewed by ASA. All authors read and approved the final manuscript for submission.
Data Availability Statement
Data will be available on request due to privacy/ethical restrictions.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Ethical Approvals
The study followed social and health research ethics principles, and it received ethical approval from the 37 Military Hospital's Institutional Review Board (37MH-IRB/NF/IPN/418/2020). Participants’ participation was voluntary, and their anonymity and confidentiality of the information was ensured.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
