Awareness, Knowledge, and Perception of the Baby-Friendly Hospital Initiative Among Final-Year Midwifery Students at the University of Health and Allied Sciences, Ghana

doi:10.21203/rs.3.rs-5098141/v1

Background

The Baby-Friendly Hospital Initiative (BFHI) was launched by the World Health Organization (WHO) and UNICEF in 1991 to combat the low prevalence of breastfeeding worldwide. This initiative is structured to ensure that breastfeeding is initiated and sustained according to WHO's recommended standards. BFHI has been shown to significantly improve both the initiation and continuation of quality breastfeeding, which offers numerous benefits to both mothers and newborns. These benefits include reduced rates of malnutrition and stunted growth in infants and a lower incidence of ovarian and breast cancers in mothers. Given these benefits, it is crucial for student midwives to possess adequate knowledge of the ten steps to successful breastfeeding, as they will play a pivotal role in counseling and supporting breastfeeding practices in maternity settings. This study aims to assess the awareness, knowledge, and perceptions of final-year midwifery students at the University of Health and Allied Sciences (UHAS) regarding BFHI.

Aim

To determine the awareness, knowledge, and perception of BFHI among final-year midwifery students at UHAS in Ho, Ghana.

Methodology

A descriptive cross-sectional study was conducted using a quantitative approach to assess the awareness, knowledge, and perceptions of final-year midwifery students at UHAS regarding BFHI. Data was collected using a self-administered questionnaire composed of closed-ended questions. The questionnaire was administered face-to-face to students who met the inclusion criteria and consented to participate. The collected data was analyzed using Microsoft Excel 2010 and SPSS (Statistical Package for Social Sciences) version-22. All analyses were performed with a 95% confidence level and a 5% level of statistical significance.

Results

A total of 75 students participated in the study. The age distribution revealed that 32% (24 participants) were aged 26–30 years, while 68% (51 participants) were aged ≤ 25 years. The majority of respondents, 88% (66 participants), were single, with 12% (9 participants) being married. Regarding religion, 76% (57 participants) identified as Christians, 20% (15 participants) as Muslims, and 4% (3 participants) as traditionalists. All participants were female. Importantly, all participants had heard of BFHI, with 70.7% demonstrating good knowledge of the initiative and 76.0% holding a positive perception of it.

Conclusion

This study concludes that 70.7% of final-year midwifery students at UHAS possess good knowledge of BFHI, and 76.0% have a positive perception of it. Continuous education is recommended to further enhance these levels of knowledge and perception, ultimately improving breastfeeding rates in Ghana.

Pediatrics

Preventive Medicine

Baby-Friendly Hospital Initiative (BFHI)

breastfeeding

midwifery students

knowledge

perception

awareness

Ghana.

The Baby-Friendly Hospital Initiative (BFHI) is an initiative launched by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) in 1991 in response to the Innocentia Declaration¹. The initiative encourages health facilities worldwide to support, protect, and promote breastfeeding while adhering to the International Code of Marketing of Breast Milk Substitutes. BFHI comprises ten measures that, when implemented, improve newborn nutrition through breastfeeding¹.

Breastfeeding is an essential practice with numerous benefits for both mother and child. According to the National Health Service, breast milk meets all the nutritional needs of infants, protects them from infections and diseases, and offers long-term benefits that extend into adulthood.¹ For mothers, breastfeeding lowers the risk of breast and ovarian cancers, osteoporosis, and cardiovascular diseases. Adequate nutrition during infancy and early childhood is critical for the optimal growth and development of children.²

Despite the benefits, global breastfeeding rates remain suboptimal. A study among 446 mothers with newborns under 7 months old found that 47% did not exclusively breastfeed their infants. A lack of knowledge about breastfeeding's importance and proper techniques were significant predictors of non-exclusive breastfeeding.³ According to WHO, only 44% of infants aged 0–6 months are exclusively breastfed.⁴ The BFHI has been shown to improve breastfeeding rates and adherence to evidence-based recommendations, thereby enhancing the health of both mothers and infants worldwide.

Awareness and knowledge of BFHI among healthcare practitioners and the adequate education of mothers can significantly improve breastfeeding practices.

Despite the proven benefits of breastfeeding, only about 44% of infants are exclusively breastfed globally, according to WHO. In Ghana, exclusive breastfeeding rates are similarly low, with only 50% of infants aged 0–6 months exclusively breastfed.⁵ Inadequate maternal education about the importance of exclusive breastfeeding is a key factor contributing to this low prevalence.

Knowledge of BFHI is essential for healthcare providers to support and promote breastfeeding effectively. Studies have shown that adherence to BFHI's ten steps positively impacts breastfeeding outcomes worldwide.⁶ However, knowledge and attitudes towards breastfeeding among healthcare providers, including midwifery students, remain suboptimal.

For instance, a study conducted in Nigeria revealed that while 81% of nursing students had adequate knowledge of breastfeeding, only 40% had a positive attitude towards it, and 36.6% intended to breastfeed in the future.⁷ Similar studies in South Africa and Uganda found significant gaps in knowledge and awareness of BFHI among healthcare providers.^8,9

In Ghana, no literature currently assesses midwifery students' knowledge of BFHI. This study aims to fill this gap and evaluate the awareness, perception, and knowledge of BFHI among student midwives in Ghana. Given the poor global breastfeeding rates due to inadequate knowledge and attitudes, improving awareness and understanding of BFHI among healthcare providers is crucial for enhancing breastfeeding practices.

Awareness and knowledge of BFHI are critical in clinical practice, especially for midwives who are frontline healthcare providers responsible for initiating and counseling mothers on breastfeeding practices. This study will provide insights into the readiness of final-year midwifery students at UHAS for clinical practice and help identify areas where educational interventions may be needed to improve their understanding of BFHI. The findings will guide university management in enhancing the curriculum and ensuring that future midwives are well-prepared to promote and support breastfeeding effectively.

Aim

The main objective of this study is to assess the knowledge, awareness, and perception of BFHI among final-year midwifery students at UHAS in Ho, South-Eastern Ghana.

Specific Objectives

To assess the awareness of BFHI among final-year midwifery students at UHAS, Ho.

To evaluate the perception of BFHI among final-year midwifery students at UHAS.

To assess the knowledge of BFHI among final-year midwifery students at UHAS, Ho.

Study Design and Setting

This cross-sectional study was conducted at the University of Health and Allied Sciences (UHAS), located in Ho, Ghana. The study population consisted of 75 final-year midwifery students enrolled at UHAS. Data collection took place in July 2023.

Sample Size and Sampling Technique

A total of 75 final-year midwifery students participated in the study. The inclusion criteria were final-year status in the midwifery program at UHAS and willingness to participate in the study. The sampling technique employed was a convenience sample, where all eligible students who consented were included in the study.

Data Collection Tool

A structured, self-administered questionnaire was used to collect data. The questionnaire was developed after an extensive review of existing literature on BFHI and adapted to the Ghanaian context. The questionnaire was divided into four sections: demographics, awareness, knowledge, and perception of BFHI.

Pre-testing

The questionnaire was pre-tested at a different nursing training school in the Volta Region to ensure clarity and reliability. Feedback from the pre-test was used to make necessary modifications to the questionnaire.

Data Collection Procedure

Data collection was conducted face-to-face. Participants were given the questionnaire in a conducive environment and were allowed sufficient time to complete it. Participation was voluntary, and informed consent was obtained from all respondents.

Data Analysis

Data collected was transferred into Statistical Package for Social Sciences (SPSS) version

22 for analysis, which was password-protected. This was used to describe the

frequencies, mean, median, standard deviation, proportions and percentages. Results were finally presented as a chart and tables. Statistical data analysis was used. The entities which were measured using multiple choices (Knowledge and Perception) were developed using a Likert scale. Responses were grouped into Strongly Agree, Agree, Neutral, Disagree and strongly Disagree to provide a clear overview of the distribution. Frequencies distributions were generated to understand the prevalence of different responses for each Likert item. Section C had 7 questions assessing knowledge, each with 5 options, a participant was scored 1 for choosing strongly disagree, 2 for Disagree, 3 for Neutral, 4 for Agree and 5 for Strongly agree, a participant was scored a maximum of 35 for all correctly answered questions. Disagree and Strongly disagree were categorized as poor knowledge, Neutral as moderate knowledge whiles Agree and Strongly Agree were categorized as good knowledge. Section D had 3 questions assessing perception, each with 5 options, with same scoring as for those assessing knowledge, a participant was scored a maximum of 15 for all correctly answered questions. Disagree and Strongly disagree were categorized as Negative Perception, Neutral as moderate perception whiles Agree and Strongly Agree were categorized as Positive perception. The Mean and Standard deviation were computed for each Likert item to understand the central tendency and dispersion of response. Section A and B included multiple choice questions. Section A had 3 questions on demographics and Section B had 2 questions assessing awareness of the BFHIs. All analysis was done using 95% confidence level. The level of statistical significance was set at p < 0.05.

Ethical Considerations

The study received ethical approval from the UHAS Ethics Committee. Participants were assured of confidentiality, and their identities were protected through anonymization of the data. Informed consent was obtained from each participant before data collection commenced.

Socio-Demographic Characteristics

The study involved 75 final-year midwifery students, all of whom were female. The majority (68%) were aged ≤ 25 years, while 32% were aged 26–30 years. Most participants (88%) were single, and 12% were married. In terms of religious affiliation, 76% identified as Christians, 20% as Muslims, and 4% as traditionalists.

Awareness of BFHI

All participants (100%) reported being aware of BFHI. The primary sources of information were lectures (60%), clinical placements (25%), and seminars (15%).

Knowledge of BFHI

The majority of participants (70.7%) demonstrated good knowledge of BFHI. The most well-known aspect was the benefits of breastfeeding for both mother and baby, with 80% of participants correctly identifying these benefits. However, knowledge gaps were observed concerning the International Code of Marketing of Breast Milk Substitutes, with only 45% of participants answering related questions correctly.

Perception of BFHI

Most participants (76%) had a positive perception of BFHI, recognizing its importance in promoting breastfeeding and improving maternal and child health outcomes. A smaller proportion (24%) had a neutral perception, and no participants expressed a negative perception of BFHI.

This study provides valuable insights into the awareness, knowledge, and perception of BFHI among final-year midwifery students at UHAS. The findings indicate a high level of awareness and a generally positive perception of BFHI among the students, which is consistent with previous studies in other contexts.^7,8

The high level of knowledge about the benefits of breastfeeding is encouraging, as it suggests that the students are well-prepared to promote breastfeeding in their future clinical practice. However, the observed gaps in knowledge regarding the International Code of Marketing of Breast Milk Substitutes highlight the need for targeted education in this area. Ensuring that midwifery students fully understand the ethical implications of marketing breast milk substitutes is crucial for protecting breastfeeding practices.

The positive perception of BFHI among the students is a promising finding, indicating their readiness to support the initiative in their future roles as healthcare providers. This aligns with the global push to improve breastfeeding rates through the implementation of BFHI in maternity facilities.⁶ However, continuous education and professional development are necessary to maintain and enhance this positive perception and ensure effective implementation of BFHI in clinical settings.

The study concludes that final-year midwifery students at UHAS possess a high level of awareness, good knowledge, and a positive perception of BFHI. However, there are specific areas, particularly regarding the International Code of Marketing of Breast Milk Substitutes, where further education is needed. Enhancing the curriculum to address these gaps and providing continuous professional development opportunities will help ensure that future midwives are well-prepared to promote and implement BFHI in their clinical practice.

Curriculum Enhancement: university curicula for midwifery should be updated to include comprehensive content on BFHI, with a particular focus on the International Code of Marketing of Breast Milk Substitutes.

Continuous Professional Development: Universities should organize regular workshops and seminars on BFHI to reinforce the knowledge and skills of midwifery students.

The high level of knowledge of the BFHIs among the final year midwives does not correlate with breastfeeding rates in Ghana. This disconnect between knowledge of the BFHIs among midwives and application of this knowledge in the field of work should be further studied, by the National Ministry of Health.

Further Research: Additional studies should explore the implementation of BFHI in clinical settings and its impact on breastfeeding rates in Ghana by the National Health Service.

ACKNOWLEDGEMENT

We acknowledge the Authorities of the University of Health and Allied Sciences, School of Nursing and Midwifery for their permission and support during the data collection for this study. Our data analysis was guided by Mr. Obed Amanu, and we Acknowledge his help.

Conflict of Interest.:

none of the Authors have any financial or personal conflict of interest to declare.

Funding:

no funding was obtained for this work.

Author Contributions:

Desmond Kumbuno: study design, methodology, data collection, visualisation and editting.

Dr Frank Obeng: Conceptualization, study design, supervision, data curation, visualization, first draft outline, editing of the work.

National Health Service (2023) The benefits of breastfeeding - Start for Life. nhs.uk.[Online]. Available at; https://www.nhs.uk/start-for-life/baby/feeding-your-baby/breastfeeding/the-benefits-of breastfeeding/#:~:text = release%20a%20hormone%20called%20oxytocin [Accessed on August 10]
Motee A, Jeewon R (2014) Importance of Exclusive Breastfeeding and Complementary Feeding among Infants. Curr Res Nutr Food Sci J 2(2):56–72. https://www.foodandnutritionjournal.org/volume2number2/importance-of-exclusive-breastfeeding-and-complementary-feeding-among-infants/
Zielinska MA, Sobczak A, Hamulka J, Roczniki PZH - Roczniki PZH. wydawnictwa.pzh.gov.pl. Published 2016. http://wydawnictwa.pzh.gov.pl/roczniki_pzh/
World Health Organization (2023) Infant and Young Child Feeding. World Health Organization. [Online]. Available at; https://www.who.int/news-room/fact-sheets/detail/infant-and-young-child-feeding [Accessed on August 10]
Mohammed S, Ibrahim Yakubu A-G, Fuseini A-M, Abdulai, Yakubu YH (2023) Systematic review and meta-analysis of the prevalence and determinants of exclusive breastfeeding in the first six months of life in Ghana. BMC Public Health 23(1). https://doi.org/10.1186/s12889-023-15758-w
Pérez-Escamilla R, Martinez JL, Segura-Pérez S (2016) Impact of the Baby-friendly Hospital Initiative on breastfeeding and child health outcomes: a systematic review. Matern Child Nutr 12(3):402–417. https://doi.org/10.1111/mcn.12294
Leshi OO, Makanjuola MO (2022) Breastfeeding Knowledge, Attitude and Intention of Nursing Students in Nigeria. Open J Nurs 12(03):256–269. https://doi.org/10.4236/ojn.2022.123017
Indiphile GI, Michaelis IA, Nongena P (2023) Assessing the training, knowledge, and attitudes of healthcare workers on the Baby Friendly Hospital Initiative. J Afr Neonatology 1(4):130–136. https://janeonatology.org/index.php/jan/article/view/39
Namutebi J, Nakanwagi H, Naluyima L, Edwards G Midwives’ Knowledge Of Baby Friendly Hospital Initiative in Uganda. Pract Midwife. 2018:25–29. https://ecommons.aku.edu/eastafrica_fhs_sonam/175/
Kumbuno D (2024) Assessing the Knowledge, Perception, and Awareness of Baby Friendly Hospital Initiatives Among Final Year Midwifery Students at the University of Health and Allied Sciences in Ho, Ghana. Unpublished dissertation, School of Medicine, University of Health and Allied Sciences, Ho, Ghana

Table 1:Demographic characteristics of study participants

Variable	Frequency (n=75)	Percentage (%)
Age	**Min=19 Max=30 Mean±SD= 24.12±2.9
26 to 30	24	32.0
Less than 25	51	68.0
Marital Status
Married	9	12.0
Single	66	88.0
Religion
Christian	57	76.0
Muslim	15	20.0
Traditional	3	4.0

* *Min= Minimum Age, Max=Maximum Age, Mean±SD= Mean Age ±Standard Deviation Source Field Work, 2024

The table above shows the demographic characteristics of all participants. The age distribution revealed that 32% (24 participants) were aged 26-30 years, while 68% (51 participants) were aged ≤25 years. The majority of respondents, 88% (66 participants), were single, with 12% (9 participants) being married. Also, 76% (57 participants) identified as Christians, 20% (15 participants) as Muslims, and 4% (3 participants) as traditionalists.

Table 2: Knowledge of the BFHIs among final year Midwifery students

Variables	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
Rooming in should be practiced 24hours a day	40 (53.3)	27 (36.0)	6 (8.0)	0 (0.00)	2 (2.7)
Breastfeeding is initiated within 1 hour	31 (41.3)	35 (46.7)	0 (0.00)	6 (8.0)	3 (4.0)
All pregnant women should be educated on the benefits of breastfeeding	45 (60.0)	29 (38.7)	0. (0.00)	0. (0.00)	1 (1.3)
Skin to skin contact of mother and baby is recommended	53 (70.7)	29 (38 (7)	0. (0.00)	0. (0.00)	1 (1.3)
Breastfeeding support groups are helpful in maintaining breastfeeding	42 (56.0)	30 (40.0)	0. (0.00)	2 (2.7)	1 (1.3)
Breastfeeding benefits both mother and baby	47 (62.7)	24 (32.0)	3 (4.0)	0. (0.00)	1 (1.3)
Pacifiers or artificial nipples are NOT encouraged	45 (60.0)	18 (24.0)	3 (4.0)	3 (4.0)	6 (8.0)
Knowledge Scores	*Min=7 Max=35 Mean=30.9±3.9*
Good Knowledge	53 (70.7)
Poor Knowledge	22 (29.3)

The table above shows the results from assessing the knowledge level of participants based on the questions indicated. The minimum score was 7 whiles the maximum was 35. A higher proportion of participants (70.7%) were found to have good Knowledge and a lower proportion had inadequate Knowledge.

Table 3: Perceptions of the BFHIs among Final year Midwifery students

Variables	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
All steps in the BFHIs are helpful	51 (68.0)	20 (26.7)	1 (1.3)	2 (2.7)	1 (1.3)
Adherence to the BFHIs improve quality of breastfeeding	48 (64.0)	23 (30.7)	1 (1.3)	0 (0.00)	3 (4.0)
Baby friendly Hospitals provide optimal support to breastfeeding mothers	40 (53.3)	29 (38.7)	4 (5.3)	1 (1.3)	1 (1.3)
Perception Scores	*Min=3 Max=15, Mean±SD=13.4±2.1*
Positive Perceptions	57 (76.0)
Negative Perceptions	18 (24.0)

The table above shows the findings from the assessment of the participants on their perception of BFHIs. The minimum score attainable was 3 and the highest attainable was 15. Mean score was found to be 13.4 and standard deviation, 2.1. A higher proportion (76%) showed a positive perception to the BFHIs and only 24% had moderate perception.

The authors declare no competing interests.

Awareness, Knowledge, and Perception of the Baby-Friendly Hospital Initiative Among Final-Year Midwifery Students at the University of Health and Allied Sciences, Ghana

Status:

Version 1

Abstract

Background

Aim

Methodology

Results

Conclusion

Figures

Introduction

Aim

Materials and Methods

Study Design and Setting

Sample Size and Sampling Technique

Data Collection Tool

Data Collection Procedure

Data Analysis

Ethical Considerations

Results

Socio-Demographic Characteristics

Awareness of BFHI

Knowledge of BFHI

Perception of BFHI

Discussion

Conclusion

We recommend that

Declarations

References

Tables

Additional Declarations

Status:

Version 1