Systematic review and meta-analysis of the prevalence and determinants of exclusive breastfeeding in the first six months of life in Ghana

**Background:** Exclusive breastfeeding (EBF) is a critical public health priority in sub-Saharan Africa due to its benefits for infant health, including reduced infections and long-term protection against non-communicable diseases. Despite WHO recommendations for EBF for the first six months, global prevalence remains suboptimal. In Ghana, EBF declined from 63% in 2008 to 43% in 2018. This systematic review and meta-analysis aimed to summarize the prevalence and determinants of EBF among infants 0–6 months in Ghana, as no prior review existed.

**Methods:** The authors conducted systematic searches in Embase, Medline, and Africa-Wide Information from database inception to February 2021. They included quantitative observational and experimental studies reporting EBF prevalence or determinants in Ghana. Exclusion criteria included studies pooling data without Ghana-specific estimates, those focusing on outcomes beyond EBF prevalence, and non-original research. Two authors independently screened, extracted data, and assessed quality using Joanna Briggs Institute tools. A random-effects meta-analysis pooled prevalence, with heterogeneity assessed via I² and publication bias via Egger's test. Subgroup analyses were performed by urban/rural residence, administrative region, and geographic zone. Determinants were synthesized narratively.

**Key Results:** Of 258 articles identified, 24 met inclusion criteria (21 cross-sectional, 2 prospective cohorts, 1 RCT), with total sample size 8,740. Most studies were published between 2005 and 2021, with 92% in the last decade. The pooled EBF prevalence was 50% (95%CI 41.0–60.0%; I²=98.5%). No publication bias was detected (Egger's p=0.56). Subgroup analysis showed higher prevalence in rural areas (54%; 95%CI 37.0–70.0%) than urban (44%; 95%CI 32.0–57.0%). By region, prevalence ranged from 62% (Greater Accra) to 44% (Central region). The coastal-middle belt had higher prevalence (51%) than the northern/savannah belt (43%). Facilitators of EBF included older maternal age (≥20 years), self-employment, unemployment, living in a large house, house ownership, facility delivery, non-caesarean delivery, adequate antenatal attendance, counselling, support groups, adequate knowledge, positive attitude, and higher maternal education in rural areas. Barriers included urban residence, higher maternal education in urban areas, less than three months maternity leave, maternal HIV-positive status, intimate partner violence, lack of radio access, perceived insufficient milk, lack of family support, partner desiring more children, counselling on complementary feeding, healthcare worker recommendation of formula, single marital status, and infant NICU admission.

**Clinical Implications:** The findings highlight that EBF in Ghana is suboptimal, with only half of infants exclusively breastfed. Interventions must be multi-dimensional, addressing sociodemographic, obstetric, and infant-related barriers. Strategies should include promoting EBF across all socioeconomic strata, extending paid maternity leave to at least six months, enhancing breastfeeding counselling and support during antenatal and postnatal care, and engaging family members. Special attention is needed for HIV-positive mothers, urban women, and those with short maternity leave. Policies should also regulate breastmilk substitute advertising. The study's strengths include national representativeness and comprehensive search, but limitations include high heterogeneity, reliance on cross-sectional data with potential recall bias, and lack of adjustment for confounders in some studies.