Exclusive breastfeeding among beneficiaries of a nutrition enhancement programme and its associated factors in Ghana

**Background:** Exclusive breastfeeding (EBF) is recommended by WHO for the first six months of life, yet global rates remain suboptimal. In Ghana, recent national surveys have shown declining EBF rates, from 52% in 2014 to 42.9% in 2018. The World Food Programme implemented the Enhanced Nutrition and Value Chain (ENVAC) project in northern Ghana, which included Social Behavior Change Communication (SBCC) targeting pregnant women, lactating women, adolescents, and children under two years. The SBCC aimed to promote good feeding and care practices during the critical first 1000 days of life. However, the impact of this intervention on EBF had not been formally assessed.

**Methods:** This facility-based cross-sectional study was conducted in Sagnarigu Municipality and Tamale Metropolis of northern Ghana. A total of 339 mother-child pairs who were beneficiaries of the ENVAC project were recruited from six purposively selected health facilities. Participants were randomly selected from Child Welfare Clinic registers using Excel-generated random numbers. Data were collected via face-to-face interviews using a semi-structured questionnaire based on WHO infant and young child feeding guidelines. EBF was assessed by asking mothers of children under six months whether they had given any food or drink other than breastmilk or prescribed medications; mothers of children aged six months were asked the same question following WHO recommendations. Prelacteal feeding was also assessed. Maternal education was categorized as none (no formal education), moderate (primary or junior high school), or high (senior high school or above). Data were analyzed using SPSS version 23. Multivariable logistic regression was performed using forced entry; variables with p>0.2 in bivariate analyses (age categories, marital status) were excluded from the multivariable model. The sample size for EBF estimation and regression was 327.

**Key Results:** The mean age of children was 11.9±5.1 months; 51.0% were male. Most mothers were aged 24–29 years (44.0%), married (94.4%), Muslim (84.7%), and of Dagomba ethnicity (74.3%). About 25.1% had high education, and 92.6% had pipe-borne water as their main household water source. EBF prevalence was 74.6% (95% CI = 69.5%–79.2%), representing a 31.7 percentage point increase over recent national levels. Nearly all women (98.2%) initiated breastfeeding within 30 minutes of delivery, and 72.9% were still breastfeeding at the time of the study. Multivariable logistic regression showed that moderate maternal education was associated with significantly higher odds of EBF compared to no education (aOR = 4.1; 95% CI = 2.18–7.66; P<0.001), and high maternal education showed an even stronger association (aOR = 9.15; 95% CI = 3.3–25.4; P<0.001). Households with pipe-borne water as the main source had nearly three times the odds of EBF compared to those using wells (aOR = 2.87; 95% CI = 1.1–7.43; P = 0.029). The model explained 25.4% of the variability in EBF (Nagelkerke R² = 0.254), and the Hosmer-Lemeshow test indicated good fit (χ² = 6.91, P = 0.438).

**Clinical Implications:** The EBF prevalence of 74.6% among ENVAC beneficiaries is substantially higher than recent national estimates (43–52%), suggesting that the SBCC strategy implemented through the project may have contributed to improved breastfeeding practices. The strong association between maternal education and EBF—with odds increasing progressively from moderate to high education—highlights the importance of educational attainment in enabling mothers to adopt and sustain optimal infant feeding practices. The finding that access to pipe-borne water was associated with higher EBF is noteworthy; the authors hypothesize that women who must fetch water from wells face increased workload and stress, which may contribute to lactation insufficiency, and that extended family caregivers may introduce food or water to infants in mothers' absence. Additionally, water from unprotected wells may pose contamination risks leading to diarrhea, which could prompt early introduction of other foods. The study has several limitations: no control group was included, so the high EBF cannot be definitively attributed to the ENVAC project; social desirability bias may have led to overestimation of EBF; facility-based sampling may have selected more educated or motivated mothers; and the model explained only 25.4% of variability, indicating unmeasured confounders (e.g., cultural practices). Despite these limitations, the findings suggest that combining SBCC strategies with interventions addressing maternal education and household water access may be an effective approach to improving EBF rates in impoverished communities. Future research should include controlled designs to establish causality and explore additional determinants of EBF.