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. 2021 Jun 3;16(6):e0252517. doi: 10.1371/journal.pone.0252517

The association between paternal characteristics and exclusive breastfeeding in Ghana

Frank Kyei-Arthur 1,¤,*,#, Martin Wiredu Agyekum 1,#, Grace Frempong Afrifa-Anane 1,¤,#
Editor: Joann M McDermid2
PMCID: PMC8174696  PMID: 34081726

Abstract

Background

Studies have shown that partners play an influential role in exclusive breastfeeding practice and that they can act as either deterrents or supporters to breastfeeding. However, there are limited studies on the influence of partners’ characteristics on exclusive breastfeeding in Ghana. This study examined the association between partners’ characteristics and exclusive breastfeeding in Ghana.

Methods

This cross-sectional study used data from the 2014 Ghana Demographic and Health Survey. Infants less than 6 months old (exclusively breastfed or not) with maternal and paternal characteristics were included in the study. A total of 180 participants were used for the study. A binary logistic regression was used to examine the influence of partners’ characteristics on exclusive breastfeeding.

Results

Partners’ characteristics such as education, desire for children, religion, and children ever born were associated with exclusive breastfeeding. Mothers whose partners had primary education (AOR = 0.12; CI 95%: 0.02–0.93; p = 0.04) were less likely to practice exclusive breastfeeding compared to those whose partners had no formal education. Also, mothers whose partners desired more children (AOR = 0.20; CI 95%: 0.06–0.70; p = 0.01) were less likely to practice exclusive breastfeeding compared to those whose partners desire fewer children.

Conclusion

Improving EBF requires the involvement of partners in exclusive breastfeeding campaigns/programmes. A more couple-oriented approach is required by health practitioners to educate and counsel both mothers and partners on the importance of exclusive breastfeeding in Ghana.

Introduction

Exclusive breastfeeding (EBF) has been identified as an essential practice to enhance the nutritional status and growth of infants aged under 6 months [1]. EBF is the practice of giving infants only breast-milk and no liquids or solids with the exceptions of drops or syrups consisting of vitamins, mineral supplements, or medicines [2]. The World Health Organisation (WHO) and United Nations Children’s Fund (UNICEF) recommend EBF for the first six months of an infant’s life since breastmilk contains all the essential nutrients required by an infant to attain optimal growth and health [1]. Exclusive breastfeeding has enormous benefits for mothers and their infants. It reduces neonatal and infant mortality and morbidity, enables infants to crawl early, enhances growth and cognitive development, and reduces the risk of childhood obesity [3–7]. In addition, it helps mothers to lose weight after birth, reduces their risk of pregnancy in the first 6 months after birth, and reduces their risk of breast and ovarian cancers [3, 8, 9]. It is estimated that increasing breastfeeding could annually help avert 823,000 child deaths and 20,000 breast cancer deaths [10].

Despite these benefits, the practice of EBF is generally low [11]. In 2019, two-fifth (41%) of infants aged under 6 months were exclusively breastfed worldwide. The WHO estimates that at least 50% and 70% of infants aged under 6 months globally should be exclusively breastfed by 2025 and 2030 respectively [12, 13]. Ghana’s EBF rate rose steadily from 53% in 2003 to 63% in 2008. The increase in Ghana’s EBF rate can be attributed to the implementation of policies and programmes such as the Breastfeeding Promotion Regulations 2000 [14], Imagine Ghana Free of Malnutrition [15], and Infant and Young Child Feeding Strategy [16]. These policies and programmes highlighted the importance of practicing exclusive breastfeeding. For instance, the Breastfeeding Promotion Regulations 2000 prohibits the sale and promotion of infant formula or any other product marketed as appropriate for feeding infants less than six months of age in health facilities or public places [14]. It is worth noting that these policies and programmes placed less emphasis on couple-oriented approaches to enhance exclusive breastfeeding.

However, a total of 52% of infants below 6 months were breastfed exclusively in 2014 [17]. This is a reduction upon the 2008 rate of 63%, and thus, calls for further investigation. The decline in exclusive breastfeeding can be attributed to factors such as violation of the Ghana Breastfeeding Promotion Regulation, selective implementation of funded breastfeeding initiatives at the district and regional levels, and increased participation of women in the labour market [18, 19]. Participation of women in the labour market, especially formal employment has been linked with a decline in the practice of exclusive breastfeeding since their workplace and working conditions do not support the practice of exclusive breastfeeding [20, 21].

Previous studies in Ghana have established that mothers breastfeeding practices are influenced by interpersonal and community factors including pressure from family members and cultural beliefs and practices [22, 23]. For instance, Diji et al.’s [24] study among mothers at a public health facility in Kumasi South Hospital revealed that the belief that breastmilk is inadequate to meet the nutritional needs of infants and pressure from family members to give water and food to infant hindered the practice of exclusive breastfeeding. Studies have also documented the traditional practice of giving herbal concoctions to infants to drink after birth, especially in the Northern part of Ghana. It is perceived that herbal concoctions make the infants strong and healthy [25–27].

Evidence suggests that a partner (a man who is either currently married or living with a woman) is one of the most influential persons to the mother and that he can act as either a deterrent or supporter to breastfeeding [28–31]. For instance, a father can provide the practical and emotional support needed for successful breastfeeding, contribute to maternal breastfeeding confidence, and influence decisions on the duration of breastfeeding [32, 33]. In addition, studies in Brazil and Sweden have found that paternal age and education influence the practice of exclusive breastfeeding [34, 35].

However, studies on EBF in sub-Saharan Africa, particularly Ghana, have mainly focused on maternal characteristics, child characteristics, household characteristic (such as household size), family influence (grandmothers and in-laws), health-related factors (such as place of delivery), and spatial characteristics (such as place of work) [20, 24, 36–39]. There is a dearth of information on the influence of partners on EBF. In light of the limited literature and reduction in exclusive breastfeeding rate in Ghana, this study seeks to examine the influence of partners’ characteristics on EBF in Ghana using a nationally representative sample. Understanding the influence of partners’ characteristics on EBF in addition to other factors will provide a holistic understanding to help develop appropriate interventions to promote exclusive breastfeeding among mothers in Ghana.

Materials and methods

Data and study population

This study used data from the 2014 Ghana Demographic and Health Survey (GDHS). The GDHS is a nationally representative sample survey that is conducted every five years and the 2014 GDHS is the sixth round in the series. A two-stage sample design was employed to select participants for the interview. The 2014 GDHS sampling procedure and methodology have been described in detail in the Ghana Demographic and Health Survey manual [18]. The 2014 Ghana Demographic and Health Survey had a sample of 5,884 infants. However, the analysis of the current study was based on a sample size of 180 infants less than six months (exclusively breastfed or not) who had both maternal and paternal characteristics.

Variables

Dependent variable

The dependent variable for the study was exclusive breastfeeding. Exclusive breastfeeding was defined based on the World Health Organisation 24-hour recall method. This was measured as a binary variable using several food items such as breastmilk, water, liquids, milk, and solid food. Infants who were fed only on breast milk 24 hours preceding the survey were coded as “1” for exclusive breastfeeding while infants who were fed on breastmilk and any other food 24 hours preceding the survey were coded as “0” and classified as non-exclusive breastfeeding.

Independent variables

Partners’ characteristics such as age, education, occupation, religion, ethnicity, place of residence, partners’ attitude towards wife beating, desire for children, and number of children by partner were the independent variables for the study. These variables were selected based on literature review. Partners’ age was categorized as 15–24 years, 25–34 years, and 35 years and above. The level of education of a partner was re-categorized as no education, primary, and secondary, and above. The proportion of partners with higher education was few so they were added to partners who had secondary education. Partners’ main occupation was categorized as professionals, sales and service, agriculture, skilled manual, and unskilled manual. In addition, partners’ religion was classified as Christians, Muslims, and Other comprising Traditionalist, Buddhist, and Hinduism. Partners’ ethnicity was categorized as Ewe, Ga/Dangme, Akan, Mole-Dagbani, Gurma, and other including Grussi and Mande. Partner’s place of residence was categorized as urban and rural areas while attitude towards wife beating was classified as favourable and unfavourable. Moreover, a partner’s desire for having children was classified as a partner desiring for fewer children than the mother, a partner desiring for more children than the mother, both the partner desire for the same number of children. Lastly, children ever born was measured as the total number of children born by the partner.

Control variables

The study controlled for other variables that may influence exclusive breastfeeding based on the review of the literature. The control variables were mother’s age (15–24, 25–34, and 35 years and above), mother’s education (no education, primary, and secondary and above), mother’s marital status (married and living with a partner), mother’s children ever born (single child mothers and multiparous mothers), decision on health (woman alone, partner alone, and both partner and woman), mother’s ethnicity (Akan, Ewe, Mole-Dagbani, Gurma and other groups comprising Ga/Dangme, Guan, and Grusi), frequency of antenatal clinic, maternity leave (No, and Yes), postnatal (Yes and No), mother’s attitude towards wife beating (favourable and unfavourable), sex of the child (male and female), age of infant (less than one month, 1 month, 2 months, 3 months, 4 months and 5 months) and birth order. All variables and their categories used in this study align with the standards for Ghana.

Data analysis

The data was analyzed using Stata version 15. The data were weighted to make it representative and to provide a better statistical estimate. The proportion of each variable was described using tables and percentages. A binary logistic regression model was used to examine the relationship between partners’ characteristics, and exclusive breastfeeding, controlling for other variables. A binary logistic regression was used because the dependent variable (exclusive breastfeeding) is a dichotomous variable “with responses “yes” and “no”. All associations were tested at a significance level of 0.05.

Results

Characteristics of partners

Table 1 shows the exclusive breastfeeding practice and partner’s characteristics. More than half (58.33%) of the infants were exclusively breastfed 24 hours preceding the survey. About six out of ten (58.33%) partners were aged 35 years and older, and about 58% of the partners had at least secondary or higher education. Also, about 32% of partners had no formal education. The highest proportion (48.9%) of partners were engaged in agricultural work and a few (8.3%) were into sales and services. In addition, more than half (53.89%) of the partners were Christians and about three out of ten (31.11%) partners belonged to the Mole-Dagbani ethnic group. Most partners were living in rural areas (56.67%) and had favourable attitude towards wife beating (82.78%). With regards to partner desire for children, about 46% of both mothers and their partners wanted the same number of children. Additional socio-demographic characteristics of the partners are presented in Table 1.

Table 1. Description of exclusive breastfeeding and partner’s characteristics.

Variables Frequency Percentage
Exclusive breastfeeding
No 75 41.67
Yes 105 58.33
Partner’s age
15–24 9 5.00
25–34 66 36.67
35+ 105 58.33
Partner’s educational level
No education 57 31.67
Primary 18 10.00
Secondary/higher 105 58.33
Partner’s occupation
Professionals 22 12.22
Sales and service 15 8.33
Agriculture 88 48.89
skilled manual 30 16.67
Unskilled manual 25 13.89
Partner’s religion
Christian 97 53.89
Muslims 45 25.00
Other 38 21.11
Partner’s ethnicity
Ewe 22 12.22
Ga/Dangme 11 6.11
Akan 46 25.56
Mole-Dagbani 56 31.11
Gurma 26 14.44
Other 19 10.56
Partner’s place of residence
Urban 78 43.33
Rural 102 56.67
Partner’s attitude towards wife beating
Unfavourable 149 82.78
Favourable 31 17.22
Partner’s desire for children
Partner wants fewer 47 26.11
Partner wants more 51 28.33
Both want same 82 45.56
Min, Max Mean, std
Partner’s children ever born 1, 21 4.71, 3.60
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Characteristics of mothers and infants

The results indicate that more than two-fifths (43.89%) of the mothers were within the age group 25–34 years and the highest proportion (40.6%) of the mothers had no formal education (Table 2). Also, seven out of ten mothers (76.11%) were married and the majority (89.44%) of the mothers were multiparous mothers. Regarding decision on health, more than half (56.11%) of the mothers made a joint decision with their partner. Furthermore, the majority (86.7%) of the mothers had no maternity leave and 68.89% of them attended postnatal clinics. Regarding the infants, more than half (53.89%) were males and the highest proportion (22.78%) of the infants were aged five months old. Additional socio-demographic characteristics of the mothers and infants are presented in Table 2.

Table 2. Description of mother and infant characteristics.

Variables Frequency Percentage
Age of mother
15–24 47 26.11
25–34 79 43.89
35+ 54 30.00
Education of mother
No education 73 40.56
Primary 40 22.22
Secondary and higher 67 37.22
Marital status of mother
Married 137 76.11
Living with partner 43 23.89
Mother’s children ever born
Single 19 10.56
Multiparous 161 89.44
Decision on health
Respondent alone 22 12.22
Respondent and partner 101 56.11
Partner alone 57 31.67
Mother’s ethnicity
Ewe 23 12.78
Akan 43 23.89
Mole Dagbani 66 36.67
Other 48 26.67
Maternity leave
No 156 86.67
Yes 24 13.33
Postnatal
No 56 31.11
Yes 124 68.89
Mother’s attitude towards wife beating
Unfavourable 116 64.44
Favourable 64 35.56
Sex of infant
Male 97 53.89
Female 83 46.11
Age of infant
0 13 7.22
1 33 18.33
2 36 20.00
3 27 15.00
4 30 16.67
5 41 22.78
Min, Max Mean, std
Partner’s children ever born 1, 21 4.71, 3.60
Frequency of ANC 0, 98 7.14, 10.13
Birth order 1, 10 3.74, 2.10
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Predictors of exclusive breastfeeding

Table 3 illustrates factors associated with exclusive breastfeeding in Ghana. The model shows the effects of partner, mother, and infant characteristics on exclusive breastfeeding. The R-square of the model (0.3460) shows that about 34.60% of the partner, maternal and infant characteristics explain variations in EBF practice in Ghana.

Table 3. Binary logistic regression showing the factors associated with exclusive breastfeeding.

Exclusive breastfeeding (EBF)
Variables Adjusted Odds Ratio (AOR) 95% CI P-value
Partner’s educational level
No education (RC)
Primary 0.12 0.02–0.93 0.04
Secondary/higher 0.50 0.10–2.55 0.40
Partner’s occupation
Professionals (RC)
Sales and service 0.38 0.05–3.05 0.36
Agriculture 3.52 0.51–24.49 0.20
Skilled manual 2.53 0.49–13.09 0.27
Unskilled manual 0.48 0.10–2.43 0.38
Partner’s age
15–24 (RC)
25–34 1.09 0.12–9.97 0.94
35+ 0.97 0.09–10.63 0.98
Partner’s desire for children
Partner wants fewer (RC)
Partner wants more 0.20 0.06–0.70 0.01
Both wants same 0.33 0.10–1.13 0.08
Partner’s religion
Christian (RC)
Muslims 0.20 0.05–0.76 0.02
Other 2.59 0.64–10.56 0.18
Partner’s ethnicity
Ewe (RC)
Ga/Dangme 2.17 0.22–21.96 0.51
Akan 1.29 0.18–9.40 0.80
Mole-Dagbani 2.36 0.15–37.74 0.55
Gurma 0.39 0.02–6.61 0.51
Other 4.12 0.32–53.06 0.28
Partner’s place of residence
Urban (RC)
Rural 0.75 0.19–3.03 0.69
Partner’s children ever born 1.38 1.08–1.77 0.01
Partner’s attitude towards wife beating
Unfavourable (RC)
Favourable 0.44 0.14–1.39 0.16
Age of mother
15–24 (RC)
25–34 0.97 0.27–3.48 0.97
35+ 0.20 0.03–1.21 0.08
Education of mother
No education (RC)
Primary 1.79 0.39–8.18 0.45
Secondary and higher 5.14 0.95–27.91 0.06
Marital status of mother
Married (RC)
Living with partner 1.49 0.45–4.93 0.51
Mother’s ethnicity
Ewe (RC)
Akan 0.15 0.02–1.10 0.06
Mole Dagbani 0.50 0.04–6.65 0.60
Other 0.55 0.06–5.14 0.60
Mother’s children ever born
Single (RC)
Multiparous 1.30 0.23–7.17 0.77
Decision on health
Respondent alone (RC)
Respondent and partner 2.63 0.63–10.96 0.18
Partner alone 0.99 0.21–4.63 0.99
Frequency of antenatal visits 1.08 1.00–1.16 0.04
Maternity leave
No (RC)
Yes 2.02 0.43–9.43 0.37
Postnatal
No (RC)
Yes 0.71 0.24–2.09 0.54
Mother’s attitude towards wife beating
No (RC)
Yes 1.14 0.36–3.65 0.82
Sex of child
Male (RC)
Female 0.69 0.28–1.71 0.42
Age of child
Less than 1 (RC)
1 0.07 0.00–1.19 0.07
2 0.03 0.00–0.41 0.01
3 0.01 0.00–0.23 0.00
4 0.01 0.00–0.18 0.00
5 0.01 0.00–0.12 0.00
Birth order 0.95 0.64–1.42 0.82
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RC: Reference category; R square = 0.3460.

The results of the adjusted regression model indicate that partner’s education, partner’s desire for children, partner’s religion, and partner’s children ever born were significantly associated with EBF.

Mothers whose partners had primary education were less likely to practice EBF compared to those whose partners had no formal education (AOR = 0.12; CI 95%: 0.02–0.93; p = 0.04). Also, mothers whose partners desire more children were less likely to practice EBF compared to those whose partners desire fewer children (AOR = 0.20; CI 95%: 0.06–0.70; p = 0.01). In addition, mothers whose partners were Muslims were less likely to practice EBF compared to mothers whose partners were Christians (AOR = 0.20; CI 95%: 0.05–0.76; p = 0.02). Moreover, as the number of children by a partner increases, the odds of a mother practicing EBF increases (AOR = 1.38; CI 95%: 1.08–1.77; p = 0.01).

Other factors that were found to predict EBF include frequency of antenatal visits and age of infant. Regarding frequency of antenatal care visits, an increase in antenatal care visits increases the practice of exclusive breastfeeding by mothers (AOR = 1.08; CI 95%: 1.00–1.16; p = 0.04).

Lastly, infants who were two months old were less likely to be exclusively breastfed compared to infants less than one month old (AOR = 0.03; CI 95%: 0.00–0.41; p = 0.01). Also, infants who were three months old were less likely to be exclusively breastfed compared to infants less than one year old (AOR = 0.01; CI 95%: 0.00–0.23; p = 0.00). Furthermore, infants who were four months old were less likely to be exclusively breastfed compared to infants less than one year old (AOR = 0.01; CI 95%: 0.00–0.18; p = 0.000).

Discussion

Considering the reduction of EBF practice in Ghana, identifying partner characteristics that influence EBF would help develop policies and other interventions to increase EBF prevalence in Ghana. In the light of scant literature on significant role partners’ play in EBF, we examined the influence of partner’s characteristics on exclusive breastfeeding (EBF) in Ghana. Our findings unearth the relevance of partner’s education, desire for children, religion, and children ever born in the practice of EBF which have implications for policy and research. In addition, the results of the study show that mother’s antenatal visits and age of child explain mothers’ exclusive breastfeeding behaviour in Ghana.

We found that EBF was practiced by more than half (58.33%) of mothers in this study. The results indicated that more than half of the mothers practiced EBF in Ghana. However, the proportion of mothers practicing EBF is below the recommended rate of 90% by WHO [40]. This, therefore, has implications for the welfare of children in relation to morbidity and mortality. Comparing the prevalence of EBF (58.33%) in this study to the 2008 Ghana Demographic and Health Survey EBF prevalence (63.00%), there is a decline in the practice of EBF. Despite the decline in the practice of EBF in Ghana, other child nutrition indicators (such as stunting, wasting, and underweight) have improved over time. Since 1988, the prevalence of stunting, wasting, and underweight has reduced from about 34%, 9%, and 23% to 19%, 5%, and 11% respectively [17].

The reduction of EBF practice could therefore explain the slight decline of neonatal mortality from 43 per 1000 live births in 2003 to 29 per 1000 live births in 2014 [17]. There is a need for measures and policies to be strengthened to promote the practice of EBF. For instance, Tsai [41] reported that encouragement of mothers to use lactation rooms and milk expression breaks programme increased breastfeeding in Taiwan. Similarly, the involvement of men in breastfeeding programmes in Brazil led to an increase in exclusive breastfeeding practice [42]. In addition, assistance with preventing and managing lactation difficulties among couples in Italy improved exclusive breastfeeding [43].

Although formal education has been recognized to have a positive effect on attitude and health-related behaviours [44, 45], findings from the present study indicate otherwise. The likelihood to practice EBF was lower among mothers whose partners had primary education compared to those whose partners had no formal education. The finding is consistent with previous studies in Sweden and India which found that partners with low education are less likely to practice exclusive breastfeeding compared to those with no education [34, 46]. A probable reason is that having knowledge about behaviour does not always translate into an attitude or behavioural change [47]. Therefore, mothers whose partners have acquired some level of formal education may not necessarily be empowered to practice EBF.

Furthermore, the findings revealed that the likelihood to practice EBF was lower among mothers whose partners desired more children than those whose partners desired fewer children. The practice of EBF reduces mothers’ risk of pregnancy in the first 6 months after birth. This is because it serves as a family planning method and could delay mothers in conceiving and having children [3, 9].

It was also evident in the findings that the likelihood to exclusively breastfeed was lower among mothers whose partners were Muslims compared to those whose partners were Christians. This finding is consistent with previous studies [23]. The Holy Quran encourages breastfeeding among Muslims [48]. However, the reasons why mothers whose partners were Muslims are less likely to exclusively breastfeed compared to those whose partners are Christians could not be explained in the present study and therefore further studies using qualitative approaches could explore the probable reasons.

The findings also indicated a positive association between partner’s number of children ever born and practice of EBF. The reasons underlying this finding could not be explained in the present study due to data limitation and therefore needs further exploration using qualitative approaches.

Importantly, partner characteristics such as age, occupation, place of residence, and attitude towards wife beating, were not significantly associated with the practice of EBF. This finding is similar to other studies in Malaysia [49] and Brazil [50] which found that paternal age is not significantly associated with exclusive breastfeeding. Despite the non-significant association between occupation and EBF, mothers whose partners were engaged in agriculture were more likely to practice EBF than those whose partners were professionals. A plausible explanation is that in Ghana, agricultural extension officers, (for example, Women in Agricultural Development (WIAD) officers) provide health and nutrition education to farmers during the provision of extension services to enhance the wellbeing of their households, including the practice of exclusive breastfeeding [51].

Furthermore, there was a positive association between antenatal care visits and the practice of EBF. Previous studies have established that antenatal clinics provide an opportunity for health care workers (midwives, community health nurses) to interact and educate mothers on infant feeding, the nutritional value of EBF, and challenges associated with EBF. The health education provided by health care workers during antenatal care visits increases knowledge on infant feeding and thus, enhances the practice of exclusive breastfeeding [52–54].

Finally, the findings showed that the likelihood to exclusively breastfeed decreased as the age of an infant increased. Similar findings have been reported in Nigeria [55, 56] and India [57]. It is explained that most mothers perceive that as an infant’s age increases, he/she does not get satisfied when exclusively breastfed. This leads to persistent crying and sleeplessness. The introduction of complementary foods, therefore, reduces hunger and calms the infants [58]. In addition, Ghanaian women working in the formal sector are entitled to three-month maternity leave after delivery. Therefore, the early return to work tends to affect exclusive breastfeeding especially when the infant is aged three months or above [59]. The introduction of complementary foods as infants get older enables the mothers to attend to other activities particularly work [56, 60]. This calls for the need for the Ministry of Health and other government agencies to advocate for a longer duration of maternity leave since exclusive breastfeeding is beneficial to the mother and infant.

Results of this study provide an understanding of the influence of partners in the practice of EBF. This study is very relevant towards the inclusion of partners in exclusive breastfeeding campaigns. Countries (such as Brazil and Taiwan) that have included men in breastfeeding-specific interventions have succeeded in improving exclusive breastfeeding practice [42, 43]. In Ghana, there are no direct policies or measures targeting partners in breastfeeding practices. Programmes involving partners and women such as partners offering assistance with preventing and managing lactation difficulties, partners helping with household tasks and child care, partners encouraging their women to use lactation room and milk expression breaks could help improve exclusive breastfeeding practice in Ghana. Findings from this study could inform policy makers to encourage men to follow women to antenatal clinics. Through this, they will be educated on the importance of exclusive breastfeeding and on how to manage the challenges associated with it. In addition, there could be breastfeeding schools for partners to help them understand breastfeeding, other maternal and child issues as well as addressing concerns of partners related to exclusive breastfeeding.

Limitations

This study had some limitations that are worth noting. First, due to the cross-sectional nature of the study, we cannot infer causality. Second, the sample size for the study was small (n = 180) because some data on partners of mothers with an infant less than six months were missing. Third, exclusive breastfeeding was limited to 24 hours preceding the survey. This does not accurately measure the exclusive breastfeeding of infants less than six months. Despite these limitations, this study is one of the few to examine the influence of partners’ characteristics on exclusive breastfeeding. The findings, therefore, contribute to exclusive breastfeeding literature in sub-Saharan Africa.

Conclusions

Findings from this study indicate an association between partners’ characteristics and EBF. As found in this study, partner’s education, religion, desire for more children, and children ever born significantly predicted the practice of EBF. This is an indication that partners play a crucial role in the practice of EBF in Ghana. The Global Strategy for Infant and Young Child Feeding emphasizes the need for those involved in promoting breastfeeding to understand the benefits and importance of exclusive breastfeeding. Therefore, health policy makers should provide incentives to partners to promote their involvement in attaining optimal nutrition and breastfeeding. To achieve the full benefit of partners’ involvement, future research should encompass qualitative approaches to help understand and explain the association between the partners’ characteristics and exclusive breastfeeding.

Supporting information

S1 Data

(XLSX)

Click here for additional data file. (27.6MB, xlsx)
S2 Data

(XLSX)

Click here for additional data file. (16.6MB, xlsx)

Acknowledgments

The authors acknowledge the Measure Demographic and Health Survey programme for making the 2014 Ghana Demographic and Health Survey data set available for this study. The authors are grateful to the academic editor and reviewers for their constructive comments and suggestions.

Data Availability

All relevant data are within the manuscript and its Supporting Information files.

Funding Statement

The authors received no specific funding for this work.

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Decision Letter 0

Joann M McDermid

10 Mar 2021

PONE-D-20-36508

Partner characteristics and exclusive breastfeeding in Ghana

PLOS ONE

Dear Dr. Kyei-Arthur,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Paternal influence on exclusive breastfeeding practices are an important consideration, although a significant gap in our knowledge exists - especially from your region. Following the suggestions of the two peer-reviews will certainly strengthen, focus and clarify a number of aspects of your work. 

Please submit your revised manuscript by Apr 08 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

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We look forward to receiving your revised manuscript.

Kind regards,

Joann M. McDermid, MSc, PhD, RDN, FAND

Academic Editor

PLOS ONE

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We will update your Data Availability statement on your behalf to reflect the information you provide.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #1: No

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This is a very important topic that the researchers have decided to study. Overall, they did a good job approaching this study. However, there are some major revisions necessary before considering for review for resubmission.

Consider making the title more descriptive.

Rationale/justification for the study needs to be stronger. What specifically is this adding to the current literature?

If the analyses were adjusted, that needs to be explained and adjusted results should be listed as AORs instead of ORs.

Description of inclusion criteria should be more specific in the abstract methods and methods section.

Results should be presented with 2 decimals; remove "95%" from methods

Conclusion in abstract should be more specific. How do these findings help? How can they inform policies and interventions? What should public health professionals do differently in Ghana based on your findings?

Are all authors are the same institution? If yes, that should be clarified on the title page.

Line 18 should read sub-Saharan

Line 43 Odd to reference EBF as an intervention; consider calling it an "essential practice"

Be sure to be consistent using EBF throughout - see Line 44

Line 46 Define WHO and UNICEF at first use

Line 56 Provide reference for this claim

Line 57-58 Who is saying they should be? Be sure to state if this is the WHO goal

Line 62 Would be interesting if you could discuss why the increase in EBF between 2003-2008; were there certain interventions that were successful but possible excluded partners? This would be a good place to improve your justification and rational for this study

Line 62-63 Also, discuss possibilities for why EBF decreased again in 2014

Line 71 How are partners defined here? Since this is a key point of your study, should clarify who is considered a partner using the DHS data

Line 91-107 Too much discussion of the DHS methods; you can simply reference the DHS manual that explains all these details

Line 105-106 contradicts your findings. You state that 613 were identified as exclusively breastfed? So did you only include infants who were exclusively breastfed? This contradicts your coding of 0 and 1; please explain and clarify the inclusion and exclusion criteria

Line 119-129 Need rationale for the inclusion of these partner characteristics; it's concerning that a large independent variable is missing from this study; intimate partner violence and its' many forms should considered to be included; this is largely a partner characteristic that is known to influence exclusive breastfeeding; also the number of children the partner has

Line 132-137 Were antenatal visits included? If yes, please add. If not, please justify why they were not included.

Line 138-155 This can be explain by adding it to one of your results tables; does not need to be listed out in the text.

Line 157 Data Analysis: Please clarify in detail how you addressed and adjusted for the sample weights and cluster that is used in the DHS data. Also, please be specific how the binary logistic regressions were adjusted for. Describe in detail how multicollinearity was accounted for.

Line 171 This contradicts your statement that 613 children were exclusively breastfed

Table 1 Title should be more descriptive in nature; consider adding the sample sizes and n

Table 3 is very confusing. Review other PloS One articles for information on how to construct these types of tables.

Line 262-263 Your paper is specifically about exclusively breastfeeding and not maternal health; consider revising this statement to more accurately reflect your study

Line 271 Need reference after WHO

Line 275 Too vague. Consider giving specific examples on measures and policies that need to be strengthened. What types of interventions have worked well in other countries? There are examples of programs that involve partners to improve breastfeeding.https://journals.sagepub.com/doi/abs/10.1177/0890334408323545?casa_token=1F5hkpPBVpcAAAAA:ZwVCiiboCCN616qR5YLnd-miBsRO_pHq_Qg-SltAWJGnK5_rbsJVZ-H9Wr-MRqVXqneiuSjON_dJ https://www.mdpi.com/1660-4601/17/2/413 https://www.sciencedirect.com/science/article/pii/S1871519219300654?casa_token=VGbKnwR_KQUAAAAA:zDkbBiALfqtUw2Y46kYEy46P5DNjmAM515gs2W5eTeloZ4xvw7PeBIunfD-iOtyW2_94cp5I0Q

Line 287-298 This needs to be explained more. Many studies find that higher maternal education is associated with formula feeding and non-exclusive breastfeeding. It is possible this is a statistical error based on sample sizes within the education variable or may be an error related to unaccounted for multicollinearity.

The discussion is mostly about mother's characteristics. The title and justification of the study was built on the premise of partner's characteristics. Consider revamping the study if you want to look at maternal characteristics as well. If the paper is about partner characteristics then the discussion needs to adequately reflect that. Discussion should also include specific recommendations to policy makers, public health professionals, and detailed recommendations on intervention design. What should be changed in Ghana because of the study results to improve exclusive breastfeeding in Ghana? Give examples of what has worked in other countries involving fathers and partners to improve breastfeeding. Could those be used in Ghana? What would be possible barriers? What type of future research should be done because of your study?

Double check references to make sure they are accurate

Reviewer #2: Recommendations and overarching statements –

First and foremost, I would like to congratulate the authors on their hard work. The topic and objectives of the research paper are pertinent to the current need in the maternal and child health literature. The paper is full of potential and opportunity to highlight a key research area that can guide interventions to come.

Secondly, and perhaps most importantly, the research paper in its current form requires some major modifications for the crux of the research to be brought out. Currently, the paper misses the objective it set out to achieve and needs to align with the research question again. There is an emphasis on maternal characteristics instead of paternal ones. I would strongly recommend that the authors use the Strobe checklist to present their research.

Major revisions –

1. The objective of the article is to establish and comment on the pattern between exclusive breastfeeding and partner characteristics, however, the abstract does not mention this relationship as much as it needs to. There seems to be a greater emphasis on maternal characteristics instead which defeats the purpose. The authors need to bring out the effect of paternal characteristics more.

2. The list of paternal characteristics that influence breastfeeding is certainly not exhaustive, however, some key paternal characteristics have been left out of consideration. This includes – paternal religion, paternity leave, paternal ethnicity, children fathers have had, father’s place of residence, etc. These indicators are generally available in the DHS surveys and should be available in the data dump the authors obtained. Additionally, similar factors have been considered for mothers but not for fathers who are the primary subject of this study. I believe the author’s need to revisit their overall study objective and align the methodology of the paper accordingly.

3. The entire discussion section beyond paragraphs 1 and 3 (page 22) talks only about maternal characteristics. The authors need to revisit this entire section.

4. Page 22, para 3, line 1 – The line states that “the findings indicate that partner’s occupation was the only characteristic of a partner that influenced the practice of exclusive breastfeeding”. This statement although true in the given context of the study is appreciated, would only be valid if supported with a more extensive assessment of other characteristics (mentioned in point 2)

5. Page 23, para 1, line 1 “This probably enables them to understand the need and importance to practice exclusive breastfeeding as well as motivating their partners/women to practice their exclusive breastfeeding”. This is a very broad and unsubstantiated statement and feels more like conjecture than fact. Every statement commenting beyond the results of the paper should be cited appropriately.

Minor but recommended revisions–

1. Page 22, para 1, line 3 – “relevant” to “relevance”

2. The discussion section of a paper is meant to fit the results and observations of a study in the wider context of existing literature. Some interesting parallels can be made by drawing on other aspects of maternal and child health. For instance, are similar trends seen in the case of infant malnutrition, maternal health-seeking behavior etc.

3. The authors can also add a paragraph in the introduction to explain the cultural context of breastfeeding in Ghana. Since breastfeeding often has social and cultural significance, it would help the readers understand if that might have any potential impact on overall breastfeeding practice in Ghana.

**********

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Reviewer #1: No

Reviewer #2: Yes: Prerna Gopal

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

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PLoS One. 2021 Jun 3;16(6):e0252517. doi: 10.1371/journal.pone.0252517.r002

Author response to Decision Letter 0

6 Apr 2021

Academic Editor

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

Response: We thank the academic editor for the comment and suggestion. We have revised the entire manuscript to ensure it meets PLOS ONE requirements.

2. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly.

Response: We apologise for the error. The Data Availability Statement should be modified to read “Data are available from the Measure Demographic and Health Survey Program (visit https://www.dhsprogram.com/data/ ) for researchers who meet the criteria for access to confidential data. The data is labeled Ghana: Standard DHS, 2014 and it can be accessed on the following link: https://dhsprogram.com/data/dataset/Ghana_Standard-DHS_2014.cfm?flag=0”.

3. In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially sensitive information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

Response: We have indicated in the revised cover letter that “The Measure Demographic and Health Survey program is authorised to distribute the 2014 Ghana Demographic and Health Survey data. If a researcher needs the data for research purpose, he/she is required to register with the Measure Demographic and Health Survey program to gain unrestricted access to the data”.

4. b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

Response: The datasets used for the analysis have been attached as Supplementary Information files and we have indicated in the revised cover letter that “We have also attached the files we analysed as Supplementary Information files” (last sentence on page 1).

5. For studies involving humans categorized by race/ethnicity, age, disease/disabilities, religion, sex/gender, sexual orientation, or other socially constructed groupings, authors should: 1) Explicitly describe their methods of categorizing human populations, 2) Define categories in as much detail as the study protocol allows, 3) Justify their choices of definitions and categories, 4) Explain whether (and if so, how) they controlled for confounding variables such as socioeconomic status, nutrition, environmental exposures, or similar factors in their analysis.

Response: We have described how we categorised characteristics of respondents which are social constructs and how we controlled for confounding variables in the revised cover letter as follows: “In our study, we used characteristics of respondents such as sex, age, ethnicity, and religion. We followed the categorization of these variables used in the 2014 Ghana Demographic and Health Survey manual. We checked for multicollinearity using Variation Inflation Factor (VIF) and highly correlated variables such as maternal place of residence and religion were excluded from the analysis” (page 2, paragraph 1).

Reviewer 1

1. Consider making the title more descriptive.

Response: We thank the reviewer for the suggestion. We have changed the wording of the topic to make it more descriptive. The revised topic is “The association between paternal characteristics and exclusive breastfeeding in Ghana” (page 1, line 1).

2. Rationale/justification for the study needs to be stronger. What specifically is this adding to the current literature

Response: We have modified the rationale/justification for the study in the revised manuscript. The study adds to the exclusive breastfeeding literature by identifying partner characteristics that significantly predict the practice of exclusive breastfeeding in Ghana by using a nationally representative sample. Please see page 4, lines 79-81, and page 5, lines 82-95.

3. If the analyses were adjusted, that needs to be explained and adjusted results should be listed as AORs instead of ORs

Response: The results were adjusted and they have been explained in the revised manuscript. The partner, mother, and infant characteristics were run together at the regression stage using the ENTER METHOD. All adjusted results have been changed from ORs to AORs. See page 2, lines 29-31, and page 11, lines 191-206.

4. Description of inclusion criteria should be more specific in the abstract methods and methods section.

Response: We thank the reviewer for the comment. All infants under 6 months old with maternal and paternal characteristics were included in the present study. This, therefore, includes infants who were either exclusively breastfed or not. We have made the inclusion criteria more specific in the abstract (page 2, lines 23-24) and methods section (page 6, lines104-106) in the revised manuscript.

5. Results should be presented with 2 decimals; remove "95%" from methods

Response: The results section of the revised manuscript has been modified and the results are presented in two decimals where applicable (see from page 8, lines 158 - page 14, line 210). In addition, we have removed the” 95%” from the methods section and replaced it with “a significance level of 0.05” (page 8, lines 153-154).

6. Conclusion in abstract should be more specific. How do these findings help? How can they inform policies and interventions? What should public health professionals do differently in Ghana based on your findings?

Response: We have revised the conclusion in the abstract and the main manuscript to include what public health professionals can do differently. Public health professionals can adopt a couple-oriented approach to educate and counsel both mothers and partners on the importance of exclusive breastfeeding in Ghana (page 2, lines 34-36, and page 19, lines 319-320).

7. Are all authors in the same institution? If yes, that should be clarified on the title page

Response: At the time of submission of the manuscript, all authors were from the same institution. Currently, the first and third authors have moved to a different institution (the University of Environment and Sustainable Development). This has been clarified on the title page (page 1, lines 7-10).

8. Line 18 should read sub-Saharan

Response: We have modified the background of the abstract in the revised manuscript and the phrase “sub Saharan” has been deleted from it (page 1, lines 18-19).

9. Line 43 Odd to reference EBF as an intervention; consider calling it an "essential practice"

Response: We agree with the comment of the reviewer. We have changed the word “intervention” in the introduction to “practice” in the revised manuscript (page 3, line 39). Also, we have changed “exclusive breastfeeding” to “EBF” almost throughout the entire revised manuscript.

10. Line 46 Define WHO and UNICEF at first use

Response: We have defined “WHO” and “UNICEF” in the revised manuscript (page 3, lines 42-43).

11. Line 56 Provide reference for this claim

Response: Thanks for the observation. We have provided Olufunlayo et al., 2019 as a reference to support our claim on page 3, line 51.

12. Line 57-58 Who is saying they should be? Be sure to state if this is the WHO goal

Response: In the revised manuscript, we have indicated who made the estimation and it now reads “The WHO estimates that at least 50% and 70% of infants aged under 6 months globally should be exclusively breastfed by 2025 and 2030 respectively” (page 3, line 52).

13. Line 62 Would be interesting if you could discuss why the increase in EBF between 2003-2008; were there certain interventions that were successful but possible excluded partners? This would be a good place to improve your justification and rationale for this study

Response: In the revised manuscript, we have included policies and programmes that may have contributed to the increase in Ghana’s EBF rate between 2003 and 2008 as follows: “The increase in Ghana’s EBF rate can be attributed to the implementation of policies and programmes such as the Breastfeeding Promotion Regulations 2000 [14], Imagine Ghana Free of Malnutrition [15], and Infant and Young Child Feeding Strategy [16]. These policies and programmes highlighted the importance of practicing exclusive breastfeeding. For instance, the Breastfeeding Promotion Regulations 2000 prohibits the sale and promotion of infant formula or any other product marketed as appropriate for feeding infants less than six months of age in health facilities or public places [14]. It is worth noting that these policies and programmes placed less emphasis on couple-oriented approaches to enhance exclusive breastfeeding” (page 5, line 55 to page 6, line 61).

14. Line 62-63 Also, discuss possibilities for why EBF decreased again in 2014

Response: We have explained plausible reasons for the decline in EBF in 2014 in the revised manuscript (page 4, lines 64-70).

15. Line 71 How are partners defined here? Since this is a key point of your study, should clarify who is considered a partner using the DHS data

Response: We defined partners as the biological father of the child irrespective of the marital status (page 4, lines 79-80).

16. Line 91-107 Too much discussion of the DHS methods; you can simply reference the DHS manual that explains all these details

Response: We agree with the comment of the reviewer. We have reduced the discussion of the DHS methods and have referenced the DHS manual for detailed information (page 5, lines 102-103).

17. Line 105-106 contradicts your findings. You state that 613 were identified as exclusively breastfed? So did you only include infants who were exclusively breastfed? This contradicts your coding of 0 and 1; please explain and clarify the inclusion and exclusion criteria

Response: Thank you for the observation. The 613 included all infants under six months who were either exclusively breastfed or not. However, with the inclusion of other variables suggested by the reviewers the sample size has currently reduced to 180. This includes all infants under six months with information on both maternal and paternal characteristics. It also includes those who were exclusively breastfed as well as those who were not exclusively breastfed. See from page 5, line 103 to page 6 line 106.

18. Line 119-129 Need rationale for the inclusion of these partner characteristics; it's concerning that a large independent variable is missing from this study; intimate partner violence and its' many forms should be considered to be included; this is largely a partner characteristic that is known to influence exclusive breastfeeding; also the number of children the partner has

Response: We acknowledged that some partner characteristics were missing in the first manuscript. This has been rectified and we have included other partners’ characteristics such as husband desire for children, religion, ethnicity, place of residence, partner’s attitude towards wife beating, and number of children by partner in the revised manuscript. See from page 6, line 118 to page 7, line 133.

19. Line 132-137 Were antenatal visits included? If yes, please add. If not, please justify why they were not included.

Response: Antenatal visits was included in the first manuscript we submitted for review and it is also included in the revised manuscript (page 7, line 142).

20. Line 138-155 This can be explained by adding it to one of your results tables; does not need to be listed out in the text.

Response: The section on the control variables has been summarised (page 7, lines 136-145).

21. Line 157 Data Analysis: Please clarify in detail how you addressed and adjusted for the sample weights and cluster that is used in the DHS data. Also, please be specific how the binary logistic regressions were adjusted for. Describe in detail how multicollinearity was accounted for.

Response: The data were weighted using the sampling weight variable (v005). A weight variable was generated by dividing the variable (v005) by 1,000,000. This was applied throughout the various stages of the analysis. The binary logistic regression was adjusted by using the enter mode in the mode where all variables were put in the model and run at the same time. In addition, we checked for multicollinearity and highly correlated variables such as mothers' place of residence and religion were excluded from the analysis because they were collineated.

22. Line 171 This contradicts your statement that 613 children were exclusively breastfed

Response: The entire results section of the revised manuscript has been modified (page 8, lines 158 - page 14, line 210).

23. Table 3 is very confusing. Review other PloS One articles for information on how to construct these types of tables

Response: We thank the reviewer for the observation. We have reviewed other PloS One articles and revised all tables in the revised manuscript.

24. Line 262-263 Your paper is specifically about exclusively breastfeeding and not maternal health; consider revising this statement to more accurately reflect your study

Response: We have modified the sentence to accurately reflect exclusive breastfeeding. We changed the phrase “maternal health” to “EBF” in the revised manuscript (page 14, line 215).

25. Line 271 Need reference after WHO

Response: We thank the reviewer for the observation. The statement has been referenced in the revised manuscript (page 15, line 223).

26. Line 275 Too vague. Consider giving specific examples on measures and policies that need to be strengthened. What types of interventions have worked well in other countries? There are examples of programs that involve partners to improve breastfeeding

Response: We have included specific programmes in Italy, Brazil and Taiwan, and their impact on both breastfeeding and exclusive breastfeeding in the revised manuscript (page 15, line 231-237).

27. Line 287-298 This needs to be explained more. Many studies find that higher maternal education is associated with formula feeding and non-exclusive breastfeeding. It is possible this is a statistical error based on sample sizes within the education variable or may be an error related to unaccounted for multicollinearity.

Response: We have revised the manuscript to account for multicollinearity. Variables such as maternal place of residence and religion were collineated and consequently, they were excluded from the analysis.

28. The discussion is mostly about mother's characteristics. The title and justification of the study was built on the premise of partner's characteristics. Consider revamping the study if you want to look at maternal characteristics as well. If the paper is about partner characteristics then the discussion needs to adequately reflect that. Discussion should also include specific recommendations to policy makers, public health professionals, and detailed recommendations on intervention design. What should be changed in Ghana because of the study results to improve exclusive breastfeeding in Ghana? Give examples of what has worked in other countries involving fathers and partners to improve breastfeeding. Could those be used in Ghana? What would be possible barriers? What type of future research should be done because of your study?

Response: We have included more other partner characteristics such as husband desire for children, religion, ethnicity, place of residence, partner attitude towards wife beating, and number of children by partner in the revised manuscript (page 6, lines 118-120). In addition, the discussion now reflects partner characteristics and recommendations on policy to health workers. Specific programmes involving men and women that have worked in other countries have been included in the discussion. In addition, specific programmes that could be also be adopted in Ghana have been added to the revised manuscripts. Also, future research has been indicated in the manuscript. See from page 14, line 213 to page 19, line 323.

29. Double check references to make sure they are accurate

Response: We have double check references to make sure they are accurate.

Reviewer 2

1. The objective of the article is to establish and comment on the pattern between exclusive breastfeeding and partner characteristics, however, the abstract does not mention this relationship as much as it needs to. There seems to be a greater emphasis on maternal characteristics instead which defeats the purpose. The authors need to bring out the effect of paternal characteristics more

Response: The abstract has been revised to include the influence of partner characteristics on exclusive breastfeeding (page 2, lines 18-36).

2. The list of paternal characteristics that influence breastfeeding is certainly not exhaustive, however, some key paternal characteristics have been left out of consideration. This includes – paternal religion, paternity leave, paternal ethnicity, children fathers have had, father’s place of residence, etc. These indicators are generally available in the DHS surveys and should be available in the data dump the authors obtained. Additionally, similar factors have been considered for mothers but not for fathers who are the primary subject of this study. I believe the author’s need to revisit their overall study objective and align the methodology of the paper accordingly.

Response: We thank the reviewer for the observation: We have included other partner characteristics such as husband desire for children, religion, ethnicity, place of residence, partner attitude towards wife beating, and number of children by partner in the revised manuscript (page 6, lines 118-120).

3. The entire discussion section beyond paragraphs 1 and 3 (page 22) talks only about maternal characteristics. The authors need to revisit this entire section.

Response: The entire discussion section has been modified to reflect the influence of partner characteristics and exclusive breastfeeding in the revised manuscript. See from page 14, line 213 to page 19, line 311.

4. Page 22, para 3, line 1 – The line states that “the findings indicate that partner’s occupation was the only characteristic of a partner that influenced the practice of exclusive breastfeeding”. This statement although true in the given context of the study is appreciated, would only be valid if supported with a more extensive assessment of other characteristics (mentioned in point 2).

Response: We agree with the reviewer’s comment. As a way of making the results robust, we have added other partner characteristics such as husband desire for children, religion, ethnicity, place of residence, partner attitude towards wife beating, and number of children by partner in the revised manuscript (page 6, lines 118-120).

5. The discussion section of a paper is meant to fit the results and observations of a study in the wider context of existing literature. Some interesting parallels can be made by drawing on other aspects of maternal and child health. For instance, are similar trends seen in the case of infant malnutrition, maternal health-seeking behavior etc.

Response: We thank the reviewer for the comment. We have highlighted in the revised manuscript that although Ghana’s EBF rate has declined, there has been improvement in other child health indicators such as stunting, wasting, and underweight (page 15, lines 226-229).

6. The authors can also add a paragraph in the introduction to explain the cultural context of breastfeeding in Ghana. Since breastfeeding often has social and cultural significance, it would help the readers understand if that might have any potential impact on overall breastfeeding practice in Ghana.

Response: We have added a paragraph in the introduction section which talks about the influence of interpersonal and community factors on exclusive breastfeeding in Ghana in the revised manuscript (page 4, lines 71-78).

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Decision Letter 1

Joann M McDermid

9 May 2021

PONE-D-20-36508R1

The association between paternal characteristics and exclusive breastfeeding in Ghana

PLOS ONE

Dear Dr. Kyei-Arthur,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Important comments have again been offered in this second peer-review that should be addressed.  In particular, please consider how empirical evidence and authors' speculation are worded throughout the Discussion.  Both can be communicated (and are valuable given the unique insight in terms of knowledge of the local context), but it is important to clearly distinguish for the reader the difference.      

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We look forward to receiving your revised manuscript.

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Joann M. McDermid, MSc, PhD, RDN, FAND

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

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Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors have thoroughly addressed each question and concern that was raised during the initial review process. I have no further questions or concerns with this manuscript.

Reviewer #2: Line no. 22 – Correction to “This cross-sectional study used data from the 2014 Ghana Demographic and Health Survey”

Line no. 30 – Replace “desire” with “desired”

Line 78-79 – Partner is defined according to empirical evidence. However, it must also be mentioned if it aligns with the definition as per the DHS data

Authors also need to recheck the language and grammar of the overall article during this stage of revision.

Methodology –

1. Was the sample representative of the ethnic, religious, occupational standards for Ghana? In either case, this should be mentioned in the methodology and then inference accordingly made in the discussion.

Discussion –

The discussion section is steeping in conjecture and needs to be empirical in nature. Every statement should either be derived from the findings of the study or should be cited accurately. The authors also need to revisit the objective of the study and align the content with it.

1. Line 231- 232 – Why is neonatal mortality being mentioned here? It hasn’t been talked about any where in the passage. How is this adding to the overall discussion?

2. Line 241- 246 – The authors need to establish who the primary focus of the study is – partners or mothers? If the objective is to compare the two, that needs to be brought out better

3. Line 251 – 252 – Is there any evidence to support this statement?

4. Line 255 – 262 - Is there any evidence to support these statements? Was the survey done during Ramadan? The relevancy of these statement is not clear or justified.

5. Line 266 – Which finding do the authors mean when they say “this finding”

6. Line 271 – 287 – How does this fit into the objective of the study – understanding partner characteristics that impact EBF?

7. Of the ~40 AOR calculated, majority are insignificant. The authors should include a segment discussing these observations.

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PLoS One. 2021 Jun 3;16(6):e0252517. doi: 10.1371/journal.pone.0252517.r004

Author response to Decision Letter 1

13 May 2021

Responses to the academic editor and reviewers’ comments

Academic Editor

1. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Response: We have gone through all the references to ensure that they are complete and correct. We have removed two references (Asare et al. [38]; Sika-Bright and Oduro [46]) from the revised manuscript since they talked about the effect of mothers' education on exclusive breastfeeding. We have included new references (Ludvigsson and Ludvigsson [34]; Chudasama, Patel, and Kavishwar, [46]) in the revised manuscript to corroborate our finding that partners with low education are less likely to practice exclusive breastfeeding compared to those with no education. Also, we have modified the sentence “Therefore, formal education by itself may not necessarily empower a mother to practice EBF.” to read “Therefore, mothers whose partners have acquired some level of formal education may not necessarily be empowered to practice EBF.” Please see Line no: 252-253.

In addition, we have removed the reference Bhatta [48] from our revised manuscript since it did not support our argument in the manuscript. Also, we have deleted the reference Adsera [50] from the revised manuscript since we have deleted the argument it supports from the revised manuscript.

38. Asare BY-A, Preko JV, Baafi D, Dwumfour-Asare B. Breastfeeding practices and determinants of exclusive breastfeeding in a crosssectional study at a child welfare clinic in Tema Manhean, Ghana. International Breastfeeding Journal (2018) 13:12 2018;13(1):12.

46. Sika-Bright S, Oduro GY. Exclusive breastfeeding practices of mothers in Duakor, a traditional migrant community in Cape Coast, Ghana. Journal of Global Initiatives: Policy, Pedagogy, Perspective. 2013;8(1):87-102.

34. Ludvigsson JF, Ludvigsson J. Socio‐economic determinants, maternal smoking and coffee consumption, and exclusive breastfeeding in 10 205 children. Acta Paediatrica. 2005;94(9):1310-9.

46. Chudasama RK, Patel PC, Kavishwar AB. Determinants of exclusive breastfeeding in south Gujarat region of India. Journal of Clinical Medicine Research. 2009;1(2):102.

48. Bhatta DN. Involvement of males in antenatal care, birth preparedness, exclusive breast feeding and immunizations for children in Kathmandu, Nepal. BMC Pregnancy and Childbirth. 2013;13(1):1-7.

50. Adsera A. Differences in desired and actual fertility: An economic analysis of the Spanish case. Bonn: IZA; 2005.

Reviewer 2

1. Line no. 22 – Correction to “This cross-sectional study used data from the 2014 Ghana Demographic and Health Survey”.

Response: We thank the reviewer for the comment and observation. This has been corrected in the revised manuscript. Please see Line no. 22.

2. Line no. 30 – Replace “desire” with “desired”

Response: The word “desire” has been changed to “desired” in the revised manuscript. Please see Line no. 30.

3. Line 78-79 – Partner is defined according to empirical evidence. However, it must also be mentioned if it aligns with the definition as per the DHS data

Response: We thank the reviewer for the comment. We have revised the definition of a partner in the revised manuscript to align with the DHS definition. A partner is defined as “a man who is either currently married or living with a woman”. Please see Line no. 79.

4. Was the sample representative of the ethnic, religious, occupational standards for Ghana? In either case, this should be mentioned in the methodology and then inference accordingly made in the discussion.

Response: Ethnicity, religion, and occupation are aligned with the standards for Ghana. We have included the statement “All variables and their categories used in this study align with the standards for Ghana.” in the revised manuscript to that effect. Please see Line no. 145-146.

5. Line 231- 232 – Why is neonatal mortality being mentioned here? It hasn’t been talked about any where in the passage. How is this adding to the overall discussion?

Response: We thank the reviewer for the comment. Neonatal mortality is very important with regard to exclusive breastfeeding. In that non-exclusive breastfeeding has a consequence on mortality. We have therefore modified the sentence “It reduces infant mortality and morbidity, enables infants to crawl early, enhances growth and cognitive development, and reduces the risk of childhood obesity [3-7].” to read “It reduces neonatal and infant mortality and morbidity, enables infants to crawl early, enhances growth and cognitive development, and reduces the risk of childhood obesity [3-7].” in the introduction section to that effect. Please see Line no. 46-47.

6. Line 241- 246 – The authors need to establish who the primary focus of the study is – partners or mothers? If the objective is to compare the two, that needs to be brought out better

Response: We thank the reviewer for the observation and comment. Partners are the primary focus of this study. We used mothers’ education to explain partners’ education. We have therefore modified it in the revised manuscript. Please see Line no. 247-249. In addition, we have modified the sentence “It was also evident in the findings that the likelihood to exclusively breastfeed was lower among Muslim mothers compared to Christian mothers.” to read “It was also evident in the findings that the likelihood to exclusively breastfeed was lower among mothers whose partners were Muslims compared to those whose partners were Christians.” Please see Line no. 259-260.

7. Line 251 – 252 – Is there any evidence to support this statement?

Response: The statement “Therefore, partners who desire more children may discourage the practice of EBF to ensure their fertility desire is accomplished.” is speculative and we have deleted it from the revised manuscript.

8. Line 255 – 262 - Is there any evidence to support these statements? Was the survey done during Ramadan? The relevancy of these statement is not clear or justified.

Response: We thank the reviewer for the comment. We have modified the paragraph in question as follows: “It was also evident in the findings that the likelihood to exclusively breastfeed was lower among mothers whose partners were Muslims compared to those whose partners were Christians. This finding is consistent with previous studies [23]. The Holy Quran encourages breastfeeding among Muslims [48]. However, the reasons why mothers whose partners were Muslims are less likely to exclusively breastfeed compared to those whose partners are Christians could not be explained in the present study and therefore further studies using qualitative approaches could explore the probable reasons.” Please see Lines no. 259-265.

9. Line 266 – Which finding do the authors mean when they say “this finding”

Response: We thank the reviewer for the comment. We have revised the manuscript and deleted the section “This finding however contradicts our finding that mothers whose partners desire more children were less likely to practice EBF compared to those whose partners desire fewer children. A probable reason for the discrepancy in the findings is that there is a difference between actual and desired fertility. Desired fertility may not necessarily translate into actual fertility due to several factors including labour market and economic conditions [49].”

10. Line 271 – 287 – How does this fit into the objective of the study – understanding partner characteristics that impact EBF?

Response: We thank the reviewer for the comment. Although our study focused on the influence of partner characteristics on exclusive breastfeeding, mothers and infant characteristics also influence exclusive breastfeeding. Consequently, we controlled for these characteristics. Since the mother’s antenatal care visits and age of infant were found to be significantly associated with exclusive breastfeeding in this study, we, therefore, discussed it in the “Discussion Section”.

11. Of the ~40 AOR calculated, majority are insignificant. The authors should include a segment discussing these observations.

Response: We thank the reviewer for the suggestion. We have discussed the non-significant paternal characteristics in the “Discussion Section”. Please see Line no. 269-278.

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Click here for additional data file. (20.6KB, docx)

Decision Letter 2

Joann M McDermid

18 May 2021

The association between paternal characteristics and exclusive breastfeeding in Ghana

PONE-D-20-36508R2

Dear Dr. Kyei-Arthur,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Joann M. McDermid, MSc, PhD, RDN, FAND

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Acceptance letter

Joann M McDermid

24 May 2021

PONE-D-20-36508R2

The association between paternal characteristics and exclusive breastfeeding in Ghana

Dear Dr. Kyei-Arthur:

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