Work, Protection, and Exclusive Breastfeeding Among Migrant Female Head Porters (Kayayei) in Urban Ghana: A Mixed-Methods Study

Work, Protection, and Exclusive Breastfeeding Among Migrant Female Head Porters (Kayayei) in Urban Ghana: A Mixed-Methods Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Work, Protection, and Exclusive Breastfeeding Among Migrant Female Head Porters ( Kayayei ) in Urban Ghana: A Mixed-Methods Study Rehana Ama Obosu, Daniel Buor, Seth Agyemang, David Forkuor This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9372498/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background Exclusive breastfeeding (EBF) for the first six months is a core global recommendation, but feasibility is unequally distributed. In urban Ghana, migrant female head porters ( kayayei ) work in informal market settings characterised by long hours, income insecurity, limited privacy, and an absence of maternity protection. This study examined how work conditions, economic resources, and institutional gaps shape EBF practice and duration among kayayei in Kumasi. Methods An explanatory sequential mixed-methods design was used. The quantitative phase surveyed 398 kayayei mothers using a structured interviewer-administered questionnaire. Binary logistic regression was estimated across three staged models aligned with a Social Ecological Model: individual characteristics (Model 1), interpersonal and service-access factors (Model 2), and organisational and work-related factors (Model 3). The qualitative phase used two focus group discussions with kayayei mothers and ten key informant interviews with health workers and governance actors to interpret observed statistical patterns. Results Self-reported EBF was high (95.5%), but WHO-consistent six-month EBF was 12.1%, with a mean duration of 2.86 months (SD 1.70). Organisational factors were the strongest predictors of sustained EBF. Longer working hours reduced the odds of six-month EBF (OR 0.81, 95% CI 0.71–0.93, p = 0.002), while having breaks increased the odds (OR 1.62, 95% CI 1.16–2.25, p = 0.005). Perceiving EBF as incompatible with work was the strongest inverse predictor (OR < 0.01, 95% CI < 0.01–0.04, p = 0.001). Being outside a marital or union relationship (OR < 0.01, p = 0.007), lower social support (OR 0.03, 95% CI < 0.01–0.44, p = 0.001), and lower daily expenditure (OR 1.33, 95% CI 1.08–1.64, p = 0.008) were also significantly associated with not meeting the six-month criterion. Qualitative findings showed that breastfeeding decisions were framed as survival strategies rather than failures, and that no targeted policy framework existed for kayayei in market settings. Conclusions Low sustained EBF among kayayei reflects a protection gap rather than a knowledge deficit. Closing this gap requires market-based breastfeeding spaces, locally enforced breaks, outreach postnatal support, peer counsellors, and economic buffering for postpartum mothers. Counselling-only interventions are insufficient without structural protections that make EBF feasible in informal work settings. exclusive breastfeeding kayayei informal labour migrant mothers maternity protection Social Ecological Model Ghana mixed methods Figures Figure 1 Figure 2 1. Background Exclusive breastfeeding (EBF), providing only breast milk for the first six months of life, except oral rehydration salts, vitamins, and medications, is among the most effective interventions for child survival and maternal health [ 1 ]. The World Health Organisation (WHO) recommends EBF initiation within the first hour of birth, exclusive breastfeeding for 6 months, and continued breastfeeding alongside complementary foods for up to 2 years [ 1 ]. In Ghana, the 2022 Demographic and Health Survey estimates a national EBF rate of approximately 53% among infants aged 0–5 months, suggesting progress but masking wide variation across social groups [ 2 ]. A growing body of research in Ghana shows that EBF is shaped not only by maternal knowledge but by social support, economic resources, work conditions, and health service contact [ 3 , 4 ]. Yet most breastfeeding research and promotion implicitly assumes that mothers have stable housing, predictable schedules, privacy, and supportive caregiving arrangements. For mothers in informal employment, where income is earned by the hour or the trip, these assumptions often do not hold. This study focuses on kayayei , migrant female head porters who carry goods for a fee in major market settings across urban Ghana. Their work is physically demanding, informal, and time-sensitive: earnings depend on constant availability and physical endurance. Motherhood in this context involves a direct, daily conflict between feeding on demand and earning enough to cover food, shelter, and childcare. Formal maternity protections, paid leave, nursing breaks, and designated breastfeeding spaces are built into Ghana's Labour Act for regulated employment [ 5 ] and are supported by international labour standards [ 6 ], but do not extend to informal workers without a fixed employer. Kayayei are therefore among the clearest cases in which the policy conditions assumed by breastfeeding promotion do not exist. The present study makes three contributions. First, it distinguishes between self-reported EBF and WHO-consistent six-month EBF in this population, revealing how reported practice can mask early discontinuation. Second, it estimates predictors at the individual, interpersonal, and organisational levels using staged regression modelling aligned with the Social Ecological Model (SEM), enabling comparisons across levels of influence. Third, it uses qualitative evidence from mothers and stakeholders to identify implementation gaps that explain observed patterns and to propose interventions that align with market realities. 2. Conceptual Framework This study is guided by the Social Ecological Model (SEM), originally proposed by McLeroy et al. [ 14 ] and building on Bronfenbrenner’s ecological systems theory [ 15 ]. The SEM conceptualises health behaviour as the outcome of interacting influences operating at multiple levels rather than as the product of individual choice alone. Applied to EBF, this framework (Fig. 1 ) treats sustained breastfeeding not as a simple maternal decision but as a practice shaped simultaneously by individual capacity, social support structures, community and work environments, and broader policy conditions. At the individual level, the framework highlights maternal characteristics that shape capacity and confidence, including age, educational attainment, economic resources, and knowledge of EBF. Among kayayei , low educational attainment, income insecurity, and food poverty operate at this level to constrain the practical ability to sustain exclusive feeding even when the intention is present. At the interpersonal level, the framework focuses on close relationships and social networks that shape the availability of care options and emotional support. For kayayei , who are predominantly migrants separated from kin networks, this level is often characterised by instability: many women manage both income generation and infant care without a partner or family member in proximity. Union status, social support, and household composition operate at this level. At the organisational level, the framework draws attention to the settings in which daily life occurs and the rules and routines that govern them. For kayayei , the market is the primary organisational context. Working hours, the availability of breaks, access to a private breastfeeding space, and the perceived compatibility of EBF with market work all operate at this level. These conditions are not incidental features of individual circumstances; they are structural properties of informal market labour that apply to women in this occupation. At the policy level, the framework considers the broader institutional environment within which EBF promotion operates. Ghana has national breastfeeding promotion regulations and labour protections for nursing mothers in formal employment [ 5 , 18 ]. However, these protections do not extend to informal workers without a contract of employment. The policy level in this study is therefore characterised by what might be called a protection gap: EBF is promoted as a standard, yet the institutional conditions are not put in place for those in the most precarious work arrangements. The staged regression models used in this study are directly aligned with the SEM. Model 1 estimates individual-level associations; Model 2 adds interpersonal and service-access factors; and Model 3 incorporates organisational and work-related variables. This structure allows the analysis to show where constraints are strongest across levels, and where targeted intervention is most likely to improve EBF outcomes. 3. Methods 3.1 Study design and setting This study used an explanatory sequential mixed-methods design [ 7 ]. A cross-sectional survey was conducted first to estimate EBF prevalence and identify statistical predictors; qualitative data collection followed to explain and contextualise the quantitative findings. The study was conducted in the Kumasi Metropolitan Assembly (KMA), Ghana’s second-largest city, at four principal market sites where kayayei are highly concentrated: Kejetia, Adum, Asafo, and Bantama (Fig. 2 ). 3.2 Participants and sampling The quantitative sample comprised 398 kayayei mothers aged 15–49 with at least one child aged 24 months or below who were actively working in the selected markets at the time of data collection. Because no sampling frame exists for this mobile population, the study used purposive sampling to select market sites and convenience sampling to recruit eligible respondents within them. Sample size was calculated using Cochran's formula for unknown populations, with a 95% confidence level, a 5% margin of error, and the national EBF estimate of 53% from the 2022 GDHS, yielding a minimum of 383, increased to 398 to account for non-response participants [ 8 ]. For the qualitative phase, ten key informants were purposively selected: two assemblymen, one district assembly representative, two market queens, one representative from the Ministry of Gender, Children and Social Protection, and four midwives. Two focus group discussions (FGDs) were conducted with kayayei mothers — FGD 1 with 12 younger women (aged 22–36) and FGD 2 with 8 older women (aged 38–49). 3.3 Measures The primary outcome was WHO-consistent EBF: whether the respondent reported feeding her most recent child only breast milk for the full six months (coded 1 = yes, 0 = no). This was assessed through retrospective maternal recall during a face-to-face interview. Because the study enrolled mothers with children aged 24 months or below, the maximum recall window was 24 months; restricting inclusion to children under 24 months was a deliberate strategy to limit recall decay and reduce the likelihood of telescoping bias, consistent with standard DHS practice for infant feeding indicators. Mothers were asked to reconstruct their most recent child’s feeding history from birth, including when liquids other than breast milk, like water, formula, or porridge, were first introduced. WHO-consistent six-month EBF was coded as achieved only when the respondent reported no introduction of any other liquid or food during the first six months. Self-reported EBF and self-rated EBF duration in months were retained as secondary indicators to allow comparison between claimed practice and WHO-consistent practice. The gap between these two measures, documented in the results, provides an internal validity check for the measurement approach. Secondary indicators included self-reported EBF practice and EBF duration in months. Predictors were organised by SEM level. Individual-level variables included maternal age, educational attainment, union/marital status, number of children, daily income, and daily expenditure. Interpersonal and service-access variables included social support, antenatal care attendance, postnatal care, household headship, and accommodation type. Organisational and work-related variables included daily working hours (continuous, in hours), break availability (continuous, measured as total break time in hours per day), access to a clean private breastfeeding space (binary), whether EBF information was encountered at work (binary), whether breastfeeding training had been received (binary), and whether the respondent perceived EBF as affecting her ability to work (binary). For continuous predictors, odds ratios reflect a one-unit change: one additional hour of work, one additional hour of breaks per day, and one additional GHS of daily expenditure, respectively. The social support variable was operationalised as a composite score based on respondents’ ratings of support from partners, family, and community members; the scale was coded so that higher scores indicate lower levels of support, making this variable an inverse measure of social protection. 3.4 Data analysis Descriptive statistics summarised socio-demographic characteristics, work conditions, and EBF indicators. Binary logistic regression estimated associations between predictors and WHO-consistent EBF across three staged models reflecting SEM levels: Model 1 (individual characteristics), Model 2 (adding interpersonal and service-access variables), and Model 3 (the fully adjusted model including organisational and work-related factors). Results are reported as odds ratios (ORs) with 95% confidence intervals. Model fit was assessed using the Nagelkerke R². Qualitative data were analysed thematically, with findings used to interpret and extend the quantitative results. 3.5 Ethics Ethical approval was granted by the Humanities and Social Sciences Research Ethics Committee of Kwame Nkrumah University of Science and Technology (Ref: HuSSREC/AP/14/VOL. 3). The study was conducted in accordance with the Declaration of Helsinki. Participation was voluntary, and informed consent was obtained from all participants before data collection. Anonymity is preserved throughout; participants are identified by role only. 4. Results 4.1 Socio-demographic and work profile Respondents reflected the social location of migrant informal workers in urban markets. Most had no formal education (57.3%), were Muslim (73.9%), and worked exclusively as kayayei (96%). Tables 1 and 2 summarise key characteristics. Working days were long (mean 12.95 hours), breaks were minimal (mean 1.91 hours), and daily income (GHS 47.70) substantially exceeded daily expenditure (GHS 27.64), indicating that most earnings were absorbed by basic survival costs. Most women lived in group homes, kiosks, or open spaces with limited privacy, and nearly 90% reported very low food security. Additional key characteristics: 96% were migrants from northern Ghana; 69.8% were in a marital or union relationship; 44.0% lived in couple households with children; 28.1% were single mothers; and 27.1% lived in extended family households. Table 1 Selected socio-demographic characteristics (N = 398) Characteristic / Category % Education: No formal education 57.3 Education: Basic education 40.2 Education: Secondary or vocational 2.0 Education: Tertiary 0.5 Religion: Muslim 73.9 Religion: Christian 26.1 Table 2 Work and economic profile (N = 398) Indicator Mean SD Daily working hours 12.95 3.34 Break time (hours) 1.91 3.62 Daily income (GHS) 47.70 20.90 Daily expenditure (GHS) 27.64 15.28 4.2 EBF awareness, prevalence, and the six-month gap Table 3 summarises EBF awareness and practice. Although 79.9% of respondents had heard of EBF, only 2.5% rated themselves as well-informed about it. Self-reported EBF was high (95.5%), but WHO-consistent six-month EBF was 12.1%, with a mean duration of 2.86 months. This 83-percentage-point gap between reported and sustained practice is the study's central empirical finding. Qualitative data revealed that the conceptual mismatch was a significant driver. Many mothers described EBF as giving breast milk before introducing other feeds, without a clear understanding that six months of exclusivity is the recommendation. As one participant explained: "My friend told me that as long as you breastfeed, even for just a few days without adding anything, it is called exclusive breastfeeding. So let us say I start with two days of breastfeeding, and then maybe for some reason I give the baby water and come back to give it some more days — as long as I have given the breast for a day without water, I have done exclusively." (39 years, FGD 2) Health workers corroborated this pattern, noting that most mothers had already introduced supplementary feeds by the time they appeared at postnatal visits. Table 3 EBF awareness and prevalence (N = 398) Indicator N % Ever heard of EBF 318 79.9 Self-reported EBF with last child 380 95.5 WHO-consistent six-month EBF 48 12.1 Self-rated as well-informed about EBF 10 2.5 4.3 Constraints to EBF practice Table 4 reports the distribution of self-reported constraints. Stress and fatigue, financial problems, and inadequate maternal nutrition were the most commonly cited barriers. Long working hours, time constraints, and workplace environment were also frequently reported. Qualitative accounts consistently linked early supplementation to survival rather than choice: "I stopped breastfeeding at 3 months because I had to go back to work and could not keep bringing the baby to breastfeed. You know how difficult our work is. If I decide to take the baby everywhere and breastfeed, it is tiring and difficult. So, I stopped." (39 years, FGD 2) Stakeholders confirmed that no specific policy or programme existed for kayayei in market settings. One assemblyman stated: "At the district level, we do not have any specific policies that address the needs of breastfeeding kayayei. If we are to help them in anything, it is from our own pockets." (KII, Assemblyman) Table 4 Self-reported constraints affecting ability to practise EBF (N = 398, % reporting as a barrier) Constraint % reporting as a barrier Stress and fatigue 44.7 Financial constraints 41.7 Inadequate maternal nutrition 38.2 Work-related demands 36.2 Insufficient breastmilk 30.7 Long working hours 29.6 Lack of support 27.6 Time constraints 25.6 Workplace environment 15.6 4.4 Predictors of WHO-consistent six-month EBF Table 5 presents results from the three-stage logistic regression. The pattern is consistent with the SEM framework: constraints accumulate across levels, and organisational factors in Model 3 are the strongest predictors. At the individual level (Model 1), older age was negatively associated (OR 0.84, 95% CI 0.75–0.95, p = 0.004), while basic education (OR 2.94, 95% CI 1.28–6.74, p = 0.011) and daily expenditure (OR 1.19, 95% CI 1.07–1.33, p = 0.001) were positively associated with six-month EBF. The tertiary education estimate in Model 1 (OR 19.19, 95% CI 1.05–352.10) was also significant but carries a very wide confidence interval due to the very small number of tertiary-educated respondents (n = 2); it should be treated as unreliable. When interpersonal and service-access variables were added (Model 2), not being in a union became significant (OR 0.04, 95% CI < 0.01–0.55, p = 0.016), and lower social support was strongly negatively associated (OR 0.03, 95% CI < 0.01–0.29, p = 0.002). Daily expenditure remained significant (OR 1.21, 95% CI 1.05–1.39, p = 0.011). In the fully adjusted model (Model 3), the strongest predictors were at the organisational level. Each additional working hour reduced the odds of six-month EBF (OR 0.81, 95% CI 0.71–0.93, p = 0.002). Breaks were protective (OR 1.62, 95% CI 1.16–2.25, p = 0.005). Perceiving EBF as incompatible with work was the most powerful inverse predictor (OR < 0.01, 95% CI < 0.01–0.04, p = 0.001). Being outside a union (OR < 0.01, p = 0.007), low social support (OR 0.03, p = 0.001), and daily expenditure (OR 1.33, p = 0.008) remained significant. The education estimate for tertiary-level respondents was very large (OR 71.71, 95% CI 2.41–2132.01) and should be treated with particular caution given the very small cell size. Similarly, the near-zero odds ratios for union status (OR < 0.01) and perceived EBF-work incompatibility (OR < 0.01) in Model 3 are consistent with near-complete separation in the logistic model for these predictors, that is, virtually all women in the reference category met the six-month criterion while virtually none in the exposed category did. These estimates confirm very strong associations, but their precise magnitude is unreliable and should not be interpreted literally. Table 5 Logistic regression predicting WHO-consistent six-month EBF (N = 398) Predictor OR [95% CI] M1 P OR [95% CI] M2 P OR [95% CI] M3 P Age (years) 0.84 [0.75, 0.95] 0.004** 0.92 [0.78, 1.10] 0.366 0.86 [0.70, 1.06] 0.158 Not in union (ref: in union) 0.34 [0.07, 1.76] 0.200 0.04 [0.00, 0.55] 0.016* < 0.01 [< 0.01, 0.18] 0.007** Basic education (ref: none) 2.94 [1.28, 6.74] 0.011* 6.38 [1.46, 27.99] 0.014** 5.45 [0.82, 36.14] 0.079 Tertiary education (ref: none) 19.19 [1.05, 352.10] 0.046* 0.87 [0.02, 47.69] 0.949 71.71 [2.41, 2132.01] 0.008** Daily expenditure (GHS) 1.19 [1.07, 1.33] 0.001** 1.21 [1.05, 1.39] 0.011* 1.33 [1.08, 1.64] 0.008** Social support score – – 0.03 [0.00, 0.29] 0.002** 0.03 [0.00, 0.44] 0.001** Daily working hours – – – – 0.81 [0.71, 0.93] 0.002** Breaks during work – – – – 1.62 [1.16, 2.25] 0.005** EBF perceived to affect work (ref: no) – – – – < 0.01 [< 0.01, 0.04] 0.001** OR = odds ratio; CI = confidence interval; – = not included in this model. * p < 0.05; ** p < 0.01. Tertiary education estimates have very wide CIs due to small cell sizes; interpret with caution. Social support score coded so that higher scores indicate lower support received. 5. Discussion 5.1 Overview: findings through the Social Ecological Model The findings of this study are interpreted through the Social Ecological Model (SEM) outlined in Section 2 . The SEM predicts that health behaviour is shaped by interacting influences at the individual, interpersonal, organisational, and policy levels, and that constraints at any level can undermine practice even when knowledge and intent are present [ 14 , 15 ]. The 83-percentage-point gap between self-reported EBF (95.5%) and WHO-consistent six-month EBF (12.1%) is the central finding, and the staged regression confirms that constraints accumulate across SEM levels. Individual-level resources matter, but interpersonal conditions, especially organisational work factors, are the decisive predictors. This pattern confirms the SEM’s core proposition: that individual awareness cannot sustain EBF when the surrounding environment makes it infeasible. Within this overall picture, the gap between reported and sustained EBF has two likely drivers. First, many mothers did not share the technical definition of EBF. Qualitative accounts showed that women often understood EBF as any period of exclusive milk-giving rather than six continuous months, consistent with evidence that 24-hour recall measures and lay understandings inflate EBF estimates relative to sustained duration [ 9 ]. Second, even mothers with accurate knowledge described the practical impossibility of exclusivity once they returned to market work. Both explanations point to the level above the individual: within this sample, the binding constraint appears to be not what mothers know but what their environment allows. 5.2 Organisational level: work intensity and the absence of protection At the organisational level, the SEM focuses on the settings in which daily life occurs and the rules and routines that govern them. For kayayei , that setting is the market. The most distinctive finding of this study is that organisational-level variables, working hours, breaks, and perceived compatibility of EBF with work, were the strongest predictors of WHO-consistent EBF in the final model and remained significant independently of individual and interpersonal factors. This is precisely what the SEM predicts: organisational conditions can override individual-level resources when they are sufficiently constraining. In regulated employment, maternity protections and nursing breaks are legal entitlements that soften this constraint. For informal workers with no identifiable employer, those protections do not automatically apply [ 5 , 6 ], and the market provides no equivalent. Within the markets studied, the kayayei context therefore suggests an SEM case where the organisational level is almost entirely unprotected. The finding that perceived incompatibility with work, rather than measured hours alone, is the strongest predictor aligns with qualitative accounts in which mothers described supplementation as a strategy to keep earning, not a rejection of breastfeeding. This distinction matters for intervention design: it shows that the organisational barrier operates through perception and economic fear, not just time. Within this sample, mothers did not appear to stop because they lacked information; the evidence indicates they stopped because the market environment made exclusivity economically costly. This is consistent with evidence that lactation spaces and protected breaks are reliably associated with longer EBF duration [ 10 ], the same SEM organisational conditions that are absent for kayayei . 5.3 Individual level: economic resources and the material conditions of breastfeeding At the individual level, the SEM highlights maternal characteristics that shape capacity and confidence. Daily expenditure was positively and consistently associated with six-month EBF across all three regression models. It is best understood not as income in isolation but as a proxy for the material resources that enable sustained EBF at the individual level: adequate food and hydration, the ability to take rest, access to transport for health services, and the option to secure informal childcare support. The SEM predicts that individual-level resources mediate the relationship between structural conditions and behaviour, and the data from this sample support this prediction. Among women with very low food security (89.9% of this sample), expenditure capacity cushions against the immediate economic cost of pausing work to breastfeed [ 11 ]. Mothers who reported inadequate nutrition also cited perceived milk insufficiency as grounds for early supplementation, connecting food insecurity at the individual level directly to milk production and early discontinuation [ 4 ]. Notably, education was also a significant individual-level predictor, consistent with evidence across Ghana that maternal education strengthens the ability to interpret health guidance and seek appropriate support [ 3 , 4 ]. 5.4 Interpersonal level: relational support, partnership, and migrant isolation At the interpersonal level, the SEM focuses on close relationships and social networks that shape the availability of time, care options, and emotional support. Union status and social support score were both significantly associated with six-month EBF in the adjusted model. Women outside union relationships had very low odds of sustained EBF, consistent with evidence across Ghana that partner support and shared care arrangements influence breastfeeding duration [ 3 , 4 ]. For kayayei , the interpersonal-level deficit is compounded by migration: most women are separated from kin networks and must manage both income generation and infant care entirely on their own. The SEM predicts that weak interpersonal support increases vulnerability to barriers at other levels, and the data from this sample are consistent with this. The social support score remained significant in the fully adjusted model even after organisational variables were included, demonstrating that interpersonal-level protection and organisational-level protection operate independently and cumulatively. Within this sample, mothers without either relational or organisational protection were at particularly high risk of early EBF discontinuation. 5.5 Policy level: the institutional gap and the limits of clinic-based support At the policy level, the SEM highlights the institutional environment within which all other levels operate. Ghana has national breastfeeding promotion regulations and nursing break entitlements within the Labour Act for formal employment [ 5 , 18 ], but these protections do not extend to informal workers without a fixed employer. The result is a policy-level gap that the SEM framework makes legible: the outermost level of the system, which should buffer and support conditions at inner levels, is effectively absent for kayayei . Health facilities were the primary source of EBF information (61.3% of the 318 who had heard of EBF, equivalent to approximately 49% of all respondents), yet clinic-based counselling alone was not sufficient to sustain EBF. Qualitative evidence from health workers confirmed that standard postnatal follow-up assumes stable housing, predictable schedules, and the ability to attend appointment-based sessions, conditions that kayayei often cannot meet. This is consistent with broader evidence on migrant mothers in Ghana showing that structural and mobility barriers limit use of maternal health services [ 12 ]. The qualitative data confirmed a policy vacuum at all governance levels: no directive existed at the district, municipal, or ministry levels that explicitly addressed breastfeeding support for kayayei . Governance actors acknowledged awareness of the problem but reported a lack of resources and programme ownership. This policy silence is not simply a resource constraint; it reflects a structural mismatch between how maternal health policy is designed (around stable households and formal employment) and how kayayei live and work. The SEM would predict that when the policy level fails to create enabling conditions, individual-level knowledge and interpersonal support cannot compensate. The data from this sample are consistent with this prediction. 5.6 Cross-level synthesis and implications for intervention The SEM framework shows that low sustained EBF among kayayei is not explained by any single level but by the cumulative failure of conditions across all four. At the policy level, there is no protection for informal market mothers. At the organisational level, work is long, breaks are minimal, and there is no space for breastfeeding. At the interpersonal level, migration has severed kin networks, and many women lack partner support. At the individual level, food insecurity and inadequate expenditure constrain the material basis for sustained feeding. The regression models confirm this layered picture: each level adds explanatory power, and the full model explains 68.6% of the variance. This means that single-level interventions such as counselling alone are unlikely to be sufficient. The SEM logic calls for a matched multi-level response. At the organisational level, protected breastfeeding spaces within markets and locally enforceable break norms address the dominant constraints directly; a systematic review confirms that such workplace-level protections are linked to longer EBF duration [ 10 ]. At the interpersonal level, peer counsellors embedded in market settings can compensate partially for absent kin networks; peer support has been shown to reduce early EBF discontinuation in low- and middle-income countries [ 13 ]. At the individual level, economic buffering, such as modest food support or social protection linkages, addresses the expenditure-EBF association. At the policy level, explicit recognition of migrant informal worker mothers as a target group would fill the current policy vacuum, establishing clear ownership and accountability. Each of these components responds to a specific SEM-identified constraint; together, within market settings comparable to those studied, they are likely to represent the minimum conditions under which the WHO six-month recommendation becomes more achievable. In summary, the SEM framework transforms this study’s findings from a set of statistical associations into a coherent account of why sustained EBF is rare among kayayei . It is rare not because mothers do not value breastfeeding, most do, but because the conditions at every level of their social ecology work against it. In contexts comparable to those studied here, closing the gap between reported and WHO-consistent EBF is likely to require interventions that operate at the same levels where the constraints are produced. 6. Strengths and Limitations This study has several strengths. First, the mixed-methods design is a notable asset; the combination of cross-sectional survey data and qualitative evidence from focus group discussions and key informant interviews allowed statistical associations to be interpreted through the lived experiences of mothers and the institutional accounts of governance actors, producing a richer and more actionable analysis than either method alone would have provided. Second, the sample size of 398 is adequate for the regression models used and is large relative to most studies of this specific and hard-to-reach population. Recruiting kayayei at their place of work across four major market sites improved coverage across different market settings within the KMA. Third, the use of WHO-consistent six-month EBF as the primary outcome, alongside self-reported EBF as a secondary measure, is a methodological strength: it enabled the study to document the awareness-practice gap directly and to base the analysis on the technically accurate definition of EBF rather than self-classification, which is commonly subject to inflation. Fourth, the study is grounded in the Social Ecological Model, which provides a theoretically coherent structure for organising predictors across multiple levels and for aligning the intervention recommendations with the level at which each constraint operates. Fifth, restricting enrolment to mothers of children aged 24 months or below was a deliberate strategy to reduce recall decay, consistent with standard DHS practice for infant feeding indicators. Nevertheless, this study also has limitations. The cross-sectional design means that associations cannot be interpreted as causal. Self-reported measures of EBF may be affected by recall bias and conceptual confusion about the definition of exclusivity, and the gap between reported and WHO-consistent EBF suggests that measurement inflation is likely. The use of convenience sampling in the absence of a sampling frame limits statistical generalisability, though the underlying constraints of informal market work are likely to be similar across comparable urban settings. Finally, the cross-sectional design cannot identify the precise timing of supplementation, which limits understanding of when, within the six months, the constraints become decisive. 7. Conclusions Among kayayei in Kumasi, awareness of EBF is widespread, but WHO-consistent six-month exclusivity is rare. Within this sample, the evidence indicates that low sustained EBF is better understood as a feasibility and protection problem than as a knowledge deficit. Work conditions, working hours, breaks, and the perception that EBF conflicts with earning were the strongest predictors of sustained EBF in this sample, and they operated independently of individual-level factors. Relational insecurity, economic vulnerability, and the absence of targeted institutional support compound these constraints. Closing this gap requires market-level action alongside and beyond facility counselling: protected breastfeeding spaces, locally enforceable break norms, market-based postnatal outreach, peer counsellor models, and economic support for postpartum mothers in high-risk circumstances. These interventions do not require complex systems, but they do require acknowledging that markets function as care spaces for migrant mothers and that the conditions for sustaining EBF cannot be assumed to exist there without deliberate action. Abbreviations EBF Exclusive Breastfeeding SEM Social Ecological Model KMA Kumasi Metropolitan Assembly WHO World Health Organisation GDHS Ghana Demographic and Health Survey FGD Focus Group Discussion KII Key Informant Interview OR Odds Ratio CI Confidence Interval GHS Ghana Cedis. Declarations Ethics approval and consent to participate: Ethical approval was granted by the Humanities and Social Sciences Research Ethics Committee of Kwame Nkrumah University of Science and Technology (Ref: HuSSREC/AP/14/VOL. 3). Written or verbal informed consent was obtained from all participants. Competing interests: The authors declare no competing interests. Funding: This study received no external funding. Author Contribution RAO designed the study, collected data, performed analysis, and wrote the manuscript. DB, SA, and DF supervised the research and contributed critical revisions. All authors approved the final manuscript. Acknowledgements: We gratefully acknowledge all individuals who contributed to data collection and all respondents who participated in the study. ChatGPT (OpenAI) was utilised to support language editing, manuscript restructuring, and the rewriting of selected sections. All AI-assisted text was reviewed, verified, and revised by the authors, who take full responsibility for the final content. Data Availability The datasets for this study are not publicly available, but can be made available upon request. References World Health Organisation. Exclusive breastfeeding for optimal growth, development and health of infants. WHO; 2023. Service GS, Service GH. ICF. Ghana Demographic and Health Survey 2022: Summary Report. Accra: GSS, GHS, ICF; 2024. Mensah KA, Acheampong E, Anokye FO, Okyere P, Appiah-Brempong E, Adjei RO. Factors influencing the practice of exclusive breastfeeding among nursing mothers in a peri-urban district in Ghana. Int Breastfeed J. 2017;12:20. Thompson GH, Frimpong JB, Adjorlolo S, Amu H. Factors associated with exclusive breastfeeding for the first six months among mothers in Ghana: evidence from the 2014 Ghana Demographic and Health Survey. PLOS Glob Public Health. 2024;4(1):e0002706. Republic of Ghana. Labour Act, 2003 (Act 651). Accra: Ghana Publishing; 2003. International Labour Organization. Maternity Protection Convention, 2000 (No. 183) and Recommendation (No. 191). Geneva: ILO; 2000. Creswell JW, Creswell JD. Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. 5th ed. Thousand Oaks, CA: Sage; 2018. Cochran WG. Sampling Techniques. 3rd ed. New York: Wiley; 1977. Nanishi K, Green J, Shibanuma A, Hongo H, Okawa S, Tabuchi T. Challenging the utility of 24-hour recall of exclusive breastfeeding in Japan. BMJ Glob Health. 2023;8(12):e013737. Vilar Compte M, Hernández Cordero S, Rollins N, Brownell EA, Parides M, Baker P. Breastfeeding at the workplace: a systematic review of interventions to improve workplace environments to facilitate breastfeeding among working women. Int J Equity Health. 2021;20(1):110. Alive. and Thrive. Factors influencing the practice of exclusive breastfeeding in West Africa: Literature review. Alive and Thrive; 2022. Yiran GSA, Teye JK. Accessibility and utilisation of maternal health services by migrant female head porters in Accra, Ghana. Matern Child Health J. 2014;18(8):1924–33. Sudfeld CR, Fawzi WW, Lahariya C. Peer support and exclusive breastfeeding duration in low and middle income countries: a systematic review and meta-analysis. PLoS ONE. 2012;7(9):e45143. McLeroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Educ Q. 1988;15(4):351–77. Bronfenbrenner U. The Ecology of Human Development: Experiments by Nature and Design. Cambridge, MA: Harvard University Press; 1979. Republic of Ghana. Breastfeeding Promotion Regulations, 2000 (L.I. 1667). Accra: Ghana Publishing; 2000. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 13 May, 2026 Reviewers invited by journal 23 Apr, 2026 Editor assigned by journal 11 Apr, 2026 Submission checks completed at journal 11 Apr, 2026 First submitted to journal 09 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9372498","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":633648483,"identity":"0d341f07-0a88-4e36-aae1-cb0e35c380ec","order_by":0,"name":"Rehana Ama Obosu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA00lEQVRIiWNgGAWjYFACHjCZAMSMDxgYDpCmhdmAZC1sEkRpMW/vPfi5oMYmj5//jFk1T80dOX4G5oePbuDRInPmXLL0jGNpxZIzcsxu8xx7ZizZwGZsnINHi4REjoE0D9vhxA03eIBaQIwDPGzSeLXIvzH+zfMPqPL8GbNiMIOgFgkeM2neNpDKHDNmCIOQFp4cM2vePpBfgHhu32FjyWZCfmE/Y3yb5xsoxA5v/PDm22E5fvbmh4/xaUEBTOA4YiZWOQgw/iBF9SgYBaNgFIwYAABLGkk521QzFwAAAABJRU5ErkJggg==","orcid":"","institution":"Kwame Nkrumah University of Science and Technology","correspondingAuthor":true,"prefix":"","firstName":"Rehana","middleName":"Ama","lastName":"Obosu","suffix":""},{"id":633648486,"identity":"b29241a6-353b-48d4-b303-467de05e91cf","order_by":1,"name":"Daniel Buor","email":"","orcid":"","institution":"Kwame Nkrumah University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Daniel","middleName":"","lastName":"Buor","suffix":""},{"id":633648487,"identity":"f5420863-596c-4a14-93f5-b749d3dbf35b","order_by":2,"name":"Seth Agyemang","email":"","orcid":"","institution":"Kwame Nkrumah University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Seth","middleName":"","lastName":"Agyemang","suffix":""},{"id":633648489,"identity":"c1c7d1e8-7620-4771-86be-828c3a46c4f4","order_by":3,"name":"David Forkuor","email":"","orcid":"","institution":"Kwame Nkrumah University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"David","middleName":"","lastName":"Forkuor","suffix":""}],"badges":[],"createdAt":"2026-04-09 21:23:58","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9372498/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9372498/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108449246,"identity":"c49ad7fa-82ae-41a7-855d-dc5755764a59","added_by":"auto","created_at":"2026-05-04 18:54:49","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":107756,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eSocial Ecological Model framework showing multilevel influences on exclusive breastfeeding among kayayei in Kumasi, Ghana. Source: Author’s construct based on McLeroy et al. (1988) [14] and Bronfenbrenner (1979) [15].\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9372498/v1/7412ae9f1130be00ae4621bc.png"},{"id":108449248,"identity":"fd4510f1-79e9-4cea-b11a-e1e5d69406a3","added_by":"auto","created_at":"2026-05-04 18:54:50","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":466099,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eMap of the Kumasi Metropolitan Assembly (KMA) showing the four study sites (red dots): Kejetia, Adum, Asafo, and Bantama. Inset maps show the location of the Ashanti Region within Ghana and KMA within the Ashanti Region—source: Ghana Statistical Service (2020).\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-9372498/v1/b0a8ea709a6f966a08d36ff0.png"},{"id":108493106,"identity":"8210aba1-6feb-4f56-9e1c-bef2d2d7a899","added_by":"auto","created_at":"2026-05-05 09:59:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":884498,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9372498/v1/8d6186f4-f998-4b61-8bb2-ab9bb94d13e7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eWork, Protection, and Exclusive Breastfeeding Among Migrant Female Head Porters (\u003cem\u003eKayayei\u003c/em\u003e) in Urban Ghana: A Mixed-Methods Study\u003c/p\u003e","fulltext":[{"header":"1. Background","content":"\u003cp\u003eExclusive breastfeeding (EBF), providing only breast milk for the first six months of life, except oral rehydration salts, vitamins, and medications, is among the most effective interventions for child survival and maternal health [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The World Health Organisation (WHO) recommends EBF initiation within the first hour of birth, exclusive breastfeeding for 6 months, and continued breastfeeding alongside complementary foods for up to 2 years [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In Ghana, the 2022 Demographic and Health Survey estimates a national EBF rate of approximately 53% among infants aged 0\u0026ndash;5 months, suggesting progress but masking wide variation across social groups [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA growing body of research in Ghana shows that EBF is shaped not only by maternal knowledge but by social support, economic resources, work conditions, and health service contact [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Yet most breastfeeding research and promotion implicitly assumes that mothers have stable housing, predictable schedules, privacy, and supportive caregiving arrangements. For mothers in informal employment, where income is earned by the hour or the trip, these assumptions often do not hold.\u003c/p\u003e \u003cp\u003eThis study focuses on \u003cem\u003ekayayei\u003c/em\u003e, migrant female head porters who carry goods for a fee in major market settings across urban Ghana. Their work is physically demanding, informal, and time-sensitive: earnings depend on constant availability and physical endurance. Motherhood in this context involves a direct, daily conflict between feeding on demand and earning enough to cover food, shelter, and childcare. Formal maternity protections, paid leave, nursing breaks, and designated breastfeeding spaces are built into Ghana's Labour Act for regulated employment [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] and are supported by international labour standards [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], but do not extend to informal workers without a fixed employer. \u003cem\u003eKayayei\u003c/em\u003e are therefore among the clearest cases in which the policy conditions assumed by breastfeeding promotion do not exist.\u003c/p\u003e \u003cp\u003eThe present study makes three contributions. First, it distinguishes between self-reported EBF and WHO-consistent six-month EBF in this population, revealing how reported practice can mask early discontinuation. Second, it estimates predictors at the individual, interpersonal, and organisational levels using staged regression modelling aligned with the Social Ecological Model (SEM), enabling comparisons across levels of influence. Third, it uses qualitative evidence from mothers and stakeholders to identify implementation gaps that explain observed patterns and to propose interventions that align with market realities.\u003c/p\u003e"},{"header":"2. Conceptual Framework","content":"\u003cp\u003eThis study is guided by the Social Ecological Model (SEM), originally proposed by McLeroy et al. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] and building on Bronfenbrenner\u0026rsquo;s ecological systems theory [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The SEM conceptualises health behaviour as the outcome of interacting influences operating at multiple levels rather than as the product of individual choice alone. Applied to EBF, this framework (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) treats sustained breastfeeding not as a simple maternal decision but as a practice shaped simultaneously by individual capacity, social support structures, community and work environments, and broader policy conditions.\u003c/p\u003e \u003cp\u003eAt the individual level, the framework highlights maternal characteristics that shape capacity and confidence, including age, educational attainment, economic resources, and knowledge of EBF. Among \u003cem\u003ekayayei\u003c/em\u003e, low educational attainment, income insecurity, and food poverty operate at this level to constrain the practical ability to sustain exclusive feeding even when the intention is present.\u003c/p\u003e \u003cp\u003eAt the interpersonal level, the framework focuses on close relationships and social networks that shape the availability of care options and emotional support. For \u003cem\u003ekayayei\u003c/em\u003e, who are predominantly migrants separated from kin networks, this level is often characterised by instability: many women manage both income generation and infant care without a partner or family member in proximity. Union status, social support, and household composition operate at this level.\u003c/p\u003e \u003cp\u003eAt the organisational level, the framework draws attention to the settings in which daily life occurs and the rules and routines that govern them. For \u003cem\u003ekayayei\u003c/em\u003e, the market is the primary organisational context. Working hours, the availability of breaks, access to a private breastfeeding space, and the perceived compatibility of EBF with market work all operate at this level. These conditions are not incidental features of individual circumstances; they are structural properties of informal market labour that apply to women in this occupation.\u003c/p\u003e \u003cp\u003eAt the policy level, the framework considers the broader institutional environment within which EBF promotion operates. Ghana has national breastfeeding promotion regulations and labour protections for nursing mothers in formal employment [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, these protections do not extend to informal workers without a contract of employment. The policy level in this study is therefore characterised by what might be called a protection gap: EBF is promoted as a standard, yet the institutional conditions are not put in place for those in the most precarious work arrangements.\u003c/p\u003e \u003cp\u003eThe staged regression models used in this study are directly aligned with the SEM. Model 1 estimates individual-level associations; Model 2 adds interpersonal and service-access factors; and Model 3 incorporates organisational and work-related variables. This structure allows the analysis to show where constraints are strongest across levels, and where targeted intervention is most likely to improve EBF outcomes.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"3. Methods","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Study design and setting\u003c/h2\u003e \u003cp\u003eThis study used an explanatory sequential mixed-methods design [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. A cross-sectional survey was conducted first to estimate EBF prevalence and identify statistical predictors; qualitative data collection followed to explain and contextualise the quantitative findings. The study was conducted in the Kumasi Metropolitan Assembly (KMA), Ghana\u0026rsquo;s second-largest city, at four principal market sites where \u003cem\u003ekayayei\u003c/em\u003e are highly concentrated: Kejetia, Adum, Asafo, and Bantama (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Participants and sampling\u003c/h2\u003e \u003cp\u003eThe quantitative sample comprised 398 kayayei mothers aged 15\u0026ndash;49 with at least one child aged 24 months or below who were actively working in the selected markets at the time of data collection. Because no sampling frame exists for this mobile population, the study used purposive sampling to select market sites and convenience sampling to recruit eligible respondents within them. Sample size was calculated using Cochran's formula for unknown populations, with a 95% confidence level, a 5% margin of error, and the national EBF estimate of 53% from the 2022 GDHS, yielding a minimum of 383, increased to 398 to account for non-response participants [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFor the qualitative phase, ten key informants were purposively selected: two assemblymen, one district assembly representative, two market queens, one representative from the Ministry of Gender, Children and Social Protection, and four midwives. Two focus group discussions (FGDs) were conducted with \u003cem\u003ekayayei\u003c/em\u003e mothers \u0026mdash; FGD 1 with 12 younger women (aged 22\u0026ndash;36) and FGD 2 with 8 older women (aged 38\u0026ndash;49).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Measures\u003c/h2\u003e \u003cp\u003eThe primary outcome was WHO-consistent EBF: whether the respondent reported feeding her most recent child only breast milk for the full six months (coded 1\u0026thinsp;=\u0026thinsp;yes, 0\u0026thinsp;=\u0026thinsp;no). This was assessed through retrospective maternal recall during a face-to-face interview. Because the study enrolled mothers with children aged 24 months or below, the maximum recall window was 24 months; restricting inclusion to children under 24 months was a deliberate strategy to limit recall decay and reduce the likelihood of telescoping bias, consistent with standard DHS practice for infant feeding indicators. Mothers were asked to reconstruct their most recent child\u0026rsquo;s feeding history from birth, including when liquids other than breast milk, like water, formula, or porridge, were first introduced. WHO-consistent six-month EBF was coded as achieved only when the respondent reported no introduction of any other liquid or food during the first six months. Self-reported EBF and self-rated EBF duration in months were retained as secondary indicators to allow comparison between claimed practice and WHO-consistent practice. The gap between these two measures, documented in the results, provides an internal validity check for the measurement approach. Secondary indicators included self-reported EBF practice and EBF duration in months.\u003c/p\u003e \u003cp\u003ePredictors were organised by SEM level. Individual-level variables included maternal age, educational attainment, union/marital status, number of children, daily income, and daily expenditure. Interpersonal and service-access variables included social support, antenatal care attendance, postnatal care, household headship, and accommodation type. Organisational and work-related variables included daily working hours (continuous, in hours), break availability (continuous, measured as total break time in hours per day), access to a clean private breastfeeding space (binary), whether EBF information was encountered at work (binary), whether breastfeeding training had been received (binary), and whether the respondent perceived EBF as affecting her ability to work (binary). For continuous predictors, odds ratios reflect a one-unit change: one additional hour of work, one additional hour of breaks per day, and one additional GHS of daily expenditure, respectively. The social support variable was operationalised as a composite score based on respondents\u0026rsquo; ratings of support from partners, family, and community members; the scale was coded so that higher scores indicate lower levels of support, making this variable an inverse measure of social protection.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Data analysis\u003c/h2\u003e \u003cp\u003eDescriptive statistics summarised socio-demographic characteristics, work conditions, and EBF indicators. Binary logistic regression estimated associations between predictors and WHO-consistent EBF across three staged models reflecting SEM levels: Model 1 (individual characteristics), Model 2 (adding interpersonal and service-access variables), and Model 3 (the fully adjusted model including organisational and work-related factors). Results are reported as odds ratios (ORs) with 95% confidence intervals. Model fit was assessed using the Nagelkerke R\u0026sup2;. Qualitative data were analysed thematically, with findings used to interpret and extend the quantitative results.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Ethics\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003e was granted by the Humanities and Social Sciences Research Ethics Committee of Kwame Nkrumah University of Science and Technology (Ref: HuSSREC/AP/14/VOL. 3). The study was conducted in accordance with the Declaration of Helsinki. Participation was voluntary, and informed consent was obtained from all participants before data collection. Anonymity is preserved throughout; participants are identified by role only.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Socio-demographic and work profile\u003c/h2\u003e \u003cp\u003eRespondents reflected the social location of migrant informal workers in urban markets. Most had no formal education (57.3%), were Muslim (73.9%), and worked exclusively as \u003cem\u003ekayayei\u003c/em\u003e (96%). Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e summarise key characteristics. Working days were long (mean 12.95 hours), breaks were minimal (mean 1.91 hours), and daily income (GHS 47.70) substantially exceeded daily expenditure (GHS 27.64), indicating that most earnings were absorbed by basic survival costs. Most women lived in group homes, kiosks, or open spaces with limited privacy, and nearly 90% reported very low food security. Additional key characteristics: 96% were migrants from northern Ghana; 69.8% were in a marital or union relationship; 44.0% lived in couple households with children; 28.1% were single mothers; and 27.1% lived in extended family households.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSelected socio-demographic characteristics (N\u0026thinsp;=\u0026thinsp;398)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic / Category\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation: No formal education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e57.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation: Basic education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation: Secondary or vocational\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation: Tertiary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReligion: Muslim\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e73.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReligion: Christian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eWork and economic profile (N\u0026thinsp;=\u0026thinsp;398)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndicator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDaily working hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreak time (hours)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDaily income (GHS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e47.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20.90\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDaily expenditure (GHS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e4.2 EBF awareness, prevalence, and the six-month gap\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e summarises EBF awareness and practice. Although 79.9% of respondents had heard of EBF, only 2.5% rated themselves as well-informed about it. Self-reported EBF was high (95.5%), but WHO-consistent six-month EBF was 12.1%, with a mean duration of 2.86 months. This 83-percentage-point gap between reported and sustained practice is the study's central empirical finding.\u003c/p\u003e \u003cp\u003eQualitative data revealed that the conceptual mismatch was a significant driver. Many mothers described EBF as giving breast milk before introducing other feeds, without a clear understanding that six months of exclusivity is the recommendation. As one participant explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"My friend told me that as long as you breastfeed, even for just a few days without adding anything, it is called exclusive breastfeeding. So let us say I start with two days of breastfeeding, and then maybe for some reason I give the baby water and come back to give it some more days \u0026mdash; as long as I have given the breast for a day without water, I have done exclusively.\" (39 years, FGD 2)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHealth workers corroborated this pattern, noting that most mothers had already introduced supplementary feeds by the time they appeared at postnatal visits.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEBF awareness and prevalence (N\u0026thinsp;=\u0026thinsp;398)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndicator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEver heard of EBF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e318\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e79.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-reported EBF with last child\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e380\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e95.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWHO-consistent six-month EBF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-rated as well-informed about EBF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e4.3 Constraints to EBF practice\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e reports the distribution of self-reported constraints. Stress and fatigue, financial problems, and inadequate maternal nutrition were the most commonly cited barriers. Long working hours, time constraints, and workplace environment were also frequently reported. Qualitative accounts consistently linked early supplementation to survival rather than choice:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"I stopped breastfeeding at 3 months because I had to go back to work and could not keep bringing the baby to breastfeed. You know how difficult our work is. If I decide to take the baby everywhere and breastfeed, it is tiring and difficult. So, I stopped.\" (39 years, FGD 2)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eStakeholders confirmed that no specific policy or programme existed for \u003cem\u003ekayayei\u003c/em\u003e in market settings. One assemblyman stated:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"At the district level, we do not have any specific policies that address the needs of breastfeeding kayayei. If we are to help them in anything, it is from our own pockets.\" (KII, Assemblyman)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSelf-reported constraints affecting ability to practise EBF (N\u0026thinsp;=\u0026thinsp;398, % reporting as a barrier)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstraint\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e% reporting as a barrier\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStress and fatigue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e44.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinancial constraints\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInadequate maternal nutrition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWork-related demands\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e36.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInsufficient breastmilk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLong working hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLack of support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime constraints\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorkplace environment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e4.4 Predictors of WHO-consistent six-month EBF\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e presents results from the three-stage logistic regression. The pattern is consistent with the SEM framework: constraints accumulate across levels, and organisational factors in Model 3 are the strongest predictors.\u003c/p\u003e \u003cp\u003eAt the individual level (Model 1), older age was negatively associated (OR 0.84, 95% CI 0.75\u0026ndash;0.95, p\u0026thinsp;=\u0026thinsp;0.004), while basic education (OR 2.94, 95% CI 1.28\u0026ndash;6.74, p\u0026thinsp;=\u0026thinsp;0.011) and daily expenditure (OR 1.19, 95% CI 1.07\u0026ndash;1.33, p\u0026thinsp;=\u0026thinsp;0.001) were positively associated with six-month EBF. The tertiary education estimate in Model 1 (OR 19.19, 95% CI 1.05\u0026ndash;352.10) was also significant but carries a very wide confidence interval due to the very small number of tertiary-educated respondents (n\u0026thinsp;=\u0026thinsp;2); it should be treated as unreliable.\u003c/p\u003e \u003cp\u003eWhen interpersonal and service-access variables were added (Model 2), not being in a union became significant (OR 0.04, 95% CI\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u0026ndash;0.55, p\u0026thinsp;=\u0026thinsp;0.016), and lower social support was strongly negatively associated (OR 0.03, 95% CI\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u0026ndash;0.29, p\u0026thinsp;=\u0026thinsp;0.002). Daily expenditure remained significant (OR 1.21, 95% CI 1.05\u0026ndash;1.39, p\u0026thinsp;=\u0026thinsp;0.011).\u003c/p\u003e \u003cp\u003eIn the fully adjusted model (Model 3), the strongest predictors were at the organisational level. Each additional working hour reduced the odds of six-month EBF (OR 0.81, 95% CI 0.71\u0026ndash;0.93, p\u0026thinsp;=\u0026thinsp;0.002). Breaks were protective (OR 1.62, 95% CI 1.16\u0026ndash;2.25, p\u0026thinsp;=\u0026thinsp;0.005). Perceiving EBF as incompatible with work was the most powerful inverse predictor (OR\u0026thinsp;\u0026lt;\u0026thinsp;0.01, 95% CI\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u0026ndash;0.04, p\u0026thinsp;=\u0026thinsp;0.001). Being outside a union (OR\u0026thinsp;\u0026lt;\u0026thinsp;0.01, p\u0026thinsp;=\u0026thinsp;0.007), low social support (OR 0.03, p\u0026thinsp;=\u0026thinsp;0.001), and daily expenditure (OR 1.33, p\u0026thinsp;=\u0026thinsp;0.008) remained significant. The education estimate for tertiary-level respondents was very large (OR 71.71, 95% CI 2.41\u0026ndash;2132.01) and should be treated with particular caution given the very small cell size. Similarly, the near-zero odds ratios for union status (OR\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and perceived EBF-work incompatibility (OR\u0026thinsp;\u0026lt;\u0026thinsp;0.01) in Model 3 are consistent with near-complete separation in the logistic model for these predictors, that is, virtually all women in the reference category met the six-month criterion while virtually none in the exposed category did. These estimates confirm very strong associations, but their precise magnitude is unreliable and should not be interpreted literally.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLogistic regression predicting WHO-consistent six-month EBF (N\u0026thinsp;=\u0026thinsp;398)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePredictor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR [95% CI] M1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOR [95% CI] M2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOR [95% CI] M3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.84 [0.75, 0.95]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.004**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.92 [0.78, 1.10]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.366\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.86 [0.70, 1.06]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.158\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot in union (ref: in union)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.34 [0.07, 1.76]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.04 [0.00, 0.55]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.016*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01 [\u0026lt;\u0026thinsp;0.01, 0.18]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.007**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBasic education (ref: none)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.94 [1.28, 6.74]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.011*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.38 [1.46, 27.99]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.014**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5.45 [0.82, 36.14]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.079\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTertiary education (ref: none)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19.19 [1.05, 352.10]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.046*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.87 [0.02, 47.69]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.949\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e71.71 [2.41, 2132.01]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.008**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDaily expenditure (GHS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.19 [1.07, 1.33]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.001**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.21 [1.05, 1.39]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.011*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.33 [1.08, 1.64]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.008**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial support score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.03 [0.00, 0.29]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.002**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.03 [0.00, 0.44]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.001**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDaily working hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.81 [0.71, 0.93]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.002**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreaks during work\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.62 [1.16, 2.25]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.005**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEBF perceived to affect work (ref: no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01 [\u0026lt;\u0026thinsp;0.01, 0.04]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.001**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eOR\u0026thinsp;=\u0026thinsp;odds ratio; CI\u0026thinsp;=\u0026thinsp;confidence interval; \u0026ndash; = not included in this model. * p\u0026thinsp;\u0026lt;\u0026thinsp;0.05; ** p\u0026thinsp;\u0026lt;\u0026thinsp;0.01. Tertiary education estimates have very wide CIs due to small cell sizes; interpret with caution. Social support score coded so that higher scores indicate lower support received.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"5. Discussion","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e5.1 Overview: findings through the Social Ecological Model\u003c/h2\u003e \u003cp\u003eThe findings of this study are interpreted through the Social Ecological Model (SEM) outlined in Section \u003cspan refid=\"Sec2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The SEM predicts that health behaviour is shaped by interacting influences at the individual, interpersonal, organisational, and policy levels, and that constraints at any level can undermine practice even when knowledge and intent are present [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The 83-percentage-point gap between self-reported EBF (95.5%) and WHO-consistent six-month EBF (12.1%) is the central finding, and the staged regression confirms that constraints accumulate across SEM levels. Individual-level resources matter, but interpersonal conditions, especially organisational work factors, are the decisive predictors. This pattern confirms the SEM\u0026rsquo;s core proposition: that individual awareness cannot sustain EBF when the surrounding environment makes it infeasible. Within this overall picture, the gap between reported and sustained EBF has two likely drivers. First, many mothers did not share the technical definition of EBF. Qualitative accounts showed that women often understood EBF as any period of exclusive milk-giving rather than six continuous months, consistent with evidence that 24-hour recall measures and lay understandings inflate EBF estimates relative to sustained duration [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Second, even mothers with accurate knowledge described the practical impossibility of exclusivity once they returned to market work. Both explanations point to the level above the individual: within this sample, the binding constraint appears to be not what mothers know but what their environment allows.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e5.2 Organisational level: work intensity and the absence of protection\u003c/h2\u003e \u003cp\u003eAt the organisational level, the SEM focuses on the settings in which daily life occurs and the rules and routines that govern them. For \u003cem\u003ekayayei\u003c/em\u003e, that setting is the market. The most distinctive finding of this study is that organisational-level variables, working hours, breaks, and perceived compatibility of EBF with work, were the strongest predictors of WHO-consistent EBF in the final model and remained significant independently of individual and interpersonal factors. This is precisely what the SEM predicts: organisational conditions can override individual-level resources when they are sufficiently constraining. In regulated employment, maternity protections and nursing breaks are legal entitlements that soften this constraint. For informal workers with no identifiable employer, those protections do not automatically apply [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], and the market provides no equivalent. Within the markets studied, the \u003cem\u003ekayayei\u003c/em\u003e context therefore suggests an SEM case where the organisational level is almost entirely unprotected.\u003c/p\u003e \u003cp\u003eThe finding that perceived incompatibility with work, rather than measured hours alone, is the strongest predictor aligns with qualitative accounts in which mothers described supplementation as a strategy to keep earning, not a rejection of breastfeeding. This distinction matters for intervention design: it shows that the organisational barrier operates through perception and economic fear, not just time. Within this sample, mothers did not appear to stop because they lacked information; the evidence indicates they stopped because the market environment made exclusivity economically costly. This is consistent with evidence that lactation spaces and protected breaks are reliably associated with longer EBF duration [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], the same SEM organisational conditions that are absent for \u003cem\u003ekayayei\u003c/em\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e5.3 Individual level: economic resources and the material conditions of breastfeeding\u003c/h2\u003e \u003cp\u003eAt the individual level, the SEM highlights maternal characteristics that shape capacity and confidence. Daily expenditure was positively and consistently associated with six-month EBF across all three regression models. It is best understood not as income in isolation but as a proxy for the material resources that enable sustained EBF at the individual level: adequate food and hydration, the ability to take rest, access to transport for health services, and the option to secure informal childcare support. The SEM predicts that individual-level resources mediate the relationship between structural conditions and behaviour, and the data from this sample support this prediction. Among women with very low food security (89.9% of this sample), expenditure capacity cushions against the immediate economic cost of pausing work to breastfeed [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Mothers who reported inadequate nutrition also cited perceived milk insufficiency as grounds for early supplementation, connecting food insecurity at the individual level directly to milk production and early discontinuation [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Notably, education was also a significant individual-level predictor, consistent with evidence across Ghana that maternal education strengthens the ability to interpret health guidance and seek appropriate support [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e5.4 Interpersonal level: relational support, partnership, and migrant isolation\u003c/h2\u003e \u003cp\u003eAt the interpersonal level, the SEM focuses on close relationships and social networks that shape the availability of time, care options, and emotional support. Union status and social support score were both significantly associated with six-month EBF in the adjusted model. Women outside union relationships had very low odds of sustained EBF, consistent with evidence across Ghana that partner support and shared care arrangements influence breastfeeding duration [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. For \u003cem\u003ekayayei\u003c/em\u003e, the interpersonal-level deficit is compounded by migration: most women are separated from kin networks and must manage both income generation and infant care entirely on their own. The SEM predicts that weak interpersonal support increases vulnerability to barriers at other levels, and the data from this sample are consistent with this. The social support score remained significant in the fully adjusted model even after organisational variables were included, demonstrating that interpersonal-level protection and organisational-level protection operate independently and cumulatively. Within this sample, mothers without either relational or organisational protection were at particularly high risk of early EBF discontinuation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e5.5 Policy level: the institutional gap and the limits of clinic-based support\u003c/h2\u003e \u003cp\u003eAt the policy level, the SEM highlights the institutional environment within which all other levels operate. Ghana has national breastfeeding promotion regulations and nursing break entitlements within the Labour Act for formal employment [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e18\u003c/span\u003e], but these protections do not extend to informal workers without a fixed employer. The result is a policy-level gap that the SEM framework makes legible: the outermost level of the system, which should buffer and support conditions at inner levels, is effectively absent for \u003cem\u003ekayayei\u003c/em\u003e. Health facilities were the primary source of EBF information (61.3% of the 318 who had heard of EBF, equivalent to approximately 49% of all respondents), yet clinic-based counselling alone was not sufficient to sustain EBF. Qualitative evidence from health workers confirmed that standard postnatal follow-up assumes stable housing, predictable schedules, and the ability to attend appointment-based sessions, conditions that \u003cem\u003ekayayei\u003c/em\u003e often cannot meet. This is consistent with broader evidence on migrant mothers in Ghana showing that structural and mobility barriers limit use of maternal health services [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe qualitative data confirmed a policy vacuum at all governance levels: no directive existed at the district, municipal, or ministry levels that explicitly addressed breastfeeding support for \u003cem\u003ekayayei\u003c/em\u003e. Governance actors acknowledged awareness of the problem but reported a lack of resources and programme ownership. This policy silence is not simply a resource constraint; it reflects a structural mismatch between how maternal health policy is designed (around stable households and formal employment) and how \u003cem\u003ekayayei\u003c/em\u003e live and work. The SEM would predict that when the policy level fails to create enabling conditions, individual-level knowledge and interpersonal support cannot compensate. The data from this sample are consistent with this prediction.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e5.6 Cross-level synthesis and implications for intervention\u003c/h2\u003e \u003cp\u003eThe SEM framework shows that low sustained EBF among \u003cem\u003ekayayei\u003c/em\u003e is not explained by any single level but by the cumulative failure of conditions across all four. At the policy level, there is no protection for informal market mothers. At the organisational level, work is long, breaks are minimal, and there is no space for breastfeeding. At the interpersonal level, migration has severed kin networks, and many women lack partner support. At the individual level, food insecurity and inadequate expenditure constrain the material basis for sustained feeding. The regression models confirm this layered picture: each level adds explanatory power, and the full model explains 68.6% of the variance. This means that single-level interventions such as counselling alone are unlikely to be sufficient. The SEM logic calls for a matched multi-level response. At the organisational level, protected breastfeeding spaces within markets and locally enforceable break norms address the dominant constraints directly; a systematic review confirms that such workplace-level protections are linked to longer EBF duration [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. At the interpersonal level, peer counsellors embedded in market settings can compensate partially for absent kin networks; peer support has been shown to reduce early EBF discontinuation in low- and middle-income countries [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. At the individual level, economic buffering, such as modest food support or social protection linkages, addresses the expenditure-EBF association. At the policy level, explicit recognition of migrant informal worker mothers as a target group would fill the current policy vacuum, establishing clear ownership and accountability. Each of these components responds to a specific SEM-identified constraint; together, within market settings comparable to those studied, they are likely to represent the minimum conditions under which the WHO six-month recommendation becomes more achievable.\u003c/p\u003e \u003cp\u003eIn summary, the SEM framework transforms this study\u0026rsquo;s findings from a set of statistical associations into a coherent account of why sustained EBF is rare among \u003cem\u003ekayayei\u003c/em\u003e. It is rare not because mothers do not value breastfeeding, most do, but because the conditions at every level of their social ecology work against it. In contexts comparable to those studied here, closing the gap between reported and WHO-consistent EBF is likely to require interventions that operate at the same levels where the constraints are produced.\u003c/p\u003e \u003c/div\u003e"},{"header":"6. Strengths and Limitations","content":"\u003cp\u003eThis study has several strengths. First, the mixed-methods design is a notable asset; the combination of cross-sectional survey data and qualitative evidence from focus group discussions and key informant interviews allowed statistical associations to be interpreted through the lived experiences of mothers and the institutional accounts of governance actors, producing a richer and more actionable analysis than either method alone would have provided. Second, the sample size of 398 is adequate for the regression models used and is large relative to most studies of this specific and hard-to-reach population. Recruiting \u003cem\u003ekayayei\u003c/em\u003e at their place of work across four major market sites improved coverage across different market settings within the KMA. Third, the use of WHO-consistent six-month EBF as the primary outcome, alongside self-reported EBF as a secondary measure, is a methodological strength: it enabled the study to document the awareness-practice gap directly and to base the analysis on the technically accurate definition of EBF rather than self-classification, which is commonly subject to inflation. Fourth, the study is grounded in the Social Ecological Model, which provides a theoretically coherent structure for organising predictors across multiple levels and for aligning the intervention recommendations with the level at which each constraint operates. Fifth, restricting enrolment to mothers of children aged 24 months or below was a deliberate strategy to reduce recall decay, consistent with standard DHS practice for infant feeding indicators.\u003c/p\u003e \u003cp\u003eNevertheless, this study also has limitations. The cross-sectional design means that associations cannot be interpreted as causal. Self-reported measures of EBF may be affected by recall bias and conceptual confusion about the definition of exclusivity, and the gap between reported and WHO-consistent EBF suggests that measurement inflation is likely. The use of convenience sampling in the absence of a sampling frame limits statistical generalisability, though the underlying constraints of informal market work are likely to be similar across comparable urban settings. Finally, the cross-sectional design cannot identify the precise timing of supplementation, which limits understanding of when, within the six months, the constraints become decisive.\u003c/p\u003e"},{"header":"7. Conclusions","content":"\u003cp\u003eAmong \u003cem\u003ekayayei\u003c/em\u003e in Kumasi, awareness of EBF is widespread, but WHO-consistent six-month exclusivity is rare. Within this sample, the evidence indicates that low sustained EBF is better understood as a feasibility and protection problem than as a knowledge deficit. Work conditions, working hours, breaks, and the perception that EBF conflicts with earning were the strongest predictors of sustained EBF in this sample, and they operated independently of individual-level factors. Relational insecurity, economic vulnerability, and the absence of targeted institutional support compound these constraints.\u003c/p\u003e \u003cp\u003eClosing this gap requires market-level action alongside and beyond facility counselling: protected breastfeeding spaces, locally enforceable break norms, market-based postnatal outreach, peer counsellor models, and economic support for postpartum mothers in high-risk circumstances. These interventions do not require complex systems, but they do require acknowledging that markets function as care spaces for migrant mothers and that the conditions for sustaining EBF cannot be assumed to exist there without deliberate action.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEBF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eExclusive Breastfeeding\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSEM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSocial Ecological Model\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eKMA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eKumasi Metropolitan Assembly\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organisation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGDHS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGhana Demographic and Health Survey\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFGD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFocus Group Discussion\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eKII\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eKey Informant Interview\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOdds Ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConfidence Interval\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGHS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGhana Cedis.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e \u003cp\u003e Ethical approval was granted by the Humanities and Social Sciences Research Ethics Committee of Kwame Nkrumah University of Science and Technology (Ref: HuSSREC/AP/14/VOL. 3). Written or verbal informed consent was obtained from all participants.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests:\u003c/h2\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThis study received no external funding.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eRAO designed the study, collected data, performed analysis, and wrote the manuscript. DB, SA, and DF supervised the research and contributed critical revisions. All authors approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements:\u003c/h2\u003e \u003cp\u003eWe gratefully acknowledge all individuals who contributed to data collection and all respondents who participated in the study. ChatGPT (OpenAI) was utilised to support language editing, manuscript restructuring, and the rewriting of selected sections. All AI-assisted text was reviewed, verified, and revised by the authors, who take full responsibility for the final content.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e \u003cp\u003eThe datasets for this study are not publicly available, but can be made available upon request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organisation. Exclusive breastfeeding for optimal growth, development and health of infants. WHO; 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eService GS, Service GH. ICF. Ghana Demographic and Health Survey 2022: Summary Report. Accra: GSS, GHS, ICF; 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMensah KA, Acheampong E, Anokye FO, Okyere P, Appiah-Brempong E, Adjei RO. Factors influencing the practice of exclusive breastfeeding among nursing mothers in a peri-urban district in Ghana. Int Breastfeed J. 2017;12:20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThompson GH, Frimpong JB, Adjorlolo S, Amu H. Factors associated with exclusive breastfeeding for the first six months among mothers in Ghana: evidence from the 2014 Ghana Demographic and Health Survey. PLOS Glob Public Health. 2024;4(1):e0002706.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRepublic of Ghana. Labour Act, 2003 (Act 651). Accra: Ghana Publishing; 2003.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInternational Labour Organization. Maternity Protection Convention, 2000 (No. 183) and Recommendation (No. 191). Geneva: ILO; 2000.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCreswell JW, Creswell JD. Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. 5th ed. Thousand Oaks, CA: Sage; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCochran WG. Sampling Techniques. 3rd ed. New York: Wiley; 1977.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNanishi K, Green J, Shibanuma A, Hongo H, Okawa S, Tabuchi T. Challenging the utility of 24-hour recall of exclusive breastfeeding in Japan. BMJ Glob Health. 2023;8(12):e013737.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVilar Compte M, Hern\u0026aacute;ndez Cordero S, Rollins N, Brownell EA, Parides M, Baker P. Breastfeeding at the workplace: a systematic review of interventions to improve workplace environments to facilitate breastfeeding among working women. Int J Equity Health. 2021;20(1):110.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlive. and Thrive. Factors influencing the practice of exclusive breastfeeding in West Africa: Literature review. Alive and Thrive; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYiran GSA, Teye JK. Accessibility and utilisation of maternal health services by migrant female head porters in Accra, Ghana. Matern Child Health J. 2014;18(8):1924\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSudfeld CR, Fawzi WW, Lahariya C. Peer support and exclusive breastfeeding duration in low and middle income countries: a systematic review and meta-analysis. PLoS ONE. 2012;7(9):e45143.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcLeroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Educ Q. 1988;15(4):351\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBronfenbrenner U. The Ecology of Human Development: Experiments by Nature and Design. Cambridge, MA: Harvard University Press; 1979.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRepublic of Ghana. Breastfeeding Promotion Regulations, 2000 (L.I. 1667). Accra: Ghana Publishing; 2000.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-breastfeeding-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ibfj","sideBox":"Learn more about [International Breastfeeding Journal](http://internationalbreastfeedingjournal.biomedcentral.com/)","snPcode":"13006","submissionUrl":"https://submission.nature.com/new-submission/13006/3","title":"International Breastfeeding Journal","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"exclusive breastfeeding, kayayei, informal labour, migrant mothers, maternity protection, Social Ecological Model, Ghana, mixed methods","lastPublishedDoi":"10.21203/rs.3.rs-9372498/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9372498/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eExclusive breastfeeding (EBF) for the first six months is a core global recommendation, but feasibility is unequally distributed. In urban Ghana, migrant female head porters (\u003cem\u003ekayayei\u003c/em\u003e) work in informal market settings characterised by long hours, income insecurity, limited privacy, and an absence of maternity protection. This study examined how work conditions, economic resources, and institutional gaps shape EBF practice and duration among \u003cem\u003ekayayei\u003c/em\u003e in Kumasi.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eAn explanatory sequential mixed-methods design was used. The quantitative phase surveyed 398 \u003cem\u003ekayayei\u003c/em\u003e mothers using a structured interviewer-administered questionnaire. Binary logistic regression was estimated across three staged models aligned with a Social Ecological Model: individual characteristics (Model 1), interpersonal and service-access factors (Model 2), and organisational and work-related factors (Model 3). The qualitative phase used two focus group discussions with \u003cem\u003ekayayei\u003c/em\u003e mothers and ten key informant interviews with health workers and governance actors to interpret observed statistical patterns.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSelf-reported EBF was high (95.5%), but WHO-consistent six-month EBF was 12.1%, with a mean duration of 2.86 months (SD 1.70). Organisational factors were the strongest predictors of sustained EBF. Longer working hours reduced the odds of six-month EBF (OR 0.81, 95% CI 0.71\u0026ndash;0.93, p\u0026thinsp;=\u0026thinsp;0.002), while having breaks increased the odds (OR 1.62, 95% CI 1.16\u0026ndash;2.25, p\u0026thinsp;=\u0026thinsp;0.005). Perceiving EBF as incompatible with work was the strongest inverse predictor (OR\u0026thinsp;\u0026lt;\u0026thinsp;0.01, 95% CI\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u0026ndash;0.04, p\u0026thinsp;=\u0026thinsp;0.001). Being outside a marital or union relationship (OR\u0026thinsp;\u0026lt;\u0026thinsp;0.01, p\u0026thinsp;=\u0026thinsp;0.007), lower social support (OR 0.03, 95% CI\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u0026ndash;0.44, p\u0026thinsp;=\u0026thinsp;0.001), and lower daily expenditure (OR 1.33, 95% CI 1.08\u0026ndash;1.64, p\u0026thinsp;=\u0026thinsp;0.008) were also significantly associated with not meeting the six-month criterion. Qualitative findings showed that breastfeeding decisions were framed as survival strategies rather than failures, and that no targeted policy framework existed for \u003cem\u003ekayayei\u003c/em\u003e in market settings.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eLow sustained EBF among \u003cem\u003ekayayei\u003c/em\u003e reflects a protection gap rather than a knowledge deficit. Closing this gap requires market-based breastfeeding spaces, locally enforced breaks, outreach postnatal support, peer counsellors, and economic buffering for postpartum mothers. Counselling-only interventions are insufficient without structural protections that make EBF feasible in informal work settings.\u003c/p\u003e","manuscriptTitle":"Work, Protection, and Exclusive Breastfeeding Among Migrant Female Head Porters (Kayayei) in Urban Ghana: A Mixed-Methods Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-04 18:54:43","doi":"10.21203/rs.3.rs-9372498/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"210196807428651879214414862155783093899","date":"2026-05-13T15:29:13+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-23T14:53:33+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-11T07:46:36+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-11T07:46:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Breastfeeding Journal","date":"2026-04-09T21:17:43+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-breastfeeding-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ibfj","sideBox":"Learn more about [International Breastfeeding Journal](http://internationalbreastfeedingjournal.biomedcentral.com/)","snPcode":"13006","submissionUrl":"https://submission.nature.com/new-submission/13006/3","title":"International Breastfeeding Journal","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cccec0ba-b092-496d-b4b7-428d8405b644","owner":[],"postedDate":"May 4th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"210196807428651879214414862155783093899","date":"2026-05-13T15:29:13+00:00","index":29,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T18:54:43+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-04 18:54:43","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9372498","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9372498","identity":"rs-9372498","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}