The relationship between income-generating activities of women, dietary behaviours and feeding practices of infants and young children in urban Ghana

Background

Malnutrition is a major global public health concern especially in low and middle-income countries including Ghana, with children aged 6 to 23 months being particularly at risk. Complementary feeding practices are particularly important for this age group as this age group represents a “critical window of opportunity” for child growth and development. 

Maternal income-generating activities (IGAs) play an important role in the health and nutrition of infants and young children. Although maternal IGAs can increase women’s income and household food purchases, several studies suggest that maternal IGAs may decrease time spent on infant and young child feeding (IYCF) practices and subsequently affect child nutritional status. In Ghana, the relationship between maternal IGAs, IYCF practices and child nutritional status using a mixed methods approach remains unexplored. The aim of this study therefore was to examine the dietary behaviours and infant feeding practices among women with IGAs compared to those without IGAs in Oyarifa, Ghana.

Methodology

A community-based cross-sectional survey was carried out among mothers and infants aged 6-23 months in Oyarifa, near Accra, Ghana from March to July 2018. Participants were recruited through house-to-house visits using convenience sampling. Breastfeeding and complementary feeding practices were assessed with the World Health Organization’s IYCF indicators of minimum meal frequency (MMF), minimum dietary diversity (MDD), minimum acceptable diet (MAD) and exclusive breastfeeding. Nutritional status (stunting, wasting, underweight and overweight) were assessed among children using anthropometric measurements. Anthropometric measures of infant weight and length were used to calculate z-scores for length-for-age (LAZ), weight-for-age (WAZ) and weight-for-length (WHZ). Maternal height and weight were used to calculate body mass index (BMI). Qualitative data were collected using two focus group discussions with IGA and non-IGA mothers (22 mothers) and one-to-one semi-structured interviews with IGA and non-IGA mothers (18 mothers). 

Results

Of the 323 mother-infant pairs recruited, 174 mothers had an IGA and 149 mothers did not have an IGA. Among infants and young children, 10% were underweight, 3% were overweight, 5% were stunted and 13% were wasted and these malnutrition rates were attributed to factors including lack of time for food preparation, lack of time to visit health facilities and inadequate feeding. Among mothers, 33% were overweight, 14% were obese and 10% were underweight. There were no significant differences between women in IGA and non-IGA women in relation to giving colostrum, breastfeeding within the first hour, exclusive breastfeeding and consumption of iron-rich foods (p> 0.05). However, women in IGAs were more likely to meet the WHO recommendation of MDD (58% versus 39%, p< 0.001) and MAD (53% versus 36%, p= 0.003) than women who were not in an IGA. There were no significant differences observed between maternal IGA status and MMF. Multivariable logistic regression analyses showed that after controlling for maternal level of education, child age and head of household status of mothers, maternal IGA remained a significant predictor of meeting MDD (OR= 1.98, 95% CI: 1.21, 3.25 p= 0.007) and MAD (OR= 1.83 95% CI: 1.22, 2.99 p= 0.016). In addition, having a mother with an IGA was also significantly associated with some unhealthy dietary behaviours such as feeding infants with sugar-sweetened beverages (25% versus 13%, p< 0.05), savoury and fried snacks (17.2% versus 8%, p< 0.05) and infant formula (18% versus 7%, p< 0.05). Children belonging to IGA mothers had significantly lower LAZ scores than children belonging to non-IGA mothers (-0.09 versus 0.23, p= 0.026) and a higher stunting prevalence (8.1% versus 1.4%, p= 0.006). Children belonging to IGA mothers also had significantly lower WAZ scores than children belonging to non-IGA mothers (-0.52 versus 0.23, p= 0.041). 

Five major themes were identified from the qualitative analysis that compromised IYCF practices and childcare. The themes included child support, IGA, environmental influences on dietary practices and behaviour, nutrition transition and the Oyarifa environment. Indications are that mothers felt that long hours spent in IGA, the lack of childcare centres to provide alternative forms of care arrangements and need for financial autonomy compromised IYCF practices.

Conclusion

The findings demonstrate the existence of a double burden of malnutrition in Oyarifa characterised by a high prevalence of overweight and obesity among mothers and underweight in children. Maternal IGA was associated with lower LAZ and WAZ scores of children but not WHZ. In the context of maternal income-generating activity, having a mother in IGA increased a child’s likelihood of meeting MMF and MDD however did not decrease the likelihood of stunting and underweight in children. The accounts from mothers in the qualitative study highlighted the trade-offs between informal employment and IYCF practices and childcare. The findings help to understand the facilitators and challenges faced by women in IGA in practising recommended IYCF practices and the impact of these practices on the nutritional status of children. The lessons learned can be applied to future programmes and policies surrounding IGA and childcare. These findings may be applicable to other low-income areas in Ghana with similar socio-demographic characteristics.