Awareness, knowledge, and perception of the baby-friendly hospital initiative among final-year midwifery students at a University in Ghana: a short communication

¹School of Medicine, University of Health and Allied Sciences, Ho, Ghana, ²Department of Surgery, Urology Unit, University of Health and Allied Sciences, Ho, Ghana

^&Corresponding author
Frank Obeng, School of Medicine, University of Health and Allied Sciences, Ho, Ghana

Introduction    

The Baby-Friendly Hospital Initiative (BFHI), launched by the World Health Organization (WHO) and UNICEF in 1991 [1-3], aims to promote breastfeeding and improve maternal-child health outcomes globally [1-6]. Despite its benefits, exclusive breastfeeding rates remain suboptimal, including in Ghana [1-10]. Healthcare providers, particularly midwives, are essential to BFHI implementation. However, limited evidence exists regarding midwifery students´ understanding of BFHI in Ghana [2,5]. This study aims to assess the awareness, knowledge, and perception of BFHI among final-year midwifery students at UHAS.

Methods     

This descriptive cross-sectional study was conducted in July 2023 at the University of Health and Allied Sciences (UHAS) in Ho, Ghana. The study targeted all final-year midwifery students enrolled in the institution´s School of Nursing and Midwifery. The entire population of 75 eligible students was considered for participation using a total enumeration strategy to avoid bias. Inclusion criteria comprised students who had reached final-year status in the midwifery program and voluntarily consented to participate.

A structured, pre-tested, self-administered questionnaire was employed for data collection. The questionnaire was adapted from validated BFHI assessment tools and modified for contextual relevance. It consisted of four sections: (A) socio-demographics, (B) awareness, (C) knowledge, and (D) perception. The tool was pre-tested among final-year students in a similar program at a neighboring institution to ensure clarity and reliability.

Data were collected in a controlled classroom environment with adequate time provided for completion. Responses were anonymized to preserve participant confidentiality. Ethical approval was obtained from the UHAS Research Ethics Committee (UHAS-REC A.10(92)23-34), and informed consent was secured from all participants prior to data collection.

Data were entered and cleaned in Microsoft Excel and exported to SPSS version 22 for analysis. Descriptive statistics such as frequencies, percentages, means, and standard deviations were calculated. Knowledge and perception scores were derived using 5-point Likert scale items. For knowledge, scores ranged from 7 to 35 and were categorized as poor, moderate, or good. Perception was assessed on a 3-item Likert scale with total scores ranging from 3 to 15. Correlations between knowledge and perception were analyzed using Spearman's rho, while associations with demographic factors were tested using Chi-square statistics. Significance was set at p<0.05.

Results     

A total of 75 final-year midwifery students participated in the study, representing a 100% response rate. All participants were female. The mean age was 24.12 years (SD ±2.9), with 68% (n=51) aged ≤25 years and 32% (n=24) aged 26-30 years. The majority were single (88%, n=66), and most identified as Christian (76%, n=57), followed by Muslim (20%, n=15), and traditional religious affiliations (4%, n=3).

All students (100%) reported awareness of the Baby-Friendly Hospital Initiative (BFHI), with lectures identified as the primary source (54.7%), followed by personal reading (28%) and online resources (17.3%) [10].

Regarding knowledge of BFHI, 70.7% (n=53) demonstrated good knowledge, while 29.3% (n=22) were classified as having poor knowledge. The most commonly recognized items were the benefits of breastfeeding (identified correctly by 80% of students) and the need for early initiation within one hour (recognized by 88%). However, gaps were observed regarding the International Code of Marketing of Breast Milk Substitutes, with only 45% correctly responding (Table 1).

For perception, 76% (n=57) of students exhibited a positive outlook towards BFHI, agreeing that adherence to BFHI improves breastfeeding outcomes. A small proportion (24%) expressed neutral views, and no respondents held negative perceptions (Table 1). The mean perception score was 13.4 (SD ±2.1).

A strong positive correlation was observed between knowledge and perception scores (ρ=0.872, p<0.001), indicating that students with higher knowledge scores were more likely to report positive perceptions. Age and religion showed statistically significant associations with both knowledge and perception levels (p<0.001 for both). Older students and those identifying as Christians demonstrated higher knowledge and more positive attitudes. No significant associations were found for marital status (p=0.167) (Table 2).

Discussion     

This study provides critical insight into the readiness of final-year midwifery students to implement the principles of the Baby-Friendly Hospital Initiative (BFHI) in clinical practice. Universal awareness of BFHI among students is encouraging, particularly in light of global calls to prioritize breastfeeding support in maternity settings [4]. Our findings align with prior research in Nigeria and Uganda, which revealed moderate to high levels of awareness among nursing and midwifery trainees [7,9].

The observed good knowledge in 70.7% of participants is a promising indication of curriculum effectiveness. The strong performance on items related to breastfeeding benefits and early initiation mirrors previous reports from South Africa and Ghana [5,8]. However, significant knowledge deficits were noted regarding the International Code of Marketing of Breast Milk Substitutes, an area often neglected in training programs despite WHO's emphasis on its role in protecting breastfeeding [6]. Targeted educational content addressing these gaps should be integrated into midwifery curricula.

Positive perception (76%) suggests that students are not only informed about BFHI but are likely to promote it in their professional roles. This is essential as positive provider attitudes influence patient education, policy adherence, and breastfeeding uptake in health facilities [6,8]. Interestingly, no negative perception was recorded, though 24% held neutral views. These may stem from insufficient clinical exposure or a lack of reinforcement during internships. Addressing this through structured clinical rotations and mentoring could enhance both confidence and advocacy for BFHI.

The strong positive correlation between knowledge and perception (ρ=0.872, p<0.001) underscores the link between cognitive understanding and attitudinal disposition. Similar patterns were documented by Pérez-Escamilla et al. in their global review on BFHI effectiveness [6]. When trainees comprehend the rationale and benefits of BFHI, they are more likely to support its implementation. This supports the WHO´s call for continuous professional development as a vehicle for sustaining health worker motivation [4].

Sociodemographic differences were evident, with older students and Christians scoring higher in both knowledge and perception. Age likely reflects maturity and cumulative exposure, while religious alignment may influence breastfeeding beliefs, as noted in faith-based communities [5,7]. These findings offer valuable cues for curriculum designers and program implementers. Marital status showed no statistical impact, which may be attributed to participants´ youth and limited parenting experience.

Overall, this study supports the inclusion of structured BFHI training in all midwifery programs. The high awareness and knowledge levels reported here set a good foundation, but knowledge gaps and neutral attitudes highlight areas for intervention. Tailoring educational interventions to address weaker domains and sociodemographic variation can enhance the preparedness of midwives to lead in promoting optimal infant feeding practices. Future studies could assess how this knowledge and attitude scores translate into actual clinical behaviors or compare pre- and post-intervention cohorts to evaluate curriculum impact [8-10].

Conclusion     

Awareness of BFHI is high among final-year midwifery students at UHAS. However, knowledge and perception levels vary, highlighting the need for targeted education. Age and religious background significantly influence understanding. Curriculum strengthening is recommended to ensure future midwives are well-prepared to promote BFHI.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Kumbuno Desmond: study design, methodology, data collection, visualization, and editing; Frank Obeng: conceptualization, study design, supervision, data curation, visualization, first draft outline, and critical revision of the manuscript. All the authors read and approved the final version of this manuscript.

Acknowledgments     

We acknowledge the authorities of the University of Health and Allied Sciences, School of Nursing and Midwifery, for their permission and support during the data collection for this study. Mr. Obed Amenu guided our data analysis, and we acknowledge his help.

Tables     

Table 1: knowledge of the Baby-Friendly Hospital Initiatives among final-year midwifery students: a summary of knowledge, perception, and associated demographic factors among final-year midwifery students

Table 2: summary of correlation and association tests

References