Structural Determinants of Exclusive Breastfeeding among Migrant Head Porters (Kayayei) in Urban Ghana: A Mixed-Methods Health Systems Analysis

Background: Despite Ghana’s established breastfeeding promotion infrastructure, exclusive breastfeeding (EBF) for the WHO-recommended six months remains critically low among migrant female head porters (kayayei). This study examines the structural, interpersonal, and organisational determinants of EBF among this group and identifies a targeting and delivery failure within Ghana’s maternal and child health system, specifically the absence of operational mechanisms within existing maternal health programmes to reach informal migrant populations. Methods: An explanatory sequential mixed-methods design was employed. Interviewer-administered questionnaires were completed by 398 kayayei mothers at four major Kumasi market sites. Binary logistic regression across three hierarchical models identified predictors of six-month EBF adherence; Firth penalised likelihood regression was applied where separation occurred. Ten key informant interviews (KIIs) and two focus group discussions (FGDs; n=20) were analysed thematically. Qualitative components follow COREQ guidance; overall mixed-methods reporting follows GRAMMS criteria. Results: Although 95.5% reported practising EBF, only 12.1% met the WHO six-month criterion (mean duration: 2.86 months, SD=1.70). Strong negative predictors included being outside a union and perceiving EBF as incompatible with work (both identified via Firth penalised regression due to near-complete separation), lack of antenatal care, and not seeking professional breastfeeding help — confirmed qualitatively as the dominant barrier. Daily expenditure (OR=1.39, 95% CI 1.15–1.67, p=0.001) and secondary/higher education were protective (secondary/higher education OR=71.96 [95% CI: 3.07–1685.46], p=0.009; noting the wide CI due to sparse data). The final model explained 68.6% of the variance (Nagelkerke R²=0.686). No institutional actor identified any policy specifically addressing EBF among kayayei. Conclusions: EBF disparities among kayayei reflect a structural policy implementation gap, not maternal noncompliance. Improving outcomes requires labour-sensitive outreach, market-based care infrastructure, social protection, and formal designation of migrant informal workers as a maternal health priority within Ghana's health system.