A descriptive study to explore working conditions and childcare practices among informal women workers in KwaZulu-Natal, South Africa: identifying opportunities to support childcare for mothers in informal work

Early Infant Feeding Practices among Women Engaged in Paid Work in Africa: A Systematic Scoping Review

Around the world, paid work without appropriate structural support is a key barrier to optimal breastfeeding practices. To better protect, promote, and support optimal breastfeeding practices among working women in Africa, this scoping review sought to understand how paid work influences infant feeding practices in the first 6 mo of life and what support women need to manage work and optimal infant feeding practices. We systematically searched PubMed, Scopus, Global Health, and CINAHL Plus, screened 2436 abstracts, and reviewed 322 full-text articles using Covidence for review and charting. We identified 203 articles that met the inclusion criteria. We identified 32 quantitative, 10 qualitative, 3 mixed-methods, and 2 review articles that focused on examining the relationship between work and breastfeeding, and 109 quantitative, 22 qualitative, 21 mixed-methods, and 4 review articles that included work as part of broader breastfeeding research but did not focus on work. Most studies reported a significant negative association between work and exclusive breastfeeding. Three major domains were reported in the qualitative studies: challenges to managing work and infant feeding, receiving support from employers and family members/caregivers, and strategies for feeding infants when the mother is working. Reviewed studies proposed recommendations to increase support for breastfeeding through changes to policies and support within worksites, the health system, and childcare; however, evidence of previously implemented policies or programs is limited. We recommend more consistent definitions and measurement of women's work. Future research is needed on the impact of implementing various strategies and benefits for breastfeeding at workplaces, as well as efforts to support breastfeeding among informal workers.

Associations of formal childcare use with health and human capital development for adolescent mothers and their children in South Africa: A cross-sectional study

AIM

This study aims to investigate associations of formal childcare with maternal and child outcomes in a large sample of adolescent mothers.

BACKGROUND

Forty percent of adolescent girls in Africa are mothers. Increasing evidence shows positive impacts of formal childcare use for adult women, but no known studies in the Global South examine associations for adolescent mothers and their children.

METHODS

We interviewed 1046 adolescent mothers and completed developmental assessments with their children (n = 1139) in South Africa's Eastern Cape between 2017 and 2019. Questionnaires measured childcare use, maternal and child outcomes and socio-demographic background variables. Using cross-sectional data, associations between formal childcare use and outcomes were estimated in multivariate multi-level analyses that accounted for individual-level and family-level clustering.

RESULTS

Childcare use was associated with higher odds of being in education or employment (AOR: 4.01, 95% CIs: 2.59-6.21, p < .001), grade promotion (AOR: 2.08, 95% CIs: 1.42-3.05, p < .001) and positive future ideation (AOR: 1.58, 95% CIs: 1.01-2.49, p = .047) but no differences in mental health. Childcare use was also associated with better parenting on all measures: positive parenting (AOR: 1.66, 95% CIs: 1.16-2.38, p = .006), better parental limit-setting (AOR: 2.00, 95% CIs: 1.37-2.93, p < .001) and better positive discipline (AOR: 1.77, 95% CIs: 1.21-2.59, p = .003). For the children, there were no differences in temperament or illness, but a significant interaction showed stronger associations between childcare use and better cognitive, language and motor scores with increasing child age (AOR: 5.04, 95% CIs: 1.59-15.96, p = .006).

CONCLUSIONS

Adolescent mothers might benefit substantially from formal childcare, but causal links need to be explored further. Childcare use was also associated with improved parenting and better child development over time, suggesting positive pathways for children. At an average of $9 per month, childcare provisions for adolescent mothers may offer low-cost opportunities to achieve high returns on health and human capital outcomes in Sub-Saharan African contexts.

Mothers' Willingness to Use Workplace Lactation Supports: Evidence from Formally Employed Mothers in Central Kenya

Background

Formally employed mothers are vulnerable to early cessation of exclusive breastfeeding. Kenyan national policy requires employer-provided maternity benefits and workplace lactation supports.

Objective

The objective of this study was to evaluate willingness to use nationally mandated workplace lactation supports among formally employed women in Kenya.

Methods

We conducted a cross-sectional survey among 304 mothers of children ages ≤12 mo in Naivasha, Kenya, who were currently formally employed and employed before delivery of the most recent child to assess availability of and willingness to use current and potential future workplace lactation supports.

Results

The most available reported workplace lactation supports were schedule flexibility to arrive late or leave early (87.8%) or visit a child to nurse during lunch (24.7%), followed by company-funded community-based daycare (7.6%). Few (<4.0%) reported the availability of lactation rooms, on-site daycares, transportation to breastfeed during lunch, refrigerators for expressed milk, or manual or electric breastmilk pumps. If made available, >80% of mothers reported moderate or strong willingness to use flexible schedules to arrive late or leave early, break during lunch, and transportation to visit a child to nurse. A moderate proportion reported strong willingness to use on-site daycares (63.8%), company-funded community-based daycare (56.9%), on-site lactation rooms (60.5%), refrigeration for expressed milk (49.3%), manual (40.5%), and electric pumps (27.6%). Mothers expressed fear of missing production targets and reported more willingness to use on-site compared with off-site daycare to save transportation time but noted concerns about chemical exposures and early arrival times with young infants. Hesitations regarding the use of on-site lactation rooms included concerns about privacy, milk identification and storage, and use and sharing of pumps.

Conclusions

Flexible schedules were the workplace lactation supports in highest demand among formally employed mothers. Maternal willingness to use lactation rooms, refrigeration, and pumping equipment was moderate to low, suggesting sensitization may help to increase demand as the implementation of Kenyan policies moves forward.

Knowledge, understanding and perceptions of key stakeholders on the maternity protection available and accessible to female domestic workers in South Africa

Maternity protection enables women to combine reproductive and productive roles. Domestic workers are a vulnerable group due to heterogeneous non-standard employment relationships and are unlikely to have access to comprehensive maternity protection. This study aimed to explore the knowledge, understanding and perceptions of key stakeholders in government, trade unions, non-governmental organisations and other relevant organisations of the maternity protection entitlements that should be available and accessible to female domestic workers in South Africa. This qualitative cross-sectional study included in-depth interviews with fifteen stakeholders working in different sectors in South Africa and mainly at a national level involved in maternity protection availability and access. Results show that stakeholders appear to have limited understanding of comprehensive maternity protection. Many challenges related to accessing cash payments while on maternity leave were described and suggestions were provided for how this could be improved. Participants described how certain labour-related characteristics unique to the domestic work sector were barriers in accessing maternity protection. Ensuring greater awareness of all components of maternity protection and improving implementation of existing labour legislation intended to guarantee maternity protection for non-standard workers in South Africa is important to improve access to maternity protection for this vulnerable group. Improved access to maternity protection would contribute to optimal maternal and new-born health and ensure economic security for women around the time of childbirth.

Parental experiences of childcare in an informal urban settlement: qualitative interview findings from the Nairobi Early Childcare in Slums (NECS) project

OBJECTIVES

To gain an in-depth understanding of parent/carers' perspectives on, and decision-making about, early childhood care in general, and paid childcare specifically, in informal settlements in Nairobi.

DESIGN

In-depth telephone interviews, conducted using a topic guide, were analysed through a combination of deductive and inductive thematic analysis and regular reflexivity meetings. We explored parents' childcare needs and experiences over time, and their perspectives on the provision of paid childcare in the slums.

SETTING

Three informal settlements or slums in Nairobi: Kibera; Kawangware; and Mukuru-Viwandani.

PARTICIPANTS

A purposively selected sample of 21 parental and non-parental carers of children aged under 5 years who were currently living in three Nairobi slums, including men and women, and users and non-users of paid childcare.

RESULTS

Childcare is complex, with a plurality of approaches being used. Common strategies include family member provided care (often but not exclusively by mothers, at home or at a place of work), paid childcare and informal or ad hoc arrangements with neighbours. Childcare decision-making in these settings is constrained by economics and the broader context of living in the slum. Paid childcare is frequently used, but is widely understood to be lacking in quality, especially for the poorest. Quality of childcare is understood to comprise a combination of structural factors, such as the physical space, play and learning resources and processes such as interactions between the care provider and children or parents.

CONCLUSIONS

These findings suggest a need, and opportunity, to improve early childhood care in slums. Understanding parental perspectives on both the deficiencies and valued features of childcare is likely to be vital to informing efforts to improve childcare in these settings.

Access to Maternity Protection and Potential Implications for Breastfeeding Practices of Domestic Workers in the Western Cape of South Africa

Access to comprehensive maternity protection could contribute to improved breastfeeding practices for working women. Domestic workers are a vulnerable group. This study aimed to explore perceptions of and accessibility to maternity protection among domestic workers in the Western Cape, South Africa, and potential implications of maternity protection access for breastfeeding practices. This was a mixed-method cross-sectional study including a quantitative online survey with 4635 South African domestic workers and 13 individual in-depth interviews with domestic workers. Results from the online survey showed that domestic workers had inconsistent knowledge of maternity-protection entitlements. Data from individual in-depth interviews showed that most participants struggled to access all components of comprehensive maternity protection, with some entitlements being inconsistently and informally available. Most domestic workers were unfamiliar with the concept of breaks to breastfeed or express milk. Participants provided suggestions for improving domestic workers' access to maternity protection. We conclude that improved access to all components of maternity protection would result in improved quality of care for women during pregnancy, around the time of childbirth and on return to work, and for their newborns, especially if an enabling environment for breastfeeding were created. Universal comprehensive maternity protection could contribute to improved care for all working women and their children.

Maternity protection entitlements for non-standard workers in low-and-middle-income countries and potential implications for breastfeeding practices: a scoping review of research since 2000

BACKGROUND

Recommended breastfeeding practices contribute to improved health of infants, young children, and mothers. Access to comprehensive maternity protection would enable working women to breastfeed for longer. Women working in positions of non-standard employment are particularly vulnerable to not accessing maternity protection entitlements. The objective of this scoping review was to determine the current research conducted on maternity protection available and accessible to non-standard workers in low-and-middle-income countries and any potential implications for breastfeeding practices.

METHODS

Nine databases were searched using search terms related to maternity protection, non-standard employment, and breastfeeding. Documents in English published between January 2000 and May 2021 were included. The approach recommended by the Joanna Briggs Institute was used to select sources, extract, and present data. The types of participants included in the research were female non-standard workers of child-bearing age. The core concept examined by the scoping review was the availability and access to comprehensive maternity protection entitlements of pregnant and breastfeeding women. Research from low-and-middle-income countries was included. The types of evidence sources were limited to primary research.

RESULTS

Seventeen articles were included for data extraction mainly from research conducted in Africa and Asia. Research on maternity protection for non-standard workers mostly focused on childcare. Components of maternity protection are inconsistently available and often inaccessible to women working in non-standard employment. Inaccessibility of maternity protection was described to disrupt breastfeeding both directly and indirectly, but certain characteristics of non-standard work were found to be supportive of breastfeeding.

CONCLUSIONS

Published information on maternity protection for non-standard workers is limited. However, the available information indicates that non-standard workers have inadequate and inconsistent access to maternity protection rights. The expansion of comprehensive maternity protection to all women working in positions of non-standard employment could encourage significant social and economic benefits.

“Working with little:” Access to market infrastructure and its effect on food handling and food safety among vegetable traders in an African city

Despite the crucial role played by informal markets in food distribution globally, the sector is ignored and marginalized. This study examined vegetable traders, the trading infrastructure available to them in the market, and how they conduct their businesses to explain the high food safety challenges in the sector. This paper is based on a survey, a learning journey, and transformation labs with market traders in Kumasi, Ghana. The study revealed that most traders were self-employed women with low education who worked for long hours. Access to electricity, water, refrigerators, and storage facilities was limited in the market. Vegetable spoilage was the highest cost associated with their trade. Due to the high spoilage rate, the traders sold the best vegetables at high prices and sold the bruised and rotten vegetables to local eateries and animal farms. The women made no losses through these strategies but used unsafe food handling practices and highly-priced wholesome vegetables. Their actions can reduce urban food security, especially in low-income households. Access to market infrastructure was influenced by availability, power and cost. Vegetable trading was the predominant livelihood of the traders. To improve the efficiency of the sector, efforts can be made toward the provision of services at the markets, and advocacy of the traders about food security implications of their actions by the municipal assemblies and market leaders.

Factors Associated with Adequate Breastfeeding: Evidence from the Peruvian Demographic and Health Survey, 2019

OBJECTIVE

To assess the factors associated with adequate breastfeeding (ABF) among Peruvian mothers during 2019.

MATERIALS AND METHODS

We performed a secondary analysis of the 2019 Demographic and Family Health Survey (ENDES) database of Peru. ABF was defined based on the recommendations of the World Health Organization, which defined it as starting breastfeeding within the first hour of life and continuing with exclusive breastfeeding for up to 6 months. To determine the factors associated with ABF, a Poisson generalized linear models with log-link function was used. Adjusted prevalence ratios (aPR) with their respective 95% confidence intervals (95% CI) were calculated.

RESULTS

A prevalence of ABF of 48.1% was identified among 11,157 women who reported at least one child in the last five years. Most of them were young (68.6%) and lived in urban areas (65.5%). Furthermore, being unemployed (aPR:1.02; 95% CI:1.00-1.04); residing on the coast, except for Metropolitan Lima (aPR:1.08; 95% CI:1.04-1.11), the highlands (aPR:1.14; 95% CI:1.11-1.18), and the jungle (aPR:1.20; 95% CI: 1.16-1.24); having had a vaginal delivery (aPR:1.30; 95% CI:1.27-1.05); and having two children (aPR:1.03; 95% CI:1.01-1.05) or three or more children (aPR:1.03; 95% CI:1.01-1.05) were associated with a higher frequency of ABF.

CONCLUSIONS

One out of two women between 18-59 with children performed ABF. The factors associated with ABF were the current occupation, region of residence, type of delivery, and parity. Health policies and strategies should be implemented, considering our results, to promote maternal counseling by health personnel in order to increase the prevalence of ABF in the Peruvian population.

Has Food Security and Nutritional Status Improved in Children 1-<10 Years in Two Provinces of South Africa between 1999 (National Food Consumption Survey) and 2018 (Provincial Dietary Intake Study (PDIS))

The 1999 National Food Consumption Survey in South Africa showed that food insecurity (hunger) was prevalent in households with children aged one to <10 years. A repeat of the survey in two provinces: Gauteng (GTG) and the Western Cape (WC) was undertaken in 2018. Results showed that in all domains (living areas) in GTG, food shortage prevalence decreased between 1999 and 2018, from 55.0% to 29.6% in urban informal areas, from 34.1% to 19.4% in urban formal areas and from 42.1% to 15.6% in rural areas. While the prevalence of food shortage in urban formal areas in the WC remained similar in 2018, prevalence decreased from 81.8% to 35.7% in urban informal areas and from 38.3% to 20.6% in rural areas. Energy and macronutrient intakes improved significantly in GTG between 1999 and 2018 but not in the WC; intakes were significantly higher in the WC at both time points. The only significant change in stunting, wasting, overweight and obesity prevalence was that 7-<10-year-olds in GTG were significantly more likely to be wasted (BAZ < 2SD) in 2018 than in 1999 (20.2% versus 6.9% respectively). In the WC, 1-3-year-olds were significantly more likely to be obese in 2018 than in 1999 (8.1% versus 1.7% respectively) and 7-<10-year-olds were less likely to be stunted (14.5% versus 4.9% respectively). There were significant negative correlations between the hunger score and dietary variables in both provinces in 1999. In GTG in 2018, only the correlation with fat intake remained while there were still several significant correlations in WC in 2018. Changes in top 12 energy contributors reflect a shift to high or moderate energy foods low in nutrients from 1999 to 2018. Nutrient dense (high micronutrients, low energy/g) foods (e.g., fruit) fell off the list in 2018. Logistic regression analyses reflect the importance for food security of having a parent as head of the household and/or caregiver, and parents having grade 12 or higher education and being employed. We conclude that food security nutritional status indicators improved amongst 1-<10-year-old children especially in GTG between 1999 and 2018. However, the shift to poorer food choices and increase in wasting in older children and overweight in younger children are of concern.

The future of human malnutrition: rebalancing agency for better nutritional health

The major threat to human societies posed by undernutrition has been recognised for millennia. Despite substantial economic development and scientific innovation, however, progress in addressing this global challenge has been inadequate. Paradoxically, the last half-century also saw the rapid emergence of obesity, first in high-income countries but now also in low- and middle-income countries. Traditionally, these problems were approached separately, but there is increasing recognition that they have common drivers and need integrated responses. The new nutrition reality comprises a global ‘double burden’ of malnutrition, where the challenges of food insecurity, nutritional deficiencies and undernutrition coexist and interact with obesity, sedentary behaviour, unhealthy diets and environments that foster unhealthy behaviour. Beyond immediate efforts to prevent and treat malnutrition, what must change in order to reduce the future burden? Here, we present a conceptual framework that focuses on the deeper structural drivers of malnutrition embedded in society, and their interaction with biological mechanisms of appetite regulation and physiological homeostasis. Building on a review of malnutrition in past societies, our framework brings to the fore the power dynamics that characterise contemporary human food systems at many levels. We focus on the concept of agency, the ability of individuals or organisations to pursue their goals. In globalized food systems, the agency of individuals is directly confronted by the agency of several other types of actor, including corporations, governments and supranational institutions. The intakes of energy and nutrients by individuals are powerfully shaped by this ‘competition of agency’, and we therefore argue that the greatest opportunities to reduce malnutrition lie in rebalancing agency across the competing actors. The effect of the COVID-19 pandemic on food systems and individuals illustrates our conceptual framework. Efforts to improve agency must both drive and respond to complementary efforts to promote and maintain equitable societies and planetary health.

'I can no longer do my work like how I used to': a mixed methods longitudinal cohort study exploring how informal working mothers balance the requirements of livelihood and safe childcare in South Africa

Background

Returning to work after childbirth is challenging for working mothers. Childcare quality may have lifelong effects on children’s health, development and cognitive function. Over 60% of working women globally are informal workers without employment or maternity protection, but little is known about how these women care for their children.

Methods

We conducted a mixed-methods longitudinal cohort study among informal women workers in Kwazulu-Natal, South Africa between July 2018 and August 2019. Participants were followed up from late pregnancy until they had returned to work. We conducted structured quantitative interviews and in-depth qualitative interviews at different time points: before and after the baby was born, and after returning to work. Subsequently, a photovoice activity was conducted with groups of participants to explore the childcare environment. We employed narrative thematic analysis for qualitative data and descriptive analysis for quantitative data.

Results

24 women were recruited to participate. Women returned to work soon after the baby was born, often earlier than planned, because of financial responsibilities to provide for the household and new baby. Women had limited childcare choices and most preferred to leave their babies with family members at home, as the most convenient, low cost option. Otherwise, mothers chose paid carers or formal childcare. However, formal childcare was reported to be poor quality, unaffordable and not suited to needs of informal workers. Mothers expressed concern about carers’ reliability and the safety of the childcare environment. Flexibility of informal work allowed some mothers to adapt their work to care for their child themselves, but others were unable to arrange consistent childcare, sometimes leaving the child with unsuitable carers to avoid losing paid work. Mothers were frequently anxious about leaving the child but felt they had no choice as they needed to work.

Conclusion

Mothers in informal work had limited childcare options and children were exposed to unsafe, poor-quality care. Maternity protection for informal workers would support these mothers to stay home longer to care for themselves, their family and their baby. Provision of good quality, affordable childcare would provide stability for mothers and give these vulnerable children the opportunity to thrive.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01425-y.

Breastfeeding knowledge and practices of working mothers in the informal economy in New Delhi: A formative study to explore new intervention pathways towards improved maternal and child health outcomes

This was a formative study to yield evidence on the conceptual and empirical pathways to improve maternal and child health (MCH) outcomes among informally working mothers while securing livelihoods, and for this, explores how informally working women navigate time sensitive childcare practices such as exclusive breastfeeding (EBF) with their work, and how do the conditions and nature of informal employment shape it. This study was conducted in February-May 2017 using non-probability sampling for cross-sectional semi structured interviews (n = 92) and focus group discussions (n = 56) with working mothers with a child under 2 and 5 years respectively, having regular and stable working history in the informal economy. The study team partnered with Self-Employed Women's Association for site selection and recruitment of study participants across 4 sectors of work in New Delhi, India: home-based work, pheri or barter work, street vending and domestic work. While 65% women report EBF for 6-months, checks with infant feeding recall reveal several disruptions from customary practices and working conditions, and successful EBF only in home-based work, the least paying of all. 59% women reported returning to work under 6-months, leading to early weaning. 90% women were aware of the importance of EBF in the standard language of public health messaging, however, checks with non-standard language queries reveal a drop to 55-80% exhibiting lack of effective knowledge that women could use. The findings emphasise that conditions and nature of informal employment shape MCH outcomes in cities of the global south, where such employment dominates. Furthermore, we use the findings to suggest the following responsive approaches for intervention: delaying mother's return to work, increasing proximity between mother and child, deeper and engaged knowledge of breastfeeding and early child development practices, improving problem solving capacity and agency of the mother, and enabling home and workplace conditions.

The roles of men and women in maternal and child nutrition in urban South Africa: A qualitative secondary analysis

Industrialization and urbanization processes have challenged deeply held traditional gender norms and facilitated the emergence of modern ideologies in South Africa. This paper seeks to explore the gendered roles of family members on maternal and child nutrition and investigate indications of perceived change in related practices. A qualitative secondary analysis was conducted of data from nine focus group discussions (FGDs) held with men (n = 3) and women (n = 6) aged ≥18. Data from the FGD were coded and thematic analysis conducted. We found that elderly women seem to have a central advisory role with respect to maternal and child nutrition and that men and elderly women upheld patriarchal gender divisions of labour, which entrust mothers with the primarily responsibility for young children's nutrition. Young mothers relied on elderly women for provision of childcare and nutritious foods for children; however, they demonstrated some resistance to traditionally feminized forms of food preparation. We found that men's involvement in children's nutrition was limited, though they expressed a preference to be more involved in maternal and child nutrition and care practices. A gender transformative approach to policy development, which includes elderly women and men, has the potential to promote more gender‐equitable nutrition practices, increase young women's self‐efficacy and support them to overcome barriers that could be limiting their decision making power in achieving optimal nutrition for themselves and their children.

Talking the Talk but not Walking the Walk: Donating to Human Milk Banks in South Africa

BACKGROUND

The human milk donor pool in South Africa is severely limited due to the low rate of continued breastfeeding and the HIV pandemic. It was crucial to determine why willing donors did not donate to determine if infrastructure could be implemented to prevent this loss.

RESEARCH AIM

To determine why mothers who had committed to donating to a human milk bank in South Africa did not donate their milk.

METHODS

Participants (N = 37) were interviewed using a telephone administered questionnaire. Variables measured were initiation and continuation of breastfeeding, reasons for discontinuation, age of introduction of solids and type, and reasons for not donating. Data were interpreted using descriptive statistics and Pearson's chi-square test.

RESULTS

Participants were mainly unemployed (70.2%, n = 26), single (73%, n = 27), black African (83.7%, n = 31), Christian (62.2%, n = 23) women with a M age of 25.7 (5.2) years, and a secondary or higher education level (81.1%, n = 30). Most lived in urban areas (70.2%, n = 26), with piped water (100%, n = 37), electricity (100%, n = 37), and refrigerators (100%, n = 37). Only 29.7% (n = 11) owned a vehicle. The major barrier was infrastructure related, as 62.2% (n = 23) were unaware of the process after discharge. This was followed by practical issues including no transport (21.6%, n = 8), no freezer for milk storage (18.9%, n = 7), or working (5.4%, n = 2).

CONCLUSION

The major barrier was ignorance of the post discharge process and lack of support from clinic staff. No transportation challenged the maintenance of the cold chain. A potential solution is mothers donating only at clinic immunization visits.

Addressing the interaction between food insecurity, depression risk and informal work: findings of a cross-sectional survey among informal women workers with young children in South Africa

Background

There is a high burden of depression globally, including in South Africa. Maternal depression is associated with poverty, unstable income, food insecurity, and lack of partner support, and may lead to poor outcomes for mothers and children. In South Africa one-third of working women are in informal work, which is associated with socioeconomic vulnerability.

Methods

A cross sectional survey explored work setting and conditions, food security and risk of depression among informal working women with young children (0–3 years). Depression risk was assessed using the Edinburgh Postnatal Depression Score (EPDS) and Whooley score. Food insecurity was evaluated using Household Food Insecurity Access Scale. Data was analysed using SPSS and Stata.

Results

Interviews were conducted with 265 informal women workers. Types of work included domestic work, home-based work, informal employees and own account workers, most of whom were informal traders. Most participants (149/265; 56.2%) earned between US$70–200 per month, but some participants (79/265; 29.8%) earned < US$70 per month, and few earned > US$200 per month (37/265; 14.0%). Many participants experienced mild (38/267; 14.3%), moderate (72/265; 27.2%) or severe (43/265; 16%) food insecurity. Severe food insecurity was significantly higher among participants with the lowest income compared to those with the highest income (p = 0.027). Women who received financial support from the baby’s father were less likely to be food insecure (p = 0.03). Using EPDS scores, 22/265 (8.3%) women were designated as being at risk of depression. This was similar among postnatal women and women with older children. Household food insecurity was significantly associated with depression risk (p < 0.001).

Conclusions

Informal women workers were shown to be vulnerable with low incomes and high rates of food insecurity, thus increasing the risk for poor maternal health. However, levels of depression risk were low compared to previous estimates in South Africa, suggesting that informal workers may have high levels of resilience. Interventions to improve social protection, access to health services, and support for safe childcare in the workplace could improve the health and wellbeing of these mothers and support them to care for their children.

'I decided to go back to work so I can afford to buy her formula': a longitudinal mixed-methods study to explore how women in informal work balance the competing demands of infant feeding and working to provide for their family

BACKGROUND

In South Africa almost 2 million women work informally. Informal work is characterised by poor job security, low earnings, and unsafe working conditions, with high rates of poverty and food insecurity. The peripartum period is a vulnerable time for many working women. This study explored how mothers navigate the tension between the need to work and the need to take care of a newborn baby, and how this affects their feeding plans and practices.

METHODS

A mixed methods longitudinal cohort method was employed. Informal workers were recruited in the last trimester of pregnancy during an antenatal visit at two clinics in Durban, South Africa. Data were collected using in-depth interviews and quantitative questionnaires at three time points: pre-delivery, post-delivery and after returning to work. Framework analysis was used to analyse qualitative data in NVIVO v12.4. Quantitative analysis used SPSSv26.

RESULTS

Twenty-four participants were enrolled and followed-up for a period of up to 1 year. Informal occupations included domestic work, home-based work, informal trading, and hairdressing, and most women earned <R3000 (US$175) per month. Participants had good knowledge of the importance of breastfeeding for child health. Most women planned to take time off work after the birth of their babies, supporting themselves during this time with the child support grant (CSG) received for older children, their savings, and support from the baby's father and other family members. However, financial pressures forced many mothers to return to work earlier than planned, resulting in changes to infant feeding practices. Several mothers tried expressing breastmilk, but only one was able to sustain this while away from the baby. Most participants introduced formula, other foods and fluids to their babies when they returned to work or stopped breastfeeding entirely, but some were able to change their work or adapt their working hours to accommodate breastfeeding.

CONCLUSIONS

Interventions are needed within the social and work environment to support mothers with breastfeeding while they continue earning an income in the informal economy. The extension of the CSG to the antenatal period could assist mothers to stay at home longer post-delivery to breastfeed their babies.

Labour market incorporation of immigrant women in South Africa: Impacts of human capital and family structure

This paper examines the labour market incorporation of African-born immigrant women in South Africa using data from the 2011 Census. It investigates women's labour force participation, employment prospects, and access to formal employment, assessing how human capital and household factors explain labour market decisions. Results underscore significant challenges to immigrant incorporation in South Africa. Not only are immigrants less likely to participate in the labour force than black South African women, but for those who participate, employment levels are lower. Although immigrants have an employment edge over South Africans once individual and household factors are held constant, immigrants are over-represented in informal jobs. Returns to human capital are also lower among foreign- than South-African-born women. Together, these results suggest a segmented pattern of incorporation for immigrant women in South Africa. Results by national origin emphasize the importance of egalitarianism and co-ethnic community characteristics in structuring women's labour force participation.

Attitudes and perceptions about breastfeeding among female and male informal workers in India and South Africa

BACKGROUND

Worldwide, over 740 million women make their living in the informal economy and therefore lack formal employment benefits, such as maternity leave, that can improve infant feeding practices. Returning to work is one of the biggest challenges women face to maintaining breastfeeding. This study aimed to explore attitudes and perceptions towards breastfeeding in the informal work environment among male and female informal workers.

METHODS

The study used a qualitative research design. Purposive and snowball sampling was employed. Focus group discussions (FGDs) were conducted among men and women working in different types of informal jobs, in India and South Africa. Data was analysed using a thematic approach and the framework method.

RESULTS

Between March and July 2017, 14 FGDs were conducted in South Africa and nine in India. Most women were knowledgeable about the benefits of breastfeeding and reported initiating breastfeeding. However, pressures of family responsibilities and household financial obligations frequently forced mothers to return to work soon after childbirth. Upon return to work many mothers changed their infant feeding practices, adding breastmilk substitutes like formula milk, buffalo milk, and non-nutritive fluids like Rooibos tea. Some mothers expressed breastmilk to feed the infant while working but many mothers raised concerns about expressed breastmilk becoming 'spoilt'. Breastfeeding in the workplace was challenging as the work environment was described as unsafe and unhygienic for breastfeeding. Mothers also described being unable to complete work tasks while caring for an infant. In contrast, the flexibility of informal work allowed some mothers to successfully balance competing priorities of childcare and work. Sociocultural challenges influenced breastfeeding practices. For example, men in both countries expressed mixed views about breastfeeding. Breastfeeding was perceived as beneficial for both mother and child, however it was culturally unacceptable for women to breastfeed in public. This affected working mothers' ability to breastfeed outside the home and contributed to a lack of respect for women who chose to breastfeed in the workplace.

CONCLUSION

Mothers working in the informal sector face multiple challenges to maintaining breastfeeding. Interventions are required to support feeding and childcare if global nutrition and development goals are to be met.