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. The study used a qualitative design as part of a broader mixed-methods study [10]. The qualitative design was informed by the framework method for thematic analysis [19] which enabled the researchers to explore themes related to the commonalities of participants’ experiences and the understandings, challenges and complexities of infant feeding practices and child care within the context of informal work [20]. The qualitative design also created space for in-depth and shared dialogue between the researchers and participants [21]. We conducted the study from February to July 2017 in one urban and one rural site in KwaZulu-Natal, South Africa and in four sites in New Delhi, India. The sites were selected to reflect the heterogeneity of the informal economy, in terms of sectors and places of work represented. In India, the informal economy is the dominant form of work. It makes up to 90% of the total workforce and 90% of women workers. This includes domestic workers, market traders and home-based workers. By comparison, South Africa’s informal economy makes up a third (34%) of the total workforce with a slightly higher percentage of working women engaged in informal work (35.9%) compared to men (32.5%) [8]. The informal economy is smaller than other developing countries, but it constitutes a significant source of employment in the country. Almost all domestic workers are women, accounting for around 20% of all women informal workers [22]. Workers in the informal economy in South Africa earn on average around two-thirds less than formal workers (R1 733(US$120) per month vs R5 000 (US$ 340) per month). Women make only around 75% of men’s earnings [23]. In India, informal workers can receive average daily earnings of between INR 205 (US$3) and INR 411 (US$6), compared with INR 750 (US$11) earnt by regular formal workers. As in South Africa, the labour market in India is characterized by gender-based disparities [24]. Rates of exclusive breastfeeding are low in both South Africa and India, estimated at 31.6 and 54.9% respectively [25–27]. While informal women workers in both countries lack formal job benefits, there are some state provisions in South Africa and India for new mothers. In South Africa most births occur in public health facilities at no cost, and new mothers can also apply for a child support grant of R400 per month (US$ 34) [28]. In India, women have access to monetary rewards if they opt for institutional births. They can receive up to INR 6000 (US$100) for hospital costs, immunization and nutrition through programmes like the Jananai Suraksha Yojna [29]. In addition, nutritional support for pregnant, and lactating mothers can be accessed through the Integrated Child Development Scheme [30]. In South Africa, the urban study site was Warwick Junction, an informally structured public market in central Durban. It is situated in a large transport interchange for approximately 460,000 commuters each day and between 6000 and 8000 street vendors spread across nine different market areas. The rural site was Uthukela District, one of the 11 districts of KwaZulu-Natal province. There are a range of covered markets and street markets in three small towns in Uthukela. Each market has representation from both peri-urban and rural informal workers. There is no data available about the informally working population in the district. In India, there was an overlap between the sector of work and site of study. Informal work and informal housing are often connected in Indian cities because the costs of transport are high and informal workers look to reside close to their worksites. The study was conducted in four settlements in New Delhi and covered four sectors of work: Anand Vihar where domestic work was the dominant form of work for women; Jahangirpuri settlement for its street vending of fruit and vegetables; Raghubir Nagar settlement where women engaged in traditional pheri work and bartered utensils for second-hand clothes in private households and then sold the clothes in public markets; and Sundarnagri settlement for its predominantly home-based work. Focus group discussions (FGDs) were used to collect data. This methodology allowed for discussions on a specific topic of interest with a relatively small number of participants from a similar sociocultural background [21]. A FGD guide was developed to explore infant feeding practices of mothers working in the informal economy and the perceived role of women within the informal economy (supplementary file 1). The guide also focused on the care of children in the workplace or while mothers are at work, and attitudes to breastfeeding in the informal work environment. Different FGD guides were used for women and for men (supplementary file 2), and the guides were adapted as required for each setting. We conducted FGDs with women and with men in different types of informal work, including domestic workers, street traders and waste pickers, in order to obtain different perspectives about breastfeeding from different types of informal workers. A recent study in Durban suggested that different categories of informal workers face different challenges in feeding and caring for their children [10]. Male participants were included to provide a gendered perspective about breastfeeding in the informal workplace. In each country FGDs were conducted by experienced researchers trained in qualitative research to masters level (SL, AS, AC). All researchers were female, and currently employed as researchers by their affiliated institutions. The research teams had a complementary mix of valuable experience with the topic. The team in India had strong knowledge and experience with female workers in the informal economy and had worked closely with Self-employed Womens’ Association (SEWA) on different occasions. The research team in SA had a proven expertise in maternal and child health. FGDs were convened according to work type among women, with separate FGDs conducted with different types of informal workers and in different areas as shown in Table 1. Each FGD included only workers with the same occupation working in the same area, and discussions with men were conducted separately. The FGDs were held in central venues away from the workplace, such as local halls, municipal offices or small hired venues. Discussions took place in participants’ language of preference, either English or isiZulu in South Africa, or Hindi and Bengali in India. Researchers had minimal contact with participants prior to the FGDs. Participants were provided with information about the objectives of the study and the researchers role in conducting the FGDs. Only participants and researchers were present during the discussions. All FGDs were audio recorded. FGDs were continued until researchers agreed that data saturation had been reached. Description of focus group participants in India and South Africa a Male participants were related to informal women workers but did not undertake the work themselves Women and men were eligible to participate if they were 18 years or older and had been working in the informal economy for more than 6 months. Women participants had to have a child under the age of 5 years. The research teams used purposive and snowball sampling techniques to facilitate a diverse representation of women working in the informal economy [31]. The snowball technique has been shown to be useful in engaging hard to reach populations [32]. The sampling approach aimed to recruit participants from a variety of informal jobs to include diverse viewpoints and experiences among participants. At both sites recruitment was facilitated by local organisations working with informal workers who introduced participants to researchers. In India, SEWA supported the identification of women workers in the sectors of street vending, home-based work, traditional pheri bartering, and domestic work. In Durban AeT led the process of engagement to informal workers at the Warwick Junction site, participants included waste pickers, street vendors and market traders. In the Uthukela district members of the study team initiated contact with women working in the informal economy. They visited places where groups of women commonly meet, such as churches, to identify eligible participants away from the workplace and approached women in person. This included women working as informal traders as well as domestic workers. All women were invited to suggest other women from their networks or community who might be interested in participating, as well as male family members working in the informal economy. The research teams provided information to all participants on the purpose of the study before discussions took place. Participants were also assured of confidentiality and that they could withdraw from the study at any time. Transcripts were de-identified and included no personal information. Participants were compensated for the time spent away from the workplace. Exact payments in the different sites were agreed with local stakeholders to ensure that the amount was commensurate with lost earnings to avoid being an undue incentive. To mitigate potential risks and sensitivities among the informal workers, research teams worked with organisations in each setting that had long-standing engagement and experience of the respective communities. Feedback on study results was provided to the organisations after completion of the study. Trained members of the research teams transcribed the FGD recordings verbatim and translated the transcripts into English. The data was analysed using thematic approach and the framework method. Framework analysis was selected as a suitable approach to manage and organise the data across the two sites and to provide a systematic analysis structure which enabled commonalities and differences in the data to be identified as well as relationships between different parts of the data. This approach enabled descriptive and explanatory conclusions to be drawn around themes [19]. The research teams read and reread all participants’ accounts for a priori themes in the FGD guide as well as for themes emerging from the data. Based on this, two members of the research team in each country independently applied codes to a sample of transcripts to describe the content, key ideas and themes, such as reasons for returning to work or factors influencing breastfeeding practices. Initial coding was shared among team members via email. The research teams held meetings via Skype to further discuss the codes and the emerging patterns and themes. This process informed the development of an initial analytical framework which was applied to the remaining transcripts using the existing codes. Any new themes were discussed, and the analytical framework was further refined until no new themes were identified. A matrix was developed for each country, with data from each transcript summarized by theme. To ensure consistency, the team members compared their summary styles in the early stages of the analysis process. The research teams jointly discussed the initial findings to ensure accurate interpretation of the data. The software programme NVivo was used to manage the data analysis process (NVIVO v12, 2019).