How is breastfeeding perceived in the informal work environment? A qualitative study among working mothers in India and South Africa

Background Worldwide, over 740 million women make their living in the informal economy. These women do not benefit from 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 but little is known about how informal work impacts on infant feeding. 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 the informal sector in India and South Africa. Data was analysed using a thematic approach and the framework method. Findings 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 often 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 breastmilk becoming ‘spoilt’. Breastfeeding in the workplace was challenging as the work environment was described as unsafe and unhygienic for breastfeeding and childcare. Mothers also described being unable to complete their work tasks while caring for an infant. In contrast, the flexibility of informal work allowed some mothers to successfully balance competing priorities of child care and work. Sociocultural challenges influenced breastfeeding practices. For example, men in both countries expressed mixed views about breastfeeding. Breastfeeding was perceived as good for both mother and child, however it was culturally unacceptable for women to


Introduction
The Global Strategy for Women's, Children's and Adolescents' Health (2016)(2017)(2018)(2019)(2020)(2021)(2022)(2023)(2024)(2025)(2026)(2027)(2028)(2029)(2030) promotes a vision of health and development centred around the three objectives of Survive, Thrive and Transform [1]. Improving protection, promotion, and support of breastfeeding contributes to the realization of both the Global Strategy and the 2030 sustainable development agenda, as optimal breastfeeding is critical for reducing morbidity and mortality as well as for enhancing child development, intelligence and human capital, including school attainment [2,3]. Mothers also benefit. Breastfeeding decreases the risk of mothers developing breast cancer, type 2 diabetes and heart disease, and also aids in birth spacing [2]. Optimal breastfeeding, as defined by WHO, includes exclusive breastfeeding to six months followed by continued breastfeeding to two years and beyond, with the introduction of nutritious complementary feeds from six months of age [4]. Although the benefits of breastfeeding are well-documented, globally only 41% of infants less than six months of age are exclusively breastfed [5].
The determinants of breastfeeding practices are multifaceted and operate at social, structural and individual levels [3]. It was been widely shown that among women working in the formal sector returning to work is one of the biggest challenges women face to maintaining exclusive breastfeeding [6,7]. A variety of legislative and policy measures can improve breastfeeding among working mothers, including paid maternity leave and breastfeeding-friendly workplaces. However, worldwide close to 60% of women make their living in the informal economy which is not regulated or protected by the state [8], with the result that this population of mothers do not benefit from formal employment-related protections that are known to improve infant and young child feeding practices [9].
What's more the informal economy is continuing to grow in most regions and in urban settings. Over 90% of the world's informal employment is in emerging and developing countries [8]. While definitions of "informal sector," "informal work" and the "informal economy" vary considerably, informal workers are often described as those who do not have any job security, income security or social security and are therefore extremely vulnerable to exogenous shocks [10]. The informal economy is heterogenous in its numerous sectors, variety of employment statuses and places of work. It includes contributing family workers and self-employed own account workers such as street vendors, waste pickers, construction workers, home-based workers and employed domestic workers [9,11]. Informal workers struggle with poor housing, lack of basic services such as electricity and water, and extreme overcrowding. They are particularly neglected when it comes to health [12].
Women are overrepresented in self-employed informal occupations with a lower chance of high returns and poor working conditions [8]. In sub-Saharan Africa, Latin America and Southern Asia, informal employment is a greater source of employment for women than for men [8]. Women workers in the informal economy face a higher risk of poverty than those in the formal economy and do not have the same degree of access to health care [8]. While there is some evidence of an association between job informality in the Global South and poor health among women workers [13], we still know very little about how informal work affects maternal, newborn and child health.
This study focused on the informal economy in South Africa and India. It is part of a multi-country collaboration to better understand breastfeeding and child care practices among women informal workers, and to develop appropriate strategies in response. In this paper we describe informal worker attitudes and beliefs about breastfeeding in the informal work environment. We explore some of the challenges women informal workers face in breastfeeding and caring for children while continuing to work. Increasing the proportion of infants exclusively breastfeed is a major target of the 2016-2025 Decade of Action on Nutrition [14], and we must address the needs of this somewhat invisible and growing population if global nutrition goals are to be met.

Methods
The study used a qualitative design. This enabled the researchers to explore the understandings, challenges and complexities of infant feeding practices and child care within the context of informal work [15]. The qualitative approach also created space for shared dialogue between the researchers and participants [16].

Study setting
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 [17]. 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 [18] 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 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 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 little or 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.

Data collection
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 [16]. 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. 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.
Data collection was led by a research team in each country. FGDs were convened according to work type among women. 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. They were facilitated by experienced qualitative researchers in both countries. All FGDs were audio recorded.

Participant recruitment
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 six months. Women participants had to have a child under the age of five years. The research teams used purposive and snowball sampling techniques to facilitate a diverse representation of women working in the informal economy [26]. The snowball technique has been shown to be useful in engaging hard to reach populations [27]. In India, Self-Employed Womens' Association (SEWA) supported the identification of women workers in the sectors of street vending, homebased work, traditional pheri bartering, and domestic work.
In Durban AeT led the process of engagement and introduction to informal workers at the Warwick Junction site. This 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. 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.

Ethical considerations
The research teams provided information to all participants on the purpose of the study before discussions took place. They 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.

Data analysis
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 research teams in two countries 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 [28].
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. Two members of the research team in each country independently applied codes to a sample of transcripts to identify key ideas and themes. Initial coding was shared among team members via email and further discussions on the codes and emerging analytical framework took place between the research teams via Skype. The analytical framework 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).

Findings
In South Africa 14 FGDs were conducted and nine FGDs were conducted in India (see Table   1). Demographic characteristics, including type of work, of South African and Indian participants are provided in Table 2.

Breastfeeding practices on return to work
Despite the well-known benefits of breastfeeding, on returning to work many mothers changed their infant feeding practices, including adding breastmilk substitutes. Some mothers continued to breastfeed albeit not exclusively. Others shortened the duration of any breastfeeding or ceased breastfeeding altogether. In some cases, this led to children receiving inadequate feeds and several mothers reported that they were unable to afford formula milk. They instead gave their children tea in South Africa and buffalo's milk mixed with water in India. Several women also gave their child expressed breastmilk as an alternative to continuing to breastfeed. In addition, given the level of sanitation in low-income settlements where many women lived, they were concerned the expressed milk might become contaminated.
"They taught us at the clinic that we can express milk for the baby, but the problem is that you don't know how the nanny will handle baby's milk. Maybe she will get it dirty; maybe she leave it to rot all those things. So to avoid that it's better to tell yourself that ok……that was the reason I stopped." Domestic worker, urban, South Africa.
Women, particularly in the India groups, also conveyed the perception that breastfeeding stifled the independence of both mother and child. As such, many women introduced other food and mixed fed their children at an early age due to fears that child would become dependent on breastfeeding and 'refuse anything else, even food'. Pheri vendors in India Similar sentiments were expressed in relation to the health and independence of the mother. Mothers noted that continued or prolonged breastfeeding impacted on their own strength and energy as well as their ability to return to work and earn for their families.
To address this concern, mothers discussed different strategies for weaning their children off breastmilk. For example: "Some children drink breastmilk for a long time, then the mother is troubled. If the child drinks mother's milk for a longer time, the

Financial and household responsibilities
Several socioeconomic factors contributed to the inability of working mothers to continue breastfeeding and delay their return to work after childbirth. This included the pressure of financial and family responsibilities, absence of a dual income in the household and lack of access to government cash grants or benefits. A woman's ability to decide when to return to work was also determined by whether she could draw on her kinship network to provide support as a substitute for her earnings.
"What made me go out to work is because I was tired of asking for everything from my mother. In both countries' household income was dependant on women's work. Women's earnings contributed centrally to household expenses and this was a specific determinant to returning to work soon after childbirth. Many women in India indicated that their husbands were either unemployed, or had irregular work and were underemployed. This forced some women to return to work as soon as two weeks after childbirth.
"We take the responsibility to earn for our children's sake. However, informal work was insecure, irregular and less well paid. It was also the only income-earning opportunity available to many women. They therefore had to also consider how taking time off work after the baby was born might impact on their work options. For example, with no protected maternity leave, or other labour protections such as trading licenses, safeguarded trading spaces, or employment contracts, there was no guarantee a woman could return to work after having a child. Working mothers were often faced with having to forgo work at a site (vending, domestic work, pheri, waste pickers), or with a contractor (home-based work) to find other work options. This was a significant concern for domestic workers in South Africa who often lost their jobs while on maternity leave and had to look for new service work. In both countries cultural attitudes towards women's bodies contributed to a woman's decision to cease exclusive breastfeeding or to reduce the duration of breastfeeding. In  Women also highlighted the practical difficulties involved with taking time to breastfeed and care for their child while trying to meet their multiple work tasks, whether it be serving customers, cleaning houses or picking waste. As a result, to avoid disruptions and the potential safety concerns described above, many women opted not to take their children to work.

Discussion
Despite the extent of women working informally in the Global South, little is known about child care among women informal workers. This formative study sought to better understand breastfeeding and child care practices among women informal workers in different settings in India and South Africa, with the intention to inform the development of strategies to improve maternal and child health and provide better income security for these women. Our findings show that, although women working in the informal sector understand the importance of breastfeeding, they are frequently unable to practice exclusive and sustained breastfeeding because of multiple adverse factors. They must return to work early to fulfil their financial obligations to the household and the family but are often unable to take the baby with them on returning to work because of a hazardous work environment, their inability to undertake their work tasks while looking after the baby, and lack of support from male colleagues. While breastfeeding was the focus for this study, we saw breastfeeding as a proxy for child health, and based on our findings we discuss possible pathways for intervention.
In our study, women informal workers did not have access to formal protections which safeguarded their time away from employment allowing them to recover from childbirth, breastfeed, be close to their infants and plan for a new life. Returning to work placed an enormous physical and emotional stress on some mothers who found it difficult to balance the need to earn an income as well as care for themselves and their child. Women were forced to decide between returning to work and devolving care of their infant to someone else or staying at home to care for the child and forfeiting income. However, it is important to note that informal work offered some of the women in this study independence and flexibility. A review of poor working women and child care provision in Africa, Latin America and Asia also suggests that poorer women may use the flexibility of informal economy work to navigate the trade-off between impoverished households, child care and earning work when their children are young. Although this allows them time to care for their children, the work is also insecure and poorly paid [13]. Women informal workers need more options for securing their incomes to delay time to return to work.
Possible approaches include saving schemes, safeguarding trading spaces, and community support for child care to free women's time to increase their productivity.
The stress of balancing this 'double-burden' of earning an income and shouldering the main responsibility for child care was significant for women in our study. Women working in the formal sector also experience this, but it is likely that women in informal employment with few social protections face greater hardship [13,29]. Child care, and breastfeeding more specifically, is generally thought to be an individual's decision and success the sole responsibility of the woman. This ignores the role of society, including social and public services, in the support and protection of breastfeeding [3,30]. Informal working mothers cannot and should not be expected to maintain exclusive breastfeeding without support. It is imperative that collective responsibility and positive attitudes towards breastfeeding be shared by caregivers, family members, and colleagues and coworkers within the informal economy. Communities where women live and work must recognize the importance of child care in helping mothers manage complex situations. In addition, primary health care systems should also orient their services to working women and their needs rather than expecting women to respond to the configuration of the health system.
Evidence shows that women's work and short maternity leave are leading factors contributing to women not establishing breastfeeding or early cessation of breastfeeding [3,31,32]. In many settings lack of support for continued breastfeeding in the workplace is associated with shorter durations of breastfeeding [6,7,31,33,34]. In our study, without any maternity benefits, and with strong pressure to earn for their households, mothers often returned to work soon after childbirth. In doing so mothers frequently reduced breastfeeding and opted to use breastmilk substitutes or to stop breastfeeding altogether. This supports the findings of Rollins et al (2016), that working women in the informal economy are not appropriately supported through adequate maternity and workplace entitlements to be able to work and continue to breastfeed [3]. Further, mothers who took their child to work with them faced adverse environmental factors, as well as spatial and sociocultural challenges to breastfeeding precisely because of working in public. There were limited opportunities to breastfeed or express milk at the workplace and breastfeeding in public led to embarrassment and or was restricted in some cases.
Mothers who brought their child to work risked loss of income because they might be distracted, or customers may have a prejudice against buying from a woman with a baby.
Men in this study understood the importance of breastfeeding but conveyed an ambivalence and in many cases, antipathy towards breastfeeding in public. This has been found in a range of contexts [3].
Studies in formal employment settings suggest that the workplace is important in maintaining breastfeeding rates among working mothers and breastfeeding facilities in the workplace are associated with a higher probability of breastfeeding [35]. Characteristics of breastfeeding friendly workplaces include the availability of on-site nurseries, extended breaks, facilities to express and store milk, lactation rooms and lactation consultants or programmes [35]. Safe and supportive spaces in work and public spaces to enable closeness between a mother and her child are critical and can be customized to informal workplaces. This may include infrastructure and safe areas in public places, such as markets, as well as in private homes, as in the case of domestic workers. These could range from play areas, lactation spaces, or places for a mother to breastfeed in private, rest and wash herself as needed. Working mothers in our study needed to have better options for breastfeeding, especially those working outside the home. This has been shown elsewhere in the Global South [31].
With respect to study limitations, identifying informal working mothers was a challenge.
We used purposive and snowball sampling to address this constraint, however we acknowledge that this may have resulted in women with similar views being sampled. In addition, in South Africa we focused on market traders and domestic workers, so many informal work settings were not represented, including farm workers, construction workers and home-based workers.

Conclusion
Unless the challenges facing women working in the informal economy are addressed at the individual, household, community and municipal level, it is unlikely that global health and development goals, and global breastfeeding targets more specifically, will be met. This will require removing the structural and societal barriers to child care and increasing the value that communities place on maternal and child health. Investments in social protection and public services are required, -including child care -to support gender equality within families and society at large [30]. The next step of our multi-country collaboration is to address the interconnected pathways for intervention and support informal working mothers to sustain their livelihoods, protect their own health and nurture their children.