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

More than half of the global workforce works in the informal economy, which exists in all labour markets in both low and high-income countries [1]. In many parts of the world most new jobs created are in informal work, and it is now recognised that the informal economy does not necessarily recede as economies grow, with many successful economies showing increases in informal employment [2]. The size, heterogeneity and universality of the informal economy, its ability to emerge in new guises in new situations, and its contribution to gross domestic product (GDP) has led to increasing recognition of its importance [2]. Informal work can be defined in different ways but in all settings and definitions, informal workers generally lack the social protection enjoyed by formal workers, including access to sick leave, maternity leave or unemployment benefits. The informal work environment is characterised by low earnings, unsafe working conditions, and poor job security [3]; as a result, working in the informal economy is frequently associated with poverty and vulnerability. Women are disproportionally represented in the informal economy and childcare responsibilities fall disproportionally on women, so it is challenging to manage these dual responsibilities, and the need to work impacts on how these mothers care for and feed their children [4].

In South Africa (SA) in 2017, of a working population of 16 million people, almost 5 million were in informal work. Among 6.8 million working women, almost 2 million were working informally, the largest groups being informal traders, agricultural workers and workers in private homes (domestic workers). Almost all domestic workers are women, accounting for around 50% of all women informal workers [5]. Two-thirds of informal workers are employed, whereby they receive payment from an employer in an informal enterprise [6]. However, informal workers may also be own-account workers (25%) or informal employers themselves (3%). Overall, in the informal work environment in SA, women earn around 25% less income than men [7].

Providing children with an adequate diet is essential for child health and development, and for children of low income mothers working informally, is crucial to breaking the cycle of poverty. In particular, optimal breastfeeding practices, which include exclusive breastfeeding (EBF) for 6 months and sustained breastfeeding to 2 years, are critical for child health and development [8, 9]. It is estimated that high coverage (> 90%) of optimal breast feeding practices could prevent over 800,000 child deaths globally [10], and the United Nations has included achieving 50% EBF in the first 6 months, as a key target to eradicate malnutrition [11].

However, early return to paid employment is consistently associated with shorter durations of breastfeeding in formal work settings [12‐15]. Several workplace interventions have been shown to improve breastfeeding rates among working women in the formal work sector [16‐20]. Longer durations of maternity leave can improve breastfeeding practices, as can providing on-site childcare [13, 21, 22]. However, breastfeeding remains a challenge for working women and, even in formal settings, mothers who choose to breastfeed frequently suffer greater and more prolonged earnings losses compared to women who choose not to breastfeed [23].

Achieving optimal breastfeeding has particular challenges for informal women workers. Women working as street vendors, for example, face spatial challenges of working in a public space that may change from day-to-day, and where hygiene and safety conditions are often poor. As a result, mothers describe the difficulties of balancing the economic necessity of working, often returning to work soon after the baby is born, with continuing to breastfeed, particularly given the lack of a supportive environment in many low paid or informal jobs [4, 15, 24]. In contrast, supportive work environments in some low-income or informal work settings have allowed working mothers to keep their infants close to their work stations, helping them to successfully breastfeed [25]. Some studies have shown that mothers working informally are more likely to breastfeed compared those in formal employment, suggesting that the informal work environment, by its flexible nature, may be more supportive to breastfeeding [26, 27], and mothers may chose informal work because it allows them to adapt working hours to suit childcare [4].

Appropriate interventions to support breastfeeding and childcare must strike a balance between the woman’s right to work and provide for herself and her family, and the rights of children to the best care to promote health and development. Given the large numbers of women in informal work, its association with vulnerability, and the conditions and quality of informal employment, it is important to establish how these forms of work impact on childcare practices. The aim of this study was to understand and explore possible factors impacting on child care practices among women informal workers, including income, food security, work environment, household/childcare environment, and access to health services.

A cross sectional survey was conducted among informal women workers with children aged < 2 years, in two sites in the province of KwaZulu-Natal (KZN), SA to explore childcare and feeding practices, income, working environment, among mothers in different types of informal work. Two main sectors of the informal economy were included, these were domestic workers, who make up the largest share of women’s informal employment in SA, and informal traders. Informal traders included street traders, and traders working in formal markets with some infrastructure provided, including those who are cooking and selling food in the street or market.

A total of 247 interviews were conducted with informally working mothers between February and May 2017. Interviews were conducted with 170 informal traders and 77 domestic workers in the two sites: 122 mothers participated in the urban site and 125 mothers were from the rural district.

The mean age of participating mothers was 32.2 years (SD 6.7). Demographic characteristics were largely similar between domestic workers and informal traders. However, there were significant differences in the household environment between the two groups with domestic workers having better access to safe water and sanitation in their homes compared to informal traders (Table 1).

Our findings provide an initial picture of the work and childcare circumstances among women working as informal traders and domestic workers in KZN, SA. Findings suggest that most women working in the informal economy in these sectors have worked in the same job for several years, receive a regular salary either weekly or monthly, and work in the same place each day. However, these women work long hours, with many women earning <R1000 ($80) per month, most do not receive payment when they are sick, and many women work outdoors without shelter. Women report high levels of food insecurity not just for themselves but also for their child. Although working mothers and their children are vulnerable, the relative stability of the work environment provides opportunities for interventions to support childcare and feeding.

Another opportunity for possible interventions is that most children in this age group live with their mother rather than being cared for in a different household, which is a common practice in South African communities. Mothers who do not take the child to work usually rely on family members to look after their children in their own homes, and few mothers paid for childcare. Most carers were grandmothers, and research suggests that grandmothers have a strong role to play in decision making about childcare, infant feeding and child health in several African settings [20‐22]. A holistic approach to encouraging breastfeeding among working women should therefore involve the carers who feed the child during working hours, and family members who influence decision-making about childcare. Interventions to improve feeding practices should therefore not only be situated in the workplace but community-based support for childcare could play an important role, and the support of families and communities is likely to be important for success of any proposed intervention.

A range of interventions in the work environment have shown to successfully support breastfeeding in the formal work sector. These include educating mothers about how to continue breastfeeding while away from their child, and providing physical facilities for lactating mothers, including for expressing and storing breastmilk [16]. Mother-friendly work places can effectively support breastfeeding, by providing breastfeeding breaks, flexible working hours, and facilities for the child to stay with the mother safely in a work environment that may otherwise be hazardous [17‐20]. Many of these interventions may be adaptable to informal work settings, and employers and/or co-workers could be an important resource to support mothers to breastfeed safely by assisting to provide the time, space and opportunity for mothers to care for their children during working hours.

In addition, it has been suggested that breastfeeding rates could be higher among informal workers because of the flexible nature of informal work, and that working mothers may even choose informal work for this reason [26, 27]. However, a recent study of breastfeeding practices in KZN reported 90.0% of mothers of children aged 14 weeks initiated breastfeeding [30], compared to 84.2% of mothers in this study. This suggests that in our setting breastfeeding is not higher among informal workers, but further research is needed to confirm this.

In the two sectors included in this study, domestic workers appeared to work in better circumstances than informal traders because of the nature of their work. Domestic workers frequently lived in relatively well-resourced situations, often in the home of their employer, and were generally better paid, more likely to receive sick pay, and to work indoors, compared to informal traders. However, despite this, domestic workers were significantly less likely to be taking their child to work, suggesting that they may be unable to take their child to the employers’ household during working hours. This highlights the diverse and unpredictable nature of informal work, so that informally working women in sectors not included in this preliminary study, for example workers in informal shops or factories, or working at home making crafts, are likely to have different childcare challenges. A variety of different approaches will be required to support informal women workers and their children and proposed interventions should be flexible and adaptable to different work settings.

Access to health services was good in this population and similar to the general population of mothers in SA [18]. Mothers usually take the child to the health facility themselves, despite this being associated with possible loss of earnings, providing an opportunity for health workers (HWs) to give mothers appropriate and relevant support for infant feeding throughout the perinatal period. Research suggests that support or advice from HWs can improve breastfeeding practices [19], but it is important that HWs be aware of the particular challenges and vulnerabilities of women in informal work and provide infant feeding counselling relevant to the context in which these mothers find themselves. In particular, HWs require good practical information about maintaining breastfeeding while away from the child, and the challenges associated with achieving ongoing breastfeeding while working. Availability of good quality and relevant counselling could make giving expressed breastmilk to their child while at work a realistic option for many women. A substantial minority of our participants reported that they had given expressed breastmilk to their child, suggesting this practice is familiar to this community, and could be more widely supported and practiced.

A major limitation of this study is that it is not representative of all informal traders or domestic workers. This population is difficult to reach and there was no available sampling frame, so for this formative work we employed a non-probability sampling approach. This almost certainly led to bias towards selecting those sub-sectors of this community that were most visible and easily accessed. Women working at home or employed in other informal settings were excluded, in particular agricultural workers, and it is likely that other sectors have specific challenges. Comparisons between domestic workers and informal traders should be viewed with caution given that these populations were not representative of these sectors. However, our study provides useful preliminary work to inform a future research agenda. In particular, additional research is required to explore child care practices among working women in different informal work sectors and to identify possible interventions. It would be particularly important to employ qualitative methodologies to further explore the interactions between child care and the informal work environment, and to further understand what determines mothers’ childcare practices. Any proposed interventions should be carefully piloted and evaluated in different settings.

This study provides a preliminary description of this population of women who despite having stable work, are vulnerable, low paid and food insecure. Some opportunities for supporting these mothers to improve feeding practices have been identified from our results, and further research is required to develop and evaluate such interventions. However, any intervention should focus not just on the work setting but on the wider context of the mother’s life, including her home and community, and the role the health system can play in supporting the intervention. Investments in promoting breastfeeding will reap benefits in improved health and development of the children in these communities as well as improving the health of mothers.