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

Depression represents a huge burden of disease globally, particularly among women during pregnancy and in the post-partum period [1]. Depression in pregnancy and after childbirth is highly prevalent in low-income countries, especially in high poverty settings [2‐4]. In South Africa (SA) estimated rates of depression in the antenatal period range from 22 to 47% [5‐7], and several studies suggest that about one-third of postnatal women are at high risk of depression [8‐11]. Depression contributes heavily to the overall disease burden in SA [12], and recent evidence suggests that perinatal anxiety disorders are also prevalent [13].

Depression is associated with significant life challenges, including poverty, unstable income, food insecurity, lack of partner support, violence and poor health [9, 10, 14‐17]. Maternal depression reduces quality of life and is a leading cause of disability and poor maternal health outcomes, especially in the context of HIV [11, 18]. Further, maternal depression has been associated with adverse effects on the quality of the mother-infant relationship and child development outcomes [4, 19], which can have implications for young children’s long-term psychosocial, cognitive, and economic well-being [10, 11]. Maternal mental health is therefore an important public health concern in SA, however it is frequently neglected and continues to be of low priority in health care practices [3, 7].

Food insecurity is defined as having uncertain or limited availability of nutritionally appropriate food or being unable to procure food in socially acceptable ways [20, 21]. Depression and food insecurity frequently occur together. Food insecurity has been shown to be strongly associated with depression [22], and depression in mothers in low-income households may be a predictor of household food insecurity [23]. Household food insecurity is associated with poor health, development and behavioural outcomes among children [24, 25], and is common in SA, with around 25% of the population considered food insecure [26].

Informal work is frequently associated with vulnerability and poverty, particularly financial and food insecurity [27, 28]. Of the 6.8 million working women in SA, almost 2 million work informally, the largest groups being informal traders, agricultural workers and workers in private homes (domestic workers) [29]. By definition, informal workers do not have access to income protection including unemployment, sickness and maternity benefits. The period during pregnancy and after childbirth is a vulnerable time for all mothers since childcare and household responsibilities often fall disproportionately on women [29]. In SA, female-headed households are common (43%) [30], and it may be especially difficult for mothers in informal work, often already vulnerable due to their working conditions and reduced earning potential, to manage ongoing childcare and household responsibilities [30]. Several studies have shown how poverty and food insecurity interact in a vicious cycle among socially and economically deprived populations, leading to depression and poor health outcomes among women [9, 15].

Thus, factors associated with food insecurity and depression are likely experienced by women working in the informal economy. However, little focus has been given to the multiple risks of depression facing female informal workers and data is sparse among this population group, especially in low- and middle-income settings [16]. Data from one Brazilian study suggests a higher risk of psychological symptoms among women informal workers compared to formal workers living in the same neighbourhood [31].

Women who work in the informal economy in SA as a group are particularly neglected in maternal and child health programmes, and there have been no attempts to address their particular needs [32]. For example, informal workers face barriers that may prevent their seeking antenatal, immunisation or reproductive health care services, but no provision is made for them to attend outside of working hours or be fast-tracked so they can return to work. To address this gap, we conducted this study to explore the interaction between informal work, food insecurity and depression among women with young children working in the informal economy in urban and peri-urban areas of Durban, KwaZulu-Natal (KZN) Province, SA.

A cross sectional survey methodology was employed to explore the work setting and conditions, income, food security and risk of depression among informal working women with children under the age of 3 years.

A total of 265 interviews were conducted with mothers in informal work between December 2018 and March 2019. Just over 50% of participants had completed secondary school and nearly half were in a relationship but not living with their partner. Close to 50% of participants reported themselves HIV positive. Characteristics of participating mothers are shown in Table 1.

Despite the large number of women working informally in SA and throughout the Global South, very little is known about the relationship between informal work, food security and depression among mothers of young children working in the informal economy. This study sought to address this gap to inform the development of strategies to improve maternal and child health and enable more stable livelihoods for these women.

Our findings show that women in informal work were living in poverty, frequently on very low, unstable incomes despite being responsible for many household and personal expenses. Almost one third of women were earning < R1 000 per month, well below the upper bound poverty line for SA, meaning that this amount is insufficient to supply an individual’s basic food and non-food requirements [47]. Types of work, employment conditions and places of work differed among these women, with employed women and domestic workers benefitting from a relatively stable income and work environment compared to self-employed workers, particularly informal market traders. Informal women workers reported high levels of moderate or severe household food insecurity, when compared with the SA average. Most women took very little or no time off work after childbirth, most likely for financial reasons, and this was likely to affect their ability to breastfeed and care for their children. Studies have shown that inability to adequately provide for the households’ food needs is a key indicator of poverty, and is a significant source of anxiety and determinant of poor mental health [22, 48]. More multi-disciplinary interventions are needed to address these intersecting life challenges of informal working women using a cross-cutting approach [49].

The post-partum period is a vulnerable time for many women, one reason for this is the loss of income at the same time as they have the additional expense of providing for a new baby. Although some women who received the CSG experienced food insecurity, many women reported that the grant money they received for their older children helped support them during their maternity leave. This is supported by other studies, which have further shown that receipt of the CSG can reduce hunger, and improve child nutrition [50]. However, although the SA CSG is the largest cash transfer programme in Africa, reaching over 11 million children, the amount is insufficient to ensure adequate dietary diversity for children or protect low-income families from financial shocks [51]. The CSG is a cornerstone of poverty alleviation in SA but access to the grant remains a challenge, particularly for mothers in extreme poverty. Over 10% of women in our study did not receive any grant, and more needs to be done to address this [52]. In addition, payments start several weeks after the baby is born. Therefore, extension of the CSG to cover the antenatal period would improve coverage and be very likely to improve mothers’ ability to take time off work to breastfeed and care for their new baby.

The depression risk among our population was lower than has been found in several other studies in SA [5, 7, 8], and was similar using two different validated screening tools for depression. This relatively low depression risk was found despite women living in contexts of social and economic adversity and food insecurity, that are known to be associated with high rates of depression [15]. Employment is associated with improved self-esteem and being employed is associated with a reduced risk of anxiety and depression [53]. The support that mothers received from their own family, both financial and practical, could also be a factor in protecting women from depression. Another explanation for low rates of depression risk is that informal women workers may have built significant agency and resilience in response to the considerable adversities they have faced in the workplace. The converse may also be true if high levels of resilience enable women to identify and take up opportunities to generate income from informal work. A person displays resilience when they are able to adjust well to significant risk [54]. Although our study did not measure women’s sense of agency or resilience, it appears that informal workers are resourceful and empowered women who may have learned to actively buffer their health from life stressors. Very few studies are available that explain resilience among women in SA, let alone women who work in the informal economy who face many risks. More research is needed to understand, demonstrate and explain this resilience, as well as the role of social support, to inform more effective mental health interventions, particularly for marginalised women [54].

Most mothers relied extensively on practical and financial support from their family, including after childbirth and before their return to work. In particular, we found that receiving financial support from a current partner was an important mitigating factor for both food insecurity and depression. This suggests that the intimate partner relationship is central to women’s well-being, supporting findings from other studies [5]. However, despite being in a relationship with the father of their child, most women were living with their own family. This is common in SA because of the custom for men to pay a substantial bride price (known as “Lebola”) before marriage. As a result, while the child’s father contributed to the child’s expenses, this support did not extend to cover household running costs or women’s personal expenses, leaving women to carry the burden of providing a home for themselves and their child. Thus, these women experienced the ‘‘double-burden’’ of income earning work and managing childcare and household responsibilities. While this is common among women in many settings, it is likely that women working in the informal sector, with few labour protections, are particularly affected [30]. In addition, childcare is often considered to be the mother’s decision and her sole responsibility [55]. Encouraging positive gender and social attitudes towards childcare in the community and in the workplace through increased awareness of the importance of early nutrition and nurturing care, could strengthen the role of society, including social and public services, in supporting and protecting childcare. Clinic staff, community health workers, and local organisations could support awareness campaigns in the community to improve awareness of nurturing care.

Lack of service support and policy frameworks for women working in the informal economy means public authorities, employers and decision-makers currently have no responsibilities to engage with these issues. However, where there are informal workers working in formal work settings, for example undertaking casual cleaning or administrative work, labour regulations should be enforced. While some organizations have been active in advocating for women's rights and livelihoods [56], it will be important to further mobilise worker and women’s rights organisations and key decision-makers to acknowledge or advocate for the rights of informal working women and their children. This includes advocacy for maternity leave agreements, by-laws which support working pregnant women and mothers, the allocation of safer spaces for childcare facilities and the safe-guarding of trading spaces when pregnant women and mothers are away due to childbirth, breastfeeding or caring for their children. Providing social protection to informal working women during the perinatal period, such as through a pregnancy grant, extended CSG or community saving schemes, could safeguard women’s employment during late pregnancy or the early postnatal period, thereby stabilizing incomes and supporting women’s and children’s health, in particular by delaying the time to return to work after childbirth.

The health system also has an important role to play in addressing the interaction between food insecurity, depression, poverty and informal work. First, health services, including mental health care, should be free, available and accessible to informal working mothers and their children. This would require reorienting the health system so PHC opening hours and available services are organised to meet the needs of women working in the informal economy. For example, women start their trading or domestic work well before health facilities commonly open. As a result, women lose income if they attend a clinic, especially if it is a distance away. To enable more responsive, people-centred care, a solution could be to extend the role of community health workers (CHWs) from visiting homes to include visiting public spaces, which are also women’s workspaces.

Second, in addition to clinical services, women need the capacity, including personal and social efficacy, to sustain their livelihoods while ensuring infants are appropriately fed and cared for. Health providers have a critical role to play in providing life-skills training and mentoring support for women to enable them to problem-solve, plan, and make decisions about their lives and caring for their child. In addition, to support early nutrition and nurturing care, infant feeding and responsive childcare training would enable mothers and caregivers to make and implement optimal, evidence-based caregiving choices for their infants and young children.

Lastly, service support and health workforce strengthening are critical. For example, health care providers must have the capacity to confidently and competently provide services to women working in the informal sector and their children, and be supported by systems that invest in their professional development and well-being.

Our study provides unique and important insights into the association between food insecurity, depression, poverty and informal work among women in Durban, SA. The health and livelihoods of women working in the informal economy, and the health and well-being of their infants and young children are compromised by a vicious cycle of vulnerability. This presents a major public health concern, particularly as the high rate of food insecurity greatly increases the risk for poor maternal health and child health and development outcomes [5, 22]. Further research is needed to improve our understanding of these interactions, particularly the role of social support and resilience as a protective factor, and to understand how these interactions compare with women in formal work.