In South Africa 14 FGDs were conducted and nine FGDs were conducted in India (see Table 1).The duration of the discussions varied between 50minutes and 1hour 20minutes. It was not possible to determine whether any participants refused because recruitment was undertaken by local informal worker organisations. Demographic characteristics, including type of work, of South African and Indian participants are provided in Table 2.
Table 1. Description of focus group participants in India and South Africa
Table 2: Participants’ demographic details
The benefits of breastfeeding were well understood
Women in both countries strongly valued and acknowledged the importance of breastfeeding for child health and development. Most of the women reported having initiated breastfeeding after birth and showed themselves to be knowledgeable about the benefits of breastfeeding. The reported benefits for children ranged from cognitive and physical development to protection from infection or disease.
’What made me to choose breastfeeding is that I wanted her to grow up well, be intelligent and also have strong bones for when she starts to crawl. I wanted her to be fit and proper. A mother’s milk is important. I also could not afford to give her formula. There was no money’. Female street trader, rural, South Africa
Mothers showed themselves to be knowledgeable about the hazards of formula feeding. Several women gave examples of how they perceived that their children were healthy because of being breastfed, or that their children became sick or did not grow well once breastfeeding was stopped.
“Just to emphasize, breastmilk is healthy for the baby. He needs it in every way such that I am a living witness of that. My first child is now 13 years old and he’s never been to a doctor; he’s never been sick to need a doctor.” Female waste-picker, urban, South Africa
Breastfeeding was also seen as a convenience especially in financial terms given the expense of purchasing alternatives. Mothers could also avoid the special preparation required with formula milk or other milk such as buffalo milk which had to be boiled and mixed with water. For example:
“There is formula milk that is available, and people ask us to give the child that, but it is so expensive that we are not able to give it. Breastmilk is free. Sometimes we give the milk we get outside for Rs.10-15 to the child, but if we do not have money to buy milk, we mix sugar and water and give it to the child”. Female street/market trader, India.
Breastfeeding practices changed on returning 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.
“When I went to work, I expressed for him, because I had milk I wouldn’t buy the tin (formula milk). I would express for him so that I could leave him with my milk that would cover him for the whole day until I came back” Domestic worker, rural, South Africa.
Mothers in both India and South Africa, however, raised hygiene concerns with expressed milk. For example, women in India perceived expressed milk as “spoilt” once it had left their breast. This was coupled with the lack of infrastructure to support it, such as a fridge at home.
“It is not a question of me feeling okay with pumping or expressing milk – the milk can go bad. When the child drinks directly from the mother that is the right way. If it (breastmilk) is exposed …then it goes bad…It becomes poison outside. Yes, there are more of disadvantages. The milk breaks. It becomes yellow and green. I have never done it, neither have I heard about anyone doing it.” –Domestic worker, India.
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 viewed the stopping of exclusive breastfeeding as a strategy of care so their infants could get used to their absence on return to work. For example:
“Many mothers-in-law tell their daughters-in-law to get the infant used to buffalo (milk) in a week of delivery, so that she can resume her work again. Usually within 40 days the infant has started drinking multiple things.” Pheri vendor, 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 mother becomes thin and weak and the child becomes healthy/fat. If the child is weaned after a year, then it is better. It takes a toll on the mother. My child drank up to his 3rd year. I had to apply neem [bitter] leaves on my breasts to make him stop being so dependent on my milk.” Domestic worker, India
Women faced a range of constraints that prevented them delaying their return to work
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. My mother works hard at the (taxi) rank. The child’s father disappeared a long time ago. He is absent. So I decided that it was not right for me to ask for everything from my mother whereas she is also supporting my two children. So I decided to go out to look for a job. It is quite difficult to be a woman. I do not want to lie.” Female street trader, rural South Africa.
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. If the children need anything for their studies and my husband’s income isn’t enough, then I should be able to get it for him/her. If I would ask him to give me money for anything out of ordinary, he would get angry. I started working to earn some money to be able to cover such expenses, but soon I was taking care of most expenses.” Female market/street trader, India
Likewise, in South Africa many women received limited or no financial support from the father of their children. In some cases, a small child support grant, eased participants’ return to work by providing enough money to sustain the household.
“My mother helped me at home. The social grant also helped. My sister who is in Johannesburg - she is my cousin – when I called her and told her that we were starving at home and it was going to be a while before the social grant pay date, she would ask me how much I needed, and I would tell her any amount that she can afford.” Female street trader, rural, South Africa
Work flexibility and stability
The benefits of informality meant women were able to take on work that was more flexible. For example, informal work afforded some pregnant women and mothers flexibility in terms of adapting their work to their circumstances. Some participants were able to change from market or street vending to home-based work (such as doing laundry) which enabled more time for rest and child care. Informal work also gave women independence and the opportunity to provide for themselves and their babies.
“I got my last born child, when I got him I was selling brooms in Johannesburg but because I am now pregnant I wasn’t able to go to the hill and fetch the material, I stayed at home and I did laundry for people until I gave birth. I waited for 3 months, when he turned 4 months I started again to help people with their laundry and I stopped now that I’m selling mealies”. Female street trader, rural, South Africa.
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.
“They told me that when I’m ready I will still have my job, I should just go home and raise the baby. I raised my baby when I called them to tell them that I’m ready (to return to work) they told me to wait a bit it’s still quiet at work but there were people working…there was someone who was working on my account, but I couldn’t come back because I had a baby.” Domestic worker, urban, South Africa.
Women in India also had concerns about loss of work after childbirth, however, their concerns were related to the limited work options available to them that were more suitable to their situation. For example, women claimed it was simple to resume self-employed work, such as street vending, but it was not always the best option for child care.
“If I could get a home-based part time job I would be able to look after my child better. In our community women only work as pher-waalii, there is no other option. I would want to try options other than pheri.” Pheri vendor, India
Experiences of breastfeeding when returning to work
Sociocultural barriers to child care, including lack of privacy
Male participants in both countries displayed an ambivalence towards women breastfeeding in the workplace. They acknowledged the value of breastfeeding and were sympathetic to women working who were breastfeeding. However, there was frequently a strong feeling among male participants that women had to cover themselves while doing so.
“My opinion about breastfeeding by women in the market is tolerance even when it is difficult. If your neighbour is a woman, you cannot say to her “go and breastfeed somewhere else far from my table”. You have to be tolerant and she must cover up whilst the baby is feeding.” Male street vendor, urban, South Africa
Male vendors in India spoke about the concerns of privacy and respect for women who chose to breastfeed in public spaces.
“There are men who would whistle or tease women, but as far as I can speak for myself and the men around me there is a different opinion for breastfeeding mothers. If there is a breastfeeding mother, then most people turn away when they see what she is doing. If a woman were wearing the same clothes and standing by herself I’m sure we would look her up and down and keep staring but not for a breastfeeding mother.” Male market trader, India
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 India home-based workers were able to breastfeed their children during work hours in the privacy of their homes because their home and worksite overlapped. Domestic workers strategized to breastfeed their children in the early morning, afternoon and late evening in their own homes by making frequent visits back and forth between worksite and home in a day. Pheri women who took their children to the market where they sold second-hand clothes faced criticism about breastfeeding in public but continued nonetheless. This was true for most of the women in India who, despite feeling embarrassed to breastfeed in public spaces, attempted to overcome their discomfort by placing a scarf or the open end of a sari across their chest when breastfeeding.
“See, the thing is you have to cover yourself with your aanchal (part of a sari garment). What can you do? You have to feed your child. There’s no option when it comes to that.” Female Fruit and Vegetable Vendor, India.
Women in South Africa expressed it was culturally unacceptable for women to breastfeed in public. This was reinforced by male participants who explained that cultural norms prohibit the showing of breasts in public, although young girls are permitted to show bare breasts. For example, according to Zulu culture in South Africa, women who had recently given birth or were breastfeeding were considered unclean and should not handle or serve food. It was said people felt “disgusted” by a food vendor who was a breastfeeding mother and male customers in particular would experience misfortune if they consumed her food. Many women street traders recalled having to hide when breastfeeding their children in the workplace, or otherwise “return home with all my goods not sold.”
“Eh…let me expand by touching on culture although some of us no longer take it into consideration when working with women who recently gave birth. Working with her and buying food prepared by her is culturally unacceptable because she is supposed to be home until at least a child is 5 or six months old.…You wouldn’t come near or touch your child until about six months. Some of us still observe that ritual because if we don’t observe it, accidents befall you, even bad luck. It also weakens the muthi (medicine to strengthen manhood)” Male street trader, urban, South Africa.
Physical environment can be hazardous
Despite the varied work environments of participants, most work settings were perceived by male and female participants to be unsafe and unhygienic for breastfeeding and childcare. Waste pickers, in particular, were not always able to keep clean or wash themselves before breastfeeding. In India, street vendors were afraid of exposing their infants to extreme weather conditions during vending hours. The difficulties of focusing on work while caring for small children meant children could be less safe in the workplace. Participants voiced their fears about children getting lost, kidnapped, left unattended and exposed to violence and crime. Other situations included children being exposed to chemicals, faecal matter and eating out of dustbins. Several participants gave examples of where children had been injured or even killed.
“You can’t take your child to the market. Forget the heat and the winter, someone will pick my child up! Or he will destroy all the piles of vegetables I’ve put up!” Female Fruit and Vegetable Vendor, India
Work responsibilities and proximity with the infant
Some women reported that breastfeeding was time consuming and impractical to continue on return to work. Workplace conditions (a pavement for street vendors; or a private home for domestic workers) often hindered the proximity between mother and infant needed for breastfeeding. The logistics of keeping a child close were a challenge, especially for mothers who worked as waste pickers or vendors as they often walked long distances and carried heavy loads.
“I do not take my child with me to work; I wouldn’t be able to because you sometimes have to carry a lots of cardboard; sometimes I walk a long distance say from here to that Cambridge so I am unable bring him with me.” Female waste-picker, urban, South Africa.
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.
“Should I work or should I take care of my child? They’ll create a mess in the kothi and I’ll get yelled at. Even if I didn’t get yelled at, why would I want to clean double the mess in someone else’s house?” Domestic Worker, India