RESEARCH

 

A qualitative study on breastfeeding experiences of employed mothers in manufacturing, retail and public sectors at designated workplaces in Worcester, South Africa

 

 

L C Daniels; X G Mbhenyane; L M Du Plessis

PhD; Division of Human Nutrition, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, Cape Town, South Africa

Correspondence

 

 

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ABSTRACT

BACKGROUND: The work environment presents major challenges for breastfeeding mothers through the physical separation of the mother and the baby post maternity leave
OBJECTIVE: To explore the experiences of employed breastfeeding mothers from designated workplaces (with more than 50 employees) in Worcester, South Africa
METHOD: This qualitative study was conducted using focus group discussions (FDGs). Employed breastfeeding mothers from designated retail, manufacturing and public workplaces were recruited from local communities. Eligible participants were those who had exclusively or predominantly breastfed their children for up to 6 months and had given birth within the last 24 months. A community fieldworker recruited participants and coordinated scheduling for the FDGs
RESULTS: Five FDGs (N=24) were conducted. The mothers described returning to work as emotionally and logistically challenging. Those who continued breastfeeding while working demonstrated a strong commitment to and belief in breastfeeding. Consistent enabling factors and main sources of support mentioned included immediate family members, such as grandmothers, siblings and spouses. The challenges identified were a lack of private spaces and time to express breastmilk at work, an unsupportive workplace culture and a lack of work-life balance. The support needs identified for a successful return to work while breastfeeding included flexible schedules, designated private spaces for expressing milk, supportive colleagues and managers and active engagement with senior management on breastfeeding support
CONCLUSION: There is a need for psychosocial support for breastfeeding mothers to manage the emotional demands of returning to work and logistical support, such as providing breastfeeding spaces and time for expressing breastmilk. Human resource managers, occupational health nurses and wellness officials should inform mothers about the recommendation to provide breastfeeding breaks at work. Engagement and advocacy efforts with workplaces and these stakeholders on the importance of breastfeeding support should be initiated

Keywords: Breastfeeding, experiences, focus group, employed mothers.

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Breastfeeding is one of the most natural, protective and cost-effective practices that mothers can perform to nurture and bond with their infants.^[1] Both the United Nations Children's Fund (UNICEF) and the World Health Organization (WHO) recommend exclusive breastfeeding for the first 6 months, followed by continued breastfeeding for up to 2 years and beyond.^[2] Success in breastfeeding is not the sole responsibility of a woman and involves many stakeholders from different environments.^[3,4] The 2016 Lancet series on breastfeeding identified workplace and employment conditions as significant factors affecting breastfeeding decisions and behaviour.^[4]

A non-baby-friendly work environment presents major challenges for breastfeeding mothers owing to the physical separation from their babies. Therefore, the transition period of returning to work is a critical time to provide support to help employees continue breastfeeding. Breastfeeding is important for both maternal and child health.^[4] It contributes to achieving Sustainable Development Goal 3 attaining good health and wellbeing.^[5] Providing breastfeeding support in the workplace offers several benefits, including an increased likelihood that mothers will return to work sooner. This support helps maintain work skills, reduces staff turnover and lowers absenteeism rates because breastfed babies are healthier compared to formula-fed babies.^[6,7]

In South Africa (SA), the exclusive breastfeeding rate remains low at 32%.^[8] Women employed in the formal market are entitled to four consecutive months of maternity leave. However, for many, this leave is unpaid, and mothers must claim from the Unemployment Insurance Fund if they have contributed to the fund for at least 13 weeks preceding their pregnancy.^[9] As a result, many mothers often return to work earlier as they do not have an income.^[10] The literature lacks a contextually rich understanding of employed mothers' breastfeeding experiences. This study explores the experiences of employed breastfeeding mothers who exclusively or predominantly (mainly breastmilk, may receive liquids and medicines) breastfed their children from birth up to 6 months. By exploring mothers' experiences, the study aims to identify enablers and support needs, which can help improve support for these and other breastfeeding mothers in the workplace.

 

Methods

This qualitative study was conducted using focus group discussions (FGDs). The study was conducted in Breede Valley, located in the Worcester area of Western Cape Province, SA. This setting encompasses workplace linkages to local, regional and provincial organisations (e.g., government departments), as well as national-level entities (retail stores and large commercial food companies).

A community fieldworker with experience in qualitative research recruited mothers who met the inclusion criteria. The inclusion criteria were employed breastfeeding mothers who exclusively or predominantly breastfed their children from birth for any period up to 6 months and who had given birth within the last 24 months. Convenience and snowball sampling were used for recruitment. The researcher contacted a community fieldworker in the area to identify employed mothers who met the inclusion criteria and displayed advertisements within the communities. The fieldworker completed the community recruitment form for interested mothers. These mothers were then contacted with details about the date, time and venue of the FGDs. The FGDs were conducted in February and March of 2018.

Permission to conduct the study was obtained from the Health Research Ethics Committee of Stellenbosch University (Ethics approval number: S17/04/089). Written informed consent was obtained from all participants, including separate consent for audio recording the discussions. Each participant received a copy of the consent form. The principal researcher conducted all the FGDs in Afrikaans (one of the official languages in SA), which was preferred by most participants. Confidentiality was discussed with all participants at the start of the FGDs.

A discussion guide was developed to direct the FGDs, including introductory questions and probes. Participants also completed a short one-page demographic questionnaire before the discussions commenced. All five FGDs were held at a central and convenient venue in Worcester. The fieldworker assisted with transport to the venue, managed logistical arrangements and observed participants' non-verbal cues. Refreshments were provided at each FGD and participants were reimbursed for their time. Additionally, one pilot FGD was conducted with employed breastfeeding mothers residing in the Cape Metropole district to test the FGD guide.

The information gathered from the FGDs was transcribed by a professional transcription service. Following transcription, the first author conducted quality control checks to ensure the accuracy of the captured information. Data analysis was performed using the Atlas ti 8.2.31 software program.^[11] The first author systematically worked through the transcripts, applying open coding to the text. Codes were then categorised and condensed into overarching themes, with thematic content analysis employed. An inductive approach was used to develop themes from the data. To ensure comprehensive theme identification and to check for inconsistencies, the text was reviewed multiple times. Co-authors engaged with the themes after the first draft was completed, reviewing and deliberating on the emerging themes.

 

Results and Discussion

Five FGDs, with four to six participants each, were conducted with employed breastfeeding mothers (N=24) from the retail, manufacturing, and public sectors. One of the FGDs (n=4) included employed breastfeeding mothers who were professionals working at government health facilities, comprising one pharmacist, two information clerks and one medical officer. This group was classified as the health professional group. The majority of the participants were employed as general workers in manufacturing (n=16), with others in retail (n=2) and community health (n=2) from non-profit organisations, collectively classified as the non-professional group.

Four themes emerged: (1) breastfeeding motivation and attitude, (2) combining breastfeeding and work, (3) breastfeeding challenges and (4) workplace breastfeeding support needs.

Breastfeeding motivation and attitude

The theme was discussed under two sub-headings: value and belief in breastfeeding and commitment and planning for breastfeeding.

Value and belief in breastfeeding

It was apparent that the motivating factors for these mothers to breastfeed included their belief in the benefits of breastfeeding, such as providing the best nutrition for their child, promoting health and fostering bonding with the child. Some mothers also mentioned financial benefits as a motivation. Among the professional health group, all participants felt compelled to breastfeed owing to their work environment and their awareness of the benefits of breastfeeding. This aligns with a study conducted on female medical doctors in SA, which found that being a doctor influenced the participants' breastfeeding duration, both positively, as they understood the benefits of breastfeeding, and negatively, in terms of time limitation, infrequent presence at home due to overtime work, poor facilities for expressing breastmilk at work and increased anxiety and stress experienced in the profession.^[12]

'I think for me, there was no alternative. I knew all the benefits of breastfeeding and it was never in my mind that I will give my child a bottle. When I had my baby shower, everyone gave bottles and I said: but why are you giving me bottles? I am going to breastfeed my baby. It was always a given that I would breastfeed him. (Health professional group 1, P1)

Commitment and planning for breastfeeding

The health professional mothers showed a strong commitment to breastfeeding by planning their schedules to either express milk at work or return home to breastfeed their infants, as highlighted by one mother who said, till today. I go home every lunch hour to breastfeed my child'. (Health professional group 1, P2)

Similarly, non-professional mothers also showed dedication by breastfeeding their infants before leaving for work and again upon returning home.

'So in the morning when I leave home then I would give her breastmilk, through the day she has nothing. So again, in the evening when I am home, I will breastfeed again. (Non-professional group 3, P3)

Two other studies similarly found that maintaining breastfeeding while returning to work requires significant commitment from mothers.^[13,14] A UNICEF review^[3] also showed that personal traits, such as commitment, assertiveness and a strong belief in the importance and benefits of breastfeeding are common among mothers who successfully manage to breastfeed while working. Research from SA has shown that while mothers value and want to breastfeed, they often doubt the adequacy or quality of their breast milk.^[15] In contrast, the mothers in this study demonstrated the value of and a strong belief in the benefits of breastfeeding. Therefore, it is essential to help mothers develop a belief in the advantages of breastfeeding. Healthcare workers, including professionals and occupational health nurses, need to continue promoting and emphasising the importance and benefits of breastfeeding.

Combining breastfeeding and work

This theme will be discussed under two sub-themes: emotional stress and enabling factors for combining breastfeeding and work.

Emotional stress

The mothers experienced the return to work as challenging. Many reported that their children did not want to feed on anything else but breastmilk. Some mothers indicated that their babies only wanted breastmilk from the breast and refused expressed breastmilk from a bottle, which posed a significant challenge. Most non-professional mothers indicated feeling uncomfortable at work with full, painful breasts owing to work pressure and lack of time to express milk. This created stress for the participants.

'Then if one tells them about one's breasts, they are like it looks now you're lying to them now or you want to sit outside, they don't understand how uncomfortable it is. They just want you to do their job, they don't worry about you'. (Non-professional group 1, P1)

'So then you have to work with those painful breasts now, it's full, sometimes you get glands under your arm pits and there is no support processes at works, because you can't go and tell your team leader but I just want to go milk my breast out soon. (Nonprofessional group 2, P1)

Wolde et al.^[16] similarly reported that mothers face emotional stress, worry and instability when trying to continue breastfeeding while working. Another SA study found that employed mothers in a provincial government setting experienced stress from balancing work demands with their infant's breastfeeding needs.^[17]

Enabling factors for combining breastfeeding and work

Regarding the support that enabled mothers to breastfeed exclusively or predominantly, the main support mentioned by all participants was from their immediate family-their mothers, grandmothers, siblings and spouses. This support mainly involved assistance with household duties, encouragement, motivation, and advice. Among health professional mothers, spouses were highlighted as their biggest supporters, providing significant encouragement and motivation. These mothers often discussed the importance of breastfeeding with their husbands. The difference in support could stem from the fact that professional mothers can afford a house and live independently with their spouses/partners, while non-professional mothers with limited income often live with other immediate family members, such as parents or grandparents. This close proximity to their immediate family members provides additional support.

'you can do it ... you're doing the right thing. So he was all the way, like, he was sold out (meaning convinced that it's the right thing). I think he also, from what I've spoken about before about breastfeeding, he was sold that it's the way to go. (Health professional group 1, P4)

These findings align with other research indicating that practical and emotional support from partners during maternity leave and after returning to work is crucial.^[18] Tsai's^[19] study found that partners' initial support for breastfeeding significantly predicted the intention to continue breastfeeding once the mother returned to work.

Breastfeeding challenges

This theme is discussed under three subheadings: lack of breastfeeding space and time at work, unsupportive workplace culture and work-life balance.

Lack of breastfeeding space and time at work

The workplace was identified as the biggest challenge to breastfeeding, primarily because of the physical separation of mothers from their children for 8 - 9 hours a day. Common workplace challenges included a lack of designated space and time for breastfeeding, as well as poor communication about the topic. Participants reported having no designated breastfeeding area at work, with some having to use the toilet or their car to express milk. Two participants shared,

'And then when your breasts are so full, then you can't sit in the toilet for a long time either, because the farmer come knocking on the door, "get done, you can't," we working ...'. (Non-professional group 3, P4)

'If you want to go and express your milk out, then you just have to go into the toilet. (Non-professional group 4, P4)

A study in Ethiopia found that the absence of a breastfeeding break time was significantly associated with the cessation of exclusive breastfeeding (adjusted odds ratio (AOR) 6.7; 95%CI 3 - 14.5).^[20] Regarding the provision of time, most mothers reported using their lunch breaks for expressing milk owing to a lack of time allowance. During the discussions, professional mothers also mentioned a lack of awareness about the Department of Health's breastfeeding policy^[21] and the entitlement to breastfeeding breaks. This lack of awareness was true for most mothers in the FGDs.

'We did not know that there is a law that states: that we can get a half an hour extra for breastfeeding and so...'. (Health Professional group 1, P2)

This lack of awareness about the recommendation to provide mothers with breastfeeding time and non-compliance with the Code of Good Practice on the protection of employees during pregnancy and after the birth of a child may be due to employers' concerns about costs in providing a space and the influence on staff productivity. Advocacy is needed to raise awareness about breastfeeding support needs and the recommendation for breastfeeding breaks in the workplace.

Our findings show that employed breastfeeding mothers are generally unaware of the recommended breastfeeding breaks according to the South African Basic Condition of Employment Act of 1997 Section 87(1)(b) Code of Good Practice on the protection of employees during pregnancy and after the birth of a child.^[22] Increasing awareness among mothers would ensure that they advocate for this entitlement and not use their lunch and tea breaks for expressing breast milk. The relevant shop stewards and occupational health nurses at these workplaces are in a unique position to create more awareness, ensuring better adherence to the recommendation and improving breastfeeding support in the workplace.

Unsupportive workplace culture

Participants reported significant challenges with unsupportive supervisors and staff, who often did not permit or express irritation when employees requested time to express milk. Some participants noted that supervisors were distrustful and did not understand the need for breastfeeding breaks. The workplace was generally perceived as very strict, reflecting an unsupportive culture and a lack of knowledge about the Code of Good Practice regarding breastfeeding breaks. These results are consistent with findings in the literature, which identify issues faced by breastfeeding mothers, such as inadequate space, lack of breastfeeding time and lack of support from employers and co-workers.^[18,23]

'If I tell our supervisor, I cannot pack the boxes anymore, my breast is full then he will tell me, then he tells me you cannot tell me this, the boxes must go on the roller, so ...'. (Non-professional group 1, P6)

Other work-related challenges included fear of communicating with supervisors owing to anticipated negative responses, being told they are replaceable and threats of job loss. These issues point to potential victimisation and discrimination, which should be reported to labour unions, human resource managers and/or whistleblowing facilities at the Department of Labour. Similarly, another SA study found that even highly educated mothers lacked the confidence to request support for breastfeeding despite holding professional jobs.^[16]

'You're too scared to communicate with them (the workplace) because you already know what the answer is going to be'. (Nonprofessional group 1, P2)

'They say "take your stuff and go.' (Non-professional group 4, P5) 'He's going to tell you you're replaceable. That's what happens. (Non-professional group 4, P4)

Work-life balance

Another challenge that indirectly relates to the workplace is the struggle to balance breastfeeding with household duties. Employed breastfeeding mothers face the added stress of managing their infant's care by expressing milk at work so that there is breastmilk for the following day. At home, they juggle caring for their baby, breastfeeding, household responsibilities, caring for their other children and fulfilling the role of a partner. This imbalance between work and family life often makes breastfeeding the most challenging to sustain. Often when there is a work-life imbalance, mothers forgo their duty to breastfeed.

A study by Jantzer et al.^[24] found that reduced workplace support leads to greater interference between work and personal life. Research further indicates that working mothers who continue breastfeeding experience more family-to-work conflict and overload compared with those who do not.^[25] Imbalances in work and family life are significant barriers to exclusive breastfeeding.^[26] Therefore, breastfeeding mothers need robust support from both family and workplace to maintain a healthy work-life balance. Additionally, adopting flexible workplace arrangements, such as part-time work, job sharing, flexible working hours and assistance with daycare,^[9] can help mothers manage this balance effectively.

'When you get home, then you need to sit and feed the child and the house needs to be cleaned and washing must be done, the food must be......So that was very stressful for me. (Health professional group 1, P3)

'I need to be able to sit in the tea room in a specific spot where I know I can milk myself out .... So tonight I can take it home, then there's extra milk again for tomorrow when I'm not home now, to be able to breastfeed her...'. (Non- professional group 1, P6)

Workplace breastfeeding support needs

Mothers generally felt that the workplace should be more accommodating to breastfeeding needs. Several needs were identified by the participants to support successful return to work and breastfeeding. Flexible times for breastfeeding and providing the time to express, the provision of information to staff and breastfeeding women regarding policies and their rights. Also, a crèche facility near work, supportive staff, colleagues and managers, private rooms and spaces to express breastmilk were also identified needs. Accommodating mothers after their maternity leave, especially in respect of physical work and shifts and the provision of resources, e.g., cups to express, and availability of a nurse. Other support mentioned was communicating or having a meeting with senior management relating to support for breastfeeding in the workplace.

At the government level, participants identified the need for legislation or recommended policies to mandate space for expressing breastmilk at work, provide resources like breast pads and expressing cups and prioritise the promotion of women's breastfeeding rights and workplace support.

 

Conclusions

The research has demonstrated the need for psychosocial and logistical support for breastfeeding mothers returning to work. Psychosocial support is crucial to address the emotional challenges, while logistical support includes providing designated breastfeeding spaces and time for expressing breastmilk. Human resource managers, occupational health nurses and wellness officials should inform mothers about the recommended breastfeeding breaks. Adopting family friendly arrangements, such as part-time work, job sharing and flexible working hours, is essential to support continued breastfeeding. Advocacy for improved workplace breastfeeding support and adherence to the recommendations for breastfeeding breaks is also needed.

Declaration. None.

Acknowledgements. The authors wish to acknowledge all the participants who took part in the study.

Author contributions. LD conceived the study and the protocol, planned the research, undertook data collection with the assistance of a fieldworker, captured, analysed and interpreted the data and drafted the article. Co-authors, XM and LdP, provided input at all stages of the research and revised the protocol, provided input on analysis and interpretation and reviewed the article. All authors contributed to critically revising the article and gave final approval of the manuscript.

Funding. This research was supported by the National Research Foundation Thuthuka (TTK1704192276830), Stellenbosch University HOPE project and Stellenbosch University Early Research Career. The stated funders had no role in the design, analysis or writing of this article.

Data availability statement. The datasets generated and analysed during the current study are available from the corresponding author upon reasonable request.

Conflicts of interest. None.

 

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Correspondence:
L C Daniels
ldaniels@sun.ac.za

Received 19 December 2023
Accepted 5 June 2024