Formal maternal employment is associated with lower odds of exclusive breastfeeding by 14 weeks postpartum: a cross-sectional survey in Naivasha, Kenya

ABSTRACT

Background

In many low- and middle-income countries, improvements in exclusive breastfeeding (EBF) have stalled, delaying reductions in child mortality. Maternal employment is a potential barrier to EBF.

Objectives

We evaluated associations between maternal employment and breastfeeding (BF) status. We compared formally and non–formally employed mothers in Naivasha, Kenya, where commercial floriculture and hospitality industries employ many women.

Methods

We conducted a cross-sectional survey among mothers (n = 1186) from September 2018 to October 2019 at 4 postpartum time points: at hospital discharge (n = 296) and at 6 wk (n = 298), 14 wk (n = 295), and 36 wk (to estimate BF at 24 wk; n = 297) postpartum. Mothers reported their BF status and reasons for EBF cessation. We used multivariable logistic regression models to test the association between formal maternal employment and 3 outcomes: early BF initiation (within 1 h of birth), EBF at each time point, and continued BF at 9 mo. Models were informed by a directed acyclic graph: a causal diagram used to characterize the relationship among variables that influence the independent (employment) and dependent (BF status) variables.

Results

EBF did not differ by employment status at hospital discharge or at 6 wk postpartum. However, formally employed mothers were less likely than those not formally employed to report EBF at 14 wk (59.0% compared with 95.4%, respectively; AOR: 0.19; 95% CI: 0.10, 0.34) and at 24 wk (19.0% compared with 49.6%, respectively; AOR: 0.25; 95% CI: 0.14, 0.44). The prevalence of continued BF at 36 wk did not differ by group (98.1% for formally employed compared with 98.5% for non–formally employed women; AOR: 0.80; 95% CI: 0.10, 6.08). The primary reasons reported for early EBF cessation were returning to work (46.5%), introducing other foods based on the child's age (33.5%), or perceived milk insufficiency (13.7%).

Conclusions

As more women engage in formal employment in low- and middle-income countries, additional supports to help prolong the period of EBF may be beneficial for formally employed mothers and their children.

Introduction

Exclusive breastfeeding (EBF) for the first 6 mo is among the most effective practices to promote survival during infancy (1–3). The universal scale-up of EBF could prevent over 800,000 deaths annually in children under 5 y (4). EBF reduces the risk of infections among infants, including diarrheal disease and pneumonia, and reduces the breast cancer risk among mothers (2, 4, 5).

In many low- and middle-income countries (LMICs), EBF coverage for the first 6 mo remains below international targets, and improvement has stalled in the most disadvantaged communities (4, 6). Despite nearly universal breastfeeding (BF) initiation in Kenya (62.2% within 1 h and 90.6% within 1 d of birth), only 42% of mothers maintain EBF through the recommended period of 6 mo (7). However, most Kenyan children (90.0%) continue BF for at 1 y (7). Following guidance on Infant and Young Child Feeding (IYCF) practices for HIV-infected women in 2010 (8), EBF promotion efforts have improved and the availability of antiretroviral therapy has increased, leading to improved EBF practices for the HIV-infected population (9).

Over the past 2 decades, there have been sharp increases in the proportion of women in the workforce and shifts from informal to more formalized work among women in LMICs (10, 11). These changes have been, in part, due to economic development strategies aimed at promoting women's employment to improve health and alleviate poverty (12). Approximately 50% of women in LMICs are employed (11).

Data on maternal employment and IYCF practices in LMICs are limited and inconclusive. A recent 49-country study found that formally employed mothers may breastfeed for shorter durations compared to informally employed mothers who work without legal and social protection (13). While maternal employment is the most frequently cited barrier to EBF in LMICs (14), there is conflicting evidence in single-country studies, which may be due to different employment classifications and the nature of the employment and EBF relationship (15, 16). Both behavioral interventions, such as IYCF education, and workplace accommodations, such as paid breaks, hygienic lactation spaces, on-site daycare, and national laws on maternity leave, may mitigate the adverse effects of employment on BF (17–20). In Kenya, current policies require employers to provide lactation breaks and suitable lactation facilities, including refrigerated storage for expressed milk and a paid 3-mo maternity leave (21–23). It is unclear how the type of employment influences BF. Commercial farms have led efforts to implement maternity and BF-support policies in Kenya.

Given the limited evidence and recent policy changes in Kenya, a better understanding of employment and the BF relationship is critical to better target interventions and supports for this population. The objective of this study was to evaluate the associations between formal work and the early initiation of BF, the duration of EBF, and continued BF practices among mothers in Naivasha, Kenya, and to describe factors related to these practices.

Methods

Overview

Between September 2018 and October 2019, we repeatedly conducted cross-sectional surveys at 4 postpartum time points to investigate the associations between maternal employment and BF practices in Naivasha, Kenya. We hypothesized that formal employment would be associated with a lower prevalence and reduced odds of BF at each time point and across each indicator (early initiation of BF at 0 wk; EBF at 0, 6, 14, and 24 wk; predominant BF at 0, 6, 14, and 24 wk; and continued BF at 36 wk).

Study setting

Naivasha is a peri-urban city in Nakuru County, located 100 km north of Nairobi, with a population of ∼355,000 (24). This area contains the largest concentration of commercial flower farms in the country, which are the primary sources of employment in this region. The majority of flower farm employees reside in several densely populated peri-urban informal settlements, with varying access to electricity and sanitation services. Employment within the floriculture industry is characterized by long commuting distances and separation from children, compared to employment in the informal sector (e.g., tailoring, subsistence farming, self-employment, trading), where women have more flexible schedules and BF opportunities (25).

Study participants and recruitment

Mothers were recruited 1–4 d postpartum and at routine infant immunization visits at 6, 14, and 36 wk postpartum at 2 public facilities (the Naivasha Sub-County Referral Hospital and the Karagita Dispensary) and a private facility subsidized by a local floriculture company that serves farmworkers (the South Lake Medical Center). All postpartum women with a live birth admitted to the maternity wards or presenting for immunizations to the health facilities on recruitment days were screened for eligibility. Mothers who were 1–4 d, 5–7 wk, 13–15 wk, or 9 mo (± 1 wk) postpartum were eligible, regardless of past or present child morbidity. Screening did not include evaluating mental health status. Health center staff introduced mothers to the research team. The research team explained the study purpose to all mothers present for immunizations and within the maternity wards through group announcements. Upon recruitment, we obtained written, informed consent from all participants. Surveys were administered verbally by a team of 5 trained research staff in Swahili, English, or another preferred language of the mother, using paper questionnaires. Mothers were eligible to participate once in the cross-sectional survey.

Data collection tools

The survey collected information on 5 domains: 1) household assets and demographics; 2) employment status and benefits; 3) IYCF practices; 4) access to reproductive and other health services; and 5) health status of the child and the mother.

Household assets and demographics

We queried participants about their household assets (house material composition, vehicle, television, mobile phone) and demographics (educational attainment, household income, marital status, household size, parity, religion, and tribe) using questions from the Demographic and Health Survey (7).

Employment status and benefits

We asked mothers about whether they were employed, the type of employment and responsibilities, the name of the employer, the availability of a formal contract, the hours worked, and the availability of maternity leave and other policies to support BF.

IYCF practices

IYCF practices were assessed using standardized questions from the Demographic Health Survey and WHO Indicators (7, 26). Using a 24-h list-based recall method, we recorded the types of liquid, semisolid, and solid foods given during the previous day and the number of BF and other feeding episodes.

Access to reproductive and other health services

Demographic Health Survey questions were used to assess antenatal care utilization, the delivery setting, the type of delivery, and the presence of a skilled attendant at childbirth (7).

Health status of the child and the mother

We assessed child morbidity in the prior 2 wk according to 5 common illnesses and symptoms: diarrhea, pneumonia, fever, malaria, and cough. The HIV status of the mother was self-reported.

The primary anticipated reason for EBF cessation was assessed using a single question with multiple response options (going to work, child refusal, uncomfortable/did not want to, perceived milk insufficiency, pregnant again, baby cries after being breastfed, child age, other). Upon cessation of EBF, we also queried mothers regarding actual reasons why they introduced mixed feeding, defined as the initiation of feeding other liquids and foods along with breastmilk (26). The same multiple response options were provided. The survey also assessed the availability of workplace supports for BF through questions on maternity leave benefits and the availability and use of employer-supported lactation rooms, childcare, and housing. The full survey is available in Supplementary Methods 1.

We examined missing data and replaced missing values by recontacting mothers by phone.

Sample size

To identify a 20% difference in EBF rates at each time point (1–4 d, 6 wk, 14 wk, and 24 wk postpartum), with 80% power and an alpha <0.05, we aimed to recruit a minimum of 124 mothers at each point. We successfully enrolled 296 women at 1–4 d postpartum, 298 women at 6 wk postpartum, 295 women at 14 wk postpartum, and 297 women at 36 wk postpartum who reported retrospectively to 24 wk postpartum. This higher sample size increased power to 96.4% for EBF, 96.4% for early initiation, and 99.9% for detecting a 20% difference in these outcomes between employment groups. Our initial recruitment approach did not use employment as a screening factor, which resulted in a higher proportion of non–formally employed mothers. Thus, we focused later recruitment on formally employed mothers at each time point, resulting in higher recruitment numbers than initially planned.

Primary independent variable

Maternal employment status was ascertained by self-report. We first asked women about their current employment or, if mothers were not working and were within 6 wk postpartum, about their recent employment status. Mothers were then asked about the type of occupation, the number of hours worked per week, and the existence of a contract to be further classified as formally, informally, or self-employed. We classified employment as formal if women worked for a registered employer (e.g., a commercial farm, business, company, school, health-care facility), worked ≥20 h/wk, and received regular compensation. For mothers currently on maternity leave (recruited at 0 and 6 wk postpartum), employment type was classified based on the type of work before delivery. Mothers were classified as not employed if they indicated that they reported no current employment. If mothers were employed during their pregnancies, but indicated that they did not intend to return to work and were not receiving maternity leave benefits, they were classified as not employed. In the study context, women usually work through 36 wk of pregnancy.

Primary dependent variables

Our dependent variables encompassed 3 BF indicators: 1) early initiation of BF; 2) EBF or predominant BF at 6, 14, and 24 wk postpartum (coded as separate variables in the analysis); and 3) continued BF at 9 mo postpartum. Early initiation of BF was defined as BF within 1 h of childbirth (26). EBF was defined as feeding breastmilk only with no other liquids or solids (26) from childbirth through the time point of data collection. EBF duration, defined as the number of weeks of reported EBF, was measured retrospectively by mothers who were recruited at 36 wk. These mothers were considered to have been EBF at 6 mo if only breastmilk was fed through 24 wk of age. To establish conservative estimates of BF status, we applied a modified approach to the WHO method to determine BF status. BF status was determined by the IYCF practices during the previous 24 h, as well as by assessing the last week when mothers gave breastmilk exclusively. Thus, a mother who was EBF during the previous day, but who fed infant formula in the previous week, was classified as not EBF. We classified children as predominantly breastfed if they were given breastmilk along with juice, water, or other liquids, including medicines and vitamins/minerals, but not milk or semisolid or other foods through the specified time (26). Continued BF at 9 mo was defined as any BF among children in this age group (26).

Minimizing bias

We attempted to minimize social desirability or recall bias in the assessment of BF outcomes by including multiple questions about BF duration and exclusivity. We assessed EBF duration, the week at which other foods and drinks were first consumed, and the child's diet in the 24 h preceding the survey, using the validated IYCF feeding practices tool (26). Vitamin or mineral supplements were not assessed. We sought to minimize temporal changes in BF practices by completing study recruitment over 13 mo. To reduce the likelihood of selection bias, we restricted our recruitment to 3 health facilities that represented 3 levels of the health-care system and we recruited women without prior knowledge of their socio-demographic factors. The research team received training on responsible conduct in research, survey procedures, and anthropometric assessments. Reporting bias related to maternal employment was minimized by describing the purpose of the study as seeking to identify opportunities to better support mothers by understanding the challenges they encounter in feeding their infants. The study was not promoted as an employment study. For questions related to reasons for cessation of EBF, self-reported answers were coded into categories. “Returning to work” was indicated if a participant responded that this was a reason for EBF cessation; it was not provided as an option before the respondent offered a response.

Statistical analysis

Confounders

To identify confounding variables, we constructed a directed acyclic graph (Supplemental Figure 1): a causal diagram used to characterize the relationships among variables that influence the primary independent variable (employment) and the dependent variable (BF status) and are not on the causal pathway (27). Informed by existing literature on the employment–BF relationship and influences of BF in the study context, the same set of confounders were used for all models (13, 16, 28). These include maternal age (years), marital status (married or not), maternal education (some secondary or higher versus less than secondary), tribal affiliation (Kikuyu, Luhya, Kiisi, or other), child morbidity (presence of diarrhea, fever, malaria, cough, or fever in the previous 2 wk), cesarean delivery (versus vaginal birth), and HIV status (positive or negative).

We assessed the linearity of continuous variables (maternal age, maternal education) with outcomes by specifying disjointed indicator variables. Household income was hypothesized as a mediator of the association a priori. Maternal employment would likely result in increased individual-level income, thus increasing household wealth and, subsequently, influencing BF practices. However, wealth prior to workforce entry could be a plausible confounder of the employment–EBF association (i.e., household wealth could influence whether a woman works or not). In these cross-sectional data, we cannot establish the temporality of wealth and workforce entry. Therefore, wealth was considered a mediator and was not included as a covariate in our models (29).

We employed separate multivariable logistic regression models to test the association between maternal employment (formally employed versus informally employed, self-employed, and not employed) and each BF variable (early initiation of BF and EBF, predominant BF, and continued BF at 9 mo).

Sensitivity analyses

In sensitivity analyses, we compared BF outcomes by employment status when restricting formal employment to only mothers employed at flower farms or in other commercial agricultural farms (n = 398). In addition, we adjusted for multiple comparisons using the Holm-Bonferroni sequential correction, given that we assessed associations for multiple outcomes across 4 time points (30). First, results for both chi-square tests and linear regressions were ordered from the smallest P value to the largest P value. Second, the second-smallest P value was corrected with a Bonferroni approach [(number of tests − order of test + 1) × P value]. The correction procedure stops when the first nonsignificant test is obtained (30).

In our main analyses, the alpha was set to 0.05. STATA version 14.1 (StataCorp LP) was used to conduct all analyses. The study adhered to the Strengthening Research for Observational Studies in Epidemiology (STROBE) guidance (Supplementary Methods 2) (31). All study procedures were approved by the Kenya Medical Research Institute Scientific Ethical Review Unit (study number KEMRI/SERU/CCR/0112/3712) and the Wheaton College Institutional Review Board (study number 3712).

Results

Descriptive results

We approached 1198 mothers. There were 12 eligible mothers who refused participation; of these, 9 stated time constraints and the other 3 did not provide a reason. In total, 1186 mothers participated in the survey (n = 296 at 0 wk, n = 298 at 6 wk, n = 295 at 14 wk, and n = 297 at 36 wk).

Figure 1 illustrates the classification of maternal employment and the size of the final analytic sample. The final analytic sample included 2 groups: 1) formally employed mothers (n = 564); and 2) informally employed, nonemployed, and self-employed mothers (n = 622). BF practices were not statistically significantly different among informally employed, self-employed, and nonemployed women. Therefore, these women were aggregated into a single category of “non–formally employed” mothers (n = 622; Supplemental Table 1).

FIGURE 1.

Flowchart of final analytic sample selection and classification by maternal employment category.

Most participating mothers were married, and they had a mean of 2.2 children (Table 1). The mean age was 27.2 y. Approximately one-third (32.7%) of the mothers had at least some primary education, while nearly half (48.7%) had at least completed secondary education. The majority reported having electricity at their homes (91.2%), 42.8% reported a drinking water source at the household premises, and only 15.0% owned their home. Over half of employed mothers lived >5 km from their workplace. Most reported facility deliveries (97.8%), 4 or more antenatal care visits (64.3%), and receipt of BF counseling from a health-care worker (79.8%).

TABLE 1.

Descriptive characteristics of participants

	All participants, n = 1186, n (%)	Formally employed, n = 564, n (%)	Not formally employed, n = 622, n (%)	P value
Child age
1–4 d	296 (25.0)	128 (22.7)	168 (27.0)	0.086
6 wk	298 (25.1)	134 (23.8)	164 (26.4)	0.301
14 wk	295 (24.9)	144 (25.5)	151 (24.3)	0.618
36 wk/9 mo	297 (25.0)	158 (28.0)	139 (22.3)	0.0252
Child morbidity in the past 2 wk
Any fever, diarrhea, cough, or lower respiratory symptoms1	369 (31.1)	176 (31.2)	193 (31.0)	0.945
Maternal age
15–19 y	18 (1.5)	0 (0)	18 (2.9)	<0.0012
20–24 y	415 (35.0)	159 (28.2)	256 (41.2)	<0.0012
25–30 y	344 (29.0)	181 (32.1)	163 (26.2)	0.026
>30 y	409 (34.5)	224 (39.7)	185 (29.7)	<0.0012
Maternal education
None	12 (1.0)	5 (0.9)	7 (1.1)	0.681
Any primary to completed primary	388 (32.7)	167 (29.6)	221 (35.5)	0.0302
Any secondary to completed secondary	578 (48.7)	261 (46.3)	317 (51.0)	0.107
Above secondary (some university, diploma, completeduniversity)	208 (17.5)	131 (23.2)	77 (12.4)	<0.0012
Tribe
Kikuyu	595 (50.2)	206 (36.5)	389 (62.5)	<0.0012
Luyha	255 (21.5)	168 (29.8)	87 (14.0)	<0.0012
Kiisi	101 (8.5)	67 (11.9)	34 (5.5)	<0.0012
Luo	86 (7.3)	49 (8.7)	37 (5.9)	0.070
Other: Kalenjin, Kamba, Maasai, Turkana, Meru, Pokot	149 (12.6)	74 (13.1)	75 (12.1)	0.521
Religion
Christian	1170 (98.7)	559 (99.1)	611 (98.2)	0.189
Marital status
Married/living with partner	974 (82.1)	476 (84.4)	498 (80.1)	0.052
Single/divorced/separated/widowed	212 (17.9)	88 (15.6)	124 (19.9)	0.052
HIV status
Know HIV status	1181 (99.6)	560 (99.3)	621 (99.8)	0.270
HIV positive	100 (8.4)	51 (9.0)	49 (7.9)	0.453
Parity
1	370 (31.2)	155 (27.5)	215 (34.6)	0.0092
2–4	772 (65.1)	393 (69.7)	379 (60.9)	0.0022
5 or more	44 (3.7)	16 (2.8)	28 (4.5)	0.130
Distance to drinking water
On premises	509 (38.8)	221 (39.2)	288 (46.3)	0.0112
<1 km	585 (49.3)	304 (53.9)	281 (45.2)	0.0032
≥1 km	92 (7.8)	39 (6.9)	53 (8.5)	0.302
Electricity access in household	1081 (91.2)	542 (96.1)	539 (86.7)	<0.0012
Monthly household income
≤$50	259 (21.8)	80 (14.2)	179 (28.8)	<0.0012
$51 to $150	569 (48.0)	254 (45.0)	315 (50.6)	0.054
$151 to $400	287 (24.2)	182 (32.3)	105 (16.9)	<0.0012
>$400	71 (6.0)	48 (8.5)	23 (3.7)	<0.0012
Health service factors
Facility-based delivery	1160 (97.8)	553 (98.0)	607 (97.6)	0.588
Private facility delivery	219 (18.5)	148 (26.2)	71 (11.4)	0.028
Attended 4 or more antenatal visits	763 (64.3)	389 (69.0)	374 (60.1)	0.0022
Counseled on breastfeeding by a health worker afterdelivery	947 (79.8)	462 (81.9)	485 (78.0)	0.091
Cesarean delivery	160 (13.5)	86 (15.3)	74 (11.9)	0.087
Preterm birth: <37 weeks of gestation	50 (4.2)	28 (5.0)	22 (3.5)	0.222

¹Lower respiratory symptoms included wheezing, fast breathing, or chest in-drawing/retractions during inhalation.

² P < 0.05, group differences are statistically significant.

Availability of workplace supports

Most formally employed mothers worked at commercial flower or other agricultural farms (70.6%). We examined workplace supports among all formally employed mothers (n = 564), as well as among a subgroup restricted to those who worked at commercial farms (n = 398). Among all formally employed mothers (n = 564), 16.9% had on-site housing provided by their workplace (Table 2). Few formally employed mothers (9.2%) reported the availability of a childcare facility at their workplace, including those employed at commercial farms (10.8%). Also, of those who reported access to such childcare facilities, few indicated visiting them during working hours to breastfeed (9.0% among all formally employed mothers and 5.3% among commercial farmworkers). Very few (2.3%) formally employed mothers (1.7% of farmworkers) reported the availability of private lactation rooms at their workplace (Table 2). Among all formally employed mothers, most (92.9%) reported that their employer provides maternity leave and 75.1% indicated that this leave was paid. The mean ± SE maternity leave lengths were 13.0 ± 1.0 and 13.2 ± 1.2 wk among formally employed and commercial farmworkers, respectively.

TABLE 2.

Workplace data of cross-sectional survey sample among formally employed mothers

	Number	Percent
Distance to maternal workplace, among formally employed mothers,n = 564
<1 km	100	17.7%
1 to <5 km	96	17.0%
5 to 10 km	286	50.7%
>10 km	82	14.5%
On-site housing at workplace
Formally employed, n = 564	95	16.9%
Among commercial farmworkers,1  n = 398	69	17.3%
Use of childcare among formally employed mothers, n = 564	175	31.0%
Among commercial farmworkers, n = 398	154	38.7%
Availability of childcare at workplace
Formally employed, n = 564	52	9.2%
Among commercial farmworkers, n = 398	43	10.8%
Visit on-site childcare during work
Formally employed, n = 564	51	9.0%
Among commercial farmworkers, n = 398	22	5.5%
Availability of private lactation rooms at workplace
Formally employed, n = 564	13	2.3%
Among commercial farmworkers, n = 398	7	1.7%

¹Commercial farmworkers are a subset of formally employed mothers (n = 398).

Early initiation, EBF, and predominant BF

Two-thirds (65.6%) of formally employed mothers reported early initiation of BF, compared to 75.6% of non–formally employed mothers (Table 3). At 1–4 d postpartum, >96% of mothers in both groups reported practicing EBF. At 6 wk postpartum, the prevalence of EBF was 94.0% among formally employed mothers and 86.6% among those without formal employment.

TABLE 3.

Prevalence of early initiation, exclusive breastfeeding, and predominant breastfeeding by maternal employment status¹

	Formally employed,2n = 564			Not formally employed, n = 622			Formally employed in flower farm/commercial agriculture, n = 398
		BF indicator	Predominant BF or EBF3		BF indicator	Predominant BF or EBF		BF indicator	Predominant BF or EBF
	n	Prevalence ± SE	Prevalence ± SE	n	Prevalence ± SE	Prevalence ± SE	n	Prevalence ± SE	Prevalence ± SE	Total n
Early initiation at 1–4 d4	128	65.6% ± 0.04%	Not applicable	168	75.6% ± 0.03	Not applicable	85	72.9% ± 0.05	Not applicable	296
1–4 d, EBF	128	97.7% ± 0.01%	99.2% ± 0.01%	168	98.8% ± 0.01%	100 ± 0.00	85	96.4% ± 0.02%	98.8% ± 0.01%	296
6 wk, EBF	134	94.0% ± 0.02%	97.8% ± 0.01%	164	86.6% ± 0.03%	98.2 ± 0.01	82	91.4% ± 0.03%	96.3% ± 0.02%	295
14 wk, EBF	144	48.6% ± 0.04%	59.0% ± 0.04%	151	80.8% ± 0.04%	93.4 ± 0.02	106	37.7% ± 0.04%	48.1% ± 0.05%	297
24 wk,5 EBF	158	17.7% ± 0.03%	19.0% ± 0.01%	139	48.9% ± 0.03%	49.6 ± 0.04	128	16.8% ± 0.03%	18.4% ± 0.02%
Continued BF at 9 mo	158	98.1% ± 0.01%	Not applicable	139	98.5% ± 0.01%	Not applicable	128	97.6% ± 0.01%	Not applicable	298

¹BF, breastfeeding; EBF, exclusive breastfeeding.

²Includes mothers employed at flower or other commercial farms.

³Predominant breastfeeding was defined as breastmilk along with juice, water, or other liquids, including medicines and vitamins/minerals, but not milk or semisolid or other foods in the 24 h preceding the survey (26).

⁴Early initiation was defined as BF within the first hour after delivery.

⁵EBF at 24 wk was estimated from retrospective recall from a 36-wk/9-mo immunization visit.

At 14 wk postpartum, formally employed mothers had a lower prevalence of EBF compared to non–formally employed mothers (48.6% versus 80.8%, respectively). Similarly, at 24 wk, we observed a lower prevalence among formally employed mothers (17.7%) compared to non–formally employed mothers (48.9%).

At 1–4 d postpartum, 99.2% of formally employed and 100% of non–formally employed mothers were practicing predominant BF, and over 96% of all mothers were predominantly BF at 6 wk postpartum (Table 3). However, by 14 wk postpartum, only 59.0% of formally employed mothers were predominantly BF, as compared to 93.4% of non–formally employed mothers. At 24 wk, 19.0% of formally employed mothers were predominantly or exclusively BF compared to 49.6% of non–formally employed mothers. The prevalence of predominant or EBF was lower among flower farm/agriculture workers, with the most substantial difference observed at 14 wk (48.1% of farm/agriculture workers compared to 95.4% of non–formally employed mothers; P < 0.001).

Continued BF at 9 mo

At 36 wk, the prevalence of continued BF was ≥98% in both groups.

Adjusted comparisons

Table 4 reports the unadjusted and adjusted comparisons of BF practices by employment status. Employment status was not associated with EBF at 1–4 d postpartum (OR: 0.62; 95% CI: 0.08, 4.70) nor at 6 wk postpartum (OR: 2.20; 95% CI: 0.87, 5.53). However, by 14 wk and 24 wk postpartum, formally employed mothers had 81% (OR: 0.19; 95% CI: 0.10, 0.34) and 75% (OR: 0.25; 95% CI: 0.14, 0.44) lower odds of EBF, respectively, compared to their non–formally employed counterparts. The odds of early initiation at 1–4 d (OR: 0.63; 95% CI: 0.35, 1.14) and continued BF at 36 wk (OR: 0.80; 95% CI: 0.10, 6.08) did not differ by group.

TABLE 4.

Unadjusted and multivariable models of early initiation, exclusive breastfeeding, and predominant breastfeeding by maternal employment status¹

	Unadjusted early initiation and EBF				Early initiation and EBF2				Predominant or exclusive BF2,3
	n	OR	95% CI	P value	n	AOR	95% CI	P value	n	AOR	95% CI	P value
1–4 d, early initiation	296	0.62	0.37, 1.02	0.061	2954	0.63	0.35, 1.14	0.13	—	—	—
1–4 d	296	0.50	0.08, 3.05	0.454	2675	0.62	0.08, 4.70	0.65	NA6	1.00	NA	NA
6 wk	298	2.44	1.05, 5.70	<0.01	2974	2.20	0.87, 5.53	0.10	2377	0.71	0.12, 4.28	0.71
14 wk	295	0.22	0.13, 0.39	<0.01	2944	0.19	0.10, 0.34	<0.01	2944	0.09	0.04, 0.19	<0.01
24 wk8	297	0.22	0.13, 0.38	<0.01	2954	0.25	0.14, 0.44	<0.01	2954	0.26	0.15, 0.45	<0.01
Continued BF at 36 wk	297	0.75	0.12, 4.5	0.759	2399	0.80	0.10, 6.08	0.83	—	—	—

¹BF, breastfeeding; EBF, exclusive breastfeeding; NA, not applicable.

²Models compare being formally employed with not being formally employed in women and control for maternal age, maternal education, HIV status, delivery type, child morbidity, parity, delivery setting, marital status, and tribal affiliation.

³Predominant breastfeeding was defined as breastmilk along with juice, water, or other liquids, including medicines and vitamins/minerals, but not milk or semisolid or other foods in the 24 h preceding the survey (26).

⁴Missing data due to unknown HIV status (1 at 1–4 d, 1 at 6 wk, 1 at 14 wk, 2 at 24 wk/36 wk).

⁵The 29 observations dropped because of HIV status, delivery setting, and morbidity predict success perfectly.

⁶Model at 1–4 d could not be calculated because of a lack of variation in the outcome.

⁷The 60 observations dropped because of HIV status (n = 36) and delivery type (n = 24) predict the outcome perfectly.

⁸EBF at 24 wk estimated from retrospective recall from a 36-wk immunization visit.

⁹The 56 observations dropped because of marital status predict the outcome perfectly.

At 6 wk postpartum, the odds of predominant or exclusive BF were the same among formally employed versus non–formally employed mothers (OR: 0.71; 95% CI: 0.12, 4.28). At 14 wk and 24 wk postpartum, formally employed mothers had 91% (OR: 0.09; 95% CI: 0.04, 0.19) and 74% (OR: 0.26; 95% CI: 0.15, 0.45) lower odds, respectively, of predominant or exclusive BF, compared to their non–formally employed counterparts.

Sensitivity analysis

Supplemental Table 2 reports the adjusted comparisons of BF practices in an analysis restricted to mothers formally employed at flower farms or in other commercial agricultural farms and compared to those who are not formally employed. There were no meaningful differences in outcomes in this analysis compared to the main analysis of all formally employed women.

The results did not change after adjustment for multiple comparisons.

Reasons for EBF cessation

The most common reported reason for discontinuing EBF was returning to work (46.5%), followed by the belief that it is appropriate to introduce other foods based on the child's age (33.5%) and perceived milk insufficiency (13.7%; Figure 2 ). Mothers of 14-wk-old children were more likely to report returning to work as the primary reason for EBF cessation than mothers surveyed at 9 mo (60.6% ± 0.05 compared with 38.9% ± 0.03, respectively; P < 0.001). Among the 746 women who were still practicing EBF, mothers were asked what would cause them to eventually introduce other foods or liquids to their child's diet. The main expected reasons were child age (i.e., when the child turned 6 mo; 53.2%) and returning to work (39.7%; Figure 3).

FIGURE 2.

Reported reasons for introducing mixed feeding (n = 440).

FIGURE 3.

Reported reasons for anticipated mixed feeding among mothers still practicing EBF (n = 746). EBF, exclusive breastfeeding.

Discussion

Results from this study indicate that most mothers had initiated BF within 1 h of birth and were practicing EBF at the time of discharge after childbirth, irrespective of employment status. The prevalence of EBF declined somewhat by 6 wk, regardless of employment status. However, the prevalence of EBF (and predominant BF) among formally employed mothers dropped in half by 14 wk, coinciding with the end of the federally protected 3-mo maternity leave. There were still lower odds of EBF among formally compared to non–formally employed mothers at 24 wk, at which point less than one-fifth of formally employed mothers were EBF compared to almost half among those who were not formally employed. It was noteworthy that mothers described returning to work after maternity leave as the primary reason for introducing liquids and foods, ahead of perceived milk insufficiency, which is a leading barrier to EBF in other contexts (32).

These findings from a semi-urban region of Kenya where many women work for commercial flower farms are consistent with other data throughout LMIC contexts, where similarly high rates of early initiation of BF and lower odds of EBF after 3 mo are practiced among formally employed mothers (13). A recent study in Ethiopia that compared the EBF prevalence by maternal employment status and included mothers working for government and nongovernmental agencies found a lower prevalence of EBF among employed mothers after 3 mo. The delivery setting and receipt of BF education did not explain differences in the odds of EBF between 3 and 5 mo (33). The prevalence estimates of EBF in our study are consistent with those in national surveys in Kenya that report the median duration of EBF to be 3.3 mo and show a 42% prevalence of EBF between 4 and 5 mo (7).

Our study also demonstrated that most formal employment settings, including commercial farms, lacked private lactation rooms. Also, there is a lack of availability of childcare facilities at workplaces; among mothers who do have access to such facilities, very few report visiting these facilities to breastfeed during working hours. Notably, our study was conducted soon after the Health Act in Kenya that mandated private lactation spaces and flexible work schedules to support BF (23). This act was approved in March 2017, 6 mo before data collection began for this survey. Most commercial farms that employed mothers in our study had not yet complied with this policy, based on the low percentage of mothers reporting the availability of on-site lactation rooms.

Improving BF practices requires multilevel supports, including legislation, BF promotion, peer or health worker BF counseling, workplace support policies and services, and addressing social norms (9, 34–37). Maternal employment is considered to be a component of mothers’ “resources” for the provision of nutrition and health behaviors that contributes to and reflects women's autonomy (38–40). Formal employment is associated with improved complementary practices in the first 2 y, especially related to dietary diversity and meal frequency (13). When modeled through autonomy, the employment and dietary association is also positive and significant, as demonstrated in a recent study in Bangladesh and Vietnam (38). Notably, a study in Indonesia that included a multidimensional measure of women's empowerment, with labor force participation as 1 component, only found significant associations of reduced EBF with employment status, but not with other empowerment variables (41). However, greater autonomy has also been linked with poorer BF outcomes (42). While strengthened autonomy enables mothers to make favorable decisions for children and to spend more on nutrition (43), it may also create unintended adverse nutrition effects through reduced time with children and using childcare that is unsupportive of EBF or healthful complementary feeding (44). Given that many countries do not yet substantially align with the International Code of Marketing of Breastmilk Substitutes in their legal measures (45), it is possible that the autonomy and increased income associated with employment may unintentionally increase the purchasing of breastmilk substitutes. Female empowerment through formal employment should continue without neglecting improved structural support for EBF.

Breastfeeding promotion efforts and the establishment of policies to achieve global targets should take into account the workplace setting, particularly within industries where lactation support is not yet normative. It is noteworthy that in this population of formally employed mothers, the availability of BF education and health-seeking behaviors did not attenuate the barriers to EBF that result from formal employment. As fewer than half of nonemployed and informally employed mothers practice EBF at the recommended period of 24 wk, this group is also in need of further BF supports, especially given the potentially lower access to health insurance and health services in this population (46).

Kenya has undertaken several national BF strategies, in addition to recent maternity leave and workplace lactation support legislation. The Baby-Friendly Hospital Initiative (BFHI) was successful in promoting BFHI certifications between 1994 and 2008, with 69% of targeted facilities designated as baby friendly in 2008. By 2010, only 11% of facilities qualified for this designation (47). In 2012, Kenya passed the Breast Milk Substitutes Act and implemented the Maternal and Infant and Young Child Nutrition Strategy, which guided facility-based BF promotion through 2017. To complement these facility-based efforts, Kenya also championed the Baby-Friendly Community Initiative (BFCI) in 2016, which trained and deployed community health workers as BF promoters. Despite these efforts, continued support for the BFHI has proven challenging, and linkages between facility and community BF promotion strategies have been weak (47). Health worker training and the provision of small incentives to motivate community health workers have been suggested to improve the implementation of BFHI and BFCI in Kenya (48). While BF counseling—through facilities and communities—can effectively increase the duration of EBF, the impact of this strategy depends on the counseling quality and the relationship between the counselor and mother (49). A lack of training and misconceptions about optimal BF practices among health workers can diminish counseling quality through inconsistent messaging and may increase mothers’ distrust of counselors (50). Furthermore, one-off exposures to BF counseling may be insufficient; 4 to 8 sessions are optimally needed across the antenatal and postnatal periods (49, 51).

Limitations and strengths

The strengths of the study include a large sample size, robust examination of confounding factors, and recruitment of a representative sample across multiple time points. However, there were several limitations. First, because of the cross-sectional study design, we cannot make any causal inferences. However, we hypothesize that employment is a durable social and economic characteristic that precedes BF practices. Moreover, while a cohort study offers the advantages of longitudinal trajectories of BF status according to employment type, the high degree of migration out of the study catchment area meant that maintaining contact with mothers over 6 or more months was not feasible in this setting. Since many mothers seek perinatal and postnatal care at a variety of health-care settings within the district, maintaining contact with the same mothers over 6 mo would pose considerable challenges. Second, BF practices at 24 wk were estimated using retrospective recall at 36 wk. In the study context, mothers do present to maternal and child health clinics at 24 wk, but do so for anthropometric check-ups and not immunizations, representing a sample of mothers who are either more motivated in caregiving or whose children are more likely to be unhealthy. While mothers may have inaccurately recalled BF practices from 12 wk prior, we recruited mothers at 36 wk because this visit was part of the regular immunization sequence, increasing the likelihood that mothers at each time point represented the same source population. The use of multiple questions (week of last exclusive BF, week of introducing complementary foods and other liquids) to estimate the BF status at 24 wk attempted to mitigate this potential recall bias. Additionally, due to some missing demographic data, the adjusted models omit some observations. The pattern of missing data was random, and therefore would not be expected to introduce selection bias in the analysis.

We cannot rule out the possibility of recall and social desirability bias, given the self-reported assessments of BF practices. Our study used a different method for assessing BF than most national surveys; we included the last week when mothers gave breastmilk exclusively, along with the feeding practices from the previous 24 h, to determine BF status. However, the low prevalence of EBF at 6 mo is similar to the prevalence rates reported in national surveys. We included the category “predominant or exclusive BF” in an adjusted analysis to help demonstrate that more children in both groups are BF predominantly or exclusively when we broaden the criteria. Use of this definition also demonstrates that the trend of lower odds of predominant or exclusive BF among formally employed mothers at 14 and 24 wk still stands.

Some of the findings may be specific to the study setting, which should be considered when interpreting the external validity. The study sample included mothers who presented with their children for immunizations, mainly from government or company-subsidized health facilities. Employed mothers commuted a relatively long distance to work, as the median distance between home and work was between 5 and 10 km. Many women commuted via company buses that do not generally provide opportunities to return home for nursing breaks in the middle of shifts. The 2017 Health Act makes provision for a lactation room where mothers can express breastmilk and mandates refrigeration to store expressed milk (23). However, mothers in this study had limited access to these benefits. The women included in this study reported high rates of maternal health services utilization and exposure to ≥1 postpartum BF counseling session with a health worker. It is noteworthy that despite these opportunities, 83.3% of formally employed and 51.1% of non–formally employed mothers do not practice EBF for the recommended duration. Finally, the primary type of employment in the study sample—commercial agriculture—may pose an additional challenge to EBF that does not apply to other forms of work, as mothers may be concerned about transmitting pesticides through milk expressed during work (52, 53).

In conclusion, formally employed mothers in Naivasha, Kenya, experience shorter durations of EBF by 14 wk postpartum as compared to mothers who are not formally employed, and this association continues at 24 wk. Additional supports for formally employed mothers to help prolong the period of EBF may be beneficial to improve child health. A follow-up evaluation is needed to understand whether recent legislation in Kenya will help to address employment-related BF disparities.

Notes

This study was supported by the National Institutes of Health Fogarty International Center (grant number K01TW010827).

Supplemental Tables 1 and 2 and Supplemental Figure 1 are available from the “Supplementary data” link in the online posting of the article and from the same link in the online table of contents at https://academic.oup.com/ajcn/.

Abbreviations used: BF, breastfeeding; BFCI, Baby-Friendly Community Initiative; BFHI, Baby-Friendly Hospital Initiative; EBF, exclusive breastfeeding; IYCF, Infant and Young Child Feeding; LMIC, low- and middle-income country.