Source of poster (cover) image: World Health Organization (WHO), 1 August 2023 https://twitter.com/WHO/status/1686154029640904704?s=20

This paper formed part of five publications that resulted from my PhD research, completed through the University of the Western Cape School of Public Health. Together with my supervisors and other colleagues, we investigated the components of comprehensive maternity protection available and accessible to non-standard workers in the Western Cape, using domestic workers as a case study. Part of the initial phase of this research was to conduct a systematic scoping review of previous research conducted on maternity protection for non-standard workers, and we expected to (and did) find that there is insufficient primary research on maternity protection for non-standard workers. Scoping reviews are commonly used to identify research gaps and opportunities, which is what we did in this case. While I coordinated the research, my colleague Dr Alison Feeley conducted the screening of all documents and assisted with the write up of the paper, and my two PhD supervisors, Prof Tanya Doherty and Prof Mieke Faber supervised and provided guidance at all stages of the research process.

To describe the people behind the research:

I am a dietitian by training and have been working in public health nutrition since 2005. I have an interest in the protection, promotion and support of breastfeeding and optimal infant and young child nutrition and have worked in government, research, and academia where most of my previous work was in South Africa and other low-and-middle-income countries. I relocated to the UK in 2020 and am currently a Senior Nutritionist at First Steps Nutrition Trust and a consultant to Alive and Thrive East Asia Pacific where my work focuses on maternity protection and implementation of the International Code of Marketing of Breastmilk Substitutes. LinkedIn Catherine (Katie) Pereira Kotze Twitter @KatiePNutrition

Dr Alison Feeley is a registered public health nutritionist (RNutr) and works as a Nutrition Specialist in Overweight and Obesity Prevention at the UNICEF East Asia and Pacific Regional Office, based in Bangkok, Thailand. She is also a Senior Honorary Researcher with the South African Medical Research Council (SAMRC) Developmental Pathways for Health Research Unit (DPHRU) at the School of Clinical Medicine at the University of the Witwatersrand, Johannesburg, South Africa. Social justice is very important to Alison who believes in a rights-based approach to nutrition. LinkedIn Alison Feeley PhD RNutr Twitter @alisonbbfeeley

Prof Tanya Doherty is Chief Specialist Scientist at the Health Systems Research Unit of the South African Medical Research Council (SAMRC), Cape Town, South Africa, an Extraordinary Professor at School of Public Health, University of the Western Cape (UWC), Cape Town, South Africa and an Honorary Professor in the School of Public Health, University of the Witwatersrand. Tanya’s research has a focus on maternal and child health research including prevention of mother-to-child transmission (PMTCT) of HIV, infant feeding, multi-country child survival evaluations and community health workers.

Prof Mieke Faber is a Chief Specialist Scientist at the Non‑communicable Diseases Research Unit of the South African Medical Research Council (SAMRC), Cape Town, South Africa, an Extra-ordinary Professor at Department of Dietetics and Nutrition, University of the Western Cape, Cape Town, South Africa and an Extraordinary professor at North-West University, Potchefstroom, South Africa. Mieke’s research focus includes the assessment of dietary intake, the food environment affecting dietary intake, dietary quality within the context of food and nutrition security, and food-based strategies for improved nutrition, particularly in infants and young children. LinkedIn Mieke Faber

Getting back to the scoping review that we did; it is important to understand what is meant by comprehensive maternity protection, which refers to a set of entitlements that should be available to all working women during pregnancy, around the time of childbirth and while breastfeeding. This is defined by the International Labour Organization (ILO) in the Maternity Protection Convention C183 of 2000 as including health protection at work, maternity leave, cash and medical benefits during maternity leave, non-discrimination, job security, breastfeeding or expressing breaks, and childcare support.

The next important concept relevant to this research is non-standard employment. This is because most maternity protection focuses on women in permanent, full-time positions who traditionally work in the formal sector. Women working in positions of non-standard employment often cannot access basic labour rights, let alone maternity protection entitlements. The informal workforce is substantial; around 60% of workers globally, work informally and in some regions, especially those with low-and-middle-income countries (LMIC) such as Africa, this is as high as 86% (ILO, 2018). Therefore, the rights and entitlements of this group of workers needs to be prioritised. Workers in positions of non-standard employment include those who are placed by temporary employment services or labour brokers (agency workers) or in a ‘multi-party employment relationship’; employees on fixed-term contracts (temporary contract workers) which could involve project-based contracts, seasonal work, casual work, or daily work; part-time employees, who may or may not have a contract with their employer and those in ‘disguised employment relationships’ and ‘dependent self-employment’. Common examples of non-standard employees include domestic workers, farm workers, people in contract positions, workers employed by agencies and self-employed people.

It is important to understand that access to more generous paid maternity leave policies positively impacts early initiation of breastfeeding, exclusive breastfeeding under 6 months and breastfeeding duration (Chai, et al, 2018) and this will confer benefits to the child, mother and society. Other benefits of paid maternity leave and breastfeeding support at work have been documented for children, mothers, employers, and businesses including longer breastfeeding duration, improved immunization rates, lower infant mortality in low-and-middle-income countries, improved workplace productivity and decreased work absenteeism.

Our scoping review revealed only 17 articles that met the inclusion criteria of being research that had been conducted on maternity protection amongst non-standard workers in LMIC and considered breastfeeding. The research on non-standard workers has previously been done in a piecemeal manner and much more research was conducted on formally employed workers. Existing research was mainly from Africa and Asia. Most research only considered one aspect of maternity protection, as opposed to comprehensive maternity protection. From available research focused on childcare. Components of maternity protection were found to be inconsistently available and often inaccessible to women working in non-standard employment. This inaccessibility of maternity protection was described to disrupt breastfeeding, but certain characteristics of non-standard work (such as flexibility or workplaces where it was possible to bring children to work) were found to be supportive of breastfeeding.

We concluded that more research is needed to determine the accessibility to all components of comprehensive maternity protection by non-standard workers in LMIC. Since non-standard work arrangements are diverse and can be unpredictable, flexible, and heterogeneous approaches are required to ensure that all women can access maternity protection which could in turn provide a workplace environment that is supportive of breastfeeding. The expansion of comprehensive maternity protection to all women working in positions of non-standard employment could encourage significant social and economic benefits.

Our vision is that all women can access all components of comprehensive maternity protection, thereby supporting optimal breastfeeding, which in turn leads to improved nutrition and health for many infants, young children, women, and society as a whole.