Work-Related Factors Affecting Exclusive Breastfeeding Among Employed Women in Ethiopia: Managers’ Perspective Using a Qualitative Approach

Background

The World Health Organization (WHO) recommends exclusive breastfeeding (EBF) until six months as an optimal way of feeding infants.¹ However, this recommendation can be challenging for employed mothers.² Evidence has shown the continuation of breastfeeding is often negatively affected by the mother’s return to work.^3,4 Mothers who are not employed in full-time work, generally breastfeed for a longer period compared to those who are employed.^4,5

Studies have shown that the support employed women receive in their workplace has a crucial, positive role in the duration of breastfeeding among employed women.^6,7 Breastfeeding support in the workplaces is essential not only for employed mothers but also for the employers because it results in the retention of staff and reduced staff turnover.⁸ Additionally, employees who receive appropriate assistance are likely to feel more ownership of the organization and commit extra work effort and hours.⁸ In contrast, unsupportive work environments increase workplace stress, which in turn could impact the breast milk production.⁹

Approximately one third of Ethiopian women are employed in different occupations such as sales and services, technical, professional or managerial works.¹⁰ According to the civil service law of the country each employee is expected to work eight hours a day from Monday to Thursday and seven hours in Friday [39 hours a week] over two shifts [morning and afternoon].¹¹ A study conducted in Ethiopia reported that only 21% employed women breastfeed exclusively until six months.¹²

Research indicates that the support from managers ranges from verbal encouragement, to scheduling flexible working hours for breastfeeding women.⁶ However, information on how on managers perceptions towards EBF in the workplace in Ethiopia is lacking. Therefore, the aim of this study was to explore the perspective of managers regarding breastfeeding among employed women in North Ethiopia.

Methods

A mixed-methods study exploring the determinants of EBF among employed women in two towns in Tigray region, north Ethiopia was conducted. Data were collected between October 2018 and January 2019. This paper reports on the qualitative findings of managers’ attitude and preference in supporting employed women on breastfeeding.

Participants

The study participants were managers of a variety of government organizations Wereda (district) level. The decision to interview these managers was based on the fact that they have direct and daily engagement with employed mothers. The government offices were purposely targeted because they are required to abide by the formal rules and regulations of civil service, such as maternal leave and specific working hours.

Study Procedure

Purposive sampling was utilised to select the study participants because the aim was to recruit participants who were likely to be typical of the managers in the area and would reflect a variety of views. After receiving official permission from administrative bodies of both towns, personal contact was made by the researcher (an Ethiopian national), and potential participants were provided with an explanatory letter in their native language. A week later, managers were contacted by phone and asked if they are willing to be interviewed. In total, managers of 30 offices from both towns were approached and 15 agreed to be interviewed (8 from Axum and 7 from Shire town). An interview guide was developed to explore managers’ views and reported preference towards breastfeeding mothers in the workplace (Figure 1). The semi-structured, face to face interviews were conducted and recorded in the participants’ workplace. Written informed consent was obtained from participants at the time of interviews.

Figure 1 Interview guide of managers.

Data Analysis

The interviews were audio-recorded and transcribed verbatim and then translated from Tigrigna to English by KG who is fluent in both languages. The accuracy of translation and transcription was checked by a bilingual nurse with a master’s degree and a PhD student. They each assessed eight and seven interviews, respectively. Qualitative data were analyzed using the six-phase thematic analysis framework set out by Braun and Clarke.¹³ These phases of thematic analysis are 1) becoming familiar with the data, 2) generating initial codes, 3) searching for themes, 4) reviewing theme, 5) defining themes and 6) producing the final report.¹³

To ensure the trustworthiness of the data, the criteria outlined by Lincoln¹⁴ were employed. These criteria include credibility, dependability, confirmability, and transferability. The mixed-method research design was selected to triangulate the qualitative and quantitative data; the use of a variety of methods to collect data on the same topic is a widely used approach to ensure credibility and conformability of a data. Additionally, the primary researcher (KG) undertook prolonged engagement to ensure trustworthiness in the data collection process.

Ethics Approval

Ethical approval was obtained from Monash University Human Research Ethics Committee (ethics approval number: 13794) and Mekele University Research Ethics Approval Committee (ethics approval number: ERC 1490/2018). Pseudonyms are used throughout this paper to protect participants’ privacy.

Results

Participants Characteristics

Fifteen managers from 12 different organizations were interviewed, of whom six (40%) were female. The workplaces from which the managers interviewed include; health science college,¹ agriculture office,¹ health office,³ revenue office,¹ health centre,² finance office,¹ civil service office,¹ women’s affairs office,¹ hospital³ and education office.¹ All these offices were governmental.

Thematic Analysis

Three themes emerged from the qualitative data; 1) Attitude and preference towards breastfeeding; 2) Impact of breastfeeding on staffing and work productivity; and 3) Policies and physical resources impacting breastfeeding.

Attitude and Preference Towards Breastfeeding

The first theme captures a) managers’ attitude, and b) preference within the work environment towards breastfeeding.

Many participants valued breastfeeding and considered it an important aspect of good care. Managers often described feeling guilty about requesting breastfeeding mothers to work, due to the impact it may have on their babies. Kiros’ (male) explanation is a typical example:

… at least we tried to see their problem as brother and sister, or as a colleague, or as a father, everybody here tried to help them as a family …

Similar sentiments were voiced by Abeba (female)

… we can say that the respect to breastfeeding mothers is good … but they cannot feel comfortable when they came to work late and going early … the work colleagues give good moral support …

In terms of their preference, participants in this study asserted that flexibility in the workplace was one of the most important supports they could provide for breastfeeding mothers. In most organizations, they relax attendance time for mothers, until their baby is one year old. For example, many managers allowed mothers to come to work late in the morning, and after they completed their work, they could go home early. Managers like Gidey (female) clarifies this:

… we did not control the mothers strictly, after they finish their job, we allowed them to go home … she starts to work full time work after a year … in the morning, she [a mother] can come late at 9:00 am … if she finished her job early, she can go earlier after 10:00 or 11:00 am for lunch …

Similarly, if there is shift work, priority is given to breastfeeding mothers to choose a convenient shift. For example, in one workplace [a hospital], there is a schedule arrangement for the mothers to work either in the morning or in the afternoon and to compensate the remaining hours in the weekend. Moreover, the mothers could get specific support upon discussion with their immediate managers and colleagues. However, such support tended to depend on the preference of individual managers and colleagues regarding mother’s breastfeeding. Kiros’ (male) explanation follows:

… When we have breastfeeding mothers in our working area, the staff did not have any bad feeling … as much as they can, the staff members and their team leaders tried to support mothers …

Similar idea was raised by Gidey (female)

… the staff does not control mothers strictly, from practice everybody has adapted it … the staff are good in helping the mothers to do their job …

The current policy of Ethiopia allows mothers to have four months maternal leave that can be started from last month of pregnancy and lasted up until three months after birth.¹¹ Among the managers who highlighted this, Gidey (female) stated that:

… the maternity leave is increased from three months to four months. After that, they could take their annual leave one-month working days excluding holidays, including weekends it becomes about forty-five days …

However, most participants claimed that most mothers prefer to get the whole four months after birth, because this time is more challenging for them. Hence, the managers often allowed them to continue working until a few days before birth based on preference of the mothers. After the maternal leave is finished, it is also common for managers to support the mother’s request for annual leave straight after maternity leave; a right of every government employee. Kiros (male) explained the woman’s leave entitlements:

… after they finish the four month’s maternal leave, the mothers could get their annual leave … all mothers who gave birth did not start work before they finished their maternal leave and annual leave consecutively …

An exception to this was identified for teachers; their annual leave is seasonal which is usually in the summer (July and August), because schools are closed at this time. Therefore, unlike other employed mothers, they have to start work immediately after they finish their maternal leave. Senait’s (female) idea is typical example of this:

… After they finish the four months, if she brings sick leave we allowed her … if she want, she could also use one-month leave without salary because annual leave of teachers is in the summer (June-August) …

In work positions where there was difficulty to replace the work by other staff members, the annual leave could be given to the mothers as a half a day, either in the morning or afternoon shift. One of the managers, Abeba (female) described that:

… For the mothers we give priority, we make the others to take their annual leave as a shift. It may become about five months; but this will be good if the maternal leave increased to six months …

Additionally, mothers often used their sick leave, which was generally accepted by the organization. Interviews with the managers indicate that there is variable support provided to breastfeeding mothers such as maternal and annual leave, managerial and staff support. Managers also claimed this could help the mothers to breastfeed their babies without workplace pressures until five months.

Impact of Breastfeeding on Staffing and Work Productivity

The second theme captures managers’ views about how breastfeeding influences staffing and workplace productivity. This theme has two sub-themes; a) impact on staffing, highlighting the influence of the woman’s decision to continue breastfeeding on the staffing of the organization, and b) impact on work performance, capturing the impact on breastfeeding mothers’ work performance.

In many workplaces, women are not replaced by another employee in the absence of previous staff member resulting in a shortage of staff. The impact of the shortage is even more critical in some work positions and in situations where two or more mothers are on maternity leave, simultaneously. For example, a manager of Senait (female) stated the challenges they have in replacing teachers who are on leave:

… if four teachers go to maternal leave from one school, it would be difficult to manage the work load because we do not have teachers who could replace them … we have shortage of teachers; even though the schools are requesting more teachers considering such issues …

It also became evident from the managers’ account that the nature of the women’s work often determines if they could be replaced or not. In situations with only one or two employees, it is often difficult to manage the gaps at work. Additionally, if the woman has specific professional skills, it was very challenging for the managers to replace her expertise. Gebre’s (male) explanation is a typical example:

… If there is no any other professional in the same department, it is difficult to replace their work by others … for example, we have two pharmacists, both are pregnant at the same time, the organizational structure allowed only two … the work will not be substituted by anyone …

In terms of work productivity, participants in the interviews also raised concerns that mothers with young babies might not fully concentrate on their work due to dealing with additional responsibilities. Participants asserted that some mothers come to work late and/or go home early, to breastfeed their baby. Kibrom’s (male) views were typical:

… When a breastfeeding mother is working on fieldwork with her baby, she could not perform as expected; she may not be able to collect proper data. Therefore, there would be gaps in her work …

Similarly, another manager Gidey (female) raised her concern in work performance of breastfeeding mothers.

… when you come to work especially to her individual work … it may not be done as expected, we cannot say that it is equivalent as compared to those who are engaged in their job fully …

Hence, from managers’ point of view, the woman’s decision to continue breastfeeding when returning to work may have important implications for both her work performance and the quality of service provided by the organisation.

Policies and Physical Resources Impacting Breastfeeding

The third theme that emerged captures contextual factors that affect breastfeeding including policies and physical resources. This theme has two sub-themes; a) employment policies affecting breastfeeding as well as b) physical resources affecting breastfeeding.

Although managers often try their best to support breastfeeding mothers in their workplace, many believe that the support given is not enough. As a result, the managers often referred to the government asserting that the provision of the required supports is beyond the capacity of individual workplaces. These issues were raised by managers, such as Kaleb (male):

… when they face such childbirth and related issues, the government should support them … the government should make the work places comfortable to mothers …

Employment policies that managers’ assert could have an impact on breastfeeding include maternal leave, annual leave and sick leave. These supports are applied uniformly in all workplaces and are underpinned by government policy and guidelines. However, some participants highlighted that the maternal and annual leave is still short of the recommendation from the health professionals, for EBF until six months. For example, John has the following recommendation:

… they are allowed to take four months maternal leave followed by one-month annual leave … this means they could stay on leave for about five months or more, but this is not enough … it will be better if the maternal leave is six months …

Apart from maternal leave and annual leave, there are currently no any other policies or guidelines on how to support breastfeeding mothers after they returned to work in Ethiopia. Hence, even though the managers would be willing to support more, absence of government mandated strategies impacts the support they can give to the mothers. Hagos’ (male) explanation is typical example:

… Even though we want to support the mothers, but absence of guideline is also another factor, so focus should be given, and separate guideline should be prepared …

Another manager Abraham (male) also suggested the need to have a policy to support breastfeeding mothers.

… we did not set out a policy to support breastfeeding mothers … if there is any policy come from the top-level governmental officials, the institutions might work on it …

The managers also commented that availability of physical resources in the workplace could impact the decision of mothers to continue breastfeeding after they are returned to paid employment. For example, if there is inadequate space for the child, there are occasions in which the mother works holding her baby. This sometimes created difficulties because the baby could distract the mother or other colleagues. Askale’s (female) comments were typical of the attitudes of managers with such concerns:

… If she comes with her child to work, she could not teach properly, and she (the mother) could not provide service in other offices, even it is not good for the other staff …

To continue breastfeeding until six months, the managers recommended to have a separate child waiting room for breastfeeding in the workplaces. However, preparation of a room only is not enough, it also needs its own caregiver to look after the babies while the mothers are at work. However, participants reported that their workplace had no furnished room prepared for this purpose. One of the managers, Kaleb (male) mentioned this saying:

… We did not have a separate room prepared for breastfeeding mothers … if you see our office it is old. Even it is not well-furnished for work …

Managers asserted that the main reason for the lack of appropriate infrastructure to support breastfeeding in the workplace is the absence of policy, and budgetary restraints. As a result, most of the managers think of an availability of a policy or guideline as an enabling factor because if it is supported by a policy from the top-level management, a budget could be allocated for this purpose. Participants like Abraham (male) addressed this issue as follows:

… to prepare a waiting room including necessary facilities, our budget is limited. If there is any support on this, we believe that probably there will be some improvement …

Therefore, from the participants’ account, it has become clear that commitments from managers to support breastfeeding women, policies and physical resources can impact the woman’s ability to continue breastfeeding.

Discussion

Our aim was to explore the perspective of managers regarding breastfeeding in North Ethiopia. The findings indicate that while managers have positive perceptions towards supporting breastfeeding mothers, their preference is often limited by budget constraints and lack of government policies. Participants in this study also assert that flexibility in the workplace was one of the most important factors to support breastfeeding mothers. Such support could encourage mothers to continue breastfeeding after returning to work.

Participants in our study expressed concern about the impact of breastfeeding on work productivity and the mother’s individual performance. Similar concerns have been reported in a study by Chow, Smithey Fulmer¹⁵ who interviewed 24 managers in Michigan, USA.¹⁵ The participants of this study raised concerns about the potential loss of productivity, when mothers are breastfeeding instead of working.¹⁵ However, in a review of the published research conducted by Basrowi et al, found that while breastfeeding is often perceived as potentially hindering employed mothers’ work productivity, it could actually improve efficiency and decrease absenteeism because the infants are likely to be healthier than children receiving formula milk.¹⁶ Similarly, another review found an improvement in productivity and decrease in days of absenteeism as a result of support for breastfeeding at the workplace, because infants tend to be healthier than children receiving formula milk and therefore there is less absenteeism.¹⁷ Therefore, managers should be reassured that supporting breastfeeding mothers is likely to have positive benefits. Workplace support such as flexibility in work hours may contribute to improved workplace productivity over time.

The availability of physical resources, such as nursery room and storage facilities, was another important factor impacting breastfeeding in the workplace. This study found that in almost all of the organizations, there was no room available for either childcare or for women wanting to breastfeed. Similarly, a study by Soomro, Shaikh⁸ conducted in Pakistan among 297 managers in Pakistan found that the presence or absence of physical facilities, including a breastfeeding corner or room for maintaining privacy, could impact the mothers’ decision to continue breastfeeding. However, only 6% of the sites participating in the Pakistan study had a designated breastfeeding area.⁸ There were similar findings in a Michigan study in which participants said that their workplace lacked designated facilities and privacy for accommodating breastfeeding women.¹⁵ Most of the participants indicated that the available space was a bathroom, closet space, or storage room and that this space was either inadequate or inappropriate.¹⁵ However, different findings were obtained in a study conducted in Hong Kong. Dodgson, Chee⁴ conducted a survey of 19 hospitals to assess the workplace support provided to breastfeeding mothers in Hong Kong. These authors found that five (26%) workplaces had a private room with a locking door solely for breastfeeding mothers.⁴ Even though it was considered to be very important, almost all the workplaces did not have physical facilities to support breastfeeding. Given the importance of physical resources availability also emphasized by mothers in different studies,^18,19 it is strongly advised that all workplaces provide such facilities to breastfeeding mothers.

The study by Dodgson, Chee⁴ conducted in Hong Kong also identified the need for a policy to support breastfeeding mothers. None of the hospitals included in the Hong Kong study had policies in place to address employees’ rights regarding breastfeeding. This left the level of support given to breastfeeding mothers to the goodwill of the managers.⁴ Additionally, research conducted among 297 managers in Pakistan found availability of policies as a facilitator of breastfeeding continuation.⁸ However, a study conducted in Michigan, USA found the availability of company policy on breastfeeding to be a challenge because they think it would restrict their ability to be flexible whereas few participants supported the availability of policies on breastfeeding.¹⁵ Participants explained different views about company policies on breastfeeding. Some asserted that a policy would assist women while others stated a policy would restrict their ability to be flexible.¹⁵ Findings of this study supported this evidence. The managers who participated in this study were concerned about the absence of national policies or guidelines to support breastfeeding mothers in Ethiopia. Therefore, it appears that the availability of policies on breastfeeding would be a facilitator to continue breastfeeding in workplaces.

Another finding which emerged from interviews with the managers highlighted that a woman’s leave entitlements that could have a significant influence on the duration of EBF. A study undertaken in Pakistan among 297 women suggested that managers found maternal leave as a facilitating factor for the continuation of breastfeeding.⁸ The authors reported that all workplaces were providing the women with at least three months paid maternity leave as per the national policy of Pakistan.⁸ An opposite example of maternity leave entitlement is in Michigan, in the United States where there was limited government-mandated maternity leave. Women could choose to return to work soon after childbirth for personal and career reasons.¹⁵ In Ethiopia employed mothers have four months maternal leave, to be taken before birth and after birth. However, upon agreement with their managers the mothers can have all the four months after birth. Findings from this study indicate that if this practice was applied uniformly in all workplaces it would be an important factor to assist employed mothers to exclusively breastfeed for longer period of time.

Implications of the Study

This study found that there was lack of government policies to support breastfeeding mothers except those relating to maternal and annual leave. The managers who participated in this study asserted the need for a national policy or guidelines to support breastfeeding mothers. Findings of this study will help policy makers to identify the gaps and to improve the support given to breastfeeding women who return to paid employment. Increasing the maternal leave to six months may be the best solution to increase EBF and promote wellbeing for both the baby and the mother. However, if this is not possible in the current political and fiscal climate, then providing resources for the establishment of breastfeeding rooms in workplaces would encourage mothers to continue to exclusively breastfeed until six months. Of note, this study mainly focused on lower-level managers; therefore, future study involving higher-ranking managers and policy makers is recommended.

Limitation in This Study

The data were translated verbatim from local language; therefore, some words might not be translated exactly with the Tigrigna version. An addition, the translation and transcription of the data were done by the student researcher which can lead researcher bias. Since the interviewees are managers of their offices, they might have reported a more positive perspective than the reality of the situation.

Conclusion

It is promising that managers in north Ethiopia expressed a positive attitude and preference towards supporting breastfeeding mothers. However, their concern about work performance and productivity and the absence of physical facilities and polices (especially from the government) impacts the level of support they could provide. This warrants attention by policy makers in Ethiopia if they intend to increase breastfeeding percentage in employed mothers. Therefore, the government should consider budgetary and policy support for options to promote EBF.