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06 Mar 2016

Maternal Employment and Child’s Weight for Age: A Study of an Indonesian Urban Middle-Class Community

Airin Roshita, August 2011
The University of Queensland

In many developing countries, overnutrition and undernutrition in children are seen alongside the rise of middle class communities and increased participation of women in the workforce. As mothers are recognised as the primary caregivers for young children, it is widely assumed that deprivation in maternal care when the mother works is associated with malnutrition in young children.

Whilst previous studies have examined the relationship between maternal employment and child malnutrition, few of them have explored that relationship amongst the emerging middle class in developing countries. Indonesia provides an excellent setting for the study because of the emergence of a middle class in urban areas since the 1980s, an increasing proportion of middle class mothers who work and evidence of the double-burden of child undernutrition and overnutrition. This thesis explores the relationship between maternal employment and child outcomes in terms of nutritional status in an urban area of Indonesia within a middle class community. In an attempt to examine the relationship in a broad socio-economic, demographic and cultural perspective, a mixed method study design was adopted and the study was divided into two parts. Middle class families were defined as having a minimum family income of 2.5 million Indonesian Rupiah (IDR) per month. The inclusion criteria for children participating in this study were those aged 12.0-36.0 months, had no congenital abnormalities, severe allergies or chronic illnesses, had normal birth weight (at least 2.5 kg) and were born full-term (gestational age of at least 37 weeks). The study was conducted in Depok city, a growing urban area on the southern side of Jakarta, the capital of Indonesia.

The first phase of the study was a qualitative multiple case study involving 26 middle class families in 13 residential housing estates in Depok city. The expected outcome of this qualitative study was a rich description of the domestic environment and child caring experience which related to maternal employment and child nutritional status. Child nutritional status was determined from weight-for-age Z scores (WAZ). Families were chosen in order to provide a mix of those with working mothers and non-working mothers, children cared for by family caregivers or Domestic-Paid Caregivers (DPC) and children that were underweight, normal weight and overweight. The primary data collection method was semi-structured in-depth interviews with the mothers and the children’s caregivers as the study participants. The children’s weight was measured prior to the in-depth interviews to determine the WAZ of the children. Children’s food intake was assessed by a repeated 24-hour recall amongst the mothers and primary caregivers on two non-consecutive days; a week day and a week-end day, to obtain the children’s dietary diversity data.

The qualitative research provided a description of child care arrangements that existed in urban middle class families and found that both working and non-working mothers experienced problems of child rearing. Five themes emerged from this study in regard to socio-economic and demographic environments of the families. The themes were mothers’ reasons for working/not working, support for mother and caregiver, decision-maker on child’s food and food preparation, maternal self-confidence, and access to resources. The non-working mothers of underweight and overweight children perceived their role of homemaker as an obligation which occurred due to limitations in child care arrangements available to them. Non-working mothers of normal weight children described feelings of “mother is the best caregiver for a child”. The availability of acceptable and trusted alternative caregivers and the need to provide additional income for the family were the reasons described by working mothers regarding whether to seek employment or return to employment after having a child. Several non-working mothers and caregivers appeared to experience a lack of support in performing child care and domestic tasks which may have compromised their children’s nutritional status. Working mothers tended to allow family caregivers and long standing DPCs to decide and prepare the child’s meals. Working mothers with new DPCs chose and prepared the children’s meals or supervised the DPC to prepare the meals, whilst non-working mothers tended to be involved in the decision-making process and preparation of their children’s meals. Several working mothers who had family caregivers expressed feelings of low confidence in child care matters especially in regard to food preparation. Several non-working mothers had limited access to big traditional markets or supermarkets and purchased raw foods only at mobile street vendors.

The qualitative study also provided descriptions of child feeding practices from which five themes emerged. These were breastfeeding and formula milk; child’s appetite; meal time; snacking; and mother’s involvement in child feeding, mother’s trust in caregiver and child’s dietary diversity. Twenty-three out of 26 children were breastfed but 11 of these children were also receiving infant formula milk from birth. Only 5 children were exclusively breastfed for the optimum duration of 6 months. Working was not the main reason for mothers supplementing breastmilk with formula milk. Mother’s familiarity with many brands of formula milk was reported in this study and the aggressive marketing of formula milk companies was mentioned. Several mothers, both working and non-working, described challenges in encouraging a child to eat. The underweight children in this study were described by their mothers and caregivers as having poor appetite, difficult to feed and having poorly regulated meal times because they frequently refused to eat. Overweight children were also described as having poorly regulated meal times due to long afternoon naps and a plentiful consumption of formula milk and snacks. Snacking was related to child’s appetite (underweight children with poor appetite were offered snacks to increase their food intake) and related to poorly regulated meal times (overweight children were given snacks every time they asked for them). Working mothers with trustworthy caregivers (family and long standing DPCs) appeared to have a reduced involvement in child feeding practices while their children were found to have lower dietary diversity on weekends compared to that of weekdays due to conflicts of shared responsibility during the weekends between mothers and caregivers.

The second phase of the study was a case-control study, with underweight children as cases and normal weight children as controls. The overall aim of the case-control study was to quantify the associations between maternal employment and child nutritional status, considering the socio-economic and demographic characteristics and other factors identified in the qualitative study as well as those identified from the literature review. The case-control study involved 288 children, comprising 109 cases and 179 controls. Child underweight was chosen over child overweight as the case to study because the prevalence of underweight is still higher than overweight amongst children under 5 years in Indonesia and there were constraints in time and available funding to include overweight children as another case group. Cases were defined as children who met the general inclusion criteria and were mild to moderately underweight (WAZ ranging from -1.00 to -3.00 SD). Control children were those who met the general inclusion criteria and were defined as normal weight children with a WAZ of at least -1.00 SD to a maximum +2.00 SD. Cases and controls were residents of Beji district and were drawn from the Posyandus (Pos Pelayanan Terpadu, the community-run health centres responsible for monitoring the growth of children under 5 years) registries in Beji district. Random sampling of controls was drawn from this population. The data collection methods consisted of structured interviews, 24-hour food recalls to measure the children’s food intake, Infant and Child Feeding Index (IFCI) to measure the children’s feeding practices and HOME (Home Observation for Measurement of the Environment) questionnaires to measure the psychosocial care received by the children. The structured interviews consisted of questions pertaining to socio-demographic characteristics of the families, maternal employment characteristics (working hours, regularity of income) and availability of caregivers, feeding practices, child illnesses in the preceding 2 weeks and support for mothers and caregivers.

The case-control study presented factors associated with child underweight amongst Indonesian urban middle class families. The univariate logistic regression showed that children whose mothers did not have income earning activities was 1.63 (CI = 1.00–2.66, p = 0.049) times as likely to be underweight compared to children of working mothers, suggesting that maternal employment was beneficial for children’s weight-for-age in this study. Mothers working outside the home for less than 20 hours per week was associated with 6.04 higher odds (CI = 1.20–30.57, p = 0.030) of their children being underweight, compared to mothers working outside the home for more than 40 hours per week, after adjusting for children’s characteristics, socio-economic and demographic characteristics, support for mother, child care arrangements, children’s food intake and children’s health status. Mothers working outside the home for 20–40 hours per week and mothers not working outside the home were associated with higher odds of their children being underweight, but the association was not significant. When feeding practices and psychosocial care were included in the model, mothers working outside the home for less than 20 hours per week was associated with 8.53 higher odds (CI = 1.29–56.18, p = 0.026) of a child being underweight compared to a child whose mother worked for more than 40 hours per week. The main caregiver of the children whose mothers worked outside the home for less than 20 working hours per week and those not working outside the home were the mothers themselves, whereas the majority of child’s caregivers in the group of mothers working 20–40 hours and more than 40 hours were family members. A child having a non-mother caregiver, whether it was a family (OR = 1.59, CI = 0.37–6.82, p = 0.531) or a non-family caregiver (OR = 3.10, CI = 0.77–12.43, p = 0.111), was associated with higher odds of being underweight in the multivariate model, but the associations were not significant. When feeding practices and psychosocial care were included in the model, the association of having a non-family member as the child’s main caregiver and child underweight was significant (OR = 4.89, CI = 1.00–23.93, p = 0.050), the association of having a family member as the main caregiver and child underweight was not significant. The socio-economic and demographic characteristics of the families and support for mothers for performing child care and domestic tasks were not associated with child underweight. A child having a lower birth weight (2.5–2.99 kilograms) was 5.30 (CI = 2.53–11.11, p = <0.001) times more likely to be underweight compared to a child having a birth weight of more than 3.30 kg according to the multivariate model.

The total ICFI scores were the only significant predictor of child underweight amongst the variables of feeding practices assessed in this study. However, the total ICFI scores were associated with child underweight in an unexpected direction, with low ICFI scores (3–7) associated with lower odds of child underweight (OR = 0.28, CI = 0.10–0.81, p = 0.018) compared to high ICFI scores (10-12). The HOME sub-scale “Acceptance” was the only significant predictor of child underweight amongst the variables relating to psychosocial care measured in this study. The HOME sub-scale “Acceptance” measured the parental acceptance of less than optimal behaviour from the child and the avoidance of undue restriction and punishment. A child having a lower (below median) HOME sub-scale score of “Acceptance” was 2.79 (CI = 1.17–6.68, p = 0.021) times as likely to be underweight compared to a child having a higher (median and above median) “Acceptance” score. The mediation analysis shows that ‘Child was bottle fed in the last 24 hours’ was the main variable mediating the relationship of maternal employment and child underweight, suggesting that in this study formula milk feeding influenced child underweight and the relationship between maternal employment and child underweight operated through formula milk feeding.

Additional findings related to child food intake in the case-control study showed that the consumption of formula milk amongst the control children contributed to a large portion of their energy intake and majority of the children had low dietary diversity. Moreover, only 10.4% of all children studied received 6-month exclusive breastfeeding (EBF), whilst more than half of the mothers in this study had offered formula milk to their children before the children were 1 month old.

The results of the qualitative study which show the mothers’ difficulties in providing appropriate childcare arrangements for their children in their absence and where family support is declining and the results of the case control study which show the significant association of mothers working outside the home for less than 20 hours per week and child underweight attributed to not having an alternative caregiver, and the higher odds associated with having a non-family caregiver to child underweight compared to having the mother and a family member as the child’s caregiver highlight the importance of providing parents with qualified and flexible options for child care arrangements. Nutrition and child health policy responses should be directed to provision of alternative high standard child care arrangements for dual-working parents (such as a development of qualified and affordable day care centres) and development of a standardised training program, including infant and child feeding education for alternative caregiver provision at home. It is recommended that research on the characteristics of non-maternal caregivers and their relationship with child nutritional status and health be conducted in Indonesia. This research would serve as baseline information for research exploring the possible alternatives for child care arrangements in Indonesia.

The findings of the qualitative study in regard to mother’s familiarity with many brands of formula milk, the low dietary diversity amongst almost all case and control children and the larger contribution of formula milk to total energy intake compared to other types of food amongst the control children in the case-control study warns of several potential problems for the health of Indonesian children. A large government strategy addressing mothers and caregivers complementary feeding practices which includes improving dietary diversity and appropiate frequency of feeding as well as increasing the awareness of parents on the importance of providing healthy and balanced meals for their children’s growth and health is needed. Further research on the quality and quantity of food consumed by young children of middle class families in urban areas of Indonesia and other developing countries and on the reasons why these children have low dietary diversity is recommended. This should be linked with an assessment of the knowledge on child health and nutrition amongst urban middle class mothers in developing countries.

The finding which shows that child birth weight between 2.5–2.99 kilograms (kg), which is not yet categorised as low birth weight, has already been associated with a higher risk of child underweight compared to birth weight of more than 3.30 kg, highlights the importance of antenatal care programs as well as programs to increase the nutritional status of young women as they enter their child-bearing years. Programs to increase the health and nutrition knowledge of women of reproductive age should be started at an early age, for instance included as school programs in order to target girls and female adolescents.

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