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Addressing the interaction between food insecurity, perinatal depression and informal work: findings of a cross-sectional survey among informal women workers with young children in South Africa. CURRENT STATUS: UNDER REVIEW

Background: There is a high burden of depression globally, including in South Africa. Maternal depression is associated with poverty, unstable income, food insecurity, and lack of partner support, and may lead to poor outcomes for mothers and children. In South Africa one-third of working women are in informal work, which is associated with socioeconomic vulnerability. Methods: A cross sectional survey explored work setting and conditions, food security and risk of depression among informal working women with young children (0-3years). Depression risk was assessed using the Edinburgh Postnatal Depression Score (EPDS) and Whooley score. Food insecurity was evaluated using USAID Household Food Insecurity Access Scale (HIFAS). Data was analysed using SPSS and STATA. Results: Interviews were conducted with 265 informal women workers. Types of work included domestic work, home-based work, informal employees and own account workers, most of whom were informal traders. Most participants (149/265; 56.2%) earned between US$70-200 per month, but some participants (79/265; 29.8%) earned less than US$70 per month, and few earned >US$200 per month (37/265; 14.0%). Many participants experienced mild (38/267; 14.3%), moderate (72/265; 27.2%) or severe (43/265; 16%) food insecurity. Severe food insecurity was significantly higher among participants with the lowest income compared to those with the highest income (p= 0.027). Women who received financial support from the baby’s father were less likely to be food insecure (p=0.03). Using EPDS scores, 22/265 (8.3%) women were designated as being at risk of depression. This was similar among postnatal women and women with older children. Household food insecurity was significantly associated with depression risk (p<0.001). Conclusions: Informal women workers were shown to be vulnerable with low incomes and high rates of food insecurity, thus increasing the risk for poor maternal health, and child health and development outcomes. However, levels of depression risk were low compared to previous estimates in South Africa, suggesting that informal workers may have high levels of resilience. Interventions


Background
Depression represents a huge burden of disease globally, particularly among women in the perinatal period immediately before and after childbirth [1]. Perinatal depression is highly prevalent in lowincome countries, especially in high poverty settings [2][3][4]. In South Africa (SA) estimated rates of depression in the antenatal period range from 22-47% [5,6], and may be as high as 50% during the postnatal period [7]. Depression contributes heavily to the overall disease burden in SA [8].
Depression is associated with significant life challenges, including poverty, unstable income, food insecurity, lack of partner support, violence and poor health [9][10][11][12][13][14]. Maternal depression reduces quality of life and is a leading cause of disability and poor maternal health outcomes, especially in the context of HIV [15,16]. Further, maternal depression has been associated with adverse effects on the quality of the mother-infant relationship and child development outcomes [4,17], which can have implications for young children's long-term psychosocial, cognitive, and economic well-being [13,16].
Maternal mental health is therefore an important public health concern in SA, however it is frequently neglected and continues to be of low priority in health care practices [3,18].
Food insecurity, defined as having uncertain or limited availability of nutritionally appropriate food or being unable to procure food in socially acceptable ways [19,20], has been shown to be an important risk factor for depression [21]. Further, depression in mothers in low-income settings is a strong predictor of household food insecurity [22]. Household food insecurity is associated with poor health, development and behavioural outcomes among children [23,24], and is common in SA, with around 25% of the population considered food insecure [25].
Informal work is frequently associated with vulnerability and poverty, particularly financial and food insecurity [26,27]. Of the 6.8 million working women in SA, almost 2 million work informally, the largest groups being informal traders, agricultural workers and workers in private homes (domestic workers) [28]. By definition, informal workers do not have access to income protection including unemployment, sickness and maternity benefits. The perinatal period is a vulnerable time for all mothers since childcare and household responsibilities often fall disproportionately on women [29]. In SA female-headed households are common (43%) [30], and it may be especially difficult for mothers in 4 informal work, often already vulnerable due to their working conditions and reduced earning potential, to manage ongoing childcare and household responsibilities [29]. Several studies have shown how poverty and food insecurity interact in a vicious cycle among socially and economically deprived populations, leading to depression and poor health outcomes among women [9,11].
Thus, factors associated with food insecurity and depression are likely experienced by women working in the informal economy. However, little focus has been given to the multiple risks of depression facing female informal workers and data is very sparse among this population group, especially in low-and middle-income settings [12]. Data from one Brazilian study suggests that informal work may increase the risk of psychological symptoms among women informal workers [30].
Women who work in the informal economy in SA are largely invisible in maternal and child health programmes and in efforts for equitable economic development. To address this gap, we conducted this study to explore the interaction between informal work, food insecurity and depression among women with young children working in the informal economy in urban and peri-urban areas of Durban, KwaZulu-Natal (KZN) Province, SA.

Methods
A cross sectional survey methodology was employed to explore the work setting and conditions, income, food security and risk of depression among informal working women with children under the age of three years.

Study setting
The study was conducted in three primary health care (PHC) clinics in three townships in Durban, South Africa. In these areas unemployment is high at around 20%, with high rates of poverty, and an average annual income of R29 400 (USD2000) [31]. In addition, there is poor access to basic services including water and sanitation and informal housing is common, but most households do have access to electricity [32]. A recent study in Durban found that women in the informal economy work long hours and many only earn <R1000 (USD70) per month [26]. Primary caregivers of children living in a low-income household are entitled to a SA government provided Child Support Grant (CSG) of R420 (USD30) per month for each child [33].

5
Health care for pregnant women and children is provided free of charge in PHC clinics, and there are high rates of antenatal clinic attendance (94%) and facility-based delivery (96%) [34]. HIV prevalence is high among young women in KZN, with 47% of pregnant women attending government antenatal clinics testing HIV positive in 2015 [35].

Recruitment and sampling
Eligible participants were informal workers, aged 18 years or older, with a child under the age of three years. Informal workers were either informally employed or own account (self-employed) workers.
Informally employed women were defined by: 1) receiving money from an employer; 2) having no formal work contract; and 3) not contributing to SA's mandatory Unemployment Insurance Fund (UIF).
Own-account workers provided goods and services directly to customers but were not tax registered or paying tax. Women were excluded from the study if they worked fewer than three days per week or had been in informal work for less than six months.
A stratified sampling approach was employed to recruit equal numbers of eligible women with children aged less than one year (defined as the postnatal period) and mothers of children aged 12-35 months. Given the well-documented high risk of postnatal depression in SA, this approach was used to determine depression prevalence in the postnatal population compared to the wider population of informally working mothers.
A sample size of 192 women (96 with children aged < 1 year and 96 with children aged 1-<3 years) was required to detect a 20% difference in depression risk among postnatal women compared to the general population. This sample size calculation assumes a 35% rate of depression risk in women with children 1-<3 years of age with 95% probability and 80% power.

Data collection
Trained fieldworkers approached women in the clinic waiting area and explained the study. Eligibility was determined using a structured screening tool. All eligible women agreed to participate. Data were collected using a structured questionnaire administered in the local language (IsiZulu) and continued until the sample size was reached. Risk of depression was assessed using two tools validated for use in SA and translated into IsiZulu: the Edinburgh Postnatal Depression Score (EPDS) [5,36] and the 6 Whooley score [37]. The USAID Household Food Insecurity Access Scale (HFIAS), adapted and translated to IsiZulu, was used to assess food insecurity. The HFIAS tool is designed to be easy to use and applicable to diverse sociocultural settings, and examines food security related to three domains: anxiety about food access; insufficient quality of food; and insufficient quantity of food [38].
A professional psychologist who was IsiZulu-speaking and had experience with both the EPDS and Whooley tools trained the fieldworkers to assess depression risk using the two tools. The psychologist also supervised data collection to ensure the correct administration of the tools in the field.

Data Analysis
Quantitative analysis was undertaken using SPSS version 24 and Stata V13. For the EPDS high risk of depression was determined by a score of ≥ 13. Two positive answers were considered a positive score for the Whooley questions. For both tools a positive answer to questions about suicidal ideation was considered high depression risk, regardless of the answers to the other questions.
Participants were retrospectively categorised according to the type of work they were doing. Firstly, all women who reported they worked from home were categorised as home-based workers. Women were categorised as domestic workers if they reported they worked in a private household undertaking domestic or childcare work. All other women were categorised either as employees if they reported receiving a wage from an employer, or as own account workers if they were selfemployed. Sub-categories of own account workers included informal traders and a variety of other own account jobs.
For the multivariable analysis the food insecurity index was dichotomised into food secure (none or mild food insecurity) and food insecure (moderate or severe food insecurity), and the postnatal depression score was analysed on a continuous scale and means and standard deviations reported.
The analysis was a two-step process. Initially a multi variable logistic model was used to identify factors associated with food insecurity. Due to the over dispersion of the PND score, a multi-variable negative binomial model including food insecurity was used to identify factors associated with PND score. In both cases only factors significant at p < 0.3 in bivariate analysis were included in the multivariable model. Adjusted and unadjusted odds ratios and 95% confidence limits are reported. Stata 7 V15 statistical software was used in the analysis

Ethical considerations
All participating women provided written informed consent. Screening, consent processes and data collection were conducted in a private area in the PHC clinics. Referral procedures were established with staff at each of the PHC clinics to offer additional clinical and social support to participants as required. All women identified as at risk of depression or with any thoughts of self-harm were immediately referred to clinic staff for further assessment. Follow up support from a study counsellor was offered to all women identified at risk of depression. Women identified as having moderate or severe food insecurity were referred to a clinic-based social worker.

Results
A total of 265 interviews were conducted with mothers in informal work between December 2018 and March 2019. Just over 50% of participants had completed secondary school and nearly half were in a relationship but not living with their partner. Close to 50% of participants reported themselves HIV positive. Characteristics of participating mothers are shown in Table 1.

Infant feeding and childcare
There were similar numbers of participants with children aged less than 12 months of age and with The duration of leave taken at the time of childbirth was short, and over one-third of mothers did not take any time off work (Table 2).

Conditions of informal work
Over 40% of participants had been at the same job between one and three years, and close to half worked five to six days each week. Most women reported they worked regular hours, however over 60% did not benefit from a fixed income and were paid depending on the work done. An overview of informal working conditions reported by participants is shown in Table 3.

Types of informal work
Just over 40% of participants reported they worked as employees in informal enterprises, including as cleaners (19), hairdressers (18), waiters (7), shop assistants (24), factory workers (12), office administrators (4), call centre workers (3), and security guards (3). Home based work included hairdressing (23), and making and selling goods, such as crafts, sewing, and baking (9). Other participants were self-employed as informal traders and in a variety of other own account jobs such as crèche work, fashion design, catering, plumbing, welding, sewing and marketing (Table 4).
A comparison of the characteristics of the different categories of informal work are shown in Table 4.
Home-based workers were most likely to work seven days per week and not receive a fixed wage.
Employed women and domestic workers benefited from more regular hours compared with other informal workers, however, many still could not rely on a fixed wage.

Financial responsibilities
Participants were asked about current financial outgoings for themselves, their baby and the household. Most expenses for which the mother was responsible were shared with others (  A small number of participants expressed thoughts of self-harm. Using EPDS, 12 mothers (4.5%) reported they had thought of harming themselves in the past 7 days, as compared to Whooley where 10 mothers (3.8%) reported they had thoughts about self-harm in the past two weeks.

Factors associated with high depression risk
In order to determine the relationship between food insecurity and depression, we dichotomised the food insecurity variable as no or mild food insecurity versus moderate or severe food insecurity.
Using the EPDS score as a continuous variable, Table 6 shows after adjusting for possible confounders there is a significantly higher risk of postnatal depression among mothers living in households where there is moderate or severe food insecurity. However, receiving financial support from the child's father and working regular hours were associated with a lower average EPDS score. In our study there was no association between risk of depression and HIV status.

Discussion
Despite the large number of women working informally in SA and throughout the Global South, very little is known about the interaction between informal work, food security and depression among mothers of young children working in the informal economy. This study sought to address this gap to inform the development of strategies to improve maternal and child health and enable more stable livelihoods for these women.
Our findings show that women in informal work were living in poverty, frequently on very low, unstable incomes despite being responsible for many household and personal expenses. Almost one third of women were earning less than R1 000 per month, well below the upper bound poverty line for SA, meaning that this amount is insufficient to supply all the individuals needs [39]. Types of work, employment conditions and places of work differed among these women, with employed women and domestic workers benefitting from a relatively stable income and work environment compared to selfemployed workers, particularly informal market traders. Informal women workers reported high levels of moderate or severe household food insecurity, when compared with the SA average. The inability to adequately provide for the households' food needs is a key indicator of poverty, and is a significant source of anxiety and determinant of poor mental health [21]. As a result, most women took very little or no time off work after childbirth, which was likely to affect their ability to breastfeed and care for their children.
The peri-partum period is a vulnerable time for many women as their incomes are reduced at the same time as they have the additional expense of providing for a new baby. Although some women who received the CSG experienced food insecurity, many women reported that the grant money they received for their older children helped support them during their maternity leave. This is supported by other studies, which have further shown that receipt of the CSG can reduce hunger, and improve child nutrition [40]. However, although the SA CSG is the largest cash transfer programme in Africa, reaching over 11 million children, the amount is insufficient to ensure adequate dietary diversity for children or protect low-income families from financial shocks [41]. The CSG is a cornerstone of poverty alleviation in SA but access to the grant remains a challenge, particularly for mothers in extreme poverty, and more needs to be done to address this [42]. In addition, payments start several weeks after the baby is born. Therefore, extension of the CSG to cover the perinatal period would improve coverage and be very likely to improve mothers' ability to take time off work to breastfeed and care for their new baby.
The depression risk among our population was lower than has been found in several other studies in SA [6,7,18], and was confirmed using two different validated screening tools for depression. This relatively low depression risk was found despite women living in contexts of social and economic adversity and food insecurity, that are known to be associated with high rates of depression [11]. The support that mothers received from their own family, both financial and practical, could be a factor in protecting women from depression. Another explanation for low rates of depression risk is that informal women workers may have built significant agency and resilience in response to the considerable adversities they have faced in the workplace. A person displays resilience when they are able to adjust well to significant risk [43]. Although our study did not measure women's sense of agency or resilience, it appears that informal workers are resourceful and empowered women who may have learned to actively buffer their health from life stressors. Very few studies are available that explain resilience among women in SA, let alone women who work in the informal economy who face many risks. More research is needed to understand demonstrate and explain this resilience, as well as the role of social support, to inform more effective mental health interventions, particularly for marginalised women [43].
Most mothers relied extensively on practical and financial support from their family, especially after childbirth and before their return to work. In particular, we found that receiving financial support from a current partner was an important mitigating factor for both food insecurity and depression. This suggests that the intimate partner relationship is central to women's well-being, supporting findings from other studies [6]. However, despite being in a relationship with the father of their child, most women were living with their own family. This is common in SA because of the custom for men to pay a substantial bride price (known as "Lobolo") before marriage. As a result, while the child's father contributed to the child's expenses, this support did not extend to cover household running costs or women's personal expenses, leaving women to carry the burden of providing a home for themselves and their child. Thus, these women experienced the ''double-burden'' of income earning work and managing childcare and household responsibilities. While this is common among women in many settings, it is likely that women working in the informal sector, with few labour protections, are particularly affected [29]. In addition, childcare is often considered to be the mother's decision and her sole responsibility. Encouraging positive attitudes towards childcare in the community and in the workplace through increased awareness of the importance of early nutrition and nurturing care, could strengthen the role of society, including social and public services, in supporting and protecting childcare.
Lack of service support and policy frameworks for women working in the informal economy means public authorities, employers and decision-makers currently have no responsibilities to engage with these issues. While some organizations have been active in advocating for women's rights and livelihoods [44], it will be important to further mobilise worker and women's rights organisations and key decision-makers to acknowledge or advocate for the rights of informal working women and their children. This includes advocacy for maternity leave agreements, by-laws which support working pregnant women and mothers, the allocation of safer spaces for childcare facilities and the safeguarding of trading spaces when pregnant women and mothers are away due to childbirth, breastfeeding or caring for their children. Providing social protection to informal working women during the perinatal period, such as through a pregnancy grant, extended CSG or community saving schemes, could safeguard women's employment when they are not working during late pregnancy or the early postnatal period. Thereby stabilizing incomes and supporting women's and children's health, in particular by delaying the time to return to work after childbirth.
The health system also has an important role to play in addressing the interaction between food insecurity, depression, poverty and informal work. Lastly, service support and health workforce strengthening are critical. For example, health care providers must have the capacity to confidently and competently provide services to women working in the informal sector and their children and be supported by systems that invest in their professional development and well-being.

Strengths And Limitations Of The Study
One strength of this study was the use of two different tools to assess depression risk, which allowed for validation of data and strengthened the interpretation of the findings. Field workers were trained and supervised by a professional psychologist to ensure consistency and appropriate use of the tools.
However, some limitations must be acknowledged. Although mothers' risk of depression was identified using screening tools, we did not conduct a full depression assessment to confirm the depression diagnosis. In addition, although the tools used to assess depression and food insecurity had been validated in SA and were translated into isiZulu, it is possible that cultural and language differences may have led to different interpretations of the questions. All participants were aware that referral mechanisms were in place, and participants may have believed that over-reporting indicators 21 of poverty and depression would give them access to additional support. However, we provided a link to referral services and support that is available to all South Africans, including emergency food supplementation and referral to the South African Social Security agency (SASSA).

Conclusion
Our study provides unique and important insights into the association between food insecurity, depression, poverty and informal work among women in Durban, SA. The health and livelihoods of women working in the informal economy, and the health and well-being of their infants and young children are compromised by a vicious cycle of vulnerability. This presents a major public health concern, particularly as the high rate of food insecurity greatly increases the risk for poor maternal health and child health and development outcomes [6,21]. Further research is needed to improve our understanding of these interactions, particularly the role of social support and resilience as a protective factor. were used for each participant based on the study site.

Consent for publication
Not applicable

Availability of data and material
The data or material used in the study is available from the corresponding author upon reasonable request.

Competing interest
The authors declare that they have no competing interests.

Funding
Funding for the study was provided by the World Health Organization.

Disclaimer
The views expressed in the manuscript do not necessarily represent the policies or recommendations of the World Health Organization

Authors' contributions
CH, LH, SL and NR conceptualized the study. SL supervised the data collection process and CC oversaw the analysis of the data. CH, LH, RH and CC interpreted the results. CH, LH and RH wrote the first drafts. All the authors reviewed and commented on the manuscript throughout the writing process. All authors approved the final manuscript.