The study revealed that the pathway between the employment situation and nutrition-related outcomes via child care (primary, substitute, mixture of both) is extremely complex in this urban poor context, often depending on the families’ specific circumstances.

1. Economic Empowerment and Increased Influence in Decision-Making The study indicated that having access to her own income changed a mother’s influence within her home on how money is spent. Many of the informally employed and almost all of the formally employed mothers decided themselves how to spend their own income.

Working mothers, in both formal and informal employment, expressed a sense of pride in their independence and the ability to provide for their children.

A few mothers stated that their influence in decisions increased as their income increased. Despite this progress, several working mothers said that they were unaware of their husband’s income or employment and that he would spend it all himself. Comparatively, in households where the mother stays at home, husbands commonly make the decision on spending.

2. How Mothers Manage Child Care Both stay-at-home and working mothers utilized multiple sources of substitute care for their young children. Working mothers, however, relied more heavily on substitute care over longer periods of time. The options available to mothers in Korogocho included day-care (both formal and informal), neighbors, relatives/older siblings of the child, and leaving children alone in the house or neighborhood. A minority of mothers, more so those informally employed, were able to take the child with them to work. In the in-depth interviews, almost all formally working mothers mentioned that they paid their substitute caregiver, though very few of the informally working mothers and none of those staying at home did so.

This study suggests that nutrition and health knowledge of working and stay-at-home mothers did not differ substantially, although the sources of information varied. The ability to translate this knowledge into practice, however, was influenced by time, access to income and the level of decision-making power. Lack of money was a specific barrier for mothers to act on their health/nutrition knowledge. Mothers with greater access to and control over money could more easily overcome this barrier.

Two key factors were found to influence substitute care: first, a majority of mothers said they were only able to give instructions about how to care for their child if they paid the substitute caregiver. Remuneration of substitute caregivers, if mothers were financially able to do so, was felt to both increase motivation and responsibility of substitute caregivers.

Secondly, a mother’s personal relationship with a substitute carer, especially neighbors and relatives, was considered to improve child care quality, particularly when the mother could not pay for the care. While this form of social capital was important, mothers who were away working faced difficulties maintaining good rapport because they had less time to interact within their community.

3. Linkages to well-being and child nutrition The quality of care given to young children has long been recognized as a key determinant of child health and nutritional status. Mothers’ reports and direct observation of day-care centers confirmed that the quality of substitute care available in Korogocho was largely poor. Daycare centers were generally overcrowded and without adequate sanitation or safe play-areas for children.

Many day-care workers oversaw more than ten children under two years of age single-handedly, reducing time for individual attention, including active and responsive feeding. Most centers and other substitute carers relied on mothers to bring food for the children; otherwise they would not eat until the mother returned. While mothers themselves recognized that these sub-standard substitute care options compromised their child’s wellbeing, without alternatives, they were forced to continue to rely on them.

The study indicates that by earning their own income, working mothers in Korogocho increased their influence in decisions about purchasing food, health care, and other essential needs for their children.

However, the increase in resources could not be translated easily into better nutrition and health because substitute care options available to working mothers in Korogocho were sub-optimal. Mothers staying at home, however, could provide care, but were limited in their ability to purchase food, health care, and other essential needs.

Implications for Programs and Policy

The positive benefits of mothers’ labor force participation and control over their own income on improving child health and nutrition are well documented. This study reinforces these findings. First, a mother’s ability to earn an income was found to increase her ability to control how income was spent in the household. That control extended to income contributed by other household members. It also strengthened her own sense of independence and her ability to provide for her children.

However, these very positive gains were offset by the fact that working required mothers to leave their young children in sub-standard caring environments. Therefore, access to affordable, quality, substitute care needs to be addressed so that the positive benefits of mothers who work can be fully realized.

Second, given that social capital is an important asset for all women, interventions aimed at supporting mothers – either through economic empowerment or in their role as caregivers – need to include ways to increase mutual support and social networks. Strengthening group saving and credit schemes or building in a child care aspect, for example, has the potential to both increase economic opportunities and contribute to the provision of quality substitute care.

Third, the research reinforced the need for programs to consider the implications of interventions targeted to mothers on their various roles in the community and household. Programs seeking to increase women’s economic empowerment need to consider the implications on mothers’ ability and time to provide quality care to their children.

Further research is required to fully understand the complex gender relations in the slums and their impact on child care and nutrition as well as to place this aspect of care into the wider context of poverty, food insecurity, and poor hygiene and sanitation that contribute to childhood malnutrition in the slums.

Acknowledgements

We gratefully acknowledge the women and men in Korogocho who generously gave us their precious time during the discussions and interviews and community health care workers and enumerators who assisted in the study.

Footnotes

1. Mitullah, W. 2003. Urban slums reports: the case of Nairobi, Kenya. Understanding slums: case studies for the Global Report on Human Settlements 2003. United Nations Centre for Human Settlement.  
2. African Population and Health Research Center (APHRC). 2002. Health and livelihood needs of residents of informal settlements in Nairobi City. Nairobi. APHRC.  
3. Population extrapolated from Pamoja Trust. Korogocho informal settlements enumeration report. July, 2001. Nairobi. Pamoja Trust.  
4. Schofield, L. 2009. Report of baseline urban nutrition assessment in the slums of Nairobi, East and North Districts, Nairobi, Kenya. February 2009. Concern Worldwide Kenya.  
5. Based on WHO 2006 growth standards.  
6. Kurz, K.M., and Johnson-Welch, C. 2000. Enhancing nutrition results: the case for a women’s resources approach. ICRW/ OMNI Research Program. Washington, D.C.. ICRW.  
7. UNICEF. 1998. The state of the world’s children 1998. Oxford. Oxford University Press.  
8. Smith, L., Ramakrishnan U., Ndiaye A., Haddad L., Martorell, R. 2003. The importance of women’s status for child nutrition in developing countries. IFPRI Research Report 131. Washington, D.C.. IFPRI.  
9. Kurz, K.M., and Johnson-Welch, C. 2000. Enhancing nutrition results: the case for a women’s resources approach. ICRW/OMNI Research Program. Washington, D.C.. ICRW.