Background Returning to work after childbirth is challenging for working mothers. Childcare quality may have lifelong effects on children’s health, development and cognitive function. Over 60% of working women globally are informal workers without employment or maternity protection, but little is known about how these women care for their children. Methods We conducted a mixed-methods longitudinal cohort study among informal women workers in Kwazulu-Natal, South Africa between July 2018 and August 2019. Participants were followed up from late pregnancy until they had returned to work. We conducted structured quantitative interviews and in-depth qualitative interviews at different time points: before and after the baby was born, and after returning to work. Subsequently, a photovoice activity was conducted with groups of participants to explore the childcare environment. We employed narrative thematic analysis for qualitative data and descriptive analysis for quantitative data. Results 24 women were recruited to participate. Women returned to work soon after the baby was born, often earlier than planned, because of financial responsibilities to provide for the household and new baby. Women had limited childcare choices and most preferred to leave their babies with family members at home, as the most convenient, low cost option. Otherwise, mothers chose paid carers or formal childcare. However, formal childcare was reported to be poor quality, unaffordable and not suited to needs of informal workers. Mothers expressed concern about carers’ reliability and the safety of the childcare environment. Flexibility of informal work allowed some mothers to adapt their work to care for their child themselves, but others were unable to arrange consistent childcare, sometimes leaving the child with unsuitable carers to avoid losing paid work. Mothers were frequently anxious about leaving the child but felt they had no choice as they needed to work. Conclusion Mothers in informal work had limited childcare options and children were exposed to unsafe, poor-quality care. Maternity protection for informal workers would support these mothers to stay home longer to care for themselves, their family and their baby. Provision of good quality, affordable childcare would provide stability for mothers and give these vulnerable children the opportunity to thrive.

Background In South Africa almost 2 million women work informally. Informal work is characterised by poor job security, low earnings, and unsafe working conditions, with high rates of poverty and food insecurity. The peripartum period is a vulnerable time for many working women. This study explored how mothers navigate the tension between the need to work and the need to take care of a newborn baby, and how this affects their feeding plans and practices. Methods A mixed methods longitudinal cohort method was employed. Informal workers were recruited in the last trimester of pregnancy during an antenatal visit at two clinics in Durban, South Africa. Data were collected using in-depth interviews and quantitative questionnaires at three time points: pre-delivery, post-delivery and after returning to work. Framework analysis was used to analyse qualitative data in NVIVO v12.4. Quantitative analysis used SPSSv26. Results Twenty-four participants were enrolled and followed-up for a period of up to 1 year. Informal occupations included domestic work, home-based work, informal trading, and hairdressing, and most women earned <R3000 (US$175) per month. Participants had good knowledge of the importance of breastfeeding for child health. Most women planned to take time off work after the birth of their babies, supporting themselves during this time with the child support grant (CSG) received for older children, their savings, and support from the baby’s father and other family members. However, financial pressures forced many mothers to return to work earlier than planned, resulting in changes to infant feeding practices. Several mothers tried expressing breastmilk, but only one was able to sustain this while away from the baby. Most participants introduced formula, other foods and fluids to their babies when they returned to work or stopped breastfeeding entirely, but some were able to change their work or adapt their working hours to accommodate breastfeeding. Conclusions Interventions are needed within the social and work environment to support mothers with breastfeeding while they continue earning an income in the informal economy. The extension of the CSG to the antenatal period could assist mothers to stay at home longer post-delivery to breastfeed their babies.

Background Electronic decision-making support systems (CDSSs) can support clinicians to make evidence-based, rational clinical decisions about patient management and have been effectively implemented in high-income settings. Integrated Management of Childhood Illness (IMCI) uses clinical algorithms to provide guidelines for management of sick children in primary health care clinics and is widely implemented in low income countries. A CDSS based on IMCI (eIMCI) was developed in South Africa. Methods We undertook a mixed methods study to prospectively explore experiences of implementation from the perspective of newly-trained eIMCI practitioners. eIMCI uptake was monitored throughout implementation. In-depth interviews (IDIs) were conducted with selected participants before and after training, after mentoring, and after 6 months implementation. Participants were then invited to participate in focus group discussions (FGDs) to provide further insights into barriers to eIMCI implementation. Results We conducted 36 IDIs with 9 participants between October 2020 and May 2021, and three FGDs with 11 participants in October 2021. Most participants spoke positively about eIMCI reporting that it was well received in the clinics, was simple to use, and improved the quality of clinical assessments. However, uptake of eIMCI across participating clinics was poor. Challenges reported included lack of computer skills which made simple tasks, like logging in or entering patient details, time consuming. Technical support was provided, but was time consuming to access so that eIMCI was sometimes unavailable. Other challenges included heavy workloads, and the perception that eIMCI took longer and disrupted participant’s work. Poor alignment between recording requirements of eIMCI and other clinic programmes increased participant’s administrative workload. All these factors were a disincentive to eIMCI uptake, frequently leading participants to revert to paper IMCI which was quicker and where they felt more confident. Conclusion Despite the potential of CDSSs to increase adherence to guidelines and improve clinical management and prescribing practices in resource constrained settings where clinical support is scarce, they have not been widely implemented. Careful attention should be paid to the work environment, work flow and skills of health workers prior to implementation, and ongoing health system support is required if health workers are to adopt these approaches (350).

Background Globally, increasing numbers of higher education institutions (HEIs) in non-English-speaking countries have adopted English as a medium of instruction (EMI), because of the perception that this provides opportunities to attract high-calibre students and academic staff, and engage with the international research community. We report an evaluation of a North–South-South collaboration to develop health research capacity in the Democratic Republic of the Congo (DRC) by establishing a postgraduate programme in nutritional epidemiology at the Kinshasa School of Public Health (KSPH), where EMI was adopted. We report experiences and perceptions of stakeholders, facilitators and students about using EMI. Methods In-depth qualitative interviews were conducted between October and December 2019 among convenience sampled stakeholders (8), facilitators (11) and students (12) involved in the programme from all three partner institutions (University of Kinshasa; University of KwaZulu-Natal, South Africa; University of Bergen, Norway). Interviews were conducted in participants’ language of preference (English or French), audio-recorded, transcribed verbatim and translated into English when required. Analysis employed a thematic approach. Results Most participants viewed EMI positively, reporting that studying in English created opportunities to access relevant literature, improve interactions with the scientific community and advance their careers. As a result of adopting EMI, some students had opportunities to present research findings at international conferences and publish their research in English. English-speaking researchers from partner institutions were able to participate in supervision of students’ research. However, inadequate English competency, particularly among students, was challenging, with some students reporting being unable to understand or interact in class, which negatively affected their academic performance. Further, EMI created barriers at KSPH among academic staff who were not proficient in English, leading to poor participation among non-English-speaking staff and lack of integration with other postgraduate programmes. Participants suggested additional English language support for EMI. Conclusion Partnerships between HEIs could be a powerful tool to develop research capacity in low-income countries in line with United Nations Sustainable Development Goals. EMI could be a solution to language barriers faced by many such partnerships, but wide-ranging support to develop English proficiency among staff and students is essential to ensure that the challenges do not outweigh the benefits.

Background Low- and Middle-income countries (LMIC) face considerable health and nutrition challenges, many of which can be addressed through strong academic leadership and robust research translated into evidence-based practice. A North-South-South partnership between three universities was established to implement a master’s programme in nutritional epidemiology at the Kinshasa School of Public Health (KSPH), Democratic Republic of Congo (DRC). The partnership aimed to develop academic leadership and research capacity in the field of nutrition in the DRC. In this article we describe the educational approach and processes used, and discuss successes, challenges, and lessons learned. Methods Self-administered questionnaires, which included both open and closed questions, were sent to all graduates and students on the master’s programme to explore students’ experiences and perceptions of all aspects of the educational programme. Quantitative data was analysed using frequencies, and a thematic approach was used to analyse responses to open-ended questions. Results A two-year master’s programme in Nutritional Epidemiology was established in 2014, and 40 students had graduated by 2020. Key elements included using principles of authentic learning, deployment of students for an internship at a rural residential research site, and support of selected students with bursaries. Academic staff from all partner universities participated in teaching and research supervision. The curriculum and teaching approach were well received by most students, although a number of challenges were identified. Most students reported benefits from the rural internship experience but were challenged by the isolation of the rural site, and felt unsupported by their supervisors, undermining students’ experiences and potentially the quality of the research. Financial barriers were also reported as challenges by students, even among those who received bursaries. Conclusion The partnership was successful in establishing a Master Programme in Nutritional Epidemiology increasing the number of nutrition researchers in the DRC. This approach could be used in other LMIC settings to address health and nutrition challenges.