The Weight of Work: The Relationship Between Maternal Employment and Maternal and Child Overweight in Low- and Middle-Income Countries

Background: Over the past two decades, there have been vast increases in maternal employment in low- and middle-income countries (LMIC). These increases coincide with an increase in the prevalence of overweight among women and children and have occurred in parallel with countries’ nutrition transitions. Objective: To evaluate the relationship between maternal employment and maternal and child overweight in LMIC. Methods: Demographic and Health Surveys (2010 to 2016) were utilized to investigate the association between maternal employment and overweight among women (N=162,768) and children (N=268,763), in approximately 40 LMIC. Mothers were categorized as formally employed, informally employed, or non-employed. Overweight was defined as body mass index [BMI] ≥ 25 kg/m2 among mothers and BMI z-score > 2 among children. Country-specific associations were explored using adjusted logistic regression models, which included an interaction term to assess heterogeneity in the employment-overweight association by maternal education level. Meta-analysis was used to estimate odds ratios pooled across countries. Differences in the association between countries by log-gross domestic product (GDP) and urbanization were investigated using meta-regression. Concurrently, this dissertation study drew on a sample of 20 mothers in Guatemala and utilized semi-structured interviews to explore the pathways by which maternal employment may be associated with weight status. Qualitative data analysis combined deductive and inductive methods and themes were used to develop a conceptual framework. Results: Compared to non-employed mothers, formally employed mothers had higher odds of overweight (pooled odds ratio [POR]=1.3; 95% Confidence Interval [CI] 1.2, 1.4), while informally employed mothers had lower odds of overweight (POR=0.72; 95% CI: 0.64, 0.81). Neither formal nor informal employment were associated with childhood overweight, in most LMIC. However, children of employed mothers, compared to children of non-employed mothers, had a higher BMI z-score (formal employment pooled =0.042; 95% CI: 0.0020, 0.082; informal employment pooled =0.033; 95% CI: -0.010, 0.076). In both women and children, the relationship between formal and informal employment and overweight varied by maternal education in roughly one-fourth of the countries. For example, children of formally employed women with a high education, compared to children of non-employed women with a high education, had higher odds of overweight (POR=1.2; 95% CI: 1.0, 1.4). However, neither the formal employment-, nor informal employment-overweight associations for mothers or children varied by log-GDP or urbanization. Qualitative data suggested that there were 4 pathways through which employment could lead to changes in weight status: employment changed food purchasing behaviors; employment improved household well-being; employment changed maternal time allocation; and mothers perceived that employment had psychological effects. Conclusions: Future studies should consider formal and informal employment separately in studies of overweight outcomes. Findings also suggest that maternal employment may have unintended consequences, as formally employed women had higher odds of overweight, as did children of formally employed women with a high education in some contexts. Program planners and policy-makers in LMIC will need to consider approaches that both support women’s participation in the labor force and address increasing overweight prevalence