Assessment of the feasibility and potential effectiveness of a baby-friendly workplace support initiative in rural Kenya: a study protocol


  • Elizabeth W. Kimani-Murage African Population and Health Research Center
  • Teresia N. Macharia African Population and Health Research Center
  • Eva W. Kamande African Population and Health Research Center
  • Peter M. Gatheru African Population and Health Research Center
  • Hermann P. P. Donfouet African Population and Health Research Center
  • Taddese Alemu African Population and Health Research Center
  • Laura Kiige UNICEF Country Office
  • Susan Jobando UNICEF Country Office
  • Lynnette A. Dinga UNICEF Country Office
  • Betty Samburu Ministry of Health, Unit of Nutrition and Dietetics
  • Joyce Atinda Ministry of Health, Unit of Nutrition and Dietetics
  • Samuel Watson University of Warwick
  • Claudia Mitchell McGill University
  • Paula Griffiths Loughborough University
  • Richard Lilford University of Warwick
  • Debra Jackson UNICEF Headquarter
  • France Begin UNICEF Headquarter
  • Grainne Moloney UNICEF Country Office



Breastfeeding, Workplace support, Plantation, Kenya


Background: Employment poses a barrier in achieving the World Health Organization’s recommendation of exclusive breastfeeding for the first six months of life. Effective strategies and evidence to improve breastfeeding for women working in the agricultural sector – the main employer for women in Kenya – is lacking. This study aimed to inform (with evidence) the design and implementation of a scalable model of workplace support for breastfeeding in an agricultural setting in Kenya; as well as investigated the model’s potential operational feasibility and potential effectiveness, and its cost-effectiveness.

Methods: The study employed a mixed methods approach and participatory methods at the pre-implementation, implementation and post-implementation phases. The pre-implementation phase generated evidence to inform the implementation. Mothers with children under 12 months were interviewed at the pre-implementation (2016) and post-implementation (2018) phase. Managers, supervisors, decision and policy makers, as well as other community members were also targeted. Statistical methods will include analysis of covariance and logistic regression. Additionally, cost-effectiveness and cost-benefit analyses will be done. Qualitative data will be analysed in vivo, using thematic analysis technique.

Conclusions: Findings from this study aimed to inform the potential feasibility and potential effectiveness of a baby-friendly workplace support for breastfeeding initiative in an agricultural setting with a goal of improving child nutrition and health. The findings also contribute to policy and practice in Kenya by informing the development of workplace support guidelines.

Trial Registration: ISRCTN registry, ISRCTN 64692465; date of registration: 21 December 2016 – retrospectively registered,


WHO. Breastfeeding. 2016. Available at: Accessed on: 28 September 2020.

Bahl RF, Kirkwood C, Edmond BR, Martines K, Bhandari J, Arthur PN. Infant feeding patterns and risks of death and hospitalization in the first half of infancy: multicentre cohort study. Bull World Health Organiz. 2005;83(6):418-26.

Diallo FB, Bell L, Moutquin JM, Garant MP. The effects of exclusive versus non-exclusive breastfeeding on specific infant morbidities in Conakry. Pan Afr Med J. 2009;2:2.

Victora CG, Bahl R, Barros AJD. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016;387(10017):475-90.

Kramer MS, Kakuma R. The optimal duration of exclusive breastfeeding: a systematic review. Adv Exp Med Biol. 2004;554:63-77.

WHO. Global strategy for infant and young child feeding. Singapore. 2003. Available at: Accessed on: 02 August 2015.

UNICEF Statistics. 2014. Available at: Available at: Accessed on: 02 August 2015.

Republic of Kenya. National Nutrition Action plan 2012-2017. Calverton, Maryland: KNBS and ICF Macro, 2012. 2012.

Kenya National Bureau of Statistics (KNBS) and ICF Macro. Kenya Demographic and Health Survey 2014. Nairobi. 2015.

Chuang CH, Chang PJ, Chen YC. Maternal return to work and breastfeeding: a population-based cohort study. Int J Nurs Studies. 2010;47(4):461-74.

Chuang CH, Chang PJ, Hsieh WS. The combined effect of employment status and transcultural marriage on breast feeding: a population-based survey in Taiwan. Paediatr Perinatal Epidemiol. 2007;21(4):319-29.

Gielen AC, Faden RR, O'Campo P, Brown CH, Paige DM. Maternal employment during the early postpartum period: effects on initiation and continuation of breast-feeding. Pediatr. 1991;87(3):298-305.

Hawkins SS, Griffiths LJ, Dezateux C, Law C. Maternal employment and breast-feeding initiation: findings from the Millennium Cohort Study. Paediatr Perinatal Epidemiol. 2007;21(3):242-7.

Tsai SY. Impact of a Breastfeeding-Friendly Workplace on an Employed Mother’s Intention to Continue Breastfeeding After Returning to Work. Breastfeeding Med. 2013;8(2):210-6.

Weber D, Janson A, Nolan M, Wen LM, Rissel C. Female employees' perceptions of organisational support for breastfeeding at work: findings from an Australian health service workplace. Int Breastfeeding J. 2011;6:19.

Labor force participation rate, female (% of female population ages 15+). 2015. Available at: Accessed on: 02 August 2015.

Philips Africa Innovation Hub. Breastfeeding in urban Africa:Towards empowering working mothers through innovation. 2015. Available at: /08/2015-August-Breastfeeding-in-Urban-Africa-Philips-Report-FINAL.pdf. Accessed on: 02 August 2015.

Vanek J, Chen M, Heintz J, Hussmanns R. Statistics on the Informal Economy: Definitions, Regional Estimates & Challenges.WIEGO Working Paper (Statistics) No 2. Cambridge, MA:: WIEGO. 2014. Available at: Accessed on: 02 August 2015.

Kimani-Murage EW, Wekesah F, Wanjohi M. Factors affecting actualisation of the WHO breastfeeding recommendations in urban poor settings in Kenya. Maternal Child Nutrition. 2015;11(3):314-32.

Ziraba AK, Madise N, Mills S, Kyobutungi C, Ezeh A. Maternal mortality in the informal settlements of Nairobi city: what do we know? Reproductive Health. 2009;6(1):6.

Ortiz J, McGilligan K, Kelly P. Duration of breast milk expression among working mothers enrolled in an employer-sponsored lactation program. Pediatric Nursing. 2004;30.

Wyatt SN. Challenges of the working breastfeeding mother. Workplace solutions. AAOHN J. 2002;50(2):61-6.

Mulama J. Africa, Development & Aid, Headlines Development: Women Produce Most of the Tea Grown in Kenya. 2002. Available at: Accessed on: 14 November 2017.

Gitonga A. Flower firm garlands workers with rosy benefit. Standard digital. 2009.

Andrieu J, Chichester O, Meiers R, Poynton C, Shields L. Working Women and Health in East Africa’s Agricultural Sector. BSR Working Paper. San Francisco.: BSR. 2014.

Hector D, King L, Webb K, Heywood P. Factors affecting breastfeeding practices: applying a conceptual framework. New South Wales Public Health Bull. 2005;16(3-4):52-5.

Wells KB. Treatment research at the crossroads: the scientific interface of clinical trials and effectiveness research. Am J Psychiatr. 1999;156(1):5-10.

Glasgow RE, Lichtenstein E, Marcus AC. Why don't we see more translation of health promotion research to practice? Rethinking the efficacy-to-effectiveness transition. Am J Public Health. 2003;93(8):1261-7.

OECD. DAC Guidelines and Reference Series: Quality Standards for Development Evaluation. 2010.

MoH-Kenya. Adolescent Sexual And Reproductive Health In Kericho County. 2009. Available at: Accessed on: 10 November 2017.

Lohia N, Udipi SA. Infant and child feeding index reflects feeding practices, nutritional status of urban slum children. BMC Pediatrics. 2014;14(1):290.

WHO. Child Growth Standards based on length/height, weight and age. Acta paediatrica (Oslo, Norway : 1992). 2006;450:76-85.

Gold MR. Cost-effectiveness in health and medicine. Oxford university press; 1996.

Kansas CfCHaDUo. 2017. CRM Guidelines for Community Readiness Scoring. Available at:; Accessed on: 15 October 2017.

Chen YC, Wu YC, Chie WC. Effects of work-related factors on the breastfeeding behavior of working mothers in a Taiwanese semiconductor manufacturer: a cross-sectional survey. BMC Public Health. 2006;6:160.

McIntyre E, Pisaniello D, Gun R, Sanders C, Frith D. Balancing breastfeeding and paid employment: a project targeting employers, women and workplaces. Health Promotion International. 2002;17(3):215-22.