Abstract
The Academy of Breastfeeding Medicine is a worldwide organization of physicians dedicated to the promotion, protection, and support of breastfeeding and human lactation. Our mission is to unite into one association members of the various medical specialties with this common purpose.
Overview
Goals
1. To support policies and strategies that minimize separation of mothers and babies during employment or education.
2. To protect, support, sustain, and optimize the health and well-being of lactating women who are separated from their infants/children because of employment or education.
Background
Providing human milk to infants through direct breastfeeding or hand/mechanical expression can be viewed as a right for both mothers1,2 and their infants. 3 Worldwide, many women spend significant amounts of time separated from their children during the first year of life because of formal employment or education. New Zealand census data indicate a 160% increase in the number of women with infants under 1 year of age returning to work. 4 Approximately 40% of Australian mothers are in paid employment during the first 12 months postpartum (mostly part-time and/or after 6 months). 5 In the United States and Canada, over half of women with a child under 1 year of age are in the labor force.6,7 International efforts to encourage mothers to initiate and sustain breastfeeding past the early weeks must address these facts. The availability of workplace setting support programs significantly influences an individual woman's ability to successfully sustain breastfeeding or lactation. Supporting employed women to continue breastfeeding has the potential to impact such critical issues as the health of mothers and children, employee retention and productivity, and cost savings to business and society.
This Academy of Breastfeeding Medicine Summary Statement of Breastfeeding Support for Mothers in Paid Workplace Employment or Out of the Home Educational Settings systematically reviews the literature on breastfeeding support for employed and student mothers. 8 The level of evidence of the majority of the articles reviewed is moderate to weak, with many of them either review articles or studies with very small sample sizes and no comparison groups. 9
Principles of Support
1. Physiology of breastfeeding initiation and duration with respect to separation of the mother–infant dyad
Lactation is the normal physiological state for postpartum women. In the early months of lactation, the breastfeeding mother is susceptible to health issues such as engorgement, mastitis, plugged ducts, and abscesses if her infant is not breastfeeding frequently or well or she is not removing milk effectively while separated from her infant.
a. Establishing milk supply. Placental lactogen, progesterone, estrogen, and prolactin all play important roles in achieving a continuous production of maternal milk. 10 After lactogenesis is initiated by parturition, these endocrine responses are normally sustained by ongoing removal of milk from the breast by infant suckling, a physiological process that will be disrupted if the mother and infant are separated for more than 4 hours. Establishment of an adequate milk supply typically takes a minimum of 1 month (and can take up to 3 months of exclusive breastfeeding), during which time feedings need to be frequent with minimal separation of the dyad. 10
b. Method of milk delivery. Once lactation is well established, the provision of maternal milk needs to be continued when mother and infant are separated. To facilitate this process, women may wish to introduce a cup or a bottle of expressed human milk to their baby and then continue to offer it every few days. 11
c. Milk reserves and storage. With advanced planning and support, the mother can work towards accumulating milk in preparation for separation from her infant. 4 This can be done by expressing and storing milk once daily in addition to exclusive breastfeeding if refrigeration/freezing capability exists. Expressed milk can be saved by freezing it in increments similar to what the infant consumes from a bottle or cup at a single feed. 11 However, in developing countries, this is frequently not practical. Mothers often do not have access to a freezer.
d. Breastfeeding during the workday. Ideally, arranging for mother and child to be together at regular intervals during work or school allows for continued breastfeeding. In some cases, other family members or childcare providers may be able to bring the infant/child to the mother for some or all feeds. 12 It is currently unclear whether direct breastfeeding as compared with the provision of expressed human milk feedings via bottle is equivalent in health outcomes for both mothers and infants/children. 13
e. Expression of human milk. If physical separation is unavoidable, then the mother may be able to maintain her milk supply by expressing milk with an electric breast pump (double may be more efficient than single), a manual pump, or manual expression at least every 3–4 hours throughout the workday.14–16 The opportunity to regularly empty her breasts throughout the day and night (for shift workers) is essential to maintaining milk supply. Time needed is dependent on how far the mother has to travel from her work site to the place she will express her milk and back again, plus time needed to set up, express, and clean pump and/or collection parts if used. The actual process varies from woman to woman, but on average 30 minutes is suggested.9,14,16,17
2. Effect of length of maternity leave and whether it is paid or unpaid on breastfeeding success
a. Length of maternity leave. Longer maternity leaves correlate with a longer duration of breastfeeding and so may be important to the long-term health of the mother and child.18–29 Additionally, women with short or no maternity leave are less likely to initiate breastfeeding.19–25,28,30
b. Paid or unpaid leave
i. Most developed countries have paid maternity leaves, with the United States being a significant exception (Table 1).8,12,32–38
ii. The U.S. Surgeon General's Call to Action to Support Breastfeeding, 12 the new Healthy People 2020 breastfeeding goals, 32 and the Patient Protection and Affordable Care Act 39 all indicate a desire by public policymakers in the United States to remove the barriers mothers encounter when attempting to continue breastfeeding while separated from their children. Of note was the recent case brought to the Massachusetts Supreme Judicial Court in April 2012 (in which ABM served as an amicus) that ruled that breastfeeding women must be given special accommodations when taking state medical licensing exams. 40
iii. Unpaid leave may not be a realistic option for many working women and their families worldwide. Employers should be encouraged to offer some form of paid leave.
3. Major types of workplace accommodations for full-time and part-time professionals and laborers
a. Flexibility. Accommodating breastfeeding through lactation breaks, flexible start and finish times, and access to part-time work while the infant is young can be key. Professional women may have greater success than laborers as they are more likely to have a private office to express milk and/or a supportive work environment.26,41–44 Women who are bound by shift work may have a strictly regulated schedule and less flexibility to express milk when needed. Part-time workers may fare better than full-time workers presumably because they can spend more time with their infants.28,41,45–48
b. Infant on-site or in close proximity to the workplace. The best accommodation for the breastfeeding employed woman may be to have the infant at or in close proximity to the workplace. 12 This can be considered "the gold standard." Some organizations facilitate mothers bringing their infants to work on a regular basis and caring for them while doing their jobs. This can include on-site child care that allows mothers to partially attend to their infants while working.15,49–58 More flexible options include working from home, working flexible hours, and other negotiations with the employer such that both productivity and breastfeeding are maintained. Pilot programs like the one at the Nevada Health Department, which allows infants in the workplace until they are mobile, report maternal satisfaction, breastfeeding success, and co-worker tolerance with infants on-site, as well as employer satisfaction with mothers returning to work sooner, less time with unfilled positions, and employees working hard to make the program work, with no complaints lodged by other workers. 59
4. Employer resources
a. Physical space. The minimal requirements for workplace lactation support is a private, clean, and safe space that is not a bathroom (with a handwashing facility in proximity) for a mother to express milk or breastfeed. Better still is a sink in the room, a table or counter, a comfortable chair, access to a refrigeration unit, and an electrical outlet for an electric pump and the refrigeration unit.15,39,49,50
b. Supportive workplace culture. A supportive culture in the work environment is crucial to effective support of breastfeeding mothers.44,55,60–65
i. Management's knowledge of breastfeeding. This is achieved when fellow employees and managers are knowledgeable about the risks of artificial milk feeding, benefits of breastfeeding, and the need for mothers to continue to breastfeed or express milk to maintain an adequate milk supply and breast health.15,49,66 “Research has shown that a corporate environment designed to enable and encourage continued breastfeeding does not engender negative attitudes in other employees.” 59 Educational kits such as the Business Case for Breastfeeding in the United States 49 and the Australian equivalent, the Breastfeeding Friendly Workplace program, 66 provide suggestive evidence to illustrate the financial benefits for employers who support these initiatives.
ii. Benefits of breastfeeding to employers. Lower healthcare costs, decreased absenteeism, increased employee retention, and positive public relations are the tangible benefits to employers that have been shown in individual studies when establishing this kind of support in their workplace.49,61
c. Other options
i. Subsidized breast pumps are an amenity that can be included as part of a more comprehensive lactation program.15,49–55
ii. Prenatal education, employment consultation, and ongoing telephone support have all been shown to be positively associated with breastfeeding success.15,49–58
A workplace lactation program that features all of these accommodations would be considered the “top of the line.”
5. Legal and public policy considerations with respect to workplace breastfeeding policies
Employment and public policies can contribute significantly to whether employed women can establish and maintain breastfeeding and to whether women have a realistic choice to breastfeed after beginning employment or education.67,68
a. The International Labour Organization's recent “Review of National Legislation Regarding Maternity at Work.” At least 92 countries have legislation that provides for breastfeeding breaks, in addition to regular breaks, for breastfeeding mothers. Both Conventions Number 103 and 183 of the International Labour Organization's stipulate that work interruptions for the purpose of nursing are to be counted as working time and remunerated accordingly. 33 Although the frequency, allotted time, length of shift, and paid or unpaid nature vary, the common denominator throughout the world is flexibility to accommodate a breastfeeding mother's needs. 69 Provisions to support breastfeeding employees, including lactation breaks, are numerous around the world. 8 For example, Irish mothers can choose to take the allowed breaks or reduce their working hours for 26 weeks after birth. 70 In Chile, a breastfeeding mother may come to work an hour later than normal or leave an hour earlier with no impact on pay. 69 In Croatia, a mother can have 120 minutes/day of paid lactation breaks for 12 months. 8
b. World Alliance for Breastfeeding Action document "Status of Maternity Protection by Country." 8 Updated in 2011, this is an excellent resource on maternity leaves, payment, and breastfeeding breaks in the workplace throughout the world. Some countries in which maternity leave is unpaid consider breastfeeding breaks as paid working time. 33 Provisions to support breastfeeding employees including lactation breaks now exist within an increasing number of workplace agreements in Australia. New South Wales and Queensland Public Service provide for up to 60 minutes a day for expressing milk or breastfeeding. Also in Australia, National Employment Standards generally entitle employees to unpaid leave of 12 months, with the right to request a further 12 months of leave. 71 Parents also have a right to request part-time work or other flexible work arrangements there. 72
c. U.S. Federal legislation through 2010. In the United States, prior to 2010, federal law offered little support to working breastfeeding mothers, requiring individual states to pass workplace accommodation legislation.73–76 The Patient Protection and Affordable Care Act federal law mandates reasonable break time and a place, other than a bathroom, for mothers to express milk. 34 This is further enforced by the U.S. Department of Labor, which amended its Fair Labor Standards Act to include the change in the law and, more importantly, a means to file a complaint if these mandates are not upheld. 77 Some public policies in the United States have discouraged breastfeeding, for example, welfare policies increasing maternal return to work requirements. In many states, these work requirements apply to mothers whose children are a few months old, which may increase the costs and decrease the prevalence of breastfeeding. One study suggested that in the absence of welfare reform, the national breastfeeding rate 6 months after birth would have been 5.5% higher in 2000; such negative consequences of these policies must be weighed against potential benefits as states refine their welfare programs. 78
d. Australian Commonwealth Parliament amended the Sex Discrimination Act (May 2011). The amendments ensure that there is clarity that breastfeeding is covered, that employers or service providers cannot discriminate against breastfeeding women, and that special measures must be taken to accommodate the needs of breastfeeding women in the workplace and elsewhere.79,80
Conclusions and Recommendations
Separation of mother and child by employment or education can harm breastfeeding and lead to adverse maternal and child health outcomes. Whenever possible, increased contact for the mother with the infant/child during the day should be encouraged with on-site childcare or infant in close proximity to her worksite.
Adequate maternity leave is critical to establishing milk supply and improving breastfeeding outcomes for employed or student mothers. Therefore, all countries should support paid maternity leave policies to reduce disparities in breastfeeding rates among women who work outside the home or attend school.
Breastfeeding women employed in professional settings have higher rates of breastfeeding initiation and duration, suggesting that laborers require more workplace support than they are currently receiving.
Women who are able to work or attend school part-time have a significantly improved duration of breastfeeding than women who work/study full-time. Therefore flexible employment, job sharing, and working from home should be encouraged and supported.
The presence of formalized lactation programs and support and physical facilities in schools or places of employment improves mothers' capabilities to breastfeed successfully and should be commonplace.
Informed employers understand how support of breastfeeding employees will positively affect their businesses. Legislation and other public policy initiatives may improve compliance with workplace breastfeeding accommodation and provide greater choice for working women to breastfeed. Continued dissemination about successful programs will be helpful.
Suggestions for Future Research
Prospective controlled studies may be needed to establish the efficacy of corporate lactation programs or public policy measures in increasing breastfeeding initiation rates and duration and to further document the potential economic benefit to employers:
1. Focus on individual programs and include the incidence and duration of breastfeeding by employed or student mothers, both full-time and in various categories of part-time, in different employment and education conditions throughout the world.
2. Measure productivity changes between workplaces that are breastfeeding friendly versus controls.
3. Evaluate the relationship between timing of employment or student status, either full-time or part-time, and subsequent success in maintaining breastfeeding.
4. Study the effect of passage of local and national regulations and policy concerning support of breastfeeding during paid employment and education throughout the world, preferably with a comparison before and after legislation or policy is placed into effect. Public policy changes can amount to a natural experiment that adds to our knowledge. 81
Footnotes
ABM position statements expire 5 years from the date of publication. Evidence-based revisions are made within 5 years or sooner if there are significant changes in the evidence.