Relationship of Maternal Perceptions of Workplace Breastfeeding Support and Job Satisfaction

Abstract

Objectives:

Decades of research supports the health benefits of breastfeeding. Prior research has shown that unsupportive work environments are frequently cited as reasons women abandon breastfeeding early. The objective of this study is to determine if mothers' perceptions of workplace lactation support are associated with job satisfaction.

Materials and Methods:

Female employees of Seattle Children's Hospital (SCH) and a large corporation were e-mailed a survey to measure perceptions of workplace lactation support. Women were eligible to participate if they had a child born within the last 5 years. Questions were asked about lactation support across five domains; organization, manager, coworker, time, and physical environment. The main outcome was job satisfaction. Linear regression models were run to evaluate the association between workplace support scores and the outcome of interest.

Results:

The survey was completed by 420 women at SCH and 131 women at the large corporation (response rate, 47%). Ninety-eight percent of study participants initiated breastfeeding, and most sustained breastfeeding for at least 6 months. Increased total workplace support score was associated with increased job satisfaction at both companies (p<0.001). Increased support scores within each domain were independently associated with increased job satisfaction (p values<0.005). When all domains were considered together, only manager and coworker supports were significant at SCH (p=0.04), and only time support was significant at the large corporation (p=0.01). The workplace support score was not significantly associated with breastfeeding duration at either institution.

Conclusions:

Improved lactation support in the workplace may improve new mothers' job satisfaction, which could be beneficial to businesses.

Background

Decades of research supports the health benefits of breastfeeding for infants, young children, and mothers.^1–4 Nearly all medical organizations, including the American Academy of Pediatrics, recommend that all infants be exclusively breastfed for about the first 6 months of life with continued breastfeeding through at least the first year.¹ Although steady progress has been made over the last decade in improving breastfeeding initiation rates, the majority of infants in the United States are not breastfed as long as recommended. Currently, although 79% of new mothers initiate breastfeeding, only 49% and 27% are still breastfeeding when their babies are 6 and 12 months of age, respectively.⁵

Research into breastfeeding behavior has consistently shown that maternal return to work is an important reason why women stop breastfeeding earlier than recommended.^6–10 Women frequently cite unsupportive work environments as a reason for early discontinuation of breastfeeding, including lack of time and privacy for expressing breastmilk.¹¹ Under the Affordable Care Act of 2010 employers are required to provide reasonable break time for women to express breastmilk at work for 1 year after a child's birth. It also requires the provision of a non–bathroom facility that is free from view and intrusion of coworkers.^12,13 Women now represent a significant portion of the workforce, with more than 60% of women with children under the age of 1 year participating in formal employment.¹⁴ The great majority of these women return to work within 3 months of the birth of their child.¹⁴

Companies that support their nursing mothers may reap significant financial benefits, including decreased healthcare costs, decreased absenteeism, and increased employee retention.¹⁵ Employers with workplace lactation programs in place have seen increased breastfeeding duration among breastfeeding employees who participate in the program.^16–18 However, to our knowledge no prior study has evaluated the association between workplace lactation support and overall job satisfaction. This information could have important ramifications for businesses looking to retain their talented female employees. It is also unknown which specific domains of workplace lactation support are associated with increased breastfeeding duration. We therefore conducted a study with the following aims:

1. To determine if mothers' perceptions of workplace breastfeeding support are associated with job satisfaction

2. To determine which domains of breastfeeding support are associated with job satisfaction

3. To determine if mothers' perceptions of workplace breastfeeding support are associated with increased breastfeeding duration.

Materials and Methods

We e-mailed a survey (Breastfeeding and Employment Study [BESt]) designed to measure mothers' perceptions of workplace lactation support to female employees of two large companies.^19–21 This survey was conducted in 2013, after enactment of the reasonable break time for nursing mothers' provision under the Affordable Care Act. The first company was a large children's hospital in the Pacific Northwest, Seattle Children's Hospital (SCH); the second was a large corporation in the Southeast. The BESt survey is a previously developed tool designed to measure women's perceptions of workplace lactation support.¹⁹ The survey asks 41 questions about breastfeeding support across five domains: organizational support, manager support, coworker support, time, and physical environment. Most questions use a 4-point Likert-type scale to measure responses of strongly agrees, agrees, disagrees, and strongly disagrees. A few questions use a simple yes or no answer structure. We also obtained baseline demographic and breastfeeding information from the respondents.

Women were eligible to complete the survey if they had a child born within the last 5 years and were asked to complete this survey according to their experience with their most recent child. Women were subsequently excluded if they worked for a different company at the time of return to work after their most recent child. All women were identified using employment records from the human resources departments of each company. At SCH, records specifically identifying women who had a child in the last 5 years were not available. Therefore, all women under the age of 40 years were sent an e-mail inviting them to participate in the survey. The first survey question asked whether they had a child in the last 5 years. If the answer was “yes,” they were able to complete the full survey. The large company provided records for only women who were known to have had a child born in the last 5 years. Only these women were sent the e-mail invitation to participate in the survey. SCH does not currently have an official workplace lactation program in place; the large corporation does. The study protocol was approved by the Seattle Children's Research Institute Institutional Review Board.

Outcome

The primary outcome of this study was job satisfaction. We measured this using a previously validated single item measure of job satisfaction.²² This question asked simply, “Taking everything into consideration, how do you feel about your job as a whole?” This item was measured using a 7-point Likert scale, with 1=extremely dissatisfied and 7=extremely satisfied.²² The secondary outcome of this study was the duration of any breastfeeding measured in weeks. Respondents were asked how long they breastfed their most recent child either in weeks or months. If they responded in months, the response was multiplied by 4.

Predictors

The main predictor variable was workplace support scores for each domain. All Likert responses were assigned a numerical value between 1 and 4: the number 1 corresponded to responses indicating the least perceived support, and the number 4 corresponded to responses indicating the most support. Yes/No questions were similarly assigned a numerical value, with 1 corresponding to the response of least support and 2 to the response of most support. Within each domain the Likert response values were summed to give an overall domain-specific support score. Similarly, the domain-specific support scores were then summed to give an overall survey score. For all scores a high value indicates a high level of perceived support, and a low value indicates a low level of perceived support.

Analysis

We developed two sets of linear regression models. In the first model, each individual domain was tested for its association with workplace satisfaction. In the second model, all domains were included simultaneously to test their independent contribution to job satisfaction. The models were adjusted for the potential confounders of maternal age, education, income level, number of hours worked per week, whether an hourly wage or salary is paid, amount of time off before returning to work, and whether any of the time off was paid. The models evaluating duration of breastfeeding were also adjusted for currently breastfeeding mothers. Because the BESt score values are themselves difficult to interpret and the number of questions vary across each domain, we created standardized scores for each domain. A 1-unit change in z score can be interpreted as a 1 standard deviation (SD) change. We analyzed the data from the two companies separately, and they are presented side by side for comparison.

Results

At SCH, 2,409 female employees were identified using human resources records, and an invitation to participate in the survey was e-mailed to all of them. Of these, 1,129 women responded and were identified as either eligible or ineligible to participate, yielding a response rate of 47%. Four hundred twenty women were eligible and answered a survey question for at least one of the outcomes of interest. At the large corporation, the human resources department provided e-mail addresses for all women who had a child born in the last 5 years, yielding 215 women. An e-mail link with an invitation to participate in the survey was sent to all of them. One hundred forty-one of these women responded, giving a response rate of 65%. At both companies the respondents were primarily older, white, married, and highly educated (Table 1). The majority had been with their current employer for greater than 5 years and benefited from a paid maternity leave (Table 1).

Table 1.

Demographic Characteristics of the Study Population

Characteristic	Children's hospital	Large corporation
Age (years)	33.2±3.8	34.5±2.9
Race
White	332 (81.8%)	104 (81.3%)
Asian	33 (8.1%)	11 (8.6%)
Black or African American	10 (2.5%)	6 (4.7%)
Other	31 (7.6%)	7 (5.4%)
Married or living with partner	393 (96.3%)	124 (96.9%)
Highest level of education attained
Less than college graduate	65 (15.9%)	5 (3.9%)
4-year college	206 (50.4%)	69 (53.5%)
Advanced degree	138 (33.7%)	55 (42.6%)
Yearly household income
Less than $60,000	71 (17.5%)	3 (2.3%)
More than $60,000	335 (82.5%)	126 (97.7%)
Length of time with current employer
Less than 1 year	36 (8.6%)	0
13 months to 5 years	153 (36.6%)	39 (30%)
More than 5 years	229 (54.8%)	91 (70%)
Hours worked per week
Less than 30	158 (38.2%)	1 (0.8%)
31–40 hours	191 (46.1%)	93 (71.5%)
Greater than 40 hours	65 (15.7%)	36 (27.7%)
Paid hourly wage	253 (60.5%)	3 (2.3%)
>6 weeks of paid maternity leave	242 (69.3%)	104 (79.4%)
Average weeks of leave after most recent child	15.1±11.4	11.5±4.2
Initiated breastfeeding	412 (98%)	131 (100%)

Data are mean±standard deviation values or number (%) as indicated.

Overall job satisfaction was good at both companies. The mean job satisfaction score for the study population was 5.8, with a range of 2–7, at SCH and 6.4, with a range of 4–7, at the large corporation.

The mean breastfeeding duration was long at 41.8 (SD 24.0) weeks with an observed range of 1–144 weeks at SCH and 38.8 (SD 34.1) weeks with a range of 2–216 weeks at the large corporation (Table 2). At SCH 98% of the respondents initiated breastfeeding with their most recent child, and 79% of participants were still offering breastmilk at 6 months of age. At the large corporation 100% of the respondents initiated breastfeeding, and 60% were offering breastmilk at 6 months of age.

Table 2.

Description of Outcomes and Predictors of Interest

		Children's hospital			Large corporation
	Possible range	Observed range	Mean	SD	Observed range	Mean	SD
Job satisfaction score	1–7	2–7	5.8	1.0	4–7	6.4	0.8
Breastfeeding duration (weeks)	—	1–144	41.8	24.0	2–216	38.8	34.1
Total score	41–156	89–156	124.5	14.9	99–156	137.7	15.1
Domain-specific support scores
Organizational support	11–44	17–44	35.9	4.9	27–44	39.5	4.5
Manager support	12–48	18–48	37.3	6.1	18–48	39.6	6.3
Coworker support	6–24	11–24	19.4	3.1	11–24	19.9	3.3
Time support	3–12	3–12	8.0	2.4	6–12	10.6	1.8
Physical environment	9–28	12–28	22.1	3.3	16–28	25.4	3.0

SD, standard deviation.

The possible range of total workplace support scores for this survey tool was 41–156, and the observed ranges of scores were 89–156 at SCH and 99–156 at the large corporation. The mean total workplace support score was 124.5 (SD 14.99) for SCH and 137.7 (SD 15.1) for the large corporation. The domain-specific support score ranges and means are summarized in Table 2. In the linear regression model the total workplace support score was significantly associated with job satisfaction at both institutions: β=0.41 (95% confidence interval, 0.30, 0.51) at SCH and β=0.27 (95% confidence interval, 0.14, 0.40) at the large corporation. Each domain-specific support score was also independently significantly associated with increased job satisfaction with p values of <0.002 at both institutions (Table 3). In the multivariate regression model adjusting for all confounders and including all BESt domains, manager support (β=0.19, p=0.04) and coworker support (β=0.15, p=0.04) remained significantly associated with improvement in job satisfaction at the children's hospital, whereas only time support (β=0.29, p=0.01) remained significantly associated with improvement in job satisfaction at the large corporation (Table 3).

Table 3.

Workplace Support Scores and Association with Job Satisfaction by Domain

	Children's hospital			Large corporation
	β	p value	95% CI	β	p value	95% CI
Total workplace support score	0.41	<0.001	0.30, 0.51	0.27	0.001	0.14, 0.40
Domain-specific support scores^a
Organizational support	0.40	<0.001	0.31, 0.50	0.42	<0.001	0.28, 0.55
Manager support	0.42	<0.001	0.33, 0.51	0.35	<0.001	0.22, 0.48
Coworker support	0.33	<0.001	0.24, 0.43	0.40	<0.001	0.27, 0.53
Time support	0.34	<0.001	0.25, 0.44	0.35	<0.001	0.21, 0.49
Physical environment	0.17	0.003	0.06, 0.29	0.28	0.001	0.14, 0.41
Domain specific support scores^b
Organizational support	0.12	0.18	−0.06, 0.31	−0.05	0.77	−0.41, 0.30
Manager support	0.19	0.04	0.00, 0.37	0.05	0.56	−0.14, 0.24
Coworker support	0.15	0.04	0.01, 0.28	0.13	0.29	−0.12, 0.38
Time support	0.14	0.06	−0.01, 0.26	0.29	0.01	0.07, 0.52
Physical environment	−0.07	0.23	−0.18, 0.06	−0.09	0.39	−0.31, 0.12

Univariate models including only domain of interest and adjusting for all confounders.

Multivariate model with all domains and all confounders included in the model.

CI, confidence interval.

We did not find any association between breastfeeding duration in weeks and total workplace support score or any domain-specific support score at either location (Table 4).

Table 4.

Regression Model of Breastfeeding Duration in Weeks by Workplace Support Scores

	Children's hospital			Large corporation
	β	p value	95% CI	β	p value	95% CI
Total score	0.53	0.73	−2.47, 3.53	1.43	0.75	−7.76, 10.63
Domain specific support scores
Organizational support	−1.01	0.44	−3.58, 1.56	0.48	0.87	−5.01, 6.01
Manager support	−1.08	0.39	−3.54, 1.37	1.41	0.63	−4.43, 7.26
Coworker support	1.54	0.23	−0.99, 4.06	0.66	0.86	−6.63, 7.94
Time support	−1.05	0.41	−3.58, 1.48	3.71	0.17	−1.64, 9.07
Physical environment	0.61	0.69	−2.38, 3.60	−4.05	0.19	−10.08, 1.98

CI, confidence interval.

Discussion

Prior studies have looked at the association between workplace lactation support and breastfeeding duration; however, to our knowledge none has evaluated the association between workplace breastfeeding support and job satisfaction. We found that women who reported feeling supported to maintain breastfeeding in their workplace had higher overall job satisfaction than those who did not feel as supported. Similarly, in the univariate models, increases in each domain-specific support score were also independently, and significantly, associated with increased job satisfaction (Table 3). On average, one-quarter to one-third of an SD change in each domain was associated with a 1 unit higher job satisfaction score. This association was true for the two separate institutions. The magnitude of this difference in satisfaction, although small, is comparable to the association between opportunity for promotion and job satisfaction.²³

When all of the domains of support were included in the same model, only manager support and coworker support remained significantly associated with job satisfaction at SCH, and only time support remained significantly associated with job satisfaction at the large corporation. It is not completely clear why this is the case, but this finding may point to the importance of unique challenges within each institution that make it more or less challenging for women to express breastmilk at work. Although the women from the two institutions in this study had many similarities, there were also significant differences between them. The children's hospital population consisted of many shift workers who were paid an hourly wage and worked fewer than 40 hours per week. Many of these women are bedside nurses and have little control over their daily schedules. The women at the large corporation were primarily salaried full-time employees with significant flexibility in their day-to-day schedules. They also enjoyed a formal on-site lactation program. At SCH, where there is no lactation program in place, women may have to rely on the support and good will of their managers and coworkers to cover patients and other responsibilities while they pump. At the large company only time support was meaningful after considering all domains, perhaps indicating that even with a workplace lactation program in place women still find it difficult to make time to express breastmilk during the workday.

Our study did not demonstrate any difference in breastfeeding duration (offering any breastmilk) among those women who felt the greatest amount of breastfeeding support at work and those who felt the least amount of support. In our linear regression models a 1 point increase in total workplace support score did not significantly change overall breastfeeding duration. This study population consisted of primarily older, white, highly educated women, a population that is known to breastfeed at higher rates than the general population at baseline.^24–26 Of the mothers who participated in this survey at the children's hospital and the large corporation, 98% and 100%, respectively, initiated breastfeeding in their most recent child, and 79% and 60%, respectively, were still offering some breastmilk at 6 months of age. This is significantly higher than the national average of 79% of mothers initiating breastfeeding and 49% offering any breastmilk at 6 months, as well as the state averages where these two companies are located: 92% initiation and 64% breastfeeding at 6 months for the children's hospital and 77% initiation and 48% breastfeeding at 6 months for the large corporation.⁵

This study population also benefited from a predominantly paid and lengthy maternity leave. At SCH, 69% of women had greater than 6 weeks of paid maternity leave, whereas at the large corporation, almost 80% of women received greater than 6 weeks of paid leave. It is known that longer maternity leave is associated with a longer duration of breastfeeding.²⁷

It is possible that the reason we did not demonstrate an association between perceived workplace support and breastfeeding duration in this study is that our study population had a very high baseline dedication to breastfeeding. It is likely that women who work in industries with far less control over their daily schedules face much greater challenges in combining breastfeeding and employment. It is also possible that other unmeasured factors unrelated to the workplace impacted breastfeeding choice and duration.

There were several limitations of this study that warrant mention. First, it was conducted within two institutions with highly educated, very skilled female employees. The two companies also had very high baseline rates of breastfeeding and an interest in improving the breastfeeding experience for new mothers. The extent to which these findings can be generalized to other companies with different employee profiles is unknown but warrants further study. Nevertheless, we were able to demonstrate an association between employee perception of breastfeeding support and job satisfaction even in two workplaces where overall job satisfaction was very high. We also did not control for general employee happiness, which is likely to be related to job satisfaction. Additionally, this survey was unable to determine if the breastfeeding was exclusive. It is very possible that workplace support has a greater impact on the duration of exclusive breastfeeding than the duration of any breastfeeding. Like any survey study, it is possible that we had response bias. In the e-mail that accompanied the survey it was difficult to completely conceal that the topic of interest was breastfeeding. It is therefore possible that women who did not breastfeed or were not interested in this topic did not respond. Lastly, the cross-sectional nature of our study precludes drawing causal inferences. Although it is plausible and consistent with our a priori hypothesis that workplace lactation support would improve job satisfaction, further study will be needed to confirm our findings.

Conclusions

In spite of these limitations, our study has some important implications. Improved lactation support in the workplace may increase new mothers' job satisfaction, which is likely beneficial to businesses. More satisfied employees have been shown to have lower levels of burnout and fewer turnovers than less satisfied employees, which can save a company significant money and time in finding and training new workers.^28–31 Many of the supports necessary are not particularly resource intensive, which employers may deem to be cost-effective. Future longitudinal research should attempt to confirm our findings and estimate the magnitude of change in satisfaction that can be achieved at a given cost.

Footnotes

Acknowledgments

This research was made possible through funding from a National Research Service Award training grant and the Global Breastfeeding Initiative of Excellence in Paediatrics.

Disclosure Statement

No competing financial interests exist.

References

American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics, 2012; 129:e827–e841.

Chantry

, Howard

, Auinger

. Full breastfeeding duration and associated decrease in respiratory tract infection in US children. Pediatrics, 2006; 117:425–432.

Chen

, Rogan

. Breastfeeding and the risk of postneonatal death in the United States. Pediatrics, 2004; 113:e435–e439.

Duijts

, Jaddoe

, Hofman

, et al. Prolonged and exclusive breastfeeding reduces the risk of infectious diseases in infancy. Pediatrics, 2010; 126:e18–e25.

Centers for Disease Control and Prevention. Breastfeeding Report Card. 2014. Available at www.cdc.gov/breastfeeding/pdf/2014BreastfeedingReportCard.pdf (accessed January 28, 2015).

Baker

, Milligan

. Maternal employment, breastfeeding, and health: Evidence from maternity leave mandates. J Health Econom, 2008; 27:871–887.

Kimbro

. On-the-job moms: Work and breastfeeding initiation and duration for a sample of low-income women. Matern Child Health J, 2006; 10:19–26.

Ogbuanu

, Glover

, Probst

, et al. Balancing work and family: Effect of employment characteristics on breastfeeding. J Hum Lact, 2011; 27:225–238.

Noble S; The ALSPAC Study Team. Maternal employment and the initiation of breastfeeding. Acta Paediatr, 2001; 90:423–428.

10.

Chuang

C-H

, Chang

, Chen

, et al. Maternal return to work and breastfeeding: A population-based cohort study. Int J Nurs Stud, 2010; 47:461–474.

11.

Raju

TNK

. Continued barriers for breast-feeding in public and the workplace. J Pediatr, 2006; 148:677–679.e1.

12.

U.S. Department of Labor. Break Time for Nursing Mothers. 2014. Available at www.dol.gov/whd/nursingmothers/ (accessed May 30, 2014).

13.

Murtagh

, Moulton

. Working mothers, breastfeeding, and the law. Am J Public Health, 2011; 101:217–223.

14.

Laughlin

Maternity Leave and Employment Patterns of First-Time Mothers: 1961–2008. 2011. Available at www.census.gov/prod/2011pubs/p70-128.pdf (accessed January 22, 2014).

15.

Carothers

, Hare

. The business case for breastfeeding. Breastfeed Med, 2010; 5:229–231.

16.

Balkam

, Cadwell

, Fein

. Effect of components of a workplace lactation program on breastfeeding duration among employees of a public-sector employer. Matern Child Health J, 2011; 15:677–683.

17.

Tsai

. Impact of a breastfeeding-friendly workplace on an employed mother's intention to continue breastfeeding after returning to work. Breastfeed Med, 2013; 8:210–216.

18.

Ortiz

, McGilligan

, Kelly

. Duration of breast milk expression among working mothers enrolled in an employer-sponsored lactation program. Pediatr Nurs, 2004; 30:111–119.

19.

Greene

, Olson

. Development of an instrument designed to measure employees' perceptions of workplace breastfeeding support. Breastfeed Med, 2008; 3:151–157.

20.

Greene

, Wolfe

, Olson

. Assessing the validity of measures of an instrument designed to measure employees' perceptions of workplace breastfeeding support. Breastfeed Med, 2008; 3:159–163.

21.

Hojnacki

, Bolton

, Fulmer

, et al. Development and piloting of an instrument that measures company support for breastfeeding. J Hum Lact, 2012; 28:20–27.

22.

Dolbier

, Webster

, McCalister

, et al. Reliability and validity of a single-item measure of job satisfaction. Am J Health Promot, 2005; 19:194–198.

23.

Ellickson

, Logsdon

. Determinants of job satisfaction of municipal government employees. Public Pers Manage, 2002; 31:343–358.

24.

Fein

, Mandal

, Roe

. Success of strategies for combining employment and breastfeeding. Pediatrics, 2008; 122(Suppl 2):S56–S62.

25.

Jones

, Kogan

, Singh

, et al. Factors associated with exclusive breastfeeding in the United States. Pediatrics, 2011; 128:1117–1125.

26.

Kelly

, Watt

. Breast-feeding initiation and exclusive duration at 6 months by social class—Results from the Millennium Cohort Study. Public Health Nutr, 2005; 8:417–421.

27.

Guendelman

, Kosa

, Pearl

, et al. Juggling work and breastfeeding: Effects of maternity leave and occupational characteristics. Pediatrics, 2009; 123:e38–e46.

28.

Scanlan

, Still

. Job satisfaction, burnout and turnover intention in occupational therapists working in mental health. Aust Occup Ther J, 2013; 60:310–318.

29.

Organ

, Ryan

. A meta-analytic review of attitudinal and dispositional predictors of organization citizenship behavior. Pers Psychol, 1995; 48:775–802.

30.

Schnake

. Organizational citizenship: A review, proposed model, and research agenda. Hum Relat, 1991; 44:735–759.

31.

Spector

. Job Satisfaction: Application, Assessment, Causes and Consequences. Sage, Thousand Oaks, CA, 1997.