Abstract
D
Although many women initiate breastfeeding and want to continue to breastfeed for at least the first year, they often find it difficult to combine breastfeeding with being in the paid workforce. Returning to work or study is a major reason for women to wean prematurely, so addressing some of the factors that have a negative impact on breastfeeding for working women has the potential to improve breastfeeding rates in many countries.
First, breastfeeding is a learned art and a dynamic process. A woman can initiate and maintain a breastmilk supply without the infant actually feeding at the breast, and an infant can receive breastmilk using bottles, teats (nipples), or other equipment. However, the most effective and efficient way to establish breastfeeding is for a woman and her infant to be together, especially in the first few weeks and months when breastfeeds are frequent and often irregular. Returning to work during this establishment period and when the mother is recovering from her pregnancy and birth is especially problematic and results in significantly lower breastfeeding initiation, exclusivity, and duration rates.
The International Labour Organization (ILO) Convention 183 on Maternity Protection considers that all women should be entitled to at least 14 weeks of paid maternity leave, and in 2014 all but two countries in the world (the United States and Papua New Guinea) had at least some form of universal paid maternity leave. In some jurisdictions, government-sanctioned paid leave (sometimes being split between the mother and father) is much longer than 14 weeks, and in many, this paid leave may be augmented by employer-funded maternity leave and unpaid leave. Although some may argue against paid maternity leave, the reality is that many families cannot afford for the mother to not be working, so there is significant pressure for an early return to work. However, the benefits of longer maternity leave are unequivocal. Positive effects on breastfeeding rates, maternal mental health, and maternal workforce participation with increasing lengths of maternity leave have been found in studies from countries throughout the world. These advantages translate into benefits for the family and community as a whole and should be seen as an investment in the country's future.
Second, when a mother does return to paid work, she needs time to be able to either breastfeed her infant (if there is on-site child care or the carer is able to bring the infant to the workplace for breastfeeds) or express her breastmilk. The ILO Convention includes provision for paid lactation breaks for these purposes. Mothers may also use regular breaks, such as lunch or tea breaks, to express, but this may not be sufficient if the mother is still establishing her milk supply or is adjusting to using a breast pump. Flexibility of working hours, such as part-time work, being able to take breaks when needed, or alternative working arrangements such as telecommuting, also facilitates ongoing breastfeeding.
Third, women need to have clean, private facilities where they can express breastmilk at work, as well as a safe and appropriate place to store their breastmilk. It is not appropriate for a woman to express in the bathroom, just like we would not expect to eat lunch in the bathroom.
Fourth, information about their legal entitlements, accommodations available in their particular workplace, and reasons why continued breastfeeding is important should be made available to all pregnant women so that they can plan to breastfeed and are able to anticipate problems when they return to work. It may be necessary to negotiate with the employer to ensure that breastfeeding can continue without undue stress for the mother or infant. Overt support from family, the community, and the workplace also facilitates ongoing breastfeeding.
Althugh many women would benefit from improved conditions for breastfeeding at work, what I find most concerning is the difficulties experienced by female physicians. There is an expectation that they take minimal maternity leave so as not to inconvenience the workplace or their colleagues. Working hours are long, and prolonged separation from the infant is routine. This separation, coupled with the view that breaks to express should not interfere with any other work-related activity, can result in infrequent expressing or breastfeeding opportunities leading to insufficient breast stimulation to maintain an adequate milk supply. Flexibility of working conditions, particularly for hospital-based physicians, also appears to be very difficult to organize. Physicians are expected to encourage and support women to exclusively breastfeed for the first 6 months, yet many fail to reach this goal because of work conditions outside their control.
If we really want to increase exclusive breastfeeding rates to 6 months as well as breastfeeding duration, strategies such as paid maternity leave and workplace accommodations for breastfeeding women should be the norm rather than an exception. What we can do is advocate for policy change at all levels of society.
Material to support WABA's World Breastfeeding Week is available at http://worldbreastfeedingweek.org