Workplace Breastfeeding Support Varies by Employment Type: The Service Workplace Disadvantage

Abstract

Background:

The majority of women are returning to work full-time after childbirth, and support within their place of employment may influence intention and duration for breastfeeding, but more research is needed. Therefore, the purpose of this study was to explore the influence of employment type on breastfeeding duration upon return to work by examining informal (i.e., verbal encouragement) and direct (i.e., lactation space, flexible time) factors of support.

Methods:

This was a retrospective survey of women's returning-to-work experiences while breastfeeding. Survey contents included respondent demographics as well as questions surrounding perceptions of employer support, work environment, and goal/satisfaction regarding breastfeeding. Data were analyzed via crosstabs and chi-square goodness of fit tests.

Results:

A total of 1,002 women completed the survey. Significant differences were seen across different employment types. Women within the professional/management industry were most likely to receive informal and direct support for breastfeeding upon return to work. Women within the service industry and production/transportation industry reported receiving the lowest levels of informal and direct support.

Conclusion:

Workplace support varies by employment type and women in the service and production/transportation industry appear to be at a disadvantage compared with other employment types. There is a need for more breastfeeding support programs to be developed that target specific workplace characteristics.

Introduction

The prevalence of working mothers has greatly increased in the past several decades. In 1967, 49% of women were stay-at-home mothers; in 2012, this number had reduced to 29%.¹ Unfortunately, working outside of the home is associated with reduced initiation of breastfeeding and shorter breastfeeding duration.^2–6 In regard to initiation, one study found women who planned to work full-time postpartum were less likely to initiate breastfeeding in comparison with women who planned to work part-time.³ Furthermore, timing for return to work and breastfeeding cessation are significantly associated with one another. Kimbro found that in the month before returning to work, a mother was 34% more likely to quit breastfeeding and twice as likely to stop breastfeeding in the month she began working.⁵ Research is needed to identify factors that may influence breastfeeding cessation upon return to work.

While breastfeeding initiation and duration appear to be impacted by returning to work postpartum, characteristics of the employer may influence this relationship.⁵ The support a woman receives in her work environment can be critical to her continued intention and duration for breastfeeding. Specifically, informal support such as verbal encouragement from an employer and direct support factors such as flexible scheduling or existence of a breastfeeding policy has been shown to play a contributing role.⁵ However, the influence of these factors varies based on employment type. Women working in administrative and manual labor positions appear to stop breastfeeding earlier than women working in other professions.⁴ However, previous research studies were limited primarily to low-income women and only looked at broad job categories (e.g., professional, administrative, manual, and service). Larger samples with more diverse employment types need to be examined to elaborate on these results. Therefore, the purpose of this study was to explore the influence of employment type on breastfeeding duration upon return to work by examining informal and direct factors of support.

Materials and Methods

Research subjects and design

This was a retrospective survey of women's returning-to-work experiences while breastfeeding. The Nebraska Breastfeeding Coalition developed a voluntary survey as part of their strategic goal around improving support for breastfeeding mothers in the workplace. A sample size calculation was conducted based on the 2015 Nebraska breastfeeding rate of 20% of mothers' breastfeeding at 6 months and ∼26,000 infants being born per year in Nebraska.⁷ Results showed a total of 358 women were needed to provide appropriate representation of the state population. The survey was administered electronically to women within the state of Nebraska and a convenience sampling method was utilized. Women were eligible to participate if they had returned to work breastfeeding within the last 5 years. The open survey was disseminated via social media (i.e., Facebook), e-mail, and the Nebraska Breastfeeding Coalition's website from October 25, 2016 to November 1, 2016 using an automatic response capturing program (i.e., Google Forms). Within this time period, a total of 1,060 participants completed the survey. The survey took ∼10 minutes to complete, and although no monetary incentives were provided, mothers were informed that their responses would help to better understand women's return-to-work experiences while breastfeeding.

Assessment instrument

The 26-item, 5-page questionnaire included questions that explored predictors of continued intention and duration for breastfeeding upon return to work. Mothers were required to provide a response to each question; however, they were given the option to answer “other” or “not applicable” if so desired. All responses were able to be reviewed and altered before survey submission through the utilization of a “back” button. Responses could not be altered once the survey was submitted. Questions eliciting demographic variables of zip code, ethnicity, and highest level of education as well as content around work industry type were asked. Furthermore, questions assessed perceptions of informal support (employer support, goal/satisfaction) and direct support (work environment) regarding breastfeeding.

Informal support

Employer support

Four questions were utilized to evaluate perceptions of support from an employer regarding pumping. Questions included “Was your employer supportive of your breastfeeding and pumping goals?” and “Did the support in the workplace help you achieve your goals?.” Furthermore, women were asked if they had discussed their breastfeeding goals with their employer before their maternity leave and if so, who had initiated that conversation.

Goals and satisfaction

Four questions assessed goals and satisfaction related to pumping duration, goal achievement, goal hindrance, and overall satisfaction with breastfeeding upon return to work. For example, women were asked; “With your most recent return to work, how long did you pump?” and “Were you satisfied with your breastfeeding and return-to-work experience?”

Direct support

Work environment

Five questions were specific to the direct support a woman received in her work environment. Direct support factors investigated included flexible scheduling, sufficient time, as well as if a lactation space other than a bathroom was provided. If a lack of flexible scheduling was reported from the question “were you given a flexible schedule to fit in pumping breaks?” respondents described the reason why. The survey also inquired if their company had a breastfeeding policy.

Data analysis

Data were initially obtained by the Nebraska Breastfeeding Coalition. Upon approval from a University affiliated Institutional Review Board, the data were de-identified by the coalition and provided to the research team for analysis. Before providing the data set to the research team, the Nebraska Breastfeeding Coalition removed any duplicate surveys and incomplete questionnaires. Data were then embedded in an Excel document for cleaning.⁸

One researcher categorized all open-ended content, including geographical location, factors influencing schedule flexibility, and employment type. Geographical location consisted of categorizing zip codes as urban or rural. Urban areas were defined from standards set by the United States Census Bureau as cities, villages, or towns consisting of 2,500 or more people. Rural areas were those with less than 2,500 people.⁹ In addition, one researcher was responsible for ensuring proper categorization of the primary independent variable of interest for this study, employment type. Women were provided multiple choice options for employment type based on the employment categories established by the United States Census Bureau healthcare (e.g., doctor), management/professional (e.g., chief executive, production/transportation (e.g., machine operator), sales/office (e.g., receptionist), service (e.g., server), and other (e.g., corrections officer).¹⁰ The researcher first evaluated all of the “other” responses. If an employment type did fit into a preestablished category based on the Census occupation list, they were moved to that category; otherwise, they remained in the other category. Coding categories were reviewed by the entire research team for consensus. This process ultimately allowed for a large visualization of the data and the contents to better describe the data through identified values, making them accessible for data analysis.

All analyses were performed using SPSS Version 23.¹¹ The limit for statistical significance was set at p < 0.05. Descriptive analyses were conducted to evaluate demographic variables and to determine mean responses for all yes/no questions. Crosstabs and chi-square goodness of fit tests were used to assess for associations between independent and dependent variables.

Results

Respondent characteristics are provided in Table 1. The majority of women were white (94.5%) and had a bachelor's degree or some form of technical training (64.4%). The most common industry women reported working in was healthcare (34.4%) followed by management/professional (22.5%). More women denoted zip codes associated with urban areas (57.6%) rather than rural areas (42.4%) within the state of Nebraska. Several factors related to employer support, work environment, and breastfeeding goals showed significant differences when evaluated, based on employer type.

Table 1.

Respondent Demographics

Variable	n	Total (%)
Ethnicity
White	1,002	94.5
Black or African American	27	2.5
Asian or Pacific Islander	9	0.8
Two or more races	7	0.7
n/a	15	1.5
Education
High school education and below	27	2.5
Some college	100	9.4
Technical training/associate's degree	122	11.5
Bachelor's degree	461	43.5
Master's degree and above	326	30.7
N/A	24	2.4
Home environment
Urban	609	57.6
Rural	441	42.4
Employment type
Healthcare	364	34.3
Management/professional	238	22.5
Education	184	17.4
Production/transportation	23	2.2
Sales/office	136	12.8
Service	112	10.6
Other	3	0.3

Informal support

Employer support

In regards to aspects of employer support, significant differences between employer types were found for all questions. Those in the management/professional realm were most likely to report “yes” to having an employer who supported their goals (81.9%) and to state that this support helped them achieve their breastfeeding goals (81.9%). Approximately half of women in each employment group reported discussing pumping with their employer before their maternity leave; however, those in the production/transportation industry were most likely to do so (65.2%). Those in the production/transportation industry were also the most likely to initiate this conversation themselves rather than having a supervisor or human resource personnel member reach out to them (92.8%) (Table 2).

Table 2.

Employer Support

(%)	Healthcare	Management/professional	Education	Production/transportation	Sales and office	Service	p-Value for χ² test
Employer supported goals
Yes	70.6	81.9	67.4	73.9	73.5	66.1	0.032
No	22.3	10.9	21.2	21.7	19.1	26.8
Other	7.1	7.1	11.4	4.3	7.4	7.1
Support/goal achievement
Yes	60.7	81.9	53.3	69.6	72.8	62.5	0.000
No	39.3	18.0	46.7	30.4	27.2	37.5
Pumping discussion with employer
Yes	47.8	57.8	54.3	65.2	62.5	58.9	0.002
No	52.5	42.2	45.7	34.8	37.5	41.1
Initiated pumping conversation
Self	87.7	81.3	92.4	92.8	88.0	81.8	0.000
Supervisor	11.7	6.9	6.7	0.0	0.3	13.6
Human Resources	0.5	11.8	0.9	7.2	11.7	4.6

Goals and satisfaction

Significant differences regarding goals and satisfaction were found for all questions (Table 3). Breast pumping duration was longest for women working in the healthcare industry, as they reported utilizing a breast pump for the longest duration of 12 or more months (22.8%). Women working in the service industry were most likely to report using a breast pump for 1 month or less (22.8%). Women in the management/professional industry were most likely to report “yes” to meeting their breastfeeding goals (86.6%). Conversely, women in the service industry were most likely to report “no” to meeting breastfeeding goals (71.4%). Finally, in regard to overall satisfaction, those in education were least likely to report “yes” to being satisfied with their return-to-work experience while pumping (57.1%). Those in the management/professional realm were most likely to report that they were satisfied with their return-to-work experience (78.2%).

Table 3.

Goals and Satisfaction

(%)	Healthcare	Management/professional	Education	Productions/transportation	Sales and office	Service	p-Value for χ² test
Breast pumping duration
<1 month	3.6	2.5	2.2	13.0	5.10	22.8	0.04
1–3 months	9.3	9.7	12.5	4.30	12.5	22.7
4–6 months	19.5	13.4	20.1	17.4	22.1	14.1
7–9 months	15.4	20.6	27.2	26.1	14.0	13.0
10–12 months	29.4	31.1	23.9	26.1	27.9	18.4
12+ months	22.8	22.7	14.1	13.0	22.3	16.1
Met goals
Yes	75.0	86.6	75.0	87.0	79.4	71.4	0.002
No	25.0	13.4	25.0	13.0	20.6	28.6
Overall satisfaction
Yes	64.3	78.2	57.1	69.6	72.8	59.8	0.000
No	35.7	21.8	42.9	30.4	27.2	40.2

Direct support

Work environment

Table 4 provides findings for work environment. Significant differences between employer type were seen for all questions and can be viewed in Table 4. Those working in management/professional positions were most likely to report “yes” they received adequate lactation space (82.8%), sufficient time for pumping (84.5%), a flexible schedule for pumping (84.0%), and were aware of an existing breastfeeding policy (38.7%). Women working in education were least likely to report being provided lactation space (57.6%) as well as least likely to report that they received sufficient pumping time (58.2%) or a flexible schedule for pumping (34.8%). In regard to policy existence, women working in the production/transportation industry were least likely (17.4%) to report being aware of a policy around breastfeeding.

Table 4.

Work Environment

(%)	Healthcare	Management/professional	Education	Productions/transportation	Sales and office	Service	p-Value for χ² test
Provided lactation space
Yes	70.6	82.8	57.6	73.9	70.6	67.9	0.00
No	24.2	11.8	31.0	17.4	26.5	24.1
Other	5.2	5.5	11.4	8.7	2.9	8.0
Policy existence
Yes	31.6	38.7	19.0	17.4	27.2	25.0	0.000
No	53.0	56.3	69.6	78.3	62.5	71.4
Other	15.4	5.0	11.4	4.3	10.3	3.6
Provided sufficient time
Yes	62.1	84.0	58.2	82.6	75.7	67.0	0.026
No	31.0	12.2	38.0	13.0	17.6	27.7
Other	7.7	3.8	3.8	4.4	6.7	5.3
Flexible schedule
Yes	57.1	84.5	34.8	78.3	77.2	59.8	0.000
No	34.1	9.2	51.6	17.4	16.2	29.5
Other	8.8	6.3	13.6	4.3	6.6	10.7

Discussion

This study suggests providing a supportive breastfeeding friendly work environment is key to increasing breastfeeding rates. This confirms previous findings suggesting the level of support a woman perceives from her employer depends on her employment type.^4–6 Encouraging findings showed that the majority of women felt supported by their employer to breastfeed, are meeting their breastfeeding goals, and are satisfied with their return-to-work experience while breastfeeding. However, the national averages for breastfeeding duration continue to be below the recommended amounts, and additional efforts are needed.

Women working in management/professional occupations were most likely to report feeling they were in a supportive work environment and that the environment helped them reach their breastfeeding goals. This finding was similar to previous research showing women in professional occupations had higher rates of breastfeeding.⁵ Those working in professional/management occupations were also most likely to report having a lactation space, be aware of an existing breastfeeding policy have sufficient time for pumping breaks, and a flexible schedule. The existence of these factors appears to enable women to continue breastfeeding and thus should continue to be a top priority for other employment types.⁶

Conversely, our findings differed from previous research showing women in the service industry had similar breastfeeding rates to women in the management/professional industry.⁵ In our study, women in the service industry had shorter breastfeeding duration and were most likely to report “no” when asked if they received support from their employer to continue breastfeeding. Women in the service industry were also most likely to report not meeting their breastfeeding goals, indicating the lack of support from their employer may be influential. Approximately a quarter of women working in service jobs stated that they did not receive adequate lactation space or sufficient time for pumping. This could be due to the nature of service work (i.e., serving, bartending). As over two-thirds of women in this field reported not having a lactation policy, the development of such a policy that ensures adequate space and provides appropriate pumping time could help reduce these barriers. Easily adaptable sample policy templates are readily available through online resources such as the Health and Human Services Maternal and Child Health Bureau.¹² These templates can provide information on basic breastfeeding needs as well as provide an opportunity for employers to add workplace specific information. For instance, previous research has shown having a clean room for pumping is key to breastfeeding duration; this could be an additional component that is noted when developing policies within the service industry.⁶ Although policy development is crucial to improving the work environment, the need to improve employer support remains. Providing educational opportunities for supervisors, managers, and administrators regarding the benefits of breastfeeding and the tools needed to support breastfeeding in the workplace should be a focus of future research and health promotion efforts.

Furthermore, developing opportunities that combine state initiatives and workplace efforts to increase knowledge about breastfeeding benefits could provide consistent support regardless of the setting for women's breastfeeding efforts. An example can be seen through the Nebraska Breastfeeding Coalition's “Really? Really” campaign. “Really? Really.” provides valuable education materials regarding breastfeeding education. Adapting such materials and providing them to expectant parents (mothers and fathers) as well posting general breastfeeding infographics around the workplace could increase knowledge and support for breastfeeding.^1,13 Further research is needed to evaluate these types of approaches and their influence on breastfeeding upon return to work.

Our study was limited by the nature of our cross-sectional recall survey design. The one-time survey collected data at a single time point, and women were asked to recall information from up to 5 years previously. Furthermore and importantly, despite greatly exceeding the needed sample size of 358 women, the survey was disseminated by the Nebraska Breastfeeding Coalition, which may have limited respondent variability, as women were recruited through breastfeeding friendly sources and were primarily Caucasian with a Bachelor's degree or some form of technical training. In addition, a zip code analysis revealed a high prevalence of respondents came from high urban socioeconomic areas, which could also hinder the generalizability of findings. This study should be replicated in low socioeconomic areas as these areas are often correlated with low rates of breastfeeding initiation and duration and findings may vary. Strengths of this study included the large sample size and wide variety of employment types.

Conclusion

This study contributed to the literature by determining how perceptions of breastfeeding support vary by employer type. By understanding the specific barriers associated with each type of employment, future interventions and policy development can be better equipped to address the needs of their employees. Employers can help support women in achieving their breastfeeding goals by providing better informal (i.e., verbal encouragement) and direct (i.e., lactation space, flexible time) support as well providing better communication opportunities to discuss breastfeeding among coworkers. The workplace offers an ideal location to provide crucial support to improving breastfeeding duration within the United States.

Footnotes

Acknowledgment

This study was supported by the Nebraska Breastfeeding Coalition.

Disclosure Statement

No competing financial interests exist.

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