Supporting Breastfeeding Moms at Work: How a Doctor's Note Can Make the Difference

Initiating breastfeeding is now the norm for most U.S. women. Through the dedication of community advocates, healthcare workers, and, of course, mothers themselves, breastfeeding initiation is at a new high of 81% nationwide. ¹ Unfortunately, the same transformation has not been seen in rates of breastfeeding duration. Making it possible for women to continue breastfeeding throughout the medically recommended term requires an even broader community of support.

One of the most critical junctures for community support of breastfeeding is the mother's return to work. ² The vast majority of working women in the United States return to the workforce soon after birth and before their milk supply is well established: one quarter return within <2 weeks of giving birth, and more than half are working by the time their infant reaches 3 months of age. ³ As such, breastfeeding mothers need both time and space to express milk during their workday. Yet many have little control over the location or general conditions of their work and are often denied the accommodations they need. These problems are particularly pronounced for a key demographic—low income workers—who are both more likely to need to return within weeks of delivery and less likely to have access to workplace lactation accommodations.

A recent study revealed that 41% of breastfeeding workers were not provided reasonable break time for expressing breast milk on the job, and 55% did not have access to a private space to do so. ⁴ Looking at the two factors together, 60% of nursing mothers did not have access to both the break time and space needed to express breast milk on the job. ⁴ Lower income workers were significantly less likely to have access to these accommodations. ⁴ It is no surprise, then, that the Surgeon General's Call to Action notes that returning to work can be a “significant barrier to breastfeeding.” ⁵

When breastfeeding workers did have access to both time and space for expressing breast milk, the impact was pronounced. These mothers were 2.3 times as likely to breastfeed exclusively at 6 months. ⁴ And the benefit continued: workers with access to both time and space for expressing breast milk were 1.5 times as likely to continue breastfeeding exclusively over each additional month. ⁴

Given the profound impact that time and space accommodations can make on breastfeeding, one must wonder—shouldn't there be a law for that? Just over half of U.S. states have workplace breastfeeding accommodation laws, ranging from statements of principle to a handful of concrete protections for time and space accommodations. ⁶ Federally, there are two key laws that protect breastfeeding workers. The first, Title VII of the Civil Rights Act of 1964, is the primary federal law prohibiting sex discrimination in employment. Although the law has been on the books for decades, courts have only begun applying Title VII to protect breastfeeding workers within the past few years. The law provides a minimal level of protection to almost all workers by requiring employers to treat breastfeeding employees as well as they treat other employees. The Title VII standard requires that, at minimum, breastfeeding employees have the same ability to address lactation-related needs (through schedule changes, break time, accommodations, etc.) that coworkers have to address other needs. It may sound simple, but the concept that women are entitled to pumping breaks is news to the very same employers who do not think twice about giving their workers regular smoke breaks.

A more specific federal law, the Break Time for Nursing Mothers provision, also protects many U.S. workers. This provision, a part of the Affordable Care Act, requires employers to provide eligible employees with (1) reasonable break time to express breast milk as needed throughout the workday and (2) a lactation space that is shielded from view, free from intrusion, and not a bathroom. Unfortunately, this law only protects those employees who are eligible for overtime, and it is only useful where employees feel empowered to actually assert their rights. Many of the workers, typically hourly, lower wage earners, feel they have to choose between breastfeeding and earning a paycheck.

Even if U.S. laws on workplace breastfeeding were clear and comprehensive—and they are not—the mere existence of law would not be enough. Achieving a shift toward workplaces supportive of breastfeeding is best accomplished through multiple channels. We must have both the cultural shift in the acceptance of expressing breast milk at work and the enforcement to back it up. Surprisingly, healthcare providers are in a position to make a big difference in advancing both aims.

How can healthcare providers support nursing mothers in the workplace? First, when discussing breastfeeding, providers should encourage patients to make a plan for expressing breast milk at work and assure them that it is indeed possible. Often the most challenging experiences for nursing mothers are the first few days back at work; having a plan and initiating conversations with employers early can ensure that problems are resolved before a patient is painfully engorged, leaking, and frantic in front of her colleagues.

Next, clinicians can write a note to help patients who are having challenges breastfeeding at work get the accommodations they need. This can be a game-changing asset for workers. Effective notes, even brief ones, can serve to educate the employer about breastfeeding and pumping, and shift their attitude. In addition to shifting attitudes, notes for breastfeeding workers can be critical for mothers whose only legal entitlement to accommodations is that colleagues with other medical conditions receive accommodations. Often, employer policies require some form of medical certification for their workers to get the changes they need. This may apply to even the most basic accommodations, such as regular break time or allowing a retail worker to keep a bottle of water at her side. In these cases, a doctor's note will shift the conversation from one wherein the worker is asking for a “favor” to one wherein she is asserting a legal right.

The best notes help employers understand that breastfeeding is medically important and physician recommended, not simply a casual personal choice or parenting decision. The key to doing so is clearly stating that breastfeeding is important for the patient's health, in addition to the health of the baby. Doctors should be careful to note that while a patient is lactating, she must continue to express breast milk throughout the day and accommodations such as break time and a sanitary pumping location for doing so are not simply helpful, but medically necessary.

Writing an effective work note for a patient who is nursing also requires specificity about her needs. Explain the need for a private space to pump other than a bathroom, and consider noting an estimated frequency and duration of breaks. Mentioning this in a simple doctor's note can lend credibility to a mother whose boss refuses to believe that she needs to express breast milk every hour or two, or can dissipate resentment from a boss who thinks that his breastfeeding worker can assemble her pump, fully express breast milk, and return to work within her 15 minute break.

Physicians should be certain to mention if the patient or her baby has a medical condition or impairment as some patients may have special needs that entitle them to additional accommodations or protection. Alternately, other patients may have special needs not stemming from complications. For example, the unique nature of an employee's work environment may require more unique accommodations, such as avoiding radiation or a modification to a uniform. The final best practice for writing these notes is to clearly communicate that the patient is able to continue working. At times, employers overreact and assume breastfeeding workers are not capable of carrying on with their duties. Physicians should clearly state if this is not the case.

It may be surprising, but a simple note can accomplish much for a nursing mother in little time. Templates are available to assist healthcare providers in writing these notes quickly. ⁷ Armed with a note, women are no longer entering into negotiations about lactation accommodations alone—but in the company of her physician and the law. We have much work to do to support breastfeeding women in the workplace, and no isolated effort is enough to do it. But this is one rare instance wherein a simple action can go a long way. With physicians' increased awareness of this simple intervention, we can create a community where fewer mothers have to question whether they can bring in a paycheck and provide their babies with the first food they need.