Abstract
Abstract
Introduction:
Women account for over 50% of the workforce in the United States with many working women being of childbearing age. The United States does not provide long paid parental leave, thus mothers who choose to breastfeed are confronted with the reality of combining breastfeeding and returning to work. Return to work is reported to negatively impact breastfeeding exclusivity and duration. While the existing federal law protects some women, not all women have legal support to breastfeed or express milk at work. Exemptions to the federal law include limitations related to the employee's status, classification of employer, total number of employees and the employer's annual revenue. This study aimed to examine existing city-level legislation protecting the rights of women to breastfeed or express milk at their place of employment during the postpartum period.
Materials and Methods:
Prospective descriptive study with survey. The national sample includes the three largest cities of each state and the capital city of the United States (Washington, DC) for a total of 151 cities. The data were collected in a tiered approach with three phases: (1) assessment of city website, (2) e-mail to city mayor's office, and (3) telephone follow-up with the city's office.
Results:
Only 2/151 (1.3%) of cities had specific legislation outlining the protections for all breastfeeding women in the workplace.
Conclusions:
This research demonstrates a clear need for political action to increase the number of women who have workplace regulations to protect breastfeeding.
Introduction
W
On March 23, 2010, the Patient Protection and Affordable Care Act amended Section 7 of the Fair Labor Standards Act (FLSA), Section 4207: Reasonable break time for nursing mothers and to require employers to provide reasonable break time for an employee to express breast milk for her child for 1 year after the child's birth. 3 Section 4207 calls for employers to provide a place, other than a bathroom, that is private, shielded from view, and free from intrusion by coworkers or the public, to be used by the employee to express breast milk. 3 However, for a woman to be covered by the FLSA, she must work for an employer with more than 50 employees and an annual dollar volume of sales or business of at least $500,000. 3 Furthermore, exempt employees (those paid salary) are not covered by the FLSA. 3
The National Conference of State Legislatures provides details on state legislation that provides for and protects the rights of breastfeeding mothers, including those who are employed. Only 28/50 (56%) states have state-level legislation that directly accommodates any female employee who wishes to breastfeed or pump while at work. 4 However, important to note is that 12 of those states (42.8%) have legislation that holds particular stipulations. Out of 28, four (14.2%) states (Hawaii, Indiana, Oregon, and Virginia) require an employer to have a minimum number of employees before accommodations are to be made, and 6/28 (21.4%) states (Colorado, Hawaii, Maine, New York, Oregon, and Vermont) set parameters on the length of time that an employer is required to make accommodations (1–3 years postpartum). In Montana, the law only applies to public employees, and in Louisiana, the law only applies to public school teachers. The state law of Georgia stipulates that employers are allowed to, but not required to, provide break times for breastfeeding or breast pumping women while at work. 4
Given the limitations of Section 4207 of the FLSA and of present state-level legislation, cities across the United States are in a unique position to develop and implement legislation to protect lactation for employed breastfeeding mothers. Currently, there is no national clearinghouse for city-level breastfeeding legislation.
Materials and Methods
The study received Institutional Review Board approval from the University of Pennsylvania. The purpose of this prospective descriptive study is to describe current city-level legislation related to the promotion and protection of breastfeeding and/or pumping for women returning to the workplace in the first postpartum year.
Participants
A purposeful national sample of cities across the United States of America was used for the purposes of the study. The study team's research assistants utilized the US Census Data to make a catalog of the three largest cities in each state by population. The final study sample consisted of the capital city and the 2 largest cities (by population) across all 50 states of the United States of America as well as Washington, DC. If the capital was one of the two largest cities in that state, then the next largest city (by population) was selected. This resulted in a final sample of 151 cities.
Survey design
The survey was designed by the first and last author and piloted by the research team (Fig. 1). The survey consisted of one main question: “Does your city hold legislation specific to accommodating women returning to work during the first postpartum year in regard to breastfeeding and/or pumping at work?” If the representative answers, “no,” that ends the survey and the data collection. If the representative answers, “yes,” then three subsequent questions are prompted detailing the name/title/number of the legislation, availability of the legislation for online access, and a comparison of the city's legislation to the federal law, Section 4207 of the FLSA.
Survey implemented in University of Pennsylvania study to assess city-level legislation related to the promotion and protection of breastfeeding and/or pumping for women returning to the workplace in the first postpartum year. FLSA, Fair Labor Standards Act.
Approach and data collection
The approach for completion of the survey was designed in tiers with a phased approach: (1) city website review, (2) email to city mayoral office with electronic survey link, and (3) telephone call to city mayoral office and verbal completion of the electronic survey.
A database was constructed by the study team cataloging the three largest cities in each state and Washington, DC. with the mayoral point of contact. The research assistants began phase 1 of the data collection approach: review of the city's website. The websites were searched for any information related to breastfeeding and legislation. Keywords, including “lactation,” “breastfeeding,” “breast pump,” and “breast milk,” were used for search purposes. For those cities with information related to breastfeeding legislation present on the city website, the research assistant completed the survey.
Following surveillance of all cities' websites, the research assistants began phase 2 of the approach for the remaining cities. Phase 2 was an email communication with each mayoral office. Standard email templates were constructed by the first and last authors, including a link to the electronic survey. The emails were sent out to all remaining cities within the same week. One week later, a reminder email was sent to those cities yet to complete the survey. A third and final reminder was sent 1 week after the second reminder for a total of three attempts of email-stimulated electronic survey completion.
Similar to phase 2, phase 3 included a direct telephone communication to the city mayoral offices for all cities that had not completed data collection in phase 1 or 2. A standard telephone script was used by the research assistants in communicating with city representatives. The goal of the telephone communication was to have the city representatives verbally complete the survey with the research assistants detailing verbal responses. For those city representatives who requested an alternative to resend, the electronic survey link via email was provided. Telephone communication attempts were made weekly to each city office over the course of 3 weeks for a total of three attempts of telephone-stimulated survey completion.
Results
Data were collected from 118 cities (78.1%) with 33/151 cities (21.9%) failing to respond to any point of contact. Only 2 (1.3%) of the 151 US cities surveyed for this study have existing city-level legislation to protect the rights of all women returning to work in the postpartum period and pump or breastfeed while at work: New York City (NY) and Philadelphia (PA).
New York City council members amended the administrative code of the city of New York to prohibit discrimination in employment based on pregnancy, childbirth, or a related medical condition. This law, 2013/078, was enacted on October 2, 2013 and covers all employees except those working for “any employer with fewer than four persons in his or her employ” (2013/078, page 2). Break times are not specified and the law only makes mention of bathroom and water breaks. The law does not hold exemptions for an employer based on the annual revenue of business or the classification of the employer. In addition, this legislation outlines parameters for failure of compliance by the employer.
Philadelphia City Council Bill 130992, enacted September 3, 2014, amended the city's Fair Practices Ordinance making it illegal “for any employer to fail to reasonably accommodate an individual's need to express breast milk” while at work (September 3, 2014). This legislation covers all employees, exempt and nonexempt, in the City of Philadelphia, regardless of the classification of employer or the annual revenue of business. Break times for breastfeeding and/or pumping women are specified, and failure of employers to comply with the law constitutes sex discrimination and includes a $2,000 fine and compensatory damages.
Discussion
The study was designed with a three tiered approach with a potential for seven contact points (city website review, three email reminders to complete the survey and three telephone calls to complete the survey). This approach was specifically designed to address projected difficulties of ascertaining the data related to the presence of existing city-level legislation to protect postpartum women returning to work and breastfeeding/breast pumping would be difficult to access. For the majority of cities (117/151, 77.5%), it took all seven points of contact to collect the necessary data. The level of difficulty associated with accessing what should be readily transparent and available information was striking to all members of the study team.
Along with difficulty of access, the team encountered many city representatives that lacked knowledge related to the presence of existing city-level legislation. Verbal responses (collected during the third phase of data collection: telephone communication) included response phrases similar to “We just follow the state law” or “What do you mean a law that applies to breastfeeding women at work?” or “To do what? Breastfeed while at work?” were not uncommon. This speaks volumes to the lack of knowledge and understanding surrounding the limitations of the federal law and the presence, absence, or limitations to existing state-level legislation.
Working women account for over half of the US workforce and the federal law does not currently offer any protections for women in a variety of subgroups. 1 Women who are paid a salary are not covered by Section 4207. 3 Women who work for an employer who has an annual revenue of less than $500,000 (unless those employers are engaged in the operation of a hospital or an establishment, which is an institution primarily engaged in the care of the sick, the aged, or the mentally ill or defective who reside on the premises) are not covered by Section 4207. 3 And employers who employ less than 50 employees are not subject to the stipulations of Section 4207, if in doing so would cause the employer undue hardships (significant difficulty or expense). 3
The lack of legal protections for all breastfeeding women returning to work impacts individual businesses across America. Over 81% of women across the United States begin breastfeeding. 5 When women return to work in cities and states without legal protections, the decision to support or not support breastfeeding and breast pumping in the workplace falls onto the employer. The Office on Women's Health within the US Department of Health and Human Services offers a plethora of resources to individual businesses related to supporting breastfeeding and breast-pumping employees. 6 Within the Business Case for Breastfeeding, the Office on Women's Health centralizes data related to the return on investment for a commitment support and encourages breastfeeding employees. Breastfeeding employees miss work less often than mothers of formula-feeding infants, 7 breastfeeding lowers healthcare costs,8,9 and businesses with lactation support programs have increased retention rates. 10
Implications
This research highlights the potentially significant burden that breastfeeding women face when returning to work. Because there is not strong national support for long paid maternity leave, such as in Canada and Europe, women in the United States are faced with the challenges of combining breastfeeding and employment. In the current paradigm, women face the burden of determining their rights to express milk when they return to work. For some mothers, this task is daunting, and some women stop breastfeeding before going back to work because negotiating work and breastfeeding seems unattainable. There is clear need to improve federal, state, and city legislation.
Currently, Senator Jeff Merkley (D-OR) and Representative Carolyn B. Maloney (D-NY-12) are sponsoring the Supporting Working Moms Act (SWMA), which would protect and expand working moms' right to breastfeed by extending the existing federal law to ensure that executive, administrative, and professional employees, including elementary and secondary school teachers, have the right to reasonable break time and a private, nonbathroom place to express breast milk at work. This is not the first time SWMA has been proposed, and in the past, the bill failed to garner enough support to make it to congress.
Health professionals must be politically active and serve as advocates for legislation to improve policies for all employed breastfeeding women regardless of their employment status or the type of employer. This legislation should exist at the city, state, and federal level. The more legislation enacted will help to normalize breastfeeding and milk expression in the workplace and enable women to reach their personal breastfeeding goals.
Conclusion
This research serves as a spotlight on a large segment of the US workforce that is without protection under the FLSA Section 4207 and state-level legislation. The findings of this research demonstrate the paucity of city-level legislation to protect the employed breastfeeding and/or pumping employee. It is well understood that human milk is the ideal form of nutrition for infants and is recommended by leading health organizations. As those who care for women, children, and families, healthcare professionals can continue to advocate to improve city, state, and national legislation to further protect the rights of all breastfeeding women. It is imperative to improve legislation so that mothers are able to reach their personal breastfeeding goals.
Footnotes
Disclosure Statement
No competing financial interests exist.