Lactation Space Experiences and Preferences Among Health Care Workers in an Academic Medical Center

Abstract

Background:

Comprehensive workplace lactation support programs can reduce the risk for early breastfeeding discontinuation; however, scant evidence is available to inform user-centered design of employee lactation spaces. This study describes health care workers' preferences for lactation space.

Materials and Methods:

In 2016–2017, a convenience sample of 151 women who pumped at work at an academic medical center reported on demographics, lactation experiences, and room and equipment preferences through an online survey.

Results:

Respondents worked in research and administration (32%), were nurses (30%), physicians and medical students (19%), or allied health or clinical support staff (19%). Seventy percent had ever used one of the hospital's dedicated lactation spaces. Forty-nine percent ranked hospital-grade pumps the most important piece of lactation room equipment; 83% preferred multiple occupancy lactation suites; and the average maximum acceptable distance to lactation space was 5.6 minutes.

Conclusions:

Optimal lactation infrastructure supports the immediate and long-term health of female workers and their children. User needs and preferences can guide design of lactation space to ensure a minimum standard for design, equipment, and distance. Workers may have different preferences depending on roles and experiences; thus, a variety of solutions may be most effective.

Introduction

Public health, pediatric, and women's health associations agree that increasing breastfeeding among U.S. women is an important public health goal.^1–3 Breastfeeding has been shown to reduce short- and long-term common and serious health risks in infants as well as promoting health benefits for women, including reduced rates of breast and ovarian cancer, hypertension, diabetes, and postpartum depression.^1,4,5 Breastfeeding benefits are dose dependent and U.S. recommendations include breastfeeding at least through the first year.¹

Regardless, breastfeeding continuation rates lag due to significant cultural and structural barriers to breastfeeding.¹ According to CDC, although 81% of infants born in 2013 were breastfed at birth, only 22% of 6-month olds were fed only human milk and only 31% of 1-year olds were still receiving any human milk.² A recent analysis projected that increasing compliance with breastfeeding recommendations to 90% for 6-month olds would save 911 lives and $13 billion in health care costs per year.⁵

Work outside the home is an important barrier to breastfeeding continuation⁶ since milk supply depends on frequent expression⁷ and women may not have access to their child or adequate support for pumping milk at work. About half of the health care workforce is female, and the proportion in some key clinical occupations, such as nurses and medical assistants, is above 90%.⁸ In academic medicine, women's representation is growing; 37% of full-time medical school faculty and almost half of all medical school graduates are female.⁹

Hospital staff at all levels and roles may face demands that discourage them from meeting the evidence-based recommendations as well as their personal breastfeeding goals.¹⁰ Several studies have shown that, although clinicians have higher breastfeeding initiation rates than the national average, their continuation rates fall to between 26% and 42% at 1 year, comparable to the national rate.^11–13 Furthermore, some felt their job kept them from breastfeeding as long as they wanted and that actual and perceived pressure from coworkers and managers discouraged them from using lactation program accommodations.^13–16 For clinicians in particular, there may be increased psychosocial consequences of early weaning. A qualitative study of pediatrics trainees described how many women felt when they did not meet their breastfeeding goals: devastated, guilty, embarrassed, sad, and like a failure.¹⁷

The relationship between lactation support and burnout has not been well described, but research demonstrates that trying to balance breastfeeding and work contributes to work-life conflict,^17–19 which is a risk factor for burnout, particularly for women.²⁰ Female health care providers are at an increased risk of burnout, which compromises both their own wellness and the quality and safety of care,²¹ and physician mothers report both gender and maternal identity discrimination.²²

Not only do poor rates among health care providers compromise the health of these employees and their infants but also, their negative experiences may blunt the impact they could have on community rates of breastfeeding. Research shows that providers' personal and spousal breastfeeding experiences are associated with their attitudes and advocacy of breastfeeding to their patients, as well as their confidence in breastfeeding management.^10,14,17

Comprehensive workplace lactation support programs, including dedicated lactation spaces, are an important component of wellness programs and can mitigate some of the barriers to breastfeeding and result in improved continuation rates.^{11,12,23–26} Furthermore, physicians who report experiencing maternal identity discrimination have identified lactation support as an important workplace policy change.²² Lactation support programs benefit employers as well, through talent retention, increased loyalty, and cost savings through reduction in absenteeism and health care costs related to health risks for infants and mothers.^27,28

The Affordable Care Act expanded requirements for employers to provide time and space for lactation in 2010 and architectural certifications are beginning to incorporate lactation space (e.g., Fitwel²⁹ and WELL Community³⁰ Design Standards), but best practices for the design of Breastfeeding Friendly Workplaces are nascent. There are some toolkits outlining recommendations for lactation space, such as the American Institute of Architects Best Practice recommendations,^31,32 National Business Group on Health's guidance,³³ and the Office of Women's Health's Breastfeeding at Work Project.³⁴ Best practices include minimizing distance to the lactation room, with a widely used guideline of no more than 5–7 minutes and preference that each building has at least one lactation room.^34,35 Although adequate lactation rooms, with hospital-grade pumps and dedicated milk storage have been demonstrated to increase the efficiency and convenience of milk expression at work,²⁴ data to inform user-centered design of lactation space are limited.

As part of an institutional faculty and staff wellness initiative to develop a Breastfeeding Friendly Workplace, Penn Medicine conducted a needs assessment survey in 2016–2017 to assess experiences with pumping at work and preferences for lactation space. In this article, we describe the preferences for equipment and whether those preferences differed by workers' experiences and roles, as well as access to lactation space in this sample of health care workers' experienced with lactation.

Materials and Methods

Setting

Penn Medicine is a large academic medical center, encompassing multiple hospitals, with ∼30,000 staff, faculty, and students who work in its clinical, academic, research, and administrative facilities across several campuses, including a diffuse urban campus and multiple satellite locations in the region. Beginning in 2000, the first official dedicated lactation space for employees opened and the number of spaces has increased over time. At the time of this survey, there were ∼30 dedicated employee lactation spaces indexed throughout seven health system building complexes, and several informal lactation spaces were known to be designated by departments for use by their own staff. Planning for lactation space was decentralized and, as such, there was a wide variation in room standards. The largest lactation room in the main university hospital maintained a contact list of users.

Participants

Women were eligible if their primary work location was a Penn Medicine facility and they had pumped milk at work within the previous 5 years.

Measures

Questions were derived from similar surveys,^13,16 informed by the literature, and reviewed by a breastfeeding content expert (D.S.). The survey questionnaire is available as Supplementary material (Supplementary Data are available online at www.liebertpub.com/bfm).

Demographics

Participants reported age, race, income bracket, number of children, job role, job responsibilities, availability of office privacy, and number of hours worked per week.

Pumping experiences

Participants were asked about their pumping history, whether they met their pumping goal, how easy or difficult pumping at work had been, whether work interfered with pumping, where they had pumped, how often they pumped, where they stored their milk, and whether they ever used a hospital-grade pump.

Preferences for lactation space

Participants were asked about seat preference with the following question: “Given limited resources, if only one designated lactation room could be added near you, would you prefer it be a single seat (with a wipe board to indicate occupancy, giving you maximum privacy) or multiple seats (with curtained privacy, but a lower chance of having to wait)?” Distance to lactation room preference was assessed with the following item: “What is the maximum number of minutes you are willing to walk to get to a dedicated lactation space?”

Participants were also asked to rank 11 pieces of common lactation room equipment from most (1) to least (11) important: hospital-grade pump, dedicated refrigerator, vinyl (or other wipeable material) chair, comfortable chair, countertop space, microwave, sink (in room or nearby), computer to use while pumping, locker or secure area for personal supplies, mirror, and coat hook.

A single item requested an e-mail address if participants were willing to be contacted for research.

Procedures

Because this needs assessment survey was part of a quality improvement initiative, the University of Pennsylvania IRB determined this study was exempt from review.

A convenience sample was recruited. The survey was made available publicly on Qualtrics (a secure data collection platform) from December 2016 through May 2017. Flyers were posted in all known Penn Medicine lactation rooms. E-mails with a survey link were sent to the distribution list of the hospital's largest dedicated lactation room, the School of Medicine's listserv, and included in the health system-wide weekly e-mail blast for 1 month. Participants were encouraged to refer their coworkers.

A total of 515 responses were collected; 409 were analyzable (excluding ineligibles, duplicates, and insufficient data provided). Penn Medicine provided permission for the researchers to contact all subjects who provided a contact e-mail (n = 198) and these respondents were approached ∼6 months to 1 year postcompletion to consent for inclusion in this analysis; 151 women consented and were included.

Data analysis plan

All data were managed and analyzed using SPSS 24 (IBM Corp., Armonk, NY) after being imported directly from the Qualtrics web platform. Variables were constructed to count the number of different lactation spaces used, dichotomize work hours, dichotomize equipment rank in top 3, and code job categories. Descriptive statistics were run for all variables and means, standard deviations, medians, ranges, and percents are presented to characterize the sample. A boxplot comparison of equipment preferences was created in SPSS.

To address the secondary aim of whether preferences varied by experiences and work roles, the ranking of hospital-grade pump in the top 3, the mean maximum acceptable distance to lactation space in minutes, and preference for multiple occupancy were compared by the following variables (informed by the literature and plausible relationships): has clinical duties for most of the day; regular duties require traveling between multiple sites; is currently pumping; works more than 50 hours per week on average; is a physician; is a nurse; usually pumps in one's own office; and usually pumps in a designated lactation room. Hospital-grade pump rank was also compared by whether respondents had ever used a hospital-grade pump.

Fisher's exact tests were used to assess the statistical significance of observed differences between groups for pump preference rank in the top 3, t tests were used for maximum acceptable distance, and chi-square tests were used for occupancy preferences.

Results

Twenty-four buildings/complexes were represented; 58% of participants worked primarily in the main university hospital complex. Table 1 describes the demographics of the sample. The average respondent was 34 years old, white, worked 39 hours per week, and had a household income over $117,000. Participants worked in research and administration (32%), were nurses (30%), physicians or medical students (19%), or allied health or clinical support staff (19%); 57% had clinical duties most of the day and 39% had regular duties in secondary locations at least once weekly. The majority (64%) did not have an office or seat they considered private enough to pump in. About half were currently pumping at work and 65% had pumped for at least one child at some time during their employment. The median duration of time spent pumping was 10 months in total.

Table 1.

Survey Respondents

	n = 151
Demographic profile	Mean (SD)/median
Mean age (range = 27–46)	34 (3.6)
Median months pumped at Penn Medicine in total (range = 1–46)	10
	n (%)
Currently pumping	73 (48)
Completed pumping for at least one child in past 5 years	98 (65)
Total no. of children
1	82 (54)
2	42 (28)
3	20 (13)
4 or more	7 (5)
Race
White	114 (76)
Asian	13 (9)
Black/African American	11 (7)
All other/prefer not to answer	13 (8)
Household income
$23,000–44,000	2 (1)
$44,000–72,000	13 (9)
$72,000–117,000	34 (23)
Over $117,000	80 (53)
Prefer not to answer/blank	22 (15)

Work information	Mean (SD)
Hours worked per week (range = 3–70)	39 (11.7)
	n (%)
MD or Medical student	29 (19)
Nurse	45 (30)
Allied Health and Clinical Support	49 (19)
Research and Administration	48 (32)
Clinical duties most of the day	86 (57)
Regularly travel to multiple sites/offices	58 (39)
Have an office or seat private enough for pumping	55 (36)

SD, standard deviation.

Workers' lactation experiences

Of the 97 women who had pumped for at least one child, the majority (68%) reported reaching their personal pumping goal, and those women pumped for a significantly longer duration than women who did not reach their goal (p = 0.02) (Table 2). Nevertheless, 57% of respondents reported that pumping was difficult for them and 38% reported they felt their job prevented them from breastfeeding or exclusively breastfeeding as long as they wanted.

Table 2.

Pumping Experiences

	n (%)
How easy or difficult has pumping been for you?
Extremely-slightly easy	57 (38)
Neither easy nor difficult	8 (5)
Extremely-slightly difficult	85 (56)
My job prevented me from breastfeeding or exclusively breastfeeding as long as I wanted to?
Strongly-somewhat agree	57 (38)
Neither agree or disagree	15 (10)
Strongly-somewhat disagree	78 (52)
Pumping goal among those who completed pumping (n = 98)
I pumped milk for my baby until I reached the personal pumping goal I had set	67 (68)
I did not pump as long as I thought I would, but stopped pumping when I wanted to	15 (15)
I stopped pumping milk for my baby before I wanted to	14 (14)

	Mean (SD)
Mean months pumping among subset of women with 1 child who completed pumping^* (n = 40)
I pumped milk for my baby until I reached the personal pumping goal I had set	10 (2.638)
I did not pump as long as I thought I would, but stopped pumping when I wanted to	7.6 (3.457)
I stopped pumping milk for my baby before I wanted to	6.5 (4.037)

p = 0.02.

Workers' lactation space experiences

Most respondents needed to pump twice or thrice during the workday (90%) and 72% had used a hospital-grade pump at least once (Table 3). The median number of lactation spaces ever used by respondents was 3. Seventy percent had ever used a dedicated lactation space and 44% used one as their primary pumping location, while 26% usually pumped in their own office. The remainder usually pumped in someone else's office or an empty clinic room (18%), a bathroom or closet (4%), call, locker, or shower rooms (3%), informal lactation rooms (3%), multiple spaces, or their answer could not be categorized (3%). A minority of respondents reported ever pumping in their car (23%) and in bathrooms (21%) during work.

Table 3.

Pumping Equipment, Frequency, and Locations

	n (%)
Ever used a hospital-grade pump?	108 (72)
Where do you store your milk?
Employee kitchen refrigerator	87 (58)
Cooler	28 (19)
Personal refrigerator in my office	14 (9)
Lactation room refrigerator	17 (11)
At room temperature	3 (2)
How many times per day do you pump at work?
1	6 (4)
2	59 (39)
3	77 (51)
4	6 (4)
More than 4	2 (1)

Pumping locations	n (%)
Ever used a designated lactation space at Penn Medicine	106 (70)
Primary pumping location
Official designated lactation room	66 (44)
Own office	39 (26)
Someone else's office or unused clinic room	27 (18)
Bathroom or closet	6 (4)
Call, locker, or shower rooms	4 (3)
Multiple/other/unclear	5 (3)
Informal lactation room	4 (3)

	Median
Median no. of spaces used for lactation at work (range = 1–15)	3

Among women who reported having an office or seat they considered private enough for pumping, only 60% reported their office as their primary location. Of women who reported that their office was their primary pumping location, 15% also reported that they did not consider it private enough to pump in.

Lactation space preferences and group differences

The maximum time women reported they were willing to walk to reach a lactation room was 5.6 (standard deviation = 2.55; range 0–15) minutes. Those whose primary pumping location was a dedicated lactation room were willing to accept significantly more maximum distance (mean = 6.7 minutes; 95% confidence interval [CI] = 6.04–7.41 vs. mean = 4.7 minutes; 95% CI = 4.23–5.06). Most respondents (83%) preferred multiple occupancy lactation suites, with only one group difference: those who were currently pumping were significantly more likely to report a preference for multiple occupancy (89% vs. 77%; p = 0.049).

Figure 1 shows the distribution of equipment preference ranking. Hospital-grade pumps were strongly preferred as the most important equipment in the lactation room, with 49% of respondents ranking pumps number one (compared to 16% ranking sinks top). To further explore relative importance of items, we assessed how many women ranked each piece of equipment in their top three preferred, with results as follows: hospital-grade pumps (62%), sink (59%), a comfortable chair (46%), a dedicated refrigerator (42%), countertop space (32%), computer (27%), wipeable chair (18%), lockers (10%), microwave (3%), coat hook (1%), and mirror (0%). Women who had ever used a hospital-grade pump were significantly more likely to rank pumps in their top three (77% vs. 26%; p < 0.0001), as were those who had clinical duties for the majority of the workday (71% vs. 51%; p = 0.02).

FIG. 1.

Lactation room equipment preferences.

Discussion

As they do in other environments, women who work in clinical settings experience work-related barriers to breastfeeding.^13,15,36 Institutional lactation policies, including adequate lactation spaces, can support women meeting breastfeeding recommendations.^11,26,37 Although comprehensive lactation programs are an important piece of workplace wellness planning,^38,39 little attention has been paid to this facet of wellness in addressing burnout among health care providers, even though physician mothers who experience maternal discrimination report a need for more lactation support.²²

This research is the first to our knowledge to describe health care worker preferences around lactation space design, including equipment, distance, and occupancy. Strengths of the study include that we queried respondents on elements of lactation space design that are essential for institutional decision makers to inform policies for constructing lactation space. Also, our respondents had significant experience (average of 10 months) with pumping at work that informed their preferences. Finally, we recruited women representing the diverse job roles in hospitals and for whom lactation spaces need to be designed.

This study had several limitations. Respondents could have pumped up to 5 years previous to the survey and responses could be subject to recall bias. It used a convenience sample, rather than a representative sample, which is vulnerable to response bias. This bias could have been exacerbated by the request for contact information and the follow-up request, 6–12 months later, to consent for participation in this research. Thus, our sample may consist of the most highly motivated respondents, who may have strong preferences.

The sample had little racial or socioeconomic diversity. We directed recruitment efforts, in part, to women who had used dedicated lactation spaces at work. In addition, we surveyed only women who had experienced pumping at the institution and did not capture the experiences of women who did not breastfeed, did not return to work after giving birth, or did not choose to pump once returning to work. For these reasons, our sample may represent a group with especially high dedication to and success with breastfeeding. Future research should consider how preferences may differ by personal demographics and job characteristics and investigate how to develop and implement comprehensive lactation programs that address the diversity of workers' breastfeeding experiences.

The majority of our respondents reported using the hospital's dedicated lactation spaces and hospital-grade pumps. The majority also reported meeting their personal pumping goal, and those who met their goal reported long breastfeeding durations. However, they also reported difficulty meeting the demands of pumping and identified work as a factor in their ability to meet their breastfeeding goals. The finding that some women reported pumping primarily in bathrooms, closets, and offices they did not consider sufficiently private demonstrates that there is room to improve lactation support even in hospitals with comprehensive lactation support programs in place.

Women in this study reported a high level of flexibility, pumping in multiple locations and using a variety of solutions for milk storage. Although 36% of respondents reported having enough privacy in their office or seat to pump, almost half of them reported they usually pumped elsewhere. Many women did not have a single designated place where they pumped, but made decisions about where to pump on a continuous basis, based on a variety of factors. Lactation support program designers should similarly consider a variety of factors when considering how women may attend to their need to pump, including user preferences, hospital layout, workflow of roles, and work time policies.

Different roles and responsibilities may pose a variety of challenges. Our finding that access to a computer while pumping had a wide distribution in ranking underscores that a variety of lactation space solutions may be appropriate to address diverse needs. Individual women may also have different needs at different times; for example, workers who have regular duties at multiple sites may require access to multiple different spaces for pumping throughout a day. Planning for flexible accommodations may be required to optimize lactation support.

Most guidance for lactation room design includes hospital-grade pumps as a state-of-the-art amenity rather than an essential piece of equipment.³³ Our findings demonstrate that users consider pumps the most important piece of equipment and other research has demonstrated that including pumps in a comprehensive workplace lactation program impacts breastfeeding continuation rates.²⁶ Other items rated most essential by participants included a sink (in room or nearby), a comfortable chair, and a dedicated refrigerator.

Multiple seat lactation rooms were strongly preferred with few group differences in this preference. Multiple user suites reduce the chance of having to wait for a seat to begin the pumping session and optimize the space resources for institutions. Further research is needed to understand whether women in different work environments exhibit the same preference.

Women in this study reported a willingness to travel a maximum of 5.6 minutes to access lactation space, which is within the guidance of 5–7 minutes.³⁴ Those whose primary lactation space was a dedicated lactation room were willing to tolerate more distance to access. It is possible that the perceived benefits of dedicated lactation space are so great that women are willing to go further for them, or it may be that women who do not rely on dedicated lactation spaces perceive distance to be a stronger barrier. Regardless, planning for convenience of access must be a primary priority. High traffic areas, central to the flow of workers' job duties are ideal locations for clearly marked, multiple-occupancy, dedicated lactation spaces, so women can access them conveniently multiple times per day. Facilities planning for conference, meeting, and training space should also incorporate consideration of appropriate access to lactation space for attendees.⁴⁰

Conclusion

Despite the fact that early weaning increases health risks for infants and women, mothers returning to work face many barriers to meeting breastfeeding recommendations and their personal goals. It is imperative to address institutional challenges to breastfeeding through system-level initiatives, such as access to lactation space and supportive policies. Comprehensive lactation support is emerging as an important aspect of fostering a workplace “culture of health” and recognition of the need for interventions to improve work-life balance. Lactation professionals are essential partners with human resources, occupational health, campus facilities planners and architects, and institutional leadership to optimize design of lactation spaces and ensure the effectiveness of accommodations by assessing and addressing users' needs and preferences.

Footnotes

Acknowledgments

The authors would like to thank the survey respondents, the human resource departments at University of Pennsylvania Health System and University of Pennsylvania, as well as Amy Behrman, MD, and Frances Shofer, PhD, for their invaluable feedback on this article. Portions of these data were presented at the 2018 American Occupational Health Conference and the 2018 American Public Health Association Conference. Funding: This work was completed without financial support from any entity.

Disclosure Statement

Dr. Spatz has received honoraria from Medela for speaking engagements. There are no competing financial interests for the remaining authors.

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