An Exploration of Lactation Facilities and Planning in U.S. Higher Education Campuses

Abstract

Background:

Women in academia face challenges in continuing breastfeeding. Higher education campuses are investing in lactation support, but little is known about their approaches. This study explores the planning and design of lactation spaces on college and university campuses from the perspectives of campus planners and facility professionals, administrators, and other decision-makers.

Materials and Methods:

We conducted an online survey with a convenience sample of members of the Society for College and University Planning (SCUP). Representatives from each U.S. member campus were invited to participate in an online survey.

Results:

One hundred five individuals responded, representing their institutions; 94% reported at least one dedicated lactation space (range 0–50). Sixty-eight percent reported having a policy for creating/identifying lactation spaces; 28% reported that the lactation space was included in campus construction standards. Over 80% of spaces were structurally enclosed, lockable, Americans with Disabilities Act (ADA) compliant, and had open electrical outlets and in-room light control. Campus/facility planning was involved in lactation space planning at 77% of institutions and in funding for creation and maintenance at 59%.

Conclusions:

Many campuses are building lactation infrastructure, but there is considerable variability in approaches and accommodations for lactation at higher education institutions. While local conditions, constraints, and demands will inform program development, decision-makers can leverage campus resources, recommendations, and design best practices to improve lactation experiences of women.

Introduction

Lactation space planning and investment in sustainable building design have both increased on college and university campuses in the last decade, but despite the increasing recognition of health promotion in building design considerations,¹ lactation space is not yet fully integrated into healthy building design. The built environment is an integral social determinant of health^2,3 and incorporating health promotion into infrastructure could improve health and reduce disparities.^1,4,5 Higher education campuses can be incubators for innovation in healthy building design with internal interdisciplinary expertise and the important role of campus design in the reputation and vitality of schools.^6,7

Breastfeeding is a health behavior that has numerous benefits for women and infants; suboptimal U.S. breastfeeding rates cost $3 billion a year and contribute to over 3,000 excess annual deaths.⁸ Breastfed infants have lower rates of sudden infant death syndrome, acute ear infections, gastrointestinal infections, lower respiratory infections, allergies, eczema, and leukemia, as well as reduced long-term risk for obesity, type 2 diabetes, and asthma.⁹ Women who breastfeed reduce their risk for breast and ovarian cancer, hypertension, diabetes, and postpartum depression.^8–10 For optimal health benefits, breastfeeding should be exclusive for 6 months and continued at least through the first year.⁹ To maintain lactation, women must negotiate a work–life balance that involves finding the time and private space to breastfeed or pump approximately every 3 hours during the day.^11,12

Return to work or school negatively influences breastfeeding exclusivity and duration.¹³ Student mothers may face particular challenges¹⁴; insufficient accommodation for lactation on higher education campuses is one important factor.¹⁵ Therefore, improving the lactation infrastructure on campuses is critical.¹⁴ In 2016, women were more likely than men to enroll in college and to complete associates, bachelors, masters, and doctoral degrees.¹⁶ Women were also close to parity (49%) in faculty positions.¹⁶ Although the average age of childbearing is increasing¹⁷ and is correlated with educational achievement, there is a substantial minority of students who have children¹⁸; among undergraduates, 26% are parents,¹⁹ and among graduate students, 31% are parents.²⁰ Lack of consideration and planning for lactation needs of female faculty, students, and visitors contributes to the motherhood penalty in higher education.^21–23

While the Affordable Care Act (ACA) protects the right of women to pump at work, and requires that employers provide private spaces, ACA protections do not cover all categories of employees and do not apply to students.²⁴ Research indicates that many campuses may not have appropriate accommodations in place and that students perceive the lack of access to a lactation space to be an important barrier to continuing breastfeeding.^25,26 Approaches to lactation support planning in higher education have varied; still, some campuses have risen to the challenge of expanding lactation accommodations for students.^25,27–30 A recent study by Bostick et al. collected information from 139 U.S. colleges and universities; 55% had designated lactation spaces, yet only 4% had an official policy for lactating students or mentioned lactation spaces in the student handbook.³¹

Because many institutions are implementing lactation planning in response to the ACA, meeting increasing expectations for lactation support, and as part of a commitment to campus wellness, now is a critical moment to understand more about lactation infrastructure approaches on college and university campuses. Characterizing current practices and stakeholders can help identify assets and inform best practices for future lactation support planning. This descriptive study explores the involvement of decision-makers in lactation space planning and knowledge of campus planners and administrators around lactation spaces, policies, and construction.

Materials and Methods

Participants

The Society for College and University Planning (SCUP) is a community of higher education leaders responsible for strategic, academic, resource, and physical planning on their campuses. Its mission is to support individual and organizational planning capacities and knowledge development and dissemination. SCUP was identified as a partner for this research because its membership includes the most extensive network of campus planners for colleges and universities in the United States.

U.S. SCUP member campuses were invited to participate if they had at least one representative who had provided SCUP a valid e-mail address and permission to contact them by e-mail. Participation was limited to U.S. campuses to reduce variability in international breastfeeding legislation and cultural attitudes.

Procedures

This study was deemed exempt by the University of Pennsylvania IRB. An e-mail invitation to complete an online survey using Qualtrics was sent to U.S. SCUP members in 50 states, DC, and Puerto Rico. The researchers and SCUP collaborated on a sampling selection system based on a hierarchy of possible job titles on campus, specifically physical planning roles, then administrative roles, and so on, so that only one SCUP member per campus would receive the mailing. To preserve the privacy of their members, SCUP sent e-mail invitations directly to identified members; 684 campuses were contacted between November 2017 and February 2018. Recipients were asked to either answer to the best of their ability or forward the e-mail to a colleague (in any role, regardless of SCUP membership) who could better address the survey questions. They were informed that only one response per campus was requested and they were the sole representative selected to complete the survey. The e-mail blast was repeated 4 weeks later to nonresponsive campuses. For those campuses that were nonresponsive after the reminder e-mail, a second individual was identified, again based on title, to receive the e-mail. A reminder e-mail was sent to nonresponsive campuses about 4 weeks later.

Measures

Demographics

Participants reported their job title/department, institution they represented, and approximate undergraduate and graduate enrollment.

Policies and processes

Participants were asked about their knowledge of lactation accommodation policies for staff and students; guidelines around the creation and selection of locations for lactation spaces; and whether the lactation room use was tracked.

Collaboration

Participants were asked which institutional departments and internal or external entities were involved in planning for and funding the expenses of creating and maintaining lactation spaces on campus.

Lactation accommodations

Participants were asked about their knowledge of the number of dedicated and informal/temporary lactation spaces on campus, whether a directory of the spaces exists, and what percentage of staff and students they estimated could access the lactation space in 5–7 minutes. They were asked to estimate how many (none, a few, most, all, or unknown) of their campus's lactation spaces had self-contained/dedicated spaces (i.e., four permanent walls); a locking mechanism; locked access (key/code required to enter); Americans with Disabilities Act (ADA) compliance (handicap accessible); sound proof; in-room thermal control; in-room light control; Ethernet port/WiFi access; open electrical outlets; hospital-grade pump; sink; counter space/table; refrigerator; microwave; wipes or towel dispenser; privacy curtain/screen (multiuser rooms); lockers or cubbies for personal storage; coat hooks or hangers; full-length mirror; art and/or music; phone; computer/laptop; and contact information for problems/requests. They were also asked to describe their typical lactation room seating.

Additional information

Participants were asked, “Do you have any additional information to share about breastfeeding accommodations for staff, students, and guests at your institution?”

Data analysis plan

All data were cleaned, managed, and analyzed using SPSS 24 (IBM Corp., Armonk, NY) or Excel after being imported directly from the Qualtrics web platform. Variables were constructed in SPSS to code job categories, SCUP regions, campus size, number of different entities involved in planning and funding lactation spaces, typical seating, and to combine most and all responses for lactation space amenities. Descriptive statistics were run for all variables. Means, standard deviations, ranges, and percentages are presented to characterize the sample.

Open-text variables for each respondent—including questions about policies or guidelines around creation of lactation spaces, guidelines for selecting locations of lactation spaces, and additional information—were exported to Excel for analysis. The first author explored each campus's response to pertinent open-text questions to characterize each campus's approach to the lactation room selection process. Themes were identified using a grounded theory approach³² since no literature on this subject existed on which to base a priori codes. A set of seven mutually exclusive codes were constructed from a review of the themes and each campus was assigned one code. All authors then reviewed and discussed how each code was assigned to quotes to establish consensus.

Results

Representatives from 105 campuses, in 33 states, responded (Table 1). The majority of respondents had job titles in planning/architecture (65%); others were in finance and administration (24%) or human resources (11%). Campus size distribution was 9% very large, 31% large, 32% medium, and 28% small; 81% of institutions had graduate students. Pacific, Southern, North Central, Mid-Atlantic, and North Atlantic regions of the United States were all represented.

Table 1.

Profile of Institutions

	n = 105
	n (%)
Respondent role category
Facilities or planning	68 (65)
Administration or finance	25 (24)
Human resources	11 (11)
SCUP region
Mid-Atlantic	18 (17)
North Atlantic	18 (17)
North Central	21 (20)
Pacific	36 (34)
Southern	12 (11)
Campus size (undergraduates)
Small (<5,000)	29 (28)
Medium (5,000–15,000)	34 (32)
Large (15,000–30,000)	33 (31)
Very large (>30,000)	9 (9)
Type^a
4-Year, public	53 (50)
2-or 4-Year, primarily associates, public	19 (18)
4-Year, private not-for-profit	33 (31)
Graduate school	85 (81)
Have lactation policy for
Faculty/staff	58 (55)
Students	27 (26)
If both, same policy	24 (89)
Guideline or process for creating lactation spaces	71 (68)
Dedicated spaces (yes)^b (range = 0–50)	99 (94)
Directory of spaces	48 (49)
Track use	14 (13)
Informal spaces (yes)^b	52 (50)
Access to lactation in 5–7 minutes	Mean (SD)
Estimated % staff	73 (29.7)
Estimated % students	76 (27.1)

Type as per the National Center for Education Statistics.

Two institutions reported neither dedicated nor informal lactation spaces.

SCUP, Society for College and University Planning; SD, standard deviation.

Ninety-four percent (n = 99) of responding campuses reported at least one dedicated lactation room (DLR) and the range of DLRs was 0–50. Half of the respondents reported the existence of informal lactation rooms, but many were not able to give a precise estimate of the number. Respondents were aware of lactation policies for staff (55%) and students (26%). Sixty-eight percent were aware of a campus policy around creation of the lactation space; 46% knew of a publicly accessible directory of lactation spaces on their campus. Respondents on average reported that on their campuses, 73% of staff and 76% of students could access a lactation space within 5–7 minutes.

Lactation space stakeholders

Respondents identified entities involved in lactation space planning (Table 2): facility planning and design (77%), human resources (60%), student affairs (30%), departments (27%), external designers (24%), and breastfeeding or women's health experts (18%). Other internal resources (26%) for planning lactation spaces were also identified, including the work–life committee, diversity and inclusion office or committee, legal, equal employment opportunity office, college health services, lactating women, parenting or women's group, and finance. Nine respondents identified a single entity responsible for planning, while 87 (81%) identified multiple resources involved in planning (range: 2–6).

Table 2.

Entities Involved in Lactation Space Planning and Funding

	Planning, n (%)	Funding creation and maintenance, n (%)
Facility planning and design	81 (77)	62 (59)
Human resources	63 (60)	22 (21)
External design consultant/architect	25 (24)	0 (0)
Student affairs	31 (30)	14 (13)
Departments themselves	28 (27)	33 (31)
Internal breastfeeding/women's health expert	17 (16)	0 (0)
External breastfeeding/women's health expert	2 (2)	0 (0)
Other internal	27 (26)	38 (36)
Other external	0 (0)	1 (1)

Funding for lactation spaces came from facility planning and design (59%), internal funding (36%—including capital funds, general/operating funds, grants/private gifts, work–life committee, diversity office, and student/faculty organizations), departments themselves (31%), human resources (21%), student affairs (13%), and local health departments (1%). Multiple sources of funding were identified by 52% of respondents (range: 2–4), while 40% identified one funding source. One campus with no DLRs identified zero costs associated with lactation accommodation.

Lactation space planning processes

Institutions had a variety of processes for lactation space selection (Table 3). Many (28%) had a construction standard that includes consideration for a lactation space. Typically, this standard was described as applying to new construction and major renovation and included a requirement or recommendation of at least one space per building. Other respondents described a centralized request process (23%), for example, “Planning office or requestor sends proposal to space committee for approval of space assignment and funding” or “Facilities planner checks with HR and Student Services.” A concentration analysis was used by 4% of institutions to identify locations that would maximize access. Informal processes, such as “Space was identified in commonly used buildings across campus as opportunities arose,” were described by 17%. A decentralized or ad hoc process was used by 10% of institutions, for example, “Identifying a room is typically handled at the department level if a private office is not available.”

Table 3.

Lactation Room Selection Process

Construction standard includes lactation spaces	29 (28)
As requested/central process	24 (23)
No selection process	18 (17)
Unclear/informal	18 (17)
Ad hoc/decentralized process	10 (10)
Concentration analysis	4 (4)
Unknown	2 (2)

Lactation space specifications and equipment

Table 4 describes the specifications and equipment of campus lactation spaces, to the knowledge of our respondents. Eighty-three percent of respondents were able to identify some features of lactation spaces on campus. Over 80% of those reported that most or all of the lactation spaces on their campus were ADA accessible, had in-room light control, open electrical outlets, a locking mechanism, and were dedicated spaces. Responses regarding many other features and equipment showed more variability, for example, 40% reported a sink in most or all lactation rooms, 21% in a few, and 27% in none, while 11% were unsure. Uncommon features, reported by less than 10% of respondents in most or all lactation rooms, were phones, hospital-grade pumps, mirrors, lockers, microwaves, and computers.

Table 4.

Thinking About All of the Formal and Informal Lactation Spaces on Your Campus, How Many of Those Lactation Spaces Have

	Unknown, n (%)	None, n (%)	A few, n (%)	Most or all, n (%)
Locking mechanism	2 (2)	0 (0)	1 (1)	83 (97)
Self-contained/dedicated spaces (i.e., four permanent walls)	1 (1)	0 (0)	4 (5)	82 (94)
Open electrical outlets	6 (7)	0 (0)	1 (1)	79 (92)
In-room light control	6 (7)	2 (2)	1 (1)	77 (90)
ADA compliant (handicap accessible)	8 (9)	0 (0)	8 (9)	71 (82)
Ethernet port/WiFi access	19 (22)	7 (8)	1 (1)	59 (69)
Counter space/table	8 (9)	4 (5)	15 (18)	58 (68)
Locked access (key/code required to enter)	11 (13)	16 (19)	13 (15)	46 (53)
Wipes or towel dispenser	17 (20)	15 (17)	10 (12)	44 (51)
Soap/soap dispenser	16 (19)	18 (21)	10 (12)	41 (48)
Sound proof	30 (34)	11 (13)	7 (8)	39 (45)
In-room thermal control	21 (24)	18 (21)	9 (10)	39 (45)
Coat hooks or hangers	21 (24)	11 (13)	19 (22)	35 (41)
Sink	9 (11)	23 (27)	18 (21)	34 (40)
Contact information for problems/requests	23 (27)	26 (31)	3 (4)	33 (39)
Refrigerator	13 (15)	35 (41)	18 (21)	20 (23)
Art and/or music	20 (23)	33 (38)	16 (19)	17 (20)
Privacy curtain/screen (multiuser rooms)	20 (24)	45 (53)	4 (5)	16 (19)
Phone	16 (19)	52 (60)	10 (12)	8 (9)
Hospital-grade pump (women bring their own tubing)	13 (15)	62 (73)	4 (5)	6 (7)
Full-length mirror	25 (29)	44 (51)	14 (16)	3 (3)
Lockers or cubbies for personal storage	19 (22)	53 (62)	11 (13)	3 (3)
Microwave	17 (20)	58 (67)	8 (9)	3 (3)
Computer/laptop	15 (17)	65 (76)	5 (6)	1 (1)

ADA, Americans with Disabilities Act.

Typical seating was described by 75% (79/105) of respondents: 32% said their typical lactation room had lounge chairs; 30% said rooms vary (lounge chairs were listed as one possible option for 79% of these); 9% said recliners or rockers were typical; 6% said ergonomic chairs; 4% said office chairs; 4% said a couch; 1% said a club chair; 9% provided an unclear response (e.g., comfortable chair); and 5% did not know. Several descriptions specified that chairs were selected for comfort or for vinyl fabric that could be wiped clean.

Discussion

This study is the first, to our knowledge, to explore the perspectives of those decision-makers involved in higher education campus planning on lactation spaces. Strengths include diverse representation of institutions from all areas of the United States, a variety of different sized campuses, public and private institutions, those with and without graduate programs, and in many different stages in developing campus lactation support programs. This is the first study to document which stakeholders are involved in the planning and funding for lactation spaces on college campuses, which may be useful for informing coalition building around lactation support. It is also the first to explore which recommended features of lactation spaces are being incorporated into lactation space construction on campuses.

Limitations of the study include a convenience sample rather than a representative sample, which may lead to response bias. We recruited participants based on membership in a professional organization. We did not reach out to or sample every college and university in the country, thus there may be response bias related to which institutions have joined SCUP.

Expectations regarding lactation space are shifting from accommodating on an individual basis to incorporation of DLRs in public spaces. Stakeholder collaboration to craft strategies for ensuring that faculty, staff, students, and guests can easily access lactation accommodations when they are required must include campus planners and other relevant decision-makers. We found that collaborations in lactation space planning were very common among respondents, with 81% citing between two and six partners in planning. Facility planning and design (77%) and human resources (60%) were the most common contributors, followed by student affairs and affected departments (approximately one-third). Including breastfeeding or women's health experts was fairly uncommon. Only 16% involved internal and 2% involved external entities with lactation expertise. This may be because of an approach to lactation space creation as a legal compliance issue rather than an aspect of healthy building design, which could limit integration into facility planning standards. Higher education institutions should consider involving health professionals to ensure that the lactation space is designed appropriately from a health promotion perspective and with an appreciation of the physiological process of lactation.

Most respondents characterized typical lactation rooms as having minimum qualities of being enclosed lockable spaces that were ADA accessible, with in-room light control and open electrical outlets. Typical seating was most often a lounge chair. Other features and furnishings varied considerably in their inclusion. Recommended amenities were not reported to be universal: a work surface was standard in 68%, a sink in 40%, a refrigerator in 23%, and hospital-grade pumps in 7%. American Institute of Architects best practices suggest that lactation spaces be ADA accessible and include seating, a sink, countertop, sound attenuation, appropriate lighting and temperature, and a tranquil environment.³³ The National Business Group on Health employer toolkit for workplace lactation support and space design³⁴ and the Office of Women's Health recommendations for lactation support at universities offer additional guidance.³⁵ These toolkits suggest that first-class programs also often incorporate hospital-grade pumps, multiseat lactation suites, and movable lactation pods.^11,36,37

Nearly 60% of respondents indicated that campus facility planning and design had a role in funding lactation spaces on campus. Following architectural or business guidelines and recommendations may be the most appropriate use of resources for some campuses, especially within constraints. Within this model, there is room for a user-centered design approach, which includes diverse voices of women who are experienced in pumping. Room use tracking or a feedback process for ensuring that lactating women's needs are being met is important to ensure that planning remains responsive. Only 13% of respondents reported tracking use and only 39% reported that most or all lactation rooms contained information about who to contact for room problems.

We found a high prevalence (94%) of reporting DLRs compared with reporting that a directory listing the location of dedicated spaces was available (46%). Increasing public listing may help improve women's access. Guidelines suggest that lactation rooms be accessible within 5–7 minutes^11,35 and that one lactation space be located for every 100 female workers, up to 6 per every 1,000.³⁵ Respondents reported relatively good access to DLRs for staff and students—over 70% with access in 5–7 minutes—in contrast with other literature reporting that lactating women often report lack of access to appropriate spaces as a barrier.^15,31 Concentration analysis is one strategy to ensure appropriate distribution when prioritizing limited resources, but only 4% of respondents noted this approach in their descriptions of room selection processes.

A variety of lactation room selection processes and policies was noted. While some processes were structured and formal, others were ad hoc and individualized. A nimble approach to accommodating breastfeeding staff, students, and visitors has benefits, including quick response to immediate demands, potential responsiveness to close location of lactation space, potential cost minimization, and flexibility of space purposes where space may be limited. On the other hand, lack of a consistent integrated approach to lactation space planning may create barriers for users and could open the door to serious deficits in accommodation. The need for appropriate spaces to accommodate lactating women is something that can be anticipated and systematically planned for. Integrating lactation space planning into a design strategy could facilitate reducing variability in the quality and appropriateness of space and help improve access for those most vulnerable to early weaning (e.g., younger and minority women)³⁸ and who may lack influence to effectively self-advocate.

Conclusions

As a component of a healthy building strategy to improve campus inclusiveness and to comply with ACA provisions, planning for lactation spaces on higher education campuses is increasing, yet few meet best practice recommendations³¹ and women still report breastfeeding barriers related to insufficient lactation space.³⁹ Table 5 presents a list of key recommendations higher education campuses should consider in lactation support planning. Nearly all respondents in this study reported lactation spaces on campus, but we found considerable variability in accommodations. Different communities may have diverse needs and must consider all potential users as their needs and experiences may differ.^25,40 Ideally, mothers returning to public life at work or school would have access to lactation spaces where and whenever they need it. To accomplish this, every university and college campus would have multiple DLRs to serve the needs of employees, students, and visitors on campus. Information about lactation spaces would be public so that lactating women do not have to navigate confusing processes or gatekeepers to access appropriate facilities.

Table 5.

Suggested Lactation Planning Considerations

1. Anticipate and plan for faculty, staff, student, and visitor lactation needs

2. Consider developing a multidisciplinary, campus-wide lactation committee

3. Involve stakeholders, including campus planners, student life administrators, affected departments, health professionals, and users, in lactation accommodation planning

4. Develop and publicly communicate (e.g., on the university website) clear policies that detail the rights of breastfeeding faculty, staff, students, and visitors

5. Integrate dedicated lactation rooms into the campus design strategy

6. Establish a minimum campus standard for lactation space design specifications and equipment, informed by best practice resources, and design guidelines

7. Clearly and publicly communicate locations of lactation spaces and how to obtain access on university websites and through physical signage

8. Clearly communicate to users the appropriate process to offer real-time feedback about lactation accommodations and needs

9. Conduct regular campus-wide reassessments of lactation space usage and needs

Campus planning and facilities, human resources, student health, campus administration and finance, individual academic departments, women's health experts, new mothers, and outside consultants may all have a role to play in the creation, design, and maintenance of lactation spaces. Effective strategies may vary based on local and institutional resources, but minimum standards based on evidence, expertise, and user-centered design should be employed to ensure that spaces meet the needs of all women on campus. In addition to building lactation infrastructure, clear communication of policies regarding lactation for staff and students and advertisement of lactation facilities and support are essential to normalize lactation.³⁹ This research contributes a snapshot of current strategies of lactation space planning in higher education. We hope that increasing awareness of standards and best practices among campus planners and decision-makers will provide a guidepost to improve access.²⁸

Footnotes

Acknowledgments

The authors would like to thank the survey respondents, Society for College and University Planning (SCUP), and the SCUP research advisory team. Portions of these data were presented at the 2018 American Public Health Association Conference. Funding: This work was completed without financial support from any entity.

Disclosure Statement

Hospitals sometimes contract with the Medela Corporation for Dr. Spatz to provide speaking engagements. Mamava has sponsored the printing of distribution materials for the AIA Best Practice cowritten by Ms. Lee.

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