Breastfeeding in the Workplace: Attitudes Toward Multiple Roles,Perceptions of Support,and Workplace Outcomes

Abstract

Objective:

American women are consistently tasked with breastfeeding, while returning to work, but little research examines how women perceive support in the workplace and their own working outcomes. This study examined the associations among breastfeeding women's perceptions of breastfeeding support in the workplace (i.e., managerial, organizational, co-worker, time, and physical environment), attitudes toward multiple roles, and workplace outcomes (i.e., affective commitment, job satisfaction, and workplace productivity).

Materials and Methods:

Survey data from 109 mothers who have or are currently breastfeeding/pumping human milk at their workplace were collected and analyzed.

Results:

Results indicated significant positive relationships among attitudes toward multiple roles and workplace productivity. In addition, perceptions of breastfeeding support were significantly associated with both affective commitment as well as job satisfaction. Finally, our sample of breastfeeding employees returned to work after having a baby primarily for financial reasons, and do not generally feel very supported in the workplace.

Conclusions:

Overall, organizations can promote more investment and satisfaction in employees by providing explicit communication about breastfeeding-supportive policies to all employees. These findings underscore the importance of organizational breastfeeding support for mothers as well as their coworkers, which ultimately influences the success of the organization as a whole.

Introduction

The World Health Organization¹ recommends that new mothers exclusively breastfeed for at least 6 months after birth. In 2016, 84.1% of new mothers in the United States breastfed their babies, while 58.3% continued breastfeeding when their child was 6 months old, and only 35% continued breastfeeding until the child was 12 months old.² Due to the lack of nationally mandated paid maternity leave in the United States, many women return to the workplace long before the 6 months recommended for exclusive breastfeeding has passed. These women must navigate how to successfully continue breastfeeding, while also working.

This phenomenon is not affecting a small number of women. In 2016, 72% of women who gave birth were also part of the labor force.³

In addition, mothers contribute significantly to the economic well-being of the family,⁴ with 59.8% of married couples consisting of dual incomes in 2020 and 75.9% of mothers in other marital statuses (e.g., never married, widowed, and divorced) working full time.⁵ The U.S. Department of Labor noted that women with children younger than one year represent significantly less of the workforce compared to women with older children (57.8–76.4%, respectively).⁶ This discrepancy could suggest a desire to stay at home with the new baby or could suggest a lack of support in some area of the new mother's life that does not allow her to successfully work. For example, lack of maternal confidence or lack of managerial support has been reported as hindrance on women successfully returning to work and staying with their organization.⁷

While there are mental and physical benefits to allowing new mothers leave to care for the new baby and recover,⁸ the United States does not currently provide any federally mandated leave to support this. For those new mothers who work after having a child, this study explores if the women perceive their workplace to be supportive of this new role and their attitudes regarding multiple roles within 1 year of having their baby and returning to work. The intersection of breastfeeding and the workplace highlights a unique situation for women as they must combine their personal and the professional roles to work simultaneously for the betterment of both the home and work domains.

This study is designed to gain a better understanding of the associations between perceptions of workplace support, working mothers' attitudes toward multiple roles, and work outcomes, including job satisfaction, organization (affective) commitment, and workplace productivity, to further explore the organizational benefits of providing support to breastfeeding employees.

Workplace support and organizational outcomes

Breastfeeding support is “to support lactating women to breastfeed their babies”⁹ and can be provided by sources such as family, employers/managers, and/or colleagues. Past research has explored several types of workplace support (e.g., manager, coworker, time, and physical environment) and how they influence new mothers' workplace experiences.¹⁰ This study naturally extends the work by Jantzer et al.¹⁰ by exploring organizational outcomes that capture a more holistic view (i.e., affective as well as behavioral aspects) of breastfeeding employee's experiences in their workplace. These variables include affective commitment, job satisfaction, and work productivity.

Also described as workplace commitment, affective commitment can be conceptualized as employees who feel a sense of belonging and identification that increases their desire to remain with the organization.¹¹ Communication and psychological support are associated with greater affective commitment, specifically for women in management roles.¹² When examining family and its connections to affective commitment, research has examined ideas surrounding breastfeeding, but not studied it directly. For example, Talukder found work-life balance positively related to organizational commitment.¹³ Focusing specifically on the relationship between breastfeeding support and affective commitment could help provide ways for new mothers to remain feeling valued and connected to their workplaces, which has significant positive benefits for both the employee⁷ and the organization.¹³

Next, job satisfaction refers to a positive emotional condition derived from work experience.¹⁴ Research focusing on job satisfaction and breastfeeding support has identified overall workplace support as a factor for breastfeeding mothers' increased job satisfaction¹⁵ as well as negative associations between work-related breastfeeding problems and job satisfaction.¹⁶ Jantzer et al. noted that breastfeeding employees who were provided adequate time to pump felt their work enhanced their personal life and thus reported greater job satisfaction.¹⁰ Job satisfaction is typically examined as a construct related to breastfeeding success, so examining job satisfaction and attitudes toward multiple roles could help inform this phenomenon in greater detail.¹⁷

Finally, work productivity refers to perceptions of one's general work functioning of a person (e.g., task completion, concentration on work, and time management).¹⁸ Although breastfeeding women in the workplace have been found to have fewer absences due to infant illness, which indirectly increased their workplace productivity,¹⁹ specific measures and studies focusing on how breastfeeding women perceive their own workplace productivity are limited. Existing research surrounding breastfeeding support typically focuses on one component of the workplace,^10,17 so focusing on these three aspects of the workplace will allow a more holistic representation of a new mother's perceptions of her success at work.

Theoretical frameworks

Organizational support theory

According to organizational support theory (OST), employees see an organization as human-like entities and as having a favorable or unfavorable orientation toward the “person.”²⁰ By viewing the organization in this way, the employee is able to use perceived organizational support to serve socioemotional needs.²¹ OST posits that perceived organizational support should improve when employees are provided benefits that are used.²⁰

For breastfeeding mothers, these benefits may include a designated lactation room and time for pumping, among other things. Kurtessis et al. found that perceived organizational support was strongly related to greater organizational identification as well as higher reports of affective commitment.²² According to OST, these relationships exist through social exchange and self-enhancement processes (e.g., esteem or emotional support).^21–23 Therefore, it is plausible that the more working mothers perceive breastfeeding support within their workplace, the more positive their workplace outcomes will be.

Model of work-family enrichment

The model of work-family enrichment (MWFE) offers a framework for understanding the multiple role systems of working mothers. When a positive influence between roles exists, success in multiple domains (e.g., work and family) can be achieved.²⁴ Thus, resources gained in one role as a by-product of social relationships may be reinvested in other roles. For example, a manager explained the relevance of her work and family roles through the MWFE lens: “I think being a mother and having patience and watching someone else grow has made me a better manager. I am able to be patient with other people and let them grow and develop in a way that is good for them.”²⁵

Participating in roles within the workplace as well as within the family can also help buffer individuals from stress in one of the roles. Women who have difficulty reconciling the “breastfeeding mother” and “worker” roles are more likely to experience role conflict.²⁶ To better understand these experiences, this study explores the following research questions:

RQ1: What is the relationship between perceptions of breastfeeding support and workplace outcomes (i.e., affective commitment, job satisfaction, and workplace productivity)?

RQ2: What is the relationship between attitudes toward multiple roles and workplace outcomes (i.e., affective commitment, job satisfaction, and workplace productivity)?

This study sample reflects women who have returned to the workplace after having a baby. While there is a hypothesized relationship between multiple roles and workplace outcomes, this relationship does not help explain why these women are returning to work. As noted previously, many women face barriers to returning to work through both personal and/or professional influences.⁷ To better understand this decision, the following research question is proposed:

RQ3: What are the main reasons mothers continue working after having a baby?

In addition, while women who return to work may receive support from their organizations, it is unclear how satisfied they may be with the support. This information would be useful to know because research indicates that employees who feel supported report better workplace outcomes.^10,13,22 A final research question explores this:

RQ4: How do working mothers perceive breastfeeding support in their organization?

Materials and Methods

Sample

Participants in this study were 109 mothers residing in the United States, who had breastfed/pumped human milk within the last year of data collection and/or were currently breastfeeding/pumping human milk at their workplace. Participants' age ranged from 23 to 40 years (mean [M] = 31.56, standard deviation [SD] = 4.08).

Measurement

Attitudes toward multiple roles

The positive attitudes of multiple role subscale from Matias and Fontaine's 6-item work-family conciliation strategies scale²⁷ was administered as an index of attitudes toward holding both work and family roles. Items were answered on a 7-point Likert scale where 1 = strongly disagree and 7 = strongly agree. Higher scores reflected more positive attitudes toward multiple roles. Cronbach's alpha for this study was 0.77 (M = 4.87, SD = 0.96).

Workplace outcomes

Three aspects of workplace outcomes were assessed: affective commitment, job satisfaction, and workplace productivity. Allen and Meyer's 8-item affective commitment scale²⁸ was used to measure coworker perceptions of breastfeeding mothers' attachment to/identification with her workplace. Items were measured on a 7-point Likert scale (1 = strongly disagree and 7 = strongly agree) with higher scores reflecting greater affective commitment to the organization. Cronbach's alpha was 0.87 (M = 4.39, SD = 1.22).

Spector's job satisfaction survey²⁹ was used to measure participant's satisfaction with their job. The 36-item survey included 9 subscales examining pay, promotion, supervision, benefits, contingent rewards, operating procedures, co-workers, nature of work, and communication. All items were measured using a 7-point Likert scale (1 = strongly disagree and 7 = strongly agree) with higher scores indicating greater satisfaction with work. Cronbach's alpha for the composite scale was 0.94 (M = 4.43, SD = 1.01).

Finally, Endicott's work productivity scale¹⁵ was used to assess attitudes and behaviors that affect work performance and efficiency. The modified 25-item survey investigated women's experiences during the course of their time breastfeeding and/or pumping human milk at their workplace. The scale includes four subscales that assess attendance (absenteeism, time on task), quality of work, performance capacity, and person factors (social/mental/physical/emotional). Items were answered on a 5-point Likert scale (1 = never and 5 = always) and were reverse scored so higher scores reflected perceptions of greater work performance and productivity. The composite scale achieved a Cronbach's alpha of 0.93 (M = 3.88, SD = 0.58).

Reasons for returning to work

To assess the top reasons why breastfeeding mothers return to work after having a baby, participants were asked to rank their top three reasons from the following list: lucrative salary, income necessary, job is meaningful, job is part of identity, job is stimulating and interesting, close to a job advancement, lack of alternative employment, helps create balance in life, and other—with an option to include a reason not listed.

Perceptions of breastfeeding support in the workplace

Breastfeeding support was measured using the employee perceptions of breastfeeding support questionnaire from Greene and Olson.³⁰ A modified version containing 35 items examined how employees perceive breastfeeding support within their workplace with five subscales examining organizational support, manager support, co-worker support, time, and physical environment. Items were measured using a 7-point Likert scale (1 = strongly disagree and 7 = strongly agree) with higher scores indicating greater perceptions of support in the workplace. The composite measure demonstrated strong reliability (α = 0.96) with scores averaging 4.83 (SD = 1.23).

Procedure

A convenience sample of participants was recruited during the spring of 2017 through Facebook pages dedicated to working mothers. The researchers received approval from each page's owner/moderator to post information about the nature of the study, participation criteria (i.e., had to be a working mother and breastfed/pumped milk in the past year), and a secure survey link. If working mothers were eligible and wanted to participate, they completed an online questionnaire that took ∼20 minutes to complete. Although 253 participants clicked on the survey link, 120 participants completed less than 22% of the survey, an additional 20 participants completed less than 55% of the survey, and 4 participants were missing all demographic information, resulting in unusable data.

Complete data sets from the remaining 109 participants were retained for analyses. Informed consent was presented and obtained on the first page of the survey. The study procedure was approved by the institution's human subjects review board.

Statistical methods

The data were analyzed using IBM SPSS Statistics (IBM)³¹ predictive analytics software. Before data analysis, study variables were tested for skewness and kurtosis; all variables were normally distributed.

Inferential analyses were used to answer research questions one and two. Due to past literature reporting that working mothers are significant contributors to the economic well-being of the family,⁴ and given the fact that income affects both family³² and work³³ domains, we wanted to control for household income to make sure it was not affecting the hypothesized relationships among study variables. Therefore, partial correlations were conducted among all study variables (i.e., attitudes toward multiple roles, perceptions of breastfeeding support in the workplace, affective commitment, job satisfaction, and work productivity), while controlling for combined household income. Descriptive analyses (i.e., frequencies) were used to answer research questions one and two.

Results

Table 1 summarizes the demographic characteristics of the 109 mothers working, while breastfeeding and/or pumping milk. Participants reported having an average of 1.72 children residing in their household (SD = 89). The majority of women self-reported their race/ethnicity to be primarily Caucasian (90%). Forty-three percent of participants reported being the primary breadwinner in their household. Regarding combined household income, 30% reported earning between $10,000 and $69,999, 27% reported earning between $70,000 and $99,999, 24% reported earning between $100,000 and $149,999, and 19% reported earning more than $150,000. Participants reported working on average 37.68 (SD = 8.6) hours per week, averaged 5.16 (SD = 3.64) years at their current job, and held their current position an average of 3.7 (SD = 2.98) years.

Table 1.

Demographics of Working and Breastfeeding Mothers (N = 109)

	n (%)	M (SD)	Range
Age		31.56 (4.08)	23–40
No. of children		1.72 (0.89)	1–5
Race/ethnicity^a
Asian	3 (3)
Black/African American	2 (2)
Hispanic	6 (6)
Native American	3 (3)
White/Caucasian	98 (90)
Other	1 (1)
Highest level of education
High school diploma	4 (4)
Some college	13 (12)
2 Year degree	12 (11)
4 Year degree	42 (39)
Advanced/professional degree	38 (35)
Primary breadwinner
Self	47 (43)
Partner	62 (57)
Combined household income
$10,000–$49,999	19 (17)
$50,000–$99,999	43 (39)
$100,000–$149,999	26 (24)
$150,000+	21 (19)
No. of working hours per week
While breastfeeding		37.68 (8.60)	8–60
Years with current employer		5.16 (3.64)	0–20
Years in current position		3.70 (2.98)	0–15

Race/ethnicity = Total N exceeds 109 because participants were instructed to select all that apply.

SD, standard deviation.

Research question one assessed the association between attitudes toward multiple roles and workplace outcomes. When controlling for combined family income, there was one significant positive relationship among attitudes toward multiple roles and workplace outcomes. Specifically, women who believe it is important to have both work and family roles are more likely to report being productive at their place of employment (r = 0.19, p < 0.05). Attitudes toward multiple roles were not significantly associated with affective commitment (r = −0.08, ns) or job satisfaction (r = −0.10, ns). In sum, there was a positive relationship between holding favorable attitudes toward multiple roles and work productivity.

Next, research question two examined the relationships between perceptions of breastfeeding support in the workplace and organizational outcomes. When controlling for combined family income, significant relationships were found between perceptions of breastfeeding support in the workplace and affective commitment (r = 0.56, p < 0.001), as well as job satisfaction (r = 0.63, p < 0.001), but not work productivity (r = 0.07, ns). In sum, the more breastfeeding mothers feel supported in their workplace, the more they feel emotionally connected and satisfied with their job.

Research question three examined the main reasons why mothers continue working after having a baby. As can be seen in Table 2, the top ranked reason mothers reported returning to work after having a baby was because they needed the income (75.2%), followed by having a meaningful job (26.6%) and having a stimulating and interesting job (22%).

Table 2.

Top Three Reasons for Returning to Work After Having a Baby

Reason	Number 1	Number 2	Number 3
	Reason	Reason	Reason
	n (%)	n (%)	n (%)
Income needed	82 (75.2)^a	4 (3.7)	7 (6.4)
Part of identity	7 (6.4)	12 (11)	14 (12.8)
Lucrative salary	6 (5.5)	15 (13.8)	8 (7.3)
Job is meaningful	5 (4.6)	29 (26.6)^a	16 (14.7)
Job is stimulating and interesting	4 (3.7)	13 (11.9)	24 (22)^a
Job helps create a balance in life	2 (1.8)	14 (12.8)	22 (20.3)
Close to job advancement	1 (0.9)	2 (1.8%)	7 (6.4)
Lack of alternative employment	0 (0)	17 (15.6)	7 (6.4)
Other	2 (1.8)	3 (2.8)	4 (3.67)

N = 109.

Subscale	M (SD)	Observed range
Organizational support	4.72 (1.24)	1.18–7
Manager support	4.85 (1.45)	1.5–7
Coworker support	4.98 (1.28)	1.33–7
Time support	4.78 (1.84)	1–7
Physical environment support	5.42 (1.45)	1.8–7

Discussion

This study's main objectives were descriptive and exploratory in nature. We examined two research questions centered on the relationships between (1) positive attitudes toward multiple roles and workplace outcomes and (2) perceptions of workplace support and workplace outcomes. In addition, this study explored the reasons why breastfeeding mothers return to work and their perceptions of breastfeeding support in the workplace.

The first research question examined the relationships among perceptions of breastfeeding support in the workplace and workplace outcomes (affective commitment, job satisfaction, and job productivity). Two of the three relationships were significant, which suggest that perceived support for breastfeeding is associated with more attitudinal outcomes (i.e., affective commitment and job satisfaction) rather than behavioral outcomes (i.e., job productivity). On average, our sample of breastfeeding mothers had very neutral perceptions of workplace support. Despite only having neutral perceptions of support, these perceptions were still associated with their affective commitment and job satisfaction.

Although longitudinal data would be needed to make causal claims, these findings suggest that with greater support, even greater organizational outcomes may be achieved, thus further benefiting both the breastfeeding mother⁷ and the organization.¹³ However, to confirm this, longitudinal data would be needed. These findings also support extant literature surrounding OST. Because the perception of organizational support is communicated through social interactions,²⁰ the lack of relationship with job productivity (or job self-efficacy) could be related to the lack of clear feedback from other sources in the workplace. The relationship between feeling valued by an organization (affective commitment) and being involved in the job (job satisfaction) supports Kurtessis et al.'s findings that perceived organizational support was related to higher reports of affective commitment.²²

The second research question examined the relationships between working mothers' attitudes toward multiple roles and workplace outcomes. Only one significant finding emerged. Specifically, positive attitudes toward occupying both family and work roles were associated with greater perceptions of work productivity, but not significantly related to affective commitment or job satisfaction.

According to the MWFE, positive outcomes experienced in one role can produce positive experiences in another role.²⁴ It is possible that women who feel it is important to adopt both family and work roles not only feel they are productive within the home (e.g., staying organized, successful with completing chores, etc.) but also perceive themselves to be more productive in the workplace (e.g., arrive to work on time, are able to concentrate on tasks, etc.). Ladge and Greenberg found that women returning to work postbaby faced re-socialization into the workplace, which influenced identity uncertainty.³⁴ This uncertainty could reflect a lack of affective commitment as one's personal and professional identities are in a state of flux.

The women in this study were all employed mothers, who were currently breastfeeding/pumping milk at work or had been in the past year. It should be noted that while they chose to occupy both family and work roles, it does not mean that they had positive beliefs about endorsing both family and work responsibilities. In fact, the mean score on this scale was 4.87 (out of 7), suggesting that, on average, attitudes toward multiple roles were not exceedingly positive. This might be informed by the top reason mothers chose to go back to work after having a baby—because they need the income. In addition, this finding could reflect the conflicting roles women face when tasked with returning to work and being both a “worker” and “breastfeeding mother” simultaneously.²⁶ In contrast, breastfeeding workers who feel supported may feel both their professional and personal lives are enhanced.¹⁰

This study can speak to perceptions of organizational support in that even neutral perceptions are associated with positive outcomes, but it is unclear whether these extend to the family domain as suggested by the MWFE.

It is important to note that the results of research questions one and two also take into consideration participants' combined household income (see Table 1 for the breakdown of income for the participants).

Regardless of the amount of money the family makes, women who hold favorable attitudes toward occupying multiple roles are more productive at their place of employment, and perceptions of workplace support are associated with more affective commitment to their place of employment and greater job satisfaction. This is an important contribution of this research because past literature has identified that income has direct effects on family³² and work³³ domains, and these findings control for this potentially confounding variable. This may indicate that money helps create a means to an end, but it does not appear to be an influential factor that affects the relationships among their perceptions of family and work domains for this sample of working mothers.

This study also explored the reasons mothers go back to work as well as perceptions of breastfeeding support in the workplace. Breastfeeding mothers reported income as the main reason to return to work and neutral perceptions of support provided in the workplace, which is consistent with the larger national trend of mothers contributing significantly to the family's finances.⁴ The second most popular ranked item (26.6%) indicated returning to work because their job is meaningful, while the third most popular ranked item (22%) indicated women return to work because their work is stimulating and interesting. Participants reported feeling connected to their jobs, which may have led to positive benefits in both their professional as well as personal roles.²⁴ Overall, this finding suggests that women work for a paycheck, but they also feel connected to their work.

Of all types of breastfeeding support, perception of physical environment support received an average mean of 5.42 (out of 7), reflecting a response of “somewhat agreed” that this type of support was present. The means for organizational, managerial, co-worker, and time support ranged between 4.72 and 4.98, reflecting “neither agree nor disagree.” The inconsistencies in perceptions of workplace support may reflect the ways in which workplace support is conveyed to employees. Specifically, positive perceptions of these types of support often require clear communication between the sender and receiver (e.g., manager and employee), which supports OST in that social interactions convey organizational support.²⁰

In addition, clear communication is a critical disconnect for many managers and breastfeeding employees in that managers do not even know how to bring up the topic, and sometimes actively work to avoid it.³⁵ The findings of this question may reflect the general lack of communication surrounding breastfeeding support in the workplace in that their manager and organizational support may not even be known to them. Consequently, a lack of knowledge may cause participants to choose a neutral response regarding support since the communication did not occur. The physical environment, however, is a tangible space that is either provided or not by a workplace that participants were able to distinguish if they perceived support due to the presence of appropriate space and equipment to breastfeed/pump.

Practical implications

The findings of this study present both microlevel and macrolevel implications for organizations. Supporting OST, the findings reinforce the impactful relationship between perceived organizational support and organizational outcomes. Therefore, it is in an organization's best interest to clearly communicate all available types of support for mothers because this could result in greater emotional attachment to, identification with, and involvement in the organization. More specifically, managers need to be proactive and know and/or create policies surrounding leave and breastfeeding accommodation and explicitly talk about them with their employees.³⁵ Managers would also do well to talk to all employees about the benefits of these accommodations, not just people who may need them.

When a colleague is supported, this benefits more than just the one person receiving the accommodation³⁶; the whole organization is able to grow and thrive. Organizations that explicitly support workers show that they promote well-being, display support, create an inclusive culture, and reduce worker turnover.³⁷ While basic accommodations have been federally mandated,³⁸ these accommodations and breastfeeding support are not nationally recognized and honored as workplace norms in the United States.^35,39 It is in an organization's best interest to invest in its employees. If supported breastfeeding is an organizational norm, all employees are able to value it and provide support.

These findings present further support for the need to increase visibility and accessibility of breastfeeding in the workplace through various types of support as well as the organizational benefits of providing clear policies that support breastfeeding and articulating those policies explicitly to all members of the organization. Finally, as we start to see more states pass legislature regarding breastfeeding support, providing comprehensive federally mandated family leave policies,⁸ as have been adopted in countries such as Sweden, and include over a year of paid parental leave,⁴⁰ could provide additional macrolevel support.

Limitations and future research

There were a few limitations within this study. First, these data were cross-sectional. Future research would benefit by tracking working mothers' perceptions of workplace support prepartum and postpartum to provide a more comprehensive understanding into breastfeeding mothers' workplace experiences. In addition, the analyses were limited to descriptive statistics and correlations. While this study's findings undoubtedly make practical and theoretical contributions, future research could employ more advanced statistical techniques and explore potentially mediating variables (e.g., organizational culture, perceptions of value, and care for holistic well-being of employees) that may help explain the link between perceived support and workplace outcomes.

Finally, this study did not measure perceptions of productivity within the family. Those who have positive attitudes toward occupying both family and work roles also reported greater work productivity and yet, while this is informative and can be guided by the MWFE, both concepts would need to be measured (i.e., work and family productivity) to fully test this theory.

Conclusions

The results of this study indicate that breastfeeding workers' perceived support is associated with greater affective commitment as well as job satisfaction. In addition, women who adopt positive attitudes toward enacting both family and work roles are more likely to report greater work productivity. Finally, our sample of breastfeeding employees returned to work after having a baby primarily for financial reasons, and do not generally feel very supported in the workplace. These findings suggest that organizations can promote more investment and satisfaction in employees by providing explicit communication about breastfeeding-supportive policies to all employees, specifically by managers.

Footnotes

Authors' Contributions

The authors confirm contribution to the article as follows: study conception and design: E.R. and A.W. Data collection: E.R. Analysis and interpretation of results: E.R. and A.W. Draft article preparation: E.R. and A.W. All authors reviewed the results and approved the final version of the article.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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