ABM Position Statement: Paid Maternity Leave—Importance to Society,Breastfeeding,and Sustainable Development

Abstract

Background:

Paid maternity leave benefits all of society, reducing infant mortality and providing economic gains. It is endorsed by international treaties. Paid maternity leave is important for breastfeeding, bonding, and recovery from childbirth. Not all mothers have access to adequate paid maternity leave.

Key Information:

Paid leave helps meet several of the 17 United Nations' Sustainable Development Goals (2, 3, 4, 5, 8, and 10), including fostering economic growth. A family's expenses will rise with the arrival of an infant. Paid leave is often granted with partial pay. Many low-wage workers earn barely enough to meet their needs and are unable to take advantage of paid leave. Undocumented immigrants and self-employed persons, including those engaging in informal work, are often omitted from maternity leave programs.

Recommendations:

Six months of paid leave at 100% pay, or cash equivalent, should be available to mothers regardless of income, employment, or immigration status. At the very minimum, 18 weeks of fully paid leave should be granted. Partial pay for low-wage workers is insufficient. Leave and work arrangements should be flexible whenever possible. Longer flexible leave for parents of sick and preterm infants is essential. Providing adequate paid leave for partners has multiple benefits. Increasing minimum wages can help more families utilize paid leave. Cash benefits per birth can help informal workers and undocumented mothers afford to take leave. Equitable paid maternity leave must be primarily provided by governments and cannot be accomplished by employers alone.

About ABM Position Statements: The Academy of Breastfeeding Medicine empowers health professionals to provide safe, inclusive, patient-centered, and evidence-based care. Women and others who are pregnant and lactating identify with a broad spectrum of genders, pronouns, and terms for feeding and parenting. There are two reasons ABM's use of gender-inclusive language may be transitional or inconsistent across protocols. First, gender-inclusive language is nuanced and evolving across languages, cultures, and countries. Second, foundational research has not adequately described the experiences of gender-diverse individuals. Therefore, ABM advocates for and will strive to use language that is as inclusive and accurate as possible within this framework. For more explanation, please read ABM Position Statements on Infant Feeding and Lactation-Related Language and Gender (DOI: 10.1089/bfm.2021.29188.abm) and Breastfeeding As a Basic Human Right (DOI: 10.1089/bfm.2022.29216.abm).

Introduction

Paid maternity leave benefits all of society by promoting healthier mothers and children, reducing infant mortality, reducing poverty and income inequality, reducing gender inequality, and helping meet many of the United Nations' Sustainable Development Goals (UN SDGs), including fostering economic growth.¹ Maternity leave should be afforded to all women in accordance with other fundamental human rights, according to the 2000 Maternity Protection Convention,² adopted by the member states of the United Nations' International Labour Organisation (ILO).

Paid maternity leave is part of ensuring nondiscrimination in the right to work under the United Nations' 1979 Convention on the Elimination of all Forms of Discrimination Against Women (CEDAW).³ Time to bond with a child and recover from childbirth are important for all new parents, regardless of feeding method, but it is especially important for breastfeeding. The goals of this statement are to demonstrate how paid maternity leave benefits all of society, how it promotes breastfeeding, and why it should be available to all women. Furthermore, we will examine the complex issues related to the success of maternity leave and provide recommendations regarding paid parental leave.

One of the most important reasons for paid maternity leave is to support breastfeeding, which provides many societal benefits that help meet the UN SDGs. Some research has found that return to employment has been the main reason for early breastfeeding cessation.⁴ Many mothers return to employment early for economic reasons, as they do not have entitlement to adequate paid maternity leave. In addition, many mothers return to an employment situation that is not conducive to continued breastfeeding.

Breastfeeding is a dose-dependent health determinant for children, mothers, and population health,^5,6 and is important for children's cognitive development.^6,7 Breastfeeding also has a significant economic impact, with the cost of not breastfeeding totaling hundreds of billions of dollars per year worldwide, over $100 billion annually in the United States alone.^8–11

Maternity leave provides an opportunity for the establishment of breastfeeding by allowing frequent feedings of the infant directly at the breast, led by the mother's response to the subtle hunger cues of the infant. This time allows the mother and infant to learn how to breastfeed and enables the mother's milk production to become consistent and reliable. During the establishment of breastfeeding, proximity of the mother and infant is critical for the mother to respond to early signs of hunger. Infants' brains and bodies grow rapidly during the first year of life,¹² and they initially require about 8–12 feedings daily for appropriate growth and neurological development.

Breastfeeding is associated with epigenetic changes that benefit infants and may be related to the actual act of breastfeeding, and not merely the milk.^13,14 The World Health Organization (WHO) recommends 6 months of exclusive breastfeeding with continued breastfeeding for 2 years and beyond, as long as mother and child desire.¹⁵

Research shows that earlier return to employment is associated with lower breastfeeding rates, compared with later return to employment.^4,16 Infants and young children in childcare settings have higher stress levels than similar children cared for at home, as indicated by higher cortisol levels.^17,18 For those women who use breast pumps, direct breastfeeding is more effective at milk production and transfer than breast pumping,¹⁹ making the mother's time spent with her infant even more significant.

As a shortened time of lifetime lactation is associated with an increased risk of maternal diseases including cancers, diabetes, and cardiovascular diseases,²⁰ women who are deprived of the right to breastfeed due to inability to take paid maternity leave are deprived to the right to health, and their children are also at increased risk for a number of acute and chronic diseases.^8,20

All mothers and infants have the right to breastfeed,^21,22 regardless of income, employment, or immigration status. Providing paid maternity leave is a crucial governmental role that cannot be filled by employers alone.²³ In 2015, the signatories of the Stockholm Symposium on breastfeeding and work (United Nations Children's Fund [UNICEF], the World Alliance for Breastfeeding Action, and global representatives) declared that women have a right to breastfeed and earn a living wage.²² Women also have the right to maternity protection, which consists of maternity leave (whether paid or unpaid), pregnancy safety, and breastfeeding breaks.²⁴

The ABM Position Statements on Breastfeeding Support for Mothers in Workplace Employment or Educational Settings (2013)²⁵ and Breastfeeding as a Basic Human Right (2022)²¹ serve as important adjuncts to this position statement.

Key Information

Background

At its first meeting in 1919, the ILO, under the League of Nations, advocated for 6 weeks of unpaid maternity leave and paid breastfeeding breaks.²⁶ International organizations such as UNICEF and WHO currently advocate family-friendly policies in employment,²⁷ including paid maternity leave, access to quality childcare, breastfeeding breaks, and dedicated lactation spaces.^27–31

Nearly all of the world's countries provide some form of government-mandated paid maternity leave, with the United States being a notable exception (Table 1). However, paid leave policies do not apply to all mothers with new infants. In many countries, provisions are not available for self-employed mothers (including informal workers), part-time employees, formerly employed mothers, or unemployed mothers who have insufficient outside income to have access to paid maternity leave. In most countries, noncitizens and those without legal status cannot access government benefits such as child benefits, paid leave, or social insurance. A family's financial needs increase when an infant is born, yet paid leave is often not 100% of full pay.

Table 1.

Paid Parental Leave in Selected Countries

Country	Length of maternity leave	Percentage of wages	Optional additional leave	Percentage of wages	Paternity leave
Australia^a	20 weeks	National minimum wage	None	None	Pay is to share with partner if there is one
Bangladesh^b	13 weeks postpartum	100%	None	None	None
Canada	16 weeks	47.7%	35 weeks	52%	5 weeks unpaid
Chile	18 weeks	100%	12 weeks	100%	1 week at 100%
Costa Rica	17 weeks	100%	None	None	None
Democratic Republic of Congo	14 weeks	100%	(Information not listed)	(Information not listed)	(Information not listed)
Columbia	18 weeks	100%	None	None	1 week at 100%
Denmark	18 weeks	52%	32 weeks	52%	2 weeks at 52%
India^c	26 weeks	100%	(Information not listed)	(Information not listed)	(Information not listed)
Israel	15 weeks	100%	None	None	None
Italy	21 weeks	80%	25 weeks	30%	1 week at 100%
Japan	14 weeks	67%	44 weeks	59.9%	52 weeks at 60.3%
Mexico	12 weeks	100%	None	None	1 week 100%
Norway	18 weeks	96%	68 weeks	33.4%	15 weeks at 96%
South Africa^d	17 weeks	67%	(Information not listed)	(Information not listed)	(Information not listed)
United Kingdom	39 weeks	29.8%	(Information not listed)	(Information not listed)	2 weeks at 19%

Sources: World Population Review unless otherwise noted.

World Population Review. Maternity leave by country 2023. Walnut, California: World Population Review; 2023. Available from: https://worldpopulationreview.com/country-rankings/maternity-leave-by-country. Cited 2023 August 5.

https://www.fairwork.gov.au/leave/maternity-and-parental-leave/paid-parental-leave#australian-government-plps

International Labour Organisation. Bangladesh: Maternity protection 2011: International Labour Organization; 2011. Available from: https://www.ilo.org/dyn/travail/travmain.sectionReport1?p_lang=en&p_structure=3&p_year=2011&p_start=1&p_increment=10&p_sc_id=2000&p_countries=BD&p_countries=BR&p_print=Y#:~:text=%2C%2030(2)-,Duration,are%20optional%20for%20private%20companies. Accessed 2023 December 11.

Beria T. Maternity benefits for building and construction workers in India: A regulatory quagmire Kolkata: University of India; 2022. Available from: https://jils.blog/2022/01/27/maternity-benefits-for-building-and-other-construction-workers-in-india-a-regulatory-quagmire/. Cited 2023 July 5.

International Labour Organisation. Care at work: Investing in care leave and services for a more gender equal world of work, Executive Summary. Geneva; 2022.

For those workers whose pay barely covers their expenses, low wages may make taking paid leave difficult, even if the employee receives 100% of earnings. Such workers may need to work longer hours to meet the increased expenses of a new child. Thus, paid leave is also affected by factors such as minimum wage. In the United States, research showed that an increase in infant mortality was observed after the reversal of minimum wage increases, and that some of the increase in infant mortality could be attributed to the reversal of the minimum wage increases.³²

The ILO Maternity Protection Convention of 2000 states that women should have the right to at least 14 weeks of paid maternity leave with cash benefits at a level that ensures that the woman can maintain herself and her child in proper conditions of health and with a suitable standard of living (C183).² The ILO stipulates that this figure should leave them healthy and out of poverty, and should be at least two-thirds of her previous earnings, with the recommendation to increase it to 100%.^23,33 The percentage of countries enacting such standards has hardly changed since 2014 (from 72 countries in 2014 to 83 in 2022).³⁴

In addition to the right to 14 weeks of paid leave with two-thirds pay, the ILO Convention further recommends that countries enact legislation providing 18 weeks of maternity leave with 100% pay, covered by public funds (R191).³³ In 2022, only 10% of countries met this set of recommendations, far from the 2030 WHO/UNICEF target of at least 25%, and no country in Africa or Oceania did so.³⁴

Parents who welcome a new child by adoption or through foster parenthood also need paid leave to bond and adjust to life with the child, as well as the intense time required to care for a young infant, if applicable. Although time off is essential for infants and young children, time off is also important to help families welcoming older children to adapt to their new lives. Some amount of paid leave is also necessary for women who give birth to a stillborn infant or an infant who dies shortly after birth, as these women require time to recover from childbirth as well as bereavement time. The ILO Convention mandates 6 weeks of compulsory leave after (any) childbirth (C183).²

Paid maternity leave is sometimes part of a system of paid employee leave across the lifespan. When part of such a care package, as advocated by the ILO,²³ maternity leave and breastfeeding breaks are not seen solely as a women's or children's issue. Virtually everyone, at some point in their adult life, may require time off to recover from illness or surgery, to care for a sick or dying loved one, or may need long-term care. The ILO notes that investing in lifespan care can fuel economic growth and create jobs.²³ The value of bonding with a new infant and the value of women's health from prolonged lactation are often underappreciated. The importance of maternal and paternal mental health is gaining increasing recognition, and the strain of working on parents of newborn and young infants can be tremendous.

It is important to note that some countries have paid maternity leave and yet low breastfeeding rates (e.g., Canada and the UK), signifying that other factors beyond the mere existence of paid leave are also necessary to achieve high population rates of breastfeeding. In addition to the paid leave being sufficiently adequate to allow families to afford to use it, the presence of Baby-Friendly hospitals; controlling the marketing of commercial milk formula; the availability of qualified lactation support and donor human milk; employment conditions supportive of breastfeeding; the cultural acceptance of breastfeeding; issues of poverty, equity, social determinants of health, infant, and maternal medical issues; and individual factors can all affect overall breastfeeding rates.

Individual factors also affect whether a mother will be able to breastfeed even with paid leave or after returning to work. Such factors include a mother's knowledge and skills with breastfeeding and expressing milk, her self-efficacy, smoking status, medical issues in the mother and infant, and her attitudes based on advice she has been given, her previous experience, as well as her cultural norms.⁸

How paid maternity leave benefits society

Paid parental leave is essential for reaching some of the United Nations' 17 Sustainable Development Goals^1,35 in part due to its role in supporting breastfeeding. Specifically, paid leave is important to reducing poverty (Goal 1), promoting nutrition and achieving food security (Goal 2), ensuring healthy lives across the lifespan (Goal 3), promoting cognitive development and education (Goal 4), achieving gender equality (Goal 5), achieving economic growth and productivity (Goal 8), and reducing inequality within and among countries (Goal 10), and ensuring sustainable production and consumption patterns (Goal 12).

Longer maternity leave reduces infant mortality in countries of all income levels.¹ In low- and middle-income countries (LMICs), each additional month of paid maternity leave is associated with 7.9 fewer deaths per 1,000 live births.³⁶ In addition, paid leave is associated with higher vaccination rates in LMICs, particularly those vaccines given in the early months of life.^1,37,38 In higher income countries, more generous paid leave is associated with more on-time immunizations.^1,39,40 Paid leave has been shown to enable women to physically recover from childbirth before returning to work.^1,41,42 Paid maternity leave is also associated with a reduced risk of postpartum depression.^43,44

In studies from high-income countries, researchers have found that extending the duration of paid leave increases rates of breastfeeding for at least the critical first 6 months of the infant's life (Canada, Taiwan, and Germany).^45–48 In the United States, where there is no federally mandated maternity leave, women who returned to work at or after 13 weeks had a higher odds of predominant breastfeeding at 3 months when adjusted for other factors, compared with women who returned much sooner.⁴⁹ Following reforms to Canada's maternal (maternity plus parental) leave policy, which increased from 6 months to nearly 1 year in most provinces in 2000,⁵⁰ the share of women breastfeeding exclusively for at least 6 months increased by between 7.7% and 9.1%.^1,36

There is a strong economic case for governments to invest in paid maternity leave. The human capital involved in raising a child into a productive adult is generally underappreciated, and such work, particularly in the early years, is disproportionately accomplished by women.⁵¹ This work, and breastfeeding or the provision of breast milk in particular, are rarely included in a nation's gross domestic product.¹¹ In 2013, by one estimate, the United States had the potential to produce $110 billion worth of breast milk annually, but at that time, nearly two-thirds of that value was lost due to premature weaning.¹¹ Similar estimates give the cost of not breastfeeding for the United States to be in the range of $100 billion annually, mainly in cognitive costs.^8,9

Paid leave has been associated with improved worker retention, better employee morale, and higher employment rates of young women.⁵² Using the World Breastfeeding Costing Initiative, Holla-Bhar et al. estimated that the global cost of implementing a minimum maternity entitlement for 214 countries based on the World Bank poverty line is only $12.6 billion (or $2 per mother per day),¹⁰ which is minimal compared with the costs of undernutrition and the other costs of not breastfeeding.

The same authors note that the global value of breast milk, if optimal breastfeeding were achieved by 95% of infants and young children, would be worth $3,380 billion per year. Given that one of the biggest causes of premature weaning is returning to work, the investment in any paid leave would be expected to have a positive social impact.

There is a business case for family-friendly worksite support to reduce absenteeism, diminish employee stress, and promote loyalty.⁵³ There is also a business case for employers to provide paid leave. In many countries, particularly LMICs, mandated paid leave is often financed by employers²³ and in the United States, where paid leave is voluntary, employers often finance it where it does exist. When U.S. employers have provided any type of paid leave, it has offered a positive return on investment.

A U.S. analysis showed that organizations pay an average of $6.87 weekly per worker for any paid leave policies, but gain an average of $12.32 weekly per worker from increased productivity and reduced turnover.^54,55 Compared with U.S. organizations without paid leave, organizations that provide paid leave have increased productivity and morale, lower job turnover, greater job satisfaction, and often better pay.⁵⁴

Paid leave is important for women's long-term economic security. A range of studies have shown that paid leave positively impacts women's later earnings, as well as their ability to remain in the workforce.^1,56–58 In the United States, the only industrialized country without federally mandated paid maternity leave, economists have estimated that the lack of “family-friendly” policies is responsible for nearly a third of the relative decline in female labor force participation compared with other countries in the Organisation for Economic Co-operation and Development (OECD) between 1990 and 2010.^1,59

Through improved children's cognitive development from breastfeeding, paid leave helps children meet their potential in education and earnings.⁷ By increasing birth spacing, breastfeeding also helps improve women's health and economic opportunities. Gender equality is also advanced when governments offer leave to both parents.^1,23 In addition to promoting healthy communities, adequate benefits and duration of paid leave help keep women and children out of poverty, reduce economic inequality, and promote economic independence for families. When families have more disposable income, the economy benefits. All these factors improve a society's economic growth.

Maternity leave at the government and community levels

Maternity leave is a complex topic. This section is organized into two levels: (1) government level, which describes government roles and paid leave policies, and (2) community and family level, which consists of the family setting, the workplace setting, and the childcare setting. These levels can interact with one another (Fig. 1). For example, a government might have a law allowing for paid leave, but a mother may not be able to take advantage of it because the pay is insufficient for her family's needs. A mother may also be concerned she will lose her low-wage job if she takes leave, and will be powerless to advocate for her rights even if it would be illegal to fire her.

FIG. 1.

The diagram illustrates the ecological system showing interacting factors that influence whether a mother can afford to breastfeed (exclusively or not, and for how long). Policies and health services interested in promoting optimal maternal and child health should take these factors into account when developing interventions and plans, and monitor the impact of any interventions affecting each factor.

Government level: types of leave policies, their benefits and drawbacks

Models of paid leave vary throughout the world, from no national leave policy at all (the United States) to very generous leave (Sweden). In the United States, a handful of states have implemented paid maternity leave (e.g., California, Massachusetts, New York, New Jersey, Colorado, and several others). Swedish parents are entitled to 480 days of paid leave (which can be split between two parents, if there are two).⁶⁰ India has been lauded for its 2017 law granting 26 weeks of paid maternity leave, but its provisions exclude 90% of the workforce because it only applies to a narrowly defined “organized sector.”⁶¹

Canada's standard benefit provides 55% pay up to $650 (Can$) per week for the first 15 weeks with unpaid time off for 52 weeks.⁶² In the United Kingdom, eligible employees can take up to 52 weeks of leave, of which 39 weeks is paid: employees receive 90% of their average weekly earnings for the first 6 weeks, then £172.48 per week or 90% of their average weekly earnings (whichever is lower) for the following 33 weeks.⁶³ Australia provides up to 20 weeks at the national minimum wage taken between two parents (if there are two), and there is some flexibility around when the leave can be taken.⁶⁴

Paid leave schemes may fail many employees. Low wages mean that even at full pay, some families may not be able to take advantage of much, if any, paid leave, for example, if a mother works multiple jobs to make ends meet. Even for higher wage employees, policies that grant <100% of earnings may leave families unable to meet their housing and other fixed expenses. A significant proportion of pregnancies worldwide is unplanned, more so among those with lower incomes.^65,66 With a maternity policy that pays a fraction of earnings, families may not have the ability or opportunity to save up the necessary reserves to make up for a shortfall before an infant arrives. Thus, many mothers may have little choice but to return to employment quickly if their housing and other fixed expenses are based on higher earnings.

As noted above, in many parts of the world, women are mainly employed in the informal sector, as domestic workers, vendors, or construction workers, or in home-based work on a piece rate basis. These mothers may not be recognized as employees and thus not covered by laws or systems that provide paid maternity leave, even in high-income countries. Undocumented immigrants would not also typically be eligible for government-sponsored benefits. Countries such as Sweden or Norway have cash payments per birth, but they are only available to legal residents, and infants of undocumented foreign nationals would not be eligible.

Currently, only 33 countries grant birthright citizenship, with nearly all of these countries being in the Americas.⁶⁷ Infants born in countries with birthright citizenship could be eligible for government benefits, but for the rest of the world, a different model of financing such families would be necessary. If a birth is registered, payments could be granted per child born or per birth, irrespective of immigration or employment status. Malaysia skirts this issue of paid leave for infants of foreign born workers, as its government bars foreign workers from getting pregnant and deports them at their own expense, in violation of the CEDAW, of which it is a signatory.^68,69

A strategy proposed for providing more universal maternity protection would be to implement a minimum maternity entitlement globally within the framework of the Global Strategy of Infant and Young Child Feeding. Holla-Bhar et al. recommended the establishment of a global special maternity benefit fund for cash assistance to women below the poverty line, centered on the Global Strategy measures.¹⁰ As noted above, this is estimated to cost $12.6 billion (based on the World Bank poverty line), would be cost-effective, and would have wider benefits for maternal and child health.¹⁰

It could be implemented within countries' own legislative and policy frameworks and social protection systems, with funding from high-income countries, and accessible by LMICs. Paid at adequate levels to all new mothers, such a model of maternity entitlements could help undocumented, unemployed, self-employed, or informally employed mothers, and could help to mitigate family poverty. Even such a universal scheme would exclude vulnerable mothers who do not claim the benefit due to fear or other barriers, and those mothers who do not have a registered birth.

Paid parental leave (as differientiated from maternity leave) enables both parents, if there are two, to take time off of work after the birth of a child while maintaining their jobs and at least partial income. One of the SDGs (Goal 5.4) calls on countries to promote “shared responsibility within the household and the family.”³⁵ In 2021, 115 out of 185 countries surveyed by the ILO offered paid leave explicitly for fathers (paternity leave), although the average duration was just 9 days.²³

Paid parental leave has the potential to have health benefits for infants and mothers, and may also reduce economic and gender inequality and improve employment conditions.¹ If paid leave were only available to women, it risks discrimination in the labor market and widening existing gender gaps in wages and employment. In addition, traditional gender roles, as supported by the lack of paternity leave, deprive men of the opportunity of caregiving. Several studies have found that fathers who take paid leave are more involved in childcare both during the leave period and later in the child's life^1,70–72

A longitudinal Swedish study also found that when fathers took paid leave (in addition to mothers), their infants were more likely to be breastfed at 2, 4, and 6 months.⁷³ Based on data from a wide range of high-income countries from 2000 to 2013, a wage replacement rate of at least two-thirds appears to be the minimum for even modest participation by fathers, whereas a rate of 80–100% of regular wages is needed for broader participation.^1,74 Distinct policy interventions are required to facilitate fathers’/partners' engagement in enabling and supporting breastfeeding through sharing the other unpaid care work associated with parents' time-consuming care responsibilities, for both infants and young children and related household work.⁷⁵

Structural supports from government, particularly maternity protection and childcare, are needed to ensure that childbearing and breastfeeding do not disadvantage women amid efforts to reduce gender pay gaps and gender economic inequality.⁷⁵ Although paid maternity leave may decrease the risk of poverty, a “motherhood penalty” has been well described,^58,76 in which time out of the workforce results in less accumulated work experience and may thus adversely affect women's long-term earnings and career goals.

A body of research shows this income inequality is related to the number of children, which is associated with reduced earnings in most wealthy countries.⁵⁸ National policies of extended maternity leave (>156 weeks) further diminish mothers' work experience, decrease their attachment to the labor market, and may discourage employers from hiring women of childbearing age.⁵⁸ However, short leave or no leave is even more harmful to mothers' long-term economic status than very long times out of the workforce.

In a study modeling paid leave in 22 high-income countries, very short leave had the highest motherhood penalty, defined in the study as the amount each additional child lowers women's earnings. Countries with 2 years of job-protected leave were associated with the smallest per-child penalties, which was roughly 73% smaller compared with countries with no leave. In this study, even the longest leaves were associated with smaller penalties than no leave at all.⁵⁸

Governments play a central role in the financing and distribution of paid leave. ILO minimum standards in the Maternity Protection Convention 2000 (No. 183)² are for countries to provide cash benefits to the majority of women for 14 weeks, funded through compulsory social insurance or public funds, or in a manner determined by national law and practice,²³ and to provide ineligible women with adequate benefits out of social assistance funds. Governments have financed paid leave either through taxation and/or through employment-based contributions, which can also cover other types of leave, such as that which might be necessary to recover from major illness, in employees of any gender or age.

Relying on voluntary employer schemes will be insufficient for low wage or casual workers, and may result in discrimination against potential mothers, and low industry coverage. Furthermore, although many national laws require that workers have maternity leave paid by their employers, many informal workers, which comprise the majority of mothers in some countries, may not receive paid leave, may lose their jobs, and may return to work early due to poverty.^77–79 The introduction of a publicly funded paid parental level scheme in Australia that had wide eligibility and was paid to the primary caregiver for 18 weeks at the national minimum wage was found to increase breastfeeding at 12 months by 4%.⁸⁰

Governments play an important role in creating laws and regulations that affect workplace support such as breastfeeding breaks, time, and hygenic space to express milk. Governments can also play other important roles that affect breastfeeding rates, such as regulating the marketing of commercial milk formula, ensuring the availability and equitable distribution of donor milk, and the support and promotion of Baby-Friendly hospitals. Addressing these issues is outside the scope of this document.

Community and family level: circumstances and settings that affect leave policies

Family setting

Parents' circumstances require that parental leave be flexible, and the timing and length of leave for the mother and her partner may depend on factors such as whether there are older children, whether a mother or her partner can perform any of the duties of their employment from home, whether the mother can return to work part-time, whether the infant was born preterm, sick or has any special needs, and what options the family has for childcare. Flexibility in leave and in the workplace arrangements is important.

Infants who are born ill, preterm, low birthweight, or with serious congenital defects, have unique issues with respect to maternity leave, and both parents, if there are two, may be important to support the infant's health. Such infants may require weeks or months in a neonatal intensive care unit, often in a tertiary care hospital that may be far from their mother's home and worksite. Such infants are often particularly dependent on their mothers' expressed breast milk to prevent necrotizing enterocolitis and other life-threatening complications.

In addition, there is improved survival among infants who are continually carried skin-to-skin against their mother's chest (kangaroo mother care), or if she is not available, the other parent.^81,82 Thus, having the infant's mother nearby to be able to pump and deliver her fresh expressed milk and hold her infant is essential.

At the same time, when such infants are eventually discharged, they and their parents will have the same needs as all other parents for time off work to care for their newborn infant. In addition, these infants often have special needs once they are discharged from the hospital, such as oxygen requirements, developmental issues, or feeding challenges, all requiring increased medical appointments. If a mother has limited maternity leave, she may be forced to choose whether to use her leave while her infant is critically ill in the hospital, or when the infant is discharged.

If the infant is hospitalized far from home, she may need to choose between being near her vulnerable infant to provide her own vital breast milk, or returning to work. Returning to work with a critically ill infant in the hospital may impact both her work performance and her ability to express milk. The mother may also be in the early weeks postpartum herself, and not yet physically recovered from giving birth.

Mothers of critically ill infants and their partners need longer leave than may be typically provided. For example, 12 weeks of leave may be insufficient, as all or most of that time may be spent prenatally in observation or bed rest, or for many infants, in the hospital, particularly the intensive care unit. Leave for the other parent would be particularly important in these circumstances to support the mother to provide her milk, which is vital for the infant's survival, and to help with older children or other household duties.

With multiple gestations, the amount of leave is usually the same as with a singleton birth, as leave is generally per birth, not per child born. The ILO's Maternity Protection Convention (R191) recommends that paid maternity leave be extended in cases of multiple gestations.³³ Such infants may be preterm, low birthweight, and require more time for parents to adapt and establish breastfeeding and other normal routines. In addition, some mothers will require leave late in pregnancy to minimize the risk of complications such as preterm birth. However, extended leave for maternal disability may be possible in some countries for this purpose, if early paid leave during pregnancy is not an option.

Workplace setting

Societal structures, including employment and discrimination laws, influence workplace policies and whether policies at work are supportive or discriminatory. Returning to work or school can be a difficult transition, especially for mothers of younger infants. Those mothers who can work from home, who can work part-time, or have access to onsite childcare or who have worksite policies that allow them to bring their infants to work will be able to adapt more readily.⁸³ Mothers who work away from their infants will need time and suitable, private, and hygienic space for milk expression, which is in reasonable proximity to their actual work location.

Employers have a role in ensuring that mothers returning to work receive adequate breastfeeding breaks and have appropriate facilities in which to express milk, or have the ability to directly breastfeed, to supply milk to their infants and maintain their milk production. Rates of breastfeeding after returning to employment are quite low worldwide.⁸⁴ Only 20% of countries have mandatory provisions for both paid breastfeeding breaks and adequate breastfeeding space (UNICEF/WHO target of 40% by 2030).³⁴

In a recent study from Nepal, both breastfeeding and maternal work together were important for survival in children younger than 36 months,⁸⁵ suggesting that supporting working breastfeeding mothers would be particularly important in LMICs. Government attention should also be paid to the needs of informal workers, including measures to enable proximity to the infant, improve safety of physical work environments, and to alleviate family poverty.⁷⁸

A mother's employer must provide sufficient support to enable her to take leave. Those women with low-wage jobs, little power or agency at their workplace, or those with particularly demanding jobs may need to return to employment very soon after giving birth. In an era where more employees are working online, some are expected to be checking in with work even while on maternity leave, and are never truly off duty.

In India, where women construction workers are common, such women work in construction sites alongside their newborns, often returning to employment shortly after giving birth, as they are ineligible for maternity leave and are dependent on their low wages to survive. With only two breastfeeding breaks per day, their infants suffer high rates of malnutrition.⁸⁶ In this situation, working with one's infant nearby is of necessity, and is clearly inferior to paid maternity leave.

Please refer to ABM's 2013 Position Statement on Breastfeeding Support for Mothers in Workplace Employment or Educational Settings.²⁵

Childcare setting

In order for a mother to return to work, a mother's social support system and childcare provisions must be in place, especially if she wants to breastfeed. Childcare providers also need appropriate competence to accommodate breastfeeding mothers, and parents need to know how to evaluate providers for such competence.^87,88 Subsidized child care can minimize the motherhood penalty by allowing mothers to more easily return to work, should they desire.⁵⁸ Subsidized child care in Sweden is part of a systemized program to promote gender equity, along with paid leave for both parents.⁷⁰

Onsite childcare might be beneficial in some situations, but in other situations, onsite childcare does not work in practice, and thus mothers may be forced to wean early. For example, in garment factories in Bangladesh, 2 months maternity leave and onsite childcare may be provided, but the childcare site is only open when buyers visit or is unstaffed, so is not a real option, and thus many women wean their infants upon returning to work.⁸⁹ Thus, longer and adequately paid maternity leave is superior to working in such conditions.

Recommendations

(1)

Mothers should not be forced to stop breastfeeding because they must return to work.

(2)

Mothers should not have to choose between working and being with their critically ill newborns and providing them with breast milk essential to their health and growth. Mothers who live far from their hospitalized newborns should be provided space to sleep so as not to be separated from their newborns, and efforts should be made to support their entire family.

(3)

ABM recommends 6 months (26 weeks) leave with 100% pay, and urges WHO to advocate for this measure in UN agencies including the ILO. The pay should be provided by the government, not employers. At the very least, ABM recommends legislation allowing leave of 18 weeks per birth with 100% pay, a current ILO recommendation.

(4)

Paid leave should be flexible and holistic, accounting for varying circumstances, such as the birth of sick and preterm infants, multiple gestations, adoption, pregnancy, and postpartum complications, including stillbirth. Couples should be allowed to take parental leave in a manner that best suits their situation, whether that is simultaneously or sequentially, and may be many months after the birth of the child, or after addition of a new child from adoption, fostering, or other means.

(5)

Parental leave may be best viewed as part of a package of paid leave across the lifespan, as most adults will require paid leave at some point to recover from illness, surgery, or to care for a sick or dying loved one.

(6)

One-time payments to families per registered birth, regardless of immigration or employment status, may help provide a safety net for informal workers, unemployed mothers with no other source of financial support, infants who do not qualify for citizenship, or whose mothers are undocumented immigrants.

(7)

Workplace accommodations should be as flexible as possible, allowing for part-time work, working from home, onsite childcare, and babies-at-work policies, in addition to break time and space for expressing breast milk.

(8)

Minimum wage structures should be sufficient to relieve the strain on parents, alleviating the need to work long hours and early termination of otherwise legally supported parental leave.

(9)

Providing equitable paid maternity leave must be primarily accomplished by governments, and cannot be accomplished by employers alone.

(10)

Maternity leave, workplace accommodation for breastfeeding breaks, and milk expression, childcare, and flexible working and parental leave options should all support the WHO recommendation for exclusive breastfeeding for 6 months with continued breastfeeding for 2 years or beyond.

Summary

An adequate amount of paid maternity leave for all women is important for all of society. Paid leave that realistically incentivizes both parents to take leave has multiple benefits for families and society. Including paid leave as part of a package of care along the lifespan can help fuel economic growth. Lack of paid leave increases the risk of family and childhood poverty and gender inequality, and increases the risk of maternal depression among other adverse maternal outcomes. Paid leave is an essential part of a comprehensive package of breastfeeding support needed to enable mothers to breastfeed.

Future Directions

The changing landscape of workplaces, online work, wage structures, and milk expression technology necessitates ongoing reassessment of breastfeeding and working. Income inequalities and low wages create particular challenges for families with infants. In addition, ever changing world events are likely to spur large and fluctuating number of migrants, who may be ineligible for government benefits. The world's governments must be increasingly prepared to holistically support breastfeeding within these challenging conditions.

Footnotes

Authors' Contributions

All authors contributed to the conception and drafting of the article.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

References

Heymann

, Sprague

, Nandi

, et al. Paid parental leave and family wellbeing in the sustainable development era. Public Health Rev, 2017; 38:21.

International Labour Organisation. C183—Maternity Protection Convention, 2000 (No. 183). Available from: https://www.ilo.org/dyn/normlex/en/f?p=NORMLEXPUB:12100:0::NO::P12100_ILO_CODE:C183 [Last accessed: May 29, 2023].

Office of the High Commissioner for Human Rights. Convention on the Elimination of All Forms of Discrimination against Women, New York, 18 December 1979. 2023. Available from: https://www.ohchr.org/en/instruments-mechanisms/instruments/convention-elimination-all-forms-discrimination-against-women [Last accessed: June 12, 2023].

Navarro-Rosenblatt

, Garmendia

. Maternity leave and its impact on breastfeeding: A review of the literature. Breastfeed Med, 2018; 13(9):589–597.

Meek

, Noble

, Section on Breastfeeding. Policy Statement: Breastfeeding and the use of human milk. Pediatrics, 2022; 150(1).

Perez-Escamilla

, Tomori

, Hernandez-Cordero

, et al. Breastfeeding: Crucially important, but increasingly challenged in a market-driven world. Lancet, 2023; 401(10375):472–485.

Horta

, Loret de Mola

, Victora

. Breastfeeding and intelligence: A systematic review and meta-analysis. Acta Paediatr, 2015; 104(Suppl. 467):14–19.

Rollins

, Bhandari

, Hajeebhoy

, et al. Why invest, and what it will take to improve breastfeeding practices?. Lancet, 2016; 387(10017):491–504.

Walters

, Phan

LTH

, Mathisen

. The cost of not breastfeeding: Global results from a new tool. Health Policy Plan, 2019; 34(6):407–417.

10.

Holla-Bhar

, Iellamo

, Gupta

, et al. Investing in breastfeeding—The world breastfeeding costing initiative. Int Breastfeed J, 2015; 10:8.

11.

Smith

JP.

“Lost milk?”: Counting the economic value of breast milk in gross domestic product. J Hum Lact, 2013; 29(4):537–546.

12.

Gilmore

, Knickmeyer

, Gao

. Imaging structural and functional brain development in early childhood. Nat Rev Neurosci, 2018; 19(3):123–137.

13.

Gialeli

, Panagopoulou

, Liosis

, et al. Potential epigenetic effects of human milk on infants' neurodevelopment. Nutrients, 2023; 15(6).

14.

Lester

, Conradt

, LaGasse

, et al. Epigenetic programming by maternal behavior in the human infant. Pediatrics, 2018; 142(4):e20180194.

15.

World Health Organization. Infant and young child feeding. 9 June, 2021. Available from: https://www.who.int/news-room/fact-sheets/detail/infant-and-young-child-feeding [Last accessed: June 8, 2022].

16.

de Lauzon-Guillain

, Thierry

, Bois

, et al. Maternity or parental leave and breastfeeding duration: Results from the ELFE cohort. Matern Child Nutr, 2019; 15(4):e12872.

17.

Vermeer

, Groeneveld

. Children's physiological responses to childcare. Curr Opin Psychol, 2017; 15:201–206.

18.

Pereira Gray

, Dean

. Childcare outside the family for the under-threes: Cause for concern?. J R Soc Med, 2020; 113(4):140–142.

19.

Meier

, Patel

, Hoban

, et al. Which breast pump for which mother: An evidence-based approach to individualizing breast pump technology. J Perinatol, 2016; 36(7):493–499.

20.

Bartick

, Schwarz

, Green

, et al. Suboptimal breastfeeding in the United States: Maternal and pediatric health outcomes and costs. Matern Child Nutr, 2017; 13(1):3–6; Erratum in Matern Child Nutr 2017:2013(2012):null.

21.

Feldman-Winter

, Van

, Varadi

, et al. Academy of breastfeeding medicine position statement: Breastfeeding as a basic human right. Breastfeed Med, 2022; 17(8):633–634.

22.

World Alliance for Breastfeeding Action. Breastfeeding and Work: Framework for Action on Contemporary Solutions to an Age-Old Problem. World Alliance for Breastfeeding Advocacy: Penang, Malaysia; 2015.

23.

International Labour Organisation. Care at Work: Investing in Care Leave and Services for a More Gender Equal World of Work, Executive Summary. International Labour Organisation: Geneva; 2022.

24.

Galtry

Strengthening the human rights framework to protect breastfeeding: A focus on CEDAW. Int Breastfeed J, 2015; 10:29.

25.

Marinelli

, Moren

, Taylor

, et al. Breastfeeding support for mothers in workplace employment or educational settings: Summary statement. Breastfeed Med, 2013; 8(1):137–142.

26.

International Labour Organisation. C003—Maternity Protection Convention, 1919, (No. 3). Available from: https://www.ilo.org/dyn/normlex/en/f?p=NORMLEXPUB:12100:0::NO::P12100_INSTRUMENT_ID:312148 [Last accessed: May 29, 2023].

27.

UNICEF. Breastfeeding Support in the Workplace: A Global Guide for Employers. UNICEF: New York, NY, USA; 2020.

28.

Global Breastfeeding Collective

, ICEF

World Health Organization

. Breastfeeding and Family-Friendly Policies. Global Breastfeeding Collective, UNICEF, World Health Organization: New York, NY, USA; 2019.

29.

UNICEF. Family-Friendly Policies: A Global Survey of Business Policy-Working Paper. UNICEF: Geneva; 2020.

30.

UNICEF. Family-Friendly Policies: Redesigning the Workplace of the Future- A Policy Brief. UNICEF: New York, NY, USA; 2019.

31.

United Nations Global Compact. Family friendly policies. Available from: https://unglobalcompact.org/academy/families-friendly-policies [Last accessed: August 3, 2023].

32.

Wolf

, Monnat

, Montez

. Effects of US state preemption laws on infant mortality. Prev Med, 2021; 145:106417.

33.

International Labour Organisation. R191—Maternity Protection Recommendation, 2000 (No. 191). Available from: https://www.ilo.org/dyn/normlex/en/f?p=1000:12100:::NO:12100:P12100_INSTRUMENT_ID:312529 [Last accessed: July 5, 2023].

34.

Global Breastfeeding Collective

, ICEF

Wolrd Health Organization

. Global Breastfeeding Scorecard 2022: Protecting Breastfeeding Through Further Investings and Policy Actions. UNICEF: New York, NY, USA; 2022.

35.

United Nations. SDG Indicators: Global Indicator Framework for Sustainable Development Goals and Targets of the 2030 Agenda for Sustainable Development. United Nations: New York, NY, USA; 2017.

36.

Nandi

, Hajizadeh

, Harper

, et al. Increased duration of paid maternity leave lowers infant mortality in low- and middle-Income countries: A quasi-experimental study. PLoS Med, 2016; 13(3):e1001985.

37.

Daku

, Raub

, Heymann

. Maternal leave policies and vaccination coverage: A global analysis. Soc Sci Med, 2012; 74(2):120–124.

38.

Hajizadeh

, Heymann

, Strumpf

, et al. Paid maternity leave and childhood vaccination uptake: Longitudinal evidence from 20 low-and-middle-income countries. Soc Sci Med, 2015; 140:104–117.

39.

Ueda

, Kondo

, Takada

, et al. Maternal work conditions, socioeconomic and educational status, and vaccination of children: A community-based household survey in Japan. Prev Med, 2014; 66:17–21.

40.

Berger

, Hill

, Waldfogel

. Maternity leave, early maternal employment, and child health and development in the US. Econ J, 2005; 115(February):F29–F47.

41.

McGovern

, Dowd

, Gjerdingen

, et al. Time off work and the postpartum health of employed women. Med Care, 1997; 35(5):507–521.

42.

Dagher

, McGovern

, Dowd

. Maternity leave duration and postpartum mental and physical health: Implications for leave policies. J Health Polit Policy Law, 2014; 39(2):369–416.

43.

Chatterji

, Markowitz

. Family leave after childbirth and the mental health of new mothers. J Ment Health Policy Econ, 2012; 15(2):61–76.

44.

Mandal

The effect of paid leave on maternal mental health. Matern Child Health J, 2018; 22(10):1470–1476.

45.

Baker

, Milligan

. Maternal employment, breastfeeding, and health: Evidence from maternity leave mandates. J Health Econ, 2008; 27(4):871–887.

46.

Chuang

, Chang

, Chen

, et al. Maternal return to work and breastfeeding: A population-based cohort study. Int J Nurs Stud, 2010; 47(4):461–474.

47.

Huang

, Yang

. Paid maternity leave and breastfeeding practice before and after California's implementation of the nation's first paid family leave program. Econ Hum Biol, 2015; 16:45–59.

48.

Kottwitz

, O'ppermann

, Spiess

. Parental leave benefits and breastfeeding in Germany: Effects of the 2007 reform. Rev Econ Househ, 2016; 14(4):859–890.

49.

Ogbuanu

, Glover

, Probst

, et al. The effect of maternity leave length and time of return to work on breastfeeding. Pediatrics, 2011; 127(6):e1414–e1427.

50.

Heymann

, Gerecke

, Chaussard

. Paid health and family leave: The Canadian experience in the global context. Can J Public Health, 2010; 101(Suppl 1):S9–S15.

51.

Smith

JP.

Paying for care in Australia's ‘wage earners' welfare state’: The case of child endowment. In: Tax, Social Policy and Gender. (Stewart M. ed.) ANU Press: Canberra; 2017.

52.

Isaacs

, Healy

, Peters

. Paid Family Leave in the United States. Urban Institute: Washington; 2017.

53.

OECD. Babies and Bosses—Reconciling Work and Family Life. OECD: Paris; 2007.

54.

Davison

, Blackburn

. The case for offering paid leave: Benefits to the employer, employee, and society. Compens Benefits Rev, 2023; 55(1):3–18.

55.

Chen

The growing costs and burden of family caregiving of older adults: A review of paid sick leave and family leave policies. Gerontologist, 2014; 56(3):391–396.

56.

Waldfogel

The family gap for young women in the United States and Britain: Can maternity leave make a difference?. J Labor Econ, 1998; 16(3):505–545.

57.

Rasmussen

AW.

Increasing the length of parents' birth-related leave: The effect on children's long-term educational outcomes. Labour Econ, 2010; 17(1):91–100.

58.

Budig

, Misra

, Boeckmann

. Work-family policy trade-offs for mothers? Unpacking the cross-national variation in motherhood earnings penalties. Workk Occup, 2016; 43(2):119–177.

59.

Blau

, Kahn

. Female labor supply: Why is the United States falling behind?. Am Econ Rev, 2013; 103(3):251–256.

60.

Swedish Institute. In Sweden, it's possible to combine career with family life. Here's why. 2022. Available from: https://sweden.se/life/society/work-life-balance [Last accessed: May 29, 2023].

61.

Beria

Maternity benefits for building and construction workers in India: A regulatory quagmire. The Journal of Indian Law and Society Blog. Available from: https://jils.blog/2022/01/27/maternity-benefits-for-building-and-other-construction-workers-in-india-a-regulatory-quagmire/ [Last accessed: July 5, 2023].

62.

Government of Canada. EI Maternity and parental benefits. 2023. Available from: https://www.canada.ca/en/services/benefits/ei/ei-maternity-parental.html [Last accessed: May 29, 2023].

63.

UK Government. Statutory maternity pay and leave: Employer guide. Available from: https://www.gov.uk/employers-maternity-pay-leave#:~:text=The%20first%2026%20weeks%20is,as%20'Additional%20Maternity%20Leave’ [Last accessed: July 3, 2023].

64.

Australian

Government

, Fair Work

Ombudsman

. Paid parental leave. Available from: https://www.fairwork.gov.au/leave/maternity-and-parental-leave/paid-parental-leave#australian-government-plps [Last accessed: July 2, 2023].

65.

Bearak

, Popinchalk

, Ganatra

, et al. Unintended pregnancy and abortion by income, region, and the legal status of abortion: Estimates from a comprehensive model for 1990–2019. Lancet Glob Health, 2020; 8(9):e1152–e1161.

66.

UNFPA (United Nations Population Fund). State of the World Population 2022:-Seeing the Unseen: The Case for Action in the Neglected Crisis of Unintended Pregnancy. United Nations: New York, NY, USA; 2022.

67.

World Population Review. Countries with birthright citizenship 2023. Available from: https://worldpopulationreview.com/country-rankings/countries-with-birthright-citizenship [Last accessed: May 29, 2023].

68.

Augstin

Letting foreign workers get pregnant: Bosses say no, union says yes. Free Malaysia Today. Available from: www.freemalaysiatoday.com/category/nation/2018/03/28/letting-foreign-workers-get-pregnant-bosses-say-no-union-says-yes/ [Last accessed: July 5, 2023].

69.

Loganathan

, Rui

, Pocock

. Healthcare for migrant workers in destination countries: A comparative qualitative study of China and Malaysia. BMJ Open, 2020; 10(12):e039800.

70.

Haas

, Hwang

Programs and policies promoting women's economic equality and men's sharing of child care in Sweden. In: Organizational Change and Gender Equity: International Perspectives on Fathers and Mothers at the Workplace. (Haas L, Hwang P, Russell G. eds.) Sage: Thousand Oaks; 2000; pp. 133–161.

71.

Nepomnyaschy

, Waldfogel

. Paternity leave and fathers' involvement with their young children: Evidence from the American Ecls-B. Commun Work Fam, 2007; 10(4):427–453.

72.

O'Brien

Fathers, parental leave policies, and infant quality of life: International perspectives and policy impact. Ann Am Acad Pol Soc Sci, 2009; 624(1):190–213.

73.

Flacking

, Dykes

, Ewald

. The influence of fathers' socioeconomic status and paternity leave on breastfeeding duration: A population-based cohort study. Scand J Soc Med, 2010; 38(4):337–343.

74.

Koslowski

, Blum

, Dobrotić

, et al. International Review of Leave Policies and Research 2022. 2022. Available from: http://www.leavenetwork.org/lp_and_r_reports/

75.

Gribble

, Smiith

, Gammeltroft

, et al. Breastfeeding and infant care as ‘sexed’ care work: Reconsideration of the three Rs to enable women's rights, economic empowerment, nutrition and health: Front. Public Health 2023:11:1181229.

76.

Grimshaw

, Rubery

The Motherhood Pay Gap: A Review of the Issues, Theory, and International Evidence. International Labour Organization: Geneva; 2015.

77.

Horwood

, Surie

, Haskins

, et al. Attitudes and perceptions about breastfeeding among female and male informal workers in India and South Africa. BMC Public Health, 2020; 20(1):875.

78.

Chowdhury

, Surie

, Bhan

. Breastfeeding knowledge and practices of working mothers in the informal economy in New Delhi: A formative study to explore new intervention pathways towards improved maternal and child health outcomes. Soc Sci Med, 2021; 281:114070.

79.

Bhan

, Ravindranath

, Rai Chowdhuray

, et al. Deficits in Decent Work: Employer Perspectives and Practices on the Quality of Employment in Domestic Work in Urban India. International Labour Organization: Geneva; 2022.

80.

Martin

, Broadway

, Kalb

, et al. PPL Evalution: Final Report. The University of Queensland: Brisbane; 2014.

81.

W.H.O. Immediate KMC Study Group, Arya S, Naburi H, et al. Immediate “Kangaroo Mother Care” and survival of infants with low birth weight. N Engl J Med, 2021; 384(21):2028–2038.

82.

Conde-Agudelo

, Diaz-Rossello

. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database Syst Rev, 2016; 2016(8):CD002771.

83.

Smith

, Javanparast

, Craig

. Bringing babies and breasts into workplaces: Support for breastfeeding mothers in workplaces and childcare services at the Australian National University. Breastfeed Rev, 2017; 25(1):45–56.

84.

Dutheil

, Mechin

, Vorilhon

, et al. Breastfeeding after returning to work: A systematic review and meta-Analysis. Int J Environ Res Public Health 2021;18(16).

85.

Timilsina

, Sawangdee

, Bhandari

, et al. Breastfeeding and female labor force participation: The probability of survival of children in Nepal under 3 years old. Int Breastfeed J, 2023; 18(1):24.

86.

Ravindranath

How labour conditions at construction sites are leading to higher rates of child malnutrition. Scroll.in. 2019. Available from: https://scroll.in/article/938248/how-labour-conditions-at-construction-sites-are-leading-to-higher-rates-of-child-malnutrition. [Last accessed: July 5, 2023].

87.

Lundquist

, McBride

, Donovan

, et al. An exploratory look at the role of childcare providers as a support and resource for breastfeeding mothers. Breastfeed Med, 2019; 14(5):313–319.

88.

Roig-Romero

, Livingston

, Schafer

, et al. The state of our breastfeeding friendly childcare programs: Ten years after the 2011 Surgeon General's Call to Action to Support Breastfeeding. J Hum Lact, 2022; 38(3):477–486.

89.

Awaj Foundation. Maternity Rights and Childcare in Bangladesh. Awaj Foundation: Dhaka; 2019.

90.

ABM protocols expire 5 years from the date of publication. Content of this protocol is up to date at the time of publication. Evidence-based revisions are made within 5 years or sooner if there are significant changes in the evidence.