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Do workplace policies influence a woman's decision to breastfeed?

Winegar, Rhonda DNP, RN, FNP-BC, CPN, CCRN; Johnson, Alisha MSN, RN

doi: 10.1097/01.NPR.0000513338.92438.65
Feature: MATERNAL HEALTH: DNP SPECIAL ISSUE

Abstract: This literature review addresses workplace breastfeeding policies in the United States. Breastfeeding yields many important benefits to both mother and infants, yet workplace barriers contribute to low rates of breastfeeding. NPs often serve as the initial point of education for new mothers and may impact decisions to breastfeed.

This literature review addresses workplace breastfeeding policies in the United States. Breastfeeding yields many important benefits to both mother and infants, yet workplace barriers contribute to low rates of breastfeeding.

Rhonda Winegar is an NP at Austin Neurology & Sleep Associates, Austin, Tex.

Alisha Johnson is a clinical assistant professor at St. David's School of Nursing, Texas State University, Round Rock, Tex.

The authors have disclosed that they have no financial relationships related to this article.

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The U.S. Department of Labor reports that 69.9% of working mothers are in the labor force and are the fastest-growing segment of the U.S. labor market.1-3 While 75% of individuals in the United States support breastfeeding, only 60% feel that breastfeeding is compatible with working, and only 53% support the idea that employers should provide facilities to encourage working mothers to continue breastfeeding.4 These results suggest that individuals may be supportive of breastfeeding in general but may not always support working mothers who choose to breastfeed.

Healthcare providers have identified breastfeeding as the preferred method of nutrition for infants, with many benefits for both the mother and infant.4 However, there are many reasons working mothers may choose not to breastfeed. Research has shown that workplace barriers contribute to low rates of breastfeeding in the United States and are often the primary reason for early cessation.5

In the United States, breastfeeding is considered a personal choice, and legislation in support of breastfeeding in the workplace is more limited than in most other countries.6 In order to effectively integrate the dual roles of breastfeeding mother and employee, women need the support of their employers as well as encouragement and advice from trusted healthcare providers.

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Background

Women prior to the 20th century had no choice but to breastfeed their infants or hire a wet nurse because feeding alternatives were not readily available. Formula was developed in the 1920s, and marketing focused on formula as an easy and fast method of feeding infants that was clean and safe. Pediatricians even “highly recommended” formula in the 1930s and 1940s.7

As the use of formula continued to rise, breastfeeding dropped; by the 1970s, only 23% of women chose breastfeeding, and only 10% continued breastfeeding their infants to age 6 months.4 A rebound in breastfeeding occurred during the 1980s due to public health campaigns that addressed the benefits of breastfeeding and provided training and support for breastfeeding women.4 Today, the majority of infants in the United States are supplemented with formula by age 6 weeks (53%), and this number increases to 90% of infants being supplemented at age 6 months.8

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Benefits of breastfeeding

A decrease in the incidence of ovarian and breast cancer has been noted in lactating mothers.9 Women who do not breastfeed may have difficulty losing pregnancy weight, which may predispose them to type 2 diabetes mellitus, metabolic syndrome, and myocardial infarction.9 There is a delay in the return of fertility in women who choose to breastfeed, which may lead to fewer unplanned pregnancies and less time needed away from work.4 Mother-child bonding is also enhanced through breastfeeding.10-12

Breastfed infants have fewer illnesses and severity of illnesses as compared with formula-fed infants.7 Stuebe reported that infants who are not breastfed have an increased risk of developing leukemia, diabetes mellitus (types 1 and 2), sudden infant death syndrome, asthma, and childhood obesity.13 Infants who are fed formula also have more infectious diseases during the first year of life, especially respiratory illnesses, such as Haemophilus influenzae and Streptococcus pneumoniae.4 The most prevalent infection seen in infants is otitis media, and the risk of developing this infection is increased twofold for infants who are fed formula.4,12

According to the U.S. Breastfeeding Committee, direct healthcare cost savings of $13 billion would be achieved if 90% of women were able to breastfeed as medically recommended.9 Research has shown that healthcare costs in the United States increased over $1 billion a year related to the incidence of medical diseases in infants who are fed formula. These costs may have been decreased if mothers had chosen to breastfeed.4

Society in general benefits from mothers and infants who are healthier. Breastfeeding is more ecologically friendly and places less burden on the environment. There is also less cost to society as compared with formula feeding due to the reduced need for disposal of cans, bottles, and other associated items needed for formula feeding.4

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Why women choose not to breastfeed

It is no longer the norm for a mother to give up a job in order to stay home and care for her children. Most women return to work within 6 months of giving birth, and one-third of working mothers will return to work within 3 months of delivery.2 A seminal 2001 report by Christrup found that 85% of working women would become pregnant at some point during their employment.4 Several studies have identified employment as the greatest barrier to breastfeeding success for working mothers.4,8,14,15

The majority of women choose breastfeeding at birth (73.9%), but this number drops dramatically once they return to work.11 The odds of terminating breastfeeding are 2.18 times greater for women who return to work as compared with nonworking mothers. In addition, employed women have a 9% lower rate of breastfeeding 6 months after delivery.11,12

Wolf reported that women are often uncomfortable breastfeeding in public, and society is not comfortable seeing women breastfeed their infants.8 The rates of breastfeeding dropped significantly in the 1940s, 1950s, and 1960s due to women's fear of exposing themselves to males inadvertently as well as the fear of affecting the visual appeal of the breasts due to breastfeeding (sagging, decreased muscle tone, and elongated nipples).8

Sociocultural factors may play into the decision to breastfeed. Miller-Bellor reported the incidence of breastfeeding among different races and found that 86.4% of Asian infants were breastfed, compared with 80.6% of Hispanic infants, 77.7% of White infants, and 58.7% of Black infants.1 Almost one-third of breastfeeding women surveyed thought mothers who used formula were “selfish and lazy,” but 83% thought they were looked down upon by mothers who used formula.1,8

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Workplace issues

Workplace support is needed to ensure women continue to breastfeed after returning to work, as only 40% of women will continue breastfeeding upon return.16 The CDC identified three barriers to breastfeeding in the workplace: lack of supplied refrigerators for breast milk storage, inadequate breaks to use breast pumps, and concern regarding employer and coworker support.2

Incidents of harassment, lawsuits, and employment termination have been noted in the workplace due to breastfeeding.17 The U.S. Department of Health and Human Services has monitored employer support and began reporting as early as 1984 that employers were not supportive of women who chose to breastfeed.1 There is a noted bias in many workplaces against working mothers, especially in male-dominated fields of employment.14 Working mothers may be perceived as being undependable, which may affect promotions.14 Women may also choose less desirable jobs that are more accepting of family obligations.

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Workplace breastfeeding policies

Corporations with lactation programs in place have shown a 75% continuation rate for employees who have chosen to breastfeed until at least age 6 months.2 Company image is enhanced when workplace policies contribute to employee perception of support.16

Weber and colleagues identified benefits of encouraging working women to breastfeed, which include decreased turnover of staff, less time off for new mothers due to infant-related illnesses, and improved overall morale and job productivity.16 Healthy People 2020 added a specific objective to increase the proportion of employers who have a worksite lactation program.

The costs of supporting breastfeeding employees are relatively low. While breaks are needed for breastfeeding, employers are not required to pay for additional breaks above what is usually paid to all employees for approved breaks.18 Time needed to use a breast pump may be accomplished by allowing for a flexible work schedule, break times, or even job sharing.2 Few modifications of the physical employment site are required, as only a private room for breast milk expression is required. Women may request a refrigerator for breast milk storage; however, breast milk can be kept at room temperature for up to 8 hours, and an insulated container with ice packs can be used to prevent spoilage.15

Although there may be costs associated with employer training and related materials, this information can be obtained from community resources at no cost.19 The initial investment is negligible when compared with the reduction in employee tardiness and absenteeism as well as decreased healthcare costs. These savings may also affect the employer's insurance plans, and employee retention will lead to a decrease in the cost of recruiting and training new staff.4

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Current legislation

In spite of the demonstrated benefits of lactation policies, Mason and colleagues state it is unlikely that employers will adopt promotion programs unless there are regulations to enforce these policies.20 Globally, the United States lags behind all industrialized countries and only provides paid maternity leave, whereas 145 countries provide paid leave.6 Heymann and colleagues identified 130 countries that had a policy guaranteeing paid breastfeeding breaks, and 111 of those countries specified the actual time allotted for breastfeeding breaks in their policies.6,21 These policies increased the rate of exclusive breastfeeding of infants under age 6 months by 8.86%.6 There is a strong correlation between duration of breastfeeding and national policy, as it sets guidelines and norms for employers.21

Multiple efforts to address employer support concerns have been attempted at the federal level in 2001, 2007, and most recently in 2011 with the proposed Breastfeeding Promotion Act. This Act recommended protecting breastfeeding by new mothers and offered tax incentives to employers who promoted breastfeeding. This bill was introduced but never enacted into law, has not yet made it into law, and the latest action on this bill was on September 8, 2011, at which time it was referred to the Subcommittee on Health, Employment, Labor, and Pensions (www.govtrack.us/congress/bills/112/hr2758).

Federal legislation in place that has attempted to address breastfeeding concerns includes the Pregnancy Discrimination Act (PDA) of 1978, the Family and Medical Leave Act (FMLA) of 1994, and most recently, the Affordable Care Act (ACA) of 2010 (see Breastfeeding legislation resources).6 In spite of these protections, employers are not required under federal law to have a sick leave policy and are not required to accommodate pregnancy or breastfeeding.6

The FMLA was designed to provide protection for pregnancy, childbirth, and care of ill children by allowing up to 12 weeks of unpaid leave. However, the majority of mothers cannot afford to go without a paycheck, and therefore do not take the full amount of time allotted.6 This 12-week allowance under FMLA is less than the 12-month time frame recommended for breastfeeding by the American Academy of Pediatrics.22 FMLA is not applicable if the employer has fewer than 50 employees; according to the U.S. Census Bureau in 2012, 16.7% of workers were employed by small enterprises (20 to 99 employees), and 17.6% of workers were employed by very small enterprises (fewer than 20 employees).6,23

The Break Time for Nursing Mothers law, as part of the ACA, went into effect in 2010 and requires employers to provide a suitable area to breastfeed and outlines that a bathroom is not an acceptable site. The ACA health plan coverage guidelines help ensure that women receive counseling and education from trained lactation professionals during pregnancy and after delivery and the use of breast pumps with no insurance deductible or copayment.

The Break Time for Nursing Mothers provision of ACA mandates employers designate “reasonable” time and accommodations for expressing milk at work; however, the definition of “reasonable” is left up to the employer, and this statute is not applicable if the employer has fewer than 50 employees.5 The protection afforded by this law only lasts until the employee's child is age 1.18

Forty-nine states in the United States had legislation in relation to breastfeeding as of 2016.24 State legislation addressing breastfeeding rights has continued to expand, and 37% of states encouraged or required employers to provide break time and accommodations as of 2013.24 However, laws vary from state to state, and many breastfeeding women are not aware of the laws in their states.20

Historically, the courts have not supported breastfeeding and have stated that breastfeeding is not a “pregnancy-related medical condition” under the PDA. Similarly, courts have also found breastfeeding discrimination is not illegal under Title VII because women who choose to breastfeed are not the same as men.5 Furthermore, enforcement and monitoring of adherence to these federal laws are left up to local and state authorities, leading to great variance and inconsistency in application.25

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Breastfeeding support resources

Many organizations promote breastfeeding, including La Leche League and Women, Infants and Children (WIC). La Leche League is a lactation promotion organization that aims to educate women on breastfeeding and serve women through lobbying and advocacy to increase breastfeeding awareness and access. WIC is a state-run program supported by federal grants and serves to promote breastfeeding via education and counseling as well as to provide breast pumps and supplies to women who qualify.

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The role of the NP in breastfeeding promotion

The NP often serves as the initial point of contact for both education and information for pregnant women and may have the ability to impact their decision to breastfeed. Brand, Kothari, and Stark reported that healthcare provider support positively influences both the initiation and duration of breastfeeding.12 Dykes stated that a healthcare provider's attitude, knowledge, and skill set can influence a breastfeeding mother, and when the provider possesses confidence, it is more likely to positively promote and support breastfeeding.26

In industrialized countries, healthcare providers have exhibited decreased knowledge regarding breastfeeding, ambivalent or negative attitudes, and low levels of proficiency with breastfeeding techniques and education.26 This lack of healthcare provider education indicates a low priority in regards to breastfeeding promotion.26 Healthcare providers responsible for patient care in the postpartum period can have a positive impact on the continuation of breastfeeding by providing continuing education and support.

Face-to-face individualized interactions between the clinician and the patient showed improved results over impersonal communications, such as the use of pamphlets and brochures.12 Emphasis must be placed on the communication of NPs and the mother to ensure that the mother is aware of all information prior to making the decision to breast- or bottle-feed her infant. Breastfeeding is a dynamic process, and the NP must be aware of current issues in breastfeeding at the federal, state, and workplace levels and maintain competency in breastfeeding education, techniques, and strategies. The core competencies required of healthcare professionals for breastfeeding care and services can be accessed online at www.usbreastfeeding.org/p/cm/ld/fid=170.

NPs can promote breastfeeding in the workplace by many methods and must stay attuned to resources available for patients who choose to breastfeed and continue working. Returning to work may be daunting for many patients, and a prescription for a quality breast pump may mean the difference between choosing to continue breastfeeding and electing to use formula. Electric breast pumps are expensive, and a prescription written by the NP may allow insurance to cover the cost of purchase or rental, especially if the patient is at risk for developing mastitis, has had problems in the past with letdown or engorgement, or if the infant was born prematurely and has difficulty with suckling.27

A regular program of breast pumping can increase milk production and assist in the treatment of clogged milk ducts.27 Prescriptions may also be written for a lactation consultant. This is important for women who have never breastfed or who have an inverted nipple. Lactation consultants can assist women with different strategies to encourage breastfeeding, and they can also provide suggestions for additional equipment, such as a nipple shield for an inverted nipple. These consultations are addressed in the ACA, and patients covered under the ACA do not pay deductibles for these services.28

NPs can also serve as sounding boards for women who have never breastfed and can offer suggestions for common concerns, such as milk leakage on work clothes. Nursing mothers may not be aware of breast pads or may not know where to purchase them. NPs can also guide women on how to treat the excoriation of nipples and how to decrease the chances of developing sore nipples by providing advice such as letting nipples air dry after feedings, using a well-ventilated nursing bra, not allowing the baby to fall asleep on the breast, and other counseling advice.

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Providing a positive influence

The U.S. government has identified breastfeeding as a National Health Goal in 2000 and 2010 and continues to address this need by including breastfeeding objectives in Healthy People 2020.19 In order for a successful workplace breastfeeding policy to be implemented, the employer should support the employee's desire to breastfeed by designating appropriate breaks to express milk, providing a suitable area for use of the breast pump, and a storage facility for the expressed milk, if requested.

NPs should stay current on current legislation and community resources that are available to support breastfeeding once these patients return to work. Through this role, NPs can positively influence the incidence of breastfeeding and ultimately improve the health of society in general.

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Breastfeeding legislation resources

ACA: Break Time for Nursing Mothers law

www.dol.gov/whd/nursingmothers

Breastfeeding Promotion Act

www.congress.gov/bill/112th-congress/house-bill/2758

Breastfeeding state laws

www.ncsl.org/research/health/breastfeeding-state-laws.aspx

FMLA

www.dol.gov/whd/fmla/fmlaAmended.htm

PDA

www.eeoc.gov/laws/statutes/pregnancy.cfm

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REFERENCES

1. Miller-Bellor CM. Barriers to breastfeeding in male dominated society. Int J Med Med Sci. 2002;2(9):175–180.
2. Centers for Disease Control and Prevention. Support for breastfeeding in the workplace. 2013. http://www.cdc.gov/breastfeeding/pdf/strategy5-support-breastfeeding_workplace.pdf.
3. U.S. Department of Labor, Bureau of Labor Statistics. Employment characteristics of families summary. 2014. http://www.bls.gov/news.release/famee.nr0.htm.
4. Christrup SM. Breastfeeding in the American workplace. Am Univ J Gend Soc Policy Law. 2001;9(3):471–503.
5. Ehrehreich N, Siebrase J. Breastfeeding on a nickel and dime: why the Affordable Care Act's nursing mothers amendment won't help low-wage workers. Michigan J Race Law. 2014;20(65):65–116.
6. Eichner M. Parenting and the workplace: the construction of parenting protections in United States law. Int Breastfeed J. 2008;3:14.
7. Stevens EE, Patrick TE, Pickler R. A history of infant feeding. J Perinat Educ. 2009;18(2):32–39.
8. Wolf JH. Got milk? Not in public! Int Breastfeed J. 2008;3:11.
9. United States Breastfeeding Committee. Workplace accommodations to support and protect breastfeeding. 2010. http://www.usbreastfeeding.org/p/cm/ld/fid=196.
10. McIntyre E, Pisaniello D, Gun R, Sanders C, Frith D. Balancing breastfeeding and paid employment: a project targeting employers, women and workplaces. Health Promot Int. 2002;17(3):215–222.
11. Murtagh L, Moulton AD. Working mothers, breastfeeding, and the law. Am J Public Health. 2011;101(2):217–223.
12. Brand E, Kothari C, Stark MA. Factors related to breastfeeding discontinuation between hospital discharge and 2 weeks postpartum. J Perinat Educ. 2011;20(1):36–44.
13. Stuebe A. The risks of not breastfeeding for mothers and infants. Rev Obstet Gynecol. 2009;2(4):222–231.
14. Poduval J, Poduval M. Working mothers: how much working, how much mothers, and where is the womanhood. Mens Sana Monogr. 2009;7(1):63–79.
15. Amin RM, Said ZM, Sutan R, Shah SA, Darus A, Shamsuddin K. Work related determinants of breastfeeding discontinuation among employed mothers in Malaysia. Int Breastfeed J. 2011;6(1):4.
16. Weber D, Janson A, Nolan M, Wen LM, Rissel C. Female employees' perceptions of organisational support for breastfeeding at work: findings from an Australian health service workplace. Int Breastfeed J. 2011;6:19.
17. Leeming D, Williamson I, Johnson S, Lyttle S. Making use of expertise: a qualitative analysis of the experience of breastfeeding support for first-time mothers. Matern Child Nutr. 2015;11(4):687–702.
18. United States Breastfeeding Committee. Workplace Support in Federal Law. 2016. http://www.usbreastfeeding.org/workplace-law.
19. Department of Health and Human Services. Healthy People 2020: Maternal, Infant, and Child Health. http://www.healthypeople.gov/2020/data-search/Search-the-Data?nid=4864.
20. Mason DJ, Leavitt JK, Chaffee MW. Policy & Politics. 6th ed. St. Louis, MO: Elsevier Saunders; 2012.
21. Heymann J, Raub A, Earle A. Breastfeeding policy: a globally comparative analysis. Bull World Health Organ. 2013;91(6):398–406.
22. American Academy of Pediatrics. AAP reaffirms breastfeeding guidelines. 2012. http://www.aap.org/en-us/about-the-aap/aap-press-room/pages/AAP-Reaffirms-Breastfeeding-Guidelines.aspx.
23. Caruso A. Statistics of U.S. Businesses Employment and Payroll Summary: 2012. 2015. http://www.census.gov/content/dam/Census/library/publications/2015/econ/g12-susb.pdf.
24. Nguyen TT, Hawkins SS. Current state of US breastfeeding laws. Matern Child Nutr. 2013;9(3):350–358.
25. Abdulloeva S, Eyler AA. Policies on worksite lactation support within states and organizations. J Womens Health (Larchmt). 2013;22(9):769–774.
26. Dykes F. The education of health practitioners supporting breastfeeding women: time for critical reflection. Matern Child Nutr. 2006;2(4):204–216.
27. Buckley KM, Charles GE. Benefits and challenges of transitioning preterm infants to at-breast feedings. Int Breastfeed J. 2006;1:13.
28. Affordable Care Act. Breastfeeding support. 2017. http://www.healthcare.gov/search/?q=breastfeeding support.
Keywords:

breastfeeding; child health; legislation; maternal health; patient education

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