Journal of Public Health Advance Access originally published online on July 22, 2006
Journal of Public Health 2006 28(3):183-191; doi:10.1093/pubmed/fdl012
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Breastfeeding works: the role of employers in supporting women who wish to breastfeed and work in four organizations in England
Joanna Kosmala-Anderson, Research Fellow in Psychology1
Louise M. Wallace, Professor of Psychology and Health, Director Health Services Research Centre2
1 Health Services Research Centre, CWG04, Coventry University, Priory Street, Coventry CV1 5FB, UK
2 Health Services Research Centre, GE404, Coventry University, Priory Street, Coventry CV1 5FB, UK
Address correspondence to Louise M. Wallace, E-mail: l.wallace{at}coventry.ac.uk
An important factor influencing duration of breastfeeding is mother’s employment status. The main aim of this study was to determine the experience and views of employees (n = 46) in four large public sector organizations concerning breastfeeding support at work. Participants were recruited if they were employed by one of four public service employers and if they were planning to go on maternity leave in the next 6 months, on maternity leave or within 6 months of return from maternity leave. They completed a questionnaire anonymously. Almost 80% of women wanted to continue breastfeeding after returning to work. However, 90% of all respondents were not aware of any employer policy nor offered any information concerning support to enable breastfeeding after returning to work, despite two organizations having a range of maternity- and breastfeeding-related policies in development and some facilities in place. Almost 90% of respondents stated the employers should do more to support breastfeeding. This should include providing pregnant staff with information about breastfeeding support that they should expect and could therefore plan to use, including access to facilities to express and to store breast milk, to enable them to work flexible hours and to take rest breaks during working hours. Recommendations are made for employers.
Keywords: breastfeeding, emploment, infant feeding, infamt nutrition, maternal health
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Introduction |
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The nutritional, immunological, psychological and economic benefits of breastfeeding are well documented.1 Both UNICEF and The World Health Organization2,3 recommend mothers should breastfeed exclusively for at least 6 months. However, the full benefits of breastfeeding will not be realized if breastfeeding is curtailed by unsupportive employment practices. We report on a survey of the employees of four public sector organizations in England and the recommendations made to address the deficiencies which may have benefits to mothers and babies and to their employers.
There are important differences in health outcomes between those mothers and babies who breastfeed and those who artificially feed.4 Babies who are breastfed are less likely than formula-fed babies to suffer from constipation or diarrhoea5 and also are less prone to childhood diseases including juvenile diabetes, allergies, asthma, eczema, gastrointestinal, urinary and respiratory tract infections. They are less likely to be obese and have high blood pressure later in life.5 Breastfeeding also confers health advantages on the mother by helping her regain her figure and long-term reduction of risks of developing ovarian cancer, premenopausal breast cancer and osteoporosis.6
The early introduction of other foods is of public health concern because it exposes infants to increased infection, particularly diarrhoeal diseases. In some cultures, it may lead to poorer infant nutrition and adversely affect growth rates.7 As work can be essential to economic survival for some families, it is likely that work will take precedence over breastfeeding, leading to early introduction of artificial food and early weaning. Of interest to employers, however, is likely to be the impact on staff absence resulting from higher rates of respiratory, ear and gastrointestinal infections, often a cause of childhood illness and maternal work absence.8 Potentially, enabling female employees to breastfeed when they return to work could impact on absenteeism. Employers may also benefit from retaining skilled female employees, who may consider returning to work rather than leaving, if they are enabled to continue breastfeeding when they work.9 Therefore, it is in the interest of mothers, babies and employers that mothers are enabled to continue to breastfeed when they return to work.
Yet, there is evidence from surveys of breastfeeding duration that employment status and associated employment practices may adversely impact on breastfeeding duration. The UK national infant feeding survey10 found that 19% of those who stopped breastfeeding by 4 months attributed this to the need to return to work, and it was the most often cited reason for cessation (19%) by those who breastfed but ceased between 4 and 6 months (39%). A Scottish Infant Feeding Survey in 2002 found that 28% of new mothers stopped breastfeeding because of returning to work.11 In a Spanish study by Escriba and colleagues, 32% of mothers attributed ‘occupational reasons’ as the cause of stopping breastfeeding.12 Similar results were obtained by Ong and colleagues in a study conducted in Singapore. Working mothers were significantly more likely to stop breastfeeding than non-working mothers, and they most often attributed this to the need to work.13 In a survey conducted in Turkey by Ylmaz and colleagues, the two most important influences on duration of breastfeeding were conditions at work and maternal leave period.14 Results from a study in Brazil show that duration of exclusive breastfeeding was longer among women with support for breastfeeding at work and shorter for those working weekends or shifts.15 A recent study of female military personnel in the United States showed that similar rates of initiation were achieved by active and non-active duty personnel, but significantly more active duty mothers stopped breastfeeding at 4 months.16 However, a cross-sectional study in Kenya showed that among the lowest socioeconomic group of working women, nearly all breastfed (99%), and 89% of the higher socioeconomic group breastfed, but shift patterns compared with fixed hours influenced exclusivity of breastfeeding.17 These results show that the issue of continuing breastfeeding after returning to work is important in different countries. See Table 1.
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A national survey of family growth conducted in the United States in 1988 showed that one-quarter of women employed post-partum made attempts to breastfeed; however, most gave it up about a month after their return to work.18 Another influential factor is the availability of maternity leave. Several studies show that women who breastfed also had longer maternity leave in comparison with women who formula fed from the beginning.19–21 For examp1e, mothers who breastfed had averaged 3.4 months of maternity leave, whereas those who formu1a fed averaged 2.3 months.19 The duration of breastfeeding is also influenced by the duration and flexibility of employment.14,15 Women who were employed part-time achieved longer duration rates than those who worked full-time.19,20 In Nairobi, Kenya, mothers surveyed between 4 and 12 months postpartum achieved 94.1% breastfeeding, supported by opportunities to feed their child in breaks or while at work.17 Such flexible work practices are generally not available in developed countries.
While allowing more flexibility in organizing the total hours worked and shortening the hours worked in the immediate period after return to work are obvious remedies open to most employers, there are studies that describe the active health promotion efforts of employers. It is suggested that women are more likely to continue to breastfeed after entering employment when lactation rooms and breast pumps are available in their workplace.8,21 Job-related stress may limit women’s ability to express breast milk for an infant feeding.1 Cohen and Mrtek describe the positive impact on breastfeeding of an employer providing lactation rooms and breast pumps as a part of support programme, such that breastfeeding duration among employees matched women who do not work.8 Approximately 75% of mothers who took part in their survey were able to maintain breastfeeding for at least 6 months after returning to work. A more intensive prenatal, perinatal and postnatal programme is described by Cohen and Mrtek, as summarized in Table 1.22 Five Californian companies provided lactation support including a preparatory class about breastfeeding, information to supervisors, access to a lactation consultant and access to rooms and equipment for pumping and storage of breast milk. Results showed that 97.5% of those enrolled initiated breastfeeding and 57.8% continued for at least 6 months, whereas maternity leave was on average 2.8 months. A programme to support fathers is described by Cohen and others.23 Ortiz and colleagues describe a lactation programme offered to five corporations, which shows the positive impact of lactation support and the provision of equipment and facilities.24 However, in none of these workplace intervention studies are there baseline data nor were there control groups, limiting the conclusions that can be drawn (see Table 1).
The regulatory framework of each country provides a context for employers’ duties towards the health of pregnant and lactating workers and employees rights. See Table 2 for a description of legislation in countries comparable to the United Kingdom. In the United States, breastfeeding legislation has been enacted in over a half of the states.25 In three states (Connecticut, Illinois and Minnesota), it is mandatory for employers to provide reasonable work time breaks for expressing milk, and they must provide a suitable room in proximity to the employee’s work area. By contrast, in the United Kingdom, there is less legislative support to protect women’s right to breastfeed after returning to work. Women have the right to facilities to express at work, to reasonable work time breaks, facilities to express and store breast milk and to rest to maintain breast milk production. More recently, direct benefits to breastfeeding may be enabled through longer maternity leave. The Parental Rights Act 200326 guarantees that all pregnant employees are able to take 26 weeks of paid ordinary leave followed by 26 weeks of unpaid additional maternity leave (but only for employees who worked for the employer for 26 weeks by the 15th week before the baby is due). Fathers are entitled to 2 weeks of paid paternity leave. This legislation also states that parents of children aged under 6 can apply for flexible working hours that can be refused only if there is a clear business reason.
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However, it is unlikely these measures will impact on breastfeeding if employees are unaware of their rights, and employers do not publicize policies to support breastfeeding. Within a health scrutiny review of health services to support breastfeeding undertaken by two local government authorities in England,27 a survey was undertaken of four large public sector organizations to determine the awareness, experience and views of relevant female employees and their partners.
The aims of the study were to determine (i) the awareness of employees of their legal rights, (ii) the awareness of employees of their employer’s policies, where these existed, (iii) the views and experiences of employees in relation to the breastfeeding support provided by their employers, and (iv) to make recommendations for changes in the policy and practice of the four large public sector organizations surveyed to support the public health goals of the health services of Coventry and Warwickshire.
Two of these organizations provide hospital and community health care to mothers and infants, one was one of the two local authorities conducting the health scrutiny, the fourth was a local University. It was ascertained before the study that all the four organizations were developing practices to support breastfeeding, but that explicit statements of employees’ rights and the availability of facilities were not yet enshrined in formally adopted policies at the time of the survey. The results of the survey would therefore inform the adoption of such policies.
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Procedure |
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Permission for access to staff was sought from each organization. A senior member of staff in each organization undertook to distribute the survey to eligible staff. These were employees in the Coventry City Council who expressed an interest and staff in the other organizations (Coventry University, South Warwickshire Primary Care National Health Service Trust and South Warwickshire General Hospitals National Health Service Trust) who were planning to go on maternity leave in the next 6 months, on maternity leave or within 6 months of return from maternity leave. Those on paternity leave were included on a similar basis.
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Results |
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Characteristics of the sample
Forty-six employees completed the questionnaire. They were employed by four organizations: Coventry Council (n = 19), South Warwickshire PCT (n = 11), Coventry University (n = 9) and South Warwickshire General Hospitals NHS Trust (n = 7). Two-thirds of the sample (n = 30) were part-time employed and so may have been benefiting from some flexibility in employed hours to suit family circumstances. The sample was predominantly white (n = 41), with only two males, with an age spectrum quite typical of the postpartum population,10 with a median in the range 30–35 years, and 72% aged 30–40 years, 61% had education after they reached 18 years, and 61% of the respondents had taken maternity leave in the past 5 years, 31 of 44 women (70.5%) were currently on maternity leave, one woman was about to go on maternity leave, and for the two males, this last question did not apply. In data presented below, relevant data for breastfeeding are reported for the 44 women.
Information and facilities offered by the employer about the availability of breastfeeding support on return to work
A workplace nursery was available to 17 (37%) of respondents, but only 14 (31%) expressed interest in using it, and only nine women (20.5%) would want to visit their babies there during work to breastfeed. This suggests that provision of facilities to support expression and storage and rest breaks to maintain breastfeeding may be more important for most mothers.
Only 1 of 44 respondents reported being offered information about the support that she might be offered to enable breastfeeding to continue after returning to work, and she reported that she obtained this through her work role as a midwife, not directly as an employee. She obtained information about the benefits of breastfeeding and voluntary groups such as National Childbirth Trust, La Leche League and Maternity Alliance, rather than specific workplace policies or facilities available to all employees. She did, however, report that she was offered a free loan of a breast pump for use at work and a milk storage flask usually available to patients.
Only seven respondents (15.9%) were aware of facilities such as prebooked rooms, where mothers could express and store breast milk while at work, and only three (6.8%) had used it. However, no participants, men included, were aware of information about formula feeding from their employer nor did they receive promotional literature through work. None of the respondents were made aware of arrangements to support flexible working hours or flexible working within the working day to accommodate childcare and breastfeeding nor information about breast pumps for home use. Just seven women (15.9%) were aware of some prebookable rooms in which they could express, and three made use of them, but comments reveal that these were mostly those facilities that they found for themselves. One woman stated: ‘I used to sneak into my boss’s office and quickly express hoping nobody would come in’.
Some mentioned that if the facilities had been available, they would maintain breastfeeding after returning to work, for example: ‘I was not aware of this availability, this would have encouraged me to continue breastfeeding’. Three women mentioned finding the sole-designated room in the University by accident, for example: ‘Just because there is a sign on the door where I walk by daily’. Some women who decided to express breast milk at work had to do it in unsuitable places and in stressful conditions: For example: ‘I asked for somewhere to express milk, I was offered a toilet cubicle or a shower room which didn’t have a lock on the door’.
Factors influencing the decision about returning to work after having a baby
Eleven (25%) of women respondents stated that the support offered by the employer regarding breastfeeding would be an important factor when considering the decision about returning to work after having a baby. This may be a lower rate than if the sample was exclusively of those women surveyed before returning to work, because by definition, many respondents had already decided to return to work in this sample. One respondent reported: ‘I felt pressured into returning early from my first spell of maternity leave so was unable to feed after that – it just wasn’t an option according to my boss. The nursery at the hospital is very expensive and so I’ve decided not to return to work after this spell of maternity leave’. Thirty-five women (79.5%) regarded it as important to continue to breastfeed on their return to work, for example: ‘I took eight months maternity leave and was able to breastfeed my babies for this long. Flexible working hours on return allowed me to continue one out of three feeds a day, either before work or on return home’. But some women reported they decided not to breastfeed to avoid anticipated problems on their return to work: ‘I would have breast fed if I had more info and support, however, as none was given I chose to bottle feed as I felt it would be easier knowing I had to return to work’. Of greater concern is where health and safety issues for the mother as an employee arose that appeared to influence her decision to breastfeed: ‘I was asked to work in [the] isolation ward, so [I was] looking forward to it. [But] I had to wean my baby off the breastfeeding because I did not want to introduce any infections which I may carry in my body to my baby. I was/am very unhappy about it’.
On considering whether to return to work, flexible hours were considered important for 40 (90.7%) of respondents, and 16 (36.4%) wanted breaks to express and store milk during the working day. For example: ‘I was keen to breastfeed each child which I did till they were 15 and 18 months. I think because of this determination nothing would stand in my way. Practical things like finding space in a fridge to store milk and of course a room where there was no school children was important. With my second child there was a new Head teacher and she kindly gave me her office at lunch time. I carried on expressing’. A further 14 (31.8%) wanted breaks to breastfeed the child directly, which required access to affordable and local childcare.
Awareness of workplace policies that support breastfeeding by employees
Only four (8.7%) of all respondents were aware of any workplace policies related to breastfeeding, covering employer and employees’ rights and duties.
Organizational support for breastfeeding
Forty-one (91%) of all participants thought that their employer should do more to support employees regarding breastfeeding. Some 38 (82.6%) believed this should include information in advance of maternity/paternity leave about how breastfeeding can be managed at work, for example, ‘More information provided earlier on to ensure an informed choice’. Although some participants were very specific about what they thought the employer should provide: ‘I don’t think it is the employer’s responsibility to provide information/advice about benefits/practicalities of either breast or bottle feeding. There are plenty of other agencies who already do this. However, the availability of a bookable, private room and fridges for storage of breast milk would be useful should women wish to express milk whilst at work’. Such facilities and equipment were welcomed by 34 (73.9%) of all respondents. Health promotion information about the benefits of breastfeeding were welcomed by 22 (48%) of all participants, but only seven out of all participants were interested in knowing about formula feeding and five were interested in the role fathers could take in supporting breastfeeding.
The best and the worse aspect of experience of the current employer that affected breastfeeding
Thirty-one women respondents submitted their comments on the best experience and 22 on the worst experience. The most often mentioned best experience was long maternity leave that enabled mothers to finish breastfeeding before they came back to work, for example, from a healthcare employee: ‘Employer has shown no interest but I never expected it! Just pleased that maternity leave has increased. Breastfeeding [was] finished by [my] return to work after 6 months’. Six participants commented on the support from their employer (such as access to lactation rooms, breaks for storing and expressing milk), and three participants mentioned flexible work hours after returning from maternity leave, as the best experience affecting breastfeeding.
The most often mentioned worst experience, reported by 21 women, was the apparent lack of interest, information and support from their employer. For example, ‘I had to sort out a lot of things myself – a room, fridge etc. Surprise was shown that I was planning to breastfeed for longer than six months – I got the feeling that they expected me to only be expressing at work for a couple of weeks until my son reached 6 months. Women should be encouraged to breastfeed for as long as they/baby wants!’ Four participants felt pressured to come back to work early after having a baby. For example, ‘It would have been ideal to have had a year off work to breastfeed the babies for this long – however, [I] had to return to work – maternity pay does not last that long!; Babies [were] transferred to formula milk for 2/3 feeds on return to work. [I] Did not fancy the idea of expressing at work’. Four respondents did not feel confident to express milk at work because of poor facilities, for example, ‘As the rooms offered to me to express milk were not private or were not suitable, this meant that I stopped breastfeeding/offering expressed breast milk on my return to work. The lack of facilities to express milk was the only reason that I moved to formula milk for my daughter’. Another added... ‘My husband used to collect my milk in his lunch hour to take it home to the fridge as there was no storage facilities either’.
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Discussion |
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Limitations of this study
The sample was relatively small, although it does represent over a half of the eligible employees in each organization, according to the personnel departments’ figures. As the study was mainly concerned with breastfeeding, employees who did not intend to breastfeed may be under-represented, although some questions such as those concerning childcare were relevant to all. Generalization to the circumstances of those employed in other organizations is not possible to determine. However, a brief search of the web pages we were given access to by the personnel departments of three major local private employers (e.g. an automotive manufacturer) showed no mention at all of breastfeeding on the employee welfare aspects of these sites. We have some foundation therefore for believing the absence of policies may reflect absence of work site support for breastfeeding.
Main findings of this study
The results show that despite the efforts of the four employing organizations to develop general policies for mothers’ well-being and two of them having some facilities and breastfeeding policies in development, forty-two participants (91%) were unaware of any support that might be offered to enable breastfeeding after returning to work, yet this is widely available to employers and the public.28-31 Those women who accessed bookable rooms and equipment largely did so through their own efforts, and many experienced unhealthy conditions in their use. Access to workplace childcare was only available for a minority. But for three-quarters of the sample it was or would have been important to continue breastfeeding after returning to work. It is clear that these employers are failing to meet their health and safety obligations and are indirectly hampering public health efforts to improve the duration of breastfeeding.
What is already known on this topic
The research reviewed above suggests that many women perceive work and the continuation of breastfeeding to be incompatible and that they have low expectations of support. However, skilled lactation support and workplace policies can enable many mothers to plan to breastfeed on return to work.
What this study adds
In the UK public sector, there are many skill shortages in professional posts, so it may be of intrinsic interest to employers to know that a lack of employer support was perceived to be a major source of dissatisfaction and in some cases a reason for leaving the employer after maternity leave. Also, some respondents stayed away from work longer than they would have wished because they anticipated poor support on their return. The survey shows that the required support is within the grasp of most employers if they were to make their existing policies and practices better known, provide simple prebookable rooms and equipment and provide active encouragement of breastfeeding as the norm. This may take leadership, because one respondent noted ‘It’s not {just} the employer but the staff members which need educating!’
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Recommendations |
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- Employees should have access to information on support that is offered by their employer, and by local organizations, to enable breastfeeding to continue after returning to work.
- Suitable, comfortable and stress-free facilities to express and store breast milk should be provided.
- More flexible arrangements in working within time at work and in overall working hours are necessary to give mothers the opportunity to express breast milk or to breastfeed their baby at local childcare facilities.
Addressing these issues may benefit employees and employers alike, at very low cost to the employer, and support local public health initiatives to improve breastfeeding rates. Research on a wider spectrum of organizations, including those operating with similar policies in different countries, would help show how workplace welfare and health promotion activities can improve breastfeeding, the company and the local economy.
Resources relevant to expressing and storing breast milk: http://www.breastfeedingnetwork.org.uk/pdfs/BFNExpressing&Storing.pdf; http://www.breastfeedingnetwork.org.uk/pdfs/BreastfeedingAndReturningToWork.pdf.
Resources relevant to maternity rights, flexible working and other employment rights: http://www.workingfamiliies.org.uk.
Resources relevant to employers and employees in relation to breastfeeding and maternity rights and safety: http://www.hse.gov.uk/pubns.
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References |
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