Breastfeeding is associated with a well-known host of benefits for both women and infants (Stuebe & Schwarz, 2010). Indeed, there is consensus among clinicians, scientists, and public health professionals that breast milk is the optimal food for human infants (Kramer, 2010; World Health Organization, 2017). For every 1,000 babies not breastfed, there are an extra 2,033 physician visits, 212 days of hospitalization, and 609 prescriptions written (Ball & Wright, 1999). One study on the economic impact of breastfeeding estimated that if 90% of women breastfed exclusively for 6 months, the U.S. would save $13 billion annually (Bartick & Reinhold, 2010).
Because the U.S. does not have consistent policies regarding paid maternity leave, many women return to work while still breastfeeding. Enabling women to maintain lactation while working is thus imperative for overall breastfeeding success, yet mothers who return to full-time employment outside of the home are less likely to breastfeed to 3 months, despite the desire to do so (Mirkovic, Perrine, Scanlon, & Grummer-Strawn, 2014a). This is especially true for women who return to work earlier in the postpartum period (Mirkovic, Perrine, Scanlon, & Grummer-Strawn, 2014b).
Multiple barriers to breastfeeding once women return to work have been identified: lack of flexibility in the work schedule to allow for milk expression; lack of accommodations to express or store breast milk (Murtagh & Moulton, 2011); and concerns about support from supervisors and colleagues (Centers for Disease Control and Prevention [CDC], 2011; Frank, 1997). All of these issues contribute to real or perceived low milk supply (Haviland, James, Killman, & Trbovich, 2015; Infant, Child, & Adolescent Nutrition, 2012).
Because major changes to maternity-leave policies in the U.S. are unlikely to be forthcoming, particularly for hourly wage workers, one potential solution is to make workplaces breastfeeding-friendly, enabling women to combine working and lactation. Breastfeeding-friendly worksites have been associated with benefits for both lactating employees and their employers that include reduced employee absenteeism; increased employee retention, morale, and loyalty; healthcare cost savings; and positive public relations and company image (National Business Group on Health, 2010; Stuebe, 2014). The American Academy of Family Physicians (2002) estimated that for every dollar invested to support breastfeeding, employers save three dollars. Despite research showing that well-designed employee lactation-support programs can increase breastfeeding duration (Stuebe, 2014), only an estimated 25% of employers offer such programs (CDC, 2016).
In 2008, a collaborative, expert panel, composed of chronic disease organizations, public and private institutions, local and state government representatives, and the CDC developed a 122-question Worksite Health ScoreCard (HSC), used by employers for worksite assessment and quality improvement programming. Questions on the HSC cover themes related to lifestyle, counseling services, environmental supports, policies, and health plan benefits (CDC, 2016). After testing and validating the HSC with employers in the CDC's National Healthy Worksite Program, lactation-specific items were added in 2013. The current HSC lactation items are shown in the left-hand column of Table 1 in the companion paper (Cheyney, Henning, Horan, Bovbjerg, & Ferguson, 2019).
Since the lactation questions were added, over 1,500 worksites throughout the U.S. have used the HSC; 82% of employers using the HSC have 100 employees or more, and 72% are private employers (CDC, 2017). Despite the widespread use of the HSC, including the lactation-specific items needed to confer a “breastfeeding-friendly” worksite designation, there is a dearth of research exploring women's perceptions of workplace-based employee breastfeeding wellness programs (CDC, 2011; Dieterich, Felice, O'Sullivan, & Rasmussen, 2013; Dinour, Pope, & Bai, 2015; Murtagh & Moulton, 2011; National Business Group on Health, 2010; Rollins et al., 2016). While numerous studies have documented the medical benefits of breastfeeding for 12 months or more, few have examined the social and cultural politics of combining lactation with a return to wage-labor (Boyer, 2014), and fewer still have explored women's lived experiences of combining breastfeeding and employment. None have explored whether worksites that have made an effort to become breastfeeding-friendly (e.g., as quantified by the HSC) are perceived as such by the women themselves. Thus, the purpose of this project described here and in the companion piece (Cheyney et al., 2019), was to examine participant's experiences of returning to work at worksites that were deemed “breastfeeding-friendly” per the CDC's HSC criteria.
This qualitative study utilized a one-time, open-ended, semi-structured interview design and voluntary, convenience sampling (Bernard, 2006). Employees from 15 worksites in a rural New England town that had been deemed “breastfeeding-friendly” following participation in a county-level CDC HSC assessment project were invited to participate in this study if they were at least 18 years old and had attempted to continue breastfeeding after returning to work at the breastfeeding-friendly worksite in the last 5 years. Interviews lasted between 20 and 60 minutes, depending on the amount of information participants wished to share.
With the CDC HSC lactation-support criteria as a template (see Table 1 of the companion article, Cheyney et al., 2019), we designed semi-structured interview prompts to elicit participant's experiences with breastfeeding after returning to work at a breastfeeding-friendly worksite. We asked participants to reflect on which programs and policies were most helpful and which created barriers. More targeted questions about workplace policies, space allotted for milk expression, breaks, support groups, and maternity leave were also included. Data collection occurred over 5 months, between May and October of 2015.
Audio-recorded interviews were transcribed verbatim and saved under pseudonyms. Transcripts were analyzed by four of the authors using an inductive or “open” consensus coding approach whereby each researcher independently coded narratives and produced a preliminary list of topical and theoretical codes using Microsoft Word (Creswell & Poth, 2013). Researchers identified overlapping themes and negotiated any unique themes or subthemes until consensus was reached. This method enables a diversity of codes to emerge from participant narratives, despite inherent individual researcher biases that might influence which themes are identified and which are overlooked (Maxwell, 2013).
Demographic Characteristics of the Participants (N = 18)
| 25–29 years||1 (5.6)|
| 30–35 years||5 (27.8)|
| 36–40 years||6 (33.3)|
| 41 + years||6 (33.3)|
| Associate's degree||1 (5.9)|
| Bachelor's degree||6 (35.3)|
| Master's degree||7 (41.2)|
| Doctoral degree||3 (17.6)|
|Years employed in current position|
| 0–5 years||7 (38.9)|
| 6–10 years||5 (27.8)|
| 11–15 years||2 (11.1)|
| 16 years +||4 (22.2)|
| Current||8 (47.1)|
| Previous||9 (52.9)|
The use of multiple coders has also been shown to add rigor to qualitative data analysis making it more likely that findings will accurately and dependably reflect the range of experiences conveyed in interviews (Bernard, 2006; Creswell, 2006). The Institutional Review Board at (Oregon State University) approved the study protocol, and all participants provided verbal informed consent.
Twenty-one eligible individuals volunteered to participate; demographic characteristics of the sample are summarized in Table 1. Due to confidentiality concerns, 3 of the 21 participants chose not to answer at least one of the demographic questions because they feared their answers could identify them. Most participants had a college degree, and almost half of the sample included healthcare professionals, many of whom specialized in maternal and infant health.
As expected, given the HSC-based structure of the interview prompts, issues raised by participants clustered around the six HSC lactation-support criteria. The following five key themes, numbered to mirror the first five HSC lactation items (see Table 1 in the companion article, Cheyney et al., 2019), emerged from participants' narratives: (a) “Closing the gap”: written policies are not enough; (b) A “private space” for milk expression: barriers and supports in the built environment; (c) Breast pump accessibility: exploring what “access” means in this context; (d) Flexibility: rights versus favors; and (e) “We need a cultural shift!”: moving beyond support groups and breastfeeding education. We identified but did not achieve concept saturation for the theme related to the sixth criterion (paid maternity leave). Below we describe themes 1, 4, and 5—which focus on the ways written policies fall short in practice—using participants' narratives to illustrate their experiences attempting to continue breastfeeding in a workplace that had been officially deemed “breastfeeding-friendly.” Themes 2 and 3 focus on barriers in the built environments of workspaces, and are described in the companion article (Cheyney et al., 2019).
Theme 1. “Closing the Gap”: Written Policies Are Not Enough
Theme 1 highlights the recurrent concern that, even when a workplace has a written policy supporting breastfeeding, there can be breakdowns or ambiguities in how that policy translates into practice. Any disconnects or gaps between policy and practice can introduce unforeseen and rarely acknowledged barriers as participants return to work. Participants wanted, instead, to see clearer connections between official policies and actual practices in the workplace.
The ambiguity between policy and practice was sometimes as simple as the fact that: “No one could locate the actual policy; it was just a part of institutional memory.” In these cases, the document itself was difficult or impossible to find. Other times the written policy document was easily accessible but vague and unhelpful. One participant said:
Someone needs to close the gap! I mean, write the policy, describe the supports offered, actually offer the supports, then ask if they are working, and if not, go back and fix the policy.
Participants argued that without a well-defined approach to translating policy into practice, policy efforts are likely to fail. Participants were also quick to note that they did not see a more effective connection between policy and practice “happening any time in the near future,” and certainly not soon enough for the participants who were struggling to maintain lactation at the time of the interview.
Those most committed to seeing a change are those most affected by the policy, and because the period they can expect to be affected by the policy is inherently finite, so is their interest in fixing the problem. One participant reflected: “There were definitely problems with policy implementation when I was nursing, but it would have taken longer to fix them than I was planning to nurse.”
Participants also described a more basic problem: they did not know whom to ask about worksite breastfeeding policies and were “afraid to try to find out.” Their limited knowledge of worksite policies and how they translated into practice was layered with an explicit hesitancy to call attention to their needs. Many worried that if they advocated too strongly for their rights, or even asked to see a written policy, that they would lose valuable social capital and be perceived as “difficult to work with” or “expecting special treatment.” One participant said: “We have one [policy], I think, but I am not sure how to find out about it. I guess I would ask HR [human resources], though I am reluctant to do that.” She went on to describe a fear of alienating colleagues: “I am new, and I don't want to look like I'm asking for special considerations. Maybe the policy is hard to find on purpose.”
Another participant expressed a similar fear:
I was given information as part of the packet that was handed out at one of my first meetings, but when the time came, and I needed support, I was not sure who to contact to set up the space and time to pump. That might not seem like a big barrier, but for me it was. I was tired and worried about coming back to work.
For some participants, figuring out whom to talk to, let alone advocating for themselves, seemed like a “total impossibility.” Participants' narratives make clear: a written policy is not enough. Several participants described the fear of compromising professional relationships or losing social capital if they “pushed too hard” or “asked too many questions” around breastfeeding rights. Employers must explicitly close the gap between policy and practice, making sure that policies are easily accessible and that their implementation contributes to an environment that is experienced as breastfeeding-friendly.
Theme 4. Flexibility: Rights Versus Favors
The fourth criterion on the HSC lactation-support questions requires that worksites provide flexible, paid, or unpaid break time to allow mothers to express milk. In discussing the way this criterion worked in practice, participants questioned the ways “flexibility” may be interpreted and offered (or not) in practice. All participants agreed that flexibility was important; however, what was most salient for them was the attitude attached to this flexibility from co-workers and supervisors. One quarter of our participants reported that flexibility for breast milk expression was given freely or respected as a right, while the remaining 75% felt that the flexibility was bestowed “grudgingly,” “with a dose of guilt,” or “as a favor, as in‘okay, but now you owe me one’.” The participants who were “given” flexibility around time for breast milk expression, perceived as a favor with strings attached, described being surprised and sometimes angered, especially when they had been told expressly that their worksite was “breastfeeding-friendly.” One participant said:
This is not a gift, it is a right, but it feels like I am asking for a gift. I am only asking for what they already said they thought I should have … at least in theory.
Those who were given flexibility with minimal to no guilt described themselves as “lucky,” crediting an “unusually supportive boss” or a “supportive built and
emotional environment” (emphasis in the original), and an advocate who worked to make sure they had flexible schedules. One participant said:
My boss was so wonderful and supportive. I work with a group of mostly women who also breastfed. I know I had a much easier time than most.
While not always so overtly positive, some felt their co-workers and superiors at least “looked the other way” and thus, provided an unspoken agreement to let them express breast milk within their work schedule: “I feel people left me alone, so I was able to pump … probably because I had paid my dues before my baby was born.”
Support for breastfeeding mothers in the workplace has been referred to in the feminist literature as a middle-class privilege (Bai & Wunderlich, 2013; Boyer, 2014; Hausman, 2013), and participants were all acutely aware of this perception. Those who did not feel supported in taking breaks to express breast milk struggled with guilt due to missing or arriving late to meetings, and negative or questioning comments from co-workers. One participant said:
There is just so little flexibility, so the burden falls to the new moms to try to find a way to make it work. That was not at all what I needed in trying to go back to work.
With my second child, when I came back to work, I was pumping and didn't have much control over my schedule. There was new management, and I did not feel like I had the freedom to say no … if they said I needed to drive three hours to be somewhere, I needed to drive three hours to be somewhere. Milk expression certainly did not count as a priority.
One participant summarized this collective struggle: “Nursing mothers need greater flexibility with less shaming.”
Theme 5. “We Need a Cultural Shift!”: Moving Beyond Support Groups and Breastfeeding Education
The fifth HSC lactation-support criterion requires that worksites provide free or subsidized breastfeeding support groups or educational classes but allows enormous flexibility in how they are provided; worksites can address breastfeeding as a single health topic or alongside other topics (CDC, 2014). In general, participants felt their worksites did provide them with accurate and updated information about community resources for breastfeeding mothers. Many described getting similar information from their obstetric or pediatric providers. In this way, worksites were fully compliant with the fifth criterion; however, all participants felt that providing information on access to support and educational opportunities was largely beside the point. Participants described needing more immediate support from their co-workers and supervisors: “Information on La Leche League meetings is great, but what I needed was a supportive work environment.”
Participants also described feelings of isolation after returning to work due in part to occupational cultures they felt were not emotionally or socially supportive. Their solution?—A cultural shift whereby worksites and co-workers value both the reproductive and productive labors of its employees. Two participants felt their workplace had already experienced such a cultural shift “as a result of strong leadership” and “explicit breastfeeding advocacy by those in power.” For those employed by organizations that were perceived as lacking this shift, the desired magnitude of this change was far greater then we had anticipated. When asked what she would have needed to breastfeed successfully after returning to work, one participant said:
A complete and total change in our work culture! It has to go beyond a written policy. It has to be in how HR works with new families or even second-time moms. It has to be through education and not education for me. I mean education for our co-workers and managers.
Participants offered several concrete examples supporting their assertions that a cultural shift was necessary. One participant described a co-worker's experience:
Her letdown wasn't as quick, or, I don't know, she just really struggled to get milk out with a pump. Anyway, people felt like that time away from her desk was her taking advantage of the situation. That lack of support made it so much harder for her. It also shows you that our co-workers do not know very much about pumping.
Another participant echoed this sentiment, saying: “People used to walk in while I was pumping … I changed the note on the door to say, ‘in a meeting’ … so I did not have to explain what I was doing.” This participant felt her co-workers and supervisors did not understand how they could change workplace culture to better support returning employees: “It's up to all of us to create a supportive environment,” she concluded.
Some participants also noted a decline in support or worsening of worksite culture around breastfeeding, over time. Multiple participants reported worksite pressure not to breastfeed for longer than 1 year:
People asked how long I was going to breastfeed. I am not sure why they needed to know or if it was just something to talk about, but it was clear that by age one, people think you just need to be done. What if you want to nurse until 2 years old? Well, you definitely get the message that this “choice” [indicates she is making air quotes] only goes so far.
One participant summarized such experiences this way:
I don't think the institution, in general, has much support for the breastfeeding mother, but as long as it doesn't interfere with your productivity or make your co-workers uncomfortable and you don't do it for too long, then they are fine with it. I wonder, is that really breastfeeding-friendly?
From participants' perspectives, the presence of support groups and educational materials is insufficient when they are not accompanied by a workplace climate that is experienced as supportive.
A Note on Criterion #6: Paid Maternity Leave
The sixth HSC lactation-support criterion requires that worksites offer paid maternity leave that is separate from annual leave, sick leave, or vacation time. Recent research demonstrates that a longer duration of breastfeeding is associated with paid maternity leave for 3 months or more (Mirkovic et al., 2014a). As mentioned above, we did not reach concept saturation for this item because only four participants discussed this criterion beyond characterizing it as something that is currently out of reach in any meaningful form. Those who did discuss maternity leave at any length emphasized that a minimum of 12-weeks paid maternity leave was needed but also that this was a “really lofty” or an “unattainable” goal despite protections through the Family Medical Leave Act (FMLA; U.S. Department of Labor, n.d.). One participant reflected on the challenges of returning to work at just 6 weeks postpartum saying: “If I was answering this question a year ago when I had just returned to work, I feel like I probably would have just started to cry because of how difficult it felt at the time.” Another participant concluded her interview by saying: “If we had three months of paid maternity leave, you would not have so much to interview us about. All of these other barriers would not matter so much.”
Despite being employed by so-called breastfeeding-friendly workplaces, participants in our study largely did not report feeling supported or encouraged, and thus sometimes not able, to continue lactating after returning to work. In the three themes numbered to correspond to the HSC criteria and discussed at length above—1) “Closing the gap”: Written policies are not enough; 4) Flexibility: Rights versus favors; and 5) “We need a cultural shift!”: Moving beyond support groups and breastfeeding education—participants described the institutional policy, expectation, and workplace climate/attitude barriers that they experienced while attempting to combine working with breast milk pumping. Arguably, the women who volunteered to describe their experiences of returning to work while breastfeeding for this study were among those most likely to succeed at this endeavor, as they were predominantly privileged, white, middle-class, college-educated, salaried, health and education professionals working at so-called supportive worksites. The fact that these women struggled to maintain lactation after returning to work suggests that the barriers for lower-wage, hourly workers would be even greater.
In addition, the themes described in this article highlight the difficulty of legislating or regulating workplace cultural and inter-professional attitudes that allow a shared space to be experienced as “breastfeeding-friendly.” Written policies, even those with a high degree of support from leadership, do not necessarily translate into supportive spaces as experienced by employees. Thus, assessment efforts must find ways to center the experiences of the individuals such policies aim to support. This study illustrates the value of ongoing assessment, as well as the value of qualitative approaches. In the companion article (Cheyney et al., 2019), we explore participant-reported barriers and supports associated with the physical workspace and propose revisions to the HSC lactation criteria that might help to shift the norms around breastfeeding after returning to work.
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We would like to thank the Healthy Moanadnock initiative of Cheshire County and the Monadnock region for facilitating access to community worksites. We would also like to thank all of the women who participated in interviews. We are grateful for your time and insights.
The authors have no conflicts of interest related to the topic of this article.