Barriers and Facilitators for Breastfeeding Among Working Women in the United States Marina L. Johnston and Noreen Esposito

IN REVIEW Barriers and Facilitators for Breastfeeding Among Working Women in the United States Marina L. Johnston and Noreen Esposito Objective : To review the literature and describe the barriers and facilitators to the continuation of breastfeeding for at least 6 months by working women in the United States. Data Sources : A search of PubMed, CINAHL, Sociological Abstracts, ISI, PsychInfo, and ProQuest. Study Selection : Twenty studies based on the inclusion criteria and published between January 1, 1995, and January 2006. Data Extraction : An ecologic framework, which includes the individual (microsystem), social support and relationships (mesosystem), and the workplace environment (exosystem). Data Synthesis : When working mothers possess certain personal characteristics and develop a strategic plan, breastfeeding is promoted. When social support is available and when support groups are utilized, lactation is also facilitated. Part-time work, lack of long mother-infant separations, supportive work environments and facilities, and child care options facilitate breastfeeding. Conclusions : Health care providers can use the findings of this review to promote breastfeeding among working women by using tactics geared toward the mother, her social network, and the entire community. JOGNN, 36, 9-20; 2007. DOI: 10.1111/ J.1552-6909.2006.00109.x Keywords : Breastfeeding Employment Lactation Women Working mother Workplace Accepted: September 2006 Successful breastfeeding is imperative for infants, mothers, and the public health of our nation ( U.S. Department of Health and Human Services [USDHHS], 2000; Wambach et al., 2005 ). Professional organizations recommend 6 months of exclusive breastfeeding and the addition of iron-fortified foods with breastfeeding until at least 1 year of age ( American Academy of Family Physicians, 2005; American Academy of Pediatrics [AAP], 1997; American College of Nurse Midwives, 2004; American Dietetic Association, 2001; Association of Women s Health, Obstetric and Neonatal Nurses, 1999; National Association of Pediatric Nurse Practitioners, 2001; World Health Organization, 2001 ). Despite these recommendations, the breastfeeding goals for Healthy People 2010, that 75% of all new mothers initiate breastfeeding, 50% continue to 6 months, and 25% continue to 1 year, are unmet (USDHHS). In 2002, although an initiation rate of 70.9% neared the goal, continuation rates of 36.2% and 17.2% at 6 and 12 months fell far below expectations ( U.S. Centers of Disease Control, 2003 ). Low breastfeeding rates can negatively impact the health of women and children and the economic status of their families, communities, and the nation. Breastfed infants are less likely to acquire illnesses than those who are bottle fed and illnesses that do occur tend to be milder (Cohen, Mrtek, & Mrtek, 1995). Working mothers who do not breastfeed have higher absentee rates and health costs than those who do ( AAP, 1997; Witters-Green, 2003 ). A recent report examining the past 20 years of breastfeeding research summarized the salient issues ( Wambach et al., 2005 ). One of the issues presented was the negative association between breastfeeding continuation and employment. Many mothers return to the workplace during their infant s first year of life and face multiple challenges when they combine lactation with employment. More than half of women in the United States who have a child less than 1-year old work outside the home, and about 60% of employed 2007, AWHONN, the Association of Women s Health, Obstetric and Neonatal Nurses JOGNN 9

mothers with a child younger than 3 years old are employed full time ( U.S. Department of Labor, 2006 ). Employment is one factor that makes it difficult for women to continue breastfeeding ( Kimbro, 2006 ). Research has shown that mothers who work full time have similar initiation rates as those who do not work; however, their continuation rates at 6 months were 9% lower than rates for stay-at-home mothers ( Ross Products Division of Abbott Laboratories, 2003 ). A high percentage of new mothers are entering the workforce, and with the clear link between employment and premature weaning, an in-depth look at what is currently known about workplace barriers to breastfeeding can impact both practice and research efforts. Mothers who work full time tend to breastfeed for shorter intervals than those who work part time or are unemployed. What follows is a systematic review of research that examines the barriers and facilitators that exist for working women in the United States to breastfeed for at least 6 months ( Kirkevold, 1997 ). A literature search of CI- NAHL, ISI Web of Science, PsychInfo, ProQuest, PubMed, and Sociological Abstracts used the inclusion criteria of primary research studies addressing any aspect of breastfeeding continuation or weaning in the work environment, published in peer-reviewed professional journals from January 1, 1995, through January, 2006, written in English and restricted to the U.S. key words breastfeeding, working women, working mother, work, work environment, employment, and worksite. The searches resulted in the listing of 143 articles of which 20 primary research articles met the study criteria. The findings are organized using a framework of human ecology that considers the mother in the context of her immediate and broader environment ( Bronfenbrenner, 1979; Grzywacz & Fuqua, 2000; Tiedje et al., 2002 ). Thus, the findings are categorized by the maternal ecosystem starting with the mother s characteristics and behaviors (microsystem), her personal social relationships (mesosystem), her community/health care/work environment (exosystem), and the larger socioculture, policy, and law (macrosystem). Table 1 summarizes the articles using a grid adapted from Cooper (1998). The Individual: Microsystem Individual Characteristics. A mother s personal beliefs, way of being, and view of herself in the world are central components of breastfeeding success during maternal employment. Rojjanasrirat (2004), in a content analysis of responses ( N = 50) to four open-ended questions that were part of a larger survey, found that mothers who continued to breastfeed while working possessed determination, commitment, assertiveness, dedication, positive feelings about breastfeeding, and belief in the benefits of breast milk. Researchers found similar themes in a qualitative study using individual interviews of military mothers ( N = 9) who had considered commitment an essential component of breastfeeding while employed ( Stevens & Janke, 2003 ). Bonding during the breastfeeding relationship was felt to carry the mothers through periods of separation caused by working full time. Additionally, in a cross-sectional retrospective survey of 121 employees at six Women, Infants, and Children (WIC) agencies, intent to exclusively breastfeed was the strongest predictor of breastfeeding duration ( Whaley et al., 2002 ). In that study, unlike most reports in the literature, maternal age, education, and ethnicity did not significantly contribute to duration. In a national survey on feeding, an older age, higher education, and attendance at prenatal classes did have positive effects on duration for 712 working mothers ( Roe et al., 1999 ). Personal comfort with the act of breastfeeding was also a factor for this group because those who reported embarrassment about breastfeeding weaned 10 weeks earlier than those who were not embarrassed. Comfort or breastfeeding skill was a factor in a study of 1,488 survey respondents in which researchers found that working women breastfed longer if they had breastfed a previous child ( Fein & Roe, 1998 ). Mothers without prior experience may choose to avoid anticipated difficulty. Witters-Green (2003) reported that in a focus group of WIC clients ( N = 13), some mothers planned to wean before returning to work or delay returning to work until ready to wean because of anticipated difficulties. Individual Behaviors. The behaviors of mothers are also an important component of successfully combining work and breastfeeding. When women who developed a strategic plan on how to balance breastfeeding and work, potential difficulties were minimized ( Roe et al., 1999 ). Mothers reported that time management, planning ahead, anticipating breastfeeding or pumping breaks, being flexible, and or ganizing their workload helped to merge breastfeeding and work ( Rojjanasrirat, 2004 ). Mothers also found it important to discuss breastfeeding needs with one s boss or supervisor prior to returning to work ( Rojjanasrirat; Thompson & Bell, 1997 ). Mothers believed that an adequate milk supply could be developed by starting to pump a few weeks prior to returning to work ( Rojjanasrirat, 2004 ), expressing milk regularly while at work ( Rojjanasrirat; Thompson & Bell, 1997 ), building stores of milk, and breastfeeding frequently when not working ( Rojjanasrirat ). Interviewed mothers also believed that eating nutritious foods, drinking fluids, 10 JOGNN Volume 36, Number 1

TABLE 1 Summary of Findings Authors/Year Methods Sample Significant Findings Authur, Saenz, and Replogle (2003 ) questionnaire N = 146, mostly White physician mothers Longer maternity leave increased duration of BF, full-time workers shorter duration than part time Bridges, Frank, and Curtin (1997) Quantitative-correlational questionnaire N = 69, rural employers Supportive if prior experience with employees who BF or knew of other businesses who employed BF women, or both Brown, Poag, and Kasprzycki (2001 ) Qualitative-descriptive two focus groups N = 18, employers from 18 businesses No established BF policies, address BF as needed basis, employer support of BF stress, salaried employees greater control of schedule, but job demands interfere with BF/pumping Chezem and Friesen (1999 ) Quantitative-longitudinal quasi-experimental telephone interviews N = 89, working mothers majority White Attendance at a postpartum BF support meeting increased duration and likelihood of meeting BF goals Chezem, Friesen, Montgomery, Fortman, and Clark (1998 ) longitudinal telephone interviews N = 53, primiparas planning employment, 96% White BF significantly shorter in those whose infants were given formula during hospitalization. BF at 6 weeks significantly shorter in those who received formula samples in the mail Dunn, Zavela, Cline, and Cost (2004 ) questionnaires N = 157, employers 28% provide formal BF support services, many more provide other services conducive to BF; large businesses provide significantly more services than small businesses; 70.5% employers would support BF needs Fein and Roe (1998) longitudinal mailed survey N = 1,488, mothers majority White Part time (<35 hr/week or maximum 7 hr/day) no decrease in initiation or duration; full time by 3 months after childbirth had decreased initiation and duration compared to nonworking (continued) January/February 2007 JOGNN 11

TABLE 1 (CONTINUED) Summary of Findings Authors/Year Methods Sample Significant Findings Haider, Jacknowitz, and Schoeni (2003 ) Kimbro (2006 ) Libbus and Bullock (2002) Lindberg (1996 ) Miller, Miller, and Chism (1996 ) mailed survey, from Ross Laboratory Mothers Survey Quantitative-discrete time logit models and logistic regression, in person + telephone Fragile Families Study questionnaire, cross-sectional, retrospective nationwide survey, cross-sectional, questionnaire N not given, mailed to 420,000 Work requirements of 32 (1991), 720,000 (1992), hr/ week reduced BF by 3.1% 1.4 million (2000) new compared to nonworkers; mothers working WIC mothers had 22% decrease in BF at 6 months N = 2,446, BF mothers who returned to work 38% African American, 20% White, 25% Hispanic, 24% immigrant N = 85, employers N = 2,431, mothers N = 60, resident physician mothers Mother planning to work in first year of life is negatively related to initiation. Odds of quitting BF 25% greater, 34% greater, and 32% greater, respectively, at 2 months before work, 1 month before work, and during first month of work than stay-at-home mother. Two months after return to work, odds of quitting similar to nonworking mothers More than half would be willing to establish an area for employees to BF Increased likelihood of BF cessation within 3 months of returning to work; part-time workers had higher rates and longer BF durations than full-time workers; non-black women, the older the child when returning to work, the less likely to stop BF 48 (80%) initiated, 24 (50%) of those weaned upon returning to work; 9 (15%) of original group BF at 6 months; facilitators: supportive attending and colleagues, contact with infant during on-call nights; barriers: residency schedules, routinely spent 25 hr apart from infant when on-call, no place to pump (continued) 12 JOGNN Volume 36, Number 1

TABLE 1 (CONTINUED) Summary of Findings Authors/Year Methods Sample Significant Findings Ortiz, McGilligan, and Kelly (2004) Roe, Whittington, Fein, and Teisl (1999 ) Rojjanasrirat (2004 ) retrospective chart reviews longitudinal questionnaire Descriptive: survey secondary content analysis of four open-ended questions N = 462, working mothers N = 712, mothers, predominantly White, married mothers N = 50, working mothers 97.5% enrolled in corporate lactation program initiated BF, 57.8% BF at 6 months and 18.2% at 1 year; breast milk expressed at work mean of 6.5 months; mean age of infant when stopped 9.1 months Women who worked before childbirth and planned to return to work within 12 months of birth. Each week of maternity leave increased BF by almost one half week, lowest BF duration for those who returned to work in the first 10 weeks after delivery Facilitators: accepting/ supportive work environment, strategic plan, maternal characteristics of commitment, determination, assertiveness, dedication, and belief in benefits of BF Stevens and Janke (2003) Qualitative interviews N = 9, military mothers Facilitators: type of pump, time management, place to pump, commitment, bonding experience, and work support. Barriers: being sent to temporary duty assignment, military obligations, BF may be easier for different ranks Thompson and Bell (1997 ) Qualitative-descriptive, open-ended questionnaires N = 38, WIC mothers Barriers: boss, time, privacy, storage. Facilitators: flexibility, boss, child s location. Believe pumping, intake important for milk supply, advice to others have + attitude, anticipate, plan (continued) January/February 2007 JOGNN 13

TABLE 1 (CONTINUED) Summary of Findings Authors/Year Methods Sample Significant Findings Visness and Kennedy (1997 ) Whaley, Meehan, Lange, Slusser, and Jenks (2002 ) Witters-Green (2003 ), cross-sectional, questionnaires, cross-sectional 92-item retrospective survey interview Qualitative/quantitative descriptive: multimethod N = 1,506, mothers employed and breastfeeding; White = 67.5%, Black = 15.4% N = 121, mothers employed by WIC majority Hispanic n = 4, WIC staff n = 423, prenatal women Individual interviews n = 14, employers Surveys n = 13, WIC clients Individual interviews Four focus groups Compared with nonworkers, White women had significantly shorter duration of BF in all types of jobs and no significant difference in BF duration between Black women in service positions and those in manufacturing jobs. Of all groups, White professionals most likely to continue after returning to work and had longest duration; longer duration of maternity leave associated BF duration Paraprofessional and professional employees more than 99% initiated BF, 87.6% BF at least 6 months, 68.6% at least 1 year, Regression analysis of 10 predictors: intent to exclusively BF strongest predictor of BF duration Facilitators: health professional; nearby daycare, autonomous job, supportive coworkers/ employers, breastfeed at home/wean during workday; privacy. Barriers: Poorly informed health professional; 12 hr rotating shifts, unsupportive employer, inflexible job, no privacy, pump/feed in bathroom, unsupportive child care provider. Some employers will not allow mothers to leave work to BF, do not know BF benefits Note. BF = breastfeeding; WIC = Women, Infants, and Children. 14 JOGNN Volume 36, Number 1

and getting enough rest were important ( Rojjanasrirat; Thompson & Bell ). Social Support and Relationships (Mesosystem) Personal Social Support. Social relationships with and support from others affect a mother s continuation of breastfeeding during employment. Interactions may occur with persons in the mother s home, such as a significant other or immediate family members or with close friends, extended family members, and individuals in everyday life. WIC clients in a focus group reported that a supportive partner, encouraging family members, and friends enabled them to continue breastfeeding during employment ( Witters-Green, 2003 ). They also cited friends and family members who had previously breastfed a child had a positive impact on the working mother s success. In contrast, a partner or relative with a negative attitude toward breastfeeding made it difficult to continue while working. In addition to negative emotional support, some individuals physically interfered with breastfeeding, for example, by feeding the baby formula instead of breast milk while the mother was away at work. Additionally, some child care providers were uneasy handling breast milk ( Witters-Green ). Local, Community, and Health Care Support and Resource (Exosystem) Support from health professionals can contribute to breastfeeding success or failure in working women. WIC staff and breastfeeding mothers reported separately that health professionals made an important contribution to the promotion of breastfeeding through encouragement, recommenda tions, and role modeling ( Witters-Green, 2003 ). However, the same groups expressed concern about the negative impact of many health care professionals who lack knowledge about breastfeeding, make little effort to offer information, and in some cases discourage breastfeeding ( Witters-Green ). Support groups can promote successful breastfeeding among working women. Chezem and Friesen (1999), in a longitudinal study of 89 working mothers recruited from a prenatal clinic, found that those who attended an optional breastfeeding support meeting by the sixth postpartum week were three times more likely to breastfeed beyond 6 months and meet their personal breastfeeding goals compared to those who did not attend. The researchers recognized that an underlying maternal characteristic such as commitment or intent may have contributed to both meeting attendance and breastfeeding success. The Workplace Environment (Exosystem) The workplace, a significant part of the breastfeeding mother s external environment (exosystem), can be viewed as its own ecosystem. The breastfeeding mother (microsystem), with unique characteristics and behaviors, is at the center of the workplace ecosystem. Social Support in the Workplace (Mesosystem). The workplace can be an influential social environment, and coworkers can be barriers to or a facilitators of breastfeeding ( Brown et al., 2001; Rojjanasrirat, 2004; Witters-Green, 2003 ). Coworkers who previously combined breastfeeding and work served as role models and a source of encouragement for some mothers ( Rojjanasrirat ). However, in another study, some coworkers, including those who had not breastfed their infants, were critical of those who did ( Witters-Green ). Some mothers encountered pressure at work from coworkers and supervisors not to take work breaks to pump ( Rojjanasrirat ). In another study, an employer who returned to work as a breastfeeding mother was unable to express milk at her workplace because of coworkers negative attitudes ( Brown et al. ). Attending worksite breastfeeding support groups was one of four significant predictors of breastfeeding duration for a mostly Latina group of WIC employees, of which 87.6% breastfed for at least 6 months ( Whaley et al., 2002 ). Support From Workplace Supervisors. An accepting work environment with supportive supervisors is important for success ( Rojjanasrirat, 2004; Stevens & Janke, 2003; Witters-Green, 2003 ). In a study with WIC mothers, participants indicated that flexibility by supportive supervisors can greatly diminish workplace stress associated with breastfeeding and that a nonsupportive boss made it almost impossible to maintain an adequate milk supply ( Thompson & Bell, 1997 ). That insight is consistent with that of employers in a focus group who discussed the role they played in decreasing employee stress related to breastfeeding and work ( Brown et al., 2001 ). Of 157 Colorado employers who responded to a survey mailed to 609 listings in a national business directory database, fewer than 30% reported that they provided formal breastfeeding support but 70% were willing to accommodate breastfeeding and offered flextime, job sharing, part-time employment, and breaks to breastfeed or pump ( Dunnet al., 2004 ). Witters- Green found that although some employers indicated that they would allow employees to have access to their infants during work, others said such options were impossible ( Witters-Green ). Some participants in an employers focus group worried that coworkers would be jealous of breastfeeding mothers who received special treatment, thereby compromising employee morale ( Brown et al. ). Employers who were familiar with working breastfeeders and who knew of other businesses that employed women who breastfed were more supportive and more willing to establish breastfeeding sites than employers without those experiences ( Bridges et al., 1997 ). Mothers reported that having a supervisor who had breastfed made their experience easier ( Witters-Green, 2003 ). January/February 2007 JOGNN 15

Although some employers grasped the benefits of breastfeeding for their employees, their families, and to their agency, others did not. All participants in one employer focus group recognized the health benefits of breastfeeding ( Brown et al., 2001 ), but only 20% ( N = 69) of surveyed employers believed that infants receiving human milk were healthier than formula-fed infants ( Bridges et al., 1997 ). Similarly, some employers did not know of any benefits associated with breastfeeding ( Witters-Green, 2003 ). Some employers did not perceive breastfeeding as an employer responsibility ( Dunn et al., 2004 ). In an analysis of employer attitudes, only 35% ( N = 85) saw any value in promoting breastfeeding ( Libbus & Bullock, 2002 ). Time and Timing (Exosystem) Maternity Leave. Most employers provide 8 to 12 weeks of paid or unpaid maternity leave ( Bridges et al., 1997; Dunn et al., 2004 ). The more time a woman has for maternity leave, the longer she is likely to combine breastfeeding and employment ( Authur et al., 2003 ). Lindberg (1996) found that chances of weaning increased during the first 3 months following return to work. For 712 mothers in a national survey, each week of work leave increased breastfeeding duration by almost one half week ( Roe et al., 1999 ). In that study, the largest significant negative effect maternity leave had on breastfeeding was a return to work during the first 10 weeks after birth. Data from a national study (Fragile Families and Child Wellbeing Study) indicate that the racially, ethnically, and socioeconomically diverse mothers ( N = 2,466) had 32% higher odds of weaning in the first month of returning to work than a comparative group of stay-at-home mothers ( Kimbro, 2006 ). Odds of quitting breastfeeding in anticipation of return to work were 25% greater 2 months before and 34% greater 1 month before maternity leave ended ( Kimbro ). Required Time on the Job. The amount and distribution of work time has significant consequences for breastfeeding. In two studies with large sample sizes ( N = 1,488, N = 2,431), part-time workers had higher rates and longer breastfeeding duration than those working full time ( Fein & Roe, 1998; Lindberg, 1996 ). Duration was significantly lower when women were working full time by the 12th postpartum week ( Fein & Roe ). African Americans were significantly more likely to stop breastfeeding when working full time compared to other ethnic populations ( Lindberg ). Physician mothers who worked full time after the birth of their first child tended to breastfeed for a shorter duration than those who worked part time ( Authur et al., 2003 ). Jobs that require long mother/baby separations further complicate breastfeeding. In a study of 60 resident physicians, 45 (75%) routinely spent more than or equal to 25 continuous hours apart from their infants when on call; subsequently, breastfeeding duration increased for the mother-infant dyads that made contact during those call shifts ( Miller et al., 1996 ). Military mothers face unique obligations requiring longer mother-infant separations than those experienced by their civilian counterparts. Mothers worried about the possibility of mandatory training, war exercises, temporary duty assignment (e.g., longterm training or contingencies), or deployment that would force premature weaning ( Stevens & Janke, 2003 ). Flexible Scheduling at Work. Many employers supported the idea of flexible scheduling for lactating employees, including 97 of 157 (62%) surveyed by Dunn et al. (2004). Several stipulations such as customers coming first, work being completed, or the employee arranging coverage accompanied the flexible support offered by 12 of 14 interviewed employers ( Witters-Green, 2003 ). Some employers worried that giving time off to pump would decrease employee productivity ( Brown et al., 2001 ). Some mothers complained that breaks were insufficient to both pump and eat lunch, and others said that it was hard to get away or that there was an unpredictable workload, making pumping difficult ( Rojjanasrirat, 2004 ). Flexibility varies with job type. Mothers in certain professions, such as law and sales, had more control over their schedules ( Rojjanasrirat, 2004 ), and the autonomy from self employment supported pumping when needed ( Witters-Green, 2003 ). Jobs that require someone to stepin and cover for another s break have less flexibility, and some positions such as a bus driver or machine operator would need to be transferred to another kind of job to accommodate breastfeeding ( Brown et al., 2001 ). Other examples of low flexibility jobs include security ( Dunn et al., 2004 ), the military ( Stevens & Janke, 2003 ), jobs with 12-hour rotating shifts ( Witters-Green ), and residency for physicians ( Authur et al., 2003; Miller et al., 1996 ). Witters-Green reported that only 1 of 14 large employers offered flextime. Salaried workers face different time challenges than hourly waged workers. Salaried employees usually have more control over their schedules than hourly workers do; however, the demands of higher paid job such as attending meetings and working late hours may limit time for pumping or breastfeeding. Hourly employees may have pumping time deducted from their pay or may have to make up the time ( Brown et al., 2001 ). Ortiz et al. (2004), in a retrospective study of 462 mothers who participated in a comprehensive corporate lactation program, reported that salaried employees were more likely to express their breast milk than hourly workers. As a military mother s rank increased, so did her job responsibilities, making it more difficult to find time to pump ( Stevens & Janke, 2003 ). Kimbro (2006 ), in a national study ( N = 2,466), demonstrated that while professional 16 JOGNN Volume 36, Number 1

and stay-at-home mothers had the same breastfeeding duration, mothers with administrative or manual jobs had 34% and 35% higher odds of weaning, perhaps because of job inflexibility. Instrumental Support in the Workplace (Exosystem) Child Care. Dunn et al. (2004) reported that only 14 (8.8%) of 157 employers provided on-site child care. According to Thompson and Bell (1997), when child care was on-site or nearby, working mothers reported increased breastfeeding success. Equipment and Physical Design of Setting. Type of equipment and physical layout of the workplace can be breastfeeding facilitators. High-quality, double-sided breast pumps were preferred by mothers over nonelectrical pumps that took longer and used up valuable pumping time ( Rojjanasrirat, 2004; Stevens & Janke, 2003 ). When mothers in several studies did not have breastfeeding or pumping stations at work, they resorted to pumping in the restroom, an approach associated with premature weaning ( Brown et al., 2001; Miller et al., 1996; Rojjanasrirat, 2004; Stevens & Janke, 2003; Thompson & Bell, 1997; Witters-Green, 2003 ). Although some employers viewed the bathroom as an acceptable setting for pumping, other employers recognized the need for appropriate, private sites but lacked the space and financial resources to provide designated lactation areas ( Brown et al. ). Women ( N = 462) in one study who did have access to on-site lactation rooms with hospital grade breast pumps, professional lactation support, and time to express milk had longer durations (57.8% at 6 months and 18.5% at 1 year) than the average working woman in the United States (36.2% at 6 months and 17.2% at 1 year) ( Ortiz et al., 2004 ). When their jobs required travel, workplace support continued with the supply of lightweight electrical pumps and coolers. Subsequently, 365 (79%) women at that workplace pumped and continued breastfeeding on average until the infant reached 9.1 months of age. Many employers reported that they did or were willing to provide breastfeeding support services. Libbus and Bullock (2002) indicated that more than half 54% ( N = 85) of employers in their study had been willing to establish breastfeeding or pumping areas, and 30 (35%) believed that the workplace should change to allow breastfeeding. Similarly, 43% ( N = 69) of rural employers supported the establishment of an area for breastfeeding or expressing breast milk ( Bridges et al., 1997 ). In a study of 157 employers, 44 (28%) provided formal breastfeeding support services ( Dunn et al., 2004 ). Another 54 (34.3%) provided benefits and services conducive to breastfeeding such as a private space, other than a bathroom, for pumping or breastfeeding. Businesses with more than 500 employees provided significantly more breastfeeding support than businesses with only 50 to 499 employees. Policies on Breastfeeding (Exosystem) The majority of workplaces did not provide any policies on breastfeeding ( Bridges et al., 1997; Brown et al., 2001; Dunn et al., 2004; Witters-Green, 2003 ), although some businesses without a specific policy accommodated lactating employees on an as needed basis ( Brown et al. ). Only 7 (4.4%) of the 157 Colorado employers had a specific breastfeeding policy about worksite support, but 22(14%) had policies allowing the working mother to have her infant brought to her for breastfeeding ( Dunn et al. ). Other types of policies, such as allowing women to take additional time after lunch to breastfeed, were reported by 41% of 69 rural employers ( Bridges et al. ). None of the studies linked national policies to breastfeeding duration. Implications for Research This review of the literature identifies research across the social and physical environments of human ecology. Important issues such as characteristics of the mother, of the employer, and of the workplace were linked with longer durations of breastfeeding. Further research could clarify these characteristics and explore how and under what conditions they influence duration. Gaps in the research appear at various ecosystem levels. At the individual level, research on which characteristics of the infant and the mother/infant dyad are associated with breastfeeding duration and work are needed. Researchers might also explore the effect of partial weaning on breastfeeding; best practices for maintaining milk supply; and the relationships among types of mother/infant dyads, types of jobs, types of separation (hours/day or days/week), and milk supply. Questions also remain about the physiological difficulties (milk supply, plugged ducts, mastitis, etc.) that are unique to working women and may contribute to premature weaning. Another area for research is the impact of job options such as flextime on breastfeeding maintenance. At the mesosystem level, evaluating the knowledge about and acceptance of breast milk and breastfeeding by child care workers and family members may provide information on practice interventions at the community level. Similarly, it may be prudent to direct intervention studies toward the workplace mesosystem, targeting coworker and manager support and increasing employer acceptance and system changes in the exosystem. More research could also clarify issues across the ecosystem of race/ethnicity, social class, rural/urban, and small/large employers. January/February 2007 JOGNN 17

It is imperative that health care providers understand the factors that infl uence a mother s ability to combine breastfeeding and employment. Implications for Practice To achieve Healthy People 2010 goals, it is imperative that health care providers understand the factors that influence a mother s ability to combine breastfeeding and employment successfully. Breastfeeding counseling and promotion could be done preconceptually to promote a positive attitude and commitment through the use of posters, videos, and pamphlets or by referrals to lactation consultants. Providers should be supportive of working women during prenatal and postpartum visits and dispel any myths about their ability to continue to breastfeed after returning to work. All prenatal clients should be encouraged to attend breastfeeding classes and support groups, especially clients planning on returning to the workplace. Encouraging close family members or friends to attend any prenatal, postpartum, or well-baby visits can also elicit social support. Providers should ensure that members of the social network understand the importance of their support for the mother to successfully combine employment with breastfeeding. Additionally, providers should emphasize the need for the working mother to develop a strategic plan for breastfeeding or milk expression after returning to work and to ensure the availability of a high-quality electrical pump. Health care professionals play an important role in community-wide breastfeeding advocacy. As expert resources of scientifically based information, professionals can proactively raise awareness through a variety of activities such as writing an article for a local free newspaper or by serving as a resource for community groups and planners. Providers can offer key employers and agencies anticipatory guidance in promoting and supporting breastfeeding. Employers should be encouraged to have a breastfeeding policy in place that allows for a maternity leave of 12 weeks or longer, a flexible work schedule, and an appropriate place to breastfeed or express milk. Employers should also have policies in place that exempt lactating employees from any duties that would require long separations from their babies. Health professionals networking with breastfeeding organizations such as LeLeche League International can bring information about innovative successful workplace interventions and programs back to their local communities and employers. Finally, health care professionals should support and promote local policies as well as state and federal legislation that diminish workplace barriers. Limitations This literature review contains only studies conducted in the United States from 1995 to 2006. An appropriate next step would be to broaden this review to include primary research from other countries in which social policies, cultural norms, and breastfeeding duration rates may differ. Research conducted prior to 1995 would provide an expanded perspective of this international health issue. Practitioners can promote breastfeeding by using tactics geared toward the mother, her social network, and her community. Conclusions Breastfeeding at work moves an intimate interpersonal relationship into a broader sociophysical ecosystem. Viewing the reported studies through an ecologic lens makes potential areas of intervention and gaps in the literature become more apparent. Breastfeeding practices can have a significant impact on the health status of working mothers and their infants. However, mothers face numerous obstacles when they combine lactation and employment, a combination that presents a challenge for them to achieve optimal breastfeeding duration. Health care providers can use the findings of this analysis to promote breastfeeding in this population by using tactics geared toward the mother, her social network, and her entire community. Acknowledgment The authors thank James Vickers, lecturer for scientific writing at the University of North Carolina at Chapel Hill, for editorial support. REFERENCES American Academy of Family Physicians. ( 2005 ). Breastfeeding: Position paper. Policy and advocacy. Retrieved June 25, 2005, from http://www.aafp.org/x6633.xml American Academy of Pediatrics. ( 1997 ). Breastfeeding and the use of human milk. Pediatrics, 100, 1035-1039. American College of Nurse Midwives. ( 2004 ). Breastfeeding: Position statement. Retrieved June 25, 2005, from http:// www.midwife.org/prof/display.cfm?id=405 18 JOGNN Volume 36, Number 1

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Journal of Human Lactation, 21, 245-258. Whaley, S. E., Meehan, K., Lange, L., Slusser, W., & Jenks, E. ( 2002 ). Predictors of breastfeeding duration for employees of the special supplemental nutrition program for women, January/February 2007 JOGNN 19

infants, and children (WIC). Journal of the American Dietetic Association, 102, 1290-1293. Witters-Green, R. ( 2003 ). Increasing breastfeeding rates in working mothers. Families, Systems & Health, 21, 415-434. World Health Organization. ( 2001 ). The optimal duration of exclusive breastfeeding. Information office. Retrieved April 11, 2005, from http://www.who.int/inf-pr-2001-07.html Marina L. Johnston, MSN, RNC, is a major in United States Air Force (USAF), Nurse Corps and a women s health nurse practitioner, at Women s Health Care Clinic, Cannon AFB, NM. Noreen Esposito, EdD, RNC, APRN, BC, is a women s health nurse practitioner, a family nurse practitioner, and an assistant professor of nursing in the University of North Carolina at Chapel Hill. Address for correspondence: Marina L. Johnston, MSN, RNC, 7807A Alaska Ct, Clovis, NM 88101. E-mail: marina43402@ earthlink.net. 20 JOGNN Volume 36, Number 1