Determinants of breastfeeding initiation and cessation among employed mothers: a prospective cohort study

The U.S. continues to have one of the lowest breastfeeding rates in the industrialized world [1, 2]. Data from 2010 indicate that 76.5 % of U.S. mothers initiated breastfeeding, and only 49 % reported feeding any human milk to their infants at six months [3]. These figures fall short of the Healthy People (HP) 2020 goals of 81.9 % for initiation of breastfeeding and 60.6 % for any breastfeeding at 6 months [4]. Breastfeeding has established benefits for both maternal and child health [2]; however, employers may also benefit from supporting breastfeeding in the workplace. Employed mothers who breastfeed incur lower healthcare costs for themselves and their babies [5], and have lower workplace absenteeism than non-breastfeeding mothers [6]. Yet, often mothers find it difficult to continue breastfeeding after returning to work. About 70 % of employed mothers of infants younger than three years have full-time jobs and around one third of these mothers return to their jobs within the first three months postpartum [7]. Therefore, it is important to understand workplace-related barriers and facilitators to the initiation and continuation of breastfeeding.

The literature on employment characteristics has shown factors such as having a non-professional occupation [8, 9] and planning to work full-time after childbirth [10, 11] decreased the likelihood of breastfeeding initiation. Moreover, factors such as being employed full-time [11, 12] and early return to work after childbirth [13, 14] increased the likelihood of early breastfeeding cessation after childbirth, whereas having a professional job [9, 15], a flexible job [13, 14], and access to employer family-friendly benefits [13] decreased the likelihood of early breastfeeding cessation. However, scarce research has examined the impact of employer paid leave policies on breastfeeding.

The U.S. is the only industrialized country in the world that does not have a national paid maternity leave policy [16]. Having access to paid leave has been associated with longer leaves among mothers after childbirth [17]. The main federal law governing leave in the U.S. is the Family and Medical Leave Act (FMLA) of 1993, which mandates unpaid leave of 12 weeks for perinatal care, childbirth, and caring for a newborn or an adopted child [18]. Thus, it is not surprising that U.S. national data on first time mothers show that 58.6 % returned to paid work in the first 3 months postpartum [19]. Economic theory on the household production function [20], predicts that women may choose the duration of leave from work after childbirth as an input to the production of their child’s health (in this case through taking time off to breastfeed) subject to constraints such as relatively low household income and employer paid/unpaid leave policies.

The objectives of this study are to identify the rates of breastfeeding among employed women during the first 6 months after childbirth and to investigate the association of employer paid leave policies and other employment characteristics with the initiation and cessation of breastfeeding by 6 months postpartum. This study contributes to the literature by focusing exclusively on employed mothers in the state of Minnesota, which has one of the highest female labor force participation rates in the nation (71.2 %) but does not have a statewide paid leave policy [21], and identifying the influence of employer paid leave policies on breastfeeding initiation and cessation.

The Maternal Postpartum Health Study is a prospective cohort study that recruited employed Minnesota women while hospitalized for childbirth [22]. The study population included women ages 18 and older and admitted to one of 3 community hospitals in Minneapolis and St. Paul for childbirth in 2001. Recruitment occurred between April 9, 2001 and November 19, 2001. According to vital statistics data, recruited mothers were comparable on demographics and birth characteristics to mothers who delivered at 41 other hospitals in the seven-county metropolitan area [22]. Sample selection criteria included: having had a healthy singleton infant, English-speaking, prenatally employed for at least 20 h per week, planning to continue employment after childbirth, and planning to keep the infant.

Among 2,736 women giving birth at the 3 study hospitals for the enrollment period, 1157 met our sample selection criteria (42 % of all births). Of these 1157 women, 817 agreed to participate in the study and were enrolled in the hospital (response rate: 71 %) (see Fig. 1). The primary reasons for nonparticipation were concerns about time commitment and lack of interest. Study participants were compared to women who refused participation to identify systematic bias using limited data from hospital medical records and interviews. Using a t-test of differences in the means, there were no significant differences between participants and refusals in regards to infant birth weight, gestational age, maternal age, marital status and years of employment. In addition, subjects were given gift certificates of $5 for completion of questionnaires at each data collection period to enhance subject compliance.

Telephone interviews of 45 min each were conducted at 6 weeks, 12 weeks, and 6 months after delivery. The follow up telephone interviews used a four week window for conducting interviews at each of 6 weeks (i.e., 4 to 8 weeks) and 12 weeks (10 to 14 weeks) postpartum and an 8 week window at 6 months (5 to 7 months) postpartum. Out of the 817 recruited women, 716 (88 %) completed the 6 weeks interview, 661 (81 %) completed the 12 weeks interview, and 625 (76 %) completed the 6 months interview. Extensive training in non-biased interviewing techniques was provided to all University of Minnesota research staff who conducted the interviews. All interviews from 6 weeks to 6 months were completed by computer-assisted telephone interviewing (CATI) which does not allow the interviewer to skip a question.

Additionally, information was gathered from a random subsample of 195 women (25 % of the participants) to request their permission for contacting human resources representatives for purposes of validation of self-report information concerning the employer’s written family and medical leave policies. Trained staff conducted a 15 min telephone interview with employers to collect information on characteristics of written leave policies, including: paid vacation and sick leave, paid maternity leave, and any unpaid parental, family or medical leave.

The sample of employed mothers in this study had a breastfeeding initiation rate of 81 %, which exceeded HP 2010 goals of ever breastfeeding (75 %) [35], and came very close to HP 2020 goals of ever breastfeeding (81.9 %) [4]. In our sample, the rate of any breastfeeding at 6 months was 33 %, which fell below HP goals for any breastfeeding at 6 months (HP 2010 goals: 50 %; HP 2020 goals: 60.6 %) [4, 35]. These results are consistent with the literature suggesting the challenges for employed women to breastfeed for 6 month duration [36], and the potential need for interventions to support employed women.

This is one of the first studies to examine whether access to paid leave through employer policy is associated with improved breastfeeding. Having an employer that provides paid leave was not associated with breastfeeding initiation and the longest paid leave available to a woman given her employer’s policy benefits was not associated with breastfeeding cessation during the 6 months after childbirth. In a sub study where we interviewed 90 employers representing 118 women in our sample about their leave policies, we found that only 29 % to 35 % of women’s self-report data matched their employers’ reports of total duration of available job-protected leave, paid and unpaid [36]. These findings are consistent with national findings on employees’ general awareness of their leave eligibility under the FMLA [28]. Thus, employers that solely institute paid leave policies without ensuring their employees’ awareness of these policies may not improve breastfeeding rates among new mothers. This may potentially explain why in our study the duration of paid leave per employer policy was not associated with breastfeeding duration while duration of leave taken by the mother was associated with breastfeeding duration. Future research should explore potential strategies employers can use to improve their employees’ awareness of their leave policies. It is also possible that women have access to some paid leave but do not use it because of stigma or only partial subsidized leave.

Conversely, the hazard for breastfeeding cessation during the first 6 months after childbirth was higher for women who returned to work at any time during the 6 months postpartum compared to those who did not return. The positive association between maternity leave duration and breastfeeding duration is consistent with other studies [13–15]. The association between return-to-work and early breastfeeding cessation highlights some role incompatibility between breastfeeding and employment. This suggests the importance of having employer support for breastfeeding practices by encouraging women to utilize their paid leaves, instituting lactation support programs in the workplace, and following the provisions of Section 4207 of the Affordable Care Act (ACA) in accommodating breastfeeding mothers in the workplace [37]. As part of the ACA of 2010, employers are required to provide employees with a reasonable break time to express breast milk for her nursing child for one year after the child’s birth; and a place for expressing breast milk, that is shielded from view and free from intrusion from coworkers and the public [37]. Primary care providers and occupational health nurses could work with pregnant and postpartum women to identify barriers and potential solutions to enhance breastfeeding outcomes in the workplace.

The findings that professional women had a higher likelihood of breastfeeding initiation and a lower likelihood of breastfeeding cessation compared to clerical women are consistent with other studies [9]. Women in professional occupations generally have greater job autonomy which affords them more privacy and more flexibility to accommodate the timing and place requirements of breastfeeding [38]. Professional women may also enjoy better access to employer-sponsored lactation programs than women in non-professional occupations, sometimes within the same workplace [39]. Thus, occupational health or human resources personnel who design worksite intervention programs that encourage breastfeeding upon return to work after childbirth would be well served to seek input from women across occupational categories to understand any potentially unique needs based upon job class, schedules and locations. Future research should investigate the mechanisms (e.g., job flexibility, access to private space, workplace support, or leave policies) through which having a professional occupation influences breastfeeding initiation and continuation.

Similar to prior research, we found that mothers who do not initiate breastfeeding are more likely to be multiparae [40], have a high school education or less [41], have smoked during pregnancy [42], have no friends or family who breastfeed [43], and to have experienced breastfeeding problems [44]. Also consistent with the literature, mothers who stopped breastfeeding during the first 6 months after childbirth were more likely to be single [41], less educated [45], and have no friends or family who breastfeed [43]. These findings are helpful in identifying specific target groups for public health interventions to promote breastfeeding initiation and continuation. For example, primary care providers could inform pregnant women on the effects of smoking on breastfeeding success and refer them to smoking cessation programs as early as feasible before childbirth. It is also important to provide women access to lactation counselors who can teach them strategies to prevent breastfeeding problems and effective management of these problems if they arise. In exploratory analyses, we found that women who had no family or friends who breastfeed had significantly lower income, were less likely to be college-educated and more likely to be in clerical and blue collar jobs than those who had family or friends who breastfeed (results available upon request). Thus, lack of family or friends who breastfeed can be a marker that identifies underprivileged groups of women and may help primary care providers recognize women who require more support and guidance for breastfeeding and in turn connect them with support groups for breastfeeding such as La Leche League International [46] and other breastfeeding peer support groups. Future research should explore whether breastfeeding by family and friends can be effective as a flag for obstetricians and nurses to recognize women who may need additional education and support in prenatal care, in the hospital at childbirth, and in postpartum care.

Our findings show that having a professional occupation had positive effects on breastfeeding initiation and continuation. Moreover, not returning to work in the first 6 months after childbirth was associated with lower likelihood of breastfeeding cessation. Given that a substantial amount of employed women return to work in the first three months postpartum, work policies that support longer duration of breastfeeding in line with HP2020 goals are warranted. Additionally, research is needed to identify the structural components of a professional job that facilitate maternal breastfeeding and could potentially be extended to women employed in nonprofessional occupations. Intervention programs that encourage breastfeeding should specifically target at-risk populations of women, including the single, less educated, those in non-professional occupations, those who smoked during pregnancy, and women with no family or friends who breastfeed.

ACA, affordable care act; FMLA, family and medical leave act; HP, healthy people