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Evidence based workplace interventions to promote breastfeeding practices among Pakistani working mothers

Aga Khan University School of Nursing and Midwifery, Stadium Road, P.O. Box 3500, Karachi, Pakistan

Received 19 May 2011; received in revised form 11 December 2011; accepted 30 December 2011. published online 06 February 2012.
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Article Outline

Summary 

Background and aim

Breastfeeding is an essential source of nutrition for young babies; however, it is challenging for employed mothers to continue breastfeeding with employment, especially if workplace support is minimal or missing. In Pakistan, from 1983 to 2008, the prevalence of breastfeeding at 6 months has decreased from 96% to 31%. In this region, workplace barriers have been reported as one of the reasons that result in early cessation of breastfeeding among working mothers. This paper aims at reviewing global literature to explore workplace interventions that can promote the breastfeeding practices among working mothers in Pakistan.

Methods

A literature search of peer reviewed databases, including CINHAL (1980–2009), MEDLINE (1980–2009), Pub Med (1980–2009), Springer Link (1980–2008), and Cochrane Database of Systematic Reviews (3rd quarter, 2008), was undertaken. Considering the pre-set inclusion and exclusion criteria, out of more than 500 literature sources, 50 were shortlisted and reviewed.

Results

A review of global literature revealed that in order to promote breastfeeding practices among employed mothers, the most powerful workplace interventions include: educating working mothers about management of breastfeeding with employment; enhancing employers’ awareness about benefits of breastfeeding accommodation at workplace; arranging physical facilities for lactating mothers (including privacy, childcare facilities, breast pumps, and breast milk storage facilities); providing job-flexibility to working mothers; and initiating mother friendly policies at workplace that support breastfeeding.

Conclusion

In Pakistani workplace settings, where little attention is paid to sustain breastfeeding practices among working mothers, there is a need to initiate lactation support programmes. These programmes can be made effective by implementing composite interventions at the level of breastfeeding working mothers, employers, and workplace.

Keywords: Workplace interventions, Breastfeeding, Working mothers, Lactation support programmes, Employers, Physical facilities, Mother friendly policies, Pakistan

 

Breastfeeding is an important aspect of parenting1 as well as an essential source of nutrition that contributes to optimal growth and development of young babies.2 A comparison of breastfed and formula fed infants reveals that breastfed babies score higher on cognitive development3 and have lesser prevalence of illnesses.4, 5 Therefore, as one of its priority actions, the World Health Organization has encouraged promotion of appropriate feeding practices for infants and young children by supporting breastfeeding mothers.6 Also, through the promotion of baby-friendly campaign, the ten steps to successful breastfeeding have been proposed to protect, promote, and support breastfeeding.7 Table 1 summarizes the ten essential steps for promoting breastfeeding practices of lactating mothers.

Table 1. 10 steps to successful breastfeeding as proposed by WHO and UNICEF (2009).
1. Having a written breastfeeding policy that is routinely communicated to health care staff
2. Training health care staff to implement the breastfeeding policy
3. Informing all expectant mothers about importance and management of breastfeeding
4. Assisting mothers to initiate breastfeeding within a half-hour of child birth
5. Showing mothers how to breastfeed and how to maintain lactation even if the mother–child separation is desired
6. Providing only breast milk to newborns unless medically contraindicated
7. Allowing mothers and babies to be together at all time
8. Encouraging on demand breastfeeding
9. Avoiding artificial teats or pacifiers for breastfeeding babies
10. Fostering the establishment of breastfeeding support groups, and referring mothers to these groups on discharge from the hospital or clinic

Working mothers are one of those groups who often find it challenging to continue breastfeeding with employment, especially if workplace support is minimal or missing.8, 9, 10, 11, 12, 13, 14, 15 Studies conducted among American working mothers reported that early cessation of breastfeeding was greater among employed mothers,16, 17 and mothers who returned to work after childbirth reported to have a 6–9 weeks shorter duration of breastfeeding as compared to mothers who stayed at home.18 The problem of early cessation of breastfeeding among employed mothers indicates that at each country level, there is a need to extend support to these mothers to sustain their breastfeeding practices.

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Breastfeeding prevalence and challenges of lactating working mothers in Pakistan 

Pakistan, one of the developing countries that has the second highest child mortality rates in South Asia,19, 20 is showing a gradual decline in breastfeeding prevalence rates.21, 22 The Society for the Protection of the Rights of Child (SPARC) reported that from 1975 to 1983 around 96% mothers were breastfeeding at 6 months, and 90% mothers were breastfeeding (along with complementary feeding) at 12 months; whereas, in 2008 only 31% Pakistani mothers were breastfeeding their babies between 6 and 9 months along with the provision of complementary foods.22 In this region, lack of workplace support has been reported as one of the major obstacles for working mothers who breastfeed.22 As a matter of fact, in Pakistan where labor force participation among females is gradually increasing,23 little attention is paid at initiating workplace lactation support programmes for working mothers who breastfeed. Consequently, working mothers find it challenging to continue their breastfeeding practices. While highlighting this issue, qualitative studies conducted among lactating mothers employed in the urban setting of Karachi, Pakistan, indicated that lack of supportive measures at workplace settings, including availability of breastfeeding breaks, privacy to express breast milk, employers’ support towards breastfeeding, and flexibility in duty hours, leads towards early cessation of breastfeeding among working mothers.24, 25 Furthermore, although the country's maternity benefit ordinance maintains that upon completion of four months of employment, or the qualifying period, lactating working mothers in Pakistan are entitled to avail 12 weeks of paid leaves (6 weeks prenatal and 6 weeks postnatal leaves),26 in actual, full time working mothers are reported to receive 4–9 weeks of paid leaves instead of 12 weeks of leave as per the stated national policy.25 Moreover, breastfeeding policy does not exist at workplace settings in Pakistan, which further hinders these mothers from continuing breastfeeding. Considering the problem stated above, the aim of this paper is to review global literature to explore evidence-based working interventions that could promote breastfeeding practice among lactating working mothers in Pakistan.

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Operational definitions of terms 

Lactating working mothers 

Women of childbearing age who return to the workplace during the infancy period of their babies and who combine breastfeeding with employment. The review includes all breastfeeding working mothers, regardless of their nature of job, i.e. part time or full time, type of employment, marital status, nationality, and socio-economic status.

Breastfeeding 

Provision of breast milk to infants along with provision of complementary feeding.

Complementary feeding 

Provision of solid or semi-solid food, water, juices, non-human milk, and formula milk to infants.

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Literature search strategy and data bases searched 

As the aim was to conduct a systematic search with a focus on workplace interventions for lactating working mothers, therefore, a systematic literature search of peer reviewed databases, including CINHAL (1980–2009), MEDLINE (1980–2009), Pub Med (1980–2009), Springer Link (1980–2008), and Cochrane Database of Systematic Reviews (3rd quarter, 2008), was undertaken. Review was undertaken from 1980 so as to appraise the utility and feasibility of various workplace interventions over the past decades. The key words used for the search included: workplace breastfeeding support, breastfeeding working mothers, and breastfeeding. Moreover, a free text search strategy was used; therefore, a search was conducted in all databases for keywords appearing in the title, abstract, body of text, or subject heading. To supplement the search, the WHO website (http://www.who.int), the government of Pakistan website (http://www.statpak.gov.pk/), and the Society for the Protection of the Rights of Child (SPARC) website (http://www.sparck.org/) were also reviewed. Additionally, the relevant theses of Master's student were accessed from the Faculty of Health Sciences Library of the Aga Khan University and reviewed.

The literature search and its short listing were guided by the inclusion and exclusion criteria that have been summarized in Table 2. As an inclusion criteria, the search was limited to articles published between 1980 and 2009. For the literature review, all types of literature, i.e. research studies, review articles, meta-analysis, meta-synthesis, editorials, letters, and grey literature, were considered. Also, studies with all types of study designs were considered. The short listing of literature was done by looking at all implemented, described, and/or recommended workplace interventions for breastfeeding promotion among employed mothers. Literature that presented interventions for non working or non breastfeeding mothers was excluded during the short listing of articles. Altogether, out of more than 500 literature sources, 50 were shortlisted, that included 36 published studies, 5 review articles, 7 grey literature sources, 1 letter to the editor, and 1 book chapter.

Table 2. Inclusion and exclusion criteria for literature search and short listing of literature.
Inclusion criteriaExclusion criteria
PopulationPopulation
Female and maleaAge: below 19 year or above 44 years
Focus: breastfeeding working mothersNon working mothers
Age: 19–44 years
Working mothers of all nationality, culture, race, and professionSearch year
Breastfeeding working mothers could have any marital status, e.g. single, married, etc.Before 1980
Search yearFocus of literature
1980–2009None
Focus of literature
Describing, explaining or recommending any workplace intervention that could affect mothers’ breastfeeding practicesFocus of interventions
Focus of interventionsInterventions for non working mothers
All interventions for breastfeeding working mothersInterventions for non breastfeeding working mothers
Interventions could be in the context of working mother, working father, employer, workplace, or policy
Type of articles
All type (review articles, research articles, reports, letters to editor, clinical practice guidelines, etc.)

aMale gender was considered in the population to review the interventions at the level of male employers, employed fathers, and husbands of working mothers.

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Findings 

Overview of workplace breastfeeding support programmes: global perspective 

The notion of workplace interventions for breastfeeding working mothers has been widely discussed under the broader umbrella of workplace breastfeeding support programmes. Literature asserts that workplace breastfeeding support programmes aim to accommodate the rights of breastfeeding mothers and breastfeeding babies,27 and they accommodate these needs by offering various logistic arrangements at the workplace.28 Workplace lactation support programmes have been viewed as planned and collective efforts of a company to assist breastfeeding mothers via specialized arrangements.29 Literature discusses that these programmes serve as a work-life conflict resolution strategy and as an avenue for promoting work-life balance among working mothers.15, 30 A synthesis of the literature indicates that workplace lactation support is a set of strategies that can enable breastfeeding mothers to continue breastfeeding with employment.

The review indicates that mothers’ workplace settings have a deep impact on their decision to continue or discontinue the breastfeeding practices.31, 32 Several publications have revealed that the presence of workplace lactation support programmes enhances working mothers’ capacity to continue breastfeeding along with employment.8, 16, 27, 33, 34 One of the studies reveals that female employees, who received support from employers and workplace, described their experiences as “the best experience affecting breastfeeding”.35 This indicates that the presence or absence of workplace interventions can impact the breastfeeding practices of working mothers, and these interventions could be viewed as mother and baby friendly initiatives at workplace settings.

Sets of workplace interventions for breastfeeding working mothers 

Findings from the literature reveal that for the successful implementation of such programmes, workplace interventions must be designed at multiple levels.36 It is emphasized that collective efforts are required at the level of employee, employer, and workplace to promote a balance between breastfeeding and employment.37 Therefore, the following workplace interventions have been identified from literature for supporting employed mothers to continue breastfeeding.

Educating and guiding working mothers about breastfeeding 

At the level of working mothers who breastfeed, provision of knowledge and guidance about strategies to manage breastfeeding with employment is one of the most essential interventions to promote breastfeeding practices among working mothers.11 This intervention is considered as one of the essential elements of workplace lactation support programmes.4, 28, 33 Literature further emphasizes the importance of enhancing mothers’ knowledge about breastfeeding to enable them to plan and manage breastfeeding with their work.17 A study conducted among American mothers emphasizes that breastfeeding working mothers could be assisted for successful breastfeeding through provision of accessible educational services to them, as well as to their mothers and mothers-in-law.18 Findings from a qualitative descriptive study conducted among 50 American mothers highlight the importance of assisting breastfeeding working mothers to plan strategically and to hold a positive attitude towards breastfeeding.9 Another United States based qualitative study on working mothers (n=38) further highlights the importance of provision of prenatal and postnatal breastfeeding information and practical assistance to working mothers to enable them to decide the best suited method to feed their babies after returning to the workplace.38 Moreover, a study conducted in Dhaka, on 238 Bangladeshi working mothers, emphasizes the importance of enhancing working mothers’ knowledge about breastfeeding and maternity entitlements at the workplace.39

Enhancing employers’ awareness about breastfeeding 

As employers can help to promote breastfeeding practice in working mothers, therefore, literature highlights that raising employers’ awareness about benefits of breastfeeding is one of the essential interventions at workplace settings.38 While valuing the importance of employers’ and managements’ know how about benefits of breastfeeding accommodation at workplace, literature reveals that a well aware employer could instill receptivity among co-workers with regard to breastfeeding accommodation for employed mothers.40 Also, an Australia-based project that aimed to promote a balance between breastfeeding and employment indicated that dissemination of educational material to workplaces helped employers in revisiting their existing workplace policies; therefore, designing assistance programmes for employers has been recommended to maximize the implementation of breastfeeding support at the workplace setting.37 While the notion of raising employers’ awareness about breastfeeding has been widely supported by several authors, literature underscores that interventions for employers must move beyond the arena of providing information to them and employer focused interventions must be strong enough to challenge their negative attitude towards breastfeeding.41

Arranging physical facilities at workplace 

To promote breastfeeding practices among working mothers, another widely discussed intervention includes arranging physical facilities at workplace settings. The commonly discussed physical facilities in literature include: onsite child care, breast pumps, storage facilities, privacy, and, most importantly, provision of time to breastfeed or express breast milk. Literature recommends that working mothers must be provided with facilities to avail breastfeeding breaks, pump breast milk, and store breast milk hygienically at workplace settings.42 Literature further asserts that long term breastfeeding could be encouraged among employed mothers via workplace initiatives through provision of private, clean pumping locations and regular breaks for pumping breast milk.17 Also, while supporting the notion of physical facilities at workplace, a quantitative study conducted at one of the workplaces in New Jersey, revealed that out of 38 participants, working mothers who were a part of a workplace breastfeeding support programme (n=22) continued breastfeeding for a longer duration (mean duration 11.7 months, range 4–24 months) as compared to mothers (n=16) who only availed maternity leaves (mean duration 6 months, range 1–18 months).28

Besides the above, a quasi experimental study conducted at two corporations in the United States reveals that provision of physical facilities and equipments like breast pump, breast milk storage facility, pumping room, and privacy enabled 59 working mothers in the breastfeeding group to continue their breastfeeding practices; thus, the reported illness rates among their babies were three times lesser (p-value<0.05) than in the formula fed babies.4 This finding indicates that logistic arrangements facilitate breastfeeding promotion as a primary outcome and lower illness rates among breastfed babies, as a secondary outcome. Furthermore, a study describes breastfeeding accommodation at workplace as provision of a private room with a breast pump, refrigerator, sink, and desk to enables working mothers to breastfeed or express milk at work.43 Findings from another study also report the arrangement of a private room for breastfeeding as being the cheaper and easier aspect of implementation.40 Moreover, a mix method study conducted in Thailand highlights the importance of having private space to breastfeed, flexible timetable, breastfeeding breaks, and child care facilities to promote breastfeeding practices of working mothers.14 Also, a United States based retrospective study, on 462 women, reveals that the provision of prenatal counseling, counseling facilities, privacy, equipment for pumping, and breastfeeding breaks, under a company sponsored lactation support programme, enabled 97.5% mothers to initiate breastfeeding and supported them to continue breastfeeding till the mean age of 9.1 months (SD 4.1, range 1.9–25 months).33 Also findings from literature highlight that working mothers decide to continue breastfeeding with employment if they get time and space to express milk at work.10

Flexibility in work environment 

Literature reveals that mothers’ workplace environment plays a vital role in enabling or disabling mothers to continue breastfeeding practices along with employment.11, 31 Therefore, literature supports that, along with other interventions, provision of flexibility at workplace settings is an essential intervention.8 While highlighting job flexibility as one of the interventions at the workplace, literature recommends that flexible work hours and paid maternity leaves could enhance breastfeeding mothers’ capacity to continue optimal breastfeeding.31 Also, United States based studies support the notion that a flexible work environment facilitates breastfeeding continuation among lactating working mothers.38, 44 Furthermore, study findings by some other authors suggest that flexibility and facility at the workplace could increase breastfeeding initiation rates among working mothers.45, 46

Mother and baby friendly policies 

Besides other interventions, several study findings reveal the importance of having mother and baby friendly policies to support breastfeeding continuation. A Hong Kong based cross-sectional study suggests, “Policies can validate employees’ right to provide their milk for their children, even when individual supervisors or co-workers are less than supportive”.27 This reveals that presence of breastfeeding policies could secure rights of breastfeeding mothers at workplace settings. One of the cross-sectional studies conducted at a Taiwanese semiconductor manufacturer plant reports that presence of breastfeeding policies at the workplace and having awareness about them influences the initiation rates of breastfeeding among working mothers; however, differences exist in breastfeeding continuation among office workers and fab (fabricating) workers due to differences in job flexibility and working environments of both. Hence, the study revealed that along with supportive policies, flexibility in workplace is also essential.36 Case studies in Ireland, Sweden, and the United States, highlight the importance of breastfeeding supportive policies that include: paid parental leave policy, child care policies, and workplace polices for the promotion of breastfeeding.47 Also, findings from a prospective survey conducted in Washington, DC reveal that a breastfeeding friendly maternity leaves policy should be employed to support breastfeeding mothers.48 A Canadian study reveals that provision of extended maternity leave, of more than three months, could enhance breastfeeding duration among working mothers.49 Also, two other studies have highlighted that longer duration of maternity leaves serves as a powerful predictor for sustaining breastfeeding practices of working mothers.50, 51

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Discussion of appropriate workplace interventions for working mothers in Pakistan 

Review of literature from global perspective suggests the importance of composite workplace interventions to promote breastfeeding practices among working mothers. In Pakistani workplace settings, where little attention is paid to initiate lactation support programmes for working mothers, implementation of need based interventions will not only provide basis for introducing mother and baby friendly initiatives at Pakistani workplace settings but will also enable health care professionals, workplace supervisors, and policy makers to continue to develop programmes, policies and practice guidelines to sustain breastfeeding practices of Pakistani working mothers.

For Pakistani working mothers, like women worldwide, provision of practical assistance and guidance regarding ways to continue breastfeeding with employment can serve as a powerful intervention. In this regard, provision of prenatal and postnatal guidance to mothers in their first language will enable them to clarify their misconceptions about breastfeeding,52 and sustain their breastfeeding practices. Moreover, this intervention will enable working mothers to get awareness about strategies to manage their breastfeeding activities during their working hours, including expressing and storing breast milk at workplace, as well as setting schedules for breastfeeding breaks. Previously conducted studies among Pakistani working mothers also support that mothers’ knowledge about breastfeeding enables them to initiate and continue their breastfeeding practices.24, 25

In Pakistani workplace settings, it is challenging for employed mothers to sustain their breastfeeding practices if their employers are non-supportive.13, 24, 25 A qualitative study conducted among Pakistani mothers reported that despite the documented parental leaves policy at the institution level, working mothers were not able to avail these leaves if they did not get their employers’ permission.25 This stresses that raising employers’ awareness about the above multidimensional benefits of breastfeeding accommodation at workplace could result into initiation of supportive measures for these mothers. In the Pakistani context, this intervention can not only accommodate flexibility and facility for lactating working mothers, but can also enable these mothers to avail official time off from work (to breastfeed or express breast milk during working hours), and utilize physical facilities at workplace. As workplace breastfeeding accommodation is mostly viewed as a supportive measure only for the employed mothers and their babies,30, 43 therefore, to assure success of this intervention, it seems vital to raise employers’ awareness about the benefits of breastfeeding accommodation for themselves and the institution. Some of these benefits include raise in job-satisfaction and retention of female employees,15, 29, 40 company's cost saving through reduction in mothers’ absenteeism rates and sickness rates among their breastfed babies,4 and promotion of the company's image.29, 53

As compared to the Western world, in Pakistan, where workplace settings lack a conducive environment for breastfeeding working mothers, some of the most common reasons for early cessation of breastfeeding by working mothers include: non-availability of breastfeeding breaks, limited options for child care at workplace setting, and absence of physical facilities like privacy to express breast milk, breastfeeding rooms, breast pumps, and breast milk storage facilities.13, 24, 25 Among physical facilities, availability of privacy at workplace to breastfeed baby or express breast milk at work is pivotal for Pakistani working mothers as many mothers do not prefer to breastfeed their baby or express breast milk at work in the presence of their male colleagues or employers. It is reported that in the absence of privacy Pakistani working mothers opt to use wash rooms or store rooms as a private place to express their breast milk which results in early cessation of breastfeeding practices.13, 24, 25, 52 This indicates that in the Pakistani context, assuring the provision of physical facilities and supportive measures at workplace could serve as another powerful intervention to enable employed mothers to continue their breastfeeding practices. Also, considering the anticipated positive outcomes of this intervention, it can be inferred that the benefits from this intervention could overweigh the cost invested into it.

Evidences from literature reveal that extension of maternity leaves till the weaning age of a young child could enable mothers to breastfeed their babies. In the context of Pakistani working mothers, where most of the workplace settings are not following the national policy, and mothers are expected to return to work 6–9 weeks after childbirth, enhancement of duration of maternity leaves could serve as a powerful promoter of breastfeeding practices of working mothers. While supporting this notion, qualitative studies conducted among Pakistani working mothers revealed that the 9-week duration of maternity leaves was considered inadequate by these mothers, therefore, an extension of these leaves till 6 months of the child's age was recommended.24, 25 Also, in these studies mothers stressed the need for a well documented breastfeeding policy, so as to be able to avail the breastfeeding breaks (to breastfeed baby or express breast milk) during working hours. This indicates that, similar to other countries, Pakistani working mothers require availability of supportive workplace-based mother and baby friendly policies to sustain their breastfeeding practices.

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Conclusion 

Evidences from literature support that employed mothers experience challenges in combining breastfeeding with employment, therefore, composite workplace interventions at the level of mother, employer, and workplace are essential to promote breastfeeding practices among working mothers. In Pakistan where a gradual rise in the rate of female participation in the labor force and a decline in breastfeeding prevalence rates has been reported, there is a need to initiate workplace lactation support programmes at workplace settings. It is viewed that breastfeeding practices of Pakistani working mothers can be sustained by providing them knowledge and practical assistance to manage breastfeeding while working, raising employers’ awareness about breastfeeding accommodation at workplace, arranging physical facilities (child care facilities, breastfeeding rooms, breast pumps, and storage facilities) at the workplace, provision of breastfeeding breaks during working hours, and initiating mother friendly supportive policies at workplace, including breastfeeding policies, parental leaves policy, and, more importantly, policies on maternity leaves as per country's labor policy. It is anticipated that implementation of composite interventions will not only enable the government and the country's workplace settings to promote breastfeeding practices among Pakistani working mothers but will also contribute effectively in improving the health of young Pakistani children.

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Acknowledgment 

We are grateful to Ms. Fatima Shahabuddin, the English language editor, for providing English language editorial support for this manuscript.

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PII: S1871-5192(12)00002-9

doi:10.1016/j.wombi.2011.12.005

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