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Breastfeeding and Return to Work or School


Key Points

  • Although it is not easy, mothers need not make any choice between their employment and the optimal nutrition of their infant through breastfeeding.

  • As women’s role in the workplace continues to assert itself, employers and policy makers must ensure that proper accommodations are available to breastfeeding employees; it is good for business.

  • Physicians must advocate for child health and parental well-being by providing sound developmental information, practical advice, and access to appropriate support organizations for employed breastfeeding mothers.

Mothers have always worked. All women work when work is defined as expending energy for a purpose, but not all women are employed when it is defined as earning money for labor. The decision to breastfeed is a very personal one embedded in the context of family, friends, culture, and life. The decision to breastfeed and return to work or education is equally complex with the varied perspectives (personal, social, psychological, emotional, relational, economic, and environmental) on work, life, and balance.

We need to continue to listen to and understand mothers’ reasons for breastfeeding, their goals for breastfeeding, and their perception of potential barriers to breastfeeding and engage them in a conversational manner for understanding their reasons for breastfeeding and returning to work or school. This understanding has to be on a familial, communal, social, and generational level but discussed with personal respect, acknowledgment, and empathy for the individual mother’s choices. The tremendous variation in types and amount of education and in the myriad job situations, along with the mother’s individual reasons for working while pregnant or breastfeeding, make any generalizations about work or return to school and breastfeeding almost irrelevant.

Breastfeeding and Employment

Mothers were the fastest-growing segment of the labor force and the rate of maternal employment outside the home was increasing globally in the early years of this century (2000). 1 , 2 Reports from 2018 suggest that participation of women in the labor force has been decreasing worldwide from 51.4% in 1990 to 48.5% in 2018 as the participation of men in the workforce has changed from 80% in 1990 to 75% in 2018. 1 In an analysis by the International Labour Organization (ILO), important factors contributing to the differences by gender included structural barriers, cultural restrictions, increasing number of years that women spend in school, and lack of employment opportunities, especially for young women. There was significant variation in those percentages by country as reflected by a selected sample range of percentage of women participating in the workforce: Yemen 6%, Syria and Algeria 12%, United States 56%, Australia 60%, Lao PDR 77%, and for Madagascar and Rwanda 84%. 3 In many countries throughout the world women account for over 40% of the workforce, including across Europe. 4 Data from the US Department of Labor show that mothers with children under 18 years old are the primary or sole earner in 40% of US households. Nevertheless, women continue to spend more time than men doing “unpaid work,” including child care and housework. 5 In the United States, the estimate of time spent in unpaid work was 4 hours and 3 minutes versus 2 hours and 30 minutes for women and men, respectively. In 2017 in the United States mothers with children younger than 3 years of age were 62.3% of the labor force. 6

Women in general make a huge contribution to national economies and significant contributions to the economic stability of their families. The trend for mothers to work through much of pregnancy has lessened per reports in the United States through 2008. 7 Of women who had a first child in 2006 to 2008, 66% worked during their pregnancy. In that same period approximately 80% of those women worked to within 1 month of delivery of their first child. Similarly, 73% of the women returned to work within 6 months after delivery of a first child occurring in 2005 to 2007. 7 One explanation for this trend is economic, with young households requiring two incomes or the mother is the primary household earner. Another reason is that new mothers are more likely to use paid along with other forms of leave rather than to leave their job. 7 Recognition of women’s and mothers’ contribution to a growing economy and to a degree an increased understanding of the benefits of breastfeeding to both maternal and infant health has led to an awareness by legislators of the importance of improved working conditions, parental leave, and maternity protection. 8

Organized Support for Breastfeeding and Return to Work or School

Along with the recognition that mother’s return to work is one of the dominant reasons for stopping breastfeeding between 3 and 6 months of age, efforts to counteract this effect have been augmented. This is occurring on the international level (World Health Organization [WHO], United Nations Development Programme [UNDP], United Nations International Children Education Fund [UNICEF], World Alliance for Breastfeeding Action [WABA], La Leche League, ILO) and national level (in individual countries). In the United States, this is being addressed by the efforts of the United States Breastfeeding Committee, the Division of Nutrition Physical Activity and Obesity at the Centers for Disease Control and Prevention (CDC), 9 US Department of Labor, Office of Women’s Health of the US Department of Health and Human Services (DHHS), National Conference of State Legislatures (NCSL), Health Resources and Services Administration (HRSA), and the Center for Food Safety and Applied Nutrition of the US Food and Drug Administration (FDA). The efforts of these various organizations range from cataloging the maternity support and paid parental leave laws in individual countries (or states), making recommendations to professionals and businesses about how to support breastfeeding women returning to work and providing guidance to women and families regarding working and breastfeeding and achieving one’s breastfeeding goals. The American Academy of Pediatrics (AAP) firmly adheres to the position that breastfeeding ensures the best possible health and the best developmental and psychosocial outcomes for infants. 10 The American Academy of Breastfeeding Medicine (ABM) outlines goals and principles of support for breastfeeding mothers in the workplace or educational settings. 11 Enthusiastic support and involvement of all physicians in the promotion and practice of breastfeeding and continuation as exclusive breastfeeding through 6 months of life are essential to the achievement of optimal infant and child health, growth, and development. The American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Family Practice have made equally strong statements supporting working breastfeeding mothers. 12 , 13

Parental Leave Policies Globally

Various international agencies have reported on paid parental leave as it occurs in individual countries around the world. The World Policy Analysis Center reported on the 34 countries in the Organization of Economic Cooperation and Development (OECD), which are predominantly European countries, and developed countries around the world in 2018. 14 Of the 34 OECD countries, 33 have national laws guaranteeing paid leave for mothers of infants and 32 of 34 have legislated paid leave for fathers of infants. The United States is the only country that does not have a nationally regulated policy regarding such paid leave, although various states have passed such legislation. 15 The duration of paid leave for mothers in the OECD countries is guaranteed for at least 14 weeks, and 25 of 34 countries guarantee at least 6 months of paid leave. The 14 weeks fits with the Maternity Protection Convention (2000, no. 183) as the most up-to-date international labor standard on maternity protection produced by the ILO, and 6 months fits with the recommended length for exclusive breastfeeding for all infants. 16 Wage replacement for paid leave is legislated as a maximum rate of two-thirds of one’s salary in 31 of 34 OECD countries and a maximum rate of 80% in 25 of 34 countries. The analysis of “Paid Parental Leave” by Raub et al. from the World Policy Analysis Center extensively reviews the connection of paid parental leave with infant health, maternal health, and some aspects of the economic significance of paid parental leave. 14 WABA has a summary document cataloging the nationally mandated maternity protection by country. 17 The list includes all of the world’s countries and documents maternity leave and who pays for it, other forms of nationally mandated parental leave, and breastfeeding break legislation. A total of 126 countries have legislation for breastfeeding breaks, the majority of which are intended as paid breaks for a minimum of 60 minutes a day. In the United States, the Patient Protection and Affordable Care Act (ACA) of March 30, 2010 included provisions, specifically Section 4207, amending the Fair Labor Standards Act (FLSA) of 1938, which dictated that employers provide “reasonable break time” for employees to express breast milk for her nursing child for 1 year after birth. 15 There is no required compensation for this break time, but there are stipulations regarding an adequate space for pumping and for the “applicability” of the law under different employment situations. The ACA (2010) also required private health insurance plans to cover breastfeeding support supplies and lactation counseling as a preventive health service. The US Department of Labor Wage and Hour Division developed the Wage and Hour Fact Sheet (no. 73), which is available online. 18 Selected elements of the legal provisions from Fact Sheet no. 73 are outlined in Table 18.1 .

Table 18.1
Select Elements of the Reasonable Break Time for Nursing Mothers Legal Provisions
(Abridged from Fact Sheet no. 73. Washington, DC: Wages and Hours Division, US Department of Labor. Accessed July 9, 2019.)
Elements Specifics
Time and location of breaks

  • Provide a reasonable amount of break time to express milk as frequently as needed by the nursing mother.

  • A bathroom, even if private, is not a permissible location.

  • The location must be functional as a space for expressing breast milk.

  • A temporarily created space is sufficient, provided it is shielded from view and free from any intrusion by coworkers and the public.

Coverage and compensation

  • Employers with fewer than 50 employees are not subject to break time requirement if compliance with the provision would impose an undue hardship.

  • “Undue hardship” is determined by looking at the difficulty or expense of compliance for the employer.

  • Employers are not required to compensate nursing mothers for breaks taken for the purpose of expressing milk.

  • If employers already provide compensated breaks and an employee uses such times to express milk, she must be compensated in the same way that other employees are compensated for break times.

  • The employee must be completely relieved from duty, or else the time must be compensated as work time.

Fair Labor Standards Act prohibitions on retaliation

  • It is a violation to discriminate against any employee because such employee has filed any complaint under or related to this act.

  • Employees are protected regardless of whether the complaint is made orally or in writing.

All 50 US states now have laws that allow women to breastfeed in any public or private location, and 29 states, the District of Columbia, and Puerto Rico have laws regarding breastfeeding in the workplace. The National Conference of State Legislature supports and tracks much of the ongoing legislation at the state level related to breastfeeding. 15 The obvious goal of all of this legislation is the protection of breastfeeding leading to enabling women to exclusively breastfeed for longer periods and glean the subsequent health benefits related to breastfeeding for both the infant and the mother ( Box 18.1 ).

Box 18.1
Resources Related to Maternity Protection, Maternity Leave, Paid Parental Leave, and Lactation Accommodations in the Workplace

The Gender Equality and Inequality Indices

The Gender Equality Index (GEI) is a measure used by the UNDP in the Human Development Report to examine the status of gender equality as it influences human development in six core domains (power, money, knowledge, work, health, and time). 19 By contrast, the Gender Inequality Index (GII) is used to assess the ongoing inequalities in female reproductive health, education/empowerment, and labor/employment that continue to limit human development on the national, international, and global levels. Another index employed by the UNDP, intimately linked to health, education, and inequality, is the Multidimensional Poverty Index (MPI). MPI is an attempt to understand the “experience of poverty,” assessing indicators of nutrition, child mortality, years of schooling, school attendance, cooking fuel, sanitation, drinking water, electricity, housing, and assets. Although none of these indices use breastfeeding rates, and specifically continued exclusive breastfeeding rates after women return to school or work, there is significant discussion of how enabling breastfeeding influences the other measures employed in these indices. 19 , 20 Additionally, WABA, ILO, WHO, UNICEF, and the UNDP, as well as other global organizations, argue that best practices for human development require a generous, universal, gender-equalitarian, and flexible parental leave policy, financed through social insurance. A more comprehensive parental leave policy (inclusive of mothers and fathers) can lead to improved maternal health throughout pregnancy and delivery and into the postpartum period facilitating exclusive breastfeeding through 6 months or longer.

Demographic Disparities

Global Disparities

Globally, the largest disparity in the economy or workplace is the difference between the formal economy or employment and the informal economy or employment. Informal employment is a very heterogenous group of employment situations from straightforward self-employment in one’s own business, migrant workers, domestic or agricultural workers, or casual or temporary workers to the both visible (push-cart vendors, jitney or cab drivers, daily market vendors, etc., all visible to the passerby) and invisible workers (working in small shops, workshops, and factories or in homes, out of sight). 21 This informal economy is directly linked to the formal economy, each somewhat dependent on the other, but with the informal economy further linked to poverty and inequality as well. Informal employment is in many instances connected to both lower levels of education and higher levels of poor health, morbidity, and mortality. Of the world’s workers, 61% are informally employed. Overall, higher rates of men are informally employed; however, in 56% of countries, the rate of informal employment is higher in women, especially in lower income countries. Approximately 90% of employment in Africa is informal, 70% to 80% in eastern and southeastern Asia is informal, and over 60% is informal in northern Africa and the Middle East compared with 54% in Latin America and the Caribbean and 37% in Eastern Europe and Central Asia. 22 , 23

Additional barriers to breastfeeding that informal workers may face on return to work after pregnancy include little or no time between delivery and return to work, distance from work and difficult transportation for an infant, dangerous work environment, long working hours, limited or no breaks, and time worked or actual production linked tightly to income. The majority of the interventions to facilitate and sustain breastfeeding on return to work (paid parental leave, legislation for breastfeeding breaks, and interventions in the workplace to increase awareness and acceptance of the benefits of breastfeeding to business) have had an impact only on the formal employment setting. Even though many of the world’s leading companies are creating more inclusive and generous parental leave and family-friendly situations and policies, they predominantly affect formal employment. 24 Nevertheless, there are ways to support pregnant women and breastfeeding mothers in informal work settings through adjusting work hours and breaks, assigning different tasks to different individuals, creating informal child-care situations, and making work environments safer for all workers. 20 Guaranteeing breastfeeding protection and support even in informal settings through both legislation and effective interventions is essential to have an impact on the very large numbers of women employed in informal work settings.

Disparities in the United States

The diversity of the US labor force is predicted to continue to increase slowly. Women in low-income jobs are predominantly minorities (black and Hispanic) and return to work earlier and to jobs that do not accommodate breastfeeding. 25 This occurs in both formal employment and informal employment. Some of the barriers in the workplace to returning to work and being able to continue to breastfeed an infant include inflexible schedules, lack of daycare at the site of employment, lack of space for breastfeeding or pumping milk, and lack of understanding and support from employers and colleagues.

There were 131 million working age women (16 years of age or older) in the United States in 2016, representing 51.7% of the total working age population, and 74.4 million were in the labor force. Of that number, 101.4 million were white, 17.4 million were black, 8.1 million Asian, 4.3 million “other,” and 20.4 million Hispanic ( Fig. 18.1 ). 26 The percentage of women participating in the workforce approached the percentage of men participating without any consideration for pregnancy or early child care.

Fig. 18.1, Labor force participation by sex, race, and Hispanic ethnicity, 2016 annual averages.

The labor force participation rate of mothers in the workforce with children under 18 years of age in 2016 was 70.5%, 75.0% for mothers with children 6 to 17 years of age, 68.6% for mothers with children between 3 and 5 years of age, and 61.8% for mothers with children under 3 ( Fig. 18.2 ). 26 This reinforces what a significant contribution working mothers make to the economy and the importance of protecting maternity, paid parental leave, and accommodations for breastfeeding/pumping in the workplace.

Fig. 18.2, Mothers’ participation in the labor force (percentage of total number of women in the workforce).

Of employed women, 74.1% worked full time (35 hours or more) and 24.9% worked part time compared with 87.6% and 12.4% of employed men.

Differences in education is a major factor in disparity with the over 64 million women 25 years or older in the labor force; 6.0% had less than a high school diploma, 23.2% had no more than a high school diploma, 16.9% had some college, and 53.8% had a bachelor’s degree or higher. The overall women-to-men ratio of earnings is 80.5% (a woman earns approximately $0.80 for each dollar a man earns), with white women only 77.0% and black women 87.3%, Hispanic women 82.3%, and Asian women only 75.9%. 26

As of 2014 the largest percentage of employed women were in education and health services (36.2%), wholesale and retail trade industry (13.1%), professional and business services (10.5%), and leisure and hospitality services (10.3%). 25

There are two recent large studies of racial, ethnic, or geographic differences in breastfeeding in the United States. 27 , 28 McKinney et al. 27 analyzed data from the Community and Child Health Network study with 1636 mother–infant pairs for initiation and duration and demographic variables. 27 Spanish-speaking Hispanic mothers had higher initiation (91%) and longer duration of breastfeeding (mean duration, 17.1 weeks) than English-speaking Hispanic mothers (initiation 90%, mean duration 10.4 weeks) compared with white mothers (initiation 78%, mean duration 16.5 weeks) and black mothers (initiation 61%, mean duration 6.4 weeks). The subsequent analysis demonstrated that demographic factors and formula feeding in hospital explained differences in breastfeeding duration, and demographic factors and family breastfeeding history accounted for the differences between Hispanic mothers and white or black mothers. In another study using data from the National Immunization Survey (NIS) for children born between 2010 and 2013, Anstey et al. reported significant racial and geographic differences between black and white mother–infant pairs. 28 Breastfeeding initiation rates were lower for black infants than white infants in 23 states, and in 14 of those states in the South and Midwest there were differences of at least 15 percentage points in initiation. There was also a difference of at least 10 percentage points in exclusive breastfeeding through 6 and 12 months (white > black in 12 states at 6 months and white > black in 22 states at 12 months). In a separate analysis using Monte Carlo simulations, Bartick et al. 29 estimated risk for illness for eight pediatric and five maternal illnesses assuming the published causal relationships between breastfeeding and specific illnesses. They created hypothetical cohorts using 2012 breastfeeding rates by race and ethnicity with expected outcomes if 90% of infants met the recommendations for exclusive breastfeeding and recommended duration. 29 Comparing the “hypothetical cohorts,” suboptimal breastfeeding would lead to 1.7 times the number of excess cases of otitis media, 3.3 times the cases of necrotizing enterocolitis, and 2.2 times the number of excess child deaths in non-Hispanic blacks compared with a non-Hispanic white population. In a hypothetical Hispanic cohort, there would be 1.4 times the number of gastrointestinal infections and 1.5 the number of excess child deaths compared with a hypothetical non-Hispanic white population. Racial and ethnic disparities in breastfeeding have real and important economic and health consequences.

Maternal Employment Affects Breastfeeding Exclusivity and Duration

Maternal employment has been cited by many authors as one of the major reasons for the decline in breastfeeding worldwide; however, this may not be universally true. From 1984 through 2002, the Mothers Survey in the United States confirmed that a large percentage of women initiating breastfeeding in the hospital included women who planned to return to full-time employment, the next highest percentage was among women who plan to return to part-time employment, and the lowest percentage of women initiating breastfeeding in the hospital was among those who plan to remain at home (see Figure 18.3 ). In that same review of breastfeeding trends, more women who were employed full time discontinued breastfeeding through the first 6 months compared with those working part time or not working. In 2003 initiation in the hospital was 65.5% among women fully employed, 68.8% among those employed part time, and 64.8% among those not employed. The duration, however, was affected by employment, with 36.6% of those employed part time still breastfeeding at 5 to 6 months, 35.0% of nonemployed women still breastfeeding at that point, and only 26.1% of those employed full time still breastfeeding at 5 to 6 months. 30 Additional data from Listening to Mothers II (2007) and III (2013) from the Reports of National Surveys of Women’s Childbearing Experiences reported that of mothers completing the survey 20% exclusively breastfed at 6 months (2007) and 17% exclusively breastfed at 6 months (37% exclusively breastfed at 3 months, 9% at 9 months, and 2% at 12 months) (2013), but did not report data in this report on working status. 31 Reasons given by 8% or more of the mothers for not breastfeeding at the time of follow-up for the survey included trouble getting breastfeeding going well (39%); formula or solid food was more convenient (22%); I fed my baby breast milk as long as I had planned (22%%); my baby stopped nursing, it was the baby’s decision (18%); I was working a paying job or attending school and other people were feeding the baby (9%); and I did not have enough support to work through all the challenges (8%). Numerous other studies provide lists of reasons mothers stop breastfeeding in the first year of life. Return to work or school was reported commonly among the reasons along with other significant reasons, including inconvenience or fatigue, concerns about milk supply, medical reasons, lactational factors, psychosocial factors, lifestyle considerations, length of maternity leave, and infant self-weaning ( Fig. 18.4 ). 32 , 33 , 34 , 35 , 36

Fig. 18.3, Comparison of breastfeeding duration rates during first 6 months postpartum among mothers who are working full time, working part time, and not employed.

Fig. 18.4, Breastfeeding cessation, Kaplan-Meier failure assessment. A , All subjects. B , According to length of maternity leave.

To investigate the effect of maternal postpartum employment on breastfeeding duration in Australia in the first 6 months after birth in 2008, Cooklin et al. 37 performed a secondary analysis of the Longitudinal Study of Australian Children. Data on 3697 children were completed. Multivariable logistic regression was used to measure the effect of the timing of a mother’s return to work and the effect of employment on breastfeeding status. Adjustments were made for maternal age, history of smoking during pregnancy, and socioeconomic status. Breastfeeding rates dropped to 39% at 6 months among employed mothers compared with unemployed mothers at 56%. Full-time employment before 6 months had a major impact; 44% of those who were employed part time were breastfeeding at 6 months. The authors concluded that in spite of controlling for risk factors, employment before 6 months had a negative impact on dedicated breastfeeding ( Fig. 18.5 ).

Fig. 18.5, Percentage of mothers still breastfeeding, by age of child and hours worked.

Effects of Paid Maternity Leave or Workplace Accommodations on Breastfeeding

One modified experimental study documented that access to paid leave, as instituted in California, was associated with increases in the rates of exclusive and overall breastfeeding for 3 to 9 months after birth. 38 The probability of establishing breastfeeding has been associated with a longer maternity leave of 8 weeks of more. 39 , 40 Additional data reported in 2016, from an analysis of Listening to Mothers III national survey data, noted that only 40% of the women had access to both break time and private spaces at work as stipulated by the breastfeeding workplace accommodation provisions of the ACA. Women who had both private space and adequate break time were 2.3 times (95% confidence interval [CI] 1.03, 4.95) as likely to be exclusively breastfeeding at 6 months. 41 Ogbuanu et al. 40 analyzed data of 6150 mother–infant pairs from the Early Childhood Longitudinal Study–Birth Cohort (ECLS-B) in the United States. Of the study population, 69.4% initiated breastfeeding, although in adjusted analyses neither paid maternity leave nor total time of maternity leave influenced breastfeeding initiation or duration. When they compared mothers who had returned to work between 1 and 6 weeks postpartum with those who had not returned to work at the 9th-month interview there were greater odds of initiating breastfeeding (odds ratio [OR] 1.46, 95% CI 1.08 to 1.97), continuing any breastfeeding beyond 6 months (OR 1.41, 95% CI 0.87 to 2.27), and continuing predominant breastfeeding longer than 3 months (OR 2.01, 95% CI 1.06 to 3.80) for women who returned to work at the later time. When women returned to work after 13 weeks postpartum the odds ratio of still predominantly breastfeeding after 3 months was 2.54 (95% CI 1.51 to 4.27). 40 In Brazil, Rimes et al. 42 reported on 429 mother–infant pairs, demonstrating that return to work after some maternity leave was associated with a higher adjusted prevalence ratio (APR 1.91, 95% CI 1.32 to 2.78) of exclusive breastfeeding than in mother–infant pairs in whom the mother worked without any maternity leave. In China, a survey of 715 working breastfeeding mothers from a single electronics manufacturing plant demonstrated that higher education level (OR 2.66), lower work load (8 h/day) (OR 2.66), lactation room with dedicated space (OR 2.38), breast pumping breaks (OR 61.6), and encouragement from colleagues (OR 2.78) and supervisors (OR 2.44) to use the breaks were associated with persistent breastfeeding over 6 months after returning to work. 43 A more recent analysis of data from the Listening to Mothers II national survey (2011 to 2012) compared paid maternity leave and maternal and child health. 44 At 21 months postpartum, women who used paid maternity leave compared with taking unpaid or no leave had a 47% decrease in odds of rehospitalization of their infants and a 51% decrease in maternal rehospitalization. Women with paid maternity leave also had 1.8 times the odds of improved stress management and benefits from exercise.

In a review of studies on maternity leave length and workplace breastfeeding policies, Steurer reported on six studies on maternity leave length and eight studies on the effects of workplace breastfeeding policies. 45 She noted the lack of consistency in maternity leave and workplace accommodations by country. Although longer maternity leave had a positive effect on the duration of breastfeeding, she concluded that the optimal duration of maternity leave to achieve the recommended 6 months of exclusive breastfeeding still needs to be determined. Adequate break time for pumping, a private space for pumping, and coworker and supervisor support are each important to foster extending exclusive breastfeeding. It was noted in some of the included studies that some women (especially in lower paying jobs) did not use the policy benefits for fear of consequences at work. Consistent access for all women to multiple breastfeeding accommodations at work and effective enforcement of the policies will be essential to glean the optimal benefits of such policies on breastfeeding exclusivity and duration. The full spectrum of interventions to support breastfeeding should be considered within hospitals, communities, and the workplace to reach the goals of 6 to 12 months of exclusive breastfeeding at home or after returning to work. 46 In another review of the literature Navarro-Rosenblatt and Garmendia (2018) 47 analyzed 21 studies (1996 to 2017) on maternity leave and breastfeeding duration. They reported that women with a maternity leave of 3 months or longer had a 50% likelihood of extending breastfeeding through 3 months than mothers who returned to work before 3 months. Mothers who had 6 months or more of maternity leave had a 30% chance of continuing breastfeeding for 6 months. They also reported on some of the barriers and the importance of providing equal access to the benefits of maternity for all women. In another systematic review of seven studies of paid maternity leave and maternal health outcome, Aitken et al. 48 noted differences between individual-level and policy-level results. The four individual-level studies noted improvements in psychologic stress, depression scores, mental well-being, physical well-being, and reported intimate partner violence with duration of paid leave. The three policy-level comparison studies (from Canada, California, and Norway and Sweden) showed new evidence of an association between maternal health and paid leave. The study from California suggested improved health with 6 weeks of paid leave compared with 12 weeks. 48 A separate systematic review and meta-analysis by McFadden et al. 49 reviewed 73 studies on support for healthy breastfeeding mothers with term infants. “All forms” of additional support for breastfeeding mothers led to a decrease in women stopping exclusive breast by 6 months (relative risk [RR] 0.88, 95% CI 0.85 to 0.92) and at 4 to 6 weeks after delivery (average RR 0.79, 95% CI 0.71 to 0.89). Employment was not a covariable considered in the analysis. The studies were very heterogeneous, as were the analysis by subgroups of covariates (who provided care, type of support, timing of support, and number of postnatal contacts) such that no conclusive comments could be made about the effect of individual factors of support. 49

Additional interventions to support maternity leave and breastfeeding accommodations in the workplace in all employment and educational settings need to continue to be studied to understand the effects on women’s successes with their breastfeeding goals (incidence, duration, satisfaction), their return to work or school, and work and school productivity in “breastfeeding-friendly” environments.

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