Abstract
Objectives
Maternal employment postpartum can have a powerful influence over infant-feeding behaviors. The objective of this cross-sectional online survey was to explore the infant-feeding intentions and behaviors of a convenience sample of lawyer mothers. We compared our findings with those for physician mothers.
Methods
Lawyers participated in an anonymous online survey. To eliminate the influence of multiple births, only study subjects with one child were reviewed for inclusion in this analysis. We used SPSS for calculation of descriptive statistics, the Mann-Whitney test for comparisons, and the Spearman rank correlation test for testing correlations.
Results
All mothers (29 lawyers and 47 physicians) included in the final analysis reported an intention to breast-feed, with 55% of lawyers wanting to breast-feed for at least 12 months. Physicians’ breast-feeding rates were 98% at birth, 83% at 6 months, and 51% at 12 months. Lawyers’ breast-feeding rates were 100% at birth, 55% at 6 months, and 17% at 12 months. Their duration of breast-feeding correlated with the support level at work and the sufficiency of time and availability of appropriate places at work to express milk.
Conclusions
This study did not detect statistically significant differences in infant-feeding intentions and behaviors of lawyer mothers when compared with physician mothers. Although the majority of lawyer mothers intended to breast-feed for at least 12 months, only a minority achieved that goal. Our findings support the development of workplace strategies and programs to promote breast-feeding duration among lawyers returning to work after childbirth.
Keywords: breast-feeding, infant-feeding intentions, lawyer mothers
Breast-feeding is an integral part of a healthy life for both infants and mothers.1,2 The benefits of breast-feeding extend beyond the individual to the community, affecting the economy and environment.3 Increased breast-feeding would not only mean healthier children and mothers, but also decreased spending for programs such as the Special Supplemental Nutrition Program for Women.4,5 The Healthy People 2020 initiative recognized the importance of breast-feeding and issued objectives that included achieving breast-feeding rates of 82% in the early postpartum period, 61% at 6 months, and 34% at 12 months.6 Breast-feeding rates in the United States are 76.9% at birth, 47.2% at 6 months, and 25.5% at 12 months.7 Comparison of these data with the Healthy People 2020 goals suggests that despite successful breast-feeding initiation, mothers in the United States still have difficulty maintaining breast-feeding. Identifying maternal characteristics associated with low breast-feeding continuation would be an important initial step in developing successful interventions to improve breast-feeding rates. One such characteristic is maternal employment postpartum outside the home.8–11
An important limitation of published studies that have associated maternal employment with shorter breast-feeding duration is the lack of data regarding breast-feeding intentions of the participants. In other words, it is not known whether mothers who return to work after childbirth have shorter breast-feeding duration goals than nonemployed mothers or whether, despite their desire to continue breast-feeding after return to employment, they are simply not able to overcome work-related obstacles to achieve their breast-feeding goals. The results of our studies among physician mothers suggest that there is a discrepancy between their breast-feeding duration goal and actual breast-feeding length.12,13 Furthermore, work-related factors seem to have a larger negative impact on breast-feeding duration of physician mothers than their educational background, personal breast-feeding goals, or breast-feeding initiation practices.12,13 These results challenge earlier epidemiologic studies that suggested that mothers employed in professional/managerial positions are more likely to continue breast-feeding after returning to work.10,11,14,15 Breast-feeding intentions and behaviors of other professional groups of mothers have not been investigated in depth.
The present study was designed to explore infant-feeding intentions and the behavior of lawyers, another group of professional mothers. Because the low breast-feeding continuation rates of physician mothers seem to be associated with their occupation,12,13,16 we hypothesized that despite being professionals, physician mothers are a distinct group of mothers at high risk for premature breast-feeding cessation. As such, we chose lawyers, a nonmedical professional group for this study. There are several other characteristics, including increased age, level of education, and socioeconomic status, that have been positively correlated with breast-feeding initiation17 and make lawyers an ideal study population. We hypothesized that although lawyer mothers would have similar breast-feeding intentions and initiation patterns as physician mothers, lawyers’ breast-feeding continuation behavior would be more similar to the general population. We expected to find higher breast-feeding initiation rates than the general population and higher breast-feeding continuation rates than physician mothers. The main outcomes were maternal plan for breast-feeding (initiation and duration), breast-feeding behavior (initiation and duration), and barriers to breast-feeding. We assessed exclusive breast-feeding and any breast-feeding. For the purposes of this study, we defined “exclusive breast-feeding” as the infant only receiving breast milk and “any breast-feeding” as the infant receiving any breastmilk (we included infants who were exclusively breastfed as well as infants who received other nutrition along with breastmilk in this category).
Methods
Physician Study
The study was approved by the institutional review boards (IRBs) at the University of Florida and Johns Hopkins University. Study instrument development, recruitment, participants, and data collection have been described previously.12,13 The physician study was conducted from February 2009 to July 2011. One author (M.S.) interviewed physician mothers, using the questionnaire described previously.12,13 Criteria for participation included being a female physician and having had at least one biological child. Physicians were included regardless of their infant-feeding methods.
A total of 130 physician mothers, including physicians-in-training (residents and fellows) and practicing physicians (in an academic or a private practice setting), participated in the study. Fifty were recruited and interviewed at Johns Hopkins University School of Medicine (Baltimore, Maryland). The remaining 80 were recruited and interviewed at the University of Florida College of Medicine (Gainesville). To eliminate the influence of multiple births, we did not include subjects who had had more than one child at the time of the study (eg, multiparous subjects or subjects with nonsingleton births). In total, 47 of the physician participants had given birth to one child, were reviewed for inclusion in this study, and were included in the final analysis.
Lawyer Study
The lawyer study was approved by the University of Florida IRB and was conducted from July 2010 through November 2010.
Survey Instrument Development
The questionnaire used for the physician study was critically reviewed for its applicability in the new study population. Survey items and response scales were maintained or modified to assess areas pertinent to breast-feeding among lawyers. The final instrument contained 68 questions and took approximately 20 to 30 minutes to complete. In accordance with the IRB, this questionnaire was then used to create an anonymous online survey. Questions pertained to demographics, including maternal age, marital status, the state of the participant’s career, the number of children, and the age of the children. The infant-feeding intentions of study participants were assessed by two questions: “Did you plan for your child to be breast-fed?” and “What was your original goal for length of breast-feeding?” To assess infant-feeding behavior, we used the following questions: “How was your infant fed immediately after birth?” “At what age was the child first fed something other than breast milk or medication (eg, formula, juice, solids)?” and “At that age was your infant weaned from breast milk completely?” We also included questions to assess work-related factors and other enablers of and obstacles to breast-feeding. To assess availability of time for milk expression at work, participants chose among “never,” “occasionally,” “sometimes,” “often,” and “always.” Similarly, availability of worksite lactation facilities was assessed by asking each participant their frequency of “access to appropriate place to express milk.” Participants also were asked to rate the support from colleagues that they believed they received for their breast-feeding efforts. Participants could choose “always opposed my efforts,” “usually opposed my efforts,” “neither supportive nor oppositional,” “usually supportive,” or “always supportive.” To assess maternal postpartum stress level, mothers chose “very stressed,” “sometimes stressed,” or “seldom stressed.” Similarly, to rate their energy level while breast-feeding, mothers chose from “always,” “often,” “sometimes,” or “seldom” tired. Postpartum depression scores were based on the answers “severely depressed” (score of 1), “mildly depressed” (score of 2), and “not depressed at all” (score of 3).
Recruitment
Using the alumni listserv, the administrative office of the University of Florida’s Levin College of Law e-mailed alumni and students of the college. The e-mail contained a link that took participants directly to the survey. Participants were provided with contact information of the principal investigator (R.A.), should they have wished to ask questions or provide feedback on the survey, but they were not asked to supply any identifying information. Criteria for participation included being a female lawyer and having at least one biological child. Their eligibility was not affected by infant-feeding choices and methods.
In total, 126 lawyers, either students or alumni of the Levin College of Law, responded to the online survey. To eliminate the influence of multiple births, only the study subjects with 1 child were included in the analysis; 31 lawyer participants had had 1 child and were reviewed for inclusion in this study. Two of the 31 participants were excluded because of incomplete survey responses. The final analysis included 29 lawyer mothers.
Data Analysis
Descriptive statistics, including means, standard deviations, and frequencies of all of the demographic variables in the dataset, were calculated using SPSS version 16 (SPSS, Chicago, IL). The Mann-Whitney test (nonparametric test) was used for comparisons between the two groups (physicians and lawyers). All of the comparisons were performed at a 95% confidence level. The Spearman rank correlation test with α = 0.05 was used to test correlation and determine which survey variables had statistically significant correlations with breast-feeding duration among lawyer mothers. We considered any variable with P < 0.05 to have a statistically significant correlation with the duration of breast-feeding.
Results
Demographics
As shown in Table 1, lawyer mothers as a group were older than physician mothers and had older children. Conversely, physician mothers were more likely to be married at the time of the survey and to be in school or training at time of childbirth. Six lawyers and 15 physicians were still breast-feeding at the time of study.
Table 1.
Comparison of lawyer and physician groups
| Lawyers (29) | Physicians (47) | P | |
|---|---|---|---|
| Age, y | 0.008 | ||
| Mean ± SD | 40.2 ± 10.0 | 34.6 ± 6.2 | |
| Median | 38.0 | 34.0 | |
| Range (%) | 26–64 | 26–54 | |
| 26–30 | 3 (10) | 14 (30) | |
| 31–35 | 9 (31) | 16 (34) | |
| 36–40 | 7 (24) | 11 (23) | |
| ≥41 | 10 (34) | 6 (13) | |
| Marital status (%) | 1 missing | 0.017 | |
| Married | 22 (76) | 41 (87) | |
| Not married | 6 (21) | 6 (13) | |
| Child’s age, mo | 0.009 | ||
| Mean ± SD | 102.0 ± 120.6 | 40.7 ± 60.3 | |
| Median | 48.0 | 20.0 | |
| Range | 3.0–468.0 | 3.0–276.0 | |
| Currently breast-feeding (%) | 6 (21) | 15 (32) | 0.084 |
| Partner worked outside home at time of childbirth (%) | 28 (97) | 42 (89) | 0.378 |
| Mother in school or training at the time of childbirth (%) | 2 (7) | 36 (77) | 0.000 |
Bold type indicates statistical significance. SD, standard deviation
Breast-feeding Intentions, Goals, and Behavior
Lawyers and physicians did not have statistically significant differences in their intention to breast-feed, breast-feeding duration goals, exclusive breast-feeding behavior, nonexclusive breast-feeding behavior, or actual breast-feeding duration (Table 2). All of the mothers in both groups intended to breast-feed. The two most common reasons lawyers gave for their breast-feeding intention were infant health (93%) and the reduction of infection in infants (90%). Although the majority of lawyers (55%) and physicians (57%) reported wanting to breast-feed for at least 12 months, the mean breast-feeding duration was only 9.71 months for lawyers and 9.88 months for physicians (P = 0.232).
Table 2.
Breast-feeding intentions and behavior of lawyers and physician mothers
| Lawyers (29) | Physicians (47) | P | |
|---|---|---|---|
| Intention to breast-feed (%) | 29 (100) | 47 (100) | |
| Breast-feeding duration goal, mo | 0.476 | ||
| Mean ± SD | 9.24 ± 3.17 | 9.77 ± 3.31 | |
| Median | 12.00 | 12.00 | |
| Range | 3–12 | 2–12 | |
| Wanted to breast-feed for at least 12 mo (%) | 16 (55) | 27 (57) | |
| Breast-feeding initiation (%) | 29 (100) | 46 (98) | 0.432 |
| Breast-feeding at 6 mo (%) | 16 (55) | 39 (83) | 1.000 |
| Breast-feeding at 12 mo (%) | 5 (17) | 24 (51) | 1.000 |
| Exclusive breast-feeding at birth (%) | 25 (86) | 37 (79) | 1.000 |
| Exclusive breast-feeding at 3 mo (%) | 17 (59) | 30 (64) | 1.000 |
| Exclusive breast-feeding at 6 mo (%) | 12 (41) | 12 (26) | 1.000 |
| Exclusive breast-feeding duration, mo | 0.515 | ||
| Mean ± SD | 3.53 ± 2.59 | 3.32 ± 2.36 | |
| Median | 2.50 | 4.00 | |
| Range | 0.0–9.0 | 0.0–6.0 | |
| Breast-feeding duration, mo | 0.232 | ||
| Mean ± SD | 9.71 ± 9.10 | 9.88 ± 6.48 | |
| Median | 7.00 | 9.00 | |
| Range | 2–48 | 0–30 | |
| Mothers who expressed milk at work (%) | 23 (79) | 42 (89) | 0.083 |
SD, standard deviation.
As illustrated in Table 2, all of the physician and lawyer mothers reported attempting to breast-feed their infants. At the time of hospital discharge, all of the lawyers (100%) and most of the physicians (98%) reported establishing breast-feeding successfully. At 6 months, 55% of lawyers and 83% of physicians continued to breast-feed. At 12 months, 17% of infants of lawyer mothers and 51% of infants of physician mothers still received breast milk.
The mean duration of exclusive breast-feeding was 3.52 months for lawyers and 3.32 months for physicians (P = 0.515). Presented in Table 2, 86% of infants of lawyer mothers and 79% of infants of physician mothers received breast milk exclusively at birth. At 3 months, these rates had dropped to 59% for lawyers and 64% for physicians. At 6 months, 41% of infants of lawyer mothers continued to receive breast milk exclusively, compared with 26% of infants of physician mothers.
Mother’s Satisfaction with Breast-feeding
The self-reported satisfaction with breast-feeding duration was similar in the two groups (Table 3). Interestingly, 65% of physician mothers and 35% of lawyer mothers stated that breast-feeding cessation was caused by the demands of their occupation,
Table 3.
Work-related factors
| Lawyers (29) | Physicians (47) | P | |
|---|---|---|---|
| Score of support at work environment, 1–5, mean ± SD (%) | 3.52 ± 1.40 | 4.17 ± 0.96 | 0.050 |
| Very unsupportive | 4 (14) | 0 (0) | |
| Somewhat unsupportive | 2 (7) | 4 (9) | |
| Neutral | 8 (28) | 6 (13) | |
| Somewhat supportive | 5 (17) | 15 (32) | |
| Very supportive | 10 (34) | 22 (47) | |
| Duration of maternity leave, wk, mean ± SD | 11.4 ± 12.9 | 9.2 ± 4.0 | 0.476 |
| Duration of paid maternity leave, wk, mean ± SD | 6.3 ± 5.9 | 7.2 ± 4.2 | 0.364 |
| Had to make up maternity leave (%) | 4 (14) | 9 (19) | 0.611 |
| Return to work when had planned (%) | 18 (62) | 41 (87) | 0.011 |
| Full-time employment postpartum (%) | 23 (79) | 43 (91) | 0.130 |
| Depression score while breast-feeding, mean ± SD (%) | 2.67 ± 0.48 | 2.60 ± 0.58 | 0.716 |
| Severely depressed | 0 (0) | 2 (4) | |
| Mildly depressed | 9 (31) | 15 (32) | |
| Not depressed at all | 18 (62) | 30 (64) | |
| Missing | 2 (7) | ||
| Energy score while breast-feeding, mean ± SD (%) | 2.90 ± 0.62 | 2.04 ± 0.91 | 0.000 |
| Always tired | 0 (0) | 15 (32) | |
| Often tired | 7 (24) | 18 (38) | |
| Sometimes tired | 18 (62) | 11 (23) | |
| Seldom tired | 4 (14) | 3 (6) | |
| Stress score with breast-feeding, mean ± SD (%) | 2.21 ± 0.77 | 1.72 ± 0.71 | 0.025 |
| Very stressed | 6 (21) | 11 (41) | |
| Somewhat stressed | 11 (38) | 12 (26) | |
| Seldom stressed | 12 (41) | 4 (15) | |
| Missing | 20 | ||
| Time sufficiency score at work to express milk, mean ± SD (%) | 3.50 ± 1.34 | 3.24 ± 0.96 | 0.157 |
| Never | 4 (17) | 1 (2) | |
| Occasionally | 0 (0) | 10 (29) | |
| Sometimes | 3 (13) | 11 (26) | |
| Often | 11 (49) | 18 (43) | |
| Always | 4 (17) | 2 (5) | |
| Missing | 1 (4) | ||
| Availability of appropriate place at work to express milk score, mean ± SD (%) | 3.59 ± 1.59 | 3.83 ± 1.23 | 0.790 |
| Never | 4 (17) | 2 (5) | |
| Occasionally | 2 (9) | 6 (14) | |
| Sometimes | 3 (13) | 5 (12) | |
| Often | 3 (13) | 13 (31) | |
| Always | 10 (43) | 16 (38) | |
| Missing | 1 (4) | ||
| Satisfaction with breast-feeding duration | 1.46 ± 0.69 | 1.30 ± 0.59 | 0.274 |
Bold type indicates statistical significance. SD, standard deviation.
Factors Associated with Breast-feeding
Although physician mothers were significantly more likely than lawyer mothers to rate their work environment as supportive, they also reported higher degrees of stress and fatigue during their breast-feeding period (Table 3). There were no significant differences between the two groups of mothers regarding the duration of maternity leave and paid maternity leave, the sufficiency of time and availability of an appropriate place at work for milk expression, and depression scores.
For lawyers, duration of both exclusive and any (exclusive and nonexclusive) breast-feeding correlated with the support level at work and the sufficiency of time at work to express milk (Table 4). Mothers who reported a more supportive work environment and greater availability of time to express milk at work not only breast-fed their infants longer but also supplemented them later. The duration of any breast-feeding also correlated with the availability of a place at work for milk expression (Table 4). Lawyers who reported more access to appropriate space for milk expression at work were able to breast-feed longer. Maternal energy level almost reached statistical significance, meaning that mothers who reported less fatigue during their postpartum period breast-fed longer (Table 4).
Table 4.
Factors associated with breast-feeding duration among lawyer mothers
| Variable | Spearman correlation factor | P |
|---|---|---|
| Duration of exclusive breast-feeding | ||
| Work environment support | 0.402 | 0.031 |
| Sufficient time at work for milk expression | 0.462 | 0.030 |
| Duration of breast-feeding | ||
| Work environment support | 0.448 | 0.032 |
| Postpartum energy level | 0.403 | 0.056 |
| Sufficient time at work for milk expression | 0.493 | 0.044 |
| Appropriate place at work for milk expression | 0.504 | 0.039 |
Bold type indicates statistical significance.
The age of supplementation correlated with the age of weaning (Spearman correlation coefficient 0.518, P = 0.011). We did not find a correlation between breast-feeding duration (exclusive and nonexclusive) and maternal age, child age, maternal marital status, state of the study participant’s career at the time of childbirth, the number of years practicing law, work status (full-time or part-time), maternal goal for breast-feeding duration, maternity leave duration, paid maternity leave, flexibility of schedule after returning to work, postpartum maternal depression or stress level, or recommendations from the obstetrician.
Discussion
Although 100% of lawyer mothers initiated breast-feeding at birth and 55% wanted to breast-feed for at least 12 months, only 17% were able to continue breast-feeding to 12 months. Similar to physicians,12,13 lawyer mothers in this study reported an intention to breast-feed, and breast-feeding intention correlated 100% with breast-feeding initiation. Their breast-feeding maintenance did not correlate with their initial breast-feeding duration goals or initiation practices, however. Instead, breast-feeding continuation appeared to be influenced by work-related factors, such as level of support at the workplace and the availability of sufficient time and an appropriate place at work for milk expression. In fact, 35% of lawyer mothers who had stopped breast-feeding reported that the discontinuation of breast-feeding was caused by demands at work.
Previous studies have suggested that inflexible work schedules are associated with breast-feeding cessation, whereas longer maternity leave duration, the availability of worksite lactation facilities, and support from coworkers and supervisors predict breast-feeding success for working mothers.10,18–20 Similarly, we found a positive correlation between the breast-feeding success of lawyers and the availability of worksite lactation facilities and workplace support; however, we did not find a correlation between the length of maternity leave and breast-feeding duration. Although earlier epidemiologic studies found a correlation between professional maternal occupation and longer breast-feeding duration after returning to work, the results of this study, as well as our physician research, indicate that despite successful breast-feeding initiation, these two groups of professional mothers were not able to achieve their personal breast-feeding goals.
Lawyers and physicians in this study had similar infant-feeding intentions and breast-feeding initiation behaviors. Although it did not reach statistical significance, the lower breast-feeding rates for lawyer mothers at 6 and 12 months, when compared with physician mothers, were unexpected. Our results suggest that worksite factors may account for some of these observed differences. For example, lawyer mothers as a group reported a less supportive work environment, when compared with physician mothers. Interestingly, the perceived support level at work correlated not only with the duration of breast-feeding for lawyers in this study but also with the breast-feeding duration among physicians.21 We also detected statistically significant differences between lawyers and physicians in terms of maternal age, child age, maternal marital status, the stage of the study participant’s career at the time of childbirth, and postpartum maternal levels of stress and energy. None of these variables had a statistically significant correlation with the duration of exclusive breast-feeding or any breast-feeding among lawyer mothers, however.
To our knowledge, this study is the first published report of infant-feeding intentions and behaviors in female lawyers. It has potential limitations. Because we collected data on voluntary participants, our study could be affected by selection bias. Although the use of a convenience sample would not affect the internal validity of our results, the study findings may not be representative of the entire population of female lawyers in the United States. Because of the small sample sizes in our study, we may not have adequate power to detect statistically significant differences in infant-feeding behavior between the two groups. Another potential limitation is that physician data were gathered by interviews, whereas lawyer data were gathered online. These two data collection modes could cause measurement differences between the two groups. Because we gathered data on previous breast-feeding behavior, recall bias is another potential limitation. Although the validity and reliability of maternal recall for breast-feeding intent and exclusive breast-feeding are not clear, previous studies have established that maternal recall is a valid and reliable estimate of breast-feeding initiation and duration, especially when the duration of breast-feeding is recalled within 3 years.22,23 Potential for recall bias regarding the lawyer data is greater than that of the physician data because lawyer mothers were older at the time of the study. Differences in age between the two groups may be the result of our recruitment methods. We recruited lawyer mothers through the law school listserv, which included mostly alumni. Conversely, we recruited physician mothers through two different medical schools and therefore, targeted not only faculty but also physicians in training. As such, the pool of possible lawyer participants may have been older in average than the pool of medical participants. Differences in maternal age would explain differences in the ages of the children at the time of study and may contribute to generational and societal differences between the two groups. Issues of time and change of practice also may have affected our results because the enablers and obstacles that older study participants reported may be different than those currently facing younger women.
To overcome these limitations, future prospective studies of infant-feeding among larger samples of all working mothers at multiple sites should be conducted and include physician mothers because the personal breast-feeding behavior of these mothers also affects their clinical breast-feeding advocacy and in turn, the well-being and health of their patients and patients’ families.13 Our study also highlights the importance of further investigation pertaining to worksite-related factors, such as resources for breast-feeding, degree of support at work, and attitudes and acceptance of breast-feeding in the maternal workplace. The results of such studies would then clarify the impact of worksite factors on infant-feeding behavior in these mothers and be the first step in the development of evidence-based worksite interventions and programs to improve breast-feeding duration and success of all working mothers.
Conclusions
This study did not detect statistically significant differences in infant-feeding intentions and behaviors of lawyer mothers when compared with physician mothers. Although the majority of lawyer mothers intended to breast-feed for at least 12 months, only a minority achieved that goal. The discrepancy between maternal breast-feeding intentions and actual breast-feeding duration among lawyer mothers, as well as correlations between worksite factors and breast-feeding duration, support the development and implementation of workplace strategies and programs to promote breast-feeding duration among lawyers returning to work. The results of this study suggest that providing dedicated time and space for milk expression and support and reinforcement at the worksite are modifiable factors that could influence lawyer mothers’ breast-feeding duration after returning to work.
Key Points.
All 29 lawyers mothers included in the final analysis reported an intention to breast-feed, with 55% wanting to breast-feed for at least 12 months.
Breast-feeding rates were 100% at birth, 55% at 6 months, and 17% at 12 months.
The duration of breast-feeding correlated with the level of support at work and the sufficiency of time and availability of an appropriate place at work to express milk.
Our findings support the development of workplace strategies and programs to promote breast-feeding duration among lawyers returning to work after childbirth.
Acknowledgments
The study was supported by the Clinical and Translational Science Institute, National Institutes of Health grant no. 1UL1RR029890.
J.R.S. receives grant funding from the Centers for Disease Control and Prevention for an adolescent immunization study.
Footnotes
The remaining authors have no financial relationships to disclose and no conflicts of interest to report.
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