Employers' readiness for the mother‐friendly workplace: an elicitation study

Abstract

Currently over half of mothers of infants under 1‐year‐old are in the workforce in the United States. These women face challenges to continue breastfeeding when they return to work 3 to 6 months post‐partum. This study explored the perspectives of employers on mother‐friendly environments to assess their readiness to provide breastfeeding accommodation using the elicitation under the theory of planned behaviour. Researchers conducted phone/in‐person interviews with a convenient sample of 20 human resource managers from companies that had 500 or more employees in the New York metropolitan area in 2009. Content analyses identified the common concepts that represent underlying beliefs of the constructs of the theory. The demography of the participants is 40% male and 80% White, with mean ages of 34.3 ± 8.5 years. ‘Happy employees’ and ‘high retention rate and improved loyalty’ were the most frequently mentioned (95%) benefits to the company (behavioural beliefs). Supporters of a mother‐friendly environment (normative beliefs) in the workplace included ‘mothers and expectant mothers (70%)’, and ‘managers supervising women and new mothers (55%)’. Most frequently mentioned company drawbacks (control beliefs) were ‘not cost effective (65%)’ and ‘time consuming (65%)’, followed by ‘perception of special favours for some (50%)’. Workplace breastfeeding promotion efforts can be successful by reinforcing positive beliefs and addressing the challenges associated with implementation of breastfeeding accommodation through education and other incentives such as recognition of model companies and tax breaks. The identified beliefs provide a basis for the development of a quantitative instrument to study workplace breastfeeding support further.

Introduction

Women are in the labour force more than ever before in the United States. Of these women, more mothers are returning to paid employment within months after giving birth. About one‐third of post‐partum mothers return to work within 3 months and two‐thirds return within 6 months (U.S. Department of Labor 2002). In 1975, approximately 29% of mothers of infants were in the labour force. By 1995, this number had increased to over 50% (Broom 1998). In 2008, 60.4% of mothers of children under age three were employed, and 56.4% of mothers with infants under 1‐year‐old were employed (U.S. Bureau of Labor Statistics 2008). Projections indicate that the proportion of post‐partum mothers returning to the workplace will continue to increase, especially with the enactment of welfare reform in many states where mothers on welfare are required to return to the workforce (Wagner et al. 1997).

In the United States, paid maternity leave is available for approximately half of the female workforce. The duration of the paid leave varies depending on the type of employer. Federal employees are entitled to 4 weeks of paid parental leave for the birth or adoption of a child (H.R. 626 2009). Twenty‐four percent of the 100 family‐friendliest companies in the United States provide 4 or fewer weeks of paid maternity leave, with 5 to 6 weeks being the most common (Lovell et al. 2007). Though employees may take a total of up to 12 weeks of unpaid leave without the fear of losing their employment, many families cannot afford to take time off because of the resulting financial hardship (U.S. Office of Personnel Management 2007). Many women give up breastfeeding upon return from maternity leave, eventhough breastfeeding is the optimal method of infant feeding. Stay‐home mothers are more than twice as likely to breastfeed at six months than mothers who work full time (Ryan et al. 2006). This suggests that working mothers face workplace‐related challenges to continue breastfeeding and that a mother‐friendly environment could alleviate their difficulties (Suyes et al. 2008). Providing breastfeeding accommodation in the workplace can be the first step to creating such an environment.

Breastfeeding accommodations include providing designated private space for milk expression, allowing flexible scheduling for breastfeeding mothers, providing high‐quality breast pumps and writing corporate policies to support breastfeeding women (Shealy et al. 2005). Currently, 24 states in the United States plus the District of Columbia and Puerto Rico have breastfeeding laws promoting breastfeeding in the workplace (National Conference of State Legislatures 2010). However, breastfeeding upon return to the workplace remains a struggle for working mothers, and the issue continues to be ignored and downplayed by employers. While employers are starting to recognize the value and benefits of breastfeeding, few place priority on providing the services and support that nursing mothers need (Mills 2009).

Breast milk provides the necessary nutrients that an infant needs. Breastfed infants demonstrate a reduction in the incidence and severity of infections. They have fewer allergies and better cognitive development (O'Connell 2003; Greer et al. 2008; Kramer et al. 2008). Additionally, they have a reduced risk for post‐neonatal death (Chen & Rogan 2004). Breastfeeding also has long‐term positive effects including the prevention of obesity, hypertension and diabetes as the child ages. Evidence for emotional and mental health benefits of breastfeeding among nursing mothers continues to increase (Gribble 2006). Benefits of breastfeeding extend to employers and workplaces by reducing health care costs and absenteeism as well as improvement of productivity as a result of healthier children (Ball & Bennett 2001). A study estimated that savings for employers could range between $331 and $471 in health care expenditures per infant that was exclusively breastfed for 3 months (Ball & Wright 1999; U.S. Breastfeeding Committee 2002). The US Breastfeeding Committee reports employers' cost savings of $3 for every $1 invested to support breastfeeding in the workplace (U.S. Breastfeeding Committee 2011).

In light of the health and economic benefits of breastfeeding and the recently passed Health Care Reform Bill (H.R. 3590 2009) that requires the provision of reasonable breastfeeding support in the workplace, there is no better time to assess the readiness of employers to provide a mother‐friendly environment. The purpose of this study was to elicit the underlying beliefs specific to employers and their readiness to provide workplace breastfeeding accommodation under the framework of the theory of planned behaviour.

Key messages

• • Employee satisfaction, high retention rate and improved loyalty were some of the perceived company benefits of having breastfeeding accommodation in the workplace.
• • Cost‐effectiveness and perception of negative employee dynamics are concerns for employers to implement breastfeeding accommodation.
• • Shaping underlying beliefs identified in this study, according to the theory of planned behaviour, can lead to effective strategies to implement breastfeeding accommodation.

Theoretical framework

The theory of planned behaviour (Ajzen & Fishbein 1980) is the theory that a person's cognitive readiness to perform a behaviour (‘intention’) can be measured, even influenced based on the right set of beliefs about the behaviour (Fig. 1). Under this theory, one's intention to provide breastfeeding accommodation is determined by three constructs: attitude toward the behaviour, subjective norm and perceived behavioural control. Each of these constructs can be measured by examining the person's underlying beliefs: ‘behavioural’ beliefs that providing breastfeeding accommodation will lead to positive or negative outcomes influencing the person's attitude, ‘normative’ beliefs about whether valued social referents approve of this behaviour influence subjective norms, and ‘control’ beliefs about the presence of facilitating or hindering situational factors influence perceived behavioural control. The theory of planned behaviour is one of the most commonly utilized models to predict health‐related behaviours (Ajzen & Fishbein 1980; Ajzen 1991). It provides a good framework for eliciting employers' beliefs in order to determine appropriate breastfeeding promotion strategies for the workplace.

Figure 1.

Theory of planned behaviour – underlying beliefs, direct constructs, intention and behaviour (modified from Ajzen 1991).

Previous studies have used surveys or focus groups to assess employer attitudes, knowledge and practices regarding breastfeeding support (Brown et al. 2001; Libbus & Bullock 2002; Writters‐Green 2003; Dunn et al. 2004) but generally lack theoretical guidance. This study utilized the theory of planned behaviour to elicit the underlying beliefs that characterize the employer's motivation to provide a breastfeeding accommodation in the workplace. A robust, theory‐driven instrument is needed in order to systematically identify and eventually address the employer's attitudes toward providing breastfeeding support. A future survey derived from the beliefs elicited in this study will allow insightful understanding of the dynamics of employer's decision‐making process for providing the mother‐friendly environment.

Methods

Researchers conducted interviews in the spring and fall of 2009. Using a convenience sampling method, 35 companies located in the New York metropolitan area were solicited via email invitation letters for participation in the study. The goal was to obtain a wide range of companies regardless of their intention to provide breastfeeding accommodation. The sample population consisted of managers and representatives from human resources at companies with 500 or more employees, ranging from financial institutions and food distributors to manufacturing firms and publishing houses. Researchers aimed to recruit 20–30 volunteers for the study based on the recommendations on qualitative research and utility of the theory of planned behaviour (Sandelowski 1995; Francis et al. 2004). The Montclair State University Institutional Review Board approved the study protocol. Once participants replied to volunteer for the study, phone or in‐person interviews were scheduled (response rate 57%). Detailed notes were taken during the interview for subsequent analysis. The participants' identities were coded, then linked to their responses in order to keep the responses anonymous and to categorize them by demographic characteristics.

Interview questions were carefully structured and guided by the theory of planned behaviour (see Table 1) to specifically elicit the underlying behavioural, normative and control beliefs relating to the employer's intention to provide a breastfeeding‐friendly workplace. Direct contact with the target population (i.e. employers) through the elicitation procedure enhances (applicable and real) the list of salient beliefs that are developed solely from a review of literature and discussion with experts (Middlestadt et al. 1996; Fishbein 2000; Bai et al. 2009).

Table 1.

Sample questions that guided personal interviews to explore managers' attitudes and opinions of mother‐friendly environment

Definition provided to participants at the time of interview

Breastfeeding‐friendly environment is any action, policy, program or behaviour in place at a company that supports a woman who makes the choice to breastfeed. Examples include written policy, a culture of acceptance, dedicated physical space to feed or pump

Child‐bearing age women are defined as women aged between 18 to 45

Open‐ended questions

What might be some benefits to the company if they offered a breastfeeding‐friendly environment?

Who do you think would approve or support breastfeeding‐friendly environment in the workplace?

Who do you think might disapprove or object to breastfeeding‐friendly environment in the workplace?

What might be some drawbacks or obstacles for the company to offer a breastfeeding‐friendly environment?

Responses went through a content analysis to sort them by belief type and rank them by frequency as recommended by Ajzen and Fishbein (1980). The responses were organized based on commonly recurring words, phrases or sentences, then translated into the three belief types: behavioural, normative and control beliefs. The frequency of responses determined the salient set for each belief. The descriptive analysis summarized the demographic data. In addition to each participant's age, gender, ethnicity and breastfeeding experience (self or partner), general information on the company was collected, e.g. the proportion of childbearing‐aged women in the company, current maternity leave policies or if on‐site day care was offered.

Results

Twenty volunteers, consisting of managers, supervisors and human resource representatives, participated in the study. As shown in Table 2, the majority of the participants were women, White, and the mean age of the participants was 34.3 years old (standard deviation = 8.5), ranging from 24 to 52 years. About half of the participants were breastfed as an infant. Forty percent of the participants had breastfed their babies. The proportion of childbearing‐aged women in the participants' companies ranged from 10% to 95%. All of the participants except one were aware that their companies permitted either paid or unpaid maternity leave. Three companies that allowed paid maternity leaves also provided paternity leave, a new parent support group and lactation rooms for breastfeeding mothers. One company had a written policy on breastfeeding support in the workplace.

Table 2.

Description of participants and their employers

Characteristics	Frequency (n = 20)	Percentage (%)
Gender
Male	8	40
Female	12	60
Race
African American	1	5
Asian	2	10
Latino	1	5
White	16	80
Breastfeeding experience*
Some	8	40
None	12	60
Breastfed as infant
Yes	11	55
No	7	35
Unsure	2	10
Maternity leave
12 weeks, unpaid	10	50
12 weeks, paid	9	45
Unsure	1	5
Other supporting system
Paternity leave allowed	4	20
On‐site day care available	4	20
New parent support group	3	15
Nursing and pumping rooms available	3	15
Written breastfeeding policy	1	5
None	5	25

^* Either self‐ or partner‐breastfeeding experiences..

The beliefs elicited from the interviews fell into three main content categories (Table 3): benefits to the company (behavioural beliefs), supporters and opponents (normative beliefs) and company drawbacks (control beliefs). These are consistent with the three categories of underlying beliefs of the theory of planned behaviour.

Table 3.

Three major content categories from interviews, framed under the theory of planned behaviour

Categories	Verbatim	Frequency (n = 20)	Percentage* (%)
Attitude (behavioural beliefs) benefits to the company	1. Happy employees, pleasant/comfortable place to work, good for morale	19	95
	2. High retention rate, improved loyalty	19	95
	3. Better recruitment	17	85
	4. Stable productivity	14	70
	5. Good PR or corporate citizenship, demonstrate support for employees	13	65
	6. Promotes equality in the workplace, fosters respect	11	11
	7. Relieves stress on workforce for returning mothers, help them come back sooner, easier	10	50
	8. Less absenteeism, less sick days, healthy workforce, lowers health care cost	7	35
	9. Encourage women not to give up breastfeeding early	1	5
Subjective norm (normative beliefs of social referents) supporters of breastfeeding friendly atmosphere	1. Mothers and expectant mothers	14	70
	2. HR department	12	60
	3. Managers supervising women and new mothers	11	55
	4. Women	11	55
	5. Fathers	10	50
	6. Female leadership	7	35
	7. Upper management	7	35
	8. Those who have experience, knowledge about breastfeeding	4	20
	9. Special population: Latino	2	10
Perceived behavioural control (control beliefs) company drawbacks	1. Not cost‐effective, not worth the cost, not economically feasible	13	65
	2. Temporary loss of productivity, too time consuming	13	65
	3. Coverage and schedule challenges	10	50
	4. Distracting, disruptive	10	50
	5. Perception of special treatment or favours for some. Resentment from others not utilizing the benefit	10	50
	6. ‘Privacy’ issues, work should be about work, personal life is separate	7	35
	7. Physical space is at a premium	6	30
	8. Too political of an issue to get involved in	6	30

^* Percentages of respondents expressed similar verbatim. PR, promotion; HR, human resource.

‘Happy employees’ and ‘high retention rate and improved loyalty’ were the most frequently mentioned benefits to the company, followed by ‘better for recruitment’ and ‘increased and stable productivity’. The idea that employees should be comfortable and content was perceived to be directly linked to a company's output. As one participant noted, ‘Offering supports and benefits make you feel good about your company. It makes the workplace a more pleasurable place to go. You want your employees to want to be there. And in the end, the company wins’. Participants agreed that breastfeeding support was the better part of a larger culture of family‐friendly values, which contributed to achieving the goal of work‐life balance for all employees. For example, one male participant pointed out that while he would never take advantage of breastfeeding support, he appreciated the support because it could lead to his ability to take time off for his child's baseball game. ‘It all comes down to respecting family values’, he added. On the other hand, the fundamental benefit of ‘encourage women not to give up breastfeeding early’ was least appreciated by the participating employers as a benefit to the company. This may be because of the lack of knowledge that a prolonged breastfeeding eventually leads to healthy children, subsequently less absenteeism and decreased health care costs.

Social referents who would approve of a mother‐friendly environment included ‘mothers and expectant mothers in the workplace’, and ‘managers supervising women and new mothers’. Those who would object to a mother‐friendly environment were ‘men in my office’ and ‘women who did not make the choice to marry, have no children and/or did not breastfeed’. Participants agreed that objectors tended to do so because of ignorance, as opposed to ill will.

The most frequently mentioned company drawbacks were ‘not cost effective’, ‘time consuming’, followed by ‘coverage and schedule challenge’ and ‘perception of special treatment or favours for some’. The ‘special treatment or favour for some’ was described to be a privilege to which only breastfeeding mothers can be eligible. Fifty percent of participants viewed breastfeeding support or accommodation as a ‘special’ benefit that not every employee can take advantage of. They feared that this issue of exclusivity might result in co‐workers becoming jealous or resentful. Other concerns or barriers of having workplace breastfeeding support included the space limitation to provide designated nursing and pumping rooms, and negative employee dynamics, e.g. ‘time consuming to pump’, ‘too political of an issue to get involved in’, ‘physical space is at a premium’, ‘multiuse of the intended breastfeeding space’ or ‘possible resentment from others not utilizing the accommodation’.

The responses were further analyzed across two demographic binaries (having lactation rooms vs. no lactation room, having breastfed vs. non‐breastfed). Frequently mentioned benefits to the company were the same regardless of the demographic category. However, participants who had lactation rooms in their workplace talked less about company drawbacks than those who did not have lactation rooms. In particular, they did not mention ‘resentment from others not utilizing the benefit’ to be one of the company drawbacks. However, one participant expressed concerns regarding the possibility of multiuse of the intended breastfeeding space.

Discussion

This study clearly demonstrates that employers hold positive attitudes toward providing a mother‐friendly environment in the workplace. ‘Happy employees’, ‘high retention rate’ and ‘improved loyalty’ were most mentioned benefits, which agree with earlier reports that examined the role of work‐life initiatives such as breastfeeding accommodation (McDonald et al. 2005; U.S. Breastfeeding Committee 2011). However, it is also clear that they hold a number of negative normative beliefs (i.e. their perception of those who would oppose workplace breastfeeding accommodation) and control beliefs (i.e. the company drawbacks). Under the theory of planned behaviour, to improve the employer's intention and thus influence actual behaviour change, these negative beliefs must be addressed.

Cost‐effectiveness and schedule challenges were big concerns for companies in this study sample. These concerns suggest that employers perceived a decrease in productivity with a mother‐friendly environment. On the contrary, a mother‐friendly environment enhances employee satisfaction, boosts company savings from health care costs and reduces absenteeism, consequently leading to the long‐term benefit of increased productivity (Ball & Bennett 2001). The mother‐friendly environment can be the crucial condition to achieve this long‐term benefit. Educating employers about return on investment may allay their perceived uncertainty of cost‐effectiveness. It becomes clear that providing a private space for lactating women to express their breast milk is a small investment to reap the rewards.

Studies have reported that breastfeeding requires a break of 30 min two or three times per working day (Cohen & Mrtek 1994; Brown et al. 2001). A more recent study confirmed that the majority of breastfeeding and working mothers who work in an environment supportive of breastfeeding spend less than an hour per day expressing breast milk (Slusser et al. 2004). The frequency and time will decrease as the baby grows. Functional lactation accommodations are necessary for seamless scheduling adjustment in the workplace, ultimately producing cost‐effectiveness for the company. Promotion efforts, e.g. Business Case for Breastfeeding (U.S. Department of Health and Human Services 2008), can help overcome these challenges through education, effective communication and awareness campaigns.

The other identified concern was the fear of negative reactions from other employees. However, a recent study that examined how other employees would actually react to such accommodations reported no negative repercussions from other employees (Suyes et al. 2008). Moreover, the same study reported that a mother‐friendly atmosphere did not endanger positive attitudes towards breastfeeding in other employees. In order to alleviate fear and facilitate implementation, employers need to be made aware of such study findings.

Barriers found in previous studies against creating a mother‐friendly atmosphere include lack of time, equipment and private spaces that would allow for expressing milk environment (Brown et al. 2001; Libbus & Bullock 2002; Writters‐Green 2003; Dunn et al. 2004). Many of the employers in those studies placed higher priority in meeting the needs of their customers over the needs of nursing mothers. Employers felt that nursing and pumping milk was permitted in the workplace as long as customers, productivity and other employees did not suffer because of the absence of the breastfeeding mother (Brown et al. 2001; Writters‐Green 2003). The employers in the current study had more diverse concerns about the company drawbacks of having a mother‐friendly workplace.

In the past, bathrooms or bathroom stalls were perceived as acceptable lactation facilities (Brown et al. 2001; Writters‐Green 2003). The participants of this study, who did not believe that to be the case, expressed other concerns about the lactation facilities available to them. For example, they were concerned about the possibility of a designated nursing room to be used as a multi‐purpose room if not being utilized frequently enough. Moreover, even if the company provided lactation rooms, participants were concerned about the functionality of the rooms. Those who had designated space described their lactation room to be ‘totally wrong’, – too far away, no proper chairs or no sink in the room. Another concern was the social stigma of workplace lactation support. Participants shared stories of managers who grudgingly went along with breastfeeding support but made their negative attitudes clear.

The strength of this study is in its utilization of the theory of planned behaviour to elicit employers' beliefs relevant to providing breastfeeding accommodation in the workplace. While the theory of planned behaviour has been supported by various domains, one potential concern with the application of this theory is the limited use of elicitation phase (Bai et al. 2009). This study can model the elicitation phase for other theory‐based studies. Findings of this study can assist health professionals to propose innovative and successful ways to address behavioural, normative and control beliefs toward mother‐friendly workplace.

The quantitative instrument from this study can be used in future studies to measure the intention and three direct constructs of the theory of planned behaviour. Comparisons of intenders vs. non‐intenders of providing breastfeeding accommodation can guide the effective strategy to target organizations to improve the existing support or to implement the comprehensive support tailored to their organizations. In addition, studies examining the economic benefits of workplace breastfeeding accommodation can further energize this movement.

One limitation of this study is the somewhat homogeneous sample population that consisted of predominantly White managers from the New York metropolitan area. Future elicitation studies that include ethnically and geographically diverse employers can enrich the findings of the current study. More diverse employers can also help generate a more inclusive list of underlying beliefs relevant to the provision of breastfeeding accommodation.

Conclusions

In the provision of workplace breastfeeding accommodation, a theory‐guided analysis on the behaviour and underlying perceptions of employers was in need. The theory of planned behaviour is a demonstrated theory that links a specific set of underlying beliefs to the intention and actual execution of a behaviour. This study applied this theory to elicit a comprehensive list of underlying beliefs specific to providing workplace breastfeeding accommodation to open the opportunity to systematically address the barriers against this behaviour.

There is no doubt that a mother‐friendly workplace is necessary to encourage working mothers maintain breastfeeding for as long as they intend. Our findings clearly demonstrate that employers recognize the company benefits of having lactation accommodation in the workplace. Remaining fears or negative beliefs about breastfeeding in the workplace can be eased through targeted education. Generally, well‐recognized health and economic benefits need to be translated into cost‐effective strategies. Legislation that provides employers with a tax credit or national recognition for providing breastfeeding accommodation can serve as extra incentives.

Studies like this have never been more appropriate in view of the recent federal requirement for employers to provide reasonable breastfeeding support. Future studies will help uncover the appropriate guidelines that tailor each facility to accommodate the specific needs of the worksite. Continuing research will hopefully launch new breastfeeding accommodations and improve existing ones. Future studies that compare different lactation support programs in the workplace can help standardize the level of support across workplaces.

Source of funding

None.

Conflicts of interest

The authors declare that they have no conflicts of interest.

Contributions

YB substantially contributed to study conception, study design, data analysis, data interpretation, manuscript drafting, critical revision and final approval of the published version. SW substantially contributed to study conception, design, data interpretation, critical revision and final approval of the published version. MW substantially contributed to study design, data collection, data analysis, data interpretation, manuscript drafting, critical revision and final approval of the published version.