Working & Breastfeeding: 20 Years On and STILL a Contemporary Workplace Dilemma

Few issues are as incendiary as breastfeeding. Well-worn arguments tend to pit women’s empowerment against the rights of the child. Sometimes what is in the best interest of the child is not what is in the best interest of the mother, or at least not aligned with her self-interests and/or aspirations.(1) Some mothers will always choose to breastfeed; Some mothers will always choose to not breastfeed. But these “sides” present a false dichotomy that serves mostly to let government and other stakeholders off the hook. The longer the debate stays rooted in these ageless arguments–instead of what needs to be done to create an environment that supports a basic biological function of nearly 40% of the global workforce–the longer nothing changes.

 Importance of breastfeeding for women and children. Decades of research underlie the mantra that “breast is the best” for most infants. In brief, breastfeeding confers protection for infants from diarrheal and respiratory diseases, and is associated with improved cognitive development, and reductions in overweight and diabetes.(2) It also reduces the mothers’ risk of breast cancer and improves birth spacing, and is associated with decreased risk of ovarian cancer and diabetes.(3) In low-income countries and households especially, breastfeeding can be critical for child survival. Over 800,000 child deaths could be saved by breastfeeding each year, mostly by reducing diarrhoea, respiratory infections and malnutrition from diluted formula – itself a reflection of poor water, sanitation and hygiene and the unsustainable expense of formula in these contexts.(4) And the evidence of positive linkages is still growing, with recent research highlighting the important role of breastfeeding in development of the infant’s gut microbiome.(5)

 Evolution of female labour force participation. Women account for approximately 40% of the total labour force globally and 45% of the total labour force in low income countries, data that have remained steady since 1990. (6) Globally, over half of women work; In low-income countries that increases to over two-thirds.(7) The decision to participate in wage labour is not made in isolation; it shapes and is shaped by other household practices and time allocation of other household members.(8) Most women work out of economic necessity. An undeterminable proportion of working women are mothers with young children. Evidence from Australia suggests that nearly a third return to work in the first year of their baby’s life. (9) However there is little information available on breastfeeding practices of working women globally, how considerations for breastfeeding contribute to women’s decision to return to work, or ,vice versa, how returning to work contributes to women’s decision to breastfeed.

“. . . if breastfeeding were accepted as necessary and usual practice by government and employers, then arrangements must be made for a woman’s baby to be near her for the first six months or so of life” – Margaret Mead

 Impact of women’s work on breastfeeding. Adherence to breastfeeding recommendations–and the factors influencing them–are numerous and vary globally and across the socio-economic spectrum.(10) A working mother faces constraints on her time available and proximity for child care and feeding (11). Instead of breastfeeding, she may opt for formula feeding or early introduction of complementary foods. The impact of the complex trade-offs between time and income on child care and nutrition is also influenced by other factors such as the status of the mother within the household, and age of the child (individual); the socio-economic status, farming system, and availability of other caregivers (household and community); community production structures (12), and food prices and wages (13) (community); and social and labour policies (societal). Literature commonly ascribes returning to work as a reason for weaning, and evidence from such disparate contexts as Thailand and the U.S. indicate that prevalence and duration of breastfeeding among working women may be cut in half compared to unemployed women.(14) However, overall empirical evidence for the effect of women’s work on breastfeeding–and child nutrition more generally–is mixed and inconclusive.(15)

 Urbanization and women’s work. Traditionally–and in contexts where children can accompany their mothers to work–women have simultaneously performed the dual roles of producer and reproducer. But with increasing urbanization and participation in the formal labour market, patterns of work for women are changing, requiring regular and sustained separation of mother from child. (16) To sustain lactation and maintain adequate milk supply requires hand expression of milk, use of formula or animal source milk, or use of a wet nurse.(17) Challenges for working mothers in urban and/or formal markets–and low income women especially–are numerous and function at various levels, and there is little practical advice available.(18) It is therefore unsurprising that low-income working women in urban settings demonstrate a clear trend towards decreased exclusive breastfeeding and decreased duration of breastfeeding.(19)

Fostering a “mother friendly” workplace. Female labour force participation is beneficial for women, their families, their communities and their employers. (20) Yet benefits to the child secured through women’s increased income earned may be undermined if obtained at the expense of time for and/or quality of child care. (21) However, around the world women have fought long and hard to acquire the freedom to work, and women’s work need not necessarily be a detriment to quality child care if there are substitute caregivers—older siblings, grandmother, father, or crèche—and/or other key provisions available. (22) As women are inextricably linked to the health and welfare of their children, it is essential that efforts to increase women’s economic opportunities incorporate appropriate provisions for the care of children. The question is not whether women’s work is good, but rather how to put in place policies and services to encourage and promote women’s work without compromising women’s or their children’s nutrition.

Studies showing that women decide feeding practices as early as the first trimester of pregnancy suggest that interventions to enable working women to breastfeed–and bolster her confidence in her own ability to nurture her baby–may be effective in prolonging breastfeeding duration. (23) It is entirely possible for women to successfully combine employment and breastfeeding, and the nature of her workplace can be the deciding factor. Serious commitment to systemic supports for women in the workforce to continue breastfeeding is needed, so that mothers are not forced to choose between their own well-being and that of their child. Fostering ‘mother friendly’ workplaces that recognise mothers’ needs and support her in her dual roles–and demanding that the biological needs of 40% of the global workforce be recognized–can make the difference.

See Annex 2 for specific interventions that can help.

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ENDNOTES

World Development Indicators (database), World Bank, Washington, DC (accessed 2018), http://data.worldbank.org/data-catalog/worlddevelopment-indicators.

Annex 1. A few good (recent) resources on the basics of breastfeeding

• NYTimes (https://www.nytimes.com/2018/07/08/health/world-health-breastfeeding-ecuador-trump.html)
• CNN (https://edition.cnn.com/2016/01/28/health/breast-feeding-global-rates-health-impact-lancet/index.html)
• NPR’s Goats and Soda (https://www.npr.org/sections/goatsandsoda/2018/07/13/628105632/is-infant-formula-ever-a-good-option-in-poor-countries)
• Al Jazeera (https://www.aljazeera.com/news/2018/07/long-protected-commercial-interests-breastfeeding-180714091204660.html)

Annex 2. Illustrative mother-friendly workplace interventions.

In 1993, the World Alliance for Breastfeeding Action (WABA) launched the Mother-Friendly Workplace Initiative (MFWI), which proposes specific interventions in terms of  time, space, and support across multiple levels of influence (employee, employer and the workplace).

1. ILO 1976; Holmboe-Ottesen 1988
2. Victora et al. 2016
3. Ibid.
4. Ibid.
5. Ibid
6. WDI
7. Ibid.
8. Rubin 1990
9. James 1999
10. Wolfe & Behrman 1982; Soekirman 1985; Engle & Pedersen 1989; Engle 1991; Pérez-Escamilla et al. 1995; Yimyam & Morrow 1999; Lakati et al. 2002; Flores et al. 2005; Agunbiade & Ogunleye 2012; Njai & Dixey 2013; Lesorogol et al. 2017
11. Popkin & Solon 1976; Leslie & Paolisso1989; Blau 1996; Lamontagne et al. 1998
12. Rubin 1990
13. Blau 1996
14. Yimyam & Hanpa 2014
15. Van Esterik & Greiner 1981
16. Brown 1970; Popkin & Solon 1976; Greiner 1979; Van Esterik & Greiner 1981
17. Jelliffe 1979; Popkin 1980; Van Esterik & Greiner 1981
18. Hills-Bronczyk et al. 1993; Auerbach 1984; Farmer 1988; Laterra et al. 2014; James 1999; Lesorogol et al. 2017
19. Dearden et al. 2002; Dörnemann & Kelly. 2013; Menon et al. 2005; Zalla 2015; Lesorogol et al. 2017)
20. IFC 2017
21. Abbi et al. 1991; Lamontagne et al. 1998; Kadiyala et al. 2014
22. Gryboski 1996; Hawkes 1997; Nti et al. 1999; Quinlan 2005; Keng & Lin 2005; Agunbiade & Ogunleye 2012; Dörnemann & Kelly 2013; Njai & Dixey 2013; Lesorogol et al. 2017;
23. James 1999

REFERENCES

Abbi, R., P. Christian, S. Gujral, and T. Gopaldas. 1991. “The Impact of Maternal Work Status on the Nutrition and Health Status of Children.” Food & Nutrition Bulletin 13 (1): 20–25.

Agunbiade, Ojo M, and Opeyemi V Ogunleye. 2012. “Constraints to Exclusive Breastfeeding Practice among Breastfeeding Mothers in Southwest Nigeria: Implications for Scaling Up.” International Breastfeeding Journal 7 (1): 5. https://doi.org/10.1186/1746-4358-7-5.

Auerbach, K. 1990. “Assisting the Employed Breastfeeding Mother.” Journal of Nurse-Midwifery 35 (1): 26–34. https://doi.org/10.1016/0091-2182(90)90054-9.

Blau, David M., David K. Guilkey, and Barry M. Popkin. 1996. “Infant Health and the Labor Supply of Mothers.” The Journal of Human Resources 31 (1): 90. https://doi.org/10.2307/146044.

Brown, J. K. 1970. “A Note on the Division of Labor by Sex.” American Anthropolog 72: 1073–78.

Dearden, Kirk, Mekibib Altaye, Irma de Maza, Maritza de Oliva, Maryanne Stone-Jimenez, Ardythe L. Morrow, and Barton R. Burkhalte. 2002. “Determinants of Optimal Breast-Feeding in Peri-Urban Guatemala City, Guatemala.” Revista Panamericana de Salud Pública 12: 185–92.

Dörnemann, Jenny, and Ann H. Kelly. 2013. “‘It Is Me Who Eats, to Nourish Him’: A Mixed-Method Study of Breastfeeding in Post-Earthquake Haiti: Breastfeeding in Post-Earthquake Haiti.” Maternal & Child Nutrition 9 (1): 74–89. https://doi.org/10.1111/j.1740-8709.2012.00428.x.

Engle, Patrice L. 1991. “Maternal Work and Child-Care Strategies in Peri-Urban Guatemala: Nutritional Effects.” Child Development 62 (5): 954–65. https://doi.org/10.1111/j.1467-8624.1991.tb01582.x.

Engle, Patrice L., and Mary E. Pedersen. 1989. “Maternal Work for Earnings and Childrens Nutritional Status in Urban Guatemala.” Ecology of Food and Nutrition 22 (3): 211–23. https://doi.org/10.1080/03670244.1989.9991070.

Farmer, Paul. 1988. “Bad Blood, Spoiled Milk: Bodily Fluids as Moral Barometers in Rural Haiti.” American Ethnologist 15 (1): 62–83. https://doi.org/10.1525/ae.1988.15.1.02a00050.

Flores, Mario, Marta Rivera Pasquel, Irene Maulén, and Juan Rivera. 2005. “Exclusive Breastfeeding in 3 Rural Localities in Mexico.” Journal of Human Lactation 21 (3): 276–83. https://doi.org/10.1177/0890334405278147.

Greiner, T. 1979. “Breastfeeding Decline: Perspectives on the Causes.” Lactation, Fertility, and the Working Woman.

Gryboski, K.L. 1996. “Maternal and Non-Maternal Time Allocation to Infant Care, and Care during Infant Illness in Rural Java, Indonesia.” Social Science and Medicine 43 (2): 209–219.

Hawkes, K., J. F. O’Connell, and N. G. Blurton Jones. 1997. “Hadza Women’s Time Allocation, Offspring Provisioning, and the Evolution of Long Postmenopausal Life Spans.” Current Anthropology 38 (4): 551–77. https://doi.org/10.1086/204646.

Helsing, E. 1976. “Lactation Education: The Learning of the Obvious.” Breastfeeding and the Mother.

Hills‐Bonczyk, Sharon G., Melissa D. Avery, Kay Savik, Susan Potter, and Laura J. Duckett. 1993. “Women’s Experiences with Combining Breast-Feeding and Employment.” Journal of Nurse-Midwifery 38 (5): 257–66. https://doi.org/10.1016/0091-2182(93)90104-O.

Holmboe-Ottesen, Gerd, Ophelia Mascarenhas and Margareta Wandel. 1988. “Women’s Role in Food Production and Nutrition: Implications for Their Quality of Life.” Food Nutr Bull, no. 10.3: 9–15.

International Finance Corporation (IFC). 2017. “Tackling Childcare: The Business Case for Employer-Supported Childcare.” International Finance Corporation (IFC).

International Labour Office (ILO), ed. 1976. Employment, Growth, and Basic Needs: A One-World Problem: Report of the Director-General of the International Labour Office. Geneva: International Labour Office.

James, Jenni. 1999. “Working & Breastfeeding: A Contemporary Workplace Dilemma.” Australian College of Midwives Incorporated Journal 12 (4): 8–11. https://doi.org/10.1016/S1031-170X(99)80024-5.

Jelliffe, E.F.P. 1979. “Breast-Feeding and the Working Woman: Bending the Rules.” Lactation, Fertility and the Working Woman.

Kadiyala, Suneetha, Jody Harris, Derek Headey, Sivan Yosef, and Stuart Gillespie. 2014. “Agriculture and Nutrition in India: Mapping Evidence to Pathways: Agriculture-Nutrition Pathways in India.” Annals of the New York Academy of Sciences 1331 (1): 43–56. https://doi.org/10.1111/nyas.12477.

Keng, Shao-Hsun, and Chun-Hung Lin. 2005. “Wives’ Value of Time and Food Consumed Away from Home in Taiwan.” Asian Economic Journal 19 (3): 319–34. https://doi.org/10.1111/j.1467-8381.2005.00215.x.

Lakati, Alice, Colin Binns, and Mark Stevenson. 2002. “The Effect of Work Status on Exclusive Breastfeeding in Nairobi.” Asia Pacific Journal of Public Health 14 (2): 85–90. https://doi.org/10.1177/101053950201400206.

Lamontagne, Jessica F., Patrice L. Engle, and Marian F. Zeitlin. 1998. “Maternal Employment, Child Care, and Nutritional Status of 12–18-Month-Old Children in Managua, Nicaragua.” Social Science & Medicine 46 (3): 403–14. https://doi.org/10.1016/S0277-9536(97)00184-6.

Laterra, A, MA Ayoya, JM Beaulière, M Bienfait, and H Pachón. 2014. “Infant and Young Child Feeding in Four Departments in Haiti: Mixed-Method Study on Prevalence of Recommended Practices and Related Attitudes, Beliefs, and Other Determinants.” Revista Panamericana de Salud Pública 36 (5): 306–313.

Leslie, Joanne, and Michael Jeffrey Paolisso, eds. 1989. Women, Work, and Child Welfare in the Third World. AAAS Selected Symposia Series 110. Boulder, Colo: Published by Westview Press for the American Association for the Advancement of Science, Washington, D.C.

Lesorogol, Carolyn, Caitlin Bond, Sherlie Jean Louis Dulience, and Lora Iannotti. 2018. “Economic Determinants of Breastfeeding in Haiti: The Effects of Poverty, Food Insecurity, and Employment on Exclusive Breastfeeding in an Urban Population.” Maternal & Child Nutrition 14 (2): e12524. https://doi.org/10.1111/mcn.12524.

Menon, Purnima, Marie Ruel, Gretel Pelto, Yves-François, Elisabeth Metellus, and Arsène Ferrus. 2005. “A Qualitative Study of the Patterns of Infant Feeding and Care in the Hinche Area of Plateau Central, Haiti.” The Food and Nutrition Technical Assistance (FANTA) Project.

Njai, M, and R Dixey. 2013. “A Study Investigating Infant and Young Child Feeding Practices in Foni Kansala District, Western Region, Gambia.” Journal of Clinical Medicine and Research 5 (6): 71–79. https://doi.org/10.5897/JCMR11.039.

Nti, Christina A., Dora Inkumsah, and Grace Fleischer. 1999. “Influence of Women’s Workload on Their Nutritional Status in Selected Communities in Ghana.” Journal of Consumer Studies & Home Economics 23 (3): 165–70. https://doi.org/10.1046/j.1365-2737.1999.00106.x.

Pérez-Escamilla, Rafael, Chessa Lutter, Maria Segall, Ada Rivera, Sandra Treviño-Siller, and Tina Sanghvi. 1995. “Exclusive Breast-Feeding Duration Is Associated with Attitudinal, Socioeconomic and Biocultural Determinants in Three Latin American Countries.” The Journal of Nutrition 125 (12): 2972–2984.

Popkin, B. M. 1980. “Time Allocation of the Mother and Child Nutrition.” Ecology of Food and Nutrition 9 (1): 1–14. https://doi.org/10.1080/03670244.1980.9990579.

Popkin, B. M., and F. S. Solon. 1976. “Income, Time, the Working Mother and Child Nutriture.” Journal of Tropical Pediatrics 22 (4): 156–66. https://doi.org/10.1093/tropej/22.4.156.

Quinlan, Robert J., Marsha B. Quinlan, and Mark V. Flinn. 2005. “Local Resource Enhancement and Sex‐biased Breastfeeding in a Caribbean Community.” Current Anthropology 46 (3): 471–80. https://doi.org/10.1086/430017.

Rubin, D. S. 1990. “Women’s Work and Children’s Nutrition in South-Western Kenya.” Food and Nutrition Bulletin 12 (4): 268–72.

Soekirman. 1985. “Women’s Work and Its Effect on Infants’ Nutritional Status in Central Java, Indonesia.” In Colloquium on Adequacy of Breastfeeding and Maternal Nutrition Status. Brighton, England.

Van Esterik, Penny, and Ted Greiner. 1981. “Breastfeeding and Women’s Work: Constraints and Opportunities.” Studies in Family Planning 12 (4): 184. https://doi.org/10.2307/1965600.

Victora, Cesar G, Rajiv Bahl, Aluísio J D Barros, Giovanny V A França, Susan Horton, Julia Krasevec, Simon Murch, Mari Jeeva Sankar, Neff Walker, and Nigel C Rollins. 2016. “Breastfeeding in the 21st Century: Epidemiology, Mechanisms, and Lifelong Effect.” The Lancet 387 (10017): 475–90. https://doi.org/10.1016/S0140-6736(15)01024-7.

Wolfe, Barbara L., and Jere R. Behrman. 1987. “Women’s Schooling and Children’s Health.” Journal of Health Economics 6 (3): 239–54. https://doi.org/10.1016/0167-6296(87)90011-7.

Yimyam, Susanha, and Martha Morrow. 1999. “Breastfeeding Practices Among Employed Thai Women in Chiang Mai.” Journal of Human Lactation 15 (3): 225–32. https://doi.org/10.1177/089033449901500313.

Yimyam, Susanha, and Wasana Hanpa. 2014. “Developing a Workplace Breast Feeding Support Model for Employed Lactating Mothers.” Midwifery 30 (6): 720–24. https://doi.org/10.1016/j.midw.2014.01.007.

Zalla, Lauren. 2015. “The Prevalence and Social Determinants of Exclusive Breastfeeding and Implications for Infant Growth in Rural Haiti: A Mixed-Methods Study.” Master’s thesis, Duke University.