Mothers are the fastest-growing segment of the labor force. Maternal employment has become more common in developed countries. Mothers who work and continue to breastfeed have also become more common. Part of the reason for this trend is the need for a second income in young households. Among professional women, the age of childbearing has been delayed to the 30s and early 40s, when a woman has established a career she wants to continue. Another reason for the increase of breastfeeding among employed mothers has been the exhaustive efforts by the United States Breastfeeding Committee, the Division of Nutrition Physical Activity and Obesity at the Centers for Disease Control and Prevention (CDC), and the Center for Food Safety and Applied Nutrition of the Food and Drug Administration (FDA). The development of the Business Case for Breastfeeding campaign has been accomplished by their combined efforts. The Center for Economic and Policy Research reported on Parental Leave Policies in 21 countries, emphasizing their generosity, gender equality, the level of support provided to the parents, and the degree to which leave policies promote egalitarian distribution between mothers and fathers of the time devoted to child care. All 21 countries studied protect at least one parent’s job for a period of weeks, months, or years at the birth of a child. Leaves vary from 14 weeks in Switzerland to over 300 weeks (about 6 years) in France and Spain. The United States is 20th out of 21, providing 24 weeks combined for both parents. Switzerland also provides financial support of 80% of a mother’s earnings.
In terms of money, most countries provide direct financial support between three months and one year at least for part of the protected leave time. The United States is one of two countries that provide a generous financial baby bonus but no paid leave; Australia is the other.
The Gender Equality Index is a single measure to examine the effect of parental leave policies on both the workplace and care giving. Sweden rated highest and the United States fell in the middle in terms of equality of gender in the workplace. Best practices require a generous, universal, gender-equalitarian, and flexible parental leave policy, financed through social insurance. There are states in the United States that provide some benefits but none provide generous benefits by international standards.
The issues of working women are no longer in the shadows. They are on the minds of federal legislators who are considering legislation to improve work environments, family leave, and accommodations for breastfeeding. The Patient Protection and Affordable Care Act was signed into law in March of 2010; it includes an amendment to section 7 of the Fair Labor Standards Act (FLSA). This amendment requires employers to provide reasonable break time for an employee to express breast milk for her nursing child for a year after the child’s birth.
Employers are required to provide a place, other than a bathroom, that is shielded from view and free from intrusion from coworkers and the public, which may be used by an employee to express breast milk. The break time requirement became effective when the Affordable Care Act was signed into law on March 23, 2010. The Wage and Hour Fact Sheet #73 is available from the U.S. Department of Labor Wage and Hour Division ( Table 18-1 ).
| Elements | Specifics |
|---|---|
| Time and location of breaks |
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| Coverage and compensation |
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| Fair Labor Standards Act prohibitions on retaliation |
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Low income women who are predominantly minorities (black and Hispanic) return to work earlier and to jobs that do not accommodate breastfeeding. The barriers in the workplace include inflexible schedules and lack of support from employers and colleagues.
There were 127.1 million working age women (16 years of age or older) in the United States in 2013 and 72.7 million were in the labor force. Of that number, 99.5 million were white, 16.6 million were black, 7.1 million Asian, and 18.7 million Hispanic ( Figure 18-1 ). By 2022 it is projected that women in the work force will increase by 5.4% compared to a 5.6% increase in the number of men. Women are expected to reach 46.8% of the labor force in 2022. The labor force participation rate of mothers with children under 18 years of age in 2013 was 69.9%, 74.7% for mothers with children 6 to 17 years of age, 63.9% for mothers with children under 6 years of age, 61.1% for mothers with children under 3, and 57.3% for mothers with infants ( Figure 18-2 ). Of employed women, 74% worked full time (35 hours or more) and 24% worked part time compared to 86.9% and 13.1% of employed men. 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 (10.3%).
Education was a major factor with the over 64 million women 25 or older in the labor force; 6.7% had less than a high school diploma, 25.3% had no more than a diploma, 17.5% had some college, and 37.8% had a bachelor’s degree or higher. The overall women-to-men ratio of earnings is 82.1%, with white women only 81.7% while black women are 91.3%, Hispanic women 91.1%, and Asian women only 77.3%.
Maternal employment, however, has been cited by many authors as the major reason for the decline in breastfeeding worldwide. International data do not actually support this conclusion. Year after year the Mothers Survey in the United States confirmed that the highest percentage of women initiating breastfeeding in the hospital is among women who plan to return to full-time employment, the next highest among women who plan to return to part-time employment, and the lowest among those who plan to remain at home. In 2002, initiation in the hospital was 69% among women fully employed, 72.9% among those employed part time, and 69% among those not employed. The duration, however, is affected by employment, with 36.8% of those employed part time still breastfeeding at 5 to 6 months, 35.2% of nonemployed women still breastfeeding at that point, and only 27.1% of those employed full time still breastfeeding at 5 to 6 months ( Figure 18-3 ). A mother who chooses to return to work and breastfeed is confronted by significant constraints, regardless of the statistical data. Although economic, cultural, and political pressures often confound decisions about infant feeding, 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. Enthusiastic support and involvement of all physicians in the promotion and practice of breastfeeding 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. ,
Historical Perspective
In modern cultures, a stigma has been attached to a mother earning money while her children are young, but no such stigma is associated with leaving her children for social interaction, personal reasons, or a volunteer job. 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. Before industrialization, working mothers were the rule and not the exception. Home and work were separated by industrialization, making parenting a separate role for women.
Women’s work has been described as domestic or productive, public or private, traditional or modern. Domestic work, when performed for the family, is unpaid, thus undervalued, and not considered productive work. Domestic work is performed in the private domain, and “productive” work is associated with the public domain. Women had previously worked in agriculture and cottage industries as well as in small-scale marketing, whereas today they participate in formal work (i.e., they are employees), including clerical, factory, and professional jobs, predominantly in urban settings.
More women are employed outside the home today than previously. In 1900, 20% of the labor force were women; in 1950, 29%; in 1997, 56.6%; in 2003, 57.5%; and in 2008 (at the onset of a recession), 59.9%. Women with children younger than 6 years old are the fastest-growing segment of the female work force; their numbers reached 59% in 1992 and more than 65% in 1996 but dropped to 59.4% in 2002 and 63.6% in 2008. Even more important is that the number of employed mothers with infants younger than 1 year old rose to 48% of all women in 1985 and has continued to climb. Many more women facing the decision about infant feeding methods must include early return to work in their considerations. In 1998, at least 50% of women employed in the United States when they became pregnant returned to the labor force by the time their children were 3 months old. U.S. Department of Labor statistics show that 54.3% of mothers with children younger than 1 year old were in the work force in 1996 and 57.3% in 2008. This figure rises to 63.3% for women with children younger than 2 years of age. In Australia, 27% of women with infants younger than 1 year old return to work and 49% of women with children younger than 5 years old are part of the paid work force.
Generations ago, the woman who worked violated the Victorian norms of role definition. Even when forced to work by sheer necessity, she was accused of neglecting her primary responsibility to her children. The new ethic proclaims work a cardinal virtue for liberated women, so that now women who can and do stay home may begin to feel inadequate.
Knowing why women enter the work force is important to understanding the trend. Before 1970, the need to earn money motivated 3 million women either because the woman was a single parent or because husband-fathers were unable to earn an adequate income. For women whose husbands earned “enough,” there was the desire to have a higher standard of living or to provide the father with greater freedom of career choice. Few women sought employment for the sake of having a career because the need for income was the only socially acceptable, defensible reason for a mother to work outside the home.
Since that time many women have found that the full-time care of a home leads only to higher standards of cleanliness with no greater sense of achievement or completion. Some believed that the exclusive investment of energy and emotion in the rearing of one to three children would involve a considerable hazard not only to a mother, but also to her children’s ultimate achievement and ability to form a variety of responsive and satisfying personal relationships. Women are responding to the pressures of a depressed economy, to the costs of higher education, to the opportunities for personal fulfillment, and to the growing market for service occupations. Married women continue to carry at least 70% to 80% of the child care and household duties when both parents work.
Women have reached the point where marriage in itself has relatively little effect on the labor supply, according to Cohen and Bianchi. Educational differentials in the labor market have grown over time, widening the gap between more educated and less educated women, giving the former greater opportunities. ,
Attitudes of Health Care Professionals Toward Working Mothers
Professional and lay books alike on child rearing have viewed working negatively except for economic necessity, thus enhancing a working mother’s guilt and providing little substantial advice about how to balance or how to continue breastfeeding.
The AAP strongly states that pediatricians should “encourage employers to provide appropriate facilities and adequate time in the workplace for breast-pumping.” The AAP provides extensive recommendations for a mother to prepare for returning to work and maintaining her milk supply when she does return.
The ACOG has acknowledged the current trend to work throughout pregnancy and to return to work promptly after delivery by preparing a physician’s guide to patient assessment and counseling, which has not been updated since 1987. ACOG also provides a patient occupational questionnaire for the practitioner. This forms a basis of discussion with a patient and provides an opportunity to counsel the patient and her husband about plans to maintain a healthy environment and any special needs for child care. With few exceptions, “the normal woman with an uncomplicated pregnancy and a normal fetus, in a job that presents no greater potential hazards than those encountered in normal daily life in the community, may continue to work without interruption until the onset of labor and may resume working several weeks after an uncomplicated delivery.” An obstetrician has a role in facilitating continued breastfeeding after the return to work or school. This includes counseling regarding pumping and storing milk and avoiding exhaustion ( Tables 18-2 and 18-3 ).
| Reason | Frequency | |
|---|---|---|
| No. | % | |
| Economic | 1709 | 25 |
| Never recommend mother work | 1566 | 22 |
| Mother’s emotional needs | 1220 | 18 |
| Mother’s fulfillment | 1059 | 15 |
| Child is better off without mother | 644 | 9 |
| Reassure mother | 270 | 4 |
| Adequacy of child care | 266 | 4 |
| Child’s age | 170 | 2 |
| Mother does important work | 64 | 1 |
| Total | 6968 | |
| Reason | Frequency | |
|---|---|---|
| No. | % | |
| Child’s physical health | 1724 | 24 |
| Child’s mental health | 1445 | 20 |
| Never recommend against work | 1318 | 18 |
| Inadequate child care | 701 | 10 |
| Child’s age | 591 | 8 |
| Mother feels guilty | 540 | 7 |
| No economic need | 459 | 6 |
| Usually say, “Do not work” | 72 | 1 |
| Other | 402 | 6 |
| Total | 7252 | |
Physicians play an important role in guiding parents with information about quality and availability of child care facilities and with advice about coping strategies. Multiple studies have demonstrated the affect of clinician support and duration of breastfeeding. As the family counselor, a physician can support mothers and fathers seeking to fulfill parental, occupational, and personal needs in a rapidly changing society. With the firm recommendation of the AAP to breastfeed throughout the first year and beyond, support from pediatricians will be critical.
Attitude of Employer and Employees Toward Working Women
Studies of employer attitudes toward working mothers, and specifically toward women who need accommodation to breastfeeding and to pump, reflected lack of knowledge. When employers understood the benefits of breastfeeding, attitudes changed.
Personal experience with breastfeeding had the greatest impact. Almost all at the managerial level were unaware of the existence of company policy. It appears that the greatest progress in supporting breastfeeding in the workplace has come when it has been mandated by state or federal policy.
Employers who accommodate lactating mothers can fear negative reactions from other workers. In a large U.S. corporation that provided a wide variety of accommodations for lactating mothers, 407 employees were studied by Suyes et al. They observed that overall attitudes were favorable. Those who had previous exposure to a work colleague who was breastfeeding were associated with a positive attitude even after the investigators controlled for respondent’s gender, length of employment, and personal exposure to breastfeeding. The authors concluded that lactation accommodations did not have a negative impact on the work environment or other employees.
A program directed at the male employees has been functioning at the Los Angeles Department of Water and Power since 1990. There has been a full-time, on-site lactation program offered to the male employees. In addition to classes and individual instruction, information is available on the electronic pump and the pump kit and its use. Meetings with a lactation consultant and daily assistance for the mother when needed also are offered. It has grown by word of mouth, fathers’ interest in the benefits of breastfeeding for the infant, and the female partners’ interest in obtaining a free pump rental. It is a model that could well be implemented in any corporation.
Outcome for Children of Employed Mothers
Numerous studies since the early 1930s have looked at the effects of maternal employment. Assessment of infant behavior, school achievement and adjustment, children’s attitudes, adolescence, and delinquency have all been used as outcome measures. Annotated bibliographies covering the range of research in areas of medicine, psychology, sociology, and education are available. The four major considerations are the variables that facilitate or impede maternal employment, the effect of maternal employment on children during the four developmental stages, the effects on the family, and the effects on society in general. Society is far more accepting of working mothers in the twenty-first century.
It has been emphasized that the presence of a mother in the home does not guarantee high-quality mothering. It has also been shown that well-educated (college) mothers, including those who are employed, spend time with their children at the expense of their own personal needs. Because employed mothers encompass a large group of women with different educational levels, different reasons for working, and different opportunities for employment, it is difficult to generalize about effects. Literature reviews have emphasized critical factors that are more important than maternal employment, such as good substitute care, maternal role satisfaction, family stability, paternal attitude toward maternal employment, and the quality of the time spent with the children. Despite the abundance of research on school-age children, there is still little reported about preschoolers because no school records or test results are available to use in large-population analysis.
To date, there is no direct effect of nonexclusive mothering per se. Studies of infants of adolescent mothers have shown that the children do better socially and academically if there are multiple caregivers instead of the adolescent mother alone. No uniformly harmful effects on family life or on the growth and development of children have been demonstrated. Maternal employment may jeopardize family life when the conditions of the mother’s employment are demeaning to self-esteem, when others are strongly disapproving of her work away from the home, or when arrangements for child care are not adequate.
Questions have been raised about the impact of separation of mother and infant and the timing of this separation. Resumption of full-time employment when the child is younger than 1 year old has prompted studies. Using the Ainsworth “strange situation” validated techniques, no relationship between maternal work status and the quality of the infants’ attachment to their mothers is reported. , Early resumption of employment may not impede development of a secure infant-mother attachment. A significantly higher proportion of insecure attachments to fathers in employed-mother families is reported for boys but not for girls. Boys are more insecurely attached than girls in most studies. It is believed that an infant’s attachment relationship to mother emerges at approximately 7 months. Other studies suggest that maternal employment can have a positive effect on girls but not boys. Whether breastfeeding accounts for some of the variability in these studies is not stated. No study recorded feeding method or considered the impact breastfeeding has on the mother-infant relationship or the infant’s development. One of the strategies suggested is to advocate for infant care centers that provide breastfeeding facilities in the workplace, schools, and other locations serving working women.
Breastfeeding and Employment
An important distinction must be made between work that separates mothers and infants for blocks of time and work that does not. In rural settings, women’s work is usually compatible with all aspects of child care, including breastfeeding. Work in or around the home is usually flexible. If there are provisions for infants at the workplace, even formal urban work is compatible with child care and breastfeeding. The higher the education of the mother and the more advanced the job, the more opportunity exists for flexible arrangements that permit breastfeeding. Among the strategies available is pumping and saving milk while on the job to be fed to the baby by the babysitter the next day.
Overall, the breastfeeding rates for working women do not show that breastfeeding and employment are mutually exclusive. In Finland the incidence of mothers breastfeeding at 1 month is 78% among nonemployed and 80% among employed mothers. The duration is also unaffected: 29% of nonemployed and 32% of employed mothers are breastfeeding at 3 months, and 8% and 7%, respectively, at 6 months. Similar statistics are reported from Nigeria, the Philippines, and Chile.
An infant feeding practices study reported that those mothers at 6 months who were employed full time numbered 22,316 (26.6%), part time 12,186 (14.5%), and not employed 49,483 (58.9%). The same proportion (55%) of employed mothers as not employed mothers were breastfeeding when they left the hospital. Only 10% of full-time employed mothers were breastfeeding at 6 months compared with 24% of those who were not employed, however. The highest incidence of breastfeeding at birth and at 6 months was among mothers older than 30 years who are well educated and in a higher socioeconomic group. In 2002, the duration of breastfeeding at 6 months was as follows: of those mothers employed full time, 27.1% were breastfeeding, of those employed part time, 36.8% were breastfeeding, and of those not employed, 35.2% were breastfeeding—not a remarkable rate for those at home. At 6 months, 42.3% of women older than 30 years were still breastfeeding; those with a college education were at 44.6%.
Although there was no association between planning to be employed within the first 6 months and initiation of breastfeeding, there was a significant association with cessation of breastfeeding as early as 2 to 3 months postpartum, even with adjustment for demographics. Among employed mothers, working 20 hours a week or less was protective for continuation of breastfeeding. When the factors influencing the duration of breastfeeding at 6 months were examined by postal questionnaire in Edinburgh, only 5 of 116 mothers listed “return to work” as a reason for discontinuing.
Employment among black women around Johannesburg, South Africa, after the birth of a baby strongly influenced duration of breastfeeding. Although 97% had initiated breastfeeding, only 30% continued for 20 weeks; duration of breastfeeding had a direct association with return to work because these women did not consider it feasible to do both. Similar findings were reported in Washington, District of Columbia, where 80% of black women worked during pregnancy and those who planned to return to work part time only were more likely to breastfeed. In this study, those who returned to a professional occupation had a longer duration of breastfeeding than those who returned to sales or technical jobs, regardless of whether the individual was black or white.
Although work has been listed as the primary cause of early weaning, women seldom give employment as a reason for terminating breastfeeding. A review of the world literature documenting reasons for weaning, starting bottle-feeding, or not initiating breastfeeding rarely mentioned employment. In studies of the effect of mother’s employment on the nutritional status of her children, poverty, not mother’s work, was associated with poor nutrition.
The effect of employment on the duration of breastfeeding may be influenced by the fact that breastfeeding can be carried out while a mother performs other tasks around the house so that it is easier to breastfeed when she is home. Many studies have found that employment has little or no effect on the duration of breastfeeding, especially where cottage industry was prevalent. The greatest problems are the difficulties encountered finding a place to pump and store the milk on the job. Those women who work outside the home must schedule and plan carefully and are motivated to continue once the complex schedule is established. They also are more able to accommodate themselves to the stresses involved ( Figure 18-4 ).
