APHA supports breastfeeding, paid maternity leave, and workplace accommodations for mothers in the United States. However, there are no policy statements to support breastfeeding through maternity protection worldwide. Although the International Labour Organization has supported paid maternity leave and workplace accommodations for breastfeeding since 1919, protections vary by country, leaving 830 million women without adequate protection. APHA recognizes that the health of the US population cannot be ensured without attention to global health. Therefore, it is time for APHA to actively support breastfeeding worldwide through maternity protection. APHA members working in global health could support maternity protection through research, advocacy, and health programs.
Relationship to Existing APHA Policy Statements
APHA has previously supported global reductions in barriers to optimal breastfeeding. APHA Policy Statement 200714 (A Call to Action on Breastfeeding: A Fundamental Public Health Issue) acknowledges breastfeeding’s contribution to birth spacing and fertility reduction, cites the importance of the lactational amenorrhea method for postpartum contraception, and describes differences in long-term outcomes between breastfed and nonbreastfed children. It also cites the Bellagio Study Group’s conclusion that 1.3 million child deaths per year worldwide could be prevented with 6 months of exclusive breastfeeding and continued breastfeeding for the first year of life. In addition, APHA has acknowledged that worksites generally do not support the needs of lactating employees and that there are wide disparities in access to skilled breastfeeding support among different groups.
APHA supports the Nestlé boycott as well as the International Code of Marketing of Breast-milk Substitutes and subsequent World Health Assembly resolutions.
APHA is committed to the global defense of health and human rights, as described in APHA Policy Statement 20092 (Border Crossing Deaths: A Public Health Crisis Along the US–Mexico Border).
In Policy Statement 201113 (Call to Action to Reduce Global Maternal, Neonatal, and Child Morbidity and Mortality), APHA noted the need for increased attention to the health of women and new mothers and cited a review published in the Lancet reporting that exclusive breastfeeding for 6 months, in combination with immediate postpartum skin-to-skin contact, continued breastfeeding for at least 1 year, and proper complementary feeding, would prevent more than 20% of infant deaths.[2,6] APHA recommended that the US Congress, the executive branch, federal agencies, and their partners make a sustained political commitment to global maternal, neonatal, and child health at all levels of the US government that concern foreign assistance and increase funding in this area. Also, APHA called on public health professionals and international organizations to “support more intensive promotion of breastfeeding, including measures to dissuade the promotion and use of breastmilk substitutes.”
Concern for women’s health and birth spacing (a benefit of exclusive breastfeeding) was confirmed in APHA Policy Statement 20111 (Improving Access to Over-the-Counter Contraception by Expanding Insurance Coverage).
In APHA Policy Statement 201115, the association strongly endorsed the Surgeon General’s Call to Action to Support Breastfeeding, which includes the following recommended actions: working toward the establishment of paid maternity leave, ensuring that employers establish and maintain comprehensive high-quality lactation support programs, expanding the use of workplace programs that allow lactating mothers to have direct access to their babies, and ensuring that all child-care providers accommodate the needs of breastfeeding mothers and infants.
In 2013, two new relevant and supportive policies were approved. APHA Policy Statement 20132 (An Update to A Call to Action to Support Breastfeeding: A Fundamental Public Health Issue) confirms and updates the need to support women in their efforts to succeed in breastfeeding, and APHA Policy Statement 20136 (Support for Paid Sick Leave and Family Leave Policies) calls for federal legislation extending paid family and sick leave to more employees. This policy updates APHA Policy Statement 20001 (Expanded Family and Medical Leave), which called for expanding family and medical leave in the United States to reflect leaves provided by other industrialized countries. These policies focus on mothers in the United States; APHA has not yet issued a policy statement in support of paid family and sick leave globally.
The health benefits of breastfeeding to mothers and infants are well established. In addition to the beneficial effects of any breastfeeding, exclusive breastfeeding for the first 6 months of an infant’s life has particular benefits.[12,13] These advantages endure throughout the life course; few public health interventions can match the scale and breadth of the benefits of breastfeeding at a population level. In addition, optimal breastfeeding contributes significantly to birth spacing by delaying return of fertility postpartum, and a reliable method of birth spacing, the lactational amenorrhea method, has been developed on the basis of this physiology. Birth spacing has a significant impact on nutritional status and mortality among neonates, infants, and children in developing countries.
Suboptimal breastfeeding has significant public health costs and has been cited as both an outcome and a cause of social as well as health inequality. According to researchers at the University of Sheffield: “It is an outcome of inequality because (i) low income families have the lowest rates of breastfeeding; (ii) there is a marked inter-generational effect that perpetuates these low rates…; (iii) the long-term health and development of the child is affected by whether or not she/he is breastfed and (iv) the social patterning of infant feeding results in the greatest burden of ill health and adverse effects falling on the poorest families.”[14,18] At the same time, breastfeeding can redress health inequalities because a lower-income child who is breastfed will, in all likelihood, have better health outcomes than a wealthier child who is not breastfed.[14,19]
Evidence suggests that duration of maternity leave is associated with duration of breastfeeding. Currently, about 830 million women around the world do not have adequate maternity protection for leave and cash benefits, and 80% of them live in Africa and Asia. Detrimental effects of lack of maternity leave and financial security in the perinatal period have been documented in low-income countries.[21–24] Only 45% of countries have policies ensuring that individuals receive two-thirds of their wages in cash benefits for 14 weeks, and only 23% of countries adhere to the minimum duration of protected maternity leave (18 weeks) recommended by the International Labour Organization (ILO). While most countries have legislated some kind of maternity protection, the ILO cites a “persistent challenge” to ensuring that all workers have access to that protection and do not experience discrimination. Meanwhile, many mothers work out of financial necessity, and circumstances require them to return to work before their infant is 4 months of age. This is in contrast to the recommendation of exclusive breastfeeding for the first 6 months of life. Thus, policies in most nations around the world directly challenge mothers’ and infants’ rights to exclusive breastfeeding.
It has been shown that mothers who are employed at workplaces where lactation is supported breastfeed longer,[25,26] and other benefits to mothers, infants, and workplaces have been documented in the Health Resources and Services Administration’s “Business Case for Breastfeeding.” Approximately 40% of women of reproductive age work outside of the home in developing countries, where mothers’ work is associated with malnourishment among children less than 3 years of age. It has been found that, in some developing countries, exclusive breastfeeding durations are shorter among employed mothers than among unemployed mothers.[30,31] In the absence of adequate workplace support, working is not compatible with breastfeeding owing to the supply and demand production cycle of breast milk. According to the ILO, “throughout the world, returning to work is a major factor in women’s decisions to quit or to reduce breastfeeding.”[21,32–35]
There are documented barriers to breastfeeding once a mother returns to work, and even in instances in which accommodations exist, they are often inadequate. Twenty-four percent of countries do not have legal protection for nursing breaks. In more than half of the countries with statutory provisions for nursing or child care facilities, those rules apply only if a minimum number of women are employed, leading to concerns related to potential hiring discrimination against women. Given the proportions of mothers and women of reproductive age who are employed, exclusive breastfeeding rates are unlikely to change substantially without workplace interventions supported by public policies. In addition, hourly wage workers may face different challenges than salaried workers in terms of time and flexibility to breastfeed or express breast milk. APHA Policy Statement 20092 notes that migrant or undocumented laborers also face particular challenges with respect to their health and human rights.
Global policies support paid leave and workplace accommodations. Consistent with Article 24 of the United Nations Convention on the Rights of the Child, the World Alliance for Breastfeeding Action reports that the United Nations Children’s Fund (UNICEF) recognizes breastfeeding as “an essential component in assuring the child’s right to the highest attainable standard of health…. This means that governments are under an obligation to ensure an environment that empowers women to breastfeed their children if they choose to do so. Working women do not lose the right to this enabling environment because they are in paid employment.”[36,37] The 2000 ILO Maternity Protection Convention and its accompanying recommendation call for the establishment of an integrated set of measures to help initiate, establish, and maintain optimal breastfeeding practices.
Evidence-Based Strategies to Address the Problem
The following interventions are recommended to support optimal infant feeding among mothers who work outside of the home.
1. Paid maternity leave: There are benefits to mothers and babies when mothers have postpartum maternity leave to heal from birth and to bond with their infants without a significant financial penalty. Positive effects on breastfeeding have been found. Delayed return to work is associated with longer duration of breastfeeding.[32,40]
2. Workplace support: Rates of breastfeeding initiation and duration are higher among women who are employed in workplaces with lactation support programs, which may accommodate direct breastfeeding through telecommuting and child care on site or nearby in addition to supporting breast milk expression.[25–27,41]
APHA supports these interventions in the United States. This proposed policy statement extends that support to mothers around the world.
Sources of funding for paid maternity leave range from employer liability to social safety nets. According to ILO Convention 183, Article 6(8), paid maternity benefits should be provided by social insurance or public funds, and employers are not liable for direct costs with the exception of cases in which such costs were stipulated by national law prior to the date of the convention’s signing or an agreement was subsequently reached between the government and employer/worker organizations. Currently, most countries have a policy of shared contributions between employers and employees to jointly fund maternity benefits. Systems that depend solely on employer liability tend to work against employees, sometimes through discrimination in hiring practices. Employers are not generally supportive of policies that detract from their bottom line. According to the ILO, maternity protection is affordable even in low-income countries and facilitates social and economic development, and thus solutions are seemingly within reach of joint public policy and workplace efforts.
Employers may also argue that it is not in their financial interest to support lactation in the workplace. The cost of providing nursing breaks is usually assigned entirely to the employer, creating a disincentive that could potentially result in hiring discrimination and underscoring the need for public policies supporting workplace initiatives. US evidence-based recommendations indicate that it is in the interest of businesses to support lactation, citing costs saved and benefits to employees. The ILO states that work-family measures result in better performance and commitment, higher employee retention, lower absenteeism, preservation of skills, and healthier parents in the workforce. The health imperative necessitates a “can-do” approach to this issue to ensure the greater public good.
1. APHA calls on the US government, including the Department of State and the US Agency for International Development (USAID), as well as public health professionals and international organizations to orient US foreign assistance to the creation and support of policies and programs that promote increased availability of paid maternity leave and workplace accommodations for breastfeeding in both formal and informal workplaces. This includes programming to promote and support both direct breastfeeding and the feeding of expressed milk when necessary. Workplace accommodation means that workplaces provide paid time or a reduction in hours for breastfeeding or milk expression, a clean and private space near the employee’s workspace, clean water, electricity (where applicable), a place to store related supplies and expressed milk,[21,42] and the flexibility to express milk as needed. This includes fostering a supportive workplace environment as well. APHA also urges the entities and individuals mentioned above to monitor the progress and effects of these efforts.
2. APHA urges public health professionals and international organizations to acknowledge, address, and monitor work-related barriers to breastfeeding (and their effects on maternal and child health and birth spacing) and advocate for paid maternity leave and workplace accommodation of breastfeeding worldwide.
3. There is a need for further research on this issue, including studies focusing on local solutions in different country and employment contexts. Therefore, APHA urges the US government, public health professionals, and international organizations to fund and conduct this research, advocate for maternal protection policies, and monitor the implementation of these policies.
1. American Public Health Association. Policy Statement 200714. Available at: https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/29/13/23/a-call-to-action-on-breastfeeding-a-fundamental-public-health-issue. Accessed December 27, 2014.
2. Jones G, Steketee RW, Black RE, et al. How many child deaths can we prevent this year? Lancet. 2003;362:65–71.
3. American Public Health Association. Policy Statement 8126. Available at: https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/10/13/13/nestle-boycott. Accessed December 27, 2014.
4. International Code of Marketing of Breast-milk Substitutes. Geneva, Switzerland: World Health Organization; 1981.
5. American Public Health Association. Policy Statement 20092. Available at: https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/24/08/56/border-crossing-deaths-a-public-health-crisis-along-the-us-mexico-border. Accessed December 27, 2014.
6. American Public Health Association. Policy Statement 201113. Available at: https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/24/10/10/call-to-action-to-reduce-global-maternal-neonatal-and-child-morbidity-and-mortality. Accessed December 27, 2014.
7. American Public Health Association. Policy Statement 20111. Available at: https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/24/10/31/improving-access-to-over-the-counter-contraception-by-expanding-insurance-coverage. Accessed December 27, 2014.
8. American Public Health Association. Policy Statement 201115. Available at: https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/07/10/42/apha-endorses-the-surgeon-generals-call-to-action-to-support-breastfeeding. Accessed December 27, 2014.
9. American Public Health Association. Policy Statement 20132. Available at: https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/09/15/26/an-update-to-a-call-to-action-to-support-breastfeeding-a-fundamental-public-health-issue. Accessed December 27, 2014.
10. American Public Health Association. Policy Statement 20001. Available at: https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/29/08/47/expanded-family-and-medical-leave. Accessed December 27, 2014.
11. Agency for Healthcare Research and Quality. Breastfeeding and maternal and infant health outcomes in developed countries. Available at: http://archive.ahrq.gov/downloads/pub/evidence/pdf/brfout/brfout.pdf. Accessed December 27, 2014.
12. Exclusive Breastfeeding for Six Months Best for Babies Everywhere. Geneva, Switzerland: World Health Organization; 2011.
13. Technical Focus: Exclusive Breastfeeding. Durham, NC: FHI 360 Alive and Thrive Project; 2013.
14. University of Sheffield. Benefits of breastfeeding. Available at: http://www.shef.ac.uk/scharr/sections/ph/research/breastmilk/benefitsofbreastfeeding. Accessed December 27, 2014.
15. Labbok M, Perez A, Valdes V, et al. The lactational amenorrhea method (LAM): a postpartum introductory family planning method with policy and program implications. Adv Contracept. 1994;10:93–109.
16. Rutstein S. Effects of preceding birth intervals on neonatal, infant and under-five years mortality and nutritional status in developing countries: evidence from the Demographic and Health Surveys. Int J Gynaecol Obstet. 2005;89(suppl 1):S7–S24.
17. Bartick M, Reinhold A. The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis. Pediatrics. 2010;125:e1048–e1056.
18. Information Centre for Health and Social Care. Infant Feeding Survey 2005. Available at: http://www.hscic.gov.uk/catalogue/PUB00619/infa-feed-serv-2005-rep.pdf. Accessed December 27, 2014.
19. Wilson AC, Forsyth JS, Greene SA, Irvine L, Hau C, Howie PW. Relation of infant diet to childhood health: seven year follow up of cohort of children in Dundee infant feeding study. BMJ. 1998;316:21–25.
20. Guendelman S, Kosa JL, Pearl M, Graham S, Goodman J, Kharrazi M. Juggling work and breastfeeding: effects of maternity leave and occupational characteristics. Pediatrics. 2009;123:e38–e46.
21. International Labour Organization. Maternity and paternity at work. Available at: http://fortunedotcom.files.wordpress.com/2014/05/wcms_242615.pdf. Accessed December 27, 2014.
22. Holmes R, Jones N. Gender and Social Protection in the Developing World: Beyond Mothers and Safety Nets. New York, NY: Zed Books; 2013.
23. Lund F, Srinivas S. Learning From Experience: A Gendered Approach to Social Protection for Workers in the Informal Economy. Geneva, Switzerland: International Labour Organization; 2000.
24. Jhabvala R, Sinha S. Social protection for women workers in the informal economy.
Compar Labour Law Policy J. 2006;27:167–185.
25. The Surgeon General’s Call to Action to Support Breastfeeding. Washington, DC: US Department of Health and Human Services, Office of the Surgeon General; 2011.
26. Tsai SY. Impact of a breastfeeding-friendly workplace on an employed mother’s intention to continue breastfeeding after returning to work. Breastfeed Med. 2013;8:210–216.
27. Business Case for Breastfeeding. Washington, DC: US Department of Health and Human Services, Health Services Research Association; 2009.
28. Mukuria A, Aboulafia C, Themme A. The context of women’s health: results from the Demographic and Health Surveys 1994–2001. Available at: http://dhsprogram.com/pubs/pdf/CR11/CR11.pdf. Accessed December 27, 2014.
29. Mukuria A, Cushing J, Sangha J. Nutritional status of children: results from the Demographic and Health Surveys 1994–2001. Available at: http://dhsprogram.com/pubs/pdf/CR10/CR10.pdf. Accessed December 27, 2014.
30. Yimyam S, Morrow M. Breastfeeding practices among employed Thai women in Chiang Mai. J Hum Lact. 1999;3:225–232.
31. Chen YC, Wu YC, Chie WC. Effects of work-related factors on the breastfeeding behavior of working mothers in a Taiwanese semiconductor manufacturer: a cross-sectional survey. BMC Public Health. 2006;6:160.
32. Ogbuanu C, Glover S, Probst J, Liu J, Hussey J. The effect of maternity leave length and time of return to work on breastfeeding. Pediatrics. 2011;127:e1414–e1427.
33. Fein SB, Roe B. The effect of work status on initiation and duration of breast-feeding.
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34. Kearney MH, Cronenwett L. Breastfeeding and employment. J Obstet Gynecol Neonatal Nurs. 1991;20:471–480.
35. Mandal B, Roe BE, Fein SB. The differential effects of full-time and part-time work
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36. Mulford C, Omer-Salim A. Breastfeeding and the workplace. Available at: http://www.waba.org.my/whatwedo/womenandwork/pdf/bf-workplace.pdf. Accessed December 27, 2014.
37. World Alliance for Breastfeeding Action. Statement by UNICEF to the Committee on Maternity Protection. Available at: http://www.waba.org.my/whatwedo/old-womenandwork/unicefilo2000.htm. Accessed December 27, 2014.
38. International Labour Organization. Maternity Protection Convention. Available at: http://www.ilo.org/dyn/normlex/en/f?p=1000:12100:0::NO::P12100_ILO_CODE:C183. Accessed December 27, 2014.
39. International Labour Organization. Maternity Protection Recommendation. Available at: http://www.ilo.org/dyn/normlex/en/f?p=1000:12100:0::NO::P12100_ILO_CODE:C183. Accessed December 27, 2014.
40. Roe B, Whittington LA, Fein SB, Teisl MF. Is there competition between breastfeeding and maternal employment? Demography. 1999;36:157–171.
41. Fein SB, Mandal B, Roe BE. Success of strategies for combining employment and breastfeeding. Pediatrics. 2008;122(suppl 2):S56–S62.
42. International Labour Organization. Maternity protection resource package. Available at: http://mprp.itcilo.org/pages/en/. Accessed December 27, 2014.