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Table 6 Summary of Publications Included in the Realist Analysis Following a Cross-Sectional Design. Realist Review on “How Do Breastfeeding Workplace Interventions Work?”

From: How do breastfeeding workplace interventions work?: a realist review

CROSS-SECTIONAL DESIGN

Lead Author; Publication Year

Jacknowitz [40]; Chapter 4; 2004

 Study Population

National Longitudinal Survey of Youth 1979, analysis is limited to birth between 1989 and 1999;

Birth mother must have worked ≥20 h per week during six months prior to birth;

Maternal age: 31.4 ± 3.34 years;

Maternal race: 56.7% Non-Hispanic White, 23.8% Non-Hispanic Black, 19.5% Hispanic;

Marital status: 82.9% husband/partner present;

BF initiation: 59.6%;

Any BF rate at 6 months: 19.5%;

N = 893

 Country

USA

 Intervention

Employer-sponsored childcare

Flexible work schedule

Hours worked at home

 Outcomes

Employer-sponsored childcare

 • BF initiation: NS

 • BF at 6 months: 11.4% higher probability of BF at 6 months with employer-sponsored childcare than without, p < 0.01

Flexible schedule

 • BF initiation: NS

 • BF at 6 months: NS

Hours worked at home

 • BF initiation: every 8 h worked at home per week is associated with 0.7% higher probability of BF initiation, p < 0.05

 • BF at 6 months: every 8 h worked at home per week is associated with 0.5% higher probability of BF at 6 months, p < 0.01

Shift work

 • BF initiation: NS

 • BF at 6 months: NS

Lead Author; Publication Year

Ortiz et al. [39]; 2004

 Study Population

Participants of corporate lactation programs of five companies who gave birth between April 19, 1993 and December 31, 1997 and full-time employed before taking maternity leave;

Maternal race (only 4 of the 5 companies provided demographic data): 0.6% American Indian, 14.1% Asian/Pacific Islander, 6.2% African American, 26.8% Hispanic, 52.3% White;

N = 462

 Country

USA

 Intervention

Corporate management policies guaranteeing that BF employees will be supported

Private, locked rooms for pumping

Provision of electric breast pump

Breast pump instructions

BF class

BF education and lactation consultations

BF telephone consultations 24/7

 Outcomes

BF initiation: 97.5%

Any BF rate at 6 months: 57.8%

Pumped at work: 152 of 194 (salaried) vs. 104 of 157 (hourly), p ≤ 0.01

Mean age of infant when pumping was discontinued: 9.1 ± 4.11 months

 • 9.0 ± 4.26 months (full-time) vs. 8.6 ± 2.95 (part-time), p = 0.72

 • 8.7 ± 3.92 months (salaried) vs. 9.3 ± 4.51 (hourly), p = 0.31

Lead Author; Publication Year

Chen et al. [44], 2006

 Study Population

Female employees of Company T who have taken maternity leave between January 1999 and April 2003;

Maternal age: 6.6% 20–24 years, 42.0% 25–29 years, 40.7% 30–34 years, 10.7% ≥35 years;

Mean maternal age: 29.8 ± 3.7 years;

Maternal education level: 51.6% ≤ high school, 48.2% ≥ college;

Worksite: 82.1% clean room;

Shift work: 77.2% yes;

Flextime: 29.4% yes;

N = 998

 Country

Taiwan

 Intervention

Lactation rooms

Lactation break times

 Outcomes

OR for ever breastfed:

 • Awareness of lactation room (yes vs. no): 1.60, 95% CI: 1.14–2.24, p = 0.006

 • Awareness of lactation breaks (yes vs. no): 0.87, 95% CI: 0.59–1.28, p = 0.474

 • Awareness of lactation room among clean room workers (yes vs. no): 7.88, 95% CI: 2.36–26.32, p = 0.001

 • Awareness of lactation breaks among clean room workers (yes vs. no): 0.84, 95% CI: 0.56–1.26, p = 0.399

 • Awareness of lactation room among office workers (yes vs. no): 2.83, 95% CI: 0.99–8.06, p = 0.052

 • Awareness of lactation breaks among office workers (yes vs. no): 1.14, 95% CI: 0.33–3.95, p = 0.833

 • High awareness of policy (office vs. clean room): 2.38, 95% CI: 0.65–8.71, p = 0.189

OR for continued breastfeeding after returning to work:

 • Awareness of lactation room (yes vs. no): 2.71, 95% CI: 1.19–6.15, p = 0.017

 • Awareness of lactation breaks (yes vs. no): 2.68, 95% CI: 1.57–4.58, p < 0.001

 • Awareness of lactation room among clean room workers (yes vs. no): 2.06, 95% CI: 0.78–5.40, p = 0.143

 • Awareness of lactation breaks among clean room workers (yes vs. no): 2.15, 95% CI: 1.09–4.26, p = 0.028

 • Awareness of lactation room among office workers (yes vs. no): 6.53, 95% CI: 1.33–32.13, p = 0.021

 • Awareness of lactation breaks among office workers (yes vs. no): 4.91, 95% CI: 1.79–13.46, p = 0.002

 • High awareness of policy (office vs. clean room): 8.65, 95% CI: 2.48–30.18, p = 0.001

Lead Author; Publication Year

Johnston Balkam [34]; 2006

 Study Population

Women who had participated in employer’s corporate lactation program within the last 3 years prior to the start of the study and who were still employed by the organization;

Maternal race: 69% White, 9% Chinese, 8% Black, 5% Spanish, Hispanic or Latina, 3% Asian Indian, 3% Filipina, 2% Korean, 3.6% other;

Maternal education level: 0.8% high school diploma, 10% some college or technical school, 20% Bachelor’s degree, 20% Master’s degree, 48% doctoral degree;

Marital status: 97% married, 3% not married;

Household income: 30% < USD 100,000, 38% USD 100,000-149,999, 27% ≥ USD 150,000;

N = 128

 Country

USA

 Intervention

Prenatal BF classes

Telephone support by lactation consultants for new mothers during maternity leave

RTW consultation with lactation consultants

Ongoing lactation support from lactation consultants during after RTW

 Outcomes

Time of program registration and type of feeding at 6 months

 • Registration before birth: 45% EBF vs. 27% any formula

 • Registration around birth: 13% EBF vs. 16% any formula

 • p < 0.05

Number of received services and type of feeding at 6 months:

 • 1 service: 10% EBF vs. 14% any formula

 • 2 service: 13% EBF vs. 14% any formula

 • 3 service: 20% EBF vs. 10% any formula

 • 4 service: 14% EBF vs. 5% any formula

 • p < 0.05

Lead Author; Publication Year

Dabritz et al. [25], 2009

 Study Population

Birth mothers who resided in Yolo County, CA at the time of delivery;

Maternal age: 15% < 20 years, 25% 20–24 years, 47% 25–34 years, 13% ≥35 years;

Maternal ethnicity: 5% Asian, 53% White, 6% others;

Maternal education level: 11% ≤8th grade, 15% 9th–11th grade, 73% ≥12th grade;

N = 399 of which 214 returned to school/work after giving birth

 Country

USA

 Intervention

Lactation room

Lactation break times

Workplace/school lactation policy

 Outcomes

201 of 214 (94%) infants were at least once breastfed

Type of feeding

 • Presence of lactation room:

  • Yes: 78% (almost EBF) vs. 68% (partial BF) vs. 64% (no BF)

  • No: 13% (almost EBF) vs. 28% (partial BF) vs. 26% (no BF)

  • Did not know: 6% (almost EBF) vs. 4% (partial BF) vs 7% (no BF)

  • p = 0.094

 • Lactation break times:

  • Yes: 92% (almost EBF) vs. 81% (partial BF) vs. 79% (no BF)

  • No: 2% (almost EBF) vs. 4% (partial BF) vs. 7% (no BF)

  • Did not know: 6% (almost EBF) vs. 15% (partial BF) vs 14% (no BF)

  • p = 0.22

 • Knowledge of lactation policy:

  • Yes: 79% (almost EBF) vs. 61% (partial BF) vs. 61% (no BF)

  • No: 21% (almost EBF) vs. 39% (partial BF) vs. 39% (no BF)

  • p = 0.018

Lead Author; Publication Year

Balkam et al. [26]; 2011

 Study Population

Female employees working on the employer’s campus, who had finished workplace lactation program within 3 years prior to study and were still employed by the organization in April 2005;

Mean maternal age at delivery: 34.4 ± 4.0 years;

Marital status: 97% married, 3% not married;

Maternal race: 70% White, 30% non-White;

Maternal education level: 48% doctoral degree, 20% Master’s degree, 20% Bachelor’s degree, 10% some college or tech school, 2% high school diploma or less;

Household income: 31% < USD 100,000, 40% USD 100,000-149,999, 29% ≥ USD 150,000;

N = 128

 Country

USA

 Intervention

Prenatal BF education

Telephone support

RTW consultation

Lactation room

 Outcomes

EBF 6 months:

 • Registered for program: 57%

 • Time of registration: 62.6% before birth vs. 43.2% around RTW; p < 0.05

 • Prenatal education: 57.4% yes vs. 57.5% no; NS

 • Telephone support: 62.8% yes vs. 45.2% no; p < 0.05

 • RTW consultation: 68.0% yes vs. 41.5% no; p < 0.05

 • Lactation room: 59.8% vs. 48.4% no; NS

 • # services received: 41.9% 1 service, 47.1% 2 services, 66.6% 3 services, 75.0% 4 services, p < 0.05

Any BF 6 months:

 • Registered for program: 85.9%

 • Time of registration: 83.5% before birth vs. 91.9% around RTW; NS

 • Prenatal education: 81.5% yes vs. 90.4% no; NS

 • Telephone support: 83.7% yes vs. 90.5% no; NS

 • RTW consultation: 92.0% yes vs. 77.4% no; p < 0.05

 • Lactation room: 88.7% vs. 77.4% no; NS

 • # services received: 83.9% 1 service, 85.3% 2 services, 84.6% 3 services, 91.7% 4 services, NS

Lead Author; Publication Year

Weber et al. [52]; 2011

 Study Population

Female employees of Sydney South West Area Health Service who took maternity leave between January 2008 and August 2009 with a valid home address;

Mean maternal age: 35 years;

Maternal background: 66% English speaking, 34% non-English speaking;

Marital status: 97% married/de-factor, 1% divorced/separated, 2% never married;

Maternal education level: 84% university, 13% technical or trade certificate or diploma, 3% less than tertiary education, 1% other;

Household income: 10% < AUD 39,999, 33% AUD 40,000-79,999, 58% ≥ AUD 80,000;

N = 496

 Country

Australia

 Intervention

Flexible work practice

30-min paid lactation break per shift (only for women under the nursing and midwifery award)

 Outcomes

98% initiated BF

Discontinued BF:

 • 13% at 3 months

 • 24% at 6 months

59% intended to BF after RTW, 40% BF after RTW

How BF and work was combined:

 • 37% BF before and after work/infant formula during work hours

 • 36% BF before and after work/expressed BM during work hours

 • 1% BF before, after and during work hours

 • 26% other

Lead Author; Publication Year

Bai et al. [33]; 2013

 Study Population

Working mothers aged ≥18 years who are currently BF or had BF within 18 months prior to the beginning of the study and who were either staff or faculty at a higher-education institution or who gave birth in the spring and fall of 2010 in one hospital obstetrics unit;

Maternal mean age: 33.8 ± 6.0 years;

Maternal education level: 2.7% high school, 15.0% some college, 40.7% college graduate, 41.6% postgraduate;

Maternal race: 1.8% African American, 2.7% Asian, 2.7% Hispanic, 89.4% White, 3.5% other;

Marital status: 92% married, 8% single;

N = 113

 Country

USA

 Intervention

N/A

 Outcomes

Perceived workplace lactation support and EBF duration:

 • Technical support: r = 0.71, p = 0.01

 • Workplace environment: r:0.26, p = 0.01

 • Break time: r = 0.05, p = 0.52

 • Workplace policies: r = 0.13, p = 0.24

Lead Author; Publication Year

Tsai [42]; 2013

 Study Population

Female employees of Company C who have taken maternity leave between January 2009 and January 2011;

Maternal age: 23.9% 20–29 year, 74.6% 30–39 years, 1.5% ≥40 years;

Maternal education level: 28.3% high school education and below, 71.7% college and above;

Worksite: 44.8% clean room, 55.2% office;

Shift work: 46.7% yes;

Work hours per day: 16.7% 8 h, 83.3% 9–14 h;

N = 715

 Country

Taiwan

 Intervention

Lactation facilities (independent space or no independent space, only curtains for separation)

 Outcomes

OR for continued BF for 1–6 months after return to work:

 • Using lactation breaks (yes vs. no): 33.1, 95% CI: 18.0–64.1, p < 0.0001

 • Supportive co-worker (yes vs. no): 2.53, 95% CI: 2.21–5.32, p = 0.0133

 • Supportive supervisor (yes vs. no): 2.45, 95% CI: 1.17–5.05, p = 0.0156

 • NS difference for worksite, shift work, daily working hours, type of lactation room, awareness of lactation breaks

OR for continued BF for > 6 months after return to work:

 • Daily working hours (≤8 vs. 9–14): 2.66, 95% CI: 1.16–6.11, p = 0.0206

 • Type of lactation room (independent vs. no independent space): 2.38, 95% CI: 1.14–6.32, p = 0.0284

 • Using lactation breaks (yes vs. no): 51.6, 95% CI: 31.2–121.6, p < 0.0001

 • Supportive co-worker (yes vs. no): 2.78, 95% CI: 1.14–6.76, p = 0.0235

 • Supportive supervisor (yes vs. no): 2.44, 95% CI: 1.06–5.61, p = 0.0355

 • NS difference for worksite, shift work, awareness of lactation breaks

Lead Author; Publication Year

Cohen et al. [29]; 2014

 Study Population

Mothers employed at one of the two participating companies and who participated in the onsite corporate lactation program between 1989 and 1992, returned to work for at least 16 h per week after maternity leave;

Utilities company (1992):

 • Average age: 29.5 years (range: 23–41 years)

 • Average salary: USD 36,000 (range: USD 24,000-50,000)

 • Average BF duration: 7.4 months (range: 3–14 months)

 • Maternal race/ethnic origin: 37.9% White, 20.7% African American, 13.8% Asian, 24.1% Hispanic, 3.4% other

Aeronautics company (1992):

 • Average age: 33.1 years (range: 26–40 years)

 • Average salary: N/A

 • Average BF duration: 8.4 months (range: 2–16 months)

 • Maternal race/ethnic origin: 60.0% White, 10.0% African American, 10.0% Asian, 20.0% Hispanic, 0% other

N = 187

 Country

USA

 Intervention

Prenatal BF classes

Perinatal counseling regarding lactation and RTW lactation maintenance services

Provision of electric breast pump

 Outcomes

Utilities company (100 birth/year; 1992):

 • Women returning to work BF and pumping: 29%

 • Women still in program 6 months after birth: 23%

 • Women still in program 1 year after birth (1991): 8%

Aeronautics company (30 birth/year; 1992):

 • Women returning to work BF and pumping: 67%

 • Women still in program 6 months after birth: 47%

 • Women still in program 1 year after birth (1991): 9.5%

Lead Author; Publication Year

Spatz et al. [27]; 2014

 Study Population

Female employees of Children’s Hospital of Philadelphia (CHOP) who filed for maternity leave between 2007 and 2011 and had a CHOP email address;

Maternal ethnicity: 75.8% White/Caucasian, 13.0% Black/African American, 7.9% Asian/Pacific Islander, 2.9% Hispanic American, 0.4% American Indian/Alaskan Native; maternal age at delivery (years): 0.2% < 20, 1.8% 20–24, 24.0% 25–29, 47.9% 30–34, 26.1% ≥ 35;

N = 545

 Country

USA

 Intervention

Employee lactation policy

Personal pump purchase program

Pump loaner program from off-campus locations

Prenatal BF class

BF resource nurse class

Lactation rooms

 Outcomes

94.5% initiated BF

EBF 3 months: 62.9%

EBF 6 months: 35.0%

Lead Author; Publication Year

Tsai [43]; 2014

 Study Population

Female employees of Company C who have taken maternity leave between January 2009 and January 2011;

Maternal age: 23.9% < 30 years, 76.1% ≥30 years;

Maternal education level: 28.3% ≤ high school, 71.7% ≥ college;

Worksite: 44.8% clean room, 55.2% office;

Shift work: 46.7% yes;

Work hours per day: 16.7% 8 h, 83.3% 9–14 h;

N = 715

 Country

Taiwan

 Intervention

Lactation room with table, chair, sink, electrical outlets and refrigerator

2 lactation breaks of 30 min each per working day

 Outcomes

Differences in use of breast-pumping breaks according to age (p = 0.0459), maternal education (p < 0.0001), husband’s education (p = 0.0002), worksite (p < 0.0001; clean room uses less often, office uses more often), shift work (p < 0.0001; shift workers use less often), NS difference according to work hours per day (p = 0.5164)

Positive association between the use of lactation breaks after returning to work and awareness about lactation rooms (p = 0.0173), breast-pumping breaks policy (p < 0.0001), support from supervisor (p < 0.0001) and coworkers (p < 0.0001), encouragement to use lactation room from environmental health nurses (p < 0.0001) and provision of lactation consultant by employer (p = 0.0074)

Negative association between the use of lactation breaks after returning to work and feeling of embarrassment (p = 0.0046), perception of inefficiency (p < 0.0001) and believing that lactation breaks would affect supervisor’s assessment of performance (p = 0.0079)

OR for intention to use breast-pumping break after returning to work:

 • Awareness of lactation room: 2.27, 95% CI: 0.64–11.00, p = 0.2408

 • Awareness of lactation breaks: 4.70, 95% CI: 2.90–7.88, p < 0.0001

 • Provision of lactation consultant: 0.97, 95% CI: 0.67–1.42, p = 0.8207

 • Guilty feelings when using breast-pumping breaks: 0.81, 95% CI: 0.54–1.21, p = 0.3148

 • Coworker support: 1.76, 95% CI: 1.01–3.13, p = 0.0500

 • Supervisor support: 1.47, 95% CI: 0.86–2.51, p = 0.1522

 • Encouragement by environmental health nurses: 1.16, 95% CI: 0.68–1.95, p = 0.5762

 • Perception of work inefficiency: 0.55, 95% CI: 0.37–0.82, p = 0.0031

 • Perception of influenced supervisor’s work evaluation: 1.07, 95% CI: 0.71–1.59, p = 0.7470

 • Awareness of BF benefits: 1.08, 95% CI: 1.02–1.12, p = 0.0050

Lead Author; Publication Year

Basrowi et al. [55]; 2015

 Study Population

Female employees of five workplaces in Jakarta whose children were between 6 and 36 months of age and who completed the questionnaire between December 2012 and February 2013;

Maternal education level: 24.7% low, 38.7% middle, 36.6% high;

Status of home: 36.6% owned, 41.4% rented, 22.0% owned by relatives;

N = 186

 Country

Indonesia

 Intervention

Lactation room with refrigerator, hand washing facilities and dedicated seat or bed

 Outcomes

OR EBF:

 • Workplace (office vs. factory): 3.33, 95% CI: 1.77–6.25, p < 0.001

 • Proper dedicated BF facility (yes vs. no): 2.62, 95% CI: 1.27–5.38, p = 0.008

 • BF support program (yes vs. no): 5.93, 95% CI: 1.78–19.79, p = 0.001

Lead Author; Publication Year

Froh et al. [38]; 2016

 Study Population

Female employees of Children’s Hospital of Philadelphia (CHOP) who filed for maternity leave between 2007 and 2011 and had a CHOP email address;

N = 410

 Country

USA

 Intervention

 • Employee lactation policy

 • Personal pump purchase program

 • Pump loaner program from off-campus locations

 • Prenatal BF class

 • BF resource nurse class

 • Lactation rooms

 Outcomes

5 major themes

 • Positive reflections

 • Non-supportive environment/work culture

  • Available resources but work culture does not allow to make use of the resources

  • Perception of non-supportive supervisors and co-workers – missing understanding for situation, understaffed departments, no knowledge about needed pump frequency

 • Supportive environment/work culture

  • Environment made the mothers feel comfortable with their BF choice

 • Accessibility of resources

  • Not all employees are aware of resources or know how to access them

  • Difficulties navigating work and BF – busy work schedules, occupied lactation rooms

 • Internal barriers

Lead Author; Publication Year

Lee et al. [45]; 2015

 Study Population

Disproportionate probability sample based on maternal residence in 25 cities/counties in Taiwan: Mothers aged ≥20 years who gave birth in 2008, 2009, 2010 or 2011 and infant was alive at the time of the interview;

Maternal age:

 • 20–24 years: 7.7% (2008), 6.5% (2009), 7.5% (2010), 7.2% (2011)

 • 25–29 years: 28.4% (2008), 26.9% (2009), 28.4% (2010), 26.9% (2011)

 • 30–34 years: 40.9% (2008), 42.7% (2009), 42.8% (2010), 43.1% (2011)

 • ≥35 years: 23.0% (2008), 23.9% (2009), 21.3% (2010), 22.9% (2011)

Maternal education level:

 • ≤ junior high school: 12.2% (2008), 8.3% (2009), 7.0% (2010), 6.0% (2011)

 • High school: 38.2% (2008), 31.6% (2009), 29.7% (2010), 29.1% (2011)

 • Vocational school: 26.4% (2008), 26.6% (2009), 21.8% (2010), 21.6% (2011)

 • ≥ university: 23.3% (2008), 33.5% (2009), 41.5% (2010), 43.3% (2011)

Employed outside the home: 65.0% (2008), 69.6% (2009), 57.0% (2010), 55.5% (2011);

N = 2163 (2008); 1453 (2009); 11,011 (2010); 12,410 (2011)

 Country

Taiwan

 Intervention

Lactation room

 Outcomes

OR of EBF: 2.68, 95% CI: 2.44–2.94, p < 0.001

OR of any BF: 3.25, 95% CI: 2.99–3.53, p < 0.001

Lead Author; Publication Year

Kozhimannil et al. [28]; 2016

 Study Population

Women who gave birth in U.S. hospital between July 2011 and June 2012 and who were employed at the time of the follow-up survey between January and April 2013;

Maternal age: 27.5% 18–24 years, 25.9% 25–29 years, 26.8% 30–34 years, 19.7% ≥35 years;

Maternal race: 62.3% White, 13.7% Black, 18.0% Hispanic, 6.1% other/multiple race;

Maternal education level: 26.3% ≤ high school, 28.4% some college/associate’s degree, 27.3% Bachelor’s degree, 18.0% graduate education/degree;

Income: 32.3% ≤ USD 52,300, 47.4% USD 52,301-102,000, 20.3% > USD 102,001;

N = 550

 Country

USA

 Intervention

Lactation break times

Private lactation space

 Outcomes

PP employment plans affected BF-related decision

 • Sufficient break time (yes): 46.9%, p = 0.302

 • Private room (yes): 46.7%, p = 0.379

 • Break time + private room (yes): 44.0%, p = 0.122

Employment posed a challenge to BF

 • Sufficient break time (yes): 35.2%, p = 0.371

 • Private room (yes): 33.3%, p = 0.918

 • Break time + private room (yes): 31.0%, p = 0.570

BF intention at the end of pregnancy

 • Sufficient break time (yes): p = 0.17

  • BF only: 62.6%

  • Formula only: 10.7%

  • BF + formula: 26.7%

 • Private room (yes): p = 0.163

  • BF only: 57.7%

  • Formula only: 11.3%

  • BF + formula: 31.1%

 • Break time + private room (yes): p = 0.189

  • BF only: 59.7%

  • Formula only: 10.6%

  • BF + formula: 29.7%

BF status at 6 months

 • Sufficient break time (yes): p = 0.030

  • BF only: 71.4%

  • Formula only: 14.7%

  • BF + formula: 14.0%

 • Private room (yes): p = 0.677

  • BF only: 75.7%

  • Formula only: 11.9%

  • BF + formula: 12.4%

 • Break time + private room (yes): p = 0.722

  • BF only: 75.1%

  • Formula only: 12.4%

  • BF + formula: 12.5%

Mean EBF duration (months)

 • Sufficient break time (yes): 5.37, p = 0.397

 • Private room (yes): 5.89, p = 0.002

 • Break time + private room (yes): 5.64, p = 0.088

AOR of EBF at 6 months

 • Reasonable break time to express milk: 2.593, 95% CI: 1.00–6.71

 • Private room to express milk: 2.669, 95% CI: 0.43–16.48

 • Break time + private room: 2.255, 95% CI: 1.03–4.95

AOR of any BF at 6 months

 • Reasonable break time to express milk: 3.004, 95% CI: 1.23–7.32

 • Private room to express milk: 0.555, 95% CI: 0.12–2.57

 • Break time + private room: 1.946, 95% CI: 0.88–4.28

Lead Author; Publication Year

Paddock [24]; 2017

 Study Population

Cornell employees with at least one dependent child aged 12 years or younger in February 2009;

Maternal education level: 47.7% graduate degree, 34.3% college degree, 12.2% attended college, 5.6% completed high school;

N = 919

 Country

USA

 Intervention

Financial support to spend on any legal childcare for children up to age 13 years

 Outcomes

BF was associated with higher education, marriage, higher income, academic position bs. Hourly position and work unit

Inflexible work schedule as reason for not initiating/stopping BF

Missing information about BF rights as reason for not initiating/stopping BF

Flexible work schedule/availability to work part-time as BF facilitator

Lead Author; Publication Year

Butudom [50], 2018; quantitative analysis

 Study Population

Mothers working for Company A and who took maternity leave between June and December 2016;

Maternal age: 5.6% < 25 years, 38.4% 25–29 years, 32.4% 30–34 years, 20.4% 35–39 years, 3.2% ≥40 years;

Maternal education level: 15.3% < high school, 56.9% high school, 21.8% vocational degree, 6.0% ≥ Bachelor’s degree;

Marital status: 10.6% single, 2.3% separated/divorced, 87.0% married;

Monthly income: 10.6% < Baht 10,000, 87.0% Baht 10,000-19,999, 0.9% Baht 20,000-29,999, 1.4% ≥ Baht 30,000;

N = 216

 Country

Thailand

 Intervention

Fully equipped lactation room

Breast pumping equipment

Refrigerator to store expressed BM

BM drop-off service

BF training program

 Outcomes

EBF rate: 76.9% at 1 month, 46.3% at 3 months, 7.4% at 6 months

Reported reasons to stop BF: 36% insufficient milk supply, 31% infant lives with grandmother too far away, 12% RTW, 21% other reasons

Lead Author; Publication Year

Butudom [50], 2018; qualitative analysis

 Study Population

Mothers working for Company A and who took maternity leave between June and December 2016;

Mean maternal age: 31.70 ± 4.46 years;

Monthly income: 16.7% < Baht 10,000, 73.3% Baht 10,000-19,999, 10.0% ≥ Baht 20,000;

N = 30

 Country

Thailand

 Intervention

Fully equipped lactation room

Breast pumping equipment

Refrigerator to store expressed BM

BM drop-off service

BF training program

 Outcomes

BF policy was seen as helpful to decide to BF the infant

Impact of RTW on BF

 • Infant living in distant location: grandmothers are lacking knowledge how to feed frozen BM; mothers are concerned that expressed/frozen BM will be spoiled because of the long transport (2–3 days)

 • BM transportation: difficult to send expressed/frozen BM because of inadequate public transport

 • Importance of social support during BF

Lead Author; Publication Year

Payton [35]; 2018; quantitative analysis

 Study Population

Women BF a biological child within the last 5 years while being full-time employed by organization who is member of the Greater Philadelphia Business Coalition on Health or the Pittsburgh Business Group on Health;

Maternal mean age: 33.65 ± 4.07 years;

Maternal race: 7% Asian, 11% Black or African American, 76% White, 4% mixed, 3% other;

Maternal education level: 2% high school, 12% some college, 45% college degree, 42% graduate degree, 1% not documented;

Marital status: 22% married/with partner, 1% not married/with partner, 78% not documented;

N = 199

 Country

USA

 Intervention

N/A

 Outcomes

64% BF as long as intended

BF durations and achieved BF goals

 • 77% of mothers who BF for > 6 months, BF for as long as intended

 • 51% of mothers who BF for 3–6 months, BF for as long as intended

 • 37% of mothers who BF between 6 weeks and 3 months, BF for as long as intended

 • 25% of mothers who BF for < 6 weeks, BF for as long as intended

 • p < 0.001

BF location at workplace and achieved BF goals

 • 58% of mothers who pumped in a bathroom did not BF for as long as intended

 • 29% of mothers who did not pump in a bathroom BF for as long as intended

 • p < 0.001

Significant association between BF intention and perceptions of workplace lactation support with BF duration, p < 0.001

Significant association between perception of workplace lactation support BF duration for ≥6 months, p < 0.001

Significant association between utilization of workplace lactation support and BF duration for ≥6 months, p < 0.001

Lead Author; Publication Year

Payton [35]; 2018; qualitative analysis

 Study Population

Women BF a biological child within the last 5 years while being full-time employed by organization who is member of the Greater Philadelphia Business Coalition on Health or the Pittsburgh Business Group on Health;

Maternal mean age: 32.86 ± 3.72 years;

Maternal race: 14% Black or African American, 64% White, 21% other/mixed;

Maternal education level: 21% some college, 17% college degree, 58% graduate degree;

Marital status: 93% married/with partner, 7% not married/with partner;

N = 14

 Country

USA

 Intervention

N/A

 Outcomes

Main themes from interviews with BF employees

 • Cognitive influences on behavior

 • Environmental influences on behavior

 • Supporting behavioral factors

Lead Author; Publication Year

Santos et al. [47]; 2018

 Study Population

Mothers working at a higher education institution but not being a student or resident at the time of the birth of the infant as well as at the time of the study; infants attending childcare center at the mother’s workplace;

Maternal age: 47.8% < 35 years, 52.2% ≥35 years;

Maternal education level: 65.2% higher education, 26.1% vocational education, 8.7% medium;

N = 46

 Country

Brazil

 Intervention

Child-care center

Lactation breaks (2 × 30-min breaks or 1-h reduction in workload)

 Outcomes

Median BF duration according to availability of lactation breaks

 • Lactation breaks: 120 days (25 percentiles: 90 days – 75 percentiles: 180 days)

 • No lactation breaks: 150 days (25 percentiles: 120 days – 75 percentiles: 150 days)

 • p = 0.5148

Lead Author; Publication Year

Wambach et al. [30]; 2018

 Study Population

Registered nurses who have been employed at the hospital for a minimum of 2 years and concurrently BF or had done so within the past 12 months;

Maternal education level: 11.5% associate’s degree, 78.2% Bachelor’s degree, 10.3% Master’s degree;

Maternal race: 1.3% Asian, 98.7% White;

Maternal ethnicity: 1.3% Hispanic or Latino, 98.7% non-Hispanic or non-Latino;

N = 78

 Country

USA

 Intervention

N/A

 Outcomes

94% had designated lactation space

Positive correlation between Workplace Breastfeeding Support Scale (WBSS) subscale “Break Time” and BF duration: r = 0.335, p = 0.035

NS correlation between WBSS subscales “Environment”, “Technical Support”, “Workplace Policy” and BF duration

Lead Author; Publication Year

Chen et al. [53]; 2019; quantitative analysis

 Study Population

Mothers with children under 12 months who are living in one of the 12 randomly chosen county level regions (4 urban cities, 4 small and medium sized cities, 2 rural areas, 2 poor rural areas);

Mean maternal age: 29.15 ± 5.11 years;

Maternal education level: 8.08% ≤ primary school, 36.53% middle school, 18.04% high/vocational school, 37.35% ≥ college;

Employment status: 69.66% informal, 30.34% formal;

N = 9725

 Country

China

 Intervention

N/A

 Outcomes

AOR of early BF initiation (unemployment as base)

 • Agriculture related occupation: 1.32, 95% CI: 1.15–1.51

 • Industry related occupation: 1.00, 95% CI: 0.75–1.34

 • Business and white-collar occupation: 1.38, 95% CI: 1.23–1.56

AOR of EBF for 0–6 months (unemployment as base)

 • Agriculture related occupation: 1.30, 95% CI: 1.04–1.62

 • Industry related occupation: 0.77, 95% CI: 0.44–1.34

 • Business and white-collar occupation: 0.95, 95% CI: 0.78–1.17

Lead Author; Publication Year

Chen et al. [53]; 2019; qualitative analysis

 Study Population

Mothers with children under 12 months who are living in one of the 12 randomly chosen county level regions (4 urban cities, 4 small and medium sized cities, 2 rural areas, 2 poor rural areas);

Maternal education level: 6% primary school, 27% middle school, 20% high school, 47% ≥ college;

Household income: 27% ≤ yuan 50,000, 35% yuan 50,000-100,000, 24% yuan 100,000-200,000, 14% ≥ yuan 200,000;

N = 84

 Country

China

 Intervention

Lactation breaks

 Outcomes

Themes from interviews

1) Employment benefits: Formal employment can provide maternal benefits ensured by law and regulations

 • Paid maternity leave: Mothers wish to extend paid maternity leave (min. 98 days) to be able to adhere to WHO BF recommendations, provision of longer unpaid breaks often difficult because of financial needs of families

 • BF breaks: Mothers feel encouraged by BF breaks (1 h per workday for infant < 1 year) to continue BF after RTW. But if commute time is too long, mothers do not feel able to continue to BF after RTW despite provision of BF breaks

2) Commute time: Length of commute time determines if formally employed mothers feel able to continue BF after RTW; for informally employed mothers, length of commute time determines if family support was accessible

3) Workplace environment: Use of electric breast pumps as alternative for direct BF among working mothers, but concerns about physical lactation environment at the workplace

 • Space for Lactation: Social support as well as private and clean space as necessity to continue BF

 • Equipment for pumping: limited equipment (possibilities to store BM, power outlets for breast pumps) at workplace as challenge to continue BF

4) Labor intensity: Work schedule and workload influences frequency of BF or use of breast pump

 • Flexibility of work schedule: Flexible work schedule as supporting factor; night shifts and irregular work schedules as reason for weaning

 • Stress from work: BF with busy work schedule was tiring; high level of stress as a reason for perceived decrease of BM supply

Lead Author; Publication Year

Scott et al. [31]; 2019

 Study Population

Female adult employees (age ≥ 18 years) of the health care system who have been employed for ≥6 months and BF in the past 3 years prior to the study;

Maternal age: 72.7% ≤35 years, 27.3% > 35 years;

Maternal race: 76.8% White, 16.2% Black, 7.0% other;

Marital status: 88.8% married, 8.4% never married, 2.8% other;

Maternal education level: 26.5% ≤ some college, 39.2% college degree, 34.3% graduate degree;

N = 165

 Country

USA

 Intervention

N/A

 Outcomes

OR of BF duration

 • Organizational support: 1.05, 95% CI: 0.84–1.32, p = 0.65

 • Managerial support: 1.13, 95% CI: 0.88–1.44, p = 0.34

 • Co-worker support: 0.88, 95% CI: 0.67–1.14, p = 0.32

OR of EBF

 • Organizational support: 1.81, 95% CI: 1.06–3.09, p = 0.03

 • Managerial support: 0.87, 95% CI: 0.50–1.49, p = 0.61

 • Co-worker support: 0.89, 95% CI: 0.52–1.54, p = 0.69

OR of EBF duration

 • Organizational support: 1.10, 95% CI: 0.76–1.60, p = 0.61

 • Managerial support: 1.47, 95% CI: 1.03–2.09, p = 0.03

 • Co-worker support: 0.83, 95% CI: 0.62–1.12, p = 0.22

Lead Author; Publication Year

Ibarra-Ortega et al. [56]; 2020

 Study Population

Mothers working at institutions with more than 251 employees in Guadalajara, Mexico, with children aged between 6 and 35 months and who were working when BF was initiated;

Maternal mean age: 34.9 ± 4.3 years (with lactation room) vs. 31.4 ± 4.7 years (no lactation room);

Maternal education level: 21.1% ≤ high school, 78.9% ≥ college vs. 26.8% ≤ high school, 73.2% ≥ college;

Marital status: 17.1% single, 78.9% married, 4.0% others vs. 36.6% single, 58.5% married, 4.9% other;

N = 158

 Country

Mexico

 Intervention

Lactation room

 Outcomes

OR of BF duration ≥6 months (lactation room vs. no lactation room): 3.15, 95% CI: 1.60–6.19, p = 0.001

OR of BF duration ≥12 months (lactation room vs. no lactation room): 2.69, 95% CI: 1.23–5.86, p = 0.014

OR of EBF duration ≥6 months (lactation room vs. no lactation room): 2.53, 95% CI: 1.16–5.54, p = 0.022

OR of EBF at 6th months (vs. partial BF) (lactation room vs. no lactation room): 2.98, 95% CI: 1.41–6.29, p = 0.006

NS difference in EBF and BF duration between mother who had access to lactation room but did not use lactation room and mothers without lactation room

Lead Author; Publication Year

Kebede et al. [54]; 2020

 Study Population

Permanently employed mothers with children aged 6–24 months working in governmental and/or nongovernmental organization in Dukem town;

Mean maternal age: 27.1 ± 3.44 years;

Maternal age: 16.6% 18–23 years, 60.4% 24–29 years, 23.0% ≥30 years;

Maternal ethnicity: 90% Oromo, 1.0% Tigre, 6.7% Amara, 1.9% others;

Maternal education level: 19.8% secondary, 44.1% diploma, 36.1% ≥ degree;

Marital status: 1.3% single, 92.7% married, 5.4% divorced, 0.6% widowed;

Income: 1.3% ≤ Ethiopian Birr 500, 15.3% Ethiopian Birr 501–1000, 8.9% Ethiopian Birr 1001–1500, 16.9% Ethiopian Birr 1501–2000, 57.5% > Ethiopian Birr 2001;

N = 313

 Country

Ethiopia

 Intervention

Lactation break

 Outcomes

OR of EBF discontinuation

 • No lactation break: 6.7, 95% CI: 3.0–14.5

 • BF at workplace: 3.5, 95% CI: 1.7–7.2

 • Pumping BM: 4.3, 95% CI: 1.7–11.0

  1. 95% CI 95% confidence interval, AOR adjusted odds ratio, BF breastfeeding, BM breastmilk, EBF exclusive breastfeeding, N/A not applicable, NS not significant, OR odds ratio, RTW return to work