BREASTFEEDING MEDICINE

Volume 10, Number 4, 2015 Public Health and Policy

ª Mary Ann Liebert, Inc.
DOI: 10.1089/bfm.2014.0151

Relationship of Maternal Perceptions of Workplace

Breastfeeding Support and Job Satisfaction

Whitney M. Waite and Dimitri Christakis

Abstract

Objectives: Decades of research supports the health benefits of breastfeeding. Prior research has shown that
unsupportive work environments are frequently cited as reasons women abandon breastfeeding early. The
objective of this study is to determine if mothers’ perceptions of workplace lactation support are associated with
job satisfaction.
Materials and Methods: Female employees of Seattle Children’s Hospital (SCH) and a large corporation were
e-mailed a survey to measure perceptions of workplace lactation support. Women were eligible to participate if
they had a child born within the last 5 years. Questions were asked about lactation support across five domains;
organization, manager, coworker, time, and physical environment. The main outcome was job satisfaction.
Linear regression models were run to evaluate the association between workplace support scores and the
outcome of interest.
Results: The survey was completed by 420 women at SCH and 131 women at the large corporation (response
rate, 47%). Ninety-eight percent of study participants initiated breastfeeding, and most sustained breastfeeding
for at least 6 months. Increased total workplace support score was associated with increased job satisfaction at
both companies ( p < 0.001). Increased support scores within each domain were independently associated with
increased job satisfaction ( p values < 0.005). When all domains were considered together, only manager and
coworker supports were significant at SCH ( p = 0.04), and only time support was significant at the large
corporation ( p = 0.01). The workplace support score was not significantly associated with breastfeeding du-
ration at either institution.
Conclusions: Improved lactation support in the workplace may improve new mothers’ job satisfaction, which
could be beneficial to businesses.

Background Research into breastfeeding behavior has consistently

D ecades of research supports the health benefits of
breastfeeding for infants, young children, and moth-
ers.1–4 Nearly all medical organizations, including the
American Academy of Pediatrics, recommend that all infants
be exclusively breastfed for about the first 6 months of life
with continued breastfeeding through at least the first year.1
Although steady progress has been made over the last decade
in improving breastfeeding initiation rates, the majority of
infants in the United States are not breastfed as long as re-
commended. Currently, although 79% of new mothers initi-
ate breastfeeding, only 49% and 27% are still breastfeeding
when their babies are 6 and 12 months of age, respectively.5
shown that maternal return to work is an important reason
why women stop breastfeeding earlier than recommended.6–10
Women frequently cite unsupportive work environments as
a reason for early discontinuation of breastfeeding, includ-
ing lack of time and privacy for expressing breastmilk.11
Under the Affordable Care Act of 2010 employers are re-
quired to provide reasonable break time for women to express
breastmilk at work for 1 year after a child’s birth. It also
requires the provision of a non–bathroom facility that is free
from view and intrusion of coworkers.12,13 Women now
represent a significant portion of the workforce, with more
than 60% of women with children under the age of 1 year
participating in formal employment.14 The great majority of

Seattle Children’s Research Institute, University of Washington, Seattle, Washington; Center for Child Health, Behavior, and Devel-
opment, Seattle, Washington.
An abstract of this work was previously published at the 2014 Pediatric Academic Societies meeting, held on May 3, 2014, in Vancouver,
BC, Canada.
Neither the National Research Service Award program nor the Global Breastfeeding Initiative of Excellence in Paediatrics had any role in
this study design, data collection, data analysis and interpretation, the writing of the manuscript, or the decision to submit it for publication.

222
WORKPLACE BREASTFEEDING SUPPORT AND JOB SATISFACTION
these women return to work within 3 months of the birth of
their child.14
Companies that support their nursing mothers may reap
significant financial benefits, including decreased healthcare
costs, decreased absenteeism, and increased employee re-
tention.15 Employers with workplace lactation programs in
place have seen increased breastfeeding duration among
breastfeeding employees who participate in the program.16–18
However, to our knowledge no prior study has evaluated the
association between workplace lactation support and over-
all job satisfaction. This information could have important
ramifications for businesses looking to retain their talented
female employees. It is also unknown which specific domains
of workplace lactation support are associated with increased
breastfeeding duration. We therefore conducted a study with
the following aims:
1. To determine if mothers’ perceptions of workplace
breastfeeding support are associated with job satis-
faction
2. To determine which domains of breastfeeding support
are associated with job satisfaction
3. To determine if mothers’ perceptions of workplace
breastfeeding support are associated with increased
breastfeeding duration.
Materials and Methods
We e-mailed a survey (Breastfeeding and Employment
Study [BESt]) designed to measure mothers’ perceptions of
workplace lactation support to female employees of two large
companies.19–21 This survey was conducted in 2013, after
enactment of the reasonable break time for nursing mothers’
provision under the Affordable Care Act. The first company
was a large children’s hospital in the Pacific Northwest,
Seattle Children’s Hospital (SCH); the second was a large
corporation in the Southeast. The BESt survey is a previously
developed tool designed to measure women’s perceptions of
workplace lactation support.19 The survey asks 41 questions
about breastfeeding support across five domains: organi-
zational support, manager support, coworker support, time,
and physical environment. Most questions use a 4-point
Likert-type scale to measure responses of strongly agrees,
agrees, disagrees, and strongly disagrees. A few questions
use a simple yes or no answer structure. We also obtained
baseline demographic and breastfeeding information from
the respondents.
Women were eligible to complete the survey if they had a
child born within the last 5 years and were asked to complete
this survey according to their experience with their most re-
cent child. Women were subsequently excluded if they
worked for a different company at the time of return to work
after their most recent child. All women were identified using
employment records from the human resources departments
of each company. At SCH, records specifically identifying
women who had a child in the last 5 years were not available.
Therefore, all women under the age of 40 years were sent an
e-mail inviting them to participate in the survey. The first
survey question asked whether they had a child in the last
5 years. If the answer was ‘‘yes,’’ they were able to complete
the full survey. The large company provided records for only
women who were known to have had a child born in the last
223
5 years. Only these women were sent the e-mail invitation to
participate in the survey. SCH does not currently have an
official workplace lactation program in place; the large cor-
poration does. The study protocol was approved by the
Seattle Children’s Research Institute Institutional Review
Board.
Outcome
The primary outcome of this study was job satisfaction. We
measured this using a previously validated single item measure
of job satisfaction.22 This question asked simply, ‘‘Taking ev-
erything into consideration, how do you feel about your job as a
whole?’’ This item was measured using a 7-point Likert scale,
with 1 = extremely dissatisfied and 7 = extremely satisfied.22
The secondary outcome of this study was the duration of any
breastfeeding measured in weeks. Respondents were asked
how long they breastfed their most recent child either in weeks
or months. If they responded in months, the response was
multiplied by 4.
Predictors
The main predictor variable was workplace support scores
for each domain. All Likert responses were assigned a nu-
merical value between 1 and 4: the number 1 corresponded to
responses indicating the least perceived support, and the
number 4 corresponded to responses indicating the most
support. Yes/No questions were similarly assigned a nu-
merical value, with 1 corresponding to the response of least
support and 2 to the response of most support. Within each
domain the Likert response values were summed to give an
overall domain-specific support score. Similarly, the domain-
specific support scores were then summed to give an overall
survey score. For all scores a high value indicates a high level
of perceived support, and a low value indicates a low level of
perceived support.
Analysis
We developed two sets of linear regression models. In the
first model, each individual domain was tested for its as-
sociation with workplace satisfaction. In the second model,
all domains were included simultaneously to test their in-
dependent contribution to job satisfaction. The models
were adjusted for the potential confounders of maternal
age, education, income level, number of hours worked per
week, whether an hourly wage or salary is paid, amount of
time off before returning to work, and whether any of the
time off was paid. The models evaluating duration of
breastfeeding were also adjusted for currently breastfeed-
ing mothers. Because the BESt score values are themselves
difficult to interpret and the number of questions vary
across each domain, we created standardized scores for
each domain. A 1-unit change in z score can be interpreted
as a 1 standard deviation (SD) change. We analyzed the
data from the two companies separately, and they are pre-
sented side by side for comparison.
Results
At SCH, 2,409 female employees were identified using
human resources records, and an invitation to participate in
224 WAITE AND CHRISTAKIS

Table 1. Demographic Characteristics to participate in the survey was sent to all of them. One
of the Study Population hundred forty-one of these women responded, giving a re-
sponse rate of 65%. At both companies the respondents were
Children’s Large primarily older, white, married, and highly educated (Table
Characteristic hospital corporation 1). The majority had been with their current employer for
Age (years) 33.2 – 3.8 34.5 – 2.9 greater than 5 years and benefited from a paid maternity leave
Race (Table 1).
White 332 (81.8%) 104 (81.3%) Overall job satisfaction was good at both companies. The
Asian 33 (8.1%) 11 (8.6%) mean job satisfaction score for the study population was 5.8,
Black or African American 10 (2.5%) 6 (4.7%) with a range of 2–7, at SCH and 6.4, with a range of 4–7, at
Other 31 (7.6%) 7 (5.4%) the large corporation.
Married or living with partner 393 (96.3%) 124 (96.9%) The mean breastfeeding duration was long at 41.8 (SD
Highest level of education attained 24.0) weeks with an observed range of 1–144 weeks at SCH
Less than college graduate 65 (15.9%) 5 (3.9%) and 38.8 (SD 34.1) weeks with a range of 2–216 weeks at the
4-year college 206 (50.4%) 69 (53.5%) large corporation (Table 2). At SCH 98% of the respondents
Advanced degree 138 (33.7%) 55 (42.6%) initiated breastfeeding with their most recent child, and 79%
Yearly household income of participants were still offering breastmilk at 6 months of
Less than $60,000 71 (17.5%) 3 (2.3%) age. At the large corporation 100% of the respondents initi-
More than $60,000 335 (82.5%) 126 (97.7%) ated breastfeeding, and 60% were offering breastmilk at 6
Length of time with current employer months of age.
Less than 1 year 36 (8.6%) 0 The possible range of total workplace support scores for
13 months to 5 years 153 (36.6%) 39 (30%) this survey tool was 41–156, and the observed ranges of
More than 5 years 229 (54.8%) 91 (70%) scores were 89–156 at SCH and 99–156 at the large corpo-
Hours worked per week ration. The mean total workplace support score was 124.5
Less than 30 158 (38.2%) 1 (0.8%) (SD 14.99) for SCH and 137.7 (SD 15.1) for the large cor-
31–40 hours 191 (46.1%) 93 (71.5%) poration. The domain-specific support score ranges and
Greater than 40 hours 65 (15.7%) 36 (27.7%)
means are summarized in Table 2. In the linear regression
Paid hourly wage 253 (60.5%) 3 (2.3%) model the total workplace support score was significantly
> 6 weeks of paid 242 (69.3%) 104 (79.4%) associated with job satisfaction at both institutions: b = 0.41
maternity leave
Average weeks of leave 15.1 – 11.4 11.5 – 4.2 (95% confidence interval, 0.30, 0.51) at SCH and b = 0.27
after most recent child (95% confidence interval, 0.14, 0.40) at the large corporation.
Initiated breastfeeding 412 (98%) 131 (100%) Each domain-specific support score was also independently
significantly associated with increased job satisfaction with
Data are mean – standard deviation values or number (%) as p values of < 0.002 at both institutions (Table 3). In the
indicated. multivariate regression model adjusting for all confounders
and including all BESt domains, manager support (b = 0.19,
the survey was e-mailed to all of them. Of these, 1,129 women p = 0.04) and coworker support (b = 0.15, p = 0.04) remained
responded and were identified as either eligible or ineligible to significantly associated with improvement in job satisfaction
participate, yielding a response rate of 47%. Four hundred at the children’s hospital, whereas only time support (b = 0.29,
twenty women were eligible and answered a survey question p = 0.01) remained significantly associated with improvement
for at least one of the outcomes of interest. At the large cor- in job satisfaction at the large corporation (Table 3).
poration, the human resources department provided e-mail We did not find any association between breastfeeding
addresses for all women who had a child born in the last 5 duration in weeks and total workplace support score or any
years, yielding 215 women. An e-mail link with an invitation domain-specific support score at either location (Table 4).

Table 2. Description of Outcomes and Predictors of Interest

Children’s hospital Large corporation
Observed Observed
Possible range range Mean SD range Mean SD
Job satisfaction score 1–7 2–7 5.8 1.0 4–7 6.4 0.8
Breastfeeding duration (weeks) — 1–144 41.8 24.0 2–216 38.8 34.1
Total score 41–156 89–156 124.5 14.9 99–156 137.7 15.1
Domain-specific support scores
Organizational support 11–44 17–44 35.9 4.9 27–44 39.5 4.5
Manager support 12–48 18–48 37.3 6.1 18–48 39.6 6.3
Coworker support 6–24 11–24 19.4 3.1 11–24 19.9 3.3
Time support 3–12 3–12 8.0 2.4 6–12 10.6 1.8
Physical environment 9–28 12–28 22.1 3.3 16–28 25.4 3.0
SD, standard deviation.
WORKPLACE BREASTFEEDING SUPPORT AND JOB SATISFACTION 225

Table 3. Workplace Support Scores and Association with Job Satisfaction by Domain
Children’s hospital Large corporation
b p value 95% CI b p value 95% CI
Total workplace support score 0.41 < 0.001 0.30, 0.51 0.27 0.001 0.14, 0.40
Domain-specific support scoresa
Organizational support 0.40 < 0.001 0.31, 0.50 0.42 < 0.001 0.28, 0.55
Manager support 0.42 < 0.001 0.33, 0.51 0.35 < 0.001 0.22, 0.48
Coworker support 0.33 < 0.001 0.24, 0.43 0.40 < 0.001 0.27, 0.53
Time support 0.34 < 0.001 0.25, 0.44 0.35 < 0.001 0.21, 0.49
Physical environment 0.17 0.003 0.06, 0.29 0.28 0.001 0.14, 0.41
Domain specific support scoresb
Organizational support 0.12 0.18 - 0.06, 0.31 - 0.05 0.77 - 0.41, 0.30
Manager support 0.19 0.04 0.00, 0.37 0.05 0.56 - 0.14, 0.24
Coworker support 0.15 0.04 0.01, 0.28 0.13 0.29 - 0.12, 0.38
Time support 0.14 0.06 - 0.01, 0.26 0.29 0.01 0.07, 0.52
Physical environment - 0.07 0.23 - 0.18, 0.06 - 0.09 0.39 - 0.31, 0.12
a
Univariate models including only domain of interest and adjusting for all confounders.
b
Multivariate model with all domains and all confounders included in the model.
CI, confidence interval.

Discussion point to the importance of unique challenges within each

Prior studies have looked at the association between
workplace lactation support and breastfeeding duration;
however, to our knowledge none has evaluated the associa-
tion between workplace breastfeeding support and job sat-
isfaction. We found that women who reported feeling
supported to maintain breastfeeding in their workplace had
higher overall job satisfaction than those who did not feel as
supported. Similarly, in the univariate models, increases in
each domain-specific support score were also independently,
and significantly, associated with increased job satisfaction
(Table 3). On average, one-quarter to one-third of an SD
change in each domain was associated with a 1 unit higher job
satisfaction score. This association was true for the two
separate institutions. The magnitude of this difference in
satisfaction, although small, is comparable to the association
between opportunity for promotion and job satisfaction.23
When all of the domains of support were included in the
same model, only manager support and coworker support
remained significantly associated with job satisfaction at
SCH, and only time support remained significantly associ-
ated with job satisfaction at the large corporation. It is not
completely clear why this is the case, but this finding may
institution that make it more or less challenging for women to
express breastmilk at work. Although the women from the
two institutions in this study had many similarities, there
were also significant differences between them. The chil-
dren’s hospital population consisted of many shift workers
who were paid an hourly wage and worked fewer than 40
hours per week. Many of these women are bedside nurses and
have little control over their daily schedules. The women at
the large corporation were primarily salaried full-time em-
ployees with significant flexibility in their day-to-day
schedules. They also enjoyed a formal on-site lactation pro-
gram. At SCH, where there is no lactation program in place,
women may have to rely on the support and good will of their
managers and coworkers to cover patients and other re-
sponsibilities while they pump. At the large company only
time support was meaningful after considering all domains,
perhaps indicating that even with a workplace lactation
program in place women still find it difficult to make time to
express breastmilk during the workday.
Our study did not demonstrate any difference in breast-
feeding duration (offering any breastmilk) among those
women who felt the greatest amount of breastfeeding support
at work and those who felt the least amount of support. In our

Table 4. Regression Model of Breastfeeding Duration in Weeks by Workplace Support Scores

Children’s hospital Large corporation
b p value 95% CI b p value 95% CI
Total score 0.53 0.73 - 2.47, 3.53 1.43 0.75 - 7.76, 10.63
Domain specific support scores
Organizational support - 1.01 0.44 - 3.58, 1.56 0.48 0.87 - 5.01, 6.01
Manager support - 1.08 0.39 - 3.54, 1.37 1.41 0.63 - 4.43, 7.26
Coworker support 1.54 0.23 - 0.99, 4.06 0.66 0.86 - 6.63, 7.94
Time support - 1.05 0.41 - 3.58, 1.48 3.71 0.17 - 1.64, 9.07
Physical environment 0.61 0.69 - 2.38, 3.60 - 4.05 0.19 - 10.08, 1.98
CI, confidence interval.
226
linear regression models a 1 point increase in total workplace
support score did not significantly change overall breast-
feeding duration. This study population consisted of primarily
older, white, highly educated women, a population that is
known to breastfeed at higher rates than the general popula-
tion at baseline.24–26 Of the mothers who participated in this
survey at the children’s hospital and the large corporation,
98% and 100%, respectively, initiated breastfeeding in their
most recent child, and 79% and 60%, respectively, were still
offering some breastmilk at 6 months of age. This is signifi-
cantly higher than the national average of 79% of mothers
initiating breastfeeding and 49% offering any breastmilk at 6
months, as well as the state averages where these two com-
panies are located: 92% initiation and 64% breastfeeding at 6
months for the children’s hospital and 77% initiation and 48%
breastfeeding at 6 months for the large corporation.5
This study population also benefited from a predominantly
paid and lengthy maternity leave. At SCH, 69% of women
had greater than 6 weeks of paid maternity leave, whereas at
the large corporation, almost 80% of women received greater
than 6 weeks of paid leave. It is known that longer maternity
leave is associated with a longer duration of breastfeeding.27
It is possible that the reason we did not demonstrate an as-
sociation between perceived workplace support and breast-
feeding duration in this study is that our study population had a
very high baseline dedication to breastfeeding. It is likely that
women who work in industries with far less control over their
daily schedules face much greater challenges in combining
breastfeeding and employment. It is also possible that other
unmeasured factors unrelated to the workplace impacted
breastfeeding choice and duration.
There were several limitations of this study that warrant
mention. First, it was conducted within two institutions with
highly educated, very skilled female employees. The two
companies also had very high baseline rates of breastfeeding
and an interest in improving the breastfeeding experience for
new mothers. The extent to which these findings can be gen-
eralized to other companies with different employee profiles is
unknown but warrants further study. Nevertheless, we were
able to demonstrate an association between employee per-
ception of breastfeeding support and job satisfaction even in
two workplaces where overall job satisfaction was very high.
We also did not control for general employee happiness, which
is likely to be related to job satisfaction. Additionally, this
survey was unable to determine if the breastfeeding was ex-
clusive. It is very possible that workplace support has a greater
impact on the duration of exclusive breastfeeding than the
duration of any breastfeeding. Like any survey study, it is
possible that we had response bias. In the e-mail that accom-
panied the survey it was difficult to completely conceal that the
topic of interest was breastfeeding. It is therefore possible that
women who did not breastfeed or were not interested in this
topic did not respond. Lastly, the cross-sectional nature of our
study precludes drawing causal inferences. Although it is
plausible and consistent with our a priori hypothesis that
workplace lactation support would improve job satisfaction,
further study will be needed to confirm our findings.
Conclusions
In spite of these limitations, our study has some important
implications. Improved lactation support in the workplace
WAITE AND CHRISTAKIS
may increase new mothers’ job satisfaction, which is likely
beneficial to businesses. More satisfied employees have been
shown to have lower levels of burnout and fewer turnovers
than less satisfied employees, which can save a company
significant money and time in finding and training new
workers.28–31 Many of the supports necessary are not par-
ticularly resource intensive, which employers may deem to
be cost-effective. Future longitudinal research should attempt
to confirm our findings and estimate the magnitude of change
in satisfaction that can be achieved at a given cost.
Acknowledgments
This research was made possible through funding from a
National Research Service Award training grant and the
Global Breastfeeding Initiative of Excellence in Paediatrics.
Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Whitney M. Waite, MD, MPH
Center for Child Health, Behavior, and Development
2001 Eighth Avenue
Seattle, WA 98121
E-mail: wmillig@uw.edu