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DEVELOPMENT AND PILOTING OF AN INSTRUMENT
THAT MEASURES COMPANY SUPPORT FOR
BREASTFEEDING

presented by

SARAH ELIZABETH HOJ NACKI

has been accepted towards fulfillment
of the requirements for the

MS. degree in Human Nutrition

 

 

 

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5(08 K:IProi/Aoc&Pres/CIRCIDateDue.indd

DEVELOPMENT AND PILOTING OF AN INSTRUMENT THAT MEASURES
COMPANY SUPPORT FOR BREASTFEEDING

By

Sarah Elizabeth Hojnacki

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE
Human Nutrition

2010

ABSTRACT

DEVELOPMENT AND PILOTING OF AN INSTRUMENT THAT MEASURES
COMPANY SUPPORT F OR BREASTFEEDING

By
Sarah Elizabeth Hojnacki

Breastfeeding duration among women employed full-time is lower than for women
who do not work outside the home or are employed part-time. There is limited research
from the perspective of breastfeeding, working women on what the barriers to and
facilitators of breastfeeding while employed are. There are also few studies identifying
support provided by employers, which could assist breastfeeding employees. Prior to this
study, no instrument was available that measured the level of formal breastfeeding support
in companies. The purpose of this study was to develop an instrument to be used in
companies which measures the amount of formal breastfeeding support based on the
existence of policies, programs, and benefits that may help women combine breastfeeding
and employment. Survey design and item development was done through an iterative
process. Items and formatting followed the Tailored Design Method (TDM). Expert
reviews (n=9) and cognitive interviews (n=4) were performed to ensure validity of the
measures of the instrument. The final instrument had 28 items collecting information on
formal breastfeeding support; employee demand for breastfeeding support; family-friendly,
wellness, and health benefits; and company demographics. The instrument was pilot-tested
in 151 companies in Michigan. The results indicated that although few companies had
written breastfeeding policies, most allowed women to express milk at work and provided
space other than a restroom for this purpose. However, the majority of companies did not

provide many other supports such as lactation consultants or electric breast pumps.

ACKNOWLEDGEMENTS

I would like to express my appreciation for wonderful guidance during my
graduate program and on my thesis project to my major advisor, Dr. Beth Olson. Her
knowledge about and passion for breastfeeding support is inspirational, and her
dedication to me as a student helped me grow as a scholar and researcher. I would also
like to express gratitude to my committee members, Dr. Lorraine Weatherspoon and Dr.
Ingrid Fulmer. Their support and feedback through my journey as a graduate student was
invaluable, and I am grateful for all their help despite busy schedules and being in
different states. I would like to thank Dr. Edward Wolfe for his assistance in instrument
design, as well as the lactation consultants and human resource personnel who gave
helpful input for the instrument

I am grateful for my experiences while part of the Department of Food Science
and Human Nutrition and especially thankful for all of the support from Community
Nutrition faculty and students. I would like to extend my deepest thanks to all of my lab
mates, Tracie Bolton, Tan Chow, Tara Fischer, Sally Greene, Krystyna Iwanski,
Shabnam Momin, and all the undergraduate assistants for all of their encouragement and
help.

Finally I would like to thank my family, friends, and boyfriend for their
continuous and incredible support during this journey. I would not be where I am today

without all of these exceptional individuals.

iii

TABLE OF CONTENTS

LIST OF TABLES ...................................................... vi

LIST OF FIGURES ..................................................... vii

LIST OF ABBREVIATIONS ............................................. viii
CHAPTER 1

INTRODUCTION ....................................................... 1

1.1 Background .................................................... l

1.2 Rationale ..................................................... 4

1.3 Research goal .................................................. 6

1.4 Research objectives ............................................. 6
CHAPTER 2

LITERATURE REVIEW .................................................. 7

2.1 Benefits of breastfeeding ......................................... 7

2.2 Breastfeeding recommendations and prevalence ....................... 8

2.3 Breastfeeding and employment .................................... 10

2.4 Legislation .................................................... 12

2.5 Work climate ................................................. 14

2.6 Formal organizational support .................................... 17

2.6.1Written policies ......................................... 17

2.6.2 Maternity leave and the Family and Medical Leave Act of 1993

(FMLA) .............................................. 19

2.6.3 Corporate lactation programs .............................. 22

2.6.4 Nursing rooms and breast pump equipment ................... 24

2.6.5 Break time ............................................ 26

2.6.6 Education and support ................................... 27

2.6.7 Onsite daycare ......................................... 28

2.6.8 Flexible schedules ...................................... 29

2.6.9 Framework characterizing formal breastfeeding support ........ 30
CHAPTER 3

METHODS ............................................................ 33

3.1 Item development .............................................. 33

3.2 Pretesting the instrument ......................................... 34

3.3 Sample demographics ........................................... 36

3.4 Company recruitment ........................................... 38

3.5 Descriptive analysis ............................................ 40

3.6 Exploratory analysis ............................................ 41

3.7 Recommendations for revision of the instrument ...................... 41

iv

CHAPTER 4
“DEVELOPMENT AND PILOTING OF AN INSTRUMENT THAT MEASURES

COMPANY SUPPORT FOR BREASTFEEDING” A MANUSCRIPT ............ 43
4.1 Abstract ..................................................... 43
4.2 Introduction ................................................... 43
4.3 Methods ...................................................... 46
4.4 Results ....................................................... 52
4.5 Discussion .................................................... 58

CHAPTER 5

CONCLUSIONS AND DISCUSSION ...................................... 62
5.1 Conclusions ................................................... 62
5.2 Implications ................................................... 63
5.3 Future research ................................................ 64

APPENDICES
Appendix A: Pilot instrument ........................................ 68
Appendix B: Expert review comment form ............................. 81
Appendix C: Cover letter for initial contact ............................. 86
Appendix D: Sample report ......................................... 88
Appendix E: Phone script for second contact ............................ 94
Appendix F: Reminder postcard for third contact ........................ 98
Appendix G: Table 4. Scoring system for formal breastfeeding support ...... 99
Appendix H: Table 5. Prevalence of breastfeeding supports ............... 101
Appendix I: Table 6. Correlations between independent variables and the

dependent variable, total breastfeeding support score ........... 103

Appendix J: Table 7. Multiple linear regression model ................... 104

REFERENCES ........................................................ 106

LIST OF TABLES

Table 1. Healthy People 2010 objectives and national averages for breastfeeding

initiation and duration in 2005 (Data from CDC, 2008) ................... 10
Table 2. Scoring system for time, structural, and total breastfeeding support items . . . . 51
Table 3. Mean scores for total breastfeeding support by variable group ............. 55
Table 4. Scoring system for formal breastfeeding support ........................ 99
Table 5. Prevalence of breastfeeding supports ................................ 101

Table 6. Correlations between independent variables and the dependent variable, total
breastfeeding support score ....................................... 103

Table 7. Multiple linear regression model ................................... 104

vi

LIST OF FIGURES

Figure 1. Work climate model for breastfeeding support ......................... 15

Figure 2. Framework characterizing formal means of company breastfeeding support. . 32

vii

LIST OF ABBREVIATIONS

ADA .......................................... American Dietetic Association
AAFP ................................ American Academy of Family Physicians
AAP ........................................ American Academy of Pediatrics
CDC ................................ Centers for Disease Control and Prevention
DHHS ........................... US. Department of Health and Human Services
DOL .............................................. US. Department of Labor
DWP ...................................... Department for Work and Pensions
EPBS ................ Employee Perceptions of Breastfeeding Support questionnaire
MABS . ................... Manager Attitudes toward Breastfeeding Support survey
FMLA .................................. Family and Medical Leave Act of 1993
IBCLC ......................... lntemational Board Certified Lactation Consultant
NLSY .................................. National Longitudinal Survey of Youth
SHRM ............................... Society for Human Resource Management
TDM ............................................... Tailored Design Method
USBC .................................. United States Breastfeeding Committee
USDA ................................. United States Department of Agriculture

WIC . . . The Special Supplemental Nutrition Program for Women, Infants, and Children

WHO ............................................ World Health Organization

viii

CHAPTER 1

INTRODUCTION

1.1 Background

Breastfeeding is the optimal infant feeding method given the significant health
benefits it provides to infants and mothers (American Academy of Pediatrics [AAP],
2005; American Dietetic Association [ADA], 2009; US. Department of Health and
Human Services [DHHS], 2000a). In addition to short- and long-term health benefits for
mothers and their infants, breastfeeding results in economic savings for families, health
insurance providers, employers, and society (Ball & Bennett, 2001; Ball & Wright, 1999;
Montgomery & Splett, 1997). Due to the numerous important benefits, it is recommended
that infants be exclusively breastfed for six months with the addition of complementary
foods and continued breastfeeding for at least the remainder of the first year of life
(American Academy of Family Physicians [AAFP], 2005; AAP, 2005, ADA, 2009). The
World Health Organization ([WHO], 2002) recommends that breastfeeding continues for
two years or longer. Despite the known benefits, breastfeeding rates in the United States
remain below the Healthy People 2010 objectives. Seventy—four percent of mothers who
had just given birth initiated breastfeeding in 2005, nearly reaching the national objective
of 75% (Centers for Disease Control and Prevention [CDC], 2008). However, only 43%
and 21% continued to breastfeed at six and 12 months, respectively (CDC, 2008). These
rates do not meet the 50% and 25% national objectives.

Maternal employment status during the first year of an infant’s life is a frequently

cited barrier to meeting the recommended breastfeeding duration. Many studies have

shown that returning to work within a year of childbirth is negatively associated with
breastfeeding duration (Cardenas & Major, 2005; Chatterji & F rick, 2005; Chezem &
Friesen, 1999; Cohen & Mrtek, 1994; Fein & Roe, 1998; Haider, Jacknowitz, & Schoeni,
2003; Hills-Bonczyk, Avery, Savik, Potter & Duckett, 1993; Ryan, Zhou, & Arensberg,
2006; Visness & Kennedy, 1997). Among working women, those who are employed full-
time have the lowest sustained breastfeeding rates. Full-time employed women have a
similar initiation rate to women who are not employed or are employed part-time, but
approximately 10% fewer are continuing to breastfeed at six months (Ross Products
Division, 2003; Ryan, Zhou, & Arensberg, 2006). Fein, Manda], and Roe (2008) showed
that breastfeeding intensity, or the proportion of feedings that are breast milk versus other
liquids, also decreased after women returned to work. Employment is associated with
decreased rates of breastfeeding intensity and decreased breastfeeding rates in general,
and therefore negatively affects the overall amount of breast milk an infant receives.

Due to their employment status, over half of all women with infants are at risk for
early cessation of breastfeeding. More than half (59.5%) of all women are part of the US
labor force, 75% of whom are employed full-time (US. Department of Labor [DOL],
2009a). Of even greater importance, 56.4% of women with a child under one year of age
were employed in 2008 (DOL, 2009b). It is imperative to understand how employment
influences successful breastfeeding. The workplace climate may be one input, among
others, that factors into breastfeeding rates among working mothers.

Workplace climate can influence whether or not a woman perceives her employer
as supportive of breastfeeding. Work climate has been defined as the “shared perceptions

of organizational policies, practices, and procedures, both formal and informal”

(Schneider, 1990, p.23). This includes the events and behaviors that are rewarded,
supported, and expected in a particular environment. Organizational family support, or
“family friendliness,” is a construct consisting of the work-family policies and practices
that are offered by an organization (Thompson, Jahn, Kopelman, & Prottas, 2004). It also
includes messages conveyed to employees about the organization’s interest in helping
employees balance their work and family lives. Family-friendly benefits, including
breastfeeding support, are an important aspect of an organization’s climate.

Formal means of organizational support include written policies, schedule
flexibility, and work-family benefit availability; informal means include job autonomy,
manager support, an organization’s ability to communicate respect for employees’ non-
work lives, and career impact concerns (Behson, 2005; Thompson, Jahn, Kopelman, &
Prottas, 2004). A few studies (Behson, 2005; Thompson, Jahn, Kopelman, & Prottas.
2004) have found that informal means of organizational work-farnily support are greater
predictors of job satisfaction, work-family conflict, stress, organizational attachment, and
turnover intentions than are formal means of organizational support. However, formal
means of support still constitute a portion of work climate and are an important
component for consideration of the overall work climate.

Previous studies cite barriers to and facilitators of breastfeeding in the workplace.
The formal aspects of companies identified as barriers to breastfeeding include short
maternity leave, insufficient break time to express milk at work, and inadequate facilities
for expressing milk (Auerbach, 1990; Chezem & Friesen, 1999; Cohen & Mrtek, 1994;
Dodgson, Chee & Yap, 2004; Guendelman, Kosa, Pearl, Graham, Goodman, & Kharrazi,

2009; Hills-Bonczyk, Avery, Savik, Potter, & Duckett, 1993; Kearney & Cronenwett,

1991; Roe, Whittington, F ein & Teisl, 1999). Factors that are supportive of breastfeeding
at the workplace include a clean, private space for milk expression, support groups,
adequate break time for pumping or nursing, on-site day care, flexible schedules, and
educational materials or programs about breastfeeding (Auerbach, 1990; Cardenas &
Major, 2005; Cohen & Mrtek, 1994; McLeod, Pullon, & Cookson, 2002; Thompson &
Bell, 1997; Visness & Kennedy, 1997; Whaley, Meehan, Lange, Slusser, & Jenks, 2002).
From a review of the literature, a framework characterizing formal means of
company breastfeeding support was constructed. This framework consists of two
components that are key factors for defining company breastfeeding support: 1) time
support; and 2) structural support. Time is composed of breaks, maternity leave, and
flexible scheduling options. This category describes the time it takes for women to
establish and continue breastfeeding, and may alter her work schedule. Structural support
is made up of the tangible supports a company can offer that help women combine
breastfeeding and work. It includes designated rooms for breastfeeding, breast pump
equipment, lactation services such as lactation consultant referrals, and onsite daycare.
Furthermore, it includes education for employees on breastfeeding or expressing milk,
including education on any written policies concerning these behaviors at the workplace.
The two components of time and structural support were used in this study to determine a

company’s level of formal breastfeeding support.

1.2 Rationale
Limited research has been conducted around work climate and breastfeeding

support. Many studies have identified individual facilitators of and barriers to

breastfeeding in the workplace, providing a better understanding of working mothers’
perceptions of how companies can be supportive of combining breastfeeding and
employment. However, no studies to date have thoroughly examined the extent to which
breastfeeding support is formally provided in companies. Additionally, no instrument is
available that can quantitatively measure a company’s level of formal breastfeeding
support. A survey of small, medium, and large businesses in Colorado was used to
calculate the frequency of select breastfeeding support policies and practices (Dunn,
Zavela, Cline, & Cost, 2004). However, the survey was not inclusive of all facilitators of
the combining of breastfeeding and employment found in the literature (e.g., support
groups for breastfeeding employees, educational classes on breastfeeding and pumping).
Furthermore, the survey was only intended to calculate the prevalence of policies and
practices and not to score companies on their overall level of formal breastfeeding
support. The Society for Human Resource Management (SHRM, 2007b) also collects
data on company breastfeeding support. However, they only survey for onsite lactation
rooms, onsite daycare, and lactation consulting and education, and do not include all
breastfeeding supports that may be available. No study of breastfeeding supports
available in Michigan companies has been performed, which provides justification for a
pilot study in this state.

It was necessary to develop an instrument that measures the level of formal
company breastfeeding support as determined by policies, programs, and benefits that
help women combine breastfeeding and employment. This instrument will be valuable
for identifying which breastfeeding support components are common or less prevalent

across companies. By knowing which support components are less prevalent, specific

lactation support programs can be developed and targeted toward organizations lacking
support. The measure of existing breastfeeding support will also be helpful to individual
companies assessing their own formal breastfeeding support. It will allow them to
identify gaps in support at their organization, and will be useful as an employee

recruitment and retention tool.

1.3 Research Goal
To develop an instrument for use in companies that determines the amount of
formal breastfeeding support based on the existence of policies, programs, and benefits

that help women combine breastfeeding and employment.

1.4 Research Objectives
Research Objective #1: Develop an instrument that identifies the prevalence of
policies, programs, and benefits in companies that are supportive of
breastfeeding.
Research Objective #2: Pilot the instrument in select business sectors in Michigan.
Research Objective #3 .' Evaluate the levels of time, structural, and overall
breastfeeding support in companies completing the survey.
#3a: Determine if the overall level of company support for breastfeeding can be
assessed based on the framework characterizing formal means of company
breastfeeding support.

#3b: Characterize companies offering greater versus less breastfeeding support.

CHAPTER 2

LITERATURE REVIEW

2.1 Benefits of breastfeeding

Breastfeeding is the optimal infant feeding method given the significant health
benefits it provides to both infant and mother. Extensive research presents evidence that
breastfeeding decreases the risk and severity of many illnesses throughout life. Breastfed
children have fewer incidences of diarrhea, respiratory and ear infections, allergic
diseases including asthma, and postneonatal death (Chen & Rogan, 2004; Cushing,
Samet, Lambert, Skipper, Hunt, Young, et al., 1998; Dewey, Heinig, & Nommsen-
Rivers, 1995; Duffy, Faden, Wasielewski, Wolf, & Krystofik, 1997; Ip, Chung, Raman,
Chew, Magula, DeVine, et al., 2007; Oddy & Peat, 2003; Scariati, Grummer-Strawn, &
Fein, 1997). Positive associations with cognitive development and visual acuity have also
been found (Anderson, Johnstone, & Remley, 1999; Singhal, Morley, Cole, Kennedy,
Sonksen, lsaacs, et al., 2007). Furthermore, many studies have shown lower rates of
several chronic diseases later in life for those who were breastfed as infants. Decreased
rates are suggested for overweight and obesity, type 1 and type 2 diabetes, some cancers,
and gastrointestinal diseases (Dewey, 2003; Gillman, Rifas-Shiman, Camargo, Berkey,
Frazier, Rockett, et al., 2001; Klement, Cohen, Boxman, Joseph, & Reif, 2004; 1p,
Chung, Rarnan, Chew, Magula, DeVine, et al., 2007; Owen, Martin, Whincup, Smith,
& Cook, 2006; Rosenbauer, Herzig, & Giani, 2008).

Women also receive health benefits from breastfeeding their children. Those who

choose this feeding option have a faster return to pre-pregnancy weight and a decreased

risk for ovarian and breast cancer compared to women who do not breastfeed (Danforth,
Tworoger, Hecht, Rosner, Colditz, & Hankinson, 2007; Dewey, Heinig, & Nommsen,
1993; Ip, Chung, Raman, Chew, Magula, DeVine, etal., 2007; Labbok, 2001).
Breastfeeding may help enhance the psychological bonding between mother and child
(Kuzela, Stifier, & Worobey, 1990; Windstrom, Wahlberg, Mattiesen, Eneroth, Uvnas-
Moberg, Werner, et al., 1990). Due to the numerous important benefits, it is
recommended that infants be exclusively breastfed for six months, with the addition of
complementary foods and continued breastfeeding for at least the remainder of the first
year of life (AAFP, 2005; AAP, 2005, ADA, 2009). The World Health Organization
([WHO], 2002) recommends that breastfeeding continue for up to two years or longer.
In addition to benefits for infants and mothers, there are economic benefits of
breastfeeding in comparison to formula feeding for families, society, health insurance
providers, and employers (Ball & Bennett, 2001). Savings include decreased annual
health care costs, lower costs for public health programs such as The Special
Supplemental Nutrition Program for Women, Infants, and Children (WIC), less
environmental burden due to decreased formula packaging and bottle waste, and less
expenditure on breast milk substitutes by individuals and families (Ball & Bennett, 2001;

Ball & Wright, 1999; Montgomery & Splett, 1997; Weimer, 2001 ).

2.2 Breastfeeding recommendations and prevalence
Despite the known benefits of breastfeeding, initiation and duration rates are
below national goals (CDC, 2008). Recognizing the potential consequences of not

breastfeeding, the US Department of Health and Human Services ([DHHS], 2000b) set

objectives for 75% of mothers to initiate breastfeeding, and for 50% and 25% to continue
breastfeeding through six and 12 months, respectively, as part of the Healthy People 2010
health objectives (Table 1). Given the dose-response effect evidenced in studies of
exclusive breastfeeding, many organizations recommend that exclusive breastfeeding
should be practiced rather than mixed-method feeding during the first six months of an
infant’s life (AAFP, 2001; AAP, 1997; United Nations Children’s Fund, 1999; WHO,
2001). Therefore, objectives for exclusive breastfeeding were added to Healthy People
2010 at the midcourse review. These objectives aim for 40% and 17% of mothers to
provide their infants breast milk only, without the addition of other liquids or solids, for
three and six months, respectively (DHHS, 2006). However, results of the National
Immunization Survey showed that, in 2005, breastfeeding duration objectives were not
met. While 74% of mothers initiated breastfeeding — just below the 75% goal — at six and
12 months , breastfeeding sustenance fell short of objectives at 43% and 21%,
respectively (CDC, 2008). The prevalence of women exclusively breastfeeding was also
lower than objectives, as only 32% were breastfeeding at three months, and 12% at six
months (CDC, 2008). Furthermore, average breastfeeding initiation and duration rates at
six and 12 months in 2005 in Michigan were even lower than the national averages

(Table l) (CDC, 2008) indicating a need for studies understanding this discrepancy.

Table 1. Healthy People 2010 objectives and national averages for breastfeeding
initiation and duration in 2005 (Data from CDC, 2008).

 

 

 

 

 

 

.
Initiation 75% 74% 66%
Through 6 months 50% 43% 35%
Through 12 months 25% 21% 19%
Exclusively through 3 months 40% 32% N/A
Exclusively through 6 months 17% 12% N/A

 

 

 

 

The United States Department of Agriculture’s [USDA] Economic Research
Service found that by meeting national objectives for exclusive breastfeeding, at least 3.6
billion dollars could be saved in the US annually on medical expenses, wages lost by
parents caring for an ill child, and the prevention of premature deaths (Weimer, 2001).
This figure is based solely on the reduction in incidences of otitis media, gastroenteritis,

and necrotizing enterocolitis.

2.3 Breastfeeding and employment

Breastfeeding initiation and duration are lower than desired for US women
collectively. However, breastfeeding duration among women who return to work full-
time after having a child is even lower than the duration of their non-working and part-
time employed counterparts. Women employed full-time have almost the same initiation
rate as women who are not employed or are employed part-time, but the amount of full-
time employed women continuing to breastfeed at six months is approximately 10%

fewer than their counterparts (Ross Products Division, 2003; Ryan, Zhou, & Arensberg,

10

2006). F ein, Manda], and Roe (2008) showed that breastfeeding intensity, or the
proportion of feedings that are breast milk versus other liquids, also decreased after
women returned to work. The decline in breastfeeding intensity was less for women who
had reduced work hours compared to other women upon return to the job. Therefore,
employment not only has an effect on duration of breastfeeding, but also on rates of
exclusive breastfeeding. The discrepancy in breastfeeding rates provides evidence that
full-time maternal employment is a barrier to achieving national breastfeeding objectives.
The difference in breastfeeding rates between women employed full-time and their
counterparts may be due to mother employees perceiving the work place as not being
supportive of breastfeeding (Cardenas & Major, 2005; Rojjanasrirat, 2004). Therefore, it
is imperative to understand work climate from the perception working mothers.

With the proportion of women in the workforce continually increasing (US.
Department of Labor [DOL], 2009a), the US will likely continue to fall short of its
breastfeeding goals. In 2008, 59.5% of all women were part of the labor force, 75.4% of
whom were employed full-time (DOL, 2009a). Of even greater importance, 56.4% of
women with an infant under one year of age were employed (DOL, 2009b). Therefore,
over half of mothers who had a baby within the last year have an increased risk for
decreased breastfeeding rates due to their employment status.

Reduced or early discontinuation of breastfeeding by working mothers results in
negative consequences not only for the mother and infant, but for employers as well.
Infants who are not breastfed are ill more often and need more annual physician visits
(Ball & Wright, 1999; Raisler, Alexander, & O’Campo, 1999). This results in loss of

productivity to companies due to more frequent and longer absenteeism of mothers as

11

well as diminished attention to work tasks for mothers required to be at work while
worrying about a sick child at home (Cohen & Mrtek 1994; Cohen, Mrtek, & Mrtek,
1995). Infant illnesses also account for an increase in medical costs to companies due to
greater use of health insurance (Ball & Bennett, 2001; Ball & Wright, 1999; Cohen,
Mrtek, & Mrtek, 1995).

It is beneficial for employers to help mothers combine breastfeeding and work. In
addition to reduced absenteeism and increased productivity, employers can experience
improved employee morale and job satisfaction (Ball & Bennett, 2001); organizational
attractiveness (Seijts, 2002; United States Breastfeeding Committee [USBC], 2002);
greater employee commitment (Bond, Galinsky, & Swanberg, 1998; Thompson,
Beauvais, & Lyness, 1999); higher employee retention rates (Ball & Bennett, 2001; Ortiz,
McGilligan, & Kelly, 2004); and overall annual savings (Ball & Bennett, 2001; Bond.
Galinsky, & Swanberg, 1998; USBC, 2002). In sum, organizations have a positive return

on investment for offering breastfeeding support.

2.4 Legislation

It has been shown that breastfeeding promotion legislation is associated with the
percentage of infants who are ever breastfed, and the duration for which they are
breastfed. In states that have passed multiple pieces of legislation, including the right for
mothers to take breaks at work to breastfeed or express breast milk, 76% of children were
reported to have ever been breastfed compared to only 63.7% of children in states with no
such legislation (Kogan, Singh, Dee, Belanoff, & Grummer-Strawn, 2008). Similarly,

more children were estimated to have been breastfed for at least six months in states with

12

multiple pieces of breastfeeding promotion legislation (42.4% vs. 32.1%). Even though
the reasons for low breastfeeding rates are complex, supportive breastfeeding legislation
may also influence breastfeeding decisions.

Unfortunately, there is not much legislative support for workplace breastfeeding
in the United States. There is no federal legislation related to breastfeeding at the
workplace. While 24 states, the District of Columbia, and Puerto Rico all have laws
regarding breastfeeding in the workplace, Michigan is not included (National Conference
of State Legislatures, 2010). Under Michigan law, women are protected from public
indecency charges when breastfeeding in public (Mich. Comp. Laws § 41.18l,67.1aa
and § 117.4i et seq. (1994)). A few states, such as California, Connecticut, Illinois, and
Washington have state laws requiring employers to provide private rooms where mothers
can express milk (National Conference of State Legislatures, 2009). Other states also
require employers to allow reasonable time during the workday for a mother to breastfeed
or express. Although nearly half of the states have laws addressing breastfeeding at work,
many are worded vaguely, thus leaving it up to individual employers to use their own
discretion as to what is appropriate support. Furthermore, most of these laws do not have
enforcement provisions or penalties, making it easier for employers to not abide by them.

The “Breastfeeding Promotion Act of 2009” (HR. 2819) was introduced to the
US House of Representatives in June, 2009 by Representative Carolyn B. Maloney (D-
NY) (Maloney, 2009). The goals of this amendment to the Civil Rights Act of 1964 are to
promote the health and well-being of infants whose mothers return to the workplace after
childbirth, and to clarify that breastfeeding and expressing breast milk in the workplace

are protected conduct under the amendment made by the Pregnancy Discrimination Act

13

of 1978. This act states that any employer with 50 or more employees shall provide break
time for an employee to express breast milk for one year after a child’s birth. The
employer shall also make efforts to provide a space (other than a restroom) that is
shielded from view and free from intrusion from co-workers and the public, and can be
used by an employee to express breast milk. Under this act, employers who accommodate
mothers who are breastfeeding or expressing will also receive a 50% credit on
expenditures on qualified breastfeeding promotion and support. If this bill is passed, it
will ensure protection of all mothers who wish to continue breastfeeding after returning
to work, and be the first nation-wide attempt at incorporating breastfeeding support into
the workplace. It should also be noted, however, that this act has limitations. Not all
companies may have space available in order to provide a private area for breastfeeding
or pumping. Secondly, this is the fifih time that this act has introduced, leaving the

success of its acceptance uncertain.

2.5 Work climate

A successful combination of the roles of breastfeeding mother and employee can
result in valuable outcomes for a woman, her infant, and her employer. However, the
successful dual role is challenging for many full-time employed women with infants if
her workplace is not supportive of breastfeeding (Cardenas & Major, 2005; Rojjanasrirat,
2004). Work climate has been defined as the “shared perceptions of organizational
policies, practices, and procedures, both formal and informal” (Schneider, 1990, p.23).
This includes the events and behaviors that are rewarded, supported, and expected in a

particular environment. The climate of a woman’s workplace influences whether or not

14

she perceives her employer as supportive. Figure 1 displays the work climate model for

breastfeeding support.

     
  

   

Formal Company

<———> Manager Attitudes
Support

 
 

Work

-.\ Climate /.-'

Perception of
Employees
(Mothers)

   
 
    

Figure 1. Work climate model for breastfeeding support.

Organizational Family Support, or “family friendliness,” is a construct consisting
of the work-family policies and practices that are offered by an organization and the
messages that are conveyed about the organization’s interest in helping employees
balance their work and family lives (Thompson, Jahn, Kopelman, & Prottas, 2004).
Family—friendly benefits are therefore an important aspect of an organization’s climate.
Commitment-based human resource practices like offering family-friendly benefits create
an organizational climate that motivates employees to act in the best interest of their
employer, rather than only in their individual self-interest (Collins & Smith, 2006). By
providing benefits for employees that help them balance family life and work, a situation
that is beneficial to the employee and organization is created. The employee perceives the

work climate as supportive of a work-family balance which leads to increased job

15

satisfaction, employee morale, and loyalty and commitment to their company
(Thompson, Beauvais, & Lyness, 1999; Work & Family Connection, 2005). In turn,
results for the organization include increases in individual job performance, overall
company performance, and effectiveness due to lower turnover and absenteeism (Goff,
Mount, & Jamison, 1990; Patterson, Warr, & West, 2004; Work & Family Connection,
2005). F amily—friendliness creates motivation for employees to work towards
organizational goals.

Breastfeeding support falls within the family-friendliness construct. Drawing
conclusions from the effects that work-family benefits in general have on companies and
their employees, it is logical that breastfeeding support would create similar results.
While work climate has not been thoroughly studied through the perceptions of new
mother employees, the following scenario is plausible. If a company offers employees a
supportive way to combine breastfeeding and employment, the employees would have
greater ease in combining breastfeeding with work, resulting in greater job satisfaction.
This would contribute to an increase in productivity for the organization due to less
maternal absenteeism and greater company loyalty from breastfeeding employees.
Incorporating breastfeeding support into organizations is one practice that can lead
toward achievement of organizational goals, and decreased barriers to continued
breastfeeding.

Formal means of organizational support include written policies, schedule
flexibility, and work-family benefit availability. Informal means include job autonomy,
manager support, an organization’s ability to communicate respect for employees’ non-

work lives, and career impact concerns. Some studies (Behson, 2005; Thompson, Jahn,

16

Kopelman, & Prottas, 2004) have found that informal means of organizational work-
family support are greater predictors of job satisfaction, work-family conflict, stress,
organizational attachment, and turnover intentions than are more formal means of
organizational support. However, formal means of support still constitute a portion of
work climate and are important to consider.

Many employees that are pregnant or have infants think their employers should do
more to help support breastfeeding at the workplace (Kosmala-Anderson & Wallce,
2006; Wallace, Kosmala-Anderson, Mills, Law, Skinner, Bayley, et al., 2008). If
organizations are to create a supportive work climate and properly accommodate
breastfeeding employees, an understanding of workplace facilitators of and barriers to
breastfeeding must be achieved. The remainder of this literature review focuses on formal
means of organizational support that may help a woman combine breastfeeding and

employment.

2.6 Formal organizational support
2. 6.] Written policies

There have been very few studies to date that have examined the existence of
formal breastfeeding accommodations within US companies. Only one study could be
identified that reported the prevalence of written Workplace policies regarding
breastfeeding support in US businesses (Dunn, Zavela, Cline, & Cost, 2004). This study
surveyed small, medium, and large companies in Colorado to identify the frequency of
breastfeeding policies and practices within the state. The researchers reported that, of 157

companies that responded, only six reported having a specific written policy regarding

17

worksite breastfeeding support. The authors concluded that for companies that already
had some breastfeeding supports available, but no written policy, there was an
opportunity for low-cost expansion of worksite breastfeeding support through translation
of already available services into breastfeeding support policies

Dodgson, Chee, and Yap (2004) also advocated the creation of workplace policies
since without policies in place, the type or amount of breastfeeding support employees
receive may solely depend on their supervisor’s goodwill. Furthermore, they claim that
breastfeeding support policies are essential as they validate the right for women to
provide their children breast milk even when individual supervisors are not supportive.

Studies that indentify the prevalence of written company policies specific to
breastfeeding support are lacking. Studies should be conducted to identify their existence
state-wide as well as nationally. Where non-existent, policies should be advocated to
ensure the opportunity for women to continue breastfeeding after returning to work. A
study that surveyed the general public’s beliefs about breastfeeding policies in various
settings found that a large proportion of the general public supports policies regarding
breastfeeding support (Li, Hsia, Fridinger, Hussain, Benton-Davis, & Grummer-Strawn,
2004). The most acceptable policies surveyed were establishing workplace breastfeeding
policies and lactation rooms in public places. Although this study surveyed the general
public, the findings show a general acceptability of having breastfeeding support policies

at the workplace, and should make it easier for employers to implement such policies.

18

2. 6.2 Maternity Leave and the Family and Medical Leave Act 0f1993(FMLA)

A greater proportion of women with children are in the workforce now than ever
before. After having a child, mothers may elect to return to work or may find it
financially necessary. The Family and Medical Leave Act of 1993 (FMLA) requires that
employers with 50 or more employees provide up to 12 weeks of unpaid, job-protected
leave to qualified employees for the birth or adoption of a child, or for the employee’s
personal or family health needs. Qualified employees have been employed with the
employer for a minimum of 12 months and with a total of 1,250 hours worked in the
calendar year prior to requesting the time off (DOL, 1993). With these stipulations, not
all workers are covered by this law; approximately one-half of the workforce is not
covered by FMLA due simply to the size of their employers (Berger, Hill, & Waldfogel,
2005; Repa, 2007). Some states and the District of Columbia have legislation that
provides longer or paid family leaves, or allows women to be eligible for maternity leave
under broader conditions than set by the federal FMLA (DOL, 2009c; Repa, 2007).
However, Michigan does not have its own leave laws and thus its employees are only
entitled to benefits under the federal FMLA.

The Society for Human Resource Management [SHRM] conducted a survey of
human resource professionals about the impact of FMLA on their companies (2007a).
Results of the study indicate that the second largest request to use FMLA is for maternity,
birth, or adoption of a child. In 2007, less than half (44%) of employers surveyed offered
any extension of job-protected leave (paid or unpaid) beyond F MLA provisions. The
most common extension of job-protected leave was by substituting accrued sick or

vacation leave for F MLA. However, some organizations did offer more than 12 weeks of

19

job-protected leave or allowed employees who had not met the minimum requirements
for FMLA eligibility to have job protected leave.

Adequate length of maternity leave may be essential to establishing breastfeeding
(Rea & Morrow, 2004) and may also predict longer breastfeeding duration. Guendelman,
Kosa, Pearl, Graham, Goodman & Kharrazi (2009) examined the relationships between
breastfeeding and maternity leave for women in California, one of the few states offering
paid pregnancy leave that can be extended for infant bonding. Their findings showed that
maternity leave less than six weeks, or between six and 12 weeks in length was
associated, respectively, with fourfold and twofold higher odds of failure to establish
breastfeeding along with an increased probability of cessation after successful
establishment compared to maternity leave greater than 12 weeks in length.

A secondary analysis of the 1987-2000 waves of the National Longitudinal
Survey of Youth [NLSY] found that 63% of women who worked prenatally returned to
work within 12 weeks of giving birth, and half of these women returned full-time
(Berger, Hill, & Waldfogel, 2005). The length of leave between birth and return to work
can impact a woman’s duration of breastfeeding. Literature greatly supports that longer
maternity leaves are associated with longer breastfeeding duration (Auerbach & Guss,
1984; Authur, Saenez & Replogle, 2003; Chezem & F riesen, 1999; Cohen & Mrtek,
1994; Guendelman, Kosa, Pearl, Graham, Goodman & Kharrazi, 2009; Hills-Bonczyk,
Avery, Savik, Potter, & Duckett, 1993; Keamy & Cronenwett, 1991; Roe, Whittington,
& Teisl, 1999; Visness & Kennedy, 1997). Some studies have found that the greatest risk
of early cessation of breastfeeding is for women who return to work within 12 weeks of

childbirth (Authur, Saenez & Replogle, 2003; Chatterji & Frick, 2005; Fein & Roe, 1998;

20

Guendelman, Kosa, Pearl, Graham, Goodman, & Kharrazi, 2009; Lindberg, 1996; Roe,
Whittington, Fein, & Teisl, 1999), the length of job-protected leave mandated by FMLA.
One study found that returning to work when the infant was older rather than younger
was significantly associated with a greater decline in breastfeeding intensity and shorter
duration, but it was also theorized that this may be confounded with the general trend of
weaning older infants (Fein, Mandal, & Roe, 2008). In another study, it was shown that
having maternity leave had no effect on breastfeeding rates, unless the leave was taken
(Guendelman, Kosa, Pearl, Graham, Goodman & Kharrazi, 2009). This stresses the
importance of employer support for education of leave policies as well as acceptance of
breastfeeding behaviors. Because FMLA only provides 12 weeks of leave and
recommendations for breastfeeding are longer, other workplace supports become
necessary.

Paid leave policies result in more maternal time off work (McGovern, Dowd,
Gjerdingen, Moscovice, Kochevar, & Murphy, 2000). This is a concern for women who
lack paid maternity leave since they are likely to use vacation and sick days to be paid
during maternity leave, and therefore lack any paid leave benefits for the remainder of the
infant’s first year — the period when the incidence of acute illness for both mothers and
infants is relatively high (Karnerman, Kahn, & Kingston, 1983). By exhausting F MLA
benefits after childbirth, a woman may have no other parental leave benefits for the year.

Other developed countries have more legislative support for maternity leave than
the US. In the United Kingdom, women can receive paid maternity leave for up to 39
weeks given certain employment conditions (Department for Work and Pensions [DWP],

2008). A number of other European countries, including Germany, Italy, Spain, and

21

Portugal, also mandate that maternity leaves be paid (Galtry, 2003). Sweden, which has
one of the highest breastfeeding rates, provides paid leave for 16 months, with 13 months
paid at 80% of previous earnings, and the remaining three months paid at a standard and
flat rate for all recipients. These benefits are taken from the general taxes with no direct
costs to the employers (Ronsen & Sundstrom, 1996). In a survey conducted in England of
women’s experiences and views of breastfeeding support at work, the most common
mentioned positive experience was a long maternity leave (Kosmala-Anderson &
Wallace, 2006). Another study conducted in the US found that when women were asked
what changes they most desired in their workplace to help combine breastfeeding and
employment, nearly half of the sample stated ‘paid leave to care for newborns... would
constitute a high priority for change’ (McGovern, Dowd, Gjerdingen, Moscovice,
Kochevar, & Murphy, 2000). Because the FMLA is unpaid, individual employers should
consider providing pay during this leave to increase breastfeeding rates among employed

mothers.

2. 6. 3 Corporate lactation programs

While there is no universally agreed upon definition of what should be included in
a corporate lactation program, these programs are designed to promote breastfeeding
among working mothers by providing appropriate facilities and other types of support at
the worksite (Click, 2006). The United States Breastfeeding Committee (USBC, 2002)
issued a report outlining components of different levels of workplace breastfeeding

,9 ‘6

support. The “adequate, expanded,” and “comprehensive” levels of support include

suggestions on what types of facilities, written company policies, and workplace

22

education are appropriate. These suggestions are meant to help companies tailor a
lactation program to the needs of their employees.

Companies such as CIGNA Corporation that incorporate lactation programs at
their worksites have found increased breastfeeding durations among their employees
utilizing the benefits. The lactation program offered at this company includes
consultations with a professional lactation consultant before and after birth, access to a
private room at the worksite, a hospital grade breast pump, refrigeration and a carry case
for expressed breast milk, along with all the supplies that are needed to express breast
milk. Seventy-two percent of new mother employees at CIGNA were breastfeeding at six
months compared to 21% of new mother employees nation-wide when a study designed
to evaluate the effectiveness of their lactation program was performed (CIGNA, 2000).
They also reported an annual savings of $240,000 in health care costs for 182
breastfeeding mothers and their children who utilized their lactation program, as well as
an additional $60,000 in savings by decreasing absenteeism among breastfeeding
employees compared to non-breastfeeding employees with infants. (CIGNA, 2000).

Breastfeeding rates among employees from five different corporations contracting
Limerick, Inc. to provide company-paid-for breastfeeding services as part of employee
benefits packages were also evaluated (Ortiz, McGilligan, & Kelly, 2004). These
programs included corporate policies assuring that employees who decided to breastfeed
would be supported; private, locked rooms at the worksite for pumping; lightweight,
electric, autocycling breast pumps with accessories enabling both breasts to be pumped
simultaneously; and prenatal breastfeeding classes given by International Board Certified

Lactation Consultants [IBCLCs]. In addition, the IBCLCs educated supervisors at each

23

worksite on the needs of lactating women and assured them that the program was
designed to avoid interference with the productive workday by using employees’ regular
breaks and lunch time for expressing breast milk. For the participants enrolled in this
program and who returned to work after childbirth, 57.8% were still breastfeeding at six
months. This result was above the national average as well as the Healthy People 2010
objective.

The results of studies assessing the effectiveness of corporate lactation programs
should be interpreted with caution, however, as mothers enrolling in these types of
programs are self-selected and may have greater intentions to breastfeed longer. While it
has been shown that mothers who participate in corporate lactation programs tend to have
longer breastfeeding durations than working mothers who do not, it is not known which
elements of the programs are responsible for these rates, or if it is the combination of
numerous types of support. This gap in research provides an opportunity for future
research to examine which elements of a lactation program have are most effective at

increasing continued breastfeeding among working mothers.

2. 6. 4 Nursing rooms and breast pump equipment

It is imperative that women have a private, comfortable space to breastfeed or
express milk when at work since breastfeeding or pumping regularly throughout the day
has been cited by women as one way to maintain adequate milk supply and continue
breastfeeding (Thompson & Bell, 1997). It is also important for sanitation and health
reasons that this space not be a restroom. When women from several studies did not have

designated breastfeeding or pumping areas at the worksite, they discontinued

24

breastfeeding or resorted to using the restroom, which is associated with a lower duration
of breastfeeding (Brown, Poag, & Kasprzycki, 2001; Cohen & Mrtek, 1994; Chezem &
Friesen, 1999; Hills-Bonczyk, Avery, Savik, Potter, & Duckett, 1993; Rojjanasrirat,
2004; Stevens & Janke, 2003; Thompson & Bell, 1997; Witters-Green, 2003).

If a worksite does not have extra space for a dedicated lactation room, women
may use private offices, unused conference rooms, or other unoccupied space that is
private from coworkers in order to breastfeed or express milk. Ideally, however,
employers should have dedicated spaces that are appropriate for nursing or expressing
milk. The United States Breastfeeding Committee (USBC, 2002) provides suggestions
for space that is acceptable for breastfeeding employees to use. The USBC states it is
important that a sink be in or near the room women use to pump in order to wash their
hands and clean breast pump equipment. They also suggest that rooms include a table,
comfortable chair, electrical outlet for the use of breast pumps, aesthetics that promote
relaxation, and refrigerator space for the storage of breast milk.

The absence of breast pumps at the workplace has been cited as an obstacle to
continuing breastfeeding after returning to work (Cohen & Mrtek, 1994) and availability
was found to be a significant predictor of breastfeeding (Whaley, Meehan, Lange,
Slusser, & Jenks, 2002). Therefore, if employers provide breast pump equipment in
addition to providing private, comfortable space for breastfeeding or pumping, they will

facilitate the continuation of breastfeeding for women who return to work after having a

baby.

25

2. 6.5 Break time

In order for women to provide adequate amounts of milk to her infant,
breastfeeding or pumping milk must occur at regular intervals according to the needs of
her infant. This generally includes breastfeeding or expressing regularly while at work
(Rojjanasrirat, 2004; Thompson & Bell, 1997). A study was conducted to determine the
amount of time it takes mothers to express milk at work each depending on the age of her
infant (Slusser, Lange, Dickson, Hawkes, & Cohen, 2004). This study (conducted in a
workplace environment supportive of breastfeeding) found that on average, a woman
expresses just over two times per day (2.2 :l: 0.8) when her infant is three months old. At
six months of age, the frequency significantly decreases to just under two times per day
(1.9 i 0.6). At both ages, the majority of women (82-96%) spend a total of one hour or
less expressing milk each day, and the amount of time is significantly less with older
infants. This study, along with a previous study (Roe, Whittington, Fein, & Teisl, 1999),
found that the number of expressions during the workday did not affect the amount of
time mothers worked during the week. Both studies found that women could successfully
adapt breastfeedings or time for expression to her workday routine in order to overcome
the time barrier.

However, finding adequate time to breastfeed or express milk during the workday
is still considered one of the barriers to combining breastfeeding and employment
(Auerbach, 1990; Auerbach & Guss, 1984; Cohen & Mrtek, 1994; Hills-Bonczyk, Avery,
Savik, Potter, & Duckett, 1993; Kearney & Cronenwett, 1991). Providing break time to
breastfeeding mothers is an inexpensive way to provide support at the workplace,

especially when it does not take away from the amount of time a woman works overall.

26

2. 6. 6 Education and support

Employers can promote breastfeeding by providing access to breastfeeding
education for their employees. Studies have found that breastfeeding education can be
pivotal in influencing women’s intentions on how long to continue breastfeeding
(Kearney & Cronenwett, 1991) and is significantly related to longer total duration of
breastfeeding (Hills-Bonczyk, Avery, Savik, Potter, & Duckett, 1993). Employers can
help shape this intention and influence breastfeeding rates by providing educational
materials or offering classes that promote the benefits of continued breastfeeding as well
as solutions for combining breastfeeding and employment. This type of education can
help women form realistic expectations of breastfeeding and is a less expensive
intervention that can be applied across different industries and occupational levels
(Cardenas & Major, 2005). 1

Lactation consultants are instrumental in providing education and support to
breastfeeding employees (Bar-Yarn, 1998; Cohen & Mrtek, 1994; Kuan, Brito,
Decolongon, Schoettker, Atherton, & Kotagal, 1999). Companies can employ them to
work onsite with breastfeeding employees or give referrals to local lactation consultants,
and may cover the cost of these lactation services. By working with a lactation
consultant, companies can build their own lactation programs that suit the needs of their
employees and provide education to their employees.

Breastfeeding support groups that are sponsored by employees can help ease a
nursing mother’s return to work by providing emotional support and guidance during this
transition (Cardenas & Major, 2005). They may also help to identify barriers to

breastfeeding in the workplace and provide strategies for overcoming these barriers. It

27

has been shown that women who participate in breastfeeding support groups, including
worksite support groups, breastfeed significantly longer than women who do not
(Chezem & Friesen, 1999; Whaley, Meehan, Lange, Slusser, & Jenks, 2002). These types
of groups can provide meaningful information to breastfeeding employees and onsite

lactation consultants can help facilitate sessions.

2. 6. 7 Onsite daycare

Women who have on-site or nearby daycare are more successful at continuing to
breastfeed after returning to work (Jones & Matheny, 1993; Thompson & Bell, 1997).
Having daycare either directly onsite or near the workplace allows mothers to visit their
infants during the workday or have their infants brought to them in order to breastfeed.
An analysis of 810 mothers who were concurrently working and breastfeeding showed
that mothers who breastfed or breastfed and pumped during the work day had longer
breastfeeding durations than mothers who only pumped or mothers who did neither (Fein,
Mandal, & Roe, 2008). An onsite or nearby daycare center allows mothers to breastfeed
during the workday rather than just pump. While onsite daycare centers may be costly,
they contribute to increased breastfeeding rates among maternal employees which can
lead to decreased infant illnesses and reduced absenteeism costs associated with child
care conflicts (Cardenas & Major, 2005). This valuable option may also assist employers’

efforts in recruitment and retention of employees.

28

2. 6. 8 Flexible schedules

A more indirect way of supporting the continuation of breastfeeding after
returning to work for maternal employees is offering flexible schedule options. Flexible
scheduling includes options such as part-time return to work (employees that worked full-
time prior to a leave can work part-time upon return), telecommuting (working from
home or another off-site location), flextime (ability to adjust beginning and end times of
the work schedule), and compressed work weeks (working longer hours for fewer days
during the week) (SHRM, 2007b). While these options may benefit more than maternal
employees, it can assist the latter by allowing them to schedule their work hours around
breaks needed to breastfeed or express milk, or to work fewer hours. Flex options that
allow a slower return to full-time work provide more time to establish breastfeeding.
while other options decrease the total time a mother is away from her infant or allow for
more ability to either breastfeed or pump milk. Women who have greater job flexibility
take less time off work immediately after childbirth (McGovern, Dowd, Gjerdingen,
Moscovice, Kochevar, & Murphy, 2000) which is also a benefit to employers.

In a qualitative study involving working mothers, women identified flexibility in
their work schedules as a facilitator for successful continuation of breastfeeding after
returning to work (Thompson & Bell, 1997). Research has found that women who work
fewer hours after returning to work from maternity leave are more likely to continue
breastfeeding since they are separated from their infants for shorter amounts of time
(Hills-Bonczyk, Avery, Savik, Potter, & Duckett, 1993; Roe, Whittington, Fein, & Teisl,
1999; Ryan, Wenjun, & Acosta, 2002). Women who are able to work part-time after

returning also have the option of going home to breastfeed their infants. Other women

29

find schedule flexibility important for scheduling breaks to breastfeed or express onsite
(Cohen & Mrtek, 1994; Thompson & Bell, 1997). By being able to adjust their work
schedules with flexible schedule options, women are able to decrease the time-based

conflict of combining breastfeeding and employment.

2. 6. 9 Framework characterizing formal breastfeeding support

Research identifies and summarizes specific elements important to the successful
combination of breastfeeding and employment. Bar-Yam (1998) categorizes the elements
as space, time, support, and gatekeepers. Space consists of the areas where a woman is
allowed to breastfeed her infant or pump milk; time refers to the amount of time during
the workday she needs to be able to breastfeed or pump (including time it takes to get to
and from the designated area); support includes the individuals who are supportive of her
decision to breastfeed, and; gatekeepers are those in the workplace who ensure the other
three elements are helpful for the nursing mother. Dodson, Chee, and Yap (2003) also
summarize types of support. They describe supportive elements as being structural,
employee-supportive, and organizational. The structural element encompasses designated
spaces for nursing mothers as well as equipment for pumping milk; employee-supportive
consists of the time required to pump, the nature of her work, and informational
resources, and; the organizational element is composed of the workplace administration,
supervisors, and colleagues.

Missing from these summaries are maternity leave, flexible scheduling, onsite or
referred lactation services, and onsite daycare. These have all been identified in the

literature to be important to women who continue breastfeeding after returning to work.

30

Maternity leave and flexible scheduling appropriately fit into Bar—Yam’s time category as
they may become necessary to effectively establish and continue breastfeeding, and alter
employees’ work flow. Lactation services and onsite daycare correspond with Dodson,
Chee, and Yap’s employee-supportive category as they are tools that help a woman
combine breastfeeding and work. Two previous surveys were developed that encompass
informal means of company support for breastfeeding. These were the Employee
Perceptions of Breastfeeding Support survey (EPBS; Greene & Olson, 2008) and the
Manager Attitudes toward Breastfeeding Support (MABS; unpublished). Therefore, the
survey developed in this study does not encompass informal organizational
characteristics such as attitudes about breastfeeding or support for breastfeeding from
individuals at or outside of the work place. The categories of time and structural support
are the formal means by which an employer can help support the combination of
breastfeeding and employment and were focused on in this study. These two components
create a framework (Figure 2) that characterizes formal company breastfeeding support

by employers and are the basis for the items included in the survey.

31

 

 

Maternity T K W

Leave

 

 

Flexible 7
Scheduling j

t r

 

 

Ill

Breaks

 

J

 

Designated Formal Company
Breastfeeding
Support

 

 

_[
__[
_[R Level of
_[

Breast 00%ij
Structural __[ Onsite ]
Support Daycare
Lactation ]
I Services

 

 

 

 

 

 

Written
Policy

 

 

 

”11111

x J

Figure 2. Framework characterizing formal means of company breastfeeding support.

32

CHAPTER 3

METHODS

The purpose of this research was to develop an instrument that measures company
support for breastfeeding at the formal level. The first step was to generate items for the
instrument based on a literature review, creation of a framework that characterizes formal
breastfeeding supports within companies, and the Tailored Design Method [TDM].
During the instrument development phase, pretesting activities of expert reviews and
cognitive interviews were used to strengthen the validity of the measures of the
instrument. The instrument was then piloted in Michigan companies meeting specific
demographic criteria and by using a multiple contact recruitment method. Descriptive and

exploratory analyses of data were performed.

3.] Item development

Item structure and survey formatting were based on the Tailored Design Method
(TDM), which is a method of designing respondent-friendly questionnaires that are clear
and salient to the participants, with minimal respondent burden (Dillman, 2000). Items of
the instrument were based on a review of the literature and a framework that categorizes
formal elements of company breastfeeding support (Figure 2). Items capturing time and
structural support concepts of the framework were used for scoring companies’ overall
level of breastfeeding support. Information on company demographics and the position of
the individual completing the survey were collected. Additionally, items regarding

family-friendly and wellness benefits, health insurance, and employee demand for

33

breastfeeding support were included for exploratory data analysis. The completed pilot
instrument had 28 items (Appendix A). Seven items on the survey pertaining to the time
support component cover: availability of pay during the 12 weeks of leave provided
under F MLA; availability of maternity leave longer than the 12 weeks provided under

F MLA (either paid or unpaid); the types of flexible scheduling options available for
employees at the company; and times during the workday when women are allowed to
breastfeed or pump milk. Nine items related to the structural support component
encompass: existence of a written policy on breastfeeding or pumping milk at work, and
which employees are informed about the policy; company allowance of women to either
breastfeed or pump milk at work; space available at the worksite for breastfeeding or
pumping mil, and composition of the space; and other lactation support services that are
available such as breastfeeding education and electric breast pumps. The next step of the
instrument development phase was to strengthen the validity of the measures of the

instrument through pretesting activities.

3.2 Pretesting the instrument

Pretesting of the instrument prior to piloting consisted of expert reviews and
cognitive interviews. These processes test for comprehension, clarity, ambiguity, and
difficulty in responding, and ensure that people can quickly, easily, and confidently
answer the questions (Dillman, 2000; Punch, 2003).

The goals of the expert review were to ensure items were comprehensive of the
time and structural components of the framework, that all items could be answered by

each respondent, and that the overall instrument was clear with minimal respondent

34

burden. Lactation consultants and individuals with experience working in human
resources were recruited to provide reviews of the instrument. In total, nine individuals
reviewed the instrument, five of whom were International Board Certified Lactation
Consultants (IBCLCS), and four were individuals with corporate work experience in
either human resources or a benefits division. All experts were provided with a copy of
the survey and a form (Appendix B) for commenting on item clarity, accurate use of
business and lactation terms, and whether there was other relevant information not
captured by the survey items. The four experts with corporate work experience were also
asked to complete the survey as if they had been recruited for the actual study. Because
these individuals had access to the information in question in the survey, this allowed the
researchers to identify if any of the items were unanswerable due to subject sensitivity,
data unavailability, or unclear intent.

After revision of the survey using the comments from the expert review, cognitive
interviews were performed. Think-aloud interviewing and verbal probing techniques
were used to evaluate whether the items could be consistently interpreted by the subjects
and that each item could be answered by all respondents given the answer choices
provided (Collins, 2003; Fowler, 2002). Four individuals with human resource
experience were used for these interviews, as they represented the target population for
piloting. Agreements on changes among the research team were incorporated into the
instrument for the pilot study. The study was approved by the Institutional Review Board

at Michigan State University.

35

3.3 Sample demographics

Following item development and refinement, companies were identified to be
recruited for participation in a pilot study. Sampling was focused on headquarter and
single location companies in Michigan to eliminate possible confounding of multiple
states’ laws on breastfeeding support at the workplace. Specific business sectors were
targeted that previous research suggests are most likely to have a measurable level of
breastfeeding support: communication, health care, finance, insurance, real estate, and the
public sector. These sectors have been shown to be more likely to offer family-friendly
benefits (Evans, 2001; Galinsky & Bond, 1998), and therefore are more likely to have
breastfeeding supports in place than other sectors lacking family-friendly benefits.

This instrument will eventually be used in a larger study requiring participation of
human resource executives, managers, and women who have recently had a baby while
employed in order to assess work climate as a whole. It is essential for companies that
will be included in this study to have all of these participants. Using current fertility rates
of 69/ l 000 women being of childbearing years, women composing 46% of the labor
force, and an estimate that half of these women would be in their childbearing years, a
company of at least 250 employees would be expected to have four female employees
giving birth each year (Bureau of Labor Statistics, 2008; Martin, Hamilton, Sutton,
Ventura, Menacker, Kirmeyer, et al., 2009), with an additional two pregnant women.
Therefore, based on US Census data, companies with at least 250 employees were
recruited to participate. In addition, larger companies tend to have more breastfeeding
support available (Dunn, Zavela, Cline, & Cost, 2004), which is imperative to test the

instrument. Companies with a greater number of employees may also have a greater

36

demand for breastfeeding support. This demand may increase the salience of the survey
to human resource executives, in turn increasing the response rate (Cycyota & Harrison,
2006; Gupta, Shaw, & Delery, 2000; Sudman & Blair, 1999).

Companies were identified using two databases, ReferenceUSA
(ReferenceGroup, Inc., http://www.referenceusa.com/) and Direct Media, Inc. (Direct
Media, Inc., http://www.directmedia.com/). ReferenceUSA is an online database which
provides demographic information about US and international businesses. Direct Media,
Inc. is a marketing service company that administers mailing lists for organizations of
human resource professionals. Both databases allowed access to contact information of
human resource executives at companies meeting the demographic criteria for the pilot
test. Each database was accessed in April, 2009, and both databases were used to obtain a
larger sample size. It was decided prior to sampling that if companies not meeting these
criterion returned surveys, the data obtain would still be used in the data analysis.

The Direct Media, Inc. list provided 865 contact names meeting the criteria for
the pilot test. However, there were 621 company duplicates since multiple contact names
for some companies were provided, resulting in 244 companies for the sample. A human
resource professional at Michigan State University was contacted to help determine,
based on positions listed, who would be the best individual to contact from companies
providing more than one name. A total of 578 eligible companies were identified through
ReferenceUSA, with no company duplicates. There were 15 duplicates between the two
databases. The contact information from Direct Media, Inc. was used for these companies

since this database is updated more frequently. Additionally, contact information for this

37

database was provided directly by the listed individuals and was presumed to be more
accurate.

After duplicates between the two databases were eliminated, all eligible
companies (n=807) were recruited for participation. The expected response rate was
expected to be low (Dillman, 2000; Punch, 2003), so all companies were recruited to
maximize the likelihood of receiving enough returned surveys to determine the
appropriateness of the instrument via completeness, accuracy, and open ended comments,
as well as to use in data analyses. Furthermore, all companies were recruited in order to
be able to sample from companies with different levels of breastfeeding support in the

future study previously explained.

3.4 Company recruitment

Companies were contacted several times during the recruitment stage. This
technique is essential for maximizing response rates among company key informants
(Dillman, 2000; Sudman & Blair, 1999), since response rates for mail surveys can be
especially low (Dillman, 2000; Punch, 2003). A meta-analysis of 231 studies on business
executives’ response rates to mail surveys reported a mean response rate of 34%
(Cycyota & Harrison, 2006). Another study investigating the effects of research
procedures on response outcomes among key informants in organizations found a
response rate range of 19-71% depending on the procedures utilized (Gupta, Shaw, &
Delery, 2000). Therefore, using multiple contacts to recruit participants was crucial in
this study. Human resource executives were chosen as the most appropriate recipients as

they have the most knowledge about policies, programs, and benefits at their company.

38

The information in the survey was also most relevant to these individuals which can
significantly enhance the response rate and data quality (Cycyota & Harrison, 2006;
Gupta, Shaw, & Delery, 2000; Sudman & Blair, 1999).

The first contact was a personalized mailing to the most appropriate human
resource executives identified by the databases, and determined in consultation with
individuals knowledgeable about human resource personnel structure. If there a human
resource executive was not identified, mailings were addressed to the “Chief Human
Resource Officer.” Included in the mailing was a detailed cover letter (Appendix C)
explaining the purpose of the study, the benefit to the company for participating, and how
to contact the researchers. A sample report (Appendix D) detailing intended analyses of
the study was included as an incentive for companies to participate. This report informed
companies they would learn how they scored on breastfeeding support after data
analyses, and this would allow them to compare their company’s policies and programs
with the averages of other participating companies. Finally, a hard copy of the survey was
included with a pre-paid return envelope. Participants were notified in the cover letter
that an electronic version of the survey could be obtained if they preferred. Using mixed
modes of data collection is suggested to obtain cooperation from participants (Dillman,
2000; Sudman & Blair, 1999). Using personalization, first class mail, and pre-paid return
envelopes may also increase response rates (Dillman, 2000) and all were utilized during
this contact.

The second contact was a telephone call to each executive from one of the
research investigators two weeks after the initial mailing. The purpose of this call was to

confirm whether or not the survey had been received and to remind individuals of the

39

benefit to the company for completing the survey. This contact gave researchers the
opportunity to provide a replacement survey if the initial one was not received, or to
contact a different individual within the company if necessary. This special type of
contact has also been shown to improve overall response rates to mail surveys (Dillman,
2000). The phone script used for these calls is in Appendix E.

The third and final contact was a reminder postcard (Appendix F). This reminder
was mailed out four weeks after the initial mailing. The postcard briefly summarized the
purpose of the study and the benefit to the company for participating. It also provided the
contact information of the researchers so companies could obtain either a paper or
electronic replacement survey if necessary.

All companies that returned a completed survey were mailed a thank you letter
and reminded that they would receive a follow-up report after data analyses were

completed.

3.5 Descriptive analysis

Data collected was initially entered into Microsoft Excel by a research assistant,
and then double checked by the primary investigator for accuracy. It was then transferred
into PAS W Statistics 17 (SPSS Inc., 2008) which was then used to perform all statistical
analyses. Descriptive statistics were used for characterizing the sample data. Frequencies
were calculated for each policy, program, or benefit related to breastfeeding support. A
scoring system was created so that companies received scores for the amount of time and
structural support available. The scores for the two support components were summed to

assign companies an overall score for formal breastfeeding support (Appendix G). Means

40

for time, structural, and total breastfeeding support scores were calculated to determine
the average level of support offered in the sample. Pearson’s correlations were also used

to determine the relationships between the variables.

3.6 Exploratory analysis

Because this was a pilot study, exploratory analyses were performed. Results
were used to identify how breastfeeding support is distributed among the time and
structural support components. The association between the two categories was
calculated using Pearson’s correlation. This determined if companies receiving a high
overall rating were scoring high in both components. The relationship between
breastfeeding benefits and other benefits (i.e., family-friendly and wellness benefits) was
also determined by calculating a correlation.

An analysis of variance (ANOVA) and multiple linear regressions were
performed to determine which company characteristics were associated with greater
breastfeeding support. ANOVA was used with categorical and dichotomous independent
variables to determine if there were significant differences in the mean breastfeeding
support scores between the groups of these variables. Multiple linear regressions were
run to establish if any of the continuous or dichotomous independent variables were

significant predictors of the dependent variable, total breastfeeding support score.

3.7 Recommendations for revision of the instrument
The final step was to make recommendations for revision of the instrument based

on the data and comments received from participating companies. Recommendations

41

considered elimination of items from or addition of items to the instrument based on non-
response rates for individual items and comments mentioning information not covered by
any of the current items, respectively. The length of the survey and wording of questions

was also considered based on comments from respondents and agreements among

researchers.

42

CHAPTER 4
“DEVELOPMENT AND PILOTING OF AN INSTRUMENT THAT MEASURES
COMPANY SUPPORT FOR BREASTFEEDING”

A MANUSCRIPT

4.1 Abstract

Maternal employment has been cited as a barrier to continued breastfeeding, yet
there have been very few studies identifying company breastfeeding support. Prior to this
study, no instrument was available that could measure the level of company breastfeeding
support. The purpose of this study was to develop an instrument that measures formal
breastfeeding support in companies. In the study sample, significantly more support was
offered in companies having 1,000 or more worksite or US. employees and in companies
from the health care versus all other sectors. In addition, a higher level of support was
found in companies having breastfeeding support requests, upper management that had
breastfed or pumped while employed, or an employee population likely to benefit from
this type of support. Few companies had written policies on breastfeeding or pumping at

work, but the majority indicated they allow women to pump milk at the worksite.

4.2 Introduction

Maternal employment is a cited barrier to reaching national breastfeeding
objectives. Mothers employed full-time are as likely to initiate breastfeeding as those
who are employed part-time or who do not work outside the home, but on average their

duration rate at six months is 10% lower than their counterparts (Ross Products Division,

43

2003; Ryan, Zhou, & Arensberg, 2006). F ein, Mandal, and Roe (2008) have also shown
that breastfeeding intensity, or the proportion of feedings that are breast milk versus other
liquids, decreases after women return to work. In their study, the decline in breastfeeding
intensity was less for women who had reduced hours of work after return from maternity
leave. Therefore, full-time employment not only has an effect on breastfeeding duration,
but also on breastfeeding intensity.

The discrepancy in breastfeeding duration among women employed full-time is of
concern given the benefits that breastfeeding provides to infant and mother. Infants who
are breastfed have decreased incidences and severity of several acute and chronic
illnesses (AAP, 2005; ADA, 2009; DHHS, 2000a). Mothers also benefit from
breastfeeding as they are more likely to have a faster return to pre-pregnancy weight, and
a decreased risk for ovarian and breast cancers compared to women who do not
breastfeed (Danforth, Tworoger, Hecht, Rosner, Colditz, & Hankinson, 2007; Dewey,
Heinig, & Nommsen, 1993; Ip, Chung, Raman, Chew, Magula, DeVine, et al., 2007;
Labbok,2001)

The percentage of women who enter the workforce is continually increasing. In
2008, 59.5% of all women were part of the labor force, a 12.6% increase since 1998
(DOL, 2009a). Furthermore, 75.4% of women in the workforce in 2008 were employed
full-time (DOL,2009a). Of greatest importance, however, is that 56.4% of women with
an infant under one year of age were employed this same year (DOL, 2009b). Therefore.
over half of mothers with a baby under one year of age are at risk for early cessation of
breastfeeding or decreased breastfeeding intensity due to their employment status. It is

necessary to understand the workplace climate from the perception of new mother

44

employees’ in order to understand why breastfeeding rates are lower for women
employed full time.

9“

Workplace climate has been defined as employees shared perceptions of
organizational policies, practices, and procedures, both formal and informal” (Schneider,
1990, p.23). Formal means of organizational support include written policies, schedule
flexibility, and work-family benefit availability, whereas informal support includes job
autonomy, manager support, an organization’s ability to communicate respect for
employees’ non-work lives, and career impact concerns (Behson, 2005). It is essential to
understand all of the elements of a workplace, both formal and informal, that a woman
perceives to be a barrier to or supportive of combining breastfeeding and employment.
An instrument that assesses one form of informal support, manager attitudes towards
breastfeeding support, has been developed and is currently being piloted (Chow, Fulmer,
& Olson, 2010). Therefore, this study focuses solely on formal means of company
breastfeeding support.

Even though formal barriers to and facilitators of combining breastfeeding and
employment have been identified, no instrument exists that can measure companies’
overall level of formal breastfeeding support. The purpose of this study was to develop an
instrument for use in companies that determines the amount of formal breastfeeding
support based on the existence of policies, programs, and benefits that may help women
combine breastfeeding and employment. This study was approved by the Institutional

Review Board at Michigan State University.

45

4.3 Methods

Items for the instrument were developed based on a literature review of the
barriers to and facilitators of combining breastfeeding and employment. From the
literature, formal breastfeeding supports were categorized as either time or structural
support (Table 2). The completed instrument had 28 items, 16 of which cover
breastfeeding support. Seven of these items cover time support, and nine items cover
structural support. Additional items regarding family-friendly and wellness benefits,
health insurance, employee demand for breastfeeding support, and company
demographics were also developed and included for data analysis. Item structure and
survey formatting were based on the Tailored Design Method (TDM) (Dillman, 2000).

Prior to piloting, the instrument was pretested using expert reviews and cognitive
interviews. The goals of the expert review were to ensure that items were comprehensive
of the time and structural components of breastfeeding support, that all items could be
answered by a company representative, and that the overall instrument was clear with
minimal respondent burden. Nine individuals provided expert review the instrument, five
of whom were International Board Certified Lactation Consultants (IBCLCs), and four of
whom had corporate work experience in either human resources or a benefits division.
All nine experts were provided with a copy of the survey and a form to comment on item
clarity, accurate use of business and lactation terms, and whether there was other relevant
information not covered by the survey items. The four experts with corporate work
experience were also asked to complete the survey as if they had been recruited for the

actual study. Because these individuals had access to the information asked for in the

46

survey, this allowed researchers to identify if any of the items could not be answered due
to subject sensitivity, data unavailability, or unclear intent.

After revision of the survey using the comments from the expert review, cognitive
' interviews were performed. The goals of these interviews were to ensure that each item
was interpreted similarly by all individuals and that each item could be answered by all
respondents given the answer choices provided. Four individuals with human resource
experience were used for the cognitive interviews as they represented the target
population for piloting. Following these interviews, the research team discussed and
came to agreement on the final changes to make to the instrument before piloting.

Participants for the pilot test were Michigan companies meeting specific
demographic criteria. Specific business sectors were targeted that previous research
suggests are most likely to have family-friendly benefits, and therefore a measurable
level of breastfeeding support (Evans, 2001; Galinsky & Bond, 1998). Sectors included
communication, health care, finance, insurance, real estate, and the public sector. These
sectors have been shown to be more likely to have family-friendly benefits, and therefore
are more likely to have breastfeeding support than other sectors lacking family-friendly
benefits.

Companies were identified through the use of two databases, ReferenceUSA
(ReferenceGroup, Inc., http://www.referenceusa.com/) and Direct Media, Inc. (Direct
Media, Inc., http://www.directmedia.com/). ReferenceUSA, an online directory which
provides demographic information about US and Canadian businesses, allowed access to
contact information of companies meeting the demographic criteria for the pilot test. This

database was accessed in April, 2009. Direct Media, Inc. is a marketing service company

47

that administers mailing lists for organizations of human resource professionals. A
mailing list was customized by Direct Media, Inc. to meet demographic criteria and was
also purchased in April, 2009. Both databases were used to obtain a larger sample size.

The Direct Media, Inc. list provided 865 contact names meeting the criteria for
the pilot test. However, there were 621 company duplicates since multiple contact names
for many companies were provided. A human resource professional assisted in the
determination, based on positions listed, of who would be the best individual to contact
from companies providing more than one name. A total of 578 eligible companies were
identified through ReferenceUSA, with no company duplicates. For the 15 duplicates
between the two databases, the contact information from Direct Media, Inc. was used.
This database is updated more often and contact information was provided directly by the
listed individuals and therefore presumed to be more accurate.

After duplicates between the two databases were eliminated, all eligible
companies (n = 807) were recruited for participation. As previous literature suggests that
response rates for surveys mailed to companies are typically low (Dillman, 2000; Punch
2003), it was assumed that by sampling all eligible companies, the amount of data
collected would be maximized. This was necessary to obtain written comments from
participants which would allow for input on what may be missing from the survey, as
well as to judge the performance of the survey, and subsequently improve the instrument
after piloting.

Companies were contacted several times during the recruitment stage. This
technique is essential for maximizing response rates (Dillman, 2000; Sudman & Blair,

1999) as response rates for company surveys can be especially low (Dillman, 2000;

48

Punch, 2003). Human resource executives were chosen as the most appropriate recipients
as they have the most knowledge about policies, programs, and benefits at their company.
The information in the survey is also most relevant to these individuals which can
significantly enhance the response rate and data quality (Cycyota & Harrison, 2006;
Gupta, Shaw, & Delery, 2000; Sudman & Blair, 1999).

The first contact was a personalized, first-class mailing to the human resource
executives identified by the databases. If there was no individual identified, but the
company still met eligibility criteria, mailings were addressed to the “Chief Human
Resource Officer.” Included in the mailing was a detailed cover letter explaining the
purpose of the study, how to reach the investigators, and the benefit to the company for
participating. A sample report detailing intended analyses of the study was included as an
incentive for companies to participate. This report informed companies they would learn
how they scored on breastfeeding support after data analyses, and that the report would
also allow them to compare their company’s policies and programs with the averages of
other participating companies. Companies were assured that their individual data would
only be shared with their company, and that data shared outside of their company would
be in aggregate form only. Finally, a hard copy of the survey was included with a pre-
paid return envelope. Participants were notified in the cover letter an electronic version of
the survey could be obtained if they preferred. First class mail and pre-paid return
envelopes were utilized during this contact.

The second contact was a telephone call to each executive from one of the
research investigators two weeks after the initial mailing. The purpose of this call was to

confirm whether or not the survey had been received and to remind individuals of the

49

benefit to the company for completing the survey. This contact gave researchers the
opportunity to provide a replacement survey if the initial one was not received or to
contact a different individual within the company if necessary.

The third and final contact was a reminder postcard. This reminder was mailed
out four weeks after the initial mailing. It reiterated the goal of the survey and the benefit
to the company for participating. It also gave information on how to obtain either a paper
or electronic replacement survey if necessary. All companies that returned a completed
survey were mailed a thank you letter and reminded that they would receive a follow-up
report after data analyses were completed. Data collected was initially entered into
Microsoft Excel by a research assistant, and then double checked by the primary.
investigator for accuracy. Data was then transferred into PAS W Statistics 17 (SPSS Inc.,
2008), which was used to perform all statistical analyses.

A scoring system was created in which companies received scores for the amount
of time and structural support available (Table 2). Answers to survey items received a
score ranging from zero to two (0 = benefit is not available; 1 = part of benefit is
available; 2 = benefit is fully available). If there was more than one survey item per
category, the sum of all items was the maximum score for that category. The scores from
the time and structural support components were summed to assign companies an overall
score for formal breastfeeding support. Means of the component and overall scores were

calculated.

50

Table 2. Scoring system for time, structural, and total breastfeeding support items.

 

 

 

 

 

 

 

 

 

 

 

 

 

Component Maximum Possible Score
Time support 10
Maternity leave 4
Breaks for breastfeeding or 4
pumping
Flexible scheduling 2
Structural support 16
Written policy 2
Space. for breastfeeding or 4
pumping
Lactation consultant 2
Employee support group 2
Educational resources 2
Breast pump 2
On-site day care 2
Total Breastfeeding Support 26

 

Frequencies were run on the different types of breastfeeding support. Means for
time, structural, and total breastfeeding support score were calculated. Pearson’s
correlations were used to show inter-relationships of independent variables, as well as
relationships between independent variables and the continuous, dependent variable of
total breastfeeding support score. An analysis of variance (ANOVA) was run on the
categorical independent variables of number of worksite and US. employees (<50, 50-
99, 100-499, 500-999, 1,000-4,999, 25,000), sector, and headquarters, as well as on the
dichotomous independent variables of whether the employee population could benefit
from breastfeeding support or not, whether there had been requests for breastfeeding
support in the past three years or not, and whether any employees in upper management
had previously breastfed or pumped at work or not in order to see if there were any

differences between groups on the dependent variable of total breastfeeding score.

51

Multiple linear regression analyses were also performed to identify whether any of the
continuous or dichotomous independent variables were significant predictors of total

breastfeeding support score.

4.4 Results

Following the initial mailing, 18 surveys were returned by the post office.
Deliverable addresses for these companies could not be identified and were dropped from
the sample. Of the remaining 789 companies, 154 returned surveys yielding a response
rate of 19.5%. There were two pairs of duplicates which were not initially screened out,
and the survey from each pair completed by the least appropriate individual was dropped
from analysis. An additional survey had significant missing data and no contact
information for follow-up and was also dropped from analysis. The 151 completed
surveys used in analysis yielded an adj usted return rate of 19.2%. Ninety-seven
companies identified by the ReferenceUSA database responded, and 48 identified by the
Direct Media, Inc. database responded. This corresponds to response rates for the lists of
17.2% and 19.7%, respectively. Companies belonged to the industries of communications
and marketing (4), education (25), finance (10), health care (42), insurance (8),
manufacturing (19), non-profit (4), public administration (25), and other (14).

Frequencies of the reported available breastfeeding supports are displayed in
Appendix H. The most commonly offered supports were pay during maternity leave
(96%), the ability to pump milk at work (94%), a space other than a restroom for
breastfeeding or pumping (78%), and the ability to breastfeed or pump as needed as

opposed to during set times only (73%). Few companies offered the remaining lactation-

52

specific services of access to a lactation consultant (28%), educational material (23%) or
classes about breastfeeding or pumping (20%), availability of an electric breast pump
(16%) and equipment (12%) onsite, or an employee support group for breastfeeding
(7%). F urtherrnore, only 15% of companies allowed women to directly breastfeed at
work.

The mean scores for time, structural, and total breastfeeding support were 6.74 (:l:
1.91 ), 3.79 (:l: 3.42), and 10.5 (i: 4.41), respectively. Because maximum possible scores
for time and structural support were not equal (10 vs. 16 points, respectively), mean
percentages were calculated to standardize and compare the two averages. The mean
percentage of time support was 67.4% while the mean percentage of structural support
was 23.7%. Therefore, on average, companies offered more time support than structural
support for breastfeeding employees. The Pearson’s correlation between time and
structural support was 0.316 (P < .01). Because these measures are positively correlated,
it suggests that as a company scores higher on one component of support, they are likely
to score higher on the other component as well.

Total breastfeeding support score had significant positive correlations with total
family-friendly benefits offered (r = .464, P < .01) and total wellness benefits offered (r =
.436, P < .01). Therefore, companies offering more family-friendly and wellness benefits
were more likely to offer breastfeeding support. The only independent variables that did
not have a significant correlation with total breastfeeding support score were sector,
whether or not the company was headquarters, the percentage of female employees

working full-time, and unionization. All correlations between the independent variables

53

and the dependent variable of total breastfeeding support score are displayed in Appendix
I.

An analysis of variance (ANOVA) showed a significant difference in total
breastfeeding support score by number of worksite employees (F1144 = 9.603, P < .01 ),
and number of US. employees (134,135 = 8.044, P < .01). Means in total breastfeeding
score were significantly greater in companies having 1,000 or more worksite or US.
employees. ANOVA also revealed significantly greater means in total breastfeeding
support score when the company reported having an employee population that could
benefit from breastfeeding support (FLm = 7.799, P < .01), having breastfeeding support
requests in the past three years (Fl,129 = 10.672, P < .01), and having any employees in
upper management who had previously breastfed or pumped at work (FHog = 6.359, P <
.01). ANOVA revealed no significant differences in mean breastfeeding support score by
company sector. However, when sector was dichotomized into the categories of “health
care” and “all others”, health care had a significantly greater mean breastfeeding support
score (Fl.l49 = 1 1.569, P < .01). Means for groups within these variables are listed in

table 3.

54

Table 3. Mean scores for total breastfeeding support by variable group.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Independent Variable Mean score
Number of worksite employees
<50 8.25
50-99 9.20
100-499 941
500-999 10.13
1,000-4,999 13 .91
>5,000 16.33
Number of U.S. employees
<50 5.40
50-499* 9.69
500-999 9.60
1,000-4,999 12.32
>5,000 13.91
Can employee population benefit from breastfeeding
support?
Yes 11.34
No 8.28
Have there been any requests for breastfeeding support in
the past 3 years?
Yes 13.08
No 9.94
Have any employees in upper management previously
breastfed or pumped milk at work?
Yes 1 1.58
No 9.53
Sector
Health care 12_40
All others 9.77

 

 

*There were only two companies that had 50-99 US employees, therefore were grouped into the
100-499 US employee category for analysis purposes.

A multiple linear regression model including dichotomous and continuous

variables was run to determine if any of these variables were significant predictors of

55

total breastfeeding support score. The dichotomous variables were: whether the employee
population could benefit from breastfeeding support or not; whether there had been any
breastfeeding support requests in the past three years or not; whether any employees in
upper management had previously breastfed or pumped at work or not; and a variable for
the number of worksite employees dummy coded for having <1 ,000 or 21,000
employees. The variable for number of U.S. employees was not included in the model
due to its collinearity with number of worksite employees. The continuous variables
included in the model were total number of family-friendly benefits and percentage of
female employees. The variable for total number of wellness benefits was also not
included in the model due to its collinearity with total number of family-friendly benefits.
This model represents a significant amount of variance in total breastfeeding support
score (F5,72 = 5.653, P < .01, R2 = 0.320). Within this model, significant predictors of
breastfeeding support score were number of worksite employees (13 = 0.232, P < .05) and
total family-friendly benefits (13 = 0.228, P < .05). Results of the multiple linear
regression model are in Appendix J.

After reviewing the returned surveys, written comments left by respondents
indicated difficulty in providing answers for some of the survey items. The largest
concern was in the items referring to types of pay that women can receive during FMLA
leave time and if extension of this leave beyond 12 weeks is permitted. It is suggested
that these items be reworded and broken down into several more items that more clearly
capture the concepts. These items should also provide categorical choice options rather
than fill-in-the-blank options as the latter often left the opportunity for vague answers or

were left blank.

56

Some items on the survey were open-ended questions as there was not relevant
research prior to the creation of the instrument suggesting appropriate answer options to
provide. While some respondents did provide comments for these items, the majority of
respondents did not. It is suggested that in future use of this instrument, that the
comments provided be used to create categorical answer options for these items in order
for researchers to run quantitative analyses.

This instrument employed the use of skip patterns multiple times throughout.
Although proper use of this technique was followed as instructed by the Tailored Design
Method (Dillman, 2000), some respondents did not follow the patterns correctly. This
caused confusion in some instances about the data provided. In most cases respondents
could be reached for follow-up, however this was not always the case. In order to avoid
obtaining potentially inaccurate data due to incorrect use of skip patterns, it is suggested
that this technique be removed wherever possible. Rewording and reformatting of some
of the survey items would allow for this.

In some instances, companies not meeting the predetermined criteria returned
completed surveys. This may have been due to inaccurate identification of company
characteristics by the databases, or to forwarding of the survey by the intended recipients
to other departments or worksites with different demographics. For the pilot study,
researchers decided prior to data collection that if this happened, these surveys would still
be used for data analysis. Therefore, the pilot version of the survey included categorical
answer options that did not parallel the selection criteria. In future use of this survey,

these options may be used as a screening option, or may be eliminated from the survey.

57

4.5 Discussion

While only a few companies in this study had a written policy on breastfeeding
support at the workplace, the majority of companies indicated that they allow women to
pump milk while at the worksite. However, few did much more than provide a space
other than a restroom for this purpose. In a survey of breastfeeding practices in Colorado
businesses (Dunn, Zavela, Cline, & Cost, 2004), only 34% of companies reported having
a private area other than a restroom to breastfeed or pump compared to 78% in the
current study. In both surveys, the supports offered the least were onsite daycare,
provision of electric breast pumps, access to a lactation consultant, educational
breastfeeding resources, and written policies on breastfeeding support. Supports that are
more lactation-specific are less commonly offered compared to forms of breastfeeding
support which are more broadly family-friendly benefits such as paid leave and flexible
scheduling.

Further research is necessary to identify why companies with a larger number of
employees offer more breastfeeding support. The finding from this study that companies
with 1,000 or more employees tended to offer more breastfeeding support are consistent
with findings that larger companies are more likely to offer some types family-friendly
benefits's. However, it needs to be understood if this may be due to larger companies
employing more females, having a greater need for this type of support, or having more
company resources that would allow them to provide this type of support. Furthermore, it
is unknown what type of role having employees in upper management who have

breastfed or pumped at work plays in companies offering more breastfeeding support.

58

Some of the independent variables (i.e., sector, headquarters, percentage of
females who are employed full-time, and unionization) were not significantly correlated
with total breastfeeding support score. This finding may be due to small sizes in the
groups of the variables. For instance, a few studies have shown that companies that are in
communication, health care, finance, insurance, real estate, and the public sectors are
more likely to have family-friendly benefits (Evans, 2001; Galinsky & Bond, 1998).
Because of this, it is assumed they would also likely have more breastfeeding support
than companies in other sectors since this support is considered family-friendly. Further
studies with larger sample sizes would better determine which company characteristics
are most strongly correlated with more breastfeeding support.

Strengths of this study include that this is the first instrument developed to
measure the formal level of company breastfeeding support using a scoring system.
Furthermore, the instrument is comprehensive of all identifiable breastfeeding-specific
supports and family-friendly benefits that would facilitate the combination of
breastfeeding and work. This study was the first attempt to identify company
breastfeeding supports available in Michigan. Various types of research-tested company
and mail survey methodologies were implemented in order to construct an instrument
with valid measures and to maximize the response rate including a literature review,
expert reviews, cognitive interviews, and multiple contact recruitment.

A major limitation to this study is the low response rate that was achieved.
Although it is similar to previous response rates seen among other company surveys
(Dillman, 2000; Dunn, Zavela, Cline, & Cost, 2004; Punch, 2003), it is undesirable for

making broad conclusions. Furthermore, there is a potential response bias from

59

companies having breastfeeding supports in place or having an interest in providing
breastfeeding support at their company. Therefore, the results found in this study are not
representative of breastfeeding support in all Michigan companies.

Another limitation to this study is that only one human resource personnel was
asked to complete the survey. It is unknown if the individual completing the survey was
the most knowledgeable at the company or if more information could have been collected
with more than one person responding. Furthermore, lactation consultants rather than
human resource executives often completed the survey for hospitals. While these
individuals may be more knowledgeable about lactation-specific services, the data
provided for other portions of the survey may not have been as reliable. Further inter-
rater reliability testing could be performed in order to strengthen the methodology of
having only one individual complete the survey.

Some of the analyses should be interpreted with caution, as sample sizes for some
categories within the independent variables were small. For example, a few sectors were
composed of very few companies. This could have led to the lack of significance found in
the ANOVA results before collapsing the sector variable into “health care” and “all
others”.

As the percentage of women in the workforce continues to increase, including
women with children, it is important that employers provide adequate breastfeeding
support to assist in the combination of breastfeeding and employment. States are enacting
more legislation requiring employers to accommodate breastfeeding employees (National
Conference of State Legislatures, 2009). Creating more workplace support for

breastfeeding employees may help these women achieve desirable breastfeeding rates

60

which provide numerous health benefits for mothers and infants, and can even benefit the
workplace (Ball & Bennett, 2001; Ball & Wright, 1999; Cohen & Mrtek, 1994; Cohen,
Mrtek, & Mrtek, 1995; Ortiz, McGilligan, & Kelly, 2004; Seijts, 2002). This instrument
is also useful for employers as it allows them to assess their level of breastfeeding
support. This will enable them to identify what types of support are lacking at their
company so they can institute more services that accommodate breastfeeding employees.
As a benefit to employers, they can advertise their policies and benefits that are
supportive as breastfeeding, as well as their breastfeeding support score, as an employee
recruitment and retention tool.

This instrument contributes to the understanding of which company
characteristics are associated with varying levels of breastfeeding support, and health care
professionals can use it to identify which breastfeeding supports are prevalent or less
common in companies. From this information, lactation programs can be better tailored
to individual companies or companies with similar characteristics known to have more or
less breastfeeding support. The tailored programs can be marketed more effectively to
companies, resulting in adoption of more breastfeeding support programs. When the
instrument is used in combination with the Employee Perceptions of Breastfeeding
Support questionnaire (EPBS) (Greene & Olson, 2008) and the Manager Attitudes toward
Breastfeeding Support survey (MABS) (Chow, Fulmer, & Olson, 2010), it will also be
helpful in understanding work climate as a whole and which aspects of work climate can

be improved to have the greatest impact on breastfeeding rates of working women.

61

CHAPTER 5

CONCLUSIONS AND DISCUSSION

5.] Conclusions

While only a few companies in this study had a written policy on breastfeeding
support at the workplace, the majority of companies indicated that they allow women to
pump milk while at the worksite. However, most did little more than provide a space
other than a restroom for this purpose. In a survey of breastfeeding practices in Colorado
businesses (Dunn, Zavela, Cline, & Cost, 2004), only 34% of companies reported having
a private area other than a restroom to breastfeed or pump compared to 78% in the
current study. In both studies, however, the least offered benefits and services were onsite
daycare, provision of electric breast pumps, access to a lactation consultant, breastfeeding
educational resources, and written policies on breastfeeding support. Therefore, supports
that are more lactation-specific are less commonly offered compared to indirect forms of
support such as paid leave and flexible scheduling.

For this sample, companies with 1,000 or more worksite or US employees had
significantly higher breastfeeding support scores than companies with fewer than 1,000
employees. Companies also had significantly higher breastfeeding support scores if they
had an employee population that could benefit from breastfeeding support, if they had
breastfeeding support requests in the last three years, or if they had employees in upper
management positions who had previously breastfed or pumped milk at work while
employed at the company. Additionally, companies from the health care sector had

significantly higher breastfeeding support scores when compared to all other industries

62

 

combined. The only significant predictors of total breastfeeding support score in this
sample were number of worksite employees and total number of family-friendly benefits.
Some of the independent variables (i.e., sector, headquarters, percentage of
females who are employed full-time, and unionization) were not significantly correlated
with total breastfeeding support score. This finding may be due to small sizes in the
groups of the variables. For instance, a few studies have shown that companies that are in
communication, health care, finance, insurance, real estate, and the public sectors are
more likely to have family-friendly benefits (Evans, 2001; Galinsky & Bond, 1998).
Because of this, it is assumed they would also likely have more breastfeeding support
than companies in other sectors since this support is considered family-friendly. Further
studies with larger sample sizes would better determine which company characteristics

are most strongly correlated with more breastfeeding support.

5.2 Implications

As the percentage of women in the workforce continues to increase, including
women with children, it is important that employers provide adequate breastfeeding
support to assist in the combination of breastfeeding and employment. States are enacting
more legislation requiring employers to accommodate breastfeeding employees (National
Conference of State Legislatures, 2009). Creating more workplace support for
breastfeeding employees may help these women achieve desirable breastfeeding rates
which provide numerous health benefits for mothers and infants, and can even benefit the
workplace (Ball & Bennett, 2001; Ball & Wright, 1999; Cohen & Mrtek, 1994; Cohen,

Mrtek, & Mrtek, 1995; Ortiz, McGilligan, & Kelly, 2004; Seijts, 2002). This instrument

63

is also useful for employers as it allows them to assess their level of breastfeeding
support. This will enable them to identify what types of support are lacking at their
company so they can institute more services that accommodate breastfeeding employees.
As a benefit to employers, they can advertise their policies and benefits that are
supportive as breastfeeding, as well as their breastfeeding support score, as an employee
recruitment and retention tool.

This instrument contributes to the understanding of which company
characteristics are associated with varying levels of breastfeeding support, and health care
professionals can use it to identify which breastfeeding supports are prevalent or less
common in companies. From this information, lactation programs can be better tailored
to individual companies or companies with similar characteristics known to have more or
less breastfeeding support. The tailored programs can be marketed more effectively to
companies, resulting in adoption of more breastfeeding support programs. When the
instrument is used in combination with the Employee Perceptions of Breastfeeding
Support questionnaire (EPBS) (Greene & Olson, 2008) and the Manager Attitudes toward
Breastfeeding Support survey (MABS) (Chow, Fulmer, & Olson, 2010), it will also be
helpful in understanding work climate as a whole and which aspects of work climate can

be improved to have the greatest impact on breastfeeding rates of working women.

5.3 Future research
Further use of this instrument can contribute greater knowledge to the field of
breastfeeding and employment. This instrument can be used to measure company

breastfeeding scores nation-wide. This will allow the comparison of levels of

64

breastfeeding support region-to-region or state-to-state. It can also be used to determine if
different company characteristics are associated with higher scores of breastfeeding
support in different regions of the US. Use of this survey nation-wide could also be used
prior to and after enacting legislation requiring employers to accommodate breastfeeding
employees. This would determine if legislation alone changes work climates.

It is not fully understood why some companies offer more breastfeeding supports
than others. The survey used to quantify breastfeeding practices in Colorado included
items addressing incentives and motivation for adopting breastfeeding support (Dunn,
Zavela, Cline, & Cost, 2004). Results from the survey indicated that companies with no
provision of breastfeeding supports did not perceive a need for these services at their
company. Whether there truly was a need within these companies or not is unknown.
Incentives most attractive to employers were information on successful breastfeeding
support programs in similar companies, information on the benefits of breastfeeding to
employers, and tax credits for providing breastfeeding support services. However,
motivation for companies that did offer breastfeeding supports is unclear. Additional
research using the instrument developed during the current study, along with items
similar to the ones from the Colorado survey could help strengthen this understanding.

This instrument should also be used in combination with the EPBS and MABS
surveys. When all three surveys are analyzed together, it will allow for greater
understanding of work climate from new mother employees’ perspectives. This will help
better identify what specific aspects of work climate have the most impact on mothers,
and what constitutes a good climate that encourages breastfeeding. This is important

when incorporating breastfeeding support into the workplace, as it necessary to

65

implement services that are the most helpful. By understanding which types of support
are most important, a weighting system for the overall breastfeeding support score can
also be developed to obtain standardized scores. This way, companies with greater
breastfeeding support scores may not just have more supports available, but have the
supports that are most helpful to breastfeeding employees.

If this instrument were to be used longitudinally in companies with different
levels of breastfeeding support, it will lend to the understanding of which types of
support influence breastfeeding intensity and duration of employed women. Some studies
(CIGNA, 2000; Ortiz, McGilligan, & Kelly, 2004) have shown that companies with
various breastfeeding supports do have women that breastfeed at rates comparable to the
national averages. However, it is not yet understood which of the supports available are
responsible for these rates. By using this instrument first, companies with low amounts of
support can be identified. Then, as these companies increase the amount of support
offered, it can be determined if these additions increase breastfeeding rates among
employees.

Further reliability testing of the survey can also be performed. In order to do this,
more than one human resource executive from a single company should complete the
survey. The reliability can then be computed between responses that are the same or
different between the raters. If reliability is high, this will strengthen the methodology of
using only one rater to fill out the survey. If reliability is low for certain items, additional

changes could be made to increase accuracy.

66

APPENDICES

67

APPENDIX A

PILOT INSTRUMENT

BESt: Breastfeeding & Employment Study
Company Policies and Programs

SURVEY

Instructions:

0 Please answer the questions in this survey as they pertain to full-
time employees at your location.

0 Provide only one answer per question, unless instructed to do
otherwise.

Terms:

0 “Breastfeeding” refers to women directly nursing their infants or
young children from the breast.

0 “Pumping” refers to women pumping breast milk either by hand
expression, or by using a manual or electric pump, and storing it for
later use.

68

Breastfeeding Policy

1. Does your company have a written policy on breastfeeding and/or pumping milk at

work?
Cl Yes
[Please attach a copy of the policy if possible, and continue with
Question #2]
Cl No

 

[If your company does not have a policy, skip to Question #3]

2. a) Are a_ll employees informed about this policy (e. g., when hired, at orientation,

etc.)?
CI Yes
CI No

b) Are employees who become pregnant informed about this policy?

D Yes
D No

3. Does this company have a Corporate Lactation Program? <

 

 

Cl Yes [Please attach a written description of this program if possible]

DNo

Breastfeeding Support Needs

4. Please answer the following questions:

Yes

No

Don’t
Know

 

a) Does this company have an employee population
that may desire or benefit from policies or
programs pertaining to breastfeeding or pumping
milk at work?

 

b) In the past two years have there been any requests
from employees or managers for policies or
programs allowing breastfeeding or pumping milk
at work to be created?

 

c) Have any female employees in upper management
(e.g., executives, vice presidents, or senior-level
staff including senior-level HR personnel) breastfed
or pumped milk at work while employed with this
organization?

69

 

 

 

 

Maternity Leave

5. During the 12 weeks provided under the Family and Medical Leave Act (FMLA). can
women receive pay for any period of the time?

D Yes
D No

 

[IF NO, skip to Question #7]

6. Please indicate which of the following types of pay are available to use during the
12 weeks provided under FMLA:
[Please check all that apply]

Cl Disability pay —>IF YES:
What percentage of pay do employees receive? %
How long do employees receive this pay?

CI Company leave —’ IF YES:
What percentage of pay do employees receive? %
How long do employees receive this pay?

 

 

D Earned time off (e.g., vacation time, sick time, personal days)
C] Other (please describe):

 

 

 

 

 

7. Does this company allow women to extend their maternity leave longer than the 12 F
weeks provided under FMLA?

D Yes
D No

 

V

[IF NO, skip to Question #9 on the next page]

8. a) Please describe any paid time that can be used to extend maternity leave (e. g.,
banked time off, etc.):

 

 

b) Please describe any unpaid time that can be used to extend this leave:

 

 

70

9. Please include any comments you have regarding maternity leave here:

 

 

 

 

 

Breastfeeding and Pumping Milk at Work

10. Does this company allow women to bring their infants to work to breastfeed
them?

CI Yes
D No

11. Does this company allow women to pump milk at work?
CI Yes

D No
[IF NO, skip to Question #15 on page 6]

12. When women breastfeed or pump milk at work, when are they allowed to do so?
[Please check all that apply]

Cl During set break times
Cl As needed
D During lunch

13. Please answer the following questions: Yes No

if

 

a) Is space available at work to breastfeed or pump
milk? Cl C]

[IF NO, skip to Question #15 on page 7]

 

b) Are restrooms the only spaces available for
breastfeeding or pumping milk? Cl D

[IF YES, skip to Question #15 on page 7]

 

 

71

 

14. Please answer the following questions about space
available for breastfeeding or pumping milk:

Yes

No

 

a) Is there any designated space where women are
allowed to breastfeed or pump milk when not being
used for other purposes (e.g., a conference room)?

IF YES: How many?

 

b) Is there any space dedicated solely to breastfeeding or
pumping milk?

IF YES: How many?

 

c) Are any of the following available in the spaces where
women can breastfeed or pump milk (do not include
restrooms)?

Locking door .............................

Chair ....................................
Electrical outlet ............................
Table ....................................
Sink .....................................

Refrigerator (either in or near the room and
storage of breast milk is allowed) ..............

 

[30000

D

 

[300130

13

Please add any additional comments you may have about space available for

breastfeeding or pumping milk:

 

 

 

 

72

 

Lactation Services and Breastfeeding Support

 

 

 

 

 

 

 

Yes, Yes,

15. Are any of these services available at thfs '5 lb.” ‘3 No
your company? avallable; available; this is
[Please provide only o_ng answer the company the company not

for each service] M at least does not pay available
some of the ally of the
cost cost
a) Access to a Lactation Consultant
(either onsite or through a D D D
referral service)
b) Employee support group for E] D D
breastfeeding
c) Educational classes that include
information on breastfeeding or D D D
pumping
(1) Educational materials/handouts
on breastfeeding or pumping Cl C] 13
(Please provrde copies of any
materials if possible)
e) Electric breast pump 0 D 0
Cl CI CI

f) Kit for pumping (e.g., tubing, etc.)

 

 

 

Please describe how managers are made aware of any available lactation services

or breastfeeding support:

 

 

 

 

 

 

73

 

NOTE: The remaining questions in this survey pertain to ALL full-time

employees at this location (not just women).

Flexible Scheduling

16. Are any of these flexible scheduling options

available to full-time employees at your company?

Yes,
this is
available

No,
this is not
available

 

a) Earned time off:
Employees take these days at their own
discretion (e.g., sick leave, vacation time, and
personal days are grouped into one set of paid

days off).

 

b) Part-time return:
Employees who worked full-time before a leave
can permanently return to work for less than 35
hours per week. Benefits are usually prorated to
hours worked.

 

c) Phase back:
Employees return from leave to full-time
workload gradually over several weeks or
months.

 

d) F lextime:
Employees arrange to work hours to suit their
schedules. Arrival, departure, or meal/break
times may be adjusted (e.g., 7am-3pm, or 10am-
6pm).

 

. e) Compressed workweek:
Employees work longer hours on fewer days
(e. g., 10 hours/day for 4 days/week).

 

t) Telecommuting:
Employees work at home or another offsite
location one or more days a week.

 

g) Job sharing:
Two or more employees all work part-time and
share the responsibilities and
compensation/benefits of one full-time job.

74

 

 

 

Family-Friendly Benefits

 

 

 

 

 

 

 

 

 

17. Are any of these family-friendly benefits available tlTiZSi’s thisNighot
t full-t' l t ?
o lme emp oyees a your company available available
a) Dependent care flexible spending account:
Spending account that allows employees to set C1 C1
aside pretax dollars that can later be used for
dependent care expenses (e. g., for daycare)
b) Bring child to work in an emergency D D
c) Health care benefits for dependent grandchildren D D
d) Domestic partner benefits:
May include opposite-sex partners or other 0 D
eligible individuals
e) Eldercare referral service D D
i) Childcare referral service D D
g) Adoption assistance:
Helps employees pay for an adoption and related 0 D
expenses.
h) On-site licensed daycare D D
i) Educational assistance for employees and their CI Cl

family members (e. g., scholarships, tuition
reimbursement, and loans)

 

Please describe any other family-friendly benefits you offer:

 

 

 

 

 

75

 

Wellness Benefits

Yes, N0.
this is this is not
available available

18. Are any of these wellness benefits available to full-
time employees at your company?

 

a) Employee Assistance Program:
Counseling service for employees and their Cl Cl
families who may be experiencing personal or
work related problems.

 

b) Medical flexible spending account:
Spending account that allows employees to deduct E] El
pretax dollars from their paychecks to use to pay for
health care expenses.

 

c) Wellness/preventive health program:
Includes resources and information for employees
that help maintain or improve health and prevent D D
the development of serious health conditions in
the future (e.g., nutrition education).

 

d) CPR/first aid training D D

 

e) Health screening program (e.g., screenings for C] C]
cholesterol, blood pressure, etc.)

 

 

 

 

 

f) Smoking cessation classes D D

g) Employer-subsidized/reimbursed gym Cl C]
memberships, or on-site fitness center

h) On-site vaccinations (e.g., flu shots) 0 D

i) Weight loss/control program D D

j) Work/life newsletter/column D D

 

 

Please describe any other wellness programs you offer:

 

 

76

 

19. Please describe how managers are made aware of flexible scheduling options,
family-friendly benefits, and wellness benefits:

 

 

 

 

20. At your company, would breastfeeding support be best described as a family-friendly
benefit or a wellness benefit?
[Please choose only one]

Cl Family-friendly benefit
CI Wellness benefit

Health Insurance

21. Does your company offer health insurance to full-time employees?
Cl Yes
Cl No

V

[IF NO, skip to Question #23 on the next page]

22. a) Please indicate what types of insurance are offered at your company:
[Please check all that apply]

[:1 Medical
D Dental

b) Does this company cover any of the cost of medical insurance?
CI Yes
D No
c) Please add any additional comments you may have (e.g., what is included in full-

time employees’ health insurance packages, what percentage of insurance is covered
by the company, etc.):

 

 

 

 

77

Company Information

Reminder: Any information identifying the company or individual filling
out the survey will be kept confidential.

23. Please provide the following information about the company you work for and the
contact information of the person completing the survey:

Company name:

 

Worksite address:

Corporate website address:

Name of person completing the survey:

 

 

 

Position:

Telephone:

 

 

Email address: Date: / /

 

 

24. Is this site corporate headquarters?
D Yes
Cl No

IF NO:

How much ability does management at this site have to customize or adapt
human resource policies and practices to reflect local conditions/demands,
versus having to adhere to centralized policies and procedures?

CI No ability (must adhere to centralized policies from corporate
headquarters)

Cl Some ability (usually need approval from corporate headquarters)

Cl Complete ability (without necessarily obtaining approval from
corporate headquarters)

25. Is this organization a subsidiary of another organization?

 

 

Cl Yes
D No

[IF NO, skip to Question #26 on the next page]

IF YES:
Parent company name:

 

Parent company address:

 

 

Parent company website address:

 

78

v

26. Which of the following best describes your organization’s primary industry?
[Please choose only one]

D Communications
Finance

Health Care
Insurance

Public Administration
Public Education
Real Estate

Utilities

DDUUDUDU

Other (please specify):

 

27. Which of the following best describes the physical layout of this worksite?
Cl A single building
Cl Multiple buildings, each within walking distance of each other

 

0 Multiple buildings, not within walking distance of each other
D Other (please describe):

 

 

 

28. Please provide:

a) How many workers are employed at this company?

 

 

 

At this worksite: In the US: Globally:
El < 50 D < 50 D < 50
CI 50—99 CI 50—99 CI 50—99
Cl 100—499 C] 100—499 Cl 100—499
D 500 — 999 U 500 — 999 CI 500 — 999
CI 1,000 — 4,999 CI 1,000 — 4,999 CI 1,000 - 4,999
O > 5,000 C1 > 5,000 E] > 5,000
b) Of all US employees, what percentage is female? ........ %
c) Of all US employees, what percentage of females are employed full-time?. . . .
................................................ %
d) Of all US employees, what percentage of workers is unionized? ............
................................................ %

 

Thank you for taking the time to complete this survey. Please use this space to
include any additional comments you may have.

 

 

 

 

 

 

 

 

 

 

 

80

Your Name (please include credentials):

APPENDIX B

EXPERT REVIEW COMMENT FORM

 

 

 

 

 

 

 

 

 

Employer:
Position:
Please check the box
in this column if you
Question do not have any Please give any comments/suggestions for the
# comments/suggestions corresponding question in this column:
on the corresponding
question:
1 Cl No comments for
this question
2 Cl No comments for
this question
3 E] No comments for
this question
4 E] No comments for
this question
5 D No comments for
this question

 

 

 

 

81

 

 

D No comments for

 

 

 

 

 

 

 

 

 

6 this question
7 E] No comments for
this question
8 Cl No comments for
this question
9 Cl No comments for
this question
[I] No comments for
10 . .
this question
[I] No comments for
1 1 this '
question
D No comments for
12 . .
this question
C] No comments for
13 . .
this question
C] No comments for
14

 

this question

 

 

82

 

 

Cl No comments for

 

 

 

 

 

 

 

 

15 this question
[:1 No comments for
16 . .
this question
17 [:1 No comments for
this question
C] No comments for
1 8 . .
this question
D No comments for
1 9 . .
thrs question
[:1 No comments for
20 . .
this question
D No comments for
2 1 . .
this question
Cl No comments for
22

 

this question

 

 

83

 

 

[I] No comments for

 

 

 

 

 

 

 

 

 

23 this question
24 C] No comments for
this question
2 5 C] No comments for
this question
26 D No comments for
this question
27 Cl No comments for
this question
28 D No comments for
this question
29 Cl No comments for
this question
30 E] No comments for
this question
1:] No comments for
3 l

 

this question

 

 

84

 

 

Additional Questions concerning the completion of the survey:

1)

2)

3)

4)

5)

6)

How long did it take you to complete this survey?

Please comment on the difficulty of this survey (i.e. was it time consuming or
difficult to find any of the information asked for?)

When asked how many employees use the different policies or programs
mentioned in this survey, how feasible was it to provide an approximate
percentage?

For female employees only, how feasible was it to report an average age and
percentages within the given age ranges?

Please refer to question #13 in the survey. This question is getting at whether or
not women are able to extend maternity leave beyond FMLA requirements by
using any other leave time available. Do you feel this question accurately
captures this? Are there any additional items you would add to this list that may
be used?

Please refer to question #18 in the survey. If companies already have some
breastfeeding policies, we would like them to appropriately identify which they
are categorized as. If they do not, or the policies are not clearly defined as one or
the other, we would like them to identify under which category these policies Em
fit. Do you have any suggestions on the wording of this question?

85

APPENDIX C

COVER LETTER FOR INITIAL CONTACT
Name, Credentials
Company Name
Address
City, ST Zip

<DATE>

Dear ,

 

Your company has been selected to participate in the Breastfeeding & Employment Study
(BESt). As the <Human Resource Director>, you were identified as the most appropriate
individual at your company to answer questions about policies and programs that may
support breastfeeding employees. We are asking that you complete the enclosed survey, or
if you wish, email us at bfproject@anr.msu.edu to receive an electronic version to complete
and email back to us. If you do not feel you are the most apprOpriate individual to
complete this survey, please forward it to the appropriate person.

 

The BESt research study is being conducted by Michigan State University and is funded
by the United States Department of Agriculture (USDA) National Research Initiative.
The objective of the study is to determine the best support that may be provided to
employees wishing to combine breastfeeding and employment. The goal of this survey is
to determine the types of support that are available in Michigan companies with more
than 250 employees.

After data collection and analyses are complete, you will receive an individualized
follow-up report that will allow you to compare your company’s policies and programs
with other companies in Michigan. Your results will only be shared with your company.
Results from all participating companies will only be presented in collective form. The
information from the study results may be helpful to your company as a recruiting and
retention tool.

All of the company data that is provided in the survey responses will be kept confidential.
Only the researchers will have access to the individual company data. No personal or
company identifiers will appear in presentations or publications of the study results.

Participation in completing this survey is completely voluntary and you may stop at any
time or not answer certain questions. There are no anticipated risks for completing the
survey, and the benefit of completing it is the ability to compare your results with other
companies in Michigan. The estimated time to complete this survey is 30 minutes. By

86

completing and returning the survey, you indicate your voluntary agreement to
participate.

If your company has more than one location, please complete the survey only for the
location identified below:

Company Name: <Name>
Address: <Address>
<City, ST Zip>

If you have questions about this study or completing the survey, please contact the
research investigators at bfpro'Lect@anr.msu.edu, or at 517-355-8474 extension 154.

Thank you for your time and participation in this research project.

 

Sincerely,
. .. l - ' ....‘.. . Q -. . m5)“

til/Ul’ “Cf
/:(l(_.t'.t't . (at A - t,'.w---- (\ul L .t/ W

Beth Olson, PhD Sarah Hojnacki

Primary Investigator Project Manager

Food Science and Human Nutrition Food Science and Human Nutrition

Michigan State University Michigan State University

Don Conlon, PhD Ingrid F ulmer, PhD

Co-Investigator Co-Investigator

Department of Management, College Of Management

Eli Broad College of Business Georgia Institute of Technology

Michigan State University

87

APPENDIX D

SAMPLE REPORT

 

BESt: Breastfeeding & Employment Study
Company Policies and Programs in Michigan

A Sample of the Follow-up Report

 

 

 

This research is \

being conducted \ /—N -
through Michigan /
i

State University.

 

 

Funding is provided
by the United States
Department of
Agriculture.
What will be included in the follow-up report:
0 Information on the survey and the scoring
system
0 Your company’s overall score and sub-
scores for individual categories
For questions or 0 Overall scores and sub-scores for all
comments contact' companies and for companies of similar size
' to yours

Beth Olson, PhD
517-355-8474 x113 - Resources on how to incorporate

breastfeeding support at the workplace
olsonbe@anr.msu.edu

 

 

88

 

BESt: Breastfeeding & Employment Study
Company Policies and Programs in Michigan

 

 

SAMPLE REPORT

About this report:
This is a sample of the follow-up report that will be mailed to your
company after completion and analysis of this study. The survey is
being used to collect information on company policies and programs
that provide support for combining breastfeeding and employment.
Your individual company scores will only be reported to your company.
Scores for other companies will be reported as a group average.

 

Composite Scores for the 2009 BESt Survey

‘7 m ,_ ._ ici_~ V,__,—

  

 

 

 

 

Your Company Similar Size All Companies
Average*

*The average for companies with a similar employee size will be reported

89

 

Benefits to Companies

Research has shown that having policies and programs
supportive of breastfeeding practices can provide many benefits
to employers.

A summary of these benefits will be provided in the follow-up report along
with literature references.

.IIIIIIIIIIIIICIIIIII

What will be in the follow-up What are the survey components?
report? 0 Based on previous research, the
0 Information on the survey availability of the following at

questions and scoring system the workplace have been shown
0 Composite scores and sub- to help mothers combine

scores of survey components breastfeeding and employment:

for:

0 Your company
0 Companies of similar
size

1. Company policies
ll. Maternity and paid

0 All corn anies leaves
p . 111. Corporate lactation
0 Resources on breastfeedrng
programs

support at the workplace
IV. Space to breastfeed or

Who is being asked to participate pump
in this survey? V. Break time and flexible
0 Michigan companies with over scheduling

250 employees that were
identified through an online

database and mailing list Vl- Lactation sen/ices

' A human IPSOUICC o Other survey components are
representative from each included because they may be
company was identified and the related to breastfeeding
survey was mailed to that support. These components
individual include:

0 Industry sectors include
communication, education,
health care, finance, real estate, II. Wellness benefits
insurance, public
administration, and utilities

0 The survey response rate will be
reported in the follow-up report

I. Family—friendly benefits

III. Health insurance

IV. Employee
characteristics

90

How will the survey be scored?

0 Each question is part of a survey component. A score will be assigned
to each question based on your response and added to the sub-score
for that component.

0 Component sub-scores will be totaled to obtain a composite score.
0 Scores will be presented in a similar fashion to the table below.

Composite and Sub-scores from the 2009 BESt Survey
of Michigan Companies

Your Companies of All
Company Similar Size Companies

 

Composite Score

 

Component Sub Scores:
Company policy

 

Maternity and paid
leaves

 

Corporate lactation
program

Space for
breastfeeding and/or

pumping

Break time

 

 

 

Flexible scheduling

 

Lactation services

 

Family-friendly benefits

 

 

 

 

91

 

The Survey Components

The follow-up report will include a summary of the survey questions,
rationale for including them in the survey, and the response you
provided. They will be presented in a similar format as this table:

 

1. Company policy
Rationale:

 

Question: Your Response:

 

 

ll. Maternity Leave
Rationale:

 

Question: Your Response:

 

 

 

Ill. Corporate lactation program
Rationale:

 

Question: Your Response:

 

 

IV. Space to breastfeed or pump
Rationale:

 

Question: Your Response:

 

 

V. Break time and flexible scheduling
Rationale:

 

Question: Your Response:

 

 

Vl. Lactation Services
Rationale:

 

Question: Your Response:

 

 

V. Family-friendly benefits
Rationale:

 

Question: Your Response:

 

 

 

 

92

Breastfeeding Support Examples

The follow-up report will include examples of breastfeeding support
options categorized into different levels. They will be presented in a

similar format as below.

 

Lactation Program Options

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Good Better Best
Lactation Room Options
Good Better Best
Education Options
Good Better Best
Support Group Options
Good Better Best

 

 

 

 

 

Additional Resources

The follow-up report will include additional resources on incorporating

breastfeeding support at the workplace.

93

 

 

 

 

 

APPENDIX E

PHONE SCRIPT FOR SECOND CONTACT

Phone Script for Company Survey Recruitment
Use after Survey Mailings

This screening call will be made to all companies identified through the ReferenceUSA
database and DirectMedia mailing list after mailing of the survey has begun. The intent
is to ensure the survey has been mailed to the most appropriate individual to complete it.
The calls will:
1. Obtain the name and contact information of the Human Resource Director or
person in a similar position.
2. Inform the individual of the survey mailing and benefits to the company for
completing it.

Call instructions for companies with a human resource contact listed:
1. Hello. [am calling for <Contact Name>.

If this employee no longer works for the company, ask to be directed to the Human
Resource Director and follow the screening guide for companies without a contact
listed.

After being connected:

Hello, my name is <Screener Name>. I am with a research team from Michigan State
University’s Department of Human Nutrition and Eli Broad School of Business. We
are conducting a USDA National Research Initiative-funded study of company
policies and programs that may support new mother employees who wish to combine
breastfeeding and work. Your company has been mailed a survey and I am calling to
confirm whether you have received the survey and the most appropriate person to
complete it. Upon completion of this study, an individualized follow-up report will
be mailed to your company, which will allow you to compare your company’s
policies with other companies in Michigan. We hope you will find the information
helpful to your company as a recruiting and retention tool.

2. Are you the Human Resource Director or in a similar position, and the most
appropriate person to complete the survey?
Cl Yes
Cl No

IF YES, confirm their name and contact information and record below.

94

 

IF NO, ask for the name and contact information of the human resource director
and record here:

Name:

 

Title:

 

Address:

 

3. Have you received the survey?

Cl Yes
Cl No

IF NO, indicate you will send the survey to their address above.

I would like to thank you for your time and help today and look forward to receiving your
completed survey. My contact information is on the cover letter and should you have any
questions please feel free to call me.

Call instructions for companies without a contact listed:

1.

Hello. May I please be connected with the Human Resource Director?
If you are connected to this person, continue with part 3.

If this is not possible, continue with:

Hello, my name is <Screener Name>. I am with a research team from Michigan State
University’s Department of Human Nutrition and Eli Broad School of Business. We
are conducting a USDA National Research Initiative-funded study of company
policies and programs that may support new mother employees who wish to combine
breastfeeding and work. Your company has been mailed a survey and I am calling to
confirm whether it has been received and who the most appropriate person to
complete it is. Upon completion of this study, an individualized follow-up report will
be mailed to your company, which will allow you to compare your company’s
policies with other companies in Michigan. We hope you will find the information
helpful to your company as a recruiting and retention tool.

We would like to make sure the survey reaches the Human Resource Director or
someone in a similar position. I am hoping you can help me identify who this would
be.

95

 

 

Record name, position, and address here:

Name:

 

Title:

 

Address:

 

 

2. Are you aware whether or not the survey has been received?

3.

Cl Yes
Cl No
IF NO, indicate that a copy will be mailed to the address that was provided.

Conclude by saying:

I would like to thank you for your time and help today and look forward to receiving
your completed survey. My contact information is on the cover letter and should you
have any questions please feel free to call me.

After being connected to the Human Resource Director, continue with:

Hello, my name is <Screener Name>. I am with a research team from Michigan State
University’s Department of Human Nutrition and Eli Broad School of Business. We
are conducting a USDA National Research Initiative-funded study of company
policies and programs that may support new mother employees who wish to combine
breastfeeding and work. Your company has been mailed a survey and I am calling to
confirm whether you have received the survey and the most appropriate person to
complete it. Upon completion of this study, an individualized follow-up report will
be mailed to your company, which will allow you to compare your company’s
policies with other companies in Michigan. We hope you will find the information
helpful to your company as a recruiting and retention tool.

Are you the Human Resource Director or in a similar position, and the most
appropriate person to complete the survey?

Cl Yes

Cl No

IF YES, confirm their name and contact information and record below.
IF NO, ask for the name and contact information of the human resource director
and record here:

96

 

 

Name:

 

Title:

 

Address:

 

 

C onclude by saying:

I would like to thank you for your time and help today and look forward to receiving
your completed survey. My contact information is on the cover letter and should you
have any questions please feel free to call me.

 

97

 

APPENDIX F

REMINDER POSTCARD FOR THIRD CONTACT

FRONT:

 

 

 

Breastfeeding & Employment Study
Michigan State University

2125 S. Anthony

East Lansing, MI 48823

 

 

 

BACK:

 

 

This is a reminder to please complete and return the Breastfeeding &
Employment Study survey that was mailed to you a couple weeks ago.
The objective of this study is to determine the best support that may
be provided to employees wishing to combine breastfeeding and
employment. The goal of this survey is to determine the types of
support that are available in Michigan companies.

After data collection and analyses are complete, you will receive an
individualized follow-up report that will allow you to compare your
company’s policies and programs with other companies in Michigan.
Your company may benefit from the results as a retention and
recruitment tool.

If you need a replacement survey or have any questions about this
study, please contact the research investigators at
brproject@anr.msu.edu, or at 517-355-8474 x 154.

Thank you for your time and participation.

 

 

98

 

APPENDIX G

TABLE 4. SCORING SYSTEM FOR FORMAL BREASTFEEDING SUPPORT

 

Maximum Score

Component Possible

Scoring Description*

 

Scores for categories falling under
time support were summed
I = Only earned time off can be
used to receive pay during
FMLA
2 = Disability pay or a company
leave can be used to receive pay
during FMLA (may also be able

Maternity leave 4 to use earned time off)

1 = Maternity leave may be
extended beyond 12 weeks, but
is unpaid

2 = Maternity leave may be
extended beyond 12 weeks, and
is paid

Time support 10

 

I = Women may pump milk at
work

1 = Women may breastfeed at work

Breastfeeding & 4 l = Women many breastfeed or

pumping at work pump during set break times
only

2 = Women may breastfeed or
pump as needed

 

1 = Part-time return, phase back, or

. job sharing is available
F lexrble _ -
scheduling 2 1 — Flextrme, compressed
workweek, or telecommuting is
available

 

Scores for categories falling under

Structural support 16 structural support were summed

 

 

99

Written policy
education

1 = There is a written policy on
breastfeeding and/or pumping
milk at work and only pregnant
employees are informed about it

2 = There is a written policy on
breastfeeding and/or pumping
milk at work and all employees
are informed about it

 

Space to
breastfeed or

pump

1 = There is space, other than a
restroom, available at work for
women to breastfeed or pump

1 = There is a space dedicated
solely to breastfeeding or
pumping

l = Spaces have some, but not all of
the following: locking door,
chair, or electrical outlet

2 = Spaces have all of the
following: locking door, chair,
and electrical outlet

 

Lactation
consultant

1 = There is access to a lactation
consultant (either onsite or
through a referral service)

1 = The lactation consultant is at
least partially paid for by the
company

 

Employee
support group

1 = There is an employee support
group for breastfeeding

1 = The support group is at least
partially paid for by the
company

 

Education

1 = There are educational classes or
education materials/handouts on
breastfeeding or pumping

1 = The educational resources are at
least partially paid for by the
company

 

Breast pump

1 = There is an electrical breast
pump available to use at work

1 = The breast pump is at least
partially paid for by the
company

 

On-site daycare

2 = There is an on-site, licensed
daycare at the worksite

 

TOTAL SCORE

 

26

 

Scores for the time and structural
support components were summed

 

100

APPENDIX H

TABLE 5. PREVALENCE OF BREASTFEEDING SUPPORTS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total N = 151
N. Total N
offering . 0
service / completing /o
Type of support, breastfeeding-specific benefit item
Written policy on breastfeeding 5 151 3
support .........................
Allemployees are informed of 2 53 40
policy ........................
Pregnant employees are informed of a 1 00
policy ........................ 5 5
Pay during maternity leave 145 151 96
Disability pay 1 11 145a 77
Company pay 13 I458 9
Earned time off (e.g., vacation, srck 1 3 6 145, 94
time)
Ability to extend maternity leave
beyond FMLA 85 151 56
Allowed to breastfeed at work 22 143b 15
Allowed to pump at work 141 150b 94
Breastfeed/pump as needed (vs. set 101 139th: 73
breaks only)
Space other than restroom available at
for breastfeeding/pumping 106 136 78
Room dedicated solely to 34 106’ 32
breastfeeding/Empmg
Spaces° for breastfeeding/pumping
include: b
. 91 1033‘ 88
Locking door b
. 104 1043‘ 100
Chm 104 104"“b 100
Electrical outlet b
. 55 96" 57
Sink 82 101” 81
Refrigerator (in or near room;
storage of breast milk allowed)

 

101

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Access to lactation consultant 42 149,, 28
At least partially paid for by
23 42a 55
company
Employee support group 11 1 51 7
At least partially paid for by a
7 11 64
company
Educational classes . 30 1 5] 20
At least partially paid for by
14 30a 47
company
Educational meterlal ' 34 1 50b 23
At least partially paid for by
25 34a 74
company
Availability of an electric breast pump 24 1 5 1 1 6
At least partially paid for by
19 24a 79
company
Availability of breast pump kit 1 8 149,, 1 2
At least partially paid for by 12 1 8a 67
company
Type of support, non-specific to breastfeeding
Onsite daycare 22 151 15
Flextime 92 151 61
Telecommuting 53 1 5 1 35
Compressed workweek 79 151 52
Job sharing 40 151 27
Phase back 72 151 48
Part-time return 77 151 51

 

 

 

 

'N<151 due to some companies being directed not to answer the question
bN<l 51 due to missing data

cRefers to any space other than a restroom available for breastfeeding/pumping (not just spaces
dedicated solely to breastfeeding/pumping)

102

APPENDIX I

TABLE 6. CORRELATIONS BETWEEN INDEPENDENT VARIABLES AND
THE DEPENDENT VARIABLE, TOTAL BREASTFEEDING SUPPORT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SCORE

Independent Variable Pearson’s r P-value
# of family-friendly benefits .464 .000**
# wellness benefits .436 .000**
Unionization .005 .949
% female workers .185 .039*
% full-time females .108 .252
# worksite employees .319 024*
# U.S. employees .416 .000M
Sector .103 .209
Breastfeeding requests .276 .001**
Employee demand .241 .006”
Upper management has breastfed/pumped .236 .013*
Headquarters .030 .71 2
*P < .05
**P < .01

103

APPENDIX J

TABLE 7. MULTIPLE LINEAR REGRESSION MODEL

Dependent variable: Total Breastfeeding Support Score
R2 = .320, 1?,72 = 5.653, P<.Ol

 

 

 

 

 

 

 

 

 

Independent Variable B P-value
# worksite employees .232 .041 *
# family-friendly benefits .228 .049*
% female employees .097 .365
Breastfeeding requests .127 .223
Enmoyee demand .117 .272
Upper management has breastfed/pumped .143 .190

 

*P < .05

104

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105

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