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Abstract
Introduction The UK has no legislation protecting employees’ access to breastfeeding facilities. Without specific breastfeeding policy, provisions to access workplace facilities can be inconsistent and negatively impact employees’ breastfeeding duration, retention and morale, particularly servicewomen who work in varied and demanding military environments. This is an important policy area for the British Army to retain talented and trained soldiers.
Methods Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement principles, PubMed, Embase, CINAHL and Pro-Quest Databases were searched for studies relevant to accessing appropriate breastfeeding facilities in UK workplaces and high-income countries’ Armed Forces. Factors acting as barriers and enablers to accessing facilities were identified. UK government and Armed Forces’ websites were searched for grey literature on existing policies and guidance for accessing facilities.
Results Barriers and enablers to access from 16 studies were described by three thematic areas: attitudes to breastfeeding, facility provisions and use of facilities. Factors which employers could influence included specific breastfeeding policy, universal workplace education, existence of suitable facilities and individualised breastfeeding plans. The key areas for policy development identified were clearly defined responsibilities; individualised risk assessments and breastfeeding plans; appropriate, but flexible, facility provision and access; signposting of relevant workplace accommodations; and physical fitness provisions.
Conclusions Five recommendations are presented: development, implementation and evaluation of breastfeeding policy; universal workplace breastfeeding education; the need for breastfeeding risk assessments and plans based on individual breastfeeding practice; written minimal and ideal standards for breastfeeding facilities and access, which considers workplace locations; and exceptions from deployment and physical fitness testing.
- public health
- reproductive medicine
- occupational & industrial medicine
- health policy
Data availability statement
Data sharing is not applicable as no datasets were generated and/or analysed for this study. There are no datasets used or produced in this study.
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Key messages
Facilitating breastfeeding on return to work (RTW) benefits the maternal and infant physical and mental health, and can improve employee presenteeism, loyalty and retention.
More research and evaluation of breastfeeding servicewomen in the United Kingdom (UK) Armed Forces or other militaries around the world are needed to better support this population.
A single, easily accessible breastfeeding-specific policy or guidance document that clearly states minimum and optimal standards is required for both servicewomen and commanders.
Facility access and appropriateness are improved by ensuring individual risk assessments and breastfeeding plans, which account for individual circumstances and career group requirements, are undertaken.
Organisational cultural acceptability of breastfeeding is influenced by universal workplace, commander and medical chain education covering breastfeeding on RTW specific to the setting.
Effective peer support and empowerment of breastfeeding servicewomen to address the unique challenges faced could be achieved through a military-specific breastfeeding network.
Introduction
The World Health Organisation (WHO) recommends exclusive breastfeeding for six months and continuation, alongside solids, to the age of two years.1 2 Breastfeeding benefits infant3 4 and maternal long-term health,4–6 employee presenteeism7 and retention.8 9 However, for many complex demographic,10 cultural11 and socioeconomic reasons,12 13 United Kingdom (UK) breastfeeding rates are among the world’s lowest.14 The UK is one of 15/56 high-income countries (HICs) without legislation guaranteeing suitable workplace facilities or breastfeeding breaks.15 16 The only relevant legislation states: ‘Suitable facilities shall be provided (for) a nursing mother to rest.’17 This must not be the toilets.18 19 Consequently, access to suitable workplace breastfeeding facilities varies significantly. These uncertainties can delay maternal return to work (RTW) or shorten breastfeeding duration.12 20 Societal expectations of servicewomen, periods of separation, physical fitness requirements, deployments and hazardous environmental exposures21 make Armed Forces RTW breastfeeding even more complex.
All nations’ servicewomen have similar roles, but differences in working conditions and breastfeeding provisions mean recommendations22 from other militaries are not always transferable to the British Army. Although UK triservice policy advocates private safe spaces with breastmilk storage,23 in reality, breastfeeding expectations and provisions depend on individual commanders’ approaches. Such uncertainties may contribute to decisions to terminate service or resentfully cease breastfeeding.24 The proportion of trained and talented women, who the British Army need to retain,25 is ever increasing, and with 6.4% taking maternity leave annually,26 breastfeeding policy is required. This review identifies barriers and enablers to accessing appropriate workplace breastfeeding facilities and the relevance of these factors to the British Army.
Methodology
A literature review was undertaken in 2017 in accordance with ethics approval. Standardised Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement27 principles were adhered to. To account for occupational circumstances and UK workplace legislation, the search strategy combined UK workplaces and English-speaking HIC military breastfeeding studies, existing policy and guidance. Databases searched included the Cochrane Library, CINAHL, PubMed, Embase and PRO-Quest Military Collection (Supplement S3). The World Bank’s definition of an HIC, as one with a per capita income of $12 476 or more, was used. The UK Government and British-speaking Defence sites were searched for publicly available grey literature (Supplement S4). To improve search sensitivity and to ensure comprehensive study inclusion, common synonyms and Boolean operators for key concepts were used; Breastfeeding, Employment, Barrier, Enabler, Facilities and Military. Search specificity was improved following a pilot, by making ‘breast’ a mandatory term (Supplements S1 & S2).
Inclusion criteria for UK workplace studies were English language and peer-reviewed journal publication post-2006. HICs Armed Forces studies were limited; therefore, all publicly available studies and theses, of any age, with a formal review and ethics process, were included. For English language policies and guidance, newest versions were sought. Opinion pieces, news stories, informal advice, social media recommendations, and studies focusing on healthcare professionals (HCPs) or partner outcomes were excluded. All search results details were exported into Endnote V.X7.5 and duplicates were removed. Remaining abstracts and documents were scanned for suitability, and results are displayed in Tables 1–4.
Study characteristics
Factors enabling access to appropriate facilities
Barriers to accessing appropriate facilities
Characteristics of breastfeeding policy and guidance documents
Study quality was assessed using validated Critical Appraisal Skills Programme tools28 for literature reviews, cohort and qualitative studies; the Strengthening the Reporting of Observational Studies in Epidemiology checklist assessed bias in cross-sectional studies (Supplement S5).29 As each tool assessed a differing number of elements, the mean average score was calculated; each element scored fully (1.0), partially (0.5) or not (0) achieved. Mean scores were used to grade study quality as unsatisfactory (0–0.4), satisfactory (0.41–0.7) or good (0.71–1.0).
Results
Figure 1 illustrates primary search strategy results.27 Table 1 details the 16 included studies’ characteristics, risk of bias and quality. Due to limited study availability, one unsatisfactory quality study was included; however quality was considered in the discussion. Fourteen studies were peer-reviewed30–41 (1995–2017),22 42 including two US theses (1998–1999).43 44 Six studied UK mothers30–34 42 and 10 HIC servicewomen,22 35–44 of which 80% were US-centric. Differences in gender, ethnicity and role composition made studies less representative of a contemporaneous British Army, demonstrating why a review was required.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram.27 HIC, high-income country.
Study design varied significantly and included one literature review of otherwise not-included studies22; three large UK31 33 42 population cohort studies; seven quantitative cross-sectional studies, using online,32 34 37 38 41 written44 or telephone surveys35; and five cross-sectional qualitative studies, using interviews30 36 39 servicewomen30 38 39 43 or stakeholder36 narratives.38 43 Only three recognised limitations of recall bias in cross-sectional studies, especially where workplace recollections may be corrupted by overall breastfeeding experience. Only two addressed33 41 selection bias and temporality8 of including only currently working mothers30 32 34 35 37–41 43; excluded mothers may delay RTW to breastfeed longer. UK civilian employees may also differ from servicewomen; characteristics which drive enlistment may also influence responses to breastfeeding barriers.
Differing study methodologies, sizes (range 1–17 597 mothers) and outcomes measures limited comparability and accurate quantification of factor dominance or breastfeeding outcome. Additionally, no single concept of access model45 could be used to explain all identified factors or their interconnectivity. However, inclusion of multiple complementary study designs offered scope to identify a more comprehensive range of enabling factors and barriers (Tables 2 and 3).46 Findings were based only on factors which emerged from thematic analysis of the included studies and therefore may not be exhaustive. All themes interacted through feedback loops within a complex system. While some connections were explored, conclusions drawn may oversimplify, may not fully explain or may underestimate the root cause factors influencing access to breastfeeding facilities.
Table 4 details characteristics of the 16 RTW policy and guidance documents. Table 5 identifies the five key areas from policy analysis, in which recommendations can be made: employer, employee and medical responsibilities; individualised risk assessments and breastfeeding plans; requirements for breastfeeding facility provision and access; provisions for RTW physical fitness; and workplace accommodations.
Key areas in document
Attitudes
The most common enabler to accessing breastfeeding facilities, identified by six military35 37–39 43 44 and five UK studies,30–33 42 was maternal motivation to reach a predetermined goal. Maternal disclosure of breastfeeding status, as well as behaviour actively seeking access to breastfeeding facilities on RTW, was positively influenced by actual or perceived supervisor, military HCP35–38 43 44 or colleague support.30 32 34 36 37 39 42–44 Workforce acceptance was strongly influenced by knowledge of the benefits of breastfeeding to the employer.37 38 43
Lack of support,33 34 37 39 41 workplace pressure to stop and separation from external breastfeeding support networks all reduced breastfeeding duration.31 35 39 41–44 Hostile behaviours30–41 were fuelled by limited employer education and subsequent misconceptions.30 32 34 37 41 These included maternity leave being the only acceptable time and place to breastfeed,40 43 support for breastfeeding conveying a subversive feminine organisational image32 and negatively impacting workforce effectiveness.30 32 33 39 43 Military studies identified concerns that breastfeeding could threaten operational deployability and capability, but all concluded long-term benefits for retention needed to be recognised.36 39 44 Workplace attitudes can be addressed by changing organisational culture and adopting protective breastfeeding-specific policies.31 32 34 36–38 43
Facility provision
Organisational policies for provision,30 32 34 36 38 knowledge of and facility existence32 36 38 are prerequisites for access.32 34 36 However, without national legislation and sufficient research on RTW breastfeeding, policy development often stalls.31 37 All studies identified timely knowledge of workplace facility existence as vital in preventing mothers prematurely ceasing breastfeeding on false assumptions. This was most common in male-dominated organisations,30 32 35 42 43 as was maternal concealment of breastfeeding, which prevented supervisors from facilitating appropriate access.22 35 38 43
Restricted physical access, through limited opening times for mothers working non-standard hours,39 41 42 or need of a key,34 was a barrier. Advance warning of changes in working patterns, hours42 or location37–39 enabled arrangements for ongoing access to be made. Where employers offered only indirect breastfeeding facilities, mechanical,32 41 psychological33 39 43 44 and financial39 difficulties transitioning from direct breastfeeding were frequently cited barriers. While an on-site nursery can facilitate access,32 ,34 this is not always practical. Alternative off-site access32–34 37 40 42 43 can be enabled by workplace accommodations, including shift pattern changes,33 42 flexible32–34 41 or part-time working,32–34 42 or additional leave.33 40–43
Use of facility
Facility suitability influenced maternal use. Synthesising these findings, we found that essential requirements were privacy and safety.30 32 34 36 39 41–43 Ideal facilities were designated and lockable,30 32 34 36 39 41–43 with basic amenities, including electricity and running water,32 34 36 38 41 43 even in austere military working environments.37 38 Optimal use of facilities34 36–39 43 came with provision of refrigerated storage or equipment loans of hospital-grade pumps.34 36–39 43 Unsuitable locations were toilets, public spaces and thoroughfares,32 34–37 39 41 43 and those which exposed mothers to breastmilk transmissible hazards.22 32 38 41 Lack of advice or logistical support for transporting breastmilk during periods of separation resulted in breastfeeding cessation.38
Appropriate access was enabled through maternal antenatal35 36 44 and universal workforce education,30–32 34–38 43 which in three military studies was best received when delivered by HCPs.36 38 44 Addressing maternal and supervisor expectations was equally important with use of facilities and time to breastfeed optimised through formally written and agreed breastfeeding plans.34 35 37–39 42 43 Six studies32 36 37 39 41 43 identified insufficient time as a barrier to accessing facilities. This was caused by occupational stress34 35 37 39 41 42; time-consuming, unpredictable workloads; inability to manage one’s own schedule34 42; or limited flexible-working options.32–34 37 39 42 Unplanned changes to workload,35 39 working location39 and patterns42 all negatively impacted use of facilities.
Discussion
Maternal motivation to breastfeed, which is predominantly driven by factors external to the workplace, was the most commonly identified factor enabling access of facilities.30 33–35 37–44 The five key areas identified from policy analysis and the potential options for future policy development are explored and discussed based on the key barriers and enablers are identified. Recommendations focus on those factors which the British Army, as an employer, could influence.
Specific responsibilities
Maternal duty to inform her employer18 19 23 47–59 and medical officer47 48 52–54 59 of breastfeeding status was the most commonly identified responsibility and is required in the UK.23 However, numerous studies found actual or perceived lack of support,34 37 39 41 42 pressure to stop or tolerance of hostile behaviours towards breastfeeding mothers30 41 was a barrier to disclosure and accessing facilities. Non-disclosure could harm both maternal and infant health. The British Army has a duty to protect the breastfeeding servicewoman and risk assess the potential impact of exposure to any of the known harmful occupational hazards identified in two observational studies and a comprehensive literature review.18 22
Disclosure, facility provision, access and use can be improved through breastfeeding-specific policy18 19 42 51 and universal workplace education.42 54 57 Workplace breastfeeding policy is supported as good practice by Advisory, Conciliation and Arbitration Service19 and recommended by the NHS,51 HSE18 and the US Army.42 Following good practice from the USA, a multidisciplinary working group to evaluate policy implementation and breastfeeding outcome should be established.42 However, policies must be appropriate38 43; promoting extended maternity leave for breastfeeding fuels the misconception that it is unacceptable in the workplace.30 40 43 To be effective, policies must empower the servicewomen, must be widely available30 32 34 36 and must be provided in a timely manner before RTW,32 36 38 ideally in the antenatal period.32 34 36 44
Policy implementation is most successful when accompanied by universal workforce education, which tackles stigma and barriers and improves practical knowledge and awareness of the benefits of breastfeeding.30–32 34–38 43 All US military studies which trialled educational programmes found military HCP delivery to have the greatest efficacy.36 38 44 The US Army medical chain is now responsible for breastfeeding self-learning42 and education delivery,42 54 and any British Army programme would need to start with HCP education. HCP engagement was crucial in 60% of studies in advocating and supporting improved access and use of facilities.35–38 43 44 While policy and education are commonly cited organisation responsibilities which demonstrate support and organisational acceptance,31 32 34 36–38 43 alone they are insufficient; true change comes through creation of a supportive organisation culture where inappropriate behaviours are challenged.
Individualised plans and risk assessments
Three military studies32 36 38 and most policies42 48 49 54–56 identify line managers’ and medical officers as respectively responsible for completing individualised risk assessments18 19 23 42 48 49 51 54–56 and medical grading assessments,42 48 52 53 60 ideally prior to RTW.19 23 42 48 55 56 Line manager risk assessment should not, however, be replaced by medical grading.49 54 55 In most cases, reasonable adjustments for breastfeeding should be an employer and not a medical responsibility; however, it may be appropriate to apply medical workplace restrictions due to individual postpartum functionality.22 59 In line with HSE legislation,18 triservice British Armed Forces policy does recommend individualised risk assessment.23 59
In addition to risk assessments, eight studies and six policies, including from the US Army and Royal Air Force, which provide the paperwork for completion, recommend individualised breastfeeding plans either concurrently or independently.35 37–39 43 Well-considered and successfully implemented plans help manage expectations of the servicewomen, line managers and colleagues and counter misconceptions about workforce cohesion and operational capability.36 39 Plans should be thorough, account for maternal breastfeeding practices and infant breastmilk requirements; notice for changes to work pattern or location37–39 42 47 48; and what facilities can be optimally provided in a range of settings, including the home base, courses, exercises and deployments.47 49
Although only identified by a few studies, mothers need time to psychologically prepare and practically plan adjustments to breastfeeding practices, storage and transportation. If cessation is required and timelines are insufficient, or facilities in a new location are inappropriate or inaccessible, medical complications such as engorgement, pain or mastitis50 can occur and a period of absence and treatment may be required. Compromise and circumstantially appropriate plans should be agreed, balancing the needs of the service; the servicewoman’s career; and her practical, psychological and medical breastfeeding needs.34 35 37–39 42 43
Breastfeeding facilities
For mothers to access facilities, they must exist.33 34 36 43 Most policies and studies30 32 34 36 39 41–43 identify privacy and safety as the minimum standard, even for exercises and deployments.47 This, along with space to rest, is legally required in UK workplaces.18 Toilets, public thoroughfares and locations with hazardous exposures were universally recognised as unsuitable.18 19 22 23 32 34–37 39 41 42 47–49 51–57 US and Australian policies specify minimum requirements for exercises and deployments,47 and recommend access to running water and electricity.47–49 54–58 Water is required for hygiene reasons and to prevent infection.7 9 16 17 20 23 Electricity is a necessity for electric pumps, but manual pumps and hand expression could be considered; it is also ideal for refrigerated storage; however, cold storage boxes can be temporarily used.
Refrigerated storage was recommended in the UK,19 51 Australia49 and the USA for shifts over 12 hours.55 Although UK workplace legislation is lacking,15 Ministry of Defence (MOD) policy does make provisions for privacy and breastmilk storage,23 53 59 and this is identified as an enabler. In other countries, cold-storage provision is a maternal responsibility, although support with arranging cold chains for transportation from deployments or austere environments is an enabler.19 47 48 54 Provision of pumping equipment was consistently a maternal responsibility; however, access to hospital-grade loan pumps was viewed as beneficial by servicewomen and employers.47 48 54 Firm-based locations23 should provide electricity and refrigerated storage. To enable appropriate planning.37–39 locations and circumstances where these cannot be provided, alongside the essentials of privacy, safety and running water, should be made clear.
Sufficient time to access facilities should be provided,19 47 49 51 54–60 determined by maternal needs,49 51 56 individual breastfeeding practices49 or medical recommendations.56 Facility provision is a futile gesture if mothers cannot access them. For mothers unable to manage their own schedule,34 37 39–43 formally agreed breastfeeding plans are the most commonly identified enabler.33 36 41 43 RAAF breastfeeding models49 provide guidance and frameworks to manage expectations of break duration and frequency.
Physical fitness provisions
Two studies identify fear of career ramifications, secondary to failure to meet physical fitness requirements or to attend career courses, as a barrier to accessing workplace facilities.39 41 However, challenges of physical fitness are not just restricted to breastfeeding mothers and are considered in various nations’ policies on military RTW physical fitness provisions for all postpartum mothers.48 49 52 58 60 These include providing specialist postnatal Physical Training (PT),49 52 60 deconflicting breastfeeding breaks with scheduled PT,48 and exempting physical testing for 90 days and 658 or 12 months.52 British Army policy makes provisions for this; however, future recommendations will be reviewed, in line with results from ongoing postpartum musculoskeletal studies.
Workplace accommodations
Fear or actual infant separation can cause practical storage and transportation and psychological difficulties when transitioning from direct breastfeeding to expressing.33 39 43 44 Longer and uncertain duration often results in breastfeeding cessation. Separation from a formed breastfeeding support network is also a barrier to continuation of breastfeeding, although many military studies found a virtual military-specific peer network to be enabling.35 39 41 43 44 To protect from early separation, all HICs’ Armed Forces recommend exemption from deployment,47 49 54–59 but duration varies from 6 to 24 months postpartum.47 49 54–59 The British Army offer 6 months, with provision to extend to 12 months at the commanders discretion.59 Numerous studies and policies47 49 51 recognise the beneficial impact flexible-working and part-time working policies can have on maternal access of appropriate facilities.32 33 37 40 43 Such workplace accommodation policies are now offered subject to the needs of the service, but should be signposted in breastfeeding policy.
Recommendations
Five key recommendations were drawn from this work (Table 6), and these have been presented to the Director of Personnel department, Women’s Health Advisory Group and Primary Care Women’s Health Special Interest Group.
Five key recommendations to enable access to breastfeeding on return to work in the British Army
Conclusions
RTW breastfeeding benefits the infant, mother and employer. However, numerous factors can either enable or present a barrier to breastfeeding. Thematic analysis identified three key areas impacting access: attitudes towards breastfeeding, issues relating to facility provision and those related to use. Dominant workplace themes influencing access included breastfeeding policy protecting mothers and facilities, workplace support to access facilities, universal workforce education, provision of suitable breastfeeding facilities, individualised risk assessments and breastfeeding plans, and planning for infant and breastfeeding support network separation. Five key recommendations were made when these themes were considered in relation to British Army employment. There remains a need for further research and appropriate monitoring, evaluation and oversight of British Army breastfeeding implementation to inform subsequent policy amendments.
Supplemental material
Supplemental material
Data availability statement
Data sharing is not applicable as no datasets were generated and/or analysed for this study. There are no datasets used or produced in this study.
Ethics statements
Patient consent for publication
References
Supplementary materials
Supplementary Data
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Footnotes
Contributors This research and article was undertaken by HT as sole author.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.