Breastfeeding and returning to work

THE SCOTTISH BREASTFEEDING GROUP (SBG) -
Breastfeeding and returning to work

Introduction

The Scottish Breastfeeding Group

The Secretary of State announced in a circular on 7 November 1994 a national target for improving the rates of breastfeeding to 'more than 50% of women to be still breastfeeding their babies at 6 weeks of life by 2005' (NHS MEL(1994)110).

As part of the effort to tackle inequalities and improve children's health 'The Priorities & Planning Guidance for the NHS in Scotland 1999-2002' (NHS MEL(1998)63) highlighted the need for a co-ordinated approach to promoting the uptake of breastfeeding .

In order to achieve the National Breastfeeding Target, a Scottish Breastfeeding Group (SBG) was set up on 1 October 1995 with the appointment of a part-time National Breastfeeding Adviser. The SBG is a multi-disciplinary group representing the range of professional and lay organisations with an interest in breastfeeding and chaired by the Chief Nursing Officer, Miss Anne Jarvie. It provides a focus for breastfeeding at a national level and complements the work being undertaken locally.

The Remit of the Sub-Group

The remit of the sub-group was taken from the minutes of the Scottish Breastfeeding Group 2 September 1998 Item 6 - Breastfeeding Facilities for Working Mothers in The Scottish Office and National Health Service. It was agreed to set up "a small working party, which could examine what was happening elsewhere, pull together best practice, and prepare a paper or summary guideline on what they see as the role of a good employer in this area".

The Case for a Workplace Policy for Breastfeeding Mothers Returning to Work

• In 1980, 12% of mothers in Britain returned to work or were on maternity leave when their babies were 6-10 weeks old. This number had increased to 50% in Scotland by 1995 (Foster et al 1997).
• Breastfeeding has major health benefits for both mother and baby. Breastfed babies have a reduced risk of:
• Chest infection (Howie et al 1990)
• Diarrhoeal illness (Howie et al 1990)
• Middle ear infection (Duncan et al 1993)
• Urinary tract and other infections (Piscane et al 1990)
• Juvenile onset diabetes (Mayer et al 1988, Virtansen et al 1993)
• Atopic disease (Saarinen and Kajosaari 1995).

A recently published long term study has also shown that some of these benefits carry on into childhood, in terms of lower blood pressure and less respiratory diseases (Wilson et al 1998).

• Women who breastfeed experience long term health benefits such as reduced risk of:
• Premenopausal breast cancer (Newcomb 1994)
• Epithelial ovarian cancer (Gwinn et al 1990, Hartge et al 1989)
• Hip fractures in later life (Cumming and Klineberg 1993).

Given that exclusive breastfeeding for 4-6 months offers major health advantages to mothers and babies (DoH 1994), it is important that mothers are enabled to continue breastfeeding when they return to work.

• There is evidence that some mothers don't start to breastfeed or give up breastfeeding before they had intended, because they are returning to work; therefore limiting the beneficial effects of breastfeeding (Foster et al 1997). Employers can contribute to the health of their employees and their families by establishing a policy of support for breastfeeding mothers.

Advantages to Employers

• Employers may also benefit from their employees continuing to breastfeed.

Experience from companies in America and the UK shows that companies themselves benefit when they provide support for breastfeeding mothers. Benefits may include:

• Reduced parental absence (healthier children)
• Higher rate of return to work
• Increased staff loyalty
• Staff continuity
• Recruitment incentive
• Reduced training budget. (Maternity Alliance 1997)
• The Maternity Alliance (1997) in its publication 'Breastfeeding and Work' offers a guide to good practice by employers and to the benefits that have ensued from extended maternity leave. One example quoted is Rank Xerox, which found the number of skilled and experienced women returning to the company after maternity leave increased from 20% to 80%. Other examples of employers who have made efforts to offer facilities for breastfeeding or expressing breastmilk are also given in the publication and also in their further publication 'Going Back' (1998).
• A study from America (Cohen et al 1995) comparing the maternal absenteeism and infant illness rates among a self-selected sample of breastfeeding and formula feeding women in 2 corporations, concluded that fewer and less severe infant illnesses and less maternal absenteeism was found in the breastfeeding group. Of the 28% of the infants who had no illnesses, 86% were breastfed and 14% formula fed. One day maternal absences were 3 times more common among mothers of formula fed babies.

There are therefore significant benefits to the employer as well as the family to be gained from establishing a policy for breastfeeding mothers who are returning to work.

Current Legislation & Guidelines on Breastfeeding in the Workplace

(a) EU Directives

Working in the public sector (health service, local government, civil service, police force) gives women the right to continue breastfeeding, as they are protected by European law.

The EU Council Directive 92/85/EEC of 19 October 1992 introduces measures to encourage improvements in the health and safety at work of pregnant workers and workers who have recently given birth or are breastfeeding. It states the need for employers to protect breastfeeding by temporarily altering working conditions, hours of work or offering alternative work. Women do not have to persuade their employer that their baby's health is at risk if they are prevented from breastfeeding, because employers have to safeguard the actual process of breastfeeding. This will require the employer to be flexible about breaks and other working conditions.

(b) UK Legislation & Guidance

• Legislation required to implement the European Directive on Pregnant Workers was introduced into the Management of Health and Safety at Work Regulations (SI No 2051) (1992) by the Management of Health and Safety at Work (Amendment) Regulations 1994 (SI No 2865) from 1 December 1994. They require the employers to protect the safety and health at work of pregnant workers and workers who have recently given birth or are breastfeeding. To make use of this protection, women must notify their employer in writing that they are breastfeeding.
• The Health and Safety Executive produces a guide for employers "New and Expectant Mothers at Work" (1994) which fully explains the general duties of all employers to assess risks to all employees, including new and expectant mothers, and to do what is reasonably practicable to control those risks. The guidance sets out the known risk to new and expectant mothers and gives advice on what is required to comply with the law. Employers are expected to consider the risks from night working, travelling and mental and physical fatigue as well as from potentially hazardous processes (Section 15, page 5).
• The regulations do not put a time limit on breastfeeding. While many women may stop after the first few weeks, the Government, following the COMA Report (1994) recommends exclusive breastfeeding for at least the first 4 to 6 months. After that time, breastfeeding can be continued with advantage together with the safe introduction of solid foods. It is interesting to note that the World Health Organisation (WHO) states that there are health advantages in breastfeeding for up to 2 years or more (WHO/UNICEF 1990). It is for women themselves to decide on how long they wish to breastfeed, depending on individual circumstances.
• The Sex Discrimination Act 1975 Section 1(1)(b) states that there is indirect discrimination if an employer requires a woman to work particular hours (full-time, for example) and states that employers must have a good reason for refusing to let women work flexibly in order to look after children.
• The Health and Safety Executive guide (1994) further suggests to employers that although there is no legal requirement, they would want to consider:
• a safe and healthy environment for workers who are breastfeeding to express and store (breast) milk
• regularly reviewing risks for those workers continuing to breastfeed for many months after birth
• where risks are identified, application of the 3 steps to avoid exposure to the risk; i.e. adjustment of working hours/conditions, alternative work and paid leave, for as long as it threatens the health and safety of a breastfeeding worker or her child
• ensuring that employers are controlling risk from exposure to lead in line with regulations.
• The Workplace (Health, Safety and Welfare) Regulations (SI No 3004) (1992), introduced on 1 January 1996 states that "suitable facilities shall be provided for any person at work who is a pregnant woman or a nursing mother to rest" (para 25). It stipulates minimum standards in the workplace environment and welfare facilities including protection from the effects of cigarette smoke. This is particularly important for a woman in the early terms of her pregnancy and following childbirth.
• The legislation and guidance described in this section are summarised in Appendix 1.

(c) WHO Initiative

• The INNOCENTI Declaration on the Protection, Promotion and Support of Breastfeeding was produced and adopted by participants of the WHO/UNICEF policy makers meeting on "Breastfeeding in the 1990s: A Global Initiative - 30 July/1 August 1990". The UK Government was one of the 30 signatories. In recognising the benefits of breastfeeding the declaration states

"efforts should be made to increase women's confidence in their ability to breastfeed. Such empowerment involves the removal of constraints and influences that manipulate perceptions and behaviour towards breastfeeding, often by subtle and indirect means. This requires sensitivity, continued vigilance, and a responsive and comprehensive communications strategy involving all media and addressed to all levels of society. Furthermore obstacles to breastfeeding within the health system, the workplace and the community must be eliminated." (our emphasis)

• The declaration sets operational targets and suggests that by 1995 Governments should have enacted imaginative legislation protecting the breastfeeding rights of working women and established means for its enforcement.
• UNICEF has also considered breastfeeding as an issue of human rights. In relation to breastfeeding there are 3 particular rights which need to be addressed:

   

  1. the right of a child to food security, optimum nutrition and the highest standard of health;

  2. the right of a woman to be supported in carrying out her role as a mother;

3. the right of a woman not to be discriminated against in the workplace on the basis of pregnancy or maternity.

• It further suggests that once the rights of women in relation to breastfeeding are accepted, then working women will find support more easily obtained and therefore exclusive breastfeeding more easily achieved. (UNICEF 1990)

Approaches by other Countries to the Issues of Work and Breastfeeding

• In many other European countries there is much greater support for women continuing breastfeeding on return to work. It is accepted as an issue of importance. In Scandanavia the ample maternity and paternity benefits enable successful initiation and continuation of breastfeeding, with much public childcare "on site".
• In Norway, breastfeeding mothers are entitled to 2 hours off during their working day to breastfeed.
• The Maternity Alliance (1997) quotes the following other examples:

   

  "In France, a woman breastfeeding a baby under 12 months is allowed two 30 minute breaks per working day.

  In Italy a new mother who works full-time is entitled to 2 daily rest periods of one hour each, and can take them together at the end of the day, to shorten her working day.

  In Spain - working parents of a baby under 9 months old can take an extra hour long break per day or 2 half hour breaks.

  In Portugal - a working woman who is breastfeeding a baby under 12 months can take 2 hour long breaks each working day.

  In Austria a woman who is breastfeeding can take two 45 minute breaks per day if her working day is more than 8 hours or one 45 minute break if her working day is between 4 and 8 hours."

Statutory Maternity Leave, Benefits and Changes 2000

Maternity Leave

• The Government's White Paper 'Fairness to Work' has introduced a change to the basic maternity leave to18 weeks, in 2000.
• 'Fairness to work' now gives women who have worked for the same employer for at least 1 year by the start of the 29th week of their pregnancy entitlement to extended maternity absence. This gives them the right to return to work up to 29 weeks from the week of birth.
• The European Union Parental Leave Directive was also adopted in the UK in December 1999. This gives a minimum of 3 months unpaid parental leave to both men and women after one year's service, with protection from job loss.

Maternity Benefit

• Statutory Maternity Pay (SMP) is paid to women continuously employed with the same employer for at least 26 weeks up to and including the qualifying week (ie the 15th week before the baby is due). At present employees must earn a minimum average of £67 per week to qualify, and from August 2000 the minimum average will be £30. SMP is payable for a maximum of 18 weeks. The basic rate is 90% of salary on payment at qualifying week for the first 6 weeks, then a lower rate of £60.20 (rate from 2 April 2000 to 5 April 2001) for the remaining 12 weeks.
• Maternity Allowance may be payable to a woman who does not qualify for SMP, if she meets certain conditions based on NI contributions. This is also paid for 18 weeks, at a higher rate of £60.20 and a lower rate of £52.25 (rates from 10 April 2000).
• Maternity Payments/ Sure Start Maternity Grant(SSMG).From April 2000, the Maternity Payment will be replaced by the Sure Start Maternity Grant. It is payable to people in receipt of certain benefits. Payments will increase to up to £200 per child, born or due after 11th June 2000, conditional on claimants providing evidence of having received infant breastfeeding advice etc from an appropriate professional.
• (Further information about Maternity Benefits is available from the DSS in booklets CA29: Statutory Maternity Pay Manual for employers and NI17A: A guide to maternity benefits.)

Support for Breastfeeding - The NHS In Scotland

• The legislation gives employers an opportunity to develop their role as good employers. It is particularly important to the NHS in Scotland.
• In The Scottish Office Department of Health Human Resource Policy Statement, "Towards a New Way of Working - The Plan for Managing People in the NHS in Scotland" (1998), reference is made to a "new framework in which people can release their potential and feel properly valued". It urges "everyone involved with the provision of healthcare to rise to the challenge" with a plan for managing people and to "make it happen" (pv).
• Also within the HR Strategy, it is suggested that "an employment framework is put in place which offers both employers flexibility and staff modern employment practices, based on equality of opportunity" and "the environment in which staff work, is safe and secure, free from harassment and gives people the opportunity to manage their own health and fitness" (p.2).
• It suggests as one of its key areas of employment practice to undertake to "establish clear equal opportunity programmes, including the Commission for Racial Equality's standard, which incorporates support for flexible working, job sharing and flexible child care arrangements" (p.8).
• The HR Strategy notes that three-quarters of the NHS workforce is female: about half work part-time and about half are nurses (ie nurses, health visitors and midwives) and it recognises that "the issues of flexible working patterns and career progression, while balancing family commitments are particularly relevant in an organisation which is largely female" (p.8).

Current NHS Initiatives on Breastfeeding at Work in Scotland

• Most Trusts in Scotland are working towards Certificates of Commitment for the UNICEF Baby Friendly Initiative (BFI), which involves an assessment of the hospitals positive approach towards breastfeeding mothers. Facilities are already being made available to ensure mothers are supported to breastfeed within the hospital environment.
• Some Health Boards/Trusts in Scotland have also started to introduce a breastfeeding work place policy for staff.

Some examples of good practice are provided:

In the former Angus NHS Trust, now within the Tayside Primary Care NHS Trust

Prior to implementation of the policy

• An employee, initially encouraged by her health visitor, and then by the occupational health nurse, was able to negotiate accommodation for expressing breast milk on her return to work. The estates department provided a drugs fridge which was surplus to requirements so that her milk could be stored safely.
• An employee negotiated with her manager, a temporary change to working hours so that she was able to continue to breastfeed her baby on her return to work. This entailed removing her from the internal rotation system so that she did not have to work night duty. This was negotiated for 3 months in the first instance, to be reviewed at the end of this time.

Since adoption of the policy

• Accommodation has been made available at each of the hospital sites, and equipped with a low comfortable chair and a 30 litre fridge, exclusively for the storage of EBM. Accommodation is provided in areas such as 'sleep-over' rooms and a little-used office. Privacy in the health centres is available by booking time in interview or consulting rooms.
• Information about the policy is included in both the Management Guidance and the Employees Information Package on 'Maternity Leave and Maternity Pay' issued through the Human Resources Department.

Glasgow

• Within the former Glasgow Royal Infirmary University NHS Trust, in 1998, now North Glasgow University Hospital NHS Trust, a policy for employees returning to work and wishing to continue breastfeeding, following encouragement from the Greater Glasgow Health Board's Breastfeeding Strategy Group, was developed.

The Trust provided:

• a comfortable and private room for expressing breast milk, equipped with a steam steriliser, fridge and wash hand basin, at each of its four hospitals;
• information on all the benefits of breastfeeding and details of support on return to work to all pregnant employees;
• two additional breaks of 45 minutes per 8 or 12 hour shift, if required, to express breast milk; and
• access to midwives for support if necessary.

Health Promotion and the Health Promoting Health Service (HPHS)

The main aim of the NHS in Scotland is 'to improve the health of the people in Scotland' and 'adopt a range of policies which establish it as a health promoting institution, promoting positive health and well-being within hospitals and health centres and thereby setting an example to the organisations in the community and at large'.

Everyone in the health service has a role to play in health promotion and this should be confirmed by their attitudes and actions within the workplace. Appropriate support and management structures need to be in place to ensure that health promotion is an integral and sustainable part of health care, service delivery and organisational/workplace development.

The Health Promoting Health Service framework provides a way of integrating a common language and understanding of health promotion across different health service settings. It can be used to identify needs and develop policies, health promotion programmes, education/training and staff health initiatives.

The Scottish Healthy Choices Award

This award is open to catering establishments who wish to be awarded for providing high quality food including a healthy choice at every course, smoke-free areas and high food hygiene standards. Catering establishments receiving the award must also support mothers who wish to breastfeed.

CONCLUSION

The policy, statement on page 2, is to be implemented by The Scottish Executive and NHS employers in Scotland, in line with current legislation and family friendly policies.

The Scottish Executive as an employer can play an important role in encouraging and supporting mothers who wish to continue breastfeeding after they return to work. The Scottish Executive, by introducing breastfeeding and returning to work policies, can act as a good practice employer for other employers in Scotland. Policies for breastfeeding support for NHS Staff will include similar terms and conditions, but will also need to acknowledge the practicalities of providing 24 hour direct patient care.

An Employers Exemplar

In order to encourage and support mothers returning to work who wish to continue breastfeeding the following will be provided:

(1) Support for Breastfeeding

Human resources policies and procedures should encourage an understanding of the value of breastfeeding and a positive attitude to breastfeeding amongst all staff.

(2) Information to Pregnant Employees

Information sent to pregnant employees should include a brief summary of the benefits of breastfeeding, as well as an explanation of the support mothers can expect upon their return to work. Details of publications, which may be purchased, on breastfeeding after returning to work should also be included.

(3) Working Patterns

Managers should be flexible, with respect to working patterns when a breastfeeding mother returns to work. This may mean temporarily changing working conditions or hours of work. Employees should not be required to work shifts, or to attend training courses or meetings that would involve excessively long working days, which might be detrimental to breastfeeding.

(4) Breastfeeding or Expressing Breast Milk During Working Hours

Where practicable employees should be allowed time off during working hours to breastfeed if their baby is cared for nearby, or to express breast milk.

(5) Facilities available to Breastfeeding Mothers

Facilities available to breastfeeding mothers should include:

(a) Areas for Rest/Expressing Breast Milk

1. These should be clean and warm with a low comfortable chair, and where necessary, the facility to lie down.

2. The area should have a lock or have an arrangement for ensuring privacy.

3. There should be hand washing facilities nearby.

4. There should be an electric point for an electric pump if necessary.

(b) Facilities for Storing Breast Milk

1. There should be a clean area where sterilising equipment may be stored.

2. A dedicated refrigerator should be available for storing expressed breast milk at 2°-4°C until it is taken home.

REFERENCES

Council of European Community Directive 92/85/EEC 19 October 1992 on the introduction of measures to encourage improvements in the safety and health at work of pregnant workers and workers who have recently given birth or are breastfeeding.

Cohen R, Mrtek M B, Mrtek R G - Comparison of Maternal Absenteeism and Infant Illness Rates among Breastfeeding and Formula Women in Two Corporations. American Journal of Health Promotion 1995 Vol 10, 2, pages 148-153.

Cumming R G, Klineberg R J. Breastfeeding and other reproductive factors and the risk of hip fracture in elderly women. International Journal of Epidemiology 1993: 2, No 4: 684-91.

Department of Health Report on Health and Social Subjects. Weaning and the Weaning Diet Report of Working Group on the Weaning Diet of the Committee on Medical Aspects of Food Policy (COMA) London HMSO 1994.

Duncan B, Ey J, Holberg J, Wright A L, Martinez F D and Taussig L M. Exclusive Breastfeeding for at least four months protects against otitis media. Paediatrics 1993; 91. No 5: 867-72.

Foster K, Lader D, Cheesbrough S. Infant Feeding 1995. Survey carried out by the Social Survey Division of the Office for National Statistics on behalf of UK health departments. London: The Stationery Office 1997.

Hartge P, Schiffman M H, Hoover R, et al. A case-control study of epithelial ovarian cancer. American Journal Obstetrics and Gynaecology 1989; 161, No 1, Jul: 10-16.

Health & Safety Executive - New and Expectant Mothers at Work - A Guide for Employers. HS(G)122 HMSO 1994

Howie P W, Forsyth M S, Ogsten S, Clark A, Florey C. Protective Effects of Breastfeeding Against Infection. British Medical Journal 1990; 300; 184-92.

Gwinn M. Pregnancy, Breastfeeding, Oral Contraceptives and the Risk of Epithelial Ovarian Cancer. Journal of Epidemiology 1990 Vol 43, pages 559-568.

Maternity Alliance - Breastfeeding and Work. Facing the Management Challenge. The Maternity Alliance London ISBN 0 946741 40 9 - 1997

Maternity Alliance - Going Back - A Woman's Guide to Returning to Work after Maternity Leave. The Maternity Alliance London ISBN 0946 741 557, 1998.

Maternity Alliance - Child Friendly Working Hours - Your Rights. Maternity Alliance London 1997

Maternity Alliance - Having It All - A Woman's Guide to Combining Breastfeeding and Work, 1997

Mayer E, Hamman R, Gay et al. Reduced Risk of IDDM among breastfed children. The Colorado IDDM Registry - Diabetics 1988 Vol 37, pages 1625-1632.

Newcomb B E, Lactation and a reduced risk of premenopausal breast cancer. New Eng. J. Medicine 1994: 330, No 2: 81-7.

Piscane A, Graziano L, Zona G - Breastfeeding and Urinary Infection. The Lancet 1990, 330:50

Saarinen U and Kajosarri. Breastfeeding as prophylaxis against atopic disease: prospective follow up study until 17 years old. The Lancet 1995 Vol 346, pages 1065-1069.

The Scottish Office NHS MEL(1994)110 - Local Breastfeeding Targets. 22 November 1994.

SHHD/CMO(94)11 and SHHD/CNO(94)14. Weaning and the Weaning Diet. 20 October 1994.

The Scottish Office. Designed to Care: Renewing the National Health Service. 1997

The Scottish Office Department of Health. Towards a New Way of Working - The Plan for Managing People in the NHS in Scotland. The Stationery Office 1998

The Scottish Office Department of Health. Working Together for a Healthier Scotland. A consultation paper. 1998

The Scottish Office Department of Health NHS MEL(1998)63 - Priorities & Planning Guidance for the NHS in Scotland 1999-2002. 1998

Statutory Instrument 1992 No 3004 Health and Safety - The Workplace (Health, Safety and Welfare) Regulations 1992

Statutory Instrument 1994 No 2865 Health and Safety - The Management of Health and Safety at Work (Amendment) Regulations 1994

UNICEF - The Convention of the Rights of the Child 1990

Virtanen S, Rasanen L and Ylonen K. Early Introduction of Dairy Products associated with increased risk of IDDM in Finnish Children. Diabetes 1993 Vol 42 pages 1786-1790.

Wilson A C, Forsyth S, Greene A S, Irvine L, Hau C, Howie P W. Relation of Infant Diet to Childhood Health: Seven year follow up of cohort of children in Dundee infant feeding study. British Medical Journal 1998: 316: 21-5

WHO/UNICEF Innocenti Declaration - Breastfeeding in the 1990's: A Global Initiative: 30 July/1 August 1990