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A call to action: Ensuring reasonable break time for nursing mothers

      The American Academy of Pediatrics and the World Health Organization recommend human milk as the sole means of infant nutrition for the first 6 months of life (
      American Academy of Pediatrics
      Breastfeeding and the use of human milk.
      ). Breastfeeding and the provision of human milk are of upmost importance to ensuring the health of both mothers and infants (
      • Ip S.
      • Chung M.
      • Raman G.
      • Chew P.
      • Magula N.
      • DeVine D.
      • Lau C.
      Breastfeeding and maternal and infant health outcomes in developed countries.
      ). Among the goals for Healthy People 2020 are objectives to increase the proportion of infants who are breastfed (
      US Department of Health and Human Services
      The surgeon general's call to action to support breastfeeding (p. 37).
      ). By the year 2020 it is the goal of the United States to see 25.5% of infants provided exclusively with human milk for the first 6 months of life (
      US Department of Health and Human Services
      The surgeon general's call to action to support breastfeeding (p. 37).
      ). Despite these recommendations, the United States has low national statistics related to both the initiation and duration of breastfeeding. The most recent statistics show 76.9% of infants as “ever breastfed,” whereas rates of exclusivity at 6 months of age plummet to 16.3% (

      Centers for Disease Control and Prevention. (2012). Breastfeeding Report Card 2012, United States: Outcome Indicators. Retrieved from http://www.cdc.gov/breastfeeding/data/reportcard2.htm.

      ). Barriers to obtaining exclusivity are documented throughout the literature. One of the most critical barriers is the need to return to work and the lack of breastfeeding support in the workplace (
      • Ryan A.S.
      • Zhou W.
      • Arensberg M.
      The effect of employment status on breastfeeding in the United States.
      ;

      U.S. Department of Labor. (2012). Frequently asked questions–break time for nursing mothers. Retrieved from http://www.dol.gov/whd/nursingmothers/faqBTNM.htm.

      ).

      Section 4207: Reasonable Break Time for Nursing Mothers

      On March 23, 2010, President Obama signed the Patient Protection and Affordable Care Act Section 4207: Reasonable Break Time for Nursing Mothers was amended to include essential pieces of legislation to protect nursing mothers returning to work and their desire to continue to provide human milk for their infants. Essentially, the amended Section 7 of the Fair Labor and Standards Act (FLSA) requires employers (with more than 50 employees) to provide “reasonable break time for an employee to express breast milk for her nursing child for 1 year after the child's birth each time such employee has need to express the milk; and a place, other than a bathroom, that is shielded from view and free from intrusion from coworkers and the public, which may be used by an employee to express breast milk” (see Table 1). The legislation also stipulates the federal requirements do not deter any state law that has superior protections for nursing mothers returning to work.
      Table 1Considerations for an Exemplary Employee Lactation Support Program
      Reasonable Break Time—need to consider all of the steps necessary to express human milk
      • Consider frequency and number of breaks a nursing mother may require;
      • consider the time to travel to and from a private space;
      • consider the length of time for a session to express human milk (15–20 minutes on average); and
      • consider the time to properly and safely store the expressed human milk.
      Space for expressing human milk
      • May not be a bathroom;
      • shielded from view from coworkers/public;
      • free from intrusion from coworkers/public;
      • when a room is unavailable; curtains or partitions may be used;
      • windows should have window coverings;
      • signage or locks should be provided to ensure privacy;
      • the designated space may be temporary and used only when needed; and
      • minimum requirements: a place to sit, a flat surface (not the floor), and electricity.
      The details supporting the recent amendment to Section 4207 are important to acknowledge. First, for an employee to be covered by the FLSA, s/he must be employed by a business or organization that has a minimum of two employees and (1) an annual dollar volume of sales or business of at least $500,000; or (2) is a hospital, care facility, school/preschool, and/or government agency. If this is not the case, then the employee may have individual coverage under FLSA if his/her work requires the employee to participate in interstate commerce. In addition, there is coverage for nonexempt employees (i.e., hourly workers). Exempt employees would be those persons who work on salary and are exempt from overtime. Often, in this situation there are accommodations already in place to support break time for nursing mothers. However, it is our recommendation to further investigate individual state laws.
      Currently the Department of Labor's Wage and Hour Division is responsible for enforcing the FLSA (inclusive of the newest amended Section 4207: Reasonable Break Time for Nursing Mothers). To assist employers with meeting the standards established, the Wage and Hour Division has created fact sheets and posted Frequently Asked Questions on its webpage (

      U.S. Department of Health and Human Services. (March 29, 2012). 2020 topics & objectives: Maternal, infant, and child health. Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=26.

      ).

      Breastfeeding and Business

      It is estimated that women comprise one-half of the United States workforce, and the fastest-growing segment of the workforce is women with children younger than 3 years of age (

      The United States Breastfeeding Committee. (2012). FAQs: Break time for nursing mothers. Retrieved from http://www.usbreastfeeding.org/Default.aspx?TabId=188.

      ). In the case of employee lactation support, employers are required to follow their state's individual laws. However, in states that do not have legislation in place to promote and protect breastfeeding in the workplace, employers are now subject to the newest federal legislation. Not only does the current legislation promote the health of mothers and their infants, it also benefits employers. Employers who offer lactation support to their employees see overall lower health care costs, absenteeism, and turnover rates (). Further, employees in these establishments report higher job satisfaction, morale, and productivity (

      The United States Breastfeeding Committee. (2012). FAQs: Break time for nursing mothers. Retrieved from http://www.usbreastfeeding.org/Default.aspx?TabId=188.

      ).
      In efforts to assist employers with meeting the requirements for this legislation, the U.S. Department of Health and Human Services offers an excellent resource, The Business Case for Breastfeeding, which was published in 2008 (). This is a comprehensive program that demonstrates how the business/organization as a whole benefits when they support breastfeeding for their employees. The program offers resources to both employers and employees, including a tool kit for building a lactation support program. Furthermore, the documents and tool kits can all be accessed free of charge through the U.S. Department of Health and Human Services Office on Women's Health's website (www.womenshealth.gov).

      Components of an Exemplary Employee Lactation Support Program

      Since 2000, Diane Spatz, PhD, RN-BC, FAAN, (Chair of the Expert Panel on Breastfeeding for the American Academy of Nursing [AAN]) has worked at the Children's Hospital of Philadelphia (CHOP). As the director of lactation services, Dr. Spatz faced a plethora of barriers, including no organizational policies, untrained staff, insufficient equipment and materials, and limited space. With more than 3,000 members of the nursing staff, Dr. Spatz focused her immediate efforts in educating the staff members. Through this process, the staff's knowledge base grew and although the nurses were pleased with the support they were able to provide to their patients and families, there was a lack of breastfeeding support among employees. The nurses questioned what could be done to support breastfeeding employees at CHOP. A multidisciplinary team was formed with the sole mission to create a comprehensive lactation support program. Specific policies and procedures were formulated, and the essential components of the program were outlined. The CHOP employee lactation support program includes the following (

      Spatz, D. L. (2010). Making it happen: Staff education on inpatient breastfeeding leads to employee lactation program. Advance for Nurses, Retrieved from http://nursing.advanceweb.com/Features/Articles/Making-it-Happen.aspx.

      ) components.

      Pump Rooms

      After a comprehensive hospital-wide assessment, it was clear an insufficient number of pump rooms existed (four in the year 2000). A systematic plan was developed to purchase pumps for each unit in the hospital as well as expand the number of pump rooms on the main campus as well as at off-site locations. To date, CHOP has 14 pump rooms available for employees.

      Loaner Pumps for Off-Site Locations

      Despite the expanded number of pump rooms, some off-site locations did not have the physical space to build permanent pump rooms. Therefore, in a partnership with human resources, Symphony (Medela, McHenry, IL) hospital-grade pumps were purchased to fill the need for additional pumping accommodations. Employees complete a contract to receive a loaner hospital grade pump for the duration of their breastfeeding experience. Upon stopping breastfeeding, the pump is returned for future use.

      Pumps for Purchase

      In addition, to ensure maximal flexibility for employees to express milk for their child, a personal use pump-purchase program was added. Employees can purchase a Pump-in-Style (Medela) personal use pump at cost. Employees submit payment to the cashier on main campus and receive a voucher to pick up the pump in the occupational health office. For those employees outside of the main campus, a check is mailed to human resources, and the pump is subsequently delivered. In addition, all employees can take advantage of this program and purchase pumps for family members or friends.

      Expectant Parent Classes and Prenatal Breastfeeding Classes

      Through CHOP's Wellness and Work-Life Balance program, employees have the opportunity to take free classes to learn about new parenting skills. In addition, one of CHOP's internationally board-certified lactation consultants teaches prenatal breastfeeding classes to CHOP employees. Again, these classes are free to all employees.

      Employee Lactation Policy

      Perhaps the most critical piece of the CHOP program is the employee lactation policy. This policy predated the national law and is more comprehensive. The policy includes the following: employees are entitled to suitable private space (that is not a bathroom), employees are allotted 20- to 30-minute breaks for pumping three times a day (arranged with their supervisor) in a typical 8 hour shift—more breaks may be necessary for longer shifts, space is designated to store the expressed human milk while at work, and employees are expected to establish a plan for return to work with their supervisor ahead of time.

      Intranet/Internet Resources

      There is a comprehensive internal website for employees that details information related to hospital standards and policies, the location of all pump rooms, information related to the lactation rental station, the CHOP breastfeeding committee, and all patient family education materials related to breastfeeding. In additional, there is an external website (www.chop.edu/breastfeeding).

      A Call to Action

      Although the law exists, it does not mean that workplaces are actively educating their employees regarding the law or ensuring all components of law are enforced. The Surgeon General's Call to Breastfeeding Action states “Only through the support of family members, communities, clinicians, health care systems, and employers will we be able to make breastfeeding become the easy choice, the default choice” (
      • Wyatt S.
      Challenges of the working breastfeeding mother. Workplace solutions.
      ). To improve the health of mothers, children, and our nation, we all have a role in helping mothers achieve their personal breastfeeding goals. Returning to work should not be a barrier to preventing a woman's breastfeeding success.
      The Expert Panel on Breastfeeding of the AAN urges members to advocate for workplace accommodation for breastfeeding mothers in their local communities. Furthermore, the Expert Panel on Breastfeeding would like to take this opportunity to express a strong need for collaboration and outreach between the AAN and other organizations, groups, associations, and/or employers. It is essential to work together to advance the knowledge surrounding the Patient Protection and Affordable Care Act for both employers and employees. Each of us has a role in our individual communities to ensure that our own workplaces not only follow the law but make it a priority to educate their employees on the law. Hospitals and universities, in particular are difficult organizations with large areas to cover. It is imperative that each nurse and nurse leader take on the task of ensuring implementation of break time for breastfeeding employees. The amendments to Section 7 of the Fair Labor Standards Act of 1938 under Section 4207: Reasonable Break Time for Nursing Mothers, are critical to these efforts to promote successful exclusive breastfeeding in the United States of America. There are resources available; it is up to us to change policy!

      References

        • American Academy of Pediatrics
        Breastfeeding and the use of human milk.
        Pediatrics. 2012; 129: e827-e841
      1. Centers for Disease Control and Prevention. (2012). Breastfeeding Report Card 2012, United States: Outcome Indicators. Retrieved from http://www.cdc.gov/breastfeeding/data/reportcard2.htm.

        • Ip S.
        • Chung M.
        • Raman G.
        • Chew P.
        • Magula N.
        • DeVine D.
        • Lau C.
        Breastfeeding and maternal and infant health outcomes in developed countries.
        Evidence Report/Technology Assessment No. 153. Vol. 7. Agency for Healthcare Research and Quality, Rockville, MD2007
        • Ryan A.S.
        • Zhou W.
        • Arensberg M.
        The effect of employment status on breastfeeding in the United States.
        Women's Health Issues. 2006; 16: 243-251
      2. Spatz, D. L. (2010). Making it happen: Staff education on inpatient breastfeeding leads to employee lactation program. Advance for Nurses, Retrieved from http://nursing.advanceweb.com/Features/Articles/Making-it-Happen.aspx.

      3. The United States Breastfeeding Committee. (2012). FAQs: Break time for nursing mothers. Retrieved from http://www.usbreastfeeding.org/Default.aspx?TabId=188.

      4. U.S. Department of Health and Human Services. (2010). Business case for breastfeeding. Retrieved from http://www.womenshealth.gov/breastfeeding/government-in-action/business-case-for-breastfeeding/.

        • US Department of Health and Human Services
        The surgeon general's call to action to support breastfeeding (p. 37).
        Office of the Surgeon General, Washington D.C.2011
      5. U.S. Department of Health and Human Services. (March 29, 2012). 2020 topics & objectives: Maternal, infant, and child health. Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=26.

      6. U.S. Department of Labor. (2012). Frequently asked questions–break time for nursing mothers. Retrieved from http://www.dol.gov/whd/nursingmothers/faqBTNM.htm.

        • Wyatt S.
        Challenges of the working breastfeeding mother. Workplace solutions.
        AAOHN. 2002; 50: 61-66