Date of Award
Projects: SPU Access Only
Doctor of Nursing Practice (DNP)
Cindy Dong, DNP, ARNP, AGNP-C
Aaberg, Vicki, BS, MSN, PhD
Background and Significance
Many health care organizations including the World Health Organization and the American Academy of Pediatrics (AAP) recommend exclusive breastfeeding for newborns up to six months due to its highly essential benefits (American Academy of Pediatrics 2012; Eidelman & Schanler, 2012). The AAP also recommends breastfeeding should continue up to one-year while supplemental food items are introduced to the infants (Eidelman & Schanler, 2012). Exclusive breastfeeding is recommended because it lowers the risk of type II diabetes and obesity in children (Pugh et al., 2010). Nevertheless, breastfeeding rates in the United States are not satisfactory especially in terms of duration and exclusivity (Center for Disease Control and Prevention, 2020). According to Fein and Roe (1998), full-time working mothers at three-month postpartum had an average of 8.6 weeks lower breastfeeding duration than non-working mothers. The same authors also found that working part-time for three months increased the duration of breastfeeding but was still less than those of the non-working mothers. Only 10% of full-time working mothers breastfed at six months, which is three times less than those of the stayed-home mothers. This discovered trend suggested work as a significant negative impact to breastfeeding duration (Bai et al., 2015; Wolf, 2003).
Maternal employment poses major challenges to the continuity of breastfeeding practice. The association between maternal employment and low breastfeeding rates was evident across all ethnic, age and education groups in this study (Wolf, 2003). Although exclusive breastfeeding leads to higher productivity and lower absenteeism from work for lactating mothers, they could have lower breastfeeding compliance rate due to employer pressure, lack of frequent breaks, and no place to pump when at work (Schmied, et al., 2019). Organizational and managerial support are crucial for workplace breastfeeding support (Murtagh & Moulton, 2011; Schmied, et al., 2019).
Problem and Purpose Statement
This Doctoral Nurse Practitioner (DNP) project partnered with an Agency (referred to as “Agency” hereinafter) that is located in the Greater Seattle Area. The Agency provides primary care services to a patient population that is both ethnically diverse and economically underserved. Historically, a significant portion of the Agency’s obstetric patients discontinued breastfeeding upon returning to work due to the lack of breastfeeding nursing room, frequent breaks, and employer support (ICHS, 2020). The Agency aims to increase employers' support in breastfeeding through educational training with the Women, Infant and Children (WIC) program. This DNP student partnered with the Agency to facilitate and help mothers overcome some of the barriers. The goal of this DNP project was to create, implement, and evaluate an educational tool for registered dieticians, social worker, registered lactation nurse, and lactation consultant to guide lactating mothers, both working and soon-to-be working, on how to negotiate for a breastfeeding-friendly environment with their employers. Given the lack of pre-existing training program, this project also surveyed and compared participants’ confidence levels before and after the intervention to evaluate the effectiveness of the educational tool.
The implementation design of this project followed the Plan-Do-Study-Act (PDSA) cycle. This DNP student created a two-page education training tool as a teaching guide for the participants in the “Planning” phase that is based on the Breastfeeding Coalition of Washington guidelines and the United States Breastfeeding Committee (USBC). During the “Do” phase, the project lead recruited and intervened 10 participants virtually via phone calls in the Agency due to social restrictions of Covid-19 from April to June 2021. The recruitment criteria were the Agency obstetric patients enrolled in the WIC program. They must be over 18-year-old, within 12 months since their most recent delivery, currently working or planning to return to work within a year, and planning to breastfeed exclusively. This DNP student collected demographic information and implemented a 30-minute education session for the participants one at a time. The “Study” phase of the PDSA cycle involved with using preliminary descriptive analysis to study the frequencies and percentage of demographics variables. Comparison of the 7-point Likert scale questions pre- and post-training was used to evaluate the effectiveness of the teaching tool. The project leads did not carry out the final “Act” stage of the PDSA cycle in this DNP scholarly project because it will take place after modifications and potential recommendations have been made to the Agency.
Demographically speaking (Table 1), the majority of the participants (80%) were aged 35-45, and 20% were aged 46 to 55 years old. Half of the women (50%) had a high school diploma, 40% had an elementary degree, while only 10% had a college/university education. Only 10% of the participants were working part-time, while 90% of mothers were unemployed but had plans to return to work within a year. Black or African American comprised 60% of the subjects compared to 40% were Asians. The majority (70%) of the mothers were married, and 100% were multiparous. Sixty percent of the most recent newborns were aged four to six months and 30% were from seven to ten months. The majority (80%) of the mothers had a vaginal delivery with no complications.
In a seven-point Likert scale survey regarding their breastfeeding-friendly environments, the majority (60%) of the mothers agreed their leading cause to discontinuing exclusive breastfeeding was due to the lack of support from their employers. Forty percent of the mothers indicated that they could not have a quiet place other than a bathroom to pump breastmilk at work. Only 10% reported of having a designated space to nurse or pump breast milk at their workplace. Sixty percent of the mothers said their supervisor was not supportive. Twenty percent of the mothers strongly disagreed that breastfeeding was shared at their workplace, while only 30% felt comfortable taking breaks during the work hours to pump breast milk (see Table 2).
When comparing the difference before and after intervention in participants' comfort level to negotiate for a breastfeeding-friendly workplace with their employer, there was a drastic increase of participants’ comfort level, as evidenced by an increase from 10% to 70% of participants who rated themselves as “extremely comfortable” negotiating. When asked how likely they were to negotiate for a breastfeeding-friendly workplace, both “extremely likely” and “very likely” respondents increased from 0% and 0% before the training, respectively, to 40% and 30% after the training. Although this result may suggest a significant improvement in the participants' comfort level, the p-value was irrelevant due to the sample size being very small (N=10). Thus, additional work will be needed to evaluate the effectiveness of the educational training tool.
In parts of the sustainability plan, the Agency’s outpatient obstetric dietician may utilize this training tool to provide one-on-one education for working mothers to negotiate for a breastfeeding-friendly environment. The Agency will review and adopt changes based on the data gathered from this DNP project and additional financial considerations. Since this project was delivered virtually over the phone due to COVID-19 restriction, further adaptation measures must taken into consideration of the possibility to transition from virtual to an in-person and group meeting setting. The WIC program may also develop a brochure of the educational tool to benefit breastfeeding mothers who plan to return to work.
Implications for Nursing
Nurse-led consultation and registered dietician appointment have a pivotal role in addressing lactating mothers' concerns regarding breastfeeding and returning to work. This DNP project suggested that educational training may be useful to inform lactating employees of their rights to self-advocate for a breastfeeding friendly workplace. To preserve a desirable exclusive breastfeeding rate among working mothers, it is necessary and invaluable for nursing researchers to continue looking into effective ways to deliver quality education to support this vulnerable population on this matter.
American Academy of Pediatrics. (2012). Breastfeeding and the use of human milk. PEDIATRICS, 129(3), e827-e841. https://doi.org/10.1542/peds.2011-3552
Bai, D. L., Fong, D. Y. T., & Tarrant, M. (2015). Factors associated with breastfeeding duration and exclusivity in mothers returning to paid employment postpartum. Maternal and child health journal, 19(5), 990-999. http://dx.doi.org/10.1007/s10995-014-1596-7
Centers for Disease Control and Prevention. (2020). Breastfeeding guidelines & recommendations. https://www.cdc.gov/breastfeeding/recommendations/index.htm
Fein, S. B., & Roe, B. (1998). The effect of work status on initiation and duration of breast-feeding. American Journal of Public Health, 88(7), 1042-1046. https://doi.org/10.2105/ajph.88.7.1042
Murtagh, L., & Moulton, A. D. (2011). Working mothers, breastfeeding, and the law. American Journal of Public Health, 101(2), 217-223. https://doi.org/10.2105/ajph.2009.185280
Pugh, L. C., Serwint, J. R., Frick, K. D., Nanda, J. P., Sharps, P. W., Spatz, D. L., & Milligan, R. A. (2010). A randomized controlled community-based trial to improve breastfeeding rates among urban low-income mothers. Academic Pediatrics, 10(1), 14-20. https://doi.org/10.1016/j.acap.2009.07.005
Schanler, R. J., Eidelman, A., & L. (2012). Breastfeeding and the use of human milk. Pediatrics, 129(2), e827-e841. https://doi.org/10.1542/peds.2011-3552
Schmied, V., Burns, E., & Sheehan, A. (2019). Place of sanctuary: An appreciative inquiry approach to discovering how communities support breastfeeding and parenting. International Breastfeeding Journal, 14(1). https://doi.org/10.1186/s13006-019-0219-8
Wolf, J. H. (2003). Low breastfeeding rates and public health in the United States. American Journal of Public Health, 93(12), 2000-2010. https://ajph.aphapublications.org/doi/pdfplus/10.2105/AJPH.93.12.2000
Dakane, Ahlam Mohamed, "Implementation of a Workplace Breastfeeding Promotion Training for Working Mothers" (2022). Doctor of Nursing Practice (DNP) Scholarly Projects. 30.