Supporting breastfeeding at work in a public sector setting: A qualitative exploratory study among managers and employed mothers

Background: Return to employment is a major barrier to breastfeeding continuation, globally and in the Southern African context. The Lancet breastfeeding series revealed an explicit need for research exploring breastfeeding as a workplace issue in low- and middle-income countries. A dearth of research on workplace breastfeeding in South Africa, and limited awareness about legislation to protect breastfeeding employees, calls for attention to this topic. Methods: This qualitative study explored experiences of workplace breastfeeding amongst employed mothers and senior managers in two provincial government departments in South Africa. Twelve in-depth interviews were conducted with senior managers ( n = 4) and employed mothers ( n = 8). Results: Thematic analysis of the data revealed findings important to understanding mothers’ decisions about breastfeeding at work, across three critical maternity periods: 1) During pregnancy: poor knowledge about comprehensive maternity benefits and an absence of a conversation on infant feeding plans with managers meant mothers were disempowered to make informed choices about breastfeeding at work; 2) During maternity leave: stress from anticipated work-family conflict and logistical considerations influenced mothers’ decisions to wean infants; and 3) Upon return to work: mothers experienced a lack of workplace infrastructural support for breastfeeding. Conclusion: Our study contributions emphasise that breastfeeding support from managers should begin prior to the mother taking maternity leave. Immediate supervisors were found to be an important but overlooked agent to enforce legislation and provide breastfeeding support. Implications for management for advancing support for breastfeeding at work in the public sector are presented. This study provides important new insights into the experiences among mothers and managers in a provincial government context in South Africa, a middle-income country. Our findings show that managers and mothers did not discuss breastfeeding after returning to work and the needed support at any point in time from the mother’s pregnancy to their return to employment from maternity leave. Accordingly, breastfeeding was not viewed as a workplace issue.


Background
Breastfeeding is a key child survival strategy to prevent childhood illnesses and deaths. Positive economic and environmental changes and improved maternal health have also been associated with breastfeeding [1]. Current data on breastfeeding practices in South Africa shows that 93% of mothers initiate breastfeeding within the first hour of birth, but that only 24% of infants are breastfed exclusively by age four-five months [2,3]. South Africa has had a history of the lowest exclusive breastfeeding rates in the world at eight percent between 1998 and 2012 [2]. While improvements have been made [4], the progress is still too slow and far from the Global Nutrition target of 50% by 2025 [5].
Return to employment is a major reason breastfeeding is compromised both globally [6][7][8][9] and in the Southern African context [10,11]. Not surprising, breastfeeding at work is a complex work-family issue because in order to maintain the World Health Organisation's (WHO) recommendation to breastfeed exclusively for the first six months of the infant's life [12], most mothers must engage in this responsibility in the time and space of paid work. Employed mothers tend to stop breastfeeding in preparation to return to workplaces that are not conducive to maternal needs [13] [14]and breastfeeding mothers often fall short of the ideal worker ideology around which organisations are built. Ideal employees single-mindedly devote their efforts to organisational goals [15], not allowing distractions such as reproductive needs which are experienced by pregnant and breastfeeding mothers [14]. Workplace breastfeeding support could make positive contributions by decreasing absenteeism, job dissatisfaction, staff turnover and improve staff retention [16][17][18].
In South Africa, since the first democratic elections in 1994, there has been an increase in the number of females in the labour force because of feminist supportive legislative policies that promoted access to education and employment. According to the 2019 Quarterly Labour Force Survey (Quarter 2) 44.6% of the employed labour force were female, of which most (30.7%) were in the formal sector [19]. The increased female representation [20] has focused the government's attention on laws that promote gender equality, such as 17 weeks unpaid maternity leave with a subsidy of 66% of the mother's salary that can be claimed from the Unemployment Insurance Fund[21]. With the optimal infant feeding recommendation being six months exclusive breastfeeding [12], mothers returning to work at four months or earlier would need to breastfeed or express milk whilst in the workplace. Thus the state also provides for legislated breastfeeding breaks at work, for 30 minutes twice per working day for the first six months of the child's life [22]. Unfortunately, the limited available literature has shown great ignorance and poor enforcement of the legislated maternity protection by South African employers, particularly regarding breastfeeding breaks [23].
While current workplace breastfeeding literature is mostly from high income countries, research from low and middle-income countries in the Global South are lacking in providing a contextually rich understanding of employed mothers' breastfeeding practices and salient forms of support to advance breastfeeding at work. Nuanced insights can inform context specific interventions [24,25]. The aim of this study was therefore to explore experiences of workplace breastfeeding among employees and managers in provincial government in South Africa to gain an understanding of the contextual specificities that shape this phenomenon. This in turn could inform appropriate interventions for creating breastfeeding supportive workplaces and help contribute to the international body of literature.

Study design
An exploratory qualitative design with multi-perspective in-depth interviews was used [26]. Senior managers and employed mothers were interviewed to explore their experiences of breastfeeding at work. The use of more than one group of participants was effective in ensuring a richer understanding of the subject compared to single perspective interviews [27].

Study setting and participants
The study focuses on breastfeeding at work experiences within the provincial government, being the largest employer of all government sectors. The government sector aims to serve as a model employer and hence provides fully paid maternity leave for the legislated four months. The Western Cape province is the fourth largest province in South Africa by population and its provincial government employs 81 000 individuals, 52% of which are female. Two of their 13 departments participated in the study. Criteria for inclusion in interviews for managers were that they have supervised pregnant employees who returned to the same workplace after maternity leave. For mothers, those who had babies and returned to the same workplace in the previous two years, were eligible to participate in the study. Emails were sent to heads of departments inviting eligible employees to participate. With no replies to the invitation, the first few participants were then found through contacts of provincial government employees who were part of a larger research project in this area. Thereafter we relied on snowball sampling. Interview arrangements were made with the 12 participants directly, eight of whom were mothers and four were managers.

Data collection
The interviews were conducted between April and August 2018 by a small team of interviewers. Each interview lasted between 30 to 77 minutes and were conducted at the participants' workplaces. In a conversational manner, participants were asked to share personal breastfeeding experiences or experiences of supporting breastfeeding employee(s) upon return to work post maternity leave, as well as how they thought that support for breastfeeding at work could be improved. Basic demographic data were also collected to describe the sample. All interviews were conducted in English.

Data Analysis
The audio recordings of the interviews were transcribed verbatim by a professional transcription company and pseudonyms were used for names and departments. Raw data was imported into NVIVO 12 Pro, a computer software program used to manage qualitative data. Inductive thematic analysis was used where themes were generated from responses and not guided by structured questions or theory [28]. The analysis started by the researchers reading and rereading the raw data repeatedly to become familiar with the data. Data that provided insight towards answering the research question was coded. Following critical analyses, initial themes were reviewed, redundant codes were removed, and themes were renamed [28]. The second and third authors independently read the raw data and together all authors reached consensus on the main themes and presentation of the data [29]. Time specific themes emerged for three critical phases for supporting breastfeeding at work: pregnancy, maternity leave, and the return to work. A summary of themes per time phase are presented in Table 1.

Results
Participants had diverse characteristics in gender, race, level of education and age. All except one participant had post graduate qualifications and held professional positions. Three of the four managers were male (Table 2).

Minimal discussion about maternity benefits with pregnant employees
Most participants did not have knowledge of their full maternity protection rights, other than knowledge of legislated four months maternity leave and time off for prenatal visits. Only a few mothers reported knowledge of the option to apply for a maternity leave extension to six months, but shared that they did not apply for it in fear of their manager thinking that they were trying to take advantage of the circumstances, as maternity leave tended to be viewed as a holiday. Others chose not to apply for it because it was unpaid and there was a financial necessity to return to work. As a result, some mothers described doing their own research, most commonly on the internet, to find out information about their maternity rights, such as breastfeeding breaks (Box 1).

Box 1: Mothers' and managers' perceptions of the pregnancy period
Breastfeeding not talked about at work "Actually no [conversation about breastfeeding], the only discussion we have had in terms of that, is okay, what plans and arrangements are you going to make when the maternity leave is [over]…Who is going to look after the baby, and those kind of things. I don't know if every woman is comfortable discussing their personal matters like that especially with a male principal…but I have never had a discussion, maybe it is something I need to think about going forward." (Manager 1) "I think the conversation ended there after me telling them I am expecting a baby. There was no conversations about how I am going to handle the pregnancy or whatever or breastfeeding later on, so no conversations like that". (Mother 5) Fear of exercising maternity rights "I didn't [have any conversation about the possibility of extending maternity leave]. I must admit I was actually dying to have that conversation with my boss, but I also didn't want to give that impression that I am trying to ride this leave out, or take advantage of the situation. (Mother 5) "The fact that I couldn't take maternity leave for longer, even that was under question, taking the full four months. So I didn't dare ask them for anything more." (Mother 1) Mothers search for information on their own "I went and found the policy and so I took it upon myself to educate them [my manager] around what the policies are, because I did feel conscious that I am going to have to express and it is going to take time." (Mother 2)

Maternity leave phase
Most mothers shared that during their maternity leave they started to become anxious thinking about how to provide optimal nutrition for their infants after returning to work. This was because of: the lack of decent space to express at work and adequate storage for mother's milk, working with painful breasts, and commuting for hours with expressed mother's milk. Consequently, most mothers decided to wean their infants before or shortly after returning to employment. A few mothers made plans during their maternity leave to maintain exclusive breastfeeding and started storing milk for when they were back at work (Box 2).

Box 2: Mothers experiences of the maternity leave phase
"I just sorted it out myself before I came back to work because I knew I was going to work with kids and I don't want to feel uncomfortable and now you are teaching and suddenly there is a wet patch. I decided to do that [stop breastfeeding and started the baby on formula] before I went to work so by the time I returned to work there was nothing [no milk leaking]". (Mother 7) "I think speaking about the commuting and not only the actual carting of the milk from here to there, that is obviously one of the problems but the ultimate thing was I was afraid of the contamination and of the spoiling of the milk because it is a long day. For me to leave at eight and get home after six or seven and still question whether the milk is fine and so I would rather prepare a formula feed and know that this bottle has been sterilised and the milk is fresh and I am not going to cause my baby to get ill or anything like that." (Mother 5) "So, I started probably two or so weeks before I came back and I started expressing and freezing milk. So, we had a backup in the freezer supply and then obviously I ensured that there was at least four bottles for him in the fridge and then during the day at work I expressed two bottles." (Mother 8)

Return to work phase
Upon return to employment mothers reported stress dealing with conflict between work demands and their infant's breastfeeding needs and expectations to be efficient at work whilst experiencing discomfort from full breasts because of a lack of facilities to express mother's milk. In the few instances where mothers experienced support supervisors, co-workers and supportive facilities were effective enablers (Box 3).

Workplace supportive breastfeeding facilities
None of the work spaces in the two departments provided supportive infrastructure for mothers to breastfeed or express mother's milk during the workday. A third department (not part of this study), did have a breastfeeding room available that was offered to mothers from other department to use.
However, it was often not a logistically viable option to access during the 30 minutes breastfeeding break as it was in a different building. While few mothers could use this facility enabling their continued breastfeeding, other mothers used the bathroom or offices to express. Managers were not aware of the legislation recommending a conducive environment and breastfeeding breaks. (Box 3).

Social supportive enablers
Few mothers reported to have continued breastfeeding exclusively after returning to employment and stated that supportive supervisors and co-workers were important enablers. On the other hand, some mothers shared that co-workers were resentful of mothers who expressed at work, suggesting that they were 'avoiding work'. Mothers in more senior positions who maintained exclusive breastfeeding reported that their seniority and consequently levels of autonomy might have influenced their agency to demand support from their managers. None of the mothers knew anyone who had breastfed at their workplaces and thus had no positive role models. Managers described not having received any requests for breastfeeding support from employees and thus did not consider it to be a priority.
However, a few managers were willing to offer flexible arrangements to accommodate mothers returning from maternity leave, but these gestures were not specifically related to breastfeeding (Box 3).

Box 3: Mothers' and managers' experiences of the return to work post maternity leave
Stress from juggling work and breastfeeding needs "I remember also going home every day with really sore breasts because I wasn't expressing at school and so the milk was building up and building up and it becomes so full and so painful and I also thought this time around [with a new baby] I wouldn't want to go through that again because it is embarrassing if it breaks through and milk spilling out… you come to work and smile on your face and go on teaching as normal but you are actually there with full breast and in pain." (Mother 5) "…you come back, no one is talking to you to ask if you are breastfeeding or just to assist you when you come back." (Mother 4) Lack of breastfeeding infrastructure "I think what motivated me to stop [breastfeeding] besides the fact that I didn't have much milk was the fact that the toilet I was using, they were renovating them and so I did not have anywhere else to express." (Mother 3) "This is a very unfortunate part because the government doesn't have [facilities] and most offices there are no infrastructure for breastfeeding." (Manager 2) Support from co-workers "The rest of the people [colleagues]were absolutely brilliant and if they knew I was pumping then they would make sure no one would come in and that kind of thing, so they respected that and everything and they were just supportive." (Mother 1) Support from supervisor " my job requires me to be out in the field and travel a lot and he [supervisor] actually said he understands that and he is limiting my operations to day trips so in the metro and the winelands so I don't have to sleep over in the west coast and stuff like that. So in terms of his overall [support] he is very accommodating. ( Mother 8) This study provides important new insights into the experiences of workplace breastfeeding support among mothers and managers in a provincial government context in South Africa, a middle-income country. Our findings show that managers and mothers did not discuss breastfeeding after returning to work and the needed support at any point in time from the mother's pregnancy to their return to employment from maternity leave. Accordingly, breastfeeding was not viewed as a workplace issue.
Senior managers perceived breastfeeding as an issue that mothers took care of privately without any consideration of its impact on mother's wellbeing and job performance. Mothers on the other hand resorted to privately using bathrooms and offices to express milk, as they struggled to reconcile breastfeeding with employment.
Researchers have argued that the perception of breastfeeding as a personal issue is consistent with the view of breasts as private sexual objects. Breastfeeding is associated with an emotional, leaky body that is in conflict with the ideal worker ideology [30][31][32]. The disapproval of breasts in public spaces leads to feelings of discomfort and shame which when combined with non-supportive workplaces result in early breastfeeding cessation as was evident in this study [33]. Consistent with previous research, managers expected mothers to request breastfeeding support when they required it [34], while most mothers were too afraid to 'rock the boat' and hence avoided taking advantage of their full maternity benefits. [35] A study in the United State found that it was unlikely that mothers would request support at non-supportive workplaces thus creating a false belief that there is no demand nor need for breastfeeding support. The passive tendency to expect mothers to demand support creates a vicious cycle where mothers hold back out of fear of negative consequence(s) and keep breastfeeding needs a secret, while managers withhold support maintaining an unconducive work environment for mothers' breastfeeding needs [36]. Our study confirms these findings that mothers lacked confidence to request support, despite most mothers in this study being highly educated and holding professional jobs.
Similar to findings from a South African survey [23], most participants lacked knowledge of the legislation on breastfeeding breaks. Only a few self-informed mothers had researched the full benefits available to them as government employees [37,38]. Poor knowledge dissemination within the public sector and a bureaucratic system that impedes creativity in policy adoption, could contribute to poor implementation of breastfeeding legislation at work [23]. The managers in the study expressed a sincere willingness to support mothers to breastfeed at work if given the necessary training, and the study findings imply that immediate supervisors of pregnant and breastfeeding women (more so than senior management) could be champions for change. These findings are consistent with prior research which can be attributed to immediate supervisors' autonomy to control day-to-day utilisation of resources and policies and to restructure the work time and place to meet employee needs as senior managers are distant from employees daily activities [34,35,39]. Similarly, research shows that mothers thought empathetic supervisors would ease their stress and enable access to maternity benefits, taking the pressure off them to initiate conversations about workplace breastfeeding [39].
Thus, formal breastfeeding at work programs without supervisor support has been shown to result in poor uptake of work-family benefits 49 .
Anticipated work-family conflict [40,41] experienced by mothers during maternity leave contributed to them weaning their infants sooner than six months. Furthermore, socio-structural barriers such as work travel and lack of infrastructure at work contributed to increased anxieties and feelings of not being supported to maintain breastfeeding. New insights from this study revealed that workplace breastfeeding support should be initiated from pregnancy through maternity leave until after returning to employment. Most workplace breastfeeding literature has focussed on support when the mother has returned to employment, but our findings suggest that this is too late. In the absence of any conversation on reconciling work and breastfeeding prior to the mother going on maternity leave, many mothers tend to cease breastfeeding during maternity leave in preparation to return to work [11,38,42]. We also suggest that employers and the Human Resource office provides supportive information during maternity leave to ease stress experienced by mothers during this phase. Similar to existing studies, we recommend increasing awareness about the legislation and enforcing its implementation in line with good employment practice [34,43]. Furthermore, for improved workplace support, suggestions for management include: developing a written breastfeeding at work policy that is well communicated through various channels to all employees (not just mothers), identifying private spaces with appropriate mother's milk storage, training supervisors to offer appropriate support, providing flexible work arrangements and on-site child care [44]. Increasing the 30 minutes allocated for breastfeeding breaks and extending maternity leave to 6 months could moderate stress and enable continued breastfeeding beyond the first six months.

Limitations
The use of workspaces for interviews might have restricted the mothers' openness about negative experiences they might have had in their workplaces. However, the researchers were trained in qualitative research and probed often to get more information from participants and read their body language for signs of discomfort. Experiences from mothers in lower job positions might have been missed as the majority of study participants held professional jobs. Transferability and application of the findings should be limited to countries with similar demographics and national maternity benefits.

Conclusion
This study revealed that breastfeeding needs to be viewed as an important workplace issue. The main findings from this study were that comprehensive support initiatives should begin as early as pregnancy and continue once the mother returns to employment. Also, conversations between pregnant mothers and their immediate supervisors about the mothers intended breastfeeding needs after returning to work would be beneficial in fostering breastfeeding friendly workplaces. Further indepth research is needed to explore the explicit nature of the support for breastfeeding at work that should be provided by the immediate supervisors. This study has provided new insights on workplace breastfeeding support in a provincial government context from a middle-income country marked by low rates of breastfeeding. The findings can inform strategies for employers and policy makers towards creating supportive workplaces for breastfeeding.

Availability of data and materials
The datasets used and analysed during the current study are available from the corresponding author upon reasonable request.