The compelling case for supporting pregnancy and breastfeeding in the workplace

 Department of Paediatrics and Child Health, University of KwaZulu-Natal, Durban, South Africa


Correspondence: Dr Penelope Reimers, Department of Paediatrics and Child Health, University of KwaZulu-Natal, 719 Umbilo Rd, Durban 4001, South Africa. e-mail:



The Lancet Breastfeeding Series is a comprehensive study that evaluated breastfeeding globally, and researched the short- and long-term implications of not breastfeeding on maternal and infant health in low- and high-income countries. The evidence has provided opportunities to eliminate the identified barriers to breastfeeding, and turn the tide on the unacceptably high infant and maternal mortality and morbidity rates. Highlighted in the report were the increasing numbers of women in the workforce, the negative effects of work on breastfeeding, and the urgent need to reduce barriers to breastfeeding within the workplace by ensuring maternity protection, support and nursing breaks for working mothers. Commitment by governments, society and businesses is urgently required to provide enabling environments, societal acceptance of breastfeeding as the norm, and workplace policies that enable women to breastfeed optimally. The Lancet Series warns that, without this, the “major losses and costs will be borne by generations to come.”


Keywords: breastfeeding, employment, workplace, lactation support, workplace interventions



In recent years, there has been an exponential increase in the number of women employed outside the home, without much time and attention paid to issues around pregnancy and breastfeeding in the workplace. In fact, working and breastfeeding have been largely regarded as mutually exclusive. However, a wealth of research regarding the health and economic benefits of supporting breastfeeding makes this topic increasingly unwise to ignore. Having an organisational culture supportive of pregnancy and breastfeeding is imperative to ensure early intervention and good outcomes for both the mother and her infant.1 In addition, legislation in South Africa demands that the rights of the pregnant and breastfeeding woman, and those of her infant, are protected. 2-6



The World Health Organization (WHO) recommends exclusive breastfeeding for the first six months and advocates continuing breastfeeding for two years and beyond. In South Africa, the prevalence of exclusive breastfeeding is estimated to be only 25.7% at six months.7

The recent Lancet Breastfeeding Series, published in 2016, presented compelling evidence about short and long-term health implications of breastfeeding, and how critical it is for reducing mortality and morbidity of both mother and child.8 This holds true for low-, middle-, and high-income countries.

There is evidence that improving breastfeeding practices could, globally, save the lives of over 820 000 children a year: 13% of all deaths under five years of age. In addition, increasing breastfeeding can prevent nearly half of the cases of diarrhoea and one third of respiratory infections – both leading causes of death among children aged under five years. In terms of maternal health, improved breastfeeding rates could save 20 000 deaths from breast cancer and reduce the incidence of ovarian cancer. 8 The Lancet Series found that cognitive losses in children who were not breastfed resulted in an estimated reduction in annual earning potential of $302 billion.8 In light of the overwhelming evidence, countries and governments are duty-bound to introduce policies supportive and protective of breastfeeding; it is a win-win solution for all.



Maternal employment is a leading cause for not initiating or continuing breastfeeding10 and short maternity leave (< six weeks) is responsible for a fourfold increase in the cessation of breastfeeding.11 The Maternity Prevention Convention of the International Labor Organization (C183) has laid down recommendations for paid maternity leave and lactation breaks.12 These include maternity leave of longer than 18 weeks, with a minimum of six weeks compulsory leave after delivery; daily breaks or reduction in working hours for nursing mothers; the provision of facilities for nursing mothers; and payment of maternity benefits of not less than two-thirds of the salary.

This Convention has not been fully adopted in South Africa (SA). Maternity leave in SA is less than 18 weeks, and daily breaks and a reduction in working time for breastfeeding mothers are suggested but seldom provided, as are breastfeeding facilities in the workplace; maternity benefits are less than two-thirds of the salary. Only 53% of                 185 countries included in the Lancet Breastfeeding Series met the 14-week minimal standard, and only 23% met the recommendation of 18 weeks leave.8 In the informal work sector, almost 80% of working women, who live mainly in Africa and Asia, have no maternity benefits at all.8

In Europe, daily breastfeeding breaks for mothers range from    60 minutes in Spain, to two hours in Norway, Austria and Italy.13 In South Africa, the Basic Condition of Employment Act Code of Good Practice suggests that women with an infant younger than six months be allowed two 30-minute breaks during the working day, to either breastfeed or express breast milk.3 No provision is made for babies older than six months. However, the powerful Normalise Breastfeeding social media campaign in South Africa has lobbied government, and legislation changes to further accommodate breastfeeding women at work and in public have been proposed.13

The South African Constitution grants all South African women formal recognition as citizens equal to men. Consequently, women may not be discriminated against on the grounds of gender or pregnancy. It is interesting to consider whether breastfeeding could be regarded as a woman’s right, as first suggested by Labbok.14 If a mother’s choice to breastfeed were considered her right, then simply returning to employment should not deny her that right. Nor should it deny her child who, under separate Acts, is entitled to the right to the highest attainable standard of health, the right to be breastfed.15,16



The law clearly protects the rights of pregnant and breastfeeding women in the workplace, and employers are obligated to supply information and training regarding related risks to health and safety, and how to minimise these risks.3 Allowing women the time to attend antenatal clinics is also mentioned. Despite this, many women feel disadvantaged when pregnant, as pregnancy is often not welcomed by employers and colleagues. It is viewed as an inconvenience that is disruptive to work and that places more pressure on colleagues who will carry the burden during the maternity leave. Consequently, many delay the announcement of their pregnancy.17

Women who feel that the organisational structure is supportive will report pregnancies early, ensuring that the necessary steps are taken to conduct a risk assessment of the physical, chemical, ergonomic and biological environments in which they work. The early weeks of pregnancy are the most critical for exposure and potential detrimental effects on the developing foetus. A supportive culture contributes to reduction in stress, decreasing the risk of preterm delivery and contributing to greater job satisfaction. Balancing the dual role of mother and employee provides significant challenges to pregnant women, and the work culture largely determines maternal psychosocial health and intentions to return to work after maternity leave.18



Research has shown that the most powerful workplace interventions to support breastfeeding women are education of employed mothers on the management of breastfeeding with employment;19-25 enhancing the employer’s knowledge about the benefits of supporting breastfeeding;26,27 providing physical facilities for lactating mothers;28-30 having childcare facilities within or close to the workplace;31 providing storage facilities for expressed breast milk; 32,33 allowing job flexibility;34,35 and developing mother-friendly policies that support breastfeeding. 36 Table 1 lists prerequisites for enabling women to sustain lactation and express milk during their working days. 37

Breastfeeding policy

A written breastfeeding policy should be communicated to all employees prior to pregnancy. The policy should address education around the initiation and sustaining of breastfeeding during maternity leave planning; advice on the transition from maternity leave to employment and the resultant impact on breastfeeding; and breastfeeding breaks allowed and facilities available for expressing milk. In Australia, where companies communicated their breastfeeding policies, 61% of women were exclusively breastfeeding at six months; where there was no policy or women were unsure if one existed, only 34% were exclusively breastfeeding.38


Enhancing skills and knowledge

Education around lactation and breastfeeding should include how to start breastfeeding immediately after delivery, realistic expectations around demand feeding, boosting maternal confidence by providing skills to deal with common problems, and ensuring that women have support on hand. Tables 2 to 4 list helpful information for nurses within the occupational health setting to share with lactating women. Knowledge about how to combine work and breastfeeding is also essential, as is advice on effective milk expressing techniques.


Many women are unaware of their rights to breastfeeding breaks and many employers are equally unaware that these breaks are a legal requirement. Due to the sensitive nature of breastfeeding, employees do not feel confident about raising the issue with management, and trade unions generally do not see breastfeeding as an important issue. Some workplaces do not provide a clean, private, appropriate place for women to express milk and, as a result, some women are forced to use public toilets for this activity. Attitudes around inadequacy of breast milk to meet the needs of their infants and fears around insufficient supply are common, and can be addressed through education, self-efficacy and good breastfeeding practices.



Increasing awareness should be done through establishing support groups to educate and inform women about breastfeeding at work, and using women who have successfully combined the roles of breastfeeding and working as role models. Educating shop stewards around the importance of breastfeeding will increase their awareness and that of the unions. Meetings can be arranged with human resource management to present research on the benefits for the business. In addition, if no facilities to express in the workplace exist, a private space for this purpose should be identified.



Many studies have shown that supporting breastfeeding reduces loss of skilled staff, decreases costs associated with recruitment, reduces absenteeism due to improved health of mother and infant, and increases staff loyalty.40 In addition, there is the added benefit of the corporate image and media recognition.



As stated in the Lancet Breastfeeding Series, not breastfeeding is associated with increased mortality and lower intelligence which reflects in annual economic losses of around $302 billion or 0.49% of world gross national income.8 To reverse this situation and advance physical and psychological health and economic gains, breastfeeding needs support: financial, political and societal.

Breastfeeding does not occur in a vacuum and it is not the sole responsibility of an individual. It is a combined societal responsibility, and is influenced by social and cultural attitudes. Rebuilding a breastfeeding culture is the only way to restore and improve breastfeeding rates. Women need to be supported to breastfeed their babies in public places; they need breastfeeding facilities in shopping centres, and employers and employees need to support the provision of facilities for a woman to express milk in the workplace. Healthcare workers who provide guidance on breastfeeding at critical time points need updated knowledge and skills to enable them to provide good evidence-based advice, as considerable gaps in their breastfeeding knowledge have been identified.41,42

Reducing the barriers to breastfeeding in the workplace by providing a supportive culture, lactation rooms and breastfeeding breaks for women to express milk would not only improve the short- and long-term health of mothers and their infants, but would also reduce company costs and absenteeism, and improve performance and commitment.43 Occupational healthcare workers can and should play an important role in creating a safe and  supportive environment and positive attitudes towards pregnancy and breastfeeding in the workplace. They can do this by ensuring that management has a breastfeeding policy that is clearly communicated to all employees. Supportive actions include educating supervisors to allow breastfeeding breaks, and making sure they are flexible as women acclimatise and merge breastfeeding and work. Champions and role models in the workplace are invaluable in providing reassurance and helping to ease the anxiety when the time comes to return to work.


The author has no conflict of interest or affiliation to declare.


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