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Interventions in the workplace to support breastfeeding for women in employment

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Abstract

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

(1) To identify and describe workplace interventions designed to encourage, assist and support breastfeeding for women returning to work after the birth of their child.
(2) To assess the effectiveness of workplace interventions in assisting with the initiation, continuation, duration and exclusiveness of breastfeeding.
(3) To evaluate the impact of workplace interventions on process outcomes pertinent to employees and employers.

Background

Women of childbearing age constitute a high proportion of the workforce and make significant contributions to national economies. In industrialised countries where the collection of organised statistics allows the easy estimation of their numbers, women of childbearing age represent anywhere from 45% to 60% of the total labour force (ABS 2003; Statcan 2001; UK Office 2002; US Census 2002).

Women of childbearing age may become pregnant during employment and many of them may decide to return to work after the birth of their babies. Unless supported by their employers, this return to employment can be a barrier to breastfeeding because they can be separated from their babies and it may impact on the duration and exclusivity of breastfeeding (Osis 2004; Visness 1997). If they are not supported, women may decide to entirely wean their children when returning to work (Arthur 2003). It is encouraging to know that most women report the desire to continue breastfeeding after returning to work if they have access to facilities, work flexible hours and take rest breaks during working hours (Kosmala‐Anderson2006). In addition, a large number of working mothers can continue breastfeeding for six months (Cohen 1994; Ortiz 2004) if the workplace is ideal and supportive. Workplace intervention may also have a positive impact on breastfeeding initiation. A study from the US showed that among working mothers enrolled in an employer‐sponsored lactation program, breastfeeding was initiated by 97.5% of the women (Ortiz 2004). Hence, workplace interventions could have a positive impact on both initiation and duration of breastfeeding.

The range of health benefits of breastfeeding for infants and mothers are well documented. The benefits of breastfeeding also extend to employers as it reduces work absenteeism and increases employee morale and retention (Cohen 1994; Cohen 1995). Similarly, if employers support breastfeeding in the workplace, women who continue to breastfeed after returning to work miss less time from work because of baby‐related illnesses, and have shorter absenteeism when they do miss work (Cohen 1995). The public health benefits of continued breastfeeding are improved maternal (CGHFBC 2002; Labbok 2001) and infant health (Bick 1999; Dewey 1995; Gillman 2001; Kramer 2001; Kramer 2002; Mortensen 2002; Wilson 1998).

Exclusive breastfeeding for at least the first six months of life is recommended by the World Health Organization (WHO) (WHO 2002). This recommendation is evidence‐based and adherence to it improves infants outcomes (Kramer 2001), such as decreased risk of gastrointestinal tract infections and atopic eczema in the first year of life (Kramer 2001). Unfortunately, a minority of the world's infants (35%) are exclusively breastfed beyond the first three to four months of age (WHO 2003), and even this is short of the duration recommended by the WHO. Information about breastfeeding by employed versus unemployed women is not available. However, the prevalence of exclusive breastfeeding rates for all women vary worldwide. In industrialised countries like Australia and the US, 54% and 41.1% of women exclusively breastfeed for three months, and 32% and 14.2% for six months, respectively (ABS 2004; CDC 2004). In developing countries such as Kenya, Bangladesh, Vietnam and Turkey, the exclusive breastfeeding rate for three months by working mothers ranges from 13% to 59% (Dearden 2002; Haider 1995; Lakati 2002; Yilmaz 2002). Overall, these rates are low.

To reach the WHO's recommendation of six months of exclusive breastfeeding, women need a supportive environment (at home and work) that protects and promotes breastfeeding. For women in the workforce, merging breastfeeding and paid work is difficult. Undoubtedly, workplaces are excellent settings for interventions to encourage and assist the initiation and continuation of exclusive breastfeeding (Cohen 1994; NSW 2004; Ortiz 2004). However, women face various barriers in the workplace and the type of support and information needed to encourage them to continue breastfeeding (Zinn 2000) has yet to be fully identified and addressed by all parties. In this regard, policies at the level of both the government and employers may be warranted.

Various types of workplace strategies are available to support the promotion of breastfeeding. They include maternity leave provisions; flexible employment practices; lactation breaks; and physical facilities such as private rooms and access to refrigeration (NSW 2004; Rea 2004). To date, few workplace interventions have been implemented and their findings reported in the literature (Cohen 1994; Cohen 2002; Ortiz 2004). In general, to achieve high rates of both breastfeeding and women's employment, socio‐cultural support and labour market, health and early childhood policies are vital (Galtry 2003).

The WHO and UNICEF have initiated the Global Strategy for Infant and Young Child Feeding. The strategy highlights the priority actions, duties and responsibilities of various organisations and calls for governments to pass imaginative legislation to protect the rights of working women to breastfeed, and to establish the means to enforce these policies, which are consistent with international labour standards (WHO/UNICEF 2003).

To date, various systematic reviews addressing issues associated with breastfeeding have been conducted and reported in the Cochrane Database of Systematic Reviews (Anderson 2003; Dyson 2005; Kramer 2002; Shah 2006). In addition, one other review is currently underway (Ram 2002). However, none of these reviews are explicit to mechanisms for facilitating breastfeeding among women in employment. Our review aims to assess the interventions in the workplace to support, encourage and promote breastfeeding among working mothers.

Objectives

(1) To identify and describe workplace interventions designed to encourage, assist and support breastfeeding for women returning to work after the birth of their child.
(2) To assess the effectiveness of workplace interventions in assisting with the initiation, continuation, duration and exclusiveness of breastfeeding.
(3) To evaluate the impact of workplace interventions on process outcomes pertinent to employees and employers.

Methods

Criteria for considering studies for this review

Types of studies

Randomised controlled trials (including those using cluster randomisation) and quasi‐randomised controlled trials comparing workplace interventions with no intervention or two or more workplace interventions against each other will be considered.

Types of participants

Women in full‐time or part‐time employment in both private and public sectors returning to paid work after giving birth.

Types of interventions

Any type of workplace strategy (including creches and nurseries) to support or facilitate continued breastfeeding (nursing or expressing) for women returning to work after giving birth. Studies will be included if the intervention occurred on‐site or outside the workplace as long as it is delivered in the context of employment. Interventions during pregnancy will be excluded.

Types of outcome measures

Primary outcomes
The rate, duration and prevalence of exclusive or partial breastfeeding. (Breastfeeding is defined as the baby is fed exclusively on breast milk including expressed milk).

Secondary outcomes

  • Employer‐related (return rates after maternity leave, turnover following childbirth, retention following childbirth, work absenteeism associated with infant illness, productivity).

  • Mother‐related (health, emotional and physical well‐being, job satisfaction, morale, sick leave, resignation from work).

  • Infant level outcomes if reported (for example, health, emotional well‐being, etc).

Search methods for identification of studies

We will contact the Trials Search Co‐ordinator to search the Cochrane Pregnancy and Childbirth Group's Trials Register.

The Cochrane Pregnancy and Childbirth Group's Trials Register is maintained by the Trials Search Co‐ordinator and contains trials identified from:
(1) quarterly searches of the Cochrane Central Register of Controlled Trials (CENTRAL);
(2) monthly searches of MEDLINE;
(3) handsearches of 30 journals and the proceedings of major conferences;
(4) weekly current awareness search of a further 37 journals.

Details of the search strategies for CENTRAL and MEDLINE, the list of handsearched journals and conference proceedings, and the list of journals reviewed via the current awareness service can be found in the 'Search strategies for identification of studies' section within the editorial information about the Cochrane Pregnancy and Childbirth Group.

Trials identified through the searching activities described above are given a code (or codes) depending on the topic. The codes are linked to review topics. The Trials Search Co‐ordinator searches the register for each review using these codes rather than keywords.

In addition, we will develop search strategies for LILACS and a number of social sciences databases. We will list the databases searched, years covered, and search strategies used for each database in the review.

We will not apply any language restrictions.

Data collection and analysis

Selection of studies
We will design a prior inclusion assessment form based on selection criteria for the relevant studies (randomised control trials including those using cluster randomisation and quasi‐randomised controlled trials). Both authors will independently assess the identified studies for inclusion, read and evaluate the full text of the retrieved studies against the inclusion form. Differences will be resolved by consensus and, if required, by advice from the editorial team.

Quality assessment of included studies
We will independently assess the methodological quality of the selected studies based on the methods described in Section Six of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2005) and the guidelines of the Cochrane Pregnancy and Childbirth Group (Gates 2005). The randomisation method, adequacy of allocation concealment, blinding (study participants and outcome assessors), loss to follow up, and use of intention‐to‐treat analysis will be assessed and rated as adequate, inadequate or unclear (blinding scored as yes, no or unclear). Participant withdrawal or loss to follow up will be graded as less than 5%, 5% to 10%, 11% to 20% or greater than 20%. The use of intention‐to‐treat analysis in each trial will be established if all those initially randomised were analysed in their respective randomised groups at the conclusion of the study. Results of the quality assessment will be documented in the 'Characteristics of included studies' table and in the text of the review.

Data extraction
Both authors will independently extract data from the included studies using a predeveloped data extraction form. For dichotomous outcomes, we will abstract the number of per‐group participants and the number experiencing the outcome, and for continuous variables we will extract the number of participants per group and the mean (and standard deviation) within each group. In the event of missing information, we will endeavour to contact the authors of the included studies for clarification.

Data analyses
The Review Manager software will be used to enter and analyse the data (RevMan 2003) and obtain summary statistics for outcomes. When possible, we will combine the results of included studies in the meta‐analysis. For the meta‐analysis of the continuous outcome (primary: breastfeeding duration), mean difference and 95% confidence interval will be reported if the outcome is measured in the same way between trials. Otherwise, the standardised mean difference will be used to combine trials reporting the same outcome measured with different methods. For dichotomous outcomes (primary and secondary), we will report the relative risks and 95% confidence intervals or Peto odds ratios (if events are rare). We will use the fixed‐effect model if studies are sufficiently clinically, methodologically and statistically similar. If there is statistical heterogeneity (I² test), we will explore possible causes through subgroup analyses and consider applying random‐effects models to obtain an overall summary. Where trials are considered too dissimilar to combine in the meta‐analysis, results will be tabulated. We will evaluate heterogeneity by visual scrutiny of tabulated outcomes and by deriving two measures of heterogeneity (H and I² statistics) (Higgins 2002). Subgroup analyses will be performed according to trial quality (trials with adequate concealment of allocation versus others). We will use Funnel plots to examine publication bias as recommended in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2005).