8

Return to Work and School

Laws and policies at the federal, state, territory, tribal, and local levels play a critical role in shaping environments that support breastfeeding. This chapter begins by examining the timing of return to work, as well as unpaid and paid leave policies, which help ensure that families have the time to recover from childbirth, bond with their infant, and initiate and sustain breastfeeding. Leave policies directly affect a mother’s ability to initiate and sustain breastfeeding, and evidence increasingly supports their importance for breastfeeding duration. The chapter then explores workplace accommodations that enable continued breastfeeding upon return to work, including legal requirements for break time and private spaces for milk expression, as well as additional supports offered by employers, schools (e.g., Ashby et al., 2024), and childcare settings. Additionally, state and local laws have been established to support the breastfeeding needs of incarcerated postpartum mothers (e.g., Asiodu et al., 2021). Across these domains, legal protections also address access to breastfeeding support in health care settings, insurance coverage for lactation services, and the right to breastfeed in public spaces.

Despite the breadth of these policies, navigating the complex and fragmented system of lactation support can be challenging for families, particularly in the absence of clear information, consistent enforcement of legal protections, or their comprehensive implementation. This chapter reviews the evidence on these policies and enforcement mechanisms, with special attention to promising strategies, such as paid family leave, for improving breastfeeding outcomes.

TIMING OF RETURN TO WORK

The U.S. civilian labor force has undergone significant changes over the past seven decades, with women’s participation rising substantially. According to the U.S. Bureau of Labor Statistics (BLS; 2024a), women constituted 47% of the workforce in 2023 (79,252,000 out of 168,547,000 total labor force participants), a notable increase from just 30% in 1950 (Glynn, 2019; Schaeffer, 2024). A substantial portion of working women are mothers, with participation rates varying based on their children’s ages: data collected in 2023 for the Current Population Survey of the U.S. Department of Labor (DOL; 2023a) show that 68.9% of all mothers with children under age six years participated in the labor force, and 53.2% of all mothers with children under age six years worked full time. Data from BLS (2024c) show that in 2023, 62.0% of mothers with children under age one year were in the labor force, suggesting that a significant proportion of mothers return to work within the first year of their child’s life.

Maternal employment postpartum is associated with shorter breastfeeding duration and decreased initiation of breastfeeding. In a recent review of the literature summarizing the association between the length of maternity leave and breastfeeding duration, all 23 articles meeting the authors’ inclusion criteria found a positive relationship between increased maternity leave and duration of breastfeeding in the United States (Wicklund et al., 2024). For example, Chatterji and Frick (2005) examined the relationship between the timing and intensity of returning to work after childbirth and the likelihood of initiating breastfeeding and the number of weeks of breastfeeding. Data from the National Longitudinal Survey of Youth indicate that returning to work within three months is associated with a reduction in the probability that the mother will initiate breastfeeding by 16–18%, and among those mothers who initiate breastfeeding, returning to work within three months is associated with a reduction in the length of breastfeeding of 4–5 weeks (Chatterji & Frick, 2005).

Similarly, Guendelman et al. (2009) examined the relationship between breastfeeding and maternity leave before and after delivery among working mothers in California. Drawing from a case-control study of preterm birth and low birth weight, the study recorded whether 770 full-time working mothers established breastfeeding in the first month, and for those that established breastfeeding, the duration. The authors used multivariate regression models weighted for probability of sampling to calculate odds ratios for breastfeeding establishment and hazards ratios for breastfeeding cessation. Maternity leaves of less than or equal to six weeks or 6–12 weeks after delivery were associated, respectively, with fourfold and twofold higher odds of failure to establish breastfeeding and an increased probability of cessation after successful establishment, relative to women not returning to work, after adjusting for covariates. The relationship between short

postpartum leave (i.e., quicker return to work or school) on breastfeeding cessation was stronger among nonmanagers, women with inflexible jobs, and with high psychosocial distress (Guendelman et al., 2009).

Mirkovic et al. (2014) assessed the relationship between prenatal plans for maternity leave duration and return to full-time/part-time status and plans for exclusive breastfeeding. Their study included 2,348 prenatally employed women from the Infant Feeding Practices Study II (2005–2007) who planned to return to work in the first year postpartum. Bivariate analysis and logistic regression were used to describe the association of maternity leave duration and return status with plans for infant feeding. Overall, 59.5% of mothers planned to exclusively breastfeed in the first few weeks. Mothers planning to return to work within six weeks had 0.60 times (95% confidence interval [CI]: 0.46–0.77 times) and mothers planning to return between seven and 12 weeks had 0.72 times (95% CI: 0.56–0.92 times) the odds of planning to exclusively breastfeed compared with mothers who were planning to return after 12 weeks (Mirkovic et al., 2014). Prenatal plans to return full-time (≥30 hours/week, vs. part-time) were also associated with lower odds of planning to exclusively breastfeed (adjusted odds ratio = 0.61; 95% CI: 0.51–0.77). Mirkovic et al. (2014) also found that mothers who planned to return to work within 12 weeks postpartum were less likely to start breastfeeding and more likely to stop breastfeeding earlier than those who returned later or not at all.

While not all the included studies in Wicklund et al. (2024) adjusted for potential confounders such as race, education, or income, the consistent patterns across studies suggest that policies that support parental leave following the birth of a child have the potential to increase breastfeeding prevalence. This finding reinforces work by Berger et al. (2005), who found that early return to work by mothers (within 12 weeks of giving birth) is associated with reductions in breastfeeding as well as regular checkups and immunizations. These results are corroborated with survey responses, which indicate that a leading reason mothers stop breastfeeding is that they need to return to work (Kirkland & Fein, 2003; Thulier & Mercer, 2009).

However, the relationship between breastfeeding duration and occupation type may vary. Kimbro (2006), using data from the Fragile Families and Child Wellbeing Study (a sample of mostly low-income, unmarried U.S. mothers) conducted a logistic regression analysis to determine the relationship between the expectation of work and breastfeeding initiation, and discrete-time logit models to examine breastfeeding duration, the timing of the return to work, and occupation type.¹ Kimbro (2006) found that

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¹ The author used census codes for each job to create four job categories: Professional, Administrative, Manual, and Service, with the omitted category “Stay-at-Home Mom.”

expecting to work in the year after birth did not impact breastfeeding initiation. The timing of weaning or ceasing breastfeeding and return to work are closely linked, however. Mothers with administrative and manual occupations are more likely to cease breastfeeding than stay-at-home moms, with 34% and 35% higher odds, respectively. The author explained that this relationship could indicate a lack of flexibility in their working environment. Mothers with professional jobs and service occupations did not differ from stay-at-home moms in terms of breastfeeding duration. Kimbro (2006) suggested that this finding could reflect the fact that mothers with these types of jobs have flexibility in scheduling, so are better able to incorporate breastfeeding into their daily routines. Overall, Kimbro’s (2006) research suggests that low-income women have difficulty combining work and breastfeeding: the results of the discrete-time logit models indicate that women are ceasing breastfeeding or weaning right before or right after returning to work (Kimbro, 2006).

Moreover, studies have also found variation by race and ethnicity. Spencer and Grassley (2013) and Johnson et al. (2015) found that Black women are more likely to return to work earlier and work in environments that are not conducive to breastfeeding (Johnson et al., 2015; Spencer & Grassley, 2013).

In sum, earlier return to work is associated with shorter breastfeeding duration, plausibly linked to the challenging situations women face in balancing work with the demands of pregnancy and postpartum care (Arena Jr. et al., 2023; Grandey et al., 2020; Shockley et al., 2017). Global literature also aligns with these findings (e.g., Pérez-Escamilla et al., 2023). These impacts are likely felt most by workers with less flexible work employment, low-income workers, and Black and Hispanic workers (Beauregard et al., 2019). For parents returning to work, a lack of supportive policies and environments can lead to early cessation of breastfeeding (Kozhimannil et al., 2016). Consistent with this, the American Academy of Pediatrics, World Health Organization, International Labor Organization, and Centers for Disease Control and Prevention, among others, include policies such as guaranteed adequate paid parental leave in their calls for societal and workplace policies that support breastfeeding parents.

SUPPORTING BREASTFEEDING THROUGH LEAVE POLICIES

As described above, early return to work is negatively associated with breastfeeding initiation and duration. The federal government, states, and employers have supported a variety of leave policies to assist working mothers in delaying their return to work (see Box 8-1). However, the United States is the only high-income country in the world without a national paid family leave entitlement.

Unpaid and Paid Family and Medical Leave

Current federal policy provides eligible employees with up to 12 weeks of unpaid, job-protected leave for the care of a newborn child through the Family and Medical Leave Act (FMLA; enacted in 1993). To be eligible for FMLA, employees must have worked for their employer for at least 12 months, and for at least 1,250 hours in the prior 12 months. They must also work in a location where their company employs 50 or more workers within 75 miles. Because of these criteria, many new mothers do not qualify. According to a 2018 survey commissioned by the DOL (Brown et al., 2020), FMLA covered only 56% of employees. Moreover, eligibility rates vary by education (~60% for workers with at least some

college vs. 50% for those whose highest level of education is a high school diploma and 42% for those who have not graduated from high school), family structure (63% for workers in dual-parent families vs. 43% for those in single-parent families), and ethnicity (57% for non-Hispanic workers vs. 52% for Hispanic workers; Brown et al., 2020).

Even among the subset of mothers eligible for unpaid leave under the FMLA, many cannot afford the financial implications of taking time away from work (Brown et al., 2020). Unpaid leave is often most feasible for high-income or two-parent families (Han et al., 2009). According to the results of a DOL (Brown et al., 2020) survey in 2018, 15.3% of the workforce takes leave for an FMLA-qualifying reason annually, and 6.9% of workers reported needing FMLA-type leave but not taking it, with 66% of those citing inability to afford unpaid leave as the primary reason.

Because the FMLA does not provide for wage replacement, paid leave is generally available only to those whose employers provide coverage voluntarily (Congressional Budget Office, 2021). Only about 19% of all U.S. workers have access to such leave through their employer (Pac et al. 2023). Access to paid family leave in the United States shows significant variances across wage levels, with only 6% of private industry workers in the lowest decile of the wage distribution having access, compared with 43% in the highest 10% (BLS, 2022). Overall, these statistics confirm that higher-wage workers are much more likely to have access to employer-provided paid family and medical leave than their lower-earning counterparts, consistent with previous research findings (Bartel et al., 2019; Gault et al., 2014).

Since the 1978 Pregnancy Discrimination Act, which mandated that states with existing temporary disability insurance (TDI) programs allow women to take leave to prepare for and recover from childbirth, employed residents in a few states (California, Hawaii, New Jersey, New York, and Rhode Island) have been able to take approximately six weeks of paid leave through the TDI program. Many of these same states (and a few others) have also recently enacted laws that entitle new parents to paid family leave. For example, California has provided eligible workers with 55% of their normal earnings (up to a maximum benefit) for up to 12 weeks postpartum; the state recently extended this to 14 weeks. California was the first state to enact a paid family leave law in 2004. As a result, much of the evidence on the impacts of paid family leave is based on analyses of California. As of January 2025, comprehensive paid family and medical leave programs have been enacted in 13 states and the District of Columbia, with 10 of these programs currently providing benefits (see BPC, 2024).

Evidence on Leave-Taking

Studies suggest that adopting both unpaid and paid job-protected leave policies and implementing and extending programs increase leave-taking among new parents with follow-on impacts for breastfeeding (Rossin-Slater, 2017). Studies on the impacts of family leave in the United States have typically investigated the impacts of the (unpaid) FMLA by observing changes in outcomes pre- and postenactment of the law in states that had existing leave policies (and were, therefore, unaffected) and comparing those outcomes with changes in states that did not have preexisting leave policies. Using this approach, Waldfogel (1999) found that the introduction of FMLA increased leave-taking by about 23% between the years of 1992 and 1995. Han et al. (2009) also found that the implementation of FMLA in 1993 and subsequent state-level maternity leave policies increased maternal leave-taking by 13% during the birth month, 16% during the month following birth, and a marginally significant 20% during the second month after birth (see also Rossin-Slater, 2011).

More recent information suggests that the impact of paid family leave policies has been even more substantial on leave-taking. Focusing on the effects of paid leave, there is consistent evidence that the enactment of California’s paid family leave in 2004 had large positive impacts on mothers’ leave-taking (e.g., Bailey et al., 2025; Bartel et al., 2018; Baum & Ruhm, 2016; Rossin-Slater et al., 2013). Rossin-Slater et al. (2013) found that California’s policy doubled maternity leave usage among new mothers and had particularly large impacts on less-advantaged groups, such as mothers who are unmarried or have low incomes. Bailey et al. (2025), Baum and Ruhm (2016), and Bartel et al. (2018) also found that California’s policy increased leave-taking among fathers. Additionally, studies of other countries’ policies demonstrate that paid leave increases mothers’ leave-taking (e.g., Baker & Milligan, 2008; Carneiro et al., 2015; Lalive & Zweimüller, 2009).

In sum, data from numerous studies suggest that paid leave programs provide more access and increases in leave-taking compared with unpaid leave policies such as the FMLA. In addition, Wang et al. (2024) estimated that a national paid family leave program in the United States may yield substantial net social benefits, ranging from $7,275 to $29,406 per $1,000 invested.

Evidence of Paid Family Leave’s Impacts on Breastfeeding Outcomes

Several causal studies find that paid leave increases the duration of breastfeeding. Investigating the impacts of the introduction of paid family leave in California in 2004, Pac et al. (2023) found that the likelihood of breastfeeding exclusively for at least six months increased by at least 15%.

Analysis of data from the 1993–1994 and 2005–2006 Infant Feeding Practices Study by Huang and Yang (2015) also showed that implementation of California’s paid family leave was associated with increased breastfeeding rates by 10–20 percentage points, three, six, and nine months after the child’s birth. Examining the effects of both California and New Jersey’s paid family leave programs, Hamad et al. (2019) found that paid family leave was associated with an increase in exclusive breastfeeding at six months, particularly among advantaged mothers. In earlier findings from Canada, Baker and Milligan (2008) found that a 25-week expansion in paid maternal leave (from 25 to 50 weeks) was associated with an extended duration of any and exclusive breastfeeding.² Taken together, these results suggest that extending paid family leave to families in states that do not currently provide this type of coverage would have a positive impact on breastfeeding duration. In addition, based on the findings of Baker and Mulligan (2008), states with 12 weeks of paid leave might be able to increase duration by increasing the length of paid leave.

Most studies examining the effect of paid leave policies on breastfeeding outcomes are unable to consider heterogeneous effects because they are based on small samples. However, the Pac et al. (2023) analysis of California’s 2004 paid family leave is based on a large representative sample of over 314,000 children born between 2000 and 2013 (drawn from the restricted use versions of the 2003–2014 National Immunization Survey). They concluded that the impact of paid family leave on breastfeeding duration is generally larger among historically underserved populations (Pac et al., 2023). This is consistent with the evidence described above indicating that paid family has bigger effects on disadvantaged mothers’ leave-taking.

Taken together, these findings show that paid family leave is an important vehicle to reduce differences in breastfeeding rates. The evidence above provides compelling evidence of the effect of paid family leave policies on increasing breastfeeding duration, particularly among disadvantaged populations.

Evidence on Outcomes Related to Child Health and Well-Being

There is evidence that both paid and unpaid family leave lead to improvements in infant health. Using variation in the timing of unpaid FMLA introduction, together with the timing of similar leave policies that were adopted in some states before the FMLA and making use of variation in

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² Baker and Milligan did not find a significant impact on breastfeeding initiation. This result is not unexpected as paid family leave is targeted at breastfeeding duration and exclusivity, which are most affected by return to work (Baker & Milligan, 2008).

mothers’ access to leave across counties based on counties’ share of firms with at least 50 employees, Rossin (2011) found that the implementation of the FMLA lead to a 10% reduction in the infant mortality rate. Importantly, the effects of federal job protected leave were only present for children of highly educated mothers and/or married mothers. These groups were most likely to be eligible for FMLA and able to afford to take time away from work (Rossin, 2011).

Evidence to date also suggests that paid parental leave improves a number of infant health measures, including birth weight, infant mortality, hospitalizations for vaccine-related illnesses, regular checkups and immunizations, and asthma (e.g., Bullinger, 2019; Chen, 2023; Choudhury & Polacheck, 2021; Montoya-Williams et al., 2020; Pac et al., 2023; Pihl & Basso 2019; Ruhm, 2000; Stearns, 2015). In contrast to Rossin’s (2011) findings for unpaid leave, most studies that consider heterogeneous effects have shown that the impacts of paid leave on infant health are largest among historically disadvantaged groups.

The handful of studies that examine longer-term effects of paid and unpaid leave on children also point towards positive impacts. For example, Lichtman-Sadot and Pillay Bell (2017) found that the introduction of California’s paid family leave program was associated with later childhood reductions in obesity, attention deficit hyperactivity disorder, and hearing-related problems. A striking new working paper by Flores et al. (2023) discusses the long-term impacts of job-protected family leave on mothers and children using variation in the timing of 18 states’ unpaid job-protected leave policies. Focusing on the 2-decade period before the implementation of the FMLA, Flores et al. (2023) compared differences in outcomes between children born before and after the implementation of job-protected leave to the difference in outcomes for children born in states with no such policies. They found that children born in states and in years where job-protected leave was available completed 0.23 more years of education, were 4.1 percentage points less likely to drop out of high school, and had average hourly wages that were almost $4.00 higher in adulthood. The positive effects of the policies were concentrated on children born to mothers who had less education (Flores et al., 2023). Similarly, Carneiro et al. (2015) found that a change in maternity leave entitlements in Norway from 12 weeks of unpaid leave to four months of paid leave and 12 months of unpaid leave, led to a two percentage point decline in the high school dropout rate and a five percent increase in affected children’s wages.

It is important to note that most of these studies examined outcomes resulting from state or federal adoption of family leave programs. While there is evidence from the United States that short paid and unpaid leave improves children’s outcomes, studies that examine the impacts of extensions

to existing leave policies in countries with longer baseline leaves have found little evidence of improvements in child well-being (Rossin-Slater, 2017). For example, Baker and Milligan (2008, 2010, 2015) found that while an extension of paid maternity leave in Canada from six to 12 months increased maternal time at home and breastfeeding rates, it had much more limited impacts on measures of children’s health and cognitive and behavioral development in early childhood. Studies of leave extensions in Sweden, Denmark, Austria, Norway, and Germany demonstrate similarly weak evidence of large improvements in measures of older children’s academic success (Dahl et al., 2016; Danzer & Lavy, 2018; Dustmann & Schonberg, 2012; Liu & Skans, 2009; Rasmussen, 2010). These results suggest that, for the outcomes that have been analyzed to date, the benefits to children of subsidizing family leave that lasts more than 6–12 months are likely to be limited. However, existing leave policies in the United States currently fall far short of this window.

Evidence on Maternal Outcomes

Several studies have also examined the impacts of family leave policies on maternal health and labor market outcomes. Causal evidence on health impacts among U.S. mothers is limited, and additional research is warranted, but two studies by Chatterji and Markowitz (2005, 2012) have shown that mothers living in states with more generous family leave policies take longer maternal leaves and have fewer depressive symptoms in the months after childbirth. Similarly, Bullinger (2019) found suggestive evidence that California’s adoption of paid family leave led to improvements in mothers’ mental health.

Bütikofer et al. (2021) provided some of the most convincing evidence on maternal health effects to date. Using large-scale registry data on a wide variety of health indicators, the authors compared outcomes for mothers who gave birth in the months right before and right after Norway adopted paid maternity leave (in 1977; Bütikofer et al., 2021). They found strong evidence that paid maternity leave improves many measures of maternal health and health behaviors, including body mass index, blood pressure, chronic pain, mental health, exercise, and smoking. They also found that women who had their first child after paid leave was adopted experienced fewer health problems during their next pregnancy (Bütikofer et al., 2021).

As with the evidence on later childhood outcomes, studies of policies that increased the length of paid parental leave in Canada, Denmark, and Germany have found little evidence of improvements in maternal physical or mental health (e.g., Baker & Milligan, 2008; Beuchert et al., 2016; Guertzgen & Hank, 2018).

Conclusion 8-1: There is consistent causal evidence that state mandates providing 12 weeks of paid family leave have positive effects on the duration of breastfeeding. Therefore, 12 weeks should be the minimum threshold for a federal paid family leave policy. Moreover, compelling evidence from Canada suggests that providing for longer periods of paid family leave will generate even bigger increases on breastfeeding duration.

Conclusion 8-2: Consistent with the scientific consensus on the health benefits of exclusive breastfeeding for the first six months postpartum, several studies show that paid family leave policies of up to six months in other high-income countries confer health benefits to mothers and infants.

Recommendation 8-1: Congress should enact national paid family and medical leave for all postpartum mothers. In the absence of a national plan, states and employers should enact this coverage.

FEDERAL RETURN TO WORK PROTECTIONS FOR BREASTFEEDING

This section reviews federal protections for breastfeeding in the workplace, including amendments to the Fair Labor Standards Act (FLSA) through the Break Time for Nursing Mothers Act, and the PUMP Act. Evidence of the impacts of these policies is focused on breastfeeding initiation, duration, and exclusivity outcomes.

Break Time for Nursing Mothers Act

Lack of adequate break time may be an obstacle to continued breastfeeding, particularly for hourly workers or those in inflexible work environments (Izumi et al., 2024). The Break Time for Nursing Mothers Act, which was signed in 2010 as part of the ACA (DOL, 2023b), amended the FLSA to require employers to provide (a) reasonable break time for employees to express human milk for up to one year after the child’s birth and (b) a private, nonbathroom space for pumping at work. The lactation space must be shielded from view and free from intrusion by others. Of note, however, employers with fewer than 50 employees may be exempt from the break time requirement if they can demonstrate that compliance with the provision would impose an undue hardship (DOL, 2023b).

One study found that workplace requirements related to the Break Time for Nursing Mothers Act increased the likelihood of exclusive breastfeeding

at six months for mothers who gave birth in 2011 and 2012, but only 40% of the study population reported access to time and space accommodations (Kapinos et al., 2017). This highlights the ongoing need for comprehensive support for breastfeeding mothers in the workplace, particularly for those from historically underserved communities.

With respect to federal enforcement, the DOL Wage and Hour Division is responsible for enforcing the break time for nursing mothers’ provision under the FLSA. Employers who fail to provide reasonable break time and a private space for breastfeeding employees can face civil penalties for each violation and may be required to pay back wages if the violation results in unpaid work time. The Equal Employment Opportunity Commission enforces laws against pregnancy discrimination, which can include discrimination against breastfeeding mothers. The Pregnancy Discrimination Act and Title VII of the Civil Rights Act protect against such discrimination. Employers who discriminate against breastfeeding employees may be required to pay compensatory and punitive damages.

PUMP for Nursing Mothers Act

The federal Providing Urgent Maternal Protections for Nursing Mothers Act (PUMP Act), which was signed into law in 2022, updates the Break Time for Nursing Mothers Act by including millions more employees, such as agricultural workers, nurses, teachers, truck and taxi drivers, home care workers, and managers (Providing Urgent Maternal Protections [PUMP] for Nursing Mothers Act, 2022).

The PUMP Act does not require employees to be paid during pump breaks, but if the employee is not completely relieved from their work duties, the time must be considered hours worked. The act makes it possible for workers to file a lawsuit to seek monetary remedies if their employer fails to comply (see Box 8-2).

The PUMP Act covers almost all employees for a year after a child’s birth except for airline pilots and flight attendants. Members of other transportation industries (e.g., train crews, rail carrier employees, motorcoach employees) will not receive the protections from the PUMP Act until December 2025. In railway industries, employers will not be required to make accommodations if they require a significant expense (e.g., removing seats from the carriers). Airline flight crewmembers and others in the transportation industry may be able to receive break time and space as a reasonable accommodation under the Pregnant Workers Fairness Act (PWFA), which was signed into law in 2022 and applies to employers with 15 or more employees. This law is for employees who have limitations related to pregnancy or pregnancy-related conditions, such as childbirth and lactation/breastfeeding.

STATE-LEVEL RETURN TO WORK PROTECTIONS FOR BREASTFEEDING

At the state level, three categories of workplace laws impact breastfeeding or pumping in the workplace: break time and space, reasonable accommodation, and antidiscrimination laws. The federal PUMP Act provides the minimum requirements related to break time and space and reasonable accommodation, but some states provide additional protections in these areas. Break time and space laws require employers to allow employees to express

milk during existing breaks at work and/or require employers to provide additional break time for that purpose. Laws in this category may also require employers to provide a space for expressing milk. Some laws include additional requirements, such as requiring that the space have a sink or be located near the lactating employee’s workstation. Reasonable accommodations require employers to adjust how, when, or where the employee works or to make other changes that accommodate the employee’s lactation-related needs. It may include break time space for expressing milk, the ability to breastfeed at work, temporary transfers to light duty or less-hazardous positions, or other modifications that accommodate the employee’s individual needs.

Antidiscrimination laws prohibit employers from discriminating against an employee because of breastfeeding or lactation—for example by firing, demoting, refusing to hire, harassing, or taking other adverse action because the employee is breastfeeding. Some antidiscrimination laws also require employers to treat employees who are affected by conditions related to pregnancy and childbirth the same as other employees who are similar in their ability to work.

In some cases, state laws provide additional protections beyond federal requirements for pumping in the workplace. In these instances, state laws remain in effect and are not changed by federal policies. This means that when it comes to workplace lactation or breastfeeding policies, employers are required to follow whichever requirement—federal or state policies—is stricter. About 20 states and the District of Columbia have laws related to breastfeeding in the workplace; many have policies with stronger protections than federal policies (National Conference of State Legislatures, 2021). For example, California, Indiana, Oregon, New York, and Vermont all provide lactation protection for more than one year. In New York, employers must provide nursing employees with 30 minutes of paid break time to express milk as needed (New York State Senate, 2024).

California has some of the most comprehensive laws for lactating employees in the workplace. However, its state laws are not uniformly stricter than the PWFA and PUMP Act. California law is stricter in that it provides breaks and a place to pump near work areas for all employees; includes exempt employees with no time limit; specifies a penalty of $100 for each violation; and applies to companies with five or more employees (whereas the federal laws apply to companies with at least 50 employees). In these instances, state law is more favorable to the employee and must be followed. On the other hand, California law provides that an employer is not required to provide lactation break time if doing so would seriously disrupt the operations of the employer. In this instance, federal law is more favorable to the employee and must be followed.

Many states have their own labor departments or agencies that enforce state-specific breastfeeding laws. Some states, such as New York, Illinois,

and Minnesota, have human rights divisions or departments that handle complaints related to discrimination, including discrimination against breastfeeding mothers. These agencies can investigate complaints and ensure compliance with state regulations. For example, in California the Department of Industrial Relations, through its Division of Labor Standards Enforcement (DLSE), is responsible for enforcing labor laws, including those related to breastfeeding accommodations. Employers who violate California’s lactation accommodation laws can face civic penalties of up to $100 per violation. Also in California, the Department of Fair Employment and Housing (DFEH) enforces laws against discrimination, including pregnancy and breastfeeding discrimination. Employees can file complaints with DLSE or DFEH if they believe their rights have been violated or if they face discrimination related to breastfeeding.

EMPLOYER-LED RETURN TO WORK SUPPORTS FOR BREASTFEEDING

Employers can play a role in supporting working mothers as they return to work and continue breastfeeding and pumping (Litwan et al., 2021). Qualitative and survey literature suggests that employers can find value in supporting breastfeeding employees in the workplace (see Box 8-3).

The sections that follow describe the emerging literature related to employer-led supports for breastfeeding. While growing, this literature is small and largely comprises qualitative studies with samples of working mothers in professional jobs with middle to high incomes.

It is important to consider both the supports provided to women during pregnancy itself, as well as the supports and challenges that exist when working women reenter the workforce. For example, providing support to workers who are pregnant can come in the form of organizational leaders helping women navigating the human resources infrastructure within their organization (Chawla et al., 2024). This can include sharing knowledge surrounding leave (e.g., combining leave available via FMLA with additional vacation of sick leave time); information about policies and how to utilize them and/or file for them correctly; and providing early information surrounding how to pump when women return to work (Chawla et al., 2024). Signaling the importance of support, Spitzmueller et al. (2016) found that women who perceived that their organizations were going to be supportive of their breastfeeding journey postpartum (e.g., “In your opinion, how supportive of breastfeeding is your place of employment?” [p. 699]) were more likely to report positive breastfeeding goal intentions before the baby was born (e.g., “How old do you think your baby will be when you completely stop breastfeeding?” [p. 698]). Critically, these intentions contributed to a significant decrease in the cessation of breastfeeding after returning to work,

such that these women with stronger intentions to breastfeed—as a function of perceived support from their job—were less likely to stop breastfeeding within the first 12 months of their child’s life (Spitzmueller et al., 2016). Thus, having knowledge that one’s organization will support breastfeeding prior to giving birth can be one way for organizations to promote the initiation

of breastfeeding—though, as reviewed by Vilar-Compte et al. (2021) and Litwan et al. (2021), different sources of support may have mixed effects (or may operate indirectly, as found by Spitmueller et al., 2016).

Indeed, as noted earlier, during this “fifth trimester” (the months in which mothers return to the workforce, often encompassing the first three months [Brody, 2018]), mothers who are employed and transitioning back to the workforce after having a child may feel as though they are violating “ideal worker norms” and “ideal mother norms,” not being fully available 24/7 to either their work role nor their motherhood role (Ladge & Greenberg, 2015; Little & Masterson et al., 2021). It is likely for these reasons that organizational scholars have advocated for more flexible return to work practices (Chawla et al., 2024; Little & Masterson, 2021), a benefit of which can be ensuring that women have time not only to heal from pregnancy and childbirth beyond the standard 12 weeks offered by FMLA programs, but also have more sufficient time to dedicate to breastfeeding and caregiving without the added stress of work (Gabriel et al., 2020).

Upon return to work, several job characteristics and/or experiences may contribute to women’s ability to continue breastfeeding and/or pumping (e.g., Humphrey et al., 2007). Following research conducted by Spitzmueller et al. (2018) examining the intersection of breastfeeding and work, three classifications of factors may affect breastfeeding continuation once women return to the workplace: (a) job autonomy/schedule flexibility; (b) physical (i.e., hazardous) work conditions; and (c) job-related supports (i.e., formal policies and/or practices, interpersonal supports).

Job Autonomy

Job autonomy focuses on the extent to which employees “are able to make independent decisions about how to do their work and what tasks and methods to use” (Spitzmueller et al., 2018, p. 460; see also Parker et al., 2001). Particularly after the COVID-19 pandemic, another aspect of having job autonomy relates to where the work is done, as well as having flexible work schedules that can aid in the juggling of work and family demands (Shockley et al., 2021). In any job—regardless of whether one is breastfeeding and/or pumping or not—job autonomy is a core predictor of employee well-being and performance (Hackman & Lawler, 1971; Parker et al., 2017). Particularly when it comes to breastfeeding and/or pumping at work, research has demonstrated the importance of having flexibility in one’s schedule and/or location where they work, as this can correlate with the ease with which women are able to take lactation breaks or easily breastfeed their child (i.e., during work-from-home arrangements or being able to see a child who may be in a nearby daycare facility; Chawla et al., 2024; Litwan et al., 2021; Vilar-Compte et al., 2021).

Flexible work arrangements, such as telecommuting or flexible schedules, can make it easier for parents to balance work and breastfeeding, but these benefits are not applicable across all sectors or job types. Murtagh and Moulton (2011) found that mothers with flexible work arrangements were more likely to continue breastfeeding. Workplace education programs that inform both employees and employers about breastfeeding benefits and support needs can also create more supportive environments (Dinour & Szaro, 2017).

More specifically, increased levels of job autonomy can allow for individuals to more easily find time to breastfeed or pump throughout the workday. Indeed, breastfeeding continuation may be more likely when employees can work from home and more easily connect with their baby, and when employees have less-rigid schedules and can easily build in pumping breaks (Jacknowitz, 2008; Spitzmueller et al., 2018; Vilar-Compte et al., 2021). Such sentiments are reflected in emerging research highlighting that during the lockdowns associated with the COVID-19 pandemic, women reported some “silver linings,” in the sense that remote work afforded easier facilitation of breastfeeding and bonding with their child (e.g., Devi et al., 2024).

However, remote work and teleworking benefits are not equally distributed across all sectors or job types, with many essential workers unable to access remote work options (Dey et al., 2020; National Conference of State Legislatures, 2021). Dingel and Neiman (2020), using surveys that describe the typical experience of U.S. workers in nearly 1,000 occupations, classified each occupation as able or unable to be done entirely from home; they found that only 37% of workers had jobs that could be performed entirely from home, underscoring the variances in access to flexible work arrangements (DOL, 2022).

Educational attainment significantly influences access to telework opportunities for mothers. The 2023 American Time Use Survey by the BLS (2024b) indicates that mothers with higher levels of education are more likely to engage in telework than those with lower educational attainment; 52% of those with a bachelor’s degree or higher performed some work at home on days they worked, while only 22% of those with a high school diploma and no college performed some work at home on days they worked. This lack of remote work access can exacerbate existing variances, as lower-income workers are more likely to be employed in essential roles or on an ad hoc basis and cannot work remotely (Friedland & Balkin, 2023; Gaitens et al., 2021); it also highlights the need for targeted interventions to support breastfeeding in these sectors.

Moreover, Spitzmueller et al. (2018) found that job autonomy—conceptualized as an occupational characteristic (i.e., having a job with generally more or less autonomy as classified by Occupational Information

Network [O*NET])—was positively related to breastfeeding intentions as well as breastfeeding initiation. Perhaps surprisingly, Spitzmueller et al. (2018) also found that higher job autonomy related negatively with breastfeeding duration. While inconsistent with some of the aforementioned results, a possible post hoc explanation the authors provided is that higher levels of autonomy can naturally come with higher levels of job demands and work-related stressors (e.g., increased time pressure that interferes with pumping breaks, having direct reports that need to be managed and may encroach on flexible time for pumping). Alternatively, the authors noted that this negative effect could be due to statistical suppression (attributed to the control variables in their model, such as age, education, ethnicity, marital status, income, and birth history), as the correlation itself between job autonomy and breastfeeding duration was positive (r = .09, p < .05) (Spitzmueller et al., 2018). Thus, on the whole, autonomy—and particularly having autonomy with time and one’s work location—can be an impactful predictor of the extent to which women initiate and continue to breastfeed after returning to work. Such findings also underscore the importance of communicating to employees how to flexibly implement breaks for pumping.

As a final caveat, more research is needed to understand how more extreme forms of job autonomy and flexibility may impact women’s breastfeeding. For instance, the gig economy provides increasing levels of autonomy (for reviews, see Ashford et al., 2018; Cropanzano et al., 2023). Goods et al. (2019) found that gig work was a way for individuals to navigate demands tied to the family domain. While gig work may provide increased autonomy in choosing when, where, and how much to work (Augustine et al., 2024), it often lacks traditional workplace protections and benefits, potentially impacting the ability to maintain consistent breastfeeding schedules (Zipperer et al., 2022). Moreover, gig work can be financially unstable and precarious, coming with unpredictable cash flows and little-to-no paid benefits (Cropanzano et al., 2023; Wu & Huang, 2024). This makes the likelihood of parental leave seemingly implausible; it also makes the likelihood of paid breaks to support pumping or subsidized childcare costs nonexistent. As the gig economy continues to grow, it becomes increasingly important to address the unique challenges faced by breastfeeding parents in nontraditional work arrangements. Ensuring access to adequate support and resources for balancing work, education, and caregiving responsibilities will be crucial in mitigating potential negative impacts on breastfeeding outcomes and overall worker well-being. Future research is needed to develop innovative solutions to support breastfeeding parents in the evolving landscape of work, recognizing the diverse needs of those engaged in gig economy employment.

Physical Work Conditions

Physical work conditions may be another factor that impact the extent to which women are able to continue their breastfeeding journey. Based again on classifications within O*NET, Spitzmueller et al. (2018) defined physical work conditions as those that are hazardous, encompassing repeated exposure on the job to noise, extreme temperatures, and/or chemicals. Past research has found that physical job demands such as these can be significant predictors of employees’ burnout on the job (e.g., Bakker & Demerouti, 2017), with significant physiological consequences (e.g., increased blood pressure, cortisol, and norepinephrine; Ganster & Rosen, 2013; Tafalla & Evans, 1997). Spitzmueller et al. (2018) found that those working in occupations with higher classifications of hazardous physical work conditions were less likely to intend to breastfeed as well as initiate breastfeeding, though there was no relationship between work conditions and breastfeeding duration. Still, as posited by these authors, women who work in jobs with hazardous conditions may elect to not breastfeed at all given concerns associated with their working conditions harming the quality of their breastmilk produced (e.g., chemical exposures). Supporting this, Spitzmueller et al. (2018) found that hazardous work conditions related indirectly and negatively to breastfeeding duration via reduced breastfeeding initiation rates.

Job-Related Supports

Lastly, job-related supports may be important for breastfeeding mothers (Bakker & Demerouti, 2017). Such supports can of course include the formal policies and practices that exist within the organization to support employees (e.g., paid family medical leave, subsidized childcare, spacious and private lactation facilities). Support also can be more social, or interpersonal, in nature, capturing the extent to which employees perceive that they are advocated for and supported by their supervisors and their coworkers (e.g., Chawla et al., 2024; Cohen & Willis, 1985; Gabriel et al., 2020). Spitzmueller et al. (2016) focused on three aspects of breastfeeding support (stemming from supervisors, coworkers, and formal policies) that employees can experience: (a) negative remarks from supervisors and coworkers pertaining to breastfeeding, (b) instrumental forms of support tied to formal policy (i.e., having sufficient break time, a convenient place to pump, a refrigerator to store breastmilk), and (c) perceived workplace breastfeeding support (i.e., “In your opinion, how supportive of breastfeeding is your place of employment?”). Interestingly, neither negative remarks tied to breastfeeding, nor instrumental support, predicted breastfeeding continuation upon returning to work postpartum. Yet, in predicting exclusive breastfeeding (i.e., without supplementing with formula), negative remarks from supervisors hindered this outcome, and conversely, perceived workplace breastfeeding support enhanced this outcome (Spitzmueller et al., 2016). Follow-up research by

Spitzmueller et al. (2018), also using coding from O*NET, found limited relationships between job-related supports and breastfeeding—there was only a marginal positive relationship between occupation-level supports and breastfeeding duration. However, this could be because support was highly perceptual—occupation-level coding may miss some benefits that exist. To unpack this further, both formal and informal supports need to be considered.

Overall, additional research is warranted to better understand these factors and continue to add to the existing evidence base.

Formal Supports

The Break Time for Nursing Mothers Act, discussed above, requires the designation of 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 human milk. There are many important features of lactation facilities or spaces (Bostick et al., 2016; Froh et al., 2018; Henry-Moss et al., 2018, 2019; Spatz et al., 2014), and it may be ideal to provide more than the minimum legal requirements. Parents need time and space to express milk or nurse. Box 8-4 outlines some essential features of a lactation room. Gabriel et al. (2020) found that having lactation spaces that were appraised

as comfortable, relaxing, spacious, quiet, and private on a daily basis (likely reflecting features of lactation rooms that go beyond the elements required by law) related positively to breastfeeding women feeling more content and calm on a daily basis; while not directly tied to production daily at work, this was tied to increased feelings of work–family balance satisfaction (e.g., “I was satisfied with the balance I achieved between my work and family life”; Gabriel et al., 2020, p. 1353). Given that conflict between work and breastfeeding demands can significantly hinder women’s breastfeeding continuation (Gabriel et al., 2020), such findings underscore the importance of having positive experiences in the lactation areas that are provided to women.

Informal (Social) Supports

More recent work from Gabriel et al. (2020) continued to unpack the social environment and cues that may affect breastfeeding mothers on a day-to-day basis at work. They initially found that women who felt that their work and breastfeeding demands were in balance (i.e., low interference between responsibilities associated with pumping breastmilk and their responsibilities with work) reported lower fatigue, which helped benefit the daily production of ounces of breastmilk. Feelings of enrichment between work and breastfeeding (i.e., feeling as though the responsibilities fit together and were not hindering work or breastfeeding) further benefited ounces of breastmilk produced directly (Gabriel et al., 2020).

In addition, acts of breastfeeding compassion—defined as recognition from coworkers about the challenges and trials associated with breastfeeding on a daily basis—helped improve mood but offered more limited effects on breastmilk production itself (Gabriel et al., 2020). Mothers navigating pumping at work who experienced acts of compassion from coworkers reported feeling more positive emotions within their work environment, with the quality of the breastfeeding space provided by the organization also having beneficial affective effects (e.g., lower fatigue, higher positive emotions; Gabriel et al., 2020). Such findings dovetail with those of Chawla et al. (2024), who studied postpartum allyship—acts of allyship to support and advocate for mothers during the return to work—and the impacts that this allyship can have to help working mothers understand the human resources infrastructure (e.g., policies associated with breastfeeding/pumping) and the physical breaks available for pumping. Overall, creating daily work conditions where work and breastfeeding demands can work in balance with each other, versus in conflict, can benefit daily human milk production. Others have found that psychological support from members of one’s organization can help contribute to longer rates of exclusive breastfeeding and lactation duration (e.g., Bai & Wunderlich, 2013; Smith et al., 2023; Spitzmueller et al., 2016).

A brief summary of opportunities, identified by the Office on Women’s Health, for employers to support breastfeeding employees is provided below (Table 8-1).

TABLE 8-1 Opportunities for Employers to Support Employees Who Are Lactating

NOTE: It is possible to support nursing women working across industries, through various creative and flexible space solutions for all staff levels. These accommodations are typically inexpensive to implement, easy to establish, and highly valued by employees, resulting in improved productivity and morale across the organization. Individual fact sheets for the industries above are available (see Office on Women’s Health, n.d.b).

SOURCE: Office on Women’s Health, n.d.b.

BREASTFEEDING SUPPORTS FOR STUDENTS RETURNING TO SCHOOL

Dabritz et al. (2009) reported that women returning to school likely face similar challenges as women returning to work (e.g., a quick return to work postpartum “within a few weeks or months of delivery” [p. 182]); they face additional challenges due to the lack of breastfeeding supports for students that (salaried) employees may have access to (e.g., Patient Protection and Affordable Care Act). These challenges highlight the need for interventions that support mothers as they return to school.

Supporting breastfeeding mothers when they return to school involves a combination of federal laws, state policies, and school-specific practices. These school or education settings may include K–12 public or private schools, as well as universities, colleges, community colleges, or trade schools. Title IX of the Education Amendments of 1972 prohibits discrimination based on sex, including pregnancy and parental status, in educational programs and activities. This means that schools must provide reasonable accommodations for pregnant and parenting students, which can include time and space for breastfeeding or pumping.

Some states—such as California, Illinois, Minnesota, Oregon—have specific laws that support breastfeeding in schools (National Conference of State Legislatures, 2021). For example, California has implemented comprehensive laws to support breastfeeding students in educational

settings: AB 302, signed into law in 2015, reaffirms and expands the rights of parenting students to reasonable lactation accommodations in schools. This law requires all California schools with lactating students to provide:

• A private, secure room (not a restroom) for breastfeeding or expressing milk
• Permission to bring breast pumps and other necessary equipment to school
• Access to a power source and safe storage for expressed milk
• Reasonable break time for lactation without academic penalties
• Opportunity to make up any work missed during these breaks

These accommodations apply to all levels of education, from K–12 to higher education institutions (California Department of Public Health, n.d.). For instance, California Community Colleges and California State University must provide similar accommodations, including access to a private room with a comfortable seat and table, and permission to bring necessary equipment on campus (California Department of Public Health, n.d.). The law also establishes a complaint process under the Uniform Complaint Procedure, allowing students to report noncompliance, with schools required to investigate and respond within 60 days (American Civil Liberties Union of Northern California, 2015). This comprehensive approach ensures that breastfeeding students can continue their education without sacrificing their choice to breastfeed, promoting both educational equity and public health.

To assess the implementation of these policies, the California Women’s Law Center (2021) conducted a comprehensive audit of 414 school districts across 57 counties in California. This audit impacted nearly 3.7 million students and 356,633 employees. Initially, the average grade for California districts was a C, indicating inadequate support for breastfeeding women. However, through California Women’s Law Center’s (2021) efforts to create tools and training to assist in policy implementation, 84% of the districts in California now have a grade of A or B, improving the state’s average grade to B. The audit evaluated districts based on five key criteria: lactation accommodation policies for (a) employees and for (b) students, (c) complaint procedures, (d) Title IX coordinator presence, and (e) website information accessibility (California Women’s Law Center, 2021). This work highlights the importance of not only implementing laws but also actively monitoring and supporting their execution to ensure that breastfeeding students and employees have equal access to educational and employment opportunities (California Women’s Law Center, 2021).

Colleges and universities can also offer supports to breastfeeding students. The Society for College and University Planning (2019) study on lactation policy and facilities across higher education campuses revealed significant findings regarding the availability and standardization of lactation spaces in these institutions (see Box 8-5). The study, conducted in collaboration with the University of Pennsylvania, surveyed representatives from 105 colleges and universities across the United States (Henry-Moss et al., 2019; Society for College and University Planning, 2019); it found that nearly all surveyed institutions had at least one dedicated lactation space on campus, indicating a growing awareness of the need for such facilities. Approximately two-thirds of the institutions reported having a policy for creating lactation spaces, demonstrating a commitment to supporting breastfeeding mothers. However, only about a quarter of the surveyed schools included lactation spaces in their campus construction standards, suggesting room for improvement in institutionalizing these facilities (Henry-Moss et al., 2019; Society for College and University Planning, 2019).

The research highlighted populations that may require access to lactation spaces on college campuses, including graduate students, faculty, staff, and visitors. This underscores the importance of considering lactation support as more than just an employee benefit. The study also examined the proximity of lactation spaces to campus populations, the features of these spaces (e.g., locking mechanisms and hospital-grade pumps), and the involvement of various campus stakeholders (including campus and physical

planners and women’s health experts) in designing and funding these facilities. As a result of this research, Society for College and University Planning (2019) created a resource page to assist campus administrators in improving lactation support, emphasizing the need to view this issue as part of a broader health-promoting campus environment. The initiative aims to streamline the process for breastfeeding mothers. Spatz, one of the study’s authors, emphasizes the need for systemic support, stating: “I’ve said this before. I’ve said it a million times. All the onus is on the woman to figure it out herself. Moms shouldn’t have to work so hard to be able to meet their personal breastfeeding goals. We need to make it easier” (Berger, 2019, p. 2).

CHILDCARE

Childcare facilities can support continued breastfeeding of infants in their care. While no federal policy mandates breastfeeding accommodations in childcare centers, at least four states have laws related to childcare facilities and breastfeeding (National Conference of State Legislatures, 2021). Louisiana prohibits any childcare facility from discriminating against breastfed babies. Mississippi requires licensed childcare facilities to provide breastfeeding mothers with a sanitary place that is not a toilet stall to breastfeed their children or express milk, to provide a refrigerator to store expressed milk, to train staff in the safe and proper storage and handling of human milk, and to display breastfeeding promotion information to the clients of the facility. Maryland requires childcare centers to promote proper nutrition and developmentally appropriate practices by establishing training and policies promoting breastfeeding. Nevada instructs childcare facilities to provide an appropriate, private space on the premises of the childcare facility where a mother may breastfeed.

Other states promote breastfeeding-friendly childcare designation programs. For example, New York State’s Department of Health’s (n.d.) Child and Adult Care Food Program (CACFP) encourages childcare centers and family day care homes to actively support breastfeeding families. To be recognized as breastfeeding friendly, these facilities must complete an assessment demonstrating their support for breastfeeding families. Key aspects of supporting breastfeeding in childcare settings under the program include providing a designated place for breastfeeding, not offering solids to infants younger than four months, and not giving formula to breastfed infants without parental permission (Child Care Aware of America, 2021). Moreover, meals containing human milk are reimbursable through CACFP, providing financial benefits to the childcare facilities (New York State Department of Health, n.d.). Similar initiatives exist in other states, such as North Carolina’s Breastfeeding-Friendly Child Care Designation Program, which further highlights the growing recognition of the importance of breastfeeding support

in childcare settings (North Carolina Department of Health and Human Services, n.d.).

Table 8-2 presents information from Child Care Aware (a national research organization supporting childcare providers) as to common barriers or concerns with supporting breastfeeding in childcare facilities and potential solutions for overcoming these challenges.

TABLE 8-2 Supporting Breastfeeding in Childcare Settings: Barriers, Concerns, and Solutions

SOURCE: Child Care Aware of America, 2018.

Conclusion 8-3: Systems of support provided by governments, employers or schools can be opaque and hard to navigate, and it is typically left to the individual to navigate various complexities while also experiencing significant shifts in their identity as a parent and worker or student.

Conclusion 8-4: Several laws protect lactation accommodations for employees and students in the United States, but enforcement mechanisms vary across workplaces and educational institutions. While federal laws establish baseline protections, enforcement depends largely on complaints, legal action, and oversight by government agencies—and accountability systems remain weak, leaving many parents without the support they need.

Recommendation 8-2: Federal, state, territorial, tribal, and local governments, in collaboration with the public and private sectors, should (a) strengthen and enforce existing laws and legislation that guarantee that lactation accommodations and spaces are available in all workplaces, schools, colleges, universities, and childcare centers and (b) ensure that they comply with federal and state legal requirements.

REFERENCES

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