Understanding Lactation Policies and Resources Across a University System: Survey & Document Review

Understanding Lactation Policies and Resources Across a University System: Survey & Document Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Understanding Lactation Policies and Resources Across a University System: Survey & Document Review Emily L. Ashby, Sritha Donepudi, Heather M. Padilla This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3897750/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background: In the U.S., working women often return to work within 8-12 weeks of giving birth, therefore, it is critical that workplaces provide support for female employees combining breastfeeding and work. The Affordable Care Act requires any organization with more than 50 employees to provide a space other than a restroom for women to express breastmilk and a reasonable amount of time during the workday for women to express breastmilk. States and worksites differ in the implementation of ACA requirements and may or may not provide additional supports for female employees combining breastfeeding and work. The purpose of this study was to conduct an analysis of 26 institutions within a state university system to evaluate the differences in breastfeeding policies and resources available on each campus. Methods: Survey data was collected from well-being liaisons in the human resources departments at each institution. In addition, we conducted a document review of policies and online materials at each institution. We used univariate statistics to summarize survey results while a thematic analysis was used to analyze institutional resources available on websites and in policies provided by the liaisons. Results: A total of 18 (65.3%) liaisons participated in the study and revealed an overall lack of familiarity with the policies in place and inconsistencies in the resources offered to breastfeeding employees across the university system. Only half of the participating liaisons reported a formal breastfeeding policy was in place on their campus. From the document review six major themes were identified: placing the burden on female employees, describing pregnancy or postpartum as “disability,” having a university specific policy, inclusion of break times for breastfeeding, supervisor responsibility, and information on lactation policies. Conclusion: The review of each institutions online resources confirmed the survey findings and highlighted the burden placed on female employees to discover the available resources and advocate for their needs. This paper provides insight into how institutions support breastfeeding employees and provides implications on strategies to develop policies at universities to improve breastfeeding access for working mothers. Pregnancy Breastfeeding Lactation Maternity Workplace Pumping Support Workplace Facilities Employer Support Introduction Breastfeeding & Return to Work Exclusive breastfeeding for the first six months of an infant’s life is one of the greatest protective health factors for both mother and child (World Health Organization, 2021 ). Mothers who breastfeed have lower incidence of hypertension, type 2 diabetes, and ovarian and breast cancer; infants who receive breastmilk have greater sensory and cognitive development, as well as protection from multiple acute and chronic illnesses (Centers for Disease Control and Prevention, 2020). Additionally, for infants, not being breastfed has been found to be associated with increased incidence of other illnesses such as pneumonia, gastroenteritis, and leukemia, and Sudden Infant Death Syndrome (Stuebe, 2009 ). Even after adjusting for maternal age, education, smoking status, race, gender, birth weight and order, and other factors, there was still 1.3 times higher risk of infant mortality in infants who were formula fed as opposed to breastfed (Chen & Rogan, 2004). Despite the costs of not being able to breastfeed, only 58.3% of infants born in the US in 2017 were breastfed at six months old and only a quarter of those infants were exclusively breastfed (World Health Organization, 2021 ). The CDC, WHO, and American Academy of Pediatrics agree that the best practices for breastfeeding include exclusive breastfeeding for the first six months of life (Centers for Disease Control, 2021 ; World Health Organization, 2021 ). The availability of time off from work postpartum, especially paid time, is significantly associated with higher rates of women achieving the nationally recommended breastfeeding goals (Chatterji, 2005 ). Of the 41 member nations in the Organization for Economic Cooperation and Development (OECD), 40 mandate paid leave for mothers (and sometimes fathers, too) postpartum (Livingston & Thomas, 2019 . The only nation within OCED that does not provide federal paid leave is the United States (Livingston & Thomas, 2019 ). In the United States, women often return to work within the first three months of giving birth due to lack of paid maternity leave. Lack of paid time off impacts women’s’ ability to sustain breastfeeding, as seen in breastfeeding rates dropping from 81% at childbirth to 67% at 6 weeks, 49% at 12 weeks, and 33% at 6 months postpartum (Dagher, et al, 2016 ). Women who hold professional jobs or return to work within the first 6 months postpartum are more likely to stop breastfeeding early, which justifies an examination of how employer policies affect ability to breastfeed (Dagher, et al., 2016 ). To support female employees in achieving breastfeeding goals while returning to work, it is imperative for workplaces to have clear, informative, and supportive policies in place that set the standard for all employees and their supervisors. Previous research suggests that workplace employee health policies that help protect, and support employee health have lower rates of absenteeism and higher productivity (Steurer, 2017). Impact of Workplace Policies The workplace has a major influence on employee health and behavior; workers in the US spend an average of 8.10 hours at work each workday (Centers for Disease Control, 2016 ; U.S. Bureau of Labor Statistics, 2021 ). Comprehensive employee wellness programs have been shown to be effective in promoting healthy employee behaviors and reducing employer healthcare costs (Goetzel et al., 2020). Policies are an important element of comprehensive employee wellness programs (Centers for Disease Control, 2016 ). Worksite policies set the written expectation of the value of health, thereby creating a culture of prioritizing wellbeing at the worksite, and specifying the available resources provided to employees to promote health (Day A, 2014 ). The Workplace Health in America (WHA) survey (2019) found that nearly half (46.1%) of worksites offered some type of health promotion or employee wellness program, with a majority focusing on physical activity or nutrition programming. Only 7.6% of worksites offered lactation support programs, the lowest of all program categories (Linnan et al., 2019 ). The Case for Lactation Policies While a significantly personal decision, a mother’s decision to breastfeed can be impacted by the policies, resources, and culture at their workplace. A workplace culture that encourages positive perceptions of breastfeeding children among employees and supporting adequate time and space for pumping breastmilk has been associated with women sustaining breastfeeding after returning to work (Dunn et al., 2015 ; Steurer, 2017). Breastfeeding self-efficacy for female employees was positively associated with female coworker support of breastfeeding (Zhuang et al., 2019 ). Programs focused on lactation support policy implementation in the workplace have been successful in facilitating continued breastfeeding among female employees (Garvin et al., 2013 ). Further, creating designated spaces for pumping breastmilk at work and maintaining a clean and comfortable environment within those spaces has been shown to increase employee rates of continued breastfeeding after returning to work (Tsai, 2013 ). Impact of the Affordable Care Act The Affordable Care Act requires any organization with more than 50 employees to provide a space other than a restroom and a reasonable amount of time during the workday for women to express breastmilk (U.S. Department of Labor, 2010 ). Each state within the United States applied this federal mandate differently, allowing employers to interpret the law in various ways (U.S. Department of Labor, 2010 ). When the stipulations of the ACA were applied in a comprehensive workplace policy there were positive associations with better breastfeeding outcomes among employees (Garvin et al., 2013 ). Women who were provided both adequate break time and private space were 2.3 times more likely to be breastfeeding exclusively at six months and 1.5 times more likely to continue breastfeeding exclusively with each passing month compared with women without access to these accommodations (Kozhimannil et al., 2016 ). Additionally, human resource officers and those charged with overseeing and directing employee wellness policies have a major impact on breastfeeding policy creation and implementation within their worksite (Uribe et al., 2019 ). Barriers in lactation policy Despite some positive changes in national laws surrounding lactation support at work, implementation and success of lactation policies face difficulties. Barriers for workplaces introducing lactation policies include limited resources, perceptions on the need for breastfeeding policies, and certain organizational characteristics such as workforce age (Bradford et al., 2017 ). Additionally, even in worksites where breastfeeding support initiatives exist, women encounter challenges in gaining equitable access to the resources that may be available via their workplace policies (Johnson & Salpini, 2017 ). Even in female dominated professions, a lack of female-supportive language within breastfeeding policies creates a culture of apathy and does not encourage translation of policy to practice, decreasing the potential impact of these policies on breastfeeding outcomes (Burns et al., 2022 ). Present Study To better understand the implementation of breastfeeding policies in workplaces, we conducted a study with 26 institutions that are part of a state university system with a system-wide employee well-being program. Each institution has its own leadership and employee policies and practices. More specifically, we analyzed the differences in breastfeeding policies and resources available on each campus when female employees return to work after giving birth. Methods Setting & Participants This study was conducted within a southeastern university system comprised of 26 institutions that range from four-year Research One universities to smaller community colleges. The institutions within the system range in total number of employees from 141 to 10,544. Characteristics of the institutions are described in Table 1 . Within each institution, the human resources department identifies one staff person to be the “well-being liaison.” The Well-being Liaisons are tasked with providing wellness content, resources, and communication of wellbeing policies to all sectors of their colleges and universities. They serve populations including faculty, staff, facilities management, and every person employed by the institution. The well-being liaison connects the institution to the system-wide well-being program and is responsible for connecting its campus to well-being efforts, events, and information. Collectively, the liaisons are part of a comprehensive approach to create a culture and environment of well-being. The 26 individuals serving as well-being liaisons at the time of this study were invited to participate. Table 1 Institution Employee Demographics Institution Total Faculty % Female Faculty % Black Faculty % Hispanic Faculty Full Time Employees Institution 1 1054 44.1 6.1 5.2 4096 Institution 2 1014 26.6 2.7 5.2 6834 Institution 3 1515 50.8 14.7 3.4 4090 Institution 4 1842 39.3 5.5 3.6 9091 Institution 5 956 51.3 7.1 4.0 2273 Institution 6 1209 48.2 9.3 3.9 2237 Institution 7 433 58.2 7.6 3.7 1240 Institution 8 382 52.1 7.1 3.7 748 Institution 9 175 54.9 50.9 1.1 529 Institution 10 204 55.9 27.9 2.9 439 Institution 11 280 47.1 11.1 4.3 584 Institution 12 92 45.7 58.7 1.1 488 Institution 13 293 53.9 7.2 4.4 687 Institution 14 115 53.0 1.7 2.6 183 Institution 15 252 50.8 12.7 2.8 427 Institution 16 122 40.2 41.0 3.3 486 Institution 17 660 48.9 4.7 5.2 1054 Institution 18 135 50.4 7.4 1.5 265 Institution 19 31 41.9 71.0 3.2 167 Institution 20 94 54.3 9.6 4.3 187 Institution 21 140 54.3 5.0 1.4 197 Institution 22 54 50.0 5.6 5.6 158 Institution 23 444 52.7 10.6 4.1 403 Institution 24 120 57.5 10.0 1.7 226 Institution 25 86 52.3 14.0 0.0 210 Institution 26 62 53.2 3.2 3.2 133 INSERT Table 1 Recruitment An initial email was sent to all well-being liaisons inviting them to complete an online survey in Qualtrics. Follow-up emails were sent three weeks after the initial invitation. Due to low response rate after reminder emails, the research team adapted the survey to a phone interview and two members of the research team called any liaison who had not responded to the initial surveys and invited them to participate. Reaching out to participants via phone occurred in three phases. In the first phase, one member of the research team called each liaison inviting them to participate. For those who did not answer the initial phone call, a second member of the research team called back. Any remaining institutions that were not reached with the first two phone call attempts were called a third and final time by the first research team member. Upon completion of the survey, all participants were mailed an incentive valued at $ 20. Liaison Survey The liaison survey was adapted from the Breastfeeding and Employment Study organization survey (Olson, 2014). This survey aimed to gain insight into the liaisons’ perspectives and knowledge regarding lactation policies and resources on their respective campuses. The information gathered was based on their individual observations and knowledge of institution policies. The survey was organized into four categories of breastfeeding support: policy, resources, lactation space availability, and time. Examples of the survey questions in each category are provided below. Policy The survey contained twelve questions regarding university-specific policies on breastfeeding at work and maternity leave. For example, we asked “Does your institution have a written policy on breastfeeding and/or pumping milk at work?”. We also asked about employee awareness of policies (e.g., “Are all employees informed of this policy?” Response options were “yes” and “no”. Additional questions inquired about maternity leave payment policies. For example, we asked “Where does that maternity leave pay funding come from?” Respondents could select multiple options including “short-term disability insurance,” “accrued time,” “organizational-paid leave,” and write in an institutional-specific source of funding. This section of the survey also offered the opportunity for each liaison to provide their formal, written policies on breastfeeding and maternity leave. Resources This section of the survey contained questions on resources available to employees on campus, including whether the resource was available and the provider of the resource. Seven resources were assessed: access to a lactation consultant, educational classes on breastfeeding/pumping, electric breast pumps or pumping kits, and onsite daycare availability. For each resource, respondents indicated if the resource existed and whether it was provided by the wellness program, employee assistance program, health insurance or other. Lactation Spaces The next section of the survey included questions focused on pumping breastmilk at work. We asked seven questions about specific places on campus where female employees can to express breastmilk. An example question was “Are restrooms the only spaces available for breastfeeding or pumping?” with answer choices of “yes” or “no.” We also asked about availability of designated lactation spaces and the amenities available in these spaces. The questions we asked included, “Is there any space(s) on your campus dedicated solely to breastfeeding or pumping breastmilk?” and, “What amenities are available in these spaces?” The first question had response options of “yes” or “no,” and the second question had a list of possible amenities including a sink, electrical outlet, and refrigerator. Time The last section of the survey included questions regarding time provided to female employees for breastfeeding, as well as what maternity leave looked like at each institution. We asked five questions inquiring to the availability and qualification for maternity leave. An example of these questions included, “Are employees who qualify for Family and Medical Leave Act (FMLA), eligible to receive pay during maternity leave?” Answer choices to these questions included “yes,” “no,” or “I don’t know.” We also asked about funding for maternity leave by asking each liaison, “Where does that maternity leave pay funding come from?” Possible answers included “short-term disability insurance,” “accrued time (sick, vacation, personal),” “donated time,” or “some other organization paid leave.” We then asked three questions about time to pump once female employees returned to work. Questions included “What are, if any, the flexible time scheduling options available to full-time employees at your college?” with response options of flextime, telecommuting, job sharing, or none. Additionally, we asked about time given to women to pump during the workday (e.g., “When are women allowed to pump breastmilk during work?” with answer options of only during break or lunch times, as needed, or unsure. Document Review During the liaison survey, we asked each participant to provide copies of their institution’s breastfeeding and maternity leave policies. The document review included policies we received from the liaisons and policies or information found on institution websites. Two research team members assessed information and resources for breastfeeding and lactation publicly available on each institution’s website. These resources included employee handbooks, student handbooks, publicly available online policies and any other information that could be found on human resource webpages. The research team members reviewed each institution’s website for information on specific employee breastfeeding policies, lactation rooms on campus, and any other information relevant for expecting mothers. Data Collection All liaison survey data were collected and stored via Qualtrics. Initially the survey was self-administered but due to the low response rate, the survey was adapted to allow the survey to be conducted via phone by trained research staff. No changes were made to the main aspects of the survey questions when adapted to phone administration. Instead, the wording shifted from “Please note how women are made aware of lactation policies on campus” on the electronic survey to “Can you describe how female employees are made aware of lactation policies on your campus?” on the phone-adapted version. Research team members would then list the possible answer choices that matched those on the electronic survey. Data from the document review were organized in a Microsoft Excel spreadsheet. Analysis Survey data were analyzed by univariate statistics to provide frequencies and means. Data from the document review was analyzed by constant comparative method to develop themes via a deductive and inductive approach (Glaser, 1965 ). Deductive Approach Each policy was reviewed based on its compliance with and expansion of the requirements for employers through the Affordable Care Act (Bick et al.) (U.S. Department of Labor, 2010 ). Compliance was defined by the research team as the University providing a policy that stated, at minimum, a space other than a restroom on campus for women to express breastmilk as well as time during the workday to express breastmilk. The ACA amended the Fair Labor Standards Act requiring employers to provide “reasonable break time for an employee to express breastmilk for her nursing child for one year after the child’s birth each time such employee has need to express the milk” (U.S. Department of Labor, 2010 #115). Employers are also required to provide “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 breastmilk” (U.S. Department of Labor, 2010 #115). Based on language found within institution policies, the research team coded the data as compliant or not compliant with the ACA requirements. Inductive Approach We used an inductive approach to allow themes to emerge from the data. Two research team members read through each policy independently to identify themes. After identifying themes, the two research team members met to review themes and resolve any discrepancies. Results The survey was sent to 26 well-being liaisons. Nine well-being liaisons completed the self-administered version of the survey, and nine participants completed the survey by telephone. The remaining eight liaisons either declined to participate or were not reached via telephone after the third attempt. The total response rate for surveys was 69.2% (n = 18). Demographics Survey participants were mostly white (70.6%), non-Hispanic (94.4%), female (88.9%), with some postgraduate education (41.2%). Most participants held the wellness liaison position for nine years or less (78.9%). Table 2 describes the sample demographics. Table 2 Liaison Demographics Variable Participants (N = 18) (no %) Sex Male 2 (11.1%) Female 16 (88.9%) Hispanic/ Latino Yes 1 (5.6%) No 17 (94.4%) Age (n = 16) 20–29 1 (6.3%) 30–39 7 (43.7%) 40–49 4 (25%) 50–59 2 (12.5%) 60–69 2 (12.5%) Race (n = 17) Black or African American 5 (29.4%) White 12 (70.6%) Highest Education Level (n = 17) Some college of technical/ vocational training 1 (5.9%) Associate’s degree (2 years) 4 (23.5%) Bachelor’s degree (4 years) 5 (29.4%) Postgraduate Work (PhD, or MD) 7 (41.2%) INSERT Table 2 Liaison Survey. Overall, many of the well-being liaisons were uncertain about the existence of breastfeeding policies on their campus beyond the federal requirements of the Affordable Care Act (i.e., mothers will be provided a space to pump other than a restroom and reasonable break time during the workday to pump). The esults of the survey are described in detail in Table 3 .. Table 3 Summary of Survey Questions & Responses Survey Section # of questions Example questions % of schools with access to resources and information on policies Policy 12 Does your institution have a written policy on breastfeeding and/or pumping milk at work? How are supervisors made aware of policies? 50% have no formal policy 42.1% of supervisors are made aware of resources when employees seek use, 31.6% by the employee handbook, 31.6% by the HR website, and 31.6% by word of mouth Resources 7 Do you have access to onsite daycare? 47.4% have onsite daycare Lactation Spaces 7 Is there any space(s) on your campus dedicated solely to breastfeeding or pumping breast milk? What amenities are available in these spaces? 86.7% report women are allowed to pump at work 42.1% provide lactation-specific spaces Time 5 Where does that maternity leave pay funding come from? When are women allowed to pump breast milk during work? 68.4% reported accrued time, 57.9% reported short term disability benefits, and 42.1% reported donated time (only available at select places) 53.9% claim female employees can pump as needed Policy Half of the participants said there is no formal policy (50%) for breastfeeding at work on their campus, and 58.3% of those indicated that not all employees are informed of the policy. y. Supervisors are made aware of the lactation resources available mostly when employees are seeking use of those benefits (42.1%), by the employee handbook (31.6%), the HR website (31.6%), or by simple word of mouth (31.6%). Resources The survey assessed specific resources listed as best practices from the Breastfeeding and Employment Study (Olson, 2014). Best practices resources include providing breast pumps, educational materials, educational classes on breastfeeding, access to a lactation consultant, on-campus childcare, and a pumping kit to all breastfeeding employees. All resources, except for childcare services, were reportedly available to individuals who are enrolled in health insurance. Resources such as providing breast pumps to employees, educational materials, educational classes, or access to a lactation consultant were not provided through any on campus or employee benefits programs. Less than half of institutions (47.4%) reported offering onsite daycare for employees’ children. Lactation Spaces Most liaisons indicated that they believe their institution allows women to pump milk at work (86.7%) and 53.8% of liaisons responded women can pump as needed. Most participants noted that there are specific locations other than restrooms available for women to use for pumping (64.3%). However, only 42.1% mentioned lactation-specific spaces available to everyone. The majority of liaisons said that women can only access their own private offices (if their position provides it), a vacant office, or a vacant conference room. Time Most institutions have a formal leave policy under FMLA (93.3%), which provides 12 weeks of unpaid, job-protected leave per year for those who qualify. Funding for maternity leave for pregnant and postpartum employees predominantly comes from accrued time (i.e., sick leave; 68.4%), short-term disability benefits (57.9%), and donated time (only available at select places; 42.1%). Most participating liaisons (75%) noted that job protection and holding are only available to women who qualify for FMLA, which may not cover all workers employed across a variety of positions on their campuses. Flextime was the most common scheduling option offered to female employees returning to work postpartum (35.7%) with telecommuting as the second most common option (28.6). Most liaisons indicated that women could pump at work as needed (53.9%) though 31% said women can pump only during set break times. Table 3 below summarizes the survey questions and results. INSERT Table 3 Document Review Overall, six themes emerged from the data during the document review. The themes included placing the burden on female employees, describing pregnancy or postpartum as a “disability,” having a university-specific policy, inclusion of break times for breastfeeding, supervisor responsibility, and information on lactation policies. Definitions of each theme are provided in Table 4 . Table 4 Summary of Document Review Theme Definition No. of Institutions Placing Burden on Women Institution policy contains no information on lactation OR responsibility for accessing the resource falls solely on the female employee 13 Disability Language Referring to “disability due to pregnancy” and funding maternity leave from disability leave 3 Break Times Policy clearly states providing break time for female employees to breastfeed 10 University Specific Policy The institution has created and made available an institutional lactation policy that is different from the general requirements of the ACA or university system 13 Supervisor Responsibility Explicit mention of supervisors’ involvement in providing break time and resources to women returning to work post-partum 5 Lactation Spaces Policy contains information about lactation spaces on campus 11 INSERT Table 4 . Most participating universities had policies or statements that contained language matching the Affordable Care Act, such as space other than a restroom for breastfeeding and reasonable break times. Placing Burden on Women Thirteen institutions had no policy or lacked information on breastfeeding on their websites. Additionally, thirteen institutions lacked information in the policy about the supervisors’ role in supporting breastfeeding for employees or suggested that it was the employees’ responsibility to identify resources. Below is an example of language within a policy that placed the burden on women when they return to work postpartum: If the employee uses time other than a regularly scheduled break time [for pumping breastmilk] or if the employee’s department does not have designated break times, then the employee will be required to either: (1) make up that time during the same workday; (2) use vacation leave; or (3) take leave without pay for that period of time. Disability Language Three institutions had policies that referred to “disability due to pregnancy” or classified any policies regarding pregnancy or breastfeeding within their disability category. Almost all institutions only provided paid leave for female employees via short-term disability leave. Still, there was no distinction between leave due to pregnancy/ postpartum and other situations that would be classified as disability. An example of this theme was the following statement in an institution’s maternity leave policy, “Disability due to pregnancy shall be considered as any other disability…” Break Times Ten institutions included language for break times specific to “nursing,”“pumping,” or “lactation” within their policies. Example quotes of this language include: Lactating mothers shall be granted flexible and reasonable breaks, using their normal break periods and mealtimes, to accommodate milk expression. [Employees will be provided] …reasonable break times to express milk for her baby, so long as the break does not unduly disrupt the operations of the college. The break time shall, if possible, run concurrently with any break time already provided to the employee. No work duties will be required to be performed during this break period. University-Specific Policy Half (n = 13) of the universities had their own institutional policy on breastfeeding and lactation. The remaining institutions (n = 13) only referred to the larger university system policy or had no information.. Institutions that created individual breastfeeding policies contained language such as: The University supports parents employed by [this institution] by providing lactation and nursing support. A lactation and nursing parent support program allows a lactating parent to express breastmilk periodically during the workday or nurse an infant child. This policy is in accordance with the Official Code of [State], Federal Labor Standards Act, as well as [University System], [this institution], local, State and Federal regulations. Supervisor Responsibility Policies at five institutions contained information regarding supervisor responsibility. For each of these schools, there is explicit mention of female employees needing to coordinate with their direct supervisor to ensure reasonable break times for breastfeeding are met. Examples of this language within policies included: Lactating mothers who wish to express milk during the work period should keep supervisors informed of their needs so that appropriate accommodations can be made to satisfy the needs of both the employee and the department. Supervisors should attempt to provide as much schedule flexibility and break time as reasonably possible to accommodate the employee’s needs. Lactation Spaces Twelve (46.15%) institution policies contained language about lactation spaces on campus. Of those 12, very few provided specific details on where the spaces are, how to access them, and what amenities were available. An example of language of a policy that included details is provided here: “The designated lactation room is located in [location]. The lactation room provides an electrical outlet, comfortable chair, and nearby access to hot running water and soap.” Some institutions mentioned having a designated lactation space on campus, but there was no information on who to contact or how to access the space. Instead, there was vague language about including a space other than a restroom, but no further details on a lactation space on campus. An example of this vague language includes, “[This institution] will provide to any employee who is breastfeeding her child…” Discussion This study was conducted within a University System in the Southern United States to understand how a group of institutions in higher education support female employees with breastfeeding when they return to work after giving birth. With the passage of the Affordable Care Act in 2014, all worksites that employ more than 50 people are required to provide a place other than a bathroom and reasonable break time during work hours for female employees to pump breastmilk (U.S. Department of Labor, 2010 ). Understanding how this policy has or has not been translated into worksites provides insight into how organizations are caring for their employee’s health and well-being. Summary of Findings Our survey of well-being liaisons within a university system revealed a large variation in lactation policies and resources across institutions. While we found that liaisons reported and formal policies reflected the minimum ACA requirements, how these policies are implemented on campuses was unclear. Of great concern is that about half of institutions did not have a formal policy for breastfeeding. Further, communication of the policy to supervisors was very passive in nature and only when needed for an employee or through written material available to all employees. Establishing policies at all institutions and making all supervisors aware of the policy increases the likelihood that employees are supported in their breastfeeding goals when they return to work. Although the survey of liaisons suggested there is opportunity for women to pump on campus, without any formal policy or a lack of detail in existing policies, the burden is placed on female employees to discover and advocate for their needs when returning to work after giving birth. The lack of explicit language protecting breastfeeding employees leads to discrepancies in experiences when returning to work. Previous studies in workplace wellness have highlighted the difficulty in adopting wellness policies, especially across worksites of varying size and cultures (Bradford et al., 2017 ; Kozhimannil et al., 2016 ; Tsai, 2013 ). Except for onsite daycare, best practice resources for breastfeeding were available to employees, though these resources were available through an individual’s insurance provider. Even within institutions where childcare may be provided, no information was provided on the capacity of those childcare settings or the difficulties an employee may experience enrolling their child. This may mean that employees on spouse’s insurance plans or those who are on spouse’s insurance plans or those who are ineligible for insurance (i.e., part-time, or temporary employees) do not have access to these resources. Lactation space and time are included explicitly in the ACA language and seem to be available at all institutions. However, the details of how those amenities are provided to ensure all employees have equitable access to both space and time to pump are not detailed in the policies. More research is needed to understand why these discrepancies exist across institutions, how to combat them, and how to support complex work structures like colleges and universities in adopting these across institutions exist, how to combat them, and how to support complex work structures like colleges and universities in adopting these kinds of policies. The review of available policies from the institutions corroborates the findings from the survey of the liaisons that there is a lack of detail around the practice of providing support for breastfeeding when women return to work after giving birth. In the U.S., the only national job protection for mothers returning to work after giving birth is through FMLA, which is not specific to pregnancy but covers any medical condition. As such, most of the policies described pregnancy as a disability and, in some cases, women’s leave from work and return to work after birth was treated as any other medical condition. Limitations This study is not without its limitations. First, due to limited response to surveys sent via email, the survey was adapted to be conducted over the phone thus, word change occurred. Also, the individuals who serve as the wellness liaisons from each institution do not all have the same job title or training as this is not their primary role in the workplace. Therefore, some participants may have been more familiar with the policies than others depending on their regular job duties. Previously, all wellness liaisons participated in a well-being board, but from initial data collection to present, that group has been disbanded. Although they all work on separate campuses across the university system, it is possible that participants at the time of data collection communicated with one another about the survey, introducing potential response bias to survey results. However, no indication was made during the phone interviews that any participants had heard about the study or had spoken to other liaisons. Additionally, the authors recognize the reality of potential social bias being introduced due to the phone medium for some survey responses versus electronic medium for others. While our survey and document review investigated the availability of childcare on campus, the questions did not investigate whether or not female employees could visit the on-campus childcare and breastfeed their child. Female employee’s ability to do this remains a gap in our understanding. Finally, due to access restrictions, the document review was limited to online information that the research team could access. More nuances and detailed information on each institution’s policies were unavailable to this research team. Strengths of Study Despite these limitations, this current study has some strengths. We included two sources of data – wellbeing liaison surveys and qualitative document review. This allows us to compare data from both sources to understand the policies and practices at the institutions. To the author’s knowledge, the scope of research done on what policies and resources exist for breastfeeding employees within complex work structures is limited. Investigating the differences across a university system sheds light on inconsistencies in how female employees experience returning to work and breastfeeding. Implications Academic institutions like the colleges and universities analyzed in this study employ a wide range of personnel. Due to the complexity of their employment and work structure, it is difficult to assess how institutions support all their faculty and staff. The findings from this current study highlight the need for improved policies that protect female employees, especially regarding returning to work postpartum. Creating consistent, written policies across a university system and allowing individual institutions to adapt them is necessary. To create a healthier work environment for women working at colleges and universities, university leadership and human resource officials need to establish policies and resources to ease female employees’ return to work postpartum. Abbreviations ACA Affordable Care Act FMLA Family Medical Leave Act Declarations Ethics approval and consent to participate. All study materials were approved by the International Review Board for Human Research Ethics at the University of Georgia. This study also meets the ethical guidelines and has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. All study participants provided written informed consent or verbal consent based on the medium of interview. All participants were over 20 years old. Consent for publication It was obtained from all individual participants included in the study. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no conflicts of interest in relation to this work. Funding The authors have no statement of funding. Author’s contributions Emily Ashby was the primary author on this paper. Emily Ashby and Dr. Heather Padilla adapted the survey tool for data collection. Emily Ashby wrote the main manuscript text and she and Sritha prepared table 1-3. Sritha assisted in data collection and analysis. All authors reviewed the manuscript. Acknowledgments The authors would like to acknowledge Ms. Kismet Adams of the University of Georgia as an inspiration for this work. References Bradford VA, Walkinshaw LP, Steinman L, Otten JJ, Fisher K, Ellings A, O'Leary J, Johnson DB. Creating environments to support breastfeeding: The challenges and facilitators of policy development in hospitals, clinics, early care and education, and worksites. Matern Child Health J. 2017;21(12):2188–98. https://doi.org/10.1007/s10995-017-2338-4 . Burns E, Gannon S, Pierce H, Hugman S. Corporeal generosity: Breastfeeding bodies and female-dominated workplaces. Gend Work Organ. 2022;29(3):778–99. https://doi.org/10.1111/gwao.12821 . Centers for Disease Control. (2016). Workplace Health Model. https://www.cdc.gov/workplacehealthpromotion/model/index.html . Centers for Disease Control. (2021). National immunization survey, results: breastfeeding rates. cdc.gov/breastfeeding/data/nis_data/results.html . Chatterji P, Frick KD. Does Returning to Work After Childbirth AffectBreastfeeding Practices? Rev Econ Househ. 2005;3(3):315–35. https://doi.org/10.1007/s11150-005-3460-4 . Chen A, Rogan WJ. Breastfeeding and the risk of postneonatal death in the United States. Pediatrics. 2004a;113(5). https://doi.org/10.1542/peds.113.5.e435 . Dagher RK, McGovern PM, Schold JD, Randall XJ. Determinants of breastfeeding initiation and cessation among employed mothers: A prospective cohort study. BMC Pregnancy Childbirth. 2016;16(1). https://doi.org/10.1186/s12884-016-0965-1 . Day A, Hurrell KE Jr JJ. Workplace well-being: How to build psychologically healthy workplaces. John Wiley & Sons, Ltd.; 2014. Dunn RL, Kalich KA, Henning MJ, Fedrizzi R. Engaging field-based professionals in a qualitative assessment of barriers and positive contributors to breastfeeding using the social ecological model. Matern Child Health J. 2015;19(1):6–16. https://doi.org/10.1007/s10995-014-1488-x . Garvin CC, Sriraman NK, Paulson A, Wallace E, Martin CE, Marshall L. The business case for breastfeeding: A successful regional implementation, evaluation, and follow-up. Breastfeed Med. 2013;8(4):413–7. https://doi.org/10.1089/bfm.2012.0104 . Glaser BG. The Constant Comparative Method of Qualitative Analysis. Soc Probl. 1965;12(4):436–45. https://doi.org/10.2307/798843 . Goetzel RZ, Henke RM, Head MA, Benevent R, Rhee K. Ten Modifiable Health Risk Factors and Employees' Medical Costs-An Update. Am J Health Promot, 34(5), 490–9. https://doi.org/10.1177/0890117120917850 . Johnson KM, Salpini C. Working and nursing: Navigating job and breastfeeding demands at work. Community Work Family. 2017;20(4):479–96. https://doi.org/10.1080/13668803.2017.1303449 . Kozhimannil KB, Jou J, Gjerdingen DK, McGovern PM. Access to workplace accommodations to support breastfeeding after passage of the Affordable Care Act. Women's Health Issues. 2016;26(1):6–13. https://doi.org/10.1016/j.whi.2015.08.002 . Linnan LA, Cluff L, Lang JE, Penne M, Leff MS. Results of the Workplace Health in America Survey. Am J Health Promot. 2019;33(5):652–65. https://doi.org/10.1177/0890117119842047 . Livingston G, Thomas D. (2019). Among 41 countries, only U.S. lacks paid parental leave. https://www.pewresearch.org/short-reads/2019/12/16/u-s-lacks-mandated-paid-parental-leave/ . Olson BH, BreastfeedingAndEmploymentSteurer LM. (2017). Maternity leave length and workplace policies' impact on the sustainment of breastfeeding: Global perspectives. Public Health Nursing, 34(3), 286–294. https://doi.org/10.1111/phn.12321 . Stuebe A. The risks of not breastfeeding for mothers and infants. Rev Obstet Gynecol. 2009;2(4):222–31. Tsai S-Y. Impact of a breastfeeding-friendly workplace on an employed mother’s intention to continue breastfeeding after returning to work. Breastfeed Med. 2013;210–6. https://doi.org/10.1089/bfm.2012.0119 . U.S. Bureau of Labor Statistics. (2021). Average hours employed people spent working on days worked by day of week. https://www.bls.gov/charts/american-time-use/emp-by-ftpt-job-edu-h.htm . U.S. Department of Labor. (2010). Section 7(r) of the Fair Labor Standards Act – Break Time for Nursing Mothers Provision. https://www.dol.gov/agencies/whd/nursing-mothers/law . Uribe ALM, Bolton TA, Woelky KR, Olson BH. Exploring human resource managers’ decision-making process for workplace breastfeeding-support benefits following the passage of the Affordable Care Act. Matern Child Health J. 2019;23(10):1348–59. https://doi.org/10.1007/s10995-019-02769-6 . World Health Organization. (2021). Breastfeeding. https://www.who.int/health-topics/breastfeeding#tab=tab_1 . Zhuang J, Bresnahan MJ, Yan X, Zhu Y, Goldbort J, Bogdan-Lovis E. Keep doing the good work: Impact of coworker and community support on continuation of breastfeeding. Health Commun. 2019;34(11):1270–8. https://doi.org/10.1080/10410236.2018.1476802 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 06 Apr, 2024 Reviews received at journal 04 Apr, 2024 Reviewers agreed at journal 04 Apr, 2024 Reviews received at journal 01 Apr, 2024 Reviewers agreed at journal 22 Mar, 2024 Reviewers agreed at journal 15 Mar, 2024 Reviewers invited by journal 13 Mar, 2024 Editor assigned by journal 13 Mar, 2024 Editor invited by journal 31 Jan, 2024 Submission checks completed at journal 31 Jan, 2024 First submitted to journal 25 Jan, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3897750","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":270472723,"identity":"c9be287f-99e2-4149-9a96-83240463e6d3","order_by":0,"name":"Emily L. Ashby","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA00lEQVRIiWNgGAWjYDACCeb2HxIGEvX8EC4zMVoYGyQsCmwSJBtI0lLxIS3B4ACxWvilGxsMbhgczjO+kX7xA0OFdWIDIS2Scw42JM4wOFxsdiOnWILhTDphLQY3EhsOSxgcZtx2IydBgrHtMGEt9jcSG5v/ALVsnpGT/IPxHxFaDCQSmxkkDNISN0ikHwMGBRFaJG4ktgG12BhLnHnDZpFwLN2YoBb+GcnHGCT+SMjxt6c/vvGhxlqWoBYkwGPAkECCchBgf0CihlEwCkbBKBgpAADPIUMQ3oraIAAAAABJRU5ErkJggg==","orcid":"","institution":"University of Georgia","correspondingAuthor":true,"prefix":"","firstName":"Emily","middleName":"L.","lastName":"Ashby","suffix":""},{"id":270472724,"identity":"52bcafc9-208d-42d3-971c-0d7d606be952","order_by":1,"name":"Sritha Donepudi","email":"","orcid":"","institution":"University of Georgia","correspondingAuthor":false,"prefix":"","firstName":"Sritha","middleName":"","lastName":"Donepudi","suffix":""},{"id":270472725,"identity":"2f660a24-1349-401a-8e3c-eb256a99b69d","order_by":2,"name":"Heather M. Padilla","email":"","orcid":"","institution":"University of Georgia","correspondingAuthor":false,"prefix":"","firstName":"Heather","middleName":"M.","lastName":"Padilla","suffix":""}],"badges":[],"createdAt":"2024-01-25 16:14:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3897750/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3897750/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":50537359,"identity":"d106ebfe-7aa2-4371-a1fc-dd2d53814baf","added_by":"auto","created_at":"2024-02-02 05:30:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":291210,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3897750/v1/f7a5011e-6aa3-45e6-be0d-5edfe6327708.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Understanding Lactation Policies and Resources Across a University System: Survey \u0026 Document Review","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBreastfeeding \u0026amp; Return to Work\u003c/p\u003e \u003cp\u003eExclusive breastfeeding for the first six months of an infant\u0026rsquo;s life is one of the greatest protective health factors for both mother and child (World Health Organization, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Mothers who breastfeed have lower incidence of hypertension, type 2 diabetes, and ovarian and breast cancer; infants who receive breastmilk have greater sensory and cognitive development, as well as protection from multiple acute and chronic illnesses (Centers for Disease Control and Prevention, 2020). Additionally, for infants, not being breastfed has been found to be associated with increased incidence of other illnesses such as pneumonia, gastroenteritis, and leukemia, and Sudden Infant Death Syndrome (Stuebe, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). Even after adjusting for maternal age, education, smoking status, race, gender, birth weight and order, and other factors, there was still 1.3 times higher risk of infant mortality in infants who were formula fed as opposed to breastfed (Chen \u0026amp; Rogan, 2004). Despite the costs of not being able to breastfeed, only 58.3% of infants born in the US in 2017 were breastfed at six months old and only a quarter of those infants were exclusively breastfed (World Health Organization, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe CDC, WHO, and American Academy of Pediatrics agree that the best practices for breastfeeding include exclusive breastfeeding for the first six months of life (Centers for Disease Control, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; World Health Organization, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The availability of time off from work postpartum, especially paid time, is significantly associated with higher rates of women achieving the nationally recommended breastfeeding goals (Chatterji, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2005\u003c/span\u003e). Of the 41 member nations in the Organization for Economic Cooperation and Development (OECD), 40 mandate paid leave for mothers (and sometimes fathers, too) postpartum (Livingston \u0026amp; Thomas, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2019\u003c/span\u003e. The only nation within OCED that does not provide federal paid leave is the United States (Livingston \u0026amp; Thomas, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). In the United States, women often return to work within the first three months of giving birth due to lack of paid maternity leave. Lack of paid time off impacts women\u0026rsquo;s\u0026rsquo; ability to sustain breastfeeding, as seen in breastfeeding rates dropping from 81% at childbirth to 67% at 6 weeks, 49% at 12 weeks, and 33% at 6 months postpartum (Dagher, et al, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Women who hold professional jobs or return to work within the first 6 months postpartum are more likely to stop breastfeeding early, which justifies an examination of how employer policies affect ability to breastfeed (Dagher, et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). To support female employees in achieving breastfeeding goals while returning to work, it is imperative for workplaces to have clear, informative, and supportive policies in place that set the standard for all employees and their supervisors. Previous research suggests that workplace employee health policies that help protect, and support employee health have lower rates of absenteeism and higher productivity (Steurer, 2017).\u003c/p\u003e \u003cp\u003eImpact of Workplace Policies\u003c/p\u003e \u003cp\u003eThe workplace has a major influence on employee health and behavior; workers in the US spend an average of 8.10 hours at work each workday (Centers for Disease Control, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; U.S. Bureau of Labor Statistics, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Comprehensive employee wellness programs have been shown to be effective in promoting healthy employee behaviors and reducing employer healthcare costs (Goetzel et al., 2020). Policies are an important element of comprehensive employee wellness programs (Centers for Disease Control, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Worksite policies set the written expectation of the value of health, thereby creating a culture of prioritizing wellbeing at the worksite, and specifying the available resources provided to employees to promote health (Day A, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). The Workplace Health in America (WHA) survey (2019) found that nearly half (46.1%) of worksites offered some type of health promotion or employee wellness program, with a majority focusing on physical activity or nutrition programming. Only 7.6% of worksites offered lactation support programs, the lowest of all program categories (Linnan et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe Case for Lactation Policies\u003c/p\u003e \u003cp\u003eWhile a significantly personal decision, a mother\u0026rsquo;s decision to breastfeed can be impacted by the policies, resources, and culture at their workplace. A workplace culture that encourages positive perceptions of breastfeeding children among employees and supporting adequate time and space for pumping breastmilk has been associated with women sustaining breastfeeding after returning to work (Dunn et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Steurer, 2017). Breastfeeding self-efficacy for female employees was positively associated with female coworker support of breastfeeding (Zhuang et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Programs focused on lactation support policy implementation in the workplace have been successful in facilitating continued breastfeeding among female employees (Garvin et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Further, creating designated spaces for pumping breastmilk at work and maintaining a clean and comfortable environment within those spaces has been shown to increase employee rates of continued breastfeeding after returning to work (Tsai, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2013\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eImpact of the Affordable Care Act\u003c/p\u003e \u003cp\u003eThe Affordable Care Act requires any organization with more than 50 employees to provide a space other than a restroom and a reasonable amount of time during the workday for women to express breastmilk (U.S. Department of Labor, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). Each state within the United States applied this federal mandate differently, allowing employers to interpret the law in various ways (U.S. Department of Labor, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). When the stipulations of the ACA were applied in a comprehensive workplace policy there were positive associations with better breastfeeding outcomes among employees (Garvin et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Women who were provided both adequate break time and private space were 2.3 times more likely to be breastfeeding exclusively at six months and 1.5 times more likely to continue breastfeeding exclusively with each passing month compared with women without access to these accommodations (Kozhimannil et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Additionally, human resource officers and those charged with overseeing and directing employee wellness policies have a major impact on breastfeeding policy creation and implementation within their worksite (Uribe et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBarriers in lactation policy\u003c/p\u003e \u003cp\u003eDespite some positive changes in national laws surrounding lactation support at work, implementation and success of lactation policies face difficulties. Barriers for workplaces introducing lactation policies include limited resources, perceptions on the need for breastfeeding policies, and certain organizational characteristics such as workforce age (Bradford et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Additionally, even in worksites where breastfeeding support initiatives exist, women encounter challenges in gaining equitable access to the resources that may be available via their workplace policies (Johnson \u0026amp; Salpini, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Even in female dominated professions, a lack of female-supportive language within breastfeeding policies creates a culture of apathy and does not encourage translation of policy to practice, decreasing the potential impact of these policies on breastfeeding outcomes (Burns et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePresent Study\u003c/p\u003e \u003cp\u003eTo better understand the implementation of breastfeeding policies in workplaces, we conducted a study with 26 institutions that are part of a state university system with a system-wide employee well-being program. Each institution has its own leadership and employee policies and practices. More specifically, we analyzed the differences in breastfeeding policies and resources available on each campus when female employees return to work after giving birth.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eSetting \u0026amp; Participants\u003c/p\u003e \u003cp\u003eThis study was conducted within a southeastern university system comprised of 26 institutions that range from four-year Research One universities to smaller community colleges. The institutions within the system range in total number of employees from 141 to 10,544. Characteristics of the institutions are described in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Within each institution, the human resources department identifies one staff person to be the \u0026ldquo;well-being liaison.\u0026rdquo; The Well-being Liaisons are tasked with providing wellness content, resources, and communication of wellbeing policies to all sectors of their colleges and universities. They serve populations including faculty, staff, facilities management, and every person employed by the institution. The well-being liaison connects the institution to the system-wide well-being program and is responsible for connecting its campus to well-being efforts, events, and information. Collectively, the liaisons are part of a comprehensive approach to create a culture and environment of well-being. The 26 individuals serving as well-being liaisons at the time of this study were invited to participate.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInstitution Employee Demographics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitution\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal Faculty\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e% Female Faculty\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e% Black Faculty\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e% Hispanic Faculty\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFull Time Employees\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitution 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1054\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4096\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitution 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6834\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitution 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1515\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4090\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitution 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1842\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9091\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitution 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e956\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e51.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2273\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitution 6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1209\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e48.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2237\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitution 7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e433\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e58.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1240\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitution 8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e382\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e748\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitution 9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e175\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e50.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e529\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitution 10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e204\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e27.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e439\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitution 11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e280\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e584\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitution 12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e58.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e488\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitution 13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e293\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e53.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e687\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitution 14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e53.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e183\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitution 15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e252\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e427\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitution 16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e41.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e486\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitution 17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e660\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e48.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1054\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitution 18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e135\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e265\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitution 19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e71.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e167\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitution 20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e187\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitution 21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e197\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitution 22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e158\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitution 23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e444\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e403\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitution 24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e226\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitution 25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e210\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitution 26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e53.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e133\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eINSERT Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003c/h2\u003e \u003cp\u003eRecruitment\u003c/p\u003e \u003cp\u003eAn initial email was sent to all well-being liaisons inviting them to complete an online survey in Qualtrics. Follow-up emails were sent three weeks after the initial invitation. Due to low response rate after reminder emails, the research team adapted the survey to a phone interview and two members of the research team called any liaison who had not responded to the initial surveys and invited them to participate. Reaching out to participants via phone occurred in three phases. In the first phase, one member of the research team called each liaison inviting them to participate. For those who did not answer the initial phone call, a second member of the research team called back. Any remaining institutions that were not reached with the first two phone call attempts were called a third and final time by the first research team member. Upon completion of the survey, all participants were mailed an incentive valued at \u003cspan\u003e$\u003c/span\u003e20.\u003c/p\u003e \u003cp\u003eLiaison Survey\u003c/p\u003e \u003cp\u003eThe liaison survey was adapted from the Breastfeeding and Employment Study organization survey (Olson, 2014). This survey aimed to gain insight into the liaisons\u0026rsquo; perspectives and knowledge regarding lactation policies and resources on their respective campuses. The information gathered was based on their individual observations and knowledge of institution policies. The survey was organized into four categories of breastfeeding support: policy, resources, lactation space availability, and time. Examples of the survey questions in each category are provided below.\u003c/p\u003e \u003cp\u003ePolicy\u003c/p\u003e \u003cp\u003eThe survey contained twelve questions regarding university-specific policies on breastfeeding at work and maternity leave. For example, we asked \u0026ldquo;Does your institution have a written policy on breastfeeding and/or pumping milk at work?\u0026rdquo;. We also asked about employee awareness of policies (e.g., \u0026ldquo;Are all employees informed of this policy?\u0026rdquo; Response options were \u0026ldquo;yes\u0026rdquo; and \u0026ldquo;no\u0026rdquo;. Additional questions inquired about maternity leave payment policies. For example, we asked \u0026ldquo;Where does that maternity leave pay funding come from?\u0026rdquo; Respondents could select multiple options including \u0026ldquo;short-term disability insurance,\u0026rdquo; \u0026ldquo;accrued time,\u0026rdquo; \u0026ldquo;organizational-paid leave,\u0026rdquo; and write in an institutional-specific source of funding. This section of the survey also offered the opportunity for each liaison to provide their formal, written policies on breastfeeding and maternity leave.\u003c/p\u003e \u003cp\u003eResources\u003c/p\u003e \u003cp\u003eThis section of the survey contained questions on resources available to employees on campus, including whether the resource was available and the provider of the resource. Seven resources were assessed: access to a lactation consultant, educational classes on breastfeeding/pumping, electric breast pumps or pumping kits, and onsite daycare availability. For each resource, respondents indicated if the resource existed and whether it was provided by the wellness program, employee assistance program, health insurance or other.\u003c/p\u003e \u003cp\u003eLactation Spaces\u003c/p\u003e \u003cp\u003eThe next section of the survey included questions focused on pumping breastmilk at work. We asked seven questions about specific places on campus where female employees can to express breastmilk. An example question was \u0026ldquo;Are restrooms the only spaces available for breastfeeding or pumping?\u0026rdquo; with answer choices of \u0026ldquo;yes\u0026rdquo; or \u0026ldquo;no.\u0026rdquo; We also asked about availability of designated lactation spaces and the amenities available in these spaces. The questions we asked included, \u0026ldquo;Is there any space(s) on your campus dedicated solely to breastfeeding or pumping breastmilk?\u0026rdquo; and, \u0026ldquo;What amenities are available in these spaces?\u0026rdquo; The first question had response options of \u0026ldquo;yes\u0026rdquo; or \u0026ldquo;no,\u0026rdquo; and the second question had a list of possible amenities including a sink, electrical outlet, and refrigerator.\u003c/p\u003e \u003cp\u003eTime\u003c/p\u003e \u003cp\u003eThe last section of the survey included questions regarding time provided to female employees for breastfeeding, as well as what maternity leave looked like at each institution. We asked five questions inquiring to the availability and qualification for maternity leave. An example of these questions included, \u0026ldquo;Are employees who qualify for Family and Medical Leave Act (FMLA), eligible to receive pay during maternity leave?\u0026rdquo; Answer choices to these questions included \u0026ldquo;yes,\u0026rdquo; \u0026ldquo;no,\u0026rdquo; or \u0026ldquo;I don\u0026rsquo;t know.\u0026rdquo; We also asked about funding for maternity leave by asking each liaison, \u0026ldquo;Where does that maternity leave pay funding come from?\u0026rdquo; Possible answers included \u0026ldquo;short-term disability insurance,\u0026rdquo; \u0026ldquo;accrued time (sick, vacation, personal),\u0026rdquo; \u0026ldquo;donated time,\u0026rdquo; or \u0026ldquo;some other organization paid leave.\u0026rdquo; We then asked three questions about time to pump once female employees returned to work. Questions included \u0026ldquo;What are, if any, the flexible time scheduling options available to full-time employees at your college?\u0026rdquo; with response options of flextime, telecommuting, job sharing, or none. Additionally, we asked about time given to women to pump during the workday (e.g., \u0026ldquo;When are women allowed to pump breastmilk during work?\u0026rdquo; with answer options of only during break or lunch times, as needed, or unsure.\u003c/p\u003e \u003cp\u003eDocument Review\u003c/p\u003e \u003cp\u003eDuring the liaison survey, we asked each participant to provide copies of their institution\u0026rsquo;s breastfeeding and maternity leave policies. The document review included policies we received from the liaisons and policies or information found on institution websites. Two research team members assessed information and resources for breastfeeding and lactation publicly available on each institution\u0026rsquo;s website. These resources included employee handbooks, student handbooks, publicly available online policies and any other information that could be found on human resource webpages. The research team members reviewed each institution\u0026rsquo;s website for information on specific employee breastfeeding policies, lactation rooms on campus, and any other information relevant for expecting mothers.\u003c/p\u003e \u003cp\u003eData Collection\u003c/p\u003e \u003cp\u003eAll liaison survey data were collected and stored via Qualtrics. Initially the survey was self-administered but due to the low response rate, the survey was adapted to allow the survey to be conducted via phone by trained research staff. No changes were made to the main aspects of the survey questions when adapted to phone administration. Instead, the wording shifted from \u0026ldquo;Please note how women are made aware of lactation policies on campus\u0026rdquo; on the electronic survey to \u0026ldquo;Can you describe how female employees are made aware of lactation policies on your campus?\u0026rdquo; on the phone-adapted version. Research team members would then list the possible answer choices that matched those on the electronic survey. Data from the document review were organized in a Microsoft Excel spreadsheet.\u003c/p\u003e \u003cp\u003eAnalysis\u003c/p\u003e \u003cp\u003eSurvey data were analyzed by univariate statistics to provide frequencies and means. Data from the document review was analyzed by constant comparative method to develop themes via a deductive and inductive approach (Glaser, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e1965\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDeductive Approach\u003c/p\u003e \u003cp\u003eEach policy was reviewed based on its compliance with and expansion of the requirements for employers through the Affordable Care Act (Bick et al.) (U.S. Department of Labor, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). Compliance was defined by the research team as the University providing a policy that stated, at minimum, a space other than a restroom on campus for women to express breastmilk as well as time during the workday to express breastmilk. The ACA amended the Fair Labor Standards Act requiring employers to provide \u0026ldquo;reasonable break time for an employee to express breastmilk for her nursing child for one year after the child\u0026rsquo;s birth each time such employee has need to express the milk\u0026rdquo; (U.S. Department of Labor, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2010\u003c/span\u003e #115). Employers are also required to provide \u0026ldquo;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 breastmilk\u0026rdquo; (U.S. Department of Labor, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2010\u003c/span\u003e #115). Based on language found within institution policies, the research team coded the data as compliant or not compliant with the ACA requirements.\u003c/p\u003e \u003cp\u003eInductive Approach\u003c/p\u003e \u003cp\u003eWe used an inductive approach to allow themes to emerge from the data. Two research team members read through each policy independently to identify themes. After identifying themes, the two research team members met to review themes and resolve any discrepancies.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe survey was sent to 26 well-being liaisons. Nine well-being liaisons completed the self-administered version of the survey, and nine participants completed the survey by telephone. The remaining eight liaisons either declined to participate or were not reached via telephone after the third attempt. The total response rate for surveys was 69.2% (n\u0026thinsp;=\u0026thinsp;18).\u003c/p\u003e \u003cp\u003eDemographics\u003c/p\u003e \u003cp\u003eSurvey participants were mostly white (70.6%), non-Hispanic (94.4%), female (88.9%), with some postgraduate education (41.2%). Most participants held the wellness liaison position for nine years or less (78.9%). Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e describes the sample demographics.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLiaison Demographics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParticipants (N\u0026thinsp;=\u0026thinsp;18)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(no %)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (11.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (88.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHispanic/ Latino\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (5.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (94.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (n\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (6.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (43.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e40\u0026ndash;49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (25%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e50\u0026ndash;59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (12.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e60\u0026ndash;69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (12.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRace (n\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlack or African American\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (29.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (70.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHighest Education Level (n\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSome college of technical/ vocational training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (5.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAssociate\u0026rsquo;s degree (2 years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (23.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBachelor\u0026rsquo;s degree (4 years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (29.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostgraduate Work (PhD, or MD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (41.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eINSERT Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003c/h2\u003e \u003cp\u003eLiaison Survey.\u003c/p\u003e \u003cp\u003eOverall, many of the well-being liaisons were uncertain about the existence of breastfeeding policies on their campus beyond the federal requirements of the Affordable Care Act (i.e., mothers will be provided a space to pump other than a restroom and reasonable break time during the workday to pump). The esults of the survey are described in detail in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e..\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of Survey Questions \u0026amp; Responses\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurvey Section\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e# of questions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExample questions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e% of schools with access to resources and information on policies\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePolicy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDoes your institution have a written policy on breastfeeding and/or pumping milk at work?\u003c/p\u003e \u003cp\u003eHow are supervisors made aware of policies?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50% have no formal policy\u003c/p\u003e \u003cp\u003e42.1% of supervisors are made aware of resources when employees seek use, 31.6%\u0026nbsp;by the employee handbook, 31.6% by the HR website, and 31.6% by word of mouth\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResources\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDo you have access to onsite daycare?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47.4% have onsite daycare\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLactation Spaces\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIs there any space(s) on your campus dedicated solely to breastfeeding or pumping breast milk?\u003c/p\u003e \u003cp\u003eWhat amenities are available in these spaces?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e86.7% report women are allowed to pump at work\u003c/p\u003e \u003cp\u003e42.1% provide lactation-specific spaces\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWhere does that maternity leave pay funding come from?\u003c/p\u003e \u003cp\u003eWhen are women allowed to pump breast milk during work?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e68.4% reported accrued time, 57.9% reported short term disability benefits, and 42.1% reported donated time (only available at select places)\u003c/p\u003e \u003cp\u003e53.9% claim female employees can pump as needed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePolicy\u003c/p\u003e \u003cp\u003eHalf of the participants said there is no formal policy (50%) for breastfeeding at work on their campus, and 58.3% of those indicated that not all employees are informed of the policy. y. Supervisors are made aware of the lactation resources available mostly when employees are seeking use of those benefits (42.1%), by the employee handbook (31.6%), the HR website (31.6%), or by simple word of mouth (31.6%).\u003c/p\u003e \u003cp\u003eResources\u003c/p\u003e \u003cp\u003eThe survey assessed specific resources listed as best practices from the Breastfeeding and Employment Study (Olson, 2014). Best practices resources include providing breast pumps, educational materials, educational classes on breastfeeding, access to a lactation consultant, on-campus childcare, and a pumping kit to all breastfeeding employees. All resources, except for childcare services, were reportedly available to individuals who are enrolled in health insurance. Resources such as providing breast pumps to employees, educational materials, educational classes, or access to a lactation consultant were not provided through any on campus or employee benefits programs. Less than half of institutions (47.4%) reported offering onsite daycare for employees\u0026rsquo; children.\u003c/p\u003e \u003cp\u003eLactation Spaces\u003c/p\u003e \u003cp\u003eMost liaisons indicated that they believe their institution allows women to pump milk at work (86.7%) and 53.8% of liaisons responded women can pump as needed. Most participants noted that there are specific locations other than restrooms available for women to use for pumping (64.3%). However, only 42.1% mentioned lactation-specific spaces available to everyone. The majority of liaisons said that women can only access their own private offices (if their position provides it), a vacant office, or a vacant conference room.\u003c/p\u003e \u003cp\u003eTime\u003c/p\u003e \u003cp\u003eMost institutions have a formal leave policy under FMLA (93.3%), which provides 12 weeks of unpaid, job-protected leave per year for those who qualify. Funding for maternity leave for pregnant and postpartum employees predominantly comes from accrued time (i.e., sick leave; 68.4%), short-term disability benefits (57.9%), and donated time (only available at select places; 42.1%). Most participating liaisons (75%) noted that job protection and holding are only available to women who qualify for FMLA, which may not cover all workers employed across a variety of positions on their campuses. Flextime was the most common scheduling option offered to female employees returning to work postpartum (35.7%) with telecommuting as the second most common option (28.6). Most liaisons indicated that women could pump at work as needed (53.9%) though 31% said women can pump only during set break times. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e below summarizes the survey questions and results.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eINSERT Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003c/h2\u003e \u003cp\u003eDocument Review\u003c/p\u003e \u003cp\u003eOverall, six themes emerged from the data during the document review. The themes included placing the burden on female employees, describing pregnancy or postpartum as a \u0026ldquo;disability,\u0026rdquo; having a university-specific policy, inclusion of break times for breastfeeding, supervisor responsibility, and information on lactation policies. Definitions of each theme are provided in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of Document Review\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDefinition\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo. of Institutions\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlacing Burden on Women\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInstitution policy contains no information on lactation OR responsibility for accessing the resource falls solely on the female employee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisability Language\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReferring to \u0026ldquo;disability due to pregnancy\u0026rdquo; and funding maternity leave from disability leave\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreak Times\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePolicy clearly states providing break time for female employees to breastfeed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity Specific Policy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe institution has created and made available an institutional lactation policy that is different from the general requirements of the ACA or university system\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSupervisor Responsibility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExplicit mention of supervisors\u0026rsquo; involvement in providing break time and resources to women returning to work post-partum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLactation Spaces\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePolicy contains information about lactation spaces on campus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eINSERT Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eMost participating universities had policies or statements that contained language matching the Affordable Care Act, such as space other than a restroom for breastfeeding and reasonable break times.\u003c/p\u003e \u003cp\u003ePlacing Burden on Women\u003c/p\u003e \u003cp\u003eThirteen institutions had no policy or lacked information on breastfeeding on their websites. Additionally, thirteen institutions lacked information in the policy about the supervisors\u0026rsquo; role in supporting breastfeeding for employees or suggested that it was the employees\u0026rsquo; responsibility to identify resources. Below is an example of language within a policy that placed the burden on women when they return to work postpartum:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIf the employee uses time other than a regularly scheduled break time [for pumping breastmilk] or if the employee\u0026rsquo;s department does not have designated break times, then the employee will be required to either: (1) make up that time during the same workday; (2) use vacation leave; or (3) take leave without pay for that period of time.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eDisability Language\u003c/p\u003e \u003cp\u003eThree institutions had policies that referred to \u0026ldquo;disability due to pregnancy\u0026rdquo; or classified any policies regarding pregnancy or breastfeeding within their disability category. Almost all institutions only provided paid leave for female employees via short-term disability leave. Still, there was no distinction between leave due to pregnancy/ postpartum and other situations that would be classified as disability. An example of this theme was the following statement in an institution\u0026rsquo;s maternity leave policy, \u0026ldquo;Disability due to pregnancy shall be considered as any other disability\u0026hellip;\u0026rdquo;\u003c/p\u003e \u003cp\u003eBreak Times\u003c/p\u003e \u003cp\u003eTen institutions included language for break times specific to \u0026ldquo;nursing,\u0026rdquo;\u0026ldquo;pumping,\u0026rdquo; or \u0026ldquo;lactation\u0026rdquo; within their policies. Example quotes of this language include:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eLactating mothers shall be granted flexible and reasonable breaks, using their normal break periods and mealtimes, to accommodate milk expression.\u003c/p\u003e\u003cp\u003e[Employees will be provided] \u0026hellip;reasonable break times to express milk for her baby, so long as the break does not unduly disrupt the operations of the college. The break time shall, if possible, run concurrently with any break time already provided to the employee. No work duties will be required to be performed during this break period.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eUniversity-Specific Policy\u003c/p\u003e \u003cp\u003eHalf (n\u0026thinsp;=\u0026thinsp;13) of the universities had their own institutional policy on breastfeeding and lactation. The remaining institutions (n\u0026thinsp;=\u0026thinsp;13) only referred to the larger university system policy or had no information.. Institutions that created individual breastfeeding policies contained language such as:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe University supports parents employed by [this institution] by providing lactation and nursing support. A lactation and nursing parent support program allows a lactating parent to express breastmilk periodically during the workday or nurse an infant child. This policy is in accordance with the Official Code of [State], Federal Labor Standards Act, as well as [University System], [this institution], local, State and Federal regulations.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSupervisor Responsibility\u003c/p\u003e \u003cp\u003ePolicies at five institutions contained information regarding supervisor responsibility. For each of these schools, there is explicit mention of female employees needing to coordinate with their direct supervisor to ensure reasonable break times for breastfeeding are met. Examples of this language within policies included:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eLactating mothers who wish to express milk during the work period should keep supervisors informed of their needs so that appropriate accommodations can be made to satisfy the needs of both the employee and the department.\u003c/p\u003e\u003cp\u003eSupervisors should attempt to provide as much schedule flexibility and break time as reasonably possible to accommodate the employee\u0026rsquo;s needs.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eLactation Spaces\u003c/p\u003e \u003cp\u003eTwelve (46.15%) institution policies contained language about lactation spaces on campus. Of those 12, very few provided specific details on where the spaces are, how to access them, and what amenities were available. An example of language of a policy that included details is provided here:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;The designated lactation room is located in [location]. The lactation room provides an electrical outlet, comfortable chair, and nearby access to hot running water and soap.\u0026rdquo;\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome institutions mentioned having a designated lactation space on campus, but there was no information on who to contact or how to access the space. Instead, there was vague language about including a space other than a restroom, but no further details on a lactation space on campus. An example of this vague language includes, \u0026ldquo;[This institution] will provide to any employee who is breastfeeding her child\u0026hellip;\u0026rdquo;\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study was conducted within a University System in the Southern United States to understand how a group of institutions in higher education support female employees with breastfeeding when they return to work after giving birth. With the passage of the Affordable Care Act in 2014, all worksites that employ more than 50 people are required to provide a place other than a bathroom and reasonable break time during work hours for female employees to pump breastmilk (U.S. Department of Labor, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). Understanding how this policy has or has not been translated into worksites provides insight into how organizations are caring for their employee\u0026rsquo;s health and well-being.\u003c/p\u003e \u003cp\u003eSummary of Findings\u003c/p\u003e \u003cp\u003eOur survey of well-being liaisons within a university system revealed a large variation in lactation policies and resources across institutions. While we found that liaisons reported and formal policies reflected the minimum ACA requirements, how these policies are implemented on campuses was unclear. Of great concern is that about half of institutions did not have a formal policy for breastfeeding. Further, communication of the policy to supervisors was very passive in nature and only when needed for an employee or through written material available to all employees. Establishing policies at all institutions and making all supervisors aware of the policy increases the likelihood that employees are supported in their breastfeeding goals when they return to work.\u003c/p\u003e \u003cp\u003eAlthough the survey of liaisons suggested there is opportunity for women to pump on campus, without any formal policy or a lack of detail in existing policies, the burden is placed on female employees to discover and advocate for their needs when returning to work after giving birth. The lack of explicit language protecting breastfeeding employees leads to discrepancies in experiences when returning to work. Previous studies in workplace wellness have highlighted the difficulty in adopting wellness policies, especially across worksites of varying size and cultures (Bradford et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Kozhimannil et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Tsai, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2013\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eExcept for onsite daycare, best practice resources for breastfeeding were available to employees, though these resources were available through an individual\u0026rsquo;s insurance provider. Even within institutions where childcare may be provided, no information was provided on the capacity of those childcare settings or the difficulties an employee may experience enrolling their child. This may mean that employees on spouse\u0026rsquo;s insurance plans or those who are on spouse\u0026rsquo;s insurance plans or those who are ineligible for insurance (i.e., part-time, or temporary employees) do not have access to these resources. Lactation space and time are included explicitly in the ACA language and seem to be available at all institutions. However, the details of how those amenities are provided to ensure all employees have equitable access to both space and time to pump are not detailed in the policies. More research is needed to understand why these discrepancies exist across institutions, how to combat them, and how to support complex work structures like colleges and universities in adopting these across institutions exist, how to combat them, and how to support complex work structures like colleges and universities in adopting these kinds of policies. The review of available policies from the institutions corroborates the findings from the survey of the liaisons that there is a lack of detail around the practice of providing support for breastfeeding when women return to work after giving birth. In the U.S., the only national job protection for mothers returning to work after giving birth is through FMLA, which is not specific to pregnancy but covers any medical condition. As such, most of the policies described pregnancy as a disability and, in some cases, women\u0026rsquo;s leave from work and return to work after birth was treated as any other medical condition.\u003c/p\u003e \u003cp\u003eLimitations\u003c/p\u003e \u003cp\u003eThis study is not without its limitations. First, due to limited response to surveys sent via email, the survey was adapted to be conducted over the phone thus, word change occurred. Also, the individuals who serve as the wellness liaisons from each institution do not all have the same job title or training as this is not their primary role in the workplace. Therefore, some participants may have been more familiar with the policies than others depending on their regular job duties. Previously, all wellness liaisons participated in a well-being board, but from initial data collection to present, that group has been disbanded. Although they all work on separate campuses across the university system, it is possible that participants at the time of data collection communicated with one another about the survey, introducing potential response bias to survey results. However, no indication was made during the phone interviews that any participants had heard about the study or had spoken to other liaisons. Additionally, the authors recognize the reality of potential social bias being introduced due to the phone medium for some survey responses versus electronic medium for others. While our survey and document review investigated the availability of childcare on campus, the questions did not investigate whether or not female employees could visit the on-campus childcare and breastfeed their child. Female employee\u0026rsquo;s ability to do this remains a gap in our understanding. Finally, due to access restrictions, the document review was limited to online information that the research team could access. More nuances and detailed information on each institution\u0026rsquo;s policies were unavailable to this research team.\u003c/p\u003e \u003cp\u003eStrengths of Study\u003c/p\u003e \u003cp\u003eDespite these limitations, this current study has some strengths. We included two sources of data \u0026ndash; wellbeing liaison surveys and qualitative document review. This allows us to compare data from both sources to understand the policies and practices at the institutions. To the author\u0026rsquo;s knowledge, the scope of research done on what policies and resources exist for breastfeeding employees within complex work structures is limited. Investigating the differences across a university system sheds light on inconsistencies in how female employees experience returning to work and breastfeeding.\u003c/p\u003e \u003cp\u003eImplications\u003c/p\u003e \u003cp\u003eAcademic institutions like the colleges and universities analyzed in this study employ a wide range of personnel. Due to the complexity of their employment and work structure, it is difficult to assess how institutions support all their faculty and staff. The findings from this current study highlight the need for improved policies that protect female employees, especially regarding returning to work postpartum. Creating consistent, written policies across a university system and allowing individual institutions to adapt them is necessary. To create a healthier work environment for women working at colleges and universities, university leadership and human resource officials need to establish policies and resources to ease female employees\u0026rsquo; return to work postpartum.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eACA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAffordable Care Act\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFMLA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFamily Medical Leave Act\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate.\u003c/p\u003e\n\u003cp\u003eAll study materials were approved by the International Review Board\u0026nbsp;for Human Research Ethics at the University of Georgia. This study also meets the ethical guidelines and has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. All study participants provided written informed consent or verbal consent based on the medium of interview. All participants were over 20 years old.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for publication\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIt was obtained from all individual participants included in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompeting interests\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflicts of interest in relation to this work.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFunding\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors have no statement of funding.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthor\u0026rsquo;s contributions\u003c/p\u003e\n\u003cp\u003eEmily Ashby was the primary author on this paper. Emily Ashby and Dr. Heather Padilla adapted the survey tool for data collection. Emily Ashby wrote the main manuscript text and she and Sritha prepared table 1-3. Sritha assisted in data collection and analysis. All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgments\u003c/p\u003e\n\u003cp\u003eThe authors would like to acknowledge Ms. Kismet Adams of the University of Georgia as an inspiration for this work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eBradford VA, Walkinshaw LP, Steinman L, Otten JJ, Fisher K, Ellings A, O\u0026apos;Leary J, Johnson DB. Creating environments to support breastfeeding: The challenges and facilitators of policy development in hospitals, clinics, early care and education, and worksites. Matern Child Health J. 2017;21(12):2188\u0026ndash;98. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10995-017-2338-4\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eBurns E, Gannon S, Pierce H, Hugman S. Corporeal generosity: Breastfeeding bodies and female-dominated workplaces. Gend Work Organ. 2022;29(3):778\u0026ndash;99. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/gwao.12821\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eCenters for Disease Control. (2016). Workplace Health Model. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cdc.gov/workplacehealthpromotion/model/index.html\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eCenters for Disease Control. (2021). National immunization survey, results: breastfeeding rates. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ecdc.gov/breastfeeding/data/nis_data/results.html\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eChatterji P, Frick KD. Does Returning to Work After Childbirth AffectBreastfeeding Practices? Rev Econ Househ. 2005;3(3):315\u0026ndash;35. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s11150-005-3460-4\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eChen A, Rogan WJ. Breastfeeding and the risk of postneonatal death in the United States. Pediatrics. 2004a;113(5). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1542/peds.113.5.e435\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDagher RK, McGovern PM, Schold JD, Randall XJ. Determinants of breastfeeding initiation and cessation among employed mothers: A prospective cohort study. BMC Pregnancy Childbirth. 2016;16(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12884-016-0965-1\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDay A, Hurrell KE Jr JJ. Workplace well-being: How to build psychologically healthy workplaces. John Wiley \u0026amp; Sons, Ltd.; 2014.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDunn RL, Kalich KA, Henning MJ, Fedrizzi R. Engaging field-based professionals in a qualitative assessment of barriers and positive contributors to breastfeeding using the social ecological model. Matern Child Health J. 2015;19(1):6\u0026ndash;16. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10995-014-1488-x\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eGarvin CC, Sriraman NK, Paulson A, Wallace E, Martin CE, Marshall L. The business case for breastfeeding: A successful regional implementation, evaluation, and follow-up. Breastfeed Med. 2013;8(4):413\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1089/bfm.2012.0104\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eGlaser BG. The Constant Comparative Method of Qualitative Analysis. Soc Probl. 1965;12(4):436\u0026ndash;45. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2307/798843\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eGoetzel RZ, Henke RM, Head MA, Benevent R, Rhee K. Ten Modifiable Health Risk Factors and Employees\u0026apos; Medical Costs-An Update. Am J Health Promot, 34(5), 490\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/0890117120917850\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eJohnson KM, Salpini C. Working and nursing: Navigating job and breastfeeding demands at work. Community Work Family. 2017;20(4):479\u0026ndash;96. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/13668803.2017.1303449\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKozhimannil KB, Jou J, Gjerdingen DK, McGovern PM. Access to workplace accommodations to support breastfeeding after passage of the Affordable Care Act. Women\u0026apos;s Health Issues. 2016;26(1):6\u0026ndash;13. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.whi.2015.08.002\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLinnan LA, Cluff L, Lang JE, Penne M, Leff MS. Results of the Workplace Health in America Survey. Am J Health Promot. 2019;33(5):652\u0026ndash;65. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/0890117119842047\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLivingston G, Thomas D. (2019). Among 41 countries, only U.S. lacks paid parental leave. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.pewresearch.org/short-reads/2019/12/16/u-s-lacks-mandated-paid-parental-leave/\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eOlson BH, BreastfeedingAndEmploymentSteurer LM. (2017). Maternity leave length and workplace policies\u0026apos; impact on the sustainment of breastfeeding: Global perspectives. Public Health Nursing, 34(3), 286\u0026ndash;294. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/phn.12321\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eStuebe A. The risks of not breastfeeding for mothers and infants. Rev Obstet Gynecol. 2009;2(4):222\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eTsai S-Y. Impact of a breastfeeding-friendly workplace on an employed mother\u0026rsquo;s intention to continue breastfeeding after returning to work. Breastfeed Med. 2013;210\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1089/bfm.2012.0119\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eU.S. Bureau of Labor Statistics. (2021). Average hours employed people spent working on days worked by day of week. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.bls.gov/charts/american-time-use/emp-by-ftpt-job-edu-h.htm\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eU.S. Department of Labor. (2010). Section 7(r) of the Fair Labor Standards Act \u0026ndash; Break Time for Nursing Mothers Provision. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.dol.gov/agencies/whd/nursing-mothers/law\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eUribe ALM, Bolton TA, Woelky KR, Olson BH. Exploring human resource managers\u0026rsquo; decision-making process for workplace breastfeeding-support benefits following the passage of the Affordable Care Act. Matern Child Health J. 2019;23(10):1348\u0026ndash;59. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10995-019-02769-6\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eWorld Health Organization. (2021). Breastfeeding. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/health-topics/breastfeeding#tab=tab_1\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eZhuang J, Bresnahan MJ, Yan X, Zhu Y, Goldbort J, Bogdan-Lovis E. Keep doing the good work: Impact of coworker and community support on continuation of breastfeeding. Health Commun. 2019;34(11):1270\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/10410236.2018.1476802\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pregnancy, Breastfeeding, Lactation, Maternity, Workplace, Pumping, Support, Workplace Facilities, Employer Support","lastPublishedDoi":"10.21203/rs.3.rs-3897750/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3897750/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e In the U.S., working women often return to work within 8-12 weeks of giving birth, therefore, it is critical that workplaces provide support for female employees combining breastfeeding and work. The Affordable Care Act requires any organization with more than 50 employees to provide a space other than a restroom for women to express breastmilk and a reasonable amount of time during the workday for women to express breastmilk. States and worksites differ in the implementation of ACA requirements and may or may not provide additional supports for female employees combining breastfeeding and work. The purpose of this study was to conduct an analysis of 26 institutions within a state university system to evaluate the differences in breastfeeding policies and resources available on each campus.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e Survey data was collected from well-being liaisons in the human resources departments at each institution. In addition, we conducted a document review of policies and online materials at each institution. We used univariate statistics to summarize survey results while a thematic analysis was used to analyze institutional resources available on websites and in policies provided by the liaisons.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e A total of 18 (65.3%) liaisons participated in the study and revealed an overall lack of familiarity with the policies in place and inconsistencies in the resources offered to breastfeeding employees across the university system. Only half of the participating liaisons reported a formal breastfeeding policy was in place on their campus. From the document review six major themes were identified: placing the burden on female employees, describing pregnancy or postpartum as “disability,” having a university specific policy, inclusion of break times for breastfeeding, supervisor responsibility, and information on lactation policies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThe review of each institutions online resources confirmed the survey findings and highlighted the burden placed on female employees to discover the available resources and advocate for their needs. This paper provides insight into how institutions support breastfeeding employees and provides implications on strategies to develop policies at universities to improve breastfeeding access for working mothers.\u003c/p\u003e","manuscriptTitle":"Understanding Lactation Policies and Resources Across a University System: Survey \u0026amp; Document Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-02 05:21:56","doi":"10.21203/rs.3.rs-3897750/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-04-06T21:01:44+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-04T20:26:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"8e62572f-4949-46c0-9800-d2dd78d4e0ef","date":"2024-04-04T15:26:08+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-01T10:26:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"cabe971b-938e-4f42-8722-41f7bcda28d7_SNPRID","date":"2024-03-22T09:53:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"ce326892-7cde-4523-a74c-769c1a49dbd3","date":"2024-03-15T23:04:48+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-03-13T23:02:38+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-03-13T23:00:52+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-02-01T04:04:19+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-02-01T03:56:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2024-01-25T16:08:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"90eef304-e0c6-48a7-8186-a6518a2102cd","owner":[],"postedDate":"February 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-04-24T17:13:06+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-02 05:21:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3897750","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3897750","identity":"rs-3897750","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}