Maternal employment characteristics as a structural social determinant of breastfeeding after return to work in the European Region: a scoping review

Variations in breastfeeding practices across Europe can be explained in part by different social policies, primarily the length of maternity leave (for example, Sweden, Finland and Portugal offer long and well-paid maternity leave), but also paternity leave and whether there is flexibility to share leave between parents, which encourages both starting and continuing breastfeeding. According to the conceptual model proposed by the Lancet Breastfeeding Series, the determinants of breastfeeding depend on the socio-cultural context, the practices of the breast milk substitute industry, the healthcare system, the composition of the family or community, and the workplace. Individual factors also come into play, including the mother-child relationship. "Baby Friendly" hospitals (BFHI) also play a role in encouraging mothers who are taking up breastfeeding¹.

Turning to the workplace and employers, while there are regulations governing the rights of breastfeeding mothers, continuing to breastfeed when you return to work can be particularly difficult. 
In Europe, breastfeeding remains a socially differentiated practice. In fact, we see that the most highly educated women, the most financially comfortable, and women in senior management roles breastfeed more than less well-educated women, less well-off women and women who work in jobs with less responsibility or in manual roles.  In order to reduce this inequality, we need to improve our understanding of the social determinants associated with continuing to breastfeed and, in particular, structural determinants like employment. This is important in view of the fact that women who breastfeed more are those who have chosen to work part-time or take a temporary break from employment, and this is a choice that results in a drop in income and affects women's careers. Improving support for working mothers who choose to breastfeed is not only a public health issue, but also a crucial strand in the fight against gender inequalities and, more broadly, social inequalities in health from early childhood. This is because early intervention in the first two years of life after birth has a decisive impact on a child's development and the health of the adult they will become. The "First 1000 Days", a campaign launched by UNICEF, promotes conceptualising the health of mothers and children holistically to foster environments in which pregnancies and newborn babies can develop harmoniously.

The aim of this literature review was therefore to identify which aspects of women's employment enable mothers to continue breastfeeding when they return to work. 

¹The "Baby Friendly Hospital Initiative" (BFHI) was launched in 1991 by the WHO and UNICEF. One of the main aims of this initiative is to promote breastfeeding. The results of a Santé publique France study of BFHI hospitals in France will be covered in the next Article of the Month:  3 questions for...".

This study reveals that being self-employed, working in a non-manual profession with flexible hours, having a room to breastfeed in at work, being supported by colleagues and having a workplace breastfeeding support policy in place are the most important factors that encourage mothers to continue breastfeeding. These conditions appear to foster a sense of freedom, capability and motivation in mothers, playing a crucial role in breastfeeding practices. This means that the barriers and levers for breastfeeding when returning to work relate to three aspects of employment which are correlated: 1) the type of job (e.g. job status, job title), 2) working conditions (e.g. flexibility) and 3) the working environment (e.g. social support, facilities). However, these aspects are rarely investigated together in public health studies and initiatives.

The top priority is to take action to help working mothers who are socio-economically deprived and who choose to breastfeed, which is of key importance given the multitude of barriers that these mother-child dyads encounter.

This means introducing policy guidelines or workplace interventions to promote balance between work and family life: for example, low-skilled or insecure jobs could be targeted and encouraged to increase flexibility or reorganise manual workstations to decrease the stress they cause, as a way to approach reducing social inequalities in health, with a particular focus on breastfeeding practices. 

More broadly, promoting work-life balance at this crucial time of the arrival of a new baby must address the issue of gender inequalities in domestic work. In this respect, this research also argues for action on a larger scale in Europe, with the implementation of regulations on parental leave that is well-paid, flexible and fair for both parents. 

Santé publique France's breastfeeding strategy is to promote breastfeeding-friendly environments everywhere, including in the workplace.