Author ORCID Identifier

https://orcid.org/0000-0002-6168-7163

Year of Publication

2021

Degree Name

Doctor of Philosophy (PhD)

Document Type

Doctoral Dissertation

College

Nursing

Department/School/Program

Nursing

First Advisor

Dr. Ellen J. Hahn

Abstract

Low rates of breastfeeding are a global public health issue. Despite national and international health agency recommendations for breastfeeding until infants are six months of age when solid foods are introduced and continued breastfeeding until 12 months of age or older, many mothers in the United States discontinue breastfeeding at an early age. Return to work after childbirth is one of the leading contributing factors to early cessation of breastfeeding in employed mothers. Understanding the association between individual and organizational factors and breastfeeding practices in employed mothers is essential for the development, implementation, and evaluation of programs and policies to promote, support, and encourage continued breastfeeding consistent with national and international health recommendations.

The purpose of this dissertation was to: 1) review literature on the psychometric properties of existing instruments used to measure nursing mothers’ perceptions of workplace lactation support; 2) perform psychometric testing on a 9-item Breastfeeding and Employment Scale used in the Infant Feeding Practices Study II (IFPS II); and 3) examine the association between individual and organizational factors and breastfeeding practices in employed mothers who participated in the IFPS II.

This dissertation has three components; a systematic review of the psychometric properties of workplace lactation support instruments; an analysis of the psychometric properties of the IFPS II Breastfeeding and Employment Scale; and a secondary analysis of the IFPS II examining individual and organizational factors associated with breastfeeding practices in employed mothers. First, a search of literature published between 1993 and May 2020 on psychometric properties of existing instruments used to measure nursing mothers’ perceptions of workplace lactation support was conducted using the electronic databases, PubMed, CINAHL and PsycINFO, with key words, breastfeeding AND support AND instrument”; “breastfeeding support AND workplace”; “breastfeeding AND instrument AND workplace”; “perceived AND breastfeeding support AND instrument”. Lactation was used in the place of “breastfeeding” for a repeated search. Of 26 full text eligible articles, 10 articles were included in the review. Four instruments including the 12-item Workplace Breastfeeding Support Scale (five articles); 41-item Employee Perceptions of Breastfeeding Support (two articles); 29-item Perceived Breastfeeding Assessment Tool (two articles); and 9-item IFPS II Breastfeeding and Employment Scale (one article) were identified and reviewed for scope and conceptual definitions, reliability, and validity. The modified 18-item Workplace Breastfeeding Support Scale was selected as the preferred instrument based on adequate reliability demonstrated in multiple studies, limited respondent burden and cross-cultural application outside the U.S. Additional psychometric testing and research are needed to strengthen the adaptation and applicability of the various instruments in cross-cultural settings.

Next, psychometric testing was conducted on the IFPS II 9-item Breastfeeding and Employment Scale including internal consistency reliability; test-retest reliability; construct validity using factor analysis; and convergent validity of the 9-item scale and an IFPS II item measuring perceived level of breastfeeding support in the workplace. The sample was comprised of employed breastfeeding mothers in the U.S. who completed the 9-item Breastfeeding and Employment Scale and an IFPS II survey item measuring perceived level of breastfeeding support in the workplace at two time intervals (3-month [n=498] and 6-month [n=413] assessment). Kuder-Richardson 20 was used as the measure of internal consistency due to the dichotomous nature of the responses. Test-rest reliability (3- and 6-month assessments) was conducted using chi-square and Spearman’s rank correlation coefficient. Construct validity was conducted using a tetrachoric correlational matrix. Spearman’s rho correlation coefficient was used to evaluate convergent validity to associate the 9-item Breastfeeding and Employment Scale with a survey item measuring perceived level of breastfeeding support in the workplace at the 3-month assessment (n=266). The Breastfeeding and Employment Scale was reliable and valid in a sample of employed breastfeeding mothers (N=498) in the U.S. who participated in the IFPS II. Additional testing is warranted to further evaluate the reliability and validity of the instrument in cross-cultural and more diverse populations.

Finally, a secondary analysis was conducted on a sample of 953 employed mothers who participated in the IFPS II to compare infant feeding status (breastfeeding/feeding pumped milk vs. not breastfeeding/feeding pumped milk) over a 12-month postpartum period. The purpose was to identify individual (e.g., prenatal infant feeding intentions and smoking status) and organizational (e.g., employment status, occupation type, and perceived level of breastfeeding support in workplace) factors, guided by the Socio-Ecological Model, associated with breastfeeding practices in a sample of employed mothers who participated in the IFPS II. At baseline (3-months postpartum survey), 57% of employed mothers were breastfeeding/feeding pumped milk. At this time point, employed breastfeeding mothers were significantly older, more likely to be married and they had higher SES compared to non-breastfeeding employed mothers; and they expressed prenatal infant feeding intentions to breastfeed only, were nonsmokers, employed part-time in a professional/executive occupation, and reported a higher level of perceived breastfeeding support in the workplace. In a subsample of employed mothers who worked either part-time (≤ 34 hours/week) or full-time (> 35 hours/week) over the 12-month postpartum period (n=302), generalized linear mixed modeling (GLMM) revealed that predictors of breastfeeding over time were individual factors of prenatal breastfeeding intention and non-smoking, and organizational factors of part-time employment and perceived support for breastfeeding in the workplace. Employed mothers who were non-smokers were 291% more likely to breastfeed/feed pumped milk over the 12-month period (OR= 3.91, p < 0.001) compared to smokers. Employed mothers who expressed prenatal feeding intentions to only breastfeed their infants were 953% more likely to report sustained breastfeeding over time (OR=10.53, p < 0.001) compared to those who did not. In regard to organizational factors, employed mothers who were employed part-time (compared to full-time) were 97% more likely to continue breastfeed over the follow-up period (OR=1.97, p = 0.002). Finally, employed mothers who perceived high levels of breastfeeding support in the workplace (‘somewhat supportive’ or ‘very supportive’) were 178% more likely to continue breastfeeding over the 12-month follow up period compared to those with low levels of perceived breastfeeding support in the workplace (OR=2.78, p < 0.001).

In summary, occupational health nurses are instrumental in promoting breastfeeding supportive workplace environments. Future research is needed to examine individual, interpersonal, organizational, community, and public policy components of the Socio-Ecological Model to better understand the complex processes influencing breastfeeding continuation in employed mothers. Additional research is needed to develop, implement, and evaluate breastfeeding supportive workplace programs; guide public health policy; and better understand the relationship between multi-level factors of workplace lactation, breastfeeding practices, and maternal and child health outcomes.

Digital Object Identifier (DOI)

https://doi.org/10.13023/etd.2021.456

Funding Information

This study was supported by the Central Appalachian Regional Education and Research Center Grant (no.: 6T42OH010278) between 2017-2021.

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