"Analytic Frameworks for Decision Making in Work-related Lactation Supp" by Kathrin Litwan

Analytic Frameworks for Decision Making in Work-related Lactation Support Policies

Date of Award

Spring 2024

Document Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

Department

Public Health

First Advisor

Pérez-Escamilla, Rafael

Abstract

Breastfeeding is associated with improved short- and long-term health benefits for the breastfeeding mother and the breastfed child. Despite recommendations by the World Health Organization and UNICEF to initiate breastfeeding within an hour after birth, breastfeed exclusively for the first six months, and continue breastfeeding until the age of 2 years and beyond, global breastfeeding rates remain suboptimal. In 2022, only 48% of infants younger than 6 months were exclusively breastfed globally, well below the WHO/UNICEF Global Nutrition Target for 2030 calling to exclusively breastfeed 70% of infants younger than 6 months. Maternal employment is a consistently reported obstacle to exclusive breastfeeding and is associated with earlier breastfeeding cessation. But maternal employment also contributes to the reduction of gender inequalities, Goal 5 of the UN Sustainable Development Goals. To successfully reach the Global Nutrition Targets and the UN Sustainable Goals without compromising on either side, family-friendly work policies are needed. Work-related lactation interventions, such as the provision of lactation rooms, paid lactation breaks, and paid maternal leave, have direct breastfeeding benefits for working mothers and bear potential indirect benefits to the offering employers – and to society as a whole. Using Mexico as a case model, this dissertation explored three questions: 1) who is involved in the design and implementation of successful workplace breastfeeding interventions?; 2) how big are monetary benefits of workplace lactation support to the offering employer?; and 3) is longer paid maternal leave always better? We answered the question about actors in workplace breastfeeding interventions in Mexico by applying the NetMap analysis approach. We performed 11 semi-structured interviews with experts from 10 different organizations from Mexico in late 2022, identified 83 actors involved in the design and implementation of workplace breastfeeding interventions in Mexico, and visualized connections between different actors in four different networks. By computing network statistics, we identified the Mexican Institute of Social Security, Mexican Secretariat of Labor and Social Welfare, UNICEF, and the Mexican Secretariat of Health as key actors. To address the question of monetary benefits to employers offering a workplace lactation support program, we developed a model to estimate the net financial impact of workplace lactation support. We estimated associated annual program costs, savings in sick days associated with increased breastfeeding rates, and savings in recruitment costs associated with increased employee retention, all resulting from the introduction of workplace lactation support. By modeling a hypothetical Mexican workforce with 1,000 employees (women and men), we found that the value of a workplace lactation program to an employer strongly depends on the range of benefits that are taken into account. If attention is restricted to breastfeeding mothers, the program benefits may be insufficient to justify the costs. If, on the other hand, attention is expanded to include all employees, costs are easily covered by the benefits. We addressed the question of an optimal paid maternal leave length by developing an analytic framework combining outcomes of infant mortality reduction, increases in infant quality-adjusted life expectancy, and changes in female labor force participation, all resulting from paid maternal leave. To define a total monetary benefit as a function of paid maternal leave between 0 and 60 weeks, we utilized previously established relationships between the outcomes of interest and paid maternal leave length. Using data from Mexico from 2021 to explore the developed framework and gain initial insights, we observed a strong dominance of monetary benefit associated with female labor force participation rate on the total monetary benefit, dwarfing the benefits associated with improvements in infant mortality and health resulting from paid maternal leave. While the results are preliminary and warrant further examination, we were able to provide an analytic framework that we hope will be useful to decision makers in organizing their assumptions, assembling their evidence and/or testing their hypotheses. The results of this dissertation highlight several aspects of work-related lactation support: 1) re-introduction of a national breastfeeding strategy in Mexico – including workplace lactation policies – may help to improve coordination of the different actors and their activities, thus, improving the compatibility of work and family responsibilities and strengthening working mothers’ position in Mexico. 2) Financial attractiveness of a workplace lactation support program to the offering employer depends on the range of effects and beneficiary populations that are taken into account. While workplace lactation support is beneficial to breastfeeding mothers, it is associated with net costs to the offering employer. Net savings may only be observed when indirect effects such as increased retention among a wider group of beneficiaries are included. 3) Using established relationships between paid maternal leave duration and infant mortality, infant health, and female labor force participation, it is possible to estimate an optimal paid maternal leave length; optimal duration appears to be strongly dominated by the effect of female labor force participation resulting from paid maternal leave, warranting further investigation. Increases in female employment will help to minimize existing gender inequalities. To further improve family-work compatibility, future research should 1) explore who needs to be involved in the design and implementation of workplace lactation interventions and how to best structure and coordinate such efforts, 2) investigate the broader effects of workplace lactation support including indirect benefits, and 3) examine competing benefits and costs associated with changes in paid maternal and or parental leave duration. The findings of this dissertation indicate potential to improve the promotion of work-related lactation support by including indirect effects of such interventions; to incentivize the implementation of workplace lactation programs, indirect benefits of increased work retention among non-breastfeeding employees should be emphasized. And, in assessing a societally desirable paid maternal leave length, the effects of paid maternal leave on both female labor force participation and improved infant health outcomes should be taken into account. Together, this will not only help to promote breastfeeding in the work environment, but also to further increase compatibility between family and work responsibilities.

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