Helping Mothers Who Work Outside the Home
Kirsten Berggren, PhD
Burlington VT USA
From: LEAVEN, Vol. 41 No. 6, December 2005-January 2006, pp. 123-26.
Editor's Note: the term "working mother" is used for clarity. It is understood that mothers may experience separation from their babies for a variety of reasons and the author means to include mothers who are volunteers, students, or those who may experience separation for other reasons. All mothers work whether or not they are employed and many working mothers may not be separated from their babies.
When a mother who works outside the home calls you or comes to a meeting, you may face special challenges. It can be helpful to look at these challenges from the perspective of the mother who has decided to return to employment or school, either full- or part-time.
This article is presented in two parts: the main body of the article offers practical tips and information for mothers on combining working and breastfeeding; while the sidebar offers some insight into the counseling challenges that might be encountered when helping working mothers.
There are several breastfeeding challenges that are common among working mothers, including maintaining an adequate milk supply, managing nighttime feedings, and working with care providers who often give most of the baby's feedings during the day. The following tips provide an overview of these challenges and some strategies for dealing with them.
Insufficient Milk Supply
The most common problem faced by working mothers is that they have difficulty expressing enough milk for their baby's needs during the day (Fein 1998). Because a breast pump is usually not as efficient at extracting milk as a baby is, even women with an abundant milk supply can have difficulty pumping enough during the work day. Reassure the mother that her body can continue to make plenty of milk for her baby, but she may have to work on some creative solutions to extract it with the pump.
If milk supply is a problem, ask how often the mother is pumping and what kind of pump she is using. Most mothers need to pump frequently, at least once for each missed feeding, and for 15 to 20 minutes each time. If she is working full-time, she may need a high-quality double electric pump. A single-sided electric or battery-operated pump is not usually adequate for full-time separation. If she is concerned about her pump, you can suggest that she contact her pump's manufacturer or rental station and ask about having her pump tested.
If a mother cannot pump often enough at work to produce the milk her baby needs, perhaps she can add pumping sessions at different times through the day. Some suggestions to add pumping sessions include:
- Wake up before the baby, pump, and then nurse. (Because babies are more efficient than pumps, her baby will still get milk even if she has just pumped.)
- Pump one side while nursing the baby on the other. (The football hold is useful for this tip.)
- Pump upon arriving at work. (Even if a mother has just nursed her baby, she can usually have a productive pumping session as soon as she gets to work. The pressures of the day have not set in, and high morning prolactin levels make it easier to pump more in the early part of the day.)
- If the baby goes to bed before the mother, she can pump right before she goes to bed.
- If the baby sleeps through the night, she can set an alarm and pump once during the night—or she can wake the baby and encourage a nighttime feeding.
A mother may tell you that she tried extra pumping but was getting little milk—remind her that extra pumping not only gets milk that she needs for that day, but "places the order" for more milk by letting her body know that there is an increased demand. It may take a few days for a mother to produce milk at a new pumping time, but she should see her milk supply increase within a week if she pumps at the same new time each day.
An important pumping tip you can give a working mother is to stop watching the bottles and counting ounces when she's pumping. Help her think of relaxing things to do while pumping, such as relaxation breathing, pleasure reading, talking on the phone, or browsing entertaining or inspiring Web sites.
Encourage More Breastfeeding
If a mother is having trouble pumping, encourage her to breastfeed as often as possible when she is with her baby. Emphasize that the best way to maintain her milk supply is frequent feedings at the breast. A working mother can reduce the amount she has to pump by feeding her baby right before she leaves for work, and again as soon as he returns home. She can allow the baby unlimited access to the breast when she is home—because the baby provides better stimulation to increase supply than the pump does, and also to ensure that he is getting plenty to eat. If her baby does not seem hungry in the evening, she can speak with her baby's caregiver about limiting feedings late in the day so he will nurse more when they are together.
Safe cosleeping is a great strategy to increase breastfeeding time at night for working mothers. It not only increases her milk supply and reduces the amount that she has to pump, but can also increase the quality of rest she gets during the night. A working mother may be concerned about cosleeping, and may worry that she will not get enough rest for work the next day. Research has shown that breastfeeding mothers who share sleep do not show any overall increase in the amount of wakefulness during the night (Mosko 1997). Since the baby is fed before he cries and fully wakes, mother and baby can both settle back to sleep more quickly. Many working mothers said they would never cosleep, until they tried it and found out how well-rested they could feel when they didn't have to get out of bed to feed during the night.
A common reason that a mother cannot pump enough during the day is that her baby is being overfed by his care provider. Providing small amounts in bottles can prevent waste and overfeeding.
If for example, a baby is with the caregiver eight hours and is taking 20 ounces (621 ml) of milk, it is time to look more closely at the situation. Eight hours is one-third of a 24-hour day. Ideally, a baby should be taking about one-third of his intake during those eight hours, or about eight to 13 ounces (236 to 384 ml) (Mohrbacher 2005).
On the Web site, Mama Cherie, Dr. Jack Newman suggests using only newborn flow nipples no matter the age of the baby, because a rapid flow can cause a baby to prefer the bottle or to overfeed. You can discuss ways for the mother to approach her baby's care provider about feeding the baby only when he's hungry, not pressuring him to finish bottles, and using soothing methods other than bottles when he is fussing. It may be helpful to share with the caregiver the tear-off sheets Storing Human Milk (Available from the LLLI Online Store) and Working and Breastfeeding (Available from the LLLI Online Store), which have some tips for feeding a breastfed baby. The pamphlet The Balancing Act (Available from the LLLI Online Store) has a section with tips for feeding a breastfed baby, and the Frequently Asked Questions section of the LLLI Web site has a list of tips that a mother can print out and share with her baby's caregiver. /p>
Mothers might want to discuss with their baby's health care provider whether they feel comfortable with reheating a bottle that was not finished during a feeding, and then share their decision with the baby's caregiver. In her book, Breastfeeding: A Guide for the Medical Profession, Dr. Ruth Lawrence states that "Breast milk may safely stand at room temperature for six to eight hours, and need not be discarded if the first feeding attempt is incomplete" (Lawrence 2005). Another study showed that if a bottle is reheated one time within four hours of the first feeding, there is no appreciable bacterial growth and the milk is still safe to feed (Brusseau 1998). If a mother is having trouble pumping enough and her baby is old enough to take solids, she can have her care provider give all of the baby's solid foods so that she can exclusively breastfeed when she is home (boosting her supply while reducing the amount she needs to pump).
The Freezer-Stash Trap
Most mothers know that giving a baby supplemental bottles of formula can decrease their milk supply. But some working mothers are supplementing without even knowing they are doing it. How? They are supplementing from their "freezer stash"—a supply of their own frozen milk. Since it is their own milk, it doesn't occur to them that it has the same effect on their milk supply as supplementing with formula. They may be using three or four ounces a day from the freezer stash, and can't understand why their supply is diminishing. Explain that every ounce they supplement from the freezer is an ounce their body doesn't make that day. It can be hard to break this pattern, and it usually involves adding pumping sessions to increase her supply. As she is able to pump more milk for her baby, the caregiver can gradually decrease the amount of frozen milk she uses to supplement the amount the mother is pumping and leaving for the day. A hungry baby can boost his mother's supply by nursing frequently when they are together, and the mother can encourage this by offering free access to the breast in the evenings and during the night.
A mother who is with her baby all day may not notice a small supply dip, since her baby will nurse more frequently until the supply rebounds. However, a mother who is pumping during the day will notice the decrease in output right away and may be concerned. It is important to avoid or at least recognize things that can decrease supply.
Stress contributes to supply problems. You can help the mother identify any avoidable stresses, such as household chores or optional, extra work assignments. At about six months postpartum, many working mothers start taking on more responsibility at work to "make up for" maternity leave, so she might want to watch for increased stress (and related supply dips) around this time. Remind her that her baby is only this young once, and she will have plenty of energy and time for her job when her baby is a little older.
Remind the working mother that good hydration and nutrition help her make lots of nutritious milk for her baby; one suggestion is to have a water bottle with her all day, and keep nutritious high-protein snacks with her at work.
If a mother has a cold, she may decide to take "over-the-counter" medications to decrease her symptoms so she won't miss work. Encourage her to discuss any medications, including over-the-counter ones, with her baby's health care provider. Decongestants have been shown to decrease supply significantly (Aljazaf 2003). You can suggest natural ways to take care of cold symptoms, such as steam or a humidifier, and encourage her to slow down and take care of her body.
Due to regular missed feedings, working mothers sometimes notice that their menstrual cycles return sooner than for women who are breastfeeding full-time, thus presenting another hurdle. There can often be a supply dip right before her flow begins. There is evidence that supplementing with calcium and magnesium from the middle of the month until flow begins may minimize the alterations in progesterone levels associated with the pre-menstrual time period (Thys-Jacobs 1998), and it has been reported anecdotally that this treatment also reduces the associated decrease in milk supply (Bonyata 2002). Reassure her that a supply dip before her period is usually temporary. She may need to pump a little extra to keep up during this time, but it can be encouraging to know that if return of menses is the cause, the supply dip will only last a few days.
All or Nothing
It can be challenging to help a mother who says she is going to quit breastfeeding because she "can't keep up" with her baby's needs when she is at work. The combination of working and taking care of a new baby can be overwhelming, and she may think that switching to formula can make it easier. You can help her explore her options by talking about what it would be like getting up to mix bottles in the middle of the night and having to prepare formula all weekend.
However, this mother may be too overwhelmed to think about adding even one more pumping session. If she perceives you as being adamant that she needs to provide only human milk, she may disregard all of your information. If you can support her in her need to simplify by pumping less, she will be more likely to come to you for ongoing support of her breastfeeding relationship with her baby. Let her know that breastfeeding does not have to be all or nothing. If giving one or two bottles of formula during the day allows the mother to reduce her stress levels, she may finally begin to truly enjoy breastfeeding when she is with her baby. She needs good information on how to supplement wisely; she can contact her baby's health care provider about an appropriate supplement and give formula only when she and her baby are separated.
Some women can wean from pumping during the day and still maintain their milk supply so that they can continue to exclusively breastfeed when they are with their baby. Others find that reducing the amount they are pumping reduces their supply throughout the day—a woman's response to reduced milk removal is extremely variable. A woman who is planning to reduce pumping should be aware that it could negatively impact her supply in her non-work hours. She can be encouraged to make changes gradually. If her supply reduces too drastically, she can always add pumping sessions back as needed. She is more likely to be able to wean from the pump and keep breastfeeding if her baby is at least six months old and taking some other foods.
Breast Refusal (nursing strike): Breast refusal or nursing strike is a particularly painful problem for a working mother—she may feel rejected by her baby and may believe her baby is rejecting her because she has returned to work. Reassure her that breast refusal can happen in babies who are with their mothers 24 hours a day! The strategies for resolving it are the same whether the mother works or not. When mother and baby are together, encourage baby-wearing, skin-to-skin contact, feeding in a quiet place when the baby is relaxed, and encourage the mother not to give her baby a bottle when they are together. Babies will learn that mother is for breastfeeding, and bottles are only for when mother is away. Since working mothers are used to preparing bottles, they may be more likely to offer one in cases of breast refusal. Reassure this mother that without giving bottles, the breast refusal or nursing strike should resolve quickly. If it does not and baby needs to eat, spoon or cup feeding or asking someone else to give him a bottle may help further avoid confusing her baby.
Speaking with Employers: Working mothers may encounter resistance from their employers when requesting time and a private space for pumping. Many countries and some US States have various laws regarding breastfeeding (for more information see www.lalecheleague.org/Law/Bills7.html). Some US states protect a woman's right to breaks during the workday to express her milk. Others provide no legal protection at all. In many states you can obtain information about working and breastfeeding for women and employers through the State Department of Health or WIC (Women, Infants, and Children) programs. For example, one good resource for working mothers is the Texas WIC program's breastfeeding promotion Web site (www.dshs.state.tx.us/wichd/lactate/mother.shtm). Your state or country may have similar programs and information available. Being aware of the laws where you live is helpful; Leaders can also utilize their Area Professional Liaison for additional information.
Finding Support: Being a working mother can be extremely isolating. At work, you are not supposed to feel like a mother, but at home, you often feel as if you are floundering through everything alone. Working mothers have very little time to connect with other mothers, and we all know the value of peer support as we transition into parenthood. Encourage a working mother to reach out for support by connecting with friends who are also breastfeeding and working, joining an online La Leche League meeting, or attending evening meetings. Some areas have lunchtime LLL meetings specifically designed for the working mother; some LLL meetings may be held in the workplace. The Internet can be a tremendous resource for working and breastfeeding mothers, providing support groups, information, and community message boards (several of which are listed in the "For More Information" box).
By providing a warm welcome and useful information for a working mother, you can help her not only with her breastfeeding questions, but you will also be helping her to find the community of peer support every mother needs.
Aljazaf, K. et al. Pseudoephedrine: effects on milk production in women and estimation of infant exposure via breastmilk. Br J Clin Pharmacol 2003 Jul; 56(1):18-24.
Bonyata, K. Low milk supply associated with menstruation: Calcium/magnesium supplement. KellyMom 2002; www.kellymom.com/herbal/natural-treatments.html#calcium.
Brusseau, R. Bacterial analysis of refrigerated human milk following infant feeding. Unpublished study, 1998.
Fein, S.B. and Roe, B. The effect of work status on initiation and duration of breast-feeding. Am J Pub Health 1998; 88:1042-46.
Lawrence, R. Breastfeeding, A Guide for the Medical Profession, fifth edition. St. Louis, Missouri: Mosby Publishing, 2005.
Mohrbacher, N. THE BREASTFEEDING ANSWER BOOK POCKET GUIDE. Schaumburg, IL: LLLI, 2005.
Mosko, S., Richard, C., and McKenna, J. Maternal sleep and arousals during bedsharing with infants. Sleep 1997; 20(2):142-50.
Thys-Jacobs, S. et al. Calcium carbonate and the premenstrual syndrome: Effects on the premenstrual and menstrual symptoms. Am J Obstet Gynecol 1998; 179(2): 444-52.
For More Information
LLLI Frequently Asked Questions
LLLI Message Board
http://forums.lalecheleague.org/ [address updated for website]
LLLI Community Network for Leaders
("Working Moms" under the topic of "Breastfeeding Information")
Work and Pump.com: Information for Employed Mothers
Kellymom.com: Working and Pumping
Mama Cherie: Information by Dr. Jack Newman
iVillage: Working and Pumping Message Board
Breastfeeding.com: Working and Breast-feeding Message Board
LLLI can only be responsible for information contained within our own Web pages.
The Leader: When working with a mother who works outside the home, you may find yourself reflecting on your personal choices regarding employment. It may have been a difficult decision to step out of a rewarding career to be home with your children, or maybe you always knew you would leave the workforce when your children were born. Or maybe you found a way to combine working and breastfeeding in ways that met your family's needs. Whatever your experience has been, it will influence how you interact with a working mother. Remind yourself that in order for her to be receptive to your suggestions, you must listen attentively and respond to what the mother is asking. If the mother has questions regarding her decision to return to work, let her bring these up at her own pace. Providing information about breastfeeding is the primary responsibility of the LLL Leader.
The Mother: By providing a welcoming environment to all mothers, you can have a positive impact on a working mother's choices about breastfeeding and parenting for years to come. However, a working mother may approach LLL feeling nervous about how she will be received, or defensive about her decision to work. She may have heard other working mothers say they didn't feel they "fit in" with La Leche League, or that they felt criticized for their choice to return to work. With an initial assurance that all mothers are welcome, and that you can help her to combine working and breastfeeding, you will have made an important first step in supporting her breastfeeding relationship. Mothers often find combining working and breastfeeding to be challenging, and it is helpful for Leaders to provide practical tips and information specific to working mothers. You can help this mother remember her initial motivations for breastfeeding and encourage her to set small goals so she feels successful, no matter how long she breastfeeds.
The Response of the Group: When a working mother comes to a meeting, mothers who are staying home with their children may react without thinking: "I couldn't bear to ever leave my children!" or "We gave up X or Y so I could stay home." When a working mother hears comments like these, she may feel judged or defensive. It can be helpful to redirect the discussion to breastfeeding and this mother's need for information. It is not constructive to let a discussion start about what are "good enough" reasons to work. Avoiding judgments will lead the discussion in positive and helpful directions, and encourage all mothers to share positive aspects of their own breastfeeding experience in your discussions. All mothers make decisions based on individual family needs and no one can determine what's best for another mother and her family.
Talking to the Working Mother: When first speaking with any mother, whether at a meeting or through a phone conversation, it may take some gentle questions to find out what her real concern is. A working mother may not be in regular contact with other breastfeeding mothers, so her questions may be framed more around the bottle-feeding culture she encounters at work. For example, she may not know that it is normal for babies to share sleep with their parents, and may have concerns about how to get her baby to sleep through the night. If she is having a lot of anxiety about returning to work, she may say that she is thinking of weaning when she is really looking for reassurance that she will be able to keep breastfeeding. Use active listening skills to hear what her concerns are. It can be helpful to let her know that you would be glad to help her with breastfeeding after she returns to work. If she is expecting to hear that she really should be staying home, this simple reassurance can help so much in establishing a constructive relationship.
Kirsten Berggren is a full-time working mother of two children, Kai and Talia, both of whom were breastfed through their third year. Her husband, Robyn, is a middle-school teacher. Kirsten has been the moderator of the ivillage "Working and Pumping" message board, and currently works for the Vermont Department of Health on their "Breastfeeding-Friendly Employer Project." She is writing a book for working and breastfeeding mothers, and has just launched her own Web site, www.workandpump.com. Kirsten is an LLL Member.