Women’s and Employers’ Experiences and Views of Combining Breastfeeding with a Return to Paid Employment: A Systematic Review of Qualitative Studies

Introduction: Returning to paid employment is one of the reasons women stop breastfeeding earlier than they planned to. This systematic review aimed to provide insight into the experiences and views of women and employers on breastfeeding and returning to paid employment, with findings used to inform practice and policy. Methods: The review was guided by the Joanna Briggs Institute (JBI) methodology for systematic reviews of qualitative evidence. Medline, CINAHL, PsycINFO, and Web of Science databases were searched for studies published in English. JBI’s meta-aggregative approach informed data analysis. The studies in this analysis included women who stopped breastfeeding before, and those who continued breastfeeding after, returning to paid employment and the employers, work managers, or supervisors of women who continued breastfeeding after returning to paid employment. Results: Twenty-six articles presenting findings from 25 studies were included and critically appraised. Synthesized findings showed that women experienced physical and emotional difficulties and described gender and employment inequalities in accessing and receiving the support they needed. Women reported that the importance of their own motivation and having workplace legislation in place facilitated breastfeeding during employment. Support from employers, colleagues, and family members, as well as access to convenient child care, helped women continue breastfeeding on return to paid employment. Employers’ personal experiences influenced their views on breastfeeding and working, and the need for more education and communication between employers and employers on breastfeeding in the workplace was recognized. Discussion: Support from family, work colleagues, and employers was important to reduce the physical and emotional challenges women experienced when combing breastfeeding with return to paid employment. Gender inequalities, especially in low- and middle-income countries, in accessing support exacerbated the difficulties women experienced. Limited data were identified regarding employers’ experiences and views, suggesting an urgent need for further research to explore employers’ and work colleagues’ experiences and views. J Midwifery Womens Health 2021;66:641–655 c (cid:2) 2021 The Authors. Journal of Midwifery & Women’s Health published by Wiley Periodicals LLC on behalf of American College of Nurse Midwives (ACNM).


INTRODUCTION
The World Health Organization (WHO) recommends that infants be exclusively breastfed for the first 6 months of life 1 ; however, breastfeeding rates remain low globally. Only 37% of infants younger than 6 months of age are exclusively breastfed in low-and middle-income countries. 2 In the United States, 26% of infants born in 2017 were exclusively breastfed through 6 months. 3 Given known health benefits associated with breastfeeding, there is a recognized need to improve breastfeeding rates internationally. This review inves-tigated women's and employers' perspectives of combining breastfeeding with a return to paid employment, as returning to paid employment has been found to be a factor influencing women's decisions about breastfeeding. 4 The adverse impact of returning to paid employment on breastfeeding rates has become more concerning in recent years. Evidence from a wide range of countries, including Australia, Brazil, China, Ireland, Sweden, the United States, and the United Kingdom, shows more women returning to paid employment after giving birth. [5][6][7][8][9] When considering how to combine work and breastfeeding, common concerns raised by women include insufficient time or lack of suitable work environment to express and store breast milk and lack of adequate access to their infant to breastfeed. 10 Globally, exclusive breastfeeding rates of infants younger than 6 months were 9% higher in countries where work breaks for breastfeeding were mandated. 11 Maternity leave had a positive association with breastfeeding continuation in one literature review, but other characteristics, including a woman's socioeconomic status, race, education, and work role, were also found to influence breastfeeding cessation after returning to paid employment following maternity leave. 12 A number of policies and guidelines have been introduced for employers with the aim of improving breastfeeding ✦ Women encountered a range of physical and emotional challenges to breastfeeding on return to paid employment.
✦ Women experienced gender and employment inequalities when accessing support to continue to breastfeed.
✦ Some employers considered that providing breastfeeding breaks would not be cost-effective for their business.
✦ Women's right to breastfeed during paid employment requires implementation of breastfeeding-friendly workplace policies.
✦ Effective communication about breastfeeding support between women and their employers is needed in the workplace. Workplace education that aims to improve employers' and employees' attitudes about the need to support colleagues who are breastfeeding is urgently needed.
rates. For example, the Global Strategy for Infant and Young Child Feeding, published by the WHO, highlights the importance of women continuing breastfeeding, particularly when returning to work, and recommends interventions such as appropriate maternity leave, facilities for storing breast milk, and paid work breaks so women can maintain breastfeeding. 1 The United Nations' International Labor Organization set the labor standard that women in paid employment should be offered a minimum of 14 weeks of maternity leave, at two-thirds of previous earnings, paid by social insurance or public funds; however, only 34% of 167 countries fully met this standard in 2013. 13 In the United States, following the 2010 Patient Protection and Affordable Care Act, employers became required to provide break time and a private space other than a bathroom for employees to express breast milk for one year after a child's birth. 14 There have been a few literature reviews on aspects of breastfeeding and return to paid employment. [15][16][17][18] A literature review of quantitative and qualitative studies that assessed barriers and facilitators to breastfeeding among women who work 15 reported that a woman's individual characteristics (including personal beliefs and views of herself), characteristics of an individual employer, and type of workplace environment affected breastfeeding among working women in the United States. Factors such as level of commitment to breastfeeding, previous breastfeeding experience, duration of mother-infant separation, and child-care options influenced breastfeeding duration during employment. However, this review only included studies from the United States and was published more than a decade ago. Two previous literature reviews identified similar barriers and facilitators to breastfeeding on return to employment. 16,17 A recent systematic literature review, which excluded qualitative studies, investigated perceptions, experiences, and outcomes of employer breastfeeding support in the United States from 2009 to 2019. 18 Employees' reported perceptions of workplace lactation support varied according to their employment and demographic characteristics, including race, ethnicity, and education.
The aim of this review was to analyze evidence from qualitative studies to provide an in-depth understanding and insight into the experiences and views of women and employers about women combining breastfeeding with a return to paid employment. Review findings could inform recommendations for practice to improve breastfeeding continuation rates among women who need to return to paid employment.
Two review questions were developed: (1) What are the views and experiences of women on combining breastfeeding with return to paid employment? (2) What are the views and experiences of employers regarding support for women combining breastfeeding with return to paid employment? No other current registered review protocols or published reviews were identified addressing this aim.

METHODS
This review was guided by Joanna Briggs Institute (JBI) methodology for systematic reviews of qualitative evidence. 19 Qualitative studies were chosen because this research methodology provides rich data about participants' experiences and views. The review protocol was registered on the PROSPERO international prospective register of systematic reviews (PROSPERO 2018 CRD42018089624). The "Enhancing Transparency in Reporting the Synthesis of Qualitative Research" (ENTREQ) statement was followed in presenting this analysis. 20 Qualitative studies were considered if they explored women's and or employers' experiences and views on combining paid employment with breastfeeding in any country and setting. Study participants included women who stopped breastfeeding before and those who continued breastfeeding after returning to paid employment. Studies that included pregnant women (as feeding intentions may alter following birth) and women who breastfed but did not return to paid employment were excluded. Studies that included employers, line managers, or supervisors of women who may have continued breastfeeding after returning to paid employment were also considered to better understand the experiences of employers.
Qualitative primary studies published in English from 2003, when the WHO Global Strategy for Infant and Young Child Feeding 1 was published, to July 2019 were considered. Quantitative and mixed methods studies were excluded, as was gray literature such as dissertations, policy documents, guidelines, and opinion papers. Reviews were excluded to avoid duplications of including findings from the same primary studies, but reference lists of reviews were hand searched to ensure all relevant primary studies were included.
Following JBI guidelines, 19 a 3-phase search strategy was used to identify all available publications. The first phase was a search of CINAHL and Medline databases to identify key words from the titles, abstracts, and index terms within the identified papers. The second phase included a search of Medline, CINAHL, PsycINFO, and Web of Science to identify articles from 2003 to February 2017 using Medical Subject Headings (MeSH) and free text terms. MeSH terms included the following: women, mother, employer, breastfeeding, and work. The third phase included identification of relevant articles from the reference lists of included studies and previous reviews. Searches were conducted in February 2017, and updated searches were conducted in July 2019. The initial search strategies and results were discussed between 2 reviewers and revised following discussion.
All articles identified were initially assessed for relevance by reviewing the title and abstract. The full text was retrieved for articles that appeared to meet the inclusion criteria and for those where it was not clear after viewing the abstract alone. Two reviewers then screened the full texts to assess whether they met the inclusion criteria. Any disagreement was resolved with discussion.
The methodological quality of the articles that met inclusion criteria was assessed using the adapted Critical Appraisal Skills Program (CASP) 21 critical appraisal tool for qualitative research, which consists of 10 appraisal questions to guide quality assessment of each study (see Supporting Information: Table S1). Each CASP question was given a "yes," "no," or "can't tell" answer. A score that rated the study from 1 to 10 was allocated to each article, with each "yes" answer given one point. "How valuable is the research?," the original question 10 of the CASP checklist, was adapted for this review to "Is the research valuable?" to facilitate scoring. Quality assessment was independently assessed by 2 pairs of reviewers. Any discrepancies were resolved through discussion.
Meta-aggregation as described by the JBI 19 informed the qualitative synthesis, an approach sensitive to the usability and practicality of authors' findings without seeking to reinterpret original findings. The following stages were undertaken: (1) Findings were inductively identified line by line from the results or findings section of included papers, with relevant direct quotes supporting findings extracted from the text. (2) Similar findings were aggregated together to make a category (a category shows a statement that communicates the meaning of a number of similar findings). (3) Similar categories were organized into a synthesized finding ( Table 1). All authors agreed on the final categories and synthesized findings.

RESULTS
Twenty-six articles  presenting data from 25 studies were included (2 articles were based on data from the same study 43,44 ). The selection process is presented in Figure 1. Seventeen included papers were from uppermiddle-and high-income countries: 7 from the United States, 22,23,25,31,32,34,42 3 from Malaysia, 30,43,44 2 each from Iran 45,46 and Australia, 24,28 and one each from the United Kindgom, 27 Ireland, 26 and New Zealand. 40 Two articles were from Tanzania, 35,37 the only low-income country represented, and 7 articles were from lower-middle-income countries: 3 from India, 36,38,39 3 from Pakistan, 29,41,47 and one from Bangladesh. 33 Twenty-three included papers focused on the experiences of women, 22,24,26-33,35-47 and 3 focused on the ex-periences of employers. 23,25,34 Table 2 presents the characteristics of included papers.
Three studies 34,37,41 had an overall CASP score of 10. Two studies 27,42 scored 6, the lowest score, as it was unclear how participants were selected and the rigor of data analyses was questioned by the reviewers (see Supporting Information: Table S1). One item included in the CASP checklist, "Has the relationship between researcher and participants been adequately considered?," was not addressed in most of the included studies.
Two synthesized findings were identified in this analysis, as shown in Table 1.

Synthesized Finding 1: Women's Experiences and Views
Women experienced physical and emotional difficulties and needed support from employers, colleagues, partners, and other family members, as well as convenient child care, to help them continue breastfeeding while in paid employment. Gender and employment inequalities in accessing and receiving support, workplace legislation including maternity leave, and women's own motivation, knowledge, and previous experience can affect continuation of breastfeeding.
Seven categories are identified that contributed to this synthesized finding: (1) support from partners and other family members, (2) support from colleagues and employers, (3) physical challenges, (4) convenient and flexible child care, (5) maternal emotional difficulties, (6) maternal attributes, and (7) breastfeeding-friendly workplace legislation and maternity leave.

Support from Partners and Other Family Members
Practical and emotional support from partners and other family members, including help with child care and housework, were important influences. Some partners became the primary caregiver for the infant, whereas others would bring the infant to the woman during the day to facilitate feeding. Some family members took on additional help with housework so that the woman could rest: "I breastfed both my babies. My husband was really good about accommodating me, bringing the baby to me, going out of his way when I worked nights and afternoons. He worked days, so it was really good there." 25(p 141) By contrast, some found their partners unsupportive, which might reflect gender inequality in how men perceive women's role at home, particularly in low-and middleincome countries. For example, a woman from Iran stated:

Support from Colleagues and Employers
Support from colleagues and employers was identified as an important facilitator that helped women continue breastfeeding, whereas lack of support was identified as a barrier to continued breastfeeding. Women appreciated an employer who  was flexible about their work pattern, who was approachable and someone they could discuss their breastfeeding needs with, as this quote illustrated: "The people I worked with were real great and worked with me. Without the support and everything there is no way I could have done [expressing milk, breastfeeding]…" 42(p 381) Practical support from work colleagues enabled women to continue to breastfeed during work hours by helping them find time to express milk and adjust work shifts to accommodate their breastfeeding needs. Emotional support from managers and coworkers was also important for breastfeeding women.
However, women in unsupportive work environments and those unable to reduce or revise their working hours were in some instances encouraged to start bottle feeding by their managers on their return to work. For example, "… They were not understanding my need that I need to express this milk for my baby and even I didn't get support from my senior management; they were saying start bottle feeding." 29(p 149) Some women stopped breastfeeding because of concerns about what their work colleagues thought about them. For example, one woman felt her coworkers may think, "Who does she think she is, going off and feeding her baby? It's not like you are going to be five minutes is it? It takes a bit of time …" 40(p 23) Women frequently found it difficult to access the level of practical breastfeeding support they needed, such as finding time to express milk, at their workplace. Often this was due to a lack of open discussions about breastfeeding, as women felt their colleagues were uncomfortable about discussing this. However, women stated that breastfeeding issues needed to be discussed more with employers and employees to ensure women were aware of the support available in their workplace and felt less embarrassed about asking for it. Breastfeeding support was not widely discussed in the workplace, and many women hid that they were breastfeeding. Some women breastfed secretly and away from workplace premises, although in some instances, having to hide that they were breastfeeding eventually caused them to give up, often because of tiredness: "… I just couldn't [keep going] because as well as hiding you so are tired when you are breastfeeding, and I didn't feel I could be [seen to be] tired at work." 20(p 39)

Physical Challenges
Physical challenges to breastfeeding while working described by women included time constraints, physical discomfort because of not breastfeeding or expressing breast milk frequently  (1) benefits to the company (most frequently mentioned "happy employees" and "high retention rate and improved loyalty"), (2) supporters and opponents (most frequently mentioned supporters were "mothers and expectant mothers" and "managers supervising women and new mothers"), (3) company drawbacks (most frequently mentioned "not cost effective," "time consuming," "perception of special favours for some").  (2) support and information provision, (3) returning to work, (4) feeding in the workplace.

Gatrell 27 2007
United Kingdom To understand the experiences of professional women who were combining paid work with caring for preschool children In-depth interviews 20 educated women with preschool children in managerial and professional occupations Women who tried to combine feeding with work found it difficult as breastfeeding was seen as "taboo" in the workplace. They either stopped or concealed breastfeeding activities.
Gilmour  from companies with a range of breastfeeding support benefits 3 themes: (1) Human resource managers' primary concern was meeting the needs of their employees, regardless of the benefit.
(2) General employee benefits were viewed as essential to recruitment and retention, whereas breastfeeding support benefits were discretionary. (3)  were qualified nurses from 6 hospitals, working full-time and breastfeeding 3 themes: (1) positive experiences, with subcategories personal pleasure, mother-infant relationship, and fitness or quality of breast milk; (2) mediating health behavior, with subcategories mother's caregiving activities, mother's dietary practices, and mother's infant weaning practices; (3) negative experiences, with subcategories personal discomfort, environmental problems and lack of facilities, lactating problems, and administrative problems.
enough, and lack of workplace facilities for breastfeeding or expressing and storing breast milk. Many women identified difficulties finding time to express breast milk, as they were not allocated designated time to breastfeed and had to use their routine break times to pump and express milk. Others found that pumping and expressing breast milk or breastfeeding their infants in a workplace nursery encroached too much on their work time. Long working hours and shift work, particularly night shifts, also meant longer periods away from their infants. Unable to breastfeed or express milk regularly caused physical discomfort for women: "Milk accumulates in the breast; it swells and is painful when I don't feed the child from time to time." 36(p 4) Even if there was time to directly breastfeed or express breast milk, some workplaces lacked space for expressing or storing expressed milk, resulting in women having to discard any breast milk expressed during working hours. Others reported that they were forced to sit in a prayer room or toilet to express their breast milk, which raised concerns about privacy and hygiene in terms of not being in an environment suitable for a collecting breast milk. However, some women expressed breast milk where possible, their ability to adapt being fundamental to continuing breastfeeding. One woman stated:

Convenient and Flexible Child Care
The flexibility of child care and proximity to the woman's family or place of work contributed positively to breastfeeding continuation. Having child-care facilities close to work or on site clearly influenced whether a woman could or could not continue to breastfeed without it impacting on her work. Some women who lived close to their place of work could go home to breastfeed their infant during the daytime, whereas other women could continue to breastfeed as their infant was cared for during working hours in an on-site day-care facility. The importance of this level of facility was highlighted by some women. One woman stated: As soon as I found out I was pregnant …, I put him down on the waiting list at the crèche because I just knew sort of with the experience of it I had with my first child it would be much less stressful to have them in child care rather than trying to organise times with nannas and work around them. 28(p 27) On the other hand, a consideration for needing child-care facilities in or near hospital among health workers in low-and middle-income countries was the potential risk of the infants being in the ward or unit. 41,47 However, there was inequality of access to child-care facilities based on an individual's employment position. A study from Pakistan found that nurses were told that child-care facilities were only for the doctors' children and not for the nurses' children. 41

Maternal Emotional Difficulties
Women who returned to paid employment because of financial pressures before or at the end of a planned short maternity leave often described feeling guilty about leaving their infant: It was a mistake to rush to work and leave a helpless newborn infant without a mother … this is the greatest cruelty and injustice done to a breastfeeding infant who is so dependent on the mother. I felt that I was sacrificing him for money … I doubted myself and wondered if I was a good mother at all. 38(p 107) Pressure to adjust infant feeding practices prior to returning to paid employment resulted in women feeling stressed and anxious: It annoyed me that I felt under pressure to get her on bottles, I felt really pressurised a month before I was going back, I remember I felt under pressure the month before, because she still was very finicky with bottles… 26(p 5) Women also expressed a lack of confidence to ask for the support they needed from employers and colleagues and were uneasy about taking time out of the working day to breastfeed. Some were particularly embarrassed to discuss breastfeeding needs with their male colleagues: "I didn't like telling any male that I need to express […] there are so many things about which you can communicate to a female but not to males." 29(p 149)

Maternal Attributes
Women's determination to successfully breastfeed for as long as planned, together with an understanding of breastfeeding benefits, previous experience, and their needs when returning to work, helped some to plan and persevere with breastfeeding. A woman stated: When I started to go back to work, I made it public to all my colleagues that I fully breastfeed my baby and because of that I have to make time to have regular breaks for milk expression. I would not be joining them for lunch and will use that time to express my milk. 43(p 829) Some women gave up breastfeeding when they encountered obstacles, including working for employers who discouraged breastfeeding. Other women decided they were ready to stop by the time they returned to paid employment, as they had breastfed for as long as they had planned.

Breastfeeding-Friendly Workplace Legislation and Maternity Leave
Women stated that legislation was needed so that breaks to enable women to breastfeed or express breastmilk were protected by law, as illustrated by the quote: Legal protection for women to feed after their return to work, I work in a private company and they have no obligation to allow me to take breaks to pump or feed (Baby) if it was a legal right I would be much more confident in saying it to my boss. 26(p 7) However, studies 31,32 from the United States conducted after the 2010 Patient Protection and Affordable Care Act reported that most participants, such as African Americans on low incomes, were not covered by the legislation, which primarily addressed hourly workers and businesses with more than 50 employees. Furthermore, legislation alone was inadequate, with communication between employers and employees an essential component. 22 Paid maternity leave entitlement was an important influence, and women with no access to paid maternity leave often had to decide to stop breastfeeding. Those only entitled to a short period of maternity leave referred to weaning their infants before returning to employment:

Synthesized Finding 2: Employers' Experiences and Views
Although many employers were supportive and understanding, some viewed breastfeeding women negatively in the workplace, and more education about breastfeeding in the workplace is needed. Employers' personal experiences influenced their views, and employers should discuss with women their breastfeeding needs, even if this is difficult for them or the woman.
Five categories are identified in this synthesized finding: (1) openness to support employees' needs, (2) concerns about negative effects on workplace, (3) lack of education and knowledge about breastfeeding, (4) personal experiences influencing views on support for breastfeeding, and (5) awareness of employees' difficulties in discussing breastfeeding with (male) employers.

Openness to Support Employees' Needs
In line with the finding that women appreciated employers who discussed their breastfeeding needs, employers in some cases reported that they would be willing to discuss the needs of employees who were breastfeeding. They would address needs similarly to support they would offer to any other employee experiencing issues such as family illness. They understood that providing relevant support could assist women to continue to breastfeed and facilitate a good work-family balance for women:

Concerns About Negative Effects on Workplace
By contrast, some employers viewed breastfeeding more negatively. This was due to concerns that women would be less productive, would need to take more breaks, and would "not be cost effective" employees. 23(p 488) Similar to women's concerns about their colleagues' negative views of them breastfeeding during work hours as described above, employers also had concerns that other employees could view providing breastfeeding breaks as special treatment, leading to resentment among other members of their workforce: "Special treatment or favour for some." 23(p 488)

Lack of Education and Knowledge About Breastfeeding
A lack of education and knowledge about breastfeeding was apparent among some employers. They felt that polices or laws to support breastfeeding would tie them into providing additional support and facilities. For example, when asked about workspace available for women to express breast milk, and in direct contrast to women's views as described earlier, one manager thought that the women's toilets would be suitable: "…. I believe the women's bathrooms have some extra space with some extra seating in there, probably just bench seats I would imagine." 25(p 142) Personal Experiences Influencing Views on Support for Breastfeeding An employer's personal experience of breastfeeding was perceived by those employing or managing women in the workplace as helpful. Employers who had breastfed themselves or had a partner who had breastfed understood the importance of supporting women: "[Breastfeeding is] certainly something I appreciated in my life and I would want to encourage any young mom who has the opportunity to do that." 34 (Table 4)

Awareness of Employees' Difficulties in Discussing Breastfeeding with (Male) Employers
Some managers were aware that women found it challenging to speak about their breastfeeding needs, especially in a maledominated work environment. This awareness also echoed the views of women as reported above. One manager said, "Quite frankly, it isn't as comfortable talking with me maybe as a male as they (breastfeeding employee) would be a female about I need to use a breast pump." 25(p 143)

DISCUSSION
This systematic review of qualitative studies provides an in-depth understanding and insight into the experiences and perspectives of women and employers about combining breastfeeding with employment. The review found that women experienced physical and emotional difficulties on return to employment and that women identified the importance of support from their families, work colleagues, and employers, including emotional and practical support. The review highlights gender and employment inequalities in receiving and accessing support needed, especially in low-and middle-income countries. Breastfeeding-friendly workplace legislation that addresses the needs of all postnatal women is needed, with education for the workforce to improve breastfeeding awareness and knowledge, and attention to the importance of communication between employers and employees about breastfeeding support needs and rights.
This review's findings support previous studies. [15][16][17][18] Quantitative studies that investigated associations between paid employment and breastfeeding practices reported similar findings regarding the emotional and physical challenges women experienced and the lack of support women received in workplaces. For example, a study in the United Kingdom (n = 46) of public sector employees found that almost 90% of participants felt employers should do more to support breastfeeding, including informing women of available support. 48 Providing breastfeeding support at workplaces has been shown to increase breastfeeding rates. For example, a national cross-sectional survey of more than 500 employed women in the United States reported that women who had a private workspace to express milk and sufficient break times to express were 2.3 times more likely to be exclusively breastfeeding at 6 months than women who did not have access to such support. 49 A systematic review of workplace-based breastfeeding support interventions found that the most common intervention studied was providing a breastfeeding space, followed by breastfeeding breaks, with positive outcomes reported, such as increased rates of breastfeeding exclusivity and duration. 50 Attitudes of breastfeeding women, their managers, and work colleagues also matter. For instance, many women in paid employment in southern Taiwan felt that they would receive poor evaluations from their supervisors if they took breastfeeding breaks. 51 Inequalities in accessing and receiving support manifested through gender role expectations wherein employed women in low-and middle-income countries were viewed as responsible for doing housework and caring for children. Gender role expectations were also evident in employment roles and status (eg, male managers and female employees). Barriers to breastfeeding because of lack of equality in the workplace have been reported in quantitative studies; for example, shorter maternity leave had a particularly detrimental effect on the breastfeeding decisions of women who were not in managerial positions. 52 A recent review on partners' and family members' experiences of breastfeeding support confirmed that gender inequality is a major influence on their level of support. 53 A review of father-and partner-inclusive perinatal breastfeeding interventions found that specific interventions did increase paternal breastfeeding support to women and improved rates of breastfeeding initiation, duration, and exclusivity. 54 The findings of this review also show that women desired breastfeeding-friendly workplace legislation. Although the review included studies from the United States conducted before and after passage of the Patient Protection and Affordable Care Act, most women in the studies conducted after this act was passed were not covered by legislative mandates; thus differences in women's experiences of combining breastfeeding with a return to paid employment following implementation of the act cannot be determined. A cross-sectional online survey with 52 working postnatal women aged 18 to 50 years found that around 79% of them had access to break times to express breast milk and 65% had access to a private space that was not a restroom. 55 Fewer of the respondents reported having access to support groups, breast pumps, or lactation consultants. Of note, most respondents in this study were white, college-educated women working in clerical or administration support and education occupations. One of the issues identified by Dinour and Bai about the Patient Protection and Affordable Care Act is that not every woman is protected by this legislation. 56 For instance, small business with fewer than 50 employees can apply for an exemption. Therefore, Dinour and Bai recommended an amendment to the law so that women currently exempt will be included. 56

Implications for Policy, Practice, and Research
Evaluations of workplace support show that if employers are willing to make some adjustments, even small ones, to help women who want to breastfeed, it will have positive benefits for women, children, their families, and the workplace. 50 This message should be widely promoted to employers. Providing breastfeeding support could improve a woman's job satisfaction, 57 which in turn could support retention and possibly improve productivity, although evidence is needed. Further research is also needed to explore how attitudes among employers and workplace colleagues can be improved to provide breastfeeding-friendly workplaces.
Encouraging fathers and partners to participate in perinatal breastfeeding sessions and allowing them paid time off from work to attend such sessions could be included as part of breastfeeding and family workplace policy and practices. Health care professionals, including midwives, nursemidwives, public health nurses, and family doctors, can provide family-centered care by engaging partners and family members in breastfeeding discussion and support.
A transparent breastfeeding-friendly workplace policy and legislation that incorporates local employment legislation and is well communicated to the workforce could help women plan to continue to breastfeed. However, policy and legislation alone will not achieve change, and approaches to support effective communication between women and their workplace managers to clarify expectations about a return to work and the continuation of breastfeeding are essential. Better information and publicity of the legislation and policy are also needed if breastfeeding-friendly workplaces are to ensue. Cultural change through education from school, media, and health care professionals is needed to promote gender equality.
This study has some limitations. Only papers published in English were included, which might have introduced selection bias. However, a comprehensive search strategy informed this review with no restrictions to country setting or type of paid employment. All included papers were critically appraised and reviewed. Furthermore, findings might not be generalizable to all country settings, as most included studies were from upper-middle-or high-income countries. Future research is needed to explore employers' experiences and perspectives from a range of private and public sectors.

CONCLUSION
This review found that pro-breastfeeding environments with supportive employers, partners, and families enabled women to combine breastfeeding with paid employment. Gender and employment inequalities should be addressed to reduce the barriers that hinder women from successfully breastfeeding after returning to work. Although legislation to support a woman's right to breastfeed while in employment is essential, it has to address the rights of all postnatal women, accompanied by effective implementation and communication of breastfeeding needs between women and their managers. Further research is urgently needed to explore how attitudes among employers and women's workplace colleagues can be improved to provide breastfeeding-friendly workplaces in a global effort to increase breastfeeding duration. Without Journal of Midwifery & Women's Health r www.jmwh.org employers' support, many women will continue to cease breastfeeding earlier than they may have planned to.