A cross-sectional study of lactation room quality and Dutch working mothers' satisfaction, perceived ease of, and perceived support for breast ...
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van Dellen et al. International Breastfeeding Journal (2021) 16:67
https://doi.org/10.1186/s13006-021-00415-y
RESEARCH Open Access
A cross-sectional study of lactation room
quality and Dutch working mothers’
satisfaction, perceived ease of, and
perceived support for breast milk
expression at work
Sjoukje A. van Dellen1,2* , Barbara Wisse1,3, Mark P. Mobach2,4, Casper J. Albers1 and Arie Dijkstra1
Abstract
Background: The challenge of combining professional work and breastfeeding is a key reason why women choose
not to breastfeed or to stop breastfeeding early. We posited that having access to a high-quality lactation room at
the workplace could influence working mothers’ satisfaction and perceptions related to expressing breast milk at
work, which could have important longer term consequences for the duration of breastfeeding. Specifically, we
aimed to (1) develop a checklist for assessing the quality of lactation rooms and (2) explore how lactation room
quality affects lactating mothers’ satisfaction and perceptions. Drawing on social ecological insights, we
hypothesized that the quality of lactation rooms (operationalized as any space used for expressing milk at work)
would be positively related to mothers’ satisfaction with the room, perceived ease of, and perceived support for
milk expression at work.
Methods: We conducted two studies. In Study 1 we developed a lactation room quality checklist (LRQC) and
assessed its reliability twice, using samples of 33 lactation rooms (Study 1a) and 31 lactation rooms (Study 1b). Data
were collected in the Northern part of the Netherlands (between December 2016 and April 2017). Study 2
comprised a cross-sectional survey of 511 lactating mothers, working in a variety of Dutch organizations. The
mothers were recruited through the Facebook page of a popular Dutch breastfeeding website. They completed
online questionnaires containing the LRQC and measures aimed at assessing their satisfaction and perceptions
related to milk expression at work (in June and July 2017).
Results: The LRQC was deemed reliable and easy to apply in practice. As predicted, we found that objectively
assessed higher-quality lactation rooms were associated with increased levels of satisfaction with the lactation
rooms, perceived ease of milk expression at work, and perceived support from supervisors and co-workers for
expressing milk in the workplace.
* Correspondence: s.a.van.dellen@rug.nl; s.a.bos-van.dellen@pl.hanze.nl
1
Department of Psychology, University of Groningen, Groningen, The
Netherlands
2
Institute of Future Environments, Hanze University of Applied Sciences,
Groningen, The Netherlands
Full list of author information is available at the end of the article
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data made available in this article, unless otherwise stated in a credit line to the data.van Dellen et al. International Breastfeeding Journal (2021) 16:67 Page 2 of 13 Conclusions: The availability of a high-quality lactation room could influence mothers’ decisions regarding breast milk expression at work and the commencement and/or continuation of breastfeeding. Future studies should explore whether and how lactation room quality affects breastfeeding choices, and which aspects are most important to include in lactation rooms. Keywords: Breastfeeding, Breastfeeding duration, Maternal employment, Breast milk expression, Lactation room, Facility management, Netherlands Background exclusivity of breastfeeding [7]. However, research focus- Research findings have shown that the challenge of com- ing on the effects of the quality of lactation rooms re- bining working and breastfeeding is one of the main rea- mains a gap in the literature. To encourage further sons why women do not breastfeed their babies or stop research in this as yet unexplored domain, the current breastfeeding early [1]. To support women continuing to study focussed on two research questions. Firstly, how breastfeed their babies when they return to work, orga- can a lactation room quality be assessed? Secondly, how nizations may, among other things, offer paid breastfeed- is a lactation room quality related to women’s satisfac- ing breaks and a lactation room. Maternity protection tion and perceptions regarding breast milk expression at legislation regarding these aspects can differ per country work? [2]. According to research by the International Labour Organization, the provision of paid breastfeeding breaks Assessing lactation room quality is included in the legislation of 71% of the countries, and A breastfeeding woman needs to breastfeed or express the provision of a lactation room is included in the legis- milk regularly during the day to maintain her milk sup- lation of only 31% of countries worldwide [2]. ply and avoid medical problems relating to a build-up of In the Netherlands, where this research took place, milk. Although, in principle, there could be various ways breastfeeding rates are relatively low. In 2018, the per- to achieve this, ranging from taking breastfeeding breaks centage of exclusive breastfeeding (operationalized as at home to having the child brought to the workplace. still receiving breast milk, without receiving infant for- The option that arguably is most prevailing in practice, mula) and any breastfeeding at 6 months of age were also in the Netherlands, is for mothers to express breast only 19 and 28% respectively [3]. At the same time, the milk in a lactation room at the workplace. Most official number of working women in the childbearing age is guidelines for designing lactation rooms focus on basic high: in 2019, 82.1% of Dutch women in the ages of 25 functional aspects, such as hygiene, privacy, and required to 45 were employed [4]. Mandatory paid maternity facilities. For instance, Dutch guidelines specify that a leave in the Netherlands is 16 weeks, with minimally 10 lactation room should be lockable from the inside, hy- weeks postnatal leave (Article 3.1, paragraph 1–3 of the gienic, and offer sufficient privacy. It should be suitable Labour and Care Act). Subsequently, when a breastfeed- to rest in and should have a (folding) bed or a couch. ing mother returns to work, she is entitled to paid Moreover, it should offer fresh air and adequate climate breastfeeding breaks until her infant is 9 months of age; control facilities, while not posing specific risks (e.g., the moreover, her employer is responsible for providing a presence of hazardous materials and contaminants) [8]. suitable, lockable, and private space for this purpose However, the guidelines only stipulate minimum stan- (Article 4.8, paragraph 1 of the Working Hours Act). dards, and the quality of lactation rooms is likely to be However, such legislative provisions cannot guarantee influenced by more than just these basic functional as- that a lactation room will actually be present for the ma- pects. For instance, a recent literature review [9] focus- jority of mothers. For example, studies have shown that ing on office environments concluded that the quality of 32% of Dutch working women who breastfeed do not indoor environments is not only influenced by basic have any access to a lactation room [5] and 24% of functional aspects, such as indoor air quality, thermal women have access to a lactation room that cannot be comfort, lighting, acoustics, and office layout, but also by locked [6]. Clearly, despite legislation, there appears to natural, aesthetic, and recreational aspects, i.e., more be considerable room for improvement regarding the psychologically oriented aspects. In the case of a lacta- provision and enforcement of suitable breastfeeding fa- tion room, examples of these aspects are the presence of cilities worldwide, and in the Netherlands specifically. plants or flowers (natural aspects), paintings or pictures, To date, scientific studies on the impact of lactation and coloured walls (aesthetic aspects), books or maga- rooms have mainly focused on the effects of the avail- zines, and radio or television (recreational aspects). We ability of lactation rooms, revealing that their mere would argue that such natural, aesthetic, and recre- availability promotes the initiation, duration, and ational aspects should also be included when assessing
van Dellen et al. International Breastfeeding Journal (2021) 16:67 Page 3 of 13
the quality of lactation rooms. In general, natural, aes- First of all, we posit that the quality of lactation rooms
thetic, and recreational aspects of indoor environments may influence women’s overall satisfaction with these
are known to reduce stress [10–13], which impedes the rooms. Satisfaction with the physical environment re-
milk ejection reflex [14–16]. Therefore, taking account lates to the extent to which the physical environment
of natural, aesthetic, and recreational aspects may be im- meets individuals’ physiological, functional, and psycho-
portant if lactation rooms are expected to facilitate logical needs [24, 25]. Accordingly, it can be assumed
breastfeeding practices. An appropriate method for easily that the extent to which a lactation room meets the
and reliably assessing the quality of lactation rooms does needs of the mothers using it, determines their satisfac-
not seem to be readily available at the moment. The de- tion with the room. Because a higher-quality lactation
velopment of such a method or checklist was therefore presumably meets the needs of lactating mothers to a
one of the aims of the present study. larger extent, we expect that lactation room quality is
positively related to women’s satisfaction with the room.
Secondly, we posit that the quality of a lactation room
The relationship between lactation room quality and may influence mothers’ perceived ease of expressing
working mothers’ satisfaction and perceptions milk at work. Notably, organizations routinely offer facil-
A review of the global literature on employer-based pro- ities to support the performance of certain activities by
grams, policies, and interventions to support breastfeed- employees or the ease of their execution. For example,
ing among working women was conducted in 2015 [7]. organizations sometimes offer their employees sport fa-
The most common employer-based intervention studied cilities to enable them to engage in physical activities
revolved around whether or not organizations provided [26–28], or they offer healthy canteen food options to
a private space to express milk. Positive effects associ- promote healthy eating [29]. Thus, provisions offered by
ated with access to a lactation space were found for organizations can influence employees’ perceived ease of
breastfeeding initiation, breastfeeding duration, breast- certain behaviours within specific domains. Similarly,
feeding exclusivity, the use of infant formula, predomin- lactation room quality may affect women’s perceptions
ant breastfeeding, and job satisfaction. One study [17] of the ease with which milk can be expressed at work.
found that while access to a lactation space did not have Therefore, we expect that lactation room quality is posi-
a significant effect on its own, the combination of an tively related to women’s perceived ease of breast milk
available lactation space and a refrigerator was associ- expression at work.
ated with continued breastfeeding. This last finding sug- Our third and final argument is that the quality of a
gests that the mere availability of a lactation room may lactation room may also influence women’s perceptions
not be the only important consideration; features or fa- of support within the workplace for expressing milk. Re-
cilities within that room may also be important. In other search in the field of environmental psychology has
words, the quality of a lactation room may matter for shown that individuals often derive broader conclusions
breastfeeding-related outcomes. and judgments about people or organizations from en-
We posit that a lactation room could be regarded as vironmental cues [30–33]. The fact that an organization
an environmental factor that is meaningful in the con- is willing to spend time and money on establishing a lac-
text of breastfeeding employees. As such, the socio- tation room can be viewed as being indicative that an
ecological model, which posits that human behaviour is organization deems breastfeeding important and wants
influenced not only by individual factors but also by to support it. Furthermore, research has shown that en-
socio-environmental factors, provides a relevant theoret- vironmental cues can communicate not only prevalent
ical framework [18]. Socio-environmental factors (like types of behaviour in a particular setting, but also what
individual factors) can influence behaviour directly, but kinds of behaviour are expected [34]. Therefore, the
they can also have indirect effects by influencing percep- availability of a high-quality lactation room may commu-
tions, attitudes, or feelings that consequently impact on nicate to employees that managers and co-workers con-
behaviour [19, 20]. The socio-ecological model has sider women’s milk expression at work to be both
already been successfully applied within multiple breast- customary and desirable. In sum, we expect that lacta-
feeding studies [21–23]. In the current study we investi- tion room quality is positively related to perceived sup-
gated the impact of lactation room quality women’s port of managers and co-workers for milk expression at
satisfaction with the room, their perceived ease of milk work.
expression, and their perceived support for milk expres-
sion at work from their supervisors and co-workers. Es- Current research
tablishing these relationships is important because The current research aimed to develop an appropriate
mothers’ satisfaction and perceptions may influence method for easily and reliably assessing the quality of
their breastfeeding behaviour. lactation rooms (Study 1) and to advance understandingvan Dellen et al. International Breastfeeding Journal (2021) 16:67 Page 4 of 13
of the effects of lactation room quality on the satisfac- minor adjustments: we added ‘wet wipes’ as an item to
tion and perceptions of breastfeeding women who work the list, and grouped the items into categories to make
(Study 2). Given the growing number of women joining the LRQC more user-friendly. The third and final step
the labour market and the long-term health benefits of entailed pre-testing the revised LRQC using a think-
breastfeeding for both mothers and children, acquiring aloud protocol [37, 38]. Two mothers with personal ex-
insights into how lactation room design may facilitate perience of expressing milk at work pilot-tested the
the combination of breastfeeding and work seems highly LRQC while talking to the researcher about difficulties
relevant. Study 1 was conducted to develop a checklist or uncertainties with regard to items in the list, which
for lactation room quality that takes into consideration led to some minor changes in wording. The final LRQC
basic functional aspects of lactation rooms, as well as contained 35 easily observable items relating to lactation
natural, aesthetic, and recreational aspects. Study 2 room quality, phrased in a simple and unambiguous way
aimed to test the hypotheses that lactation room quality (see Additional file 3 for the full list). We conducted two
would be positively related to women’s satisfaction with studies (Study 1a and 1b) to examine the interrater reli-
the lactation room, their perceived ease of breast milk ability of the lactation room quality checklist.
expression at work, and perceived support of supervisors
and co-workers regarding breast milk expression at Design and procedure study 1a
work. These hypotheses were tested within a large cross- Thirty-three different lactation rooms in 31 different or-
sectional sample of women who expressed milk at work. ganizations were rated by three raters to assess the inter-
The current study constitutes an important step in an rater reliability of the lactation room quality checklist.
inquiry of whether and how the quality of lactation The lactation rooms included in the research were for
rooms may be associated with breastfeeding women’s staff only (no public used lactation rooms were in-
satisfaction and perceptions regarding breast milk ex- cluded). Convenience sampling was used to select orga-
pression at work. nizations with lactation rooms. The selected
organizations with lactation room facilities mostly in-
Methods study 1 cluded large public sector organizations (22 of the 33 ex-
Developing the lactation room quality checklist (LRQC) amined rooms were located in such organizations), as
We created a concept LRQC for assessing the quality of small organizations often do not have lactation rooms.
lactation rooms using a multi-step procedure to ensure The following inclusion criteria were applied in Study
the inclusion of the basic functional qualities of these 1a: geographical proximity to our location (the northern
rooms as well as their natural, aesthetic, and recreational part of the Netherlands) to enable direct observation of
qualities. As a first step, we compiled items derived from the room, the availability of a lactation room, and the
our review of a variety of online sources and literature possibility of visiting the organization on one of the
providing guidelines and recommendations for the de- three dates that we had selected for the ratings. The
sign of lactation rooms. Since there are currently no em- principal researcher phoned personnel within the orga-
pirically validated best practices for lactation rooms, we nizations to inquire whether there was an on-site lacta-
relied on a range of available sources instead. We tion room and to request permission to visit the
merged items derived from the Dutch guidelines on lac- lactation rooms at these organizations on one of the
tation rooms [8], a list of best practices in lactation room three selected dates. In total, 72 organizations were
design produced by the American Institute of Architects approached; 31 organizations agreed to a visit, 30 orga-
[35], and recommendations for lactation rooms formu- nizations did not have a lactation room at that moment,
lated by a major breast-pump producer [36]. Items fo- 1 organization did have a lactation room, but refused for
cusing on natural, aesthetic, and recreational aspects privacy reasons, and 10 organizations did not know
were then added to these items to create an initial com- whether they had a lactation room and/or could not
prehensive list with items that can be used to evaluate identify the correct contact person. Data were collected
the quality of lactation rooms. from December 2016 to January 2017. The three raters,
The second step entailed eliciting experts’ inputs. Ex- namely the principal researcher (female) and two stu-
perts (N = 8) were recruited from the network of the first dents (one female and one male) visited all 33 lactation
author, and comprised international board-certified lac- rooms together and filled out a LRQC in each room in-
tation consultants and mothers with personal experience dividually, without discussing their observations with the
of expressing milk at work. Experts received a copy of other raters. In this pilot study the LRQC took on aver-
the list and were instructed to assess whether the word- age 3 minutes to complete. The raters were deliberately
ing was clear, whether additional items were needed, not provided with training or instructions because the
and to offer any further feedback to improve the lacta- LRQC is intended to be filled in without requiring train-
tion room quality checklist. This process led to two ing or further instruction. If more than one lactationvan Dellen et al. International Breastfeeding Journal (2021) 16:67 Page 5 of 13 room was present in an organization, all of the lactation rooms were rated, unless the rooms were similarly de- signed, in which case one room was chosen at random for rating. Design and procedure study 1b To enable a further examination of interrater reliability of the LRQC, a second reliability study was designed. This study included 31 lactation rooms that were rated by the principal researcher and one mother (a different mother for each lactation room). Of the 31 lactation rooms in Study 1b, 13 rooms had also been examined in Study 1a. The Principal Investigator (PI) visited these rooms again in order to place a recruitment message in the lactation room. In principle, the PI did not fill out the checklist again, unless changes in the lactation room called for it (e.g. one lactation room had had a sink in- stalled since the previous rating). Again, we used con- venience sampling to select organizations that were mostly large public sector organizations (21 out of 31 examined rooms were provided by such organizations). The following inclusion criteria were used: geographical Fig. 1 Examples of lactation rooms visited during Studies 1a and 1b proximity to our location (the northern part of the Netherlands) and the availability of a lactation room that was being actively used at the time of the study. The Data analyses study 1a and 1b principal researcher phoned personnel within the orga- The interrater reliability of the nominal items on the nizations to ask whether there was a currently used on- LRQC was assessed with Cohen’s kappa (κ) coefficient site lactation room and to request permission to visit the using ReCal3, an online tool that computes interrater re- lactation room. Data were collected from March 2016 to liability coefficients for nominal data coded by three or April 2017. The principal researcher visited 41 lactation more coders [39, 40]. Responses indicating that the par- rooms, filled out a LRQC and left a leaflet in each room, ticipants did not know whether or not the item was requesting mothers who made use of the lactation room present were considered missing values and were to contact the principal researcher per e-mail to partici- dropped from the analysis (leading to a lower number of pate in a study about breastfeeding and work. We ap- ratings for the items concerned, see Table 1). plied no additional selection criteria (such as frequency of using the lactation room). Mothers who responded were sent an e-mail with a link to an online version of Results study 1 the lactation room quality checklist. No instructions Using Altman’s benchmark values [41] for Cohen’s κ, we were provided on where the LRQC was to be completed found that the scores for 24 of the 35 items in the LRQC because we assumed that women could fill out the ques- ranged between moderate and (very) good in both stud- tionnaire without actually being present in the room, ies (see Table 1). In Study 1a, a poor score (< 0.20) was given that they expressed milk in these rooms multiple obtained for one item, fair scores (0.21–0.40) for two times a day. To prevent participants from guessing while items, moderate scores (0.41–0.60) for four items, good filling out the LRQC, we provided an option for them to scores (0.61–0.80) for nine items, and very good scores indicate that they did not know whether or not the item (0.80–1.00) for 15 items. The κ values could not be com- was present. Participating mothers received a €10 gift puted for four of the items because of perfect agreement certificate. We received responses from mothers for 31 between (two or three) raters. In Study 1b, poor scores out of the 41 visited lactation rooms, leading to a final (< 0.20) were obtained for seven items, fair scores (0.21– sample of 31 lactation rooms that had been observed by 0.40) for two items, moderate scores (0.41–0.60) for five the principal researcher and a mother. In this study too, items, good scores (0.61–0.80) for seven items, and very all of the lactation rooms provided by participating orga- good scores (0.80–1.00) for nine items. The κ values for nizations were rated unless their designs were similar, in five items could not be computed because of perfect which case, one room was randomly chosen for rating agreement between two or more raters and the absence (Fig. 1). of variation in rating scores.
van Dellen et al. International Breastfeeding Journal (2021) 16:67 Page 6 of 13
Table 1 Interrater reliability of the Lactation room quality checklist items (Studies 1a and 1b)
Study 1a 1b
Description n % Agreement Cohen’s Kappa n % Agreement Cohen’s Kappa
Access:
Door with a lock 33 97.97 0.76 31 100 1.00
Lactation room sign 33 95.95 0.91 31 80.60 0.59
Occupied sign 33 83.83 0.65 31 87.10 0.74
Furniture:
(Folding) bed 33 95.95 0.89 31 96.80 0.93
Couch 33 93.93 0.53 31 100 undefined
Chair 33 100 1.00 31 100 undefined
Table(s) or surface 33 93.93 0.67 31 96.80 0.00
Facilities:
Coat rack or hook* 33 100 1.00 23 78.30 0.16
Room divider 33 100 undefined 31 100 undefined
Functional socket 33 100 1.00 27 100 undefined
Breast pump 33 95.95 undefined 31 100 1.00
Paper towels 33 91.91 0.83 31 90.30 0.81
Wet wipes 33 97.97 0.76 31 93.50 0.00
Trash can 33 91.91 0.78 30 86.70 0.60
Sink 33 100 1.00 31 96.80 0.92
Fridge 33 100 1.00 31 87.10 0.72
Mirror 33 91.91 0.80 29 100 1.00
Entertainment/relaxation:
Radio 33 95.95 0.75 31 100 1.00
Television 33 97.97 0.76 31 100 undefined
Books and/or magazines 33 95.95 0.90 31 100 1.00
Facilities to make coffee or tea* 33 97.97 undefined 31 93.50 −0.03
Pillow on the couch or chair* 33 91.91 0.73 30 86.70 0.29
Blanket* 33 81.81 0.25 30 83.30 0.21
Decoration:
Posters or paintings 33 95.95 0.91 30 86.70 0.72
Artificial plants or flowers 33 97.97 0.89 30 96.70 0.78
Real plants or flowers 33 100 1.00 31 93.50 −0.03
Coloured wall(s) 33 97.97 0.91 30 86.70 0.44
Bulletin board 33 91.91 0.46 31 90.30 0.52
Other decorative items* 33 83.83 0.50 29 79.30 0.13
Windows and lighting:
Window 33 97.97 0.95 31 100 1.00
Artificial light 33 100 undefined 30 93.30 −0.03
Dimmer 33 100 1.00 30 96.70 0.65
Ambient lighting 33 89.89 0.23 31 96.80 0.65
Climate control:
Heating 33 72.72 0.51 20 95.00 0.77
Air-conditioning* 33 48.48 0.19 5 80.00 0.55
‘undefined’ means that the κ value could not be computed because of perfect agreement between two or more raters and the absence of variation in rating
scores. Removed items are marked with an asterisk (*)van Dellen et al. International Breastfeeding Journal (2021) 16:67 Page 7 of 13
Items that scored below 0.41 (indicating poor or fair the survey. All of the respondents provided their in-
reliability scores) in either Study 1a, Study 1b, or in both formed consent before continuing to the survey. Data
studies were in principle removed from the LRQC. An collection occurred in June and July 2017. The study was
exception was made for the five items with a low κ value approved by the Ethical Committee of Psychology (ECP)
as a result of a highly skewed distribution (high level of of the University of Groningen, The Netherlands (refer-
overall agreement among the raters) because these items ence number: 16394-O).
were also retained [42]. These items, which tended to be
always present or always not present in the lactation Measures
rooms were ‘a table or surface where you can place a Lactation room quality was measured using the LRQC
breast pump’, ‘artificial light’, ‘wet wipes’, ‘real plants or developed in Study 1. We used the sum score of all
flowers’, and ‘ambient lighting’. Ultimately, six items items with positive responses (‘yes (present)’; min = 0,
(marked with an asterisk in Table 1) were removed from max = 29). The internal reliability of the LRQC was ac-
the lactation room quality checklist. The final LRQC ceptable (α = .73) [43]. All items had a positive item total
thus comprised 29 items. correlation. Exceptions were ‘a door with a lock’ (r = .02)
and ‘artificial lighting’ (r = −.01). These items can be
Conclusion study 1 viewed as basic prerequisites for a lactation room. Be-
In Studies 1a and 1b, we developed a practical checklist cause Cronbach’s alpha did not change significantly
for quickly, easily, and objectively assessing the quality when any of the items were deleted (remaining within a
of lactation rooms. The LRQC’s reliability was tested range of 0.71 to 0.74), we decided to retain all items.
with two samples, and items considered unreliable were Mothers were furthermore asked to indicate whether the
removed. The final list contained 29 items and was lactation room was a dedicated lactation or multi-
found to be reliable regardless of whether a fixed set of purpose room with the following item: ‘Is this room
raters (Study 1a) or a changing set of raters (Study 1b) used only as a lactation room or is it also used for other
filled out the LRQC. After developing the LRQC in purposes?’ Answering options were: ‘only as a lactation
Study 1a and 1b, we subsequently used the LRQC to in- room’ and ‘also for other purposes’.
vestigate the relationships between lactation room qual- Satisfaction with the lactation room was measured
ity and mothers′ satisfaction with the room and with one bipolar item: ‘With the room in general I am. ..
perceptions related to expressing milk while at work in (very satisfied - very unsatisfied)’. Perceived ease of
Study 2. breast milk expression at work was measured with one
bipolar item: ‘How easy or difficult do you think it is to
Methods study 2 express breast milk at work? (very easy - very hard)’.
Design Perceived co-worker support was measured with two bi-
We recruited respondents through a call to participate polar items: ‘My co-workers find that I express breast
in an online cross-sectional survey posted on the Face- milk at work … (very positive - very negative)’ and ‘My
book page of a popular Dutch website that provides co-workers find that I express breast milk at work …
breastfeeding information (www.borstvoeding.com). (very important - very unimportant)’ (α = .77). Perceived
Mothers who used a lactation room at their workplace supervisor support was measured with the same two
and had internet access were eligible to participate in items, but ‘my co-workers’ was replaced with ‘my super-
the study. We did not specify any criteria that the lacta- visor’ (α = .83). All of the items were answered using a 7-
tion room had to meet. Therefore, any space used for point Likert scale, and the responses were recoded so
expressing milk at work, and that was perceived by the that higher scores reflected more positive outcomes. Fi-
users as a lactation room, was regarded as a lactation nally, demographics (i.e., age, average working hours per
room in this Study. week, and education level) were gathered at the end of
the questionnaire.
Procedure
Mothers who clicked on the link posted on the Facebook Data analysis
page received further information about the research be- We performed univariate regression analyses with the
fore proceeding to the survey. The instructions empha- quality of lactation rooms as the independent variable
sized that participation in the study was voluntary and and satisfaction, perceived ease of milk expression, and
anonymous and that participants were free to withdraw perceived support of co-workers and supervisors as the
from the study at any time. Participants were further in- dependent variables to test our hypotheses. A p-value of
formed that a total of 15 breastfeeding and/or parenting .05 was considered significant (p < 0.0125 after perform-
books would be raffled off and that the winners would ing a Bonferroni correction for the number of compari-
be selected from among the respondents who completed sons). The responses of women who did not completevan Dellen et al. International Breastfeeding Journal (2021) 16:67 Page 8 of 13
the survey were excluded from the analysis. Responses p < .01) were all significant and positive (see Table 2).
indicating that the participants did not know whether or Although the correlations between lactation room qual-
not an item of the LRQC was present were considered ity and the dependent variables were significant, they
missing values and were dropped from the analysis. were not particularly strong: most correlations were
Demographic variables were only used for descriptive smaller than .30 (small effect size, according to Cohen’s
purposes. conventional guidelines [47]), with the exception of the
correlation with satisfaction with the room (r = .49,
Results study 2 medium effect size [47]).
Respondents
A total of 511 mothers completed all of the survey ques- Hypotheses testing
tions. The respondents’ mean age was 32.05 years (SD = All four hypotheses were supported (see Table 3). Thus,
3.98) and they worked an average of 26.59 h per week when the quality of lactation rooms was objectively
(SD = 6.53). The majority of mothers reported having a higher, women experienced more overall satisfaction
high or medium education level (78.5 and 20%, respect- with the lactation room, and they felt that milk expres-
ively). A high education level is defined as a Bachelor’s sion at work was easier. Moreover, when the quality of
or a Master’s degree, a medium education level as sec- lactation rooms was objectively higher, women perceived
ondary vocational training, secondary general training more support for milk expression from their co-workers
and pre-university training, and a low education level as and managers at work. Notably, we also performed all of
everything that is ranked below that. The distribution of the analyses with age and education level as the covari-
women with varying levels of education in the sample, ates. All of the effects remained significant. Therefore,
and especially the high proportion of women with high we did not include age and education level as covariates
or medium levels of education is not necessarily repre- in the final analyses presented in Table 3, because in-
sentative of Dutch women in general. In 2016, 49% of cluding unnecessary covariates may negatively impact
Dutch women between the ages of 30 and 35 years re- the interpretability of the results [48, 49].
ported having a high level of education and 36% re-
ported having a medium level of education [44]. Discussion
However, given that breastfeeding is positively related to The primary goals of this study were (1) to develop a
education levels [45] and that individuals with a higher questionnaire for assessing the quality of lactation rooms
level of education are more likely to work than those and (2) to explore the impact of the quality of lactation
with a lower level of education [46], the relatively high rooms on breastfeeding mothers’ satisfaction and per-
proportion of well-educated women in our sample was ceptions related to breast milk expression at work. Study
not unexpected. 1 focused on developing the LRQC questionnaire, which
was found to be reliable regardless of whether it was
Quality of lactation rooms filled out by a fixed set of assessors (Study 1a) or a chan-
In our sample only 16.2% of the women used a dedi- ging set of assessors (Study 1b). Generally, we found that
cated lactation room, while 83.8% used a multi-purpose the reliability of the LRQC items was higher in Study 1a
room. Basic functional aspects of lactation room quality than in Study 1b. This could have several causes. First,
were reported to be present in most cases. For example, in Study 1a the raters were all non-users of the room,
artificial light, a functional socket, and a chair were and therefore more similar than in study 1b, where one
present in almost all of the lactation rooms (90% or rater was the principal researcher, and the other rater
more). However, natural, aesthetic, and recreational as- was a mother using the lactation room. Second, in Study
pects relating to the quality of lactation rooms were less 1a the LRQC was filled out by all raters at the same
common, see Fig. 2. time, but in Study 1b the raters filled out the LRQC at
Scores for the quality of lactation rooms ranged from different time-points. This means that in Study b, any
1 to 24 (out of 29 possible positive responses), with a differences in ratings could have been caused by not
mean score of 10.33 (see Table 2). Notably, dedicated only a different perspective (non-user versus user-
lactation rooms were assigned higher scores relating to perspective), but also by actual differences due to
their quality than those assigned to non-dedicated rooms changes in the lactation room between the ratings. This
(M = 12.57 and M = 9.90; F (1,509) = 39.46, p < .001). As could have led to an underestimation of the reliability of
we had hypothesized, the correlations between lactation the LRQC in Study 1b, and suggests that the reliability
room quality and satisfaction with the lactation room estimates found in Study 1b could be considered as con-
(r = .49, p < .01), perceived ease of milk expression (r = servative estimates. Summarizing, the LRQC was
.21, p < .01), perceived co-worker support (r = .27, deemed a reliable instrument for quick, easy, and object-
p < .01), and perceived supervisor support (r = .21, ive assessment of the quality of lactation rooms and thusvan Dellen et al. International Breastfeeding Journal (2021) 16:67 Page 9 of 13
Fig. 2 Reported frequencies of lactation room characteristics (n = 511)
Table 2 Means, standard deviations, and correlations of the
Table 3 Univariate associations between lactation room quality
independent and dependent variables
and the dependent variables
Mean SD 1. 2. 3. 4. 5.
Dependent variable b SE B Beta t R2 p
1. Lactation room quality 10.33 3.67 –
Satisfaction .13 .01 .49 12.77 .24van Dellen et al. International Breastfeeding Journal (2021) 16:67 Page 10 of 13 suitable for application in research and practice. The Furthermore, the associations between lactation room availability of a reliable measuring instrument is import- quality and women’s perceptions of their co-workers’ ant because it can stimulate and facilitate research on and supervisors’ support suggests that the quality of lac- the effects of the quality of lactation rooms on breast- tation rooms can also be interpreted as conveying sup- feeding, milk expression at work, and other possible out- port for breastfeeding and milk expression at work. In come measures. Moreover, it can guide facility managers this context, the provision of high-quality facilities may in organizations in developing evidence-based designs have consequences that extend beyond simply enabling for lactation rooms, and by doing so, improve support mothers to express milk at work; their availability may for breastfeeding women in their workplaces. signal that milk expression at work is supported by co- In Study 2, we applied the LRQC within a Dutch sam- workers and supervisors and is considered normative be- ple and investigated the relationship between lactation haviour. Previous studies have shown that the communi- room quality and women’s satisfaction, their perceived cation of positive norms is especially important for ease of milk expression, and perceived support for milk promoting breastfeeding intentions and behaviour. For expression. We found that although most lactation example, Spitzmueller and colleagues [51] found that rooms contain at least a chair, a socket, and artificial perceptions of support at the workplace for breastfeed- light, surprisingly several other basic functional aspects, ing and supervisors’ comments about breastfeeding pre- such as a door with a lock, a table, heating, a fridge, or a dicted the duration of exclusive breastfeeding. We sink were absent in many of the lactation rooms. Nat- believe that within organizations, facility management ural, aesthetic, and recreational aspects, such as plants and human resources departments can play an import- or flowers, paintings or pictures, books or magazines, ant role in implementing and advancing such policies. and radio or television were present only in a minority Notwithstanding the relevance of other factors, our find- of the sampled lactation rooms, even though literature ings do show that lactation room quality may contribute suggests that these aspects are important for improving to removing practical and normative barriers to breast the quality of indoor environments [9]. The low preva- milk expression at work. Organizations should therefore lence of dedicated lactation rooms in our sample is also pay attention to the quality of the facilities they offer to a concern, since we found that on average the quality of their employees who breastfeed. a multi-purpose room is significantly lower than that of a dedicated lactation room. All in all, the relatively low Limitations and directions for future research quality of the lactation rooms in our study is worrisome Although our findings are promising and accord with and suggests that despite existing regulations [8], the those in the literature and with our expectations, our quality of many lactation rooms can be improved. Al- study had some limitations. The first entails our use of a though only Dutch lactation rooms were examined in cross-sectional design for Study 2. Such designs have this study, there is no reason to assume that the situ- two important drawbacks: the influence of common ation would be better in other parts of the world. For ex- method variance and the inability to draw causal conclu- ample, for a discussion of the gaps between legislation sions [52]. With regard to common method variance, we and lactation room quality in the United States, see argue that because we used the LRQC to measure the Dinour and Bai [50]. It is furthermore interesting to note quality of lactation rooms, and scores assigned to items that even though the average quality of the rooms was on this list can be assumed to be relatively objective in low (M = 10.33 out of a maximum of 29), the mean nature, the associations that we found were most likely score for satisfaction was not unfavourable (M = 4.68 on not strongly affected by common method variance. An- a scale from 1 to 7, indicating a score between neutral other concern is the directionality of the effects. In the and a little bit satisfied). This may mean that not all case of lactation room quality, we deem it unlikely that items on the list are equally important or necessary to satisfaction, perceived ease of milk expression, or per- achieve a certain minimum level of satisfaction. It could ceived co-workers’ support would have influenced par- also be interpreted as indicative of low expectations with ticipants’ observations regarding the presence of certain regard to lactation room quality (causing mothers to be items or options in the lactation room. However, be- relatively satisfied even with a relatively low-quality cause supervisors are generally able to influence working lactation room). conditions, it is conceivable that supervisor support in The results of Study 2 also suggest that the quality of an organization would contribute to a high-quality lacta- lactation rooms matters because a higher quality is asso- tion room. Therefore, reversed causality could be an ciated with increased satisfaction with the lactation room issue in the relationship between lactation room quality and mothers’ perceived ease of milk expression at work, and perceived supervisor support. Moreover, a possible suggesting that a high quality lactation room may help alternative explanation for the associations that we mothers to feel more able to express milk at work. found is that a third factor influenced both the quality of
van Dellen et al. International Breastfeeding Journal (2021) 16:67 Page 11 of 13
lactation rooms and the outcome variables. For example, Supplementary Information
a breastfeeding-friendly organizational policy, or a very The online version contains supplementary material available at https://doi.
org/10.1186/s13006-021-00415-y.
high personal motivation to breastfeed, could both lead
to improvements of the lactation room, and impact the Additional file 1. LRQCL rating scores Study 1a. LRQCL rating scores
outcome variables. Future studies should therefore con- Study 1a
sider experimental research designs to test the causality Additional file 2. LRQCL rating scores Study 1b. LRQCL rating scores
of the associations found. Study 1b
In the current study, we measured only age and educa- Additional file 3. Lactation room quality checklist. Lactation room
quality checklist
tion level as biographical variables. Future studies should
Additional file 4. SPSS Dataset Study 2. SPSS Dataset Study 2
consider adding more variables that could be helpful in
Additional file 5. SPSS syntax for Study 2. SPSS syntax for Study 2
getting insight into the composition of the sample, and
in understanding if the effects of lactation room quality
Acknowledgements
on mothers’ satisfaction and perceptions may depend We would like to thank all of the respondents who participated in this
on, for instance, their job and workplace characteristics, research and the experts and mothers who contributed to the development
the age of the baby, and parity. Future studies could also of the lactation room quality checklist. Finally, we would like to thank Stefan
Kleintjes, lactation consultant and director of the Breastfeeding Knowledge
measure other factors related to instrumental Center at the time of the study, for his invaluable help with the recruitment
organizational support for breastfeeding (e.g., break time of respondents for this study.
policies, proximity of the lactation room to one’s office,
Authors’ contributions
and occupancy rates), as well as factors related to emo- SvD conceived and designed the study, was responsible for the data
tional organizational support (e.g., positive norms), to collection, analysed and interpreted the data, and took the lead in writing
paint a more complete picture of the role that organiza- the manuscript. BW, MM, and CA provided critical feedback and helped
shape the research, analysis, and manuscript. AD and MM supervised the
tions play in facilitating the combination of breastfeeding conceptualization and design of the study. All authors read and approved
and work. Finally, future studies could investigate the the final manuscript.
impact of lactation room quality on a broader range of
Funding
dependent variables (behavioural outcomes, such as No funding was received for this research.
breastfeeding duration and the duration of the period of
women’s milk expression at work, would be especially Availability of data and materials
All of the data generated or analysed during this study are included in this
interesting). Moreover, organizationally relevant out- published article and in the supplementary information files.
comes could be included. Future studies may examine
the effects of lactation room quality on, for instance, Declarations
perceived organizational support, organizational citizen-
Ethics approval and consent to participate
ship behaviours, job satisfaction, exhaustion, and turn- This study was approved by the Ethical Committee of Psychology (ECP) of
over intentions. Elucidating how lactation room quality the University of Groningen (reference number: 16394-O). Participants were
fully informed about the study and provided their informed consent to par-
impacts on organizational outcomes is highly pertinent
ticipate in this research in the online questionnaire, in accordance with the
for organizations dealing with ever-increasing shortages ECP’s guidelines.
on the labour market due to ageing of society, and could
help to create a win-win situation for organizations and Consent for publication
Not applicable.
their breastfeeding employees.
Competing interests
The authors declare that they have no competing interests.
Conclusions
We found that lactation room quality is associated with Author details
1
Department of Psychology, University of Groningen, Groningen, The
satisfaction and perceptions relating to breast milk ex- Netherlands. 2Institute of Future Environments, Hanze University of Applied
pression at work and may thus affect the combination of Sciences, Groningen, The Netherlands. 3Department of Management &
work and breastfeeding. The ability of increasing num- Marketing, Durham University, Durham, UK. 4Faculty of Management and
Organization, The Hague University of Applied Sciences, The Hague, The
bers of mothers to combine work and breastfeeding suc- Netherlands.
cessfully offers important societal benefits. Therefore,
future studies should explore whether and how lactation Received: 19 October 2020 Accepted: 23 August 2021
room quality affects breastfeeding choices among work-
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