“Lactivism,” or activism around breastfeeding, has gained traction since the early 2000s. Businesses from Burger King to Starbucks made pledges to allow breastfeeding mothers to nurse publicly on their premises in 2003 and 2004, respectively, after breastfeeding advocates staged protests at their businesses. In 2005, about 200 women famously held a nurse-in outside of ABC studios after Barbara Walters disparaged public breastfeeding on “The View.” Breastfeeding rates have continued to increase since the turn of the century, from 34.2% of mothers breastfeeding up to 6 months of age in 2000 to 58.3% by 2017.
When I chose to breastfeed last year, I recognized the silent and not-so-silent approval of those around me. “Are you breastfeeding?” a neighbor yelled from her porch as I went on my first outdoor excursion postpartum. “Yes!” I yelled back, confident I had gained her approval. Breastfeeding is du jour now, and its trendiness makes it easy to visibly champion.
Yet, too many employers continue to neglect comprehensive support for mothers. They may champion breastfeeding and hide behind easy-to-establish perks that satiate new parents with small wins, but the buck stops at enacting more meaningful policies, from reasonable parental leave to childcare support. Perhaps nowhere is this more apparent than hospitals.
In 2011, the CDC scolded the fact that, “most hospitals don’t fully support breastfeeding.” From 2007 to 2015, the percent of births happening in hospitals designated as “baby-friendly” — so named for their adherence to the World Health Organization’s 10-step strategy to encourage breastfeeding — increased from 1.8% to 11.5%, per Baby-Friendly USA, the national accrediting agency that awards the designation. Yet, many hospitals proudly cite themselves as Baby Friendly, meaning their protocols encourage breastfeeding, regardless of whether their employees have space or time to pump.
Meanwhile, 40% of female physicians either leave medicine or become part time within 6 years of training. Numerous studies show that physicians have double the rate of infertility, higher risk of preterm labor, higher rates of postpartum depression and anxiety correlated with insufficient maternity leave, and difficulty meeting their breastfeeding goals compared to non-physician mothers, despite the fact that a substantial number of women in the general population face breastfeeding challenges too. Of those concerns, breastfeeding is just a temporary one among many. While breastfeeding does typically provide benefits to mothers and children, simply creating spaces to breastfeed does nothing to aid the physical recovery, mental health, and emotional labor required to rear a child.
The American Academy of Pediatrics recommends 12 weeks of parental leave to encourage bonding and physical healing, and to establish breastfeeding. However, a national survey of top medical schools revealed an average paid parental leave of just 5.1 weeks, with 42% of the 59 schools surveyed not offering paid parental leave at all. Women physicians are also staring down inflexible work hours and a pay gap between men and women noted to be $2 million in a 40-year career.
As grateful as I am to have been able to breastfeed my daughter with the support of my department these past 10 months, as a physician and mother, I am frustrated by how breastfeeding has been co-opted by hospitals to demonstrate solidarity with mothers in healthcare without investing in more comprehensive and meaningful changes.
At one institution, aggrieved medical trainee parents conducted a survey on trainee parental wellness showing higher levels of stress among female parent trainees compared to their male counterparts. The findings were not institution-unique: young female physicians reported miscarrying during shifts, struggling to find childcare, and inadequate parental leave that created marital stress. Within my own experience, meetings between trainees and hospital leadership to address deficits in support quickly browse over sustainable parental leave policies and subsidized childcare to focus solely on breastfeeding. “Let’s set up an app to schedule lactation rooms,” and “How about ice pack carriers?” rise to the conversational surface while discussion of other remedies fall away.
Other solutions hospitals can put in place are not a mystery — and indeed have strong precedents. As early as 1986, Sandra Burud, PhD, and Wendy Wayne, RNP, MPH, produced a study on a Bakersfield, California hospital that provided an on-site childcare center, citing the influx of women into the labor force as an important driver of policies to address increasing demands for childcare. The center was effective: it reduced turnover, absenteeism, tardiness, and increased recruitment — with a third of employees citing the center as the reason they accepted their position. Yet, more than 30 years later, a 2010 national survey of graduating pediatric residents found that only 24% had access to on-site childcare at their training institution.
Having hospitals invest in childcare makes financial sense. At the Mayo Clinic, a sick-child day care center was opened after the hospital noted it was losing a half day of work per employee per year due to absent backup childcare for ill children of employees. The saved workdays offset the center’s operating costs. Alternatively, the cost of subsidizing half the cost of childcare for a single worker with two children under 5 is just $10,000 per year. This is a nominal expense to retain parent physicians — especially as the cost of replacing a single physician is approximately $500,000. With non-profit hospitals running a surplus of as much as $800 million in revenue even during the pandemic, hospitals have both the ability and incentive to expand childcare support.
Without the support of hospitals, our childcare solution is to force families to make major sacrifices: per a 2013 Vanderbilt survey of clinical fellows and residents, 27% of resident partners reported no longer working outside the home after their first child was born.
With women now comprising the majority of U.S. medical students, we need to think beyond lactation rooms to keep mothers in healthcare and support families. Encouraging breastfeeding might be an easy step to take, but for parents in medicine and elsewhere, it’s a woefully incomplete one.
Megana Dwarakanath, MD, MEd, is a fellow in adolescent medicine in Pittsburgh.