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What support is needed prior to the designation as baby-friendly hospital?

Open AccessPublished:May 11, 2022DOI:https://doi.org/10.1016/j.cegh.2022.101045

      Abstract

      Introduction

      Breastfeeding rates remain low in Jordan. Exploring facilitators and barriers contributing to women's difficulties in juggling exclusive breastfeeding (EBF ≤ 6months) and work to achieve positive outcomes, is critical.

      Aim

      To assess EBF rate and challenges faced by mothers after returning to work at a hospital setting prior to its designation as a Baby Friendly Hospital.

      Methods

      face to face cross-sectional study using validated questioner was conducted over a one-month period on all 75 working mothers at our institute who had a new baby aged 6–48 months before the study date.

      Results

      The EBF initiating rate was 56%. The perceived identified barriers include a lack of flexibility in the work schedule for breast feeding/milk expression, a lack of pumping space, dissatisfaction with maternity leave, and concerns about support from supervisors and co-workers’ employers. The adherence to EBF among mothers who had co-worker support, self-confidence of EBF, and environmental support at the workplace differed significantly from those who did not have these conditions (p < 0.05).

      Conclusion

      Despite putting confidence in EBF and family/partner support, the mother's return to work was a significant impediment to EBF continuation.
      Mothers' adherence to exclusively nursing their infants increased if they had environmental support at work and co-worker employee support.

      Keywords

      1. Introduction

      Exclusive breastfeeding (EBF) is the practice of feeding the infant breast milk only for the first 6 months of life without any other type of food or drink, not even water.
      • Organization W.H.
      Infant and Young Child Feeding: Model Chapter for Textbooks for Medical Students and Allied Health Professionals.
      It is considered complete nutrition for infants in the first 6 months of their lives, which can prevent life-threatening infections at this period. It has been estimated that 90% of deaths among children aged below five years due to respiratory tract infections, diarrhea diseases and neonatal sepsis could be prevented through practicing EBF.
      • Chale L.E.
      • Fenton T.R.
      • Kayange N.
      Predictors of knowledge and practice of exclusive breastfeeding among health workers in Mwanza city, northwest Tanzania.
      In addition, EBF has a long-term effect on infants’ health by decreasing risks of asthma, diabetes mellitus type −1, leukemia and food allergies.
      • Binns C.
      • Lee M.
      • Low W.Y.
      The long-term public health benefits of breastfeeding.
      ,
      • Amitay E.L.
      • Keinan-Boker L.
      Breastfeeding and childhood leukemia incidence: a meta-analysis and systematic review.
      Regarding mothers' health, EBF decreases postpartum depression, delays mothers' fertility span, and decreases the risk of breast cancer.
      • Eidelman A.I.
      • Schanler R.J.
      Breastfeeding and the use of human milk.
      Breastfeeding has a positive impact on the family, society and economy, including decreasing the annual health care costs and supplemental nutritional programs; it also plays a major role in decreasing employees' absenteeism and affecting the families’ income.
      • Kuma A.
      Economic and health benefits of breastfeeding: a review.
      Early initiation of BF is defined as putting new-born to the breast within the first hour of life. The World Health Organization (WHO) recommends initiating BF with immediate skin to skin contact between the mother and her new-born after birth and allowing the mother to stay with the new-born during the first 24 h of life.
      • Organization W.H.
      Guideline: Protecting, Promoting and Supporting Breastfeeding in Facilities Providing Maternity and Newborn Services.
      There was a decline in early initiation of BF from 37.2% in 2007 to 18.6 in 2012 according to UNICEF Global database on early initiation of BF.
      • Organization W.H.
      Guideline: Protecting, Promoting and Supporting Breastfeeding in Facilities Providing Maternity and Newborn Services.
      Sadly, a similar decline was reported in EBF rate in Jordan in the first 6 months from 38% in 1995 to 26.7% in 2002, 22.7% in 2012 and 25.4% in 2019.
      • UNICEF W.
      Capture the Moment–Early Initiation of Breastfeeding: The Best Start for Every Newborn.
      ,
      • Statistics Do
      International I. Jordan Population and Family Health Survey 2017–2018.
      Breastfeeding while working is a difficult issue. Initiation, exclusivity, and continuation of EBF in working places can be facilitated by different factors including direct supervisor manger and co-worker's employees support.
      • Waite W.M.
      • Christakis D.
      Relationship of maternal perceptions of workplace breastfeeding support and job satisfaction.
      It is also facilitated by improving access to EBF information and strengthening EBF counselling efforts.
      • Senghore T.
      • Omotosho T.A.
      • Ceesay O.
      • Williams D.C.H.
      Predictors of exclusive breastfeeding knowledge and intention to or practice of exclusive breastfeeding among antenatal and postnatal women receiving routine care: a cross-sectional study.
      ,
      • Sabin A.
      • Manzur F.
      • Adil S.
      Exclusive breastfeeding practices in working women of Pakistan: a cross sectional study.
      Nevertheless, the presence of comprehensive training and monitoring programs for health workers regarding different EBF issues,
      • Chale L.E.
      • Fenton T.R.
      • Kayange N.
      Predictors of knowledge and practice of exclusive breastfeeding among health workers in Mwanza city, northwest Tanzania.
      nature of work, employee awareness of their company's breastfeeding-friendly policies,
      • Chen Y.C.
      • Wu Y.-C.
      • Chie W.-C.
      Effects of work-related factors on the breastfeeding behavior of working mothers in a Taiwanese semiconductor manufacturer: a cross-sectional survey.
      and previous EBF experience have a positive effect on mothers' EBF knowledge, attitudes, and self-efficacy.
      • Brodribb W.
      • Fallon A.
      • Jackson C.
      • Hegney D.
      The relationship between personal breastfeeding experience and the breastfeeding attitudes, knowledge, confidence and effectiveness of Australian GP registrars.
      Returning to work is responsible for early EBF cessation
      • Waite W.M.
      • Christakis D.
      Relationship of maternal perceptions of workplace breastfeeding support and job satisfaction.
      ,
      • Altamimi E.
      • Al Nsour R.
      • Al Dalaen D.
      • Almajali N.
      Knowledge, attitude, and practice of breastfeeding among working mothers in South Jordan.
      and decreasing mothers adherence to EBF practices due to lack of time to express milk
      • Brodribb W.
      • Fallon A.
      • Jackson C.
      • Hegney D.
      The relationship between personal breastfeeding experience and the breastfeeding attitudes, knowledge, confidence and effectiveness of Australian GP registrars.
      and the absence of a private dedicated place for BF g and pumping.
      • Duke P.S.
      • Parsons W.L.
      • Snow P.A.
      • Edwards A.C.
      Physicians as mothers: breastfeeding practices of physician-mothers in Newfoundland and Labrador.
      Early EBF cessation is also affected by long working hours, type of profession, family income, lack of proper knowledge and training about EBF, absence of supportive EBF organization busy work schedule, and stressful working conditions.
      • Brodribb W.
      • Fallon A.
      • Jackson C.
      • Hegney D.
      The relationship between personal breastfeeding experience and the breastfeeding attitudes, knowledge, confidence and effectiveness of Australian GP registrars.
      ,
      • Anyanwu O.U.
      • Ezeonu C.
      • Ezeanosike O.B.
      • Okike C.O.
      The practice of breastfeeding by healthcare workers in the Federal Teaching Hospital, Abakaliki, southeastern Nigeria.
      In addition, postpartum mothers who have maternal leave of less than or equal to 6 months had low BF initiation rates and have ceased EBF earlier.
      • Chuang C.-H.
      • Chang P.-J.
      • Chen Y.-C.
      • et al.
      Maternal return to work and breastfeeding: a population-based cohort study.
      Rigid hospital policies and practices, such as a short and non-negotiable period of maternity leave, inflexible shift patterns, and lack of childcare provision can affect EBF negatively.
      • Riaz S.
      • Condon L.
      The experiences of breastfeeding mothers returning to work as hospital nurses in Pakistan: a qualitative study.
      Therefore, we conducted this study to determine the prevalence of EBF among working mothers who gave birth to a new infant aged 6–48 months at the tertiary care teaching University Hospital. Furthermore, the study evaluated working mothers' confidence in continuing EBF after returning to work, as well as workplace difficulties that affected working mothers' adherence to EBF. This research helps to close one of the WHO-required research gaps by assisting various stakeholders involved in promoting, protecting, and supporting maternal EBF efforts by providing evidence-based supportive work environment needs that will improve EBF outcomes.

      2. Methods

      This cross-sectional study was conducted at Jordan University Hospital, a tertiary care teaching hospital located in Amman, Jordan, prior to the facility being designated as a baby-friendly facility. The hospital lacked breastfeeding support services such as training, rooms or space for pumping and storing breast milk at the time of the study, and not all women had access to their infants during work hours.
      It was designated as a baby-friendly facility in June 2019. (six months after the current study was completed). According to the National Labour Law in Jordan, Maternity Leave and Maternity Protection Laws. Women workers are entitled to maternity leave with full pay for ten weeks including periods of rest before and after birth, Leave after delivery shall be no less than six weeks long. In this hospital, all female employees are entitled to this maternity leave period except female physicians in training, who are entitled to two weeks only.
      All maternal employees in this hospital are entitled to 70 days of maternity leave, with the exception of the physician in training, who is entitled to two weeks. These mothers were chosen because they had not been exposed to any of the policies put in place at the hospital as it prepared to become a Baby Friendly Hospital. Participants were recruited by contacting the Hospital's Department of Human Resources. All employee mothers (n = 75) who had given birth to a new child between the ages of 6 and 48 months prior to data collection were contacted and interviewed.

      2.1 Data collection

      The Employee Perceptions of Breastfeeding Support Questionnaire (EPBS-Q) in English was adopted
      • Greene S.W.
      • Olson B.H.
      Development of an instrument designed to measure employees' perceptions of workplace breastfeeding support.
      ,
      • Greene S.W.
      • Wolfe E.W.
      • Olson B.H.
      Assessing the validity of measures of an instrument designed to measure employees' perceptions of workplace breastfeeding support.
      and slightly modified by five academics through face validation to fit our culture, piloted on 15 non-study participants, and retested for reliability with Cronbach's alpha of 0.79. The researchers conducted direct face-to-face interviews to collect data.

      2.2 Study instrument

      The Employee Perceptions of Breastfeeding Support Questionnaire consisted of closed-ended questions covering the following topics (items 1–4):
      Mother demographics and characteristics (n = 16).
      • 1.
        Exclusive Breastfeeding rate at 2 and 6 months
      • 2.
        Workplace environment characteristics and maternity leave infrastructure (dedicated breastfeeding space, availability of electric pumps) and nature of paid leave after Resources that support (n = 10) They are as follows:
        • a.
          Gender of manger/direct supervisor and Co-worker's employees. (n = 2)
        • b.
          Flexibility of time after returning to work: weekly hours, full time, part time. (n = 2)
        • c.
          Infrastructure support: the availability of electric pumps, flexible time options for pumping and/or breastfeeding, and the availability of a pumping location for breastmilk. (n = 3)
        • d.
          Maternity leave: Nature and Payment of Leave After Delivery, Satisfaction with Maternity Leave Length. (n = 3)
      • 3.
        Breast feeding practices, resources of getting information and lactation support after they return to work. (n = 13)
        • a.
          Breast feeding practices: The ability to pump or EBF at work, the ability to pump as frequently as needed, flexible time options for EBF/pumping, and women believing that there is a written policy supporting pumping milk at work. (n = 4)
        • b.
          Source of getting lactation support and information. (n = 6)
        • c.
          Source of personal support to continue EBF: source of family a supportive person to continue EBF and New-born care provider when mother at work (n = 2)
        • d.
          Had extended the maternity. (n = 1)
      4. Perceived maternal confidence and environmental factors at workplace to continue EBF after returning to work using Likert scale. The Degree of assessment included 8 items with a scale of 0–5 points (1 = never, and 5 = always). A value ≥ 2.5 was considered good.

      2.3 Data analysis

      Once the data was collected, it was managed and analyzed using IBM SPSS Statistics version 24 software (SPSS Inc. Chicago, IL, USA). The demographics and the characteristics of working mothers were determined using descriptive statistics. The Likert scale was created for variables that use the Likert type to calculate mean scores. The data then were analyzed to calculate statistical significance of each variable by using Mann-Whitney U Test and Kruskal-Wallis Fisher's. The Fisher's exact tests were applied at frequencies of less than five. The threshold for statistical significance was set at p value < 0.05.

      2.4 Ethical considerations

      The participants were informed that the answers to the questions will be completely private and will only be used for the sake of research only. They were asked to fill consent form before starting the interview. The whole process, confidentiality and preservation of data were explained to the participants before they gave their consent. The study was approved and funded by the Deanship of Scientific Research at the University of Jordan (reference grant number (1120/2019/19) and had ethical approval by the Institutional Review Board of Jordan University Hospital (reference number (67/2019/1438)).

      3. Results

      3.1 Participant's characteristics

      The ages of the participants (n = 75) ranged from 21 to 45 years, with a mean age of 32 years (SD = 4.92). The majority of participants (n = 57, 76.7%) had a bachelor's degree or higher, were married to postgraduate educated husbands (n = 62, 82.7%), lived in Jordan's middle region (93.3%), lived with their families (96%), and had a family monthly income of more than 850 dollars (n = 53, 70.7%). The majority of participants (n = 65; 86.7%) worked in health care (resident doctors, nurses, pharmacists, laboratory technicians, nutritionists, and others). Seventeen of the participants were primiparous (22.6%). Slightly less than half (48%) had a caesarean birth, and the majority (84%) gave birth to a term infant (≥37 weeks of gestation), with a male to female ratio of 1.1:1. The average length of maternity leave taken by participants was 66.6 days (SD = 14.28).
      Slightly more than half of working mothers initiate BF in the first hour (56%), Furthermore, the EBF rate at discharge was nearly complete (97.3%). Surprisingly, at two months, this rate had dropped to 34.7%, while at six months, it had dropped even further to 16% (n = 12). However, among those who had previously breastfed, more than half (n = 35, 59.3%) reported EBF for more than or equal to 6 months. Half of them (n = 42; 56%) reported starting BF within the first hour of birth. In general, 98.7% of the mothers believed that EBF is a healthy way to feed infants. Table 1 shows the demographic characteristics and EBF practices of participants.
      Table 1Demographic characteristics and breastfeeding practices of participants. (N = 75).
      Variablen (%)
      1Mother's education
       Less than Bachelor18 (24%)
       Bachelor or more57 (76%)
      2Father's education
       Less than Bachelor36 (48%)
       Bachelor or more39 (52%)
      3The nature of maternal work
       Non- health provider10 (12.3%)
       Health Provider65(86.7%)
      4Monthly Income USD
      <85022 (29.3%)
      >85053 (70.7%)
      5Working years
       ≤5 years19 (25.3%)
       6–10 years27(36.0%)
       >10 years29(38.7%)
      6Mother lives with
       Husband and Kids72 (96.%)
       Single headed household3 (4.0%)
      7Total number of children
       117 (22.6%)
       229 (38.6%)
       316 (21.3%)
       ≥413 (17.3%)
      8Mode of delivery
       Caesarean birth36 (48%)
       Vaginal birth39 (52%)
      9Gestational age at birth
       <37 weeks12 (16%)
       ≥37 weeks or more63 (84%)
      10sex of current new-born
       Male39 (52%)
       Female36 (48%)
      11First hour breastfeeding (initiation)
       Yes42 (56%)
       No33 (44%)
      12Breastfeeding at hospital discharge
       Yes73 (97.3%)
       No2 (2.7%)
      13Previous experience of ever breastfeeding for those who have more than one child (n = 59)
       Yes52 (88.1%)
       No7 (11.9%)
      14Previous experience of EBF for more than 6 months (n = 59)
       Yes35 (59.3%)
       No24 (40.7%)
      15Exclusive breastfeeding for the current infant at any time
       Yes29 (38.7%)
       No46 (61.3%)

      3.2 Characteristics of the workplace environment 75 participants

      Table 2 shows work place characteristics for the EBF mothers. Direct work supervisors' mangers were mostly females (n = 49, 65.3%) and most of the reported co-worker's employees were also females (40%). Regarding satisfaction with maternity leave duration about 72% of the working mothers were not satisfied with the duration of maternity leave.
      Table 2Characteristics of the workplace environment (N = 75).
      Variablen (%)
      Gender of manger/Direct supervisor and Co-worker's employees'
      1Gender of manger/Direct supervisor
       Male26 (34.7)
       Female49 (65.3%)
      2Gender Co-worker's employees'
       Mostly male12 (16%)
       Mostly female30 (40%)
       Equally distributed33 (44%)
      Flexibility of time after returning to work
      3Weekly working hours after returning to work
       30–39 h/week6 (8%)
       ≥40 h/week69 (92%)
      4Type of work after returning from maternity leave
       Part time –same workplace4 (5.3%)
       Full time - same workplace71 94.7%)
      Infrastructure support:
      5Availability of electric breast pump at working site*5 (6.7%)
      6Availability of pumping Place for breastmilk during work (environmental support)24 (32%)
      7Availability of flexible time options for Pumping and/or Breastfeeding place in work
       Did not pump51 (68%)
       Pump in Locked room and used space when not occupied14 (18.7%)
       Bathroom6 (8%)
       Pump in Dedicated space4 (5.3%)
      8Nature of leave after delivery
      Maternity leave69 (92%)
      Sick leave6 (8%)
      9Paid Maternity leave69 (92%)
      10Satisfaction about length of maternity leave
       Strongly dis-satisfied34 (45.3%)
       Dis-satisfied20 (26.7%)
       Somewhat satisfied12 (16%)
       Satisfied8 (10.7%)
       Strongly satisfied1 (1.3%)

      3.2.1 Resources to help mothers stick to the EBF after they return to work

      As shown in Table 3, About one quarter of the working mothers did not have any sort of EBF supportive person. Regarding where infants stay during mothers’ working hours, only 14.7% had sent their infants to a day-care Centre at the workplace.
      Table 3Breast feeding practices, resources of getting information and lactation support after they return to work (N = 75).
      Variablen (%)
      Breast feeding practices
      Women were able to pump or BF at work24 (32%)
      Women were able to pump as frequent as they needed8 (10.6%)
      Women can have flexible time options for EBF/pumping3 (4%)
      Women thought that there is a written policy supporting pumping milk at work7 (9.3%)
      Source of getting lactation support information
      Through Social network source for getting source of information and support (Facebook, What's App, etc..)47 (62.7%)
      Through Search engines for getting source of information and support (google searching engine,etc.)36 (48%)
      Through visiting appointment to Mother/baby clinic at work33 (44%)
      Through routine check-ups by GP, family doctor or pediatrician23 (30.7%)
      Through seeking advice from lactation consultant (out of their work place)23 (30.7%)
      Through Breastfeeding support group at work site11 (14.7%)
      Supportive person to continue EBF
      Mother26 (34.7%)
      Husband23 (30.7%)
      Other family members8 (10.6%)
      No support18 (24%)
      New-born care provider when mother at work
      Family member37 (49.3%)
      Daycare outside workplace15 (20%)
      Daycare in the workplace11 (14.7%)
      Daily home. Caregiver/friend12 (16%)
      Had extended the maternity-leave beyond paid maternity leave (n = 69)17 (24.6%)
      Regarding educational information sources, social media ranked as the highest among resources utilized for knowledge about EBF (n = 47. 62.7%).
      In terms of structured educational counselling on BF, less than half of participants (n = 32,42%) reported having no formal counselling about BF, while only 28% reported (n = 21) have received BF counselling and support from the nursing staff at the hospital once their infant was born). As far as EBF work support is concerned, majority of working mothers (68%) did not pump during working. Just5.3% of nursing mothers had access to a dedicated breast pumping location. Most of the participants (n = 46, 61.4%) however, indicated that a total of 60 minutes or more should be given as a break in total to allow for breastfeeding/pumping during the official working hours .

      3.2.1.1 Factors affecting breastfeeding

      Table 4 shows the mean scores of factors affecting EBF using Likert scale with a range of 1–5, where
      • Organization W.H.
      Infant and Young Child Feeding: Model Chapter for Textbooks for Medical Students and Allied Health Professionals.
      represents Never and
      • Eidelman A.I.
      • Schanler R.J.
      Breastfeeding and the use of human milk.
      represents Always. Most mothers were supported by their families (mean 3.84; SD = 0.86), and confident about their ability to successfully breastfeed (mean 4.05 ; SD = 0.83). However, they think that workplace does not support them to breastfeed during work (Mean 1.94; SD = 1), where as shown in Table 4 below, the mean score for Flexibility and adequacy of breastfeeding/pumping breaks was 2.02 (SD = 0.82), and the mean score for support by direct supervisor manger during work was 1.79 (SD = 1.03).
      Table 4Perceived maternal confidence and Environmental factors at workplace to continue EBF after returning to work (N = 75) .
      FactorMean score (SD)
      • 1.
        Mothers' confidence in maintaining successful breastfeeding after going back to work
      4.05 (0.83)
      • 2.
        Getting support and influence from family to continue EBF while mother at work
      3.84 (.86)
      • 3.
        Availability of other employee co-worker's support for breastfeeding during work
      2.48 (1.03)
      • 4.
        Availability of physical space For Pumping of Breastmilk and environmental support
      2.12 (0.83)
      • 5.
        Flexibility and adequacy of breastfeeding/pumping break in work
      2.02 (0.82)
      • 6.
        Workplace support for breastfeeding during work
      1.94 (1.00)
      • 7.
        Direct supervisor manger support for breastfeeding during work
      1.79 (1.03)
      • 8.
        Direct supervisor support manager for getting education and consultation about breastfeeding at work
      1.78 (1.15)
      5 = always, 4 = most often,3 = occasional, 2 = rarely, 1 = never
      When examined further, maternal, work place, and environmental support variables that would statistically affect EBF adherence, showed that mother's confidence about her ability to successfully breastfeed, co-worker's employees support, and environmental support at work place have a positive effect on the mother's decision to exclusively breastfeed (p less than 0.038, 0.001, 0.041) respectively (see Table 5).
      Table 5Factors influencing EBF adherence following a return to work.
      VariableP value
      Mother's education!0.232
      Previous EBF experience#0.403
      First hour BF (initiation) !0.187
      Mode of delivery !0.166
      Mother's confidence about ability to successfully continue to breastfeed 0.038
      Antenatal and postnatal BF education by healthcare provider 0.822
      Antenatal and postnatal information to facilitate EBF given by the supervisor manger 0.255
      Family support 0.519
      New-born care provider#0.186
      Work place EBF support 0.640
      Co-worker employee EBF support 0.001
      Supervisor manger support to facilitate pumping and EBF during work 0.222
      Environmental support in providing place for EBF (availability of space and equipment) 0.041
      Quality of EBF breaktime 0.086
      ! Chi-square.
      # Chi-square (Fischer's Exact Test).
      ♦ Mann-Whitney U Test and Kruskal-Wallis Test.
      On the other hand, maternal education, previous EBF experience, BF initiation, mode of delivery, ante-natal and post-natal education by health-care provider, family support, sex of new born, workplace support, and quality of BF break didn't have any significant relationship with adherence to EBF.

      4. Discussion

      To the best of our knowledge, this is Jordan's first study as an example of upper middle income country to report EBF rates at 6 months as well as EBF challenges among health and non-health care working mothers in a hospital setting using validated questionnaire. There is a paucity of empirical regional and international research on the prevalence and barriers to EBF among working lactating mothers. According to the current study's findings, while working mothers' awareness of EBF is nearly complete (98.7%), exclusive BF practice at six months was low (16%). This is lower than the Jordanian Demographic Health Survey 2017–2018, which found only 25.4% of mothers at the population level continued EBF for six months.
      • Statistics Do
      International I. Jordan Population and Family Health Survey 2017–2018.
      The Healthy People 2020 initiative report states that the goal is for 60.6% of mothers to continue EBF for 6 months,
      • People H.
      which is far from the intended goal. This study describes additional barriers that prevented lactating working mothers from continuing to breastfeed exclusively. Of these reported barriers, short maternity leave that was a driving factor in early weaning BF infants in the current study and other studies, such as African American women in the Detroit area of the United States and female employees of the Sydney South West Area Health Service who return to work.
      • Johnson A.M.
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      Overcoming workplace barriers: a focus group study exploring African American mothers' needs for workplace breastfeeding support.
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      Female employees' perceptions of organisational support for breastfeeding at work: findings from an Australian health service workplace.
      This study found that the presence of co-worker and direct supervisor manager support was associated with significantly higher EBF rates (P 0.05). These findings were consistent with the findings of another study, which found that managers can influence EBF decisions by controlling BF policies or informally supporting or discouraging working mothers.
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      Barriers and facilitators for breastfeeding among working women in the United States.
      Possible hindrances to the sustained practice of EBF among working mothers, as indicated by this study, included lack of BF facilities and short or lack of official break time. In other words, the demand to perform official duties is difficult with the obligation to breastfeed at the same time.
      According to research that studied and evaluated the legislation of 193 United Nations member nations for information on BF breaks and maternity leave guarantees, working moms have not attained their full EBF and health potential because they are not permitted to breastfeed at work.
      • Atabay E.
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      • et al.
      Facilitating working mothers' ability to breastfeed: global trends in guaranteeing breastfeeding breaks at work, 1995-2014.
      According to this study, adherence to EBF differed significantly when there was environmental support versus when there was none (p = 0.041), implying that it is critical to implement breastfeeding-friendly policies at work to ensure that lactating mothers have access to private, clean spaces to express their breast milk via pumping.
      • Iellamo A.
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      Working mothers of the World Health Organization Western Pacific offices: lessons and experiences to protect, promote, and support breastfeeding.
      In the current study, the majority of nursing mothers (66.7%) did not pump at all, and those who did (8%) pumped their breast milk in the toilet room. The importance of early initiation of BF is well recognized.
      • Iellamo A.
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      Working mothers of the World Health Organization Western Pacific offices: lessons and experiences to protect, promote, and support breastfeeding.
      In the current study, around half (56%) the participants-initiated BF within the first hour of delivery.
      According to the Jordan Population and Family Health Survey, 2017–2018, 67% of the new-borns to mothers with a secondary level of education were breastfed in their first hour of life, compared to 80% of mothers with no education.
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      Dads make a difference: an exploratory study of paternal support for breastfeeding in Perth, Western Australia.
      In this context, the findings revealed that, despite the fact that all moms had a higher education level, a surprising 56% of them commenced breastfeeding their infants within the first hour. This decreased rate of first-hour BF initiation in comparison to the overall educated population is most likely related to our respondents' high C-section rates (48%). Possible explanation: caesarean birth is connected with postoperative care routines that might delay or disrupt contact between the mother and her new-born in the postpartum period, especially in a non-baby friendly environment. According to a study conducted in Northern Jordan, women (both employed and unemployed) with mothers who had more children and were experienced in EBF were more likely to exclusively breastfeed.
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      • Khasawneh A.A.
      Predictors and barriers to breastfeeding in north of Jordan: could we do better?.
      This contradicts our study's findings, which found no significant difference between previous EBF experience and multi-party with continuing EBF. One possible explanation is that all of the participants in this study were working mothers, and factors related to work had a greater impact on the rate of EBF than previous experience. Approximately 42% of our respondents never discussed EBF or provided educational materials to them during their pregnancy. Furthermore, approximately one-third of them (28%) received BF education at the hospital during the postpartum period. The lack of a BF education program during the prenatal, natal, and postnatal periods may explain why some lactating mothers rely on informal resources, which may be inaccurate and untrustworthy. In this regard, it was observed in Jordan that moms who commenced BF before discharge were more likely to be employed, have a normal vaginal birth, and have had antenatal or post-birth BF education.
      • Safadi R.
      • Badran E.
      • Sa’d Basha A.
      • Jordan S.
      • Ahmad M.
      Initiation and continuation of breastfeeding among Jordanian first-time mothers: a prospective cohort study.
      In agreement with a prior recent study,
      • Badran E.F.A.N.
      • Shamasneh A.
      • Braik L.M.
      • Allehdan S.S.
      • Tayyem R.F.
      I. Nfluence of online sources and social networking sites on breastfeeding rate and practices in Jordan.
      social networking sites were the most commonly used resource in this context (62.7%), followed by online resources (48%)
      This study report that mothers who were confident in their ability to successfully breastfeed had significantly higher adherence to EBF at 6 months (p = 0.038).This result is congruent with a study that was conducted on working mothers in Dengkil Health Clinic in Selangor, Malaysia, that found that mothers’ beliefs and self-efficacy are important to determine practice of EBF in the work place.
      • Rashid A.A.
      • Shamsuddin N.H.
      • Ridhuan R.D.A.R.M.
      • Amalina N.
      • Sallahuddin N.K.D.
      Breastfeeding practice, support, and self-efficacy among working mothers in a rural health clinic in Selangor.

      5. Strengths and limitations

      The study's strength is its contribution to a better understanding of the influences of EBF among working mothers, as well as the barriers that prevent them from continuing to breastfeed. The current study's findings provided critical information that will assist stakeholders, policymakers, and health care professionals in developing and implementing programs to improve EBF outcomes. Despite its contributions, this study has some significant limitations that should be considered when interpreting the findings. To begin, the sample consisted of 75 working mothers. Because participants were chosen in one health institute, generalizability is limited. Second, because of their work commitments, some participants may have been bored by our questionnaire's 54 questions. We may also consider recall bias because we asked mothers to recall events that occurred within the last six - 48 months. The response in the mothers will differ widely due to difficulty in recollecting facts and different environmental situation in the mothers of older children.

      6. Implication for practice

      This study disclosed a variety of modifiable variables that can affect EBF rates among working mothers. The rate of EBF can be increased in communities through laws and policies. There is a desperate need to improve managers' and co-workers’ employee support as he or she facilitates a better environment, infrastructure, and educational programs, as well as providing maternity leave extension and part-time employment for the first year after giving birth. Furthermore, Collaboration among various stakeholders, including Health Services, the Ministry of Health, the Department of Employment and Labour Relations, and all heads of professional organizations/institutions, may result in breastfeeding-friendly policies and EBF -sensitive work environments and infrastructures that promote BF outcomes.

      7. Conclusion and recommendations

      While nearly all mothers are aware of and confident in their ability to continue EBF with the support of their family, partner and co-workers many report EBF cessation when they return to work due to workplace barriers that are beyond their control. This was offset by unsatisfied needs at their workplace, which hampered their EBF practice. These prerequisites include a lack of work site, infrastructure, and environmental support, as well as insufficient maternity leave and full-time employment status upon their return. Further steps for creating BF friendly supportive worksites are needed to enhance EBF -related attitudes at the workplace. This can be achieved by engaging hospital managers, co-worker's employees, prenatal and postnatal educators and social network sites through creating trustable BF groups. Future research is recommended to help to develop guidelines and policies that embrace EBF promotion programs at the national level.

      Availability of data and materials

      The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

      Ethics approval and informed consent

      The study protocol was approved by the Institutional Review Board at Jordan University Hospital (Ref: 67/2019/1438) and dean ship of scientific research (Ref: 1120/2019/19).The relevant procedures were carried in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) as well as with the principles of Good Clinical Practice issued by the Declaration of Helsinki (2004; Tokyo) and its later amendments. Beth Olson from the University of Wisconsin-Madison provided us with the validated Research tool for our team, which we modified slightly to fit our culture.

      Participants consent form

      Informed consent was obtained from all the participants before inclusion in the study.

      Declaration of participants consent

      The authors certify that they have obtained all appropriate participants consent forms.

      Authors’ contributions

      Eman F. Badran, Reema Safadi, and Raeda Al-Qutob and Du'a Al-Maharma conceived designed and supervised the project.
      Aseel Qutaishat, Deema Masarweh, Yazeed Bani Hamad, Ahmad Khamees, and Asmaa Shabsough shared in Acquisition of data and participated in planning the research tool, and collecting the data.
      Reema Safadi, Du'a Al-Maharma, and Raeda Al-Qutob, reviewed the research tools and final manuscript.
      Basheer Khamees participated in statistical designee and statistical analysis.
      Aseel Qutaishat, Deema Masarweh and Ahmad Khamees contributed to the interpretation of the results with supervision from Prof Basheer Khamees and. Du'a Al-Maharma.
      Eman Badran, Aseel Qutaishat, Deema Masarweh, Yazeed Bani Hamad, Ahmad Khamees, and Asma Shabsough took the lead in Drafting the manuscript.
      Revising the manuscript critically for important intellectual content: Eman F. Badran, Reema Safadi, and Raeda Al-Qutob.
      All authors provided critical feedback, participated in the research and analysis, and approved the final manuscript.

      Financial support and sponsorship

      Nil.

      Declaration of interest statement

      Alle authors have declared that they have no potential conflicts of interest related to the research, authorship, and/or publication of this article.
      ‘What is already known about this topic?
      • Returning to work is to blame for early EBF cessation due to a variety of challenges.
      • Rigid hospital policies and practices can have a negative impact on breast feeding.
      • women who do work and breastfeed often lack support.
      ‘What does this article add?
      • Identify obstacles that will help stakeholders involved in promoting baby friendly hospital designation by providing specific evidence-based supportive workplace needs that will improve EBF outcomes.

      Declaration of competing interest

      Alle authors have declared that they have no potential conflicts of interest related to the research, authorship, and/or publication of this article.

      Acknowledgment

      We would also like to thank and appreciate to all participating mothers working at the Jordan university hospital for their assistance. We would like to extend our thanks and gratitude and appreciation to Beth Olson and her research team from University of Wisconsin-Madison for their permission to use the research tool in order to create ours.

      Appendix A. Supplementary data

      The following is the Supplementary data to this article:

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