breastfeeding experiment

• Research article
• Open access
• Published: 24 July 2019

The effect of a breastfeeding support programme on breastfeeding duration and exclusivity: a quasi-experiment

• S. A. van Dellen 1 , 2 ,
• B. Wisse 1 , 3 ,
• M. P. Mobach 2 , 4 &
• A. Dijkstra 1  

BMC Public Health volume  19 , Article number:  993 ( 2019 ) Cite this article

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Breastfeeding has important positive long-term health consequences for infants and mothers. The World Health Organization recommends that all infants should be exclusively breastfed for six months or longer, and advises continuation of breastfeeding for two years or beyond. However, these recommendations are not met in many countries. This study examined whether a comprehensive, evidence-based breastfeeding intervention, the Breastfeeding Support Programme (BSP), promotes prolonged duration and exclusivity of breastfeeding among its participants.

A quasi-experimental design was used to compare breastfeeding duration and exclusivity in the BSP group ( N  = 66) to breastfeeding duration and exclusivity in a control group ( N  = 72). Participants who followed the BSP were provided with 6 consults delivered by a lactation consultant. The consults started during pregnancy and continued up until 10 weeks after delivery. Participants in the control group did not follow the BSP. Pretest and posttest questionnaires were administered through the internet. A Cox proportional hazards regression analysis was used to estimate adjusted hazard ratios (HR) and 95% confidence intervals (CI) for cessation of any and exclusive breastfeeding, while controlling for differences at baseline.

The effect of the BSP on survival rates for any and exclusive breastfeeding were significant while controlling for differences between the two groups at baseline (respectively HR = 0.34, p  < .001 [95% CI = 0.18–0.61] and HR = 0.46, p  < .001 [95% CI = 0.29–0.72]). Among mothers in the BSP group there was on average 66% less risk of cessation of any breastfeeding and on average 54% less risk of cessation of exclusive breastfeeding at any point in time compared to those in the control group.

Conclusions

The BSP appears to be an effective means to delay cessation of any and exclusive breastfeeding cessation and therefore to increase breastfeeding duration and exclusivity. This is an important finding, because earlier cessation of breastfeeding than desired is a common problem in many countries. Future research into the effectiveness of the BSP could consider random assignment to conditions and test the effectiveness of the intervention in other populations to investigate further whether wide-scale implementation of this intervention could be useful to promote breastfeeding.

Peer Review reports

Due to the development and subsequent commercialization of infant formula in the eighteenth, nineteenth and twentieth centuries, there has been a strong decline in breastfeeding rates worldwide [ 1 , 2 ]. However, an increasing body of research shows that breastfeeding has important positive long-term health consequences for infants and mothers. A 2016 meta-analysis of research into the health consequences of breastfeeding for mothers and children concluded that infants who are breastfed for longer periods have lower infectious morbidity and mortality, fewer dental malocclusions and higher intelligence than infants who are not breastfed or breastfed for shorter periods [ 2 ]. Furthermore, breastfeeding may also protect against sudden infant death syndrome (SIDS), decrease the risk of necrotising enterocolitis (NEC) for premature babies, and protect children against overweight and diabetes later in life [ 2 ]. The beneficial effects of breastfeeding for mothers include protection against breast cancer, improved birth spacing, and potential protection against diabetes and ovarian cancer [ 2 ]. Moreover, it was estimated that scaling up breastfeeding to near universal levels could prevent approximately 823,000 child deaths and 20,000 deaths due to breast cancer worldwide annually. Breastfeeding therefore plays an important role in public health for mothers and children around the globe ([ 2 ]; also see [ 3 , 4 , 5 , 6 ]). As a consequence increasing the prevalence and duration of breastfeeding are important health goals in most nations. The World Health Organization (WHO) recommends that all infants should be exclusively breastfed (i.e., receive only breast milk and no other food or drink) for the first 6 months of life to achieve optimal growth, development, and health. Infants should receive complementary foods from 6 months, while breastfeeding should be continued for up to 2 years or beyond [ 7 ]. However, these recommendations are not met in many countries. Recent research by the WHO found in a sample of 194 nations, that only 40% of children younger than 6 months are breastfed exclusively [ 8 ]. Research findings also suggest that many mothers would like to breastfeed for longer, and that approximately 60% of US mothers stopped breastfeeding earlier than they desired [ 9 ]. Mothers stopped breastfeeding prematurely mainly because they had concerns about maternal or child health and concerns about the breastfeeding process (e.g., lactation and milk-pumping problems). The researchers concluded that professional support could help to address these challenges and help mothers to attain their breastfeeding goals [ 9 ]. Although some women cannot breastfeed for physical or medical reasons [ 10 ], many women could benefit from breastfeeding support.

In the Netherlands, breastfeeding rates also leave ample room for improvement. Although Dutch breastfeeding rates have gradually increased in the past decades, and 80% of Dutch mothers initiate breastfeeding, only 39% of Dutch babies are exclusively breastfed at 6 months Footnote 1 , according to a recent study [ 11 ]. Moreover, many women in the Netherlands report difficulties with breastfeeding and do not maintain the practice for as long as they intended [ 12 ]. In the past decades, national campaigns, emphasising the health benefits of breastfeeding, have been developed to extend the duration of breastfeeding [ 13 ]. As part of these campaigns, virtually all hospitals and maternity organisations in the Netherlands have received Baby Friendly Hospital Initiative (BFHI) certification [ 14 ], as developed by WHO in 1991 [ 15 ]. With regard to breastfeeding recommendations, Dutch guidelines initially followed the WHO guidelines, advising to breastfeed exclusively for at least six months. However, in 2011 the Dutch breastfeeding recommendations were adjusted, in an attempt to prevent the development of food allergies in children [ 16 , 17 ]. Since 2011 it is therefore advised that mothers should breastfeed for at least six months [ 18 ], but should start with complementary foods when the baby is between 4 and 6 months old, if possible [ 19 ]. Therefore, exclusive breastfeeding until six months is no longer recommended in the Dutch breastfeeding guidelines; also no mention is made of continuation of breastfeeding for two years or beyond. These deviating national guidelines may partly explain why the prevalence of (exclusive) breastfeeding in the Netherlands is relatively low, and why breastfeeding support and education is especially important in the Netherlands.

Systematic reviews and meta-analyses on breastfeeding promotion interventions have shown that breastfeeding education and/or support can effectively increase breastfeeding rates [ 20 , 21 , 22 , 23 , 24 , 25 , 26 ]. For instance, a recent meta-analysis, including 27 randomized controlled trials (RCT’s) and 36,051 mothers, found that breastfeeding support interventions aiming to increase exclusive breastfeeding for 6 months were indeed effective. A subgroup analysis looking into the effects of different types of interventions found that a BFHI intervention, an intervention combining education and support, a professional provider led intervention, an intervention that has a protocol available for the provider training program, and an intervention that takes place both during the prenatal and postnatal periods, all increased the rate of exclusive breastfeeding for 6 months [ 26 ]. Likewise, a recent systematic review, focussing specifically on professional support interventions, found that interventions spanning from pregnancy to the postnatal period were more effective than interventions that took place in a shorter period, and that interventions using various methods of education and support were more effective than interventions concentrating on a single method [ 22 ]. Moreover, it was found that during pregnancy, the BFHI as well as teaching combined with support were effective approaches. During the postnatal period effective approaches included home visits, telephone support, and the use of breastfeeding centres combined with peer support [ 22 ].

The current study examines the effectiveness of a comprehensive, evidence-based, professional support intervention for breastfeeding that was implemented in the Netherlands: the Breastfeeding Support Program (BSP). The BSP was developed by two International Board Certified Lactation Consultants (IBCLC), based on theoretical findings and practical experiences. The Theory of Planned Behaviour (TPB) [ 27 ] constitutes the theoretical framework for the BSP. The TPB states that human behaviour is predicted by three kinds of considerations: a person’s general evaluation of a given behaviour (attitude); a person’s beliefs about how relevant others will view the behaviour in question (subjective norm); and a person’s perceived ease or difficulty in performing the behaviour (perceived behavioural control). The attitude, subjective norm and perceived behavioural control combined lead to the formation of a behavioural intention to display a certain behaviour. As a general rule, the more favourable the attitude and subjective norm, and the higher the perceived control, the stronger the person’s intention to perform the behaviour in question. Finally, intention is assumed to be the immediate antecedent of behaviour. The TPB is a well-known framework for designing behavioural change interventions [ 28 ], and several studies have shown that the TPB can be successfully applied to breastfeeding [ 29 , 30 , 31 , 32 ].The BSP applies the TPB by aiming to influence positively a mother’s attitude towards breastfeeding, the subjective norm and her perceived behavioural control. The BSP is not only based on the TPB, but also integrates the empirical research findings from systematic reviews of support interventions for breastfeeding promotion [ 22 , 26 ], suggesting that the most effective interventions are usually delivered by well-trained professionals, combine education and support, and are long-term and intensive, spanning both the prenatal and postnatal period. Although evidence suggests that all these separate elements should increase the effectiveness of a breastfeeding intervention [ 22 , 26 ], studies that investigate their combined effect are still largely lacking.

The research question we will answer in this study is: do the mothers enrolled in the BSP engage in prolonged breastfeeding in terms of duration and exclusivity compared to mothers in a control group? Based on the accumulated research into the effectiveness of breastfeeding promotion interventions [ 20 , 21 , 22 , 23 , 24 , 25 , 26 ], and on studies showing the successful application of the TPB to breastfeeding [ 29 , 30 , 31 , 32 ], we hypothesized that the BSP is an effective intervention in principle. A test of this hypothesis further facilitates the elimination of unsound or ineffective practices in favour of those that have better outcomes, and as such this study aims to support the implementation of evidence-based practice.

Design and recruitment

The study had a quasi-experimental design (with one experimental group and one control group) with pre- and posttest. This design is common in studies aiming to establish the effectiveness of health-related interventions and is considered to be of relatively high quality in the hierarchy of quasi-experimental study designs [ 33 ]. Notably, a quasi-experiment may be preferable over a true experiment (or Randomized Controlled Trial; RCT) for testing the effectiveness of interventions, when randomisation is considered to be not ethical, expedient, or possible [ 33 , 34 , 35 ], or to create unwanted bias (e.g., low compliance, selective attrition, and questionable ecological validity) [ 36 ]. For the current study, we opted for a quasi-experimental design because randomisation was impractical (a Dutch health insurance company offered the BSP to their clients at the time of the research; we were able to carefully monitor the effects, but had no possibility to intervene), and moreover randomisation was considered to limit the ecological validity (women usually make a personal choice to participate in a breastfeeding programme or not; limiting personal choice could create unwanted bias in testing the effectiveness of such a programme). Because in a quasi-experiment allocation to conditions is not randomized, treatment and control groups may not be comparable at baseline. That is, selection effects can lead to pre-existing differences between treatment groups, which can pose a threat to internal validity [ 35 ]. We therefore thoroughly screened and controlled for a broad range of possibly confounding factors (see control variables in the Measurements Section).

Our experimental group consisted of pregnant women who were planning to breastfeed and who made a personal decision to enrol in the BSP (supported by their health insurance) on the BSP website. These women were recruited for this study through the enrolment form for the BSP, where they were asked to indicate if they were interested in participating in a study on breastfeeding experiences. The control group consisted of an independently recruited cohort of pregnant women with breastfeeding intentions, who were recruited through primary care facilities (obstetrician/general practitioner). At those facilities we made an enrolment form available for women who were planning to breastfeed. On this form the women could indicate whether they were interested in participating in a study on breastfeeding experiences. Thus, although women in the intervention group and the control group were recruited separately, they all were pregnant, they all planned to breastfeed and they all self-enrolled on the basis of the same written information. Recruitment for this study was conducted in the period of March 2013 to December 2014 Footnote 2 . Final inclusion criteria were (1) being pregnant; (2) planning to breastfeed; (3) having access to the internet; (4) having singleton gestation; (5) non-missing data for breastfeeding duration.

All the women who indicated an interest in participating in the study received an e-mail with further instructions and a link to complete an online pretest questionnaire. Invitations to complete the pretest questionnaire were sent from month 6 of pregnancy, making sure participants had some time to consider their breastfeeding plans. Invitations for the posttest questionnaire were sent from 28 weeks after the due date, thus making sure that at least 26 weeks had passed since delivery (health policy in the Netherlands aims to achieve that delivery is never more than 2 weeks after the due date). Both the pretest and posttest questionnaires emphasized that participation in the study was voluntary, that responses would be treated confidentially, that results would be reported anonymously, and that it was possible to withdraw from the study at any time without penalty. To encourage participation in the study, prizes were raffled among the participants. The pretest and posttest questionnaires were linked with the use of participants’ e-mail addresses. All the participants provided their informed consent. The research was approved by the Ethical Committee of Psychology of the University of Groningen, the Netherlands.

Intervention

The BSP tries to increase the proportion of mothers who breastfeed exclusively for six months or longer by positively influencing 1) the mother’s attitude towards breastfeeding (by focussing on the positive effects of exclusive breastfeeding for 6 months or longer for mother and child), 2) the subjective norm (by explicitly involving the father and by forming a reliable source of support and positive messages about breastfeeding throughout the programme) and 3) the mother’s perceived behavioural control (by providing information, encouragement and practical support to improve breastfeeding skills). As such, the BSP uses most of the behavioural change techniques proven to be effective in health interventions [ 37 ]. The BSP combines both education and support, extends from pregnancy to the postnatal period, and uses a protocolled series of six individual consults delivered by an IBCLC.

The protocol for the six consults within the BSP is as follows. 1) The programme begins with an intake consult at the lactations consultant’s office during pregnancy. This consult incorporates the following topics: medical history and breast check-up, breastfeeding experience, information about breastfeeding effects on mother and child, advice about breast care during pregnancy, information about the breastfeeding process, food, smoking, alcohol and drugs, the provision of written information about breastfeeding, and the opportunity to discuss questions and problems. 2) The second consult is held during the first week after delivery, either in the hospital or at the family home and focusses on the breastfeeding process as experienced up to that point. 3) The third consult is conducted by telephone on day 14 after delivery to discuss the breastfeeding process. 4) The fourth consult is again conducted by telephone on day 28 after delivery to discuss the breastfeeding process. 5) The fifth consult is held five weeks after delivery at the lactations consultant’s office and consists of a weighing of the baby, discussion of possible problems, breast check-up, and preparation for return to work if applicable. It also provides an opportunity to ask other questions. 6) The sixth and final consult is held 10 weeks after delivery by telephone and focuses on further support for returning to work (if applicable) and other possible questions and issues that mothers may wish to discuss. The number of in-person consults is fixed, but the timing of the consults can be adjusted if necessary (e.g., in case of urgent breastfeeding problems). Moreover, for the duration of the BSP, participants can always contact their IBCLC by phone for questions. The length of the BSP (until 10 weeks after the baby’s birth) is appropriate because most mothers who discontinue breastfeeding early do so during the first three months, mostly due to lactation problems [ 27 ]. Before the start of the program a day-long calibration session was organized for all the participating IBCLCs. The protocol was discussed and an example case was used to agree on its practical application. The fact that all lactation consultants in the BSP were IBCLCs contributed to the consistency of the information.

Measurements

Dependent variables.

Two dependent variables were used to assess the effectiveness of the intervention: 1) duration of any breastfeeding and 2) duration of exclusive breastfeeding. We measured these variables by asking three questions in the posttest questionnaire: ‘How many weeks old was your baby when he/she received breast milk for the last time?’ (breast milk was defined in the questionnaire as ‘mother’s milk from the breast or expressed breast milk’), ‘How many weeks old was your baby when he/she received artificial feeding for the first time?’ and ‘How many weeks old was your baby when he/she received solid food for the first time?’

Control variables

To screen and control for the comparability of participants in the BSP group and the control group, a total of 45 possible confounders was measured at pretest and at posttest (perinatal variables). We arrived at the list of 45 potential confounders after scrutinizing review articles which focus on the determinants of the duration and exclusivity of breastfeeding [ 11 , 38 , 39 , 40 , 41 ]. These possible confounders included psychosocial variables (attitudes, subjective norms, perceived control, prenatal intention, breastfeeding knowledge, maternal work conditions, social and professional support for breastfeeding and/or artificial feeding), demographic variables (age, level education, relationship status and nationality), and biomedical variables (parity, method of delivery, BMI-index, alcohol usage and smoking). To be exhaustive, maternal or paternal asthma, eczema, hay-fever or other allergies were added to this list. It is explicitly advised in the Netherlands to breastfeed babies at increased risk of these health issues [ 42 , 43 ], which might result in increased motivation to breastfeed. See Additional file  1 for a complete overview of the 45 possible confounders we measured, including a description of the operationalization.

Comparability between the BSP group and the control group was assessed by comparing both groups on the 45 possible confounding variables by means of univariate analyses. Because the data on breastfeeding duration were censored (some of the mothers were still breastfeeding or breastfeeding exclusively at the time of the post-test) Survival Analysis was most suited for the analysis [ 44 ]. Cessation of any and exclusive breastfeeding were taken as the final events for the analysis. The week the infant received breast milk for the last time was considered to be the time to event for cessation of any breastfeeding. The week the infant received artificial feeding or solid food Footnote 3 for the first time was considered to be the time to event for cessation of exclusive breastfeeding. First, Kaplan-Meier plots were used to assess survival for any breastfeeding and exclusive breastfeeding in the BSP and the control group, without controlling for differences between the two groups at baseline. Second, a Cox proportional hazards regression analysis was used to estimate adjusted hazard ratios (HR) and 95% confidence intervals (CI) of breastfeeding cessation, controlling for variables that differed between both groups at baseline. Visual examination of survival plots was carried out to check the proportional hazard assumption [ 45 ]. All analyses were performed using the Statistical Package for the Social Sciences (SPSS Version 23). See Additional file 2 for the data set; see Additional file  3 , Additional file 4 , and Additional file 5  for the analyses performed.

Response and attrition

A total of 234 women enrolled in the BSP programme (Fig.  1 ). Of these 234 women, 112 (48%) indicated that they were interested in participating in our study on breastfeeding experiences. In the control group 133 women indicated interest in participation. All of these 245 women received an invitation to participate. We obtained a final sample of 138 women (66 mothers in the BSP group and 72 mothers in the control group), due to non-response at the pretest ( N  = 28 in the BSP group, N  = 40 in the control group) or posttest ( N  = 12 in the BSP group, N  = 18 in the control group), missing data on breastfeeding duration ( N  = 5 in the BSP group, N  = 2 in the control group) or multiple births ( N  = 1 in the BSP group, N  = 1 in the control group). The response rates in the BSP group and the control group did not differ significantly in the pretest (75.0% versus 69.91%, χ 2 (1) = 0.781, p  = .377) or the posttest (58.9% versus 54.1%, χ 2 (1) = 0.568, p  = .451).

The attrition rates in the BSP group and the control group

Sample description

In the pretest sample 3.5% of the participants reported a lower level education, 22.1% a medium level education and 74.4% a higher level education, and the average age was 31.5 years ( SD  = 4.39). In the posttest sample 1.4% of the participants reported a lower level education, 18.8% a medium level education and 79.7% a higher level education, and their average age was 31.7 years ( SD  = 4.29). The women who dropped out at follow-up had reported mainly lower or medium level education, increasing the proportion of higher educated women in the posttest. Furthermore, the mean age at the time of delivery increased by 0.2 year from pretest to posttest, meaning some of the younger women dropped out. Finally, breastfeeding initiation was almost universal (99.3%) and did not differ significantly between the BSP group and the control group (100% versus 98.6%, χ 2 (1) = 0.92, p  = .337).

Differences between the two groups at baseline

To check for comparability between the BSP group and the control group, the two groups were compared on 45 possibly confounding variables (see Additional file 1 ) by means of univariate analyses. Eleven differences between the BSP group and the control group were found at baseline with a p -value lower or equal to .10 (see Table  1 ). The mothers in the BSP group experienced more social support for artificial feeding ( p  = .045), had a lower perceived control for breastfeeding ( p  = .039), and would find it more difficult to breastfeed in various situations than the mothers in the control group at baseline ( p  = .062). Furthermore, the mothers in the BSP group were more likely to have been first-time mothers than the mothers in the control group ( p  = .010), had on average less breastfeeding experience ( p  = .003) and had experienced previous breastfeeding less positively than the mothers in the control group at baseline ( p  < .001). The mothers in the BSP group planned to work more hours than the mothers in the control group after their babies were born ( p  = .041). They were also better educated than mothers in the control group ( p  = .002) and the same was true of their partners ( p  = .036). Finally, the mothers in the BSP group were more likely to suffer from asthma ( p  = .011) and were more likely not to have been born in the Netherlands than the mothers in the control group ( p =  .039). A mixed picture emerges: compared to the control group, mothers in the BSP group were mostly characterized by factors which can be expected to have a negative effect on breastfeeding duration and exclusivity (such as experiencing more social support for artificial feeding, having a lower perceived control for breastfeeding, finding it more difficult to breastfeed in various situations, being more likely to be a first-time mother, having less and less positive experiences with previous breastfeeding, planning to work more working hours after the baby is born), but also by some factors which can be expected to have a positive effect on breastfeeding duration and exclusivity (such as being better educated and having better educated partners, a higher asthma incidence and being more likely not to have been born in the Netherlands). The differences between the two groups at baseline were statistically controlled for by including these variables as covariates in the Cox proportional hazards regression analysis.

The effects of the BSP without controlling for differences between groups

First, we used Kaplan-Meier plots to compare the survival curves in the BSP and the control group for duration of any breastfeeding and duration of exclusive breastfeeding, without controlling for differences between the two groups (Figs.  2 and 3 ). Breastfeeding survival rates were significantly higher in the BSP group than in the control group for any breastfeeding (log-rank test: χ 2 (1) = 4.79, p  = .029) and for exclusive breastfeeding (log-rank test: χ 2 (1) = 4.07, p  = .044). The survival curves showed that mothers in the BSP group had a higher probability of breastfeeding and breastfeeding exclusively than mothers in the control group at each point in time. The mean duration of any breastfeeding was 25.08 weeks in the BSP group versus 20.51 weeks in the control group and the mean duration of exclusive breastfeeding was 15.52 weeks in the BSP group versus 12.81 weeks in the control group.

Kaplan-Meier survival estimates for duration of any breastfeeding

Kaplan-Meier survival estimates for duration of exclusive breastfeeding

The effects of the BSP when controlling for differences between groups

A Cox proportional hazards regression analysis was performed, including variables which differed between the two groups at baseline Footnote 4 , to correct for potential confounding (see Table 1 ). The effect of the BSP on survival rates for any breastfeeding was significant while controlling for differences between the two groups at baseline (HR = 0.34, p  < .001 [95% CI = 0.18–0.61]). The effect of the BSP on survival rates for exclusive breastfeeding was also significant while controlling for differences between the two groups at baseline (HR = 0.46, p  < .001 [95% CI = 0.29–0.72]). See Table  2 . The HRs of 0.34 for any breastfeeding and 0.46 for exclusive breastfeeding indicate that there was on average 66% less risk of cessation of any breastfeeding and on average 54% less risk of cessation of exclusive breastfeeding at any point in time among mothers in the BSP group compared to those in the control group.

The effects of the BSP among nulliparous women only

To further strengthen the evidence for the effectiveness of the BSP, we attempted to create more comparable groups at baseline by selecting first-time mothers only. This sample of nulliparous women consisted of 72 participants in total ( n  = 42 in the BSP group, and n  = 30 in the control group). To check for comparability between the BSP group and the control group, the two groups were again compared on 45 possibly confounding variables (see Additional file 1 ) by means of univariate analyses. Among the nulliparous women, six differences between the BSP group and the control group were found at baseline with a p -value lower or equal to .10. The mothers in the BSP group experienced less professional support for breastfeeding (by their obstetrician or course instructor) ( p  = .027), had experienced less stress during the pregnancy ( p  = .069), planned to work more hours after their babies were born ( p  = .017), and planned for a longer pregnancy leave than the mothers in the control group ( p  = .081). Finally, they were better educated than mothers in the control group ( p  = .004) and the same was true of their partners ( p <  .001). First, we used Kaplan-Meier plots to compare the survival curves in the BSP and the control group for duration of any breastfeeding and duration of exclusive breastfeeding, without controlling for differences between the two groups. Breastfeeding survival rates were significantly higher in the BSP group than in the control group for any breastfeeding (log-rank test: χ 2 (1) = 7.85, p  = .005) and for exclusive breastfeeding (log-rank test: χ 2 (1) = 13.63, p  < .001). The survival curves showed that mothers in the BSP group had a higher probability of breastfeeding and breastfeeding exclusively than mothers in the control group at each point in time. The mean duration of any breastfeeding was 27.52 weeks in the BSP group versus 19.45 weeks in the control group, and the mean duration of exclusive breastfeeding was 16.76 weeks in the BSP group versus 10.50 weeks in the control group. Finally, a Cox proportional hazards regression analysis was performed, including variables which differed between the two groups at baseline, to correct for potential confounding effects. The results show that the effect of the BSP on survival rates for any breastfeeding was still in the expected direction, but no longer significant (HR = 0.42, p  = .113 [95% CI = 0.15–1.23]). The effect of the BSP on survival rates for exclusive breastfeeding however was still significant while controlling for differences between the two groups at baseline (HR = 0.35, p  = .006 [95% CI = 0.17–0.74]). In conclusion, we find similar effects as in our main analysis when assessing the effectiveness of the BSP among nulliparous women only. Although for any breastfeeding the results did not reach significance, the results for exclusive breastfeeding did reach significance, despite a limited sample size.

This study examined whether mothers enrolled in the BSP engage in longer and more exclusive breastfeeding compared to mothers in a control group. Controlling for differences at baseline, there was on average 66% less risk of cessation of any breastfeeding and on average 54% less risk of cessation of exclusive breastfeeding at any point of time among mothers in the BSP group compared to those in the control group. A subgroup analysis, including nulliparous women only, showed similar results, providing evidence for the robustness of the findings. In the current population, the BSP therefore appears to be an effective means to delay cessation of any and exclusive breastfeeding, and therefore to increase breastfeeding duration and exclusivity. This is an important finding, because breastfeeding rates are suboptimal in many countries [ 8 ], and interventions which could increase breastfeeding rates are valuable given the positive effects of breastfeeding on the mothers’ and children’s health and well-being [ 2 , 3 , 4 , 5 , 6 ]. Notably, our findings are in line with findings from systematic reviews and meta-analyses showing that breastfeeding promotion interventions can indeed effectively increase breastfeeding rates [ 20 , 21 , 22 , 23 , 24 , 25 , 26 ].

A strong point of the BSP is that it is a very comprehensive breastfeeding intervention: it combines support and education, is led by a professional provider, has a protocol available, and is implemented during both the prenatal and postnatal periods. The programme is also evidence based, incorporating elements which have been proven to increase the effectiveness of a breastfeeding intervention [ 22 , 26 ]. Finally, the BSP has a firm theoretical foundation in the Theory of Planned Behaviour [ 27 ].

The number of studies evaluating breastfeeding interventions in the Netherlands is very limited: only two other studies are known to us. One study evaluated a breastfeeding intervention aimed at extending the continuation of breastfeeding until at least 3 months by educating postpartum health professionals, but found no significant effect [ 46 ]. Another study evaluated an educational programme to promote exclusive breastfeeding for 6 months in families with a history of asthma: breastfeeding exclusively at 6 months was significantly higher in the intervention group than in the control group [ 47 ]. In comparison to this last study, the BSP offers the added benefit that it is not tailored to a specific group, but is in principle applicable to the general population. Therefore, the BSP might be deployed as an effective general support measure for mothers intending to breastfeed, to improve the relatively low breastfeeding rates in the Netherlands [ 11 ].

An important limitation of the current research is that no randomization was performed, which led to pre-existing differences between groups. Although we believe we had valid reasons to opt for a quasi-experimental design (basing our decision on practical and ecological grounds), the lack of randomization could have resulted in pre-existing differences between the control and the intervention group that affected our findings [ 33 ]. Pre-existing differences can pose a threat to internal validity, mainly if they are related to the outcome variable of interest, and can thus provide an alternative explanation for the effect of the intervention. Therefore, the quality of any quasi-experiment is dependent on the degree of comparability between treatment groups, and it is essential to screen and control for possibly confounding factors [ 33 ]. In the current study we used post-hoc adjustment to control for potential confounders; another possibility is to prospectively match treatment groups on important confounding variables to create more comparable groups [ 35 ]. However, matching can be difficult and sometimes impractical, for example when the sample size is limited compared to the number confounding factors [ 48 ], as in the current study. Furthermore, controlling for differences has its limits, in the sense that one cannot control for unmeasured or imperfectly measured confounders [ 35 ]. Although we carefully measured and controlled for a broad range of possibly confounding variables in this study, future studies testing the effectiveness of the BSP may consider using alternative designs, most notably those in which participants are randomly assigned to conditions. For example, a RCT where all participants receive some form of BSP, but in different forms or intensities, could prevent selection bias, while at the same time precluding unwanted bias from randomisation (such as low compliance or selective attrition [ 36 ]). Studies focussing on the effectiveness of the current intervention at different intensities (e.g., more or fewer consults) and on the effectiveness of its various elements (i.e., which of the elements – information, practical advice or the role of the father etc. – contribute most to the programme’s effectiveness) could also help fine-tune the BSP, potentially making it more effective and efficient.

Another important limitation of the current research (related to the previous point) is that it is unclear to what extent the current findings are generalizable to other populations. The present research focussed explicitly on testing the effectiveness of the BSP among the current participants, and the sample of women in the BSP group was therefore self-selected. As a consequence, it is possible that certain characteristics of the current sample serve as moderators for the effectiveness of the intervention [ 33 ]. Two characteristics of our sample seem noteworthy in this respect. First, the women in the BSP group can be characterized by a relatively high education level, and second, it seems that women in the BSP group may have anticipated breastfeeding problems or were planning to return to work. Although we controlled for these differences (making it unlikely that they compromised our results), future research may want to zoom in on their potential effects. For example, the BSP seems to be effective for the women that we investigated, but perhaps it is less effective for, for instance, lower educated women, women who do not anticipate breastfeeding problems, or women who do not plan to return to work. It seems likely that mothers encountering difficulties during breastfeeding could particularly benefit from participating in a BSP. Evidence to this effect could point towards the effectiveness of targeting pregnant women with a higher propensity towards breastfeeding problems. Because the present research showed promising effects in the current population, future research could consider sampling from a broader set of populations to test the differences of BSP effectiveness between sub-groups of women and to test the generalizability of the current findings. Finally, future studies could include more dependent variables, such as whether women sought additional breastfeeding support or the extent to which breastfeeding problems are perceived as effectively handled, to provide greater insight into the effects and working mechanisms of the programme.

Given the important positive long-term health consequences of breastfeeding for infants and mothers [ 2 , 3 , 4 , 5 , 6 ], knowledge about effective breastfeeding support programmes is highly relevant. This research demonstrated that mothers enrolled in the BSP engage in prolonged breastfeeding in terms of duration and exclusivity compared to mothers in a control group. Therefore, we found empirical support for the BSP being effective in its current form and for the current client group. Future research should test the effectiveness of the intervention in other populations and use randomization to determine whether wide-scale implementation of this intervention could be useful to promote breastfeeding.

Availability of data and materials

All the data generated or analysed during this study are included in this published article and its additional files.

In this research exclusive breastfeeding was defined as still receiving breast milk, without artificial feeding. No information was recorded in this research on complementary feeding (i.e.: consumption of other foods or drinks alongside breastfeeding or artificial feeding).

Since the BSP is a relatively small-scale programme, recruitment was spread out over a longer period to ensure sufficient participants for a reliable effect measurement.

Since questions about drinks other than infant formula were not included in our questionnaire, this was not included in our operationalization of exclusive breastfeeding. However, we estimate that it is unlikely that children would have received other drinks than formula, unless they had also begun to receive solid foods and/or formula, since the Dutch Nutrition Centre advises introducing solid foods from month 4-6, and not to introduce water or other drinks until after month 6 [ 18 , 19 ]. If parents had taken the step not to introduce solid foods or formula before 6 months, then they would most likely not have introduced other drinks either before 6 months. The operationalization used therefore offers a good approximation of exclusive breastfeeding according to the WHO definition.

A negative experience with previous breastfeeding is the only variable which differed at baseline but was not controlled for in the Cox proportional hazards regression analyses. We decided not to control for this variable because first-time mothers were unable to answer this question. Note that a negative experience with previous breastfeeding was negatively correlated to breastfeeding duration in the current sample ( r  = -.40, p  = 0.001). Since the participants in the BSP group scored higher on this variable than participants in the control group, not controlling for this variable leads to a more conservative estimate. The decision not to control for this variable therefore seems justified. Furthermore, because there were almost no individuals with low-level education, we dichotomized education level and education level of the partner into low-medium versus high level to improve reliability of the estimates.

Abbreviations

Baby Friendly Hospital Initiative

Breastfeeding Support Program

International Board Certified Lactation Consultant

Randomized controlled trial

Theory of Planned Behaviour

World Health Organisation

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Acknowledgements

We would like to thank all the participants for taking part in this research. Furthermore we would like to thank MAKIBO and the primary care facilities involved for their help in the recruitment of participants.

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SvD conceived and designed the study and was responsible for the data acquisition, analysed and interpreted the data, and wrote and revised the manuscript. BW contributed to the analysis and interpretation of the data and helped revise the manuscript. MM contributed to the analysis and interpretation of the data and helped revise the manuscript. AD supervised the conception and design of the study and contributed to the analysis and interpretation of the data. All the authors read and approved the final manuscript.

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This study was approved by the Ethical Committee of Psychology (ECP) of the University of Groningen (reference number ppo-012-062). Participants were fully informed and gave their permission for participation in this research by indicating their informed consent in the online questionnaire, in accordance with the ECP’s guidelines.

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The authors declare that they have no competing interests. The author SvD received a gift for the birth of her child (<EUR 30) from MAKIBO, the company which developed and commercially exploits the BSP. Except for the above, the authors declare they were not paid or rewarded by MAKIBO.

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Additional file 1:.

An overview of the 45 possible confounders, including a description of the operationalisation. (DOCX 16 kb)

Additional file 2:

Data file BSP anonymized data. (CSV 151 kb)

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Spss syntax for preparation of the data file. (DOCX 16 kb)

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Spss syntax for Cox regression. (DOCX 12 kb)

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Spss syntax for Cox regression nulliparous women only. (DOCX 14 kb)

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van Dellen, S.A., Wisse, B., Mobach, M.P. et al. The effect of a breastfeeding support programme on breastfeeding duration and exclusivity: a quasi-experiment. BMC Public Health 19 , 993 (2019). https://doi.org/10.1186/s12889-019-7331-y

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Effects of lactation room quality on working mothers’ feelings and thoughts related to breastfeeding and work: a randomized controlled trial and a field experiment

• Sjoukje A. van Dellen   ORCID: orcid.org/0000-0003-0598-892X 1 , 2 ,
• Barbara Wisse 1 &
• Mark P. Mobach 2 , 3  

International Breastfeeding Journal volume  17 , Article number:  57 ( 2022 ) Cite this article

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The challenging combination of breastfeeding and work is one of the main reasons for early breastfeeding cessation. Although the availability of a lactation room (defined as a private space designated for milk expression or breastfeeding) is important in enabling the combination of breastfeeding and work, little is known about the effects of lactation room quality on mothers’ feelings and thoughts related to breastfeeding and work. We hypothesized that a high-quality lactation room (designed using the Theory of Supportive Design) would cause mothers to experience less stress, have more positive thoughts about milk expression at work, perceive more organizational support, and report more subjective well-being, than a low-quality lactation room.

In an online randomized controlled trial (Study 1), Dutch mothers ( N  = 267) were shown either a high-quality or a low-quality lactation room (using pictures and descriptions for the manipulation) and were then asked about their feelings and thoughts. In a subsequent field experiment (Study 2) we modified the lactations rooms in a large organization in Groningen, the Netherlands, to manipulate lactation room quality, and asked mothers ( N  = 61) who used either a high-quality or low-quality lactation room to fill out surveys to assess the dependent variables.

The online study showed that mothers exposed to the high-quality lactation room anticipated less stress, more positive cognitions about milk expression at work, more perceived organizational support, and more subjective well-being than mothers exposed to the low-quality lactation room ( p  <  0.05). Moreover, the effect of lactation room quality on perceived organizational support was especially pronounced for mothers who were higher in environmental sensitivity. The field experiment showed that use of the high-quality room led to less reported stress than use of the low-quality room ( p  <  0.05). We also found that mothers who were higher in environmental sensitivity perceived more control over milk expression at work and experienced more subjective well-being in the high-quality condition than in the low-quality condition ( p  <  0.05).

The current studies show that not only the availability, but also the quality of lactation rooms is important in facilitating the combination of breastfeeding and work.

Research findings indicate that the challenging combination of breastfeeding and work is one of the main reasons for early breastfeeding cessation [ 1 , 2 ]. To prevent mothers from having to choose between breastfeeding and career development, it is important to find new ways to better support breastfeeding mothers at work. While many factors play a role in creating a breastfeeding-friendly environment in the workplace, paid breastfeeding breaks and the availability of a lactation room (defined as a private space designated for milk expression or breastfeeding) are important basic requirements for enabling mothers to continue breastfeeding their babies when they return to work. However, related maternity protection legislation differs per country; the provision of paid breastfeeding breaks is included in the legislation of 71% of the countries worldwide, but the provision of a lactation room is included in the legislation of only 31% of countries [ 3 ]. Furthermore, legislation rarely offers any guidance related to the quality of nursing facilities.

In the Netherlands, breastfeeding rates are relatively low: the percentages of exclusive breastfeeding (operationalized as still receiving breast milk without receiving infant formula) and any breastfeeding at 6 months of age are 19 and 28% respectively [ 4 ]. Mandatory paid maternity leave in the Netherlands is 16 weeks, with a minimal of 10 weeks postnatal leave (Article 3.1, paragraph 1–3 of the Labour and Care Act ). A breastfeeding mother is entitled to paid breastfeeding breaks during her workday until her infant is 9 months of age. The Dutch law furthermore states that an employer should provide a suitable, lockable, and private space for a breastfeeding employee (Article 4.8, paragraph 1 of the Working Hours Act ), but does not further specify what suitable means in this context. A recent cross-sectional study conducted in the Netherlands showed that lactation room quality was generally low, and that lactation room quality was positively related to mothers’ satisfaction with the room and perceived ease of and support for milk expression at work [ 5 ].

Experimental research on the causal impact of lactation room quality on mothers’ thoughts and feelings related to milk expression at work has been lacking so far. Therefore, we conducted two experimental studies to investigate if the use of a high-quality (vs. low-quality) lactation room reduces mothers’ stress, and has a positive influence on their cognitions about milk expression at work, perceived organisational support, and subjective well-being. Lactation room quality was manipulated using the recommendations of the Theory of Supportive Design, which states that the built environment can have a psychological impact on individuals [ 6 ]. In addition, we explored the extent to which these effects are more pronounced in mothers who are higher in environmental sensitivity, since these mothers have the tendency to process stimuli and information strongly and deeply [ 7 ] (see Fig.  1 ). With this research we hope to uncover whether the provision of a high-quality lactation room can contribute to facilitating the combination of breastfeeding and work.

Conceptual model and hypotheses

The provision of lactation rooms to support breastfeeding

Breastfeeding women need to breastfeed or express milk regularly during the day in order to maintain milk supply and avoid medical problems related to a build-up of milk. For women who want to combine breastfeeding and work it is therefore important that measures are taken to enable breastfeeding or milk expression during working hours. Although there are several other options, such as allowing breastfeeding breaks at home or at the day-care, arguably the most common solution is to provide women with a lactation room at work where they can pump milk for their baby. Various studies have investigated if the presence of a lactation room can support breastfeeding by working mothers. A 2017 review found positive effects of access to a lactation space on breastfeeding initiation, breastfeeding duration, breastfeeding exclusivity, use of infant formula, predominant breastfeeding, and job satisfaction [ 8 ]. Yet, effects were not always strong and sometimes effects could only be found when certain conditions were met. For instance, one study found that while access to a lactation space did not have a significant effect on its own, the combination of an available lactation space and a refrigerator was associated with continued breastfeeding [ 9 ]. It may be that, apart from lactation room availability , lactation room quality is also important in predicting working mothers’ responses. Research on the effects of lactation room quality, however, is scarce. Moreover, guidelines on lactation room design are often limited to functional aspects. For instance, in the Netherlands the law states that a lactation room should be suitable, lockable, and private (Article 4.8, paragraph 1 of the Working Hours Act ). Further directives explain that the lactation room should be lockable from the inside, it should have good hygiene and sufficient privacy, it should be sufficiently quiet and secluded, it should have a bed or couch, sufficient fresh air and climate control facilities, and there should be no risks involved (such as the presence of hazardous materials and contaminants) [ 10 ]. Although these basic functional requirements are a helpful starting point, they are not construed with the notion in mind that going above and beyond these basic aspects may have additional positive consequences for how mothers feel about combining breastfeeding and work. In the following, we will explain 1) how high-quality lactation rooms can be designed, and 2) why we think that lactation room quality may impact stress, cognitions about milk expression at work, perceived organizational support, and subjective well-being.

Enhancing lactation room quality by applying the theory of supportive design

In line with the tenets of a recent cross-sectional study on lactation room quality [ 5 ], we posit that the quality of lactation rooms is determined by more than just basic functional aspects. Just like the quality of office rooms is enhanced by, for instance, indoor air quality, thermal comfort, lighting, acoustics, and natural, aesthetic and recreational aspects [ 11 ], the quality of lactation rooms is also dependent on more than the bare essentials required by legislation. A theory that provides guidance in how high quality lactations rooms can be designed is Ulrich’s Theory of Supportive Design [ 6 ]. The Theory of Supportive Design stems from a school of thought promoting evidence-based design in healthcare settings in order to create so-called ‘healing environments’. Literature reviews offer evidence that the built environment may indeed affect the health and well-being of users in healthcare settings [ 12 , 13 , 14 ]. Ulrich based his theory largely on the observation that, traditionally, the interior design of health facilities has emphasized only the functional delivery of healthcare, leading to facilities that may seem effective, but are also stressful because they don’t attend to the psychological needs of patients. The Theory of Supportive Design argues that more accommodating designs can reduce stress, by fostering perceptions of control, offering positive distraction, and encouraging social support [ 6 ]. Thus, to be considered high-quality, a room should address both psychological and functional needs. Applying these insights to lactation room design we argue that lactation rooms that incorporate the principles of the Theory of Supportive Design (by fostering perceptions of control, offering positive distraction, and encouraging social support) should be considered higher quality lactation rooms than rooms that do not incorporate these principles.

Impact of lactation room quality on breastfeeding mothers

Based on the above, we first of all hypothesized that a high-quality lactation room, designed by the principles of the Theory of Supportive Design, will reduce mothers’ stress levels to a larger extent than rooms that are designed without adhering to those principles. Stress-reducing qualities may be particularly relevant for a lactation room, as stress has been shown to interfere with the release of oxytocin, a hormone responsible for the milk ejection reflex, and may thus lead to a disruption of the milk flow and a reduced milk volume, hence adversely affecting the process of breastfeeding [ 15 , 16 , 17 ]. Moreover, a recent review showed that stress reduction and relaxation can indeed help to improve breastfeeding outcomes [ 18 ]. Two recent studies that focused specifically on testing the tenets of Ulrich’s theory [ 6 ] showed that the greater the number of design features fostering perceptions of control, positive distraction, and social support, the lower patients’ perceived stress turned out to be [ 19 , 20 ]. Although these studies focused on patients in hospital environments, we posit that these findings may apply to breastfeeding mothers in work settings as well. Therefore, we hypothesized that when mothers use a high-quality lactation room, they will experience lower stress levels than when they use a low-quality lactation room (Hypothesis 1, see Fig. 1 ).

Apart from reducing mothers’ stress levels, we hypothesized that high-quality lactation rooms may have additional beneficial effects, in particular on mothers’ thoughts related to milk expression at work. Evidence in this direction comes from a recent cross-sectional study that found an association between lactation room quality on the one hand and perceived behavioural control and perceived support for milk expression at work on the other [ 5 ]. In the current experimental study, we therefore examined the effects of lactation room quality on perceived behavioural control and perceived support for milk expression at work, and added two additional cognitions that are theoretically considered important in predicting behaviour [ 21 ]: attitude towards expressing milk at work, and intention to express milk at work. We hypothesized that when mothers use a high-quality lactation room, they will have more positive cognitions about milk expression at work than when they use a low-quality lactation room (Hypothesis 2, see Fig. 1 ).

Finally, we expect that lactation room quality may have an impact beyond mothers’ cognitions about milk expression at work. Since a lactating working mother spends several hours of her working week in a lactation room, lactation room quality may also affect cognitions that are not directly tied to breastfeeding and milk expression. In the current study, we focused in particular on whether lactation room quality influences mothers’ perceptions of organizational support and their subjective well-being. Perceived organizational support refers to the extent to which employees believe that the organization values their contribution and cares about their well-being, and has been shown to be positively related to favourable outcomes for employees (e.g., job satisfaction, positive mood) as well as organizations (e.g., affective commitment, performance, and lessened withdrawal behaviour [ 22 ]). A recent meta-analysis has shown that perceptions of family-supportive work practices are related to perceived organizational support, especially for those employees who need such practices [ 23 ]. Viewing the provision of high-quality breastfeeding facilities as family-supportive work practices, we hypothesized that when mothers use a high-quality lactation room, they will perceive more organizational support than when they use a low-quality lactation room (Hypothesis 3, see Fig. 1 ).

Subjective well-being refers to people’s cognitive and affective evaluations of their lives, or in other words, to the extent to which people are happy and satisfied with their lives [ 24 ]. Subjective well-being is associated with a wide spectrum of favourable outcomes, such as good health and longevity, better social relationships, creativity, and work performance [ 24 ]. A recent review has shown that a positive work-life balance is related to life satisfaction [ 25 ], which is one of the core components of subjective well-being [ 26 ]. Viewing high-quality breastfeeding facilities as a way of improving the work-life balance of breastfeeding employees, we hypothesized that when mothers use a high-quality lactation room, they will report more subjective well-being than when they use a low-quality lactation room (Hypothesis 4, see Fig. 1 ).

Exploring the influence of individual differences in environmental sensitivity

When investigating the effect of environmental features on people, it is important to take into account that not all individuals may react equally to variations in the external environment. One variable that may be of particular importance in this regard is environmental sensitivity. Environmental sensitivity, measured as sensory processing sensitivity, is viewed as a fundamental trait and is defined as the degree to which an individual registers, processes, and responds to external stimuli [ 7 , 27 ]. Whereas one person may be very sensitive to environmental influences, another may remain unperturbable under all circumstances. Although studies on the role of sensory processing sensitivity in environmental interventions are largely lacking, previous research with a precursory measure of environmental sensitivity – i.e., stimulus screening and arousability [ 28 ] – showed that this variable could moderate the effects of environmental interventions. For example, it was found that stimulus screening and arousability moderated people’s stress, arousal, and cognitive appraisals of a room in reaction to colour-use in a simulated hospital room [ 29 ] as well as workers’ productivity in reaction to colour-use in office settings [ 30 ], indicating that people high in stimulus screening and arousability show stronger reactions to environmental interventions. Based on this research, we expect that the effects of lactation room quality will be stronger to the extent that mothers are higher in environmental sensitivity (see Fig. 1 ). Given the lack of direct empirical support for this notion, we will investigate whether this is the case in exploratory moderation analyses.

In sum, we aimed to investigate the influence of lactation room quality on working mothers’ feelings and thoughts related to breastfeeding and work. We hypothesized that a high-quality lactation room will reduce mothers’ stress, and have a positive influence on their cognitions about milk expression at work, perceived organisational support, and subjective well-being. In addition, we expected these effects to be more pronounced to the extent that mothers are higher in environmental sensitivity. We used a mixed-methods research design and tested our hypotheses in two methodologically complementary studies. We used an online randomized controlled trial to minimize threats to internal validity (Study 1) and a field experiment to improve the ecological validity of the research findings (Study 2).

Study 1: a randomized controlled trial

Design and participants.

Study 1 was set up as a randomized controlled trial, which is considered the golden standard for testing causal claims, because it minimizes threats to internal validity [ 31 ]. A total of 267 Dutch mothers participated in an online study that employed a 1 × 2 (lactation room quality: high versus low) between-subjects experimental design. Mothers were randomly assigned to either the high-quality lactation room condition ( n  = 136) or the low-quality lactation room condition ( n  = 121), using pictures and descriptions for the manipulation of lactation room quality. Environmental sensitivity was added to the design as a continuous variable. Inclusion criteria were: (1) current or previous experience with breastfeeding and (2) being employed. Exclusion criteria were: (1) not meeting the inclusion criteria, and (2) age and/or completion time deviating more than 3 SD from the mean. The mothers had a mean age of 32.5 years (SD = 4.3), and worked on average 27.1 hours per week (SD = 6.8).

Mothers were recruited through a message on the Facebook page of a popular Dutch website with breastfeeding information and were informed that breastfeeding and/or parenting books would be raffled among the participants who completed the survey. All mothers provided their informed consent before initiating the survey. First, we assessed environmental sensitivity, then mothers were randomly assigned to either the high-quality or the low-quality lactation room condition. They were shown pictures and a description of either the high-quality or the low-quality lactation room, and asked to imagine a scenario where they made use of this lactation room to express milk. After viewing the pictures and reading the description, they answered the survey questions comprising a manipulation check, the dependent variables, and demographic items.

Manipulation of lactation room quality

The manipulation of lactation room quality was based on the premise that a high-quality lactation room should not only meet the basic functional requirements, but should also follow the recommendations from the Theory of Supportive Design [ 6 ]. The stimulus materials for the high-quality and the low-quality lactation room conditions consisted of design drawings created by a professional interior designer, accompanied by a matching description of the room. The design drawings of the low-quality lactation room were based on examples of existing Dutch lactation rooms that only met the minimum requirements for lactation rooms according to Dutch law and guidelines, but did not foster perceptions of control, positive distraction, or social support. These design drawings showed a white room, containing a chair, a table, and a hospital bed. The design drawings of the high-quality lactation room met the minimum requirements, and in addition they aimed at fostering perceptions of control (e.g., adjustable lighting and pillows), positive distraction (e.g., nature images and decoration), and social support (e.g., supportive messages about breastfeeding). The drawings in this condition showed a room decorated with green paint on one wall and a forest-photo-wallpaper on another wall, containing a comfortable chair, a table, a bed, and many decorations, such as: pillows, a mood light, a bulletin board, books, ceramic plants, a radio etc. Both design drawings were accompanied by the following text: ‘Below you can see images of one lactation room from three different viewpoints, and a list of the available facilities. Study these images and the accompanying text carefully. Imagine expressing milk in such a room; try to imagine what this would feel like.’ For the low-quality lactation room, the text proceeded as follows: ‘This lactation room contains the following: A chair, a table for the breast pump, and a bed. There is also an adjoining room with a sink, and a door with a lock.’ In contrast, for the high-quality lactation room the text proceeded as follows: ‘This lactation room contains the following: a chair, a table for the breast pump, a bed with pillows, a mood light, a bulletin board, a card with the text: ‘Good that you are here! Take your time’, two shelves, a breastfeeding book, two picture books with nature images, a radio and 3 ceramic plants, wallpaper with an image of sun rays in the forest, a cabinet with two drawers. There is also an adjoining room with a sink, and a door with a lock.’ Because the study took place during the COVID-19 pandemic, we added information in both conditions about hygienic measures (indicating that the room is cleaned daily and that water and soap, paper towels, hygienic wipes, and disinfecting hand gel are also provided). See Fig.  2 a and b for the design drawings.

a Drawings of the high-quality lactation rooms. b Drawings of the low-quality lactation rooms

Manipulation check

To verify that our manipulation of lactation room quality based on the Theory of Supportive Design was successful, we developed a 4-item scale. Items were: ‘This room contains images of nature’, ‘This room contains nice, beautiful, or interesting things’, ‘This room is adjustable to my needs’, ‘This room makes me feel supported in milk expression at work’. Mothers were asked to indicate their agreement on a seven-point Likert scale from (1) ‘totally disagree’ to (7) ‘totally agree’ (α = .79). Furthermore, we asked mothers to award a report grade for lactation room quality on a scale of 1 to 10 (1 = very bad; 10 = very good). As intended, one-way ANOVAs showed that mothers perceived the high-quality lactation room as being more consistent with the Theory of Supportive Design ( M = 6.01, SD  = 0.68) than the low-quality lactation room condition ( M  = 3.13, SD  = 0.88, F (1,265) = 893.60, p  <  0.001). Moreover, mothers awarded a higher report grade for lactation room quality in the high-quality lactation room condition ( M = 8.93, SD  = 1.14) than in the low-quality lactation room condition ( M  = 6.69, SD  = 1.57, F (1,265) = 981,01, p  <  0.001). We therefore conclude that our manipulation of lactation room quality was successful.

• Environmental sensitivity

Environmental sensitivity was assessed before participants saw the design drawings and consisted of the 12-item short version of the HSP Scale [ 7 , 32 ]. Example items of the HSP-scale are ‘Do you notice and enjoy delicate or fine scents, tastes, sounds, works of art?’ and ‘Are you bothered by intense stimuli, like loud noises or chaotic scenes?’ Answering options ranged from 1 ‘not at all’ to 7 ‘extremely’. The internal consistency of the scale was good (α = .82).

Anticipated stress was measured using the short version of the State-Trait Anxiety Inventory for adults [ 33 ]; this short version [ 34 ] is well validated and has been shown to correlate highly with physiological measures of stress [ 35 ]. Mothers could indicate on a four-point Likert scale, ranging from (1) ‘not at all’, to (4) ‘very much so’ the extent to which they would feel calm/ tense/ upset/ relaxed/ content/ worried in the room that was shown to them (α = .82).

Cognitions about milk expression at work

Anticipated attitude, perceived support, and perceived behavioural control towards milk expression at work were operationalized according to the guidelines by Ajzen [ 21 , 36 ]. Attitude was measured by presenting mothers with the following statement: ‘For me expressing milk at work in the room that was shown would be…’. This statement was followed by three 7-point, semantic, differential adjective scales: ‘unenjoyable – enjoyable, unpleasant – pleasant, negative – positive’ (α = .94). Perceived support was measured with four bipolar items: ‘Judging from the room that was shown I think that my supervisor approves of me expressing breast milk at work’ and ‘Judging from the room that was shown I think that my supervisor supports me expressing breast milk at work’. These two items were then repeated, replacing ‘my supervisor’ with ‘my co-workers’. All of the items were answered using a 7-point Likert scale, ranging from (1) ‘strongly disagree’ to (7) ‘strongly agree’ (α = .93). Perceived behavioural control was measured by two items: ‘In the room that was shown, expressing milk at work would be…for me’, rated on a scale from (1) ‘impossible’ to (7) ‘possible’, and ‘In the room that was shown, I could express milk at work if I wanted to’, rated on a scale from 1 ‘strongly disagree’ to 7 ‘strongly agree’ (α = .61). Anticipated intention to express milk at work was measured with a single item, based on an Australian study on breastfeeding duration [ 37 ]. The item was: ‘How long would you like to express milk at work if the lactation room shown was available at work? In that case, I would like to express milk at work until my baby is ... months old’. Participants were asked to indicate their intended duration of milk expression at work as a whole number of months.

Perceived organizational support

Perceived organizational support was measured by selecting eight high-loading items (loadings from .71 to .84) from the Survey of perceived organizational support [ 38 ]. Examples of items that were used are: ‘The organization fails to appreciate any extra effort from me’ (reversed), ‘The organization really cares about my well-being’, ‘The organization cares about my general satisfaction at work’, ‘The organization shows very little concern for me’ (reversed). The statements were preceded by the sentence: ‘Taking into account the room that was shown I would think that…’. Participants indicated their agreement with each item using a 7-point Likert-type scale (1) ‘strongly disagree’, (7) ‘strongly agree’ (α = .92).

Subjective well-being

Subjective well-being was measured based on the 2-item scale developed by Statistics Netherlands [ 39 ]. The items were: ‘On a scale from 1 to 10 can you indicate to what extent you would consider yourself to be a happy person if you expressed milk in the room that was shown? (1 = completely unhappy, 10 = completely happy)’ and ‘On a scale from 1 to 10 can you indicate how satisfied would you be with the life you lead at the moment if you expressed milk in the room that was shown? (1 = completely dissatisfied and 10 = completely satisfied)’ (α = .93).

Study 2: a field experiment

To complement the results of Study 1 and improve the ecological validity of our research findings, a second experimental study was conducted in a real-life setting. A total of 61 lactating employees from a large hospital in Groningen, the Netherlands, participated in the research. Since on average 90 mothers make use of the lactation rooms on the maternity ward each year according to the secretary of the ward (Mollema, Y., personal communication, August 15, 2017), 61 participants over a two-year period reflects a response rate of approximately 34%. We used a 1 × 2 (lactation room quality: high versus low) between-subjects experimental design, with two measurement points: the first (T1) as soon as the mother returned to work (or maximally four weeks afterwards), and the second (T2) four weeks after their return to work (thereby making sure mothers could have used the lactation room for at least four weeks). Although the intention was that mothers filled in the T1 questionnaire as soon as they returned to work, most mothers signed up somewhat later. It was decided that the T1 questionnaire could be filled in maximally four weeks after the return to work. Environmental sensitivity was added to the design as a continuous variable. Inclusion criteria were: (1) returning from maternity leave no more than 4 weeks prior to T1, and (2) making use of the lactation rooms on the maternity ward of the hospital at work at T1. Exclusion criteria were: (1) no longer making use of the respective lactation rooms at work at T2. The experiment took place over a two-year period: from June 2018 until June 2020. In the first year, all participating mothers were assigned to the low-quality lactation room condition ( n  = 32) and in the second year all participating mothers were assigned to the high-quality lactation room condition ( n  = 29). The mothers had a mean age of 31.5 years ( SD  = 3.1) and worked on average 30.3 hours per week ( SD  = 7.1). On average mothers used the lactation room 5.8 times per week ( SD  = 2.8). About two thirds of the mothers (62.7%) also used an alternative lactation room ( M  = 3.4 times per week; SD  = 2.4). There were no significant differences between mothers in the experimental group and the control group with regard to these characteristics.

Mothers were recruited by placing flyers in the three lactation rooms in the maternity ward at the hospital. The flyers pointed out that participants for a study on experiences with milk expression at work were sought and that breastfeeding and/or parenting books would be raffled among the participants who completed the survey. Mothers could receive further information and an invitation to participate, by leaving their name, e-mail, and the date they had returned from maternity leave on a participation form. Every mother who handed in the participation form (at the front desk of the maternity ward), received a chocolate bar as a token of our gratitude. Invitations for the pre-test questionnaire were sent as soon as the mothers signed up for the study, mostly in the first week after they returned to work. Invitations for the post-test questionnaire were sent four weeks after the mothers returned to work. We emphasized that participation in the study was anonymous and voluntary and that they could withdraw from the study at any time. All mothers provided their informed consent before continuing to the survey. In the pre-test, mothers answered survey questions about their environmental sensitivity and demographic information. In the post-test, when mothers had been using the hospital’s lactation room for at least four weeks, they answered survey questions comprising a manipulation check and the dependent variables.

The manipulation of lactation room quality corresponded to that in Study 1, but in the field experiment, we used and adapted the existing lactation rooms in the maternity ward of the hospital. In the low-quality condition, mothers made use of three identical standard lactation rooms in the hospital maternity wards where the research took place. These low-quality lactation rooms were basic white hospital rooms, containing a chair, a table, a hospital bed, and a hospital grade breast pump (which prevented unwanted individual variance in pumping experiences due to the breast pump used.) After one year the three lactation rooms were refurbished and painted in order to create the high-quality condition, based on the design drawings that had been created for Study 1. Similar to Study 1, these high-quality lactation rooms were identically decorated with green paint on one wall and a forest-photo-wallpaper on another wall, they contained a comfortable chair, a table, a bed with multiple pillows, a mood light, a bulletin board, with a card that welcomed mothers to the lactation room, a breastfeeding information book, two picture books with nature images, ceramic plants, a cabinet with two drawers, and a hospital grade breast pump. For photographs of the lactation rooms in the high-quality and the low-quality condition, see Fig.  3 a and b.

a Photos of the high-quality lactation rooms. b Photos of the low-quality lactation rooms

The manipulation checks (α = .86 for the 4-item scale) were measured exactly as in Study 1. As intended, one-way ANOVAs showed that mothers perceived the high-quality lactation room as being more consistent with the Theory of Supportive Design ( M  = 5.45, SD  = 0.90) than the low-quality lactation room condition ( M  = 2.28, SD  = 0.86, F(1,59) = 196.18, p  <  0.001). Moreover, mothers awarded a higher report grade for lactation room quality in the high-quality lactation room condition ( M = 7.79, SD  = 0.94) than in the low-quality lactation room condition ( M  = 6.22, SD  = 1.52, F(1,59) = 23.12, p <  0.001). We therefore conclude that our manipulation of lactation room quality was again successful.

The measures we used corresponded to the ones we used in Study 1. We made some small adjustments in wording, taking into account that this was a field study instead of a scenario study. This, for instance, allowed us to use the present tense (e.g., I feel) instead of the conditional simple tense (e.g., I would feel).

Environmental sensitivity (α = .81) was measured exactly as in Study 1. Stress (α = .81), subjective well-being (α = .76), and perceived organizational support (α = .90) were measured using the same items as in Study 1, but stated in the present tense. To assess attitude (α = .88), perceived support (α = .87), and perceived behavioural control (α = .77) towards milk expression at work we used similar measures as in Study 1. However, we specified the behaviour of ‘expressing milk at work’ further by adding ‘until my baby is at least 6 months old’. Moreover, for the measurement of attitude we added two semantic, differential adjective scales: ‘worthless – valuable’ and ‘useless – useful’, to also include utilitarian aspects of attitude [ 40 ]. For perceived behavioural control we added 2 items to improve the reliability of the scale: ‘For me pumping milk at work until my baby is at least 6 months old is…’, rated on a scale from 1 ‘hard’ to 7 ‘easy’, and ‘It is mostly up to me whether or not I pump milk at work until my baby is at least 6 months old’, rated on a scale from 1 ‘strongly disagree’ to 7 ‘strongly agree’. We replaced the intention to express milk at work of Study 1 with a 3-item measure based on the guidelines developed by Ajzen [ 21 ]. Answer options were on a scale from (1) ‘strongly disagree’ to (7) ‘strongly agree’. The items were: ‘I intend to express milk at work until my baby is at least 6 months old’, ‘I will do my best to express milk at work until my baby is at least 6 months old’, and ‘I plan to express milk at work until my baby is at least 6 months old’ (α = .94).

One-way ANOVAs were performed to test the hypotheses. A p -value of 0.05 was considered significant ( p  <  0.020 after applying Holm-Bonferroni correction to reduce the chance of a type I error). First, as hypothesized, mothers anticipated to experience less stress when the lactation room was high-quality rather than low-quality (see Table  1 ). Furthermore, mothers that were presented a lactation room that was high-quality as compared to low-quality anticipated to have a more positive attitude towards expressing milk at work, to perceive more support from managers and coworkers, and to have more behavioural control towards expressing milk at work. Finally, mothers in the high-quality lactation room condition anticipated to perceive a higher level of organizational support, and to experience a higher level of subjective well-being than did mothers in the low-quality lactation room condition. Contrary to expectations, the intended duration of breastfeeding did not differ for mothers presented with the high-quality or low-quality lactation room condition.

Exploratory analyses of the moderating role of environmental sensitivity

Hayes Process macro [ 41 ] (model 1) was used to test whether environmental sensitivity moderated the effect of lactation room quality on each of our dependent measures. A p -value of 0.05 was considered significant (we decided not to apply a Holm-Bonferroni correction in these exploratory analyses, because we did not want to increase the chance of a type II error because of the exploratory nature of the analyses). For the main effects, we found that in the high-quality condition mothers anticipated less stress ( b  = − 3.13, t  = − 11.02, p  <  0.001), a more positive attitude towards milk expression at work ( b  = 1.49, t  = 10.13, p  <  0.001), more support from managers and coworkers ( b  = .86, t  = 5.50, p  <  0.001), more behavioural control towards expressing milk at work ( b  = .31, t  = 2.58, p  <  0.01), more organizational support ( b  = 1.25, t  = 10.12, p  <  0.001), and more subjective well-being ( b  = 1.60, t  = 9.99, p  <  0.001) than in the low-quality condition. Furthermore, we found that as mothers scored higher on environmental sensitivity, they anticipated more stress ( b  = .58, t  = 2.43, p  < 0.05), a less positive attitude towards milk expression at work ( b  = −.36, t  = − 2.92, p  < 0.01), less organizational support ( b  = −.25, t  = − 2.47, p  < 0.05), and less subjective well-being ( b  = −.30, t  = − 2.24, p  < 0.05). Apart from these main effects, we also found a significant interaction effect of lactation room quality and environmental sensitivity on perceived organizational support ( b  = .27, t (263) = 1.98, p  < 0.05). Simple slopes analysis [ 42 ] showed that there was a significant positive relationship between lactation room quality and perceived organizational support when environmental sensitivity was both low (− 1 SD ; b =  1.00, t  = 5.69, p  < 0.001) and high (+ 1 SD , b =  1.49, t  = 8.56, p  < 0.001), but that the effect was stronger in the latter case. This means that, in line with our expectations, the effect of lactation room quality on perceived organizational support was especially pronounced for mothers who are high in environmental sensitivity, see Fig.  4 . No other significant interaction effects were found.

Moderating effect of environmental sensitivity in the relationship between lactation room quality and perceived organizational support

One-way ANOVAs were performed to test the hypotheses; again, a p -value of 0.05 was considered significant ( p  < 0.021 after applying Holm-Bonferroni correction to reduce the chance of a type I error). As hypothesized, mothers experienced less stress when the lactation room was high-quality rather than low-quality (see Table  2 ). Although other main effects were in the expected direction, they were not significant. During the last few months of this research the COVID-19 pandemic reached the Netherlands. To rule out that these circumstances influenced the results, we also analyzed the data while excluding those mothers that filled out questionnaires during the COVID-19 pandemic. This reduced the sample to 55 participants; the conclusions flowing from the analysis remained the same as with the larger sample of 61 participants.

Hayes Process macro [ 41 ] (model 1) was used to test whether environmental sensitivity moderated the effect of lactation room quality on each of our dependent measures. A p -value of 0.05 was considered significant (again, we decided not to apply a Holm-Bonferroni correction here, because we did not want to increase the chance of a type II error). For the main effects, we found that in the high-quality condition mothers anticipated less stress ( b  = − 2.15, t  = − 3.03, p  < 0.01) than in the low-quality condition. Furthermore, we found that as mothers scored higher on environmental sensitivity, they experienced less subjective well-being ( b =  −.46, t  = − 2.47, p  < 0.05). Apart from these main effect, we also found two interaction effects.

First, we found a significant interaction effect of lactation room quality and environmental sensitivity on perceived behavioural control ( b =  .82, t (57) = 2.57, p  < 0.05). Simple slopes analysis showed that there was a significant positive relationship between lactation room quality and perceived behavioural control when environmental sensitivity was high (+ 1 SD , b =  .79, t  = 2.01, p  < 0.05), which was not the case when environmental sensitivity was low (− 1 SD , b =  −.68, t  = − 1.75, p =  .09). This means that the positive effect of lactation room quality on perceived control was only present for mothers who are high in environmental sensitivity, see Fig.  5 .

Moderating effect of environmental sensitivity in the relationship between lactation room quality and perceived behavioural control

Second, we found a significant interaction effect of lactation room quality and environmental sensitivity on subjective well-being ( b =  0.52, t (57) = 2.30, p  < 0.05). Simple slopes analysis showed that there was a significant positive relationship between lactation room quality and subjective well-being when environmental sensitivity was high (+ 1 SD, b =  0.73, t  = 2.63, p  < 0.05), which was not the case when environmental sensitivity was low (− 1 SD, b =  − 0.20, t  = −.73, p =  .47). This means that the positive effect of lactation room quality on subjective well-being was only present for mothers who are high in environmental sensitivity, see Fig.  6 . No other significant interaction effects were found.

Moderating effect of environmental sensitivity on the relationship between lactation room quality and subjective well-being

In the current paper, we reported two methodologically complementary experiments, both examining the effects of lactation room quality on mothers’ feelings and thoughts. In Study 1, an online scenario study, we found that mothers exposed to a high-quality lactation room anticipated less stress, more positive cognitions about milk expression at work, more perceived organizational support, and more subjective well-being than mothers exposed to a low-quality lactation room. Also, we found that environmental sensitivity moderated the effect of lactation room quality on perceived organizational support. Specifically, we found that the positive effect of lactation room quality on perceived organizational support was more pronounced for mothers higher in environmental sensitivity. In Study 2, a field experiment, we replicated some, but not all of the findings. Importantly, we again found that mothers who used the high-quality room experienced less stress than mothers who used the low-quality room. Moreover, although we did not find significant main effects for other dependent variables in Study 2, we did find significant interaction effects of lactation room quality and environmental sensitivity on perceived behavioural control and subjective well-being. That is, mothers who scored higher on environmental sensitivity, experienced more behavioural control and subjective well-being in the high-quality condition than in the low-quality condition. Mothers who scored lower on environmental sensitivity were not affected by the quality of the lactation room with respect to experienced control and subjective well-being.

Our aim with this research was to uncover whether the provision of a high-quality lactation room could help to facilitate the combination of breastfeeding and work, and our results suggest that this is indeed the case, especially so for mothers higher in environmental sensitivity. The fact that Study 2 had less significant results as compared to Study 1, could be explained by the fact that people sometimes overestimate the extent to which certain prospective events or conditions will impact their responses (a so-called impact bias [ 43 ]). Because Study 1 assessed mothers’ anticipated responses to hypothetical lactation rooms (that is, they saw drawings of rooms and were asked to imagine making use of that room), they may have underestimated the extent to which other factors may also influence their stress-levels and cognitions (so-called focalism [ 43 ]), and they may have overestimated the effect of lactation room quality. Given the generally weaker effects in Study 2, mothers may indeed have overestimated the effects of lactation room quality to some extent in Study 1. However, another potentially relevant factor may be that the sample size in Study 2 was limited to 61 participants. As such, the statistical power was on the low side, and this may have hampered the obtainment of significant results.

Our findings have several theoretical implications. Importantly, we found support for the expected positive effect of lactation room quality on mothers’ stress-levels (Hypothesis 1) in both studies. This confirms the tenets of the Theory of Supportive Design, stating that a design that fosters perceptions of control, offers positive distraction, and encourages social support can reduce stress levels [ 6 ] - as corroborated in two previous studies [ 19 , 20 ]. Even though the Theory of Supportive Design was originally developed as a framework to study how design can be supportive to patients in a hospital setting [ 19 , 20 ], the current findings show that the theory can be usefully applied to the design of lactation rooms as well. Possibly, the Theory of Supportive Design can be applied to an even broader range of settings than originally envisioned, most notably to settings in which promoting relaxation is desirable (such as lactation rooms, dental practice waiting rooms, or wellness and meditation rooms within organizations). To our knowledge, there is only one previous study that also focused on design as a means of mitigating stress in breastfeeding mothers [ 44 ], although not in a work-setting. This study examined the experiences of breastfeeding mothers with a so-called Snoezelen room in a hospital [ 44 ]. The room included moving images, music, and aromatherapy, and was evaluated very positively by the participating mothers. Furthermore, most mothers were able to achieve breastfeeding in the room, despite previous breastfeeding problems [ 44 ]. Although this was a qualitative study, and consisted of only a small sample ( N  = 11), it confirms our current experimental findings, indicating that a high-quality environment can positively affect mothers’ stress levels and facilitate breastfeeding.

Another key finding of our research is that lactation room quality (by itself or in conjunction with environmental sensitivity) affects mothers’ cognitions related to milk expression at work (Hypothesis 2). We found mothers’ positive attitude towards and perceived support of milk expression at work was higher in the high-quality than in the low-quality lactation room (Study 1). Moreover, mothers’ perceived behavioural control with respect to milk expression at work was also positively affected by lactation room quality (Study 1), particularly for mothers high in environmental sensitivity (Study 2). The current study therefore corroborates and extends the findings of a previous cross-sectional study showing that lactation room quality was positively related to mothers’ cognitions about milk expression at work [ 5 ]. Interestingly, we did not find any effects of lactation room quality on intention to express milk at work in either study; however, this might be due to a ceiling effect, as the intended duration in Study 1 was already high (on average 15 months), compared to the relatively low breastfeeding rates in the Netherlands [ 4 ].

In addition, in Study 1 we found that lactation room quality affects mothers’ perceived organizational support and subjective well-being (Hypothesis 3 and 4), and that latter finding was also found in Study 2 for mothers high in environmental sensitivity. Therefore, it seems that providing a high-quality lactation room can have positive consequences even for factors that are not directly related to breastfeeding. Although previous studies have indicated that perceptions of family-supportive work practices and a positive work-life balance are positively related to perceived organizational support and subjective well-being [ 23 , 25 ], this is the first study to link lactation room quality to these important outcomes. The fact that we only found effects on perceived organizational support in Study 1, and not Study 2, can have several reasons. Apart from the earlier mentioned potential effects of impact bias in Study 1, the influence of other forms of organizational support (e.g., direct emotional support by colleagues and managers) could have been relatively strong in Study 2, thus reducing the relative effects of lactation room quality. Another possibility is that the participants attributed any supportive influence of the high-quality lactation room to the researchers instead of to their organization, due to the fact that the participants were aware that they were taking part in research. Nonetheless, these findings are highly relevant, as perceived organizational support and subjective well-being are linked to a myriad of positive outcomes for organizations and employees, such as job satisfaction, positive mood, affective commitment, performance, and lessened withdrawal behaviour (perceived organizational support [ 22 ]), and good health and longevity, better social relationships, creativity, and work performance (subjective well-being [ 24 ]).

A final theoretically important finding is that environmental sensitivity moderated the effect of lactation room quality on several dependent measures in both Study 1 and 2. These findings are in line with previous research, showing that people high in environmental sensitivity respond more strongly to interventions [ 29 , 30 , 45 ]. Our findings testify to the importance of taking this variable into account in research on (environmental) interventions, because it allows for a better understanding of the effectiveness and efficiency of such interventions within certain sub-groups of people. Moreover, since employees who are high in environmental sensitivity are particularly sensitive to stressors [ 45 ], they are an important potential target group for organizational interventions focused on preventing mental health problems and improving well-being among employees.

Strengths, limitations and directions for future research

A major strength of the current research is that we used methodological triangulation to test our hypotheses. Although all methods have their own strengths and weaknesses, limitations of individual methods can be mitigated by using triangulation in so-called mixed methods research. This is considered to be valuable as it helps to show the robustness of findings across different research methods [ 46 ]. In our research, we used an online randomized controlled trial to minimize threats to internal validity (Study 1) and a field experiment to improve the ecological validity of the research findings (Study 2). By using methodological triangulation to investigate the effects of lactation room quality on mothers’ feelings and thoughts, we were able to show that various findings were not limited to one study (taking away concern that findings may potentially partially be explained by bias resulting from used methods) and therefore we provide stronger evidence and support for the conclusions of our research.

Another strength of the current research is that our lactation room design manipulations, based on the Theory of Supportive Design [ 6 ], were studied in a field experiment. Previous studies using the Theory of Supportive Design were either laboratory studies [ 19 ] or field studies that were observatory rather than experimental in nature [ 20 ]. Therefore, the fact that rooms designed according to the insights from the Theory of Supportive Design yielded positive effects in a real-life setting, testifies to the applicability of the theory. However, a potential limitation of our field experiment is that we were not able to control all factors. Specifically, our design was such that we first researched the effects of the low-quality room (in year 1), and then, after remodelling, researched the effects of the high-quality room (in year 2). Although seasonal effects were controlled for in this set-up (we gathered participants for each condition during one whole year), our results may have been impacted by changes or events that occurred during the two years we ran this study. One important event in this regard was the COVID-19 pandemic that started during the end of year two of our study. However, we found that when we excluded mothers who participated during the COVID-19 period our conclusions flowing from the analysis remained the same, which strengthens our confidence in our findings. Nonetheless, other potential changes or events may in principle play a role. Future research may therefore replicate our study using a design in which participants for both conditions are gathered in the same time frame. Another useful suggestion would be to incorporate virtual reality techniques into the research designs. Virtual reality allows for more controlled circumstances than a field experiment, while at the same time increasing possibilities to recruit a larger sample. Moreover, given that virtual reality offers the enhanced capacity for an immersive, interactive experience with the design [ 47 ], it may be easier for participants to imagine oneself in a certain situation than with the use of scenario studies.

An important limitation of the current study is that while we examined the effects of lactation room quality on the feelings and thoughts of breastfeeding mothers, we did not examine the downstream effects on behavioural outcomes, such as the duration of breast milk expression and breastfeeding. Notably, previous research underscores the importance of mothers’ stress and cognitions for breastfeeding practices. For example, a recent review showed that stress reduction and relaxation interventions can indeed help to improve breastfeeding outcomes [ 18 ], and several studies suggest that maternal cognitions are important predictors of milk expression and breastfeeding behaviour [ 48 , 49 , 50 ]. Future research could fruitfully examine the effects of lactation room quality on (long-term) behavioural outcome measures, such as breast milk expression and breastfeeding duration, and investigate if these effects are mediated by feelings and thoughts of breastfeeding mothers. Moreover, future studies could also consider adding physiological outcome measures, such as breast milk volume and composition (e.g., fat content), and, for example, physiological measures of stress (e.g., cortisol level, heart rate, blood pressure, and fingertip temperature). Furthermore, it would be interesting to study the effects of lactation room quality, in combination with other methods of relaxation-enhancement, such as meditation [ 18 ]. Finally, although the current study focused on the impact of lactation room quality as an independent factor, creating a breastfeeding-friendly work environment goes beyond the provision of a high-quality lactation room. Future studies could therefore examine the impact of a composite program of family-friendly measures, including paid parental- and sick leave, breastfeeding support, affordable child care, flexible work arrangements, and high-quality breastfeeding facilities. This would help to paint a broader picture of the critical role that organizations play in enabling women to continue breastfeeding upon their return to work.

Practical implications

For organizations it is important to realize that offering good breastfeeding facilities creates a win-win situation, benefitting not only mothers and babies, but organizations as well. Since breastfeeding improves the health and well-being of infants and mothers [ 51 ], it can lead to reduced sick leave and health care costs. Moreover, breastfeeding support at work can lead to higher job satisfaction, a better work-life balance [ 52 ], and may even reduce staff turnover [ 53 ]. As such, facilitating breastfeeding in the workplace is a highly relevant topic to facility management practices, not only to respect diversity and stimulate inclusiveness, but also to foster a healthier workplace. The current research offers important insight into what organizations can do to facilitate mothers in combining breastfeeding and work. To support organizations in implementing high-quality lactation rooms, it would be useful to further explore practical organizational issues of costs and benefits, occupancy rates, and possibilities for multi-functional use of spaces, as well as to help raise awareness of the multiple value creation resulting from the provision of high-quality breastfeeding facilities.

The current study highlights the importance of the quality of the breastfeeding facilities that organizations offer for lactating mothers’ feelings and thoughts. Moreover, the current study provides clear guidelines that organizations can use in lactation room design: a high-quality lactation room should not only include the basic functional requirements as currently outlined in legislation and government guidelines [ 10 ], but should also address psychological needs, by fostering perceptions of control, offering positive distraction, and encouraging social support, as outlined in the Theory of Supportive Design [ 6 ].

The ability of mothers to combine work and breastfeeding successfully offers important societal benefits due to the important long term health benefits for mothers as well as children [ 51 ]. While many factors play a role in creating a breastfeeding-friendly environment in the workplace, the availability of a lactation room is an important prerequisite for enabling mothers to continue breastfeeding when they return to work. The current study shows that not only the availability, but also the quality of lactation rooms is important in facilitating the combination of breastfeeding and work. The inclusion of quality guidelines for breastfeeding facilities in organisations’ family-friendly policies could therefore further expand and secure much-needed support for breastfeeding workers.

Availability of data and materials

All of the data generated or analysed during this study are included in this published article and in the supplementary information files.

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Acknowledgements

We would like to thank Daphne van der Knijff-Looman for the designs drawings she created for Study 1, and for her help in implementing these designs at the UMCG lactation rooms in Study 2. Also we would like to thank the Maintenance & Facilities department of the UMCG for their help in implementing the designs. Furthermore, we would like to thank Stefan Kleintjes (IBCLC and director of the Breastfeeding Knowledge Center at the time of the study) for his help with the recruitment of respondents for Study 1, and Yvonne Mollema and Lammie Wiemann from the UMCG maternity ward for their help with the recruitment of respondents for Study 2. Finally, we would like to express our sincere gratitude to all of the respondents who participated in this research.

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SvD conceived and designed the study, was responsible for the data collection, analysed and interpreted the data, and took the lead in writing the manuscript. BW and MM supervised the conceptualization and design of the study, provided critical feedback and helped shape the research, analysis, and manuscript. All authors read and approved the final manuscript.

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van Dellen, S.A., Wisse, B. & Mobach, M.P. Effects of lactation room quality on working mothers’ feelings and thoughts related to breastfeeding and work: a randomized controlled trial and a field experiment. Int Breastfeed J 17 , 57 (2022). https://doi.org/10.1186/s13006-022-00499-0

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Science experiment shows the amazing powers of breastmilk

A viral photo of a science project showcases the healing power of breast milk, and it makes a compelling case for breastfeeding well beyond a baby's first birthday.

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Say goodbye to stressful schedules, painful latching, and worries over milk supply. In the same sensible and sensitive voice that has made baby-led weaning a growing sensation, authors Gill Rapley and Tracey Murkett show how easy nursing can be when you let your baby lead the way. This comprehensive, easy-to-follow guide will help you understand your baby’s unique, natural pattern and develop a trusting and healthy breastfeeding relationship. With the help of personal anecdotes and color photos from real moms, Rapley and Murkett explain how to:

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Breastfeeding shouldn’t be a struggle, and, if you stay in tune with your baby, it can be effortless. Baby-Led Breastfeeding will give you the tools to create a happy and fulfilling breastfeeding experience for you and your baby.

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“I decided to test whether antimicrobial properties of breastmilk changes the older the child is feeding for a small microbiology project as part of my bioscience degree,” Greene told The Huffington Post, adding that her classmate, Emma Browne, is assisting her with the experiment.

In the caption for her photo, the mom explained that one breast milk sample is from a mother feeding her 15-month-old while the second comes from a mother nursing her 3-year-old. She also plans to examine colostrum.

Greene’s early findings suggested that breast milk’s antimicrobial properties persist beyond the first year. “So proud ... here you have 9 Petri dishes containing the bacteria M. Luteus,” she wrote. “The white spots in the middle are discs soaked in two samples of breastmilk. See the clear bit around the discs ― that’s where the proteins in the milk have inhibited the bacteria!”

She concluded, “I’m so excited!!! It also worked with E. coli and had a fairly good go at MRSA too ... the future is bright, the future is breastmilk.”

The post received over 25,000 likes.

Greene told HuffPost she was pleased to see so far that breast milk’s antimicrobial properties don’t seem to diminish as the child ages. Still, she stressed that this is just preliminary data, and there will be more detailed results later on.

“Now, obviously, this is just one photo which went viral, and much more study is required to get definitive results,” she said. “ But I have had doctors and nurses tell me that feeding past a year is completely pointless from a healthcare perspective. What I hope to raise awareness for is that extended breastfeeding isn’t useless.”

For Greene, this research has a personal component, as she is a single mom with three children, ages 13, 10 and 3. She breastfed her first child for five months, her second for 11 months and is still nursing her 3-year-old.

“I have been on the wrong end of judgment about my breastfeeding choices, and I’m fed up of it!” the mom said, adding that she trained to be a breastfeeding peer counselor in 2012 and will soon become a student midwife as well.

“There is a massive stigma surrounding breastfeeding an older child, and there shouldn’t be,” Greene continued, adding that she wants to inspire people to consider breastfeeding a little bit longer. “ The World Health Organization recommends breastfeeding up to and beyond the age of 2 years, s o we need to support women with this,” she noted.

The mom said she isn’t looking to fuel a breast versus formula debate. “ It is not my aim to guilt women into breastfeeding,” she said. Instead, Greene wants to empower women to make informed choices and add to the wealth of information and research around breast milk.

“I hope this photograph, and later a full study, contributes to the cause, and gives women the confidence they deserve to make decisions about whether they want to breastfeed for six days, six months, or six years!”

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Should You Breastfeed Your Husband or Partner?

Some people are interested in breastfeeding their partner, but is it safe? Here's how adult breastfeeding affects milk supply, plus other things to consider.

Many people are curious about adult breastfeeding, also known as erotic lactation. Generally speaking, breastfeeding your husband or partner is OK.

It's not perverted or wrong if you want the person you're intimate with to breastfeed, they ask to try nursing, or they're curious about the taste of your milk . It's also normal to be sexually interested in your partner's breasts even when they're producing milk. Plus, some people are more sensitive to breast stimulation in the postpartum phase, and they enjoy the sensation of feeding their partners.

Sharing this intimate experience with another adult can be satisfying for both of you, and it could bring you closer together as a couple. As long as both people are comfortable doing it—and barring a few situations that might pose a health risk—you can feel free to try it.

Keep reading to learn more about adult breastfeeding, how the practice affects breast milk supply, and how to start lactation if you're not already nursing. We also share circumstances where adult breastfeeding may not be safe.

Illustration by Julie Bang

Reasons Why Partners Want to Breastfeed

Some adults aren't interested in breastfeeding from their partner's milk-filled breasts. Others are curious about adult breastfeeding, interested in the taste of breast milk, or simply turned on by lactating breasts. This interest is perfectly normal. Here are some of the reasons why your partner may want to breastfeed.

Health benefits

Across the world, breast milk is used as a home remedy for certain conditions. But it's important to note that consuming breast milk has no research-proven health benefits for adults.

Fulfilling a fantasy

Your partner may be turned on by your lactating breasts, or they may have a sexual fantasy that involves breastfeeding. Erotic lactation and adult breastfeeding (adult nursing) websites and groups exist just for this purpose. So, as long as you feel comfortable, this is a fantasy that you can safely experience with your partner.

Feeling more included

Now that you're breastfeeding, your partner may feel as though your breasts are off-limits or reserved for the relationship you share with your baby. By giving your partner access to your breasts, they can feel included in the experience as well.

Tasting breast milk

Some partners just want to know how breast milk tastes. And, since breast milk is typically creamy and sweet, they may even like the flavor.

Reasons Why Lactating People Want to Breastfeed Their Partners

If you've been thinking about asking your partner to breastfeed, you're not alone, and there's nothing wrong with this desire. Some people are curious about how it would feel to breastfeed their partner, or they just want to include their lactating breasts in their intimate relationship. Here are several common reasons why some people consider it.

Balance out uneven breasts

If your baby has a breast preference—or if one of your breasts doesn't produce as much milk as the other—your partner can help even things out by nursing on the smaller or neglected side.

Boost breast milk supply

Breastfeeding works through supply and demand. Additional drainage of breast milk can naturally trigger your body to make more.

Prevent plugged milk ducts and engorgement

Your partner will have a stronger suck than your baby, so they can drain your breasts more thoroughly. This can prevent  clogged milk ducts  and  milk blebs , as well as relieve mild breast engorgement.

Heighten arousal and intimacy

Some people are sensitive to breast or nipple stimulation, and they may experience sexual feelings while breastfeeding their husband or partner. Indeed, adult breastfeeding could bring about an unexpected and enjoyable aspect of your sexual relationship.

Concerns About Breastfeeding Your Partner

It's normal to have some concerns about breastfeeding your partner. For example, you may wonder whether you'll have enough milk for your baby if your partner also breastfeeds, especially if you struggle with supply. However, the additional stimulation at your breast can actually help you produce more breast milk . If you're worried, consider nursing your baby first to ensure they have a full feeding before spending time with your partner.

You might also have doubts about the safety of this practice. Adult breastfeeding is usually safe, as long as the milk comes from someone you know (not bought online). HIV and other infectious diseases can pass through your breast milk, so understand any potential risks beforehand.

Just make sure your partner doesn't bite down on your nipples; this could lead to small breaks in the skin, which might develop into a breast infection and possibly interfere with your ability to continue breastfeeding your baby .

If you have any personal or emotional concerns about adult breastfeeding, talk to your partner about how you feel. By having an open line of communication and working out any uncertainty together, any experiences that you choose will be better for both of you. Consult with your OB-GYN if you have any practical or medical concerns about adult breastfeeding.

Can You Start Lactation to Breastfeed Your Partner?

Many people who enjoy adult breastfeeding do so after they're already nursing a child. However, this isn't necessarily a prerequisite for breastfeeding your partner.

You can start lactating without first giving birth, though it's not easy. The process requires a committed effort, which involves consistent pumping or hand expression to start and maintain lactation. Hormone-mimicking drugs are often needed in most cases. You can also take some medications and herbs that may help to support the process, though they aren't regulated in the U.S.

Consult your OB-GYN before taking any supplements or medications, and with any questions you may have about inducing lactation.

When Not to Breastfeed Your Partner

In general, breastfeeding your adult partner doesn't pose a problem, but it's not recommended in the following circumstances.

You feel uncomfortable

Some people aren't interested in breastfeeding their partner for a variety of reasons. Maybe you find it awkward or physically uncomfortable, you don't like the idea of sexualizing the practice, or you feel worn out from nursing your baby. Whatever is causing the reluctance, you should never feel pressured to do something that you don't want to do. Talk to your partner about your feelings and see if you can find a solution you'll both enjoy.

You have pain

If you're experiencing sore breasts, your nipples are very sensitive, or you have a painful let-down reflex, adult breastfeeding may hurt. The strength of an adult's suck can be even more painful than that of a baby.

Your have oversupply issues

If your breasts are engorged, nursing your partner may feel like a relief. However, the extra feeding sessions can cause your body to produce even more breast milk, which can be troublesome if you already have an  overabundant milk supply .

You have HIV or an infectious disease

HIV and other infectious diseases can enter your breast milk and pass on to your partner. Some sexually transmitted diseases, including herpes and syphilis, can also spread through breastfeeding if you have active sores on your breasts, nipples, or areola.  Your partner should be aware of any risks involved.

Your partner has an infection or virus

If your partner has a health issue—especially one that's transmitted through the mouth—they can give it to you and your baby through contact at the breast. Don't breastfeed your partner if they have a contagious infection or virus.

You or your baby has thrush

A yeast infection can pass quickly to your partner and back to you from breastfeeding. If you, your child, or your partner develop any signs of thrush —like a burning sensation around your nipple or white patches around the baby's mouth —call your doctor. You should all receive treatment as soon as possible.

You're pregnant and high risk

If you're pregnant with multiples , you've had a previous miscarriage, or you have a history of preterm labor, talk to your doctor about safe levels of stimulation at the breast. There's some evidence that breast and nipple stimulation can lead to uterine contractions and early labor, so you may want to hold off on adult breastfeeding if your pregnancy is considered high-risk.

Key Takeaways

While the practice isn't commonly discussed, some people enjoy adult breastfeeding. You might want to experiment with this practice for many reasons, though you might also find it uncomfortable. There aren't major health concerns in most cases, so if you're intrigued, free to try breastfeeding your husband or partner.

More than a lucrative liquid: the risks for adult consumers of human breast milk bought from the online market . J R Soc Med . 2015.

Lactation . Cleveland Clinic . Reviewed 2021.

Plugged Ducts, Mastitis, and Thrush . U.S. Department of Agriculture .

Low Milk Supply . U.S. Department of Agriculture .

Adult craze for breast milk bought online has health risks, experts warn .  BMJ . 2015.

Serious Illnesses and Breastfeeding . American Academy of Pediatrics . 2021.

Lactation . Cleveland Clinic .

Induced Lactation: Breastfeeding for Adoptive Parents . American Academy of Pediatrics . Updated 2022.

Sexually transmitted infections, pregnancy, and breastfeeding . Office on Women's Health. U.S. Department of Health and Human Services.

Thrush . United Kingdom National Health Service .

Breast‐feeding during pregnancy and the risk of miscarriage .  Perspect Sex Repro H . 2019.

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Effects of lactation room quality on working mothers' feelings and thoughts related to breastfeeding and work: a randomized controlled trial and a field experiment

Affiliations.

• 1 Department of Psychology, University of Groningen, Groningen, The Netherlands. [email protected].
• 2 NoorderRuimte, Research Centre for Built Environment, Hanze University of Applied Sciences, Groningen, The Netherlands. [email protected].
• 3 Department of Psychology, University of Groningen, Groningen, The Netherlands.
• 4 NoorderRuimte, Research Centre for Built Environment, Hanze University of Applied Sciences, Groningen, The Netherlands.
• 5 Faculty of Management and Organization, The Hague University of Applied Sciences, The Hague, The Netherlands.
• PMID: 35945573
• PMCID: PMC9361273
• DOI: 10.1186/s13006-022-00499-0

Background: The challenging combination of breastfeeding and work is one of the main reasons for early breastfeeding cessation. Although the availability of a lactation room (defined as a private space designated for milk expression or breastfeeding) is important in enabling the combination of breastfeeding and work, little is known about the effects of lactation room quality on mothers' feelings and thoughts related to breastfeeding and work. We hypothesized that a high-quality lactation room (designed using the Theory of Supportive Design) would cause mothers to experience less stress, have more positive thoughts about milk expression at work, perceive more organizational support, and report more subjective well-being, than a low-quality lactation room.

Methods: In an online randomized controlled trial (Study 1), Dutch mothers (N = 267) were shown either a high-quality or a low-quality lactation room (using pictures and descriptions for the manipulation) and were then asked about their feelings and thoughts. In a subsequent field experiment (Study 2) we modified the lactations rooms in a large organization in Groningen, the Netherlands, to manipulate lactation room quality, and asked mothers (N = 61) who used either a high-quality or low-quality lactation room to fill out surveys to assess the dependent variables.

Results: The online study showed that mothers exposed to the high-quality lactation room anticipated less stress, more positive cognitions about milk expression at work, more perceived organizational support, and more subjective well-being than mothers exposed to the low-quality lactation room (p < 0.05). Moreover, the effect of lactation room quality on perceived organizational support was especially pronounced for mothers who were higher in environmental sensitivity. The field experiment showed that use of the high-quality room led to less reported stress than use of the low-quality room (p < 0.05). We also found that mothers who were higher in environmental sensitivity perceived more control over milk expression at work and experienced more subjective well-being in the high-quality condition than in the low-quality condition (p < 0.05).

Conclusion: The current studies show that not only the availability, but also the quality of lactation rooms is important in facilitating the combination of breastfeeding and work.

Keywords: Breastfeeding; Environmental sensitivity; Facility management; Lactation room quality; Nursing facilities; Relaxation; Stress reduction; Theory of supportive design.

© 2022. The Author(s).

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Conflict of interest statement

The authors declare that they have no competing interests.

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• Lactation in Anesthesiology. Garcia-Marcinkiewicz AG, Titler SS. Garcia-Marcinkiewicz AG, et al. Anesthesiol Clin. 2022 Jun;40(2):235-243. doi: 10.1016/j.anclin.2022.01.014. Epub 2022 May 4. Anesthesiol Clin. 2022. PMID: 35659397 Review.
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Breastfeeding discussion highlights benefits of mother’s milk

During an intimate roundtable discussion in a Dorchester school, seasoned and expecting mothers recently exchanged information and experiences about their journeys with breastfeeding and the benefits of mother’s milk.

“I’m a mom of two young children, and I was shocked and terrified to learn that Black women are three times more likely than white women to die from pregnancy-related complications,” said Amber Payne, a discussion convener who serves as publisher and general manager of The Emancipator, a Boston-based nonprofit digital magazine.

“We are also less likely than white women to meet our own breastfeeding goals,” she said.

Payne and local radio host and breastfeeding advocate Pamela Cesar began the discussion in a meeting room at the Brooke Charter School by sharing their personal experiences with breastfeeding before opening the conversation up for the circle of participants.

“These listening sessions give us the opportunity to talk with people who are grappling with and living through these issues — at ground level,” said Payne. “They are experts on their own lives. They are also experts on what they need to thrive.”

Fabyola Faublas, an expecting first-time mother from Mattapan, attended the event hopeful that she would receive the information and support she needed to feel confident about breastfeeding her newborn when the time comes.

Participants share their experiences with breastfeeding. BANNER PHOTO

“That’s why I wanted to come, because I’m like I’m a new parent, I don’t know anything really about breastfeeding, so I wanted to come here and learn about any tips or challenges that people have gone through with breastfeeding and how I can avoid that or deal with it, and also just to inform myself about breastfeeding in general,” said Faublas.

Cesar offered her point of view as someone who experienced losing a child, in part because of formula-based milk provided by a hospital.

“My oldest was born at 32 weeks,” she said. “Despite that, I successfully breastfed her for almost two years and even had oversupply — but my son, who has since passed, was where I experienced complications. My son was also born prematurely in 2006, so breastfeeding wasn’t an option.”

He was given formula in the neonatal intensive care unit and developed necrotizing enterocolitis, an often-fatal bacterial condition linked to formula-feeding in neonatal infants, she said.

“My son Na’Kye is the inspiration for me advocating for breastfeeding within my community,” she said.

During the information exchange, Faublas and another first-time expecting mother, Brittany, were equally curious about how beneficial breastfeeding really is and how strongly they should consider it.

Lisa Mitchell, a registered nurse working in the Maternal Health Unit of Boston Medical Center, offered an abundance of advice both from her medical expertise and her personal experience as a mother of two now-adult children.

“I loved breastfeeding,” said Lisa. “I have to say, I was one of those moms that were very fortunate, I had pretty, very straightforward pregnancies with both children. And as a result, I wanted to always give back.”

While Lisa adopted nursing as a career later in life, she is adamant and passionate about the benefits of breastfeeding, not only for the baby but also for the mother.

“The benefits are amazing, not only for your baby, but if I’m going to speak for the mom, I felt such an energy and a clarity. I did not feel like I was weighted, or the weight of the world was on me. I felt empowered. I said, ‘I can feed my child.’ I felt invincible in many ways,” she said.

Mitchell breastfed both of her boys for 17 months before introducing them to other forms of nutrition. As she described her experience to the expecting mothers in the discussion, she was unwavering in her message that a mother’s milk is the best option.

“Moms are able to lose a lot of the extra weight and water weight that they developed during pregnancy. In reference to health and stress, the oxytocin that is released when you’re breastfeeding really does give you a high. It’s almost like a runner’s high that you can’t duplicate whatsoever,” she said.

“And the love and the bond and the calm and the serenity that you feel, in the strength and the womanhood and the being feminine and knowing that you have the power to give birth,” she added. “Men don’t have that power; we need them, but they don’t have that power to give birth like we do. And so, it is such a beautiful experience.”

Unfortunately, while Mitchell’s experience was idyllic, many Black and brown mothers do not experience the same ease when attempting breastfeeding for various reasons — with the necessity of going back to work high on the list.

In a National Institutes of Health study titled “Reflections of Black Women Who Choose to Breastfeed: Influences, Challenges and Supports,” Dr. Melanie Lutenbacher, Dr. Sharon M. Karp, and Dr. Elizabeth R. Moore conducted a controlled experiment to examine the experiences of Black women who chose to breastfeed.

The majority of women who participated were influenced by many factors in their decision to breastfeed. Still, most women found that what influenced them the most was the mentorship and guidance they received.

“All participants spoke of the importance of role models who contributed to their decision to breastfeed and then later as they breastfed their infants,” they reported. “Many participants did not identify any available role models, and to compensate, intentionally surrounded themselves with women who were either breastfeeding or had breastfed.”

A major hindrance to breastfeeding for Black women was having to switch to formula feeding when economic pressures forced them to return to their jobs or the classroom.

“[M]any participants found formula feeding easier when they returned to work. If they continued to breastfeed, they had to juggle work, breaks and pumping, sometimes without a supportive work environment,” said the report.

During the roundtable discussion, participants and facilitators were shocked to find that both expecting mothers in attendance weren’t even aware that they are legally entitled to a “mother’s room” in any work environment.

As the roundtable ended, the event facilitators conducted an activity where participants outlined the different obstacles and solutions they came up with during the discussion about breastfeeding and how they might move forward with the information they received during the exchange.

“Everyone’s experience is different,” said Payne during an interview after the discussion, “but I hope that by sharing our stories, we could also encourage [mothers] and ease their fears and anxieties around breastfeeding.” 

Because Black women are so disproportionately affected by the lack of support surrounding breastfeeding their infants, The Emancipator continues to be committed to encouraging conversations like these to enlighten Black women further about their maternal options and rights and provide them community and support.

“As journalists,” Payne stated, “I think it’s critical to give people the opportunity and platform to advocate for themselves.”

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Hidden camera experiment shows what people think of breastfeeding in public.

by Claire Gillespie

Claire Gillespie

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YouTubers Trollstation are known for their pranks but their latest video actually provides a valuable insight into people’s views on breastfeeding in public.

More: Politician threatens to “grab” breastfeeding mums’ nipples

Actress Amina Maz kicks off the 6-minute video on a platform at Elephant & Castle Tube station in London, explaining: “Today we’re doing a breastfeeding experiment. Let’s see if people find this uncomfortable.”

Aboard a busy Tube carriage Maz begins to “breastfeed” her baby (it’s actually a doll hidden under layers of blanket). Quickly a fellow passenger starts giving her a hard time — but he’s actually an actor, James Slattery. He accuses her of “exposing” herself and demands that she move to a different carriage.

Slattery starts off the exchange, which is being filmed by a hidden camera, by saying: “Excuse me… you’re not breastfeeding, are you?”

Maz replies: “I am… do you have a problem?” to which Slattery says: “I’m not trying to be argumentative or anything but I feel a little bit uncomfortable about it. It’s just a thing that’s been passed down in my family.”

More:  Why mums breastfeed in public: The truth and nothing but the truth

“There should be a designated carriage on here for it. I just don’t want you to do it in front of me. Why could you not make express or something before you came on here? I just feel uncomfortable,” he continues.

“My baby needs to eat,” Maz replies.

Other passengers then join in and the majority of them take Maz’s side. One woman asks James, ‘Why don’t you move onto the next carriage?” and another tells him, “You should probably move away.”

At one point a man moves seats to sit between Maz and Slattery, telling the latter that he is “behaving quite aggressively.”

Eventually the entire section of the carriage joins in, before the hidden camera is revealed and the passengers realise the whole thing was a prank. “We’re making a movie, so you’re a hero,” the man who sat between the actors is told.

The man said he found the exchange “a bit tense” and explained that he works in the mental health sector and “it’s our job.”

A female passenger said she thought Slattery’s reaction to the breastfeeding was “despicable.”

Watch the video in full below: 

Do you feel comfortable breastfeeding in public? Have you ever experienced negativity for doing so? Let us know.

More: Even Disney princesses can’t breastfeed in public without harassment

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Under close supervision of the Accounting Administrator I, Supervisor of the Debt Issuance and Cash Analysis Section, the Accountant Trainee, in a learning capacity, is responsible for performing the least complex professional accounting duties related to the management of bond issuance and administration of the State Water Project (SWP) debt portfolio including General Obligation bonds, Water Revenue bonds, and SWP commercial paper program. Provides the necessary support to issue bonds and commercial paper to finance the construction, improvement, and maintenance of the State Water Project.

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Department of Water Resources (DWR) was established in 1956 by the California State Legislature.  We manage California’s water resources, systems, and infrastructure, including the State Water Project, in a responsible sustainable way.

At DWR, we are embedding climate change response into every project we undertake. We have set standards to help evaluate how each project incorporates climate resilience principles and ensure consistency across the Department.  Our mission is to sustainably manage the water resources of California, in cooperation with other agencies, to benefit the state’s people and protect, restore, and enhance the natural and human environments.

DWR also strives to create a trusting and welcoming workplace where employees embrace diverse viewpoints and treat each other with civility and respect.  An important component of DWR’s equal employment opportunity program centers around +diversity, equity, and inclusion.

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Free career consultation services including one-on-one State career consultations, application/resume review, tips for applying, and mock interviews, provided by experienced recruiters are now available at the California Natural Resources Agency (CNRA) Career Center, located at the Poppy Pavilion, 715 P Street, Sacramento, CA 95814. Walk-ins are welcome every Tuesday and Thursday from 11am-4pm.

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Can Chemical Agents and Pollens Induce Food Allergies?

Aude Lecrubier

June 13, 2024

Can the increasingly present "irritants" in our environment, such as detergents or microplastics, alter the intestinal barrier and induce food allergies?

During a session at the French-speaking Allergy Congress, Virginie Doyen, MD, a pneumologist at University Hospital Namur in Namur, Belgium, reviewed the current knowledge on this subject, explaining that few studies have been conducted on the potential link between "irritants" and food allergies.

The mechanisms involved are progressive, and the multiple predisposing factors (eg, genetic, epigenetic, internal, and external environmental factors) make the study of this question particularly complex, said Doyen.

Poor Dietary Habits

Regarding changes in dietary habits, data indicate that the consumption of additives and preservatives, foods rich in sugars and fats, and foods low in short-chain fatty acids is associated with an increased risk for food allergies. In contrast, the Mediterranean diet during breastfeeding and pregnancy and a diet rich in fruits and vegetables during childhood are associated with a decreased risk for food allergies.

But by what mechanisms can poor dietary habits alter the protective systems at the intestinal level and allow food allergens, which are the origin of sensitization, to pass through? One hypothesis is that the lack of dietary fiber consumption could stimulate the degradation of intestinal mucus via the microbiome.

"Neglected by scientific work, mucus nonetheless plays an important role in the intestine by limiting exposure to antigens and maintaining immune tolerance. It is rich in glycoproteins, carbohydrates, antimicrobial peptides, and IgA [immunoglobulin A]," said Doyen. "It is also a niche for our commensal flora, which has immunomodulatory effects and can degrade this mucus if modified by our diet."

In addition, data from cellular models and experimental animal models show that ingesting large amounts of advanced glycation end products (eg, ultraprocessed food) seems to alter the intestinal barrier.

Researchers have shown that exposing epithelial cell cultures or peripheral blood mononuclear cells (PBMC) from children at risk for food allergy to advanced glycation end products leads to an alteration of tight junctions between epithelial cells, which ensure the cohesion of the intestinal barrier.

Contact with ultraprocessed foods reduces occludin, a component of these tight junctions, and the ZOT1 protein, which regulates these junctions. Allergens and other irritants, therefore, have the possibility of passing through the barrier.

Furthermore, following exposure to advanced glycation end products, researchers observed an increase in the production of T helper cells 2 (Th2)-type proinflammatory cytokines by PBMC and the alarm signals interleukin (IL)-25 and IL-33, which direct the Th2-type immune response.

Dysbiosis and a less diverse microbiome are observed in cases of food allergy. It seems that the initial alteration of the microbiome leads to a fragility of the intestinal barrier. However, a defective barrier due to a genetic mutation in filaggrin is also associated with an increased risk for peanut allergy. The relationship is bidirectional.

Detergents, Emulsifiers, Microplastics

Besides the effect of an unbalanced diet, chemical agents and pollens may have an indirect effect on the occurrence of food allergy symptoms in sensitized patients, said Doyen.

Studies have shown that emulsifiers (eg, lecithin, carboxymethylcellulose, sorbitol, monostearate, and polysorbate 80) that solubilize aqueous and oily phases affect the intestinal level. Contact with an emulsifier induces a thickening of the dense part of the intestinal mucus , which limits interactions between the epithelium and the intestinal flora.

The disruption of interactions between mucus and bacteria leads to a modification of the microbiota via a change in bacteria that express more proinflammatory molecules such as flagellins and lipopolysaccharides.

In mice, this activation of inflammatory processes has been associated with chronic inflammation in the digestive tract. In wild-type mice without predisposition, only metabolic disorders were observed. However, in predisposed mice, inflammatory colitis developed.

Regarding detergents (eg, residues from dishwasher detergents and rinse products on dishes), researchers have observed from explanted pseudo-organs that when tissues are not exposed to these detergents, the epithelial barrier is intact. However, if epithelial structures are exposed to detergents, the barrier shows alterations associated with an overexpression of genes involved in immune response and inflammatory processes.

Another experiment looked at the effect of the detergent sodium dodecyl sulfate , which is present in toothpaste, on the digestive epithelium. They found that it decreases the integrity of the epithelial barrier, promoting eosinophilia, CD4 lymphocyte–type inflammation, and remodeling of the intestinal epithelium. The altered barrier can promote the penetration of irritating substances, bacteria, or allergens.

As for microplastics (insoluble particles < 5 mm), data suggest that they penetrate tissues at the skin and respiratory levels. But what about the intestinal level?

Two studies in mice given food containing microplastics have shown that these microplastics penetrate the epithelium and induce dysbiosis. They reduce mucus production and alter the intestinal barrier function.

What About Pollen?

Pollution and climate change are responsible for increased protease activity in pollens. These pollens are responsible for an increasing number of respiratory allergies, but do they affect the intestinal barrier? An international study showed in a cellular culture model and in mice that actinidin (Act d 1), a kiwi allergen , causes a rupture of tight junctions and increased intestinal permeability.

In summary, food allergies are associated with an alteration of the digestive epithelial barrier, and experimental data suggest that certain irritants could contribute to this phenomenon, making us more susceptible to inflammatory reactions and inappropriate immune responses.

"It would be possible to consider joint actions in terms of prevention and therapy," said Doyen. "Therapeutic approaches could include antialarmin treatments, particularly anti-TSLP, which blocks the cascade of reactions at the starting point, at the epithelial level in severe asthma. We could also consider modifying the microbiota to act on mucus. Finally, there seems to be a dose factor. Limiting the quantity of all the toxic products we use, without completely abstaining from them, is probably a path to follow."

This story was translated from the Medscape French edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

Send comments and news tips to [email protected] .

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Effects of lactation room quality on working mothers’ feelings and thoughts related to breastfeeding and work: a randomized controlled trial and a field experiment

Sjoukje a. van dellen.

1 Department of Psychology, University of Groningen, Groningen, The Netherlands

2 NoorderRuimte, Research Centre for Built Environment, Hanze University of Applied Sciences, Groningen, The Netherlands

Barbara Wisse

Mark p. mobach.

3 Faculty of Management and Organization, The Hague University of Applied Sciences, The Hague, The Netherlands

Associated Data

All of the data generated or analysed during this study are included in this published article and in the supplementary information files.

The challenging combination of breastfeeding and work is one of the main reasons for early breastfeeding cessation. Although the availability of a lactation room (defined as a private space designated for milk expression or breastfeeding) is important in enabling the combination of breastfeeding and work, little is known about the effects of lactation room quality on mothers’ feelings and thoughts related to breastfeeding and work. We hypothesized that a high-quality lactation room (designed using the Theory of Supportive Design) would cause mothers to experience less stress, have more positive thoughts about milk expression at work, perceive more organizational support, and report more subjective well-being, than a low-quality lactation room.

In an online randomized controlled trial (Study 1), Dutch mothers ( N  = 267) were shown either a high-quality or a low-quality lactation room (using pictures and descriptions for the manipulation) and were then asked about their feelings and thoughts. In a subsequent field experiment (Study 2) we modified the lactations rooms in a large organization in Groningen, the Netherlands, to manipulate lactation room quality, and asked mothers ( N  = 61) who used either a high-quality or low-quality lactation room to fill out surveys to assess the dependent variables.

The online study showed that mothers exposed to the high-quality lactation room anticipated less stress, more positive cognitions about milk expression at work, more perceived organizational support, and more subjective well-being than mothers exposed to the low-quality lactation room ( p  <  0.05). Moreover, the effect of lactation room quality on perceived organizational support was especially pronounced for mothers who were higher in environmental sensitivity. The field experiment showed that use of the high-quality room led to less reported stress than use of the low-quality room ( p  <  0.05). We also found that mothers who were higher in environmental sensitivity perceived more control over milk expression at work and experienced more subjective well-being in the high-quality condition than in the low-quality condition ( p  <  0.05).

The current studies show that not only the availability, but also the quality of lactation rooms is important in facilitating the combination of breastfeeding and work.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-022-00499-0.

Research findings indicate that the challenging combination of breastfeeding and work is one of the main reasons for early breastfeeding cessation [ 1 , 2 ]. To prevent mothers from having to choose between breastfeeding and career development, it is important to find new ways to better support breastfeeding mothers at work. While many factors play a role in creating a breastfeeding-friendly environment in the workplace, paid breastfeeding breaks and the availability of a lactation room (defined as a private space designated for milk expression or breastfeeding) are important basic requirements for enabling mothers to continue breastfeeding their babies when they return to work. However, related maternity protection legislation differs per country; the provision of paid breastfeeding breaks is included in the legislation of 71% of the countries worldwide, but the provision of a lactation room is included in the legislation of only 31% of countries [ 3 ]. Furthermore, legislation rarely offers any guidance related to the quality of nursing facilities.

In the Netherlands, breastfeeding rates are relatively low: the percentages of exclusive breastfeeding (operationalized as still receiving breast milk without receiving infant formula) and any breastfeeding at 6 months of age are 19 and 28% respectively [ 4 ]. Mandatory paid maternity leave in the Netherlands is 16 weeks, with a minimal of 10 weeks postnatal leave (Article 3.1, paragraph 1–3 of the Labour and Care Act ). A breastfeeding mother is entitled to paid breastfeeding breaks during her workday until her infant is 9 months of age. The Dutch law furthermore states that an employer should provide a suitable, lockable, and private space for a breastfeeding employee (Article 4.8, paragraph 1 of the Working Hours Act ), but does not further specify what suitable means in this context. A recent cross-sectional study conducted in the Netherlands showed that lactation room quality was generally low, and that lactation room quality was positively related to mothers’ satisfaction with the room and perceived ease of and support for milk expression at work [ 5 ].

Experimental research on the causal impact of lactation room quality on mothers’ thoughts and feelings related to milk expression at work has been lacking so far. Therefore, we conducted two experimental studies to investigate if the use of a high-quality (vs. low-quality) lactation room reduces mothers’ stress, and has a positive influence on their cognitions about milk expression at work, perceived organisational support, and subjective well-being. Lactation room quality was manipulated using the recommendations of the Theory of Supportive Design, which states that the built environment can have a psychological impact on individuals [ 6 ]. In addition, we explored the extent to which these effects are more pronounced in mothers who are higher in environmental sensitivity, since these mothers have the tendency to process stimuli and information strongly and deeply [ 7 ] (see Fig.  1 ). With this research we hope to uncover whether the provision of a high-quality lactation room can contribute to facilitating the combination of breastfeeding and work.

Conceptual model and hypotheses

The provision of lactation rooms to support breastfeeding

Breastfeeding women need to breastfeed or express milk regularly during the day in order to maintain milk supply and avoid medical problems related to a build-up of milk. For women who want to combine breastfeeding and work it is therefore important that measures are taken to enable breastfeeding or milk expression during working hours. Although there are several other options, such as allowing breastfeeding breaks at home or at the day-care, arguably the most common solution is to provide women with a lactation room at work where they can pump milk for their baby. Various studies have investigated if the presence of a lactation room can support breastfeeding by working mothers. A 2017 review found positive effects of access to a lactation space on breastfeeding initiation, breastfeeding duration, breastfeeding exclusivity, use of infant formula, predominant breastfeeding, and job satisfaction [ 8 ]. Yet, effects were not always strong and sometimes effects could only be found when certain conditions were met. For instance, one study found that while access to a lactation space did not have a significant effect on its own, the combination of an available lactation space and a refrigerator was associated with continued breastfeeding [ 9 ]. It may be that, apart from lactation room availability , lactation room quality is also important in predicting working mothers’ responses. Research on the effects of lactation room quality, however, is scarce. Moreover, guidelines on lactation room design are often limited to functional aspects. For instance, in the Netherlands the law states that a lactation room should be suitable, lockable, and private (Article 4.8, paragraph 1 of the Working Hours Act ). Further directives explain that the lactation room should be lockable from the inside, it should have good hygiene and sufficient privacy, it should be sufficiently quiet and secluded, it should have a bed or couch, sufficient fresh air and climate control facilities, and there should be no risks involved (such as the presence of hazardous materials and contaminants) [ 10 ]. Although these basic functional requirements are a helpful starting point, they are not construed with the notion in mind that going above and beyond these basic aspects may have additional positive consequences for how mothers feel about combining breastfeeding and work. In the following, we will explain 1) how high-quality lactation rooms can be designed, and 2) why we think that lactation room quality may impact stress, cognitions about milk expression at work, perceived organizational support, and subjective well-being.

Enhancing lactation room quality by applying the theory of supportive design

In line with the tenets of a recent cross-sectional study on lactation room quality [ 5 ], we posit that the quality of lactation rooms is determined by more than just basic functional aspects. Just like the quality of office rooms is enhanced by, for instance, indoor air quality, thermal comfort, lighting, acoustics, and natural, aesthetic and recreational aspects [ 11 ], the quality of lactation rooms is also dependent on more than the bare essentials required by legislation. A theory that provides guidance in how high quality lactations rooms can be designed is Ulrich’s Theory of Supportive Design [ 6 ]. The Theory of Supportive Design stems from a school of thought promoting evidence-based design in healthcare settings in order to create so-called ‘healing environments’. Literature reviews offer evidence that the built environment may indeed affect the health and well-being of users in healthcare settings [ 12 – 14 ]. Ulrich based his theory largely on the observation that, traditionally, the interior design of health facilities has emphasized only the functional delivery of healthcare, leading to facilities that may seem effective, but are also stressful because they don’t attend to the psychological needs of patients. The Theory of Supportive Design argues that more accommodating designs can reduce stress, by fostering perceptions of control, offering positive distraction, and encouraging social support [ 6 ]. Thus, to be considered high-quality, a room should address both psychological and functional needs. Applying these insights to lactation room design we argue that lactation rooms that incorporate the principles of the Theory of Supportive Design (by fostering perceptions of control, offering positive distraction, and encouraging social support) should be considered higher quality lactation rooms than rooms that do not incorporate these principles.

Impact of lactation room quality on breastfeeding mothers

Based on the above, we first of all hypothesized that a high-quality lactation room, designed by the principles of the Theory of Supportive Design, will reduce mothers’ stress levels to a larger extent than rooms that are designed without adhering to those principles. Stress-reducing qualities may be particularly relevant for a lactation room, as stress has been shown to interfere with the release of oxytocin, a hormone responsible for the milk ejection reflex, and may thus lead to a disruption of the milk flow and a reduced milk volume, hence adversely affecting the process of breastfeeding [ 15 – 17 ]. Moreover, a recent review showed that stress reduction and relaxation can indeed help to improve breastfeeding outcomes [ 18 ]. Two recent studies that focused specifically on testing the tenets of Ulrich’s theory [ 6 ] showed that the greater the number of design features fostering perceptions of control, positive distraction, and social support, the lower patients’ perceived stress turned out to be [ 19 , 20 ]. Although these studies focused on patients in hospital environments, we posit that these findings may apply to breastfeeding mothers in work settings as well. Therefore, we hypothesized that when mothers use a high-quality lactation room, they will experience lower stress levels than when they use a low-quality lactation room (Hypothesis 1, see Fig. ​ Fig.1 1 ).

Apart from reducing mothers’ stress levels, we hypothesized that high-quality lactation rooms may have additional beneficial effects, in particular on mothers’ thoughts related to milk expression at work. Evidence in this direction comes from a recent cross-sectional study that found an association between lactation room quality on the one hand and perceived behavioural control and perceived support for milk expression at work on the other [ 5 ]. In the current experimental study, we therefore examined the effects of lactation room quality on perceived behavioural control and perceived support for milk expression at work, and added two additional cognitions that are theoretically considered important in predicting behaviour [ 21 ]: attitude towards expressing milk at work, and intention to express milk at work. We hypothesized that when mothers use a high-quality lactation room, they will have more positive cognitions about milk expression at work than when they use a low-quality lactation room (Hypothesis 2, see Fig. ​ Fig.1 1 ).

Finally, we expect that lactation room quality may have an impact beyond mothers’ cognitions about milk expression at work. Since a lactating working mother spends several hours of her working week in a lactation room, lactation room quality may also affect cognitions that are not directly tied to breastfeeding and milk expression. In the current study, we focused in particular on whether lactation room quality influences mothers’ perceptions of organizational support and their subjective well-being. Perceived organizational support refers to the extent to which employees believe that the organization values their contribution and cares about their well-being, and has been shown to be positively related to favourable outcomes for employees (e.g., job satisfaction, positive mood) as well as organizations (e.g., affective commitment, performance, and lessened withdrawal behaviour [ 22 ]). A recent meta-analysis has shown that perceptions of family-supportive work practices are related to perceived organizational support, especially for those employees who need such practices [ 23 ]. Viewing the provision of high-quality breastfeeding facilities as family-supportive work practices, we hypothesized that when mothers use a high-quality lactation room, they will perceive more organizational support than when they use a low-quality lactation room (Hypothesis 3, see Fig. ​ Fig.1 1 ).

Subjective well-being refers to people’s cognitive and affective evaluations of their lives, or in other words, to the extent to which people are happy and satisfied with their lives [ 24 ]. Subjective well-being is associated with a wide spectrum of favourable outcomes, such as good health and longevity, better social relationships, creativity, and work performance [ 24 ]. A recent review has shown that a positive work-life balance is related to life satisfaction [ 25 ], which is one of the core components of subjective well-being [ 26 ]. Viewing high-quality breastfeeding facilities as a way of improving the work-life balance of breastfeeding employees, we hypothesized that when mothers use a high-quality lactation room, they will report more subjective well-being than when they use a low-quality lactation room (Hypothesis 4, see Fig. ​ Fig.1 1 ).

Exploring the influence of individual differences in environmental sensitivity

When investigating the effect of environmental features on people, it is important to take into account that not all individuals may react equally to variations in the external environment. One variable that may be of particular importance in this regard is environmental sensitivity. Environmental sensitivity, measured as sensory processing sensitivity, is viewed as a fundamental trait and is defined as the degree to which an individual registers, processes, and responds to external stimuli [ 7 , 27 ]. Whereas one person may be very sensitive to environmental influences, another may remain unperturbable under all circumstances. Although studies on the role of sensory processing sensitivity in environmental interventions are largely lacking, previous research with a precursory measure of environmental sensitivity – i.e., stimulus screening and arousability [ 28 ] – showed that this variable could moderate the effects of environmental interventions. For example, it was found that stimulus screening and arousability moderated people’s stress, arousal, and cognitive appraisals of a room in reaction to colour-use in a simulated hospital room [ 29 ] as well as workers’ productivity in reaction to colour-use in office settings [ 30 ], indicating that people high in stimulus screening and arousability show stronger reactions to environmental interventions. Based on this research, we expect that the effects of lactation room quality will be stronger to the extent that mothers are higher in environmental sensitivity (see Fig. ​ Fig.1). 1 ). Given the lack of direct empirical support for this notion, we will investigate whether this is the case in exploratory moderation analyses.

In sum, we aimed to investigate the influence of lactation room quality on working mothers’ feelings and thoughts related to breastfeeding and work. We hypothesized that a high-quality lactation room will reduce mothers’ stress, and have a positive influence on their cognitions about milk expression at work, perceived organisational support, and subjective well-being. In addition, we expected these effects to be more pronounced to the extent that mothers are higher in environmental sensitivity. We used a mixed-methods research design and tested our hypotheses in two methodologically complementary studies. We used an online randomized controlled trial to minimize threats to internal validity (Study 1) and a field experiment to improve the ecological validity of the research findings (Study 2).

Study 1: a randomized controlled trial

Design and participants.

Study 1 was set up as a randomized controlled trial, which is considered the golden standard for testing causal claims, because it minimizes threats to internal validity [ 31 ]. A total of 267 Dutch mothers participated in an online study that employed a 1 × 2 (lactation room quality: high versus low) between-subjects experimental design. Mothers were randomly assigned to either the high-quality lactation room condition ( n  = 136) or the low-quality lactation room condition ( n  = 121), using pictures and descriptions for the manipulation of lactation room quality. Environmental sensitivity was added to the design as a continuous variable. Inclusion criteria were: (1) current or previous experience with breastfeeding and (2) being employed. Exclusion criteria were: (1) not meeting the inclusion criteria, and (2) age and/or completion time deviating more than 3 SD from the mean. The mothers had a mean age of 32.5 years (SD = 4.3), and worked on average 27.1 hours per week (SD = 6.8).

Mothers were recruited through a message on the Facebook page of a popular Dutch website with breastfeeding information and were informed that breastfeeding and/or parenting books would be raffled among the participants who completed the survey. All mothers provided their informed consent before initiating the survey. First, we assessed environmental sensitivity, then mothers were randomly assigned to either the high-quality or the low-quality lactation room condition. They were shown pictures and a description of either the high-quality or the low-quality lactation room, and asked to imagine a scenario where they made use of this lactation room to express milk. After viewing the pictures and reading the description, they answered the survey questions comprising a manipulation check, the dependent variables, and demographic items.

Manipulation of lactation room quality

The manipulation of lactation room quality was based on the premise that a high-quality lactation room should not only meet the basic functional requirements, but should also follow the recommendations from the Theory of Supportive Design [ 6 ]. The stimulus materials for the high-quality and the low-quality lactation room conditions consisted of design drawings created by a professional interior designer, accompanied by a matching description of the room. The design drawings of the low-quality lactation room were based on examples of existing Dutch lactation rooms that only met the minimum requirements for lactation rooms according to Dutch law and guidelines, but did not foster perceptions of control, positive distraction, or social support. These design drawings showed a white room, containing a chair, a table, and a hospital bed. The design drawings of the high-quality lactation room met the minimum requirements, and in addition they aimed at fostering perceptions of control (e.g., adjustable lighting and pillows), positive distraction (e.g., nature images and decoration), and social support (e.g., supportive messages about breastfeeding). The drawings in this condition showed a room decorated with green paint on one wall and a forest-photo-wallpaper on another wall, containing a comfortable chair, a table, a bed, and many decorations, such as: pillows, a mood light, a bulletin board, books, ceramic plants, a radio etc. Both design drawings were accompanied by the following text: ‘Below you can see images of one lactation room from three different viewpoints, and a list of the available facilities. Study these images and the accompanying text carefully. Imagine expressing milk in such a room; try to imagine what this would feel like.’ For the low-quality lactation room, the text proceeded as follows: ‘This lactation room contains the following: A chair, a table for the breast pump, and a bed. There is also an adjoining room with a sink, and a door with a lock.’ In contrast, for the high-quality lactation room the text proceeded as follows: ‘This lactation room contains the following: a chair, a table for the breast pump, a bed with pillows, a mood light, a bulletin board, a card with the text: ‘Good that you are here! Take your time’, two shelves, a breastfeeding book, two picture books with nature images, a radio and 3 ceramic plants, wallpaper with an image of sun rays in the forest, a cabinet with two drawers. There is also an adjoining room with a sink, and a door with a lock.’ Because the study took place during the COVID-19 pandemic, we added information in both conditions about hygienic measures (indicating that the room is cleaned daily and that water and soap, paper towels, hygienic wipes, and disinfecting hand gel are also provided). See Fig.  2 a and b for the design drawings.

a Drawings of the high-quality lactation rooms. b Drawings of the low-quality lactation rooms

Manipulation check

To verify that our manipulation of lactation room quality based on the Theory of Supportive Design was successful, we developed a 4-item scale. Items were: ‘This room contains images of nature’, ‘This room contains nice, beautiful, or interesting things’, ‘This room is adjustable to my needs’, ‘This room makes me feel supported in milk expression at work’. Mothers were asked to indicate their agreement on a seven-point Likert scale from (1) ‘totally disagree’ to (7) ‘totally agree’ (α = .79). Furthermore, we asked mothers to award a report grade for lactation room quality on a scale of 1 to 10 (1 = very bad; 10 = very good). As intended, one-way ANOVAs showed that mothers perceived the high-quality lactation room as being more consistent with the Theory of Supportive Design ( M = 6.01, SD  = 0.68) than the low-quality lactation room condition ( M  = 3.13, SD  = 0.88, F (1,265) = 893.60, p  <  0.001). Moreover, mothers awarded a higher report grade for lactation room quality in the high-quality lactation room condition ( M = 8.93, SD  = 1.14) than in the low-quality lactation room condition ( M  = 6.69, SD  = 1.57, F (1,265) = 981,01, p  <  0.001). We therefore conclude that our manipulation of lactation room quality was successful.

Environmental sensitivity

Environmental sensitivity was assessed before participants saw the design drawings and consisted of the 12-item short version of the HSP Scale [ 7 , 32 ]. Example items of the HSP-scale are ‘Do you notice and enjoy delicate or fine scents, tastes, sounds, works of art?’ and ‘Are you bothered by intense stimuli, like loud noises or chaotic scenes?’ Answering options ranged from 1 ‘not at all’ to 7 ‘extremely’. The internal consistency of the scale was good (α = .82).

Anticipated stress was measured using the short version of the State-Trait Anxiety Inventory for adults [ 33 ]; this short version [ 34 ] is well validated and has been shown to correlate highly with physiological measures of stress [ 35 ]. Mothers could indicate on a four-point Likert scale, ranging from (1) ‘not at all’, to (4) ‘very much so’ the extent to which they would feel calm/ tense/ upset/ relaxed/ content/ worried in the room that was shown to them (α = .82).

Cognitions about milk expression at work

Anticipated attitude, perceived support, and perceived behavioural control towards milk expression at work were operationalized according to the guidelines by Ajzen [ 21 , 36 ]. Attitude was measured by presenting mothers with the following statement: ‘For me expressing milk at work in the room that was shown would be…’. This statement was followed by three 7-point, semantic, differential adjective scales: ‘unenjoyable – enjoyable, unpleasant – pleasant, negative – positive’ (α = .94). Perceived support was measured with four bipolar items: ‘Judging from the room that was shown I think that my supervisor approves of me expressing breast milk at work’ and ‘Judging from the room that was shown I think that my supervisor supports me expressing breast milk at work’. These two items were then repeated, replacing ‘my supervisor’ with ‘my co-workers’. All of the items were answered using a 7-point Likert scale, ranging from (1) ‘strongly disagree’ to (7) ‘strongly agree’ (α = .93). Perceived behavioural control was measured by two items: ‘In the room that was shown, expressing milk at work would be…for me’, rated on a scale from (1) ‘impossible’ to (7) ‘possible’, and ‘In the room that was shown, I could express milk at work if I wanted to’, rated on a scale from 1 ‘strongly disagree’ to 7 ‘strongly agree’ (α = .61). Anticipated intention to express milk at work was measured with a single item, based on an Australian study on breastfeeding duration [ 37 ]. The item was: ‘How long would you like to express milk at work if the lactation room shown was available at work? In that case, I would like to express milk at work until my baby is ... months old’. Participants were asked to indicate their intended duration of milk expression at work as a whole number of months.

Perceived organizational support

Perceived organizational support was measured by selecting eight high-loading items (loadings from .71 to .84) from the Survey of perceived organizational support [ 38 ]. Examples of items that were used are: ‘The organization fails to appreciate any extra effort from me’ (reversed), ‘The organization really cares about my well-being’, ‘The organization cares about my general satisfaction at work’, ‘The organization shows very little concern for me’ (reversed). The statements were preceded by the sentence: ‘Taking into account the room that was shown I would think that…’. Participants indicated their agreement with each item using a 7-point Likert-type scale (1) ‘strongly disagree’, (7) ‘strongly agree’ (α = .92).

Subjective well-being

Subjective well-being was measured based on the 2-item scale developed by Statistics Netherlands [ 39 ]. The items were: ‘On a scale from 1 to 10 can you indicate to what extent you would consider yourself to be a happy person if you expressed milk in the room that was shown? (1 = completely unhappy, 10 = completely happy)’ and ‘On a scale from 1 to 10 can you indicate how satisfied would you be with the life you lead at the moment if you expressed milk in the room that was shown? (1 = completely dissatisfied and 10 = completely satisfied)’ (α = .93).

Study 2: a field experiment

To complement the results of Study 1 and improve the ecological validity of our research findings, a second experimental study was conducted in a real-life setting. A total of 61 lactating employees from a large hospital in Groningen, the Netherlands, participated in the research. Since on average 90 mothers make use of the lactation rooms on the maternity ward each year according to the secretary of the ward (Mollema, Y., personal communication, August 15, 2017), 61 participants over a two-year period reflects a response rate of approximately 34%. We used a 1 × 2 (lactation room quality: high versus low) between-subjects experimental design, with two measurement points: the first (T1) as soon as the mother returned to work (or maximally four weeks afterwards), and the second (T2) four weeks after their return to work (thereby making sure mothers could have used the lactation room for at least four weeks). Although the intention was that mothers filled in the T1 questionnaire as soon as they returned to work, most mothers signed up somewhat later. It was decided that the T1 questionnaire could be filled in maximally four weeks after the return to work. Environmental sensitivity was added to the design as a continuous variable. Inclusion criteria were: (1) returning from maternity leave no more than 4 weeks prior to T1, and (2) making use of the lactation rooms on the maternity ward of the hospital at work at T1. Exclusion criteria were: (1) no longer making use of the respective lactation rooms at work at T2. The experiment took place over a two-year period: from June 2018 until June 2020. In the first year, all participating mothers were assigned to the low-quality lactation room condition ( n  = 32) and in the second year all participating mothers were assigned to the high-quality lactation room condition ( n  = 29). The mothers had a mean age of 31.5 years ( SD  = 3.1) and worked on average 30.3 hours per week ( SD  = 7.1). On average mothers used the lactation room 5.8 times per week ( SD  = 2.8). About two thirds of the mothers (62.7%) also used an alternative lactation room ( M  = 3.4 times per week; SD  = 2.4). There were no significant differences between mothers in the experimental group and the control group with regard to these characteristics.

Mothers were recruited by placing flyers in the three lactation rooms in the maternity ward at the hospital. The flyers pointed out that participants for a study on experiences with milk expression at work were sought and that breastfeeding and/or parenting books would be raffled among the participants who completed the survey. Mothers could receive further information and an invitation to participate, by leaving their name, e-mail, and the date they had returned from maternity leave on a participation form. Every mother who handed in the participation form (at the front desk of the maternity ward), received a chocolate bar as a token of our gratitude. Invitations for the pre-test questionnaire were sent as soon as the mothers signed up for the study, mostly in the first week after they returned to work. Invitations for the post-test questionnaire were sent four weeks after the mothers returned to work. We emphasized that participation in the study was anonymous and voluntary and that they could withdraw from the study at any time. All mothers provided their informed consent before continuing to the survey. In the pre-test, mothers answered survey questions about their environmental sensitivity and demographic information. In the post-test, when mothers had been using the hospital’s lactation room for at least four weeks, they answered survey questions comprising a manipulation check and the dependent variables.

The manipulation of lactation room quality corresponded to that in Study 1, but in the field experiment, we used and adapted the existing lactation rooms in the maternity ward of the hospital. In the low-quality condition, mothers made use of three identical standard lactation rooms in the hospital maternity wards where the research took place. These low-quality lactation rooms were basic white hospital rooms, containing a chair, a table, a hospital bed, and a hospital grade breast pump (which prevented unwanted individual variance in pumping experiences due to the breast pump used.) After one year the three lactation rooms were refurbished and painted in order to create the high-quality condition, based on the design drawings that had been created for Study 1. Similar to Study 1, these high-quality lactation rooms were identically decorated with green paint on one wall and a forest-photo-wallpaper on another wall, they contained a comfortable chair, a table, a bed with multiple pillows, a mood light, a bulletin board, with a card that welcomed mothers to the lactation room, a breastfeeding information book, two picture books with nature images, ceramic plants, a cabinet with two drawers, and a hospital grade breast pump. For photographs of the lactation rooms in the high-quality and the low-quality condition, see Fig.  3 a and b.

a Photos of the high-quality lactation rooms. b Photos of the low-quality lactation rooms

The manipulation checks (α = .86 for the 4-item scale) were measured exactly as in Study 1. As intended, one-way ANOVAs showed that mothers perceived the high-quality lactation room as being more consistent with the Theory of Supportive Design ( M  = 5.45, SD  = 0.90) than the low-quality lactation room condition ( M  = 2.28, SD  = 0.86, F(1,59) = 196.18, p  <  0.001). Moreover, mothers awarded a higher report grade for lactation room quality in the high-quality lactation room condition ( M = 7.79, SD  = 0.94) than in the low-quality lactation room condition ( M  = 6.22, SD  = 1.52, F(1,59) = 23.12, p <  0.001). We therefore conclude that our manipulation of lactation room quality was again successful.

The measures we used corresponded to the ones we used in Study 1. We made some small adjustments in wording, taking into account that this was a field study instead of a scenario study. This, for instance, allowed us to use the present tense (e.g., I feel) instead of the conditional simple tense (e.g., I would feel).

Environmental sensitivity (α = .81) was measured exactly as in Study 1. Stress (α = .81), subjective well-being (α = .76), and perceived organizational support (α = .90) were measured using the same items as in Study 1, but stated in the present tense. To assess attitude (α = .88), perceived support (α = .87), and perceived behavioural control (α = .77) towards milk expression at work we used similar measures as in Study 1. However, we specified the behaviour of ‘expressing milk at work’ further by adding ‘until my baby is at least 6 months old’. Moreover, for the measurement of attitude we added two semantic, differential adjective scales: ‘worthless – valuable’ and ‘useless – useful’, to also include utilitarian aspects of attitude [ 40 ]. For perceived behavioural control we added 2 items to improve the reliability of the scale: ‘For me pumping milk at work until my baby is at least 6 months old is…’, rated on a scale from 1 ‘hard’ to 7 ‘easy’, and ‘It is mostly up to me whether or not I pump milk at work until my baby is at least 6 months old’, rated on a scale from 1 ‘strongly disagree’ to 7 ‘strongly agree’. We replaced the intention to express milk at work of Study 1 with a 3-item measure based on the guidelines developed by Ajzen [ 21 ]. Answer options were on a scale from (1) ‘strongly disagree’ to (7) ‘strongly agree’. The items were: ‘I intend to express milk at work until my baby is at least 6 months old’, ‘I will do my best to express milk at work until my baby is at least 6 months old’, and ‘I plan to express milk at work until my baby is at least 6 months old’ (α = .94).

One-way ANOVAs were performed to test the hypotheses. A p -value of 0.05 was considered significant ( p  <  0.020 after applying Holm-Bonferroni correction to reduce the chance of a type I error). First, as hypothesized, mothers anticipated to experience less stress when the lactation room was high-quality rather than low-quality (see Table  1 ). Furthermore, mothers that were presented a lactation room that was high-quality as compared to low-quality anticipated to have a more positive attitude towards expressing milk at work, to perceive more support from managers and coworkers, and to have more behavioural control towards expressing milk at work. Finally, mothers in the high-quality lactation room condition anticipated to perceive a higher level of organizational support, and to experience a higher level of subjective well-being than did mothers in the low-quality lactation room condition. Contrary to expectations, the intended duration of breastfeeding did not differ for mothers presented with the high-quality or low-quality lactation room condition.

One-way ANOVA reports the effect of lactation room quality on the dependent variables ( N  = 267)

Note : df = 1, df error = 265 for all seven tests. *Significant at p  < 0.020

Exploratory analyses of the moderating role of environmental sensitivity

Hayes Process macro [ 41 ] (model 1) was used to test whether environmental sensitivity moderated the effect of lactation room quality on each of our dependent measures. A p -value of 0.05 was considered significant (we decided not to apply a Holm-Bonferroni correction in these exploratory analyses, because we did not want to increase the chance of a type II error because of the exploratory nature of the analyses). For the main effects, we found that in the high-quality condition mothers anticipated less stress ( b  = − 3.13, t  = − 11.02, p  <  0.001), a more positive attitude towards milk expression at work ( b  = 1.49, t  = 10.13, p  <  0.001), more support from managers and coworkers ( b  = .86, t  = 5.50, p  <  0.001), more behavioural control towards expressing milk at work ( b  = .31, t  = 2.58, p  <  0.01), more organizational support ( b  = 1.25, t  = 10.12, p  <  0.001), and more subjective well-being ( b  = 1.60, t  = 9.99, p  <  0.001) than in the low-quality condition. Furthermore, we found that as mothers scored higher on environmental sensitivity, they anticipated more stress ( b  = .58, t  = 2.43, p  < 0.05), a less positive attitude towards milk expression at work ( b  = −.36, t  = − 2.92, p  < 0.01), less organizational support ( b  = −.25, t  = − 2.47, p  < 0.05), and less subjective well-being ( b  = −.30, t  = − 2.24, p  < 0.05). Apart from these main effects, we also found a significant interaction effect of lactation room quality and environmental sensitivity on perceived organizational support ( b  = .27, t (263) = 1.98, p  < 0.05). Simple slopes analysis [ 42 ] showed that there was a significant positive relationship between lactation room quality and perceived organizational support when environmental sensitivity was both low (− 1 SD ; b =  1.00, t  = 5.69, p  < 0.001) and high (+ 1 SD , b =  1.49, t  = 8.56, p  < 0.001), but that the effect was stronger in the latter case. This means that, in line with our expectations, the effect of lactation room quality on perceived organizational support was especially pronounced for mothers who are high in environmental sensitivity, see Fig.  4 . No other significant interaction effects were found.

Moderating effect of environmental sensitivity in the relationship between lactation room quality and perceived organizational support

One-way ANOVAs were performed to test the hypotheses; again, a p -value of 0.05 was considered significant ( p  < 0.021 after applying Holm-Bonferroni correction to reduce the chance of a type I error). As hypothesized, mothers experienced less stress when the lactation room was high-quality rather than low-quality (see Table  2 ). Although other main effects were in the expected direction, they were not significant. During the last few months of this research the COVID-19 pandemic reached the Netherlands. To rule out that these circumstances influenced the results, we also analyzed the data while excluding those mothers that filled out questionnaires during the COVID-19 pandemic. This reduced the sample to 55 participants; the conclusions flowing from the analysis remained the same as with the larger sample of 61 participants.

One-way ANOVA reports the effect of lactation room quality on the dependent variables ( N  = 61)

Note : df = 1, df error = 59 for all seven tests. *Significant at p  < 0.021

Hayes Process macro [ 41 ] (model 1) was used to test whether environmental sensitivity moderated the effect of lactation room quality on each of our dependent measures. A p -value of 0.05 was considered significant (again, we decided not to apply a Holm-Bonferroni correction here, because we did not want to increase the chance of a type II error). For the main effects, we found that in the high-quality condition mothers anticipated less stress ( b  = − 2.15, t  = − 3.03, p  < 0.01) than in the low-quality condition. Furthermore, we found that as mothers scored higher on environmental sensitivity, they experienced less subjective well-being ( b =  −.46, t  = − 2.47, p  < 0.05). Apart from these main effect, we also found two interaction effects.

First, we found a significant interaction effect of lactation room quality and environmental sensitivity on perceived behavioural control ( b =  .82, t (57) = 2.57, p  < 0.05). Simple slopes analysis showed that there was a significant positive relationship between lactation room quality and perceived behavioural control when environmental sensitivity was high (+ 1 SD , b =  .79, t  = 2.01, p  < 0.05), which was not the case when environmental sensitivity was low (− 1 SD , b =  −.68, t  = − 1.75, p =  .09). This means that the positive effect of lactation room quality on perceived control was only present for mothers who are high in environmental sensitivity, see Fig.  5 .

Moderating effect of environmental sensitivity in the relationship between lactation room quality and perceived behavioural control

Second, we found a significant interaction effect of lactation room quality and environmental sensitivity on subjective well-being ( b =  0.52, t (57) = 2.30, p  < 0.05). Simple slopes analysis showed that there was a significant positive relationship between lactation room quality and subjective well-being when environmental sensitivity was high (+ 1 SD, b =  0.73, t  = 2.63, p  < 0.05), which was not the case when environmental sensitivity was low (− 1 SD, b =  − 0.20, t  = −.73, p =  .47). This means that the positive effect of lactation room quality on subjective well-being was only present for mothers who are high in environmental sensitivity, see Fig.  6 . No other significant interaction effects were found.

Moderating effect of environmental sensitivity on the relationship between lactation room quality and subjective well-being

In the current paper, we reported two methodologically complementary experiments, both examining the effects of lactation room quality on mothers’ feelings and thoughts. In Study 1, an online scenario study, we found that mothers exposed to a high-quality lactation room anticipated less stress, more positive cognitions about milk expression at work, more perceived organizational support, and more subjective well-being than mothers exposed to a low-quality lactation room. Also, we found that environmental sensitivity moderated the effect of lactation room quality on perceived organizational support. Specifically, we found that the positive effect of lactation room quality on perceived organizational support was more pronounced for mothers higher in environmental sensitivity. In Study 2, a field experiment, we replicated some, but not all of the findings. Importantly, we again found that mothers who used the high-quality room experienced less stress than mothers who used the low-quality room. Moreover, although we did not find significant main effects for other dependent variables in Study 2, we did find significant interaction effects of lactation room quality and environmental sensitivity on perceived behavioural control and subjective well-being. That is, mothers who scored higher on environmental sensitivity, experienced more behavioural control and subjective well-being in the high-quality condition than in the low-quality condition. Mothers who scored lower on environmental sensitivity were not affected by the quality of the lactation room with respect to experienced control and subjective well-being.

Our aim with this research was to uncover whether the provision of a high-quality lactation room could help to facilitate the combination of breastfeeding and work, and our results suggest that this is indeed the case, especially so for mothers higher in environmental sensitivity. The fact that Study 2 had less significant results as compared to Study 1, could be explained by the fact that people sometimes overestimate the extent to which certain prospective events or conditions will impact their responses (a so-called impact bias [ 43 ]). Because Study 1 assessed mothers’ anticipated responses to hypothetical lactation rooms (that is, they saw drawings of rooms and were asked to imagine making use of that room), they may have underestimated the extent to which other factors may also influence their stress-levels and cognitions (so-called focalism [ 43 ]), and they may have overestimated the effect of lactation room quality. Given the generally weaker effects in Study 2, mothers may indeed have overestimated the effects of lactation room quality to some extent in Study 1. However, another potentially relevant factor may be that the sample size in Study 2 was limited to 61 participants. As such, the statistical power was on the low side, and this may have hampered the obtainment of significant results.

Our findings have several theoretical implications. Importantly, we found support for the expected positive effect of lactation room quality on mothers’ stress-levels (Hypothesis 1) in both studies. This confirms the tenets of the Theory of Supportive Design, stating that a design that fosters perceptions of control, offers positive distraction, and encourages social support can reduce stress levels [ 6 ] - as corroborated in two previous studies [ 19 , 20 ]. Even though the Theory of Supportive Design was originally developed as a framework to study how design can be supportive to patients in a hospital setting [ 19 , 20 ], the current findings show that the theory can be usefully applied to the design of lactation rooms as well. Possibly, the Theory of Supportive Design can be applied to an even broader range of settings than originally envisioned, most notably to settings in which promoting relaxation is desirable (such as lactation rooms, dental practice waiting rooms, or wellness and meditation rooms within organizations). To our knowledge, there is only one previous study that also focused on design as a means of mitigating stress in breastfeeding mothers [ 44 ], although not in a work-setting. This study examined the experiences of breastfeeding mothers with a so-called Snoezelen room in a hospital [ 44 ]. The room included moving images, music, and aromatherapy, and was evaluated very positively by the participating mothers. Furthermore, most mothers were able to achieve breastfeeding in the room, despite previous breastfeeding problems [ 44 ]. Although this was a qualitative study, and consisted of only a small sample ( N  = 11), it confirms our current experimental findings, indicating that a high-quality environment can positively affect mothers’ stress levels and facilitate breastfeeding.

Another key finding of our research is that lactation room quality (by itself or in conjunction with environmental sensitivity) affects mothers’ cognitions related to milk expression at work (Hypothesis 2). We found mothers’ positive attitude towards and perceived support of milk expression at work was higher in the high-quality than in the low-quality lactation room (Study 1). Moreover, mothers’ perceived behavioural control with respect to milk expression at work was also positively affected by lactation room quality (Study 1), particularly for mothers high in environmental sensitivity (Study 2). The current study therefore corroborates and extends the findings of a previous cross-sectional study showing that lactation room quality was positively related to mothers’ cognitions about milk expression at work [ 5 ]. Interestingly, we did not find any effects of lactation room quality on intention to express milk at work in either study; however, this might be due to a ceiling effect, as the intended duration in Study 1 was already high (on average 15 months), compared to the relatively low breastfeeding rates in the Netherlands [ 4 ].

In addition, in Study 1 we found that lactation room quality affects mothers’ perceived organizational support and subjective well-being (Hypothesis 3 and 4), and that latter finding was also found in Study 2 for mothers high in environmental sensitivity. Therefore, it seems that providing a high-quality lactation room can have positive consequences even for factors that are not directly related to breastfeeding. Although previous studies have indicated that perceptions of family-supportive work practices and a positive work-life balance are positively related to perceived organizational support and subjective well-being [ 23 , 25 ], this is the first study to link lactation room quality to these important outcomes. The fact that we only found effects on perceived organizational support in Study 1, and not Study 2, can have several reasons. Apart from the earlier mentioned potential effects of impact bias in Study 1, the influence of other forms of organizational support (e.g., direct emotional support by colleagues and managers) could have been relatively strong in Study 2, thus reducing the relative effects of lactation room quality. Another possibility is that the participants attributed any supportive influence of the high-quality lactation room to the researchers instead of to their organization, due to the fact that the participants were aware that they were taking part in research. Nonetheless, these findings are highly relevant, as perceived organizational support and subjective well-being are linked to a myriad of positive outcomes for organizations and employees, such as job satisfaction, positive mood, affective commitment, performance, and lessened withdrawal behaviour (perceived organizational support [ 22 ]), and good health and longevity, better social relationships, creativity, and work performance (subjective well-being [ 24 ]).

A final theoretically important finding is that environmental sensitivity moderated the effect of lactation room quality on several dependent measures in both Study 1 and 2. These findings are in line with previous research, showing that people high in environmental sensitivity respond more strongly to interventions [ 29 , 30 , 45 ]. Our findings testify to the importance of taking this variable into account in research on (environmental) interventions, because it allows for a better understanding of the effectiveness and efficiency of such interventions within certain sub-groups of people. Moreover, since employees who are high in environmental sensitivity are particularly sensitive to stressors [ 45 ], they are an important potential target group for organizational interventions focused on preventing mental health problems and improving well-being among employees.

Strengths, limitations and directions for future research

A major strength of the current research is that we used methodological triangulation to test our hypotheses. Although all methods have their own strengths and weaknesses, limitations of individual methods can be mitigated by using triangulation in so-called mixed methods research. This is considered to be valuable as it helps to show the robustness of findings across different research methods [ 46 ]. In our research, we used an online randomized controlled trial to minimize threats to internal validity (Study 1) and a field experiment to improve the ecological validity of the research findings (Study 2). By using methodological triangulation to investigate the effects of lactation room quality on mothers’ feelings and thoughts, we were able to show that various findings were not limited to one study (taking away concern that findings may potentially partially be explained by bias resulting from used methods) and therefore we provide stronger evidence and support for the conclusions of our research.

Another strength of the current research is that our lactation room design manipulations, based on the Theory of Supportive Design [ 6 ], were studied in a field experiment. Previous studies using the Theory of Supportive Design were either laboratory studies [ 19 ] or field studies that were observatory rather than experimental in nature [ 20 ]. Therefore, the fact that rooms designed according to the insights from the Theory of Supportive Design yielded positive effects in a real-life setting, testifies to the applicability of the theory. However, a potential limitation of our field experiment is that we were not able to control all factors. Specifically, our design was such that we first researched the effects of the low-quality room (in year 1), and then, after remodelling, researched the effects of the high-quality room (in year 2). Although seasonal effects were controlled for in this set-up (we gathered participants for each condition during one whole year), our results may have been impacted by changes or events that occurred during the two years we ran this study. One important event in this regard was the COVID-19 pandemic that started during the end of year two of our study. However, we found that when we excluded mothers who participated during the COVID-19 period our conclusions flowing from the analysis remained the same, which strengthens our confidence in our findings. Nonetheless, other potential changes or events may in principle play a role. Future research may therefore replicate our study using a design in which participants for both conditions are gathered in the same time frame. Another useful suggestion would be to incorporate virtual reality techniques into the research designs. Virtual reality allows for more controlled circumstances than a field experiment, while at the same time increasing possibilities to recruit a larger sample. Moreover, given that virtual reality offers the enhanced capacity for an immersive, interactive experience with the design [ 47 ], it may be easier for participants to imagine oneself in a certain situation than with the use of scenario studies.

An important limitation of the current study is that while we examined the effects of lactation room quality on the feelings and thoughts of breastfeeding mothers, we did not examine the downstream effects on behavioural outcomes, such as the duration of breast milk expression and breastfeeding. Notably, previous research underscores the importance of mothers’ stress and cognitions for breastfeeding practices. For example, a recent review showed that stress reduction and relaxation interventions can indeed help to improve breastfeeding outcomes [ 18 ], and several studies suggest that maternal cognitions are important predictors of milk expression and breastfeeding behaviour [ 48 – 50 ]. Future research could fruitfully examine the effects of lactation room quality on (long-term) behavioural outcome measures, such as breast milk expression and breastfeeding duration, and investigate if these effects are mediated by feelings and thoughts of breastfeeding mothers. Moreover, future studies could also consider adding physiological outcome measures, such as breast milk volume and composition (e.g., fat content), and, for example, physiological measures of stress (e.g., cortisol level, heart rate, blood pressure, and fingertip temperature). Furthermore, it would be interesting to study the effects of lactation room quality, in combination with other methods of relaxation-enhancement, such as meditation [ 18 ]. Finally, although the current study focused on the impact of lactation room quality as an independent factor, creating a breastfeeding-friendly work environment goes beyond the provision of a high-quality lactation room. Future studies could therefore examine the impact of a composite program of family-friendly measures, including paid parental- and sick leave, breastfeeding support, affordable child care, flexible work arrangements, and high-quality breastfeeding facilities. This would help to paint a broader picture of the critical role that organizations play in enabling women to continue breastfeeding upon their return to work.

Practical implications

For organizations it is important to realize that offering good breastfeeding facilities creates a win-win situation, benefitting not only mothers and babies, but organizations as well. Since breastfeeding improves the health and well-being of infants and mothers [ 51 ], it can lead to reduced sick leave and health care costs. Moreover, breastfeeding support at work can lead to higher job satisfaction, a better work-life balance [ 52 ], and may even reduce staff turnover [ 53 ]. As such, facilitating breastfeeding in the workplace is a highly relevant topic to facility management practices, not only to respect diversity and stimulate inclusiveness, but also to foster a healthier workplace. The current research offers important insight into what organizations can do to facilitate mothers in combining breastfeeding and work. To support organizations in implementing high-quality lactation rooms, it would be useful to further explore practical organizational issues of costs and benefits, occupancy rates, and possibilities for multi-functional use of spaces, as well as to help raise awareness of the multiple value creation resulting from the provision of high-quality breastfeeding facilities.

The current study highlights the importance of the quality of the breastfeeding facilities that organizations offer for lactating mothers’ feelings and thoughts. Moreover, the current study provides clear guidelines that organizations can use in lactation room design: a high-quality lactation room should not only include the basic functional requirements as currently outlined in legislation and government guidelines [ 10 ], but should also address psychological needs, by fostering perceptions of control, offering positive distraction, and encouraging social support, as outlined in the Theory of Supportive Design [ 6 ].

The ability of mothers to combine work and breastfeeding successfully offers important societal benefits due to the important long term health benefits for mothers as well as children [ 51 ]. While many factors play a role in creating a breastfeeding-friendly environment in the workplace, the availability of a lactation room is an important prerequisite for enabling mothers to continue breastfeeding when they return to work. The current study shows that not only the availability, but also the quality of lactation rooms is important in facilitating the combination of breastfeeding and work. The inclusion of quality guidelines for breastfeeding facilities in organisations’ family-friendly policies could therefore further expand and secure much-needed support for breastfeeding workers.

Acknowledgements

We would like to thank Daphne van der Knijff-Looman for the designs drawings she created for Study 1, and for her help in implementing these designs at the UMCG lactation rooms in Study 2. Also we would like to thank the Maintenance & Facilities department of the UMCG for their help in implementing the designs. Furthermore, we would like to thank Stefan Kleintjes (IBCLC and director of the Breastfeeding Knowledge Center at the time of the study) for his help with the recruitment of respondents for Study 1, and Yvonne Mollema and Lammie Wiemann from the UMCG maternity ward for their help with the recruitment of respondents for Study 2. Finally, we would like to express our sincere gratitude to all of the respondents who participated in this research.

Authors’ contributions

SvD conceived and designed the study, was responsible for the data collection, analysed and interpreted the data, and took the lead in writing the manuscript. BW and MM supervised the conceptualization and design of the study, provided critical feedback and helped shape the research, analysis, and manuscript. All authors read and approved the final manuscript.

No funding was received for this research.

Availability of data and materials

Declarations.

These studies were approved by the Ethical Committee of Psychology of the University of Groningen (reference number PSY-1920-S-0461 for Study 1 and 17365-O for Study 2). Participants were fully informed about the study and provided their informed consent to participate in this research in the online questionnaire, in accordance with the ECP’s guidelines.

Not applicable.

The authors declare that they have no competing interests.

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