A Constant Struggle of Breastfeeding at Workplace: A Narrative Review

Breastfeeding has been shown and proved to offer numerous health benefits for infants and mothers. Despite this fact, studies have found that the level of exclusive breastfeeding continues to be low both in developed and developing countries. The issues with breastfeed and continue breastfeeding due to multiple factors, one of the biggest challenges is as a working mother. Working mothers face the challenge of balancing breastfeeding and paid work, thereby increasing the risk of early cessation of breastfeeding in general and exclusive breastfeeding. There are many studies to overcome these issues, however not many studies exposing the ethical issues, difficulties and opportunities while solving this matter. Such as moral work women undertake when engaging with breastfeeding, influenced by cultural and social norms that makes it harder for breastfeeding mother.


Background
Infant nutrition is one the most important determinants of the health of children.Breastfeeding has been shown and proved to offer numerous health benefits for infants and mothers. 1 The World Health Organization (WHO) recommends "exclusive breastfeeding for the first 6 months of life and introduction of nutritionally adequate and safe complementary (solid) foods at 6 months together with continued breastfeeding up to 2 years of age or beyond. 2 However despite this recommendation, studies have found that the level of exclusive breastfeeding continues to be low both in developed and developing countries. 3lobally, less than 40% of infants under 6 months of age are exclusively breastfed. 4Developing countries report an exclusive breastfeeding prevalence of 36% among infants younger than 6 months. 5In 2015, approximately 83.2% of infants in the US were breastfed at birth, but the proportion of infants who were breastfed decreased with increasing age, with 46.9% exclusively breastfed at 3 month, and 24.9% at 6 months. 6The issues with breastfeed and continue breastfeeding due to multiple factors, such as confidence, social support, cultural factors, breastfeeding education, hospital factors, not to mention other health concerns that might interfere with breastfeeding process. 7Women of childbearing age constitute a high proportion of the workforce and make significant contributions to national economies.They might become pregnant during employment and many of them decide to return to work (RTW) after the birth of the babies. 8,9This is one of the main barriers to breastfeeding duration among working mothers in the United States. 10Combining breastfeeding and work may be hard for mothers depending on their working conditions, sociocultural heritage and gender role ideology, public health policies and economy and lobby group. 11,12Although both the culture of work and breastfeeding differ between countries, there is a much lower prevalence of exclusive breastfeeding among professional working mothers in developing countries. 13For example, in a Taiwanese study, 67% of working mothers initiated breastfeeding, but only 10% continued after RTW. 14 Research has shown that working mothers' positive attitudes toward breastfeeding were associated with a longer breastfeeding period where the mothers tended to breastfeed exclusively and had a higher chance of success in breastfeeding. 3,4Working mothers face the challenge of balancing breastfeeding and paid work, thereby increasing the risk of early cessation of breastfeeding in general and exclusive breastfeeding in particular.A key challenge contributing to the early cessation of breastfeeding among working others is an inflexible work schedule.][17] To this days, there are various interventions to overcome this barriers.Several studies included more than one intervention, hence, were not mutually exclusive The most common interventions were providing mothers a designated space for breastfeeding or breastmilk extraction, and the support from coworkers and supervisors.These were followed by flexible time to express milk, breastfeeding education or counselling at the workplace and institutional written policies to support breastfeeding.The least common interventions were providing breast pumps and giving mothers the flexibility to work from home or reducing in-office hours. 18Workplace intervention may also have a positive impact on breastfeeding initiation.A study from the US showed that among working mothers enrolled in an employer-sponsored lactation program, breastfeeding was initiated by 97.5% of the women.Hence, workplace interventions could have a positive impact on both initiation and duration of breastfeeding. 19any studies have reviewed the impacts of RTW for breastfeeding mothers and created several intervention at the workplace, however there is still lack of review in terms of ethical point of view, what are the challenges and opportunities to solve this issue in the future.Therefore, the objective of this study is to review the ethical point of view, along with the challenges and opportunities that might be beneficial for working mothers who have to breastfeed the children.

Method
A literature review was conducted in November 2023 which targeted manuscripts by searching the articles related to ethical dilemmas in breastfeeding and lactation intervention for working mother with ethical overview, challenges and opportunities.Only English-language reports were included.We search relevant topics such as 'breastfeeding working mother, 'breastfeed at work' and 'intervention in breastfeeding at work' in Google Scholar and PubMed.The focus of this study was literature reviews, including understanding the concept and overviewing ethical point of view in interventional study, along with reviewing challenges and opportunities in the future to solve this issues, the studies included were conducted by researchers, corporations, governments, and other entities involved.

Results
The results of this study exploring some ethical issues in breastfeeding for working mothers.First of all, ethical concept should be understood by researchers and health care professional who plan to do the study.Failures associated with professional services can have serious expectations and human consequences.
The general ethical concepts and ethical issues in maternal care, such as: 20 1. Patient's autonomy -ethical issues: the right to life, the right for quality services, the right to get information, respect patient's right 2. Advocacy -provide beneficence, informed consent, advocate patient's right, exploitation women 3. Justice -priority services, equal health services, mental health 4. Confidentiality -keep patient's information, not disclosure patient's illness, mother with infectious diseases, disclosing foetal abnormality 5. Beneficence -quality of care, promote a good care, beneficence of intervention 6. Non-Maleficence -protect the women and foetus, do no harm, neglected care that impaired foetus development

Assessing the Risks of Parental Medication Use Versus the Benefits of Their Own Milk
For most medications that are categorized as safe for breastfeeding, the potential for harming the infant is minimal; although small amounts of medication are transferred into human milk and absorbed by the child. 21The importance of breastfeeding and human milk has been widely recognized, not only for infants, but also for the mothers 22 and authors usually conclude their reviews with the recommendation that the benefits of medication use during lactation outweigh the risks, especially if the medications are categorized as safe for breastfeeding. 23However in current situation, the concept of weighing risks and benefits can be challenging, given the lack of research pertaining to medications used during lactation, the concept of but is commonly used in reviews of medications for breastfeeding women. 18ecisions to breastfeed are strongly influenced by cultural and social norms. 24Parents are often socialized to believe that sacrificing their own well-being for that of their child is indicative of being a good parent. 25hey are also socialized, however, to take responsibility and care for themselves, acting on health care advice as provided by health professionals.These competing discourses challenge the process of informed decision making, particularly the capability to reason and exercise individual autonomy. 26At present, health professionals need improved education about how to communicate risks and decision-making principles to their patients and clients.Research is also needed to improve risk communication about medications during lactation for both health professionals and consumers.

Confidence in breastmilk extraction and breastfeeding at the workplace
A systematic review of interventions for breastfeeding at the workplace have highlighted that confidence in breastmilk expression at the workplace is related to four aspects: individual characteristics of working mothers, type of employment, partners' support, and support from colleagues and supervisors. 18Evidence suggest that women's confidence in using lactation spaces and pumping breaks is associated with different ecological levels including individual characteristics (e.g.prior experience, education, type of work) and interpersonal factors (e.g.support from colleagues and partners). 18

Organizational support and breastfeeding
Employees and co-workers with children and experience in breastfeeding or milk expression at the workplace reported stronger support for breastfeeding accommodations. 27Breastfeeding interventions among working women are fundamental to fulfil their goals, but that they need to be accompanied with an actual sense of support, as woman can feel discouraged from pumping due to peer pressure and lack of practical support from peers and supervisors. 28From a managerial perspective, breastfeeding support can be helpful to recruit and hold employees, but, in addition, the actual value of breastfeeding needs to be understood by co-workers and managers, as it is common to encounter barriers such as negative perceptions about breastfeeding support, and the perception that it reduces productivity. 29Studies suggest that support for breastfeeding mothers at the workplace is mediated by experience and knowledge from co-workers.In addition, perceptions of fairness and stigmatization of breastfeeding in work/professional settings are important predictors of lack of support.
Qualitative studies describe that support and feeling comfortable in breastfeeding or extracting breastmilk at the workplace is fundamental in achieving successful breastfeeding interventions at the workplace.Negative perceptions about the impact of breastfeeding on productivity also impact organizational effective support. 18

Moral work in women's narratives of breastfeeding
Majority of writing about breastfeeding presents it in positive biomedical and public health terms.It is relatively little has been written about the moral work women undertake when engaging with breastfeeding and its cultural milieu. 31Women's narratives of breastfeeding are sites of daily construction and reconstruction of self as they undertake moral work in relation to feeding their baby, 'actively negotiating' tensions and contradictions, relationships and social networks in an attempt to make sense of their experiences. 32The work described here extends the sociological aspect by taking understandings of moral work beyond the decision to breast or bottle feed and into everyday practices associated with committed breastfeeding. 33This study also thinking beyond the psychological, emotional, physical and social tensions and ambiguities inherent in current rhetoric about breastfeeding practice to look at the type of moral work that women undertake to reconcile these factors with their embodied experience in their constitution of self. 34Furthermore, we build on an understanding of breastfeeding women as moral and ethical subjects engaged in gendered and embodied performance. 31

Moral work as biographical preservation
This category refers to the work that some women undertook to maintain a pre-determined subject position as a breastfeeding mother and to overcome feelings of inadequacy and disappointment, or to realign desire with reality.Their need to justify and rationalise their actions was indicative of the moral work that they were undertaking.For example, many of the women spoke about 'not succeeding', not being able to realise pre-determined expectations of themselves in relation to child bearing and rearing.They engaged in moral work that allowed them to feel better about themselves as mothers.Several women spoke about providing breast milk for their sick child and how this made them feel that they were able to 'do something' in a difficult situation.One woman, who was unable to breastfeed, mourned the loss of the physical act of breastfeeding and all that accompanied it.This woman did not have to breastfeed; indeed, she was being told she should not but, to maintain her sense of self as a breastfeeding mother, she insisted on doing so.The moral work here was designed to maintain her (previously decided upon) identity as a breastfeeding mother.She was articulating a course of action that fitted with her identity and then found ways (such as telling health professionals what she wanted) to make that happen.Her account appeared designed to present her actions as rational and reasonable in light of the identity that she was striving to maintain.Other examples of moral work as preservation included women who, with hindsight, readjusted their assessment of themselves and took a more lenient and tolerant view of how they had managed as breastfeeding mothers.In summary, moral work as biographical preservation included the actions that women took and the way they constructed their narratives to maintain their pre-determined sense of self as a breastfeeding mother, even in situations where they had weaned prematurely, mixed fed or (exclusively) fed expressed breast milk.For them, the issues were to appear rational, align themselves with currently acceptable discourses around mothering and infant feeding and to maintain their preconceived identity and self-respect.

Moral work as biographical repair
Moral work as biographical repair was undertaken by several women who wished to modify their sense of self from an undesirable or uncomfortable position to one that they felt or thought would be more comfortable or socially acceptable.The difference between moral work as biographical repair and as biographical preservation is in the pre-determined subject position.Repair results in the change from one subject position to another whereas preservation is the moral work undertaken to maintain a previous or pre-determined position.A subtle variation on moral work as biographical repair was exhibited by some women who had breastfed a previous baby and had intended to breastfeed the next one but for some reason were unable to do so.These women rationalised their situation, reflected on why they couldn't breastfeed a subsequent baby, found an external reason, stated repeatedly that they had tried their best, acknowledged that things were better once they had made the decision to 'give up' and shifted to a new subject position (still as a 'good mother').Reparative moral work was about moving from an uncomfortable or untenable position, coming to terms with unrealised expectations or changed circumstances, or reframing a situation to regain internal harmony.

Moral work as altruism
This category empowered numerous women to realize a subject position that permitted them to feel great almost themselves, indeed in spite of the fact that their breastfeeding may not have been going as well as anticipated.Our working definition of benevolence is sacrificial behaviour for the great of others; be that as it may, we do acknowledge those contentions claiming that there's no such thing which all behaviour has a few component of self-interest.Ethical work as charitableness in breastfeeding and its associated activities that characterized women's sense of self was too watched within the stories of women who said they had concurred to be met since they trusted their story may be of utilize to other individuals.So also, the stories of ladies who went through numerous hours in intentional back work shown examples of ethical work as benevolence.The issues raised beneath ethical work as benevolence incorporate ideas of giving, either breast milk or service in the name of breastfeeding.

Moral work as political action
Political activity may be seen as a subtlety of ethical work as charitableness but it was so specific that we kept it partitioned.It was pointed at effectively changing other people's states of mind towards breastfeeding and moving forward the breastfeeding environment whereas building an personality as a ethically mindful citizen.For some women, it took the frame of open work or back for political campaign bunches; for others it showed itself more secretly inside neighbourhood social systems.The issues around moral work as political action included endeavours to bring about change and to educate communities.
To reach the WHO's recommendation of six months of exclusive breastfeeding, women need a supportive environment (at home and work) that protects and promotes breastfeeding.For women in the workforce, merging breastfeeding and paid work is difficult.While a maternity leave is fundamental to promote, protect and support breastfeeding initiation, duration and exclusivity, the reality is that only half (53%) of the countries around the world comply with the ILO standard of at least 14 weeks of leave. 35arious types of workplace strategies are available to support the promotion of breastfeeding.There are many types of intervention for breastfeeding mother in the workforce, some of the interventions were effective to extend the duration of breastfeeding, along with other outcomes. 34,36In current situation, the concept of weighing risks and benefits can be challenging, given the lack of research pertaining to medications used during lactation, the concept of but is commonly used in reviews of medications for breastfeeding women. 37,38

Conclusion
Decisions to breastfeed are strongly influenced by cultural and social norms.These competing talks challenge the method of educated choice making, especially the capability to reason and work out person independence.Another challenge faced by breastfeeding mother in workforce is the moral work women undertake when engaging with breastfeeding.We have presented here four categories of moral work that breastfeeding women undertake in their constitution as moral beings: biographical preservation is aimed at maintaining a predetermined identity; biographical repair reframes identity to regain internal harmony; altruism is about giving selflessly; and political action is involved with educative change.
By listening to women's narratives of their breastfeeding experiences and examining and typifying the private, internal moral work that they undertake in their practice and telling we may open up a way of thinking that leads to new discursive spaces and subject positions.There is more to be done on the moral work undertaken by women in their narrative accounts of breastfeeding, especially around other activities such as breast milk expression, co-sleeping, weaning, feeding older babies, and others.