Female employees’ perception of breastfeeding support in the workplace, public universities in spain: a multicentric comparative study

International Journal of Environmental Research and Public Health Article Female Employees’ Perception of Breastfeeding Support in the Workplace, Public Universities in Spain: A Multicentric Comparative Study Águeda Cervera-Gasch 1, Desirée Mena-Tudela 1,* , Fatima Leon-Larios 2, Neus Felip-Galvan 1, Soukaina Rochdi-Lahniche 1, Laura Andreu-Pejó1and Víctor Manuel González-Chordá1 1Department of Nursing, Faculty of Health Sciences, Universitat Jaume I, Avda. Sos I Baynat s/n, 12071 Castellón, Spain; [email protected] (Á.C.-G.); [email protected] (N.F.-G.); [email protected] (S.R.-L.); [email protected] (L.A.-P.); [email protected] (V.M.G.-C.) 2Nursing Department, Faculty of Nursing, Physiotherapy and Podiatry, University of Seville, 41009 Seville, Spain; [email protected] *Correspondence: [email protected] Received: 1 July 2020; Accepted: 31 August 2020; Published: 2 September 2020   Abstract: Background: Despite scientific recommendations for exclusive breastfeeding until 6 months of age and complementary breastfeeding to 2 years of age, breastfeeding abandonment rates increase with time, and one of the main reasons is that women go back to work. Aim: To analyze the perception of support of breastfeeding workers to continue breastfeeding at two Spanish universities, and associated factors. Methods: A multicenter retrospective cross-sectional comparative study conducted in a population of 777 female workers at the Universidad de Sevilla (US) and the Universitat Jaume I (UJI) in Spain using an online questionnaire. Results: The response rate was 38.74% (n=301). Of all the participants, 57.8% continued breastfeeding after returning to work. The factors associated with continuing breastfeeding for longer were the university having a breastfeeding support policy and special accommodation (p<0.001); participating in breastfeeding support groups (p<0.001); intending to continue breastfeeding after returning to work (p<0.001); knowing the occupational legislation in force (p=0.009); having a female supervisor (p=0.04). Conclusion: Breastfeeding support initiatives and having special accommodation to pump and preserve breast milk after returning to work are associated with a longer duration of female workers’ breastfeeding. Keywords: breastfeeding; workplace; female employment; lactation; breastfeeding support; breastfeeding barrier 1. Introduction The World Health Organization (WHO) recommends exclusive breastfeeding for the first 6 months of life, introducing appropriate safe foods for the baby’s age, and maintaining breastfeeding until 2 years, if the breastfed infant still wants breast milk [ 1 ]. The newborn’s first year of life is the period of fastest growth and physical development, which is why the nutritional demands during this period are so high. During this period, breast milk as a first natural food provides all the nutrients and energy required to cover a baby’s requirements [ 2 ]. Breast milk also positively affects breastfed infants’ and mothers’ health [3–5]. Notwithstanding, international breastfeeding rates fall after birth. The United Nations Children’s Fund (UNICEF) indicates that only 43% of newborns continue to receive exclusive breastfeeding at 6 months of life [ 3 , 6 ]. In Spain, a recent study indicates that the breastfeeding rate at 6 months of life is 16.8% [ 7 ]. These figures are far removed from the world objective set out by the WHO in Int. J. Environ. Res. Public Health 2020,17, 6402; doi:10.3390/ijerph17176402 www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2020,17, 6402 2 of 14 the Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition for 2025: increasing the exclusive breastfeeding rate for the first 6 months of life to at least 50% [8]. In Spain, maternity leave is established at 16 weeks [ 9 ]. After returning to work, mothers have one paid hour a day to breastfeed their infant until he or she is 9 months old [ 9 ]. Unpaid childcare leave can be extended up to the infant’s third birthday. All this is reflected in the Spanish law of 2009. Women returning to work seriously affects breastfeeding rates 4 months after the baby’s birth [ 7 , 10 ], which is the second reason for abandoning breastfeeding [ 11 ]. The main reason why the mothers who return to work interrupt breastfeeding is the work–family conciliation challenge [ 12 ]. The challenge of work–family conciliation is for companies to create the appropriate conditions for men and women to develop their respective roles, both in the family and in the workplace. Work–life balance has a direct impact on the attitudes and behaviors of workers, improving results [13,14]. The need to adopt policies that defend work–family conciliation and support breastfeeding is fundamental, and legislation and financial investment are necessary [ 15 ] for this conciliation to become a reality. Changing and supporting these policies by employers appears to be effective in maintaining breastfeeding [ 16 ]. Such policies do not appear to have been widely adopted in Spain [ 14 , 16 ]. Recently, the Spanish Ministry of Health and the Baby-Friendly Hospital Initiative (BFHI) reached an agreement to promote, protect and support breastfeeding by promoting environments that favor it; e.g., creating mother-friendly places for women who decide to continue breastfeeding after going back to work [ 17 ]. However, no literature has been found that shows results from these changes. A recent systematic review shows evidence that breastfeeding support programs and support policies at work can positively influence breastfeeding beyond maternity leave [ 18 ]. However, studies also agree on the need to evaluate if such interventions prolong breastfeeding duration after returning to work [16,19]. The main objectives of this study were to: (a) analyze mothers’ perception of breastfeeding support from both the organization and coworkers after returning to work at two Spanish public universities; (b) establish which variables predict breastfeeding duration at university. 2. Materials and Methods 2.1. Design A multicenter retrospective cross-sectional comparative study took place between January 2017 and April 2020. For the study design, the STROBE statement for cross-sectional studies was applied [ 20 ]. A questionnaire was sent with a letter of presentation to inform about the study objectives, and to indicate thatthestudywasvoluntary, confidential and anonymous. TheEthics Committee of the Universidad de Sevilla(17102/2016)andthe DeontologicalCommitteeoftheUniversitatdeJaume I(CD/49/2019)approved this study. The Declaration of Helsinki principles were respected. Spanish Organic Law 3/2018, of 5 December, on Personal Data Protection and the Spanish Guarantee of Digital Rights, was met. 2.2. Setting The study took place at two Spanish public universities from Andalusia (Universidad de Sevilla– US–south Spain) and the Valencian Community (Universitat Jaume–UJI-east Spain). The UJI has four specific areas designated for breastfeeding in different faculties. Since 2006, meetings with breastfeeding mothers have been held at the UJI. These sessions are organized and led by the local breastfeeding support group, which deals with matters like the benefits of breastfeeding, and pumping/ preserving/storing breast milk and experiences. They last approximately 3 h. At the time this article was written, the US had neither a breastfeeding room, nor any program to support or promote breastfeeding. 2.3. Sample In 2016, the US had 6652 employees (4120 teachers/researchers (PDI) and 2532 administration/ services staff(PAS)). Of these, 37.67% (n=1552) were female PDI and 48% (n=1215) were female Int. J. Environ. Res. Public Health 2020,17, 6402 3 of 14 PAS [ 21 ]. The UJI had 2195 employees (1542 PDI and 653 PAS), of whom 47.28% (n=729) were female PDI and 60.64% (n=396) were female PAS [22]. The inclusion criteria of our sample were: female, of age, employed at the US or the UJI (PAS or PDI) and having given birth in the past 10 years. The exclusion criteria were women who did not work for either university when they gave birth and/or breastfed, and not completing questionnaires properly. A sample of 107 participants was estimated to be necessary by assuming both an infinite population and maximum indetermination hypothesis, a 95% confidence level, 10% accuracy and a 10% replacement rate. 2.4. Measurement The questionnaire included socio-demographic variables, workplace (PAS-PDI), gyneco-obstetric variables (including birth experience on a Likert scale from 1: very bad to 5: marvelous), intention to continue breastfeeding (yes/no), continuing breastfeeding when back at work (yes/no) and mothers perceiving breastfeeding support at their workplace. Mothers’ perception was measured with the validated Workplace Breastfeeding Support Scale (WBSS) [ 23 ]. The WBSS version employed was that validated for the Spanish context [ 12 ], with 18 items measured on a Likert scale from 1 to 7 (1: strongly disagree, 7: strongly agree) grouped into four categories: Technical Support, Environmental Support, Break Time; Workplace Policy. This scale was answered by those women who continued breastfeeding after returning to work (Supplementary Materials). For this study, the Cronbach’s alpha of this scale’s internal consistency was 0.840. 2.5. Data Collection Data collection was performed with an online questionnaire created with Google Drive ™ , which was sent to all the female workers who had become mothers in the past 10 years. This questionnaire was distributed by the Central Services of the two universities to all the working mothers of their university community via email. Data collection also involved consecutive case sampling to complete the required sample size. The questionnaires that met the inclusion criteria were selected. 2.6. Data Analysis Data were processed by SPSS v.25 (IBM, Armonk, NY, USA). A descriptive analysis was done of all the variables. For the quantitative variables, the mean, standard deviation, maximum and minimum were calculated, while the distribution of frequencies and percentages were calculated for the qualitative variables. For the bivariate analysis, chi-squared, Mann–Whitney U and Kruskal–Wallis tests were run according to the applicability conditions (Kolmogorov–Smirnov <0.05). A multivariate analysis was performed by ordinal logistic regression. The maximum likelihood method was employed, and the complementary log–log link method was followed because the higher category of the dependent variable was expected to be the most frequent (longer breastfeeding duration). Owing to the low frequency of some multivariate analysis categories, the following variables were categorized: birth weight (<3000 g; >3000 g); birth type (vaginal/cesarean); birth experience (less than or equal to 3 points; more than 3 points); breastfeeding duration (less than 6 months/1–2 years/more than 2 years); time maternity leave lasted (less than 16 weeks/more than 16 weeks). Women currently breastfeeding were excluded from this analysis. A first regression was done by including all the socio-demographic and gyneco-obstetric variables considered in this study to calculate the Wald z statistic and to determine the dependence of variables. Next, a new regression was done that included the statistically significant independent variables in at least one dependent variable category. Goodness of fit was explored by the likelihood ratio G statistic and Pearson’s chi-squared and chi-squared test of deviations. The employed determination coefficient to study the explained variance was Nagelkerke pseudo-R2 (acceptable value R2 ≈ 0.5). The parallel lines test was carried out to verify the suitability of the coefficients of the independent variables and to determine the model’s feasibility. Finally, in order to evaluate the different models’ predictive capacity, Int. J. Environ. Res. Public Health 2020,17, 6402 4 of 14 the predicted categories were stored in the database and the index of similarity (observed agreement) was obtained with contingency tables. The level of significance was taken as p<0.05. 3. Results From both universities, 777 (US =556, UJI =221) female workers were eligible to participate in this study. The response rate was 38.74% (n=301; US: 35.6%, n=198; UJI: 46.6%, n=103) and there was no access to, or records for, their reasons for not participating. The final study sample included 301 women. Their mean age was 41.94 years (SD =4.55, Min =31, Max =53; p=0.333). Of them all, 91.7% (n=276) had completed university studies, 46.2% (n=139) were PAS and the rest were PDI (53.8%; n=162 ). Of the whole sample, 17.3% (n=52) had problems during their last pregnancy, with gestational diabetes (28.9%, n=15), possible premature birth (13.5%, n=7 ), possibility of spontaneous miscarriage (13.5%, n=7 ) and preeclampsia (11.5%, n=6) being the most frequent problems. Babies’ mean birth weight was 3.27 kg (SD =0.56, Min=0.71, Max =5.3; p=0.992). Birth experience obtained a mean score of 3.87 points (Min =1, Max =5; p=0.016). Table 1provides a comparison of the samples between both universities, which were homogeneous. Table 1. Socio-demographic and gyneco-obstetric data of the female sample (n=301). Universidad de Sevilla (US; n=198) Universitat Jaume I (UJI; n=103) p-Value 1 n%n% Nationality 0.677 Spanish 193 97.5 102 99 North American 2 1 0 0 Italian 1 0.5 1 1 French 1 0.5 0 0 Swiss 1 0.5 0 0 Level of Education 0.004 Primary education 2 1 0 0 Secondary education 22 11.1 1 1 University studies 174 87.9 102 99 Job post 0.808 Administration/Services Personnel (PAS) 90 45.5 49 47.6 Teacher/Researcher (PDI) 108 54.5 54 52.4 Have a partner 0.230 Yes 184 92.9 102 99 No 14 7.1 1 1 Number of children 0.001 1 44 22.2 44 42.7 2 115 58.1 50 48.5 3 33 16.7 8 7.8 4 6 3 1 1 Health problems during pregnancy 0.770 No 158 79.8 91 88.3 Yes 40 20.2 12 11.7 Last birth 0.443 Cesarean for fetal emergency 21 10.6 17 16.5 Scheduled cesarean 28 14.1 17 16.5 Natural birth 107 54 44 42.7 Induced birth 17 8.6 10 9.7 Instrumented birth 24 12.1 15 14.6 Attended antenatal classes 0.088 No 34 17.2 10 9.7 Yes 164 82.8 93 90.3 1Chi-squared test with Fisher’s correction whenever necessary. Int. J. Environ. Res. Public Health 2020,17, 6402 5 of 14 On the whole, 87.4% (n=263) breastfed all their children. Of those female workers who did not breastfeed all their children (n=38, 12.6%), the main reasons were hypogalactia (47.4%, n=18), own decision (13.2%, n=5) and health problems (13.2%, n=5). Information about breastfeeding during pregnancy was received by 90% (n=271) and 96.3% (n=290) intended to breastfeed their infant while pregnant. Intention to continue breastfeeding when back at work was reported by 70.4% (n=212) , and 57.8% (n=174) continued breastfeeding once back at work. Table 2offers the results of the breastfeeding-related variables and the family–work conciliation measures compared by sample. Table 2. Data on breastfeeding and family–work conciliation measures (n=301). Universidad de Sevilla (US; n=198) Universitat Jaume I (UJI; n=103) p-Value 1 n%n% You breastfed your children 0.823 No 14 7.1 7 6.8 Yes, all of them 174 87.9 89 86.4 Yes, but not all of them 10 5.1 7 6.8 Breastfeeding information 0.226 No 23 11.6 7 6.8 Yes 175 88.4 96 93.2 Intention to breastfeed 0.051 No 4 2.0 7 6.8 Yes 194 98.0 96 93.2 Breastfeeding last-born child 0.837 No 18 9.1 10 9.7 Yes 180 90.9 93 90.3 Attended a breastfeeding support group <0.001 No 164 82.8 40 38.8 Yes 16 8.1 53 51.5 Intention to continue breastfeeding when back at work 0.580 No 48 24.4 13 12.6 Yes 132 66.7 80 77.7 Continued breastfeeding when back at work 0.001 No 78 39.4 19 18.4 Yes 100 50.5 74 71.8 Breastfeeding duration <0.001 Less than 6 months 79 39.9 16 15.5 6–12 months 36 18.2 14 13.6 1–2 years 33 16.7 29 28.2 More than 2 years 21 10.6 33 32.0 Currently breastfeeding 8 4 - - Maternity leave time 0.451 6 weeks 3 1.5 4 3.9 7–11 weeks 6 3 4 3.9 12–16 weeks 43 21.7 26 25.2 More than 16 weeks 116 58.6 59 57.3 Work a shorter working day 0.800 No 138 69.7 68 66 Yes 42 21.2 25 24.3 Knowledge of legislation 0.784 No 89 44.9 50 48.5 Yes 91 46 43 41.7 1Chi-squared test with Fisher’s correction whenever necessary. Int. J. Environ. Res. Public Health 2020,17, 6402 6 of 14 3.1. Results of the Breastfeeding Duration Variables The socio-demographic variables showing statistical significance for breastfeeding duration were: the university (US: M =1.98, SD =1.080; UJI: M =2.86, SD =1.095, p<0.001); having participated in a breastfeeding support group (Yes: M =3.05, SD =0.999, No =2.03, SD =1.03; p<0.001); intending to continue breastfeeding once back at work (Yes: M =2.58, SD =1.107; No: M =1.28, SD =0.696; p<0.001 ); continuing breastfeeding when back at work (Yes: M =2.82, SD =1.029; No: M =1.34, SD =0.699 ; p<0.001 ); knowing the breastfeeding legislation currently in force (Yes: M =2.17, SD =1.200 ; No: M=2.40 , SD =1.118; p=0.009); supervisor’s gender (Man: M =2.32, SD =1.159; Woman: M=2.26 , SD =1.174; p=0.040). 3.2. The Workplace Breastfeeding Support Scale (WBSS) Results The mean general score obtained for the WBSS scale was 3.61 points (SD =1.060, 95%CI =3.45–3.78). For all the dimensions, the general score was: mean of 3.82 points (SD =1.602, 95%CI =3.57–4.08) for the Break Time dimension; mean of 3.95 points (SD =1.218, 95%CI =3.75–4.14) for the Environmental Support dimension; the mean score for the Technical Support dimension was 2.59 points (SD =1.453, 95%CI =2.36–2.82); the mean score for the Workplace Policy dimension was 3.61 points (SD =1.060, 95%CI =3.45–3.78). The highest scoring items were: “My coworkers do not make fun of me when I sometimes leak milk through my clothes” (M =5.01, SD =1.964, 95%CI =4.70–5.32); “My coworkers agree that breastfeeding is better for baby’s health than formula feeding” (M =4.66, SD =1.707, 95%CI =4.39–4.93); “I would feel comfortable asking for accommodation to help me breastfeed or pump breast milk at work” ( M=4.54 , SD =2.007, 95%CI =4.22–4.85) and “My coworkers listen to me talk about my breastfeeding experience” (M =4.44, SD =1.820, 95%CI =4.15–4.73). The items with the lowest scores for the general outcomes were: “My workplace has a breast pump for nursing mothers to use” (M =1.39, SD =1.072, 95%CI = 1.22–1.56); “My job could be at risk (e.g., lose my job or get fewer scheduled hours) if I breastfed or pumped breast milk at work” (M =2.45, SD =2.014, 95%CI =2.13–2.77); “Breastfeeding is common in my workplace” (M =2.48, SD =1.759, 95%CI =2.20–2.76) and “I can easily find a quiet place other than the bathroom at work to pump breast milk” (M =2.97, SD =2.106, 95%CI =2.63–3.30). The WBSS scale results are shown in Table 3according to job post (PAS/PDI), in Table 4according to the university where the women worked and Table 5according to the occupational situation at each university. Table 3. Results obtained with the Workplace Breastfeeding Support Scale. Comparison of occupational situation (n=155). PAS (n=64) PDI (n=91) p-Value 1 M SD M SD Total 3.35 1.006 3.80 1.061 0.013 Break Time dimension 3.31 1.537 4.18 1.556 0.001 My breaks are frequent enough for breastfeeding or pumping breast milk 3.09 1.998 4.30 2.095 0.001 My breaks are long enough for breastfeeding or pumping breast milk 3.13 2.035 4.31 2.133 0.001 I could adjust my break schedule in order to breastfeed or pump breast milk 3.25 2.024 4.75 2.042 <0.001 I feel comfortable taking several breaks during working hours to pump breast milk 2.50 1.727 3.43 2.146 0.009 I have supportive coworkers who cover for me when I need to pump my milk 3.39 2.150 3.76 2.228 0.337 I would feel comfortable asking for accommodation to help me breastfeed or pump breast milk at work 4.52 2.039 4.55 1.996 0.976 Int. J. Environ. Res. Public Health 2020,17, 6402 7 of 14 Table 3. Cont. PAS (n=64) PDI (n=91) p-Value 1 M SD M SD Environmental Support dimension 3.82 1.150 4.03 1.262 0.515 Breastfeeding is common in my workplace 2.30 1.580 2.60 1.873 0.469 My coworkers agree that breastfeeding is better for baby’s health than formula feeding 4.53 1.718 4.75 1.704 0.481 My supervisor says things that make me think he/she supports breastfeeding 3.95 1.794 4.24 1.797 0.523 My coworkers do not make fun of me when I sometimes leak milk through my clothes 4.98 1.972 5.03 1.969 0.955 I can easily find a quiet place other than the bathroom at work to pump breast milk 2.53 1.755 3.27 2.281 0.084 My coworkers listen to me talk about my breastfeeding experience 4.63 1.804 4.31 1.830 0.323 Technical Support dimension 2.40 1.395 2.72 1.485 0.195 My workplace has a refrigerator that I can use to store my milk 3.03 2.330 3.35 2.536 0.581 My workplace has a breast pump for nursing mothers to use 1.52 1.069 1.31 1.072 0.071 My workplace has an on-site day care 2.64 2.256 3.51 2.705 0.059 Workplace Policy dimension 3.42 1.156 3.66 1.184 0.013 My job could be at risk (e.g., lose my job or get fewer scheduled hours) if I breastfed or pumped breast milk at work 2.52 2.031 2.41 2.011 0.868 I would have enough maternity leave (paid and/or unpaid time off) to get breastfeeding started before going back to work 4.11 2.344 4.66 2.363 0.164 I am certain my company has written policies for employees that are breastfeeding or pumping breast milk 3.63 2.097 3.91 1.924 0.374 1Mann–Whitney U Test. Table 4. Results obtained with the Workplace Breastfeeding Support Scale. Comparison of universities (n=155). US (n=102) UJI (n=53) p-Value 1 M SD M SD Total 3.47 0.929 3.88 1.239 0.031 Break Time dimension 3.71 1.508 4.04 1.764 0.321 My breaks are frequent enough for breastfeeding or pumping breast milk 3.64 2.043 4.11 2.284 0.228 My breaks are long enough for breastfeeding or pumping breast milk 3.67 2.122 4.11 2.242 0.245 I could adjust my break schedule in order to breastfeed or pump breast milk 3.95 2.164 4.47 2.127 0.185 I feel comfortable taking several breaks during working hours to pump breast milk 2.94 1.979 3.25 2.130 0.452 I have supportive coworkers who cover for me when I need to pump my milk 3.54 2.183 3.74 2.237 0.685 I would feel comfortable asking for accommodation to help me breastfeed or pump breast milk at work 4.51 2.105 4.58 1.823 0.780 Int. J. Environ. Res. Public Health 2020,17, 6402 8 of 14 Table 4. Cont. US (n=102) UJI (n=53) p-Value 1 M SD M SD Environmental Support dimension 3.80 1.090 4.22 1.403 0.047 Breastfeeding is common in my workplace 2.05 1.594 3.30 1.782 <0.001 My coworkers agree that breastfeeding is better for baby’s health than formula feeding 4.68 1.719 4.62 1.701 0.892 My supervisor says things that make me think he/she supports breastfeeding 4.03 1.777 4.30 1.835 0.282 My coworkers do not make fun of me when I sometimes leak milk through my clothes 5.15 1.937 4.75 2.009 0.225 I can easily find a quiet place other than the bathroom at work to pump breast milk 2.69 2.025 3.51 2.172 0.020 My coworkers listen to me talk about my breastfeeding experience 4.24 1.798 4.83 1.816 0.074 Technical Support dimension 2.25 1.219 3.24 1.645 <0.001 My workplace has a refrigerator that I can use to store my milk 3.03 2.511 3.58 2.307 0.100 My workplace has a breast pump for nursing mothers to use 1.19 .641 1.79 1.536 0.004 My workplace has an on-site day care 2.53 2.383 4.34 2.480 <0.001 Workplace Policy dimension 3.57 1.191 3.53 1.155 0.989 My job could be at risk (e.g., lose my job or get fewer scheduled hours) if I breastfed or pumped breast milk at work 2.63 2.082 2.11 1.847 0.107 I would have enough maternity leave (paid and/or unpaid time off) to get breastfeeding started before going back to work 4.64 2.311 4.04 2.433 0.152 I am certain my company has written policies for employees that are breastfeeding or pumping breast milk 3.45 1.922 4.45 1.986 0.002 1Mann–Whitney U Test. Table 5. Results obtained with the Workplace Breastfeeding Support Scale. Comparison of occupational situation at universities (n=155). US (n=102) UJI (n=53) p1 PAS (n=37) PDI (n=65) PAS (n=27) PDI (n=26) M SD M SD M SD M SD Total 3.15 0.895 3.66 0.903 3.62 1.099 4.16 1.335 0.005 Break Time dimension 3.08 1.319 4.07 1.499 3.64 1.769 4.47 1.688 0.004 My breaks are frequent enough for breastfeeding or pumping breast milk 2.81 1.808 4.11 2.032 3.48 2.208 4.77 2.215 0.002 My breaks are long enough for breastfeeding or pumping breast milk 2.86 1.932 4.12 2.103 3.48 2.155 4.77 2.178 0.003 I could adjust my break schedule in order to breastfeed or pump breast milk 2.57 1.482 4.74 2.101 4.19 2.304 4.77 1.925 <0.001 I feel comfortable taking several breaks during working hours to pump breast milk 2.19 1.488 3.37 2.103 2.93 1.960 3.58 2.283 0.035 I have supportive coworkers who cover for me when I need to pump my milk 3.30 2.080 3.68 2.244 3.52 2.276 3.96 2.218 0.745 I would feel comfortable asking for accommodation to help me breastfeed or pump breast milk at work 4.73 2.117 4.38 2.104 4.22 1.928 4.96 1.661 0.431 Int. J. Environ. Res. Public Health 2020,17, 6402 9 of 14 Table 5. Cont. US (n=102) UJI (n=53) p1 PAS (n=37) PDI (n=65) PAS (n=27) PDI (n=26) M SD M SD M SD M SD Environmental Support dimension 3.64 1.058 3.90 1.104 4.07 1.242 4.38 1.562 0.186 Breastfeeding is common in my workplace 1.92 1.498 2.12 1.654 2.81 1.570 3.81 1.877 <0.001 My coworkers agree that breastfeeding is better for baby’s health than formula feeding 4.62 1.754 4.71 1.711 4.41 1.693 4.85 1.713 0.850 My supervisor says things that make me think he/she supports breastfeeding 3.81 1.777 4.15 1.779 4.15 1.834 4.46 1.860 0.598 My coworkers do not make fun of me when I sometimes leak milk through my clothes 5.03 1.907 5.22 1.964 4.93 2.093 4.58 1.943 0.471 I can easily find a quiet place other than the bathroom at work to pump breast milk 2.08 1.422 3.03 2.236 3.15 1.994 3.88 2.321 0.021 My coworkers listen to me talk about my breastfeeding experience 4.38 1.861 4.15 1.770 4.96 1.698 4.69 1.955 0.291 Technical Support dimension 1.90 1.097 2.45 1.249 3.07 1.492 3.41 1.804 <0.001 My workplace has a refrigerator that I can use to store my milk 2.73 2.329 3.20 2.611 3.44 2.309 3.73 2.342 0.342 My workplace has a breast pump for nursing mothers to use 1.30 0.777 1.12 0.545 1.81 1.331 1.77 1.751 0.016 My workplace has an on-site day care 1.68 1.564 3.02 2.631 3.96 2.410 4.73 2.539 <0.001 Workplace Policy dimension 3.55 1.240 3.58 1.171 3.23 1.025 3.85 1.219 0.298 My job could be at risk (e.g., lose my job or get fewer scheduled hours) if I breastfed or pumped breast milk at work 3.24 2.253 2.28 1.908 1.52 1.087 2.73 2.255 0.012 I would have enough maternity leave (paid and/or unpaid time off) to get breastfeeding started before going back to work 4.41 2.339 4.77 2.303 3.70 2.334 4.38 2.531 0.305 I am certain my company has written policies for employees that are breastfeeding or pumping breast milk 3.00 1.886 3.71 1.910 4.48 2.101 4.42 1.901 0.007 1Kruskal–Wallis test. 3.3. Multivariate Analysis Results Generally speaking, with the first regression results, and by including all the socio-demographic and gyneco-obstetric variables, the parallel lines test did not confirm that the estimations were the same for all the variables of the dependent category (p<0.001). Those variables whose categories showed statistical significance to be included in the second regression were: university, having a partner, attended antenatal classes, received breastfeeding information, time maternity leave lasted, participated in breastfeeding support groups and continued breastfeeding once back at work (p<0.05) (Table 6). In the second regression, the overall fit test with G statistic confirmed that the model improved when variables were included as opposed to the model with only the constant (chi-squared =147.044; p<0.01 ). The model’s goodness of fit was confirmed with Pearson’s chi-squared (chi =134.667; p=0.055 ) and the chi-squared test of deviations (chi =113.651; p=0.387). The Nagelkerke pseudo-R2 obtained a value of 0.480 and the parallel lines test confirmed that the ß coefficients were the same for all the independent variables categories (chi-squared =3.930; p=0.996). The model had a predictive capacity of