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Jornal de Pediatria

Print version ISSN 0021-7557On-line version ISSN 1678-4782

J. Pediatr. (Rio J.) vol.93 no.5 Porto Alegre Sept./Oct. 2017

http://dx.doi.org/10.1016/j.jped.2016.11.016 

Original articles

Influence of maternity leave on exclusive breastfeeding

Fernanda R. Monteiroa  * 

Gabriela dos S. Buccinib 

Sônia I. Venâncioc 

Teresa H.M. da Costad 

aUniversidade de Brasília (UnB), Faculdade de Ciências da Saúde, Programa de Pós-graduação em Ciências da Saúde, Brasília, DF, Brazil

bUniversidade de São Paulo (USP), Faculdade de Saúde Pública, Departamento de Nutrição, São Paulo, SP, Brazil

cSecretaria de Estado da Saúde de São Paulo, Instituto de Saúde, São Paulo, SP, Brazil

dUniversidade de Brasília (UnB), Faculdade de Ciências da Saúde, Departamento de Nutrição, Brasília, DF, Brazil

Abstract

Objectives:

To describe the profile of women with children aged under 4 months living in the Brazilian state capitals and in the Federal District according to their working status and to analyze the influence of maternity leave on exclusive breastfeeding (EBF) among working women.

Methods:

This was a cross-sectional study with data extracted from the II National Maternal Breastfeeding Prevalence Survey carried out in 2008. Initially, a descriptive analysis of the profile of 12,794 women was performed, according to their working status and maternity leave and the frequency of maternity leave in the Brazilian regions and capitals. The study used a multiple model to identify the influence of maternity leave on EBF interruption, including 3766 women who declared they were working and were on maternity leave at the time of the interview. The outcome assessed in the study was the interruption of the EBF, classified by the WHO.

Results:

Regarding the working status of the mothers, 63.4% did not work outside of their homes and among those who worked, 69.8% were on maternity leave. The largest prevalence among workers was of women older than 35 years of age, with more than 12 years of schooling, primiparous and from the Southeast and South regions. The lack of maternity leave increased by 23% the chance of EBF interruption.

Conclusion:

Maternity leave contributed to increase the prevalence of EBF in the Brazilian states capitals, supporting the importance of increasing the maternity leave period from four to six months.

KEYWORDS Exclusive breastfeeding; Maternity leave; Women and work

Introduction

Exclusive breastfeeding (EBF) offers many benefits for the health of infants and their mothers.1 However, it is estimated that only 37% of children under 6 months of age are exclusively breastfed worldwide, a reality that is far from that recommended by the World Health Organization (WHO), which has established an EBF prevalence goal of 50% by 2025.2 In Brazil, the II Maternal Breastfeeding Prevalence Survey (Pesquisa Nacional de Prevalência de Aleitamento Materno [PPAM]), carried out in 2008, found that 41% of children under 6 months of age were exclusively breastfed.3 Considering this scenario, identifying factors and strategies that may contribute to increase EBF is a worldwide challenge. Among the factors associated with early interruption of EBF, maternal work outside of the home has been identified as an obstacle.4-8

The International Labor Organization (ILO), in the beginning of the 20th century, held in Washington their third convention on women's employment before and after childbirth. In 1935, Brazil ratified the recommendations of this convention, which guaranteed return to work at six weeks of postpartum and two half-hour breaks to breastfeed during the working day.9 In 1988, the Brazilian Constitution established the women's right to a maternity leave lasting 16 weeks (120 days),10 longer than the 14-week international maternity leave recommendation (ILO n. 183/2000).11 I In 2008, Law n. 11,770 was passed, giving women the option to extend the maternity leave to 180 days (24 weeks).12

Concerns about maternal work and breastfeeding have increased due to the growing participation of women in the labor market,13,14 making it impossible for women to stop working for an unpaid period to dedicate themselves to the care of their children, which can lead to changes in the childcare and feeding patterns.

Thus, it becomes essential to identify the impact of maternity leave on breastfeeding protection, aiming to strengthen and create new public policies. Therefore, this study aimed to describe the profile of women with children aged under 4 months residing in the Brazilian capitals and in the Federal District according to their working status and to analyze the influence of maternity leave on EBF among women working outside of the home.

Methods

This is a cross-sectional study, whose data were obtained from the II PPAM carried out in 2008. This survey collected information from children under 1 year of age who were brought for the second phase of the 2008 multi-vaccine campaign in all Brazilian capitals and in the Federal District (Distrito Federal [DF]). The PPAM was carried out using conglomerate samples, by drawing lots in two stages and probability proportional to the size of the conglomerates.

In the first stage, the vaccination units were selected by drawing lots, and in the second, the children were systematically selected in each unit, also by drawing lots. The sample size considered information on the distribution of vaccinated children in each vaccination unit in 2007 and the prevalence of EBF obtained at the I PPAM, carried out in 1999 in the 26 capitals and in the DF.15 Details on the sampling procedures have been described in previous publications.3,16 To reach the aims of this study, children under 4 months of age was analyzed, the age range in which it would be possible for mothers to be on maternity leave in 2008.

The data collection tool was applied to the children's caregivers during the vaccination campaign. The questionnaire contained closed questions about the characteristics of the children and their mothers, about infant feeding in the last 24 h, and about the healthcare services they attended. The mothers also stated, at the time of the interview, whether they were working outside of the home or not, and whether they were on maternity leave. The data were entered into a web application by team members in each municipality.

Initially, a descriptive analysis was performed on the profile of the 10.995 women participating in the study, according to their working status and maternity leave, as well as the frequency of maternity leave in Brazilian regions and capitals. Subsequently, to identify the influence of the maternity leave on EBF interruption, a multiple model was developed, which included only the 3766 women who reported working outside of the home or being on maternity leave at the time of the interview. The outcome adopted in the present study was EBF interruption, classified according to the WHO definition.17

The main independent variable was whether the working mother was or not on maternity leave at the time of the interview. The following variables were analyzed: maternal age (<20, 20–35, >35 years), maternal schooling (0–8, 9–12, >12 years of schooling), primiparity (yes/no), type of delivery (vaginal/forceps, cesarean section), the child's gender (female/male), low birth weight (yes/no), health care (Public Network – Sistema Único de Saúde [SUS]; Private Service/Health Insurance), pacifier use in the last 24 h (yes/no), and the child's age (0–60 days and 61–120 days).

Poisson regression was used to estimate the prevalence ratio (PR) and 95% confidence intervals (95% CI), with robust variance for bivariate and multiple analyses. Variables that showed p < 0.20 in the bivariate analysis were introduced in the multiple model. In the multiple model, variables that showed p < 0.05 were considered to be associated with the outcome. A linear trend test was performed for the variables in which there was a theoretical assumption of a dose–response association. Although the child's age was a control variable, a multiple model was tested with the age variable categorized from month to month. In this analysis, there was no relevant adjustment in the prevalence ratio of the response variable, and thus, this approach was not explored (data not shown).

The II PPAM database was exported to the Stata software (Stata Statistical Software: Release 9. StataCorp., 2005, College Station, TX, USA) for data analysis. The sample complexity was considered at all analytical stages of the analysis.15

The research protocol was approved by the Ethics Committee of Instituto de Saúde de São Paulo (Protocol n. 001/2008, of 05/06/2008), after consulting the National Commission for Research Ethics (Comissão Nacional de Ética em Pesquisa [CONEP]).

Results

The study involved 12,794 women with children under 4 months of age, from which 10.995 mother replied regarding the work variable. Half of the sample consisted of women with male children and the infants' mean age was 59.5 days. It was verified that 37.4% of the children were born in a hospital accredited as a “Child-Friendly Hospital”; low birth weight occurred in 8.7% of the cases and pacifier use was reported for 36.4% of the children. In the analyzed sample, 51% of the children were exclusively breastfed. Half of the mothers were primiparous, 18.4% were under 20 years of age, and 47.6% of the mothers had 9–12 years of schooling. Regarding the working status at the moment of the interview, it was verified that 63.4% of the women interviewed in Brazil did not work outside of the home. Of those working outside of the home, 69.8% were on maternity leave.

Table 1 shows the distribution of women in Brazilian capitals and in the DF regarding their working status and maternity leave. It was important to characterize the profile of women according to the working status to understand the characteristics of those who did not work outside of the home. There was a great variability among the capitals in relation to the working status at the time of the interview, and it was verified that less than 25% of the women reported working outside of the home in some of the capitals located in the North and Northeast regions. The same variability was observed in relation to the prevalence of women on maternity leave, with the Southeast and South regions showing the highest percentages of women working outside of the home.

Table 1 Frequency of maternity leavea and maternal working status, stratified by Brazilian regions and by capital of each state. II Maternal Breastfeeding Prevalence Survey in the Brazilian Capitals and Federal District, 2008. 

Region/State Total nb Works outside the home Maternity leave
Totalc 0-4 monthsd
% n % n
Brazil 10,995 36.57 3766 69.88 2579
North 2634 28.79 777 71 516
Rio Branco - AC 196 23.98 47 51.06 24
Manaus - AM 452 29.87 135 73.33 99
Macapá - AP 420 24.76 104 61.54 64
Belém - PA 704 27.56 194 75.77 147
Porto Velho - RO 159 24.53 39 61.54 24
Boa Vista - RR 370 31.35 116 50.86 57
Palmas - TO 333 42.64 142 71.13 101
Northeast 3630 30.19 1.041 66.24 684
Maceió - AL 246 29.67 73 68.49 50
Salvador - BA 531 34.46 183 68.31 125
Fortaleza - CE 180 27.22 49 65.31 32
São Luís - MA 266 18.8 50 56 28
João Pessoa - PB 341 29.91 102 66.67 68
Recife - PE 1053 24.6 259 67.95 176
Teresina - PI 315 26.03 82 64.63 53
Natal - RN 506 35.38 179 61.45 110
Aracaju - SE 192 33.33 64 65.63 42
Midwest 1590 38.34 600 72.11 408
Brasília - DF 482 39 188 77.13 145
Goiânia - GO 393 38.17 150 64.67 97
Campo Grande - MS 424 36.79 156 66.67 104
Cuiabá - MT 291 36.43 106 41.51 62
Southeast 2028 42.35 857 70.56 622
Vitória - ES 495 42.02 208 79.33 165
Belo Horizonte - MG 312 55.13 172 71.51 123
Rio de Janeiro - RJ 813 37.52 305 69.84 213
São Paulo - SP 408 42.16 172 70.35 121
South 1113 42.55 491 68.13 349
Curitiba - PR 390 44.62 174 68.97 120
Porto Alegre - RS 347 36.89 128 62.5 80
Florianópolis - SC 376 50.27 189 78.84 149

aMaternity leave reported by the mother.

bThis analysis included all the participating women who answered the question related to the maternal working status (total n = 10,995).

c% in relation to the total of women participants who answered the question related to the maternal working status (total n = 10,995).

d% in relation to the total number of women who reported working outside of the home (n = 3766).

Table 2 presents the sociodemographic profile and the type of healthcare service used by the women according to their working status and maternity leave. There was a higher concentration of women working outside of the home among those older than 35 years of age, with more than 12 years of schooling, primiparous, living in the Southeast and South regions and in urban areas. It is interesting to observe the low percentage of working women who used SUS. The maternity leave frequency was higher among women aged 20–35 years, with more than 12 years of schooling, primiparous, those who had health insurance or used the private healthcare network, and those living in the Midwest and North regions.

Table 2 Profile of the women according to the working status and maternity leave situation. II Maternal Breastfeeding Prevalence Survey in the Brazilian Capitals and Federal District, 2008. 

Works outside of the home Maternity leave
Total 0-4 months
% (n)a % (n)b
Infant's age
0-60 days 36.24 (1837) 74.36 (1365)
61-120 days 36.87 (1929) 65.67 (1214)
Maternal age (years)
20-35 40.73 (2973) 71.09 (2057)
<20 10.42 (194) 54.28 (104)
≥35 50.68 (587) 68.93 (412)
Maternal schooling (years)
>12 69.50 (1017) 73.15 (767)
9-12 38.86 (1943) 71.77 (1342)
0-8 22.05(763) 61.48 (435)
Primiparity
No 34.93 (1808) 65.61 (1165)
Yes 38.37 (1915) 73.88 (1384)
Healthcare service
Public Network (SUS) 30.21 (1779) 68.01 (1161)
Private Service or Health Insurance (non-SUS) 49.00 (1742) 71.70 (1249)
Region
North 28.79 (777) 71.00 (516)
Northeast 30.19 (1041) 66.24 (684)
Midwest 38.34 (600) 72.11 (408)
Southeast 42.35 (857) 70.56 (622)
South 42.55 (491) 68.13 (349)
Area
Urban 36.68 (3760) 69.87 (2576)
Rural 9.34 (6) 80.06 (3)

a% in relation to the total number of women who answered the question related to the maternal working status (total n = 10,995).

b% in relation to the total number of women who reported working outside of the home (n = 3766).SUS, Brazilian Unified Health System.

Table 3 shows the results of the gross and adjusted analysis of the association between maternity leave and EBF interruption for the working mothers' population. For the women not in the LMAT, after adjust in all co-variables, there was an increase in the prevalence of the interruption of the AME (RP [IC95%] adjusted 1,23 [1,11 – 1,37]). Children with low birth weight who used pacifiers and children of primiparous mothers also had a greater chance of EBF interruption. Moreover, a dose–response component was observed between maternal schooling and EBF interruption, i.e., the lower the woman's educational level, the greater the risk of EBF interruption (p = 0.01).

Table 3 Crude and adjusted analysis by Poisson regression of exclusive breastfeeding interruption among working women and covariables. II Maternal Breastfeeding Prevalence Survey in the Brazilian Capitals and Federal District, 2008. 

Variables Total na EBF interruption Non-adjusted PR [95%CI] Adjusted PR [95%CI]
n b %c
Maternity leave
Yes 2415 998 42.45 1 1
No 1126 634 56.33 1.33 [1.19-1.48] 1.23 [1.11-1.37]
Infant's age
0-60 days 1709 638 37.76 1 1
61-120 days 1832 994 54.79 1.45 [1.29-1.62] 1.38 [1.24-1.55]
Maternal age (years) d
20-35 2786 1247 45.28 1 1
<20 106 270 49.42 1.28 [1.05-1.55] 1.11 [0.92-1.33]
≥35 270 106 57.93 1.09 [0.94-1.25] 1.11 [0.99-1.30]
Maternal schooling (years) e
>12 952 409 42.99 1 1
9-12 1827 846 46.8 1.09 [0.95-1.24] 1.14 [1.00- 1.30]
0-8 726 364 50.7 1.18 [1.01-1.38] 1.22 [1.05-1.43]
Primiparity
No 1693 732 43.89 1 1
Yes 1809 879 48.86 1.11 [1.00-1.24] 1.13 [1.01-1.27]
Type of delivery
Normal/Forceps 1397 617 44.95 1 -
Cesarean section 2121 1005 47.76 1.06 [0.95-1.19]
Infant's gender
Female 1768 780 44.43 1 1
Male 1773 852 48.93 1.10 [0.99-1.22] 1.07 [0.96-1.19]
Low birth weight (<2500 g)
No 3197 1448 45.57 1 1
Yes 290 162 58.08 1.27 [1.09-1.49] 1.24 [1.05-1.45]
Birth in CFH
Yes 1063 474 46.1 1
No 2325 1079 46.97 1.02 [0.91-1.14] -
Health care (routine)
Public Network (SUS) 1675 776 46.34 1
Private Service or Health Insurance 1637 767 48.52 1.05 [0.93-1.16] -
Use of pacifier
No 2199 736 36.24 1 1
Yes 1324 822 61.03 1.68 [1.51-1.87] 1.63 [1.46-1.82]

PR, prevalence ratio; CFH, Child-Friendly Hospital; SUS, Brazilian Unified Health System.

aTotal number of infants under 4 months of age whose mothers declared working outside the home or on maternity leave at the time of the interview.

bInfants under 4 months of age who discontinued exclusive breastfeeding.

c% of infants under 4 months of age who interrupted exclusive breastfeeding considering the sample weight of each capital.

dp of linear tendency > 0.05.

ep of linear tendency < 0.05.

Discussion

This is the first study of national scope that assesses the association between maternity leave and EBF prevalence and presents the results according to Brazilian regions and capitals, based on the data obtained in the II PPAM, in the Brazilian Capitals and Federal District, held in 2008 by the Ministry of Health.

A large variability was observed in relation to the prevalence of women on maternity leave; the Southeast and South regions showed the highest percentages of women working outside of the home. The increase in women's participation in the labor market in regions of high industrial concentration are aspects that have been observed in studies carried out in high and middle-income countries. Between 1960 and 2009, there was an increase in this participation, from 32% to 46% in the United States, from 25% to 47% in Canada, and from 21% to 41% in Latin America and the Caribbean.13,14 In Brazil, in 1996, approximately 21% of Brazilian households had a female head of the family, and in 2012, 37.4% of the families had a woman in charge of the household.18

Among working mothers, it was observed that those on maternity leave had a lower chance of EBF discontinuation in the first four months of the infant's life, after adjusting for other factors indicated in other studies as determinants or associated to EBF, such as maternal level of schooling, parity, low birth weight, and pacifier use.4-8,19

Corroborating the present findings, a study carried out by Venâncio et al.20 in 77 municipalities in the state of São Paulo also showed a higher percentage of EBF among mothers who were on maternity leave (54.6%) and a lower percentage (25.6%) among those who were working without maternity leave. Similarly, Vianna et al.,21 in a study carried out in 70 municipalities in the state of Paraíba, verified that maternity leave positively influenced the prevalence of EBF. A North-American study carried out by Mirkovic et al.,22 who analyzed the influence of maternity leave duration and working hours on breastfeeding duration, found that returning to work before 3 months of postpartum on a full-time basis reduced the chance of women reaching the period they had declared as being their intention to breastfeed. It is worth mentioning that studies have demonstrated the influence of maternity leave on the total duration of breastfeeding,23 in addition to benefits related to the reduction in infant mortality rates.24,25

The adoption of strategies and legislations to protect working women who breastfeed has been emphasized in several documents by international organizations, such as the Innocenti Declaration on Protection, Promotion, and Support of Breastfeeding (1990) and the Global Strategy for Infant and Young Child Feeding in Early Childhood.26 The Brazilian Ministry of Health has developed some strategies, such as the Breastfeeding Program Support for Working Women, which aims to stimulate managers of public and private companies to adhere to the six-month maternity leave, having a daycare at the workplace and a breastfeeding support room. Although Brazil has stood out in the international scenario as one of the countries that offers the longest maternity leave in weeks and the highest percentage of wages paid to the women,27 the seventh in a ranking of 202 countries surveyed by the United Nations, further actions are still required.

Breastfeeding among working women is a complex subject and permeated by many choices, often requiring more than employee benefits for the continuation of EBF.28 Several authors point out that EBF rates vary worldwide and that postpartum support technologies, such as breastfeeding support at workplaces, breaks during working hours for breastfeeding, maternity leave, and professional counseling and lactation management during this transition period of returning to work are positive factors for breastfeeding stimulation.29

Some study limitations are noteworthy. Secondary data were used, and the set of variables available was used to construct the model. Nonetheless, important variables pointed out in the literature related to the mother and child were included.30 Due to the cross-sectional design, the results shown here may be useful to formulate hypotheses and not to establish a causal association. In this sense, the authors verified that maternity leave can influence the duration of the EBF, but longitudinal studies are necessary to confirm this hypothesis. The data analyzed here were collected in 2008 and, thus, there is a temporal distance from the present, but there are no data of national scope on the subject, emphasizing the importance of this research.

It was observed that maternity leave is associated with an increase in the prevalence of EBF in the Brazilian capitals and the DF, reinforcing the importance that government and society offer strategies to encourage breastfeeding, such as the universal increase of maternity leave from 4 to 6 months.23,29 The result of this study may influence decisions that will benefit thousands of Brazilian women with the increase of maternity leave.

Funding

The data analyzed in the article were extracted from the II PPAM, carried out in 2008 and funded by the Brazilian Ministry of Health.

Please cite this article as: Monteiro FR, Buccini GS, Venâncio SI, Costa TH. Influence of maternity leave on exclusive breastfeeding. J Pediatr (Rio J). 2017;93:475–81.

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Received: July 25, 2016; Accepted: November 10, 2016

* Corresponding author. E-mail:fernanda.nutricao@gmail.com (F.R. Monteiro).

Conflicts of interest

The authors declare no conflicts of interest.

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