This scoping review aimed to identify maternal employment characteristics that support any breastfeeding continuation when returning to work in the WHO European Region. To better highlight the characteristics of employment that can lead to social inequalities, we proposed a classification through three main dimensions: type of employment, working conditions, and work environment. While these dimensions are interrelated, our review highlights that no study to date has combined all three dimensions in their measured variables. Furthermore, there is a large heterogeneity of measured work-related and breastfeeding variables, time frames, and fields of inquiry, thus revealing the lack of a conceptual framework for the links between work, breastfeeding, and social health inequalities. Nevertheless, it appears that being self-employed or working in a non-manual occupation with time flexibility, the availability of breastfeeding facilities at work, the support of co-workers, and the existence of a breastfeeding workplace policy are salient factors that promote breastfeeding among working mothers. These results are interpreted in Fig. 2.

Maternal employment characteristics that support any breastfeeding continuation when returning to work in European countries. Maternal employment characteristics were grouped into three main dimensions. The type of employment dimension refers to the terms that govern the organization of work, generally stated in the contract between the employer and employee. The working conditions dimension refers to the level of constraints to which workers are subjected. The work environment dimension pertains to factors generally not defined by the contract (e.g., family-friendly breastfeeding workplace policies, occupational exposure, social network)

Being self-employed implies a high level of autonomy with an early return to work. This work status was associated with longer breastfeeding duration in France [22]. As emphasized by authors, the autonomy inherent in the self-employed status can be seen as a factor favoring flexibility and thus the continuation of breastfeeding. Nevertheless, it also implies a greater dedication to work and less institutional support, which would affect the initiation of breastfeeding. A longitudinal Australian cohort study illustrated this duality by showing that women in occupations with higher levels of autonomy and limited hazards (e.g., exposure to extreme noise, temperature levels, chemicals) were more likely to intend to breastfeed and initiate it [32]. Unfortunately, in the articles identified by this scoping review, occupational exposure was neither measured nor investigated. Finally, it appears that non-manual jobs positively influence breastfeeding [28, 33]. These working mothers from socially advantaged backgrounds and with higher education levels probably have a higher degree of health awareness, better health literacy, greater autonomy over their work schedule, more resources to seek help, and better compliance with the existing recommendations [33, 34]. In agreement, breastfeeding surveys conducted in 19 European countries showed that a low education level is associated with a lower initiation of breastfeeding and earlier weaning [35]. As underlined by several European studies, the promotion, protection, and support of breastfeeding should be provided to all breastfeeding mothers, with specific interventions tailored to the more disadvantaged groups such as young and less educated mothers [23, 33, 35, 36]. Alternative explanations could be that manual working mothers are more likely to stop breastfeeding when resuming work than their non-manual counterparts, so as not to add to the stress or fatigue of their already physically demanding job. As stressed by Rollins et al., the impact of work on breastfeeding is multidimensional, including fatigue and practicality [5]. A French survey conducted on 1,000 women showed that breast pain, fatigue, and back pain were the main difficulties encountered during breastfeeding [37].

In terms of the work conditions dimension, the qualitative studies show that worktime flexibility is a major facilitator of breastfeeding continuation. Having the freedom to organize their own working time can potentially increase breastfeeding mothers’ capability, which refers to whether people have the knowledge, skills, and abilities required to engage in a particular behavior. Based on the framework of behavior change by Michie et al., capability influences motivation, which plays a major role in breastfeeding practices [38,39,40]. A recent Spanish study showed, for example, that women who decided to opt for exclusive breastfeeding and maintain it “as long as I can” were five times more likely to meet their expectations than women who set less ambitious expectations concerning exclusive breastfeeding duration [41]. Overall, these results highlight that employment may influence the entire breastfeeding process from intention to continuation. Indeed, breastfeeding intention – which is the strongest predictor of breastfeeding initiation and duration – is formed during pregnancy [39, 42]. The mother’s choice could be influenced by the anticipation of their expected work-life balance after resuming work [43, 44].

Regarding the work environment dimension, the studies summarized here identified a key feature, namely the importance of a set of underlying conditions: organizational (i.e., presence of adequate lactation room, childcare close to the workplace), structural (i.e., breastfeeding policies in the workplace), and even interpersonal conditions (i.e., support from co-workers), which must coexist to allow mothers to express their milk. In line with the interpersonal dimension, it was underlined that female-dominated environments were perceived to be more positive and supportive, thus enhancing breastfeeding practices [18, 23, 24]. A female environment would facilitate communication and shared experiences [23]. Findings from a study in the US showed that compared with female coworkers, males were more stigmatizing to lactating colleagues, had more responses of disgust, had a poorer perception of the fairness of the additional break time accorded for pumping breast milk, and showed less support [45]. Recent literature reviews and meta-analysis unanimously pointed out the lack of research on the effectiveness of interventions to support breastfeeding in the workplace in high-income countries, specifically in the European Region [46,47,48,49]. As demonstrated in 2022 by Tomori et al. in their review of reviews, inadequate attention is given to interventions addressing policy and structural factors, and only 9% addressed workplace intervention settings [48].

Our results should also be considered according to different national parental leave and return-to-work policies that play a crucial role in influencing breastfeeding practices. The five countries represented in our corpus (i.e., Spain, France, UK, Ireland and the Netherland) have different statutory well-paid maternity leaves durations that vary from 16 weeks (Spain, France and the Netherland) to 39 weeks (UK) whilst paternity leaves durations vary from 1 week (UK and The Netherland) to 16 weeks (Spain) [50]. Additional parental leaves are generally low or unpaid, inflexible, and not evenly distributed between fathers and mothers, because of the conservative division of gender roles predominant in these countries [4, 51]. Conversely, Sweden, which has one of the most generous, supportive and equitable parental leave programs in the world provides some insights into the integration of breastfeeding and women’s employment [52]. A cross sectional study among Swedish families revealed that a longer period of shared parental leave was associated with an extended duration of breastfeeding [53]. Thus, from national policy directives to sociocultural attitudes and values, maternal employment conditions play a crucial role to improve breastfeeding.

This study has several limitations. Inherent to the design of scoping reviews, we did not assess the methodological quality of the included papers, and so we only discuss general, albeit, limited findings regarding breastfeeding and maternal employment. This work lacks representativeness, since only five of the 53 countries included in the WHO European Region were represented in our study selection with an exclusive representation of the countries in North-West and Southern Europe. Finally, from a methodological point of view, we observed heterogeneity in the description and analysis of maternal work-related variables, thus making comparisons difficult across studies. As underlined by some authors, data on work characteristics were often limited [22], and job title classifications should be homogenized throughout the European Region [54]. While not investigated in our corpus, we may assume that other stressor factors such as job insecurity, occupational exposure to chemicals, and physical strain may also affect breastfeeding practices. Given that some studies from our corpus did not specifically aim to assess the associations between breastfeeding and maternal work, the infant’s age at the time of breastfeeding cessation was not always reported or considered in the adjusted models: this made it difficult to interpret the reason for breastfeeding cessation (e.g., work-related, meeting expectations, duration regarded as sufficient). The strength of this scoping review lies in its innovative approach by considering maternal employment characteristics in light of social inequalities. Broadly, and as conceptualized by the WHO [15], employment conditions can lead to social health inequalities through numerous behavioral, psychosocial, and physio-pathological pathways: employment conditions (e.g., full-time work, precarious employment) influence working conditions (e.g., physical and chemical hazards, ergonomics, psychosocial), and both are affected by social and family networks, health system, material deprivation, and economic inequalities. The scoping review methodology allowed us to apply a broad research question and iterative search strategy to gain a comprehensive overview of the current literature on maternal work characteristics and breastfeeding as a major public health outcome. Additionally, we considered the association between maternal work characteristics and any types of breastfeeding, without restricting the analysis to exclusive breastfeeding. We believe that this inclusive approach is relevant given the beneficial effects of breastfeeding, even partial, compared with not breastfeeding [55, 56].