*5.1. Implications*

Our study illustrates how breastfeeding worksite supports are critical to TWH and well-being and suggests that women with a supportive environment are more likely to initiate breastfeeding and breastfeed longer compared to those without a supportive environment. When women begin the WIC program, they are often overwhelmed with the demands of working and caring for their family on a limited income. Although women are encouraged to explore their specific workplace policies and environment during breastfeeding education sessions and counseling appointments, these factors may contribute to the high rates of "not sure" reported in this study. Recently, there has been increased attention to breastfeeding support within the workplace to ensure compliance with the Patient Protection and Affordable Care Act (2010), which amended Section 7 of the Fair Labor Standards Act to require employers to provide: (1) "reasonable break time for an employee to express breast milk for her nursing child for 1 year after the child's birth each time such employee has need to express the milk," and (2) "a place, other than a bathroom, that is shielded from view and free from intrusion from coworkers and the public, which may be used by an employee to express breast milk." [37,38]. This study was conducted six years after the law was enacted and women still reported not having space or flexible time at work to express breast milk.

#### *5.2. Recommendations*

Currently, there are numerous ambiguities across breastfeeding research, policies, and practice at the state and federal level. There is a need to make clear connections between federal statutes, public health research, official company-specific policies, and actual practices in the workplace, especially the transparent designation of a workplace contact for breastfeeding policies and practice. Human resource or occupational health personnel in the workforce who write policies or design lactation space

should be educated on core components that make up comprehensive lactation programs. Managers and supervisors need to be aware of the unique, acute, and transient needs of breastfeeding mothers returning to work specific to their job class, duties, schedules, and locations. Providing education and training directed toward leadership, supervisors, and human resource personnel regarding the benefits of breastfeeding for both employees and employers and the supports needed when returning to work should be included in any TWH framework. In addition, our study found that many women were unaware of their employer's benefits for lactation support after returning to work, demonstrating the need for improved communication and awareness about the benefits of health-related employer policies in the context of the TWH framework.
