Physicians have been taught to advocate for breastfeeding with our patients; however, our profession makes it challenging to practice what we preach.

Background

The World Health Organization and American College of Obstetricians and Gynecologists (among many others) support breastfeeding exclusively for six months and continued breastfeeding for two years or more based on evidence showing benefits to mother and child.^1–3 Some parents choose formula instead of breast milk for a variety of reasons, but in the United States, working mothers’ right to express (pump) breast milk for their infants is protected through amendments to the Fair Labor Standards Act.⁴ Nevertheless, returning to work correlates strongly with a decision to stop breastfeeding, particularly for those working in environments that are unsupportive.^5,6

Our workplace, the hospital, is where many mothers learn to breastfeed. Supporting breastfeeding and pumping is a key strategy in recent efforts to make hospitals “baby-friendly.”³ For working physicians, resources and policies that encourage pumping on shift are critical. But that’s not where it ends. Our careers, especially in academia, do not exclusively take place within the hospital walls.

As part of career advancement and professional requirements, we attend professional conferences. We use testing centers to take standardized exams, including the United States Medical Licensing Examination (USMLE) and specialty board certification exams. Although “tips” exist for lactating women who want to pump at national conferences, systemic challenges remain.⁷ Similarly, social media backlash for the lack of lactation support at testing centers has made it clear that there is extensive room—and need—for improvement.⁸ When breastfeeding women are not supported to pump and/or breastfeed at conferences and testing centers, they are forced to choose between professional opportunities and their personal and family health. Like many women’s issues, this affects more people than is commonly appreciated: Women troubleshoot quietly or silently stay home, skipping conferences and thus losing out on networking and career development opportunities. Clearly, allowing for the physiological necessity of expressing breast milk in these overlooked venues is an issue of gender equity for our field.

Breastfeeding at Conferences: Mothers Without Infants On-Site

Basic requirements to allow women to pump at conferences are not extensive. Lactation spaces must:

• Provide spaces to sit with a power outlet within three to four feet.
• Be close to the conference hall and easy to get into with minimal (or no) help; requiring security to provide a key to a room is a burdensome step.
  • Consider multiple pumping areas for large convention centers.
• Ensure privacy even with opening the door.
  • Portable screens can create visual barriers as well as multiple private lactation stations within a larger room.
  • Commercial options also exist for stand-alone stations (eg, Mamava).
• Offer nearby running hot water and soap for handwashing and cleaning pumping parts.
• Have cold storage space to store expressed milk during the conference day and either bagged ice or freezer space to protect ice packs for travel.

In addition to these basic accommodations, if feasible, it’s also helpful to provide:

• Storage space for individual breast pumps.
• Sanitizing wipes for surfaces in the pumping room and gloves to wear while cleaning up.
• Multi-user (hospital-grade) breast pump(s) that conference participants can use—these can be rented—with advertising about the type of pump in advance so participants can bring appropriate adapters.
• Information on conference hotels that can guarantee cold storage for guests.
• Breast milk donation. Facilitating expressed milk donation gives participants the option of skipping transport home. The American Academy of Pediatrics has a Donor Milk Drive toolkit available to those interested in organizing this.⁹

For estimating the amount of space required for lactation, organizers should ask registrants about their lactation needs. Estimating that women will use these spaces for 20–30 minutes every three to four hours, with disproportionate use during break time, a reasonable starting point would be to offer one lactation station for every four women who will need to pump during the event.

Breastfeeding at Conferences: Mothers with Infants On-Site

The best lactation support includes providing accommodations for mothers who prefer to bring their infants with them and breastfeed at conferences and other events. Very young infants are rarely disruptive, and conferences should allow them in sessions.

• Signs such as “Mothers with Breastfeeding Infants Are Welcome” or “Breastfeeding and/or Pumping Are Welcome Here” signal all participants to accept the mild disruption of hearing noises from infants or from pumps being used by women who are comfortable pumping in public (with subtle wearable pumps or covered traditional pumps).
• Remote viewing options, such as a separate room where the conference content is live-streamed, allow parents to step out or share child-care responsibility among multiple care providers.
• Advertising inclusion of young children and breastfeeding in addition to pumping will support all early parents, not just lactating women, during a time of early career development that is often overlooked.

Special Considerations for Testing Centers

No matter the specialty, becoming a licensed physician requires sitting for multi-hour examinations. Given that lactating women have a physiological need to express breast milk at least once or twice during a full-day examination, testing centers must allow for pumping as a matter of gender equity for all participants. This can be accomplished with the same rigor as other test accommodations.

• Timing: Lactating women need additional break time to allow for pumping (approximately 30 minutes every three to four hours). Test administrators can increase total available break time for all participants to maintain parity among test takers, acknowledging this will likely be utilized only by those who need to pump or have another extenuating reason.
• Administrative barriers: Currently, there are significant hurdles to being allowed to pump during testing. These should be removed. One example: In addition to a three-page application for obtaining extra break time during USMLE examinations, mothers who want to pump during the exam must submit, weeks ahead of time, photos of their personal equipment and a letter from their personal physician stating the medical necessity of pumping.¹⁰ For any lactating woman, pumping is a medical necessity. These barriers must be reexamined and removed.
• Storage: Testing centers are unlikely to be able to provide durable lactation stations with multi-user devices, making it critical to allow for the safe storage of personal breast pumps within the testing center. Regulations regarding in-center storage and a test taker’s access to their personal equipment need to be altered for lactating health professionals. In addition, testing centers should provide access to a refrigerator in which lactating women may store breast milk throughout their testing day(s).

Conclusion

Support for lactating women during clinical shifts has been a focus of gender equity in emergency medicine in recent years.¹¹ Though there is still much to accomplish, it is critical to recognize that support for lactating professionals in other settings, including episodic events like standardized testing and medical conferences, is part of supporting the professional development of women in our field. The accommodations described here supplement several ways emergency medicine is moving to support work-family balance, including child care at medical conferences and family-friendly networking events. Parents with young families make up a considerable segment of our early career professional group. By showing support for lactating women and those with young children, we can all benefit from the inclusion of some of the most active members in our field.

For a more extensive discussion, please see our related article “Best Practices for Lactation Support at Conferences and Standardized Testing Centers” in Obstetrics & Gynecology, doi: 10.1097/AOG.0000000000003661.

Dr. Manchanda is in the department of emergency medicine at Brigham and Women’s Hospital and Harvard Medical School in Boston.

Dr. Vogel is an attending physician in the department of emergency medicine at North Shore Medical Center in Salem, Massachusetts.

Dr. Rouhani is in the department of emergency medicine at Brigham and Women’s Hospital and Harvard Medical School.

References

1. Wolf JH. Low breastfeeding rates and public health in the United States. Am J Public Health. 2003;93(12):2000-2010.
2. Bartick MC, Schwarz EB, Green BD, et al. Suboptimal breastfeeding in the United States: maternal and pediatric health outcomes and costs. Matern Child Nutr. 2017;13(1):e12366.
3. WHO, UNICEF. Baby-friendly hospital iInitiative: revised, updated and expanded for integrated care. World Health Organization website; 2009. Accessed Jan. 24, 2020.
4. U.S. Department of Labor Wage and Hour Division. Fact sheet #73: break time for nursing mothers under the FLSA. US Department of Labor website. Accessed Jan. 24, 2020.
5. Kimbro RT. On-the-job moms: work and breastfeeding initiation and duration for a sample of low-income women. Matern Child Health J. 2006;10(1):19-26.
6. Alvarez R, Serwint JR, Levine DM, et al. Lawyer mothers: infant-feeding intentions and behavior. South Med J. 2015;108(5):262-267.
7. Brown A. A practical guide to pumping at national conferences. FemInEM website. Accessed Jan. 24, 2020.
8. Arnold S. This is me pumping. Facebook website. Accessed Jan. 24, 2020.
9. American Academy of Pediatrics. Donor Milk Drive Toolkit. American Academy of Pediatrics websit. Accessed Jan. 24, 2020.
10.  National Board of Medical Examiners. Request for additional break time/standard testing time. U.S. Medical Licensing Examination website. Accessed Jan. 24, 2020.
11. Whiteside T, Frasure SE, Ogle K, et al. Barriers to breastfeeding for emergency medicine physicians in the emergency department [published online ahead of print Oct. 14, 2019]. Am J Emerg Med. doi: 10.1016/j.ajem.2019.158494.