Supporting Lactation Within an Academic Anesthesia Department: Obstacles and Opportunities

Abstract

WOMEN IN ANESTHESIA AND LACTATION The number of women in academic anesthesiology has continued to grow over the past decade. Anesthesiology had the sixth-highest proportion of full-time female faculty and seventh-highest proportion of female residents when compared to other specialties.1 Training in anesthesiology often coincides with women’s prime reproductive years. After returning to work following maternity leave, many new mothers wish to continue breastfeeding. However, several obstacles in the workplace may hinder continued breastfeeding, including lack of space, lack of time away from clinical duties, unpredictable schedules, and a maternity leave that is too short.2–4 These barriers tend to affect trainees more than faculty.5 It is important that we, as medical professionals, support our colleagues who wish to continue breastfeeding by working to remove these barriers. We will discuss recent requirements for lactation spaces, as well as common obstacles to lactation in the workplace and highlight opportunities to eliminate these obstacles. BENEFITS OF BREASTFEEDING Multiple studies have shown the benefits of breastfeeding for the infant, including a reduction in risk of acute otitis media, gastroenteritis, severe lower respiratory tract infections, atopic dermatitis, sudden infant death syndrome (SIDS), and probable reductions in obesity and diabetes mellitus.6 The American Academy of Pediatrics recommends exclusive breastfeeding for the infant’s first 6 months of life, with continued breastfeeding for at least the first year of life.7 Mothers who breastfeed have improved birth spacing and protection against breast cancer. They may also be protected against ovarian cancer and type 2 diabetes mellitus.6,8 Mothers who do not breastfeed or have early cessation of breastfeeding have an associated increased risk of maternal postpartum depression.6 Breastfeeding also benefits employers by contributing to lower health care costs, increased employee productivity, and less work missed due to time off to care for sick infants.6,9 LACTATION SESSION FREQUENCY AND PHYSIOLOGICAL NEEDS Infrequent or insufficient expression of milk can lead to plugged ducts, mastitis, or decrease in milk supply. The time required for lactation sessions depends on the age of the infant and can vary from woman to woman. Federal law allows for break time to express milk “as frequently as needed” for 1 year after the child’s birth.10 A starting point for pumping frequency may be every 2–3 hours if the baby is <6 months and every 3–4 hours if the baby is 6 months and older. A pumping session typically takes a minimum of 15–20 minutes, not including time for transit, a bathroom break, cleaning pump parts, and storing breast milk. Alternatively, some physicians, especially in procedural specialties, choose to use wearable breast pumping technology.11 In addition to lactation sessions, the nutritional needs of the lactating woman should be considered. Lactating women need to consume approximately 400–500 more calories daily in excess of what is needed to maintain their weight.12 Lactating women need to increase their total water consumption to 3.8 L/d, from the 2.3–2.9 L/d needed when not lactating.13 In considering optimal pumping session duration and interval frequency, access to food and water is critical. OBSTACLES AND OPPORTUNITIES TO PROVIDING LACTATION FACILITIES FOR ANESTHESIA CLINICIANS It is difficult, if not impossible, to establish a reliable schedule for lactation session each day in the unpredictable environment of the operating room. This unpredictability may have a negative emotional impact on the lactating clinician. One institution’s survey of female physicians reported that 97% of women with breastfeeding experience reported at least 1 perceived barrier to breastfeeding. The trainees in this group identified more barriers than their faculty counterparts.4 The barriers frequently identified were lack of time and an appropriate place to pump breast milk, short maternity leave, unpredictable schedules, and long work hours. Surgeons and physicians in procedural-based subspecialties all reported lack of lactation facilities in close proximity to the operating room as a significant barrier to breastfeeding.14 The practice of anesthesia varies minute to minute and day to day depending on the operating room schedule. The typical anesthesia clinician’s schedule does not have built-in time for breaks or a predictable end time and may involve providing anesthesia outside of the operating room in remote locations. This unpredictability in schedule and location presents a significant barrier to lactating women who may be unable to travel to the designated lactation rooms within the hospital. These designated lactation rooms may be located far from the operating rooms and may require an advanced reservation. There are several ways in which anesthesia departments can purposefully and thoughtfully help lactating women overcome the obstacles discussed above. Establishing a culture that is supportive of breastfeeding begins with education. There is limited breastfeeding education throughout medical education, and medical personnel are often misinformed. Education about lactation and the needs of lactating women should be presented to all members of the department. It is important to allow for frequent pumping sessions that are adequate in length for lactating women. Anesthesia clinicians who require time for pumping sessions need to inform their department or program director or break coordinator to allocate personnel and resources for the necessary lactation sessions. In addition, the daily case assignments should be considered. For example, it may be necessary to limit assignments in remote locations due to difficulty traveling to the lactation rooms in a reasonable time frame. There are also opportunities to establish private lactation rooms in close proximity to operating room suites, thus allowing women to be close to clinical care and reducing transition time to other lactation rooms that may be distant from the operating rooms. When establishing this space, institutions should consider providing phones, computers, refrigerators (for breast milk storage), and a sink. This would allow the clinician to continue some components of clinical care, if needed, while pumping breast milk. When considering the needs of the breastfeeding clinicians within the department, it is important to solicit feedback from the lactating women, since each anesthesia provider, department, and institution will have different opportunities and obstacles.4 THE ACCREDITATION COUNCIL FOR GRADUATE MEDICAL EDUCATION REQUIREMENTS AND FEDERAL LAW The Accreditation Council for Graduate Medical Education (ACGME) included lactation facilities as a common program requirement for Graduate Medical Education in Anesthesiology in July 2019 (Table).15 The ACGME, which will begin citing noncompliant programs in July 2020, states that “clean and private facilities for lactation that have refrigeration capability, with proximity for safe patient care” must be provided by all programs. The requirement further explains that the lactation facility should be in close proximity to clinical responsibilities, and adds that “it would be helpful to have additional support within these locations that may assist the resident with continued care of patients, such as a computer and a phone.” The ACGME intent also includes a statement that space is important, and stipulates that “the time required for lactation is also critical for the well-being of the resident and the resident’s family.” Table. - Lactation Considerations for Academic Anesthesiology Programs Federal Fair Labor Standards Act10 ACGME Common Program Requirements 201915 Local Considerations at the University of Iowa Faculty and staff support • “It is a violation for any person to…discriminate against any employee because such employee has filed any complaint…related to this Act.” • Include “attention to scheduling, work intensity, and work compression that impacts resident well-being.” • Create a culture of breastfeeding support with faculty and staff education, leadership buy-in, and a consistent, reliable break allocation system• Immediate patient care needs and high-quality communication remain prioritized• Establishment of a diversity, equity, and inclusion team as a resource and mediary if conflicts arise Lactation facilities “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.” • Clean• Private• Refrigeration access• Proximity to patient care• Helpful: computer and phone • Call rooms may provide proximity and privacy during daytime hours• Providing hospital-grade pumps minimize time spent retrieving and returning equipment• Consider off-site facilities Time • “A reasonable break time for an employee to express breast milk for her nursing child for 1 y after the child’s birth each time such employee has need to express the milk.” • “Time required for lactation is also critical.” • Clear messaging that time taken for lactation supports the trainee’s well-being Abbreviation: ACGME, Accreditation Council for Graduate Medical Education. The ACGME requirements for lactation facilities are in addition to the federal law concerning pumping breaks (Table). In March 2010, “Break Time for Nursing Mothers,” a provision of the federal health care reform law that supports breastfeeding, requires employers to provide employees with break time for breast milk expression until the employee’s baby turns 1 year of age.10 The lactation space provided must not be a bathroom, must be shielded from view, and free of coworker and public intrusion. If the lactation space is not dedicated to the nursing mother’s use, it must be made available to the nursing mother when needed, to meet this requirement.16 The federal law dictates that not only the time for lactation breaks but lactation space must be provided to employees. State laws concerning lactation breaks may provide greater protection for employees, and this federal law does not preempt those state laws. UNIVERSITY OF IOWA DEPARTMENT OF ANESTHESIA: OUR SOLUTIONS At the University of Iowa, Department of Anesthesia, we approached the ACGME and federal law requirements in several ways. We met with key perioperative leaders to understand the needs of lactating mothers and review the hospital facilities for lactation. We searched the literature for best practices and legal requirements for lactating health care workers. Programs of similar size and location were contacted to share resources. We then presented our findings at a faculty meeting which included a refresher on the physiological needs of lactating women. Our residents train primarily at the University of Iowa Hospitals and Clinics (UIHC) with rotations at the Stead Family Children’s Hospital (SFCH), a separate pediatric hospital with a connector bridge to UIHC. UIHC has 2 lactation facilities within the women’s locker room near the operating rooms. These 2 facilities are heavily used, as they are shared by all lactating women working in the 32 operating rooms. In a busy academic center where space adjacent to the operating rooms is at a premium, the Department of Anesthesia elected to use call rooms during the day to provide lactation facilities for the department. Two call rooms are used for trainees (residents and Student Registered Nurse Anesthetists) needing lactation facilities and an additional call room is designated for anesthesia faculty and Certified Registered Nurse Anesthetists lactation. The rooms may be used for lactation during the day (08:00–17:00), and for call rooms at night. To make the rooms more hospitable to pumping, a comfortable chair, cushions, in-use signage, a hospital-grade breast pump, and a door lock were added to each call room. The call rooms already had existing computers and phones, and a refrigerator designated for breast milk was added to each call room to comply with ACGME requirements. SFCH is a new building with an 8 operating rooms suite, which opened in 2017. In the SFCH operating room support areas, 2 lactation rooms were designated with construction of the new building. In addition to the designated lactation rooms, additional pumping space in the SFCH anesthesia call rooms is available during the day. A breast milk storage refrigerator was added to the anesthesia break area at SFCH to ensure adequate breast milk storage space. The Operating Room Clinical Coordinators at both SFCH and UIHC are responsible for designating personnel to ensure that our department’s lactating women are given adequate time and frequency for lactation breaks. Our department has the advantage of a new and modern facility with planned lactation rooms before construction at SFCH, and we have converted existing call room space at UIHC into lactation space during the day. The new ACGME lactation requirements presented an opportunity for our department to improve our trainee’s access to adequate space and time for lactation. More importantly, we have improved lactation space for all our clinicians. As your institution considers this ACGME requirement for lactation facilities, consider taking the extra step of providing these facilities for all lactating women in your department. DISCLOSURES Name: Sarah S. Titler, MD. Contribution: This author helped write and edit the article. Conflicts of Interest: None. Name: Amy C. S. Pearson, MD. Contribution: This author helped write and edit the article. Conflicts of Interest: A. C. S. Pearson is the social media manager for the Anesthesia Patient Safety Foundation, President of the Women in Anesthesia Society, and American Society of Regional Anesthesia Chair in 2022. This manuscript was handled by: Nancy Borkowski, DBA, CPA, FACHE, FHFMA.

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