Introduction
Breastfeeding provides the optimal first food for infant growth and development and positively impacts the health of the parent–child dyad [1]. The American Academy of Pediatrics recommends exclusive breastfeeding for 6 months with continued breastfeeding for another 2 years plus complementary foods [2]. Given these health benefits and national recommendations, ensuring that lactating student parents have the support and protections to breastfeed is crucial.
Background on laws
Passed in 1972, the US Department of Education’s Title IX protects lactating student parents from discrimination. This federal law covers student rights against discrimination on the basis of sex, including pregnancy, and conditions related to pregnancy/postpartum (e.g. lactation, recovery from caesarean section), in K-12 and higher education schools that receive federal funds [3]. Title IX mandates that schools provide accommodations that enable students to fully participate in and benefit from their education [3].
To enforce and monitor compliance with Title IX policies, each campus must have a campus coordinator who serves as the central point of contact for all matters related to sex-based discrimination [4]. This role is critical not only to ensure compliance with federal laws but also to provide key support and guidance for institutional implementation [3].
Unfortunately, vague language and lack of customized support for lactating student parents prevent these federal protections from working as intended. Further, lactating student parents are lumped in with students with similar temporary medical needs, which is not adequate to this population’s needs [3]. To address these shortcomings, the Title IX law was updated in 2021 to include “the California Sex Equity in Education Act requiring schools to provide pregnant students and those recovering from childbirth-related conditions with the same accommodations and support services available to other students with temporary medical conditions.” [4].
On 19 April 2024, the US Department of Education released final regulations strengthening the rights of lactating student parents under Title IX [5]. These regulations went into effect on 1 August 2024, and included specific provisions such as requiring institutions to provide reasonable accommodations for lactation needs, including access to private, clean lactation spaces and reasonable break times for expressing milk [6].
Lactation policies in California’s higher education
Despite these recent changes to Title IX, California already had stronger laws in place to complement the federal laws in order to better support lactating student parents navigating academic demands plus parenting and lactating in higher education institutions [4]. However, some areas of California, such as Los Angeles, still face challenges [4]. Since its initial report in 2019, BreastfeedLA has updated information regarding academic institutions’ compliance with Title IX regulations and compiled a graded ranking system to reflect their improvements (e.g. an institution had a pregnant and parenting policy for students; student policy included a lactation policy) [4].
The criteria for that past report included (i) whether an institution’s general policies are accessible on its website, (ii) whether an institution had a lactation policy for employees, (iii) whether an institution had a pregnant and parenting policy for students, (iv) whether the student policy included a lactation policy, and (v) whether the name and contact information for the Title IX coordinator was posted on the institution’s website [4]. According to the study’s survey of 103 public and private higher educational institutions in Los Angeles County, only 8% met all five criteria, 22% met four or more of the five criteria, and 5% failed to meet any of the criteria [4]. This report highlights the paucity of data on lactating student parents in Los Angeles and their college or university’s limited resources to support them [4].
Since the release of the report [4], the lactation environment in the State of California was improved with the passing of two California bills that went into effect on 1 January 2020: Assembly Bill (AB) 2785 [5] and Senate Bill (SB) 142 [7]. These bills built upon the federal laws by creating clear guidance on policy development, specifics such as room composition, and clear compliance guidance to support lactating student parents’ rights [8]. AB 2785 updated the state education code for California State Universities, but not for University of California (UC) campuses, to require reasonable lactation accommodations whenever a student is on campus, including private space, time, and a complaint process that explicitly prohibits students incurring academic penalty when exercising these rights [5].
AB 2785 notes that UC campuses were encouraged to adopt this law, but the UC Office of the President had already adopted a fully comprehensive lactation policy in 2013 for all its campuses, which exceeded the law’s room requirements [9]. SB 142 updated the state labor code with specific lactation room requirements as well as employer policy and compliance requirements and strictly prohibits discrimination or retaliation against employees exercising these rights [7]. As a state labor law, SB 142 applies to both UC and CSU campuses [10].
On a similar note, California Assembly Bill No. 2881 [11], which took effect on 1 July 2023, mandates priority registration for student parents, improves data collection processes, and requires universities to provide resources for student parents to navigate on- and off-campus resources. This bill complements student lactation accommodation laws by accurately reflecting the needs of student parents enrolled in higher educational institutions and providing accommodations that reflect the true number of student parent enrollments [12].
The need for accurate and current data
The literature has primarily examined the availability of lactation policies only minimally assessing the quality of these policies [4, 13, 14]. Therefore, little to no research evaluates how well these policies are articulated, implemented, or experienced by breastfeeding individuals. This gap is concerning as policy’s quality has significant implications for lactating student parents and their ability to successfully breastfeed.
Various barriers present themselves to lactating student parents seeking to breastfeed while accessing higher education, including limited campus-wide lactation policies and resources, lack of awareness of lactation room locations or accommodations, scheduling conflicts, and the absence of private pumping spaces [15–17]. These studies highlight the consequences of poor policy communication and demonstrate that even when policies are in place, they may be ineffective. Some websites and student handbooks for higher education institutions offer descriptive assessments that range from direct and specific to unclear; however, currently no standardized or quantitative method exists to evaluate or compare the strength and quality of an institution’s lactation policies.
The present study evaluated the quality of higher education lactation policies in California for comprehensiveness (i.e. breadth of areas covered) and strength (i.e. degree to which policies included specific and clear language) and to score these policies for comparative analyses. Guiding questions for the study objectives included the following: What are some of the common weaknesses and strengths in lactation policies among private/public universities in the California Higher Education Systems? What is the overall comprehensiveness score and strengths score in lactation policies among private/public universities in the California Higher Education Systems?
California’s diverse and evolving legislative landscape makes it an ideal context in which to study lactation policies in higher education. The California State University, Northridge Institutional Review Board (IRB) deemed this study exempt from IRB approval.
Materials and methods
Eligibility criteria
Inclusion criteria included public or private California colleges and universities (e.g. CSU and UC systems) with at least one publicly accessible lactation policy for students, staff, or faculty. The exclusion criteria were not public or private college/university located outside of California and/or not having at least one lactation policy that was privately accessible or not having any lactation policies.
Selection and assessment of a lactation accommodation policy coding tool
Study researchers developed a standard system for abstracting and coding lactation policies in higher education with the purpose of identifying the quality of these policies [18]. In fall 2019, study researchers did an internet search for pregnant, lactating, and parenting policy evaluation tools and identified model policies from (i) the American Civil Liberties Union, (ii) BreastfeedLA, (iii) The Pregnant Scholar, (iv) California Breastfeeding Coalition, (v) the United States Breastfeeding Committee, and (vi) Southern Connecticut State University. Further, study researchers employed methods utilized to develop this coding system that were adapted from school wellness policy methods in Schwartz and colleagues [19].
Study researchers contacted an expert panel to lead efforts in developing a lactation policy coding tool. This panel included internationally board-certified lactation professionals (IBCLC), certified lactation counselors, lactation legal and policy professionals, certified lactation educators, lactation advocates, and student parents. It recommended that in addition to reviewing the university lactation policy, researchers should simultaneously evaluate supplemental information (e.g. pamphlets, websites, and infographic) related to the university lactation policy.
Translating policies for the general public enables the intended audience to access information about legal rights, responsibilities, and services availability. This expert panel recommended items that should be included in a student–parent policy coding tool. The resulting consensus policy coding tool consisted of 70 items, spread across 14 domains (Table 1).
The 14 domains included state- and federal-level lactation requirements (e.g. private area for lactation, break time for lactation) and other domains (milk expression location, breastfeeding equipment, access to breastfeeding tools/equipment/supplies, lactation education, lactation support, student/parent program such as family resources, staff support for student parent employees, communication with supervisors/instructors, maintenance of milk expression areas, and accessibility of policies).
Scoring of policy coding tool
Next, the expert panel categorized the items into domains based on their respective professional experience. The study team developed a scoring system for the items based on the literature [20]. This system assesses strength and comprehensiveness of lactation policy language.
Scoring for the items included a quantitative scale of 0–2 based on the following guidelines: one if the topic is mentioned with vague language, two if the topic is addressed in a specific and directive manner, and zero for no mention of the item. The comprehensiveness score reflects the proportion of items coded as a one or two, indicating that the policy addressed the topic. The strength score reflects the proportion of items coded as a two, indicating that the policy addressed the topic with clear and specific language.
There were 70 total items. Therefore, the maximum total comprehensiveness score was 70 (possible range score 1–70) and the maximum total strength score was 140 (possible range score 2–140). If a university policy scored all 1 s, then the maximum score would be 70 for their score and a strength score of 0.
The minimum possible score for comprehensiveness and strength is 0. To distinguish between a score of one and two, expert panel coders were asked to visualize the implications of a policy’s language. After developing the policy coding tool, the expert panel independently coded a model higher-education lactation policy to test the coding tool.
Then, the expert panel met to review score discrepancies, provide revisions on the coding tool (e.g. clearer definitions of items), and revise decision rules.
Collection of policies
Study researchers identified lactation policies by going onto university websites and identifying the student/employee handbook, locating information about a university health center, women’s center, and student center webpages and/or about Title IX, or by calling/emailing university personnel (e.g. Title IX coordinator, health center admin). While the authors also requested copies of resources not available to the general public, such as those housed on websites accessible only to authorized users (e.g. registered students and/or staff), they cannot confirm receiving all such resources.
Further, this policy-collection process may not have captured policies disseminated in other ways.
Scoring of policies by research assistants
Twelve research assistants (RAs) were trained to score their assigned set of policies using the same scoring method as that of the expert panel, and each policy was coded independently by two RAs. When discrepancies could not be resolved by the original pair, a third trained person graduate RA or principal investigator (K.B.) was brought into review the data and make a final decision.
Coder training presented a scenario in which a lactating student parent approaches the Office of Student Affairs about a lactation accommodation or parenting-related question or concern. Policy language that did not clarify (vague and unclear) the campus’s position on that issue was coded as a one; directive policy language was coded as a two. Table 2 provides examples from the coding manual to illustrate this designation.
Each RA analyzed the clarity of policy to address meeting the needs of lactating student parents across the 14 domains (see Table 1) in the coding tool. Each lactation policy was evaluated to determine and identify the frequency scores, averages, and medians to determine the lactation accommodation strengths and level of comprehensiveness.
Analyses
Interrater reliability analyses demonstrate how consistently different coders obtain the same scores [19]. Intraclass correlation coefficient (ICC) statistics were computed to evaluate coding consistency between two independent coders. For each policy, the ICC value was calculated to determine the interrater reliability for the total comprehensiveness and total strength scores.
The mean scores across all policies were calculated for the final interrater reliability coefficients. Median and interquartile ranges (i.e. 25th and 75th percentiles) of the number of policy items within each university that were classified as strong, or as comprehensive, by type of university, were computed.
Additionally, we computed the proportion of policies that were classified as strong or comprehensive within each policy item, by school type. We used the Kruskal–Wallis test to test whether the mean proportion of policies in each of these domains varied significantly by school type, since the data were not normally distributed. A P-value of 0.05 was deemed significant.
Results
Sample
The sample included 29 4-year California public universities (e.g. UC and CSU systems) and four private universities. One public university had no policies present, and thus was excluded from the analysis.
The total comprehensiveness and total strength scores demonstrated good range and variability: comprehensiveness scores for CSU ranged from 14 to 34; UC ranged from 17 to 32; and private universities ranged from 10 to 19. Strength scores for CSU ranged from 13 to 32; UC ranged from 11 to 32; and private universities ranged from 3 to 13. The mean interrater across all scores was ICC 0.83, indicating a good level of interrater reliability.
Comprehensiveness and strength
Figure 1 shows the average percent of policies in each group that are classified as comprehensive or strength by policy domain. On average (communication policies only), schools had comprehensiveness (items coded as a one or two) language in over 90% of their policies and strong language (items coded as a two) in over 75% of their policies. Conversely, schools on average, had almost no strength/comprehensive policy language in the education or tools domain.
Testing for significance in total strength scores between policies
The following school types differ in their percent of strong policies by policy domain (Fig. 2). Private schools had a lower median percentage of strength in communication, access, maintenance, and lactation support policies compared to UC and CSU schools (Kruskall–Wallis P’s ≤ .01).
CSU schools had a higher median percentage of strength in maintenance and student/parent program (P’s < .001), but a lower percentage of strength in milk expression policies (P = 007), compared to UC and private universities. While all institutions generally had a low number of strengths in tools and education policies, the median proportion of strengths in these domains was higher in UC schools than in CSU and private schools (P’s = 03).
Testing for significance in total comprehensiveness scores between policies
The following school types differ in their percent of comprehensive policies by policy domain (Fig. 3). Private schools had a lower median percentage of comprehensiveness in access and lactation support policies compared to UC and CSU schools (P’s ≤ .02).
CSU schools had a higher median percentage of comprehensiveness in maintenance and student/parent program (P < .001), but a lower percentage of comprehensiveness in milk expression policies (P = .01), compared to UC and private universities. The median proportion of comprehensiveness for tools was higher in UC schools compared to CSU and private schools (P = .03), and for access policies was higher in CSU schools compared to private (P = .02).
Met state requirements
Of the CSUs, 5% explicitly referenced AB 2785 and 5% explicitly referenced SB 142. None of the UCs explicitly referenced AB 2785 and 10% cited SB 142. None of the private schools mentioned AB 2785 or SB 142.
Schools could still have met this coding section without mentioning these bills by name.
Discussion
This study examined the quality of higher education lactation policies in California for comprehensiveness (i.e. breadth of areas covered) and strength (i.e. degree to which policies included specific and clear language). The findings from this study build on extant scholarship, which has predominately examined the availability of lactation accommodations in the workplace and often minimally assessed the quality of these accommodations among students that are not employees [21–23]. Additionally, the coding system utilized in this study builds upon other research evaluating higher education lactation policies [24].
It was developed by an expert interdisciplinary group and provides a quantitative method to code higher education wellness policies across 14 domains. This robust coding system allows for a more comprehensive and standardized assessment of policy quality.
Among the 34 universities participating in the study, all but one had lactation-related policies in place. These findings are somewhat consistent with those from BreastfeedLA, which surveyed 103 colleges and universities in Los Angeles. In their sample, approximately 36% of these institutions had a lactation policy for employees, whereas 21% had a policy for students [6].
In terms of quality, policies consistently scored higher on comprehensiveness than strength. Having policies that are comprehensive and strong is critical to ensure not only coverage of a wide range of issues but also effective and uniform implementation for lactating individuals. However, the present findings suggest that achieving a high level of policy strength is a more challenging standard to meet than comprehensiveness.
Compared to private universities, public universities exhibited more comprehensive and stronger policies across all domains. Across all university settings, CSU schools scored the highest for comprehensiveness and strength. The school system’s website highlights the lived experiences of student parents [25].
One potential reason that public universities scored higher than private universities is differences in funding. Public universities typically receive funding from federal, local, and state governments, which often comes with greater flexibility in how funds are allocated [26, 27]. Private universities rely more heavily on tuition, endowments, and donations, which are often restricted to specific purposes determined by the donor [27].
Furthermore, many state-level lactation policies apply only to public institutions, meaning private schools are not required to comply and therefore have more discretion in whether or how they provide lactation accommodations [5]. Based on the higher comprehensiveness and strength scores of lactation policies, their impact for lactating CSU student parents may be more beneficial compared to private universities’ lactating student parents. Greater availability and clearer communication by university personnel (e.g. administration, faculty, and staff) about lactation policies can help lactating student parents overcome barriers to breastfeeding, such as needing private space to pump, and may support longer breastfeeding.
Overall, schools have almost no strength/comprehensive policies in the education or tools categories. While many resources and tools exist outside of higher education, including in community and clinical settings, these gaps highlight the need for campuses to better disseminate, leverage, and build upon these existing supports [20, 28, 29]. Addressing this shortcoming will require intentionally integrating lactation-related support into institutional policies.
These findings can inform national policy, advocacy, and funding efforts by underscoring the need for clear standards and accountability measures to better guide institutions in supporting lactating student parents. Therefore, increased effort must be made to explicitly integrate policies that ensure access to tools, education, and expert support into the current policy landscape within higher education.
Limitations
The current study has several limitations. The data are not generalizable nationally because only California higher education institutions were included. Future research will need to utilize this tool in universities in different states and will need to adapt the tool according to state-specific policies.
If more states use this tool, then cross comparisons can be performed to more comprehensively assess the gaps in supporting lactating student parents and what resources/programs are available/accessible that should be addressed by policies. Additionally, unmeasured variables such as campus culture and leadership commitment may influence the quality of lactation policies. For instance, a university with a strong culture of equity, belonging, and inclusion may be more likely to implement, enforce, and assess comprehensive and strong lactation accommodations, even in the absence of strict mandates.
Although these contextual factors are not captured in the current analysis, they likely play a critical role in shaping policy development and enforcement across institutions. Lastly, the policies were viewed from a heteronormativity lens. Lactation policies, practices, and experiences need more representation of the LGBTQIA+ community and of those who induce lactation for an adopted child or partner’s child.
Future directions
The coding system in this article provides a reliable method for further studying lactation and parenting accommodations and resources to quantitatively assess policy strength. To complement these quantitative methods, future research should examine the qualitative experiences of lactating student parents to provide insight into how they perceive and experience these policies as well as into their needs and how they can be best met. Lastly, interdisciplinary collaborations are essential to designing and implementing interventions that address identified policy gaps.
Conclusion
Overall, the present findings have identified gaps in the robustness and thoroughness of lactation policies across higher education institutions. While current policies are comprehensive and cover a wide range of needs, they lack the specific and clear language necessary for greater effectiveness. Strong, detailed policies are essential not just for compliance but for providing meaningful support that addresses the unique needs of lactating student parents.
These findings highlight the need for adequate and clearer language of lactation policies across all higher education institutions to ensure sufficient support for lactating student parents.
Supporting this population through comprehensive and dependable accommodations improves campus satisfaction, reduces absenteeism, and allows students to focus on their education, physical/mental health, and well-being. These benefits have significant implications for enhancing workforce participation and promoting long-term economic stability. Beyond the need to develop strong lactation policies, policymakers must establish clear guidelines for monitoring and enforcing these policies to ensure higher education institutions are held accountable.
Further, model policies should be shared across higher education. To ensure policies are effective, researchers must evaluate the extent to which these policies are being implemented and assessing their impact on lactating student parents’ well-being, retention, and academic success, and on preventing mental and physical illness during key interactions with students, such as student orientations. Ensuring availability and accessibility of strong, comprehensive lactation support within higher education can strengthen physical and mental health and academic outcomes and lay the groundwork for a healthier, more inclusive future workforce.