Spring 2020 Journal: United States Maternity Leave Policy Proposal to Improve Breastfeeding

This article is the second article featured in our Spring 2020 journal. For the complete journal, please see the “Journal Archive” tab above.

by Marie Salem

Edited by: Annelise Osterberg, Reyna McKinnon, and Anna Garfink

It is well established in the literature that breastfeeding improves infant health, maternal health, and overall societal health and economics, but there are numerous barriers involving work, time, stigma and education that mothers face. Not only does the U.S. have one of the lowest breastfeeding rates among high-income countries, but the U.S. is also the only high-income country that does not guarantee paid maternity leave. Case studies show paid maternity leave is associated with an increase in breastfeeding. The U.S. can enable women to breastfeed more by passing maternity leave legislation. Such laws will support maternal and child health, which will have compounding positive effects on society. The United States should mandate six weeks of universal paid maternity leave at partial pay in order to improve breastfeeding rates, health, and productivity and avoid excluding mothers who are unable to take unpaid leave.


The Health Benefits of Breastfeeding

There is no dispute in the literature that breastfeeding is beneficial for an infant’s nutrition and for the mother herself. Breast milk is the most complete form of nutrition for infants, matching all nutritional requirements for growth and development, including colostrum, which formula excludes [1].  Breastfeeding is very effective at preventing mortality in children under five because of its immunological benefits (protective cells, binding proteins, enzymes) and decreases the risk of acute diseases and chronic childhood diseases [2]. The mother also gains a variety of benefits from breastfeeding, including cost savings, self-confidence, infant bonding, lower risk of ovarian and breast cancer, and reduced fertility [3]. Further, mothers benefit from the release of oxytocin during lactation, which has been associated with a decrease in maternal postpartum bleeding, a decrease in anxiety and stress [4], a decrease in postpartum depression [5], an increase in positive social interaction [6], and helps the uterus return to its normal size [7].

Breastfeeding Barriers and Disparities

Despite the immense positive outcomes associated with breastfeeding, rates are low in comparison to medical recommendations. The World Health Organization (WHO) recommends babies breastfeed for six months exclusively (nothing other than breastmilk), and partially breastfeed alongside complementary food until age two. However, nationally only 20 percent of mothers exclusively breastfeed for six months and 27.8 percent of mothers partially breastfeed until two years of age [8].

A few factors contribute to overall low national rates including individual, physical, social, political and economic barriers. Individual barriers can include discomfort while breastfeeding, postpartum depression, concern about ability to breastfeed, and initial struggle to produce [9]. Although physical barriers to breastfeeding are rare, many women fear personal physical complications such as HIV and malnourishment will prevent them from being able to breastfeed [10]. The World Health Organization recommends that women with HIV still breastfeed because the benefits outweigh the risk of transmission and women can only not produce breastmilk in the most extreme cases of malnourishment [11]. Both of these issues are rarer in the United States, however fear can still lead to lower breastfeeding rates. In terms of social barriers, there remains a stigma around breastfeeding in public due to the sexualization of breasts. Evidence shows that self-objectification attitudes influence whether a woman thinks breastfeeding in public will lead to embarrassment and indecency, an idea generated by destructive influences of society on women [12]. These social barriers help explain the lack of social support and education at the community and household levels.

The economic and political barriers to breastfeeding are greatly intertwined and thus policies should act to address both. Time constraints, inadequate work environments, public indecency laws, parental leave laws and formula marketing all contribute to low breastfeeding rates in the U.S. Specifically, low-income mothers have cited time constraints and returning back to work as the largest barrier to breastfeeding [13]. Therefore, mothers who have the luxury to take unpaid maternity leave or work in well-resourced environments have increased abilities to breastfeed their children or pump breastmilk at work. This inequity can lead to more health disparities for the children, further perpetuating a cycle of poor health and poverty for certain populations. Laws that protect women in the workplace from public indecency laws are extremely limited and will be discussed in a future section. Lastly, the U.S. is one of six countries that has not adopted any part of the UN’s International Code of Marketing Breastmilk Substitutes [14]. Formula companies are criticized for marketing to low-income mothers and offering free samples, which can cause a dependence on formula. A mother’s breast milk production dries up and decreases after extended amount of time away from breastfeeding, therefore making it biologically harder to breastfeed after using formula and once the free samples end [15].

There are disparities in breastfeeding rates between different racial and socio-economic groups in the U.S. For instance, only 64.3 percent of black mothers start breastfeeding, compared to 81.5 percent of their white counterparts. Additionally, 14 percent of black mothers exclusively breastfeed through six months compared to 22.5 percent of white mothers. Socio-economic status certainly affects barriers to breastfeeding; however, certain barriers are experienced disproportionately by black women. Evidence shows that earlier return to work, inadequate receipt of breastfeeding information from providers and lack of access to professional breastfeeding support specifically affect black breastfeeding rates in the U.S. [16]. Issues relating to implicit bias amongst health care professionals can cause inadequate care and support for black mothers in pregnancy, post-partum and general health care [17].

Maternity Leave Laws in the U.S. Compared to Other Countries

Paid maternity leave does not directly address implicit bias, but it has the potential to decrease these disparities and support women in breastfeeding by increasing time with the child and decreasing stress about losing work hours and income. Unfortunately, the U.S. has one of the most limited maternity leave policies in the world, and also one of the lowest breastfeeding rates as compared to other OECD countries (Organization for Economic Cooperation and Development), which are essentially high and middle-income countries. The U.S. ranks 26th out of 30 OECD countries for the percentage of children who have ever been breastfed, and 21st out of 24 for the percentage of children who are exclusively breastfed for six months [18]. Out of the 193 United Nations member nations, the U.S. is one of only four countries that does not guarantee paid maternity leave (the others being Swaziland, Papua New Guinea, and Liberia) despite being one of the wealthiest nations in the world [19]. By 1994, all western European countries offered at least 10 weeks of paid maternity leave, ranging from between 25 to 100 percent of a mother’s salary. Norway, which has the highest ‘ever been’ breastfed rate in the world, guarantees mothers 46 weeks of maternity leave at 100 percent of salary [20].

The U.S., however, has not changed its federal maternity leave law for decades. In 1993, the Family and Medical Leave Act (FMLA) was passed, guaranteeing mothers up to 12 weeks of unpaid maternity leave. Eligibility requirements include the following: mothers must have worked under their current employer for at least 1,250 hours in the past 12 months, and the employer must have 50 or more employees [21]. States are allowed to pass different requirements regarding the number of weeks and pay, however only four states – California, New Jersey, New York, and Rhode Island – provide paid maternity leave [22]. One of the largest issues with unpaid leave is that it only supports mothers who can afford to take time off of work, which exacerbates already existing health and well-being disparities for low-income and single mothers. Paid maternity leave can be costly for the government and employers; however, an infant’s health and savings on health care costs must be considered.

Examples of Maternity Leave Policies

Research indicates that breastfeeding rates increase in countries that offer extended paid maternity leave. For instance, Canada, a country with relatively similar demographics to the U.S., experienced an increase in breastfeeding rates after the passage of extended paid maternity leave. In 2000, Canada’s provinces extended paid maternity leave from an average of six months to at least one year. The new law was associated with a 40 percent increase in exclusive breastfeeding for six months [23].

European countries also show positive associations between increasing maternity leave and increasing breastfeeding rates. Spain originally allowed 12 weeks of paid maternity leave, and in 1989 expanded their policy to allow for one year of unpaid maternity leave with job security. The change was associated with an increase in exclusive breastfeeding duration for mothers who took the long unpaid maternity leave compared to the women who just took the short paid maternity leave, however only by one half of a month [24]. This indicates that increasing unpaid maternity leave might not produce a significant increase in breastfeeding rates, given that many mothers cannot afford to take unpaid leave.

The United Kingdom in 2003 expanded its paid maternity leave at a flat rate. Mothers in the UK now have paid leave for 39 weeks, with 90 percent of the salary for the first six weeks and a paid flat rate for another 33 weeks [25]. After the policy change, a large cohort study with over 6,000 mothers in the UK showed evidence that the longer leave a mother took , the more likely she was to breastfeed her child for at least four months. In addition there was a 0.86 increased risk of mothers being less likely to breastfeed for four months if they specifically needed to return to work for financial reasons [26]. Following the same UK law change, a study in Scotland showed that returning to work earlier was associated with early breastfeeding cessation [27], and a study in Ireland showed that mothers who took between six and 12 months of maternity leave (as opposed to up to six months) had higher breastfeeding rates [28]. In addition, Thailand, Ghana, Brazil, Jordan, Turkey, China, Myanmar, Malaysia, and countries from every continent have produced studies in the literature in support of the association between extended paid leave and increased breastfeeding rates [29].

The literature on the effect of maternity leave on breastfeeding rates in the United States is limited due to the U.S.’s limited maternity leave laws, although a few studies show positive correlation between unpaid leave and breastfeeding rates. However, this is in mostly higher income and white populations. The non-diverse study population shows that unpaid leave and the U.S.’s FMLA policy does not support a large population in the U.S. – specifically, it is leaving out low-income and single mothers.

There is one study examining California’s maternity leave policy and the change in breastfeeding rates after California became the first state in the U.S. to implement a paid maternity leave policy in 2004. The law allowed mothers to take up to six weeks of maternity leave at 55 percent of their pay, a good first step, but still significantly less than other countries. A cohort study looked at mothers before the policy and after the policy and determined a three to five percent increase for exclusive breastfeeding, and a 10 to 20 percent increase for breastfeeding duration. These are promising results that highlight the potential impact of longer paid leave policies. However, six weeks of about half of pay is still very limiting and often does not support lower income mothers [30], which demonstrates the importance of higher income replacement in a robust paid leave policy.

Maternity Leave and Child Health Outcomes

Maternity leave also has health benefits in addition to the health benefits that stem from increased breastfeeding rates. Cross-national longitudinal studies involving different OECD countries have found that longer maternity leave laws are significantly associated with lower infant and child mortality, controlling for many factors [31]. A 10 week maternity leave extension in OECD countries was significantly associated with a 2.59 percent decrease in infant mortality, a 4.06 percent decrease in post-neonatal mortality, and a 3.02 percent decrease in child mortality rates [32]. Furthermore, the U.S. – which has no national paid leave policy – has the highest infant mortality rate amongst all high-income countries. Therefore, a national paid maternal leave policy would be a step to addressing infant mortality. Additionally, maternity leave before birth is associated with lower preterm, early term, and low birth weight births [33]. Unpaid maternity leave in the U.S. is also associated with normal birth weight, on time births, and decreases of infant mortality. However, these positive effects were mostly only among higher income mothers who could take unpaid leave, therefore creating further health disparities [34]. Paid maternity leave would alleviate these disparities between higher-income and lower-income mothers and their children.

Policy Proposal

The United States should implement a six week maternity leave law with partial pay based on an income sliding scale called the Federal Paid Parental Leave Act (FPPLA). This policy is an appropriate starting point that is politically feasible, will bring the U.S. closer to other OECD maternity leave laws, and will comply with the International Labor Organization recommendations. This law provides mothers with their rightful time to bond with their child after birth and has the potential to increase breastfeeding rates, improve infant health, and decrease adverse health outcomes for children later in life.

Six weeks is the average time of California, New York, Rhode Island, and New Jersey’s current paid maternity leave laws, which are the only states in the U.S. to guarantee paid leave [35]. Although this is significantly less time than the number of weeks other OECD countries offer, this is the most reasonable and feasible for the U.S. currently. The International Labor Organization specifies that the benefits of maternity leave should be no less than two-thirds of the mother’s current pay, which is why the proposed policy is based at 66 percent of pay [36].

It is recommended that the paid maternity leave is conducted on an income sliding scale in order to account for the varying income levels in the country. All mothers will be guaranteed 66 percent of their pay; mothers below 185 percent of the Federal Poverty Line (FPL) will receive 80 percent of their pay; and mothers below 100 percent of FPL will receive 90 percent of their pay. The income sliding scale is crucial to avoid leaving out low-income mothers who cannot afford to take large pay cuts during leave. Further, 185 percent of FPL is a common measure used in WIC, Head Start, CHIP, and many other governmental programs in order to address the gap between the set federal poverty line and varying costs of living throughout the country [37]. Evidence shows that a wage replacement of at least 80 percent is necessary to keep families out of poverty, and therefore low-income mothers must have at least this percentage in any proposal [38]. A major problem reported from California’s Paid Family Leave law, which only differs between 55-70 percent of pay based on income, was that the lowest income mothers still could not afford to take pay cuts. One third of respondents from a policy evaluation study indicated that they knew about the paid maternity leave law but did not take it because the wage replacement was too low [39].

The eligibility criteria for this policy is as follows: the mother must have worked for the employer for a total of 12 weeks in the last year. This criteria is modeled after the U.S.’s FMLA. Although this has the possibility to restrict mothers who started a job more recently, employers will be less likely to discriminate against pregnant mothers by not hiring those who are far along in their pregnancy. If there was no limit to how long a mother had to work at the job, employers could feel more inclined to not hire someone who is far along in their pregnancy, knowing that they could go on paid maternity leave shortly after being hired.

For the purpose of infant health benefits and breastfeeding, the proposal is only focused on maternity leave rather than leave for both parents. However, one partner from same sex relationships and one partner of an adopted child will have the same access to this proposal. Each aspect of this policy proposal is rooted in evidence, at the suggestion of international agencies, and modeled after other countries’ paid leave laws.

Economic Feasibility

Although the exact requirements are not the same as other OECD countries due to the differences in the social and political context, the finances of FPPLA can be modeled after OECD countries because of the similar economic statuses of the U.S. and the other OECD countries (high and middle income countries under an economic cooperation). A review of all OECD countries’ maternity leave laws found that the most compatible way to finance leave for a “strong national economy” is through social security schemes [40]. No OECD country finances maternity leave solely by employers, and in fact 33 out of 36 countries provide the total amount of leave payments through the government’s social security or public funds.

There are many ways to finance this policy proposal, however the best option is through the Social Security Disability Insurance Programs. Social security is a well-liked program that benefits all working retirees, and although not everyone will directly get the money from paid maternity leave, more productive mothers, healthier mothers, and healthier infants help the economy and workforce as a whole. Employers would be required to withhold a small payroll tax from their employees, that they too are required to match as employers, similar to Social Security and Medicare.  By dividing the cost between employees and employers, the costs remain low and employees are more likely to agree with the tax, and employers are less likely to cost shift and lower wages [41].

A common argument made against paid maternity leave is that it will be economically infeasible for businesses, and specifically small businesses will be disproportionately negatively affected. FPPLA does not include criteria regarding a minimum number of employees for an establishment to have in order to comply with the mandated maternity leave law, unlike other mandates such as ACA’s Fair Labor Standards Act and Employer Mandated Health Insurance which only applies to 50 or more employee establishments. These criteria are put in place to not overly burden small businesses, however, unlike the other laws, FPPLA is not paid for by the employers solely. Furthermore, adding the criteria of allowing small businesses to opt out of the law might dissuade mothers from wanting to work for small businesses in the first place. Additionally, the review of California’s law showed that small businesses were less likely than larger establishments to report any negative effects [42]. No OECD countries completely deny paid parental leave based on employee size, and neither should the U.S.

Political Feasibility

This proposal is politically feasible to pass through the U.S. Congress. Although six weeks of paid maternity leave is significantly less than what all other OECD countries offer, it is a crucial first step to parental leave policy in the U.S. The lowest number of weeks that an OECD countries provides paid maternity leave is 12 weeks, which suggests it would be politically and economically feasible to pass a law for six weeks [43]. Although critics who say six weeks is still not enough time have merit, the fact that only four states out of 50 have paid leave for six weeks, suggests the U.S. would not be able to feasibly pass a law that mandates more than six weeks with bipartisan support.

Paid maternity leave also has significant public support, and at times, bi-partisan support in the U.S. According to a Pew Research Center report from 2016, 82 percent of people say that mothers should have paid maternity leave and 69 percent of people say that fathers should have paid paternity leave [44]. In addition, politicians from both political parties have been outwardly in favor of paid parental leave. Democrats have been working on paid parental leave for over a decade, and four republican senators have announced similar laws in the past two years [45]. There is also evidence of support from the current Administration and President Trump has declared this as a bi-partisan issue [46].

“Why Women Really Quit Breastfeeding” by Kathryn Wirsing photo, describing the struggle of private pumping at work.

There are other policy alternatives that have attempted or could attempt to address the issue of low breastfeeding rates in the U.S. As previously mentioned, the Affordable Care Act amended the Fair Labor Standards Act to require employers to provide a place for women to express breastmilk other than a bathroom [47]. This policy, however, is limiting because it only applies to non-exempt workers excluding salaried workers and smaller businesses can opt out if it is too inconvenient. The law also gives no specifications about what type of space it can be other than a non-bathroom, leaving lots of room for interpretation and low regulation.

Exemption from indecency laws, or laws protecting breastfeeding/pumping in public, while essential first steps, are not strong enough to completely change stigma or make women feel completely comfortable breastfeeding. They are also limited because they refer to non-work hours [48]. Lastly, there are global attempts to limit formula marketing due to past unethical targeting and promotion. The UN’s International Code on Breastmilk Substitutes Marketing is only effective in countries which pass individual legislation, and this law seems politically unfeasible in the U.S. In 2018, under the direction of the Trump Administration, the U.S. delegation tried to remove the World Health Assembly’s language around “promoting breastfeeding” and embrace the interests of the infant formula companies [49]. Many laws around the world and specifically in the U.S. provide strong attempts to increase breastfeeding rates, however, a maternity leave policy is able to address many of the downfalls mentioned above.

The Infant Health and Social Benefits of Six Week Leave

As discussed above, there is a large body of evidence that positively associates paid maternity leave with increased breastfeeding. Research suggests that six weeks is an adequate  amount of time for health benefits to manifest because of the following reasons: The first week of breastfeeding provides colostrum to the baby, which acts as an immunization, stabilizes blood sugar, kickstarts the infant’s digestive system, and cannot be artificially produced in formula [50]. At four weeks of breastfeeding, the infant’s immune system has significantly been built up and this will protect against food and respiratory allergies later in life [51]. At six weeks the baby will be at lower risk of childhood chest infection [52]. In addition, breastfeeding is associated with lower risks of developing chronic childhood diseases including celiac disease, inflammatory bowel disease, neuroblastoma, asthma, allergies, and infections [53] and literature associates breastfeeding with a small reduction in risk of being overweight and obese [54].

These positive health effects could not only benefit the infant and immediate family, but also offer socio and economic benefits for all of society. For every 1000 never-breastfed children, there were 2033 more sick care visits, 212 days of hospitalization, and 609 more prescriptions in comparison to breastfed children due specifically to lower respiratory tract illness, otitis media, and gastrointestinal disease [55]. Specific to governmental costs, breastfed WIC infants had $175 lower Medicaid costs per 5 months compared to non-breastfed WIC infants, which displays the direct potential of savings breastfeeding and maternity leave can produce for the government and tax payers [56]. Additionally, it is estimated that about 13 percent of families with a newborn become poor within the first month, but a positive income during leave could boost economic security [57].

In addition to the economic benefits from public health prevention measures, paid leave has other business, economic, and productivity benefits to society. One main argument discussed against paid maternity leave is that employers and companies will take a hit because they are losing an employee. Although losing an employee for six weeks might be organizationally difficult, mothers will be happier and more productive, miss less work in the future, and the employer will not have to pay for the leave. One study showed that the rate mothers had to miss work to care for their infant was two-thirds lower in breastfeeding mothers compared to non-breastfeeding mothers, which is directly associated with the length of maternity leave [58]. Women are also shown to return back to work nine to 12 months after birth at higher rates than women who do not take paid or unpaid leave, showing a benefit for the employers themselves who enjoy less turnover [59]. Studies analyzing businesses in the U.S. that have paid maternity leave have found that the majority of employers did not experience increased costs, a majority of employers reported a “positive effect” or “no noticeable effect” on productivity, and businesses were not economically hurt [60]. Specifically with California’s Paid Parental Leave policy, a review found that the policy had “minimal impact on business operations” and covering the work of employees on leave was not a large burden [61]. Creating a space of respect and understanding for a family after birth has the potential to increase good morale and productivity at work in the future. Although this policy is a first step and specifically targeted to paid maternity leave for breastfeeding and health purposes, these overall economic benefits show that paid parental leave for fathers or other identifying parents could also be very beneficial.


The U.S. is one of four countries in the world without paid maternity leave, and the only high-income country that does not guarantee pay. The U.S. also has some of the lowest breastfeeding rates amongst high-income countries, therefore showing a possible correlation between maternity leave and breastfeeding rates. Although there are numerous barriers to breastfeeding, paid maternity leave is a good first step to increase breastfeeding rates, especially for mothers who cannot afford to take unpaid leave. Not only does breastfeeding have proven health benefits, but it also has direct medical costs savings. Investing in paid maternity leave to improve health outcomes is a necessary step that not only helps mothers and their children, but also society, the economy, and the government.

Marie Salem is a second-year Master of Public Health student at the University of California, Berkeley.


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