Paid Family Leave Effects on Breastfeeding: A Quasi-Experimental Study of US Policies

Paid family leave policies modestly increased the likelihood of exclusively breastfeeding at 6 months among married, White, higher-income, and older mothers.

Introduction

The United States of America is the only high-income country that does not have a national policy on paid family leave, a policy that allows new parents paid time off work after the birth of their child to recover and take care of their child. Family leave policies have important implications for lower-income women and women of color, who experience disparate maternal health outcomes and are more likely to face financial barriers when taking unpaid leave. The absence of paid family leave often forces parents without financial resources to return to work early. Returning to work early is associated with shorter breastfeeding time, reduced immunization, and poorer maternal health. Moreover, breastfeeding duration has been found to affect infant infection risk and other long-term health outcomes.  Guidelines from the 2005 American Academy of Pediatrics recommend exclusive breastfeeding for 6 months, where an infant only consumes breast milk, and continuing breastfeeding for 12 months in addition to the introduction of other nutrition. 

Despite the lack of a federal policy for paid family leave, California and New Jersey are two examples of states that have implemented family leave policies, in 2004 and 2009, respectively. In 2017, California’s family leave policy allowed workers to receive 55% of usual pay up to a maximum amount ($1,173/week). This policy increased average leave-taking from three to six weeks and doubled leave take-up. In 2017, New Jersey’s policy allowed workers to receive 67% of usual pay up to a maximum ($633/week). 

This study analyzes breastfeeding data before and after the implementation of California and New Jersey’s paid family leave policies compared to states with no leave policies at that time to determine the connection between paid family leave and the duration of breastfeeding. With the passage of more recent state policies since this paper was published, there are now over a dozen states that offer their own paid leave policies.  

Findings

Paid family leave policies increased exclusive breastfeeding at the 6-month benchmark. Breastfeeding duration for married, White, higher-income, and older mothers improved more from paid family leave policies compared to disadvantaged women.

Outcome Analysis

  • There was a 1.3 percentage point increase in the number of children exclusively breastfed at 6 months due to paid family leave policies.
  • The other six breastfeeding outcomes were whether parents had ever breastfed their child; whether the child remained exclusively breastfed at 3 months; whether the child was still breastfed at 6 and 12 months; days of exclusive breastfeeding; and days of any breastfeeding. These were not statistically significant in the overall sample.

Subgroup Analyses

  • After the implementation of family leave policies:
    • Married women had higher rates of exclusive breastfeeding at 3 months, any breastfeeding at 6 months, and exclusive breastfeeding duration, compared to unmarried women.
    • Black women had reduced breastfeeding at 12 months compared to White women.
    • Hispanic women had improved exclusive breastfeeding at 6 months compared to White women.
    • Women of other races experienced reductions in ever breastfeeding compared to White women.
    • Middle- and high-income women had higher rates of ever breastfeeding, exclusive breastfeeding at 3 months, and breastfeeding duration compared to low-income women.  
    • Women younger than 30 years experienced reduced breastfeeding duration compared to older women.

The study suggests that existing paid family leave policies favored more advantaged women. California and New Jersey’s policies provided only modest salary coverage at the time this study was done (although both states’ policies have since been expanded). Given that low-income families may have lower take-up of unpaid and (partially) paid leave, the implementation and design of family leave policies must center disadvantaged women to avoid exacerbating health disparities.

Methodology

The National Immunization Survey (NIS) is a nationally representative serial cross-sectional survey that includes questions on breastfeeding. This study analyzed NIS data of a large and diverse sample of 306,266 children born from 2001 to 2013 drawn from the 2003-2015 NIS waves.  

This study uses a linear regression model to estimate the impact of the paid family leave policy on length of breastfeeding. The primary independent variable was if a birth occurred in a year and state with (versus without) a paid family leave policy. Seven breastfeeding outcomes were considered: ever breastfed; whether the child remained exclusively breastfed at 3 and 6 months; whether the child was still breastfed at 6 and 12 months; days of exclusive breastfeeding; and days of any breastfeeding. A difference-in-differences approach was applied to test the differences in breastfeeding practices before and after policies were implemented in California and New Jersey compared to states without paid family leave policies. Analysis was also conducted to determine if the effects of paid family leave policies impacted breastfeeding length differently depending on variables like maternal marital status, race/ethnicity, income, and age. 

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