One of the first questions mothers answer after giving birth is whether they will breastfeed or not. More and more women in the U.S. are saying “yes.”
In fact, according to the Centers for Disease Control and Prevention (CDC), four out of every five infants born in 2013 started to breastfeed. Over half of them were still breastfeeding at six months, and almost one third were still breastfeeding at 12 months.
“There is certainly a growing popularity of breastfeeding over the past decades,” says Dr. Lauren Hanley, breastfeeding medicine specialist at Massachusetts General Hospital and chair of the Gynecology Expert Work Group on Breastfeeding for the American Congress of Obstetrician (ACOG).
“The more we learn about breastmilk and breastfeeding and the numerous benefits, the more women are generally motivated to breastfeed,” she adds.
Why breastfeeding is important for a baby’s development
According to the World Health Organization and UNICEF, babies should receive breast milk exclusively until they are 6 months old. Then from 6 months until at least 2 years old, they should receive breast milk, as well as food.
The CDC’s Healthy People 2020 initiative aims to increase the percentage of U.S. moms who breastfeed up to a target of 81.9 percent. At present, 29 states meet that goal.
While that number is encouraging, their data shows that when it comes to duration, many moms don’t make it to six months of breastfeeding. In fact, only 51.8 percent of U.S. moms are still breastfeeding at the six month point, and only 30.7 percent at the one year mark.
This indicates that while most moms want to breastfeed their children, they “may not be getting the support they need, such as from healthcare providers, family members, and employers,” according to the CDC.
The existing barriers to working moms
“We know that most moms want to breastfeed. More than 80 percent choose to breastfeed and start out in the hospital,” says Megan Renner, executive director of the United States Breastfeeding Committee (USBC). “We know especially in the United States where we don’t have paid family leave in any great measure that when moms go back to work, we see the breastfeeding rates drop off pretty significantly as the weeks go by.
“It can be truly devastating when moms want to breastfeed but do not receive the support from their family or employer or healthcare providers.”
Despite the known benefits to both mother and baby, Dr. Hanley says there are still many barriers in the U.S. that make successful breastfeeding a challenge.
“Among these are our high rates of employment of women and lack of paid maternity leave. Thus, the pressures to return to work quickly after birth are a huge challenge for women to navigate breastfeeding, parenting, and working outside the home,” she says.
This is exactly why the breastfeeding provisions in the Affordable Care Act (ACA) are important, she adds.
How is breastfeeding protected in the ACA?
In 2010, President Obama signed the ACA into law. There are three provisions of the ACA that have had a direct impact on providing new investments and supports for breastfeeding families.
1. Workplace breastfeeding support
Section 4207 of the ACA, “Reasonable Break Time for Nursing Mothers,” requires employers with more than 50 workers to provide reasonable break time for moms to express breast milk for up to a year, and to provide a private place (that isn’t a bathroom) to do so. This is the first time that there has been federal protection for breastfeeding at work. While the provision technically only applies to nonexempt (hourly) workers, many employers have also extended this support to their salaried employees.
“Having this in the federal landscape for the first time as part of the ACA, although the coverage aspect wasn’t perfect, was really a landmark moment to demonstrate support for working moms who want to breastfeed,” says Renner. Especially because it was supported with a unanimous bipartisan vote in the Senate health committee.
Renner says it’s important that the provision is maintained within the efforts to repeal, replace, or revise the ACA, though she believes the provision will not be impacted by those plans. That’s because the approach being taken in congress to repeal the ACA is through a process called budget reconciliation. This targets provisions of the ACA that affect federal government spending and revenues. The “Break Time for Nursing Mothers” provision does not meet these criteria.
While the breastfeeding in the workplace provision seems to be protected, Renner says there are two other breastfeeding provisions of the ACA that are in jeopardy.
2. Prevention and Public Health Fund
The Prevention and Public Health Fund (PPHF) was established to “provide expanded and sustained national investments in prevention and public health, to improve health outcomes, and to enhance healthcare quality.” Renner says breastfeeding initiatives make up just a tiny portion of the fund.
“We’re concerned that breastfeeding could lose this funding if the PPHF is repealed, which is a very real risk since its clearly related to budget, and has been targeted in past ACA repeal attempts,” Renner says.
3. Preventive services coverage
The ACA requires health plans to provide coverage for in-network preventive care services without coinsurance, deductible, or copayment. Breastfeeding support is covered under two components of this provision:
- preventive services that have a Grade A or B from U.S. Preventive Services Task Force (USPSTF)
- women’s preventive services that are supported by the Health Resources and Services Administration
These services can include educational materials, nursing bras, and breast pumps, plus counseling and education during the antenatal, perinatal, and the postpartum periods.
“We understand that there are lots of preventive services covered by the ACA, but we want to see both breast pumps and counseling/education maintained as a mandate for insurers regardless of the broader repeal situation,” says Renner.
Dr. Hanley agrees that protecting this coverage is critical. While she says there’s no way to prove if the ACA pump provision has contributed to the rise of breastfeeding initiation rates, she believes that having access to a pump helps women make sure their babies get breastmilk even if they’re separated for multiple hour stretches.
“This affords more women the freedom to be separated from their babies while lactating. And many women in the U.S. return to work starting at one week postpartum due to financial constraints. So it is certainly plausible that some of these women who may not have started breastfeeding due to work considerations now do start to breastfeed because of the pump provision,” Hanley says.
If the ACA repeal eliminates the coverage mandate for preventive services, states may need to step up to reinstate these coverage benefits at the state level. Renner reports that the USBC supports a network of state breastfeeding coalitions in all 50 states, who are poised to take action should this need arise.
What laws protect moms at the state level?
Several types of breastfeeding legislation exist at the state level. However, when it comes to breastfeeding or pumping in public or at work, many mothers face societal constraints.
“Women continue to be ostracized and criticized for feeding their baby in public despite laws which protect them in almost all states,” says Dr. Hanley.
How do maternity rights in the U.S. compare to other countries?
Attitudes toward breastfeeding in public and at work don’t just vary across the U.S., but across the world. According to a comprehensive study of public attitudes toward breastfeeding found that, in Europe, the laws and attitudes vary drastically by country. Breastfeeding in public is encouraged in Scandinavia as well as Germany, despite no specific laws protecting it in the latter. Women in the Balkans and Mediterranean, meanwhile, are more discreet about breastfeeding in public, even though they have laws protecting their right to do so.
The U.S. is one of only eight countries — and the only high income country — that offers no guaranteed paid maternity leave.
Expecting parents must instead rely on their employers to provide them leave, but only 12 percent of private sector employees actually get it.
As a result, almost half of new mothers find themselves returning to work within three months, often working the same hours as before. Which is why it should be no wonder that many choose to give up breastfeeding before the six month mark, or even avoid it altogether.