The Importance of Strengthening Workplace and Health Policies to Support Breastfeeding

Introduction

In recent years, there has been renewed attention to the central role that clinicians and healthcare institutions can play to support women in initiating and sustaining breastfeeding through the first year of their infant's life. There has been, however, considerably less focus on how to support the breastfeeding needs of new mothers who return to work, particularly those who go back shortly after the birth of their infant. While many women intend to continue breastfeeding when they go back to work, about 3 in 10 women report breastfeeding as a major challenge. ¹ For many women, the lack of paid family leave, limited flexibility with their work hours, and workplaces that offer few accommodations can make it especially hard for them to sustain breastfeeding. For women who breastfeed or who must express milk while they work, having health insurance benefits and Medicaid policies that cover the costs of lactation supplies and support services can make a difference in the decision to continue to provide their infants with breast milk through the first year of their lives.

The Role of Workplace Policies in Supporting Pregnant Women and Mothers

For most women, the decision to return to work after having a baby is shaped by economic factors. Research shows that returning to work shortly after childbirth affects breastfeeding rates. About half of women who return to work report that their plans to return to work affected their breastfeeding decisions, with most reporting that the volume and/or duration of breastfeeding would have been greater had they not been working. Research finds that mothers who return to work before 6 weeks postpartum are more than thrice as likely to stop breastfeeding than women who return later. In the month that a mother restarts work, she is more than twice as likely to quit breastfeeding than a mother who is not restarting work that month. ²

Only about half of women who work report that they receive paid family or maternity leave through their employers. ³ The United States does not have mandatory paid family leave like most developed nations. Rather the federal Family Medical Leave Act only guarantees that women have a job to return to after taking leave for up to 12 weeks, but the law does not require paid compensation. While there is no federal law, six states (MA, WA, CA, NY, RI, and NJ) and the District of Columbia have passed paid leave laws. The costs are typically borne by the employees or employers or shared between the two. ⁴

Once women go back to work, many face work-related obstacles that can make it challenging to continue to breastfeed. Challenges include lack of support, rigid or unpredictable schedules, and lack of workplace flexibility in terms of hours worked. ¹ In addition to making insurance coverage more affordable and available, the Affordable Care Act (ACA) amended the Fair Labor Standards Act to require employers with 50 or more workers to provide reasonable break time and a private space that is not a bathroom for expressing milk. Research has shown that these policies have had an impact. Women with adequate break time and a private place to express breast milk are 2.3 times as likely to be exclusively breastfeeding at 6 months and 1.5 times as likely to continue breastfeeding exclusively with each passing month. ⁵ However, compliance with these regulations still falls short. In a survey of women who returned to work after pregnancy, 59% reported that they had reasonable break time to express breast milk, 45% reported that they had a private place that was not a bathroom to express milk, and only 40% had both. ⁵ While state and federal requirements for employers to provide these accommodations matter, these workplace policies need to be overseen and enforced to have a broader impact and allow more women to breastfeed as long as they wish rather than as long as they can manage.

The Role of Coverage

The ACA also made significant changes to insurance coverage of maternity care and breastfeeding services. Before the passage of the ACA, the Federal Pregnancy Discrimination Act provided important protections to pregnant women that affected their health coverage and their ability to continue to work without discrimination, but only women who had employer-sponsored insurance enjoyed the right to have maternity coverage. For women who either were not offered insurance through their employers or who sought to purchase individual policies, pregnancy was considered to be a preexisting condition. Insurance carriers in the individual market were able to deny pregnant women, exclude all pregnancy-related services from the plan, or impose a waiting period for up to a year before their coverage could be used. Women who otherwise qualified had to purchase a rider, a limited coverage supplemental plan, which was typically extremely expensive and could have numerous limitations. ⁶ Before the ACA, only a handful of states had maternity care coverage mandates. The ACA defined maternity and newborn care as Essential Health Benefits (EHBs), meaning that all plans, not just those issued by employers, had to cover those services. In addition, because the ACA banned insurance plans from excluding or charging individuals more because of preexisting conditions, pregnancy is no longer a barrier to obtaining coverage in the individual market.

While the ACAs' insurance reforms made private coverage more accessible and affordable to many more women, the vast majority of low-income women, in fact, nearly half of women in the United States, have relied on Medicaid to pay for their maternity care. ⁷ Before the ACA, most women who qualified for Medicaid because they were pregnant became uninsured 60 days postpartum because that is when their pregnancy-related eligibility ended and they no longer qualified for coverage. The ACA offers states the choice to expand their Medicaid programs, financed with mostly federal dollars. To date, 33 states have opted to expand their Medicaid programs, enabling women to extend Medicaid coverage far beyond the 60-day postpartum period. In the remaining states that have resisted making this change, parents who live in households with incomes at the federal poverty level ($20,780 for a family of three in 2018) make too much to qualify. In 11 of these states, the eligibility level is 50% of the poverty level or lower. ⁸

In addition to assuring that maternity care and other EHBs are covered by all plans, the ACA entitles all women with private insurance (individual and employer plans) or who qualify as part of the Medicaid expansion to no-cost coverage of preventive services recommended by the U.S. Preventive Services Task Force. This includes prenatal visits and all other pregnancy-related recommendations, such as screening tests and folic acid supplements. The ACA also includes critical new coverage protections for new mothers. All women covered by private plans and who qualify as a result of the Medicaid expansion are entitled to: breastfeeding education; lactation counseling by providers that include, but not limited to, lactation consultants, breastfeeding counselors, certified midwives, Certified Nurse Midwives, certified professional midwives, nurses, physician assistants, and nurse practitioners; and breastfeeding equipment and supplies, which includes double electric breast pumps (not predicated on failure of a manual pump), parts, milk storage, and maintenance. This coverage must last through the duration of breastfeeding and is available for each pregnancy.

For women who qualify for Medicaid through traditional pathways, maternity care is also a mandatory benefit, but coverage of breastfeeding support services is largely up to the state for this group. A 2015 survey of state coverage policies for pregnancy-related services found that six states did not cover electric or manual pumps, and several states imposed utilization controls to breast pump benefits such as requiring prior authorization, limiting coverage to women with infants in critical care, or limiting the times or conditions in which women may rent or own breast pumps. ⁹ In addition, 13 states did not cover any breastfeeding education in their Medicaid programs, and many did not offer coverage for lactation consultants in hospitals (15 states), outpatient clinics (25 states), or through home visits (30 states). These services, of course, are critical to assuring that women receive the support they need to successfully initiate and sustain breastfeeding. An industry-supported study found that the cost of breastfeeding supplies, support, and counseling is equal to $0.20 per $500 expenditure for a Medicaid enrollee, a small fraction of the costs. Utilization management practices are also frequently found in the private sector. In fact, federal regulations allow insurers to use “reasonable medical management techniques” to set “frequency, method, treatment, or setting for which a recommended preventive service will be available without cost-sharing requirements—to the extent not specified in a recommendation or guideline.” ¹⁰

A 2015 study conducted by the National Women's Law Center documents a variety of private insurer practices that limit utilization, such as requiring a woman to obtain a pump within 6 months of delivery, imposing a time limit on pump rental, limiting coverage for counseling to the postdelivery hospital stay, or requiring women to pay for counseling and seek reimbursement. ¹¹ In addition, the report documents an insufficient lactation counseling provider network with a limited number of in-network providers and denials of coverage for out-of-network providers when women cannot find in-network consultation services. These types of practices can serve as road blocks to women who are already experiencing other challenges related to sustaining breastfeeding while they are at work or at home.

Looking Ahead

In the past decade, we have witnessed sizable advances in federal policies that shape workplace accommodations for breastfeeding mothers and in health insurance reforms that improve access to coverage and the scope of coverage for pregnant women and new mothers. While paid leave efforts are gaining momentum in several states, paid family leave has not risen to the top of policy agendas of the Trump Administration and the Republican-led Congress. Furthermore, ongoing Congressional efforts to repeal and weaken ACA protections could erode coverage expansions and protections that have benefited millions of new mothers. While Medicaid expansion is still an option for states (VA and ME have recently expanded), many states still choose to keep their traditional lower eligibility levels, which disqualify all but the very poorest mothers from continued eligibility for Medicaid.

Assuring compliance with workplace protections and employer education could further improve women's ability to continue to breastfeed while working. Oversight and enforcement of health plans at the federal and state levels could allow more women to take advantage of the lactation benefits to which they are entitled, but sometimes cannot receive. Finally, more research is needed to document the impact of workplace policies, health insurance reforms, and other protections on breastfeeding practices and maternal and infant health outcomes.