Despite Potential Health Benefits of Maternity Leave, US Lags Behind Other Industrialized Countries

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JAMA

February 16, 2016

The United States and Papua New Guinea usually aren’t mentioned in the same sentence, but they have at least 1 unlikely thing in common. They’re the only 2 countries worldwide that don’t guarantee paid maternity leave, according to the International Labour Organization, a United Nations agency, which recommends at least 18 weeks of maternity leave (http://bit.ly/1TOKuAW; http://bit.ly/1RQTGXh).

In contrast, US working women on average reported being eligible for 9 weeks of maternity leave, with only 3.7 weeks of that fully paid or partially paid, according to the government’s Infant Feeding Practices Study II, conducted in 2005-2007 (http://1.usa.gov/1n3jqUx). Low-wage workers are even less likely to have access to paid family leave through their employers, which includes maternity leave, relative to high-wage workers—5% vs 22% (http://1.usa.gov/1MgaGPw).

Although the 1993 Family Medical Leave Act (FMLA) provides 12 weeks of unpaid leave, only women working in public agencies, public and private elementary and secondary schools, and companies with at least 50 employees qualify. Plus, employees have to have worked at a company for at least a year, putting in a minimum of 1250 hours, to be eligible (http://1.usa.gov/1MgYb6c).

“Only about 60% of the worker population is actually eligible for FMLA, which is crazy,” said Jessica Milli, PhD, an economist and study director at the Institute for Women’s Policy Research in Washington, DC.

Because many women can’t afford to go on unpaid leave, they and their babies face potential harm. The lack of paid maternity leave has been linked to lower rates of breastfeeding and childhood immunizations and higher rates of infant and child mortality and depression in mothers (Hajizadeh M et al. Soc Sci Med. 2015;140:104-117; Heymann J et al. Public Health Rep. 2011;126[suppl 3]:127-134).

While Yahoo chief executive officer (CEO) Marissa Mayer famously took only 2 weeks off from work after the birth of her son in 2012 and twin daughters in December 2015, “postpartum, not everyone bounces back in 2 weeks,” said Laura Riley, MD, director of labor and delivery at Massachusetts General Hospital and president of the Society for Maternal-Fetal Medicine.

In fact, most women need 4 to 6 weeks to physically recover from giving birth before returning to work, according to the 7th edition of Guidelines for Perinatal Care, published by the American Congress of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) (http://bit.ly/1TOAjN6, p 208). Recovery from a cesarean delivery typically takes longer, according to ACOG (http://bit.ly/1FXWtHS).

But just because a woman’s body has recovered from childbirth doesn’t necessarily mean it’s time to return to the job. “Although physiologic considerations indicate that a woman can return to a normal work schedule 4 to 6 weeks after delivery, attention also should be given to maternal-infant bonding,” the guidelines note.

The contrast between Mayer, a wealthy CEO who returned to work by choice and could install a nursery adjacent to her office, and the many women rushed back to work in 2 weeks because they have no alternative represents a gaping disparity, say physicians who care for pregnant women and their babies.

“African American women have the highest risk of maternal morbidity in pregnancy,” such as hypertension, diabetes, prematurity, and obesity, Riley said. “And who’s going to go back to work the soonest? African American women. If they don’t, they don’t have a job. It’s one huge, painful cycle.”

Delivering a healthy baby is stressful enough, but a newborn who requires intensive care complicates the situation even further, said Kristi Watterberg, MD, chair of the AAP Committee on the Fetus and Newborn.

“As a neonatologist, I see that all the time: ‘Do I go back to work now so I can take the time off when my baby comes home? But I have to leave my baby [in the NICU],’” said Watterberg, who’s on the faculty of the University of New Mexico. “They have to make these terrible choices. It hits the most economically fragile families the hardest.”

When then-Surgeon General Regina Benjamin, MD, issued “The Surgeon General’s Call to Action to Support Breastfeeding” in 2011, one of the 20 actions she recommended was to “work toward establishing paid maternity leave for all employed mothers” (http://1.usa.gov/1HIJryE). Benjamin also noted in her report that breastmilk has immunological and anti-inflammatory properties that protect mother and child from a host of illnesses.

Despite those benefits, the United States lags behind the Healthy People 2020 breastfeeding goals for the percentage of new mothers who breastfeed (http://1.usa.gov/22960qd). The goal for breastfeeding, exclusively or not, is 60.6% at 6 months of age, as recommended by the AAP, American Academy of Family Physicians, World Health Organization, and the ACOG. However, among infants born in 2012, the most recent year for which the Centers for Disease Control and Prevention (CDC) has data, only 51.4% were still breastfed at 6 months.

Mothers may be well-intentioned, but work seems to get in the way of their breastfeeding plans. Research shows that nearly 2 out of 3 women in their third trimester of pregnancy said they planned to breastfeed exclusively in the first few weeks (Mirkovic KR et al. J Hum Lact. 2014;30[3]:292-297). But mothers planning to return to work within 6 weeks were 40% less likely to say they expected to breastfeed exclusively than those planning to return to work after 12 weeks.

Although the researchers didn’t have information about why women didn’t plan to breastfeed exclusively, “anecdotally, a lot of women are worried about maintaining their milk supply when they return to work,” said Kelsey Mirkovic, PhD, a coauthor of the CDC studies and an epidemic intelligence service officer at the agency.

In a follow-up study, Mirkovic and her collaborators examined whether pregnant women who intended to breastfeed for at least 3 months met that expectation. They found that nearly 30% didn’t, and those who returned to work full-time before 6 weeks were the least likely of all to breastfeed 12 weeks as planned (Mirkovic KR et al. J Hum Lact. 2014;30[4]:416-419).

“There are a lot of reasons why a mom might choose not to breastfeed her baby that are totally independent of work,” Mirkovic said. “But I think it’s important to support moms who do decide to breastfeed their baby.”

One recent study suggests that paid leave may affect breastfeeding. In 2002, California became the first state to pass a law providing some income to workers who take time off to bond with a new baby. The California Family Rights Act, which took effect July 1, 2004, provides up to 6 weeks of partial pay, 55% of a worker’s weekly wage up to a maximum benefit.

Perhaps not surprisingly, breastfeeding rates increased significantly in California but not in other states after the law was passed (Huang and Yang. Econ Hum Biol. 2015;16:45-59). “We cannot say there is a definite causal effect, but we provided some suggestive evidence that this paid family leave had some impact on breastfeeding practice,” said coauthor Muzhe Yang, PhD, a Lehigh University economist.

Taking too little time off of work after having a baby might also increase mothers’ risk of depression, research suggests.

Among mothers of 6-month-old infants—“a point at which child-rearing is particularly time-intensive and maternal employment may have its most important effects,” according to the authors—maternal work hours were positively associated with depressive symptoms and parenting stress and negatively associated with mothers’ assessment of their overall health, one study found (Chatterji P et al. J Popul Econ. 2013;26[1]:285-301).

However, despite the higher levels of parenting stress on the part of the working mothers in the study, trained observers found no difference in the quality of their parenting compared with the mothers who were not working.

Among mothers who returned to work in the first year, having less than 12 weeks of maternity leave and less than 8 weeks of paid maternity leave were both associated with increases in depressive symptoms (Chatterji and Markowitz. J Ment Health Policy Econ. 2012;15[2]:61-76).

“The mother’s mental and physical health can be an important route through which infants are affected by parents’ employment decisions,” the authors note.

Coauthor Pinka Chatterji, PhD, said it appears that maternal depression related to having to return to work early is transitory.

For some women, returning to work might actually relieve stress by providing structure, income, and even enjoyment, said Chatterji, an associate professor of economics at the University of Albany. However, “on average, mothers would benefit from having access to longer leave,” she said.

Although only a dream for most, 6 months seems to be the optimal maternity leave duration for minimizing mothers’ depressive symptoms (Dagher RK et al. J Health Polit Policy Law. 2014; 39[2]:369-416). For reasons that aren’t clear, a maternity leave longer than 6 months increased mothers’ risk of depression.

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