Breastfeeding and the Affordable Care Act

Increasing breastfeeding rates is a national priority due to the health, psychosocial, and economic benefits accrued by families and society. 1–3 The American Academy of Pediatrics recommends that infants are exclusively breastfed for approximately the first six months of life, after which complementary foods can be introduced, and to continue breastfeeding for one year or longer. 2 The most recent data from 2011 demonstrate that 79.2% of infants started to breastfeed and 18.8% were exclusively breastfed for the first six months, while 49.4% of infants received some breast milk at six months. 4 The Healthy People 2020 target is to increase the proportion of infants who are ever breastfed to 81.9%; those who are exclusively breastfed at six months to 25.5% and those who receive any breast milk at six months to 60.6%. 3 Although more advantaged mothers have already met and often exceed the Healthy People 2020 breastfeeding targets, groups of women with lower levels of education or income, or who are receiving WIC benefits are far from achieving these goals. 1, 5, 6

The 2011 US Surgeon General’s Call to Action to Support Breastfeeding identified returning to work as an important barrier to breastfeeding for many women. 9 Research has found that women who return to work soon after birth or return full-time are less likely to start breastfeeding than women who are not employed. 7–9 Mothers who work full-time also have a shorter duration of breastfeeding than non-employed mothers. 8–10 Guendelman and colleagues examined the role of maternity leave and occupational characteristics on breastfeeding among women who were employed fulltime in California, one of only a few states that provides paid family leave. 9 They found that women with maternity leave of 12 weeks or less were less likely to start breastfeeding and more likely to stop after successfully beginning than women who did not return to work. Women with short maternity leave who were nonmanagers or had inflexible jobs had poorer breastfeeding outcomes than their more advantaged counterparts. 9 In addition, a study of low-income mothers found that those in administrative and manual occupations quit breastfeeding earlier than other women. 11 Taken together, this evidence suggests that in order to achieve national breastfeeding targets 3 additional support in the workplace is needed to promote breastfeeding.

Thus despite progress toward achieving the Healthy People 2020 breastfeeding targets, 4 socioeconomic status and the workplace create barriers to breastfeeding for many women. The recent implementation of the Patient Protection and Affordable Care Act (ACA)12 and its highly publicized provisions in support of breastfeeding, provides an opportune time to consider current legislation and its potential to address the socioeconomic disparities associated with breastfeeding. To that end, we first review the reported benefits of breastfeeding and current data on breastfeeding among US women, identifying disparities in breastfeeding rates based on income and employment status. We then analyze and compare the breastfeeding provisions of the major statutory programs designed to support breastfeeding, including the ACA, Medicaid, and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) 13 . We examine whether such measures adequately address the socioeconomic disparities in breastfeeding rates and consider how well they assist working mothers who choose to breastfeed. We conclude with a set of recommendations.

DISPARITIES IN BREASTFEEDING

The population-level benefits of breastfeeding are well-established. 1, 2, 14, 15 Fullterm infants who are breastfed are at reduced risk for sudden infant death syndrome, ear infections, gastrointestinal infections, and respiratory infections, as well as chronic conditions including asthma, obesity, and type 2 diabetes mellitus. 1, 2, 14, 15 Preterm infants who are not breastfed have higher rates of necrotizing enterocolitis. 14 Mothers who breastfeed are at lower risk for type 2 diabetes mellitus, and breast and ovarian cancers. 1, 2, 14, 15 The benefits of breastfeeding also extend to the economy and environment. If 90% of US mothers meet the recommendation of exclusive breastfeeding for 6 months, Bartick and Reinhold estimate that 911 deaths would be averted and the US economy would save nearly $13 billion. 16 The largest impact would be on reductions in sudden infant death syndrome ($4.7 billion; 447 deaths), necrotizing enterocolitis ($2.6 billion; 249 deaths), and lower respiratory tract infections ($1.8 billion; 172 deaths). 16 Furthermore, 90% compliance would save the US economy $3.7 billion in direct and indirect pediatric health costs, $10.1 billion in premature death from pediatric disease, and $3.9 billion on infant formula. 17 Breast milk is a renewable food and does not have an environmental footprint. In contrast, infant formulas and other human milk substitutes have packaging, shipping, and fuel costs required for the manufacture and transporting of these products. 1

Despite these benefits and steady improvement in breastfeeding rates over recent decades, 4, 18 significant disparities persist. Mothers’ socioeconomic circumstances remain one of the strongest indicators of breastfeeding. Mothers who receive or qualify for WIC or who have lower levels of education are less likely to start and continue breastfeeding than their more advantaged counterparts. 1, 5 Table 1 illustrates these socioeconomic disparities in breastfeeding rates using 2011 data from the National Immunization Survey. 6 Regardless of whether the indicator is education, income, or WIC eligibility, there is approximately a twenty percentage point gap in rates of breastfeeding initiation between the most disadvantaged mothers and those who are better off. The gap extends to almost thirty percentage points for mothers reporting any breastfeeding at six months. For example, 72% of women who receive WIC initiated breastfeeding and 38% breastfed to six months, while comparable rates for women who were ineligible for WIC were 90% and 66%, respectively. 6

Table 1

Healthy People 2020 breastfeeding targets and rates of any and exclusive breastfeeding by socio-demographics among children born in 2011