Short Paper 4: The ACA and Nursing Mothers

Despite overwhelming evidence that breastfeeding and the exclusive provision of breast milk to infants improves health, saves money and increases productivity, the percentage of American women who breastfeed remains far below that recommended by medical experts and governmental organizations.1 The necessity of returning to work combined with lack of supportive work environments including appropriate time and space to express milk is a significant contributing factor to low levels of exclusive breastfeeding in the United States.2
The Patient Protection and Affordable Care Act (?ACA? or ?the Act?) aims to improve access to health care and health outcomes through a number of mechanisms.3 While the bulk of the ACA?s impact is likely to come from provisions that improve access to health insurance and evidence-based care, many others are likely to have a positive impact on individual and public health as well.4 Among these is Section 4207.
Section 4207 is intended to make it easier for the more than 56% of women with children under the age of one who participate in the labor force to initiate and continue breastfeeding and providing breast milk to their children.5 The section, which amends the Fair Labor Standards Act (?FLSA?), requires certain employers to provide both time and space for some employee nursing mothers to express breast milk.6 This change is expected to increase the likelihood that employees to which it applies will be able to feed their children breast milk, with attendant positive effects on health for both mothers and their children and on productivity for the employer.
The benefits of breastfeeding and the exclusive feeding of breast milk to infants are wide ranging and well documented.7 Exclusive breastfeeding is associated with a reduced rate of gastrointestinal and respiratory tract infections in infants, as well as a reduced risk of children later developing diseases including obesity, diabetes, and certain types of leukemia.8 It has been estimated that increasing the rate of exclusive breastfeeding among American mothers to 90% would save 900 lives per year, most of them infants.9 Maternal benefits include a reduced risk that mothers will later develop maternal type 2 diabetes, breast cancer, and ovarian cancer.10
Based on this evidence, expert panels and professional organizations including the American Academy of Pediatrics Section on Breastfeeding, the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians and the World Health Organization recommend that infants be exclusively breastfed for the first six months of life.11 The Surgeon General of the United States has repeatedly noted the benefits of breastfeeding to women, infants and employers.12
The economic case for breastfeeding is strong. The United States Department of Agriculture has concluded that a minimum of $3.6 billion would be saved if the prevalence of exclusive breastfeeding increased from current rates to those recommended by the Surgeon General.13 A more recent study using updated data found that if 90% of American mothers breastfed exclusively for six months, the United States would save over $13 billion per year.14 It is reasonable to believe that many of the economic benefits of breastfeeding accrue to employers in the form of reduced absenteeism and lower health care costs, and at least one study has found that mothers who breastfed reported fewer absences than those who did not.15

Significant disparities exist in rates of breastfeeding based on maternal education, age, race, ethnicity, and socioeconomic status.16 While approximately 70% of white women in the United States begin breastfeeding, the rate for blacks is only about 40%.17 Lack of support in the workplace perpetuates and exacerbates these inequities, particularly for the more than 60% of American women who work in hourly paid positions that are less likely to offer the flexibility or workplace support that is needed to maintain and facilitate continued breastfeeding for new mothers.18 Hispanic and black women in particular are more likely to work in service occupations than white and Asian women, with the latter women being more likely to work in management, professional, and related occupations.19 Not surprisingly, mothers in administrative and manual occupations are more likely to stop breastfeeding sooner than women in professional occupations and those who do not need to enter the workforce before their children are weaned.20

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