The Importance of Addressing Breastfeeding Policies in Health Equity Work

June 11, 2020 | Leah Silva, Aika Aluc

Breastfeeding has long been considered the gold standard in postnatal care for both mom and baby. Health benefits of breastfeeding include reduced risks of asthma and obesity for babies and a lower risk of high blood pressure and breast cancer for mothers. Unfortunately, systematic barriers can make it difficult for some women to initiate and continue breastfeeding through their infant’s first year. These barriers include lack of support from a woman’s partner, family, hospital, or workplace.

Breastfeeding disparities are greater among systemically vulnerable communities, notably African American women who continue to experience the lowest rates of breastfeeding. There also continues to be a scarcity of literature on breastfeeding patterns among American Indian/Alaska Native mothers. Maternity care facilities in neighborhoods with larger Black populations are also less likely to offer maternity care practices supportive of breastfeeding than facilities in areas with a lower percentage of Black residents. Mothers with lower rates of breastfeeding tend to be young African American women with a low income. African American mothers are 2.5 times less likely to breastfeed than white mothers. Research shows that low-income minority women report the following barriers:

  • Lack of social, work, and cultural acceptance or support.
  • Language and literacy barriers.
  • Lack of maternal access to information that promotes and support breastfeeding.
  • Lifestyle choices, including tobacco and alcohol use.

In addition, the COVID-19 pandemic disproportionately impacts systemically vulnerable populations further exacerbating existing barriers to breastfeeding and has raised questions about the safety of breastfeeding and potential risks of infection. According to the CDC, it is not known whether mothers with COVID-19 can transmit the virus via breast milk, but the limited data available suggests it isn’t likely. Mothers with COVID-19 should take necessary precautions to avoid spreading the virus to her newborn by wearing a face covering and by washing her hands before breastfeeding. Pasteurized donor milk is also important in the care of many infants, and there is no information currently available regarding the effect of pasteurization on the COVID virus. CDC also notes that there may be disruptions in human milk donations during the pandemic, which may have a disparate impact on already vulnerable populations.

Laws and policies can help reduce barriers and improve women’s access to support, time, equipment, and space for breastfeeding. In recent legislative sessions, state law makers are acting on several policy approaches, which include aligning state laws with workplace accommodation requirements, improving breastfeeding practices in maternity hospitals, and addressing the needs of pregnant and parenting students in schools. Below is an overview of state legislative activity addressing access to and support for breastfeeding or lactation practices.

In 2019, two states enacted legislation that increases access to information about breastfeeding as well as breastfeeding counseling for new mothers and families. Illinois enacted HB 2 giving every woman the right to receive complete information about the benefits of breastfeeding in advance of labor. While the enacted bill does increase access to information for all women, the original bill would have addressed many of the barriers to initiating or continuing breastfeeding among systemically vulnerable populations. New York enacted companion bills S3387 and A2345, which require Medicaid to cover lactation counseling services without a referral from a physician, registered physician’s assistant, registered nurse practitioner, or licensed midwife. This year the District of Columbia enacted B23-0416 authorizing the Department of Health to collect information from hospitals and birthing facilities to create a report card regarding compliance with newborn screening requirements, lactation support services, parent education, and discharge standards.

In 2010, the Affordable Care Act required employers with more than 50 employees to provide women with adequate break time as well as private, clean spaces to express breast milk during the workday for one year after a child’s birth. Research on these policy changes found an increase in the duration of breastfeeding, and other positive impacts of breastfeeding. In 2019, three states enacted legislation addressing workplace compliance with lactation accommodation. California enacted SB-142 requiring every employer to provide lactation rooms or locations with prescribed features for women to express milk. Employers cannot deny reasonable break time or adequate space to express milk nor can employers discharge or discriminate against employees exercising their rights to express milk. Kentucky bill SB18 makes it unlawful for employers with 15 or more employees to fail to provide reasonable accommodations for any employee with limitations related to pregnancy, childbirth, or a related medical condition. The bill also addresses private spaces designated for expressing breast milk. In Texas, HB541 amends current law to include the right to express milk in addition to the right to breastfeed in any location in which the mother is otherwise authorized to be, which impacts employers.

In addition to supportive breastfeeding policies, legislation that promotes educational achievement for adolescent parents have long-term, and even multi-generational, benefits. Pregnancy is the leading cause of school dropout for adolescent girls, and less than 2 percent of mothers who had children before the age of 18 earn a college degree by age 30. This gap in education translates into lower lifetime earnings. Additionally, the children of teenage mothers are more likely to drop out of school themselves. A growing body of research connects low levels of income and education to poor health outcomes, so supporting pregnant and parenting teens is a vital public health intervention. To address this, Pennsylvania’s legislature is considering HB 2048, which would require each schools to provide reasonable accommodations for a lactating pupil on a school campus to express breast milk, breastfeed, or address other needs related to breastfeeding. Lactating pupils would also be provided reasonable time during the school day. Compulsory attendance, leave of absence, maternity leave, and parental leave are also addressed in the bill. Missouri is also considering companion bills HB 1279 and HB 1490, which would require local boards of education to adopt policies providing accommodations and designated times for employees, teachers, and students to express breast milk, breastfeed a child, or address other needs related to breastfeeding.

Donor milk and human milk banks (HMBs) play an important role in promoting breastfeeding and increasing breastfeeding rates. Newborns may receive donor milk because of preterm birth, failure to thrive, malabsorption syndromes, allergies or infectious diseases. Access to donor milk among populations that are already at a higher risk of poor health outcomes is extremely important. Connecticut bill HB 7165, enacted in 2019, requires the commissioner of social services to provide Medicaid reimbursement for pasteurized donor breast milk if certain conditions are met. Similarly, Illinois bill HB 3509, also enacted in 2019, requires that pasteurized donated human breast milk be covered under health insurance and the medical assistance program.

State and territorial health agencies play an important role in promoting efforts to improve the nutritional environment for infants and children by collaborating with healthcare providers, communities, and hospitals to implement evidence-based breastfeeding best practices. In addition, increasing access to key information and breastfeeding services among systemically vulnerable populations may reduce health disparities and improve health outcomes for women and infants. ASTHO will continue to monitor this important public health issue.