The Relationship Between State Paid Family and Medical Leave and Breastfeeding, Postpartum Depression and Postpartum Visits

CQ #290 - December 11, 2023

by Anne Eglash MD, IBCLC, FABM

#LactFact

People living in states with strong paid family and medical leave have higher rates of breastfeeding and lower odds of reporting postpartum depression symptoms.

Association Between State Paid Family and Medical Leave and Breastfeeding, Depression, and Postpartum Visits
Obstet Gynecol 2023 Nov 2 doi: 10.1097/AOG.0000000000005428. Online ahead of print.

What is the association between state paid family and medical leave and breastfeeding and postpartum depression rates?

According to the authors of this week’s study, in the USA 25% of all people and 10% of those who are low-income have access to paid family and medical leave (FML). Paid FML is different from the Family Medical Leave Act (FMLA), in that FMLA provides 12 weeks of unpaid job protected leave to care for a new child or family member without income replacement. FMLA has been found to mostly benefit those with higher income.

Previous studies have shown increased rates of breastfeeding, pediatric visit attendance, and newborn vaccination, along with lower rates of postpartum depression and suicide, intimate partner violence, and infant mortality in association with paid FML.

The researchers of today’s study designed a 2016-2019 cross-sectional study looking at the association between state paid FML policy and postpartum outcomes, comparing multiple states.

The authors analyzed data from the CDC’s Pregnancy Risk Assessment Monitoring System (PRAMs) database. They evaluated responses to the following 3 questions: 1. Whether they were breastfeeding (defined as any breastfeeding at 6 months), 2. Postpartum depression symptoms, and 3. Whether they had a postpartum checkup.

Each state was given a score based on the opportunities for paid FML, which was partially determined by state laws that provide coverage, laws for public and private sector workers such as allowing accrued paid sick time, and the ability to flexibly use sick time for a new child. Massachusetts had the highest composite score (160), while Alabama, Idaho, Michigan, South Dakota, Utah, and Wyoming scored a 0 for composite paid leave.

The study incorporated 143,131 PRAMs respondents, with 26.2% in states with the most generous paid FML, 20.5% in states with moderate paid FML, and 53.3% in states with little or no paid FML. States with low FML coverage had higher non-Hispanic White and non-Hispanic Black respondents, whereas states with high FML coverage had higher rates of Asian and Hispanic respondents.

The researchers found that state paid FML was associated with higher breastfeeding rates, lower postpartum depression prevalence, and higher postpartum visit attendance frequency.

What do you think are accurate statements, based on this study, regarding the association between rates of postpartum depression, postpartum visits, breastfeeding, and state paid family and medical leave (FML)? Choose 1 or more:

The prevalence of postpartum depression symptoms decreased with increasing household income, and education attainment.
The association between breastfeeding rates and state paid FML was stronger when only analyzing respondents with Medicaid insurance.
Among people who had Medicaid at the time of birth, breastfeeding rates were approximately 30% higher in states with high paid FML compared to those in states with low paid FML.
The higher the state paid FML, the higher the rate of breastfeeding in that state.
People who lived in states with medium or high paid FML had a 3% increased rate of postpartum visit attendance.

Click here to view the answer to this question.

Correct Answers: All are correct!

Association Between State Paid Family and Medical Leave and Breastfeeding, Depression, and Postpartum Visits
Obstet Gynecol 2023 Nov 2 doi: 10.1097/AOG.0000000000005428. Online ahead of print.
Madelin F. Perry, MD, Lilian Buis, BS, Lynn M, Yee, MD, MPH, and Joe Feinglass PhD

Abstract

Objective

To evaluate the association of state paid family and medical leave policies with the likelihood of breastfeeding, postpartum depression symptoms, and attendance of the postpartum visit.

Methods

This was a cross-sectional study that used 2016–2019 data from PRAMS (Pregnancy Risk Assessment Monitoring System) for 43 states and Washington, DC. We describe the association of state paid family and medical leave generosity with rates of breastfeeding, postpartum depression symptoms, and attendance of the postpartum visit. Logistic and Poisson regression models tested the significance of state paid family and medical leave coverage generosity after controlling for individual respondent sociodemographic characteristics, with sensitivity analyses for respondents with deliveries covered by Medicaid insurance.

Results

Of the 143,131 respondents, representative of an estimated 7,426,725 population, 26.2% lived in eight states and DC with the most generous paid family and medical leave, 20.5% lived in nine states with some paid family and medical leave, and 53.3% lived in 26 states with little or no paid family and medical leave. Overall, 54.8% reported breastfeeding at 6 months or at time of the survey, ranging from 59.5% in the most generous paid family and medical leave states to 51.0% in states with the least paid family and medical leave coverage. Post-partum depression symptoms varied from 11.7% in the most generous states to 13.3% in the least generous states (both P,.001). State differences in postpartum visit attendance rates (90.9% overall) did not differ significantly. After adjusting for respondent characteristics, compared with states with the least paid family and medical leave, breastfeeding was 9% more likely (adjusted incidence rate ratio [aIRR] 1.09, 95% CI, 1.07–1.11) in states with the strongest paid family and medical leave coverage and 32% more likely (aIRR 1.32, 95% CI, 1.25–1.39) in analyses limited to respondents with deliveries covered by Medicaid insurance. A more generous state paid family and medical leave policy was significantly associated with a lower likelihood of postpartum depression symptoms compared with states with the least paid family and medical leave (adjusted odds ratio 0.85, 95% CI, 0.76–0.94) and a modest but significant increase in postpartum visit attendance (aIRR 1.03, 95% CI, 1.01–1.04) among respondents with deliveries covered by Medicaid insurance.

Conclusions

Respondents from states with strong paid family and medical leave had a greater likelihood of breastfeeding and had lower odds of postpartum depression symptoms, with stronger associations among respondents with deliveries covered by Medicaid insurance. Despite major potential health benefits of paid family and medical leave, the United States remains one of the few countries without federally mandated paid parental leave.

IABLE Comment by Anne Eglash MD, IBCLC, FABM

For information on state family medical leave laws, visit the National Conference of State Legislatures.

The only states in the USA with state payments for family medical leave include California, Colorado, Connecticut, Delaware, Massachusetts, Maryland, New Jersey, New York, Oregon, Rhode Island, Washington, and Washington DC.

Previous studies have largely measured breastfeeding rates within a state before and after enactment of state paid FML laws. This study is unique in that it compares breastfeeding rates between states based on their paid FML score. This data is good evidence to support a federal policy mandating paid FML.

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Comments (1)

Sanpri Purdy-Porter

December 11, 2023 at 11:16 PM

It makes sense. Finances are a big stressor when it comes to planning a family and when you have paid leave it helps eliminate some of that stress so you can do important things like be able to parent your children and focus on breastfeeding.