Social Policies to Reduce Breastfeeding Inequities

The American Academy of Pediatrics updated its breastfeeding guidelines in 2022 based on decades of research regarding the health and socioemotional benefits of breastfeeding for the parent and child.1 In the United States, however, exclusive breastfeeding rates for children aged 3 months were just 47% in 2021, with 40% still breastfeeding at 1 year, far below the guidelines and far below breastfeeding rates in other high-income countries, recommending exclusive breastfeeding for 6 months.2 Furthermore, exclusive breastfeeding rates at 3 months were 40% for those below the federal poverty line compared with 53% among those above 6 times the poverty line, highlighting inequities in breastfeeding among socially marginalized groups.3In this Perspectives piece, we discuss evidence on social policies as upstream drivers of breastfeeding rates and potential solutions to inequities. We focus on rigorous experimental or quasi-experimental studies, as these provide strong evidence on policy impacts and are preferentially used by decision-makers and governmental institutions like the Congressional Budget Office in projecting policy impacts.4,5 We focus on the largest US social policies that are targeted toward low-income populations and have the potential to impact breastfeeding by addressing upstream social and economic conditions. We do not discuss downstream individual-based, hospital-based, community-based, or breastfeeding-specific policies because those have been described previously by organizations such as the US Breastfeeding Committee.6 Clinicians, health care systems, and public health professionals have important roles in bolstering social policies to reduce breastfeeding inequities and improve population health.7,8The United States is one of only a few countries worldwide without a national paid family leave (PFL) policy. The motivation for PFL is to provide job protection and wage replacement after the birth or adoption of a child to enhance financial security and infant-parent bonding. Only 25% of private sector workers have PFL access through their employer, and 6% of the lowest-wage workers have access. Women are less likely to qualify.To fill this vacuum, 13 states and Washington, DC, have implemented their own PFL policies.9 There is sizable literature linking state PFL policies with breastfeeding,10–12 showing that they increase breastfeeding duration through 6 months by about 5 percentage points (a 10% increase from baseline). Most research examines the effects of California’s 2004 PFL policy, the first to be passed; however, 1 study has examined 6 states with more recent adoptions of PFL policies, demonstrating similar improvements in breastfeeding.13 Most studies also find PFL policies increase women’s return to work after childbirth. PFL evaluations have also found improved maternal psychological distress and subjective well-being.14,15There is conflicting evidence on subgroup effects of these policies, such as whether impacts differ for families with low income, and some studies do not conduct subgroup analyses at all. Subgroup differences may be driven by variation in state PFL policies, for example, in terms of number of weeks of leave offered, percent of wages covered, and availability of job protection, which may differentially affect health among economically marginalized groups. There is also variation in take up (ie, use of benefits among those who qualify); not all employees are aware they are eligible, and some might not take advantage of the policies they qualify for, for example, if the wage replacement rate is too low, and they need to return to work to earn their full salary. State variation in take up may therefore be driven by different policy implementation or design, for example, wage replacement generosity. Studies should further examine subgroup effects on breastfeeding and differences in take up of state PFL policies.Additional evidence regarding PFL is provided in the Supplemental Materials.The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is another major US program with the potential to support breastfeeding practices, serving about 20% of pregnant women and 40% of infants and their postpartum mothers.16 It provides an electronic benefit transfer card for the purchase of specific healthy foods for women and children aged 1–4 years, including formula for infants aged under 1 year who are partially or not breastfeeding. WIC also provides breastfeeding support, peer counseling, and nutrition education for women.Historically, one criticism is that providing formula discourages breastfeeding.17 WIC participants have lower breastfeeding rates than nonparticipants.17 This may be partly associated with the provision of formula at no cost to the participant, which reduces an economic incentive for breastfeeding by providing a free alternative. However, studies also implicate selection bias: women who know they will not breastfeed may be more likely to enroll. WIC participants also have other structural barriers to breastfeeding like reduced access to paid leave. Accounting for sociodemographic characteristics attenuates these differences in breastfeeding rates.Importantly, funding for breastfeeding peer counseling in 2004 enabled states to hire and train community members to provide peer counseling support to WIC participants. In randomized trials, peer counseling has been shown to increase breastfeeding rates.18 In 2009, the US Department of Agriculture revised WIC food packages to make them healthier, for example, by adding fruits and vegetables, in addition to increasing the amount of food for breastfeeding women and breastfed infants after age 6 months and reducing the amount of formula to partially breastfeeding infants. This 2009 revision modestly increased breastfeeding, particularly when paired with nutrition and breastfeeding education efforts.19,20 These programmatic changes suggest key policy design features that can be enhanced to promote breastfeeding among WIC participants.Additional evidence regarding WIC is provided in the Supplemental Materials.Poverty alleviation policies also have the potential to increase breastfeeding rates through several pathways, including enhanced financial security and health care access.3 Alternately, US antipoverty policies may reduce breastfeeding by incentivizing an earlier return to employment after childbirth because many involve work requirements to qualify for benefits, or they enable formula purchasing. Here, we discuss 3 of the largest income-based poverty alleviation policies.The largest antipoverty program is the earned income tax credit (EITC), which provides $2500 annually per family on average. Only 1 study to our knowledge examined EITC breastfeeding impacts, with larger benefits associated with a marginally statistically significant increase in initiation.21 There are numerous studies demonstrating that the EITC improves other aspects of recipients’ health.22,23The second program is Temporary Assistance for Needy Families (TANF). TANF provides short-term assistance—an average of $500 monthly—for pregnant women or people with children, contingent on employment or looking for a job. Quasi-experimental research has found work requirements under TANF and its predecessor, Aid to Families with Dependent Children, reduced breastfeeding rates at 6 months by 6 percentage points24 and that states’ pandemic-era relaxation of work requirements increased breastfeeding.25The third major income policy is the child tax credit (CTC). Congress temporarily expanded the CTC in 2021 to increase the benefit size (from a maximum of $2000 per year per child to a maximum of $3600) and to provide the largest benefits to families with the lowest income. The expansion also removed the work requirement, so the benefit was available even to those who were unemployed. No studies to our knowledge examine impacts on breastfeeding, although several find improved parental mental health.26,27Additional evidence regarding poverty alleviation policies is provided in the Supplemental Materials.One of the largest changes to health insurance policy for low-income individuals that may affect breastfeeding was the 2010 Affordable Care Act. One provision that went into effect in 2012 was that private insurers were required to provide coverage for lactation support and breast pumps without cost to the patient. In 2014, this same requirement went into place for Medicaid recipients in Medicaid expansion states and those receiving coverage through the health insurance exchanges. The Affordable Care Act also mandated enhanced coverage of other pregnancy-related benefits (eg, routine prenatal and postpartum care) and expanded eligibility to more low-income individuals.These provisions increased insurance claims for breast pumps and breastfeeding initiation and duration.28–30 As expected, in 2012, breastfeeding gains were greater for privately insured patients, whereas in 2014, gains were greater for Medicaid-insured patients. In 2014, Black, less-educated, and unmarried mothers (who are more likely to have Medicaid coverage) also experienced greater gains.28–30During the COVID-19 pandemic, provisions to ensure continuous Medicaid eligibility allowed for continuous postpartum coverage beyond the usual 60 days. One study found that this did not affect breastfeeding initiation, suggesting that additional longer-term health insurance coverage may not be a major contributor for these outcomes.Additional evidence regarding Medicaid is provided in the Supplemental Materials.This article summarizes the evidence showing that several state and federal policies to support families experiencing economic disadvantages have consistently been associated with higher rates of breastfeeding, whereas others fall short.The largest body of evidence addresses paid family leave, although some state policies may contribute to inequities by providing insufficient wage replacement. The American Academy of Pediatrics issued a 2024 policy statement supporting universal access to paid leave, which could help addresses these inequities.8 For WIC participants, evidence also supports ensuring that every prenatal and early postpartum participant can access breastfeeding peer counseling. Studies also suggest that insurance coverage of relevant breastfeeding support is critical, with reduced inequities particularly when Medicaid-covered populations are targeted. For antipoverty policies, there is limited research examining impacts on breastfeeding; although a few have been linked with improved maternal health, work requirements may undermine women’s ability to breastfeed.Clinicians interested in supporting breastfeeding could focus their attention on advocating for policies with strong evidence and providing support in clinical settings to link patients with programs for which they are eligible.7 For public health professionals and policymakers, redesigning key features of policies—for example, addressing strict work requirements of antipoverty policies—may help reduce breastfeeding inequities. Meanwhile, researchers can conduct additional evaluations of breastfeeding impacts. For example, most studies focus on the federal versions of these policies. Yet, more than half of states have their own EITC policies, about a dozen states have CTC policies, and there is tremendous variation in states’ implementation of TANF and WIC; future research could examine impacts of state policy variation on breastfeeding.