Introduction

According to the Mirror, Mirror, 2024 report, the United States has the worst health outcomes of all resource rich nations studied. (Blumenthal et al., 2024) To close this health disparity gap will require many interventions, including increased access to healthcare coverage, better preventative care, and addressing social determinants of health. (Blumenthal et al., 2024) Within the U.S. there are additional health disparities, with racially/ethnically marginalized populations suffering even poorer health outcomes. (Blumenthal et al., 2024)

To reduce health outcome disparities, it is important to focus on early childhood health, especially birth to three years. One intervention that directly targets both preventative healthcare and social determinants of health, is providing human milk for infants. Human milk feeding is shown to protect against many negative health outcomes for infants and their parents, while supporting food justice and security. (Asiodu et al., 2021)

However, lack of paid family leave is a significant barrier to establishing lactation after childbirth, and the United States is the only high-income country without a national paid family leave policy. (Rosenberg et al., 2024; Rosin-Slater, 2018) Returning to work before 12 weeks, especially full-time work, is common in the U.S. and is associated with less intention to exclusively breast/chestfeed. (Beauregard, 2019)

Therefore, a national policy of paid family leave (PFL) is proposed to support more optimal and equitable human milk feeding and reduce health outcome disparities within the U.S., and in comparison, to other nations.

Research Overview

Human milk feeding has been shown to protect infants from diarrhea, iron deficiency anemia, respiratory infections, obesity, and to promote full intellectual potential. (Asiodu et al., 2021) Completing the lactational phase after gestation and birth, provides protection for the parent from postpartum hemorrhage, postpartum depression, breast, uterine, and ovarian cancers, metabolic disease, and cardiovascular disease. (Asiodu et al., 2021) The U.S. Surgeon General recommends exclusive breast/chestfeeding for the first 6 months and afterward for at least one year with complementary foods provided as the optimal human milk feeding goal. (General (US) et al., 2011)

Longer workplace leave after childbirth is associated with higher rates of breast/chestfeeding globally. (Steurer, 2017) However, only 56% of U.S. workers qualify for unpaid family leave and only 15% have access to paid family leave. States in the U.S. with paid family leave policies are shown to have higher rates of any breastfeeding, longer breastfeeding duration, and higher rates of exclusive breastfeeding, suggesting that nationwide paid family leave could improve breastfeeding rates in the U.S. for all families. (Rosenberg et al., 2024)

While breast/chestfeeding rates in the United States are improving, there are significant disparities, especially regarding Black and Indigenous populations. (Asiodu et al., 2021) Black infants in the United States who are at highest risk for poor health outcomes are also those who are least likely to receive human milk. (Chiang, 2021; Hill et al., 2024) Black infants and their birthing parents also experience inequities in peripartum care due to structural barriers related to systemic racism. (Asiodu et al., 2021)

Pregnancy and peripartum mortality rates for Indigenous and Black birthing parents in the U.S. are more than 3 times the rates for their White counterparts, 63.4 and 55.9 vs. 18.1 per 100,000, respectively. (Hill et al., 2024) These Black and Indigenous parents also are more likely to have inadequate prenatal care, while their infants suffer higher rates of low birth-weight, preterm birth, and perinatal mortality. (Hill et al., 2024) Black birthing parents are also at significant risk for postpartum hemorrhage and other negative birth and postpartum outcomes that can be ameliorated by breast/chestfeeding. (Asiodu et al., 2021)

Formula is more frequently offered to Black infants in hospitals than non-Black infants, further sabotaging optimal breast/chestfeeding. (Asiodu et al., 2021) Indigenous infants also receive less human milk due to racial inequities in breast/chestfeeding support. (Asiodu et al., 2021)

Black women, birthing people, and their families may have negative views about breast/chestfeeding due to abusive practices during chattel slavery and directed predatory marketing from the commercial milk formula industry. Grassroots organizations such as Reaching our Sisters Everywhere (ROSE) and Black Mammas Matter Alliance (BMMA) support Black parents and infants by normalizing breast/chestfeeding in their communities and advocating for representation and culturally competent care in the field of birth and lactation. (BMMA, n.d.; ROSE, 2018) Similarly, there are Indigenous led lactation support organizations such as Indigenous Milk Medicine Collective and projects such as Indigenous Breastfeeding, Birthworks, and First Foods, that support the traditional practice of breast/chestfeeding disrupted by colonization. (IMMC, 2025; Longmont et al., n.d.)

Even with support, there remain significant barriers to Black and Indigenous birthing parents establishing and fully experiencing an optimal course of breast/chestfeeding. This is due in part to racial/ethnic inequities for access to adequate leave from employment after childbirth. (Goodman et al., 2021) Returning to work is self-reported as a significant breast/chestfeeding barrier to Black parents who are more likely to return to work early and have unsupportive work environments than other ethnic groups. (Johnson et al., 2015) Indigenous families also have inequitable access to paid family leave, even in states with PFL policies. (University of Washington, 2023)

Challenges, Barriers, and Solutions

There are legislative barriers to enacting universal paid family leave policies. The commercial milk formula industry uses predatory marketing tactics to promote their replacement for human milk, and actively lobbies against paid family leave to protect revenues which amount to $55 billion annually, with a marketing budget of about $3 billion. (Lancet, 2023) This industry pressure on government has kept the United States from aligning with the World Health Assembly’s International Code of Marketing of Breast-milk Substitutes, which sets standards to prevent predatory marketing practices. (Lancet, 2023) Unfortunately, the United States is not among the 32 countries that have already enacted legislation supporting this code. (Lancet, 2023)

KConnect, an equity collective from Kent County Michigan, along with the Michigan League for Public Policy, has partnered with Mothering Justice to build a coalition for promoting paid family leave in Michigan. (Young & Vosovic, 2024) They are championing the Michigan Family Leave Optimal Coverage (MI-FLOC) bills which are currently in legislature and are supported by 71% of Michigan residents. (Young & Vosovic, 2024) Additionally, these bills are promoted by small business organizations as providing competitive advantage. These efforts provide an advocacy blueprint that can be used to build coalition around promotion of national paid family leave.

It is critical to educate legislators regarding the benefits to society and the economy of paid family leave. While there may be some initial opposition from employers to PFL, evidence shows that it supports career continuity, positively affects employee productivity and morale, and has minimal or no impact on employer costs. (Rosin-Slater, 2018) According to the People First Economy, the programs supported by the MI-Floc bills would cost nothing for businesses of fewer than 20 employees. (Young & Vosovic, 2024)

Discussion

Breast/chestfeeding is lifesaving and health protecting. Increasing optimal breast/chestfeeding supports both preventative health efforts and addresses social determinants of health by protecting the health of marginalized populations and supporting food security. Increasing optimal breast/chestfeeding rates would help to close the disparity gap between U.S. health outcomes and those of other resource rich nations, while also promoting health justice within the United States. Research supports that a national paid family leave policy would contribute to increased levels of optimal breast/chestfeeding in the United States and increase equitable access for marginalized communities to the lifesaving and health promoting benefits of human milk feeding.

While challenges remain to enacting a national PFL policy, there are trailblazers creating a base of support for policy implementation. It is important to build coalitions with existing community partners to amplify their efforts and bring more support and resources for paid family leave. This policy is good for birthing parents, infants, caretakers, and small business owners. Joining their efforts and promoting breast/chestfeeding justice as an additional advantage for paid family leave, strengthens the case for implementation nationwide. Each success builds a base for national enactment of policy that supports all U.S. citizens to have the necessary paid time off from employment to establish lactation after childbirth.

Conclusion

The United States is at a public health crossroads. With the highest spending on healthcare of all resource rich nations, alongside the poorest health outcomes, solutions must be pursued with urgency. (Blumenthal et al., 2024) Increasing optimal breast/chestfeeding is a proven health promoting policy. While paid family leave will not remove all barriers to optimal breast/chestfeeding, it will support grassroots lactation organizations’ efforts to improve the health of all infants and birthing people though increased and equitable access to this lifesaving, health promoting, human birthright.

Paid family leave policies work for nations, states, communities, and families. We must work alongside grassroots stakeholders to build the political will to implement national paid family leave in the United States

© Laura Spitzfaden, BSPH, IBCLC

References

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