- Breastfeeding can benefit both mothers and children.
- Breastfeeding rates in the United States vary substantially across demographic groups, with less advantaged populations breastfeeding at lower rates.
- The Affordable Care Act (ACA) requires most health insurers to cover professional lactation support services and breast pumps.
- This provision of the ACA led to increases in breastfeeding initiation, exclusive breastfeeding duration, and breastfeeding duration.
- The effects are largest for less educated mothers, unmarried mothers, and black mothers.
Breastfeeding offers disease protection for both mothers and children.1 The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding (without formula or food supplementation) for the first six months of life, and continued breastfeeding through the first year. But the majority of mothers in the U.S. are not breastfeeding as long as they intended to or for as long as the AAP recommends. Breastfeeding can be challenging and labor intensive. Newborns require feeding every 2 to 3 hours, babies often have difficulty latching, and mothers may experience pain or milk supply issues. The cost and accessibility of lactation counseling may prohibit mothers from obtaining assistance. Furthermore, the expense of a breast pump and the availability of a place and time to express milk after returning to work or school may make continued breastfeeding infeasible. Indeed, only 20% of mothers exclusively breastfeed for the first six months, and 28% are still breastfeeding at 12 months. If 80% of mothers breastfed for six months, the U.S. could save $10.5 billion a year in health care costs through health improvements in the infant’s first year of life alone.
Figure 1. Breastfeeding Can Improve Health and Development for Children and Mothers
Although most mothers initiate breastfeeding for their newborns, there are substantial differences across sociodemographic groups. For example, Figure 2 shows that among children born between 2010 and 2013, 68.8% of those born to mothers with less than a high school (HS) education were breastfed, compared to 91.1% of those born to a mother with a college degree. Similarly, 21.8% of mothers with less than a high school degree were still breastfeeding at 12 months compared to 40.3% of college-educated mothers (Figure 3). Breastfeeding initiation rates and lengths among mothers participating in the Women, Infants, and Children (WIC) program are also lower than non-WIC participants.
While 79.2% of infants born between 2010 and 2013 began breastfeeding, only 27.8% met the recommended breastfeeding duration of 12 months. This disparity in persistence with breastfeeding indicates women may need more support to continue breastfeeding. The use of lactation consultants, peer counseling, and breast pumps can increase a woman’s success with sustained breastfeeding.2 A breast pump may be necessary for mothers returning to work or school and can retail for almost $400. Having to pay for these services out of pocket can be prohibitively expensive, especially for mothers who must return to work soon after giving birth.
Based on a recommendation from the Institute of Medicine (IOM), the Affordable Care Act (ACA) included several provisions intended to support sustained breastfeeding. For example, firms with 50 or more employees must provide time and space for breastfeeding mothers to pump. This workplace requirement increased the likelihood of exclusive breastfeeding at six months.3 Another ACA provision required most health insurance plans to cover professional lactation support services and breast pumps. New research shows that this provision, which went into effect in 2012, has improved breastfeeding rates, particularly among vulnerable populations for whom the costs of buying pumps and lactation services are more burdensome.
Some recent research addresses the extent to which the ACA lactation support services and equipment mandate affected breastfeeding. Kapinos, Bullinger, and Gurley-Calvez4 use birth certificate data from the National Vital Statistics System from 2009-2014 to investigate the effect of the policy on breastfeeding initiation. Gurley-Calvez, Bullinger, and Kapinos5 use the National Immunization Survey from 2008-2014 to estimate whether the policy affected sustained breastfeeding by measuring exclusive breastfeeding duration and non-exclusive breastfeeding duration. In both studies, we use a difference-in-differences approach to compare breastfeeding outcomes among mothers whose health insurance plans were required to comply with the ACA lactation support services and equipment coverage mandate relative to mothers who were not affected by the provision. Mothers unaffected by the ACA’s breastfeeding coverage mandate primarily include those who were covered by Medicaid or other government-sponsored insurance and uninsured mothers. We also compare these groups before and after the ACA provision went into effect. In one study, we are particularly interested in whether the ACA provision affected sociodemographic disparities in breastfeeding outcomes.
What We Found
Kapinos, Bullinger, and Gurley-Calvez (2017) find that mandating coverage of lactation support services and breastfeeding equipment increased the probability that a baby would be breastfed by 2.5 percentage points, or about 4 percent. This increase translates to about 47,000 more infants for whom breastfeeding was initiated in 2014. The effects were largest among less advantaged populations. Specifically, breastfeeding rates increased the most among mothers with a high school degree, unmarried mothers, and black mothers. For example, mothers with a high school degree or equivalent were about 2 percentage points more likely to initiate breastfeeding after the mandate relative to more highly educated mothers. Unmarried and black mothers were about 1 percentage point more likely to breastfeed compared to married and white mothers, respectively. The ACA’s lactation services and equipment mandate also improved sustained, or longer-term, breastfeeding practices. In Gurley-Calvez, Bullinger, and Kapinos (2018), we find the policy increased exclusive breastfeeding by 21 percent and non-exclusive breastfeeding by 10 percent in the eligible population relative to those whose insurance plans were not affected by the ACA.
With 74% of women of childbearing age in the workforce, developing ways to support continued breastfeeding in the home and workplace may be effective at improving child and maternal health. Providing reasonable break time and a private place for expressing breastmilk as well as mandating health insurance coverage of lactation support services and equipment have so far been effective ways to support women who want to start and continue breastfeeding. There may even be longer-term impacts on infant and maternal health related to more frequent and sustained breastfeeding as a result of this ACA provision. In particular, increasing breastfeeding rates and durations among populations who were less likely to breastfeed before the ACA could potentially reduce health disparities in the U.S., exhibiting even greater health gains in the long term. Although the ACA provisions supporting breastfeeding have documented successes, there remain implementation and enforcement issues. According to one study, for example, only 40% of working women reported having access to time and space accommodations required of the ACA.6 And recently, some large insurance companies have reduced their reimbursement rates for breast pumps. Our findings imply that expanding access to workplace breastfeeding accommodations and enforcement of the insurance coverage mandate will likely require collaborative efforts for continued effectiveness. For example, healthcare providers should actively share information about the ACA lactation support services and equipment provision during prenatal appointments. Additionally, many new mothers are covered by health insurance plans that are not required to cover lactation support. For example, Medicaid covers roughly half of all births in the U.S., but many states do not require their Medicaid programs to cover lactation counseling, education, and breast pumps. This means that women who are the least likely to start and sustain breastfeeding may not have access to these health insurance benefits.
1 Breastfeeding, S. O. (2012). Breastfeeding and the Use of Human Milk. Pediatrics, 129(3): e827-41.
2 Bonuck, K. A., Trombley, M., Freeman, K., & McKee, D. (2005). Randomized, Controlled Trial of a Prenatal and Postnatal Lactation Consultant Intervention on Duration and Intensity of Breastfeeding up to 12 Months. Pediatrics, 116(6), 1413–1426.
2 Olson, B. H., Haider, S. J., Vangjel, L., Bolton, T. A., & Gold, J. G. (2010). A Quasi-Experimental Evaluation of a Breastfeeding Support Program for Low Income Women in Michigan. Maternal and Child Health Journal, 14(1), 86.
2 Haider S.J., Chang L.V., Bolton T.A., Gold J.G., & Olson B.H. (2014). An Evaluation of the Effects of a Breastfeeding Support Program on Health Outcomes. Health Services Research, 49(6), 2017–2034.
3 Kozhimannil, K. B., Jou, J., Gjerdingen, D. K., & McGovern, P. M. (2016). Access to Workplace Accommodations to Support Breastfeeding after Passage of the Affordable Care Act. Women’s Health Issues, 26(1), 6–13.
4 Kapinos K. A., Bullinger, L.R., & Gurley‐Calvez, T. (2017). Lactation Support Services and Breastfeeding Initiation: Evidence from the Affordable Care Act. Health Services Research, 52(6), 2175–2196.
5 Gurley-Calvez, T., Bullinger, L.R., & Kapinos, K. A. (2018). Effect of the Affordable Care Act on Breastfeeding Outcomes. American Journal of Public Health, 108(2), 277–283.
6 Kozhimannil, K. B., Jou, J., Gjerdingen, D. K., & McGovern, P. M. (2016). Access to Workplace Accommodations to Support Breastfeeding after Passage of the Affordable Care Act. Women’s Health Issues, 26(1), 6–13.