Breastfeeding Medicine

Physicians blogging about breastfeeding

Questioning the Feasibility of a Paid Maternity Leave Policy During a Time of Ecconomic Crisis

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Reviewing the proceedings of the Fourth Annual Summit on Breastfeeding1 was an informative and inspiring experience for me. Still, I must confess to a measure of disappointment regarding the absence of any meaningful discussion about paid maternity leave as a strategy to improve upon breastfeeding rates in the United States. This is curious, considering that paid maternity leave was the second most common topic for public comment in the preparation of The Surgeon General’s Call to Action to Support Breastfeeding2. I suspect that the reason for this omission from the Summit agenda was an unspoken presumption that a national paid maternity leave policy is not going to happen, and so it makes no sense to talk about it. If true, I would like to challenge this presumption.

We need not review what is now a substantial body of research underscoring the importance of paid maternity leave in the promotion and support of the practice of breastfeeding3-11. The question that we must now address is this: how can we convince our policymakers that a paid maternity leave makes financial sense, especially in times of economic crisis? One thing is clear: rightly or otherwise, policymakers will not be convinced that an investment in maternity leave, even a modest investment, can be justified solely on the grounds of improving breastfeeding rates. If we as breastfeeding advocates wish to make a case for a paid maternity leave policy, an argument that policymakers perceive as being more compelling must be advanced, one which would demonstrate a substantial “return on investment.”

Fertility rates have been declining in developed countries, resulting in a contraction of the work force that finances social insurance programs like social security. Some economists have argued that a paid maternity leave policy would help to reverse this decline12-14. However, there are many nations which have instituted paid leave policies, yet the anticipated rise in fertility rates has not yet happened. The reason for the failure may be that a paid leave policy is necessary but not sufficient. It has to be a part of a package deal to make workplace conditions more compatible with family living. Even so, there is to date no convincing evidence to support a paid leave policy as an antidote to declining birth rates.

Suppose that we could advance a paid leave policy as a public health imperative. If the public health benefits could clearly be shown to be highly substantial, then even in times of economic hardship, investing in a paid leave program would make financial sense. There are a number of possible health benefits deriving from a paid leave policy, but the strongest benefit may relate to neurodevelopment.

The limbic system continues to grow and develop for a year after the birth of the infant, during which time it is profoundly dependent on environmental factors, the most important of which is the interaction between the infant and her mother15-18. If that relationship is disrupted, appropriate development of the limbic system may be seriously compromised, with severe, long-term and perhaps permanent consequences.

The limbic system is primarily responsible for the orientation of the child to the world around him. This orientation is of a pre-conceptual and social-emotional nature, developing well before neocortical capabilities of reasoning and critical thinking. To a great degree, the limbic system is also responsible for the ability of the child to focus on and attend to matters of importance in her environment. It is not unreasonable to postulate that a disturbance in the proper development of limbic functioning could substantially contribute to, if not cause, mood disorders (depression and anxiety), social affiliation disorders (autism), and attention disorders (ADHD). If this is true, then an abbreviated time during which an employed mother may remain with her newborn infant before returning to work could reasonably be expected to result in disrupted limbic system development, leading to devastating developmental and psychiatric disorders.

In light of this hypothesis, it is not surprising that we have witnessed an alarming rise in the incidence of all of these disorders over the last several decades, the very period of time when mothers by the millions returned to work only a few weeks to months after giving birth. As late as the 1960’s the overwhelming majority of mothers would remain with their infants for at least one year before returning to work, if they returned to work at all19. The relatively recent phenomenon of early return to work in developed countries is truly unprecedented, and it is hard to imagine that such a radical social change would not have serious neurodevelopmental and perhaps other health-related consequences. Could the widespread disruption of the mother-infant attachment in contemporary society be related to the pediatric behavioral health epidemic besetting us? The American Academy of Pediatrics tells us that 21% of children between the 9 and 17 years of age have a diagnosable mental health disorder; five percent of adolescents are clinically depressed at any given period of time; and the suicide rate among adolescents has risen 128% from 1960 to 2000, compared to a 2% rise in the population at large20. Is it particularly hard to imagine that at least some of this pathology might be attributable to premature mother-infant separation stemming from early return to work?

Further research is necessary to determine whether or not the early separation of the employed mother from her newborn or young infant can have deleterious neurodevelopmental consequences. Fortunately, the necessary studies can now be conducted by means of electronic health records. Such studies will generate data prospectively, harvested directly from medical records rather than the recall of the respondents. The number of subjects recruited will not be limited by budgetary constraints related to stationery and postage; as a result, we can potentially have studies sufficiently powered to ascertain associations between maternal care practices and neurodevelopmental outcomes. And as long as the collected data are “de-identified,” its collection will not require the consent of the subjects involved, as have epidemiological studies in the past, since such data would not be considered “protected health information.” 21

An objection could be raised that collecting all of this data electronically would require the consent and cooperation of hundreds of pediatric care providers; an objection obviated by the emergence of Accountable Care Organizations. ACO’s will employ large numbers of providers and will be responsible for managing the health care of thousands, and tens of thousands, of patients. It will therefore only be necessary to recruit a small number of ACO’s in order to conduct such studies. Here is an example of one study that could be done electronically without much difficulty: developmental outcomes can be evaluated relative to duration of maternity leave. Developmental screening tools such as Ages and Stages (A & S) and Parents’ Evaluation of Developmental Status (PEDS) can serve as a proxy for developmental health. Collecting these data should not be difficult, since the American Academy of Pediatrics now recommends use of such screening tools routinely for all infants at the nine, eighteen and thirty-month well baby examination22. A similar study could be done looking at duration of maternity leave and its possible association with M-CHAT scores (Modified Checklist for Autism in Toddlers), also suggested by the AAP as a universal procedure at the eighteen and twenty four-month well baby examination22. M-CHAT is not a diagnostic test for autism, but it has proven to be a reliable screening test and can serve as a valuable proxy for this disorder. Better yet, M-CHAT scores can be correlated with duration and exclusivity of direct breastfeeding, which might serve as a more reliable proxy for mother-infant attachment than maternity leave, per se; after all, there is no way of knowing what exactly a mother is doing with her infant during her maternity leave, but there is no better indicator of mother-infant attachment than direct breastfeeding.

However many the obstacles, it is clear that there is an urgent need for this research.

If we can prove (as I believe we can) that failure to have a sufficiently long paid maternity leave policy will likely result in profound neurodevelopmental and behavioral health impairment involving huge numbers of children for generations to come, then the return on investment of a paid leave policy immediately becomes evident. Will paid leave policy cost money? Of course it will, but what price tag would we want to attach to the well-being of our children, or to the future of our nation?

The Family Leave Insurance Act would only require a payroll charge of 0.2% accruing to employer and employee alike. This, however, would cover only eight weeks of maternity leave, probably not nearly enough time for mothers to remain with their infants after delivery. Just how long should that time be? To get an idea, we can use breastfeeding as a proxy for attachment. Unencumbered by artificial feedings, humans generally breastfeed for a minimum of one to two years or longer23. It has only been very recently in human history, specifically in the last one hundred years, that the widespread use of infant formula has undermined this virtually universal practice. If indeed the assumption is correct that uninterrupted breastfeeding provides us with a reasonable estimate for the natural duration of mother-infant attachment, then it is logical to conclude that a paid leave should cover a minimum of the first full year of life.

So now we are talking about a lot of money, the kind of money not likely to be covered by a payroll tax. Especially in this day and age of recession-impelled austerity planning and governmental belt-tightening, does this kind of program make any sense at all? In fact, it does. The Nobel Prize-winning economist, Paul Krugman24, argues that Keynesian economics remains as relevant and urgently needed today as it did during the Great Depression. To break out of the “liquidity trap” that has kept us in a devastating recession, government must become the investor of last resort. During such times, the government must spend not less, but more: much, much more.

Krugman recommends governmental financial intervention in a number of areas, including mortgage relief, local and state-level budgetary support, and infrastructure/resource development. Let us look at the last of these. When we talk about infrastructure and resource development, we generally think of things like roads, bridges, high-speed railways, and alternative energy resources. To this list we might also add another critical resource: our children.

An important domain of labor which has contributed immeasurably to the well-being of the nation has been badly neglected for decades due to inadequate compensation; this is the domain of motherhood. As a form of labor, motherhood has always been undervalued, because it has never been compensated, at least in the formal economy. Yet traditionally, mothers have always been informally compensated for their work by the household “provider,” who shared his income with her, not because of his generous or charitable impulses, but because she was in fact providing a vital service, namely the rearing of their children. Today the model of the single-provider family is rapidly disappearing. The income of the father alone is not sufficient to meet family needs. Over the last few decades, it has become necessary for the mother to enter the formal work force in order to make ends meet. The work of child-rearing has become badly neglected, with what in time will probably be found to have devastating social consequences. We need, as a society, to acknowledge the value of motherhood by compensating employed mothers for the very hard but extremely rewarding and socially critical work of child-rearing. In other words, we need a paid maternity leave policy. If the government needs to spend billions toward this end, so much the better for our economy.

It is indisputable that in the foreseeable future, there is no chance at all that the United States will adopt a paid maternity leave policy. But what exactly is the foreseeable future? One conclusion upon which most of us can agree is that it is a very short future, indeed. We are fast approaching a time when we, as a people, will have to decide in a very fundamental manner what constitutes the proper role of government in the twenty first century. If we choose wisely, I believe that a national paid maternity leave policy will not only become feasible, but virtually inevitable. If we do not choose wisely, then the question of a paid leave policy will be the very least of our problems.

Jerry Calnen, MD, FABM is a pediatrician and president of the Academy of Breastfeeding Medicine.

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.


  1. Fourth Annual Summit on Breastfeeding. Breastfeeding Medicine 2012;7:321-381.
  2. U.S. Department of Health and Human Services. Surgeon General’s Call to Action to Support Breastfeeding. Washington, D.C: U.S. Department of Health and Human Services, Office of the Surgeon General, 2011.
  3. Fein SB and Roe B. the effect of work status on initiation and duration of breast-feeding. Am J Public Health 1998;88:1042-1046.
  4. Visness CM, Kennedy KI. Maternal Employment and Breastfeeding: Findings from the 1988 National Maternal and Infant Health Survey. Am J Public Health 1997;87:945-950.
  5. Gielen AC, Faden RR, O’Campo P, et al Maternal employment during the early period effects on the initiation and duration of breast-feeding. Pediatrics 1991;87:298-305.
  6. Ryan AS, Wenjun Z, Acosta A. Breastfeeding continues to increase into the new millennium. Pediatrics 2002;110:1103-1109.
  7. Auerbach KG, Guss E. Maternal employment and breastfeeding. AJDC 1984;138:958-960.
  8. Hawkins SS et al. Maternal employment and breastfeeding initiation: findings from the millennium study. Paediatric and Perinatal Epidemiology 2007; 21: 242-247.
  9. Ogbuano C et al. The effect of maternity leave length and time of return to work on breastfeeding. Pediatrics 2011; 127 e1414 – 1427.
  10. Roe B,Whittington LA, Fein SB, et al. Is there competition between breast-feeding and maternal employment? Demography 1999;36:157-171.
  11. Kurinij N, Shiono PH, Ezrine SF, et al. Does maternal employment affect breast-feeding? Am J Public Health 1989;79:1247-1250.
  12. Averett SL and Whittington LA. Does maternity leave induce births? Southern Economics Journal 2001;68:403-417.
  13. Winegarden CR and Bracy PM. Demographic consequences of maternal-leave programs in industrial countries: evidence from fixed-effects models. Southern Economics Journal 1995;61:1020-1035.
  14. United States Office of Personnel Management, report to Congress on paid parental leave. Available at:
  15. National Research Council and Institute of Medicine (2000). From Neurons to Neighborhoods:The Science of Early Childhood Development. Committee on Integrating the Science of Early Childhood Development. Jack P. Shonkoff and Deborah A Phillips, eds. Washington, DC: National Academy Press, pp 185-198.
  16. Schore AN. The experience-dependent maturation of a regulatory system in the orbital prefrontal cortex and the origin of developmental psychopathology. Dev Psychopath 1996;8:59-87.
  17. Schore AN. The experience-dependent maturation of a regulatory system in the orbital prefrontal cortex and the origin of developmental psychopathology. Dev Psychopath 1996;8:59-87.
  18. Lautin A 2001). The Limbic Brain.New York:Kluwer Academic?Plenum Publishers, pp 89-90.
  19. Smith K, Downs B, O’Connell M. Maternity Leave and Employment Patterns: 1961-1995. U.S. Census Bureau, Current Population Reports, Washington, DC, 2001.
  20. Hagan JF, Shaw JS, Duncan PM, eds. 2008. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third Edition. Elk Grove Village, IL: American Academy of Pediatrics.
  21. HIPAA ‘Protected Health Information’: What Does PHI Include? (accessed October 29, 2012)
  22. American Academy of Pediatrics, Council on Children with Disabilities, Section on Developmental Behavioral Pediatrics, Bright Futures Steering Committee, and Medical Home Initiatives for Children with Special Needs Project Advisory Committee. identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening. Pediatrics 2006;118:1 405-420.
  23. Lawrence RA, Lawrence RM. Breastfeeding: a guide for the medical profession. 6th ed. Philadelphia: Mosby, Inc. 2005, pp357-360.
  24. Krugman P. End This Depression Now. New York:WW Norton & Co, 2012.

Written by gcalnen

November 15, 2012 at 9:49 am

One Response

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  1. Interesting insightful article. This subject of paid maternity is often overlooked.
    Thank you for the post.


    December 25, 2012 at 11:40 am

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