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

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.

Attachment, development and the Surgeon General

It will not be denied, that a child, before it begins to write its alphabet and to gain worldly knowledge, should know what the soul is, what truth is, what love is, what powers are latent in the soul.

Mohandas Gandhi, 1927

One of the most significant statements in the recently released Surgeon General’s Call to Action is the recommendation that our society “work toward establishing paid maternity leave for all employed mothers.” ¹ The acknowledgement that the absence of paid leave is a barrier to breastfeeding is of monumental significance.   Without paid leave, it seems highly unlikely that our society will ever be able to come close to achieving the now universally accepted recommendations to breastfeed exclusively for 6 months, and to continue to breastfeed after the addition of complementary foods until the infant is at least one year of age.   Although strategies that enable mothers to express their milk while at work are certainly laudable, it is far more preferable to put the infant to breast than to offer breast milk in a bottle.   In other words, it is best to keep mothers and infants together as much as possible, for as long as possible.   This can only happen by guaranteeing employed mothers a paid maternity leave.

It can happen here

I’ve been closely following the story of the Pakistan floods on CNN.   The horrors of the flood itself are now being replaced by the inevitable catastrophe of contaminated water.   Countless numbers of children are suffering and dying from dehydration due to gastroenteritis.   Every day I wait to hear Dr. Sanjay Gupta state the obvious: breastfeeding plays a critical role in saving lives under such circumstances.   I’m still waiting.   I also waited as I followed the Haiti earthquake story, and before that, Hurricane Katrina.   Maybe I missed it, missed somebody saying so, but I doubt it.

Why is that? After all of the natural and man-made catastrophes over the last few years, why do we still not hear more about a cost-free intervention that could save hundreds or thousands of lives?  There are a number of possible explanations:

• Preventive health measures just aren’t sexy.   In fact, they’re downright invisible.   Nobody exalts over how many children don’t die because they were breastfed.   Nobody even notices it.   But it’s the low-profile preventive health measures that have been responsible for the greatest medical care break-through’s over the last century, not the far more dramatic and eye-catching technological advances in diagnostics, pharmaceuticals, and surgery.  
• The education of health care workers continues to minimize the importance of breastfeeding.   Breastfeeding is still widely regarded as desirable but not really necessary.   And by the time it does become necessary (as, for example, in Pakistan, Haiti, or New Orleans), it’s too late… so why bother to mention it?
• More broadly, at the end of the day, our culture doesn’t really see a difference between formula-feeding and breastfeeding, such oversight being the inevitable result of the ubiquitous marketing of infant formula. 
• We still believe that “it can’t happen here.” Starvation and dehydration is a “developing nation” phenomenon.   Sure, there was Katrina, but that was an anomaly… wasn’t it?  

But it can happen here, and there is good reason to believe that it will, perhaps with a vengeance.   With global warming we can expect droughts, flooding and hurricanes to become far more frequent and far more severe.   A decaying national infrastructure may increasingly subject great segments of the population to catastrophic events, with resultant loss of access to food, water, and medicine.   Finally, the ongoing recession combined with the spiraling national deficit and calls for reductions in government spending could conceivably result in the eventual and dangerous contraction of the WIC and other social assistance programs.

Shades of Chicken Little, perhaps.   But sometimes the sky really is falling:

“ ‘He’s dyin’, I tell you! He’s starvin’ to death, I tell you…’

“She moved slowly to the corner and stood looking down at the wasted face, into the wide, frightened eyes.   Then slowly she lay down beside him.   He shook his head slowly from side to side.   Rose of Sharon loosened one side of the blanket and bared her breast.   ‘You got to,’ she said.   She squirmed closer and pulled his head close.   ‘There!’ she said.   ‘There.’”

                                                                                    – From “The Grapes of Wrath,” the story of the impoverished and starving  Okies of 1930’s America.  

It can indeed happen here.

Jerry Calnen 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.

Health care reform, bright futures, and the community lactation center

Perhaps a little belatedly, an epiphany has dawned upon policy makers in the field of health care financing: it makes far more sense to prevent disease than to treat it.

Breastfeeding and Maternity Leave

It is mystifying that those of us truly interested in advocating for breastfeeding spend so much of our time trying to make employment outside of the home more compatible with breastfeeding, never acknowledging the fact that it is employment, per se, that constitutes the problem.   A study recently published online in the Archives of Disease in Childhood  has demonstrated that mothers are significantly more likely to breastfeed if they care for their infants themselves than if they have others care for their infants for them (Medscape Medical News, June 24, 2010).   The results of the study are a reaffirmation of a truth so basic that it should be self-evident: in order to breastfeed, mothers must be with their infants.  

So, what conclusion can we draw from this? Should a woman indeed be kept barefoot and in the kitchen?

I don’t think so.

For the good of my patients

In every house where I come, I will enter only for the good of my patients.   – The Hippocratic Oath.

At first blush, this moral imperative would appear to be a truism.   And yet every day, it is violated with complete impunity.  

 Whenever, in my capacity as a physician, I encounter my patient – “enter his house,” so to speak – do I really interact with him only in his own best interests, or do I also carry with me a number of ulterior, and hidden, motives? My patient presumes that I am acting exclusively in his interests.   That is why he trusts me.   He trusts me with his health, his well-being, his very life.   He trusts me.   And that is why I should regard that trust as a sacred thing, and do whatever I can to protect it and preserve it.

Breastfeeding Promotion and the Accountable Care Organization

Health care is not only becoming unaffordable to the average American family; it is also becoming unaffordable to the Government of the United States.   As Medicare and Medicaid spending spiral farther and farther out of control, the federal deficit will inevitably reach the breaking point.   The cost of medical care will continue to rise with increasing provision of services, each one of which demands its own separate fee.  

The health care reform package proposes to solve this problem, at least in part, by changing the reimbursement paradigm: why not replace the volume-driven, fee-for-service model with a performance-driven model based on accountability of care? If the medical care system shifts its focus from numbers of patients treated to quality of care provided, the cost of care may return to sustainable levels.   The emphasis will shift from treatment of disease to disease prevention and health maintenance, an orientation which will hopefully save the health care system millions of dollars every year.  

One strategy for linking reimbursement to performance is the Accountable Care Organization (ACO).   The ACO involves a partnership of primary care physicians, specialists, and a hospital (or hospitals) serving a given community in a manner that ensures cost containment and achievement of defined standards of high-quality performance.   The Medicare savings realized from this approach will be shared with the ACO participants.   Because the principle objective will be maintaining health rather than treating disease, the physicians most likely to benefit from the ACO will be primary care practitioners.

For primary care, breastfeeding support constitutes the quintessential health maintenance and disease prevention intervention.   Billions of dollars could potentially be at stake.   Traditionally, medical practitioners may have eschewed breastfeeding support interventions because they tend to be labor intensive, which as a general rule are poorly reimbursed.   There is now an opportunity to turn this situation around entirely.   If breastfeeding-related metrics can be included in performance standards upon which Medicare bonuses are based, there could quite conceivably be a very substantial financial incentive for physicians to become far more actively involved in breastfeeding support in their respective practices.   The nature of primary care could be radically altered in a short period of time, and in a very favorable manner.

Our task now is to keep the importance of breastfeeding support front and center in the thinking of our policy makers.   We need to educate the leaders of our professional health societies and the Centers for Medicare and Medicaid Services (CMS) that breastfeeding must not be overlooked if we truly wish to reduce the cost of medical care and safeguard the health of American citizens in the years ahead.

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

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

The Redbook Controversy

Erin Ruddy (“No, you don’t have to breastfeeding“Redbook, May 2010) correctly points out that breastfeeding mothers all too often encounter serious obstacles to successfully breastfeeding their infants.   A more productive approach to this problem, however, would have been to identify what those obstacles are and try to eliminate them, rather than simply to launch into a pointless tirade against the practice of breastfeeding, and those who support it.   Nothing productive can be gained by such an exercise.

Breastfeeding Promotion and the Electronic Medical Record

By now, most physicians have come to acknowledge that the electronic health record (EHR) is an idea whose day has come.   Until recently, each physician (or group of physicians) had hoped to move at his or her own pace in making the necessary accomodations.   With the passage of the Health Information Technology for Economic and Clinical Health Act (HITECH Act), however, there is some measure of urgency in making the conversion to the EHR.

Under HITECH, the Centers for Medicare and Medicaid Services (CMS) have been directed to implement incentive payment programs for the “meaningful use” of EHR technology.   In order to qualify as meaningful users, hospitals and providers must meet three requirements.   The first is to utilize certified EHR technology in a manner condducive to appropriate care (for example, electronic prescribing).   Second, the adopted technology must be capable of exchanging information with other IT systems so as to enhance the quality of care.

Finally, by means of such technology, the user must be able to provide to the government information related to clinical quality measures.   An integral part of this process is to be able to capture data relevant to the prevention and treatment of disease, and to the optimization of health.   Equally important is the collection of health-related data for research purposes. 

Breastfeeding Promotion and Health Care Reform

In the United States, breastfeeding support may have gotten an urgently needed boost from the recently passed health care reform package.   Underlying the package is a tacit acknowledgement that health care consists of much more than simply treating illnesses and caring for injuries; its primary objectives are the prevention of diseases and the optimization of health.   Preserving health is not only the right thing to do; economically, it’s also the smartest thing to do.   In an attempt to keep down the cost of caring for patients afflicted with life-threatening and chronic diseases, the United States Government has chosen to make a significant investment in preventive health measures.

Thus it is that, effective October of this year, all new health insurance policies will be required to cover preventive health services, with no out-of-pocket expenses accruing to the consumer.   The cost of the policy will cover all preventive health benefits (New York Times, April 9, 2010).   The specific services to be covered will be determined by the rating system of the United States Preventive Services Task Force; insurance policies will be required to cover all A- and B-rated services.  

This should be a real boon for those of us who have dedicated a significant portion of our professional lives to breastfeeding support and promotion.   The most recent estimates are that $13 billion dollars could be saved every year if there were to be 90% compliance with the recommendation that all infants be exclusively breastfed for the first six months of life (Bartick and Reinhold. Pediatrics. 2010; 125(5):e1048-e1055).   It would be hard to imagine any other preventive health intervention that could offer such impressive savings.   To a degree, the health care reform package almost seems to have been fashioned with breastfeeding promotion in mind.  

But there are a few glitches.