We know paid family leave saves infant lives — so when will policymakers catch up?

During a pandemic that has overwhelmed many intensive care units, those that serve our youngest infants have so far been spared from a surge of COVID-19 patients. This is in part due to the apparent low risk of mother-to-baby transmission of this virus. But as a neonatologist, I am increasingly alarmed at how the COVID-19 pandemic has laid bare stark failures in American public policy that threaten infants’ health. Chief among these is the lack of a broad-reaching federal policy on paid family leave.

Paid family leave promotes the health and well-being of both working parents and their children. Women who have access to and take paid maternity leave have lower odds of being re-hospitalized after giving birth, lower rates of depression, increased levels of physical and emotional well-being, and experience less intimate partner violence. However, we don’t often discuss the connection between paid family leave and crucial measures of infant health.

Infant mortality is considered a good measure of a country’s overall health because its causes are related to structural factors that affect the health of entire populations. Large international studies show that paid family leave is associated with reductions in infant deaths in the first year of life. Infant mortality rates in the United States have persistently been higher than other wealthy nations, and much of this disparity is related to postneonatal mortality — death after the first 28 days of life. The literature on the impact of paid family leave on neonatal mortality — death in the first 28 days of life — is mixed, which may reflect the fact that some deaths are unpreventable due to congenital anomalies that occur in the first month of life. However, my research and that of others has shown evidence that paid family leave is associated with decreased postneonatal mortality. The research can’t establish causality, but it’s clear from all the evidence this is more than just an association – paid family leave leads to better health outcomes for families.

In recent work with colleagues at Children’s Hospital of Philadelphia, we found that the implementation of paid family leave in California in 2004 was associated with a 12% reduction in postneonatal mortality. Our study represents the first large‐scale study limited exclusively to births in the U.S., and the first to find an association between paid parental leave and lower postneonatal mortality in this country. While it is not entirely known why paid family leave is associated with decreased rates of postneonatal mortality — and overall infant mortality — one important mechanism appears to be the association between paid family leave and increased rates of breastfeeding. In other words, mothers who are able to take paid leave appear to be able to breastfeed their babies more often, which in turn lowers infant mortality rates.

Crucially, unpaid leave has not been proven to have the same health benefits to either children or their parents. California’s policy, offering parents up to six weeks of partial pay, was the first in the country to offer income protection during family leave. While the federal Family and Medical Leave Act (FMLA) offers job protection, only 60% of American workers are eligible for it. Many small business, private-sector, and low-wage workers are left out of even this basic job protection policy. Low-wage workers are particularly unlikely to have access to any form of family leave, and data shows that even when eligible for unpaid leave, they are less likely to take it, likely because they can’t afford to take time off without pay. While there is some evidence that FMLA is associated with lower infant mortality, this effect appears to be limited to college-educated white mothers, potentially worsening racial and socioeconomic disparities in infant mortality.

The U.S. is the only high-income country in the world that does not provide its workers with both job and income protection when caring for a new infant or sick family member. In March 2020, President Trump signed the Families First Coronavirus Response Act (FFCRA) into law, creating new emergency paid leave requirements in response to COVID-19. Yet the income protections it affords working caregivers are set to expire on Dec. 31, 2020.

At the state level and outside of emergency pandemic-related measures, only eight states and the District of Columbia have enacted legislation to offer their workers paid family and medical leave. Colorado just became the first state to approve a paid family leave initiative via a ballot measure. This still leaves the vast majority of states without a paid family leave policy, despite the fact that public support for paid family leave policies is high, with a recent public survey showing that 82% of Americans support paid leave for mothers after the birth or adoption of a child. Critically, paid family leave policies have not been shown to adversely impact business productivity or profitability. There are different financial models for paid leave, and states can and should learn from those that have already implemented policies. However, while policymakers at the state and federal levels continue to debate the financial and programmatic details of paid leave policies, we must not forget that they leave families without critical income protection during family leave.

Paid family leave impacts how many infants die before reaching their first birthday. This is crucial to me as a neonatologist and as a mother who wants nothing more than for fewer parents to experience the loss of an infant. But more broadly, enacting paid family leave at the federal level is crucial to the health of our nation. The evidence that paid family leave promotes the health and well-being of both working parents and their children was available before COVID-19 struck, but the pandemic has sharpened the focus on its crucially important societal role. Paid family leave should be considered not only as a social policy, but also an important health policy, especially when looking at protecting the youngest among us.

Diana Montoya-Williams, MD, is a faculty member at PolicyLab at Children’s Hospital of Philadelphia (CHOP), an instructor of pediatrics at the University of Pennsylvania’s Perelman School of Medicine and an attending neonatologist in CHOP’s division of Neonatology.