Abstract
Objectives
Despite the passage of state laws promoting breastfeeding, a formal evaluation has not yet been conducted to test whether and/or what type of laws may increase breastfeeding. The enactment of breastfeeding laws in different states in the US creates a natural experiment. We examined the impact of state breastfeeding laws on breastfeeding initiation and duration as well as on disparities in these infant feeding practices.
Methods
Using data from the Pregnancy Risk Assessment Monitoring System, we conducted differences-in-differences models to examine breastfeeding status before and after the institution of laws between 2000 and 2008 among 326,263 mothers from 32 states in the US. For each mother we coded the presence of two types of state breastfeeding laws. Mothers reported whether they ever breastfed or pumped breast milk (breastfeeding initiation) and if so, how long they continued. We defined breastfeeding duration as continuing to breastfeed for ≥4 weeks.
Results
Breastfeeding initiation was 1.7 percentage points higher in states with new laws to provide break time and private space for breastfeeding employees (p=0.01), particularly among Hispanic mothers (adjusted coefficient 0.058). While there was no overall effect of laws permitting mothers to breastfeed in any location, among Black mothers we observed increases in breastfeeding initiation (adjusted coefficient 0.056). Effects on breastfeeding duration were in the same direction, but slightly weaker.
Conclusions
State laws that support breastfeeding appear to increase breastfeeding rates. Most of these gains were observed among Hispanic and Black women and women of lower educational attainment suggesting that such state laws may help reduce disparities in breastfeeding.
Keywords: Breast Feeding, Public Policy
INTRODUCTION
The health, psychosocial, and economic benefits of breastfeeding are well known.1, 2 Despite increases in breastfeeding initiation and duration over the past few decades,3 white and Hispanic mothers have higher rates than black mothers and mothers from more disadvantaged circumstances are less likely to start and continue breastfeeding.4 Among the known barriers to breastfeeding, returning to work and embarrassment about breastfeeding, particularly in public, remain challenges for many women.1 These findings suggest that for women to successfully breastfeed outside the home, whether at work or in public, additional support is needed.
Substantial progress in breastfeeding promotion at both the political and structural levels has been made in recent years.3, 5 The passage of the Patient Protection and Affordable Care Act represents the first federal legislation in the US to protect breastfeeding, requiring employers to provide mothers with break time and private space to express milk for one year after their child’s birth.6 However, not all women who are employed may be covered as there are possible exemptions for small businesses and the federal law generally includes only hourly employees. Most laws supporting breastfeeding are currently enacted at the state level.7, 8 State laws can fill gaps in the federal policy, for example by covering salaried employees or prohibiting employer discrimination based on breastfeeding, and also protect women who are not employed. Legislation can allow women to breastfeed in any public or private location, exempt breastfeeding from public indecency laws, and exempt breastfeeding women from jury duty. A recent review found that the number of state breastfeeding laws has increased over the past decade, but the coverage of legislation varies widely.7
Despite the passage of laws promoting breastfeeding, a formal evaluation has not yet been conducted to test whether and/or what type of laws may increase breastfeeding.7–9 Kogan and colleagues found that states with multiple pieces of breastfeeding legislation in 2003 had higher levels of breastfeeding initiation and continuation to six months than states with none.9 However, a cross-sectional study cannot determine whether it was the laws influencing breastfeeding levels or states with higher breastfeeding levels were more likely to introduce laws. It was also not possible in this study to discern which type of legislation was related to breastfeeding.
The enactment of breastfeeding laws in different states creates a natural experiment which can be exploited by comparing changes in infant feeding practices among mothers both within and across states. Furthermore, state level legislation supporting breastfeeding may not affect all mothers similarly. Our aim was to examine the impact of state breastfeeding laws in the US on breastfeeding initiation and duration as well as on disparities in these infant feeding practices.
METHODS
The Pregnancy Risk Assessment Monitoring System (PRAMS) is a state level surveillance system designed to monitor maternal health behaviors and outcomes before, during, and after pregnancy.10 PRAMS selects mothers at random approximately 4 months postpartum, with oversampling of mothers at higher risk for adverse pregnancy outcomes. Questionnaires are standardized across all states. Initial survey administration is by mail and followed-up by phone call if necessary to increase response. States receive questionnaires from 1,300–3,400 mothers per year, and they link survey data with data from infants’ birth certificates.
From 2000 through 2008, 349,780 mothers participated in PRAMS from 31 states plus NYC (32 “states”) with 2 or more years of data (Alaska, Alabama, Arkansas, Colorado, Delaware, Florida, Georgia, Hawaii, Illinois, Louisiana, Massachusetts, Maryland, Maine, Michigan, Minnesota, Mississippi, North Carolina, Nebraska, New Jersey, New Mexico, New York, New York City, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, Utah, Washington, Wisconsin, West Virginia, Wyoming). Not all states participate in PRAMS and 4 states were excluded because data were only collected for one year over this time period. Table 1 presents the years in which data were collected for the 32 states. We excluded mothers if there was missing information on breastfeeding initiation (18,277), race/ethnicity (1547), education (4866), or age (33), or the sampling stratum had only one mother (3). Mothers were more likely to be excluded if they were from an ethnic minority group, younger, and had fewer years of education (p<0.01); however, the absolute differences between groups were small. Analyses on breastfeeding initiation included 326,260 mothers. We excluded a further 6829 mothers with missing data on breastfeeding for at least 4 weeks. Analyses on breastfeeding duration included 319,431 mothers.
Table 1.
Breastfeeding initiation and breastfeeding for at least 4 weeks across states participating in PRAMS from 2000–2008
| Breastfeeding initiation No. (Weighted %) |
Breastfeeding for at least 4 weeks No. (Weighted %) |
||||
|---|---|---|---|---|---|
| Years data available | 2000 (N=30899) | 2008 (N=36512) | 2000 (N=30209) | 2008 (N=35655) | |
| Alaska | 2000–2008 | 1293 (88.9) | 1144 (92.0) | 1255 (78.4) | 1117 (80.5) |
| Alabama | 2000–2003 | 1449 (55.4) | 1427 (39.6) | ||
| Arkansas | 2000–2008 | 1591 (60.0) | 1581 (66.8) | 1554 (44.0) | 1551 (47.5) |
| Colorado | 2000–2008 | 2034 (85.4) | 1954 (90.6) | 1978 (75.0) | 1900 (79.2) |
| Delaware | 2007–2008 | 1189 (74.0) | 1172 (58.3) | ||
| Florida | 2000–2005 | 1910 (77.3) | 1863 (61.8) | ||
| Georgia | 2004–2008 | 946 (71.9) | 926 (59.1) | ||
| Hawaii | 2000–2008 | 2349 (89.5) | 1674 (92.5) | 2234 (77.3) | 1618 (81.7) |
| Illinois | 2000–2008 | 1898 (68.9) | 1599 (77.8) | 1852 (55.7) | 1565 (65.7) |
| Louisiana | 2000–2004 | 2038 (46.2) | 1981 (35.7) | ||
| Massachusetts | 2007–2008 | 1433 (81.6) | 1395 (70.5) | ||
| Maryland | 2001–2008 | 1607 (81.1) | 1581 (67.5) | ||
| Maine | 2000–2008 | 1085 (75.6) | 1092 (78.6) | 1074 (62.6) | 1066 (64.6) |
| Michigan | 2001–2008 | 1547 (73.7) | 1517 (57.1) | ||
| Minnesota | 2002–2008 | 1399 (84.8) | 1370 (73.9) | ||
| Mississippi | 2003–2004; 2006; 2008 | 1362 (49.5) | 1313 (35.3) | ||
| North Carolina | 2000–2005; 2007–2008 | 1688 (63.1) | 1334 (73.2) | 1669 (50.3) | 1312 (60.4) |
| Nebraska | 2000–2008 | 2050 (71.8) | 1545 (80.7) | 1993 (59.0) | 1510 (66.9) |
| New Jersey | 2002–2008 | 1462 (80.1) | 1424 (67.6) | ||
| New Mexico | 2000–2005 | 1503 (79.7) | 1486 (65.9) | ||
| New York | 2000–2008 | 1174 (69.1) | 1076 (75.5) | 1161 (56.6) | 1055 (62.8) |
| New York City | 2004–2007 | ||||
| Ohio | 2000–2003; 2005–2008 | 1552 (63.0) | 1381 (70.5) | 1525 (50.5) | 1358 (56.8) |
| Oklahoma | 2000–2008 | 1785 (67.4) | 1852 (79.1) | 1765 (53.7) | 1801 (58.3) |
| Oregon | 2003–2008 | 1550 (93.8) | 1532 (84.1) | ||
| Rhode Island | 2002–2008 | 1134 (74.9) | 1120 (61.6) | ||
| South Carolina | 2000–2007 | 1366 (52.8) | 1339 (38.5) | ||
| Utah | 2000–2008 | 1500 (87.7) | 1663 (91.3) | 1472 (78.9) | 1620 (81.2) |
| Washington | 2000–2008 | 1393 (88.5) | 1490 (92.2) | 1363 (77.5) | 1432 (78.8) |
| Wisconsin | 2007–2008 | 993 (78.6) | 946 (68.0) | ||
| West Virginia | 2000–2008 | 1241 (53.7) | 1623 (58.5) | 1218 (38.1) | 1594 (45.0) |
| Wyoming | 2007–2008 | 882 (85.3) | 860 (72.9) | ||
Note: Missing values indicate that data were not collected that year
The Harvard School of Public Health Institutional Review Board reviewed this study and considers it exempt.
Breastfeeding initiation and duration
On PRAMS questionnaires, mothers reported whether they ever breastfed or pumped breast milk and fed it to their baby after delivery. We defined breastfeeding initiation as a response of yes. At the time of the questionnaire mothers were asked if they were still breastfeeding or feeding their baby pumped milk and if not, the number of weeks or months they had done so. Since mothers reported how long they breastfed, either in weeks or months, the smallest unit for breastfeeding duration was 4 weeks (combining ≥4 weeks and ≥1 month). We defined breastfeeding duration as continuing to breastfeed for at least 4 weeks.
Breastfeeding laws
Based on previous work, we coded the following laws for each state (yes/no): 1) employers are encouraged or required to provide break time and private space for breastfeeding employees; 2) breastfeeding is permitted in any public or private location.7 Women’s breastfeeding intention during pregnancy is strongly associated with infant feeding practices.11 Using the law’s effective date, for each mother we coded whether there was a law in place in her state 6 months prior to birth. Between 2000 and 2008, 7 of the 32 states in the PRAMS data had laws come into effect which encouraged or required employers to provide break time and private space for breastfeeding employees (Colorado, Illinois, New York, New York City, Oklahoma, Oregon, Rhode Island) and 11 states had laws come into effect that permitted breastfeeding in any public or private location (Arkansas, Colorado, Hawaii, Illinois, Louisiana, Maryland, Maine, Mississippi, Ohio, Oklahoma, Wyoming).
Socio-demographic characteristics
We obtained maternal socio-demographic characteristics from infants’ birth certificates. Each mother reported her race/ethnicity, years of education, age, marital status, number of previous live births, whether she was on the Special Supplemental Program for Women, Infants, and Children (WIC) during pregnancy, and the number of babies born.
Statistical analyses
We conducted analyses using STATA statistical software, version 12.0 SE. We used the analysis weights provided with the dataset to calculate weighted percentages and included them in all regression analyses. We estimated differences-in-differences models, a quasi-experimental causal inference technique, to examine the impact of changes in breastfeeding laws on changes in breastfeeding initiation and, separately, on a mother’s probability of breastfeeding for at least 4 weeks. This type of model compares breastfeeding within a state before and after a policy change as well as across states during the same time period. The model explicitly allows for time-invariant differences in breastfeeding practices across states as well as overall nationwide time trends in the prevalence of breastfeeding, both of which are known to be important.3, 12 We examined laws for workplace provisions (yes/no) and, separately, breastfeeding in any location (yes/no). The ordinary least squares (OLS) regression models included the analysis weights provided by PRAMS and year and state fixed effects. The estimated coefficients on the policy variables in OLS models with a dichotomous outcome are interpreted as the percentage point increase/decrease in breastfeeding, given a change in policy. State fixed effects account for the unobserved state-specific characteristics that do not change over time, while year fixed effects allow us to account for underlying national time trends in breastfeeding rates. Standard errors were clustered at the state level to account for differences in error variance across states. All models were adjusted for maternal race/ethnicity, education, age, marital status, previous live births, WIC status, and multiple births. In addition to examining the overall effect of each policy on all mothers (Model 1), we estimated interactions between each policy and maternal race/ethnicity (Model 2), education (Model 3), and age (Model 4) to investigate whether these policies had differential effects on women according to subgroups of each of these three covariates.
RESULTS
Across all states breastfeeding initiation increased over the period from 2000 to 2008 (Table 1); 69.4% of mothers reported giving their infant any breast milk in 2000 compared to 78.0% in 2008. Similarly, breastfeeding for at least 4 weeks increased from 56.3% to 64.9%. Black mothers, mothers with less education and younger mothers had lower rates of breastfeeding initiation and duration over this period (Table 2).
Table 2.
Maternal characteristics of breastfeeding initiation and breastfeeding for at least 4 weeks
| Breastfeeding initiation No. (Weighted %) |
Breastfeeding for at least 4 weeks No. (Weighted %) |
|||
|---|---|---|---|---|
| 2000 (N=30899) | 2008 (N=36512) | 2000 (N=30209) | 2008 (N=35655) | |
|
| ||||
| Maternal race/ethnicity | ||||
| White | 17236 (71.2) | 19484 (78.6) | 16915 (58.8) | 19119 (65.7) |
| Hispanic | 3851 (82.7) | 5538 (87.1) | 3717 (66.4) | 5318 (74.2) |
| Black | 5586 (47.9) | 6004 (61.9) | 5491 (34.3) | 5865 (46.2) |
| Other | 4226 (80.1) | 5486 (86.4) | 4086 (68.3) | 5353 (75.9) |
| Maternal education | ||||
| 0–11 years | 6136 (57.1) | 6349 (65.7) | 5993 (40.8) | 6162 (49.9) |
| 12 years | 10919 (60.1) | 10616 (70.2) | 10677 (45.5) | 10377 (53.3) |
| 13–15 years | 7038 (73.8) | 8941 (80.6) | 6880 (59.9) | 8725 (66.6) |
| 16+ years | 6806 (86.5) | 10606 (89.6) | 6659 (78.4) | 10391 (82.0) |
| Maternal age | ||||
| <17–19 years | 4757 (57.0) | 3687 (63.6) | 4659 (36.3) | 3607 (39.0) |
| 20–24 years | 8280 (63.4) | 8781 (72.8) | 8113 (47.8) | 8580 (55.4) |
| 25–29 years | 8108 (71.9) | 10225 (80.5) | 7926 (60.0) | 9967 (68.8) |
| 30–34 years | 6137 (76.5) | 8097 (83.5) | 5986 (66.8) | 7907 (74.8) |
| 35+ years | 3617 (76.3) | 5722 (81.9) | 3525 (67.8) | 5594 (73.2) |
We found that breastfeeding initiation was 1.7 percentage points higher in states with laws which provided break time and private space for breastfeeding employees after such laws were in place (p=0.01) (Model 1, Table 3a). Since the prevalence of breastfeeding initiation in 2000 was 69.4%, on average, nation-wide this would represent an additional 2.4% relative increase in breastfeeding initiation in states in which such policies were implemented. We also observed a significant interaction between laws for workplace provisions and maternal race/ethnicity (Model 2). The sign and statistical significance of the estimated interaction term for Hispanic mothers indicates that the increase in breastfeeding initiation associated with laws for workplace provisions was driven by an increase in breastfeeding among Hispanic mothers. These mothers had a 5.8 percentage point (0.048 Hispanic + 0.010 reference) increase in breastfeeding initiation in states with new laws for workplace provisions. All models were repeated to examine the impact of changes in laws for workplace provisions on breastfeeding for at least 4 weeks (Table 3b). While the patterns of the results were similar for both the overall effect as well as the interaction with maternal race/ethnicity, the strength of the associations was attenuated slightly.
Table 3.
Differences-in-differences models of state breastfeeding laws for workplace provisions* on (a) breastfeeding initiation (N=326,260) and (b) breastfeeding for at least 4 weeks (N=319,431)
| Model 1† | Model 2† | Model 3† | Model 4† | |
|---|---|---|---|---|
|
| ||||
| Coefficient (95% CI) | Coefficient (95% CI) | Coefficient (95% CI) | Coefficient (95% CI) | |
|
| ||||
| (a) Breastfeeding initiation | ||||
| Employment policy | 0.017 (0.00, 0.03) | 0.010 (−0.01, 0.03) | 0.020 (−0.00, 0.04) | −0.002 (−0.03, 0.03) |
| Policy* Race/ethnicity | ||||
| White | 0.0 (ref) | |||
| Hispanic | 0.048 (0.01, 0.09) | |||
| Black | −0.019 (−0.07, 0.03) | |||
| Other | 0.001 (−0.06, 0.06) | |||
| Policy* Education | ||||
| 0–11 years | 0.0 (ref) | |||
| 12 years | −0.002 (−0.03, 0.02) | |||
| 13–15 years | −0.004 (−0.04, 0.03) | |||
| 16+ years | −0.003 (−0.04, 0.03) | |||
| Policy* Age | ||||
| <17–19 years | 0.0 (ref) | |||
| 20–24 years | 0.017 (−0.00, 0.04) | |||
| 25–29 years | 0.018 (−0.01, 0.05) | |||
| 30–34 years | 0.023 (−0.01, 0.06) | |||
| 35+ years | 0.030 (−0.00, 0.06) | |||
|
| ||||
| (b) Breastfeeding for at least 4 weeks | ||||
| Employment policy | 0.008 (−0.00, 0.02) | −0.005 (−0.02, 0.01) | 0.014 (−0.01, 0.03) | −0.015 (−0.03, 0.00) |
| Policy* Race/ethnicity | ||||
| White | 0.0 (ref) | |||
| Hispanic | 0.062 (0.01, 0.12) | |||
| Black | −0.00 (−0.04, 0.04) | |||
| Other | 0.019 (−0.07, 0.11) | |||
| Policy* Education | ||||
| 0–11 years | 0.0 (ref) | |||
| 12 years | −0.002 (−0.03, 0.02) | |||
| 13–15 years | −0.018 (−0.04, 0.01) | |||
| 16+ years | −0.003 (−0.04, 0.03) | |||
| Policy* Age | ||||
| <17–19 years | 0.0 (ref) | |||
| 20–24 years | 0.024 (0.00, 0.04) | |||
| 25–29 years | 0.016 (−0.02, 0.05) | |||
| 30–34 years | 0.029 (0.00, 0.06) | |||
| 35+ years | 0.042 (0.02, 0.06) | |||
7/32 states had new laws for workplace provisions: Colorado, Illinois, New York, New York City, Oklahoma, Oregon, Rhode Island
Models adjusted for maternal race/ethnicity, education, age, marital status, previous births, WIC status, multiple births; models included analysis weights and year and state fixed effects
We did not observe any interactions between the policy change and maternal age for breastfeeding initiation; however, there was a significant interaction for breastfeeding duration. We found that mothers age 20 years and older were more likely to breastfeed for at least 4 weeks in states with new laws for workplace provisions after such laws came into effect. We did not find any interactions between the policy and maternal education for breastfeeding initiation or duration.
While on average there was no overall association between laws for breastfeeding in any public or private location with breastfeeding initiation (Model 1, Table 4a), we observed interactions with maternal race/ethnicity (Model 2) and, separately, education (Model 3). States with new laws permitting breastfeeding in any location saw an increase in breastfeeding initiation by 5.6 percentage points for Black mothers (0.060 Black + −0.004 reference).
Table 4.
Differences-in-differences models of state breastfeeding laws for location policies* on (a) breastfeeding initiation (N=326,260) and (b) breastfeeding for at least 4 weeks (N=319,431)
| Model 1† | Model 2† | Model 3† | Model 4† | |
|---|---|---|---|---|
|
| ||||
| Coefficient (95% CI) | Coefficient (95% CI) | Coefficient (95% CI) | Coefficient (95% CI) | |
|
| ||||
| (a) Breastfeeding initiation | ||||
| Location policy | 0.008 (−0.00, 0.02) | −0.004 (−0.02, 0.01) | 0.038 (0.01, 0.06) | 0.019 (−0.01, 0.05) |
| Policy* Race/ethnicity | ||||
| White | 0.0 (ref) | |||
| Hispanic | 0.012 (−0.04, 0.06) | |||
| Black | 0.060 (0.01, 0.11) | |||
| Other | −0.003 (−0.06, 0.05) | |||
| Policy* Education | ||||
| 0–11 years | 0.0 (ref) | |||
| 12 years | −0.014 (−0.03, 0.01) | |||
| 13–15 years | −0.039 (−0.07, −0.01) | |||
| 16+ years | −0.060 (−0.11, −0.01) | |||
| Policy* Age | ||||
| <17–19 years | 0.0 (ref) | |||
| 20–24 years | 0.005 (−0.03, 0.04) | |||
| 25–29 years | −0.015 (−0.06, 0.02) | |||
| 30–34 years | −0.023 (−0.07, 0.02) | |||
| 35+ years | −0.021 (−0.06, 0.02) | |||
|
| ||||
| (b) Breastfeeding for at least 4 weeks | ||||
| Location policy | 0.00 (−0.01, 0.01) | −0.012 (−0.03, 0.01) | 0.025 (0.00, 0.05) | 0.002 (−0.02, 0.03) |
| Policy* Race/ethnicity | ||||
| White | 0.0 (ref) | |||
| Hispanic | 0.016 (−0.04, 0.08) | |||
| Black | 0.056 (0.02, 0.10) | |||
| Other | −0.001 (−0.06, 0.06) | |||
| Policy* Education | ||||
| 0–11 years | 0.0 (ref) | |||
| 12 years | −0.009 (−0.04, 0.02) | |||
| 13–15 years | −0.033 (−0.06, −0.01) | |||
| 16+ years | −0.053 (−0.09, −0.02) | |||
| Policy* Age | ||||
| <17–19 years | 0.0 (ref) | |||
| 20–24 years | 0.012 (−0.02, 0.04) | |||
| 25–29 years | 0.001 (−0.03, 0.03) | |||
| 30–34 years | −0.015 (−0.05, 0.02) | |||
| 35+ years | −0.015 (−0.05, 0.02) | |||
11/32 states had new laws for breastfeeding in any location: Arkansas, Colorado, Hawaii, Illinois, Louisiana, Maryland, Maine, Mississippi, Ohio, Oklahoma, Wyoming
Models adjusted for maternal race/ethnicity, education, age, marital status, previous births, WIC status, multiple births; models included analysis weights and year and state fixed effects
There was also evidence of an interaction between laws for breastfeeding in any location with maternal education (Model 3). While breastfeeding initiation among mothers with 0–11 years of education increased on average after the implementation of policies, the association between the policy implementation and initiation rates diminished for mothers in the two highest educational groups. For mothers with 13–15 years or 16+ years of education, rates of breastfeeding initiation were still higher than those for less educated mothers; however, the differences between these groups decreased after the implementation of policies. Similar patterns of results were seen for breastfeeding for at least 4 weeks (Table 4b). There was no significant interaction between the policy and maternal age for breastfeeding initiation or duration.
We repeated Model 1 including laws for workplace provisions and location together and the results were the same for breastfeeding initiation and duration (results not shown).
DISCUSSION
We found that state laws that support breastfeeding in the workplace and in other locations appear to increase breastfeeding initiation and duration. Most of these gains were observed among Hispanic and Black women and women of lower educational attainment, suggesting that such state laws may help reduce disparities in breastfeeding rates. To our knowledge, this evaluation provides the first longitudinal, quasi-experimental evidence that state laws may promote breastfeeding.
Previously cross-sectional studies reported that states with breastfeeding laws had higher levels of breastfeeding.9, 13 However, using this approach it was not possible to rule out reverse causation. The differences-in-differences approach we undertook allowed us to evaluate laws through a natural experiment in a situation in which randomized controlled trials are difficult to conduct. These quasi-experimental methods allowed us to model the causal effects of breastfeeding laws as well as identify which mothers are affected by the laws.
We found that the introduction of new breastfeeding laws was most likely to benefit mothers from ethnic minority groups and those who are the most at-risk for not starting or continuing breastfeeding. Specifically, laws for workplace provisions increased breastfeeding initiation and duration overall and for Hispanic mothers. In addition, laws which permit women to breastfeed in any location increased breastfeeding initiation and duration among Black mothers and mothers with less than a high school degree. Given that these mothers have the lowest levels of breastfeeding, our results suggest that state policies may help reduce disparities. While location policies do not seem to have had a positive impact on breastfeeding initiation for mothers in the two highest educational groups, our models suggest that they were associated with a narrowing of the gap between breastfeeding rates for high and low education women. In particular, the policies were associated with a smaller additional likelihood of breastfeeding for high education mothers, a group of women who already have some of the highest rates of breastfeeding nationally (Table 2). While the empirical models suggest a potential narrowing of the education gradient in breastfeeding practices, information in PRAMS unfortunately does not allow us to uncover the mechanisms for these changes. State laws promoting breastfeeding may be improving workplace conditions to allow mothers greater access or flexibility at work to continue breastfeeding. Alternatively, or in addition to the above, the passage of such laws may change cultural norms around seeing women breastfeed in public. Further research is needed to understand why specific breastfeeding laws may support breastfeeding differently across racial/ethnic and educational groups.
Current breastfeeding laws vary across states, particularly laws in the workplace.7 Fewer than half of states have laws to provide break time and private space for breastfeeding employees, and the majority of those do not require the provisions if they would disrupt operations. Furthermore, the legislation often specifies that employers are only encouraged but not required to comply.7 Nevertheless, we found that breastfeeding initiation and duration was higher in states with new laws to provide break time and private space for breastfeeding employees, particularly among Hispanic mothers. Indeed, given the potential weakness of the laws, the fact that it may take time before their effects are fully observed in the population, and that PRAMS does not collect information on maternal employment, our results may be an under-estimation of the true effect of laws for workplace provisions on breastfeeding among working mothers.
Healthy People 2020 calls for an increase in the proportion of employers that have lactation support programs to 38%.14 There is some evidence that a supportive workplace and provisions for breastfeeding employees may help women to continue breastfeeding after returning to work.15–17 However, a survey in 2011 found that only 28% of companies reported having an on-site lactation room and 5% offered lactation support services.18 Despite the new federal legislation6 and state laws to promote breastfeeding in the workplace,7, 8 not all women are protected. Furthermore, federal regulations for implementing these provisions have not been issued and there are no penalties for non-compliance.19 Laws to provide stronger workplace provisions that fill these gaps will further support women who wish to successfully combine employment and breastfeeding.
Over 90% of states currently have laws to permit mothers to breastfeed in any public or private location.7 However, the 2010 HealthyStyles Survey found that only 59% of adults agreed with a statement that women should have the right to breastfeed in public places.20 There is clearly a gap between the proportion of women whose right to breastfeed in public is protected and public opinion. Further work is needed to understand this disconnect and what actions can be taken in addition to legislation to increase support for breastfeeding outside the home.
Breastfeeding laws are only effective if mothers, employers, and the public know that they exist. As of 2009, 7 states had legislation for campaigns to promote breastfeeding or raise the public’s awareness about women’s legal rights related to breastfeeding.21 Nevertheless, some businesses may violate state laws because they are not aware of the legislation. Despite women’s legal right to breastfeed in any public or private location mothers have been asked to stop breastfeeding or leave a range of establishments.22 Furthermore, even if a state encourages or requires employers to provide break time and private space for breastfeeding employees, the translation of these laws into workplace provisions and the implementation of these policies are likely to vary by employment sector and/or size of employer. Since little is known about how state laws promote breastfeeding, the next steps may be a qualitative study or further survey work with mothers, employers, lactation support personnel, or policy makers.
While the PRAMS dataset does not include all states, it provides detailed information on infant feeding practices during a time of active policy change. Although mothers reported on their infant feeding practices approximately 4 months after birth, others have shown mothers’ recall of breastfeeding is reliable and valid within three years postpartum.23 We found slightly higher estimates for the impact of state breastfeeding laws on breastfeeding initiation than for duration. This suggests that laws in place during a woman’s pregnancy may be influencing decisions to start breastfeeding, but less so for continuing. In a previous study we identified three additional state breastfeeding laws: exempting breastfeeding from public indecency laws, exempting breastfeeding women from jury duty, and prohibiting employer discrimination based on breastfeeding.7 However, too few states with these policies participated in PRAMS to be able to include them in this evaluation. Although we also cannot account for other state-level policies, such as educational campaigns, that may have been implemented at the same time and potentially upwardly bias our results, year and state-level fixed effects account for much of the time and state-invariant differences we may observe. Our analyses should be repeated in other samples, particularly among women who are employed outside the home, to corroborate the findings.
Breastfeeding initiation rates vary widely across the US, ranging from 49% in Louisiana to 91% in Oregon, with a similar pattern for continuation to 6 months.12 Disparities in breastfeeding initiation and duration persist across maternal race/ethnicity, education, and age. However, the Healthy People 2020 targets for breastfeeding initiation and duration do not capture these differences across states and socio-demographic characteristics.14 We have shown that state laws can help address some of the barriers to breastfeeding that many mothers experience. Currently, there are few population-level interventions to increase breastfeeding.1 Our results suggest that enacting state laws should be considered as a strategy to continue the momentum for breastfeeding support3, 5 by helping to promote breastfeeding, reduce disparities, and achieve public health goals.
What is already known on this subject
Although the passage of the Patient Protection and Affordable Care Act represents the first federal legislation to protect breastfeeding, most laws supporting breastfeeding are enacted at the state level.
However, a formal evaluation has not yet been conducted to test whether and/or what type of laws may increase breastfeeding.
What this study adds
The differences-in-differences approach we undertook allowed us to evaluate laws through a natural experiment in a situation in which randomized controlled trials are difficult to conduct.
We found that state laws that support breastfeeding in the workplace and in other locations appear to increase breastfeeding initiation and duration. Most of these gains were observed among Hispanic and Black women and women of lower educational attainment, suggesting that such state laws may help reduce disparities in breastfeeding rates.
Our results suggest that enacting state laws should be considered as a strategy to help promote breastfeeding, reduce disparities, and achieve public health goals.
Acknowledgments
We would like to thank the PRAMS Working Group: Alabama—Albert Woolbright, PhD; Alaska—Kathy Perham-Hester, MS, MPH; Arkansas— Mary McGehee, PhD; Colorado—Alyson Shupe, PhD; Delaware— George Yocher, MS; Florida— Aruna Surendera Babu; Georgia—Carol Hoban, Ph.D, MS, .MPH; Hawaii— Emily Roberson, MPH; Illinois—Theresa Sandidge, MA; Louisiana—Joan Wightkin, DrPH; Maine—Tom Patenaude; Maryland—Diana Cheng, MD; Massachusetts—Hafsatou Diop, MD, MPH; Michigan—Violanda Grigorescu, MD, MSPH; Minnesota—Judy Punyko, PhD, MPH; Mississippi— Marilyn Jones, M.Ed; Missouri—Venkata Garikapaty, MSc, MS, PhD, MPH; Montana—JoAnn Dotson; Nebraska—Brenda Coufal; New Jersey—Lakota Kruse, MD; New Mexico—Eirian Coronado, MA; New York State—Anne Radigan-Garcia; New York City—Candace Mulready-Ward, MPH; North Carolina—Kathleen Jones-Vessey, MS; North Dakota—Sandra Anset; Ohio—Connie Geidenberger PhD; Oklahoma—Alicia Lincoln, MSW, MSPH; Oregon—Kenneth Rosenberg, MD; Pennsylvania—Tony Norwood; Rhode Island—Sam Viner-Brown, PhD; South Carolina—Mike Smith; South Dakota Tribal—Jennifer Irving, MPH; Texas—Kate Sullivan, PhD; Tennessee—David Law, PhD; Utah—Laurie Baksh; Vermont—Peggy Brozicevic; Virginia—Marilyn Wenner; Washington—Linda Lohdefinck; West Virginia—Melissa Baker, MA; Wisconsin—Katherine Kvale, PhD; Wyoming—Angi Crotsenberg; CDC PRAMS Team, Applied Sciences Branch, Division of Reproductive Health
Funding Statement
Funded by grants from NIH— NICHD K99HD068506 to Dr. Hawkins and K24 HL060841 to Dr. Gillman and T32-AG000186 to the National Bureau of Economic Research for Ms. Stern.
Footnotes
Licence for Publication
“The Corresponding Author has the right to grant on behalf of all authors and does grant on behalf of all authors, an exclusive licence (or non exclusive for government employees) on a worldwide basis to the BMJ Publishing Group Ltd and its Licensees to permit this article (if accepted) to be published in JECH editions and any other BMJPGL products to exploit all subsidiary rights, as set out in our licence (http://group.bmj.com/products/journals/instructions-for-authors/licence-forms/).”
Contributorship Statement
SSH contributed to the development of the study aims and analytic plan, conducted all data analyses, interpreted the results, and wrote the manuscript. ADS contributed to the development of the analytic plan, interpretation of the results, and revision of the manuscript. MWG contributed to the interpretation of the results and made significant contributions to the revision of the manuscript.
Competing interests
All authors have no competing interests to declare.
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