Removing Barriers to Breastfeeding

By Kate Bradford | Vol . 28, No. 36 | October 2020


The health benefits of breastfeeding are well understood. Breast milk is the best source of nutrition for most babies and contains antibodies to protect against several illnesses and diseases. Breastfed babies have a lower risk of certain infections, asthma, diabetes and obesity, and tend to have fewer health care visits. Breastfeeding mothers have decreased postpartum blood loss and are less likely to experience postpartum depression. They have a lower risk of developing hypertension, ovarian cancer, premenopausal breast cancer and osteoporosis later in life.

Positive short- and long-term health outcomes can translate to economic savings for families and states. In 2019, the Economic Research Service studied the economic impacts of breastfeeding with a focus on the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Among results, researchers found that if 90% of infants were breastfed at rates recommended by the American Academy of Pediatrics (AAP), about $9.1 billion in total health-related costs could be saved annually among WIC households or their health insurance providers, including Medicaid.

AAP recommends exclusive breastfeeding for the first six months of life, followed by continued breastfeeding alongside food, as mutually desired by mother and baby. Though there are many benefits, in some cases breastfeeding is not possible or recommended and formula can be a nutritious alternative. For mothers infected with COVID-19, limited available data suggest breast milk is not a likely source of transmission. The Centers for Disease Control and Prevention (CDC) and AAP provide guidance for breastfeeding mothers with suspected or confirmed COVID-19, including measures such as wearing a face covering and practicing hand hygiene to minimize the risk of transmission while feeding. 

According to the CDC, 84% of U.S. women begin breastfeeding immediately after birth, but rates decline with time and only 25% of women exclusively breastfeed through the recommended six months. Moreover, 60% of breastfeeding mothers report stopping earlier than desired and cite barriers, which disproportionately affect certain groups. The rates of Black infants who are breastfed, for example, are lower than those of all other infants. Factors including hospital practices, workplace policies, and access to education and supports can affect a mother’s propensity and ability to start and continue breastfeeding. Certain policy strategies may influence these factors, enable more mothers to breastfeed, and have the potential to improve population health while avoiding increasing health care costs.

State Action

All 50 states, the District of Columbia, Puerto Rico and the Virgin Islands have laws that explicitly authorize women to breastfeed in any public or private location where they are otherwise authorized to be. Many states also specifically exempt breastfeeding from public indecency laws and have policies related to breastfeeding in the workplace.

In the past several years, state legislatures have taken a variety of approaches to further reduce breastfeeding barriers. Since 2019, at least 23 states have enacted or adopted bills supporting women’s ability to breastfeed at work or in certain locations, receive breastfeeding support or access milk banks.

Workplace accommodations in state law can include several types of employee benefits and services. Since 2019, Georgia, Kentucky, Maine, Oregon, South Carolina, Tennessee, Virginia and Washington have enacted laws requiring employers to provide a breastfeeding employee with reasonable accommodations, including more frequent or longer breaks. Many of these laws also require a space other than a bathroom, which is not a sanitary space to prepare and handle food, for employees to express or pump breast milk. California SB 142 requires breastfeeding accommodations to include access to a sink and refrigerator and Oklahoma SB 285 requires state agencies to provide employees paid break time for nursing.

Other locations with breastfeeding protections include schools, correctional settings and some public spaces. California, Illinois, Nebraska and Virginia have laws requiring public or charter schools to provide accommodations for breastfeeding students. In 2019, California also passed AB 752 to require new or renovated transit stations to include a lactation room. New Mexico enacted SB 124 to require correctional facilities to implement a breastfeeding policy based on current best practices. New Jersey SB 1735 and Oklahoma SB 1877 require certain public facilities and offices to offer a lactation room.

Some states are exploring ways to increase access to breastfeeding support or milk banks, services that collect and dispense donated breast milk to mothers who need it. Connecticut and New Jersey require private insurance coverage for breastfeeding support and supplies (HB 5210 and AB 5509, respectively) and Medicaid coverage for donated breast milk (HB 7165 and SB 3159). Georgia HB 1114 requires Medicaid coverage for lactation services and New York SB 3387 authorizes lactation counseling services without a referral, an extra step that can be time-consuming. In 2019, Oregon passed HB 2005 to create a family and medical leave insurance program and allow certain benefits, including services related to lactation, to be extended for a period of time.

Federal Action

The Patient Protection and Affordable Care Act (ACA), signed into law in 2010, amended the Fair Labor Standards Act to require an employer to provide reasonable break time for an employee to express breast milk in a place other than a bathroom. In addition, the ACA requires most private health insurance plans to provide coverage for certain preventive services, including breastfeeding support and supplies with no cost-sharing. Last year, Congress passed the Fairness for Breastfeeding Mothers Act of 2019, which requires certain public buildings to provide a room, other than a bathroom, that is hygienic and available for use by the public to express breast milk.  

The Health Resources and Services Administration’s Maternal and Child Health Bureau continues to support breastfeeding women through various initiatives, including the Title V MCH Block Grant, the Women’s Preventive Services Initiative, the Healthy Start Program and the Maternal, Infant, and Early Childhood Home Visiting Program.