Racial and Ethnic Inequities in Paid Family and Medical Leave: United States, 2011 and 2017-2018

Maternal Leave Practices and Health Outcomes After Prolonged Postnatal Infant Hospitalization

OBJECTIVE

To assess the association between paid leave and breastfeeding and mental health among mothers of infants with prolonged postnatal hospitalization.

STUDY DESIGN

Data were obtained from 13 states participating in the Centers for Disease Control and Prevention's Pregnancy Risk Assessment and Monitoring System from 2016 to 2021. Prolonged postnatal hospitalization was defined as hospitalization >14 days. Maternal leave-taking was categorized as paid, unpaid, or no leave. The primary outcomes included breastfeeding initiation and continuation at 4 weeks, and postpartum depressive symptoms. We fit adjusted logistic regression models to estimate adjusted odds ratios (aORs, 95% CI) and marginal probabilities of the outcomes.

RESULTS

Among 2622 mothers whose infants had a prolonged hospitalization, 53% reported paid leave, 39% unpaid, and 7.3% no leave. Mothers with paid leave were more likely to have at least some college education, private insurance, and identify as White. No leave was associated with significantly decreased odds of ever breastfeeding (aOR 0.34 [95% CI 0.15, 0.76]) and breastfeeding at 4 weeks postpartum (aOR 0.38 [95% CI 0.19, 0.76]) compared with paid leave; comparisons with unpaid leave were similar. Associations with postpartum depressive symptoms were not statistically significant (no leave compared with paid leave aOR 1.31 [95% CI 0.65, 2.65]).

CONCLUSIONS

Significant disparities exist in utilization of paid leave among mothers of infants with prolonged postnatal hospitalizations. Given the association between leave-taking and breastmilk provision, policies to support maternal leave-taking may promote breastfeeding in this population.

Citizenship Status and Race/Ethnicity: Inequities in Access to Paid Family and Medical Leave and Workplace Flexibility

OBJECTIVES

Racial and ethnic minorities face disparities in access to paid family and medical leave (PFML) and workplace flexibility compared to non-Hispanic white workers. This study examines a new layer of inequity: citizenship status. Understanding citizenship-based disparities can inform policy changes to increase access to these benefits for all workers.

STUDY DESIGN

This cross-sectional analysis of the American Time Use Survey (2017-2018) focused on Hispanics, non-Hispanic Asians, and non-Hispanic White workers (N = 8602).

METHODS

We used weighted multivariate logistic regressions to investigate inequities in access to PFML and workplace flexibility across racial, ethnic, and citizenship categories. All models controlled for demographic, socioeconomic, and employment characteristics and included state fixed effects.

RESULTS

Despite overall low access (51.9% for PFML, 56.7% for flexible work hours, and 30.2% for work-from-home options), the study revealed significant disparities across race/ethnicity and citizenship status. In the fully adjusted models, non-citizen White (OR = 0.51, 95% CI = 0.28-0.93), US citizen Hispanic (OR = 0.65, 95% CI = 0.53-0.81), non-citizen Hispanic (OR = 0.37, 95% CI = 0.25-0.56), citizen Asian (OR = 0.59, 95% CI = 0.42-0.82), and non-citizen Asian workers (OR = 0.51, 95% CI = 0.31-0.85) had statistically significant lower odds of reporting access to paid family and medical leave compared to citizen White workers. In addition, non-citizen Hispanic workers had the lowest predicted probabilities of reporting being able to work from home.

CONCLUSIONS

This study underscores the need for equitable workplace policies. Addressing the unique challenges faced by different racial/ethnic and citizenship groups is crucial to achieving health equity.

Approaching neuro-palliative care with historically minoritized groups in the United States: A literature review and actionable recommendations

This review critically examines neuro-palliative care disparities in historically minoritized groups in the U.S., particularly in Asian, Black, and Latino communities. Addressing a gap in the 2022 American Academy of Neurology guidelines, this review synthesizes current literature and our clinical experiences as neurologists who identify as members of these communities in diverse care settings. We identify common barriers to palliative care access and acceptance, influenced by cultural heterogeneity, mistrust, and systemic disparities. The review offers targeted, actionable recommendations at the provider, healthcare system, and policy level to improve care and reduce disparities.

Leveraging Social Determinants of Health to Enhance Recruitment of Underrepresented Populations in Clinical Trials

Historically marginalized communities are disproportionately affected by cardiometabolic diseases yet are underrepresented in clinical trials that investigate needed interventions. This review investigates the barriers to equitable inclusion in clinical trials, identifying opportunities for improvement at the institutional, trial, community, and individual level. It proposes a social determinants-based approach that serves as a toolkit to target these barriers using structural, economic, community, healthcare access, and technology solutions, supporting constructive improvement in the clinical trial recruitment process.

Intersection of adverse childhood experiences, suicide and overdose prevention

Adverse childhood experiences (ACEs), suicide and overdose are linked across the life course and across generations and share common individual-, interpersonal-, community- and societal-level risk factors. The purpose of this review is to summarise the shared aetiology of these public health issues, synthesise evidence regarding potential community- and societal-level prevention strategies and discuss future research and practice directions.Growing evidence shows the potential for community- and societal-level programmes and policies, including higher minimum wage; expanded Medicaid eligibility; increased earned income tax credits, child tax credits and temporary assistance for needy families benefits; Paid Family Leave; greater availability of affordable housing and rental assistance; and increased participation in the Supplemental Nutrition Assistance Program (SNAP), to contribute to ACEs, suicide and overdose prevention. Considerations for future prevention efforts include (1) expanding the evidence base through rigorous research and evaluation; (2) assessing the implications of prevention strategies for equity; (3) incorporating a relational health perspective; (4) enhancing community capacity to implement, scale and sustain evidenced-informed prevention strategies; and (5) acknowledging that community- and societal-level prevention strategies are longer-term strategies.

State paid family leave policies and breastfeeding duration: cross-sectional analysis of 2021 national immunization survey-child

BACKGROUND

Paid parental leave policies may promote breastfeeding, which can have short- and long-term health benefits for both members of the birthing person-infant dyad. In the United States, where 56% of the workforce qualifies for unpaid federal medical leave, certain states have recently enacted paid parental and family leave policies. We aimed to assess the extent to which living in states with versus without paid family leave was associated with feeding regimens that included breastfeeding.

METHODS

In this cross-sectional analysis of the 2021 National Immunization Survey-Child, we assessed feeding outcomes: (1) exclusively breastfed (only fed breastmilk-never infant formula-both before and after six months of age), (2) late mixed breastfeeding (formula after six months), (3) early mixed breastfeeding (breastfed, formula before six months), and (4) never breastfed. We conducted Pearson χ2 to compare social-demographic characteristics and multivariable nominal regression to assess extent to paid family leave was associated with breastfeeding regimens, compared with never breastfeeding.

RESULTS

Of the 35,995 respondents, 5,806 (25% of weighted respondents) were from states with paid family leave policies. Compared with never breastfeeding, all feeding that incorporated breastfeeding-exclusive breastfeeding, late mixed feeding (breastfed, formula introduced after six months), and early mixed feeding (breastfed, formula introduced before six months)-were more prevalent in states with paid family leave policies. The adjusted prevalence ratio (aPR) and differences in adjusted prevalence compared with never breastfeeding in states with versus without paid family leave policies were: aPR 1.41 (95% CI 1.15, 1.73), 5.36% difference for exclusive breastfeeding; aPR 1.25 (95% CI 1.01, 1.53), 3.19% difference for late mixed feeding, aPR 1.32 (95% CI 1.32, 1.97), 5.42% difference for early mixed feeding.

CONCLUSION

States with paid family leave policies have higher rates of any breastfeeding and of exclusive breastfeeding than states without such policies. Because all feeding types that incorporate breastfeeding were higher in states with paid family leave policies, expansion of paid family leave may improve breastfeeding rates.

"How Do I Prepare for This?" Patient Perspectives on Providers' Employment-related Support During Pregnancy

BACKGROUND

Health care providers can offer employment-related support to pregnant patients by providing information about occupational risks and benefits, discussing adjustments, and/or completing paperwork to help patients obtain accommodations or benefits, but little research has examined whether and how this support is provided.

METHODS

We conducted interviews with 20 adults who had been employed while pregnant within the 5 years preceding data collection. Eligible participants had low incomes, were hourly wage earners, or were employed in service or retail occupations. Applied thematic analysis was used to identify emergent themes.

RESULTS

People who had been employed while pregnant described a range of experiences during that time, including physical and psychological demands from work, lack of access to appropriate accommodations, difficulties combining breastfeeding with work, and work-related challenges accessing health care. Participants described four primary roles that health care providers played: 1) completing paperwork needed to apply for benefits or receive work modification; 2) providing information about how to mitigate employment-related risks; 3) providing referrals to social or medical services; and 4) advocating for patients to ensure receipt of accommodations, resources, and information. Strategies identified by patients that could be enacted within health care to help them better navigate the work-pregnancy interface include increasing appointment flexibility, providing information about work-related risks and benefits programs and referrals to legal support, and helping providers to understand and support their patients' individual work-related concerns.

CONCLUSIONS

Health care providers have a critical role to play in supporting employed pregnant people to achieve flexibility in managing their work and to be active participants in discussions about recommended workplace accommodations.

Association Between Length of Maternity Leave and Breastfeeding Duration in the United States: A Systematic Review

OBJECTIVE

To perform a systematic review to assess the association between the length of maternity leave and breastfeeding duration in the United States.

DATA SOURCES AND METHODS OF STUDY SELECTION

This review was conducted with a five-stage model for reviews. We included publications from 2000 to 2023, U.S.-based studies written in English, and primary research and peer-reviewed articles. In February 2023, a medical librarian conducted a search across seven databases, yielding 1,540 results. ClinicalTrials.gov was later searched, yielding no results. After duplicates were removed, 835 abstracts were screened. A full-text article review was then conducted of the remaining 34 articles.

TABULATION, INTEGRATION, AND RESULTS

Twenty-three articles met inclusion criteria, two of which were reviews. Of the nonreview articles, all found a positive relationship between increased maternity leave and duration of breastfeeding. Data showed that earlier return to work for the birth parent decreased the odds of breastfeeding dyads meeting breastfeeding recommendations. Many studies adjusted for confounders (eg, race, socioeconomic status); however, Black or Latinx mothers still experience shorter breastfeeding durations or lower breastfeeding exclusivity when given equal leave compared with White mothers.

CONCLUSION

Results show a positive relationship between length of maternity leave and breastfeeding duration. Advocacy for longer, paid parental leave and more robust research rooted in rigorous methods are needed.

Racial and Ethnic Identity and Vulnerability to Upper Respiratory Viral Infections Among US Children

BACKGROUND

It is unclear whether there are racial/ethnic disparities in the risk of upper respiratory viral infection acquisition and/or lower respiratory manifestations.

METHODS

We studied all children and children with asthma aged 6 to 17 years in the National Health and Nutrition Examination Survey (2007-2012) to evaluate (1) the association between race/ethnicity and upper respiratory infection (URI) and (2) whether race/ethnicity is a risk factor for URI-associated pulmonary eosinophilic inflammation or decreased lung function.

RESULTS

Children who identified as Black (adjusted odds ratio [aOR], 1.38; 95% CI, 1.10-1.75) and Mexican American (aOR, 1.50; 95% CI, 1.16-1.94) were more likely to report a URI than those who identified as White. Among those with asthma, Black children were more than twice as likely to report a URI than White children (aOR, 2.28; 95% CI, 1.31-3.95). Associations between URI and pulmonary eosinophilic inflammation or lung function did not differ by race/ethnicity.

CONCLUSIONS

Findings suggest that there may be racial and ethnic disparities in acquiring a URI but not in the severity of infection. Given that upper respiratory viral infection is tightly linked to asthma exacerbations in children, differences in the risk of infection among children with asthma may contribute to disparities in asthma exacerbations.

A Surgical Desirability of Outcome Ranking (DOOR) Reveals Complex Relationships Between Race/Ethnicity, Insurance Type, and Neighborhood Deprivation

OBJECTIVE

Develop an ordinal Desirability of Outcome Ranking (DOOR) for surgical outcomes to examine complex associations of Social Determinants of Health.

BACKGROUND

Studies focused on single or binary composite outcomes may not detect health disparities.

METHODS

Three health care system cohort study using NSQIP (2013-2019) linked with EHR and risk-adjusted for frailty, preoperative acute serious conditions (PASC), case status and operative stress assessing associations of multilevel Social Determinants of Health of race/ethnicity, insurance type (Private 13,957; Medicare 15,198; Medicaid 2835; Uninsured 2963) and Area Deprivation Index (ADI) on DOOR and the binary Textbook Outcomes (TO).

RESULTS

Patients living in highly deprived neighborhoods (ADI>85) had higher odds of PASC [adjusted odds ratio (aOR)=1.13, CI=1.02-1.25, P <0.001] and urgent/emergent cases (aOR=1.23, CI=1.16-1.31, P <0.001). Increased odds of higher/less desirable DOOR scores were associated with patients identifying as Black versus White and on Medicare, Medicaid or Uninsured versus Private insurance. Patients with ADI>85 had lower odds of TO (aOR=0.91, CI=0.85-0.97, P =0.006) until adjusting for insurance. In contrast, patients with ADI>85 had increased odds of higher DOOR (aOR=1.07, CI=1.01-1.14, P <0.021) after adjusting for insurance but similar odds after adjusting for PASC and urgent/emergent cases.

CONCLUSIONS

DOOR revealed complex interactions between race/ethnicity, insurance type and neighborhood deprivation. ADI>85 was associated with higher odds of worse DOOR outcomes while TO failed to capture the effect of ADI. Our results suggest that presentation acuity is a critical determinant of worse outcomes in patients in highly deprived neighborhoods and without insurance. Including risk adjustment for living in deprived neighborhoods and urgent/emergent surgeries could improve the accuracy of quality metrics.

Association Between State Paid Family and Medical Leave and Breastfeeding, Depression, and Postpartum Visits

OBJECTIVE

To evaluate the association of state paid family and medical leave policies with the likelihood of breastfeeding, postpartum depression symptoms, and attendance of the postpartum visit.

METHODS

This was a cross-sectional study that used 2016-2019 data from PRAMS (Pregnancy Risk Assessment Monitoring System) for 43 states and Washington, DC. We describe the association of state paid family and medical leave generosity with rates of breastfeeding, postpartum depression symptoms, and attendance of the postpartum visit. Logistic and Poisson regression models tested the significance of state paid family and medical leave coverage generosity after controlling for individual respondent sociodemographic characteristics, with sensitivity analyses for respondents with deliveries covered by Medicaid insurance.

RESULTS

Of the 143,131 respondents, representative of an estimated 7,426,725 population, 26.2% lived in eight states and DC with the most generous paid family and medical leave, 20.5% lived in nine states with some paid family and medical leave, and 53.3% lived in 26 states with little or no paid family and medical leave. Overall, 54.8% reported breastfeeding at 6 months or at time of the survey, ranging from 59.5% in the most generous paid family and medical leave states to 51.0% in states with the least paid family and medical leave coverage. Postpartum depression symptoms varied from 11.7% in the most generous states to 13.3% in the least generous states (both P <.001). State differences in postpartum visit attendance rates (90.9% overall) did not differ significantly. After adjusting for respondent characteristics, compared with states with the least paid family and medical leave, breastfeeding was 9% more likely (adjusted incidence rate ratio [aIRR] 1.09, 95% CI, 1.07-1.11) in states with the strongest paid family and medical leave coverage and 32% more likely (aIRR 1.32, 95% CI, 1.25-1.39) in analyses limited to respondents with deliveries covered by Medicaid insurance. A more generous state paid family and medical leave policy was significantly associated with a lower likelihood of postpartum depression symptoms compared with states with the least paid family and medical leave (adjusted odds ratio 0.85, 95% CI, 0.76-0.94) and a modest but significant increase in postpartum visit attendance (aIRR 1.03, 95% CI, 1.01-1.04) among respondents with deliveries covered by Medicaid insurance.

CONCLUSION

Respondents from states with strong paid family and medical leave had a greater likelihood of breastfeeding and had lower odds of postpartum depression symptoms, with stronger associations among respondents with deliveries covered by Medicaid insurance. Despite major potential health benefits of paid family and medical leave, the United States remains one of the few countries without federally mandated paid parental leave.

Racial/ethnic and gender inequities in the sufficiency of paid leave during the COVID-19 pandemic: Evidence from the service sector

BACKGROUND

Access to paid family and medical leave (PFML), including leave to care for a seriously ill loved one or recover from one's own serious illness, conveys health and economic benefits for workers and their families. However, without a national PFML policy, access to paid leave remains limited and unequal. Previous work documenting inequitable access by socioeconomic status and race/ethnicity primarily focuses on parental leave, measures theoretical access to paid leave rather than actual leave uptake, and lacks an accounting for why workers of color and women may have less access to PFML. We extend this literature by looking at leave-taking for medical needs or caregiving among a high-risk population during the COVID-19 pandemic.

METHODS

We draw on data from 2595 service-sector workers surveyed by the Shift Project in 2020 and 2021 to estimate inequities in leave uptake among workers who experienced qualifying events. We then estimate the relative importance of worker demographic characteristics, qualifying event types (medical vs. caregiving leave), proxies for access to state and employer PFML policies, job characteristics, and ultimately within-firm differences to these gaps.

RESULTS

Overall, one-fifth of workers reported sufficient leave. Women are significantly more likely than men to report insufficient or no leave. Hispanic and Black workers are more likely to take insufficient or no leave, respectively, but these differences were attenuated when controlling for covariates.

CONCLUSIONS

The dearth of PFML laws leaves women and workers of color without access to leave that is paid and of sufficient duration when facing a qualifying event.

Early Effects of the New York City Paid Safe and Sick Leave Law

CONTEXT

Paid sick leave (PSL) is a public health strategy associated with benefits for workers, businesses, and consumers. In the absence of a federal law, in 2014, New York City (NYC) joined other state and municipal governments with local PSL policies.

OBJECTIVES

To examine changes in PSL after the implementation of NYC's 2014 Paid Safe and Sick Leave Law and to assess which communities remain less likely to use PSL.

DESIGN

This study uses data from multiple panels of the NYC Longitudinal Survey of Wellbeing (NYC-LSW)-a population-representative study of NYC adults-to track changes in PSL, using data collected before and after NYC's Paid Safe and Sick Leave Law was implemented. We use weighted cross-tabulations and multinomial logistic regression models to assess changes in payment for sick leave since the implementation of the law.

SETTING AND PARTICIPANTS

The study includes 2985 NYC adults aged 18 to 64 years who reported working for pay in the year preceding the survey where PSL questions were asked (2014-2019).

MAIN OUTCOME MEASURES

Use of sick leave and payment for sick leave.

RESULTS

Weighted descriptive results show a 7-percentage-point increase ( P = .02) in the rate of being paid for all sick days and a 6-percentage-point decrease ( P = .02) in not being paid for any sick days. Results from multinomial logistic regression models, adjusting for potential confounders, show that after implementation of the law, workers with low levels of education, who are younger, Latino, and foreign-born remain less likely than their peers to use PSL.

CONCLUSIONS

We demonstrate that the PSL mandate expanded access for employees but not evenly across groups. These results offer guidance to other jurisdictions implementing PSL policies, suggesting the need for targeted education and enforcement efforts to ensure policies reach sectors where low-wage workers are most prevalent.

The impact of paid sick leave mandates on Women's health

The United States does not have a national program to provide job-protected paid leave to workers when they or a family member are ill or need to seek medical care. Many workers receive paid sick leave through their employers, but women, particularly parents, those without a college degree, and Latinas, are less likely than their counterparts to receive employer-provided paid sick leave (PSL). To address the shortfall in PSL coverage, several states and localities have passed laws mandating employers to provide PSL. I examine the impacts of three recent state-level paid sick leave policies on women's self-reported health using data from the Behavior Risk Factor Surveillance System. Using static and event-study difference-in-differences models, I find that PSL mandates decreased the proportion of women reporting fair or poor health by an average of 2.4 percentage points and reduced the number of days women reported their physical and mental health was not good by 0.68 days and 0.43 days in the past 30 days respectively. Effects were concentrated among parents, women without college degrees, and women of color. This study demonstrates that despite being a low-intensity policy, PSL improves women's health and well-being and that mandating workplace benefits may play a role in achieving health equity.

Work as an Understudied Driver of Racial Inequities in Breastfeeding

Breastfeeding inequities by race are a persistent public health problem in the United States. Inequities in occupation and working conditions likely contribute to relatively less breastfeeding among Black compared to White mothers, yet little research has addressed these interrelationships. Here, we offer a critical review of the literature and a conceptual framework to guide future research about work and racial inequities in breastfeeding. There is a strong public health case for promoting breastfeeding equity for mothers across race groups and occupation types. Existing theory suggests that employment opportunities and working conditions are a likely pathway that connects structural racism to Black-White breastfeeding inequities, in addition to other known factors. We propose a new conceptual model for studying the interrelationships among work, race, and breastfeeding outcomes.