Population Health and Paid Parental Leave: What the United States Can Learn from Two Decades of Research

Are medical associations' paid parental leave recommendations instituted for United States medical school faculty?

Longer paid parental leaves have many well-documented biopsychosocial benefits for parents and children. However, many United States (U.S.) employers do not offer 8-12 weeks of paid parental leave as recommended by medical associations such as The American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, and the American Medical Association. This study compared and summarized the quality of parental leave policies offered across U.S. allopathic medical schools to determine their alignment with medical associations' recommendations. Parental leave policies were analyzed to determine 1) whether employers offered standalone parental leave policies and/or relied on the Family Medical Leave Act, 2) who received parental leave, 3) whether leave was paid or unpaid, and 4) the number of paid weeks offered, if any. Differences in leave durations were compared according to Carnegie classifications, school control, and geographic region. Of the 134 (85.9%; 134/156) allopathic medical schools with retrievable policies, one-fifth (21.6%; 29/134) offered 12 weeks or more of fully compensated birthing parent leave. Schools offered an average of 6.72 weeks (median = 6) of paid birthing parent leave and 5.82 weeks (median = 6) of paid non-birthing parent leave. Private (p < 0.001) and Northeast (p < 0.001) schools offered more weeks of paid birthing parent leave. Despite the benefits of longer paid parental leaves, over three-quarters of parental leave policies used by allopathic medical schools did not offer faculty 12 weeks of fully paid birthing parent (78.4%; 105/134) or non-birthing parent leave (84.3%; 113/134). This suggests that most parental leave policies offered to academic medicine faculty are misaligned with medical associations' recommendations.

Placental ischemia during pregnancy induces hypertension, cerebral inflammation, and oxidative stress in dams postpartum

BACKGROUND

Preeclampsia (PE) is characterized as de novo hypertension (HTN) with end-organ damage, especially in the brain. PE is hypothesized to be caused by placental ischemia. PE affects ~5-8% of USA pregnancies and increases the risk for HTN and cerebrovascular diseases (CVD) later in life. We hypothesize that blood pressure (BP), cerebral oxidative stress, and cerebral inflammation will increase in postpartum (PP) placental ischemic dams.

METHODS

Placental ischemia was induced in pregnant Sprague Dawley dams, utilizing reduced uterine perfusion pressure (RUPP) surgery. At 6 weeks PP (~3 human years), BP was measured via carotid catheterization, and cerebral oxidative stress and inflammation were assessed via ELISAs, biochemical assays, and Western blots.

RESULTS

BP, cerebral pro-inflammatory cytokines (TNF-α and IL-6), and GFAP (a marker of astrocyte activity) were increased in PP RUPP dams. Cerebral hydrogen peroxide (H2O2) was also increased in PP RUPP dams, and had a strong correlation with PP RUPP BP, proinflammatory cytokines (TNF- α and IL-6), and GFAP astrocyte activation.

CONCLUSION

PP RUPP dams have increased BP, cerebral oxidative stress, and cerebral inflammation at 6 weeks postpartum. These changes in cerebral inflammation and oxidative stress may contribute to the pathology and development of HTN and CVDs in postpartum dams.

Associations Between Infant Formula Exposure, Housing Instability and Postneonatal Mortality Among Participants in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

OBJECTIVES

To quantify infant mortality rates (IMR) using expanded racial categories, and to examine associations between infant formula exposure, housing instability and postneonatal mortality among Minnesota WIC Participants.

METHODS

Births in Minnesota from 2014 through 2019 (n = 404,102) and associated infant death records (n = 2034) were used to calculate neonatal and postneonatal rates using expanded racial categories. Those births that participated in the WIC program (n = 170,011) and their linked death records (n = 853) were analyzed using logistic regression to examine associations between formula exposure, housing instability, and postneonatal death.

RESULTS

Postneonatal IMR was more than twice as prevalent among Black (African American) as East African immigrant infants (IMR = 3.9 vs 1.5). After adjustment for confounding (term status and nativity of mother (U.S. vs foreign born), infants exposed to formula by 28 days were four times as likely to die in the postneonatal period as those without formula exposure (aOR = 4.0; 95% CI 3.2-4.9). WIC participants who experienced housing instability at birth were 1.7 times as likely to lose an infant in the postneonatal period (28 to 364 days of age) as those in stable housing (aOR = 1.7; 95% CI 1.2, 2.4).

CONCLUSIONS FOR PRACTICE

Disaggregating Black mortality rates revealed inequities in infant mortality among Black families of varied backgrounds. Formula exposure and housing instability are modifiable risk factors associated with postneonatal mortality. Appropriate interventions to reduce barriers to breastfeeding and provide housing stability for vulnerable families could reduce disparities in postneonatal mortality.

How Did We Get So Bored? A Bioecological Model of the Development of Boredom

Boredom is a negative emotion that most people experience on occasion. However, boredom is also present on a trait level. People high in trait boredom experience boredom more frequently or have difficulty tolerating it. Individuals high in trait boredom are more likely to experience depression or anxiety or engage in risk behaviors. Little is known about the development of trait boredom. We propose a bioecological model of the development of trait boredom in which it originates from early individual differences in temperament and executive control. Trait boredom is shaped over time through interactions between the child and their developmental context, such as parents, teachers, and neighborhoods. Boredom can also spur creativity. Capitalizing on the creative side of boredom may help promote low levels of trait boredom and healthy coping. We provide a roadmap to study the development of trait boredom to advance our understanding of how it emerges and develops.

A National Survey of Pregnancy and Parenthood among Nephrology Trainees: A Focus on Nephrology Fellowship

Key Points

Parental leave policies for physician trainees are inconsistent. Nephrology fellows are largely unaware of parental leave policies and pregnancy accommodations in their programs. Individual nephrology programs should improve awareness about national and local program policies among trainees.

Background

National and international policies on parental leave for physician trainees are inconsistent. Physician trainees, including nephrology fellows, may be at higher risk of pregnancy complications. Physician trainees face barriers in meeting their breastfeeding goals and in finding childcare because of nontraditional work hours with extended or unpredictable shifts. We examine awareness of current policies in US nephrology fellowship programs regarding parental leave, pregnancy/breastfeeding accommodations, and fellows' perspectives on family planning.

Methods

An anonymous, online survey of US nephrology fellows was undertaken from June 9 to August 24, 2023.

Results

One hundred twenty nephrology fellows submitted the survey. Most of the fellow respondents were unaware of parental leave policies of their training programs (63%), the Accreditation Council for Graduate Medical Education (75%), and/or the American Board of Medical Specialties (75%). Forty-two percent were unaware of the duration of parental leave at their program. Nearly 45% of all respondents were unsure if their program limited night shifts or shifts >24 hours for pregnant trainees. Forty-three percent reported they were unsure of lactation accommodations, and 40% were unsure of access to subsidized childcare. When fellows received work accommodations for pregnancy or parenthood, their work obligations were largely covered by co-fellows (60%) or attendings (38%). Over 60% of fellows agreed or strongly agreed that they would avoid a pregnancy in fellowship because of concern that they would have to extend their training. Of the 40 fellows who chose to pursue pregnancy or parenthood during medical training, 75% did not change their career plans as a result.

Conclusions

Most nephrology fellows were unaware of parental leave policies and pregnancy/lactation accommodations. While the topic itself has a broad effect to all physician trainees, there is a need for improved awareness about national and local program policies among trainees across individual nephrology programs.

A Qualitative Study Describing Experiences of Pregnancy Discrimination in the Workplace

OBJECTIVES

Qualitatively assess experiences of occupational pregnancy discrimination.

METHODS

A fully remote phenomenological qualitative study was completed leveraging semistructured interviews with a sample of pregnant employees in the United States. Inclusion criteria included being pregnant, working at least 35 hours per week, employed at least 1 year at current employer, and without diagnosed depression/anxiety.

RESULTS

Participants (N = 20) were, on average, 30 years of age, worked 42.6 hours per week, self-identified as non-Hispanic black (50%), and earned least a bachelor's degree (85%). Individuals successfully identified various forms of pregnancy discrimination, believing it occurred due to systemic issues or perceptions that women are weak. Most did not report experiences of discrimination fearing retaliation or being unaware of workplace protections.

CONCLUSION

Pregnancy discrimination in the workplaces comes in various forms and is an issue for some working pregnant individuals.

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.

Maternal Psychological Symptom Trajectories From 2 to 24 Months Postpartum: A Latent Class Growth Analysis

BACKGROUND

Postpartum women experience an array of psychological symptoms that are associated with adverse health behaviors and outcomes including postpartum suicidal ideation and long-term depression. To provide early management of postpartum psychological symptoms, it is important to understand how the symptom experiences change over time.

OBJECTIVE

The aim of this study was to examine maternal psychological symptom trajectories over 2, 6, 15, and 24 months postpartum using latent class growth analysis and to examine how each trajectory is associated with maternal depression outcome at 24 months.

METHODS

We used secondary data from the Family Life Project ( N = 1,122) and performed multitrajectory latent class growth analysis based on four observed symptom variables (depression, anxiety, somatization, and hostility). After the final model was identified, bivariate analyses were conducted to examine the association between each trajectory and (a) individual characteristics and (b) outcome (Center for Epidemiologic Studies Depression Scale [CES-D]) variables.

RESULTS

A four-class model was selected for the final model because it had better fit indices, entropy, and interpretability. The four symptom trajectories were (a) no symptoms over 24 months, (b) low symptoms over 24 months, (c) moderate symptoms increasing over 15 months, and (d) high symptoms increasing over 24 months. More postpartum women with the trajectory of high symptoms increasing over 24 months (Trajectory 4) were in low economic status (92.16%), unemployed (68.63%), or did not complete 4-year college education (98.04%). Most postpartum women (95.56%) in Trajectory 4 also had higher CES-D cutoff scores, indicating a possible clinical depression at 24 months postpartum.

DISCUSSION

Postpartum women who experience increasing symptom trajectories over 15-24 months (Trajectories 3 and 4) could benefit from tailored symptom management interventions provided earlier in the postpartum period to prevent persistent and worsening symptom experiences.

Barriers to increasing paid parental leave in U.S. neurology residencies: a survey of program directors

BACKGROUND

The American Board of Psychiatry and Neurology (ABPN) and the Accreditation Council for Graduate Medical Education (ACGME) require that residency programs allow at least 6 weeks of parental leave. The American Medical Association (AMA) recommends 12 weeks of paid parental leave. Despite these recommendations, there is little information about parental leave policies across U.S. neurology residencies. The objective of our study was to assess parental leave policies in U.S. adult neurology residencies and barriers to increasing the duration of leave.

METHODS

We distributed an anonymous online survey to U.S. adult neurology program directors (PDs) to assess demographics, components and length of parental leave, perceived impact on residents' clinical training and academic development, and barriers to increasing the length of leave.

RESULTS

We contacted 163 PDs and received 54 responses (response rate of 33%). 87% reported policies for both childbearing and non-childbearing residents. The average maximal length of leave allowed without extension of training was 8.5 weeks (range 0-13) for childbearing and 6.2 weeks (range 0-13) for non-childbearing residents. Most PDs felt that parental leave had a positive impact on resident wellness and neutral impact on clinical competency, academic opportunities, and career development. The most common barriers to providing a 12-week paid policy were concerns about equity in the program (82%), staffing of clinical services (80%), and impact on clinical training (78%).

CONCLUSIONS

Although most programs in our study have parental leave policies, there is significant variability. Policies to improve parental leave should focus on addressing common barriers, such as additional solutions to staffing clinical services.

Pumps: A Possible Tool to Promote More Equitable Lactation Outcomes

Pregnant individuals and infants in the US are experiencing rising morbidity and mortality rates. Breastfeeding is a cost-effective intervention associated with a lower risk of health conditions driving dyadic morbidity and mortality, including cardiometabolic disease and sudden infant death. Pregnant individuals and infants from racial/ethnic subgroups facing the highest risk of mortality also have the lowest breastfeeding rates, likely reflective of generational socioeconomic marginalization and its impact on health outcomes. Promoting breastfeeding among groups with the lowest rates could improve the health of dyads with the greatest health risk and facilitate more equitable, person-centered lactation outcomes. Multiple barriers to lactation initiation and duration exist for families who have been socioeconomically marginalized by health and public systems. These include the lack of paid parental leave, increased access to subsidized human milk substitutes, and reduced access to professional and lay breastfeeding expertise. Breast pumps have the potential to mitigate these barriers, making breastfeeding more accessible to all interested dyads. In 2012, The Patient Protection and Affordable Care Act (ACA) greatly expanded access to pumps through the preventative services mandate, with a single pump now available to most US families. Despite their near ubiquitous use among lactating individuals, little research has been conducted on how and when to use pumps appropriately to optimize breastfeeding outcomes. There is a timely and critical need for policy, scholarship, and education around pump use given their widespread provision and potential to promote equity for those families facing the greatest barriers to achieving their personal breastfeeding goals.

Achieving paid family leave in Oregon, USA: analysis of the policy process using the advocacy coalition framework

Only a few states have adopted a paid family leave (PFL) policy in the United States of America. Local media described the 2019 Oregon PFL legislation as "the most progressive" policy in the country, with coalitions as crucial policy advocates. This case study applies the Advocacy Coalition Framework (ACF) to examine policy learning and negotiated agreements as causal mechanisms to explain the adoption of the PFL. We identified three modes of policy learning: previous policy cycles, learning from other coalitions, and learning from community organizations. ACF explains the evolution of negotiated agreements based on the stability of coalition belief systems, including consensus on leave time, inclusivity, and cost-sharing contributions. ACF helps describe how coalitions adopted progressive ideas such as equity. However, ACF's elements that allow a deeper exploration of narratives were missing. Future studies should include interviews with coalition members and compare state policies to assess strategies. Future policy initiatives could integrate feedback from community organizations into policy strategies.

Parental, caregiving, and family leave during clinical neuropsychology postdoctoral training: Recommendations and guidelines from the Women in Neuropsychology (WIN) committee and Education Advisory Committee (EAC) of the Society for Clinical Neuropsychology (SCN; APA division 40)

Objective: Parental and other caregiving leave is important to postdoctoral fellows, yet there is no field-wide recommendation for leave policies among clinical neuropsychology postdoctoral training programs, which is of particular relevance given the two-year requirement for eligibility for board certification. The aims of this manuscript are to (a) discuss general guidelines and recommendations for leave policies, both informed by prior empirical evidence as well as relevant existing policy guidelines from various academic and healthcare organizations, and (b) use vignettes to provide possible solutions for potential leave scenarios. Method: A critical review of literature on family leave from public policy and political science, industrial-organizational psychology, academic medicine, and psychology was conducted and findings were synthesized. Results and Conclusions: Fellowship training programs are encouraged to adopt a competency-based model that permits flexibility in leave during training without necessarily requiring an extended end date. Programs should adopt clear policies and make this information readily available to trainees and think flexibly about training options that best meet the training needs and goals of each individual. We also encourage neuropsychologists at all levels to engage in advocacy for broader systemic supports of trainees seeking equitable family leave.

The neonatal perspective of paid family medical leave (PFML)

Paid family medical leave (PFML) offers infants, parents, and society at large numerous health and economic benefits. It has been shown to improve neonatal and maternal outcomes, breastfeeding rates, familial relationships, and decrease gender inequalities in the workplace. Though the economic feasibility of PFML has been well established in many countries, the USA lacks a cohesive and comprehensive federal PFML policy. Neonatal healthcare providers play a critical role in impacting neonatal health and should actively advocate for the development and promotion of a federal PFML policy, particularly one that is inclusive of both mothers and fathers and is at least 12 weeks in duration.

Case-control study of exclusive breast feeding and severe bronchiolitis in the United States

BACKGROUND

Bronchiolitis is a major cause of infant illness, with few known modifiable risk factors. Breast feeding may reduce risk of severe bronchiolitis, but the association of exclusive vs. partial breast feeding with severe bronchiolitis is unclear.

OBJECTIVE

To estimate the association of exclusive vs. partial breast feeding during ages 0-2.9 months with bronchiolitis hospitalisation during infancy.

METHODS

We conducted a case-control study as a secondary analysis of two prospective US cohorts in the Multicenter Airway Research Collaboration. Cases were enrolled in a 17-centre study of infants hospitalised for bronchiolitis during 2011-2014 (n = 921). Controls were enrolled in a five-centre study of healthy infants during 2013-2014 and 2017 (n = 719). Breast feeding history during ages 0-2.9 months was collected by parent interview. Among breastfed infants, the association of exclusive vs. partial breast feeding with odds of bronchiolitis hospitalisation was estimated using a multivariable logistic regression model adjusted for demographic variables, parental asthma history, and early-life exposures. As a secondary analysis, we estimated the associations of exclusive, predominant, and occasional breast feeding vs. no breast feeding with the odds of bronchiolitis hospitalisation.

RESULTS

Among 1640 infants, the prevalence of exclusive breast feeding was 187/921 (20.3%) among cases and 275/719 (38.3%) among controls. Exclusive vs. partial breast feeding was associated with 48% reduced odds of bronchiolitis hospitalisation (adjusted odds ratio [OR] 0.52, 95% confidence interval [CI] 0.39, 0.69). In the secondary analysis, exclusive vs. no breast feeding was associated with 58% reduced odds of bronchiolitis hospitalisation (OR 0.42, 95% CI 0.23, 0.77), whereas predominant breast feeding (OR 0.77, 95% CI 0.37, 1.57) and occasional breast feeding (OR 0.98, 95% CI 0.57, 1.69) were not associated with meaningfully reduced odds of bronchiolitis hospitalisation.

CONCLUSION

Exclusive breast feeding had a strong protective association against bronchiolitis hospitalisation.

Navigating Personal Health Crises, Imposter Syndrome, Sexual Harassment, Clinical Mistakes, and Leadership Challenges: Lessons for Work-Life Wellness in Academic Medicine: Part 3 of 3

In this final manuscript of the three-part series, the authors address issues of imposter syndrome, pregnancy, and parental leave, second victim phenomenon, sexual harassment, response to suicide, and managing a budget while advancing diversity, equity, and inclusion. The case scenarios have learners and non-clinicians as their main characters, bringing attention to the cross-cutting nature of the complex issues we see both in and around a career in medicine.

New York State's Paid Family Leave Program is Associated with More Equitable and Increased Use of Paid Leave Following Childbirth

OBJECTIVES

This study aimed to assess changes in paid maternity leave before and after New York's (NY) Paid Family Leave (PFL) law went into effect (1/1/2018) and changes in disparities by maternal characteristics.

METHODS

We used specific data collected on maternity leaves by women who gave birth in 2016-2018 in NY State (outside NY City) participating in the Pregnancy Risk Assessment Monitoring System survey. Multiple logistic regressions were conducted to evaluate the effect of the PFL law on prevalence of paid leave taken by women after childbirth.

RESULTS

After NY's PFL law went into effect, there was a 26% relative increase in women taking paid leave after childbirth. Use of paid leave after childbirth increased among all racial and ethnic groups. The increases were greater among Black non-Hispanic or other race non-Hispanic women, compared to white non-Hispanic women, suggesting that NY's law was associated with more equitable use of paid leave following childbirth.

CONCLUSIONS FOR PRACTICE

Wider implementation and greater utilization of paid maternity leave policies would promote health equity and help reduce racial/ethnic disparities in maternal and child health outcomes.

COVID-19 Spotlights Connections between Disease and Multiple Lifestyle Factors

The SARS-CoV-2 virus (severe acute respiratory syndrome coronavirus 2), and the disease it causes (COVID-19), have had a profound impact on global human society and threaten to continue to have such an impact with newly emerging variants. Because of the widespread effects of SARS-CoV-2, understanding how lifestyle choices impact the severity of disease is imperative. This review summarizes evidence for an involvement of chronic, non-resolving inflammation, gut microbiome disruption (dysbiosis with loss of beneficial microorganisms), and impaired viral defenses, all of which are associated with an imbalanced lifestyle, in severe disease manifestations and post-acute sequelae of SARS-CoV-2 (PASC). Humans' physiological propensity for uncontrolled inflammation and severe COVID-19 are briefly contrasted with bats' low propensity for inflammation and their resistance to viral disease. This insight is used to identify positive lifestyle factors with the potential to act in synergy for restoring balance to the immune response and gut microbiome, and thereby protect individuals against severe COVID-19 and PASC. It is proposed that clinicians should consider recommending lifestyle factors, such as stress management, balanced nutrition and physical activity, as preventative measures against severe viral disease and PASC.

The Role of Work as a Social Determinant of Health in Mother's Own Milk Feeding Decisions for Preterm Infants: A State of the Science Review

In the United States, 10% of infants are born preterm (PT; <37 weeks gestational age) each year and are at higher risk of complications compared to full term infants. The burden of PT birth is borne disproportionately by Black versus non-Black families, with Black mothers significantly more likely to give birth to a PT infant. One proven strategy to improve short- and long-term health outcomes in PT infants is to feed mother's own milk (MOM; breast milk from the mother). However, mothers must make decisions about work and MOM provision following PT birth, and more time spent in paid work may reduce time spent in unpaid activities, including MOM provision. Non-Black PT infants are substantially more likely than Black PT infants to receive MOM during the birth hospitalization, and this disparity is likely to be influenced by the complex decisions mothers of PT infants make about allocating their time between paid and unpaid work. Work is a social determinant of health that provides a source of income and health insurance coverage, and at the same time, has been shown to create disparities through poorer job quality, lower earnings, and more precarious employment in racial and ethnic minority populations. However, little is known about the relationship between work and disparities in MOM provision by mothers of PT infants. This State of the Science review synthesizes the literature on paid and unpaid work and MOM provision, including: (1) the complex decisions that mothers of PT infants make about returning to work, (2) racial and ethnic disparities in paid and unpaid workloads of mothers, and (3) the relationship between components of job quality and duration of MOM provision. Important gaps in the literature and opportunities for future research are summarized, including the generalizability of findings to other countries.

Policy measures to expand home visiting programs in the postpartum period

The postpartum period is characterized by a myriad of changes-emotional, physical, and spiritual; whilst the psychosocial health of new parents is also at risk. More alarmingly, the majority of pregnancy-related deaths in the U.S. occur during this critical period. The higher maternal mortality rate is further stratified by dramatic racial and ethnic variations: Black, brown, and American Indian/Alaska Native indigenous people have 3-4x higher rates of pregnancy-related deaths and severe morbidity than their White, non-Hispanic, and Asian/Pacific Islander counterparts. This policy brief explores how expanding evidence based home visiting programs (HVPs) and strengthening reimbursement policies that invest in such programs can be pivoted to optimize the scope of care in the postpartum period.

The Case for Offering Paid Leave: Benefits to the Employer, Employee, and Society

The COVID-19 pandemic has highlighted numerous problems in the labor market in the U.S., including high and low unemployment rates, burnout of employees in many industries, and inadequate time off for caregiving and medical issues. In this manuscript, we propose that employer-sponsored paid leave is increasingly important given that the U.S. lags behind most other nations in its leave policies, and many employees, particularly those in lower-wage, part-time, or front-line occupations do not have paid leave from their employers. We first discuss the common types of paid leave. Then, we make the case that paid leave is advantageous for both employees and employers, as well as society. We conclude with specific recommendations on how to implement paid leave in organizations.

The Use of Patient Engagement to Gather Perceptions on the Cost of Infant Feeding

Purpose

Patient-oriented research (POR) and patient engagement (PE) has highlighted the value of incorporating patients' ideas and priorities in health research. Using the guiding principles of POR and PE, the current study conducted PE sessions to gain insight on the perceptions of mothers regarding the costs of infant feeding.

Methods

Four patient engagement sessions were held with mothers residing in Newfoundland and Labrador between November 2019 and January 2020. Mothers were targeted through the Brighter Futures Coalition of St. John's, a not-for-profit community organization. PE sessions were designed in a two-hour format, allowing the research team to engage mothers and identify costs of infant feeding from a mothers' perspective.

Results

Through the guiding principles of patient-oriented research and patient engagement, our research team successful engaged with mothers in discussions surrounding the costs of infant feeding. The sessions allowed for an in-depth discussion surrounding monetary costs (eg, incidentals of breast or formula feeding), the associated costs of infant feeding and the workplace (eg, perceived productivity) and environment impacts (eg, single use plastics). During each session, evaluations were provided to solicit feedback on whether the goals and expectations of mothers had been met, and whether they felt their opinions were heard and understood.

Conclusion

By conducting patient engagement sessions, informed by patient-oriented research guiding principles, we were able to successfully recruit and engage mothers in discussions that led to a better understanding of their perspectives on the costs of infant feeding.

New York State Paid Family Leave Law Associated with Increased Breastfeeding Among Black Women

Background: While breastfeeding has increased during the past 50 years, disparities continue, with Black women having the lowest rates. Use of paid leave has been associated with longer breastfeeding duration. Objective: Evaluate the impact of New York (NY)'s Paid Family Leave (PFL) law on breastfeeding, after it became effective on January 1, 2018. Materials and Methods: Women in NY (excluding NY City), who gave birth in 2016-2019 and completed the Pregnancy Risk Assessment and Monitoring System (PRAMS) survey, were included. Data from PRAMS and the NY State Expanded Birth Certificate were combined. Changes in breastfeeding initiation and duration and use of paid leave were compared, before and after NY's PFL law became effective, with separate analysis by sociodemographic factors. Results: Before NYPFL, Black women were least likely to initiate breastfeeding and breastfed for the shortest duration. After NYPFL went into effect, breastfeeding initiation and duration to 8 weeks increased for Black women, but not for other racial/ethnic groups; these findings persisted after adjustment for sociodemographic factors. Use of paid leave after childbirth increased 15% overall, with greater increases among Black women and Hispanic women. Conclusions: Implementation of the NYPFL law was associated with increased breastfeeding among Black women and increased use of paid leave by all. Greater increases in breastfeeding among Black women significantly reduced breastfeeding disparities by race/ethnicity. More widespread implementation of PFL programs in the United States would promote equity in the use of paid leave, which could reduce disparities in breastfeeding initiation and duration and possibly improve infant and maternal health outcomes.

Paid maternal leave is associated with infant brain function at 3 months of age

The first months of life are critical for establishing neural connections relevant for social and cognitive development. Yet, the United States lacks a national policy of paid family leave during this important period of brain development. This study examined associations between paid leave and infant electroencephalography (EEG) at 3 months in a sociodemographically diverse sample of families from New York City (N = 80; 53 males; 48% Latine; data collection occurred 05/2018-12/2019). Variable-centered regression results indicate that paid leave status was related to differences in EEG power (ps < .02, R² s > .12). Convergent results from person-centered latent profile analyses demonstrate that mothers with paid leave were 7.39 times as likely to have infants with EEG profiles characterized by increased higher-Hz power (95% CI, 1.9-36.9), potentially reflecting more mature patterns of brain activity.

Normative range parenting and the developing brain: A scoping review and recommendations for future research

Studies of early adversity such as trauma, abuse, and neglect highlight the critical importance of quality caregiving in brain development and mental health. However, the impact of normative range variability in caregiving on such biobehavioral processes remains poorly understood. Thus, we lack an essential foundation for understanding broader, population-representative developmental mechanisms of risk and resilience. Here, we conduct a scoping review of the extant literature centered on the question, "Is variability in normative range parenting associated with variability in brain structure and function?" After removing duplicates and screening by title, abstract, and full-text, 23 records were included in a qualitative review. The most striking outcome of this review was not only how few studies have explored associations between brain development and normative range parenting, but also how little methodological consistency exists across published studies. In light of these limitations, we propose recommendations for future research on normative range parenting and brain development. In doing so, we hope to facilitate evidence-based research that will help inform policies and practices that yield optimal developmental trajectories and mental health as well as extend the literature on the neurodevelopmental impact of early life stress.

Serious mental illness in women

PURPOSE OF REVIEW

Psychiatric illnesses are very prevalent in the United States and impact women and men differently. In this review, we will explore some gender differences in the expression of psychopathology, discuss the most common serious mental illnesses (SMI) affecting women, and review treatment options according to specific life stages. We hope to raise awareness of these issues and consequently improve outcomes for women with serious mental illness.

RECENT FINDINGS

SMI have different rates and are manifested differently in women and men because of biological, psychological, social, and cultural factors. Some SMI are more prevalent in women whereas others uniquely affect them during particular life stages. Even in disorders that have a similar prevalence in men and women or are more prevalent in men, the presentation, course, management, and repercussions can vary significantly between the two genders. Medical and psychiatric comorbidities, which directly influence treatment, prognosis, and disability, are more common in women.

SUMMARY

Several differences in the gender expression of SMI have not yet been fully described. It is important to become familiar with important characteristics of SMI in women, including biological determinants, treatment differences, and psychosocial aspects. Recognizing gender biases, cultural considerations, and adaptive responses can help identify women at risk, promote early recognition of symptoms, and prompt interventions that may lead to improved outcomes.

Awareness, Perceptions, Gaps, and Uptake of Maternity Protection among Formally Employed Women in Vietnam

Maternity protection is a normative fundamental human right that enables women to combine their productive and reproductive roles, including breastfeeding. The aim of this study is to examine the uptake of Vietnam's maternity protection policy in terms of entitlements and awareness, perceptions, and gaps in implementation through the lens of formally employed women. In this mixed methods study, we interviewed 494 formally employed female workers, among whom 107 were pregnant and 387 were mothers of infants and conducted in-depth interviews with a subset of these women (n = 39). Of the 494 women interviewed, 268 (54.3%) were working in blue-collar jobs and more than 90% were contributing to the public social insurance fund. Among the 387 mothers on paid maternity leave, 51 (13.2%) did not receive cash entitlements during their leave. Among the 182 mothers with infants aged 6-11 months, 30 (16.5%) returned to work before accruing 180 days of maternity leave. Of 121 women who had returned to work, 26 (21.5%) did not receive a one-hour paid break every day to express breastmilk, relax, or breastfeed, and 46 (38.0%) worked the same or more hours per day than before maternity leave. Although most women perceived maternity leave as beneficial for the child's health (92.5%), mother's health (91.5%), family (86.2%), and society (90.7%), fewer women perceived it as beneficial for their income (59.5%), career (46.4%), and employers (30.4%). Not all formally employed women were aware of their maternity protection rights: women were more likely to mention the six-month paid maternity leave (78.7%) and one-hour nursing break (62.3%) than the other nine entitlements (2.0-35.0%). In-depth interviews with pregnant women and mothers of infants supported findings from the quantitative survey. In conclusion, although Vietnam's maternity protection policy helps protect the rights of women and children, our study identified implementation gaps that limit its effectiveness. To ensure that all women and their families can fully benefit from maternity protection, there is a need to increase awareness of the full set of maternity entitlements, strengthen enforcement of existing policies, and expand entitlements to the informal sector.

Development and Impact of a Progressive Parental Leave Policy in a Neurology Residency

Appropriate parental leave policies remain an unmet need in graduate medical education. Although legal and institutional guidelines allow for policies that support parental leave, there are many challenges and perceived barriers to consider in developing and implementing a successful policy. In 2018, we revised the parental leave policy for our neurology residency. Here we describe the development of our policy, measure its effects, and offer guidelines for other programs to develop a similar approach. We propose solutions to commonly encountered problems, focusing on training and education, staffing of clinical services, evolving legal requirements, resident well-being and equity, and financial support.

From Requisite to Right: Assessing and Addressing Paid Maternity Leave in US Psychiatry Residency Programs

OBJECTIVE

Data on the physical and mental health benefits of paid maternity leave for mothers and infants is abundant. Data on the make-up of current maternity leave policies in US psychiatry residency programs is not. This survey of program directors was undertaken to assess the components of their program's policies and the perceived impact of maternity leave on the training of childbearing residents, co-residents, and programs.

METHODS

An anonymous 19-question survey was emailed to US psychiatric residency program directors. Questions assessed demographics for respondents and their programs, composition of maternity leave including paid and unpaid components, and the perception of effects of maternity leave on childbearing residents, co-residents, and programs (with optional free-text elaboration).

RESULTS

The response rate was 19.5% (49 out of 262 program directors). Many programs require the use of FMLA (81%), vacation days (75%), sick days (75%), and short-term disability (30%) for maternity leave. Around a third (34%) offer separate paid time off varying from 2 to 12 weeks at 80-100% of pay. Most respondents relate a neutral to strongly positive impact of leave on the psychiatric training of childbearing residents (98%) and co-residents (84%), citing benefits like improved empathy, compassion, and patience.

CONCLUSIONS

Maternity leave is seen to have minimal negative impact on training received within psychiatry residency programs. A minority of residents have access to paid maternity leave policies that would best support their health and career trajectories.

Are Psychiatry Programs Providing Adequate Parental Leave to Their Residents?

OBJECTIVE

During residency training, parental leave is frequently briefer than may be optimal for the well-being of the family. The Accreditation Council for Graduate Medical Education (ACGME) requires residency programs to have a parental leave policy without providing specific guidelines on its makeup, resulting in varying policies and confusion among residents planning parental leave. This study identifies differences in parental leave policies in psychiatry residencies and discusses if these policies are adequate.

METHODS

A 45-question, anonymous survey was emailed to general psychiatry and fellowship program directors in the USA.

RESULTS

Out of 520 program directors contacted, 186 completed the survey (35.7% response rate). Among the respondents, 94.1% had policies for maternity leave, 79.8% had policies for paternity leave, and 67.2% had policies for non-childbearing parental leave (e.g., adoption). Variations were reported in implementation, coverage, and accommodations. Most respondents (57.1%) believed that residents would benefit from more parental leave. Some (11.5%) believed that parenthood negatively affected residents' overall performance, especially regarding patient care and clinical skills; 36.5% endorsed that parenthood negatively affected overall residents' well-being; and 7.5% felt negatively when an applicant was pregnant or was planning to become pregnant during residency. Lastly, 32.9% were not confident regarding ACGME, American Board of Psychiatry and Neurology, federal, and hospital policies.

CONCLUSIONS

Parental leave policies are not universal in US psychiatry residency and fellowship programs. Some program directors feel that parenthood adversely affects residents' clinical performance as well as well-being. If true, reformation of parental leave policies may be a remedy.

Prenatal origins of suicide mortality: A prospective cohort study in the United States

Most suicide research focuses on acute precipitants and is conducted in high-risk populations. Yet, vulnerability to suicide is likely established years prior to its occurrence. In this study, we aimed to investigate the risk of suicide mortality conferred by prenatal sociodemographic and pregnancy-related factors. Offspring of participants (N = 49,853) of the Collaborative Perinatal Project, a U.S. population-based cohort of pregnancies enrolled between 1959 and 1966, were linked to the U.S. National Death Index to determine their vital status by the end 2016. We examined associations between sociodemographic factors during pregnancy, pregnancy complications, labor and delivery complications, and neonatal complications with suicide death coded according to ICD-9/10 criteria. By the end of 2016, 3,555 participants had died. Of these, 288 (214 males, 74 females) died by suicide (incidence rate = 15.6 per 100,000 person-years, 95% Confidence Interval [CI] = 13.9-17.5). In adjusted models, male sex (Hazard Ratio [HR] = 2.98, CI: 2.26-3.93), White race (HR = 2.14, CI = 1.63-2.83), low parental education (HR = 2.23, CI = 1.38-3.62), manual parental occupation (HR = 1.38, CI = 1.05-1.82), being a younger sibling (HR = 1.52, CI = 1.10-2.11), higher rates of pregnancy complications (HR = 2.36, CI = 1.08-5.16), and smoking during pregnancy (HR = 1,28, CI = 0.99-1.66) were independently associated with suicide risk, whereas birth and neonatal complications were not. Consistent with the developmental origins of psychiatric disorders, vulnerability to suicide mortality is established early in development. Both sociodemographic and pregnancy factors play a role in this risk, which underscores the importance of considering life course approaches to suicide prevention, possibly including provision of high-quality prenatal care, and alleviating the socioeconomic burdens of mothers and families.

Progress in National Policies Supporting the Sustainable Development Goals: Policies that Matter to Income and Its Impact on Health

From education to working conditions, from income to discrimination, social determinants of health (SDH) shape the majority of health outcomes. Governments are often best positioned to address the major SDH on a population-wide basis. In 2015, governments around the world committed to improving all core SDH when all countries agreed to a set of goals that would improve education, work, income, and equal opportunity, among other areas, in the Sustainable Development Goals (SDGs). Using data from the WORLD Policy Analysis Center, this article highlights how quantitative policy measures can be used to hold governments accountable for their commitments to the SDGs and thus to improve the SDH. Three areas are examined in detail to illustrate this approach to monitoring policy change: ensuring an adequate income, enhancing equal opportunities at work by prohibiting discrimination and sexual harassment, and enabling children and youth to complete their education.

Supporting Breastfeeding in 2021 and Beyond-Lessons from the Pandemic

The COVID-19 pandemic has affected maternal and infant health globally both directly from infection with the SARS-CoV-2 virus and indirectly from changes in health care resulting from social, economic, and health care policies unique to each country. The developing countries have to share the disproportionate burden on maternal and infant health. In this review, we discuss the uncertainties resulting from SARS-CoV-2 infection in pregnancy, vertical transmission of the virus, and its effects on breastfeeding of the newborn. The problems of families and communities caring for mothers with COVID-19 and its impact on breastfeeding in newborns are discussed. The challenges posed by the pandemic have forced us to think and devise innovative solutions, including telemedicine help for antenatal counseling, breastfeeding education, and lactation support. Optimal utilization of resources and technology to find creative solutions at the individual and the community level will help in facilitating maternal-infant bonding soon after birth. Appropriate health care policies to support pregnant and lactating mothers will go a long way in meeting healthy child development goals.

The impact of paid family leave in the United States on birth outcomes and mortality in the first year of life

OBJECTIVE

To evaluate the effect of paid family leave in California on statewide rates of preterm birth, low birthweight, postneonatal mortality, and overall infant mortality.

DATA SOURCES

Live birth and death certificates from all in-hospital deliveries occurring in California (state exposed to the family leave policy) and two unexposed states (Missouri and Pennsylvania) from 1999 to 2008 (n = 6 164 203).

STUDY DESIGN

We used a difference-in-differences approach to compare rates of infant health outcomes before and after implementation of the 2004 policy in California with rates in two states without paid family leave policies. Prespecified stratified analyses examined whether policy response differed by maternal characteristics. Conditional regression models using comparisons matched on a mother's likelihood of living in California in the pre-family leave period were then employed as sensitivity analyses to confirm our findings.

DATA COLLECTION/EXTRACTION METHODS

Probabilistic methods were used to match live birth records to maternal and newborn hospital records. Only singleton births were included. Dyads were excluded if the infant gestational age was <23 weeks or greater than 44 weeks or if the birthweight was an outlier.

PRINCIPAL FINDINGS

Compared to the unexposed states, adjusted postneonatal mortality rates decreased by 12 percent in California after 2004 (aOR 0.88, 95% CI 0.80-0.97). There were no significant effects on the other outcomes. There were no differences in the effect by race/ethnicity or insurance status except for increased odds of low birthweight among privately insured women in California after 2004. Point estimates in the propensity score-matched sensitivity models were similar to the results of the fully adjusted models for all four outcomes, but confidence intervals crossed one.

CONCLUSIONS

Implementation of paid family leave policies in California was associated with a 12 percent reduction in postneonatal mortality after adjusting for maternal and neonatal factors.

Turning Chutes into Ladders for Women Faculty: A Review and Roadmap for Equity in Academia

Despite significant progress in recent decades, the recruitment, advancement, and promotion of women in academia remain low. Women represent a large portion of the talent pool in academia, and receive >50% of all PhDs, but this has not yet translated into sustained representation in faculty and leadership positions. Research indicates that women encounter numerous "chutes" that remove them from academia or provide setbacks to promotion at all stages of their careers. These include the perception that women are less competent and their outputs of lesser quality, implicit bias in teaching evaluations and grant funding decisions, and lower citation rates. This review aims to (1) synthesize the "chutes" that impede the careers of women faculty, and (2) provide feasible recommendations, or "ladders" for addressing these issues at all career levels. Enacting policies that function as "ladders" rather than "chutes" for academic women is essential to even the playing field, achieve gender equity, and foster economic, societal, and cultural benefits of academia.

Integrative Review of Breastfeeding Support and Related Practices in Child Care Centers

OBJECTIVE

To synthesize the extant research on the support of breastfeeding and breast milk feeding and related practices in child care centers (i.e., daycare centers) in the United States and globally.

DATA SOURCES

We used key terms to search Ovid, CINAHL, and PubMed for articles that met eligibility criteria. When potentially relevant articles were identified in PubMed, we used the cited by and similar articles features to identify additional articles. We also examined the reference lists of reviewed studies.

STUDY SELECTION

We included original research articles on breastfeeding or breast milk feeding in child care centers published in 2000 or after and available in English. We reviewed titles and/or abstracts of 1,984 articles and abstracted 37 for full-text review. Of these, 16 studies met eligibility criteria and were included in the review.

DATA EXTRACTION

We abstracted data from the 16 articles to facilitate comparison and identification of patterns related to support of breastfeeding/breast milk feeding and related practices in child care centers. These data included year of publication, setting, design/methodology (and methodologic limitations), type of respondent/sampling unit (e.g., directors and staff members of child care centers, mothers), sample size, outcome measures, and pertinent study findings.

DATA SYNTHESIS

We categorized study findings into three themes: Knowledge, Attitudes, and Experiences of Staff Members in Child Care Centers; Implementation and Adherence to Policies, Practices, and Regulations in Child Care Centers; and Prevalence of Breastfeeding in Child Care Centers. Findings indicated staff members generally had positive attitudes toward breastfeeding but tended to remain neutral regarding encouragement and support of breastfeeding. Training and knowledge about breastfeeding among staff members in child care centers appears limited and focused mainly on the storage and preparation of breast milk; however, staff members indicated the desire to obtain additional education about breastfeeding. Few U.S. child care centers or states have comprehensive, evidence-based policies and regulations to address support for breast milk feeding and breastfeeding. The prevalence of breastfeeding in U.S. child care centers is less than that in other child care settings (home-based child care, etc.), child care centers in other developed countries, and national breastfeeding averages.

CONCLUSION

We found a general lack of policies and practices to support breastfeeding in child care centers, particularly in the United States. The degree to which this policy/practice deficit contributes to suboptimal breastfeeding rates among women who use child care centers requires further study.

Maternal distress across the postnatal period is associated with infant secretory immunoglobulin A

Employing a longitudinal design, relationships between maternal distress (i.e., perceived stress, negative affect, depressive symptomology), and infant secretory immunoglobulin A (sIgA) across the peripartum period were examined in 51 mother-infant dyads. Indices of maternal distress were assessed at four time periods: third trimester of pregnancy and 1, 3, and 6 months postpartum. Infant saliva samples were collected at each of the three time points in the postpartum period to assess sIgA levels. No relationships were found between prenatal maternal distress and infant sIgA. Results indicated that during the postnatal period, higher concurrent maternal distress was associated with reduced infant sIgA. Maternal distress did not prospectively predict infant sIgA. These findings advance our understanding of the social-context of infant development, highlighting the significance of maternal regulation of infant immunity.

ACOG Committee Opinion No. 733: Employment Considerations During Pregnancy and the Postpartum Period

In the United States, it is common for women, including mothers and pregnant women, to work outside the home. Working during pregnancy is generally safe. For those in high-risk occupations or with medically complicated pregnancies, work accommodations often can allow for continued safe employment. The major employment issues concerning pregnant women include pregnancy-related discrimination, work accommodations that allow continued employment, job-protected leave, and wage replacement while on leave. Workplace discrimination related to being pregnant and pregnancy-related harassment, including discrimination in the hiring process, is prohibited by federal and state law. There is no federal law guaranteeing comprehensive accommodations for pregnant and postpartum workers. Current federal and state laws provide protection for some pregnant women, but not others, because of eligibility requirements and state-by-state differences. By writing appropriate notes to employers, obstetrician-gynecologists and other obstetric care providers can be instrumental in obtaining accommodations for their patients who are able to continue working. Accommodations that allow a woman to keep working are the most reliable way to guarantee pay, benefits, and job protection. Obstetrician-gynecologists and other obstetric care providers also can assist pregnant women and their partners by providing them with information and resources that might help them better understand their employment rights. However, in cases for which potential job discrimination has occurred, accommodations are denied, extended medical leave is necessary, or when other complex employment questions arise, legal assistance should be obtained.

Parental Leave, Lactation, and Childcare Policies at Top US Schools of Public Health

OBJECTIVES

To describe policies related to parental leave, breastfeeding, and childcare for faculty and staff at top schools of public health in the United States.

METHODS

We identified the top 25 schools of public health from the US News and World Report rankings. We reviewed each institutional Web site to identify publicly available policies as of July 2018.

RESULTS

For birth mothers, 80% (20/25) of the schools provided paid childbearing leave to faculty (mean = 8.2 weeks), and 48% (12/25) provided paid childbearing leave for staff (mean = 5.0 weeks). For nonbirth parents, 68% (17/25) provided paid parental leave for faculty and 52% (13/25) for staff (range = 1-15 weeks). We found that 64% (16/25) of the schools had publicly available lactation policies, and 72% (18/25) of the schools had at least 1 university-run on-campus childcare center.

CONCLUSIONS

The majority of top US schools of public health provide paid leave to faculty birth mothers. However, most schools fall short of the 14 weeks recommended by the American Public Health Association.

Relationship between paid leave, financial burden, and patient-reported outcomes among employed patients who have undergone bone marrow transplantation

PURPOSE

The US does not have universal paid family and medical leave. We examine the direct effects of access to paid leave on patient-reported health, quality of life (QOL), and perceived stress of employed patients who underwent bone marrow transplantation (BMT) to treat advanced blood cancer as well as the indirect effects through reductions in the financial burden (FB) that patients face.

METHODS

Our cross-sectional observational study took place at three US transplantation centers in 2014 and 2015. All English-speaking cancer patients 6-month post-BMT were mailed a 43-item survey assessing financial situation, employer benefits, and patient-reported health outcomes. The sample includes the 171 respondents who were employed at the time of BMT.

RESULTS

Seemingly unrelated regression analysis confirms that patient access to paid leave was associated with reductions in all three measures of FB, and lower levels of financial hardship were related with improved health, QOL, and perceived stress outcomes. For self-reported health and perceived stress outcomes, all of the effects of patient paid leave operate indirectly through reductions in FB. For QOL outcomes, there is both a direct effect (over 80%) of paid leave and an indirect effect through reduction of FB.

CONCLUSION

We found that paid leave affected health outcomes for BMT patients mostly through alleviating FB. These findings suggest universal paid leave policies in the US might alleviate financial hardship and have positive effects on the self-reported QOL of employed patients facing intensive medical treatments.

Employee Experiences with a Newly Adopted Paid Parental Leave Policy: Equity Considerations for Policy Implementation

Purpose: Paid parental leave (PPL) policies offer immense opportunity to enhance health equity by providing financial stability to workers and promoting the health of families in the United States. Working in partnership with a local county government, which recently adopted a paid leave policy, we engaged in a qualitative substudy to enhance our understanding of how workers perceived and experienced the policy across levels of the socioecological framework. Methods: Working in partnership with Multnomah County, a large public-sector employer in Portland, OR that recently adopted a PPL policy, we collected qualitative data through focus groups with employees. Data were transcribed, coded, and analyzed thematically. Results: We conducted seven focus groups with county employees (N=35) in the fall of 2017. Three major themes emerged from the focus group data: intersectional inequities, disparities by department, and uneven benefits. Conclusions: Our findings highlight the inequities of experience with the PPL policy across employees at individual, organization, and environmental levels. These findings offer insight and guidance for entities considering the adoption and implementation of such policies to consider concrete steps to enhance equity of access and experience.

Reducing toxic stress in the neonatal intensive care unit to improve infant outcomes

In 2011, the American Academy of Pediatrics (AAP) published a technical report on the lifelong effects of early toxic stress on human development, and included a new framework for promoting pediatric health: the Ecobiodevelopmental Framework for Early Childhood Policies and Programs. We believe that hospitalization is a specific form of toxic stress for the neonatal patient, and that toxic stress must be addressed by the nursing profession in order to substantially improve outcomes for the critically ill neonate. Approximately 4% of normal birthweight newborns and 85% of low birthweight newborns are hospitalized each year in the highly technological neonatal intensive care unit (NICU). Neonates are exposed to roughly 70 stressful procedures a day during hospitalization, which can permanently and negatively alter the infant's developing brain. Neurologic deficits can be partly attributed to the frequent, toxic, and cumulative exposure to stressors during NICU hospitalization. However, the AAP report does not provide specific action steps necessary to address toxic stress in the NICU and realize the new vision for pediatric health care outlined therein. Therefore, this paper applies the concepts and vision laid out in the AAP report to the care of the hospitalized neonate and provides action steps for true transformative change in neonatal intensive care. We review how the environment of the NICU is a significant source of toxic stress for hospitalized infants. We provide recommendations for caregiving practices that could significantly buffer the toxic stress experienced by hospitalized infants. We also identify areas of research inquiry that are needed to address gaps in nursing knowledge and to propel nursing science forward. Finally, we advocate for several public policies that are not fully addressed in the AAP technical report, but are vital to the health and development of all newborns.

Does paid vacation leave protect against depression among working Americans? A national longitudinal fixed effects analysis

Objectives The United States is the only advanced economy globally that does not guarantee its workers paid vacation leave. Although empirical studies have linked paid vacation leave to happiness and stress, no study has investigated the association between paid vacation leave and depression. Using a nationally-representative longitudinal sample of 3380 working men and women aged 45-52 years from the National Longitudinal Survey of Youth 1979, this study explored whether paid vacation leave may protect against depression. Methods Multivariate linear and logistic regression models were employed to estimate the impacts of the number of annual paid vacation days of leave measured at age 40 on depression measured using the 7-item Center for Epidemiologic Studies Depression Scale short form (CES-D-SF) scale at age 50. Models were adjusted for demographic and socioeconomic factors, physical health, weekly hours, and individual fixed effects. Results For every ten additional days of paid vacation leave, the odds of depression in women was 29% lower [odds ratio (OR) 0.71, 95% confidence interval (CI) 0.55-0.92, P=0.01); there was no association in men. Linear regression models showed no association in either men or women. For every 10 days of paid leave, the odds of depression were 36% lower in White women and 38% lower in women with ≥2 children. Conclusions This study provides the first evidence on the linkage between paid vacation leave and depression, and supports a protective effect in White women with ≥2 children. Should this association be truly causal, and assuming a uniform effect across all ages in working adult women, the results from this study would suggest that a hypothetical increase in the average number of days of paid vacation leave of 10 days could avoid an estimated 568 442 cases of depression in women each year and lead to a cost savings of US$2.94 billion annually. Policies that mandate paid vacation leave may have marked positive impacts on the population health and economic burden of depression among working women in the USA.