Summary

Parental leave duration can significantly affect postpartum care attendance, with shorter leave periods leading to lower attendance rates and thus increasing the risk of negative health outcomes. Comprehensive research led by Community to Community Impact Engine (C2C) Seed Grant Recipient Brianna Keefe-Oates indicates that individuals with less than seven weeks of leave are less likely to attend postpartum care visits, which may negatively impact health.[1] Low-income families face the highest absolute risks, regardless of leave duration, indicating additional barriers to postpartum healthcare access.

This policy brief, based on research using data from the Center for Disease Control and Prevention, advocates for implementing comprehensive paid parental leave policies and providing additional support for low-income families to improve postpartum healthcare access. These support services are essential to improving postpartum care attendance and health outcomes, reducing racial and economic disparities, and promoting overall health equity in the postpartum period.

Background

The postpartum period is a critical time for parents and infants, yet some new parents do not receive adequate postpartum care. Traditional parental leave policies in the U.S. are often insufficient, with only some employers offering paid leave, and only a small (but growing) number of states ensuring paid parental leave, while the federal government only guarantees unpaid parental leave. Historical and current social practices rooted in structural racism can restrict access to stable employment and jobs with generous benefits, including adequate parental leave; combined with a lack of national policies, the outcome is that those receiving paid leave are more likely to be white and earn a higher income.[2] This leads to disparities in leave access and duration, especially among low-income and racially minoritized groups.

Postpartum care is essential for addressing maternal health issues such as physical recovery, mental health support, and long-term healthcare continuity. Research suggests that increased parental leave periods are associated with improved maternal and infant health.

Notably, significant gaps exist in postpartum care attendance, particularly among low-income and minoritized racial and ethnic groups. These groups can face significant barriers to accessing adequate postpartum care. Improving parental leave policies may support postpartum care access and mitigate negative health outcomes.

Methodology

This study utilized data from the CDC’s Pregnancy Risk Assessment Monitoring System (PRAMS) from 2016-2019, involving a sample of 12,442 individuals from six states without paid leave policies.

To detect patterns of postpartum care attendance among people working during their pregnancy, a comparison was drawn between those with less than seven weeks of parental leave and those with seven or more weeks. The researchers then tested for the association between leave length and postpartum care attendance after controlling for other influential factors. Results were stratified by income to understand any differences by group and identify policy interventions.

Key Findings

Like other studies, disparities in leave duration were observed; higher proportions of respondents who identified as Black, Hispanic, or had low incomes took less than 7 weeks of leave. When isolating the effect of leave duration on postpartum care:

• Individuals with shorter leave durations (less than seven weeks) were significantly less likely to attend postpartum care visits.
• Low-income individuals were significantly less likely to access postpartum care, regardless of leave duration.

Policy Implications & Recommendations

The findings of this study suggest that designing paid leave policies that facilitate leave-taking for lower-income individuals could help improve postpartum care uptake and duration and improve maternal and infant health outcomes. While previous research has found people who are postpartum often desire more than one postpartum care visit, disparities in care vary, with lower-income groups less likely to receive even a single visit.[3] More support, beyond longer leave durations, is needed to expand equitable access to postpartum care.

Comprehensive Paid Parental Leave
By implementing paid leave for all workers, we can increase the ability of new parents to access necessary postpartum care. While this study found that more than 7 weeks improved postpartum care access, other studies have found health benefits are strongest when leave is 12 or more weeks.[4] Paid leave policies that replace wages in full, relieving the financial burden of taking time off, could increase the amount of time all parents can take leave, decreasing disparities in leave access and improving postpartum care and health outcomes.
When new parents have more time to adjust to a newborn and aren’t forced to start worrying about getting back to work right away, they are more enabled to access the healthcare they need.
Ensuring that both parents are covered by parental leave can also help promote shared responsibility and ensure there is time for the birthing parent to attend healthcare visits, leading to better physical and mental health outcomes.

Support for Quality Postpartum Care Access for Low-Income Families
Adequate support for low-income families must involve financial and other types of support to remove barriers to healthcare access.
To address barriers that keep people from scheduling and attending their appointments, other supports for low-income families, such as transportation, childcare, expanded clinic hours, and telehealth are likely necessary.
Guaranteeing postpartum insurance coverage can also ensure access to postpartum care. Existing research suggests that expanding postpartum Medicaid coverage to 12 months increases the use of postpartum care and improves health outcomes.[5]

Additional Supporting Research

A study of related policies in Rhode Island found that the introduction of a paid parental leave policy was associated with increased postpartum care attendance.[6]

The potential health benefits of paid parental leave extend beyond increased care visits. Research suggests that more comprehensive family leave programs could increase rates of breastfeeding in the first nine months of infancy. In California, rates of breastfeeding increased up to 20 percentage points after a paid family leave program was implemented. Breastfeeding has proven to have many benefits for infants.[7]

These paid leave policies can have other benefits as well. One study of the effects of California’s PFL program estimated that the policy reduced psychological distress experienced by mothers postpartum.[8] Paid parental leave at the employer level has also been found to reduce the odds of maternal and infant re-hospitalizations and increase the odds of managing exercise and stress.[9]

However, even in places with more comprehensive parental leave policies, low awareness of parental leave laws can be an additional barrier to accessing benefits.[10] Policymakers should address this information gap in the crafting and implementation of paid parental leave policy.

Conclusion

Overall, the research shows that shorter parental leaves are associated with lower postpartum care attendance and that care attendance is lowest among people who are low-income. These issues can be addressed with comprehensive paid parental leave policies, which could not only improve access to care but also decrease disparities in leave access and improve health outcomes.

Policymakers concerned with maternal child health must support and implement comprehensive paid parental leave policies. Further policies to improve postpartum care could include expanding postpartum Medicaid coverage to 12 months and removing other barriers to care access through transportation, childcare, and creative care models.  A final priority must be the inclusive and culturally competent education of families on their rights when leave laws are enacted.

[1] Keefe-Oates, Brianna et al. Disparities in Postpartum Care Visits: The Dynamics of Parental Leave Duration and Postpartum Care Attendance. Maternal and Child Health Journal, 2024.

[2] Goodman, Julia M., Connor Williams, and William H. Dow. Racial/Ethnic Inequities in Paid Parental Leave Access. Health Equity, 2021.; Hawkins, Devan. Disparities in the usage of maternity leave according to occupation, race/ethnicity, and education. American Journal of Industrial Medicine, 2020. ; Horowitz, Juliana Menasce et al. An inside look at family and medical leave in America: The experiences of those who took leave and those who needed or wanted to but couldn’t. Pew Research Center, 2017.; Kaiser Family Foundation. 3: Employee Coverage, Eligibility, and Participation Employer Health Benefits Survey. 2021.

[3] Henderson, Vita et al. Understanding Factors Associated with Postpartum Visit Attendance and Contraception Choices: Listening to Low-Income Postpartum Women and Health Care Providers. Maternal and Child Health Journal, 2016.; Peahl, Alex Friedman et al. Patient Preferences for Prenatal and Postpartum Care Delivery: A Survey of Postpartum Women. Obstetrics & Gynecology, 2020.

[4] National Partnership for Women & Families, The Child Development Case for a National Paid Family and Medical Leave Insurance Program. 2023.

[5] Gordon, Sarah H et al. Effects Of Medicaid Expansion On Postpartum Coverage And Outpatient Utilization. Health Affairs, 2020.

[6] Streenland, Maria W., Susan E. Short, and Omar Galarraga. Association Between Rhode Island’s Paid Family Leave Policy and Postpartum Care Use. Obstetrics & Gynecology, 2021.

[7] Huang, Rui and Muzhe Yang. Paid maternity leave and breastfeeding practice before and after California’s implementation of the nation’s first paid family leave program. Economics and Human Biology, 2015.

[8] Lee, Bethany C et al. The effect of California’s paid family leave policy on parent health: A quasi-experimental study. Social Science & Medicine, 2020.

[9] Jou, Judy et al. Paid Maternity Leave in the United States: Associations with Maternal and Infant Health. Maternal and Child Health Journal, 2018.

[10] Goodman, Julia M., Holly Elser, and William H. Dow. Among Low-Income Women In San Francisco, Low Awareness of Paid Parental Leave Benefits Inhibits Take-Up. Health affairs (Project Hope), 2020.