Lactation Support Services and Breastfeeding Initiation

Evidence from the Affordable Care Act

Published in: Health Services Research [Epub November 2016]. doi:10.1111/1475-6773.12598

Posted on RAND.org on November 28, 2016

by Kandice A. Kapinos, Lindsey Bullinger, Tami Gurley-Calvez

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Research Question

  1. Did mandated coverage of lactation support services under the Affordable Care Act (ACA) change breastfeeding behavior?

OBJECTIVE: Despite substantial evidence of the benefits of breastfeeding for both mothers and children, rates of sustained breastfeeding in the United States are quite low. This study examined whether mandated coverage of lactation support services under the Affordable Care Act (ACA) affects breastfeeding behavior.  DATA SOURCE: We studied the census of U.S. births included in the National Vital Statistics System from 2009 to 2014.  STUDY DESIGN: We used regression-adjusted difference-in-differences (DD) to examine changes in breastfeeding rates for privately insured mothers relative to those covered by Medicaid. We adjusted for several health and sociodemographic measures. We also examined the extent to which the effect varied across vulnerable populations—by race/ethnicity, maternal education, WIC status, and mode of delivery.  PRINCIPAL FINDINGS: Results suggest that the ACA mandate increased the probability of breastfeeding initiation by 2.5 percentage points, which translates into about 47,000 more infants for whom breastfeeding was initiated in 2014. We find larger effects for black, less educated, and unmarried mothers.  CONCLUSIONS: The Affordable Care Actmandated coverage of lactation services increased breastfeeding initiation among privately insured mothers relative to mothers covered by Medicaid. The magnitude of the effect size varied with some evidence of certain groups being more likely to increase breastfeeding rates.

Key Findings

  • Coverage of lactation support services boosted the rate of moms starting breastfeeding by as much as 2.5 percentage points, which translates to as many as 47,000 more infants being breastfed than before the ACA mandate.
  • The estimate of increased breastfeeding initiation may be lower than the true effect; if about one-quarter of those insured are in grandfathered plans (for which the mandate would not apply) the rate increase may be closer to 3.4 percentage points.
  • Some groups historically less likely to breastfeed were more likely to respond to the "treatment" of the mandate: black/African American moms, mothers with a high school (as opposed to college) degree, and unmarried mothers.
  • Rates of breastfeeding increased more among mothers who are not participants of the WIC (Women, Infant, and Children) program, than among WIC participants, which was a surprising result.

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