Effects of US state paid family leave policies on perinatal and postpartum health: a quasi-experimental analysis

Abstract

The United States is the only high-income country without a national paid family leave (PFL) policy, although several states have implemented policies recently. This study evaluated whether PFL policies in 6 states improved maternal and infant health. We used difference-in-differences, a quasi-experimental approach, to estimate the impact of state-level policy implementation. We leveraged recently developed methods designed to account for staggered policy implementation and treatment effect heterogeneity. Data were drawn from the 2004-2021 waves of the Pregnancy Risk Assessment Monitoring System. Primary outcomes included breastfeeding, maternal postpartum depressive symptoms, and attendance at a postpartum checkup; secondary outcomes included birth outcomes. Multivariable regressions were adjusted for possible confounders. PFL policies led to increased breastfeeding duration (0.53 weeks; 95% CI, 0.06-0.99) and decreased depressive symptoms (-0.93 percentage points; 95% CI, -1.84 to -0.01). Policies were also associated with worsening of some birth outcomes, possibly reflecting selection in utero, data limitations, or true negative effects. Estimates were largely robust to alternative specifications, with subgroup differences by race/ethnicity and income. This study adds important evidence on the health effects of state-level PFL policies at a critical point when many states are considering or enacting policies and during ongoing conversations about national PFL policy implementation. This article is part of a Special Collection on Methods in Social Epidemiology.

Keywords: Pregnancy Risk Assessment Monitoring System; breastfeeding; difference-in-differences analysis; paid family leave; perinatal health; policy evaluation.