Breast-feeding: Impact on Health, Employment and Society
CRS Report for Congress
Impact on Health,
Employment and Society
July 18, 2003
Donna V. Porter
Specialist in Life Sciences
Domestic Social Policy Division
Congressional Research Service ˜ The Library of Congress
Breast-feeding: Impact on Health,
Employment and Society
The rate of breast-feeding in the United States has risen and fallen over time as
a result of changing lifestyles and the availability of substitutes for human milk.
However, since the 1970s the rates of breast-feeding initiation and duration have
increased, in part due to the increasing medical evidence of the significant health
benefits both to mothers and children. The federal government’s Health Objectives
for 2010 are for 75% of mothers to initiate breast-feeding at the time of birth and for
50% to continue breast-feeding until their infants reach 6 months of age. Current
rates are about 69.5% at the time of hospital discharge and 32.5% at 6 months of age.
The health benefits to the infant include the high nutritional quality of human
milk, and a decrease in various infectious and other diseases of infancy that are
reduced by the anti-microbial, anti-inflammatory and immunological-stimulating
agents present. Mothers seem to benefit with a more rapid return to the pre-
pregnancy state of their bodies, improved glucose and lipid metabolism, delayed
ovulation, and the possible reduction of certain cancers.
Proponents of workplace lactation programs cite their benefits to employers as
reduced employee absenteeism, increased productivity, increased company loyalty
and morale, lower health care costs, and improved employee retention. The societal
benefits of increased breast-feeding may include significant savings in health care
costs, savings in the costs of infant formula, and the potential that intellectual
development of children is enhanced by breast-feeding in the first year of life.
Breast-feeding promotion is a policy promoted by the U.S. Government and
numerous non-governmental organizations. The infant formula industry also
publishes educational literature that promotes breast-feeding as the preferred method
of infant feeding in the first year of life.
Federal legislation has promoted various aspects of breast-feeding. The
Treasury and General Government Appropriations Acts of the last 4 years have
contained a provision that supports breast-feeding at government sites. In the 108th
Congress, the Pregnancy Discrimination Act Amendments of 2003 (S. 418) was
introduced to protect the rights of new mothers to breast-feed. Language in the Leave
No Child Behind Act of 2003 (H.R. 936 and S. 448) would require consideration of
government policies to provide lactation facilities, support and services in the federal
government; it was reintroduced from the 107th Congress. The Breastfeeding
Promotion Act (H.R. 285), introduced in the 107th Congress, would have provided
protection of breast-feeding by new mothers, required development of a performance
standard for breast pumps, and provided tax incentives to encourage employers to
provide lactation programs. As of November 2002, 32 States had enacted legislation
to protect mothers and promote breast-feeding.
This report will be updated to track legislative developments.
Trends in Breast-feeding and Lifestyle.............................1
Health Impacts for Mothers and Infants.............................2
Societal Impact of Breast-feeding Promotion........................4
Factors Affecting the Decision to Breast-feed........................5
Government Policies to Promote Breast-feeding......................7
Congressional Action on Breast-feeding Promotion...................7
State Breast-feeding Statutes.....................................8
Observations on the Promotion of Breast-feeding.....................9
Breast-feeding: Impact on Health,
Employment and Society
Women with infants and toddlers are a significant segment of the labor force
today. As a result, a variety of laws and policies have been modified to provide the
opportunity for these women to be successful both as parents and employees. This
report summarizes information on the impact of breast-feeding on the health of
mother and child, and on employers and employees where lactation support programs
or other workplace supports are provided. Also addressed are current administrative
and congressional efforts to promote breast-feeding.
Trends in Breast-feeding and Lifestyle
Until 1950, almost all U.S. babies were breast-fed, but in the last 50 years,1
infant feeding has changed dramatically. Following World War II, bottle feeding
became popular with the development and large-scale manufacture of infant formula
products. Between 1946 and 1956, breast-feeding fell by 50%, and by 1967, only
25% of American infants were being breast-fed at the time of hospital discharge. By
declined to around 46% in 1990, and then had another upswing, reaching 64% in2
1998. The pattern of breast-feeding for 6 month old infants parallels that for
newborns, although at a considerably lower rate. In 1998, about 29% of 6 month old
infants were being breast-fed. Current U.S. rates of breast-feeding are 69.5% for
mothers in-hospital and 32.5% at 6 months postpartum, despite recommendations
from government and health professional organizations to breast-feed until at least
are for 75% breast-feeding in-hospital and 50% breast-feeding at 6 months of age.
1 Jon Weimer, U.S. Dept. of Agriculture, Economic Research Service, The Economic
Benefits of Breast Feeding: A Review and Analysis. Food Assistance and Nutrition
Research report no. 13, Mar. 2001, 14 pp. (Hereafter cited as Weimer, The Economic
Benefits of Breast Feeding.)
2 A.S. Ryan, The Resurgence of Breastfeeding in the United States, Pediatrics, vol. 99, no.
3 U.S. Department of Health and Human Services, Office of the Assistant Secretary for
Health, Healthy People 2010, vol. I and II. (Washington, GPO), Jan. 2000.
While the overall rates of breast-feeding have increased in recent years, the rates
have remained uneven among various population groups.4 Breast-feeding rates have
generally been higher in western states, and among women who were older, college
educated and multiparous (given birth several times), those who had not enrolled in
the Special Supplemental Nutrition Program for Women, Infants and Children
(WIC), were not employed outside the home, had normal birth weight infants and had
higher disposable incomes. Recent increases have been greater among groups that
have historically been less likely to practice breast-feeding: women who were black,
younger than 25 years of age, in the lowest income group (less than $10,000
annually), have no more than a grade school education, primiparous (given birth
once), lived in the south Atlantic region, had low birth weight infants, were employed
full time outside the home, and participated in WIC. However, these groups still
remain the least likely to initiate breast-feeding.
Health Impacts for Mothers and Infants
The documented advantages of extended breast-feeding include nutritional,
immunological and psychological benefits to both the mother and child. Human milk
provides optimal nutrition to infants in both its composition and balance of nutrients.
The relatively low protein content is adequate nutritionally, while not putting an
unnecessary load of nitrogen on the immature kidney. Human milk protein is mainly
whey, which is easily digestible by the infant. Generous amounts of essential fatty
acids, saturated fatty acids, medium-chain triglycerides and cholesterol are also
present. Long-chain polyunsaturated fatty acids promote optimal development of the
central nervous system. Breast milk is relatively low in sodium content, allowing
fluid requirements to be met without overwhelming the renal load. The minerals in
human milk are protein-bound and balanced for bioavailability, and it provides iron,
zinc, and calcium to meet infant needs, while putting a minimal demand on the
maternal supply of these nutrients.
Recent recommendations from the American Academy of Pediatrics suggest that
exclusively breast-fed infants should receive vitamin D supplementation to prevent
rickets.5 The Academy recommends that vitamin supplements begin at 2 months of
age and continue until the infants are consuming at least 17 ounces daily of vitamin-
D fortified milk. The use of multivitamins containing 200 international units of
vitamin D is suggested, because supplements containing only vitamin D generally are
too concentrated to be safe for routine use. The recommendation also applied to
nonbreast-fed babies who are drinking less than17 ounces of fortified formula or milk
daily, as well as children and adolescents who do not drink that much fortified milk,
get regular sunlight exposure or take multiple vitamins with at least 200 international
units of vitamin D. Previously, physicians believed that babies got adequate amounts
of vitamin D, because sunlight stimulates the body to produce vitamin D. However,
recent recognition that sunlight exposure over time is a risk factor for skin cancer has
led to protecting children, and infants in particular, from direct sunlight, so they are
4 U. S. Department of Health and Human Services, Health People 2010, Washington, D.C.,
5 “Vitamins Urged for Breast-fed Babies.” Pediatricians recommend vitamin D to prevent
rickets. The Washington Post, Apr. 7, 2003, p. A5.
not making the vitamin D that this exposure once provided. In recent years, there
have been reports of dozens of cases of rickets nationwide, caused by a deficiency of
Human milk contains a variety of components that provide protection against
common infectious diseases by inhibiting the growth of microbial pathogens, and
enhance the nutritional status of infants under conditions in which poor sanitation
and low quality weaning foods are present.6 In addition, human milk contains an
array of antimicrobial agents, anti-inflammatory agents, and immunologic
stimulating agents, most of which are absent from or present in only small amounts
in infant formula, and which the infant produces only in limited amounts. Research
has demonstrated significant protection during breast-feeding against diarrhea,
respiratory infections, otitis media, bacteremia, bacterial meningitis, botulism,
urinary tract infections and necrotizing enterocolitis.7 The frequency of
gastrointestinal infections appears to be significantly lower in breast-fed infants
compared to formula-fed infants. For some infections, the duration is shorter and the
intensity is less in breast-fed infants than in formula-fed infants. In addition, breast
milk appears to be protective against food allergies.
While considerable attention has focused on the health benefits of breast-feeding
for the infant, which is the reason given by most women who choose to breast-feed,
considerably less attention has been given to the health effects of breast-feeding on
the mothers. A1991 National Academy of Sciences report concluded that there was
insufficient evidence at that time to reach any conclusions on the impact of breast-
feeding on maternal health, beyond the delay of return to regular ovulation.8 A more
recent review of the maternal health benefits examined the short- and long-term
advantages from the available literature, which continues to be limited.9 Breast-
feeding in the early postpartum period was shown to promote a more rapid return of
the uterus to its pre-pregnant state, and may also lead to a more rapid return to pre-
pregnant weight. Among studies on duration and intensity of lactation, the majority
showed a significant association between lactation and weight loss, although the
researchers reported that there is no evidence that lactation prevents obesity.
Lactation also seems to affect glucose and lipid metabolism, which may have
implications for preventing the subsequent development of diabetes and heart
disease. Lactation delays the return of ovulation and significantly reduces fertility
during the period of lactational amenorrhea. While the researchers reported that the
evidence from epidemiological studies is mixed, several large studies have shown
that extended lactation is associated with reduced risk of premenopausal breast,
6 National Academy of Sciences, Institute of Medicine, Food and Nutrition Board, Nutrition
During Lactation, Committee on Nutritional Status During Pregnancy and Lactation,
Subcommittee on Nutrition During Lactation, National Academy Press, 1991. (Hereafter
cited as National Academy of Sciences, Nutrition During Lactation).
7 L.A. Hanson, Human Milk and Host Defense. Immediate and Long-term Effects, Acta
Paediatric Supplement, vol. 88, no. 430, Aug. 1999, pp. 42-46.
8 National Academy of Sciences, Nutrition During Lactation.
9 J.M. Heinig and K.G. Dewey, “Health Effects of Breast Feeding for Mothers: A Critical
Review,” Nutrition Research Review, 1997, vol. 10, 1997, pp. 35-56.
ovarian and endometrial cancers. While bone mineralization declines during
lactation, repletion occurs after weaning, and does not seem to cause long-term bone
loss or increase the risk of osteoporosis.
A number of health and professional organizations have policies and positions
supporting breast-feeding promotion, including the American Academy of Family
Physicians, American Academy of Pediatrics, American Dietetic Association,
American College of Nurse-Midwives, American College of Obstetricians and
Gynecologists, Association of Women’s Health, Obstetric and Neonatal Nurses, and
National Association of Pediatric Nurse Practitioners. In addition, the infant formula
industry, which consists of four companies in the United States, provides literature
that supports the view that breast-feeding is the best choice in the first year of life.
An example is the recent publication of Abbott Laboratories.10
Societal Impact of Breast-feeding Promotion
The recognized societal benefits of an increase in the rate of breast-feeding until
infants are 6 months old include the savings that might be realized in health care
costs. An analysis of the economic benefits of breast-feeding, conducted by the
Economic Research Service of the U.S. Department of Agriculture and published in
2001, estimated that a minimum of $3.6 billion could be saved in the United States
if breast-feeding increased from current levels to the levels recommended in Healthy
People 2010.11 This analysis represents cost savings from treatment of three
childhood illnesses (otitis media, gastroenteritis, and necrotizing enterocolitis) and
probably underestimates total savings, according to the researchers.
The savings to families of reduced spending on infant formula are substantial
as well. Recent estimates are that out-of-pocket costs for families that use infant
formula amount to $855 for the first 6 months of life.12 While breast-feeding would
likely result in some increase in food costs, since lactating women have increased
nutrient needs, this cost would likely be less than the cost of infant formula for a year.
The cost of purchasing formula has been shown to be several hundred dollars more
than the cost of providing supplemental food for the breast-feeding mother.13
Finally, breast-feeding may enhance the intellectual development of children
due to the benefits of certain polyunsaturated fatty acids (DHA — docosahexaenoic
acid and AA — arachidonic acid) that have been demonstrated to promote visual and
neural development. The recent decision by infant formula manufacturers to add
these expensive fatty acids to their products in order to provide a product more
10 Abbott Laboratories, Ross Products Division, Ensuring Optimal Infant Nutrition: A
Shared Responsibility, Apr. 2003, 12 pp.
11 Jon Weimer, The Economic Benefits of Breast-feeding.
12 T.M. Ball and A. L. Wright, “Health Care Costs of Formula-feeding in the First Year of
Life,” Pediatrics, vol. 103, no. 4, Apr. 1999, pp. 870-876.
13 D. Montgomery and P. Splett, “Economic Benefit of Breast-Feeding Infants Enrolled in
WIC,” Journal of American Dietetic Association, vol. 97, no. 4, Apr. 1997, pp. 379-385.
comparable to human milk suggests recognition of the potential benefit of these
ingredients, especially to premature infants.
Factors Affecting the Decision to Breast-feed
Decisions to initiate or refrain from breast-feeding are made for various reasons,
but a number of barriers to breast-feeding have been identified. A significant factor
is that breast-feeding is not necessarily accepted as a cultural norm, particularly
within certain demographic groups. The decline in breast-feeding several decades
ago led to a loss of traditional knowledge and support from the older generation for
new mothers who wanted to breast-feed. In addition, health care professionals
frequently lack adequate training in lactation and managing breast-feeding problems
when they arise with new mothers. Societal changes in childbearing and child
rearing, such as the increased numbers of teenage and single mothers and more
reliance on child care outside the home, also create challenges to sustained breast-
feeding. In the workplace, the relatively short term of maternity leave and difficulty
of maintaining an adequate milk supply with prolonged separation from the infant
contribute to early termination of breast-feeding. The effect of the commercial sector
on breast-feeding has also had an impact through both marketing practices and the
availability of products that promote the use of human milk substitutes, especially
when these products are provided in hospital discharge packages.
While full-time work has been shown to have no effect on the initiation of
breast-feeding, it does seem to have a profound effect on breast-feeding duration.14
One survey found that while equal numbers of employed and unemployed mothers
initiated breast-feeding, by the time their infants were 6 months old, only 10% of
full-time employed working women reported that they were still breast-feeding,
compared to 24% of non-employed women.15 Women who are presumed to have the
most influence over their working conditions, i.e., professional women, are the most
likely to breast feed after returning to work and have the longest duration of breast-
feeding, regardless of the length of maternity leave. The duration of maternity leave
was shown to be highly significantly associated with the duration of breast-feeding.
However, this association does not necessarily mean that returning to work directly
causes weaning. Some women may wean in anticipation of returning to work, while
others may wean in the face of difficulties in managing both work and breast-
feedi n g. 16
Breast-feeding supporters advocate a variety of ways to promote the initiation
and duration of breast-feeding, including more part-time employment opportunities,
improved training for health care personnel, longer maternity leaves, greater access
14 C.M. Visness and K.I. Kennedy, “Maternal Employment and Breastfeeding: Findings
Form the 1988 National Maternal and Infant Health Survey,” American Journal of Public
Health, vol. 87, no. 6, June 1997, pp. 945-950.
15 B. Roe, et al., “Is There Competition Between Breast-feeding and Maternal
Employment?,” Demography, vol. 36, no. 2 May 1999, pp. 157-171.
16 S.B. Fein, and B. Roe, “The Effect of Work Status on Initiation and Duration of Breast-
feeding,” American Journal of Public Health, vol. 88, no. 7, July 1998, pp. 1042-1046.
to child care and lactation facilities in the workplace, and education campaigns to
promote public recognition that breast-feeding for at least 6 months is optimal, with
the use of human milk substitutes reserved only for a minority of infants with specific
indications. There are situations in which breast-feeding is not generally possible or
appropriate, such as in mothers who are HIV-positive, use illegal drugs, are receiving
chemotherapy, have physical or mental disabilities that prevent effective or adequate
milk production, or in cases of adoption or multiple births. Some women simply
choose not to breast-feed.
Given the number of women of childbearing age currently in the workforce, the
provision of lactation support for those mothers who wish to breast-feed after
returning to work has been advocated as an employment benefit that could serve as
an incentive to select or remain in a job. Providing easily accessible and comfortable
surroundings for women to use breast pumps to express milk and/or day care so that
babies can be fed on-site is seen as a way to support a woman’s desire to breast-feed.
In making a decision to provide lactation support facilities, factors considered by
employers include such issues as company size and the type of work a company or
agency performed that will be interrupted when breast-feeding occurs. Workplace
lactation programs have been suggested to provide a relatively inexpensive way to
reduce employee absenteeism, increase productivity, increase company loyalty and
morale, lower health care costs and improve employee retention.17 The provision of
lactation services at the work site and during maternity leave seem to both enhance
a woman’s ability to initiate and sustain breast-feeding her child as well as
commitment to the employer.
One review of the rise in breast-feeding in the United States suggested that
pressure to remove existing barriers to breast-feeding could eventually come from
health maintenance organizations and insurance companies, which are increasingly
likely to recognize the costs of not breast-feeding. The author identified such options
as flexible work hours and paid maternity leave, offered either by the government or
family-friendly workplaces, that could increase the ability of employed women to
optimally feed their infants.18 In countries where governments have passed laws
which guarantee all mothers paid leave from their work (with as much as 80% of
their salary) for 9 months after childbirth (and in some cases up to a year), there has
been a significant increase in the prevalence of breast-feeding between 6 and 9
months of age.19 The World Health Organization/UNICEF program to create “baby-
friendly” maternity hospitals, with the goal of enabling all women to practice
exclusive breast-feeding immediately after birth, is credited with further supporting
the increase in breast-feeding in countries where this program has been
17 K. Tyler, “Got Milk? Breastfeeding Programs,” Human Resources Management
Magazine, vol. 44. Mar. 1, 1999, p. 68.
18 A.L. Wright, “The Rise of Breastfeeding in the United States,” Pediatrics Clinical North
America., vol. 48, no. 1, Feb. 2001, pp. 1-12.
19 R. Zetterstrom,”Breastfeeding and Infant-mother Interaction,” Acta Paediatric
Supplement, v. 88, no. 430. Aug. 1999, pp. 1-6.
20 Armstrong, H. UNICEF: Lessons Learned from the Baby-Friendly Hospital Initiative,
Government Policies to Promote Breast-feeding
In 2000 the Department of Health and Human Services (HHS) under the
auspices of Surgeon General of the United States issued its HHS Blueprint for Action
on Breastfeeding.21 The document outlined the public health challenge of breast-
feeding, the benefits of and cautions about breast-feeding, facilitations and support
for breast-feeding, major HHS breast-feeding activities in the 1990s and the blueprint
for action on breast-feeding. The intent of this report was to provide a
comprehensive framework under which a variety of governmental programs and
policies would be pursued to increase breast-feeding and promote breast-feeding
In 1998, the U.S. Breastfeeding Committee was established to develop a
strategic plan to protect, promote and support breast-feeding in the United States.
The committee is supported by the HHS Health Resources and Services
Administration’s Maternal and Child Health Bureau. It is composed of
representatives from over three dozen health professional organizations and relevant
government departments and non-governmental organizations. The committee’s
strategic plan, published in 2001, has four goals, which have related objectives and
strategies to achieve them.
!assure access to comprehensive, current and culturally appropriate
lactation care and services for all women, children and families;
!ensure that breast-feeding is recognized as the normal and preferred
method of feeding infants and young children;
!ensure that all federal, state and local laws relating to child welfare
and family law recognize and support the importance and practice of
!increase protection, promotion and support for breast-feeding
mothers in the workforce.
Congressional Action on Breast-feeding Promotion
In the last two decades, numerous bills have been introduced in Congress that
addressed various aspects of breast-feeding promotion. Many bills addressed breast-
feeding in the context of the Special Supplemental Nutrition Program for Women,
Infants and Children (WIC), which will not be discussed in this report. (See CRS
Report RL31577, Child Nutrition and WIC Programs: Background and Funding.)
The Treasury and General Government Appropriations Acts of 2000, 2001,
2002, and 2003 (P.L. 106-58, P.L. 106-554, P.L. 107-67, and P.L. 108-7) were each
enacted with a provision that supports breast-feeding at government sites. The
identical language in these Acts states that “notwithstanding any other provision of
law, a woman may breast-feed her child at any location in a federal building or on
in Women Friendly Health Services — Experiences in Maternal Care: A Report of a
WHO/UNICEF/UNFPA Workshop, Mexico City, Jan. 28, 1999.
21 U.S. Department of Health and Human Services, Office of Women’s Health,
Breastfeeding: HHS Blueprint for Act on Breastfeeding, 2000, 32 pp.
federal property, if the woman and her child are otherwise authorized to be present
at the location.” This provision supports breast-feeding by both federal employees
The Pregnancy Discrimination Act Amendments of 2003, S. 418, has been
introduced by Senator Snowe in the 108th Congress. This bill would protect the
rights of new mothers to breast-feed their infants, by amending the Civil Rights Act
of 1964 to include lactation, including the expression of milk, within the definitions
of “because of sex” or “on the basis of sex” for purposes of the Act. It was referred
to the Committee on Health, Education, Labor and Pensions, but no further action has
been taken. The bill was also introduced in the 107th Congress.
Identical bills, introduced in the 108th Congress as the Leave No Child Behind
Act of 2003 (H.R. 936 and S. 448), by Representative G. Miller and Senator Dodd
respectively, contain a provision that provides for an interagency council to be
established by the administrator of the General Services Administration. This
council would address policy issues regarding child care, including the provision of
areas for nursing mothers and other lactation support facilities and services, in the
federal government. Similar legislation was introduced in the 107th Congress, but no
action was taken on H.R. 1990 and S. 940.
A bill, entitled the Breastfeeding Promotion Act, H.R. 285, was introduced in
the 107th Congress by Representative Maloney. Title I, to be known as the Pregnancy
Discrimination Act Amendments of 2001, would have amended the Civil Rights Act
of 1964 as described above in relation to S. 418. Title II would have provided a tax
credit for employer expenses providing an appropriate environment on the business’
premises for employed mothers to breast-feed or express milk for their children, by
amending the Internal Revenue Code to allow a limited credit to employers for
expenses incurred in enabling employed mothers to breast-feed. Title III, the Safe
and Effective Breast Pump Act, directed the Secretary of HHS to establish and
implement a performance standard for breast pumps, irrespective of the classification
of the breast pumps under the Federal Food, Drug and Cosmetic Act, and to issue
a compliance policy guide which would ensure that women who want to breast-feed
a child are given full and complete information regarding breast pumps. Title IV
would have expanded the Internal Revenue Code definition of medical care to
include qualified breast-feeding equipment and services. The bill was referred to the
Committees on Ways and Means, Education and the Workforce, and Energy and
Commerce. No further action was taken by any committee.
State Breast-feeding Statutes
As of November 2002, 32 states had enacted legislation related to breast-
feeding. Seventeen states permit mothers to breast-feed in any public or private
location where the mother is legally entitled to do so. Thirteen states have exempted
breast-feeding from public indecency statutes. Another five states exempt breast-
feeding mothers from jury duty. Three states have enacted provisions that either
implement or encourage the development of a breast-feeding awareness education
campaign. For more detailed information, see CRS RL31633, A Summary of State
Breast Feeding Laws.
Observations on the Promotion of Breast-feeding
There is substantial evidence that breast-feeding of infants for 6 months, and
perhaps as much as a year, has significant health benefits to the child. There also
seems to be evidence that mothers benefit as well. However, less clear is the impact
of programs to promote breast-feeding on the rates of breast-feeding initiation and
duration. While the rates of initiation are up compared to the rates in the 1970s,
these numbers are not maintained at 6 and 12 months of age, at the level current
health guidelines would suggest for attaining maximum benefit for the child.
In Healthy People 2010, the federal government has set a goal of increasing
rates of breast-feeding. Providing mothers and their children with the necessary
support for successful breast-feeding might contribute to the achievement of this
goal. Various options that have been suggested, include greater support in the
workplace, extended paid maternity leave, job-sharing or other part-time
employment, better training for health care professionals in working with pregnant
and lactating women, and providing better coordination among government policies
that promote women working and breast-feeding. However, given the difficulty
experienced by many women of simultaneously balancing the demands of
employment and breast-feeding, it is not possible to estimate the potential of these
options in increasing the rate of breast-feeding toward meeting the national goals.