Public Policy and Maternal Decision-making: Evidence from the Affordable Care Act

Breastfeeding offers remarkable disease protection for both mothers and children, yet breastfeeding rates in the U.S. fall below clinical guidelines. There are also significant differences across socio-demographic groups. Lactation support services, including lactation consultants and breast pumps, can increase a woman’s commitment to and success with breastfeeding. The purpose of this study was to assess whether mandated coverage of lactation support services under the Affordable Care Act, which went into effect in August 2012, affected breastfeeding initiation. We examined the extent to which this policy change differentially affected vulnerable groups. We used birth certificate data from 2009 to 2014 from the National Vital Statistics System, which is the universe of hospital births in the U.S. We employed a regression-adjusted difference in differences (DD) design to compare breastfeeding initiation rates among births paid for by private health insurance relative to births paid for by Medicaid. Our results suggest that the ACA mandate increased the probability of breastfeeding initiation by 2.6 percentage points overall between 2009 and 2014, which translates to about 47,000 more infants in 2014 who were breastfed as a result of the mandate. We found breastfeeding rates increased about 1 percentage point more for black/African-American infants relative to white infants, 20 percentage points more for Hispanic infants relative to non-Hispanic infants and 2 percentage points more for infants born to mothers with only a high school education relative to infants born to college educated mothers. Our findings suggest policies that increase access to lactation support services can increase breastfeeding rates and help reduce the disparities in breastfeeding rates across socio-demographic groups.