By Rada Dagher, Ph.D., M.P.H.
Division of Scientific Programs
Clinical and Health Services Research
National Institute on Minority Health and Health Disparities
Maternal mortality rates in the United States have reached an all-time high. While these rates have dropped globally in the last few decades1, in the United States, they have more than doubled between 1987 and 20152. The picture is even grimmer for racial and ethnic minority communities, where African American and American Indian/Alaska Native women have the highest maternal mortality rates of all racial/ethnic groups2.
While most of the discussions about the maternal mortality crisis focus on the physical causes of death, the relationship between maternal mental health and mortality rates is largely ignored. For example, postpartum depression leads the list of mental health conditions affecting new mothers, and women experiencing this disorder may have suicidal thoughts and thoughts of harming the baby3. The novel coronavirus (SARS-CoV-2) pandemic that is causing COVID-19 disease outbreaks is another factor to consider. Due to social distancing, women have much lower access to the usual support systems (e.g. family, doulas) that promote their mental health during the vulnerable period of transitioning into motherhood. Recently published data from China on the impact of the COVID-19 pandemic suggests increased rates of postpartum depression4 among Chinese women. Moreover, a recent report from a convenience sample of U.S. mothers of children of ages 0-18 months, shows elevated depression (34.1%) and anxiety (34.6%) rates5. Yet, the currently proposed interventions to address maternal mortality do not consider approaches to prevent and/or treat postpartum depression. One such approach is providing paid leave for new mothers.
Research has consistently shown that access to paid leave is associated with better maternal mental health6. For example, my research on Minnesota mothers has shown that taking up to six months of leave after childbirth is associated with decreased postpartum depressive symptoms, and an employer’s paid leave policy predicted longer leaves7. Notably, the U.S. is one of two countries in the world (the other is Papua New Guinea) that do not have a national paid leave law8. Thus, women’s access to paid leave is contingent on their employer’s policy or the state they reside in. Only eight U.S. states and the District of Columbia have some form of paid leave policy, but none provide full wage replacement9. Without mandated federal policies, only about 15% of workers have paid maternity leave.
This lack of a national paid leave law lends itself to racial and ethnic disparities in access to leave benefits, especially given the occupational segregation and workplace discrimination in the United States. For example, African American and Hispanic mothers are more likely than their White counterparts to report being fired by an employer for taking leave after childbirth or quitting their jobs after childbirth10. Three out of 10 discrimination claims were filed by African American women between 2011 and 201511. These claims ranged from being fired for taking maternity leave, being denied a promotion or raise due to pregnancy, having inadequate maternity leave allowance, and having to endure physically taxing work conditions or extreme manual labor during pregnancy11. California’s Paid Leave Program is an example of how paid leave can have a positive impact. Prior to this law, African American women took an average of a week of leave after childbirth compared to four weeks for White women12. After the program was implemented, the average maternity leave taken by both African American and White women increased to seven weeks12.
Another example is a study that evaluated leave policy reform in Norway, which provided four months of paid maternity leave for women13. The reform was associated with a range of better outcomes for Norwegian mothers. This included lower body mass index, obesity, blood pressure and pain, improved mental health and better self-reported health. The reform also lowered the likelihood of smoking and increased engagement in vigorous exercise13. It is notable that countries where maternal mortality rates have significantly dropped (~ -50%) in the past few decades (e.g., France, Germany, Sweden), have generous paid leave laws.
Maternity leave provides new mothers with the time to adapt to multiple physical, social, and psychological changes:
- Time to heal from childbirth
- Ability to breastfeed
- More time to care for newborns
- Adherence to postpartum care visits
- Receipt of postpartum depression screening
Yet, in the United States, one quarter of mothers are back to work two weeks after childbirth 14. In light of the COVID-19 pandemic and lack of necessary support systems for new mothers, paid leave seems even more pressing. On December 20, 2019, the President signed the Federal Employee Paid Leave Act, which provides 2.1 million federal workers with up to 12 weeks paid leave following childbirth, adoption or fostering. This is an important first step to increase the population of workers with access to paid leave which would perhaps reduce maternal mortality rates. As U.S. researchers delve deeper into the causes of racial disparities in maternal mortality, they would be remiss not to investigate the relationship between uneven access to paid leave policies in minority populations and the disparities in maternal deaths.
Note: For more information on work policies and disparities in maternal mental health, check out Dr. Dagher’s presentation at the Institute for Women’s Policy Research webinar.
- WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. (2015). Trends in Maternal Mortality: 1990 to 2015. https://www.unfpa.org/publications/trends-maternal-mortality-1990-2015.
- Sieber, R.A., (2019). Rising Maternal Mortality: Key Concepts and Opportunities for Intervention. The Journal of Lancaster General Hospital. http://www.jlgh.org/Past-Issues/Volume-14-Issue-4/Sieber_Maternal-Mortality.aspx.
- Stewart, D.E., & Vigod, S.N. (2019). Postpartum Depression: Pathophysiology, Treatment, and Emerging Therapeutics. Annual Review of Medicine, 70: 183-196. https://doi.org/10.1146/annurev-med-041217-011106.
- Sun, G., Wang, F., & Cheng, Y. (Preprint with the Lancet, 2020). Perinatal Depression During the COVID-19 Epidemic in Wuhan, China. http://dx.doi.org/10.2139/ssrn.3576929.
- Cameron, E., Joyce, K., & Delaquis, C., et al. (2020). Maternal Psychological Distress & Mental Health Services Use During the COVID-19 Pandemic.
- Aitken, Z., Garrett, C.C., Hewitt, B., Keogh, L., Hocking, J.S., & Kavanagh, A.M. (2015). The Maternal Health Outcomes of Paid Maternity Leave: A Systematic Review. Social Science & Medicine, 130: 32-41. https://doi.org/10.1016/j.socscimed.2015.02.001.
- Dagher, R.K., McGovern, P.M., & Dowd, B.E. (2014). Maternity Leave Duration and Postpartum Mental and Physical Health: Implications for Leave Policies. Journal of Health Politics, Policy and Law, 39(2): 369–416. https://doi.org/10.1215/03616878-2416247.
- The International Labour Organization. (2014). Maternity and Paternity at Work: Law and Practice Across the World. https://www.ilo.org/global/publications/ilo-bookstore/order-online/books/WCMS_242615/lang–en/index.htm.
- National Partnership for Womean and Famililes. (2019). State Paid Family and Medical Leave Insurance Laws. https://www.nationalpartnership.org/our-work/resources/economic-justice/paid-leave/state-paid-family-leave-laws.pdf.
- Donovan, S.A. (2019). Paid Family Leave in the United States. Congressional Research Service Report. https://fas.org/sgp/crs/misc/R44835.pdf.
- National Partnership for Women and Families (2018). Black Women’s Maternal Health: A Multifaceted Approach to Addressing Persistent and Dire Health Disparities. https://www.nationalpartnership.org/our-work/resources/health-care/maternity/black-womens-maternal-health-issue-brief.pdf.
- Rossin‐Slater, M., Ruhm, C.J., & Waldfogel, J. (2013). The effects of California’s Paid Family Leave Program on Mothers’ Leave‐Taking and Subsequent Labor Market Outcomes. Journal of Policy Analysis and Management, 32(2): 224-45. https://doi.org/10.1002/pam.21676.
- Butikofer, A., Riise, J., & Skira, M. (2018). The Impact of Paid Maternity Leave on Maternal Health. http://dx.doi.org/10.2139/ssrn.3139823.
- Abt Associates Inc. (2012). Family and Medical leave in 2012: Technical report. https://www.dol.gov/sites/dolgov/files/OASP/legacy/files/FMLA-2012-Technical-Report.pdf.