Barriers to Accessing Paid Parental Leave Among Birthing Parents With Perinatal Health Complications: A Multiple-Methods Study.

INTRODUCTION: Even in the small number of U.S. states with paid parental leave (PPL) programs, studies have found awareness of PPL remains low and unevenly distributed among parents. Moreover, little is known about whether parents with perinatal health complications have unmet needs in obtaining information about and support for accessing parental leave during that time. This study aims to address this research gap. Given the strong evidence linking paid leave with improvements in maternal and infant health, it is critical to evaluate access among vulnerable populations. METHODS: We used a multiple methods approach, including a subset of the 2016-2017 Bay Area Parental Leave Survey of Mothers (analytic sample = 1,007) and interview data from mothers who stayed at a neonatal intensive care unit in 2019 (n = 7). All participants resided at that time in California, a state that offers PPL. The independent variable for the survey analysis was a composite measure of perinatal complications, quantified as binary with a value of 1 if respondents reported experiencing any of the four complications: poor maternal mental health during or after pregnancy, premature birth, or poor infant health. Dependent variables for the survey analysis measured lack of support or information for accessing PPL. We used linear probability models to assess the relationship between perinatal complications and PPL support. Thematic analysis was conducted with the interview data to understand how perinatal complications shape the process of accessing PPL. RESULTS: Survey results revealed that parents with perinatal complications had a lower understanding of PPL benefits and low overall support for accessing leave, including from employers, compared with parents without perinatal complications. From interviews, we learned that perinatal complications present unique challenges to parents navigating PPL. There were multiple entities involved in managing leave and providing information such as the benefits coordinator and employers. Supervisors were reported as providers of critical emotional and financial support. CONCLUSIONS: Taken together, the findings from surveys and interviews suggest that health care and human resources personnel should be better equipped to provide information and support, particularly to those who experience perinatal complications and might struggle to complete paperwork while facing health challenges.

"How Do I Prepare for This?" Patient Perspectives on Providers' Employment-related Support During Pregnancy.

BACKGROUND: Health care providers can offer employment-related support to pregnant patients by providing information about occupational risks and benefits, discussing adjustments, and/or completing paperwork to help patients obtain accommodations or benefits, but little research has examined whether and how this support is provided. METHODS: We conducted interviews with 20 adults who had been employed while pregnant within the 5 years preceding data collection. Eligible participants had low incomes, were hourly wage earners, or were employed in service or retail occupations. Applied thematic analysis was used to identify emergent themes. RESULTS: People who had been employed while pregnant described a range of experiences during that time, including physical and psychological demands from work, lack of access to appropriate accommodations, difficulties combining breastfeeding with work, and work-related challenges accessing health care. Participants described four primary roles that health care providers played: 1) completing paperwork needed to apply for benefits or receive work modification; 2) providing information about how to mitigate employment-related risks; 3) providing referrals to social or medical services; and 4) advocating for patients to ensure receipt of accommodations, resources, and information. Strategies identified by patients that could be enacted within health care to help them better navigate the work-pregnancy interface include increasing appointment flexibility, providing information about work-related risks and benefits programs and referrals to legal support, and helping providers to understand and support their patients' individual work-related concerns. CONCLUSIONS: Health care providers have a critical role to play in supporting employed pregnant people to achieve flexibility in managing their work and to be active participants in discussions about recommended workplace accommodations.

Client-reported quality of facility-managed medication abortion compared with pharmacy-sourced self-managed abortion in Bangladesh.

OBJECTIVE: We used the newly developed Abortion Care Quality Tool (ACQTool) to compare client-reported quality of medication abortion care by source (facility-managed vs pharmacy-sourced self-managed abortion (SMA)) in Bangladesh. METHODS: We leveraged exit and 30-day follow-up surveys collected to develop and validate the ACQTool collected at nongovernmental organisation (NGO)-supported or -operated facilities in the public and private sector and pharmacies from three districts in Bangladesh. We used bivariate statistics to compare 18 client-reported quality indicators grouped in six domains and eight abortion outcomes, by source (facility vs pharmacy). We used multivariable logistic regression to identify factors associated with selected quality indicators and outcomes (abortion affordability, information provision, and knowing what to do for an adverse event), controlling for client sociodemographic characteristics. RESULTS: Of 550 abortion clients, 146 (26.5%) received a facility-managed medication abortion and 404 (73.5%) had a pharmacy-sourced SMA. Clients reported higher quality in facilities for five indicators, and higher in pharmacies for two indicators; the remaining 11 indicators were not different by source. Compared with facility-based clients, pharmacy clients had higher odds of reporting that the cost of abortion was affordable (adjusted odds ratio (aOR) 3.55; 95% CI 2.27 to 5.58) but lower odds of reporting high information provision (aOR 0.14; 95% CI 0.09 to 0.23). Seven of eight abortion outcomes showed no differences; pharmacy clients had lower odds of knowing what to do if an adverse event occurred (aOR 0.45; 95% CI 0.23 to 0.82). CONCLUSIONS: In Bangladesh, there is no difference in client-reported quality of medication abortion care between health facilities and pharmacies for the majority of quality and outcome indicators. However, information provision and preparedness were higher quality at facilities, while pharmacies were more affordable.

Racial/ethnic and gender inequities in the sufficiency of paid leave during the COVID-19 pandemic: Evidence from the service sector.

BACKGROUND: Access to paid family and medical leave (PFML), including leave to care for a seriously ill loved one or recover from one's own serious illness, conveys health and economic benefits for workers and their families. However, without a national PFML policy, access to paid leave remains limited and unequal. Previous work documenting inequitable access by socioeconomic status and race/ethnicity primarily focuses on parental leave, measures theoretical access to paid leave rather than actual leave uptake, and lacks an accounting for why workers of color and women may have less access to PFML. We extend this literature by looking at leave-taking for medical needs or caregiving among a high-risk population during the COVID-19 pandemic. METHODS: We draw on data from 2595 service-sector workers surveyed by the Shift Project in 2020 and 2021 to estimate inequities in leave uptake among workers who experienced qualifying events. We then estimate the relative importance of worker demographic characteristics, qualifying event types (medical vs. caregiving leave), proxies for access to state and employer PFML policies, job characteristics, and ultimately within-firm differences to these gaps. RESULTS: Overall, one-fifth of workers reported sufficient leave. Women are significantly more likely than men to report insufficient or no leave. Hispanic and Black workers are more likely to take insufficient or no leave, respectively, but these differences were attenuated when controlling for covariates. CONCLUSIONS: The dearth of PFML laws leaves women and workers of color without access to leave that is paid and of sufficient duration when facing a qualifying event.

Work as a social risk factor in pregnancy: A systematic review of screening practices related to working conditions and family leave among pregnant adults.

BACKGROUND: Paid family leave and working conditions are components of employment quality-a key social determinant of health across the life course, particularly during pregnancy. Increased research on prenatal social risk screening has not extended to employment quality. The objective of this systematic review was to identify prenatal screening practices and interventions in health care settings that address employment and working conditions as social risk factors among pregnant adults and to describe their properties and key findings. METHOD: We searched MEDLINE, PsychINFO, SocINDEX, EMBASE, and the SIREN Evidence and Resource Library for studies published through February 14, 2022. We selected multiple search terms related to four domains: (1) employment or working conditions; (2) screening; (3) health care settings; and (4) pregnancy or maternal health. RESULTS: Of the 2317 unique titles and abstracts that were potentially relevant, eight articles met all inclusion criteria and focused on pregnant populations. The content of identified screening practices varied substantially, highlighting the multiple ways employment is conceptualized as a potential risk factor. Few studies included multidimensional measures of employment to assess working conditions, which may be particularly relevant during pregnancy. CONCLUSIONS: Our review suggests that screening for employment as a social risk factor does not regularly occur in prenatal care. Although pragmatic properties of the screening tools we assessed are promising, tools seldom examine the multidimensional nature of work. Understanding the principal intent of screening for employment prenatally could provide greater opportunity to collect and interpret contextual factors that influence how both providers and patients respond to social risk.

Evaluating the Effect of San Francisco's Paid Parental Leave Ordinance on Birth Outcomes.

Since 2017, San Francisco's Paid Parental Leave Ordinance (PPLO) has allowed parents who work for private-sector employers to take 6 weeks of fully paid postnatal parental leave. Previous studies have linked paid parental leave with health improvements for birthing people and babies, although evidence for birth outcomes is limited. We hypothesized that the PPLO may have improved birth outcomes via reduced stress during pregnancy due to anticipation of increased financial security and postnatal leave. We used linked California birth certificate and hospital discharge records from January 2013 to December 2018 (n = 1,420,781). We used quasi-experimental difference-in-difference (DD) models to compare outcomes among SF births before and after PPLO to outcomes among births in control counties. Births from January 2017 through December 2018 among working San Francisco (SF) people were considered "exposed" to PPLO; births during this time among working people outside of SF, as well as all births before 2017, served as controls. We conducted subgroup analyses by race/ethnicity, education and Medicaid coverage at delivery. Overall analyses adjusting for covariates and indicators for time and seasonality indicated no association between PPLO and birth outcomes. Our results indicate that PPLO may not have affected the birth outcomes we examined among marginalized groups who, due to structural racism, are at heightened risk of poor outcomes. We speculate that this result is due to the PPLO's design and focus on postnatal leave. Future work should examine the policy's effects on other outcomes.

Racial and Ethnic Inequities in Paid Family and Medical Leave: United States, 2011 and 2017-2018.

Objectives. To examine racial and ethnic inequities in paid family and medical leave (PFML) access and the extent to which these inequities are mediated by employment characteristics. Methods. We used data from the 2011 and 2017-2018 American Time Use Survey in the United States to describe paid leave access by race/ethnicity. We present unadjusted models, models stratified by policy-targetable employment characteristics, and adjusted regression models. Results. We found that 54.4% of non-Hispanic White workers reported access to PFML in 2017-2018 but that access was significantly lower among Asian, Black, and Hispanic workers. Inequities were strongest among private-sector and nonunionized workers. Leave access improved slightly between 2011 and 2017-2018, but the inequity patterns were unchanged. Conclusions. We observed large and significant racial and ethnic inequities in access to PFML that were only weakly mediated by job characteristics. PFML has a range of health benefits for workers and their families, but access remains limited and inequitable. Public Health Implications. Our findings suggest that broad PFML mandates (such as those in other high-income countries) may be needed to substantially narrow racial and ethnic gaps in paid leave access. (Am J Public Health. 2022;112(7):1050-1058. https://doi.org/10.2105/AJPH.2022.306825).

Inequities in paid parental leave across industry and occupational class: Drivers and simulated policy remedies.

Introduction: Paid family leave (PFL) has the potential to reduce persistent health disparities. This study aims to characterize differences in access to paid leave by industry sector and occupational class. Methods: The Bay Area Parental Leave Survey of Mothers included respondents 18 years of age or older who worked in the San Francisco Bay Area and gave birth from 2016 to 2017. Using linear probability models, we examined differences in five separate measures of PFL by industry sector and occupational class. We extended our regression analysis to simulate the full pay equivalent (FPE) weeks of leave that would have been taken under hypothetical scenarios of increased uptake and wage replacement rates. Results: Our study included 806 women in private for-profit or non-profit jobs. In fully adjusted models, blue-collar workers were 10.9% less likely to take 12 weeks of paid parental leave versus white-collar workers (95% CI: -25.9, 4.1). Respondents were 19.2% less likely receive 100% of their regular pay if they worked in education and health services (-29.1, -9.3) and 17.0% less likely if they worked in leisure and hospitality (-29.5, -4.4) versus respondents in professional and financial services. Respondents in leisure and hospitality reported 1.6 fewer FPE weeks of leave versus respondents in professional and financial services (-2.73, -0.42) and blue-collar respondents reported an average of 1.5 fewer FPE weeks versus white-collar workers (-2.66, -0.42). In our simulation analysis, when we manipulated rates of uptake for paid leave, the disparities in FPE by industry sector and occupational class were eliminated. Conclusion: We observed substantial inequities in access to paid leave by industry sector and occupational class. These findings underscore the potential importance of universal PFL programs with universal benefits to reduce clear inequities that persist within the labor market today.

Racial/Ethnic Inequities in Paid Parental Leave Access.

Purpose: Severe racial inequities in maternal and infant health in the United States are caused by the many forms of systemic racism. One manifestation of systemic racism that has received little attention is access to paid parental leave. The aim of this article is to characterize racial/ethnic inequities in access to paid leave after the birth of a child. Methods: We analyzed data on women who were employed during pregnancy (n=908) from the Bay Area Parental Leave Study of Mothers, a survey of mothers who gave birth in the San Francisco Bay Area in 2016-2017. We examined differences in access to government- and employer-paid leave, the duration of leave taken, and the percent of usual pay received while on leave. To explore these differences, we further examined knowledge of paid leave benefits and sources of information. Results: Non-Hispanic (NH) black and Hispanic women had significantly less access to paid leave through their employers or through government programs than their NH white and Asian counterparts. Relative to white women, Asian, Hispanic, and black women received 0.9 (p<0.05), 2.0 (p<0.01), and 3.6 (p<0.01) fewer weeks, respectively, of full-pay equivalent pay during their parental leaves. Despite inequitable access to paid leave, the duration of parental leave taken did not differ by race/ethnicity. Conclusions: Inequitable access to paid parental leave through both employers and government programs exacerbates racial inequities at birth. This form of structural racism could be addressed by policies expanding access to paid leave.

The association of paid medical and caregiving leave with the economic security and wellbeing of service sector workers.

BACKGROUND: Service-sector workers in the U.S. face extremely limited access to paid family and medical leave, but little research has examined the consequences for worker wellbeing. Our objective was to determine whether paid leave was associated with improved economic security and wellbeing for workers who needed leave for their own serious health condition or to care for a seriously ill loved one. METHODS: We analyzed data collected in 2020 by the Shift Project from 11,689 hourly service-sector workers across the US. We estimated the impact of taking paid leave on economic insecurity and wellbeing relative to taking unpaid leave, no leave, or not experiencing a need to take leave. RESULTS: Twenty percent of workers needed medical or caregiving leave in the reference period. Workers who took paid leave reported significantly less difficulty making ends meet, less hunger and utility payment hardship, and better sleep quality than those who had similar serious health or caregiving needs but did not take paid leave. CONCLUSIONS: Access to paid leave enables front line workers to take needed leave from work while maintaining their financial security and wellbeing.

Among Low-Income Women In San Francisco, Low Awareness Of Paid Parental Leave Benefits Inhibits Take-Up.

Paid family leave policies have the potential to reduce health disparities, yet access to paid leave remains limited and unevenly distributed in the United States. Using California administrative claims data, we examined the impact of the San Francisco Paid Parental Leave Ordinance, the first in the US to provide parental leave with full pay. We found that the law increased parental leave uptake in San Francisco by 13 percent among fathers, but there was little change in leave among mothers. Data from a survey of mothers suggest that the limited impact may be partly a result of low understanding of benefits. Lower-income mothers reported even less knowledge of their maternity leave benefits than other mothers, and fewer than 2 percent of lower-income mothers had accurate information about the policy. The San Francisco policy also excludes small employers, which further limits its reach among low-income workers. A simpler universal policy may be more effective in expanding parental leave among vulnerable workers.

Employer-Reported Access to Paid Parental Leave: A study of San Francisco's Paid Parental Leave Ordinance.

A growing body of research finds that paid leave policies have significant population health benefits for workers and their families, but the lack of a national paid leave policy in the United States leaves most workers without access to any paid leave. In 2017 San Francisco implemented the nation's first fully paid leave policy, mandating that covered employers provide up to six weeks of leave to care for a new child. The objective of our study is to examine how the San Francisco Paid Parental Leave Ordinance (PPLO) affected paid leave access, including among workers in low-wage industries. Methods: We surveyed Bay Area employers in 2018, the year after PPLO took effect. We estimated difference-in-differences models of changes in access to paid leave before versus after implementation of the PPLO in San Francisco compared to surrounding counties. Results: Availability of paid leave in San Francisco firms increased from 45% in 2016 to 79% following implementation of the PPLO. This is significantly more (p < 0.05) than the increase from 32% to 47% in surrounding counties. Compliance was lowest (67%) among low-wage firms. We found minimal evidence of self-reported negative effects on employers. Overall, 82% of firms supported the PPLO. Conclusions: San Francisco's experience demonstrates the feasibility of using local policy to increase parental leave access.

The tipping point: could increasing the subminimum wage reduce poverty-related antenatal stressors in U.S. women?

PURPOSE: Tipped workers, primarily women of reproductive-age, can be paid a "subminimum wage" 71% lower than the federal minimum wage, contributing to economic hardship. Poverty-related antenatal stress has deleterious health effects for women and their children. The purpose of this study was to investigate the effects of increasing the state-level subminimum wage (currently $2.13 per hour) on poverty-related antenatal stress for women in the United States. METHODS: Utilizing a difference-in-differences approach comparing state wage policies over time, we estimated the impact of increases in the subminimum wage on poverty-related antenatal stress using data from 35 states participating in the Pregnancy Risk Assessment Monitoring System between 2004 and 2014, linked to state-level wage laws, census, and antipoverty policy data. RESULTS: The effect of increasing the subminimum wage on poverty-related stress differed by year and sociodemographics. Wage increases in 2014 were associated with the largest decreases in stress for unmarried women of color with less than a college degree, a population that we estimated would have experienced a 19.7% reduction in stress from 2004 to 2014 if subminimum wage was equivalent to the federal minimum wage. CONCLUSIONS: Increasing the subminimum wage can reduce poverty-related stress and may be a potential intervention for reducing poor health outcomes.

A nationwide investigation of the impact of the tipped worker subminimum wage on infant size for gestational age.

Tipped workers, primarily women of reproductive-age, can be paid a "subminimum wage" 71% lower than the federal minimum wage. We estimated the effects of increasing the state-level tipped worker subminimum wage (federally, $2.13 per hour) on infant size for gestational age in the US as infants born small or large are at risk for poor health across the lifecourse. Utilizing unconditional quantile regression and difference-in-differences analysis of data from 2004 to 2016 Vital Statistics Natality Files (N = 41,219,953 mother-infant dyads), linked to state-level wage laws, census, and antipoverty policy data, we estimated the effect of increasing the subminimum wage on birthweight standardized for gestational age (BWz). Smallest and largest infants are defined as those in the 5th and 95th BWz percentiles, respectively. Increases in the subminimum wage affected the BWz distribution. When compared to a static wage of $2.13 for the duration of the study period, wage set to 100% of the federal minimum ($5.15-$7.25) was associated with an increase in BWz of 0.024 (95% CI: 0.004, 0.045) for the smallest infants and a decrease by 0.041 (95% CI: -0.054, -0.029) for the largest infants. Increasing the subminimum wage may be one strategy to promote healthier birthweight in infants.

Effects of citizenship status, Latino ethnicity, and household language on health insurance coverage for U.S. adolescents, 2007-2016.

OBJECTIVE/STUDY QUESTION: To examine changes in uninsurance rates among U.S. adolescents ages 12-17 and assess whether trends over time differed by citizenship status, Latino ethnicity, and household language. DATA SOURCES/STUDY SETTING: 2007-2016 National Health Insurance Survey (NHIS). STUDY DESIGN: Multivariable logistic regression and postestimation marginal effects were used to assess changes in the current uninsured rate. Logistic regression models were used to determine significant trends over time for each demographic group and compare them to trends in the broader adolescent population. Marginal effects were employed to calculate adjusted outcome probabilities for each year. PRINCIPAL FINDINGS: Across all 12- to 17-year-olds, the unadjusted uninsured rate dropped significantly between 2007 and 2016, from 10.2 percent to 6.0 percent. For noncitizen youth, the probability of being uninsured increased from 26.6 percent in 2007 to 28.4 percent in 2016, after controlling for covariates. Latino youth and those in Spanish-speaking households saw declines in their adjusted uninsurance rate that was proportional to non-Latino and English-speaking youth. CONCLUSIONS: Most adolescents saw significant improvements in health insurance coverage between 2007 and 2016; however, disparities remain among Spanish-speaking and Latino adolescents and no improvements were seen among noncitizen youth. This suggests a need for equity-focused eligibility, outreach, and enrollment policies that expand insurance options for these populations.

Employee Experiences with a Newly Adopted Paid Parental Leave Policy: Equity Considerations for Policy Implementation.

Purpose: Paid parental leave (PPL) policies offer immense opportunity to enhance health equity by providing financial stability to workers and promoting the health of families in the United States. Working in partnership with a local county government, which recently adopted a paid leave policy, we engaged in a qualitative substudy to enhance our understanding of how workers perceived and experienced the policy across levels of the socioecological framework. Methods: Working in partnership with Multnomah County, a large public-sector employer in Portland, OR that recently adopted a PPL policy, we collected qualitative data through focus groups with employees. Data were transcribed, coded, and analyzed thematically. Results: We conducted seven focus groups with county employees (N=35) in the fall of 2017. Three major themes emerged from the focus group data: intersectional inequities, disparities by department, and uneven benefits. Conclusions: Our findings highlight the inequities of experience with the PPL policy across employees at individual, organization, and environmental levels. These findings offer insight and guidance for entities considering the adoption and implementation of such policies to consider concrete steps to enhance equity of access and experience.

Analyzing Policies Through a DOHaD Lens: What Can We Learn?

Social, health, and environmental policies are critical tools for providing the conditions needed for healthy populations. However, current policy analyses fall short of capturing their full potential impacts across the life course and from generation to generation. We argue that the field of Developmental Origins of Health and Disease (DOHaD), a conceptual and research framework positing that early life experiences significantly affect health trajectories across the lifespan and into future generations, provides an important lens through which to analyze social policies. To illustrate this point, we synthesized evidence related to policies from three domains-family leave, nutrition, and housing-to examine the health implications for multiple generations. We selected these policy domains because they represent increasing distance from a reproductive health focus, each with a growing evidence base to support a potential impact on pregnant women and their offspring. Each of these examples represents an opportunity to extend our understanding of policy impact using a DOHaD lens, taking into account the potential life course and intergenerational effects that have previously been overlooked.

Laboring Until Labor: The Prevalence and Correlates of Antenatal Maternity Leave in the United States.

Introduction Most women in the U.S. are employed during pregnancy and work until the month of childbirth. For many, working throughout pregnancy poses little threat to their health; however, women experiencing difficult pregnancies and/or working in strenuous or inflexible jobs may benefit from taking time from work as they approach childbirth, but almost no empirical evidence examines antenatal leave (ANL). Methods Using a national survey of English-speaking women, this paper offers the first national description of ANL and examines state policy predictors of uptake. Results Thirty-seven percent of employed women worked until the week their baby was due. After controlling for characteristics of women and their jobs, living in a state with any or multiple leave laws increased the probability of ANL by 14 and 23% points, respectively. Women living in states with multiple leave laws stopped work almost 2 weeks earlier than women in states without a policy. Discussion Paid leave policies currently being considered at the federal, state, and local levels should consider the potential impact on antenatal leave, in addition to postnatal leave, and how they influence population health.