Sunday, May 9, 2010

The Patient Protection and Affordable Care Act Overlooking the Implicit Needs of a Mother and Infant – Andrea DiNetta

The Patient Protection and Affordable Care Act (PPACA) was recently passed by Congress to address important issues surrounding health care in the U. S. One little known section of this bill contains a directive that attempts to meet one of the needs of new mothers and their infants, breastfeeding. Breastfeeding has been established as one of the most valuable contributions to infant health. The U.S. Department of Health and Human Services and World Health Organization both recommend exclusively breastfeeding infants up to 6 months of age. Components in breast milk have been found to have immune enhancing benefits, which reduce the rate of infant morbidity and mortality. There has also been consistent research showing that a breastfed infant’s neurocognitive development is accelerated compared to non-breastfed infants (1). The mother of the child also reaps benefits from breastfeeding. Increased post-partum weight loss and decreased risk of pre-menopausal breast cancer has been documented among the benefits. Some research suggests that breastfeeding mothers may also reduce their risk for ovarian cancer, osteoporosis and coronary heart disease (1).

The potential monetary savings in breastfeeding can be estimated at $1 billion dollars of savings from four major types of childhood illness that are believed to be preventable through breastfeeding. Each year non-breastfed infants cost the healthcare system $291.3 million for infant diarrhea, $225 million for respiratory syncytial virus, from $9.6 to $124.8 million for insulin-dependent diabetes mellitus, and $660 million for otitis media. Moreover, the intellectual gains of a breastfed infant, even though they cannot be precisely calculated, do have a significant impact on society as a whole. Expanding intelligence across the nation can make our country more advanced, which in turn will help the world grow with new technologies and progress in all areas of life (2).

With these statistics in mind, the new health care law contains an initiative to increase the human milk consumption of infants by targeting working mothers. With so many women in the workforce today, the government has chosen to address the needs of new mothers at their place of employment. Approximately 70% of mothers with children under three years old, work full time (3). Section 4207 in the PPACA states that companies with over 50 employees must allow mothers “reasonable break time” to express milk during work hours, until their infant is 1 year old (4). The PPACA attempts to address the importance of breastfeeding newborns by mandating lactation breaks in the workplace.

Applying Maslow’s Theory of Human Motivation, one can discover the implicit faults of this policy. Maslow’s theory recognizes that in addition to basic physiological and safety needs, the human requires a sense of love and belonging, self-esteem and self-respect, and finally, self-actualization or full potential. While offering mothers and newborns a basic physiological solution, the PPACA it does not address the other needs defined in Maslow’s theory, the psychological needs of the new mother or the psychological needs of the infant.

The PPACA intervention fails to address many of the actual needs of the mother and the infant in several ways. First, mothers may feel they have to return to work too soon and they have experienced more severe psychological stressors than those who wait (5). Secondly, the bond the mother creates through direct breastfeeding is too valuable to neglect and creates motivation in the mother for more breastfeeding (6). Lastly, the act of breastfeeding provides the physical comfort of a mother’s touch and a safe environment in which the infant can thrive (7).
Criticism #1:

According to Maslow’s Hierarchy of needs for self esteem, new mothers have a need to view themselves as having attained a very important role in society. Self-esteem is achieved through feelings of adequacy, confidence, and achievement (8). Governments have a role in creating the perceived status of groups of people by the very laws they create. Extreme examples of this can be found throughout history in laws created for segregation or voting rights for example. The PPACA does not acknowledge the importance of a mother taking time off from work to care for her newborn. On the contrary it has, in effect, declared that a woman can “do it all” - work while still breastfeeding her baby. The status of the new mother is not elevated to its rightful position. By offering her a room to express milk for her newborn, the government has placed employment at a higher level than motherhood. In addition to financial concerns, acceptance by her working peers and the rest of society could drive her to return to work earlier than desired.

When women do return to work postpartum many declare it as a negative experience. Mothers returning to work too soon after having a baby report feelings of remorse and stress. The first challenge mothers experience is identifying their role as both working employee and a nurturing mother. Often trying to balance time between these two roles leads to conflict where they feel guilty leaving their child behind in order to take care of work. Another challenge mother’s face is family stress. When a child is born, the mother’s relationship with her significant other diminishes rapidly as she tries to raise her child and dedicate time to work. Family and child care issues may also arise, when there is not enough family support to help raise the child, or there is no appropriate and affordable day-care center available. Financial issues further put a strain on the mother, as she weighs the pros and cons of staying home with the child and going to work to earn enough money to take care of the child. Lastly, psychosocial challenges present themselves when the mother feels absolutely drained from having no time for herself. Often the mother may feel depressed due to lack of sleep and neglecting personal needs (5).

The stronger these challenges interfere with the mother’s life, the harder it is for her to care for the family. The choices are often confusing and the mother may feel pressured to make uncomfortable decisions or decisions she may regret later. For example, putting a child in daycare is such a simple solution, yet the mother feels inadequate that she is not “motherly” enough to care for her own child. Society views breastfeeding as a motherly role to be filled by a mother. However, society often views working women in a more masculine type role and doesn’t associate working women with motherly instinct. Fulfilling the role of a mother and an employee is a constant conflict that no woman should have to be subject to. In the long run, parents of breastfed babies take less time off from work, since their child grows up healthier than bottle-fed infants. A labor statistic report revealed that caring for a sick child can lead up to a $360 financial loss per day if an employee is home taking care of a sick child. Stress from taking care of a sick child can cause a parent to transfer their stress onto others at work, or simply become absent-minded or distracted (9).
Criticism #2:

The PPACA also ignores the fact that there are physiological factors that drive mothers to breastfeed. Maslow’s Theory of Motivation (8) would show that the natural drive to nurture and feed one’s young must be realized in order for the mother to feel satisfied. When children suckle at the breast, the hormone, oxytocin is released, which stimulates feelings of relaxation and bondedness. Mothers expressing milk or pumping milk for later use are not creating a meaningful interaction with their child. A randomized placebo controlled human trial study tested oxytocin’s effect by injecting the hormone intranasally. As a result the subjects, injected with the active hormone showed increased trust and recognition of facial affects. They also showed a decrease in anxiety and decrease in fear related brain response patterns (10). The feelings of connection that oxytocin delivers are an essential aspect of breastfeeding. When oxytocin is released during these times it establishes a certain bond between mother and infant. Indeed, human mother’s milk is relatively diluted to increase contact with the child throughout the day (11). As a result, bottle feeding human milk will not give the mother the same association if the oxytocin is not released at the same time as feeding the baby. Also, as a mother spends more time at work, and less time producing oxytocin in the presence of her child, the further the feelings of separation may continue.

When these hormones are released in mothers, a maternal instinct kicks in, allowing the mother to perform instinctive behaviors of protecting her child. A mother who breastfeeds directly is more likely to watch over her child in dangerous situations, which further increases the chance of the child to survive. (6). Oxytocin also perpetuates maternal behavior so that the infant will not be neglected. One study in a hospital found a decrease in abandonment after delivery in association with breastfeeding (12). Another study revealed that breastfeeding less than 4 months is associated with maltreatment of the child, especially neglect. The lack of oxytocin released, which is meant to dampen the sympathetic nervous system “fight or flight” response, is believed to be the reason for the negative reaction (10).

The plan to create lactation rooms only deepens the divide between mother and child. Now mothers can return to work almost immediately, leaving their child to another caretaker. As women become more career focused, they may lose sight of special things, such as the innate connection developed with one’s child through breastfeeding. Furthermore, they are denying a basic physiological response to childbirth, which is breastfeeding, and the hormones that are released as a result of it.
Criticism #3

The PPACA also ignores the physiological needs of the infant. According to Maslow’s Hierarchy of Needs, the infant must feel safe in order to thrive. Infants have uninhibited reactions to the entire world around them, making them feel venerable. Stress related to the unpredictability of their world can be assuaged through human contact. The mother also feels a sense of satisfaction and connection when holding her child, which will further motivate her to breastfeed.

Physical touch provides nurturing to the child who, if deprived of this, is less likely to thrive (11). Back in the early nineteen hundreds, many parentless babies were put into large, clean facilities with ample food and nutrition. However, most of these babies did not live past seven months due to physical human neglect. Without human skin to skin contact, babies lose the motivation to eat and drink, fail to thrive and eventually starve to death. We now understand that human touch is an integral part of a baby’s ability to grow and develop. In hospital care units, such as the NICU, hospital volunteers and other staff members, massage the baby every 15 minutes or bring them out to hold them. In fact, the volunteers and staff that massage the babies regularly have lower anxiety, lower depression, and higher self esteem. They also drink less coffee and visit the doctor less frequently (7).

One study discovered that mothers who breastfed their babies tended to touch, cuddle, and smile more than mothers who used a bottle for feedings. Another study focused on the other reactions of sensory stimuli between mother and infant. At 3 days old, mothers who bottle fed were twice as likely to be gazing away from the infant than breastfeeding mothers. By the time the infant reaches 3 months old bottle feeding mothers were 8 times more likely to be gazing away from the infant. Tactile stimulation during feedings decreased from 3 days to 3 months in all the infants, however, breastfed infants still scored much higher throughout the study than bottle fed infants. Auditory stimulation for the infants increased from 3 days to 3 months, and the results were mixed (13).

Lactation rooms allow for mothers to be away from their child for much longer. There is no incentive or need for mothers to return home to breastfeed their child. A baby’s main mode of exploring their world is through skin contact, as their eyesight is very poor. As a result, they react to physical stimuli on their skin, which in turn will inform the infant whether or not they are in danger. Infants are not born fully developed, able to protect themselves. They rely on the physical safety they find in familiar skin to skin contact with their mother (7). The mother needs to be present, as the familiar touch and smells will soothe the child.

Intervention Strategy

In order to increase the rates of breastfeeding, the U.S. should create a policy intervention in which work organizations would be required to offer a maternity leave of up to 6 months with at least partial salary payment and job protection for all full-time employees. The goal is to motivate the new mother towards personal caretaking of her child. The motivation for the mothers will be based on the understanding that breastfeeding is a natural drive to feed one’s offspring. The time off from work will allow the new mother to adjust to the new role of motherhood. The drive to take care of her offspring will be focused on feeding and nurturing the child, instead of the concern about money for the family. As a result, the mother and infant will attain a higher level of satisfaction in Maslow’s Hierarchy of Needs (8). For the mother, she will attain self-esteem through breastfeeding and raising her child at home through a government mandated program which recognizes the importance of motherhood. The mother and infant will also attain the physiological needs that breastfeeding provides. The mother satisfies her drive to nurture her offspring, which is a basic instinct in all mammals. The infant satisfies his/her need through being fed by the mother. The human milk is the basic form of nourishment for the child, which is one aspect of what a child needs to grow. Lastly, the infant and mother will be motivated by the need of safety. The infant requires feelings of safety in order to grow, while the mother provides that role and helps protect her family. These are the more important factors that develop for a women who has just given birth. Striking evidence of the benefits of better maternity leave has been documented, while the use of lactation rooms has not (on a national-wide level).

In order for the mother to feel a higher sense of self-esteem and satisfaction, she will use the maternity leave as a chance to connect with her child and use her most basic drive, to raise offspring, to fulfill her self-worth. Several studies have shown that lengthened maternity leave promotes breastfeeding. Mothers report the need to return to their jobs as one of the top reasons to forgo breastfeeding in the long run (1). Several studies have shown that there is no significant difference in the initiation of breastfeeding between employed and non-employed mothers. However, employed women who planned to return to work within six weeks of giving birth were less likely to initiate breastfeeding. The compelling evidence arises when one views the relationship between duration of breastfeeding versus employed and non-employed mothers. One survey found that non-working mothers, on average, breastfed for 25.1 weeks compared to full-time working mothers who breastfed for only 16.1 weeks. Employed women were significantly less likely to be breastfeeding at three months compared to non-working mothers (9). The difference between initiation and duration of breastfeeding in working mothers proves that, although a mother may intend to breastfeed, there are few available resources to support the continuation of breastfeeding. If mothers could spend time away from work to take care of their child, while still maintaining a meaningful salary, then breastfeeding duration would increase in mothers who intend to breastfeed for longer.

A mother naturally deserves the right to care and breastfeed her child in a safe comfortable setting without distractions. The United States is almost the only developed country in the world that does not mandate paid maternity leave. In 2011 Australia will be the last developed country, besides the U.S., to have paid maternity leave policy. Currently under the Family and Medical Leave Act, enacted in 1993, employers must allow women three months of unpaid maternity leave with job security. Before this Act, maternity leave was actually under the Disabilities Act as a disabilities leave (14), which in itself is a misleading and derogatory label. Only 24 percent of the “top employers for working mothers” voluntarily provide paid leave for 4 or less weeks and over half voluntarily provide pay for 6 weeks or less (15). Six weeks does not fill the quota of the recommended 6 months of exclusive breastfeeding.

Canada has shown vast improvements in its maternity leave policies. When Canada extended their maternity leave with job security and compensation up to 12 months, new mothers waited to return to work for much longer. This expansion resulted in a 8.4% increase in mothers who exclusively breastfed for up to 6 months. Mothers were more likely to breastfeed for 1/3 of a month longer for each month they stayed home (16). One can see that Canada’s policy change undoubtedly assisted mothers in breastfeeding their infants. The example Canada has set for us should prove feasible in the United States if we were to implement a similar policy.

Research also shows that lengthened maternity leaves decreases stress and depressive symptoms in mothers. For each week maternity leave was lengthened, the mother reduced their depression by 6-7% rated on a depression scale (17). It has been reported that breastfeeding mothers, not bottle feeding mothers, showed overall decrease in anxiety and negative mood. The mothers reported less stress and their physiological function of stress response seemed to be diminished. A salient factor in this response is one of the primary hormones in breastfeeding: oxytocin. It appears that there are physiological hormones in place to allow mothers to cope with the stress of a new child. The physiological aspect of breastfeeding is an essential component in raising a child, and is concurrent with Maslow’s Hierarchy of Needs.

There is solid evidence that a comprehensive maternity is associated with a reduction in infant morbidity and mortality rate. Scandinavian countries have the longest and most comprehensive maternity leave compared to any other industrialized country, and also have the lowest infant and maternal mortality rates. Two studies have shown that longer maternity is associated with significant reduction in infant mortality and child mortality between the ages of 1-5 years old. The first study showed that each time the maternity leave is extended for another 10 weeks, the infant gains a 3-4% decrease chance in mortality. The next study showed, similarly that extending maternity leave by 10% decreases infant mortality by 3-5%. Furthermore, there is evidence showing that mother-child interactions can be affected by the length of maternity leave. In women attaining only 6 weeks of maternity leave, mother-infant interactions within four months of childbirth were significantly more negative than mothers who received 12 weeks of maternity leave (18). The importance of physical nurturing, mother to child, creates the sense of safety and security for both involved. One can see Maslow’s second level of motivation (safety needs) manifest as the mother becomes more and more attached and protective of her child.

The decision to ignore these drives or give in to these drives depends on the resources available, and what the mother views as the best possible outcome for her infant and for herself and family. The current PPACA does not go far enough in protecting the well being of mothers and their infants. If Maslow's theory is applied to the decisions involving the health of mothers and infants it becomes clear that a comprehensive maternity leave policy provides the best solution. The mother will have the safety of knowing she has an income and job protection, which will allow her to attain the need for self-esteem through breastfeeding. Maternity leave will also provide greater benefits to the infant than simply supplying human milk for physical sustenance. There is concrete evidence that proves that maternity leave is the best option for an employed mother to raise a child.



References

1. Heymann, J. & Kramer, M.S. Public Policy and Breastfeeding: A Straightforward and Significant Solution. Canada Journal of Public Health. 2009; 100(5):381-383.

2. Riordan, J.M. (19967). The cost of not breastfeeding: A commentary. Journal of Human Lactation. 13(2), 93-97

3. Center For Disease Control and Prevention. Lactation Support Program. Web. Accessed April 26th 2010. http://www.cdc.gov/nccdphp/dnpao/hwi/toolkits/lactation/

4. Unite States Breastfeeding Committee. “Health care freeform boosts support for employed breastfeeding mothers.” Web. Accessed April 26th 2010. http://www.usbreastfeeding.org/Workplace/WorkplaceSupport/WorkplaceSupportinHealthCareReform/tabid/175/Default.aspx.

5. Nichols M.R., and Roux, G.M. Maternal perspectives on postpartum return to the workplace. JOGNN. 2004; 33:463-471.

6. Barret, J.R. Breastfeeding and babies’ lives. Environmental Health Perspectives. 2004; 112(10):A547.

7. Benjamin, B. & Werner, R. The primacy of human touch. Health Touch News. pp:1-2. Web. Accessed April 26th 2010. http://www.benbenjamin.com/pdfs/Issue2.pdf.

8. Maslow, A.H. A Theory of Human Motivation. Brooklyn College. Pg: 370-396.

9. Calnen, G. Paid maternity leave and its impact on breastfeeding in the United States: an historic, economic, political, and social perspective. Breastfeeding Medicine, 2007; 2:34-44.

10. Strathearn, L. et al. Does breastfeeding protect against substantiated child abuse and neglect? A 15-cohort study. Pediatrics. 2009; 123(2):483-493.

11. Kluger, J. “Why We Love.” Time Magazine. January 19th 2008.

12.Huffman, S.L., & Lamphere, B.B. Breastfeeding performance and child survival. Population and Development Review. 1984; 10:93-116

13. Lavelli, M & Poli, M. Early mother-infant interaction during breast- and bottle-feeding. Infant Behavior & Development. 1998; 21(4):667-684

14.Equal Employment Opportunity Commission. Pregnancy Discrimination. Web. Accessed April 26th 2010. http://www.eeoc.gov/laws/types/pregnancy.cfm

15. Lovell, V. et al. Maternity Leave in the United States. Institute for Women’s Policy Research. August 2007. IWPR #A131. Web. Accessed April 26th 2010. http://www.iwpr.org/pdf/parentalleaveA131.pdf

16.Baker, M. & Milligan. Maternal employment, breastfeeding, and health: Evidence from maternity leave mandates. Journal of Health Economics, 2008; 27:871-887.

17. Chatterji, P & Markowitz. Does length of maternity leave affect maternal health? Southern Economic Journal. 2005; 72(1):16-41.

18.Staehelin, K., et al. Length of maternity leave and health of mother and child – a review. International Journal of Public Health. 2007; 52:202-209.

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