Health Law, Policy & Management

Paid Parental Leave and Infectious Disease Risk Among Infants

Following his new commentary in JAMA Pediatrics, Justin White discusses study findings that suggest a possible link between New York’s paid family leave law and reductions in RSV and respiratory tract infections among newborns.

Despite widespread, bipartisan support for a national paid leave policy, the United States remains the only industrialized country that does not guarantee paid family and medical leave, instead providing unpaid, job-protected leave to most workers through the Family and Medical Leave Act (FMLA). Only 1 in 4 private-sector workers maintain access to this benefit, and even fewer low-wage workers—who are disproportionately women and people of color—are eligible, forcing families to choose between economic security and caring for themselves, a newborn, or other loved ones.

Numerous studies show that paid parental leave, in particular, provides physical, mental, and financial benefits for growing families, but the majority of this research focuses on the maternal benefits of the policy—such as the ability to bond with their baby or recover postpartum—rather than benefits to the newborn baby. A new commentary led by Justin White, associate professor of health law, policy & management, examines the positive impact of paid leave policies on infant health in New York State, which is among 13 states (plus Washington, DC) that have taken their own actions to ensure workers receive mandatory paid time off for family or medical purposes.

Published in JAMA Pediatrics, the commentary dissects findings from a new study, also published in JAMA Pediatrics, which assessed the impact of New York State’s paid family leave law on the frequency of emergency room visits or hospitalizations for respiratory tract infections (RTIs) and respiratory syncytial virus (RSV) among young infants from 2015 to 2020. It compared this data to ER visits or hospitalizations for RSV/RTI among infants in Massachusetts, New Hampshire, Vermont, and Maine, which all have similar paid leave policies to New York.

The study, led by Katherine Ahrens, associate research professor of public health at the University of Southern Maine Muskie School of Public Service, showed an 18-percent reduction in RTI visits and a 27-percent reduction in RSV visits in New York compared to the New England states. The authors believe these reductions most likely occurred as a result of reduced exposure to viruses in childcare settings outside of the home after the policy was implemented.

“Ahrens’ study is noteworthy as it is among the first to show that state paid family leave can also reduce the risk of acute RTIs, which are the leading cause of emergency department visits and hospitalizations among US children,” writes White, lead and corresponding author of the editorial, along with coauthor Rita Hamad, associate professor of social and behavioral sciences at Harvard T. H. Chan School of Public Health. “…As the body of evidence [between paid leave and infant health] grows, it strengthens the case for adopting a national paid family leave policy, which could significantly improve public health outcomes and provide economic stability for more families across the country.”

These findings are also noteworthy as the US approaches respiratory virus season in the winter months, hoping to avoid a third consecutive “tripledemic” of RSV, COVID-19, and flu cases.

The authors of the commentary praise the study’s rigorous methodology that compares RSV/RTI hospitalizations in New York to comparable states in order to rule out temporal factors that could have influenced the decline in New York cases. They also call for additional methodological refinement in future research to better understand the association between the paid leave policies and respiratory disease rates among newborns.

White, Hamad, and the study authors say that this latest data can encourage policymakers in the states that have no paid family leave law to implement this policy, as well as inform federal law. 

The current leading national paid family and medical leave bill is the Family and Medical Insurance Leave (FAMILY) Act, which Congress has introduced every year over the last decade, most recently in November 2023 by Connecticut Representative Rosa DeLauro and New York Senator Kirsten Gillibrand. If passed, the bill would provide up to 12 weeks of partial wages for all of the same situations detailed under FMLA, and it would extend to employees in all companies, no matter the size or type.

Below, White shares additional thoughts about the new findings on paid family and medical leave and infant health, and why the US continues to lag behind the rest of the world on this issue. 

What was most notable to you about this new study? With the emergence of a “tripledemic” over the last few winters, is it likely that the reduction in New York RSV/RTI cases was even larger after 2020? 

WHITE: The study by Ahrens and colleagues is one of the first to show that paid family leave can reduce the risk of infectious diseases for infants. RSV is a leading cause of hospitalization for infants, making this finding particularly important. We know from prior studies that paid family leave can improve various dimensions of health for the mother and infant, but it’s been unclear whether PFL programs reduce infectious disease risk for the baby.

Since the onset of COVID-19, the public health community has faced down overlapping outbreaks of COVID, influenza, and RSV. New York’s PFL policy may have buffered its residents against RSV and other respiratory tract infections. While the study data does not go beyond 2020, the findings suggest that the PFL policy likely reduced the number of RSV-related infant hospitalizations throughout the COVID pandemic.

The study period occurred before the federal approval of RSV preventive treatment, including a maternal vaccine and monoclonal antibodies for infants. What do we know about the efficacy and uptake of these treatments thus far, and do you think the availability of these treatments would have substantially changed the study results?

The newer RSV treatments, including the maternal vaccine and monoclonal antibodies for infants, have great potential to reduce the risk of RSV infection and hospitalization. Yet, vaccine coverage has been limited so far. Less than 20 percent of pregnant persons had received the maternal vaccine as of January 2024, according to CDC data. Thus, I would not expect these new treatments to have made much difference so far. In the long run, as the treatments become more common, they could reduce the importance of the positive effect of PFLs on RSV risk.

Most data suggest that the majority of the country supports a national paid family leave, so why do you think it has been so difficult to pass bipartisan legislation at the national level, even with the Biden administration’s latest efforts? What are some of the main arguments against developing a mandatory federal law?

Much of the political opposition comes from the business community. Common arguments against offering paid family leave are that PFL reduces employees’ attachment to their jobs, leads to discrimination against women who are more likely than men to take leave, and imposes a substantial cost on employers. In theory, PFL could improve or inhibit labor market outcomes for new parents. If PFL increases time away from work among working parents, they could experience some loss of job-specific skills and gender discrimination from employers. Yet, if a new parent quits a job in the absence of PFL, there could be a benefit for job continuity and future labor market success. Most of the evidence points toward PFL programs increasing employment after childbirth and having positive or no effects on wages.

Meanwhile, employer costs can include the cost of partial wage replacement and the cost of program administration. These costs have been thought to be particularly burdensome for small employers. But a few studies have suggested that PFL does not have large negative impacts, including for smaller employers. For example, there are no reported adverse impacts on employer ratings of worker performance.

Employer support for PFL increased during the COVID pandemic. Opposition to PFL policies may, therefore, be weakening.   

While states are increasingly adopting their own mandatory paid leave policies, there is still a gap between passing legislation and getting people to actually take parental leave. How do we change the ingrained workplace culture that discourages this critical time off?

There are many reasons why people do not take paid family leave when it is available. In some cases, the benefits might not be all that great. The duration of leave may be short, and the wage replacement may not be good. Some studies have found that increasing the duration of leave can increase take-up. In general, offering a longer leave duration—at least 12 weeks—and more complete reimbursement of wages may increase the number of new parents who are taking leave. Legislation could also better support new parents by allowing for more flexibility in how paid leave is taken, for example, by allowing workers to return to work on a part-time basis.  

Some workers are not aware that they are entitled to paid family leave. The government and employers can do a better job of informing workers about the benefits to which they are entitled.

In other cases, the work culture discourages leave-taking. Some countries, such as Sweden, require that, when there are two parents, leave-taking must be split between both people. This encourages men and women to take leave and reduces any stigma associated with leave-taking.

What additional research would you like to see to better understand the health impacts, and particularly infant health impacts, of paid parental leave? 

Many of the state PFL policies are relatively new. A lot of the US evidence is restricted to the first adopters, namely California and New Jersey. We have recently been trying to understand the impacts of the newer state policies on perinatal health. The additional state policies will also offer an opportunity for understanding how state programs with different features, such as leave duration or percent wage replacement, have different effects.

Similarly, we know very little about the heterogeneous effects on different groups of workers. We need more research to understand whether PFL can reduce health disparities among historically marginalized groups, such as low-income and Black and Latina women.

I would also like to see more granular studies about how employers respond to PFL policies. Do they try to drop employees to avoid leave-taking or change work hours? Payroll data might be valuable for addressing these sorts of questions.