Paid Family and Medical Leave: Policy Statement

Despite great wealth, the United States is the only industrialized country that lacks universally available paid family and medical leave (PFML) for all families. PFML policies are intended to help employees balance work and family responsibilities by advancing health, well-being, and financial security. Because no universally available PFML currently exists in the United States, families are often forced to make difficult choices between a paycheck and unpaid leave to care for a sick loved one or newly arrived child, resulting in lost wages for unpaid caregivers and subsequent health, income, and wealth inequities across gender, race, ethnicity, and socioeconomic status.

Currently, the Family and Medical Leave Act (FMLA) provides up to 12 weeks of unpaid, job-protected leave per year. FMLA entitles eligible employees of covered employers to take unpaid, job-protected leave for specified family and medical reasons with continuation of group health insurance coverage under the same terms and conditions as if the employee had not taken leave.¹  FMLA applies to all public agencies, all public and private elementary and secondary schools, and companies with 50 or more employees for any of the following reasons:

• For the birth and care of the newborn child of an employee;

• For placement with the employee of a child for adoption or foster care;

• To care for an immediate family member (ie, spouse, child, or parent) with a serious health condition; or

• To take medical leave when the employee is unable to work because of a serious health condition.

Additionally, FMLA allows up to 26 work weeks of leave during a single 12-month period to care for a covered military servicemember with a serious injury or illness if the eligible employee is the servicemember’s spouse, son, daughter, parent, or next of kin (military caregiver leave).¹ 

Although FMLA provides job security and protections for those instances listed above, more than 50% of employees are ineligible because of restrictions on new or part-time employee status, independent contractors, and business size, and most of the eligible employees lack the understanding of its policies.²  Additionally, because FMLA is unpaid, many caregivers and parents are unable to use the program. This lack of utilization of FMLA disproportionately affects low-income and racial and ethnic minority families (eg, American Indian/Alaska Native, Black, Hispanic, Native Hawaiian/Pacific Islander, hereafter, “minoritized”).

This policy statement includes all family constellations and parenting or caregiving teams, although most of the published evidence relates to the historical or “traditional” model of a mother, father, or spouse. State and federal policy and language should be inclusive and respectful of all types of caregivers and family structures.³  In this policy statement, the term “parent” is used broadly to mean an adult playing a primary role in caregiving. Gender-neutral language is used where possible. References to gendered language reflect the inclusion criteria and terminology used in specific studies referenced.

The positive effects of PFML on the physical and mental health of infants, children, and their families are well documented.^4–6  Low-income and part-time workers benefit most from PFML programs^7,8 ; however, there would be several positive economic aspects if a universal PFML program was available to all families. Most employees who take leave return to the same employer, improving talent retention and attracting new employees. Businesses report positive effects on employee productivity and profitability, reduction of attrition costs, improvement in employees’ morale and engagement, and a lower level of public benefit use.^9,10 

Access to paid maternity, paternity, parental, family, and personal medical leave through one or more programs is standard in other countries of the Organization for Economic Cooperation and Development (OECD), the majority of which are high-income countries and of which the United States is a member. All 41 OECD countries, except for the United States, offer some form of paid parental leave. These programs provide new birthing parents with a minimum of 14 weeks of paid leave with varied wage replacement rates and lengths of leave across the countries. The total paid leave available to birthing parents ranges from 14 weeks in Switzerland to 164 weeks in the Slovak Republic, with a European Union average of 63.5 weeks; the wage replacement percentage ranges from 25% to 100%.¹¹ 

In the United States, PFML is a benefit currently available to a minority of workers, ranging from 6% to 27% of the workforce.¹²  It is typically funded either by states or employers through payroll taxes or employer benefits, respectively. Parents in the federal civilian workforce who have a newborn infant, or a newly placed child (adopted or fostered) receive PFML. Several states have enacted PFML laws. However, state-level programs vary widely in wage replacement levels, time off, and funding.^13–16 

A positive side effect of PFML is that it improves labor market economics by allowing for job continuity and retention of women in the workforce, which has been shown to increase the number of hours women can work,¹⁷  subsequently decreasing the risk for poverty and increasing household income, especially for low-income, single mothers.¹⁸  It helps keep new parents or caregivers in the labor force while enabling them to develop a bond with their infants and increasing fathers’ participation in parenting.¹⁹ 

During the coronavirus disease 2019 (COVID-19) pandemic, the federal government enacted historic PFML legislation, protecting some workers with time off to manage repercussions of the pandemic (eg, quarantine and isolation requirements, etc). However, these provisions expired at the end of 2020.^20,21  The United States can use the lessons learned from the pandemic and state policy innovation to create national PFML standards to provide workers the time and financial stability to address family and health-related needs.

A wealth of scientific evidence demonstrates the critical nature of parental presence on infant mental and physical development, allowing for parents to be emotionally available, sensitive, and responsive to the needs of the infant.^4,22–24  PFML is associated with lower rates of preterm birth, low birth weight, and child hospital admissions²⁵ ; reduced neonatal, infant, and child mortality rates^26,27 ; higher rates of breastfeeding²⁸ ; and higher timely vaccination rates.²⁹ 

Breastfeeding and provision of human milk has health benefits for children, including a reduced risk for sudden infant death syndrome, childhood infections, cancers, and chronic conditions, such as asthma, obesity, and diabetes.^30,31  For infants with special care requirements, parental physical and emotional closeness to the infant is even more crucial for long-term development.³² 

PFML provides the financial security and time for parents to be closely involved in their infant’s care and find high-quality, affordable early care and education.³³  Parents of children and adolescents with special health care needs require support managing their work-life balance, finances, employment security, and stress.^34–36  Medical complexity itself is an important determinant of health care disparities,³⁵  especially when compounded by racial, ethnic, and economic maternal-child health inequities.³⁷  Raising children with disabilities requires extra time for health care-related tasks, which often increase over time.^38,39  Parents report that access to paid leave improves the health of their children with special health care needs.⁴⁰ 

PFML is associated with better parental health. For maternal health, it reduces rehospitalization rates after delivery,⁴¹  increases breastfeeding initiation and duration rates,^28,42,43  decreases postpartum depression rates,^28,42,44  and leads to better spousal relationships,⁴⁵  all of which improve infant neurodevelopment.⁴⁶  Benefits for lactating parents include reduced rates of breast, ovarian, and endometrial cancer; metabolic syndrome; hypertension; myocardial infarction; type 2 diabetes mellitus; and cardiometabolic diseases.^30,31,47  PFML leads to better parenting⁴  and improved parent-child relationships in the postnatal period when both mothers^48,49  and fathers or partners⁵⁰  are primed for parental engagement and sensitive care. Paid leave policies for partners of the birthing spouse appear to improve children’s long-term school performance, reduce frequency of conflicts over housework, and increase partner involvement in child care, enabling people who have given birth to return to work faster.⁵¹  Improvements in new parent’s health^52,53  and infant’s health²⁶  reduce the risk for parent stress and child maltreatment.⁵⁴  Although the literature on leave policies and the health of caregivers of children with special health needs is emerging, PFML allows for the provision of care hours at home, reduces its high economic costs,⁵⁵  and improves caregivers’ emotional health⁴⁰  and finances.⁵⁶ 

The length and amount of paid leave matter. Mothers of newborn infants who took more than 12 weeks of maternity leave were more knowledgeable about child development; showed better parenting; and had higher self-reported positive attributes (eg, self-esteem, marriage),⁵⁷  lower frequency of maternal depression, and more optimal personal, marital, and social–contextual characteristics.⁵⁸  More generous PFML policies are associated with improvements in the prevalence and duration of breastfeeding,²⁸  reduced incidents of abusive head trauma admissions among children younger than 2 years,⁵⁴  and increased infant vaccination rates.⁵⁹  Longer leave is associated with more equal division of housework⁶⁰  among opposite-sex parents and increased paternal time spent on child care for fathers with lower education.⁶¹ 

Inequities exist in all areas of health and health care, and they persist because of long-standing structural racism and discrimination.⁶²  These inequities include infant and maternal mortality rates, access to health care, and a higher burden of chronic diseases and caring for special health care needs.⁶³  Inequities also exist in the usage of maternity leave according to maternal occupation, race, ethnicity, and education.⁶⁴  Many nonbirthing parents, including fathers and adoptive parents, lack eligibility for leave.⁶⁵  Moreover, most eligible parents cannot afford to take leave without pay.^8,66  Women, low-wage workers, immigrant workers, Black, Hispanic, and Indigenous people,^67,68  and people who are lesbian, gay, bisexual, transgender, queer, or questioning (LGBTQ+) disproportionately lack access to leave options.

The absence of universal PFML discourages all but the largest companies from providing PFML and creates an environment in which only higher-paid professionals at large companies receive PFML, and frontline workers do not. In 2022, the highest-wage workers were 8 times more likely to have PFML but also more likely to work remotely, have scheduling control, or have savings to cushion an unpaid leave.^69,70  The unpaid leave that FMLA offers has negatively affected women’s participation in the labor force, thereby widening disparities in socioeconomic status and health.⁷¹  The COVID-19 pandemic revealed and widened existing health inequities, specifically for working women and the low-paid workforce,⁷²  thus increasing the need for well-designed, universally available PFML⁷³  to promote health equity.⁷⁴ 

Paid leave could address these inequities and help women to remain in the workforce. Universal PFML has the potential to improve overall child health and wellness and offers the greatest opportunity for a healthy productive life to the next generation. Enacting PFML in the United States is essential for improving racial, ethnic, and gender equity and for mitigating health disparities.

The positive effect of PFML on the labor market is well documented in other advanced economies.¹⁷  Among OECD countries, the average duration of parental leave is 57 weeks, and the leave is at least partially paid.¹¹  Women’s labor force participation in the United States is no longer among the highest of industrialized countries, which may be attributable, in part, to the lack of family-friendly policies, including PFML benefits. PFML helps women’s retention in the workplace¹⁹  and improves maintenance of preleave wages,⁷⁵  enabling representation in high-level positions and closing the gender wage gap.^76–79  California’s first-in-the-nation 2004 paid leave program doubled leave usage, increased weekly work hours and income of employed mothers of young children,⁸⁰  and lowered the poverty rate by 10.2%.¹⁸ 

Longer paid leave enables mothers to extend time away from work while remaining in the labor force, which increases the female employment‐to‐population ratio.⁸¹  Extending PFML to 6 to 12 months increases leave taking with no negative effect on economics but better maternal-child health with lower mortality rates and an increase in fathers taking leave.⁸²  PFML reduces and prevents poverty and economic insecurity, in particular, for low-income families and part-time workers, who currently lack access to PFML.⁷³ 

A federal program that provides at least 12 weeks of PFML within a 1-year period to care for a family member,⁸³  in which workers would earn a percentage of their monthly wages up to a capped amount, independent of company size, would strengthen families economically and save families that face economic hardship or poverty if compelled to take unpaid leave.^83,84 

Advancing universal PFML in the United States would promote equity for parents in the workforce while improving health outcomes, providing cost savings for businesses, and strengthening the national economy.⁸³  Expenses could be funded through a national social insurance program. Some state paid leave programs finance part of the benefits through small, evenly shared employee and employer payroll contributions.⁸⁵  In addition to the inclusion of parents, spouses, and minor and adult children incapable of self-care, it could include extended family members and caregivers who need support to reduce disparities in health care and leave access among minoritized people⁷³  and lesbian, gay, bisexual, transgender, queer, or questioning families. Wage replacements for low-income families should be progressive up to 80% to 100%.^86,87  Since the federal Families First Coronavirus Response Act has expired, some state and local lawmakers have started to fill the gap for paid sick leave.^13,15,16  However, a systematic federal approach to PFML policies is critical to promoting health and economic equity, as highlighted by the COVID-19 pandemic. The need for paid leave is high, and nearly everyone in the United States will require extended time off from work to care for a new child, to care for a loved one, or for a personal illness at some point in their lives. Because some states currently have more generous policies than others, state laws and corresponding outcomes should be tracked to better inform the development of a universal PFML policy.

Some small businesses, including small pediatric practices, may encounter challenges in implementing the requirements for PFML. Employers may have difficulties in securing temporary workers, have concerns about employee attachment to their jobs, or worry about potential costs and maintaining financial viability.

Recent studies demonstrated a positive impact on both employers and employees in firms with fewer than 50 employees.⁸⁸  Employees benefited from paid leave while employers had “no statistically or economically meaningful adverse impacts,” while the presence of standard processes around paid leave made it easier to manage employee absences. PFML has been associated with a lower cost per worker and lower turnover rate, and the limited number of negative effects were reported by larger businesses with more than 100 employees.⁸⁹  Flexibilities could be built into the PFML program to accommodate the potential fiscal, staffing, and administrative burden to entities with less than 50 employees. Policy makers must effectively and equitably implement universal paid leave policies while protecting small business interests.

The American Academy of Pediatrics (AAP) recommends that PFML be available to all families to improve health outcomes and reduce health inequities. This will require action by a variety of professionals who are concerned about child and family well-being, including pediatricians and other health care professionals, public health officials, businesses, nonprofit organizations, and state and federal policy makers.

• Create, enact, and enforce a universal PFML policy that is comprehensive and provides parity across all leave categories, including leave for parents of newborn infants; parents of newly placed children (adopted or fostered); workers caring for loved ones who are seriously ill, injured, or disabled; or workers’ own serious health problems:

• Guarantee that access to job-protected paid leave is inclusive of all types of employees and businesses of all sizes, including government employees, contractors, self-employed individuals, domestic agricultural workers, part-time employees, gig economy workers, and those with multiple employers.

• Ensure that paid leave is meaningful in duration: at least 12 weeks to meet the broad set of medical, safety, and caregiving needs.

• Support longer-term needs for families of children and adolescents, particularly with medical complexity, such as flexible employer scheduling, remote work options, government-subsidized medical day care, home care services, and paid family caregiving.

• Safeguard affordable access to paid leave for low-income workers and ensure equity regarding family configuration, gender, race, ethnicity, religion, sexual orientation, and gender identity, physical or intellectual ability, or any other special groups covered by civil rights law.

• Ensure paid leave is provided equally for both parents, including nonbirthing parents.

• Understand and educate that the definition of family is culturally effective, responsive, and as inclusive as possible, comprising biological, foster, kinship, adoptive, same-sex, and extended family members and fictive kin and nontraditional families.

• Develop sustainable funding mechanisms without reducing funding from or otherwise harming other essential programs and services by creating a financing mechanism that all businesses can effectively implement.

• Guarantee job protection for those who take paid leave by ensuring job security upon return to work and protection from employer retaliation.

• Structure financing of paid leave programs in a progressive manner so that sufficient wage replacement can be provided with up to 80% to 100% for lower-income workers.

• Provide incentive grants and other supports for workplaces to become more family friendly.

• Maintain the progress of state innovation on PFML by ensuring that a federal policy does not preempt state policies that are at least as generous as the federal program and that it does not preclude states from providing more generous benefits.

• Educate parents, community partners, policy makers, and other stakeholders of the benefit of PFML on child development and physical and relational health between parents and child.

• Enlist local business and corporate partners as advocates for PFML by emphasizing enhanced employee satisfaction, improved recruitment and retention, increased productivity, and ultimately, a favorable return on investment.

• Ensure that PFML benefits at the state and local level are sustainably funded, have safeguards to ensure fair access, and have benefits that adequately meet family needs, including wage replacement and leave duration.

• Use state policies to build on and further expand the support provided by any universal federal PFML program.

• Evaluate effectiveness of PFML state programs and to include all family constructions and caregiver roles.

• Use incentives to create cultures in which employee participation in PFML programs is rewarded and expected.

• Encourage AAP chapters to advocate for enactment of PFML policies at the state level until a universal PFML policy exists.

• Pediatricians can advocate at the local, state, and federal level to promote PFML benefits for infants, children, adolescents, and young adults with special health care needs using stories from their practice. The AAP provides advocacy training programs to support pediatricians in advocacy efforts.⁹⁰ 

• Pediatricians can educate and refer families who may be eligible for existing leave policies while also educating families about the benefits of universal PFML so that families can advocate on their own behalf.

• Pediatricians, clinics, and hospital systems can promote research and advocacy on the benefits of PFML.

• Pediatricians can advocate for health care systems to provide a robust paid leave benefit for all their employees.

• Pediatricians may work with institutional training programs to educate trainees on the importance of these policies for their patients and themselves,⁹¹  which would improve recruitment and retention of pediatricians with young families.

Christiane E. L. Dammann, MD

Kimberly Montez, MD, MPH

Mala Mathur, MD, MPH

Sherri L. Alderman, MD, MPH, IMHM-E

Maya Bunik, MD, MPH

Andrea E. Green, MD, FAAP, Chairperson

Alexy Darlyn Arauz Boudreau, MD, FAAP

Percita Loren Ellis, MD, FAAP

Christopher Spencer Greeley, MD, FAAP

Joyce Rivera Javier, MD, MPH, MS, FAAP

Gerri Mattson, MD, MSPH, FAAP

Mala Mathur, MD, MPH, FAAP

Rita Nathawad, MD, FAAP

Mikah Caldwell Owen, MD, MPH, MBA, FAAP

Kenya Maria Parks, MD, FAAP

Christopher B. Peltier, MD, FAAP

Laura Conklin, MPH

Dipesh Navsaria, MPH, MSLIS, MD, FAAP, Chairperson

Chidiogo “Diogo” Anyigbo, MPH, MD, FAAP

Mariana Glusman, MD, FAAP

James P. Guevara, MD, FAAP

Andrew Nobuhide Hashikawa, MD, FAAP

Anna Miller-Fitzwater, MD, FAAP

Bergen Ballard Nelson, MD, FAAP

Hilda Loria, MD, FAAP

Nicole Garro – Child Care Aware of America

Dina Joy Lieser, MD, FAAP – Maternal & Child Health Bureau

Rebecca Parlakian – Zero to Three

Maritza Gomez – AAP Section on Pediatric Trainees

Maya Bunik, MD, MPH, FAAP, FABM, Chairperson

Sahira Long, MD, IBCLC, FAAP, FABM

Emily Hannon, MD, IBCLC, FAAP

Ann Kellams, MD, IBCLC, FAAP, FABM

Temitope Awelewa, MBChB, MPH, FAAP, IBCLC, NABBLM-C

Tara Williams, MD, FAAP, FABM

Sharon Mass, MD, FACOG – American College of Obstetricians and Gynecologists Liaison

Larry Noble, MD, FAAP, FABM

Jennifer Thomas, MD, MPH, IBCLC, FAAP, FABM

Joan Younger Meek, MD, MS, RD, FAAP, FABM, IBCLC

Lori Feldman-Winter, MD, MPH, FAAP, FABM

Julie Ware, MD, MPH, FAAP, FABM, IBCLC

Kera Beskin, MPH, MBA

Lauren Barone, MPH

Munish Gupta, MD, Chairperson

Clara Song, MD, Chairperson Elect

Lily Lou, MD, Immediate Past Chairperson

James Barry, MD

Alexis Davis, MD

Brian Hackett, MD

John Loyd, MD

Craig Nankervis, MD

Ravi Patel, MD

Joshua Petrikin, MD

Shetal Shah, MD

Wendy Timpson, MD

Michael Posencheg, MD

Jim Couto, MA

We have received administrative support from Dana Bennett-Tejes and would like to thank her for her help and passion. We would like to thank Laura Conklin, Kera Beskin, Lauren Barone, and Zach Laris for their significant contribution to revisions. We also appreciate the support that Zach Laris provided during the writing process and all his advocacy efforts around the topic of paid family and medical leave.

AAP

American Academy of Pediatrics

FMLA

Family and Medical Leave Act

OECD

Organization for Economic Co-operation and Development

PFML

paid family and medical leave