•Identify a policy that is not usually intended to be a health policy but that you think may have important health implications.
As described in a systematic review by Borrell et. al (2013), gender policies are important in enforcing the promotion of gender equality, and target existing gender inequalities in power, income, paid and unpaid work, and use of time. While most countries have some sort of parental leave policy, they differ in length, with the U.S. having notoriously shorter leaves. Parental leave policies secure women’s income during leave and their return to work while promoting mother and infant well-being. Similarly, paternity leave policies further promote gender equality by facilitating greater involvement of fathers in childcare and mothers in the labor force.
•Describe why an evaluation of that policy is informative (primarily about the policy, or primarily a test of hypothesized mediators?)
Despite having a longer life expectancy, women suffer more than men from nonfatal, disabling physical and mental illnesses and live fewer years in good health (Verbrugge 1985, Glei 2007)). Investigating both the biological and sociobehavioral differences are important to identify the mechanisms through which this occurs, but evaluating the mechanisms through which societal laws and pressures promote income and health differences by gender may also reveal modifiable risk factors. When women have less access to paid work, worse paid jobs, lower salaries for the same jobs (and therefore, lower pensions), this results in having unequal access to income, a strong promoter of health. Alleviation of these gender equalities impacts health, especially for women, through mechanisms such as reduction in stress, discrimination, violence, financial difficulties, poverty, double burden of work, or time pressure.
•Specify the outcomes and populations you think most affected or least affected by the policy.
- While maternity leave has been shown to have beneficial results for fathers, it is mothers and their infants who would be most affected. Furthermore, the job security, promise of income upon return, and likely maintained health insurance coverage by their employer protect mothers from poverty, thus highly impacting poor, single mothers who would otherwise be vulnerable to slipping into poverty if they do not return to work promptly after delivery.
- As for outcomes, mental health in the postpartum period is extensively researched, with longer leaves associated better self-reported health status and with reductions in depressive symptoms (Chatterji 2005). It is possible that longer maternity leave could result in fewer illnesses, physician outpatient visits, hospitalizations, and clinical symptoms of depression. Self-reported overall health would also likely be affected, as would reduction in stress, workplace discrimination, and financial insecurity, which have all been shown to act as mediators of health. Mothers being able to maintain health insurance coverage through their employer would also impact access to quality care, child immunizations, and postpartum screening for depression, urinary incontinence, poor healing, etc. Furthermore, the longer length of maternity leave has a dose response effect with the duration of breastfeeding (Ogbanu et. al 1997), leading to less illness, less allergies, higher IQ, and improved immune function in the infant that will set the baseline for health in later childhood and adulthood. Women may also feel more comfortable taking a maternity leave that extends into the antenatal period, which will prevent women from waiting until the last minute to use their limited maternity leave. As found by Guendelman et.al (2009) and Xu et. al (2002), antenatal leave reduces the odds of delivering my c-section, preterm delivery, and the presence of an intervention or complication during delivery.
•Propose a study design to evaluate the policy
As the U.S. has a notoriously short maternal leave policy, there have already been several observational studies looking at international comparisons. However, it is difficult to draw comparisons when there is a multitude of differences between countries. I would propose a prospective longitudinal study within a company or business that has multiple sites throughout the United states. Sites would be randomly selected to either maintain the current maternity leave policy, or have employees be given the option of an extended paid parental leave similar to that of northern European countries. Locations would be stratified to be equally representative of neighborhood characteristics and socioeconomic characteristics of their employees for a valid comparison. Long term health and financial outcomes (as listed in response to question above) would be longitudinally tracked for mothers, fathers, and infants.
–Describe biggest challenge to implementing and drawing inferences about the impact of the policy on health
Convincing companies to employ this policy change would be difficult without financial backing and promise of improved outcomes and productivity of their employees. Care would need to be taken to ensure that the locations of company sites are comparable and without risk of confounding characteristics. Furthermore, loss-to-follow up and the extensiveness of a comprehensive survey would impede data collection.