Paid family leave

Evidence Rating  
Scientifically Supported
Evidence rating: Scientifically Supported

Strategies with this rating are most likely to make a difference. These strategies have been tested in many robust studies with consistently positive results.

Health Factors  
Decision Makers

Paid family leave (PFL) provides employees with paid time off for circumstances such as a recent birth or adoption, a parent or spouse with a serious medical condition, or a sick child. Some employers allow the use of other paid time off, such as sick leave, for these purposes rather than designating family leave; some employers also offer maternity and paternity leave. PFL may be provided by employers or via state-level programs. State programs vary in the amount of benefit and maximum length of leave provided, and whether leave is job protected1. PFL is distinct from the federal Family and Medical Leave Act (FMLA), which provides eligible employees with at least 12 work weeks of job-protected leave without pay2.

What could this strategy improve?

Expected Benefits

Our evidence rating is based on the likelihood of achieving these outcomes:

  • Increased labor force participation

  • Increased use of parental leave

  • Improved health outcomes

Potential Benefits

Our evidence rating is not based on these outcomes, but these benefits may also be possible:

  • Improved mental health

  • Increased preventive care

  • Increased breastfeeding rates

  • Improved birth outcomes

  • Reduced infant mortality

  • Improved well-being

  • Improved economic security

What does the research say about effectiveness? This strategy is rated scientifically supported.

There is strong evidence that short-term paid family leave (PFL) policies in the U.S. increase the likelihood that mothers remain in the labor force after childbirth3, 4, 5, particularly mothers without bachelor’s degrees4. PFL improves child and family health outcomes6, 7, 8, 9, 10, 11. It also increases use of parental leave to recover and care for children after birth3, 6, 12, particularly for mothers with lower levels of education and mothers who are Black or Hispanic5.

Paid family or maternity leave appears to reduce the likelihood of low birthweight births and pre-term birth9, particularly among unmarried mothers and Black mothers9, and can increase use of postpartum care, particularly for women of color13. Expansion of paid maternity and parental leave can increase breastfeeding initiation and duration10, 14, 15, 16, 17, though its effects may be concentrated in those already most likely to breastfeed, such as married, higher income, and older mothers18. However, one study of New York State’s paid family leave program suggests it may increase breastfeeding rates among Black women19. Access to paid family leave may improve mothers’ mental health7, 20, and those mothers who have a longer delay returning to work after giving birth may experience fewer depressive symptoms than those who return to work earlier10, 11. Taking paid maternity leave may also decrease the risk of hospitalization for mothers7 and infants7, 21, and may increase mothers’ exercise levels. International evidence suggests PFL may improve mental and physical health outcomes for mothers when fathers are able to take leave as well22.

Paid leave can improve child6, 23 and family health and well-being, and contribute to greater family economic security23. An analysis of California’s statewide PFL program indicates children born after the program was implemented have better health outcomes in elementary school, particularly children from less advantaged backgrounds, than children born prior to program introduction8. PFL is associated with improved mental health in those caring for family members with special health care needs24 and may reduce nursing home use among the elderly25. Access to paid leave can increase the likelihood of parents taking leave when their children have health problems17, 26, especially in families with children with special health care needs27. Paid parental leave may also increase access to immunizations and other preventive care17, 28, and may reduce child abuse29.

Early assessments of statewide paid leave programs in California and New Jersey suggest little impact on employers6, 30 and such programs may decrease turnover30. Programs may increase labor force participation31, hiring, and mobility among young women32, but also have potential for small decreases in employment and hiring1 and some increased unemployment, perhaps due to firms shifting hiring away from young women to men and older women31. Higher benefit levels may increase individuals’ leave duration as well as the likelihood that they are employed one year after taking leave30. International evidence from OECD countries suggests paid leave, in combination with other supportive programs including child care, increases women’s labor force participation33. Leaves shorter than one year may increase women’s employment rates for several years after childbirth, though leaves longer than a year may harm women’s employment, earnings and career advancement6. Similarly, in other high-income countries, access to paid, job-protected parental leave has been shown to increase infant and child health34 and reduce infant and child mortality34, 35, 36, with longer leave durations resulting in greater reductions in death among infants and young children37.

While PFL can increase men taking leave3, 30, 38, particularly job protected leave39, fathers appear to be less likely to take their full leave than mothers30, 40, 41. International evidence from OECD countries suggests that gender neutral paid parental leave does not appear to increase leave for new fathers but paid paternal leave with high wage replacement rates does34.

Evidence related to the use of PFL to care for older adults is limited, but one study of California’s PFL suggests it may increase employment among female caregivers 45-54 with earnings just above the poverty line and those with higher education levels. however, it does not appear to increase employment among those with lower levels of education and who live below the poverty line, perhaps because the wage replacement rate is too low. PFL alone may not mitigate the stress of ongoing and multiple care duties42.

Barriers to taking paid family leave include lack of awareness of the program, misconceptions about whether a worker qualifies, the complexity of the application process, lack of job protection, employers discouraging leave-taking or providing incorrect information, insufficient benefit levels, insufficient flexibility for intermittent leave (for caregivers of older individuals), and lack of enforcement of leave-taking rights43.

Experts suggest that the U.S. create a publicly-administered paid leave program with a progressive benefit structure and inclusive coverage, with additional policies supporting workers’ access to leave and public education and community engagement on the program, in addition to child care policy reform44. Leave benefits should include caregiving for older adults44, 45.

How could this strategy advance health equity? This strategy is rated potential to decrease disparities: supported by some evidence.

Paid family leave has the potential to decrease disparities in women’s economic conditions and health outcomes3, 7, 10, 11, 20, 23, 34, particularly for mothers with low incomes54, women of color5, 9, 13, and those with less education ,4, 54. Creating a comprehensive national paid family leave policy is also a suggested strategy to reduce disparities in income, health, and access to leave for workers across racial and economic groups7, 14, 45, 55, 56, 57, 58, 59.

Paid family leave used following a birth may reduce poverty and increase income for mothers, particularly single mothers with lower incomes and less education54, and can increase return to work after having a child rather than dropping out of the labor force3, particularly among women with less education4. State PFL programs can increase use of leave after having a child, especially among women with less education, women of color,5 and women with lower incomes40 and may close the gap in amount of leave taken between Black and white mothers5. PFL can help create workplace cultures that are more female-friendly by increasing the number of women in leadership60.

Paid family leave has the potential to increase gender equity by increasing men’s participation at home58, but so far women are more likely to take PFL14 and fathers are less likely to take their full leave allotment30, 40, 41, which could exacerbate the earnings gap between genders14. International evidence indicates availability of PFL increases the use of leave for both men & women30.

In New York State, men and women with lower incomes were more likely to take PFL when the state-wide program was introduced, perhaps due to lack of paid leave from their employers. Employees of color and those with lower incomes were more likely to take the full 8 weeks of PFL available, possibly due to the high costs of child care upon returning to work40.

Current programs have room for improvement. D.C.’s program saw uneven take up rates in its first 18 months, with equal numbers of whites and Blacks making claims, despite Blacks being the largest group in D.C., and higher rates of denials in majority Black wards61. In California, workers with the lowest earnings may take shorter leaves30 and are also the least likely to take any leave41, and the program may not be generous enough to benefit caregivers of older adults living below the poverty line and those with lower levels of education42. More general evidence from the U.S. and Canada on maternity and parental leave suggests individuals with the lowest incomes may take shorter leaves7, 62 and be less likely to take any leave than parents with higher incomes7, 41.

Black women and lower- and middle-income women are less likely to take maternity leave, paid or unpaid7. Black and Latina women are also more likely to be providing high intensity caregiving for parents63 due to higher rates of chronic disease and an increased likelihood of living in multigenerational households58, and as such have more negative health, economic/financial, and employment consequences due to providing uncompensated care. These conditions perpetuate a cycle of disadvantage among families historically prevented from building generational wealth by structurally racist policies and practices63. During the COVID-19 pandemic, workers from groups marginalized in U.S. society were more likely to miss work, and to go without pay due to the lack of paid leave, including workers with low incomes, people of color, women, and families with children. Additionally, women were disproportionately responsible for child care and other family obligations, and their absences were the least likely to be paid. The lack of universal paid leave combined with the COVID-19 pandemic compounded economic and health disparities between families with high incomes and most other families55.

The Family and Medical Leave Act (FMLA) provides unpaid, job protected leave, but unpaid leave does not appear to provide the same potential health and economic benefits as paid leave. Evidence from FMLA suggests unpaid maternity leave may actually increase disparities, as its benefits are concentrated among those who can afford to take it34.

To create more equitable paid family leave, experts suggest programs include job protection39, 47, 55, anti-discrimination and anti-retaliation provisions47, progressive wage replacement47, 55, and at least 12 weeks of leave47. Programs should cover part-time and gig workers, include all firms no matter their size, and have broad coverage and eligibility requirements55. Programs should also tie paid leave to the worker and their work and earnings history, rather than a specific job or employer47 and should include education and outreach about the program and benefits, and enforcement provisions47, 56. A permanent federal program could also include clauses to expand reasons for leave (such as child care) and length of leave in case of future public health emergencies such as that presented by the COVID-19 pandemic55. For example, California and Rhode Island could immediately provide coverage to workers, before federal emergency paid leave programs began64.

What is the relevant historical background?

Programs that built the U.S. middle class excluded families of color, limiting their ability to build wealth through homeownership and access to banking institutions, and programs lowering the cost of college47. State marginalization of Black workers also meant they were largely excluded from social welfare programs65. Today, workers of color are generally paid less and are more likely to be in low-wage jobs that don’t offer benefits such as leave47. Black and Hispanic women specifically are less likely to hold jobs with paid leave due to occupational segregation and previous policy choices benefiting workers who are salaried or in professional fields66. All this leaves workers of color particularly vulnerable when needing leave, with little in the way of savings or assets to rely on if leave is unpaid47.

Legislative origins for paid family leave in the U.S. started with paid maternity leave, which first began in the 1978 Pregnancy Discrimination Act, which prohibited discrimination related to pregnancy and childbirth67 and provided wage replacement through temporary disability insurance. This policy increased labor force participation among pregnant women and women with young children68. In the mid-1980s, bills were introduced to provide unpaid, job-protected leave, but these were not enacted. Opponents successfully pushed for companies with fewer than 15 employees to be excluded and reduced the unpaid leave available from 44 weeks per year to 36 weeks over a two-year period. Advocates for retirees successfully expanded leave eligibility to include caring for a spouse or elderly parent. Congress passed the Family and Medical Leave Act (FMLA) in 1990 and 1992, but it was vetoed both times by President George H.W. Bush, who did not support requiring businesses to provide paid leave67. In 1993, the FMLA was signed into law by President Bill Clinton. It allows for 12 weeks of unpaid leave per year and does not cover all workers47. Limited expansions to FMLA since 1993 include coverage for spouses in same-sex marriages.

Approximately 60 percent of low wage workers do not qualify for FMLA, including many women, people of color, single parents, and part time workers56. Women of color have less access to leave than white women and are generally paid less even when they do have leave66. Households of color are also more likely to be multi-generational, entailing additional care burdens47 and Black women have higher rates of pregnancy complications and mortality, making their lack of access to paid parental leave particularly concerning.

Discriminatory policies and systems have resulted in a low-wage work force largely made up of women, people of color, and immigrants69. Workers with the greatest needs have the lowest access to paid leave70: low wage workers14, 71, 72, women72, people of color14, 61, 70, part time workers72, and single parents14 are significantly less likely to have access to paid family leave, and structural and historic racial inequities in U.S. economic systems mean that Black, Hispanic, Native American, and Pacific Islander workers are significantly less likely to have access to any leave73. Most of these workers cannot take necessary leave due to being unable to afford lost wages14, 56, 73. Those without paid leave are more likely to be uninsured, have trouble paying bills such as rent and utilities, and have unmet medical needs70. Only 23 percent of private-sector workers have access to PFL74, and only 6 percent of low wage workers do75.

The lack of supportive policies in the U.S., including paid family leave, has negative impacts on caregivers, most often women. Such impacts include reduced labor force participation and harms to economic well-being, including the ability to build wealth, advance a career, own a home, and save for retirement, which is associated with worse physical and mental health43. While gender differences in access to paid leave may be attributable to women’s higher likelihood of working in part time jobs72, this occupational segregation may be due to previous systematic efforts to “protect women” through their exclusion from large swathes of the workforce68. Caregiving has traditionally fallen to women, limiting their ability to work and advance in careers. These barriers continue for working women today58, with women giving up paid work to provide informal care for children or other family members42, a pattern exacerbated during the COVID-19 pandemic when school closures and family care needs led over 800,000 women to leave the labor force within 6 months57. Lack of leave likely increases vulnerability44 alongside the U.S. child care crisis, limited publicly-funded pre-K, and removal of reproductive rights76.

In recent decades, local paid sick leave laws have been a subject of state-level policy preemption. Lawmakers have used state-level preemptions as a tool of structural racism, preventing the expansion of local policies that could reduce racial inequality77. However, state or federal preemption can be used to protect and expand local policies that reduce health inequities, as in the case of civil rights laws78.

Some states offer greater unpaid leave than the FMLA or versions of paid leave, with 50-100% of wage replacement. The 12 weeks allowed under the FMLA fails to meet the International Labor Organization’s recommended standard for maternity protection, which is 14 weeks of leave for new mothers with at least two-thirds of wage replacement79. The U.S. remains the only OECD nation without a national paid family leave policy67, 80.

Many countries in the global North and South had enacted national paid maternity leave policies by 192581. Parental leave policies are designed to reduce financial and opportunity costs of parenthood and work-family conflict which threatens parents’ emotional and financial well-being80. A study of OECD countries finds that a stronger package of national policies supporting working parents, specifically paid leave and work flexibility, is associated with greater emotional well-being among parents80. Lack of investment in children and parents leaves the United States falling behind the rest of the OECD based on social and economic indicators33.

Equity Considerations
  • Who doesn’t have access to paid family leave in your community? Are there specific groups or industries that are most in need but lacking access?
  • How do preemption laws impact your ability to implement paid family leave?
  • Who is opposed to paid family leave expansion and what is at the root of that opposition? What role can public health play in (re)framing the discussion?
  • What community partners can assist in efforts to expand paid family leave? Is there a history of labor organizing or labor partners in your community who could be involved?
  • If you have paid leave laws in place, do the laws include job protection? Are all types of workers eligible? Are different industries or business sizes exempt from participating?
Implementation Examples

Legislation guarantees paid leave for eligible employees in California, Connecticut, Massachusetts, New Jersey, New York, Rhode Island, Washington, and Washington, D.C.46, 47, 48. Paid family leave laws have also been passed in Oregon, Colorado, Delaware, and Maryland46 and will begin paying benefits over the next several years: Oregon in 2023 49, Colorado in 202350, and Delaware and Maryland in 202351, 52. Georgia, New Hampshire, and South Carolina offer paid parental leave to state employees46. The U.S. is the only OECD country that does not provide paid parental leave (Adema 2016). As of 2019, state legislation pre-empts local laws requiring employers to provide paid family leave in Alabama, Arkansas, Florida, Georgia, Indiana, Iowa, Kansas, Kentucky, Louisiana, Michigan, Mississippi, Missouri, North Carolina, Ohio, Oklahoma, South Carolina, Tennessee, and Wisconsin53.

Implementation Resources

Resources with a focus on equity.

ABB-US PFL laws - A Better Balance (ABB). Comparative chart of paid family and medical leave laws in the United States. 2022.

AIC-PFL - All-In Cities, an Initiative of PolicyLink. All-In Cities Policy Toolkit: Paid family leave (PFL).

BPC-PFL 2022 - Bipartisan Policy Center (BPC). State paid family leave laws across the US. 2022.

CLASP-Baldino 2022 - Baldino N, Perez R. Early lessons from DC’s paid leave program. Washington, DC: Center for Law and Social Policy (CLASP); 2022.

FVW-Paid leave resources and toolkit - Family Values @ Work (FVW). Guides and resources.

Hamilton-Byker 2021 - Byker T, Patel E. A proposal for a federal paid parental and medical leave program. The Hamilton Project. Washington, DC: Brookings Institution; 2021.

NCSL-PFL resources - National Conference of State Legislatures (NCSL). Paid family leave resources.

NCSL-State leave laws - National Conference of State Legislatures (NCSL). State family medical leave laws.


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