illustration of a Black woman, looking tired, holding a baby in her lap. A bottle sits atop a stack of books next to her

Care Crisis

Can We Fix Our Family-Leave Policies?

Americans have to return to work two weeks after giving birth—without a guaranteed paid day off. Parents cobble together time off, often racking up debt. Which is why Biden needs to enact a comprehensive plan.

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Molly Jewell never expected childbirth to be so debilitating. Jewell, then a 30-year-old admissions counselor in the music department at Vanderbilt University in Nashville, had “breezed” through her pregnancy. She’d expected her recovery to be similarly easeful. To support her transition to parenthood, she’d arranged 12 weeks of paid time off, using a combination of sick leave, short-term disability, and her employer’s leave for new parents. But her labor and birth were tough. During birth, she suffered a third-degree laceration—her perineum tore into the muscles around her sphincter—and, in what would come to haunt her, her epidural was twice placed incorrectly.

Days later, back at home, things started to get worse. Jewell had not had a bowel movement since she gave birth. Concerned and uncomfortable, Jewell made a doctor’s appointment; the physician advised her to drink a cup of coffee to relieve her constipation. “Long story short, my husband had to take me to the ER because the sutures [on her perineal laceration] ripped,” she said. “It was horrible … One of the most traumatizing things I’ve ever experienced.” At the hospital Jewell was given multiple enemas and “every laxative in the book.” When those failed, she had another epidural and an operation to disimpact her bowels. At home days later, she experienced headaches so intense she could not open her eyes; the epidural had caused a blood leak in her spine, which required another hospitalization.

The perineal laceration was slow to heal; it took seven weeks for Jewell to be ready to take “really slow walks” with her son in his stroller. But then, she says, “I felt so happy because I was finally getting to do things with [the baby]. And my mom was like, ‘Let’s go to Target.’”

When Jewell put a box of wipes on the checkout belt, she felt “a really strange pop” in her body. “It felt so tiny, and yet I felt sick—like I was going to throw up when it happened,” she recalls. “I couldn’t catch my breath.”

Jewell hoped the feeling would pass. When it didn’t, her panic mounted. In the parking lot, she realized she couldn’t lift her son into his car seat. “I was afraid to tell [my mother], because I didn’t want her to worry about something else, and I didn’t want to go back to the hospital,” says Jewell. “That was the first [spinal] fracture, I later found out. I got seven all and all.”


The United States remains one of three countries worldwide that does not guarantee access to paid leave for those who are birthing or adopting children. Federal law guarantees up to 12 weeks of job-protected, unpaid leave to care for a new baby. But because the law applies only to businesses with at least 50 employees, and to a person who has worked at least 1,250 hours, at the same business, for a year, FMLA does not cover about 40 percent of the American workforce. The Netherlands offers at least 16 paid weeks; the U.K., 52, two weeks of which are mandatory; Canada offers 15 paid weeks plus 35 paid weeks of parental leave. By contrast, in the U.S, people return to work an average of two weeks after giving birth—without a single, guaranteed paid day off. To stretch time off, like some of the ten people interviewed for this story, parents cobble together vacation, sick, or personal days; use short-term disability; rely on credit cards; request modified duties; bring infants to work; or go unpaid. One person saved her sick leave for nine years.

President Biden’s new “Build Back Better” proposal, a $3 trillion plan that the administration is presently developing, is slated to include a national paid leave program. Pressure is mounting for it to do so.

The need for paid leave is especially stark following physically traumatic births, like Jewell’s. But any birth demands more than two weeks to recover. “At the minimum—the minimum—it’s 13 weeks,” says Helena A. Grant, director of midwifery at Brooklyn’s Woodhull Hospital. But really, “it’s a year,” she says. “Even if a birth is gentle the body will sustain injury. A woman can have a [small] laceration which is completely normal—baby needs space to come out and that needs to heal. It burns when a woman urinates as the lacerations of all sizes heal. She will lose blood, which will deplete her iron stores, her electrolytes. She’ll be physically exhausted, emotionally exhausted. When the placenta is released, the hormones immediately decrease. She is in a state of unbalance.”

Some physical problems don’t even show up until a person returns to work, says Dr. Ashley Hocutt, a pelvic-floor physical therapist in Poughkeepsie, New York. And even if tissue has healed, from a perineal tear, say, that doesn’t mean their function “has resumed to what their normal is,” or that they are ready “to return to work,” she explains.

Yet the impact of paid leave on new mothers’ physical well-being has not been widely investigated, perhaps because only a paltry 21 percent of civilian workers in the U.S. have access to it. The few studies on it show it is associated with lower hospitalizations and that it reduces maternal stress—itself a factor in poor maternal health.

But the paucity of research on the topic is emblematic of a larger problem: We focus more on infants’ health than on birth parents’ physical and emotional experiences. So even as childbirth in the U.S. has become safer for infants (despite racial and economic disparities), it’s become far more dangerous for people carrying babies—and for Black and Indigenous people in particular.

What’s more, pregnancy and birth can be so difficult—at times, unexpectedly so—that even people who have access to paid leave, like Jewell, rarely have enough of it. Despite our culture’s obsession with how quickly new mothers “bounce back,” the often slow and painful recovery is largely absent from the national conversation, even though, according to the Centers for Disease Control and Prevention (CDC), a third of pregnancy-related deaths occur in the year after a baby’s birth.

“Women are supposed to work, work, work—no matter what field,” says Grant. “You are expected not to honor the physicality of what it takes to create another human in your body.” She traces the country’s lack of paid leave to the brutal spectacle of slavery. “As a Black woman, I feel like it comes from seeing the tenacity of women who were brought here, enslaved, and forced to do plantation work and breed,” she says. “Have a baby and get right back to work.” In time that legacy became harmful for all American women, she says.

As a result, many new parents return to work before they are physically ready, sometimes hiding conditions from colleagues. Hocutt recalls a patient, a nurse with fecal and urinary incontinence, who was so worried she’d have an accident, she did not eat or drink for the duration of her shift.

The inadequacy of paid leave “puts women in a place of … choosing between financial support or health support,” says Kiley Mayfield, birth equity policy analyst at the National Birth Equity Collaborative (NBEC), an organization that advocates for Black maternal and infant health through policy advocacy, training, research, and community work. “We shouldn’t have to be placed between those two burdens. Paid leave would eliminate that hard decision.”


Despite being the first and youngest person to achieve the rank of sergeant at her jail in New York’s Warren County, corrections officer Julia Barton was unemployed for much of her pregnancy. When Barton became pregnant, she says, her employer did not accord to the stipulations of her doctor’s note. (She is suing her employer.) Nor does the jail offer paid family leave. Concerned for her own and her baby’s health and safety, she stopped working early in her pregnancy. After draining her six weeks of accrued sick leave, she went on disability, which at around $150 a week, barely covered her car payment—to say nothing of her mortgage, cell phone, water, electricity, gas, or groceries.

When the disability payments ended, months before the baby came, Barton had no income at all.

To keep herself afloat over the course of seven months, Barton took out loans totaling over $10,000, racked up credit card debt, and enrolled in public insurance. The financial stress drove her to snap at her mother and her husband, and sapped the joy from setting up a nursery and buying a crib.

When her daughter was born, in April 2019, she couldn’t stop crying. Was it from happiness? the nurses attending her asked. Pain? “I just shook my head,” says Barton. It was the thought going through her mind: “Thank God it’s almost over—the battle is almost done,” she remembers. “I can almost go back to work.”

When it was time for her to go home, the nurses gave her information about the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and community groups that support new mothers; she’d overheard the nurses wondering why she, a corrections officer, was on public insurance. Barton had been stereotyped as a low-income, unemployed new mother, which hurt her; she had been only the second woman to achieve the rank of sergeant at her jail, had put herself through “misery” working at her job. “They were like WIC, do you need WIC?” she remembers. “I was like, No. Like, if you guys only knew.

Barton had ended up with a fourth-degree tear, which she says healed quickly. Still, during her recovery, her stitches had to be clipped, and she had intermittent “pinchy” pain that was distracting—a constant pain, she says, she could have dealt with better. Eight weeks after the birth, she returned to work. She tried to pump in a conference room, but eventually, to her chagrin, gave up: There were dirty dishes in the sink; people with keys to the room frequently interrupted her; her shifts, which could last as long as 17 hours, made it difficult to keep up a regular pumping schedule.

Two years later, Barton is still paying back the debt she accrued. The payments are irritating, she says, but she is focused on the long game: bringing paid family leave to her job. “I’m looking at all these young girls we’re hiring and who could make this a career. I wanted a change not just for myself and future children but also for other people getting hired.” She is still waiting.


As with other benefits, people who do not have paid leave are disproportionately Black, Latinx, or low income. Grant recalls a patient in a work-release program who, in the last few weeks of her pregnancy, in the summer rain and heat, was supposed to pick up trash in New York City parks.

Such inequities are further exacerbated by inequalities that shape people’s lives before and during their pregnancies, like access to safe housing, transportation, food, and equal pay for equal work. For Black women in particular, the stress of returning to work before they are physically ready compounds the weathering they experience throughout their lives.

Frankie Robertson, who runs her own consulting firm in Baton Rouge, Louisiana, on the social inequities of health, recognizes that toxic stress stemming from structural racism’s impacts on society shaped her 2017 pregnancy. Following Alton Sterling’s 2016 death—the Black man shot and killed by two white police officers in front of a convenience store in Baton Rouge—Robertson, now 44, felt called to make public life safer for her son, then one. She threw herself into activism against police brutality against Black people. But the activism took a toll, she says. A year later, shortly after a diagnosis of depression, she found out she was pregnant.

At the time, Robertson was also becoming aware of the dangers facing pregnant Black women in the United States, regardless of education or income. She recalls reading about Dr. Shalon Irving, the CDC epidemiologist who died from high blood pressure-related complications weeks after her daughter’s birth. “It frightened me,” Robertson says. “My heart started racing for days and it didn’t stop.” Robertson identified with Irving: “I’m a Black woman, I’m 41 years old, I have a college degree, I meet all of these statistics—and I’m scared,” she says.

At 27 weeks, Robertson was hospitalized for pregnancy-induced hypertension. She stabilized, but because her daughter wasn’t receiving enough oxygen, she had an emergency C-section. Robertson’s daughter would stay in the NICU for 56 days, nearly the duration of Robertson’s paid leave. “As I was sitting there at the NICU, and watching my time trickle down for my leave, I started thinking: What on Earth is a woman doing who has no leave?

Later, Robertson wondered, “Did I do this wrong? Was I too active? Should I have turned the news off because all these things are stressing me out? Should I not have been an activist the year leading up” to the pregnancy? But, she says, “These societal issues, these larger structures—they do chip away at us. That’s the essence of weathering, whether you know it or not.”


That day in Target, Jewell thought she’d thrown out her back. Over the following weeks, she grew more debilitated; at a checkup for her laceration, she was in so much pain a nurse had to help her undress. She couldn’t pick up her baby. Soon she even struggled to put her hair in a ponytail.

Eventually an X-ray and MRI revealed Jewell’s seven fractured vertebrae. An orthopedist ordered a brace and told her the fractures would heal on their own. “‘You can go to work,’” she recalls him saying. “‘You just need to wear the brace and be as careful as possible.’” So she did. But that first day when she arrived back at work, she was too weak to open the door to her building.

Jewell would be diagnosed with pregnancy-associated osteoporosis (PLO), a disorder that affects some 200,000 lactating and pregnant women in the U.S. every year, and that results in bone loss, particularly in the spine. Her endocrinologist delivered the stunning news that Jewell would need to take another three months off of work “at a minimum.” She also recommended that Jewell go to an in-patient rehabilitation center for two weeks.

These were some of Jewell’s darkest days; she felt so lonely and disconnected from her baby. She’d had to stop nursing, because lactating worsened osteoporosis. Weaning was devastating. After nearly two months of not being able to pick him up, breastfeeding “was the only offering I had.”

Even before the birth money was tight; Jewell had used savings and a loan for fertility treatments. Now, because Jewell could not be alone with her baby, she needed to pay a sitter while her husband worked. Her husband took on extra gigs bartending and landscaping, her parents pitched in on child care, and colleagues donated more than $1,000. She is especially lucky, she says, because her long-term disability kicked in, supporting her—at a fraction of her salary—for what would be an additional four months off from work.


Some nine states and the District of Columbia have enacted paid family leave through insurance programs, funded by employers; by employees who pay for them through payroll contributions; or both. Other states are considering such programs, including New Mexico, Minnesota, and Delaware, and Connecticut’s is slated to begin in 2022.

Such social insurance systems are a “sustainable and affordable” way to support paid leave, says Molly Weston Williamson, director of paid leave at A Better Balance, a nonprofit that advocates for paid family leave and pregnant workers’ rights. The most useful ones are flexible, Williamson says, allowing employees to use paid leave for postpartum and prenatal needs.

But NBEC’s Mayfield cautions that states that most need such programs—those with the worst maternal health outcomes for Black women, like Mississippi and Louisiana—are unlikely to adopt them. What’s more, even states with such policies do not cover all workers, as Barton experienced.

Even as states adopt these programs, A Better Balance and other organizations continue to push for a national paid leave program. But a federal policy needs to be carefully constructed, says Dawn Godbolt, Policy Director at the National Birth Equity Coalition, given that the U.S. has “a history of constructing federal policy in a way that doesn’t offer the same benefits” to Blacks as whites. Too often, she cautions, provisions “exclude people” based on the number of hours they work or the type of work they do. “That creates a new structure and a new system to further marginalize people, and locks people out of high incomes and financial goals and family planning,” she says.

Because pregnancy and birth can have unpredictable outcomes, Mayfield and others argue that new legislation should include people who have had stillbirths and miscarriages, perhaps even people whose babies require extended NICU stays, like Robertson’s. (The U.K., New Zealand, and Canada’s Ontario province provide paid leave for stillbirth or miscarriage.) And Williamson, Grant, and others say that a robust program would also support a range of caregivers—partners, mothers, friends, cousins—to take paid leave to support their loved ones’ recoveries.

Jewell returned to work more than seven months after her baby’s birth. “I had the time I needed, but it was because of what happened to me,” she says. “I feel very lucky in the fact that I did have a lot of options for leave, and partially paid leave, and that my job was protected,” she says. “I know that not everyone is in that boat.”

Grant insists that we look more closely at what it means to recover from pregnancy and birth. “The economic instability” that women “feel like they’re causing if they do not go out and fry the bacon and be breadwinners … is a physical, psychological, emotional and spiritual torture,” she says. “If we had paid leave we would have a healthier society. Period.”

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