MCH Leads Health Equity Edition – In order to advance health equity for MCH populations, beginning January 2023, MCH Leads will feature trainees’ health equity-focused work. We look forward to highlighting trainees’ experiences supporting the health and well-being of vulnerable and underserved populations and communities. Also, their work assessing and addressing the underlying causes of health disparities–and their efforts to promote diversity, equity, and inclusion–ultimately improving MCH outcomes. In addition, we encourage trainees to reflect on how the MCH Leadership Competencies are applicable to their health equity-focused stories.

Karah Waters

Karah Waters graduated in the Spring of 2023 with her Master of Public Health degree with a concentration in Maternal and Child Health (MCH) from the University of South Florida (USF) College of Public Health and received a graduate certificate in Infant and Family Mental Health. She became an MCH Scholar at the USF Center of Excellence in MCH, Education, Science, and Practice in the Fall of 2022. Her expertise is in perinatal health, infant and family mental health, and child development. Before pursuing her master’s degree, she graduated from Belmont University in Nashville, TN in 2017 with her Bachelor of Science in Nursing (BSN) and worked in a wide array of settings as a registered nurse (RN) both domestically and internationally. One of her most meaningful jobs before graduate school was working as a nurse-home visitor with the Nurse-Family Partnership program serving low-income, first-time mothers and families in Colorado Springs, CO. In this role, she was able to cultivate self-efficacy in the parents she worked with, prevent adverse childhood experiences while nurturing positive childhood experiences, and promote healthy pregnancies and child development. She became a certified lactation counselor (CLC) so she could better support mothers in lactation, which in turn helps promote secure attachments. Creating an even better world gives Karah purpose. She is excited to continue working in community settings with vulnerable populations by implementing programs that strengthen infant and family mental health through nurturing 0-3 social and emotional development and giving parents the support they need to create healthy relationships with their children. Healthy children start with healthy families. If you’re interested in connecting with Karah and learning more about her work and passions, you can find her on LinkedIn and Instagram!

Competency 2: Self-Reflection

During my time at USF, my passion for lactation and family-centered care continued to grow. The Summer of 2022, I did a lactation internship with A Breastfeeding and Childbirth (ABC) Program at Champions for Children, a non-profit organization in Tampa, FL. This experience gave me the opportunity to work with breastfeeding mothers in the community setting. I went to Baby Cafés throughout Hillsborough County in underserved areas where breastfeeding support was limited. 

This opportunity evolved into a leadership internship for my Applied Practice Experience course in the Spring of 2023 where I worked directly under the ABC Prenatal and Lactation supervisor. I helped with creating outreach materials and prenatal flyers informed by public health, putting together outreach lists and delivering materials to community agencies and clinics throughout Hillsborough County, and evaluating postpartum doula services in terms of breastfeeding support and continuation through developing, piloting, and validating a survey in hopes to renew and expand funding for this service. I also received training from the supervisor on creating and handling budgets; leading and managing a team; interviewing and hiring; and attending events for community outreach. 

This experience taught me the importance of being an authentic leader and helped show me that one of my leadership qualities is being soft-spoken. I am slow to speak and quick to listen to those around me so that I have a better understanding of the situation at hand. I also have a better grasp of working in the non-profit sector. Moreover, this experience opened my eyes to what lactation work looks like in a community setting and gave me a better understanding of how the protective factors framework applies to breastfeeding. Breastfeeding promotes secure attachments and bonding, thus mitigating child maltreatment. Serving communities in rural areas that lack infrastructure and resources is very important to me as I am from a rural town in TN. A goal of mine is to return home and help implement more Baby Cafés throughout the state of TN. 

Competency 12: Policy

My experience in the public health arena throughout my nursing career and during my time in graduate school has given me the ability to promote and protect the health of people and the communities in which they live, implement and evaluate programs, and advocate for social determinants of health. One way to advocate is to make my voice heard through creating a policy brief that is supported by the literature. The one that I wrote for a course is below and focuses on promoting lactation in the U.S. The audience for this brief was for those who are responsible for creating and/or influencing policy (i.e., policymakers, employers, stakeholders, etc.). 

I thoroughly enjoyed writing this policy brief as it was my first exposure to writing one. Since it was for a course assignment, I really let my creative outlet come alive and tried to capture the reader’s attention with the title. Also, I was too optimistic and overzealous with what I wanted changed in policy: six months of paid maternity leave. In reality, starting off with requesting for three months would get more buy-in and be more likely to pass. A tool that helped me write this brief was the fishbone diagram. This is a visual diagram that allows you to see the root causes of a problem instead of focusing on the mere symptoms. I was able to see the underlying issues the current policies were not addressing. Throughout the writing process, I learned the importance of being concise and getting all of the major points across as clearly as possible and backed up with evidence-based sources. It was my goal to consider both sides of the political spectrum and write accordingly, as I feel strengthening maternal and infant health is bipartisan. Later in my career, after I have gotten more experience and exposure to implementing MCH programs, I hope to be involved in public policy since this is where the largest lever of change and influence is. If you are interested in reading some more of my work that focuses on policy change for this population, here is my recent research study that was published in the Journal of Pediatric Nursing titled, The association between parent-child quality time and children’s flourishing level. In the practice implication section, it discusses how nurses can advocate for programmatic and policy changes to ensure familial work/life balance and licensing/accreditation of all child centers.

Policy Brief

Need Milk? Addressing the Cries of Infants Lacking Their Mother’s Milk

Executive Summary

Breast milk has all the nutrients an infant needs for the first 6 months of life (World Health Organization [WHO], 2019). This makes it the best preventative health care because it does not cost the government anything whether it be state or federal. Shockingly, breastfeeding rates drop by 40% when looking at infants who were exclusively breastfed at 6 months compared to when they were first born (American College of Obstetricians and Gynecologists [ACOG], 2021; Centers for Disease Control and Prevention [CDC], 2021b; Feltner et al., 2018; Grubesic & Durbin, 2019; United States Department of Health and Human Services [HHS], 2020). One of the main reasons for this is due to the current federal maternity leave policy (ACOG, 2021; Boushey & Glynn, 2012). Too many mothers have to go back to work sooner than they would like, and breastfeeding suffers.

The current Family and Medical Leave Act (FMLA) of 1993 needs to be reformed because as more women enter the labor force (as of 2019 57.4% of women were working) they need to have an appropriate amount of time off so that they can be a well-balanced mother (U.S. Bureau of Labor Statistics, 2021). The current act does not allow for work/life balance, sufficient bonding time with the newborn, and an appropriate amount of time for breastfeeding to occur (Boushey & Glynn, 2012; Office of the Surgeon General, 2011). This policy brief is a call to action for policymakers to improve the well-being of mothers and infants across the U.S. by extending the current FLMA from 12 weeks of unpaid leave to 6 months of paid maternity leave.

Statement of the Problem

One of the biggest factors impeding mothers’ ability to breastfeed exclusively for the first 6 months of life in the U.S. is not having paid time off during an infant’s first 6 months of life (ACOG, 2021; CDC, 2021). When mothers have to stop breastfeeding in order to go back to work the short and long-term benefits and protective factors of breastfeeding for both the mother and infant are impacted. Infants that are not breastfed are more likely to have sudden infant syndrome (SIDS), gastrointestinal issues such as constipation, diarrhea, and upset stomachs, childhood infections, and their chances of becoming obese, developing asthma, and having type 1 diabetes are increased (ACOG, 2020; CDC, 2021a; Feltner at al., 2018; Grubseic & Durbin, 2019; New York State Department of Health, 2015; Panzera et al., 2017; WHO, 2019). Mothers who do not breastfeed are more likely to struggle to lose their pregnancy weight, can struggle to bond with their child, and are at an increased risk for developing ovarian and breast cancer as well developing type 2 diabetes and having hypertension later in life (ACOG, 2020; CDC, 2021a; Feltner at al., 2018; Grubseic & Durbin, 2019; Panzera et al., 2017; WHO, 2019). 

Returning to work is a significant barrier to breastfeeding not only because of minimal maternity leave benefits but also because of work environments not being conducive to breastfeeding (Office of the Surgeon General, 2011). Work hours tend to be inflexible, there is limited privacy for expressing milk, and there are not many appropriate places to store breast milk (Office of the Surgeon General, 2011). Moreover, it is difficult to find daycares near work (Office of the Surgeon General, 2011). All of these adversities can be stressful for women and cause women to fear job insecurity.

Critique of Current Policies

The current legislation of the Family and Medical Leave (FMLA) Act of 1993 only requires the government to provide new moms with 12 weeks of unpaid leave (Organization for Economic Cooperation and Development [OECD], 2018; U.S. Department of Labor, 2020). This policy is currently not helping mothers and infants (Boushey & Glynn, 2012). A step in the right direction was pursued with the Federal Employee Paid Leave Act, when federal employees were granted three months of paid leave upon having a child as of October 2020 (U.S. Department of the Interior, 2020; U.S. Department of Labor, 2020). Unfortunately, this does not impact women who are not in federal jobs. The most recent data reveals that just 23% of non-government workers had paid parental leave (U.S. Bureau of Labor Statistics, 2021). It is extremely difficult to continue breastfeeding as well as pump while on the job. Worksite lactation support programs ensure breastfeeding breaks, a proper place to pump, and a place to store breast milk while on the clock; however, less than half of employers provide this type of program (CDC, 2018).

Not having paid maternity leave increases breastfeeding disparities among low-income families by damaging their economic security, which in turn increases families’ use of welfare like Temporary Assistance for Needy Families (TANF) during job interruptions caused by having a new child (Kang, 2019). The current social policy implications are detrimental to vulnerable mothers and families (Kang, 2019; Louis-Jacquers et al., 2017; Segura-Perez et al., 2021). When comparing the U.S. on the global stage, it ranks last in terms of government-mandated paid leave for having a new child (OECD, 2018).

Policy Recommendations

There is a positive correlation between paid family leave policies and women being able to exclusively breastfeed their infant until 6 months of age (Hamad et al., 2019). Changing the current federal policies from 12 weeks of unpaid leave to 6 months of paid leave for all women in the workforce will drastically increase infants being breastfed exclusively for the first 6 months of life (Hamad et al., 2019; Nandi et al., 2018). With this new policy, disparities among women who are of low socioeconomic status will be mitigated (Feltner et al., 2018; HSS, 2020; Kapinos et al., 2017; Panzera et al., 2017).

This change in policy would have impacts on health outcomes and socioeconomic outcomes (Nandi et al., 2018). Having an increase in paid parental leave would have positive implications on infant and child health (Nandi et al., 2018; Office of the Surgeon General, 2011). Most prevalent health changes are reductions in mortality rates (Nandi et al., 2018). Looking at the socioeconomic outcomes, there is minimal evidence on extending maternity leave having negative employment or financial consequences (Boushey & Glynn, 2012; Nandi et al., 2018). It has quite the opposite. Having paid leave increases lifetime employment as well as lifetime earnings (Boushey & Glynn, 2012). Women are more likely to return to their original employer after their paid time off and tend to have the same pay or higher (Boushey & Glynn, 2012). The current social policy of maternity leave needs to be reformed in order to promote and protect women and infant health. Infants need breast milk.


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Boushey, H., & Glynn S. J. (2012). The effects of paid family and medical leave on employment stability and economic security. Center for American Progress.

Centers for Disease Control and Prevention. (2018, August 20). CDC releases 2018 breastfeeding report card. breastfeeding-report-card.html

Centers for Disease Control and Prevention. (2021a, July 27). Breastfeeding benefits both baby and mom.

Centers for Disease Control and Prevention. (2021b, August 24). Key breastfeeding indicators.

Feltner, C., Weber, R. P., Stuebe, A., Grodensky, C.A., Or, C., & Viswanathan, M. (2018).      Breastfeeding programs and policies, breastfeeding uptake, and maternal health outcomes in developed countries. Agency for Healthcare Research and Quality, 210

Grubesic, T. H. & Durbin, K. M. (2019). A spatial analysis of breastfeeding and breastfeeding support in the United States: The leaders and laggards landscape.” Journal of Human Lactation, (35)4, 790–800.

Hamad, R., Modrek, S., & White, J. S. (2019). Paid family leave effects on breastfeeding: A quasi-experimental study of US policies. American Journal of Public Health, (109)1,164-166. doi: 10.2105/AJPH.2018.304693.

Kang, J. Y. (2019). The effect of paid maternity leave on low-income families’ welfare use in the        US. Social Policy and Administration, (54)6, 952–970. doi: 10.1111/spol.12618

Kapinos, K. A., Bullinger, L., & Gurley‐Calvez, T. (2017) Lactation support services and breastfeeding initiation: Evidence from the Affordable Care Act. Health Services Research, (52)6, 2175–2196. doi:10.1111/1475-6773.12598

Louis-Jacques, A., Deubel, T. F., Taylor, M., & Stuebe, A. M. (2017). Racial and ethnic disparities in the U.S. breastfeeding and implications for maternal and child health outcomes. Seminars in Perinatology, (41)5, 299–307.

Nandi, A., Jahagirdar, D., Dimitris, M. C., Labrecque, J. A., Strumpf, E. C., Kaufman, J. S.,     Vincent, I., Atabay, E., Harper, S., Earle, A., & Heymann, S. J. (2018). The impact of parental and medical leave policies on socioeconomic and health outcomes on OECD   countries: A systematic review of empirical literature. The Milbank Quarterly, (96)3,    434–471.

New York State Department of Health. (2015, December) Why is breastfeeding important for your baby?

Office of the Surgeon General. (2011). The surgeon generals call to action to support breastfeeding.

Organization for Economic Cooperation and Development. (2018). Parental leave systems.

Panzera, A. D., Castellanos-Brown, K., Paolicelli, C., Morgan, R., Potter, A., & Berman, D.     (2017). The impact of federal policy changes and initiatives on breastfeeding initiation rates and attitudes toward breastfeeding among WIC participants. Journal of Nutrition  Education and Behavior, (49)7, 207–211.

Segura-Pérez, S., Hromi-Fiedler, A., Adnew, M., Nyhan, K., & Perez-Escamilla, R. (2021). Impact of breastfeeding interventions among United States minority women on breastfeeding outcomes: A systematic review. International Journal for Equity in Health, (20)1, 72–72. doi:10.1186/s12939-021-01388-4

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United States Department of Health and Human Services. (24, August 2020). How laws and policies can help families overcome barriers to breastfeeding.

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U.S. Department of the Interior. (2020, September 22). Office of human capital.

World Health Organization. (2019, February 11). Exclusive breastfeeding for optimal growth, development, and health of infants.

Funding provided by the Center for Leadership Education in Maternal and Child Public Health at the University of Minnesota and the University at Albany School of Public Health Maternal and Child Health Public Health Catalyst Program, which are supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS). This information or content and conclusions of related outreach products are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.