Although the United States has made significant progress increasing overall rates of breastfeeding in recent years, racial and ethnic disparities persist in who breastfeeds and for how long. For example, only 49 percent of Black infants receive any breastmilk at six months of age compared with 61 percent of non-Hispanic White infants. Given the many health benefits of breastfeeding, such gaps may perpetuate health disparities that affect children well into adulthood.
The good news is that telelactation—video visits with lactation consultants—can significantly improve these rates. We led a randomized controlled trial (the study was published this month in JAMA Network Open) of more than 2,000 new mothers and observed improvements in breastfeeding duration and exclusivity when mothers had access to on-demand telelactation services. Notably, we saw statistically significant improvements among Black women; 65 percent of Black women who received access to telelactation services were breastfeeding at six months postpartum compared with 57 percent in the control group.
The causes of breastfeeding disparities are complex; no one intervention will solve this problem. Our findings, however, suggest that telelactation can help. The next big challenge is how to implement state and federal telelactation policies that realize this promise.
The causes of breastfeeding disparities are complex; no one intervention will solve this problem.
Coverage of Breastfeeding Support
Telelactation services face a policy environment that is unfriendly to breastfeeding support more broadly and to telehealth breastfeeding support in particular. In the United States, professional breastfeeding support is provided in multiple locations and through multiple payment models, some of which exist outside of visit-based reimbursement or health insurance in general. For example, free professional breastfeeding support is provided to low-income women in the context of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Many hospitals (PDF) employ lactation consultants to support new mothers during their postpartum hospitalization, and that's where most parents report interacting with them.
It is important to note that a mother's breast milk supply often does not come in until two to five days postpartum. Access to lactation consultants after hospital discharge is key to navigating this transition. But new mothers are less likely to obtain outpatient support due to factors such as a shortage of local lactation consultants and patchy insurance coverage in outpatient settings.
Postnatal breastfeeding support, supplies, and counseling are all supposed to be covered by most insurance plans under the Affordable Care Act (ACA) of 2010. There is also supposed to be no patient cost sharing for the duration of breastfeeding. However, coverage gaps remain more than a decade later due to lack of implementation and enforcement. Furthermore, 15 state Medicaid programs do not cover outpatient professional breastfeeding support. Even those states that have Medicaid coverage have other barriers. Michigan (PDF), for example, limits the total number of lactation support visits. Other states only permit visits within a few months after birth. Other health plans cover professional breastfeeding support only if the internationally board certified lactation consultant (IBCLC) also holds another license (for example, MD, RN). As it is, there are rarely enough in-network providers of breastfeeding support.
Coverage of Telehealth Services
The ACA's provision on breastfeeding support doesn't explicitly exclude or include telehealth services, allowing payers to interpret their obligations in this area. Furthermore, only 33 states have payment parity laws for telehealth. In the other 17 states, telelactation may be reimbursed at a lower rate than in-person support, thereby discouraging providers from delivering the service. Furthermore, commercial and Medicaid plans can limit who is eligible to provide telehealth services, which can mean excluding certain settings and types of clinicians including IBCLCs.
Policy Recommendations
In our study, free virtual visits were available throughout the perinatal period, including in the third trimester of pregnancy. In an earlier analysis that we published in 2024, we found that 14 percent of trial participants who used telelactation requested a visit prior to giving birth, suggesting that some women saw value in using telelactation to prepare for breastfeeding. Furthermore, although trial participants could have unlimited visits, they only requested an average of two visits.
Given these findings, we believe the following policy recommendations could ensure greater availability of and use of telelactation services by minorized parents:
Telelactation should be provided through multiple mechanisms, including outside of health insurance. Employers, community-based organizations, and public health agencies can contract with telelactation providers to offer services. Some WIC agencies, for example, offer telelactation to augment in-person support, but access through WIC is not universal.
Telelactation should be provided through multiple mechanisms, including outside of health insurance. Employers, community-based organizations, and public health agencies can contract with telelactation providers to offer services.
Organizations that offer telelactation should take steps to increase access among breastfeeding mothers affected by the digital divide (for example, provide devices and digital literacy training). In addition, policymakers should ensure that the ACA's rules on providing breastfeeding support services are enforced among non-grandfathered health plans.
Payers have a key role in this space. First, payers should explicitly state that telelactation is eligible for reimbursement, and they should reimburse telelactation and in-person support at the same rate to ensure services are offered to parents. Second, they should include telelactation organizations and remote IBCLCs as in-network providers of breastfeeding support services, particularly when there aren't enough providers to serve a community. Third, payers should not require IBCLCs to be “otherwise licensed” to become in-network providers. Fourth, payers should provide comprehensive coverage of breastfeeding support services by IBCLCs during pregnancy, in labor and delivery, and in postpartum settings, extending for as long as a mother is breastfeeding. Fifth, they should not limit the total number of breastfeeding support visits or put restrictions on the timing of those visits relative to birth. Finally, state Medicaid programs should recognize IBCLCs as both a provider group type and individual provider type in their Medicaid Management Information Systems (MMIS) for IBCLCs to obtain a MMIS number for payer contracts.
In his book The Doctor Who Wasn't There, Jeremy A. Greene, M.D., Ph.D., explains that technology is just a tool. It has no agenda. Telehealth's potential to improve access and decrease disparities is entirely dependent on whether we choose to use it that way. Effective telehealth services could foreseeably exacerbate disparities—in fact, this is the more likely outcome if we don't design policy in a thoughtful manner, continue to evaluate, and correct course when necessary.
The recommendations we present are intended to facilitate the use of telelactation to address breastfeeding disparities. Without parallel efforts to ensure that telelactation services are widely available, culturally competent, trustworthy, and usable for women with limited digital health literacy and reduced access to devices and broadband, we may squander a clear opportunity to advance maternal and infant health.
