This article was originally published in the Washington Post on January 24, 2017.

Nikki Little gave birth via C-section at 33 weeks to her sons Nolan and Evan, this after five-and-a-half weeks in the hospital on strict bed rest. The premature baby boys stayed in the NICU for an additional 13 days. During that time, Little, a director of social media at a Detroit-based firm, benefited from being able to work with a lactation consultant, had access to a pump and accessories in the hospital, and another rental pump once she left to go home. Little took an eight-month break from work and returned to her agency, which offers a private space for pumping.

The majority of her care, the care of the babies, her pumps, the lactation support, and the space to pump along with break times were all provided thanks to a single paragraph in the Affordable Care Act (ACA).

[What a pumping room at work should look like, and why]

When President Obama signed the highly complex bill into law in 2010, the ACA opened a new world for new mothers. Now that it appears the ACA may be repealed the provisions that aim to benefit new moms and their children may disappear forever. (There is a change.org petition to keep the provision.) While we don’t know what will happen, we do know the support that Little and millions of other breast-feeding mothers have had with ACA resulted in greater success in breast-feeding rates, as well as the ability for employers to bring pumping mothers back to work with ease and success for both the companies and their families.

The ACA includes a singular clause that is specific to breast-feeding and covers:

* lactation support and counseling, such as lactation education and consulting services;
* equipment and supplies, such as pumps;
* infrastructure, such as pump rooms and break time.

The equipment and the space and time to pump became an embraced standard that leaned right into the surgeon general’s Healthy People 2020 objectives. The objectives include increased breast-feeding initiation and retention rates, as well as workplace lactation spaces. This leads to healthier mothers and babies and reduced absenteeism at work, and provides a path for keeping families in the workplace.

The fine print within the ACA that points to infrastructure is critical: This guarantees a private space for pumping (not a germ-infested bathroom, for example), complete with a lock and access to a sink and a refrigerator. A space like this not only keeps a baby’s food safe but also helps women decide that breast-feeding can be continued. This was originally part of the Fair Labor Standards Act and was moved over as an amendment to ACA.

What do nursing mothers, and, therefore, families, stand to lose without the ACA? I spoke with some of the most respected leaders in lactation for insight about breast-feeding to help make sense of what the ACA has meant for breast-feeding in the United States, and what might come next.

Diane Spatz, Director of Lactation at Children’s Hospital of Philadelphia.
Diane L. Spatz, PhD, RN-BC, FAAN, is a nurse researcher and director of the lactation program at CHOP. She also shares an appointment as the Helen M. Shearer Term Chair in Nutrition and Professor of Perinatal Nursing at the University of Pennsylvania’s School of Nursing. In addition, Spatz sits as a representative on the United States Breastfeeding Committee. She characterizes that organization as woefully underfunded and underrepresented in terms of lobbying power, compared with the formula industry, and she feels this lack of power resulted in ACA breast-feeding provisions being not as carefully constructed as they should have been. “The services were not set up to meet the specific needs of the mom,” she says. For example, a hand pump is not an electric pump, and an electric pump is not a hospital-grade pump, and the nuances between them further define what a woman might need to meet her breast-feeding goals. A woman who has given birth to a preemie and needs a strong, hospital-grade pump might be given a weaker, much less effective hand pump that would lead to her premature infant not getting a reliable milk supply. “So perhaps there is positive change on the horizon,” Spatz speculates. However, Spatz says, “A pivot could go in another direction, too.” She said she is nervous with the majority Republican Congress “regarding services for women and children.”

Cheryl Petran, CEO of the Pump Station & Nurtury, Santa Monica, Calif.
The Pump Station, established in 1986, is known as the West Coast’s answer to all things for new mothers. Cheryl Petran is an industry elder statesman who has been focused on the well-being of new mothers for the last 10 years. In general, Petran feels that ACA was good for breast-feeding. The level of dialogue and care around issues central to the lives of new, nursing mothers rose. But despite all of that, Petran felt that the ACA and its breast-feeding provisions were far from perfect. “The lines needed to be much more clearly defined. What is covered needs to be explicit and spelled out, there should be more options, and more attention to actual maternal needs.” In some ways, the ACA made her job of helping families more difficult. “Less powerful pumps were suddenly in the hands of our customers — pumps we were not trained in meant we could not provide the high level of support we are known for. It is difficult to train a new mother on a pump [if] neither you nor she has ever seen the model or even the brand before.” Also, the ambiguous level of reimbursement became a major undertaking for the Pump Station. “We learned how to assure our clients had the care and attention they needed at such an important time. But it got tricky.” Still, Petran notes, “ACA kept the breast-feeding conversation top of mind, kept the initiation rates high and continues to keep employers well aware of what new mothers need to pump and feel balanced in the workplace.” A major plus within the law is that it requires employers to provide adequate break time and a private place to express milk. “No more pumping in bathrooms or broom closets!” And, yes, that is a major advancement.

Amanda Cole, founder of Yummy Mummy, New York
Amanda Cole is not only a leading voice and advocate for breast-feeding, her New York City retail operation is certified as a “Durable Medical Equipment” (DME) shop, which means she is able to provide insurance-covered pumps and services. This has put her at the epicenter of the new ACA normal. She has seen moms take advantage of the ACA benefits that have created supports for nursing women. And she has seen the immediate rewards of this greater access, which she describes as both good for business and good for moms. Cole finds it hard to imagine that the positive cost savings of healthier babies as a result of consuming breast milk are lost on anyone. “Just think — one fewer trip to the doctor or ER for an ear infection. This means mom doesn’t have to skip work and baby can skip a trip to the doctor and antibiotics. Considering the cost savings associated with breast-feeding, it makes sense for plans to keep the benefits intact.” This fact, she says, is what she believes will protect the clause. “I’m confident the preventative benefit will outlast a repeal if such a thing happens. Access to breast pumps and support are creating healthier moms and babies.”

Regardless of what comes next, the standard of care and the quality of conversation around pumping has come a long way since 2009. Increased societal transparency has led us to elevate our expectations of employers, airports, restaurants and even retailers when it comes to nursing or pumping mothers. Private sector employers, for example, understand the economic value of developing internal policies to regularly cover pumps, lactation services and certainly pumping spaces — no regulation required. The public now has a much greater understanding of why we must keep pumping women out of bathroom stalls and other ill-equipped spaces that are unsanitary, demoralizing and lead to greater drop-off rates.

We have already agreed that the progress that has been made should not be lost. But even more essential is the protection of our national care to support parents in a way that keeps the Healthy People 2020 momentum going for all of us, not just a lucky few.

Julia Beck is the founder of the It’s Working Project and Forty Weeks. Beck is based in Washington, D.C., where she is the matriarch of a blended family that includes a loving husband, a loyal golden retriever and four children — all of whom are her favorite.