Why Invest, and What It Will Take To Improve Breastfeeding Practices PDF
Why Invest, and What It Will Take To Improve Breastfeeding Practices PDF
Breastfeeding 2
Why invest, and what it will take to improve breastfeeding
practices?
Nigel C Rollins, Nita Bhandari, Nemat Hajeebhoy, Susan Horton, Chessa K Lutter, Jose C Martines, Ellen G Piwoz, Linda M Richter, Cesar G Victora,
on behalf of The Lancet Breastfeeding Series Group*
Despite its established benefits, breastfeeding is no longer a norm in many communities. Multifactorial determinants Lancet 2016; 387: 491–504
of breastfeeding need supportive measures at many levels, from legal and policy directives to social attitudes and See Editorial page 404
values, women’s work and employment conditions, and health-care services to enable women to breastfeed. When See Comment pages 413
relevant interventions are delivered adequately, breastfeeding practices are responsive and can improve rapidly. and 416
The best outcomes are achieved when interventions are implemented concurrently through several channels. The This is the second in a Series of
marketing of breastmilk substitutes negatively affects breastfeeding: global sales in 2014 of US$44·8 billion show the two papers about breastfeeding
industry’s large, competitive claim on infant feeding. Not breastfeeding is associated with lower intelligence and *Members listed at the end of
the paper
economic losses of about $302 billion annually or 0·49% of world gross national income. Breastfeeding provides
Department of Maternal,
short-term and long-term health and economic and environmental advantages to children, women, and society. To
Newborn, Child and Adolescent
realise these gains, political support and financial investment are needed to protect, promote, and support breastfeeding. Health (MCA) (N C Rollins MD),
and Department of
Introduction improper and biased information that persuades mothers Noncommunicable Diseases
and Mental Health
Breastfeeding improves the survival, health, and to give up breastfeeding.7 In 1991, the Baby Friendly (C K Lutter PhD), WHO, Geneva,
development of all children.1 It saves women’s lives and Hospital Initiative (BFHI) was launched to scale up ten Switzerland; Centre for Health
contributes to human capital development. The benefits interventions in birthing facilities to protect, promote, Research and Development,
span populations living in high-income, middle-income, and support successful breastfeeding (appendix p 1).8 Society for Applied Studies,
New Delhi, India
and low-income countries.1 In the second paper in this Despite these initiatives being established 25 years ago, (N Bhandari PhD); FHI 360,
Series, we summarise the evidence on determinants of, global breastfeeding rates remain far below international Hanoi, Vietnam
and interventions to improve, breastfeeding practices. We targets,9 and commitment to breastfeeding, in terms of (N Hajeebhoy MHS);
discuss the effect of the breastmilk substitute industry on policy and investment, is in a state of fatigue.10 For all Department of Economics,
University of Waterloo, ON,
breastfeeding practices, and explore the reasons why low-income and middle-income countries with data, Canada (S Horton PhD); Centre
some countries have been more successful in improving exclusive breastfeeding rates increased from 25% in 1993 for Intervention Science in
breastfeeding than others. We also estimate some of the to 37% in 2013; in the wealthiest 20% in each country, Maternal and Child Health
economic costs and environmental consequences of not breastfeeding increased from 16% to 36%, whereas the (CISMAC), Centre for
International Health,
breastfeeding. poorest 20% followed the general trend. Continued University of Bergen, Norway
(J C Martines PhD); Global
The Innocenti Declaration: an ideal not yet Development Program,
realised Key messages Bill & Melinda Gates
Foundation, Washington, DC,
Breastfeeding became less common in high-income • The world is still not a supportive and enabling USA (E G Piwoz ScD); DST-NRF
countries during the 20th century.2 Similar patterns were environment for most women who want to breastfeed. Centre of Excellence in Human
also seen in better-educated, wealthier, and urban women • Countries can rapidly improve breastfeeding practices by Development, University of the
Witwatersrand, Johannesburg,
in low-income and middle-income countries.1,3 Breastmilk scaling up known interventions, policies, and South Africa (L M Richter PhD);
substitutes were perceived as modern and prestigious, programmes. and International Center for
and breastfeeding was associated with being poor and • Success in breastfeeding is not the sole responsibility of a Equity in Health,
unsophisticated.4 In August, 1990, policy makers and woman—the promotion of breastfeeding is a collective
Post-Graduate Programme in
Epidemiology, Federal
international agencies adopted the Innocenti Declaration,5 societal responsibility. University of Pelotas, Pelotas,
which affirmed that all infants should receive “exclusive • The breastmilk substitute industry is large and growing, Brazil (C G Victora MD)
breastfeeding from birth to 4–6 months of age [WHO and its marketing undermines efforts to improve Correspondence to:
recommendations amended to 6 months in 20016] and breastfeeding. Nigel C Rollins, Department of
thereafter should continue to be breastfed”. In the • The health and economic costs of suboptimal Maternal, Newborn, Child and
Adolescent Health (MCA), WHO,
same year, the UN Convention on the Rights of the Child breastfeeding are largely unrecognised. Investments to 1211 Geneva, Switzerland
enshrined health and health care, including the promote breastfeeding, in both rich and poor settings, [email protected]
advantages of breastfeeding, as a legal right of the child need to be measured against the cost of not doing so.
and the promotion of breastfeeding as a legal obligation • Political support and financial investment are needed to See Online for appendix
of countries that ratified the Convention. The Convention protect, promote, and support breastfeeding to realise its
called for states to take appropriate measures for children advantages to children, women, and society.
of working parents, and to protect the public from
breastfeeding at 12–15 months decreased from 76% to low-birthweight newborn babies,21 can result in
73% globally, driven largely by the decrease in prevalence breastfeeding starting later, as can hospital practices
in poor populations.1 such as mother–infant separation,22 prelacteal supple-
mentation, and free samples of breastmilk substitutes.23
Determinants of breastfeeding Within families, the practices and experience of female
We did a systematic review of available studies to identify relatives affect the incidence and duration of
the determinants of breastfeeding (appendix pp 2–86), and breastfeeding.24,25 In many traditional societies, colostrum
reviewed and revised previous conceptual frameworks. is viewed as harmful and discarded,26 and prelacteal feeds
The conceptual model (figure 1) includes the determinants can delay breastfeeding for several days.27 The attitudes
that operate at multiple levels and affect breastfeeding and preferences of fathers can also affect breastfeeding:
decisions and behaviours over time. Nearly all women are women whose partners support breastfeeding breastfeed
biologically capable of breastfeeding, bar very few with for longer.28,29
severely limiting medical disorders.11 However, breast- Women’s work is a leading motive for not breastfeeding
feeding practices are affected by a wide range of historical, or early weaning. Its effect is multi-dimensional, including
socioeconomic, cultural, and individual factors (figure 1). fatigue, practicality, and intensity.30 The increasing
Social and cultural attitudes and market factors shape numbers of women in the workforce draw attention to the
the structural context for breastfeeding.12 Breastfeeding is importance of work-time breaks and on-site rooms for
often portrayed as the ideal for babies, demonstrating breastfeeding and the provision of maternity leave.31,32 Most
maternal devotion. However, in some settings women studies report negative effects of work on breastfeeding;33–35
who want to breastfeed in public experience negative women planning to return to work after childbirth are
reactions.13,14 Some employers and fellow employees report less likely to begin or continue breastfeeding.36,37 Short
being uncomfortable with women breastfeeding at work. maternity leave (<6 weeks) leads to a four-times increase in
In health systems, health-care providers influence and the odds of either not establishing or early cessation of
support feeding decisions at key moments before and after breastfeeding.38
birth and later, when challenges occur, to maintain At the personal level, breastfeeding intentions are
exclusive and continued breastfeeding.15 Nevertheless, generally established by the third trimester.39 Subjective
substantial gaps in knowledge and skills to support norms and benefits of breastfeeding are the most
breastfeeding are reported at all levels of health-care staff.16,17 frequently cited reasons for intending to breastfeed.
High-risk pregnancies,18 assisted delivery and long Intention is strongly predictive of initiation40 and of
hospital stays,19 maternal illness,20 and preterm, ill, or duration,41 provided the context is supportive.42
Individual factors, including advice and practices
Determinants Interventions that undermine maternal confidence and self-efficacy,
negatively affect breastfeeding.43,44 Poor breastfeeding
Structural Sociocultural and market context Social mobilisation and
positioning and latching45 as well as inadequate support,
mass media especially in the first weeks after birth, and anticipation
+ of breastfeeding difficulties are common reasons
Settings Health systems Family and Workplace and Legislation, policy, financing, for abandoning breastfeeding. Mothers who do not
and services community employment monitoring, and enforcement successfully breastfeed are less likely to attempt
+ breastfeeding in subsequent pregnancies.46 Infant crying
Counselling, support, and or fussiness, perceived hunger, and the inability to settle
Individual Mother and Mother–infant
infant attributes relationship
lactation management her infant47,48 often cause a mother to assume that she has
insufficient milk and to introduce breastmilk substitutes.49
Individual-level factors, including smoking,50,51 over-
Early Exclusive Continued
weight and obesity,52 and depression,53 are important
initiation breastfeeding breastfeeding determinants because of the large number of women
affected.54,55 In the past 20 years, the HIV epidemic has
Figure 1: The components of an enabling environment for breastfeeding—a conceptual model
significantly affected policy and programmatic recom-
The structural level refers to the social factors that affect the whole population. For determinants, these factors
include social trends, advertising, media, and products available in stores; interventions at the structural level mendations, community and family attitudes, and
include legislation, policy, and media and social mobilisation to change social attitudes and practices. These health-care worker confidence in breastfeeding, all of
factors are distal and unidirectional. The population is uniformly exposed to them, but they are not uniformly which have detrimentally affected individual feeding
interpreted. Pregnant women and women with young children are affected in more direct and personalised ways
practices (appendix pp 87–88).56–62
than are women with no children and men and community members. This effect occurs through various
interactions, attitudes, practices, and information in the three main settings, which are, in turn, affected by the
social, cultural, and market context. At the most intimate level, women’s breastfeeding behaviour is influenced by Interventions to improve breastfeeding practices
personal attributes such as her age, weight, education, and confidence, and by attributes of her baby such as sex, Many aforementioned determinants of breastfeeding are
wellbeing, and temperament. Breastfeeding is a behaviour that entails a relationship between mother and baby.
Moment-by-moment interactions between them, including whether the baby is thought to be satisfied and
amenable to interventions to protect, promote, or support
content, are the result of the mother’s internalisation of the influences at the level of structural determinants and improved breastfeeding.63 We examined the effects of
settings. interventions according to settings identified in the
conceptual model: health systems and services, family media on breastfeeding suggested that it has a major
and community, and workplace and employment. We effect on early initiation of breastfeeding (RR 5·33
also reviewed available data for policies to address [2·33–12·19]). Social media needs additional study in
structural factors that create an enabling environment view of its wide and effective use to market breastmilk
for breastfeeding. We did a systematic review and substitutes and other products.65
meta-analysis64 of interventions delivered in these
settings according to the conceptual model. We also The workplace, maternity protection, and nursing breaks
examined combined interventions—ie, those delivered for working mothers
concurrently in more than one setting. We assessed four Although nearly all countries have maternity protection
outcomes: breastfeeding initiation within 1 h of birth, legislation, only 98 (53%) of 185 countries meet the
exclusive breastfeeding up to 6 months, continued International Labour Organization’s 14-week minimal
breastfeeding from 12 months to 23 months, and any standard and only 42 (23%) meet or exceed the
breastfeeding up to 6 months of age (see appendix recommendation of 18 weeks’ leave;32 large informal
pp 89–96 for further information about our methods and work sectors further compound these inadequacies.
findings). Consequently, hundreds of millions of working women
have no or inadequate maternity protection, the over-
Health systems whelming majority (80%) of whom live in Africa and
For our meta-analyses we considered several interventions Asia. The few data available suggest that maternity leave
included in the BFHI: individual counselling or group policies are effective at increasing exclusive breastfeeding
education, immediate breastfeeding support at delivery, (RR 1·52 [1·03–2·23]). Breastfeeding can be continued
and lactation management. These interventions increased after a return to work in settings where maternity leave37
exclusive breastfeeding by 49% (95% CI 33–68) and any or child care is available and where breastfeeding or the
breastfeeding by 66% (34–107; table 1). expressing of breastmilk is supported.66
An earlier meta-analysis reported a negative The reduction of barriers for working mothers to
association between caesarean sections and early breastfeed by providing lactation rooms and nursing
breastfeeding but no effect at 6 months.19 Our findings breaks are low-cost interventions that can reduce
suggest that in the presence of adequate support, a absenteeism and improve workforce performance,
caesarean section is not necessarily a barrier to timely commitment, and retention.32 An analysis of national
breastfeeding initiation (risk ratio [RR] 0·95 [95% CI policies in 182 countries showed that breastfeeding
0·84–1·07]) or to exclusive breastfeeding (1·08 breaks with pay were guaranteed in 130 countries (71%),
[0·82–1·41]; data not shown). unpaid breaks were offered in seven countries (4%), and
45 countries (25%) had no policy. In multivariate models,
Family and community paid-break guarantees for at least 6 months were
We did a meta-analysis of interventions providing associated with an 8·9% point increase in exclusive
antenatal and postnatal support to mothers, fathers, and breastfeeding.67 Findings from a study in the USA
other family members at home, including community showed that lactation rooms and breaks to express
health workers and peer-to-peer counsellors: counselling breastmilk increased breastfeeding at 6 months by 25%
by a nurse, trained lactation counsellor, or other health (95% CI 9–43).68
provider, including post-discharge telephone calls
combined with home visits. Fathers were targeted Other enabling policies and interventions
individually, and in group counselling sessions. Home Most studies reviewed explored the effects of direct
and family-based interventions were effective at interventions, rather than the role of policies and
improving exclusive (RR 1·48 [95% CI 1·32–1·66]), enabling interventions on breastfeeding outcomes.
continued (1·26 [1·05–1·50]), and any (1·16 [1·07–1·25]) Enabling interventions operate by removing structural
breastfeeding, and tended to improve early initiation and societal barriers that interfere with women’s ability
(1·74 [0·97–3·12]). Interventions that provided antenatal to breastfeed optimally. Examples include maternity and
and postnatal counselling were more effective than were workplace policies or regulations to restrict marketing
those targeting one period only, whereas interventions of breastmilk substitutes; health insurance or other
targeting fathers gave mixed results. financing mechanisms for lactation support; and
Community-based interventions, including group baby-friendly hospital certification.
counselling or education and social mobilisation, with or Data about the effect of policies are rarely reported.
without mass media, were similarly effective, increasing However, a study from 14 countries with baseline
timely breastfeeding initiation by 86% (95% CI 33–159) exclusive breastfeeding rates lower than 30% showed
and exclusive breastfeeding by 20% (3–39). We identified that rates had a 1% point increase per year in countries
no studies that examined the effect of community-level that scored highly on a composite indicator rating
interventions on continued breastfeeding. Findings from implementation of pro-breastfeeding policies and
the one study we identified on the effect of mass or social programmes. By contrast, little change (0·2% point
Data are risk ratio (RR; 95% CI) or odds ratio (OR; 95% CI). All estimates of effect and methods are provided in Sinha and colleagues.64 *Antenatal counselling focused on
infant feeding decision making and preparation for breastfeeding; periodic postnatal home and family encounters focused on establishing exclusive breastfeeding,
managing problems and challenges, and continued breastfeeding.
change per year) was recorded in countries with low In summary, our meta-analyses indicate that
composite scores.69 Such data emphasise that societies breastfeeding practices are highly responsive to
also need to protect women’s personal decisions, and interventions delivered in health systems, communities,
policies are a means of empowering women to and homes. Maternity leave and workplace interventions
breastfeed while conveying social value to breastfeeding are also beneficial, although studies are few and are
as a norm. generally limited to high-income settings. The largest
effects of interventions on breastfeeding outcomes are and use of data. Strong civil society engagement and
achieved when interventions are delivered in comb- participation was a common element across all three of
ination. For example, combined health systems these countries, whereas it was weak in the countries
and community interventions increase exclusive that had static or declining breastfeeding rates.
breastfeeding by 2·5 times (table 1).
The effect of industry
The International Code of Marketing of Knowledge of the breastmilk substitute market and
Breastmilk Substitutes marketing practices are essential for understanding the
Compelling accounts of inappropriate and unethical competing environment in which efforts to protect,
marketing of breastmilk substitutes and of many promote, and support breastfeeding operate. Market
infants becoming malnourished or dying from research was commissioned for this Series from
contaminated or diluted breastmilk substitutes70 were Euromonitor International (specific methods,
followed by the adoption of the International Code of definitions, and results are in appendix pp 99–114;
Marketing of Breastmilk Substitutes at the 34th World market research terminology to describe baby milk
Health Assembly in 1981. The Code implicitly formula are used— standard: for infants <6 months;
recognised that health workers, women, and families follow-on: for infants 7–12 months; toddler: 13 months
are susceptible to direct and indirect marketing onward; special: for specific medical conditions; and “all
strategies. It consists of 11 articles which, along baby milk formula”: all of these together).
with subsequent resolutions from the World Health The retail value of the baby milk formula industry is
Assembly, outline the responsibilities of governments, growing. Unlike other commodities, baby milk formula
health-care systems, and workers, and of the companies seems to be resilient to market downturns. In 2014,
that market or manufacture breastmilk substitutes. global sales of all baby milk formula were about
The Code represents the collective will of the member US$44·8 billion—by 2019, the market value is projected
states of the UN and so carries substantial political and to reach $70·6 billion (figure 2). In 2009, when the
moral weight. However, it depends on national growth of real gross domestic product turned negative
legislation, monitoring, and enforcement for its globally, baby milk formula sales still grew by
effectiveness. Violations of the Code remain prevalent71 8% annually in constant value terms (figure 2).
and show that without enforceable legislation and Marketing by the infant feeding industry and the
investment to support monitoring, it will have limited availability of formula, including the distribution of free
effect (appendix p 97). samples,77–79 increase rates of bottle-feeding.80,81 Formula
advertisements portray formula milk to be as good as or
Contextual factors on breastfeeding trends better than breastmilk, or present it as a lifestyle choice
Findings from case studies complement quantitative data rather than a decision with health and eco-
by showing how synergies created through a mixture of nomic consequences.82 Mothers report that media is an
interventions can improve breastfeeding. We discuss important source of information, and findings from studies
three pairs of countries (representing about a quarter of all in several countries associate recollection of formula
children younger than 4 years worldwide) that are similar advertisements with decreased breastfeeding.83,84 Marketing
in economic development but differ in breastfeeding messages can also convey that breastfeeding is difficult and
trends to explore why breastfeeding prevalence has that breastmilk substitutes help to settle fussy babies.85
increased, stagnated, or declined with time (panels 1 and 2). Findings from a 2008 population-based study in the USA
In addition to having large populations, these countries showed that 67% of mothers had received free milk formula
reflect the world’s largest regions and comprise different samples, and that such gifts were associated with shorter
mixes of public and private health care. Bangladesh is a breastfeeding duration.86 Industries selling breastmilk
low-income country and Nigeria is a lower middle-income substitutes and related products often sponsor health
country, Brazil and China are upper middle-income professional associations87,88—for which comprehensive For Sociedade Brasileira de
countries, and the UK and the USA are high-income funding data are scarce—which might introduce conflicts Pediatria see http://www.sbp.
com.br
countries (see appendix p 98 for breastfeeding practices of interest in their support of breastfeeding.
and trends in each country). Per-child consumption of all types of formula (total
These case studies show that breastfeeding can retail volumes divided by the population of children
increase when countries implement and coordinate aged 0–36 months, corrected for population growth) is
two or more actions. In Bangladesh, the focus was on highest in western Europe and Australasia, followed by
comprehensive health-worker training, strategic use of North America. However, projected growth from 2014 to
data, and mass media. Brazil also focused on 2019 in these regions is only about 1%. Although present
health-worker training while at the same time made consumption is lower in other regions, the corresponding
hospitals baby friendly and strengthened maternity increase in the Middle East and Africa is expected to
protection and the implementation of the Code. In the be more than 7% and in the Asia Pacific it is expected
USA, there were policy changes and strategic collection to be more than 11%.
As expected, per-person annual expenditure (total retail of market maturity, decreasing birth rates, and legislation
sales divided by the population of children aged on advertising and sales. The enormous difference in
0–36 months, corrected for population growth) is greater market sales between high-income and middle-income
in high-income countries ($2528) than it is in high middle- countries is due to large and increasing sales of follow-on
income countries ($209) and low-income and middle- and toddler milks: these products are often not covered
income countries ($151; appendix pp 106–114). In under national Code-related laws and regulations. In
high-income markets, sales of standard milk formula (for middle-income countries, year-on-year total sales until
infants aged <6 months) are static or decreasing because 2019 are expected to grow by 8%, mainly due to standard
formula sales. In high-income countries, it is follow-on The economic argument for investment in
and toddler milks that will drive the estimated future breastfeeding
15·2% growth. Similar data are not available for Improved breastfeeding practices would prevent
low-income countries. France and the USA are the only 823 000 annual deaths in children younger than 5 years
two major economies where the market growth rate is of age and 20 000 annual deaths in women caused by
expected to turn negative (−2·5% in France and −0·3%, breast cancer.1 Breastfeeding also reduces morbidity and
in the USA): the decreases are the result of legislation, improves the educational potential of children and
public awareness campaigns, and actions by civil society probably their earnings as adults.1
in support of breastfeeding. We will now discuss the economic value of
Brazil exemplifies how vulnerable breastfeeding breastfeeding, using new data for relative risks from a
practices can be during economic transitions. Even series of systematic reviews (the first paper in this
though breastfeeding is deeply valued, and government Series).1 We first provide global estimates of the economic
and civil society have invested in its support, per-baby magnitude of the cognitive benefits associated with
consumption of breastmilk substitutes is projected to breastfeeding, and then of reduced direct treatment costs
increase by 6·8% between 2014 and 2019, making Brazil’s associated with lower child morbidity in four countries.
one of the highest growth rates in the world (appendix We have taken a conservative approach by restricting our
pp 106–114). This increase is probably due to increased analysis to children—ie, by excluding women’s cancers
purchasing power and replacement of locally available and not estimating the economic value of non-treatment-
animal milk by breastmilk substitutes, rather than a related savings, such as time and travel-related savings
decrease in breastfeeding rates. for caregivers and patients.
Data for marketing budgets for breastmilk substitutes
were not available, but these budgets are assumed to be The economic cost of lower cognition
large. The trajectories of retail sales indicate that We modelled the economic benefits of improved cognition
marketing strategies are effective, which emphasises the based on estimates from a 2015 meta-analysis,89 the
importance of comprehensive national laws and findings of which showed that longer breastfeeding
regulations to curb inappropriate marketing practices duration was associated with a 2·6 point (95% CI
with adequate monitoring and meaningful penalties to 1·25–3·98) increase in intelligence quotient (IQ) score,
protect breastfeeding. which is equivalent to 0·17 standard deviations (SDs) in
A
80 000 Standard Follow-on Toddler Special Total milk formula annual growth 12
10·8% 9·5%
70 660
70 000 9·6%
9·8% 9·8% 9·7%
9·3% 9·5% 64 525 10
9·1%
58 854
60 000 8·4%
7·8%
Retail sales (US$ millions)
53 629
8
2
10 000
0 0
B
4000 Standard Follow-on Toddler Special 9·5% 8·1% 10
8·1% 8·1% 3566
3500 8·1% 3053 3300
7·8%
7·5% 8
7·2%
3000 6·8% 6·9% 6·8% 2824
6·5%
Volume (1000 tonnes)
2619
0 0
C
7·5
Growth (%)
5·0
2·5
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Estimated
Figure 2: The total baby milk formula market by value (A) and volumes (B) and growth in real gross domestic product (C) from 2000 to 2014 and estimated growth from 2015 to 2019
Price sensitivity was more evident in high-income countries as milk formula growth rates decreased, whereas most emerging markets saw income growth despite the global economic recession.
Emerging market consumers in effect drove the purchase in milk formula. Data for these graphs were provided by Euromonitor International (2015).
cognitive score. The investigators reported a dose effect in We use the effect size for breastfeeding on IQ, to estimate
that greater benefits are achieved with longer durations of the global loss of gross national income (GNI) associated
breastfeeding. However, because of data limitations we with present levels of any breastfeeding at 6 months, as
can only model the effect of extending breastfeeding to compared with all children receiving any breastfeeding up
6 months or longer. On the basis of a detailed survey of to 6 months of age. We chose “all” children receiving any
published studies, Hanushek and Wössmann estimated breastfeeding at 6 months for comparison, because 40 of
that one SD increase in cognitive scores (ie, 15 IQ points) the 103 countries for which we had data already exceed
is associated with a 12% increase in hourly earnings in 90%, and six countries exceed 99%.
high-income countries and a 16% increase in low-income Table 2 summarises our estimates, for which we used a
and middle-income countries.90 We assumed that labour prevalence-based method (see appendix pp 115–116 for
income is about half of total national income (as estimated methods and additional data related to cognition
by the World Bank World Development Indicators), and economic analyses). The losses amount to $302 billion
that cognitive improvements affect only this half of annually, or 0·49% of world GNI. Losses in low-income
national income. and middle-income countries account for $70·9 billion,
Historically, the United States Agency for International estimated that it will cost $17·5 billion globally for a
Development (USAID) has been a major supporter of larger set of interventions.105 This latter estimate is driven
breastfeeding programmes. One analysis showed that by the recurring costs of maternity entitlements for poor
their funding for breastfeeding promotion increased women: to attribute all these cost to the promotion of
from $8·3 million in 1989 to $16·6 million in 1999, and breastfeeding would be inappropriate because the
subsequently decreased to $13·3 million in 2003 and same investment would have many benefits beyond
$2·3 million in 2005.10 In 2008, 79% of breastfeeding breastfeeding. From our analyses, the economic
coordinators in 15 Latin American countries reported a consequences of cognitive losses and the conservative
decrease in funding for breastfeeding promotion estimates of reduced treatment costs suggest that the
between 2000 and 2008 compared with funding levels in economic benefits for countries of promoting
the 1990s.10 In 2013, the US Women, Infant and Children breastfeeding are likely to be substantial. Nevertheless,
Program (WIC), which covers more than half of all research into the costs of breastfeeding-enabling policies
US infants, spent $210 million on breastfeeding and programmes relative to their full range of benefits,
promotion and peer counselling and an additional including maternity entitlements, is urgently needed.
$110·4 million on an enhanced food package as an Sustainability and development are imperatives and
incentive for breastfeeding women, which contrasts crucial considerations for our world that is undergoing
sharply with the 2010 expenditure of $926·6 million on demographic and social change. In low-income and
infant formula.103 middle-income countries, the improvement of breast-
feeding will contribute to the unfinished agenda of
Discussion preventable infant and child deaths. In both high-income
Our Series shows that breastfeeding contributes to a and low-income countries, improvements in breast-
world that is healthier, better educated, more equitable, feeding will improve human capital and help to prevent
and more environmentally sustainable. But the relevance non-communicable diseases in women and children1,89,106
of breastfeeding is questioned across society. Women are that today account for more deaths than does
drawn to substitutes for breastmilk and doubt their own undernutrition. Low-income and middle-income coun-
ability to breastfeed. They, their families, and health tries are at a crossroads of deciding whether to act to
professionals are not fully convinced by the benefits of avoid the downward trends in breastfeeding practices
breastfeeding: breastfeeding in public can generate that have been noted in high-income countries in the
embarrassment and has even been prohibited whereas past century. High-income countries need to attribute
bottle-feeding causes little reaction; the Code is not value again to the benefits of breastfeeding for children
legislated, enforced, or monitored in all countries, and and women beyond protection from diseases of poverty.
the breastmilk substitute industry attempts to circumvent The review of the evidence and country case studies
the Code to protect sales. show that successful protection, promotion, and support
Although breastfeeding is cited as a reason for women of breastfeeding need measures at many levels, from
leaving the job market (appendix pp 9–10), the evidence legal and policy directives to social attitudes and norms,
shows that the reverse—women remaining in work and women’s work and employment conditions, and health
at school and using breastmilk substitutes or stopping and services to support women and their families to
breastfeeding—is more common. Too few women are breastfeed optimally. So how would policy makers and
appropriately supported through adequate maternity and programme managers approach the challenge? We
workplace entitlements to be able to work or attend propose six action points.
school and still breastfeed; either they are not provided or The first is to disseminate the evidence. The promotion
the women are working in the informal economy and are of breastfeeding starts with robust dissemination of
not eligible. evidence for its fundamental role, for both rich and poor
We did not estimate the cost of scaling up interventions societies. Scientists, policy makers, programme managers,
to promote and support breastfeeding, nor did we health workers, and communities too often do not
quantify the global net gain or loss associated with the recognise the value of breastfeeding as a powerful
promotion of breastfeeding. Our data show that the intervention for health and development that benefits
patterns and drivers of suboptimal breastfeeding vary by children and women alike.
setting. Therefore, the mixture of interventions and The second action point is to foster positive societal
investments needed to implement them, including the attitudes towards breastfeeding. Negative societal
cost of maternity entitlement, are likely to differ greatly attitudes—as shown by inadequate maternity leave, lack
between settings. Without more robust data, reliable of opportunity to breastfeed or express milk at the
estimates of the costs and benefits of the actions needed workplace, and restrictions on breastfeeding in public—
to support optimal breastfeeding are difficult to calculate. are all too common. Breastfeeding is generally thought to
Estimated costs vary widely: one study estimated that it be an individual’s decision and the sole responsibility of
will cost $653 million annually to scale up counselling a woman to succeed, ignoring the role of society in its
interventions in 34 countries,104 and another study support and protection. Establishment of a high value of
breastfeeding within society needs, as stated in the entrusted to protect and promote wellbeing in the
Innocenti Declaration, “the reinforcement of a communities that elect them—this includes
‘breastfeeding culture’ and its vigorous defence against breastfeeding. Countries that have ratified the Convention
incursions of a ‘bottle-feeding culture’”.5 In an age of of the Rights of the Child are also accountable for specific
expert social marketing and communication innovations, actions to protect children and promote their health.
redressing the misperceptions of breastfeeding should Legislation and accountability mechanisms should ensure
be possible. that maternity protection and workplace interventions
Third is to show political will. Politicians need to that support breastfeeding are implemented (although
demonstrate they appreciate that breastfeeding these will not reach women who are self-employed or in
promotion saves lives and money. The promotion of informal employment, such as street vending, domestic
breastfeeding is entirely different from the scaling up of work, or agriculture) and that all maternity health services
commodity-based interventions, such as vaccines or comply with the Code and the BFHI.
drugs, which are appealing because their implementation All 194 member states of the World Health Assembly
is easier to measure, and commercial pressures are in have agreed on breastfeeding targets for 2025. In the
their favour rather than against. Breastfeeding should be first paper in this Series, we showed that these targets
mainstreamed into preventive programmes for are realistic and could even be exceeded. Breastfeeding
non-communicable diseases for both children and is not explicitly mentioned in the Sustainable
women, as well as for the prevention of morbidity and Development Goals, but our Series shows that
mortality from infections of early childhood. The improvements in breastfeeding would help achieve the
economic gains provided by breastfeeding through targets for health, food security, education, equity,
increased intelligence, reduced health-care costs, and the development, and the environment. Without commit-
benefits of breastfeeding to the environment should be ment and active investment by governments, donors,
fully appreciated and evaluated when funding for the and civil society, the promotion, protection, and support
promotion and protection of breastfeeding is assessed. for breastfeeding will remain inadequate and the
Fourth is to regulate the breastmilk-substitute industry. outcome will be major losses and costs that will be borne
Breastmilk substitutes are a multi-billion-dollar industry, by generations to come.
the marketing of which undermines breastfeeding as the Contributors
best feeding practice in early life. No new interventions All authors contributed to the design, writing, and revision of the final
are needed—the Code is an effective mechanism for version of the report.
action. However, much greater political commitment is The Lancet Breastfeeding Series Group
needed to enact and enforce the relevant, comprehensive Switzerland R Bahl (World Health Organization, Geneva). Brazil
A J D Barros, G V A França (Federal University of Pelotas). India
legislation and national investment to ensure imple- R Chowdhury, B Sinha (Society for Applied Studies, New Delhi), J Sankar
mentation and accountability. Without these (All India Institute of Medical Sciences, New Delhi). USA J Krasevec
commitments, agreed principles of responsible marketing (United Nations Children’s Fund, New York, NY). UK S Murch
will continue to be violated. As such, breastfeeding is an (University Hospital Coventry & Warwickshire, Coventry). France
E Speakman (Independent consultant, Divonne). Canada D Wu
important way for governments to fulfil their obligations (University of Waterloo, Waterloo, ON).
to ensure “to the maximum extent possible the survival
Declaration of interests
and development of the child” (International Convention NCR reports that WHO received funds from the Bill & Melinda Gates
on the Rights of the Child).7 Foundation for commissioning systematic reviews and specific analyses
The fifth action point is to scale up and monitor in preparation for this paper. NB, NH, SH, CKL, JCM, EGP, LMR, and
breastfeeding interventions and trends in breastfeeding CGV declare no competing interests.
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