Elsevier

The Lancet

Volume 387, Issue 10017, 30 January–5 February 2016, Pages 491-504
The Lancet

Series
Why invest, and what it will take to improve breastfeeding practices?

https://doi.org/10.1016/S0140-6736(15)01044-2Get rights and content

Summary

Despite its established benefits, breastfeeding is no longer a norm in many communities. Multifactorial determinants of breastfeeding need supportive measures at many levels, from legal and policy directives to social attitudes and values, women's work and employment conditions, and health-care services to enable women to breastfeed. When relevant interventions are delivered adequately, breastfeeding practices are responsive and can improve rapidly. The best outcomes are achieved when interventions are implemented concurrently through several channels. The marketing of breastmilk substitutes negatively affects breastfeeding: global sales in 2014 of US$44·8 billion show the industry's large, competitive claim on infant feeding. Not breastfeeding is associated with lower intelligence and economic losses of about $302 billion annually or 0·49% of world gross national income. Breastfeeding provides short-term and long-term health and economic and environmental advantages to children, women, and society. To realise these gains, political support and financial investment are needed to protect, promote, and support breastfeeding.

Introduction

Breastfeeding improves the survival, health, and development of all children.1 It saves women's lives and contributes to human capital development. The benefits span populations living in high-income, middle-income, and low-income countries.1 In the second paper in this Series, we summarise the evidence on determinants of, and interventions to improve, breastfeeding practices. We discuss the effect of the breastmilk substitute industry on breastfeeding practices, and explore the reasons why some countries have been more successful in improving breastfeeding than others. We also estimate some of the economic costs and environmental consequences of not breastfeeding.

Section snippets

The Innocenti Declaration: an ideal not yet realised

Breastfeeding became less common in high-income countries during the 20th century.2 Similar patterns were also seen in better-educated, wealthier, and urban women in low-income and middle-income countries.1, 3 Breastmilk substitutes were perceived as modern and prestigious, and breastfeeding was associated with being poor and unsophisticated.4 In August, 1990, policy makers and international agencies adopted the Innocenti Declaration,5 which affirmed that all infants should receive “exclusive

Determinants of breastfeeding

We did a systematic review of available studies to identify the determinants of breastfeeding (appendix pp 2–86), and reviewed and revised previous conceptual frameworks. The conceptual model (figure 1) includes the determinants that operate at multiple levels and affect breastfeeding decisions and behaviours over time. Nearly all women are biologically capable of breastfeeding, bar very few with severely limiting medical disorders.11 However, breastfeeding practices are affected by a wide

Interventions to improve breastfeeding practices

Many aforementioned determinants of breastfeeding are amenable to interventions to protect, promote, or support improved breastfeeding.63 We examined the effects of interventions according to settings identified in the conceptual model: health systems and services, family and community, and workplace and employment. We also reviewed available data for policies to address structural factors that create an enabling environment for breastfeeding. We did a systematic review and meta-analysis64 of

The International Code of Marketing of Breastmilk Substitutes

Compelling accounts of inappropriate and unethical marketing of breastmilk substitutes and of many infants becoming malnourished or dying from contaminated or diluted breastmilk substitutes70 were followed by the adoption of the International Code of Marketing of Breastmilk Substitutes at the 34th World Health Assembly in 1981. The Code implicitly recognised that health workers, women, and families are susceptible to direct and indirect marketing strategies. It consists of 11 articles which,

Contextual factors on breastfeeding trends

Findings from case studies complement quantitative data by showing how synergies created through a mixture of interventions can improve breastfeeding. We discuss three pairs of countries (representing about a quarter of all children younger than 4 years worldwide) that are similar in economic development but differ in breastfeeding trends to explore why breastfeeding prevalence has increased, stagnated, or declined with time (Panel 1, Panel 2). In addition to having large populations, these

The effect of industry

Knowledge of the breastmilk substitute market and marketing practices are essential for understanding the competing environment in which efforts to protect, promote, and support breastfeeding operate. Market research was commissioned for this Series from Euromonitor International (specific methods, definitions, and results are in appendix pp 99–114; market research terminology to describe baby milk formula are used— standard: for infants <6 months; follow-on: for infants 7–12 months; toddler:

The economic argument for investment in breastfeeding

Improved breastfeeding practices would prevent 823 000 annual deaths in children younger than 5 years of age and 20 000 annual deaths in women caused by breast cancer.1 Breastfeeding also reduces morbidity and improves the educational potential of children and probably their earnings as adults.1

We will now discuss the economic value of breastfeeding, using new data for relative risks from a series of systematic reviews (the first paper in this Series).1 We first provide global estimates of the

Discussion

Our Series shows that breastfeeding contributes to a world that is healthier, better educated, more equitable, and more environmentally sustainable. But the relevance of breastfeeding is questioned across society. Women are drawn to substitutes for breastmilk and doubt their own ability to breastfeed. They, their families, and health professionals are not fully convinced by the benefits of breastfeeding: breastfeeding in public can generate embarrassment and has even been prohibited whereas

References (106)

  • CG Victora et al.

    Maternal and child health in Brazil: progress and challenges

    Lancet

    (2011)
  • R Perez-Escamilla et al.

    Scaling up of breastfeeding promotion programs in low- and middle-income countries: the “breastfeeding gear” model

    Adv Nutr

    (2012)
  • KM AlFaleh

    Perception and knowledge of breast feeding among females in Saudi Arabia

    J Taibah Univ Med Sci

    (2014)
  • S Horton et al.

    The economics of iron deficiency

    Food Policy

    (2003)
  • Contemporary patterns of breast-feeding. Report of the WHO Collaborative Study on Breast-feeding

    (1981)
  • LM Grummer-Strawn

    The effect of changes in population characteristics on breastfeeding trends in fifteen developing countries

    Int J Epidemiol

    (1996)
  • B Meldrum

    Psychological factors in breast feeding versus bottle feeding in the Third World

    Bull Br Psychol Soc

    (1982)
  • Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding

  • The optimal duration of exclusive breastfeeding. Report of an expert consultation

    (March 28-30, 2001)
  • United Nations Office of the High Commissioner on the Rights of the Child. Conventions on the Rights of the Child

  • Baby-Friendly Hospital Initiative. Revised, updated and expanded for integrated care

  • Global Nutrition Report 2015: actions and accountability to advance nutrition and sustainable development. Washington, DC: International Food Policy Research Institute

  • CK Lutter et al.

    Backsliding on a key health investment in Latin America and the Caribbean: the case of breastfeeding promotion

    Am J Public Health

    (2011)
  • Acceptable medical reasons for use of breast-milk substitutes

  • A Cattaneo

    Academy of breastfeeding medicine founder's lecture 2011: inequalities and inequities in breastfeeding: an international perspective

    Breastfeed Med

    (2012)
  • M Acker

    Breast is best…but not everywhere: ambivalent sexism and attitudes toward private and public breastfeeding

    Sex Roles

    (2009)
  • A Hannan et al.

    Regional variation in public opinion about breastfeeding in the United States

    J Hum Lact

    (2005)
  • M Labbok et al.

    Achieving exclusive breastfeeding in the United States: findings and recommendations

    (2008)
  • H McAllister et al.

    A study of in-hospital midwifery practices that affect breastfeeding outcomes

    Breastfeed Rev

    (2009)
  • G Leviniene et al.

    The evaluation of knowledge and activities of primary health care professionals in promoting breast-feeding

    Medicina

    (2009)
  • KB Kozhimannil et al.

    Medically complex pregnancies and early breastfeeding behaviors: a retrospective analysis

    PLoS One

    (2014)
  • D Simmons et al.

    In-hospital breast feeding rates among women with gestational diabetes and pregestational type 2 diabetes in South Auckland

    Diabet Med

    (2005)
  • A Thurston et al.

    Infant formula samples: perinatal sources and breast-feeding outcomes at 1 month postpartum

    J Perinat Neonatal Nurs

    (2013)
  • RO Meyerink et al.

    Breastfeeding initiation and duration among low-income women in Alabama: the importance of personal and familial experiences in making infant-feeding choices

    J Hum Lact

    (2002)
  • M Bandyopadhyay

    Impact of ritual pollution on lactation and breastfeeding practices in rural West Bengal, India

    Int Breastfeed J

    (2009)
  • EO Ojofeitimi et al.

    Infant feeding practices in a deprived environment: a concern for early introduction of water and glucose D water to neonates

    Nutr Health

    (1999)
  • NB Bar-Yam et al.

    Fathers and breastfeeding: a review of the literature

    J Hum Lact

    (1997)
  • CM Gibson-Davis et al.

    The association of couples' relationship status and quality with breastfeeding initiation

    J Marriage Fam

    (2007)
  • B Roe et al.

    Is there competition between breast-feeding and maternal employment?

    Demography

    (1999)
  • CM Visness et al.

    Maternal employment and breast-feeding: findings from the 1988 National Maternal and Infant Health Survey

    Am J Public Health

    (1997)
  • Maternity and paternity at work: Law and practice across the world

    (2014)
  • KA Dearden et al.

    Work outside the home is the primary barrier to exclusive breastfeeding in rural Viet Nam: insights from mothers who exclusively breastfed and worked

    Food Nutr Bull

    (2002)
  • G Ong et al.

    Impact of working status on breastfeeding in Singapore: evidence from the National Breastfeeding Survey 2001

    Eur J Public Health

    (2005)
  • C Ogbuanu et al.

    The effect of maternity leave length and time of return to work on breastfeeding

    Pediatrics

    (2011)
  • KR Mirkovic et al.

    In the United States, a mother's plans for infant feeding are associated with her plans for employment

    J Hum Lact

    (2014)
  • SS Hawkins et al.

    The impact of maternal employment on breast-feeding duration in the UK Millennium Cohort Study

    Public Health Nutr

    (2007)
  • S Guendelman et al.

    Juggling work and breastfeeding: effects of maternity leave and occupational characteristics

    Pediatrics

    (2009)
  • A Stein et al.

    Social and psychiatric factors associated with the intention to breastfeed

    J Reprod Infant Psychol

    (1987)
  • R Lawton et al.

    Employing an extended Theory of Planned Behaviour to predict breastfeeding intention, initiation, and maintenance in White British and South-Asian mothers living in Bradford

    Br J Health Psychol

    (2012)
  • A DiGirolamo et al.

    Intention or experience? Predictors of continued breastfeeding

    Health Educ Behav

    (2005)
  • Cited by (1374)

    View all citing articles on Scopus

    Members listed at the end of the paper

    View full text