2 Breast Milk, Global Health and Sustainable Development

Leith Greenslade, MPP, MBA

Expected Key Learning Outcomes

• Why breastfeeding is so important

• How breastfeeding can help reduce the inequalities in health

• The health and economic benefits from increasing breastfeeding rates

• Reasons why mothers do not breastfeed despite all the evidence from research demonstrating the benefits

• The required change of policy focus needed to support a global increase in breastfeeding rates

2.1 The Importance of Empowered Mothers

Nature has empowered mothers with control over the production and distribution of an extraordinarily protective substance for the health and development of their babies - breast milk. This evolutionary innovation provides all of the nutrition an infant needs for the first six months of life and affords protection from infectious diseases, reduces the risk of sickness and death, and contributes to healthy digestive and brain development well into early childhood.

Unlike the vast majority of health interventions, breast milk is wholly owned and operated by mothers who function as "doctors" administering their "medicine". To unleash the protective powers of breast milk, mothers must not only be knowledgeable about the benefits of breast milk. They must also be freely able to exercise their choice to breastfeed, unfettered by external barriers. If mothers cannot breastfeed due to sickness or absence, they should be able to ensure that their babies have access to their own breast milk and, where that is not possible, to donor breast milk from the newborn period onwards.

It is critical that development actors confront the reality that for almost all mothers - an estimated 140 million women give birth every year - breastfeeding is not always a choice. Depending on the severity of the barriers, a mother may be so constrained by forces beyond her control (e.g., lack of education, lack of family support, the need to earn an income) that she cannot exercise a preference to breastfeed. For many tens of millions of mothers, breastfeeding is not possible in the environments in which they live. For these women, reducing or removing the external constraints is what will ultimately lead to sustained increases in breastfeeding.

Women facing the most significant barriers to breastfeeding are also most likely to live in communities where the costs of not breastfeeding fall most heavily on children. These are the populations where very low breastfeeding rates coexist with very high rates of newborn and child sickness and death. Empowering mothers in these high-risk environments to exercise a real choice to breastfeed in supportive homes, workplaces, and public spaces should be the primary focus of development efforts to increase breastfeeding rates.

2.2 The Benefits of Breast Milk

In the past 15 years the health benefits of breastfeeding have become extremely well known and extensively promoted. There is consensus among the global health community that breast milk confers its powerful protective properties on children by providing all of the nutrients, vitamins, and minerals children need in the first six months of life, alongside antibodies that combat infectious diseases, especially diarrhoea and pneumonia 1, 2, and enzymes for optimal digestion. There is now widespread acceptance that the health benefits of breastfeeding continue well into early childhood, and potentially beyond. The benefits of breastfeeding for women include reduced risk of pregnancy and potentially lower lifetime risks of certain cancers, obesity, diabetes, and heart disease 3.

Several Lancet series on maternal, newborn, and child health and nutrition have laid out the evidence for the benefits of breast milk. The Maternal and Child Undernutrition Series 4, the Maternal and Child Nutrition Series 5, the Childhood Pneumonia and Diarrhoea Series 6, the Every Newborn Series 7, and the Breastfeeding Series 8 all cite evidence that breastfed babies are much more likely to survive the first six months of life 9, that initiation of breastfeeding within 24 hours of birth could reduce the risk of newborn death by 43% of all newborn deaths 10, 11, 12 and that breastfeeding could prevent 823,000 child deaths and 20,000 breast cancer deaths annually 13. Other sources accord with these findings, including the Born Too Soon Report, which stresses the importance of breast milk for preterm babies 14, and the Global Burden of Disease Study 2016, which ranks "suboptimal breastfeeding" as a leading behavioural risk factor in child death, especially across African and Asian countries 15. According to this body of evidence, no other single intervention has the power to prevent newborn and child deaths at the scale of breast milk.

There is less consensus about the long-term health and related benefits of breastfeeding for both breastfeeding mothers and breastfed infants. The many studies that report adult health benefits including reductions in heart disease, diabetes, and cancers; cognitive improvements including higher IQ; and even economic gains including higher educational performance and income 16 all suffer from methodological weaknesses as they are based on cross-sectional retrospective studies rather than randomised control trials. A recent meta-analysis of these studies cautioned that these methodological challenges limit the ability to draw firm conclusions 17, 18.

The 2016 Lancet Breastfeeding Series quantified the impact of these health and development benefits on healthcare costs and economic growth, reporting that increases in breastfeeding rates could save US$400 million in healthcare costs in the US, UK, Brazil, and China alone, and inject US$300 billion into economies from more productive workforces 19.

2.3 Breastfeeding as an Equity Strategy

Children born to low income families in high-risk environments disproportionately benefit from the special protective properties of breast milk because they are more likely to be exposed to infections exacerbated by poor living conditions and less likely to access quality healthcare as formal health services so often fail to reach them. A recent study reported that a 10% increase in breastfeeding prevalence across all households resulted in a larger absolute reduction in child deaths in the poorest households 20. The authors concluded that breastfeeding is better positioned to reduce wealth-related child health inequalities than other interventions.

Although breastfeeding is one of the few health interventions where the gaps in coverage between high and low income households are narrow in low income countries, early and exclusive breastfeeding rates among poor families remain very low 21. Globally, just 40% of infants from the poorest households are exclusively breastfeed for the first six months of life, and in many countries with the highest child mortality breastfeeding rates are even lower 22. For example, the ten countries with the highest child mortality rates all have exclusive breastfeeding rates below 50% ( ? Table 2.1), and several have rates below 20%. Further, eight of the ten countries with the largest numbers of child deaths have exclusive breastfeeding rates below 50% ( ? Table 2.2). These include India, Nigeria, Pakistan, China, Democratic Republic of Congo, Indonesia, Angola, and the Philippines.

Country

Child Mortality Rate
2016

% Early Breastfeeding
(0-1 hour)
2008-2015

% Exclusive Breastfeeding
(0-6 months)
2008-2015

Angola

157

55

No data

Somalia

133

26

5