Breastfeeding provides a vital source of nutrition to infants and in low income countries, where resources are limited, it is particularly important in combating infant mortality. According to the children’s charity UNICEF, in these settings, infants up to the age of five months who are not breastfed are five times more likely to die from pneumonia and seven times more likely to die from diarrhoea. Suboptimal breastfeeding is also associated with a greater susceptibility to perinatal infections. UNICEF estimates that the simple intervention of immediate and exclusive breastfeeding could reduce child mortality in those under five by up to 13 percent. In a recent study in BMC Medicine, Emmanuela Gakidou from the University of Washington, USA, and colleagues analyze breastfeeding patterns in over 130 developing countries to answer the question, ‘can breastfeeding promote child health equity?’. Gadikou discusses their findings, explores the relationship between child health equity and breastfeeding, and suggests what needs to be done next to influence breastfeeding behaviors.
What is suboptimal breastfeeding?
This all starts with the idea that early, exclusive breastfeeding is the most effective way for women, particularly in low-income countries, to make sure their children are getting the right nutrients during the first part of their life. The World Health Organization (WHO) issues breastfeeding recommendations that reflect the state of the epidemiological literature. Currently their recommendations have three key components: initiation of breastfeeding within one hour of birth, exclusive breastfeeding up to the age of 6 months, and continued breastfeeding through 24 months. When those recommendations aren’t met, we call that suboptimal breastfeeding.
How does suboptimal breastfeeding contribute to child mortality and child health inequity?
Suboptimal breastfeeding has been associated with many short-term and long-term health outcomes. The most significant of these outcomes are diarrhoea and pneumonia. According to the Global Burden of Disease, Injuries, and Risk Factors Study 2010, suboptimal breastfeeding is the second largest risk factor for children under five, accounting for 47.5 million years of life lost due to premature death and disability and 544,817 deaths in 2010. These effects of suboptimal breastfeeding are primarily mediated through increased pathogen exposure and decreased immunopotentiation.
With respect to child health inequity, it is important to distinguish that it is the lack of progress on breastfeeding promotion rather then simply suboptimal breastfeeding that is connected with child health inequity. It is well documented that when being scaled up, some child health interventions, such as vaccinations, tend to reach those with the lowest incomes last. This trend can have the effect of increasing health inequalities until these interventions are able to reach almost everyone. Breastfeeding promotion is different. It is not closely linked to health system infrastructure and therefore its uptake is less dependent on health system access. Breastfeeding promotion allows you to not only improve child health, but promote equity as well.
What are the main changes in patterns of breastfeeding you observed?
Globally, progress toward the WHO recommendations on breastfeeding was very limited between 1990 and 2010. In 1990, 27.9 percent of children less than six months old were exclusively breastfed, compared to 34.2 percent in 2010. That is a very slow increase over 20 years. Between 1990 and 2010, we actually found a slight decrease in continued breastfeeding between six and 11 months, from 75.6 percent in 1990 to 72.4 percent in 2010. The most notable decrease was seen in the prevalence of timely initiation of breastfeeding, which dropped from 41.5 percent in 1990 to 32 percent in 2010. On a more positive front, globally, there was progress for continued breastfeeding between the ages of 12 and 23 months. Those rates climbed from 31.9 percent in 1990 to 59.2 percent in 2010. At the country level, we saw huge variation across all indicators. Exclusive breastfeeding prevalence varied from 3.5 percent in Djibouti to 77.3 percent in Rwanda. Timely breastfeeding initiation ranged from 6.3 percent in Malawi to 58.0 percent in Chad, and continued breastfeeding for children between six and 11 months ranged from 13.4 percent in Qatar to 95.5 percent in the Gambia.
What do you think reasons are for the large differences in breastfeeding practices among countries?
Cultural attitudes and social forces towards breastfeeding behaviours are complex. Breastfeeding promotion efforts, and public policy related to breastfeeding are hugely variable between countries. Beyond these, social forces such as the media and the availability and cost of breastfeeding alternatives can have large effects on attitudes towards breastfeeding. Several studies have revealed some fascinating relationships at the regional and country level, but more research on the traits and behaviors associated with breastfeeding in different contexts is definitely needed to help us better understand the variation we are seeing.
What impact do you think your findings will have on public health, policy and clinical practice?
We hope that our research will enable policy makers to intensify efforts on breastfeeding promotion in countries that have low breastfeeding rates. Our research shows that breastfeeding programs are well positioned to reduce child mortality and wealth-related child health inequities. We also hope that our findings call to attention the need for a greater understanding of the drivers of breastfeeding behaviors so that future money spent on interventions can achieve the largest possible effects.
How can health systems ensure that breastfeeding becomes a priority?
The evidence is there: breastfeeding promotion has incredible potential for improving child health outcomes. It is widely regarded as one of the most cost-effective child health interventions, and one which does not require extensive health infrastructure. Case studies in countries such as Ghana, Madagascar, Bolivia, and Brazil show how community-based promotion, legislative efforts, and media campaigns were successfully used to improve breastfeeding behaviors. Health systems just have to allocate the resources to design interventions that are contextually appropriate and implement them.
What are the main barriers to breastfeeding?
One of the main issues is the complexity of cultural attitudes towards breastfeeding that varies across countries and income groups. Take a look at Ghana and Cote d’Ivoire. They are neighboring countries that both had very low prevalence of exclusive breastfeeding in 1990. By 2010, Ghana increased exclusive breastfeeding prevalence by 47 percent, yet Cote d’Ivoire only increased by 2 percent. Looking at the data alone, it is not possible to determine what caused these changes in rates, but there are clearly factors at play that need to be explored.
Are there any other easily implementable strategies besides breastfeeding that could further reduce child mortality in resource-limited settings?
Breastfeeding promotion is one of the most overall beneficial interventions that can be implemented without a large health system infrastructure. Case studies of several countries showed success in using legislative or media campaigns and community-based promotions can improve breastfeeding behaviors.
What further research is needed to reduce child health inequities?
There is little research regarding the complex cultural social forces that influence breastfeeding behaviors. That’s a ripe area for future research. Additionally, there is little known about the interactions between breastfeeding and other child health interventions such as water and sanitation interventions. We also have little evidence on the effects of HIV prevalence and antiretroviral therapy scale-ups on breastfeeding behaviors. Once we better understand these trends and interactions, as well as improve the overall quality and availability of breastfeeding prevalence data, we will begin to better understand how breastfeeding promotion can most efficiently reduce inequities.