Series L, Number 14
Issues in World Health

CONTENTS

Home (Key Points)

Breastfeeding Gains and Goals
Table 1. Breastfeeding Practices Improving
Web Table 1. Early Initiation of Breastfeeding Over Time
Web Table 2. Exclusive Breastfeeding Over Time
Web Table 3. Breastfeeding at Two Years
Table 2. Breastfeeding Common but Not Usually Optimal
Web Figure 1. Most Infants Breastfed Initially
Web Figure 2. Levels of Breastfeeding Vary Widely

Comprehensive Strategies Needed

Spotlight: Madagascar’s Comprehensive Approach Improves Breastfeeding

Breastfeeding Increases Women’s Contraceptive Options
Table 3. When Breastfeeding Mothers Can Begin a Family Planning Method After Childbirth Compared with Mothers Not Breastfeeding

Centerspread: Breastfeeding Is Best
Figure 1. Better Breastfeeding Reduces Diarrhea

Women with HIV Face Crucial Breastfeeding Decisions
Figure 2. Estimated Risk of HIV Infection in Infants and Young Children

Bibliography

Credits

• Counseling Aid: When Can a Woman Use LAM?
• Counseling Aid: HIV and Infant Feeding Counseling Flow Chart

• Box: Taking Ten Steps to Successful Breastfeeding
• Table: When Breastfeeding Mothers Can Begin a Family Planning Method

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Breastfeeding Gains and Goals

Breastfeeding saves infants' lives, provides the best nutrition for infants and young children, and benefits mothers' health. Breastfeeding provides the best health benefits when started immediately after an infant's birth, continued exclusively (without introducing other foods, liquids, or water) for the first six months of life, and then continued along with suitable complementary feeding through age two or longer (see 'What Is Optimal Breastfeeding?').

Frequent and intense breastfeeding can reliably delay pregnancy for up to six months after childbirth. The lactational amenorrhea method (LAM), as this form of contraception is known, is effective when a woman's menstrual periods have not yet returned and the infant receives no food but breastmilk for the first six months.

Breastfeeding choices are ultimately a mother's individual decision. Women can make informed decisions when health care providers offer information about breastfeeding and support for it. As more women breastfeed, more children survive their first years and grow up healthy. Gains in the practice of any breastfeeding reduce levels of malnutrition and prevent child deaths from diarrhea and pneumonia. Gains in optimal breastfeeding practices reduce risks of illnesses, malnutrition, and early death the most.

A growing percentage of infants are breastfed, according to findings from countries surveyed more than once since 1986 by the Demographic and Health Surveys (DHS) and Reproductive Health Surveys (RHS) programs (see Table 1). Comparable data show that in all but 4 of 65 countries surveyed at least 90% of children are breastfed. Yet only a minority of infants are breastfed in optimal ways (see Table 2). For instance, in most countries less than half of infants are breastfed within one hour of birth. Also, less than half are exclusively breastfed for the first six months of life.

Breastfeeding practices fall short of the optimal for many reasons. An estimated 60% of births in developing countries are not attended by trained health care workers. In addition to facing greater risk because they lack access to adequate health care, these mothers and babies rarely receive antenatal or extended postpartum health care services that support optimal breastfeeding (251).

Women increasingly work in jobs outside of the home. When women resume full-time employment after childbirth, the separation from their infants makes it difficult to maintain exclusive breastfeeding for the full first six months of the child's life.

Also, many women hold incorrect views about breastfeeding or do not recognize its health benefits (6, 83, 118, 166, 209). Women and their family members may believe incorrectly that breastmilk is not enough to satisfy or nourish their infants. In fact, breastmilk is a complete food and contains all the water and nutrients an infant needs. Others mistakenly believe that breastfeeding too often, or feeding from both breasts, will deplete the supply of breastmilk. In fact, these practices lead to more production of breastmilk. Still others may think that their child is still hungry when the child cries or reaches out and thus give foods other than breastmilk, instead of continuing to breastfeed. Such misperceptions and social pressures about breastfeeding often reflect accepted community wisdom and long-held beliefs.

Table 1. Breastfeeding Practices Improving
Breastfeeding Trends in Countries with Multiple Surveys Since 1986, by Number of Countries
	% Breastfed Within 1 Hour After Birth	% Breastfed Within 1 Day After Birth	% Exclusively Breastfed Through 6 Months	% Exclusively or Fully Breastfed Through 6 Months	% Breastfed At Least 2 Years
Increased in...	36 countries	37 countries	30 countries	32 countries	27 countries
Unchanged* in...	None	3 countries	3 countries	1 country	2 countries
Decreased in...	8 countries	4 countries	9 countries	9 countries	9 countries
*No change or change was less than 1% For trends by country, see Web tables 1, 2, and 3 Exclusive breastfeeding refers to feeding infants only breastmilk and no other solids or liquids. Full breastfeeding refers to feeding infants water, water-based drinks and fruit juices (but no other food-based fluid) in addition to breastmilk.

Table 2. Breastfeeding Common but Not Usually Optimal
Breastfeeding Levels, Most Recent Available Surveys, 1994-2005
Percentage of Infants Breastfed…	Unweighted Average Among Countries	Range Among Countries	Number of Countries with Data
Ever	96%	86%-99%	65
Within 1 hour after birth	41%	3%-81%	65
Within 1 day after birth	71%	25%-97%	65
Exclusively up to 3 months	38%	1%-79%	47
Exclusively up to 6 months	31%	<1%-90%	57
Exclusively or fully up to 3 months	62%	19%-90%	47
Exclusively or fully up to 6 months	54%	13%-91%	57
At least 2 years	40%	5%-89%	42
The data presented in Tables 1 and 2 come principally from online DHS STAT compiler tabulations as well as from RHS country final reports. Final DHS country report data have been used in cases where data were not available from STAT compiler. Not all surveys include questions on all the indicators presented in the tables, nor are the respondents defined the same way in all surveys. As a result, the number of countries reported in different sections varies. For region- and country-specific data, see Web figures 1 and 2.

A Call to Action

In 1990 the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) called on governments, donors, and international organizations to "protect, promote, and support" breastfeeding to improve infant nutrition and survival (269). This call to action, known as the Innocenti Declaration, led to a number of positive steps during the 1990s:

• In 1991 WHO and UNICEF established the Baby-FriendlyT Hospital Initiative to help ensure that maternity clinics encourage optimal breastfeeding practices.

• Many countries appointed national breastfeeding coordinators and developed national breastfeeding policies.

• Countries did more to enforce the 1981 International Code of Marketing of Breastmilk Substitutes, which limits unethical marketing by manufacturers of breastmilk substitutes.

In recent years, however, government and donor support for optimal breastfeeding has declined. Perhaps the main reason is that the AIDS crisis has focused attention on HIV transmission through breastmilk, while drawing attention away from the risks to children's health of not breastfeeding. The mistaken belief that all HIV-positive mothers will pass HIV to their infants through breastfeeding has overshadowed the health and life-saving benefits of breastfeeding (129) (see 'Renewing support for breastfeeding in the era of AIDS'). At the same time, some manufacturers of infant formula have continued unethical promotion that may discourage breastfeeding.

Concerned about declining national and international commitment to breastfeeding, WHO and UNICEF in 2000-2002 developed the Global Strategy for Infant and Young Child Feeding (258). The strategy calls on national governments, health care services, communities, and international donors to apply lessons learned about breastfeeding to better enable and support women to breastfeed optimally.