Action Folder '98
Breastfeeding - The Best Investment

Throughout the world, families, communities and nations seek to promote the health and welfare of their children. Unfortunately, economic factors often hinder these efforts through lack of funds for nutritious foods, clean water, and preventive and curative health care. Breastfeeding requires very little investment and has a tremendous payback for families, employers, communities, health care institutions and governments. 

World Breastfeeding Week 1998 aims to initiate actions to protect, promote and support breastfeeding as one of the best investments in the health of a nation. 

This year's goals are to: 

• Raise public awareness on the economic value of breastfeeding and the high cost of bottle feeding. 
• Provide concrete data on the economic advantages of breastfeeding for public advocacy. 
• Help governments appreciate the economic value of breastfeeding to all sectors of society and the need to include breastfeeding promotion and support programmes in the national health budget.

Breastfeeding can bring economic benefits to many levels of society: 

• For households 

• savings on the unnecessary purchase of artificial breastmilk substitutes and equipment 
• savings on time to artificially feed infants and to fetch water and fuel for preparation and clean-up 
• savings on medical care through fewer trips to physician or hospital for a sick child, medications and time caring for a sick child 
• savings on cost of birth control methods and menstruation supplies time 
• savings on work days lost in caring for a sick child 
 

Households can save, not only on the purchase price of artificial baby foods, but on the equipment, fuel and time required for preparation and clean-up

• For employers 

• savings from greater productivity and less absenteeism among breastfeeding mothers 
 

Employers whose policies and facilities support the needs for breastfeeding will have more loyal workers who less often miss work to care for sick babies.

• For nations 

• savings, often in foreign exchange, on the purchase and distribution of artificial breastmilk substitutes 
• savings on health care for preventable acute and chronic illnesses 
• savings in ecological damage avoided by reduced ABS production, distribution and disposal 
• savings on remedial education or special education

Savings in scarce foreign exchange and reduced burdens on health care facilities make breastfeeding promotion a good investment for nations.

Families from the former Yugoslavia would spend approximately 70% of their income for the purchase of artificial breastmilk substitutes (ABS) in the first six months if they did not breastfeed. At present only 30% of infants are partially breastfed at 4 months. If this could be increased to 70%, it is calculated that US$449 million could be saved while 99,000 respiratory infections, 33,000 ear infections, 123 cases of early onset diabetes, 84 cases of childhood cancer, and 152 cases of ovarian cancer could be averted each year. The cost of artificial feeding is thus high even in industrialized countries (1).

• costs in extra food for the mother 
• costs to provide working mothers with their maternity entitlements from paid leave to child-care facilities at the workplace. 
• costs to provide breastfeeding education and sustain voluntary breastfeeding support organisations such as mother-to-mother support groups. 

Artificial feeding costs billions of dollars to institutions, nations, governments, health care organizations and families 

Health care 

Artificial feeding in the infant's first year is associated with: 

• more diarrhea than in breastfed infants 
• more respiratory infections 
• more meningitis 
• more ear infections 
• increased allergies 
• more chronic digestive disorders and dental/orthopedic problems 
• more diabetes 
• more learning difficulties and delayed development 
• more hospitalization 
• in many countries, malnutrition and increased death rates from diluted formula, unsafe water and poor hygiene 

Families pay for ABS, feeding and sterilizing equipment, fuel, and for health care associated with diarrhea and other illnesses. ABS also takes time to purchase, to prepare and to administer. In many rural areas it takes hours every day to collect water (a three month old infant needs over three litres of water a day for mixing and boiling) and wood (it takes 200 grams of wood to boil this water) (2). 

An Argentinean who spends $ 50 per month to purchase ABS could have bought 15 kg of meat, 75 kg of oranges, or 50 kg of vegetables for his or her family with that same money. 

ABS utilizes scarce foreign currency when imported. In Pakistan ABS imports were $ 4 million in 1982-3, $ 8.5million in 1987-1988, and $ 43.5 million from July 1995 to April 1996. This increase coincides with Nestle's aggressive new marketing policy (5). 

Companies 

Artificially fed babies are sick much more often and for longer periods than breastfed babies. Corporate breastfeeding support programs in the USA resulted in a 27% decrease in absenteeism and a 36% decrease in health care costs (3). 

Nations 

Use of ABS jeopardizes food security. 

The net value of breastmilk produced in Ghana if breastfeeding were optimal would be $ 165 million dollars. The actual 'lost breastmilk production' was worth $ 33 million dollars (4). 

A superior product and process is replaced with an inferior one at the cost of foreign exchange. At the same time, artificial feeding exacerbates deforestation and solid waste problems, as outlined in the 1997 WABA action folder Breastfeeding: Nature's Way. Finally, the cost of human capital due to failure to achieve children's full physical and intellectual potential is important, although.difficult to measure. 

Exclusive Breastfeeding 

Premature supplementation is often advised by health workers who are unaware that breast-fed infants grow differently than the largely bottle-fed ones upon whom today's growth charts were based (8). 
 

• the supplement usually just replaces breast milk with something of lower nutritional value
• unnecessary contamination and infection occur at a younger and more vulnerable age this can lead to malnutrition and even death 
• the child's intellectual development can be harmed 
• the contraceptive effect of breastfeeding is reduced and closer child spacing increases the risk of low birth weight 
• there is a loss of oxytocin, the "calming, love" hormone 

Baby food companies and the scientists whose work they fund encourage early supplementation. They know that this often results in dependence on costly commercial baby foods. 

Recognizing this, IBFAN, WABA and other organizations are monitoring baby food promotion for violations of the International Code of Marketing of Breast-milk Substitutes, as well as for false claims by manufacturers. 

Many women do not know that their milk is of much better quality than ABS, and have instead been tricked into believing that ABS is as good or better than their own breastmilk. The commonest reason women give for not breastfeeding is that their milk "dried up." 

Actually, 'drying up' is easily overcome by frequent feeds and maternal confidence in her ability to feed her baby. Misled by the baby foods industry and poorly trained health workers' messages promoting mixed feeding, women's faith in their ability to breastfeed is often undermined. 
 

Economic Studies 

Breastfeeding is "priceless." Advocacy of exclusive breastfeeding, rare worldwide, requires an appreciation of its importance throughout society. Economic measurements cannot put a value on any expression of love or altruism. Most women view breastfeeding with pride. Placing human milk on food balance sheets could increase its perceived value (9), but listing breastmilk production may be equated with cow's milk production, which some women perceive as degrading. 

Breastfeeding, one of women's unique contributions to society, is worth far more than any economic value assigned to it. However, seeing the real size of this contribution in terms of the food supply to a nation is surely impressive and demonstrates to responsible policy makers the importance of this activity in terms they can more easily relate to. 

Breastmilk has economic value 

In Norway it was calculated in 1992 that 8.2 million kg of breastmilk was produced, valued at $50/liter based on what Norwegian hospitals pay for it. While the value of manufacturing artificial baby foods is included in the calculation of the gross national product (GNP), the value of producing breastmilk is not. This leads to the absurd conclusion that the GNP declines when breastfeeding rates increase! (10) 

Annual breastmilk production has been estimated in several African countries to average 10 kg per capita (range 8-17). Even if breastmilk is valued at only $1/litre, the GNP would increase by 1% in Zimbabwe and 6% in Mali if it were included in GNP calculations (11). 

The value of the breastmilk produced annually in Australia was calculated to between A$1.7 and A$2.7 billion, depending on the valuation method used. If the Innocenti Declaration breastfeeding targets were achieved, the value of breastmilk would increase by another A$3.4 billion, representing 3.1% of the Gross Domestic Product (GDP) and 40% of public expenditure on health (9). 

Breastfeeding promotion leads to healthcare savings 

• For each baby breast-fed for six months, the US government can save $450-$800 in welfare and health care costs (12). 
• Disease attributable to artificial feeding in the USA costs $291 million/year for infant diarrhea; $225 million for respiratory syncytial virus; $660 million for otitis media, and $10-125 million for insulin dependent diabetes mellitus (IDDM) (13). 
• If the prevalence of exclusive breastfeeding up to three months of age increased from 60-80% in Australia, A$11.5 million would be saved on health care costs for otitis media, IDDM, gastrointestinal disease, and eczema alone (14). 
• In India, if exclusive breastfeeding prevented only one episode of diarrhea per child per year, the money saved would exceed the national budget for child health. Lactation amenorrhea is by far the top contraceptive in the country; the value of this to the national family planning programme is equal to nearly half its budget (15). 

Ideas for Action

WBW in Brazil, South America

• Calculate the cost of ABS in your country and how much food that would buy for the family. A baby needs 2.5 kg of ABS powder in the first month, 3.2 kg the second month, and 4 kg per month after that. Find the cost per kg of a locally popular brand of ABS (infant formula) and you can use these figures to calculate the total cost of ABS for six months of artificial feeding. But remember that there are many other costs!
• As a rough rule of thumb, the health care costs may be twice as high as the cost of ABS for that period. This will allow you to more closely estimate the cost of formula feeding for a family and for the nation. 

• Talk with your boss about the economic benefits of establishing breastfeeding programs at your work place. Ask for WABA's flyer Steps Toward a Mother-Friendly Workplace. 
• Find ways through TV and newspapers to give recognition to workplaces that encourage breastfeeding, such as giving a mother-friendly workplace award. 
• Give a copy of this folder to the people in government responsible for establishing maternity protection laws, labor regulations and health programs. 
• Organize community group discussions and presentations on the cost of formula feeding. 
• Offer to talk at schools, women's groups, business groups etc about the real cost of not breastfeeding. 
• Help people recognize that breastfeeding is a valuable natural resource to the country. Calculate the costs of artificial feeding for one year for one infant and then compare it with the per capita GNP. 
• What do the price differences between different brands of infant formula hide? (Need for food technology insight) 

• Write to your governmental representatives at local and national levels mentioning WBW and urge them to promote breastfeeding in government offices and improve the support available for breastfeeding women on their staff. 
• Suggest ways to cut costs and increase savings in hospitals, health facilities, family planning programmes, and for families by promoting breastfeeding. 
• Urge health professionals to influence economists, statisticians and those involved in drawing up health and food statistics to include human milk in their calculations of food supply, availability of food and nutrients and the economic value of food. 
• Show how hospital costs can be reduced when breastfeeding increases. They realize savings in purchase of IV fluids, ABS, bottles, staff nursing time, reduced hospital days for premature and newborns and medications. 
• In advocacy, first, action should be urged on the basis of breastfeeding as a woman's right; then breastfeeding-promoting actions should be encouraged by showing their economic benefits and how easily they pay for themselves by reducing costs for imported infant foods and for health care.

While economic data may be useful in certain settings for creating awareness of the importance of breastfeeding among policy makers, WABA cautions that economic calculations underestimate the complete value of breastfeeding. Its economic value is only a fraction of its human welfare value. Breastfeeding guarantees the baby skin-to-skin contact, attention from mother and other caring attributes. Bottlefeeding does not guarantee any of these. 

However, discussions on breastmilk production and its food value should be handled delicately so as not to 'offend' some women with the comparison to cows. Policy makers should be made aware of the importance of exclusive breastfeeding, the need to make mother support available, to provide extra support for working women, and to have a system for the regulation of the baby food industry so breastfeeding is not undermined. 

This year's Action Folder provides information on the economic value of breastfeeding and serves as an advocacy tool to value the economic benefits of breastfeeding. WABA emphasizes that cost savings is not the only nor the major benefit of breastfeeding. Indeed, mothers and babies have a right to breastfeed. 

Women should not be made to choose between mother work and other work. It is in society's interest to fund breastfeeding promotion and support programs and to consider breastfeeding time as work time for mothers in paid jobs, or even to pay women to breastfeed. 

In Quebec, Canada, since 1995 there is a programme which pays mothers receiving public assistance who 'opt' to breastfeed. Mothers who breastfeed should also be protected from advertising and promotion of ABS, as specified in the International Code of Marketing of Breast-Milk Substitutes. 

Mothers have a right to breastfeed and babies a right to breastmilk. Success in breastfeeding should not be a luxury only afforded by the resourceful, the rich or the lucky. 

References 

1. Tolstoplatov B, et al. (1996). Cost of Infant Feeding in the Former Yugoslavia. International Child Health, vii(1);39-44. 
2. Cohen R and Mrtek MD (1995). Comparison of Maternal Absenteeism and Illness Rates Among Breastfeeding and Formula Feeding Women in Two Corporations. American Medical Journal of Health Promotion 10(2):148. 
3. Linkages, AED (1998). Ghana: suboptimal breast-feeding in infants. Washington, DC: Linkages, AED. 
4. Network Newsletter of the Association for Rational use of Medication in Pakistan 5:1, March 1996, page 13. 
5. American Academy of Pediatrics Working Group on Breastfeeding (1997). Pediat rics 100(6): 1035-9. 
6. Cohen RJ, et al (1994). Effects of age of introduction of supplementary foods on infant milk intake, total energy intake and growth: a randomized intervention study in Honduras. Lancet 344: 288-93. 
7. WHO Working group on Infant Growth (1994).An evaluation of Infant Growth. Geneva: WHO. 
8. Smith JP and Ingham LH (1997). Unpublished manuscript on the economics of breastfeeding in Australia. 
9. Oshaug A and Botten G (1994). Human milk in food supply statistics. Food Policy 19(5):479-482. 
10. Hatby A and Oshaug A (1997). Human milk-an invisible food resource. Washington DC: International Food Policy Research Institute. 
11. Tuttle CR and Dewey KG (1996). Potential cost savings for Medi-Cal, AFDS, Food Stamps and WIC programs associated with increasing breast-feeding among low-income Hmong women in California. J Amer Dietetic Assn 96:885-890. 
12. Riordan JM (1997). The cost of not breastfeeding: a commentary. Journal of Human Lactation 13(2):93-97. 
13. Drane D (1997). Breastfeeding and formula feeding: a preliminary economic analysis. Breastfeeding Review 5(1):7-15. 
14. Gupta A and Rhode J (1993). Economic Value of Breast-feeding in India. Economic and Political Weekly, June 26, pp. 1390-3. 
15. WELLSTART International (1996). Breastfeeding Promotion: A Cost Effective Intervention. Washington DC: WELLSTART EPB. 
16. UNICEF (1998). State of the World's Children. New York:UNICEF.

WBW Coordinating and Distributing Centres

WABA Secretariat 
Director Sarah Amin 
P O Box 1200 
10850 Penang, 
Malaysia 
Fax: 60-4-657 2655 
Email: waba@waba.org.my

WBW International Coordination
Denise Arcoverde 
Av. Beira Mar, 3661 Lj. 18 
Casa Caiada - Olinda - PE 
CEP 53130-540 - Brazil 
Fax: 55-81-4327701 
Email: origem@elogica.com.br

AFRICA

IBFAN Africa 
P O Box 781 
Mbabane, Swaziland 
Fax: 268-405 46 

IBFAN Afrique Francophone 
01 B.P. 1776 
Ouagadougou 01 
Burkina Faso 
Fax: 226-303 888 

MAPBIN/ICP 
P O Box 1134 
Port Louis, Mauritius 
Fax: 230-211 4436 

ASIA 

WABA Secretariat (See address above) 

South Asia Breastfeeding Promotion Network of India (BPNI)
P O Box 10551, BP-33 
Pitampura Delhi 
110 034, India 
Fax: 91-11-721 9606 

EUROPE 

BMAC 
23 St. Andrew's Street 2nd Floor, 
Cambridge CB2 3AX, UK 
Fax: 44-1223-464 417 
Email: babymilkacti@gn.apc.org

GIFA 
C.P. 157, CH 1211 
Geneva 19 
Switzerland 
Fax: 41-22-798 4443 
Email: philipec@iprolink.ch 

LATIN AMERICA

CEPREN - Centro de Promocion de Estudios en Nutricion 
Av. Pardo, 1335 OF.302 
Lima-18 Peru 
E-mail: cepren@amauta.rcp.net.pe
Fax: 051 1 241-6205 
Tel. 051 1 445-1978 

IBFAN Latin America 
Conaplam
23 Calle 26-60 zona 5 
"Interior Casa del Nino No. 4" 
Ciudad Guatemala, Guatemala C.A. 
CP 01005 Fax 502 3353711 
E-mail ruth.arango@starnet.net.gt

Cefemina
Apartado 5355 
1000 San Jose, 
Costa Rica 
Fax: 506-224 3986 
Email: cefemina@sol.racsa.co.or

Brazil & Lusophone countries 
Origem Group/WABA Brasil
(See address WBW International Coordinator above) 

NORTH AMERICA 

NABA 
254 Conant Road Weston, 
MA 02193-1756 
Fax: 1-617-893 8608 
Email: Marshalact@aol.com

LLL International
1400 N. Meacham Road 
Schaumburg IL 60173-4840 - 
USA Fax: 1-847-519 0035 
Email: lllhq@pop.wwa.com

PACIFIC

NMAA 
P.O. Box 231, 
Nunawading VIC 3131, 
Australia 
Fax: 61-3-989 43270 
Email: nursingm@vicnet.net.au

Secretary PINDA
c/o USP-Alaufa Campus, 
Private Bag, Apia, 
Western Samoa 
Fax: 685-229 33 
Email: brenda@elele.peacesat.hawaii.edu

WABA does not accept sponsorship of any kind from companies producing breastmilk substitutes, related equipment and complementary foods. WABA encourages all participants of World Breastfeeding Week to respect and follow this ethical position. 

This action folder was produced by Ted Greiner, in colaboration with Naomi Baumslag and Nomajoni Ntombela. Many thanks to all who reviewed this folder and to UNICEF and the Dutch Ministry of Foreign Affairs for their financial support to WABA.

Pictures: Infact Canada, La Leche Liga Deutschland, Grupo Origem (Brazil), Indonesian Breastfeeding Foundation, IBFAN Africa, AFS (Germany)