Finally, data on lives saved each year by breastfeeding: only 8% of WHO claim!

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In 2016 The Lancet published a paper that made an extraordinary claim. According to Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect:

The scaling up of breastfeeding to a near universal level could prevent 823,000 annual deaths in children younger than 5 years …

It’s an extraordinary claim because it is belied by all existing real world data on the impact of formula around the world. Indeed countries with the lowest breastfeeding rates have the LOWEST infant mortality rates and countries with the highest infant mortality rates have the HIGHEST breastfeeding rates. And after 30 years of breastfeeding promotion that resulted in increased breastfeeding rates in a variety of countries, there’s no evidence that increasing the breastfeeding rate has any impact on infant mortality.

Breastfeeding doesn’t save lives; clean water saves lives.

Since that claim was published I’ve searched incessantly for real world data to support that claim and was unable to find any. Neither could anyone else; I’ve challenged just about every major breastfeeding professional from every major breastfeeding organization to show me how many terms babies’ lives* are actually saved by breastfeeding. Thus far, no one could identify even a single one.

Now finally — finally! — a paper shows just how many lives are saved each year by breastfeeding: 65,000, a tiny fraction of the 800,000 claimed by The Lancet and the World Health Organization.

The paper is Mortality from Nestlé’s Marketing of Infant Formula in Low and Middle-Income Countries.

It’s an economics paper not a peer reviewed scientific paper. I wasn’t able to find it before because it was published only a few months ago in March 2018.

In contrast to The Lancet paper that relies on mathematical modeling, it it an attempt to find out exactly how many babies die when women who otherwise could breastfeed are pressured by companies to choose formula feeding instead.

The authors note what I have repeatedly emphasized: the WHO has staked out the claim that increasing breastfeeding rates could save more than 800,000 lives per year without ANY data to support it.

Intensive and controversial marketing of infant formula is believed to be responsible for millions of infant deaths in low and middle-income countries (LMICs), yet to date there have been no rigorous analyses that quantify these effects…

The authors attempt to rectify that problem. They start by explaining the “original sin” of Nestle:

The beginning of the public controversy over infant formula marketing practices in the developing world began in August 1973 when an article, The Baby Killer, was published in the New Industrialist. The article stressed the nutritional inadequacy of infant formula relative to breast milk, and provided examples of specific marketing abuses by Nestlé, the first major formula manufacturer to enter LMICs and the largest supplier worldwide. At the same time, public health researchers documented a large decline in breastfeeding contemporaneous with the introduction of infant formula, and published estimates of infant deaths resulting from the introduction of infant formula into LMICs ranging from annual figures of 1 million to 10 million …

The World Health Organization reacted:

In response, the World Health Organization and UNICEF organized a meeting of stakeholders out of which the International Code of Marketing of Breast-milk Substitutes (ICMBS) was created and later enacted in 1981.

The authors attempted to determine the impact of Nestle’s behavior on infant mortality over the past decades:

Nestlé’s phased entry over time into national infant formula markets provides plausibly exogenous variation in the market availability of formula conditional on location fixed effects. We exploit this variation to identify the causal effect of formula availability by estimating difference-in-differences models with location and year fixed effects. We interpret the results as Intent-to-Treat (ITT) estimates that capture the average mortality response to the availability of infant formula for purchase proxied by whether Nestlé is actively selling formula in the country. Our estimated treatment effects represent the intersection of adoption of infant formula by mothers within the exposed population and the impacts on infants from consuming the formula. The impact on infant mortality will also vary depending on whether formula is combined with clean water and whether it substitutes for breast milk or for some inferior nutritional supplementation such as water, diluted condensed milk, juice, rice water, or other low-quality substitute.

Looking at the data as a whole they found NO IMPACT of formula feeding on infant mortality:

The introduction of infant formula shows no statistically significant average impact on infant mortality for the population as a whole.

That’s why I and others have been unable to find any real world population data that shows that breastfeeding saves the lives of term babies.

The authors then drilled down into their data to find the impact of formula feeding among populations that lack access to clean water.

…[O]ur results show large and significant infant mortality deaths from formula introduction concentrated in vulnerable sub-populations. Specifically, infant formula availability had a significantly negative effect on mortality of infants born in households that used surface water. The availability of formula increased infant mortality by 12.9 per 1000 for households that used surface water relative to higher-quality water using households. The net effect of formula availability is an increase of 9.4 infant deaths per 1000 among mothers with poor-quality water.

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What’s the magnitude of that effect? The authors looked at what happened in 1981, the year where Nestle’s market penetration was the highest:

We estimate the number of deaths for 1981, arguably the peak year of the controversy when media attention was the highest. We do this by multiplying the 47.8 million 1981 live births that occurred in Nestlé formula sales countries by the fraction of those households with surface water in those countries and by our estimate of the impact of formula on infants from households with only unclean surface water access, i.e. This yields an estimate of 65,676 infant deaths with a 95% confidence interval of [24,868, 106,485], lower than earlier estimates of one million or more, but unquestionably a substantial loss of human life.

It’s a substantial loss of life, but only a tiny fraction of the one to ten million lives claimed by lactation professionals and the WHO.

Since then the impact of formula on infant mortality has dropped both because of reductions in use of formula and increases in the availability of clean water. The claim that breastfeeding could save more than 800,000 lives per year is absolute nonsense. Indeed the real number is fewer than 65,000 lives per year, only 8% of the claimed impact.

Formula itself does NOT harm babies. Only contaminated water harms them. If we really wanted to save lives we would improve water quality since even breastfed babies have to bathe in that contaminated water and eventually drink it as they grow older. But it’s so much easier and cheap to hector mothers and pontificate about breastfeeding than it is to provide the very poor with clean water.

That doesn’t mean we should stop promoting breastfeeding; it’s still a valuable goal even if it only saves tens of thousands of lives each year instead of hundreds of thousands as claimed by the WHO. But it does mean that aggressive breastfeeding promotion through programs like the Baby Friendly Hospital Initiative has no place in societies with easy access to clean water. It means that draconian restrictions on formula advertising in industrialized countries are totally unwarranted. Most importantly, it means that the documented harms of aggressive breastfeeding promotion: brain injuries and deaths from dehydration, hypoglycemia, kernicterus, and babies falling from or being smothered in their mothers’ hospital beds, are inexcusable.

It also means that we cannot trust the WHO’s claims about breastfeeding being lifesaving. The claims were supported by real world data; now that we finally have that data, it appears that increasing breastfeeding rates can save less than 65,000 lives per year, a far cry from the 800,000 claimed by the WHO.

 

*There is real world data to show that breastmilk reduces the risk of necrotizing enterocolitis, a serious complication of extreme prematurity.

  • It should be noted that the study is a floor estimate. They did not have data from all countries, they only looked at infant mortality and not child mortality, and they did not have any historical data on unclean water and thus had to use a minimal proxy. In the study it explicitly stated that they are only giving the lower bound of the effect.

    And in contradiction to what you claim elsewhere:

    “Many of these deaths could have been avoided if more mothers had breastfed. There are a number of effective antenatal and postnatal behavioral change interventions that improve breastfeeding practices and thereby reduce infant formula use (35). Examples include education and counseling during the prenatal period as well as hospital and homebased support in the postpartum period (36, 37), and effects of which can be enhanced by including fathers (38). A very effective program is the Baby Friendly Hospital Initiative, which bans promotion of bottle feeding infants post-partum and supports breastfeeding immediately after birth and throughout the crucial first few days (38).”

  • carovee

    I got into a rather pointless fight on another site over the recommendations introduced by Ecuador. My point was that “supporting” can slide into “promoting” and then “enforcing” fairly quickly and pointed to BFI as my example. The other party absolutely refused to acknowledge that that was my argument and kept inserting her own words in my mouth, so to speak.

    • Sarah

      Sounds like you were fighting the good fight, never mind pointless! Its worth getting the message out there.

  • swbarnes2

    On the other hand, the gray dots seem to be the same or lower after formula introduction. So formula was saving lives among families with access to clean water.

    • Young CC Prof

      The error bars are quite large, so you can’t say that the mortality rate really dropped, but the graph does suggest it might.

  • Jet Kin

    So the headline should read: Access to clean water could save 65,000 lives per year.

    • Young CC Prof

      Heck of a lot more than that. By UNICEF’s own estimates, 1,000 children under 5 die of waterborne infections every day.

      • swbarnes2

        So the Lancet paper was claiming that breastfeeding would save 2x as many children as die across the first 5 years of all waterborne diseases?

        • Young CC Prof

          Yes. If you read the paper, they honestly believe that more breastfeeding will cut SIDS by a third, diarrhea in half, and respiratory infections by a third.

      • Jet Kin

        Oh definitely agree on that score. But I guess my point is, we’ll save a lot more lives through poverty-reduction strategies and providing access to clean water than we ever will through boobs.

      • Who?

        How many of them were breastfed, I wonder, until either mum got too sick from a waterborne illness to continue, or died from a waterborne illness. The lack of joined up thinking this whole story has uncovered for me is frankly alarming.

  • CSN0116

    Did the Lancet piece claim 800,000 lives in high income countries? Or low-to-middle?

    Regardless, if “only” 65,000 stand to be saved in the worst of situations, I’m going to guess 0 are saved in the best (high-income, developed world, access to clean water).

    • Young CC Prof

      They claimed 800,000 worldwide, mostly in poorer countries.

      • CSN0116

        Because it’s cited in the NYT and everywhere else right now in a very misleading way: as if the 800,000 lives would be spared right here at home in the US and Trump basically wants to kill his own babies.

        • Young CC Prof

          People have no sense of numbers. There are only 2.5 million deaths per year in the USA total, and almost all are from old-age-related conditions.

  • Young CC Prof

    Well, it’s not necessarily exactly the same number now. There are more births per year now, but fewer people living without clean water. (Yes, really, less than 1 billion now.)

    The key question is, how many mothers who potentially could breastfeed, and are not able to safely bottle-feed nevertheless choose to do so. I can’t believe there are very many.

  • lawyer jane

    I’m super curious now about the reality behind HIV and breastfeeding research. In the US, the firm recommendation is for mothers with HIV not to breastfeed at all. In developing countries, WHO and others strongly push exclusive breastfeeding, based on research supposedly showing that exclusive BF IF the mother is on anti-retrovirals actually reduces infant death. But this depends on the mother staying on the anti-retrovirals. This poses a huge ethical dilemma it seems to me — why are you going to expend public health resources on promoting breastfeeding, rather than formula? http://www.who.int/bulletin/volumes/88/1/10-030110/en/

    I feel like there must be an underground of critics of the WHO’s stance on HIV and breastfeeding …

    • Young CC Prof

      Basically, it comes down to whether it’s easier to provide the mother with antiretrovirals or safely-prepared formula. Sometimes, the HIV meds are actually easier to deliver. And of course, they prolong HER life, which is both an important end in itself and improves outcomes for the child.

      When formula is a feasible option, breastfeeding with even controlled HIV is stupid. When it’s not, well, it’s not so simple.

      • Sarah

        There is also the issue of stigma. In some communities, not breastfeeding is associated with being HIV positive… and stigma can be fatal itself.

        • lawyer jane

          Clearly this issue is extremely, extremely context-dependent, and therefore should not be the subject of WHO “guidelines” or “resolutions” that prescribe uniform approaches.

          • Sarah

            Certainly not. It’s not even as if all third world societies with high HIV rates are all the same, much less all societies per se.

    • CSN0116

      This has long been an issue for me. And Courtney Jung does a great chapter on it in her book. WHO has basically killed droves of babies with this one.

      The complexities and money involved in keeping women on the appropriate antiretroviral schedule (their travel to the clinics, dangers associated with travel, time away from work, compliance, the drugs themselves, the staffing) compared to giving them powder formula, a burner, pot, and bottle — it has to cost less for formula feeding.

      In the best of antiretroviral treatment and EBF, the HIV transmission rate is still some 1-3%! It goes up, up, up when everything isn’t followed to the letter. It also goes up when they use the “quick dose” antiretroviral instead of the series (see paper below). WHY would you risk that?!

      Look at this paper: https://jamanetwork.com/journals/jama/fullarticle/203174

      Conclusion: Uhhhhhh… formula is risky. Are you fucking kidding me?! It cut the initial transmission rate nearly in half! Get people the resources they need to use it properly so it’s not dangerous! FUCK.

      • swbarnes2

        For a long time the KellyMom site (which obviously isn’t aimed at third world women) had a few posts about how great breastfeeding was for HIV+ mothers in third world countries, while the information that HIV+ mothers in America should not breastfeed was buried.

        • Young CC Prof

          A lot of sources were doing that. The WHO finally had to release a new statement.