World Breastfeeding Week 2019: where’s the return on investment in breastfeeding promotion?

ROI (Return On Investment)

As a society, we invest in public health campaigns because they provide two main benefits: improved health of populations and cost savings.

But what if a public health campaign provided neither?

It’s World Breastfeeding Week 2019 and it’s time to ask: where is the return on investment in breastfeeding promotion?

It’s time to end the fiction that breastfeeding has a public health benefit.

For 25 years, we’ve been told that it was worth spending millions on breastfeeding campaigns because the result would be improved health for infants, children and adults. Where are the improvements? For 25 years, we’ve been told to spend ever more because we would glean massive healthcare savings. Where are the savings?

What does it look like when a public health campaign leads to improved health?

Vaccination has provided spectacular gains. There have been dramatic reductions in both cases of disease and deaths from disease.


Vaccination didn’t merely reduce the incidence of vaccine preventable diseases, it often resulted in NO CASES at all. Vaccination didn’t merely reduce the number of deaths from vaccine preventable diseases, in some cases it ELIMINATED them entirely.

It is important to note that these are not theoretical benefits. This is what actually happened when vaccination programs were implemented.

Let’s look at another public health campaign, the effort to reduce lung cancer from tobacco smoking. The results have not been as spectacular, but are impressive nonetheless.


In the wake of the Surgeon General’s 1964 report warning about the link between smoking and lung cancer, per capita cigarette consumption dropped dramatically. After a lag period, lung cancer deaths began to drop dramatically, too. This is not a theoretical benefit. This is what actually happened.

In the past 25 years we have spent millions of dollars promoting breastfeeding even though the scientific evidence on the benefits is weak, conflicting and riddled with confounding variables.

An entire industry, the breastfeeding industry, has arisen to promote and profit from efforts to increase breastfeeding rates. Lactation consultants did not exist prior to the mid 1980’s. Now they are everywhere, in hospitals, in doctors’ offices and in independent practice.

A private company, Baby Friendly USA, is allowed into hospitals to promote their philosophy. For a fee of more than $10,000, a hospital can to be designated as breastfeeding friendly — but only if it is in lockstep with the practices recommended by the breastfeeding industry.

Breastfeeding initiation rates have risen in response. But the breastfeeding rate appears to have had no impact on the infant mortality rate. The graph below illustrates the steep drop in infant mortality over the course of the 20th Century. I’ve added markers for the breastfeeding rate at various points. As you can see, the precipitous drop in breastfeeding rates did not have an impact on infant mortality and the rising rate of breastfeeding initiation does not seem to have an impact, either.


The only measurable impact has been the reduced incidence of necrotizing enterocolitis among very premature infants, a benefit that was not predicted but was found as breastfeeding rates rose.

There are papers predicting health and spending benefits of breastfeeding, but I haven’t found any evidence of actual benefits, with one exception: the reduced incidence of necrotizing enterocolitis among very premature infants, a benefit that was not predicted but was found as breastfeeding rates rose. If other benefits actually occur, I invite anyone who has seen the evidence to share it with the rest of us. Otherwise, we must conclude that — unlike vaccination efforts and efforts to reduce smoking — the benefits are purely theoretical and therefore probably not real.

Moreover, there is a growing body of evidence that the aggressive promotion of breastfeeding is harming babies through dehydration and starvation due to insufficient breastmilk (affecting up to 15% of first time mothers). Exclusive breastfeeding is now the LEADING risk factor for newborn hospital readmission. It is nothing short of appalling that 1 in 71 breastfeeding newborns will be readmitted to the hospital. That’s tens of thousands of hospitalizations per year at a cost of hundreds of millions of dollars.

That doesn’t mean that breastfeeding is a bad thing. It’s a good thing, but the benefits for term babies in first world countries are trivial. If those benefits were anything other than trivial, we should have seen a dramatic impact on infant health and pediatric care expenditure by now, but we haven’t seen anything of the kind.

No doubt the lactation industry has benefited. The number of lactation consultants in the US has increased from 0 in 1980 to approximately 14,000 lactation consultants in 2013.

What do the rest of us have to show for it?


Unless, of course, you count the soul searing guilt and feelings of inadequacy among women who can’t or choose not to breastfeed.

It’s World Breastfeeding Week 2019 and it’s time to admit that breastfeeding promotion has been an expensive failure.

Going forward we should dramatically scale back spending on breastfeeding promotion. In an era of scarce healthcare dollars, we can’t afford to waste millions on public health campaigns that produce no discernible return on investment.

It’s time to end the fiction that breastfeeding has a public health benefit. It’s a personal choice, no more, no less. There is no reason — scientific or economic — to spend millions promoting it.

21 Responses to “World Breastfeeding Week 2019: where’s the return on investment in breastfeeding promotion?”

  1. doctork
    August 3, 2019 at 11:00 pm #

    The charge was probably the normal fee for an office visit during which problems with breastfeeding were discussed. Billing for any office visit with a doctor requires the listing of a diagnosis that must be selected from a bizarre and non-sensical collection of 80,000 codes called “ICD10.” Quite possibly the doctor suggested that mom consider adding some formula feedings if the baby was not gaining weight, or if breastfeeding seemed problematic for some other reason. Hence the code for “non-adherence to EBF.” Good for the doc, and for mom and baby! Fed is best.

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  3. andrea
    August 1, 2019 at 2:03 pm #

    I keep reading a friend’s posts about their grandchild’s feeding issues and all I can think is “normalization of infant starvation and maternal suffering.” I even heard her doctor charges for non adherence to EBF. Is that even a thing?

    • Cartman36
      August 1, 2019 at 2:18 pm #

      I have never heard of that. That seems unethical at best.

    • rational thinker
      August 1, 2019 at 2:33 pm #

      If he is charging for that it needs to be reported. That is absolutely not a thing. That is unethical maybe criminal too?

      • mabelcruet
        August 2, 2019 at 4:16 am #

        Maybe he charges because he thinks formula feeding will make the baby ill so he’ll need to do more work? It doesn’t matter what reason he has if it’s true, it’s bizarre and inappropriate

        • AnnaPDE
          August 2, 2019 at 8:14 am #

          I’m not sure how it works where andrea is, but everywhere I lived, doctors billed for items that are on some kind of standardised list, and couldn’t just make up prices willy-nilly for random stuff like “non adherence to EBF”.

          • Lurker
            August 2, 2019 at 9:55 am #

            I’ve never heard of such a thing, but I imagine it’s more like the fees my doctor charges if you cancel an appointment at the last minute, or ask them to fill out paperwork. There are a bunch of things Drs could charge for that I imagine don’t involve medical billing codes.

            Hmmm . . . I wonder if a doctor who wanted to incentivize vaccination without refusing to accept unvaccinated patients could charge an administrative fee for failure to adhere to the recommended vaccine schedule?

    • BeatriceC
      August 1, 2019 at 5:41 pm #

      That is horrifying.

    • AnnaPDE
      August 1, 2019 at 7:48 pm #

      Charges what? Money? How is her not EBFing something he can get paid for?

    • andrea
      August 1, 2019 at 8:32 pm #

      Good! I hope it’s just a rumor.

  4. mabelcruet
    August 1, 2019 at 1:08 pm #

    Today is also the International Childfree Day, which, if you follow some of the more extreme lactivist prohibitions about exclusivity and never supplementing, you might end up celebrating instead.

    • StephanieJR
      August 1, 2019 at 3:42 pm #

      It is? Let’s get drunk!

      (Parents welcome if you leave the kid with a sitter)

      • mabelcruet
        August 1, 2019 at 4:15 pm #

        And its national Raspberry Cream Pie Day-so a slice would go nicely with the G&T!

    • BeatriceC
      August 1, 2019 at 5:52 pm #

      Next year I get to celebrate a less morbid way. I am now 10 months away from my youngest child becoming a legal adult. The countdown to no minor children is on!

      • mabelcruet
        August 1, 2019 at 8:04 pm #

        It doesn’t matter how big and grown up they get, they’ll always be your babies!

        • BeatriceC
          August 1, 2019 at 10:56 pm #

          Always my babies, but soon to be no longer children. It’s kinda bittersweet.

          • August 2, 2019 at 5:47 am #

            Actually, my experience has been that they become nicer people, the older they get (and the more they begin to understand just how hard parenting is )

          • BeatriceC
            August 2, 2019 at 12:21 pm #

            This has also been my experience. My 20 year old has recently apologized for all his shit. He has found himself responsible for a 12 year old recently. Long story, but the short version is said 12 year old is his girlfriend’s brother. Their mother passed away and their father isn’t coping well. He also works nights, so that complicates things. CPS got involved. My son has been staying at their apartment more often than not due to commuting issues with school. When it was all said and done, CPS left the brother with their father on the condition that my son and his girlfriend take a significant role in supporting her father and caring for her brother. It’s a lot of responsibility for a couple of 20 year olds, but he decided it was worth it. And now he’s beginning to understand why he was such a shit himself at that age.

  5. Cartman36
    August 1, 2019 at 11:51 am #

    The reason that the government and public healthy authorities like breastfeeding promotion is because it sounds good (who doesn’t want to support breastfeeding) and it doesn’t require anything other than money from anyone except the mother. Whether or not it works is likely an afterthought if considered at all.

    • rational thinker
      August 1, 2019 at 2:36 pm #

      I could think of a lot better uses for the money wasted on this crap.

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