If breastfeeding saves lives why do countries with the highest infant mortality rates have the highest breastfeeding rates?

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It sounds spectacular. The headlines in The Guardian are typical, Breastfeeding could prevent 800,000 child deaths, Lancet says:

If almost every mother breastfed her children it could prevent more than 800,000 child deaths a year, yet governments are failing to promote and support breastfeeding, with rates remaining far below international targets, new research has found.

Poor government policies, lack of community support and an aggressive formula milk industry mean breastfeeding is not as widespread as it could be, according to a two-part Lancet breastfeeding series published on Thursday.

[pullquote align=”right” cite=”” link=”” color=”#F90207″ class=”” size=””]Countries with the highest infant mortality rates have the highest breastfeeding rates.[/pullquote]

It certainly seems plausible since breastfeeding is known to prevent diarrheal illnesses and colds and since formula prepared with contaminated water can be deadly. I had no reason to doubt the claim when I started reading the main paper Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect.

According to the authors:

Our meta-analyses indicate protection against child infections and malocclusion, increases in intelligence, and probable reductions in overweight and diabetes. We did not find associations with allergic disorders such as asthma or with blood pressure or cholesterol, and we noted an increase in tooth decay with longer periods of breastfeeding. For nursing women, breastfeeding gave protection against breast cancer and it improved birth spacing, and it might also protect against ovarian cancer and type 2 diabetes. The scaling up of breastfeeding to a near universal level could prevent 823 000 annual deaths in children younger than 5 years …

But the more I read, the less convinced I became.

Why?

Countries with the highest infant mortality rates have the highest breastfeeding rates.

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I created this scatter plot of 121 low and middle income countries by comparing breastfeeding rates at one year (found in the supplementary material) and infant mortality rates (deaths from birth to 1 year, UN data).

As you can see, there’s no relationship between breastfeeding rates and infant mortality rates. Indeed, the countries with the highest rates of infant mortality often have the highest breastfeeding rates.

Why doesn’t breastfeeding have an impact on observed infant mortality?

Part of the reason is that the benefits of breastfeeding are quite small. Over 800,000 deaths prevented is a great thing, but when you consider that over 135,000,000 babies are born around the world each year, the deaths prevented present 6 babies per 1000. That’s too small to be reflected in country wide infant mortality.

So if infant mortality rates don’t change with breastfeeding rates, how did the authors reach the conclusion that 800,000 lives could be saved if all mothers breastfed? They extropolated from small studies and made a myriad of assumptions in doing so. It seems to me that many of these assumptions are simply wrong, rendering the authors’ conclusions unlikely to be true.

I’m no statistician and I haven’t read all the studies that the authors rely upon, so if I’m making mistakes with my analysis please let me know, but here are my concerns.

1. The authors assumed that findings of small studies could be extrapolated to entire nations. But each study had its own parameters and confounding variables and therefore might not be generalizable.

2. The authors assumed that substantial numbers of babies are dying from formula or contaminated formula itself. But the scatter plot suggests that there are other factors responsible for the bulk of infant deaths. These could be malnutrition (of mother and/or baby), infectious diseases that cannot be prevented by breastfeeding, civil unrest, etc. For example, promoting breastfeeding is not going to save a baby whose mother dies of malnutrition leaving him without any source of food.

3. The authors assumed that the lifesaving benefits of increasing the breastfeeding rate would be evenly distributed over populations, but that can’t possibly be true. When a country has a high infant mortality rate and also has a breastfeeding rate of 97% of 1 year olds, there’s no room to raise the breastfeeding rate.

4. The authors ignore history. There was a time when 100% of infants were breastfed … and the infant mortality rate was astronomical because the benefits of breastfeeding are really limited.

There’s nothing wrong with promoting breastfeeding. But there is something wrong with making spectacular statements about breastfeeding saving hundreds of thousands of lives in the absence of population data to support it. Small scale studies can provide valuable insights, but they can’t replace real world experience. In the real world, breastfeeding rates don’t seem to have much impact on infant mortality rates at all.

It would be interesting to model how many lives could be saved by other measures such as water filtration and food donations; those have the added benefit of being able to save lives of older children and adults, not just infants. I suspect that something like water filtration could save far more lives than promoting breastfeeding. It’s much cheaper to promote breastfeeding though than to provide, run and maintain water filtration technology.

Where does that leave us? It leaves us telling poor women that they could solve their own problems by breastfeeding, and patting ourselves on the back for our insights. Meanwhile babies continue to die in droves from causes that have nothing to do with breastfeeding at all.

  • itry2brational

    If circumcision prevents STDs, why does the US have one of the highest circ rates but also the highest rate of STD infections?
    If your rhetoric works to debunk breast feeding it works even better and more clearly against circ yet you promote it. Can the good doctor explain her lack of consistency?

  • demodocus

    OT: the baby was bouncing so much my OB had kind of a hard time finding her heartbeat. I’m going to be in *such* trouble when she learns to walk.

    • Megan

      Oh I know the feeling. I can’t get my current uterine tenant to stay head down or breech. She likes to flip transverse and stretch out as much as she can which makes me feel like my diastasis is being ripped open. Kicks constantly and has knocked the remote control off of my belly. (I guess she objects to me using it as a shelf.) I keep reminding myself that active is a good sign! Glad you have a healthy active one too! How far along are you now?

      • demodocus

        19 or 20 weeks; I’ve lost track. I don’t feel much yet, though. Mostly it’s what she’s up to on ultrasound.

    • BeatriceC

      Fair warning: they seem to keep the same activity level after birth as before. My middle son once kicked the doppler out of a nurse’s hands. Another time, he kicked a keyboard off my belly. This is the child who’s now the figure skating, ballet dancing, high school offensive lineman.

      • demodocus

        Is it too early to sign her up for soccer? 😉

        • BeatriceC

          Maybe a little, but those “mommy and me” gym classes might be an option. For later in childhood, I highly recommend figure skating for it’s ability to completely wipe a kid out. Nothing even comes close.

  • Adelaide

    I lived in very rural East Africa for a while. We were shocked to find out that the local doctors never tested for HIV because there was no way the people could afford to pay the bus fair to get to the hospital with the free ARVs. That meant that if a mother was lucky enough to not give her child HIV during pregnancy/delivery she was most likely going to infect the child at some point through breast feeding. There is no way this study was taking those type of situations into consideration. The women there breastfeed at all cost because there was no other option. It wasn’t saving lives, it was taking them. Sadly the way we most often saw these children die was through loss of fluids due to constant diarrhea.
    On a side note we did help start a program (and after I left it grew into a clinic) to help the people in our area get treatment for HIV and formula when needed. Before we could get formula we did the best we could with cows milk sugar, oil, and infant vitamins. These researchers can’t possibly know what they are talking about. While the situation in our area has improved vastly there is no doubt problems like these across third world countries with high HIV rates.

    • CSN0116

      As somebody who has seen this first-hand, how large of an effect do you think universally available formula and clean water (for mixing) could have in populations like the ones you describe? I always think about this :/

      • Adelaide

        Those things are really unfathomable. The scale of the problem is just so large. The area I was in is not an isolated problem. The problem is everywhere. Formula is an issue for a small part of the population, but water is a much much bigger issue. The time it takes to haul it, then collect firewood to start the fire to boil it is just huge. On top of that there is a huge lack of education. People don’t know that is bad for their unborn children to drink alcohol, or that they shouldn’t give alcohol to their children (it could be made for free from the bamboo where I lived.)
        There are a lot of great organizations that focus on bringing clean water to communities out there (both Christian and secular). For anyone looking to get involved or make a difference I would encourage you to look for organizations where communities being served help build and retain ownership of their water projects. Projects with higher community involvement and ownership almost always have higher long term success rates.
        Formula is a critical need for a portion of the population, but the reality is, is that making it widely and freely available would be extremely costly and the money could be better spent at this point in time. I am not saying that women who can breastfeed should have to, but clean water, readily available parasite treatments, malaria prevention and tuberculosis screenings/treatment would be a much bigger help to most women than having the option to formula feed even if they could breastfeed. On the flip side, making formula freely available to critical need parts of the population could have a huge impact on infant mortality.
        I know there are a lot of medical professionals on this board so I will risk over stepping a send out a suggestion to you whether you are a doctor, midwife, or nurse. If you are looking to take a vacation, think about choosing a third world country you could sight see and enjoy yourself, but also spend a few days partnering with a mission or charity helping with medical needs in a poor community. I have very little medical training, and when doctors and nurses came to visit us they had a huge impact on the people they help (sometimes saving their lives). On top of the immediate help they were able to give us, they would give us and the local doctors more information and training to help those around us. Many of them found the lack of paperwork and liability and the deep appreciation of the people they helped to be extremely rewarding. Several of them made return trips. I know you all give your lives in service of others in the western world and I don’t mean to trivialize that in anyway with this suggestion. Please know you are valued and appreciated for all that you already do.

  • Gatita

    OT: If my doctor had ignored my intuition about my pregnancy, I’d be dead

    She had an impending feeling of doom through the whole pregnancy and ended up having an AFE during labor. Terrifying.

    • Taysha

      Actually, I have heard of the “sense of impeding doom” as a wothwhile signal to listen to. Happens to some diabetics on the onset of a hard blood sugar crash, too.

  • Amazed

    OT: Pity party at our house and the maternity ward: SIL is already feeling like a rag. She’s pumping and tossing away, pumping and tossing away. Turned out she has breastmilk to feed the entire ward… and it isn’t nice. Oversupply is a problem. Instead of enjoying her baby, she’s pumping and trying to learn when to unlatch her because Treasure still hasn’t grasped that the quantity isn’t adapted to her needs.

    We need more milk banks here. We only have one and it’s nowhere near so SIL will have to keep throwing her milk in the sink. She’s getting terribly weary already – and that’s with a kid as good as gold, sleeping and being satisfied with holding a finger. She’s pumped three bottles in the last two hours, with a hand pump that’s nowhere near good so the Intruder will have to buy her one that works better and faster.

    My dad has placed Treasure’s pictures on all PC screens at home and he keeps talking to her… Since he’s deaf in one ear, he sits before the screen or keeps asking if one of us heard a beep, meaning that SIL has written to him again… It’s so heartwarming.

    • CSN0116

      That sounds terrible for SIL :/ Is that a less common problem? I’ve never known anyone with oversupply, at least not that early on. Overactive letdown, yes. HA- I take ephedrine to dry up my milk. I realize she doesn’t want it *all* gone, so maybe she can just like suck on one and spit it out lol. I’m just kidding. Hopefully there’s some med or tactic to help her out?

      • Amazed

        I don’t know what they do in the USA. Not exactly the first world country here so what they’re doing is telling her to limit her liquid intake. No idea what this is supposed to do for her. For now, it has served to help her temperature rise and that isn’t a good thing for her, although they say it’s normal. She has what I call low high temp, of the one that gives you a headache and make you feel weak and hazed without actually being sick, exactly.
        Her milk came in the second day and the kid promptly threw up because she got overfed. There was this scene between SIL and a doctor. Doctor (seeing her pump): “Well, you’ve got quite the excessive amount here.” SIL: “That’s just ONE breast and I’m not nearly done here!”
        Perhaps they’re giving her something but she hasn’t mentioned it. She told me that she’d thirsty, headache-y, and with aching arms from dealing with this dreaded pump.
        Good thing is, looks like they’ll be able to drop Treasure with my mom and dad and never look back for a week after… and she’ll be still exclusively breastfed. No need for my parents to prepare formula!

        • Megan

          If you’re saying she has fever and an oversupply, I’d be worried she’s developing mastitis.

          I never had oversupply issues (quite the opposite, in fact) but I know our LC’s usually have moms try to pump off a little fore milk before feeds and do block feeds to try to reduce the supply.

          • Amazed

            Thanks! They should be discharged tomorrow and I know they should both be examined beforehand, so I hope if there is such a problem – any problem, in fact – they’d catch it in time to prevent readmitting.
            I still can’t get the reasoning of restraining her liquids but I am not a doctor.
            Her fever is still low-grade and she was told that with such a huge oversupply, it was normal. I don’t know if it was a doctor or midwife who said so, though. I really hope she doesn’t unluck on some weirdo who thinks that you can never get too much milk and if you do, it isn’t this big of a problem.

      • demodocus

        I had oversupply, too, ‘though not that bad. Mom really did nurse two of us in the hospital, so I’m guessing she had some oversupply, too.

      • FormerPhysicist

        I pumped 15 ounces on the first try, 4th day, first day home from the hospital and first day I had my breast pump. I think I did that twice that day. Not as bad, and I got it regulated, but … sympathy and empathy.

  • Carrie Mitchell

    “It leaves us telling poor women that they could solve their own problems by breastfeeding” DUH!! Do you know how expensive formula is???

    • Sarah

      I know it’s sometimes less expensive than breastfeeding, and the costs are more evenly spread…

    • CSN0116

      The number one thing breastfeeding takes from women is their TIME. Money is by far second in line, whether it’s costs associated with breast or formula feeding.

      In nations like the ones referenced in this study, women use their time traveling to get clean water; growing, harvesting and preparing food; building, repairing or safeguarding their homes; caring for the elderly or other children; traveling enormous distances for vaccines and basic health care, etc. Their time is PRECIOUS. In many ways it is invaluable.

    • Amy

      That’s assuming women have 24-7 access to their nursing baby and don’t use any feeding aids. Nothing. No SNS, milk bags, pumps, breast pads, nursing bras, lanolin, nipple shields. No job taking them away from the baby, requiring them to pump. No difficulties necessitating consultation with a lactation consultant.

      I nursed both my kids exclusively and practiced child-led weaning. Because I work fulltime outside the home, this required a hospital-grade pump, which fortunately for me my health insurance covered. I also had to pay out of pocket for milk storage bags and bottles. I personally never used breast pads, but at one point I developed an infection and some other breastfeeding-related issues that required APNO from a compounding pharmacy and an antibiotic. I had a supportive family who helped pick up the supplies I needed and care for my other child when my younger child was a newborn.

      If poor women lack ANY of that support, breastfeeding compared to formula could end up being a wash financially. A low-paying, low-skill job isn’t going to allow the time or private location to pump while away from the baby. Breastfeeding equipment may or may not be covered, but formula MAY be covered through a program like WIC or food pantry donations.

      Like anything else, the finances surrounding the decision to breastfeed or use formula are going to vary considerably to the point where making a blanket statement is completely useless and baseless.

      • CSN0116

        Oh, if we’re talking first world, United States – I exclusively formula feed each infant for less than $500 per year. I don’t have a single breastfeeding friend who spends less than that to feed the first year, though I know some women (mainly those who stay home) can spend next to nothing.

        And my TIME AND PRODUCTIVITY are the #1 savings. The $500 is arbitrary, honestly. I simply do NOT have the time to spend nursing. I would stand to lose enormously professionally and personally for zero observable gain.

        • Megan

          I spent FAR FAR more breastfeeding than formula ever cost me. Breast pump, travel and hotel for tongue tie revision x 2, nursing camis, bottles, pump parts (and you really need multiple sets unless you want to be constantly washing them, not to mention time off of work/lost productivity. I even bought formula without any discounts or coupons and it STILL cost way less than breastfeeding. It really is totally dependent on the situation for each mom/baby pair.

          • Megan

            Oh yes, and my hospital pump rental and LC fees. Plus supplements and domperidone. I know I spent thousands on breastfeeding.

    • moto_librarian

      Thanks for your nuanced discussion of the topic.

  • toni

    apologies if this dismal story has already been discussed http://www.mirror.co.uk/news/uk-news/parents-baby-who-suffocated-birth-7266638 friends from chesire have been sharing on fb, some of them know the family. The CONSULTANT persuaded them to deliver naturally?

    • toni

      “The trust have admitted they failed to discuss and document the pros and cons of a natural birth with Hayley.” what pros? should we discuss the pros and cons of leaving your baby in the bath unsupervised as well? probably about as safe.

      • Joy

        It was the NHS, it is quite possible she never got an ultrasound to check the position once they realised it was breech. How did they not consider a footling breech an emergency? I was trained as an EMT and hell.no.

      • Amazed

        Perhaps they mean financial pros for the NHS.

    • Kelly

      The baby was kicking and he was dying. Oh my goodness, it makes me so sick.

  • Sue

    Thanks for clarifying this, Dr Amy.

    The error, of course, is to assume that kids who might be prevented from dying from contaminated water or malnuitrition from diluted formula would never die from other causes, such as infectious diseases, malnutrition/starvation and trauma, or not simply die from the same contaminated water after weaning.

  • swbarnes2

    OT (third world countries with dangerous water supplies): Does anyone think that the La Leche League in Flint was begging nursing mothers to avoid tap water? Isn’t it likely that some of them were telling mothers not to worry about that? Is it possible that “baby-friendly” hospitals were refusing to tell new moms to use bottled water only for formula?

    • BeatriceC

      I can’t answer your questions, but I do know that the ebil Planned Parenthood was passing out water filters to Flint residents as early as October. I don’t know how long the program lasted, but at least they did something.

      • swbarnes2

        The LLL page for Michigan has nothing about the water problem, only a generic page about how breatfeeding doesn’t pass on appreciable amounts of environmental toxins. Which is likely true for many things, but the lead contamination in Flint was really substantial. If they were advising women not to worry, that might have been dangersous advice. And yeah, you can see who really cares about women and babies…it was the people handing our water filters. One would hope that LLL Michigan would at least have a big warning “Women in Flint, do not breastfeed while drinking tap water” but nada.

        • The Computer Ate My Nym

          What? How can breast milk, which is basically a filtrate of blood, not pass on what’s in the blood, be it lead, viruses, anything else? Not to mention fail to pass on what’s not in it (i.e. iron, vitamin D)? This is bordering on magical thinking.

          • The Bofa on the Sofa

            I agree. If anything will be passed through breast milk, it would be metal ions. You know, viruses and other organic or biological matter at least has multiple opportunity for complexation and therefore filtering. However, metals ions are ubiquitous.

        • Megan

          Here’s what the CDC has to say:

          Counseling on breastfeeding (Chapter 9)

          Initiation of breastfeeding should be encouraged for mothers with BLLs <40 μg/dL. At maternal blood lead levels between 20-39 μg/dL, breastfeeding should be intiated accompanied by sequential infant BLLs to monitor trends. A woman with a confirmed BLL ≥0 μg/dL should not initiate breastfeeding. She should be advised to pump and discard her breast milk until her blood lead has declined to <40 μg/dL. Breastfeeding should continue for all infants with BLLs 20 μg/dL and infant BLLs ≥ μg/dL, then breast milk should be suspected as the source, and temporary interruption of breastfeeding until maternal blood lead levels decline should be considered.”
          So what LLL ought to be recommending is that breastfeeding women get their lead level tested.

          • Megan

            That should say:

            “A woman with a confirmed BLL ≥40 μg/dL should not initiate breastfeeding”

            Not sure why that didn’t copy/paste correctly. Sorry. The link didn’t want to copy/paste either so I had to hand type it. I hope it works OK. The info above is on page 73 of the document.
            http://www.cdc.gov/nceh/lead/publications/leadandpregnancy2010.pdf

          • demodocus

            Wonder if that’s yet another element for why many poor urban American mothers tend to choose formula over nursing.

  • hmmhmm
  • Valerie

    I think this was my favorite conclusion of theirs:

    “Finally, by helping close the gap between rich and poor, breastfeeding can contribute to goal number ten—reducing inequalities.”

    Maybe I’m not understanding their logic (and I didn’t read very carefully), but I’m totally missing any evidence that breastfeeding reduces wealth disparity within and between countries (besides in the poorest countries, the poorest people do the most breastfeeding). This seems like a feel-good conclusion that was just thrown in there.

    • guest

      I think they mean that if you closed the gap between the rich and poor, then you’d reduce inequality. Well, yes! And you might get higher rates of breastfeeding then – but the breastfeeding itself cannot in anyway reduce the gap between the rich and poor.

      Maybe they thought that the powers that be that resist closing the income gap for any other reason would be swayed by the idea that breastfeeding lowers infant mortality? Having a higher income also lowers infant mortality, and no one has been swayed by that argument yet.

      • Valerie

        I think somebody would actually have to look at the effects of breastfeeding on a family’s income. If the mom is not working, than it might improve the family’s economic standing (relative to formula) on the short term. If the mom quits her job so that she can breastfeed, it’s likely going to have the reverse effect. It can also damage income inequality between the sexes, at least without some significant overhauling of employment policies. It just doesn’t make sense to make blanket statements like that- “Increase breastfeeding rates for more equality!” Right.

        • guest

          I agree. I stopped breastfeeding when I went back to work. I could have been a pumper, but I was concerned that pump breaks would have slowed my productivity and put my continued employment in danger. It’s not that I would have been directly fired for pumping, but I have a salaried position where I’m measured on my accomplishments, not my hours spent working. I couldn’t see my way to spending so much time pumping and then having to work extra to make up the time when formula was readily available.

          • sdsures

            I’ve been watching old episodes of “ER”. In season 8, Dr Elizabeth Corday, a trauma surgeon, goes back to work after the birth of her and Dr Mark Greene’s baby girl, Ella.

            Despite the obviously gigantic workload and typical hours of doctors and surgeons, Corday never, ever EVER uses formula, when there are clearly situations in which doing so would be better for her whole family. Greene and Corday argue about feeding her, and Greene says “Elizabeth, if I could breastfeed, I would.” Erm, GET SOME FORMULA, YOU IDIOT! Corday screams at him about the various painful side effects of breastfeeding she has to deal with, yet neither of them ever says “Hey, let’s use formula and give you a break.” They even go so far as to freeze expressed breastmilk.

            In that type of situation, I really think it was stupid for Corday to go back to work. She also leaks breastmilk through her surgical gown when operating on a patient, contaminates herself, and is ordered by Romano to go and pump.

          • guest

            I’m sure I saw that episode since I was a fan of the show, but that was so long ago! But yes, let the poor woman have formula. I don’t think the show’s agenda was particular feminist.

          • sdsures

            Now that you mention it, no, I don’t think it was particularly feminist. Which is strange, because in seasons 6-8 they have at least 3 attending or resident female physicians and a flotilla of female nurses on staff. There was a big story arc when one of them (Jing-Mei Chen, aka “Deb”) got preg, decided to give the baby up for adoption and as a result, got cheated out of her chance to become chief resident because she lost time during maternity leave that she otherwise would have had to clock in to qualify as an applicant.

    • swbarnes2

      I think you are reading it right…they are saying that since breastfeeding results in smarter, healthier kids then they’d otherwise have, that it’s going to close the inequality gap; as if thousands of years of human history didn’t show a pretty damn large income gap concurrent with lots of breastfeeding. Or like you can’t look at the map and observe that the countries that clearly need the most help are already breastfeeding the hell out of their kids; there’s little room to grow that. And that if the poorest of women are giving up a cheap source of food for their children, it’s not because they are lazy. It’s because they have awfully compelling reasons that no LC can change.

      • Sue

        Ironically, in previous generations, it was the wealthy who could afford breast milk substitutes, while the very poor had little choice but to BF.

        In my own extended family, I know that one option for those living with livestock was goat’s milk.

  • Brooke

    I’m not sure which is worse, the idea that you know this is a bunch of bs or that you actually serious. This data and it’s conclusions are not anything new.

  • Guestll

    “It would be interesting to model how many lives could be saved by other measures such as water filtration and food donations; those have the added benefit of being able to save lives of older children and adults, not just infants. I suspect that something like water filtration could save far more lives than promoting breastfeeding. It’s much cheaper to promote breastfeeding though than to provide, run and maintain water filtration technology.”

    This type of modeling has been done, and it’s no secret that WASH saves countless lives. Clean water and access to it would save more lives than “promoting breastfeeding”, but that’s not really a fair comparison. WASH is not as simple as “water filtration”, not by half. I think you’re greatly underestimating the inherent complexities. In LDCs, it’s less about agenda and more about short to medium term solutions within a framework of longer term capacity building.

    • fiftyfifty1

      But isn’t that exactly her point? That full scope Water, Sanitation and Hygiene programs are deemed “too complex” and “too expensive” and so breastfeeding is offered as a substitute “solution” for Least Developed Countries.

      • Guestll

        I don’t think that’s her point at all. She makes no reference to WASH being too complex or too expensive, only that it’s cheaper to promote breastfeeding than it is to “provide, run and maintain water filtration technology.”

        In case anyone’s interested, long but good reading: http://www.unicef.org/publications/files/Progress_on_Sanitation_and_Drinking_Water_2015_Update_.pdf

        • fiftyfifty1

          I still don’t get your point. Which of her statements do you disagree with? Do you think it is LESS expensive to provide, run and maintain water filtration systems than it is to promote breastfeeding? Your own unicef link says that 9% of humans are still reliant on unfiltered, unimproved water sources like ditches and ponds. And the proportion of rural residents having truly high quality water (clean and piped to their homes) is almost non-existent in some countries. To say she is wrong because she uses a shortcut term like “water filtration” rather than a jargon abbreviation like WASH that few of her readers will recognize seems pedantic.

  • auntbea

    Sorry, Dr A. You can’t draw inferences about individual correlations from aggregate correlations. It’s called the ecological inference fallacy.

    Also, the fact that Z causes Y doesn’t mean that X does not. It can be true both that income is the strongest predictor of infant death AND that breastfeeding reduces mortality rates as well.

    As far as I can tell, there isn’t much in the original article that’s problematic. It tells us what we already know: breastfeeding reduces GI and respiratory infections, especially in premies and especially in the developing world, and doesn’t do a whole lot else. It’s not that controversial.

    • BeatriceC

      However, this article, and at least one other that was written about it attempt to draw inference from this data and apply it to developed countries in North America and Europe, even going so far as to start talking about numbers of healthcare dollars saved. I read Dr. Amy’s analysis not as saying “it’s all a bunch of hooey”, but saying “there’s major problems with this analysis, and here’s what I think they are”. She doesn’t deny that breastfeeding in areas without access to clean water saves lives, but questions the “silver bullet” approach the researchers are taking on the subject. And that, I think, is a valid assessment.

      • auntbea

        And? She asked for critiques of her methods. The fact that there is a strong correlation between income and breastfeeding at the national level is not valid evidence that breastfeeding does not have an effect at the individual level. It’s simply not. Most breastfeeding studies are hooey, but this is not a valid critique.

        Actually, a lot of criticisms in this particular blog post make me cringe. They’re just not right. Or rather, not applicable.

        • CSN0116

          You’re not being very specific. Of her four (or so) critiques above, what alternative rationales can you provide? Or what does the study do to answer those pretty obvious methodological/analysis questions that one is left with after reading?

          Rather, I’d love for you to answer my main question regarding the analysis of this study: can what’s causing the excess 800,000+ deaths be prevented by some mechanism in breast milk? And I’m not being snarky with you – it’s hard to judge tone in writing – I truly want to discuss it.

          Otherwise, the grand titles sweeping the press, which are not, “breastfeeding reduces GI and respiratory infections, especially in premies and especially in the developing world, and doesn’t do a whole lot else” and are instead, “breastfeeding can stop 800,000 babies from dying, so breastfeed now!” are totally sensational and false. And the authors are allowing that to happen based on how they presented their work.

          • CSN0116

            I think I answered my own question. Somebody on Dr. T’s Facebook page posted that the countries included in the study, and their health statistics, came from the project on this website: http://www.countdown2015mnch.org/country-profiles

            I don’t have full-text view to the full Lancet paper at the moment, so I’m taking this woman’s word for it.

            I opened up Afghanistan, South Africa, Ethiopia and Congo – outside of neonatal deaths – what is killing these kids of under 5 years of age is a combination of the following: HIV, injuries, malaria, pneumonia, measles, sepsis, and diarrhea. Is there a mechanism in breast milk to mediate these things? Some ‘meh’ results for lower diarrhea incidence (though this is probably diarrhea due to poor water supply not harmless tummy bugs), but as for the rest? Breast milk cannot affect death by injuries, malaria or sepsis, etc.

            Of the handful of countries that I looked at –

            AFGHANISTAN has no breastfeeding data and a 91 per 1000 child under-five mortality rate 🙁 (watch “Motherland Afghanistan” sometime, if you haven’t already!), and 66% stunted or underweight of children under-five.

            DEMOCRATIC REPUBLIC OF THE CONGO has 48% EBF rate, 98 per 1000 child under-five mortality rate, and 66% stunted or underweight of children under-five.

            SOUTH AFRICA has an 8% EBF rate; 41 per 1000 child under-five mortality rate, and 33% stunted or underweight children under-five.

            ETHIOPIA has a 52% EBF rate; 59 per 1000 child under-five mortality rate, and 65% stunted or underweight children under-five.

            Where EBF rates go up, child mortality goes up, as does malnutrition. And the children’s deaths are from things that no amount of nursing will cure or prevent (but other things could!).

            It seems as if Dr. T’s scatterplot – which may or may not be referencing these specific countries – is nonetheless relatively on par with the same data The Lancet authors used.

        • swbarnes2

          But the high correlation between breastfeeding and mortality suggest that as a broad public policy, moar breastfeeding! isn’t going to do anything. Infant and maternal mortality can barely go lower in rich countries, breastfeeding can barely go higher in most of those poor ones. Taking formula away in British hospitals isn’t going to solve malnutrition in Malawi.

    • Amy Tuteur, MD

      Wouldn’t the ecological fallacy be if I had claimed that because the countries with high infant mortality have high breastfeeding rates that breastfeeding causes infant death?

      How is pointing out that breastfeeding appears to have no impact on infant mortality an ecological fallacy?

      • auntbea

        That’s an example of an ecological fallacy, yes, but it is also a fallacy to say that because there is a no correlation (or a negative correlation) between breastfeeding and death at the nation level, breastfeeding *doesn’t* increase death at the individual level. You can’t use aggregate outcomes to say anything about individual level effects without some statistical adjustment.

        • Sue

          If I understood correctly, Dr AMy’s exercise was to turn the thinking in the paper around the other way.

          If the methodology is flawed, then it shows that the methodology in the paper is flawed, no?

  • Joy

    It’s ok. Hardcore bfers won’t like this study because everyone knows bfing, even all night long for years, doesn’t cause tooth decay. I mean, duh.

    • AirPlant

      That claim never fails to blow my mind. How is it possible to simultaneously believe that a baby/toddler can suck multiple times before swallowing and not have pooling in the mouth? If a baby goes suck suck swallow then breastmilk must pool. There is simply no other possibility.

      And seriously, even I have seen tiny dribbles and milky smiles from babies popping off mid feed. That shit is collecting in their mouth and that is bad for their teeth. Hearing that it is impossible makes me feel like I am being gas lighted.

      • Bugsy

        Of course it doesn’t cause tooth decay! Breastmilk is liquid gold that can do no wrong.

        Seriously, that was one of the biggest issues I had with nighttime feedings with #1. It’s full of sugars – how on earth would it not damage his teeth?

        • Joy

          You hear it a lot on tt boards. That dentists are wrong for suggesting nightfeeding a three year old could cause cavities and that it is the fault of the tt trapping food. I’m sure tt don’t help, but constantly bathing your kid’s teeth in milk isn’t a good idea either.

          • Bugsy

            Yep.

            What is tt?

          • Joy

            Tongue tie.

      • FormerPhysicist

        I breastfed overnight. Tried to wipe off teeth when I was awake enough to be coherent. 8 cavities at age 3, rotten 4 front teeth, 3 day hospital stay for an abscessed tooth and then molar lost and space retainer until age 12.
        I don’t recommend anyone follow my example.

  • BeatriceC

    “I’m no statistician and I haven’t read all the studies that the authors rely upon, so if I’m making mistakes with my analysis please let me know, but here are my concerns”

    *Raises Hand*

    Me, me, me, me, me!!!!

    *Jumps up and down*

    Seriously, I’d love to have access to all the studies they used. While I “only” have a master’s (in math) my concentration area is statistics and probability theory. I’d started a Ph.D in biostats, but birth of a 24 week preemie forced me to drop out. Plus it’s been a long time since I’ve done anything in the field, but I’d still really love to be able to do my own review of their number crunching.

    From what I have seen, it looks like you’ve identified all the major problems with their paper. I would have more strongly worded your third point about the bias of the researchers going into it, but you’ve still made the point clear.

    The Lancet doesn’t make all of that available for free. I tried to convince MrC that he wanted to get me a subscription last night and call it a Valentine’s Day gift. He said no. I’m a sad penguin.

  • CSN0116

    Does the study do anything to address how many lives would be saved and where? Surely the “800,000” isn’t evenly distributed in every country, state and village.

    Is it like 400,000 in 3rd world; 300,000 in 2nd; 100,000 in 1st?

    And how are the excess 800,000 dying? Does breast milk even contain a mechanism by which to prevent the deaths? If it’s malaria, maternal malnutrition, warfare, HIV, water contamination …how would breast feeding solve any of this?

    And in what UNIVERSE will 100% of women breastfeed for a year? To even suggest such a thing is an attack on women and bodily autonomy.

    And in what universe are governments (in developed nations) not promoting breastfeeding?! The formula companies have to print “breast is best” on their containers!

    I’m left with so many questions and seriously don’t understand how this got published in this way. It is funded by The Gate’s Foundation, so there’s that…

    • Bugsy

      Great points. Another question I have comes from my experience of knowing a lactivist who was also an anti-vaxxer. Even if breastmilk were to save lives, how many of these same lives would then be lost through VPDs? Seems ridiculously hypocritical.

  • BeatriceC

    I love how people take what they want to take out of data. I could just as easily look at that scatter plot and claim that breastfeeding increases infant mortality.

    • CSN0116

      …which it very well may in nations with limited food for mothers to consume, among other issues.

      • BeatriceC

        I’d venture a guess that poor maternal nutrition is definitely a cofounding factor in infant mortality.

        • Roadstergal

          And if you live in a country where it’s ‘breastfeed or die,’ there is going to be a lot more of both breastfeeding and dying.

  • Inmara
    • pandapanda

      But I thought breastfeeding stopped babies from getting eczema. Yet another lie from the lactivists.

    • BeatriceC

      I started to read that when it got posted on another site. I couldn’t even finish it.

    • Bugsy

      As someone who has fought tooth-and-nail to get my own teeny kid out of the zero percentile, its absolutely infuriating that a kid would intentionally be subjected to this.

  • Madtowngirl

    My local news station ran this story this morning. I live in a relatively “crunchy” area. Of course all the comments on their Facebook page were disheartening. “Breastfeeding should be the law!” “It should only be available by prescription!” “Only 1% of women can’t breastfeed.”

  • Tiffany Aching

    There was the same headline in Le Monde yesterday. Funny how the answer to the sanitary problems caused by contaminated formula is “We need to insist on breastfeeding” and not “We need to work on clean water supply and distribution”. Cheaper, of course.

    • Gatita

      Also gives you a convenient scapegoat: it’s the fault of those damned stupid, selfish women won’t breastfeed.

      • Sarah

        Well, it can’t be the fault of poverty, inequality or anything that might make privileged people worse off if it were fixed.

    • namaste863

      And, conveniently, it requires no actual effort on their part. It requires far less of someone to preach the Gospel of Breastfeeding than it does to, say, go to Malawi (Where the overwhelming majority of babies are breastfed anyway) and dig a well, or to set up a vaccination clinic in Afghanistan. You know, stuff that might produce an actual result.

    • KeeperOfTheBooks

      And there are sooooo many factors that go into clean water for all, not even just the infrastructure, which is an intimidating enough problem to begin with.
      A few years ago, I used to read a blog by a civil engineer who retired and decided to dedicate a lot of his time to helping people in Haiti by getting them access to clean water. He’d hold classes, train the locals on how to access the water, lay pipelines, and so on, and then do a lot of the hands-on work with them, too.
      You’d think this was freaking awesome: he not only was helping a lot of people, but was teaching them to help themselves and their communities. Almost inevitably, however, he’d come back to the village in six months or so and find that one or two powerful/big/wealthier/whatever families had relaid the pipelines to their own homes, and either wouldn’t let other people have access or would charge them exorbitant rates for it.
      Really, really sad.

      • Gatita

        This is reminiscent of the situation in Flint, MI. Poor, black city? Lead water for you! Clean water for rich whites only!

        • Liz Leyden

          When Flint’s GM plant found out that Flint River water was corroding car parts, the city provided a separate line with Lake Huron water.

    • Roadstergal

      And it’s hardly an either/or. Breastfed babies are going to do a lot better in places with clean water – mom (for BM) and sibs (for help with work and food) will be healthier, and it’s not like babies don’t get washed and get water in their mouths sometimes.

      They act like breastfeeding is a substitute for clean water. It’s not – it’s a few sandbags against an awful tide.

      • Tiffany Aching

        The sad thing is, I think people writing / sharing such articles just find a narcissistic satisfaction in it that has nothing to do with real issues. People I know who shared this article (I belong to the 30ish, college educated, working in the media subset of population, not that I claim to be representative, but you get the idea) gave the impression that they were thinking “hey, I breastfed my little one till he was two (because obviously I’m in a position where I can have flexible hours / long maternity leave / hired help at home, but nevermind, I’m still a hero), so obviously I’m doing something for the reduction of infant mortality in developed countries !”. They are ready to buy into that kind of thing because it flatters their egos, really.

        • AirPlant

          It’s like how I shared that Facebook status for Malawi. I am a big god damn hero, right?

          • Roadstergal

            Big god damn heroes, sir!

  • J.B.
    • J.B.

      And to be annoying about the water point (because people actually care right now!) amount and safe distribution of water are both critical. If a well can be properly constructed with enough yield, that probably has least potential for contamination. Otherwise treating water and finding some safe means of distribution makes it available. Could be hauling but more centralized? Water for people is a good organization.

  • ArmyChick

    Demodocus: Maybe the mothers should try harder? Maybe they should drink Unicorn milk spiced up with rainbow sprinkles in order to produce more liquid gold? I guess those malnourished mothers just don’t care about their babies enough to give them the BREAST start in life!

    • Azuran

      Why can’t I give the unicorn milk directly to the baby? Is breastmilk even more magical than unicorn milk?

      • Bombshellrisa

        Because your baby would turned rainbow colored. Duh.

    • demodocus

      mmm rainbow sprinkles on top of ice cream…

      • demodocus

        sorry, pregnancy sidetrack. Still haven’t gotten the birthday ice cream the musical one promised me.

        • Megan

          Friendly’s chocolate almond chip has been a favorite for this pregnancy.

          • Bombshellrisa

            I was deeply into any and all things “cake batter” or “birthday cake” during my pregnancy with my son. Tillamook Cake Batter ice cream, Menchie’s cake batter frozen yogurt and birthday cake Oreos. Yum.

    • Bombshellrisa

      Can you imagine the “my baby’s poop doesn’t smell because I breastfeed” ravings if the baby was being fed unicorn milk? “My baby’s poop is rainbow colored” would be all over MDC

  • demodocus

    if a mother is malnurished, how can she make enough to feed her baby? If the mom is sick from nasty water, is her body even capable of filtering enough to prevent her baby from getting sick too? Better than straight-up water mixed with formula, of course, but how much?

    • AirPlant

      The party line that I have heard is that your body will self cannibalize in order to provide food for the baby, but that doesn’t seem like it would pan out when you really think about it. We know of several observable conditions completely outside of the standard supply/demand that cause a decrease in the mothers milk supply. Stress, dehydration, or illness all have been observed to cause issues. Sure breastfeeding might rob your body of nutrients, but it seems to me that once the body is in immediate stress it is far more likely to prioritize its own survival than the baby’s. From an evolutionary perspective a live woman can go on to have surviving children, a motherless baby will generally die.

      • Madtowngirl

        But…but….science says breast is best! We ignore everything else science says, though.

        • AirPlant

          You just described my relationship with my mother! She is just so correct about all the topics which I agree with her on.

          • BeatriceC

            My mother as well. Although she’s pretty much evil incarnate, there’s a couple topics where she really knows her stuff. One of them is actually early infant care and feeding. She’s pretty awesome with that. She thinks breastfeeding is the best as long as it’s going well, but she was the first person to suggest combo feeding or straight up formula if issues arise. She claims that all this stuff about breastfeeding and bonding is straight up bullshit, and that it’s the snuggling and interacting with the baby that creates a bond, and that can be created just as easily with a bottle. Once kids get to where they can talk back and are mobile, she’s horrible, but those early days there’s no one better. Also, she’s the ultimate iPhone expert.

      • Sarah

        Yeah, it’s a no brainer really. Especially as lots of mothers will also have one or more older children.

        • AirPlant

          It feels to me almost like when I was a child learning about the trail of tears. I was taught that the native americans were forced to walk for days and many died horrible deaths. I was skeptical and so I asked the teacher how walking could kill someone when it was so easy to walk and I could walk forever without getting tired.
          As a child I had no experience with walking other than a leisurely stroll on a smooth, flat surface. In my undeveloped mind walking could never cause death because it never occurred to me that walking on an uneven surface with no food, little rest, and with all your earthly possessions on your back was a very different experience than walking from the car to the store.
          To an ardent lactivist there is no world where breastfeeding is anything but easy, joyful, and the perfect cure to all ills rather than a physiological process dependant entirely on the whims of biology.

          • BeatriceC

            May I steal this for use later when similar topics come up? I will happily credit you as best I can.

          • AirPlant

            Go nuts. I credit “stranger on the internet” for things all the time 🙂

          • BeatriceC

            I use “member of a forum” or “commenter on a blog”. “Stranger on the internet” is probably easier. And thanks. That’s one of the better analogies I’ve seen to explain experiential bias. I’m copying and pasting it into my teacher resource files.

          • AirPlant

            AWWW. My childhood idiocy is good for something!

          • BeatriceC

            See, I don’t think it’s idiocy at all, at least not coming from a child who has limited world experience. Your story does, however, illustrate what happens when you can’t think outside of your own world experience. That’s a behavior that’s perfectly acceptable in children, and to some extent even teenagers and young adults, but shouldn’t be acceptable in adults past the college years. Unfortunately, many people don’t actually recognize their own biases, and I think your story perfectly illustrates that concept in action.

      • Megan

        Hell, I routinely see breastfeeding moms complain about their supply going down if they try to start an exercise program!

        • AirPlant

          Anecdotes like that make me wonder SO HARD how celebrities uniformly get back into fighting shape a month out and uniformly claim to be breastfeeding. The only explanation that I can come up with is insane exercise programs, a nanny, and PR lies.

          • Amy M

            Maybe donor milk? Then they can claim baby is getting breast milk, even if the breast milk was from someone else?

          • An Actual Attorney

            It’s almost like you can’t believe the supermarket tabloids.

          • AirPlant

            I am putting my money on nannys, starvation diets, cosmetic surgery, photoshop and a PA who makes formula runs.
            Still makes an interesting piece of social commentary that they all claim that it was breastfeeding that did the trick.

          • Monkey Professor for a Head

            I’m guessing that many of these cases of instant baby weight loss were to do with the celebrities in question continuing high intensity exercise regimes and calorie restricted diets throughout pregnancy so that there wasn’t much actual fat to lose.

          • StephanieA

            Drives me crazy when other moms tout breastfeeding as a magic weight loss tool. I know for some it is, but for others it can cause you to hold onto some weight until baby weans (which makes sense). Breastfeeding does not equal effortless weight loss for every woman. I EFF my son and had no issues losing the baby weight plus some.

          • Bugsy

            With #1, I was so starving during BF that I maintained 10 lbs above my pre-pregnancy weight. The problem was that after I weaned him at age 2, I was so accustomed to eating more that, coupled with fertility treatments, I started gaining additional weight immediately. We will see where I end up with #2 – I’m now three months PP and five pounds heavier than my pre-preg weight for #2. This time, however, I’m making a conscious effort to exercise daily to tone my body (and have some precious mommy time).

          • Kelly

            I lost weight and more but when I stopped I went back to my normal weight. I wish it were the other way around for me.

      • demodocus

        you can only cannibalize so far…

        • AirPlant

          And different bodies most likely have different thresholds for stress vs. lactation. One lady might keep a full supply until death where another might get mad at a stoplight and have her boobs peace out on her. Human bodies are weird and inconsistent in so many ways.

          • Suzi Screendoor

            LOL @ peace out boobs!

          • AirPlant

            It’s been real, but I can see that you are struggling with that jammed printer and we have decided that you are too stressed out for a baby right now. Better luck next time!

          • BeatriceC

            Or you have people like me who produce enough for an army. If I was living a couple centuries ago I’d have been the village wet nurse. I seriously produced enough to feed half a dozen infants at one time.

          • Bugsy

            I’d be right there with you. We have pictures of #2 covered in milk when he pulls off during my fire hydrant-mimicking letdowns. 🙁

      • namaste863

        Jesus Christ, now women are supposed to breastfeed until it literally kills them? The mother is a human being too, dammit! Her life is important, too!

        *note: I am expressing rage at the people you mention, not you, AirPlant. I’m not going to shoot the messenger.*

      • BeatriceC

        If I recall correctly from observational studies in mammals (I think it was stray cats…I used to be involved in cat and dog rescue, so I read a lot), the body will self-canabilzie to an extent. The weakness of looking at mammals like cats and dogs is they have an extremely short period where nursing is absolutely necessary. Kittens can survive off chewed up food as early as 2-3 weeks (though not well). A queen living a cushy indoor life will wean her kittens later than a stray queen. It seems to me that the mammalian body can self-canibalize for a short time, but once maternal resources drop below a certain threshold or exceed a certain amount of time, nature is going to sacrifice the offspring for the survival of the adult.

        • Bugsy

          Interesting. I wonder if this logic applied to humans in part explains the push lactivist groups have towards increasingly extended breastfeeding – in other words, it is a sign that you have reached a certain high level/quality of motherhood.

        • Mel

          Plus, in cats (and dogs and anything with multiple offspring per pregnancy) the queen can reduce the litter size. On our farm, the average number of kittens surviving in a season per dam to fully weaned is 1.

          Despite having access to complete nutrition cat food and plentiful rodents, first-time mothers have horrible death rates among the kittens – I’ve seen 1 surviving kitten from a first-time mother ever.

          Second-time and higher parity mothers have better survival rates, but the most effective ones seem to either abort the litter down to two kittens or dispatch of other kittens in the litter to get the size of the litter down to two. Those moms have a 50-100% survival rate of kittens. On the flip side, we have a few prolific breeding cats that produce 15+ kittens in the spring and summer – but they often lose an entire litter of 4-5 kittens and rebreed twice before getting two kittens that can outcompete their sibs and survive.

      • Blue Chocobo

        When I was breastfeeding, any drop below around 2,000 calories per day sustained for more than 2 or 3 days caused my supply to falter.

        If I was eating the typical 3rd world poverty diet, my breastfed baby would have starved.

      • Mel

        Yes, exactly. Mammals will self-cannibalize for short periods of time to keep up milk production, but human babies are dependent on EBF in “natural” (also known as hunter/gatherer societies studied by anthropologists) societies for 1.25 -3.5 years with a mean of about 2 years. Women literally cannot short themselves enough calories for two years to keep an infant alive. Instead, the body will short breast milk production and bet that the infant may survive by growing at a slow rate – or dies and allows the mother to regain body fat to produce another child.

        • mythsayer

          I guess…except my body never once tried to eat itself to feed my daughter. Nope. I GAINED weight after she was born for no reason and I NEVER made enough milk. So not only was I NOT self cannibalizing, I was full on GAINING for myself and passing none of that onto her. I suppose some people might self cannibalize but it can’t be something that happens to everyone. And I really tried to ebf pretty hard….including a two week period where she was stuck on me 20 hours a day bc she had chicken pox and refused to take a bottle because it hurt and just wanted to nurse mostly for comfort, I think. I still never made enough milk.