Why breastfeeding is a public health issue

While the whole world is trying to shift to a less industrialised, ‘natural’ lifestyle, why is breastfeeding not universally perceived as the most pure and sustainable way to feed babies? It is potentially one of the easiest and cheapest ways to set babies on a pathway to good health with proven benefits for mothers too; and breastmilk is a free and natural resource that could help reduce the social disparities and inequalities entrenched in our health system.

Results from Growing up in New Zealand, an ongoing study following 7000 Kiwis from birth, show almost all mothers (97 percent) start off breastfeeding their newborns. Half are still exclusively breastfeeding their baby at four months, but by six months this has dropped to only 15 percent. The study reveals cultural differences too: Māori, Pacific and Asian mothers are less likely to start breastfeeding and to exclusively breastfeed for four months or more.

Ongoing research continues to prove the amazing benefits of breastmilk. Robust studies involving nearly 35,000 have shown breastfeeding has the potential to reduce 13 percent the prevalence of overweight and obesity. The many protective effects conveyed by breastmilk are of particular interest to New Zealand, where 1 in 8 kids are overweight or obese.

We are now learning the longer mothers breastfeed, the greater the potential benefits. Women who breastfeed for one year or more have between 23 and 37 percent lower risk of developing breast and ovarian cancer compared to women who never breastfed. Breastfeeding for any time at all lowers a woman’s risk of developing these cancers by seven to 17 percent. Mothers who breastfeed for at least one year in their life time benefit from a nine percent protection against type 2 diabetes. Exclusive breastfeeding also helps with recovery from pregnancy by delaying the return of fertility and allowing the body to restore itself.

But reading the evidence and listening to women’s experiences, the reasons mothers give up breastfeeding are entirely understandable and often due to forces beyond their control.

Patchy postnatal support to resolve common breastfeeding issues, practical and financial barriers, misinformation and cultural attitudes all work against normalising breastfeeding. For some women, feeding comes easily, but others need help and scientific evidence suggests many women do not receive high quality, timely support with breastfeeding issues. Many workplaces lack private, comfortable spaces for breastfeeding or pumping and storing milk and families are still receiving misleading information about the relative merits of breast and formula. And mothers still get judged and shamed for breastfeeding in public.

But all this mother-blaming misses the point. It’s not up to individual women to shift attitudes and practical arrangements, it needs a co-ordinated, whole-of-society effort. Breastfeeding is a public health issue: if we want as many babies and mothers as possible to get the proven benefits of breastfeeding, we need to get serious about supporting families.

Let’s be clear: breastmilk substitutes (formula) are the best alternative when breastmilk is not available, when mothers can’t breastfeed for health reasons or don’t want to – and ultimately, it is the mother’s choice.

However, formula does lack some of benefits of breastmilk which is rich in maternal antibodies and bacteria-fighting substances that stimulate a baby’s immune system. This means breastfed babies are less likely to have, for example, ear, respiratory and intestinal infections. One study showed babies fed only formula are three times more likely to be hospitalised for lower respiratory tract infections than babies exclusively breastfed for at least three months. This is relevant to New Zealand where one in six children are affected by respiratory infection.

Some health professionals perceive the faster weight gain of formula-fed babies as beneficial. But recent evidence shows this rapid growth might impact on later health and contribute to childhood obesity. A large European study found infants who received high protein formula in their first year had excessive weight gain in the first two years and more body fat at school age than those who received formula with lower protein content whose growth was similar to breastfed children.

Another advantage of breastmilk is that its composition changes to meet baby’s needs. For example, breastmilk hormones help regulate circadian rhythms in the baby so that milk produced during the evening helps put the baby to sleep. These changes occur within a single feed, over a day and maybe in relation to the sex-specific nutritional requirement of the infant. A large study at the University of Auckland is looking to understand if the mothers of boys and those of girls produce milk with different composition.

So how do we get the message across? Health campaigns have traditionally focused on the benefits of breastfeeding, but perhaps they should emphasise the risks of not offering babies any breastmilk at all. According to one estimate, a 10 percent increase in exclusive breastfeeding rates in the UK would save the government around US$7·8 million through decreased treatment costs for childhood disorders. And this is only for childhood diseases; if we consider the potential cost-effectiveness of breastfeeding on long-term outcomes such as obesity, type 2 diabetes and cancer, the money saved could be even greater – not to mention the human cost.

What would it take to make breastfeeding the easy, natural choice for families? We need culturally appropriate education and support for all mothers, especially for those most likely to stop breastfeeding early. This should start before birth and continue until feeding is established.

Investing in human milk banks is also an important public health strategy – this provides donor breastmilk to sick infants and supports lactating mothers who can donate milk if their production exceeds their baby’s needs.

Health professionals – midwives, Plunket Nurses, GPs, dietitians – need to be trained to detect and swiftly address issues with breastfeeding. Workplaces need to give genuine support and we need integrated health and social policies that promote breastfeeding including extending the period of statutory maternity pay. Media campaigns such as international breastfeeding week, which occurs in the first week of August, could be as effective as anti-smoking or cancer prevention campaigns. This year’s campaign focuses on empowering parents to facilitate breastfeeding. Celebrities could endorse campaigns and show breastfeeding is a normal and positive lifestyle choice for all, regardless of ethnicity or social status.

We know breastfeeding is not always easy, and it is an individual’s choice. But any breastmilk may be better than none at all, and all mothers deserve personalised and timely help to overcome early difficulties. We urgently need to increase rates and duration of exclusive breastfeeding and support must come from all levels of society: it is in everyone’s interest that all New Zealand babies get a healthy start to life.