BREAST-FEEDING VERSUS BOTTLE-FEEDING IN DEVELOPING COUNTRIES: A BRIEF FOR POLICY-MAKERS

Item

Title: BREAST-FEEDING VERSUS BOTTLE-FEEDING
IN DEVELOPING COUNTRIES: A BRIEF FOR
POLICY-MAKERS
extracted text: SDA-RF-CH-1.18

BREAST-FEEDING VERSUS BOTTLE-FEEDING
IN DEVELOPING COUNTRIES: A BRIEF FOR
POLICY-MAKERS
Recently there has been a surge of interest in the relative
value of breast-feeding versus artificial feeding, i.e., bottle
feeding. Obviously, this subject is of concern to parents
and health workers, but because of the possible implications
for family planning, the employment of women, the use
of foreign currency for imported formulas, and the
development of dairy or infant-food industries, it is also
of great concern to planners.

WHY IS BREAST-FEEDING BETTER THAN
BOTTLE-FEEDING?

Bottle-fed babies, especially those from poor homes, have
a higher incidence of infection, are more apt to become
malnourished, and have a higher death rate than those who
are breast-fed. For example, in a Peruvian study, bottle
fed infants were found to be 414 times more likely to
become undernourished. The reasons for this are:
— Breast milk has anti-infective properties that protect
the baby in the early months; these are absent in
formula feeds.
— In a poor environment with shortages of fuel, clean
water, utensils, and storage facilities, it is extremely
difficult to prepare a hygienic bottle feed. The bottle,
nipple, water, milk, or hands may be contaminated,
and germs quickly multiply in a prepared formula if it
is not kept in a refrigerator.
— Bottle feeds are often too dilute because the mother
makes the milk last as long as possible and often does
not follow written instructions on the can.

Breast-feeding is much cheaper than artificial feeding even
when the extra food required by the lactating mother is
taken into account. In some contexts, the cost of adequate
quantities of milk (excluding the cost of fuel and utensils)
exceeds 50 per cent of a labourer's wage.

Mothers who breast-feed usually have longer periods of
infertility after birth than do non-lactators. Although not
a reliable contraceptive method for the individual, lactation
has a greater impact on birth spacing in developing
countries than conventional family planning programmes.

Breast-feeding requires no preparation, it encourages
contraction of the womb after delivery (thus helping the
mother to regain her figure), it carries no risk of inducing
cow's milk allergies or obesity, and it promotes the vital
psychological bonding between the mother and baby that
is so important for the latter's development.

Thus, breast milk can provide a complete and perfect food
for the early months of life; and, when other foods are
introduced at about four to six months, it continues to
be an important and safe source of nutrients for as long
as breast-feeding continues.

WHY HAS THERE BEEN A DECLINE IN BREAST
FEEDING IN THE THIRD WORLD?

In spite of the many advantages described above, both the
proportion of breast-fed babies and the duration of breast' feeding have been declining in many developing
countries. This has been most marked in urban and peri
urban areas.

This decline can largely be explained by the adverse effects
of "modernization" on the two basic conditions necessary
for successful lactation. These are:
— frequent suckling throughout the day and also at night;
in traditional societies a baby is often in continuous
contact with his mother and may suckle many times
throughout the 24 hours;
— a mother who is consciously or subconsciously confident
and proud of her ability to lactate and whose daily
contacts have the same attitude.
More specifically, the important reasons for this trend
toward bottle-feeding are as follows:
— the increased opportunities for women to be engaged
outside the home in non-traditional activities;
— the need for many women to resume work away from
home soon after delivery and the lack of facilities for
child care that allow for breast-feeding at the work
place;
— a lack of information and support for the mother as a
result of fragmentation of the extended family so that
she often has no one to advise, encourage, and help her;
— inappropriate health practices, such as separation of the
baby from the mother immediately after birth (when the
bonding and suckling reflexes are strong), rigid feeding
schedules based on the clock rather than on the baby,
or supplementary feeding by health-care personnel;
- a health profession biased by a western-derived training
towards artificial feeding, with health officials who
know little of the management of breast-feeding;
— the example set by more affluent members of society
who have adopted the fashion in developed countries
of bottle-feeding but who have the facilities to do so
safely;

Food and Nutrition Bulletin, Vol. 3, No. 2

— the adoption of western beliefs and attitudes such as
that breast-feeding in public is unsophisticated, that
breast-feeding is a messy business, and — this an
erroneous belief - that a woman will lose her figure
as a result; there is also the attitude that a "modern"
life-style does not allow or accept constant close contact
between mother and baby;
— the wide availability and aggressive promotion of
commercial breast-milk substitutes through free samples
to mothers, extensive advertising, visits by companyemployed "milk" nurses, gifts to hospitals and doctors,
and so on.

The result of these influences is that the mother's confidence
in the value of her own milk is undermined and bottle
feeding of formula comes to be seen as the best thing she
can do for her child. Consequently, the most common
reason given by mothers themselves for not starting or
for discontinuing breast-feeding is, "I did not have enough
milk." Yet it has been shown that virtually all mothers in
societies not exposed to these adverse influences do
successfully breast-feed, even when they themselves are
under-nourished.

WHAT CAN BE DONE TO ENCOURAGE
BREAST-FEEDING?

This subject should be the concern of all involved in the
development process and not be thought of as mainly the
concern of health and social workers. Indeed, in 1979
WHO and UNICEF held an international meeting that
issued detailed recommendations, subsequently approved
by the World Health Assembly. In fact, however, these
recommendations will have little effect without the strong
support of planners, policy-makers, and administrators at
the national level. Among the actions that can be taken in
different spheres are the following:
— Recognize the great economic value of breast milk and
include it in policy and planning decisions.
— Curb or eliminate the promotion of bottle-feeding. WHO
and UNICEF, in consultation with governments, milk
companies, and other agencies, are preparing an inter
national code for the marketing of breast-milk substi
tutes. For this to be effective, planners will have to
introduce, at country level, the necessary legislation,
guidelines, and monitoring systems.
— Introduce changes in the working conditions of women
that will facilitate breast-feeding. This will involve
applying, where possible, the ILO conventions relating
to paid maternity leave, job security after delivery,
facilities for child care and breast-feeding at the work
place, and provision of nursing breaks without loss of
pay.
— Ensure that adequate attention is given, in the curricula
of all educational institutions, to the value management

Breast-feeding versus Bottle-feeding

29

of breast-feeding and to the hazards of bottle-feeding.
This should start in the schools and be expanded in
tertiary education for all those who will deal with the
public, notably teachers and health and social workers,
but not forgetting the planners.
- Utilize non-formal systems of education, such as the
mass media, social groups (particularly women's organi
zations), literacy campaigns, etc., to carry the same
message to the general public.
— Enhance the social status of women in the community
by increasing their access to education and participation
in planning and decision-making from the local to the
national level.
— Examine the possible effect on breast-feeding of
development plans, particularly when plans relate to
changing roles and opportunities for women.
— Ensure that health planners and practitioners incorporate
the following practices into maternity and clinic
routines: advice on dietary needs during pregnancy and
lactation; provision of pre-natal care and food
supplements for malnourished pregnant mothers;
guidance for mothers and their families on the value,
management, and maintence of lactation; avoidance of
unnecessary drugs or surgery during delivery;
commencement of breast-feeding soon after delivery;
avoidance of separation by rooming the child with the
mother; frequent on-demand breast-feeding; discour
agement of bottle-feeding in health care institutions
except on clear medical indication; use of contraceptive
methods that do not interfere with breast-feeding;
provision of as much post-natal support as possible
through home visits, clinics, etc.; appropriate advice for
mothers; and, if necessary, provision of nutritious foods
for babies who are, for medical reasons, unable to
breast-feed.
A significant increase in breast-feeding among low-income
populations in developing countries is likely to lead directly
to a reduction in infant morbidity and mortality. In several
countries, relatively simple changes in legislation, health
routines, and mass education have been shown to be
effective. Breast-feeding is one of the few recommended
nutritional measures that requires little additional
expenditure at family or government level, and indeed
provides savings for both. Thus, its promotion should
receive high priority from both national and local planners.

SUGGESTIONS FOR FURTHER READING
Joint WHO/UNICEF Meeting on infant and Young Child Feeding:
Statement and Recommendations, WHO, Geneva, 1979. 30 pp.
WHO Maternal and Child Health Unit. Breast Feeding. WHO,
Geneva, 1979. 40 pp.
The Economic Value of Breast-Feeding. Food and Nutrition Paper
No. 11. FAO, Rome, 1979. 89 pp.
D.B. Jell iffe and E.F.P. Jell if fe. Human Milk in the Modern World.
Oxford University Press, London, 1979. 500 pp.

Reprinted from: FOOD AND NUTRITION BULLETIN, Volume 3, Number 2, April 1 981; by the International Baby Food Action Network
(IBFAN), Geneva and Minneapolis.

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