Readings in Infant Feeding Practices—3 Breast-Feeding versus Bottle-Feeding In Developing Countries ; A Brief for Policy-makers

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Readings in Infant Feeding Practices—3
Breast-Feeding versus Bottle-Feeding
In Developing Countries ; A Brief for Policy-makers
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SAD-RF-CH-1.22

Readings in Infant Feeding Practices—3
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 4J 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.
-Ina 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 nonlactators. 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;
Reprinted from "Food and Nutrition Bulletin". Vol. 3 No. 1

- 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 feed­
ing schedules based on the clock rather than
on the baby, or supplementary feeding by
health-care personnel;
- a health profession biased by a westernderived 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;
- 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 women 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 promo­
tion of commercial breast-milk substitutes
through free samples to mothers, extensive
advertising, visits by company-employed
"milk" nurses, gifts to hospitalsand 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 in­
fluences 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 in­
volved 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 international
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 mater­
nity 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 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 organizations), 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 supp­
lements for malnourished pregnant mothers;
guidance for mothers and their families on
the value, management, and maintenance 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;
discouragement of bottle-feeding in health
care institutions except on clear medical
indication; use of contraceptive methods that
do not interfere with breast-feeding; provi­
sion of as much post-natal support as possible
through home visits, clinics, etc., appropriate
advice for mothers; and, if necessary provi­
sion 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 WHOjUNICEF 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. Jelliffe and E.F.P. Jelliffe, Human Milk in the
Modern World, Oxford University Press, London,
1979. 500 pp.
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