UNICEF Breastfeeding Recommendations Paint With Too Broad A Brush

By Krystal Alexander — Aug 15, 2016
The recent UNICEF report "From The First Hour of Life" looks at the present state of infant feeding, with particular focus on the benefits of breastfeeding, highlighting the barriers that exist and providing recommendations to overcome them. However, much of the data used to support these recommendations appear unrepresentative of a global population. This article will serve as part 1 of a series of articles attempting to validate the report in its entirety.
Credit: Shutterstock Credit: Shutterstock

In 2015, there were at least 140 million live births worldwide. Less than half of these newborns were put to the breast within an hour of birth, UNICEF laments. 77 million neonates worldwide were denied the earliest possible initiation of breastfeeding, according to their report "From the First Hour of Life"?

Why is this a big deal? More importantly to those of us concerned about public health, how valid is any of the data they're using to support the recommendations outlined in the report?

To find out, they look at infant feeding, with particular focus on the benefits of breastfeeding, highlighting the barriers that exist and providing recommendations to overcome them. This is a complex subject - breastfeeding can be beneficial but it does not have some otherworldly power, hundreds of millions of mothers have raised hundreds of millions of healthy children using formula, so mothers who have to return to work and want to use formula shouldn't be made to feel like they are bad parents. That is just wrong. So this article is part 1 of a series of articles attempting to validate the report in its entirety.

Statistical data can suggest a number of different things, depending on context. So it is unclear if it should be worrisome that only 45 percent of live births had initiation of breastfeeding within the first hour of life. Regardless of the unclear evidence, the WHO and UNICEF have issued three major recommendations as part of their Global Strategy for Infant and Young Child Feeding:

1) Early initiation of breastfeeding within the first hour of life,

2) Exclusive breastfeeding to up to 6 months of life, and

3) Continued breastfeeding to the age of 2 or longer, as the infant transitions to solid food.

Who outside wealthy mothers, or the most diligent, can really do all three? Certainly in the past babies were not breastfed for two years. Given that these recommendations are primarily for the 1%, is it a surprise that survey results from low and middle income countries in UNICEF global databases show it being so low? Or that if children are unhealthy in those countries, it rarely has anything to do with breastfeeding?


The recommendations originated in results from the NEOVITA study group. The study aimed to characterize the association between breastfeeding initiation and neonatal and post-neonatal mortality. The data was pooled from three different study trials involving populations from Ghana, India and Tanzania. The UNICEF report cites the risk of neonatal death (within the first 28 days of life) is 41 percent greater for newborns with breastfeeding initiation 2-13 hours after birth, and 79 percent greater for those initiated after a full 24 hours have passed and longer. This would suggest that decreasing neonatal mortality therefore lies within initiating breastfeeding within the first hour of life. It's important to note that this epidemiological data speaks only for a specific population and therefore should be used with caution when assessing for global trends, applying to different populations, and enforcing global recommendations. The NEOVITA study should placed in the proper context and its limitations should be highlighted.

The first is that it's epidemiology, and it's based on self-reported surveys. There is a reason why you can find an epidemiology paper to find that almost any popular food (coffee, tea, meat, etc.) both causes and prevents cancer.  By using a skewed data set, the report paints a picture of a global healthcare system about to endure a fatal attack due to all those babies not being breastfed. Yet by using one metric, breastfeeding, in mostly developing countries, it ignores the role of the diversity in the state of healthcare across the globe.

In developing countries, there are poor sanitary conditions and lack of access to clean water, utensils or sterilization techniques for bottle-feeding or formula. Breastfeeding is certainly beneficial there. In another country, breastfeeding may be necessary due to a lack of reliable energy resources or financial constraints, not allowing for refrigeration of expressed breast milk or formula milk - that will not mean it's the breastfeeding that made children health care. Formula also costs money.

Breastfeeding went from being controversial in public settings to being a culture war against working mothers. It's not like smoking or exercise, where the weight of evidence is clearly on the side of giving up the former and taking up the latter. Despite the mother shaming that is popular, breastfeeding is not all or nothing. It is clear that breastfeeding supports resistance to infections, but it will have done that long before two years is up. In the U.S., infant formula has to meet FDA standards for nutrition and studies have not found that breastfeeding will create a "super baby" and formula or a bottle, or a combination of the three, will undermine a child's chances of success.

There are a lot of socioeconomic and genetic factors that come into play, not to mention the individual initiative of the child.

That is why using statistics that don’t mirror adequately the state of breastfeeding practices and don’t consider the impetus within each country that drives these practices is egregious. Extrapolating developing nation results globally is irresponsible and just a tad bit lazy. What should have been the outcome is the issuing of two separate reports, outlining the current state of breastfeeding practices within the developed and developing world separately.

Using that information, a tailored approach could have been applied to develop recommendations for each. So breastfeeding, a bottle, or formula makes a difference based on a lot of other factors, it's not one size fits all. We'll get to the specifics in Part 2.

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