Dr.
Arun Gupta
Dr. Kuldeep Khanna
Breastfeeding is medically practical and economically efficient. Breastmilk is a natural resource of tremendous value. Experience from some countries has shown that investing in its promotion is among the most cost-effective health interventions for child survival, equal to conventional practices such as immunization and vitamin A supplementation and surpassing oral rehydration therapy in importance. Breastfeeding requires very little investment and returns are invaluable for families, corporate sector, society, health care institutions, and governments. Perhaps the single greatest health problem in the developing world is infant malnutrition. Breastfeeding has a crucial role to play in combating this, and the decline of breastfeeding poses a profound threat to infant health. Increasing modernization and urbanization, ignorance, and decades of apathy on the part of health professionals have led to a decrease in breastfeeding in many parts of the world. In recent years, the dangers of this trend have been increasingly realized, but while recognition of the importance of breastfeeding in promoting infant health has been growing, little research has been done in its economic implications. Breastmilk can be viewed like any other food commodity in many respects. Its value can be considered in purely monetary terms and the cost of supplementary food for the lactating mother compared with the cost of artificial feeding for infants. Such a view, however, fails to do justice to the true economic value of human milk. Its economics can be regarded more broadly as the way in which people allocate their resources towards achieving a certain quality of life. A number of valuable non-monetary contributions made by human milk emerge, which may or may not be quantifiable such as reduction in sickness, lower mortality, better nutrition, reduced incidence of allergic illness, improved psychosocial bonding of mother and child, and overall better health of the infant and young child. Breastfeeding has also been related to possible enhancement of cognitive development1. There are advantages for the mother; breastfeeding reduces the incidence of post-partum bleeding2, leads to faster uterine involution3, reduces the risk of breast cancer4 and ovarian cancer5, delays resumption of ovulation and increases child spacing6, improves bone re-mineralisation7 after birth in women with reduction in hip fractures8 in post menopausal period and finally, it is likely that all the benefits of human milk are not presently known9. To get the best of breastfeeding, we need to create a ‘warm-chain’ of support that is, skilled care for mothers to build their confidence and show them what to do and protection from harmful practices. If this warm chain has been lost from the culture, or is faulty, then it must be made good by the health services10. Economic value of breastmilk produced in India Breastfeeding is ‘priceless’. Advocacy of exclusive breastfeeding requires an appreciation of its full importance by all of society. Economic measurements cannot put a value on any expression of love or altruism. Most women view breastfeeding with pride. However, placing human milk on food balance sheets could increase its perceived value. While the value of manufactured baby foods is included in the calculation of the Gross National Product (GNP), the value of breastmilk is not11. Seeing the real size of this contribution in terms of the food supply to a nation is impressive and demonstrates to responsible policy makers the importance of this activity in terms that they can more easily relate to. An assessment of the value of total breastmilk produced in India and its contribution to the natural resources of our economy can be made with some reasonable and realistic assumptions.
Table I – Demography of India
According to National Family Health Survey, the only nationwide study on infant feeding, incidence of exclusive breastfeeding was 50.9% in 0 to 3 months and 26.4% in 4-6 months age group (Table II). Table II – Breastfeeding and Supplementation: National Family Health Survey, India, International Institute of Population Sciences, Bombay, October 1994. A TABLE HERE
Mothers who added only water in addition to exclusive breastfeeding in first six months, are included in the group of exclusive breastfeeding, here we assume that these are not losing production of breastmilk in fact they may. Partially breastfed children who receive artificial milk, the amount of which can vary for different age groups, are assumed to receive two-third of their milk requirement in the first six months, half in the next six months and one-fourth in the second year from breastfeeding. Assuming that the average Indian mother lactates for a period of two years and produces breastmilk according to the age of child, duration of exclusive breastfeeding and addition of other supplemental foods, then, as shown in Table III, the amount of breastmilk produced over two years by an average mother would be 346 liters12. Table III – Breastmilk production by age
According to these data, we calculate annual theoretical breastmilk production capacity to be 8093 million litters. If 95% of mothers in first 6 months, 85% mothers in second six months, and 75% of mothers in second year after child birth are lactating, it results in reduction of this capacity to 6814 million litters (potential production capacity). Now, even this potential breastmilk capacity is not utilized fully as children are artificially fed and given undesirable supplementary milk or other foods at earlier age resulting in loss of potential production by 2870 million litters. This brings us to the figure of annual realistic breastmilk production of 3944 million litters (Table IV). In the absence of experimental data these estimates of breastmilk production and losses are more of an educated guess by experienced observers, and could be readily modified by curious reader. Table
IV – Breastmilk produced in India
Value of Realistic produced Breastmilk Valued at the cost of fresh animal milk (Rs 15 per liter), market value of realistic production of breastmilk would be Rs 5916 crores. Were it be replaced by tinned milk at a cost of Rs 30 per liter, the value doubles to Rs 11832 crores. If this amount of milk was to be imported, it could require US $ 4.7 billion (Table V). Table V – Market value of realistic produced breastmilk
Breastmilk as a National Resource Figure 1 places the economic value of breastmilk in the overall context of the national economy. The economic value of breastfeeding each year is compared with various central plan developmental sectors. It is equal to the plan outlay of department of Industry and of Power, more than the allocation for Railway and three times that for Education, Health and Family Welfare, and Science and Technology. It is almost 10 times the allocation for Women and Child Development. Figure 1 
Source: Central Plan Allocation, Central Budget 1998-99, Government of India (presented on June 1, 1998) Cost of producing Breastmilk The mother requires extra calories for production of breastmilk. These calories come from extra diet that the mother takes and from the fat already stored during pregnancy. The mother can take common foods that are locally available and these are quite efficiently converted to breastmilk. The mother requires 185 gms of rice and 30 gms of pulses in addition to normal diet to produce one liter of milk costing around Rs. 413. The total cost of producing 3944 million litters of breastmilk is approximately Rs. 1578 crores. If we minus this cost from the cost of realistic breastmilk production, the value of breastmilk would still stand to be above ten thousand crores (Rs. 10253 crores). Cost of artificial feeding We
now calculate what one need to spend if breastfeeding was to reduce.
Artificial feeding is very expensive to institutions, nations, governments,
health care organizations, and families. Households:
Families pay for infant formula and other breastmilk substitutes,
feeding and sterilizing equipment, fuel etc. as a result of which
the cost of artificial feeding a child with a bottle comes to Rs.
1100 per month (Table VI). This amount (Rs. 1100) is equivalent to
43% of minimum wages of a skilled urban worker, 25% salary of a class
IV employee or 12% salary of a trained graduate teacher (figure 2).
This amount is significant enough to pinch the household budget of
every family even the very rich. This amount could have bought 220
kg of wheat, 40 dozens oranges, or 50 kgs of vegetables for a family.
Table VI – Cost of bottle-feeding a child over six-months
Figure
2 – Percentages of salary spent on bottle-feeding by different sections
  
Comparing costs with other countries, Table VII shows percentage of minimum wage spent for one month on breastmilk substitute for a three-month-old baby. Table
VII – Cost of bottle-feeding a child to a family in other countries
This costing does not include the time-cost as it takes time to purchase, to prepare and administer artificial feeds. A three month old infant needs over three litters of water a day for mixing and boiling, which may takes hours to fetch in rural areas. The time required in learning correct feeding and hygienic techniques may be considerable. The preparation of feeds, washing and sterilization of utensils is time consuming, particularly for mother who possesses only one bottle. Corporate Sector: Artificially fed babies become sick more often and for longer periods than breastfed babies. Hence, working mothers who do not breastfeed are away from work more frequently, to take care of a sick child, to attend medical clinics, and to stay in the hospital with the admitted child. Corporate breastfeeding support programs in USA resulted in a 27% decrease in absenteeism and a 36% decrease in health care costs11. Other Savings by Breastfeeding It
is likely that disease-producing effects develop extremely rapidly
when artificial feeds are not correctly prepared. Poverty is characterized
not only by limited money but also by constraints on the time, energy
and patience of mothers, who are likely to over dilute powdered milk
to make it go farther. This can lead to severe under-nutrition and
eventually marasmus. Poor mothers are unlikely to understand the need
for sterilizing bottles and seldom have the necessary facilities,
fuel or time to clean them well. It follows that the more limited
a mother's time and resources are, the greater value of breastfeeding
will be to her.
As artificially fed infants usually suffer from sick disease more than breastfed ones, extra time as well as money will be needed to care for them. For the sick child the time lost in disease leads to delayed psychomotor or mental development. For the parents, it is in the form of time lost from labour and/or housework, spent in the care of the child and transport to and from medical facilities. Waiting for treatment can take several hours and a number of days are spent if the child is hospitalized. Protection against Diseases Breastfeeding
is associated with lower morbidity in comparison with artificial feeding,
at all ages. In a study conducted in Delhi, India14, the average incidence
of morbidity in breastfed infants was 4 episodes per child annually
as compared to 14.4 episodes per child annually in artificially fed
infants. Diarrhoea and vomiting occurred 5 times more frequently amongst
artificially fed infants (66 episodes per 100 child months) than the
breastfed ones (13.5 episodes per 100 child months) in the same Indian
study.
Breastfeeding decreases the risk for a large number of acute and chronic diseases. Research has shown that breastfeeding decreases the incidence and/or severity of diarrhoea15, lower respiratory tract infections16, 17, otitis media18, bacteremia19, bacterial meningitis20, botulism21, urinary tract infections22, and necrotizing enterocolitis23. There are a number of studies that show a possible protective effect of human milk feeding against sudden infant death syndrome24, insulin dependent diabetes mellitus25, Crohn’s disease26, ulcerative colitis27, lymphoma28, allergic diseases29, and other chronic digestive diseases30. Diarrhoea:
Each child in India suffers an average of 1.6 episodes of diarrhoea
per year for first five years 31, the cost treatment of which is at
an average of Rs. 40 per episode at the village level. About 10% of
these children require hospitalization, which costs around Rs. 1000
per episode (estimated hospitalization 2 days of at Rs. 500 per day).
If the incidence of breastfeeding decreases, the number of episodes
of diarrhoea may increase by 5 times. Assuming a reduction of 50%
episodes of diarrhoea by increasing the incidence of exclusive breastfeeding,
we may be able to prevent 80 million episodes of diarrhoea every year
that would otherwise cost Rs. 720 crores to the nation.
Acute Otitis Media (AOM): Breastfed babies are at lower risk for AOM in first year than the formula fed babies. Infants breastfed for 2 months or less have an incidence of AOM that is 3.3 times higher than infants breastfed for 6 months32. In a study conducted by Teele et al.33, it was found that more than 80% of children had AOM by 3 years of age and more than 40% had 3 or more episodes. Extrapolating from this study it may be calculated that approximately 50 episodes of AOM occur per 100 children each year. This works out to about 35 million episodes of AOM in India annually in 70 million children 3 years old costing to health care system as reasonable assumption of expenditure Rs. 150 per episode.Rs. 525 crores. If we estimate consenalively that not breastfeeding raises the incidence of AOM about two-third, about Rs. 350 crores could be saved by breastfeeding. Acute respiratory infection (ARI): The incidence of ARI is reported to be 3 times higher in artificially fed infants in comparison to breastfed infants. Respiratory syncytial virus (RSV) infection is a common, serious illness of the lower respiratory tract in small children. Millions of cases of RSV infection are seen in dispensaries and health centers each year and many of them are admitted to hospital. Breastfed babies receive specific antibodies and cell mediated immunologic factors and are about half as likely to be hospitalized with RSV as are top fed babies. Other Benefits The requirement of animal milk increases if mother's milk production is reduced because of reduced breastfeeding and this would lead to tremendous pressure on the environment. To produce 1000 Million litters of animal milk, 6 lac animals (producing 5-litre milk/day) are required. They would need around 75,000 acres of land for grazing and cost more than Rs.500 crores for daily maintenance. In the rural setting, wood is used for boiling bottles and making feeds which leads to loss of forest cover and environmental degradation. These can be stopped or at least reduced by increasing the number of mothers who exclusively breastfeed their babies. Ecological damage is done by more than 400 million tin packs of powdered milk of 500 gm each which are discarded as waste each year. As a family planning method Breastfeeding leads to be reduced fertility for many months. In a recent study it has been shown that breastfeeding leads to reduction in potential fertility by 30% throughout Asia34. In India, 10 months of lactation leads to an average of 8 months of amenorrhoea35, which corresponds to 16.5 Million couple protection years. The value of this protection is around Rs.495 crores (average cost of protection per couple is Rs. 300 per year calculation based on the family planing programme budget). Experience from other countries In former Yugoslavia, if breastfeeding at 4 months of age could be increased from 30% at present to 70%, then US $ 449 million could be saved in purchase of breast-milk substitutes. In addition, 99,000 respiratory infections, 33,000 ear infections, 123 cases of early onset diabetes, 84 cases of childhood cancer and 152 cases of ovarian cancer could be averted each year36. In Pakistan, imports of formula were US $4 million in 1982-83, $ 8.5 million in 1987-88 and $ 43.5 million from July 1995 to April 199637. The net value of breastmilk produced in Ghana if breastfeeding were optimal would be US $ 165 million. The actual lost breastmilk production is worth US $ 33 million38. In Norway, hospitals pay $ 50 for each liter of breastmilk. Norway produced 8.2 million litters of breastmilk in 1992 that was worth US $ 410 million39. In several African countries it is estimated that breastmilk is produced at an average of 10 kg per capital. Even if breastmilk were valued at only US $ 1/litre, the GNP of Zimbabwe would increase by 1% and that of Mali by 6% if it were included in GNP calculation40. For each baby breastfed for 6 months, the US government can save $ 450 - $ 800 in welfare and health care cost41. In Mexico, a hospital based breastfeeding project cost only US $ 4 per life saved, which is far less than interventions such as measles vaccine or oral rehydration therapy11. In Iran, exclusive breastfeeding increased from 10% in 1991 to 53% in 1996. During that period, the cost of importing breastmilk substitutes declined by US $50 million11. Illness attributable to artificial feeding in USA costs $ 291 million in a year for infant diarrhoea, $225 million for respiratory syncytial virus, $ 660 million for otitis media and $ 10-125 million for insulin dependent diabetes mellitus (IDDM)42. If the prevalence of exclusive breastfeeding upto 3 months of age were to increase from 60% to 80% in Australia, $ 11.5 million would be saved on health care costs for otitis media, insulin dependent diabetes mellitus, gastrointestinal diseases and eczema alone43. Conclusion Replacing breastmilk with any other feeding method for infants and young children results in high cost to the individual families, to the society and to the overall economy. In most developing countries the use of simple effective relactation techniques may offer greater hope for infants deprived of their mother's breastmilk rather than giving artificial infant feeding. Replacement feeding method places stress on the environment, leads to environmental pollution, and directly exacerbate population pressures through increased fertility in young mothers. The breastmilk is a national resource and is currently threatened by trends in modernization and urbanization towards bottle-feeding. This is not only physiologically undesirable and places our young children at high risk of illness and death but it cost the economy substantially. In addition to the extra food taken by the mother, other costs included in breastfeeding are: To provide adequate maternity entitlements for the working mother such as maternity leave and to have child care facilities at the workplace. To provide mothers with up-to-date knowledge about exclusive breastfeeding and to educate from health service providers. Obstetricians and Pediatricians have a major role to play especially during antenatal and immediate postnatal periods. Mother-to-mother support groups should help mothers in increasing their self-confidence. All efforts to preserve, promote and encourage breastfeeding should be made and all possible measures necessary to reduce the regrettable trend towards bottle-feeding in our country should be taken. Investing in breastfeeding promotion and support would save enormous amount of this natural resource available to the country. We need to invest in Breastfeeding, Don't we? and then look for returns. ___________________________________________________ Acknowledgment We gratefully acknowledge the editorial assistance of Dr. Joseph Sundaram. Thanks to for then continued support Dr. Rita Gupta and Dr. J.P. Dadich. We are also thankful to Amit Dahiya and Yogender Rawat of secretarial assistance. References: 1. Breastfeeding and cognitive development in the first 2 years of life. Soc. Sci Med. 1988; 26:635-639. 2.Gonzales, R : ‘A Large Scale Rooming in Programme in a Developing Country’. Proceedings of the interagency workshop on Health Care Practices related to breastfeeding. Lobbock and McDonald (ed.), International Journal of Gynecology and Obstetrics, April, 1990. 3. Chua S, Arul Kumaran S, Lim I, et al. Influence of breastfeeding and nipple stimulation on postpartum uterine activity. Br. J Obstet. Gynaecol, 1994, 101: 804-805. 4. Newcomb PA, Storer BE, Longnecker MP, et al. Lactation and a reduced risk of premenopausal breast cancer. N Eng J Med. 1994; 330:81-87. 5. Rosenblatt KA, Thomas DB, WHO Collaborative study of Neoplasia and Steroid contraceptives. Int J Epidemiol. 1993; 22:192-197. 6.Kennedy KI, Visness CM. Contraceptive efficacy of lactational amenorrhoea. Lancet. 1992; 339: 227-230. 7. Metton LJ, Bryant SC, Wahner HW, et al. Influence of breastfeeding and other reproductive factors on bone mass later in life. Osteoporosis Int. 1993; 3:76-83. 8.Cumming RG, Klineberg RJ. Breastfeeding and other reproductive factors and the risk of hip fractures in elderly women. Int J Epidemiol. 1993; 22:684-691. 9. Almroth S, Greiner T, The Economic value of breastfeeding. FAO Food and Nutrition Paper No 11. 1979. 10. Editorial, The Lancet 1994, 344:1237-1241 11.Breastfeeding: The Best Investment. World Alliance for Breastfeeding Action (WABA), 1998, P.O. Box No 1200, Penang, Malaysia. 12. Jellife DM, Jellife EFP: Human Milk in the Modern World, Oxford University Press, 1978. 13.Gupta A and Rohde J. Economic value of Breastfeeding in India. Economic and political weekly, 1993, June 26, pp1390-3. 14. Chitkara AJ and Gupta S. Infant feeding practices and morbidity. Indian Pediatrics 1987;24:865-872. 15. Dewey K G, Heining MJ, Nommsen-Rivers LA. Differences in morbidity between breastfed and formula fed infant. J Pediatric. 1995; 126: 696-702. 16. Frank AL, Taber LH, Glezen WP, et al. Breastfeeding and respiratory virus infection. Pediatrics 1982; 70: 239-245. 17. Wright AL, Holberg CJ, Taussig LM, et al. Relationship of infant feeding to recurrent wheezing at age 6 years. Arch Pediatric Adolesc Med. 1995; 149:758-763. 18. Duncan B, Ey J, Holberg CJ, et al. Exclusive breastfeeding for at least 4 months protects against otitis media. Pediatrics 1993; 91: 867-872. 19. Takala AK, Eskola J. Palmgren J, et al. Risk factors of invasive Haemophilus influenzae type b disease among children in Finland. J Pediatric. 1989; 115: 694-701. 20. Cochi SL, Fleming DW, Hightower AW, et al. Primary invasive Haemophilus influenzae type b disease: a population based assessment of risk factors. J Pediatric. 1986; 108:887-896. 21. Arnon SS. Breastfeeding and toxigenic intestinal infection: missing link in crib death? Rev Infect Dis. 1984, 6: 5193-5201. 22. Pisacane A. Graziano L, Mazzarella G, et al. Breastfeeding and urinary tract infection. J of Pediatric. 1992; 120:87-89. 23. Lucas A. Cole TJ. Breastmilk and neonatal necrotizing enterocolitis. Lancet 1990, 336: 1519-1523. 24. Ford RPK, Taylor BJ, Mitchell EA, et al. Breastfeeding and the risk of sudden infant death syndrome. Int J. Epidemiol. 1993; 22: 885-890. 25. Mayer EJ, Hamman RF, Gay EC, et al. Reduced risk of IDDM among breast-fed children. Diabetes. 1988; 37: 1625-1632. 26. Koletzko S, Sherman P, Corey M et al. Role of infant feeding Practices in development of Crohn’s disease in childhood Br. Med J. 1989; 298:1617-1618. 27. Rigas A, Rigas B, Glassman M, et al. Breastfeeding and Maternal sucking in the etiology of Crohn’s disease and ulcerative colitis in childhood. Ann Epidemiol 1993; 3: 387-392. 28. Davis MK, Savitz DA, Graubard BI. Infant feeding and childhood cancer. Lancet 1988; 2: 365-368. 29. Saarinen UM, Kajosari M. Breastfeeding as prophylaxis against atopic disease: prospective follow-up study until 17 years old. Lancet. 1995, 346:1065-1069. 30. Sveger T. Breastfeeding, Alpha 1 anti-trypsin deficiency, and liver disease? JAMA 1985, 253:2679-2682 31. Viswanathan H. Rohde J. Diarrhea in rural India. A nation wide study of mothers and Practitioners, All India Summary, Vision Books. 32. Saarinen UM. Prolonged breastfeeding as prophylaxis for recurrent otitis media. Acad Pediatric Scand. 1982; 71:567-571. 33. Teele DW, Klein JO, Rosner B, the Greater Otitis Media study group. Epidemiology of otitis media during the first seven years of life in children in Greater Boston, a prospective cohort study. J Infect Dis. 1989, 160: 83-94. 34. Thapa S, Short RV, Potts M. ‘Breastfeeding and Birth spacing and their effects on child survival Nature. 1989; 335 (20): 679-683. 35. Gopujkar PV, Chaudhury SN, Ramaswami NA, Gore MS, Gopalan C. Infant feeding practices with special reference to the use of commercial infant foods. Scientific report no 4, Nutrition Foundation of India, India International Centre, New Delhi 1984: 31-38. 36. Tolstoplatov B, et al. Cost of infant feeding in the former Yugoslavia. Int. Child Health, 1996, Vii (1); 39-44. 37. Network newsletter of the Association for rational use of medication in Pakistan 5:1, March 1996, page 13 38. Linkages, AED. Ghana: Suboptimal breastfeeding in infant. Washington, DC: Linkages, AED. 1998. 39. Oshaug A and Botten G (1994). Human milk in food supply statistics. Food policy 19 (5): 479-482. 40. Hatby A and Oshaug A. Human milk - an invisible food resource. Washington DC: International food policy research institute.1997. 41. Tuttle CR and Dewey KG: Potential cost savings for Medical, AFDS, Food Stamps and WIC programs associated with increasing breastfeeding among low income Hmong women in California. J Amer Dietetic Assn, 1996 96:885-890. 42. Riordan JM. The cost of not breastfeeding: a commentary. J of Human Lactation, 1997 13(2) : 93-97. 43. Drane D. Breastfeeding and formula feeding: a preliminary economic analysis. Breastfeeding Review, 1997 5 (1): 7-15.
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