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Impact of breastfeeding on mortality in sub-Saharan Africa: a systematic review, meta-analysis, and cost-evaluation


Sub-Saharan Africa has lower breastfeeding rates compared to other low- and middle-income countries, and globally holds the highest under-five mortality rates. The aims of this study were to estimate mortality risk for inappropriate breastfeeding, prevalence of breastfeeding, population attributable fraction, and the economic impact of breastfeeding on child mortality, in sub-Saharan Africa. The systematic review included databases from Medline and CINAHL. Meta-analysis of mortality risk estimates was conducted using random effect methods. The prevalence of breastfeeding in Sub-Saharan African countries was determined using UNICEF’s database. Population attributable fraction was derived from the prevalence and relative risk data. The cost attributable to child deaths in relation to inappropriate breastfeeding was calculated using the World Health Statistics data. The pooled relative mortality risk to any kind of infant feeding compared to exclusive and early breastfeeding initiation were 5.71 (95%CI: 2.14, 15.23) and 3.3 (95%CI: 2.49, 4.46), respectively. The overall exclusive and early initiation of breastfeeding prevalence were 35%(95%CI: 32%;37%) and 47%(95%CI: 44%;50%), respectively. The population attributable fraction for non-exclusive and late breastfeeding initiation breastfeeding were 75.7% and 55.3%, respectively. The non-health gross domestic product loss resulted in about 19.5 USB$.

Conclusion: Public health interventions should prioritize appropriate breastfeeding practices to decrease the under-five mortality burden and its related costs in sub-Saharan Africa.

What is Known:
Globally, sub-Saharan Africa holds the highest under five mortality rates and still has lower breastfeeding rates compared to other low- and middle-income countries.
There is a significant association between child mortality and inappropriate breastfeeding practices.
What is New:
A five-fold and three-fold increased risks for under-five mortality were estimated with regard to non-exclusive breastfeeding and delayed breastfeeding initiation, respectively.
55–75% of under-five deaths can be attributable to inappropriate breastfeeding practices and at least part of them could be potentially prevented with breastfeeding promotion interventions, saving a non-health gross domestic product loss of 19.5 USB$.

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Baby-friendly hospital initiative


Exclusive breastfeeding


Early initiation of breastfeeding


Gross domestic product


Human immunodeficiency virus


Intraclass correlation coefficient


Medical subject headings


Non-health gross domestic product loss attributable to child deaths


Newcastle–Ottawa scale


Population attributable fraction


Prevention of mother to child transmission


Preferred reporting items of systematic reviews and meta-analysis


Under-five mortality rate


United Nations Children’s Fund


United States billion dollars


United States dollars


World Health Organization


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Authors and Affiliations



CP and CR conceptualized and designed the study and data collection instruments and drafted the initial manuscript. CP and HA collected data and CR carried out the initial analyses. HA, JG, and SK contributed to the acquisition, analysis, or interpretation of data reviewed and revised the manuscript critically for important intellectual content. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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Correspondence to Cianté E. Pretorius.

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This article does not contain any studies with human participants or animals performed by any of the authors and is approved for ethical clearance by the North-West University Health Research Ethics Committee (NWU-00974-19-A1).

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Communicated by Gregorio Paolo Milani

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Pretorius, C.E., Asare, H., Genuneit, J. et al. Impact of breastfeeding on mortality in sub-Saharan Africa: a systematic review, meta-analysis, and cost-evaluation. Eur J Pediatr 179, 1213–1225 (2020).

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  • Child
  • Mortality
  • Breastfeeding
  • Prevalence
  • Public health
  • Africa South of the Sahara