Abstract
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$.
Conclusion: Public health interventions should prioritize appropriate breastfeeding practices to decrease the under-five mortality burden and its related costs in sub-Saharan Africa.
What is Known: • Globally, sub-Saharan Africa holds the highest under five mortality rates and still has lower breastfeeding rates compared to other low- and middle-income countries. • There is a significant association between child mortality and inappropriate breastfeeding practices. | |
What is New: • A five-fold and three-fold increased risks for under-five mortality were estimated with regard to non-exclusive breastfeeding and delayed breastfeeding initiation, respectively. • 55–75% of under-five deaths can be attributable to inappropriate breastfeeding practices and at least part of them could be potentially prevented with breastfeeding promotion interventions, saving a non-health gross domestic product loss of 19.5 USB$. |
Similar content being viewed by others
Abbreviations
- BFHI:
-
Baby-friendly hospital initiative
- EBF:
-
Exclusive breastfeeding
- EIBF:
-
Early initiation of breastfeeding
- GDP:
-
Gross domestic product
- HIV:
-
Human immunodeficiency virus
- ICC:
-
Intraclass correlation coefficient
- MeSH:
-
Medical subject headings
- NHGDPL:
-
Non-health gross domestic product loss attributable to child deaths
- NOS:
-
Newcastle–Ottawa scale
- PAF:
-
Population attributable fraction
- PMTCT:
-
Prevention of mother to child transmission
- PRISMA:
-
Preferred reporting items of systematic reviews and meta-analysis
- U5MR:
-
Under-five mortality rate
- UNICEF:
-
United Nations Children’s Fund
- USB$:
-
United States billion dollars
- US$:
-
United States dollars
- WHO:
-
World Health Organization
References
You D, Hug L, Ejdemyr S, Idele P, Hogan D, Mathers C, Gerland P, New JR, Alkema L (2015) Global, regional, and national levels and trends in under-5 mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the un Inter-Agency Group for Child Mortality Estimation. Lancet 386(10010):2275–2286. https://doi.org/10.1016/S0140-6736(15)00120-8
General Assembly SDG’s (2015) Transforming our world: The Sustainable Development goals. 2030
Pelletier DL (1994) The potentiating effects of malnutrition on child mortality: epidemiologic evidence and policy implications. Nutr Rev 52(12):409–415
Pelletier DL, Frongillo EA Jr, Schroeder DG, Habicht JP (1995) The effects of malnutrition on child mortality in developing countries. Bull World Health Organ 73(4):443–448
Pelletier DL, Frongillo EA (2003) Changes in child survival are strongly associated with changes in malnutrition in developing countries. J Nutr 133(1):107–119. https://doi.org/10.1093/jn/133.1.107
Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, AlMazroa MA, Amann M, Anderson HR, Andrews KG (2012) A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 380(9859):2224–2260
Lartey A (2008) Maternal and child nutrition in sub-Saharan Africa: challenges and interventions. Proc Nutr Soc 67(1):105–108
WHO (2003) Global strategy for infant and young child feeding. https://apps.who.int/iris/bitstream/handle/10665/42590/9241562218.pdf Accessed 15 March 2020. World Health Organization
Cai X, Wardlaw T, Brown D (2012) Global trends in exclusive breastfeeding. Int Breastfeed J 7:12. https://doi.org/10.1186/1746-4358-7-12
Smith ER, Fawzi W, Hurt L, Chowdhury R, Sinha B, Edmond KM (2017) Delayed breastfeeding initiation and infant survival: a systematic review and meta-analysis. PLoS One 12(7). https://doi.org/10.1371/journal.pone.0180722
Lamberti LM, Walker CLF, Noiman A, Victora C, Black RE (2011) Breastfeeding and the risk for diarrhea morbidity and mortality. BMC Public Health 11(3):S15
Lamberti LM, Zakarija-Grković I, Walker CLF, Theodoratou E, Nair H, Campbell H, Black RE (2013) Breastfeeding for reducing the risk of pneumonia morbidity and mortality in children under two: a systematic literature review and meta-analysis. BMC Public Health 13(3):S18
Sankar MJ, Sinha B, Chowdhury R, Bhandari N, Taneja S, Martines J, Bahl R (2015) Optimal breastfeeding practices and infant and child mortality: a systematic review and meta-analysis. Acta Paediatr 104:3–13
Horta BL, Victora CG (2013) Short-term effects of breastfeeding: a systematic review on the benefits of breastfeeding on diarrhoea and pneumonia mortality. World Health Organization
Khan J, Vesel L, Bahl R, Martines J (2015) Timing of breastfeeding initiation and exclusivity of breastfeeding during the first month of life: effects on neonatal mortality and morbidity-a systematic review and meta-analysis. Matern Child Health J 19(3):468–479. https://doi.org/10.1007/s10995-014-1526-8
Debes AK, Anjalee K, Walker N, Edmond K, Mullany LC (2013) Time to initiation of breastfeeding and neonatal mortality and morbidity: a systematic review. BMC Public Health 13(Suppl 3):1–14. https://doi.org/10.1186/1471-2458-13-S3-S19
WHO (2009) Infant and young child feeding: model chapter for textbooks for medical students and allied health professionals. World Health Organization, Geneva
Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med 6(7):e1000100
Wells G, Shea B, O'Connell D, Peterson J, Welch V, Losos M, Tugwell P (2000) The Newcastle–Ottawa scale (NOS) for assessing the quality of non-randomized studies in meta-analysis
Egger M, Smith GD, Schneider M, Minder C (1997) Bias in meta-analysis detected by a simple, graphical test. Br Med J 315. https://doi.org/10.1136/bmj.315.7109.629
WHO (2010) Indicators for assessing infant and young child feeding practices: part 2: measurement. World Health Organization https://apps.who.int/iris/bitstream/handle/10665/44306/9789241599290_eng.pdf 15 March 2020
Kirigia JM, Muthuri RDK, Nabyonga-Orem J, Kirigia DG (2015) Counting the cost of child mortality in the World Health Organization African region. BMC Public Health 15(1):1103. https://doi.org/10.1186/s12889-015-2465-z
Bahl R, Frost C, Kirkwood BR, Edmond K, Martines J, Bhandari N, Arthur P (2005) Infant feeding patterns and risks of death and hospitalization in the first half of infancy: multicentre cohort study. Bull World Health Organ 83:418–426
Lindstrom DP, Berhanu B (2000) The effects of breastfeeding and birth spacing on infant and early childhood mortality in Ethiopia. Soc Biol 47(1–2):1–17
WHO (2000) Effect of breastfeeding on infant and child mortality due to infectious diseases in less developed countries: a pooled analysis. Lancet 355(9202):451–455. https://doi.org/10.1016/S0140-6736(00)82011-5
Biks GA, Berhane Y, Worku A, Gete YK (2015) Exclusive breast feeding is the strongest predictor of infant survival in Northwest Ethiopia: a longitudinal study. J Health Popul Nutr 34(1):9
Edmond K, Kirkwood B, Tawiah C, Agyei SO (2008) Impact of early infant feeding practices on mortality in low birth weight infants from rural Ghana. J Perinatol 28(6):438–444
Edmond KM, Kirkwood BR, Amenga-Etego S, Owusu-Agyei S, Hurt LS (2007) Effect of early infant feeding practices on infection-specific neonatal mortality: an investigation of the causal links with observational data from rural Ghana. Am J Clin Nutr 86(4):1126–1131
Edmond KM, Zandoh C, Amenga-Etego S, Owusu-Agyei S, Kirkwood BR, Quigley MA (2006) Delayed breastfeeding initiation increases risk of neonatal mortality. Pediatrics 117(3):e380–e386. https://doi.org/10.1542/peds.2005-1496
Ettarh R, Kimani J (2012) Determinants of under-five mortality in rural and urban Kenya. Rural Remote Health 12(1)
Girma B, Berhane Y (2011) Children who were vaccinated, breast fed and from low parity mothers live longer: a community based case-control study in Jimma, Ethiopia. BMC Public Health 11(1):197
Neovita (2016) Timing of initiation, patterns of breastfeeding, and infant survival: prospective analysis of pooled data from three randomised trials. Lancet Glob Health 4 (4):e266-e275. doi:https://doi.org/10.1016/S2214-109X(16)00040-1
Kayode GA, Adekanmbi VT, Uthman OA (2012) Risk factors and a predictive model for under-five mortality in Nigeria: evidence from Nigeria demographic and health survey. BMC Pregnancy Childbirth 12(1):10
Mengesha HG, Wuneh AD, Lerebo WT, Tekle TH (2016) Survival of neonates and predictors of their mortality in Tigray region, Northern Ethiopia: prospective cohort study. BMC Pregnancy Childbirth 16(1):202
Orsido TT, Asseffa NA, Berheto TM (2019) Predictors of neonatal mortality in neonatal intensive care unit at referral Hospital in Southern Ethiopia: a retrospective cohort study. BMC Pregnancy Childbirth 19(1):83
Rollins NC, Ndirangu J, Bland RM, Coutsoudis A, Coovadia HM, Newell M (2013) Exclusive breastfeeding, diarrhoeal morbidity and all-cause mortality in infants of HIV-infected and HIV uninfected mothers: an intervention cohort study in KwaZulu Natal, South Africa. PLoS One 8(12):1–1. https://doi.org/10.1371/journal.pone.0081307
Shifa GT, Ahmed AA, Yalew AW (2018) Maternal and child characteristics and health practices affecting under-five mortality: a matched case control study in Gamo Gofa Zone, Southern Ethiopia. PLoS One 13(8):e0202124
Motsa LF, Ibisomi L, Odimegwu C (2016) The influence of infant feeding practices on infant mortality in Southern Africa. Matern Child Health J 20(10):2130–2141. https://doi.org/10.1007/s10995-016-2033-x
Roberts TJ, Carnahan E, Gakidou E (2013) Can breastfeeding promote child health equity? A comprehensive analysis of breastfeeding patterns across the developing world and what we can learn from them. BMC Med 11(1):254. https://doi.org/10.1186/1741-7015-11-254
Huffman SL, Zehner ER, Victora C (2001) Can improvements in breast-feeding practices reduce neonatal mortality in developing countries? Midwifery 17(2):80–92. https://doi.org/10.1054/midw.2001.0253
Jolly K, Ingram L, Khan KS, Deeks JJ, Freemantle N, MacArthur C (2012) Systematic review of peer support for breastfeeding continuation: metaregression analysis of the effect of setting, intensity, and timing. Br Med J 344:d8287. https://doi.org/10.1136/bmj.d8287
Callaghan-Koru JA, Estifanos AS, Sheferaw ED, de Graft-Johnson J, Rosado C, Patton-Molitors R, Worku B, Rawlins B, Baqui A (2016) Practice of skin-to-skin contact, exclusive breastfeeding and other newborn care interventions in Ethiopia following promotion by facility and community health workers: results from a prospective outcome evaluation. Acta Paediatr 105(12):e568–e576. https://doi.org/10.1111/apa.13597
Pérez-Escamilla R, Martinez JL, Segura-Pérez S (2016) Impact of the baby-friendly hospital initiative on breastfeeding and child health outcomes: a systematic review. Matern Child Nutr 12(3):402–417. https://doi.org/10.1111/mcn.12294
Belay S, Haidar J (2013) Effect of prenatal education on breastfeeding initiation and exclusive breast feeding rate in selected health institutions of Hawassa city, the capital of SNNPR. East African Journal of Public Health, Ethiopia
Takahashi K, Ganchimeg T, Ota E, Vogel JP, Souza JP, Laopaiboon M, Castro CP, Jayaratne K, Ortiz-Panozo E, Lumbiganon P, Mori R (2017) Prevalence of early initiation of breastfeeding and determinants of delayed initiation of breastfeeding: secondary analysis of the WHO Global Survey. Sci Rep 7:44868. https://doi.org/10.1038/srep44868
Yalçin SS, Berde AS, Yalçin S (2016) Determinants of exclusive breast feeding in sub-Saharan Africa: a multilevel approach. Paediatr Perinat Epidemiol 30(5):439–449
Agampodi SB, Fernando S, Dharmaratne SD, Agampodi TC (2011) Duration of exclusive breastfeeding; validity of retrospective assessment at nine months of age. BMC Pediatr 11(1):80
WHO, UNICEF (2003) HIV and infant feeding: a guide for health-care managers and supervisors. https://appswhoint/iris/bitstream/handle/10665/42862/9241591234pdf Accessed 15 March 2020
Coovadia HM, Rollins NC, Bland RM, Little K, Coutsoudis A, Bennish ML, Newell M-L (2007) Mother-to-child transmission of HIV-1 infection during exclusive breastfeeding in the first 6 months of life: an intervention cohort study. Lancet 369(9567):1107–1116
WHO (2000) Technical consultation on behalf of the UNFPA/UNICEF/WHO/UNAIDS inter-agency task team on mother-to-child transmission of HIV. New data on the prevention of mother-to child transmission of HIV and their policy implications Conclusions and recommendations. World Health Organization, Geneva. http://www.who.int/reproductive-health/rtis/MTCT/mtct_consultation_october_2000/index.htm. Accessed 15 March 2020
Coutsoudis A, Goga A, Rollins N, Coovadia HM (2002) Free formula milk for infants of HIV-infected women: blessing or curse? Health Policy Plan 17(2):154–160
Nkonki LL, Daviaud E, Jackson D, Chola L, Doherty T, Chopra M, Robberstad B, Group P-ES (2014) Costs of promoting exclusive breastfeeding at community level in three sites in South Africa. PLoS One 9(1):e79784
Tylleskär T, Jackson D, Meda N, Engebretsen IMS, Chopra M, Diallo AH, Doherty T, Ekström E-C, Fadnes LT, Goga A, Kankasa C, Klungsøyr JI, Lombard C, Nankabirwa V, Nankunda JK, Van de Perre P, Sanders D, Shanmugam R, Sommerfelt H, Wamani H, Tumwine JK (2011) Exclusive breastfeeding promotion by peer counsellors in sub-Saharan Africa (PROMISE-EBF): a cluster-randomised trial. Lancet 378(9789):420–427. https://doi.org/10.1016/S0140-6736(11)60738-1
Haroon S, Das JK, Salam RA, Imdad A, Bhutta ZA (2013) Breastfeeding promotion interventions and breastfeeding practices: a systematic review. BMC Public Health 13(3):S20. https://doi.org/10.1186/1471-2458-13-S3-S20
Funding
No funding was obtained for this work.
Author information
Authors and Affiliations
Contributions
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.
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical approval
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).
Additional information
Communicated by Gregorio Paolo Milani
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Electronic supplementary material
ESM 1
(DOCX 117 kb)
Rights and permissions
About this article
Cite this article
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). https://doi.org/10.1007/s00431-020-03721-5
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00431-020-03721-5