By Kelly Wallace

(CNN) I’ve written before about how I simply don’t get how we in the United States remain so squeamish about breast-feeding — and how despite all the research that ‘breast is best,’ many U.S. hospitals are still not providing women with breast-feeding support.

If we know — based on actual scientific studies — that breast-feeding can provide health benefits to mother and baby, why aren’t we doing everything we possibly can to make it easier and more socially acceptable for women who choose to breast-feed?

Maybe a new two-part comprehensive report published Thursday in the medical journal The Lancet and billed as the largest and most detailed analysis of the existing research on breast-feeding around the world will help bring about change in the United States and globally. More than 1,300 studies were reviewed, including some commissioned specifically for this report, which focused on the levels, trends and benefits of breast-feeding.

Think of the health implications alone. Based on new estimates produced for the report, dramatically scaling up breast-feeding to near-universal levels for infants and young children could save 820,000 children’s lives a year around the world, preventing 13% of all deaths of children under five.

“Breast milk acts as a baby’s first vaccine to help fight disease and illness,” said Dr. Cesar Victora, emeritus professor of epidemiology at the Federal University of Pelotas in Brazil, one of the co-authors of the report, in response to questions via email.
If ‘breast is best’ for newborns, where’s the support in hospitals?
Is breast-feeding help in U.S. hospitals improving?

One third of respiratory infections and about half of all diarrhea episodes could be avoided in low- and middle-income countries through breast-feeding, according to the report. In high-income countries, breast-feeding cuts the risk of sudden infant deaths by more than one-third.

Children who are breast-fed longer have been found to have higher intelligence than those who are breast-fed for shorter periods, the report said.

“So both for ensuring kids’ survival and then ensuring their future health and development, it’s a huge intervention,” said Shawn Baker, director of nutrition for the Bill & Melinda Gates Foundation, which provided a $650,000 grant to the World Health Organization to fund the report.

“I always characterize it that this is not some second-rate intervention we’re trying to push on developed worlds, but this is really state of the art, the gold standard intervention that’s relevant anywhere in the world.”

Mom benefits, too

The health benefits extend to the mother as well, with reductions in risk of breast and ovarian cancer. Based on all the existing research and according to new estimates created for this report, hikes in breast-feeding could prevent an extra 20,000 deaths from breast cancer each year.

And yet, the rate of breast-feeding has been relatively stagnant for the past two decades, and the wealthier the country, the less likely mothers are to breast-feed. Currently, just one in five children in high-income countries are breast-fed to 12 months while one in three children are breast-fed exclusively for the first six months in low- to middle-income countries.

“Breast-feeding is one of the few health and nutrition indicators for which poor countries are closer to international recommendations than rich ones,” said Victora, who also coordinates the International Center for Equity in Health at the Federal University of Pelotas. For each doubling of a country’s gross domestic product per capita, the prevalence of breast-feeding at 12 months drops by 10 percentage points, he said.

“What one is seeing in a number of countries, as they’ve emerged economically, is that … perception, ‘Well to be modern, one should move from breast-feeding to formula feeding,’ and that can have a real knock-on effect of undermining the social norms around breast-feeding,” said Baker of the Bill & Melinda Gates Foundation.

Extensive marketing by formula makers remains a big barrier to increase the number of children who are breast-fed, the report said.

While there is an international code that was adopted in 1981 to protect the public from inappropriate marketing strategies, it has not been vigorously enforced, implemented and monitored, the report said. Plus, the report estimates enormous growth in the formula market, with sales projected to reach more than $70 billion in 2019, far more than countries spend to promote and support breast-feeding.

“The fact is that marketing by the infant-feeding industry and the availability of formula, including through the distribution of free samples, result in increased bottle-feeding,” said Victora, the report’s author. “Formula advertisements portray it as good as or better than breast milk, or present it as a lifestyle choice rather than a decision with health and economic consequences.”

How to change social norms?

It is incredibly important to note right here that some people can’t breast-feed for medical reasons, because they physically can’t do it or don’t feel comfortable doing it. But for the people who are choosing to bottle feed over breast-feeding — and who might reverse course if they knew more about the benefits — could anything be done to help influence them to choose breast over bottle?

The report found it is possible to change social norms and behavior, even in emerging economies. For instance, the average duration of breast-feeding in Brazil jumped from 2.5 months in 1974, one of the shortest in any low- or middle-income country, to 14 months by 2006 to 2007.

Brazil rigorously monitored marketing by formula makers and set up a process to certify and recertify hospitals as “baby friendly,” meaning they provided breast-feeding supports to new moms, said Victora, one of the lead researchers behind the report. The country also added leave time for parents, he noted — 120 days for moms and five days for dads, according to the United Nations International Labour Organization.

“I do think that if you can see countries like Brazil that can make, with high-level political support, fundamental changes in the social norms throughout the whole system, I think it’s probably possible anywhere,” said Baker of the Bill & Melinda Gates Foundation. “It’s creating the right conditions and I think that’s what’s also very important. You can’t say, ‘OK, we’re just going to focus on the mom’ without understanding what context that mom lives in.”

Baker was recently in the field in Bangladesh and says one of the great innovations to change behaviors there are home visits, which include not just the mom, but also the dad and the mother-in-law. A mother’s behavior, in any part of the world, can be extremely influenced by what her mother-in-law or her mother says when it comes to child feeding. I’m sure any mother reading this understands that statement immensely.

“So, just speaking to her without trying to address the neighboring environment around her is going to … not give good results and in fact, sometimes put her in a situation where she’ll feel very frustrated because she will want to practice the better feeding behavior, but her mother-in-law or her husband will give contrary advice,” said Baker.

“I think that looking at the whole system, the environment in which the mom lives and addressing that is really quite important” in any part of the world, he added.

Reference