BACKGROUND:

Sub-Saharan Africa remains the region with the highest under-5 mortality (U5M) rates globally. Emerging evidence revealed that exclusive breastfeeding (EBF) rates are significantly associated with a decreased risk for child mortality. Our aim with this study is to fill the gap of knowledge regarding the economic impact of EBF practices in relation to U5M in sub-Saharan African countries.

METHODS:

Data were gathered from the World Bank’s database during the period 2000–2018. A meta-analytical approach was used to evaluate heterogeneity of country estimates and to perform an estimate of the prevalence of EBF and economic cost by country. The association between estimates of U5M and EBF prevalence was estimated and used to perform the total cumulative nonhealth gross domestic product loss (TCNHGDPL) attributable to U5M in 2018 and 2030.

RESULTS:

The prevalence of EBF increased by 1%, and U5M reduced significantly by 3.4 per 1000 children each year during 2000–2018. A U5M reduction of 5.6 per 1000 children could be expected if EBF prevalence improved by 10%. The TCNHGDPL in sub-Saharan Africa had a total value higher than $29 billion in 2018. The cost of U5M is estimated to increase to ∼$42 billion in 2030.

CONCLUSIONS:

If EBF prevalence improve by 10%, the related TCNHGDPL was estimated to be $27 billion in 2018 and$41 billion in 2030, therefore saving ∼$1 billion. Sub-Saharan Africa should imperatively prioritize and invest in essential approaches toward EBF implementation. What’s Known on This Subject: Sub-Saharan Africa remains the region with the highest under-5 mortality rates globally, and emerging evidence revealed that exclusive breastfeeding (EBF) rates are significantly associated with a decreased risk for child mortality. What This Study Adds: Currently, the EBF rates are not increasing adequately. If EBF rates improved by 10%, ∼$1 billion of the related nonhealth gross domestic product loss could be saved annually.

Globally, from 2000 to 2018, 5.3 million children died before their fifth birthday, although in the same period, the global under-5 mortality rate (U5MR) had declined by roughly 50%.1  Currently, sub-Saharan Africa holds the highest U5MR worldwide, corresponding to 78 deaths per 1000 live births.1  Therefore, to reach the Sustainable Development Goal (SDG) target for a U5MR of 25 or fewer deaths per 1000 live births, the World Health Organization has noted that the African region must reduce its child mortality rate by roughly 70% by 2030.2

Malnutrition has been responsible, directly or indirectly, for 60% of the 10.9 million deaths reported annually among children under 5 years of age, in which well over two-thirds of these deaths occur during the first year of life.3  As a global public health responsibility, the World Health Organization and the United Nations Children’s Fund strongly recommend exclusive breastfeeding (EBF) during the first 6 months of life.4  It has been well established that the recommended breastfeeding practices have a substantial impact on neonatal or infant and/or child mortality.512  Moreover, numerous publications on maternal and child nutrition reported that in 2013, up to 800 000 child deaths could be prevented through breastfeeding.1316

The prevalence of EBF among infants younger than 6 months of age increased in almost all regions in the developing world, with the biggest improvement seen in West and Central Africa, where the prevalence of EBF more than doubled from 12% in 1995 to 28% in 2010. Eastern and Southern Africa also had improvements, with an increase from 35% in 1995 to 47% in 2010. However, and regardless of these improvements, sub-Saharan Africa remains the region with lowest EBF rates (35%) among low- and middle-income areas.17

Child illness and mortality due to malnutrition increase health expenditure and cause attrition of future labor and productivity, which in turn erode investments in human and physical capital formation, with negative impact on future macroeconomic output.18  The aim with this study is to fill a lacuna regarding the economic impact of breastfeeding practices in relation to years of life lost by child mortality preventable by implementation of EBF in sub-Saharan African countries. To serve this aim, we first evaluated the time trend of the prevalence of EBF practice in sub-Saharan African countries during the period from 2000 to 2018. Afterward, we studied the relation between the prevalence of EBF practice and the U5MR in sub-Saharan Africa. We estimated the economic impact of child mortality by means of years of life lost in relation to lack of EBF. Finally, we estimated the economic impact of years of life lost by children in sub-Saharan Africa given by a 10% increase of the EBF prevalence.

Data on the prevalence of EBF, under-5 mortality (U5M), population under 5 years, gross domestic product (GDP), and current health expenditure per capita, along with covariates used in adjusted evaluations (poverty, hospital beds, number of nurses, number of medical doctors, prevalence of low birth weight, wasting, stunting, practice of open defecation, and availability of safe water) in sub-Saharan Africa were obtained from the World Bank’s database (https://databank.worldbank.org/source/health-nutrition-and-population-statistics). Specific World Bank database definition, data coverage, and missing values rates were reported in Supplemental Tables 1 through 7.

First, all the data collected during the period of 2000–2018 were analyzed by using a mixed model approach, with random intercepts at country level. This evaluation was done to investigate trends over time. Before the analyses, variables reported as prevalence (EBF prevalence, low birth weight, wasting, stunting, practice of open defecation, and availability of safe water) were transformed by using the arcsin function, whereas count variables (hospital beds, number of nurses and number of medical doctors) were transformed to natural logarithms. Retrotransformed estimates of marginal least square means by country were performed after model fitting and used as adjusting covariates in the models, evaluating the relation between U5M and the prevalence of EBF.19  Second, EBF prevalence was investigated by using a meta-analytical approach, which aimed to evaluate the between country heterogeneity during the period 2000–2018 and to perform an estimate for the sub-Saharan Africa region. For this reason, the under-5 population was considered as a weight variable, thereby giving more weight to the most densely populated countries.

Third, we evaluated the shape of the relation between U5M and the prevalence of EBF. Here, linear and nonlinear methods were compared and models with a better fit were chosen for further evaluations. In brief, a fractional polynomial and an ordinary linear regression were applied and compared by using the Akaike information criteria, and Wald tests were applied to the model coefficients. According to our fractional polynomial analysis, this association should be considered linear, because higher-degree polynomials do not significantly contribute to model fitting. On the contrary, an ordinary linear regression appears as significant with satisfactory model fitting (Akaike information criterion = 6.5 × 107 with R2 = 0.38 and 7.1 × 107 with R2 = 0.36 for third degree polynomials and ordinary linear model, respectively). After confirmation of linearity, the relation between U5M and EBF was modeled by using a generalized estimated equation approach, with yearly repeated evaluation (2000–2018) of U5M adjusted for EBF (approximated by 15% of the total U5M) as outcome and the median EBF prevalence during the same period as the explanatory covariate. This evaluation was adjusted for the possible confounders, as individuated in a previous study.12

Specifically, median values of low birth weight prevalence, practice of open defecation, poverty, and hospital beds were considered. A supplementary sensitivity evaluation was conducted, adjusting for wasting and stunting prevalence, availability of safe water, number of nurses, and number of medical doctors.

Finally, we estimated the economic impact of U5M due to lack of breastfeeding, by means of GDP reduction due to years of life loss. Toward this end, we reported the total cumulative nonhealth gross domestic product loss (TCNHGDPL) attributable to U5M, performed by using the approach proposed by Kirigia et al.20

In brief, we first calculated a country specific difference between per capita GDP and per capita health expenditure. This value, corresponding to a loss of net income excluding cost for health care, was then multiplied by a discount rate (3% reduction), representing the balance between the salary increase and the increase of health expenditure with age. Next, the above net cost was multiplied by the number of children who had undergone death before 5 years of age. Finally, a TCNHGDPL was performed through the summation of the above net cost by every year over the working period (assumed between 20 and 65 years of age). The calculation of TCNHGDPL was undertaken by country considering the current values in 2018 and the forecasts of child mortality, population at risk, and the difference between the per capita GDP and the per capita health expenditure, in 2018 and in 2030.

The prevalence of EBF increased significantly by 1% point in almost all sub-Saharan Africa over the period 2000–2018 each year. A large variability between countries was observed, with EBF ranging between 3% in Chad and 86% in Uganda. According to our estimates, EBF prevalence was 34% in sub-Saharan Africa during the period 2000–2018. In the same period, U5M significantly reduced by 3.4 per 1000 children each year. However, a large variability between countries was observed for U5M during the first 5 years of life, with U5M due to lack of EBF ranging between 7.5 and 24.8 deaths per 1000 children in Sao Tome and Principe and Sierra Leone, respectively. During the period between 2000 and 2018, we estimated an overall mortality rate of 15.8 per 1000 children, with the countries with the largest under-5 populations being the most influential countries, such as the Democratic Republic of the Congo and Nigeria, which contributed 17.9 and 21.45 deaths per 1000 children, respectively.

In Fig 1, we show the breastfeeding prevalence meta-analysis, and the sub-Saharan Africa time trends of U5M due to lack of EBF and EBF prevalence is represented in Fig 2A.

FIGURE 1

Meta-analysis of EBF prevalence and U5M.

FIGURE 1

Meta-analysis of EBF prevalence and U5M.

Close modal
FIGURE 2

Trends of EBF prevalence and U5M (A) and per capita GDP and health expenditure (B). The dotted lines portray moving averages with a period of 2.

FIGURE 2

Trends of EBF prevalence and U5M (A) and per capita GDP and health expenditure (B). The dotted lines portray moving averages with a period of 2.

Close modal

We observed a consistent decreasing trend for the association between U5M and EBF prevalence.

The linear analysis revealed that an expected U5M reduction of 5.6 per 1000 children would be expected if EBF prevalence improves by an average of 10%.

According to our data, per capita GDP and health expenditure increased constantly after the year 2000 (Fig 2B). Specifically, we estimate that the difference between per capita GDP and health expenditure increased significantly, by ∼$82 million per year in sub-Saharan Africa. This was also the case among single countries in sub-Sahara Africa, apart from Eritrea. A large heterogeneity of the per capita GDP health expenditure differences was observed, ranging between$586 and $29 511 for the Democratic Republic of Congo and Equatorial Guinea, respectively. We calculated the TCNHGDPL in sub-Saharan Africa to have a total value of ∼$29 billion from 2000 to 2018. This cost had a large variability, ranging between $1.3 million in Mauritius to$11.4 billion in Nigeria. According to our calculations, the cost of U5M in sub-Saharan Africa is going to increase from $29 billion in 2018 to almost$42 billion in 2030, or more than a billion per year (Fig 3).

FIGURE 3

Quartiles of total cumulative nonhealth GDP according to estimates in 2018 and 2030.

FIGURE 3

Quartiles of total cumulative nonhealth GDP according to estimates in 2018 and 2030.

Close modal

We also estimated a decrease for the TCNHGDPL, which was based on the estimated reduction in U5M associated with a 10% increased prevalence of EBF. Therefore, if EBF would improve by 10%, an expected mortality reduction of 5.6% would decrease the current TCNHGDPL to $27 billion, and the related TCNHGDPL would decrease to$41 billion in 2030. This corresponds to a saving of ∼$1 to 2 billion in 2018 and 2030, respectively. In the present work, we showed 3 main results. First, we described how the current time trends for sub-Saharan Africa between 2000 and 2018 reveal a significant increase in the prevalence of EBF and a significant decrease for U5M. Second, our analyses support that sub-Saharan Africa is likely not to reach the SDG target of a U5MR of 25 or fewer deaths per 1000 live births by 2030.21 Furthermore, although the prevalence of EBF prevalence is increasing by 1 percentage point per year, the current trend would not meaningfully contribute toward solving the unique challenges that sub-Saharan Africa faces to reduce U5MR. Moreover, the current trend for EBF indicates that sub-Saharan Africa likely may not even reach the Global Nutrition target 5, which is to increase the rate of EBF in the first 6 months up to at least 50% by 2025.22 Third, we also showed the significant linear association between U5M and EBF prevalence. According to this relation, for every 10–percentage point increase in the prevalence of EBF, a reduction of ∼5.6 per 1000 children could be expected for the total U5MR. With the current analysis, we confirm the results of a study in 2011, in which it was concluded that infant mortality rate decreases by 0.5 deaths per 1000 infants for every 1-percentage point increase in the number of infants that are exclusively breastfed for 6 months.23 Therefore, to specifically improve the current trend of EBF prevalence in sub-Saharan Africa, emphasis should be placed on current evidence-based interventions that support the scaling-up thereof. Breastfeeding support, particularly to mothers who exclusively breastfeed, among other interventions, has the greatest potential to reduce the burden of U5M. Authors of a meta-analysis focusing on low- and middle-income countries reported that group counseling during breastfeeding was associated with increased odds of EBF in the first 6 months of life (odds ratio: 3.9, 95% confidence interval: 2.1–7.2), as well as continued breastfeeding up to 12 months of life (odds ratio: 5.2, 95% confidence interval: 1.9–14.2), when compared with only routine care.24 The cost attributable to child mortality in sub-Saharan Africa indicated a large variability between countries for the nonhealth GDP per capita and the TCNHGDPL. The per capita total cumulative nonhealth GDP increased significantly after the year 2000, with an estimated$82 million per year. The TCNHGDPL in sub-Saharan Africa had a total value >$37 billion in 2018. In 2013, it was estimated that the TCNHGDPL incurred in the African region would be ∼6% from the future years of life lost among the 2 976 000 child deaths that occurred in that same year.20 A strength of this study is that it is based on reliable and recent data obtained from reliable population-based surveys updated regularly. In addition, our study holds originality because we focused on EBF practices and the economic impact in sub-Saharan Africa based on country level data. These findings are of great public health importance toward reaching the SDG target 4 and to reduce the negative economic impact of child mortality in sub-Saharan Africa. However, a limitation of this study is that the present results are defined at country level and are not generalizable to specific subregions or local areas. Also, because of missing information, our analysis excluded a few countries (Cabo Verde, Mauritius, Seychelles, Somalia, and South Sudan). Finally, we acknowledge that, according to the World Bank definition, EBF was assessed in a limited time window of the previous 24 hours, a fact that could have led to a measurement error, because breastfeeding was not assessed across a longer period. Sub-Saharan Africa ought to prioritize action by governments, the private sector, and the civil society to fully implement and invest in evidence-based approaches toward improving the prevalence of EBF. Improving the prevalence of EBF in sub-Saharan Africa will subsequently contribute to a significant decrease of U5M and may further reduce its economic cost by saving ∼$1 billion annually.

Ms Pretorius conceptualized and designed the study, collected data, drafted the initial manuscript, and reviewed and revised the manuscript; Ms Asare, Dr Genuneit, and Ms Siziba contributed to the interpretation of data and revised the manuscript critically for important intellectual content; Prof Kruger contributed to the conception and design of the study and revised the manuscript critically for important intellectual content; Dr Ricci conceptualized and designed the study, coordinated and supervised data collection, conducted the initial analyses, drafted the initial manuscript, and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/2020-040824.

• EBF

exclusive breastfeeding

•
• GDP

gross domestic product

•
• TCNHGDPL

total cumulative nonhealth gross domestic product loss

•
• SDG

Sustainable Development Goal

•
• U5M

under-5 mortality

•
• U5MR

under-5 mortality rate

1
United Nations Children’s Fund
.
Levels & Trends in Child Mortality: Estimates Developed by the United Nations Inter-Agency Group for Child Mortality Estimation
.
New York, NY
:
United Nations Children’s Fund
;
2019
2
United Nations
.
Transforming Our World: The Sustainable Development Goals
.
New York, NY
:
United Nations
;
2015
3
World Health Organization
;
United Nations Children’s Fund
.
Global Strategy for Infant and Young Child Feeding
.
Geneva, Switzerland
:
World Health Organization
;
2003
4
World Health Organization
.
Guideline: Protecting, Promoting and Supporting Breastfeeding in Facilities Providing Maternity and Newborn Services
.
Geneva, Switzerland
:
World Health Organization
;
2017
5
Smith
ER
,
Hurt
L
,
Chowdhury
R
,
Sinha
B
,
Fawzi
W
,
Edmond
KM
;
Neovita Study Group
.
Delayed breastfeeding initiation and infant survival: a systematic review and meta-analysis
.
PLoS One
.
2017
;
12
(
7
):
e0180722
6
Lamberti
LM
,
Fischer Walker
CL
,
Noiman
A
,
Victora
C
,
Black
RE
.
Breastfeeding and the risk for diarrhea morbidity and mortality
.
BMC Public Health
.
2011
;
11
(
3,
suppl 3
):
S15
7
Lamberti
LM
,
Zakarija-Grković
I
,
Fischer Walker
CL
, et al
.
Breastfeeding for reducing the risk of pneumonia morbidity and mortality in children under two: a systematic literature review and meta-analysis
.
BMC Public Health
.
2013
;
13
(
3,
suppl 3
):
S18
8
Sankar
MJ
,
Sinha
B
,
Chowdhury
R
, et al
.
Optimal breastfeeding practices and infant and child mortality: a systematic review and meta-analysis
.
Acta Paediatr
.
2015
;
104
(
467
):
3
13
9
Horta
BL
,
Victora
CG
.
Short-Term Effects of Breastfeeding: A Systematic Review on the Benefits of Breastfeeding on Diarrhoea and Pneumonia Mortality
.
Geneva, Switzerland
:
World Health Organization
;
2013
10
Khan
J
,
Vesel
L
,
Bahl
R
,
Martines
JC
.
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
.
2015
;
19
(
3
):
468
479
11
Debes
AK
,
Kohli
A
,
Walker
N
,
Edmond
K
,
Mullany
LC
.
Time to initiation of breastfeeding and neonatal mortality and morbidity: a systematic review
.
BMC Public Health
.
2013
;
13
(
suppl 3
):
S19
12
Ricci
C
,
Carboo
J
,
Asare
H
,
Smuts
CM
,
Dolman
R
,
Lombard
M
.
Nutritional status as a central determinant of child mortality in sub-Saharan Africa: a quantitative conceptual framework
.
Matern Child Nutr
.
2019
;
15
(
2
):
e12722
13
Black
RE
,
Alderman
H
,
Bhutta
ZA
, et al.;
Maternal and Child Nutrition Study Group
;
Group members
.
Maternal and child nutrition: building momentum for impact
.
Lancet
.
2013
;
382
(
9890
):
372
375
14
Hansen
K
.
Breastfeeding: a smart investment in people and in economies
.
Lancet
.
2016
;
387
(
10017
):
416
15
Rollins
NC
,
Bhandari
N
,
Hajeebhoy
N
, et al.;
Lancet Breastfeeding Series Group
.
Why invest, and what it will take to improve breastfeeding practices?
Lancet
.
2016
;
387
(
10017
):
491
504
16
Victora
CG
,
Bahl
R
,
Barros
AJ
, et al.;
Lancet Breastfeeding Series Group
.
Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect
.
Lancet
.
2016
;
387
(
10017
):
475
490
17
Cai
X
,
Wardlaw
T
,
Brown
DW
.
Global trends in exclusive breastfeeding
.
Int Breastfeed J
.
2012
;
7
(
1
):
12
18
World Health Organization
.
World Health Organization: Guide to Identifying the Economic Consequences of Disease and Injury
.
Geneva, Switzerland
:
World Health Organization
;
2009
19
Suárez
E
,
Pérez
CM
,
Rivera
R
,
Martínez
MN
.
Applications of Regression Models in Epidemiology
.
Hoboken, NJ
:
John Wiley & Sons
;
2017
20
Kirigia
JM
,
Muthuri
RDK
,
Nabyonga-Orem
J
,
Kirigia
DG
.
Counting the cost of child mortality in the World Health Organization African region
.
BMC Public Health
.
2015
;
15
(
1
):
1103
21
Mejía-Guevara
I
,
Zuo
W
,
Bendavid
E
,
Li
N
,
Tuljapurkar
S
.
Age distribution, trends, and forecasts of under-5 mortality in 31 sub-Saharan African countries: a modeling study
.
PLoS Med
.
2019
;
16
(
3
):
e1002757
22
World Health Organization
.
Global Nutrition Targets 2025: Breastfeeding Policy Brief
.
Geneva, Switzerland
:
World Health Organization
;
2014
23
Abrahams
Z
,
McHiza
Z
,
Steyn
NP
.
Diet and mortality rates in Sub-Saharan Africa: stages in the nutrition transition
.
BMC Public Health
.
2011
;
11
(
1
):
801
24
Bhutta
ZA
,
Ahmed
T
,
Black
RE
, et al.;
Maternal and Child Undernutrition Study Group
.
What works? Interventions for maternal and child undernutrition and survival
.
Lancet
.
2008
;
371
(
9610
):
417
440

## Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.