requirement.docxI want you to read 3 articles below and star.docx

requirement.docx
I want you to read 3 articles below and start a general
discussion on
1. whether you found the chapter valuable,
2. whether you agree with the author, and
3. whether the concept is still applicable.
4. Give current examples whenever you can.
This is 3 articles in
HBR’s 10 Must Reads on Strategy, Harvard Business Review
Press, ISBN 10: 1422157989
ISBN-13: 978-1422157985
Or you can find pdf on google.
Blue Ocean Strategy
Turning Great Strategy into Great Performance
The Secrets to Successful Strategy Execution
Requiment paper: answer clearly (not too long, not too short)
each article based on the ouline- so should be 4 paragraphs for
each article, criticle thinking, no plagirism.
Page required: 3 – 5 for total depends on the answer.
International Journal of Pediatrics , Vol.2, N.4-1, Serial No.10,
October 2014 339
Review Article
http:// ijp.mums.ac.ir

The Importance of Breastfeeding in Holy Quran
Saeed Bayyenat
1
, Seyed Amirhosein Ghazizade Hashemi
2
,
Abbasali Purbafrani
3
, Masumeh Saeidi
4
, *Gholam Hasan Khodaee
5
1
Assistant Professor of Anesthesiology , Department of
Anesthesiology, Baqiyatallah University of Medical Sciences,
Tehran, Iran.
2
Assistant Professor of Otorhinolaryngology, Shahid Beheshti
University of Medical Sciences, Tehran, Iran.
3
Medical Education, Ministry of Health and Medical Education,
Tehran, Iran.
134
Students Research Committee, Faculty of Medicine, Mashhad

University of Medical Sciences, Mashhad, Iran.
5
Mashhad University of Medical Sciences, Mashhad, Iran.
Abstract
Breastfeeding is the ideal and most natural way of nurturing
infants. The importance of breastfeeding has
been proved unequivocally, and the United Nations Children's
Fund (UNICEF) and World Health
Organization (WHO) have issued guidelines to ensure
breastfeeding. More than 14 centuries is that in
Islamic teachings with the most comprehensive, most beautiful
and most powerful motivation, is raised
important points in the form of advice and education about
breastfeeding. Included in Islam
recommended every mother to breastfeed her children up to the
age of two years if the lactation period
was to be completed. Aware of these recommendations and the
usage of them, will lead to the most
efficient and effective incentives to promote breast-feeding.
Keywords: Breastfeeding, Quran, Infants.

Corresponding Author:
Gholam Hasan Khodaee, Mashhad University of Medical
Sciences, Mashhad, Iran.
Email: [email protected]
Received date: Sep 26, 2014 ; Accepted date: Sep 27, 2014
Breastfeeding in Quran
October 2014 340
Introduction
The History of Breastfeeding
1. Infants have been breast-fed since
the beginning of humanity. Only since the
20th century have reasonable alternatives to
breastfeeding become available.
2. Alternatives to breastfeeding
include:
a. Modified mammalian milk

(cow's milk based formula became available
only in the 20th century).
b. Unmodified mammalian milk (such as
cows milk or goat milk) can cause metabolic
problems in the young infant.
c. Grain or legume based beverages
- soy milk based formula (only available
recently).
- other gruels based on carbohydrates are
usually low in fat and protein and do not
support adequate infant growth.
d. Wet nurse - a woman who nurses
another's baby:
- many upper class women hired wet nurses
during various periods of history.
- infants orphaned due to maternal death
have been wet-nursed.
- women worked as wet nurses for pay.

3. Inability to keep non-human milk
clean led to very high infant mortality rates
until the 20th century. This is still true in
many parts of the developing world.
Human breast milk is uniquely composed
to meet the needs of human infants
1. It has a high concentration of lactose
(milk sugar). This is an excellent source of
carbohydrates.
2. There are 3 different categories of
proteins in human milk: whey proteins,
casein proteins, and non-protein nitrogen.
The predominant type of protein in cows
milk is the casein protein (curds). The whey
proteins which are predominant in human
milk are much easier for infants to digest.
Human milk protein is 40% casein and 60%
whey compared to 80% casein and 20%
whey protein in cows' milk.

3. Infants fed human milk tend to have
stools that are less foul smelling and softer
than those of infants who are fed cow's milk
or soymilk based formula. This is due to the
large number of Bifidobacterium and
Lactobacillus bacteria, and the resulting
lower PH in the gastrointestinal tract of
infants who are solely breast fed.
Constipation, defined as hard stools (not the
absence of a daily stool), does not occur in
healthy breast fed infants.
4. The composition of the milk of
mothers who are breastfeeding varies during
the time of the day and during the feeding.
The hind milk (latter part of a breastfeeding)
has a much higher fat content than milk
produced during the beginning portion of the
feeding.
5. The odor and/or taste of breast milk
may change depending on the mother's diet.

This may help infants get used to different
tastes.
6. More information on nutritional
factors in breast milk is found in the section
on Mature Milk Components (1-3).
Breastfeeding is the act of milk transference
from mother to baby (4) that is needed for
the survival and healthy growth of the baby
into an adult (5,6). Breastfeeding creates an
inimitable psychosocial bond between the
mother and baby (7,8), enhances modest
cognitive development (9) and it is the
underpinning of the infant’s wellbeing in the
first year of life (8,10) even into the second
year of life with appropriate complementary
foods from 6 months (11). Furthermore,
breastfeeding reduces the risk of neonatal
complications (15), respiratory and other

varieties of illnesses (13-16).
http://www.breastfeedingbasics.org/cgi-
bin/deliver.cgi/content/Anatomy/com_mature.html
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3878086/#B1
Bayyenat et al.
October 2014 341
Based on anecdotal and empirical evidence
on the benefits of breastfeeding to the
mother and baby, the World Health
Organization (WHO) (11) has recommended
2 year breastfeeding; first 6 months
exclusive breastfeeding; more than 8 times

breastfeeding of the baby per day in the first
3 months of an infant’s life. The WHO and
the United Nations Children’s Fund
(UNICEF) global effort to implement
practices that protect, promote and support
breastfeeding through the Baby-Friendly
Hospital Initiative has recorded attendant
successes (17).
Results is shown that breastfeeding has
numerous benefits both for infants and
mothers. It provides all the nutrients that
infants need for healthy development and
protects children from common childhood
illnesses such as diarrhea, asthma, lower
respiratory infections, and ear infections.
Furthermore, it is positively associated with
children's cognitive development.
Breastfeeding also benefits mothers by

lowering the risks of breast cancer, ovarian
cancer, and obesity, as well as by cutting
back on household expenses (18-23).
Breastfeeding in Eastern Mediterranean
Region
Infants should be exclusively breastfed for
the first six months of life to achieve optimal
growth, development and health. Thereafter,
to meet their evolving nutritional
requirements, infants should receive
nutritionally-adequate and safe
complementary foods while breastfeeding
continues for up to two years or beyond.
Special attention and practical support is
needed for feeding in exceptionally difficult
circumstances. WHO regional policy for
breastfeeding is to implement the Global
Strategy for Infant and Young Child Feeding

by protecting, promoting and supporting
breastfeeding and timely, adequate and safe
complementary feeding of infants and young
children. The circumstances where specific
recommendations apply include: infants less
than six months of age who are
malnourished, low birth-weight infants,
infants and children in emergencies, infants
born to HIV-positive women and children
living in special circumstances, such as
orphans and vulnerable children or infants
born to adolescent mothers. Many countries
in the WHO Eastern Mediterranean Region
report high rates (>60%) of early initiation
of breastfeeding of infants and more than
60% of infants continue to be breastfed at
one year. However, rates of exclusive
breastfeeding seem to have declined, with

only 40% or less of infants under six months
in countries of the Region being exclusively
breastfed.
Breastfeeding in European Region
The WHO European Region has one of the
lowest average proportions in the world of
children exclusively breastfed at 6 months of
age. Strong evidence shows that exclusive
breastfeeding is the natural and most
efficient method to ensure optimal child
growth and development. The theme of
World Breastfeeding Week (1–7 August
2013) is supporting mothers through peer
counselling. Although mothers may begin
well, breastfeeding rates decline sharply
over time. The proportion of children
exclusively breastfed at 3 months of age was
50% or less in 24 out of 36 countries in the

European Region that participated in
October 2014 342
national surveys in 2005–2010. Only in 1
country in the Region were more than 50%
of 6-month-olds exclusively breastfed.
Breastfeeding in Pacific Region
breastfeeding initiation within the first hour
of life is not yet optimal across several
countries. The rates in the following
countries are as follows: Samoa (88%),
Nauru (76%), Solomon Islands (75%),
Vanuatu (72%), the Marshall Islands (73%),

Mongolia (71%), Cambodia (65%), Fiji
(57%), the Philippines (54%), China (41%),
Viet Nam (40%), the Lao People’s
Democratic Republic (30%) and Tuvalu
(15%).
National surveys in 2005–2010. Only in 1
country in the Region were more than 50%
of 6-month-olds exclusively breastfed.
Breastfeeding in Pacific Region
breastfeeding initiation within the first hour
of life is not yet optimal across several
countries. The rates in the following
countries are as follows: Samoa (88%),
Nauru (76%), Solomon Islands (75%),
Vanuatu (72%), the Marshall Islands (73%),
Mongolia (71%), Cambodia (65%), Fiji
(57%), the Philippines (54%), China (41%),

Viet Nam (40%), the Lao People’s
Democratic Republic (30%) and Tuvalu
(15%).
Breastfeeding in Region of the Americas
The United Nations and governments set
eight Millennium Development Goals
(MDGs) to be reached by 2015. Protection,
promotion and support of exclusive and
continued breastfeeding can contribute to all
eight. The WHO recommends that infants
are exclusively breastfed for 6 months and
that breastfeeding continue with
complementary foods for 2 years or more.
However, in the Americas, practices are far
from optimal as well as highly variable.
Although virtually all babies initiate
breastfeeding at birth, the proportion less
than 6 months of age who are exclusively

breastfed ranges from a low of 7.7% to a
high of 68.3%. The median duration of
breastfeeding is equally variable, ranging
from a low of 6 months to a high of 21.7
months. Countries that have made tremen-
dous progress are starting to show evidence
of stagnation while in others no progress and
sometimes deterioration has been observed.
U.S National (%):
Exclusive Breastfeeding at 6 months: 16.4.
Breastfeeding in African Region
Breastfeeding has a lifelong impact on
health and survival of newborns, infants and

young children. Breast milk is the ideal food
for newborns and infants: it gives all the
nutrients they need and contains antibodies
that help protect them from common
childhood illnesses, such as diarrhoea and
pneumonia, two leading causes of mortality
in children under 5 years old in the African
Region. Proper infant and young child
feeding is key to improving child survival
http://www.paho.org/
Bayyenat et al.
October 2014 343
and promoting healthy growth and
development, thus contributing to the
attainment of Millennium Development
Goal 4 of reducing by two thirds, between
1990 and 2015, the under-five mortality rate.

WHO recommends that all infants should be
exclusively breastfed starting within one
hour of birth and for the first 6 months of
life. Exclusive breastfeeding, according to
the Innocenti Declaration, means that no
other drink or food is given to the infant.
Worldwide, the actual practice is low at
38%. after 6 months, nutritious
complementary foods should be added while
continuing to breastfeed for up to 2 years or
beyond. Globally, only about half of
children aged between 20 and 23 months are
still breastfed. Data from the African Health
Observatory shows that in the great majority
of countries of the African Region the rate
of children exclusively breastfed in the first
six months is quite low, with an average of
35% for the 2007-2012 period. WHO global

target is to increase exclusive breastfeeding
in the first 6 months to at least 50% by 2025.
Early initiation of breastfeeding in the
Region shows a similar trend (48%) between
2006 and 2011. The percentage of children
6–8 months introduced to solid, semi-solid
or soft foods is high, with a regional average
of 71% in 2011.
Breastfeeding in South-East Asia Region
Initiation of breastfeeding within one hour
of birth and exclusive breastfeeding for the
first six months of an infant’s life is a key
factor for the survival of a newborn.
Ensuring optimal breastfeeding depends on
the care and support a mother receives
during pregnancy, child birth and
immediately after delivery. Healthcare

providers play a critical role in assisting
mothers and their families to initiate and
promote breastfeeding and enable all infants
to reach the goal of survival, optimum
growth and development. In the Member
States of WHO’s South-East Asia Region an
estimated 51% of the infants are exclusively
breastfed, with a range varying from 15% to
85%. Sustained efforts are required to
enhance the breastfeeding rates further in the
countries. Nearly a million newborns die
every year in WHO’s South-East Asia
Region, many of whom can be saved by
early and exclusive breastfeeding. High
newborn mortality in this Region is one of
the reasons that the Millennium
Development Goal’s target of reducing child
mortality by two-thirds by 2015 is unlikely

to be achieved. In recognition of this
constraint, WHO promotes a package of
‘Essential Newborn Care Interventions’ that
includes breastfeeding as an important
component (24).
10 facts on breastfeeding
1.WHO recommends exclusive breastfeeding
for the first six months of life. At six months,
solid foods, such as mashed fruits and
vegetables, should be introduced to
complement breastfeeding for up to two
years or more. In addition:
one hour of birth;
as often as the child wants day and night; and
acifiers should be avoided.
2. Breast milk is the ideal food for newborns

and infants. It gives infants all the nutrients
they need for healthy development. It is safe
and contains antibodies that help protect
infants from common childhood illnesses
such as diarrhoea and pneumonia, the two
primary causes of child mortality
worldwide. Breast milk is readily available
and affordable, which helps to ensure that
infants get adequate nutrition.
http://www.who.int/about/agenda/health_development/events/in
nocenti_declaration_1990.pdf
http://www.aho.afro.who.int/en/atlas/specific-programmes-and-
services
http://www.aho.afro.who.int/en/atlas/specific-programmes-and-
services
October 2014 344
3. Breastfeeding also benefits mothers.
Exclusive breastfeeding is associated with a
natural (though not fail-safe) method of birth

control (98% protection in the first six
months after birth). It reduces risks of breast
and ovarian cancer later in life, helps women
return to their pre-pregnancy weight faster,
and lowers rates of obesity.
4. Beyond the immediate benefits for
children, breastfeeding contributes to a
lifetime of good health. Adolescents and
adults who were breastfed as babies are less
likely to be overweight or obese. They are
less likely to have type-2 diabetes and
perform better in intelligence tests.
5. Infant formula does not contain the
antibodies found in breast milk. When infant
formula is not properly prepared, there are
risks arising from the use of unsafe water
and unsterilized equipment or the potential
presence of bacteria in powdered formula.

Malnutrition can result from over-diluting
formula to "stretch" supplies. While frequent
feeding maintains breast milk supply, if
formula is used but becomes unavailable, a
return to breastfeeding may not be an option
due to diminished breast milk production.
6. An the human immunodeficiency virus
(HIV-infected) mother can pass the infection
to her infant during pregnancy, delivery and
through breastfeeding. Antiretroviral (ARV)
drugs given to either the mother or HIV-
exposed infant reduces the risk of
transmission. Together, breastfeeding and
ARVs have the potential to significantly
improve infants' chances of surviving while
remaining HIV uninfected. WHO
recommends that when HIV-infected
mothers breastfeed, they should receive

ARVs and follow WHO guidance for infant
feeding.
7. An international code to regulate the
marketing of breast-milk substitutes was
adopted in 1981. It calls for:
state the benefits of breastfeeding and the
health risks of substitutes;
-milk
substitutes;
given to pregnant women, mothers or their
families;
substitutes to health workers or facilities.
8. Breastfeeding has to be learned and
many women encounter difficulties at the
beginning. Nipple pain, and fear that there is

not enough milk to sustain the baby are
common. Health facilities that support
breastfeeding by making trained
breastfeeding counsellors available to new
mothers encourage higher rates of the
practice. To provide this support and
improve care for mothers and newborns,
there are "baby-friendly" facilities in about
152 countries thanks to the WHO-UNICEF
Baby-friendly Hospital initiative.
9. Many mothers who return to work
abandon breastfeeding partially or
completely because they do not have
sufficient time, or a place to breastfeed,
express and store their milk. Mothers need a
safe, clean and private place in or near their
workplace to continue breastfeeding.
Enabling conditions at work, such as paid

maternity leave, part-time work
arrangements, on-site crèches, facilities for
expressing and storing breast milk, and
breastfeeding breaks, can help.
10. To meet the growing needs of babies at
six months of age, mashed solid foods
should be introduced as a complement to
continued breastfeeding. Foods for the baby
can be specially prepared or modified from
family meals. WHO notes that:
decreased when starting on solids;
Bayyenat et al.
October 2014 345
cup, not in a bottle;

locally available; and
children to learn to eat solid foods (24-27).
Results
More than 14 centuries ago, before any
medical knowledge on health values and the
benefits of breastfeeding was available, Islam
recommended every mother to breastfed her
children up to the age of two years if the
lactation period was to be completed.
Breastfeeding is very clearly encouraged in
the Quran and breast feeding by the mother
to her new born infant is greatly beneficial as
science had proven, and it is mandatory in the
Quran. Allah Almighty Commanded the
mother to breast feed her child for two full

years:
"The mothers shall give such to their
offspring for two whole years, if the father
desires to complete the term. But he shall
bear the cost of their food and clothing on
equitable terms. No soul shall have a burden
laid on it greater than it can bear. No mother
shall be treated unfairly on account of her
child. Nor father on account of his child, an
heir shall be chargeable in the same way. If
they both decide on weaning, by mutual
consent, and after due consultation, there is
no blame on them. If ye decide on a foster-
mother for your offspring, there is no blame
on you, provided ye pay (the mother) what ye
offered, on equitable terms. But fear God and
know that God sees well what ye do" (28).
"And We have commended unto man

kindness toward parents. His mother beareth
him with reluctance, and bringeth him forth
with reluctance, and the bearing of him and
the weaning of him is thirty months, till,
when he attaineth full strength and reacheth
forty years, he saith: My Lord! Arouse me
that I may give thanks for the favour
wherewith Thou hast favoured me and my
parents, and that I may do right acceptable
unto Thee. And be gracious unto me in the
matter of my seed. Lo! I have turned unto
Thee repentant, and lo! I am of those who
surrender (unto Thee)" (29).
"And We have enjoined upon man
concerning his partners - His mother beareth
him in weakness upon weakness, and his
weaning is in two years - Give thanks unto
Me and unto thy parents. Unto Me is the

journeying" (30).
"Forbidden unto you are your mothers, and
your daughters, and your sisters, and your
father's sisters, and your mother's sisters,
and your brother's daughters and your
sister's daughters, and your foster-mothers,
and your foster-sisters, and your mothers-in-
law, and your step-daughters who are under
your protection (born) of your women unto
whom ye have gone in - but if ye have not
gone in unto them, then it is no sin for you
(to marry their daughters) - and the wives of
your sons who (spring) from your own loins.
And (it is forbidden unto you) that ye should
have two sisters together, except what hath
already happened (of that nature) in the past.
Lo! Allah is ever Forgiving, Merciful. (This
verse refers to foster the relationship)" (31).

"Lodge them where ye dwell, according to
your wealth, and harass them not so as to
straiten life for them. And if they are with
child, then spend for them till they bring
forth their burden. Then, if they give suck
for you, give them their due payment and
consult together in kindness; but if ye make
difficulties for one another, then let some
other woman give suck for him (the father of
the child)" (32).
http://islam.about.com/od/quran/tp/Quran.htm
October 2014 346
"On the day when ye behold it, every
nursing mother will forget her nursling and
every pregnant one will be delivered of her
burden, and thou (Muhammad) wilt see

mankind as drunken, yet they will not be
drunken, but the Doom of Allah will be
strong (upon them)" (33).
"And We inspired the mother of Moses,
saying: Suckle him and, when thou fearest
for him, then cast him into the river and fear
not nor grieve. Lo! We shall bring him back
unto thee and shall make him (one) of Our
messengers" (34).
"And We had before forbidden foster-
mothers for him, so she said: Shall I show
you a household who will rear him for you
and take care of him?" (35).
Conclusion
Breastfeeding is the ideal and most
natural way of nurturing infants. The
importance of breastfeeding has been proved
unequivocally, and UNICEF and WHO have

issued guidelines to ensure breastfeeding.
Breastfeeding is very clearly encouraged in
the Quran. Breast feeding had been proven
to be extremely important to the infant's
health and body growth. It is so amazing
that Allah Almighty's Divine Claims in the
Noble Quran are always scientifically
proven to be accurate and Greatly beneficial
to humanity. It is now very evident why
breastfeeding is to be done for two complete
years, as illustrated in the Quran. Modern
science has further highlighted the
miraculous recommendation of the Quran
regarding this matter, that was revealed
more than one thousand four hundred years
ago. Allaah The Almighty Says (what
means): "We will show them Our signs in
the horizons and within themselves until it

becomes clear to them that it is the truth. But
is it not sufficient concerning your Lord that
He is, over all things, a Witness?" (36).
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26. American Academy of Pediatrics. Executive
summary, 2012 breastfeeding and the use of

human milk. Available at:
http://www2.aap.org/breastfeeding/files/pdf/Bre
astfeeding2012ExecSum.pdf. [accessed on 15
June 2013]
27.Eidelman AI. Breastfeeding and the use of
human milk: an analysis of the American
Academy of Pediatrics 2012 Breastfeeding
Policy Statement. Breastfeed Med 2012;7:323–4.
28. The Noble Quran, Chapter 2: Verse 233.
32. The Noble Quran, Chapter 65:Verse 6.
http://www.unicef.org/programme/breastfeeding/innocenti.htm
http://www.unicef.org/programme/breastfeeding/innocenti.htm
http://www.oecd.org/els/soc/oecdfamilydatabase.htm
http://www.oecd.org/els/soc/oecdfamilydatabase.htm

http://www.oecd.org/els/family/43136964.pdf
http://www.who.int/nutrition/topics/exclusive_breastfeeding/en
http://www.who.int/nutrition/topics/exclusive_breastfeeding/en
http://www2.aap.org/breastfeeding/files/pdf/Breastfeeding2012
ExecSum.pdf
http://www2.aap.org/breastfeeding/files/pdf/Breastfeeding2012
ExecSum.pdf
New Evidence on Breastfeeding and Postpartum Depression:
The
Importance of Understanding Women’s Intentions
Cristina Borra • Maria Iacovou • Almudena Sevilla
Published online: 21 August 2014
� The Author(s) 2014. This article is published with open
access at Springerlink.com
Abstract This study aimed to identify the causal effect of
breastfeeding on postpartum depression (PPD), using data
on mothers from a British survey, the Avon Longitudinal
Study of Parents and Children. Multivariate linear and
logistic regressions were performed to investigate the
effects of breastfeeding on mothers’ mental health measured
at 8 weeks, 8, 21 and 32 months postpartum. The estimated
effect of breastfeeding on PPD differed according to whe-

ther women had planned to breastfeed their babies, and by
whether they had shown signs of depression during preg-
nancy. For mothers who were not depressed during preg-
nancy, the lowest risk of PPD was found among women who
had planned to breastfeed, and who had actually breastfed
their babies, while the highest risk was found among women
who had planned to breastfeed and had not gone on to
breastfeed. We conclude that the effect of breastfeeding on
maternal depression is extremely heterogeneous, being
mediated both by breastfeeding intentions during pregnancy
and by mothers’ mental health during pregnancy. Our results
underline the importance of providing expert breastfeeding
support to women who want to breastfeed; but also, of
providing compassionate support for women who had
intended to breastfeed, but who find themselves unable to.
Keywords Breastfeeding � Mental health � Edinburgh
postnatal depression scale � Child development � ALSPAC
Introduction

Approximately 13 % of women experience postpartum
depression (PPD) within the 14 weeks after giving birth
[1]. If the antenatal period is also considered, as many as
19 % of women experience a depressive episode during
pregnancy or the first 3 months postpartum [2]. Post-natal
depression has an immediate impact on mothers and carries
long-term risks for mothers’ future mental health [3, 4]; it
also has significant negative effects on the cognitive, social
and physical development of their children [5, 6]. In
addition, post-natal depression involves substantial eco-
nomic costs, in terms of costs to healthcare systems [7] and
losses in productivity via maternal absenteeism from work,
premature retirement, and long-term unemployment [8].
The effect of breastfeeding on the risk of PPD is not well
understood. Several studies have demonstrated an associ-
ation between longer breastfeeding durations and a lower
prevalence of PPD [9–14]. However, other studies have
suggested the opposite, namely that breastfeeding mothers

are at increased risk of PPD [15, 16]; or found no associ-
ation [17, 18]. Of those studies which suggest beneficial
effects from breastfeeding, several have relied on small
samples, and few have controlled for potential confounders
such as socioeconomic factors (maternal education, family
income, marital status), the quality of relationships (marital
C. Borra (&)
Facultad de Ciencias Económicas y Empresariales, University of
Seville, Ramón y Cajal 1, 41018 Seville, Spain
e-mail: [email protected]
M. Iacovou
Department of Sociology, University of Cambridge, Free School
Lane, Cambridge CB2 3RQ, UK
M. Iacovou
ISER, University of Essex, Colchester CO4 3SQ, UK
A. Sevilla
Queen Mary University of London, Mile End Road,
London E1 4NS, UK

123
Matern Child Health J (2015) 19:897–907
DOI 10.1007/s10995-014-1591-z
stability, social networks), and stressful life events [19, 20].
Thus, it has been extremely difficult to identify whether the
observed relationships are causal, as opposed to arising
because breastfeeding is more likely to be practiced by
mothers whose characteristics are themselves associated
with a lower risk of depression [21–23]. Additionally, as Ip
et al. [24] have pointed out, most existing studies have not
controlled for pre-existing mental health conditions.
Thus, the extent to which breastfeeding influences
mental health, as opposed to mental health driving the
incidence and duration of breastfeeding, has not been clear.
The aim of the current study is to examine explicitly
whether breastfeeding affects maternal mental health out-
comes. Specifically, we examine the hypothesis that the

relationship between breastfeeding and maternal mental
health is mediated by the mother’s intention to breastfeed.
The relationship between breastfeeding and maternal
mental health may be driven by biological factors, such as
differences in hormone levels between breast- and formula-
feeding mothers [25]; if maternal mental health is also
affected by mothers’ feelings of success or failure in
relation to their original plans and aspirations, we may
expect the intention to breastfeed to play a crucial role.
Data and Methods
Data and Key Variables
This research is based on data from the Avon Longitudinal
Survey of Parents and Children (ALSPAC), a survey of
around 14,000 children born in the Bristol area of England
in the early 1990s [26]. Mothers were recruited into the
survey by doctors, at the point when they first reported their
pregnancy. Data were collected by questionnaires admin-
istered to both parents at four points during pregnancy and

at several stages following birth.
Details of all data collected in the ALSPAC survey are
available on the study website through a fully searchable
data dictionary [27]. Our study obtained ethical approval
from the ALSPAC Law and Ethics Committee and the
Local Research Ethics Committees.
We used a sample of mothers whose children form the
‘‘core sample’’ of ALSPAC. This sample consists of 14,541
pregnancies which resulted in 14,676 known foetuses;
there were 14,062 live births, and 13,988 babies surviving
to 1 year. We employed a maximizing strategy with
respect to sample size, using as many observations as
possible to analyse each outcome-effect dyad. Sample sizes
thus vary slightly between regressions. The experiences of
mothers and babies following pre-term births, or separation
due to NICU care, may differ from the experiences of other
mothers and babies. We do not exclude these mother/baby
pairs from our sample, but have checked that our results do

not change if they are excluded; these results are available
from the authors on request.
As a measure of depression, the Edinburgh Postnatal
Depression Scale (EPDS) was used. The EPDS, designed
by Cox et al. [28] to screen for PPD, was collected during
pregnancy at 18 and 32 weeks’ gestation, and post-natally
at 8 weeks, and 8, 18, and 33 months. The EPDS is the
most frequently used screening questionnaire for PPD; the
EPDS is sensitive to changes in depression over time, and
has been demonstrated to be a valid and reliable tool for the
measurement of both postpartum and antenatal depression
[29, 30]. The instrument consists of 10 questions, each with
four possible answers describing symptoms of increasing
severity or duration; aggregate scores on the EPDS range
from 0 to 30. The authors of the EPDS have suggested that
women should be referred to a mental health specialist if
they score 13 or higher during the post-partum period [31]
and 15 or more during pregnancy [32]. Therefore, we

constructed indicators of depressive symptomatology,
defined as EPDS [14 in pre-natal assessments and EPDS
[12 in postpartum assessments.
Mothers were asked during pregnancy how they intended to
feed their babies for the first 4 weeks. Following their child’s
birth, they were asked at several points how they were actually
feeding, and the ages at which infant formula and solid foods
were introduced. Using this information, we computed seven
binary indicators: (1) initiation (putting the baby to the breast
at least once); (2–4) any breastfeeding for at least 1, 2 and
4 weeks respectively; and (5–7) exclusive breastfeeding for at
least 1, 2 and 4 weeks respectively. We also computed two
continuous indicators: total duration of breastfeeding and total
duration of exclusive breastfeeding; results for these contin-
uous indicators are similar to results obtained using the binary
indicators, and are available from the authors on request.
Analysis
We estimate multivariate logistic regressions, presenting
odds ratios and 95 % confidence intervals. All hypotheses

are tested using two-tailed p values 0.05.
We present estimates from three specifications. Model A
controls only for the child’s sex and parental education.
Model B additionally controls for other socio-demographic
variables, and information on pregnancy and birth. Finally,
Model C includes information on the mother’s physical and
mental health, including antenatal EPDS assessments,
together with factors relating to the quality of interpersonal
relationships and stressful life events (see Table 6 in the
Appendix for precise definitions of these variables). Thus,
Model A provides a first approximation to the associations of
interest, Model B estimates these relationships net of a range
of potential confounders, while Model C aims to estimate
898 Matern Child Health J (2015) 19:897–907
123
causal relationships as accurately as possible by eliminating
potential reverse causality arising from the fact that previ-

ously depression-prone mothers may be less likely to decide
to breastfeed, or to breastfeed for shorter durations.
After conducting this analysis for the whole sample, we
split the sample into mothers who were, and who were not,
depressed during pregnancy; for each group, we examine
differences in outcomes between women who had planned
to breastfeed, and women who had not.
Results
Study Variables
Descriptive statistics for variables of interest are shown in
Table 1. The prevalence of antenatal depression, using a
cut-off of EPDS [14, is 7 % at 18 weeks’ pregnancy and
8 % at 32 weeks, similar to rates reported in previous
studies [33]. Rates of PPD were between 9 and 12 %, also
similar to results from former analyses [34].
80 % of mothers in this sample initiated breastfeeding
and 74 % breastfed for 1 week or more. By 4 weeks only
56 % of mothers were breastfeeding at all and only 43 %
were breastfeeding exclusively. The percentages of women

feeding for the different durations considered are shown in
Table 1; mean durations for breastfeeding and exclusive
breastfeeding are also shown.
Table 2 shows the raw relationships between postnatal
depressive symptomatology, and (a) prenatal depression,
and (b) different measures of breastfeeding duration. A
significant degree of correlation is present between post-
natal and antenatal EPDS scores; a clear negative rela-
tionship also exists between symptoms of maternal
depression measured at 8 weeks, and breastfeeding dura-
tion. The association between depression and breastfeeding
is always negative, but generally statistically insignificant,
at 8, 21 and 33 months.
Sample Characteristics
Socio-demographic characteristics for sample members are
presented in Table 7 in the Appendix. The mean age of
participants was 28.3 years (SD = 4.8). 95 % of the women
were white, 86 % were married, 13 % had university

degrees, while a further 22 % had high school qualifications
at age 18 (‘‘A’’ levels); and 74 % owned the house in which
they lived. In relation to pregnancy and birth, 64 % felt
usually well, 55 % percent were working while pregnant,
45 % were primiparous, and only 9 % delivered via Cesar-
ean section. The average gestational age was 39.5 weeks
(SD = 1.8). 48 % of mothers and 37 % of fathers had
themselves been breastfed as babies. 28 % of the pregnan-
cies were unplanned; 15 % of mothers had lived through
their own parents’ divorce before their eighteenth birthday.
Table 3 presents the results of logistic regressions esti-
mating the effect of breastfeeding on PPD.
As explained earlier, three models are estimated: Model
A controls only for the child’s sex and parental education;
Model B controls in addition for a wide range of socio-
economic and demographic factors, plus information on
pregnancy and birth; and Model C also controls for
mother’s health (including mental health) in pregnancy,

relationship quality and stressful life events.
We consider four different outcomes: EPDS [12 mea-
sured at 8 weeks, 8, 21 and 33 months postpartum. For
each model/outcome dyad, the model is estimated seven
times, for seven different measures of breastfeeding (ini-
tiation; any breastfeeding for at least 1, 2 and 4 weeks; and
exclusive breastfeeding for at least 1, 2 and 4 weeks).
Thus, each coefficient in Table 3 comes from a separate
regression.
At 8 weeks postpartum, we observe a pronounced
relationship between breastfeeding and PPD, under both
Table 1 Descriptive statistics for variables of interest
N mean s.d.
Maternal mental health during pregnancy
At risk of antenatal depression, 18 weeks
(EPDS [14)
10,904 7 % (0.3)
At risk of antenatal depression, 32 weeks
(EPDS [14)

11,305 8 % (0.3)
Maternal mental health post-partum
At risk of postpartum depression, 8 weeks
(EPDS [12)
10,756 10 % (0.3)
At risk of postpartum depression, 8 months
(EPDS [12)
10,345 8 % (0.3)
At risk of postpartum depression,
21 months (EPDS [12)
9,605 10 % (0.3)
At risk of postpartum depression,
33 months (EPDS [12)
8,985 12 % (0.3)
Breastfeeding
Mother intended to breastfeed 11,547 65 % (0.5)
Initiated breastfeeding 11,012 80 % (0.4)
Breastfed for 1 week 10,668 74 % (0.4)
Breastfed for 2 weeks 10,680 68 % (0.5)
Breastfed for 4 weeks 10,972 56 % (0.5)

Duration of any breastfeeding (months) 8,317 5.17 (4.7)
Exclusively breastfed for 1 week 10,668 64 % (0.5)
Exclusively breastfed for 2 weeks 10,680 60 % (0.5)
Exclusively breastfed for 4 weeks 10,972 43 % (0.5)
Duration of exclusive breastfeeding
(months)
8,726 1.31 (1.2)
Figures in the middle column are means in the case of
continuous
variables, and percentages of the sample in the case of
dichotomous
variables
Matern Child Health J (2015) 19:897–907 899
123
Models A and B. The odds ratios for these models indicate
that longer durations of breastfeeding are associated with
larger reductions in the risk of PPD, and exclusive
breastfeeding is associated with a larger reduction than any

breastfeeding. However, under Model C, when we control
for mothers’ health during pregnancy, these effects largely
disappear; the only significant relationship which remains
comes from exclusive breastfeeding for 4 weeks or longer
(OR 0.81, 95 % CI 0.68, 0.97).
The relationship between breastfeeding and PPD is also
weaker, the later the EPDS score is assessed; at 8 months
postpartum and thereafter, most of the estimated coeffi-
cients are not significantly different from zero (indeed, a
few of the results are counter-intuitive, suggesting that
breastfeeding may be positively related to an increased risk
of depression measured at 33 months postpartum).
Thus, for the sample as a whole, our results demonstrate little
evidence for a causal relationship between breastfeeding and the
risk of PPD. In the next section, we investigate the possibility
that the relationship between breastfeeding and depression
varies according to two factors: whether mothers were assessed
as at risk of depression during pregnancy, and whether they had

been planning to breastfeed their babies. We show that the
relationship between breastfeeding and depression is indeed
highly heterogeneous, and that this fact explains why little
effect
is found when considering women as a homogeneous group.
Heterogeneous Effects by Mental Health During
Pregnancy and Breastfeeding Intention
We re-estimated Model C separately for mothers who
were, and who were not, depressed during pregnancy (in
terms of having a score EPDS [14 at least once during
pregnancy). As before, we estimated regressions separately
for each time at which postnatal depression was assessed
(8 weeks, and 8, 21 and 33 months postpartum); for each
of these time periods, we estimated seven models, one for
each discrete measure of breastfeeding. However, instead
of simply controlling for whether or not mothers breastfed
for the relevant duration, we identify four groups of
women, by whether they had planned to breastfeed, and
whether they had actually breastfed for the relevant dura-

tion. These four groups are:
• Mothers who had not planned to breastfeed, and who
did not breastfeed (reference group)
• Mothers who had not planned to breastfeed, but who
did actually breastfeed
• Mothers who had planned to breastfeed, but who did
not actually breastfeed
• Mothers who had planned to breastfeed, and who did
actually breastfeed
Each regression thus generates three coefficients of
interest; these coefficients are expressed as odds ratios,
relative to the reference group.
Table 4 presents results for mothers without prenatal
depression symptoms. Column (2) displays odds ratios and
confidence intervals for mothers who did not plan to
breastfeed, but who did actually breastfeed; column (3)
indicates whether these mothers are significantly different
from the mothers in the reference group.
Column (4) presents odds ratios for mothers who planned
to breastfeed but who did not breastfeed for the relevant

duration; Column (5) present odds ratios for mothers who
Table 2 Raw correlations between study variables
Postpartum EPDS scores
Postnatal EPDS [12 Postnatal EPDS [12 Postnatal EPDS [12
Postnatal EPDS [12
at 8 weeks at 8 months at 21 months at 33 months
Maternal mental health during pregnancy
Antenatal EPDS [14 at 18 weeks 0.279*** 0.220*** 0.216***
0.207***
Antenatal EPDS [14 at 32 weeks 0.350*** 0.309*** 0.288***
0.271***
Breastfeeding measures
Initiated breastfeeding -0.034** -0.027* -0.018 -0.018
Breastfed for 1 week or more -0.037** -0.021 -0.019 -0.015
Breastfed for 2 weeks or more -0.038** -0.023 -0.015 -0.010
Breastfed for 4 weeks or more -0.037** -0.011 -0.005 -0.005
Duration of any breastfeeding -0.044*** -0.021 -0.020 -0.009
Exclusively breastfed for 1 week or more -0.041*** -0.019 -
0.023 -0.022
Exclusively breastfed for 2 weeks or more -0.040*** -0.033** -
0.018 -0.026*
Exclusively breastfed for 4 weeks or more -0.052*** -0.021 -
0.016 -0.013

Duration of exclusive breastfeeding -0.036** -0.025 -0.021 -
0.014
P values are indicated by asterisks, with * P 0.05, ** P 0.01,
*** P 0.001
123
planned to breastfeed, and who did breastfeed for the rele-
vant duration. Column (6) indicates whether the odds ratios
in Column (4) and (5) are significantly different from each
other. Thus, the test results in Column (3) indicate whether
breastfeeding makes a difference in the case of women who
did not originally plan to breastfeed, while the tests in Col-
umn (6) indicate whether breastfeeding makes a difference in
the case of mothers who had planned to breastfeed.
The strongest result from Table 4 is that breastfeeding is
strongly associated with a lower risk of depression at
Table 3 Results from logistic regressions: effects of
breastfeeding on postpartum depression

Model A
Adjusted OR
[95 % CI]
Model B
Adjusted OR
[95 % CI]
Model C
Adjusted OR
[95 % CI]
Dependent variable: EPDS [12 at 8 weeks
Breastfeeding initiated 0.87 [0.74,1.03] 1.06 [0.88,1.27] 1.1
[0.89,1.37]
Any b/f, 1 week ? 0.8 [0.69,0.93]** 0.95 [0.80,1.13] 1.08
[0.88,1.33]
Any b/f, 2 weeks ? 0.83 [0.71,0.96]* 0.93 [0.78,1.09] 0.98
[0.81,1.19]
Any b/f, 4 weeks ? 0.77 [0.67,0.89]*** 0.81 [0.70,0.95]** 0.88
[0.74,1.06]
Exclusive b/f, 1 week ? 0.8 [0.70,0.92]** 0.91 [0.78,1.06] 0.99
[0.82,1.19]
Exclusive b/f, 2 weeks ? 0.78 [0.68,0.90]*** 0.85 [0.73,0.99]*
0.89 [0.74,1.06]

Exclusive b/f, 4 weeks ? 0.73 [0.64,0.85]*** 0.75
[0.64,0.88]*** 0.81 [0.68,0.97]*
N 10,509–10,546 10,393–10,428 9,722–9,757
Dependent variable: EPDS [12 at 8 months
[0.79,1.24]
Any b/f, 1 week ? 0.9 [0.76,1.07] 1.04 [0.86,1.25] 1.15
[0.93,1.43]
Any b/f, 2 weeks ? 0.88 [0.75,1.03] 0.98 [0.82,1.17] 1.02
[0.84,1.25]
Any b/f, 4 weeks ? 0.89 [0.76,1.04] 0.95 [0.81,1.13] 1.05
[0.87,1.28]
Exclusive b/f, 1 week ? 0.92 [0.79,1.07] 1.02 [0.86,1.21] 1.12
[0.92,1.36]
Exclusive b/f, 2 weeks ? 0.83 [0.71,0.97]* 0.9 [0.76,1.06] 0.93
[0.77,1.12]
Exclusive b/f, 4 weeks ? 0.86 [0.74,1.00] 0.9 [0.76,1.06] 1.02
[0.84,1.23]
N 10,080–10,116 9,258–9,999 9,354–9,388
[0.87,1.37]
Any b/f, 1 week ? 0.97 [0.82,1.15] 1.14 [0.94,1.38] 1.26
[1.02,1.56]*

Any b/f, 2 weeks ? 1 [0.86,1.18] 1.11 [0.93,1.33] 1.19
[0.97,1.46]
Any b/f, 4 weeks ? 0.99 [0.85,1.14] 1.03 [0.87,1.21] 1.15
[0.95,1.38]
[0.98,1.44]
[0.92,1.33]
[0.88,1.27]
N 9,370–9,406 9,258–9,929 8,704–8,737
Breastfeeding initiated 1.04 [0.88,1.24] 1.22 [1.01,1.48]* 1.22
[0.98,1.51]
Any b/f, 1 week ? 1.01 [0.86,1.18] 1.16 [0.97,1.39] 1.27
[1.04,1.55]*
Any b/f, 2 weeks ? 1.02 [0.87,1.18] 1.13 [0.95,1.33] 1.19
[0.99,1.44]
Any b/f, 4 weeks ? 1.01 [0.88,1.16] 1.07 [0.92,1.25] 1.17
[0.98,1.39]
[0.92,1.30]
[0.84,1.18]

[0.93,1.29]
N 8,704–8,805 8,676–8,706 8,172–8,202
Coefficients are expressed as odds ratios and 95 % confidence
intervals. Each estimated coefficient comes from a different
regression. Model A
controls for the child’s sex and parental education. Model B
additionally controls for pregnancy and birth information; child
characteristics at
birth; demographic and socio-economic variables; and
breastfeeding attitudes. Model C also controls for mother’s
health in pregnancy, inter-
personal relationships, and stressful life events (see Table 6 in
the Appendix). Sample sizes vary slightly between regressions;
the range of N is
given in each panel
P values are indicated by asterisks, with * P 0.05, ** P 0.01,
*** P 0.001
123
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A
n
y
b
/f
,
4
w
e
e
k
s
?
–
1
.2
6
[0
.8
2
,
1
.9
4
]
1

.3
1
[0
.9
6
,
1
.7
8
]
0
.6
1
[0
.3
7
,
1
.0
1
]
*
*
E
x

c
lu
si
v
e
b
/f
,
1
w
e
e
k
?
–
1
.3
4
[0
.9
1
,
1
.9
7
]

1
.4
5
[1
.0
0
,
2
.0
9
]
0
.5
8
[0
.3
5
,
0
.9
5
]
*
*

E
x
c
lu
si
v
e
b
/f
,
2
w
e
e
k
s
?
–
1
.3
0
[0
.8
6
,
1
.9

6
]
1
.4
1
[1
.0
1
,
1
.9
6
]
0
.5
8
[0
.3
5
,
0
.9
6
]

*
*
E
x
c
lu
si
v
e
b
/f
,
4
w
e
e
k
s
?
–
1
.2
6
[0
.7
4
,

2
.1
4
]
1
.2
2
[0
.9
3
,
1
.5
9
]
0
.6
6
[0
.3
7
,
1
.1

7
]
*
E
P
D
S
[
1
2
a
t
8
m
o
n
th
s
(N
=
8
,3
0
0
–
8

,3
3
4
)
B
re
a
st
fe
e
d
in
g
in
it
ia
te
d
–
0
.7
5
[0
.5
1
,

1
.0
9
]
1
.3
7
[0
.6
2
,
3
.0
3
]
1
.0
9
[0
.4
6
,
2
.5

5
]
A
n
y
b
/f
,
1
w
e
e
k
?
–
0
.8
9
[0
.5
9
,
1
.3
5
]

1
.0
2
[0
.5
7
,
1
.8
4
]
1
.3
7
[0
.6
9
,
2
.7
2
]
A
n
y

b
/f
,
2
w
e
e
k
s
?
–
0
.8
7
[0
.5
6
,
1
.3
6
]
1
.4
7

[0
.9
7
,
2
.2
4
]
0
.9
2
[0
.5
2
,
1
.6
3
]
A
n
y
b
/f
,

4
w
e
e
k
s
?
–
0
.8
0
[0
.4
7
,
1
.3
4
]
1
.3
2
[0
.9
5
,

1
.8
5
]
1
.1
3
[0
.6
2
,
2
.0
3
]
E
x
c
lu
si
v
e
b
/f
,

1
w
e
e
k
?
–
1
.0
0
[0
.6
4
,
1
.5
5
]
1
.3
9
[0
.9
4
,

2
.0
6
]
0
.9
5
[0
.5
5
,
1
.6
6
]
E
x
c
lu
si
v
e
b
/f
,
2

w
e
e
k
s
?
–
0
.7
7
[0
.4
7
,
1
.2
6
]
1
.5
9
[1
.1
3
,

2
.2
4
]
0
.9
3
[0
.5
3
,
1
.6
6
]
E
x
c
lu
si
v
e
b
/f
,
4

w
e
e
k
s
?
–
0
.6
6
[0
.3
3
,
1
.3
1
]
1
.3
0
[0
.9
7
,

1
.7
3
]
1
.4
9
[0
.7
2
,
3
.0
8
]
E
P
D
S
[
1
2
a
t
2

1
m
o
n
th
s
(N
=
7
,7
5
1
–
7
,7
8
7
)
B
re
a
st
fe
e
d
in
g

in
it
ia
te
d
–
1
.1
6
[0
.8
2
,
1
.6
4
]
1
.6
7
[0
.8
0
,
3

.4
8
]
0
.5
6
[0
.2
6
,
1
.2
1
]
A
n
y
b
/f
,
1
w
e
e
k

?
–
1
.4
4
[1
.0
0
,
2
.0
8
]
*
0
.8
7
[0
.4
9
,
1
.5
5
]

0
.9
5
[0
.5
0
,
1
.8
1
]
A
n
y
b
/f
,
2
w
e
e
k
s
?
–
1

.6
2
[1
.1
2
,
2
.3
6
]
*
1
.1
8
[0
.7
7
,
1
.8
0
]
0
.6
4

[0
.3
8
,
1
.0
8
]
A
n
y
b
/f
,
4
w
e
e
k
s
?
–
1
.6
1
[1

.0
7
,
2
.4
3
]
*
1
.1
6
[0
.8
4
,
1
.5
9
]
0
.6
1
[0
.3
8

,
1
.0
0
]
*
E
x
c
lu
si
v
e
b
/f
,
1
w
e
e
k
?
–
1
.4

9
[1
.0
2
,
2
.1
8
]
*
1
.0
0
[0
.6
8
,
1
.4
8
]
0
.8
0
[0

.4
8
,
1
.3
3
]
E
x
c
lu
si
v
e
b
/f
,
2
w
e
e
k
s
?
–
1
.3

4
[0
.9
0
,
2
.0
1
]
1
.0
8
[0
.7
7
,
1
.5
2
]
0
.7
9
[0

.4
8
,
1
.2
9
]
E
x
c
lu
si
v
e
b
/f
,
4
w
e
e
k
s
?
–
1
.3

2
[0
.7
9
,
2
.2
0
]
1
.0
7
[0
.8
2
,
1
.4
0
]
0
.7
7
[0

.4
4
,
1
.3
4
]
E
P
D
S
[
1
2
a
t
3
3
m
o
n
th
s
(N
=
7

,3
0
0
–
7
,3
3
0
)
B
re
a
st
fe
e
d
in
g
in
it
ia
te
d
–
1
.1

2
[0
.8
1
,
1
.5
5
]
1
.3
2
[0
.6
3
,
2
.7
5
]
0
.9
2
[0
.4

2
,
1
.9
8
]
A
n
y
b
/f
,
1
w
e
e
k
?
–
1
.2
4
[0
.8
9
,

1
.7
4
]
1
.2
7
[0
.7
9
,
2
.0
6
]
0
.8
7
[0
.5
0
,
1
.5

0
]
A
n
y
b
/f
,
2
w
e
e
k
s
?
–
1
.4
5
[1
.0
2
,
2
.0
5

]
*
1
.6
0
[1
.1
1
,
2
.3
2
]
0
.6
2
[0
.3
9
,
0
.9
9
]
*

*
A
n
y
b
/f
,
4
w
e
e
k
s
?
–
1
.2
3
[0
.8
3
,
1
.8
2
]

1
.2
8
[0
.9
6
,
1
.7
1
]
0
.8
7
[0
.5
5
,
1
.3
8
]
E
x
c

lu
si
v
e
b
/f
,
1
w
e
e
k
?
–
1
.3
1
[0
.9
1
,
1
.8
7
]

1
.5
4
[1
.1
1
,
2
.1
4
]
0
.6
6
[0
.4
2
,
1
.0
4
]
*
*
E

x
c
lu
si
v
e
b
/f
,
2
w
e
e
k
s
?
–
1
.1
5
[0
.7
8
,
1
.6

8
]
1
.5
9
[1
.1
8
,
2
.1
3
]
0
.6
8
[0
.4
3
,
1
.0
7
]
*

*
E
x
c
lu
si
v
e
b
/f
,
4
w
e
e
k
s
?
–
1
.0
5
[0
.6
4
,

1
.7
3
]
1
.2
5
[0
.9
7
,
1
.5
9
]
1
.0
2
[0
.6
0
,
1
.7
5

]
E
a
c
h
ro
w
p
re
se
n
ts
a
se
t
o
f
th
re
e
c
o
e
ffi
c
ie

n
ts
fr
o
m
th
e
sa
m
e
re
g
re
ss
io
n
;
th
e
se
a
re
e
x
p
re

ss
e
d
a
s
o
d
d
s
ra
ti
o
s
re
la
ti
v
e
to
th
e
re
fe
re
n

c
e
g
ro
u
p
,
w
it
h
9
5
%
c
o
n
fi
d
e
n
c
e
in
te
rv
a
ls

.
T
h
e
c
o
e
ffi
c
ie
n
ts
in
e
a
c
h
ro
w
c
o
m
e
fr
o
m

a
d
if
fe
re
n
t
re
g
re
ss
io
n
.
M
o
d
e
l
C
is
e
st
im
a
te

d
,
c
o
n
tr
o
ll
in
g
fo
r
a
ll
v
a
ri
a
b
le
s
in
T
a
b
le

6
.S
a
m
p
le
si
z
e
s
v
a
ry
sl
ig
h
tl
y
b
e
tw
e
e
n
re
g

re
ss
io
n
s;
th
e
ra
n
g
e
o
f
N
is
g
iv
e
n
in
e
a
c
h
p
a

n
e
l
P
v
a
lu
e
s
a
re
in
d
ic
a
te
d
b
y
a
st
e
ri
sk
s,
w

it
h
*
P

0
.0
5
,
*
*
P

0
.0
1
,
*
*
*
P

0
.0

0
1
123
8 weeks postpartum, for women who had planned to
breastfeed. The odds ratios in Column 4 are all well over 1,
while the odds ratios in Column 5 are all well below 1; the
differences between the two are statistically significant at
the 1 % level or better for the first six measures of
breastfeeding, and significant at the 5 % level for the
remaining measure. The effects are smaller for later
assessment periods. At 8 and 21 months, the odds ratios in
Column 5 are lower than the odds ratios in Column 4 in
almost all cases; however, the differences are not statisti-
cally significant. At 33 months, the differences are larger
again, and are significant at the 1 % level for three of the
seven measures of breastfeeding.
Interestingly, among the group of mothers who had not

planned to breastfeed, the risk of depression was higher among
women who went on to breastfeed. These differences are
statistically significant for depression measured at 21 months,
the largest being for any breastfeeding for 2 weeks on EPDS at
21 months (OR 1.62; 95 % CI 1.12, 2.36); at 8 weeks and
33 months the coefficients are all positive, though not gen-
erally significant at the 5 % level). To test whether our results
were driven by a few mothers with very severe depressive
symptoms, we repeated the analysis excluding those mothers
with EPDS scores of 20 or more (the cut-off used in general
practitioners’ guidelines [35] ); the results were virtually the
same. We also investigated whether the effects depended on
whether the mother was primiparous or multiparous, as sug-
gested by [36]; again, the results were not affected.
Results for mothers who had been assessed as at risk of
depression during pregnancy are shown in Table 5. For this
group, results are less well defined, at least in part because of
the smaller sample size. Our findings suggest that among

women who had planned to breastfeed, breastfeeding is
associated with a lower risk of PPD (as for mothers not
depressed during pregnancy, although with a much smaller
effect). However, for previously depressed mothers, there
may also be a protective effect from breastfeeding when
mothers had not planned to breastfeed. These results should
be interpreted with caution: the only significant effect was
found on EPDS measured at 8 weeks and for at least 4 weeks’
exclusive breastfeeding (OR 0.42; 95 % CI 0.20, 0.90).
Discussion
The aim of this study was to examine whether breast-
feeding influenced the risks of postnatal depression. This
study extends previous research by using a large longitu-
dinal dataset; controlling for a large set of socioeconomic,
relational, and psychosocial confounders; measuring
maternal mood at different time points both before and
after delivery; and utilising several measures of breast-
feeding initiation, duration, and exclusivity.

We found that the effect of breastfeeding on maternal
mood differed by both maternal mental health during preg-
nancy; and whether mothers intended to breastfeed. To our
knowledge, this study is the first to document this result.
For the majority of mothers who did not show symptoms
of depression before birth, breastfeeding decreased the risk
of PPD among mothers who had intended to breastfeed, but
increased the risk of PPD among mothers who had not
intended to breastfeed.
We also found that the beneficial effects of breastfeed-
ing were strongest at 8 weeks after birth, and that the
association was weaker at 8 months and onwards. This
finding is in line with the findings of the only other lon-
gitudinal research in this area [37] which significant effects
at 6 weeks but not at 12 weeks postpartum. Our results are
nevertheless important, because of the established rela-
tionship between depression, even in the very early post-
partum period, and maternal-infant bonding [38].

Estimates for the smaller group of mothers who had
shown signs of depression during pregnancy were less
precise, but differed from the estimates for non-depressed
women in two important ways. The protective effects of
breastfeeding as planned were smaller for women who had
been depressed during pregnancy; but exclusive breast-
feeding for 4 weeks appeared to exercise a protective effect
for this group, which it did not do for the women who had
not been depressed in pregnancy.
We recognize several limitations in our analyses.
Although we employ the most commonly used measure of
depressive symptomatology, we acknowledge that includ-
ing a clinical diagnosis of antenatal and PPD would have
increased the value of our findings. Also, misclassification
bias may arise when relying on self-report methods to
assess breastfeeding outcomes. Thirdly, even though we
use a large population-based sample with low loss to fol-
low-up, sampling bias resulting from the voluntary nature

of participation in the survey could have influenced results.
For instance, we acknowledge a shortfall in the numbers of
ethnic minority mothers that may limit the generalizability
of the results. Finally, even though we control for many
more potential confounders than any other study on the
subject, there may remain some unobserved factor, for
example aspects of maternal IQ or personality, which could
affect the results.
In summary, the effect of breastfeeding on maternal
depression symptoms was found to be highly heteroge-
neous and, crucially, mediated by breastfeeding intentions
during pregnancy. Our most important finding relates to the
majority of mothers who were not depressed during preg-
nancy, and who planned to breastfeed their babies. For
these mothers, breastfeeding as planned decreased the risks
of PPD, while not being able to breastfeed as planned
increased the risks. These findings have implications for

123
T
a
b
le
5
R
e
su
lt
s
fr
o
m
lo
g
is
ti
c
re
g
re

ss
io
n
s:
e
ff
e
c
ts
o
f
b
re
a
st
fe
e
d
in
g
o
n
p
o
st

p
a
rt
u
m
m
e
n
ta
l
h
e
a
lt
h
(m
o
th
e
rs
a
t
ri
sk
o

f
d
e
p
re
ss
io
n
w
h
e
n
p
re
g
n
a
n
t)
D
e
p
e
n
d
e

n
t
v
a
ri
a
b
le
(1
)
D
id
n
’t
p
la
n
to
b
re
a
st
fe
e
d
,

d
id
n
’t
b
re
a
st
fe
e
d
(r
e
fe
re
n
c
e
g
ro
u
p
)
(2
)

D
id
n
’t
p
la
n
to
b
re
a
st
fe
e
d
,
d
id
a
c
u
a
ll
y
b
re

a
st
fe
e
d
(3
)
D
if
fe
re
n
c
e
b
e
tw
e
e
n
c
o
e
ff
s
(1

)
a
n
d
(2
)
(4
)
P
la
n
n
e
d
to
b
re
a
st
fe
e
d
,
d
id

n
’t
b
re
a
st
fe
e
d
(5
)
P
la
n
n
e
d
to
b
re
a
st
fe
e
d
,

d
id
b
re
a
st
fe
e
d
(6
)
D
if
fe
re
n
c
e
b
e
tw
e
e
n
c

o
e
ff
s
(4
)
a
n
d
(5
)
E
P
D
S
[
1
2
a
t
8
w
e
e
k
s

(N
=
1
,1
2
4
–
1
,1
2
8
)
B
re
a
st
fe
e
d
in
g
in
it
ia
te
d

–
1
.2
4
[0
.7
9
,1
.9
4
]
0
.8
2
[0
.2
9
,2
.3
4
]
1
.1
1
[0

.3
7
,3
.3
3
]
A
n
y
b
/f
,
1
w
e
e
k
?
–
1
.3
3
[0
.8
1
,2

.1
9
]
1
.4
5
[0
.7
4
,2
.8
4
]
0
.5
6
[0
.2
5
,1
.2
4
]
A
n
y

b
/f
,
2
w
e
e
k
s
?
–
1
.0
6
[0
.6
3
,1
.8
0
]
1
.7
1
[0
.9

5
,3
.0
7
]
0
.4
7
[0
.2
2
,1
.0
2
]
*
*
A
n
y
b
/f
,
4
w
e

e
k
s
?
–
0
.6
9
[0
.3
7
,1
.2
8
]
1
.1
0
[0
.7
3
,1
.6
7
]
1

.1
3
[0
.5
4
,2
.3
5
]
E
x
c
lu
si
v
e
b
/f
,
1
w
e
e
k
?
–

1
.1
4
[0
.6
7
,1
.9
6
]
1
.2
9
[0
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*
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123
the way in which new mothers are supported; they suggest

that the provision of expert breastfeeding support may, in
addition to increasing breastfeeding rates and durations,
have the additional benefit of improving mental health
outcomes among new mothers. At the same time, it is clear
that where mothers had intended to breastfeed, not being
able to breastfeed may have deleterious consequences on
their risk of PPD, and that providing specialised support to
new mothers who had intended to breastfeed, but who for
some reason find themselves unable to breastfeed, may also
constitute a desirable health policy objective.
Acknowledgments This paper has benefited from comments pro-
vided by participants at the 20th Public Economics Meeting and
at the
27th Annual Conference of the European Society for Population
Economics. We acknowledge comments and support from
colleagues
at ISER, particularly Emilia del Bono and Birgitta Rabe. We are
extremely grateful to all the families who took part in this
study, the
midwives for their help in recruiting them, and the whole
ALSPAC

team, which includes interviewers, computer and laboratory
techni-
cians, clerical workers, research scientists, volunteers,
managers,
receptionists and nurses. The UK Medical Research Council and
the
Wellcome Trust (Grant ref: 092731) and the University of
Bristol
provide core support for ALSPAC. This publication is the work
of the
authors, who will all serve as guarantors for the contents of this
paper.
This research was specifically funded by the UK’s Economic
and
Social Research Council (ESRC) under research Grant RES-
062-23-
1693 Effects of breastfeeding on children, mothers and
employers.
The authors are independent from the ESRC.
Open Access This article is distributed under the terms of the
Creative Commons Attribution License which permits any use,
dis-
tribution, and reproduction in any medium, provided the
original

author(s) and the source are credited.
Appendix 1
See Table 6.
Appendix 2
See Table 7.
Table 6 List of variables used in the analysis
Socio-demographic variables (at or during pregnancy)
Two dummies for housing tenure which take the value 1 if the
mother owned the house or rented the house during pregnancy
(omitted category is social housing); the number of rooms in
the house during pregnancy; neighborhood indicators with
higher values indicating a better neighbourhood; a dummy
indicating the mother’s race (white, with omitted category
nonwhite); three dummies indicating the marital status of the
mother at the time of pregnancy (married, cohabiting, single/
separated/divorced); five dummies indicating the mother’s and
father’s education level (university degree; A levels (school
qualifications obtained at age 18); O levels (school

qualifications obtained at age 16); CSE (a lower level of school
qualifications obtained at age 16) and vocational); and an
indicator variable that takes the value 1 if the mother was
working at 18 weeks of pregnancy.
Table 6 continued
Pregnancy and delivery information
A dummy that takes value 1 if the child is a female; a dummy
that takes value 1 if the child is a twin; mother’s age at birth; an
indicator variable that takes value 1 if the mother had a
cesarean section; the length of the gestation period.
Health variables
Dummy variables for different physical health levels; number of
cigarettes smoked each day measured at 32 weeks of
pregnancy; number of alcoholic beverages a day before
pregnancy; and antenatal EPDS measured at 18 and 33 months
pregnancy.
Interpersonal relationships, personality, and stressful life events
Dragona’s et al. (1992) measure of the mother’s social network

availability; Quinton and Rutter’s (1988) aggression and
affection scores for marital quality; a psychological measure of
the mother’s personality: the adult version of the Nowicki-
Strickand locus of control scale (Duke and Nowicki, 1973);
Barnett et al.’s (1983) Life Events Score; an indicator variable
that takes the value 1 if pregnancy was unplanned; an indicator
variable that takes value 1 if the mother was in local authority
care; an indicator variable that takes value 1 if she had
divorced parents by age 17; an indicator variable that takes
value 1 if the mother’s main carer died by age 17;
Table 7 Socio-demographic characteristics of study population
Units Mean (Std.
error)
Pregnancy and birth
Gestation in weeks Weeks 39.47 (1.8)
Mother’s age at birth Years 28.34 (4.8)
C-section 0/1 0.09 (0.3)
Primiparous 0/1 0.45 (0.5)

Mother works at 18 weeks 0/1 0.55 (0.5)
Cigarettes at 32 w No. 2.00 (5.1)
Previous alcohol consumption No. 2.59 (0.8)
Child characteristics at birth
Female 0/1 0.49 (0.5)
Twin 0/1 0.01 (0.1)
Birth weight grams 3,419.93 (543.9)
Head circumference inches 34.84 (1.4)
Crown-heel length inches 50.52 (2.2)
Demographic and socio-economic variables
White mother 0/1 0.95 (0.2)
Mother cohabiting 0/1 0.20 (0.4)
Mother single 0/1 0.04 (0.2)
Owner occupier 0/1 0.74 (0.4)
123
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Table 7 continued
Units Mean (Std.
error)
Private rented 0/1 0.07 (0.3)
Number of rooms 0/1 1.59 (0.9)

Neighbourhood qual. 0/1 8.25 (2.2)
Father’s education
University degree 0/1 0.17 (0.4)
A level (academic qualifications
age 18)
0/1 0.25 (0.4)
O level (academic qualifications
age 16)
0/1 0.35 (0.5)
CSE (lower-level academic quals) 0/1 0.15 (0.4)
Vocational 0/1 0.08 (0.3)
Mother’s education
University degree 0/1 0.13 (0.3)
A level (academic qualifications
age 18)
0/1 0.22 (0.4)
O level (academic qualifications
age 16)

0/1 0.42 (0.5)
CSE (lower-level academic quals) 0/1 0.14 (0.3)
Vocational 0/1 0.10 (0.3)
Breastfeeding attitudes
Mother was breastfed 0/1 0.48 (0.5)
Father was breastfed 0/1 0.32 (0.5)
Father breastfeeding attitudes score 15.39 (2.4)
Mother’s health in pregnancy
Mother health always well 0/1 0.29 (0.5)
Mother health usually well 0/1 0.64 (0.5)
Mother health sometimes unwell 0/1 0.06 (0.2)
Mother health often unwell 0/1 0.01 (0.1)
Interpersonal relationships and stressful life events
Mother’s social network score score 23.34 (3.8)
Mother’s affection score score 11.17 (4.2)
Mother’s aggression score score 10.00 (1.7)
Mother’s std. locus/control score score 0.00 (1.1)
Mother’s life events score score 8.05 (7.3)

This pregnancy unplanned 0/1 0.28 (0.4)
Mother in care 0/1 0.02 (0.2)
Mother’s parents divorced by 17 0/1 0.15 (0.4)
Mother’s parents died by 17 0/1 0.10 (0.3)
123
http://dx.doi.org/10.1186/1746-4358-2-6
http://dx.doi.org/10.1186/1746-4358-2-6
23. Seimyr, L., Edhborg, M., & Lundh, W. (2004). In the
shadow of
maternal depressed mood: experiences of parenthood during the
first year after childbirth. Journal of Psychosomatic Obstetrics
and Gynecology, 25(1), 23–34.
24. Ip, S., Chung, M., Raman, G., Chew, P., Magula, N.,
DeVine, D.,
et al. (2007). Breastfeeding and maternal and infant health out-
comes in developed countries. Evid Rep Technology Assess
(Full
Rep), 153, 1–186.
25. Groër, M. W. (2005). Differences between exclusive

breastfee-
ders, formula-feeders, and controls: a study of stress, mood, and
endocrine variables. Biological Research for Nursing, 7(2),
106–117.
26. Golding, J., Pembrey, M., Jones, R., & and the ALSPAC
Study
Team. (2001). ALSPAC-The Avon longitudinal study of parents
and children. Paediatric and Perinatal Epidemiology, 15, 74–87.
27. ALSPAC data dictionary, available online at:
http://www.bris.ac.
uk/alspac/researchers/data-access/data-dictionary/.
28. Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection
of
postnatal depression: Development of the 10-item Edinburgh
depression scale. British Journal of Psychiatry, 150, 782–788.
29. Horowitz, J. A., & Goodman, J. (2004). A longitudinal
study of
maternal postpartum depression symptoms. Research and
Theory
for Nursing Practice, 18(2–3), 149–163.
30. Matthey, S., Henshaw, C., Elliott, S., & Barnett, B. (2006).

Variability in use of cut-off scores and formats on the
Edinburgh
Postnatal Depression Scale: implications for clinical and
research
practice. Archives of Women’s Mental Health, 9(6), 309–315.
31. Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection
of
postnatal depression: Development of the 10-item Edinburgh
depression scale. British Journal of Psychiatry, 150, 782–788.
32. Murray, L., & Cox, J. L. (1990). Screening for depression
during
pregnancy with the Edinburgh Depression Scale (EPDS).
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33. Choi, S. K., Kim, J. J., Park, Y. G., Ko, H. S., Park, I. Y., &
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screening? International Journal of Medical Sciences, 9(1),
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34. O’Hara, M., & Swain, A. (1996). Rates and risk of
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123
http://www.bris.ac.uk/alspac/researchers/data-access/data-
dictionary/
http://www.bris.ac.uk/alspac/researchers/data-access/data-
dictionary/
/murie_depression_oct04.htm#refs
/murie_depression_oct04.htm#refsNew Evidence on
Breastfeeding and Postpartum Depression: The Importance of
Understanding Women’s IntentionsAbstractIntroductionData
and MethodsData and Key VariablesAnalysisResultsStudy
VariablesSample CharacteristicsHeterogeneous Effects by
Mental Health During Pregnancy and Breastfeeding
IntentionDiscussionAcknowledgmentsAppendix 1Appendix
2References
Series
www.thelancet.com Vol 387 January 30, 2016 475
Breastfeeding 1

Breastfeeding in the 21st century: epidemiology, mechanisms,
and lifelong eff ect
Cesar G Victora, Rajiv Bahl, Aluísio J D Barros, Giovanny V A
França, Susan Horton, Julia Krasevec, Simon Murch, Mari Jeeva
Sankar, Neff Walker,
Nigel C Rollins, for The Lancet Breastfeeding Series Group*
The importance of breastfeeding in low-income and middle-
income countries is well recognised, but less consensus
exists about its importance in high-income countries. In low-
income and middle-income countries, only 37% of
children younger than 6 months of age are exclusively
breastfed. With few exceptions, breastfeeding duration is
shorter in high-income countries than in those that are resource-
poor. Our meta-analyses indicate protection against
child infections and malocclusion, increases in intelligence, and
probable reductions in overweight and diabetes. We
did not fi nd associations with allergic disorders such as asthma
or with blood pressure or cholesterol, and we noted
an increase in tooth decay with longer periods of breastfeeding.
For nursing women, breastfeeding gave protection
against breast cancer and it improved birth spacing, and it might
also protect against ovarian cancer and type 2
diabetes. The scaling up of breastfeeding to a near universal
level could prevent 823 000 annual deaths in children
younger than 5 years and 20 000 annual deaths from breast
cancer. Recent epidemiological and biological fi ndings
from during the past decade expand on the known benefi ts of
breastfeeding for women and children, whether they
are rich or poor.
Introduction
“In all mammalian species the reproductive cycle
comprises both pregnancy and breast-feeding: in the
absence of latter, none of these species, man included,

could have survived”, wrote paediatrician Bo Vahlquist in
1981.1 3 years earlier, Derek and Patrice Jelliff e in their
classic book Breast Milk in the Modern World2 stated that
“breast-feeding is a matter of concern in both industrialised
and developing countries because it has such a wide range
of often underappreciated consequences”.3 The Jelliff es
anticipated that breastfeeding would be relevant to
“present-day interest in the consequences of infant
nutrition on subsequent adult health”.3 These statements
were challenged by the American Academy of Pediatrics,
which in its 1984 report on the scientifi c evidence for
breastfeeding stated that “if there are benefi ts associated
with breast-feeding in populations with good sanitation,
nutrition and medical care, the benefi ts are apparently
modest”.4
In the past three decades, the evidence behind
breastfeeding recommendations has evolved markedly
(appendix p 3). Results from epidemiological studies and
growing knowledge of the roles of epigenetics, stem
cells, and the developmental origins of health and disease
lend strong support to the ideas proposed by Vahlquist
and the Jelliff es. Never before in the history of science
has so much been known about the complex importance
of breastfeeding for both mothers and children.
Here, in the fi rst of two Series papers, we describe
present patterns and past trends in breastfeeding
throughout the world, review the short-term and long-
term health consequences of breastfeeding for the child
and mother, estimate potential lives saved by scaling up
breastfeeding, and summarise insights into how
breastfeeding might permanently shape individuals’ life
course. The second paper in the Series5 covers the
determinants of breastfeeding and the eff ectiveness of

promotion interventions. It discusses the role of breast-
feeding in HIV transmission and how knowledge about
this issue has evolved in the past two decades, and
examines the lucrative market of breastmilk substitutes,
the environmental role of breastfeeding, and its economic
implications. In the context of the post-2015 development
agenda, the two articles document how essential
breastfeeding is for building a better world for future
generations in all countries, rich and poor alike.
Lancet 2016; 387: 475–90
See Editorial page 404
See Comment pages 413
and 416
This is the first in a Series of
two papers about breastfeeding
*Members listed at the end of
the paper
International Center for Equity
in Health, Post-Graduate
Programme in Epidemiology,
Federal University of Pelotas,
Pelotas, Brazil
(Prof C G Victora MD,
Prof A J D Barros MD,
G V A França PhD); Department
of Maternal, Newborn, Child
and Adolescent Health (MCA),
WHO, Geneva, Switzerland
(R Bahl MD, N C Rollins);
Department of Economics,

University of Waterloo, ON,
Canada (Prof S Horton PhD);
Data and Analytics Section,
Division of Data, Research, and
Policy, UNICEF, New York, NY,
USA (J Krasevec MSc);
University Hospital Coventry
and Warwickshire, Coventry,
UK (Prof S Murch PhD); WHO
Collaborating Centre for
Training and Research in
Newborn Care, All India
Institute of Medical Sciences
(AIIMS), New Delhi, India
(M J Sankar DM); and Institute
for International Programs,
Bloomberg School of Public
Health, Baltimore, MD, USA
(N Walker PhD)
Correspondence to:
Prof Cesar G Victora,
International Center for Equity in
Health, Post-Graduate
Programme in Epidemiology,
Federal University of Pelotas,
Pelotas, RS, 96020, Brazil
[email protected]
See Online for appendix
Search strategy and selection criteria
We obtained information about the associations between
breastfeeding and outcomes in children or mothers from
28 systematic reviews and meta-analyses, of which 22 were
commissioned for this review. See appendix pp 23–30 for the

databases searched and search terms used. We reviewed the
following disorders for young children: child mortality;
diarrhoea incidence and admission to hospital; lower
respiratory tract infections incidence, prevalence, and
admission to hospital; acute otitis media; eczema; food
allergies; allergic rhinitis; asthma or wheezing; infant growth
(length, weight, body-mass index); dental caries; and
malocclusion. For older children, adolescents, and adults, we
did systematic reviews for systolic and diastolic blood
pressure; overweight and obesity; total cholesterol; type 2
diabetes; and intelligence. For mothers, we did systematic
reviews covering the following outcomes: lactational
amenorrhoea; breast and ovarian cancer; type 2 diabetes;
post-partum weight change; and osteoporosis.
http://crossmark.crossref.org/dialog/?doi=10.1016/S0140-
6736(15)01024-7&domain=pdf
Series
476 www.thelancet.com Vol 387 January 30, 2016
Breastfeeding indicators and data sources for this
review
WHO has defi ned the following indicators for the study of
feeding practices of infants and young children:6 early
initiation of breastfeeding (proportion of children born in
the past 24 months who were put to the breast within an
hour of birth); exclusive breastfeeding under 6 months
(proportion of infants aged 0–5 months who are fed
exclusively with breastmilk. This indicator is based on the
diets of infants younger than 6 months during the 24 h
before the survey [to avoid recall bias], not on the proportion
who are exclusively breastfed for the full 6-month period);
continued breastfeeding at 1 year (proportion of children

aged 12–15 months who are fed breastmilk); and continued
breastfeeding at 2 years (proportion of children aged
20–23 months who are fed breastmilk).
Because few high-income countries report on the
aforementioned indicators, we calculated additional
indicators to allow global comparisons: ever breastfed
(infants reported to have been breastfed, even if for a
short period); breastfed at 6 months (in high-income
countries, the proportion of infants who were breastfed
from birth to 6 months or older; in low-income and
middle-income countries [LMICs] with standardised
surveys, the proportion of infants aged 4–7 months
[median age of 6 months] who are breastfed); and
breastfed at 12 months (in high-income countries, the
proportion of children breastfed for 12 months or longer;
in LMICs, the proportion of children aged 10–13 months
[median age of 12 months] who are breastfed).
For this review, we used the last three, additional
indicators for comparisons between high-income countries
and LMICs only. Otherwise, we reported on the standard
international indicators (appendix p 4).
For LMICs, we reanalysed national surveys done since
1993, including Demographic and Health Surveys,
Multiple Indicator Cluster Surveys, and others (appendix
pp 5–12). Nearly all surveys had response rates higher
than 90% and used standardised questionnaires
and indicators.
For all high-income countries with 50 000 or more
annual births, we did systematic reviews of published
studies and the grey literature and contacted local
researchers or public health practitioners when data

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