A Healthy Start to Life: Cultural Barriers and the Global Trend Toward Early and Exclusive Breastfeeding

The following two tabs change content below.
Miriam Stats

Miriam Stats

Miriam Stats is a fourth year student at Northeastern University in Boston. She will be graduating with a bachelor’s degree in Health Sciences and plans to attend medical school with the hopes of becoming a pediatrician. She currently works at Brigham and Women’s Hospital in the Newborn Medicine department and has completed global health work in Panama. Her particular areas of interest in global health are in the fields of maternal and reproductive health.

There has been accumulating evidence that early initiation of breastfeeding, within the first hour of birth, and exclusive breastfeeding for the first 6 months of life, can have a significant impact on reducing infant mortality. Each year, approximately 4 million babies die in the first 4 weeks of life, constituting nearly 40% of total child deaths. 99% of these neonatal deaths occur in developing countries, with the highest rates concentrated in sub-Saharan Africa.1 According to the Bellagio Child Survival Study Group, exclusive breastfeeding of infants for the first 6 months, and continued feeding until at least one year of age, could prevent an estimated 1.3 million child deaths per year.2 Additionally, the proportion of child disability-adjusted life-years attributable to breastfeeding is a compelling 7.6% at the global level.3

Breastfeeding has an extraordinary range of benefits and has a significant impact on a growing child’s health and development. Breast milk not only provides all of the nutrients and hydration an infant needs, it is also well established that breast milk holds antibodies that have a protective effect against infections. For a long time this was attributed to the lack of opportunity for contamination to occur, especially in regions without sanitary conditions or potable water. However, it has also been confirmed that breast milk has a vast cellular content, notably containing interferon-producing lymphocytes. The host-resistance properties of breast milk are significant, indicating its role in stimulating the infant’s immune system and defending against pathogens.4 Because nearly one-third of total neonatal deaths are due to infections5, and because breast milk helps combat disease and functions to protect the baby from leading causes of death such as diarrhea and acute respiratory infections4, breastfeeding is an important tool in helping the UN reach the Millennium Development Goal of reducing childhood mortality.

Not only does breastfeeding have profound short-term benefits, but also the act of breastfeeding has important repercussions that last into adulthood. First and foremost, breastfeeding stimulates a special bond between the mother and the infant, leading to fewer parent-related behavior problems during childhood.6 It has also been shown that children who are breastfed have a diminished risk of developing chronic conditions such as high blood pressure, diabetes, obesity, asthma, and even childhood cancers. Finally, children and adults that were breastfed tend to have improved performance on intelligence and behavior exams as well as increased educational attainment and income compared to their formula-fed counterparts.7

In 2006, a large cohort study that took place in several regions of rural Ghana found that neonatal mortality could be significantly reduced if all infants initiated breastfeeding on the first day of life and found that both predominantly and partially breastfed infants had a higher risk of mortality as compared to those that were exclusive breastfed.8 In response, the World Health Organization (WHO) and United Nations International Children’s Emergency Fund (UNICEF) has since recommended that in order to achieve optimal growth, development, and health it is ideal that an infant be immediately breast fed within an hour of birth, and infants younger than 6 months be fed exclusively breast milk. Since then, trend data has shown that the prevalence of exclusive breastfeeding in all parts of the developing world has increased modestly. For example, the prevalence of exclusive breastfeeding in West and Central Africa increased from 12% in 1995 to 28% in 2010.9 While this marks a considerable improvement, pervasiveness of early and exclusive breastfeeding remains suboptimal.

Breastfeeding is a unique health intervention because it is available to nearly all mothers, regardless of status and doesn’t require extensive health infrastructure. However, according to a study conducted by the Lancet, in 2010, the prevalence of exclusive breastfeeding ranged from as low as 3.5% in Djibouti to nearly 80% in Rwanda.3 However, it is important to consider the cultural practices that may be preventing women from choosing to breastfeed. For example, in urban China, less than 16% of women adhere to the World Health Organization’s recommendation of six months devoted to exclusive breastfeeding. In Chinese tradition, the influential practice of zuo yuezi is a period in which the new mother is expected to stay home and recover and rest while others care for the infant. The expectation is that the burden of breastfeeding is shifted away from the mother, and the laborious task is given to a wet nurse. More recently, infant formula has replaced the need for wet nurses, thereby eliminating the opportunity for breastfeeding. It is expected that China’s growing market for infant formula will grow to $30 billion dollars in upcoming years.10 Commercial breastfeeding substitutes carry their own risks. Apart from being expensive, formula-feeding unnecessarily exposes the infant to infectious disease, especially in regions where access to clean water is limited. Additionally, while formula contains nutrients, it doesn’t provide babies with the antibodies, enzymes, essential fatty acids, and hormones, which make breast milk so invaluable.

There are other social conditions that prevent women from initiating or maintaining breastfeeding. For example, some tribes in Sierra Leone believe that sperm contaminates breast milk. Many women want to continue sexual activity and therefore cease to breastfeed. Unfortunately, many of these babies then die of malnutrition. Additionally, in countries such as Pakistan and Bangladesh, there are beliefs that a mother’s breast milk is vulnerable to batash, an evil spirit. Often, when a religious healer or physician suspects that the milk has been afflicted by the batash, it is advised that the mother stop breastfeeding completely. The mother is often blamed for her vulnerability to these spiritual powers. While the batash may be banished by placing a matchbox under the mattress in hopes that fire will frighten it away, most frequently, the mother transitions to artificially feeding her child to be certain the evil spirits have vanished.

While developed countries have a higher prevalence of early initiation and exclusive breastfeeding, they are not immune to cultural barriers that lead to substandard breastfeeding practices. Unlike in the United States and much of the Western world, in some developing countries such as Mali or Nepal, the breast does not have a sexual association for men or women. Instead, the organ serves its primary biological purpose of sustaining infants. However, in many places across the globe, the breast is related to sexuality. Because of this, many women are fearful of breastfeeding because they worry that their breasts will deteriorate and become undesirable. Therefore, because of the sexual connotation associated with it, it is not socially acceptable to expose the breast to feed an infant, a stigmatization not conducive for ideal breastfeeding.11

Overall, it is clear that cultural practices contribute considerably to breastfeeding habits and it is likely a significant reason that early and exclusive breastfeeding hasn’t been more widely adopted. Therefore, while promotion of breastfeeding is critical, the attitudes, beliefs, and traditions of various societies must be considered.11 Breastfeeding can be daunting and frustrating and women need support, encouragement, and often, assistance. Recent global initiatives that support breastfeeding as well as legislation that monitors marketing of breast milk substitutes have been extremely impactful. However, in order to make even larger leaps toward universal, early and exclusive breastfeeding, individualized community-based programs must be implemented that advocate ideal breastfeeding practices through communication and education, while simultaneously respecting and accommodating cultural traditions. If this delicate balance can be reached, real progress can be made toward decreasing childhood mortality.


  1. Lawn JE, Cousens S, Zupan J. Lancet Neonatal Survival Steering Team. 4 million neonatal deaths: When? Where? Why? Lancet. 2005; 365:891–900.
  2. Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS, Bellagio Child Survival Study Group How many child deaths can we prevent this year? Lancet. 2003; 362: 65–71.
  3. Roberts T, Carnahan E, Gakidou E. Burden attributable to suboptimal breastfeeding: a cross-country analysis of country-specific trends and their relation to child health inequalities. The Lancet. 2013; 381: S126-S126.
  4. Jelliffe DB. World trends in infant feeding. The American journal of clinical nutrition. 1976; 11: 1227-37.
  5. Mullany LC, Katz J, Li YM, Khatry SK, Leclerq SC, Darmstadt GL, Tielsch JM: Breast-feeding patterns, time to initiation, and mortality risk among newborns in southern Nepal. J Nutr. 2008; 138: 599-603.
  6. Heikkilä K, Sacker A, Kelly Y, Renfrew MJ, Quigley MA. Breastfeeding and child behaviour in the Millennium Cohort Study. Archives of Disease in Childhood. 2011; 96: 635-42.
  7. Victora CG, Horta BL, de Mola CL, Quevedo L, Pinheiro RT, Gigante DP, Gonçalves H, Barros FC. Association between breastfeeding and intelligence, educational attainment, and income at 30 years of age: a prospective birth cohort study from Brazil. The Lancet Global Health. 2015; Apr 30; 3: e199-205.
  8. Edmond KM, Zandoh C, Quigley MA, Amenga-Etego S, Owusu-Agyei S, Kirkwood BR. Delayed breastfeeding initiation increases risk of neonatal mortality. Pediatrics. 2006; 117: 380-6
  9. Cai X, Wardlaw T, Brown DW. Global trends in exclusive breastfeeding. Int Breastfeeding Journal. 2012; 7: 1.
  10. Minter A. China’s Growing Breastfeeding Problem. Bloomberg View. https://www.bloomberg.com/view/articles/2015-04-22/china-s-growing-breastfeeding-problem Published April 22, 2015. Accessed January 17, 2017.
  11. Daglas M, Antoniou E. Cultural views and practices related to breastfeeding. Health Science Journal. 2012; 2: 353-61.