The impact of breastfeeding practices on under-five mortality in sub-Saharan Africa. Systematic review, meta-analysis and evaluation of its attributable costs
Background: Sub-Saharan Africa has lower exclusive breastfeeding rates compared to other low- and middle-income countries, and globally holds the highest under-five mortality rates. The aims of this project were: to conduct a literature review with regards to breastfeeding; to conduct a systematic review and meta-analysis of breastfeeding practices in relation to under-five mortality; to estimate the prevalence of breastfeeding practices and the population attributable fraction; and to determine the economic impact of breastfeeding on child mortality, in sub-Saharan Africa. Methods: A literature review was conducted on the benefits of breastfeeding for both the child and the mother, the protection against mortality for children, the indicators of breastfeeding and determinants of breastfeeding, breastfeeding as a public health responsibility and as a human right, and breastfeeding in the context of HIV. A systematic review was conducted on observational studies (from 1 January 2000 to 31 May 2019) which reported an estimate of risk compared with exclusive and early initiation of breastfeeding and mortality in children under-five years of age, in sub-Saharan Africa. The systematic review included databases from Medline and CINAHL. Meta-analysis of mortality risk estimates was conducted using random and fixed effect methods. Heterogeneity was evaluated using the Cochrane Q test and the I² statistic. Publication bias was assessed by funnel plot visual inspection and the Egger’s test. The prevalence for the breastfeeding practices were determined using UNICEF’s database (2000-2018). Prevalence estimates by regions were compared using a linear meta-regression approach. The prevalence and all relative risk estimates were merged to provide population attributable fraction (PAF). Non-Health Gross Domestic Product Loss (NHGDPL) attributable to child deaths in relation to inappropriate breastfeeding practices was calculated using data from the World Health Statistics 2015. Results and discussion: The systematic review produced 1,511 records with the initial search. After title and abstracts screening, 51 records were assessed for eligibility. After the exclusion of 39 full text articles,16 studies were included in the qualitative synthesis. Nine were prospective studies, two were retrospective studies and four studies were surveys. The pooled relative mortality risk to any kind of infant feeding with respect to non-exclusive breastfeeding and delayed breastfeeding initiation were 5.71 (95%CI:2.14;15.23;N=6;I²=96.3%) and 3.3 (95%CI:2.49;4.46;N=5;I²=0%), respectively. According to our calculations, no indication of publication bias was observed. The overall exclusive breastfeeding and early initiation of breastfeeding prevalence were 35% and 47%, respectively. A large variability was observed between individual sub-Sahara African countries and regions for both exclusive breastfeeding and early initiation of breastfeeding prevalence. The PAF for non-exclusive breastfeeding was 75.7% and for late initiation of breastfeeding was 55.3%. The total NHGDPL attributable to inappropriate breastfeeding practices resulted in about 19.5 United States billion dollars (USB$). When considering deaths avoidable by exclusive breastfeeding and early breastfeeding initiation, the NHGDPL would be 8.3 and 8.4 USB$ in sub-Saharan Africa, respectively. Conclusion: Our results confirm that scaling up breastfeeding would be greatly beneficial for saving children’s lives and to reduce the negative economic impact of the under-five mortality rate in Sub-Saharan Africa. Therefore, public health interventions should prioritize breastfeeding practices to decrease the under-five mortality burden and its related costs in sub-Saharan Africa.
- Health Sciences