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Fourteen
Making Mothers’ Milk Count
Julie P. Smith
INTRODUCTION
In her 1988 classic Counting for Nothing, Marilyn Waring observed
that although “men who win Nobel prizes are generally considered
more observant than the rest of us”, Sir Richard Stone had invented
a system of measuring economic activity in which “reproduction is
invisible” (Waring, 181).
The example of breastfeeding was used to scathingly critique
the United Nations System of National Accounts (SNA) - Sir Richard
Stone’s “baby”. Waring argued forcefully that these accounts per-
petuated the invisibility and devaluation of women’s contribution
as infant food and health care producers. Breasts were only counted
by the SNA when exploited in advertising, in pornography, in the
lingerie industry, and cosmetic surgery.
Breastfeeding was not counted when applied to their primary
function —nourishing human infants. Meanwhile, breastfeeding
was declining worldwide, due partly to a worldwide lack of consid-
eration by employers — women who breastfed in accordance with
best practice for mother and child health were “simply expected to
get on with it, in their own time” (Waring, 171).
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JULIE P. SMITH
This vigorous feminist critique of the SNA inspired consider-
able feminist scholarship and activism on valuing women’s work
in economic statistics, and was an important contribution to the
“accounting for women’s work project” (Benaria 131). This aimed
for all women’s work to be counted in statistics, accounted for in
the representations of how economies work, and taken into account
when policy is made (Elson Progress of the World’s Women 2000).
It is also important for economic advancement that public pol-
icy is informed by statistics which more accurately portray the
economy and women’s contribution to it. Nevertheless, some ask
whether this accounting focus distracted from achieving greater
economic justice for women. As Valeria Esquival observes, “pro-
ducing household sector satellite accounts does not by itself change
macroeconomic policy” (219). More recently, UN discourse has
shifted in focus from “measuring” and “possibly compensating” un-
paid work, to counting as “essential to well-being” but “costly” for
those who provide it, and justifying claims for strategic policy inter-
ventions to reduce unpaid work and redistribute its burden within
and between households. This is known as the “three R’s of unpaid
work: recognition, reduction and redistribution” (Elson The Three
R’s of Unpaid Work ).
This chapter reviews the intellectual contributions stemming
from Counting for Nothing in the area of women’s breastfeeding
work, and illustrates from an Australian perspective how this has
been used in public policy advocacy. I explore how the feminist
critique of the national accounts system influenced research on the
economic value of breastfeeding since 1988, how it inspired women’s
breastfeeding advocacy and helped shape Australian health and
employment policy. I also consider the barriers and possibilities for
valuing breastfeeding in the SNA, and the important implications
of doing so.
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MAKING MOTHERS’ MILK COUNT
COUNTING FOR SOMETHING—VALUING MOTHERS’
MILK
Counting for Nothing was not the first call to acknowledge the
economic value of mother’s milk and breastfeeding, though it was
the first to demand its proper valuation and to insist that the costs
of breastfeeding to women be accounted for.
Until the 1990s, assessments of the economic significance of
breastfeeding valued breast milk as if it were cows’ milk or commer-
cial infant formula. This fails to count the economic value of breast-
feeding for the health and development of infants. These studies
were motivated to protect and promote breastfeeding but under-
stated its economic value by equating human milk with bovine
animal milk products (Berg; Almroth, Greiner and Latham). Im-
portantly, these studies viewed women’s time as “free”, thus under-
stating the economic cost of breastfeeding. In 1979, nutritionists
noted the time spent breastfeeding as a cost (Almroth, Greiner
and Latham). Such costs are especially important for resource
poor mothers and may influence them to wean their children from
breastfeeding prematurely (Sellen).
The “mothers’ milk equals cows’ milk” approach to valuing
breastfeeding was challenged from the 1990s. Mother’s milk pro-
duction was counted in Norway’s food production statistics from
the early 1990s, and was valued in a 1994 study using the market
price of donated breast milk traded between Norwegian hospitals
(Oshaug and Botten). Using the same valuation approach, the
economic value and strategic importance of breastfeeding in Sub-
Saharan Africa was estimated at half the annual output of cows’
milk (Hatloy and Oshaug). Conservatively valued at US$1 per
litre, this added between two and five percent to GNP.
In the mid 1990s, Oshaug and Botten’s insights on valuation
were used to estimate the economic value of breastfeeding in Aus-
tralia, within a national accounting framework. This research showed
that the price of commercially modified bovine milk massively un-
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JULIE P. SMITH
derestimated the economic value of mothers’ milk and it was more
appropriate to use the market price of expressed breast milk to
value the supply of human milk (Smith, Ingham and Dunstone;
Smith “Human Milk Supply”).
Many people are surprised that markets in mothers’ milk exist.
Hospitals and milk banks exchange and sell donated breast milk,
human milk is traded through the Internet, and breastfeeding ser-
vices are sold by wet nurses. In the past five years, the “market”
for human milk has expanded considerably. In 2009, ten North
American milk banks distributed 1.5 million ounces of human milk
for US$3 an ounce or $127 ($A153) a litre. In Europe it sold for
e130 (A$222) per litre; a price reflecting costs of processing and
storing donated milk.
Usually milk banking is conducted on a not for profit basis,
but a for-profit company now sells donated and highly processed
human milk for use in neonatal intensive care units at a price of
around US$1183 (A$1429) a litre.
Individual women have also responded to demand for breast
milk by expanding informal systems for milk exchange, facilitated
by the Internet. Websites such as “Eats On Feet” help mothers
share their milk with other mothers—recipients pay shipping costs
only. Other sites such as “Only The Breast” operate systems for
trading milk, its philosophy being to recompense mothers for costs
including their time. Breast milk is bought and sold on this site
for about US$2 an ounce, or US$131 a litre.
There is also a market for wet nurses. Wet nurses advertise
with “Only The Breast” at around US$50 per day ranging up to
$150-200 per day where childcare or housework is also offered. U.S.
employment agencies quote wages of around US$1,000 a week for
wet nurses while a recent media report cited wages in China of
US$10,000-25,000 per year.
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MAKING MOTHERS’ MILK COUNT
HEALTH CARE AND HUMAN CAPITAL BUILDING
As pointed out in 1988 “an inadequately fed infant is a cost to
the health system, . . . to the education system (because of brain
development), and to society generally” (Waring, 207). National
accounting experts now acknowledge the crucial, unpaid role of
families in building human capital (Abraham and Mackie).
Breastfeeding contributes uniquely to human development thr-
ough providing uniquely species-appropriate nutrition and care for
infants and young children. Lack of breastfeeding is now a recog-
nized risk factor for chronic disease in adulthood, as well as for
acute infectious illness during infancy and childhood. Mothers’
health is adversely affected by premature weaning, through higher
incidence of depression and mental illness, and increased rates of
breast cancer and other disorders among women with short breast-
feeding duration (American Academy of Pediatrics et al.). Over
a million infants a year die needlessly from lack of breastfeeding;
improving breastfeeding practices is the most effective and cost ef-
fective intervention to improve mother and child health globally
(Bhutta et al. 417-40; Black et al.).
Breastfeeding minimises health care costs. Several studies have
estimated health care system costs attributable to formula feed-
ing. The cost of pediatric health care and premature death at-
tributable to formula feeding in the United States is around US$13
billion annually (Bartick and Reinhold e1048); it is also a signif-
icant proportion of acute and chronic disease costs in Australia
(Smith, Thompson and Ellwood; Smith and Harvey).
Well conducted cohort and experimental studies in several coun-
tries now provide strong evidence that those deprived of human
milk or breastfeeding in infancy have poorer cognitive and aca-
demic achievement in later life (Kramer et al.; Sacker, Quigley
and Kelly; Oddy et al.). Ending exclusive breastfeeding before 4
months is estimated to reduce IQ by 3-7 percentage points, with
larger impacts for premature or small-for-gestational-age infants.
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JULIE P. SMITH
This is comparable with the effects on child cognitive development
of pre-natal lead exposure (Walker et al. , Table 4). Lifetime costs
of special education for preterm infants in Australia would be $32
million lower if 20 per cent more were fed breast milk rather than
exclusively formula fed (Drane).
Nobel Laureate James Heckman and colleagues (Heckman, Mas-
terov and National Bureau of Economic; Doyle et al.) have shown
the economic importance of early investments in children. They
quantify how early childhood experiences influence the develop-
ment of cognitive skills, socio-emotional functioning and health,
and culminate in a way that measurably affects later life earnings
and productivity.
ACCOUNTING FOR THE TIME COSTS OF
BREASTFEEDING
Revealing women’s time costs of breastfeeding can help redistribute
the costs of care more widely in society; it is mainly others who ben-
efit from women’s time investment in breastfeeding (Smith “Moth-
ers’ Milk”). Failing to count women’s time distorts public policies
and results in long term economic loss as market work is favoured
over economically valuable but unpaid care and nourishment of
infants.
Some consider loss of employment opportunities as a cost of
breastfeeding. However, the true picture is more complex (Van Es-
terik and Greiner). Rather than employment per se, factors such
as travel time and distance to work, employment conditions, and
workplace arrangements may be the critical determinants of breast-
feeding continuation among employed mothers. Whether employed
women have any real decision-making power over infant feeding
methods is determined by structural and economic factors and is
not simply a matter of personal choice or biology (Quandt; Galtry).
Our Australian Time Use Survey of New Mothers (TUSNM)
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MAKING MOTHERS’ MILK COUNT
found that having an infant added 44 hours a week to a woman’s
unpaid workload (Smith and Ellwood), and revealed the high time
cost of breastfeeding in a developed country setting. It also showed
that exclusive breastfeeding of infants for 6 months took around 17-
20 hours a week of mothers’ time, much less than formula fed or
partially weaned infants.
Time is also important to understanding which mothers can-
not afford to breastfeed, or “rationally” decide not to. For mothers
without adequate family support, early weaning from breastfeed-
ing gives them more time, whether for leisure, housework, personal
care or employment. This may more than compensate for extra
costs of commercial baby food and health care. A recent US study
showed breastfeeding mothers suffered greater earning losses than
other mothers due to longer labour force withdrawal (Rippeyoung
and Noonan). Empirical research in Canada (Baker and Milligan),
the U.S. (Mandal, Roe and Fein) and the U.K. (Hawkins, Griffiths
and Dezateux), shows that breastfeeding is increased if mothers
get more time such as through extended paid maternity leave. On
the other hand, breastfeeding in the US was reduced by welfare
reforms encouraging return to work by 12 weeks (Chatterji and
Frick). Promotion of breastfeeding as free or costless has been “a
convenient tool used by states to avoid responsibility for taking on
more costly solutions to children’s and women’s health” (Rippey-
oung, 36). How making visible these economic aspects of breast-
feeding links to pursuing economic justice for women is discussed
below.
COUNTING THE COST OF INVISIBILITY; INSPIRING AND
STRENGTHENING WOMEN’S ADVOCACY
A focus on the economic value of breastfeeding and breast milk has
made women’s lactation work more visible and assisted women’s
advocacy on breastfeeding and maternity care. Influenced by Count-
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JULIE P. SMITH
ing for Nothing and research on the economics of breastfeeding,
the Australian Breastfeeding Association (ABA), then known as
Nursing Mothers’ Association of Australia, began advocating for
including breastfeeding in GDP in 1999. By 2002, its representa-
tions to federal parliamentarians would present research evidence
of health cost savings from breastfeeding. The following year, this
research was cited in Australia’s new dietary guidelines on infant
feeding (National Health and Medical Research Council).
In 2004 the Association’s National Breastfeeding Leadership Plan
recommended including breastfeeding in national food production
statistics and GDP to increase the health policy priority of breast-
feeding. ABA’s 2006 submission to the Australian Treasury used
evidence on health system cost savings (Smith, Thompson and
Ellwood) to successfully advocate federal government funding of
breastfeeding support measures—the May 2007 Budget announced
$8.7 million for a requested national breastfeeding helpline and
health professional training.
ABA advocacy citing health system cost savings also triggered
a parliamentary inquiry on the benefits of breastfeeding in late
2006. Public submissions highlighted the economic contribution
that women make by breastfeeding. The 2007 Best Start Re-
port (Commonwealth of Australia, 53-58) urged further research
on economic impacts to drive government action and investment
in breastfeeding support. The Inquiry also heard evidence on the
time costs of breastfeeding, and its Report (54) acknowledged the
failure to properly recognize its time-intensity and economic cost to
women. It stopped short of recommending paid maternity leave,
but meanwhile the Australian government moved towards intro-
ducing a new national scheme.
The 2007 Australian Productivity Commission Inquiry into Paid
Parental Leave invited evidence on the time costs of breastfeed-
ing and on its economic importance, and in 2009, recommended
a publicly funded scheme for 18 weeks paid parental leave. It ex-
pected that as a result, “more women will be able to have longer,
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MAKING MOTHERS’ MILK COUNT
beneficial interactions in the early phase of their babies’ lives and
to breastfeed for longer” (Productivity Commission, XX11). The
Commission was influenced by the health cost savings from breast-
feeding, concluding that the economic costs of not breastfeeding
were significant for developed as well as poor countries (Productiv-
ity Commission, 4.24).
COUNTING MOTHERS’ MILK IN THE UNITED NATIONS’
SYSTEM OF NATIONAL ACCOUNTS - PROGRESS IN
PRINCIPLE
Why is it that when we pay for childcare and house-
cleaning, when we eat out, when we buy milk for our
babies, or when we call in the mechanic or the plumber,
these add to GDP and count toward economic growth
and progress; but when we look after our own children,
clear our own house, cook our own meals, breastfeed our
babies, tune up our own cars, and fix our own leaking
faucets, these have no value in our current measures of
progress? (Collas-Monsod Removing the Cloak 98)
Despite breastfeeding’s crucial importance for infant health and
survival, national statisticians do not count human milk as a food.
Not including breast milk and breastfeeding in GDP is in fact con-
trary to United Nations’ guidelines.
Revised international guidelines were published for National Ac-
counting in 1993 (commonly referred to as SNA93) (Commission
of the European Communities). SNA93 was revised to take better
account of “subsistence” production; GDP should include all “own
account” production of goods by households. This includes agri-
cultural subsistence production such as sowing, planting, tending
and harvesting field crops; growing vegetables, fruit and other trees
and shrub crops; gathering wild fruits, medicinal and other plants;
tending, feeding or hunting animals mainly to obtain meat, milk,
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JULIE P. SMITH
hair, skin or other products; and storing or carrying to some basic
processing of this produce.
SNA93 also included in GDP any agricultural produce con-
sumed on-farm. The national accounting framework thus included
all non-marketed goods, including the production, processing and
storage of food by households, within the GDP production bound-
ary.
The Australian Bureau of Statistics (ABS) includes the value
of homegrown fruit, vegetables, eggs, beer, wine and meat in esti-
mates of final private consumption expenditure and therefore GDP.
Australian core accounts now include “the own account production
of all goods retained by their producers for their own final consump-
tion or gross capital formation” (”Unpaid Work and the Australian
Economy”, 46), where these are quantitatively significant, thereby
following the practice set down in SNA93 (para 6.18).
The preferred approach to valuing production in the national
accounts system is using market values. The fundamental criteria
for inclusion of a good is that it can be traded in a market. The
existence of markets in human milk (see above, Section 1) means
there are prices of a closely related or analogous product - a shadow
price - from which to impute its economic value.
We have shown human is defined as a good within the SNA93
core production boundary (Smith and Ingham “Mothers’ Milk”;
Smith and Ingham “Breastfeeding”) because, in national accounting
language, it can be produced, stored, sold on markets, and thus be
valued (Commission of the European Communities, para. 6.7).
Demonstrably, the value of human milk production can be es-
timated using accepted valuation methods for national accounting
– an input based, wage cost approach (replacement wage, opportu-
nity cost), or using the market value of the output (Smith “Human
Milk Supply”). Estimated annual human milk production in Aus-
tralia in 1992 was 33 million kg. Using a market value of output
approach to valuing production in a national accounts framework
(i.e. a price of US$50 per litre used for the Norwegian study (Os-
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MAKING MOTHERS’ MILK COUNT
haug and Botten)), this had a market value of $2.1 billion a year.
This is qualitatively important compared to other goods pro-
duced for own consumption by households which were valued at $1
billion in 1997 and are counted in GDP by the ABS. This means
that the production and value of human milk should be included in
core account estimates of national food production, consumption
and GDP.
Others agree that GDP wrongly excludes breast milk. The 2009
French Presidential Commission on the Measurement of Economic
Performance and Social Progress, led by two Nobel Laureates in
economics, Joseph Stiglitz and Amartya Sen, cited the example of
breastfeeding to illustrate how exclusion from GDP devalued im-
portant non-market work and biased policies against unpaid pro-
duction:
There is a serious omission in the valuation of home-
produced goods – the value of breast milk. This is
clearly within the System of National Accounts produc-
tion boundary, is quantitatively non-trivial and also has
important implications for public policy and child and
maternal health. (Stiglitz, Sen and Fitoussi, 39)
Including breast milk in GDP is important not only because it
acknowledges women’s lactation work. It also provides a focus
for government actions to promote economic growth and develop-
ment. For example, if breastfeeding in Australia increased to levels
recommended by the World Health Organisation, this would add
around $3.7 billion annually (0.7%) to GDP (Smith and Ingham
“Breastfeeding and the measurement”).
BARRIERS AND ISSUES
Breast milk is still not included in GDP—why not? In 1990 the
Australian Government was advised that unpaid work should con-
tinue to be excluded from GDP because the market sector was
277
JULIE P. SMITH
the primary concern for macroeconomic policy and because unpaid
household work was not related to market forces as directly as
goods (Australian Bureau of Statistics “Measuring Unpaid House-
hold Work”, 6-7).
These arguments do not apply to human milk production. Pro-
duction levels of human milk are closely related to market activity,
with direct competition to breastfeeding from companies selling
and profiting from sale of infant feeding products. Labour market
participation and breast milk production compete directly (Man-
dal, Roe and Fein 1-21). It is also questionable as to whether other
conventional arguments for excluding unpaid work from GDP ap-
ply to human milk production. For example, Collas-Monsad (Re-
moving the Cloak) has identified arguments that excluding unpaid
work is necessary to maintain the usefulness of the accounts to
policymakers. It is said to avoid “overburdening or disrupting the
central system” (Commission of the European Communities, para.
21.4).
However, excluding human milk production from GDP means
that Australia’s policymakers focus on promoting the activities of
commercial firms producing less than $200 million of infant food
products per year, whilst giving no importance to protecting house-
hold production of human milk worth $2 billion a year or more. It
is difficult to see why disrupting the system by comparing these val-
ues is undesirable, or why it overburdens policy analysis to show the
large magnitude of non market production of infant food. Likewise,
including breastfeeding in GDP would surely enhance monitoring
and analysis of long term productivity trends and patterns in the
food, nutrition, childcare and health sectors.
Women’s work is still not measured in key economic statistics
because of the costs involved in changing the collection and use
of national accounts (Fraumeni). Experience in the Philippines
suggests only “demand driven advocacy” will improve national ac-
counting practices (Virola et al.; Collas-Monsod). Unfortunately,
few understand how such statistics can be used for better decision-
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MAKING MOTHERS’ MILK COUNT
making, or how to use them for advocacy. Without such pressures,
statisticians will do little about introducing them—though “what
we don’t know could hurt us” (Abraham 3-18, 1).
USING STATISTICS FOR EVIDENCE BASED
POLICY—“FLYING BLIND WITH SNA”
Why do statistics matter? In simple terms, they are
the evidence on which policies are built. They help to
identify needs, set goals and monitor progress. With-
out good statistics, the development process is blind:
policy-makers cannot learn from their mistakes, and the
public cannot hold them accountable (World Bank, vii).
National accounts provide a misleading picture of human food
production and consumption activities. Present practice has the
startling result that increased breastfeeding and human milk pro-
duction reduces national food output and GDP, because it lowers
artificial formula and commercial baby food sales and reduces pri-
vate and public health expenditures, which are measured. Unmea-
sured are economic benefits of using more of an environmentally-
friendly and high quality food resource, and economic resource sav-
ings from reducing illness and disease and lesser use of medical
services or products.
An equally questionable corollary of the current GDP measure-
ment practice is that the dramatic worldwide drop in breastfeed-
ing rates during the 1960s and 1970s inaccurately showed higher
national output and economic growth from expanded production
of formula and higher national health expenditures. This same
practice of ignoring the loss of household production now grossly
distorts measurement of economic progress in countries like China
and India, and overstates economic growth.
The ability of women to breastfeed is a form of national wealth.
Yet, the economic returns from this human capital asset are not
279
JULIE P. SMITH
counted as contributing to GDP or economic well-being. This ren-
ders a major national asset invisible to policymakers who use these
economic statistics and GDP estimates to determine economic pri-
orities. If it were visible, more policies and programs would be
directed at protecting and enhancing breastfeeding knowledge and
skills.
As the World Bank reinforces in the above quotation, economic
development policies which consider only market activities will be
misguided in design and poorly implemented, even counterproduc-
tive. Economic waste and lower national productivity, as well as
gender inequity result from what is, in effect, “flying blind with
SNA”.
CONCLUSION
It is the SNA that threw a cloak over women’s contri-
butions, that cloak should and can be removed. (Collas-
Monsod, “Integrating Unpaid Work into Macroeconomics”)
Counting for Nothing gave impetus to women’s push for greater
recognition of their productive and reproductive work, and has
inspired efforts to give women’s work greater visibility as well as
improving economic justice for women. Women’s lactation work
can be shown to at least “count for something” in the public eye.
Despite reservations that chasing better economic statistics could
be a blind alley for those pursing gender equity, in this case at
least, “the accounting project” has helped achieve some economic
justice for women.
Breastfeeding illustrates how improving the visibility of women’s
contribution to well-being using economic statistics has been suc-
cessfully linked to policy measures giving economic recognition to
those investing time in caregiving, and helping redistribute the cost
of care in Australia.
280
MAKING MOTHERS’ MILK COUNT
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