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TYPE Methods
PUBLISHED 30 March 2023
DOI 10.3389/fpubh.2023.1152659
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EDITED BY
Rafael Perez-Escamilla,
Yale University, United States
REVIEWED BY
Anthony Pascual Calibo,
St. Luke’s Medical Center, Philippines
Cecilia Castillo,
Nutriologa Infantil, Chile
*CORRESPONDENCE
Julie P. Smith
julie.smith@anu.edu.au
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PUBLISHED 30 March 2023
CITATION
Smith JP, Iellamo A, Nguyen TT and Mathisen R
(2023) The volume and monetary value of
human milk produced by the world’s
breastfeeding mothers: Results from a new
tool. Front. Public Health 11:1152659.
doi: 10.3389/fpubh.2023.1152659
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©2023 Smith, Iellamo, Nguyen and Mathisen.
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terms.
The volume and monetary value
of human milk produced by the
world’s breastfeeding mothers:
Results from a new tool
Julie P. Smith1,2*, Alessandro Iellamo3, Tuan T. Nguyen4and
Roger Mathisen4
1National Centre for Epidemiology and Population Health, College of Health and Medicine, The
Australian National University, Canberra, ACT, Australia, 2Crawford School of Public Policy, College of
Asia and the Pacific, The Australian National University, Canberra, ACT, Australia, 3Independent
Researcher, London, United Kingdom, 4Alive and Thrive, FHI 360/FHI Solutions, Hanoi, Vietnam
The Mothers’ Milk Tool was developed to make more visible the economic value
contributed to society by women’s unpaid care work through breastfeeding
infants and young children. This manuscript describes the development and
display key features of the tool, and reports results for selected countries. For the
development, we used five steps: (1) defining the tool by reviewing existing tools
and scholarly literature to identify uses, approaches, design features, and required
data characteristics for a suitable product; (2) specifying the best open-access
data available for measurement and easy updating; (3) analyzing development
options; (4) testing predictive models to fill identified breastfeeding data gaps; and
(5) validating the tool with prospective users and against previous research. We
developed an Excel-based tool that allows working oine, displaying preloaded
data, imputing data, and inputting users’ data. It calculates annual quantities
of milk produced by breastfeeding women for children aged 0–35.9 months,
and the quantities lost compared to a defined biologically feasible level. It
supports calculations for an individual mother, for countries, and global level.
Breastfeeding women globally produce around 35.6 billion liters of milk annually,
but 38.2% is currently “lost” due to cultural barriers and structural impediments to
breastfeeding. The tool can also attribute a monetary value to the production. In
conclusion, the Mothers’ Milk Tool shows what is at risk economically if women’s
important capacity for breastfeeding is not protected, promoted, and supported
by eective national policies, programs, and investments. The tool is of value to
food and health policymakers, public ocials, advocates, researchers, national
accountants and statisticians, and individual mother/baby dyads, and will assist
consideration of breastfeeding in food balance sheets and economic production
statistics. The tool supports the 2015 Call to Action by the Global Breastfeeding
Collective by facilitating the tracking of progress on breastfeeding targets.
KEYWORDS
breastfeeding, economic evaluation, feminist economics, milk production, food systems,
maternal and child health, reproductive labor, unpaid work and production
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Smith et al. 10.3389/fpubh.2023.1152659
Highlights
- Milk provided by breastfeeding mothers is a crucial but largely
invisible national food resource.
- The economic value of women’s milk production can and
should be measured, to ensure this contribution is visible and
properly valued.
- Much valuable production of this food is “lost” due to cultural
barriers and structural impediments to breastfeeding.
- Supportive breastfeeding culture is an important national
capital asset with large economic value.
- Breastfeeding provides food security for a country’s children
while minimizing food system pressures on the environment.
1. Introduction
1.1. The importance of breastfeeding for
nutrition and health
A large volume of epidemiological evidence and many studies
reaffirm the nutrition and health impacts of breastfeeding and
support a growing global focus on the investment case for
breastfeeding promotion. Lack of breastfeeding costs lives, and
deprives young children, their mothers, and their countries of
important health, human capital, and economic impacts (1–3).
The economic contribution made by women through
breastfeeding is still largely invisible in economic data and fiscal
decision-making (3). Applying economic frameworks for analyzing
human milk production may raise awareness of the public policy
importance of women’s economic productivity in this unique
unpaid care work.
Economists have long been aware of the limitations of
conventional economic accounting systems for measuring
economic activity and material well-being (4–8). Feminist
economists have criticized the failure of the System of National
Accounting (SNA) to count women’s unpaid and reproductive
work as economic production and its exclusion from supposedly
objective measures such as Gross Domestic Product (GDP), which,
in principle, covers all transactions in economic goods and services.
In her 1988 book, Counting for Nothing, Marilyn Waring discussed
(9) the need to value women’s work, including reproductive and
care work such as breastfeeding, in GDP.
Economic statisticians and national accounting experts have
now acknowledged the crucial, unpaid role of families in building
human capital, such as through investments of parental time
in health care and education (10). Indeed, a 2009 review of
GDP measurement for the French President led by two of the
world’s leading economists, Nobel prize-winners Amartya Sen and
Joseph Stiglitz (11), cited human milk production as an example
of how current practices for measuring GDP devalued women’s
unpaid work and biased policymaking. They stated that breastmilk
constitutes a “serious omission in the valuation of home-produced
goods, which is clearly within the SNA production boundary, is
quantitatively non-trivial and has important implications for public
policy and child and maternal health.”
The invisibility of women’s economic contribution in national
economic statistics contributes to policy bias against protecting
and resourcing nonmarket production (12). Scholars have pointed
out the significant consequences of the lack of recognition of
women’s unpaid work for policy advocacy, design, implementation,
and evaluation (12–14). Policies that acknowledge the importance
of the valuable non-market production involved in breastfeeding,
and the need to protect it, include “breastfeeding-friendly” health
and maternity care services, more adequate paid maternity leave,
and effective regulation of marketing and promotion of breastmilk
substitutes. Such policies are identified in the WHO/UNICEF
Global Strategy (15), and more recently represented in the 2015
Call for Action on Breastfeeding (16). The latter particularly
emphasized the importance of strengthening monitoring systems
to track progress toward achieving global and national policy
targets on breastfeeding.
Ignoring breastfeeding also discounts the highly valuable
role families, and in particular, mothers, play in human capital
development (10). However, more than three decades on from
changes to the SNA in 1993 that allow for counting human
milk production in GDP, the problem of valuing breastfeeding in
economic statistics remains largely unaddressed and ignored in
public policy formulation (17).
1.2. Including human milk in food statistics
and GDP
Broadly, there are three types of macroeconomic studies
of breastfeeding, including studies on (1) the economic and
health system costs of low breastfeeding rates; (2) the costs of
breastfeeding protection, promotion, and support programs; and
(3) the economic value of breastfeeding and economic costs of
‘lost milk’.
Two existing online tools - the Cost of Not Breastfeeding (CNB)
Tool, and the World Breastfeeding Costing Initiative (the WBCi
Costing Tool) - provide the means to calculate the country-level
costs of not breastfeeding (2,18), and the financing needs to invest
in implementing strategies on infant and young child feeding (19).
The PROFILES Tool for Calculating Health, Child Spacing and
Economic Benefits of Breastfeeding (BOB) was developed as part
of a larger process of nutrition policy dialogue to calculate the
costs of not breastfeeding alongside the macroeconomic value of
breastfeeding (18,20) but has not been widely used or promoted.
The Mothers’ Milk Tool has been developed to complement
and build on these other tools. The tool makes visible the economic
value contributed to society by women’s unpaid care work through
breastfeeding infants and young children.
1.3. Aims
To develop an online and downloadable tool to estimate
the economic value of breastfeeding and the monetary value
of “mothers’ milk.” We envisage that this evidence-based and
user-friendly “mothers’ milk” tool will be used by policymakers,
advocates, national accountants/statisticians, and researchers to
estimate the economic value of breastfeeding and the economic
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Smith et al. 10.3389/fpubh.2023.1152659
costs of “lost mothers’ milk” to support advocacy for breastfeeding-
friendly environments. Specific objectives are to (1) describe the
development process of the tool, (2) display key features of the tool,
and (3) report estimates for selected countries.
2. Methods
The design of the Mothers’ Milk Tool draws on more than 40
years of research. The development process used 5 steps: define,
measure, analyze, design and develop, and verify - DMADV (21,
22).
2.1. Step 1: Definition
2.1.1. Users and uses
In the first step, existing tools and scholarly literature
estimating the economic value of breastfeeding were reviewed to
identify uses, approaches, design features, and data that could be
adopted in the development and definition of a suitable product. To
identify the key design and methodological issues for such studies, a
detailed review was conducted to identify all relevant studies of the
macroeconomic value of breastfeeding, and extract summary data
on their coverage, data, methods, and results.
The review identified that significant but diverse literature
exists on the economic value of breastfeeding. The review found
around 65 country estimates of the macroeconomic value of
breastfeeding, for a total of around 25 countries.
The geographic areas covered included Europe, Asia, America,
Africa, and Australasia. Several studies produced estimates for
groups of countries, and/or for the whole world. Estimates go as
far back as 1908, and up to 2018, and for several countries in the
1950s, 1960s, and 1970s. Most identified the quantities and values of
milk produced for infant and young child populations aged 0–23.9
months. However, some country estimates were for ages 0–35.9
months. A small number of estimates were of breastmilk supplied
for infants only, aged 0–11.9 months or less. The results of the
review confirmed not only the relevance but also the feasibility,
utility, and sustainability of counting breastmilk as part of national
economic statistics. Norway’s reporting systems were identified as
a model for initial steps toward making the value of mothers’ milk
visible within a food surveillance framework.
This review also considered the potential uses and users
of the tool. Most studies aimed to improve the visibility of
breastfeeding; motivations included the desire to provide better
scientific information for public policy and budgeting decisions;
reduce the public invisibility of women’s productivity, including
breastfeeding; and highlight the need for measures to prevent or
address declines in breastfeeding. Some studies were conducted
by nutritionists working for international agencies, while others
advocated for the government to develop breastfeeding policies
and programs. For example, in the early 1970s, World Bank
nutrition advisor Alan Berg documented the expanding economic
loss associated with formula feeding replacing breastfeeding in
countries such as Chile, Kenya, Singapore, and the Philippines over
the previous decade, aiming to motivate public action to reverse this
decline (23). Likewise, pediatrician Jon Rohde (24–26) calculated
the quantities of human milk production in Indonesia during the
1970s and 1980s to emphasize the importance of breastfeeding in
the second year of that country’s food supply and nutrition policies.
A study led by nutritionist Stina Almroth in 1979 presented
estimates of the economic value of breastfeeding for Ghana and
the Ivory Coast to inform FAO considerations of breastfeeding as
infant food, for infant health protection, and child spacing (27).
Later studies from the 1990s demonstrated the magnitude of
production and the macroeconomic value of mother’s milk for
countries in Latin America, Sub-Saharan Africa, China, and India
(27–32). Studies led by (25,26) pediatrician Arun Gupta produced
estimates for India (28,32). The PROFILES project (see above)
provided estimates of breastmilk production and its financial value
for Bolivia, China, and the countries of West Francophone Africa.
This showed for example that the volume of human milk produced
in China was around 4 billion liters in 2001 (20,33). Notably, at
a time when human milk was priced at around $50 a liter in high-
income countries such as the US and Norway, the 1997 study of
the countries of Sub-Saharan Africa a study by nutritionists Anne
Hatloy and Arne Oshaug found that given a monetary value of just
$1 per liter, the economic value of human milk production ranged
from 5 to 15% of the GDP of those countries (34). Until 1994 (35),
nearly all studies calculated the value of human milk by estimating
output in physical units and then valuing it using the market price
of an alternative commodity.
2.1.2. Required tool outputs and other capabilities
The review of studies indicated that measures of actual,
potential, and lost milk were the common outputs of interest
to users. Also, useful would-be comparisons with national or
international targets and benchmarks as well as the capacity to
calculate results for significant age categories within the 0–35.9
months age range. For example, some studies examined 12–23.9
months, or 0–5.9 months, while the majority looked at 0–23.9
months including 0–11.9 months.
This analysis of the literature also indicated that the
tool should have both online and offline versions to cater
to diverse uses as well as the intended end use. Potential
use includes calculating the production of human milk
within food surveillance systems, allowing policymakers to
use the results to monitor the results of food security and
nutrition policies. Another potential use is the provision of
evidence for non-government advocacy, where users from
civil society or international agencies could demonstrate the
economic significance of breastfeeding and highlight the need
for policies targeting breastfeeding protection, promotion,
and support.
The review also demonstrated that the tool must present key
results for selected countries as well as the world, allowing users to
see country-level results from a wider comparative perspective. The
design also needed to be flexible to meet the main customization
needs of policymakers, advocates, researchers, and individuals
worldwide, and to allow for future updates and enhancements.
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In light of the available budget for tool development, a basic
version was planned for rapid development and release, to add
further enhancements over time based on feedback from users. The
type of enhancements being considered is further discussed in the
concluding section.
2.2. Step 2: Measurement
Step 2 specified the best open access data available for
measurement, and assessed which data allowed future modules to
be easily updated. Previous studies used a variety of data sources
for key inputs to the calculations, making comparisons difficult.
This highlighted the need for the tool to use consistently available
open-access data for countries to make the best estimates. It is also
important for future modules to be easily or automatically updated
with key default data in a timely and efficient manner.
There are four key measures. First, the number of infants and
young children aged 0–35.9 months is approximated by UNICEF
databases (36). UN population estimates data on live births for the
base year and estimated number of children in the first, second,
and third years of life. Second, we used country survey data on
continued breastfeeding rates, such as from Demographic and
Health Surveys (DHS) and Multiple Indicator Cluster Surveys
(MICS), as the basis for predicting breastfeeding rates for infants
and young children by month, 0–35.9 months for most countries
(37). Third, estimates of human milk intake by child age (i.e.,
by month, every six months, and overall three years), based on
reliable and commonly used studies of energy intake in breastfed
children. This is a fixed element of the tool and provides for
a total of 431 liters of milk produced over the 36 months of
lactation, derived from two authoritative studies, and based on
their published estimates for partially breastfed infants, converted
from grams to milliliters (34,38). Fourth, a price per liter of
human milk of US$100 per liter is based on the official price for
fresh human milk within Norway’s human milk banking system
(39,40). Alternative prices are summarized and discussed briefly
in Supplementary material 2.
2.3. Step 3: Analysis of tool design options
Due to the different potential uses and users and the
limitations of the data, we considered two main stages for the tool
development: a basic module and a customizable module.
The basic module would include a dashboard that shows the
findings and estimations of a selected country or the world using
the newest possible preloaded data. This module can also impute
missing values of continued breastfeeding to provide a more precise
estimate of the value of breastmilk.
The tool would also provide for customization, so users can
input alternative data such as breastfeeding rates, the size of the
population, the market value of human milk, and the currency
exchange rate for the country of interest.
The tool would allow an individual mother to enter her own
breastfeeding experience to calculate the amounts of milk provided
for her child.
2.4. Step 4: Tool development
Tool development focused on identifying and pre-loading
key data sources and developing a suitable predictive model for
breastfeeding rates.
It also required the investigation of a suitable basis for
estimating milk production levels and exploring sources of
evidence on the daily milk intake of breastfeeding children. A
further area of investigation was the biologically feasible potential
production. The difference between this and actual production
levels is the “lost” milk production calculated by the tool.
The key data sources and analyses behind the estimates are
discussed in Supplementary material 1.
2.4.1. Initial development
Initial investigation of the goals for the tool identified the
need for a downloadable tool that can be easily updated with
low investment. This stage also identified the need for the user
to be provided with key parameters which were fixed in the tool,
as well as the potential for the user to make calculations using
alternative data sources on breastfeeding or numbers of children
born and breastfed.
While the main interest was in country-level estimates, sub-
national and individual mother calculations were also identified as
useful for meeting tool goals.
The primary goal identified was advocacy, but additional
potential uses included mothers calculating production volume or
values over the breastfeeding period as motivation, as well as health
professionals supporting and encouraging breastfeeding mothers.
2.4.2. Internal discussions, external consultation,
and improvements
Discussions held fortnightly during 2021 by members of the
Organization 1 and Organization 2 teams resulted in agreed-upon
priorities for the first stage basic version of the tool, and priorities
for enhancement in future upgrades.
The most important revisions during the development phase
were to align the tool with the 0–35.9 age group for infant
and young child feeding. Many previous studies were for 0–
11.9 months, or at most 0–23.9 months. The tool is unique in
its provision of data for the extended age range, which fits into
the WHO/UNICEF recommendations for breastfeeding beyond 2
years of age.
The development of the tool also considered the maximum
biologically feasible levels of breastfeeding. The tool calculates the
lost milk on the basis that 98% of mothers can breastfeed, based on
contemporary data from Norway (41) and a review of the median
weaning age in traditional or non-industrial populations (42).
Data gaps also influenced tool design. Although DHS surveys
include breastfeeding data for 0–35.9 months, the MICS did not.
Also, few high-income countries consistently collect data, especially
beyond 11.9 months, and some had no recent data. Many did not
have data on exclusive breastfeeding. With the substantial data
gaps evident during the analysis phase, it became necessary to
invest in developing a prediction model for monthly breastfeeding
rates for children ages 0–35.9 months. The tool bridges these data
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gaps to calculate predictions of breastfeeding at each month of age
from available national data. This predictor uses a cubic regression
model for most countries, though in some countries the best fit was
predicted by a linear regression model.
In several countries where traditional breastfeeding practices
are largely intact, the value of breastfeeding was substantial to
the market economy (as measured by GDP). This pointed to the
importance of deciding on how to attribute a monetary value
to breastfeeding to allow this comparison with the conventional
official measurement of economic value. Few studies attempted to
value the act of breastfeeding per se (43,44); while breastfeeding
can be conceived of as an unpaid care service within an economic
accounting framework, most studies calculated its value by
reference to a price proxy for the human milk produced; that is,
as a food commodity. The focus was on measuring the economic
value of breastfeeding by estimating the national monetary cost of
buying or importing commercial milk formula. Nearly all studies
used the cost of replacing breastmilk with either fresh or formula
milk to infer the economic value of breastfeeding.
The Mothers’ Milk Tool places a monetary value of US$100
on human milk produced by breastfeeding women. This is linked
to the price of fresh human milk exchanged within the not-for-
profit hospital milk bank network in Norway where a US$20
per liter reimbursement of costs is made to donating mothers
(39). Price increases are regulated by the Norwegian government
and increases reflect cost recovery principles since the 1990s.
Alternative prices were evaluated in previous studies (43–45) (see
Supplementary material 2).
There were two stages of piloting the Mothers’ Milk Tool, which
occurred during the early weeks of 2022. We aimed for a range of
potential user groups to be represented in the two testing groups,
coming from a diverse range of countries and global regions.
Several improvements were implemented after piloting, mainly to
improve presentation and clarity and address functionality issues.
2.4.3. Formatting the tool
A suggestion from reviewers on the first version was to follow
a branding guideline. The branding guidelines from Organization
2 were selected and used consistently to design the Mothers’ Milk
Tool. Based on the comments, additional information was added,
such as the introduction, policy brief, and references, to make the
tool more comprehensive and standalone.
2.4.4. Description and display of key features of
the tool
Figure 1 illustrates the key functions of the Mothers’ Milk Tool,
including both country and individual calculators. The individual
calculator allows for the estimation of individual production and
value for each child of a user based on the duration of breastfeeding.
The user is to enter the information on the months she breastfed
her child, and the tool will help to estimate the volume and value
of breastmilk. The user can enter and obtain information for other
children. This function could be used by breastfeeding counselors
during breastfeeding promotion and support.
FIGURE 1
Key functions of the Mothers’ Milk Tool. Authors created this figure using snapshots of the Mothers’ Milk Tool oine (https://mothersmilktool.org).
The human identifiable images are licensed for personal, business or commercial purposes.
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For the country calculator, the Mothers’ Milk Tool
will provide the country’s breastfeeding rates and chart
using preloaded data. When the data are not up-to-date or
missing, the users have the option to input the missing data
using the predictor or enter their own-source data. Using
the data, the Mothers’ Milk Tool will estimate the annual
TABLE 1 Estimate of production of human milk.
Child age
(months) Proportion of
children
breastfed (%)
Number of
children
breastfed per
month
Average volume of
breastmilk
consumed a day per
child (L)
Estimated volume of
breastmilk
consumed a month
per child (L)
Total actual annual
production of
breastmilk
(million L)
0 (<1) 93 55,800 0.59 18 0.99
1 89 53,400 0.68 20 1.08
2 85 51,000 0.71 21 1.08
3 82 49,200 0.68 20 1.01
4 79 47,400 0.69 21 0.98
5 78 46,800 0.59 18 0.83
6 72 43,200 0.55 17 0.71
7 68 40,800 0.4 12 0.49
8 63 37,800 0.48 14 0.55
9 58 34,800 0.67 20 0.70
10 51 30,600 0.5 15 0.46
11 48 28,800 0.48 14 0.42
12 34 20,400 0.37 11 0.23
13 29 17,400 0.37 11 0.19
14 24 14,400 0.37 11 0.16
15 21 12,600 0.37 11 0.14
16 20 12,000 0.37 11 0.13
17 16 9,600 0.37 11 0.11
18 14 8,400 0.37 11 0.09
19 12 7,200 0.37 11 0.08
20 11 6,600 0.37 11 0.07
21 10 6,000 0.37 11 0.07
22 9 5,400 0.37 11 0.06
23 8 4,800 0.37 11 0.05
24 0 – 0.24 7 –
25 0 – 0.24 7 –
26 0 – 0.24 7 –
27 0 – 0.24 7 –
28 0 – 0.24 7 –
29 0 – 0.24 7 –
30 0 – 0.24 7 –
31 0 – 0.24 7 –
32 0 – 0.24 7 –
33 0 – 0.24 7 –
34 0 – 0.24 7 –
35 0 – 0.24 7 –
Methodology based on Norwegian Health Directorate 2020 (46) and Smith et al. 2022 (47).
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TABLE 2 Average volume (liters) of human milk intake by a child and by
month of age in studies on economic value of breastfeeding.
Months of infant age∗
Authors/Months of
infant age∗
0–11.9 0–23.9 0–35.9
Smith (48) 228 307 –
Norwegian Health Directorate (49) 225 306 –
WHO∗(38) 291 (214) – –
Aguayo et al.∗(29) 243 (225) 443 (436) 536 (518)
Smith (44) 224 331 –
WHO∗(50) 256 (226) 450 (421) –
Hatloy and Oshaug (34) 230 369 462
National Nutrition Council (51) 228 307 –
Oshaug and Botten (35) 224 331 –
Gupta and Khanna (32) 201 347 –
Almroth et al. (27) 234 380 –
Rohde (25) 180 288 360
Berg (23) 247 375 –
∗Values in brackets are for partial breastfeeding.
production, potential production, and lost breastmilk and
their values.
Table 1 illustrates calculations for a single country for a single
year for infants and young children aged <36 months.
Table 2 summarizes yields that were assumed in previous
studies.
Table 3 provides information on sources of data on births and
breastfeeding survey dates used in the calculations.
2.5. Step 5: Tool validation
During development, data from several countries were entered
into the tool, and results were compared with results from
published studies for the relevant country to assess the validity
of tool outputs (Supplementary material 3). This table compares
results from the original study, with calculations using the tool.
The calculations using the tool use the same birth and breastfeeding
data as the original studies, but not the milk intakes/yields assumed
in those studies, so differences arise mainly from differences
in methodologies or differences in assumed yields. Reasons for
variance are indicated in the table on this basis.
The tool was also validated by inviting country IYCF and
breastfeeding experts to provide feedback on its functioning,
usefulness, plausibility, and reliability of the results and underlying
assumptions for that country. A total of 16 potential users
responded to the invitation for testing the tool. Respondents were
from 12 countries, and their self-described occupations or interest
in the tool included advocate, nutritionist, economist, director,
peer counselor, nutrition specialist, lactation consultant, medical
doctor, and independent consultant. Feedback was centered on the
functionality and utility of the tool. User feedback from testing is
reported in Supplementary material 4.
2.5.1. Country selection and estimates
Estimates were made for a selection of high-, middle- and low-
income countries from the global regions, using the prediction
model for all those countries where complete breastfeeding data
was not available. These countries reflect a diversity of breastfeeding
prevalence, some maintaining intact breastfeeding practices at
levels consistent with those reported for non-industrial or historical
populations, and others with very disrupted breastfeeding practices.
Global production was estimated for low- and middle-income
countries (LMICs) only due to data limitations for high-income
countries (HICs).
For a small number of countries, the estimates were tested using
historical data series, and for other countries, it was possible to
compare the results of the tool with published estimates made at
another point in time for the same country. The country selection
also reflected large, medium, and small populations, which may
approximate the extent to which they are a profitable market for the
expansion of commercial milk formula and other baby food sales.
2.5.2. Continuous tool improvement
After successfully launching the Mothers’ Milk Tool offline,
we developed the Mothers’ Milk Tool online (Figure 2). We are
collecting user feedback to continue improving both online and
offline versions. The offline tool is available in English and French,
while the online tool is available in almost all languages. There are
challenges to the development and use of the tools. Breastfeeding
indicators are not or only partially available or out-of-date in select
countries, which alters the calculation. Countries need to collect
and publish this data regularly. We need to use regional estimates
or fill in the information using the predicted model. We need to
search for newly available data to update the tool. The currency
exchange rate and the number of children born each year have not
been updated since the development of the tool. We plan to update
the offline tool periodically and develop an option for updating
background information in real-time for the online tool.
2.6. Reflexivity statement
This paper is written because of the researchers’ shared
beliefs that women’s unpaid work including breastfeeding is not
well addressed by conventional economic studies which focus
on the market economy, to the disadvantage of women and
children, and that this reduces the resources invested in programs
which are important to the health of women and children in
particular breastfeeding. Our focus is on low- and middle-income
countries but our study includes global and high-income country
perspectives due to our concern to highlight that the latter present
a pathway on infant and young child feeding which may harm
women’s and children’s health if followed by LMICs.
The authors include one female who is the lead author and three
males, and the research team is based in Australia, Vietnam, and
London. The three male authors have many years of experience
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TABLE 3 Source of breastfeeding data.
Country/Location Source of breastfeeding data Year Annual Livebirths
Australia Australian infant feeding survey 2010 339,000
Brazil Health and nutrition survey 2019 2,871,000
Canada Community health survey 2009 402,000
India National health family survey 2005–2006 24,143,000
Indonesia Demographic and Health Survey 2017 4,466,000
Ireland Breastfeeding on the Island of Ireland, Report 3 2013 57,000
Kenya Demographic and Health Survey 2014 1,418,000
Nepal Multiple Indicator Cluster Survey 2019 545,000
Nigeria Demographic and Health Survey 2018 7,894,000
Norway Directorate for Health and Social Affairs, 2020 60,000
Philippines Demographic and Health Survey 2017 1,955,000
United Kingdom National survey 2011 744,000
USA National immunization survey 2018 3,991,000
Viet Nam Multiple Indicator Cluster Survey 2013–2014 1,592,000
Global UNICEF infant and young child feeding database 2020 136,077,713
FIGURE 2
Layout and key features of the Mothers’ Milk Tool online. Authors created this figure using snapshots of the Mothers’ Milk Tool online (https://
mothersmilktool.org). The human identifiable images are licensed for personal, business or commercial purposes.
in low- and middle-income countries on programs supporting
maternal and child nutrition including in emergencies. The lead
author is a former government economist and tax analyst and
a qualified breastfeeding counselor in Australia with extensive
experience and commitment to supporting women to overcome
societal and personal barriers to breastfeeding and to advocate
for societal changes to enable them to breastfeed to the extent
they see as optimal for their health and wellbeing. The four of
us have collaborated since 2020, based on a common interest in
improving the measurement of the economic value of breastfeeding
and the economic and health system costs of not breastfeeding.
In this collaboration, we have sought to develop a robust tool
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Smith et al. 10.3389/fpubh.2023.1152659
in collaboration with the diverse users, which draws on positivist
economic approaches to monetary valuation of non-marketed
production yet is also respectful that many women and cultures
view it as unnecessary and even devaluing to place a monetary
value on breastfeeding. We also respect the loving care that
mothers offer their infants and young children regardless of how
they decide to feed their children in the circumstance of their
individual lives.
3. Results
3.1. Global estimates and estimates for
selected countries
3.1.1. Global production
Global production was around 35.6 billion liters a year. This
represents just under half the potential production if women and
children 0–35.9 months were universally enabled to breastfeed
optimally (Table 4). Valuing the lost milk at around US$ 100 a
liter represents a monetary loss of production of US$ 2.2
trillion annually.
Key results for the selected countries (Australia, Brazil,
Canada, India, Indonesia, Ireland, Kenya, Nepal, Nigeria, Norway,
Philippines, United Kingdom, USA, and Viet Nam) and the world
are presented in Table 4.
Among high-income countries, human milk production ranges
from around 11 million liters in Norway, 605 million in the USA,
and 51 million in Australia (countries where around two-thirds of
potential production is lost) to 4 million liters in Ireland. In Ireland,
around 80% of mothers’ milk is lost.
Among low-income countries, Nepal maintains human
milk production at high levels (221 million liters annually)
with less than 5% lost. Other countries such as Kenya,
Nigeria, and Vietnam currently lose around a third or less
of production. Likewise, middle-income countries such
as Indonesia and The Philippines lost around a third of
potential production.
The most populous country, India, lost nearly 40%,
respectively, with a production of around 8.7 billion liters
a year.
3.1.2. Monetary values of mothers’ milk
production
In monetary terms, the value of human milk production
is substantial in most of the selected countries (Table 5). The
monetary value of lost mother milk ranges from around US$ 146.2
billion in India to US$ 900 million in Nepal.
4. Discussion and implications
4.1. Key findings and strengths of the study
Human milk produced for infants and young children by
breastfeeding mothers is a crucial national food system; this
production contributes substantially to national and global food
security and health, though much is also “lost”.
The economic value of this food production by breastfeeding
mothers can and should be measured, to ensure that this important
economic contribution is visible, properly valued, well-protected,
and sufficiently resourced to continue.
A culture of breastfeeding is an important national capital asset
with large economic value, which generates a substantial quantity of
safe, nutritious, healthy, and environmentally sustainable food for
a country’s infants and young children. A supportive breastfeeding
culture protects the reproductive health of women and minimizes
food system pressures on the environment.
Where a breastfeeding culture is not visible, valued, and
resourced, breastfeeding will diminish, and milk production
capacity is lost, due to market pressures from commercial
milk formula, hence countries’ important ’cultural capital’ of
women’s breastfeeding knowledge, skills, and experience should
be protected, and investments made in breastfeeding protection,
support and promotion to prevent and restore Lost Milk.
4.2. Limitations
The accuracy and capabilities of the Mothers’ Milk Tool
remain limited by the gaps in available data. The tool does
not adjust for exclusive breastfeeding rates during the first 6
months because of data limitations for breastfeeding prevalence
and milk intake. Breastfeeding prevalence data is particularly
lacking in high-income countries. Up-to-date scientific knowledge
is also lacking regarding the biologically feasible potential levels of
breastfeeding and the usual human milk intake, particularly among
young children.
Several enhancements have been identified during
development that can be considered for future improvement
of the tool. These include modifications to increase its accuracy,
flexibility, functionality, and add-on modules to broaden the
tool’s capabilities.
For example, the basic model could be modified to recognize
that infant and young child mortality is high in some countries,
and the number of births will be higher than the number of
breastfeeding children. Especially if better scientific data were
available, greater flexibility could also be added to the tool to
vary its assumptions about the milk intake of young children
who are breastfeeding. Also, breastfeeding has some energy costs
for the mother; users could be given the option of adjusting
the monetary value of production for the cost of any additional
necessary nutrition for mothers.
Modifications to allow other approaches to placing a monetary
value on human milk can also be considered. Options include
allowing the user to enter information on wages for women
employed as wetnurses to calculate monetary values per liter of milk
or per day of breastfeeding. Similarly, the value of maternal time
invested in breastfeeding can also provide an input-based proxy for
the monetary value of the milk produced. Estimates of maternal
time inputs over the breastfeeding period could be incorporated
into the existing tool using available data from time-use studies of
breastfeeding and childcare. As commercial trade in human milk
expands, using new sources of market data can also be explored for
monetary valuation.
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TABLE 4 Estimated amounts and values of actual and potential human milk production by country for children aged 0–36 months.
Country/Location Year Total production, at current
breastfeeding rates
(million Liters)
Potential production of
breastfeeding
(million Liters)
% of
breastmilk
lost
Australia 2010 50.8 143.2 64.5
Brazil 2019 425.4 1,212.9 64.9
Canada 2009 54.5 169.8 67.9
India 2017 8,737.6 10,200.0 14.3
Indonesia 2017 1,210.7 1,886.8 35.8
Ireland 2013 4.4 24.1 81.7
Kenya 2014 450.9 599.1 24.7
Nepal 2019 221.3 230.3 3.9
Nigeria 2018 2,150.4 2,997.1 28.3
Norway 2018–2019 10.7 25.3 57.8
Philippines 2017 574.5 826.0 30.4
United Kingdom 2011 58.0 314.3 81.6
USA 2018 604.5 1,686.1 64.1
Viet Nam 2013–2014 423.3 672.6 37.1
Global 2022 35,556.0 57,490.5 38.2
“Year” refers to the year in which available breastfeeding data is reported.
TABLE 5 Estimated production values and “lost milk” by country.
Country/Location Year Value of total breastmilk
production
(million US$)
Value of breastmilk lost
(million US$) Predicted
Australia 2010 5,079.55 9,242.6 Yes
Brazil 2019 42,538.66 78,756.1 Yes
Canada 2009 5,452.83 11,531.0 Yes
India 2017 873,755.44 146,244.7 No
Indonesia 2017 121,070.40 67,610.4 No
Ireland 2013 440.78 1,967.4 Yes
Kenya 2014 45,093.29 14,814.8 Yes
Nepal 2019 22,125.00 900.3 No
Nigeria 2018 215,038.69 84,670.6 No
Norway 2018–2019 1,069.53 1,465.4 Yes
Philippines 2017 57,446.25 25,149.1 No
United Kingdom 2011 5,796.39 25,636.3 Yes
USA 2018 60,451.21 108,161.7 Yes
Viet Nam 2013–2014 42,334.06 24,925.2 No
Global 2022 3,555,597.42 2,193,451.7 Yes
“Year” refers to the year in which available breastfeeding data is reported.
The individual mother component of the tool could be
modified to provide production data for multiple children,
and for distinguishing between months of exclusive and partial
breastfeeding. Important but more complex programming
enhancements that could be added to the tool functionalities
for countries include per capita production estimates which
would improve its value for cross-country comparisons, as well as
flexibility and pre-loaded data to allow time trend analysis. This
would also further assist in tracking progress against policy targets.
Where countries have policy targets for breastfeeding, the tool
could be enhanced to measure the gap between the actual and target
level of human milk production. The tool could also provide a
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Smith et al. 10.3389/fpubh.2023.1152659
page with a prefilled advocacy brief for explaining and presenting
country results to policymakers in a suitable format to motivate and
guide policy action.
Furthermore, by linking the estimates of lost milk production
to country data on the volume of milk formula sales or usage,
the Mothers’ Milk Tool could provide a suitable platform for
calculating environmental savings at current breastfeeding rates,
and the potential costs (such as increased greenhouse gas emissions,
and water use) of further declines in breastfeeding.
The scope for linking the Cost of Not Breastfeeding Tool to
Mothers’ Milk Tool results for lost milk production could also be
explored. Together these tools can help present the investment case
for breastfeeding. Furthermore, tools such as the WBCiCosting
tool are available to estimate the financing costs of breastfeeding
policies and programs (19). We suggest the need to also develop
ways of linking these tools to facilitate formal economic evaluations
of country-level interventions.
4.3. Policy implications
The tool provides the potential for many countries to revisit
their current maternal, newborn and child health, early childhood
nutrition, and food security strategies. Policymakers will be able
to compare the large monetary value of these current losses
against larger potential losses if current levels of breastfeeding
are not protected; the ability to minimize losses by increasing
social investments in building a more enabling environment for
breastfeeding will also be made visible.
The tool can also illustrate the extent to which a country’s
breastfeeding practices are providing mitigation, adaptation, and
resilience to climate change risks, and may assist with planning for
humanitarian emergency responses.
Human milk is valuable for its nutritional and immunological
characteristics. Using a market price to place a monetary value on
it is possible because breastfeeding is increasingly commodified.
Human milk and human milk products are being bought and sold.
This raises important policy issues but is beyond the scope of this
study. This important discussion of feminized poverty and lack
of adequate policy support for breastfeeding as a key driver of
commodification trends is considered elsewhere (52–54).
Several studies have looked at the cost of key policies to better
enable women to breastfeed, though a recent review of costing
studies concluded that the availability of cost estimates was limited
and more standardized costing frameworks are needed (55).
4.4. Implications at the country level
The tool has been verified through comparison with published
estimates of human milk production in several countries. This
shows good alignment with estimations for a variety of settings and
diverse methodologies.
The results show that the $6 billion daily value of lost
mother’s milk production can be considered alongside the US$1
billion a day of health and human costs directly attributable to
not breastfeeding that has been calculated by the Cost of Not
Breastfeeding Tool (2).
With advances in the state of scientific knowledge about
the acute and chronic disease impacts of not breastfeeding, it
could be expected that these estimates would increasingly align
(44). For example, some health services are already willing
to pay high prices for donor human milk as the health
cost savings are well documented for premature or vulnerable
infants, and this is reflected in the monetary values used in
the Mothers’ Milk Tool. However, there remain considerable
gaps in data and knowledge about the broader maternal and
child health impacts of not breastfeeding and the economic cost
consequences. As evidence accumulates on the health differential
for non-breastfeeding mothers and children, including for chronic
diseases, the measured costs of not breastfeeding will tend
to rise.
The lack of key data especially in high-income countries
means the important trends in potential health costs and
losses arising from insufficient breastfeeding are invisible to
policymakers. There is an urgent need for regular, comprehensive,
and accurate measurement of breastfeeding prevalence in all
countries to track trends and inform a range of public policies.
Systematic data collection on prices charged by human milk banks
for fresh and pasteurized milk should also be prioritized and
published regularly.
5. Conclusions
The Mother’s Milk Tool estimates the volume of human milk
currently being produced, and the volume that is potentially at
risk if women’s important production capacity for breastfeeding
is not protected, promoted and supported by effective national
policies and programs. It also calculates how much is currently
being lost at national, regional, and global levels. Monetary values
are also indicated.
The estimates show the breastfeeding mothers’ substantial
contributions to food production, and how much of this healthy
and sustainable foundation food is lost or at risk as ultra-processed
commercial baby foods, including conventional cows’ milk-based
commercial milk formula products, are more widely marketed. In
some North American and European countries, as much as 70–80%
of potential milk production is lost, a phenomenon arising from
cultural barriers or structural impediments to breastfeeding. Some
middle-income countries are approaching these levels.
The tool also informs on a range of other economically
relevant consequences such as a country’s potential educational
attainments, human capital development, poverty alleviation, non-
communicable disease prevalence, and policies for climate change
risk, adaptivity, and resilience.
We anticipate the Mother’s Milk Tool to be a user-
friendly resource that is open-source, adaptable, and useful for
a variety of users. The Mothers’ Milk Tool can be used by
policymakers, advocates, and researchers for their decision-making
and programming, and advocacy on the seven policy actions
set out in the 2015 Call to Action by the Global Breastfeeding
Collective. The tool will especially support the tracking of progress
on breastfeeding targets, by assisting food and health policymakers
and national statisticians to include breastfeeding in food balance
sheets and economic statistics.
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Smith et al. 10.3389/fpubh.2023.1152659
This tool can also be used by individual mother/baby dyads to
estimate the economic significance of their breastfeeding practices.
Future development could include real-time currency conversions,
languages other than English, and comparisons across countries, as
well as provide for regular maintenance and improvement of the
Mothers’ Milk Tool.
Data availability statement
The datasets presented in this study can be found in
online repositories. The names of the repository/repositories
and accession number(s) can be found in the
article/Supplementary material.
Ethics statement
Written informed consent was obtained from the individual(s)
for the publication of any identifiable images or data included in
this article.
Author contributions
Conception or design of the work and critical revision of the
article: JS, AI, TN, and RM. Data collection: JS and AI. Data
analysis and interpretation and drafting the article: JS, AI, and TN.
All authors have read and agreed to the published version of the
manuscript.
Funding
This work was supported in part by the Innovation Incubator,
FHI Solutions, the Bill and Melinda Gates Foundation (Grant
Numbers OPP-50838 and INV-042392), and Irish Aid. The views
and opinions set out in this article represent those of the authors
and do not necessarily represent the position of the donors. This
work was also partly supported by the Australian Research Council
under a Future Fellowship held by JS (FT140101260). Under
the grant conditions of the Foundation, a Creative Commons
Attribution 4.0 Generic License has already been assigned to
the Author’s Accepted Manuscript version that might arise from
this submission.
Acknowledgments
The authors thank Joe Lamport from the Alive and Thrive
initiative at FHI Solutions for the comments and suggestions to
improve this manuscript.
Conflict of interest
AI was employed as an Independent Researcher.
The remaining authors declare that the research was conducted
in the absence of any commercial or financial relationships that
could be construed as a potential conflict of interest.
Publisher’s note
All claims expressed in this article are solely those of the
authors and do not necessarily represent those of their affiliated
organizations, or those of the publisher, the editors and the
reviewers. Any product that may be evaluated in this article, or
claim that may be made by its manufacturer, is not guaranteed or
endorsed by the publisher.
Supplementary material
The Supplementary Material for this article can be found
online at: https://www.frontiersin.org/articles/10.3389/fpubh.2023.
1152659/full#supplementary-material
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