The countries where 1 in 5 children are never breastfed

A new UNICEF report released Wednesday that ranks countries by breastfeeding rates shows that in high-income countries, more than one in five babies is never breastfed, whereas in low- and middle-income countries, one in 25 babies is never breastfed.

Among the high-income countries, Ireland, France and the United States had the three lowest breastfeeding rates.

"The data and the analyses are a confirmation of a trend that we have seen for a number of years now," said Victor Aguayo, UNICEF's chief of nutrition, who was involved in the report's policy analysis.

"In higher-income countries, we see that the proportion of children who have never been breastfed is significantly higher than the number of children in low- and middle-income countries. That is a fact," he said. "We need to create environments -- including in the US -- that make breastfeeding the norm."

Based on the new report, here are the countries with the highest and lowest percentages of babies who are ever breastfed.

The factors that can make a difference

The new report included data on breastfeeding prevalence among 123 countries. Those data came from several sources, including UNICEF's global databases, the US Centers for Disease Control and Prevention, The Lancet and studies published in scientific journals such as Acta Paediatrica.

An analysis of the data showed that 95% of babies worldwide are breastfed at some point in their lives. The prevalence of breastfeeding varied among high-income countries but not so much among low- and middle-income countries.

The high-income countries in the report were Australia, Barbados, Canada, Chile, Finland, France, Germany, Ireland, Italy, Norway, Oman, Qatar, Singapore, South Korea, Spain, Sweden, the United Kingdom, Uruguay and the United States. The data for those countries were based on breastfeeding rate estimates from 2010 or more recently.

Of those countries, Uruguay ranked highest, with 98.7% of babies ever being breastfed, followed by Sweden and Oman, both with 98%.

Ireland ranked lowest among those countries, with only 55% of babies ever being breastfed, followed by France with 63% and then the US with 74.4%.

A CDC Morbidity and Mortality Weekly Report released last year found that the percentage of babies in the United States who start out breastfeeding increased from 73% among those born in 2004 to 83% among those born in 2014.

In the new UNICEF report, among the low- and middle-income nations, the data showed that nearly nine in 10 babies were breastfed, even in the countries with the lowest breastfeeding rates for that group.

The percentage of babies ever being breastfed was above 88% in all of those countries, reaching above 99% in Bhutan, Nepal and Sri Lanka.

The data for low- and middle-income countries were based on estimates of breastfeeding rates between 2010 and 2017, with the exception of China, where the estimate was based on 2008.

"The overall report by UNICEF is accurate and represents current research about breastfeeding rates around the world in countries with varied development and among different socioeconomic groups," said Pamela Mulder, assistant professor at the University of Iowa's College of Nursing, who was not involved in the report.

"At first glance, the data about breastfeeding rates may seem contradictory. Given the many benefits of breastfeeding, it may seem odd that some high-income countries have the lowest rates of breastfeeding ... while others have very high rates," Mulder said.

"Many of these differences are due to the personal, family, community, social, economic and legislative environments of the country and for each family," she said.

In Sweden, for instance, parents are given 480 days of paid parental leave, and "having paid leave gives mothers the freedom to focus on breastfeeding instead of making a choice between breastfeeding or employment," Mulder said.

On the other hand, in low- and middle-income countries, mothers often don't have a safe alternative to breast milk, and infant formula is expensive.

"Many families in low- and middle-income countries just can't afford to buy it," Mulder said.

Of course, the factors driving these differences in breastfeeding rates between countries are as much economical as they are political, Aguayo said.

"Societies change," he said. "As women join the formal or the informal work force, we see that in some countries, there is a tendency, among some women, to not breastfeed their babies anymore. If a significant proportion of women are not breastfeeding their children, it is, by and large, because mothers and woman and families aren't getting the support they need to do so."

That word -- support -- was the most important in the new report, Aguayo said, adding that support can be provided in various ways.

"Maternity leave and maternity protection are key for mothers in their breastfeeding choice, that is if women are given a six-month maternal leave so that they can stay home with their babies and breastfeed them exclusively, as we are recommending," Aguayo said.

"We also need to support women to be able to breastfeed in public places. Breastfeeding needs to be common more; breastfeeding should be supported by people in airports," for instance, he said. "The health system has a major role to do and to play in supporting mothers before delivery, during delivery and after delivery. So health professionals need to be trained to support mothers in attempting to breastfeed."

In the United States and other high-income countries, many of the babies who are less likely to breastfeed disproportionately come from poorer households and disadvantaged backgrounds, said Dr. Laura Kair, medical director of the Well Newborn Nursery at University of California, Davis Medical Center, who was not involved in the UNICEF report.

"Because of all the benefits of human milk that we know of, lack of breastfeeding could worsen health disparities among those populations," she said. "So I think it's good that these statistics exist, because it sort of gives a framework, and it highlights the importance of promoting breastfeeding to improve maternal-child health."

How long should babies be breastfed?

Joanne Silbert-Flagg, assistant professor and clinical coordinator for the MSN Entry into Nursing Program at Johns Hopkins University School of Nursing, and Deborah Busch, also an assistant professor at the university, pointed out the importance of clarifying what rates of "ever" being breastfed really mean. They were not involved in the UNICEF report.

" 'Ever breastfed' is if you ever gave some breast milk. If they say, 'Have you breastfed in the first six months? Have you provided any breast milk?' It could just be they breastfeed once or twice a day, and the rest of the time they give formula, but that would be included in 'ever breastfed,' as opposed to exclusively breastfeeding, meaning you're not giving anything other than breast milk. Whether it's pumped milk, breast milk or breastfeeding at the breast, they've received no formula whatsoever," Silbert-Flagg said.

"There's very few that exclusively breastfeed," she said. "So it's very interesting to look at research studies or how they're collecting the data, because you could skew the results to look like there's a higher breastfeeding rate if you included 'ever breastfed.' "

The American Academy of Pediatrics recommends to exclusively breastfeed in the first six months of a baby's life, followed by breastfeeding in combination with the introduction of complementary foods until at least 12 months of age.

UNICEF and the World Health Organization also recommend exclusive breastfeeding from within an hour after a baby is born until the baby is 6 months old, but thereafter, nutritious complementary foods should be added to a child's diet while continuing to breastfeed for up to 2 years or beyond.

"In the US, it's not really stressed to breastfeed after a year, and a lot of moms will feel like they need to wean at a year, even though that's not always necessary," Silbert-Flagg said. "Of course, you're only doing it maybe twice a day after a year, but still continuing to breastfeed has the health benefits."

Some mothers are unable to breastfeed for medical reasons, such as being infected with the human immunodeficiency virus, HIV, or not producing enough milk. The University of Iowa's Mulder said that those mothers should consult with a trained health care professional for support and guidance.

"Additionally, mothers can try breastfeeding in the hospital after birth and infant formula is available if breastfeeding is not working for them or their infants," she said. "They can also combine breast milk and infant formula feedings, and they can breastfeed for the time they choose, whether that be two weeks or six months."

The health benefits of human milk

Breastfeeding comes with both short- and long-term benefits, Silbert-Flagg said.

Short-term benefits for the baby include that breast milk coats the gut, provides good bacteria and helps protect babies from illness; for the mother, breastfeeding helps lose their pregnancy weight and balance post-pregnancy hormones.

As for long-term benefits, "moms who have gestational diabetes are more likely to get Type 2 diabetes later on in life, but breastfeeding can lessen that risk and lessen diabetes in the child," Silbert-Flagg said.

"Any allergic disorders like asthma or allergies are less in breastfed babies," she said. "Then, cancers in mom -- uterine and breast cancer -- actually are dose related to breastfeeding. So the more months a mom breastfeeds, it lessens her risk of getting breast cancer."

A study published last year in the journal Pediatrics found limited positive impacts of breastfeeding for children's cognitive development and behavior later in life. That study involved about 8,000 families in Ireland and included information on children's behaviors and cognitive activities at ages 3 and 5. Breastfeeding data were collected from their moms.

All in all, "breastfeeding is considered the optimal method of infant feeding," said Kair, of the University of California, Davis.

"Human milk has immune cells as well as commensal bacteria, or good bacteria, that help us establish our microbiota. It has highly specialized sugars and proteins that help fight infections, as well," she said. "Human milk is alive, and it's medicine that's prepared specifically for an individual baby."