A Case Study on the Economic Impact of Optimal Breastfeeding
Ping Ma, Marci Brewer-Asling & Jeanette H. Magnus
Maternal and Child Health Journal ISSN 1092-7875 Matern Child Health J DOI 10.1007/s10995-011-0942-2
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Author's personal copy Matern Child Health J DOI 10.1007/s10995-011-0942-2
BRIEF REPORTS
A Case Study on the Economic Impact of Optimal Breastfeeding Ping Ma • Marci Brewer-Asling • Jeanette H. Magnus
Ó Springer Science+Business Media, LLC 2012
Abstract To develop a framework, using Louisiana as a case study, for estimating the potential cost savings to individual states if families were able to meet current recommendations for breastfeeding. Using cost-analyses methods, cost savings, as well as, case and death reductions of infant illnesses and deaths on four selected infant diseases (respiratory tract infections, gastroenteritis, necrotizing enterocolitis, and Sudden Infant Death Syndrome) were calculated utilizing the most recent data of breastfeeding and low/very low birth weight rates in Louisiana. To estimate the incidence of a disease in exclusive breastfed infants and formula fed infants respectively, we used the following formula: x = s/br ? 1 - b. Here ‘‘x’’ is the incidence rate of one disease in formula fed infants, ‘‘s’’ is the overall incidence of the disease, ‘‘b’’ is current breastfeeding rate and ‘‘r’’ is the odds ratios in favor of breastfeeding. A total of $216,103,368 could be saved and 18 infant deaths prevented, by these four conditions alone, if 90% of newborns in Louisiana were exclusive breastfed for the first 6 months of life ($186,371,125 in savings and 16 infant deaths prevented with 80% compliance). Increased rates of breastfeeding to the level of Healthy People 2020 goals and beyond would yield significant cost savings to Louisiana. Other US states can use the presented framework to demonstrate cost savings associated with breastfeeding promotion and support interventions in their respective states. P. Ma M. Brewer-Asling J. H. Magnus Department of Community Health Sciences, Tulane School of Public Health and Tropical Medicine, New Orleans, LA, USA J. H. Magnus (&) Institute for Health and Society, University of Oslo, P.O. Box 1130, 0318 Blindern, Oslo, Norway e-mail:
[email protected]
Keywords Exclusive breastfeeding Cost-savings Mortality and morbidity prevention
Introduction Breastfeeding is an effective, low cost prevention strategy for improving the health of the maternal and child populations in both developed and developing nations [1]. A systematic review and meta-analysis on breastfeeding and maternal and infant health outcomes concludes that breastfeeding reduces Sudden Infant Death Syndrome (SIDS), gastro intestinal infection, upper and lower respiratory disease and hospitalization, childhood leukemia, asthma, ear infections, childhood obesity and diabetes mellitus (Type II) risk for children, and significantly lowers maternal risk of breast and ovarian cancers [2]. The economic impact of breastfeeding is considerable with significant cost savings associated with duration of exclusive breastfeeding [3–8]. A recent study, by Bartick and Reinhold, concluded that $13 billion US dollars and 911 deaths (most of which would be infants) could be saved if 90% of families in the US were able to meet current recommendations for exclusive breastfeeding for the first 6 months of life ($10.5 billion and 741 deaths at 80% compliance) [8]. State specific cost savings data may be relevant and useful in guiding state policies and programs to increase breastfeeding promotion and support. The aim of the current study is to develop a framework, using Louisiana as a case study, for estimating the potential cost savings if families comply with the [13] national goals for breastfeeding or if 80 and 90% of all children are exclusively breastfed for 6 months [8].
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Methods Utilizing the most recent Louisiana rates of breastfeeding and low/very low birth weight infants in cost analysis methods reported by Bartick and Reinhold [8], we calculated the potential cost savings to Louisiana from cases of illness and deaths on four selected infant diseases: hospitalization for lower respiratory tract infections (LRTIs), gastroenteritis, necrotizing enterocolitis (NEC), and SIDS. Each year in the United States, three percent of all infants are hospitalized with moderate to severe LRTIs [9]. Gastrointestinal infections are common in infants and children, and NEC is often lethal in premature infants [10]. SIDS is the leading cause of mortality among infants aged 1–12 months in the United States [11]. Each of these are thus strongly associated with morbidity and mortality in newborns, and an Agency for Healthcare Research and Quality (AHRQ) study, reported a 257, 178, 138, and 56% excess risk associated with not breastfeeding for hospitalization for LRTIs, gastroenteritis, NEC, and SIDS respectively [2]. According to the 2008 Louisiana Health Report Card data, there were 63,186 live births born to Louisiana residents in 2006, and 7,223 of them were low birth weight babies (\1,500 g), which represents 11.3% of all lives births and the very low birth weight rate was 2.1% [12]. Actual and estimated rates of breastfeeding in Louisiana by type and duration are listed in Table 1. Since it is extremely difficult to obtain accurate prevalence rates of mixed-fed infants, we categorized infants in Table 1 Healthy people 2020 goals for breastfeeding and 2006 actual Louisiana State breastfeeding rates from the breastfeeding report card CDC 2009
only two mutually exclusive groups: ‘‘exclusive breastfed infants (EBI)’’ and ‘‘formula-fed infants (FFI)’’ when estimating prevalence rates of the four conditions [8]. We followed Bartick and Reinhold’s formula: x = s/ br ? 1 - b, where ‘‘x’’ is the incidence rate of one disease in formula feed infants, ‘‘s’’ is the overall incidence of the disease, ‘‘b’’ is current breastfeeding rate and ‘‘r’’ is the odds ratios in favor of breastfeeding [8], using the current breastfeeding rate in Louisiana as the reference. All of the elements necessary in the calculation are listed in Table 2. We calculated the differences in cases by subtracting the total case numbers at varied projected breastfeeding goals, including Healthy People 2020 Goals[13], 80 and 90% of compliance with medical recommendations for breastfeeding (breastfeeding exclusively for 6 month and continued breastfeeding until at least one to 2 years old) from total case numbers at the current breastfeeding rate [14]. The cost savings, the amount saved if the breastfeeding rate in Louisiana met national goals, was determined by ‘‘differences in cases’’ multiplied by ‘‘cost per case/death.’’ The cost per case for each disease/death presented was also extracted from the Bartick and Reinhold study that used summarized figures from the 2007 AHRQ’s report and prior cost analyses studies [2, 7, 15–22]. We converted their cost in 2007 US dollars to 2010 US dollars by using the Consumer Price Index. The cost of each premature death was estimated at $11.1 million in 2010 US dollars [23].
Results Lower Respiratory Tract Infections
Type and duration of breastfeeding
Healthy people 2020 goals, %
Actual rates in Louisiana, 2006, %
Ever breastfeeding/ initiation rate
81.9
49.1
A reduction of 1,577 cases with a resulting $31 million in cost saving could be accomplished if 90% of all new Louisiana families complied with the recommendations of exclusive breastfeeding for 6 months.
Any breastfeeding at 6 months
60.6
20.7
Gastroenteritis
Any breastfeeding at 12 months
34.1
9.9
Exclusive breastfeeding at 3 months
44.3
17.8
Exclusive breastfeeding at 6 months
23.7
5.0
Extrapolated any breastfeeding at 3 months
73.9
53.1
Extrapolated exclusive breastfeeding at 4 months
37.4
13.5
* Data sources: national immunization survey (NIS). Available at: http://www.cdc.gov/breastfeeding/data/NIS_data/index.htm Healthy People Goals and Objectives. Available at: http://www.heal thypeople.gov/2020/topicsobjectives2020/pdfs/HP2020objectives.pdf
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If 80% of women could comply with the recommendation for exclusive breastfeeding for 6 months, 6,956 outpatient cases would be prevented, and close to $2.5 million saved. Necrotizing Enterocolitis (NEC) Compliance with the Healthy People 2020 recommendations would result in a reduction of 10 NEC cases ($2,138,852) and 2 NEC deaths ($22,962,897) among very low birth weight babies. A total of $63.7 million would be saved through a reduction of 26 NEC cases and 5 NEC related deaths if 90% of Louisiana families complied with current recommendations.
LRTI death
63,186
Hospitalization
63,186
Very low birth weight**
63,186
Very low birth weight**
SIDS
Any BF for 6 months
EBF for 3 months
EBF for 3 months
EBF for 3 months
EBF for 3mo
EBF for 6 months
EBF for 6 months
EBF for 4 months
EBF for 4 months
Type and duration of breastfeeding
0.64
0.42
0.42
0.42
0.42
0.36
0.36
0.28
0.28
Odds Ratio (OR)
0.00054
0.0083
0.00018
0.0414
0.0031
0.00298 (hospitalizion in infants \1 year old)
0.222
0.0409
0.0409
Overall incidence
0.00058
0.0111
0.00024
0.0554
0.0041
0.0031
0.2293
0.00008
0.0453
Incidence in formulabased infants
0.00037
0.0047
0.0001
0.0233
0.0017
0.0011
0.0826
0.00002
0.0127
Incidence in exclusive breastfed infants
* The Low birth weight infants in Louisiana in 2006 was 0.113. ** The very low birth weight rate in Louisiana in 2006 was 0.021
63,186
63,186
Low birth weight*
NEC death
63,186
Low birth weight*
NEC
63,186
Outpatient
Gastroenteritis
63,186
63,186
Hospitalization LRTI
Number of infants
$11,105,668
$11,105,668
$11,105,668
Surgical NEC (incidence = 0.43) $279,687; Medical NEC (incidence = 0.57) $151,964;
Surgical NEC (incidence = 0.40) $163,898; Medical NEC (incidence = 0.60) $89,243
$2,806
$357
$11,105,668
$4,922
Total cost per case/death
Table 2 Elements for calculating potential cost savings for lower respiratory tract infections (LRTIs), gastroenteritis, necrotizing enterocolitis (NEC), and sudden infant death syndrome (SIDS) in Louisiana (2010 US $
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Author's personal copy Matern Child Health J Table 3 Summary of cost savings and reduction in cases and deaths for LRTIs, Gastroenteritis, NEC, and SIDS if mothers exclusively breastfeed for 6 months in Louisiana meeting the healthy people 2020 Cost savings if mothers comply with healthy people 2020 goal (average reduction in cases or deaths)
goal, or if 80 or 90% of mothers meet the recommendation compared with current breastfeeding rate in 2006 (in 2010 US$)
Cost savings if 80% of mothers breastfeed exclusively for 6 months (average reduction in cases or deaths)
Hospitalization LRTI*
$2,424,514 (493)
$6,746,031
LRTI death*
$9,790,739 (0.9)
$27,242,015 (2.5)
Gastroenteritis
$684,463
(1,757)
$2,745,172
(7,049)
$3,111,195
Outpatient
$619,139
(1,734)
$2,483,178
(6,956)
$2,814,269
(7883)
Hospitalization
$65,324
(23)
$261,994
(93)
$296,926
(106) (36.5)
NEC**
(1370)
Cost savings if 90% of mothers breastfeed exclusively for 6 months (average reduction in cases or deaths) $7,760,472
(1577)
$31,338,558 (2.8) (7989)
$2,631,789 (14.1)
$5,795,253
(32.1)
$6,681,377
Low birth weight
$492,937
(4.1)
$1,085,457
(9.1)
$1,251,430
(10.5)
Very low birth weight
$2,138,852 (10)
$4,709,796
(23)
$5,429,948
(26)
$25,628,737 (2.3)
$56,434,997 (5.1)
$2,665,841 (0.2)
$5,870,235
Very low birth weight SIDS
$22,962,897 (2.1) $58,812,235 (5.3)
$50,564,762 (4.6) $87,407,657 (7.9)
$58,296,377 (5.3) $102,147,564 (9.2)
Total
$99,972,477 (2272.6)
$186,371,125 (8466.6)
$216,103,368 (9620.4)
NEC death** Low birth weight
(0.5)
$65,064,202 (5.9) $6,767,825
(0.6)
* Cost savings given for exclusive breastfeeding at 4 months. ** Cost savings given for exclusive breastfeeding at 3 months
Sudden Infant Death Syndrome (SIDS) Approximately, five deaths could be prevented and $58.8 million saved if the breastfeeding rates increased to the level of the Healthy People 2020 Goals. Table 3 summarizes the total cost savings, displaying that nearly $100 million would be saved if Louisiana met the Healthy People 2020 goals. If 90% of Louisiana newborns were exclusively breastfed for 6 months, a cost reduction of $216 million could be obtained due to these four diseases alone.
Discussion Our study demonstrates the substantial cost savings Louisiana would experience if most newborns were exclusive breastfed for 6 months. Furthermore, if breastfed, between 16 and 18 infant deaths could be avoided by the reduction in occurrence of the four conditions addressed in this study alone. Although national breastfeeding initiation rates have increased, breastfeeding initiation rates remain uneven among different states, with Louisiana having the lowest breastfeeding rate in the nation [14]. If breastfeeding rates in Louisiana remain at suboptimal levels, Louisiana will continue to pay the price in greater health care costs and poorer maternal and child health outcomes. In considering the results of our analysis and earlier cost analyses, increasing and/or expanding breastfeeding promotion programs and services would be a cost effective intervention.
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Increasing breastfeeding rates, however, requires more than just maternal knowledge about the benefits of breastfeeding [24]. The Surgeon General’s Call to Action to Support Breastfeeding, released in January 2011, discusses the many documented barriers to breastfeeding and outlines specific actions that mothers, their families, communities, employers, health care providers and policy makers can take to make breastfeeding easier for women [24]. The Institute of Medicine of the National Academies (IOM) recently published the ‘‘Clinical Preventive Services for Women—closing the gap’’ report recommending that comprehensive lactation support and counseling are considered as preventive services for women [25]. The US Department of Health and Human Services (HHS) adopted these guidelines August 1st, 2011 [26]. State policymakers should act on this information by including comprehensive lactation support and counseling, as well as coverage of donor milk for preterm and very low birth weight infants, in the state Medicaid program. Additionally, policy makers and healthcare leaders should actively support interventions shown to increase breastfeeding rates, such as: facilitating improvements in maternity care policies and practices, providing workplace lactation accommodations, increasing the capacity of peer counseling programs, launching social marketing campaigns targeting a mother’s primary support networks, including fathers and grandmothers, and adopting provisions that protect mothers from false and misleading advertising of breast milk substitutes (International Code of Marketing of Breast-milk Substitutes (the Code) [24]. Increasing infrastructure for
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breastfeeding support by establishing state and local breastfeeding coalitions or networks should also be considered [24]. The study was limited by assumptions related to costs and breastfeeding durations [8]. Our study included only four of the many diseases favorably associated with breastfeeding duration. Examining other diseases in which the 2007 AHRQ reported risk ratios favorable of breastfeeding could have yielded even greater cost savings [2]. Additionally, we speculate that the incidences of the diseases in Louisiana are actually higher than the national estimates we have used in this study so that the benefits might be even greater. A major strength of the current study is that other US states can use the models presented, and estimate their cost savings as breastfeeding promotion and support programs are implemented. Delaying investments in improving breastfeeding rates might be costly to states with low rates of exclusive breastfeeding.
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