Saritha, 27, could not manage to exclusively breastfeed her sons — now aged four and eight — for the recommended first six months despite having normal institutional deliveries. She works as a domestic help in central Delhi’s Rajendra Nagar. Her husband drives for a ride-hailing platform and takes up odd jobs such as washing cars and serving at weddings to support the family. 

“I returned to work within two months of my delivery and had no option but to introduce infant formula before my sons turned six months old. If I do not work, we cannot pay rent or meet our living expenses. Every new birth comes with additional costs. Besides, my in-laws live with us and are financially dependent on us,” she said. 

Saritha is among a growing number of mothers in India unable to exclusively breastfeed (EBF) their infants for the recommended six months. 

Why EBF matters 

EBF is considered one of the most effective interventions for ensuring the survival and healthy development of the child. Breast milk provides all the nutrients an infant needs during the first six months of life. It contains antibodies that protect against common childhood illnesses such as diarrhoea and respiratory infections, supports healthy growth and brain development, and lowers the risk of malnutrition and infant mortality. 

For mothers, breastfeeding helps in recovery after childbirth and reduces the risk of breast and ovarian cancers. 

Since it is safe, hygienic and cost-effective, the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) recommend initiating breastfeeding within one hour of birth and continuing it for the first six months. 

Consequently, trends in EBF are closely monitored in India’s National Family Health Survey (NFHS) because they are important indicators of child health, nutrition and overall public health progress. Lower EBF rates can adversely affect child nutrition, increase infections and healthcare costs, and slow progress in reducing child mortality. 

The latest NFHS-6 indicates worrying trends. 

A worrying decline 

Despite 90.6% of deliveries in the country now being institutional, fewer infants are exclusively breastfed during the first six months after birth. Although early initiation of breastfeeding has improved from 41.8% to 50.1%, EBF declined from 63.7% in NFHS-5 to 55.8% over the same period, as per NFHS-6 (2023-24).

NFHS-6 data show some of the sharpest declines in exclusive breastfeeding in India’s largest States. In Uttar Pradesh, EBF fell from 59.7% to 34.6% while in Haryana it fell from 69.5% to 41.2%. Delhi witnessed a drop from 64.3% to 54% as well. Rajasthan and Madhya Pradesh also recorded declines. 

In contrast, Kerala, Gujarat and West Bengal registered improvements in EBF rates. 

What is also worrying is that, as per the survey, the decline in EBF was observed in both urban and rural India, but it was steeper in rural areas where breastfeeding rates have traditionally remained stable. 

Data show that EBF among infants below six months fell from 65.1% to 56.2% in rural areas. In urban areas, it declined from 59.6% to 54.5%. 

A paradox 

What makes the decline particularly striking is that it comes at a time when India has made significant gains in maternal and child health. 

Early initiation of breastfeeding has improved, maternity benefits have expanded, and women are more financially and digitally empowered than ever before. The NFHS-6 also points to substantial improvements in women’s empowerment. Nearly 89% of women now participate in key household decisions while a similar proportion operate their own bank accounts. Digital inclusion has expanded rapidly, with Internet use among women rising from 33.3% in NFHS-5 to 64.3% in NFHS-6. Yet fewer infants are being exclusively breastfed during the first six months. 

“The decline in EBF despite these improvements indicates that empowerment alone may not be sufficient. Growing economic pressures, informal employment, lack of maternity protection, inadequate workplace support and limited postnatal assistance continue to constrain many mothers’ ability to exclusively breastfeed their infants for the recommended first six months,” said Arun Gupta, paediatrician and public health advocate recognised for his decades-long drive to promote breastfeeding. 

Obstacles to EBF 

Health experts attribute the decline, particularly in rural India, to increased migration and seasonal labour, early return to agricultural and informal work, changing family structures, erosion of traditional support networks, greater penetration of packaged foods and formula products, weak postnatal counselling and rising caesarean deliveries. 

The sharp rise in C-section rates — from 21.5% to 27.2%, accounting for more than half of all births in private hospitals — is also cited as a contributing factor.

Breastfeeding advocates say surgical deliveries can make early initiation and continuation of breastfeeding more challenging, especially in the absence of adequate postnatal lactation support.

“Common medical reasons for not being able to exclusively breastfeed include delayed initiation of breastfeeding after delivery, especially following a C-section; perceived or actual low milk supply; lack of breastfeeding counselling and family support; maternal illness or complications; and difficulties faced by premature or low birth weight infants,” said Delhi Medical Association member Anil Bansal.

Increased urbanisation, changing lifestyles, inconsistent maternity benefits and the marketing of infant formula appear to be prompting many families to introduce formula milk or complementary foods earlier than recommended. 

Cultural practices such as giving water, honey, animal milk or other pre-lacteal feeds before six months can also undermine potential EBF benefits, say experts.

Vandana, 32, became a mother four years ago. An HR consultant at a private firm, she was unable to exclusively breastfeed her child for the recommended six months. 

“After my C-section, despite skin-to-skin contact, lactation support and frequent feeding attempts, I could not produce enough milk to meet my baby’s nutritional needs. Supplementation became necessary,” she said, adding that early counselling may have helped in her case. 

Most mothers are aware of the benefits of breastfeeding, but successful breastfeeding often depends on maternity leave, family support, counselling and access to lactation assistance. 

Alternative feeding 

When breastfeeding is not possible, the WHO recommends infant formula as an alternative. Some hospitals also provide pasteurised donor human milk, particularly for preterm and unwell newborns. However, public health experts stress that formula is intended as a substitute when breastfeeding cannot be sustained, not as a replacement for breast milk. 

Raw cow’s milk, goat’s milk and plant-based milks are generally not suitable as the main food for infants under 12 months because they do not provide the right balance of nutrients and may be difficult for babies to digest, say experts. 

Policy measures 

In India, the government promotes breastfeeding through a combination of health services, counselling, maternity benefits and nutrition programmes, including the Pradhan Mantri Matru Vandana Yojana and Integrated Child Development Services. Additionally, Comprehensive Lactation Management Centres and Lactation Management Units provide lactation support and donor human milk for premature and unwell newborns when the mother’s milk is unavailable. 

India also has the Infant Milk Substitutes (IMS) Act, one of the world’s strongest laws that restricts the promotion of infant formula and protects breastfeeding from commercial marketing pressure. 

However, Dr. Gupta said aggressive marketing of infant formula and substitutes could still undermine breastfeeding and should be strictly regulated. He also said breastfeeding should begin within one hour of birth and continue alongside complementary feeding for up to two years and beyond. “Breastfeeding promotion should be viewed as a public health measure, not merely an individual lifestyle choice,” he added. 

According to Dr. Gupta, breastfeeding is among the most cost-effective public health interventions, even as data expose a gap between policy success and lived reality. 

While India has invested heavily in promoting institutional deliveries, maternity benefits and infant nutrition programmes, EBF rates continue to slip. Data suggest that getting mothers safely through childbirth may be only half the challenge; ensuring that they have the time, financial security, workplace support and family assistance needed to breastfeed exclusively for six months remains an unfinished task. 

Informal sector

Women employed in the organised sector are entitled to 26 weeks of paid maternity leave under the Maternity Benefit Act, 1961, amended in 2017. 

Unfortunately, these protections are largely confined to the organised sector. Many women working in the informal sector return to work soon after childbirth. 

According to the e-Shram portal, a national database of unorganised workers, more than 16.69 crore women were registered as workers in the unorganised sector as of 2025. 

Additionally, the Periodic Labour Force Survey shows that most working women are self-employed, casual workers, agricultural workers, domestic workers, home-based workers or are employed in small informal enterprises. The Labour and Employment Ministry has consistently noted that women’s employment remains concentrated in the informal economy. As a result, maternity leave, breastfeeding breaks, crèche facilities and lactation rooms remain inaccessible to a majority of working women.

Health experts say this disconnect raises a fundamental policy question: can India expect mothers to exclusively breastfeed for six months when most receive neither income support nor workplace protection during that period? 

Shweta, 25, the mother of a five-year-old girl, said many women working alongside her in a garment factory in Noida could not exclusively breastfeed their children. 

“Rising inflation and the fact that we work on contracts do not allow us the luxury of taking long breaks. We are daily wagers and are paid according to the amount of work we complete. My husband is an autorickshaw driver. If my husband and I stop working, it becomes difficult to meet household expenses, including rent,” said Shweta, who has decided not to have more children.

“Our aim is to provide the best possible education to our daughter and ensure that she has a better life than us,” she said, adding that nobody in her household has completed schooling. 

Dr. Gupta says that maternity benefits and breastfeeding support systems, particularly for women employed in the informal sector, need to be strengthened. 

According to Dr. Bansal, while policies and hospitals could help promote breastfeeding, sustaining EBF for six months depends largely on what happens after a mother leaves the delivery ward. 

“India recommends six months of exclusive breastfeeding and guarantees 26 weeks of paid maternity leave. But the benefit largely applies to women in formal employment. For the vast majority working in agriculture, domestic work, construction and other informal occupations, breastfeeding recommendations often collide with economic reality, and these women, who are most in need of support, are often the least likely to receive it,” said Dr. Bansal.

bindu.p@thehindu.co.in

Edited by Vibhooti Bhatnagar

Some truths are laced with tension. Commercial milk formula food, part of the multibillion-dollar baby food industry, are seen as economic growth planks, worthy of resource and recognition. It is another matter that the formula feeding frenzy is also linked to poor child and maternal health; it generates around 11-14 kilograms of greenhouse gas emissions (more than that of eggs, poultry, and vegetables combined); and uses more than 5,000 litres of water during its life cycle. In contrast, breastmilk is economically valuable, leaves a low carbon footprint, and is essential for well-being. Breastfeeding women nourish half the world’s infants and young children. No country, however, accounts for this care work in their GDP figures or national budgets.

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A new challenge mounts against this exclusion. Global health researchers propose to recognise the simple fact that women contribute to sustainable food production, and breastfeeding infrastructures deserve to be invested in as ‘carbon offsets’. This radical reframing benefits not only “the populations in developing countries most burdened by the harms of the commercial milk formula industry”, but also acknowledges “the value of women’s breastfeeding efforts for mitigating greenhouse gas emissions”.

The proposal

The report is part of a special issue of the Bulletin of the WHO. The research was led by Julie Smith from the Australian National University, and published in collaboration with Alive & Thrive at FHI 360 Global Nutrition, the University of Sydney, Munster Technological University, Auckland University of Technology, and the WHO.

The contention is two-fold. One, commercial milk formulas are a maladaptive practice in the context of emerging population and environmental crises. In contrast, breastfeeding is a renewable, economical and an B environmentally friendly natural resource, often neglected in sustainable food production and climate change. The current GDP-growth-based paradigm and food security statistics fail to account for the economic value of breastfeeding women in producing “vast quantities of highly valuable breastmilk”. Globally, 21.9 billion litres of human milk is annually lost because governments fail to invest in supporting breastfeeding. Breastfeeding is valued resourced but still under-valued, a dissonance the authors note in their proposal. “Caring for and nourishing children, including breastfeeding, is highly gendered work that is often ignored and under-valued economically,” co-author hPhillip Baker said..

Two, adequate recognition and resources through international climate change financing “can support new public investments in breastfeeding as a carbon offset, with significant gains and co-benefits for women’s, children’s and planetary health”.

The United Nations Clean Development Mechanism (CDM) allows lower-middle-income countries to avail financing by high-income countries for new policies and programmes to generate offsets to carbon emissions. The authors argue that the CDM could be a “potential platform” for recognising breastfeeding as a carbon offset. Policies such as funding skilled birth attendance, maternity care, and social protections like paid maternity leave would support higher breastfeeding rates, while also redirecting financial resources away from carbon-emitting activities. 

Breastfeeding, they note, is a timely illustration of how “current thinking and systems undervalue what matters, inequitably distort investment priorities and strengthen commercial drivers of health…”

The beef with breastfeeding substitutes

Research over the years hint at the conservative ecological costs of breastfeeding substitutes. Producing a commercial milk formula requires industry dairy farming for milk production, milk processing, formula manufacturing, transport, packaging, and electricity to heat the milk at a particular temperature. One estimate showed the average water footprint of milk powder is roughly 4700 L/kg6 (the equivalent of almost 140 showers). A 2016 study found emissions from this industry were equivalent to six billion miles of car travel. Water, waste and methane have shaped the prosperous commercial milk formula industry.

The social and health implications were flagged earlier. A boom in milk formula sales in emerging middle-income countries like India was associated with a decline in breastfeeding, a lack of maternity protection for breastfeeding, unregulated company marketing of baby foods and inadequate support of breastfeeding by health services. The WHO recommends newborns are breastfed within the first hour of birth; exclusively breastfed for the first four to six months, and continue to receive breastmilk for up to two years of age. However, less than half of newborns worldwide are breastfed within an hour of birth, and only 44% are exclusively breastfed from birth to six months, according to a working paper by the National Bureau of Economic Research. The same analysis found that increased marketing of formulas such as Nestle’s in LMICs “was correlated with a substantial reduction in breastfeeding”. This, in turn, has had a negative impact on infants’ health, studies show.

Commercial milk formulas have a rich history going back to the 19th century; they rose as an alternative to meet the nutrition requirements of infants who could not be breastfed. Today, more than half of the world’s children receive heavily marketed breastmilk substitutes in their first six months of life. Others receive follow-up formulas and “growing up” milk — products considered unnecessary by the WHO.

In India, popular breastmilk substitutes include Lactogen, Cerelac, Nestle, Farex, Dexolac and Similac. The milk substitutes market in India is projected to grow by 18.19% between 2024 and 2028, according to the latest CAGR report.

Breastfeeding and the link to sustainable food infrastructures

Breastfeeding is a natural, renewable resource, and also the “most economical and environmentally friendly way to feed an infant and young child, producing zero garbage, minimal greenhouse gases, and tiny water footprint”, according to the advocacy group Geneva Infant Feeding Association. It is better for the environment even if breastfeeding mothers eat and drink more. A BMJ study showed that exclusive breastfeeding for six months saves an estimated 95-153 kg CO2 equivalent per baby compared with formula feeding. Other economic benefits are derived from the associated infant and maternal health outcomes; nutrition in the early stages of life produces healthier outcomes that use fewer health course resources. Exclusive breastfeeding is a “child’s first immunisation”, the WHO notes, against respiratory infections, obesity, diarrhoeal disease, and other potentially life-threatening ailments.

Conversely, a lack of breastfeeding support is linked to increased disease prevalence in women and children, adding to the healthcare cost and deepening the caregiver burden, according to Roger Mathisen, Alive & Thrive East Asia Pacific Director. In the long run, it also betrays the need for a gender-just transition to sustainable development.

The authors propose a gender lens to build sustainable food infrastructures — scaffoldings critical in reducing disease burdens and greenhouse gas emissions and increasing nutrition and health. The first step? To consider breastfeeding as the “highest quality, local, sustainable first-food system for generations to come”.

“Governments need to better recognise women’s contributions to sustainable food production, including breastmilk, in international and national food balance sheets,” they wrote, batting to alleviate the economic burden and making seen an “invisible form of investment”.

This consideration must seep within the systems of value and measurement adhered to in the international order. New metrics, such as Mothers’ Milk Tool, are being developed to measure the economic contribution of breastfeeding mothers. In India, the annual production of breast milk amounts to $873,755; 14% of milk volume is lost in all three years due to lack of investment.

Considering breastfeeding as a carbon offset could also divert funds from commercial milk formula markets to environments where women operate. Research by urban studies scholar Divya Ravindranath showed the challenges daily wage labourers faced at construction sites in Ahmedabad: women negotiated with surveillance at workplaces, nature of work, quality of alternative care and domestic work, sapping their time and energy to provide exclusive breastfeeding. Investments in this sector could put in place creche services closer to the workplace and “support new public investments” yielding “significant gains and co-benefits for women’s, children’s and planetary health”.

“Considering breastfeeding as a carbon offset isn’t about coercion or shifting climate change responsibility,” said co-author Aoife Long from Munster Technological University. “It’s about directing funds to governments recognising the environmental impact of commercial milk formula markets, facilitating a gender-just transition to sustainable development, and creating an enabling environment for women who wish to breastfeed.”