Understanding costs associated with breastfeeding is critical to developing maximally effective policy to support breastfeeding by addressing financial barriers. Breastfeeding is not without cost; direct costs include those of equipment, modified nutritional intake, and time (opportunity cost). Breastfeeding need not require more equipment than formula feeding, though maternal equipment use varies by maternal preference. Meeting increased nutritional demands requires increased spending on food and potentially dietary supplementation, the marginal cost of which depends on a mother’s baseline diet. The opportunity cost of the three to four hours per day breastfeeding demands may be prohibitively high, particularly to low-income workers. These costs are relatively highest for low-income individuals, a group disproportionately comprising racial and ethnic minorities, and who demonstrate lower rates of breastfeeding than their white and higher-income peers. Acknowledging and addressing these costs and their regressive nature represents a critical component of effective breastfeeding policy and promotion.
Deciding how to feed their infants represents a consequential choice for new parents. The American Academy of Pediatrics (AAP) and World Health Organization (WHO) recommend exclusive breastfeeding for the first six months of life, followed by continued breastfeeding supplemented with complementary foods until age two [1, 2]. They base these recommendations upon the favorable effects of breastfeeding, which confers protective benefits to the lactating mother [1, 3,4,5,6,7,8,9,10] and feeding infant against many common [11,12,13,14] and severe conditions [1, 15,16,17,18,19,20]. These protective benefits translate to reduced burden of disease, thereby decreasing healthcare costs—Bartick et al. project billions of dollars in healthcare savings if the US were to achieve its goal of 90% of infants breastfed according to recommendations . A mere 5% increase in breastfeeding rates would save an estimated $40 million due to the reduced morbidity of otitis media and gastrointestinal infections alone . One 2013 article estimates the potential value of human milk production, determined using standard accounting practices, at $110 billion per year, two-thirds of which the US fails to realize due to premature weaning . Breastfeeding is not, however, without costs—women who choose to breastfeed bear financial, societal, and psychological costs, which may prove profound. An accurate accounting and appreciation of these costs is critical in developing effective breastfeeding promotion and policy. In this article we evaluate the direct marginal costs of breastfeeding to mothers in the United States, which include the cost of equipment, modified nutritional intake, and time. We recognize a robust body of literature documenting the extensive benefits of breastfeeding and intend to provide a complementary descriptive analysis of the often-overlooked costs associated with breastfeeding. We begin with a brief analysis of the cost of breastfeeding’s most accessible alternative, formula feeding, to serve as a point of comparison.
Cost of alternative: Formula feeding
Evaluating the cost of breastfeeding absent any comparison is of limited utility. We must appreciate costs relative to alternative options, as this approach more closely resembles the decision-making calculus applied by those deciding whether to breastfeed and, if so, for how long. We consider the cost of the most common alternative, formula. The Federal Food, Drug, and Cosmetic Act, which established the regulatory authority of the U.S. Food and Drug Administration (FDA), defines formula as “a food which purports to be or is represented for special dietary use solely as a food for infants by reason of its simulation of human milk or its suitability as a complete or partial substitute for human milk” . Formula is available as powder (to be mixed with water), as ready-to-feed liquid, and in a concentrated form to be diluted before feeding. Mothers may choose to supplement breastfeeding with formula, and the composition of infants’ nutrient intakes vary widely in proportions of formula to human milk. For the sake of this cost comparison, we will consider an exclusive formula diet, supplemented with solid foods introduced at six months per American Academy of Pediatrics (AAP) recommendations . Total formula feeding costs comprise only those of formula and bottles with which to feed, though mothers may opt for supplemental accessories, e.g. bottle sanitizers and warmers. During their first year of life, most infants will consume between 9500 and 12,000 ounces of formula [26, 27]. The 2011 Surgeon General’s Call to Action to Support Breastfeeding references Ball and Wright’s 1999 analysis that cites a cost of $1200 to $1500 for one year’s supply of formula (USD2011, approx. $1500 to $1900 USD2022) [28, 29], and a study of high-income countries found a per-person annual formula expenditure of $2528 (USD2014) . The Plutus Foundation, a non-profit, estimates the cost of exclusive formula feeding during the first year using a price of $0.08 to $0.19 per liquid ounce of prepared formula, for a formula cost of $760 to $2280 (USD2020) depending on an infant’s feeding habits and specific nutritive needs (hypoallergenic and hydrolyzed formulas are more expensive than their basic counterparts) . Many mothers pay less than even the low ends of these estimates—low-income mothers who qualify for free formula and infant foods from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) may spend only the cost of bottles, and many WIC clinics provide these as well . Of note: we consider here the monetary costs of the material goods required for formula feeding. In evaluating breastfeeding, we will also consider intangible costs. Those we include in our analysis are either much more strongly or exclusively associated with breastfeeding, and we consider them essential in a comprehensive evaluation of breastfeeding’s true cost.
Cost of breastfeeding: Direct equipment costs
Most breastfeeding mothers in America will opt to pump, which requires at least a breast pump, storage bags, and bottles . Equipment including breast pumps, storage bags, bottles, and sundry pumping supplies constitute tangible costs to breastfeeding mothers. As with other consumer goods, breastfeeding equipment comprises a broad range of products spanning many price tiers. The total cost of equipment will depend on a mother’s needs and preferences; therefore, we estimate the costs to an illustrative mother who chooses to observe the guidance of her pediatrician, informed by both AAP and WIC recommendations, purchasing retail equipment at average quality and cost. WIC Breastfeeding Support recommends nursing bras, nursing pads, a breast pump, and bottles for breastfeeding women , while the AAP adds nipple cream to this list . In purchasing a breast pump, a mother may choose a manual version ($25), a lower-end electric pump ($70), or a hospital grade pump ($200) . Hands-free pumps—which tend to cost significantly more than even hospital grade pumps, often several hundreds of dollars—exist in the “luxury equipment” tier. Since the high cost of hands-free pumps limits their use to a small proportion of breastfeeding mothers, and these mothers tend to be those with greater access to resources who may be better equipped to tolerate the costs associated with breastfeeding, we will not include the cost of hands-free pumps in our analysis, which is meant to illustrate costs borne by an average woman in the US. Mothers will also require milk storage bags at a cost of $15 per 100 bags and bottles at $5 apiece. If a mother opts for the additional nursing supplies recommended by WIC and the AAP (nipple cream, a set of nursing bras, reusable nursing pads, a nursing pillow and extra covers, and a bed rest pillow), she can expect to spend an additional $150 . The total cost of equipment, then, ranges from $120 (manual pump, 300 milk storage bags, 10 bottles, and no supplemental nursing supplies) to $445 (hospital grade pump, 300 milk storage bags, 10 bottles, and supplemental nursing supplies). Since equipment represents a fixed cost (i.e. the total money spent on equipment does not change regardless of the amount of product produced), equipment cost per unit decreases as units produced increases. According to a 2013 study by Jegier et. al., the median cost of certain essential equipment (breast pump rental fee, one-time pump kit purchase, and storage containers) for producing 100 mL of milk varies drastically, from $7.93 to mothers producing less than 100 mL per day, to a mere $0.51 to mothers producing at least 700 mL per day .
The Patient Protection and Affordable Care Act (ACA) of 2010 does attempt to mitigate some equipment costs. The law requires most private health insurers to cover, without cost-sharing, certain preventative services when provided by in-network clinicians. Covered services include lactation support services (e.g. counseling and education) and breastfeeding equipment and supplies during the antenatal, perinatal, and postpartum periods . Beginning in 2023, non-grandfathered insurance plans must comply with updated guidelines that further specify required coverage: “Breastfeeding equipment and supplies include…double electric breast pumps (including pump parts and maintenance) and breast milk storage supplies…Breastfeeding equipment may also include equipment and supplies as clinically indicated to support dyads with breastfeeding difficulties and those who need additional services.”  The landscape of insurance regulation in the US is complex and heterogeneous, and many state-enacted health insurance regulations expand coverage requirements beyond those in the ACA and further insulate mothers from equipment costs [36, 37]. Accounting for these regulations extends beyond the scope of this article, which seeks to account for broadly universal costs borne by breastfeeding mothers.
Cost of breastfeeding: Direct nutrition-associated costs
Lactation is an energy intensive process—daily energy requirements for lactating women exceed those of pregnant women during all trimesters . In addition to ensuring adequate caloric intake, breastfeeding women must also consider the nutrient content of food. Breastfeeding infants are at particular risk of certain nutrient deficiencies, the effects of which range from subclinical to severely impeded growth and development. For example, vegetarian and vegan diets tend to be low in vitamin B12, a nutrient essential for neurodevelopment [39, 40]. Mothers who abstain from meat must either alter their diets or take vitamin supplements to ensure adequate nutrition for their infants. The AAP recommends that all infants ingesting less than 28 oz of formula per day receive daily oral supplementation of 400 IU of vitamin D; alternatively, the breastfeeding mother may supplement with 6 400 IU of vitamin D to ensure an adequate supply in her breastmilk to meet her infant’s needs [1, 41]. A review of popular online retail websites and pharmacies for infant vitamin D drops reveals an approximate average price of $18 for a 90 day supply, for a cost of approximately twenty cents per one 400 IU servingFootnote 1. Although adult supplements demonstrate greater price variability, high-dose vitamin D supplements may be found for approximately the same price per serving for the lactating mother (twenty cents per 6400 IU). Over the course of one year, vitamin D supplementation adds approximately $73 to the cost of breastfeeding. Diet-associated costs of breastfeeding reflect expenses related to incorporating sufficient nutrients (e.g. via vitamin supplementation) in addition to the costs of increased intake, which themselves may be substantial. According to the USDA’s most recently published dietary guidelines based on reference intakes from the Institute of Medicine, lactating women require an additional 330 calories per day above pre-pregnancy needs during the first six months of lactation, and an additional 400 calories per day if continuing lactation beyond six months [1, 40, 42]. Compared with non-pregnant women, this represents an increased intake of 14 to 18% during the first six months, and 17 to 22% thereafter . To estimate cost, we establish the USDA’s low-cost food plan as baseline. The USDA publishes official food plans monthly at three cost levels that report average costs of diets designed to satisfy dietary guidelines for different age and sex groups. The low-cost food plan for April 2022 reports a weekly food cost of $67.68 for women 19 to 50 years of age . Given this baseline and the required percent increase in caloric intake, we expect breastfeeding women to spend an additional $9.48 to $12.18 per week for the first six months of breastfeeding, and $11.51 to $14.89 thereafter. These calculations are conservative, as they reflect only increased caloric needs and not dietary changes or inclusion of required nutritional supplements. Attempting to account for these costs would result in tenuous estimates at best, as mothers’ baseline diets vary drastically; some may comprise appropriate nutrient ratios and simply require proportional scaling up during lactation, while others may necessitate substantial supplementation or dietary changes. WIC accounts for the increased nutrition requirements of lactation in its monthly food packages—compared to non-breastfeeding mothers, those who exclusively breastfeed are granted 50% more juice, 50% more milk, 100% more eggs; and an additional one pound of cheese, one pound of whole-wheat bread, and thirty ounces of canned fish (compared to none for non-breastfeeding women) . Using values from the Consumer Price Index for April 2022 (except for canned fish, for which most recent prices are from September 2017), compiled by the U.S. Bureau of Labor Statistics , we calculate the additional monthly cost of these items (US city average) as $31.09.
Costs of breastfeeding: Opportunity costs
We have accounted for the costs of tangible goods, a category which comprises only a small fraction of the total costs borne by a breastfeeding mother. Intangible costs, though often difficult to precisely express in dollar terms, are those most frequently cited by mothers as the greatest barriers to breastfeeding and reasons for early cessation [46,47,48]. We consider opportunity cost, i.e. the potential value of the next-best alternative forgone option . Opportunity cost represents the single greatest contribution to the total cost of lactation, resulting in a three-fold increase in the cost per 100 mL of milk produced . While breastfeeding, a mother’s greatest opportunity cost is the utility of her time. According to the AAP and U.S. Breastfeeding Committee, women, on average, may expect to express milk for 30 min every two to three hours [26, 51]. While feeding time is comparable between breast- and formula-feeding, formula feeding allows distribution of the task among different individuals, for example by a partner or infant caretaker. Breastfeeding, in contrast, demands this time specifically of the mother, to relieve engorged breasts whether via pumping or direct feeding. This amounts to breastfeeding mothers dedicating four to six hours per day to expressing milk. The value of this time is best estimated by potential earning capacity, or wages. If we consider a mother earning the US federal minimum wage of $7.25 , her opportunity cost of breastfeeding is $29.00 to $43.50 per day. For low-income families, this may constitute a considerable, even prohibitive, sacrifice. It may seem, then, that the absolute opportunity cost of breastfeeding increases as a mother’s wages or salary increases—a high-powered attorney charging $1000 per hour theoretically may bear an opportunity cost of four to six thousand dollars per day of breastfeeding. However, high-income professional occupations tend to offer greater flexibility than low-wage positions , such that mothers in high-income professions may more easily balance pumping and performing professional responsibilities in a way that minimizes opportunity cost. Consider our high-powered attorney—she may simultaneously pump and review preparatory documents for her upcoming trial, thereby eliminating the opportunity cost of forgone work; this option, however, is not available to a low-income grocery store clerk or factory worker, whose jobs’ physical demands preclude concurrent performance of occupational duties and breastfeeding. Hands-free pumps represent a promising tool to address this problem of opportunity cost allowing mothers to pump and perform other hands-on tasks simultaneously. However, these pumps are relatively expensive, ranging in price from approximately one hundred to several hundred dollars, and still require a user to limit movement to a non-vigorous level. The highest quality pumps, which allow the greatest degree of movement, boast the sleekest profile, and generate the least noise—and are therefore most conducive to concurrent breastfeeding and performance of work duties—cost upwards of $500. The more affordable pumps, still out of financial reach for many low-income workers, do not perform as well and limit what tasks may be performed simultaneously, such that the tasks demanded in many low-income industries—e.g. direct customer interaction and physical activity—preclude the coincident use of even a hands-free breast pump. Consequently, though these hands-free pumps may represent a boon for certain mothers, they tend not to offer great benefit for the low-income mothers for whom the relative opportunity cost of pumping tends to be highest.
Considering this reality, in addition to the decreasing marginal utility of income (i.e. the utility of additional income tends to decrease as income increases), the relative opportunity cost is likely greatest for the lowest income individuals . As a result, we may interpret opportunity cost as a regressive tax on breastfeeding. Mothers outside the labor force are not insulated from opportunity costs by virtue of not engaging in formal work. Unpaid care work, or the unpaid services performed for the well-being, maintenance, and functioning of a household, family unit, and/or community, is performed disproportionately by women and provides tremendous value to society [55,56,57]. For example, caring for children or elderly relatives, performing domestic tasks such as cooking or cleaning, and volunteering at local food banks may all be considered unpaid care work when the provider receives no remuneration. These services are productive, in an economic sense, and if not for the unpaid care worker, they would be subject to market dynamics and require payment to a servicer to complete. Removing unpaid care work from the market renders valuation of this work extremely difficult. Researchers in the Asia-Pacific Economic Cooperation Human Resource Development Working Group estimate the value of unpaid care work in the United States at approximately 40% of the country’s Gross Domestic Product (GDP) . While it is difficult to value unpaid care work, especially given the wide variety of the tasks that comprise the category, we may consider the aforementioned opportunity cost calculated using minimum wages as a floor for the value of this work, given that if sold on the free market, the worker would necessarily receive remuneration of at least that mandated minimum wage. Clearly, women who remain outside the labor force and perform unpaid care work still bear a considerable opportunity cost if they choose to breastfeed. While this cost may not be reflected in formal indices of economic production due to measurement methodologies that exclude unpaid care work, this loss of production may be felt acutely by households and communities, and the implications ripple out to the broader economy.
Total quantified costs
We provide a conservative estimate of the total marginal direct costs of breastfeeding for one year by simple summation. All assumptions are made so as to minimize cost. We apply a range of $120–$445 spent on equipment. By averaging the additional monthly costs of food as calculated based on the USDA low-cost food plan ($37.68–$48.72 for the first six months, $46.04–$59.56 thereafter) and the WIC food packages ($31.09 up to one year), we estimate the contribution of food to marginal cost as $39.16 per month for the first six months and $45.56 per month thereafter, for a total first-year cost of $508.32. We add $73 for the annual cost of vitamin D supplementation. To calculate opportunity cost, we apply the federal minimum wage of $7.25 per hour to the three to four hours per day demanded of breastfeeding women, and arrive at a daily cost of $21.75–$29.00, or $7938.75–$10,585.00 for year one of breastfeeding. Adding these costs, we calculate the total marginal direct cost of breastfeeding for an infant’s first year as $8640.07–$11,611.32. Consider the U.S. federal poverty level for a family of two (e.g. single mother plus child) or three (e.g. two-parent household plus child) at $18,310 and $23,030 annual household income, respectively . Results from the U.S. Census Bureau’s 2021 Current Population Survey suggest that 17.5% of children under five live below poverty level; for the families of these children, the cost of breastfeeding represents a significant portion of their annual household income.
Breastfeeding is not a cost-free alternative to formula feeding, and understanding associated costs is critical to developing maximally effective policy for breastfeeding promotion. This analysis represents a conservative cost estimate, as it considers only the direct costs incurred by lactating women; indirect and intangible costs, such as labor market effects and psychological impacts, may drastically increase the total cost. Given the heterogeneous landscape of insurance coverage and regulations, availability of free- and low-cost resources, and healthcare access in the US, these costs exhibit immense variability, particularly across socioeconomic strata. Given the extensive health benefits of breastfeeding to both mother (e.g. reduced risk of breast cancer and diabetes [3,4,5, 10, 15]) and child (e.g. reduced risk of certain infections and odds of post-perinatal infant mortality [13, 15, 20, 61]), and the cost savings realized from the resulting reduced disease burden, variegated breastfeeding rates among diverse income strata, races, and ethnicities exacerbate well-documented health disparities. Low-income individuals, a group disproportionately comprising racial and ethnic minorities , typically bear the greatest relative costs and demonstrate lower breastfeeding rates than their higher-income counterparts [63, 64]. Developing policy to address these cost barriers, therefore, represents an opportunity to further the cause of health equity during the tremendously consequential earliest stages of infant and childhood development.
These estimates of per-unit cost represent an average of over-the-counter (i.e. without insurance subsidy) prices from approximately a dozen online and retail pharmacies, including the largest national corporate pharmacies and retail operations in the United States.
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Mahoney, S.E., Taylor, S.N. & Forman, H.P. No such thing as a free lunch: The direct marginal costs of breastfeeding. J Perinatol 43, 678–682 (2023). https://doi.org/10.1038/s41372-023-01646-z