Objectives. To test the inverse equity hypothesis, which postulates that new health interventions are initially adopted by the wealthy and thus increase inequalities-as population coverage increases, only the poorest will lag behind all other groups.Methods. We analyzed the proportion of births occurring in a health facility by wealth quintile in 286 surveys from 89 low-and middle-income countries and developed an inequality pattern index. Positive values indicate that inequality is driven by early adoption by the wealthy (top inequality), whereas negative values signal bottom inequality.Results. Absolute inequalities were widest when national coverage was around 50%.At low national coverage levels, top inequality was evident with coverage in the wealthiest quintile taking off rapidly; at 60% or higher national coverage, bottom inequality became the predominant pattern, with the poorest quintile lagging behind.Conclusions. Policies need to be tailored to inequality patterns. When top inequalities are present, barriers that limit uptake by most of the population must be identified and addressed. When bottom inequalities exist, interventions must be targeted at specific subgroups that are left behind. (Am J

Background Previous analyses of trends in feeding indicators of children younger than 2 years have been limited to low-income and middle-income countries. We aimed to assess time trends in the consumption of different types of milk (breastmilk, formula, and animal milk) by children younger than 2 years from 2000 to 2019 at a global level.Methods In this time-series analysis, we combined cross-sectional data from 487 nationally representative surveys from low-income and middle-income countries and information from high-income countries to estimate seven infant and young child feeding indicators in up to 113 countries. Multilevel linear models were used in pooled analyses to estimate annual changes in feeding practices from 2000 to 2019 for country income groups and world regions. Findings For the absolute average annual changes, we found significant gains in any breastfeeding at age 6 months in high-income countries (1•29 percentage points [PPs] per year [95% CI 1•12 to 1•45]; p<0•0001) and at age 1 year in high-income countries (1•14 PPs per year [0•99 to 1•28]; p<0•0001) and upper-middle-income countries (0•53 PPs per year [0•23 to 0•82]; p<0•0001). We also found a small reduction in low-income countries for any breastfeeding at age 6 months (-0•07 PPs per year [-0•11 to -0•03]; p<0•0001) and age 1 year (-0•13 PPs per year [-0•18 to -0•09]; p<0•0001). Data on exclusive breastfeeding and consumption of formula and animal milk were only available for low-income and middle-income countries, where exclusive breastfeeding in the first 6 months of life increased by 0•70 PPs per year (0•51-0•88; p<0•0001) to reach 48•6% (41•9-55•2) in 2019. Exclusive breastfeeding increased in all world regions except for the Middle East and north Africa. Formula consumption in the first 6 months of life increased in upper-middle-income countries and in east Asia and the Pacific, Latin America and the Caribbean, the Middle East and north Africa, and eastern Europe and central Asia, whereas the rates remained below 8% in sub-Saharan Africa and south Asia. Animal milk consumption by children younger than 6 months decreased significantly (-0•41 PPs per year [-0•51 to -0•31]; p<0•0001) in low-income and middle-income countries.Interpretation We found some increases in exclusive and any breastfeeding at age 6 months in various regions and income groups, while formula consumption increased in upper-middle-income countries. To achieve the global target of 70% exclusive breastfeeding by 2030, however, rates of improvement will need to be accelerated.Funding Bill & Melinda Gates Foundation, through WHO.