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Ending the marketing of breastmilk substitutes: An amazing push to increase breastfeeding rates.

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This article describes recent initiatives that were taken to better regulate the marketing of breastmilk substitutes so that mothers can choose how to feed their children based on the best information and evidence, influenced only by what is best for the child and parents and not by commercial interests.

Gwénola Desplats is a Nutrition Advisor with ENN.

The author would like to acknowledge the input and feedback provided for earlier drafts of the article from Grainne Mairead Moloney and Anuradha Narayan (UNICEF) as well as from Linda Shaker Berbari (IFE-Core Group) and Natalie Sessions (ENN). The views presented here are those of the author and do not necessarily reflect the official positions of the named organisations.

Background

The evidence is clear: breastfeeding is the best possible source of nutrition for infants. For decades, although research has consistently shown the benefits of breastmilk for growth, the prevention of infections, bonding and the brain development of children as well as the health benefits for mothers, breastfeeding rates remain suboptimal.

In 2012, the World Health Assembly (WHA) Resolution 65.6 specified that the rate of exclusive breastfeeding in the first six months of a child should increase up to at least 50% by 2025. However, globally only 41% of infants under six months of age are exclusively breastfed to date (WHO, 2022a).

The decisions and practices around infant feeding are influenced by several factors including the promotion and support that mothers receive. The impact of formula milk marketing on infant feeding decisions and practices is well known too and, since 1981, the International Code of Marketing of Breastmilk Substitutes (the Code) was passed by the WHA as a landmark public health agreement to regulate the marketing of breastmilk substitutes (BMS). Yet, 40 years on, formula milk marketing still represents one of the most underappreciated risks to infants’ and children’s health. The consequences for the health and human rights of women and children are not new, but they are often overlooked.

The marketing of formula milk influences our decisions on infant feeding

Marketing is part of everyday life, experienced by virtually everyone. In a report published in early 2022 (WHO, 2022b), the World Health Organization (WHO) highlighted that the marketing of foods predominantly promotes foods that contribute to unhealthy diets (such as ‘fast food’, sugar-sweetened beverages and chocolate and confectionery) and uses a wide range of creative strategies likely to appeal to young audiences (such as celebrity/sports endorsements, promotional characters and games). This report confirms that the marketing of foods that contribute to unhealthy diets remains pervasive and persuasive and provides evidence that strengthens the rationale for action to protect children from exposure to harmful food marketing practices.

When it comes to the marketing of BMS, for example, formula milk products, this is even more serious as the feeding practices of children in the first three years of life profoundly affect their survival, health and development throughout their lives. Deciding on how we feed our infants and children should therefore be based on robust information and evidence influenced only by what is best for the child and parents and not by commercial interests. The poorly regulated marketing of formula milk products is therefore a significant concern for the health and well-being of children globally.

"As detailed in this report, formula milk marketing - powered by enormous budgets and the deiberate misuse of science - is driving over-consumption of formula milk and discouraging breastfeeding"

– quote from the Forward of the report by the Director General of WHO and the Executive Director of UNICEF

A new report shows that formula milk marketing is pervasive, often misleading and tackles the pain points that women face.

Earlier this year, the WHO and UNICEF revealed the results of a multi-country study on the marketing of breastmilk substitutes (WHO & UNICEF, 2022). The study heard directly from women and those who influence them – health professionals, partners, family members and friends – about their exposure to and experience of formula milk marketing. Eight countries were included in the study – Bangladesh, China, Mexico, Morocco, Nigeria, South Africa, the United Kingdom and Vietnam. These countries were representative of countries in their regions yet were diverse in their income levels, exclusive breastfeeding rates and implementation of the Code. The study was conducted in urban populations where trends and values about infant feeding practices are established and spread to other communities.

Grounded in the experiences of over 8,500 women and 300 health professionals, the report exposed the aggressive marketing practices used by the formula milk industry and highlighted the impacts on families’ decisions about how to feed their babies and young children. 

The research findings (Box 1) show that formula milk companies use sophisticated techniques and misleading messaging to market their products including scientific language and imagery, pain points and emotional and aspirational appeals. They also assume a friendly, supportive role to pregnant women and mothers, exploiting vulnerabilities to gain access and increase sales.

Most women surveyed (93%) had seen promotions for formula milk online or in a store and 68% of survey respondents had received a promotion for formula milk. Digital marketing practices have grown rapidly in recent years, especially in light of the COVID-19 pandemic. For example, in China, 68% of survey participants recalled seeing a pop-up advert for BMS on social media. Digital marketing was generally cited as more effective than traditional methods of advertising, being more precise in its targeting and requiring less investment. Furthermore, digital marketing provides formula milk companies with a rich stream of personal data that they use to sharpen and focus their marketing campaigns.

Across all the countries included in the survey, women expressed a strong desire to exclusively breastfeed, ranging from 49% of women in Morocco to 98% in Bangladesh. However, this was counterbalanced by a sustained flow of misleading marketing messages that the report showed reinforced myths about breastfeeding and breastmilk and undermined women’s confidence in their ability to breastfeed.

The evidence that emerged from this study is strong: formula milk marketing (not the product itself) disrupts informed decision-making and undermines breastfeeding and child health.1

Box 1: Key finding and opportunities for action from the WHO-UNICEF report

Key findings:

  • Formula milk marketing is pervasive, personalised and powerful.
  • Formula milk companies use manipulative marketing tactics that exploit parents’ anxieties and aspirations for having a healthier and brighter child, for example.
  • Formula milk companies distort science and medicine to legitimise their claims and push their product.
  • Industry systematically targets health professionals – whose recommendations are influential – to encourage them to promote formula milk products.
  • Formula milk marketing undermines parents’ confidence in breastfeeding. 
  • Countermeasures can be effective but must be comprehensively expanded and scaled up.

Opportunities for action:

  • Recognise the scale and urgency of the problem 
  • Legislate, regulate, enforce, which means that countries should urgently adopt or strengthen comprehensive national mechanisms to prevent formula milk marketing, including through their domestic legislation – health, trade and labour – in line with the Code, closing all loopholes, robust enforcement and accountability mechanisms including holding formula milk companies accountable for their practices and commitments, regulatory measures including plain packaging for formula products and higher standards of evidence for product development and programmatic initiatives such as strengthening and expanding the Baby-friendly Hospital Initiative
  • Protect the integrity of science and medicine – including by setting mechanisms to prevent conflict of interest and to counter commercially driven messages on infant feeding
  • Safeguard children’s health on digital platforms
  • Invest in mothers and families, divest from formula milk companies
  • Expand coalitions to drive action

 

The release of the report has already triggered actions…

Government officials, civil society, the health workforce, the private sector, community representatives, nutritionists, international humanitarian practitioners, etc. participated in the launch of the report on February 23rd, 2022. Two sessions were held to account for different time zones and included prestigious panels of speakers from national governments, human rights groups, civil society organisations and marketing experts. Several thousand people participated and heard that, despite the Code and the subsequent relevant WHA resolutions, formula milk companies continue to put sales and shareholder interests before infant and population health and continue to employ ever evolving tactics to both defy and circumvent regulations.

Both the events and the subsequent media coverage around the launch of the report triggered actions: the President of Ireland issued a statement following the launch of the report,2 the traffic on social media, using the hashtag #EndExploitativeMarketing, increased and the open letter that was disseminated registered over 4,000 signatures in just a few days.3

… and offers the potential for again more opportunities for action

Based on strong evidence from the research findings, the report proposed opportunities for action, summarised in Box 1, which call for programming that supports mothers and those who influence them – close family members, health workers, friends – to make appropriate decisions about how to feed their infants and children. Deciding how to feed our infants and children should be based on reliable information and truthful evidence, influenced only by what is best for the child and parents and free of commercial interests.

This reports also gives the opportunity for health and nutrition practitioners to learn from the field of marketing. Do we properly respond to the needs of mothers? Do we appropriately tailor our messages to the challenges mothers face? Do new mothers have access to immediate support when they face a breastfeeding constraint? How do we make sure we provide appropriate support that make new mothers feel that ‘they can make it’ at a time they feel vulnerable? In humanitarian settings and conflict-affected areas, when the life-saving potential of breastfeeding is even more crucial, how can we ensure that women are supported when they are even more vulnerable and worried about their ability to properly feed their children?

“It is also undermining women’s confidence and cynically exploiting parents’ instinct to do the best for their children.”

– quote from the Forward of the report by the Director General of WHO and the Executive Director of UNICEF  

Conclusion

This report provides strong evidence of the pervasive and exploitative nature of infant formula marketing and is the call to action for all of us to do more to protect children adequately. It is based on what is often overlooked: the voices of mothers who are the primary target of marketing at a vulnerable and intimate time of their lives.

Some women choose not to breastfeed for a variety of reasons and should be supported in whatever decisions they make. However, this report highlights that marketing plays a critical role in women’s decision making on how they feed their infants. Across all the countries included in the survey, women expressed a strong desire to breastfeed exclusively, yet the report details show that a sustained flow of misleading marketing messages reinforces myths about breastfeeding and breastmilk and undermines women’s confidence in their ability to breastfeed.

Learning that the formula milk industry is investing USD 55 billion in marketing each year – which represents a larger budget than the WHO has available for its entire operations for two years – we realise that the public health sector is not equipped to reverse the trends by using the same tactics. It must use its own strengths as an alternative tool: ensuring robust enforcement and accountability mechanisms, including holding formula milk companies accountable for their practices and commitments, ensuring that health professionals are sufficiently trained to provide the necessary support to young mothers and investing in systems that prevent them from engaging in conflicts of interest.

Let us hope that this is only the beginning of a new era when mothers can choose how they feed their infants based on informed choice, free from commercial influence. Let us also hope that this is only the start of a conversation, as wished for by the WHO and UNICEF, in which health and nutrition practitioners engage and act.

If you would like to act now, please read and sign the open letter to #EndExploitativeMarketing.

For more information, please contact Gwénola Desplats at gwenola@ennonline.net

References

WHO (2022a) Health topics: Breastfeeding overview. https://www.who.int/health-topics/breastfeeding#tab=tab_1

WHO (2022b) Food marketing exposure and power and their associations with food-related attitudes, beliefs and behaviours: a narrative review. Geneva: World Health Organization. Licence: CC BY-NC-SA 3.0 IGO. https://www.who.int/publications/i/item/9789240041783

WHO and UNICEF (2022) - https://www.who.int/publications/i/item/9789240044609

Read more...

1 WHO and UNICEF recommend banning the harmful promotion and marketing of formula milk. WHO, UNICEF and the Code do not aim to limit access to formula milk products.  Restricting marketing does not mean that formula milk products cannot be sold or that factual and scientific information about them cannot be made available to health professionals or families, nor does it restrict parents’ choice. It aims to make sure that parents are free to make choices that are based on accurate information while protecting them from misleading or biased marketing claims.

2 https://president.ie/en/media-library/news-releases/statement-by-president-michael-d-higgins-sabina-higgins-following-the-launch-of-who-unicef-on-the-effects-of-marketing-of-infant-formula

3 https://www.who.int/teams/maternal-newborn-child-adolescent-health-and-ageing/formula-milk-industry/endexploitativemarketing-of-formula-milk-products

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Gwénola Desplats (). Ending the marketing of breastmilk substitutes: An amazing push to increase breastfeeding rates.. Field Exchange 67, April 2022. p20. www.ennonline.net/fex/67/bmsmarketing

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