BREASTFEEDING CONNECTION

CAROL BARTLE POLICY ANALYST

WORLD HEALTH ORGANISATION REPORT:

HOW THE MARKETING OF FORMULA MILK INFLUENCES DECISIONS ABOUT INFANT FEEDING

The International Code of Marketing of Breast-milk Substitutes (the Code), and the regular updates in the form of the World Health Assembly resolutions, are designed to not only protect breastfeeding by stopping inappropriate and misleading marketing of breastmilk substitutes, bottles and teats, but to also protect infants fed on breastmilk substitutes. All parents should have access to unbiased, commercial-free information about infant feeding, and health professionals also need a source of unbiased, scientific and factual information which is not provided, or influenced by, industry.

In 2020 the WHO and UNICEF published a national implementation of the Code status report which presented the legal status of the Code, including the extent of the provisions incorporated into national legal measures in member states (WHO, 2020). Of 194 WHO Member States (countries), 136 (70%) had enacted legal measures with provisions to implement the Code.

Of these, 25 countries had measures substantially aligned with the Code, 42 had measures which were moderately aligned, 69 had included some provisions, and 58 had no legal measures at all. Only 31 countries had legal measures that covered the full breadth of breastmilk substitutes, which includes milk products targeted for use up to at least 36 months of age. In this report, Aotearoa was identified as having no legal measures in place. Although infant formula products are regulated by the Australia New Zealand Food Standards Code, which covers quality issues such as composition, safety requirements and nutrient content, it does not apply to marketing or advertising practices. Due to the absence of legal measures, the positive aspects of Code implementation in Aotearoa’s maternity system, such as the Baby Friendly Hospital Initiative and Ten Steps to Successful Breastfeeding, were not considered in this Code status report.

The 2022 report by the WHO and UNICEF about infant formula marketing summarises the findings from a multicountry research study and presents opportunities for action. The Code was adopted by the World Health Assembly in 1981 but now, over 40 years later, the marketing of formula milk is described as “one of the most underappreciated risks to infants’ and children’s health” (WHO/ UNICEF, 2022).

The countries involved in the 2022 study were Bangladesh, Mexico, Morocco, Nigeria, South Africa, Vietnam, the United Kingdom of Great Britain and Northern Ireland. The study aimed to capture the experiences of women, and those who influence them, such as health professionals, partners, family members and friends, and their exposure to, and experience of formula marketing. Over 8,500 pregnant women/mothers of young children, and 300 health professionals were surveyed. There were 80 in-depth interviews and 100 focus groups conducted.

Of the 8,528 pregnant and postnatal women surveyed, 51% reported exposure to formula marketing in the preceding year. It was reported that companies were seeking engagement with younger newly pregnant women, referred to as the “holy grail” for sales, and data-driven algorithms were used to target digital advertising to women whose online behaviour indicated that they may be pregnant. Multiple channels, including television, digital marketing, digital influencers with large social media followings, celebrity and paediatrician endorsements were identified as being significant. Marketing messages were misleading and expansion of the portfolio of products, into follow-on, toddler and growing up milks to circumvent the Code, was found to be a common strategy. Marketing using sciencebased messages was impactful despite the incomplete evidence and unsupported health outcome claims.

Of the 8,528 pregnant and postnatal women surveyed, 51% reported exposure to formula marketing in the preceding year. It was reported that companies were seeking engagement with younger newly pregnant women, referred to as the “holy grail” for sales.

The report also noted that companies have been active during the Covid-19 pandemic to create further anxiety and increase sales. A survey of 1,360 breastfeeding women in the UK during the Covid-19 national lockdown found that 80% of these mothers reported contact from formula companies.

In terms of breastfeeding intentions, pregnant women expressed a strong desire to breastfeed but they were exposed to breastfeeding and breastmilk mythology including misinformation about the adequacy and quality of breastmilk. Exposure to formula marketing increased favourable attitudes to formula milks, and also convinced some women of the need for a wide range of products including unnecessary follow-on, toddler milks and specialised formulas.

The report is described as the “most complete picture to date of mothers’ and health professionals’ experiences of formula milk marketing” – and the executive summary of the report described the situation as “deeply troubling”.

Key findings in the report were: • Formula milk marketing is pervasive, personal and powerful. • Companies use sophisticated techniques and manipulative marketing tactics, such as claims about products solving common infant problems that exploit parents’ anxieties and aspirations. • Companies distort science and medicine to legitimise claims and push products. • False and incomplete claims are made to position formula as close to, equivalent to, or superior to, breastmilk. • Industry systematically targets health professionals using sponsorship, incentives and training incentives. • Marketing undermines parents’ confidence in breastfeeding. • Governments, health professionals and their associations, civil society and many other actors can immediately take meaningful actions to end unethical marketing.

The report also noted that companies have been active during the Covid-19 pandemic to create further anxiety and increase sales. A survey of 1,360 breastfeeding women in the UK during the Covid-19 national lockdown found that 80% of these mothers reported contact from formula companies (van Tulleken et al., 2020). Concerns were expressed that the formula industry was violating the Code and actively exploiting Covid-19 concerns about breastfeeding to increase sales by inappropriately and unethically positioning themselves as sources of public health expertise (van Tulleken et al., 2020).

Opportunities for action suggested in the WHO report included the urgent need for governments to recognise the scale and urgency of the problem, to legislate, regulate and enforce the Code and subsequent relevant World Health Assembly resolutions, and to protect the integrity of science and medicine. Investing in training and building the skills of health professionals to enable provision of accurate impartial information, and active countering of the commerciallydriven messages about infant feeding was also recommended. Health professionals were reported as being the main source of infant feeding education in the survey, highlighting their need for accessible, accurate, up-to-date and unbiased information. Strong conflict of interest policies were suggested for health professionals and their organisations.

Aotearoa’s interpretation of the Code includes a Code of Practice for Health Workers (recommending best practice) (Ministry of Health, 2009), the Code of Practice for the marketing of infant formula in New Zealand (a voluntary and self-regulated industry code), the Code for Advertising of Food and the Food Standards Code. Industry written codes of conduct do not fully represent the Code, and also ignore Code updates in the form of World Health Assembly resolutions. The Food Standards Code - which consists of a range of provisions including labelling, composition, nutrition and health claims, uses and storage information - is covered under legislation. There is a complaints-based process for the reporting of Code marketing violations, which relies on public and health worker knowledge of the Code, and complainants having the time to submit the complaint and be involved with industry responses to the complaint process (Ministry of Health, 2020). There is no formal, active, or systematic monitoring of formula marketing in Aotearoa.

Helen Clark (former Prime Minister of New Zealand) and Tedros Adhanom Ghebreyesus (WHO Director General) discuss the WHO report in the British Medical Journal (2022). They describe how the “cynical marketing tactics used to push milk formula drives over-consumption, discourages breastfeeding, undermines mothers’ confidence, and exploits parents’ instincts to do the best for their children”. Clark and Ghebreyesus call on governments to enact and enforce legislation aligned with the Code, for ethical business practices, for protection of the integrity of science, with endorsements only for public good to be given by health professional associations, and for social media platforms to reject practices that undermine children’s health. They end their article by saying that now is the time to stop prioritising corporate profits over child health.

As the WHO report points out, it is the marketing of the products and not the products themselves that disrupt informed decision-making and undermine breastfeeding and infant and child health. With the aggressive and misleading marketing of breastmilk substitutes continuing largely unabated, reported global sales revenue of US$57.12 billion in 2019, and an anticipated rise to US$110.26 billion by 2026 (Global Newswire, 2021), the WHO report highlights the need for urgent action by governments now. square

References available on request.