THE 2023 LANCET SERIES ON BREASTFEEDING

In 2016 the Lancet released a series on breastfeeding based on a growing body of evidence which highlighted the significant economic and health benefits, for both rich and poor countries alike, when governments support breastfeeding through meaningful investments and targeted programmes (Rollins et al, 2016; McFadden et al, 2016; Victora et al, 2016). The urgent need for breastfeeding support in terms of paid maternity leave, nursing breaks at work and commitment from governments and health authorities (Rollins et al, 2016) has not been fully realised in Aotearoa, and these issues have been barely addressed in some countries.

Another key issue addressed in the 2016 series was the need for coordinated global action on formula marketing (McFadden et al, 2016). The new Lancet Breastfeeding Series 2023 highlights the vast economic power of the commercial milk formula (CMF) industry, the continued underregulation of industry practice and marketing, and the chronic under-resourcing of breastfeeding support services.

International Code Background

The International Code of Marketing of Breast-milk Substitutes was adopted over forty years ago in 1981 (WHO, 1981) in recognition of declining breastfeeding rates globally, which in part are attributed to the unethical, misleading and aggressive marketing and advertising of breastmilk substitutes (Kent, 2015; Palmer, 2009; WHO / UNICEF / IBFAN, 2016). This Code is a set of recommendations from the collective membership of the World Health Assembly (WHA). The aim is to contribute to the provision of safe and adequate nutrition for infants through the protection and promotion of breastfeeding, and by ensuring the proper use of breastmilk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution (WHO, 1981). Subsequent, relevant WHA resolutions ensure the Code stays current and up to date, and together with the 1981 Code their aim is to raise awareness of policy issues on infant and young child feeding at international and national levels. In 2022, the WHO global status report on national implementation of the International Code provided data about country progress in aligning national laws with the Code. More countries had put into effect new legal measures so progress had been made, but many gaps were also noted, and the reasons for these gaps included the absence of highlevel political will, industry interference, poor accountability, and a lack of monitoring and enforcement mechanisms (WHO, 2022).

The only legal measures reported for Aotearoa New Zealand (and Australia) were the New Zealand 1991 Food Standards Australia and New Zealand Act 1991, Standard 2.9.1, 2015, Standard 1.2.1 and Standard 1.2.7, 2016. Australia has joined the World Breastfeeding Trends Initiative (WBTi), which is an initiative designed to support the breastfeeding rights of women by measuring and monitoring policy progress using an assessment tool. The first WBTi assessment of Australia was undertaken in 2018 and the score was 25.5/150 which ranked Australia third last out of 98 countries. The Australian score for implementation of the International Code and resolutions was 1.5 out of 10.

Aotearoa NZ has not yet committed to the introduction of the WBTi initiative.

2023 Lancet Series

Targeted advertising of formula now dominates the marketing landscape on the internet and within social media platforms. Covid-19 concerns have also been exploited by the CMF industry to increase the sales of their products using tactics such as positioning themselves as public health sources, and recommending inappropriate measures which potentially undermine breastfeeding. Improved implementation and enforcement of the International Code with severe sanctions for violations in every country has been called for urgently (van Tulleken, 2020).

The 2023 series consists of three papers, an editorial and a comment. The editorial highlights the point that women’s decisions about infant feeding are based on the information they receive, the support available for breastfeeding, and the influence of the predatory marketing practices of the CMF industry. As Brown (2018) highlighted, many barriers to breastfeeding exist at the societal rather than the individual level, and because these influences are typically out of the control of many women, this creates serious inequities in infant feeding choices. The editorial also emphasises that systems should be in place to support all mothers with their feeding decisions, and criticism of the “predatory marketing practices" [of the commercial milk formula industry] should not be interpreted as a criticism of women.

The Lancet Comment (Doherty et al, 2023) identifies the “striking message” of this series, which is that the consumption of commercial milk formula by infants and young children has been normalised, and more children are consuming formula than ever before. The pervasive influences of social media on families, and the control of the infant feeding discourse by industry, along with industry relationships with governments, academic institutions and health professionals, represent a significant threat at a time when global economic and climate crises disrupt formula supply chains, compromise infant health and potentially endanger the lives of infants and young children who are not breastfed. Disruptions that have threatened global stability and safe infant and young child feeding have included the Covid-19 pandemic, climate disasters such as flooding, and the war in Ukraine. The ability to make decisions about breastfeeding and infant feeding, free from commercial influences, is of significant importance, and elevating breastfeeding up to a public health priority is recommended to improve not only infant and child health but also women’s health.

In the first Lancet article, Pérez-Escamilla et al (2023), examine the structural barriers to breastfeeding in more depth, and also highlight scientific advances in knowledge around breastfeeding, breastmilk and lactation. Breastfeeding is described as a species-specific biopsychosocial system evolved to optimise the health and survival of mothers and their infants. Losing these evolutionary mammalian health benefits by undermining breastfeeding and failing to support breastfeeding women represents an irretrievable loss. The section about the complex biopsychosocial system of breastfeeding, which describes in detail how the nutritional, microbial, and bioactive components of breastmilk engage with each other, the protective antibodies provided by breastfeeding, and the unique, beneficial features of breastfeeding startlingly demonstrates how impossible it is to ever replicate this unique complexity. Expected normal infant behaviours that mistakenly often lead to parents introducing commercial milk formula due to exploitation of parental concerns by industry are also addressed. Recommendations for policy and programmatic actions to support women who want to breastfeed, which are grounded in equity, human rights and public health principles, are made.

Targeted advertising of formula now dominates the marketing landscape on the internet and within social media platforms. Covid-19 concerns have also been exploited by the CMF industry to increase the sales of their products using tactics such as positioning themselves as public health sources, and recommending inappropriate measures which potentially undermine breastfeeding.

The marketing of commercial milk formula and the range of the capture of parents, communities, science and policies is the main focus of article 2 (Rollins et al, 2023) and the key messages include how the marketing of ultra-processed commercial milk formula for use in the first three years of life has altered the infant and young child ecosystem to the detriment of health. Misleading parents, and some health professionals, into thinking that common infant feeding challenges can be resolved by using commercial milk formula, and claiming that these ultra-processed products are linked to ‘benefits’ such as increased infant and young child IQ have been very successful industry marketing strategies. Rollins et al, provide a comprehensive description of the industry marketing playbook, the value of industry capture of health professionals, including midwives, the importance of the International Code of Marketing of Breastmilk Substitutes, and the erosion of legal and regulatory standards which are invariably underpowered, underused and unable to effectively counter industry power.

There is also a section which looks at how breastfeeding advocacy is framed by industry as a harmful moral judgement that causes women to feel guilty. The marketing messages obscure the root causes of breastfeeding challenges which, as previously mentioned, are exploited by industry to influence parents who are often looking for answers to common feeding issues. A key message of this article concerns government obligations to ensure citizens have access to impartial infant and young child feeding information which is free from commercial influences. The absence and/or erosion of legal and regulatory standards means that actions to prevent misleading marketing will remain “underpowered and underused”.

Article 3 continues the focus on the structural barriers to breastfeeding globally, and it also addresses how the commercial milk formula industry contributes to not only widening socioeconomic inequities but also to environmental harms on a large scale. The environmental harms have been obvious for many years and in Aotearoa NZ the contribution of dairy farming intensification which contributes significantly to environmental degradation has been highlighted regularly by concerned ecologists such as Foote & Joy (2014). Smith has suggested that the environmental and health harms of increased formula use, combined with economic evidence, highlight the need for a strong public health response (2019). Article 3 also includes a much needed focus on women, care and work which examines women’s access to the economic resources of time and money and how dependence on commercial milk formula is fostered. Recognising and valuing the contribution of breastfeeding and breast milk in terms of women’s care work, and how this is mostly unrecognised is discussed. This has been another ongoing issue for women and breastfeeding in terms of measures of productivity and economic performance. Marilyn Waring in 1988 wrote about the failure to include reproductive functions and breastfeeding in terms of their economic value, and Smith & Ingham highlighted how economic production is underestimated when GDP measurements exclude the value of unpaid work (2001). The ongoing failures of governments to enact any or sufficient maternity protection, recognise care work, value the contribution of women and breastfeeding, and address conflicts of interest in health systems are ongoing and long standing public health damaging issues.

Conclusion

In summary, it is not possible to cover all the issues addressed in this exceptionally important Lancet 2023 Series and accessing the full series is strongly recommended to all midwives. As the Lancet commentary highlights, “the consumption of commercial milk formula by infants and young children has been normalised”, and the infant and young child feeding ecosystem has been negatively altered (Rollins, et al 2023). Midwives know that breastfeeding makes a significant contribution to population health, and they are also well aware of the systemic barriers that women who intend to breastfeed have been faced with.

While all parents need support with their infant feeding decisions regardless of the reasons why they make them, the protection, promotion and support of breastfeeding, and the need for the International Code of Marketing of Breastmilk Substitutes need to remain uppermost and visible as health priorities. square

Key Points

The commercial milk formula industry has a vast economic power

Industry marketing practices remain chronically under-regulated

Breastfeeding support services, and support for women who wish to breastfeed, remain under-resourced

Targeted advertising of formula milks dominates the marketing landscape on the internet and social media platforms

The consumption of commercial milk formula has been normalised and more infants and children are consuming formula than ever before

Governments have an obligation to ensure citizens have access to impartial infant and young child feeding information free from commercial influence

The protection, promotion and support of breastfeeding and the International Code of Marketing of Breastmilk Substitutes need to be uppermost and visible as public health priorities

References available on request.