This month, a new report by the World Health Organization (WHO), UNICEF and the International Baby Food Action Network (IBFAN) laid bare the global picture of laws to promote and safeguard breastfeeding. The report shows the extent to which 195 countries have integrated guidance from the International Code of Marketing of Breast-Milk Substitutes and its resolutions – also known as The Code – into their respective national legal frameworks.
The Code exists to promote and to protect breastfeeding through the prevention of inappropriate marketing of breastmilk substitutes – usually infant formula milk – bottles and teats. WHO recommends exclusive breastfeeding for all babies to the age of six months; formula feeding is associated with higher rates of respiratory and gastrointestinal infections among infants, and greater risk of hospitalisation in childhood. What’s more, babies fed with formula milk are more likely to develop allergies and may well be at higher risk of obesity in later life. There is also growing evidence to suggest that breastfeeding can lower a mother’s lifetime risk of developing breast and ovarian cancers, as well as postmenopausal cardiovascular disease.
With scientific consensus firmly on the side of breastfeeding, the persistent, widespread use of infant formula among otherwise healthy, well-nourished mothers is nothing short of a public health disaster. While many European countries have made impressive gains in breastfeeding rates over the last decades, the United Kingdom remains at the bottom of international league tables. It is a sad fact that 9 out of 10 UK mothers who stop breastfeeding before their baby is six weeks old would have liked to continue; we owe it to them, and to their babies, to ask how this situation came to be, and why the problem endures.
The answer is not simple. Social attitudes, workplace legislation (or lack thereof), and a scarcity of accessible breastfeeding education and support all contribute to the very poor picture of infant feeding in the UK. It may be possible however, to apportion the largest share of the blame to one particular factor: formula marketing.
While artificial infant feeding using animal milk has occurred in emergencies for millennia, it was in 1865 that a German chemist named Justin von Leibig created what he considered to be the perfect infant food, a mixture somewhat resembling today’s formula milks. Over the following decades food preservation methods improved and formula recipes were refined; by the 1920s artificial feeding was already big business. Aggressive marketing campaigns by manufacturers aimed at healthcare professionals made the false claim that formula was not only as safe as breastmilk, but was actually superior. By the 1970s breastfeeding rates in high-income countries had plummeted, societal familiarity with breastfeeding was lost, and artificial feeding had become the norm.
By the end of the 1970s, alarm bells had started to ring. Formula companies had set their sights on low- and middle-income countries, resulting in the deaths of hundreds of thousands of infants each year; while a formula-fed baby in the UK will normally survive an illness thanks to high standards of hospital care, a child who forgoes the protective qualities of breastmilk in an environment devoid of clean water, sanitation or medical care will often not be so lucky. In 1981 WHO introduced The Code in an effort to protect breastfeeding, and to safeguard young lives.
Many countries have integrated provisions from The Code into law, placing restrictions on formula milk advertisement. These laws are intended to protect the right of parents to receive accurate information on infant feeding by banning aggressive advertisements from formula companies. Such advertisements can confuse parents, and lead them to wrongly believe that formula milk is as good as breastmilk. Each brand on the UK market claims that its formula is the best, the healthiest, the nearest to nature; the reality is that none can come close to breastmilk, and they are all virtually identical due to strict legal requirements on their composition. In fact, even organic formula milks are almost indistinguishable to other, non-organic products because of firm regulations on pesticide residue content across the board.
In the UK some provisions have been made in law to protect parents from formula companies’ marketing techniques, in order to bolster abysmal national breastfeeding rates. As in many countries, it is illegal to advertise infant formula. That said, two thirds of parents believe that they have recently seen formula advertisements, so what’s going on? The short answer is that manufacturers have found ways around UK legal restrictions through the marketing of new products, and via online contact with parents.
For several years now, health professionals and other infant health experts have been calling for the law to be updated, as in its current form it does not prohibit the marketing of follow-on milk, a new and unnecessary product created specifically to circumvent legal restrictions on formula advertisement. As shown below, the labelling of follow-on formulas resembles that of infant formulas, a factor that a WHO statement notes may lead “to confusion as to the purpose of the product, i.e. a perception that follow-up formula is a breast-milk substitute.” Not only can this lead to the early introduction of follow-up formula, but also the underhanded marketing of actual infant formulas through greater brand awareness, both directly undermining breastfeeding. A quick search of popular parenting forums such as Netmums and babycentre produces dozens of threads wherein confused users seek advice on the intended purpose of follow-on formulas.
Websites and social media have also proved to be useful tools for formula companies to indirectly, and thus legally, market their products. Most of the main manufacturers have Facebook and Twitter pages broadcasting cuddly content to thousands of followers each day. While none mention formula milk explicitly, they frequently feature content on pregnancy and about babies under six months old (the cut off age for exclusive breastfeeding), forging and maintaining the association between their products and young babies.
Websites such as AptaClub and the Cow & Gate Baby Club ‘community’ dispense friendly, plain-English advice to parents eager to provide their children with the best start in life. Some advice, such as to commence solid foods around six months old, is in line with evidence-based WHO recommendations. The rest, such as instructions on artificial feeding from birth, entirely omits the risks of formula, and is hidden behind similarly worded, click-through disclaimer pages on the viewer’s “individual request for information purposes”.
While explicit advertising of infant formulas may be outlawed in the UK, current legislation is not enough. Cynical and deliberately confusing marketing of follow-on milks, as well as the insidious use of social media to access new parents both contribute to the continued normalisation of artificial feeding and undermining of breastfeeding. Enough is enough. Our lawmakers must heed the calls of public health experts and take a stand against inappropriate marketing. Legal loopholes that allow formula companies to continue to mislead the public must be closed if we are to place the health of mothers and babies before corporate profit.
Featured image © Nerissa’s Ring
Jessica Falk is co-founder and content editor at The Diagonal, and holds an MSc in Global Health & Development from UCL. She is interested in maternal, newborn and child health challenges among vulnerable populations in middle- and high-income countries, and has experience supporting and managing research projects in India, Israel, Morocco and the UK. She currently works for a large international NGO in London.