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Why South African Mums Opt for Formula Milk Despite Breastfeeding Being Best

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Decisions made by women and families regarding infant feeding are based on the information they have access to. This is among the findings of the 2023 Lancet series on breastfeeding, which comprises three papers launched in South Africa on 10th February and in the UK on 8th February.

The series interrogates baby formula companies’ exploitative marketing playbook and the commercial formula lobby.

It highlights the economic and political power of the dominant formula companies and the public policy failures that result in millions of women not breastfeeding as recommended.

In a novel analysis, the series describes how profits made by the formula milk industry benefit companies located in high-income countries while the social, economic, and environmental harms are widely distributed and most harmful in low- and middle-income countries, such as South Africa. 

Milking mums’ misery

The Series outlines the exploitative marketing playbook used by formula companies to sell their products, including taking advantage of parents’ worries about their child’s health and development.

One common reason women introduce formula is that they misinterpret unsettled baby behaviour, especially disrupted sleep and persistent crying in the first few months of life, as signs that their breast milk is insufficient.

However, the sleep patterns of babies are not the same as those of adults and unsettled baby behaviours are common adaptations to life outside of the womb.

When mothers are appropriately supported, concerns can be addressed successfully without the use of formula milk. 

Linda Richter is a distinguished professor in the Department of Science and Innovation (DSI)-National Research Foundation (NRF) Centre of Excellence for Human Development (CoE: Human) at Wits University and co-author on paper 1 and paper 2 of the series.

Professor Richter is one of only three contributors from Africa, along with Lancet issue Commentary co-author Dr Chantell Witten at the University of the Western Cape, and series co-author Dr Kopano Mabaso, Senior Programme Officer, Health, Africa, at the Bill & Melinda Gates Foundation.

Professor Richter explained: “The formula milk industry uses poor science to suggest, with little supporting evidence, that their products are solutions to common infant health and developmental challenges. Adverts claim specialised formulas alleviate fussiness, help with colic, prolong night-time sleep, and even encourage superior intelligence.

Labels use words like “brain”, “neuro” and “IQ” with images highlighting early development, but studies show no benefit of these product ingredients on academic performance or long-term cognition. These marketing techniques violate the 1981 World Health Organization International Code of Marketing of Breastmilk Substitutes, to which countries agree that labels should not idealise the use of formula, nor exploit poor science to create an untrue story to sell more products.”

‘The Baby Killer’ and the Code

The 1981 Code to which Richter refers demonstrates that exploitative formula milk marketing tactics are not new. The 1970s The Baby Killer investigative report into Nestlé’s marketing of formula milk in the Global South prompted the World Health Organization (WHO) to develop the voluntary International Code of Marketing of Breast-milk Substitutes and subsequent resolutions (the Code) in 1981 – the key word being “voluntary”.

However, the powerful influence of the formula industry, and the marketing of their products in violation of the Code, continues into the 21st century and even more insidiously with digital social media and artificial intelligence to target individual women. Sales from commercial formula milk have rapidly increased over the past 20 years and now stand at more than $55 billion a year.

A new review of 153 studies, conducted for the series, details how marketing practices in violation of the Code have continued in nearly 100 countries – including South Africa – and in every region of the world since its (voluntary) adoption more than forty years ago.

This continued exploitation persists due to the power of the formula industry to influence national political decisions and interfere with international and national regulatory processes.

The formula milk lobby

The Series also draws attention to the formula industry’s establishment of a network of trade associations and front groups that lobby against the Code and other breastfeeding protection measures.

For example, in 2012, South Africa passed new national legislation to implement the Code into law. However, this took nine years with many setbacks resulting from industry lobbying. Formula milk manufacturers formed a new lobby group, the Infant Feeding Association, which applied pressure for amendments to the regulations.

This outsourcing of lobbying allows corporations to project an image of benevolence and corporate social responsibility, suggesting that they can adequately self-regulate through corporate policies on responsible marketing. However, their self-regulation falls far short of compliance with the Code.

As well as influencing political organisations, the Series authors argue that formula milk companies also draw on the credibility of science by sponsoring professional organisations, publishing sponsored articles in scientific journals, and inviting leaders in public health onto advisory boards and committees, leading to unacceptable conflicts of interest within public health.

Co-author on the commentary, Dr Chantell Witten at the Centre of Excellence in Food Security, University of the Western Cape, says, “Creating an enabling environment for mothers to optimally breastfeed their babies needs a whole-of-society approach, with stronger monitoring and enforcement of our regulations to control the marketing of formula milk for children.”

Society-wide changes needed

In addition to ending the marketing tactics and industry influence of formula milk companies, broader actions across workplaces, healthcare, governments, and communities are needed to more effectively support women who want to breastfeed, according to the Series.

Half a billion working women globally are not entitled to adequate maternity leave. A systematic review of studies found women with a minimum of three months of maternity leave, paid or unpaid, was at least 50% more likely to continue breastfeeding compared to women returning to work within three months of giving birth.

The Series authors call for governments and workplaces to recognise the value of breastfeeding and care work, by actions such as extending the duration of paid maternity leave to align with the six-month WHO recommended duration of exclusive breastfeeding.

Women also face a lack of breastfeeding promotion, protection and support within healthcare systems due to limited public budgets, adequate training of and skilled support by health workers, influence from the milk formula industry including through the distribution of samples, and an absence of care that is culturally appropriate and led by the needs of women.

Authors argue that breastfeeding outcomes improve when health systems actively empower women and enable experienced peers to support women during pregnancy, childbirth and onwards.

Breastfeeding a collective responsibility of society

The Series authors stress that breastfeeding is a collective responsibility of society and call for more effective promotion, support, and protection for breastfeeding, including a much better-trained healthcare workforce and an international legal treaty to end exploitative formula milk marketing and prohibit political lobbying.

A linked Editorial published in The Lancet states: “Some women choose not to breastfeed or are unable to. Perceived pressure, or inability, to breastfeed – especially if it is at odds with a mother’s wishes – can have a detrimental effect on mental health, and systems should be in place to fully support all mothers in their choices.”

“Women and families make decisions about infant feeding based on the information they receive, and a criticism of the CMF (commercial milk formula) industry’s predatory marketing practices should not be interpreted as a criticism of women.

“All information that families receive on infant feeding must be accurate and independent of industry influence to ensure informed decision making.”

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