Formula milk marketing tactics are exploitative, and regulations need to be urgently strengthened and properly implemented according to a new three-paper Series published in The Lancet. Experts are calling for an international legal treaty to end irresponsible formula milk marketing and political lobbying, accompanied by more effective breastfeeding support worldwide.
“Babies are most likely to survive and grow to their full potential when breastfed,” said Series co-author Rafael Pérez-Escamilla, professor of public health at the Yale School of Public Health and a leading authority on breastfeeding policy and early childhood nutrition. “Breastfeeding promotes brain development and protects infants against malnutrition, infectious diseases, and death, while also reducing risks of obesity and chronic diseases in later life. Yet, globally, many women who wish to breastfeed face multiple barriers, including insufficient parental leave and lack of support in health care systems and at the workplace, in the context of exploitative marketing tactics of the commercial milk formula industry.”
In a novel analysis, the Lancet 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.
“The sale of commercial milk formula is a multi-billion-dollar industry that uses political lobbying alongside a sophisticated and highly effective marketing playbook to turn the care and concern of parents and caregivers into a business opportunity,” said Professor Nigel Rollins of the World Health Organization’s (WHO) Department of Maternal, Newborn, Child, and Adolescent Health and another Series co-author. “It is time for this to end. Women should be empowered to make choices about infant feeding which are informed by accurate information free from industry influence.”
“Our Series finds society, politics, and economics all contribute to why fewer than half of infants globally are breastfed as recommended,” Rollins continued. “Breastfeeding should be considered society’s collective responsibility, not the sole concern of women. We need to see wide-ranging actions across different areas of society to better support mothers to breastfeed for as long as they want.”
The 2023 Lancet Series on Breastfeeding can be found here.
An exploitative marketing playbook
Triggered by The Baby Killer investigative report into Nestle’s marketing of formula milk in the Global South in the 1970s, the World Health Assembly developed the voluntary International Code of Marketing of Breast Milk Substitutes and subsequent resolutions (the Code) in 1981. However, the powerful influence of the milk formula industry and the marketing of their products in violation of the Code continues, with sales from commercial formula milk having rapidly increased over the past 20 years and now at more than $55 billion a year.
The Lancet Series outlines the exploitative tactics used by formula milk companies to sell their products, including taking advantage of parents’ worries about their child’s health and development. One common reason women introduce formula milk is interpreting unsettled baby behavior, especially disrupted sleep and persistent crying, as a sign that breast milk is insufficient. However, sleep patterns of babies are not the same as for adults and unsettled baby behaviors are common. When mothers are appropriately supported, concerns can be addressed successfully without the use of formula milk.
“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,” said Professor Linda Richter, Wits University, South Africa. “Adverts claim specialized 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. This marketing technique violates the 1981 Code, which says labels should not idealize the use of formula and exploits poor science to create an untrue story to sell more product.”
The Lancet Series explains how formula milk marketing exploits the lack of support for breastfeeding by governments and society to use gender politics to sell its products. The authors describe how the formula milk industry frames breastfeeding advocacy as a moralistic judgment that is anti-feminist and damaging to women while presenting milk formula as a convenient and empowering solution for working mothers.
In recent years, digital communications have greatly increased the reach of marketing in ways that blur the difference between advertising and the provision of nutrition and care advice. The Series highlights examples of digital marketing such as industry-paid influencers sharing the difficulties of breastfeeding as preludes to formula milk marketing, and industry-sponsored parenting apps with 24/7 chat services that enable product placement, offer free samples or deals, and promote online sales. The authors argue there is very little regulation of the formula milk industry online and there are regular violations of the Code.
A new review, conducted for the Series, of 153 studies details how marketing practices in violation of the Code have continued in nearly 100 countries and in every region of the world since its adoption more than 40 years ago. The Lancet Series says voluntary uptake of the Code is not enough and calls for an international legal treaty on the commercial marketing of food products for babies to protect the health and well-being of mothers and families.
The formula milk lobby
The Series also draws attention to the power of the milk formula industry to influence national political decisions and interfere with international and national regulatory processes. The formula industry has established 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 the corporations themselves 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 organizations, the authors argue formula milk companies also draw on the credibility of science by sponsoring professional organizations, 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.
“The voluntary Code is not working – formula milk companies chose to disregard the guidance and lobby at every opportunity to weaken regulation,” said Professor David McCoy of the United Nations University International Institute for Global Health. “We need a stricter international legal treaty on the marketing of milk formula which is incorporated into law across the world. The treaty must protect policymaking from industry influence, with obligations for senior public officials to divulge meetings with lobbyists and requirements for scientific organizations to disclose funding sources and members of expert advisory groups. This would regulate the commercial milk formula industry while not restricting the sale of the products to those who need or want them. More generally, the global and public health community must also be much more critical about public-private partnerships that enable or tolerate conflicts of interest.”
Society-wide changes needed
In addition to ending the marketing tactics and industry influence of formula milk companies, broader actions across workplaces, health care, governments, and communities are needed to more effectively support women who want to breastfeed.
Half a billion working women globally are not entitled to adequate maternity protection. A systematic review of studies found women with a minimum of three months of maternity leave, paid or unpaid, were at least 50% more likely to continue breastfeeding compared to women returning to work within three months of giving birth. The authors call for governments and workplaces to recognize the value of breastfeeding, through actions such as extending paid maternity leave duration to align with the six-month WHO-recommended duration of exclusive breastfeeding.
Women also face a lack of breastfeeding promotion, protection, and support within health care systems due to limited public budgets, skilled support by health workers, influence from the milk formula industry, and an absence of care that is culturally appropriate and led by the needs of women. The Series authors argue that breastfeeding outcomes improve when health systems actively empower women and enable experienced peers to support women during pregnancy, childbirth, and onwards. Health care providers should offer skilled counseling before and after birth to all mothers to enable them to address unsettled baby behaviors while continuing to breastfeed if they wish to do so.
Sonia Hernández-Cordero, Universidad Iberoamericana, Mexico City said, “We are seeing improvements in some countries. A case study that we commissioned for the Series found that, despite lacking federally mandated paid maternity leave, the U.S. continues to recognize an increasing number of baby-friendly hospitals each year, and the National Supplemental Nutrition Program for Women, Infants, and Children (WIC), which reaches half of the annual births in the U.S., is increasingly providing breastfeeding counseling as it continues to support more women to choose breastfeeding.”
“Many governments fail to protect mothers and children from unethical marketing practices because of the economic and political power of transnational companies,” said McCoy. “The extreme power of corporations relative to public-interest bodies must be re-balanced. Anti-trust legislation and the ending of corporate tax abuse would help reverse the favoring of private financial interests at the expense of the rights of mothers and infants.”
Said Dr. Julie Smith, Australian National University: “Advice that breastfeeding is best for their babies' health is no use if women are not supported to understand and manage unsettled baby behaviors, or if mothers without maternity leave or pay are forced to go back to work out of financial necessity.”
A large expansion in health professional training on breastfeeding, as well as statutory paid maternity leave and other protections, are vital,” said Pérez-Escamilla. “This requires changing the way society views breastfeeding as the sole responsibility of individual women and putting the onus across all levels of society.”
A related editorial published in The Lancet said, “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 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.”