We know about the power of breastfeeding ... Why do fewer and fewer mothers choose differently?
Karen Codling, UNICEF Nutrition Officer, East Asia and Pacific Regional Office
In a mixed tale of tragedy and survival, a mother stranded in an American forest kept both her children alive by breastfeeding them. The father, who had gone for help, was found dead two days after his family was rescued. The image of the woman nursing her infant and 4-year-old daughter for days drew a stirring reminder to the strength and natural convenience of mother’s milk.
Thus it is distressing in the fight to improve the health and survival of babies in the East Asia and the Pacific region that we see an increasing trend away from exclusive breastfeeding.
Decades of medical research prove that up to two years, or even longer, of breastfeeding gives children the optimum opportunity for growth, development and good health. In the first six months of life, it is the only food and drink a baby needs. It provides optimum nutrition, protection from illness and the building blocks for cognitive development.
Which is why data on exclusive breastfeeding rates in East Asia and the Pacific, in the recently released State of the World’s Children 2007 report, is alarming.
According to the 2007 report, only 43 per cent of women in the region breastfeed exclusively for the first six months of their babies’ lives. This reflects a progressive downward trend from 56 per cent in 1999. A year ago, it was 52 per cent. In the Philippines it has fallen to 16 per cent and in Thailand, it is down to 5.4 per cent.
In most cases, declines in breastfeeding indicate an increase in the use of formula milk, which, even if used correctly, is inferior to breastmilk. And if used incorrectly – for example, mixed with unclean water or given with bottles that are not adequately sterilized – is downright dangerous.
When there is so much proof of the advantage of breastfeeding, why do an increasing number of mothers favour infant formula?
Part of the downward trend is due to strong marketing tactics of companies that produce infant formula and other processed milks for babies. These marketing tactics aim to convince women that the alternative products are equivalent to breastmilk or, at the very least, a good alternative.
In 1981, in recognition that women and their families needed to be protected from the misleading marketing of breastmilk substitutes, the 34th World Health Assembly adopted the International Code of Marketing of Breastmilk Substitutes, which aimed for the provision of safe and adequate nutrition for infants by protecting and promoting breastfeeding and ensuring the proper use of breastmilk substitutes, when these are necessary. All countries of the World Health Assembly endorsed the International Code except the United States.
Since then, most countries and areas in the East Asia and Pacific region have sought to implement the principles of the International Code through their own legislative or regulatory measures. Unfortunately despite these moves, infant formula companies continue to find innovative and persuasive ways to promote their products.
Unacceptable marketing of substitutes
The marketing zeal for the millions-of-dollars-a-year business by formula makers covers a wide range of obstructive practices. A key strategy is to develop relations with health professionals and to appear to support their work by funding professional meetings or staff retreats or providing them with gifts or free samples of their products. Materials are also provided for display in health facilities, such as posters or growth charts, so that the health system is seen to endorse the company in question.
A second strategy is to present the company as socially responsible and to position themselves as legitimate sources of health and nutrition information. In this vein, they establish ‘mother clubs’ for new mothers as a source of information or support or produce materials on child care, including the benefits of breastfeeding.
Another strategy is to exploit loopholes in national legislation; whereas most national laws or regulations control the marketing of infant formulas for children younger than six months, many do not cover products for older children. Thus the companies create a brand with three ‘phases’, each for progressively older children but all with similar packaging and logos. They then promote, for instance, the products for phase 2 and 3, which indirectly also promotes the product for phase 1, which is covered by the national legislation.
While some of these actions are direct violations of either the International Code or national legislation or regulations, others are inventive ways of complying with the letter of the regulations but not the intent.
In the Philippines, for example, substitute producers pitch the ‘brain-building blocks’ of their powdered milk for infants, which has considerable tug on the emotions of women who want to give their children as many head starts in life as possible. With television advertising now reaching 80 per cent of the 82 million population, the slick, expensive TV ads resonate widely and in stiff competition with Ministry of Health poster campaigns promoting the value of breastfeeding.
Currently, we are also seeing the infant formula producers and their supporters argue the merits of free trade over the ethics of public health. In a letter to the Philippine President, the Washington D.C.-based head of the US Chamber of Commerce implored a re-examining of a regulatory decision by the Philippine Department of Health that affected the marketing of infant formula. Noting that the regulations “would have unintended negative consequences for investors’ confidence in the predictability of business law” in the country, the Chamber of Commerce official complained that: 1) the prohibition on the marketing of formula to children up to age 3 goes beyond international standards and 2) that by treating infant formula as a “potential health hazard” and requiring “warning labels without any scientific justification” would “needlessly alarm potential consumers”.
The Philippine Supreme Court initially refused (July 2006) to place a temporary restraining order on the implementation of those new regulations on formula marketing. But after an appeal by an industry group representing manufacturers, reversed its decision in August 2006. The US Chamber of Commerce letter asked that the ban be upheld and the regulations dismissed.
Capitalizing on emergency situations
We are also seeing formula producers use emergencies as another strategy. In emergency situations, which are frequent in this region, formula donations are often among the first supplies received. These supplies are then liberally handed out, usually by well-meaning but misguided NGOs or health workers alike, to women and families who have lost their homes and support structures and are often acutely unable to use them safely.
Meanwhile, in the flurry of the emergency crisis, there often is little attention paid to reassuring affected women that they remain capable of breastfeeding or producing adequate milk. It is a common misconception that when women are stressed or malnourished that they cannot produce adequate, quality breastmilk.
The First Lady of Timor-Leste, who champions the practice of breastfeeding, experienced unexpected calls for infant formula from affected families when visiting internally displaced persons’ camps after political violence erupted in her country in May 2006, sending tens of thousands of people fleeing their communities. Simultaneously, unsolicited supplies were flowing into the country as a ‘humanitarian response to the emergency.
“It was a terrible dilemma I was presented with everywhere I went,” Kirsty Sword-Gusmao told a UNICEF officer, referring to the overwhelming requests for milk powder for children. In the end she agreed to provide it for older children, warning none was to be given to any child younger than six months. Instead, she advised, it should be given to mothers of young children as they are in need of both emotional and nutritional support at such times and assurances that they can continue to breastfeed.
Following a tremendous earthquake in May 2006 in Yogyakarta, Indonesia that left more than 150,000 people homeless, a large quantity of infant formula appeared among donated supplies received by the Government. Within a week the Government realized the danger of distributing those supplies in an environment of unsafe water for mixing and sterilizing bottles. In a press conference, the Ministry of Health asked for proper management of infant formula distribution to children who had no other option and re-iterated the belief that children are best protected through breastfeeding.
However, use of infant formula increased. A survey (A multi-agency team conducted a survey in Bantul district, Yogyakarta, of infant and young child feeding practices, focusing on children younger than 2, with the primary objective of assessing the extent and impact of infant formula donations on child feeding behaviours. The survey was conducted 18–24 June 2006, during which time 831 primary caretakers of children aged between 0 and 23 months were interviewed.) in one Indonesian district that began 21 days after the earthquake found that some 70 per cent of households with children had receiving baby milk donations. In these households, 48 per cent of infants up to 5 months old had been fed these products in the 24-hour period prior to the survey. Among those of the same age whose families had not received any donations, only 30 per cent had been fed a formula mixture. The prevalence of diarrhoea in the week prior to the survey among babies 12–23 months old was 29 per cent compared to a much lower ‘pre-emergency’ rate of around 5 per cent.
This was one of the first surveys to document the extent and scale of infant formula donations and its impact on feeding practices and illness rates.
There is no doubt that some of the donations of such products in emergency situations reflect genuine interest in providing relief. However, it is also highly likely that some companies or their associates use emergency situations to raise the profile of their brand or create familiarity with their products.
In Timor-Leste, Sword-Gusmao attributed traditional beliefs and doubts about the quality or quantity of breastmilk for the ease with which mothers gave up breastfeeding during the emergency. Yet such beliefs and doubts exist even in ‘normal’ times: Breastfeeding practices were poor in Timor-Leste prior to the violence; a surprising large number of Timorese women use infant formula despite their precarious economic situation. This pattern is familiar; exclusive breastfeeding appears not to be a traditional practice even in communities in which breastfeeding in general is the norm. The marketing of infant and other formulas builds upon the widespread belief that babies need ‘something else’ in addition to breastmilk.
But are formula manufacturers the only momentum behind the falling rates in exclusive breastfeeding?
Other reasons for breastfeeding decline
Certainly another reason for the downward trend in exclusive breastfeeding has to do with insufficient positive information on the advantages of breast milk and breastfeeding and the disadvantages of bottle feeding.
Also, there is insufficient support of breastfeeding by society in general, in particular for women who are trying to combine breastfeeding with employment outside the home. Stories abound of husbands or mothers-in-law who advise against breastfeeding, of women who have too much work to spend enough time breastfeeding or communities where breastfeeding in public is considered inappropriate.
Article 24 of the Convention on the Rights of the Child recognizes the right of every child to enjoy the highest attainable standard of health. Within this article, the right of all segments of society, in particular parents, to information on the advantages of breastfeeding, is specifically mentioned. The experiences from the region show clearly that much more work is needed to protect, promote and support breastfeeding through health systems, workplaces and communities.
And it is equally clear that, simultaneously, more work is needed to stop and to counteract the damage of the ongoing inappropriate promotion of products that take the place of breastmilk and undermine breastfeeding.
All of this requires increased resources. More funds are needed to support and promote breastfeeding if we want to achieve optimum survival and development of infants in this region.
UNICEF and WHO are hosting a regional meeting on breastfeeding in June in Manila. The meeting will seek a strategy on how to both promote a breastfeeding culture and how to avoid creating a bottle-feeding one.
UNICEF. Breastfeeding: Foundation for a healthy future. 1999.
The International Baby Food Action Network. The international code of marketing of breastmilk substitutes.