Women do not fail to breastfeed. Health professionals, health agencies and governments fail to educate and support women who want to breastfeed.
The health consequences - twice the risk of dying in the first six weeks of life, five times the risk of gastroenteritis, twice the risk of developing eczema and diabetes and up to eight times the risk of developing lymphatic cancer – are staggering. With UK formula manufacturers spending around £20 per baby
promoting this ‘baby junk food’, compared to the paltry 14 pence per baby the government spends promoting breastfeeding, can we ever hope to reverse the trend?
All mammals produce milk for their young, and the human species has been nurturing its babies at the breast for at least 400,000 years. For centuries, when a woman could not feed her baby herself, another lactating woman, or ‘wet nurse’, took over the job. It is only in the last 60 years or so that we have largely abandoned our mammalian instincts and, instead, embraced a bottlefeeding culture that not only encourages mothers to give their babies highly processed infant formulas from birth, but also to believe that these breastmilk substitutes are as good as, if not better than, the real thing.
Infant formulas were never intended to be consumed on the widespread basis that they are today. They were conceived in the late 1800s as a means of providing necessary sustenance for foundlings and orphans who would otherwise have starved. In this narrow context – where no other food was available – formula was a lifesaver.
However, as time went on, and the subject of human nutrition in general – and infant nutrition, in particular – became more ‘scientific’, manufactured breastmilk substitutes were sold to the general public as a technological improvement on breastmilk.
‘If anybody were to ask ‘which formula should I use?’ or ‘which is nearest to mother’s milk?’, the answer would be ‘nobody knows’ because there is not one single objective source of that kind of information provided by anybody,’ says Mary Smale, a breastfeeding counsellor with the National Childbirth Trust (NCT) for 28 years. ‘Only the manufacturers know what’s in their stuff, and they aren’t telling. They may advertise special ‘healthy’ ingredients like oligosaccharides, long-chain fatty acids or, a while ago, beta-carotene, but they never actually tell you what the basic product is made from or where the ingredients come from.’
The known constituents of breastmilk were and are used as a general reference for scientists devising infant formulas. But, to this day, there is no actual ‘formula’ for formula. In fact, the process of producing infant formulas has, since its earliest days, been one of trial and error.
Within reason, manufacturers can put anything they like into formula. In fact, the recipe for one product canvary from batch to batch, according to the price and availability of ingredients. While we assume that formula is heavily regulated, no transparency is required of manufacturers: they do not, for example, have to log the specific constituents of any batch or brand with any authority.
Most commercial formulas are based on cow’s milk. But before a baby candrink cow’s milk in the form of infant formula, it needs to be severely modified. The protein and mineral content must be reduced and the carbohydrate content increased, usually by adding sugar. Milk fat, which is not easily absorbed by the human body, particularly one with an immature digestive system, is removed and substituted with vegetable, animal or mineral fats.
Vitamins and trace elements are added, but not always in their most easily digestible form. (This means that the claims that formula is ‘nutritionally complete’ are true, but only in the crudest sense of having had added the full complement of vitamins and mineral to a nutritionally inferior product.)
Many formulas are also highly sweetened. While most infant formulas do not contain sugar in the form of sucrose, they can contain high levels of other types of sugar such as lactose (milk sugar), fructose (fruit sugar), glucose (also known as dextrose, a simple sugar found in plants) and maltodextrose (malt sugar). Because of a loophole in the law, these can still be advertised as ‘sucrose free’.
Formula may also contain unintentional contaminants introduced during the manufacturing process. Some may contain traces of genetically engineered soya and corn.
The bacteria Salmonella and aflatoxins – potent toxic, carcinogenic, mutagenic, immunosuppressive agents produced by species of the fungus Aspergillus – have regularly been detected in commercial formulas, as has Enterobacter sakazakii, a devastating foodborne pathogen that can cause sepsis (overwhelming bacterial infection in the bloodstream), meningitis (inflammation of the lining of the brain) and necrotising enterocolitis (severe infection and inflammation of the small intestine and colon) in newborn infants.
The packaging of infant formulas occasionally gives rise to contamination with broken glass and fragments of metal as well as industrial chemicals such as phthalates and bisphenol A (both carcinogens) and, most recently, the packaging constituent isopropyl thioxanthone (ITX; another suspected carcinogen).
Women do not fail to breastfeed. Health professionals, health agencies and governments fail to educate and support women who want to breastfeed.
Infant formulas may also contain excessive levels of toxic or heavy metals, including aluminium, manganese, cadmium and lead.
Soya formulas are of particular concern due to the very high levels of plant-derived oestrogens (phytoestrogens) they contain. In fact, concentrations of phytoestrogens detected in the blood of infants receiving soya formula can be 13,000 to 22,000 times greater than the concentrations of natural oestrogens. Oestrogen in doses above those normally found in the body can cause cancer.
For years, it was believed that the risks of illness and death from bottlefeeding were largely confined to children in developing countries, where the clean water necessary to make up formula is sometimes scarce and where poverty-stricken mothers may feel obliged to dilute formula to make it stretch further, thus risking waterborne illnesses such as diarrhoea and cholera as well as malnutrition in their babies. But newer data from the West clearly show that babies in otherwise affluent societies are also falling ill and dying due to an early diet of infant convenience food.
Because it is not nutritionally complete, because it does not contain the immune-boosting properties of breastmilk and because it is being consumed by growing babies with vast, ever-changing nutritional needs – and not meeting those needs – the health effects of sucking down formula day after day early in life can be devastating in both the short and long term.
Bottlefed babies are twice as likely to die from any cause in the first six weeks of life. In particular, bottlefeeding raises the risks of SIDS (sudden infant death syndrome) by two to five times. Bottlefed babies are also at a significantly higher risk of ending up in hospital with a range of infections. They are, for instance, five times more likely to be admitted to hospital suffering from gastroenteritus.
Even in developed countries, bottlefed babies have rates of diarrhoea twice as high as breastfed ones. They are twice as likely (20 per cent vs 10 per cent) to suffer from otitis media (inner-ear infection), twice as likely to develop eczema or a wheeze if there is a family history of atopic disease, and five times more likely to develop urinary tract infections.
In the first six months of life, bottlefed babies are six to 10 times more likely to develop necrotising enterocolitis – a serious infection of the intestine, with intestinal tissue death – a figure that increases to 30 times the risk after that time.
Even more serious diseases are also linked with bottlefeeding. Comparedwith infants who are fully breastfed even for only three to four months, a baby drinking artificial milk is twice as likely to develop juvenile-onset insulin-dependent (type 1) diabetes. There is also a five- to eightfold risk of developing lymphomas in children under 15 who were formulafed, or breastfed for less than six months.
In later life, studies have shown that bottlefed babies have a greater tendency towards developing conditions such as childhood inflammatory bowel disease, multiple sclerosis, dental malocclusion, coronary heart disease, diabetes, hyperactivity, autoimmune thyroid disease and coeliac disease.
For all of these reasons, formula cannot be considered even ‘second best’ compared with breastmilk. Officially, the World Health Organization (WHO) designates formula milk as the last choice in infant-feeding: Its first choice is breastmilk from the mother; second choice is the mother’s own milk given via cup or bottle; third choice is breastmilk from a milk bank or wet nurse and, finally, in fourth place, formula milk.
And yet, breastfed babies are becoming an endangered species. In the UK, rates are catastrophically low and have been that way for decades. Current figures suggest that only 62 per cent of women in Britain even attempt to breastfeed (usually while in hospital). At six weeks, just 42 per cent are breastfeeding. By four months, only 29 per cent are still breastfeeding and, by six months, this figure drops to 22 per cent.
These figures could come from almost any developed country in the world and, it should be noted, do not necessarily reflect the ideal of ‘exclusive’ breastfeeding. Instead, many modern mothers practice mixed feeding – combining breastfeeding with artificial baby milks and infant foods. Worldwide, the WHO estimates that only 35 per cent of infants are getting any breastmilk at all by age four months and, although no one can say for sure because research into exclusive breastfeeding is both scarce and incomplete, it is estimated that only 1 per cent are exclusively breastfed at six months.
Younger women in particular are the least likely to breastfeed, with over 40 per cent of mothers under 24 never even trying. The biggest gap, however, is a socioeconomic one. Women who live in low-income households or who are poorly educated are many times less likely to breastfeed, even though it can make an enormous difference to a child’s health.
In children from socially disadvantaged families, exclusive breastfeeding in the first six months of life can go a long way towards cancelling out the health inequalities between being born into poverty and being born into affluence. In essence, breastfeeding takes the infant out of poverty for those first crucial months and gives it a decent start in life.
So why aren’t women breastfeeding?
Before bottles became the norm, breastfeeding was an activity of daily living based on mimicry, and learning within the family and community. Women became their own experts through the trial and error of the experience itself. But today, what should come more or less naturally has become extraordinarily complicated – the focus of global marketing strategies and politics, lawmaking, lobbying support groups, activists and the interference of a well intentioned, but occasionally ineffective, cult of experts.
According to Mary Smale, it’s confidence and the expectation of support that make the difference, particularly for socially disadvantaged women.
‘The concept of ‘self efficacy’ – in other words, whether you think you can do something – is quite important. You can say to a woman that breastfeeding is really a good idea, but she’s got to believe various things in order for it to work. First of all, she has to think it’s a good idea – that it will be good for her and her baby. Second, she has to think: ‘I’m the sort of person who can do that’; third – and maybe the most important thing – is the belief that if she does have problems, she’s the sort of person who, with help, will be able to sort them out.
‘Studies show, for example, that women on low incomes often believe that breastfeeding hurts, and they also tend to believe that formula is just as good. So from the start, the motivation to breastfeed simply isn’t there. But really, it’s the thought that if there were any problems, you couldn’t do anything about them; that, for instance, if it hurts, it’s just the luck of the draw. This mindset is very different from that of a middleclass mother who is used to asking for help to solve things, who isn’t frightened of picking up the phone, or saying to her midwife or health visitor, ‘I want you to help me with this’.’
Nearly all women – around 99 per cent – can breastfeed successfully and make enough milk for their babies to not simply grow, but to thrive. With encouragement, support and help, almost all women are willing to initiate breastfeeding, but the drop-off rates are alarming: 90 per cent of women who give up in the first six weeks say that they would like to have continued. And it seems likely that long-term exclusive breastfeeding rates could be improved if consistent support were available, and if approval within the family and the wider community for breastfeeding, both at home and in public, were more obvious and widespread.
Clearly, this social support isn’t there, and the bigger picture of breastfeeding vs bottle feeding suggests that there is, in addition, a confluence of complex factors – medical, socioeconomic, cultural and political – that regularly undermine women’s confidence, while reinforcing the notion that feeding their children artificially is about lifestyle rather than health, and that the modern woman’s body is simply not up to the task of producing enough milk for its offspring.
‘Breastfeeding is a natural negotiation between mother and baby and you interfere with it at your peril,’ says Professor Mary Renfrew, Director of the Mother and Infant Research Unit, University of York. “But, in the early years of the last century, people were very busy interfering with it. In terms of the ecology of breastfeeding, what you have is a natural habitat that has been disturbed. But it’s not just the presence of one big predator – the invention of artificial milk – that is important. It is the fact that the habitat was already weakened by other forces that made it so vulnerable to disaster.
‘If you look at medical textbooks from the early part of the 20th century, you’ll find many quotes about making breastfeeding scientific and exact, and it’s out of these that you can see things beginning to fall apart.’ This falling apart, says Renfrew, is largely due to the fear and mistrust that science had of the natural process of breastfeeding.
In particular, the fact that a mother can put a baby on the breast and do something else while breastfeeding, and have the baby naturally come off the breast when it’s had enough, was seen as disorderly and inexact. The medical/ scientific model replaced this natural situation with precise measurements – for instance, how many millilitres of milk a baby should ideally have at each sitting – which skewed the natural balance between mother and baby, and established bottlefeeding as a biological norm.
Breastfeeding rates also began to decline as a consequence of women’s changed circumstances after World War I, as more women left their children behind to go into the workplace as a consequence of women’s emancipation – and the loss of men in the ‘killing fields’ – and to an even larger extent with the advent of World War II, when even more women entered into employment outside of the home.
‘There was also the first wave of feminism,’ says Renfrew, ‘which stamped into everyone’s consciousness in the 60s, and encouraged women get away from their babies and start living their lives.
So the one thing that might have helped – women supporting each other – actually created a situation where even the intellectual, engaged, consciously aware women who might have questioned this got lost for a while. As a consequence, we ended up with a widespread and declining confidence in breastfeeding, a declining understanding of its importance and a declining ability of health professionals to support it. And, of course, all this ran along the same timeline as the technological development of artificial milk and the free availability of formula.’
Before World War II, pregnancy and birth – and, by extension, breastfeeding – were part of the continuum of normal life. Women gave birth at home with the assistance and support of trained midwives, who were themselves part of the community, and afterwards they breastfed with the encouragement of family and friends.
Taking birth out of the community and relocating it into hospitals gave rise to the medicalisation of women’s reproductive lives. Life events were transformed into medical problems, and traditional knowledge was replaced with scientific and technological solutions. This medicalisation resulted in a cascade of interventions that deeply undermined women’s confidence in their abilities to conceive and grow a healthy baby, give birth to it and then feed it.
The cascade falls something like this: Hospitals are institutions; they are impersonal and, of necessity, must run on schedules and routines. For a hospital to run smoothly, patients must ideally be sedate and immobile. For the woman giving birth, this meant lying on her back in a bed, an unnatural position that made labour slow, unproductive and very much more painful.
To ‘fix’ these iatrogenically dysfunctional labours, doctors developed a range of drugs (usually synthetic hormones such as prostaglandins or syntocinon), technologies (such as forceps and vacuum extraction) and procedures (such as episiotomies) to speed the process up. Speeding up labour artificially made it even more painful and this, in turn, led to the development of an array of pain-relieving drugs. Many of these were so powerful that the mother was often unconscious or deeply sedated at the moment of delivery and, thus, unable to offer her breast to her newborn infant.
All pain-relieving drugs cross the placenta, so even if the mother were conscious, her baby may not have been, or may have been so heavily drugged that its natural rooting instincts (which help it find the nipple) and muscle coordination (necessary to latch properly onto the breast) were severely impaired.
While both mother and baby were recovering from the ordeal of a medicalised birth, they were, until the1970s and 1980s, routinely separated. Often, the baby wasn’t ‘allowed’ to breastfeed until it had a bottle first, in case there was something wrong with its gastrointestinal tract. Breastfeeding, when it took place at all, took place according to strict schedules. These feeding schedules – usually on a three- or fourhourly basis – were totally unnatural for human newborns, who need to feed 12 or more times in any 24-hour period. Babies who were inevitably hungry between feeds were routinely given supplements of water and/or formula.
‘There was lots of topping up,’ says Professor Renfrew. ‘The way this ‘scientific’ breastfeeding happened in hospital was that the baby would be given two minutes on each breast on day one, then four minutes on each breast on day two, seven minutes on each on day three, and so on. This created enormous anxiety since the mother would then be watching the clock instead of the baby. The babies would then get topped-up after every feed, then topped-up again throughout the night rather than brought to their mothers to feed. So you had a situation where the babies were crying in the nursery, and the mothers were crying in the postnatal ward. That’s what we called ‘normal’ all throughout the 60s and 70s.’
Breastmilk is produced on a supply-and-demand basis, and these topping-up routines, which assuaged infant hunger and lessened demand, also reduced the mother’s milk supply. As a result, women at the mercy of institutionalised birth experienced breastfeeding as a frustrating struggle that was often painful and just as often unsuccessful.
When, under these impossible circumstances, breastfeeding ‘failed’, formula was offered as a ‘nutritionally complete solution’ that was also more ‘modern’, ‘cleaner’ and more ‘socially acceptable’.
At least two generations of women have been subjected to these kinds of damaging routines and, as a result, many of today’s mothers find the concept of breastfeeding strange and unfamiliar, and very often framed as something that can and frequently does not ‘take’, something they might ‘have a go’ at but, equally, something that they shouldn’t feel too badly about if it doesn’t work out.
The same young doctors, nurses and midwives who were pioneering this medical model of reproduction are now running today’s health services. So, perhaps not surprisingly, modern hospitals are, at heart, little different from their predecessors. They may have TVs and CD players, and prettier wallpaper, and the drugs may be more sophisticated, but the basic goals and principles of medicalised birth have changed very little in the last 40 years – and the effect on breastfeeding is still as devastating.
In many cases, the healthcare providers’ views on infant-feeding are based on their own, highly personal experiences. Surveys show, for instance, that the most important factor influencing the effectiveness and accuracy of a doctor’s breastfeeding advice is whether the doctor herself, or the doctor’s wife, had breastfed her children. Likewise, a midwife, nurse or health visitor formula-fed her own children is unlikely to be an effective advocate for breastfeeding.
More worrying, these professionals can end up perpetuating damaging myths about breastfeeding that facilitate its failure. In some hospitals, women are still advised to limit the amount of time, at first, that a baby sucks on each breast, to ‘toughen up’ their nipples. Or they are told their babies get all the milk they ‘need’ in the first 10 minutes and sucking after this time is unnecessary. Some are still told to stick to four-hour feeding schedules. Figures from the UK’s Office of National Statistics show that we are still topping babies up. In 2002, nearly 30 per cent of babies in UK hospitals were given supplemental bottles by hospital staff, and nearly 20 per cent of all babies were separated from their mothers at some point while in hospital.
Continued inappropriate advice from medical professionals is one reason why, in 1991, UNICEF started the Baby Friendly Hospital Initiative (BFHI) – a certification system for hospitals meeting certain criteria known to promote successful breastfeeding. These criteria include: training all healthcare staff on how to facilitate breastfeeding; helping mothers start breastfeeding within one hour of birth; giving newborn infants no food or drink other than breastmilk, unless medically indicated; and the hospital not accepting free or heavily discounted formula and supplies. In principle, it is an important step in the
promotion of breastfeeding, and studies show that women who give birth in Baby Friendly hospitals do breastfeed for longer.
In Scotland, for example, where around 50 per cent of hospitals are rated Baby Friendly, breastfeeding initiation rates have increased dramatically in recent years. In Cuba, where 49 of the country’s 56 hospitals and maternity facilities are Baby Friendly, the rate of exclusive breastfeeding at four months almost tripled in six years – from 25 per cent in 1990 to 72 per cent in 1996. Similar increases have been found in Bangladesh, Brazil and China.
Unfortunately, interest in obtaining BFHI status is not universal. In the UK, only 43 hospitals (representing just 16 per cent of all UK hospitals) have achieved full accreditation – and none are in London. Out of the approximately 16,000 hospitals worldwide that have qualified for the Baby Friendly designation, only 32 are in the US. What’s more, while Baby Friendly hospitals achieve a high initiation rate, they cannot guarantee continuation of breastfeeding once the woman is back in the community. Even among women who give birth in Baby Friendly hospitals, the number who exclusively breastfeed for six months is unacceptably low.
The influence of advertising
Baby Friendly hospitals face a daunting task in combatting the laissez-faire and general ignorance of health professionals, mothers and the public at large. They are also fighting a difficult battle with an acquiescent media which, through politically correct editorialising aimed at assuaging mothers’ guilt if they bottle feed and, more influentially, through advertising, has helped redefine formula as an acceptable choice.
Although there are now stricter limitations on the advertising of infant formula, for years, manufacturers were able, through advertising and promotion, to define the issue of infant-feeding in both the scientific world (for instance, by providing doctors with growth charts that established the growth patterns of bottle-fed babies as the norm) and in its wider social context, reframing perceptions of what is appropriate and what is not.
As a result, in the absence of communities of women talking to each other about pregnancy, birthing and mothering, women’s choices today are more directly influenced by commercial leaflets, booklets and advertising than almost anything else.
Baby-milk manufacturers spend countless millions devising marketing strategies that keep their products at the forefront of public consciousness. In the UK, formula companies spend at least £12 million per year on booklets, leaflets and other promotions, often in the guise of ‘educational materials’. This works out at approximately £20 per baby born. In contrast, the UK government spends about 14 pence per newborn each year to promote breastfeeding.
It’s a pattern of inequity that is repeated throughout the world – and not just in the arena of infant-feeding. The food-industry’s global advertising budget is $40 billion, a figure greater than the gross domestic product (GDP) of 70 per cent of the world’s nations. For every $1 spent by the WHO on preventing the diseases caused by Western diets, more than $500 is spent by the food industry to promote such diets.
Since they can no longer advertise infant formulas directly to women (for instance, in mother and baby magazines or through direct leafleting), or hand out free samples in hospitals or clinics, manufacturers have started to exploit other outlets, such as mother and baby clubs, and Internet sites that purport to help busy mothers get all the information they need about infant-feeding. They also occasionally rely on subterfuge.
Manufacturers are allowed to advertise follow-on milks, suitable for babies over six months, to parents. But, sometimes, these ads feature a picture of a much younger baby, implying the product’s suitability for infants.
The impact of these types of promotions should not be underestimated. A 2005 NCT/UNICEF study in the UK determined that one third of British mothers who admitted to seeing formula advertisements in the previous six months believed that infant formula was as good or better than breast milk. This revelation is all the more surprising since advertising of infant formula to mothers has been banned for many years in several countries, including the UK.
To get around restrictions that prevent direct advertising to parents, manufacturers use a number of psychological strategies that focus on the natural worries that new parents have about the health of their babies. Many of today’s formulas, for instance, are conceived and sold as solutions to the ‘medical’ problems of infants such as lactose intolerance, incomplete digestion and being ‘too hungry’ – even though many of these problems can be caused by inappropriately giving cow’s milk formula in the first place.
The socioeconomic divide among breastfeeding mothers is also exploited by formula manufacturers, as targetting low income women (with advertising as well as through welfare schemes) has proven very profitable. When presented with the opportunity to provide their children with the best that science has to offer, many low income mothers are naturally tempted by formula. This is especially true if they receive free samples, as is still the case in many developing countries.
But the supply-and-demand nature of breastmilk is such that, once a mother accepts these free samples and starts her baby on formula, her own milk supply will quickly dry up. Sadly, after these mothers run out of formula samples and money-off coupons, they will find themselves unable to produce breastmilk and have no option but to spend large sums of money on continuing to feed their child with formula.
Even when manufacturers ‘promote’ breastfeeding, they plant what Mary Smale calls ‘seeds of ‘conditionality’ that can lead to failure. ‘Several years ago, manufacturers used to produce these amazing leaflets for women, encouraging women to breastfeed and reassuring them that they only need a few extra calories a day. You couldn’t fault them on the words, but the pictures which were of things like Marks & Spencer yoghurt and whole fish with their heads on, and wholemeal bread – but not the sort of wholemeal bread that you buy in the corner shop, the sort of wholemeal bread you buy in specialist shops.
The underlying message was clear: a healthy pregnancy and a good supply of breastmilk are the preserve of the middle classes, and that any women who doesn’t belong to that group will have to rely on other resources to provide for her baby.
A quick skim through any pregnancy magazine or the ‘Bounty’ pack – the glossy information booklet with free product samples given to new mothers in the UK – shows that these subtle visual messages, which include luxurious photos of whole grains and pulses, artistically arranged bowls of muesli, artisan loaves of bread and wedges of deli-style cheeses, exotic mangoes, grapes and kiwis, and fresh vegetables artistically arranged as crudités, are still prevalent.
Manufacturers also ply their influence through contact with health professionals (to whom they can provide free samples for research and ‘educational purposes’) as middlemen. Free gifts, educational trips to exotic locations and funding for research are just some of the ways in which the medical profession becomes ‘educated’ about the benefits of formula.
According to Patti Rundall, OBE, policy director for the UK’s Baby Milk Action group, which has been lobbying for responsible marketing of baby food for over 20 years, ‘Throughout the last two decades, the baby-feeding companies have tried to establish a strong role for themselves with the medical profession, knowing that health and education services represent a key marketing opportunity. Companies are, for instance, keen to fund the infant-feeding research on which health policies are based, and to pay for midwives, teachers, education materials and community projects.’
They are also keen to fund ‘critical’ NGOs – that is, lay groups whose mandate is to inform and support women. But this sort of funding is not allowed by the International Code of Marketing of Breastmilk Substitutes (see below) because it prejudices the ability of these organisations to provide mothers with independent information about infant feeding. Nevertheless, such practices remain prevalent – if somewhat more discreet than in the past – and continue to weaken health professionals’ advocacy for breastfeeding.
When it became clear that declining breastfeeding rates were affecting infant health and that the advertising of infant formula had a direct effect on a woman’s decision not to breastfeed, the International Code of Marketing of Breastmilk Substitutes was drafted and eventually adopted by the World Health Assembly (WHA) in 1981. The vote was near-unanimous, with 118 member nations voting in favour, three abstaining and one – the US – voting against. (In 1994, after years of opposition, the US eventually joined every other developed nation in the world as a signatory to the Code.)
The Code is a unique instrument that promotes safe and adequate nutrition for infants on a global scale by trying to protect breastfeeding and ensuring the appropriate marketing of breastmilk substitutes. It applies to all products marketed as partial or total replacements for breastmilk, including infant formula, follow-on formula, special formulas, cereals, juices, vegetable mixes and baby teas, and also applies to feeding bottles and teats. In addition, it maintains that no infant food may be marketed in ways that undermine breastfeeding. Specifically, the Code:
- Bans all advertising or promotion of these products to the general public
- Bans samples and gifts to mothers and health workers
- Requires information materials to advocate for breastfeeding, to warn against bottle feeding and to not contain pictures of babies or text that idealises the use of breastmilk substitutes
- Bans the use of the healthcare system to promote breastmilk substitutes
- Bans free or low-cost supplies of breastmilk substitutes
- Allows health professionals to receive samples, but only for research purposes
- Demands that product information be factual and scientific
- Bans sales incentives for breastmilk substitutes and direct contact with mothers
- Requires that labels inform fully on the correct use of infant formula and the risks of misuse
- Requires labels not to discourage breastfeeding.
This document probably couldn’t have been created today. Since the founding of the World Trade Organization (WTO) and its ‘free trade’ ethos in 1995, the increasing sophistication of corporate power strategies and aggressive lobbying of health organisations has increased to the extent that the Code would have been binned long before it reached the voting stage.
However, in 1981, member states, corporations and NGOs were on a somewhat more equal footing. By preventing industry from advertising infant formula, giving out free samples, promoting their products in healthcare facilities or by way of mother-and-baby ‘goody bags’, and insisting on better labelling, the Code acts to regulate an industry that would otherwise be given a free hand to pedal an inferior food product to babies and infants.
Unfortunately . . .
Being a signatory to the Code does not mean that member countries are obliged to adopt its recommendations wholesale. Many countries, the UK included, have adopted only parts of it – for instance, the basic principle that breastfeeding is a good thing – while ignoring the nuts-and-bolts strategies that limit advertising and corporate contact with mothers. So, in the UK, infant formula for ‘healthy babies’ can be advertised to mothers through hospitals and clinics, though not via the media.
What’s more, formula manufacturers for their part continue to argue that the Code is too restrictive and that it stops them from fully exploiting their target markets. Indeed, Helmut Maucher, a powerful corporate lobbyist and honorary chairman of Nestlé – the company that claims 40 per cent of the global baby-food market – has gone on record as saying: ‘Ethical decisions that injure a firm’s ability to compete are actually immoral’.
And make no mistake, these markets are big. The UK babymilk market is worth £150 million per year and the US market around $2 billion. The worldwide market for baby milks and foods is a staggering $17 billion and growing by 12 per cent each year. From formula manufacturers’ point of view, the more women breastfeed, the more profit is lost. It is estimated that, for every child exclusively breastfed for six months, an average of $450 worth of infant food will not be bought. On a global scale, that amounts to billions of dollars in lost profits.
What particularly worries manufacturers is that, if they accept the Code without a fight, it could set a dangerous precedent for other areas of international trade – for instance, the pharmaceutical, tobacco, food and agriculture industries, and oil companies.
This is why the focus on infant-feeding has been diverted away from children’s health and instead become a symbolic struggle for a free market.
While most manufacturers publicly agree to adhere to the Code, privately, they deploy enormous resources in constructing ways to reinterpret or get round it. In this endeavour, Nestlé has shown a defiance and tenacity that beggars belief.
In India, for example, Nestlé lobbied against the Code being entered into law and when, after the law was passed, it faced criminal charges over its labelling, it issued a writ petition against the Indian government rather than accept the charges.
Years of aggressive actions like this, combined with unethical advertising and marketing practices, has led to an ongoing campaign to boycott the company’s products that stretches back to 1977.
The Achilles’ heel of the Code is that it does not provide for a monitoring office. This concept was in the original draft, but was removed from subsequent drafts. Instead, monitoring of the Code has been left to ‘governments acting individually and collectively through the World Health Organization’.
But, over the last 25 years, corporate accountability has slipped lower down on the UN agenda, far behind free trade, self-regulation and partnerships. Lack of government monitoring means that small and comparatively poorly funded groups like the International Baby Food Action Network (IBFAN), which has 200 member groups working in over 100 countries, have taken on the job of monitoring Code violations almost by default. But while these watchdog groups can monitor and report Code violations to the health authorities, they cannot stop them.
In 2004, IBFAN’s bi-annual report Breaking the Rules, Stretching the Rules, analysed the promotional practices of 16 international baby-food companies, and 14 bottle and teat companies, between January 2002 and April 2004. The researchers found some 2,000 violations of the Code in 69 countries.
On a global scale, reinterpreting the Code to suit marketing strategies is rife, and Nestlé continues to be the leader of the pack. According to IBFAN, Nestlé believes that only one of its products – infant formula – comes within the scope of the Code. The company also denies the universality of the Code, insisting that it only applies to developing nations. Where Nestlé, and the Infant Food Manufacturers Association that it dominates, leads, other companies have followed, and when companies like Nestlé are caught breaking the Code, the strategy is simple, but effective – initiate complex and boring discussions with organisations at WHO or WHA level about how best to interpret the Code in the hopes that these will offset any bad publicity and divert attention from the harm caused by these continual infractions.
According to Patti Rundall, it’s important not to let such distractions divert attention from the bottom line: ‘There can be no food more locally produced, more sustainable or more environmentally friendly than a mother’s breastmilk, the only food required by an infant for the first six months of life. It is a naturally renewable resource, which requires no packaging or transport, results in no wastage and is free. Breastfeeding can also help reduce family poverty, which is a major cause of malnutrition.’
So perhaps we should be further simplifying the debate by asking: Are the companies who promote infant formula as the norm simply clever entrepreneurs doing their jobs or human-rights violators of the worst kind?
Not good enough
After more than two decades, it is clear that a half-hearted advocacy of breastfeeding benefits multinational formula manufacturers, not mothers and babies, and that the baby-food industry has no intention of complying with UN recommendations on infant-feeding or with the principles of the International Code for Marketing of Breastmilk Substitutes – unless they are forced to do so by law or consumer pressure or, more effectively, both.
Women do not fail to breastfeed. Health professionals, health agencies and governments fail to educate and support women who want to breastfeed.
Without support, many women will give up when they encounter even small difficulties. And yet, according to Mary Renfrew, ‘Giving up breastfeeding is not something that women do lightly. They don’t just stop breastfeeding and walk away from it. Many of them fight very hard to continue it and they fight with no support. These women are fighting society – a society that is not just bottle-friendly, but is deeply breastfeeding-unfriendly.’
To reverse this trend, governments all over the world must begin to take seriously the responsibility of ensuring the good health of future generations. To do this requires deep and profound social change. We must stop harassing mothers with simplistic ‘breast is best’ messages and put time, energy and money into re-educating health professionals and society at large.
We must also stop making compromises. Government health policies such as, say, in the UK and US, which aim for 75 per cent of women to be breastfeeding on hospital discharge, are little more than paying lip service to the importance of breastfeeding.
Most of these women will stop breastfeeding within a few weeks, and such policies benefit no one except the formula manufacturers, who will start making money the moment breastfeeding stops.
To get all mothers breastfeeding, we must be prepared to:
- Ban all advertising of formula including follow-on milks
- Ban all free samples of formula, even those given for educational or study purposes
- Require truthful and prominent health warnings on all tins and cartons of infant formula
- Put substantial funding into promoting breastfeeding in every community, especially among the socially disadvantaged, with a view to achieving 100-per-cent exclusive breastfeeding for the first six months of life
- Fund advertising and education campaigns that target fathers, mother sin-law, schoolchildren, doctors, midwives and the general public
- Give women who wish to breastfeed in public the necessary encouragement and approval
- Make provisions for all women who are in employment to take at least six months paid leave after birth, without fear of losing their jobs.
Such strategies have already proven their worth elsewhere. In 1970, breastfeeding rates in Scandinavia were as low as those in Britain. Then, one by one, the Scandinavian countries banned all advertising of artificial formula milk, offered a year’s maternity leave with 80 per cent of pay and, on the mother’s return to work, an hour’s breastfeeding break every day. Today, 98 per cent of Scandinavian women initiate breastfeeding, and 94 per cent are still breastfeeding at one month, 81 per cent at two months, 69 per cent at four months and 42 per cent at six months. These rates, albeit still not optimal, are nevertheless the highest in the world, and the result of a concerted, multifaceted approach to promoting breastfeeding.
Given all that we know of the benefits of breastfeeding and the dangers of formula milk, it is simply not acceptable that we have allowed breastfeeding rates in the UK and elsewhere in the world to decline so disastrously.
The goal is clear – 100 per cent of mothers should be exclusively breastfeeding for at least the first six months of their babies’ lives.
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