The formula milk industry is using  ‘unethical’ marketing tactics to influence new parents and pregnant women to substitute breast milk for formula milk in breach of the international standards on infant feeding practices and is detrimental to child nutrition and health, according to a new report by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF).

The report was based on a survey of over 8,500 pregnant women and parents and 300 health workers in Bangladesh, China, Mexico, Morocco, Nigeria, South Africa, the United Kingdom and Vietnam. It was complemented by in-depth interviews of mothers, and marketing executives in China. 

Some 51% of new parents and pregnant women surveyed had been victims of “systematic and unethical” marketing strategies by the formula milk industry in violation of the International Code of Marketing of Breast-milk Substitutes. 

“This report shows very clearly that formula milk marketing remains unacceptably pervasive, misleading and aggressive. Regulations on exploitative marketing must be urgently adopted and enforced to protect children’s health.” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General in a press release.” “Let’s stop the commercialisation of our children’s health.” 

Globally, only 44% of babies less than six months old are exclusively breastfed. The breastfeeding rates around the world have increased very little in the past two decades, but the sales of formula milk have more than doubled in roughly the same time, the press release said. 

The $55 billion-per-year formula milk industry uses an array of techniques such as unregulated and invasive online targeting of new mothers and parents, sponsored advice networks and helplines, promotions and free gifts, and practices to influence training and recommendations among health workers to influence mothers and parents into choosing formula milk over breast milk for their children, according to the report.

Need for policy change and intervention

According to the report, called How marketing of formula milk influences our decisions on infant feeding, there is a need for more serious political intervention. Political leaders at the highest level, public health institutions, health professionals and their associations, and civil society must step up to identify and halt the risks and pervasiveness of such formula milk marketing. 

“We need robust policies, legislation and investments in breastfeeding to ensure that women are protected from unethical marketing practices – and have access to the information and support they need to raise their families.” said UNICEF Executive Director Catherine Russell. 

Formula milk marketing had reached 92% of women surveyed in Vietnam and 97% of women surveyed in China, thereby increasing their likelihood of choosing breast milk substitutes. These women were significantly more likely to see nutrition as “more comprehensive and balanced in formula’” than breast milk. 

In Bangladesh, 72% of women who exclusively formula-fed their children had received a recommendation to feed formula from a health professional.

Meanwhile, a Mexican woman interviewed confirmed that her paediatrician had suggested a brand of formula milk for her: “Yes, the paediatrician suggested one and that’s what I chose, I didn’t do much research. I trusted what the paediatrician told me, that’s why I didn’t remember the ads.”, said a woman interviewed for the survey in Guadalajara, Mexico.

The report, which was commissioned by WHO, UNICEF and funded by the Bill and Melinda Gates Foundation,  recommends banning health workers from accepting sponsorship from companies that market foods for infants and young children for scholarships, awards, grants, meetings, or events.

It also recommends countering the targeted messages of the formula industry and creating awareness through informational messaging and advertising, investing in training and building the skills of health professionals , and by tightening the current rules of marketing breast milk substitutes.

In addition, the report recommends building a secure digital ecosystem to weed out misleading adverts and protect children’s health from falling prey to commercial and unregulated marketing. Furthermore, it argues that there is a need to support mothers, breastfeeding and health systems, and also to give impetus to maternity and parental leaves. 

Breastmilk is best

The benefits of breastmilk are scientifically proven to outweigh those of formula milk. Breastfeeding for six months and continued breastfeeding for up to two years or beyond, offers children a powerful line of defence against all forms of malnutrition, including wasting and obesity. It also acts as a ‘first’ vaccine for children by providing protection against common childhood illnesses. 

A switch to formula milk is not scientifically recommended and leads to increased infant morbidity and mortality, and are causes of suboptimal breastfeeding that are responsible for an estimated 823,000 deaths among children each year, according to a paper published in BMJ Global Health last week. 

The paper also called for scientific journals to cut ties with breastmilk substitute makers and the formula industry if they want to protect infants and young children from being at risk of malnutrition, illness and death.

The formula industry uses health professional financing and engagement through courses, e-learning platforms, sponsorship of conferences and health professional associations and advertising in medical/health journals to influence health professionals into prescribing and promoting formula milk over breast milk.  

Unscientific claims 

The research shows ways that formula milk companies have exploited and entered markets for their products, such as  “allergies and sensitivities” to enjoy more sales and business opportunities and circumvent restrictions on formula milk company representatives visiting health facilities. 

Formula milk is positioned as close to, equivalent and sometimes superior to breast-milk, presenting incomplete scientific evidence and inferring unsupported health outcomes, the report noted. The ingredients in formula milk which are listed as ”informed” or ”derived” from breastmilk and claimed to be linked to child developmental outcomes were found to not be supported by scientific evidence. 

According to the marketing executives interviewed for the report, formula milk companies’ engagement through digital channels has been intensified by the Covid-19 pandemic. The targeted ad campaigns are based on search histories, cookies and online profiles.

Time to revamp the code? 

The survey showed that women reported being targeted by online marketing through promotions based on their search behaviour for infant feeding advice and information.

Speaking at the launch of the report, Helen Clarke, Former Prime Minister of New Zealand and Board Chair of the  Partnership for Maternal, Newborn and Child Health, questioned whether it was time for the Code to be completely overhauled since those rules are not in the digital age.

”The code needs to be brought up to date with the new media for advertising, which is so pervasive and can be very, very harmful,” said Clark.

“Formula marketing does have a direct impact on survival health, and development, both of children and women,” said UNICEF’s Dr Nigel Rollins at the launch. “It does disrupt access to impartial truthful information and support that is so necessary for parents to make decisions and this is an essential human right.” 

WHO calls on governments, health professionals, and the baby food industry to put an end to the ‘exploitative’ formula milk market and to abide by the Code provisions. These provisions include publicly committing to full compliance with the Code and subsequent World Health Assembly resolutions globally.

A 2020 report by WHO, UNICEF and IBFAN shows that of the 194 countries that were analysed in their report, 136 had provisions for some form of legal measure related to the International Code of Marketing of Breast-milk Substitutes and subsequent resolutions adopted by the World Health Assembly.

It noted that the legal restrictions in most countries did not fully cover marketing that occurs in health facilities as only 79 countries had banned the promotion of breast-milk substitutes in health facilities, while 51 had provisions that prohibited the distribution of free or low-cost supplies within the healthcare system.

Image Credits: WHO/C. Black, WHO, WHO/UNICEF, HOW THE MARKETING OF FORMULA MILK INFLUENCES OUR DECISIONS ON INFANT FEEDING, WHO UNICEF Report .