"Advertisements will make me buy infant formula, if I see a beautiful and chubby baby on TV, well-fed and smiling."
That's the feedback from a mother in Lagos, Nigeria, one of 8,500 mothers and pregnant women in eight countries interviewed for a new report, How Marketing of Formula Milk Influences Our Decisions on Infant Feeding just released by the World Health Organization and UNICEF. The report focuses on marketing practices employed by companies that make up the $55-billion-a-year global infant formula business.
The issue is far from new. In 1981, the World Health Assembly released the International Code of Marketing and Breast-Milk Substitutes, a public health agreement whose goal was to "stop the aggressive and inappropriate marketing of breast-milk substitutes," according to WHO. The Code was developed as a global public health strategy to ensure that mothers are not discouraged from breastfeeding and that substitutes are used safely if needed.
(The report stresses that some babies do need formula because of mother or baby health issues, milk production challenges or work-related challenges.)
WHO says its position on breastfeeding is critical because of longstanding evidence that exclusive breastfeeding for six months after birth, if possible, and for up to two years or beyond protects against child malnutrition and many childhood illnesses and health issues. Yet according to WHO, only 44% of babies under 6 months are exclusively breast-fed.
Why past activism may not have produced results
Ironically, the history of activism against the aggressive marketing of formula may be one reason why the practice persists. Gerard Hastings, emeritus professor at the Institute of Social Marketing at the University of Stirling in Scotland and a member of WHO advisory group for the report, says a key challenge to ending formula company marketing is that "people think it was solved."
In the new report, WHO notes that global breastfeeding rates have increased very little in the past two decades while sales of infant formula have more than doubled in roughly the same time period.
Hastings, lead author of a 2020 study on infant formula marketing tactics called "Selling Second Best," says one way the firms have moved the issue out of the public sphere is by frequently targeting mothers directly.
"This report shows very clearly that formula milk marketing remains unacceptably pervasive, misleading and aggressive," said Tedros Adhanom Ghebreyesus, WHO director-general, in a statement following the release of the report. "Regulations on exploitative marketing must be urgently adopted and enforced to protect children's health."
Dr. Ana Langer, professor of the Practice of Public Health and Coordinator of the Dean's Special Initiative in Women and Health at the Harvard T.H. Chan School of Public Health, says the report "provides critical evidence to illustrate the pervasive, multipronged and growing efforts of the formula industry to position formula as an equally good, if not better, alternative to breast milk."
Langer, who was not involved with the WHO report and has not taken funding from infant formula companies, adds: "It's been happening for decades now, and multiple and diverse efforts have been tried to promote breastfeeding and limit the influence of the incredibly powerful and well-resourced formula industry on the public, health care systems, health professionals and other key constituencies."
How formula is marketed
While marketing by infant formula companies is pervasive across the world, public health experts are especially concerned about lower income countries, where the purchase of formula can often be a financial burden and can cause illness if it's prepared with contaminated water, a risk for millions who don't have easy access to clean, safe water.
Among the tactics the report details:
"The nature of the marketing [detailed in the report] really sought to exploit emotions, the fears and the ambitions of, women and families at a time when they're potentially most vulnerable," said Dr. Nigel Rollins, research leader for the report at a press conference. Rollins is ascientist with the Maternal, Newborn, Child and Adolescent Division at WHO.
The report's survey questions included one about women's desire to breastfeed and found a strong desire to do so, ranging from 49% of the women in Morocco to 98% of the women from Bangladesh. But these respondents said that the marketing could erode that: "I think that all those scientific acronyms [in the marketing] ... give a feeling of scientific sophistication. You don't know what it is but sounds cool," said a pregnant woman in Guadalajara.
More than half of the 8,500 parents and pregnant women interviewed said they had received marketing communications from formula companies. In the report, WHO and UNICEF said these messages were often "misleading [and] scientifically unsubstantiated" and violated the 1981 WHA Code (although some countries, including the U.S., have not adopted it).
The report also found that the companies have extended their reach by selling and promoting formula for older babies and even for mothers, marketed as "maternal milk."
Lost in the marketing, says WHO scientist Rollins, are the clear benefits of breast milk when mothers can nurse. In an overview published last year, for example, the American Academy of Pediatrics noted that children who are breastfed have improved dental health and neurodevelopmental outcomes and a decreased risk of such conditions as ear infections, diarrhea, respirator tract infection, SIDS, asthma, celiac disease, Crohn's disease, leukemia and childhood obesity.
Benefits to mothers of breastfeeding, according to the AAP overview, include a decreased risk of excessive menstrual blood loss, high blood pressure, type 2 diabetes, and rheumatoid arthritis.
There's a growing sense of how these benefits accrue, says Rafael Perez-Escamilla, professor of public health at the Yale School of Public Health, Director of the Office of Public Health Practice at the Yale Institute for Global Health and a member of the WHO advisory group that reviewed the report. "We are now understanding that the mother starts expressing antibodies, for example, to pathogens that she's being exposed to that get transferred to the baby through human milk. In many ways the most important scientific discovery of recent years is that breastfeeding is the mother's natural expression of what we now call personalized medicine."
There is also an environmental benefit to breastfeeding, says Professor Hastings. A 2019 article in the British Medical Journal noted the environmental impacts of infant formula including at least 550 million infant formula cans, made from 86,000 tons of metal and 364,000 tons of paper, added to landfills every year.
Other costs to the environment include paper use, plastic waste and transportation at multiple stages of formula production.
How formula companies are reacting
NPR reached out to four leading infant formula companies for comment on the report and heard back from one, Nestlé, and from the industry trade association.
"Nestlé has been leading the industry on responsible marketing of breastmilk substitutes since publication of the WHO Code," says Marie Chantal Messier, head of Food and Industry Affairs for the company. "Today, we do not promote formula for infants 0-12 months in 163 countries. Further, we are voluntarily stopping promoting formula for infants 0-6 months across the world by year-end."
Asked to comment, WHO, in an email to NPR, welcoming Nestlé's "reiteration of its commitment to support the adoption of laws on the marketing of infant formula" but added: "We are concerned, however, that the company does not clarify what those laws should cover. The milk formula industry has a long history of saying that it supports a level playing field for all companies. Unfortunately, evidence reveals that it then fights to weaken provisions in proposed legislation in order to open numerous loopholes for marketing.
"We hope that the new commitment will extend to supporting laws fully aligned with the international Code of marketing and subsequent relevant World Health Assembly resolutions."
In addition, NPR received an email from the International Special Dietary Foods Association, affirming the commitment of its members "to improving nutrition and providing the highest quality products that help meet the nutritional needs of mothers, infants and children" and affirmed its support of "all laws and regulations in the countries in which they operate."
In response WHO said: "Several companies claim to align with the Code" but an annual assessment of compliance finds that "the company that leads the rankings, being "highly compliant," still only scores 57 /100. The same report cites 169 incidences of that company being non-compliant with the Code."
What comes next
WHO and UNICEF plan to issue follow-up reports in the next few months, Rollins tells NPR, including one solely on digital marketing and infant formula and one on breastfeeding as a human right.
"The reports plus other activity makes it possible for the needle to move on the issue," says Gerard Hastings. He adds that desexualizing a woman's breast as a key need to promoting breast feeding — that is, if women can feel more comfortable about breastfeeding, and breastfeeding in public if needed, they are more likely feed their babies that way.
Among the actions recommended in the report are for governments to adopt laws and regulations to prevent formula marketing along with greater support for breastfeeding, including parental leave.
Dr. Langer of Harvard says that to "counteract this seemingly unstoppable campaign is an uphill battle, but one that we cannot stop engaging in."
"What we need," says Perez-Escamilla, the Yale public health professor, "is outrage."
Fran Kritz is a freelance health journalist in Washington, D.C. She has written on COVID-19 and other health policy topics for NPR.org, the Washington Post, Verywell Health and other publications. On Twitter: @Fkritz.
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