Protect breast-feeding, the ultimate personalized medicine

By Elizabeth Zehner, Elizabeth Ransom 08 April 2016

Somali mothers receive breast-feeding technique lesson at the Kobe refugee camp in Ethiopia. By increasing breast-feeding, more than 820,000 lives would be saved annually in 75 low- and middle-income countries and the global economy would expand by billions of dollars. Photo by: UNHCR

Breast-feeding plays a significant role in improving nutrition, intelligence, educational attainment, and maternal and child health and survival. But raising awareness — and breast-feeding rates — among mothers will require changes in how milk substitutes are marketed across the globe.

Helping address misperceptions about infant formula and encouraging breastfeeding could contribute significantly to reaching the Sustainable Development Goals. As Shawn Baker and Cesar Victora recently argued in Devex, “Breast-feeding is still one of the best investments we can make in maternal and child health. The numbers speak for themselves.”

A recent series on breast-feeding in The Lancet, for example, demonstrated that more than 820,000 lives would be saved annually in 75 lower- and middle-income countries by increasing breast-feeding, and the global economy would expand by billions of dollars.

Source: The Lancet breastfeeding series
Source: The Lancet breast-feeding series

The World Health Assembly aims for a 50 percent global exclusive breast-feeding rate by 2025, but the current rate in low- and middle-income countries is 37 percent.

Why aren’t breast-feeding rates improving faster?

One obstacle to raising breast-feeding rates is countering misperceptions about substitutes. While there are multiple factors influencing a mother’s decision to breast-feed, women are influenced by the promotion of infant formula.

“After drinking infant formula, the child becomes smarter and cuter; also has strong bones and grows well,” one Cambodian mother said in an interview, after watching an ad for breast milk substitutes. “The child looks cute … and it means feeding him with infant formula creates love between mother and child,” she said.

A small number of babies do require breast milk substitutes, yet marketing can negatively affect breast-feeding even among women who can breastfeed. For this reason, The World Health Assembly passed the International Code of Marketing of Breast-milk Substitutes in 1981 to prohibit manufacturers from promoting these products.

Still, recently published research conducted by Helen Keller International’s Assessment and Research on Child Feeding project in the Journal of Maternal & Child Nutrition found high levels of promotion of breast milk substitutes, even in some countries with laws against promotion.

In Phnom Penh, Cambodia, for example, where advertisement is restricted, 86 percent of mothers still reported exposure to promotion — 77 percent had seen ads on television for breast milk substitutes. Some 38 percent of stores selling infant foods had promotions for breast milk substitutes.

In Kathmandu Valley, Nepal, where local laws prohibit advertisements, over half of mothers reported feeding their babies breast milk substitutes while in health facilities after childbirth. Mothers who received a recommendation to use breast milk substitutes from a health worker were 16 times more likely to feed breast milk substitutes compared with mothers who did not.

Ad in Senegal for Bledina products cross-promotes breast milk substitutes with complementary foods for older children. Source: Aminata Ndiaye Coly, Helen Keller International, 2015

In the Dakar Department of Senegal, where promotions of breast milk substitutes are currently legal, except for in health facilities, 39 percent of mothers with children less than 2 years old saw televised ads for breast milk substitutes. Thirty-five percent of stores selling infant foods had promotions for breast milk substitutes.

What can we do to protect breast-feeding?

Source: The Lancet breastfeeding series 

National laws should align with the international code of marketing of breast milk substitutes. As of 2013, only 37 of 199 countries reported to the World Health Organization that they were implementing the code in full.

Incorporating the code into national legal frameworks can protect breastfeeding. Brazil, for example, raised breastfeeding rates by banning the advertisement of infant formula in hospitals.

In a place such as Dar es Salaam, Tanzania, where strong laws governing marketing exist, the MCN research found that promotions were fewer.

Monitor and enforce code laws

Research shows we need not only national legislation, but also strong monitoring and enforcement. In Cambodia, where the government adopted the code into national law, the government is developing tools to monitor and enforce the restrictions on promotion.

Global mechanisms for monitoring can also play an important role in supporting the code. WHO and UNICEF have created a Network for Global Monitoring and Support for Implementation of the International Code to strengthen capacity for code monitoring and implementation. This year, the Access to Nutrition Index assessed six of the world’s manufacturers of breast milk substitutes for compliance with the code. The index found that none of the companies’ policies align fully with the code and cover all breast milk substitute products. Furthermore, none of the companies applied their policies consistently in all markets as recommended by the code.

In Vietnam and Indonesia, ATNI-commissioned research by Westat revealed numerous examples of noncompliance with international standards in both countries, leading ATNI to suggest that all companies’ policies and management systems need to be overhauled.

Support new WHO guidance on inappropriate marketing of complementary foods

One of the key messages from The Lancet series was to regulate the breastmilk substitute industry, which is currently big business. Global sales of breast milk substitutes were nearly $45 billion in 2014, and are expected to reach $70 billion by 2019, and manufacturers are making large investment in marketing.

Cross-promotion is a form of marketing promotion that targets customers of one product or service with promotion of a related product. This can include packaging, branding and labeling of a product to closely resemble that of another (brand extension).

New guidance developed by WHO on Inappropriate Promotion of Foods for Infants and Young Children contains valuable recommendations. It reaffirms that all milk products marketed for feeding infants and young children are breastmilk substitutes and their promotion is prohibited. Cross-promotion of these milks with complementary foods, a practice documented in our research, is also identified as inappropriate.

The global community must support this new guidance and work together to protect breastfeeding and the health of infants and young children.

Interested in more stories about women's and girl’s health? Make sure to follow us this May for live Devex coverage of the fourth Women Deliver conference in Copenhagen, Denmark. Join the conversation by tagging @devex and using #WD2016.

About the authors

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Elizabeth Zehner

Elizabeth Zehner is the project director for Helen Keller International’s Assessment and Research on Child Feeding project. Zehner, who has managed the ARCH project for the past three years, has extensive experience as a technical adviser in the area of international maternal, infant and young child nutrition. With a master’s degree in public health from Johns Hopkins University, she has worked with several organizations which focus on child health and nutrition issues, including PAHO, Nurture, and Wellstart and has done consulting for organizations including Save the Children, UNICEF and GAIN.


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Elizabeth Ransom

Elizabeth Ransom is director of communications and advocacy for Helen Keller International’s Assessment and Research on Child Feeding project. Over the past two decades, she has worked in the public, private, and not-for-profit sectors as an international public health and communications professional, including roles with the State Department Office of the Global AIDS Coordinator, Save the Children’s Saving Newborn Lives initiative, and Marie Stopes International subsidiary Options Consultancy. She has a background in radio journalism and a master’s degree in public health from the London School of Hygiene and Tropical Medicine.


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