There has long been concern that the unethical marketing and promotion activities (using images like the one above) of some infant formula companies has led to a notable decrease in breastfeeding rates in developing countries. This has corresponded to a surge in infant formula use, often unnecessarily and with serious consequences. Data suggests that as of 2015, only 39% of children aged less than 6 months in developing nations were exclusively breastfed, which has only marginally increased from 33% in 1995.Cai X, Wardlaw T, Brown DW. Global trends in exclusive breastfeeding. International breastfeeding journal [Internet]. 2012 Sep [cited 2017 Nov 10];7(1):12. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3512504/
But what do these figures mean for the health of infants and mothers in developing countries and what has led to the trend of breastfeeding decline in these regions?
Breast is best
You have most likely heard this saying before. Recently the World Health Organization has rolled out a similar idea with their ‘breastfed is best fed’ campaign. These slogans aren’t just catchy, they absolutely ring true. The evidence on the importance of breastfeeding is conclusive: breast is best. But I’m not here to present that evidence. You can read that here in one of our previous articles.
Breastfeeding is so influential in determining health outcomes for infants, especially in developing countries, that it is predicted that if breastfeeding rates were scaled up to near universal levels, approximately 820,000 lives of children under 5 years of age would be saved every year.Victora CG, Bahl R, Barros AJ, França GV, Horton S, Krasevec J, Murch S, Sankar MJ, Walker N, Rollins NC, Group TL. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. The Lancet [Internet]. 2016 Feb [cited 2017 Nov 10];387(10017):475-90. Available from: http://www.sciencedirect.com/science/article/pii/S0140673615010247 For this reason, breastfeeding is ranked as the single most effective intervention for the prevention of deaths in children under 5 years of age.Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS, Bellagio Child Survival Study Group. How many child deaths can we prevent this year?. The Lancet [Internet]. 2003 Jul [cited 2017 Nov 10];362(9377):65-71. Available from: https://www.ncbi.nlm.nih.gov/pubmed/12853204
Risks of formula feeding in developing countries
Although infant formula is nutritionally inferior to breast milk, it is relatively safe when prepared correctly. However, various factors in developing countries contribute to a higher risk of illness and death from formula feeding.
Firstly, infant formula is expensive, which puts extra financial strain on disadvantaged families. Mothers may over-dilute formula to make the tin last longer, causing unintentional malnutrition. This can be exacerbated by unclear instructions, often in an unfamiliar language.
Secondly, formula doesn’t contain antibodies like breastmilk and therefore doesn’t offer the same immunological protection for the infant.Hanson LÅ, Korotkova M, Telemo E. Breast-feeding, infant formulas, and the immune system. Annals of Allergy, Asthma & Immunology [Internet]. 2003 Jun [cited 2017 Nov 10];90(6):59-63. Available from: https://www.ncbi.nlm.nih.gov/pubmed/12839115 Formula-fed babies are therefore at higher risk of communicable diseases, which are more prevalent in developing countries.Stuebe A. The risks of not breastfeeding for mothers and infants. Reviews in obstetrics and gynecology [Internet]. 2009 [cited 2017 Nov 10];2(4):222. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2812877/
Thirdly, formula feeding in developing countries introduces many practical challenges. Formula must be available in sufficient quantities, mixed with sterile water, and prepared using utensils and stored in bottles that are adequately cleaned and kept in a sterile environment.
Why developing countries have such high rates of infant formula use
Infant formula marketing
Infant formula marketing first sparked outrage in the 1970s when the food giant Nestlé was accused of getting mothers in developing countries ‘hooked’ on formula. It has been suggested that Nestlé and other infant formula companies accomplished this by creating a need for formula where none existed. It is proposed that Nestlé’s and others’ marketing linked their products with aspirational Western concepts of modernisation and civility that many in developing countries may have aspired to. Specifically, companies appealed to women’s ideas of beauty, the desire to live like ‘Western’ women, and the idea that only the poor breastfeed. Further, promotional campaigns focused on the concepts that breastfeeding is inherently complicated and prone to failure. Campaigns extended into hospitals and health services, with ‘discharge packs’ and free formula samples given to new mothers by doctors and nurses. This created product dependency: once bottle feeding starts, breastmilk begins to dry up, and when the free samples are finished, the mother has no other choice but to spend money on more formula. In combination with problems common in developing countries, such as illiteracy, poverty and unsanitary conditions, thousands of infants died.
Regulation of infant formula marketing
Following the Nestlé scandal, there was an organised boycott of the company in 1977, which lasted into the mid 1980s. As a result, in 1981 the World Health Organization created the International Code of Marketing Breast-milk Substitutes to address major issues with the marketing of infant formula, particularly in developing countries. The Code introduced restrictions on advertising and the distribution of free samples. Companies were also required to make labels in the local language with warnings about the health hazards associated with formula feeding.
Unfortunately, however, comparable marketing strategies to Nestlé’s are still being employed in developing countries. The Code only serves as a foundation for individual countries to create their own laws and regulations, and loopholes still exist in laws in some countries that have been exploited by lobby groups. According to the latest WHO monitoring report of 199 countries, only 35% of countries had prohibited the advertising of infant formula and just 19% had adopted all of the Code’s recommendations into law.
Feminisation of the workforce
The increased demand for infant formula may also be explained by the large-scale feminisation of the manufacturing workforce in some developing countries. More women working in manufacturing in the absence of supportive working conditions, such as paid maternity leave and lactation breaks, leads to formula feeding being an attractive option.
What’s the way forward?
The promotion of breastfeeding and the monitoring and regulation of infant formula marketing should be given high priority at global, national and local levels. An increase in exclusive breastfeeding rates, especially in developing countries, is imperative in reducing infant mortality and improving the quality of life for both mothers and babies. Firstly, it may help if action is coordinated between international organisations, governing bodies, the health sector and communities. Governments should be educated on the benefits of stricter regulation of infant formula marketing for their populations in terms of infant mortality and morbidity rates. Changes should also be introduced to the working conditions of women to facilitate breastfeeding. This involves prioritising paid maternity leave, ensuring job security after delivery, and supporting breastfeeding in the workplace. Finally, breastfeeding could be further normalised by positive marketing campaigns and educational programs, which aim to promote the benefits and reduce the stigma.
References [ + ]
|1.||⇪||Cai X, Wardlaw T, Brown DW. Global trends in exclusive breastfeeding. International breastfeeding journal [Internet]. 2012 Sep [cited 2017 Nov 10];7(1):12. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3512504/|
|2.||⇪||Victora CG, Bahl R, Barros AJ, França GV, Horton S, Krasevec J, Murch S, Sankar MJ, Walker N, Rollins NC, Group TL. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. The Lancet [Internet]. 2016 Feb [cited 2017 Nov 10];387(10017):475-90. Available from: http://www.sciencedirect.com/science/article/pii/S0140673615010247|
|3.||⇪||Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS, Bellagio Child Survival Study Group. How many child deaths can we prevent this year?. The Lancet [Internet]. 2003 Jul [cited 2017 Nov 10];362(9377):65-71. Available from: https://www.ncbi.nlm.nih.gov/pubmed/12853204|
|4.||⇪||Hanson LÅ, Korotkova M, Telemo E. Breast-feeding, infant formulas, and the immune system. Annals of Allergy, Asthma & Immunology [Internet]. 2003 Jun [cited 2017 Nov 10];90(6):59-63. Available from: https://www.ncbi.nlm.nih.gov/pubmed/12839115|
|5.||⇪||Stuebe A. The risks of not breastfeeding for mothers and infants. Reviews in obstetrics and gynecology [Internet]. 2009 [cited 2017 Nov 10];2(4):222. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2812877/|