Much discussion around breastfeeding is about women’s choice to breastfeed or not. But who really decides on how a baby is fed when a $55 billion industry is at stake?
A new series of studies published in The Lancet shows how baby food corporations influence infant feeding practices both nationally and globally, working through systems of power which are both direct and indirect, and highly gendered. Through these systems, a commercial ecosystem favourable to early weaning and sales of commercial milk formula (CMF) products is established. You can watch the Australasia & Pacific launch event of the 2023 Lancet Breastfeeding Series here.
Overall the Series helps to understand the commercial actors and structural forces that influence feeding practices across entire populations, and put an end to unhelpful and deeply unfair narratives that place responsibility for infant and young child feeding solely onto women and families. Authors call for wide-ranging actions that end this harmful commercial influence.
Gendered power systems exploit vulnerabilities and policy gaps to shape breastfeeding practices
Sales of CMF products have been booming and are now $55 billion of global retail sales a year. The industry spends least $3 billion a year on marketing. This marketing spend completely swamps any spending by governments around the world on protecting, promoting and supporting breastfeeding.
Targeting parental anxieties and protecting breastfeeding effectively
The first paper in the Lancet series identifies concerning global trends and patterns in breastfeeding, and describes how typical infant behaviours are commonly misinterpreted as signs of insufficient or inadequate milk, and result in early use of breastmilk substitutes, and disruption of lactation.
New mothers and their infants and young children are well understood to be uniquely vulnerable to marketing. For this reason governments have agreed globally since 1981 that promotion of breastmilk substitutes should not be allowed. This agreement, including numerous subsequent Resolutions by the World Health Assembly, is known as the International Code of Marketing of Breast-milk Substitutes. The Code covers specialised formulas, products known as ‘growing up’ or ‘toddler’ milks/formulas, and formula products for infants in the first year.
Women and children have specific human rights related to good quality maternity care that enables well informed decisions about breastfeeding made free from commercial influence. Women’s rights to adequate maternity protection in the workplace, freedom from discrimination and to a friendly environment for breastfeeding are also well documented. Furthermore, breastfeeding provides for realising the optimal reproductive health of women, as well as being the best way for the child to survive and grow.
The measures needed to provide an enabling environment for breastfeeding are well known but not widely implemented, and include the Baby Friendly Hospital Initiative, the International Labor Organization’s standards for maternity protections in employment, and Code implementation.
The marketing playbook
Medical researchers have demonstrated that pharmaceutical companies use ‘disease mongering’ to promote sales of drugs, but less well known is how the CMF industry also pathologizes normal infant behaviour in order to create and reinforce parental anxieties and promote sales of high priced baby milk products.
The second paper in the Lancet series describes how the marketing playbook for formula products exploits the common vulnerabilities and anxieties of parents, and plugs gaps in policies and programs needed to support women to breastfeed. For example, CMF products including specialised formulas are offered to women and health professionals as solutions to pathologized infant behaviours such as crying, fussing or sleeplessness, or in response to anxieties about insufficient milk or allergy.
With only around 10% of births in facilities meeting BFHI standards for staff competencies on breastfeeding, and adopting Code provisions for health workers, health professionals are commonly poorly equipped to help women manage these issues. It is not unusual for industry to provide their continuing medical education on infant and young child feeding.
Indeed, health professionals are a central to formula marketing and are viewed as key ‘category entry points’. Marketing also occurs via influence on scientific research and medical guidelines, as well as industry support and sponsorship for health professional journals, conferences and medical organisations.
Marketing is also shown to use gender, positioning formula as ‘liberation in a can’, especially for women’s labour force participation and upward mobility. Breastfeeding and thereby women’s bodies, are portrayed as inherently difficult, unreliable, and inconvenient. Formula is offered as a lifestyle choice and a solution to all difficulties of infant care, while breastfeeding advocacy is framed as harmful moral judgement that causes women to feel guilty.
Confrontational messaging depicting “mommy wars” (for example, the Sisterhood of Motherhood advert) divides women by challenging the importance of breastfeeding, and depicting public health messages as anti-feminist. Such industry messaging turns attention towards individual ‘choice’, and – importantly – away from structural factors and policy gaps which constrain women’s decisions on infant feeding. It emphasises breastfeeding as individual women’s responsibility, rather than a narrative that bearing and rearing children is a collective responsibility.
Two-faced and gendered corporate power systems
The global boom of milk formula sales has resulted in immense power of formula companies to shape the ‘ecosystem’ for women’s infant feeding decisions, using the same industry ‘playbook’. This extends to stakeholder marketing whereby the power of the industry is used to influence the regulatory and policy environment at global and national levels in their own interests. Women’s voices may be unrepresented in such processes.
For many decades, the public face of the formula industry has been that of benevolence and corporate social responsibility, including the companies stating their so-called commitments to breastfeeding.
Less visible are corporations’ political activities to shape the infant feeding culture or ‘ecosystem’, including extensive lobbying by an international network of front groups that often operate covertly to block or delay marketing regulations. These more hidden political activities undermine and under-resource the structural supports for breastfeeding in health systems, employment and public financing.
Industry lobbying against marketing regulations is well documented, but the size of baby food market is also affected by other public policies. Industry discussions are open about how they use parental fatigue and uncertainty to sell their product – ‘what we are selling is actually sleep”.
In Australia, a 2016 baby food market report highlighted that changes to the paid parental leave policy ‘would influence whether breastfeeding was feasible’; longer leave would decrease sales, while ‘assisting the return to work would have the opposite impact’ . In Ireland, industry lobby groups including global formula companies have cautioned against maternity protection reforms and opposed extension of breastfeeding breaks.
‘Applied patriarchy’ and economic policies
Uniquely, the Series highlights the bigger picture of how key economic institutions, and taxation and fiscal policies advantage industry at the expense of women and children, and undermine and under resource unpaid work. For example, the third paper in the Lancet Series discusses how women’s unpaid care work is unmeasured by gendered economic statistical systems, excluded by the United Nation’s System of National Accounting which sets rules for what counts in GDP. Described by feminist economist Marilyn Waring as ‘applied patriarchy’, this system shows a rise in GDP when CMF sales rise, and a fall in GDP when breastfeeding increases.
Globally, women were estimated to provide over 23 billion litres of breastmilk a year in 2010. The Mothers Milk Tool provides updated estimates. Yet breastfeeding is under-recognised as an element of food policy and planning, and excluded from international and national food monitoring systems except in Norway.
Breastfeeding provides important food security for babies, but despite this, women’s voices are silenced in relevant policy discussions. In contrast, as shown in paper 3 of the Lancet Series, the baby formula, dairy and other industry representatives are privileged to comprise around a third of government delegations to the global food regulatory body, Codex Alimentarius. Codex sets minimum benchmarks for national food policies and standards, including on how commercial milk formula can be packaged and labelled for marketing.
The authors argue that addressing gender biases in statistical systems would make the economic gains from breastfeeding more visible and the implications for women’s well-being more evident, while also raising the priority of protecting breastfeeding in international and national trade decision making.
Time to care
Care of an infant is tiring and time consuming – exclusive breastfeeding as recommended for 6 months takes around 20 hours a week. For over a century, the International Labor Organization has sought to to protect the health of mothers and infants through promoting minimum standards for working mothers.
The Maternity Protection Convention provides for a minimum standard of 14 weeks paid maternity leave, and breastfeeding breaks, with payment at two thirds of previous earnings, and funded from public revenue.
Yet, more than half a billion women globally lack any of these protections, more than three in ten did not have at least 14 weeks paid at two thirds of previous earnings, and the majority live in countries with no entitlement to nursing breaks. Providing maternity and parental leave and provide breastfeeding breaks at ILO standards was both feasible and affordable in diverse country settings, costing no more than half a per cent of GDP.
Despite calls for transformative investments in the care economy in response to an escaling global crisis of care, governments rarely allocate necessary budgets. Instead superficial campaigns promoting ‘breast is best’ substitute for more difficult and costly measures addressing the structural drivers of infant feeding decisions. Without substantial societal investments, women’s choices are open to manipulation by exploitative marketing of CMF.
Central to addressing the global boom in milk formula sales are fiscal policies which shape social protection systems providing women with income security and poverty alleviation, access to public services such as quality childcare, and ensure health financing and medical training systems which avoid creating financial pressures for health facilities and health professionals to accept gifts, donations or sponsorship from CMF companies, and instead offering culturally appropriate and women centred maternity care that is free from commercial influence.
Trumping human rights
To date, trade and commerce trump women’s and children’s rights when it comes to infant and young child feeding in Australia, and internationally, indicating that transformational change to these gendered power systems is urgently needed. Key recommendations include;
- Adoption of a framework convention on commercial marketing of foods for infants and young children obliging governments to regulate industry marketing and lobbying
- Data collections which bring women’s unpaid work into visibility in economic accounting systems,
- Alignment of ILO standards on paid maternity leave with health recommendations for 6 months of exclusive breastfeeding, and
- Using fiscal policy including gender budgeting approaches to fully resource comprehensive maternity rights protection, and channel greater investment into maternal infant and young child health and nutrition.
Please note: Picture at top is from Shutterstock