How breastfeeding is undermined
With support nearly all mothers are capable of breastfeeding. Yet in many countries breastfeeding rates are low and artificial infant feeding has become part of the culture. In this section we look at examples of company promotional methods in order to understand how the baby food industry undermines breastfeeding and encourages artificial infant feeding.
Promotion using free supplies
Free supplies were restricted by the International Code and were finally banned in all parts of the health care system by the World Health Assembly in 1994 (Resolution WHA47.5). Despite the ban companies continue to use free supplies as a means of promoting their products. Giving bottles to newborns interferes with lactation. If a mother stops producing milk she has to purchase the companys products once she leaves the hospital and it is no longer free. IBFAN has campaigned on this issue for many years and has raised awareness of the promotional nature of free supplies.
• In July 1996 Nestlé was reported to be providing free and low-cost supplies of infant formula to hospitals in Kunming Province of China. In a public statement Save the Children said:
"Nestlé has made Lactogen widely available in six hospitals in Kunming, where it has targeted health professionals with both free and discounted supplies of the formula. This helps to create an incentive for the health workers, not only to use the formula within the hospitals, but actively to encourage its use among mothers of new-born children. Lactogen has been displayed in some of the hospitals for sale. The report prepared by our China staff and local
health workers alleged that there had been an increase in the consumption of Lactogen and that breastfeeding
rates had fallen."
Companies that belong to the International Association of Infant food Manucaturers (IFM) pledged as far back as 1991 to work towards the goal of ending free and low-cost supplies. Yet IBFANs monitoring report Breaking the Rules, Stretching the Rules 1998 shows there were instances of supplies of infant formula being given to health care facilities in 19 of the 31 countries surveyed. Donations of follow-up formula and complementary foods have also been taking place.
Monitoring conducted by the IBFAN group in Pakistan and published in the report Feeding Fiasco in March 1998 found widespread distribution of free supplies. A former company representative describes in the report how hospitals receive free supplies and doctors are "purchased by companies...after which the doctor or hospital is bound to recommend the companys formula."
In Norway promotion of artificial infant feeding does not occure and 98% of mothers leave hospital breastfeeding. After 3 months 90% are still doing so.
Article 9.2 of the International Code requires that labels are in a language appropriate to the country where the products are sold.
IBFANs monitoring finds many countries where this is not respected. One long-running case concerns Malawi
in Central Africa. Both Nestlé and Wyeth were reported in Breaking the Rules 1994 for violating this provision
of the Code in Malawi. Both claimed English was the appropriate language, although Nestlé had earlier said:
"Due to cost restraints of small runs it has not been viable to change languages for specific export markets."
When checking the situation a few years later IBFAN received a letter from the Malawi Ministry of Health
saying: "The Ministry discussed the need to include Chichewa. - [the national language] - with Nestlé ...in mid 1994...not received a reply...nothing has happened." Government statistics show that of those women who could read, 43% could not read English, the language on the label.
Sometimes companies include under-lid leaflets in other languages. This will only be read after buying the product. Even parents who choose to breastfeed should be able to understand the warnings on a breastmilk substitutes so that their choice is not undermined.
Using "humanitarian aid" to create markets
In emergency and relief situations it is important that babies are breastfed, if possible. Artificial feeding
in these conditions is difficult and hazardous and can lead to increased infant mortality rates. The basic resources needed for artificial feeding, such as water, fuel and sufficient quantities of breastmilk substitutes
are scarce in emergencies. Furthermore breastmilk substitutes donated as humanitarian aid often end up in
the local market and can have a negative influence on feeding practices generally.
The baby food industry has used emergencies generally to promote its products and used "humanitarian aid" as a way of entering into the emerging markets of Europe and the former Soviet Union.
• Large quantities of baby milks were donated by the European Union to the countries of the former Soviet Union. The tins carried a company brand name, the EU logo and an inscription, "Gift from the European Union to the people of Russia." This gives the impression that the product appears to be endorsed by the EU.
• A German baby food company, Humana, donated baby milks to health centres in Russian villages. The boxes carried a baby picture and a notice saying "like breast milk", both violations of the International Code.
• Relief workers in Kazakhstan received so much free infant formula that they used it in their coffee!
• Dr Anahit Demirchyan, Coordinator of the UNICEF Baby Friendly Hospital Initiative in Armenia, said that "The distribution of breastmilk substitutes as humanitarian aid almost destroyed our breastfeeding programmes."
IBFAN is actively working with aid and development organisations on issues surrounding infant feeding in emergencies.
See the resources sheet for information on the IBFAN publication Crucial Aspects of Infant Feeding in Emergency and Relief Situations.
This tin was distributed in Russia as aid from the European Union and purchased at an open market in Estonia. IBFAN supports generic labelling (that is, labels without brand names) of products when there is a genuine need for them.
Labels which undermine breastfeeding
Article 9.2 of the International Code requires labels to be in the appropriate language and to include specified text warning that breastfeeding is best for babies and that the products should only be used on the advice
of a health professional. In addition there should be no pictures or text which might idealize the use of infant formula.
Article 9.1 says that labels should not discourage breastfeeding.
The pack shot on the right is for Nestlés Bona infant formula. Nestlé adds to the text of the Important Notice: "Infant formula can be used from birth onwards when breastfeeding is not possible, or as a supplement to breastfeeding."
Supplementing breastfeeding interferes with lactation and makes an early end to breastfeeding more likely. The feeding guide on the pack states that mothers should continue to use the formula "in the case of lack of breastmilk."
Nestlés Bona, distributed in Russia, demonstrates that it is possible to idealize the use of infant formula without using baby pictures.
Promotion to mothers and pregnant women
Companies violate the International Code and Resolutions by promoting to mothers in a variety of ways:
• Free samples
• "Help" lines and "parent clubs"
• Visits at home or at health facilities
• "Educational" materials on infant feeding
• Posters in hospitals, brand names and logos on equipment, pens, pads etc.
• Information on other products
Some examples from IBFANs monitoring report Breaking the Rules, Stretching the Rules 1998:
All major manufacturers were found to have given samples of infant formula to mothers.
• Health care facilities displayed posters, calendars, clocks and stickers with product brands. These give the impression that the health care system endorses the products. Increasingly companies donate materials which only have their company name or logo. This may be a concession to the International Code but is nonetheless a way of using the health care facility for promotion.
This calendar produced by Coberco Omefa was distributed in Bangladesh. It shows pack shots of infant formula and follow-on formula and has the slogan "Nutritious food for young and old."
Source: Breaking the Rules, Stretching the Rules 1998
• Sales representatives from all major companies were reported to have had contact with mothers or pregnant women. In the Philippines Nestlé employs nurses as "Health Educators" who visit pregnant women and mothers in their homes to promote Nestogen infant formula. When this was reported on television in July 1997 Nestlé threatened to withdraw its advertising from the television station.
Free samples distributed to mothers in Bangladesh and Indonesia.
• Nestlé received a business award in 1997 for the imaginative way in which it undermined Denmarks breastfeeding promotion programme. Nestlé set up a "Parents Club" and carried out quarterly promotional campaigns in supermarkets across Denmark. Information about infant nutrition and the club was placed in hospitals and maternity clinics. In less than one year, membership increased from under 10% of
Danish parents to over 75%.
Infant formula and follow-on formula are often packaged similarly. Advertising the follow-on formula also serves to advertise the infant formula. Source: BTR98.
• Advertising of infant formula still occurs in some countries, but more often companies advertise other products such as follow-on formulas. Often these products have the same name as the infant formula and so effectively promote the infant formula as well.
Mead Johnson distributes these "information leaflets" to health professionals in the UK and asks, "Please give one of these to parents when you suggest Enfamil AR."
Source: Campaign for Ethical Marketing, September 1997
Promotion to health professionals
Promotion to health workers is banned by the International Code Articles 6.2 and 7.2 and information
provided must be limited to scientific and factual matters.
In 1996 the World Health Assembly adopted Resolution WHA49.15 calling for Member States to adopt
measures to ensure that financial support for health workers does not give rise to conflicts of interest. The International Code Article 7.5 requires that any funding provided by a manufacturer or distributor of breastmilk substitutes is reported.
Health professionals are an important target for the baby food industrys promotion. If a company succeeds
in persuading a health worker, it can influence the infant feeding choices of many mothers.
Companies continue to provide gifts to health professionals and offer sponsorship to them and their professional organisations.
• In August 1997 the International Nutrition Conference in Montreal, Canada was sponsored by Nestlé, Wyeth and Abbott-Ross. In a speech at the conference UNICEF Deputy Director commented, "UNICEF is, frankly, uncomfortable about these international gatherings... some of whose funding comes from the infant formula companies. I wish it would be otherwise."
• Many companies give gifts of calendars, posters, pens, notepads and growth charts bearing company logos and often brand names or pictures of products.
• Conferences are arranged in luxurious conditions. For example, Milupa entered the baby food market in Mauritius in November 1993 and built support amongst health professionals through a series of meetings at a 5-star hotel.
• Nestlé organised a conference on a cruise liner for Brazilian paediatricians in 1993.
• SMA, part of Wyeth, distributed the above card at the May 1997 conference of the Royal College of Midwives in the UK. It offers midwives beauty products if they meet with an SMA representative and the chance to win a £100 prize if they provide details of mother classes held at their place of work and a work contact address and telephone number.
Undermining implementation of the International Code
Member States of the World Health Assembly are called on to implement the International Code and Resolutions in national measures. Here are a few examples of how baby food companies have opposed this process.
• Philippines - 1989. Several manufacturers lobby the government to oppose the adoption of a bill which would encourage mothers to breastfeed and sleep with their babies - The Rooming-in Bill.
• Pakistan - 1992 and 1997. Nestlé lobbied for babymilks and baby foods to be removed from the Government drug list in 1992, so that sales are not restricted to pharmacies, but can be sold in any grocery or market. In 1997 Nestlé opposed many provisions of Pakistans draft law.
• India - 1995. After Nestlé is taken to court it files a Writ Petition against the Indian Government challenging the provisions of the Infant Milk Substitutes Act under which it is being prosecuted.
• Guatemala - 1995. The US Government puts pressure on Guatemala to allow Gerber to use baby pictures on its packaging.
• Russia - 1996. Nestlé offers to translate the weak UK infant formula and follow-on formula regulations as the basis for legislation instead of the International Code and Resolutions.
• South Africa - 1997. Baby food companies in South Africa form the "Freedom of Commercial Speech Trust" to campaign against regulation of advertising.
• Sri Lanka - 1997. Nestlé opposes a revision of the Sri Lanka Code which would bring it into line with the 1996 WHA Resolution.
• Zimbabwe - 1998. Nestlé threatens to disinvest if Zimbabwe does not revoke its strong law.
• Europe and the UN - ongoing. The industry attempts to stop the International Code and Resolutions from being used as the basis for international trading standards.