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Formula milk companies continue to defy international regulations and target health centers to market their products, a WHO study on formula marketing and its impact on breastfeeding shows.

This practice is particularly prevalent in developing countries such as Nigeria and South where television marketing is less popular and formula companies target health workers.

At the health center in Ipakodo, Ikorodu, Lagos, Nigeria, SciDev.Net meets up with a nurse who cares for pregnant women and new mothers. She is one of many health workers who have witnessed the marketing gimmicks of formula companies.

"It is no news that they come, they get approval from the primary healthcare board. Sometimes, they come to help fund some of our programs but ultimately it is to market their product," the nurse, zoloft pagine sanitarie who requested anonymity because she does not have the authority to speak with the press, tells SciDev.Net.

The WHO report, a multi-country study published in February, notes that health care workers in eight countries surveyed reported that they were approached by formula company representatives.

"Health professionals in Morocco, Nigeria and Vietnam reported that contact with formula milk companies was extremely common in public and private health care settings."

"Formula milk brand representatives target different types of health professionals – including pediatricians, nurses, dieticians and hospital administrators – with a range of incentives, including funding for research, commissions from sales, ambassadorial roles, merchandise, and gifts
and all expenses paid promotional trips."

The nurse in Ikorodu admits this is the reality, but adds that the health center she works prioritizes exclusive breastfeeding for six months and makes sure that they have posters and flyers on exclusive breastfeeding.

The targeting of health workers and centers for formula marketing has direct consequences for breastfeeding rates.

In Nigeria, about 45 per cent of postpartum women received a reference from a health professional to feed their infants with formula milk, the WHO report revealed.

Omolayo Adetutu, a mother who attended the Ipakodo Primary Healthcare Centre, told SciDev.Net that "people come to market products to us, and we ask the healthcare workers for advice", but adds that doctors and nurses place emphasis on exclusive breastfeeding.

According to the WHO multi-country report, 51 per cent of 8,528 pregnant and postnatal women said they were exposed to formula marketing in 2021.

While the International Code of Marketing of Breast-milk Substitutes – a WHO public health agreement implemented in 1981 – exists to regulate formula milk marketing, companies continue to ignore this code.

Formula marketing strategies

The WHO in its report condemned what it termed the pervasive marketing by formula milk companies. It described marketing strategies as "invasive" and breaching "international standards" to influence parents' decisions on how to feed their babies.

The report found that women were substantially more likely to choose formula feeding after being exposed to marketing for breast-milk substitutes because marketing messages contained misconceptions about breastfeeding.

According to the report, messaging included claims that their products are almost like breastmilk, and that formula milk should be the first feed especially for babies birthed via Caesarean section, babies whose mothers are HIV-infected and babies with mums who have insufficient milk productions. In turn, health workers recommend these formula milk to mothers based on this information.

"Typically, we give this (formula milk) to make sure the baby is not starving. When the mother gains her strength, we encourage her to breastfeed and not continue with formula feeding. I must say that we rigorously preach baby-friendly," said the Lagos nurse.

"These mothers even feed the babies pap [maize porridge] because many are low in education and income, thereby, putting the babies at risk," another nurse at Federal Medical Centre, Owerri, Imo state, Nigeria, who also asked to remain anonymous, said.

"This is the point where we recommend formula milk, recommending alternative feeding is the last resort, if we don't, the mothers will still go ahead and feed the baby with whatever they deem fit," she adds.

Cost of not breastfeeding

Evidence have shown that breastfeeding within the first hour of birth and exclusive breastfeeding for the first six months of an infant's life are known to improve survival and health outcomes.

Breastfeeding reduces the likelihood of childhood infections including diarrhea, pneumonia and premature mortality, experts say. It also reduces the risk of depression among mothers.

Nearly 600,000 children die annually from lack of breastmilk, a 2019 study published in Health Policy and Planning shows.

The researchers used a tool they termed 'cost of not breastfeeding' to analyze the human and economic consequences of not breastfeeding at country, regional and global levels.

"Breastfeeding was attributed with 595,379 child deaths to diarrhea (38 per cent) and pneumonia (62 per cent) each year," the study added. "An estimated 974,956 cases of childhood obesity each year were attributed to not breastfeeding according to recommendations."

Around two-thirds of these cases of infectious illnesses occurred in South Asia and Sub-Saharan Africa, with 84 per cent lower middle-income and low-income countries.

The researchers said that optimal breastfeeding also had the potential to prevent an additional 98,243 deaths of mothers from cancers and type II diabetes each year.

"The total annual global economic losses [to lack of breastfeeding] are estimated to be between US$257 billion and US$341 billion, or between 0.37 per cent and 0.70 per cent of global gross national income," the study found."

The costs of not breastfeeding are significant, and should compel policymakers and donors to invest in scaling up breastfeeding and nutrition interventions for children and their mothers to strengthen human capital development and economic outcomes around the world."

Potential solutions

Better education can support health workers and parents to make breastfeeding decisions that will best support a baby's health, say nutritionists.

The WHO and UNICEF have developed training courses for health workers to provide skilled support to breastfeeding mothers and help them overcome problems.

"We have antenatal and postnatal lectures, and exclusive breastfeeding is our main topic," says the nurse at Ikorodu. "We encourage the mothers to make sure that they are feeding well, so they can produce milk, and we let them know that breast milk contains everything the baby needs for the first six months of life and can help protect babies against some short- and long-term illnesses and diseases including sudden infant death syndrome."

Goodness Anyanwu, a nutritionist at Nigeria's Federal Ministry of Health, tellsSciDev.Net there are feeding alternatives for women who are unable to breastfeed – this can be due to maternal health risks or issues such as inverted nipples.

"Breast milk banks exist for mothers who can't breastfeed. We are trying to explore this in the Federal Ministry of Health where a woman can go and donate breastmilk for cases like this," she says, adding that discussions are continuing.

Anyanwu says hormone-induced lactation – where hormones like estrogen or progesterone are administered to mimic the effects of pregnancy – can also be explored, while healthy relatives capable of breastfeeding can also be considered.