Marketing of commercial milk formula: a system to capture parents, communities, science, and policy.

Despite proven benefits, less than half of infants and young children globally are breastfed in accordance with the recommendations of WHO. In comparison, commercial milk formula (CMF) sales have increased to about US$55 billion annually, with more infants and young children receiving formula products than ever. This Series paper describes the CMF marketing playbook and its influence on families, health professionals, science, and policy processes, drawing on national survey data, company reports, case studies, methodical scoping reviews, and two multicountry research studies. We report how CMF sales are driven by multifaceted, well resourced marketing strategies that portray CMF products, with little or no supporting evidence, as solutions to common infant health and developmental challenges in ways that systematically undermine breastfeeding. Digital platforms substantially extend the reach and influence of marketing while circumventing the International Code of Marketing of Breast-milk Substitutes. Creating an enabling policy environment for breastfeeding that is free from commercial influence requires greater political commitment, financial investment, CMF industry transparency, and sustained advocacy. A framework convention on the commercial marketing of food products for infants and children is needed to end CMF marketing.

Exploring women's exposure to marketing of commercial formula products: a qualitative marketing study from two sites in South Africa.

BACKGROUND: Regulating the marketing of commercial formula products is a long-term commitment required to protect breastfeeding. Marketing strategies of formula manufacturers, retailers and distributors evolve at a rapid rate. OBJECTIVE: The aim of this research was to describe exposure of pregnant women and mothers of young children in South Africa to marketing of commercial formula products, compared to international recommendations and national legislation. METHODS: Using mobile phone marketing diaries twenty participants in Cape Town and Johannesburg documented the formula marketing they were exposed to for one week. Ten mothers were interviewed to explore their perceptions towards marketing exposure in more depth. RESULTS: Women reported limited infant formula advertising, but an abundance of strategies used to market growing-up formula and powdered drinks for children over 36 months. Strategies included product packaging, in-store displays, online distribution channels and educational material about product ranges. Online strategies were reported, namely social media marketing (sponsored adverts and support groups), websites and mobile phone applications providing infant and young child feeding information and price discounts, print and TV advertisements, and competitions. Products for children over 36 months are cross-promoted with products prohibited to be advertised by national legislation. CONCLUSIONS: South African women are being exposed to covert marketing of infant, follow-up, and growing-up formula. Explicit marketing of products for children over 36 months of age allows formula companies to provide messages about branding and use of commercial formula products to mothers. National legislation should be updated and effectively implemented to address changing marketing strategies.

They push their products through me: health professionals' perspectives on and exposure to marketing of commercial milk formula in Cape Town and Johannesburg, South Africa - a qualitative study.

OBJECTIVE: To understand the views of public and private sector health professionals on commercial milk formula, to describe their exposure to companies that market commercial milk formula within their workplaces and to describe their awareness of South African (SA) regulations. DESIGN: A qualitative study consisting of semistructured interviews. SETTING: The study was conducted in Cape Town and Johannesburg, SA. PARTICIPANTS: Forty health professionals who had regular contact with pregnant or postnatal women were interviewed between February 2020 and February 2021. RESULTS: Analysis of the interviews revealed six themes. Health professionals in the private sector reported frequent contact with industry representatives with over two-thirds reporting exposure to industry representatives to present products, provide training or sponsor educational activities. Participants held strong opinions regarding the equivalency of breastfeeding to commercial milk formula citing information from industry representatives and product packaging. Health professionals were very knowledgeable on so-called formulas for special medical purposes and these were valued as solutions to infant feeding challenges. Of the 40 health professionals interviewed, less than half (19) had ever heard of the SA regulation related to marketing of breast milk substitutes (R991). CONCLUSIONS: This study demonstrates clearly that health professionals, particularly in the private sector, are exposed to and promote the use of commercial milk formula among SA women. The findings of this study should be used to catalyse policy responses, social movements, consumer and professional association action to strengthen monitoring and enforcement of the Code regulations in order to protect breastfeeding and support the optimal health and well-being of the population.

Follow-up and growing-up formula promotion among Mexican pregnant women and mothers of children under 18 months old.

Milk formula sales have grown globally, particularly through follow-up formulas (FUF) and growing-up milks (GUM). Marketing strategies and weak regulatory and institutional arrangements are important contributors to caregivers' decisions about child feeding choices. This study describes maternal awareness, beliefs, and normative referents of FUFs and GUMs among Mexican pregnant women and mothers of children 0-18 months (n = 1044) through the lens of the theory of reasoned action (TRA). A cross-sectional survey was undertaken in two large metropolitan areas of Mexico. Descriptive analyses were conducted following the constructs of the TRA. One-third of the participants had heard about FUFs, mainly through health professionals (51.1%) and family (22.2%). Once they had heard about FUFs, the majority (80%) believed older infants needed this product due to its benefits (hunger satisfaction, brain development, and allergy management). One quarter of the participants were already using or intended to use FUFs; the majority had received this recommendation from doctors (74.6%) and mothers/mothers-in-law (25%). Similarly, 19% of the women had heard about GUMs. The pattern for the rest of TRA constructs for GUMs was similar to FUFs. Mexican women are exposed to FUFs and GUMs, once women know about them, the majority believe older infant and young children need these products, stating perceived benefits that match the poorly substantiated marketing claims of breast-milk substitutes. Health professionals, particularly doctors, act as marketing channels for FUFs and GUMs. Marketing of FUFs and GUMs represents a threat to breastfeeding in Mexico and a more protective regulatory and institutional environment is needed.

Exposure to marketing of breastmilk substitutes in Mexican women: Sources and scope.

BACKGROUND: Aggressive and unregulated marketing of breastmilk substitutes (BMS) results in increased child morbidity and mortality. Unregulated BMS marketing is a major public health concern because it encourages formula consumption at the expense of breastfeeding. This study aimed to identify the sources and characterize the nature of exposure to marketing of BMS among Mexican mothers of children under 18 months of age. As a secondary objective we explored potential association between exposure to BMS marketing and infant feeding practices. METHODS: Cross-sectional study, comprising a pre-piloted survey, was conducted between February 2020 to February 2021 with Mexican mothers of children under 18 months of age (n = 754), in two major cities in Mexico. Mothers were selected according to their current infant feeding practices (Breastfeeding only vs. Mixed feeding). We characterized the different BMS marketing sources and scope, and related them with infant feeding practices. In addition, we used logistic regression models to estimate the odds ratio for infant feeding practices by BMS marketing exposure or recommendation. RESULTS: Mothers reported different sources of exposure to BMS promotion, including BMS advertisements in diverse media channels (41.6%), recommendation by a healthcare professional and/or relative (76.2%), and receiving a BMS sample at a hospital (18.6%). By contrast, only 36.5% recalled hearing or seeing breastfeeding information the previous year. The odds of mixed feeding were substantially higher, compared to breastfeeding, when mothers were recommended to use a BMS by doctors/pediatricians (OR: 3.96, 95% CI: 2.00, 7.83). Having seen or heard breastfeeding information in the previous year was associated with a lower risk of mixed feeding compared to breastfeeding only (OR: 0.59, 95% CI: 0.35, 0.99). CONCLUSIONS: Mexican mothers of young children in the metropolitan areas studied were highly exposed to BMS marketing and through different mass media channels and inter-personal sources. Health care professionals, particularly doctors/pediatricians, are a source of BMS promotion that are likely to have a strong influence on maternal decisions about infant feeding practices. There is an urgent need to protect mothers and their families against unregulated BMS promotion through mass media channels and directly by influential individuals, including health care providers.

An exploration of pregnant women and mothers' attitudes, perceptions and experiences of formula feeding and formula marketing, and the factors that influence decision-making about infant feeding in South Africa.

BACKGROUND: Despite strong evidence showing the lifelong benefits of breastfeeding for mothers and children, global breastfeeding practices remain poor. The International Code of Marketing of Breastmilk Substitutes is an internationally agreed code of practice, adopted by the World Health Assembly in 1981, to regulate promotion of commercial formula, and is supported by legislation in many countries. However, marketing of formula remains widespread and contributes to mother's decisions to formula feed. We present South African data from a multi-country, mixed-methods study exploring women's decision-making about infant feeding and how this was influenced by exposure to formula marketing. METHODS: Using a consumer-based marketing approach, focus group discussions (FGDs) were conducted with pregnant women and mothers of children aged between 0 and 18 months in two urban sites in South Africa. Participants were purposively selected according to their child's age, infant feeding practices and socioeconomic status. Ten FGDs were conducted during February 2020 with a total of 69 participants. Thematic analysis was used to analyse the data with NVivo v.12 software. RESULTS: Despite being encouraged by health professionals to breastfeed and intending to do so, many mothers chose to give formula in the early weeks and months of their child's life. Mothers reported breastfeeding challenges as the most frequent reason for initiating infant formula, stating that family members and health professionals recommended formula to solve these challenges. Although participants described few advertisements for infant formula, advertisements for 'growing-up' formulas for older children were widespread and promoted brand recognition. Mothers experienced other marketing approaches including attractive packaging and shop displays of infant formula, and obtained information from social media and online mothers' groups, which influenced their choice of formula brand. Mothers reported strong brand loyalty derived from previous experiences and recommendations. Health professionals frequently recommended formula, including recommending specific formula brands and specialist formulas. CONCLUSION: Global formula companies use multifaceted marketing methods to promote a strong narrative portraying formula feeding as a positive lifestyle choice. Positive, coordinated efforts are required to counter pro-formula messaging and change the narrative to support breastfeeding as an aspirational choice. In particular, health professionals must stop supporting the formula industry.

Globalization, first-foods systems transformations and corporate power: a synthesis of literature and data on the market and political practices of the transnational baby food industry.

BACKGROUND: The global milk formula market has 'boomed' in recent decades, raising serious concerns for breastfeeding, and child and maternal health. Despite these developments, few studies have investigated the global expansion of the baby food industry, nor the market and political practices corporations have used to grow and sustain their markets. In this paper, our aim is to understand the strategies used by the baby food industry to shape 'first-foods systems' across its diverse markets, and in doing so, drive milk formula consumption on a global scale. We used a theoretically guided synthesis review method, which integrated diverse qualitative and quantitative data sources. RESULTS: Global milk formula sales grew from ~US$1.5 billion in 1978 to US$55.6 billion in 2019. This remarkable expansion has occurred along two main historical axes. First, the widening geographical reach of the baby food industry and its marketing practices, both globally and within countries, as corporations have pursued new growth opportunities, especially in the Global South. Second, the broadening of product ranges beyond infant formula, to include an array of follow-up, toddler and specialized formulas for a wider range of age groups and conditions, thereby widening the scope of mother-child populations subject to commodification. Sophisticated marketing techniques have been used to grow and sustain milk formula consumption, including marketing through health systems, mass-media and digital advertising, and novel product innovations backed by corporate science. To enable and sustain this marketing, the industry has engaged in diverse political practices to foster favourable policy, regulatory and knowledge environments. This has included lobbying international and national policy-makers, generating and deploying favourable science, leveraging global trade rules and adopting corporate policies to counter regulatory action by governments. CONCLUSION: The baby food industry uses integrated market and political strategies to shape first-foods systems in ways that drive and sustain milk formula market expansion, on a global scale. Such practices are a major impediment to global implementation of the International Code of Marketing of Breastmilk Substitutes, and other policy actions to protect, promote and support breastfeeding. New modalities of public health action are needed to negate the political practices of the industry in particular, and ultimately to constrain corporate power over the mother-child breastfeeding dyad.