Women’s Health Today

Alice Allan contends that breastfeeding needs the support of law.

The 2016 Lancet report states that if almost every woman breastfed her baby, 823,000 deaths per year could be prevented (Victora et al., 2016). Not only could better breastfeeding rates have an enormous effect on health and well-being in terms of lower mortality and morbidity but this could have an impact on the environment (both ecologically and in terms of savings to health services (Linnecar & Gupta et al., (2014), Brown 2016), educational attainment (Victora et al., 2015) and even social leveling (Sacker & Keller et al., 2013).

“Breastfeeding is a natural safety net against the worst effects of poverty … It is almost as if breastfeeding takes the infant out of poverty for those first few months in order to give the child a fairer start in life and compensate for the injustice of the world into which it was born.” (James P. Grant, cited in Clark, 2011)

Yet the barriers to breastfeeding are many. In the UK, they include poor education around breastfeeding, among mothers and health professionals, psychological stress and physiological problems (Brown, 2016). Elsewhere, they include harmful traditional beliefs such as the devaluing of colostrum (Rogers et al., 2010) or short maternity leaves (Huang & Yang, 2015). In recent years, though, one of the biggest global threats, as will be shown below, has been the well-documented and systematic misinforming of the public by baby milk companies.

The International Code of Marketing of Breast-Milk Substitutes is a health policy ratified by the World Health Assembly (WHA) in 1981. It puts restrictions on how breast-milk substitutes are marketed (i.e. prohibiting the marketing of milks and foods for babies under 6 months of age) and also covers the marketing of bottles and teats. It protects both mothers and health workers from the unsolicited, direct influence of formula companies, and bans free gifts and other financial inducements. It also relates to the labeling of breast-milk substitutes, insisting that information be accurate and contain information about safe preparation, the superiority of breast milk and the risks of not breastfeeding (WHO, 1981). Individual countries may sign up to all, or some of its recommendation and tailor their country’s laws accordingly. For example, while Ghana has fully implemented the code, the US (the only country in the WHA to vote against the adoption of the code) has made almost no progress towards its recommendations (WHO, 2016).

Although the code can be considered somewhat “toothless” in the face of the enormous wealth and ingenuity of formula companies, where it has been enacted effectively as part of a country’s laws and where health workers are trained to understand its ethos, it has been shown to have a huge impact on breastfeeding rates. The remarkable difference in retail markets for formula in China and India is an example of this (Save the Children, 2013, p.38). The Chinese, who do not subscribe to the code, saw their formula market grow by $12 billion in 2012 and it is estimated to keep growing by around 14% every year (Brown, 2016).

Some have raised the argument that by prescribing what is ‘good’ for people in terms of their health (i.e. breastfeeding rather than formula feeding), health promotion may be being hijacked by “governments who wish to propagandize and manipulate, to even ‘force’ people to live in healthier ways” (Dixey, 2012, p.5). An extreme example of this is the totalitarian state of Turkmenistan which has recently banned cigarettes (BBC, 2016). Larsen and Mandlesen (2009, p.608) write that—

“another way of seeing health promotion is as an ‘extended arm of the “neo-liberal” discourse’ … health promotion is one way of ‘governing the masses,’ and health education is explicit in this task: people are directed to eat healthy foods, not to smoke cigarettes or use drugs, consume alcohol moderately, exercise regularly, participate in community life, and be responsible for their own life.”

In the UK cries of ‘Nanny State!’ often accompany government attempts to create legislation to curtail unhealthy behaviour by individuals or corporations. However, this expectation of personal responsibility for health creates a tension, because, in neoliberal systems, “Freedom becomes redefined as the capacity to exercise discrete consumption choices, with scant attention to how poverty and powerlessness constrain those choices” (Larsen, 2015). And, as Dixey (2012, p.5) points out, while health is determined by some factors that are under individual control, there are many external factors that influence the ability to live healthily, such as housing, education, transport and diet. A government that did nothing to ameliorate those external factors could be accused of negligence and failing to act according to the definition of politics, “of, for, or relating to citizens.”

The UN have recently called for breastfeeding to be acknowledged as a human right and asked for all countries to uphold the code. This call too causes tensions. It is undeniable that babies who are not fed human milk face a number of harms, health challenges that can range from morbidity to mortality. Do mothers then have a moral duty to breastfeed? The right to health as declared in the Universal Declaration of Human Rights 1948 raises the question of who has the responsibility to deliver on this right, the individual or the government?

Some have equated the code with a prohibition of choice, or a penalisation of mothers, (Mail Online, November, 11, 2016). However, the code, while it curtails the activities of those that aggressively market formula, is actually both protective and permissive. In conjunction with other health promotion interventions aimed at removing the social barriers to breastfeeding, it is one of a number of political tools that can facilitate the achievement of biological, social, and educational potential among the wider populace and their children. It does this by giving them access to accurate information on which to make their choice rather than commercially biased advice.

“Women have the right to choose how they use their bodies and they cannot (and should not) be forced to breastfeed, but that does not mean that evidence about the risks of not breastfeeding should be censored.” (Palmer, 2009, p.7).

In the unregulated environment that preceded the code, baby milk companies showed themselves capable of gross misconduct in the name of market share and profit. Perhaps the most shocking example of this were the Nestlé ‘nurses’ (saleswomen) that the company deployed in developing-world hospitals to persuade women to give up breastfeeding (Muller, 1974). Today, misinformation, such as spurious, unsubstantiated health claims, and incentives to health workers are regularly reported by those who monitor the code (Allain & Kean, 2008). Loopholes around the marketing of the unnecessary and invented product ‘Follow-On/-Up Milk’ have been exploited by formula companies in order to advertise first milks (Faircloth, 2006). Globally, formula milk represents the fastest growing market in the world, with sales between 1987–2013 rising by $38 billion. While sales in high-income countries have plateaued, in developing countries formula use is rising fast, putting the health of poor children at great risk. In 2009, the markets in Nigeria and Vietnam both grew by 18% (Brown, 2016).  

The increasing globalisation of trade, predominantly based on the neoliberal political model, has opened up new markets to companies like Danone, Abbott and Nestlé. While some dream that freeing up trade regulations may lead to a reduction in the developing world, others worry that trade de-regulation will lead to legal limitations being placed on individual states that would frustrate their efforts to stop corporations marketing unhealthy products. In 2003, when Mexico tried to increase a sugar tax, US agribusiness sued them for $100 million (claiming discrimination) (Provost, 2016). It has been argued (Fooks, 2013) that the proposed Transatlantic Trade and Investment Partnership (TTIP) would allow tobacco company Phillip Morris to sue the UK for its introduction of plain packaging. It could therefore be envisaged that such a legal precedent could endanger protective legislation around breastfeeding.

Similarly, while some see linking up with private companies in partnerships for health as the practical way forward, IBFAN expresses concern about programs like ‘Scaling Up Nutrition,’ stating that “These Platforms can give businesses and their front groups unprecedented opportunities to influence the setting and shaping of nutrition strategies and policies.” (IBFAN, 2012). McMichael (2009) reminds us that corporate responsibility is often “little more than cosmetic” and suggests that “corporate accountability” may be more appropriate. The international code was created specifically in order to hold formula companies to account.

The formula industry is a many headed, multi-billion-dollar industry. According to Brown (2016) they spend $6 billion a year in advertising, many times more than budgets to promote breastfeeding. The battle to keep them at bay can sometimes seem overwhelming. In the face of such challenges, promoting breastfeeding means taking a stance against the commercialisation of society, and where individuals and organizations cannot succeed, politicians may need to enter the fray.

“Politicians don’t breastfeed our babies, but they have significant influence on whether our babies are breastfed or not.” (Brown, 2016, ch.7)

The Feeding Products for Babies and Children (Advertising and Promotion) Bill put forward by Alison Thewliss Member of Pariament, which aims to curb the ways formula companies market their products, seeks a crack-down on adverts on social media and in parenting clubs, prohibition on advertising in health journals, and a ban on advertising for the totally unnecessary invention ‘follow-on milk.’

The MP reiterated:

“I absolutely understand and respect that some families will choose to use formula milk; this is absolutely not about breastfeeding versus bottle feeding. I want to make sure parents are protected from misleading advertising and can access impartial, trusted information when making feeding decisions.”

In the face of the many challenges facing health promoters, Dixey (2012, p.71) advises “practicing optimism as an act of political resistance.” Those who care about breastfeeding must stay optimistic; the cost of inaction is too high.

Alice Allan grew up in rural Devon then studied English at Cambridge University. She worked as an actress and a corporate trainer in London and Tokyo, then as a lactation consultant in public hospitals in Addis Ababa, Ethiopia, where she taught about breastfeeding, skin-to-skin and kangaroo care for premature babies. She has written for a number of publications including The Telegraph, The Sunday Express, the Ethiopian Herald, The Green Parent and The Mother Magazine. She currently lives in Tashkent, Uzbekistan with her diplomat husband, two daughters and a large Ethiopian street dog called Frank.

Her novel, Open My Eyes That I May See Marvellous Things is published by Pinter and Martin. Set in Ethiopia, it tells the story of an adopted midwife who falls in love with an abandoned baby, and asks, “How can you hold a baby next to your skin without it touching your heart?” It is available from Amazon, pinterandmartin.com and good bookshops. www.aliceallan.co.uk Twitter: @alicemeallan and find her on Facebook.

June 2018. VOTE for Alice Allan’s Open My Eyes in The People’s Book Prize!

References

Allain, A., & Kean, Y. (2008). The youngest market: babyfood peddlers undermine breastfeeding. The Free Library (July, 1), 29(1),17.

Brown, A., (2016). Breastfeeding Uncovered: Who really decides how we feed our babies? Pinter and Martin, London.

BBC. (2016). Turkmenistan. (December, 11).  The regime that throws cigarettes on bonfires.

Burrows, T. (November, 11, 2016). Mother who can’t breastfeed her five-month-old baby blasts Tesco after staff refuse her a parking refund because she is buying formula milk. Mail Online.

Clark, D. & Rudert, C. et al. (2011). Breastfeeding: A Priority for UNICEF. Breastfeeding Medicine, October, 6(5), 349-351.

Dixey, R. (Ed.) (2012). Health Promotion. Global Principles and Practice, CABI, UK. p.5.

Faircloth, C. (2006). A weak formula for legislation: how loopholes in the law are putting babies at risk. UNICEF.

Fooks, G. & Gilmore, A. (2013). International trade law, plain packaging and tobacco industry political activity: the Trans-Pacific Partnership. Tobacco Control (June 2013). doi: 10.1136/tobaccocontrol-2012-050869.

Huang, R. & Yang, M. (2015). Paid maternity leave and breastfeeding practice before and after California’s implementation of the nation’s first paid family leave program Economics and Human Biology, 16, 45–59.

IBFAN. (November 2012). The scaling up nutrition (SUN) initiative IBFAN’s concern about the role of businesses. DISCUSSION PAPER.

Larsen, E. & Mandlesen, E. (2009). “A good spot”: Health promotion discourse, healthy cities and heterogeneity in contemporary Denmark. Health Place. 2009 Jun;15(2):606-13. doi: 10.1016/j.healthplace.2008.10.001. Epub 2008 Nov 1.

Linnecar, A. & Gupta, A., et al. (2014). A Formula for Disaster: Weighing the Impact of Formula Feeding Vs Breastfeeding on Environment, IBFAN Asia.

McMichael, A. & Bonita, R. (2009). Global Public Health: A New Era. Oxford Scholarship Online , Chapter 1.

Muller, M. (1974). The Baby Killer. War on Want, London, p.5. http://media.waronwant.org/sites/default/files/THE%20BABY%20KILLER%201974.pdf

Palmer, G. (2009). The Politics of Breastfeeding: When Breasts are Bad for Business. Pinter and Martin, London, p.7.

Provost, C. (February, 2016). Taxes on trial. How trade deals threaten tax justice Transnational Institute.

Rogers, N. et al. (2010). Colostrum avoidance, prelacteal feeding and late breast-feeding initiation in rural Northern Ethiopia. Public Health Nutrition, 14(11), 2029–2036.

Sacker, A. & Kelly, Y., et al., (2013). Breast feeding and intergenerational social mobility: what are the mechanisms? Archives of Disease in Childhood, 98, 666–671.

Save the Children. (2013). Superfood for Babies. How overcoming barriers to breastfeeding will save children’s lives.

Victora, C. et al., (2015). Association between breastfeeding and intelligence, educational attainment, and income at 30 years of age: a prospective birth cohort study from Brazil. Lancet Glob Health, 3: e199–205. glo/article/PIIS2214-109X(15)70002-1/abstract.

Victora, C. et al. (2016). Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect, The Lancet 387(10017) 475–490. 

World Health Organization. (1981). International Code of Marketing of Breast-Milk Substitutes.

World Health Organization, UNICEF, IBFAN. (2016). Marketing of breast-milk substitutes: National implementation of the international code. Status Report 2016.