Tackling marketing of formula milk: process matters
Authors: None The Lancet Global Health
Journal: The Lancet Global Health (2022)

At the end of February, WHO and UNICEF launched a co-commissioned report on the impact of marketing of breast-milk substitutes in infant feeding decisions and practices. The report received significant global media coverage with the headline that 51% of parents surveyed have been targeted by formula milk companies. The messages are stark. Formula milk marketing was found to be “pervasive, personalized and powerful” and used distorted science to manipulate and exploit parents’ anxieties and aspirations, undermining their confidence in breastfeeding. The report makes clear the issue is marketing practices around formula milk, not the product itself, and acknowledges that formula milk “has its place for women who are not able to, or do not want to breastfeed”. Such acknowledgment is of paramount importance. Just as parents’ strong desire to nourish their babies should not be manipulated by sophisticated yet misleading marketing of breastmilk substitutes, neither should they be judged for not breastfeeding. Guilt and shame are very effective motivators of human behaviour that can be misappropriated even when the behaviour itself is positive. The need for enquiry into such practices is clear for two reasons. First is the lack of ambiguity around the benefits of breastfeeding. The strength of evidence, contributed to by The Lancet series on breastfeeding, is a level advocates for few other priorities can enjoy. Second is the existence of the International Code of Marketing Breastmilk Substitutes. The Code, published by WHO in 1981, alongside subsequent additions and refinement through successive World Health Assembly resolutions, together provide a regulatory framework national governments can incorporate into legislation. Yet governments can also choose not to adopt the Code and, as highlighted in this report, alignment of national legislation with the Code is variable, and enforcement of such legislation, where it exists, is rare. Although the conclusions of this report are unlikely to be new to those with knowledge of the history of the formula milk marketing, the fact WHO and UNICEF commissioned M&C Saatchi World Services to design and conduct the research behind the report is noteworthy. The advertising and communications agency's research division designed and implemented the research protocol and analysed all data. The research, conducted over two years between August 2019 and August 2021, surveyed 8500 pregnant women and mothers of young children up to 18 months of age, and 300 health professionals across eight countries—Bangladesh, China, Mexico, Morocco, Nigeria, South Africa, the UK, and Vietnam. Over 100 focus group discussions and 80 in-depth interviews were conducted. Methods “were designed by a team with communication and behaviour change expertise as used in commercial marketing with the aim of collecting data and insights as if to inform development of a commercial marketing plan”. Deviating from standard public health and epidemiological approaches, “Study participants and data collected were not intended to be representative of national populations but were sampled from groups considered to be trendsetters”. Innovative, interdisciplinary approaches to research, policy, and implementation are desperately needed to achieve progress towards the Sustainable Development Goals (SDGs); breastfeeding is a prime example of a health behaviour that has multiple benefits across various SDGs. It is imperative we fully understand the mechanisms and impact of formula milk marketing on breastfeeding. However, the methods and results of the research conducted by M&S Saatchi are “currently in press”. At a time when public trust in science is so fragile, sharing research methods and results in advance or alongside the publicising of findings could go a long way to safeguarding public confidence in such reports. Global agencies such as WHO and UNICEF are uniquely placed to more openly demonstrate how the highest standards of scientific rigour are upheld, alongside innovative strategies to effect policy and behaviour change at scale. More timely transparency of research for this report would conserve momentum now needed for collective action to advance the health and wellbeing of families everywhere. International recommendations to eliminate reprehensible infant formula marketing practices have been flouted for too long. The actions called for by this report—robust, enforceable regulation, including of digital platforms, and strengthened conflict of interest policies—are welcome and urgent.