By Dr Nazeeia Sayed, Researcher, School of Public Health, University of the Western Cape (UWC) | DSI-NRF Centre of Excellence in Food Security (co-hosted by UWC and the University of Pretoria)
The views expressed in this article reflect my personal experience as a breastfeeding mother and health care professional who has worked with breastfeeding mothers in South Africa*
“How we feed and care for our young has a lifelong effect on individual, societal, and environmental wellbeing” – 2023 Lancet Series on Breastfeeding – Paper 2
I ended my breastfeeding journey with my daughter 14 and a half years ago, just before she turned two. I had expressed and fed her breast milk for the first month as we encountered latching problems after her stay in ICU at birth (I was pre-eclampsic – she was low birth weight). I experienced engorgement after pumping like crazy for the first three days, and both of us crying as I tried (unsuccessfully) to feed from the breast. But I also remember the many delightful hours holding and feeding her (she finally latched in month two!), and one of my favourite memories is of a toddler walking up to me when I got back from work for ‘doodoo’ (milk). Breastfeeding taught me patience, presence and persistence. It is the one action I am most proud of accomplishing. But it was tough at times. Without my firm resolve that this was something I had to do, as it was best for my child, and without the support at home and from my workplace, it would have been so easy to consider alternative feeding.
My relationship with breastfeeding blossomed over 20 years ago when I started teaching nutrition and dietetic students about breastfeeding and lactation management. I have spent a lot of time with students in maternity wards, counselling and assisting mums** and answering questions mums had about breastfeeding. Listening to the recent global launch of the 2023 Lancet Series on Breastfeeding1, and the local launch in South Africa, I couldn’t help but wonder what the real impact of our efforts were, given the enormous battleground of industry influence and health system failures that the series highlights.
Bottom-line vs. breastfeeding
“A systematic scoping review that included 153 studies showed how marketing practices in violation of the Code have continued in nearly 100 countries and in every region of the world since its adoption in 1981. The review showed that all major CMF (commercial milk formula) manufacturers are implicated and that claims of Code compliance by several companies are not true” – 2023 Lancet Series on Breastfeeding – Paper 2
Headlines following the launch have focussed primarily on the controversy surrounding the predatory marketing tactics and unsubstantiated claims made by commercial milk formula companies, and how they have commodified what should be regarded as normal infant behaviour, e.g. crying, and short night-time sleep duration. We have heard of transgressions against WHO’s International Code for the Marketing of Breast-milk Substitutes before, but the series discloses even more insidious lobbying tactics and political persuasions. The series comprises three main papers1 that articulate the challenges and recommendations to achieve optimal breastfeeding. I was struck by the third paper’s discussion on the strong hand of lobbying and highly funded efforts to thwart the progress of actions that could limit company growth plans. When this is considered against the good corporate citizenship image portrayed by companies, it does not add up that an interest in improving child health, and investment in activities that have a societal benefit, and a positive impact on the environment is really of interest to these companies. The behaviour and actions revealed by the series show underhanded actions only to benefit the company bottom-line, largely at the expense of lower-income countries.
“… global CMF (commercial milk formula) sales grew 37-fold between 1978 and 2019, from US$1∙5 billion to $55∙6 billion annually. Nestlé, Danone, Reckitt, Mead Johnson, Abbott, Friesland Campina, and Feihe dominate today’s global market, collectively controlling 60% of CMF sales in 2021” – 2023 Lancet Series on Breastfeeding – Paper 3
“… claims must be considered against the substantial negative externalities that the industry generates (panel 4). These negative externalities include adverse health outcomes for women and infants and young children; the related economic burden of higher health-care costs, reduced cognition, and workforce productivity; the diversion of household expenditure from basic foods, medicines, and health care; and the environmental harms associated with dairy production, CMF manufacturing, and packaging waste” – 2023 Lancet Series on Breastfeeding – Paper 3
When I was still in training, a highlight in our student calendar was when formula milk companies came to visit and tell us about their products, and, of course, we walked away with a bundle of branded goodies, distributed by very smartly dressed health professionals. The formula company-sponsored meetings and events at congresses were the glitziest and drew large crowds. We were blissfully unaware that we were being set up as ‘category entry points’, as the series calls it. While that scenario is, fortunately, changing in our country, we know that company representatives still call on medical doctors in South Africa. This personal marketing tactic must have payoffs for the company that continues to invest in them. A medical doctor who opened a new practice in 2022 told me they had a professionally dressed person in a fancy, expensive car come visit within the first two weeks of opening. He said that the receptionist thought it was someone with very important business, but it was just a formula company rep.
Searches, social media, sensitivity
I still have the baby book my mother received in hospital in the 1970s; it makes for interesting reading! The communication to mums on formula milk feeding is more subtle, and slicker now: as the series highlights, personal data from web searches and social media monitoring are among the tools used to target pregnant and breastfeeding mums, and then, market formula to them.
Returning to my own journey as a mother who breastfed, my experience in hospital was distressing. I received no breastfeeding counselling or support with the first latch, and there was no rooming-in until I insisted (but the nurses would bring my daughter to me when she was awake, as I indicated that I wanted to breastfeed). I expected the offer of formula (which came regularly, so I could ‘rest’), but not the young new paediatrician who had me demonstrate I could breastfeed on a cold hard chair in the middle of the neonatal ICU (addressing the nurses and not me).
The custom of spending some time in one’s own mother’s home after giving birth, as I did, is fantastic. I could focus on myself and my baby, and have the time and energy to breastfeed. I was blessed to have a very supportive family environment for breastfeeding, and a wonderful manager who approved my unpaid leave for an extended time, and who accommodated me pumping at work, as well as travelling with my baby to work meetings that required me to be away overnight.
I am grateful for my personal breastfeeding journey, and the many mothers who have shared their questions and concerns with me. It has made me aware of the realities that many mothers face, and the type of support they need. I try to bring this awareness to my students to not just talk theory to mothers, but to ask about the reality of mothers, and probe — sensitively — for issues that a mother may at first be reluctant to discuss in a counselling session. And this includes supporting a mother who chooses to formula feed.
Support for breastfeeding, support for mothers
My colleague, Dr Catherine (Katie) Pereira-Kotze’s PhD focussed on workplace support for breastfeeding mothers in South Africa, and she presented her main findings to the Department of Labour on 22 February 2023. Let’s hope policymakers take note of the urgent situation and make a commitment to revise labour regulations. My recent research paper showed that hungry mothers were less likely to breastfeed3; the odds of hungry mothers breastfeeding were significantly lower (OR = 0.66; p = 0.045). This finding highlights, again, that support for breastfeeding cannot be separated from support for mothers. The DSI-NRF Centre of Excellence in Food Security also hosts the Infant and Young Child Feeding Advocacy project, which aims to create an environment in South Africa where women are not unduly influenced by infant formula marketing. The advocacy campaign should launch this year, and the impact this has is eagerly anticipated.
We must take advantage of the global attention and current momentum around breastfeeding, and connect with colleagues in other disciplines like politics, law and economics, where we can combine minds and efforts to improve breastfeeding. With improved breastfeeding rates we will have benefits across all sectors of society: better health for infants and their mothers, improved productivity, reduced healthcare expenditure, and even a reduced environmental impact. It’s a win-win for all — except the commercial milk formula industry.
When it comes to the topic of breastfeeding, we are certainly not short on passion and energy of people who want to make a positive difference in this space. We cannot compete with large corporate marketing budgets, but we need to see all efforts as investments in our future, and not just expenses. While it may take longer for policy changes to take effect to improve the breastfeeding situation, we can each start where we are now, in our own families, communities, and workplaces – talking about breastfeeding, and supporting breastfeeding mums. This call to action is echoed in the series.
“However, despite many calls to invest in breastfeeding, governments rarely allocate necessary budgets. Instead, superficial campaigns with slogans such as “breast is best” substitute for more difficult and costly measures addressing the sociocultural, economic, and commercial determinants of infant and young child feeding” – 2023 Lancet Series on Breastfeeding – Paper 3
“To breastfeed or CMF feed is not a genuine choice if breastfeeding means that women and families must forego employment and secure livelihoods” – 2023 Lancet Series on Breastfeeding – Paper 3
With all the other global challenges we currently face, we must realise that breastfeeding cannot improve unless we have a more equitable society where the rights of women and mothers — and, by direct implication, their children — are realised.
*Disclaimer: I am not against formula and mums who chose to formula feed; I am against the marketing and influencing tactics of CMF companies. I stand for supporting mums with correct information and removing societal barriers that make it difficult to breastfeed.
**Please note that no disrespect is meant with the use of the term ‘mum’/women/mother – it is duly recognised that individuals who identify differently can also breast/chest feed.
1) THE 2023 LANCET BREASTFEEDING SERIES: https://www.thelancet.com/series/Breastfeeding-2023
PAPER 1: Pérez-Escamilla et al. (2023) Breastfeeding: crucially important, but increasingly challenged in a market-driven world. The Lancet.
PAPER 2: Rollins et al. (2023) Marketing of commercial milk formula: a system to capture parents, communities, science, and policy. The Lancet.
PAPER 3: Baker et al. (2023) The political economy of infant and young child feeding: confronting corporate power, overcoming structural barriers, and accelerating progress. The Lancet.
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