Rowena Merritt, DPhil, BSc
Expected Key Learning Outcomes
Definition of the World Health Organization (WHO) Code or Milk Code
Reasons breastfeeding rates remain so low despite the WHO Code
Reason for the market success of formula milk
Strategies to promote breastfeeding
In the mid-20th century, the promotion of breastfeeding rose rapidly as a response by public health professionals to the increasing number of women who were opting to use formula milk. These efforts were supported by the introduction of the International Code of Marketing of Breast-milk Substitutes, otherwise known as the Milk Code, which was adopted in 1981 by the Health Assembly of World Health Organization (WHO) and UNICEF. The aim of the code was to ‘contribute to the provision of safe and adequate nutrition for infants, by the protection and promotion of breastfeeding, and by ensuring the proper use of breast-milk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution’ .
The introduction of the Milk Code has been a significant achievement despite often being met with strong opposition from the formula milk companies. Within the first three years, 130 countries had passed legislation or formulated policies to restrict advertising . In Iran, for example, formula milk is obtained only via prescription and the packaging must be a generic label with no brand names or promotional messages. In Brazil, no advertising or promotion of breast milk substitutes is allowed for children younger than two years and, in Papua New Guinea, there is a ban on the advertisement of feeding bottles, cups, teats, and dummies, with sales very tightly controlled .
Large corporations such as Nestlé have also committed to the Milk Code in the developing world and higher risk countries, by implementing many different methods in order to obey the Code. These include not ‘advertising of infant and follow-on formula for babies under 12 months of age’ , and not labelling, promoting or selling complementary foods or drinks for infants under six months of age unless otherwise mandatorily required by local code or measures . Many may postulate that companies such as Nestlé only made such a commitment following the negative media they received previously due to their aggressive marketing in the developing world , and are using it to ease the criticism. However, it can also be argued that babies in vulnerable countries still benefit from the move.
There are, however, a number of loopholes within the Code that have been exploited by formula milk companies. At the time the Milk Code was written, all formula milk was known as “infant formula”. The manufacturers of breast milk substitutes thus created the concept of “follow-on formula” as a reaction to the Code. They claimed that formula milk for children over six months was not a breast milk substitute and therefore did not have to comply with the marketing regulations of infant formula .
There have been numerous reports of countries breaking the Code , . This situation has also perhaps been exacerbated by a suggested lack of awareness of the Code. For example, in 2008, 70% of 427 health professionals in Pakistan were unaware of their own breastfeeding laws and 80% were unaware of the Code; 12% had received sponsorship from pharmaceutical companies for training sessions or attendance at conferences, giving them a vested interest to promote formula milk . This example from Pakistan is by no means unique and is the situation in many other countries that have the Code in place .
In addition to the introduction of the Code, many national and local health departments have developed materials and advertising campaigns to try and encourage breastfeeding. Many of these campaigns have focused on the health benefits of breastfeeding (for both child and mother), and some the emotional bond that breastfeeding can create.
In the USA, an advert sourced as being from the US Surgeon General and the National Institutes of Health, stressed the health benefits of breastfeeding for both mothers and children, including reduced risk of obesity for the baby, and reduced stress and postpartum depression rates for the mother . In the UK, as with the US, adverts have communicated health benefits through the brand Start4Life, such as ‘Breastfeeding lowers your risk of breast cancer and ovarian cancer’ and ‘Breast milk boosts your baby’s ability to fight illness and infection’ (National Health Service [NHS], ). In Mexico City, the government launched an advertising campaign with a slogan that translates as ‘give your breast to your child, don’t turn your back on them’ .
These health messages are not always well received by mothers and the evidence base behind them is questioned. This was illustrated by the response to the Mexican City advert, where mothers and women’s groups stated that the government was ‘guilt-tripping women instead of addressing real-life barriers to breastfeeding’ . Claims around the link between obesity and breastfeeding have also been queried .
Despite the apparent backlash, promotional activities counteracting the effectiveness of the advertising of formula milk companies are critical, particularly in the non-developed world. In less developed countries, there are severe dangers of using formula milk, as the inability to access clean water and insufficient sterilisation of bottles can lead to grave consequences such as infection or even mortality , . Consequently, effective support structures have been put in place. In Africa, for example, UNICEF have intervened at the community level, creating community structures such as mother-to-mother groups, health system support to breast feeding, and health workers . UNICEF have also initiated breastfeeding campaigns, such as one showing a women breastfeeding on a farm, with the advert reading ‘Breastfeeding and work, let’s make it work’, and another with a woman breastfeeding in a factory, with the advert stating ‘Breastfeeding is universal, protecting children everywhere and giving them the best start in life’ .
Despite the progress that has been made by the Code, as well as the promotional work, there is much work still to be done. Breastfeeding rates (exclusive for the recommended six-months) remain low in many of the developing and developed world countries that have both introduced and enforced the Code, and invested heavily in health promotional campaigns.
Recent figures from Germany show that at three months around 40% of babies are exclusively breastfeeding and at six months around 22% are exclusively breastfeeding . In Haiti, in 2008– 2012, early initiation of breastfeeding occurred in just 46.7% of cases, with the proportion falling to 39.7% for exclusive breastfeeding at six months . In the UK, the Infant Feeding Survey in 2010 showed that 81% of mothers initially breastfed their infants. However, the prevalence of breastfeeding fell to 69% at one week and to 34% at six months, making infant formula an important source of nutrition for many infants .
With the focus of health promotional materials on health benefits, it might be assumed that the main barrier to uptake and continuation of breastfeeding is a lack of women’s knowledge of its benefits. However, this is not always the case; a recent survey showed that 83% of women in the UK knew of the health benefits of breastfeeding regardless of the feeding method they chose . This shows that awareness and knowledge is not always the main barrier, and that mothers will not always chose to breastfeed.
It might also be easy to blame the low breastfeeding rates on the remaining aggressive advertising still underway. The UK Infant Feeding Survey also highlighted that 46% of mothers said that they had seen an advert for first-stage formula milk, despite such adverts being banned, and when asked for reasons as to why they used formula milk, 18% of mothers said that it was better for the baby or had more nutrients . However, is it maybe time to appraise the existing promotional work done by government health departments critically and take some of the formula milk industry’s successful tactics and use them for social benefit as opposed to increasing profitability? As Professor Gerard Hastings, who has used similar tactics with the tobacco industry, stated: ‘Why should the devil have all the best tunes?’ .
Critical marketing ‘seeks not to just determine what is “wrong and bad” about commercial marketing, but to reflect on its nature, learn from its successes, and analyse its weaknesses’ . The use of critical marketing in anti-tobacco work is well established and clearly needed as in the late noughties, when the European ban on tobacco advertising was being debated, it was estimated that the tobacco industry had more than 200 lobbyists in Brussels .
Critical analysis of commercial marketing has resulted in the development of an extensive and convincing evidence base showing that marketing can influence behaviour. This is demonstrated by research conducted by the National Consumer Council in the UK, which showed that the average British child today is familiar with up to 400 brand names by the time they reach the age of ten. The study also found that 69% of all 3-year-old children could identify the McDonald’s golden arches, while half of all 4-year-olds did not know their own surname .
Competition is a fact of commercial life in that business is driven by the law governing the survival of the fittest and that any potential threats are turned into an opportunity by studying the activities of competitors. Thus McDonald’s will carefully analyse Burger King’s offerings to help work out their own efforts, and Cow & Gate will carefully monitor SMA and all the other competing brands’ marketing strategies.
In the same way, those working to promote breastfeeding can gain the same insights about their customers by studying the commercial formula milk companys’ successes and failures. By answering questions such as ‘What messages do the competition promote? How do they make mothers feel?’, and ‘What communication channels do they use?’ These questions are explored in further detail in the remainder of this chapter. Health promoters can gain insights into how the formula milk industry’s marketing is used to encourage formula milk use, and hence do the opposite.
Formula milk and other commercial companies develop their marketing strategies on comprehensive customer understanding. The industry takes great care to know its customers using a combination of ethnographic research and detailed segmentation studies. To do this they often allocate a substantial amount of budget to gain an in-depth picture of their target audiences’ lives. It is unclear what formula milk companies spend on gaining this customer understanding and usually budget depends on industry type, product type, market conditions, product life cycle, and many other factors. However, a 2013 survey of commercial companies conducted by the consulting firm, Frost and Sullivan, found the average market research spend as a percentage of revenue was 1%; that being, a company with revenues of $100 m spends about $1 m on marketing research .
It is unlikely that those working to promote breastfeeding will ever have access to budgets that commercial companies enjoy. Therefore, to develop effective campaigns and tailored services that result in the desired behaviour (i.e., increasing the number of women who choose to breastfeed exclusively to six-months), issues from the perspective of mothers need to be fully understood. Health promoters need to understand,
What benefits do mothers gain from bottle feeding (perceived and actual)?
What are the barriers to breastfeeding from the mother’s perspective (perceived and actual)?
Who do mothers listen to and trust (who are the main influencers in their lives)?
How does breast/bottle feeding make the mother feel (positive and negative emotions)?
What pressures are mothers facing in their day-to-day lives (not just in relation to breastfeeding, but looking at the person overall)?
By answering these types of questions, health departments can develop more effective campaigns and services, which do not simply promote the health benefits but overcome some of the barriers faced by mothers.
The good news is that health promoters do not need to start from scratch as the existing literature provides an understanding of the main reasons why mothers “give up” on breastfeeding early (despite them often stating that they had wanted to carry on and/or regretted their decision to stop), and the perceived benefits mothers receive from bottle feeding.
In summary, reasons for “giving up” vary but include the need for mothers to return to work, fear the baby is not drinking sufficient milk , , and more commonly, the “inconvenience or fatigue associated with breastfeeding” . Additionally, an inability for the baby to “latch on”  and being able to share the feeding task  are often cited.
Added to this, it appears that there are a number of unrealistic expectations with regard to breastfeeding, partly because the antenatal breastfeeding preparation often ‘makes it sound so easy’  and promotional materials present a romantic view of breastfeeding. Many mothers and fathers feel that the preparation they were given ‘did not prepare them well for reality’. Early discharge from hospital was also a primary concern for new mothers who did not particularly want to extend their stay. This concern was prioritised over learning how to breastfeed correctly. As such, mothers felt if they gave their baby formula milk it would expedite discharge .
Formula milk companies currently position their brands alongside the responsible and hard-working mother who wants to do their best for their child and, in some developing countries, formula milk is positioned as the sophisticated choice . The companies use aspirational images, and sympathise with the mother about how hard raising a child can be, stressing that they are doing a good job – words all tired mothers want to hear. This is demonstrated in the SMA follow-on milk advert on UK television, which highlights the struggle that having a baby can be,
‘At SMA our follow-up milk is supported by 90 years of advancing baby nutrition and over the years we’ve really got to know mums, so take it from us you’re doing great’ .
Other examples of advertising messages include:
A HiPP organic campaign played on the lack of sleep new mothers may experience, with their advert stating ‘Now everyone can get a good night’s sleep’. In reality, mothers of formula-fed babies do not sleep more than breastfeeding mothers . However, adverts suggesting that babies will sleep at night are likely to appeal to mothers who are usually suffering from sleep deprivation, while building on the widespread belief that formula milk-fed babies sleep for longer between feeds , .
The Aptamil Follow-on Milk Today for Tomorrow TV advert cleverly uses breastfeeding to promote the product by claiming that ‘Breastfeeding provides them with the best start in life, inspired by 30 years research in breast milk, our researchers created Aptamil follow on milk’ . This reassures mothers that they are giving their child something “just as good” as breast milk and, therefore, there is no need to worry about the dangers of not breastfeeding. This again is exactly what mothers want to hear, especially as many feel guilty about not breastfeeding or discontinuing before the recommended time .
In Russia, Enfamil promotes how their milk can help support the intellectual development of the baby: ‘A mother’s love and the right nutrition can do miracles. Enfamil premium – for a complete development of the brain’ (Enfamil, ). This tactic is also used by other companies that suggest that the added ingredients in formula milk improve intelligence (Alpha Parent Blog, ). This appeals to many mothers who desire for their children to achieve academically and have successful careers .
Another highly effective formula milk advert was the Cow & Gate Laughing Baby advert. A laughing baby can do nothing but make you smile and, more importantly, mothers want that for their child . They also released an advert with the soundtrack ‘If you are happy and you know it...’ . Both adverts highlight Cow & Gate’s 100 years of experience, capitalising on the trust a mother would place in them and the added “essential” nutrients their formulas contain.
In essence, it appears that formula milk companies attempt to reassure mothers that bottle feeding is not bad for their baby and that they should not feel guilty about giving up breastfeeding (something we know many mothers do feel, and one of the reason why they cite health reasons for stopping breastfeeding early) . The benefits for the baby are stressed rather than the negative consequences of not breastfeeding.
In some countries, promotional messages about formula are coupled with the development of a “trusted” sales force of healthcare professionals who provide free samples of formula milk to mothers and distribute branded promotional gifts. Internet marketing through company websites and social media forums also provide mothers with access to information and advice from healthcare professionals.
In the UK, through Cow & Gate’s website, mothers can chat online with healthcare professionals and gain instant responses, which is important for mothers who are anxious and stressed. The company also offers a first-infant milk starter pack, containing six 70 ml bottles, six teats, and a cuddly toy. The Aptamil start-up pack also contains these items but additionally is pre-sterilised and ready-to-use. For a struggling, tired, and stressed mother, a simple, ready-to-go, easy-to-use, and understandable pack is all that is needed. In contrast, for breastfeeding, a new mother will at most receive a simple booklet.
In Hong Kong, one mother claimed she received ‘a set of toys that would cost HK$599 at Toys ‘R’ Us for free when I ordered HK$1,200 of milk formula’. It was also noted that the first 200 customers who brought six cans of milk formula received a free set of Fisher-Price toys . In the US, many mothers are given discharge bags when leaving hospital, containing promotional materials about formula milk; a national survey reported that 91% of US maternity hospitals distributed company-sponsored discharge packs .
In other countries, particularly low- and middle income countries, formula milk company representatives have offered financial incentives to healthcare professionals for promoting their products in countries as diverse as Ukraine, India, China, Indonesia, the Philippines, Togo, Burkina Faso, and other parts of Central and West Africa . In China, it is reported that formula milk companies have been provided contact information on new births for the purpose of product promotion by healthcare professionals .
This aggressive marketing has led to bottle feeding becoming a social norm in many communities, with generations of women being bottle fed by their mothers. In turn, when these women have become mothers themselves, they too have often opted to bottle feed due to unsupportive social norms . The effects of this marketing is further bolstered by the formula milk adverts where parents are encouraged to buy formula milk and are able to justify their actions despite the best efforts of breastfeeding initiatives.
Despite the introduction of the Code and the restrictions it imposes on promotional work, formula milk is marketed directly to mothers through mass media, printed advertisements, and indirectly via incentives, free samples, and through health workers. Internet marketing by company web sites and social media is also on the rise .
The marketing efforts of formula milk companies have successfully positioned formula milk as a sophisticated and modern choice, which mothers should not feel guilty about using as it is comparable to (or better than) breast milk. Given the massive advertising budgets available for infant formula companies , it would be almost impossible for health promoters to directly influence the purchasing behaviour of their customers. However, healthcare professionals can learn from the way these companies position their products and engage with healthcare professionals.
Such product positioning could be used to the benefit of breastfeeding, to develop campaigns to generate the significant media and public awareness needed to put pressure on product “distributors”, and to force regulators to introduce tougher controls on the marketing of infant formula. Moreover, such action could help public health teams develop integrated public relations and marketing strategies that resonate with mothers on an emotional level, rather than solely being a health information-giving exercise.
The WHO Code is a set of recommendations to regulate the marketing of breast-milk substitutes, feeding bottles and teats that requires incorporation into a countries legal system in order to become effective
The WHO Code is not incorporated into law in many countries and even where it has, monitoring is difficult, leaving formula companies with many loopholes to exploit
Formula companies have substantial budgets at their disposal to successfully position formula milk as a sophisticated and modern choice as well as to incentivise doctors and health workers to recommend it to mothers
Formula companies are very successful with their sophisticated marketing campaigns focusing on the needs of the mother and maybe it is time for breastfeeding promotion and communication to learn from their strategies