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The trouble with milk…

Laura Godfrey-Issacs – Midwife
Recently, I observed, with horror, a major midwifery conference and awards sponsored by two Breast Milk Substitute companies (BMS), and many midwives I know and respect, seemingly co-opted to promote them as a result – it caused me to reflect, again, on the highly complex issues around breastfeeding and infant feeding, and on our professional responsibilities as healthcare professionals to be free from commercial influence and pressure.

In her seminal book ‘The politics of Breastfeeding’ (2009) Gabrielle Palmer suggests ‘our era is the first in recorded history where the breast has become a mass fetish for male sexual stimulation, while at the same time its primary function has diminished on a vast scale’. This can be charted through art, media, pornography and the beauty and fashion industry, where the breast is constantly projected as youthful, sexual and available, at distinct odds with the nurturing, maternal breast (Palmer.G, 2009; Blum.L.M, 1999). This objectification of the female breast and contradiction between its role as sexual object and nurturing site, can lead to intense cultural anxiety around breastfeeding, which effects both women’s inclination to breastfeed in public, and the initiation and duration of breastfeeding (Johnston-Robledo et al, 2007: Blum.L.M 1999. Carter.P 1995). In a recent pole, for example, 21% of mothers preferred not to breastfeed in public, due to fears of unfavourable reactions from the public, and 34% have felt embarrassed or uncomfortable whilst doing so (Start4Life, 2015).

The Politics of breastfeeding

‘The Milk and the Blood’ (203) by Helen Sargeant

Whereas some may see breastfeeding as a relatively minor, apolitical, private concern, based purely around maternal ‘choice’ in infant nutrition i.e. ‘breast or bottle’, globally, nationally and individually, breastfeeding is revealed as a highly charged, cultural, psycho-social and politicized issue, subject to fierce debate between interest groups, individual women and in the media (WHO, 2003; Renfrew et al, 2009; Hausman, 2003; Boswell-Penc, 2006;

Palmer, 2009; Hall Smith et al, 2012; Brown, 2016).

Furthermore, breastfeeding has been identified as a major public health matter, which ‘cuts across health, education, social protection, child protection, trade and commerce portfolios’ (McFadden et al, 2015), and has been championed by global policies since the mid 20th Century. The stakes are high, with statistics suggesting that the lives of 800,000 babies a year could be saved, if they were breastfed to WHO recommended levels (WHO, 2015). In addition, it is asserted that exclusive breastfeeding could reduce the over 7 million babies a year who die due to direct or indirect malnutrition, as well as lower the rate of childhood obesity, impact on the incidence of non-communicative diseases over a lifetime and improve maternal health (WHO, 2003; 1000 Days, 2016).

Historical trends

Historically, the reasons for the progressive lowering rates of breastfeeding, which has occurred since the late 19th century are complex, and include the combined effects of; industrialisation, urbanisation and globalisation. Breastfeeding is also a complex cultural practice that is heavily prescribed by issues of classism, racism and ethnocentrism (Palmer, 2009; Fildes, 1986), and has been profoundly affected by cultural and social shifts (Palmer, 2009; Baumslag & Michels, 1995). These have included the 1st, 2nd, 3rd and now 4th wave of feminism, which has both supported and problematized breastfeeding as a maternal practice (Schuster, 2013). Breastfeeding is also intimately connected to issues of gender equality, and human rights, for both women and children (Palmer, 2009). An example of this complexity is suggested by trends, stratified in Western societies, which shows breastfeeding to be a marker of privilege, with distinct racial and socio-economic disparities, where white, educated mothers are most likely to breastfeed ‘successfully’ and therefore be seen as ‘good mothers’, perhaps due to their enhanced social and economic capital (Blum, 1999). This leads some to see the development of breastfeeding advocacy in the 21st century as a ‘medicalised, expert, disciplinary and consumerist regime’, which could be seen to oppress women, particularly from disadvantaged backgrounds (Avishai, 2011).

The global Breast Milk Substitute market

Into this already conflicted and potent arena steps the breast milk substitute companies – with a global market worth of approximately $25 billion (Euromonitor, 2011) and all the marketing and advertising savvy of other commercial companies operating in an international ‘turbo capitalist’ world. There have long been battles to expose their many unethical behaviours, and drive for profits which have led to unscrupulous actions in low income as well as high & middle-income countries –  involving the co-option of Health Care Professionals (HCP’s) to promote their products (directly and indirectly), unsubstantiated ‘scientific’ claims and direct targeting of women through aggressive marketing of samples, ‘freebies’ and covert data collection.

Concern about breastfeeding rates, and the influence of BMS companies has been addressed by a myriad of actors since the mid 20th century; WHO, UNICEF, governments, numerous activists, and groups (Buse et al, 2012), with one of the most explicit global polices being ‘The Code Against….’ (1981) which provides a comprehensive list of ways in which the commercial interests & actions of BMS companies should be curbed and controlled, in order to protect the health of women, babies and by extension public health of the whole of society. The Code and its subsequent resolutions are intended as a minimum requirement in all countries, and are written into the United Nations Convention on the Rights of the Child, to which the UK is a signatory.

Alarm at BMS company’s activities originally sprung from concerns expressed by Missionaries and healthcare professionals, since the 1930’s who saw the drastic effect of aggressive BMS marketing in developing countries (Baumslag & Michels, 1995). This prompted other organisations and groups to organise to support breastfeeding, such as mother-to-mother support groups The La Leche League (2016) in 50’s America, activists such as the Infant Formula Action Coalition (INFACT) who initiated the famous Nestle boycotts of the 70’s and 80’s (IBFAN, 2016), The Association of Breastfeeding Mothers Founded in 1979 (2016) who created International Breastfeeding Week, as well as the 1000’s Days Global Nutrition initiative (WHO, 2014).  Furthermore, numerous groups and activists that operate currently on social media such as ‘Free to Feed’ (2016) and individual women who post ‘Brelfies’ (NetMums, 2016) (selfies of themselves breastfeeding) to challenge ‘breastfeeding shaming’, continue to exert pressure on negative and corrosive media, commercial and cultural pressures on breastfeeding (Palmer, 2006; Time Magazine, 2014).

BMS and the midwife

As midwives, we need to be aware of all these issues, and how they impact on public health as well as individual women and babies. We have a professional responsibility to comply with The Code, follow advice from The Baby Friendly Initiative, and our own NMC Code whilst providing individualised support and guidance to women around infant feeding.

Therefore, why is it that some major midwifery organisations choose to take sponsorship from BMS companies, and individual midwives choose to attend sponsored events?

When major organisations and individuals, whose judgement HCP’s and women trust, get into bed with BMS companies, it can further erode women’s confidence in breastfeeding, unduly influence our impartiality and promotes the idea of BMS being a societal norm. With breastfeeding so unsupported in our culture with portrayals of bottle-feeding predominating in film and TV (Dykes.F & Griffiths.H, 1998; Palmer.G, 2009; Kitzinger, 2001) and breastfeeding women often portrayed as ‘extreme’ or the practice itself as ‘problematic and potentially dangerous’ (Palmer.A, 2006), actions such as these threatens to dilute and damage messaging about the positive effects of breastfeeding from HCP’s, and support from numerous organisations, peer supporters and global initiatives to support women to breastfeed.

The argument that advertising, sponsorship and cultural representations do not influence HCP’s or the wider public is erroneous – the power of logos, splashed across magazine pages, awards ceremonies and websites should not be underestimated – this plays on the ‘halo’ affect in brand marketing terms, whereby companies assume the benefits of the organisations and individuals they associate with, and all the ‘good’ they otherwise do. In addition, some of these companies are attempting to re-position themselves as ‘health & wellbeing companies’, but as a recent report ‘Busting the Myth of Science-based formula’ (Changing Markets, 2018) which looked into Nestle  suggests, they are

‘…. in fact, not driven by nutritional science but instead by a sharp and prioritised focus on profit and growth at the expense of vulnerable infants. If Nestlé were truly science-driven, its behaviour would be very different’

Furthermore, the insidious use of brand placement through products, leaflets and merchandising, often made available at events such as these, which make their way onto postnatal wards, neonatal facilities and to student midwives in university further creates a secondary market, and feeds the relationship that keeps giving – to the sponsor. It is well documented that recommendations from HCP’s are one of the most influential way to ‘push’ BMS brands, therefore helping companies compete in the ‘battle for baby bucks’ (Save the Children, 2018).

Guidance for midwives

World Health Organisation (WHO, 2003) and UNICEF (2005) recommendations advocate exclusive breastfeeding for the first six months of life, and for up to two years thereafter, with the introduction of appropriate complimentary foods. However, despite this, and the compelling evidence around the health, psychosocial and cognitive advantages, most recently outlined in the Lancet Series (2016) and Baby Friendly Initiative updated Standards (UNICEF, 2013), globally rates for exclusive breastfeeding (at six months) remain low, at <38%, with only1% in the UK (WHO, 2014).

Therefore, particularly in the UK all HCP’s involved in infant and maternal health, should be seeking to support breastfeeding, and should be acutely aware of the dangers of BMS advertising. Recent reports such as ‘Don’t Push it – Why the formula industry must clean up its act’  (Save the Children, 2018), Guidance from UNICEF (2018)  on HCP’s association with BMS companies, The Baby Friendly Initiative (2018) and the NMC Code (2015) all make it clear that HCP’s need to be aware and steer away from insidious marketing and promotion, when making decisions, such as to attend ‘free’ study days, and in extension should also when accepting nominations to awards that are sponsored by BMS companies or attend conferences where BMS companies are marketing their products. In addition, the NMC Code () explicitly states that midwives need to –

‘Maintain clear professional boundaries’ – You must refuse any gifts, favours or hospitality that might be interpreted as an attempt to gain preferential treatment.


‘Be impartial’. You must ensure that your professional judgment is not influenced by any commercial considerations.

Therefore, all HCP’s need to be intensely aware of commercial tactics that seek to co-opt them, and organisations that currently accept BMS sponsorship should reconsider what is a damaging relationship, that discredits them and potentially damages breastfeeding in the UK.




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