The breastmilk brand: Promoting child survival

1
The breastmilk brandPromoting child survival

• Prof Anna Coutsoudis, Prof Jerry Coovadia, Judith
  King
• HIVAN/WCRP FORUM
• 9 September 2009

2
Every death counts saving the lives of infants
and children in SA

• Every year, 75 000 children under the age of 5
  die
• South Africa is not on target to reach the MDG of
  reducing child mortality by two thirds by 2015.
• Many of these deaths are due to malnutrition,
  diarrhoea and pneumonia

3
Progress toward MDG4

• Rapid progress is possible. Further analysis of
  these well-performing countries is under way.
• No country in sub-Saharan Africa is on this list

• The 10 countries with least progress are in
  sub-Saharan Africa

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GLOBALLY, MORE THAN A THIRD OF CHILDREN DIE FROM
UNDER-NUTRITION.
Joy Lawn 2009
5
Optimum breastfeeding practices could prevent
many deaths due to malnutrition, diarrhoea and
pneumonia
6
Use my picture if it will help, I dont want
other people to make the same mistake.
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One of the problems with formula feeding is
access to safe water and sanitation
More than 1.1 billion people do not have proper
access to clean water worldwide and 2.6 billion
do not have adequate access to sanitation.
Human Development Report, 2006
8

The world is facing a water crisis and
sub-Saharan Africa is bearing the brunt of the
problem. Due to a lack of clean water, diarrhoea
is killing five times more children than HIV/AIDS
and curtailing economic growth.
Human Development Report 2006 pages 6 23
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South African Scenario

• Be aware of the dangers of formula feeding even
  where there is municipal water available
• as municipalities become stretched for human and
  economic resources and we have power, our water
  supplies can be dangerous for little infants as
  happened recently in the Eastern Cape with water
  being contaminated

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CONTAMINATION AND DILUTION OF FORMULA

• Feeding bottle samples from pMTCT clinic during
  home visits directly observed
• Population of mothers living conditions fairly
  good, educational level relatively high
  demonstration of preparation.
• 81 of home samples, 67 of clinic samples, 38
  of demonstration samples contaminated by faecal
  bacteria.
• Andersen E et al. J of Trop Ped
  200753409-414

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• Even if we can assure safe water, there are
  inherent risks associated with formula feeding
  because the child is denied the natural immune
  benefits present in breastmilk.

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Under-5 deaths that could be prevented through
achievement of universal coverage with
individual interventions Jones G,
et al. Lancet 2003 362 65-71
13

• If there is so much clinical evidence linking
  child survival with breastfeeding especially
  exclusive breastfeeding - why are women choosing
  not to do so?

14
The Politics of Breastfeedingwhen breasts are
bad for business

• - comments from the book by Gabrielle Palmer,
  former HIV and Infant Feeding Officer, UNICEF,
  New York

15
Current situation A woman working in a paid
job must not flaunt signs of lactation she must
discreetly withdraw to feed her baby so as not to
offend or disturb her male colleagues. Away from
the workplace, these same workers might pay to
watch a woman expose her breasts for the sexual
stimulation of strangers. Breasts have become
a marketing tool, used to sell cars, alcohol,
clothing, music
16
Historical occurrences Market Forces It is not
a coincidence that the decline of breastfeeding
accelerated as the predominantly male medical
profession took over the management of childbirth
and infant feeding. Nor was it chance that led to
the expansion of the baby milk industry during
the late 19th and early 20th centuries, when
improved techniques and mechanisation of
milk-processing led to cows milk surpluses.
When a manufacturer has an excess product, his
business instinct is to find a way to market it
.
17
Market Forces In 2007 the US infant formula
market was estimated at US 3.9 billion. Major
players in South Africa Nestle, Nutritional
Foods, Clover, Aspen Pharmacare, Abbott
Laboratories
18
Formula milk marketing Code

• The International Code of Marketing of Breastmilk
  Substitutes (adopted by WHO in 1981)
• SA draft regulations based on the Code circulated
  in 2003 and again in 2007 for input by all
  stakeholders
• Formula milk manufacturers persist in disputing
  the terms, delaying legislation.

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The International Code

• Applies to all products marketed as partial or
  total replacement for breastmilk infant formula,
  follow-up or special formula, cereals, juices,
  vegetable mixes, baby drinks, feeding bottles and
  teats.

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The Code

• Bans all advertising and promotion of products to
  the general public.
• Bans the use of samples and gifts to mothers and
  health workers.
• Bans the use of the health care system to promote
  breastmilk
• substitutes.
• Bans free or low-cost supplies of breastmilk
  substitutes.
• Bans sales incentives for breastmilk substitutes.
• Allows samples given to health workers, but only
  for research
• purposes.
• Demands that product information be factual and
  scientific.
• Requires that information materials contain
  specific information and warnings and not contain
  pictures of babies nor text that idealises the
  use of breastmilk substitutes
• Requires that labels inform fully about the
  correct use of the
• product and the risks of misuse.
• Requires that labels do not discourage
  breastfeeding.

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Code protection and enforcement

• ASASA administers the Code in consultation with
  the Dept of Health but cannot regulate guerilla
  marketing (e.g. free samples and incentives to
  doctors and nurses)
• Consumer Protection Act (2008/09) costs of
  injury from defective products must be borne by
  those who bring them to the market anyone in
  the supply chain

22
Nestle code violations in SA

• Nestle NIDO system http//www.nestle.co.za/defaul
  t.aspx?pid189
• When to startMost babies are ready for solid
  foods from 6 months. Here's when and how to
  make the transition from breastmilk or formula to
  solid foods. It is however important to know that
  from around 6 months your child's nutrient stores
  and requirements are no longer met by breastmilk/
  formula alone, particularly when it comes to iron
  and zinc. That is why the introduction of solids
  can help to ensure your baby receives all the
  vitamins and minerals he or she needs to grow and
  develop into a healthy child.

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Nestle code violations in SA

• NESTLE NIDO 1 Growing up milk
• R50 for 400g tin
• PROTECTION
• for healthy tummies

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Nestle Code violations in SA

• Nestle NIDO 3
• Growing up milk
• R50 for 400g tin
• STIMULATION
• for active brains

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NIDO claims
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Violation S-26 Promil Gold (Aspen)
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NAN Pelargo violation

• DoH position is that
• The SA Regulations 2 (9) (b) (c) of the
  Regulations Governing the Labelling and
  Advertising of Foodstuffs, published under
  Government Notice No. R. 2034 of 29 October 1993
  strictly prohibits health / curative /
  restorative / prophylactic /medicinal claims.
• Therefore, statements such as "optimal physical
  and mental development", "activate your baby's
  immune defences" and "strengthen your baby's
  natural defences" as indicated on the labels are
  just some examples of prohibited statements on
  NAN 1 and 2.

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Another important reason why breastfeeding has
been undermined in South Africa is the threat of
HIV infection.
29
Dilemma in infant feeding
Increased illness and death from infectious
diseases Formula feeding
HIV transmission Breastfeeding
Breast feeding? Formula milk?
30
Another important reason why breastfeeding has
been undermined in South Africa is the threat of
HIV infection.

• Health Care Workers
• Scientists involved in HIV
• Health professionals (doctors and nurses)

31
HIV and infant feeding

• Overwhelming evidence showing lack of net benefit
  of formula feeding for the majority of HIV
  infected women, therefore new guidelines
• HIV infected women should exclusively breastfeed
  their infants for the first 6 months unless all
  the AFASS criteria are in place for safe
  replacement feeding.

32
Rule of thumb when is Infant feeding safe?

• If IMR gt 25/1000 live births
• Exclusive breastfeeding for 6 months with early
  cessation will result in greater HIV free
  survival
• If IMR lt 25/1000 live births
• Replacement feeding from birth will result in
  greater HIV free survival

Piwoz E, Ross J. J Nutrition 2005 135 1113
33
Unsafe choices

• Most communities in South Africa where HIV is
  prevalent has IMRs far in excess of 25/1000 and
  mothers often do not have AFASS criteria in place
  for safe replacement feeding and are often
  choosing to formula feed inappropriately.

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• Those who have promoted formula feeding for HIV
  infected women have ignored not only the child
  survival benefits of breastfeeding but have
  over-emphasised the risk of HIV transmission and
  ignored the fact that there are currently 3 key
  strategies for diminishing HIV transmission
  through breastfeeding viz
• Promoting and supporting women to practise
  Exclusive Breastfeeding in the first 6 months
• HAART
• Flash heating

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A 3-pronged plan of attack

• Govt and civil society should support and raise
  the profile of mothers who breastfeed in the
  workplace
• Mass-media marketing of breastfeeding science and
  practice.
• Civil society to push Government for urgent
  legislation of the draft regulations of marketing
  of breastmilk substitutes

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Protect, promote and support breastfeedingIn
addition to training up of counsellors, we need
policies of extended maternity leave flexible
working hours on-site breastfeeding facilities.
37

• 1. Protect, promote and support breastfeeding
• Train counsellors
• Policies of extended maternity leave flexible
  working hours on-site breastfeeding facilities.
• Donor milk banking
• Re-visit the free formula policy for HIV infected
  women

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DONOR HUMAN MILK BANKING

• Mothers own milk is best option for babies
• Where this is not possible the FIRST alternative
  according to WHO and UNICEF is the use of human
  milk from donors

39
Example from Brazil

• 1999-2000 Brazil had over 150 donor milk banks
• Processed more than 218,000 litres of donor milk
  fed to over 300,000 prem and low birth weight
  infants
• Provision of milk is estimated to have saved the
  Brazilian Ministry of Health approximately 540
  million in one year and contributed to a
  significant reduction in the infant mortality
  rate.

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South Africa is not too dissimilar to Brazil and
we believe that the time is ripe for the
establishment of a network of breastmilk banks
and a national association to regulate these
activities.
41
Re-visiting the policy of free formula

• Why double standards and not one policy for all?
• Equity of providing free formula milk for some
  women and not others?
• The issue of choice in an unequal world?

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2. Building the breastmilk brand

• We need a mass-media marketing campaign that
  counters the profit-driven formula milk
  industrys claims.
• Properly funded and focused
• Innovative
• Involving civil society
• Message ARTIFICIAL IS INFERIOR

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Branding breastmilk

• Brazil govt campaign promotes breastfeeding
  until the age of 2
• 1981-84 breastfeeding programme included
  implementing maternity laws, support groups for
  breastfeeding mothers, and disseminating
  information to policymakers.
• An intensive mass media campaign in 1982 100
  television channels began airing frequent, prime-
  time commercials, supplemented by radio,
  endorsements by celebrities, posters, and print
  advertisements.
• Castello Branco, H. Breastfeeding on prime-time
  in Brazil. Development Communication Report,
  1990 71 4, 7

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Brazils BF messaging

• Material designed to counter
• women's fears that their breast size made them
  incapable of breastfeeding
• employers' lack of support for working mothers
• lack of unity among doctors that breastfeeding is
  right for every child
• "machismo" -- men's attitude that the breast is
  only a sexual object.

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Breastfeeding is an act of love and a matter
of survival

• Advertising of all breastmilk substitutes is
  prohibited.
• Idealising images of teddy
• bears and other
• animals are banned
• from labels.
• Ministry of Health warnings
• are required.
• (Nestle NIDO)

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Yemen BF advert
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Texas, USA campaign
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Texas, USA campaign
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Texas, USA campaign
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3. Advocacy for legislation of Code

• Sign SAs draft regulations into law
• Civil society to help monitor and report formula
  milk marketing USE THE MEDIA
• Impose severe penalities for infringement
• Stop seeing formula as the norm breastfeeding
  is easy, cheap, perfect and a human right for
  families

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MARKETING OF BREASTMILK SUBSTITUTES RESURGENCE
IN THE PHILLIPINES