An exploration of pregnant women and mothers' attitudes, perceptions and experiences of formula feeding and formula marketing, and the factors that influence decision-making about infant feeding in South Africa

Background

Despite strong evidence showing the lifelong benefits of breastfeeding for mothers and children, global breastfeeding practices remain poor. The International Code of Marketing of Breastmilk Substitutes is an internationally agreed code of practice, adopted by the World Health Assembly in 1981, to regulate promotion of commercial formula, and is supported by legislation in many countries. However, marketing of formula remains widespread and contributes to mother’s decisions to formula feed. We present South African data from a multi-country, mixed-methods study exploring women’s decision-making about infant feeding and how this was influenced by exposure to formula marketing.

Methods

Using a consumer-based marketing approach, focus group discussions (FGDs) were conducted with pregnant women and mothers of children aged between 0 and 18 months in two urban sites in South Africa. Participants were purposively selected according to their child’s age, infant feeding practices and socioeconomic status. Ten FGDs were conducted during February 2020 with a total of 69 participants. Thematic analysis was used to analyse the data with NVivo v.12 software.

Results

Despite being encouraged by health professionals to breastfeed and intending to do so, many mothers chose to give formula in the early weeks and months of their child’s life. Mothers reported breastfeeding challenges as the most frequent reason for initiating infant formula, stating that family members and health professionals recommended formula to solve these challenges. Although participants described few advertisements for infant formula, advertisements for ‘growing-up’ formulas for older children were widespread and promoted brand recognition. Mothers experienced other marketing approaches including attractive packaging and shop displays of infant formula, and obtained information from social media and online mothers’ groups, which influenced their choice of formula brand. Mothers reported strong brand loyalty derived from previous experiences and recommendations. Health professionals frequently recommended formula, including recommending specific formula brands and specialist formulas.

Conclusion

Global formula companies use multifaceted marketing methods to promote a strong narrative portraying formula feeding as a positive lifestyle choice. Positive, coordinated efforts are required to counter pro-formula messaging and change the narrative to support breastfeeding as an aspirational choice. In particular, health professionals must stop supporting the formula industry.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12784-y.

Digital Marketing of Breast-Milk Substitutes: a Systematic Scoping Review

PURPOSE OF REVIEW

Globally, too few children are breastfed as recommended. Commercial promotion of breast-milk substitutes (BMS) is one factor undermining breastfeeding globally. Although the International Code of Marketing of BMS prohibits all forms of marketing, promotion has been observed in digital environments. We aimed to understand the scope and impact of digital marketing for the promotion of BMS.

RECENT FINDINGS

BMS are promoted strategically and in an integrated fashion across multiple digital channels (social media, manufacturer websites, online retailers, blogs, mobile apps and digital streaming services). Traditional marketing strategies like gifts, discounts and coupons are also disseminated digitally. Data mining, real-time direct-to-consumer advertising and partnering with peer-group social media influencers are additional avenues. Exposure to digital marketing is common. Research on the impact of digital marketing is scarce, but its negative impact on breastfeeding intention and initiation has been documented. Case reports from marketing industry press corroborate academic evidence by highlighting the benefits of digital marketing to BMS companies in recruiting new users and increasing sales. To protect and promote breastfeeding, coordinated global action and strengthened national measures will be needed to implement, monitor and enforce the International Code in a digital context. Further action could include voluntary restrictions on BMS marketing by social media platforms and greater use of government-led data and health privacy regulation.

Marketing of commercial foods for infant and young children in Uruguay: sugary products, health cues on packages and fun social products on Facebook

OBJECTIVE

To analyse the content of the marketing of commercial foods for infants and young children on packages and social media.

DESIGN

Commercial foods targeted at children, regarded as potential breast-milk substitutes according to the Uruguayan breast-feeding standard, were considered: dairy products; teas, juices and bottled waters; glucose solutions; cereals and mixtures of fruits and vegetables. All the products sold at forty-four retail outlets were purchased. A Facebook search was performed to identify accounts of these products. For each account, all the content posted by the brands between July 2017 and July 2019 was recorded. The visual and textual information included in the packages and Facebook posts was analysed using content analysis. Products were classified using the nutrient profile model of the Pan American Health Organization.

SETTING

Montevideo, Uruguay.

RESULTS

Seventy-six unique commercial foods targeted at infants and young children were identified, 96 % of which were excessive in sugar. Packages frequently included textual and visual elements to convey health-related associations, including images of fruits and vegetables, nutrient content claims and endorsement logos. Ten Facebook accounts were identified, which generated 302 posts. Parents and caregivers were the main target audience of the posts, which mainly included content related to fun and social aspects of food consumption. Additionally, the posts frequently conveyed the idea that products would contribute to children's growth and development.

CONCLUSIONS

Results suggest the need to implement comprehensive regulations on the marketing of commercial foods targeted at children, regarded as potential breast-milk substitutes according to the Uruguayan breast-feeding standard.

Maternal education and equity in breastfeeding: trends and patterns in 81 low- and middle-income countries between 2000 and 2019

BACKGROUND

In low- and middle-income countries (LMICs), low levels of formal maternal educational are positively associated with breastfeeding whereas the reverse is true among women with higher levels of formal education. As such, breastfeeding has helped to reduce health equity gaps between rich and poor children. Our paper examines trends in breastfeeding and formula consumption by maternal educational in LMICs over nearly two decades.

METHODS

We used 319 nationally representative surveys from 81 countries. We used WHO definitions for breastfeeding indicators and categorized maternal education into three categories: none, primary, and secondary or higher. We grouped countries according to the World Bank income groups and UNICEF regions classifications. The trend analyses were performed through multilevel linear regression to obtain average absolute annual changes in percentage points.

RESULTS

Significant increases in prevalence were observed for early initiation and exclusive breastfeeding across all education categories, but more prominently in women with no formal education for early breastfeeding and in higher level educated women for exclusive breastfeeding. Small decreases in prevalence were seen mostly for women with no formal education for continued breastfeeding at 1 and 2 years. Among formula indicators, only formula consumption between 6 and 23 months decreased significantly over the period for women with primary education. Analysis by world regions demonstrated that gains in early and exclusive breastfeeding were almost universally distributed among education categories, except in the Middle East and North Africa where they decreased throughout education categories. Continued breastfeeding at 1 and 2 years increased in South Asia, Latin America and the Caribbean, and Eastern Europe and Central Asia for primary or higher education categories. Declines occurred for the group of no formal education in South Asia and nearly all education categories in the Middle East and North Africa with a decline steeper for continued breastfeeding at 2 years. With a few exceptions, the use of formula is higher among children of women at the highest education level in all regions.

CONCLUSIONS

Over the course of our study, women with no formal education have worsening breastfeeding indicators compared to women with primary and secondary or higher education.