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Ireland has one of the lowest breastfeeding rates in the world. With just 37 per cent of mothers breastfeeding on discharge from hospital, baby formula sales are booming. But is the advertising of this product here sufficiently regulated? Some campaigners think not.

Irelands lax adoption of advertising codes to curb the marketing of breast milk substitutes is normalising formula feeding and misleading parents, says Baby Feeding Law Group Ireland (BFLGI). Members include individuals and breastfeeding support organisations Cuidiu, La Leche League and Friends of Breastfeeding.

Our big concern is there are a lot of unethical marketing practices and what we would consider to be predatory marketing practices, says BFLGI member Liz OSullivan, a dietician, lecturer in nutrition and mother of two. Even where there is legislation to protect families, it is really poorly enforced.

The legislation OSullivan refers to is based on the WHOs International Code of Marketing of Breast-milk Substitutes. Introduced 40 years ago this year, it was designed to stop commercial interests from undermining breastfeeding. Unicef describes the code as a response to infant-feeding industry marketing activities that were promoting formula feeding over breastfeeding, in turn leading to dramatic increases in maternal and infant morbidity and mortality.

The health of babies was too important for the usual market rules to apply. The codeasked all governments to legislate to prevent commercial interests from damaging breastfeeding and the health of their populations.

The benefits of breastfeeding are numerous. Breastfed children have a lower incidence and severity of many illnesses, including respiratory and urinary tract infections, gastroenteritis, diabetes, and childhood cancers, according to aLancet report, Breastfeeding in the 21st Century (2016). In mothers, breastfeeding was found to help prevent breast cancer and reduce the risk of ovarian cancer and diabetes. The WHOs website says breastfed children perform better on intelligence tests, too.

Separately, a long-term study in Brazil, published in Lancet Global Health in 2015, traced nearly 3,500 babies from all walks of life and found that those breastfed for longer scored higher in IQ tests as adults. Many other factors contribute to IQ, researchers and critics stressed, but their study did try to rule out the main ones such as the mothers education, family income and birth weight.

A majority of countries, including Ireland, have enacted legislation to implement at least some of the code to help safeguard the benefits of breastfeeding. In its most recent analysis of legal measures in place, the WHO, Unicef and the International Baby Food Action Network found that 25 countries scored 75 or above out of 100 and were considered substantially aligned with the Code. Irelands score, however, was just 39. BFLGI wants to see a greater adoption of the code in Ireland to restrict how baby formula is advertised.

There are few products whose packaging is required by law to tell you the alternative to buying them is actually better. Cigarettes and alcohol spring to mind, and infant formula is also one of them. Pick up any brand and it is required by law to say breast milk is better. Formula companies must state the superiority of breast milk on all of their marketing materials, which they duly do.

However as the free alternative of breast milk reduces market share, their marketing strategies, curtailed by the code, have become fairly inventive.

The code is strongest in relation to newborns. In Ireland, companies cant actively market formula for babies up to six months but are adept at getting around it, says OSullivan. They bolster brand awareness by heavily promoting similar products such as follow-on milks.

You are not allowed to have promotions or offers on stage one infant formula, but any ads you have for your stage-two formula are nearly advertising your stage-one by default because the product looks exactly the same. The only difference is the number, OSullivan says.

According to Gerard Hastings, emeritus professor of social marketing at the University of Stirling, while companies are prohibited legally from communicating about first milk, their tack is to promote baby milk formula as the best thing after maternal milk. His research, Selling second best: how infant formula marketing works, published in Globalization and Health, includes interviews with former baby milk formula industry marketers.

The formula companies are adept at creating a brand affinity without mentioning a product, one marketer says. When [corporation name] market infant formula, they do need to tiptoe a bit around stuff before 12 months, but they still do all sorts of things. They dont talk about product at all, its like, Call our advice line, Join our baby club, no mention of a product, so you can market without talking about a product. This approach gets around regulation and makes enforcement difficult.

Building long-term relationships with mothers through baby clubs and care lines is a way to reach them without breaking the code. In his research, Hastings quotes one marketer saying a particular formula company was always on a quest to identify women who are pregnant for the first timebecause how a woman feeds her baby is how she is likely to feed her subsequent babiesfirst-time mothers are the holy grail.

Technology and analytics is supercharging these efforts. Tell the company your babys due date when signing up to their baby club and you will receive emails timed to your stage of pregnancy.

The labelling of formula is covered by the code too. Packaging cant include pictures of infants or other pictures or text which may idealise the use of the product, it says. But the enforcement of this, is problematic, says OSullivan.

If you look at the products, they have teddy bears, a picture of a cot, a mammy goat and a baby goat. One logo has a love heart on it, another looks like a mum holding a baby, another has a shield. All of these things look like they are idealising the product, but the Food Safety Authority of Ireland says they are not..

The end goal of our group is to change legislation, she says. Whereas now we restrict the promotion of products to babies up to six months, we would love to see that up to 36 months. But even if Irelands adoption of the code is expanded, it wont be enough, she says. Its the monitoring and enforcement that really need to be fixed.

Still, if the benefits of breastfeeding are so compelling, why do so many Irish parents find themselves in the supermarket formula aisle? To be fair to formula companies, it cant all be down to their advertising. They see themselves as providing parents information about feeding options and offering choice.

The fact is, Irelands low breastfeeding rates are out of whack. Nationally, 63.8 per cent of women here initiate breastfeeding at their babys first feed. This compares with rates of 90 per cent in Australia, 81 per cent in the UK and 79 per cent in the US, according to the Irish Maternity Indicator System 2019 national report. On discharge, just 37.3 per cent of mothers here are breastfeeding.

Separate research as part of the ESRIs Growing Up in Ireland study (2014) asks mothers who did not initiate breastfeeding why. Almost 49 per cent said formula feeding was preferable(though the statistic does not shed light on why it was perceived as preferable). Some 17 per cent cited inconvenience/fatigue and a further 18 per cent cited reasons including difficulty with breastfeeding techniques, soreness, not enough milk and problems feeding a previous baby.

While the HSE has an Infant Feeding Policy for hospitals and community health professionals, as well as the mychild.ie website for parents, campaigners say support for breastfeeding is underfunded and voluntary breastfeeding groups run by mothers are left to fill the gaps.

There are just 20.5 dedicated lactation consultant posts across Irelands maternity hospitals and units, with another 10 operating in the community. This is in a country that recorded 55,959 births in 2020. With more than 8,000 births a year, the National Maternity Hospital at Holles Street in Dublin has just two full-time and two part-time lactation consultants. Recruitment for 24 more lactation consultant posts is due to start this year, the HSE says.

For broadcaster, UCDlecturer and mother of two Aoibhinn N Shilleabhin, the feeding of Irish babies is being left up to the market. By not adequately supporting mothers who want to breastfeed, she says, we are providing a steady supply of customers to a multimillion-euro industry.

N Shilleabhin became interested in the topic when, on the birth of her second child last year, she became part of a new health area after moving house: All of a sudden I had access to a public lactation consultant. Her child was born with a tongue tie and a toot, and this support, though online during the pandemic, made all the difference.

With regard to breastfeeding her first baby, who was also born with a tongue tie, N Shilleabhin says shewas ready to give up on day four. That time, a visit from a public health nurse experienced in breastfeeding, enabled her to continue to breastfeed exclusively for six months.

When mothers, in particular first-time mothers, dont get timely support in their areafor often fixable issues, breastfeeding can come to a painful and sometimes traumatic and guilt-ridden halt.

Between women unsupported to breastfeed and insufficient regulation on how formula is advertised, formula companies have inordinate influence in how babies are fed, according to N Shilleabhin. My point is that we really shouldnt be leaving it up to private industry, whose bottom line is profit, to tell you what the best thing is for your child.

The argument is not breast versus bottle, she adds.We absolutely need formula; some women cant breastfeed, some dont want to breastfeed. There are very many reasons we need formula, we just dont need it advertised so blatantly.

OSullivan agrees. For me its nothing to do with individual parents who use formula, its the stealth of the marketing. I have the biggest problem when someone wants to breastfeed, but doesnt get the advice and support they need or gets undermined by marketing which says its time to move on from breastfeeding.

Sabina Higgins, wife of president Michael D Higgins added her voice to the debate in August. At an event to promote breastfeeding, she called Ireland a pathetically low place when it comes to the number of children being breastfed. She said neglecting public awareness of the importance of breastfeeding was irresponsible, while the aggressive marketing of breast-milk substitutes by commercial interests continues to undermine breastfeeding.

When it comes to Irelands relationship to baby formula, it really is complicated. Three of the largest producers of infant formula in the world, Danone(which produces Cow & Gate and Aptamil), Abbott and Wyeth have manufacturing facilities in Ireland, sourcing milk supplies directly from Irish dairy processors. Irish nutritional powder exports, which includes infant formula, are valued at 929 million, according to Bord Bia figures. The body even titled a 2018 infant formula branding drive Billion Dollar Baby.

We have a big infant formula culture here because we produce so much of it, says OSullivan. We have a massive conflict between the Department of Health and the Department of Agriculture. Changing the code may ultimately be a problem of political will.

National Breastfeeding Week is October 1st-7th.On October 4th the National Womens Council of Ireland, in partnership with Baby Feeding Law Group Ireland (BFLGI) will host a public webinar on the need to provide greater choice and supports to women around breastfeeding. See eventbrite.ie/e/feeding-the-future-shared-responsibility-tickets-171998781987 *

* This article was amended on September 18th, 2021

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Aoibhinn N Shilleabhin: We shouldnt leave it to industry to say whats best for your child - The Irish Times