Social Science & Medicine 244 (2020) 112331

Contents lists available at ScienceDirect

Social Science & Medicine

journal homepage: www.elsevier.com/locate/socscimed

Commentary

Breastfeeding in the 21st century: How we can make it work T

Rafael Pérez-Escamilla
Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA

ARTICLE INFO ABSTRACT

Keywords: There is abundant knowledge on the major health and social benefits of breastfeeding, and on how to protect,
Breastfeeding promote, and support breastfeeding. Hence, it is surprising that recommended breastfeeding behaviors continue
Behavior change to be suboptimal in the 21st Century among large segments of the population, globally. Moving forward, it is
Developing nations crucial to enable the breastfeeding environments for women through family friendly employment policies and to
Evidence informed policy
enforce the WHO Code for Marketing of Breastmilk Substitutes. It is also key to invest more in training the
workforce for successful large-scale implementation and sustainability of the Baby Friendly Hospital Initiative,
community-based breastfeeding counseling, and to prevent conflicts of interests with infant formula companies.
Behavior change social marketing interventions that include social media need to be designed following social
network science and behavioral economics principles. Evidence-informed policy tools are now available to help
policy makers invest in and guide the scaling-up of cost-effective breastfeeding programs.

1. Introduction monitoring and enforcement of regulatory policies to protect breast-

feeding in Peru. This study is remarkable not so much because it pre-
Breastfeeding offers a constellation of health benefits to women and sents new discoveries, but because it shows that, in the midst of the 21st
children, and has also been positively linked with improved child de- Century, women are still experiencing similar structural barriers that
velopment, national productivity, and environmental sustainability prevent them from achieving their breastfeeding goals identified dec-
(Rollins et al., 2016; Victora et al., 2016). Thus, protecting, promoting, ades ago (Pérez-Escamilla et al., 2012). The central topic addressed in
and supporting optimal breastfeeding practices — including breast- the study, i.e., unethical marketing of infant formula through health
feeding initiation within one hour after birth, exclusive breastfeeding care providers, has been documented for decades and since the 1970's
for 6 months, and continuation of breastfeeding for at least two years has led breastfeeding advocates to request strong actions from gov-
once nutritious and safe complementary foods are introduced at six ernments and civil society (Jelliffe, 1972; Muller, 1974). In fact, this
months — is crucial for meeting the Sustainable Development Goals by historical context strongly influenced the decisions to launch the World
2030 (Pérez-Escamilla, 2017). Health Organization (WHO) Code for Marketing of Breastmilk Sub-
A well designed and implemented mixed-methods cohort study stitutes in 1981 (Table 1) (WHO, 1981), the UNICEF/WHO Baby
published in this issue, conducted in a large shantytown in the outskirts Friendly Hospital Initiative (BFHI) in 1991 (Table 2) (WHO, 2018a),
of Lima, Peru, documented that about half of Peruvian infants were and, more recently, the WHO guideline on breastfeeding counseling
being mixed fed with breast milk and formula during the first 2 months (Table 3) (WHO, 2018b).
of life (Rothstein et al., 2019); it also found that receiving a re-
commendation from a health provider to give formula increased the 2. What do we know and what can we do?
risk over 10 times that a mother would do so, after adjusting for con-
founders. Furthermore, qualitative findings based on in-depth inter- A great deal is already known about the benefits of breastfeeding,
views with mothers and health care providers indicated that formula how to prevent and manage breastfeeding difficulties (i.e., effective
recommendations along with inadequate facility-based breastfeeding lactation management), and there are evidence-based guidelines in
promotion shape mothers' positive attitudes towards formula and place that have been well operationalized to scale-up breastfeeding
weaken their ability to breastfeed exclusively. In addition, health pro- services. Hence, as studies by Rothstein et al. (2019) and others (Pérez-
viders revealed extensive formula industry influence in the health Escamilla et al., 2012) have shown, it is quite puzzling why women are
sector. The authors conclude that there is an urgent need to improve the still facing so many roadblocks to implement their right to breastfeed

DOI of original article: https://doi.org/10.1016/j.socscimed.2019.05.029

E-mail address: [email protected].

https://doi.org/10.1016/j.socscimed.2019.05.036
Received 7 May 2019; Accepted 20 May 2019
Available online 09 June 2019
0277-9536/ © 2019 Elsevier Ltd. All rights reserved.
R. Pérez-Escamilla Social Science & Medicine 244 (2020) 112331

when they choose to do so for as long as they want. Part of the answer 6 months (Pérez-Escamilla et al., 2012; Pérez-Escamilla and Chapman,
to this complex question lies in the fact that very few countries or so- 2012). The frameworks should also take into account social network
cieties have managed to strengthen the social protection and health science for understanding how to disseminate healthy lifestyles in di-
care systems needed to enable the environments surrounding women verse populations (Perkins et al., 2015) and that holds great promise for
and their infants to protect, promote, and support breastfeeding (Pérez- breastfeeding as well (Alianmoghaddam et al., 2019; DeLorme et al.,
Escamilla and Hall-Moran, 2016). Fortunately, conceptual frameworks 2018).
that take this reality into account are now available. Specifically the Moving forward and in order to respond to the findings from the
Breastfeeding Gear Model proposes eight key ingredients or gears that elegant study addressed by this commentary (Rothstein et al., 2019)
are needed for the “engine” needed for the successful operation of large- and others (Pérez-Escamilla et al., 2012), it is important to consider the
scale breastfeeding programs (Pérez-Escamilla et al., 2012). Evidence- following specific breastfeeding protection, promotion and support
based advocacy is needed to generate the political will required to actions to improve breastfeeding outcomes in the 21st Century.
develop and pass legislation that releases the fiscal resources for proper
protection, promotion, and support of breastfeeding. These resources 3. Breastfeeding protection
are needed for proper implementation and enforcement of key protec-
tion measures, including maternity protection for women employed in Two important pillars for breastfeeding protection are paid mater-
the formal and informal economy sectors, and the WHO Code. They are nity leave and breaks during the workday for breastfeeding or breast
also essential for program implementation and the training of the milk extraction. Paid maternity leave has been credited with improved
workforce responsible for implementing key health facility- and com- breastfeeding outcomes as well as reductions of infant mortality (Chai
munity-based initiatives, including BFHI and home-based peer coun- et al., 2018; Heymann et al., 2017; Nandi et al., 2016). Unfortunately,
seling. Investments are also needed for creating a demand for these more than 830 million employed women workers and their families are
services through sound behavior change social marketing campaigns still not benefitting from adequate maternity protection (International
that promote breastfeeding. Operational research is needed for identi- Labour Organization, 2018a). Even though the majority of nations
fying implementation bottlenecks and addressing them on time. The provide some form of paid maternity leave, very few of them are
master gear is responsible for overall coordination, including timely meeting the WHO recommendation for the provision of at least six
communication across and monitoring of pre-established goals based on months of paid leave to support exclusive breastfeeding (Holla et al.,
multi-level decentralized management information systems that allow 2015). This omission may be explained in part by the fact that the
for evidence-informed local decision making as well as state- and na- minimum global standards for maternity leave endorsed by the Inter-
tional-level planning. national Labour Organization (ILO) range from 14 to 18 weeks, which
Changing the default environments surrounding families with in- is well below the 26 weeks recommended by the WHO. ILO's maternity
fants and young children through health and social policies is a key step protection convention also recommends parental leave in addition to
to facilitate breastfeeding. However, at the end of the day, a better maternity leave, a recommendation that has consistently been identi-
understanding of mothers’ attitudes and behaviors toward breast- fied with positive breastfeeding outcomes (Flacking et al., 2010; Su and
feeding is crucial for increasing early breastfeeding initiation, ex- Ouyang, 2016). Additional evidence-informed maternity protection
clusivity, and duration. Furthermore, it is necessary to apply sound policies that have been endorsed to support breastfeeding include fa-
behavior change frameworks that include principles of behavioral mily-friendly work policies once employed women return to work (e.g.,
economics to understand how best to nudge women to breastfeed fol- breaks during the workday, lactation rooms for breast milk expression,
lowing global recommendations, including exclusive breastfeeding for flexible work hours, affordable high-quality childcare service in

Table 1
The WHO code for marketing of breast milk substitutes, summary of articles (WHO 1981).
Article # Article Title Article Summary

Article 1 Aim of the Code Protection and promotion of breast-feeding, and ensuring the proper use of BMS, when these are needed, following the
principles of adequate information and appropriate marketing and distribution.
Article 2 Scope of the Code Covers marketing, practices, quality, availability and information related to the use of: breast-milk substitutes,
including infant formula; other milk products, foods and beverages, including bottle-fed complementary foods.
Article 3 Definitions of terms Includes definitions of key Code terms including BMS, complementary foods, health care system related terms,
product labels, marketing techniques, and distribution points. Since then other terms such as follow-on formulas
designed for children 1–3 years old have been added (WHO 2017, 2018c).
Article 4 Information and education Governments' role ensuring: objective and consistent information is provided on infant and young child feeding that
acknowledges the superiority of breastfeeding and that does not use any pictures or text which may idealize the use of
breast-milk substitutes; control of donations of equipment or materials by manufacturers or distributors.
Article 5 The general public and mothers Includes specific provisions to prevent unethical marketing of BMS and related products, including bottles, covered by
the Code to pregnant women, mothers, family members and public at large. It targets manufacturers, distributors and
points of sale.
Article 6 Health care systems Role of health authorities in breastfeeding protection, promotion and support through Code implementation.
Adherence of health care facilities to Code including unjustified discounts for or donations of infant formula or other
products covered by the Code.
Article 7 Health workers Role of health workers at protecting and promoting breastfeeding. Training of health workers on the Code. Prevent
unethical marketing of BMS industry representatives of their products to health workers.
Article 8 Persons employed by manufacturers and BMS marketing or sales representatives should not engage in educational functions targeting pregnant women or
distributors mothers of infants and young children. Their bonuses should not be tied to infant formula or other product covered by
the code sales volumes.
Article 9 Labeling Labels of products covered by Code should not discourage breastfeeding. Include warnings to prevent misuse of
products. Include warning labels in products that are inappropriate for infant feeding (e.g. sweetened condensed milk,
whole cow's powdered milk). Clearly and unambiguously report the list of ingredients used in product formulation.
Article 10 Quality Food products covered by Code should meet food safety and nutrition standards recommended by the Codex
Alimentarius Commission and also the Codex Code of Hygienic Practice for Foods for Infants and Children.
Article 11 Implementation and monitoring Governments' responsibilities for Code legislation, implementation, and enforcement. Calls for industry to collaborate
with this effort and for civil society organizations to be heavily engaged with monitoring Code compliance.

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R. Pérez-Escamilla Social Science & Medicine 244 (2020) 112331

proximity to the work place) (Kim et al., 2019; Steurer, 2017). Fur- Table 2
thermore, it is important to identify suitable approaches for offering The Baby Friendly Hospital Initiative ten steps to successful breastfeeding
maternity benefits to women employed in the informal economy sector (WHO 2018a).a
(Vilar-Compte et al., 2019), as over 60% of the global workforce is Critical management procedures
employed informally including over 90% of women in sub-Saharan
Africa (International Labour Organization, 2018b). 1a Comply fully with the International Code of Marketing of Breast-milk Substitutes and
relevant World Health Assembly resolutions.
A third pillar for breastfeeding protection is the implementation and
1b Have a written infant feeding policy that is routinely communicated to staff and
enforcement of the WHO Code. As Table 1 shows, the Code includes 11 parents.
articles and subsequent resolutions (WHO, 1981; WHO, 2018c); adop- 1c Establish ongoing monitoring and data-management systems.
tion of the Code is voluntary. Article 1 indicates that the aim of the 2. Ensure that staff have sufficient knowledge, competence and skills to support
Code is “to contribute to the provision of safe and adequate nutrition for breastfeeding
Key clinical practices
infants, by the protection and promotion of breastfeeding, and by en- 3. Discuss the importance and management of breastfeeding with pregnant women
suring the proper use of breast-milk substitutes, when these are ne- and their families.
cessary, on the basis of adequate information and through appropriate 4. Facilitate immediate and uninterrupted skin-to-skin contact and support mothers
marketing and distribution”. The Code includes provisions that speci- to initiate breastfeeding as soon as possible after birth.
5. Support mothers to initiate and maintain breastfeeding and manage common
fically address: Information and education on infant feeding; promotion
difficulties.
of breast-milk substitutes and related products to the general public, 6. Do not provide breastfed newborns any food or fluids other than breast milk,
mothers; and to health workers and in health care settings; labeling and unless medically indicated.
quality of breast-milk substitutes and related products; and im- 7. Enable mothers and their infants to remain together and to practice rooming-in
plementation and monitoring of the Code (WHO, 1981) (Table 1). Al- 24 hours a day.
8. Support mothers to recognize and respond to their infants' cues for feeding.
though the vast majority of countries across the world signed on the 9. Counsel mothers on the use and risks of feeding bottles, teats and pacifiers.
Code, with a notable exception being the U.S., it is not being properly 10. Coordinate discharge so that parents and their infants have timely access to
enforced globally, as a result of being voluntary and the lack of political ongoing support and care.
will from regulatory agencies (McFadden et al., 2016; Piwoz and
a
Huffman, 2015; WHO, 2018c). Given that Code violations by formula The Ten Steps summarize a package of policies and procedures that facil-
ities providing maternity and newborn services should implement to support
industry companies and point of sale stores continue to be rampant, it is
breastfeeding. The World Health Organization (WHO) has called upon all fa-
important to think about new strategies (Hernández-Cordero et al.,
cilities providing maternity and newborn services worldwide to implement the
2018; McFadden et al., 2016; WHO, 2018a). Research shows that health Ten Steps.
care providers are not well aware of the Code and do not fully grasp the
nuances surrounding conflict of interest (COI) issues in the infant for- principles to advance the public good. Social marketing calls for much
mula field (Hernández-Cordero et al., 2018; Piwoz and Huffman, 2015; more than health communications campaigns. It involves four inter-
Soldavini and Taillie, 2017). For this reason, it is important to include related tasks: audience benefit, target behavior, essence (brand, re-
comprehensive COI training as part the pre-service and in-service levance, positioning), and developing the “4Ps” (product, price, place,
education offered to health care professionals. In addition, full im- promotion) marketing mix. Social marketing applications to breast-
plementation and enforcement of the Code within maternity hospitals feeding have shown that campaigns need to target the influential so-
as specifically called for by the new WHO BFHI guidance (WHO, 2018a) cietal forces (e.g., family and friends, healthcare providers, employers,
(Table 2) can help protect women and their families against unethical formula industry, legislators) that affect women's decision to breastfeed
infant formula marketing practices at a very vulnerable time. and to do so for as long as they want (Pérez-Escamilla, 2012).
There is emerging interest in the use of social media to promote and
4. Breastfeeding promotion support breastfeeding (Marcon et al., 2018) although the optimal pat-
terns of dissemination of messages via Facebook, Twitter, and In-
Breastfeeding promotion continues to be quite limited in terms of stagram are just beginning to be elucidated. This work could greatly
coverage, intensity, depth and breadth, and funding, for it pales in benefit from social network theory and analysis. The potential of social
comparison with the amount of funding that infant formula companies media channels to promote breastfeeding has indeed been recognized
spend on marketing their products (Pérez-Escamilla et al., 2012; Piwoz but little empirical evidence exists to understand the best dissemination
and Huffman, 2015). On a global scale, World Breast Feeding week, pathways, and there is a lack of behavior change conceptual frame-
celebrated in August in most countries, has become the most visible works to help guide “smart” social media breastfeeding campaigns.
breastfeeding promotion initiative. This major effort led by the World Recent research suggests that the Health Action Process Approach
Alliance for Breastfeeding Action (WABA) focuses on evidence-in- (HAPA) model has promise for breastfeeding interventions that make
formed key breastfeeding enabling environment topics each year and use of information technology, especially because it strongly empha-
allows for countries to hold very innovative events. Moving forward, it sizes empowering women to develop action plans to successfully
is important to develop “year-round” promotional activities based on translate their breastfeeding intentions into actual behaviors (Martinez-
the principles of social marketing embedded in sound behavior change Brockman et al., 2017).
frameworks to improve the quality and impact of breastfeeding pro-
motion efforts (Pérez-Escamilla, 2012). These efforts are especially
Table 3
urgent in the context of the hundreds of millions of dollars that the
Breastfeeding counseling guideline recommendations (WHO 2018b).
infant formula industry spends marketing their products every year,
often without compliance or taking advantage of loopholes in the WHO Breastfeeding counseling should be provided:

• ToIn both
Code (WHO, 2018c). The work from Alive & Thrive in South East Asia,
all pregnant women and mothers with young children.
funded in large part by the Bill & Melinda Gates Foundation, is a best
• At least the antenatal period and postnatally, and up to 24 months or longer.
practices example on how to design, implement, and evaluate impactful • Throughsixface-to-face
times, and additionally as needed.
social marketing campaigns that integrate intensive interpersonal • As a continuum of care,counseling.
counseling, community mobilization, and mass media (Kim et al., • community-based lay andbypeer appropriately trained health-care professionals and
breastfeeding counselors.
2018). A key question that remains is how to make such efforts sus-
tainable without having to rely so much on donors’ assistance. • Anticipating and addressing important challenges and contexts for breastfeeding,
in addition to establishing skills, competencies and confidence among mothers.
Social marketing involves the application of commercial marketing

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R. Pérez-Escamilla Social Science & Medicine 244 (2020) 112331

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