Pregnancy, birth and women’s bodies: Cultural socialisation, policing pregnancy, fear, and the media.

In 2016 a limited New Zealand media analysis suggested there’s often nothing much to look forward to if you’re a pregnant woman, or a birthing woman. A search on the New Zealand Herald website on February 1st 2016, using the term ‘childbirth’, resulted in over 1000 ‘hits’. An analysis of the first three pages of results found stories about discrimination against pregnant women, infertility, the brutality of childbirth, premature infants who survived, a premature infant who did not survive, maternal death, infertility, stillbirth, cancer in pregnancy, stretch marks, medical misconduct during a caesarean birth, undiagnosed pregnancy, cravings for laundry powder in pregnancy, pregnancy stress causing clumsy kids, and attempts to solve the gaps in maternal mental health services. Two stories about birth took place neither at home or in a maternity facility, but one was in a supermarket car park and the other on a motorway. Of note is the birth on the motorway, which continues a trend found in a previous media review in 2015, indicating the most positive birth stories were about policemen who ‘switch from cop to midwife duties’

A Google search on February 15th, 2016 using the term ‘Childbirth New Zealand’ yielded 970,000 results, and on the first page the Ministry of Health held the two ‘top’ spots, followed by ‘Kidspot’ in 3rd and 4th places. Of the ten first page results, two, about preparing for childbirth, were from a disposable nappy company. Three hits provided information about maternity services in New Zealand for immigrants, and one was from the site Te Ara, Encyclopaedia New Zealand, presenting a history of birth in NZ written by Kerryn Pollock, ‘Pregnancy, birth and baby care – Childbirth, 1950s to 2000s’.

A search for ‘Birth New Zealand’ found five sites out of ten concerned with birth and immigration, one about registering births, one about genealogy, and Home Birth Aotearoa came in at number 10.  The 4th entry was the Ministry of Health page – ‘where to give birth’, which presented some good information and a link to Home birth Aotearoa. If women looking for birth information click on the Ministry site or the home birth site they will reach good, evidence-based, quality information, but this represents only 20% of the sites that were privileged on the first pages of search results

There have been many research studies looking at the effect of media and cultural framing on pregnant women. Alison Brodrick explored the effects of cultural socialisation on fear of childbirth and found that anxiety around childbirth is complex and increasing.[1] Stoll and Hall found that obstetric intervention was viewed favourably by Canadian university students who viewed the media alone as a source of knowledge about pregnancy and childbirth. [2] Stoll and Hall found that media exposure to depictions of birth was significantly associated with fear of birth and commented that popular reality TV shows tend to dramatise pregnancy and birth and over-represent obstetric complications and the need for interventions. Hundley et al report on a debate entitled ‘The media is responsible for creating fear in childbirth’, where normal physiological pregnancy and childbirth are noted to not provide great images for the media, with events being drawn out, long periods of not much happening, (for the onlookers) and minimal thrills and disasters. [3] Typical media portrayal was described as drama, near-miss disasters and flashing blue lights. Although Luce argued against the motion by stating that it is easy to blame the media for everything, when in fact the media “simply reflect what is going on in society”, Duff refuted this suggestion and highlighted dramatic headlines in the UK media such as “First-time mothers who opt for home birth face triple the risk of death or brain damage in child.” The final vote in the debate, following discussion, was 71% for the media being responsible, and 29% against. [4]

Morris and McInerney performed a content analysis of 85 reality-based birth television shows in the United States and found that women’s bodies were typically displayed as incapable of birthing a baby without medical intervention. There was also an overrepresentation of married and heterosexual women.[5]  Tracey Cassels, who writes the ‘Evolutionary Parent’ blogsite, looked at the topic of how media view birth and her analysis concluded that the common themes are ‘speed, fear, pain, and danger’.[6]

Cassels also makes the point that there are two ways to interpret the media representation of birth; “(1) it reflects the attitudes and realities of birth in the culture for which it represents, and (2) it helps shape the attitudes and realities of the culture for which it represents.”  Cassels sees it as “a bit of both”, with the media helping to shape or confirm attitudes and women’s expectations of birth, particularly because some women have been found to look to the media for their main source of information. [7] Holdsworth-Taylor conducted a qualitative analysis of portrayals of childbirth on the internet and found two main types of content she refers to as ‘natural’ and ‘mainstream’. Holdsworth- Taylor describes a “tangled web of misinformation” and suggests that, “from unassisted birth to cascading interventions, each portrayal of childbirth has its own set of implications.” [8]  Walker identifies a consistent theme from visual media which is that of childbirth being pathological and following the technocratic model of birth. [9]


Lothian’s observations about childbearing women’s fears of giving birth, suggest that a risk culture, and ‘expecting trouble’ results in an escalation into fear rather than reassurance. [10] This raises the issue of how the fetus/infant is embodied in the media, and as stated by Lothian what happens now when “fear for the safety of the baby has reached new heights.” Interestingly Lothian wrote her article in 2003. Now, over twelve years later we may consider that the infant-risk focus has not only careered way out of control, but that a corresponding concern for the pregnant and childbearing woman has not kept pace. While understanding the need to communicate information to women, rarely, if ever, is it accompanied by support for pregnant women, recognition of the large workload carried by midwives, nor the every-present issues of poverty, lack of housing, poor housing, unequal access to services, overcrowding, stress, the marketing of cheap unhealthy food and the increasing cost of healthy food.

Paradoxically, in terms of media and internet noise, there has been interesting internet response to the ever-stricter guidelines released by health departments and ministries on such things as eating, drinking alcohol, and pregnancy weight gain. Recently the Centers for Disease Control and Prevention in the Unites States (CDC) circulated a media release stating, “More than 3 million US women at risk for alcohol-exposed pregnancy.”[11] Response was swift with Olga Khazan and Julie Beck in the Atlantic saying, “Protect your womb from the devil drink: Let’s talk about the CDCs bonkers new alcohol guidelines for women.” [12] Khazan and Beck talked about “hypothetical babies”, while Steph at ‘Grounded Parents’ describes “potential future unborn fetuses.” [13]


The ‘Grounded Parents’ article also states, “I am an adult human. I am whole. I am not less important than my potential future unborn fetuses. To suggest that is offensive. I am not going to make a slippery slope argument, because I think we’ve already reached the bottom of the slope. Our culture doesn’t value women and girls.” This takes us to the crux of the matter. Sarah Mirk at ‘bitchmedia’ discusses well-intentioned public health campaigns that have shamed women.[14] Rebecca Kukla, author of ‘Mass Hysteria: Medicine, Culture, and Mothers’ Bodies’ suggests that, “The ideal of zero risk is both impossible to meet and completely paralyzing to try to meet.” [15] When we treat pregnant women as commodities we relegate women to solely producers, and there is a danger that the rights and needs of the woman become invisible in an all-risk-aversive culture. If realistic, non-paternalistic information is not provided to women, and the focus is on compliance, coercion and trying to police women’s pregnant bodies, we miss an opportunity to make a real and positive difference, value women, respect autonomy and protect human rights in childbirth.

 New Zealand is very fortunate, as continuity of care midwifery provides a unique and valuable opportunity for midwives to spend quality time with women, providing evidence- based information, dispelling mythology and taking part in shared meaning-making under a partnership model. This partnership provides a safe ‘bridge’ for women, not only for access to information, but for reassurance, non-judgmental conversation and a safe space to voice any questions, fears or anxieties. Complementary to this would be a wider culture which treats women as adults capable of making decisions about their lives, births and pregnancies, and which addresses the issues of poverty, equal access, inequity, women’s health, gender bias and women’s rights.

This article first appeared in the New Zealand College of Midwives, Midwifery News in 2017 and it has been reviewed and updated for this blog.

[1] Brodrick, A. (2014). The fear factor – why are primigravid women fearful of birth? MIDIRS Midwifery Digest, 24(3):327-332.

[2] Stoll, K., & Hall, W. (2013). Vicarious birth experiences and childbirth fear: Does it matter how young Canadian women learn about birth? The Journal of Perinatal Education, 22(4): 226-233.

[3] Hundley, V., Duff, E., Dewberry, J., Luce, A., & van Teijlingen, E. (2014). Fear in childbirth: are the media responsible? MIDIRS Midwifery Digest, 24(4)444-447.

[4] Ibid

[5] Morris, T., & McInerney, K. (2010). Media representations of pregnancy and childbirth: an analysis of reality television programs in the United States. Birth, 37(2):134-140.

[6] Cassels, T. (2013). The Media and Birth: How the Media Views Birth. The Evolutionary Parent.

[7] Cassels, T. (2013). The Media and Birth: Influences and Consequences. The Evolutionary Parent.

[8] Holdsworth-Taylor, T. L. (2010). Portrayals of childbirth: An examination of internet based media. Interdisciplinary Journal of Health Sciences, 1(1):31-43.

[9] Walker, C. A. (2011). Giving birth to misconceptions: Portrayal of childbirth in popular visual media. Thesis, Haverford College, Anthropology Department.

[10] Lothian, J. A. (2003). Childbearing women’s fears: At the heart of “choice”. The Journal of Perinatal Education, 12(4):36-39.

[11] Centers for Disease Control and Prevention. (2016). More than 3 million US women at risk for alcohol-exposed pregnancy. Press release Tuesday February 2nd 2016.


[13] Grounded Parents. (2016) The CDC can rip the wine glass out of my childbearing aged hand. February 3rd 2016

[14] Mirk, S. (2016). The CDC’s new alcohol guidelines treat women as pre-pregnant. bitchmedia, February 5th, 2016.

[15] Clark-Flory, T. (2016). CDC Tells Fertile Women: Don’t Drink At All.



Expressing breast milk in pregnancy: Should all women harvest colostrum?

Some of the long awaited work about expressing in pregnancy for women with diabetes, from Forster et al, and the DAME study has been published.[1] The implications of this work are important for women with diabetes who plan to breastfeed, and hopefully the findings will lay to rest concerns about expressing in pregnancy and risk of preterm labour. The DAME study found no evidence of harm from advising low-risk, pregnant women with diabetes to hand-express breast milk from thirty-six weeks gestation.

There was misreporting of this study in the media with headlines missing out the ‘diabetes’ context, and others using photographs of breast pumps embedded within the stories. To be clear, the study was about hand expressing from thirty-six weeks gestation for low-risk pregnant women with diabetes. What now requires further research is whether other women at risk of low lactation would benefit from hand expressing and colostrum harvesting in pregnancy.

When considering women who may be at risk of low lactation a discussion about lactation ‘insufficiency’, and what is often described as biological or ‘real’, and what is described as ‘perceived’ is needed. Alison Stuebe discusses issues of ‘perceived’ and ‘real’, and suggests that from a health and wellbeing perspective it may not really matter whether biological and perceived are counted together as, “… mothers are suffering, whether they lack glandular tissue and or they lack self-efficacy and support.”[2]

It is unknown exactly how many women are at risk of primary lactation insufficiency although we know that diabetes and other medical conditions are associated with delayed lactogenesis, and some women may have supply challenges due to issues with low glandular tissue amounts, or previous breast surgery. Two percent is often quoted for numbers of women who may have lactation insufficiency, and Neifert suggested in 2001 that up to 5% of women may have primary lactation issues because of breast anatomy or medical conditions.[3] New Zealand Ministry of Health figures from 2014 suggest that out of 61,000 births, 6.6% of these pregnancies were affected by diabetes.[4]

A full breast milk supply requires sufficient breast glandular tissue, intact nerve pathways and ducts, hormone production, and frequent and effective milk removal. If any of these are parts are compromised there is a risk that full lactation may not be reached. Lactation issues with a secondary cause are as difficult to calculate as primary. Secondary refers to women who have a full lactation, or the capacity to develop a full lactation, but some ‘interference’ occurs, which results in low lactation issues. Birth interventions, caesarean births, sleepy babies, latching problems, and lack of support can all lead to secondary issues with milk supply.

Because environmental and social factors also play a significant role in lactation, how we approach discussions about lactation and breastfeeding during pregnancy is also significant, as is what happens to women in labour, birth and the post-birth period. Amy Brown explored the psychosocial and cultural issues around breastfeeding and their impact on the physiology of breastfeeding, why many mothers stop breastfeeding before they planned to, and why low milk supply is commonly cited as the reason. Brown highlights how psychological, social and cultural influences can strongly influence the physiology of breast milk supply.[5] Otsuka et al, in a study of 262 breastfeeding women in Japan found that 73% of the women had a perception of insufficient milk supply,[6] and the Growing up in New Zealand study found that 45% of the women in their cohort cited insufficient milk supply, with 32% also citing their babies were not satisfied with breastfeeds.[7]

In New Zealand there are stories of women with low risk pregnancies, without obvious risk for low milk supply, who have been advised to express colostrum in pregnancy. What is unknown is the outcome of these interventions. Whether milk supply was enhanced, maternal confidence increased or subdued, breastfeeding outcomes were favourable or unfavourable.

Rachel O’Brien, whose Master’s thesis was about women in the US and low milk supply, wrote an interesting blog on milk supply and psychology, where she used response expectant theory (RET) to explain why hearing “over and over” about low milk supply could cause bodies to “respond in the way that we expect them to – by making less milk than we need.”[8] Kirsch describes RET as the anticipation of automatic, subjective, and behavioral responses to particular situational cues,[9] suggesting a non-volitional response can occur due to expectations of one’s own response to a situation. When discussing Kirsch’s RET theories, Stewart-Williams, suggests that the hypothesis has “an intuitive plausibility. For instance, the expectation of anxiety is likely to be anxiety provoking, and the expectation of depression is likely to be depressing.[10]

Amy Brown discusses breastfeeding outcomes, why engagement in pregnancy is important for breastfeeding, and how women who feel prepared, knowledgeable, and confident about breastfeeding have better outcomes after birth.[11] Brown examined behavioural factors contributing to ‘successful’ breastfeeding and found that women with high levels of confidence, and determination about their breastfeeding decisions, managed to navigate their way through the challenges they faced to meet their goals for breastfeeding. This appears to illustrate the positive significance of the development of confidence and self-efficacy.

Funding and resources to undertake breastfeeding research, so practice can be underpinned with evidence wherever possible, is not readily available. Another issue for breastfeeding is the lack of support for breastfeeding women, and this includes limited or no maternity protection, insufficient paid maternity leave, and a lack of government engagement and recognition of breastfeeding and its link to public health. Peer support is recommended by the World Health Organisation for initiation and continuation of breastfeeding. Recent research by Aimee Grant et al, from Cardiff University, found that services for breastfeeding peer support were inadequate.[12] A similar situation exists in New Zealand where there are patchy peer support services available.

There are many interlocking pieces in the puzzle of low lactation including clinical, iatrogenic, psychological, and the care women receive, and until we have more evidence and information to complete the picture, a tailored approach is necessary. This means grounded in up to date practice and care that boosts maternal confidence and promotes self-efficacy, where the individual woman’s situation is the primary concern, and if there are previous experiences of breastfeeding, these are taken into account.

Dahlen discusses “modern maternity care” and whether it has “morphed into a super trawler of risk, scooping up with its well-meaning ‘net’ the bycatch” – well and healthy women. [13] Promoting ante-natal colostrum harvesting to all pregnant women inevitably pulls low risk women into the ‘net’, and may contribute to increased levels of anxiety about milk supply. Some women with risk factors for low lactation are likely to benefit from harvesting colostrum in late pregnancy, and they also need ongoing support for the initiation and establishment of breastfeeding. Women without risk factors for low lactation need support for the development of their breastfeeding self-efficacy and confidence. Lauwers and Swisher discuss the medicalisation of breastfeeding and suggest that:

“It is incumbent on all who work directly with families to be a part of a solution in protecting breastfeeding, not part of the problem”[14]

[1] Forster, D. A., Moorhead, A. M., Jacobs, S. E., Davis, P. G., Walker, S. P., McEgan, K. M., Opie, G, F., Donath, S. M., Gold, L., McNamara, C., Aylward, A., East, C., Ford, R., & Amir, L. H. (2017). Advising women with diabetes in pregnancy to express breastmilk in late pregnancy (Diabetes and Antenatal Milk Expressing [DAME]: a multicentre, unblended, randomised controlled trial. The Lancet, 389:2204-2213.

[2] Stuebe, A. (2012). How often does breastfeeding just not work? Breastfeeding Medicine/Physicians blogging about breastfeeding.

[3] Niefert, M. R. (2001). Prevention of breastfeeding tragedies. Pediatric Clinics North America, 48(2):273-297.

[4] Ministry of Health. (2014). Diabetes in Pregnancy. Wellington, MOH.

[5] Brown, A. (2015). Milk supply and breastfeeding decisions: the effects of new mothers’ experiences. NCT Perspective, Issue 29, December.

[6] Otsuka, K., Dennis, C.-L., Tatsuoka, H., & Jimba, M. (2008). The relationship between breastfeeding self-efficacy and perceived insufficient milk among Japanese mothers. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 37:546–555.

[7] Morton, S. M. B., Atatoa Carr, P. E., Grant, C.C., et al. (2012). Growing Up in New Zealand: A longitudinal study of New Zealand children and their families. Report 2: Now we are born. Auckland: Growing Up in New Zealand

[8] O’Brien, R. (2016). You get what you expect: low milk supply and psychology.

[9] Kirsch, I. (1997) Response expectancy theory and application: A decennial review. Applied and Preventive Psychology, 6(2):69-79.

[10] Stewart-Williams, S. (2004). The placebo puzzle: Putting together the pieces. Health Psychology, 23(2):198-206.

[11] Brown, A. (2016).What Do Women Really Want? Lessons for Breastfeeding Promotion and Education. Breastfeeding Medicine, 11(3):102-110.

[12] Grant, A., McEwan, K., Tedstone, S et al. (2017). Availability of breastfeeding peer support in the United Kingdom: A cross sectional study. Maternal and Child Nutrition, 13(3):e12476.

[13] Dahlen, H. (2014).Managing Risk or Facilitating Safety? International Journal of Childbirth, 4(2):66-68.

[14] Lauwers J., Swisher, A. (2011). Counseling the Nursing Mother: A Lactation Consultant’s Guide, 5th edition, p. 248. Sudbury, Jones and Bartlett.


Marketing of breast-milk substitutes: National implementation of the International Code – Status report 2016

A recent comprehensive report by the World Health Organisation, UNICEF, and the International Baby Food Action Network (IBFAN), has revealed the status of national laws to protect and promote breastfeeding in 194 countries.[1] The World Health Organisation issued a media release on May 9th and commented that richer countries lag behind poorer ones in their implementation of the International Code. [2]

135 countries, out of the 194 analysed, have in place some form of legal measure related to the International Code of Marketing Breast-Milk Substitutes, [3] and subsequent, relevant World Health Assembly resolutions,[4] [5] and this number has increased by 35 since the last analysis which was carried out in 2011. The International Code had a birthday this year and is now 35 years old, so it is disappointing to note that only 39 countries out of the 194 reviewed have laws that enact all International Code provisions. The International Code, and the essential updates in the form of the World Health Assembly resolutions, are designed to not only protect breastfeeding by stopping inappropriate and misleading marketing of breast-milk substitutes, bottles and teats, but to also protect infants fed on breast-milk substitutes. All parents should have access to unbiased, commercial-free, information about infant feeding, and health professionals also need a source of unbiased, scientific and factual information.

To compile the Status Report 2016, countries were invited to respond to a questionnaire on Code implementation, and additionally IBFAN, the International Code Documentation Centre (ICDC), and UNICEF, reviewed and updated categorisation of information received about country practices and legal measures.

In the report New Zealand is one of the countries with no legal measures (Annex 1, p. 50) and although it is recorded that the Ministry of Health has formal mechanisms for monitoring the Code in place, which is noted to be transparent, independent, budgeted, empowered to take action, sustainable and monitored monthly to annually, the report states that it is not free of commercial influence (Annex 3, p. 62). Additionally the NZ monitoring mandate does not include retail shops or pharmacies and the report notes that although violations were recorded no sanctions were imposed (Annex 3, p. 63). As stated in the WHO media release, monitoring is essential to detect violations but it is important that these measures are fully operational and results should be published. Meaningful sanctions are also essential to reduce violations.

It seems timely to refer back to the recent Lancet Series on breastfeeding which contained the economic argument for breastfeeding, and the need for protection of breastfeeding and infant feeding, via the International Code of Marketing of Breast-Milk Substitutes. McFadden et al, called for a coordinated global action to combat inappropriate and misleading marketing. [6] WHO/UNICEF and IBFAN urge countries who have not yet adopted legal measures to do so. With the aggressive and misleading marketing of breast-milk substitutes continuing largely unabated, and a global sales revenue of US$44.8 billion, which is expected to rise to US$70.6 billion by 2019, this Status Report highlights the need for urgent action by governments now.

[1] World Health Organisation/UNICEF/International Baby Food Action Network. (2016). Marketing of breast-milk substitutes: National implementation of the International Code – Status report 2016. Geneva, WHO.

[2] World Health Organisation. (2016). Laws to protect breastfeeding inadequate in most countries. Geneva. WHO Media Centre.

[3] World Health Organisation. (1981.) International Code of Marketing of Breast-Milk Substitutes. Geneva, WHO.

[4] World Health Organisation. World Health Assembly resolutions and documents: Infant and young child nutrition.

[5] International Baby Food Action Network. The Full Code. WHA Resolutions.

[6] McFadden, A., Mason, F., Baker, J., Begin, F., Dykes, F., Grummer-Strawn, L., Kenney-Muir, N., Whitford, H., Zehner, E., & Renfrew, M. (2016). Spotlight on infant formula: Coordinated global action needed. The Lancet, 387:433-435.

Cows & their milk do not live in a parallel universe, so support women to breastfeed, and at the same time let’s clean up the world #Regulation #Accountability #Breastfeeding

A recent article by Du, Gridneva, and Gay et al in the journal ‘Chemosphere’, ‘Pesticides in human milk of Western Australian women and their influence on infant growth outcomes: A cross-sectional study’, is about the levels of persistent organic pollutants in human milk.[1]

Highlights were reported as being;

  • Cross-sectional study of 88 POPs in human milk over first year of lactation.
  • p,p′-DDE was detected in 87.5% of the human milk samples.
  • No significant associations between p,p′-DDE and infant growth outcomes.
  • Estimated daily intake overestimates human milk POP concentration.
  • Human milk infant intake of DDTs is below the recommended daily intake guidelines.

And the abstract concluded with this;

“Furthermore, for the first time no significant association was found between p,p′-DDE concentrations in HM and infant growth outcomes such as weight, length, head circumference and percentage fat mass. The calculated daily intake was significantly different to the estimated daily intake of total DDTs and was well below the guideline proposed by WHO. The DDTs levels in WA have also significantly decreased by 42 – fold since the 1970s and are currently the lowest in Australia.”

So, good news – pollution of the environment, and human exposure to it, is reducing through the restriction of usage of some chemicals. Whether it’s fast enough and widespread enough is another question.

Why I’m writing this really is in response to the Alternet article, ‘Pesticide Levels in Breast Milk Have Dropped Significantly, but Health Concerns Remain.’[2] The article itself is quite good, given that it mentions not only human milk but also blood and urine, which is a good thing, as sometimes articles miss this point and readers can mistakenly construe that breast milk is the only fluid with an issue. But the article forgot to mention that babies are exposed to chemicals in utero and breastfeeding is really important as it mediates this exposure. So here are a few important points gathered together –

  1. Levels of pesticides in breast milk have dropped significantly over the past 40 years.
  2. Alternet doesn’t mention it, but breastfeeding actually mediates the exposure that has already occurred in utero, and breastfeeding/breastmilk supports the development of the infant immune system.
  3. This means that breastfeeding is still recommended and is optimal for infant feeding and infant growth, wellness and development.
  4. It Illustrates the positive impact banning pesticides can have on the health of individuals, especially vulnerable infants.
  5. And that’s the issue – the need to keep up the pressure to clean up our pesticide-riddled world as babies and small children, and their mothers, are exposed to hazardous chemicals through contact with products such as carpets, clothing, furniture, household and cleaning products, as well as those in food, the air and the soil.
  6. So, the chemical industries responsible, and the governments who fail to regulate them, need to be held to account.
  7. And, just to remind everyone – cows & their milk do not live in a parallel universe either, so feeding formula to infants is not the answer.



‘Why the politics of breastfeeding matter’ – Author Gabrielle Palmer -Book review

This is another excellent book from the ‘why it matters’ series from publishers Pinter and Martin. Gabrielle Palmer is well known for her ground-breaking book, The Politics of Breastfeeding, which was first written in 1988. Palmer is a nutritionist with a myriad of experience in the world of infant feeding, including working in Mozambique and China, supporting the establishment of the UK International Baby Food Action Network (IBFAN) group Baby Milk Action, and health and development agency work, including UNICEF. This new book is a condensation of the central concepts from the Politics of Breastfeeding, and it delves efficiently into the systems set up to sabotage the intentions of breastfeeding women, milk economics and the creation of a market that aggressively pushes breast-milk substitutes. It describes the differences between advertising and information provision, and also describes the International Code of Marketing of Breast-milk Substitutes.  This new book provides an accessible introduction into the corporate forces and vested interests that affect infant feeding decisions, with explanation of the historical underpinnings, as well as provision of an up to date, contemporary focus. The World Breastfeeding Week theme for 2016 was shaped around breastfeeding and sustainable development, and Palmer addresses climate change, dairy and environmental damage as part of her analysis of the costs of not breastfeeding. This revealing book is essential reading for all those who work with mothers and infants. It challenges us to rethink what we think we know about women’s infant feeding decisions, from the frame of simple, independent choices to a frame that recognises that the dice have been very loaded against breastfeeding women for a significant length of time.  Some mothers have been unknowingly situated at a distinct disadvantage, with great costs to their own health, their children’s health, society and the planet.

The International Code of Marketing Breast-milk Substitutes, dairy science fiction, and how health workers can make a positive impact in the world of infant and young child health.

The International Code of Marketing Breast-Milk Substitutes and subsequent, relevant World Health Assembly resolutions are a starting point for the consideration of ethics in the world of infant feeding. There is a surfeit of misleading marketing of breast-milk substitutes to parents who are often information hungry, unclear about the differences between breastfeeding and infant formula feeding, hoping to find the ‘best’ product for their babies, or thinking that they need to purchase the most expensive products. At the same time we read simplistic under-researched media stories that perpetuate the fantasy that breast-milk can be replicated and breastfeeding replaced. This dominant milieu influences the general public who may have limited awareness of marketing tricks. Because prime marketing strategy involves forming health alliances it is essential that health workers have a clear understanding of the issues of conflict of interest, endorsement by association and the importance of breastfeeding. It is also essential that they become sources of unbiased commercial-free information for parents on all aspects of infant feeding.

Key words: International Code, Breastfeeding, Breast-Milk Substitutes, Infant feeding, Infant formula, Marketing, Conflict of interest, Health workers, Price placebo, Puffery

We regularly see media releases heralding the scientific discovery of yet more amazing components in breast milk but most of the scientists quoted, if media reports are to be believed, appear to see their latest discoveries as a way to develop ingredients to add to cow’s milk formulas to make them closer to breast milk (Medical Xpress 2013). Regardless of this science fiction fantasy, because it is indeed a fairy story, the media perpetuate the news stories, usually without a balanced perspective, and industry continue to make misleading claims about their products already on the market. As all infant formula products are required to meet legislated criteria regarding ingredients, the nutritional composition of the majority of products is exactly the same. Kevin Frick notes that companies use substantial resources to differentiate themselves from each other for the purpose of competition. This monopolistic competitive quest for parental attention, which is inappropriate due to the vulnerability of infants and the critical importance of what they are fed, results in a market not operating efficiently to provide goods at minimum cost, with the benefits to infants of this broad range of products being unclear (Frick 2009). The International Code of Marketing Breast-Milk Substitutes (World Health Organisation 1981), and subsequent, relevant World Health Assembly resolutions provide the framework necessary to control misleading health and nutrition claims but the majority of countries do not have regulations or legislation in place to enforce the Code. Instead many allow industry to write, monitor and enforce their own voluntary codes of practice.

The International Code of Marketing Breast-Milk Substitutes is a set of recommendations from the collective membership of an international body in the field of health, the World Health Assembly. It does not ban the sale or use of breast-milk substitutes, or any particular company’s products, but instead it is directed at unethical marketing practices, and false and misleading advertising. The Code is also clear that there are legitimate reasons for using breast-milk substitutes, and it is concerned that parents who use breast-milk substitutes have access to accurate, safe and unbiased information. The International Code always needs to be considered alongside the subsequent, relevant World Health Assembly (WHA) Resolutions as they keep the Code, which was written in 1981, up to date. In 2010 a WHA resolution item,11.6, called for an end to the inappropriate promotion of food for infants and young children and highlighted the need to ensure that nutrition and health claims shall not be permitted for foods for infants and young children (Baby Milk Action 2010; World Health Assembly 2010).

The vulnerability of infants in the early months of life and the risks involved in inappropriate feeding practices underpins the International Code and this is described in the preamble to the Code. It is this infant vulnerability which makes the usual marketing practices we are exposed to relentlessly in our everyday 21st century lives, unsuitable for breast-milk substitutes.

There are a range of marketing messages tailored to appeal to parents with claims about immune system development support, beneficial gut flora support, brain development and abilities to solve infant feeding problems. However, robust independent scientific evidence for the efficacy of added novel functional ingredients is limited and unclear (Ackerberg 2012; Schulzke et al 2011; Simmer et al 2011; Starling 2010; Vy 2002; Yau 2003). A parent, Roberta, who is a Momsrising member, posted about what she termed “New Parent Infant Formula Selection Paralysis” (Farber 2010).

“The few times I had to buy formula for my son, I was paralyzed by the wall of options in the grocery store. Each brand made a different claim about what their formula would do for my son’s health, and the more claims there were, the more expensive the can. Even my son’s paediatrician couldn’t recommend a choice”.

In marketing there is a phenomenon called price placebo which is based on consumers believing that if they pay more for a product then it means it must be a better product. So at the same time parents using breast-milk substitutes are trying to decide which product to buy for their babies they are not only influenced by health and nutrition claims but by price, and they are likely to buy the high-price-high-claim products. Some parents who find it hard to afford the breast-milk substitutes for their infants, have been found to practice what is referred to as ‘formula-stretching’ which involves reducing feed amounts/times and/or watering down feeds. Formula stretching practices are associated with serious short and long-term consequences such as failure to thrive and developmental deficits (Burkhardt et al 2012). Burkhardt et al also found that 58% of the urban parents in their study would not use the cheaper generic formulas, and 50% believed that generic formulas and brand name formulas were not equivalent. The reason for this is simple – marketing.

The aim of commercial marketing is to eliminate choice or to establish a strong bias towards only one choice, rather than to increase the choices for consumers (Heinig 2006). The ultimate aim being to increase profits for your shareholders by giving consumers the impression that they need your product, and in the case of breast-milk substitutes, that parent consumers need to continue to use product for longer than recommended by global infant feeding guidelines.

Berry et al in Australia, found that toddler milks function as indirect advertising for other breast-milk substitute products such as those marketed for infants below six months –stage one – and those marketed for above six months to one year – follow-on products (Berry et al 2010). Neither the follow-on, nor the toddler products are necessary, as infants can continue up to one year on the ‘from birth’ products and after one year infant formulas are not needed as cow’s milk is considered appropriate for the majority of toddlers.

The reach of marketing has expanded significantly with the explosion of social media and sites such as Facebook and YouTube. Abrahams found that out of the eleven brands she examined, eight had Facebook pages and five a YouTube presence (Abrahams 2012). This is significant because of the reach of social media but also because of the difficulties in both monitoring and regulating this relentless marketing.

Parents buying breast-milk substitute products making health and nutrition claims are being exposed to what could be termed a form of puffery. Puffery on consumer products is recognized and accepted by industry, regulators and consumers and is described as being about the legitimate and harmless exaggeration of advertising claims to overcome natural consumer scepticism and to make a product look better than those of the competing brands. Because the claims in ‘puffery’ are described as being vague and subjective, they are not believed to be misleading to most consumers. The assumption is that consumers expect advertisers to claim that their products are the best but that they will not believe this to be true (Adams & Maine 1998).

Winstanley & Cressey reported that parents taking part in a survey about the preparation of powdered infant formula in New Zealand were ‘information hungry’ and that the information on the infant formula tin seen was seen as ‘available, authoritative and trusted’. Although the report was primarily concerned with how parents were interpreting instructions and preparing feeds it did find that some parents avidly read about ingredients and the differences between brands. One parent considered the information on the tin as a ‘legal document written by experts’ and another stated that the ‘tins did not lie’ (Winstanley & Cressy 2008). As previously described, the Code preamble clearly states that the marketing of breast-milk substitutes requires special treatment, which makes the usual marketing practices unsuitable for these products, and the assumed ‘harmless exaggeration’ is unlikely to be harmless and is therefore totally inappropriate.

Health professionals need to know about the International Code and resolutions, but they also need to consider issues such as sponsorship, conflict of interest and endorsement by association. Conflict of interest is defined as a situation in which financial or other personal, employment or professional considerations have the potential to compromise or bias professional judgment and objectivity. The International Baby Food Action Network, in their position statement concerning sponsorship and conflict of interest, ‘call upon all health care workers, including health professionals and their associations, to avoid accepting any donations or funds, offers of assistance in cash or kind from companies with a commercial interest in infant and young child health and development, particularly in the feeding of babies’ (IBFAN).

Health professionals who work with parents, infants and young children need to know about all aspects of infant and young child feeding, understand the responsibility to protect breastfeeding, and also provide non-judgmental information about the use of breast-milk substitutes to parents who require this information. There is no dispute about the value of research which could lead to an improved breast-milk substitute. However, perpetuating mythology and making claims suggesting that breast milk, containing around 150 long chain polyunsaturated fatty acids, 130 oligosaccharides, lymphocytes, secretory IgA, lactoferrin, lysozyme, nucleotides, hormones, growth factors and the recently reported over 700 beneficial bacteria, just to name a few of the components of human, living, synergistic breast milk, can ever be replicated is pure science fiction. Unfortunately as explained by Lewandowsky et al, repeated exposure to a story or statement is known to increase its acceptance as ‘true’ (Lewandowsky et al 2012), so continued work is necessary to counter misleading media reports. Davies also highlights another ever increasing concern, ‘churnalism’. This is when journalists no longer gather news but instead passively process whatever material comes their way (Davies 2009). Hence we see inaccurate, unbalanced, under-researched stories echoed all around social media sites and the internet.

Learning more about the International Code and resolutions helps to keep the policy issues on infant and young child feeding alive internationally, and at national and local levels, and provides the understanding needed for health workers to become advocates and watchdogs in regards to breastfeeding protection, safe infant feeding and formula usage and appropriate marketing. It would be valuable for health workers involved with infant feeding to support breastfeeding protection and safe infant feeding advocacy work by reporting Code violations to the appropriate monitoring bodies, keeping up to date with what is happening in the world of breast-milk substitutes and countering inaccurate stories doing the rounds in the media. Each contribution is important for infant and young child health. As Martin Luther King Jr said, You don’t have to see the whole staircase. Just take the first step”.


Abrahams SW (2012). Milk and social media: Online communities and the international Code of Marketing of Breast-milk Substitutes. Journal of Human Lactation, 28:400-406.

Ackerberg TS Labuschagne IL & Lombard MJ (2012).The use of prebiotics and probiotics in infant formula. S Afr Fam Pract, 54(4):321-323.

Adams D & Maine EL (1998). Business Ethics for the 21st Century. Chapter 7, Advertising and Marketing. Mountain View California, Mayfield Pub.

Baby Milk Action (2010).

Baby Milk Action (For reporting Code violations)

Berry N Jones S C & Iverson D (2010). “It’s all formula to me”: Women’s understandings of Toddler Milk ads. Breastfeeding Review, 17(3), 21-30.

Burkhardt MC Beck AF Kahn RS et al (2012). Are our babies hungry? Food insecurity among infants in urban clinics. Clinical Pediatrics, 51, (3):238-243.

Davies N (2009). Flat Earth News: An Award-winning Reporter Exposes Falsehood, Distortion and Propaganda in the Global Media. London, Vintage.

Farber K (2010). Formula companies can discourage breastfeeding: Take action with Momsrising.

Frick, KD (2009) ‘Use of economics to analyse policies to promote breastfeeding’, in F Dykes & V. H Moran, Infant and Young Child Feeding: Challenges to implementing a global strategy, Oxford: Wiley-Blackwell Publishing Ltd.

Heinig MJ (2006). The International Code of Marketing of Breastmilk Substitutes: The challenge is choice. Journal of Human Lactation, 22,(3):265-266

International Baby Food Action Network (IBFAN). Position statement on sponsorship and conflicts of interest. Accessed via

Lewandowsky S Ecker UK H & Seifert CM et al (2012). Misinformation and its correction: Continued influence and successful debiasing. Psychological Science in the Public Interest, 13,(3): 106-131.

Medical Xpress (2013).

Schulzke SM Patole SK & Simmer K (2011). Long-chain polyunsaturated fatty acid supplementation in preterm infants. Cochrane Database Systematic Review.

Simmer K Patole, SK & Rao SC (2011). Longchain polyunsaturated fatty acid supplementation in infants born at term (Review). Cochrane Database Systematic Review.;jsessionid=3D81A03678062194BD7E7E8926B4869F.d03t04

Starling S (2010). EFSA rejects Daone’s infant immunity prebiotic claim.

Winstanley A & Cressey P (2008). Information sources and practices – preparation of powdered infant formula in NZ. Report prepared as part of a New Zealand Food Safety Authority contract for Scientific Services by Institute of Environmental Science & Research Limited.

World Health Assembly (2010). 63rd WHA May. Infant and young child nutrition

World Health Organisation. (1981). The International Code of Marketing Breast-Milk Substitutes. Geneva, WHO.

Yau K Huang C Chen W et al (2003). Effect of nucleotides on diarrhea and immune responses in healthy term infants in Taiwan. J Pediatr Gastro Nutr, 36:37–43.

Vy Y (2002). Scientific rationale and benefits of nucleotide supplementation of infant formula. J Paediatrics Child Health, 38(6):543-549.