Big Business undermines breastfeeding campaign as mothers turn to milk formula

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Below is an excerpt from an excellent article in Today's Guardian  about baby food companies in Indonesia:


Here are links to other  Media coverage of the reportGuardian (15 February), PDF 18 February: Daily Mail - Guardian - Daily Telegraph - Daily Mirror PDF,  Guardian (19 February) Observer (24 February)  PDF

Big Business undermines breastfeeding campaign as mothers turn to milk formula

Guardian (on line version 15 February - printed version 16 February )  

 Zoe Williams in Jakarta

To get to the baby immunisation clinic in North Jakarta, the mothers of the slum pick through rubble and muck and the stagnant remains of the January floods. Towers of water-damaged mattresses and mildewed plastic sofas flank the main thoroughfare; it looks like Hell's Ikea. If gastrointestinal disease had its own smell, this would be it.

Fifi, who is 20, lives in a wooden room the size of a bathroom, with her husband and six-month-old daughter, Riska. We met her at the clinic, but only found out later that she wasn't there for jabs, she was there because her daughter was already sick.

She started feeding Riska formula, rather than breastfeeding her, when her daughter was two months old; she was on contraceptives, and thought it was interfering with her milk supply. The midwife agreed, and gave her a free sample of formula milk. Now she spends 400,000 rupiah (about £26) a month on formula, which is half of her husband's monthly salary. She seemed to be a pretty good example of one of the main problems of formula feeding in Indonesia. Even the cheapest brands punch a huge hole in a poor family's budget, and they end up over-diluting it, which leaves the babies malnourished.

'Killing fields'

But at Fifi's home, it became obvious that the sanitation problem towers over this one – 45% of Indonesians have no access to clean water. There are only two places in the capital where anyone can drink from a tap, and that's the American embassy and Jakarta international school. But Fifi can't afford gas to boil water either. She has no kitchen. She has to pay every time she goes to the loo, which is shared between 26 people, and sometimes she cuts a deal with a neighbour where one of them goes to the loo while another has a shower, to save money.

Clean hands, clean utensils, clean bottles, clean anything, it's all a total pipe dream. A paediatrician in a separate Jakartan clinic, Dr Asti Praborini, said: "Selling formula is like the killing fields, in my opinion. The babies will die of diarrhoea and they will die of malnutrition."

Here, all the statements about breastfeeding, which in the developed world are made hyperbolically – how it's the only safe choice for a baby – are true. Indonesia's child mortality rates, at 35 per 1,000, are high anyway, but in the lowest wealth quintile, mortality is nearly five times higher than in the wealthiest.

Some mothers formula feed because they're not eating enough themselves, and don't feel confident that they're producing enough milk. A Save the Children report due out on Monday will give details of breastfeeding rates and child nutrition across the developing world. Wahdini Hakim, senior programme manager, says that persuading mothers to breastfeed is a more effective intervention than efforts to improve sanitation.

But there is a looming influence, far greater than personal choice: that of the formula companies. The World Health Organisation (WHO) has codes on corporate selling of formula that go back to 1981. But this is big business for big companies – two thirds of their growth comes from Asia-Pacific. The Indonesia market is worth $1.1bn (£708m).

This is an example of how it works. Sari Husada, a subsidiary of Danone, has sales reps that build relationships with midwives. Up until 2011, it was purely financial – they would get a village midwife to sign up to a contract, which would involve selling a certain number of boxes of formula per month. Their rewards were pretty small – between 1m(£65) and 3m rupiah a year, depending on the number of deliveries the midwife's practice had, and how much formula they sold. This is in manifest breach of the WHO codes, as well as Indonesian regulations, which expressly ban free samples, as well as direct marketing to healthcare workers or new mothers.

According to Danone, this no longer happens, and has been replaced by a scheme which runs training for midwives. As Usman Tasya, who worked for a subcontractor to whom Sari Husada outsourced its sales, explained: "Basically, what changed was the price. Previously, they were given cash. Post 2012, they were given gifts in kind, once they'd signed a contract."

'Act of beneficence'

Paperwork seen by the Guardian detailing these contracts specifies the change from cash to gifts. Sometimes they'll get a gift, apparently for personal use, like a television or a laptop, but very often, it's something they need for their practice, such as an oxygen canister, a TENS machine or a nebuliser.

The spokesperson for Danone insists that there is no connection between these events – the gifts are just that, an act of beneficence to the midwife, to help her set up her practice, they are unconditional upon the sales of any formula. Asked why that would include a television, he said: "They use them in waiting rooms. To make them places where people would want to go, where they'd feel comfortable going." Asked about why sales reps have a relationship with midwives at all, the spokesman said: "We are permitted to have contacts with healthcare professionals, to tell them what's good about our products. Separate to that, we support midwives in setting up their practices. They're not necessarily separate people. But these are two separate activities."

Formula companies are not allowed to contact new mothers or pregnant women directly and yet, according to Usman, this is rife: "We get details of the mothers who are giving birth, pregnant women, through the midwife." But why would a midwife give out that information? "Midwives, when they get the samples, they really like it. They really like the gimmicks, even the small things. The patient data, they give it to Sari Husada because they think it's part of the programme they've agreed to."

The Guardian has seen a spreadsheet detailing the number of new mothers contacted, the amount of 0-6 months formula sold, and the proportion of their target this represents. Danone commented: "That may still be happening, that's something we need to address."

Sari Husada has legitimate links all the way up the chain. Doctors running seminars for midwives are in its pay. It sponsors professional bodies, conferences and midwifery awards (which are then bestowed by the minister for women's empowerment and the protection of children). The sponsorship element sounds innocuous, and is allowed under Indonesian law; but you can forgive the midwives, who do the grunt work for the company and get the smallest rewards, for thinking that everyone else is doing it, so why shouldn't they?


for the rest of the article click HERE