Creating an enabling environment for breastfeeding: Translating research into policy action

Creating an enabling environment for breastfeeding: Translating research into policy action

A reflection for World Breastfeeding Week 2023 #WBW2023

Breastfeeding is recognized by the World Health Organization as one of the most effective global child health interventions with significant implications for maternal health, community health and health equity. Suboptimal breastfeeding is responsible for over 800,000 deaths of children under age five and over 100,000 maternal deaths annually.  Today, while most women and birthing people around the world want to breastfeed, the majority find themselves stacked against a wall of systemic barriers.

The 1981 International Code of Marketing of Breast-Milk Substitutes (the Code) was adopted by the World Health Assembly to promote breastfeeding and protect it from the undermining influence of commercial formula marketing. At the time, the United States voted against the Code and has even taken actions since to erode it. Moreover, governments globally have not made adequate progress in implementing the Code or investing in systems that make breastfeeding possible.

This has not been without consequences – and the harms fall disproportionately on the most marginalized communities and families across and within nations. 

Over the last few months, I have shared our findings from the recent 2023 Lancet Breastfeeding Series at the US launch of the Series at UNICEF Headquarters in New York City and at the World Health Organization and UNICEF’s Global Congress on the Implementation of the Marketing of Breast-Milk Substitutes in Geneva, Switzerland, to highlight these barriers and to share evidence on how to create enabling and equitable environments so that all people have the opportunity to breastfeed as they wish.

It takes a structural, whole-society approach to address systemic breastfeeding barriers

Lactation is a result of millions of years of evolution and has far-reaching effects across many physiological systems. It offers protection from communicable and non-communicable diseases, and it is a dynamic process between the lactating person, child and their environment.

Global recommendations are to begin breastfeeding within the first hour, exclusively breastfeed for six months, and to continue thereafter until age two with other healthy and nutritious complementary foods. Early initiation, frequent and responsive feeding, and skilled support are key to establishing and continuing breastfeeding. Yet while most want to breastfeed, fewer than half of newborns are put to breast in the first hour and many lack skilled support. Similarly, fewer than half breastfeed exclusively for six months and many are unable to sustain breastfeeding for as long as they desire.

This is a significant problem. But it’s not up to individual lactating people or families to address low breastfeeding rates. It takes investment, policies and a whole society approach. Breastfeeding rates are low because of systemic barriers across the health system, work environments, and the regulatory sector that focuses on trade and marketing — where the Code plays a key role.

The influence of predatory marketing of commercial milk formulas

A key driver of low breastfeeding rates is the commercial milk formula (CMF) industry, which has expanded and become increasingly sophisticated in the digital landscape. Families are incessantly exposed to CMF marketing that promises their babies will sleep better, digest better, and even become more intelligent. These health claims lack scientific support and are part of a sophisticated marketing system that sells “sleep” and “peace of mind” to families.

The commercial milk formula industry has a long history of these practices, which interfere with the right to transparent information about health and actively undermine breastfeeding by turning the birth of an infant into a business opportunity.

But it’s not just new parents who are subjected to misleading marketing. Clinicians and medical professional organizations have also been targeted by industry compounding the problem by promoting particular formula products and companies. Infant feeding products are on display in health settings and formula companies sponsor medical conferences and professional education, which signals endorsement of their products and misleading claims.

The $55 billion CMF industry seeks to increase profits despite substantial harms to health. The influence of the CMF industry is far-reaching and even includes policy makers – shaping trade and marketing regulations that undermine the implementation of the Code. This prevents action that would protect the public from predatory marketing.

Hope and Solutions

Even amid the challenges, there are many encouraging signs that we have, and can continue to make progress toward improving rates of breastfeeding.

In 1991, the WHO and UNICEF launched the Baby-Friendly Hospital Initiative championing hospitals to help people breastfeed through information, breastfeeding friendly policies and skilled lactation support. Since its launch, Baby Friendly Hospitals have grown exponentially, and there are now over 590 facilities in the United States accounting for 27.96 percent of annual births. Globally, more than 20,000 facilities have earned the Baby-Friendly designation.

Breastfeeding is increasingly recognized as pivotal to population health, especially in an era of climate change and other major threats to food and health security. In 2022, the White House took a significant step and explicitly recognized the importance of breastfeeding in its National Strategy on Hunger, Nutrition, and Health, which promises to expand breastfeeding support and counseling for mothers. Some of its solutions include testing telehealth initiatives to facilitate virtual breastfeeding support, expanding workplace protections, and ensuring insurance coverage of lactation services.

Many nations are also stepping up efforts to provide longer paid leave and stronger workplace protections. While the U.S. remains a major outlier in its failure to provide federal paid leave, eleven states now provide paid family and medical leave and there are renewed efforts to pass legislation at the federal level. Importantly, the recently enacted PUMP Act greatly extends workplace protections and provides break times and a private space to express milk for most workers. 

The Future: Creating Equitable, Enabling Breastfeeding Environments

In the 2023 Lancet Breastfeeding Series which I co-authored, we argued that investment in breastfeeding needs to be scaled up across all sectors and that the marketing of CMF should end. This does not affect the manufacturing or availability of CMF – only its marketing. The Global Congress on Implementation of the Code of Marketing of Breast-Milk builds on these recommendations and focused on what the Code aims to do and how to implement it. With over 500 delegates from 133 countries, momentum is building to strengthen breastfeeding supports and implement the Code as law in diverse country settings to protect the public from predatory marketing.

On this 2023 World Breastfeeding Week, we renew our call for governments across the globe to fulfill their obligation to protect breastfeeding under human rights law, scale up investments in breastfeeding equity, and implement policies across sectors that enable all those who desire to breastfeed do so as they wish.

To learn more: watch the U.S. launch of The Lancet Breastfeeding Series and the UNICEF-WHO Global Congress on Implementation of the International Code of Marketing of Breast-Milk Substitutes.


Cecília Tomori, PhD, is an anthropologist and public health scholar whose work investigates the structural and sociocultural drivers that shape health, illness, and health inequities. Follow her on social @DrTomori.

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