Government Support for Breastfeeding and the 2023 Lancet Series

Alison Thewliss Excerpts

Monday 20th February 2023 Commons Chamber

[Alison Thewliss (Glasgow Central) (SNP)]

I have repeatedly brought matters to this House concerning infant feeding. For an issue that concerns every child ever born, it generally gets remarkably little attention from Governments. Madam Deputy Speaker, I can assure you that breastfeeding is an issue of the utmost importance. According to the World Health Organisation, breastfeeding has the potential to prevent 800,000 child deaths globally each year. As The Lancet paper editorial states:

“Breastfeeding has proven health benefits across high-income and low-income settings alike: it reduces childhood infectious diseases, mortality, and malnutrition, and the risk of later obesity; mothers who breastfeed have decreased risk of breast and ovarian cancers, type 2 diabetes, and cardiovascular disease.”

Yet despite those clear health benefits, around the world and here in the UK, we see a growth and embedding of commercial milk formula in our culture.

I stress that this is not a criticism of individual parents, or a value judgment. This is not about formula versus breastfeeding; it is a structural issue, relating to recognition of the importance of breastfeeding and to the lax regulations that have allowed a commercial industry to flourish. The recently published Lancet papers tackle the structural reasons for which breastfeeding does or does not happen. Commercial milk formula is a multibillion-dollar industry which directly targets families with multifaceted and sophisticated marketing practices—practices that influence our beliefs and values, prey on our insecurities and weaknesses, and are exacerbated by the absence of comprehensive Government support for breastfeeding.

There are three Lancet papers, each highlighting the impact of several aspects of commercial milk formula marketing. The second states:

“The marketing of commercial milk formula…for use in the first 3 years of life has negatively altered the infant and young child feeding ecosystem.”

Successful breastfeeding depends on a network of policy and society responses. It is the responsibility of Government to regulate the industry, and to implement structural policies to mitigate the impact of formula marketing. Women who do breastfeed do so despite billions of pounds’ worth of marketing designed specifically to undermine them.

However, this commercialisation does not just affect breastfed babies and their families. The cost of the marketing literally adds to the price of commercial formula on supermarket shelves. Research by Leicester Mammas—presented recently to the all-party parliamentary group on infant feeding and inequalities, which I chair—shows the influence of advertising, with many parents choosing the most heavily advertised first- stage formula rather than the cheapest. All first-stage formulas are exactly the same by law.

In 2018, the APPG produced a report highlighting the significant impact of the cost of commercial milk formula on family budgets. Inflationary pressures are much worse now than they were in 2018, with profound consequences. Feed UK has highlighted the increased costs in its own more recent research, and just yesterday an article in The Guardian revealed that supermarkets such as the Co-op are now keeping formula behind the counter to prevent shoplifting. It said:

“The cost of infant formula has soared over the past year - with the price of the cheapest brand increasing by 22%. Even if a parent is able to access the cheapest brand, Aldi’s own label, the cash value of Healthy Start vouchers, £8.50 a week, is no longer enough to pay for the amount of infant formula needed to safely feed a baby in the first six months of their life.”

That is a very difficult increase for many families to bear. The Minister should be concerned about the risks of parents’ watering down formula, feeding babies under a year old cows’ milk, or thickening milk with porridge because they simply cannot keep up with the spiralling costs of infant formula. Inadequate nutrition at an early stage can have devastating long-term health and developmental impacts. I have raised this matter with Ministers before, and I encourage them to take it seriously. I am presenting the debate this evening because I feel that it is important for the Government to engage meaningfully with the findings of The Lancet report.

[Jim Shannon (Strangford) (DUP)]

I commend the hon. Lady for initiating the debate, and for the leadership that she brings to the APPG. Her voice on behalf of breastfeeding women throughout the United Kingdom has been welcome.

In Northern Ireland, our community midwives team are extremely focused on aiding breastfeeding, yet, as the hon. Lady will know, we have the lowest breastfeeding rates in the UK. Does she agree that providing breast-milk pumps for women in low-income families who are put off by the prohibitive cost of the pumping equipment, but who need their child to be minded after the end of their all too short maternity leave, may be a useful tool to help mums to realise that “breast is best” can work in tandem with their return to work?

[Alison Thewliss]

The provision of those pumps can indeed make a huge difference to working families by giving women the flexibility to return to work. Many of them want to breastfeed, but find that returning to work presents a barrier to it. I will say a little more about the pressures from maternity leave later in my speech.

In this post-Brexit landscape, health industry professionals are making it clear that there should be no reduction in regulation on commercial milk formula. Existing regulations should be maintained as a minimum, and work should be conducted to improve on them.

Let me now take a bit of time to discuss the different angles of the three papers. The first explores the challenges of breastfeeding in a market-driven context. Many of us will be familiar with the stress of having a newborn: are they feeding enough, too much, too little? Are we getting enough sleep? Why are they still crying? Commercial milk formula companies thrive on this self-doubt. They want to exploit what are normal developmental phases and present them as problems to which only they can provide a solution. Online forums and baby clubs, apps, emails and pop-up ads are rife. They consistently undermine parents’ confidence, so that a product can be sold as the answer to their problems. When you are exhausted and your baby has been crying for hours, commercial milk formula companies are there to sell you a good night’s sleep, peace of mind, or a special type of formula to stop your baby fussing.

No one would judge parents in that position. We have all been there, and would gladly hand over all the money in our wallets to get that peace of mind. Companies have stepped into this space to offer specialist formulas in a quite unregulated way: formulas sit on the supermarket shelf offering solutions to colic and spitting up, for “hungry babies”, and to deal with allergies. The truth is, however, that there is no solution—not one that comes in a tin, anyway. Fussing and crying and disrupted sleep patterns are all extremely normal parts of human development and baby behaviour. Normal sleep patterns of babies sadly do not align with the sleep patterns of adults, no matter how they are fed. The responsibility lies on us, as policymakers, to ensure that parents are informed and helped to make the best choices for their babies. We need to ensure that any vacuum of information is not filled by aggressive marketing.

The second paper looks at the marketing playbook used by commercial milk formula companies. I should say at the outset that I am not arguing that marketing is inherently bad, or that companies should not make profits, but there is a case for an overhaul of the regulations. When marketing impacts human development and health outcomes to such an extent, Governments need to step up to the plate.

Commercial milk formula sales were worth $55.6 billion in 2019. Let me put that figure in context: it far exceeds the Scottish Government’s budget in the same year. Sales per capita have increased substantially across the world over the last decade. There are many reasons for that—poor breastfeeding support, work constraints, perceived issues with milk supply or fussiness—but the major contributor is marketing. Between $2.6 billion and $3.5 billion is spent on milk formula marketing every year, and that is likely to be the tip of the iceberg, because it does not include the costs of lobbying, social media or sponsorship of health workers, all of which are key entry points in shaping beliefs and altering consumer decisions. Industry lobby groups work to influence policy environments in favour of the milk formula industry and their shareholders.

Medical professionals are targeted as well, through deliberate efforts by formula companies to encourage the diagnosis of health issues which they claim that their products can alleviate. Dr Chris van Tulleken is among several health professionals who have explained how this has led to over-diagnosis of health issues such as cows’ milk protein allergy, an activity that is being led by formula companies presenting their products as a “solution” to normal baby behaviour. He found that, astonishingly, between

“2006 and 2016, prescriptions of specialist formula milks for infants with CMPA increased by nearly 500% from 105,029 to over 600,000, while NHS spending on these products increased by nearly 700% from £8.1m to over £60m annually.”

There is little evidence to suggest that prevalence has increased, but it is clear from those figures that industry influence has. This is a cost to the NHS of which the Government should be mindful.

The report finds that the World Health Organisation’s “The International Code of Marketing of Breast-milk Substitutes” has been routinely blocked, reinterpreted, circumvented, or ignored entirely in order for companies to achieve astronomical profits. One example is the creation of follow-on milks as a response to the marketing constraints that do exist: they are completely unnecessary, and often contain additional harmful sugars. The aim is to sell them to promote first-stage formulas that cannot be advertised on television. In the UK, the existing regulations are poorly enforced, and could well end up being scrapped in the bonfire of regulation that is the Retained EU Law (Revocation and Reform) Bill. I seek an assurance from the Government that that will not happen. I also ask the Government to use their voice at the meeting of the Codex Alimentarius Commission to tighten regulations globally, instead of allowing industry to have its own way.

The third paper highlights the way in which the political economy influences breastfeeding outcomes. The paper finds that inadequate maternity rights and poor working conditions make it difficult for many mothers to breastfeed, and, as was pointed out by the hon. Member for Strangford (Jim Shannon), a rise in insecure and underpaid work has made it even more difficult. There is evidence from around the world that where Governments fail to protect maternity rights, formula companies thrive.

This paper highlights how women’s labour is systematically undervalued. If a tin of formula is purchased in a shop, that contributes to GDP figures, which the Government record as an expression of national wealth. If that same baby is breastfed, it does not count towards GDP because women’s time is just not valued the same way as a commercial product. The paper found that if we were to put a monetary value on the milk produced by breastfeeding women globally, it would amount to an astonishing $3.6 trillion. Commercial milk formula companies are aware of that, and this report exposes how their interests are aligned with poorer maternity protections. The incentives and resources are there for lobbying companies to persuade Governments to reduce workplace rights. This acts as a distortion on the labour market and needs to be actively resisted.

Scotland has legislation specifically protecting breastfeeding in public, for which I thank the former Labour MSP Elaine Smith. The SNP Scottish Government also put breastfeeding into their programme for government, with investment which led to an increase in breastfeeding rates. It is progress, but so much more needs to be done. As I hope I have outlined, this matter goes far beyond individual choice. Ultimately, a healthier population is a positive externality: it benefits everyone, saving money for the NHS through infant and maternal health, a healthier workforce and better outcomes in education. Encouraging breastfeeding and regulating formula effectively should be seen not as a drain on the public purse but as an investment for the future.

I have some asks for the Minister. Almost exactly six years ago, I published my Feeding Products for Babies and Children (Advertising and Promotion) Bill, and I would be glad to speak to the Minister further about it, because it presented the Government with credible options that could make a difference. As I mentioned earlier, we are also at an important juncture with the retained EU law Bill, which could see current infant formula regulations being scrapped. Let us not forget that these important regulations across Scotland, England, Wales, and Northern Ireland protect the health of our youngest citizens. They must be retained, but they must also be strengthened.

Prior to Brexit, when I asked about the prospect of the UK Government joining the countries that have fully implemented the World Health Organisation’s international code of marketing of breastmilk substitutes, I was told that our membership of the EU presented a barrier to doing that. That excuse has now vanished, so I would like the Minster to tell me tonight when he aims to implement the code in full.

Will the Minister meet the authors of The Lancet reports and representatives of the all-party parliamentary group on infant feeding and inequalities to discuss further what the Government intend to do in response to these findings? Will he accept that child and maternal health should come before the profits of commercial milk formula producers? Will he commit today to exploring the role of the UK Government in stopping the aggressive marketing of the formula milk industry? As The Lancet so clearly set out, superficial slogans to encourage breastfeeding are a poor substitute for addressing the sociocultural, economic and commercial determinants of infant and young child feeding. I urge the UK Government to engage with the reports and to do much better by our youngest citizens.

[The Parliamentary Under-Secretary of State for Health and Social Care (Neil O’Brien)]

I congratulate the hon. Member for Glasgow Central (Alison Thewliss) on securing this timely debate. I know that she has a keen interest in this important matter and shows great leadership in ensuring that infant feeding remains a priority Government policy, perhaps most notably as chair of the all-party parliamentary group on infant feeding and inequalities. I welcome the publication of the 2023 Lancet series and the information it provides to add to the debate on promoting breastfeeding.

Breastfeeding is a crucial aspect of infant health and nutrition, and this Government are committed to promoting and supporting breastfeeding policy to ensure that all infants have the best start in life. The Government understand the many health benefits that come with breastfeeding for both the mother and the child, and it is our priority to encourage, support and empower women to breastfeed. We recognise that for some women, breastfeeding may not always be a viable option—for some, it may simply not be what they want to do—but the Government continue to create a supportive environment that informs and supports families when starting the infant feeding journey, ensuring that they are able to make informed decisions about how best to feed their babies. This includes providing breastfeeding advice and guidance through a range of approaches, including paid-for social media activity, personalised email programmes and the NHS Start for Life website.

In line with these commitments, we have taken a number of steps to improve support for infant feeding. From 2022-23 we are investing around £300 million in family hubs and Start for Life services, targeting the three years of funding at 75 local authorities in England that have high levels of deprivation and disproportionately poor health and educational outcomes. These 75 participating local authorities have already received at least half their year 1 allocation. As part of this, 14 local authorities have been identified to become trailblazers to lead the way and support other local authorities to improve the services offered to families. This funding package includes £50 million to invest in infant feeding services, which will enable participating local authorities to design and deliver a blended offer of advice and support for families in line with local needs to help all families to meet their breastfeeding goals. Services will enable parents to access face-to-face, virtual, and digital infant feeding support when and where they need it.

The Government also recognise the importance of creating a breastfeeding-friendly work environment, and we recommend that employers take steps to enable women to breastfeed as a matter of best practice. For example, the Health and Safety Executive has published comprehensive guidance on how employers can meet their legal requirements to support new mothers, and it advises employers that it is good practice to provide a private, healthy and safe environment for breastfeeding mothers to express and store their milk. The Advisory, Conciliation and Arbitration Service has also published guidance to support employers in accommodating employees who return to work while breastfeeding or expressing milk.

As is recognised in The Lancet series, it is critical that Governments gather reliable data on rates of breastfeeding to ensure that policies are having their desired effect and to better target our interventions. Therefore, work is currently under way on the delivery of a new infant feeding survey, commissioned for England by the Department of Health and Social Care’s Office for Health Improvement and Disparities. The new survey, which last ran in 2010, will provide valuable information on infant feeding behaviours and other related factors. Data collection is expected to commence this year and we anticipate that the results of the survey will be available in 2024.

These investments and strategies all build on existing measures that this Government continue to uphold. This includes legislation that governs the marketing, composition and labelling of infant formula and follow-on formula. The legislation reflects the latest scientific advice on the essential composition of infant formula and follow-on formula. This legislation upholds the Government’s commitment to the general principles and ambitions of the World Health Organisation’s international code of marketing of breast milk substitutes by prohibiting the promotion, marketing and advertising of infant formula to ensure that breastfeeding is not discouraged. The legislation mandates that the labelling of infant formula and follow-on formula includes information stating the advantages of breastfeeding, includes the necessary information on the appropriate use of the products and does not include pictures or text that idealise the use of the product.

I understand that there have been calls to strengthen this legislation or even go further than is specified in the WHO code, as is suggested in The Lancet series that prompted this debate. The Government of course welcome challenges to our existing ways of doing things and we are committed to ensuring that our legislation continues to be based on comprehensive evidence and sound analysis.

[Alison Thewliss]

The UK Government’s current legislation falls far short of the code’s recommendations, and it is not enforced in any meaningful way. Many tins found in shops do not comply with the legislation as it exists, never mind the code’s stronger recommendations. These tins of formula have idealised images, such as cartoon bears and animals, on their labels, which would not happen if the Government enforced even their current legislation.

[Neil O’Brien]

I will come to the hon. Lady’s point about legislation in a moment, but I will first complete my thought.

We must not forget that there are non-legislative routes by which we can achieve many of the same goals. For example, as part of the NHS’s ongoing vision to improve post-natal care, the long-term plan includes a commitment that all maternity services that do not deliver an accredited, evidence-based infant feeding programme, such as the UNICEF UK baby-friendly initiative, will begin the accreditation process with a view to all services achieving full accreditation by March 2024. Local maternity systems in England are responsible for ensuring that all maternity services are on track to achieve this commitment, which will help to improve standards and reduce variation in the care that women and families receive. Targeted support is now available for local services to fulfil the commitment.

I recognise there is always room for improvement, and we continually work to enhance our efforts and to ensure our legislation and policies reflect the latest scientific advice and evidence. The UK has strict legislation in place that gives effect to the aims and principles of the WHO international code of marketing of breast-milk substitutes, which is governed in Great Britain through retained EU legislation. There are currently no differences in GB legislation on the areas covered by the code. The protocol on Ireland/ Northern Ireland provides that EU legislation relating to nutrition continues to be directly applicable in Northern Ireland, and this includes Commission delegated regulation 2016/127 on infant formula and follow-on formula, so we have precisely the same rules in place as the European Union. I know that, in general, the SNP is always keen on that.

The Government have demonstrated, through our continued significant policy development and ongoing investment, a steadfast commitment to promoting and supporting breastfeeding, where appropriate, to ensure that all children have the best start in life. We remain committed to protecting our children, and we will continue to take the necessary steps to ensure that all mothers and families have the information and support they need to make informed decisions about how to feed their babies.

Question put and agreed to.