Our study documents pervasive CMF industry interference with breastfeeding across all early life course stages (Fig. 3), from pregnancy to toddlerhood. In addition, and as highlighted in Fig. 3, CMF interferes in all the levels and determinants and the persistent feedback loops that the CMF industry generates are very efficient in influencing caregivers’ IYCF choices. Though the industry directly interferes in all layers of the SEM, indirectly it also exploits weaknesses in systems of support and the regulatory environment for breastfeeding, such as lack of compliance with the international CMF marketing code [20], inadequate enforcement of CMF marketing restrictions, and limited or inexistent protections of breastfeeding at the workplace, among others. Overall, these findings are consistent with previous studies that documented the pervasive influence of CMF marketing [2] although none of those studies integrated the findings in the dynamic way that we did. Our findings are highly innovative not only because we clearly identify diverse marketing entry points for CMFs but also because we are able to describe how key marketing pathways work in relation to other determinants of breastfeeding in the SEM over the IYCF life course. In this context, the determinants of breastfeeding refer to factors that influence whether, for how long, and to what degree exclusive breastfeeding takes place among infants and young children. These determinants are spread throughout the SEM levels, including support and influence of family, friends, and healthcare providers, the availability and accessibility of breastfeeding counseling, and the breastfeeding cultural norms, media influence, and policies. On the other hand, the key CMF marketing entry points identified included mothers and other caregivers, healthcare providers, scientists, professional organizations, and policymakers. These entry points can occur at various life course stages, from pre-natal to post-natal care, and interact dynamically with the determinants of breastfeeding undermining the maternal infant feeding choice to breastfeed. Thes entry points are very strategic from a CMF marketing perspective as they are situated at the different levels of the socioecological model levels and collectively have a strong dynamic influence in very sensitive moments for the proper establishment of lactation during the life course. In Fig. 3 the CMF marketing entry points are portrayed by the overarching “cloud” labeled “CMF industry interferences”, as well as by the feedback loops across different levels and time points.
Influence of CMF marketing on IYCF trajectories – SEM/life course model
The pervasive influence of CMF marketing across infant and young child feeding trajectories
Marketing interference started during the prenatal period, via social media and health professionals, and played a very important role in the playbook. For example, in the case of the exclusively formula feeding mother in Case 3, exposure to marketing was very strong during pregnancy by participating in online clubs that provided ostensibly scientific information about formula. This exposure then created opportunities for these marketing messages to be remembered and acted upon during the postnatal period. The marketing messages were so effective [10] that they counteracted hospital messages about the importance of breastfeeding, leading her to believe that formula feeding was superior to breastfeeding and that hospital messages about the importance of breastfeeding were the result of “brainwashing”. These findings align with prior work on the growing influence of digital marketing in the CMF playbook [2] and showcase their influence over time: prenatal messages are particularly powerful because early “priming” creates category entry points for later on.
Other women were also exposed to highly effective marketing messages that helped shape their infant feeding trajectories. For instance, while the mixed feeding mother in Case 1 clearly expressed that her family supported breastfeeding, the constant but subliminal marketing of CMFs modified her feeding decisions. Industry influence started when she was pregnant and was reinforced during the perinatal period when her infant was formula fed at the hospital based on the incorrect assumption by her providers that it was needed to prevent neonatal hyperglycemia. This message was later reinforced by her physician who recommended formula when she was successfully breastfeeding. This is consistent with prior work on the role of health care providers in transmitting marketing messages [2, 21].
Carefully orchestrated CMF marketing interference persisted well beyond infancy. GUMs have become an important sales target of the CMF industry [22, 23]. These are expensive and unnecessary products that profit from the public’s lack of understanding and misperceptions about the properties of breastmilk after the first 12 months of life [2, 10]. The marketing of GUMs has led women to perceive that such products are superior feeding choices that are worth purchasing and using [22]. This was clearly reflected in the formula feeding mother in Case 4, who planned to give her child formula milk until age 3.
CMF marketing interacts with the SEM
CMF interference seldom acted alone in influencing IYCF decisions. Rather, it interacted with other determinants across the socioecological model. CMF marketing most prominently interacted with the health system, with hospital policies during the pre- and perinatal period (e.g., providing formula to newborns as a “just in case” preventive measure, separating newborns from mothers after birth), and with health care providers both in the peri- and postnatal stages. Social media forums and groups that included health care providers amplified these impacts across the entirety of the IYCF trajectory. Health care providers have significant credibility on IYCF recommendations and, if they are an entry point of the CMF marketing, then they become an efficient vehicle in affecting feeding decision [7, 24]. While previous work has documented the importance of each of these marketing entry points [2], no other work to our knowledge has discussed how they interact with the SEM over the IYCF life course.
Hospital policies and CMF marketing
The unnecessary use of CMF at the hospital for the Case 1 mother highlights how marketing messages can take hold in the context of the lack of adequate breastfeeding training among health care providers and the failure of institutional policies at the hospital level to protect, promote and support breastfeeding. Routine use of CMF to prevent hypoglycemia is not needed, and such use both physiologically undermines breastfeeding, and reinforces marketing messages that CMF is necessary for infant health [1, 2, 25]. Based on their own descriptions, few mothers were aware that hospital policies could influence breastfeeding; instead, most mothers assumed that their breastfeeding outcomes were determined by their bodies’ innate ability or inability to breastfeed. Only the mother who optimally breastfed in Case 2 stated that these policies could shape someone’s ability to realize their breastfeeding goals.
Inadequate or insufficient breastfeeding counseling provides opportunities for the CMF industry interference
Breastfeeding counseling is known to be an effective and powerful mechanism to empower women who want to breastfeed; when problems emerge, or mothers question their ability to adequately feed their IYC through their breastmilk, adequate counseling is fundamental [1, 26]. This was exemplified in the perinatal period of the Case 2 mother (the mother who breastfed optimally), who received adequate counseling including techniques and general support. In contrast, inadequate counseling led to painful and overall poor breastfeeding experiences for other women, for which the CMF industry offered a perceived solution. This is exemplified by the mother in Case 3 who formula fed since very early on. During the perinatal stage nurses simultaneously undermined the mother’s ability to feed her baby, “demanded” the mother to breastfeed without offering appropriate support and mistreated the mother by yelling at her. Early during the post-natal period, lack of counseling led to breastfeeding problems due to inadequate positioning and the subsequent decision to formula feed the infant by the mother, which was later reinforced by the pediatrician. This particular mother had already been highly influenced by CMF marketing during the pre-natal period through social media – the category entry point had been created. When she encountered ineffective counseling and mistreatment, she acted upon the marketing messages she came across during pregnancy, since they offered a solution.
Ineffective counseling also led to formula use for the mother in Case 4, who was given formula at the hospital after staff instructed her on breastfeeding but “nothing came out.” It is highly unlikely that this mother produced no milk, but without counseling and frequent feeding she had no opportunity to learn how to breastfeed. This was another case where insufficient breastfeeding counseling and support again reinforced the inherent necessity of CMF for infant health. These findings are consistent with previous work that shows how lack of appropriate counseling can lead to ineffective breastfeeding practices, perceptions of insufficient milk, reduced exclusive breastfeeding and, ultimately, early breastfeeding cessation [1, 26, 27]. Our work adds another dimension for how inadequate counselling interacts with CMF marketing messages.
CMF marketing and the capture of health professionals
Health system weaknesses were often compounded during the postnatal period when pediatricians frequently recommended formula to mothers. For instance, the mixed feeding mother in Case 1 was told to use formula at a time when she was successfully breastfeeding her baby. The pediatrician for the formula feeding mothers in Case 3 and 4 similarly reinforced formula feeding, rather than attempting to resolve the breastfeeding problems they encountered. These pediatricians’ recommendation may have resulted from the combination of lack of adequate provider’s training and counseling skills as well as the influence of the CMF industry playbook [2]. The playbook includes enforcing the belief among healthcare providers that CMFs are needed to “supplement” breastmilk, that CMF is the automatic solution whenever breastfeeding challenges arise, the need for specialty CMFs to address various baby behaviors, and the need for GUMs into toddlerhood [2].
Health professionals also played a prominent role in the social media parenting clubs hosted by CMF companies. For instance, it was doctors who touted the health benefits of formula in the presentation viewed by the mother in Case 3, who ended up exclusively formula feeding. These presentations convinced her that formula feeding was superior to breastfeeding. Recent work by Mota-Castillo et al. [28] has highlighted that health professionals in Mexico frequently engage in educational activities sponsored by CMF companies, even appearing in videos sponsored by industry, but do not perceive these interactions as a conflict of interest or a violation of the International Code of Marketing of Breastmilk Substitutes. Our findings add to the extensive literature that documents the importance of health professionals to the CMF industry as highly valuable category entry points [2] and highlights their influence across IYCF trajectories.
The influence of CMF marketing on perceptions of normal developmental behaviors: health professionals, social media, and parents
A common piece of misinformation that influences parents’ feeding decisions is the need to use CMF to address common baby behaviors including infant crying or unsettled, intermittent sleep, or breastmilk regurgitation [1]. In most instances these are normal baby behaviors, but they have been driven by the CMF industry playbook to be perceived as “problems” that can “easily” be solved by switching to CMF [22]. The marketing about these issues begins prenatally, as reflected by the topics discussed in the social media clubs as demonstrated by the Case 3 mother. Once the baby is born, behaviors are labeled problematic and requiring formula and specialized products. This last point was poignantly demonstrated by the mother in Case 4, who was constantly switching from brand to brand upon her pediatrician’s recommendation. These findings are consistent with prior work on how marketing exploits typical, developmentally appropriate infant behavior [1, 2]. The use of the SME/life course framework underscores how the CMF marketing messages are interacting with the health system as well as individual characteristics of the mother and baby.
Work, care work and competing demands
Our findings also highlight that CMF marketing can take hold when women’s care work is not adequately supported [6]. This was especially the case for women working outside of the household. This is consistent with extensive prior work on how insufficient maternity protections and unsupportive work environments undermine breastfeeding [1, 6, 29] and provide a marketing opportunity for the CMF industry. However, the idea that formula is simpler and made infants easier to care for was also present among some staying at home. The mother in Case 3, for instance, echoed multiple misleading CMF marketing messages (formula better supports infant development than breastfeeding, formula is more convenient) and combined them with the perception of lack of support for breastfeeding at the workplace. In this case the mother perceived that CMF replaces a substantial part of infant care, “It’s like having no baby at all!”, reinforcing the CMF marketing message that CMF is part of a more convenient approach to infant care [30]. This example showcases the power of marketing messages in shaping ideas about norms of infant care and the idea that formula feeding is “liberating” for mothers [2].
Strengths and limitations
The main strength of the study is its ability to unpack the dynamics of CMF industry interference across IYCF trajectories, demonstrating how category entry points are deployed over time, how they engage with different elements of the SEM, and exploit systemic weaknesses to undermine breastfeeding and increase profits. We developed a novel framework which incorporates the systemic and dynamic relationship between the marketing entry points at different socioecological levels and through the life course of mothers and their infants and young children. To our knowledge this is the first study that has put together these different perspectives that shapes IYCF.
A limitation of the current study is the small sample of women who participated in the in-depth interviews, as well as the geographic bias, as it included only mothers of large metropolitan areas. Nevertheless, prior research has documented the effects of CMF marketing on IYCF in rural areas in Mexico [31] as well as in other urban settings [32]. In addition, when triangulating mothers’ narratives with the evidence from prior studies [1, 6], we were able to provide rich insight into the dynamics of category entry points over time. The proposed framework was developed based on the SEM and the CMF playbook, and therefore could be employed to enlighten the dynamics elsewhere and to explore how marketing entry points are tailored across geographic regions.
Another potential limitation is a recall bias of mother’s experiences and their influence in their infant feeding decisions. However, the pool of mother entails women at different stages of their infant’s life trajectory and their narratives lead to the CMF entry points described in the recently published Lancet Breastfeeding Series [6]. These narratives become even richer among multipara women, as they also bring their prior experiences.
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