Letter to the editorial board of the British Journal of Midwifery.

A week ago, when I initially wrote about my alarm and astonishment with the BJM awards and then finding out about Cow & Gate sponsored study days for midwives I had no real idea of the prevalence of corporate sponsorship, by infant formula companies and their subsidiaries, in the continuing education of health professionals in the UK. My amazement and astonishment has grown daily since then and I have to admit to feeling an enormous sense of despair about the whole thing as this is much larger than I had ever imagined it could be. It seems that without proper government control the particular infant formula manufacturers have managed to associate themselves intimately with health professionals on every level from the College right through to individual practitioners and are an accepted part of the culture of continuing professional development in the UK. This level of corporate sponsorship is a breach of Article 7.2 as this level of support for education of health professionals is a significant financial and material inducement. One just has to look at this video from the Learning Curve, Danone, which is associated with Cow & Gate to see how the formula products are being promoted while the attendees are engaged in the workshop learning objectives. As far at the study days organised by the British Journal of Midwifery are concerned it seems that midwives are not aware that they are being funded and supported by Cow and Gate, regardless of how open you feel you have been about this. It is evident in the comments received on this group from midwives who had no idea. Midwives have a right to know where their study is being funded from. For some this may not be a concern, they may feel that they can “take the money and run” ( it is essentially a gift of money, study which would otherwise be a significant cost is free) without being unduly influenced. The formula manufacturers clearly have a different opinion, as they would not offer this service if they did not feel that they would get something out of it. There is also a large body of evidence which identifies that prescribers are influence in their prescribing patterns even by seemingly insignificant gifts from a particular company (Richter, 2005; Sandall. 2008). The International Baby Food Action Network (IBFAN), an international body monitoring the the Code have a position statement of sponsorship and conflicts of interest. They state “ IBFAN believes that: Conferences, seminars, workshops or other meetings that deal with any aspect of infant and young child health and nutrition should not be financially or materially sponsored in any way, directly or indirectly by companies that are engaged in the production, marketing or distribution of baby milks, foods or products represented to be used for infant or young child feeding" In addition they state “All health care workers including health professionals and their associations (should) 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”.
You ask how in particular I feel the code is being breached and suggest that Nestle are a particular case in point, suggesting that other formula manufacturers are above reproach and therefore should not be considered in the same category as Nestle. From my very brief sojourn into the situation in the UK at present I can see that Cow and Gate are very from above reproach in the promotion of their products in the UK. Within this report from the baby feeding law group there are several instances where Cow and Gate and Aptamil, who are affiliated with Danone have been identified as not complying with the Code. I myself found one image on Flickr, taken in 2011 where Cow and Gate advertising on a baby change mat, in a shopping mall change room, does not appear to comply with that companies requirements under the Code. Where is the information on that breast is best? While it is advertising follow on formula and not newborn formula the distinction is not clear. The impression is that Cow and Gate produces health active beautiful babies. The British Journal of Midwifery should not associate itself with a company who uses these tactics to promote its product in breach of the Code.
As Jane Sandall (2008) describes, the midwife – woman relationship is a relationship of trust. Women expect their midwives to act in their best interest, not under the influence of advertising from a formula manufacturer. IN addition I would suggest midwives expect their journal to provide evidence based information and provide them with information which they can then use as a basis for sharing with women. Information on infant formula in midwifery journal should be scientific evidence based information not promotion of a particular brand of formula. I believe formula advertising anywhere in a midwifery journal is unacceptable.

Reference
Richter, J. (2005). Conflicts of interest and policy implementation. Reflections from the fields of health and infant feeding. Geneva, IBFAN- GIFA
Sandall, J. (2008).No such thing as a free lunch. Midwifery. 123 – 125.

Why not just give him a bottle? Infant formula company sponsorship of the midwifery profession

Way back in 1990 I organised a study day in Balclutha for rural midwifery. It was a huge success and we had about 90 midwives and other medical staff attend. We sought sponsorship from local businesses and had some trade stands. The local chemist was a sponsor and on their stand had some infant formula and related products. Shortly after the event we received a formal complaint from the monitoring body for the WHO/UNICEF code of marketing of breast milk substitutes, pointing out the many areas in which we were in breach of the code. The chemist received the same complaint. We were taken aback and it took the shine off what had been a great event. I became very familiar with the code and never committed a similar offence again.

Some time ago I stumbled on a documentary series from the Philipines on Youtube. It outlines the marketing strategies of infant formula companies in that country. This includes inducements to midwives with free samples and misinformation about the benefits of one or other infant formula. These midwives then promote the products to the women they are working with.

Recently I was made aware of the association between the British Journal of Midwifery and the infant formula company Cow and Gate in a midwifery awards scheme. When I investigated this further I found that Cow & Gate have a whole arm of the company devoted to providing research grants and educational support to midwives and other health professionals such as Health Visitors who have influence with women and are in a position to promote their product. While The company does not ask midwives to promote its product none the less midwives cannot help but be influenced by this sponsorship which is significant. This sponsorship is in fact not much different to that being given to the Philipine midwives in the documentary mentioned above. Cow & Gate In Practice was actually launched at the Royal College of Midwives in 1999. clearly the Code of Marketing of Breast Milk Substitutes has been interpreted quite differently in the UK to the interpretation in New Zealand. Or is it just that it has been largely ignored in the UK? Here is a summary of the code.
Through the In Practice website Cow & Gate promote their special hospital bottles of formula, plastered with their logo and full of information about the particular benefits of this formula.

I have challenged this promotional activity between the British Journal of Midwifery and the Cow and Gate milk company in an open forum and by email. However the In Practice website was launched at the Royal College of Midwives and the study days being delivered across the country are accredited professional development for the UK Nursing and Midwifery Council. It is therefore not just the British Journal of Midwifery who need to look to themselves and their relationships with infant formula companies. It goes much wider than that.
The International Board of Lactation Consultants had a similar issue with corporate sponsorship and have identified that this is a serious issue. They now have clear policies to avoid this.

I am just a New Zealand midwife. Although I was originally UK born and trained my working life has been here in New Zealand since 1981. It may be that I am too removed from practice in the UK to see these issues clearly from the perspective of practice in that country, or it may be that from this distance I am more able to see these things clearly. I have no wish to cause offence and apologise if I have done so. Am I totally mistaken in my opinion that there is a serious problem here? I value the thoughts and comments of others on this issue.

See this photo posted on Flickr by Sophie Passmore. It was taken on November 2011 and shows a baby change mat from a UK shopping centre changing room. I would have loved to use this here but it does not have an open licence.