Peter Kerr, Jakarta – Soon after giving birth earlier this year in a major central Jakarta hospital, nursing staff gave Indra a pack containing infant milk formula, a measuring cup and other gifts provided by a big international baby-food company. Three months later, when she felt she was having difficulty breastfeeding, she started giving her baby the milk formula.
Lisa, a European woman living in Indonesia, gave birth in a south Jakarta hospital last July. She was surprised and confused soon afterwards to receive in her VIP maternity room a similar gift pack, prepared by a different baby-food manufacturer. It contained a tin of formula milk for babies aged three to six months, with a range of information and gifts. Did this mean the hospital staff thought she should change from breastfeeding to formula as soon as possible?
Stories like these, told by women who asked that their real names not be used, are a common frustration for health workers trying to promote the benefits of breastfeeding.
International regulations forbid providing samples of infant formula or related products to new mothers, but the practice appears to be widespread in Indonesia.
Many hospitals desperate for funding also accept medical equipment and other support from the makers of infant formulas, according to health professionals. Pediatricians, midwives and consumer groups also say that baby-food companies are breaching the World Health Organisation's marketing code in the way products are packaged in Indonesia and many other countries, and that information on the packaging is often inadequate or misleading. Formula companies reject these charges of improper practice, insisting they abide by international and national regulations.
One of the biggest battles in Indonesia at present, however, is over "follow-on" formulas, made for children older than six months. Indonesia last year banned advertising of all formula products for children aged below one year. Companies are aggressively advertising food products for children beyond that age.
Meanwhile, a business lobbyist acting on behalf of the Indonesian Baby Food Manufacturers' Association is challenging the ban above the age of six months. "This sort of interference ... is deplorable as it puts profits before the health of infants and young children," said Yeong Joo Kean, a legal adviser in Penang, Malaysia, for the International Baby Food Action Network.
Manufactured baby milk is big business, estimated by the network to be worth at least $A15.8 billion a year worldwide. Figures for Indonesia are unavailable publicly, but one company spokesman said total market volume for the four months to April was 6.7 million kilograms.
No-one, the formula manufacturers included, denies that breast is best for babies. Last month the World Health Assembly of the World Health Organisation agreed unanimously that the recommended period for "exclusive" breastfeeding – when a baby receives nothing other than breast milk – be increased from four months to six months.
Meanwhile, studies have shown that mothers who start using formula usually continue buying the same brand, hence the big advantage to companies getting their product into hospitals.
The health benefits of breast milk are generally greater the longer babies drink it exclusively, while babies who switch early to formula have higher rates of death and disease. In developing countries infants who do not breastfeed in the first three to four months have 10 to 15 times greater risk of dying than babies who drink only breast milk. This is mainly due to a higher rate of gastrointestinal infection.
Health professionals say poorer mothers, convinced their babies need formula, will often buy it before feeding the rest of their family properly, or cause other problems by watering down the formula to make it last longer.
One Indonesian midwife said the marketing and availability of formulas, particularly in urban areas, was largely responsible for the drop in exclusive breast feeding from 44.3 per cent of infants aged two to three months to 23.9 per cent for infants aged four to five months.
Ms Dien Sanyoto, a pediatrician with the Indonesian Breastfeeding Promotion Foundation, said many companies violated the international code by promoting their products in health facilities.
Dr Utami Roesli, a pediatrician at St Carolus Hospital's Breastfeeding Enhancement Institute in Jakarta, said it was common for formula-makers to sponsor medical seminars, provide hospitals with equipment, and offer to pay for midwives to finish their education.