Three months ago, I delivered a healthy baby boy at a private hospital in Bangalore. However, I didn't get to hold or feed him until several hours later, and much to my disappointment and without my consent, he was given infant formula for his first meal.

Turns out I’m not the only new mother to whom this has happened. Two years ago, 31-year-old photographer Sannika Chawla delivered a child in a reputed private hospital in the city. Although she had had a normal delivery, hours after the birth hospital staff fed formula to Chawla’s baby as the exhausted mother rested a few feet away.

“I didn’t have the knowledge at the time that I should immediately breastfeed,” said Chawla. “But a few days after taking my baby home, I read up a lot and joined a Facebook breastfeeding group, and realised that the more formula I buy and feed my child, the more problems I was going to have breastfeeding.”

Not nature’s design?

Many new mothers have repeated this story of having unwittingly allowed their infants’ first meals to be formula. Hospitals seem to promote the practice despite the fact that medical research has drawn links between early breastfeeding and better infant health. Lactation experts say that colostrum – the thick yellow liquid produced by the breasts during pregnancy and shortly after childbirth – is loaded with antibodies and immunoglobulins that boost infant immunity. So breastfeeding within one hour of childbirth goes a long way in reducing infant mortality.

A much-cited 2009-study by Alison Steube at the department of obstetrics and gynecology of the University of North Carolina at Chapel Hill, found that health outcomes for formula-fed babies were substantially different. The researcher, who reviewed several other studies in her paper, found that risks of formula feeding include a greater incidence of infections of the ear and lower respiratory tract, gastroenteritis and diarrhea, with other long-term consequences such as obesity.

“Infants’ intestines are designed to digest human breast milk, and not the milk of other animals like cow or buffalo, which is used in formula,” said doctor and lactation consultant Manisha Gogri.

Even the World Health Organisation recommends exclusive breastfeeding for at least six months after childbirth. And yet, consumption of infant formula is growing across the world with hospitals and nursing homes promoting the practice.

According to a 2015 Nielsen report on baby food, the global infant formula market is worth about $35 billion. The report also reveals that declining birth rates in the West, where formula has been used by generations now, have made consumers in countries like India key targets for large corporations. Further, the rise of a ‘convenience-oriented’ lifestyle and the pressure on women to return to work make exclusive breastfeeding for six months difficult for many mothers, and this includes the urban poor.

In the slums in Delhi, women return to work after within a few days of delivering a baby, observed Ram Kumar, project manager of Ehsaas, an organisation that counsels pregnant women and new mothers in nutrition. “In the communities where we work, awareness of infant formula is very high,” said Kumar, “While there is no active marketing of formula to slum dwellers, representatives of infant formula companies frequent both government & private hospitals and local chemists in the area. I even have copies of prescriptions where the doctor has recommended infant formula.”

“I used to think the culture of formula-feeding was restricted to middle and upper-classes, and I assumed breastfeeding would be the default for poorer women but I was so mistaken,” said Gogri, who is also the leader of the Mumbai chapter of La Leche League, a global breastfeeding support group.

More than 20 years ago, a growing number of sick patients alerted a Jalandhar-based paediatrician to the risks of baby formula marketing. “New mothers were being handed free tins of formula by all of the 17 maternity hospitals in the region,” said Arun Gupta, doctor and founder of the Breastfeeding Promotion Network of India. “I was seeing a lot of babies with allergies and diarrhea.”

Gupta was so concerned about the impact of infant formula marketing on public health that he closed his lucrative medical practice in Punjab and moved to Delhi to promote breastfeeding. Today, his network is India’s foremost breastfeeding advocacy and awareness group.

India’s Challenges

The risks of formula-feeding are exacerbated in the Indian context. Child Rights & You’s general manager Jaya Singh, who has commissioned several reports on malnutrition among children said, “Infant formula is really expensive. A poor household is easily tempted to stretch a box for longer than advisable. And when instructions on the box say 30 ml per scoop, it’s practically unaffordable. Besides, many women are not even be able to read these instructions.”

“In a city like Delhi where there is such severe water shortage, and particularly shortage of clean drinking water, infant formula really shouldn’t be advocated,” said Kumar. Since babies’ immune systems are still developing, infant formula needs to be mixed with clean water in sterilised containers.

The Infant Milk Substitutes Act prohibits the marketing of infant formula, but companies constantly find ways to subvert the restrictions, and often break the law. “While advertising in television and print media is not allowed, we often come across posters in clinics, sponsored by infant food companies, depicting chubby healthy babies,” says Gupta. Many infant food formula companies tout health benefits such as enhanced brain development and stronger immune system.

“Despite the IMS Act, we still get reports of field trips being organised for doctors and companies using alternative ways to promote their products...” said Gupta.

Yet, the IMS Act may have had a tremendous impact on public health by slowing down the growth of the baby formula industry in the country. In China, where there are far fewer restrictions on marketing infant formula, formula is viewed as "white gold" to foreign multinationals looking to sell in the market. According to Gupta, while India’s formula consumption grew from 24,480 to 27,783 tonnes in the last four years, China’s grew from 2,94,800 to 5,60,000 tonnes.

As India will remain an attractive market for big infant formula manufacturers like Nestle, Heinz and Abbot, there is a greater need for effectively implementing the IMS Act.

Greater Good

“Corporates are very efficient in spreading awareness about their products,” said CRY’s Singh, “The government could learn from them. At present, neither private nor government hospitals condemn formula feeding.”

In fact, many hospitals encourage it. “Lactation failure is very rare. When a mother complains of it, formula should only be prescribed after thorough investigation,” said Gogri. “Another problem is that breastfeeding is a grey area that no single department in the hospital feels responsible for. The gynaecologist thinks the paediatrician is responsible and vice versa. Overall, the medical staff in hospitals, including nurses, are not adequately trained in understanding and promoting breastfeeding.”

In 1991, UNICEF launched the Baby-friendly Hospital initiative, where hospitals are declared ‘Baby Friendly’ on meeting a set of criteria that encourages exclusive breastfeeding. However, 25 years later, only 15,000 facilities in 134 countries have been awarded baby-friendly status.

“From allergies to obesity to asthma, there are great long-term consequences to formula-feeding on public health,” said Gogri. “Many of the lifestyle diseases that we are looking at today have their roots in infancy. We need to give babies the food meant for them, which is breast milk.”