How the marketing practices of commercial milk formula companies impact infant breastfeeding practices in China

BACKGROUND: The marketing practices used by commercial milk formula (CMF) companies undermine breast feeding. However, it remains unclear how specific types of marketing practices result in suboptimal breast feeding. OBJECTIVES: We aimed to examine the associations of CMF marketing practices with breastfeeding outcomes, determine the influencing pathways, how it changes the perceptions and attitudes of mothers towards CMF, and how it impacts breastfeeding outcomes. METHODS: A cross-sectional survey was conducted in Beijing and Jinan, China that mapped the CMF marketing practices in 2020. Mothers were interviewed about the feeding practices for the youngest child under the age of 18 months. Maternal attitude towards CMF was assessed using a set of five questions. Six common CMF marketing practices were reviewed. A logistic regression was performed to examine the associations between the CMF marketing practices and predominant breast feeding, with adjustments for maternal age, education, occupation, socioeconomic class and caesarean section. Furthermore, a path analysis was conducted to explore the pathways between the CMF marketing practices, maternal attitude towards CMF and predominant breast feeding. RESULTS: A total of 750 mothers were interviewed, with 20.0% of mothers predominantly breast feeding their young children. Two marketing practices, online engagement with CMF companies and promotions and discounts, were statistically associated with a lower likelihood of predominant breast feeding, with an adjusted ORs of 0.53 (95% CI 0.35 to 0.82) and 0.45 (95% CI 0.22 to 0.92). Furthermore, per CMF marketing practice increase mothers concurrently exposed to was associated with a 0.79 (95% CI 0.68 to 0.92) times lower likelihood of predominant breast feeding. In addition, online engagement and free formula samples distributed in hospitals had indirect effects on suboptimal breastfeeding outcomes, which was partly mediated by positive maternal attitude towards CMF. CONCLUSIONS: CMF marketing practices were associated with a lower likelihood of optimal breastfeeding through influencing the maternal attitude towards CMF.