How International Companies Convinced Mothers That Baby Formula Was Best
More than half of Indonesian mothers feed their children formula, despite the fact that it consumes a huge percentage of their income. How did this happen?
Illustration by Adam Noor Iman
The Business of Babies is an on-going series by VICE's Indonesia office looking at all the ways people have turned something so basic—reproduction—into a money-making venture. In the coming days we'll cover the baby modeling industry, elite pre-schools, and the murky Instagram fertility pill industry.
Ayu Sukma pushes her cart through her neighborhood supermarket in Depok, West Java, turning down an aisle nearly entirely stocked with baby formula. She grabs three huge cans of baby formula and places them in her cart before moving on. The formula is for her 8-month-old daughter Kirara. She tells me that, of course, actual breast milk would be better, but it's not something she was able to do.
"For the first three months I was giving her ASI exclusively," Ayu told me, using the Indonesian acronym for breast milk (ASI). "But because of circumstances, I had to leave her for two months. When we were apart, I felt like my ASI production became insufficient."
Ayu had to make a decision many working moms face: find someone to either deliver your own breast milk to wherever your child is at—or a surrogate who makes more breast milk than is needed—or switch to baby formula. For Ayu, the choice was clear. She works a full-time job. Both her and her husband's parents live out of town, meaning that she had to drop baby Kirara off in another town once her three month maternity leave ran out. For two months Ayu wasn't around her daughter, a hard reality that made baby formula the only sustainable option.
"So far my daughter hasn’t had any problems consuming formula milk,” Ayu told me. “I hope she’ll grow optimally and stay healthy."
Few things are as touchy a debate as breastfeeding. Doctors worldwide say that breast milk is the healthiest option for newborn babies. It can help reduce the risk of certain kinds of disease, boost their immune system, and help them put on a healthy amount of weight. In more extreme scenarios, breast milk can help a baby stay alive. In Indonesia, nearly one in 30 newborns dies before their first day of elementary school. Babies who consume breast milk have significantly lower mortality rates from sudden infant death syndrome, or SIDS.
But for many mothers, the "no formula, ever" movement comes across more than a bit classist. Sure, breast milk is free, but it also requires a mother who can be by her baby throughout the day, or one who has access to affordable child care near their home and a steady supply of pumped breast milk each day. Not everyone has access to this kind of child care, and baby formula can fill in that gap when a child's mother isn't around.
Yet, in countries like Indonesia, this is barely a debate. In the United States, an estimated 77 percent of women breastfeed their child, according to data by the US Center for Disease Control. In Indonesia, that figure drops to 42 percent, trailing behind its wealthier neighbors in Singapore, South Korea, and Taiwan. That means that here, more than half of mothers choose baby formula, not breast milk for their child.
Regionally, baby formula is a huge cost to new families. Those three cans of baby formula Ayu put in her shopping cart cost Rp 320,000 ($22 USD) a can. She goes through four of those a month, a cost that eats up a sizable chunk of her salary.
For poorer families, that kind of money just doesn't exist. An estimated 40 percent of the country hovers around the poverty line—meaning that they aren't living in abject poverty, but they are close enough to the line to fall below it from time to time, according to World Bank data. And nationwide, 28 million people live below the line on less than $2 USD a day.
These poor mothers are still buying baby formula, but many of them are diluting it with water to make it last longer. This makes the formula less nutritious, resulting in a country where, according to UNICEF data, 37 percent of children suffer from levels of malnutrition that affect their ability to mentally and physically grow. Another 12 percent suffer from "wasting," meaning that their young bodies are emaciated.
Ironically enough, this figure, 12 percent, is the same for the number of children categorized as obese, a sad fact that illustrates Indonesia's wide rift between the top and the bottom of the economic ladder.
How did we get here? The short answer is money. Indonesia is the biggest market for baby formula in the entire Asia-Pacific, a region responsible for two-thirds of the global industry's growth. The Indonesian market alone is worth an estimated $1.1 billion USD. It's a massive market that's long been dominated by international corporations like Nestle, Mead Johnson, and Danone.
These companies reach deep into the lives of mothers, with aggressive marketing campaigns on television as well as more insidious methods like midwives and hospitals sending new mothers home with free samples of baby formula. The central government, after being pressured by the World Health Organization, banned health care workers from this kind of marketing, but the practice still continues. A recent visit to a maternity hospital in Jagakarsa, South Jakarta, found multiple boxes of Frisian Flag baby formula prominently displayed—a clear violation of government regulations. One mother told me hospital staff sent her home with some baby formula after giving birth.
PT Frisian Flag Indonesia, which owns 10 percent of the market for lower-to-middle income consumers, declined to comment on whether these kinds of illegal marketing techniques were part of their distribution strategies. Fetti Fadliah, the head of HR at the company, only told me that Frisian Flag supported the consumption of breast milk from an early age.
“Frisian Flag supports exclusive ASI as an attempt to fulfill the nutritional needs of Indonesian children for an optimum growth,” Fetti told VICE.
Other common violations include offering heavy discounts for new mothers, using midwives to sell baby formula directly to moms, and advertising that includes misleading language that implies that baby formula is a replacement for breast milk. Online forums for new mothers are commonly involved in these kinds of illegal marketing campaigns.
"One of the marketing violations is giving out discounts,” said Debora Tjandrakusuma, chief of ethic commission of Association of Brands for Nutritional Products for Mothers and Children (Appnia). “You still see a lot of this in online sales.”
Debora defended the industry, saying that baby formula companies worked hard to comply with national and international regulations. There's no doubt that breast milk is best, but that doesn't mean that baby formula doesn't have a place on the market as well, she said
“Baby formula products are needed when mother has to leave the child or when she’s not in a condition to breastfeed," Debora told VICE. "There has to be a compatible alternative to ASI."
But women like Fitria Rosatriani are trying to turn as many Indonesian mothers off baby formula as they can. Fitria is a breastfeeding counselor with the Indonesian Breastfeeding Association (AIMI), an organization that is trying to convince new mothers to breastfeed their babies. When I met Fitria she had just snuck into the postpartum room of the Pondok Kelapa hospital in East Jakarta.
“I came to the hospital under the guide of being a guest,” Fitria told me. “If someone knows I’m a counsellor, I might get kicked out."
Within no time, she received a call that a new mother wanted to learn how to breastfeed. Fitria expertly calmed the fitful newborn by holding it against her chest. She explained to the mother that the best way to breastfeed is to make sure that the child's stomach is touching her own.
“And sometimes there is a problem where the baby’s mouth isn’t sticking to the mother’s nipple properly,” Fitria explained. “That’s very common.”
Fitria signed up with AIMI eight years ago, volunteering with an organization that is trying to combat the more than $100 million USD spent annually on baby formula advertising campaigns. During the workweek, Fitria is an accountant, but on weekends she's sneaking past hospital security and holding educational seminars where she teaches mothers about the benefits of breastfeeding.
She tells me that she decided to rally behind the cause after having her first child. Fitria wants to make breast milk, not baby formula, the default option for most Indonesian mothers. But she needs to fight stigma as well as the advertising campaigns. She tells me that it's a difficult fight, but it's still one she plans to stick with.
"When I was breastfeeding my first child in public, people looked at me like I was crazy,” Fitria told me. “What’s wrong with breastfeeding? At one point, I felt ashamed. Now, I don't want people to feel what I felt.”