THE EFFECT OF MILK FORMULA ADVERTISEMENT ON BREAST FEEDING AND OTHER INFANT FEEDING PRACTICE IN LAGOS , NIGERIA

This study investigated the level of impact milk formula advertisements had on mothers’ choice of infant feeding in Lagos State, Nigeria. A total of 225 mothers with children 0-2years were randomly selected from five hospitals in Lagos Island local government area of Lagos State. Validated questionnaires were used to obtain information from the mothers on their age, occupation, infant feeding pattern and type of infant formula advertisement seen. Data collected were analyzed using frequency distribution, percentages and analysis of variance (ANOVA). The result of the study showed that 92% of the mothers were within the reproductive years (20-40years). Fifteen percent of the mothers were housewives and 84.9% had some form of occupation. The result also revealed that 70% of the mothers breast fed only, 1.8% formula fed their babies and 27% practiced mixed feeding. The percentage of the mothers who saw or heard advertisement often from television, magazines, posters, radio and bill board were 31.6%, 24.9%, 18.2%, 3.6% and 3.1%, respectively, 82.7% of the mothers had seen or heard of some form of infant formula advertisement. The most commonly advertised infant formula was NAN (51.1%). The most common type of advertisement seen was television advert (31%); 18.7% of the mothers were influenced by infant formula advert while 64% were not. The result showed that there was a significant effect on the infant feeding practices before and after infant formula advertisement was seen at (f=3.387; 0.003) and (f=4.025; 0.001), respectively. The study concluded that there was a high percentage of mothers who breast fed their infants however analyses of the data before and after advert between the groups and within the groups of women showed that infant formula advertisement had a significant effect on mothers’ choice of infant feeding.


INTRODUCTION
The two main ways a mother may decide to feed her baby are breastfeeding and formula feeding.The major decision on whether a baby is breast or bottle fed should be made in counsel with the doctor before baby's birth (Shryock & Swartout, 1970).It is recognized that breast milk is the best food for the baby and authorities have indicated the advantages and disadvantages of both types of infant feeding (ACC/ SCN, 2000;Lucas et al., 1992;Pollack, 1994;Green et al., 1995;Shryock and Swartout, 1970).However, the final decision on the feeding preference depends on the mother and her individual circumstances (Homeier et al., 2005;Righard, 1998).Bottle feeding is a substitute while breast feeding is an unequalled and incomparable way of providing ideal food for the health, growth and development of infants (WHO, 2008).Despite this awareness of the benefit of breast feeding, globally less than 40% of infants under 6 months of age are exclusively breastfed (WHO, 2008).There is a further decline on the percentage of women currently that elect to breast feed.This decline is caused by factors such as commercial promotion of infant formula through distribution of hospital discharge packs, coupons for free or discounted formula, television and magazine advertisements (Aniansson et al., 1994).
Advertisement is the most common way in which manufacturing companies market their products (Food Advisory Community, 1991).Infant formula manufacturers use various methods which include, slogans, phrases with health claims, offering free samples, gifts, providing educative materials and incentives to health professionals and health care institutions (Arun, 2000).Hospitals receive infant formula for their nurseries at no charge, a practice that originated in the 1930s and has been criticized by health care professionals as it is a form of advertising (Judith and Ann, 2005;WHO, 1992).Young mothers in many hospitals are provided with complimentary packages that include coupons for free or discounted formula (Donnelly et al., 2000;Ighogboja et al., 1996).These packages contain items such as growth charts, baby hats and refrigerator magnets advertising a particular company that manufactures infant formula.These vulnerable parents receive subtle psychological message that the hospital endorses the purchase and use of these products as necessary items for infants' growth and development (Ighogboja et al., 1996;Taylor, 1998).Advertisements give the impression that breast feeding is difficult and babies require additional nutrients with breast milk.The mothers respond by choosing milk formula which increases their sales (Judith and Ann, 2005).Some of the companies add fatty acid component found in human breast milk and advertise it as such to increase patronage (Stanley et al., 2007).Despite international codes, legislation and regulations (WHO, 2008) on marketing of breast-milk substitutes to protect and promote breast feeding, there is still aggressive marketing and promotion of infant formula across the globe (WHO, 2008(WHO, , 1981)).The objectives of this study are to assess the effect of infant formula advertising on the feeding practices of mothers in Lagos state, and to determine if there are other factors that influence mothers' choice of infant feeding

MATERIALS AND METHOD Study Area/Population
This work was conducted in Lagos-Island Local Government area.The city of Lagos is in south -western Nigeria.It is bordered to the south by the Atlantic ocean.On the west, north and east by Benin Republic, Ogun state and Ondo state respectively (Abel, 2007).The indigenous ethnic groups are the Aworis, Eguns, Ijebus and the Epe (Adekunle, 2007).The main occupations of the people include farming, hunting and fishing.Lagos city is made up of twenty local government areas with a population of 7,937,932 in the 2006 census.It is presently the most populous and the second fastest growing city in Africa (NPC, 2007).Two hundred and twenty five mothers of child bearing age with children between 0-2years of age were selected for the study.These mothers were recruited from five out of the 17 hospitals in Lagos-Island.The study was a cross sectional survey with the use of structured questionnaires.The five hospitals used were randomly selected from seventeen hospitals from the study area.

Data Analysis:
The data collected were analyzed with the Statistical Package for Social Science (SPSS).Frequencies, percentages and Analysis of Variance (ANOVA) were calculated using the same SPSS statistical program.

RESULTS
Table 1 shows the age, marital status, ethnic group and religious sect of the subjects.The result showed that majority of the mothers (88.7%) was within the child bearing age of 21-40years.However 8.0% of the subjects were less than 20years.Most of the respondents were married (88.9%), the single mothers were 5.3%, 4.9% were divorced/separated and 0.95 were widows.Fifty seven percent of the subjects were Yorubas and 59.1% were Christians and 39.1% were Moslems.Table 2 shows that majority of the subjects (41.8%) had O'Level certificate and 6.7% had no formal education while 39.6% of the subjects had NCE/HND/BSc.Majority of the mothers (50.7%) were traders, 26.7% were civil servants, 15.1% were full time housewives.Most of the mothers (68.5%) were low income earners with monthly income of N10000.00 -N30000.00.Only 13.3 % earned N70,000 and above.
Table 3 shows the percentage of mothers who saw infant formula advertisement, type seen and the source.Eighty-two percent of the subjects had seen infant advertisement, NAN was the most common form of infant formula advertised (51.1%), television was the commonest form of advertisement, radio and billboard were the least seen (3.6% and 3.1% respectively).
Table 4 shows the aspect of the advertisement that attracted the mothers, percentage of the mothers who were influenced by advertisement, other factors that influenced mothers in their choice of infant feeding.The result showed that the message of the advertisement (41%) influenced the mothers most.The percentage of mothers who were influenced by advertisement was 18.7%, while 64% were not influenced.Other factors that influenced choice of feeding were friends (31%), mothers in-law (16.4%) had an influence while husbands had the least influence (5.8%).Table 5 shows the time of commencement of breast or bottle feeding by the mothers.The result showed that 30.2% of the mothers started breast feeding immediately after the birth of their babies compared to the 16% that bottle fed their babies immediately after birth.Fifteen percent, 20.9%, 4.4% of the infants were started on breast feeding at 6-12hours, 24hours and more than 24hours after delivery, respectively.In contrast 1.3%, 0.9% of infants that were started on bottle feed 6-12hrs and 24hrs after delivery respectively.
In Table 6 analysis of variance was used to analyze the effect of advertisement on infant feeding practices before and after seeing the advertisement between the groups and within the groups.The result showed that infant formula advertisement had a significant effect on the feeding practices of the mothers before seeing the advertisement at (f =3.387; p=0.003).There was also a significant difference on the effect of advertisement on the feeding practice after the advert was seen at ( f =4.025; p=0.001).

DISCUSSION
The result of the study showed that advertising had a significant (p<0.05)effect on mothers' choice of infant feeding before advertisement and after advertisement (p=0.001) between the groups and within the groups.However, 66.2% of the mothers started breast feeding within the first 24hrs of birth while 18.2% fed their babies infant formula within the same time period.The indication is that infant formula advertisement affected the practice of exclusive breastfeeding.The consequence of this was that these babies that were formula fed from birth could be exposed to illness such as diarrhoea and vomiting.It could also lead to the introduction of complimentary food early which could also expose the babies to food allergy, diarrhoea and vomiting.There is a possibility that these formula fed infants could be left with care givers, relatives and friends thus reducing bonding between baby and mother (ACC/ SCN, 2000).The result also showed that despite the high percentage of breast fed babies, there was a 5.3% decline in breast feeding rate, 0.95% increase in the rate of formula feeding and 4.5% increase in the rate of mixed feeding.This is in line with the WHO (2008) report that showed that globally less than 40% of infants under 6months of age are exclusively breast fed.Homeier et al., (2005) showed that one reason why some mothers do not breastfeed was because of the aggressive infant formula advertisement and marketing.Infant formula advertisement has effect on infant feeding practices in several ways.The study showed that 16% of the respondents started formula feeding at birth.Some of the consequences of the use of breast milk substitute in the developing countries is the possibility of bacterial infection (UNICEF, 1994) due to poor personal hygiene, poor sanitary condition and lack of adequate supply of clean water (UNICEF, 1995).Infant formula is expensive and frequently over diluted to save money (UNICEF, 1994).This is in line with the findings of this study that mothers used less than the recommended quantity of breast milk substitute to stretch the use.This may be due to low educational attainment of the subjects (6.7%) who had no formal and (10.7%) had primary school certificate.It could also be attributed to the poor per capita income of the subjects, 31.6%earned less than ten thousand naira per month.The implication was that feeding bottles and teat may not have been properly sterilized and could become sources of microbial contamination (UNICEF, 1994).This would lead to high morbidity and mortality rate of infants (Onyechi and Okafor, 2008).Infants and children under 5 years of age are vulnerable to malnutrition, diarrhoea and vomiting.In population area like the developing countries of which Nigeria is one, the mortality rate from diarrhea and vomiting has remained high (UNICEF, 1994, 1995, Scott-Emuakpor and Okafor, 1986).There is also an association between the development of childhood obesity and consumption of breast milk substitute and the subsequent development of noncommunicable diseases (Gillian et al., 2001;Arenz et al., 2004).
Advertisement of breast milk substitute was mostly through television (31.6%).Arun, (2000) showed that Nestle advertises its products in television regularly.Advertisement gives the impression that it is not easy to breast feed or that babies need additional food with breast milk.These mothers turn to formula which increases sales for the companies (Judith and Ann, 2005).The study also revealed that there were other reasons for giving babies breast milk substitute.This includes poor health condition of the mothers (0.9%).Homeier et al., (2005) identified this as one of the reasons for introducing formula feed.Other reasons given were cracked nipples (14%), fear of unsuccessful breast feeding (3.6%), preference by baby and husband.This could be attributed to insufficient prenatal education on infant feeding practices (WHO, 1989).Other misinformation includes small breasts size, lack of role models, return to work and social concern (Wardlaw et al., 2004).The international code on marketing of Breast milk Substitutes adopted by the World Health Assembly in 1981 (WHO, 1981) and subsequent relevant World Health Assembly resolution, collectively known as "The Code", provide guidelines for the marketing of breast milk substitute, bottles and teats.This is to ensure infant feeding decisions are free from the influence of marketing pressure.Despite these facts there is high increase in the use of breast milk substitute due to the high level of formula feed advertisement.In Nigeria one third of infants are bottle fed in the first four months (ACC/ SCN, 2000).Studies have shown that infants in developing countries who consume infant formula are at the risk of non-specific gastroenteritis and sudden infant death syndrome (SIDS), (Stanley, 2007).There is less bonding and attachment (World Alliance for breastfeeding Action, 2007) and high neonatal mortality (Veneman, 2007).The aim of infant formula advertisement by companies is to encourage mothers to buy their product and make as much money as possible.These companies invest exorbitant amount of money to convince parents that their products are just as good as breast milk (Stanley et al., 2007).It is important therefore to reach women during the prenatal period, soon after delivery and within the first month postpartum, these are critical to increasing the duration of exclusive breastfeeding (ACC/ SCN, 2000).

CONCLUSION
The result of this work showed that there was a high percentage of mothers who breast fed their infants.However, formula advertisement had a significant effect on mothers' feeding practice.Advertisement of infant formula has been shown to be extensive and persuasive compared to the dissemination of information on the advantages of mothers' breast milk.However, there were other factors such as low literacy rate, demographic changes such as urbanization, increase in hospitalization for childbirth, employment outside the homes may have also contributed to the mothers giving their babies formula feed.

RECOMMENDATION
It is therefore important that health workers should ensure that women of child bearing age should be adequately informed at prenatal stage on the benefits of breastfeeding.Nutrition education at antenatal and early registration should be encouraged to enable mothers make informed decision about infant feeding.