Intended for healthcare professionals


Harnessing local jurist networks across South Asia to protect breastfeeding

BMJ 2023; 380 doi: (Published 15 February 2023) Cite this as: BMJ 2023;380:p367

Linked Research

Health and nutrition claims for infant formula: international cross sectional survey

Linked Editorial

Poorly substantiated health claims on infant formula

  1. Vani Sethi, regional nutrition specialist, Unicef Regional Office for South Asia,
  2. Zivai Murira, regional nutrition adviser, Unicef Regional Office for South Asia
  1. Kathmandu, Nepal
  1. Correspondence to: V Sethi vsethi{at}

In-country jurists remain an untapped resource for strengthening legal measures to support breastfeeding in South Asia, write Vani Sethi and Zivai Murira

Despite South Asian countries having stronger national policies and programmes than other world regions for protecting, promoting, and supporting breastfeeding, only 39% infants born in South Asia are breastfed within the first hour of birth, and only 61% are exclusively breastfed in their first six months of life.1 Annual sales of commercial milk formula are rising exponentially in the region, largely because of exploitative promotion by the baby food industry. Data show at least 15% compound annual sales growth from 2015 to 2021 in countries such as Bangladesh, India, Pakistan, and Sri Lanka,2—and drug stores and pharmacies, which are most trusted by mothers and families, have the highest share of commercial milk formula sales in these countries.2

Implementation of the International Code of Marketing of Breastmilk Substitutes, adopted by the World Health Assembly in 1981,3 as well as subsequent resolutions of the World Health Assembly and the World Health Organization’s guidance on ending inappropriate promotion of foods for infants and young children (“the code”),4 is imperative in order to protect parents, caregivers, infants, and young children from exploitative marketing and promotion by the baby food industry.

Seven of the eight countries in South Asia have legal regulatory frameworks that are either substantially aligned with the code’s recommendations (Afghanistan, Bangladesh, India, and the Maldives) or moderately aligned (Nepal, Pakistan, and Sri Lanka), although Bhutan has no legal measures in place.5 But even countries where legal regulatory frameworks are substantially aligned to the code have weaknesses in their legal regulations, which become entry points for unethical and aggressive marketing by the baby food industry.

Common practices include using data mining and algorithms to target digital marketing by capitalising on parents’ fears, making unsubstantiated claims about nutrition and health, distorting science to liken commercial milk formula to breastmilk, sponsoring health professionals and their institutions’ studies and conferences, and cross promoting infant, follow-on, toddler, and growing-up milks to confuse parents.6

While those seven countries have a legal regulatory measure, their monitoring and enforcement of legal measures remains unsystematic, underfunded, inconsistent, dependent on support from external agencies, and not necessarily funded by or implemented by national legal monitoring mechanisms.7 There are other barriers, too: only Bangladesh and Sri Lanka have a national disaster management policy that includes comprehensive plans for infant feeding in emergencies. The baby food industry exploits this by providing donations in emergency situations to widen markets. This is critical given the region’s vulnerability to natural disasters and other emergencies.

Initiating breastfeeding

Breastfeeding is a shared responsibility of society—including parents, family, service providers, and workplaces—to create conditions that protect, promote, and support breastfeeding. However, South Asian mothers working in the informal sectors are overlooked in workplace legislation. In the formal sectors, weak enforcement of maternity rights and family friendly policies results in lacking or limited safe spaces for breastfeeding or expressing breastmilk, with suboptimal paid maternity leave,8 reducing the chance that working mothers will breastfeed optimally.

Health providers and managers of public and private maternity health facilities in South Asia are not being held accountable to support early initiation of breastfeeding after birth. For example, although 82% of babies in South Asia are delivered by skilled birth attendants,1 only 39% of newborns initiate breastfeeding within an hour, and 35% are offered pre-lacteals in the first two days of birth.1 Self-reported insufficient milk continues to be one of the most common reasons for introducing commercial formula milk and stopping breastfeeding. Parents and health professionals often misinterpret typical, unsettled baby behaviours as signs of milk insufficiency or inadequacy. These fears are exploited by marketing agencies hired by the baby food industry to push them to use commercial milk formula.9

South Asia accounts for 37% of the total global burden of neonatal deaths: each year an estimated 895 000 newborns die in the region.10 Studies show that initiation of breastfeeding within one hour of birth can reduce the risk of neonatal death by as much as 22%,11 potentially saving an estimated 200 000 newborns in the region each year. Breastfeeding also aids healthy growth, a reduced infection risk, optimal brain development, cognitive stimulation, and bonding,9 which are essential for healthy early development.

Rampant exploitative marketing of commercial milk formula that undermines the power of breastfeeding must be curbed with robust legal measures that protect maternity and breastfeeding rights. This is every government’s obligation and a mother’s human right. South Asia has strong in-country jurist networks of lawyers and judges, which played a critical role in developing legal measures to propel governments to design “safety net” policies protecting and implementing rights to food and nutrition. Our discussions in the past two months with 10 human rights lawyers and judges in the region have revealed six ways to proactively engage to protect breastfeeding.

Six steps for action

First, build awareness and knowledge of judicial networks, including judges and lawyers who are practising, advocating, and teaching human rights and public health law, with national and international legal instruments that protect maternity entitlements, optimal breastfeeding, infant and young child feeding, and safe food environments.

Second, promote food and nutrition as a part of the judicial agenda, using forums including interparliamentary mechanisms, national judicial academies, and law commissions.

Third, engage in-country judges and lawyers to support governments in developing or revising legal measures including laws, regulations, executive orders, or other compulsory standards, if they are lacking or poorly aligned with global obligations. Additionally, evaluate the effectiveness of existing legal measures on outcomes, and review violations of measures for suo moto action (an act of authority taken without formal prompting), consumer education, and parliamentary action.

Fourth, nurture a network of pro-feminist jurist influencers, lawyers, and consumer rights groups, with interest in food and nutrition rights for south-south collaboration, cross learning, and voicing South Asia specific issues in regional and global discourses.

Fifth, integrate the legal aspects of food and nutrition in the pre-and in-service legal education curriculum, with incentives for training lawyers to study this subject in their higher education.

Finally, curb any unchecked, exploitative marketing of commercial milk formula, which will require health professional and jurist networks to connect and engage on issues. This requires that pre- and in-service health training includes judicial academics, that their committees include human rights and public health lawyers, and that appropriate platforms are harnessed for joint advocacy, training, and monitoring by health and judicial professional networks.

The power of in-country jurist networks to restrain exploitation remains underutilised in developing stronger legislative action to protect breastfeeding in South Asia. It’s time for networks of professionals to join forces in a movement to crack down on the menace created by the baby food industry.


  • Competing interests: none declared.

  • Provenance and peer review: commissioned, not externally peer reviewed.