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Mortality from Nestlé’s Marketing of Infant Formula in Low and Middle-Income Countries
JesseAnttila-HughesLiaC.H.FernaldPaulJ.GertlerPatrickKrause
BruceWydick
March29,2018Abstract. Intensive and controversial marketing of infant formula is believed to beresponsibleformillionsofinfantdeathsinlowandmiddle-incomecountries(LMICs),yettodatetherehavebeennorigorousanalysesthatquantifytheseeffects.Toestimatetheimpactof infant formula on infant mortality, we pair country-specific data from the annualcorporatereportsofNestlé, the largestproducerof infant formula,withasampleof2.48millionbirthsin46LMICsfrom1970-2011.Ourkeyfindingisthattheavailabilityofformulaincreasedinfantmortalityby9.4per1000births,95%CI[3.6,15.6]amongmotherswithoutaccesstocleanwater,suggestingthatuncleanwateractedasavectorforthetransmissionofwater-bornepathogenstoinfants.WeestimatethattheavailabilityofformulainLIMCsresulted inapproximately66,000 infantdeaths in1981at thepeakof the infant formulacontroversy.Acknowledgments:WethankClaireBoone,IngvildMadsen-LampeandCarolSpectorforoutstanding research assistance, and JereBehrman,MelissaBinder, Kitt Carpenter, JanetCurrie,AndrewDustan,BrianFikkert,RussellMask,TedMiguel,NigelRollins,KiraVilla,andTom Vogl as well as seminar participants at UC Berkeley, UC Davis, USF, Princeton,Vanderbilt, Notre Dame, Covenant College, New Mexico, Minnesota, and the 2017InternationalEconomicAssociationMeetingsinMexicoCity.Theauthorshavenofinancialormaterialinterestsintheresultsdiscussedinthispaper.Affiliations: Anttila-Hugers, University of San Francisco; [email protected];Fernald, University of California, Berkeley; [email protected]; Gertler, University ofCalifornia,Berkeley andNBER; [email protected];Krause, rotagonistTechnology, SanFrancisco,California;[email protected];Wydick,UniversityofSanFranciscoandCEGA;[email protected]
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1. Introduction
Thereisstrongscientificconsensusthatbreastfeedingisoptimalforchildhealthand
development (1-3). TheWorldHealthOrganization (WHO)recommends that infantsare
breastfedwithinanhourbirth,exclusivelybreastfedforthefirst4-6monthsoflife,andthen
continue to receivebreastmilk forup to twoyears (4).A recentmeta-analysispresented
evidenceontheimportanceofbreastfeedingforchildsurvivalduetotheuniquebiological
contributionofbreastmilktothechild’simmuneresponse(5).Theriskofall-causemortality
issubstantiallylowerinchildrenwhoareexclusivelybreastfedforthefirst5monthsoftheir
liveswhencomparedwithchildrenwhoareeitherpartiallybreastfedornotbreastfedatall,
receiving breastmilk substitutes instead (e.g. infant formula) (6). Children who receive
breastmilk insteadof abreastmilk substitutesbenefit fromreduced severityofdiarrheal
diseaseandrespiratory infections (7),benefits in cognitive function (5), and longer-term
benefitsforcardiovascularhealth(8).In2012,theestimatedaggregateeconomiclossfrom
shortenedbreastfeedingwas$302billion,andthat820,000infantlivesperyearcouldbe
savedifbreastfeedingwereincreasedtonearuniversallevels(9).
Despite the scientifically supported benefits of breastfeeding, the use of infant
formula as an alternative to breast milk remains widespread (10). Less than half of
newbornsworldwidearebreastfedwithinanhourofbirth,andonly43%areexclusively
breastfedfrombirthto6months(11).Therearemanyreasonscitedforwhyamothermay
choosetouseinfantformulaoverbreastfeeding,includinginsufficientortheperceptionof
insufficientbreastmilk,lackofabilitytopumpbreastmilkatwork,lackoffamilysupport,
depression,poverty,andothersocio-culturalfactors(12-14).
Akeyfactorcontributingtolowratesofbreastfeedinghasbeentheprivatesector
development andmarketing of infant formula (15). Globally, the sales of infant formula
totaledUS$44.8billionin2016,andareexpectedtorisetoUS$70.6billionby2019(16).In
the earlypart of the20th century, companies in theUnitedStates andEuropedeveloped
commercialbreastmilk substitutes,partly in response todemand fromwomenwhohad
difficultybreastfeeding.Theuseofinfantformularosesteadilyintheindustrializedworld
withpostWorldWarIIbabyboombreastfeedingratesdroppingbyhalffromearlierinthe
century(17).FormulasalesintheUnitedStatespeakedinthe1950sandbegantorecedein
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the 1960s due both to lower birth rates andmothers returning to breastfeeding. Infant
formulacompaniesthenlookedtonewmarketsinthedevelopingworldtomakeupfalling
revenues, raising widespread alarm among public health and humanitarian advocacy
groups.
Thebeginningofthepubliccontroversyoverinfantformulamarketingpracticesin
thedevelopingworldbeganinAugust1973whenanarticle,TheBabyKiller,waspublished
intheNewIndustrialist.Thearticlestressedthenutritional inadequacyof infant formula
relativetobreastmilk(18),andprovidedexamplesofspecificmarketingabusesbyNestlé,
thefirstmajorformulamanufacturertoenterLMICs(19)andthelargestsupplierworldwide
(20).1At the same time, public health researchersdocumented a largedecline in breast-
feedingcontemporaneouswiththeintroductionofinfantformula(Figure1),andpublished
estimates of infant deaths resulting from the introduction of infant formula into LMICs
ranging fromannual figuresof1millionto10million(21,22). Thearticleandresearch
becamecatalystsforactivismagainsttheinfantformulaindustry,whichultimatelyledtoan
internationalboycottofNestléproductsstartingin1977andpublichearingsontheNestlé
controversyintheU.S.SenateinMay1978(17).
In response, the World Health Organization and UNICEF organized a meeting of
stakeholdersoutofwhich the InternationalCodeofMarketingofBreast-milkSubstitutes
(ICMBS)wascreatedandlaterenactedin1981(23).Nestlé,facedwiththeboycott,lawsuits,
andincreasingpublicpressure,eventuallyagreedtoabidebytheICMBSin1984.However,
in1988theInternationalBabyFoodActionNetworkcalledforareinstatementoftheboycott
afterevidencewasproducedthatNestléhadreturnedtomarketingpracticesbannedbythe
ICMBS(24-26,33).
Nestléwasaccusedofprovidinghealthclinicswithfreeorlow-costsuppliesofinfant
formula, often dispensed by “milk nurses” (saleswomen dressed in nurses uniforms), to
encouragenewmothersintheuseof infantformula(24-26). Thispracticeisparticularly
egregiousbecauseformulauseamongneonatesincreasestheriskthatmothersreleasethe
prolactin-inhibiting factor, which signals their milk production to shut down, thereby
1Nestlehasconsistentlydeniedallegationsofunethicalmarketing(17).
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creating a future dependence on breast milk substitutes (27). In addition, critics were
concernedthatNestlé’smarketingincludedpromotingformulatomothersunlikelytohave
access to cleanwater and likely to possess limited technical understanding of nutrition,
physiology, or disease mechanisms due to relatively little formal education (19).
Inappropriatelypreparedformula(e.g.mixedwithuncleanwater,ormixedwithtoomuch
water),canincreasetheriskofinfantmortalityduetotheincreasedlikelihoodofdiarrhea
andotherintestinalinfections(28).
Inthispaperwepresent,toourknowledge,thefirstcausalestimatesoftheeffecton
infantmortality of Nestlé’s entrance into LIMC formulamarkets for the both population
overall, and for vulnerable subpopulations believed to be most at risk. Nestlé’s phased
geographicentryintonationalinfantformulamarketsovertimeinLMICsprovidesplausibly
exogenous variation in the market availability of formula conditional on location fixed
effects.Weexploit thisvariation to identify thecausaleffectof formulaavailabilityusing
difference-in-differencesandevent-historymodels.Weestimatethesemodelsbycombining
dataonthetimingofformulaimportsprovidedinNestlé’sownannualcorporatereportwith
dataoninfantmortalityfrom2.48millionindividualbirthrecordsin48countriesfor1970
through2011collectedinDemographicandHealthSurveys(DHS)(29).
2. Data
InfantFormulaAvailability:SinceNestléwasthefirstmajorformulamanufacturerto
enterLMICs(19)andthelargestsupplierbyfarworldwide(20),weproxyinfantformula
beingavailableinacountrybywhetherNestléwasactivelymarketingandsellingformulain
thatcountry.AnnualdataonthecountrieswhereNestlésells infantformulaarefoundin
Nestlé’s1966to2014corporateannualreports,intheManufacturingandSaleofProducts
section describing internationalmarket activity (SupplementaryMaterials Figure A).We
8excludesixcountrieswheretherewasalreadylocalproductionofformulabefore1966.
InfantMortality:WemergedNestlé’sinformationoninfantformulaavailabilityina
countrywithindividualinfantbirthandmortalityrecordsfromtheDemographicandHealth
Surveys(DHS),asetofnationallyandregionallyrepresentativesurveysofwomenbetween
the ages of 15 and49, covering a large sample of low andmiddle-income countries.We
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identifiedallDHScountriesforwhichNestlébegansellingformulabetween1966and2014,
creatingasampleofallchildrenbornwithinthe+/-5yearssurroundingtheyearformula
imports began, and added control countries from the same geographic region as each
treatment country, leaving uswith a sample of the 18 treated countries and 28 control
countries,foratotalsampleof2,478,842childrenin46countriesasseeninTable1.
TheDHSsurveyincludesrecalldataforallchildrenincludingdateofbirth,andageat
death if the child died, allowing us to construct location and year-specific infant-level
mortalitydataset.Wedesignateanydeathofachildage12monthsoryoungeras infant
mortalityandrescale thevariable todeathsper thousandsoas toyield rate-comparable
estimates(indeathsper1000livebirths)forpopulationprevalence.
MaternalandHouseholdCharacteristics:Weuseseveralothervariablesof interest
takenat timeof survey includingchildren'sbasicdemographic characteristics (sex,birth
order,dateofbirth),andmother'sandhousehold’scharacteristics(education,typeofwater
access,assetquartilemeasureofwealth,andlocation).Weusetwoindicatorsforbroadly
comparablemeasuresofsocio-economicstatus:avariable indicating that themotherhas
completedlessthanprimaryeducation,andavariableindicatingthatahouseholdisbelow
thecountrymedianintheDHS’sassetindextoproxyforhouseholdwealth.
Appropriatepreparationofpowderedinfantformularequirescombiningthepowder
with clean drinkingwater; safewater is critically important here becausemixing infant
formulawithuncleanwaterpresentsaseverehealthrisktonewborninfants.Wemeasure
amother’sinabilitytoaccesscleanwaterusingtheDHSwatersourcevariablethatindicates
thewatersourcemostcommonlyusedbythehousehold.Surfacewater,thelowest-quality
water source in theDHS, is thewater source associatedwith thehighest levels of infant
mortality regardless of infant formulause (30). In our sample, surfacewater is usedby
15.4%ofhouseholds.
Anindicatorofsurfacewaterasthehousehold’sprimarywaterservesasourmeasure
ofpoorwaterquality.Weassumethatanywomancurrentlyusingunsanitarywaterwas
likelytobedoingsointhepast.However,thereissomemeasurementerrorinthisvariable
asthesteadydecreaseinunsanitarywaterusegloballyoverthisperiodimpliesthatthere
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are likely to be observations that had unsanitary water in the past but do not today.
ImprovementsinwaterqualityaccessinLMICsthathaveoccurredsincethebirthofchildren
inthedatasetwouldlikelyattenuateourestimatesoftheimpactonmortalityforthesample
designatedtouseunsafewater,implyingthatourestimateswouldbelowerboundeffects.
MacroeconomicData:TocontrolforthepossibilitythatthetimingofNestléimports
andchoiceofcountrieswereendogenouslyrelatedtoeconomicconditionsthatcouldalso
affect infant mortality, we include a set of country-level macroeconomic controls for
economicgrowthandforeigninvestment.DataonGrossDomesticProduct(GDP)percapita
and Foreign Direct Investment (FDI) were taken from the World Bank Development
Indicators.
3. IdentificationandEstimation
Nestlé’sphasedentryovertimeintonationalinfantformulamarketsprovides
plausiblyexogenousvariationinthemarketavailabilityofformulaconditionalonlocation
fixedeffects.Weexploitthisvariationtoidentifythecausaleffectofformulaavailabilityby
estimatingdifference-in-differencesmodelswithlocationandyearfixedeffects.We
interprettheresultsasIntent-to-Treat(ITT)estimatesthatcapturetheaveragemortality
responsetotheavailabilityofinfantformulaforpurchaseproxiedbywhetherNestléis
activelysellingformulainthecountry.Ourestimatedtreatmenteffectsrepresentthe
intersectionofadoptionofinfantformulabymotherswithintheexposedpopulationand
theimpactsoninfantsfromconsumingtheformula.Theimpactoninfantmortalitywill
alsovarydependingonwhetherformulaiscombinedwithcleanwaterandwhetherit
substitutesforbreastmilkorforsomeinferiornutritionalsupplementationsuchaswater,
dilutedcondensedmilk,juice,ricewater,orotherlow-qualitysubstitute.
Specifically,weestimatethefollowingdifference-in-differencesmodelusingalinear
probabilityspecification:
𝑚"#$%& = 𝛽𝑁"% + 𝛼$ + 𝛾& + 𝜆"% + 𝜑" + 𝝁0𝒁𝒋 + 𝝓′𝑪𝒄𝒕 + 𝜖"#$%& , (1)
where𝑚"#$%&isanindicatorvariableequalto1000ifchildidiedduringorpriortohisorher
12thmonthoflifetoamotherinDHSregionk,incountryc,andinyeartjandequalszerois
thechildlivedthroughits12thmonthoflife,;βisthetreatmenteffectandisthecoefficient
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on𝑁"% ,whichindicateswhetherthechildiwasborninthefiveyearperiodafterNestlébegan
sellingformulaincountryc;𝛼$ representsaregionalfixedeffect;𝛾&isafixedeffectforyear
ofthechild'sbirth;𝜆"% isavectorofcountry⋅birth-monthfixedeffectstocontrolforcountry-
levelseasonalityinmortality;𝜑" isagender⋅birthorderfixedeffectforchildi;𝒁𝒋isavector
ofmotherandhousehold-levelcharacteristicsthatincludehouseholdwateraccess,mother’s
education,andwhetherthehouseholdisinthelowestwealthquartileinthecountry;𝑪𝒄𝒕is
a vector of macroeconomic controls that includes GDP per capita and Foreign Direct
Investmentincountrycinyeart,and𝜖"#$%&istheerrorterm.Weclusterthestandarderrors
at the levelof the first-levelDHSadministrativeunit, andweight thedatausing theDHS
surveyweights.
Wetestwhetherthetreatmenteffectsaredifferentforhouseholdsthatusesurface
waterversuscleansourcesofwater,loweducatedmothersversushigheducatedmothers,
and poor households versus non-poor households. Specifically, we estimate versions of
equation (1) with interactions of β𝑁"% with indictors separately for surface water, low
education,andpoverty.
Finally,weestimatean“eventstudy”versionof thedifference-in-differencemodel
that allows the treatment effects to vary in the years prior to and following formula
introduction.Specifically,
𝑚"#$%& = 𝛼$ + 𝛾& + 𝜆"% + 𝜑" + 𝝁0𝒁𝒋 + 𝝓0𝑪𝒄𝒕 + 𝜏;&<=;>&?= 𝑇%; + 𝜖"#$%&, (2)
where coefficients in (2) are as in (1) except that 𝜏; is a set of 2m+ 1 coefficients that
represent a child’s birth in different years within the event window surrounding the
introductionofinfantformulawithinacountry.Weuseaneventwindowin(2)thatranges
fromfiveyearsbefore(T=-5)tofiveyearsafter(T=+5)Nestlébegansellingformula.The
event-study estimations allow us to examine pre-treatment trends before formula
introductionandwhether introductionof formulacreatesabreak in thesepre-treatment
trends.
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4. Results
Table2reportsestimatesoftheaveragetreatmenteffectsforthemortalityeffectof
formula from our difference-in-differencesmodels. First, we note that drinking surface
water,havinglowmaternaleducation,andbeinginabelowmedianpovertyhouseholdall
significantlypredictincreasedmortalityinallmodelspecifications.Ourestimatesindicate
thatachildbornintoahouseholdinthebottomquartileofincomethatusessurfacewater
asitsmajorsourceofdrinkingwater,wherethemotherhaslessthanprimaryeducationand
livesinpovertyhasa40.1per1000livebirthshigherprobabilityofinfantmortality,or55%
higherthanthemeanmortalityrateofthesample.
Theintroductionofinfantformulashowsnostatisticallysignificantaverageimpact
oninfantmortalityforthepopulationasawhole(Table2,Model1).However,ourresults
showlargeandsignificantinfantmortalitydeathsfromformulaintroductionconcentrated
in vulnerable sub-populations. Specifically, infant formula availability had a significantly
negativeeffectonmortalityofinfantsborninhouseholdsthatusedsurfacewater(Table2,
Model 2). The availability of formula increased infant mortality by 12.9 per 1000 for
householdsthatusedsurfacewaterrelativetohigher-qualitywaterusinghouseholds.The
neteffectofformulaavailabilityisanincreaseof9.4infantdeathsper1000amongmothers
withpoor-qualitywater.
Wetestwhetherexposuretosurfacewater isaproxyforsocioeconomicstatusby
addinginteractionsofformulaavailabilitywithindicatorsforbothlowmaternaleducation
and below-median asset poverty (model 3). We find that the estimate is practically
unchanged, and thatmother’s education andwealth are insignificant. Thus, our results
indicate it isthecombinationof infant formulaavailabilityandlackofcleanwateraccess
ratherthanpovertythatdrivesourresults.
Althoughthecombinationof formula introductionandwomen’seducation itself is
insignificant,weinvestigatewhetheruneducatedmotherswithoutcleanwateraccesswere
morelikelyuseinfantformulainwaysthatputinfantlivesatrisk,followingreportsthatless-
educatedmothersdidnotknowthatthesurfacewatermixedwiththeformulaneededtobe
boiledorpurifiedinsomeotherway(19).Weinvestigatethisusingatripleinteractionof
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formulaavailabilitywithsurfacewaterandlowmother’seducation(model4)andindeed
findthattheelevatedinfantmortalityfromformulaintroductionisconcentratedamonglow-
literacy mothers in surface-water using households. Estimating the effect of formula
availabilityon justthatgroup(model5)confirmsthisresultandshowsanevenstronger
differenceof14.2perthousandrelativetothehigh-qualitywatercounterfactualgroup.
Our event study estimates in Figure 2 show estimated differences in mortality
betweenthoseeventuallytreatedcountriesandthosenottreatedfortheyearsbeforeand
after formula imports began. We estimated themodel for infants born to two types of
mothers, those using surface water and those using non-surface (higher quality) water.
Thereareminimalandstatisticallyinsignificantdifferencesininfantmortalityfortreatment
andcontrolcountriesforsurfacewaterandnon-surfacewaterhouseholdsintheyearsprior
totheintroductionofinfantformula,minimizingconcernsoverpossiblyconfoundingnon-
parallel pre-trends in the difference-in-differences estimates reported in Table 2. The
introduction of Nestlé formula, however, generates a visibly distinct increase in infant
mortality insurface-waterhouseholdsrelativetohigh-qualitywaterhouseholds,onethat
peaks three years after introduction, suggesting a wave of mortality coinciding with
increasingmarketpenetration.
Finally,wetestforanyeffectofNestléagreeingtoabidebytheInternationalCodeof
MarketingofBreast-milkSubstitutesin1984.Model(6)reportstheresultsofrestrictingthe
sampletoonlychildrenbornafter1984,findingthattheimpactoninfantmortalityfromthe
introductionofNestléformulapost-1984forsurfacewaterhouseholdschangesslightlyfrom
9.40to8.34butremainshighandstatisticallysignificant(p<0.01),providingnoevidence
thattheinternationalmarketingcodechangedmortalitydynamics.
5. Robustness
Table 3 shows four alternative specifications and robustness checks for ourmain
results.Model(1)reproducestheresultsfromourpreferredspecificationinmainresultsin
Model(2)inTable2forcomparisonpurposes.Model(2)replicatesthesamespecification
usingmother-level, instead of region-level fixed effects, allowing us to better control for
maternalandfamilycharacteristics.Identification,however,reliesonthedifferentialeffect
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offormulaonmortalityacrosstwoormorechildrenbornwithinthesamefamilyoverthe
sampleperiod,implyingthatidentificationisdrivenbydifferencesinolderversusyounger
siblings and a reduced the sample size. The coefficient on formula availability remains
virtually unchanged, and the effect of formula among surface water exposed infants
decreasesslightlyto8.9deathsper1000.
Wealsoestimatethesamespecificationsusingcountry-levelfixedeffectsinmodel
(3).Thecoefficientonformulaavailabilityremains insignificant,buttheeffectof formula
availabilityonsurfacewaterhouseholdsincreasesto14.15,oraneteffectofanincreasein
11.42infantdeathsper1000amongsurfacewaterhouseholds,indicatingaslightlygreater
impactthanourregional-fixedeffectestimations.
TheDHSdatareliesonmothers’recalltoanswerquestionsrelatedtoinfantbirths
anddeaths,whichmayaddnoisetoourestimateandincreasemeasurementerrorwhenthe
windowsurroundingtheintroductionofformulapredatesDHSsurveysbymanyyears.In
model(4)welimitthetreatmentsampletothesubsetof11countriesthatweresurveyedby
DHSwithin fifteen years of the beginning ofNestlé sales. We see that the results again
remainessentiallyunchanged.
6. Discussion
TheNestlécontroversy,oneofmostnotoriousallegationsofcorporatemalfeasance
inthemodernera,hasbeendrivenbyconcernsthatthecontroversialmarketingpractices
usedNestlétosell infant formula inLMICshada large impacton infantmortality. Inthis
research,wecombineinformationfromNestlé’sannualcorporatereportsoncountrylevel
activitywithinfantmortalityfrom2.48millionbirthsin46countriestoestimatetheeffect
of infantformulaavailabilityoninfantmortality.Althoughwefindinsignificanteffectson
infantmortality forthepopulationasawhole,wefinda largeandstatisticallysignificant
increaseininfantmortalityamonghouseholdswithoutaccesstocleanwater,especiallyfor
infants of less-educated mothers, corroborating many of the observations of health
practitionersmadeduringthepeakoftheinfantformulacontroversy.
Thestrengthsofourstudyincludethelargenumberofcountriesforwhichthereare
longitudinaldataavailable,theuseofcorporatedatatoidentifytheyearofNestlé’sentry
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intoacountry,andaverylargesampleofbirthsoveralongtimeperiod.Otherstrengths
includeourabilitytoexploitthephasedentryintoLIMCmarketsovertimetoidentifycausal
effects using difference-in-differences models, confirmation of parallel pre-trends in the
event-history specifications, and the robustness of our estimates to a wide variety of
alternativespecifications.
There are also limitations. First,we use only data fromNestlé, and although the
companyhasthelargestmarketinfantformulashareinLMICs,wedonothavedatafrom
otherinfantformulamanufacturers.Second,weonlyhavedataonwhetherinfantformula
isbeingmarketedinacountryandnotontheintensityofthemarketingoritspenetration,
noronformulause.Third,wearelimitedtousinginfantmortalitydataanddonothavedata
onchildmorbidity;giventhelargeeffectsofinfantformulainimmunesystemfunction,we
aremissingthecalculationofeffectsofinfantformulaconsumptionondiarrhea,respiratory
functioningandothertypesofinfantmorbidity.
HowmanyinfantdeathsresultedfromtheintroductionofNestléinfantformulato
mothers with poor access to clean water?We estimate the number of deaths for 1981,
arguablythepeakyearofthecontroversywhenmediaattentionwasthehighest.Wedothis
by multiplying the 47.8 million 1981 live births that occurred in Nestlé formula sales
countriesbythefractionofthosehouseholdswithsurfacewaterinthosecountriesandby
ourestimateoftheimpactofformulaoninfantsfromhouseholdswithonlyuncleansurface
wateraccess,i.e.0.0094fromTable2.Thisyieldsanestimateof65,676infantdeathswitha
95%confidenceintervalof[24,868,106,485],lowerthanearlierestimatesofonemillionor
more,butunquestionablyasubstantiallossofhumanlife.
Wecomparethemagnitudeoftheeffectoninfantmortalityduetoinfantformulato
theeffectsizesofotherfactorsimpactinginfantmortalityinLMICs.Specifically,wecompare
our results to the effects of having an uneducated mother, lacking post-natal care,
experiencingalossof10%ofacountry’sGDP,lackingaccesstocleanwatergenerally,and
having no pre-natal care (Figure 3). Our estimated infant-mortality effects of formula
availabilityonsurface-water-usinghouseholdsareonthesameorderofmagnitudeasthese
other threats to infant life. For example, the introduction of infant formula tomothers
withoutaccesstocleanwaterresultsinanincreaseininfantmortalitythatisroughlysimilar
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toalossin10%ofGDP,andsomewhatgreaterthantheeffectofuncleanwateritselforthe
absenceofprenatalcare.
Manyofthesedeathscouldhavebeenavoidedifmoremothershadbreastfed.There
are a number of effective antenatal and postnatal behavioral change interventions that
improve breastfeeding practices and thereby reduce infant formula use (35). Examples
includeeducationandcounselingduringtheprenatalperiodaswellashospitalandhome-
basedsupportinthepostpartumperiod(36,37),andeffectsofwhichcanbeenhancedby
including fathers (38). A very effectiveprogram is theBabyFriendlyHospital Initiative,
which banspromotionofbottle feeding infantspost-partumandsupportsbreastfeeding
immediatelyafterbirthandthroughoutthecrucialfirstfewdays(38).
Evenwithinterventionsthatpromotebreastfeeding,somemotherswillundoubtedly
choosetouseformula.Onemessagethatemergesfromouranalysisisthecriticalimportance
ofmakingsure thatmotherswhochoose touse formula,use it safely. Clear instructions
comprehensible to mothers of all education levels need to be included in marketing
materials,andforhouseholdsthatdonothaveaccesstocleanwater,chlorinetabletscould
beincludedinthepowderedformulaorthepre-mixingofformulawithcleanwater.
Finally,infantmortalitymaybeavertedbyregulatingunethicalmarketingpractices.
The international community’s response to concerns over marketing was to create the
InternationalCodeofMarketingBreastmilkSubstitutes (ICMBS) (31),whichhas recently
beenextendedtoincludeinappropriatemarketingofallfoodstoinfantsandyoungchildren
(32).However,compliancewiththeICMBSisvoluntaryandviolationsofbannedmarketing
practices continue. A global watch-dog group, “Breaking the Rules, Stretching the Rules
2017” documented over 800 violations of the ICMBS by 28 formula companies in 79
countries between 2014-2017 (34). The violations range from promotions claims that
mislead consumers, and surreptitious methods to influence doctors and other health
professionals, such as sponsoring medical conferences and partnering with health-
promotingNGOs.Tocombattheseabuses,WHO,UNICEFandtheInternationalBabyFood
Action Network have called for countries to enact ICMBS legislation with stringent
enforcementmechanismsandpenaltiesfornonadherence,andtocloselymonitoradherence
(16).
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Figure 1: Breastfeeding rates before (blue) and after (grey) infant formula became available in
selected countries
a(27)b(40)c(41)d(27)e(42)f(43)g(41)
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Figure 2: Event-History Estimates of the Effect of Infant Formula Availability on Infant Mortality
Notes: These figures plots the estimated differences and 95% C.I.s for infant mortality rates (×1,000) in surface and high-quality water treatment households relative to controls in the years before and after Nestlé starting marketing infant formula in treatment countries, as specified in equation (2). The estimates are normalized to 0 in the year prior to entry (t0 -1).
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Figure3:ComparisonofEffectsofFactorsAffectingInfantMortality
aRegionlevelfixedeffectestimatepresentedinTable2.bRegion-levelfixedeffectestimatepresentedinTable2c(44)d(45)e(46)f(47)gRegionlevelfixedeffectestimatepresentedinColumn(1)ofTable2.h(48)
Note:Errorbarsrepresent95%confidenceintervalsexcept(b)whichgivesstandarddeviationof10-yearinfantmortalitydeclineacrosscountries.
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Table1:DescriptiveStatistics
Region Country
FirstyearofNestlésales
N
InfantMortality
Rate(per1000births)
Householddrinkssurfacewater
Motherdidnotcompleteprimaryschool
PoorHH(lackingTV,radio,orelectricity)
Asia Bangladesh 1993 94,040 89.0 3.6% 74.2% 51.4%
Cambodia 1998 65,053 92.8 35.1% 71.5% 32.5%
Indonesia 1972 86,667 103.9 10.1% 58.3% 20.4%
Pakistan 1990 34,105 95.8 5.0% 80.6% 14.9%
SriLanka 1981 9,179 33.1 7.0% 32.1% 25.5%
Vietnam 1997 9,558 27.4 18.5% 26.3% 11.5%
Sub-Saharan Cameroon 1992 35,876 84.4 33.5% 51.3% 33.9%
Africa CongoDRC 2011 33,462 133.9 39.9% 91.7% 33.5%
Guinea 1993 8,645 103.2 34.5% 85.1% 55.8%
Madagascar 1972 19,765 131.4 2.77% 89.4% 23.1%
Senegal 1974 204 121.1 25.6% 50.3% 18.6%
Swaziland 1971 7,050 100.5 18.8% 63.4% 55.8%
Zambia 1969 20,961 79.1 15.0% 61.5% 10.5%
Americas Dom.Rep. 1971 3,891 116.4 0.0% 55.5% 9.8%
Ecuador 1970 119,228 78.6 0.1% 65.5% 4.0%
NorthAfrica Egypt 1988 55,718 25.1 4.7% 7.6% 2.4%
Jordan 1999 20,534 59.6 5.4% 85.8% 8.5%
Morocco 1992 94,040 89.0 3.6% 74.2% 51.4%
ControlCountries - 1,854,906 94.2 16.5% 64.5% 27.8%
FullSample 2,478,842 91.9 15.4% 64.1% 26.6%
Notes: This table reports the year Nestlé started selling infant formula by country and means values of key characteristics the DHS surveys in the year before entry for treatment countries and the average of sample years for the control countries. Means were computed using sample weights provided by the DHS. Control countries include Armenia, Azerbaijan, Burkina Faso, Cote d'Ivoire, El Salvador, Ethiopia, Gabon, Ghana, Guatemala, Kazakhstan, Liberia, Malawi, Maldives, Mali, Namibia, Nicaragua, Niger, Nigeria, Paraguay, Philippines, Rwanda, Tanzania, Thailand, Togo, and Yemen.
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Table 2. Effect of Infant Formula Availability on Infant Mortality
Model(1) Model(2) Model(3) Model(4) Model(5) Model(6)
InfantFormulaAvailable -1.469 -3.543 -2.693 -1.941 -3.004 -2.988 (2.249) (2.475) (2.802) (2.852) (2.397) (3.017)
FormulaxSurfaceWater 12.94*** 12.87*** 6.176 11.33***
(3.169) (3.224) (4.452) (3.448)
FormulaxLowEducationMom -2.697 -4.006
(3.055) (3.284)
FormulaxLowestWealthQuartile 2.856 2.814
(2.497) (2.504)
FormulaxSurfaceWaterxLowEd 9.821** 14.21*** (5.305) (3.500)
SurfaceWater 6.544*** 5.339*** 5.339*** 5.335*** 5.641*** 7.691*** (1.367) (1.405) (1.401) (1.401) (1.373) (1.244)
LowEducationMother 23.57*** 23.57*** 23.85*** 23.86*** 23.37*** 21.97*** (1.167) (1.167) (1.226) (1.226) (1.172) (1.188)
LowestWealthQuartile 9.958*** 9.965*** 9.727*** 9.725*** 9.955*** 8.378*** (0.946) (0.944) (0.976) (0.976) (0.944) (1.024)
SampleSize 2,478,842 2,478,842 2,478,842 2,478,842 2,478,842 2,054,604
Notes:Eachcolumnreportstheresultsofaseparateregression.Allmodelsadditionallyincludefixedeffectsforfirstsubnationaladministrativeregion,gender,sex-specificbirthorderofchild,country-specificbirthmonth,andyearaswellaslinearcontrolsforlogpercapitaGDPandpercapitaGDPgrowthobservedatyearofbirth.Standarderrorsclusteredattheleveloffirstsubnationaladministrativeregion.**(p<0.05)***(p<0.01)
21
Table 3. Alternative Specifications and Robustness Checks
Table2Column(2)
Mother-LevelFixedEffects
Country-LevelFixedEffects
SampleLimitedto11ClosestRecall
(1) (2) (3) (4)
InfantFormulaAvailable-3.543 -3.524 -2.732 -4.635
(2.475) (2.786) (2.427) (2.798)
InfantFormulaxSurfaceWater12.94*** 8.939** 14.15*** 13.00***
(3.169) (4.193) (3.774) (3.425)
SurfaceWater5.339*** 3.931** 5.704***
(1.405) (1.538) (1.432)
LowEducationMother23.57*** 27.98*** 23.01***
(1.167) (1.472) (1.202)
LowestWealthQuartile 9.965*** 12.59*** 9.893*** (0.944) (1.148) (0.962)
SampleSize 2,478,843 2,271,037 2,478,843 2,344,061
Notes:Eachcolumnreportstheresultsforaseparateregression.Column(1)isthesameascolumn2fromTable2forcomparisonpurposes.Model(1)includesfixedeffectforfirstsubnationaladministrativeregion.Model(2)replacesthosewithmotherfixed-effectsandthereforthemaineffectofsurfacewater,loweducation,andwealtharesubsumedinthefixedeffects. Model(3)replacesthosewithcountry-levelfixedeffects.Model(4)estimatesmodel(1)restrictingtreatmenttothesampleofcountrieswithaDHSsurveyconductedwithin15yearsofNestleentry.Model(5)estimatesmodel(1)restrictedtothesampleofcountries forwhichNestleenteredafter1984pluscontrolsAllmodelsadditionally includefixedeffectsgender,sex-specificbirthorderofchild,country-specificbirthmonth,andyearaswellaslinearcontrols for logpercapitaGDPandpercapitaGDPgrowthobservedatyearofbirth.Standarderrorsclusteredattheleveloffirstsubnationaladministrativeregion.**(p<0.05)***(p<0.01).
22
SupplementalOnlineAppendix
Data Nestle participation in country infant formula markets are taken from a table listing import andproductionofdifferentcategoriesofNestléproductsacrossall countries inwhich thecompanyoperates,atablewhichhasstayedremarkablyconsistentoverthefivedecadesofdataweexamine(FigureA).Whilethissectionhashadslightlydifferenttitlesovertime,thelayoutandstructurehasbeenconsistentthroughout(SeeFiguresAbelow).Weidentifythespecificcategoryineachyearinwhichbabyformulaisreported,acategorywhichchangesovertimeandinsomecasesexplicitlyidentifiesinfantformulaandinothersgroupsitunder“Milk-basedDieteticProducts”andsimilarheadingswhichwecross-referencefromwithinthereports.WeareabletospecificallyidentifytheyearNestléinfantformulaimportsbeginbasedonthecodingofthereportsandtheyearinfantformulabeginstoappearasanimportintoagivencountry.
FigureA