Between contractions, a woman whom Veasna* had never met pressed two products into her hands as she lay in her hospital bed. The first was a kind of “mother’s milk” for breastfeeding mothers; the second, she said, was a bottle of baby formula.
“For me, it was my first child. I felt so shocked, and I didn’t want anybody to talk to me, I only wanted my family to be with me,” she said.
Veasna could not recall the name of the product, but said the company representative gave her products she said would “help” her.
Navigating the waves of pain at the time, Veasna did not realise until later that marketing baby formula in hospitals directly to mothers in labour is illegal under Cambodian law.
Sub-decree 133, adopted from the World Health Organization’s International Code of Marketing of Breast-milk Substitutes, made it so in 2005.
The law forbids any distributor or manufacturer from promoting infant and young child feeding products at point-of-sale, in hospitals or health centres.
That includes “providing one or more samples of the infant and young child feeding products to any person”.
An oversight committee was established last year to crack down on breaches, but more than a decade on, companies are continuing to market their product in dubious ways.
Health Ministry spokesperson Ly Sovann on Thursday said that by law, and in all hospitals, providing free samples of infant formula is not permitted. But Cambodia’s sub-decree also provides a loophole for companies; the laws are only in effect if a company has not obtained “prior permission” or “authorisation” from the Ministry of Health.
Helen Keller International’s Hou Kroeun said those loopholes should be closed. “We need to revisit these clauses, because that made room for interpreting things in a different way,” he said.
At the capital’s Preah Ang Duong hospital, where Veasna gave birth to her son three months ago, another new mother, Ros Sophorn, 34, said she was handed a bottle of “matilia”: a France Bebe-branded milk for lactating mothers. It is a product for adults and therefore not illegal under Cambodia’s subdecree.
But a pink tin of France-Lait-brand infant formula, manufactured by Regilait, also sat on a shelf by her hospital bed. Sophorn said the midwives gave the formula to her newborn without her consent, while she was unconscious after having a caesarean section birth.
“It is just fine, because I was unconscious, so how else could my baby have something to eat?” she said.
A hospital staffer who spoke on condition of anonymity said there was a regular time-slot for companies to market their products to midwives and doctors at the hospital, but that at least one company representative has gone further, approaching mothers directly without permission.
Hospital director Lou Ly Kheang could not be reached for comment by deadline.
While the promotion of mother’s milk products is not illegal, it sits uncomfortably with Yeong Joo Kean, legal adviser at the International Code Documentation Centre with the International Baby Food Action Network (IBFAN-ICDC).
“[W]e don’t like this product, as it is being used for cross promotion for products that come under the International Code [such as baby formula],” she said in an email.
“The product is being falsely marketed as necessary for a safe pregnancy and successful breastfeeding when all that is needed is a normal diet. Women who really need the extra nutrients can’t afford the product and the women [who] can afford them don’t really need it.”
Joo Kean said the promotion was all about building brand recognition and loyalty.
“Labelling is one thing, but giving companies access to mothers in hospitals is even worse as the perception will be that the products are endorsed by the hospitals and therefore must be good,” she said.
“There is no excuse for this behaviour . . . They are putting profits before health of babies. It’s pure greed that is driving this behaviour.”
She said a lack of political will had allowed companies to treat Cambodia “like a lawless playground”, adding that “breastfeeding will have no chance unless the law is monitored and enforced”.
Both the matilia and France Lait products found in Ang Duong Hospital lacked Khmer-language instructions on the packaging – a requirement for infant formula under the sub-decree.
France Bebe this week told the Post that matilia was only for mothers but they would nonetheless investigate, while France Lait said they had no agreement with the hospital or Ministry of Health to circumvent the sub-decree.
In an email, France Lait spokesperson Tiv Sothavatey said, in line with the Ministry of Health, “companies cannot promote infant formula #1, the company can only promote ‘Growing up formula’ or #3”, for children over the age of 1.
She added they did not provide free samples. But when asked if the company provided products to the hospital for a fee or free of charge, or why there were no instructions in Khmer, she did not respond by deadline.
But it is not the only hospital where the presence of infant formulas is fraught. At Kbal Thnal Maternity Clinic, midwife Tieng Sophal said formulas are bought wholesale and sold for a profit at the hospital, including products like Dumex, Similac and Nutrilac.
“Some mothers like breast feeding, some mothers prefer to use formula,” Sophal said. “We told them to breastfeed first; but if there is no milk, then they should use formula.”
Meanwhile, in the capital’s VIP Sorphea Maternity Hospital, photos last week emerged of apparent advertising on elevator doors and seemingly free samples of the product “Dumex” – an infant formula produced by French firm Danone.
Neither free samples nor elevator advertisements were present at the hospital when the Post visited on Wednesday; however, a reporter spotted the decals displayed on elevator doors in the hospital last month.
The Khmer text on the poster reads: “Vision of our Hospital – You will receive virtuous care and trust from us. Breastfeeding is the best for feeding infants and young children. Nutrition from the Heart.”
The last sentence is a tagline for Dumex.
William Green, from Danone corporate affairs, said the company has a strict policy of adhering to the WHO code and had investigated VIP Sorphea Maternity Hospital after concerns were raised.
“We have not observed any non-compliance of our current marketing activities in this hospital … Currently, in the hospital are only unbranded posters to educate parents on the role of nutrition during the first 1,000 days, emphasising the importance of breastfeeding.
“We can confirm that we are in compliance with the Cambodian sub-decree 133, and that no free sampling is taking place in the hospital.”
When asked about the photo of elevator doors – which does not name “Dumex” but features its colour scheme and part of its heart-shaped logo beneath a flattering image of mother and child – Green stressed it was within the “prevailing Cambodian regulation” as it depicted no brand names or products.
“But it is an outdated example for us [it does not reference the importance of appropriate nutrition in the first 1,000 days] and is no longer on display at the Sorphea Hospital,” he said, without stating when it was removed.
Hou Kroeun claimed he had worked closely with Dr Aing Hoksrun, director of the food safety department at the Ministry of Health, who informed him the ministry had investigated the hospital and last week removed promotional materials and free formula – a move welcomed by Joo Kean.
Hoksrun would not answer questions for this story, instead referring reporters to health spokesman Ly Sovann, who said he was not aware of this case. Dr Pech Sothy, general manager at VIP Sorphea Maternity Hospital, denied promotional materials had been removed in recent days and added the hospital did not provide formula. If parents wanted it, she said, they had to purchase it themselves.
“We have three branches in Phnom Penh; and not one of our hospitals promoted formula . . . I really have a strict ban on promoting formula materials; we never encourage it . . . because we want our mothers to breastfeed,” Sothy said.
For Abigail Beeson, a lactation educator with Save the Children, misinformation and lack of adequate support for mothers who have had caesarean births could result in mothers choosing formula over breast milk.
While many mothers the Post spoke with insisted they could not produce breast milk for three days after delivery, Beeson said this was all down to perception, and that mothers produced small – but powerful – amounts of colostrum that were high in nutrients and immune factors for babies.
“Particularly in settings where there is a lot of infant formula . . . it doesn’t necessarily foster an environment for making informed choices about feeding a baby,” she said.
“Breast milk is hands-down the best thing you can give to a child; it responds to the needs of the child and also reduces their chances of getting ill.”
Other factors, like women returning to work after three months or the misconceived idea that formula made a baby “fatter” and therefore healthier, were examples of how the insecurities of new mothers could be preyed upon by multinational corporations to persuade them to prioritise the bottle over the breast.
For Veasna, dealing with the relentless crying of her son in the first few days was excruciating, but worth it for the benefits of breastfeeding.
“For three days to four days, my son cried a lot, and I was about to cry, too. My husband and even my mother were about to give the formula to my son, but I said no, please don’t,” she said.
“Let him cry, I am sure I can breastfeed him.”
Had Veasna not previously resolved to breastfeed, she said, she may have succumbed to the lure of formula.
“If we start to use formula at that time, when we get out of the hospital, we keep using them,” she said. “Hopefully, from our generation, there will be a change. Before, we gave breast milk to our babies. Why now don’t we do it?”
*Veasna is a pseudonym created to protect the mother’s identity.