Formula milk companies are continuing to use aggressive, clandestine and often illegal methods to target mothers in the poorest parts of the world to encourage them to choose powdered milk over breastfeeding, a new investigation shows.

A Guardian/Save the Children investigation in some of the most deprived areas of the Philippines found that Nestlé and three other companies were offering doctors, midwives and local health workers free trips to lavish conferences, meals, tickets to shows and the cinema and even gambling chips, earning their loyalty. This is a clear violation of Philippine law.

Representatives from Nestlé, Abbott, Mead Johnson and Wyeth (now owned by Nestlé) were described as a constant presence in hospitals in the Philippines, where only 34% of mothers exclusively breastfeed in the first six months. Here, they reportedly hand out “infant nutrition” pamphlets to mothers, which appear to be medical advice but in fact recommend specific formula brands and sometimes have money-off coupons.

Hospital staff were also found to be recommending specific formula brands in lists of “essential purchases” handed to new mothers. Targeted advertising on Facebook and partnerships with influential “mummy bloggers” means mothers are being exposed to more unregulated formula promotion than ever before.

Jovelyn, 32, bottle feeds her five month-old baby JM in her home and shop in Caloocan City, Metro Manila, the Philippines. Photograph: Hanna Adcock/Save the Children

At the same time, powerful lobby groups have been working to curtail government legislation regulating formula marketing and promotion, in the Philippines and across the world.

All companies have rejected the allegations and denied any wrongdoing.

‘Formula is expensive … I only gave her half bottles’

Mothers living in the ramshackle neighbourhoods of Metro Manila spoke of spending three-quarters of their income on formula milk, often forgoing food themselves.

TV advertising campaigns for follow-on milk by brands such as Bonna – which portray the “Bonna kid” as one who is smarter and succeeds in life – convinced them, they said, that bottle feeding is not only as good for the baby’s health as breast milk but will bolster their IQ and future prospects. Store displays of formula were splashed with claims such as “clinically proven to give the IQ + EQ advantage”. For mothers living in poverty, such aspirational marketing is particularly seductive.

Jessica, 24 and Trista, 2 stand in their neighbours home in a Malabon City, Metro Manila, the Philippines. Photograph: Hanna Adcock/Save the Children

Sitting in her neighbour’s kitchen in Malabon, one of the most deprived areas of Manila, Jessica Icawat, 24, wept as she recalled the sacrifices she had made to give Trista, her two-year-old daughter, Nestogen, a formula made by Nestlé. Breastfeeding had been hard and she turned to formula because the local community consensus was it is “fine, the same as breast milk”.

Stick thin, her cheek and collarbones sticking out, Icawat was visibly malnourished, as was Trista, whose swollen stomach stuck out beneath a faded pink Little Mermaid T-shirt. The average cost of Nestogen is 2,000 pesos (£28) a month but Icawat could afford to spend only 800 pesos.

They have an active campaign to get mothers to use formula, even when breastfeeding is still an option Ghi Jayona

“I didn’t eat just so I could feed the baby,” she said. “There were some days when I didn’t eat anything. And Nestogen is expensive so I could not always give it to my baby when she was hungry, I only gave her half bottles, four times a day.”

Icawat’s house – made of discarded plywood, corrugated iron and plastic sheets – sits on stilts above rubbish-infested waters. She does not have running water or electricity and admitted she found it difficult to sterilise bottles and make up the milk powder, which needs to be mixed with very hot water to be safe.

Midwife Grace Chelo Amarez with patients Jessica, 24, 2 year-old Trista, 6 year-old Zaira and 3 year-old Vanessa in a deprived area of Malabon City, Metro Manila, the Philippines. Photograph: Hanna Adcock/Save the Children

“My baby has been sick: she was admitted to the hospital three times with diarrhoea and asthma.”

The World Health Organisation’s international code explicitly prevents formula companies directly targeting mothers and healthcare professionals, and restricts advertising. Formula promotion is a particular issue in poorer countries because there is a higher risk of pneumonia and diarrhoea for babies, and with a lack of access to healthcare mothers are less informed about the benefits of breastfeeding.

Targeted tactics towards mothers and midwives directly violate the laws of the Philippines as well as the internationally recognised code. This was drawn up in 1981 after widespread protest against Nestlé’s marketing of formula as better than breastmilk, despite evidence that formula feeding was linked to babies falling ill or dying from poorly sterilised bottles.

Yet despite the industry’s claims it has cleaned up its act, the practices that were globally condemned four decades ago are still evident today across the developing world. The report by Save the Children says companies are systematically violating the milk code, with devastating consequences for infant health and mortality. Leading formula companies spend £36 on marketing for every baby born worldwide. East Asia, with its growing economies and high birth rate, is a key target.

‘A clandestine approach’

“The milk formula companies now take a clandestine approach,” said Dr Amado Parawan, who has spent 20 years working with Save the Children in the Philippines to champion breastfeeding.

Formula for Trista, 2, set up in the home of Jessica, 24 in Malabon City, Metro Manila, the Philippines. Photograph: Hanna Adcock/Save the Children

“On the face of it they have improved. But really they are skirting around the milk code by doing visits and dinners for midwives and doctors outside of office hours, in the evenings.”

Julianne Bores, a GlaxoSmithKline representative who worked alongside formula representatives in hospitals since 2009, described a culture of financial dependency, where if doctors want to go to expensive medical conferences – held mostly in lavish hotels or abroad - they would always ask the milk companies for sponsorship, and were occasionally allowed to bring their spouses. Formula representatives would also pay for “rest and recreation activities” for doctors and their families, such as tickets to Cirque du Soleil, and meals at popular restaurants.

Bores was also an observer of the “parenting” and “nutrition” forums for parents held in the hospital canteens by the formula representatives, where samples or branded freebies like umbrellas and feeding bottles would be distributed. All these practices are a violation of Philippine law.

While formula can be necessary as not every woman chooses or is able to breastfeed, the barrage of marketing, advertising on TV and social media, and persuasive free gifts ensures that misinformation is rife.

’They would give us so many free samples’

At a health centre in Malabon, midwife Grace Shelo Almarez admits that before she was given training, she was among the many wined and dined by Nestlé, Mead Johnson and Wyeth and offered numerous trips to conferences. As recently as October Nestlé offered her a trip to Iloilo, which she declined.

I didn’t eat so I could feed the baby … formula is expensive so I couldn't always give it to my baby when she was hungry Jessica Icawat

“In return for that, if a patient decided to use formula milk, I’d recommend their product and tell them ‘Nestlé is good’ or ‘you should use Nestogen’ and so on. They are very persuasive, they make it sound like their products are very good for the mothers and the babies.”

Children play in a deprived community in Navotas, Metro Manila, the Philippines. Photograph: Hanna Adcock/Save the Children

The Save the Children report shows how global pro-formula campaigning is. In Mexico, where just 31% of infants are exclusively breastfed for the first six months, 50% of mothers said they had been recommended formula by their doctor, while in Chile, 75% of doctors, nurses and midwives in hospitals reported visits from formula representatives.

In statements to the Guardian, all companies denied any wrongdoing. However, both Nestlé and Mead Johnson defended funding conference trips for doctors, even though the Department of Health confirmed it was illegal in the Philippines.

Nestlé said it would “investigate all the reported actions” and “will take fast and decisive action if any wrongdoing is found”.

“This picture does not represent Nestlé’s culture and business practices,” the statement added. “The first and most fundamental expression of our respect for mothers and babies is support for breastfeeding and compliance with the law and our own strict procedures. Nestlé strongly rejects the allegation that it does not comply with its legal obligations and the WHO code as implemented in national law.”

Abbott told the Guardian it was “committed to the ethical marketing of our products in compliance with the laws and regulations of the countries in which we do business,” and added: “The behaviour you have described is not in line with our policies. We take all reports of non-compliance seriously.”

Felicidad prepares formula in her neice’s home for grandson Dashiell in Caloocan city, Metro Manila, the Philippines. Photograph: Hanna Adcock/Save the Children

Mead Johnson said it had ”not received notification of the violations you mention. Any reports received by Mead Johnson are investigated according to the facts and information, per our rigorous compliance programme.

“We take great care to fully comply with all established laws and regulations that govern the manufacturing, distribution and marketing of all our products. Acting responsibly is core to our purpose.”

‘I don’t know if we are winning’

For those on the ground advocating for the benefits of breastfeeding, the pressures from above and below could make it seem like a Sisyphean task.

Asked if he thought they were winning the battle for breastmilk, Parawan laughed, though a little dejectedly. “I don’t know if we are winning,” he said. “But we are not going to stop fighting. I have to believe there is light at the end of the tunnel.”