What is the Code

The International Code of Marketing of Breastmilk Substitutes is an internationally recognised set of rules governing the marketing of breastmilk substitutes. The Code was adopted by the World Health Assembly (WHA) in May 1981. It is intended to be adopted as a minimum requirement by all governments and aims to protect infant health by preventing inappropriate marketing of breastmilk substitutes.

Why do we need the Code

  • Formula manufacturers promote their products to persuade mothers to buy more formula - so that they make more profit!
  • This promotion undermines women’s confidence in their breastmilk and breastfeeding.
  • Breastfeeding needs to be protected.

Scope of the Code

The Code covers the marketing of breastmilk substitutes, including:

  • Infant formula, (including preterm milks and other ’special’ milks);
  • Follow-up milks;
  • Complementary foods such as juices, waters and teas, cereal and other foods which are sometimes marketed or otherwise represented as suitable for infants under 6 months of age;
  • Feeding bottles and teats.

Summary of the Code and Relevant WHA Resolutions

  • No advertising to the public.
  • No free gifts to mothers or health workers by manufacturers.
  • No promotion or free supplies in health care facilities.
  • No company mothercraft nurses to advise mothers.
  • No free samples or supplies to pregnant women or mothers by manufacturers or health workers.
  • No words or pictures idealising artificial feeding on labels (no baby pictures). labels should provide adequate, clear information.
  • Information to health workers to be scientific and factual.
  • All information on artificial feeding (including labels) must explain the benefits and superiority of breastfeeding and costs and dangers of bottle-feeding.
  • Unsuitable products (e.g. condensed milk) should not be promoted for babies.
  • All products to be of high quality and take account of storage conditions of country where they are used.
  • No promotion of complementary foods before they are needed.
  • Donated supplies in support of emergency relief operations should only be given for infants who have to be fed on breastmilk substitutes and should continue for as long as the infants concerned need them. WHA 39.28 of 1986.
  • Companies must comply with the Code.

Why does breastfeeding need to be protected?

Breastfeeding is the best way to feed an infant in the vast majority of circumstances. The World Health Organisation (WHO) has estimated that 1.5 million infants die each year because they are not breastfed. Breastfeeding saves lives.

The benefits of breastfeeding for the infant, mother and community include:

  • Breastmilk provides all the nutrients a baby needs for the first 6 months of life, after which it continues to provide a major portion of the infant’s nutrition along with appropriate family foods.
  • Breastmilk is easily digested by the baby.
  • Breastmilk contains antibodies and other factors, which protect the baby against diarrhoea and other infections.
  • Breastmilk is clean, safe and cheap.
  • Breastfeeding provides a perfect opportunity for building a close bond between mother and baby.
  • Breastfeeding has contraceptive benefits for the mother.
  • Breastfeeding mothers have a lower risk of breast and ovarian cancer.               Breastfeeding costs less in terms of health care expenses, as breastfed infants get ill less often.
  • Breastfeeding does not damage the environment.

Mother-to-Child Transmission of HIV

The dilemma posed by the current HIV Pandemic, mother-to-child transmission (MTCT) of HIV and the debate about infant feeding is particularly difficult for the African region. The problem of HIV infection through breastmilk in Sub-Saharan Africa is of particular concern because the survival and development of children in this area, to a large extent, depends on successful breastfeeding. WHO studies show that the risk of dying from infectious diseases in the first two months of life is six times greater in infants who are not breastfed than those who are breastfed.

In the African environment, the benefits of exclusive breastfeeding often outweigh the risk of not breastfeeding. Infants who are not breastfed are up to 14 times more likely to die from diarrhoea compared to those who are exclusively breastfed. They are also three times more likely to die from acute respiratory infections. For HIV infected mothers living in poor households it is important to consider carefully the risks related to not breastfeeding. Promoting infant formula feeding to prevent HIV infection in such situations might increase infant morbidity, mortality and malnutrition.

Research shows that about 30% of children born to women who are infected with HIV in Sub-Saharan Africa become infected with HIV themselves. Transmission of HIV may occur during pregnancy, delivery or postnatally through breastfeeding. A baby born without the virus has a 1 in 7 risk of getting the virus through breastfeeding. However, many babies will not get HIV at all from their mothers. About 6 out of 10 babies born to infected mothers will never get the infection from their mothers. Recent research indicates that use of anti-retroviral drugs in the perinatal period could reduce paediatric HIV infection substantially, regardless of the mode of feeding.

The Code and HIV

The purpose of the Code is to contribute to safe and adequate nutrition for all infants regardless of their HIV status. Every child has the right to good health and nutrition, and parents and families have the right to make informed choices regarding infant feeding based on unbiased, scientific and factual information. IBFAN Africa therefore is committed to the aim and spirit of the International Code and subsequent relevant WHA  resolutions as a means to protect breastfeeding and ensure the proper use of breastmilk substitutes, when they are necessary, on the basis of scientific information, IBFAN Africa also recognizes the need for use of artificial feeding as one means of preventing postnatal MTCT of HIV and this is covered in the Code.

WHILE SOME GOVERNMENTS IN AFRICA ARE CONSIDERING WAYS TO MAKE ALTERNATIVE FEEDING OPTIONS AVAILABLE TO HIV POSITIVE MOTHERS WHO HAVE DECIDED NOT TO BREASTFEED,

  • They must protect spillover of artificial feeding to infants of HIV- negative mothers.
  • Even greater attention must be paid to the regulation of commercial promotion of breastmilk substitutes.
  • Enact a national Law on the Code.

The fact that HIV virus can be passed by an HIV-positive mother to her child through breastmilk should not be allowed to undermine breastfeeding for the majority of infants around the world whose health and chances of survival are and will be greatly improved by it (UNICEF New York, 2000).

 The Code has relevance in HIV since it aims to:      

  • Regulate the distribution of free or low-cost supplies of breastmilk substitutes to help avoid diversion from breastfeeding for babies who would benefit from breastfeeding.
  • Protects artificially fed infants by ensuring that product labels carry the necessary warnings and instructions for safe preparation and use.
  • Ensure that the choice of product is made on the basis of independent medical advice and not commercial pressure.
  • Ensure safety of all products.

 The Code does NOT:

  • Try to stop infant formula and other infant products under the scope of the         Code being available, or being sold or used when necessary,
  • Prevent governments making breastmilk substitutes available to HIV      positive mothers, free or at a subsidised price, when the government has purchased them. But ideally these should be “generically labelled” without a brand name.

The Code seeks to stop activities designed to persuade people to use breastmilk substitutes or to influence their choice. (See Summary of the Code). The code aims to prevent manufacturers from donating supplies of breastmilk substitutes, or providing them at reduced price, to any part of the health care system.

Reasons for banning free supplies:

When free supplies are made available by manufacturers to health facilities, they become too available. Many mothers who do not need them will use them. Mothers may lose confidence in their ability to breastfeed and may unnecessarily give up breastfeeding.

  • If health facilities have to buy infant formula as they usually buy drugs and food, it is more likely that its use will be controlled.
  • Donations make health facilities and infants dependent on them. If donations cease, which often happens, there may not be an alternative source of milk available, and no provision in the health service budget to buy them.
  • Donations are a very successful form of promotion. It encourages families to buy the same product when they return home. The Code forbids any form of promotion.

Practical Considerations in Making Breastmilk Substitutes Available in HIV

  • Mothers should be able to obtain their supplies of formula easily, in a manner that will maintain their privacy and avoid stigmatisation.
  • Supplies of substitutes must be reliable in the short-term and long-term to avoid mothers being left without supplies and unable to feed their infants, given that breastfeeding has already been disrupted.
  • There must be good stock control as that practiced for dangerous drugs including checking for harmful organisms.
  • If supplies are given as donations to institutions or organizations such as orphanages and social welfare institutions, they must be given only to infants who really need them and for as long as the infant needs them (minimum six months). These donations should not be used as a sales inducement. One way to avoid inducement is to request that supplies are provided without a brand name.

Health Professionals have a Responsibility to:

  • Continue to promote, protect and support breastfeeding for mothers who are HIV negative, those who do not know their HIV status and those who are HIV positive but have chosen to breastteed.
  • Learn how to counsel HIV positive mothers about the advantage and risks of the various infant feeding options and allow them to make an informed decision.
  • Teach HIV positive mothers, who opt not to breastfeed, how to use replacement feeds. This should be done in private and not in group demonstrations. Make sure that any formula used in your institution is kept out of sight of other mothers.
  • Encourage non-breastfeeding mothers to use cups for infant feeding.
  • Remove from your institution, any advertisements, promotional materials or other items bearing brand names.
  • Ensure that company representatives of baby food companies are not allowed to visit health care facilities.
  • Refuse to accept free samples or low cost supplies of formula or equipment.
  • Refuse to accept or use other gifts e.g. pens, calendars or diaries.
  • Avoid accepting invitations from formula companies, as well as sponsorship of conferences, scholarships or funding of research projects.
  • Not give free samples or promotional materials to mothers.       
  • Teach one another the basic facts about breastfeeding, MTCT, the Baby Friendly Hospital Initiative (BFHI) and the Code and mother to child transmission of HIV (MTCT).
  • Implement the Baby Friendly Hospital Initiative by practicing the Ten Steps to Successful Breastfeeding.

Help Monitor the Code in your country, for example

  • Observe labelling on infant feeding products to ensure that they do not idealize formula feeding, the instructions for preparation are in a language which mothers can understand and the label states that breastfeeding is superior.
  • Observe Information materials from companies. They should include clear factual information that should include the following points: the benefit and superiority of breastfeeding; the negative effects of introducing bottle-feeding and the difficulty of reversing the decision not to breastfeed. When it includes information on the use of infant formula, it should include the social and financial implications of its use; the health hazards of inappropriate use and should not use pictures to idealise products or feeding bottles.
  • Watch out for promotion to the public. There should be no advertising or other form of promotion to the general public of products within the scope of the Code.
  • Report any violations of the Code to a relevant body in your country or to IBFAN Africa.

In order for the Code to have a real impact each individual country should adopt it as Law. During the monitoring of the Code in Africa, violations are commonly observed, especially with regard to labelling, information and giving of free supplies.