Nutrition | Strategy/policy | The urgent need to fully implement the International Code of Marketing of Breast-milk Substitutes and relevant World Health Assembly resolutions

The urgent need to fully implement the International Code of Marketing of Breast-milk Substitutes and relevant World Health Assembly resolutions

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Policy goal

Member States are urged to implement in its entirety the International Code of Marketing of Breast-Milk Substitutes (1) and subsequent relevant World Health Assembly resolutions by developing, enacting and enforcing a national law, regulations or other appropriate measures covering all provisions in the Code, and scaling up efforts to monitor and enforce its implementation. Only a few countries have adopted a law for the implementation and monitoring of the Code and its application, namely Afghanistan, Bahrain, Islamic Republic of Iran, Jordan, Oman and Tunisia as well as the occupied Palestinian territory. Others are only in the preliminary stages of drafting national measures for this purpose, or are partially implementing some measures, while some have hardly begun. Full implementation would support the achievement of the World Health Assembly target of having at least 50% of children exclusively breastfed in the first 6 months by 2025 (2).

Products covered by the code

The Code applies to the marketing, and related practices, of the following products: breast-milk substitutes, including infant formula; other milk products; foods and beverages, including bottle-fed complementary foods, when marketed or otherwise represented to be suitable, with or without modification, for use as a partial or total replacement of breast-milk; feeding bottles and teats. It also applies to their quality and availability, and to information concerning their use. 

Rationale

WHO recommends that all infants should be exclusively breastfed for the first 6 months. However, it is estimated that this practice is followed for only 35% of infants in the Eastern Mediterranean Region (3). Only about half of children aged 20–23 months are breastfed despite the recommendation that breastfeeding continue for up to 2 years of age or beyond. The global breast-milk substitutes market exceeds US$ 31 billion per annum, according to global marketing reports. Double-digit growth is forecast for several regions up to US$ 38.7 billion by 2015. The pressure to increase market share is intense. In addition to the health benefits studies have shown a considerable cost benefit (4). 

Although 77% of countries of the Region have taken some action to implement the Code, monitoring and enforcement are still inadequate, particularly in countries where both laws and legal systems are weak. National laws that do not support implementation of the Code in its entirety have allowed inappropriate marketing practices to prevail. Only effective national legislation, properly enforced, can prevent artificial feeding, which is vastly inferior, from competing unfairly with breastfeeding.

Recommended actions by governments

1. Establish and/or activate a national committee with a multisectoral approach to oversee the proper implementation and monitoring of the International Code of Marketing Breast-Milk Substitutes, with the following terms of reference:

a. review the national law and identify loopholes with a view to incorporating amendments where needed, at least every two years, or the adoption of national law, regulations or other suitable measures for the implementation of the Code;

b. identify the roles and responsibilities of each stakeholder to ensure that the principles and provisions of the Code are widely known among health workers and all stakeholders involved;

c. develop guidance for pre-service education and in-service training of health workers and promote the development of a strategy or plan for capacity-building;

d. develop guidance on how to ensure that programmes and health professionals’ associations, conferences or networks working in infant and young child health are not financially or materially supported by manufacturers of breast-milk substitutes and are free from conflicts of interest;

e. establish an appropriate mechanism for monitoring and reporting on implementation of the national law.

2. Conduct a rapid assessment of implementation of the International Code, using as a basis the WHO Global nutrition policy review, and identify challenges.

3. Ensure that the national law, regulations or other suitable measures cover entirely the International Code of Marketing of Breast-Milk Substitutes and subsequent relevant World Health Assembly resolutions.

4. For countries that do not yet have a national law, enact a law, regulations or other appropriate measures to implement the International Code of Marketing of Breast-Milk Substitutes in its entirety and subsequent relevant World Health Assembly resolutions, and create an action plan with clear timeline, roles and responsibilities, and budget.

5. Enforce penalties on violations of the national law, regulation or other measures implementing the Code.

6. Develop a comprehensive communications strategy to protect, promote and support breastfeeding and implementation of the national law, to be integrated within the strategies of the Ministry of Health and concerned sectors. The communications strategy should include goals and objectives and propose various means of communication to target the community (mothers, families and communities), health workers/professionals, stakeholders and the private sector including manufacturers of breast-milk substitutes. It should include messages about the superiority and benefits of breastfeeding, the negative impact of introducing bottle-feeding, and the difficulty of reversing the decision not to breast-feed.

7. Establish a system for implementation, monitoring, assessment and reassessment of baby-friendly facilities, using the Baby-friendly Hospital Initiative standards. Within this strategy, proceed to the assessment and certification of hospitals, clinics and primary health care facilities not previously assessed and reassessment of those previously certified as baby-friendly.

8. Stop promotion of breast-milk substitute’s subsidies provided by manufactures of breast-milk substitutes and through safety net programmes.

9. Review national and international emergency response and preparedness plans to minimize the risks of artificial feeding, by ensuring that any required breast-milk substitutes are purchased, distributed and used according to strict criteria for infants who have to be fed on breast-milk substitutes. Such supplies should continue for as long as the infants concerned need them and not be used as a sales inducement.

10. Secure the financial and human resources required to protect, promote and support breastfeeding and the implementation of the International Code and include a line item for breastfeeding in health budgets.

11. Guidance should be derived from WHO’s position that in emergencies, no food or liquid other than breast-milk, not even water, is normally needed to meet an infant’s nutritional requirements during the first 6 months of life (5).

12. Support and protect the work of nongovernmental organizations in the area of advocacy, training and monitoring of the code.

13. The Regional Office will provide technical support, upon the request of Member States, for information, training and monitoring systems to ensure that health care providers and manufacturers comply with evidence-based practice and the International Code.

References

  1. See resolution WHA34.22.
  2. See resolution WHA65.6.
  3. World health statistics 2013. Geneva: World Health Organization; 2013.
  4. Postnatal care: Routine postnatal care of women and their babies. Costing report: Implementing NICE guidance in England. London. National Institute for Health and Clinical Excellence, 2006 (NICE clinical guideline no. 37); Bartick M, Reinhold A. The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis. Pediatrics. 2010;125:e1048–56.
  5. World Health Organization, United Nations Children’s Fund, International Committee of the Red Cross and International Federation of Red Cross and Red Crescent Societies.Call for support for appropriate infant and young child feeding in the current Asian emergency, and caution about unnecessary use of milk products. Geneva: World Health Organization; 2005. 

Annex 1. Support expected from other stakeholders for full implementation of the International Code of Marketing of Breast-Milk Substitutes

1. WHO, UNICEF, World Food Programme and Food and Agriculture Organization of the United Nations

Align their work and avoid duplication in the area of the International Code.

Support and protect the work of nongovernmental organizations in the area of advocacy, training and monitoring of the International Code.

2. Nongovernmental organizations and consumer organizations

Perform advocacy, training and monitoring for the implementation of the Inmternational Code across the Region, both independently and with governments.

Draw the attention of manufacturers and distributors to activities which are incompatible with the principles and aim of the International Code, and inform the government so that action can be taken.

Expand the network of the Gulf Cooperation Council countries on breastfeeding promotion to the whole Region.

3. Educational system

Review and update infant and young child feeding content in the curricula of faculties of medicine and nursing, and any relevant educational facilities.

Stimulate research and studies to foster evidence on monitoring the implementation of the International Code.

4. Media

Integrate the International Code within the regional code of ethics of media.

Ban all advertising and commercial promotion of products within the scope of the International Code across all media.

Promote breastfeeding through television commercials, spots, movies and magazines.

Appoint a goodwill ambassador to help promote breastfeeding.

Develop messages for key persons, such as mothers, grandmothers and fathers.

Enlist the support of religious leaders in breastfeeding promotion.

5. Manufacturers and distributors

Abide by the International Code. 

Statistics and figures

WHO has several nutrition-related global databases. They include data for countries in the Region. Please click on the links to access them.

Vitamin and Mineral Nutrition Information System

WHO Global Database on Body Mass Index

WHO Global Database on Child Growth and Malnutrition

WHO Global Data Bank on Infant and Young Child Feeding

Some nutrition-related data from the Regional Health Observatory:

Estimates of anaemia in non-pregnant women of reproductive age

Anaemia in preschool-age children

Trend estimates for under 5 child malnutrition: