Protecting breast feeding from breast milk substitutes

The WHO code is widely violated and needs monitoring and supporting

Papers p 1117

In all societies breast feeding is one of the most important measures to improve child health. An important component of the global effort to protect breast feeding is the WHO's international code of marketing of breast milk substitutes. In this week's issue an interagency group on breast feeding monitoring produces compelling evidence that the code is widely violated (p 1117).1

The World Health Organisation estimates that 1.5 million deaths a year could be prevented by effective breast feeding protection.2 A recent systematic review estimated that in a low income country with a postneonatal mortality rate of 90 per 1000 children, artificial feeding would produce an excess of postneonatal deaths per million births ranging from 11 290 (13%) to 112 900 (59%) at prevalences of artificial feeding at 6 months of 10% and 100% respectively.3 In the industrialised world a failure to breast feed increases the risk of childhood diseases,4 impairs child development,5 and may increase the risk of adult disease.6

The international code, devised in 1981, reaffirmed in 1996, and endorsed by the manufacturers, was developed to protect mothers and health workers from commercial pressure by manufacturers of breast milk substitutes. It forbids provision of free samples to mothers or health facilities (except for professional research), because of the negative impact on breast feeding.7 It also forbids inducements to health workers, because recipients are more likely to promote a particular product8 and remain passive in promoting breast feeding.

Since the code was introduced widespread violations by companies have been reported by various agencies, but companies have dismissed such evidence as unreliable, anecdotal, or distorted by activists. The report in this week's issue is a large, systematic, and random survey of mothers and health professionals that quantifies the level of violations in Bangladesh, Poland, Thailand, and South Africa.1 It seems to vindicate previous reports by the International Baby Food Action Network.9 One tenth of all mothers interviewed (range 0-26%) and a quarter of all facilities visited (8-50%) had received free samples of milk, bottles, or teats—none of them for research purposes. Violating information was received by 30% of health facilities (15-56%), and 11% of health workers surveyed had received gifts (2-18%), three quarters of which bore a company brand name.

How reliable are these estimates? While minor methodological criticisms may be made, the study used random sampling, several interviewers, subset validation, and had internal consistency (the country with legislation had the least free samples and that with no code had suffered the most violations. The study probably underestimates the size of the problem in developing countries, where failure to breast feed carries the highest risk of mortality. From the 48 least developed countries,10 only Bangladesh was included, a country with a good recent record on breast feeding protection.

It will be depressing, but predictable, if manufacturers dismiss this paper. Like tobacco companies, their promotional activities may be regulated only when they face substantial claims for damages from consumers. Meanwhile there is much that individual countries and monitoring agencies can do.

Firstly, governments should incorporate the articles of the WHO code into national legislation. Encouragingly, China, Brazil, and India (nearly half the world's population) have incorporated most of the code into legislation, although by September 1997 only 17 countries had approved laws that put them fully in compliance with the code.11 Hopefully the British government will listen to the recently formed UK Baby Milk Law Working Group and bring the code into national law.

Secondly, monitoring for overt violations should be more systematic. Even when overt violations are documented in countries with legislation, legal action against companies is often too difficult to implement. Nevertheless, systematic monitoring for violations is important for evaluating trends, mobilising public opinion, and deterring overt promotional activities.

The marketing departments of manufacturers are also innovative. Anecdotally, covert promotional methods have been reported, especially targeted at doctors, who have an important effect on the timing and choice of a breast milk substitute: unsigned, non-prescription slips with specific company names for mothers with the ill defined “insufficient milk syndrome”; free vitamin drops in containers identical to formula milk products; “anonymous” donations to national paediatric societies; complimentary textbooks or journals, particularly for residents; funds to attend scientific meetings; and electioneering support for candidates in national society elections known to be passive to breast feeding promotion and code monitoring. Future monitoring should evaluate such covert promotional activities.

Thirdly, doctors must be aware that companies try to gain “endorsement by association,” or at least passivity towards their products, from prestigious national bodies. Interestingly, neither the UK's Royal College of Paediatricians and Child Health nor the British Nutrition Foundation, both of which accept financial support from milk substitute companies, were part of the interagency group. By contrast, in 1994, while hosting the eighth Asian Congress of Paediatrics, the Indian Academy of Paediatrics declined a large donation from the industry. Such voluntary decisions by national paediatric societies represent a welcome move by paediatricians to protect breast feeding.

Fourthly, as with antismoking campaigns, legislation and monitoring are only part of a broader strategy needed to protect mothers, regardless of how they feed their infants. Positive approaches to breast feeding for mothers are equally (if not more) crucial. These measures include training midwives and doctors in lactation counselling (including guidance for HIV positive mothers, for whom breast feeding may be contraindicated), “breast feeding advertisements,” extending the “baby friendly” hospital initiative, and financial support for advocacy groups that support health promotion for mothers. Such positive attempts to protect breast feeding, and to counter company propaganda, remain a challenge largely unfulfilled by health workers and professional bodies.