::: O.N.G. RUANDI :::

The International Code of Marketing of Breastmilk Substitutes is the focus for World Breastfeeding Week 1994. The goals of the Week are to:

Every day, as many as 4,000 infants and young children die because they are not breastfed. Why does this daily tragedy continue? According to James Grant, UNICEF's Executive Director, it is because their mothers are not empowered with enough knowledge about breastfeeding and do not receive enough motivation and support. A big part of the blame for this lack of knowledge, motivation and support lies with the competition to breastmilk, the well funded marketing of breastmilk substitutes and other products for infant feeding.

Over many years, companies have invented clever slogans, striking images, free samples or supplies, and all kinds of appealing gifts to persuade mothers and health workers that while `breast is best', bottle feeding is almost as good as breastfeeding. Today, as benefits of breastfeeding are being rediscovered, parents and health workers all over the world are realising the tragic consequences of allowing commercial interests to interfere with infant feeding practices.

The International Code of Marketing of Breastmilk Substitutes, adopted by the World Health Assembly in 1981, is a tool to protect breastfeeding. However, to be effective it must be made to work in each country. The Innocenti Declaration, calls on all governments to implement the International Code and other related resolutions of the World Health Assembly by 1995. This Declaration was adopted at a meeting of high level policy makers from many countries, in Florence, Italy, August 1990.

Each year, World Breastfeeding Week takes up an important theme to help protect, promote and support breast feeding. This year, the Week focuses on ways to protect breastfeeding by eliminating advertising and other harmful marketing practices for infantfeeding products.

Did you ever notice calendars or posters on the walls of a hospital or clinic with pictures of beautiful babies or breastfeeding mothers and a company brand name or logo?
When your baby was born, did you receive a free sample of infant formula?
Was your baby given a bottle in the hospital even before you had a chance to start breastfeeding?
Did you receive coupons or infant food samples in the mail? Were you given a `free' number to phone for advice on baby feeding?
Did you receive a booklet or a videotape from an \ infant food company that explained all about breastfeeding or weaning?

These are only a few of the marketing methods infant food companies use to tempt mothers to use their products. You may be surprised about the breastfeeding booklet: all companies today `say' they support breastfeeding, but do they? Many people believe what is printed without realising that there is hidden persuasion inside the booklets.

a code of marketing not a code of ethics. It is a set of rules for industry, health workers and governments, to regulate marketing. Marketing is much more than advertising. It includes all promotional activities, from labelling to shelf space, to relations with health workers and their associations;
about breastmilk substitutes not just infant formula. It covers other milk products, cereals, teas and juices, bottles and teats;
a compromise not the ideal. It is the result of negotiations. Therefore, national measures should be stronger and adapted to include new products and changed marketing practices;
a tool not an end in itself. When properly implemented, it will regulate marketing practices. But above all, understanding it helps health workers and community members to gain a much deeper grasp of the importance of their role in shaping the decisions of mothers about infant feeding and the consequences these can have.

The Code seeks to encourage and protect breastfeeding by regulating marketing practices used to sell products for artificial feeding.

The Code applies to: artificial milks for babies; other products used to feed babies, especially when they are marketed for use in a feeding bottle or to babies under six months of age. The Code also applies to feeding bottles
and teats.

No advertising of any of these products to the public.
No free samples to mothers.
No promotion of products in health care facilities, including the distribution of free or low-cost supplies.
No company sales representatives to advise mothers.
No gifts or personal samples to health workers.
No words or pictures idealising artificial feeding, or pictures of infants on labels on infant milk containers.
Information to health workers should be scientific and factual.
All information on artificial infant feeding, including that on labels, should explain the benefits of breastfeeding, and the costs and hazards associated with artificial feeding.
Unsuitable products, such as sweetened condensed milk, should not be promoted for babies.
Manufacturers and distributors should comply with the Code's provisions even if countries have not adopted laws or other measures.

Subtle selling

After years of public pressure, most baby food companies have stopped direct advertising for formula in developing countries. Instead, they promote more through hospitals by giving them free supplies of baby milk and by influencing hospital practices so that mothers will either bottle-feed
from the start, or give up breastfeeding quite soon. The period right after birth is of vital importance. A poor start all to often means the end of breastfeeding.

In Pakistan, a mother was given a free sample of a breastmilk substitute in a hospital. She began to bottle-feed her new son, even though she had successfully breastfed her two previous children. Within six weeks, the new baby was back in hospsital with severe dehydration and malnutrition. He has suffered diarrhoea 10 to 12 times a day and weighed only 2.7 kgs (5.94 lbs).

In Yemen, a mother who saw advertising for breastmilk substitutes decided to bottle-feed her young baby. He got severe diarrhoea and the mother took him to a health centre, where the child was rehydrated and the mother was advised not to bottle-feed. It was difficult to return to breastfeeding. Also, pictures of happy and healthy infants on the labels in the shops had confused her: she wanted her baby to be like that, fair and chubby, so she switched brands. The child developed another bout of acute diarrhoea, and by the time the mother took him back to the healthcentre, it was too late. He died.

A hospital in the Philippines had a preference for a particular brand of breastmilk substitutes. The reason was simple: the company was paying for the renovation of the entire nursery. More than half the infants were fully bottle-fed and cross-infection was so severe that, at one point, the wards had to be closed.

In the USA, a Hispanic mother was given samples of ready-to feed infant formula for her new baby when she was in hospital. The label was all in English, a language that she had difficulty understanding. When the samples had run out, she went to her local supermarket to buy more formula. She picked up the same brand, but it was concentrated instead of ready to feed. Without being able to read the instructions, she simply fed it to the baby. Within a few days, she had to take the baby back to hospital. It was barely clinging to life.

Stories like these are repeated thousands of times every day, all over the world. While richer families can rush sick babies to hospital, poor and rural families often have no access to health care and suffer tragic results.

Health workers have a special responsibility for the success or failure of the Code. They are frequently the target for promotional practices, and health care facilities are used by companies as the perfect channel for encouraging the use of their products. Contrary to general public advertising, focusing on health workers gives companies access to a specialised profession with direct and authoritative influence over mothers.

Two articles of the International Code deal specifically with the use of health care systems and the role of health workers. Health workers do not have to wait for the Code to become a law in their own country. They can act now. They can make their health care facility more baby friendly by removing any promotion for infant feeding products.

1939 Dr Cecily Williams speaks on Milk and Murder in Singapore. She states that deaths resulting from "misguided propaganda on infant feeding should be regarded as murder".

1968 Dr Derrick Jelliffe in Jamaica, coins the term 'commerciogenic malnutrition' to describe the impact of industry marketing practices on
infant health.

1973 New Internationalist magazine in UK has cover story on the Baby Food Tragedy and calls for a campaign to halt promotion.

1976 Swiss court warns Nestle to change its marketing practices. This was the result of a lawsuit by Nestle against campaigners who accused the
company of killing babies. The Nestle Boycott starts in 1977.

1978 Bristol Myers, an American baby food company, settles a lawsuit by agreeing to halt all direct consumer advertising.

1979 WHO and UNICEF host an international meeting on infant and young child feeding, calling for development of an international code of marketing.

1981 International Code of Marketing of Breastmilk Substitutes adopted at World Health Assembly by 118 votes to 1, with only USA voting against.

1984 World Health Assembly adopts a resolution cautioning against cereals and other infant foods promoted for use at too early an age.

1986 Free and subsidised supplies of breastmilk substitutes to hospitals are banned by a unanimous WHO resolution.

1988 Companies continue to give free supplies and, in protest, more consumer boycotts begin in many countries.

1990 The Innocenti Declaration calls upon all countries to adopt the Code in its entirety by 1995.

1992 The Baby Friendly Hospital Initiative expands to a worldwide movement. One of the 10 baby friendly steps emphasises the ban on free supplies.

The promotion of bottle feeding over the last 30 to 40 years has been heavily supported by powerful economic interests - the baby milk industry, the food industry and feeding bottle manufacturers. In promoting their products, they have used clever and effective marketing strategies to emphasise the possible benefits of these products, but never mentioned the disadvantages or the benefits lost by not breastfeeding. This biased information has led to a bottle feeding culture. The International Code can be used to either maintain or re create a breastfeeding culture.

How? First, bottle feeding can be made less popular and less socially acceptable by enforcing the Code and by illustrating the hazards of artificial feeding. Second, examining the way companies promote bottle feeding can give ideas and techniques to promote breastfeeding. Why allow these expensive and effective marketing techniques to serve only commercial interests?

For years, baby food companies have supported baby contests where the winning baby was fed on a particular brand of milk. Why not have a breastfed baby contest? Similarly, health care facilities around the world have posters displaying babies who are linked in one way or another to companies. There are millions of beautiful breastfed babies. Why not encourage local photographers and local business groups to sponsor photo contests and posters of breastfed babies?

Infant food companies have argued that bottle feeding is more convenient or even necessary for women who work outside the home.Women should realise that it is not inconvenient to breastfeed, if they have enough support. In many countries, businesses are discovering the social and economic benefits for their companies if they provide working mothers with time and space to breastfeed. Why not encourage business leaders to talk publicly about the convenience of breastfeeding?

The baby food industry has used celebrities to promote bottle feeding and prominent health workers to endorse its products, so as to seduce parents into believing that bottle feeding is modern, healthy and glamorous. Nowadays, many health workers and celebrities are convinced that
breastfeeding is the modern, high-status, healthy way to feed babies. Organise events and get them to speak out for breastfeeding.

Babies, their mothers, their families, their community, theirenvironment, even the economy of the country in which they live, all benefit from breastfeeding.

Exclusive breastfeeding meets all the nutritional needs of a baby for the first four to six months and continue to make a significant contribution to the baby's nutritional and emotional health into the second year and beyond.
Breastfed babies have stronger immune systems and are healthier than bottle-fed babies.
Research shows that breastfeeding can save the lives of over 1,500,000 babies who die every year from diseases such as diarrhoea and pneumonia.

Benefits for women

Breastfeeding encourags women's self confidence and self-reliance, as they are able to provide quality care for their children.
Breastfeeding strengthens the bond between a mother and her child.
Women who breastfeed are less likely to develop breast and ovarian cancers.
Breastfeeding helps mothers get back into shape faster.

Benefits to the economy

The health service saves money by not having to buy infant feeding products and by not having to use nursing time to bottle-feed babies.
It also saves money indirectly because breastfed babies are less frequently and less severely ill.
Companies with mother and baby friendly workplaces increase productivity by less absenteeism and a more loyal workforce.
Countries save foreign exchange by not having to import breastmilk substitutes.

Benefits for families

Breastfeeding mothers are less likely to become pregnant. The child-spacing effect of breastfeeding is important for women for whom contraception is unavailable, unaffordable, or unacceptable.
Breastfeeding saves families the time and money that would be used for bottle feeding and for treating the illnesses caused by bottle feeding.
Breastfeeding contributes to food security and to a family's self-sufficiency.

The International Code of Marketing of Breastmilk
Substitutes

* Free samples to mothers
* Advertising to the public
* Promotion in health care facilities
* Gifts or samples to health workers
* Words and pictures that idealise bottle feeding
* Advice to mothers by company sales staff

Studies in Guatemala showed a rapidly declining breastfeeding rate. Without control over the use, promotion and marketing of breastmilk substitues, parents and health workers were exposed to advertising campaigns that undermined the effectiveness of any breastfeeding promotion.

In 1982, the Guatemalan National Commission for the Promotion of Breastfeeding (CONAPLAM) and the Health Ministry's legal department developed a proposal for a Law for the Marketing of Breastmilk Subsitutes, based on the International Code. The Law was adopted in 1983 and enforced in 1986. Guatemala became the first Latin American country to regulate the promotion of breastmilk substitutes and other supplementary foods for infants. A full-time professional in the Ministry of Health was given responsibility for enforcing the Law.

Together with other measures to protect, promote and support breastfeeding, the Law had led to a near doubling of the breastfeeding rate in urban areas.

Many other countries have also taken steps to put the provisions of the Code into practice. In particular, Brazil, Burkina Faso, Mexico, India, Kenya, Nepal, Nigeria, Peru and the Philippines have introduced the
whole Code as national legislation.

The International Code is only a tool. It will not do anything to improve infant health unless it is put into practice. Although it is up to
governments to introduce the legislation that gives effect to the Code, parents, health workers, the media, women's organisations, development
agencies, public interest groups, and business can all play a major role in encouraging the adoption of that legislation and in ensuring
that the practices suggested in the Code are adopted.

Undertake a study to find out how many mothers exclusively breastfeed during the first four to six months and the duration of breastfeeding.
Check for bottle feeding promotion in your local hospital and clinics.
Find out if health workers are aware of the Code and if health care facilities have put it into practice.
Order copies of the Code and organise a discussion group about it.
Encourage changes in health care practices that will protect and promote breastfeeding.
Arrange a small exhibition on the importance of breastfeeding and the dangers of bottle feeding in your local health care or community centre.
Prepare a slide show or series of photographs or drawings that explain about the benefits of breastfeeding and dangers of bottle feeding, and use these in talks with parents and health workers.
Encourage your hospital or local clinic to become a Code supporter - implement the Code locally.
Learn to be a Code monitor, collect promotional material, and report violations to relevant government authorities and non governmental organisations.
Encourage the local media to produce articles and radio programmes about the Code and about the hazards of bottle feeding.

National:

Find out what your health ministry is doing about implementing the Code.
Contact national health organisations - paediatricians, nurses, doctors - and find out their position on the Code.
Ask if you can set up a display or exhibition at national meetings of health workers.
Encourage any national medical schools or health worker training courses to include information about the Code and breastfeeding.
Write to national health journals about the issue.
Contact your national WHO or UNICEF representative to see what materials they have available, what programmes they are operating and how you can help them and they can help you.
Contact leading national figures - politicians, religious leaders, celebrities, sports figures - and ask them to speak out against bottle feeding and for breastfeeding.
Encourage the national media to investigate what action isbeing taken to implement the Code and to publicise theimportance of breastfeeding.
Involve the legal community. Contact the National Bar Association for voluntary legal assistance.

International:

Contact international health worker associations to ask what their position on the Code is, and urge them to take a positive stand.
Contact the International Baby Food Action Network (IBFAN) to see how it can help you and you can help it.
Contact the headquarters of any companies whose local employees are failing to abide by the Code and ask why.

Acknowledgements

This action folder was produced by the WABA Code Compliancetask force and the WABA Secretariat. Many thanks to everyone who gave input and helped review this folder. A special thanks is due to UNICEF for its support to WABA.