What is the Code?
The Code was adopted in 1981 by the World Health Assembly to promote safe and adequate nutrition for infants, by the protection and promotion of breastfeeding and by ensuring the proper use of breast-milk substitutes, when these are necessary. One of the main principles of the Code is that health care facilities should not be used for the purpose of promoting breast milk substitutes, feeding bottles or teats. Subsequent WHA resolutions have clarified the Code and closed loopholes.
How is the Code relevant to the Baby-friendly Hospital Initiative?
In launching the BFHI in 1991, UNICEF and WHO were hoping to ensure that all maternities would become centres of breastfeeding support. In order to achieve this, hospitals must avoid being used for the promotion of breast milk substitutes, bottles or teats, or the distribution of free formula. The Code, together with the subsequent relevant Resolutions of the World Health Assembly, lays down the basic principles necessary for this. In addition, in adopting the Code in 1981, the World Health Assembly called upon health workers to encourage and protect breastfeeding, and to make themselves familiar with their responsibilities under the Code.
Which products fall under the scope of the Code?
The Code applies to 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.
Since exclusive breastfeeding is to be encouraged for 6 months, any food or drink shown to be suitable for feeding a baby during this period is a breast milk substitute, and thus covered by the Code. This would include baby teas, juices and waters. Special formulas for infants with special medical or nutritional needs also fall under the scope of the Code.
Since continued breastfeeding is to be encouraged for two years or beyond, any milk product shown to be substituting for the breast milk part of the child’s diet between six months and two years, such as follow-on formula, is a breast-milk substitute and is thus covered by the Code.
What does the Code say?
The main points in the Code include:
no advertising of breast-milk substitutes and other products to the public;
no free samples to mothers;
no promotion in the health services;
no donations of free or subsidized supplies of breast-milk substitutes or other products in any part of the health care system;
no company personnel to contact or advise mothers;
no gifts or personal samples to health workers;
no pictures of infants, or other pictures or text idealizing artificial feeding, on the labels of the products;
information to health workers should only be scientific and factual;
information on artificial feeding should explain the benefits of breastfeeding and the costs and dangers associated with artificial feeding;
unsuitable products, such as sweetened condensed milk, should not be promoted for babies.
Who is a “health worker” for the purposes of the Code?
According to the Code, any person working in the health care system, whether professional or non-professional, including voluntary and unpaid workers, in public or private practice, is a health worker. Under this definition, ward assistants, sweepers, nurses, midwives, social workers, dieticians, counsellors, in-hospital pharmacists, obstetricians, administrators, clerks, etc. are all health workers.
What are a health worker’s responsibilities under the Code?
Encourage and protect breast-feeding. Health workers involved in maternal and infant nutrition should make themselves familiar with their responsibilities under the Code, and be able to explain the following:
the benefits and superiority of breastfeeding;
maternal nutrition, and the preparation for and maintenance of breastfeeding;
the negative effect on breastfeeding of introducing partial bottle-feeding;
the difficulty of reversing the decision not to breastfeed; and
where needed, the proper use of infant formula, whether manufactured industrially or home-prepared.
When providing information on the use of infant formula, health workers should be able to explain:
the social and financial implications of its use;
the health hazards of inappropriate foods or feeding methods; and
the health hazards of unnecessary or improper use of infant formula and other breast-milk substitutes.
Ensure that the health facility is not used for the display of products within the scope of the Code, for placards or posters concerning such products. Ensure that packages of breast-milk substitutes and other supplies purchased by the health facility are not on display or visible to mothers.
Refuse any gifts offered by manufacturers or distributors.
Refuse samples (meaning single or small quantities) of infant formula or other products within the scope of the Code, or of equipment or utensils for their preparation or use, unless necessary for the purpose of professional evaluation or research at the institutional level.
Never pass any samples to pregnant women, mothers of infants and young children, or members of their families.
Disclose any contribution made by a manufacturer or distributor for fellowships, study tours, research grants, attendance at professional conferences, or the like to management of the health facility.
Be aware that support and other incentives for programmes and health professionals working in infant and young-child health should not create conflicts of interests.
Does the Code ban all free and low-cost supplies of infant formula and other breast-milk substitutes (including follow-on formula) in health facilities?
Yes. Although there were some ambiguities in the wording of Articles 6.6 and 6.7 of the Code, these were clarified in 1994 by World Health Assembly Resolution (WHA 47.5) which urged Governments:
“to ensure that there are no donations of free or subsidized supplies of breast-milk substitutes and any other products covered by the International Code of Marketing of Breast-milk Substitutes in any part of the health care system”.
Breast-milk substitutes should be obtained through “normal procurement channels” so as not to interfere with the protection and promotion of breastfeeding. Procurement means purchase.
Should free supplies be donated for pre-term and low birth weight infants? Some argue that these infants need early supplementation, and therefore free supplies should be permitted
No. The prohibition applies to all types of infant formula, including those for special medical purposes. In any case, breast milk is the medically indicated feeding of choice for almost all pre-term and low birth weight babies.17 Obtaining free supplies for these babies encourages bottle (artificial) feeding, which further threatens their survival and healthy development.
Moreover, once free supplies are available in the maternities and nurseries, it is extremely difficult to control their distribution and misuse.
Should free supplies be donated for infants of HIV-positive mothers who have chosen to formula feed?
No. As stated above, once free supplies are available in the health care system it is virtually impossible to prevent their misuse and the undermining of breastfeeding. Governments should procure the formula needed through normal procurement channels.
Should the prohibition extend to Maternal Child Health, primary health, and rural clinics?
Yes. The Code defines the health care system as: “governmental, non-governmental or private institutions or organizations engaged, directly or indirectly, in health care for mothers, infants and pregnant women; and nurseries or child-care institutions. It also includes health workers in private practice”.
Why not permit free supplies in paediatric wards, since older infants may already be using feeding bottles?
Because free supplies to paediatric services or other special services for sick infants can seriously undermine breastfeeding. The WHO/UNICEF guidelines suggest, in paragraph 50:
“There will, of course, always be a small number of infants in these services who will need to be fed on breast-milk substitutes. Suitable substitutes, procured and distributed as part of the regular inventory of foods and medicines of any such health care facility, should be provided for those infants”.
Is there a working definition for “low-cost” supplies?
Yes. There is a general agreement that ending “low-cost” or “low-price” sales means ending sales at prices below the wholesale price or lower that 80 percent of the retail price, in the absence of a standard wholesale price. The reason for stopping low price sales is that low prices lead to the overuse of breast-milk substitutes.
Is the Code still relevant in view of the HIV pandemic and the increased need for formula?
Yes. Indeed the Code is even more important in the context of HIV, since the Code and resolutions:
encourage governments to regulate the distribution of free or subsidized supplies of breast-milk substitutes to prevent “spillover”;
protect children fed on replacement foods by ensuring that product labels carry necessary warnings and instructions for safe preparation and use; and
ensure that a given product is chosen on the basis of independent medical advice.
The Code is relevant to, and fully covers the needs of, mothers who are HIV-positive. Even where the Code has not been implemented, its provisions still apply.
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See WHO/UNICEF “Guidelines concerning the main health and socioeconomic circumstances in which infants have to be fed on breast-milk substitutes” (WHO, A39/8 Add. 1, 10 April 1986). The 1986 World Health Assembly based its adoption of WHA 39.28 on this document.
