Protecting Breastfeeding:
What’s law got to do with it?
Presentation by:
David Clark, Legal Officer,
UNICEF, New York
Sandton Convention Centre,
Johannesburg, 2 August, 2011.
What is wrong with this picture?
Formula company information for mothers on importance of bonding
used to undermine breastfeeding in the Caribbean.
Why do we need a Code?
Suboptimum breastfeeding still accounts for an
estimated 1.4 million deaths in children under five
annually ( Lancet 2008 Nutrition Series).
The latest available data
suggests only 8% of babies
are exclusively breastfed at
5 months in South Africa (DHS
2003)
As well as promoting and supporting breastfeeding, we
need to PROTECT it from promotion of artificial feeding.
Risks of not breastfeeding for all babies in all countries
Increased risk of
diarrhoea, gastroenteritis and tummy
upsets
Increased
risk of
diabetes
Increased
risk of cot
death
Costs more than
breastfeeding
Increased risk of
ear infection
Potentially reduced IQ
score
Bottle feeding affects
dental occlusion
Increased risk of
eczema
Increased risk of
osteoporosis in later life
Increased risk of pre-menopausal breast
cancer
Increased risk of ovarian cancer
Breastfeeding can be a matter of
life and death in industrialised
countries
• If 90% of US families breastfed exclusively for 6
months, the US would save $13 billion per year.
• An excess of 911 deaths would be avoided (mainly
infants).
• $10.5 billion and 741 lives would be saved at 80%
compliance).
Melissa Bartick, MD, MSca, Arnold Reinhold, MBAb , The Burden of
Suboptimal Breastfeeding in the United States: A Pediatric Cost Analysis,
Published online April 5, 2010, PEDIATRICS (doi:10.1542/peds.2009-1616
Growing concerns:
Intrinsic contamination
of infant formula
• Powdered infant formulas are NOT
sterile products
• They can become contaminated at
factory level with heat resistant,
pathogenic and highly contagious
bacteria such as Enterobacter
sakazakii
WHA 58.32 (2005)
Urges Member states to :
Ensure information and training by health-care
providers …. on the preparation, use and
handling of powdered infant formula
Inform that powdered infant formula may contain
pathogenic microorganisms and must be
prepared and used appropriately
Ensure explicit warning on packaging
Problem of contaminated formula not
restricted to melamine scandal in
China
Since 2000
there have been
more than 70
recalls of infant
formulas,
mainly in
industrialised
countries
According to WHO:
•“Generally speaking, all producers competing in the
marketplace do so for two reasons:
• to expand the market for a given class of product,
whatever its type; and
• to expand their share of the market – present and
future – over that of their competitors.”
•“…the marketing of infant formula presupposes a
market increasing in size as more infants are fed
artificially.”
Source:
World
Health
Health
Development,
2001.
Adapted
Source:
World
HealthOrganization,
Organization,Nutrition
Nutritionfor
for
Healthand
and
Development,Geneva,
Geneva,Switzerland,
Switzerland,June
June
2001.
Adapted
from
the
official
records
of
the
Forty-seventh
World
Health
Assembly,
document
WHA47/1994/REC/1/,
Annex
from the official records of the Forty-seventh World Health Assembly, document WHA47/1994/REC/1/, Annex 1, 1,
paragraphs
133–139.
paragraphs
133–139.
Corporate ambitions
Achieving these goals will require
clever marketing
Including marketing through
health workers!
And companies know this…..
“As breast-feeding rates are set to increase in the short
term, international companies should focus on
launching new products targeting breast-feeding
mothers”
Euromonitor International, 2008, discussing strategies for China
Promotion of bms influences infant
feeding behaviour
Study examining relationship between advertising in a parenting
magazine and breastfeeding between 1972 and 2000 found
when frequency of adverts for artificial feeding increased,
percentage change in breastfeeding rates decreased.1
•2006 study by the US Congressional
Accountability Office found a majority of
studies that examine giving free formula
samples to mothers at hospital discharge
found lower breastfeeding rates among
mothers receiving samples.2
•1 Foss, K. and Southwell, B. International Breastfeeding Journal 2006, 1:10
•2 United States Government Accountability Office, Report to Congressional
Addresees, February 2006, GAO-06-282
WHA adopted Code in 1981 to
counteract negative impact of
promotion of bms.
“In view of the vulnerability of infants in the early
months of life and the risks involved in inappropriate
feeding practices, including the unnecessary and
improper use of breastmilk substitutes, the marketing
of breastmilk substitutes requires special treatment,
which makes usual marketing practices unsuitable for
these products.”
Preamble to the International Code of Marketing of Breastmilk Substitutes, WHO, Geneva, 1981
What is the Code?
• global recommendation - All States urged to
incorporate into national legislation.
• companies urged to ensure their practices
comply with the Code at all levels.
• Code further clarified and augmented through
subsequent World Health Assembly
Resolutions
• Code and Resolutions form the MINIMUM
STANDARD
What should Governments do?
Article 11.1 of the International
Code
“Governments should take action to give effect to
the principles and aim of the Code, as appropriate
to their social and legislative framework, including
the adoption of national legislation, regulations or
other suitable measures.”
WHA 63.23 [2010]
• Expressing deep concern over persistent
reports of violations of the International Code
by some infant food companies with regard
to promotion targeting mothers and healthcare workers;
• Expressing further concern over reports of
the ineffectiveness of measures, particularly
voluntary measures, to ensure compliance
with the International Code in some
countries;
WHA 63.23 [2010]
Urges Member States:
• to develop and/or strengthen legislative, regulatory
and/or other effective measures to control the
marketing of breast-milk substitutes in order to
give effect to the International Code …;
• to end inappropriate promotion of food for infants
and young children and to ensure that nutrition
and health claims shall not be permitted for foods
for infants and young children except where
specifically provided for, in relevant Codex
Alimentarius standards or national legislation;
Progress in Code Implementation
No of countries
State of the Code by Country 1991 to 2010
Source: UNICEF 2010
Code implementation in
Eastern and Southern Africa
Law
Botswana
Madagascar
Mozambique
Tanzania*
Uganda
Zimbabwe
Many
provisions
law
Malawi
Zambia
Voluntary
Kenya*
South Africa*
Swaziland
Measure drafted
Few
provisions law
Ethiopia
* New drafts under preparation
Burundi
Namibia
Rwanda
Successful Code
implementation
prohibits the unethical
marketing practices
that undermine
breastfeeding – and
companies know it!
Code implementation impacts
bms sales
“Government Regulation a
Growing Constraint”
“There are significant international
variations in the regulations
governing the marketing of milk
formula, which are reflected in
sales differences across
countries.”
“The industry is fighting a rearguard action against
regulation on a country-by-country basis”.
WHAT WORKS?
Enforceable legislation !
Companies will respect
the law if enforced - In
response to regulatory
changes in Brazil,
companies changed
their labels. As of 2002,
labels for Isomil and
Similac no longer show
Rosco bear.
Gerber changed
its labels in Brazil and
Bangladesh, which have
good laws, but not
elsewhere
Bangladesh
Malaysia
Situation in South Africa
• Currently classified as having a “voluntary” measures;
• Work on drafting Regulations began around 2000;
• Draft Regulations Relating to Foodstuffs for Infants,
Young Children and Children published in the
Government Gazzette 26 October 2007;
• Government inundated with comments, mainly form
manufacturers of BMS and their business
assosciations
• Draft revised in light of comments
Recommended strategies: South Africa (in
addition to Code and maternity protection)
• Ten Steps to Successful Breastfeeding (BFHI principles)
full institutionalized in ALL maternity facilities
• ALL health facilities which see pregnant women and
infants should have staff trained on breastfeeding
counselling and support who provide these services to
ALL mothers at relevant contacts
• Communities (especially remote communities or those
with poor access to health facilities) have access to
trained lay counsellors and support (e.g. mother
support groups)
• Communication strategy on breastfeeding using
multiple channels & based on formative research on
the barriers to good breastfeeding practices
Conclusions
• Breastfeeding the most effective preventative public
health intervention to reduce infant mortality and
morbidity.
• Breastfeeding saves the health care system money
• Formula company promotion reduces breastfeeding
and increases use of breastmilk substitutes
• Implementation & enforcement of the Code prohibits
unethical marketing practices that undermine
breastfeeding
• Code still not in place in South Africa and parents
vulnerable to commercial pressures to artificially feed
their babies
• URGENT action needs to be taken to have the
excellent draft Regulations in force.