An International Comparison Study into the implementation of the WHO Code and other breastfeeding initiatives


Background - An International Comparison Study into the implementation of the WHO Code and other breastfeeding initiatives

Page last updated: 03 May 2012

The NHMRC Clinical Trials Centre was contracted by the Australian Government Department of Health and Ageing to undertake an international comparison study into the implementation of the World Health Organization’s (WHO) International Code of Marketing of Breast-milk Substitutes (WHO Code). The study also examined other breastfeeding initiatives which aimed to promote and support the WHO Code. By considering the countries of Canada, France, Germany, Ireland, New Zealand, Norway, UK and the USA, this study has investigated and compared:

  • the extent to which the WHO Code has been implemented
  • the methods by which it has been implemented
  • the impact that implementation has had on breastfeeding rates and infant feeding practices in these pre-specified countries.

World Health Organization (WHO) International Code of Marketing of Breast-Milk Substitutes (WHO Code)

Description of the WHO Code

The positive effects of breastfeeding on the health and wellbeing of the infant and mother are extensive and widely acknowledged worldwide (2003). In response to concerns about declining breastfeeding rates, unregulated marketing of breast-milk substitutes and the potential effect of artificial feeding on child and infant mortality, the World Health Organization (WHO) International Code of Marketing of Breast-milk Substitutes (WHO Code) was adopted by 118 member states at the 34th World Health Assembly (WHA) in 1981. The WHO Code is an overarching document which gives priority to supporting and promoting breastfeeding and the impetus to be integrated into legislation and policy in member states. The WHA made additional resolutions to the WHO Code over the subsequent three decades (i.e. 1986, 1990, 1992, 1994, 1996, 2001, 2002, 2005 and 2008). These latter resolutions mainly focus on the marketing and distribution of breast-milk substitutes.

The WHO Code was formulated with the aim of contributing to:

“the provision of 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, on the basis of adequate information and through appropriate marketing and distribution”.
The WHA recommended that each member state incorporate the WHO Code into its own system of governance (World Health Organization 1981).

The WHO Code consists of 11 articles:
  • Article 1: aim of the code (as aforementioned).
  • Article 2: scope of the code (applies to the marketing and practices related to breast-milk substitutes and their quality and availability).
  • Article 3: definitions (defines breast-milk substitutes, complementary food etc. but no definition of follow-up formula).
  • Article 4: information and education (relates to the responsibilities of governments in the dissemination of information about feeding; the clarity of informational and educational materials; and the donations of such materials by manufacturers or distributors).
  • Article 5: general public and mothers (relates to no advertising of breast-milk substitutes to the public; no free samples to mothers; no promotion of products in healthcare facilities).
  • Article 6: health care systems (states that healthcare authorities in member states should take appropriate measures to encourage and protect breastfeeding by giving appropriate information and advice to healthcare workers; no gifts or personal samples to health workers; no company “mothercraft” nurses to advise mothers).
  • Article 7: health workers (requests that health workers encourage and promote breastfeeding; information to health workers should be scientific and factual; no financial or material inducements to promote products to be offered by manufacturers or distributors to health workers; samples should not be provided to health workers except when necessary, i.e. for research).
  • Article 8: persons employed by manufacturers and distributors (states that the sales of products within the scope of the WHO Code should not be used to calculate bonuses to marketing personnel; marketing personnel should not perform educational functions in relation to pregnant women or mothers of infants and young children).
  • Article 9: labelling (asks that labels explain the benefits of breastfeeding and the costs and hazards associated with inappropriate preparation, products should be of a high quality and take into account the climatic and storage conditions of the country where they are used).
  • Article 10: quality (states that all products should be of a high quality and meet the standards recommended by the Codex Alimentarius Commission and also the Codex Code of Hygienic Practice for Foods for Infants and Children).
  • Article 11: implementation and monitoring (asks that governments should take the appropriate action to give effect to the principles and aim of the WHO Code through social and legislative frameworks; monitor the code while collaborating with non-governmental, professional and consumer groups).
The WHA resolutions include the following, as outlined by Burgess and Quigley (Burgess & Quigley 2011):
  • WHA Resolution 39.28 (1986): any food or drink given before complementary feeding is nutritionally required may interfere with the initiation or maintenance of breastfeeding and therefore should neither be promoted nor encouraged for use by infants during this period; the practice being introduced in some countries of providing infants with specially formulated milks (so called follow-up milks) is not necessary.
  • WHA Resolution 47.5 (1994): Member States are urged to foster appropriate complementary feeding from the age of about six months.
  • WHA Resolution 49.15 (1996): Member States are urged to ensure that complementary foods are not marketed for or used in ways that undermine exclusive or sustained breastfeeding; Member States are urged to ensure that financial support for professionals working in infant and young child health does not create conflicts of interest.
  • WHA Resolution 54.2 (2001): Member States are urged to strengthen activities and develop new approaches to protect, promote and support exclusive breastfeeding for six months ... and to provide safe and appropriate complementary foods with continued breastfeeding for up to two years of age or beyond.
  • WHA Resolution 55.25 (2002): Member States adopt and implement the global strategy; to strengthen existing, or establish new, structures for implementing the global strategy; to define for this purpose, national goals and objectives, a realistic timeline for their achievement, and output indicators; and ensure that marketing of nutritional supplements does not replace, or undermine support for the sustainable practice of, exclusive breastfeeding and optimal complementary feeding; that the Codex Alimentarius Commission continues to give full consideration to improve the quality standards of processed foods for infants and young children and to promote their safe and proper use at an appropriate age, with adequate labelling consistent with the International Code of Marketing of Breastmilk Substitutes, Resolution 54.2, and other relevant resolutions of the WHA.
  • WHA Resolution 58.32 (2005): to ensure that nutrition and health claims are not permitted for breastmilk substitutes, except where specifically provided for in national legislation; to ensure that financial support and other incentives for programmes and health professionals do not create conflicts of interest.
  • WHO Resolution 61.20 (2008): to achieve optimal growth, development and health, WHO recommends that infants should be exclusively breastfed for the first six months of life. Thereafter, to meet their nutritional requirements, infants should receive adequate and safe complementary foods while breastfeeding continues up to two years of age and beyond.
Despite the WHO Code and its numerous resolutions, there continues to be differences over the interpretation of some aspects of the Code, particularly in relation to which products it does or does not cover. In addition to this, there appears to be variable mechanisms in place to implement and monitor the WHO Code and to some degree, a lack of clarity in government-defined regulations.

Among all of the resolutions, there appears to be consistent concerns about follow-on milks and their place within the WHO Code. Follow-on formulas did not exist when the WHO Code was adopted in 1981. It had however appeared on the market by 1986 and its availability and use was noted by the WHA. One of the main concerns of the WHA was that the promotion and advertising of follow-on formula was undermining breastfeeding as the normal way to feed an infant. This was seen by some as getting around the prohibition on the advertising of infant formula to the general public and encouraging parents to use follow-on formula rather than breastfeeding or using follow-on formula for infants aged less than six months. As a result the WHA adopted Resolution 39.28 in 1986. However while many Member States have made efforts to implement the Code, including the transposing of the WHO Code into local legislation, the concern of follow-on milk has often not received the same attention and still remains a contentious issue.

The implementation of the WHO Code and how compliance is monitored across member states varies, and includes a mix of legislation, national policies and strategies, and voluntary agreements (National Breastfeeding Advisory Committee 2009) and has evolved over time in response to the unique economic, social and legal circumstances of each country.
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The international legislative and policy context for breastfeeding

There are many initiatives in addition to the WHO Code which are designed to protect and promote breastfeeding. The key international conventions or strategies are outlined below.

The WHO/UNICEF Joint Statement (1989)

This statement “Protecting, promoting and supporting breastfeeding: the special role of maternity services” announced for the first time the “Ten steps for successful breastfeeding” which are pertinent for healthcare services/facilities (Saadeh & Akre 1996; World Health Organization 1989). All facilities should:
  1. have a written breastfeeding policy that is routinely communicated to healthcare staff
  2. train all healthcare staff in skills necessary to implement the policy
  3. inform all pregnant woman about the benefits and management of breastfeeding
  4. help mothers initiate breastfeeding within a half-hour of birth
  5. show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants
  6. give newborn infants no food and drink other than breast milk unless medically indicated
  7. practice roaming-in: allow mothers and infants to remain together (24 hours a day)
  8. encourage breastfeeding on demand
  9. give no artificial teats or pacifiers to breastfeeding infants
  10. foster the establishment of breastfeeding support groups.

The Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding (UNICEF 1990)

This Declaration aims to enable the exclusiveness of breastfeeding during the first four to six months and to create/reinforce a “breastfeeding culture”. The Declaration states the following targets:
  • the appointment of a National Breastfeeding Coordinator and multi-sectorial advisory groups on breastfeeding
  • ensure the Baby Friendly Hospital Initiative (described below) is used in all maternity units
  • give effect to all of the articles in the International Code of Marketing of Breast-milk Substitutes
  • develop legislation to protect breastfeeding rights of working women.
A revised Declaration was issued in 2005 (UNICEF 2005).

The Baby Friendly Hospital Initiative (BFHI) 1991

WHO/UNICEF promoted the implementation of “Ten conditions for breastfeeding success” in the form of the Baby Friendly Hospital Initiative (World Health Organization & UNICEF 1991). This initiative involves maternity care facilities going through a formalised procedure of assessment in order to be accredited as a baby-friendly hospital. Assessment for Baby Friendly accreditation takes place in several stages and can take up to 5 years. The certification process involves making a self-assessment based on the 10 steps, formally requesting accreditation from the Baby Friendly Hospital National Committee or the WHO Office (Geneva), undergoing a standardised evaluation procedure by the evaluation team and receiving recommendations to certify or not certify the maternity facility for a specific period. Once the health-care facility is accredited as Baby Friendly this accreditation lasts for two years; after this, a reassessment of all the standards is carried out. All accredited facilities must collect breastfeeding statistics and must audit compliance with their policy.

In 2008 the Baby Friendly Initiative was expanded to include community health care facilities. A Seven Point Plan for Sustaining Breastfeeding in the Community was launched. The Seven Points were developed by NICEF UK and are evidence-based best practice standards to enable improved practice in community health care in order to promote, protect and support breastfeeding

Maternity Protection Convention (ILO Convention No. 183) (International Labour Organization 2000)

This Convention describes a minimum of 14 weeks maternity leave for all working women; the provision of cash benefits during maternity leave; the adoption of measures to ensure that pregnant or breastfeeding women are not obliged to perform work prejudicial to the mother’s or child’s health; protection from termination of employment during pregnancy or maternity leave; and the right to one or more paid breastfeeding breaks during each working day.

The Global Strategy for Infant and Young Child Feeding 2003

The aim of this strategy is to improve, through optimal feeding, the nutritional status, growth and development, health and thus the survival of infants and young children (World Health Organisation and UNICEF 2003).

United Nations Convention on the Rights of the Child (Office of the United Nations High Commissioner for Human Rights 1989)

This Convention, adopted by the WHO in 1989, stipulates that it is necessary to take the appropriate measures to protect the rights of children, including the right to the highest attainable state of health. The Convention states:

“to ensure that all segments of society, in particular parents and children, are informed, have access to education and are supported in the use of basic knowledge of child health and nutrition, and advantages of breastfeeding ...”

United Nations Convention on the Elimination of All Forms of Discrimination against Women (Office of the United Nations High Commissioner for Human Rights 1979)

This Convention covers maternity protection as part of eliminating discrimination, including the need for signatories to ensure that reproduction and maternity is protected.

In light of these key conventions and strategies, there is a growing recognition that the feasibility and effectiveness of strategies to enact the WHO Code and also some international strategies (such as the BFHI) vary according to the domestic context. For instance, in New Zealand, voluntary industry codes of practice were adopted in recognition that the legal restriction of advertising of breast-milk substitutes would contravene commerce and trading acts (National Breastfeeding Advisory Committee 2009) while European countries have adopted partial legislative implementation of the WHO Code in line with the European Directive (EU Directive 2006/141/EC). As a consequence, the status of the WHO Code (e.g. voluntary code, provisions law) does not necessarily guarantee effective implementation and increased breastfeeding rates. This has been exemplified in the UK where breastfeeding rates are among the lowest in Europe despite enacting aspects of the Code (UK Food Standards Agency 2007).
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