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Fadeyi Oluwaseun
Ladoke Akintola University Ogbomosho
B.tech Marketing Management
Graduate, Nigeria.
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Do you know that Hospitals and Clinics are not allowed to collect posters, free samples, calendars, pens and other sourvenirs from companies producing breast milk substitutes? Below are the responsibilities of Nurses and other health workers.

The International Code of Marketing of Breast-milk Substitutes: Frequently Asked Questions on the Roles and Responsibilities of Health Workers

Health workers have a vital role to play in educating mothers and other caregivers about infant and young child feeding. It is also their moral, legal and professional responsibility to protect, promote, and support optimal feeding.

However, health workers and health care facilities throughout the world are often used by baby food companies to promote breast-milk substitutes such as infant formula, specialized formulas, follow-up formula or growing up milks.

Image Credit: WHO

This frequently asked questions document aims to provide health workers with information on their specific roles and responsibilities in protecting breastfeeding practices against the inappropriate promotion of breast-milk substitutes by baby food companies.

1. What is the International Code of Marketing of Breast-milk Substitutes?

In 1981, the World Health Assembly adopted the International Code of Marketing of Breast-milk Substitutes as a set of recommendations to regulate the marketing of breastmilk substitutes, feeding bottles and teats.

The Code aims to ensure that breast-milk substitutes are available when needed but not promoted. It points out that, given the special vulnerability of infants and the risks involved in inappropriate feeding practices, usual marketing practices are unsuitable for breastmilk substitutes.

The Code includes a number of provisions about the role of health workers and health systems and points out that health workers should make themselves familiar with their responsibilities under the Code.

2. The Code was written almost 40 years ago. Is it still relevant today?

Yes, the Code remains as relevant and important as when it was adopted in 1981, if not more so. The World Health Assembly has reiterated the importance of the Code numerous times over the past 39 years, sometimes clarifying and adding to it with subsequent resolutions. As recently as 2018, the Assembly urged countries to continue to implement the Code.

The importance of breastfeeding has been proven in many ways. Still, the sale of breastmilk substitutes continues to increase around the world, mainly because of new, persistent and very effective marketing practices. Such practices seriously undermineefforts to protect, promote and support breastfeeding.

In addition to promoting infant formula, companies increasingly promote breast-milk substitutes for older infants and young children, from 6 months to 3 years of age. These products undermine sustained breastfeeding up to two years or beyond. The packaging and marketing of these products indirectly promotes infant formula.

3. It looks like the Code was written for baby food companies. What does it have to do with me, as a health worker?

The Code is directed at governments, health workers, baby food companies and everyone who has a responsibility to protect, promote and support breastfeeding.

As a health worker, part of your job is to inform and educate mothers and other caregivers about appropriate and optimal infant and young child feeding. Mothers should be supported to make informed and unbiased decisions free from any commercial influences by baby food companies.

The Code prohibits any type of promotion of breast-milk substitutes in health services. It also has specific recommendations for health workers on how to avoid being influenced by baby food companies.

4. How do baby food companies promote breast-milk substitutes using health workers?

Promotional practices include donating free or subsidized supplies of breast-milk substitutes, providing free samples of formula, offering education for families, giving gifts to health workers and their families, and sponsoring conferences and meetings.

Baby food companies often target health workers and health facilities to help promote their products. They build relationships and offer subtle incentives that lead to direct or indirect endorsement of the company’s products. These relationships threaten health workers’ independence, integrity and public credibility.

All of these practices are prohibited by the International Code of Marketing of Breast-milk Substitutes.

5. I work in a hospital in a poor area. We need to cut costs everywhere. Why is it so wrong to accept free formula to be used by mothers who can’t breastfeed?

Experience has shown that unregulated and unlimited free supplies of formula lead to its overuse and undermines breastfeeding. Companies donate formula knowing that free distribution creates brand loyalty among mothers after they leave the hospital.

Therefore, donations of free or subsidized supplies of breast-milk substitutes or other products are not allowed in any part of the health care system. Any infant formula needed for infants with medical reasons for its use should be obtained through normal procurement channels.

6. Many of our patients can’t afford milk products. Why shouldn’t I give free samples to families who can’t afford these products?

The Code clearly states that health workers should not give samples of any breast-milk substitute to pregnant women, mothers of infants and young children, or members of their families.

Most women are physically able to breastfeed their babies and don’t need to use breastmilk substitutes. Their use interferes with the production of the mother’s own milk. Even in the rare occasions when infants have a metabolic disorder where breastfeeding is contraindicated, or a specialized formula is needed, health workers should not give out samples.

If a mother is given a free sample in the hospital, she will tend to use it even if it isn’t needed. Samples encourage families to purchase the products when the samples run out, even if they can’t really afford the product. Families may be persuaded to formula feed because the sample is implicitly endorsed by you.

7. In my facility, can I display posters/calendars/information materials given by a baby food company that has pictures of babies breastfeeding?

No. Any gifts to health facilities from baby food companies are not allowed. Gifts, even small ones such as calendars or pens, create a sense of obligation and continuously remind the person who received them about the “generosity” of the giver.

In addition, the Code says that health care facilities should not be used for the display of products within the scope of the Code, or for placards or posters concerning such products. Usually, posters or information materials from baby food companies contain subtle messages that undermine breastfeeding even if they show pictures of breastfeeding babies.

Just as much as free samples could ‘hook’ a mother to a particular brand of breast-milk substitute, so could attractive displays of materials by a baby food company.

8. Our formula representatives bring us chocolate when they come to tell us about their products. Can I give that chocolate to
my kids?

While the offering of chocolate by your formula representative may seem innocent, even mall gifts, including chocolate, may make you feel that the company means well and that you owe the company loyalty or gratitude. Companies know that this sense of loyalty or gratitude often leads to endorsing and promoting the company’s products.

This is one of the reasons why the Code does not allow gifts to health facilities and health workers.

9. Sometimes I receive stationery, pens and other useful items from a company. Is accepting such items against the Code?

Yes. These are gifts from the company, and the Code makes it clear that gifts from baby food companies are not allowed. In addition, these items often have logos or slogans from the company that can imply an endorsement of their products.

10. A company is hosting an event in my facility for mothers and babies, and they’re giving away prizes to the winners. That’s ok, right?

No, it is not ok. If health facilities allow baby food companies to access families directly, the facility will implicitly be promoting products rather than promoting health. The Code makes it absolutely clear that marketing personnel, in their business capacity, should not seek direct or indirect contact of any kind with pregnant women or with mothers of infants and young children.

11. Can we accept donations of laptop computers from baby food companies to be used in our clinics as long as they don’t have any logos of the company?

Donations of equipment, including laptops, will positively influence the attitudes of health workers and management of the facility towards the company and its products. This sense of obligation or influence can interfere with institutional policy and decision-making and the responsibility of the health professional to give trustworthy advice.

Such practices potentially undermine optimal infant and young child health and development. Even when there is no company logo, the donation itself will create a sense of obligation and loyalty.

12. Is it acceptable for baby food companies to advertise in our waiting room?

No, the Code says that health care facilities should not be used for the display of products within the scope of the Code, or for placards or posters concerning such products.

13. We have shelves of infant formula in our hospital for babies that can’t breastfeed. Should we put up a curtain to cover it up?

Yes. Any breast-milk substitute stored in hospitals, including in maternity wards, should be stored out of sight. A closed cupboard or generic bags could also be used to prevent promotion to patients or staff members.

14. Is it ok to distribute brochures promoting breastfeeding that come from manufacturers of baby foods as long as there are no advertisements for their products?

No. The Code does not allow baby food companies to directly or indirectly provide education to parents and other caregivers on infant and young child feeding in health facilities. Brochures would be one way of providing education. Besides that, brochures from baby food companies often have pictures or implicit messages that favour commercial products over breastfeeding.

15. My patients need education on infant feeding and I don’t have enough staff to run classes. Can baby food companies help if they don’t promote their products?

No, they can’t. Representatives of companies that produce breast-milk substitutes are not allowed to provide education in health facilities, either directly or indirectly, to parents of infants and young children.

If a mother needs to use a breast-milk substitute, you must ensure that any education is done by someone with no connection with the baby food industry.

16. I need to improve my professional knowledge. Why can’t I accept funding from a baby food company for travel or attendance at professional conferences or meetings?

Funding provided by baby food companies for travel or attendance at professional conferences or meetings is another way the company tries to influence you and create a relationship in which you feel indebted to them. It is a form of financial inducement and is prohibited by the Code.

17. What do I do if a baby food company representative tells me that acceptance of samples, gifts or invitations to conferences or study programmes is allowed in the country?

It is important for you as a health worker to make yourself familiar with the Code itself as well as with any legislation that your country may have adopted to stop inappropriate promotion of breast-milk substitutes. Just because your country may not have outlawed these gifts doesn’t mean that accepting them is ethical or appropriate.

18. How do I obtain more information about how my country is regulating the promotion of breast-milk substitutes?

Your health facility should make available any information on national legislation on the Code. In addition, WHO, UNICEF and IBFAN publish reports on national Code laws in countries every two years, and you can find these on the WHO website (www.who.int/health-topics/breastfeeding).

But remember, regardless of whether your country has adopted Code legislation, you as a health worker have responsibilities under the Code to promote, protect and support breastfeeding. The Code calls on you to ensure that parents and their babies are protected from marketing practices by companies whilst in your care.

19. What do I do if I see promotion of breast-milk substitutes in my workplace?

When you learn of activities that violate the Code in your facility, you should report them to your supervisor. Your facility may have a standard reporting procedure, or it could be part of regular quality improvement assessments.

In addition, in many countries the Ministry of Health has set up a monitoring system where you can report promotional practices that you observe. Non-governmental organizations or civil society networks, such as the International Baby Food Action Network (IBFAN), can help with reporting violations as well.

Credit: The international code of marketing of breast-milk substitutes: frequently asked questions on the roles and responsibilities of health workers. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO.

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