Between the 1930s and 1970s, breastfeeding rates in developed countries declined 56 percent, caused in large part to aggressive advertising and promotion of breast milk substitutes. Companies selling formula used aggressive marketing tactics to make new mothers and health-care workers switch from exclusive breastfeeding, which is recommended by the WHO and UNICEF for the first six months, to breast milk substitutes by marketing these as “modern” alternatives and donating them to health-care workers and new mothers. These tactics, combined with lack of access to clean water, misinterpretation of labels and dosing instructions, and formula affordability, often result in improper preparation and storage of breast milk substitutes and contribute to increased infant mortality from malnutrition, infectious disease such as pneumonia, and diarrhea.
To combat these tactics and promote exclusive breastfeeding, the World Health Assembly adopted the International Code of Marketing of Breast Milk Substitutes in 1981. The code prohibits promotion of breast milk substitutes, bottles, and teats to the general public, health-care workers and facilities, and prohibits distribution of samples or vouchers to new parents. However, despite legislation enacting the code into law in 84 countries, violations remain common around the world, reaching 792 violations in 79 countries between 2014 and 2017. Public health advocates and the development community can do the following to support robust implementation and monitoring of the code and related legislation:
1. Support advocacy campaigns at local and national levels
While international campaigns are important, much of the meaningful change in reducing use of breast milk substitutes has started at national and local levels. Supporting national organizations and campaigns committed to implementing and upholding the code is, therefore critical, as enactment and implementation of the code requires a great deal of coordination, championship, and perseverance. Donor-funded programs can support these campaigns and local organizations by assisting with needs-based planning, stakeholder engagement and media training, message development, scaling up of tools such as the breastfeeding advocacy toolkit, and developing long-term, sustainable financing sources. They can also work with organizations to support linkages to regional or international campaigns to amplify their voices. For example, the Ghana Infant Nutrition Action Network, with support from UNICEF, USAID, and the International Baby Food Network, organized a campaign to sensitize stakeholders about the code and the need for national legislation. It lobbied government officials, distributors, and health professionals, and provided comprehensive feedback on draft legislation. This sustained advocacy resulted in the passage of legislation promoting breastfeeding (upholding the code) and the successful defeat of an amendment to weaken the law a year later.
2. Support robust and sustainable monitoring and enforcement mechanisms
Only 65 percent of the monitoring mechanisms in countries with legal measures in place are empowered to impose sanctions, rendering many monitoring bodies toothless against often aggressive and inappropriate marketing. For monitoring and enforcement bodies to be effective, they must engage all relevant parts of government, have adequate funding and skilled staff, tools to detect, report and investigate violations, and the ability to enact meaningful enforcement procedures. The development community can assist with the design, governance, and long-term financing of monitoring and enforcement bodies, facilitating South-to-South learning and supporting the scale-up of monitoring tools, such as the WHO endorsed NetCode Tookit. For example, the UNICEF-supported Breastfeeding Promotion Network of India is raising awareness, conducting trainings on monitoring tools and compliance. They are also raising local capacity by filing reports, taking legal action, and launching media campaigns to ensure almost full compliance with the code. Strong legislation and political will in India helped establish a monitoring body with robust support and the ability to enact sanctions, leading to exclusive breastfeeding rates to jump over 20 percent and the infant formula market to remain stagnant.
3. Carefully consider private sector engagement
Private sector engagement can be an effective way to address development challenges through enterprise-driven approaches that sustainably empower people, communities, and countries. However, engagement must prioritize the goal of protecting, promoting, and supporting breastfeeding. There is considerable debate within the policy community regarding whether or not the private sector, specifically companies that sell breast milk substitutes, should be involved in promoting breastfeeding due to the lack of regulations, conflict of interest, and consumer trust. The National Crusade Against Hunger in Mexico was lauded as a good example of uniting public and private sector actors towards a holistic goal and celebrated as a sustainable approach to increase support for nutrition programs to eradicate acute childhood malnutrition. However, the campaign also received criticism for government promotion of private sector actions with a track record of promoting breast milk substitutes over breastfeeding in the midst of a nutrition campaign. Privately sponsored breastfeeding rooms and parents’ clubs in hospitals have also received mixed reactions, with concerns these investments are solely to promote formula as an equal substitute to breast milk.
Breastfeeding is proven to improve child survival and long-term health outcomes, which is why development and public health organizations must prioritize the well-being of mothers and babies by supporting advocacy efforts and enforcement mechanisms and carefully considering and monitoring engagement to avoid real or perceived conflicts of interest. While compliance with the code is certainly not the only challenge women face to initiate and maintain exclusive breastfeeding, highlighting the importance of robust implementation of the code as a key part of a multisectoral approach to address these issues is critical during this World Breastfeeding Week and until full compliance with the code is achieved.
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