WHO Code — Who Cares?
WHO Code — Who Cares?
You and the International Code of Marketing of Breastmilk Substitutes
By Marsha Walker, RN, IBCLC
Protecting Infant Health and Supporting Breastfeeding Globally
The International Code of Marketing of Breastmilk Substitutes (the Code), adopted as a recommendation by the World Health Assembly (WHA) in 1981, is a global health policy framework aimed at promoting breastfeeding and curbing the irresponsible marketing of breastmilk substitutes. This code is an essential tool designed to safeguard infant health by advocating breastfeeding as the optimal source of infant nutrition and regulating the practices of companies involved in the production and distribution of artificial infant feeding products.
Background and Significance
The need for the International Code arose from the growing concerns about unethical marketing practices by manufacturers of breastmilk substitutes, which were linked to declining breastfeeding rates and adverse health outcomes for infants. Aggressive marketing campaigns for infant formula and other substitutes created an environment that undermined confidence in breastfeeding, particularly in developing countries, where access to clean water and proper sanitation is limited. This led to increased risks of malnutrition, infections, and mortality rates among infants relying on formula in unsanitary conditions. Even in developed countries, the Code should remain as a vigilant safeguard against predatory formula marketing that discourages exclusive breastfeeding, pressures parents into combination feeding, and manipulates the discussion of infant feeding towards the necessity of using and purchasing infant formula.
The marketing strategies of some companies continue to exploit loopholes in the Code, using indirect methods such as digital marketing or partnerships with influencers. The rise of social media and e-commerce platforms has created new avenues for promoting breastmilk substitutes, making regulation more complex. Companies use pain points (lack of sleep, sore nipples, worry of about sufficient breastmilk, crying baby, return to work, mental health) to position formula as the cure for this “pain” caused by breastfeeding. Social proofing is another marketing tactic that provides “evidence” that combination feeding is the new norm on the infant feeding journey. Social proofing taps into the basic instinct to follow the actions of others, lowering the barriers to making an infant formula purchase. “Everyone combo feeds--it’s normal--so I will too.”
Article 5.1 of the Code states that “There should be no advertising or other form of promotion to the general public of products within the scope of this Code.” One reason the US has not legislated the Code is the first amendment to the constitution, “Congress shall make no law…abridging the freedom of speech.” Advertising is a form of commercial speech. What the government can do is restrict or ban false, misleading, deceptive, or unfair statements and claims made by commercial entities under the laws of the Federal Trade Commission regarding false and deceptive advertising.
Key Provisions of the Code
The Code contains 11 Articles and 25 subsequent resolutions which are also part of the Code and designed to fill in gaps in the protection, promotion, and support of breastfeeding. Several of these provisions include:
Prohibition of Direct Marketing to Mothers
Companies are prohibited from directly advertising breastmilk substitutes to mothers or distributing free samples. This measure aims to prevent undue influence on parental feeding choices and protect breastfeeding as the primary option for infant nutrition.Proper Labeling and Information
Breastmilk substitutes must contain clear and truthful labeling, outlining the benefits of breastfeeding and the risks associated with artificial feeding. Misleading claims or terms that idealize formula are strictly prohibited.Support for Breastfeeding
The Code emphasizes the importance of breastfeeding education and support, urging governments, healthcare systems, and communities to promote breastfeeding and provide resources to mothers.Restrictions on Promotion to Healthcare Professionals
Healthcare professionals are not allowed to accept gifts, incentives, or samples of substitutes from manufacturers. This ensures that their recommendations are based solely on evidence-based practices and not influenced by commercial interests. Healthcare providers are prohibited from accepting material or financial inducements to promote formula products.
Co-opting health care providers (specifically IBCLCs)
The insidious invasion of infant formula companies into the infant feeding narrative has seen IBCLCs co-opted into working for companies not meeting their obligations under the Code and even working directly for formula manufacturers. The Code prohibits this. This is a massive conflict of interest and a violation of medical ethics. The Code’s underpinnings reflect the four cornerstones of medical ethics:
Autonomy: the individual’s right to hold views, make choices, and take action
Non-maleficence: the obligation to not cause harm
Beneficence: the obligation to promote the well-being of others
Justice: distribute benefits, risks, and costs in a fair and just manner
Working for a formula company as an IBCLC introduces bias into the provider/patient relationship. The first duty of the healthcare provider is to the patient, not a formula company from which one receives payment. Non-maleficence includes the obligation of not imposing risk for harm, which formula introduction can do. Veracity is based on respect for the patient and is the moral obligation to provide complete, accurate and non-biased information. Fidelity is a relationship based on trust and confidence. The patient must be confident that we are doing the best for them not what’s best for a formula manufacturer. Conflicts of fidelity include allegiance to colleagues, institutions, corporations, or the state as well as financial conflicts of interest. Acting as an IBCLC for a formula company violates the IBCLC Code of Professional Conduct which states that, “A crucial part of an IBCLC’s duty to protect families is adherence to the principles and aim of the International Code of Marketing of Breast-milk Substitutes and subsequent relevant World Health Assembly’s resolutions.”
We owe the families who entrust their care to us the assurance that we do not carry conflicts of interest, that we do not owe allegiance to Code violating companies, that we meet our ethical obligations as healthcare providers, and that we unequivocally support exclusive breastfeeding. We know that infant formula is sometimes needed or chosen, but inducements from formula manufacturers should not contribute to the abandonment of our ethical obligations to the patients we serve.
Resources
International Code of Marketing of Breastmilk Substitutes
https://www.babymilkaction.org/wp-content/uploads/2023/05/Code-Resolutions-2022pdf-1.pdf
Code of Professional Conduct for IBCLCs
https://ibclc-commission.org/ibclc-information/code-of-professional-conduct-for-ibclcs/
From the Lancet special issue on breastfeeding and accompanying webinars
https://www.thelancet.com/series/Breastfeeding-2023
