IBFAN Monitoring Project (IMP)
This report is the culmination of a two-year project which aimed to inerease the capacity of national IBFAN groups to monitor compliance with the International Code as part of their efforts to protect and promote breastfeeding. Monitors in 39 countries surveyed health care facilities and retail outlets. They also interviewed mothers and health professionals as to their experiences with companies manufacturing breast milk substitutes and related infant feeding products. The database, which forms the basis of this report, consists of results from the following 31 countries: Argentina, Bangladesh, Benin, Bolivia, Brazil, Colombia, Costa Rica. Cote d'Ivoire, Croatia, Dominican Republic, Gabon, Germany, Guatemala, Indonesia, Kenya, Korea, Malaysia, Mauritius, Mexico, Nicaragua, Niger, Peru, Philippines, Senegal, Spain, Tanzania, Thailand, Uruguay, Venezuela, Western Samoa and Zambia.
National surveys were also carried out in Ireland, Hungary, Latvia, Georgia, Mozambique, Slovakia, Poland and Zimbabwe as part of the IMPII project, but were not completed in time to be incorporated into the database. Information from the database is reflected in the charts at the beginning of each section of this report as well as in the text. Volunteers from many other countries also contributed information about violations on an ad hoc basis and these are described only in the text.
All countries used the International Code and related Resolutions of the World Health Assembly as the standard by which company practices were measured. Countries with national measures that differ from the International Code have made comparisons in their national reports.
The aim of this project is to show in what ways the Code continues to be violated. It was not designed to obtain statistical information, nor was it meant to 'grade' each company's level of compliance. The results, of course, show only the tip of the iceberg.
It is obvious, for example, that when one or two mothers have received a company information booklet, thousands more of these booklets would have been produced and distributed. Gifts to health professionals and donations to hospitals are very difficult to monitor. Health workers might only ad mit to one out of ten.
The International Code was adopted by the World Health Assembly in 1981, as a set of rules to protect breastfeeding from unethical marketing practices. The Preamble to the International Code explains that "the marketing of breastmilk substitutes requires special treatment; which makes usual marketing praetices unsuitable for these products." Since. 1981, the Assembly has passed resolutions that clarify or add to certain provisions of the Code, particularly Article 2, the Scope, and Article 6, which deals with free and low-cost supplies of breastmilk substitutes.
There is nothing that equals breastfeeding in providing proper nourishment and enhancing the development of infants. Breastmilk is a live substance contain ing all the essential nutrients as well as antibodies that fend off infection. Epidemiological research has shown that human milk and breastfeeding provide advantages for health, growth and development, while significantly decreasing risk for a large number of acute and chronic diseases including diarrhoea and respiratory infection. Breastfeeding plays an important role in birth spacing and has been related to enhancement of cognitive development. It is safe, clean, always at the right temperature, free an d available in just the amount the baby needs. For the mother, there is reduced risk of ovarian and pre-menopausal breast cancer. Breastfeeding is also associated with significant economic and envirorunental benefits.
In the developing world, the risk of death for infants who are not breastfed is 10 to 15 times greater in the first three to four months of life than for babies who are fed only breastmilk. In more affluent countries, even under the best conditions, a bottle-fed baby is more likely to suffer from a respiratory ailment or get a gut infection. In 1993, the Director of the World Health Organisation (WHO) stated that " WHO estimates that some 1.5 million infant deaths every year could be averted through effective breastfeeding."
WHO and UNICEF recommend exclusive breastfeeding for about six months. It has been shown that the addition of foods or drinks during this period reduces the infants demand for breastmilk thus reducing the mothers supply. Not only will the infant take in less nutritious food, but the feeding bottle is in itself a potential hazard. The American Pediatric Associations 1997 Recommendations on Breastfeeding and the Use of Human Milk state that "exclusive breastfeeding is ideal nutrition and sufficient to support optimal growth and development for approximately the first six months after birth." After the first six months, breastfeeding should continue along with appropriate complementary foods for up to two years and beyond.
The Code applies to infant formula, feeding bottles and teats as well as other breastmilk substitutes. Breastmilk substitutes are defined in the Code as "any food being marketed or otherwise represented as a partial or total replacement for breastmilk." Thus, it is not the nature of the product itself, but the way in which it is marketed or represented, which determines whether or not it falls within the ambit of the International Code.
When companies promote foods for infants younger than six months, they are in effect marketing these foods as a replacement for breastmilk, which by itself is the optimal way to feed infants up to the age of six months. The same argument applies for formulas and milks marketed for older children because they replace the part of the diet that is best fulfilled by breastmilk
Other products, depending on how they are marketed or represented, will also fall within the definition of breastmilk substitutes. An example specified in the Code is complementary foods marketed to be fed by bottle. Packaged infant foods, whatever the manufacturers recommended age, are also represented as suitable replacements for breastmilk when they are promoted to pregnant women and mothers of new-borns via the health care system. Whether the manufacturers recommended age be two, four, six months or unspecified, the combination of the implied endorsement of the health care system and the target consumer renders these products breastmilk substitutes.
Each section of this report begins with a chart that shows in which countries each company violates the relevant Code provisions. Violations are reported according to the type of product in order to show trends. For purposes of the charts, infant formula means formulas marketed for use by infants from birth. Follow-up formula refers to formulas marketed to follow an infant formula, thus with a starting age later than birth. Finally, complementary food means a food suitable as an addition to breastmilk when it no longer fulfils all of the infants nutritional requirements, but which has been marketed or otherwise represented as a partial or total replacement for breastmilk.
Wath is a violation?
As with past editions of Breaking the Rules, it is certain that the infant food industry will react to this report by claiming that many of their marketing activities do not constitute violations of the International Code. Like all legal documents, the Code is subject to interpretation. Unlike a law, however, the Code lacks binding legal force and there is no court to declare the meaning of its various provisions. IBFAN reports not only activities that violate the letter of the Code, but its spirit as well using the overall intent to protect, promote and support breastfeeding as a guide for interpretation.
The final section of this report describes marketing practices for new products in the market. Although these practices discourage breastfeeding, the products are not included within the scope of the Code for the simple reason that they did not exist when the Code was drafted. Whether the new marketing activities break or merely "stretch" the Code is mere semantics when the protection of infants lives and health is at stake.
Main | Executive
Summary | Promotion through
the Health Care System | Promotion to the
Labelling | Feeding Bottles and Teats | Stretching the Rules | Appendix | This Inform...