Violations of the International Code of Marketing of Breast-milk Substitutes: a multi-country analysis

The marketing of formula milk as a substitute for breast milk continues to be ubiquitous and multifaceted despite passage by the World Health Assembly of the International Code of Marketing of Breast-milk Substitutes (the Code) in 1981. In this paper, we summarized reports of the Code violations from eight studies using the WHO/UNICEF NetCode protocol. Among 3,124 pregnant women and mothers with young children, in eight countries, 64% reported exposure to promotion of products covered under the Code in the previous 6 months, primarily from advertisements seen outside of health facilities (62%). Nearly 20% of mothers with an infant < 6 months reported that a health care provider had advised them to feed their child food or drink other than breast milk, and 21% of providers reported contact with a representative of a formula company in the previous 6 months to distribute promotional materials, samples, or free supplies (range 2%-53%). Of the 389 retail stores and pharmacies surveyed, promotions were observed in 63% (range 0-100%), and of 1,206 labels and inserts of products reviewed, nearly half included health and/or nutrition claims (range 0-100%). A strong, though non-significant, linear relationship between the composite violations score and quality of Code legislation was found; countries with the lowest percentage of violations had the strongest Code legislation. In Latin America, over 50% of health care providers reported no knowledge of the Code, and 50% reported no knowledge of national legislation. Our study highlights three key facts: 1) the marketing of BMS is ubiquitous and multifaceted, 2) the high variability of promotion across countries generally reflects the comprehensiveness of Code legislation, and 3) health care providers have poor knowledge of the Code and national legislation.