My third year elective placement was centred on increasing my knowledge in relation to the international code of marketing of breastmilk substitutes (known as the code) (World Health Organization (WHO), 1981). In 2021, the code marked its 40th anniversary. The code is a guideline developed by the WHO to protect and promote breastfeeding for mother, infant and family. The code is designed to stop commercial interests endangering the health and wellbeing of infants. The code ensures that when human milk substitutes are required, they are used properly through adequate information and appropriate marketing and distribution (Soldavini and Taillie, 2017).
The purpose of the code is to restrict marketing and advertising of breastfeeding substitutes, such as formula milk, teats, bottles, baby foods marketed for use before 6 months (eg cereals, juices or baby teas) and soothers to mothers, families and wider public/society. The reason for this is that exposure to formula marketing can affect exclusive breastfeeding, informed choice in relation to infant feeding methods or the choice not to breastfeed (Heinig, 2006). The code ensures that women and their families have the necessary factual information to make a decision that is right for their family.
I used Gibbs' (1988) reflective cycle in addition to the information I gathered on the code to reflect and elaborate on my learning. The Gibbs reflective cycle is a useful tool that allows one to reflect concisely and systemically about an experience. The areas I focused on in relation to my learning were a description, feelings, evaluation, analysis, conclusion and action plan in relation to the code.
Description
The code (WHO, 1981) is an international health policy framework that regulates the marketing of breastmilk substitutes in order to protect infant nutrition. It was published by the World Health Assembly (now WHO) in 1981 and is an internationally agreed voluntary code of practice (United Nations Children's Fund (UNICEF), 2021). It was introduced in response to aggressive marketing tactics by infant formula companies in the 1970s and 80s. Palmer and Arendt (2021) state that during this period, some milk companies promoted their products in regions of the world where safe water was not available, sanitation was poor and there were poor levels of literacy. There was a marked increase in infant disease and death. There are also accounts of formula company personnel distributing formula to mothers on postnatal wards while wearing white coats and sales women dressed as nurses (Heinig, 2006). The politics of breastfeeding matter (Palmer, 2009), as they illuminate how companies have an effect on the relationship between mothers and their babies, making it a global public health issue.
The code aims to prevent such practices. It helps to ensure that infants' basic human rights in relation to life, survival and development are paramount (United Nations convention on the rights of the child). The code does not prohibit the provision of factual information in relation to formula milk feeding. It is designed to ensure that all parents have access to accurate and effective information free from marketing campaigns that protect profit rather than parents and infants (Health and Safety Executive (HSE), 2021).
As a student midwife, I have become aware through my lectures and independent research of the importance of breastfeeding. There is also the reality that not every woman can be successful in establishing breastfeeding. Mothers should be supported and factual information should be provided allowing them to be fully informed on alternative infant feeding options.
There are many documented benefits of breastfeeding. Breastfeeding promotes the development of the mother–child relationship from an emotional point of view (Calin et al, 2021). Studies have also shown that exclusively breastfed infants are better protected from acute and chronic infections, such as infections of the lower respiratory tract and gastroenteritis, than infants that are partially fed breastmilk. Breastfeeding is also associated with a lower risk of asthma, eczema, otitis media and obesity (Eidelman et al, 2012). Women who breastfeed have a reduced risk of breast cancer and type 2 diabetes (Liu et al, 2010; Ambrosone et al, 2014; Baerug et al, 2018). The WHO (2021) recommends exclusive breastfeeding for 6 months, followed by the continuation of breastfeeding with the introduction of complementary foods up to age 2 years.
It is recognised that there are low breastfeeding rates in Ireland (UNICEF Ireland, 2022) and the UK (Baby Friendly Initiative, 2022), therefore it is important that mothers who make an informed decision to breastfeed are supported. Likewise, mothers who make an informed decision to formula feed their baby must be provided with accurate and evidence-based information to do so.
While conducting my research, I found that there is a general international consensus about the code. Multiple global breastfeeding agencies agree on the importance of the code and how it is often undermined with the use of inappropriate, nonfactual information in company marketing strategies (Both, 2018).
Feelings
While conducting my research, I was dismayed to find that 40 years later, there are still companies in violation of the code. There is a great depiction of this in the film ‘Tigers’. The film highlights how detrimental nonfactual information is in relation to formula milk being more beneficial compared to breastmilk, and the lengths that formula companies can go to in order to make a profit, completely disregarding the safety of their consumers. As I reflect on my personal experience as a student midwife in a number of maternity units, I can confidently say that the code is being adhered to in the clinical areas I have completed practice placements in. Staff are aware of the role they play in implementing and protecting the code. This is facilitated through guidelines developed for healthcare staff, UNICEF's health professionals' guide to the code, and the recent supplementary publication from the HSE (2021), ‘working within the code’. Both provide in depth detail on the importance of the code and how it relates to the healthcare environment. This made me feel confident in understanding the code and I could relate this information back to being on practice placement.
The code forbids any promotion of baby formula, bottles or teats, gifts to mothers or ‘bribery’ of healthcare staff. The intensive marketing of breast milk substitutes increases child morbidity and mortality, particularly in resource-constrained countries. However, formula and bottle-feeding have become widely accepted societal norms, with which breastfeeding must contend, affecting women's confidence in their potential to breastfeed, the general public's access to factual health information and children's right to optimal health. As a result, there was heavy lobbying against the code; however, it was still adopted (Heinig, 2006). As of April 2020, 136 countries of the 194 analysed in a global report have implemented legal measures that are aligned with the code (WHO, 2020).
Evaluation
The code allows for the protection of women, infants and their families. It also allows all parties involved to receive factual evidence in relation to breastfeeding and breastmilk substitutes. The experience I gained while reflecting on the code was beneficial to me, as I received a further in-depth understanding of the code. It allowed me to reflect on my practice placements, to determine whether I had come in contact with any violations of the code.
I appreciated reading a joint statement from UNICEF and WHO (2021) on the 40th anniversary of the code on the 21 May 2021. It is clear that there is a need to revisit the original concept, reflect on progress and invite new thinking on how this important document might be more effective for nations in the 21st century. It is important that guidelines are revisited and updated to ensure they correlate with the ever-changing society that we live in. The world is very different than when the code was adopted in the 1980s, and information can now be received through a vast range of mediums. There is a need for continuous professional development within the healthcare field, bringing with it the challenges associated with the provision of and attendance at events organised to support infant nutrition. Staff should be conversant with the code, allowing them to better assist women in their breastfeeding and/or formula feeding journey.
Analysis
I noticed that there is a lack of information for women and their families available in the antenatal and postnatal period in relation to the code. I believe that women and their families should be provided with information on the code and its importance in ensuring factual unbiased information in relation to their child's nutrition (HSE, 2021). This will ensure that women are not directly reliant on social media sites as a source of information in relation to breastmilk substitutes. Social media sites can be unaware of the code and inadvertently include code violations (ie formula milk advertising) to vulnerable pregnant women. The availability of information on the code places women and their families at the centre of care. The inclusion of women and their partners as part of the multidisciplinary healthcare team has been described in literature as advantageous (Vogt et al, 2006; Martin and Finn, 2011).
Likewise, the multidisciplinary team must be familiar with the code and the possibility that companies could attempt to promote their brand through maternity services and its staff. While on clinical placement, I have been aware that women ask about the types of formula milk available and if one product is superior to another. This led my attention to be drawn to TV advertisements for formula milk. Healthcare staff must be aware that there is no nutritional advantage between brands of infant formula and that first milk is the first choice for the first year of life (NHS, 2008). It is not necessary for companies to contact staff directly to advise in relation to the nuances of specialist milk, this information can be cascaded via hospital dietitians (HSE, 2021). The hospital dietitian can then provide scientific information to healthcare staff. Maternity units should also provide non-formula branded teats.
Conclusion
The code has proven to be beneficial in providing a clear guideline for companies, maternity units, healthcare workers, women and their families and the wider public/society on the use of safe breastmilk substitutes. Violating it can adversely affect wellbeing of infants under the age of 6 months. Guidelines like the code allow for fact-based information to be provided to those who are not experts in the particular field. The code was created in the best interest of infant nutrition, as opposed to marketing strategies, such as distributing free formula, that are made in the best interest of increasing sales for formula companies.
In the future, I will discuss the code with women and their partners as a source of reputable information in regards to breastmilk substitutes. I will also pay closer attention to advertising tactics in relation to breastmilk substitutes. With a greater understanding of the code, I will be able to recognise violations and take the necessary actions in reporting violation(s) to the relevant authorities such as the Baby Feeding Law Group in the UK or Ireland (Baby Feeding Law Group Ireland, 2020).
Using Gibbs' reflective cycle, I was able to reflect on my learning in relation to the code. Without the code, it is safe to say the causalities from misinformation from formula companies would be much greater. Ultimately, I will support women in their choice on what method of infant feeding they decide on; whether it be breastfeeding or formula milk feeding. It is important to note that it is the woman's right to choose not to breastfeed and that not every woman will successfully establish breastfeeding.
Action plan
During my elective placement, I had the opportunity to work on an engaging newsletter for midwifery students and staff in relation to the code. I developed a colourful newsletter that included quick to read bullet points and engaging pictures to grasp the reader's attention. Key points in the newsletter highlighted that there should be no advertising to mothers of formula milks, bottles, teats, soothers and baby foods marketed prior to the infant reaching 6 months of age.
I was conscious that the code can be a challenging read and enjoyed the opportunity to make learning fun and easy for busy healthcare professionals. I am delighted that I had the opportunity to share my learning in relation to the code with my colleagues and in turn make the experience enjoyable and memorable.