Implementation of the International Code of Marketing of Breast-milk Substitutes in the Eastern Mediterranean Region

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Research article

Ayoub Al Jawaldeh ¹ and Ghada Sayed²

¹World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt (Correspondence to: A. Al Jawaldeh: This email address is being protected from spambots. You need JavaScript enabled to view it.). ²International Baby Food Action Network Arab World Coordinator, Cairo, Egypt.

Abstract

Background: Optimal breastfeeding practices and appropriate complementary feeding improve child health, survival and development. The countries of the Eastern Mediterranean Region have made significant strides in formulation and implementation of legislation to protect and promote breastfeeding based on The International Code of Marketing of Breast-milk Substitutes (the Code) and subsequent relevant World Health Assembly resolutions.

Aim: To assess the implementation of the Code in the Region.

Methods: Assessment was conducted by the World Health Organization (WHO) Regional Office for the Eastern Mediterranean using a WHO standard questionnaire.

Results: Seventeen countries in the Region have enacted legislation to protect breastfeeding. Only 6 countries have comprehensive legislation or other legal measures reflecting all or most provisions of the Code; 4 countries have legal measures incorporating many provisions of the Code; 7 countries have legal measures that contain a few provisions of the Code; 4 countries are currently studying the issue; and only 1 country has no measures in place. Further analysis of the legislation found that the text of articles in the laws fully reflected the Code articles in only 6 countries.

Conclusion: Most countries need to revisit and amend existing national legislation to implement fully the Code and relevant World Health Assembly resolutions, supported by systematic monitoring and reporting.

Keywords: International code of marketing of breast-milk substitutes; breastfeeding; child health; malnutrition; infant milk formula

Citation: Al Jawaldeh A, Sayed G. Implementation of the international code of marketing of breast milk substitutes in the Eastern Mediterranean Region. East Mediterr Health J. 2018(1):25–32. https://doi.org/10.26719/ 2018.24.1.25

Received: 17/09/17; accepted: 04/01/18

Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo)

Introduction

Optimal breastfeeding and appropriate complementary feeding improve child health, survival and development (1). Globally, breastfeeding has the potential to prevent about 820 000 deaths annually among children aged < 5 years if all children aged 0–23 months were optimally breastfed (2). Inappropriate feeding practices lead to infant malnutrition, morbidity and mortality in all countries, and improper practices in the marketing of breast-milk substitutes and related products can contribute to these major public health problems (3).

Almost all mothers can breastfeed successfully, which includes initiating breastfeeding within the first hour of life, breastfeeding exclusively for the first 6 months, and continuing breastfeeding (along with giving appropriate complementary foods) up to 2 years of age or beyond (4). An extensive body of research has demonstrated that mothers and other caregivers require active support for establishing and sustaining appropriate breastfeeding practices (5). The supportive measures at many levels range from legal and policy directives to social attitudes and values, women’s work and employment conditions, and healthcare services to enable women to

breastfeed (1).

As a minimum requirement to protect and promote appropriate infant and young child feeding, the World Health Assembly adopted the International Code of Marketing of Breast-milk Substitutes in 1981 and has since strengthened the Code with a number of resolutions (hereafter the International Code and the subsequent relevant resolutions are referred to collectively as the Code) (6). The 1981 resolution urged Member States of the Eastern Mediterranean Region to translate the Code into national legislation, regulations or other suitable measures to monitor compliance with the Code (3). Moreover, the Innocenti Declaration (2005) stated that all governments should implement all provisions of the Code and subsequent relevant World Health Assembly resolutions in their entirety as a minimum requirement, and establish sustainable enforcement mechanisms to prevent and/or address noncompliance (7).

Member States have obligations to take all necessary measures to adopt comprehensive and enforceable normative measures to protect babies and mothers from harmful, inappropriate marketing strategies and practices by baby food manufacturers and distributors. Adopting such measures must be recognized as part of Member States’ core obligations under the Convention on the Rights of the Child and other relevant United Nations (UN) human rights instruments to respect, protect and fulfil children’s right to life, survival and development; their right to safe and nutritious foods; their right to enjoyment of the highest attainable standard of health; and to ensure that women’s rights are protected from harmful interference by non-state actors, in particular the business sector (8).

Exclusive breastfeeding for the first 6 months and continued breastfeeding for 2 years have major benefits on child health, growth and development by preventing many short- and long-term diseases, as well as affecting the economy of nations by having an impact on intelligence, educational attainment and income later in life (9,10). Despite the many benefits of breastfeeding for both the mother and child, and the numerous global commitments to promote and support breastfeeding, prevalence of the practice remains low, with wealthier countries having lower breastfeeding rates than middle- and low-income countries. Only an estimated 1 in 3 infants aged 50% exclusive breastfeeding (14).

In spite of clear messages on the importance of breastfeeding, global sales of breast-milk substitutes continue to grow at a rapid pace. Sales of breast-milk substitutes totalled US$ 44.8 billion in 2014 (15), and this number is expected to rise to US$ 70.6 billion by 2019 (2).

The marketing of breast-milk substitutes presents one of the biggest challenges to breastfeeding. The recently established Global Network for Monitoring and Support for Implementation of the Code (NetCode), coordinated by WHO and UN Children’s Fund (UNICEF), provides a timely opportunity to forge and strengthen alliances in support of Code implementation. However, challenges to implementation of the Code still exist, with fewer countries in the developed world than in poor and developing countries having fully implemented the Code. This study sought, therefore, to assess the status of implementation of the Code in the Region. Implementation of the Code is the responsibility of governments (in coordination with healthcare professionals, academia, and nongovernmental and consumer organizations) who can adopt legislation, regulations or measures to protect, promote and support breastfeeding. The information generated will inform policy-makers at national and regional level about the need to focus more efforts to achieve more effective Code implementation.

Methods

The assessment was conducted in all 22 Member States of the Eastern Mediterranean Region using the WHO Module 3: International Code of Marketing of Breast-milk Substitutes and subsequent World Health Assembly resolutions questionnaire, which was translated into Arabic to suit the Arabic-speaking countries; while the original version was used by non-Arabic-speaking countries. The questionnaire captures key information and data on the status of implementation of the Code in each country.

Data collection

Data were collected using the Module 3 questionnaire by the national nutrition focal persons in all 22 Member States of the Region. All parts of the questionnaire were completed and sent back to the Regional Adviser for Nutrition. The contact information of the person who provided the responses for each module was included, to facilitate follow-up and verification of the information. The nutrition focal persons worked with the relevant departments in the ministries of health, such as legal, nutrition, and maternal and child health, to complete the entire questionnaire. A follow-up teleconference with the nutrition focal persons took place to clarify the information provided. A literature review for electronic copies of legislative documents was obtained from International Baby Food Action Network/International Code Documentation Centre (IBFAN/ICDC) files, e-Library of Evidence for Nutrition Actions (eLENA), internet search engines and government gazettes. It was noted from the literature review that there were no published studies at regional levels of this kind.

Data analysis

The laws of Egypt, Iraq, Jordan and Sudan were translated from Arabic to English by the WHO Regional Office for the Eastern Mediterranean, so that they could easily be compared with the Code on an article-by-article basis. Screening of all national legislation, codes, decrees and policies gathered from all countries in the Region was reviewed by the researcher and compared with the Code articles using spreadsheets.

Results

History of Code implementation in the Eastern Mediterranean Region

Following the adoption of the Code in 1981, a number of World Health Assembly resolutions have clarified or extended certain provisions of the Code every other year (odd years). The first country in the Region to have national legislation was Tunisia (1983), followed by Egypt (1994), Bahrain and Islamic Republic of Iran (1995), Oman (1998), Syrian Arab Republic (2000), Pakistan and Yemen (2002), Saudi Arabia (2004), Sudan (2005), Afghanistan and Jordan (2009), Djibouti (2010), Lebanon and Occupied Palestinian Territories (2011), Kuwait (2014) and Iraq (2015).

Legislative status

Seventeen of the 22 countries in the Region have enacted legislation to protect breastfeeding. Only Afghanistan, Bahrain, Kuwait, Lebanon, Pakistan and Yemen have comprehensive legislation or other legal measures reflecting all or most provisions of the Code. Egypt, Jordan, Saudi Arabia and Syrian Arab Republic have legal measures incorporating many provisions of the Code. Djibouti, Islamic Republic of Iran, Iraq, Occupied Palestinian Territories, Oman, Sudan and Tunisia have legal measures that contain a few provisions. Libya, Morocco, Qatar and UAE are currently studying the issue, and Somalia has no measures in place.

Coverage of Code articles in national legislation

There is considerable variation in the content of specific provisions contained in national legal measures. Most countries in the Region were guided by the Code in the drafting of their national laws and, as a result, reflected many of the Code articles in their legislation (Figure 1). Notably, there was 100% coverage of the 11 Code articles in the national legislation of Afghanistan, Egypt, Jordan, Kuwait and Lebanon. Bahrain, Pakistan, Saudi Arabia and Syrian Arab Republic incorporated 10 of the Code articles in their national legislation. Other countries such as Djibouti, Islamic Republic of Iran, Iraq, Oman and Tunisia had considerably lower coverage of the Code articles in their legislation.

Among the 17 countries implementing the Code, 12 stated the aim of the Code clearly in their national legislation (Table 1). Of those countries with specified age ranges for designated products, only 13 explicitly set out the scope of the Code in detail and mentioned the age limit of products under the scope of the Code. However, the age limit of milk products intended and marketed as suitable for feeding young children varied considerably between national legislations; ranging from 0–4 to 0–36 months (Table 2). This variation reflected differences in countries’ understanding of the scope of the Code. This is particularly important given the tactics of companies to promote infant formulae for children aged > 1 year; products that WHO guidance considers to be breast-milk substitutes that should be covered by Code-implementing legislation (12). The articles about definitions, information and education were present in 14 national legislations (Table 1). Although the Code contains clear and direct guidance on banning promotion to the general public and prohibiting manufacturers and distributors from seeking direct contact with pregnant women and mothers, and giving financial or material inducements to health workers or members of their families to promote designated products, only 13 national legislations had banned this promotion. Completely prohibiting free samples or low-cost supplies for health services was stated in 15 national legislations. Fifteen countries required labels of designated products to include messages on the recommended age for introduction, need for medical advice on the product, and need for appropriate preparation and use. Articles about the necessity for all products to be of high quality and take account of the climate and storage conditions of the country where they are used were stated in 12 national legislations. Only 10 countries had legal provisions that facilitate the establishment of a formal monitoring and enforcement mechanism. Afghanistan, Egypt, Jordan, Kuwait and Lebanon had articles about duties of persons employed by manufacturers and distributors. This low level of implementation of specific Code articles means that countries have not fully translated the Code into their domestic legislation, and are therefore, not fully protecting breastfeeding and optimal infant feeding, as national legislation should go beyond the minimum standard set by the Code.

Comparison of number of articles and words in national legislation and the Code

The national laws in Bahrain, Islamic Republic of Iran, Iraq, Oman, Occupied Palestinian Territories and Tunisia had less than half the number of words of the Code (Figure 2). The national legislations of Afghanistan, Djibouti, Lebanon, Saudi Arabia and Yemen had more than double the number of articles of the Code (Figure 3). Although the length of the Code has no direct relationship with its applicability and effectiveness, it is imperative for countries to follow the Code as a minimum standard when enacting laws, as countries that implemented shorter legislation did not cover all the provisions of the Code.

Discussion and recommendations

1. The development of national legislation to regulate the marketing of breast-milk substitutes is a key component of a comprehensive strategy to protect, promote and support breastfeeding in the Eastern Mediterranean Region. Although 17 countries in the Region have taken some action to implement the Code, monitoring and enforcement are still inadequate, particularly in countries where both laws and legal systems are weak. Many of the national legislations were enacted many years ago and it is therefore imperative for countries to update and amend existing legislation following the World Health Assembly resolutions. However, national laws that do not support implementation of the Code in its entirety have allowed inappropriate marketing practices to prevail. Only effective national legislation, properly enforced, can prevent artificial feeding, which is vastly inferior, from competing unfairly with breastfeeding (11). The results indicate that all countries in the Region, except Somalia, due to long internal conflict and weak government, have been working hard to protect breastfeeding by developing and updating laws and regulations following the Code. However, Member States are urged to implement the Code (11) in its entirety and subsequent relevant World Health Assembly resolutions by developing, enacting and enforcing national laws, regulations or other appropriate measures covering all provisions in the Code, and scaling up efforts to monitor and enforce its implementation. WHO recommends that all infants should be exclusively breastfed for the first 6 months. However, it is estimated that this practice is followed for only 32% of infants in the Region (11). Only about half of children aged 20–23 months are breastfed despite the recommendation that breastfeeding should continue for up to 2 years of age or beyond. The global breast-milk substitutes market exceeds US$ 44.8 billion per annum, and is expected to rise to US$ 70.6 billion by 2019 (12). The total absence or presence of weak legislation to protect and promote breastfeeding, along with strong sociocultural beliefs or taboos and powerful marketing strategies of companies manufacturing breast-milk substitutes hamper efforts to promote breastfeeding. The Code and subsequent relevant World Health Assembly resolutions are vital tools to regulate and reduce inappropriate marketing. To enforce implementation of the Code in the Region, Member States are urged to generate more support from influential policy-makers, nongovernmental organizations and civil society at different levels in each country to: (a) amend, strengthen and enforce existing partial Code-related legislation to ensure that all Code provisions and recommendations and subsequent relevant World Health Assembly resolutions are incorporated; (b) urge countries that have been studying but have not yet adopted legal measures to finalize national legislation; and (c) form partnerships, political participations, advocacy and monitoring mechanisms to reinforce implementation and enactment of legislation in countries that lack it.

2. Allocate national and international resources for legislation, monitoring and enforcement.

3. Parliamentarians and policy makers must be sensitized to the importance of Code monitoring and enforcement, and to their specific roles and support, including legislating for the Code, budgetary review, approval and oversight, and political advocacy with constituents.

4. Establish systematic monitoring and reporting mechanisms to support the implementation, monitoring and enforcement of legislation on the Code.

5. Train decision-makers, healthcare providers and relevant officials on the specifics of the Code and its monitoring. This will enhance enactment of the right laws, effective monitoring, and reporting in case of violations.

6. Work on national implementation and revival of the Baby-Friendly Hospitals Initiative to support implementation of the Code in healthcare facilities.

7. A critical mass of civil society organizations is necessary to engage and influence enactment of the proper laws and make amendments in existing laws to address salient issues impeding Code implementation and enforcement.

8. Countries must scale up their efforts to monitor and enforce national legal measures through strong, sustainable multisectoral processes and mechanisms, in particular: (a) funding for monitoring bodies and their activities should be incorporated into relevant national budgeting processes, so as to ensure sustainability; (b) countries should increase capacity for monitoring among designated staff at subnational levels; (c) funding for monitoring bodies and their activities should be incorporated into relevant national budgeting processes, so as to ensure sustainability; and (d) countries should increase capacity for monitoring among designated staff at subnational levels.

9. Technical and legal assistance must be made available to countries through collaborative and coordinated efforts, so as to pool available external expertise and avoid fragmentation. Partnerships among UN agencies and organizations, nongovernmental organizations and other relevant partners must be strengthened, while recognizing the need to avoid conflicts of interest. In this context, the recently established Global Network for Monitoring and Support for Implementation of the Code (NetCode), coordinated by WHO and UNICEF, provides a timely opportunity to forge and strengthen alliances in support of Code implementation in the Region.

Funding: None.

Competing interests: None declared.

Mise en œuvre du Code international de commercialisation des substituts du lait maternel dans la Région de la Méditerranée orientale

Résumé

Contexte : Des pratiques d’allaitement optimales et une alimentation complémentaire appropriée améliorent la santé de l’enfant, ses chances de survie ainsi que son développement. Les pays de la Région de la Méditerranée orientale ont réalisé d’importants progrès dans la formulation et l’application des législations afin de protéger et de promouvoir l’allaitement maternel sur la base du Code international de commercialisation des substituts du lait maternel (le Code) ainsi que des résolutions pertinentes ultérieures de l’Assemblée mondiale de la Santé.

Objectif : Évaluer la mise en œuvre du Code dans la Région.

Méthodologie : L’évaluation a été conduite par le Bureau régional de l’OMS pour la Méditerranée orientale sur la base d’un questionnaire standard de l’OMS. Les données issues des questionnaires et de l’étude approfondie du contenu des codes et réglementations nationaux ont été recueillies et analysées.

Résultats : Dix-sept pays de la Région ont adopté une législation visant à protéger l’allaitement maternel. Seuls six pays possèdent une législation complète ou d’autres mesures juridiques reflétant l’ensemble ou la plupart des dispositions du Code ; quatre pays disposent de mesures juridiques incluant un nombre important de dispositions du Code ; sept pays disposent de mesures juridiques contenant quelques dispositions du Code ; quatre pays étudient actuellement la question ; et seulement un pays n’a mis aucune mesure en place. Une analyse plus poussée de la législation a révélé que les articles des lois ne se conformaient pleinement aux articles du Code que dans six pays.

Conclusions : La plupart des pays doivent revisiter et modifier leur législation nationale actuelle afin de mettre pleinement en œuvre le Code et les résolutions pertinentes de l’Assemblée mondiale de la Santé, avec l’appui du suivi et de la notification systématiques.

تطبيق أحكام المدونة الدولية لتسويق بدائل لبن الأم في إقليم شرق المتوسط

أيوب الجوالده، غادة سيد

الخلاصة

الخلفية: تؤدي ممارسات الرضاعة الطبيعية المثلى والتغذية التكميلية الملائمة إلى تحسين صحة الطفل وبقائه ونمائه. وقد قطعت بلدان إقليم شرق المتوسط شوطاً كبيراً في صوغ وتنفيذ التشريعات المتعلقة بحماية وتعزيز الرضاعة الطبيعية استناداً إلى أحكام المدوّنة الدولية لتسويق بدائل لبن الأم (المدوّنة) وقرارات جمعية الصحة العالمية اللاحقة ذات الصلة.

الهدف: تهدف هذه الدراسة إلى تقييم تطبيق أحكام المدونة في إقليم شرق المتوسط.

منهجية البحث: أجرى المكتب الإقليمي لمنظمة الصحة العالمية لشرق المتوسط التقييم باستخدم استبيان منظمة الصحة العالمية المعياري. وتم جمع وتحليل البيانات المستمدة من الاستبيانات ومن دراسة معمّقة لمحتوى المدونات واللوائح الوطنية.

النتائج: عمد سبعة عشر بلداً في الإقليم إلى سن تشريعات لحماية الرضاعة الطبيعية. وتبيّن أن 6 بلدان فقط تطبق تشريعات شاملة أو تدابير قانونية أخرى تحتوي على جميع أو معظم أحكام المدونة؛ وتطبّق 4 بلدان تدابير قانونية تحتوي على كثير من أحكام المدونة؛ و7 بلدان لديها اجراءات قانونية تحتوي على بعض أحكام المدونة؛ وأن 4 بلدان بصدد دراسة المسألة في الوقت الحالي؛ وأن بلداً واحداً فقط لا يطبق أي تدابير. وأثبت إجراء تحليل إضافي للتشريعات أن عدد البلدان التي أوردت في مواد تشريعاتها جميع مواد “المدونة” في تشريعاتها لم يتجاوز 6 بلدان.

الاستنتاجات: تحتاج معظم البلدان إلى إعادة النظر في تشريعاتها الوطنية الحالية أو تعديلها لتنفيذ أحكام المدونة وقرارات جمعية الصحة العالمية ذات الصلة تنفيذاً تاماً، مدعومةً في ذلك بعملية منهجية للرصد والإبلاغ.

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