What is the WHO Code?
The WHO Code is the abbreviated name for the International Code of Marketing Breastmilk Substitutes developed in 1981 by the General Assembly of the World Health Organization, following consultation with key stakeholders, including governments and infant food manufacturers. In subsequent years additional World Health Assembly resolutions have further defined and strengthened the Code.
The aim of the WHO Code is:
To contribute to the provision of safe and adequate nutrition for infants, by the protection and promotion of breastfeeding, and by ensuring the proper use of breastmilk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution.
The main elements of the WHO Code are as follows:
- There should be no advertising or other promotion to the general public of products within the scope of the Code; ie, breastmilk substitutes (including infant formula and complementary foods), bottles or teats
- Health facilities and health professionals do not have a role in promoting breastmilk substitutes
- Free samples of breastmilk substitutes or items that promote breastmilk substitutes should not be provided to pregnant women, new mothers, or health facilities
- Health risks to infants who are artificially fed, or who are not exclusively breastfed, should be highlighted through appropriate warnings and labelling
- Labelling of breastmilk substitutes should contain instructions on how to use the product to minimise the risks of use.
- Pictures or text that idealise the use of breastmilk substitutes should not be used.
It is important to note that the WHO Code is not “anti-formula”. The Code recognises that breastmilk substitutes have a legitimate role to play in circumstances where a child is not breastfed and cannot access expressed or donor breastmilk. What the Code aims to do is protect the community from irresponsible and biased marketing of breastmilk substitutes; marketing that has the potential to seriously undermine the role of breastfeeding globally. It also recognises that inappropriate feeding practices lead to infant malnutrition, morbidity and mortality in all countries.
The World Health Organisation website provides a full copy of the WHO Code, along with subsequent resolutions of the World Health Assembly which clarify aspects of the Code.
The WHO Code, on its own, is not legally enforceable. The Code itself states that governments should take action to give effect to the principles and aims of the Code, including the implementation of legislation.
Over 70% of countries have taken some action to implement the WHO Code. For example:
- In Iran, the Government now controls the importation and sale of breastmilk substitutes. Formula is available only by prescription, and the tins must carry a generic label; no brand names, pictures or promotional messages are allowed.
- In Brazil, all advertising and promotion of breastmilk substitutes for children up to 2 years of age is prohibited and prominent health warnings are required on all breastmilk substitutes, feeding bottles and teats.
- In Papua New Guinea, the sale of feeding bottles, cups, teats and dummies is strictly controlled, and there is a ban on advertising these products as well as breastmilk substitutes.
So what is the position in Australia?
Marketing in Australia of Infant Formula
The Marketing in Australia of Infant Formulas (MAIF) Agreement is Australia’s response to the WHO Code. The MAIF Agreement is a self-regulatory agreement between infant formula manufacturers and importers who are signatories to the Agreement. The Agreement is overseen by the Department of Health and Ageing who appoints and administers an Advisory Panel (APMAIF) to deal with complaints.
The MAIF Agreement has a much narrower scope than the WHO code. For example, it doesn’t cover bottles or teats, retailers or pharmacists and it only covers infant formula for babies under 12 months.
In addition, the MAIF Agreement is not legally binding and the only sanction applied to signatories that breach the Agreement is to be named in the APMAIF Annual Report.
The following activities would be in breach of the MAIF Agreement:
- Television or print advertisements for infant formula (under 12 months) that are produced and paid for by an infant formula manufacturer
- Provision of free samples of infant formula (under 12 months) by manufacturers or importers to the general public
- A manufacturer offering money or gifts to health care professionals.
The following are examples of activities that do not constitute breaches of the MAIF Agreement:
- Any activity by an infant formula manufacturer or importer that is not a signatory to the MAIF Agreement
- Advertisements for infant formula by a retailer - for example in a supermarket catalogue or on television
- The promotion of infant feeding bottles or teats by anyone, anywhere
- Television advertisements, produced and paid for by an infant formula manufacturer, for ‘toddler milk’
- Distribution of brochures to health professionals containing information about specific infant formula products
Thus, the widespread advertising and marketing of many breastmilk substitutes, including toddler formulas, solids, bottles and teats, can legitimately continue under the MAIF agreement.
There are some areas that have not been considered breaches in the past, for example, infant formula manufacturers offering inducements such as entertaining health professionals. However, these potential breaches are considered by APMAIF on a case by case basis and recently a company was held to be in breach for an inducement (see the APMAIF Annual Report 2009-10). Companies continue to sponsor health professional meetings and conferences.
The distribution of samples of infant formula to health professionals and other areas of concern are monitored by APMAIF. There will always be emerging issues in a changing world, such as social networking and websites, and MAIF Agreement clauses are open to interpretation. The role of APMAIF is to keep up with these changes and ensure that the Agreement is not breached.
However, the narrow scope of the MAIF Agreement and its voluntary nature means that it is not an adequate protection for breastfeeding in Australia.
More information on the MAIF agreement is available from the Department of Health and Ageing.
What can you do?
The MAIF Agreement
Individuals, as well as ABA members and volunteers, are able to lodge a complaint with the secretariat for the Advisory Panel on the Marketing in Australia of Infant Formula. If you think there has been a breach of the MAIF agreement, you can:
If you receive a letter stating that your complaint is out of scope of the Agreement or that the company is not in breach of the MAIF Agreement, do not be discouraged. Statistics are kept on all complaints handled by the secretariat and these are used to inform the Minister of the types of concerns that people have. They will also used for future reviews of the Agreement.
You can also send a copy of your original complaint and the reply to your local Federal member with a letter telling them that you are unhappy with the inadequacy of Australia’s implementation of the WHO Code. You can ask him or her to request the Health Minister to seek to legislate the full WHO Code.
Implementing the WHO Code in full
Breastmilk substitutes have a legitimate role to play in circumstances where a child is not breastfed and cannot access expressed or donor breastmilk. However, inappropriate formula promotion and early introduction of solid foods undermines breastfeeding which is why the WHO Code came into effect. The Australian Breastfeeding Association stills upholds an expectation that the protective measures afforded by the WHO Code would be implemented in full. The Australian National Breastfeeding Strategy 2010-2015 notes:
“The Best Start inquiry recommended the Australian Government adopt in full the WHO’s International Code of Marketing of Breast-milk Substitutes and subsequent WHA resolutions (HoR 2007). The Australian Government’s response to the inquiry noted the recommendation and stated that the Australian Government would consider Australia’s response to the WHO Code in the context of developing an Australian National Breastfeeding Strategy. This will be progressed under the implementation plan and governance arrangements for the Australian National Breastfeeding Strategy and with respect to the development of the infant formula policy guidelines and revision of the Infant Feeding Guidelines for Health Workers” (p 26).
The Australian Breastfeeding Association asks the Australian Government to progress this by replacing the MAIF Agreement with the full implementation of the WHO Code. Australian mothers, babies and families deserve supportive environments to enable the optimal nourishment of their children.
Australian food exporters and food aid agencies are also called upon to ensure they don’t act in a way that contravenes the WHO Code. The Australian Government has the power to suspend or remove export licences for companies that do not meet Australian expectations of behaviour. This is an area which is worthy of more focussed attention.
Health Professionals and the WHO Code
The Baby Friendly Hospital Initiative has made A guide for health workers to working within the International Code of Marketing of Breastmilk Substitutes. This document guides health professionals on all the forms of professional interactions with formula companies.