Violations of the International Code of Marketing of Breastmilk Substitutes (WHO Code) in two Ecuadorian cities

Assessing Compliance: Violations of WHO Code in Breast Milk Substitute Marketing, Ecuador

Breast milk substitute (BMS) marketing significantly influences global infant feeding practices. Ecuador, like many countries, seeks to regulate these promotions under the WHO's International Code of Marketing of Breast-Milk Substitutes. This cross-sectional analysis assessed BMS marketing compliance with WHO's Code in Ecuador. Surveys were conducted with mothers (n = 330) and healthcare professionals (n = 66), complemented by observations at health facilities (n = 33) and retail outlets (n = 44). Media monitoring and product labelling evaluations were also conducted. The study revealed widespread exposure to BMS marketing outside health facilities (91.21% of mothers). Promotional activities targeted healthcare professionals, with significant interactions involving free supplies (26.09%) and gifts (21.74%). Retail outlets prominently displayed BMS promotions, often featuring discounts (95%). Compliance with labelling criteria was notably low, particularly concerning nutrition and health claims (39%). TV emerged as the dominant platform for BMS advertising, with 2884 ads aired over 16 h and 24 min, totalling $1,876,915.50 in expenditures. Digital platforms also featured BMS ads, with significant engagement on social media (533,845 interactions). This study reveals widespread violations of the WHO Code in Ecuador, emphasizing the need for stronger regulations and targeted education for healthcare professionals and the public to protect infant health and promote breastfeeding. Despite existing regulations, the pervasive advertising and substantial investment in BMS marketing across various media underscore significant enforcement gaps. To effectively safeguard maternal and child health, Ecuador must fully incorporate and rigorously enforce all Code recommendations within its national legislation.

Outcomes of implementing the International Code of Marketing of Breast-milk Substitutes as national laws: a systematic review

BACKGROUND

The International Code of Marketing of Breast-milk Substitutes, or 'the Code,' sets standards to regulate marketing of commercial milk formula (CMF) to protect breastfeeding. World Health Organization member states are advised to legislate the Code into national law, but understanding of its implementation outcomes is limited. This systematic review aimed to examine implementation outcomes in countries implementing the Code as national law.

METHODS

We systematically searched five academic databases in September 2022 for articles published in English from 1982 to 2022. We double-screened titles/abstracts and then full texts for eligible articles reporting implementation outcomes of the Code in 144 eligible countries. We used the Mixed Methods Appraisal Tool for quality assessment and synthesized data thematically. We applied the Proctor et al. framework to guide synthesis of implementation outcomes, organizing our findings according to its taxonomy.

RESULTS

We included 60 eligible articles of the 12,075 screened, spanning 28 countries. Fifty-seven articles focused on legal compliance, 5 on acceptability, and 1 on feasibility. Compliance was assessed across multiple sources, including mothers, health workers, media, points of sale, and product labels. Maternal exposure to CMF promotion remained widespread, with reports of mothers receiving free samples and coupons, and encountering media advertisements. Compliance of health workers varied across countries, with many reporting contact with CMF companies despite legal prohibitions. Public hospitals generally showed better adherence to the national law than private ones. While implementing the Code as national law effectively regulated the promotion of CMF for infants aged 0-12 months in public settings and in the media, it remains insufficient in addressing the promotion of unregulated products like growing-up milk, which are often marketed through emerging strategies such as cross-promotion and digital advertising. Point-of-sales compliance was inconsistent, with many countries reporting non-compliant price-related promotions.

CONCLUSION

To enhance legal compliance, robust monitoring and reporting systems are necessary. Utilizing technology-assisted solutions for monitoring compliance can be an option for countries with limited human resources. Adequate training for health workers and communication strategies targeting shop managers about national law are also essential in enhancing their acceptability and compliance.

Effect of baby food marketing exposure on infant and young child feeding regimes in Bangkok, Thailand

Background

Baby food marketing undermines breastfeeding by influencing women’s attitudes and decision-making favourably toward commercial baby food. This study aimed to explore the effects of various baby food marketing techniques on Thai mothers’ opinions about commercial milk formulas (CMF) and commercial complementary foods (CCF) and their infant and young child feeding behaviours.

Methods

This study used a cross-sectional survey employing the World Health Organization (WHO) NetCode Toolkit Protocol for Periodic Assessment, and the United Nations International Children’s Emergency Fund (UNICEF) Multiple Indicator Cluster Survey to collect data on mothers’ experience with and their opinion on the various types of marketing of CMF and CCF, and their feeding behaviour. Data collection used structured interviews of mothers with children aged two years or below attending 33 health facilities in Bangkok. Univariable and multivariable regression analysis then investigated links between mothers’ reported exposure to baby food marketing and their infant and young child feeding behaviours, employing a semantic scale and considering key sociodemographic and other variables.

Results

Three hundred and thirty mothers were surveyed in Bangkok. Around 90% reported experiencing exposure to at least one type of baby food marketing during the previous six months, mostly from electronic media. More than half of the women had positive opinions of CMF. Virtually all children had been breastfed initially, but 74.6% were given CMF and 72.8% stopped breastfeeding before six months. Multivariable analysis showed that mothers who lived in a couple were significantly less likely to favour CMF, and mothers in middle-income households and those who had received advice about CMF from others were more likely to have a favourable opinion. Mothers in formal employment were over six times more likely to feed formula than those not in employment. Women who experienced baby food marketing at health facilities were four times more likely to feed CMF to their children than those not experiencing such marketing.

Conclusions

Specific types of baby food marketing were strongly linked to mothers’ opinions on and use of CMF in Bangkok, Thailand. It is recommended that breastfeeding policies in health facilities and employment are fully implemented and enforced.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-022-00503-7.

Regulation of baby food marketing in Thailand: a NetCode analysis

OBJECTIVE

To report on the prevalence of different types of breast-milk substitutes (BMS) marketing and the compliance of such marketing with the 'Control of Marketing of Infant and Young Child Food Act 2017' (The Act) and the 'International Code of Marketing of Breast-milk Substitutes (WHO Code)' in Thailand.

DESIGN

Cross-sectional quantitative study, guided by the WHO/UNICEF NetCode Periodic Assessment Protocol.

SETTING

Health facilities and retail outlets in Bangkok, Thai media.

PARTICIPANTS

Mothers of 0-2-year-old children, health professionals, promotions at retail outlets and health facilities, product labels, marketing on television and the internet.

RESULTS

Marketing to mothers was highly prevalent, mostly from electronic or digital media, while BMS companies provided items to health professionals to distribute to mothers. Promotional materials in health facilities displayed company brands or logos. At retail outlets, most promotions were price-related. Approximately two-fifths of labels contained nutrition or health claims. Television marketing was growing-up-milk (GUM) advertisements, while internet promotions were varied from price-related materials to product reviews. Most instances of non-compliant BMS marketing with the Act were advertisements to mothers, and most were infant formula. Most non-compliant BMS marketing with the WHO Code was mainly concerned GUM, which are not covered by the Act and appeared in the media.

CONCLUSIONS

BMS marketing does not fully comply with the Act or the WHO Code. The Thai government should conduct regular monitoring and enforcement activities, educate health professionals, and strengthen the Act's provisions on the media and GUM to fully align with the WHO Code.

Global evidence of persistent violations of the International Code of Marketing of Breast-milk Substitutes: A systematic scoping review

The influence of marketing on infant and young child feeding and health is well recognized, and an International Code was adopted by the World Health Assembly (WHA) in 1981 to reduce inappropriate marketing and protect breastfeeding. Yet the marketing and influencing continue. This scoping review systematically examined the published research evidence on the nature and extent of exposure to International Code violations from 1981 to August 2021. We used several search strategies involving multi-language databases, organization websites, citation tracking, and expert consultation, to find research items meeting our inclusion criteria. We evaluated 657 items and retained 153 studies from at least 95 countries in the review. The majority of the studies (n = 113) documenting exposure to inappropriate marketing were published since 2010. Studies reported a broad range of marketing violations targeting mothers and families, health workers, and the general public. Marketing via digital platforms and brand extension has become more frequent. The evidence shows the use of misleading and inaccurate labeling and health and nutrition claims in breach of the Code. Our review confirms that violations of the Code have not ceased and calls for renewed attention from the WHA and national governments to protect the health of children and their mothers.