April 16th, 2010 • Comments: 0 • by Wendy • ResourcesWHO Code

A Summary of the WHO Code (including WHERE, WHAT, WHEN and HOW)


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A Summary of the WHO Code
(International Code of Marketing of Breastmilk Substitutes)
World Health Organization (WHO)
Geneva, Switzerland, 1981, 1986, 1994, 1996, 2001

Para leer este artículo en español, haga clic aquí por favor.

Have you heard of “The Code”, aka “The WHO Code” aka “The International Code of Marketing of Breastmilk Substitutes”?  If the answer to that question is “yes”, do you know what the WHO Code says?  Could you explain it to someone?

Many people, even mothers, even breastfeeding mothers, cannot, so here is our explanation of the code.  Psst!  This is really important, so pass it on!

The WHO Code includes the below 14 important provisions (let’s see how many infractions we can find in our daily travels shall we?).  Why are there so many infractions?  Well, because in North America, The WHO Code is voluntary – and thus it has no teeth.  Some countries, such as Iran, have adopted The Code as law and now infant formula is available ONLY by prescription and comes in a can with a generic label.  I sure would like to see that day in both Canada and the US I tell ya!

Oh, and one more thing… did you know that the USA was the ONLY country out of 189 that voted “NO” to adopt The Code in 1981?  SHAME.ON.YOU!  Let’s kick those formula company dudes OUT of the government’s bed NOW.

Here we go…baby bottle

1. No advertising of products under the scope of the Code to the public.

Products “under the scope of the code” include breastmilk substitutes, including infant formula; other milk products, food and beverages, including bottle-fed complimentary foods, when marketed or otherwise represented to be suitable, with or without modification, for use as a partial or total replacement of breastmilk; feeding bottles and teats.  So basically, infant formula, follow-up formula, bottles and nipples.  Nope, I’ve never seen these types of products advertised publicly ANYwhere (eye roll).

2. No free samples to mothers.

How many new moms (including yours truly) have been given free samples at the hospital, in their doctor’s office, at a “baby/pregnancy” fair, even through the Welcome Wagon?  According to a recent CDC study, nearly 2/3 of first-time mothers received a free sample of infant formula in the mail.  The formula companies will market directly to moms, against The Code, every.chance.they.get.

3. No promotion of products in health care facilities, including the distribution of free or low-cost supplies.

Have you seen pads of note paper or posters “sponsored” by a formula company at your doctor’s office or hospital?  How about the infamous formula company diaper bags given out at so many US hospitals? (read about it at Ban the Bags).  In fact, studies show that formula marketing bags shorten exclusive breastfeeding duration, even when the formula samples are removed from the bags.  To quote Dr. Alison Stuebe, the woman behind Ban the Bags, “No for-profit company gives anything away for “free”.  Formula companies give these bags to mothers as a marketing tool and their goal is to have the hospitals actually hand the bags to the moms because that implies that the hospital is endorsing a particular brand of formula.  If this wasn’t going to sell more of a particular brand of formula, it would be against the interest of the shareholders of these companies to let women have these bags.”

In fact, according to a recently-released Canadian study from the Toronto Department of Public Health, “Of 1,500 first-time mothers surveyed, 39 per cent were given formula at hospital discharge.   As a result, many of these women stopped breastfeeding sooner than those women who weren’t given formula.  Women who didn’t receive the free samples were 3.5 times more likely to be breastfeeding exclusively after 2 weeks.”

“The impact of promoting formula as they leave the hospital gives off mixed messages to new mothers”, says Linda Young, director of maternal newborn and child health at Toronto East General Hospital.  “They give it to the women ‘just in case’,” she said.  “But the real message is that you will probably fail... and one bottle leads to another.”

Listen ladies, by accepting this “formula company swag”, you are lining the formula companies’ pockets AND more importantly sabotaging yourself. Just.Don’t.Do.It.

4. No company representatives to advise mothers.infant formula

Last summer, I participated as a vendor in a baby fair.  Our table was located about ½-way around the perimeter of the venue.  To the immediate right of the entrance door (like that wasn’t planned) was a formula company’s table.  They were giving out FULL CANS OF FORMULA!  Every person who came by our table had the bag that they were given upon entry to the fair with a can of formula sticking out the top.   I took off my badge and went by their table, posing as a consumer.  I asked about the cans of formula.   Boy were they friendly! They told me that all I had to do was to sign-up for their “program” and I would get the kit which included the can of formula (I can’t remember what they called it – something obnoxious though, like “breastfeeding support kit”, because what I do remember is cringing to myself).  Signing-up for the program included handing over my email addy (of course).  Yup, that’s right! Get the mom-to-be on your mailing list so you can inundate her with emails right after she has her baby, when she is sleep-deprived, vulnerable and in a hormone-induced, emotional state.  And make sure she has a big can of your formula in the cupboard so that when the going gets tough around 4-5 weeks and she is wavering with the whole breastfeeding gig, it is there at the ready to taunt her!  These companies undermine women’s confidence by making them think they won’t be able to breastfeed and then guess what? That notion manifests and they cave.  Don’t listen to anyone that tells you, “One bottle of formula won’t hurt your baby.”, (even if it is your own mother).  Perhaps it won’t hurt your baby, but it will hurt the breastfeeding relationship you have with your baby and it will hurt your supply.  Trust me, it happened to me, “way back when” before I knew any better.

Today, I know to ask whether a consumer baby fair complies with The Code BEFORE I sign any contracts to participate as a vendor.  Not.Going.There.Ever.Again.

5. No gifts or personal samples to health care workers.

Please see #3.  This practice is rampant.  You can find extensive and truly interesting information about it here, here and here (and that was just a quick Google search).  It is high time health care workers AND HOSPITALS told the formula companies to go away, no thank you to your freebies and don’t come back. EVER!

“There has always been controversy about hospitals receiving free formula.  It is why Toronto East General Hospital – the only Baby Friendly hospital in the city and among about two dozen in (Canada) – cancelled its contract in 2005”, said Linda Young, director of Maternal Newborn and Child Health.

“When the formula companies put together a contract, they list all the things that they give – the formula, the nipples, and the bottles, and it comes up to a big number,” Young said, adding there is sometimes a signing bonus of anywhere between $130,000 and $150,000 which hospitals can use for other programs and services.

The only other GTA hospital that Young knows of that is buying formula instead of getting it free is Lakeridge in Oshawa.  “Any kind of money is hard to give up for a hospital,” she said.

6. No words or pictures idealizing artificial feeding, including pictures of infants, on the labels of the products.

OK, so “most” of the formula companies have switched to little duckies, bunnies or hearts on their labels in lieu of baby images, however, there are still many infractions.  For example, Enfamil’s Enfagrow Premium Next Step Lipil has an image of a baby and a toddler on the label and is marketed towards 9-24 month olds.   Of course aside from images, the infant formula labels are chock-full of skewed half-truths, scientific-sounding jargon and warm & fuzziness that the formula companies are hoping will be (mis)interpreted as idealizing artificial feeding.  Believe you me, they spend plenty of time and money writing the copy “just so” to convince parents to buy.

7. Information to health workers should be scientific and factual.

The information coming out of the formula companies “looks all scientific and factual” but their claims are taken out of context, skewed and again, worded “just so” by their high-powered marketing departments to brainwash you into thinking their products are “as good” as breastmilk.

8. All information on artificial feeding, including the labels, should explain the benefits of breastfeeding and all costs and hazards associated with artificial feeding.

So I haven’t read an infant formula can for a while now, however, I do know that most formula companies include the disclaimer, in very small print, stating “breastmilk is best for your baby”.  But do they detail the costs and hazards associated with artificial feeding?  Hmmmm?

9. Unsuitable products such as sweetened condensed milk should not be promoted for babies.

OK, I’m at a loss on this one.  Are there people out there that give sweetened condensed milk to their babies?  So I Googled “sweetened condensed milk for babies” and got just 4 results, mostly blogs talking about “way back when” when our mothers or grandmothers did just that, or forums asking if they can do it now.  I guess it is safe to say that if there are people asking if they can do it now, then there are others that haven’t bothered to ask.

I do know that in 3rd world countries, where they often enjoy a strong breastfeeding culture, after the formula companies have given out enough free samples so that the new mother’s milk has dried-up, she, who can’t afford to buy more formula, may substitute (sweetened) condensed milk or other milk products to feed her starving baby.  She may also mix the formula with a higher ratio of water to make it last longer.  Oh and that would be mostly unsanitary water.  This practice by the formula companies has killed millions of babies. Yes. MILLIONS.25 cents

10. All products should be of a high quality and take account of the climatic and storage conditions of the country where they are used.

High quality? Riiiiight.  You know that $20-30 can of formula that you’ve seen on store shelves?   Well the contents are worth about a quarter.  Yes, that’s right.  Twenty.Five.Cents.[1]  The rest of the money is spent on marketing.  But wait! There is a CODE prohibiting the marketing of breastmilk substitutes.  How can formula companies be spending millions, perhaps billions on marketing when this is against The WHO Code?

Not to mention the 57 product recalls of artificial foods from 1982 to 2007 – that’s over 9 MILLION units.  Ahem… breastmilk is NEVER recalled.

11. Promote and support exclusive breastfeeding for six months as a global public health recommendation with continued breastfeeding for up to two years of age or beyond.

I think a good first step is to prohibit the marketing of formula to under 6 month old infants.  Just take it off the market.  Period.  For the 5% of woman that can’t physically breastfeed[2], they can get it by prescription.  Then let’s watch our breastfeeding initiation rates and the rates at 6 months postpartum rise meteorically.

The Best for Babes FoundationAs for the promotion and support, it is mind-boggling and heart-breaking to hear the countless stories from moms - the misinformation, the contradictions depending on who was working the ward that night, the lack of training in medical school and it goes on and on.  We are working on it though!  Organizations like Best for Babes, for example, are working tirelessly “to help moms beat the “Booby Traps” – the cultural & institutional barriers that prevent moms from achieving their personal breastfeeding goals.  To inspire, prepare & empower™ moms.  To give breastfeeding a makeover and give moms the solutions they need to make it work!”

12. Foster appropriate complementary feeding from the age of six months recognizing that any food or drink given before nutritionally required may interfere with breastfeeding.

It’s really quite simple: babies don’t need ANYTHING but breastmilk for the first 6 months of life.  From 6 months onward, it is recommended that you continue to breastfeed while providing nutritious complimentary foods for up to two years or beyond.

13. Complementary foods are not to be marketed in ways to undermine exclusive and sustained breastfeeding.

Just as infant formula is marketed to undermine exclusive and sustained breastfeeding, so are complementary foods.  Being aware is half the battle. Educate yourself and spread the word!

14. Financial assistance from the infant feeding industry may interfere with professionals’ unequivocal support for breastfeeding.

We all know that the formula companies are in bed with the government.  How else have such initiatives such as the 2004 “Babies Were Born to be Breastfed” public service ad campaign, launched by the US Department of Health and Human Services and the Ad Council, been kiboshed at the last minute by formula company lobbyists?  Yes, that’s right, they made them water-down the ads to the point that they were mostly ineffective, then turned around and doubled their marketing budget to $50 million. And breastfeeding rates went down again.

It is a sad state of affairs when profit and political gain are placed at an exponentially higher level of importance than the health of our own children.

Think about it.  Talk about it.  Do something about it.  Today.

Snugabell Mom & Baby Gear is PROUD to be a WHO Code compliant company and vows to never knowingly do business with any company that does not comply.  We are also dedicated to raising awareness of The Code and to educating others about its provisions.

If you weren't aware of the provisions of the WHO Code, will you now be watching for infractions?  Will you report them?  Please share!

[1]Testimony presented in infant formula antitrust litigation in the U.S. District Court for the Northern District of Florida, Tallahassee, June 2, 1992.

Some corroborating evidence about the cost of producing infant formula appears in an unpublished USDA study conducted by the Research Triangle Institute in Apr. 1992 (Josephine Mauskopf and Nancy Dean, “WIC Program Rebates: An Economic Analysis,” Final Report. Contract, # 53-3198-0-033, Task 6.1. Center for Economic Research) in which the cost of producing a can of infant formula was estimated on the basis of the ingredients that went into it. However, USDA officials expressed concerns about the validity of these cost estimates because of methodological limitations, including the unavailability of firsthand data on the procedure for manufacturing infant formula.

[2]Neifert et al. 1990. The influence of breast surgery, breast appearance, and pregnancy-induced breast changes on lactation sufficiency as measured by infant weight gain. Birth 17(1): 31-38

{"Baby Bottle Paraphernalia" by Shevon Desai is licensed under CC BY-NC-SA 2.0}

{"AI WEIWEI 艾未未 : BABY FORMULA 卑鄙处方" by choo chin nian is licensed under CC BY-SA 2.0}

{"235/365 Pocket Change" by Joe is licensed under CC BY-NC-ND 2.0}

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nia umar says:

As for number 9; there are still plenty of mothers in Indonesia whose giving their baby and kids condensed milk. Why? They don't breastfeed and they can't afford formula. Because until now, Indonesia didn't fully adopt the code. We still have you can check the breastfeeding situation at:
www.worldbreastfeedingtrendsinitiatives.com

Posted on April 17, 2010

Wendy Armbruster Bell says:

Thank you Nia for the clarification. Your link didn't work though.  I'm interested in finding out more, so if you could update that link that would be wonderful.

Posted on April 17, 2010

Michelle says:

What an excellent, easy to read summary - thanks

Posted on April 17, 2010

Wendy Armbruster Bell says:

Thanks Michelle. We hope it helps to inform the masses...

Posted on April 18, 2010

Diane Sam says:

Great article Wendy!

I'm interested in the research re: less than 3% of women that can't breastfeed. Is that women who can't lactate at all? Or can't get enough supply? I just know so many women who struggled with "not enough milk" - or struggled so much with breastfeeding - it seems much higher than 3%, but maybe that is the number whose milk actually dries up completely or never comes in at all.

I'm curious about that statistic - could make a whole separate blog post.

Posted on April 19, 2010

Wendy Armbruster Bell says:

@Diane - that stat has been in my mind for years - I had read it somewhere. So after I read your comment I went back online. I found many sites citing anywhere from 0-5% of moms being unable to breastfeed, but no references were cited.

I did find this page that details all the REASONS why a mom may not be able to breastfeed, but again no numbers. This page is informative, but I found it hard to read myself.

http://www.breastfeedingbasics.com/html/when_breastfeeding_doesn.shtml

I will keep looking...

Posted on April 20, 2010

Abigail says:

This is fascinating to me, I'd never heard of the WHO code before. I'm glad a friend posted this link on her facebook. I've put a link to this on my blog. and will likely share it on my facebook as well.

Posted on April 22, 2010

Wendy Armbruster Bell says:

@Abigail - thank you for helping to spread the word. Every mom, whether nursing or formula-feeding, should know about the WHO Code.

Posted on April 22, 2010

Lee-Ann says:

The 0-5% stat is about mothers who cannot physiologically breastfeed, for a number of reasons.
This figure is like an ideal. What is hard to understand is that many birthing and postpartum practices that are common in north American hospitals seriously undermine the likelihood of a mother to produce a full milk supply.

The book "The Breastfeeding Mother's Guide to MAKING MORE MILK " by Diana West, BA, IBCLC and Lisa Marasco, MA, IBCLC gives much more information about supply problems and what can be done to prevent and avoid them.
http://www.makingmoremilk.com/

Posted on April 23, 2010

Wendy Armbruster Bell says:

@Lee-Ann - thank you for that. Is there a published study that talks about this stat? Further to your comment re: current birth practices in the US, I'd like to direct both yourself and my readers to this recent HuffPost article, "Peaceful Revolution: Motherhood and the $13 Billion Guilt" http://tinyurl.com/yyok2dz which asks the question, "Should you be feeling guilty when the "Booby Traps" (see http://www.bestforbabes.org/breastfeeding-booby-traps/) of our culture trip you up in your efforts to breastfeed, or should you really be feeling angry?

Posted on April 23, 2010

Alicia says:

Does that number of women who can't breastfeed include those of us who can't because of medication? Or only those that physically can't?

Posted on April 27, 2010

Wendy Armbruster Bell says:

@Alicia - thank you for your comment. We are trying to find out more information on that stat (i.e. the source). I believe, but cannot be 100% sure, that the 3% cited is those than cannot physiologically breastfeed. Please read the other comments above and follow some of the links for more information. :-)

Posted on April 27, 2010

Holly says:

Hi... I would like the opportunity to comment on that 3-5% that cannot breastfeed. I have been told I was in that number for 4 out of 6 babies. I was told that with my health conditions (PCOS and Graves Disease) my body simply did not make enough milk to sustain my children and my children required formula to supplement... which eventually led to more formula than breastmilk and eventually only formula as my supply dropped even lower. I have successfully nursed two children now (baby #6 is on breastmilk only at 24 weeks now). Knowledge is power. MANY women are told or believe that they are in that 3-5% when they simply are not. What they ARE is undereducated and lacking support. Another BIG issue that makes women THINK they are in that percent is interference!! Babies taken from mom too soon, washed, left in the NICU without mom being allowed to see/nurse, babies given bottles/pacifiers at birth or in the hospital, etc. These babies have a harder time nursing and mom is told that she simply is unable to do it and thinks she is now in that percent. She is also more unlikely to attempt it again in the future! She now believes that she is in that percent that simply cannot feed her infants and will not try again in the future out of concern of starving future children.

Posted on May 2, 2010

Wendy Armbruster Bell says:

@Holly - you hit the nail on the head and I am grateful for your first-hand account of the Booby Traps that you encountered with four out of six of your children. Kudos to you for persevering and navigating around said Booby Traps to breastfeeding success! What a great post! Totally inspiring!

Posted on May 2, 2010

Kris says:

Thanks for this post. I knew of the code, but didn't know all the details. Does anyone know if Canada signed? I see tons of "violations" all the time. I'm wondering if part of it was accepted and part of it not.

Posted on May 2, 2010

Wendy Armbruster Bell says:

@Kris Yes Canada signed, but it is only voluntary here as it is in the USA. A few countries, like Iran, have made it law. You can report violations in Canada via INFACT Canada. They have a form that you can fill in on their website. Annie at PhDinParenting wrote a great post recently detailing the process to report infractions in various countries. You can find it here: http://www.phdinparenting.com/2010/02/22/how-to-report-unethical-promotion-of-formula-bottles-and-other-breastmilk-substitutes/

Thanks for your comment!

Posted on May 2, 2010

Jo says:

Thank you for this detail & explanation. It's nice to have it spelled out in a clear and easy-to-read way. My only complaint is in regards to this comment:

Some countries, such as Iran, have adopted The Code as law and now infant formula is available ONLY by prescription and comes in a can with a generic label. I sure would like to see that day in both Canada and the US I tell ya!

I agree that, ideally, I'd love to see formula only available by Rx, BUT that would potentially put an even bigger burden on working moms and others who have struggles with breastfeeding.

With formula as easy to obtain as it is today (and with all that direct marketing to moms), we are sabotaging breastfeeding in huge ways, but if we go totally to the other extreme and make women jump through hoops to get it from a doctor, we're not doing ourselves much good either.

What we NEED to do first is to work for family-friendly policies in the U.S. We have a start with the breastfeeding/pumping regulations in the health care reform (requiring companies to provide time/resources for WOHM moms to pump), but have much more work to do before we put the burden of making breastfeeding work solely on the women doing it.

Today, many moms are already spread thin and doing their best to work and care for their babes in the best way possible, and I would hate to see us add another burden without giving them more support first.

Posted on August 31, 2010

Wendy Armbruster Bell says:

@Jo - When I made the comment about formula being available by prescription only, my intention was not that we should go "cold turkey" and pull formula from the shelves, but that we should work towards a culture in which formula was only needed in extreme cases - a culture that supported breastfeeding in such a way that having formula only available by Rx would NOT be a further burden to breastfeeding moms. Sorry for the confusion.

Best,
Wendy

Posted on August 31, 2010

Tammy Ritchie says:

My hospital, OB AND my pediatrician gave me formula after my daughter was born. I used some for supplemental feedings during the first few months and pumped breast-milk since her birth (while I was short on breast-milk I used some bottled formula). I did not fail... As a matter of fact, (my daughter is going on two years old) I've been breastfeeding her straight from the source since she was around 3 months and we're still going!

I have a friend that has CML and will not be able to breastfeed her baby (due April) for very long because she will be on medication that might harm her baby in order to keep her leukemia in remission. She has twin boys (a few months older than my daughter) and she didn't breastfeed them for long either because of the same reason.

Maybe if breast-milk banks were more wide spread (and not as expensive as formula since my friend is unemployed and might not qualify for unemployment this time) women that are in situations like this could choose breastmilk over formula. Of course there will have to be screenings of the breastmilk to make sure that the donor isn't on any harmful medication or on illegal street drugs... That might drive costs up for breastmilk though. There has to be a way for moms to get breastmilk for a lot less than formula for this to happen.

Regards,
Tammy

Posted on November 17, 2010

Tammy Ritchie says:

I'm not sure if this went through or not... My friend is expecting a baby in April and has CML (a form of leukemia) so she will not be able to breast feed her baby for long. I was hoping that there was a solution such as having low cost breastmilk banks for those who are unemployed. I was bombarded by formula at my OB before my daughter was born back in '08 - at the hospital as well as her pediatrician. We used formula + pumped breastmilk until she was around 3 months. From there on out I have been breastfeeding her straight from the source and never gone back to bottles and formula (she won't take them).

Posted on November 17, 2010

Wendy Armbruster Bell says:

Hi Tammie,

Thank you for your comment(s). Are you in the USA or Canada or?

You can check here for a listing of all North American Milk Banks. There are more and more of them opening all the time. http://www.pumpease.com/resource-links#namb

There is also a non-profit by the name of Get Pumped! that may be able to help your friend. You can contact them via their website: https://www.getpumpedonline.org/Home.html

Finally, there is private milk sharing - if you Google "breastmilk sharing" a bunch of sites come up. That is, of course, if your friend is comfortable with going this route.

All the best,

Wendy

Posted on November 17, 2010

Hannah says:

Thank you for this information! I have been thinking about finding it recently as it was brought to my attention. I will be sharing this link on my blog :)

Posted on March 17, 2011

Wendy Armbruster Bell says:

Thank you for visiting and sharing Hannah!

Posted on March 17, 2011

Brigitte says:

I'm interested to know if your research into the statistics of women who are unable to breastfeed got any reliable results. In the BF class I took while pregnant they said the same thing but I don't remember them giving a source and I didn't think to ask.

I wonder if the difficulty in finding a reliable source is because it can be hard to determine the real reason a woman is unable to breastfeed (I.e. Booby traps vs. Physiological reasons). That difficulty probably stems from the professionals not taking those who want to know why they can't breastfeed seriously.

In my case two IBCLC certified LCs said I may have IGT but no doctor would take that seriously and the folks at my OB clinic outright laughed at the notion of IGT being real.

Doesn't really pertain to your post but I felt I should address a possible explanation for difficulty finding reliable research on that 3% who can't breastfeed.

Posted on May 30, 2011

Wendy Armbruster Bell says:

Hi Brigitte,

Aside from the discussion above, I don't have any research to cite. However, I have put out a few feelers to some colleagues to see if we can find some. Keep checking back and thanks for stopping by!

All the best,

Wendy

Posted on May 31, 2011