Why does a document designed to bring out the best in people too often bring out the worst?

Such is the case with the International Code of Marketing of Breast-milk Substitutes (Code).

As individuals react to the decision by the National Alliance for Breastfeeding Advocacy (NABA) in collaboration with INFACT Canada and the International Baby Food Action Network (IBFAN) to cite Medela (maker of breast pumps and other breastfeeding aids) for Code violations, it appears that battle lines are being drawn.

Code Compliance
For those unfamiliar with the ongoing controversy, NABA was asked by the International Lactation Consultant Association (ILCA) to review Medela’s compliance with the International Code of Marketing of Breast-milk Substitutes. NABA concluded that Medela was in violation of the Code. ILCA subsequently informed Medela that until the violations are rectified, Medela will not be permitted to exhibit at ILCA’s annual conference or advertise in its journal consistent with ILCA’s Advertising Policy.

The decisions (NABA’s and ILCA’s) have set off a firestorm of confusion, with some raising concerns about the credibility and authority of the decision making organization (NABA), and others citing the lack of written guidelines as evidence that the Code is being unfairly and inconsistently applied.

History of the Code
First a little background on the document at the center of the controversy. In 1979, as more American and European women began the slow return to breastfeeding, aggressive marketing practices migrated to developing countries. In response to growing concern that pressures by commercial entities were undermining breastfeeding worldwide, the World Health Organization (WHO) and UNICEF organized an international meeting on infant and young child feeding. Participants included government representatives, scientists, health workers, infant food industry representatives, and representatives from public interest groups.

The need for a code of conduct to restrict inappropriate marketing practices was identified. Four drafts and 15 months later, in May 1981 the final version of the International Code of Marketing of Breast-milk Substitutes was adopted by the World Health Assembly by a vote of 118 to 1. The United States cast the lone dissenting vote citing concern over how the Code might affect US businesses.

Nine years later on August 1, 1990, during the WHO/UNICEF policymakers’ meeting held at the Spedale degli Innocenti, Florence, Italy, the United States finally joined with 29 other countries in restating their support for the Code and setting new standards for breastfeeding support.  In a document known as the Innocenti Declaration, participants called upon governments to:

1. Appoint a national breastfeeding coordinator with appropriate authority, and establish a multisectoral national breastfeeding committee composed of representatives from relevant government departments, non-governmental organizations, and health professional associations.

2. Ensure that every facility providing maternity services fully practices all the ten steps to successful breastfeeding set out in the WHO/UNICEF statement on breastfeeding and maternity services.

3. Give effect to the principles and aim of the International Code of Marketing of Breast-milk Substitutes and subsequent relevant Health Assembly resolutions in their entirety.

4. Enact imaginative legislation protecting the breastfeeding rights of working women and establish means for its enforcement.

Fifteen years later in 2005, in celebration of the 15^th anniversary of the Innocenti Declaration, a second meeting was held in Florence, Italy. In addition to the four operational targets identified in 1990, five more were added:

5. Develop, implement, monitor and evaluate a comprehensive policy on infant and young child feeding, in the context of national policies and programs for nutrition, child and reproductive health, and poverty reduction.

6. Ensure that the health and other relevant sectors protect, promote and support exclusive breastfeeding for six months and continued breastfeeding up to two years of age or beyond, while providing women access to the support they require – in the family, community and workplace – to achieve this goal.

7. Promote timely, adequate, safe and appropriate complementary feeding with continued breastfeeding.

8. Provide guidance on feeding infants and young children in exceptionally difficult circumstances and on the related support required by mothers, families and other caregivers.

9. Consider what new legislation or other suitable measures may be required, as part of a comprehensive policy on infant and young child feeding, to give effect to the principles and aim of the International Code of Marketing of Breast-milk Substitutes and to subsequent relevant World Health Assembly resolutions.

Decoding the Code
The Code is a remarkably clear and straight forward document. Aside from the addition of subsequent resolutions by the World Health Assembly (WHA), the Code is essentially unchanged since its inception. It applies only to the marketing of breastmilk substitutes, bottles, and nipples (teats), their quality and availability, and to information concerning their use. The Code calls upon companies who market products within the scope of the Code to do the following:

• Not advertise to the general public.

• Not distribute gifts or free samples to mothers, health care workers, or health care facilities.

• Not promote products within the scope of the Code in health care facilities.

• Avoid the use of pictures or text that idealizes the use of breastmilk substitutes, bottles, and nipples on all packaging and marketing materials.

• Avoid references to proprietary products in all information materials.

• Not pay employees on a commission basis for sales of breastmilk substitutes, bottles, and nipples.

• Ban employees from training new or expectant mothers.

• Ensure that products within the scope of the Code when sold meet established standards.

Enforcing the Code
The aim of the Code is to provide safe and adequate nutrition for all infants by protecting, promoting, and supporting breastfeeding, and ensuring the proper use of breastmilk substitutes when needed based on adequate information and appropriate marketing and distribution.

To ensure that this aim is met, Article 11 of the Code states, “Governments should take action to give effect to the principles and aim of this Code, as appropriate to their social and legislative framework, including the adoption of national legislation, regulations or other suitable measures.”  In addition, “The manufacturers and distributors of products within the scope of this Code, and appropriate nongovernmental organizations, professional groups, and consumer organizations should collaborate with governments to this end.”

The responsibility for enforcing the Code falls not only upon governments, but nongovernmental organizations, professional groups, and consumer organizations. A willingness on the part of these organizations to accept the responsibility is often embraced and the public is grateful for the watchdog nature of their work (as evidenced by product recalls of unsafe toys, etc.).  Only when these organizations make unpopular decisions are their determinations questioned. (Perhaps the pundits are right and no good deed goes unpunished.)

The National Alliance for Breastfeeding Advocacy (NABA), INFACT Canada, and the International Baby Food Action Network (IBFAN) have a long history of cataloging Code violations and establishing precedent for future actions. In the absence of an alternative authority with the knowledge and skill to render judgments on Code compliance, the current model remains. That model recognizes that child feeding experts and not marketing professionals should be consulted in the neutral determination of what is in the best interest of mothers, babies, and breastfeeding, and that any dialogue that takes place should be respectful and factual.

NABA and INFACT Respond
On March 2, 2009 in an effort to clarify NABA’s determination and ILCA’s action, a letter written by Marsha Walker of NABA/IBFAN and Betty Sterken of INFACT Canada/IBFAN was sent to all ILCA members. Walker and Sterken identified specific Code violations by Medela including direct marketing of bottles and nipples to parents, use of language in product descriptions that idealize bottle-feeding, and placement of images of bottles and nipples on packaging. They also discussed how ILCA’s actions related to the Code might affect IBCLCs.

Breastfeeding Missing in Action
In the past, the breastfeeding community has been quick to condemn the formula industry for its unethical, albeit legal marketing practices. At the same time breastfeeding advocates have embraced the manufacturers of breastfeeding aids (pumps, shields, shells, bras etc.) seemingly creating a mutually beneficial relationship e.g. ILCA accepts exhibit fees and advertising revenue and in return manufacturers gain access to ILCA members for the purpose of product promotion and sales.

Many would argue that the promotion and use of breast pumps and other breastfeeding aids is justified in a society where the majority of women return to work shortly after birth, placing their infants and young children in any of a variety of child care settings. There is also ample scientific evidence to show that expressed human milk is superior to artificial milk (infant formula).  Lacking are concerns about breastmilk feeding compared to breastfeeding; about the benefits a baby derives while breastfeeding and the extent to which they far exceed the benefits conferred by the milk alone. If this is true, then shouldn’t breastmilk feeding be viewed not as an equivalent option but rather the lesser of two evils?

Instead of breastfeeding advocates lobbying for breast pump standards, work site pumping stations and reimbursement for breast pumps, perhaps it’s time garner support for extended, paid maternity leave, on-site child care, periodic breaks throughout the work day so that mothers can truly combine breastfeeding and working, and reimbursement for breastfeeding support services rendered by certified or licensed health care providers.

Instead of building a better bottle or a better nipple, and then arguing about how they are marketed, perhaps it’s time to focus our time and energy on building a social structure that better supports breastfeeding.

The Bottom Line
Commercial industries, regardless of what products they sell, have one goal: to increase revenues. They can do this by raising prices (assuming the market will bear a price increase) or increasing market share.  To increase market share they can do one of two things: take market share away from their competitors or increase the overall size of the market. In the case of breast pump manufacturers, increasing market share means getting more mothers to use breast pumps.  However, when more mothers breast pump fewer babies breastfeed.

Perhaps Medela’s previous decision to refrain from marketing its bottles and nipples to the public was less a response to the Code and more a response to existing market conditions, as evidenced by the fact that Medela has not changed its approach in all markets. When US market conditions changed amidst concerns over bisphenol A (BPA), so too did Medela’s actions.

Right or Wrong
As an organization, ILCA has chosen to adhere to a particular standard, and to rely upon a determining body to guide its adherence. Whether you agree or disagree with NABA’s assessment or ILCA’s actions, you need to understand how the decision affects ILCA affiliates and individual ILCA members. Walker and Sterken in the aforementioned letter sent to ILCA members, attempted to help IBCLCs better understand the implications through a series of questions and answers. But at the end of the day, individuals have to decide what action is in the best interest of the mothers and babies they care for and how best to provide that care within the framework of the Code.

The Code was never intended to prevent companies from selling their products. It asks only that they do so in a responsible manner. Can a formula company be Code compliant? Absolutely. Can a breast pump company be Code compliant? Absolutely. Can an IBCLC be Code compliant? Absolutely.

It’s a matter of choice.