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Why the UK Law must change if it is to protect infant health

The International Code is an essential safeguard for all mothers and babies
- for breastfeeding and bottle-feeding mothers

Breastfeeding is the optimal way to feed a baby in the vast majority of circumstances. Breastfeeding saves lives and is one of the most cost effective ways of protecting infant and maternal health.

Most women in the UK say they want to breastfeed their babies, yet only a minority of babies in the UK receive any breastmilk at all for more than 2 weeks (Ref. 1). Too few women in the UK have access to adequate support for breastfeeding or the full impartial information they need to make the decisions which will affect their own and their child’s future health. Instead they are bombarded with commercial information which promotes bottle feeding and minimises its risks.

A number of UN Resolutions have been passed which aim to restrict the marketing and promotion activities of the baby feeding industry. The most significant Resolution included the International Code of Marketing of Breast-milk Substitutes, (the International Code (Ref. 2)) which was adopted in1981 by the World Health Assembly (the policy-setting body of the World Health Organisation) as a minimum requirement to be implemented in its entirety. The International Code is an important safeguard for health and aims to ensure that all parents - those who decide to breastfeed and those who decide to feed their babies with breastmilk substitutes - receive unbiased and appropriate information.

In many international fora the UK has consistently claimed to support the International Code and the Resolutions and Declarations relating to infant feeding which have been passed since 1981 (Ref. 3). Despite this, the previous Administration failed to implement them and on 1 March 1995 brought in a Law which is in direct contravention of these Resolutions. The decision shocked and disappointed all those who work for the protection of infant health (Ref. 4).

In March 1995 the Labour Party put forward a Motion (which received cross-party support from over 100 MPs) calling for the Regulations to be annulled which stated:

“That this House is alarmed at the decision taken recently by Health Ministers to put commercial interests before infant health when it refused to ban the advertising of infant formula in the United Kingdom; is aware that such a decision is contrary to all its statements in support of an advertisement ban over the last 13 years, and contradicts also the advice given to it from major health bodies including the British Medical Association, the British Paediatric Association, and the Royal College of Midwives; and calls upon Her Majesty’s Government to rethink its approach instead of simply responding to UK baby milk companies’ promotions.”

The UK Law arises from two European Directives (Ref. 5) which, during their formation, the Government argued should be brought into line with the International Code. As a result of the concern expressed by MEPs, policy makers and NGOs throughout Europe and worldwide, the Directives were strengthened. Although they still do not encompass all the provisions of the International Code they do, at least, specifically allow EU member states to ban advertising and to implement the International Code if they choose.

The preamble to the Directive for the Internal Market states:

“ Whereas in an effort to provide better protection for the health of infants, the rules of composition, labelling and advertising laid down in this Directive should be in conformity with the principles and aims of the International Code ....”

The decision made in the UK to opt for a weak interpretation which places some restrictions on commercial promotion, but at the same time allows it to be channelled through the health care system and in media targeted at parents negates many of the protective measures in the Directive. It also undermines the many innovative measures to protect breastfeeding which are being taken in the UK Ref. 6) British babies now have less protection from commercial pressure than those living in France, the Netherlands, Denmark, Spain and Luxembourg where infant formula advertising to the public (at least) is banned.

The current UK position regarding baby milk legislation has been likened to the practice of securing your home by locking the front door and all the windows but failing to close the backdoor. It gives the baby feeding industry in the UK the key to the expansion of the baby milk market - the use of the health care system as a market place. The NHS is left to pick up the costs - estimated to be £35 million for gastroenteritis alone (Ref. 7).

The convention on the Rights of the Child

The UK has ratified the Convention on the Rights of the Child (CRC). The CRC contains a multitude of rights that have to be protected, respected and fulfilled. States face a daunting task in adopting legislation or other measures which would guarantee those rights. The CRC Committee has indicated that the International Code should be viewed as a tool which will help governments fulfill their obligations to Article 24 of the Convention. Failure to provide adequate information, whilst at the same time allowing manufacturers to distribute misleading information, could be construed as a failure to protect a child's rights to the highest attainable standard of health.

In October 2002 the UN Committee's report welcomed the reduction of infant mortality rates in the UK but commented on the relatively low rate of breastfeeding. It specifically recommended that: "the State party takes all appropriate measures to...promote breastfeeding and adopt the International Code for Marketing of Breast-milk Substitutes." If the UK fails to act on the recommendations, when it appears before the Committee again in 5 years time, it will have to explain why.

How the UK Law must change if it is to meet minimum UN requirements

There are key areas in the UK regulations which need to change if it is to be brought in line with minimum UN requirements. These are:

SCOPE: The advertising controls in the UK cover only infant formula for babies ‘in good health’ and to a limited extent, follow-on milks. There are no advertising restrictions for specialised infant formulas (for special medical purposes) or for baby foods. The International Code covers bottles and teats and all breastmilk substitutes. This includes anything which is used instead of breastmilk - baby drinks, follow-on milks and any products marketed for use in feeding bottles - all specialised formuals also. WHA Resolutions passed in 1986 and 1994 stated that follow-on milks are ‘not necessary’ and that complementary feeding practices should be fostered from ‘about 6 months’.

PROMOTION TO THE PUBLIC: The International Code bans the promotion of any breast milk substitute (see above) within the health care system or outside it. The UK Law only bans advertising of infant formulas (for babies in good health) outside the health care system. New Regulations for specialised formulas passed in April 2000 fail to include any of the International Code’s advertising or labelling provisions.

PROMOTION TO HEALTH WORKERS: UK legislation does not include the provisions of Article 6 or Article 7 of the International Code or the 1996 WHA Resolution - which call for an end to promotion within the health care system and an end to inducements, gifts and sponsorship which creates conflicts of interest for health workers.

BABY FOOD COMPANY CONTACT WITH MOTHERS: The UK Law does not include Article 5 of the International Code which stops manufacturers from making direct or indirect contact with mothers.

LABELS: The UK Law bans baby pictures and idealising text but allows adverts to be carried on labels or under the lid and one nutrient function claim. Other aspects of labelling would also have to be changed if parents are to be fully informed.

DEFINITIONS: The UK Law should define ‘proprietary brand’ to stop the deliberate confusion between company names and brand names. The word ‘independent’ should also be defined.

FREE AND LOW COST SUPPLIES: The ban of free supplies applies only to infant formulas and is covered partly in the Law and partly in a 1989 Department of Health Circular (HC (89) 21). The Law needs to be brought in line with the 1994 WHA Resolution (47.5) which states that there should be no free or subsidised supplies of breastmilk substitutes in any part of the health care system.

Would these changes deny mother’ rights?

The aim of the International Code is to ensure that health workers, mothers and carers receive full and impartial information about all aspects of infant feeding. It respects the right of all mothers - those who breastfeed and those who decide to feed their babies with breastmilk substitutes:

• Brand name advertising and commercial promotion is not the same as impartial information. They are the opposite - they provide selective information, projecting only the aspects that the advertiser chooses. Parents have a right to know that baby milks are made from modified cow’s milk, or that they may contain beef fat, certain types of sugar, egg or fish oils. Parents also have a right to know the hazards of artificial feeding and the benefits of breastfeeding.
• Because the UK law is so limited, many products which mothers feed to babies, such as pre-term milks, goats milk formulas and sweetened drinks, are not covered. Manufacturers market these products in any way they choose;
• The International Code requires companies to be factual about their products. It would not prevent consumers from contacting companies on an individual basis if they needed more information. For example, if they wanted to know particular details about the composition of a product, how much sugar a product contains etc. The International Code would simply ensure that such requests were unsolicited and are not used to promote products and that parents are not given advice from an inappropriate source;
• The International Code does not stop the sale of baby milks. Banning baby milk promotion would not deny anyone the right to buy baby milk;
• Virtually all mothers in the UK use the health care system during their pregnancy and delivery. The companies therefore have a captive audience. A mother needing information on infant feeding is most likely to be handed commercial literature - whether she likes it or not.
• The International Code protects both the right of mothers and their babies to health care in a non-commercial environment and the mother’s right to receive impartial advice. The UK law - channelling promotional material to her when she is most vulnerable, at a time when her confidence may be at its lowest ebb - denies her that right.
• Babies have rights too. The International Code is recognised as a concrete tool in protecting a child’s right to the highest attainable standard of health under Article 24 of the Convention on the Rights of the Child (adopted at the World Summit for Children in 1989).

This booklet (picture pending) is sent to parents who telephone the SMA Careline phone number, advertised on the fridge magnet (see above). The booklet makes no mention of the Department of Health’s concern about the high levels of phytoestrogens in soya baby milks and the need to consult a health worker before use. It also promotes genetically modified soya as ‘environmentally friendly.’

Commercial promotion vs Government expenditure

According to claims made in trade journals it seems likely that £12 million is spent annually on commercial promotion of baby milks which is equivalent to £17 for each baby born in the UK. The promotion takes many forms, such as direct advertising in baby care booklets, telephone ‘carelines’, baby care videos and sponsorship of health care facilities. For example, in a recent Milupa promotion for infant formula, Milupa stated that:

“ ... the range will be supported by £2 million worth of advertising, direct mail and sampling to new mothers.”

Source: Independent Retail News 4th July 1997

In stark contrast the UK Government spends approximately £70,000 each year supporting breastfeeding, which is equivalent to 10p per baby. Governments can rarely compete with the level of expenditure which is available to commercial companies and it is illogical to expect the baby feeding industry to pay for information which will not in some way promote its brand name or products.

How companies target mothers

In November 1997 Marketing Week organised a seminar entitled, Marketing Baby & Infant Products - How to Exploit the Opportunitues and Avoid the Pitfalls of Marketing FMCG [fast-moving-consumer-goods] Products to Mothers. The speakers outlined the strategies which companies use to promote brands in the health care system and in media targeted at mothers. A third of the participants were manufacturers of products covered by the International Code.
A key speaker from one of the UK professional health bodies, gave a speech entitled Professional Endorsement - Every Brand’s Dream in which she said that the industry had identified nurses as being prime recommenders of a wide range of products.

Another speaker from the publishers of Mother & Baby magazine referred to a readership survey which revealed that:

“The creative impact of promotions (and ads) and the indirect endorsement of the magazine appear to be strong factors in generating purchasing interest.”

76% of respondents who read promotions in the magazine intended to buy the product.

A typical issue of Mother and Baby (picture pending) - a magazine which claims to support breastfeeding - contains 15 pages of advertisements and promotions which contravene the International Code and WHA Resolutions. The simplest way to ensure that parents receive consistent and impartial advice is to remove the commercial promotion. A randomised trial in the US showed that removing advertising had more impact on breastfeeding rates than intensive efforts to train staff in breastfeeding support. Other studies have demonstrated the complexity of providing infant feeding information and the negative messages which are subtly conveyed by commercial literature and labelling.

Source:Commercial Discharge Packs and Breastfeeding Counselling: Effects on infant feeding practices in a Randomised Trial. Frank et al. Paediatrics 1987; 80 An Evaluation of Breastfeeding Promotion Literature: Does it really Promote Breastfeeding? R Valaitis et al.. Revue Canadienne de Santé Publique, Vol. 84 No 1.1993; Rethinking Infant Nutrition Policies under changing Socio-Economic Conditions Marchione et al, Acta Paediatrica Scandinavica 314. 1984

The cost of bottle feeding to the NHS

Although more research is needed to establish the extent and impact of sponsorship in the NHS, it is misleading to suggest that the health service would not be able to function effectively without commercial ‘support’ from the baby food industry. Any short-term savings must be set against the long-term costs incurred by the NHS and families when incorrect information results in babies being inappropriately fed.

The 1995 Department of Health publication, Breastfeeding: Good Practice Guidance to the NHS, which was prepared in consultation with the National Breastfeeding Working Group, outlined some of these costs:

“More mothers breastfeeding would bring health gains to mothers and babies and savings for the NHS in both the short and longer term. Breastfeeding reduces the risk of a range of diseases including gastroenteritis in babies, neonatal necrotising enterocolitis (in pre-term infants), child onset diabetes mellitus and middle ear and respiratory infections. The benefits for the mother include a reduced risk of death from breast cancer under the age of 35.

" The main cost saving to the NHS comes immediately in the form of reduced hospital admissions for gastroenteritis. The rate of admissions in babies bottle fed or breastfed for only a short period is just over 5 times more than in babies breastfed for 13 weeks or more. At a cost per inpatient stay of about £1200, the saving associated with each one percentage point increase in breastfeeding in the average health district is about £4,000 - about a half a million pounds in England and Wales. If all babies were breastfed this would be equivalent to almost £300,000 a year for the average district or £35 million for the country as a whole.”

A study in the USA indicated that women who breastfeed their infants have a net reduction in absenteeism of 27% compared with those who bottle-feed their babies. This is because the bottle-fed babies have more episodes of illness which lead to the mother’s absence.

Source: Study by Rona Cohen and Marsha B Martek. reported in Wall St Journal. 13 December 1994.

The impact of commercial sponsorship

Commercial sponsorship of health services by the baby food industry has been shown to be one of the most effective ways of ensuring health worker dependence and influencing the messages that parents receive. For this reason in 1996 a World Health Assembly Resolution (WHA 49.15) was passed which stated: “... Concerned that health Institutions and ministries may be subject to subtle pressure to accept, inappropriately, financial or other support for professional training in infant and child health..." Member states are urged to: “ensure that the financial support for professionals working in infant and young child health does not create conflicts of interest..”

A study examining the level of knowledge of breastfeeding in health workers in Ireland showed the dangers of allowing companies to sponsor health worker education:

“In the units studied, continuing education takes place in the midwife’s free time at her own expense... the majority of these sessions were funded by infant formula manufacturers. Few of the respondents had access to information from sources other than the infant formula companies... Infant food manufacturers representatives were frequent visitors to all the units. A recurring comment was “The manufacturers tell us you can’t get any closer to mothers’ milk.””

Source: Breastfeeding Knowledge of Hospital Staff in Rural Maternity Units in Ireland. G. Becker. J. Human Lactation 8 (3) 1992. 137 - 142

• In 1993 a hospital in the Midlands accepted £2,000 sponsorship from Farley’s for the launch of a “New Caring Approach to Midwifery”. The hospital has 4,000 births per year and is in a region with the highest infant mortality in England. Farley’s provided promotional leaflets which were given to all mothers, glossy notice boards and badges for the midwives, and gained a permanent place in the hospital along with an implicit endorsement of its products. 75% of the mothers giving birth in the hospital said they wanted to breastfeed, yet only 28% of mothers did so exclusively. The parents of the 2,880 bottle-fed babies who left the hospital in that year would have spent £883,584 on baby milk. Farley’s recouped its £2,000 grant when just 7 mothers chose its brand. The hospital was out of pocket as soon as 2 babies returned with gastroenteritis.

Source. Baby Milk Action Update 12 1993

• In 1994 Milupa sponsored a room for testing infant hearing in Hillingdon Hospital. The room carries a large Milupa sign over the door and in 1995, sales of Milupa milks in the local clinic went up by 589%.

Source: Correspondence from Harrow & Hillingdon Healthcare NHS Trust, 1995.

• In a qualitative survey it was shown that mothers were more likely to choose a brand which they had seen being used in the hospital or endorsed by a health professional, for example a midwife using a tourniquet displaying the brand name.

Source: Martyn T Modern Midwife March 1997.

The UK Baby Milk Market

The baby milk market in the UK is currently worth approximately £100 million. However, overall sales of baby milks, drinks and foods are estimated to reach £416 million by the year 2001. The greatest growth is forecast for baby milks at 26%.

Source: Grocer June 1997

There are 4 main baby milk brands in the UK: Farley’s, owned by Heinz, (USA), Milupa and Cow & Gate, both owned by Nutricia (The Netherlands) and SMA, owned by American Home Products/Wyeth (USA). There are also two ‘own brand’ baby milk brands: Sainsbury’s and Boots. Two other companies, Abbot Ross (USA) and Mead Johnson (USA) promote soya milks and specialised formulas in the UK health system. The Swiss company, Nestlé, has only recently began to market infant formula in the UK.

Sponsorship does not have a charitable purpose

Companies are not charities and their aim is to maximise their profits for their shareholders:

“According to a government pamphlet, sponsorship is “a payment by a business firm... for the purpose of promoting its name, products or services. It is a commercial deal, not a philanthropic gift.” In other words sponsorship is a form of advertising. The Inland Revenue regards it as advertising, allowing expenditure on it to be set off against a company’s tax liability as money spent ‘wholly and exclusively for the purpose of trade.’ Any hint of philanthropic purpose would make the expenditure ineligible for tax relief.”

Source: Sir Roy Shaw, The Spread of Sponsorship. Bloodaxe Books. 1993.

Breastfeeding rates: in the UK

Despite the increased knowledge about the benefits of breastfeeding and the fact that most women in the UK want to breastfeed their babies, breastfeeding rates have remained more or less static since 1985. (The slightly higher rates in the 1995 study are thought to be due to the changes in the age and educational profiles of mothers compared with the earlier studies.)

UK Breastfeeding rates:

Only 1% of mothers who stopped breastfeeding within two weeks did so because they had breastfed for as long as they had intended. The most common reasons given for stopping breastfeeding were insufficient milk, painful breasts or nipples and that the baby would not suck. These problems can be overcome with effective care.

Source:ONS Infant feeding 1995. (May 1997)

Breastfeeding rates: in Europe

In countries where there is little or no advertising and where the hospital practices support mothers who want to breastfeed, breastfeeding rates at birth are very high. The following figures are taken from country reports compiled by the International Baby Food Action Network (IBFAN) and national statistics where available: Norway 98%; Sweden 97%; Denmark 98%; Rumania 91%; Czech Republic 92%.

In contrast, in countries where most of health information is provided by the baby feeding industry, breastfeeding rates are low: Ireland 31%; France 50%; Scotland; 50% (parts of Glasgow less than 7%)

Case study of Norway

Ninety eight percent of Norwegian women leave maternity wards breastfeeding. Ninety percent are breastfeeding at 3-4 months and 75% are still breastfeeding at 6 months.

Since 1970 the Norwegian Government has had a strong, unequivocal policy on breastfeeding. There are only two companies marketing baby milk in Norway, neither of which are allowed to promote their products (due to a voluntary agreement agreed in 1983). Norwegian health services have never been saturated with promotional material as they have in the UK and most mothers are aware of the advantages of breastfeeding and all have access to the mother-support group network.

In Norway, women with paid work outside the home breastfeed more than women at home. Maternity leave has gradually increased in length, and currently lasts for one year with 80% pay, or for 46 weeks with full pay. Working women who are breastfeeding are entitled to up to two hours leave daily.

“Recently a Norwegian cabinet minister went on maternity leave, being the first woman in the country’s history to give birth while holding a ministerial post. Newspapers wrote with concern about how she would manage to combine her duties in the Ministry with breastfeeding her child. It was taken for granted that she was to breastfeed, even with such a demanding job.”

Source: The case of breastfeeding in Norway, The Norwegian Breastfeeding Association (Ammehjelpen, 1994.) Breastfeeding in Norway in Good Times and Bad, Austveg B, Helsing E; 1992

References

1. Infant feeding 1995 ONS May 1997.
2. The WHO International Code of Marketing of Breast-milk Substitutes. 1981. (WHA 34.22)
   3 WHA Resolutions on Infant and Young Child Feeding: WHA 35.26 (1982); WHA 37.30 (1984) WHA 39.28 (1986);WHA 41.11 (88); WHA 43.3 (1990); WHA 45.34 (1992); WHA 47.5 (1994); WHA49.15 (1996);
3. Innocenti Declaration of the World Summit for Children (1990) ; the Convention on the Rights of the Child adopted at the World Summit for Children (1989) The need to protect breastfeeding was also addressed in the action plans of 1992 International Conference on Nutrition in Rome, the 1994 International Conference on Population and Development in Cairo and the 1995 4th World Conference on Women in Beijing.
4. Forty-eight of the leading health, consumer and development bodies in the UK, including, UNICEF, the British Medical Association, the British Paediatric Association, the Health Visitors’ Association, the Royal College of Nursing and the Royal College of Midwives, the National Childbirth Trust, La Leche League and over 160 individuals called on the Government to respect the International Code and for baby milk advertising to be banned.
5. Commission Directive on infant formulae and follow-on-formulae (91/321/EEC)
   Council Directive on infant formulae and follow-on-formulae intended for export to third countries (92/52/EEC) (See 'resources' section).
6. UNICEF’s Baby Friendly Initiative, the National Network of Breastfeeding Coordinators, Invest in Breast etc
7. Breastfeeding: Good Practice Guidance to the NHS Prepared by the Department of Health in consultation with the National Breastfeeding Working group. 1995