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Guidelines For Accepting Donations/Sponsorship or Contracts
Relative to The International Code of Marketing of Breastmilk Substitutes
Introduction:
As public and professional concern over the yearly deaths of thousands of
infants grew during the 1970s, two UN agencies, WHO (The World Health
Organization) and UNICEF (The United Nations Children's Fund) responded by
organizing an international meeting on infant and young child feeding in 1979.
During the next 15 months, WHO and UNICEF drafted and prepared a code to control
inappropriate marketing practices, promote, support, and protect breastfeeding
[4]. The WHO International Code of Marketing of Breast-milk Substitutes (the WHO
Code) was enacted by the World Health Assembly in 1981 and signed by 118
countries, including Canada. It provides ethical standards for marketing and
promotion of infant formula and breastmilk substitutes. Inappropriate marketing
of artificial baby milks and complementary foods, as well as feeding bottles,
nipples and pacifiers, is a cause of malnutrition and death throughout the
world. In 1994 at the World Health Assembly all WHO members including Canada
reaffirmed the Code.
In Canada the Code has been endorsed by The Canadian Medical Association, The
College of Family Physicians of Canada, The Canadian Institute of Child Health,
The Canadian Nurses Association, The Canadian Pharmacist Association, The
Canadian Paediatric Society, The Canadian Lactation Consultant Association
/Association canadienne des consultantes en lactation, The Canadian Healthcare
Association, The Canadian Confederation of Midwives, the Canadian Public Health
Association, The Society of Obstetricians and Gynaecologists of Canada, and the
Consumers Association of Canada.
In accepting donations from, or entering into a business agreement with, an
organization or business which does not adhere to the Code, health care workers
are unwittingly supporting unethical marketing practices and subverting
breastfeeding promotion, protection and support. Therefore, it is important to
know what questions to ask about a potential donor/sponsor/partner before
accepting donations, advertisements, conference subsidies, grants, and gifts, or
before entering into any business agreement with potential
donor/sponsor/partner.
For a complete copy of the Code please order Protecting Infant Health; A
Health Care Workers' Guide to the WHO Code (see Reference 4). A summary of the
Code is included on page 5.
A sample letter is enclosed for using in correspondence with a potential
donor or partner to refuse any cooperative action due to their non-compliance
with the Code.
The following questions are designed to assist in the evaluation of potential
donations, contracts, partnerships, or cooperative actions relative to
compatibility with the WHO Code. Use them to guide you in your decision on
accepting donations or forming a partnership.
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RULE OF THUMB - DO NOT ACCEPT DONATIONS OR ENTER INTO
PARTNERSHIPS WHEN YOU HAVE ANY DOUBT ABOUT ADHERENCE TO ANY ARTICLE OF THE
CODE BY YOUR POTENTIAL PARTNER OR DONOR.
"THERE IS NO SUCH THING AS A FREE LUNCH..." |
In most cases, an answer of YES indicates that you
should NOT enter into any agreements or partnerships with a
potential donor.
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KEY QUESTION:
Is the potential donor or partner involved either directly or at
arms length in the manufacture, distribution, sale or promotion of
any of the following;
 | Infant formula - an industrially produced breastmilk substitute |
| Breastmilk Substitutes - any food being marketed to partially or
totally replace breastmilk (pre-term formula, low birth weight formula,
all forms of cow and other animal milk, condensed milk, follow-up
[follow-on] milk, sugar or fruit drinks, depending on how they are
marketed ( eg, apple juice as above)) |
| Bottle-fed complementary foods - rice flakes, wheat flour, cornstarch
powders and bottle biscuits to be dissolved in liquid and used via feeding
bottle and nipple |
| Feeding bottles, nipples, and pacifiers |
If your answer is NO to this KEY question, it is assumed
that the Code would not apply and this partner or potential donor would be
compatible with the Code. Please check the "pedigree" of any potential donor
or sponsor. Watch for companies that masquerade as "Code compatible" but are
owned by multinationals who are involved in sale and marketing of the above
products. At arms length could refer to any company owned by or which owns a
manufacturer of the above products. For further information on these
connections see Appendix D and E in Reference #12.
Regarding relationships at arms length. Assessment of
relationships at arms length is up to you. It is your option to
refuse any relationship with a donor, corporation, or organization
which has dealings or relationships at any distance to an
organization or corporation which violates the WHO Code. A refusal to enter
a relationship is also known as a boycott. |
If your answer to the KEY question is YES, please answer
the following questions;
1. Direct advertising
- Does the potential partner or donor specifically market, promote or
advertise to the public or to health professionals any of the above products
(listed in the KEY question) where you perceive the intention is to replace
breastmilk for any age of baby/child?
-
- Does the potential donor or partner distribute to pregnant women or
mothers any gifts, articles or utensils which may promote the use of
breastmilk substitutes or bottle-feeding?
If the answer is YES to either question do not enter
into any agreements or partnerships with this potential donor, corporation or
organization. These actions contravene Article 5 (no advertising of these
products to the public. No distribution of gifts of articles or utensils to
pregnant women or mothers of infants and young children).
2. Product labels
- Does the potential donor modify, make unclear, or TOTALLY OMIT any of the
following information from its product labels? (All products covered by the
Code apply here.)
-
- the words "important notice" or equivalent
- a statement of the superiority of breastfeeding
- a statement that the product should be used only on the advice of a health
worker
- instructions for appropriate preparation and a warning against the health
hazards of inappropriate preparation.
- are there pictures of infants or other text which idealizes use of infant
formula, bottles or pacifiers, on any product labels?
If the answer is YES to any of the above, do not enter
into any agreements or partnerships with this potential donor, corporation or
organization. This contravenes Article 9 (labels must include proper use of
product, the superiority of breastfeeding, and must not idealize use of
artificial milks).
If the answer is NO, is the information on the label
CLEAR, CONSPICUOUS, AND EASILY READ, AND IN AN APPROPRIATE LANGUAGE?
If the answer is NO, do not engage in any partnership or
agreements with this corporation or organization. This contravenes Article 9
(labels must be easily read in the appropriate language).
3. Joint ventures or projects
- Does the potential partner or donor engage in joint ventures or projects
with manufacturers of any of the bulleted products listed in the KEY question?
Joint ventures or projects include activities such as "baby day" displays,
product demonstrations, acceptance of advertising for prohibited products,
etc.
-
- If the answer is YES do not engage in a partnership, contract or donor
agreement with this organization or corporation. These activities may
contravene Articles 4, 5, 6, and 8. (No information to and education of
mothers and families [4]. No advertising to the general public of products
within the scope of the Code [5]. Marketing personnel must not have direct or
indirect contact with pregnant women or mothers. [5] No company personnel
shall educate women or mothers of infants and young children [6, 8].)
4. Coupons etc.
- Does the potential partner or donor participate in mail-in offers for baby
clubs, mail-in coupons for free baby care items, infant feeding seminars, or
1-800 numbers for parenting or infant feeding information?
- If the answer is YES do not enter into any agreements or partnerships
with this potential donor, organization or corporation. This contravenes
Article 8 (no company personnel shall educate women or mothers of infants and
young children) and Article 5 (marketing personnel must not have direct or
indirect contact with pregnant women or mothers).
5. Educational material
- Does the potential partner or donor provide printed, video or audio
educational information for women, mothers or parents on infant feeding, or
any aspects of child care that involve infant feeding?
-
- If the answer is YES, Does the donor/partner OMIT any
of the following information, in part or in whole?
-
- the benefits and superiority of breastfeeding?
- maternal nutrition and the preparation for and maintenance of
breastfeeding?
- the negative effect on breastfeeding of introducing partial bottle-feeding
?
- the difficulty of reversing the decision not to breastfeed ?
- where needed, the proper use of breastmilk substitutes whether
manufactured industrially or home prepared?
-
- If the answer is YES to ANY of the
above, the educational material IS NOT acceptable. Do not
enter into an agreement or partnership with this potential donor, corporation
or organization. This contravenes Article 4.
-
- If the answer to #5 is NO, go to Question # 6 and
Question #7.
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CAUTION: Promotion often masquerades as
education through wording and insinuation. See Reference # 10 and 11 to help
you differentiate. |
6. Printed material
- Will the printed educational material bear a product name?
If the answer is YES, do not enter into an agreement or
partnership with this potential donor, corporation or organization. This
contravenes Article 4.
7. Identifying marks or logos
- Will the donated material or equipment bear any mark identifying the
donor?
If the answer is NO, this material is acceptable and you
may enter into an agreement or partnership.
If the answer is YES, and if this identification is a
logo, this does not contravene the Code, and you may enter into an agreement or
partnership.
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CAUTION: Some logos are now so connected
with a company product as to represent the product. Product names on any
donated materials, equipment or supplies contravenes Article 4. |
You may decide to refuse a relationship with this potential donor,
organization or corporation due to connection of their logo with products which
are covered by the Code.
8. Donated material or equipment
- Has educational material or equipment been donated to a facility of the
health care system WITHOUT a specific request and written approval of the
appropriate government authority?
If the answer is YES do not enter into an agreement or
partnership with this potential donor, corporation or organization. This
contravenes Article 6 (no health care facility should advertise products covered
under the Code).
9. Donated or low cost products
- Has the potential donor or partner donated or provided at a low cost
product covered by the Code (see Key Question above) either
with or without entering a contract, to a facility of the health care system
(hospital, maternity clinic, doctor's office, lactation clinic, birthing
centre)?
If the answer is YES, do not enter into any agreement,
partnership with this potential donor, corporation or organization. This
contravenes Articles 5 and 6 (no donation of products to families, no donation
of products to health care facilities).
10. Promotional material
- Does the potential donor or partner provide promotional materials on its
products to health professionals? Promotional materials include items such as
catchy magazine ads, flyers, glossy folders which go beyond scientific
information.
If the answer is YES, do not enter into any agreement or
partnership with this potential donor, corporation or organization. This
contravenes Article 7 (information to health care professionals must be factual
and scientific).
11. Inducements
- Does the potential donor or partner offer to health care workers or
members of their families, financial or material inducements where the
intention may be to promote products covered under the Code?
If YES, do not enter into any agreement or partnership
with this potential donor, corporation or organization. This contravenes Article
7 (no incentives to health care workers to encourage use of products covered
under the Code). This is called manipulation by assistance.
12. Contract conflicts
- Will a relationship/partnership/agreement with this
corporation/organization affect you or your organization's ability to
responsibly and fearlessly promote breastfeeding?
If the answer is YES, do not enter into any agreement,
or partnership with this potential donor, organization or corporation.
13. Other
- Will our organization's relationship / partnership / agreement with this
corporation / organization be used by the corporation/organization to
negatively influence colleagues and other health professionals in the
promotion of breastfeeding?
If the answer is YES, do not enter into any agreement or
partnership with this potential donor, organization or corporation.
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Summary of the International Code of Marketing of
Breastmilk Substitutes, World Health Organization (WHO), Geneva, 1981
"Understanding the Code: A synopsis" from BFHI News,
August 1994
- Aim: the Code aims 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.
- Scope: the Code applies to breastmilk substitutes,
including infant formula; to other milk products, foods and beverages,
when marketed or otherwise represented as a partial or total replacement
for breastmilk; to feeding bottles and nipples. It also applies to their
quality and availability, and to information concerning their use.
- Advertising: no advertising of above products to the
public.
- Samples: no free samples to mothers, their families
or health care workers.
- Facilities of Health Care Systems: no promotion of
products, i.e., no product displays, posters or distribution of
promotional materials. No use of mothercraft nurses or similar
company-paid personnel. The "health care system" does not include
pharmacies or other established sales outlets.
- Health Care Workers: no gifts or samples to health
care workers.
- Supplies: no free or low-cost supplies of breastmilk
substitutes to maternity wards and hospitals.
- Information: informational and educational materials
must explain the benefits of breastfeeding, the health hazards associated
with bottle feeding, and the costs of using infant formula. Product
information must be factual and scientific.
- Labels: product labels must clearly state the
superiority of breastfeeding, to use only on the advice of a health care
worker, instructions for the appropriate preparation and warning about the
health hazards of inappropriate preparation. No pictures of infants, or
other pictures or text idealising the use of infant formula.
- Products: unsuitable products, such as sweetened
condensed milk, should not be promoted for babies. All products should be
of a high recognized standard.
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Useful References:
- Armstrong H. The International Code of Marketing of Breast-Milk
Substitutes, a four part series appearing in J Human Lact (4)3 and 4(4), 1988;
J Human Lact 5(1) and 5(2), 1989
- Armstrong H, Sokol E. The International Code of Marketing of Breast Milk
Substitutes: What it Means for Mothers and Babies World-wide. The
International Lactation Consultant Association, 1994 (Available from ILCA, 200
Michigan Ave. Chicago Il, 60601 Tel. (312) 541-1710), Fax. (312) 541-1271)
- Palmer G. The Politics of Breastfeeding. Pandora Press, 1988
- Protecting Infant Health, A Health Workers' Guide to the International
Code of Marketing of Breast Milk Substitutes, 8th Edition, IBFAN, Penang,
Malaysia, 1996 (*)
- Walker G. Action on the WHO Code, Breastfeeding Review, No.11, November
1987
- Green M, Jones F. WHO Code. Who Cares? The Canadian Nurse, January
1991;87(1):26-28
- Protecting, Promoting and Supporting Breast-Feeding: The Special Role of
Maternity Services, WHO, Geneva 1989 (*)
- IBFAN Statement on Company Sponsorship of Conferences (*)
- Sokol E. The Code Handbook: A Guide to Implementing the International Code
of Marketing of Breastmilk Substitutes. The International CODE Documentation
Centre, IBFAN, Penang, Malaysia, 1997 (*)
- Auerbach KG. Beyond the Issue of Accuracy: Evaluating Educational
Materials for Breastfeeding Mothers. J Human Lact 1988;(4)3:108-110
- Wiessinger D. Watch your language. J Human Lact 1996;12(1):1
- Baumslag N, Michels D. MIlk, Money and Madness. Bergin and Garvey, 1995
- Karamagi D. Ethics, the health worker, and the International Code of
Marketing of Breastmilk Substitutes. IBFAN Africa News. 1995:7
- International Code: Questions and answers for health workers, IBFAN,
Penang Malaysia, 1996 (*)
(*) available from INFACT Canada, 6 Trinity Square, Toronto ON M5G 1B1 Tel.
(416)-595-9819, Fax. (416)-591-9355 or e-mail infact@ftn.net
SAMPLE LETTER FOR USE IN REJECTION OF
SPONSORSHIP/DONATION/AGREEMENT
[Inside Address]
[Address of potential donor, partner]
Dear Sir or Madam,
Thank you for your generous offer [to donate to our Conference] [to
donate to our lactation, medical, newborn, maternity, clinic] [to enter into
a contract to provide services for....]
We are unable to accept this offer as we are aware that your (corporation
/ organization / company) [name the action you want to refer to which
contravenes the Code]
This activity contravenes Article(s)[list articles], or is incompatible
with [list the articles] of the WHO International Code of Marketing of
Breast-milk Substitutes.
We have enclosed for your information a copy of the Code. It is the
policy of our organization to enter into agreements ONLY with (corporations
/ organizations / companies) which adhere to the Code.
Please contact us if you wish further information about the Code.
Sincerely,
[Your Name]
-
- cc.
- International Association of Infant Food Manufacturers (IFM) 194, rue
de Rivoli, F- 75001, Paris, France
- INFACT Canada, 6 Trinity Square, Toronto ON M5G 1B1 ph416-595-9819,
FAX 416-591-9355
- Your local breastfeeding political action group or Baby Friendly
Network Breastfeeding Committee for Canada (BCC) PO Box 65114, Toronto, ON
M4K 3Z2
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Prepared by Jennifer Peddlesden, BScPharm IBCLC, and Cheryl Levitt MBBCh CCFP
for the Breastfeeding Committee for Canada.
Copies available from the Breastfeeding Committee for Canada. PO Box 65114,
Toronto, ON M4K 3Z2
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