Implementation of International Code of Marketing Breast-Milk Substitutes in China

Abstract

Background:

Breastmilk is the best source of nourishment for infants and young children, and breastfeeding is one of the most effective ways to ensure child health and survival. In May 1981, the World Health Assembly adopted the International Code of Marketing Breast-Milk Substitutes. Since then several subsequent resolutions have been adopted by the World Health Assembly, which both update and clarify the articles within the International Code (herein after the term “Code” refers to both the International Code and all subsequent resolutions). The Code is designed to regulate “inappropriate sales promotion” of breastmilk substitutes and instructs signatory governments to ensure the implementation of its aims through legislation. The Chinese Regulations of the Code were adopted by six government sectors in 1995. However, challenges in promotion, protection, and support of breastfeeding remain. This study aimed to monitor the implementation of the Code in China.

Subjects and Methods:

Six cities were selected with considerable geographic coverage. In each city three hospitals and six stores were surveyed. The International Baby Food Action Network Interview Form was adapted, and direct observations were made. Research assistants administered the questionnaires to a random sample of mothers of infants under 6 months old who were in the outpatient department of the hospitals. In total, 291 mothers of infants, 35 stores, 17 hospitals, and 26 companies were surveyed.

Results:

From the whole sample of 291 mothers, the proportion who reported exclusively breastfeeding their infant was 30.9%; 69.1% of mothers reported feeding their infant with commercially available formula. Regarding violations of the Code, 40.2% of the mothers reported receiving free formula samples. Of these, 76.1% received the free samples in or near hospitals. Among the stores surveyed, 45.7% were found promoting products in a way that violates the Code. Also, 69.0% of the labeling on the formula products did not comply with the regulations set out in the Code.

Conclusions:

As the social and economic developments continue, the interactions of more and more factors curb further success in breastfeeding. Support from all sectors of the society is needed in order to create a social environment to enable the promotion of breastfeeding, in addition to the efforts already made by the healthcare system.

Introduction

Breastmilk is the best source of nourishment for infants and young children, and breastfeeding is one of the most effective ways to ensure a child's health and survival.^1–5 The World Health Organization and UNICEF recommend exclusive breastfeeding for the first 6 months and introducing appropriate complementary feeding at 6 months, with continued breastfeeding for up to 2 years or more.⁶ The Twenty-Seventh World Health Assembly, in 1974, noted the general decline in breastfeeding in many parts of the world, related to sociocultural and other factors, including the promotion of manufactured breastmilk substitutes (BMSs).⁷ In May 1981, the World Health Assembly adopted the International Code of Marketing Breast-Milk Substitutes (herein after the term “Code” refers to both the International Code and all subsequent resolutions) in order to regulate inappropriate marketing of BMSs.

Although many governments have passed legislation containing all or some of the relevant aspects of the Code, many of these have not passed regulations to implement this legislation.⁸ China has made significant progress in the past few years. The Chinese Regulations of the Code wwew adopted by six government sectors in 1995. However, challenges in promotion, protection, and support of breastfeeding remain. As the social and economic developments continue, the interaction of more and more factors curb further success in breastfeeding.^9,10 According to the report of “Countdown to 2015—Maternal, Newborn and Child Survival” in 2005 and 2012, the proportions of exclusive breastfeeding in 2003 and 2008 were 51% and 28%, respectively. In 2008, the National Health Services Survey in China found the proportion of women who initiated breastfeeding within an hour after delivery was 41%.

The objective of this study was to monitor the implementation of the Code in China. We selected six cities to investigate.

Subjects and Methods

The study was approved (protocol number SHERLL2013004) by the ethics committee (registration number IRB00008963) of the Capital Institute of Pediatrics, Beijing, China. Informed consent was obtained from all study participants. The period of the survey was September–October 2012.

Six cities (Hohhot, Inner Mongolia Autonomous Region; Beijing; Jinan, Shandong Province; Shanghai; Nanjing, Jiangsu Province; and Shenzhen, Guangdong Province) were selected with considerable geographic coverage. In each city three hospitals and six stores were surveyed. Interviews and direct observations were used.

Questionnaires were used to interview mothers based on the International Baby Food Action Network Interview form. Observations were made on the promotion of BMS products in stores, hospitals, and clinics and the labeling of formula products and other materials produced by BMS companies, which are included within the scope of the Code. In total, 291 mothers of infants, 35 stores, 17 hospitals, and 26 companies in the six cities were surveyed. Data management and analysis were conducted using an Excel™ (Microsoft, Redmond, WA) format, double-entry system to ensure accuracy.

“Formula” is defined as milk powder given to infants younger than 6 months of age. “Follow-up formula” is defined as milk powder given to infants at or older than 6 months of age.

Results

Targeting mothers

Use of formula versus exclusive breastfeeding

Among the mothers surveyed (Table 1), the proportion of exclusive breastfeeding was 30.9% (90/291), whereas 69.1% (201/291) of mothers reported feeding infants with commercially available formula.

Table 1.

Age Distribution of Infants in the Survey

Months of age	Number of infants	Proportion
0	4	1.4%
1	75	25.8%
2	38	13.1%
3	58	19.9%
4	53	18.2%
5	63	21.6%
Total	291	100%

Direct contact with mothers

To protect mothers from being provided with information that comes from a source with an inherent conflict of interest, the Code forbids BMS companies from having direct contact with pregnant women or mothers. However, 39.5% (115/291) of mothers reported having been contacted by sales representatives of BMS companies. Locations where the contact was made are presented in Table 2.

Table 2.

Locations Where Company Representatives Contacted Mothers

Location	Frequency	Proportion
In or near hospitals	56	48.7%
Phone	41	35.7%
Store	8	7.0%
Company activity	7	6.1%
Other	3	2.6%
Total	115	100%

The most frequent contact points were made within hospitals or surrounding areas, followed by phone contacts (a call or text message).

Free formula samples and gifts

If new mothers are given free samples to feed to their infants, it can start a vicious circle that undermines their own ability to breastfeed. An infant satiated with formula may demand less breastmilk, so the mother produces less, and that can result in her losing confidence. The Code stipulates that free samples must not be given to mothers.

However, the research found that 40.2% (117/291) of mothers of infants received free formula samples, with 76.1% (89/117) of them receiving them in or near hospitals. Among the mothers surveyed, 26.1% (76/291) received gifts of various types, such as parenting books, toys, diapers, and bibs. Who provided these items to mothers is presented in Table 3.

Table 3.

Free Formula Samples and Gifts From Providers to Infants' Mothers

	Free formula samples		Gifts
Provider	Frequency	Proportion	Frequency	Proportion
Company staff	71 (117)	60.7%	50 (76)	65.8%
Health workers	43 (117)	36.8%	10 (76)	13.2%
Other	3 (117)	2.5%	16 (76)	21.0%
Total	117 (117)	100%	76 (76)	100%

Summary of Code violations within hospitals

Of our surveyed hospitals, 82.4% (14/17) were Baby-Friendly hospitals (Table 4).

Table 4.

Formula Companies' Promotions Within Hospitals

Behavior	Hospitals impacted	% of hospitals
Free formula sample for mothers	6 (6)	35.3%
Formula company posters	3 (3)	17.6%
Gifts for physicians with company logo	7 (6)	41.2%

One of the most concerning dimensions in the continued violations of the Code is the reported targeting of health workers—doctors, nurses, and midwives—by some BMS companies. The research showed that in seven hospitals, BMS companies have produced and provided physicians with gift items with company logo, including pens, cups/mugs, calendars, and so forth.

Promotion of formula or complementary foods in stores

Among the 35 surveyed stores in six cities, 45.7% (16/35) were found promoting products in a manner which violates the Code (Table 5). Some stores applied multiple techniques in promoting products.

Table 5.

The Major Promotion Tactics Observed

Promotion tactics	Frequency	Proportion
Presenting gifts when purchasing	8 (35)	22.9%
Bundle sales	7 (35)	20.0%
Introducing product information by sales representatives	7 (35)	20.0%
Providing product discounts	6 (35)	17.1%

Product labels

Our survey included 18 companies with 29 formula products, 10 companies with 17 follow-up formula products, and 12 companies with 20 complementary food products.

It was found that 69.0% (20/29) of formula labeling did not comply with the Code. The most frequent forms of violation are presented in Table 6.

Table 6.

The Most Frequent Forms of Violation to the Code

Failing to list	Frequency	Proportion
Inappropriate preparation of formula will risk health	7 (29)	24.1%
Use only under the instruction of doctors	6 (29)	20.7%
Using text or pictures to idealize the use of infant formula	12 (29)	41.4%

Of the follow-up formula, 76.5% (13/17) suggested using a bottle to feed, and for 35% (7/20), infant complementary food was recommended for infants younger than 6 months of age (Table 7).

Table 7.

Labels of Follow-Up Formula and Complementary Food

	Follow-up formula		Complementary food
Label	Frequency	Proportion	Frequency	Proportion
Recommended bottle	13 (17)	76.5%	2 (20)	10.0%
Baby image	0 (17)	0%	6 (20)	30.0%
Similar to infant formula	5 (17)	29.4%	0 (20)	0%
Recommended for infant below 6 months	0 (17)	0%	7 (20)	35.0%

In addition, 25% (5/20) of infant complementary food was marked to use “when first introduced” instead of “for 6 months or above.”

Marketing of formula company

Our survey found eight types of promotional materials from seven companies in doctors' offices and hospital lobbies, where mothers could easily access them. We also found another four baby products' advertisements in medical professional journals.

Twelve products were promoted in child healthcare clinics, in supermarkets, and on the Internet (Table 8).

Table 8.

Missing Information from Company-Produced Materials (n=12)

Missing information	Frequency	Proportion
Missing the benefits of breastfeeding	8 (12)	66.7%
Missing the negative effect of bottle feeding	11 (12)	91.7%
Missing difficulties in resuming breastfeeding	10 (12)	83.3%
Missing insist on breastfeeding	9 (12)	75.0%

In addition, it was found that three local televisions all showed infant formula advertisements in prime time.

Discussion

Breastfeeding holds the ultimate advantage over other forms of infant feeding, as it is critically important not only to early childhood development, intellectual development, and the prevention of infectious diseases,^11–15 but it also benefits the mother by reducing the risk of obesity, breast cancer, and osteoporosis.^16–19 Although this article does not cover the issues of breastfeeding by mothers living with human immunodeficiency virus, it is recognized that in some circumstances breastfeeding may not always be the best option for an infant.^20–23

In terms of infant formula, questions and concerns remain strong on the quality as well as the safety of formula ingredients, production process, and packaging process.²⁴ In contrast, breastfeeding is natural, safe, and environmentally friendly. In recent years, several scandals regarding domestic and imported formula have shaken the confidence of parents, who have become increasingly aware of the importance of breastfeeding.

Research indicates that the exclusive breastfeeding rate in China remains low²⁵ and has declined in recent years. However, there are specific issues to consider behind these statistics:

1. In 2008, the recommendation on the duration of exclusive breastfeeding was extended from 4 to 6 months of age. Therefore, the indicator prior to 2008 only referred to infants younger than 4 months of age.

2. Also prior to 2008, the definition of exclusive breastfeeding allowed for the inclusion of giving an infant water as well as breastmilk. This changed to breastmilk exclusively in 2008.

3. The maternal leave for women is only 3 months. Even with additional leave due to late child-bearing, the total duration is at most 4 months. This results in working mothers being forced to go back to work after their children reach 4 months of age.

In 2012, the “Special provisions of labor protection of female workers (draft)” mentioned that maternity leave will be extended from 90 days to 98 days. Because of the pressure of work, the travel back and forth between work and home, and the inability to feed on demand, it is difficult to continue breastfeeding after returning to work. Although the development and use of portable pumps and other equipment opened up new possibilities for mothers and infants,²⁶ not enough support at the workplace such as lack of privacy to pump breastmilk could prevent mothers from extending the duration of breastfeeding.

Research indicates that one of the major approaches of formula sales was through the influence and recommendations of health workers.^27,28 It was found in our study that the hospital is the primary site of inappropriate marketing and violation of the Code. Some among the medical staff still believe in exclusive breastfeeding for 4–6 months after birth, which is different from the World Health Organization recommendation, which is similar to findings in other countries.²⁹ Within hospitals, health workers' use of gift items from BMS companies undoubtedly cast influence upon mothers and implicitly strengthens the promotion of artificial feeding information to mothers. The promotion of breastfeeding should be the responsibility of all health workers.

Our survey result indicates, besides marketing at hospitals, BMS companies have marketed idealized products across the entire society through various methods such as television and magazine advertisement, promotion pamphlets at supermarkets, shopping Web sites, and parenting Web sites. Many BMS companies have extended their Stage 1 formula definition from “0–6 months” to “0–12 months,” which may lay a foundation for inappropriate marketing and promotion. Research indicates a lack of regulation over infant complementary food products.³⁰ Our study found vaguely labeled complementary feeding as “when first introduced” or “applicable for infants younger than 6 months of age” instead of “for 6 months or above,” hence implicitly or explicitly suggesting that infants younger than 6 months of age could also consume the formula.

New types of complementary foods are emerging. Recently, Chinese traditional medicine drinks and flavored tea for infants younger than 6 months of age are being sold by almost all complementary food companies. The major selling point is “release heat and help digestion,” which tactfully cultivates the message into the worrying minds of Chinese parents because it echoes the healthcare philosophy advocated by traditional Chinese medicine.

Decisions made by mothers directly affect the initiation and duration of breastfeeding.^31,32 Rapid development of BMSs, inappropriate media advertisement, and marketing practices, to varying degrees, affect the knowledge and confidence, and consequently decisions, of mothers on breastfeeding.

The Code is only one of several policy efforts to protect, promote, and support breast-feeding. Implementation of the Code has not come easily because of the conflict of interest between pro-breastfeeding government agencies and nongovernmental organizations against BMS companies.⁸

Research indicates systemic failings at all levels, including the failure of the World Health Organization to successfully “urge” governments to implement the Code in its entirety, a lack of political will by Member States to implement and monitor the Code, and a lack of formal and transparent governance structures.³³

Hospitals ought to implement rules and policies to prevent various forms of influences and temptations placed on the system and its health workers by BMS companies. At the same time, education for health workers on ethics as well as knowledge and techniques needs to be strengthened so that they fully understand the critical importance of promoting, supporting, and protecting breastfeeding.^34,35

Where applicable, the establishment of national and local legislations,³⁶ innovative support systems for mothers and health workers such as a breastfeeding hotline system,³⁷ and intervention approaches³⁸ could contribute to successful breastfeeding outcomes.

To create a social environment for the promotion of breastfeeding, in addition to the efforts of the health system, support of all sectors of the society is needed. The communication and education efforts from health workers need to be better and stronger to succeed over formula promotion campaigns.

Finally, in light of emerging challenges, new strategies for monitoring and enforcing the Code, such as the use of social media, may help counter ongoing efforts of BMS companies.³⁹

The promotion and support for breastfeeding must go beyond hospital walls and buildings. It is the responsibility of international organizations, government agencies, social media, local communities, health workers, parents, and everyone who cares about the health and well-being of all children.

Footnotes

Acknowledgments

This work was supported by Save the Children.

Disclosure Statement

No competing financial interests exist.

A.L. was responsible for on-site investigation, data collection and analysis, and report writing. Y.D. was responsible for project design and overall coordination. X.X. was responsible for survey staff training. L.C. participated in report writing.

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