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Take action to bring the UK law into line with the WHO International Code

Baby Milk Action has campaigned over the years for the UK Government to adopt legislation implementing the World Health Organisation's International Code of Marketing of Breast-milk Substitutes. On 1 March 1995 the Infant Formula and Follow-on Formula Regulations (SI 1995 No. 77) were adopted as law.

The law falls short of the International Code in important respects. Most notably, it allows advertising of products through the health care system, giving the baby food industry the perfect route to influence mothers. Such promotion is in direct contravention of the WHO International Code which the previous UK Government claimed to support.

Now that the Government has changed Baby Milk Action is relaunching its campaign to have the UK Law brought into line with the International Code.

What you can do to support the campaign...

In February 1997, before the general election, the baby food industry held a buffet for MPs at the House of Commons and argued against strengthening the law. Baby Milk Action was able to attend that meeting to provide an alternative viewpoint. Please support our work by becoming a member of Baby Milk Action or send a donation to Baby Milk Action, 23 St. Andrew's Street, Cambridge, CB3 2AX, UK.

The present Minister for Public Health, Tessa Jowell MP, has set out the new Government's aim to increase breastfeeding rates. It is important that the effect of the baby food industry's promotional activities in undermining breastfeeding is considered. Please write to Tessa Jowell MP and your own Member of Parliament (both c/o House of Commons, Westminster, London) asking for the law to be brought into line with the WHO International Code and tell Baby Milk Action that you have written. Baby Milk Action's briefing paper on the law follows to give background information.

Briefing paper on the UK law



"Allowing any advertising of branded milks to mothers is a retrograde move as it has the potential for discouraging breastfeeding. This is particularly important for Scotland as certain areas of Glasgow already have less than 7% of babies breastfed at 7 days. We don't want this situation, or efforts to improve breastfeeding rates, undermined further by commercial literature.. I have just completed a study which confirms that the composition of the brains of artificially fed infants is substantially different from breastfed ones up to the age of 40 weeks of age, and that is likely to have adverse effects on intellect and vision. Breastfeeding is the obvious choice and all formula milks are at best, a third rate option."
Prof. Forrester Cockburn, Department of Child Health, University of Glasgow. March 1995

"When the new regulations that we are discussing came in, all looked well, briefly. It seemed that at last we had law controlling the advertising of infant formula milks, but it soon became clear that the law was the weakest just where it was most needed. The new regulations allow the advertising of infant formula feeds in the health service, reversing a major part of the World Health Organisation code to which the Government signed up.
Martyn Lewis MP in a debate moving that the Infant Formula and Follow-on Formula Regulations 1995 (SI 1995. No. 77) be revoked. The present Prime Minister, Tony Blair MP, was a signatory to the motion.

UK baby milk law threatens infant health

Since 1981, Britain has publicly claimed to support the World Health Organisation International Code of Marketing of Breast-milk Substitutes. Despite this, on 1 March 1995, after a year of consultation, a law was brought into effect which is in direct contravention of this Code.

Despite the advice of 48 health, consumer and development bodies, the original proposals issued in December 1993, were weakened in line with the demands of the baby food and advertising industry - the only bodies calling for such changes. The decision shocked and disappointed all those who speak on behalf of infants.

The UK was one of the strongest supporters of the International Code when it was adopted in 1981. As a signatory to the 1990 Innocenti Declaration, the Government committed itself to "taking action to give effect to the principles and aim of all the articles of the International Code... in their entirety.." and to enacting, "imaginative legislation protecting the breastfeeding rights of working women... by the year 1995." The Government 1995 White paper, The Health of the Nation, called for an increase in breastfeeding rates and the Government officially supports the UK Baby Friendly Initiative in which the International Code is the pivotal recommendation. At the 1994 World Health Assembly, British support for the Code was reiterated once again.

In December 1993, draft proposals which were significantly stronger than the new law were issued and received an unprecedented response from health, consumer and development bodies. 48 agencies 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 for the law to be further strengthened and for the advertising ban to be extended to follow-on milks.

Because it arises from two European Directives the law has to contain many strong controls on information, formula samples, labels and exports. But the Government's decision to allow advertising of infant formula throughout the health care system negates many of these protective measures. This leaves British babies with less protection than those living in France, the Netherlands, Denmark, Spain and Luxembourg where infant formula advertising to the public (at least) is banned At the same time it will provide the baby food industry with the key to the expansion of the £119 million baby milk market - the use of the health care system as a market place.

Infant feeding 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 fallen in the UK since 1980. By 2 weeks only 50% of British babies receive any breastmilk at all.

The sharpest drop occurs in the first week, when mothers are in hospital. The percentage of mothers still breastfeeding after 1 week has fallen by 4%. The most common reasons given for stopping breastfeeding are perceived as: insufficient milk, painful breasts or nipples and that the baby would not suck. These problems are overcome with effective care. Only 1 - 5 % of women give up in the first two months because they have fed for as long as they intended.

Source: OPCS Infant Feeding 1990.

UK Breastfeeding rates 1980 1990
Birth 65% 63%
1 week 57% 53%
2 weeks 52% 50%
4 months 26% 25%
6 months 22% 21%

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 are very high:Norway - 99%, Sweden 97%, Denmark 98%, Poland 93%, Rumania 91%, Czech Republic 92%.

In contrast, where the bulk of health information is provided by the baby food manufacturers, breastfeeding rates are very low: Ireland 31%, France 50%, Scotland, 50% (in some parts of Glasgow less than 7%)

The UK Baby Milk Market

The baby milk market in the UK was worth £119 m in 1995. There are 4 main baby milk brands in the UK: Farley's, owned by Heinz, (USA), Milupa (Germany); Cow & Gate, 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 does not market infant formula in the UK at the present time.

What the manufacturers spend on promotion

The baby milk manufacturers refuse to reveal their promotional budgets so it is impossible to get accurate figures. Direct media advertising of infant formula brand names has not been permitted since the mid 1970s, so infant formula promotion has occured 'below-the-line' and has not been listed in the marketing reports of research companies such as Nielsen, Meal etc. Some manufacturers have claimed that the total advertising spend on baby milks in the UK is £5m or £6m. However, companies regularly make claims in trade journals, and based on these claims it seems likely that the figure is nearer £12m. At the lowest estimate of £5m the manufacturers spend £6.25 for each baby born in the UK. The government spends 9p-16p per baby on breastfeeding promotion.

"Farley's is trebling its promotional spend [on infant formulas] to £3m this year. The promotional programme focuses on providing information direct to the consumer as well as continuing to support health professionals as key recommenders. Source:Formulae Fight Back, Community Pharmacy May 1991

Junior Milk [Farley's follow-on milk] will be supported by a £1.5 m package this year, which includes advertising in women's magazines, sampling to almost half a million mothers and on-pack promotions... Milupa are spending £1.6m on their babymilks. Source: Chemist and Druggist 7 March 1992.

NB: This was before Milupa launched a follow-on milk. Most companies now have follow-on milks - some of which share the brand name of the infant formulas. There are hardly any advertising restrictions on follow-on milks so milks which look almost identical to infant formulas can be legally advertised on TV, billboards, wherever.

Three million leaflets currently appearing under lids of all Premium and Plus tins carry a 25p off coupon redeemable against Cow & Gate ready-to-feeds...Cow & Gate are still sponsoring GMTV's Mother and Baby Programme which is said to be reaching 42% of the target audience. They are also continuing their In-Touch campaign, which was launched last October. Some 5,000 mums contact C&G; each week to join the programme. This is likely to play a major part in product promotion plans throughout the year. Babycare. Supplement to Chemist and Druggist 5 March 1994.

NB The mother- support groups reach 10% of the 'target audience'. Mothers with problems are more likely to phone Cow & Gate for advice than La Leche League or the National Childbirth Trust.

Sponsorship is advertising

In addition to 'advertisments' for specific brands - (SMA White , Farleys First etc ) millions more are spent on promoting the company names, SMA, Farley's , which have been deliberately merged with the brand names. Expenditure on booklets, videos, awards, gifts, training programmes is referred to by the companies as 'education', but comes out of promotion budgets.

"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 companyÕs 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.

How companies profit from sponsorship

Two 1995 TV programmes, Newsnight (BBC 2 15.3.95) and Food File (C4 23.3.95) showed a Milupa hearing room in Hillingdon hospital. Before this room was opened babies were tested for hearing in a basinette. Now all the mothers have to go through this room which carries a large Milupa sign over the door. In the year following the opening of this room, sales of Milupa milks in the local clinic went up by 560%.

One 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 nurses, gaining a permanent place in the hospital along with an implicit endorsement of its products. In this hospital one survey showed that only 28% of mothers breastfeed exclusively, despite the fact that 75% say they wanted to. Each bottle-fed baby needs approximately 2 tins of baby milk per week throughout its first year of life. So the parents of the 2,880 bottle-fed babies leaving this hospital will need to spend £883,584 on baby milk. Farley's recouped its £2,000 grant when just 7 mothers chose its brand.

The cost of bottle feeding to the NHS

Gastro-enteritis is up to 10 times more common among bottle-fed babies. The hospitalisation of one infant with gastro-enteritis costs between £500 and £1000. The hospital mentioned above was out of pocket after 4 babies returned for treatment of gastro-enteritis. Department of Health statistics reveal that 11,554 babies were hospitalised with gastro-enteritis in the UK in 1992. This cost the NHS aprox £12 million. Cases of gastro-enteritis treated by GPs cost the NHS a further £6 million. Breastfed babies are rarely hospitalised for gastro-enteritis.

Breastfeeding also protects against many other diseases and infections all of which incur costs to the NHS and distress to families. For example, bottle fed babies are twice as likely to suffer from respiratory infections. 49,000 babies were hospitalised with respiratory infections in 1992. Source: Protective effect of breastfeeding against infection. Howie et al., BMJ 1990 336

Breastfeeding is better for mothers too and studies have shown that it reduces the risk of pre-menopausal breast cancer. Source. Lactation and a reduced risk of pre-menopausal breast cancer. Newcombe et al. The New England Journal of Medicine. 1994; 330. Breastfeeding and a risk of breast cancer in young women. Chilvers - UKNCCSG, BMJ 1993 307.

Government expenditure on breastfeeding

In 1995 the Government supported the breastfeeding support groups with grants totalling £70,000. The groups reach approximately 10% of new mothers. This year the Government is also supporting a new scheme, Invest in Breast Together which includes a training pack for midwives and health workers. This support amounts to approx. £60,000. Government expenditure on breastfeeding totalled £265,000 between 1988 - 1992. Source Hansard and DoH. Government expenditure = 16p per baby (Live births in UK in 1992 = 781,000 Source OPCS.)

Health education: It is not clear how much money will be allocated for health education material on infant feeding for parents. In December 1993 the Government announced cuts to the Health Education Authority and there is no assurance that comparable funds will be found to provide information about the unique qualities of breastmilk and breastfeeding. The Government seems to be passing this responsibility to commercial companies.

Will the guidelines be effective?

As at 4th June 1997 the Department of Health is yet to finalise guidelines to accompany the new law. Although the previous Government can be congratulated for setting up a multi-sectorial working party to create these guidelines, it has to be remembered that however strong they are they cannot counteract the law. Advertising will still be allowed.

If, when published, the guidelines are as strong as the health agencies are urging for, they may help curb much of the misinformation which is presently contained in infant feeding literature. But it is clear that the companies are highly unlikely ever to agree to specify the real risks of bottle feeding. There is a great danger that the Government will convey the message that commercial materials which conform to the guidelines are as good as non-profit material.

NB: The UK law is not as strong as the Directive and creates an important loophole. The UK law states that donations by manufacturers of educational materials "shall not be marked or labelled with the name of a proprietary infant formula." The Directive is much stronger and states that such materials "shall not refer to a proprietary brand of infant formula." In addition to allowing advertising in booklets published by agencies such as Bounty Services or the Royal College of Midwives, it could be argued that the new law allows companies to advertise their brand names in all their donations of educational materials to the health care system. Although the guidelines may be able to overcome this, they will not have the strength of law.

The failure of the UK voluntary code prior to the law

The baby milk companies attempt to convey the message that they are 'responsible' and favour codes of practice, especially ones which give the appearance of being very strict. The voluntary code in the UK in effect since 1983 (The FMF Code of Practice for the Marketing of Infant Formulae in the UK), although superficially similar to the WHO Code, was very weak. It condoned the channelling of promotion through the health care system. An analysis of the FMF Code by a marketing expert stated that: "In effect the UK Code renders the WHO Code inoperative in the UK." Source: Hamilton R. A Comparison of the WHO and the UK Codes of Practice for the Marketing of Breastmilk Substitutes. Journal of Consumer Policy 10 (1987) 167 - 192.

The Manufacturers' Code Monitoring Committee met in secret and did not control the promotion that occurred. In recent years there has been an alarming increase in promotion with adverts extending outside the health care system - sponsored TV shows, direct mail, direct advertising in pharmacies and supermarkets. This was not allowed by the voluntary code.

Why promotion undermines health education.

A number of research articles have examined the impact of commercial promotion and whether it counteracts messages that health workers may try to convey:

Commercial Discharge Packs and Breastfeeding Counselling: Effects on infant feeding practices in a Randomised Trial. Source Frank et al. Paediatrics 1987; 80 This randomised trial in the US showed that removing advertising had more impact on breastfeeding rates than intensive efforts to train staff in breastfeeding support. The commercial packs tested in this trial were similar to packs given to mothers in UK hospitals now. "Compared with commercially prepared discharge materials, noncommercial discharge materials consistent with the WHO Code significantly prolonged by more than 2 weeks the duration of exclusive breastfeeding, delayed the introduction of daily solid foods, and increased the likelihood that infants would still be breastfeeding, at least partially, at 4 months postpartum." The (non-commercial) discharge pack was also associated with lower rates of rehospitalisation of infants than was the commercial discharge pack.

Breastfeeding Knowledge of Hospital Staff in Rural Maternity Units in Ireland. Source: G. Becker. J. Human Lactation 8 (3) 1992. 137 - 142 This study examined the level of knowledge of breastfeeding in health workers. When responding to a self-report questionnaire the health workers felt that they had adequate knowledge, but their answers did not always bear this out. "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."

An Evaluation of Breastfeeding Promotion Literature: Does it really Promote Breastfeeding?
R Valaitis et al.. Revue Canadienne de Sant? Publique, Vol. 84 No 1.1993 This study pointed out the complexity of providing useful written information on breastfeeding and shows that commercial literature in general gave negative messages about breastfeeding.

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

Does banning advertising deny mothers' rights?

All mothers have a right to feed their babies as they want. But there are important points to remember:

  • Brand name advertising is not the same as impartial information, The aim of the WHO International Code is to ensure that health workers, mothers and carers receive full and impartial information. The aim of brand name advertising is the opposite - it provides selective information, projecting only the qualities that advertiser chooses.
  • Banning advertising does not deny anyone the right to buy baby milk if they choose;
  • Consumers can always contact companies on an individual basis for more information, for example if they want to know how much sugar a product contains;
  • Virtually all mothers in the UK deliver their babies in the health care system. 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;
  • Mother and babies should have the right to a delivery in a non-commercial environment and be assured of impartial advice. The new 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. Parliamentary Secretary to the Ministry of Agriculture (Mr Nicholas Soames) stated in the Adjournment debate 27 April 1994 "It has been suggested - that it is inconsistent to consider legislating against the advertising of infant formula while refusing to take similar action in the case of tobacco. The fundamental issues are not the same. Cigarette smoking is a matter of personal choice.... It does not follow that the same solution is appropriate for infant formula advertising, where we are seeking to protect the best interests of people who are unable to exercise their own personal choice - the newborn."

Case study of Norway

"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, September 1994.)

Breastfeeding rates in Norway

98% of women leave maternity wards breastfeeding. 90% are breastfeeding at 3-4 months. 75% of women are still breastfeeding at 6 months.

Maternity leave in Norway

In Norway, women with paid work outside the home breastfeed more than women at home. Maternal 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 a two hour leave daily.

Health in Norway

Infant mortality rate is 6 per thousand (UK is 7 per thousand). Norway spends more on education than the UK (9% of central Government expenditure as against 3% in the UK) But its expenditure on health is less (10% as against 13%). Source: UNICEF State of the World's Children. 1995.

Baby milk promotion in Norway

The Norwegian Government has, since 1970 had a strong, unequivocal policy on breastfeeding. There are only two companies marketing baby milk in Norway and after a voluntary agreement was agreed in 1983 they have not been allowed to promote their products. The agreement has been respected except for the content of commercial information material which has not been conducive to breastfeeding. But Norwegian health services have never been saturated with promotional material as they have in the UK and most Norwegian mothers are aware of the advantages of breastfeeding and all have access to the mother-support group network. Source: The case of breastfeeding in Norway, The Norwegian Breastfeeding Association (Ammehjelpen, 1994.) and Breastfeeding in Norway in Good Times and Bad, Berit Austveg, Directorate of Health and Elisabet Helsing WHO. 1992

Companies lobby for a weak law

In the two Adjournment debates that took place on the law (April 1994 and March 23) David Faber MP and Mrs Angela Browning, then Parliamentary Secretary to the Ministry of Agriculture, referred to 'an independent survey' which allegedly proves that mothers and health workers do not want advertising to be banned.

In fact, the survey was commissioned by Bounty Services , a company distributes advertising and free samples of baby foods and milks to new mothers and had a clear vested interest in a weakening of the law. As Mary Daly, Professional Officer for External Relations of the Health Visitors Association said, when the survey was published, "85-90% of practising health visitors in this country are members of the HVA, yet we have not been consulted about this survey and have not approved the questions. We seriously question its validity, and the basis upon which health visitors were chosen."

The questionnaires contained leading questions such as: "There has been a voluntary code in the UK for some years now for the purpose of ensuring that infant formula milk advertising does not cause a reduction in breastfeeding. .."

The publicity for the survey failed to point out that 70% of health visitors and 74% of midwives felt that the UK voluntary Code should be replaced by a new law.

In February 1997 a UK baby food industry body called INFORM held a buffet for MPs at the House of Commons and presented the results of a similarly flawed MORI survey. The industry again campaigned against a ban on advertising, arguing that advertising was vital for providing information.

Martyn Jones MP saw through the survey and noted some other interesting findings which showed a serious knowledge gap, despite advertising. In a statement he said: "The way this survey has been conducted, it papers over any dis-benefits, thereby making infant formula appear to be as good as breastmilk...Of those mothers who never breastfed, 23% identified breastmilk as having benefits for the baby's immunity, compared to 44% of the mother who did breastfeed. Looking at the mothers who agreed breastfeeding was best for babies, 45% of those who only used bottle feed agreed, compared to 75% of mothers as a whole...This is statistically significant in highlighting a knowledge gap which must be explored. Clearly non-breast feeders have a statistically much lower appreciation of how good breastfeeding can be!"

Take action.

Write to the Tessa Jowell MP and your own Member of Parliament (c/o House of Commons, Westminster, London) and ask for the UK Infant Forumla and Follow-on Formula Regulations 1995 (SI 1995 No.77) be brought into line with the WHO International Code.

Join Baby Milk Action and support the campaign.