The WHO Code for Marketing of Breast Milk Substitutes : Private Sector Power and Industry Accountability

Background

Evidence is mounting that human milk is not only beneficial, but foundational to unlocking the biological potential inherent in well-nourished and healthy human beings. The principle is simple: Human milk is the best nutrition for human infants, and lactating is biologically beneficial to lactating parents. Yet, humans are not simple, and we live in an economic system in which the production, distribution, and investment of goods and services are fundamental to our survival. Trade and industry depend on growth, which, in turn, increases financial stability and wealth. Wealth improves lives and can increase the health and well-being of individual human beings. The International Code of Marketing of Breast-Milk Substitutes (IC; World Health Organization [WHO], 1981), sits at the intersection of these two opposing forces, providing guidance to manufacturers who produce and distribute foods for babies that can complement or replace human milk through principles of responsible marketing. Its overarching aim is to eliminate unnecessary death and disease by preventing aggressive or misleading marketing.

Ellen M. Chetwynd, PhD, MPH, BSN, IBCLC

Since 1981 maternal and child health advocates worldwide have been working to bring manufacturers of human milk substitutes into compliance with the IC through the enactment of national legislation. To date, there are 25 countries making up 13% of the nations of the world which have passed policies that are “substantially aligned with the Code,” according to a statement marking the 40th Anniversary of the IC by WHO-UNICEF (Fore & Adhanom, 2021).

Over its 40+ years, the IC has undergone expansions, adjustments, and updates, for example, World Health Assembly [WHA] Resolution 69.9 Ending Inappropriate Promotion of Foods for Infants and Young Children (WHA, 2016). It has been fodder for endless debate among researchers, practitioners, and advocates in the diaspora of lactation support. Yet, despite the controversy that surrounds adherence to the IC, it remains as relevant today as it was at its creation. This is demonstrated by the marked increase of activities discouraged in the IC by manufacturers of human milk substitutes during the Covid-19 pandemic (Ching et al., 2021).

The pressure point between business practice and nutritional integrity is exactly where we find the Access to Nutrition Initiative (ATNI). This independent, non-profit organization, based in the Netherlands and funded primarily by the United Kingdom’s Department for International Development (UKaid), the Bill and Melinda Gates Foundation, and the Dutch Ministry of Foreign Affairs, “draws on the power of the private sector to address the global nutrition crisis” (Access to Nutrition Initiative, n.d.). They produce research and tools for private sector accountability through a holistic and inclusive approach that engages stakeholders from industry as well as nutritional advocacy. Their foremost publication is the Global Access to Nutrition Index (Access to Nutrition Initiative, 2021b). This document, published every 2–3 years, is a resource stemming from work with global food and beverage manufacturers and other stakeholders, ranking the steps each manufacturer takes to protect the world from its most difficult nutritional challenges. Their contribution to the protection and promotion of human milk feeding has been to grade the performance of the world’s largest baby food manufacturers over time using a statistical tool, an index, for ranking adherence to the regulations laid out in the IC by the industries selling human milk substitutes when marketing or promoting their products.

ATNI has been ranking baby food manufacturers since the first Global Access to Nutrition Index (GAIN) was published in 2013, but this year is the first year that it distributed a ranking system of baby food manufacturers as a stand-alone index, BMS/CF Marketing Index 2021: Major baby food companies’ compliance with the International Code of Marketing of Breast-Milk Substitutes (Access to Nutrition Initiative, 2021a). The goals of the GAIN Index and BMS/CF Marketing Index are the same: They both aim to improve global nutrition through objective assessment of the food industry, increasing motivation for accountability and transparency.

As with any index, methodology is critical, and should be based on clear and transparent rules. The BMS/CF Marketing Index ranks manufacturers of artificial or supplemental baby food based on their adherence to the IC and 18 additional related WHO resolutions. This is assessed in two ways. First, each manufacturer’s own policies and procedures are gauged for their alignment with the IC, including their stance on lobbying governments about the adoption of IC-based policies. Their assessment includes anything available in the public domain, as well as documents that the company chooses to provide to ATNI. Second, two low- or middle-income countries are selected, and an evaluation of marketing practices in each country is undertaken. For the 2021 Index, marketing practices were evaluated in the Philippines and Mexico; in previous editions, the countries selected were Nigeria, Thailand, Vietnam, Indonesia, and India. Countries are selected based on the presence of as many of the indexed manufacturers as possible. Research methods include interviews with mothers and healthcare workers, visiting health facilities and retail markets, assessing labelling and inserts on products, monitoring of traditional and online media, and assessing the products being sold. Indexed manufacturers are notified of the countries chosen for research sites after all research has been completed. Each of the two arms of evaluation are treated equally to create a score from 0%–100%. A score of 100% would indicate that the company was in complete compliance with the IC.

An index and a benchmark are both ranking systems, focused on a particular area of performance (e.g., financial success or environmental integrity) for companies and manufacturers. These ranking systems differ in the participation of the included companies. A benchmark offers a ranking system for companies that freely elect to participate; whereas, an index is performed by an outside agency and includes companies based on a standardized set of rules. The companies included in an index may choose not to cooperate with the ranking process. The BMS/CF Marketing Index included the nine largest baby food industries in the world which derived 5% or more of their 2018 global revenues from human milk substitutes and complimentary foods. Three of the nine companies included in the index were new this year. All of the new companies were based in China and only marketed their products in China. Typically, ATNI visits each company, introducing the aims of the BMS/CF Marketing Index and inviting participation in the process. Limitations on travel because of Covid-19 restrictions meant that this step was not successfully completed for the three new companies; therefore, the information included in the assessment of these companies was limited to documents available in the public domain. Their overall scores of 0% are a reflection of limited data available for evaluation.

The BMS/CF Marketing Index includes assessment of all types of baby foods that are promoted to infants up to 36 months of age, as referenced in WHA Resolution 69.9 (WHA, 2016). Companies are held accountable for their marketing policies in all markets, upholding marketing minimally to the level of the IC, regardless of the level of risk status for infant mortality or malnutrition, and higher than the level of the IC if individual government policies are more stringent than needed for IC compliance. They are required to have management systems in place that ensure implementation of policies across all their business constituents, a clear policy about lobbying, and transparency regarding all policies and practices related to BMS/CF.

Companies analyzed in the BMS/CF Marketing Index were Abbott, Danone, Feihe, Friesland Campina, KraftHeinz, Mengniu, Nestle, Reckitt, and Yili. Final overall scores ranked Danone as highest in compliance at 67%, followed by Nestle at 57%, KraftHeinz at 38%, Reckitt at 32%, Abbott at 28%, and Friesland Campina at 21%. Feihe, Mengniu, and Yili had scores of 0% because of the limited material available for evaluation. While important, these final scores only tell part of the story. For example, Reckitt, which recently took over Mead Johnson Nutrition, had been upgrading the policies in marketing and lobbying that were in place prior to change in ownership, as well as fully engaging in ATNI’s research process. As a result, they were the only company whose Corporate Profile score had improved across all areas of investigation. On the other hand, both Abbott and Friesland Campina’s overall scores dropped. Abbott wrote a new human milk substitute policy and committed to upholding it equally in all countries, regardless of existing government policy; however, the wording of the policy was weaker overall than their previous policy, reducing their overall compliance with the IC. Friesland Campina’s score dropped for different reasons. They did not write a new policy, but ATNI took a firmer stance on companies that reduced their level of compliance with the IC to match the regulations present in different countries if the regulations were weaker than their own policies.

The level of detail provided in the report is explicit, relevant, and easy to understand. The following discussion of geographic application of company policies provides a good example of what can be expected throughout the report:

KraftHeinz’s BMS marketing policy (Charter) applies globally, although the company only markets its formulas in Australia, China, Italy and New Zealand. However, the Charter does not extend to include CF (complementary foods) – the products that make up the vast majority of its sales across more than 30 markets worldwide. Two other companies – Abbott and Danone – state that their policies apply globally, but then limit their application to infant formulas only. In addition, their policies apply only in higher-risk countries for follow-on formulas and do not extend to growing-up milk. (p. 31)

While the results are very explicit, the tone of the index is open and positive. ATNI “urges” companies to make improvements, pointing out the path that will bring them into alignment with the IC and increase their score, but avoids using “should,” leaving it to companies to improve their internal processes for the protection of the world’s smallest human beings.

Conclusion

Reading the CMS/CF Marketing Index is a pleasure, and a welcome addition to the sometimes-pejorative landscape of accountability for manufacturers selling human milk substitutes. This well laid out and informative index provides a tool that is as useful to companies selling human milk substitutes as those advocating for “protection, promotion and support of breastfeeding” (UNICEF, 2005). Its tone welcomes baby food manufacturers to the table, assuming their interest in the topic and addressing them as if they share a desire for contributing to the safety of the world’s infants through upholding the principles laid out in the IC.

CMS/CF Marketing Index offers an appropriate compliment to the work of the WHO’s Marketing of Breast Milk Substitutes: National Implementation Of The International Code, Status Report 2020 (WHO, 2020), which holds governments accountable to the work of providing regulatory policies. The CMS/CF Marketing Index is already being used by the investment management company Financial Times Stock Exchange Russell (FTSE Russell) in their FTSE4Good Index Series (FTSE Russell, n. d.), an index that provides ethically driven investors with the tools they need to choose companies that prioritize social responsibility. I would urge all of us in the private sector to lift up the work of ATNI, centering accountability with the companies that profit from the sale of human milk substitutes, eliminating the loopholes that can circumvent the intention of the IC, and marking the positive changes that will move all of humanity forward in the responsible feeding and nurturing of our children.