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The Breast Milk Substitute Code - Time for Implementation and Enforcement in Nigeria

Breast milk substitute manufacturers, dominated by multi-national companies, use various advertising and promotion techniques to target new mothers. Photo credit: Nigeria Health Watch

Breast will always be best
The importance of breastfeeding to improve the health and nutrition of infants and young children cannot be overemphasised. Breastfeeding gives children the healthiest start in life. It is sufficient and beneficial for nutrition in a baby’s first 6 months. Breast milk stimulates brain development and functions as an infant’s first vaccine. Experts discourage the practice of giving babies any other foods and water in the first six months, even in addition to breast milk, as it may expose the baby to disease and hamper their development.

Global breastfeeding rates remain lower than what is required to protect the health of women and children, according to the 2019 global breastfeeding scorecard. From 2013 –2018, only 43% of newborns initiate breastfeeding within one hour of birth, and only 41% of infants under six months are exclusively breastfed. In Nigeria, only a mere 28.7% of infants age 0–5 months are exclusively breastfed, leaving a whopping 71.3% of children who do not enjoy the benefits of breast milk in their formative years.

Image credit: Nigeria Health Watch

Breast Milk Substitutes (BMS) include all milk products — infant formula, follow-up formula and growing up milks — marketed or represented as a partial or total breast milk replacement to feed infants and children up to 36 months old. BMS have been aggressively marketed by infant food manufacturers, making enforcement a challenge in the promotion of breastfeeding. The increased advertising and promotion of breast milk substitutes decreases breastfeeding rates as it discourages mothers from breastfeeding putting both children’s and mothers’ health at risk.

The adoption of the Breast Milk Substitute Code
The World Health Assembly (WHA) in 1981 adopted the International Code of Marketing of Breast Milk Substitutes (BMS). The Code was meant to help curtail the adverse effects that aggressive marketing and advertising, free samples and other promotional practices by infant food manufacturers have on breastfeeding rates and duration. The Code aimed to protect the most vulnerable, banning advertising and other forms of promotion of BMS. Since its approval, the BMS Code has been regularly revised by the WHA, taking into cognisance new scientific data on breastfeeding and the BMS industry’s new products and promotional tactics.

In Nigeria, the Marketing Of Infant and Young Children Food and Other Designated Products Regulations 2019 subsidiary legislation of the National Agency for Food and Drug Administration and Control (NAFDAC), came into effect on June 1, 2019. It seeks to control and regulate the marketing of BMS and complementary foods when marketed or otherwise represented to be suitable as a partial or total replacement of breast milk. It states that the advertisement or promotion to the public of breast milk substitutes and related products are prohibited and manufacturers and distributors are prohibited from providing, directly or indirectly, samples of BMS and related products to pregnant women, mothers or members of their families.

Poor enforcement of the BMS code — at what cost?
The Federal Ministry of Health, through NAFDAC, has stated that it is the duty of the manufacturers and distributors of breast milk substitutes and complementary foods, non-governmental organisations, professional groups and consumer organisations to collaborate with the agency in the implementation of these regulations. This is a tall order, manufacturers of breast milk substitutes have so far primarily guarded their commercial interests, and have been aggressively marketing their products.

Self-monitoring has not worked, and the sanctions for non-compliance have not been enough of a deterrent for breast milk substitute manufacturers to adhere to the Code, especially when they consider that the market value of the baby food market (which includes breast milk substitutes) was valued at an estimated NGN 114.9 billion in 2017 and has continued to grow. Added to this, population dynamics make Nigeria a very profitable market, with the high birth and fertility rates, as well as the increased participation of women in the workforce. All these factors would bode well for the prospects of breast milk substitute manufacturers, and so adherence to the Code has not been in their commercial interest.

Image credit: Nigeria Health Watch

The expenditure on breast milk substitutes by far exceeds the health budget used to deal with the consequences of not breastfeeding e.g. diarrhea and pneumonia. In 2017, Alive & Thrive analysed the costs associated with breastfeeding. Their analysis showed that there was a saving of $22 million (N6.93 billion) in healthcare costs if an infant was breastfed, however, there was a loss of $9 billion (N2.84 trillion) due to cognitive loss in children, following inadequate breastfeeding.

Healthcare workers — part of the problem?
Healthcare workers also have a role to play, ensuring and encouraging exclusive breastfeeding and eradicating practices that directly or indirectly challenge the initiation and continuation of breastfeeding. According to the NAFDAC regulations, feeding with substitutes, where necessary, should be demonstrated only by health workers to mothers or family members who are medically in need of any of the substitutes. Healthcare workers have the power to ban BMS from their health facilities and seize and confiscate any BMS brought to their healthcare facility without a medical prescription. These powers cannot be overemphasised, and healthcare workers should be urged to control the introduction, use and movement of BMS in health facilities.

Image credit: Nigeria Health Watch

Recently, we shared the story of Agnes, a first-time mother who was advised by a health worker in the health facility where she gave birth to her baby, to get infant formula because she was not producing “enough” milk. This is unacceptable as health workers are supposed to explain and emphasise the benefits of exclusive breastfeeding when a child is born. This exposes gaps in the knowledge and understanding of health workers about the benefits of breastfeeding, many also are largely unaware of the BMS code and so would more easily give into the inducements offered to them by breast milk substitute manufacturers.

A comparative analysis in June 2016 of efforts made in BMS Code monitoring found promotional materials for BMS in 48% of facilities in Nigeria and 25% of healthcare workers received BMS samples from manufacturers or their distributors and sales representatives. BMS marketing inhibits optimum breastfeeding practices by influencing health systems and providers. Targeted marketing tactics like this influence mothers to view BMS use as appropriate or a recommended feeding practice if they receive biased advice and promotional materials from trusted sources like the health system.

Time to take action

This is a rallying cry to the Honourable Minister of Health to take action to show the world that Nigeria is serious about the health and wellbeing of its most vulnerable population — its children. The International Code of Marketing of Breast Milk substitutes is non-binding, but sets out recommendations. However, with the new regulations that came into effect from June 2019, the Nigerian government needs to show its firm commitment by implementing structures that would ensure enforcement of the regulations. Otherwise, Nigeria will continue to face an uphill battle as it tries to push up exclusive breastfeeding rates, contending with the commercial interests of breast milk substitute manufacturers.

Counteracting BMS marketing practices and promoting the benefits of breastfeeding should be the leading concern in advocacy for Infant and Young Child Feeding (IYCF). The Federal Ministry of Health, regulatory agencies like NAFDAC, health facilities, healthcare workers and most notably, BMS manufacturers themselves, should work together to ensure compliance with the BMS International Code of Marketing. There will also be a need to implement independent monitoring mechanisms that are unburdened by commercial interests and have a legal mandate to enforce compliance. All infants and young children deserve the healthiest start to life, and breast milk, not substitutes, is key to jumpstarting a healthy life-long development.

Have you seen examples of or experienced aggressive marketing or distribution of breast milk substitutes in health facilities? Share your experience on our social media platforms or drop us a message in the comments section of this blog.

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