Midwives Must Uphold the Ethics of the International Code of Marketing of Breast-Milk Substitutes 

Key Principles of the International Code 

• No advertising of breast-milk substitutes, feeding bottles or pacifiers to the public. 
• No free samples for mothers. 
• No promotion of these products within health services. 
• No donations of free or subsidised supplies of breast-milk substitutes in any part of the healthcare system. 
• No direct or indirect contact between industry representatives and mothers. 
• No gifts or personal samples to health workers. 
• No idealised images or claims on product labels. 
• Information provided to health workers must be strictly scientific and factual. 
• Information on artificial feeding must explain the benefits of breastfeeding and the risks of artificial feeding. 
• Unsuitable products, such as sweetened condensed milk, must not be promoted for infant feeding (3). 

Governments that sign the Code are encouraged to implement its provisions through national legislation. However, in many countries, laws do not fully protect the public from violations, and the CMF industry often exploits gaps in legislation to continue marketing efforts (4). 

An example of this was recently highlighted in a BMJ report, which detailed a case in the United Kingdom where CMF companies exploited loopholes in national legislation to market their products indirectly (5). The Code prohibits industry personnel from directly or indirectly engaging with pregnant women and mothers, yet the UK’s legislation does not align with this provision. A scheme involving a collaboration between a formula manufacturer and a supermarket chain saw midwives employed to provide in-store infant feeding advice to families. This indirect marketing violated the Code’s ethical principles and was met with strong opposition before being stopped (4, 6). 

The Impact of CMF Marketing on Breastfeeding 

There is longstanding evidence that the industry is aware of the effectiveness of utilizing women’s confidence in trusted healthcare providers as a marketing ploy (4, 6). Promotion of CMF puts profits before infant health by undermining women’s confidence in their ability to breastfeed and perpetuating myths about the inadequacy of breastmilk. Repeated exposure to various marketing techniques plays on parents’ anxieties and self-doubts and may lead to early breastfeeding cessation (7). 

A 2023 Lancet series on breastfeeding confirmed that despite overwhelming evidence of the benefits of breastfeeding for child survival, health, and development, commercial formula sales continue to rise due to aggressive marketing tactics and ongoing violations of the Code (7). 

Women face a range of real and perceived challenges when initiating and maintaining breastfeeding. Ineffective latch at the breast, nipple pain and trauma and engorgement are examples of common challenges that cause stress for the breastfeeding dyad. In addition, normal infant adaptations in the period after birth such as crying and unsettledness may be misconceived as signs that breastfeeding is inadequate. Self-reported insufficient milk supply is commonly cited as a reason for the introduction of CMF and early breastfeeding cessation. The industry perpetuates the idea that formula feeding helps parents to resolve these problems (8,9). 

The Role of Midwives in Upholding the Code 

Midwives play a critical role in supporting breastfeeding. The ICM Essential Competencies for Midwifery Practice outline the fundamental knowledge, skills, and professional behaviours required for midwives. Competency 5, which focuses on the ongoing care of women and newborns, highlights midwives’ responsibility to promote early initiation of breastfeeding, exclusive breastfeeding for the first six months, and continued breastfeeding alongside complementary foods for at least two years, while respecting the individual feeding choices of women. 

Midwives must ensure they are not inadvertently participating in CMF marketing. Some industry initiatives may appear to offer educational support for parents but function as disguised promotional campaigns. Midwives must remain vigilant and ensure they are not contributing to brand loyalty or endorsing CMF products. 

Midwives’ Responsibilities Under the International Code 

As trusted healthcare providers, midwives must be aware of the pervasive and unethical marketing strategies used by CMF companies. They may focus on providing evidence-based, impartial support for breastfeeding while ensuring that parents who use formula receive accurate information on safe preparation and feeding practices (8). 

For further information and learning, ICM recommends midwives, other health professionals, and policymakers complete the updated WHO and UNICEF training course: Introduction to the International Code of Marketing of Breast-Milk Substitutes (2nd Edition).