Ethical Commercial Sponsorships

Background

Midwives are health workers communities trust, and as a result they must safeguard their independence from all commercial influences that could compromise ethical care and service delivery. Unethical commercial sponsorship can come from a wide array of industries, including those promoting breastmilk substitutes, ultra-processed foods, or pharmaceutical, medical and technological companies with questionable ethics, safety records and/or data sharing systems, as well as others. The World Health Organization (WHO) warns that these types of relationships distort professional judgement, even unconsciously, leading to biased recommendations that can favour profit over public health (1). This effect is present regardless of the size of the contribution and whether the sponsorship is in cash or in-kind.

Midwives are in a unique and powerful position to influence decisions families make about health, wellness, newborn feeding decisions and support. These decisions are often being made at a time when women are very vulnerable. As a result, midwives are often specifically targeted by businesses. For example, since 1981, the WHO has implemented the International Code for the Marketing of Breastmilk Substitutes as a way to ensure an environment where families can make unbiased decisions about infant feeding (2). Aggressive marketing of these products continues and contributes to poor health outcomes in children (3), as well as to the burden of non-communicable disease for women (4).

Evidence shows that aggressive marketing directly influences health workers’ advice, with exposure to promotional materials, sponsored events and gifts creating unconscious bias, leading health workers, including midwives, to recommend certain products more often, for example, formula even when breastfeeding is viable (5). Health workers exposed to this type of marketing are more likely to have positive attitudes and are more likely to recommend them, while at the same time, less likely to identify false or misleading claims in marketing materials. These effects occur even when health professionals cannot recall sponsors’ names and when they believe they are not influenced by exposure to the products (6). Breastmilk substitutes are a key example of this practice with direct impact on maternal and newborn health. As a result, in 2022 WHO explicitly prohibited manufacturers of breastmilk substitutes from sponsoring health worker and scientific meetings (5), with the goal of preventing conflicts of interest and ensuring parents receive unbiased information. WHO has also published a model policy on ethical sponsorship for health workers’ associations to use (6).

Position

ICM, midwives’ associations (MAs) and individual midwives engage in a range of partnerships with non-profit agencies, as well as commercial businesses. Businesses and their partners derive significant reputational benefits from working and/or being associated with ICM, MAs and midwives in general.

It is important to ensure that any commercial partnerships deliver maximum benefits, while also respecting ethical norms, including the ICM International Code of Ethics for Midwives and WHO Code on the Marketing of Breastmilk Substitutes and other relevant WHO guidance.

Recommendations

ICM recommends policymakers and health system level decisionmakers to:

1. Adopt and enforce legal bans on sponsorship, gifts or funding from industries promoting products harmful to public health, in alignment with relevant WHO guidance (7).
2. Create funding mechanisms for all health workers (including midwives) to have access to funded, industry-free education and training, ensuring that information remains evidence-based and free from commercial influence
3. Prohibit industry representation in health policy fora, banning lobbyists and marketing representatives from participating in in national or institutional guideline committees.
4. Ensure regulation around personal data protection and use of personal data is implemented to keep sensitive health and contact information safe from third parties (including unethical artificial intelligence training models).

ICM recommends midwives’ associations:

1. Publish clear ethical guidelines on what kinds of partnerships are acceptable for the association, health facilities and individual midwives, based on this Position Statement and the WHO Model Policy (6).
2. Ensure good public communications so that partnerships do not undermine the good standing of the MA or the midwifery profession
3. Ensure all partnerships are for a finite period, in the event of new evidence emerging related to the risks, benefits or acceptability of a product or partner
4. Reject commercial sponsorships, trade displays with companies who market products that do not benefit or adversely affect the health of mothers, newborns, young children and their families
5. Work with governments through legislative, regulatory or other suitable measures to ensure ethical commercial activities for health workers, women and other consumers

ICM urges midwives and all health workers to:

1. Refuse financial or in-kind incentives for conferences, meetings, and events from manufacturers of breast milk substitutes and other products that do not benefit or adversely affect the health of women, mothers, newborns, infants, young children and families.

References

1. World Health Organization. Commercial determinants of health. 2023. Available from: https://www.who.int/news-room/fact-sheets/detail/commercial-determinants-of-health
2. World Health Organization. The International Code of Marketing of Breast-milk Substitutes. Frequently Asked Questions. 2017. Available from: https://iris.who.int/bitstream/handle/10665/254911/WHO-NMH-NHD-17.1-eng.pdf
3. Pérez-Escamilla R, Tomori C, Hernández-Cordero S et al. Breastfeeding: crucially important, but increasingly challenged in a market driven world. Lancet. 2023; 401(10375): 472−85. Available from: https://doi.org/10.1016/S0140-6736(22)01932-8
4. Louis-Jacques AF, Stuebe AM. Enabling breastfeeding to support lifelong health for mother and child. Obstet Gynecol Clin North Am 2020; 47:363−81. Available from: https://doi.org/10.1016/j.ogc.2020.04.001
5. World Health Organization, UNICEF. How the marketing of formula milk influences our decisions on infant feeding. 2022. Available from: https://www.who.int/publications/i/item/9789240044609
6. World Health Organization. Sponsorship of health professional associations by manufacturers and distributors of commercial milk formula. 2024. Available from: https://iris.who.int/server/api/core/bitstreams/2679f850-772e-4398-a8e3-60a7728f98bf/content
7. World Health Assembly. International Code of Marketing of Breast-milk Substitutes. 1981.