Manufacturers of breastmilk substitutes are routinely violating rules on the marketing of their products, regularly promoting them to health workers and mothers at health facilities across Abidjan, Côte d’Ivoire, according to an Alive & Thrive-supported study employing aspects of the WHO NetCode protocol. The study was conducted in partnership with the Government of Cote d’Ivoire.
“The study shows that we cannot let our guard down,” said Manisha Tharaney, Director of Alive & Thrive’s West Africa program. “We have to work together – with government and civil society – to support mothers to breastfeed and one way to do that is to implement the Code fully.”
Almost two-thirds of health workers at facilities in Abidjan have received information from breastmilk substitute (BMS) companies and many advise mothers to use infant formula, the study showed. Those practices – and others – violate the International Code of the Marketing of Breastmilk Substitutes (BMS Code), which was adopted 40 years ago this year, and Côte d’Ivoire’s National Decree to prevent BMS marketing, adopted in 2013. The decree bans all forms of BMS marketing, regulates product labeling, and stipulates sanctions for violations. However, challenges remain in its monitoring and enforcement, and the study helps to quantify the lack of knowledge about the type and extent of violations that occur, especially in the health system.
Marketing of breastmilk substitutes (BMS) continues to undermine breastfeeding globally, and developing countries experiencing rapid economic growth are especially vulnerable to expanding BMS markets. Côte d’Ivoire, where Nestlé runs a large subsidiary producing infant foods, has one of the fastest-growing global economies, expanding by 8% a year since 2012, with rising urbanization levels. While the country’s rate of exclusive breastfeeding has increased – from 12 to 23.5% between 2012 and 2016 – it remains far shy of the World Health Assembly Global Nutrition Target of 50% by 2025.
The violations in health facilities in Abidjan are of particular concern because breastfeeding rates are low in Cote d’Ivoire – among the lowest in the West and Central Africa region. The pervasive marketing of BMS and the promotion of baby bottles and teats may be important factors undermining efforts to improve breastfeeding rates. Indeed, bottle feeding is six times higher in urban areas than in rural areas, according to Côte d’Ivoire’s Ministry of Planning and Development.
Structured interviews with 330 mothers and 129 health workers and observation of equipment and promotional materials in 42 public and private health facilities allowed researchers to assess the prevalence of exposure to BMS promotions among mothers of children 0-23 months, the frequency of contacts between BMS companies and health workers, and the presence of educational/informational materials and branded equipment associated with BMS companies.
Forty-three percent of mothers were advised to feed milk products other than breastmilk in the past six months, with a significantly higher percentage mothers of older children (6-23 months) advised compared to infants aged 0-6 months. Two-thirds (66%) of mothers had seen BMS promotions outside of facilities. Among health workers, 63% were contacted by BMS companies, and only 8% were familiar with the BMS Code.
“This gives the government concrete information to act on,” Tharaney said. “Indeed, the Ministry of Health is introducing a new module to train workers on the Code as part of their Baby Friendly Hospital Initiative.”
In West and Central Africa, nine of 24 countries have no legal measures in place to implement the BMS Code, and only three countries have legal measures that are “substantially aligned” with it – the Gambia, Ghana, and Nigeria. Meanwhile, the West and Central Africa region has the highest rate of under-five mortality globally, with 97 children dying per 1,000 live births, and only 34% of infants under six months of age are exclusively breastfed, compared to 42% globally and 55% in Eastern and Southern Africa, according to UNICEF. At the same time, the infant food market in West Africa grew by 58% between 2005 and 2015, with the companies Nestlé and Danone accounting for more than 90% of market share in the region, according to Knowdys Consulting Group.
The full manuscript of this study is forthcoming in the journal of Maternal and Child Nutrition.