Em Mch 155 Em Reg Sct Wrk

REPORT ON THE REGIONAL SCIENTIFIC WORKING GROUP ON BREASTFEEDING NICOSIA, CYPRUS

26 - 30 January 1981 The views expressed in this Report do not necessarily reflect the official policy of the World Health Organization TABLE OF CONTENTS

1.1 RECENT ADVANCES IN KNOWLEDGE CONCERNING BREASTFEEDING 5 1.2 RECENT DEVELOPMENTS IN PROGRAMMES TO PROMOTE AND PROTECT 8 BREASTFEEDING

2. MVLEW OY THE !3MASTYEEULNG SITUATLON IN 'lXE REGION 13

3. PROPOS.ALS FOK KLSEARCH CONCERNING THC PREVA1.ESCL AN11 nI'HATTON l)r '!RI:A$II:FI:I)TUC ANn ASSOI'TATFn FACTORS

4. PROMOTIONAL AND EDUCATIONAL ACTIVITIES FOR THE PUBLIC ON 22 BREASTFEEDING

5. THE TRAINING OF HEALTH WORKERS CONCERNING BREASTFEEDING 25

6. THE PROPOSED CODE OF MARKETTNG OF BREAST-MT1.K SITRSTTT1TTF.S 28

7. THE ROLE OF WOMEN'S ORGANIZATIONS IN THE SUPPORT OF BREASTFEEDING 29

8. MATERNITY OR "LACTATION" LFAVE

9. LEARNING MATERIALS ON BREASTFEEDING RECOMMENDATIONS 40

ANNEXES

I. OPENING ADDRESS OF H.E. THE MINISTER OF HEALTH, MR G. TOMBAZOS

!i. MESSAGE FROM DR A.H. TABA, DIRECTOR WHO EASTERN MEDITERRANEAN REGION

111. TiiE TEXTS OF WORLD HEALTH ASSEMBLY RESOLUTIONS 27.43 of 1974, 31.17 "1 1978 arid 33.32 "1 1980

1V DRAFT INTERNATIONAI. CODE OF MARKETING OF BREAST-MILK SUBSTITUTES AS SUBMITTED TC: Ti!i: WHO EXECUTIVE BOARD IN JANUARY 1981; IN ITS RECOMMENMTION FORM. (WHO DOCUMENT EB 67/20 PAGES 14 THROUGH 21)

V. LIST OF PARTICIPANTS Ever since infant formulas manufactured industrially became available on a large scale early this century as substitutes for breast-milk, it is probably true that most doctors have nevertheless believed that breastfeeding was the method of feeding more likely to result in an infant's hsalthv growth. While some paediatricians deplored more emphatically than others the decline in breastfeeding, the belief also came to be widely held that really there was little difference between breast-milk and infant formulas, and that it did not much matter by which of the two methods an infant was nourished. However, scientific knowledge about the composition of human milk and its anti-infective properties has been expanding at an accelerating pace in the last twenty years. It has now come to be realised that, as H.E. the Minister of Health of Iyprus atates in his opening address to tho meeting (Anncx I): "Breastfeeding in an unequalled way of providing the ideal food for the healthy and harmonious physical and psychosocial development of infants". It is a unique biological substance with biochemical and immunological characteristics far beyond the capacity of modern science and industrial technology to replicate. With this realimtion, and accom- panying other changes in life st,yle, there has come a marked revival of interest in breastfeeding in Europe, North America and Australasia. As the Regional Director points out in his intmduotory massage (Annex 2), it is with some eurprise, as well as satisfaction, that we have seen an actual well-documented increase in the percentage of muthers breastfeeding in those regiuns. The view that breastfeeding was a "lost cause", that the slide towards bottle feeding was unavoidable and irreversible, has been shown to be wrong. However, the view that it did not much matter whether an infant was bottle fed or breastfed rarely prevailed among physicians and nurses in the developing countries except tnosa wno, in private urban pracuce anb uncnznlcingly accepting rorelgn rasnlon, were riot in touch with reality. All who served the ordinary people of developing countries were daily oonfronted with the evidence of the dreadful effects which could result from illiterate mothers in unhygienic surroundings bottle feeding their infants. The common contamination of We feeds, made worse by the absence of the specific anti- infective factors of breast-milk, produced frequent episodes of diarrhoea1 disease. If the child did not die in one such attack, the over-dilution of feeds owing to poverty and ignorance would combine with the consequences of recurrent diarrhoea to produce severe and often fatal protein-energy malnutrition. It is no wonder that Cicely Williams, the pioneer and doyenne of tropical paediatrics, entitled an address she gave in Malaya in 1940 on this subject, "Milk and Murder", or that H.C.Trowel1, co-author with D.B. Jelliffe of "Diseases of Children in the Tropics and Sub-tropics", said in 1946 that In rural Africa one ml@t as well wrltt! an infant its death certificate as write a prescription to bottle-feed it.

In our Eastern Mediterranean Region, Professor Jam1 Harfouche in her contribution (pages 13 - 16 ) summarizes well the present situation as regards breastfeeding, and explains why those dealing with child health view this state of affairs with concern and apprehension. Her views are based on what must surely be the most comprehensive review of infant feeding practices ever made in this part of the world, which was undertaken by her for WHO/EMRO in 1980, covering all published and * many unpublished reports from all countries of the Region.

AS Professor Harfouohe shows, there is in the Region a peculiarly mixed situation. We have a few industrialized or wealthy countries where breastfeeding has probably reached the lowest point it will ever reach, its nadir so to speak,, and the trend henceforth will be one of increase in breastfeeding, the speed of the trend back to breastfeeding probably depending much on the future efforts of the health professions. At the other end of the spectrum, we certainly have rural areas and populations where to a large extent the traditional mode of breastfeeding for two or more years still prevails almost undisturbed. Nomads in Central Asia and North-East Africa come to mind as examples, as well as some remote agricultur- alists or pastoralists, but it becomes harder to name such traditional groups. A great variety of patterns of breaatfeeding between these two, the nadir and the traditional, occurs over most of our Region. The bottle has penetrated even small vLllages to a much greater extent than is usually realized, even for feeding soft drinks, diluted animal milk or cereal paps. As Professor Harfouche points out, perhaps the most worrying problem which alarms the greatest number of national health authorities is cessation of breastfeeding at a veSy early age (under three months) followed by bottle-feeding undertaken by mothers who are illiterate or semi- literate and do not understand how 'to bottle-feed either in correct proportions or in a hygienic manner, having little idea that diarrhoea is caused by the ingestion of pathogenic organisms in contaminated reeds. This is largely reSpOnSiDle ror tne * This review on breastfeedingin the Eastern Mediterranean Region is to be published soon in the WHO/EMRO Technical Publication Series, and its draft version was made available to each of the participants in the meeting. change in the epidemiology of severe protein-enerw malnutrition from the kwashiorkor- type or mara~rmsof fairly late onset (e.g. 9 - 18 months), to the type of infantile - maraemus affecting infants under six months which has such a wide prevalence at present in many countries, e.g. Libya, Iraq, the Gulf Area, and parts of Yemen Arab Republic, as well as in urban areas throughout most of the Region. This type of infantile marasmus is often combined with recurrent diarrhoea and often comes to the notice of health workers during an acute episode. Indeed, in some cities the prevalence of this diarrhoea/malnutritim syndrome and incidence of acute episodes is auch as to occupy at certain seasons a large proportion, even half or more, of all available paediatric bed spaoe,

Problems such as these Led in 1974 to the adoption of World Health Aosernbly Resolution 27.43 whioh called for action on the part of WHO and its Member States to promote and protect breastfeeding; and in 1978 and 1980 to the further Resolutions 31.47 and 33.32, again strongly supporting breaetfeeding and the latter Resolution spelling out in detail a programne of actions which the Assembly requested to be undertaken by the Director-General, The texts of all three Resolutions will be found in Annex 3. Following on these Resolutions, each Reglonal Office of Wm) has begun a series of activities to promote and protect breastfeeding. The Eastern Mediterranean's activities have included among others, (1) a letter of advice to the Governments of the Region in 1976 concerning the marketing of breast-milk substitutes; (2) some seminars or parts of sednars at national or sub-national levels devoted to the subject; (3) the extensive distribution throughout the Region of several hundred (in one uase, several thousand) copiea of each of five books or booklets which deal either exclusively or in large part

with breastfeecling; (4) the inclusion 0% four of these publicstions in its Arabic Language Programme; (5) the translation, in cooperation with UNICEF, of the WHO Booklet into Urdu, Persian and Pushtu besides Arabic; (6) the drafting, as mentioned above, of the propoeed Technical Publication on breastfeeding in this Region.

Now, the Regional Office has convened this Scientific Working Group comprising in Y the win persons of experience from the Region, in order to advise the Regional Director on a programme of action for the years 1981-1983, the remaining half of the period + covered by the WHO Sixth General Program of Work. me main components of the programme of action were envisaged as coming under the seven headings specified in items 3 to 9 of the Agenda, whioh was as follows: * List of participants can be found in Annex 5 1. Review recent advances in knowledge about breastfeeding and recent developments in programmes concerning breastfeeding in the world in general.

2. Review the situation as regards breastfeeding in the various countries of the Region (draft WHO/EMFiO Techniaal Publication, plus contributions from the participants), 3. Draw up proposals for research conoerning prevalence and duration of breastfeeding and associated factors. 4, Draft proposals for promotional and health educational activities on breastfeeding addressed to the public; and for the evaluation of these activities. 5. Advise on the training of health workers at a11 levels concerning breastfeeding . 6. Review the draft International Code of Marketing of Breast-Milk Substi- tutes, and consider its implementation in the Region.

7. Consider the possible role of women's organizations in breastfeeding in countries of this Region. 8. Review the situation concerning maternity leave/'lactatlon" leave and make recommendations.

9. Make proposals for the production and distribution of learning materials to support the promotional and educational activltiws above.

Following the opening address by H,E, the Minister of HealthMr G. Tombazos and the message of the Regional Director of WHO EMRO, Dr A.H. Taba, and the election of Professor Jam1 Harfouche as Chairman, of Dr Jalal Aashi and Dr Saad Hejazi as Vice-Chairmen and of Professor Ashfaq Ahmed Khan as Rapporteur, the above Agenda was adopted. ~1*l/i4~:'rXjl55 EM~G~s@~~u~~GR~~G/A~ page 5

It has bean m~ritxoaaeri fr- the Ints48dt~-tian%ha$ especially Pa &the load, Setrade the"~ has been a rapid and acrelera'li;,c+ ~x~whsionrri lmaw3erEgg~about rhe bicckxainicsl dnd L~uE-~G-

Logical pr'ogai-tics of ?IL~,DL.mldr &nu thc ways dn rrhdlskk thebe dfffar or are absen'l -?roar GPJC cow's milk which, modified at- unmodEfs,lsd, is oommonly used as a ~~eeat-riailksu)s~LiL~ia,

War is the advance in our IW~PPS~BIL~LFLS1SmiLed Lo the specific and kulkgue p~opesliezLP

human milk, Bmeib more 1s ur-*rza~.stooci-c,oday about the psj?eh~Po&rBna tk~y~Lolsgyi.?' ~B~.LL tion, and about the birth-spncjzg eff'cet of the traditional mttam a2 bseas%xesdfng, wnlle the donplex ~~cIl&i;%o~raka%pb~ir,eueea mbuemal minutrtkri~n~iafar~t gt.owtda and 133i~ti3tloi: is a current issue, Nor ~hoi1i.d ;;re ornit another advaaee in our lmowledge, tbbt of the economics nf breastfeeding both from the pain% sf v4ew of the poor in the Fhl-d Wox~ld an%

%he relative cost t~ them and Lo other esuntries Q& breast-milk substituxen, snd of the infant food industries produclrmg them, and of their business p~sctieea,

This newly acquired informtian is too extensive to be even sum~ixdkeerae, hfk~a. follows rnefely touches ow o few intaresting point8 and for a full ae@ou!?-s, the rcat

Millians of years of evolution have gone: into the &aptation of milk< of sa-'~qp~..;<-i~ ncluding hwnan beingss Lo meet the rspecific weeds of fheir yomg, Th%a process ol

adaptation is reflected In vast aLf>csenne,s $2 &he aomosftion a-" L~L?mhll c' a'-- # 31ua 1.i~mnmilk i~ ua<:r-- 4DCa :;rhp4-..,,;5 12- T.::,2 ip)cie& 3nv 7~8)~U~~WA ',;: b*Aj ??d.en v~rlLEirr,e~t$ern sal.i"'n-G;" LC mc~nctdz

Despite o?aima rade by formu1.a carnp&~~l.ss,it can be said %hat even "&he tis:;-L "hi~mi;in~xe:-.' ", . l.:yYnfie;, r.-:yral 'j,%is~6 3?,; , , " ' ;.. !; 2:j, -S 5,;;Are.'r,s:. ?-$-!G, ,;c.-jz)~i~~

1.2. . :..lo rr.f;at fGI..,;qu.L2 a - f.31" :y{i-l.riT‘p>.@;-rz 3,--:a,- "-4% &~j&O-.a~~is. sy..!-.k,:::-:;~ :;

:':% r;t-<;-Lejn ?:.P. 3.n the f: .: .-;y 2cid :;~.t"k.qt:.,i{-- .:3f %e;s blpfdi: - ta

:,?.:$e$&, inra~y+~~yffl~j.,&~ r$;azf

3- q-,,c; 2 ->.-. .~- ,7:< -.& - .*. L , %, .I), @2:am$ke: L:,.)a?i*

r.dll

iz3 ;.nag ;~,~gv:.,zp:.$-.rg $7 :.,:;G;-o.c5; -:?.:.".. .I., :-,~vi~r-p~.;<-,~;y,: s,$G ,. . -. - au&] :-esgep-hem; :;;CI:P:~~?.-".~

&:;A 2y 9 e 2 to?- *::;;j,:!: ape Y~:~;<-ji:j": g~;z?.'-':rl'.:+n Lvt>"pdan~ &xs.,~&.Lk, The potential harm that can result from the ever-increasing sophistication of attempLtS by formula companies to mimic human mllk Is exempllfled by the recent grublem with Syntcx infant formulas in the USA, They were shown to be deficient inchloride, causing metabolic damage to infants fed solely on them,

The Fmportance of colostrum deserves special mention. It is not only a rich source of anti-infective substances but also contains concentrated amo~lntsof certain nutrients (fat soluble vitamins, zinc), enzymes and hormones including a growth-promoting factor.

Human milk has many active anti-Infective properties via its cellu?ar content and antibodies and other substances, including lysozyme, the bifidus factor, etc.

Among the many recent disaoveries relating to the anti-infective qualities of breastfeeding, the gut-mammary axia plays an important role in the prevention of infection in the baby, Infections from the mternal gut stimulate the mother's antibody production, These antibodies are eecreted in her milk, thus helping to protect the infant against these same infcotions,

Recent studies indicate that public health benefits exist in well-to-do communities whaat+: breastfeeding is practised, e.g. proteation against infections especially in newborn babies, against problems such as infantile cow's milk allergy, and, probably, against emotional problems in mother and auld such as child abuse. The Importance of biological. breast feed in^ as a form of hormonal natural child-spacing . needs emphasis, The value of close contact of the mother and baby in breastfeeding is af much significance in the emotional attachment (bonding) of the dyad. The economics of' breastfeeding compared with the cost of expensive formulas has increased significance for families and nations in times of rising inflation. Tables 1 and 2 illustrate these points quite well, and are taken respectively from publiaatLons 3 and 4 mentioned below!

Table 1 - Cost of artificial feeding in the Third World Cost of feeding a Country Minimum wage 6-month-old infant $ of wage per week (US$) Der day (US$) Unlted Kingdom 39 20 1.3 Burma 5.01 0.81 Peru 5 60 1-30 Philippines 9.69 2.59 Indonesia 5.60 l.& Tanzania 7.62 2.44 India 4.62 1.62 Nigerla 5.18 2.44 Table 2 - Cost of replacing breast-milk at world prices of powder milk - India, Philippinco and Mexico, urban arcas

I Age, months Item 0-6 17-12 113-18 119-24 I I I I India Total population in age group x 1000 10 538 9 924 9 626 9 436 Corresponding urban population(l8.8$) x 1000 1 981 1 865 1 809 1 774 Cost of milk replacement x million US$ 23.7 12.7 12.3 4.9 Philippines Total population in age group x 1000 764 749 734 719 Corresponding urban population(23.2$) x 1OOO 177 173 170 167 Cost of milk replacement x million US$ 2.1 1.2 1.1 0.5 Mexico Total population In age group x 1OOO 929 922 Corresponding urban population(61.8$) x 1OOO 574 569 Cost of milk replacement x million US$ 6.8 3.9 3.8 1.5 .-

The following are recommended as sources of information on recent advances in knowledge on breastfeeding: I. The Uniqueness of Human Milk, eds. D.B. Jelliffe and E.F.P. Jelliffe. * Reprinted from American Journal of Clinical Nutrition, 2, 968-1024, 1371.

2. Breastfeeding and Ule Mother, Ciba Symposium Number 45 held in London 2-& mrch 1976, published by Elsivier - Excerpta Medica . Holland. 1976. 3. B3astfeeding, the Biological Option, by G.J. Ebrahim. Macmillan. 1978, (EZES 19&1P~

it. Sumin Milk in the Modem Wo~ld,hy D.R. and E3.P Jei?lffe., oxford Uni~ersity ?PO:ZB -1.970 5. Breastfeeding - A Guide for the Medical Profession, by Ruth A. Lawrence. C.V,Mosh LO., St. LOUlS, ly8c

6. Human MiLk, its Biological and Social Value,eds. Freier and A.I. Eidelman, inter national Congress Baries 518, n sevfer- Excerpts Mndi na, Hni 1 and,

7. The Importanne of Breastfeeding, Monog~aphof Dr Jamal K. Harfouche, published by Journal of Tropical Paediatrics in 1970, revised to incorporate recent advances.

* S.ngle copies are avaiiable matis from WHO EMRO for interested heai-ir, workers frmm the Region. 'his publication is also to be published In Arabic by WHO EMRO as part of its Az"tiblc Language Programme 1.2 RECE,VT DEVFLOPMENTS IN PROGRAbGMES TO PROMOTE AND PROTECT BREASTFEEDING

In order to have a better idea of the type of activities which can be and have recently been undertaken for this purpose, it is helpful to consider first the reasons for the de..iine in breastfeeding in Third World countries. These include:

(i) the attitude of Blite women who may wish to imitate the infant feeding Il.i~i:.., &,i:heir Western counterparts.

,ii) 'The influence of multi-national infant food companies aggressively ~~"urituLirreLlirlr. y~~orlucLs,willoh lrlcludr rlowddays nuL or11.y formulas but fruir juices, cereals, etc. which satiate the baby's appetite and interfere with his sucking capacity.

(iii) The influence of uninformed health professionals.

(Ivj Othcr multiplc oooio-cultural cnuaco including a changc of attitude towards the female breast, considered more as a sexual .;.^%an rather than as a nurturing one.

(v) The entry of more women nowadays into the work force.

Much of the responsibility must be attributed to the medical profession. Ill-versed in matters of biological infant feeding, its benefits and the existence of both the pro- lactln and let-down rerlexes, tney nave watched the decline in breastreeding wlth compla- cency, allowing the milk companies to take over their responsibility in advising mothers an he nutrition of theii. Infants. Rinid hosrital practices in the deliverv room and obstet- ric wards nave further discouraged the estsblishment of early breastfeedinp.

i ;\ nc,,.r .cre:?:ilfeeding proKranvnes were developed between 1.946 and 1970, main1.y in the !rii tec illriaciorr, and Sweden. Participatini: health professionals based their approach on spaci;lc limited aspects of breastfeeding, e.g. (a) care of the breast (nipple retraction, engor'gement, rooming-in); (b) education of parents; (c) education of midwives, no test-weigilinp, and early skin-to-skin contact.

The ncS,ivities which have teken place since 1970 can conveniently be grouped under :ive headings, as follows: (a) Baseline Data

Efforts to promote breastfeeding need to be based on a cornunity diagnosis and from information gained from the assessment of the social factors lesponsible for the decline in biological feeding. Prevalence studies are of great usefulness. Many have been undertaken, for example, in Europe - the United Kingdom and France - as well as in the USA. The WHO collaborative studies have included Sweden and Hungary in Europe and also Third World countries in Africa (Ethiopia, Zaire. Nigeria); in Central and South America (Guatemala. Chile, ~razil)and in South East Asia (Philippines. India). National studies have been undertaken independently in mycountries such as Burma, Nepal and India.

(b) Information/Education for the Public Information is being given to the public through multiple channels including the mass media, schools and personal communication through small groups such as women's clubs and support groups, as well as at clinics. Programmes utilizing mass media have been developed both at international and looal levels, o.g. Antenna UNICEF, 114 messages (2 minute spots) for radio (in English and ~rench)which arc disseminated worldwide.

One brochure which WHO has prcduoed, entitled "~reaetfeeding",is written at a level easily understandable by educated lay persons, and this seems likely to have, in a dozen languages or more, a distribution of many tens of thousands.

The rapid return to breastfeeding which has been witnessed in many Western countries in the past 5 - 10 years among different socio-economic groups can be seen in part as a reaction against excessive reliance on technology to solve problems and as a return to a more natural life-style. Many social factors have assisted in this area, such as a changed a~i.L~udc.Luwards the functions oP tne breasts, accep-tance or breastfeeding by peers, ecolo- gical considerations, economy and increased soientific knowledge of the benefits breast-milk affords to both mother and child. The formation of women's sllpport groups in different parts of the world has helped greatly in the promotion ofbreastfeeding. These women's non-governmental organizations supporting breastfeeding in various ways, especially by public information and pemonal or group counselling, have grown considerably during the past decade. Examples which particularly come to mind are La Leche League in the USA,

AmmehJclpcn ill Nurway, NUI.J~II(I MuLkle~~sof Australia anb tne National I:hlldblrth Trust oi' the United Kingdom. They are both an effect of the trend towards breastfeeding in the industrialized countries, and also in a sense a cause. in that they c0ntriblJt.P tnwarrla accelerating this trend. EM/Mc~/155 EM/REG .SCT. WRK .GR .BRF/14 page 10

(c! Health Services

Jn all aspects of health care, practices which affect breastfeeding need crltlCal scrutiny, with speclal emphasis on those which interfere with the let-down and prolactin reflexra. Pertinent rnodificationri are gradually being introduced in pre-natal clinics, e.g. advice and breastfeeding demonstrations, care of retracted nipples, etc. Some practices in the maternity ward are at Last beginning to be revised, e.g. unnecessary or excessive sedation of the mother, anaesthesia, unnecessary episiotcmies and, later, drugs given to stop lactation - but progress is slow. Ro.~aingin should be strongly encouraged, and provided in all hospitals so that the ?>athe;-and infant are not separated, and on-demand feeding both day and night can be practised. Progress is being made nere also, but slowly.

linresolved issires in health service include, however, the use of oral contraceptives and their adverse efsect on lactation. It is, neverlk~eless, becoming widely recognioed among those responsible for family planning services that, with few exceptions, the breastfeeding mnther should be advised to use other means of contraception, such as physical barrier methods, until breastfeeding has ceased.

In the Third World, the United Nations Agencies have realized that the distribution of powdered milk as an inducement to utilize MCH services or as a nutritional supplement for infants can do more harm than good. UNICEF has virtually withdrawn from this altogether, and following WHO and FA0 technical advice, the World Food Programe endeavours as a matter cf policy tu direct food supplements distributed in the health services to the mothers and not tn infants undcr oix monthe. How well this policy aan he carried out in ~racticeis anot?er ,mtter. Bilateral aid agencies are sometimes disposing of milk surpluses produced hv tarn pricing policies which are themselves the result of domestic politics, and may not be so swam to %he dangers of their beneficence.

;dj T&~.brking Mother - Legislation k recent yeara, eapeaially in some urban areas, problems have arisen with regard to women an&aged In the labou~foroe who need to continue breastfeeding their young infants.

In some cauntries who have accepted the International Labour Organization Convention,, women engaged in industry are allowed a minimurn of six weeks paid leave before and after delivery, Facilities for breastfeeding, e.g. crbches, are to be supplied near the place ul EM/MGH/155 EM/REG.sc~.WK.CR.BRF/~~( page 11 work. Lactation breaks of 30 minutes twice a day should be allowed. However, many difficulties are encountered in this system, and it is noted that this subJect is a special item on the Agenda (item 8) and certainly it is a complex problem deserving review and particular attention.

(e) Infant Food Industry Concern regarding the infant food industry started between 1960 and 1970, through interventions by concerned nutritionists, international agencies and consumer groups.

In the 1970s a sharp controversy developed between these groups concerning the sales promotion of breast-milk substitutes in developing countries. War on Want. a British wluntary agency, published its pamphlet "The Baby ~iller". The presentation was dramatic but the content was drawn from medical literature. The even more challenging presentation of this in Switzerland led to one legal battle, and snothcr followcd in the United States involving the Sisters of the Precious Blood and hearings in a Senate Conunittee. Any victory in the law courts on a mtter such as this is a Pyrrhic victory for the infant food industry, with loss exceeding any possible gain. The infant food industry wisely ceased to defend the indefensible, and followed a policy of cooperation with the United Nations Agencies most concerned,

A Joint WHO/UNIcEF Meeting on Infant and Young Child Feeding was held in Geneva from y to 12 October 1979 as part or the two organizations' programmes aimed at promoting child health and nutrition. It was attended by representatives of governments, agencies of the ihited Nations system, non-governmental organizations, the infnnt food industry, and experts in related disciplines.

The discussions were organized around the following themen: 'he encouragement and supporr of breastfeeding; the promotion and support of appropriate and timely complementary feedink (weaning) practices with the use of local food resources; the strengthening of education, training and information on infant and young child feeding; the development of support for improved health and social status of women in relation to infant and young child 31ralLt1 antl feeding; and tne development or appropriate marxetlng and dlstributlon or breastmilk substitutes.

As a r.rrulL of Lha tllscussions, a statement on lnrant and young child feedlng, togetner with s series of recommendations, was prepared and adopted'by consensus. The statement and recommendations were first sent by the Director-General to all governments in November 1979: EM/MCH/~~~ EM/REG.SCT.WAK.GR.BRF/14 page 12

they were also appended to the Director-General's report to the Thirty-third World Health - Assembly on iol~ow-upactivities unaertaken by WHU arcer tne October 1979 MvrLlllg LII respect of the above five discussion themes.

'me ~nlmy-tnlraWorld health Assembly, In Resolution WliA33.32. crdurrrcd ill tircir- entirety the statement and recommendations made by the joint WHO/UNIcEF Meeting; made particular mention of the recommendation that "there should be an international code of marketing of infant formula and other products used as breast-milk substitutes"; and requested the Director-General to prepare such a code "in close consultation with Member States and all other parties concerned including such scientific and other experts whose collaboration may be deemed appropriate". The text of this code, a fourth revision after tho most extensive oonsultations with the induntry and with the memher gnvemments, and in the form approved by the WHO Executive Board of January 1981 for the cmsideratio,.: of the World Health Assembly of May 1981, is appended to this report (Annex 4).

Monitoring the activities of commercial food industries has already been initiated by some individual governments and other concerned groups, but will undoubtedly receive widespread attention following the World Health Assembly Meeting.

CONC74USION While there has been much progress in public information (in industrialized countries) and, one hopes, in the prevention of damaging commercial promotion of breast-milk suhsti- tutes, and some progress in gathering baseline data, much work remains to be done on behalf of the woman in paid employment outside the home who wishes to breastfeed. Although certainly the health professionals in all parts of the world are more aware today than ten years ago of the advantages of breastfeeding, there are, as will be dis-

cusocd, n number of wcaknccoco in knowledge and skill whioh s~ontlylimit their effect- ivcnrns in helping women to breastfeed. EM/MCH/155 EmG.SCT .WRK. lX?. BRF/14 ase 13

2. REVIEW OF THE BREASTFEEDING SITU4-N IN THE EASTERN MEDITERRANEAN REGION The breastfeeding situation in the Region was considered by means of: (1) information on breastfeeding studies reviewed by the Regional Office during 1980 (Draft WHOhMRO Tech- nical Publication of which photocopies were provided to members of the Group): and (2) by country reports presented by participants, inoluding some recent studies. Background information The Eastern Mediterranean Region (Em)ooinprises 23 countries of Western Asia and North Afrioa, with a total estimated population of about 250 million, varying greatly in size and population and in their levels of socio-eoonomio development, ranging from among the poorest to tne wealtnlest In tne World. The praotioe of breastfeeding in these countries, as in any other sooiety, constitute6 an integral part of the ohild-rearing patterns, which are determined by the mr~ltiplieit~of interrelated factors in the eoologioal context, including: type and organization of social institutions; economy and means of livelihood; population structure and movements; cultural and religious beliefs, customs and life-styles. Since socio-cultural systems are oonstantly changing, breastfeeding patterns are dynamiq rather than static. The transitional phases of socio-cultural change, from Stone Age (primltlve man) - nomadic - agricultural - industrial - post-industrial levels of development, have always been the most oritical and hazardous for lactating mothers and suckling infants. The resent hazalrlot~r sit~mtionof the mrginal populations in peri-urban sectors of countries in the Region bears witness to this fact.

Knowled~eof feedina oractices, including breastfeedinp, ia t'itnrlammtnl for planning effective action programmes. Unfortunately, however, the 1980 review from the Region revealed ti'at breastfeeding patterns had soarcely been studied, despite their significant relevance to the health and growth of young children, and to the wide prevalence of protein- energy malnutrition (PEM), and its well-known association with feeding malpractice and gnntro-enteritis (the mjvr killer). Although a few studies were initiated in the 1960s. they contlnue to be scarce up to thio time and n~qyof tho reported investiljatiuna had to be extracted trOm unpublished thesis material and mimeographed or typed reports and working papers at the EMRO Office and elsewhere. EM/McH/~~~ EM/REC. SCT .WRK. GR .BRF/14 pace 14

Nature, Type and Scope of the Reviewed Studies

A large majority of the studies were cross-sectional. surveys of well-children (or malnourished children, sometimes institutionalized), in relatively small numbers, rather than randomly selected samples representative of the general population, thus yielding point prevalence rates about the breastfeeding pattern with the above limitations.

Tne very few representative cross-sectional surveys were designed to assess the nutritional status of a given group, community or nation and factors associated with the various gradients of PEM in children under five. rather than being directly aimed at investigating the prevalent patterns of infant feeding.

The very few longitudinal prospective studies, designed primarily to study the growth and/or PEM patterns of infants and young children, provided a wealth of information about the incidence (or period prevalence, i.e. at the onset and during the study period) of breastfeeding at different age periods, and related factors.

Some studies were retrospeotive based on review of health records, and/or interviewing mothers for recall information about the feeding patterns of well or mlnourished children.

With the exception of some thesis material. small investigations or pilot surveys, controlled studles for variables associated with the changing incidence of breastfeeding were almost non-existent.

cross-oultura1 investlgatlons, dlreotea to study breastfeedlng in the context or the overall pattern of child-rearing practices, also were not common.

More reoenlly, sumr aaprots of breaatfe~dirrgpaLLerna were investigated in reliition to cnild-spacing and the impact of lactation as a natural biologioal means of contraception in population groups by carefullv desimed studies, conducted bv WHO and the International Planned Parenthood Federation (IPPF) in some countries of the Region such as Afghanistan.

-- -- Psttcnla of Dreostfeeding Evidence in many of the reviewed studies indicates that prolonged breastfeeding (the traditional pattern) hao not decreased in all rural co~ities,since no social or economio conditions exist to favour artificial feeding, nor is processed or safe milk available at a reasonable cost.

Delayed complementation associated with the traditional prolonged breastfeeding pattern coiitinues to be a major hazard. It should, however, serve as the main target for the education of mothers. This would ensure improvement and possible elimination of the weak link and, at the same time, help to preserve and promote the prolonged breastfeeding pattern with all its well-known physical, emotimal, demographic and economic advantages.

The most hazardous patterns which were reported are: (a) bottle-feeding following early abrupt weaning under 3 months of age; and (b) mixed feeding (i.e. breast- and bottle-fed milk given together).

Early abrupt weaning with bottle feeding under the age of 3 months appears to be largely responsible for the changing pattern of PEM from the kwashiorkor type previously cmphaoiood, to tho infantilo-mrasmio type currently having n wide prevalence in many countries of the Region (particularly in the Gulf Area) with serious implications for health and survival of infants, their physical growth and mental development, and for the overall economy and progress of the countries concerned.

The rapid infiltration of a wide variety of artificial milks, baby foods and feeding bottles is, indeed, a drastic invasion and a dramatic phenomenon brought about by skilful methods of advertisement and tremendous commercial pressure, resorting to every possible means which appeals to health professionals and the general public. Newly organized marginal connnunities in peri-urban sectors and Urban poverty pockets ,comprising large apgnwrnts of the populations in many oountrie6 of the Region, are renl victim5 of the bottle-feeding invasion and the hazardous pattern of early abrupt weaning.

Ev3denrm of breastfeeding resurgonoo among women of the urban 6lito io not yet in sight in this Region as it is in Europe, North America or Australia.

special reatures associated witn breastreeding in the Region

Many of the reviewed studies have revealed that some mothers use natural galacta- yogues such BS "renugreek"; and many stru believe in the adverse effects of "hot-cold" fooas, menstrual taboos and "evil eye" on the lactating mothers and nursing infants. mese factors deserve perhalls further tnvn~tlgatinn, in nrdev to prove or disprove the validity of claims about galactogogues, and as a guide for effective health/nutrition education.

Several substances are used in the care and feeding of infants - notably kohl (surma), used for the eyes and stump of the umbilical cord and resulting, sometimes, in lead poisoning of the infant; & (khat); and dried poppy seeds. The adverse effects of these substances on lactating mothers and nursing infants need to be identified for preventive actiori programmeil. EM/MCH/~~~ EM/REG. SCT .WRK. GR .BRF/l& page 16

Rantors associated with early weaning

The two most comon factors mentioned by mothers as being responsible for early weaning are: (a) milk inadequacy; and (b) an ensuing premancy. Both of these factors need strenuous preventive educational efforts on the part of us all.

A iivelv discu:ssio~dpontributions from Group members followed. As all new material presented is to be incorporated in the coming WHO EMRO Technical Publication it will not be repeated here. Some observations not based on surveys which several persons raised are mentioned here, however:

1. Rooming in v~riesenormously, from being virtually absent in the maJor city hospitals of Afghanistan and some other countries to being universal In cne suaiin hosylLala.

2. T'he situation vis-P-vis control of advertising of breast-milk substitutes also varies widely, some countries (e.g. Egypt, Democratic yemen) having Dnmetl 1L rrorn guvenlmsnt premises and from radio and television, whereas in others It still flourishes undisturbed.

3. All countries confirm the decilne In breastreeding, pnrtlcularly in urban areas, but at the same time there are few or no countries which have not taken some recent action to try to stem this decline. Pnsitive promotional use of the mass media, and seminars for health personnel seem to be the commonest activities so far.

4. The dangers of lead poisoninp, were reported from several countries, but it was pointed out that the danger came not only from the use of ~ohlby the mother and absorption through the miik, but also directly when kohl was used to beautify the baby's own eyes. EM/MCH/155 EM/REG.sCT.WRK.W.BRF/~~ page 17

3. PROP0.S.T.S FOR RESFARCH CONCERNING THF. mEVAT.ENCE ANn DURATION OF RRF'STREDING AND ASSOCIATED FACTORS

Objectives of research

In order that programmes to promote and protect breastieeding should be planned effectively, and resources allocated in proportion to the importanoe of problems, it is essential to know the following: - What is the magnitude of the problem regarding breastfeeding? - What is the nature of the problem? - Where Is it and with what groups or classeq of the population? - What is the apparent trend of the problem, increasing or decreasing or remaining fairly static?

- What are the known or probable consequences of the problem?

Some conclusions on these questions are of course a necessary prerequisite of action, and it is certainly much better that these conclusions be founded as much as possible on fact and not on supposition and analogy. At the same timc, it is not aennible to make the need for research an obstacle or cause to delay activities which present knowledge leads one to believe will very probably be beneficial.

Considerations about the type of survey, sampling and interpretation

The Croup, therefore, strongly endorsed the desirability of regular surveys of the prGe\rnl.t.ica bnd duration of breasfeeding in the Region, emphasizing that these are to be x?d Xn making its ceoomndations, the Croup took acoount of the usual prim nf delay between the carrying out of a survey, the time taken for analysis and the implementation of intervention. In a situation of rapid change, such as appears to be :.ne case in %hisRegion in particular, this period of delay can become a major constraint.

In the light of th- importance of monitoring the trends in society, the Gmup reoommendeci L'ous types of surveys:

I. Rapid spprsPsal and on-going monitoring of breastfeeding practices carried out simpiy and within the framework of existing health services by health personnel. The advantage of this activity is that the individual problems of each community can be Identified and local interventions can be instituted without delay. r. natal ind cms-sentinnai stirily at +he ~oi~nt.ryi eve1 to identify the interaction of several variables whioh changefrom country to country and from time to time.

3. Somc longitudi~aior ocmi longitudinal otudier. on the eubjeot are imperative to provide the kind of knowledge which is difficult to deduce from cross- sectional btudle,.

4. Anthropolo~lcaistudies. The planning and implementation of actim programmes for breastireding promotion require in-depth understanding of the underlying reasons for the mothersY choices of feeding methods. Research using the methods of social anthropology is most suitable for this purpose.

The countries 01' the Region do not have the technical know-how in sampling methods, study design, analysis and reporting. The Group recommends WHO agsistance for these activities, perhaps in the form of a multi-disciplinary team on a consultative basis.

Two important points to keep in mind in plann:ne research are the need for proper sampling and the need to exercise care in making causal inferences from the results. It is tempting to carry out studies on samples of children who attend MCH clinics, since Lhls c06f.s less an& Lakes lass tlme tilrari CommunlLy suvvryn. Huwrvrr., ruilaaa all ctlll- dren with equal regularity attend these clinics, which is very rare in our Region, the results of such research are nearly always misleading. Because in many countries nearly all children brou@it to the clinic are actually ill at the time, differences in health or nutritiollal statue !:i ?:ween breast-fed and bottle-led children rMy not appear. It would he more appropriate 20 utiiiae truly random samples such as those used in the WHO Expanded Drogramn~eof Imm~~n'.mti.onfor the evaluation of cover,age of immunization. However, even well-done research may xa1.l to reveni dii'ferenceo bstwccn brcaot- and bottlc-fcd babios, especially beyond the age of nix months. Many factors may lead to lower nutritional status among breast-fed babies, in spite of the superiority of breastfeeding: the parents of breast-fed babies are often poorer, older (with more children), less educated, and more likely to delay unduly the addition of solid foods to the baby's diet. Variables to be measured

In general, the following aspects may need to be investigated: - Prevalence, duration and factors contributing to successful breastfeedina. - Age of introduction of any other food item (liquid or semi-solid) and what and how much. - Weaning age, methods, devices and diets. - Family and household influences. - Age, parity, perinatal mortality pattern, family size, maternal illness. - Attitudes of husband and elders of the household. - Care during prenatal period, including diet and work. - Delivery, place of delivery, birth attendant, rooming-in or otherwise. - Colostrum, whether fed or discarded. Time of first feed after delivery.

- Morbidity of the child in the first year of life. - Growth curve of the child. - Type of breastfeeding, e.g. on demand or timed. - Sourcee of infomation about breaetfeeding.

- Feeding practices for p~eviouschildren and birth interval. - Post-partum amenorrhoea, and interval until birth of next child. - Socio-economic status including education level of both parents. - Urban/rural residence.

- Life patterria, e.g. nomadic, refugees, immigrants, urban squatter settlements - Family attitudes. - cost of breast-mllk substitutes compared with a labourer's wages.

-N.B. The above is a fairly comprehensive list. It is not expected that all could be measured, and indeed some are not possible in a owes-seotional survey, but are intended as elements in longitudinal studies. The investigators need to select priority variables for study according to the particular obJeotive and ciroumsta.i., of the study or survey. EM/MCH/~~~ EM/REC.SC~.KX.CR.BRF/'L~ page 20

Priority areas

In the Region there are several cities experiencing rapid growth with changing life styles and economic status of the new arrivals. The large cities such as Cairo and Karachi are good examplee of the situation.

In the Gulf States, there is a large community of immigrant workers who have left &hind their cultural tradi.t:.;ms and the usual soclal support. Moreover, the main reason for their presence being eaonomie, ijotl? parents are likely to be working. These groups may be nt spccinl rioir.

Several countries of the Hegion have nomadic cornunities about whom no information is siveils.blo.

Tivt urban dlite are not only giving up breastfeeding but also introducing supplements

8,'. a very unrly aye with potential and act.ua1 problems of overweight if the feeding is done hygienically at full strength. A much more dangerous situation exists in Countries where the availability of large amounts of money and therefore of breast-milk substitutes is relatively recent, while on the other hand the mothers are still illiterate or semi-literate. Diarrhoea1 disease with hyponatraemic dehydration is a common danger in this situation, nnother reason wnlan makes the Gulf SLaLwrr ard Llb,ya irL&i priority areas, together with !;uch countries as Yemen Arab Republic which are close beneficiaries of this expansion in

!5u3h resources,

Marasmus or underweight (less than 60% of the expected body weight) below the age of j i,.,nthr. ?.s nc:t, only a high-risk factor but can be taken as a reliable indicator of serious problcn,:i, onpoclnl.lp with regard to feeding. It ia possible that. during n survey rrspon- dents :;ive answers designed to satisfy the interviewer. Hence, the identification of the underwej.&.t child will act as an indicator of existing problems for detailed investigation.

Other indicators

bovernments in the Region are likeiy to nave data on roreign exahange spent on baby foods and mllk both im orted and locally packaged, although some milks may be introduced into the anl~ntrythmmrgh nnn-government nhannels. Analysis and reporting Maw cuuntries in the Region nor have facilities for computation of data. Aloo a variety of suitable programmes have now become available including the SPSS (Statistical Package for Social Science) which is the comnonly-used programne at the present. It would not be difficult to enter into a contractual relationship with a university for arialysis of data. As an initial step, part of the data could be analysed by hand to obtain quick feedback for the comity as well as for the investigators. Table-top computers are now becoming available. It was suggested that specialists in programing should be made available through WHO. Reporting of data without delay is essential. A newsletter - "Mother and Childrenw- published by the American Public Health Association waa Sugge6ted. Besiaea this there are several Journals both in English and Arabio whioh my be utillwd for dissemination of the information. EM/MCH jl53 EM~~~G.SCT.WRK.GR.BRF/~~I paee 22

4. --PROMOTIONaL Am EDIJCATIONli-yAACTXTIES FOR THE PUBLIC ON BRFASTFEEDINC

ObJectives

The objectives of public information on breastfeeding are;

- to i%provc the pattern of breastfeeding, where this has deteriorated, and

- to prevent deterioration in the existing status of breastfeeding, where the pattern is satisfacl,org.

The programe supplying information fo the public should form part of an overall progmmrne to promote breastfeeding, including legislation for working women, prevention of misleadins!, advertising, etc.

These will vary with local problems and cultures, but should stress and be based on helpful and beneficial practices. Above all, they should induce conf'ldence in the advantages and feasibility of breastfeeding.

Knowledge of tne content of tne messages snould be included In the training or health personnel at every level, including obstetricians and paediatricians.

'?.'he .Lnformstlori supplied snould be based on available knowledge and shwld be modlfled In t.he LL&t of action-oriented research studies mentioned in the previous section. It

:I, ,iinsitivc to tile eultur~nl.beliefs of the community.

Me?:.:.ia~eswill vary, but my cover maternal nutrition during pregnancy and lactation, rx2[.no?i:: : ' ileallna with "in.;~f'Tic,ient milk", the failure to use colostrum, concern over s reas::. erali:g during pregnancy, and traditional belief's and taboos reyarding breastfeeding. Scipfui gractiaes existing in the community should be stressed. Education and knowledge regarriiny tnr practic~lmanagement of problems of breastfeeding should be available to >riswnl rr,-,l:i:;rs' qlrcries and doubts.

Examples of some other most important messages include those endorsing the values of breastfeeding, such as the benefit to child nutrition, religious sanction in its favour, liitlc additional c':,st, cunvcnience, bonding of mother and baby, protection from infoctions, as well an the dangers of bottle feeding, and the introduction of semi-solids at the 3ppr.i8priate Lima. It is realized that there may be occasions when a mother has to be taught bottle feeding. This should be done on one-to-one basis in a separate room. Ueolsion to bottle reed should not be left to the mothers without providing them objective guidance on which to base their deoieion. Thus the availability of bahy foods in the eupemrkets in a dangerous trend, because tiw impression conveyed is not objective, but is aimed at maximizing sales.

Situations for conveying information on breastfeeding 1. Person-to-person contact at home and at clinics. This can be done through all levels oi health workers, e.g. village health workers, primary health workers, TBRs, friends and relatives. 2. Small gmups - at MCH clinics, womn's clubs, mothers' support groups. 3. Large groups - Religious congregations, including the mJlis,and schools, incorporated into appropriate curricula for both boys and girls. 4. Comities - Malis media.

~neach situation, use st~ouldbe made of existing womsn's support groups. Laotating women volunteers can be used for practical instruction wherever possible.

Fur the pll)grOme to be implemented in schools, the ourrioulum rrhould be suitably adapted by the ministries of health and education, and suitable educational material should be incorporated into existing courses about family life, or biology, or health.

Methods These should be culturally acceptable and economical, and include: practical demonstration, wherever feasible; uudiovirru~laids, flip charts, flsnnel graphs, posters, slides, eta., use of folk art (e.g. puppet shows); media: press, radio, TV.

The Group specifically wishes to recommend: (i) that Governments should include education on promotion of breastfeeding to pre-pubertal sohoolchildren, both boys and girls, In school curricula; (ii) that Governments should mke available radio and TV time, and funds for the promotion of breastfeeding. There should be some scrooning proocrro to clirninatc oommercial messages which promots bottle feeding; EM/MCH/155 EM,@EC.SCr.WRK.CR.BR."/l4 page 24

(iii) practical information regarding breastfeeding should be made available to women's groups and religious authorities.

-Evaluation Results of this program cannot be expected to develop rapidly, e.g. in a three-year period. Preliminary evaluation should be made after one or two years, which will be con- serned with the implementation of the programme; a more long-term evaluation should be carried out at the end of the third year of the programme, if %he implementation has been found to be suceessiul. Evaluation should be based on household level surveys. The information collected should be incorporated with other data on KH activities, e.g. immunization, diarrhoea1 disease, etc. The evaluation sho111d fo~~rsnot nnly nn pra-determined nutaom~s, but also be open to unforeseen beneficial and/or harmful effects.

For evaluation, control areas of limited size with similar conditions are desirable. This will also help to take into account general changes in infant feeding practices which may be occurring for other reasons.

Evaluation should include: I. Prevalence of breastfeeding. 2. Dur~ationof breastfeeding and type of breastfeeding (on demand or timed),exclusive brenstfeeding or mixed feeding. 3. Aye of introduotion of bottle feeding or other liquid or semi-solid feeding. 4. Assessment of lulowledge, attitudes and practices relevant to colostrum, advantages of bmaotfaeding, etc. ctc.

Over a period of time, mothers can be used as their own controls, by cumparing infant feeding practices with subsequent children. EM/MCH/155 EM,&~C.SC~'.WRK. W.BRF/lB page 25

5. THE TRAINING OF HEALTH WORI(W;Y CONCERNING BREASl'FEEDING Objeftive Training of health staff is of the greatest importance in the promotion of breastfeeding, because health workers play or should play a key role in motivation anb maintenance or hl.rabi.- feeding. Certain specific gaps in their knowledge at present prevent them from doing this job effeotively.

In many medical and nursing sohoolsthere is virtually no teaching on breastfeeding and the bioloeionl aspnnt.s nf lnotation. As a result, newly Qualified pkiyaicians and other health personnel have very little knowledge and ability to help breastfeeding mothers when problems arise. The reaeons for this laok of adequate tenohins are several. There is the preoocupation with science and technology and the bland assumption that good infant nutrition is going to come out of a bottle of the latest brand of baby food. There is also the effect of pseuclo-scientific literature and other msana of influencing the opinions of teachers and professional leadera.

Many of the reoent scientific developments have helped to oatabli~hbreast-milk as a biological system for establishing the infant in extra-uterine life nutritionally, metabo- lloally and immunolonicallr as well a8 emotionally. In all teaohing programea this holis- tic or integrated message should ba paramount,

Specific deficiencies in knowledge To return to those gaps in the knowledge of health staff at all levela which prevent l.lleir uSCrcLlvu L'urtoLiu~ringI&% regar4 to braaatfooding, We foLlowing ageoifio deficiencies or arms or weakness were Identified:

1. A bcllef in oartsin inappropr"lao or undeoirable feeding pfnotioen, to wit: (a) Needless supplementation: Prelaoteal feeds interfere with the establiskma~~ of the laotation reflexes. (b) Premature introduction of supplements whioh leads to early cessation of' lactation. (a) Bottle feeding is a great temptation to add oereals to tne onild's reed at an early a& (as is prompted by the oompanies marketing these cereals). . 2. The importance of rooming-in needs to be emphasizad for early establishment of lactati.

4. Maw doctors an6 nurses need some refresher training inorder that they may keep up with recent advances in breastfeeding, particularly psychophysiology of lactation and social factors operating in the community. 5. 111 some cases the physiology and biochemistry of human milk may be well understood by health personnel but skills in helping motiners with common difficultdes like engorgement and cracked nipples are lacking.

6. Some doctors, nurses and other health workers do not understand that the normal stools of a breastfed baby can be mare loose an8 rrequent than thusa uC LIa Lvttle-fad whom +hay perhaps see more frequently, and they sometimes wrongly diagnose diarrhoea.

7. Some critical awareness of the technlquev utilized in marketing of breast-milk substitutes in the co~ityis essential in order to resist this influence.

Categories of Wealth Personnel requiring training Training programes are required for the following categories of health personnel: - Traditional birth attendants in certain areas (but not in areas where the traditional pattern still prevails. In these areas it is best to let well alone). - Nurses, midwives and others. - Doctors: paedlatriaians, obstetricjans, general practitioners (family phynicians), public health doctors. - i'?~Mrmacist.~. - VLiiage health workers.

Among ail the abave groups trainers have the hlghest priority. They will require tools for effe?kiwe teaching in the form of texts, teaching material, audiovisual aids and recent literature for giving a new dimension to their teaching in feeding practices without much altering the existing cupricula. The teachim of breastfeeding in the nursing cu~risulumcan he strengthened by providing better library facilities in the form of text- books, recent literature and audiovisual aids, and by the use of a variety of teaching situations to emphasize the various biological aspects of human milk. Thus, there is scope for ' teachirg on breastfeeding during discussions on nutrition, immunology and gastroenterology as Well as on emotional drve:!.uynlent. In this respect the importance of interdisciplinary EM/MCH/155 EM/REG.SCT.WRK.GR.BRF/~~ page 27

seminars should be emphasized in order to Poous on the social, economic and other important , . aspects.

Type of training Two main types of training are recomended: 1. Short-term (in-service arrl pre-service) for the above mentioned health workers and their trainers. 2. Long-tenn or basio training for future health personnel.

WHO and UNICEF can play a partioularly valuable role in stimulating and supporting both kinds. EM/MCH/~~~ EM,~EG.SCT.WRK.GR.BRF/~~ page 28

6. THE PROPOSED CO~-MAF3W~LNCiOF BREAST-MILK S~I~S It was agreed that thls code is a positive major step in the right direction, though it is recognized that it will not completely solve the problem of marketing breast-milk substitutes. The Grou;. ij3ii every expeatation that, being the product of painstaking consul- Lation, it would be approved by the World Health Assembly in the coming May.

The siwificanee of health personnel bing manipulated by various means into becoming unwitting promoters of bottle feeding should be underlined. This should be explained and emphnsized to the health personnel. In this respect, the meeting pointed out that the articles 7.3, 7.4 and 7.:~of the code are particularly important.

The Group endeavoux~edtoselect a limited number of points as recommendations of high pri~rltywhim could be coiwnunicated by WE0 EMU0 to the Member States as matters for particular emphasis.

1. A total ban on advertisements of breast-milk substit&es in mass media and by posters, or material distributed or displayed in health premises. 2. No financial or material inoentives should be offered to any health worker in the prom- tion of sales (articles 7.3 and 7.5). 3. Tt is suggested that the Member States should also encourage positive promotion of breastfeeding through the mass media. (as well as preventing advertisement of substitutes for breast-milk). 4. Oiict: the World Health Assembly has accepted it, monltoring the code of marketing is d~sirable. WHO EMRO is invited to coordinate a monitoring system by means of correspon- f:-nt;, in the countries of the Region, issuing an annual report. on prograac. 5. In each member country there should be standardization of measures for reconstitution of the ;,z.mula. The imtructions for this should be simple and in the mtional language. 7. THE ROLE OF WOMEN'S ORGANIZATIONS IN THE SUPPORT OF aAEATmING Successful breastfeeding depends traditionally on the information and emotional support given by experienced women in the comnunity. In some societies where breastfeeding has declined, voluntary "mothers' support groups" nave evolved to supply What has been Lost witn the disappearanoe of the extended family and more traditional village life. Such groups include the La Leche League International (LLLI) in the US, the NW (Nursing Mothers Association of Australia), Armnznk.;eLpcn in Norway, etc. They kve been started as voluntary groups among educated "middle-oluse" women concerned with assisting each other with more natural child-rearing, particularly breastfeeding. They work by supplying advice and information to mothers (and husbands) through meetings, literature, ard assistance with preventing and daallng with p~.cblcms uf management of brasetfeeding. Initially, they were viewed antagonistloally by the medioal profession, but beoawe there is increasing understanding by health workers of the importmoe of breastfeeding, they are nowadays working oolluborativsly with paediatrioiane and othsra oonasrned with ohild health.

More reocmtly. a number of similar organl4mtlona aanoerned wlth the support of breaal feeding mothers has developed in som Thlrd World oountriea, such as PPPI in Malaysia, :iut*ir Mamas in New Guirra, eta. Aha, La Laohr League Intemrtional Ma a number of weraeaa *PUUPG. FOP the most part, theee have Men initiated by educated, well-to-do urban wom~ri ~~isirimpact on mothers "at risk" from inadequate bottle feeding - that is poor women ofte~i it^ .rlums - La unaartain. There la a cl,eai" need to oonaider .the develcpmsnt of support syatem8 for Lrtdeal.feu~lir:ri.

:.?, L.;kur,a tn nvun*.ries wtluro Lt'srtltl una% suppork la no longrrr a~FtluLlvo. Buoh rryettlnte oclu.i ~i i,m, dt$valoped Ln a variety of modela:

1. tJpaclai orgmizatianu lor mut;here' auppart in breastfeeding. . Within exiatlng national governmental women'a orepnilations, (e.g..comunity dcveloptni rgt ~tunoolations). 5. Wlthin existing voluntary groups in.$, family planning asrooistions), and 4. As part of an avara4.l packaga urganiurd by a braantfeeding prarno%&onpaup (as MB oaourred in Lebanon),

The most appropriate mdel will obviously vary with the circumstances in different countries, but in all cases those involved must be highly motivated women who have themselvt.-- successfully breastfed. The best methods of developing mothers' support groups appropriate for different EM/MCH/155 EM/'REG.sCT.WRK.GR.BRF/~~ page 30 countries and socio-cultural circumstances are not known, and it is felt that WHO needs to explore this matter. It would be useful, for example, for female health professionals going to Europe or the USA on WHO fellwships to visit organizations, such as LLLI and the National Childbirth Trust in United Kingdom. In addition,it was felt that a workshop on mothers' support groups would be very useful. It could be attended by representatives of established organizations in industrialimd countries (such as LLLI, Ammenhjelpen, eta.), and in developing countries (such as PPPI of Malaysia, Susu Mamas of New Guinea, etc. ) together with representatives from countries currently initiating such activities (e.g. Egypt, Cyprus. ~Tc.), and .Cr.unz ouuntries considering exploring such developments. The outcome6 of such a workshop could include the cxchange of information on mathod% urnd and guidelines to assist in the organization and development of mothers' support group6 in different circumstances. Additionally, national women's organizations can be instrumental in the enactment of legislation regarding leave and other assistance or incentives for nursing mothers. EM/MCH/~~~ EM/REG.sCT.WRK.GR.BRF/I~ pane 31

The present oituation in tlrm Rrglun The Croup discussed in detail facilities for the woman in part employment outside th~- none who wishes exclusively to breagtfeed her child for the reoomendcd pcriod of tilfils, I, r between four and six months. They reviewed the situation in countries of the Region usi,.~ an IPPF studv supplemented with information brought by members of the Group. These data are glven ln'l'able 3. It is emphasized that this information is provisional and it is reco:m:.. ded that WHO EMRO as part of its programne make a formal study, in greater depth, er~qulnilq as to what in act.t~al.lhappening in proatice as wrll as Lo wnat may exlst in the form of legislation or labour regulations.

it must be borne in mind that the oountrico of the llsgiul~, and also dirferenr. parts :'by the same country, differ very greatly in (8) the percentage of women of reproductive age who are in paid employment, outside the home. (There is some cottage industry, piece-work given out for women to complete at home, and of course this does not ini.sr.l'or,t. wlth breaetfeedlng); (b) the percentage of workers In industry and in clerical work who are wome!:, It appoara that Lr~ltulatlonexlsts in almost all countries - but usually among workerr In government service (hospitals, schools) or in industry. Agricultural workers and dt,n~,.:sticservants were not considered in most of the countries. Knowledge of mother:, u::;.: Proper ilse of maternit,y leave is inadequate. Some do not know their rights. otk~~!r~r;.I<,

II:;~~1.118 leave grAntcd I:u them for tk1e phirpone of hr*castfeoding their infant.8.

Ve~tiveaspeots oft@in~n_

1. Some emy Lwyerri do not ~~dtlem.to tkie present existing legislation. i .e. they ~iuI?~J I. provide crbches despite the fact that they employ a prescribed sufficient number workers. 2. Frequent preenanoy Leaveo oon lead to dieu~.lmtnationagainst the employmant of women. 3. Economic aonsiderations, e.g. cost to gvvernments or private agenoks may deter tht:al from providing pregnancy and laotation benefits. 4. It is sometimes said that Leave granted for both pregnancy and lactation my encijur.;-t,;: an increase in birth rates, but the Ciroup think:; this a rather superficial judgemer::..,

Cr9Bches Where legislation exists, creches my not exist, or if they do, they may be far at:&> from the work place. Difficulties in reaching them may be great and mothers may not be desirous to take their young infants in overcrowded buses where the risk of cross-infection may exzsr.

If criches do exist zhey may be badly organized with insufficient and poorly trained stbff and the danger or infection is hign. Mothers my also be reluctant to leave infants in these centres because of the expense. Good home care by a reliable relative may be preferable.

In some countries, such as India, women employed in the construction industry have organized themselves into setting up temporary crdches near the place of work. Discrimina- tion against Llie employment of women is minimised under these circumstances.

.-In cunclusion, the subJeot is not a simple one, and the Grwp wished to summarize its recommendations as follows:

It must be recognized that motherhood is not merely a biological function but an essential social and economic contribution to the nation; it must not be the occasion for any disarimination agalnat women or al7y unnecessary disadvantage to them in regard to paid employment. The essential obJective is to enable working women to breastfeed exclusively for 6lx months if they so desire. Possible means may include:

(a) Paid post-natal leave (fully or partly paid);

(b) Unpaid leave - but wholly unpaid leave is not equitable in the light of the above;

(c) A mixture of paid leave and the use of annual leave. e.n. 13 weeks of post-natal maternity leave followed by a further period of optional lactation leave in which the employer contributes one day to match each day the mother contributes from her annual leave entitlements. Precedent exists for such Joint provision; for example, where bcth employer and employee provide mutual contributions to a pension fund. In the area of maternal and laotation bsaefits, a similar device could be used.

(d) Criches should be provided at the place of work by laree employers of women; but they require efficient management, e.g. manpower, hygiene, etc., as the danger of infection needs to be reco@ised.

(e) If crhches do not exist, the employee may negotiate for more flexible working hours. A balance of interests has to be maintained. While women must not be discriminated against, particularly in this matte?, Legislation cannot be uniformly applied in each country but must be adapted to demographic, religious, political and economic aspeczs in eaoh individual aroa. In thc nclional interest the contribution of wunlsn'a work ia required. In terms of the farnily needs the woman's wages may be important. Nationai circumstanoes must dictate the choice of means for each government.

Furthermore, women must be Inlormeo of their r'ights.

The Regional Director is invited to review the legislation on this subject in the countries of the Region and the extent of its coverage and implementation.

The Director-General of WHO could approach the International Labour Oganization and the appropriate United Nations Committee to discuss the implementation in the United Nations Civil Service itself of a set of supportive actions baaed on the abcvq principles, with a view to studying their cost and effectiveness in attaining We objectives outlined above, in order to be a guidame and a stirnulus for other civil services and commercial employers. Similar "experimental" schemes could be initiated with exceptionally large employers of women as teachers, and of women as factory workers.

The Regional Director may perhaps consider embodying most of the above points in the form of a draft Resolution for con:iideration of the Regional Committee. EM/MCH/~~~ EM/REG.scT.WRK.GR.BRF/~~ page 34 EM/MCB/155 EM/REG.SCT.WRK.GR.BRF/I~ page 35 Table 3 (eontin~ed)-

,- .. ~- " ~ ! Countrj Working hvdrs Pregnariig Pernuneration "i*~~i;-~rr Remune- Available pregnancy :jaw breaks rated nursing I faciiities . .,. .. , I -- - - .-- -. - Sudan 8 weeks, 1 hour Hemune- 2 weeks prr- rated ialivery Also unpaid 6 weeks leave Lobbying for possible one year extra I I leave I

I i 2. Workers Not kncwn Not kn3m Not known I

Tunisia 1. Civil 0x1; month 2 hours for Not known Servants after deli- 6 mntts, very. 1 hour for If doctor's 1 year certificate can be otxained leave can be increased by another XI days 9. LEARNING MATERIALS ON BREASlTEEDING

Community, national and regional programes to promote breastfeeding need the aevelog, rnent of culturally and technically appropriate and cost-effective learning materials. The' Group reoognized that WHO ENRO had already been aotive In this regard (see IntrOaUOtlOn page 3) and offers the following proposals to strengthen that aspect of the regional programme. Two groups are priority targets, namely health professionals and the pubiia.

1. For health profession~;ls- (1) Library books It is necessary to supply the libraries of training schools and ministries of t~eait,~

wiWl appropriat~up-to-date least-oostly books on brcaatfeeding. These will va1.y with Lfi, type of school (e.g. medical, nurslng, public health, etc.), and the linguistic range of the students.

There is a special need for the local production of books by experienced professional: I'rom the Region. These would be in local and national languages e.g. Arabic.Urdu, ilei~::i..i, . .tc.,ana could be on breastfeeding alone, or oould cover a wider ran~e(e.g, infant f'eediriii ~eileraior additional topics in maternal and child health,growth and development.the en~ia detection or malnutrition, diarrhoea1 disease and oral rehydration, etc.) One such it; "Heal t.h Care and Nutrition of the Young Child" by Mushtaq Khan and BaXer which EWZiSio has

:t::'.?diiy iiisl.rihuti?d w.iriely in Er~~~liski~nd has ueleoted For it6 Arabic lanmmgc prop..i"ac?rr.-

.irii~-~i,ither is tile WHO/F;MRO/WICE~~ booklet "Messages for Mothers" i.n English and Ara3L.i.

Al:sc i~ I.:; st.liiat. iipji;*oyr,ist.i.hoks i*.-c,m outsl.de the Ilegion continui. k,<> fx; ::v: .v;!ilable even more widely: - WWL ireas as ti ending" booiii.et ~Snglish,Pr8encll, Arabic, Urdu, Pers~an, PushLu) (M, FH, i\ljx - "~reastfeeding: the Biological Option" (English and Arabic) (M, PH, N) - "nreustreedlng patterns. A review of studies in the Eastern ~!!ed.Lterrane;l;nRegl.onU by J.K.Harfouche.WII0 EMRO Technical Pablication No.h(ln pm~s-English) (M, pH, Nl - "~reastis Best. Bibliography on Breastfeeding and Infant Health". US Department of HEW. (M, pH)

* M: medical school; PH: school of public health N: nursing son001 - "~umanMilk in the Mocis-:> WorlC'' (EZBS Version) (Engll sh) (M. PH) - "Breastfasdkng? A guide for Wealth ~rofessionals'~. R. Lawrence (English) (M) - actat at ion. Fertility and the Working oma an" (IPPF publication) (English) (Ma pH)

lndlvidual health worn rs at all levels should receive copies of the WHO "~reastfeeding" booklet in the appropriate isnguage.

(11) UbnT,lnulng inCormr Lli,rr Again, there is a need to develop a newsletter within the Region compiled by local exye-ts. In addition, the value was emphasized of ensuring the distribution of national Journals in relevant fields (e.y. paediatrios, nutrition, etc.) to appropriate training schools throughout the Hegion (e.g. the Jordan Medical Journal; Journal of Pakistan Paediatrio Association, and others).

It was also suggested that the Journal of Tropical Paediatrics, which is very mnsi- derably concerned with breastfeeding and young chlld nutrltlon, be mdr averllable to mdical school libraries. Also, the newly prodwed others and Children", a 4 page newsletter conoerning problems of maternal and young child nutrition in developing countries could be reviewed to assess the value and feasibility of translation into Arabic with special regional features and a substantial ediborial representatiorl from the countries of the Region.

(iii) Audio-visual aids Learning aids are needed in the form of slide-tape i;ets* and films demonstrating the value of breastfeeding, its management and the ill-eft??::ts of improper bottle feeding. Such films are available, pwparea in foreign situations, but these may be emphasizing asgects lnappropriale to reyiolm; context. Howrver, they may have value in indicating conceni with breast feeding in other parts of the world, including E~ropeand the USA. Catalowss of films are available from various sources **and oould be viewed.

In addition, the "~ubfStates Health duoa at ion" Program has agreed to set aside one hour of film time specifically for breastfeeding out of a total of 50 hours. This is designed for TV presentation, but could also be used for health professionals.

+ One produced by the Caribbean Food end Nutrition Institute was noted as a possible model. ** Infomation available from La Leche League International, Franklin Park, Illinois, USA, 60131 2. The Public Learning matorlolo will bc ncedcd tu reauil tile yuLllr: UINU@I mas vedla, Lhrough brochures and pamphlets and through presentations at health services, schools, etc.

Locally made filrls (suoh ao thosc propooed by the "Gulf States Health ~clu~atiurr" Programme) will be very helpful. Short two-minute spot presentations are also to be prepared by the same programme, including some on breastfeeding.

Radio represents the most economicai way of reaching large numbers. Programmes need to be individualized to the special needs of each country and can be undertaken in many forms, making use of local popular respected individuals who can develop regular authorita- i.lve "shows". Also, short radio spots repeated frequently are very important. Possible models Sor swh messages are avdllable on the subject of breastfeeding from "Antenna UNICEF" in English and French (i.4 two-minute messages on key issues). The messages need tn be tailored to the special problems and circlrmstances of the partiaular country.

As regards printed material, the WHO booklet "~reastfeeding"will be very valuable to the li~eratepublic in the appropriat.~language. (Other pamphlets and brochures are needed for. specific purposes (e.g. pregnant women, eto.)

Presentation to the ~ublicneeds to be made through the health services and other channels. For this, learning materials of differing levels and sophistication may be i'r~asibleand approprlate in varying circumstances, including slide sets, flip charts, flanrw:. .?rtrpris, etc.

At is recommended tk~atmttiods of producing learning materials for the Region within the Hegion be explored vigorously by WHO and UNICEF as a priority. In addition to the )lrod:lc ;.;.uil oi rnaterial Yj.y ileG!.th rnl:tiotri.t?s, 9'1 was recommended that WHO should explore wit.?, ',". ,\.,.. Lkir: rirvrlrijrrnarlL or n re:llonai unLt fur the proauctlon or learnlng materials concernit&:. br.aar;tf'eeoing and other health topics as prt of "project support comnications" and with a~lltlonalsupport from voluntary contributions from the Region. EMhCH/155 EM/REG. SCT .WRK. GR .BRF/14 page 40

Given the objective of the meeting, to advise WHO EMRO on a program to promote and protect breastfeeding over the period 1981 to 1983, the recommendations are addressed to the Regional Director, but +hey clearly relate to WHO in its Wlder sense or mvernmunts or Lhe Member States plus the WHO Secretariat. The reoomnendations arise not only implicitly from the dtscusaions, but also exp1icit.l~. in that on the last day of the meeting, each member of the Group listed We practical aotions in which he or she felt that his or her country required WHO collaboration.

The Regional Scientific Working Group on Breastfeeding summarizes its principal recommendations below: 1. That WHO explore with UNICEF and the Health Secretariat of the Gulf States the possibi- lities of producing audio-visual material, including films, radio-spots, and cassette- slide sets on breastfeeding, pnrtioularly for the public, but also for health staff to some extent, in addition to the simple guides such as the WHO booklet now being produced in the various languages of tb Region. (Seations 4 and 9 of this report refer). 2. That WHO continue and strengthen its technical support for surveys and studies concerning breastfeeding and associated factors as outlimd in Seotion 3, including technical guidance on planning and on analysis of data using if possible microcomputers locally available. . That WHO continue and expand its technical support to seminars, conferences, and other teaching programes directed towards health staff (see section 5 of the report) including the distribution of scientific publlcatlons at several levels. It is noted, howver, that bottlenecks exist in the system of distribution of such materials.

4. That after the expected adoptlOn or tne Code of MnrkeLlng of Brrabtnlilk Oubstitutea by the World Health Assembly, WHO may advise Ministries of Health on praotioal aotions tn be taken, and may by means of a network of correspondents organize a form of monitoring and reporting of progress in this aspect. (Section 6 of this report).

5- That WHO EMRO revlew the situation of the working womn who wishes to breastfeed and the legislation on maternity leave and other facilities as described in Section 8 of the report, and report to the Member States of the Region on this subject, together with some guidance as to practicable improvements.

6. That WHO assist in the development of the r61e of women's organizations in the promotion and proteotion of breastfeeding by means suggested in Section 7 of the report, e.8. EM/MCH/~55 EM/RE;G.SCT .WRK. GR.BRF/l'1. page 41

facilitating contact between women's organizations in the Region and such groups as La Leche League Internationale .

I. That WHO provide to those countries who so wish short-term consultants to review activities in the health services and elsewhere concerning breastfeeding and make recommendations to strengthen them.

8. Trlat WHO write to Ministers of Health and other appropriate authorities concerning the desirability of rooming-in in the case of all normal deliveries in hospitals, maternity homes or health centres. 3. That WHO EMRO may perhaps create an intercountry project, or small group or other mechanism which the Regional Director may consider suitable, for delivery of the regional programme in promotion and protection of breastfeeding, and that EMRO produce or support production of a newsletter on the subject.

lC. That WHO EMRO promote in the .WHO Regional Committee a resolut4lon or resolutions OR various aspects of breastfeeding such as the code of marketing, maternity leave, orienta- tion of health staff, and rooming-in.

- II. That WIB provide technical advice to govemnts on three controversial issues: (i) The adverse effects of oral contraceptives on lactation and the most practical ways to prevent these ill-effects, (ii) Whether the distribution of dried skim milk or other powdered milks in the health services has, on balance, pusitive ur negaiive effects on infant nutrition. (iii) The possible hazards of the crBche in terms of spread of infections. EM/MCH/55 Annex I

ANNEX I

ADDRESS BY H.E. THE MINISTER OF HEALTH, MR G. TOMBAZOS AT THE OPENING SESSION OF THE SCIENTIFIC WORKING GROUP MEETING ON BREASTFEEDING IN THE EASTERN MEDITERRANEAN REGION ORGANIZED BY WHO (REGIONALOFFICE FOR THE EASTERN MEDITERRANEAN) AT THE PEILOXLNIA IIOTEL, NICOSIA, MONDAY 26 JANUARY 1981

It is with great pleasure that I welcome all the distinguised participants to this meeting of the Scientific Working Group on Breastfeeding in the Eastern Mediterranean Region.

It is very well known that breastfeeding is an unequalled way of providing the ideal food for the healthy and harmonious physical and psychosocial development of infants. It is also well known that it is beneficial to the health and general well- being of both mother and child and that breast-milk protects infants against disease. It is because of these and other very beneficial properties, which also constitute an important component of primary health care, that the international community (governments, societies, interm tional and other organizations) have recognized the necessity for the encouragement and support of breastfeeding.

In Cyprus, as in most other countries, there has been a decline in breastfeeding which has been attributed to socio-cultural, occupational and environmental factors, despite the fact that the policy of the Ministry of Health has always been to promote breastfeeding. Although no study or research has been undertaken on the results of the decline in breastfeeding, it can be said that this decline may have had adverse effects becousc mothcrs who fecd their bobics with monufocturcd foodo may lcad thcm to malnutrition, and because of lack of understanding of the proper amount and correct hygienic preparation of the food. During the International Year for the Child the efforts to promote breastfeeding in Cyprus were intensified and are still continuing at a satisfactory level.

Nevertheless, we do recognize the need for further promoting breastfeeding as well 3s sound eupplementary feeding and weaning practices as a prerequisite to healthy child growth and development, and we are ready to intensify our activities in the field of health education, training and information on infant and young child feeding by preparing suitable leaflets on breastfeeding and giving lectures and useful information to adult gatherings or to school-leavers by the School Health Service or other primary health care workers. We quite agree with the efforts for the preparation of an International Code of Marketing of Breast-milk substitutes, in close collaboration with all parties concerned.

We feel honoured by the selection of Cyprus as the location of your meeting, and we hope that the discussions which will take place among the distinguised participants will lead to fruitful results.

I wish you every success and hope that you will enjoy your stev 1- Cyprus.

GEORGE TOMBAZOS Minister of Health ANNEX I1

MESSAGE FROM DR A. H. TABA DIRECTOR WHO EASTERN MEDITERRANEAN REGION to the REGIONAL SCIENTIFIC WORKING GROUP ON BREASTPEEDING Nicosia, 26 - 30 January 1981

Your Excellency, Ladies and Gentlemen,

It is a great pleasure to me to convey once more to the Government of Cyprus our sincere thanks for hosting this Scientific Working Group Meeting on the important subject of Breastfeeding, the first time that WHO has had a meeting on this particular cubjcct in tho Rcgion. Thc hoopitality of Cyprus in hosting tllia dull uLllrr recent meetings of WHO manifests an exemplary spirit of co-operation which is deeply appre- ciated by our Organization.

It is an interesting indication of how far our views have al.tered, that if any- body had suggested fifteen or even ten years ago that WHO should convene a meeting solely on breastfeeding it would have been thought somewhat eccentric. It is worth considering for a moment why our view0 havo chongcd, and why the promotion or protectiuu of breastfeeding is considered a priority activity of the WHO programe in Maternal and Child Health and Nutrition at the present time. I am sure that ten, twenty or thirty years ago most WHO staff in MCH , and indeed all observant nurses and doctors working in child health in devel.oping countries, were aware of reasons in favour of breastfeeding and conversely of hazards of bottle-feeding in an environment of poverty, illiteracy and poor hygiene. Certainly there have been many recent additions to arientific knowledge about the composition of human mill< oo comparcd with that of substitutes for it, and to knowledge of the physiology of lactation, which have strengthened the case for breastfeeding. Nonetheless, I would maintain that what in- hibited us ten years ago was not a failure to appreciate the reasons in favour of breastfeeding - reasons so we 11-known now that they need no repetition here - but rather a feeling of pessimism about the possibility of ever reversing the seemingly endless decline of breastfeeding, the apparently irresistible attraction of the bottle in induatri ali zed and. alas, in developing countries also. . Thc dif fcrcncc bctwecn 1970 and today is that all that feeling of helplessness has been completely swept away by the marked revival, now quite unmistakable, of breastfeeding in those very industrialized countries which had led the way in bottle-feeding to the extent that one sometimes wondered whether the human breast was not in danger of becoming a merely vestigial organ. Now however, the percentage of mothers breastfeeding their babies at 1, 3 and 6 months has, since some time between 1970 and 1975, incr?ased steadily in the USA, Canada. Australia, Sweden, Norway, the United Kingdom, France and doubtlecc in all such countries where these data have been monitored. This demonstration that the trend to bottle-feeding was not an irreversible accompaniment of modern life has no doubt not come about entirely through the advice of health workers. More subtle changes concerning the more relaxed and "natural" and overtly affectionate way in which we now bring up our children have something to do with this al.so. However, there seems no reason to doubt that, by calm but unequivocal advice and by sympathetic counselling of the lactating mother during early minor difficulties and adjllstments, health staff can or could do much to enhance this trend. Annex I1 page ii

In our Region each year some eleven million children are born. Over one and n half million of these die before reaching the age of five years. The single most frequent cause of death is diarrhoea1 disease, and this is even more the case if we add to this the severe marasmic protein-energy malnutrition which still has, in some of our Member States, a point-prevalence of over two per cent. We can have no doubt that ill-adv~sedand unnecessary boc~le-feetli~igpldys a bignificant rolc(with other factors) in the causation of this condition.

It is our intention over the next several years to strengthen our present collaboration with our Member States and initiate new activities to promote and protect breastfeeding, in the hope that thereby we may contribute towards halting the trend towards bottle-feeding and actually to reversing the decl.ine in breastfeeding and to rhe increase u1 i~sprevalence in our Rcaion earlier than wnolrl nth~rwisehave happened. Although this is the first meeting which WHO in the Eastern Mediterranean Region has convened devoted solely to this subject, I would not like you to think that this was our first activity. As early as 1976 I wrote to all Ministers of Health in the Region concerning the sales promotion of breast-mi1.k substitures and rhe potruLial harm which this can do to that confidence of a mother in her ability to nourish her own baby which is necessary for successful lactation. More recently we have included the topic of hrcnct-feeding in a number of training activities and we have distributed a moderate amount of literatureon the subject. In particular, of recent months we have distributed throughout Pakistan 5000 copies of the WHO Breastfeeding brochure in English, and are presently producing ten thousand copies in Arabic (and this as only a first printing); also, with the assistance of UNICEF, 12 000 cupies in Urdu, and scvcrnl thousand in Persian and Pushtu are being published. We hope, too, that this will be published in the remaining languages of our Region.

However, these activities are only a beginning. We have convened this meeting in order that the participants and consultants may advise us, out of the considerable experience and scientific knowledge represented here, concerning a programme of educational and promotional activities, together with action-oriented research and evaluation, which will in the next several years help the Region to attain the objective of which I have spoken above.

May I conclude therefore by reiterating my thanks to Your Excellency and the Government of Cyprus and by wishing you all an interesting and fruitful meeting. ANNEX I11 EH/MCH/~~ Anncx I11 THE TEXTS OF WORLD HEALTH ASSEMBLY page i RESOLUTIONS 27.43 of 1974, 31.47 of 1978 and 33.32 of 1980

111.1 WllA27.43 INFAWT NUTRITION IWD BREASTFEEDINC

The Twenty-seventh World Health Assembly,

Reaffirming that bre:tiit Fccdiny, has proved to be the most appropriate and succesliful 11uLriLiurrd1 rru4uLiae lur the harmonious development of the ~hild;

Noting tile gvnarrrl dselina in bron~tfaodin&related ta sorio-?ultu~nl nnd environmental factors, including the mistak@n idea caused by misleading pale8 promotion that broaatfeeding ia inferior to feeding with manufactured breast-milk substirutrs;

Observing that this decline ia one of the factors contributing to infiiiit mortality and malnutri,tion, in particular in the developing wor1.d; and

Realizing tliat msther~who feed their Babies with manufactured foods arc often unable to afford an adequate supply af such Eoods and that even if they can afford lruct~ fnads the tendency ta malnutrition is frequently aggravated because oE Lack or underecanding aP €he maunc and correct and hy~irniiprrpn- ration of the food which should ba given to the child:

1. RECOMMENDS atrnngly the encouragement of breaatfeeding as the ideal feeding in order to promote harmonious physical and mental development of children;

2. CAI.I,S THE A'Ul;NTION of countries to tho necessity of Caking adequiltc fiocial, measures for ntntllorr: WOrKlllg ~IWLIY frum Ll~eirIIUIII~!~ du~in~Lltr 1.ati~~~itiu~JCLi~d, such aii arrsngini: ;i~~ocinlwork timetab1,es so that they can llrrastf@ed their children;

3. URGES Membrr countries to review aalcu proniotion activities on baby foods and to irltroductl appropriate remedial measures, including advertisement codes and legi sl.:ati ori wllcro necessary;

4. URGES the Director-General to intensify activities relevant to the promotion of breastfeeding, to bring those matters to the notice of the medical profession and health administrators and to emphasize the need for health personnel, mothers and the general public to be educated accordingly; and

5. REQUESTS the Ilirector-General to promote and further support activities related LU ihr pirpardtiun and use of weaning foods based on local products.

23 Mav 1.974 EMfMCH155 Annex 111 page ii

111.2 WHA31.47 THE ROLE OF THE HEALTH SECTOR IN THE DEVELOPMEN'I' OF NATIONAL AND INTERNATIONAL FOOD AND NUTRITION POLICIES AND PLANS, WITH SPECIAL REFERENCE TO COMBATING MALNUTRITION

The Thirty-first World Health Assembly,

Having considered the Director-General's report on the role of the health sector in the development of national and international food aurl nutrition policies and plans ;

Rec="iline resolurionq WHA27.43. WHA28.42 and WKA30.51;

Convinced that malnutrition is one of the major impediments in attaining the goal of health for all by the year 2000 and that new approaches based on clearly defined priorities and mmaxii~iuu u~ilizationof local resources ore needed for a more effective action to combat malnutrition;

Noting with concern the continued decline in breastfeeding in many countries, while in certain countries it has been possible to arrest or reverse this trend;

Recognizing that during the first months of life breastfeeding is the safest ruld I~u~L~p~~~~~iate way to feed infanta and that it should be maint~inerl2s long as possible, with timely supplementation and weaning which ideally should be done with locally available and acceptable foods;

1. THANKS the Director-General for his report:,

2. ENDORSES the functions of the health sector in this field, as described in thc report of the Director-General;

3. RECOMMENDS that Member States give the highest priority to stimulating permaner multisectoral coordinationd nutrition policies and prograrmnes and to preventing malnutrition in pregnant and lactating women, i~lfilr~Ladl14 yuu~18children by:

(1) supporting and promoting breastfeeding by educational activities among the general public, legislative and social action to facilitate breastfeeding by working mothers; implementing the necessary promotional and facilitating measures in the health services; and regulating inappropriate sales promotion of infant foods that can be used to replace breast milk;

(2) ensuring timely supplementation and appropriate weaning practices and the feeding of young children after weaning with the maximum utilization of locally available and acceptable foods; carrying out, if necessary, action- oriented research to support this approach; and training personnel for its promotion;

4. REQUESTS the Director-General:

(1) to develop, in cooperation with Member States, a programme of research and development in nutrition, oriented primarily to the needs of developing countries, and aimed initially at the prevention of malnutrition in pregnanr: and lactating women and in young children by promoting adequate nutrition of the mother and by encouraging breastfeeding and timely supplementation and appropriate weaning practices, with the mnximum utilization of locally available and acceptable foods; EM/MCH/55 Annex 111 page iii

(2) to take aiiy urcrssaiy lileasures to coordi~latein~ernarional activities designed to promote breastfeeding, and especially to work in close collaboration with other United Nations agencies active in this field;

(3) to cooperate with national institutions in their problem-solving research and training programmes so as to strengthen their capacity to combat malnutrition, and to stimulate technical cooperation among deve- 10~il~~LVUIILLIIS ill Litis Kield;

(4) to csllaborate with multilateral and bilateral organizations and anencies dnd with other inter-governmental and non-governmental organi~atinnc in programmes of technical cooperation with countries for the developmenq and implementation of national food and nutrition policies, plans and programmes;

(5) to stimulate the mobilization of scientific and financial resources in support of a global effort to eliminate malnutrition;

5. URGES governments, multilateral and bilateral organizations and agencies to support the proposed programme of research and development in nutrition through their technical and scientific institutions and workers and by financial contributions.

24 May 1.978 EM/MCH/55 Annex 111 page iv

111.3 WHA33.37 INFANT mn YrlITNC CHILD FEEDING

The Thirty-third World Health Assembly,

Kecalling resolution WHA27.43 01 the Twer~~y-tievent11World IIealth Assembly on "Infant nutrition and breastfeeding" and resolution WHA31.47 which in particular reaffirmed that breastfeeding is ideal for the harmonious physical and psychosocial development of the child, that urgent action is called for by governments and the Di,rector~Generalin order to intensity activities ior the promotion of breastfeeding and development of actions related to the prefiaration and use of weaning foods based on local prodncts, and that there is an urgent need for countries to review sales promotion activities on baby foods and to introduce appropriate remedial measures. including advertisement codes and legislation, as well as to take appropriate supportive social measures for mothers working away from their homes during the lactation period;

Recalling further resolutions WHA31.55 and WHA32.42 which emphasized maternal and child health as an essential component of primary health care, vital to the attainment of health for all by the year 2000;

Recognizing that there is a close inter-relationship between infant and young child feeding and social and economic development, and that urgent action by governments ia rcquirod to prornotc thc health and nutrition of infante, young children and mothers, inter alia through education, training and information in this field;

Noting that a Joint WHO/UNICEF Meeting on Infant and Young Child Feeding was held from 9 to 12 October 1979, and was attended by representatives of governments, the United Nations system and technical agencies, non-governmental organizations active in the area, the infant food industry and other scientists working in the field;

1. ENDORSES in their entirety the statement and recommendations made by the joint I~MO/UNICEFmeeting namely on the encouragement and support of breastfeeding; the promotion and support of appropriate weaning practices; the strengthening of education, training and information; the promotion of the health and social status of women in relation to infant and young child feeding; and the appropriate marketing and distribution of breastmilk substitutes. This statement and these recommendations also make clear the responsibility in this field incumbent on the health services, health personnel, national authorities, women's and other non-governmental organizations, the United Nations agencies and the infant food industry, and stress the:.:..-.: importance for countries to have a coherent food and nutrition policy and the need for pregnant and lactating women to be adeq~atcl.~nourished. The joiht meeting also recommended that "There should be, an international code of marketing of infant formula and other products used as breastmilk substitutes. This should be supported by both exporting and importing countries and observed by all manufacturers. WO/UNICEFwere requested to organize the process for its preparation, with the involvement of all concerned parties, in order to reach a conclusion as soon as possible";

2. RECOGNIZES the important work already carried out by the World Hcolth Organieation . and UNICEF with a view to implementing these recommendations and the preparatory work done on the formulation of a draft international code of marketing of breastmilk sllbstitutes; 3. URGES countries which have not already done so to review and implement resolution . WHA27.43 and resolution WHA32.42;

4. URGES women's organizations to organize extensive information dissemination cam- paigns in support of breastfeeding and healthy habits; 5. REQUESTS the Director-General

(1) to cooperate with Member States on request in supervising, or arranging for thc supervision of the quality of in fa^^^ Luuds during cheir production in the country concerned as well as during their importation and marketing;

(2) to promote and support the exchange of information on laws, regulatinnq, and other measures concerning marketing of breastmilk substitutes;

6. FURTHER REQUESTS the Director-General to intensify his activities for promoting thc application of the rccommendatiuus ui Llir juiut WO/UNICEF meefing and, 1n particular:

(1) to continue efforts to promote breastfeedine as well as sound, supplem~ntary feeding and weaning practices as a prerequisite to healthy child growth and development ;

(2) to intensify coordinationwith other internativ~lal and bilateral agencies for mobilization of the necessary resources for the promotion and support of activities related to the preparation of weaning foods based on local products in countries in need of such support and to collate and disseminate information on methods of supplementary feeding and weaning practices suaceesfully used in different cultural settings;

(3) to intcnaify activities iii the Iirld ut health education, training and information on infant and youne shild feeding, in particular through the preparation of training and other manuals for primary health care workers in different regions and countries;

(4) to prepare an international code of marketing of breastmilk substitutes in close consultation with Member States and with all other parties concerned including such scientific and other experts whose collaboration ludy be deemed appropriate, bearing in mind that:

(a) the marketing of breastmilk substitutes and weaning foods must be viewed within the framework of the problems of infant and young child feeding as a whole; (b) the aim of the code should be to contribute to the urovision of safe and adequate nutrition for infants and young children, and in particular to promote breastfeeding and ensure, on the basis of adequate information,the proper use of breastmilk substitptes, if necessary; (c) the code should be based on existing knowledge of infant nutrition; (d) the code should be governed inter alia by the following principles:

L the production, storage and distribution, as well as advertising of infant feeding products should be subject to national legislation or regulations, or other measures as appropriate to the country concerned; (ii) relevant information on infant feeding should be provided by the health care system of the country in which the product is RM/MCH/55 Annex I11 page vi

(iii) products should meet international standards of quality and presentation in particular those developed by the Codex Alimentarius Commission and their labels should clearly inform the public of the superiority ot breastfeeding;

(5) to submit the code to the Executive Board for consideration at its sixty- acventh soscion anA For forwarding with its recommendations to the Thirty-fourth World Health Assembly, together with proposals regarding its promotion and implementation, either as a regulation in the sense of Articles 21 and 22 of the Constitution of the World Health Organization or as a recommendation in the sense of Article 23, ourlining Lhr legal and othcr implications of each rhnire;

(6) to review the existing legislation for enabling and supporting breastfeeding, especially by working mothers in different countries, and to strengthen the Organization's capacity to cooperate on the request ot Member States in developir~g such legislation;

(7) to subu~iLto the Thirty-fourth World Health Assembly, in 1981, and there- after in even years, a report on the steps taken by WHO to promote breastfeeding and to improve infant and young child feeding, together with an evaluation of the effect of all measures taken by WHO and its Member States.

22 May 1980 EM/MCH/55 Annex LV page i

ANNEX IV

4. THE DRAFT

INTERNATIONAL CODE OF MARKETING

OF BREASTMILK SUBSTITUTES

(b) Recmendation form in the sense of Article 23 of the Constitution of the World Health Organization

CONTENTS

Preamble...... 14 krticlel. AimoftheCode ...... 16

Article 2. Scope of the Codc ...... 16 Article 3. Definitions ...... 16 Article 4. Information and education ...... 17 Article 5. The general public and mothers ...... 18 Article 6. Health care systems ...... 18

Article 7, Health workers ...... 19 Article 8. Persons employed by manufacturers and distributors ...... 20

ArtieloQ. Labelling ...... 20

Articlelo. Quality ...... 20 rticle 11. Implementation and monitoring ...... 21

The Member States of the World Health Organization:

Affirming the right of every child and every pregnant and lactating woman to be adequately nourished as a means of attaining and maintaining health;

Recogniri~~yLirat. lnfanr malnutrrtlon is part of the wider problems of lack of education, poverty, and social injustice;

Recognizing that the health of infants and young children ramrul be lsolared from the health and nutrition of women, their socioeconomic status and their roles as mothers;

Conscious that breastfeeding is an unequalled way of providing ideal food for the hrelLlty yruwch and development oi infants; that it forms a unique biological and emotional basis for the health of both mother and child; that the anti-infective properties of breastmilk help to protect infants against disease; and that there is an important relationship between breastfeedine and child-spacing; EM/MCH/55 Annex.IV page 11

Recognizing that the encouragement and protection of breastfeeding is an important :.cr:. of the health, nutrition and other social measures required to promote healthy growth and development of infants and young children; and that breastfeeding is an important aspcc: <,: primary health care;

Considering that when mothers do not breastfeed, or only do so partially, thcrc L< i legitimate market for infant formula and for suitable ingredients from which to priapare LL, that all these products should accordingly be made accessible to those who need them through commercial or non-connnercial distribution systems; and that they should not be marketed or distributed in ways that may interfere with the protection and promotion of breastfeed~lg,

Recognizing further that inappropriate feeding pracrices lead to infant mliiuir~~~u, morbidity and mortality in all countries, and that improper practices in the market~ng ,. breastmilk substitutes and related products can contribute to these major public health problems,

Convinced that it is important for infants to receive appropriate complementary foods, usually when the infant reaches four to six months of age, and that every effort should be mads to YEE looally ~voilnblc foodo; md sonvinocd, ncvcrthclcsa, tlm~~u~lr cuu~plrutrr~rdry foods should not be used as breastmilk substitutes;

Appreciating that there are a number of soclal and economic factors affecting breastfeeding, and that, accordingly, governments should develop social support systems to protect, facilitate and encourage it, and that they should create an environment that fosters breastfeeding, provides appropriate family and cornunity support, and protects mothers from factors that inhibit breastfeeding;

Affirming that health care systems, and the health professionals and other health workers serving in them, have an essential role to play in guiding infant feeding practices. encouraging and facilitating breastfeeding, and providing objective and consistent advice to mothers and families about the superior value of breastfeeding, or, where needed, on the proper use of infant formula, whether manufactured industrially or home-prepared;

Affirming further that educational systems and other social services should be involved in the protection and promotion of breastfeeding, and in the appropriate use of complementary foods;

Aware that families, connnunities, women's organizations and other nongovernmental organizations have a special role to play in the protection and promotion of breastfeeding and ~n ensuring the support needed by pregnant women and mothcrs of infants and young child~e~, whether breastfeeding or not;

Affirming the need for governments, organizations of the United Natlons system, nongovernmental oraanizations, experts in various related disciplines, consumer groups and ~ndustry to cooperate in activities aimed at the improvement of maternal, infant and young child health and nutrition;

Recognizing that governments should undertake a variety of health, nutrition and other social measures to promote healthy growth and development of infants ard young children, and that this Code concerns only one aspect of these measures;

Considering that manufacturers and distributors of breastmilk substitutes have an important and constructive role to play in relation to infant feeding, and in the promotion of the aim of this Code and its proper implementation;

Affirming that governments are called upon to rake action appropriate to their social and legislative framework and their overall development objectives to giveeffect 'to the' principles and aim of this Code, including the enactment of legislation, regulations or other suitable measures; EM/MCH/ 55 Annex IV Page iii

Believing that, in the llght of the foregoing considerations, and in view of the vulnerability of infants in the early months of life and the risks involved in inappropriate t - feeding pmrrir~s,including the mncccaonry and imy~uprruse of breastmllk substitutes, the marketing of breastmilk substitutes requires special treatment, which makes usual marketing - practices unsuitable for these products;

THEREFORE:

The Member States hereby agree the following articles which are recommended as a basis f"~d'Li"".

Article 1

Aim of the Code

The aim of this Code is to contribute to the provi~inncrf safe and sdcquatc nutrition for infants, by the protection and promotion of breastfeeding, and by ensuring the proper use of breastmilk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution.

Article 2

Scope oi Lhr Code

The Code applies to the marketing, and practices related thereto, of the following products: breastmilk substitutes, including infsnt formula; other milk products, fuuda dnri beverages, including bottle-fed complementary foods when marketed or otherwise represented to be suitable, with or without modification, for use as a partial or total replacement of breastmilk; feeding bottles and teats. It also applies to their sualitv and availability, dnd ro information concerning their use. --Article 3

L Definitions

--For the purposes of this Code:

"Breastmilk substitute" means any food being marketed or otherwise represented as a partial or total replacement for breastmilk, whether or not suitable for that purpose.

"Complementary food" means any food, whether manufactured or locally prepared, suitable as a complement to breastmilk or to infant formula, when either becomes insufficient to satisfy the nutritional requirements of the infant. Such food is also cmonly callcd "weaning food" or "breastmilk . supplement".

"Container" means any form of packaging of products for salp a- a normal retail unit, including wrappers.

"Distributor" means a person, corporation or any other entity in the public or private sector engaged in the business (whether directly or indirectly) of marketing at the wholesale or retail level a product within the scope of this Code. A "primary distributor" is a manufacturer's sales agenc, representative, national distributor or broker. EM/MCH/55 Annex IV page iv

"Health care system" means governmental, nongovernmental or private institutions or organizations engaged, directly or indirectly, in health care for mothers, infants and pregnant women; and nurseries or child-care institutions. It also includes health workers in private practice. For the purposes of this Code, the health care system does not include pharmacies or ocher established sales outlets.

"Health worker" means a person working in a component of sllrh a health care system, whether professional or non-professional, including voluntary, unpaid workers.

"Infant formula" means a breastmilk substitute formulated industrially in accordance with applicable Codex Alimentarius standards, to satisfy the normal nutritional requirements of infants up LU beLweru luur cllld bia LNLYLLLILL"1 as=, and adapLrd Lu their physiological characteristics. Infant formula may also be prepared at home, in which case it is described as "home-prepared".

"Label" means any tag, brand, mark, pictorial or other descriptive matter, written, printed, stencilled, marked, embossed or impressed on, or attached to, a container (see above) of any products within the scope of this Code.

means a corporation or other entity in the public or private sector engaged in the business or function (whether directly or through an agent or through an entity controlled by or under contract with it) of manufacturing a product within the scope of this Code.

"Marketing" means product promotion, distribution, selling, advertising, product public relations, and information services. 1

"Marketing personnel" means any persons whose functions involve the marketing of a product or products corning within the scope of this Code.

"Samples" means single or small quantities of a product provided without cost.

"Supplies" meins of a product provided for use over an extended period, free or at a low price, for social purposes, including those provided to families in need.

Article 4

Information and education

L.l Governments should have the responsibility to ensure that objective and consistent information is provided on infant and young child feeding for use by families and those involved in the field of infant and young child nutrition. This responsibility should cover . either the planning, provision, design and dissemination of information, or their control.

4.2 Informational and educational materials whether written, audio, or visual, dealing with the feeding of infants and intended to reach pregnant women and mothers of infants and young ~hildrm,should include clear inLorntaLiurl uu all Lhr Lullowing puinLs. (a) Lllr LrnrLiLs and EM/MCH/55 Annex IV Page v

superiority of breastfeeding; (b) maternal nutrition, and the preparation for and maintenance . of breastfeeding; (c) the negative effect on breastfeeding of introducing partial bottle- feeding; (d) the difficulty of reversing the derision not to breastfeed; and (c) where needed, the proper use of infant formula, whether manufactured industrially or home-prepared. - When such materials contain information about the use of infant formula, they should include the social and financial implications of its use; the health hazards of inappropriate foods or feeding methods; and, in particular, the health hazards of unnecessary or improper use of infant formula and other breastmilk substitutes. Such materials should not use any pictures or text which may idealize the use of breastmilk spbstitutes,

4.3 Donations of informational or educational equipment or materials by manufacturers or distributors should be made only at the request and with the written approval of the appropriate government authority or within g~~idelinar:given by goverrunento for this purpose. Such equipment or materials may bear the donating company's name or logo, but should not refer to a proprietary product that is within the scope of this Code, and should be distributed only through the health care system.

Article 5

The grurral public and mothers

5.1 There should be no advertising or other form of promotion to the genera; public of products within the scope of this Code.

5.2 Manufacturers and distributors should not provide, directly or indirectly, to pregnant women, mothers or members of their families, samples of products within the scope of this Code

5.3 In conformity with paragraphs 1 and 2 of this Article, there should be no point-of-sale advertising, giving of samples, or any other promotion device to induce sales directly to the T CULIb~~~~e~LLL t.1~recall level, such as Special displays, discount coupons, premiums, special sales, loss-leaders and tie-in sales, for products within the scope of this Code. This provision should not restrict the establishment of pricing policies and practices intended to . provide prndnrtq at Inwer prices on o long-term basic. 5.4 Manufacturers and distributors should not distribute to pregnant women or mothers of infants and young ,.hildren any gifts of articles or utensils which mav promote the usp of breastmilk substitutes or bottle-feeding.

5.5 Marketing personnel, in their business capacity, should not seek direct or indirect contact of any kind wlCh pregnant women or with mothers of infants and young children.

Article 6

Health care svstems

6.1 The health authorities in Member States should take appropriate measures f o onrnrrrape , . and protect breastfeeding and promote the principles of this Code, and should give appropriate information and advice to health workers in regard to their responsibilities, including the information specified in Article 4.2. . 6.2 No facility of a health care system should be used for the purpose of promoting infant formula or other products within the scope of this Code. This Code does not, however, preclude the dissenlii~atiuuuL iliLurmaLiur~ Lu IrralLh proIessionalS as provlded ln Artlcie 1.2.

6.3 Facilities of health care systems should not be used for the display of products within the scope of this Code, for placards or pnaters rnnr~rningsuch products, or for the distribution of material provided by a manufacturer or distributor other than that specified in Article 4.3. EM/MCH/~~ Annex IV page vi

6.4 The use by the health care system of "professional service representatives", "mothercraft nurses" or similar personnel, provided or paid for by manufacturers or distributors, should not be permitted.

6.5 Feeding with infant formula, whether manufactured or home-prepared, should be demon- strated only by health workers, or other community workers if necessary; and only to the mothers or family members who need to use it; and the 11~1onnaLlongiven shuuld include a clear explanation of the hazards of improper use.

6.6 Donations or low-price sales to institutions or organizations of supplies of infant formula or other products within the scope of this Code, whether for use in the institutions or for distribution outside them, may be made. Such supplies should only be used or distributed for infants who have to be fed on breastmilk substitutes. If these supplies are distributed for use outside the institutions, this should be done only by the institutions or organizations concerned. Such donations or low-price sales should not be used by manufacturers or distributors as a sales inducement.

6.7 Where donated supplies of infant formla or other products within the scope of this Code are distributed outside an institution, the institution or organization should take steps to ensure that supplies can be continued as long as the infants concerned need them. Donors, as well as institutions or organizations concerned, should bear in mind this responsibility.

6.8 Equipment and materials, in addition to those referred to in Article 4.3, donated to a health care system may bear a company's name or logo, but should not refer to any proprietary . product within the scope of this Code.

Article 7

Health workers

7.1 Health workers should encourage and protect breastfeeding; and those who are concerned in particular with maternal and infant nutrition should make themselves familiar with their responsibilities under this Code, including the infontlation specified in Article 4.2 4

7.2 Information provided by manufacturers and distributors to health professionals regarding products within the scope of this Codc ahould be restricted to scientific and factual matters, and such information should not imply or create a belief that bottle-feeding is equivalent or superior to breastfeeding. It should also include the information specified in Article 4.2.

7.3 No financial or material inducements to promote products within the scope of this Code should be offered by manufacturers or distributors to health workers or members of their families, nor should these be' accepted by health workers or members of their families.

7.4 Samples of infant formula or other products within the scope of this Code, or of equipment or utensils for their preparation or use, should not be provided to health workers except when necessary for the purpose of professional evaluation or research at the .% institutional level. Health workers should not give samples of infant formula to pregnant women, mothers of infants and young children, or members of their families.

7.5 Manufacturers and distributors of products within the scope of this Code should disclose . to the institution to which a recipient health worker is affiliated any contribution made to . or on his behalf for fellowships, study tours, research grants, attendance at professional conferences. or the like. Similar disclosures should be made by the recipient. EM/MCH/ 55 Annex IV page vii

Persons employed by manufacturers and distributors

8.1 In systems of sales incentives for marketing personnel, the volume of sales of products within the scope of this Code should not be included in the calculation of bonuses, nor should quotas be set specifically for sales of these products. This should not be understood to prevenc che paymenc of bonuses based on Lhe overall sales by a cuutpa~~yu1 uLltrr pruducLs marketed by it.

8.2 Personnel employed in marketing products within the scope of this Code should not, as part of their job responsibilities, perform educational functions in relation to pregnant women or mothers of infants and young children. This should not be understood as preventing such personnel from being used for other functions by the health care system at the request and with the wrrtten approval of the appropriate authoricy of rhe government concerned.

Article 9

Labelling

9.1 Labels should be designed to provide the necessary information about the appropriate use of the product, and so as not co discourage breastfeeding.

9.2 Manufacturers and distributors of infant formula should ensure that each container has a clear, conspicuous. and easily readable and understandable message printed on it, or on a label which cannot readily become separated from it, in an appropriate language, which includes all the following paints: (a) the words "Important Notice" or their equivalent; (b) a statement of the superiority of breastfeeding; (c) a statement that the product should be used only on the adv~ceof a health worker as to che need for irs use and the proper method of use; (d) instructions for appropriate preparation, and a warning against the health hazards of inappropriate preparation. Neither the container nor the label should have pictures of infants, nor should they have other pictures or text which may idealize the use of infant formula. They may, however, have graphics for easy identification of the product as a breastmilk substitute and for illustrating methods of preparation. The terms "humanized", "maternalized" or similar terms should not be used. Inserts giving additional information about the.praduct and ~tsproper use, subject to the above cond~txons,may be lncluded ln the package or retail unit. When labels give instructions for modifying a product into infant formula, the above should apply.

9.3 Food products within the scope of this Code, marketed far infant feeding, which do not meet all the requirements of an infant formula, but which can be modified to do so, should carry on the label a warning that the unmodified product should not be the sole source of nourishment of an infant. Since sweetened condensed milk is not suitable for infant feeding, nor for use as a main ingredient of infant formula, its label should not contain purported instructions on how to modify it for that purpose.

9.4 The label of food products within the scope of this Code should also state all the following points: (a) the ingredients used; (b) the composition/analysis of the product; (c) the storage conditions required; and (d) the hatch number and the date before which the product is to be consumed, taking into account the climatic and storage conditions of the country concerned.

Article 10

Quality

10.1 The quality of products 1s an essential element for the protection of the health of infants and therefore should be of a high recognized standard.

10.2 Food within the scope 06 this Code should, when sold or othcrnioc dictributed, meet applicable standards recommended by the Codex Alimentarius Commissian and also the Codex Code of Hygienic Practices for Foods for Infants and Children. EM/MCH/55 Annex IV page viii Article 11

implementation and monitoring

11.1 Governments should take action to give effect to the princiules and aim of this Code. as appropriate to their social and legislative framework, including the adoption of national legislation, regulations or other suitable measures. For this purpose, governments should seek, when necessary, the cooperation of WHO, UNICEF and other agencies of the United Nations sysrem. Narional policies and measures, including laws and regulations, which are adopred Co give effect to the principles and aim of this Code should be ~ubliclystated, and should apply on the same basis to all those involved in the manufacture and marketing of products within the srnpe of this Code.

11.2 Monitoring the application of this Code lies with governments acting individually, and collectively through the World Health Organization as provided in paragraphs 6 and 7 of this ArLLcle. Iht. manufacturers and dlStr1bUtotS of products within the scope oi this Code, and appropriate nongovernmental organizations, professional groups, and consumer organizations should collaborate with governments to this end.

11.3 Independently of any other measures taken for implementation of this Code, manufacturers and distributors of products within the scope of this Code should regard themselves responsible for monitoring their marketing practices according to the principles and aim of his Code, and for taking steps co ensure that their conduct at every level conforms to them.

11.4 Nongovernmental organizations, professional groups, institutions, and individuals concerned should have the responsibility of drawing the attention of manufacturers or distributors to activities which are incompatible with the principles and aim of this Code, so that appropriate action can be taken. The appropriate governmental authority should also be informed.

11.5 Manufacturers and primary distributors of products within the scope of this Code should apprise each member of their marketing personnel of the Code and of their responsibilities under it.

11.6 In accordance with Article 62 of the Constitution of the World Health Organization, Member States shall communicate annually to the Director-General information on action taken L" 8ivrelLe~~ LU Lllr prLncLp1es and aim of this Lode.

11.7 The Director-General shall report in even years to the World Health Assembly on the status of implementation of the Code: and shall. on request, provide technical support to Member States preparing national legislation or regulations, or taking other appropriate measures in implementation and furtherance of the principles and aim of this Code. EM/MCH/55 Annex V page i

ANNEX V

LIST OF FAETICIPANTS

WHO TEMPORARY ADVISERS Dr Jalal Aashi Secretary-General Sccrctnrint-Ccncral of Hcnlth for Arab Countries of the Gulf Area Ministry of Public Health

SAUDI ARABIA

Mrs Stina Almroth c/n Norwegian Save the Children Clinic Ibb YEMEN

vr Hassan Awadh Bin Uadeem Director Maternal and Child HealthlFamily Planning Ministry nf Health Aden DEMOCRATIC YEMEN

Ur M. El Mougi Associate Professor of Paediatrics Faculty of Medicine El Azhar University -Cairo EGYPT

Mr T. G~ei11er c/o Norwegian Save the Children Cl.inic --Ibb YEMEN

Professor B. Hamza MBdecin-Directeur de 1'Ins titut national de la SantE de 1'Enfancc Ministare de la SantB publique Tunis TUNISIA

Dr Jamal Harfouche Professor Emeritus of Maternal and Child llealth American University of Beirut -Beirut LEBANON EM/MCH/55 Annex V page ii

WHO TEMPORARY ADVISERS (cont 'd .)

Dr Saad Hijazi Associate Professor of Nutrition and Child Healch Faculty of Medicine and University Hospital -Aman JORDAN

Professor Ashfaq Ahmed Professor of Faediatrics Khvber Medical College ~eshawar PAKISTAN

Professor Mohamed Ibrahim Omar Director Portnraduate- Medicill Sttldiee Rnard Facultv of Medicine ~hartoum SUDAN

WHO CONSULTANTS

Dr G.J. Ebrahim Reader Tropical Child Health Unit InsLitutr uE Child Health --London ENGLAND

Dr D.B. Jelliffe Head Division of Population Family and International Health UCLA School of Public Health Los Angeles, California UNITED STATES OF AMERICA

Mrs E.F.P. Jelliffe Division of Population Family and International Health UCLA School of Public Health Los Angeles, California UNITED STATES OF AMERICA

OBSERVERS FROM HOST COUNTRY Mr Andreas Chara1,ambos Health Inspector Ministrv of Health Nicosia CYPRUS EM/MCH/55 Annex v page iii

OHSbKVi3RS FROM HOST COUNTRY (cont 'd .)

Dr C. Haj igeorghiou Specinlist Paediatrician Nicosia General Hospital Nicosia CYPRUS

Miss A. Marti Senior Health Visitor Nicosia Conaral Hospital Nicosia CYPRUS

-WHO SECRETARIAT

Dr R, Cook MCH Adviser and Secretary WHO Regional Office for the of the Meeting Easeern Mediterranean

Dr S. Ghosh Medical Officer, MCH WHO,Kabul

Dr P.M. Shah Medical Officer , MCH WHO Contra1 Office, Geneva

Mrs C. Cartoudia-D€m€trio Conference Officer WHO Regional Office for the Eaetern Mediterranean

Mrs M-T. Brahamcha Secretary WHO Regional Office for the Eastern Medi Ferranean