Livelihood assessment approaches in emergencies

A paper and recently summarised editorial^1,2

Violations of the International Code of Marketing of Breastmilk Substitutes have been previously reported in Field Exchange³. A paper and editorial summary recently published demonstrates how Code legislation does not, in itself, ensure Code adherence, and highlights the shortfall in monitoring mechanisms that currently exist. Given the challenges facing policy makers and aid practitioners regarding infant feeding and HIV/AIDS, particularly in environments where artificial feeding may be practised and commercial companies are active, e.g. Southern Africa, upholding the Code should go some way towards realising appropriate and informed decision-making regarding infant feeding choices. (Eds)

A recent paper has reported on the findings of a multi-site cross sectional survey in two west African countries (Burkino Faso and Togo), to monitor compliance with the International Code of Marketing of Breastmilk Substitutes (the Code). While the value of breastfeeding in infant health and growth is well recognised, the authors highlight how contact with western health practices, exposure to mass media, and aggressive marketing of breast milk substitutes (BMS) risk undermining sound practice. Whilst countries are encouraged to enact the Code into national legislation, few west African countries have done so.

The study involved staff at 43 health facilities and 66 sales outlets and distribution points, 186 health providers, and 105 mothers of infants aged 5 months, in 16 cities. Investigations were interview and questionnaire based. Significant and comparable levels of code violations were observed with (Burkina Faso) and without (Togo) regulating legislation. Examples included violations of code labelling standards (forty companies), donations of breastmilk substitutes to six health facilities (14%), distribution of donated BMS free of charge to mothers, promotional gifts to five health facilities (12%) and special marketing displays at 29 sales and distribution points (44%). Most (90%, n=144) health providers had never heard of the code, and over half of mothers (63%, n=66) had never received any counselling on breast feeding by their health providers.

The authors concluded that legislation must be accompanied by effective information, training, and monitoring systems to ensure that healthcare providers and manufacturers comply with evidence based practice and the code.

Wider implications of this study were considered in an editorial in the same issue. First, how should compliance with the code be monitored effectively to reduce continuing violations? The authors suggest that of the three international models of monitoring that currently exist⁴, the Interagency Group on Breastfeeding Monitoring (IGBM) protocol (in draft) has the greatest application and should be endorsed by the international community.

Secondly, regarding appropriate training of health workers in the protection and support of breastfeeding, the authors emphasis the importance of periodic and systematic training of workers, and suggest drawing on the evidence base and experiences of the UNICEF Baby Friendly Hospital Initiative (BFHI).

Thirdly, the authors consider how to combine support for breast feeding, with recognition of the risk of maternally transmitted HIV infection. They propose that in most poor countries affected by AIDS, the risk associated with bottle feeding is higher than the risk of mother to infant transmission of HIV infection, a fact that needs to be reiterated to decision makers, since manufacturers of breast milk substitutes may capitalise on HIV infection as a reason for formula promotion. In addition, the World Health Organisation (WHO) recommendations⁵ require maternal access to credible information, quality care, and support, to facilitate informed decisions regarding infant feeding. Whilst governments and the WHO code are central to ensuring breastfeeding protection, the editorial concludes that a better way of monitoring and enforcing its application, in both industrialised and low income countries, must be identified.

¹Monitoring compliance with the International Code of Marketing of Breastmilk Substitutes in west Africa: multi-site cross sectional survey in Togo and Burkina Faso. BMJ 2003;326:127, 18th Jan

²Editorial. Monitoring the marketing of infant formula feeds BMJ 2003; 326:113-114, 18th Jan

³See Field Exchange Issue 8, Infant feeding in emergencies: recurring challenges, and Issue 10, Infant Feeding Practice: observations from Macedonia and Kosovo

⁴1) WHO Common Review and Evaluation Framework (WHO/NUT/96., 2) the International Baby Food Action Network (IBFAN) Monitoring Forms Manual (email ibfanpg@tm.net.my), 3) Interagency Group on Breastfeeding Monitoring (IGBM) protocol currently in draft (www.scfuk.org.uk/development/links/IGBM.htm

⁵United Nations Administrative Committee on Coordination/Standing Committee on Nutrition. Nutrition and HIV/AIDS. Nutrition policy paper no. 20. In: Geneva: ACC/SCN, 2001. http://acc.unsystem.org/SCN/