EDITORIAL: How the WHO Code Impacts Breastfeeding and Pumping Moms

We all have our own personal code or recommendation on how we choose to breastfeed or express milk for our babies. But there’s another code many lactation professionals and baby-friendly hospitals are trying to follow. It’s all about how products are marketed to moms, just like you. In fact, you’re probably using many of these products on a daily basis. So, who created these recommendations, how do they impact breastfeeding and pumping moms and why is it causing a divide from within the lactation community? #SupportAllMoms

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The Boob Group
EDITORIAL: How the WHO Code Impacts Breastfeeding and Pumping Moms
Episode 162, June 13th, 2016

Please be advised, this transcription was performed from a company independent of New Mommy Media. As such, translation was required which may alter the accuracy of the transcription.
[Theme Music]

SUNNY GAULT: We all have our personal code, or recommendation, on how we choose to breastfeed or express milk for our babies. But there is another code many lactation professionals and baby-friendly hospitals are trying to follow. It’s all about how products are marketed to moms. Just like you. In fact you are probably using many of these products on a daily basis. So who created these recommendations? How did they impact breastfeeding and pumping moms? And why is it causing such a divide from within the lactation community? We are The Boob Group.
[Intro/Theme Music]

SUNNY GAULT: Welcome to The Boob Group! We are here to support all moms who want to give their babies breast milk and to respect moms who choose to feed their babies another ways. I am Sunny Gault. Thanks so much to all of our listeners who take the time and e-mail us or leave a voicemail. Your feedback is so important to us! We do believe this is your show and we will always try to do what we believe in the best interest of moms who listen.

So your input is very important! If you have a comment or a question for us, you can send us a voicemail or e-mail through our website at www.newmommymedia.com or you can reach-out to us through Facebook. Have you downloaded our free app? It’s a great way to stream all of our episodes and even download them to listen to later. We have The Boob Group app, as well as our network app for New Mommy Media. So if you want one app to access all of the New Mommy Media shows, that’s probably your best option there. And you can download them wherever you get apps. Well, we’ve got a big show for you today! So let’s take a quick break and we’ll be right back!

[Theme Music]

SUNNY GAULT: Today we are exploring an important topic. It’s important because it’s impacting you as a breastfeeding or pumping mom on a regular basis. And most moms don’t even know it exists. It’s a code or recommendation called The International Code of Marketing of Breast milk Substitutes. It’s commonly referred to as the WHO code, because it was adapted by the World Health Assembly of the World Health Organization in 1981.

Today we are going to talk about the code. What it says? And perhaps more importantly what it doesn’t say? Because there are a lot of misconceptions out there. But first you should know a little bit about me. Why? Because this is an editorial piece. And this episode was created based on my own personal experience with the code and how it’s been implemented here in the United States.

So who am I? Well, you already know my name. I am Sunny. I have a journalism background. I was a television news anchor and reporter before launching my own company, New Mommy Media, which creates podcasts for new and expecting parents. Our show The Boob Group has released more that 163 episodes that helped breastfeeding and pumping moms across the country. I am also a breastfeeding and pumping mom.

I have four children, ages 5 and under. That’s right, I said 5 and under. I have exclusively breastfed, exclusively pumped. I have supplemented while still breastfeeding and pumping. I have donated breast milk, I have received donated breast milk. I have used the F word. That is right-formula. I have breastfed in public with or without a cover. I have used nipple shields and pacifiers, and pretty much whatever I could to calm and soothe my baby and keep us breastfeeding for as long as possible.

I am currently breastfeeding my twin girls who are now two and a half years old. I am passionate about breastfeeding. I am also passionate about moms being able to make their own educated choices based on what they believe is best for their family. The WHO code has impacted me greatly. It’s impacting my business, my relationships, and my finances. And it’s impacted you too, moms, perhaps without you even knowing it. You see, the code influences how infant feeding products are marketed to you. And in some cases it prohibits the marketing of these products at all, which impacts what you buy for your family.

Now, if you are anything like me, the infant feeding products I choose to buy for my family, have a significant impact on my breastfeeding and pumping success. And that’s why this episode is so important! As moms, we need to know about this code. We need to know why it was created. We need to know who is using the code. And we need to know what it actually says. I know, from personal experience that is not easy to do. You can ask ten different people about what the code says and get ten different answers. And most of the information online is biased written by people who strongly advocate for the code.

So for this episode we went straight for the source-The World Health Organization and my interview with Doctor Laurence Grummer-Strawn, technical officer with World Health Organization’s department for Health and Development. His also the lead written 2016 code report, published last month-a document detailing the process of implementing the code worldwide. Doctor Grummer-Strawn is from the US, but resides in Geneva, Switzerland. I began my interview with doctor Grummer-Strawn by asking him questions about how the WHO code came to be:

We now in May of 1920 The World Health Assembly determined that there needed to be an international code for marketing infant formula and breast milk substitutes. So doctor Grummer-Strawn, can you tell us why this was needed? I mean, what was happening on a global scale with regards to breastfeeding and infant feeding?

LAURENCE GRUMMER-STRAWN: I’d like to say this really came out through the 1917s. It really didn’t just appear in the 1980 with The World Health Assembly. There was a lot of concern globally around malnutrition that was linked to lack of breastfeeding that you could point to children who are emaciated, stunted growth and you could trace it back to this child was clearly not being breastfed and was on some kind of a breast milk substitute. It might be infant formula, it might be other milks or foods that were given at a very early age, and that child was suffering from malnutrition.

Sometimes just because it was deluded too much, sometimes it was unhealthy water that it had to be mixed with, and sometimes it was just the nature of the formula-feeding is just not as healthy. And so this came out to a lot of public attention of the problem with that and simultaneous new information coming out about marketing practices of some companies, and pointing out that they were really pushing formula on mothers, and convincing them that they shouldn’t breastfeed, that this product was going to be good for their babies, and so were really the cause of the problem.

So it really came about from the United States. It is kind of an interesting history that it was a senator in the US that called for a meeting to really look at this issue of what can we do about the marketing of breast milk substitutes, and called UNICEF and WHO to come together and address what should be done. And it was out of that meeting that they came up with the recommendation that we really are to be establishing kind of code of ethics of how marketing are to be done. That was presented to The World Health Assembly in 1980, as you mentioned, and they said: yes, you are absolutely right, please go and develop such a code.

SUNNY GAULT: Ok, and then this resulted in the creation of the International Code of Marketing of Breast milk Substitutes. So who contributed to the drafting of this code, which I believe took about two years to do? And then what is the overall goal or aim of the code?

LAURENCE GRUMMER-STRAWN: Um so… Who put it together was in largely people at WHO in consultation with many partners weighing into it, but it was really managed here at WHO and worked with some contractors who came up with first drafts and then a very consultative process with hearing with non-government organizations, with industry itself, with countries, with academia, other UN organizations, sometimes in committees, and sometimes just hearings to share where are we at with this draft, what do you think of this, what are the issues moving forward.

A very irrative process that they would kind of take these comments, bring it back rewriting new draft, send it back for comment, a lot of back and forward, as you say, over the course of almost two years. In kind of officially one year between 1980 when it was called for and when it was adopted in ’81, but really the work itself started in 1979 before that.

Its purpose really is twofold. One is to protect breastfeeding against commercial interest. That would be fighting again breastfeeding that would be convincing mothers not to breastfeed. And the other was to ensure that when breast milk substitutes are needed, that they are communicated in a way that is actually conducive to their best use. That they are not going to be deluded too much, that they are used in a safe manner.

SUNNY GAULT: Ok, so the code was adopted by the World Health Assembly in May of 1981. It had 118 votes, three abstentions and one negative vote. The United State was the only member state to vote no. Any idea why the US voted no?

LAURENCE GRUMMER-STRAWN: Well, I think you to look at the politics of the time. This came about in 1981 and it was right in the beginning of the Ronald Reagan administration. And it was really Reagan’s decision to vote no. That was I think partly just his mindset of protecting business and saw that this was not in the best interest of companies. And it was early in his administration; I think he wanted to kind of demonstrate his pro-business stands.

I think in addition the United States has always valued free speech. And so this has been a major way that the United States has defined its position on the code for a long time is we always allow free speech on really everything, including commercial products. And so it did not like the idea of a code that defined when and how companies could speak about their products. Some people would say that that was fallacious argument because we certainly do have regulations about how speech can be done, what kind of advertising can be done, certainly a lot of that in the tobacco arena of where we can’t have ads. But it has been a stands of the United States and it was certainly promulgated by the Reagan administration at that time.

SUNNY GAULT: Ok, so let’s take a break from the interview for a second and look at some facts. We now know who created the code. We also know that from the very beginning the United States did not support it. It’s been 35years since the code was adopted by the World Health Assembly and according to the 2016 code report written by Doctor Grummer-Strawn the United States and 48 out of 184 reporting member states, or countries, to this day have no legal measures in place to support the code.

Now let’s take at some of the larger countries, both in size and population. According to this report Canada has a few provisions. Mexico-many provisions. Russia-a few provisions. United Kingdom-a few provisions. China-a few provisions. Australia-no provisions. If you want to see a complete breakdown of what each member-state has done with the WHO code recommendations, view the report, and we’ll include a link on our website. I also asked Doctor Grummer-Strawn about efforts to enforce these provisions in countries that have adopted them:

SUNNY GAULT: Enacting in one thing, right. But monitoring and enforcing the code, that’s another issue. And in your recent status report, you call the ability to monitor and enforce the code quote/unquote “weak”. Can you explain that a little bit more?

LAURENCE GRUMMER-STRAWN: So we did a survey among countries to find out what they are doing in terms of monitoring the enforcement of the code. And we got responses from 55 countries. Not as high as we would have liked, but it’s not a bad sample to have 55 countries telling us what they are doing. And very few of those 55 actually have a functioning monitoring system that regularly assesses whether or not companies are in compliance with the code. We found that only 6 of those 55 countries actually have a regular budget to do monitoring on ongoing basis.

Only 7 of them have reported of what the findings were of their last assessment. Very few of them actually have done something in the last few years. So they might have a monitoring system on the books that these are the people who should do this, this is how we should operate it, nothing has actually happened in the last few years. So the actual implementation of assessing whether or not the law has been complied with is very poor.

SUNNY GAULT: Ok, but why is it so poor? What are some of the challenges that you are seeing here?

LAURENCE GRUMMER-STRAWN: We think that there are a lot of things going on. Certainly budget is one issue with that. All governments are stretched for funding, including in high-income countries where there’s always competition for tax resources, where we going to put our budget, and so this is a competitive issue. And it’s not always given the highest priority. Some of it is a political will. Is this the top issue that people want to put resources into making sure that our laws are complied with? Or is it something that we put the laws in the books and then kind of move on to other issues?

I think there’s also an issue with interference from companies where they are exerting their lobbying efforts on the monitoring boards that would be there, on the boards that are making decisions for how funding might be spent within ministries, and make sure that doesn’t get the attention that it deserves.

SUNNY GAULT: You heard Doctor Grummer-Strawn mentioned monitoring boards. And we need to explain that a little bit. Member-states choose if and what recommendations from the WHO code they want to incorporate into law. But as we just learned, just because it is law, doesn’t mean people are going to follow the rules. And governments are doing a “weak job” of making sure their people comply.

Monitoring boards were created independently from the World Health Organization to monitor any infractions. The most well-known international group is IBFAN which stands for the International Baby Food Awareness Network. It’s comprised of consumer organizations, health work associations, parents groups and individual members. According to their website IBFAN works for universal and full implementation of the WHO code. Now IBFAN doesn’t have much to do in the US because we have not implemented the WHO code into law.

However, the United States does have their own monitoring groups, including NABA-the National Alliance for Breastfeeding Advocacy. This group again is independent of the World Health Organization, but they also monitor companies and products who aren’t code complaint here in the United States. They offer code workshops and help train volunteers to come look for companies and products who are not compliant with the code. And they’ve also released a few code monitoring publications called “Selling out mothers and babies-marketing of breast milk substitutes in the USA“.

We’ll link to both IBFAN and NABA on our website. So we have individual governments and monitoring groups such as IBFAN and BANA who are trying to uphold the WHO code in their respective areas. So what does the WHO code actually say? And perhaps more importantly, what doesn’t it say? We are breaking down the WHO code when we turn back|.

[Theme Music]

SUNNY GAULT: Welcome back! Today we are talking about the International Code of Marketing of Breast Milk Substitutes, more commonly referred to as the WHO code, and what it means for breastfeeding and pumping moms. It’s time to break down the WHO code. And I have to tell you, this code is pretty long. If you print off the PDF that’s on our website, it’s about 26pages. It has an introduction which explains why the code was needed. And then it goes through 11 articles that are part of the original code. At the end it spells out some of the resolutions to the code.

It’s important to know that the World Health Assembly meets every year in May, and every even year, there is an opportunity to make resolutions to the WHO code. So, changes have been happening to this code since 1981. Small changes, in fact in my interview with Doctor Grummer-Strawn I referred to them as twigs and he agreed. But it’s important to know that these recommendations from the World Health Organization have changes and will most likely continue to change in the future.

So let’s talk about the 11 articles in this code. Now, I have to forewarn you: this is not an in-depth analysis. The goal, moms, is to give you an idea of what the code says, to peak your curiosity so you, as a breastfeeding and pumping mom, feel inspired to do your own research, and to talk about this more. There are some articles in the code that are often misinterpreted, and those are the articles we’ll be focusing on most. You ready? Let’s learn more about the WHO code and its original intend.

Article 1: It talks about the aim of the code which was explained in the first part of our interview, but I think it’s important to reiterate here. The code focuses on the marketing and distribution of products considered breastmilk substitutes, and we’ll learn more about that just a second. This has nothing to with the making of the products, this is focused on the marketing of those products. Now, that leads us to Article 2, The scope of the code, in other words what products are impacted by the WHO code. I believe this one of the biggest misconceptions of the code, so I asked Doctor Grummer-Strawn to explain it:

SUNNY GAULT: So let’s talk a little bit about the scope of the WHO code, because whenever I ask people to tell what they think the WHO code is about, they automatically go to infant formula, but there are other products that are on this list. And the other issue I see here is there are people that think there are a lot more products that are on this list than what is actually defined under the code? So I think we need to explain this a little bit more.

LAURENCE GRUMMER-STRAWN: We are not just talking about infant formula that is really marketed for the time that is exclusive food of a baby, but really follow-up formulas as well that are milks targeted during the age-range we recommended breastfeeding, are also competing with breastfeeding. If you use those, you are not going to be breastfeeding as much. It also covers complementary foods, if they are marketed in a way that would be competing with breastfeeding. And so they are really covered if they are marketed less than 6months of age when we recommend exclusive breastfeeding, nothing but breastmilk. On the other hand, complementary food that is marketed after 6months of age aren’t really within the scope of the code.

SUNNY GAULT: Ok, so we are talking about baby food, right?



LAURENCE GRUMMER-STRAWN: It also covers bottles and nipples that would be used for the feeding of infant formula or other breastmilk substitutes.

SUNNY GAULT: Alright, does it cover breast-pumps?

LAURENCE GRUMMER-STRAWN: No, no mention at all of breast-pumps and in fact we often see breast-pump are a good way for continuing breastfeeding, and so this is not a talk at all about breast-pumps.

SUNNY GAULT: What about pacifiers?

LAURENCE GRUMMER-STRAWN: No mentions specifically a pacifiers either. Only some people have interpreted when it says teats, that that might be a kind of teats, but in general we do not count pacifiers as part of the scope of the code.

SUNNY GAULT: Yeah, I was going to ask you about that. Because teats isn’t really a term, you know, that we use too much here in the US and it does say, you know, if I am reading from this, “feeding bottles and teats”. So how does WHO defines teats?

LAURENCE GRUMMER-STRAWN: We are really talking about the nipples that are used for the feeding through a bottle essentially. If you going to put out and say that there is this new nipple that’s been shaped to look more like a breast, but it’s to be used with formula, than that will follow within the scope of the code.

SUNNY GAULT: Ok, I want to go back just for a second and ask a follow-up question, because we know now that pumps are not covered under the WHO code, right. But bottles are. So I feel like the two are kind of connected, right? Because you pump breastmilk for your baby and you got to give it to your baby in something, right?

LAURENCE GRUMMER-STRAWN: Um, so I don’t think that’s a controversy about the pumps themselves. I think the reason there might a be a little confusion on that is that some pump companies do sell bottles and teats, and so if they are not in compliance with the code on the bottles and teats, then the company itself is considered to be not following the code. And so it’s kind of guilt by association in that sense, because they are marketing the bottle, as well as the breast-pump, and people think that the breast-pump itself is a problem. They don’t automatically become non compliant just because they are selling a product. There’s nothing that says manufactures and distributors can’t sell infant formula, they can’t sell bottles.

So that breast-pump company certainly has the right to sell their bottles, and still be compliant with the code. The issue is how they sell their bottles. And so if they are advertising them directly to consumers, if they are putting out information that is inappropriate about them that makes extra claims that would be not compliant in other ways, then the company is not compliant. But if it’s not the selling, it’s how it’s been marketed. This has been a controversial area. Some people think that if the bottle is to be used with breastmilk, than it would be inappropriate for it to be considered here. It might be an issue that the World Health Assembly would want to take up in the future. But right now it is part of the code and it hasn’t been modified.

SUNNY GAULT: There are additional products that breastfeeding and pumping moms use that sometimes get lumped into this category. For example breastfeeding tanks, breastfeeding bras, pumping tanks, pumping bras, pillows that help position your baby, so you can better feed them. Are any of these products covered under the code?

LAURENCE GRUMMER-STRAWN: No, those products are not covered by the code at all. I think it might be good that those companies are paying attention to the issue, to make sure that they are doing things in an ethical way. But strictly speaking the products that they are selling do not fall within the scope of the code.

SUNNY GAULT: Ok, so for example: if we had a product, that was related to breastfeeding and pumping, let’s just say it’s a pumping bra, ok, and we’ve already established that that would not fall under the scope of the code. If they have a label that shows a baby bottle, are they not in compliance with the code?

LAURENCE GRUMMER-STRAWN: The legalities of this . . . It sounds to make like in that example they probably would not be non compliant in any way, because the product that they are marketing is the bra itself, or maybe the pump that goes with the bra. The fact that they have a bottle sitting next to it, people might be unhappy with that, but if they are not promoting the bottle, then it doesn’t follow within the scope of the code.

SUNNY GAULT: Ok, moving on as we continue to breakdown this code.
Article 3 defines much of the language included in the code. Such as what exactly is a breastmilk substitute and because it’s used throughout today’s episode, I think we should define it here. It says: 'any food being marketed or otherwise presented as a partial or total replacement for breast milk, whether or not suitable for that purpose.’’. This section is important to read, so that everyone is on the same page with terminology.

Articles 4 and 5: Article 4 talks about how information and education should be presented to the public and article 5 deals with advertising and samples of products. Ok, get comfortable, mamas, because we are going to stay here a while. These sections are extremely important because it impacts how information about the products covered under this code are presented to you. And it impacts how these products are advertised and promoted to the public.

This section impacts media the most, which by the way, I did have a separate discussion with a group of media professionals here in the US who create content for pregnant moms and new moms, to get their feedback on the WHO code. So if you want to check that out, visit our blog on our website and I’ll be sure to include a link on our episode page.

So back to article 4. Let’s focus in on 4.2. which says information and educational materials should have clear information on the following points, there’s five points here: (a) the benefits and superiority of breast-feeding; (b) maternal nutrition, and the preparation for and maintenance of breast-feeding; (c) the negative effect on breast-feeding of introducing partial bottle-feeding; (d) the difficulty and reversing the decision not to breast-feed; (e) where needed, the proper use of infant formula, whether manufactured industrially or home-prepared.

So basically they are talking about if the formula is already mixed by the company, or if it’s a powder that you need to mix yourself. And it goes on to talk a little bit more about the restrictions with formula. So, for all the content creators out there, this section is for you. To comply with the WHO code your information overall needs to be balanced. Information about bottle-feeding or formula-use needs to be balanced with information about breastfeeding. As I quickly learn in my interview with Doctor Grummer-Strawn, this section is often misunderstood:

SUNNY GAULT: I think the big question, in this section, is the timing and the release of all this information, because we as media don’t usually release all of our information at one. For us, we release our information in episodes. So we may do an episode about pumping at work, and in that episode we have experts to talk about pumping, we have moms that come on the show and talk about their pumping experience, and we may never talk about breastfeeding in that episode, because the episode is about pumping. So are we somehow not compliant with this unintentionally, because each episode doesn’t go through each of these 5 points.

LAURENCE GRUMMER-STRAWN: Yeah, I don’t think that is all the intention of what we meant in 4.2 here. This article is talking about the importance of getting these messages across to mothers and their families so we want to make sure that these messages come across. But absolutely, yeah, like you are talking about when you put information into small chunks you can’t include every message in every single chunk – that would just make very confused communications and that never was the intention here.
What they are thinking about is an informational, educational package, you know, if you are going to put together a brochure about information and education on the feeding of infants and young children, if you are going to do a show on that. But these are points that all need to be covered but clearly as you break that up into ways of communicating maybe with different web pages and you are going to have different information on a different page; as you are doing with your podcast, you might have different podcasts on different topics. That certainly is not the expectation but every one of those is going to cover every single one of these points; we have to think about it more holistically, not every little component in it.
SUNNY GAULT: Okay and I also have a question about the bottom half of that section. It says “such material should not use any pictures or text which may idolise the use of breastmilk substitutes” and I was hoping that you could expand on that a little bit. It seems to be a very subjective statement because what one person thinks is influential, another person may not.
LAURENCE GRUMMER-STRAWN: It is indeed subjective and we don’t have a hard and fast definition here nor do I think anyone else does. I think the concerns that we have are showing pictures that makes it look like bottle-feeding is just so wonderful and perfect. We have certainly seen examples of ads where you have the picture of the mother breastfeeding and it is a grayed out picture and it looks like a bad day and she is frowning and she is uncomfortable and you see a picture of a mother sitting and feeding a baby with a bottle and everything is rosy and the sun is shining through the windows.
That is the kind of imagery that we are very concerned about; seeing pictures of beautiful cute babies on the label are sharing message is that this is the way you are going to get a healthier baby. So we are certainly concerned; these are recommendations, the Code itself is not law in itself that puts out there you are on this side, you are on that side and we are going to put you in jail or we are going to find you because your picture is wrong.
We do, on the other hand, call upon member states or the countries of the world that are members of the World Health Assembly to turn this into actionable legislation and so they can take that language and try to make it real in their circumstance. And how do we do that in law? You know, often times it is not the words on the page, it does require the interpretation and interpretation may be in courts, may be interpretation of a panel that reviews materials.
There are different ways that they can look at that and the standards kind of develop overtime of where have you crossed the line and where haven’t you; it is very difficult to put on page particularly something that is going to last over the course of 35 years a specific definition that is always clear to people. So it is a concept that is being conveyed in a recommendation here and then it becomes the interpretation of people looking at it overtime like “you have really crossed the line on this” or “this looks like it is okay”.
SUNNY GAULT: This is definitely something we have had to deal with on our shows because even though we are primarily audio-based, every time we release an episode, there is an image that is tied to it and we want those images to represent the content as closely as possible because when people are looking for content online, a lot of time they are looking for images. That is what catches peoples’ attention so if someone is looking for an episode about how to get their baby to take a bottle of expressed breastmilk, they are probably going to be looking for images that have babies and bottles in it, right? We know that those images represent expressed breastmilk but under the Code, you know, there is a big grey area here in what we can and can’t use and it can definitely impact media and how people are able to get our content.
LAURENCE GRUMMER-STRAWN: This is the difficulty we have with subjective assessment, you are absolutely right and I think that the only way you can address this is through continued dialogue, you know, that there is no single authority that is making the decision that you have to be forced to. If they are saying something is an inappropriate image and is idealizing the use of breastmilk substitutes, then it is appropriate to bring that back and say “how do we deal with this” rather than just taking their answer as The Answer but it is to push back and say “we think this would be an appropriate definition of idealization and not this” and get that dialogue out in the public domain.
SUNNY GAULT: Let’s move on to article 5. In article 5.1 it says “There should be no advertising or other form of promotion to the general public of products within the scope of the Code”. So does that mean that any products within the Code should not be advertised to the public?
LAURENCE GRUMMER-STRAWN: That is correct, yes.
SUNNY GAULT: So, how are moms supposed to find out about these products?
LAURENCE GRUMMER-STRAWN: We really think that the best source of information about how to feed infants and young children should come through healthcare. We think that it is a real problem if we are relying on companies themselves as our primary source of information or a key source of information about what products are there. It really makes a whole lot more sense to be using this through reputable sources of healthcare and so advertising to the public is really not necessary to get access to the kinds of supply and foods that are needed.
SUNNY GAULT: However, here in The United States, we are very commercialized society, right? We have Smartphone’s and tablets and rely on media to get a lot of this information and much of that information is advertisements as well. I know a lot of moms that like to do their own research on products and make recommendations, do reviews and that sort of thing to determine what products are best for their family.
Also, for companies who are trying to sell a product, you have to compete in that landscape; if you are not able, if you are trying to follow the Code and therefore you can’t advertise your products, odds are your product isn’t going to sell as well as another product simply because moms don’t know about it.
LAURENCE GRUMMER-STRAWN: Well … but that’s why the Code is here. We don’t expect that one company is going to step up and say “oh well, we are going to comply with this even though we know no one else will” because yes, it will put them at a disadvantage but this is why we are calling upon governments to have laws, it is why we are calling upon healthcare providers to demand this and it is why we call upon you as a podcaster to educate people on the importance of this issue.
I think what we are starting to see with some of the companies is that because they are being held to task for not adhering to the Code, that they are getting a bad image because of that and so they have to start weighing off “am I going to get more by advertising my product or am I going to get more by being a good citizen and doing what I am expected to do by the healthcare industry and by moms themselves”.
So we are trying to shift that tide; the United States is a long way from being there – there is no question about that – and I don’t expect that it is going to turn around tomorrow but as WHO we are calling for international standards as we are calling upon industry for what do to. We think we have to call upon them to do the right thing and not just accept “well, everybody is doing it so I guess we will just have to let it go”.
SUNNY GAULT: The other question we have to ask here is what is considered an advertisement because we live in a day and age here in the United States where social media is king and everyone is sharing information about everything. So if we have a mom on Facebook that wants to tell everyone that she finally found the bottle that her baby would take so she can go back to work and not worry about it, she posts an image of the bottle and she tags the name of the company or maybe just even writes the name of the company in the post, is that considered an advertisement.
LAURENCE GRUMMER-STRAWN: Yeah so first of all, the Code doesn’t call upon mothers to take any action in the Code so if a mother voluntarily wants to say “I love this bottle”, no, we don’t consider that to be advertising of a product and she is not held responsible for adhering to the Code. Where we would be concerned though is where industry is setting up a way to promote her doing that and so if they set up a social media group for moms who are using their bottles and then they start encouraging moms to “like us on Facebook so that other moms could see that you like our product” well then that company has kind of crossed the line into using social media as a way of advertising.
This is definitely a grey area, wasn’t anticipated when the Code was written, trying to understand how social media works as an advertising way, I think it is still being sorted out; I think even aside from breastmilk substitutes just understanding the legalities of how social media is working in advertising is an evolving field and we certainly have to evolve with it. But I think the bad principle of what is the intent and who is pushing this forward should be a guiding principle for us.
SUNNY GAULT: So you said the Code doesn’t call upon moms to take action but what about bloggers because we have a lot of moms, especially moms that listen to our show that have their own blog – perhaps they get paid to do it, perhaps they just do it because they enjoy doing it. But they could very easily do a product review about a product that is not covered under the Code, it could be a product from a company that is not complying with the Code. How does that work, is that considered not compliance because they are simply blogging about it?
LAURENCE GRUMMER-STRAWN: Again, it is a grey area that we really haven’t defined specifically. In terms of principles I would say, if the blogger is truly doing it just out of their own experience and what they want to talk about that it probably is not covered currently in the way the Code has been written; but if she is getting some kind of benefit, not necessarily as a payment from a company directly but if there other ways that she has been incentivized to do that, often times there are relationships of “we will promote your blog, if you promote our product or will get you supplies or we will direct some of our users to your site”.
If there are ways that she is getting some benefits out of it, then yeah at that point she is really working partly as their actor and there is a conflict of interest in the information that she is providing, we would say yeah, now we have kind of crossed the line into that looking like advertising as opposed to just a mom speaking of her own experience.
SUNNY GAULT: Alright, let’s break from the interview. I want to quickly review other points mentioned in article 5. We now know the WHO Code states “No product under the scope of the code should be advertised. This includes special displays at baby stores, discount coupons so if you have ever received a coupon in the mail for any of these products covered under the Code - that is non-compliant.
Also, special sales so if stores hold special sales on these products, they aren’t complying with the code.” It also says “manufacturers and distributers cannot provide pregnant women, mothers or members of their families with any samples of these products”. We are going to go through the next few articles fairly quickly. They definitely impact moms but they mainly focus on healthcare systems, health workers and the manufacturers and distributors of products covered under the code. Articles 6 and 7 focus on healthcare systems and health workers.
Now, most of you moms are probably familiar with the term baby-friendly hospitals, right? There is a set of criteria that hospitals have to follow in order to become “baby-friendly”. Any hospital given this distinction must follow the WHO Code so if you are planning to deliver at a baby-friendly hospital, you will want to read these sections carefully.
Articles 6 reiterate “there is to be no advertising of products under the scope of the Code” and it limits the amount of influence manufacturers and distributors of these products have within the healthcare system. For example, they can’t provide healthcare systems with personnel or other representatives which may encourage the use of their products. They can offer donations or low-priced sales of their product as long as there is not an ulterior motive such as to encourage future sales.
This section also explains how infant formula is to be demonstrated to parents and used within the healthcare system.
Article 7 deals with health workers and how information given to them about these products should be presented. For example, health workers and their families should not receive any incentives to promote these products to their patients. Workers can be provided with samples of products for evaluation or for research purposes however workers cannot provide samples of infant formula to pregnant women or mothers with young children or their families.
Article 8 is a little bit different because it focuses on anyone employed by these manufacturers and distributors and this mainly deals with sales incentives. For any mom out there that has ever dealt with sales, a lot of it is based on incentives so for sales reps it says “sales quotas should not be set specifically for any product covered under the Code and the volume of sales for those products should not be included when determining bonuses”. So they are limiting the amount of incentives to sell these products.
Article 9 talks about the labeling of products covered under the Code. Now moms we all look at labels when we are shopping in the stores, right? And what we see impacts the products we buy. I asked Dr. Grummer-Strawn to explain the key points.
LAURENCE GRUMMER-STRAWN: Sure. So the first thing is that it needs to say that this is important information that we are going to yield but before talking about the importance of breastfeeding that it is important information; the concern there is that it might be put into too small font and just kind of lost in the back and the people can’t read it so it is important that it be highlighted information on the label.
The second is that there be a statement of the superiority of breastfeeding that we want to make sure that the message about the importance of breastfeeding is consistently conveyed in products, that they can’t make claims that “we are better than breastfeeding” that this product is somehow equivalent; that we really have to always be saying that breastfeeding is superior.
Third that the product should only be used on the advice of a health worker, we want to make sure we are maintaining that connection with the healthcare institutions and workers. We don’t want the product to be used just “I decided that I want to do … to use an alternative”; we know that often goes in the phase of advertising and making personal decisions without a healthcare provider involved but we think that it is important information to always be saying that this really needs to be under the advice of a healthcare worker.
And finally that the product needs to have instructions on the safe and appropriate preparation and that there are hazards if it is not appropriately prepared. A lot of concern is about how it is mixed, it can be very dangerous if it is over-diluted and so there are instructions that need to be very clear to make sure that the safety is adhered too.
SUNNY GAULT: Article 10 and 11, we will go through these really quickly. Article 10 says “all the product should be of high quality and recognized as such” and the last article 11 explains the implementation and monitoring of the Code which we already discussed at the beginning of this episode. And that mamma is a brief breakdown of the WHO Code but there is one more misconception about the WHO Code you should know about.
It is a misconception because many people associate it with the Code but it is not actually part of the Code nor is it endorsed by the World Health Organization. In 2012 ILCA which stands for International Lactation Consultants Association created a document to better explain how IBCLCs are impacted by the WHO Code. I have included a link on our website, if you like to check it out, look for Section 4. It talks about how ILCA does not accept any money from anyone not following the WHO Code.
It also says that the ILCA Board of Directors broadened this definition to include “any financial relationship with non-compliant companies including any company owned by non-compliant company, any company that purchases a non-compliant entity and any company with another financial relationship with a non-compliant entity”. In other words, according to ILCA, it is not just about whether or not you are compliant with the WHO Code but any company you have a financial relationship with must be compliant as well.
Now, according to ILCA, you are guilty by association. When we come back, we will wrap up our discussion on the WHO Code and talk a little bit more about its impact here in the United States and within the lactation community. We will be right back.
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SUNNY GAULT: Welcome back. Now that we have provided an overview of the WHO Code, let’s talk about how this impacts us here in the United States. Well legally, it doesn’t. For the last 35 years, the United States has never voted in favor of the WHO Code. There are now laws within the United States to support it. Our government has however created other laws to help protect breastfeeding and pumping moms.
How many moms listening right now are using a free breast pump provided to you through the Affordable Care Act? That’s just one example. Just because the United States doesn’t support the WHO Code, doesn’t mean the Code isn’t important to the world as a whole. Moms all over the world should have access to credible information so they can choose the best way to feed their babies. I think most people would agree with that.
The US not supporting the WHO Code simply means the people we have elected to make decisions for us, representatives who are responsible for our nation’s economy and healthcare have determined these recommendations are not in our country’s best interest. Not everyone here in the US agrees with that decision; that’s why we have monitoring groups, associations and individuals who are constantly pushing for WHO Code compliancy and there is nothing wrong with that.
The same free speech that opponents of the Code are trying to protect is the same free speech that allows advocates of the Code to disagree with our government. In my interview, you heard Dr. Grummer-Strawn say “the World Health Organization is not trying to put people on a good list or a bad list based on Code compliancy” and that is true, that’s not their job but other advocates are. Voluntary monitoring groups here in the US are literally creating list of who they believe is compliant and who they believe is not complaint.
They can’t look for specific violations of US law because there is no law, instead these monitoring groups are interpreting the WHO Code which the World Health Organization has already admitted in our interview is subjective in nature; so they are interpreting the Code to determine full Code compliance. Are you fully complying with this Code? At the beginning of the episode we talked about the findings from the 2016 Code Report.
Based on that recent report, we know only 39 out of 194 member states have legislation reflecting all or most of the provisions of the Code and even when they have it, their enforcement is considered weak. In addition to full Code compliancy, many of these monitoring groups in the US are making these judgments based on criteria not included in the WHO Code such as that ILCA policy I mentioned earlier which claims you are guilty by association. How do I know all of this, because I experienced it first-hand.
We as New Mommy Media tried to follow the WHO Code and in doing so we looked at these lists, we had to place people – potential sponsors, partners and even other media outlets in these compliant and non-compliant boxes and many times these people hadn’t even been vetted yet which means we had to determine for ourselves if we thought they are following the WHO Code. And we did that for three years until quite frankly, I just had enough. As a breastfeeding and pumping mom, I don’t like to be judged on how I feed my baby and yet all my company was doing.
I couldn’t bring in a new sponsor, partner with a new organization or cross-promote with another media source until they passed the WHO Code test. And if a company passed the test and later became non-compliant, I was expected to drop them immediately. Moms, those of you who own their own businesses know – that is no way to run a company. I knew we had to change our stance on the WHO Code and it was a very difficult decision to make; not because of the actual Code – I knew that wasn’t what was best for our listeners – but because I knew the backlash I was going to get from supporters of the Code within the lactation community and I was right.
I was instantly attacked online and in groups and in emails. People who didn’t even know me were judging me saying horribly mean things and I will be honest – it hurt me deeply. I just wanted out. I didn’t want to defend breastfeeding anymore, I didn’t want to talk to any lactation professionals and I certainly didn’t want to have anything to do with The Boob Group – a show I had built from the ground up with the sole intention of helping breastfeeding and pumping mom and to escape all of this - I simply planned to shut down the show.
I would just quit producing episodes, I would take down every episode we ever released and just pretend like it didn’t exist. I was inundated with all these negative thoughts and to overcome them, I had to think back on why I created the show in the first place. If I was really trying to help breastfeeding and pumping moms, why would I voluntarily take down episodes thousands of you listen to every month? That doesn’t make any sense.
I read all the email you send to the show; I know how much the show has helped moms all over the country reach their breastfeeding and pumping goals but removing episodes seemed like the only way to stop all this negativity and intimidation coming from a very small but very influential group of lactation professionals. Standing up to them meant getting hurt even more. I knew some of them would request to have their episodes removed from The Boob Group and they did. I knew some would put pressure on other lactation professionals to boycott the show and they did. I knew some would quit recommending the show to their clients and they did.
Some did much worse all in the name of the WHO Code. The more I shared my personal experience with the WHO Code, the more I learnt I am not alone. This undo peer pressure from a small group of people is causing division within the lactation community. Lactation professionals who work with people deemed to be non-compliant are criticized and sometimes ostracized by their peers. They are ridiculed, kicked out of groups even denied opportunities to participate in industry events. Why? Because they don’t play the game; they simply help moms.
Their actions aren’t defined by a code, they are inspired by their hearts. In fact, I found most lactation professionals feel this way but it is often hard to stand up to influential people, especially when you think they could make or break your career. Moms, professionals – this behavior has to stop. It is unfair and it is hurting the breastfeeding cause. This isn’t about abiding by a code; it is about tearing other people down to build yourself up. That’s now that the WHO Code stands for so quit doing it in justice. If you want to support the Code, support the Code.
In the US, you have that choice but first and foremost, support moms – all moms – regardless of how they choose to feed their babies. And let’s get the word out there. This isn’t just about me and my experience; this is about the bigger picture. I know these aren’t comfortable conversations to have; I know many people just don’t want to get involved – it is just easier that way. But getting involved and talking about these topics – that are how we grow, that’s how things change. If you are talking about it online, we have created the hashtag – support all moms – because that is what it is all about, right? Supporting all moms – Code or no Code.
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SUNNY GAULT: That wraps up our show for today. I know it was a longer one. Thanks so much for hanging in there with me.

Don’t forget to check out our sister shows:
∞ Preggie Pals for expecting parents
∞ Newbies for newly postpartum moms
∞ Parent Savers for moms and dads with toddlers and
∞ Twin Talks for parents with multiples.

This is The Boob Group where moms know breast!

This has been a New Mommy Media production. The information and material contained in this episode are presented for educational purposes only. Statements and opinions expressed in this episode are not necessarily those of New Mommy Media and should not be considered facts. While such information and materials are believed to be accurate, it is not intended to replace or substitute for professional, medical advice or care and should not be used for diagnosing or treating health care problem or disease or prescribing any medications. If you have questions or concerns regarding your physical or mental health or the health of your baby, please seek assistance from a qualified health care provider.
SUNNY GAULT: How would you like to have your own show on the New Mommy Media network? We are expanding our line-up and looking for great content. If you are a business or an organization interested in learning more about our co-branded podcasts, visit our website at www.newmommymedia.com.

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