What is the WHO-CODE?

The primary purpose of the “WHO-CODE” is to protect mothers and babies from the highly effective, aggressive and predatory marketing of substitutes for breastfeeding (i.e. infant formula, bottles, artificial nipples) at the most vulnerable period of their lives, the birth of a new baby.

Formula-fed babies are at greater risk for Necrotizing Enterocolitis, a painful, often fatal, and expensive to treat disease.

Health workers helping vulnerable new moms and babies, day after day, have discovered an alarming trend: in areas where formula and bottles are marketed heavily, breastfeeding rates go down, and infection, disease and mortality go up.  This happens in countries around the globe, independent of  a country’s economic status.  In fact, it is estimated that globally, at least 1.5 million babies’ lives could be saved every year from improved breastfeeding & complementary feeding; in the U.S., it is estimated that 900 babies’ lives could be saved every year from improved breastfeeding rates, and $13 billion could be saved in health care and associated costs for ten pediatric diseases alone.

Some people don’t believe that formula marketing affects a mother’s decision to try breastfeeding or her ability to continue. It’s understandable: it is human nature not to want to believe that we can be so easily duped out of protecting and advancing our own and our babies’ health! So, before you read further, we urge you to please read this article on the 10 Most Successful Ad Campaigns of All Time.   Read about what ad campaign helped Miller go from selling 7 million to 31 million barrels of beer, which ad increased Clairol’s sales 800%, and how Nike’s market share jumped from 18% to 43%.   Now consider that in 2004, just as the U.S. government was rolling out its largest effort, the three-year, $40 million “Babies Were Born to Be Breastfed” awareness campaign, formula advertising almost doubled to $50 million annually. More importantly, the government’s campaign was diluted and rendered ineffective under the influence of industry lobbyists.  Further, under lobbying pressure, a valuable, national meta-study conclusively showing the association of breastfeeding and lower rates of disease was suppressed.  No surprise:  Breastfeeding rates went down.  Breastfeeding was outmarketed, and this is precisely why examples of successful formula marketing make it into marketing textbooks.  Try to remain objective while watching this extremely sophisticated formula commercial, and then consider it in the context of research showing that breastfeeding protects against SIDS and is critical in the NICU.

In recognition of the devastating effect of formula and bottle marketing, the World Health Organization and Unicef adopted the “WHO-CODE” in 1981.  The “WHO-CODE” is short for the World Health Organization’s International Code of the Marketing of Breastmilk Substitutes. Scores of countries have enacted legislation implementing all or many of the provisions of the Code, but the U.S. has not.  Because “The Code” is a voluntary pledge, it is easy for countries to say they uphold the code even when they don’t enforce the following stipulations:

  1. No advertising of breast milk substitutes to families. (Read: Why formula advertising is different from other types of advertising, making it predatory.)
  2. No free samples or supplies in the health care system.
  3. No promotion of products through health care facilities, including no free or low-cost formula.
  4. No contact between marketing personnel and mothers.
  5. No gifts or personal samples to health workers.
  6. No words or pictures idealizing artificial feeding, including pictures of infants, on the labels or the product.
  7. Information to health workers should be scientific and factual only.
  8. All information on artificial feeding, including labels, should explain the benefits of breastfeeding and the costs and hazards associated with artificial feeding.
  9. Unsuitable products should not be promoted for babies.
  10. All products should be of high quality and take account of the climate and storage conditions of the country where they are used.

Note that several of these stipulations forbid the marketing of infant formula to health care workers.  Tremendous damage to mothers and babies occurs when formula companies market their products directly to parents through hospitals, physicians, health care professionals, and networking, peer support and “education” groups (such as expecting mother “classes”, lunches or events). We love to claim we are savvier at looking past the claims of a print ad or commercial–even when studies show us that rates of breastfeeding decline when formula advertising increases–but it is undeniable that we are easily influenced and persuaded by our trusted doctors, family members, and peers.  Formula companies are turning respected authorities, i.e. health professionals and organizations, into marketing arms for their product, a practice which is extremely unethical, and is especially hard for the public to see through.   Marsha Walker of NABA has collected examples of formula companies sponsoring pediatrician conferences, donating to nursing professional associations, and providing “information” and gift bags to Ob/Gyns for their patients.

We’ve learned that formula companies donate to hospital NICUs–a terribly mixed message considering that intensive care babies need breastmilk the most–with the understanding that formula gift bags are pushed on breastfeeding mothers.  Formula companies sponsor name badges, frappuccinos and breakfast “seminars” for hospital nurses, branded crib cards for the baby’s hospital bassinet, and funding for the hospital’s NICU.

Formula companies are now cross-marketing with maternity chains, huge baby registry sites and retail stores, photography studios like Olan Mills,  and even Disney to undermine breastfeeding moms with coupons and giveaways.   They know we all love coupons and giveaways! Our email addresses are being sold to formula companies and we, who struggle against the breastfeeding booby traps, are being zeroed in on and bombarded by formula marketing.   Parenting, medical websites and well-known bloggers are protecting parents’ “rights” to be educated by advertisements, instead of by unbiased physicians and feeding experts such as IBCLCs.  Formula companies routinely advertise and win the top spots in Working Mothers Magazine’s 100 Best Companies for Working Mothers, even though infant formula means more employee absenteeism, sick days, and higher health costs.

Unfortunately, formula marketing hurts not only breastfeeding mothers, but formula-feeding mothers too.   A hefty marketing budget ($2-$3 BILLION globally) artificially drives up the price of formula, making it harder to afford for those who need it, and outcompeting lower-priced generic brands.   It forces the U.S. government, health organizations and non-profits like ours to raise funds to market breastfeeding, educate hospitals and health organizations, physicians, nurses, and health professionals.    The government purchases billions in infant formula for low-income women through the WIC program.  Formula contracts, “new” formulations and advertising drives up this cost. Formula marketing experts are smart; they say that “breast is best” so we are lured into a false sense of security, yet there is no mention, ANYWHERE, of the next best thing to breastfeeding or a mother’s pumped milk, which is screened donor milk. When mothers are being bombarded by inaccurate advertising, are they really making an informed choice?

Formula marketing has cleverly hijacked the conversation about infant feeding, playing “the guilt card” and igniting the mommy wars by pitting mothers against each other, instead of harnessing and focusing our energy to demand better maternity policies, Baby-Friendly Hospitals, employer protocol, and protection of mothers’ rights.  If more mothers were being allowed to achieve their personal breastfeeding goals without being discriminated against, harassed, or humiliated, fewer of the more zealous activists would be misplacing their energy by accosting or judging formula feeding moms–a practice that we strongly condemn. As for guilt, the only people who should feel guilty are those who know about the negative impact of formula marketing and do it anyway.

If you are interested in learning about how formula marketing tactics negatively impact breastfeeding rates, we encourage you to read this summary of Selling Out Mothers and Babies, by Marsha Walker, RN, IBCLC, or order the full report.  For a list of recent Code Violations, see the IBFAN-ICDC website, and if you want to report a violation, CLICK HERE. 

We have one of the lowest breastfeeding rates of any industrialized country, and one of the highest infant and maternal mortality rates of any industrialized country. We can do better!

What can we do to raise awareness of the WHO-Code in the U.S.?   What can we do to demand that laws are put in place to enforce it?

Organizations & Resources:
World Health Organization:  Health Implications of Direct Advertising of Infant Formula

World Health Organization: Frequently Asked Questions on the WHO CODE

Unicef and the WHO-Code
National Alliance of Breastfeeding Advocacy
IBFAN: International Baby Food Action Network
Recommended Reading:
A Summary of the WHO Code (including, What, When and How) by Pumpease.com
More breastfeeding could save 900 lives, $13 billion; (news on study by Melissa Bartick, MD)
Disney and Similac Team up to Undermine Breastfeeding Moms
Infant Formula Companies Milk U.S. Food Program
Medscape.com:  Economics in the NICU
PhD in Parenting:  How to Report a Unethical Promotion of [Breastmilk Substitutes], An Open Letter to the Attendees of the Nestle Family Blogger Event,  Similac and Babble Team Up to Dupe Breastfeeding Moms,  IBCLCs and Formula Feeding, oh, heck just search WHO CODE or infant formula on her blog!
There are LOTS of great articles on the WHO-CODE, sorry I couldn’t include them all–please let me know if I’ve missed an important, seminal link!

31 thoughts on “What is the WHO-CODE?

  1. I recently had a baby and when I was leaving the hospital, the nurse came in and asked me which gift pack I would like, Enfamil, Similac or Great Start. I told her I didn’t want either of them. She said “It’s a breastfeeding pack”. I said shocked “Oh really? A breastfeeding gift pack?” She replied “Well, not really, but you will be ready for later (whatever that was supposed to mean) and it’s a free bag”. So I told her I didn’t care, whatever she decided to give me. Apparently, you are not allowed to leave the hospital without one of these gift packs. I wish someone would figure out how to make a breastfeeding gift pack. I would like to see a sample/coupon for nipple cream, nipple pads and maybe an inexpensive manual pump. Or at least a coupon for one. That would be so much more helpful than a can of formula.


    1. That is so interesting to me!! In the hospital I was sent home with a manual Medela breast pump, samples of lanolin oil and guides for breastfeeding. I did not get any samples of formula in the hospital! WOW… what an interesting experience… a “breastfeeding bag”?????? Still nursing at 3 months..


  2. I am a Lamaze certified childbirth educator, OB nurse,.& IBCLC(certified lactation consultant) I am actually angry when moms are not given the information or support they need to care for their babies. It almost borders on malpractice.


  3. When I was pregnant, I made the mistake of entering a draw for a prize at a maternity store. There was the box to not share my information and not receive the Nestle gift bag. A month or so before my due date I recieved a free can of formula and a coupon for a CASE of free forumla. I was more then a little pissed off. I had specifically requested not to recieve this yet I was targeted to recieve MORE. I now boycott that chains and all the companies is its chain (Thyme maternity) We tried to start a boycott against them but I’m not very good at organizing other people. From who knows where Similac got my name too and I recieved a can of that,(I think it may have been toys r us registry) Just at this last baby wellness appointment at my doctors I noticed that they had new paper for the scales, branded Good Start tissue. They gave me a “keepsake” heart shaped piece of paper with his weight and height on it, again branded Good start. It makes me so angry when people argue with me that they are intelligent enough to see through the marketing. We shouldn’t HAVE To fight through the marketing to get to the truth. This is the reason why the WHO code exists! Thank you for this blog post.


    1. I ticked the “no samples” box at Thyme when I was pregnant with my daughter. I got the samples too… the response by the clerk when I told her next time was “oh my goodness, that must have been a mistake”. Yeah, right.

      I refused the contest entries after that. Not worth it.


  4. Thank you so much for the link!

    I love your thorough explanation of the WHO code. I can’t believe that anyone thinks that marketing of breast milk substitutes doesn’t effect breastfeeding.


  5. Are you tired of having a marketing target painted on your forehead because you are having a baby? There is a lot you can do to raise Code awareness:
    1. Refuse formula company gifts given to you by your obstetric provider, hospital, and pediatrician. Ask that they provide you with top notch care, not peddle pricey products that adversely impact breastfeeding. Write a letter to your hospital requesting that the formula bags not be foisted on breastfeeding mothers. Hospitals are supposed to deliver evidence-based health care not act as the marketing arm of formula manufacturers. If you receive a patient satisfaction survey from your hospital, let them know that you did not appreciate a formula gift when they were supposed to be giving you optimal lactation care and services.
    2. Let those who give you these “gifts” know that such samples are one of the reasons why formula is so expensive. Many mothers who must use formula are paying the price for those “gifts.” There is probably not more than 25 cents worth of ingredients in a can of powdered formula that costs $25 dollars.
    3. If your hospital does not have the Baby Friendly designation, ask why they don’t
    4. Hospitals can make their own inexpensive gift bags and fill them with items that mothers and infants can really use


  6. Excellent article about a topic that is — really — pretty easy to grasp: no unethical marketing of certain product types to families, thank you very much. Why? It reduces breastfeeding initiation, exclusivity and duration. End of story. Even without legislation in the USA to enact and enforce WHO Code principles, any individual (and I would hope every health care worker) can choose to support the aims of the WHO Code.


  7. Funny, I keep getting these surveys in the mail about what I am feeding my child. I exclusively breastfeed. However, I keep receiving these $5 off vouchers from Similac. I simply pass them off to a friend who formula feeds to help her out, but could only imagine what the result would be if I wasn’t educated in making my choice to breastfeed.


  8. I have a picture of an infant weigh scale in a ped’s office with the Nestle Good Start formula logo splattered all over it. Seems relatively harmless until you realize the reason I was there was to support my daughter-in-law who was at the ped for a test weighing for a possible diagnosis of failure-to-thrive in my grandson. My daughter-in-law needed way more support than she received by our medical professionals – she wanted to breastfeed and struggled with all three babies. It horrifies me to realize she was bombarded with infant formula advertising right in the office of the very person who was supposed to be helping her.


    1. I was going through my pics of the birth of my son and I have a picture of his weight on the scale at birth. Sure enough right next to it is a branded similac logo comparing it to breastmilk.. I never even NOTICED it but now it will always be in my pictures of his birth.. grrrr


  9. I was recently at Thyme Maternity with my pregnant sister and refused to enter a draw to win a Similac gift pack. I was so disappointed that a maternity store would promote this product:( I spent 5+ years researching necrotizing enterocolitis. Devastating. It can be largely prevented by breastmilk. The long term consequences can significantly effect the child’s quality of life.


  10. WOW!!! this is SO well-written! You guys deserve a serious pat on the back for this one. You have covered every angle and truly approached it in a way that someone with no knowledge of the issues can easily get a complete grasp of the situation. And yet it is short and simple and accessible. A very hard balance to strike, but you have done it. This piece is going on my short list of MUST READS for new Moms and anyone who works with them. I would love to see a hard copy/pamphlet form of this snowing under our doctor’s offices, hospitals, midwives, maternity stores, and anywhere and everywhere else that expectant moms are capable of being reached. Keep up the good work!


  11. When my son was born 2.5 years ago, we were moved into the postpartum room and as I was getting out of the wheelchair, another nurse came in with a black Similac diaper bag and told me, “Here’s your baby’s diaper bag!” and left. It never occurred to me to refuse it, and no one asked if I wanted it. I brought it home and donated the cans of formula to the food bank. It ever occurred to me to leave it at the hospital.

    We are planning to deliver baby #2 at a midwifery inside a hospital that is said to be extremely baby friendly, never separating mom and baby, and they encourage breastfeeding, treating it as the expected norm. I’ll be curious to see if they offer us anything, but I would be surprised if they do.


  12. Thanks for the help for new moms. I had an easy labor and delivery and a thriving first child- I had always know I would breast feed but it was harder than I was prepared for the first couple of days. By day 3 or 4 my daughter was finally latching on well but if I had not had a good lacation consultant in our hopsital, I might have given up. But we got it figured out and were doing well. My first vist to health dept/WIC with a 2 month old baby-they just finished telling me she was perfect weight, perfectly healthy and then they want to push formula samples and add formula to my WIC. I tell them we are doing well, don’t need it. It is shoved at me again- “you never know.” Thank goodness by that time I had my act together and just laughed at them. My daughter nursed until she weaned herself at about a year old and breast feeding was one of the best overall experiences I ever had. Thanks for helping new moms make it happen. We need all the help we can get.


  13. I love what you’ve written here, Bettina, but I wish there was a different photograph to accompany the article. While formula-fed babies are at a higher risk for Necrotizing Enterocolitis, the overall risk is extremely small. I don’t like the use of scare tactics, and especially for something like breastfeeding, where it comes down to so much more than “choice” or how hard a mother tries. Women shouldn’t be scared into breastfeeding — the fear/anxiety factor can actually make breastfeeding harder.


  14. […] Hygeia is WHO Code compliant.   Basically this means they aren’t advertising in a way that does anything to promote bottle feeding.  The US does not currently enforce the WHO Code (boo US!) which means that many companies are huge violators.  Ameda is currently code compliant; Medela is not.  You can read more about the WHO Code here. […]


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