In 1981 representatives of the world's governments met at the World Health Assembly and adopted Resolution WHA 34.22. This included the International Code of Marketing of Breastmilk Substitutes as a "minimum requirement" to be implemented "in its entirety" to protect healthy practices in respect of infant and young child feeding. Since 1982 additional Resolutions clarifying and amplifying the International Code have been adopted every two years. Under Article 11.4 of the International Code NGO's are assigned the role of monitoring and reporting the activities of the manufacturers and distributors of baby foods, bottles and teats.

Why monitor the International Code?

The International Code was adopted by the 1981 World Health Assembly (WHA) to protect infant health by stopping all forms of promotion of breastmilk substitutes and bottle-fed complementary foods. The 1996 Resolution WHA 49.15 calls for all complementary foods to be marketed or used in ways that do not undermine exclusive and sustained breastfeeding. While governments are called on to implement the International Code and subsequent, relevant Resolutions, companies are called on to abide by the Code independently of any other measures taken to implement it. Monitoring around the world shows that widespread violations continue. The accurate collection and reporting of examples of violations is essential if the irresponsible marketing practices which encourage mothers and health professionals to favour artificial infant feeding is to be stopped.

Information provided by monitoring helps international organisations such as UNICEF (the United Nations Children's Fund), WHO (the World Health Organisation), aid agencies and IBFAN in their work to protect infant health. IBFAN reports on company tactics, as an independent audit of implementation of the International Code and Resolutions. These reports demonstrate the need for transparent, independent and effective controls on the marketing of the baby food and bottle and teat companies. You can help by observing the infant feeding situation in hospitals, clinics, shops and in public in your area.

It is also possible to stop specific violations if your country has implemented some or all of the measures of the International Code and Resolutions in laws or other regulations. If this is not the case pressure can be applied to companies by raising public awareness and encouraging people to take action by, for example, writing directly to the Chief Executive Officer or supporting a boycott of the company's other products.

How to monitor

Monitoring involves investigation, observation and recording of information. Be inquisitive and persistent, but also sensitive.

• Prepare carefully: familiarise yourself with the main points of the International Code and Resolutions and any national measures. Find out the names of baby milk companies and their brand names in your country (ask in a pharmacy).
  
  
• Pay close attention to detail: in all your notes, make a careful record of dates, company and brand names, name and address of hospital, clinic, store, etc. name and position of person giving information, descriptions of posters, displays, etc. (take photographs if possible).
  
  
• Protect confidentiality: assure the person giving information that his or her name will not be published or disclosed to a superior or company.

NB: we are monitoring company practices, not policing hospitals. This work is to support health workers, not to undermine them.

Collect evidence

You will find it useful to equip yourself with the following items when you are monitoring:

• Pens
• Notepad
• If possible, a camera.

Auto-focus cameras with a built-in flash unit are good because they are small and quick. Try to take good quality pictures, however, as they may later be published in reports. You can use colour or black and white film.

Obtain copies of code violations wherever possible. Examples of brochures, booklets or labels may be available or you may be able to take photocopies or photographs. Make sure you have a clear record of where and when such items were found. If you write on the items be careful not to deface them.

Monitoring in hospitals and clinics

If you are a health worker or a mother-to-be it will be straightforward to examine what happens in the hospital or clinic that you attend. If you are visiting a friend or relative you may come across violations. Otherwise, it may be best simply to contact or visit the facility, introduce yourself to the staff and explain that you are researching the support and protection of breastfeeding.

At the hospital, try to visit the maternity ward, nursery, milk kitchen, paediatric ward, malnutrition ward, rehydration unit and offices of paediatricians, obstetricians, nurses and administrators. Asking the same questions of different people will increase your chances of finding the true situation.

Be aware that some hospital officials, doctors and health workers have direct contact with the companies, sometimes depending on them for financial support. This can mean that talking to you creates a dilemma for them. It is important to be sensitive to this. However health workers all want to ensure the well being of the patients, and if they are confident that the purpose of your research is for infant health, most will want to help you. Some may be keen to talk, but uncomfortable to do so while on duty. If this is the case arrange to meet afterwards and leave a card with your contact details.

While it is important to get documentary evidence to support your research, it is also important to protect the confidentiality of health workers who need it, especially when they give you sensitive information. You may even have to withhold the names of people and hospitals from the rest of IBFAN - other groups can confirm details with you personally if necessary. If you are passing on information that should be treated sensitively, make sure documents are clearly labelled as "CONFIDENTIAL".

In hospitals and health facilities ask permission to talk to mothers with newborn babies. Mothers often have a very different perspective on hospital procedures and it is important that their experiences are taken into account. They may also suggest other useful places to visit. If possible, talk to some mothers who are about to go home since this is when many practices which violate the Code and Resolutions occur.

Interview techniques

Start interviews with basic questions about breastfeeding rates, the number of babies born, etc This will provide valuable background information.

When you come to ask about artificial feeding and marketing practices, do not ask questions which are judgemental. For example, do not ask "when was the last time you got a bribe from a company?" Saying that you heard that some companies used to give money and presents to doctors and nurses, and asking if the health worker knows if this still goes on, will get a clearer reply.

Listen - don't argue. You want to collect information, not get into a debate. So even if the health worker says something with which you disagree, listen politely. You can go back another time to discuss breastfeeding practices.

Take accurate notes throughout the whole interview, not just when someone tells you something particularly sensitive.

Direct observation

In hospitals and clinics, look for evidence of milk company influence such as:

• free tins of baby milk
• posters, charts and similar
• booklets for mothers or health workers
  gifts - any size, from clocks and fridges to pens and pads
  company representatives

It is important to observe the different rooms of the hospital: you may even be able to see things which contradict some of the information you have been given. Take photographs if possible. Write down all details about such items: e.g. does a poster advertise a milk brand or just the company? which brand? which company? what does it show? where is it? when was it given to the hospital?

Monitoring at the point of sale

Visiting shops, supermarkets, pharmacies and other locations where baby milks and feeding bottles are sold will enable you to check for special displays, leaflets, posters, special prices and other promotions. Interview an employee and ask to see examples of any literature provided by the companies.

Check product labels: buy a tin or pack of any product when labels are severe violations of the code. If the information is printed directly on to a tin you could photograph it for your records or flatten it out and photocopy it.

In a large supermarket, check the labels first and then interview an employee if possible. In a small shop, where you will be noticed immediately, introduce yourself to the owner and explain that you are researching infant feeding practices and are interested in the milks on sale in the shop. Interview the owner first and then check labels on the shelves. Do not arrive at the busiest times or just as the shop is about to close.

Monitoring the media and other direct consumer advertising

Checking the media for advertisements is easy - look particularly in magazines for parents and also check publications imported from other countries. Radio and TV may also broadcast advertisements.

Check to see if any products are advertised for use before they are nutritionally necessary: e.g. whole milk powder is sometimes promoted for babies from birth or the early months, baby foods and drinks are often advertised for use before the baby is 6 months old.

Looking in relevant trade journals - magazines aimed at the shops and pharmacies which sell baby products - may expose violations. Look for information about breastmilk substitutes or advertisements: they may give details of sales inducements, tie-in sales, special offers, discounts or competitions for shop owners and pharmacists.
Other direct advertising can include advertising hoardings (billboards), direct mail to consumers, displays at public events and baby shows. Keep an eye out for bottle feeding promotion at all times.

ALWAYS RECORD AS MUCH DETAIL AS POSSIBLE.

Collect information on anything which undermines breastfeeding even if you are uncertain whether it violates the International Code and Resolutions.

Reporting your findings

The information you gather will firstly strengthen your campaign work. If you have specific examples of malpractice it will demonstrate there is a real problem that needs to be addressed.

If there is a law or other regulatory framework implementing the International Code and Resolutions then report violations to the appropriate body. This may be the Ministry of Health.

You may wish to complain directly to the company Chief Executive Officer in your country and its head office. However, it is the company's responsibility to ensure that it abides by the International Code and Resolutions. It may be more appropriate to ask the company to change its policy so that it no longer allows activities which violate the International Code and Resolutions. Even so, companies sometimes criticise monitoring if their violations are brought to the attention of others without the company being notified first.

IBFAN has mechanisms for recording details of violations so that international action can be taken (contact your nearest IBFAN group):

The International Code Documentation Centre (ICDC) in Penang, Malaysia, is IBFAN's central record library of violations and should be kept informed of monitoring exercises.

If you think it appropriate you can also send details to the following groups. Remember to keep copies yourself and build up your own library.

The Dutch IBFAN group, WEMOS, records violations by companies manufacturing within the European Union (even when the products have been exported outside the Union - see the sheet Reporting Violations Using EU Measures).

Baby Milk Action, the IBFAN group in the UK, publicises violations through its Campaign for Ethical Marketing mailings and on the Internet to encourage the general public to complain to companies.