The WHO Code

On May 21, 1981 the Code of the Marketing of Breast-milk Substitutes was adopted by the World Health Organization (WHO). While many in the US consider breastfeeding a lifestyle choice, in fact, lack of breastfeeding results in 4000 infant deaths a day worldwide. Just 37% of babies worldwide are exclusively breastfed for the first six months even though an exclusively breastfed child is 14 times less likely to die in the first six months than a non-breastfed child. A 2016 Lancet Series on breastfeeding concludes,

“Breastmilk makes the world healthier, smarter, and more equal. The deaths of 823 000 children and 20 000 mothers each year could be averted through universal breastfeeding, along with economic savings of US$300 billion.”

The health benefits of breastfeeding are sometimes dismissed in developed countries because of access to clean water and sanitation, but non-breastfed children in developed countries are also at higher risk of dying. A study of post-neonatal mortality in the United States found a 25% increase in mortality among non-breastfed infants.


The WHO Code prohibits advertising or promotion of the following products:

  • breast-milk substitutes, including infant formula
  • milk products, foods or beverages, including bottle-fed complementary foods, used as a partial or total replacement for breast milk.
  • feeding bottles and nipples

The Code is very specific in regards to the responsibility of health care facilities and health workers.

  • 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.
  • 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.

According to “Marketing of Breast-milk Substitutes: National Implementation of the International Code Status Report 2016″:

  • 135 countries had at least some form of legal measure in place covering some provisions of the Code, up from only 103 countries in 2011.
  • A total of 39 countries have comprehensive legislation or other legal measures reflecting all or most provisions of the Code.
  • An additional 31 countries have legal measures incorporating many provisions of the Code,
  • A further 65 countries have legal measures that contain a few provisions.
  • 49 countries, including the United States have non-binding or no measures in place.


Breastfeeding advocates in the US have worked for decades to bring awareness to the important health benefits of breastfeeding and to encourage voluntary adoption of the Code. They have helped to decrease direct advertising to mothers in magazines, on websites and in other media by boycotting outlets that take formula advertising and have successfully worked to eliminate formula sample distribution in US hospitals by organizing consumer campaigns like Ban the Bags. (see below)

Formula advertising has been shown to undermine breastfeeding, but it has been difficult to reduce formula advertising to US mothers because breastfeeding advocates can always be outspent by formula companies. For example, in 2004 the US Department of Health and Human Services Office of Women’s Health launched a National Breastfeeding Awareness Campaign and spent $20 million on the media campaign. That year, formula companies in the US spent $50 million on advertising.

This cost is minimal to an industry that is growing dramatically. Between 2008 and 2013, the total worldwide total sales of milk-based infant formula grew 40.8%. Growth was most rapid in East Asia, particularly China, Indonesia, Thailand and Vietnam. Annual sales of infant formula in 2016 were almost US$ 45 billion worldwide. This is projected to rise by over 55% to US$ 70 billion by 2019.


In a 2016 report by the World Health Organization, “Laws to protect breastfeeding inadequate in most countries,”  Dr Francesco Branca, Director of WHO’s Department of Nutrition for Health and Development, says:

“It is encouraging to see more countries pass laws to protect and promote breastfeeding, but there are still far too many places where mothers are inundated with incorrect and biased information through advertising and unsubstantiated health claims. This can distort parents’ perceptions and undermine their confidence in breastfeeding, with the result that far too many children miss out on its many benefits,”

A 2016 letter in The Lancet , published as part of the series on breastfeeding, calls for regulation of formula advertising:

“From tobacco, to sugar, to formula milk, the most vulnerable suffer when commercial interests collide with public health. Robust advertising regulation—covering all milk products for children up to 3 years, and banning social media promotion—is the next step to protect them.”


One place where there is good news for breastfeeding babies is in the area of formula promotion in health care facilities. Over the past decade, hospitals have been steadily trending toward ending formula promotion. As of 2015, 79% of hospitals report banning free formula samples. Further, all hospitals in Massachusetts and Rhode Island, Massachusetts, Delaware, Maryland, District of Columbia and New Hampshire have voluntarily banned discharge bags. Here’s a list of bag-free US hospitals.


The number of Baby Friendly designated hospitals—which must prohibit formula marketing to receive that designation—is increasing. More than 500 facilities are designated Baby-Friendly in the US. According to Baby Friendly USA:

“Baby-Friendly practices are designed to optimize mother-baby bonding and to protect, promote and support breastfeeding in the first few days of a new baby’s life. Baby-Friendly designation means that a maternity facility has successfully implemented the Ten Steps to Successful Breastfeeding, which include providing appropriate education to enable families to make informed decisions about infant feeding, encouraging mothers to hold their babies skin-to-skin immediately following birth, and offering expert lactation support throughout and beyond the hospital stay.”

As recently as 2010, there were less than 100 Baby-Friendly designated facilities implementing these practices in the US, but the designation has gained significant traction since then. Reaching the 500 mark means that currently:

  • Approximately 24% of babies born in the US are born in Baby-Friendly designated facilities; and
  • Approximately 1 in 6 hospitals/birthing centers in the US are Baby-Friendly designated.

Here is a list of the 518 Baby-Friendly Facilities in the US. More than 20,000 maternity facilities in 150 countries have earned this designation.

About Peggy O’Mara. I am an independent journalist who edits and publishes I was the editor and publisher of Mothering Magazine for over 30 years and founded in 1995. My books include Having a Baby Naturally, Natural Family Living, The Way Back Home and A Quiet Place. I have conducted workshops at Omega Institute, Esalen, La Leche League, and Bioneers. I am the mother of four and grandmother of three. Please check out my email newsletter with free tips on parenting, activism, and healthy living.

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Peggy O'Mara

About Peggy O'Mara

Editor and Publisher of Longtime natural living advocate, award winning writer, and independent thinker.

4 thoughts on “The WHO Code

  1. Laura

    Peggy, thank you for keeping the formula issue in the news. It is very sad that this problem continues to grow, despite world-wide efforts to educate. Formula manufacturers, like tobacco companies, are targeting the less developed countries not to promote health but to maximize profit. I remember reading about women who were hooked on formula with free samples in the hospital and their own milk dried up. They could not afford all the formula necessary after they left the hospital and were forced to water it down. The result, malnourished children that would have done much better on mother’s milk.

  2. Peggy O'MaraPeggy O'Mara Post author

    Thanks for you comment, Laura. Yes, it seems we just keep fighting the same battles, but there is so much more public awareness now. No one even heard of the WHO Code back in the day, but now sites refuse formula advertising. Progress is slow but steady.

  3. Pingback: Breastfeeding Protections Undermined by US | Peggy O'Mara

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