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Executive Summary
In developing countries, most children who are not exclusively breastfed do not receive infant
formula, but rather dangerous substitutes, including water, water-based liquids, or adapted whole
cow’s milk. These are inappropriate substitutes because they lack the required nutritional content
and balance to satisfy a baby’s development and growth. In addition, food supplementation often
starts very early.
Besides breast milk, infant formula is the only other milk product which the medical community
considers nutritionally acceptable for infants under the age of one year (as opposed to cow's
milk, for instance). Supplementing with solid food in addition to breast milk or formula begins
during weaning, and most babies begin supplementing about the time their first teeth appear,
usually around the age of six months.
Many International laws are passed in order promote breast feeding such as the International
Code of Marketing of Breast Milk Substitutes which is adopted by the World Health
Organization (WHO) 1981. It includes some provisions and if violated by any individuals or
companies then serious action would be taken so that marketers do not take advantage of the
society at the expense of their profit. Similar laws were in passed in Bangladesh such as the
Breast Milk Substitutes Ordinance Act passed in 1984 and a more stricter law again in 2013 so
as to regulate the marketing of breast milk substitute or infant formula products.
In our research report we have researched various international rules, laws, and regulations of
Breast Milk Substitutes (BMS) and the existing and current laws practiced in Bangladesh. We
have done primary and secondary research so as to analyze the exact situation in Bangladesh
whether it complies with the international, national, legal and ethics codes in marketing of infant
formula in Bangladesh. And also analyzed the situation in USA and made comparative analysis
so as to know which country is flexible, strict, and violating the international codes of marketing
of breast milk substitutes.


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Introduction
The World Health Organization and UNICEF have for many years emphasized the importance of
maintaining the practice of breastfeeding, and of reviving the practice where it is in decline, as a
way to improve the health and nutrition of infants and young children. A variety of factors
influence the prevalence and duration of breastfeeding. The right of every child and every
pregnant and lactating woman to be adequately nourished as a means of attaining and
maintaining health. Infant malnutrition is part of the wider problems of lack of education,
poverty, and social injustice. The health of infants and young children cannot be isolated from
the health and nutrition of women, their socio-economic status and their roles as mothers.
Conscious that breastfeeding is an unequalled way of providing ideal food for the healthy growth
and development of infants; that it forms a unique biological and emotional basis for the health
of both mother and child; that the anti-infective properties of breast milk help to protect infants
against disease; and that there is an important relationship between breastfeeding and child. the
encouragement and protection of breastfeeding is an important part of the health, nutrition and
other social measures required to promote healthy growth and development of infants and young
children; and that breastfeeding is an important aspect of primary health care. Considering that
when mothers do not breastfeed, or only do so partially, there is a legitimate market for infant
formula and for suitable ingredients from which to prepare it; that all these products should
accordingly be made accessible to those who need them through commercial or noncommercial
distribution systems; and that they should not be marketed or distributed in ways that may
interfere with the protection and promotion of breastfeeding. that inappropriate feeding practices
lead to infant malnutrition, morbidity and mortality in all countries, and that improper practices
in the marketing of breast milk substitutes and related products can contribute to these major
public health problems. Convinced that it is important for infants to receive appropriate
complementary foods, usually when the infant reaches four to six months of age, and that every
effort should be made to use locally available foods; and convinced, nevertheless, that such
complementary foods should not be used as breast milk substitutes. Appreciating that there are a
number of social and economic factors affecting breastfeeding, and that, accordingly,
governments should develop social support systems to protect, facilitate and encourage it, and
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that they should create an environment that fosters breastfeeding, provides appropriate family
and community support, and protects mothers from factors that inhibit breastfeeding. Affirming
that health care systems, and the health professionals and other health workers serving in them,
have an essential role to play in guiding infant feeding practices, encouraging and facilitating
breastfeeding, and providing objective and consistent advice to mothers and families about the
superior value of breastfeeding, or, where needed, on the proper use of infant formula, whether
manufactured industrially or home prepared. Educational systems and other social services
should be involved in the protection and promotion of breastfeeding, and in the appropriate use
of complementary foods. Aware that families, communities, women's organizations and other
nongovernmental organizations have a special role to play in the protection and promotion of
breastfeeding and in ensuring the support needed by pregnant women and mothers of infants and
young children, whether breastfeeding or no. The need for governments, organizations of the
United Nations system, nongovernmental organizations, and experts in various related
disciplines, consumer groups and industry to cooperate in activities aimed at the improvement of
maternal, infant and young child health and nutrition. Governments should undertake a variety of
health, nutrition and other social measures to promote healthy growth and development of infants
and young children, and that this Code concerns only one aspect of these measures.
Manufacturers and distributors of breast milk substitutes have an important and constructive role
to play in relation to infant feeding, and in the promotion of the aim of this Code and its proper
implementation. Governments are called upon to take action appropriate to their social and
legislative framework and their overall development objectives to give effect to the principles
and aim of this Code, including the enactment of legislation, regulations or other suitable
measures. Believing that, in the light of the foregoing considerations, and in view of the
vulnerability of infants in the early months of life and the risks involved in inappropriate feeding
practices, including the unnecessary and improper use of breast milk substitutes, the marketing
of breast milk substitutes requires special treatment, which makes usual marketing practices
unsuitable for these products.



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Background
While pharmaceutical drug advertising concerns the United States, the Nestle infant milk
formula case involved less developed countries, particularly those in Africa, and showed the
power of consumer protest in countries other than those in which the alleged abuses occur.
Infant milk formula is a common, useful, and popular product, widely used in United States and
Europe as a substitute for mother’s milk. It is a useful product to supplement a woman’s milk
when she does not produce enough for her infant. In an attempt to increase sales, Nestle as well
as other producers of infant formula extended the sale of their product of many countries in
Africa. They followed some of the same marketing techniques that they had followed with
success and without customer complaint elsewhere.
One standards technique was advertising on Billboards and in magazines. A second was the
distribution of free samples in hospital to new mother as well as to doctors. In themselves, these
and other practices were neither illegal nor unethical. yet their use led to charges of following
unethical practices and to a seven-year worldwide boycott of all Nestle products
The basis for the complaints was misuse of the products. Many of the women who received
sample were poor. When they returned home their villages, they were unable to buy sufficient
quantities of formula. In the meantime, their own breast milk had dried up. Hence they stretched
formula, diluting it to make it go further. In addition, they often used local, unsterilized water to
mix the formula. The overall result was an increased in infant malnutrition and morality.

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Critics blamed the manufacturers of the infant formula, and particularly the aggressive marketing
techniques.[1] Specifically, critics charges that the ads for the product frequently showed white
women feeding their infants the milk formula from a bottle , thereby sending the message that to
be up to date, modern mothers should bottle-feed rather than breast feed their babies. Breast-
feeding, however, was preferable from a health standpoint. If the mother had a sufficient supply
of breast milk, the critics maintained, she would not have to worry about buying or stretching the
formula or about contamination from water. At the same time, they said, she could transmit some
of her antibodies to help the infant fight diseases rather than introduce diseases with the
contaminated water.
Furthermore, mothers who were given free samples immediately after giving birth were more
inclined to bottle-feed than breast-feed their newborns. The company knew that the mother’s
milk would dry up and that the mothers would be dependent on the formula when they returned
home. In addition, the representatives of the company who went through the wards giving out the
samples wore white, and so the mothers easily mistook them to nurses. Therefore, they were
more prone to accept and use the formula than if the distributors were easily identified as sales
people.
Because the techniques the distribution used were not illegal, a group that called itself INFACT
organized a boycott to apply moral pressure on the infant milk formula companies to change
their marketing techniques. The group targeted the Nestle Corporation, a worldwide corporation
based in Switzerland. INFACT asked the consumer to refrain from buying any Nestle products
until the company changed its practices. The boycott, which lasted seven years, ended in J anuary
194. In the meantime, the world Health Organization developed Code of marketing of Breast-
Milk Substitute, Which Nestle and other companies agree to follow.
Infant baby formula boycott
A boycott was launched in the United States on J uly 7, 1977, against the Swiss-based Nestlé
corporation. It spread in the United States, and expanded into Europe in the early 1980s. It was
prompted by concern about Nestlé's "aggressive marketing" of breast milk substitutes,
particularly in less economically developed countries (LEDCs), which campaigners claim
contributes to the unnecessary suffering and deaths of babies, largely among the poor.[2] Among
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the campaigners, Professor Derek J elliffe and his wife Patrice, who contributed to establish the
World Alliance for Breastfeeding Action (WABA), were particularly instrumental in helping to
coordinate the boycott and giving it ample visibility worldwide.
Formula must normally be mixed with water, which is often contaminated in poor countries,
leading to disease in vulnerable infants.[3] Because of the low literacy rates in developing
nations, many mothers are not aware of the sanitation methods needed in the preparation of
bottles. Even mothers able to read in their native language may be unable to read the language in
which sterilization directions are written. Although some mothers can understand the sanitation
standards required, they often do not have the means to perform them: fuel to boil water, electric
(or other reliable) light to enable sterilization at night. UNICEF estimates that a formula-fed
child living in disease-ridden and unhygienic conditions is between 6 and 25 times more likely to
die of diarrhea and four times more likely to die of pneumonia than a breastfed child.[4] But
many poor mothers in Africa use less formula powder than is necessary, in order to make a
container of formula last longer. As a result, some infants receive inadequate nutrition from weak
solutions of formula.
History of the boycott
Nestlé's marketing strategy was first written about in New Internationalist magazine in 1973 and
in a booklet called The Baby Killer, published by the British NGO War on Want in 1974. Nestlé
attempted to sue the publisher of a German-language translation (Third World Action Group) for
libel. After a two-year trial, the court found in favor of Nestlé because they could not be held
responsible for the infant deaths 'in terms of criminal law'.[5] Because the defendants were only
fined 300 Swiss Francs (just over US$400, adjusted for inflation, and J udge J ürg Sollberger
commented that Nestlé "must modify its publicity methods fundamentally", TIME magazine
declared this a "moral victory" for the defendants. In 1984, boycott coordinators met with Nestlé,
which agreed to implement the code, and the boycott was officially suspended. In 1988 IBFAN
alleged that formula companies were flooding health facilities in the developing world with free
and low-cost supplies, and the boycott was relaunched the following year. In May 1999 a ruling
against Nestlé was issued by the UK Advertising Standards Authority (ASA). Nestlé claimed in
an anti-boycott advertisement that it markets infant formula “ethically and responsibly”. The
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ASA found that Nestlé could not support this nor other claims in the face of evidence provided
by the campaigning group Baby Milk Action.[6]

Current status of the boycott
As of 2013, the Nestlé boycott is coordinated by the International Nestlé Boycott Committee, the
secretariat for which is the UK group Baby Milk Action.[7] Company practices are monitored by
the International Baby Food Action Network (IBFAN), which consists of more than 200 groups
in over 100 countries. In parallel with the boycott, campaigners work for implementation of the
Code and Resolutions in legislation, and claim that 60 countries have now introduced laws
implementing most or all of the provisions. Nestlé claims that it is in full compliance with the
International Code.According to Nestlé CEO Peter Brabeck-Letmathe, "we also carry out annual
audits on WHO Code compliance with a sample of Nestlé companies, and we investigate any
substantiated claims made by those who believe we have broken the Code If we find that the
Code has been deliberately violated, we take disciplinary action. The company maintains that
many of the allegations are unsubstantiated, out of date, or use IBFAN's own non-standard
interpretation of the Code.
In May 2011, the debate over Nestlé's unethical marketing of infant formula was relaunched in
the Asia-Pacific region. Nineteen leading Laos-based international NGOs, including Save the
Children, Oxfam, CARE International, Plan International and World Vision have launched a
boycott of Nestlé and written an open letter to the company. Among other unethical practices,
the NGOs criticized the lack of labeling in Laos and the provision of incentives to doctors and
nurses to promote the use of infant formula. An independent audit of Nestlé's marketing practices
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in Laos was commissioned by Nestlé and carried out by Bureau Veritas in late 2011.[8] The
audit found that "the requirements of the WHO Code and Lao PDR Decree are well embedded
throughout the business", but that "promotional materials in 4% of the retail outlets visited"
violated either the Lao PDR Decree or the WHO Code.
1

International Code of Marketing of Infant
Formula
The International Code of Marketing of Breast milk Substitutes is an international health policy
framework for breastfeeding promotion adopted by the World Health Assembly (WHA) of the
World Health Organization (WHO) in 1981.
2
The Code was developed as a global public health
strategy and recommends restrictions on the marketing of breast milk substitutes, such as infant
formula, to ensure that mothers are not discouraged from breastfeeding and that substitute are
used safely if needed. The Code also covers ethical considerations and regulations for the
marketing of feeding bottles and teats.


1. For details of this case, see J ohn Dobbing (ed0., Infant Feedings: Anatomy of a Controversy 1973-
1984(London:Springer-Verlag,1988);and The Dilemma of Third World Nutrition: Nestlé and the Role of Infant
Fornula.1985(a report prepared for distributed by Nestle)
Campaigners website stating their claims
Milking it J oanna Moorhead, The Guardian, May 15, 2007
2. http://en.wikipedia.org/wiki/International_Code_of_Marketing_of_Breast-milk_Substitutes
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The WHO Code includes the following 14 important provisions:
 No advertising of products under the scope of the Code to the public
 No free samples to mothers.
 No promotion of products in health care facilities, including the distribution of free or
low-cost supplies.
 No company representatives to advice mothers.
 No gifts or personal samples to health care workers.
 Information to health workers should be scientific and factual.
 All information on artificial feeding, including the labels, should explain the benefits of
breastfeeding and all costs and hazards associated with artificial feeding.
 Unsuitable products such as sweetened condensed milk should not be promoted for
babies.
 All products should be of a high quality and take account of the climatic and storage
conditions of the country where they are used.
 Promote and support exclusive breastfeeding for six months as a global public health
recommendation with continued breastfeeding for up to two years of age or beyond.
 Foster appropriate complementary feeding from the age of six months recognizing that
any food or drink given before nutritionally required may interfere with breastfeeding
 Complementary foods are not to be marketed in ways to undermine exclusive and
sustained breastfeeding.
 Financial assistance from the infant feeding industry may interfere with professionals’
unequivocal support for breastfeeding.








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Regulation of marketing Infant formula in Bangladesh
In 24
th
May, 1984 an ordinance was passed in Bangladesh in order to regulate the marketing of
breast-milk substitute or infant formula products. This ordinance goal was to provide protection
and encouragement of breastfeeding by banning advertising, import, distribution and sale of
breast-milk substitutes.
According to the ordinance “Breast-milk substitute” means any food represented as a partial or
total substitute for breast milk and includes a complementary food like “breast-milk supplement
or weaning food” which means any food manufactured or locally prepared to be used as a
complement to breast-milk or infant formula, when either becomes insufficient to satisfy the
nutritional requirements of infants. Under this ordinance there is a prohibition against certain
advertisement regarding breast milk substitutes which means no person shall make, exhibit,
distribute, circulate, display or publish any advertisement that promotes the use of any breast-
milk substitute or designed to create the belief or impression that breast-milk substitute feeding is
equivalent or superior to breast-milk feeding. Registration of breast-milk substitutes should be
done from the date as may be notified by the Government in the official Gazette, no breast-milk
substitute of any kind shall be imported, distributed, marketed, stored, sold, offered for sale or be
locally manufactured for sale unless it is registered under this Ordinance. A breast-milk
substitute shall be registered in such manner and on payment of such fees as may be prescribed.
A registration granted under this section shall be valid for a period of three years and may be
cancelled before the expiry of that period in such manner as may be prescribed. Registration of a
breast-milk substitute shall be published in the official Gazette. The product should be properly
labeled in the container. The breast-milk substitute shall not be marketed unless
1(a) “Breast-milk supplement or weaning food” means any food manufactured or locally
prepared to be used as a complement to breast-milk or infant formula, when either becomes
insufficient to satisfy the nutritional requirements of infants;
(b) “Complementary food” means any food represented as a complement to breast-milk or
[Infant formula, and includes any breast-milk supplement or weaning food]
(c) “Infant formula” means a breast-milk substitute formulated to satisfy the normal nutritional
requirements of infants up to six months of age;
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(d) “Protected person” means a pregnant woman, a mother of an infant whose apparent age is not
more than two years, and a person who is the husband of such woman or mother or father of such
child (Regulation of Marketing) Ordinance, 1984
(e) “Prescribed” means prescribed by rules made under this Ordinance. Prohibition against
certain advertisement regarding breast-milk substitutes
3. No person shall make, exhibit, distribute, circulate, display or publish any advertisement-
(a) Promoting the use of any breast-milk substitute; or
(b) Implying or designed to create the belief or impression that breast-milk substitute feeding is
equivalent or superior to breast-milk feeding. Promotion of breast-milk substitute prohibited.
4. No person shall promote any breast-milk substitute either by advertisement or by offering or
giving any gift, prize, discount coupon, or other free item or by any other means .Registration of
breast-milk substitutes
(a) From the date as may be notified by the Government in the official Gazette, no breast-milk
substitute of any kind shall be imported, distributed, marketed, stored, sold, offered for sale or be
locally manufactured for sale unless it is registered under this Ordinance.
(b) A breast-milk substitute shall be registered in such manner and on payment of such fees as
may be prescribed.
(c) A registration granted under this section shall be valid for a period of three years and may be
cancelled before the expiry of that period in such manner as may be prescribed.
(d) Registration of a breast-milk substitute shall be published in the official Gazette.
5. (1) No breast-milk substitute shall be marketed unless-
(a) It is put in a sealed and hermetically closed container;
(b) An easily readable and understandable message in Bangla is printed on a conspicuous part of
its container to the effect that nothing is substitute for or equivalent or superior to breast-milk;
(c) Clear instructions on the proper method of its preparation and information regarding its
composition are printed on the container or in a literature kept inside the container; and
(d) Its registration number and the dates of its manufacture and the expiry of its usefulness are
printed on the container.
(2) Neither the container nor any literature kept inside the container shall have any picture of
infant or such other picture.
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6. (1) The Government may appoint an Advisory Committee consisting of a Chairman and not
more than such number of other members as the Government may determine.
(2) The Advisory Committee shall-
(a) Advise the Government on the proper observation of the International Code of Marketing of
Breast-Milk Substitutes;
(b) Perform such other functions relating to the purpose of this Ordinance as may be prescribed
Penalties
7. (1)If the person contravening any of the provisions of this Ordinance is a company, every
person who at the time the offence has been committed was in charge of, and was responsible to,
the company for the conduct of the business of the company as well as the company, shall be
deemed to be guilty of the contravention and shall be liable to be proceeded against and punished
accordingly: Provided that nothing contained in this sub-section render any such person liable to
any punishment provided in this Ordinance if he proves that the offence was committed without
His knowledge or that he exercised all due diligence to prevent the commission of such offence.
(2) Notwithstanding anything contained in sub-section where any offence under this Ordinance
has been committed by a company and it is proved that the offence has been committed with the
consent or connivance of, or is attributable to, any neglect on the part of, any director, manager,
secretary or other officer of the company, such director, manger, secretary or other officer shall
also be deemed to be guilty of that offence and shall be liable to be proceeded against and
punished accordingly. Explanation- For the purposes of this section-
(a) “Company” means anybody corporate and includes a firm or other association of individual,
and
(b) “Director”, in relation to a firm, means a partner in the firm.
9. No Court shall take cognizance of any offence punishable under this Ordinance except upon a
report in writing made by any officer authorized by the Government.
Indemnity
10. The Government may, by notification in the official Gazette, make rules for carrying out the
purposes of this Ordinance


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1. (Ordinance No. X... 27/06/2013 http://bdlaws.minlaw.gov.bd/print_sections_all.php?
id=671
2. 1Clause (aa) was inserted by section 2 of the Breast-Milk Substitutes (Regulation of
Marketing) (Amendment) Act, 1990 (Act No. XVI of 1990)
3. 2The words and comma “infant formula, and includes any breast-milk supplement or
weaning food” were substituted for the words “infant formula” by section 2 of the Breast-
Milk Substitutes (Regulation of Marketing) (Amendment) Act, 1990 (Act No. XVI of
1990)
4. 3Section 4A was inserted by section 3 of the Breast-Milk Substitutes (Regulation of
Marketing) (Amendment) Act, 1990 (Act No. XVI of 1990)
5. 4The words “its registration number and the dates” were substituted for the words “the
dates,” by section 4 of the Breast-Milk Substitutes (Regulation of Marketing)
(Amendment) Act, 1990 (Act No. XVI of 1990)
6. 5Sub-section (2) was substituted by section 5 of the Breast-Milk Substitutes (Regulation
of Marketing)(Amendment) Act, 1990 (Act No. XVI of 1990)

These are the basic things that are covered by “THE BREAST-MILK SUBSTITUTES
(REGULATION OF MARKETING) ORDINANCE, 1984.”
Current laws in Bangladesh regarding marketing of Breast Milk substitutes
The Breast-Milk Substitutes (Regulation of Marketing) Ordinance 1984 prohibits anyone from
making, exhibiting, distributing, circulating, displaying or publishing any advertisement on the
use of breast-milk substitutes or implying to create the belief or impression that breast-milk
substitute feeding is equivalent or superior to breast-milk feeding.
However, due to weak coordination, limited coverage and ineffective community activities, low
consumer awareness about the dangers of formula milk, absence of specific guidelines for IYCF,
inadequate recognition of complementary feeding, questionable quality of services in baby-
friendly facilities, lack of a standardized monitoring system is pulling the pace of breast feeding
development.
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In 2013 the government has approved the legislation that put a ban on advertisements that
promote breast milk substitutes..Prime Minister Sheikh Hasina-led Cabinet gave the final
approval to the draft proposal.
“Cabinet Secretary Muhammad Musharraf Hossain Bhuiyan told media that the law will be
named as ‘Breast-Milk Substitutes (Regulation of Marketing) Act, 2013’.
“As per this law these substitute baby foods can be produced or supplied, but cannot be
advertised,” he said. “However, for this permission needs to be taken.”
According to the Cabinet Secretary, a ban on advertisement would discourage parents from
seeking those alternatives”(GreenwatchBD.com,July,2013).
When the law is passed, import of raw materials or accessories needed to manufacture or
distribute such items will also be banned.
The new law also proposes that a jail term for violating the ban be increased to three years from
the two. The fine amount too has been increased to Tk 500,000, up from Tk 5,000.
The law will be formulated abolishing the previous ‘The Breast-Milk Substitutes (Regulation of
Marketing). Ordinance, 1984’. “Under the current law, actions can be taken only against
individuals. Now an institution can also be sued.”
If any individual or institution breaks the law for the second time, the punishment will be double.
Mobile courts can prosecute the violators. (Source:BD News24.com)
Associations advocating against marketing of breast milk substitutes in Bangladesh
In Bangladesh there has not been any strong activists group movements against marketing of
breast milk substitutes. However government has passed a proper legislation in 2013 putting a
ban on advertisement of breast milk substitutes. The Bangladesh Breastfeeding Foundation and
the United Nations Children fund had worked in collaboration to monitor the marketing of Breast
milk substitutes in Bangladesh(BMS code) in 2012.After the discrepancies were found out, the
government had taken steps to enact a proper legislation and pass it. Other than that there are
several NGOs such as BRAC and Proshika who send health care workers to educate and promote
breastfeeding to new mothers. There are associations which advocate for women’s rights and
they also try to educate the women of Bangladesh on the benefits of breastfeeding and do not
encourage use of infant formulas.
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Breast milk substitutes are expensive to buy. In a country like Bangladesh ,where most people
are below the poverty line, repeated buying of infant formula refills is not feasible. So
government has encouraged the method of breastfeeding to lead to lower infant mortality rate.
Bangladesh is also in compliance with the World Health Organization’s code designed for
marketing of breast milk substitutes after the boycott of Nestle.
Since a proper legislation has finally passed which would encourage the practice of
breastfeeding, so voicing against the unethical marketing of breast milk substitutes or formal
protests are not of much importance now. However it should be ensured that the law is properly
functioning.

Ethical Compliance in Bangladesh
To understand the compliance level of the international and national code of marketing of infant
formula we needed to dig in to both primary and secondary data. For our secondary data we have
gone through different newspaper, journals, laws and government related website where we got
to know quite a few things and practices that are practiced by different parties.
For our primary research, we planned to survey doctors, mothers and resellers. But later due to
some difficulties while conducting surveys, as a result we also took interviews to collect the
primary data. First we will go through the secondary research and then we would go through the
primary finding to analyze the situation.
Secondary Findings
Bangladesh government is very serious about children being breastfeed after they are born and in
their early childhood. To ensure that the breast milk substitute product doesn’t overcome breast
feeding process Bangladesh enacted its first ever law regarding breast milk substitutes (BMS) to
protect and promote the breast-feeding of children almost 30 years ago. The ordinance was
called “Breast Milk Substitutes (Regulation of Marketing) Ordinance, 1984.” The law had some
limitations and was weakening over time. In 2013 Bangladesh Government has come up with a
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stricter act abolishing the previous ordinance. This act is entitled “Breast-Milk Substitutes, Baby
Foods, Commercially Manufactured Supplementary Baby Foods and Its Equipment (Regulation
of Marketing) Act, 2013.” The aim of this act is to protect the children of zero to five years of
age. The act calls for complete restriction on advertisement of breast milk substitutes, baby
foods, children’s food supplements and its equipment.
Also, it authorizes the government to form a nine member national advisory committee headed
by a chairman to ensure implementation of the law. This is the quintessence of this act.
According to section 4, following activities will be considered as violation of the law if done by
any manufacturer or representative of breast milk substitutes, baby foods, supplementary baby
foods, and its equipment with a view to promoting their products. Despite being a good piece of
legislation, the law suffers from poor enforcement. The government’s focus should be on proper
implementation of the law. Many doctors both in the public and private sectors have allegedly
been violating the Breast Milk Substitute (BMS) Code throughout the country. In a stark contrast
to the campaigns by various government and social organizations to popularize exclusive
breastfeeding for newborns for the first six months, these doctors are encouraging mothers to
feed different substitute powdered milks to their babies.
KhurshidJ ahan, director of Bangladesh Breastfeeding Foundation (BBF), told the Dhaka Tribune
on August 19 that the authorities warned at least 100 doctors who promoted different formula
companies and advised mothers to feed powdered milk to their newborns. The BBF has learnt
from many shopkeepers that certain companies are paying Tk600 a day to display their items in
the front row, she said.
The government agency has so far issued warning notices to at least a hundred doctors working
in public and private hospitals, said Dr SK Roy, chairperson of the BBFstated that medical
professionals and representatives were promoting breast milk substitutes to mothers.“There are a
lot of breast milk substitutes being sold in the markets without registration. They are displaying
these products openly and they are advertising tactfully in different print and electronic media.
These all are clear violations of the existing BMS code,” he said.
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The Breast Milk Substitute (Regulation of Marketing) Ordinance 1984 says: “No person shall
promote any breast milk substitute either by advertisement or by offering or giving any gift,
prize, discount coupon, or other free items or by any other means.”
MM Neazuddin, secretary of the health and family welfare ministry, told the Dhaka Tribune that
he was going to write a letter to the commerce ministry requesting that it looks into the issue of
contamination in powdered milk from a New Zealand company, and to extend monitoring and
supervision before importing any kind of powdered milk, including baby milk.
While global brands of milk powder and baby food supplements are expanding their presence in
Bangladesh, the country is doing well in promoting breastfeeding among mothers in general,
officials claimed.
Primary Findings
We have collected our primary data by conducting surveys and interviews to doctors, mothers
and interviews. We will be going through the research to understand the basic compliance level
in Bangladesh. We have divided the primary research part in two parts, one part will include
interview and another part will include the survey conducted by us.
Interview of Doctors & Nurses
During the research work, interviews were conducted so as to gather the insights on
infant formula usage. The intercepts of the interview given below:
INTERVIEW 1
 Interviewee Name: Dr. Nahid Sultana
Assistant Professor (Gynae & Obs)
BIRDEM

• Interviewer: What method of infant formula do you
recommend new mothers?
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Dr. Nahid: I recommend mothers first 6 months of exclusive breast feeding after 6 months
mother can provide her child spoon feeding or bottle feeding so that the baby gains more extra
essential minerals and vitamins.

• Interviewer: What are the advantages of breast feeding?
Dr. Nahid: Breast milk is ideal for infant growth and development. At the same time it helps
infant to fight bacteria as the breast milk has sufficient anti bodies and immunoglobulin which
the bottle milk of infant formula lacks. Immunoglobulin's protect babies from foreign bodies
which is present in mother's milk.

• Interviewer: When would you recommend infant formula use to a mother?
Dr. Nahid: I would recommend infant formula when mother is unable to produce enough milk
and when mother is infected with communicable diseases like chicken pox, rubella and if the
mother has died during child birth or due to sudden death. That time, there is no other alternative
than using infant formula.

• Interviewer: Are new mothers keen on breast feeding?
Dr. Nahid: Yes mother's are very much keen in breast feeding. But during circumstances like if
the mother is a working mother then she tries to breast feed her child at least the first 6 months
exclusively then she relies on the infant formula. Similar situations also arises when the mother
is unable to produce sufficient milk or has been affected by certain diseases which is
communicable then mothers rely on the infant formula so as to fulfill her babies nutrition
requirements.

• Interviewer: Have you ever been approached by sales representatives to prescribe
infant formulas to new mothers?
Dr. Nahid: Yes many sales representatives visit my office and advertise or inform me the new
baby formula their company has developed or is so going to approach in the market in near
future. They give us various indirect incentives like calendar, pen, note pads, mugs, crockery
sets, watch, wall clocks, etc. They think these gifts and incentives will make us prescribe their
products and we would pressurize our patients to stop breast feeding and recommend them infant
19


formula. Honestly, none of the doctors do that as everyone knows that there is no best alternative
to mother's milk.

• Interviewer: Do you receive free samples of infant formula from sales representatives?
Dr. Nahid: No we do not receive free samples of infant formula as it is illegal and unethical
according to WHO codes and certain laws passed in Bangladesh. But as I said you in the
previous questions that sales representatives do try to influence us by giving us the attractive and
indirect gifts. So we do not get samples of infant formula but we do get various non-infant
formula products.

• Interviewer: Have you ever prescribed infant formula due to the pressure created by
parents?
Dr. Nahid: Yes it is mostly done by working mothers but they try their level best to breast feed
for at least 4-5 months after that they depend on infant formula. There are also circumstances
when mothers are ashamed of feeding her own child due to hassle of sucking as the baby drinks
milk for 1 or 2 hours so mothers find it irritating and then rely on the infant formula before 6
months itself and pressure us to prescribe it more often.

• Interviewer: According to you how can infant formulas be improved in order to be
beneficial like breast milk?
Dr. Nahid: The vitamins and essential minerals that are present on breast milk if added to infant
food formula then it is very good and benefitting and it would be highly recommendable then.

• Interviewer: Do you think using infant formula instead of breast milk is a good option?
Dr. Nahid: Infant formula is good if and only if mother is sick, insufficient amount of milk is
produced by the mother, and/ or due to death of mother. Then formula is encouraged otherwise
breast milk is the best food for the child.




20


INTERVIEW 2

 Interviewee Name : Dr. Gulshan Ara
Consultant & Gynaecological Laparoscopic Surgeon
Gyneacology & Obstetrics
Apollo Hospitals

• Interviewer: What method of infant feeding do you recommend to new mothers?
Dr. Gulshan: I recommend mothers first 6 months of exclusive breast feeding. After 6 months,
the mother can feed her child with spoon feeding or bottle feeding.

• Interviewer: What is the best food for an infant according to you?
Dr. Gulshan: Breast milk is the best food if the mother is healthy.

• Interviewer: What are the advantages of breast feeding?
Dr. Gulshan: Breast milk is essential and perfect for infant development. At the same time it
assists infants to fight against bacterial intrusion. I don’t believe breast feeding should be ceased
before 12 months as it is the most beneficial procedure to feed an infant untill and unless the
mother is healthy and working mothers are very conscious about the child's health at the expense
of their work.

• Interviewer: What Nutrients Are Present In Infant Formula?
Dr. Gulshan: Infant formula contains standard iron-fortified elements that are nutritionally
complete and entire nourishment for normal infants. When a doctor suggests a formula not
fortified with iron, another source of iron should furthermore be recommended. A doctor may
suggest fluoride supplementation to infants not less than 6 months of age only if the water supply
is harshly depleted of fluoride. These nutrients are essential as it enhances growth but not at the
expense of breast feeding. Children who are breast fed tend to be more active and immune from
diseases compared to those child who are fed infant formulas.


21


• Interviewer: When would you recommend infant formula use to a mother?
Dr. Gulshan: If breast milk not enough then infant formulas is recommended or when the
mother is unable to produce enough milk. If mother is sick due to some illness and also if the
mother has died then infant formula is recommended.

• Interviewer: Are new mothers keen on breast feeding?
Dr. Gulshan: My preliminary advice to new mothers is to administer breast feeding exclusively
for 6 months and many of them strictly follow it. However, there are mothers who are working
and can only administer breast feeding for 4-5 months. I inform them about all the good and bad
effects of using infant formula and I highly encourage them to breast feed.

• Interviewer: Do sales representatives visit you and provide you with free samples of
infant formula?
Dr. Gulshan: Yes sales representatives do pay a visit to us but Apollo Hospital committee does
not allow them if it comes to their notice. We are not provided with any free samples as the
hospital authority prohibits it as it is not a lawful practice. Direct marketing of any medicines is
strictly restricted in the premises of the hospital. No gifts are also provided by the sales
representatives but to an extent we get free calendars, letter pads. pen, etc.

• Interviewer: Have you ever prescribed infant formula due to the pressure created by
parents?
Dr. Gulshan: Yes, parents do pressure us as because sometimes the mother is a working lady
and also due to much family stress as she cannot spent much time in breast feeding as other
chores of the house are not done as breast feeding takes a reasonable amount of time so in order
to reduce the hassle many pressurize us to recommend their babies infant formula.

• Interviewer: According to you how can infant formulas be improved in order to be
beneficial like breast milk?
Dr. Gulshan: By adding more vitamin and mineral supplements that would be equal to the
benefits of mother's milk and by making it preservative free is also an important factor.

22


• Interviewer: Do you think using infant formula instead of breast milk is a good option?
Dr. Gulshan: No of course not if mother is healthy and the baby is able to suck till 6 months
then breast milk is necessary. Then, after 6 months infant formula is recommended for better
health of the child because till 0-6 months baby's immune system is weak so mother's milk has
sufficient antibodies which the bottle milk of infant formula lacks. After 6 months baby's
immune system develops and needs extra vitamins and minerals. So infant formula in addition to
breast milk is advisable. Working mothers also provide their babies milk as they pump the milk
out and seal it from contamination.

INTERVIEW 3

 Interviewee Name : Shimul Biswas
Senior Nurse
Apollo Hospital


• Interviewer: What method of infant feeding do you recommend to new mothers?
Shimul: Breast feeding as it is important for babies as it acts as a vaccination. It has essential
vitamins and minerals.
• Interviewer: When would you recommend infant formula use to a mother ?
Shimul: Breast milk is the best food but if it is not enough then infant formula like Lactogen is
suggested. Usually we suggest first 6 months only breast feeding then if the mother is unable to
produce sufficient milk or when the mother is sick then Lactogen is required and advised by our
doctors.
• Interviewer: Did any sales representatives approach you to prescribe infant formulas to
new mothers?
Shimul: No I was never approached, in addition, our authorities do not permit sales man in the
building for any direct marketing of their products.
• Interviewer: Did you receive any free sample of infant formula from the sales
representatives?
23


Shimul: No I never received any free samples from the representatives. They visit the doctors
not us if they have any query or want to spread any information. We are usually out of contact
with the representatives.
• Interviewer: How did you become aware about the infant formula brands?
Shimul: Awareness of infant formula through advertisements in TV.
• Interviewer: Did you ever prescribe infant food formula due to the pressure created by
mothers?
Shimul: Yes, parents pressure to doctors not us as many of the mothers are working so they want
to give their child infant formula before going to their jobs.
• Interviewer: What kind of patients are more interested to use infant formula?
Shimul: Working mothers are usually interested to feed infant formula compared to other
mothers.
• Interviewer: How do you think infant formula can be improved just like mother's milk?
Shimul: If the breast milk's essential vitamins and nutritional requirements are added then to
infant formula then it is very good. Then it would be highly recommended.
• Interviewer: Do you think using infant formula instead of breast milk is a good option?
Shimul: It is good if only the mother is sick, milk not produced enough, and if the mother died.
Then formulas are highly encouraged.
Analysis of the Interviews conducted
The interviews that were conducted has made us come to an important conclusion that the
practice of breast milk feeding to infants is considered a supreme and eminent nutrition
compared to infant formulas as long as the mother is healthy and free from transmitting any
communicable diseases, and also able to produce enough milk for her child. Following are the
analysis that we have made from the interview:
• Breast feeding practice highly recommended by doctors and nurses in comparison
to infant food formula: According to the doctors and nurses, breast milk acts as a
protection shield for the infant as it protects them from the intrusion of foreign bodies.
The breast milk of mother's contains anti bodies and immunoglobulins that the bottle
milk of infant formula lacks. The analysis shed light into the fact that doctors and nurses
24


recommend infant food formula only if the mother is unable to produce sufficient
quantity of milk, inability of the baby to suckle the nipple due to the structure of the
baby's lips, mother suffering from certain illness like chicken pox, rubella, etc which has
a possibility that the baby would be affected too, and also in cases when the mother has
died during child birth or due to sudden death when infant was still in the stage of breast
feeding. Otherwise, infant food formula are not at all recommended and the doctors and
nurses had emphasized to us many times that breast feeding should be done for at least
and exclusively for 6 months without fail as it will help in the development of the baby's
brain and health. As such, there is no alternative substitute of breast milk.
• Discrepancy in the practice of marketing of infant formula by sales representatives
in high end hospitals (Apollo Hospitals) compared to low end hospitals (BIRDEM):
Our interviews has helped us to notice and make a clear difference in the marketing
practice of infant formula in well known and expensive hospitals in Dhaka like Apollo
Hospital, United Hospital, Square hospital and between the low end hospitals like
BIRDEM, Shishu hospital. The difference we found is that sales representatives are not
even allowed in the premises of the hospital building of the well known hospitals to
market any infant formula. The hospital authorities have restricted any contact of the
sales representatives with their doctors and nurses. So, the doctors do not receive any
leaflets or any latest information regarding products of infant formula. But, this was not
in the case of the low end hospitals as the sales representatives do visit these hospitals
and influence the doctors and nurses about the new products of infant formula that the
company has developed or any new infant formula that would be available in the near
future. The sales representatives do pressurize the doctors and nurses so as to recommend
there company's products to the new mothers by doing persuasive marketing, direct
marketing and also aggressive marketing as the sales representatives are also entitled to
many royalties and sales commission. But none of these tactics influence the doctors or
the nurses and they ignore the sales representatives. They have also said that they always
recommend breast milk and emphasize on the benefits of it and mostly discourage infant
formula if the mother is healthy and able to produce milk. So, this shows that infant
formula is not encouraged by doctors and nurses.

25


• Non- acceptance of free samples and gifts by both the doctors and nurses: From the
interview it has been clearly understood that doctors and nurses in most of the hospitals
in Dhaka and Chittagong do not accept or receive any free samples of infant food formula
by the sales representatives as it is illegal. It seemed that they were all aware of the rules
and regulations coded in the Breast Milk Substitute Ordinance 1984 and the new law
passed in 2013 regarding stringent practices of marketing of Breast Milk Substitutes.


Responses and Analysis of the survey conducted on Doctors
A survey on doctors was conducted in various hospitals in Dhaka and Chittagong so as to
get insights and an in depth knowledge regarding the practice of breast feeding over infant food
formula and the level of marketing of infant formula. A survey of 10 multiple choice questions
with 20 participants, aged 45 and above, was carried out. However, the sample size is too small
to make such inference, but due to time constraint further research was not possible. All the
participants were a mixture of male and female doctors who have specialization in Pediatrics,
Gynecology and Obstetrics.

26



1. What method of infant feeding do you recommend to new mothers?


For this question, we got only one response and all of them answered that they believe that breast
feeding is the best food for infants. And the infants should be given breast milk at least for the
first six months exclusively.

2. What is the best food for an infant according to you?

Majority of the respondents replied that Breast milk is the best food for infants provided that the
mother is healthy. If the mother is unable to produce sufficient amount of milk, suffering for
100%
100%
100%
Others
Spoon Feeding
Bottle Feeding
Breast Feeding
95%
4%1%
Breast milk Breast Milk Substitute(Infant formula) Other
27


communicable diseases or has died due to child birth then it is best to provide the baby infant
formula.
3. When would you recommend infant formula use to a mother?







For this question, about 45% responded that infant formula must be provided when the mother is
suffering from any diseases like chicken pox or rubella and it is very hazardous to the infant. The
rest 40% supported that infant formula should be given if the mother is unable to produce
sufficient amount of milk which is affecting the child's development. The rest 15% said that
infant formula is recommended if the child is unable to suckle the nipple due to the shape of the
lips and the other 5% encouraged infant formula if the mother has died during child birth.
4. Did any sales representative approached you to prescribe infant formulas to the
mothers?

62%
38%
Yes
No
10
40
45
5
Baby's inability to acquire
breast milk
Not enough milk produced by
mother
Mother affected by diseases
Other
28


According to the survey 62% of the doctors expressed they were approached by sales
representative and tried to persuade them to prescribe infant formulas to the mothers in exchange
of gifts and other facilities and 38% said they weren’t approached by the sales representative.
They also expressed that the reason they didn’t have to face such representative due to the
hospitals policy which helped them to avoid such representatives.
5. You have become aware about the infant formula brands through:

Another important finding that we gathered via our primary research was how the doctors got to
know about the way of knowledge about the products. About 40% of the respondents said they
were aware about these products through various magazines, newspapers, and the electronic
media. The 35% of the respondents said they were aware about infant formula through TV ads,
which we found as an outlier because as far as we know no TV ads promote these infant food
products. But when we asked them to specify which brand did they see in the ads they were
unable to recollect. So this response gives us an uncertain statistical analysis. The others answers
included through their professional studies, from word of mouth through families and friends.
None of the respondents said that they were aware about the products through samples provided
by sales representatives as it is an illegal practice and violation of laws so there was no scope to
know the formulas through them.

0%
35%
40%
25%
Marketing representatives providing samples
Advertisements in television
Print advertisements
Other
29


6. Have you ever prescribed infant formula due to the pressure created by the
parents?

About 70% of the respondents said they were pressurized by parents to prescribe infant formula.
This was very evident when mothers were working, some of them were ashamed to feed their
child in public places so wanted to rely on the formula. But most of the mothers wanted to breast
feed their children for at least 6 months. The rest 30% of the respondents said that they were
never pressurized by parents which they said mostly constituted house wives or mothers who
would never compromise their child's health at the expense of other conditions.

7. When you prescribe an infant formula to a mother, is it necessary to inform the
mother about all its good and bad effects?
Strongly Agree 1 2 3 4 5 Strongly Disagree
Majority of the respondents rated 1 which is Strongly Agree. This implies that the doctors
do not want to keep the patients in darkness and this is morally ethical and justifiable to
let a mother know what are the merits and demerits of infant formula. This make the
mother's more conscious and become selective regarding whether to feed breast milk if
they want a long term benefit for the health of their child or avoid this nuisance of breast
feeding due to lack of time.
70%
30%
YES
NO
30


8. What kind of patients are more keen to use infant formula?

From the survey, the respondents said that very few mother's are there who do not want
to breast feed as most of them have human feelings towards their child. This trend is not
much present in Bangladesh. About 45% of the respondents said that mother's who were
suffering from communicable diseases were keen to use infant formula. Next about 30%
respondents said that working mothers were very keen to use formulas as due to their job
commitments. The 10% included women who were conscious about their figure so were
keen to rely and use infant formulas.

9. How can infant formulas be improvised in order to be beneficial like breast milk
according to you?
This was an opinion based question that we had in our survey. Most of the respondents
said that by adding more vitamins, minerals, and essential nutrients that are present in the
breast milk if can be added in the infant formula would be highly recommended and
highly essential for the development of the kids.


8
5
1.4
1.2
1
Mother's suffering from
diseases
working mothers
Figure conscious women
Mother's who don't want to
breast feed
Other
31


10. Do you think using infant formula instead of breast milk is a good option? Please
specify.
This was also an opinion based question where most of the respondents replied NO
meaning breast milk is a better option. According to the logic which they provided most
of them said that if mother is healthy then it is mandatory for the baby to be breast fed for
6 months as it helps to fight foreign bacteria and gives the baby strength and develop in a
better way.

Thus from our survey responses we can clearly analyze that most of the doctors supports breast
feeding as long as it is possible for the mother to produce the breast milk and is free from
diseases. Sales representatives do try to influence the doctors and try to market them there
products in the hospitals, it is possible, especially the less famous hospitals as they have less
stringent rules regarding the visit of sales representatives in the hospitals.
But we clearly understood that most of the doctors are against recommending infant formulas to
the mothers if it is possible. And hence we come to the conclusion that doctors are complying
with the rules and regulations, to an extent, that the Breast Milk Substitute Act has passed. More
stringent rules must be advocated by the government so there is a commendable amount of
compliance which can be termed as an international standard.



32


Interview with mothers of infants
In order to conduct an in depth analysis, several mothers were interviewed and a variety of
questions were asked to them in connection with their infant feeding methods, perception about
breastfeeding, use of infant formula and many more. Some major intercepts from the interview
of a new mothers are described below.

Interview:Mrs.Farhana Akhter
Housewife
126/1 Crescent Road,Dhaka-1205

Mrs.Farhana Akhter is the happy mother of a healthy baby boy. She was asked about the
methods she used for feeding her infant,her perceptions about breastfeeding and awareness about
infant formula use in Bangladesh.The following answers were acquired.
Q.1: Around which age did you become a mother?
Ans.Well I was married in my mid 20s.I had my first born Shehzad a year and half later.
Q.2: So as a new mother,how did you learn about feeding your child?
Ans:Normally women in Bangladesh gain ideas and advices from their mothers.As it was my
first time,the doctors in the mother and child care unit taught me to breast feed my infant.It was
important to properly breast feed as the baby had to acquire the milk.
Q.3: Are you comfortable with the idea of breastfeeding?
Ans:At first I was a little cautious but then the doctors and nurses assisted me with the
procedure.As far as I know breastfeeding is good for the baby.It helps to create closeness
between the baby and mother.

33


Q.4: Would you prefer feeding your baby something other than breast milk?
Ans:I would continue breastfeeding until my baby attains one year.Maybe after that I would
supplement his diet with more options.
Q.5: So are you aware of infant formulas?
Ans:Yes.I think I have seen infant formulas manufactured by Nestle mostly on the shops. I don’t
think I would need them now.
Q.6: Do you agree with the notion that “There are no substitutes to mother’s milk”?
Ans: Yes I completely agree. And this is the message they normally display on the
advertisements of infant formula.
Q.7: Did the advertisements influence you to give infant formula a try?
Ans:The advertisements are okay but as I said before I don’t think I would need them.
Q.8: Other than advertisements, did you ever came across doctors,nurses,health workers
or even peers who advised you to use infant formula?
Ans:Actually no I was not influenced by anyone. My doctor said it was alright to breastfeed
after examining me.
Q.9: Did you come across any direct marketing of infant formula or did you ever receive
free samples?
Ans:During my stay in the hospital I did not receive any free samples.Not even after I left the
hospital.I thought these practices are not available now a days.
Q.10: So you do know about legislations against marketing of breastmilk substitutes?
Ans:Not everything but I do know that the companies display the message that breastmilk has no
substitutes.And moreover none of my peers ever received free samples.Not that I know of.


34


Results and findings from the interview
The interview with Mrs. Farhana Akhter had helped us gain some useful insights.Some of them
are stated below:
Reliance on breastfeeding:
The new mothers in urban areas such as Farhana Akhter are quiet aware about the benefits of
breastfeeding.They do not have much discomfort or uneasiness and choose breastfeeding as the
method of feeding their infant.However Farhana Akhter was a housewife.Housewives like her
put reliance on breastfeeding in case of their infants.So infant formula was not of much
importance to housewives.
Brand recognition:
Mrs Farhana said that she recalled seeing infant formulas manufactured under the Nestle label in
stores.So in Bangladesh.Nestle was the sole leader in the infant formula sector.
Little influence from expert opinion and peer pressure:
Farhana akhter said that doctors had not advised her or prescribed infant formula for
her.Moreover she was not given free samples by health workers,doctors or nurses.However she
was attended to a premium hospital such as Apollo.So it can be deduced that mostly the doctors
and nurses of high end hospitals comply with the law and do not influence patients to use infant
formula unless required.
Awareness of ethical codes about breast milk substitute marketing:
Mrs.Farhana Akhter said she was aware of the fact that distribution of free samples was no
longer under practice.So the mothers might not clearly know the proper words of the law but
they were aware that breastmilk was better than infant formulas.


35


Analysis of survey on new mothers

1. Around which age did you become a mother?


The results sow that 61% of women had become mothers at the age of 21-30 years old followed
by 32% of mothers who became mothers at the age of 15-30 years.So the majority of women
were in their 20s.

32%
61%
7% 0%
15-20
21-30
31-40
above 40
36


2. How many child/children do you have?

The results show that 49% of mothers had 2-3 children followed by 37% who had one child.So
most of the mothers had already gained experience in rearing their children.

3. What food did you use initially to nourish your infant?

The results show that 71% of mothers had used breastmilk to feed their infants.So majority of
mothers relied on breastfeeding and very few rely on other sources such as 21% of them relied
on cow’s milk and so on.
37%
49%
10.00%
4.00%
0%
10%
20%
30%
40%
50%
60%
p
e
r
c
e
n
t
a
g
e

o
f

r
e
s
p
o
n
s
e
s
categories of the responses
No. of children
1
2 to 3
4 to 6
more than 6
0.00%
20.00%
40.00%
60.00%
80.00%
71.00%
21%
2%
6.00%
p
e
r
c
e
t
a
g
e

i
n

e
a
c
h

c
a
t
e
g
o
r
y
categories of the responses
Initial choice of infant food
Breast milk
Cow's milk
Infant formula
Others
37



4. From where did you first acquire infant feeding information?

The results show that 66% of mothers acquired information to feed their infants from doctors.As
noted the doctors were key influencer about how the infant should be fed and with what.22% of
mothers got information from nurses and 10% from relatives.So mothers relied on expert opinion
from doctors.

5. How many of these brands of infant formula do you know about?


0.00%
20.00%
40.00%
60.00%
80.00%
66.00%
22%
10%
2%
38.00%
2.00%
56.00%
4.00%
0.00% 20.00% 40.00% 60.00%
categories of responses
%

o
f

r
e
s
p
o
n
s
e
s
Recognition of infant formula
brands
Others
Nestle NAN1
Parent's choice
Nestle Good Start
38


The results show that 56% of mothers were aware of the infant formula brand Nestle followed by
38% of mothers who also recognized another product under the brand umbrella of Nestle.So
Nestle was the key player of infant formula in the market.

6. How did you come to know about infant formula BRANDS?


The results show that 54% of mothers came to know about infant formula brands from point of
display on shops.So companies like Nestle were promoting their products through point of
display but indirectly such as naming the shelves “Nutrition Corner”
7. There is no substitute for breast milk”-do you agree with this statement?

0.00%
20.00%
40.00%
60.00%
20.00%
54%
20.00%
6.00%
%

o
f

e
a
c
h

c
a
t
e
g
o
r
i
e
s
categories of responses
Promotion creating awareness
TV ad
Point of Display
Print ad
Word of mouth
0.00%
20.00%
40.00%
60.00%
80.00%
35.00%
62%
2% 1.00%
p
e
r
c
e
t
a
g
e

i
n

e
a
c
h

c
a
t
e
g
o
r
y
categories of the responses
Reliance on breastmilk
Strongly agree
Agree
Disagree
Strongly disagree
39


The results show that 62% of the mothers agreed strongly with the fact that breastmilk was ideal
for babies.However they would not mind supplementing the baby with infant formula at a later
stage.35% of mothers had full reliance on the fact.

8. When you stop breastfeeding, what do you mainly plan to feed your infant?

The results showed that 42% of mothers would feed mashed food to their infants when they stop
breastfeeding.Only 2% preferred infant formula.So infant formulas were not of much importance
to mothers who preferred feeding their babies with homemade variations rather than artificial
formulas.
Q.9 and 10
The last two questions of the survey were open ended questions.The 9
th
question focused on
how much mothers planned on using infant formula and whether advertisements played a role in
influencing them to use infant formulas.The majority of mothers who were housewives answered
that they might use infant formulas at times when they have problems with breast feeding or any
other physical illness..Even the working mothers were not very keen on using infant
formulas.The 10
th
question focused on good and bad effects infant formula had on babies in case
of usage.The mothers answered that the infant formulas were good to feed when they did not
have sufficient time to breast feed and it was easy to make.But the bad effects were cited as
babies having digestion problem which may lead to diarrhea.
34%
20%
42.00%
4.00%
0%
10%
20%
30%
40%
50%
p
e
r
c
e
n
t
a
g
e

o
f

r
e
s
p
o
n
s
e
s
categories of the resposes
Future preference for infant food
Cow's milk
Infant formula
Mashed food
Others
40


Interview of the Resellers
In order to conduct an in depth analysis, we interviewed a number of resellers from low end
stores. We asked them a number of questions to understand the compliance level of the ethical
code among the resellers and the companies. We mostly conducted informal interview where
questioned them about randomly relating to the infant formula products. We will be discussing
an interview and then we will be giving an overall analysis of the interviews.
Interview 1:
Kashem Ali
Reseller
73, Central Road, Dhaka-1205.
Mr. Kashem Ali is the proud owner of Mahin general store which is located in Central Road. He
was one of the resellers who gave us a significant amount of information about the infant
formulas. The interview session transpired the following way:
Q.1: Do you sell infant formulas in your store?
Answer: Yes I do.

Q.2: How long have you been selling these breast milk substitute product in your store?
Answer: I cannot accurately tell you for how long but it’s been some time. I opened my store
here almost 6 years ago so my guess is that I am selling it for the last five years.

Q.3:Why do you sell these infant formula products?
Answer: I try to keep everything that is searched by the customers. These infant formulas are
quite popular and have a decent demand here. To fulfill the demand I keep in my store.

41


Q.4:Do you get any sort of special incentives from the companies for selling their product?
Answer: We don’t get any sort of special incentives. We receive commission like the pharmacies
do. But nothing more than that.

Q.5:Did any sales representative asked you to prioritize their product if the customers ask your
opinion and do you do it?
Answer: As a matter of fact some of them did. They requested and also promised to give gifts if
we do that. But customers rarely ask for our opinion and most of the time they know which
brand’s product they want.

Q.6:Do the customers get any kind of discount from the companies?
Answer: The customers rarely get any sort of discount. But we the resellers sometime get
discounts by the companies. Usually when they try to clear out their inventories they offer us
discount if we promise to buy in bulk.

Q.7:Did you know the basic ethical codes of marketing infant formulas?
Answer: I don’t know it accurately but I do know that companies are not allowed to give any
sorts of baby pictures in their packaging.

Q.8: Did the companies ever told you to do something special for them?
Answer: Some of the major companies gave us offer about hiring a part of our shelf and we
would only keep their product there and nothing else. As you can see that the top left corner of
the shelf is for Nestlé’s infant products only. We get commission for doing such activities.

42



Q.9: Which company’s product dominates in this industry?
Answer: Well honestly speaking, in our shop Nestlé’s Lactogen is the most popular infant form
currently available. We also keep other companies product as well but like to stock this one
much more than the other companies’ product.

Q.10: How often do you have to restock your inventories?
Answer: Since we are a low end store we don’t hold a huge inventory. We usually buy in small
amount of number and every week we need to fill up by buying new infant formulas.
43


Analysis of the Resellers

To find out the current scenario of the market we conducted interview of the resellers. From the
interview we got to know a few things.
According to the interview we got to know that most of the retailers stocks infant formulas as
inventories in their stores. The reason they store these products are purely because of the
demand. According to them, these products are very popular among the parents and the products
run out very soon. As a result they keep buying these products so that they can make more profit.
They also informed that they get commission from the producers for selling their product. The
amount they receive is similar to the amount the drug stores or pharmacies receive. So from that
point of view it seems quite ethical from the producer’s side. But we have also been told that
sometimes the companies give out offers where the resellers receive discount if they buy in bulk.
As a result the resellers buy huge amount of infant formulas and store it for future sell and makes
profit. Even though the discount is given to the resellers, it is clearly violates the Breast Milk
Substitute Ordinance of 1984. There it is clearly stated that no person shall promote any breast
milk substitute by offering discount coupon, or other free items or by any other means.
It is also been informed that the major companies give discount to clear inventories. This again
indicates violation of the ordinance in terms of promoting. This was one of the major ethical
violations we found out from the resellers.
A few of them whose store was a bit big in size informed that they are paid by the main
companies to display their product somewhere where it can easily catch the eye. Basically it’s an
indirect marketing practice that is often adapted by the huge multinational to influence the
buying pattern. According to those resellers, they are paid by MNCs if they have a different shelf
on for that company’s infant formula product. And often these selves are named like “Nutrition
Corner” etc. Although it is indirect and the companies are not forcing the resellers to adapt these
ways but it is still indirect promotion of the infant formula and it is violating the ordinance. Other
than these flaws we did not learn any other sort of irregularities from the retailers. But one thing
amazed me that most of them didn’t knew that promotion of such formulas is illegal.
44


Survey Findings
To conduct get more insight about the topic we also took survey of 10 differentresellers. Since
most of them were illiterate we personally asked the question and we also recorded the responses
for our primary data. In this section we will be focusing on some of the main findings of the
surveys. The questionnaire is attached in the appendix part:
Q1: Do you sell infant formulas in your store?
Analysis:This was the screening question. The first thing that we asked was if they sold infant
formulas in their store and astoundingly 100% replied that they sold infant formulas in their local
stores and we didn’t had to screen out anyone. This indicates the popularity of infant formula
among the low end retailers.
45




Q2: Why do you sell these infant formula products?
Analysis: In the next question we wanted to know the reason behind their selling of infant
formulas in low end stores. Around 80% replied that they sell the product purely on the basis of
demand and nothing else. Although 10% which is indicates one person replied that he gets some
kind of special incentives. And another 10% replied that they had other reason for selling those
products.




100%
0%
0%
20%
40%
60%
80%
100%
120%
YES NO
Q1: Do you sell infant formulas in your store?
10%
0%
80%
10%
Q2: Why do you sell these infant formula
products?
Extra Incentives
No special Reason
Customer Demand
Other
46


Q3. What brands of infant formula is the most popular?
Analysis:To know the market demand pattern we asked this question and we found out that 70%
of the respondent thought that Lactogen is the most popular brand currently in the market and
another 30% expressed that Nestlé’s NAN1 is popular. Interesting thing is both the brands
belong to Nestlé itself. Although there are quite a few companies in the market but Nestlé is
undoubtedly dominating the market.

Q4. Did any sales representative asked you to prioritize their product?
Analysis: The next question that we asked them was if they were asked to prioritize the product
to the customers if possible. A strong 90% of the customers replied that they received some type
of regarding the matter and were requested to do that. On the other hand only 10% said they
didn’t receive such sort of requests.

0%
70%
30%
0%
What brands of infant formula is the most popular?
Nestle Good Start
Lactogen
Nestle NAN1
Others
90%
10%
Did any sales representative asked you to prioritize their product?
Yes
No
47


Q5. Do the customers get any kind of discount from the companies?
Analysis: The areas that we targeted for this survey revealed that they haven’t seen such
discount offers for the customers. And 100% of the respondents said that. This might be due to
the recent change of the ordinance where the punishments for such activities are strongly handled
and as a result the offering of discount is low.

Q6. What attributes do consumers seek regarding infant formula purchase?
Analysis: Here we wanted to know what the customer’s preference is when they are buying the
product. Most of the respondent around 70%answered that they have noticed that the customer
prefer the product which is known for good qualities. And that is very obvious, no parent will
want to compromise with the quality of the product when it comes to their babies health. But
there are 20% who opts to choose brands over quality and the remaining 10% chooses product
for reasonable price.

0%
100%
Yes
No
10%
20%
70%
0% 10% 20% 30% 40% 50% 60% 70% 80%
What attributes do consumers seek
regarding infant formula purchase?
Others
Good quantity
Product of well-
established company
Reasonable price
48


Q7. Do you know all the basic ethical codes of marketing infant formulas?
Analysis:Here we wanted to know if the resellers knew about the ethical codes and laws relating
to the infant formulas. Despondently 90% of them don’t know the ethical codes and laws. And
only 10% of the respondent expressed that they know a bit about the topic but no clear cut idea.

8. Did the companies ever tried to rent a shelf just to display their product?
Analysis: Another strong finding here where we got to know that they have hired shelves just
places the product. 100% of respondents replied positively and given us information relating to
the topic.


0
90%
10%
Do you know all the basic ethical codes of marketing infant
formulas?
Yes
No
Some of it
100%
0%
Did the companies ever tried to rent a shelf just to display
their product?
Yes No
49


9. Did you get any sort of gifts from the companies?
Analysis: 60% of the respondents informed that they got gifts from the companies and 40%
didn’t receive any sort of gifts. We noticed that the low end store which is a bit big in size
receives these sorts of gifts. But most of the time these gifts does not contain any sort of pictures,
just the name of the product and the company name.

10. Have you ever faced customer complaints regarding infant formulas?
Analysis: Only 10% of the respondents had to face the customers since they are the resellers
they had to face such incident and the rest 90% never had to face any sort of complains regarding
the infant formulas.

60%
40%
Did you get any sort of gifts from the
companies?
Yes
No
10%
90%
0%
20%
40%
60%
80%
100%
YES NO
10. Have you ever faced customer complaints or any other
restrictions while selling infant formulas?
50


Recent Fact Sheet about USA marketing Practices
that violates International Code of Marketing Breast
Milk Substitutes

 The code says “No free samples can be provided to mothers”. However , a 2009 CDC
study shows that the vast majority (66 percent) of U.S. hospitals continue to distribute
industry-sponsored samples of infant formula to new mothers
3
. Formula makers use this
insidious marketing tactic to encourage mothers to feed their babies formula instead of
breastfeeding. Mothers who receive formula samples are less likely to breastfeed
exclusively and breastfeed for shorter periods of time. Yet, healthcare providers agree
that breastfeeding for the first six months of life offers crucial, long-term benefits for
children. It’s time to end this dangerous practice and protect children’s health.

 The Code strictly prohibits infant formula promotion in the health care system. At its
conception, the Code was intended to put an end to these forms of advertisement.
However in reality free samples and prescriptions for infant formula are common
practice. Written prescription for infant formula given to mother on discharge: 65.4 –
67.1%, significantly more in private maternity hospitals. Free samples of infant formula
are also given to mother on discharge: 35.3 – 35.7%, significantly more in private
maternity hospitals.
4





3
U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. "CDC National
Survey of Maternity Care Practices in Infant Nutrition and Care (mPINC), 2009." Table 5.2a: Distribution of
infant formula discharge packs by facility type, size, NICU level, and region. Retrieved J an 12, 2014, from
http://www.cdc.gov/breastfeeding/data/mpinc/data/2009/tables5_1a-5_2a.htm.

4
Department of Health and Human Services, Centers for Disease Control and Prevention. "Breastfeeding
Report Card--United States, 2011." Retrieved 12 J anuaryary, 2012, from
http://www.cdc.gov/breastfeeding/pdf/2011BreastfeedingReportCard.pdf.

Discharge with the Early Duration of Breastfeeding." Journal of Human Lactation 8, no. 2 (1992): 67;
Wright, Anne, Sydney Rice, and Susan Wells. "Changing Hospital Practices to Increase the Duration of
Breastfeeding." Pediatrics 97, no. 5 (1996): 669-75

51


 Several photographs documenting the existence and unconstrained circulation of free
samples of formula in many Hospitals. In some photos charts can be seen in the
background with clearly visible name of the hospital.
5

Example of Code violation (2)
Ohio State Hospital








Example of Code violation (3):
North Dakota State Hospital

2 photographs of gift-packs received by post partum women clearly showing a bottle with
a rubber teat. However free gifts of breast milk substitutes, including bottles and teats are
prohibited from the International Code.
6









5
Sadacharan, R., X. Grossman, E. Sanchez, and A. Merewood. "Trends in US Hospital Distribution of Industry-
Sponsored Infant Formula Sample Packs." Pediatrics 128, no. 4 (2011): 702-05.
6
Reiff, Michael I., and Susan M. Essock-Vitale. "Hospital Influences on Early Infant-Feeding Practices." Pediatrics
76, no. 6 (1985): 872-79.


52


 Example of Code violation (4):
Barnes Jewish Hospital
The display cabinet in the waiting room of the clinic. The big cans are various
instant creams and the little cans are from the line “Nounou Kid”, all by
“Nounou”/Friesland Foods.Photograph was taken by a pediatrician working at the
clinic, in March 2011.












 Some other examples of promotion that violates code



However the International
code prohibits promotion of
promotion of breast milk
substitutes including in health
care facilities


A Milupa ad in Alabama suggests
their products give babies “super
powers”.
53










A promotion in an American supermarket
for a Nestle Nan Toddler Talk iPhone App.
Not only are instore promotions prohibited,
but Nestle’s misleading promise—you have
to understand toddlers to understand their
needs—undermines parenting.
A Cow & Gate (now owned by Danone)
in-store promotion in the USA. In-store
promotions are not allowed under the
provisions of the Code, nor are
competitions and free samples.
The latest marketing mechanism is the
Smartphone App. Here, Abbott’s Strong
moms mothers club App offers feeding
and infant health guidance.

54


 Code Violations: Sponsorships
The Code explicitly prohibits sponsorships to the health professionals, but also promotion
in the health care system, including during symposiums. This is a well known way in
which companies try to influence health workers, with the purpose of promoting their
products
Examples
In the entrance hall to the amphitheatre – 4 higher than adult height posters advertising
infant formula from these companies: Nestle (NAN), Giotis (Sanilac), Nutricia Almiron),
Milupa















55


 VIOLATION: False Health Claims
7

EXAMPLE 1 : Company Nounou/Friesland Foods











Left: Frisomel. Artificial milk from 6 month of age

Middle: In center of oval: “new advanced composition”. In
periphery of oval: “Prebiotics, Nucleotides, DHA & AA”

Right: “The new upgraded composition of Frisomel contains:
 DHA & AA- are the most significant fatty acids that appear in mother’s milk
 Prebiotics – which help the good functioning and health of the peptic system
 Nucleotides – which help strengthen the immune system”







7
Sadacharan, R., X. Grossman, E. Sanchez, and A. Merewood. "Trends in US Hospital Distribution of Industry-
Sponsored Infant Formula Sample Packs." Pediatrics 128, no. 4 (2011): 702-05

56


…continued: False Health Claims!
























The International Code prohibits idealizing
text from being used in labels, which
represent breast milk substitutes to be close
or similar to breast milk. This product is
idealized because it states that some
ingredients play a role in child growth.
Such health claims serve to compare the
products with breast milk, which has been
shown to provide exactly what infants
need. Although true for breast milk there is
no consistent evidence that just adding
these products in artificial milk has the
same effects.
Company Milupa

“Cream Vanilla, with rice- flour”
“From 5 months of age”

This product violates the Code in two ways:

A) It promotes a breastmilk substitutes for
babies of 5 months of age...Violating the
requirement for exclusive breastmilk up to 6
months.
B) It contains the picture of baby in its label
57


VIOLATION: Products for 4 months of age + Pictures of babies!!






















These products violate the Code in two ways:

• They promote breast milk substitutes
for babies under 6 months of age...
Violating the requirement for exclusive
breast milk up to 6
• They contains pictures of infants in
their label


Right: Company Nounou/Friesland Foods - Nounou
Cream Vanilla
“Cream vanilla with riceflour and milk. With prebiotic
fibre. After 4 months of age”

Left: Company Nutricia Frutapura
“100% pure fruit . 5-36months. Apple and pear without
added sugar”


58


Example: For infants under 6 months of age






















These products violate the Code because they
promote breast milk substitutes for babies under
6months of age…. Violating the requirement for
exclusive breastmilk up to 6 months
Right : Giotis Company
“Fruitcream. 5 fruits, milk, 9 vitamins & iron. With
prebiotics. After 5
th
month”

Left : Nestlé Company
“ Cocktail of 6 fruits. From nectar of fruits. After 4
months “

59


Example: Company Chicco


Easy feed feeding bottle
“From 0 months”
“The bottle “Drink Easily” allows you to
breastfeed your child in a practical and
safe way…”

Here is translated “feed your baby” as
“breastfeed your baby”... Translator’s
mistake?

Or intentional incorrect use?


60


Comparison of ethical code compliance of breast
milk substitutes marketing between United
States of America and Bangladesh
In America as the analysis findings show that compliance to the WHO code about marketing of
breast milk substitutes is not followed in full force.Compliance to the World Health Organization
code was voluntary in America.SO advertisements were not banned on America. ,
“Vast majority (66 percent) of U.S. hospitals continue to distribute industry-sponsored samples
of infant formula to new mothers”(Breastfeeding Report Card--United States, 2011).
The mothers are still distributed free samples of infant formula according to the statistics stated
above.Especially the women who have income below the poverty line are given these free
samples.However the doctors in America encourage breastfeeding and put emphasis on it.But
still not all doctors do it. In reality free samples and prescriptions for infant formula are common
practice.
“Written prescription for infant formula given to mother on discharge: 65.4 – 67.1%,
significantly more in private maternity hospitals. Free samples of infant formula are also given
to mother on discharge: 35.3 – 35.7%, significantly more in private maternity hospitals(CDC
National Survey of Maternity Care Practices in Infant Nutrition and Care “(mPINC), 2009).
So we see that in America the ethical compliance with the code of marketing of breast milk
substitutes is not much and needs stricter laws.However in a developed country like America
mothers are not very conscious about spending and can buy infant formula whenever they need it
rather than stretching the formula which can have detrimental effects on baby’s health.
Bangladesh stands in a much better position than America when it comes to ethical compliance
with marketing of breast milk substitutes.Though there has not been active movements or
pressure from activists group,the government has been strict about enacting laws regarding BMS
marketing.The first ordinance which was passed in 1980 prohibited all advertising of infant
formula or distribution of free samples.In Bangladesh free sample distribution is very low even
compared to other developed and developing countries.Our in depth interview and analysis told
61


us so.The Bangladesh Breastfeeding Foundation in collaboration with Unicef Children Fund
monitored the compliance with law regarding BMS and then in 2013 a stricter law was passed
which prohibited all sorts of advertisements of infant formula.
The Breast Milk Substitute (Regulation of Marketing) Ordinance 1984 says: “No person shall
promote any breast milk substitute either by advertisement or by offering or giving any gift,
prize, discount coupon, or other free items or by any other means.”
.In 2013 Bangladesh Government has come up with a stricter act abolishing the previous
ordinance.This act is entitled “Breast-Milk Substitutes, Baby Foods, Commercially
Manufactured Supplementary Baby Foods and Its Equipment (Regulation of Marketing) Act,
2013.”
The aim of this act is to protect the children of zero to fiveyears of age.The act calls for complete
restriction on advertisement of breast milk substitutes, baby foods, children’s food supplements
and its equipment.
So all in all Bangladesh stands in a better position than USA when it comes to ethical
compliance with codes regarding marketing of Breastmilk substitutes.It also has a firm stand in
case of Asian countries.
“In Bangkok 97 out of 370 (26%; 95% confidence interval 18% to 36%) mothers reported
receiving free samples of a breast milk substitute, feeding bottle, or teat (table); many women
received more than one sample. This was a greater proportion than that found in the other three
cities. In Dhaka only one woman reported receiving a free sample”(BMJ,,April 1998).





62


Conclusion
The use of inadequate breast-milk substitutes may lead to stunting, underweight or wasting and
increases infant mortality. Infant feeding practices account to a large extent for the high rates of
malnutrition among children in developing countries.
The use and marketing of infant formula has come under scrutiny. Breastfeeding, including
exclusive breastfeeding for the first 6 months of life, is widely advocated as "ideal" for babies
and infants, both by health authorities and accordingly in ethical advertising of infant formula
manufacturers.
The healthiest first food for babies is breast milk. Recent research supports this and even
formula companies agree that breast milk is best. Breast milk is full of fatty acids, antibodies,
nutrients, protein and fat and is a truly perfect and complete food for babies. While formula can
provide basic food if a mother is unable to nurse, it is no match for a mother’s milk, which can
change to suit the needs of the baby as it grows. Infant formula is a manufactured food designed
and marketed for feeding to babies and infants under 12 months of age, usually prepared for
bottle-feeding or cup-feeding from powder (mixed with water) or liquid (with or without
additional water). In particular, the use of infant formula in less economically developed
countries is linked to poorer health outcomes because of the prevalence of unsanitary preparation
conditions, including lack of clean water and lack of sanitizing equipment.
So, with this research analysis we come to the conclusion that Bangladesh is partially, to an
extent, violating the code of ethics in marketing of baby food formula and the authorities must
take serious steps in order to be in par with the international codes and help Bangladesh to have
healthy, visionary, less malnutrition babies and young children.

63


References

1. Breast-Milk Substitutes (Regulation of Marketing) Ordinance, 1984 (Ordinance No.
XXXIII of 1984).. 2013. Breast-Milk Substitutes (Regulation of Marketing) Ordinance,
1984 (Ordinance No. XXXIII of 1984).. [ONLINE] Available at:
http://bdlaws.minlaw.gov.bd/print_sections_all.php?id=671. Accessed J an 8,2014.

2. World Health Organization. International Code of Marketing of Breast-milk Substitutes.
Geneva, 1981.

3. Marketing and advertising. 2013. Marketing and advertising. [ONLINE] Available at:
http://www.unicef.org/csr/215.htm.Accessed J an 8,2014.

4. United States Government Accountability Office (GAO). Breastfeeding: Some Strategies
Used to Market Infant Formula May Discourage Breastfeeding; State Contracts Should
Better Protect Against Misuse of WIC Name. Report to Congressional Addresses. GAO-
06–282, February 2006. Available at: http://www.gao.gov/new.items/d06282.pdf.
Accessed 9 J an 2014.

5. Howard CR, Howard FM, Lawrence R, Andresen E, DeBlieck E, Weitzman M. Office
prenatal formula advertising and its effect on breast-feeding patterns. Obstet Gynecol.
2000;95(2):296–303

6. Howard CR, Howard FM, Weitzman ML. Infant formula distribution and advertising in
pregnancy: A hospital survey. Birth. 1994;21(1):14–9

7. Kent G. WIC’s promotion of infant formula in the United States. Int Breastfeed J .
2006;1(1):8 April, Available at:
64


http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1481608&blobtype=pdf.
Accessed J an 8,2014.

8. Tuttle CR. An open letter to the WIC program: the time has come to commit to
breastfeeding. J Hum Lact. 2000;16(2):99–103

9. Uzzal M.100 doctors warned for promoting breast milk substitutes. Dhaka Tribune. -
Available at: http://www.dhakatribune.com/bangladesh/2013/aug/20/100-doctors-
warned-promoting-breast-milk-substitutes#sthash.LQsk4dye.dpufAccessed on: J an
8,2014.


10. Abdullah K. BMS law: Protecting the future generation. Dhaka Tribune. - Available at:
http://www.dhakatribune.com/law-amp-rights/2013/dec/04/bms-law-protecting-future-
generation. Accessed on: J an 8,2014.


11. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention.
"CDC National Survey of Maternity Care Practices in Infant Nutrition and Care (mPINC), 2009."
Table 5.2a: Distribution of infant formula discharge packs by facility type, size, NICU level, and
region. Retrieved J an 12, 2014, from
http://www.cdc.gov/breastfeeding/data/mpinc/data/2009/tables5_1a-5_2a.htm.


12. Department of Health and Human Services, Centers for Disease Control and Prevention. "Breastfeeding
Report Card--United States, 2011." Retrieved 12 J anuaryary, 2012, from
http://www.cdc.gov/breastfeeding/pdf/2011BreastfeedingReportCard.pdf


13. Discharge with the Early Duration of Breastfeeding." Journal of Human Lactation 8, no. 2 (1992): 67;
Wright, Anne, Sydney Rice, and Susan Wells. "Changing Hospital Practices to Increase the Duration of
Breastfeeding." Pediatrics 97, no. 5 (1996): 669-75

14. Sadacharan, R., X. Grossman, E. Sanchez, and A. Merewood. "Trends in US Hospital Distribution of
Industry-Sponsored Infant Formula Sample Packs." Pediatrics 128, no. 4 (2011): 702-05.