Report for monitoring of Breastmilk Substitute. Code Marketing in Mongolia
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1 Report for monitoring of Breastmilk Substitute Code Marketing in Mongolia G.Soyolgerel 1, D. Davaasuren 2, R..Galbadrakh 3 1) Ministry of Health 2) Department of Pediatrics, Health Science University of Mongolia 3) National Maternal and Child Health Center This activity highlights the Mongolia's experience in creating efforts to protect and promote breastfeeding and to implement the International Code of Marketing of Breast-milk Substitutes. Since 1992, Mongolia has successfully implemented the Baby-Friendly Hospital Initiative. The United Nations Convention on the Rights of the Child (CRC) is the most comprehensive international human rights framework in this regard. Numerous articles of the CRC are supportive of the aim of the Code, particularly the right of children to the highest attainable standard of health, by, inter alia, reducing infant mortality, and promoting breastfeeding. The CRC s recommendation to Mongolia was to ratify international code to provide legal and normative guidance on protecting, promoting and supporting infant and young child feeding. In , Mongolia conducted a study to evaluate compliance with the International Code of Marketing of Breast-milk Substitutes. The research demonstrated numerous violations of the code by various companies and confirmed the necessity of ongoing activities to promote implementation of the code. Due to the great effort of Ministry of Health and the UNICEF National Law on marketing of BMS was adopted in 2005 by the country's parliament. It reflects almost all the provisions of the international code and, thus, can be considered a strong instrument of breastfeeding protection in Mongolia and protects a mother's right to choose the method of feeding for her baby on the basis of objective and available, complete information on the advantages of breastfeeding. The law also contains provisions to protect children from low-quality and improper nutrition. The Mongolia has a long-standing history of breastfeeding. In recent years, however, despite the widely acknowledged benefits of breastfeeding, country witnessed a decline in infant breastfeeding practices and an increase of high dependence on breast-milk substitutes 1
2 The reasons for these trends were numerous. Some of the more significant influences were as follows: In recent years, the importation and distribution of breast-milk substitutes became common due to the consequences of a social economic situation in Mongolia and breastfeeding was identified as an urgent societal need in order to insure better, more secure food sources for infants in Mongolia and to reduce dependence on formula donations. Consumers are vulnerable to western-style promotion which leads to an average exclusive breastfeeding rate is declining ( 2010). 185 health facilities which have birth delivery service, have earned baby-friendly hospital certificate. Despite the implementation of code/law procedures, much more needs to be done to promote breastfeeding as the normal lifestyle for every woman and to designate all maternity hospitals as babyfriendly, thus ensuring full realization of the law. Mongolia aims to monitor the "Code" regularly to promote breastfeeding and convince infant feeding products sellers, distributors, importers. to comply with "Code." Anecdotally, covert promotional methods have been reported, especially targeted at doctors, who have an important effect on the timing and choice of a breast milk substitute: unsigned, non-prescription slips with specific company names for mothers with the ill defined insufficient milk syndrome ; free funds to attend meetings in abroad and electioneering support for candidates in national society elections known to be passive to breast feeding promotion and code monitoring. Future monitoring should evaluate such covert promotional activities. Objective: To estimate the prevalence of violations of the national law of marketing of breast milk substitutes for in capital city Ulanbatar in Mongolia. This monitoring was led by the National Maternal and Child Health Center together with Mongolian Pediatric association supported by Ministry of Health and the East Asia International Baby Food Action Network (IBFAN). Participation institutions: Department of Pediatrics and Department of Health science University of Mongolia District health centers. Methodology Consensus workshop for monitoring of Breast milk substitute code marketing was discussed with key institutions in area of child health and child nutrition - MOH, National Pediatric association, National midwifery association, Department of Pediatrics and Department of Family Medicine of Health science 2
3 University of Mongolia Maternal and Child health research center agreed to attend workshop in 1 December the proposed A team was appointed by this workshop and 8 persons from different institutions have been trained to interview mothers and health workers using code monitoring tool s questionnaires. Random sampling was used to select mothers of babies within 6 month old to interview at health facilities. 2 health workers were interviewed at each health facility to assess whether the facility provide infant formula, whether they had received free samples, to determine how they had been used, and to determine whether gifts had been given to health workers by companies that imported or distributed breast milk substitutes. Compliance with the marketing code for information given to health workers was evaluated using a checklist. Subjects: 42 mothers of infants aged 6 months, and 24 health workers at 12 health facilities, 11 shops and 3 pharmacies. Process Interview the mothers using the special checklist form in tool. Visit hospitals and clinics, collect product labels and company materials. Observe the promotion in store, Analyzing all collected information Reporting Average number of annual birth is that is profitable market for baby food importing companies, however there is no baby food manufacturers yet. The importing companies distributed number of promotional leaflet or brochure, and billboard in the streets In supermarkets, the sheets also were available in milk shelves free for pregnant mothers to take or the promotional information are published in newspaper as a advertisement. Interview with mothers 42 mothers with babies of 1-6 month of age, were interviewed. 18 mothers out of them who have babies within 6 month were using BMS mostly Humana Nan and Hi-Hi. 12 mothers have been received baby napkins, pencils and baby foods as a promotion Main reason to use of BMS is hypolactation however 1 mother had sever surgery. One mother out of 42 met with company 3
4 representative who presented a gift when she was in hospital. 13 mothers (5 in hospitals 8 at home) were counseled by health care workers to use infant formula due to their insufficient breast milk. All mothers have bought infant formula from the shops. Three mothers received some promotional brochures in Pharmacies. All women interviewed were not given any promotional gift by health care workers. Picture 1. Interview with mother at the district hospital Health facility visit A team visited 11 health facilities (6 maternity hospital, 5 family clinic) and observed no evidence of receiving the donated formula. All health facilities were buying infant formula if they needed in unavoidable circumstance. The representatives of BMS importing companies visited to 2 maternity hospitals and suggested to meet nursing mothers. Health Science University organizes one conference on infant feeding and introduced an infant formula once. 4
5 Advertisement in shops and marketing. A team visited to 1 shopping center (Sky shopping center) 3 supermarkets (Nomin, Sansar, Orgil) 7 small shops, 3 pharmacies. Supermarket chains have taken to advertise many formula brands in their catalogues, often with special offers as shown in the illustration below representing a advertisement. Since supermarkets are distributors they must also abide by the Toddler milks, also known as growing-up milks, are expected to experience the highest growth among all formula products in next future. It is common for growing-up milks to have very similar brand names and logos so as to deliberately resemble the company s infant formula and follow up formulas which cannot be promoted. Advertising and other promotion of these milks will cause confusion and undermine breastfeeding, justifying the move by some countries to include them in the scope of their law. In street billboard and daily newspaper the Nutrilon was advertised for several month..picture 2. Various infant formula commonly used by people, in Sky shopping center. Picture 3. growing-up formulas in SANSAR supermarket 5
6 As shown in this advertisement, the label design, colour schemes and illustrations of the growingup milks are almost identical to the infant formula label on the left. LABELING In Mongolia foreign brands occupy 100% of the powdered milk market. According to the Law of BMS, labels should provide information about the appropriate use of the product, and not discourage breastfeeding. Infant formula containers should carry a clear, conspicuous and easily readable message in an appropriate language about instructions for appropriate preparation, and a warning of the health hazards of inappropriate preparation and stating that the product should only be used on the advice of a health worker as to the need for its use and the proper method of use and superiority of breastfeeding.. Most commonly used infant formula in Mongolia: Hi Hi Friso Nan Milasan Nutrilon Nanyan HiPP Five Secret s Picture 3. Most of infant formulas in shops don t have these instruction in Mongolian language. While a team asked about Labeling the salesmen don t know it and answering that the companies should know why. Picture 4. Several brands in shops have fancy labels such as Gold and Premium, setting off a trend of supposedly high-grade formulas. There is now Nan Gold and Friso Gold are in higher prices.. 6
7 In Pharmacies MONOS and KHURMEN there were various kind of formulas with free advertising leaflets. Picture 5 Infant formulas in Pharmacy Khurmen 7
8 CONCLUSION In Mongolia there are no manufacturer producing infant formula. In Mongolia foreign brands occupy 100% of the powdered milk market. There is Law on BMS marketing however still implementation is weak. Last 10 years import formula import is increased drastically. 40% of mothers interviewed were using infant formula for their infants due to insufficient lactation. 28,4 % of mother received free gift as a infant napkins, baby food as a promotion. Mothers receiving free samples and napkins were from poor families. A team told by health care providers, that at the health facility, company representatives have some interest to organize promotional activity and meet with mothers. There weren t any promotional brochures in places. Some advertisement of infant formula like Nutrilon was posted in street billboard. No regular monitoring due to lack of resource therefore regular monitoring for code implementation is required. Training health workers and allow them to recognize the importance of Code and BF counseling for mothers and strengthen the management of health facilities to ensure that no promotion of breast milk substitutes in hospitals. Picture 6. Monitoring team. 8
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