Category: Research

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The WHO Code and a Scavenger Hunt

What Does a Scavenger Hunt Have to Do with the WHO Code of Marketing of Breast-Milk Substitutes?

What could a scavenger hunt possibly have to do with the WHO Code of Marketing of Breast-Milk Substitutes (BMS)?
Surprisingly—a lot.

A newly published study, “Breast-milk substitute marketing practices in four countries: an analysis using a community-based approach,” reveals how creative methods can help document and expose widespread violations of the WHO Code.

Using a Scavenger Hunt to Track WHO Code Violations

Researchers utilized an online scavenger hunt app called GooseChase to engage volunteers in four countries—Canada, Australia, the United Kingdom, and the United States. Participants were asked to identify and photograph marketing violations of breast-milk substitutes in their communities.

While most of us in the lactation and public health fields know that WHO Code violations are common, their true extent and diversity have not been well documented—especially in digital spaces. By collecting real-world photos and evidence, the researchers were able to quantify the scope of these marketing violations for the first time across multiple countries.

What the Study Found

The study documented 138 violations of the WHO Code, including:

  • Widespread digital marketing violations across all four countries.
  • False and unsubstantiated claims on breast-milk substitute (BMS) products.
  • A lack of clear preparation, handling, and storage instructions on infant formula labels.
  • Marketing within healthcare facilities, where such promotions are strictly prohibited.

These findings confirm what many practitioners already observe: predatory marketing practices are not isolated incidents—they are a systemic global issue.

Why These Violations Matter

These unethical marketing tactics undermine parents’ confidence and interfere with families’ ability to make informed feeding choices. They can negatively impact breastfeeding initiation and duration, especially when vulnerable families are targeted with misleading messages about infant formula.

As the study shows, the problem is not just the existence of violations—it’s the lack of enforcement. The WHO Code provides a strong foundation, but without national legislation and accountability, it remains a set of ideals rather than a force for protection.

The Call to Action: Legislate and Enforce the WHO Code

It’s time to give the WHO Code the legal strength it deserves. Families deserve protection from misleading marketing and the freedom to make truly informed feeding decisions.

We must move beyond acknowledging the problem to enacting and enforcing the Code in every country.
Because our families deserve no less—and, quite honestly, they deserve so much more. Because every mom deserves to have all her ways be Milky Ways.

 

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Modifiable behaviors to improve breastfeeding

We all know breastfeeding is critical for both mothers and babies. Most of us are supporters, advocates, counselors, mothers, grandmothers and just generally breastfeeding cheerleaders! We want to help and sometimes it can be hard to know how to help. In a groundbreaking new article, nine unique elements have been identified as modifiable behaviors that can increase breastfeeding success. We always knew there were things we could do! Now we have clear definitions of what those things are. Truly incredible!

The article was recently published in Acta Paediatrica and you can find it here.  The research was an observational study conducted in Masaka, Uganda. It looks at 300 newborns in the postpartum unit as well as 166 infants attending the 6-week postpartum clinic. The research team utilized the Lactation Assessment & Comprehensive Intervention Tool (LAT). A tool chosen because it did not aggregate assessment items and has been validated.

What the research found was that there are nine elements that were significantly related to effective breastfeeding: the infant state and feeding cues pre-feeding, four postitioning elements including tummy-to-mummy, infants arms around the mothers breast, the breast not being held or shaped, and the baby’s head being free of restriction, and three latching elements which include the gape, the baby’s head tilt, and the baby’s lower lip reaching the breast first.

I was delighted to speak briefly with Dr. Anna Blair, the lead author on this remarkable paper to ask her few questions on the research and the findings.

Q: What would you say are the key takeaways from the research?

Dr. Blair: There are certain predicable, easily explained things that parents can do to help their baby breastfeeding effectively, before the baby even touches the breast. We found that having the baby tummy to mummy, for example, really matters. It’s best not to hold the breast. Watch that the head is free of restrictions. There’s been a lot of focus on assessing infants already at the breast, but the pre-feeding behaviors and attaching matter.

Q: Was there anything in the results that surprised you?

Dr Blair:  Many of these elements we’ve believed for years – written about in numerous texts by experts – but now we have clear findings from research.

I think it was interesting that the baby’s head being free of restrictions mattered more with the infants in post partum than at the 6 week checkup.

Breasts being held have become such a common practice and this research shows it is negatively associated with effective breastfeeding. I was not surprised by that because there has been some previous research on breast shaping having a negative impact on breastfeeding. But look at the images of people breastfeeding and the instructions from hospitals – they largely include breast holding and shaping , which is so unfortunate.

Q: What has you excited about this research?

Dr. Blair: What we found in this study has easy to follow, straightforward ways to improve breastfeeding effectiveness and feeding and I think that is very exciting.

I hope the article sparks as much excitement for you as it did for me and for the research team.  I also hope it sparks lots of conversations in your communities and workplaces around these specific, modifiable behaviors and how it might change our practice and the way we help moms and babies.

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Newest Research on Skin-to-Skin contact in the first hour

As you may know, here at The Healthy Children Project, Center for Breastfeeding, our focus has 4 main points;

  • Education: Offering lactation training programs for novices and professionals
  • Collaboration: Working together to create meaningful change in the field of maternal and child health care delivery
  • Research: Designing and implementing collaborative inquiry to solve practical dilemmas incorporating evidence-based protocols and solutions
  • Consulting: Developing and implementing community-specific strategies to promote, protect and support breastfeeding

Last year, several of our faculty and staff traveled to Uganda for a project that embodied all four of these focus points. Research based on the work they did was recently published in Scientific Reports. The impact of implementing and sustaining the international guidelines for skin-to-skin contact in the first hour after birth in Uganda.

I was able to sit down with one of the authors of the paper, Dr. Kajsa Brimdyr, to talk about the work and the experiences of the team while in Uganda.

Dr Brimdyr, can you tell us a little about the project?

While the project began in January 2023, planning began a year earlier. We’ve known Scovia Nalugo Mbalinda for many years. She and I worked together in Gulu, Uganda on a skin-to-skin project that resulted in several papers (you can find one here) and the beautiful video Kristin Svensson and I created to educate about skin-to-skin in Gulu. (You can watch it here). Mike was a member of the International Guideline Project workshop that we conducted in Iceland in 2023 (read the guideline here) and it was thrilling to work together again. Our team was interdisciplinary, from the US, Sweden and Uganda, consisting of PhD researchers, an MD, midwives, and breastfeeding specialists along with two Ugandan research assistants. We worked collaboratively with the leadership team at the hospital, including midwives, nursing students and physicians.

When we arrived at the hospital, our team started out by observing births and the newborn behavior. We video recorded newborn behavior starting from birth and continuing for the first hour. This was to get a baseline of what was happening at the facility.

Then, we began to implement the research methodology, PRECESS, which we have used and published about in the past in Egypt (read about it here) and Texas (and here). We began with a training program for staff based on the supplementary material in the International Guideline for Skin to Skin (you can find a copy of the supplementary material here).

True skin-to-skin contact begins immediately after birth and is uninterrupted and continuous, for at least an hour after birth. We also offered guidance for potential challenges. Then, the staff began implementing the guideline: immediate, continuous, uninterrupted skin-to-skin contact for at least an hour after birth for all of the deliveries – every staff member, every shift. It was a change in practice, not just a change for those who were part of the study. The hospital made the decision to change care for all. Then, our research team came back 6 weeks later. Not only were the staff continuing to implement the guideline, but they had also improved their skill with skin to skin.

When staff first see how capable newborns are, as they see the 9 stages for the first time, it’s just so special to me. They can see how much these new babies can do.

There are still challenges ahead. For example, the beds in the labor and delivery are narrow and don’t have side rails, and mothers are worried that the baby might fall off…. and it would be helpful if the unit had beds that are more conducive to skin to skin in the first hour.

 What do you think the key take-aways are from the project?

I love that this intervention is quick and easy to implement, and that it is sustainable. It’s possible to make significant change in a short period of time.

Was there anything that surprised you while you were there?

We were not surprised by this, but we were impressed by the collaborative spirit of the team at the hospital. Our research team was at the hospital 24 hours a day and we worked long shifts to cover the time. It was important for us not to just be there for births of only one shift of staff or another, but covering nights, days and weekends. The staff were so warm and welcoming, teaching us their process, and embracing the changes.

Do you have any favorite stories about your time there?

We loved so many parts of our experience doing this research. One thing that was extra fun was the storks. They have these enormous, 5-foot-tall storks, with a wing span of 12 feet! the storks live in that part of Uganda. The maternity hospital had a tree just outside of it filled with these storks. In many parts of the world, storks are a symbol for babies being born. Our team thought it was so special that the storks like to hang out at the maternity unit!

Is there anything else you’d like us to know about your work in Uganda?

There’s more to come! We’ll let you know when the other articles are published!

Let us know what you think or if you have any questions about the newest research paper. And as always, may all your ways be Milky Ways.

 

 

 

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