On 23 August 2011, the Minister of Health, Dr. Aaron Motsoaledi, released a media statement, advising that the Government had decided to adopt an exclusive breastfeeding strategy. According to the Minister, the reason for this decision was that, central to the goal of reducing mortality under children, is the implementation of an exclusive breastfeeding strategy and discontinuing the practice of providing milk formula through hospitals and clinics, except when recommended by authorised health care practitioners. The Minister went on to state that statistics reveal that South Africa is one of the twelve only countries in the world where infant mortality has been increasing and that only 8% of infants are exclusively breastfed up to the age of six months. The country has one of the lowest exclusive breastfeeding rates in the world.
The World Health Organisation (“WHO”) recommends that, in order to achieve optimal growth, development and health, infants should be exclusively breastfed up to the age of six months. From the age of six months, infants should receive nutritionally adequate and safe complementary foods, while breastfeeding continues for up to two years of age or beyond.
One of the reasons that have contributed to the country’s low exclusive breastfeeding rate is that, in the past, the Government provided free infant formula to mothers who were infected with HIV, in order to prevent mother-to-child-transmission of HIV during breastfeeding. However, new research by the WHO and the United Nations Children’s Fund (“UNICEF”) has shown that the advantages of exclusive breastfeeding by HIV-infected mothers far outweigh the possible risk of mother-to-child-transmission of HIV. In line with the WHO recommendations, the 2013 South African Antiretroviral Treatment Guidelines stipulate that mothers that are infected with HIV should exclusively breastfeed their babies for the first six months and thereafter start introducing complementary foods. The Guidelines also provide that HIV-positive mothers should receive antiretroviral treatment to prevent mother-to-child-transmission of HIV throughout the period of breastfeeding.
It appears that, by adopting this approach, the Government’s aim is to bring the country’s practices relating to infant and young child feeding in line with the Global Strategy for Infants and Young Children (“the Global Strategy”) that was adopted by the WHO and the UNICEF in 2003. The Foreword states:
“The Global Strategy is based on the evidence of nutrition’s significance in the early months and years of life, and of the crucial role that appropriate feeding practices play in achieving optimal health outcomes. Lack of breastfeeding – and especially lack of exclusive breastfeeding during the first half-year of life – are important risk factors for infant and childhood morbidity and mortality that are only compounded by inappropriate complementary feeding. The life-long impact includes poor school performance, reduced productivity, and impaired intellectual and social development.”
Furthermore, the Global Strategy states that it should be a priority for all governments to implement new legislation that is required to give effect to the principles and aim of the International Code of Marketing of Breast-milk Substitutes, which was adopted by the WHO in 1981.
Regulations Relating to the Foodstuffs for Infants and Young Children
Against this background, the Regulations Relating to the Foodstuffs for Infants and Young Children (GN R991) (“the Regulations”) were published in the Government Gazette of 6 December 2012. The Regulations were promulgated by the Department of Health (“DOH”) under the Foodstuffs, Cosmetics and Disinfectants Act 54 of 1972.
The Regulations deal with the requirements relating to the labelling, composition, packaging, manufacturing and promotion of the following products:
- infant formula;
- follow-up formula;
- infant or follow-up formula for special dietary management for infants with specific medical conditions;
- complementary foods;
- liquid milks, powdered milks, modified powdered milks, or powdered drinks marketed or otherwise represented as suitable for infants or young children (“liquid milks and powdered milks”);
- feeding bottles, teats and feeding cups with spouts, straws or teats; and
- any other products marketed or represented as suitable for feeding infants and young children that the Minister may so designate by notice published in the Government Gazette.
Those products are collectively referred to as “designated products” in the Regulations.
Some of the important provisions of the Regulations are discussed below.
Messages that must appear on designated products
The Regulations stipulate that certain messages must appear on the labels and containers of designated products. For example, the containers and labels of infant formula or follow-up formula must contain the following statements:
“Does not contain breast milk”
“Breast milk is best for babies”
“This product shall only be used on the advice of a health professional”
All containers or labels of complimentary foods and liquid milks and powdered milks must state the following message:
“From 6 months of age, together with breast milk, infants should be fed a variety of foods. Ask a health worker or health professional for advice”.
Furthermore, the labels of feeding bottles, feeding cups and teats must include a statement on the superiority of breast milk for feeding infants and should contain the following warning:
“If you are breastfeeding your baby, using a feeding bottle and teat may interfere with the baby's natural way of suckling your breast”.
Phrases such as “Like Breastfeeding” on the label, packaging or container of feeding bottles, feeding cups and teats are prohibited. Regulation 6(6) provides that no action, motion or benefits with regard to the feeding or sucking on a feeding bottle, and teat or the physical properties of such feeding bottle and teat may, in any form or manner, be compared to the action, motion or benefits of suckling on a human breast or the physical properties of such human breast.
These provisions come into force on 6 December 2014.
Health, medicinal or nutrition claims
The Regulations provide that no health, medicinal or nutrition claims may be made in any manner in respect of any designated product. This means that phrases such as “Reduces Colic, Burping & Wind” or “Helps Preserve Vitamins” are prohibited.
According to the DOH, one of the main reasons for this provision is that such claims are often misleading to consumers and frequently serve as a marketing tool, instead of serving as educational information aimed at improving the nutrition of infants and young children.
Promotion and advertising
Of specific significance is Regulation 7, which prohibits all promotional practices and device advertising in respect of designated products, with the exception of complementary foods. Examples of prohibited promotional practices or advertising devices include:
- special displays to promote sales;
- advertisements about the availability of a product at a specific retail outlet and the price of that product;
- discounts in any form, competitions with prizes, or any other incentives and gifts; and
- advertisements in written publications, television, radio, film, electronic media, email, video, telephone displays, exhibitions and outdoor advertisements such as billboards, posters, signs and electronic signs.
This means that retailers, manufacturers, distributors and importers of those designated products are prohibited from advertising and promoting those products in whatever manner.
Furthermore, Regulation 7(3) provides that no designated product may be sold through health care personnel (for example, doctors, nurses and dentist) or health establishments (for example, hospitals). However, pharmacies do not qualify as a health establishments and the Regulations provide that institutional pharmacies in private health establishment may sell designated products, but may not advertise or promote those products.
Regulation 7 comes into force of 6 December 2013. However, there is a 3-years phase out period, from the date of publication of the Regulations, to remove all non-complying products from the market. The Government has, therefore, afforded sufficient time to those in the industry to bring their products in line with the Regulations.
In conclusion, it is evident that the Regulations have far-reaching consequences for the industry as a whole. It appears, however, that the Government firmly believes that the implementation of the exclusive breastfeeding strategy, and the changes brought about by this strategy, is in the best interest of the public, and generations to come.