The influence of marketing on infant and young child feeding and health is well recognized, and an International Code was adopted by the World Health Assembly (WHA) in 1981 to reduce inappropriate marketing and protect breastfeeding. Yet the marketing and influencing continue. This scoping review systematically examined the published research evidence on the nature and extent of exposure to International Code violations from 1981 to August 2021. We used several search strategies involving multi‐language databases, organization websites, citation tracking, and expert consultation, to find research items meeting our inclusion criteria. We evaluated 657 items and retained 153 studies from at least 95 countries in the review. The majority of the studies (n = 113) documenting exposure to inappropriate marketing were published since 2010. Studies reported a broad range of marketing violations targeting mothers and families, health workers, and the general public. Marketing via digital platforms and brand extension has become more frequent. The evidence shows the use of misleading and inaccurate labeling and health and nutrition claims in breach of the Code. Our review confirms that violations of the Code have not ceased and calls for renewed attention from the WHA and national governments to protect the health of children and their mothers.

Introduction Recommendations for the clinical management of new mothers with suspected or confirmed COVID-19 and their infants are required. Guidance must weigh the risk posed by transmission of SARS-CoV-2 against the protection that maternal proximity and breastfeeding provide infants. Our aim was to review international COVID-19 guidance for maternal and newborn care, assessing alignment with WHO recommendations and the extent to which policy supported or undermined breastfeeding. Methods Guidance documents from 33 countries on the care of infants whose mothers were suspected or confirmed as having COVID-19 were assessed for alignment with WHO recommendations regarding: (1) skin-to-skin contact; (2) early initiation of breastfeeding; (3); rooming-in; (4) direct breastfeeding; (5) provision of expressed breastmilk; (6) provision of donor human milk; (7) wet nursing; (8) provision of breastmilk substitutes; (9) psychological support for separated mothers; and (10) psychological support for separated infants. Results Considerable inconsistency in recommendations were found. Recommendations against practices supportive of breastfeeding were common, even in countries with high infant mortality rates. None of the guidance documents reviewed recommended all aspects of WHO guidance. The presence of influential guidance conflicting with WHO recommendations and an undervaluing of the importance of maternal proximity and breastfeeding to infant health appeared to contribute to this poor alignment. Conclusion Those developing guidance in the COVID-19 pandemic and other infectious disease outbreaks need to appropriately consider the importance of skin-to-skin contact, early initiation of breastfeeding, rooming-in and breastfeeding to maternal and infant physical and psychological health. In weighing the value of recommendations of others in future guidance development, countries should consider past reliability and value placed on breastfeeding. Recommendations against maternal proximity and breastfeeding should not be made without compelling evidence that they are necessary, and less harmful than maintaining dyad integrity.

Background: The promotion of breastmilk substitutes (BMS) is an important barrier to successful breastfeeding. Objective: To examine the enactment and implementation of the Code of Marketing of Breast-Milk Substitutes (the Code) in Vietnam with a focus on marketing practices by the baby food industry and perceptions of caregivers, health workers, and policy makers. Methods: From May to July 2020, we conducted a mixed-method, cross-sectional study including a survey of 268 pregnant women and 726 mothers of infants aged 0–11 months and in-depth interviews with a subset of interviewed women (n = 39), policy makers, media executives, and health workers (n = 31). Results: In the previous 30 days, two mothers (out of 726) participating in the quantitative survey reported that health workers had recommended BMS, at private hospitals in both cases. In-depth interviews with health workers showed that hospitals have internal procedures to prevent the promotion of BMS by health workers. However, companies employed representatives to promote products not covered under the Code (e.g., commercial milk formula for pregnant women) at antenatal care visits and by gaining contact information from women and using this information to promote BMS outside the hospital, often on social media. In the 30 days preceding the survey, one-fifth of pregnant women were exposed to promotions of commercial milk formula for pregnant women and 7.1% to promotions of BMS. Among mothers of infants, 7.3% and 10.7% of respondents with infants aged 0–5 and 6–11 months, respectively, were exposed to some form of BMS promotion in the past 30 days. Around the time of birth, parents commonly brought BMS to maternity facilities (52.5%) or purchased it nearby (35.4%). Conclusions: Although Vietnam has a strong regulatory environment for the protection, promotion, and support of breastfeeding, there are implementation, monitoring, and enforcement gaps. Stronger enforcement of national policies to regulate the presence of BMS industry representatives in health facilities—both public and private—and the promotion of BMS products on digital platforms are needed.

Maternity protection is a normative fundamental human right that enables women to combine their productive and reproductive roles, including breastfeeding. The aim of this study is to examine the uptake of Vietnam’s maternity protection policy in terms of entitlements and awareness, perceptions, and gaps in implementation through the lens of formally employed women. In this mixed methods study, we interviewed 494 formally employed female workers, among whom 107 were pregnant and 387 were mothers of infants and conducted in-depth interviews with a subset of these women (n = 39). Of the 494 women interviewed, 268 (54.3%) were working in blue-collar jobs and more than 90% were contributing to the public social insurance fund. Among the 387 mothers on paid maternity leave, 51 (13.2%) did not receive cash entitlements during their leave. Among the 182 mothers with infants aged 6–11 months, 30 (16.5%) returned to work before accruing 180 days of maternity leave. Of 121 women who had returned to work, 26 (21.5%) did not receive a one-hour paid break every day to express breastmilk, relax, or breastfeed, and 46 (38.0%) worked the same or more hours per day than before maternity leave. Although most women perceived maternity leave as beneficial for the child’s health (92.5%), mother’s health (91.5%), family (86.2%), and society (90.7%), fewer women perceived it as beneficial for their income (59.5%), career (46.4%), and employers (30.4%). Not all formally employed women were aware of their maternity protection rights: women were more likely to mention the six-month paid maternity leave (78.7%) and one-hour nursing break (62.3%) than the other nine entitlements (2.0–35.0%). In-depth interviews with pregnant women and mothers of infants supported findings from the quantitative survey. In conclusion, although Vietnam’s maternity protection policy helps protect the rights of women and children, our study identified implementation gaps that limit its effectiveness. To ensure that all women and their families can fully benefit from maternity protection, there is a need to increase awareness of the full set of maternity entitlements, strengthen enforcement of existing policies, and expand entitlements to the informal sector.

Background: In March 2020, the World Health Organization (WHO) published clinical guidance for the care of newborns of mothers with COVID-19. Weighing the available evidence on SARS-CoV-2 infection against the well-established harms of maternal-infant separation, the WHO recommended maternal-infant proximity and breastfeeding even in the presence of maternal infection. Since then, the WHO’s approach has been validated by further research. However, early in the pandemic there was poor global alignment with the WHO recommendations.Methods: We assessed guidance documents collected in November and December 2020 from 101 countries and two regional agencies on the care of newborns of mothers with COVID-19 for alignment with the WHO recommendations. Recommendations considered were: (1) skin-to-skin contact; (2) early initiation of breastfeeding; (3) rooming-in; (4) direct breastfeeding; (5) provision of expressed breastmilk; (6) provision of donor human milk; (7) wet nursing; (8) provision of breastmilk substitutes; (9) relactation; (10) psychological support for separated mothers; and (11) psychological support for separated infants.Results: In less than one-quarter of country guidance were the three key breastfeeding facilitation practices of skin-to-skin contact, rooming-in, and direct breastfeeding recommended. Donor human milk was recommended in under one-quarter of guidance. Psychological support for mothers separated from their infants was recommended in 38%. Few countries recommended relactation, wet nursing, or psychological support for infants separated from mothers. In three-quarters of country guidance, expressed breastmilk for infants unable to directly breastfeed was recommended. The WHO and the United Kingdom’s Royal College of Obstetricians and Gynecologists were each cited by half of country guidance documents with the United States Centers for Disease Control and Prevention directly or indirectly cited by 40%.Conclusion: Despite the WHO recommendations, many COVID-19 maternal and newborn care guidelines failed to recommend skin-to-skin contact, rooming-in, and breastfeeding as the standard of care. Irregular guidance updates and the discordant, but influential, guidance from the United States Centers for Disease Control may have been contributory. It appeared that once recommendations were made for separation or against breastfeeding they were difficult to reverse. In the absence of quality evidence on necessity, recommendations against breastfeeding should not be made in disease epidemics.

Commercial milk formula for pregnant women (CMF-PW) is an expensive, ultra-processed food with a high concentration of sugar, the consumption of which may be linked to negative health outcomes. However, CMF-PWs are promoted as beneficial for pregnant women and lactating mothers as well as their children. To date, little is known about the factors associated with the use of CMF-PW among pregnant women. We performed this analysis to examine the association between the use of CMF-PW and related beliefs and norms among pregnant women in Vietnam. We interviewed 268 pregnant women in their second and third trimesters from two provinces and one municipality representing diverse communities in Vietnam. Multinomial (polytomous) logistic regression, structural equation modeling (SEM), and propensity score matching (PSM) analysis were used to examine associations between beliefs and social norms related to CMF-PW and reported consumption, characterized as occasional, recent, and never during the current pregnancy. Overall, 64.6% of pregnant women reported using CMF-PW during the current pregnancy and 34.7% consumed CMF-PW on the day prior to the interview. Strong beliefs that CMF-PW will make a child smart and healthy (53.7%) and the perception that use of CMF-PW is common (70.9%) were associated with increased use on the previous day (beliefs: aOR: 3.56; 95% Confidence Interval (95% CI): 1.65, 7.71; p < 0.01 and social norms aOR: 2.29; 95% CI: 1.13, 4.66; p < 0.05). SEM and PSM analyses confirmed these findings for both occasional and regular CMF-PW use. Results are consistent with observations of CMF-PW product labels and marketing tactics in Vietnam. The prevalent use of CMF-PW in Vietnam is associated with the belief that these products make children smart and healthy and the perceived social norm that most mothers use these products, which mirrors marketing messages and approaches employed by the CMF industry.