Knowledge of the International Code of Marketing of Breast-milk Substitutes among maternal and child health professionals in Spain: a nationwide cross-sectional study

Abstract

The International Code of Marketing of Breast-milk Substitutes protects breastfeeding by restricting inappropriate promotion. This study assessed knowledge, attitudes and perceived compliance with the Code among maternal and child health professionals in Spain. A nationwide cross-sectional online survey was conducted from January to June 2025 among professionals caring for pregnant women, mothers, newborns, infants or children. Descriptive statistics and 95% Wilson confidence intervals were calculated. Subgroup comparisons by profession, prior Code-specific training and Baby-Friendly Hospital Initiative (BFHI) accreditation used Pearson’s chi-square or Fisher’s exact test, with Newcombe-Wilson confidence intervals. Multivariable logistic regression models were fitted to estimate adjusted associations with four pre-specified outcomes. 673 professionals participated; 89.0% were women and 96.1% worked in the public sector. Most correctly identified the Code’s main objective (77.7%), and the prohibition of free samples (87.8%); whereas 42.5% selected the comprehensive products option including infant formulae, weaning cereals, follow-on milks, feeding bottles, dummies and teats. Only 28.1% perceived full workplace compliance. In multivariable logistic regression, prior Code-specific training was the variable most strongly and consistently associated with all four modelled outcomes (adjusted OR 6.94 for correct identification objective; 3.50 for prohibition of free samples; 1.55 for perceived full compliance; 2.05 for maximum valuation of compliance). Working in a BFHI-accredited centre was independently associated with the latter three outcomes (adjusted OR 2.28, 2.62 and 1.71, respectively). In this self-selected, predominantly female nationwide sample, Spanish maternal and child health professionals showed good Code knowledge, but important gaps remained regarding product scope and workplace implementation. Code-specific education, BFHI accreditation and stronger institutional enforcement may strengthen breastfeeding protection. Not applicable.