The Level of Awareness and Compliance of the Milk Code Among Nurses in a

Tertiary Hospital in Manila: Basis for Information Enhancement Packet

A Thesis Presented to the Faculty of

Universidad De Manila
College of Health Sciences
Department of Nursing

In Partial Fulfillment for the requirements for the Degree of Bachelor of Science in
Nursing

Submitted by:
Aluarte, Elaine S.
Cajayon, Leny Rose L.
De Castro, Krizhia Elaine R.
De Jesus, Hazel C.
Dimaporo, Ana Merrynisah C.
Fernandez, Juko A.
Gomez Jr, Joel H.
Osorio, Monica A.
Sioson, Patricia Ysabel V.
Sulbiano, Maridel H.
NR- 31

Submitted to:
Sheryl H. Ramirez RN, MAN
Adviser

CHAPTER I
INTRODUCTION
Background of the Study
A Mother that whole-heartedly care for her child perform a proper and appropriate
breast feeding. Breast milk supplies the ideal nutrition for infants that has a perfect mix of
vitamins, proteins, fats and antibodies needed for every feeding during their infancy to
toddler stage, to protect their immunity and provide adequate nourishment. World Health
Organization contrive a policy framework for breastfeeding promotion adopted in World
Health Assembly in 1981 entitled as International Code for marketing of Breast Milk
Substitute to comply with the mandated code Department of Health of the
Philippinesestablished an Executive Order No. 51 also known the Milk Code in year
1986 aims that Every mother has a right to breastfeed and every child has a right to be
breastfed. No less than the Philippines's Supreme Court has acknowledged that "the best
nourishment for an infant is mother's milk. There is nothing greater than for a mother to
nurture her beloved child straight from her bosom. The ideal is, of course, for each and
every Filipino child to enjoy the unequaled benefits of breast milk.
The Milk Code or Executive Order No. 51, signed by then president Corazon
Aquino in 1986, is the law that protects and promotes breastfeeding in the Philippines.
The aim of the Code is to contribute to the provision of safe and adequate nutrition for
infants by the protection and promotion of breast feeding and by ensuring the proper use
of breast milk substitutes and breast milk supplements when these are necessary, on the
basis of adequate information and through appropriate marketing and distribution. The
Code applies to the marketing, and practices related thereto, of the following products:

breast milk substitutes, including infant formula; other milk products, foods and
beverages, including bottle-fed complementary foods, when marketed or otherwise
represented to be suitable, with or without modification, for use as a partial or total
replacement of breast milk; feeding bottles and teats. It also applies to their quality and
availability, and to information concerning their use. It regulates the industry of formula
milk and other milk products. While the Philippines has apparently one of the best
regulatory policies that protect breastfeeding, there are many challenges besetting the
Milk Code, such as court battles between the government and multinational milk
companies. The most recent of these are bills passed in both houses of Congress with
amended provisions relaxing the regulatory policy, and the attempt to lift the ban on milk
donations during the Yolanda relief response at the tail-end of 2013.
The present study seeks to determine the level of awareness and compliance of
Milk Code among staff nurses in selected tertiary hospital in Manila because the
researchers believe that the success of the Milk Code resides in the hands of those people
who actually implement it in the field of health providers specifically the nurses.
Furthermore, it will determine the efficiency of practice for the nurses in implementing
and promoting the milk code by the guide of articles and provisions of Executive Order
No. 51. As an output of this study the nurses will benefit by having a deeper
understanding of the milk code therefore, secures the health of those infants.

Statement of the Problem

This study aims to determine the level of awareness and compliance of Milk
Code among nurses in a tertiary hospital in Manila.
1.What is the demographic profile of the respondents in terms of:
1.1 Gender
1.2 Length of Experience
2.What is the level of awareness of the respondents on the Milk Code?
3.What is the level of compliance of the respondents on the Milk Code?
4. Is there a significant relationship between the level of awareness and compliance of the
respondents on the Milk Code?
5. Based on the results of the study, what information package can be proposed to
enhance their awareness and compliance towards Milk Code.
Hypothesis:
There is no significant relationship between the level of awareness and
compliance of the respondents on the Milk Code.

Theoretical Framework
Systems theory or systems science is the interdisciplinary study of systems in
general, with the goal of discovering patterns and elucidating principles that can be
discerned from and applied to all types of systems at all nesting levels in all fields of
research. The term originated The term from Bertalanffy's general system theory (GST)
and is used to refer specially to self-regulating mechanism that are self-correcting through
feedback. Self-regulating system are found in nature including the physiological system
of our body, in local and global ecosystem, in climate and in human learning process.
These ideas refer to an organized body of knowledge and any systematically presented set
of concepts, whether empirically, axiomatically or philosophically represented. Early
investigators used the term system theory to refer to the interdependence of relationships
created in organizations by defining a new way of thinking about science and scientific
paradigms (Bertalanffy, 1950 as cited by R.Stitchweh 2011).
System theory is also the transdisciplinary study of the abstract organization of
phenomena, independent of their substance, type, spatial or temporal scale of existence
(Littlejohn, S.W. 2001). It investigates both the principles common to all complex entities
and the models which can be used to describe them. A system consists of four elements.
The first is objects-the parts elements, or variables within the system. These may be
physical or abstract or both depending on the nature of the system. Second, a system
consists of attributes the qualities or properties of the system and its objects. The
internal relationships within the system are the third object. Lastly, systems exist in an

environment. The parts of the system affect one another within an environment and form
a larger pattern that is different from any of the parts.
The fundamental systems called interactive paradigm features the continual stages
of input, throughput (processing), and output, which demonstrate the concept of
openness/closeness. A closed system does not interact with its environment. It does not
take in information and therefore is likely to atrophy or vanish. An open system receives
information to interact dynamically with its environment. Openness increases the systems
likelihood to survive and prosper. Several system characteristics are: wholeness and
interdependence, correlations, perceiving causes, chain of influence, hierarchy,
suprasystems and subsystems, self-regulation and control, goal-oriented, interchange with
the environment, inputs/outputs, the need for balance/homeostasis, change and
adaptability (morphogenesis) and equifinality. Every system has an input that enters the
system from the outside. Process converts the input into a final product known as the
output. A system may be evaluated by determining if the output results in the
achievement of the objective. An effective and efficient systems need a feedback
mechanism that can ascertain whether the output of system is what it should be. If not, a
system should have the ability to adjust its input or process to improve the output. An
ideal system is self-regulating and has a feedback mechanism (Bertalanffy, 1950 as cited
by R.Stitchweh 2011).

The paradigm shows three (3) phases the input, process and output. The health
promotion of Nola J. Pender, serve as the theoretical foundation of this study. The
researchers conduct a study in tertiary hospital in Quirino, Manila while the respondents
are nurses with at least 1-year hospital experienced. Their gender and length of
experience is the input of researchers as the demographic data of respondents.
In the process, the researchers made a questionnaire to gather data from the
respondents that can be analyze and gathered data relevant to the topic under. Upon
conducting the questionnaire, it is subjected for validation by the expert for content
validity. After validation pilot testing was done in 10 nurses. The result of the pilot testing
was tallied for Cronbach alpha. After the approval, the researchers start giving a
questionnaire in different wards compose of obstetrics ward, neonatal intensive care unit,
pediatric ward, pediatric intensive care unit, pediatric and obstetrics emergency room,
pediatric and obstetrics outpatient department. The data collected were tabulated and
analyzed accordingly to the result of the tally, statistical treatment and survey
questionnaire of the study. The researchers use the frequency distribution for a
demographic data of the respondents and Pearson r for the relationship between the level
of awareness and compliance of milk code. And the researchers also use a four-point
scale adapted to Likert scale to determine the measurement of the answer of the
respondents.
The researchers create a fan with the content of milk code and distributed to the
nurses in tertiary hospital. The information packet has an essential part of the

interconnected activities that determines the product of our research. The purpose of the
fan is to spread or elaborate the deeper information about milk code.
Executive order no.51 that also called milk code the aim of this code is to
contribute the provision of safe and adequate nutrition for infants by the protection and
promotion of breastfeeding and by ensuring the proper use of breast milk substitutes and
breast milk supplements when these are necessary, on the basis of adequate information
and through appropriate marketing and distribution.

Research Paradigm

Input
The Demographic
Data of the
Respondents:
- Gender
- Length of
experience

Figure 1: The Level of

the Milk Code Among Nurses
Manila.
-

Significance of the Study

Process
Research Tool
Development
Validation
Pilot testing
Questionnaire
administration
Collation and
Tabulation data
Statistical
Treatment
Analysis of level
of awareness and
compliance of the
respondents.
Reporting

Output
Enhancement
Information
Packet

Awareness and Compliance of

in a Tertiary Hospital in

This study will be beneficial to the following:

Nursing Student: The result of study will give additional knowledge to polish their
learned principles and experience to implement the said law, also for the preparation in
becoming staff nurses in hospitals.
Registered Nurses:The study shall provide a concrete reference and planning framework
for effective design, to develop supportive intervention and implementation of the health
programs concerning Milk Code and breastfeeding mothers to childs health.
Breastfeeding/PregnantMothers:The result of study will give additional knowledge
about the importance of the Milk Code, provides information about benefits and
importance to the mothers to practice breastfeeding and to be practical in providing
adequate nutrition for their infants with support of fathers.
Infants: The output of this study will help and secure the adequate nutrition for infants.
These promote healthy growth for babies, protects against sickness, allergies, obesity,
infection like ear infection, easily digested no constipation, diarrhea or upset stomach
and raises IQ tests.

Definition of Terms

Breastfeeding: Is the normal way of providing young infants with the nutrients they need
for healthy growth and development.
Breast milk: Human milk contains a balance of nutrients that closely matches infant
requirements for brain development, growth and a healthy immune system.
Bottle feeding: The practice of feeding an infant using a bottle and substitute
for breast milk.
Hospital: Refers to the public tertiary hospitals were the study will be conducted in the
city of Manila
Registered Nurses: Refers to the participant of the study which has at least 1-year and
above hospital experience and as the promoter of the Milk Code.
Awareness: Refers to the knowledge or perception of the staff nurses specifically the
milk code.
Compliance: Refers to the practice of staff nurses on the Milk Code.
Packet: Refers to a fan with an essential part of the interconnected activities,
information, importance and prohibitions that spread and elaborate the content of Milk
Code

Scope and Delimitation

The study will focus on the level of awareness andcompliance of Milk Code
among the nurses in a tertiary hospital. The participants of this study are the nurses with
at least 1-year hospital experience that is designated in different department compose of
Pediatric Intensive Care Unit, Pediatrics, Obstetrics and Gynecology, Neonatal intensive
care unit, Out Patient Department and Pediatric Emergency Room in a tertiary hospital.
The study conducted in June to August of 2016 at the hospital that is located inQuirino,
Manila. The researchers will provide letter of consent to the administrators of the
institution to ask for their permission in conducting and participating in the study.

CHAPTER II

REVIEW OF RELATED LITERATURE AND STUDIES

This chapter presents the related literature and studies after the thorough and indepth search done by the researchers. This will also present the synthesis of the art,
theoretical and conceptual framework to fully understand the research to be done.
Foreign Literature
International Code of Marketing of Breast-Milk Substitutes
The 27th World Health Assembly in 1974 noted the general decline in
breastfeeding related to different factors including the production of manufactured breastmilk substitutes and urged Member countries to review sales promotion activities on baby
foods and to introduce appropriate remedial measures, including advertisement codes and
legislation where necessary it continues in in May 1980 when 33rd World Health
Assembly, endorsed in their entirety the statement and recommendations agreed by
consensus at this joint WHO/UNICEF meeting and made particular mention of the
recommendation that "There should be an international code of marketing of infant
formula and other products used as breast-milk substitutes".In May 1981 the Health
Assembly debated the issue after it had been introduced by the representative of the
Executive Board. It adopted the code, as proposed, on 21 May by 118 votes cited on
(WHO, 1981).

Awareness to International Code

The 427 health workers interviewed, the majority were not aware of the national
breastfeeding law or the International Code Pediatricians, and staff who had been
working for 10 years or more, were more likely to be aware of the law (Mihretab, Brian,
2008).
Practices in International Code
The health authorities and Hospitals in Member States should take appropriate
measures to encourage and protect breast-feeding and promote the principles of this
Code, and should give appropriate information and advice to health workers in regard to
their responsibilities. No facility of a health care system and hospitals should be used for
the purpose of promoting infant formula or other products within the scope of the
International Code of marketing of breast feeding substitutes (WHO, 1981).
Compliance to International Code
Only 37 countries, or the 19% of those reporting, have passed laws reflecting all
the recommendation of the International Code of Marketing Breast-Milk Substitutes
compose of 13 countries in Africa, 8 in America, 7 in East Mediterranean, 2 in Europe, 4
in South East Asia, 3 in Western Pacific according to a new WHO report published during
World Breastfeeding Week. In World Breastfeeding Week 2013, WHO and partners are
calling for more support for breastfeeding mothers. Breastfeeding has to be learned and
many women encounter difficulties at the beginning. Nipple pain and fear that there is not
enough milk to sustain the baby are common. Health facilities that support breastfeeding
by making trained breastfeeding counselors available to new mothersencourage

higher rates of the practice. To provide this support and improve care for mothers and
newborns, there are "baby-friendly" facilities in more than 150 countries, thanks to the
WHO-UNICEF Baby-Friendly Hospital initiative (WHO, 2013).
International Code Violation
It was found that 26% of mothers in Bangkok received free samples of breast
milk substitutes, infant formula, bottles, or nipples compared with 1/385 mothers in
Dhaka. 8-50% of health facilities received free samples that were not being used for
research or professional evaluation. 2-18% of health workers received gifts from
companies involved in the manufacturing or distribution of breast milk substitutes.
Information provided by companies that violated the code was available to staff in 1556% of the health facilities. It was concluded that the simple methodology developed for
this study is adequate for use by governments and nongovernmental organizations
monitoring compliance with the code and that such monitoring is essential in light of the
violations uncovered (Taylor,1998).
Almost all health workers (100%) contacted by a sales representative reported
having received a gift. This is violation of the Code that prohibits distributors or
manufacturers from providing gifts to health workers. Also, 72% of health workers
indicated that they were asked to promote breastmilk substitutes. This is a violation of the
Codes which states that no financial or material inducements to promote products within
the scope of the Code should be provided by manufacturers or distributors to health
workers. At the same time, health workers have an obligation to protect and promote

breastfeeding and should not accept gifts from manufacturers or distributors (UNICEF,
2013).
Many respondents reported having received gifts from the sales representatives of
infant formula companies. Pens, T-shirts and free samples were the most common
violations. Eight health care workers received free samples which were not for the
purpose of professional evaluation or research at the institutional level. In total, five
shopkeepers and one mother reported promotion through provision of incentives, namely,
Buy two boxes, get one free. Some gifts or practices could not be related to violations
(books or brochures, glasses or posters for example) due to insufficient documentation.
The name of the sales representatives who provided the gifts and the brands of the gifts
were not recorded(Lao, 2013).
Six (14%) health facilities had received donations of breast milk substitutes. All
donations were being given to mothers free of charge. Health providers in five (12%)
health facilities had received free samples of breast milk substitutes for purposes other
than professional research or evaluation. Health professionals in five (12%) health
facilities had received promotional gifts from manufacturers. Promotional materials of
commercial breast milk substitutes were found in seven (16%) health facilities. Special
displays to market commercial breast milk substitutes were found in 29 (44%) sales and
distribution points. Forty commercial breast milk substitutes violated the labelling
standards of the code: 21 were manufactured by Danone, 11 by Nestl, and eight by other
national and international manufacturers. Most (148, 90%) health providers had never

heard of the code, and 66 mothers (63%) had never received any counselling on breast
feeding by their health providers (Aguayo , Ross, Kanon, Ouedraogo,2003).
Gender
Nursing is one of the highest demanded and fastest growing profession in the
United States. Over 2,881,595 nurses population working in the United States, females
are dominant than males in relation of nursing profession. Women got the ninety-four
point two percent (94.2%) and men obtained five point eight percent (5.8%) (Okla,
Payton et. Al., 2012).
It is not so common to have a male nurse or midwife in obstetrics and
gynecology area. This might be due to rejectionduring maternity rotations in the
institution, genderdiscrimination, poor networking, or just a lack of interesting in this
area. Male nurses have been practicing for a longtime in neonatal intensive care
units, but when they wantto practice in obstetrics and gynecology, even if they
arequalified, they are barred due to gender bias (Cud & Winfrey, 2007).
Breastfeeding
Health organizations, including the World Health Organization, recommend
feeding for six months only through breastfeeding. This means that no other foods or
drinks other than vitamin D are typically given. Continued partial breastfeeding until at
least one year of age is then recommended. Globally about 38% of infants are only
breastfed during their first six months of life. In the United States, about 75% of women
begin breastfeeding and about 13% only breastfeed until the age of six months. Medical

conditions that do not allow breastfeeding are uncommon. Mothers who take recreational
drugs and certain medications should not breastfeed (WHO, 2007).
Babies naturally follow a process which leads to a first breastfeed. Initially after
birth the baby cries with its first breaths. Shortly after, it relaxes and makes small
movements of the arms, shoulders and head. The baby crawls towards the breast and
begins to feed. After feeding, it is normal for a baby to remain latched to the breast while
resting. This is sometimes mistaken for lack of appetite. Absent interruptions, all babies
follow this process. Rushing or interrupting the process, such as removing the baby to
weigh him/her, may complicate subsequent feeding. Activities such as weighing,
measuring, bathing, needle-sticks, and eye prophylaxis wait until after the first
feeding."UNICEF (2008).
World Health Organizationmanual for physicians and senior health workers citing
a 1992 source states: "If a baby has been breastfeeding sometimes, the breastmilk supply
increases in a few days. If a baby has stopped breastfeeding, it may take 1-2 weeks or
more before much breastmilk comes." (WHO, 1992).
Exclusive breastfeeding until the age of 4 months and partially thereafter was associated
with a significant reduction of respiratory and gastrointestinal morbidity in infants. Our
findings support health-policy strategies to promote exclusive breastfeeding for at least 4
months, but preferably 6 months, in industrialized countries.(Duijts, Jaddoe, Hofman,
Moll, 2010).

Breastfeeding, particularly when exclusive and prolonged, protects against severe

morbidity in contemporary United Kingdom. In our study, only 1.2% of infants were
exclusively breastfed for at least 6 months, and the protective effects of breastfeeding
were large; a population-level increase in exclusive, prolonged breastfeeding would be of
great public health benefit. Our results may be used to estimate the cost-effectiveness of
breastfeeding interventions. Better information on the risks and benefits that are
associated with infant feeding methods, including prolonged and exclusive breastfeeding,
will enable parents to make an informed choice (Maria A. Quigley, Yvonne J. Kelly,
Amanda Sacker, 2007).
Breastfeeding is associated with a reduction in risk for postneonatal death. This
large data set allowed robust estimates and control of confounding, but the effects of
breast milk and breastfeeding cannot be separated completely from other characteristics
of the mother and child. Assuming causality, however, promoting breastfeeding has the
potential to save or delay ~720 postneonatal deaths in the United States each year
(Chen,Rogani, 2003).
Contraindications in Breastfeeding
Milk quality may be compromised by smoking, caffeinated drinks, marijuana,
methamphetamine, heroin and methadone. However, the American Academy of
Pediatrics (AAP) states that "tobacco smoking by mothers is not a contraindication to
breastfeeding. In addition, AAP states that while breastfeeding mothers "should avoid
the use of alcoholic beverages", an "occasional celebratory single, small alcoholic drink
is acceptable, but breastfeeding should be avoided for 2 hours after the drink. A 2014

review found that "even in a theoretical case of binge drinking, the children would not be
subjected to clinically relevant amounts of alcohol [through breast milk]", and would
have no adverse effects on children as long as drinking is occasional (AAP, 2014).
Experienced breastfeeding mothers learn that the sucking patterns and needs of
babies vary. While some infants' sucking needs are met primarily during feedings, other
babies may need additional sucking at the breast soon after a feeding even though they
are not really hungry. Babies may also nurse when they are lonely, frightened or in pain.
Comforting and meeting sucking needs at the breast is nature's original design. Pacifiers
(dummies, soothers) are a substitute for the mother when she cannot be available. Other
reasons to pacify a baby primarily at the breast include superior oral-facial development,
prolongedlactation amenorrhea, avoidance of nipple confusion, and stimulation of an
adequate milk supply to ensure higher rates of breastfeeding success.(La Leche League
International, 2006).
Factors affecting Breastfeeding
Modifiable factors that influence women's breastfeeding decisions are:
breastfeeding intention, breastfeeding self-efficacy and social support. Existing
midwifery breastfeeding promotion strategies often include social support but do not
adequately address attempts to modify breastfeeding intention and self-efficacy
(Meedya , Kable 2010).
The major socio-demographic factors that affect prolonged breastfeeding
behaviors are: age, marital status, education and income level.8, 9 and 10 There is strong
evidence that older age,8, 9, 10, 11, 12 and 13 being married,8, 9, 14 and 15 being well

educated8, 9, 10, 13 and 16 and a higher income8, 9 and 10 are each associated with
longer breastfeeding duration. These factors are not amendable to change by midwives
once the woman is pregnant. Knowing that successful long term breastfeeding is less
likely to be achievable for young, poorly educated, unmarried and lower income mothers
helps midwives to focus their education and support for these groups of women
(Meedya , Kable 2010).
Local Literature
The Milk Code
An overview of the Philippines experience in regards to Code enforcement.
According to Mendoza, the Philippines had a particularly varied experience in Code
enforcement. The Philippines adopted the Code by executive order into law in 1986.
However, the Code was not fully implemented: it did not include an absolute prohibition
on advertising and marketing of breast-milk substitutes. According to Mendoza, formula
companies undertook aggressive promotion of formula. There appeared to be a decline in
breastfeeding: Mendoza cites a 2003 survey reported 16 percent of babies born in the
Philippines were exclusively breastfed after four to five months, the lowest rate among 56
countries in a 10-year period. In the mid-2000s, the government responded with a range
of measures including a tightening of the 1986 regulation to include both infants and
young children, prohibited any form of marketing of breast-milk substitutes and
supplements, created additional labeling requirements, and allowed departments to levy
sanction on offenders (Mendoza, 2003).

To support the Milk Code, in the year of 1992 Pres. Aquino signed the Republic
Act. No. 7600 the law known as the The Rooming-In and Breastfeeding Act of 1992 to
encourage, protect and support the practice of breast feeding.
In year of 2010 another act is constructed and signed by Pres. Gloria-Macapagal
Arroyo in addition to support the expanded promotion of breastfeeding, amend for the
purpose republic act no. 7600, otherwise known as "an act providing incentives to all
government and private health institutions with rooming-in and breastfeeding practices
and for other purposes" Expanded Breastfeeding Promotion Actof 2010
Department of Health (DOH) launched the exclusive breastfeeding campaign
dubbed Breastfeeding TSEK: (Tama, Sapat, Eksklusibo). The primary target of this
campaign is the new and expectant mothers in urban areas. This campaign encourages
mothers to exclusively breastfeed their babies from birth up to 6 months. Exclusive
breastfeeding means that for the first six months from birth, nothing except breast milk
will be given to babies. Moreover, the campaign aims to establish a supportive
community, as well as to promote public consciousness on the health benefits of
breastfeeding. Among the many health benefits of breastfeeding are lower risk of
diarrhea, pneumonia, and chronic illnesses (DOH, 2011).
Practices in Milk Code
In accordance to their program known as The Mother-Baby Hospital Initiative
pursuant to R.A 7600 breastfeeding should be done within one hour after birth for normal
spontaneous delivery and for caesarean sections deliveries, 3-4hrs after birth (Department
of Health, 1992).

As mandated that all health and non-health facilities, establishments or

institutions shall establish lactation stations. The lactation stations shall be adequately
provided with the necessary equipment and facilities, such as: lavatory for hand-washing,
unless there is an easily-accessible lavatory nearby; refrigeration or appropriate cooling
facilities for storing expressed breastmilk; electrical outlets for breast pumps; a small
table; comfortable seats; and other items, the standards of which shall be defined by the
Department of Health. The lactation station shall not be located in the toilet. In addition,
all health and non-health facilities, establishments or institutions shall take strict
measures to prevent any direct or indirect form of promotion, marketing, and/or sales of
infant formula and/or breast milk substitutes within the lactation stations, or in any event
or circumstances which may be conducive to the same. Apart from the said minimum
requirements, all health and non-health facilities, establishments or institutions may
provide other suitable facilities or services within the lactation station (R.A 10028 ,2010).
The Capitol Medical Center has committed itself to the delivery of quality health
care services to all mothers and their newborn babies by performing regular lectures
during the third Wednesday of each month are given by members of the Breastfeeding
and Lactation Committee to pregnant women who are on their last trimester of pregnancy
to prepare them and make them aware of the advantages of early, prolonged and
exclusive breastfeeding and rooming-in as are implemented in the institution. Lactation
Committee spearheaded by the Department of Obstetrics and Gynecology and the
Department of Pediatrics with help from the Nursing Staff Office and MEPDE. Hospital
Policies on Breastfeeding and Rooming-in were reviewed, revised and updated by the

committee to conform with the DOH policies. Activities to heighten awareness and
deepen

the

understanding

of

the

importance

of

breastfeeding

were

also

undertaken. Hospital staff undergoes training on these subjects on a regular basis. Capitol
Medical Center (CMC, 2015).
Milk Code Compliance
The World Health Organization said a study has found that Filipino mothers who
have been influenced by advertisements or their doctors to use infant formula are two to
four times more likely to feed their babies with those products.
The study appears to support the Philippines decision to limit advertising for
infant formula, which can discourage mothers from breast-feeding that provides health
benefits for newborns.
Published by the Social Science and Medicine Journal in September and released
this week, the study said those mothers were 6.4 times more likely to stop breast-feeding
babies within one year of age a step that raises risks of illness and death for the infant.
Breast milk significantly reduces infant mortality, according to international
health experts, who recommend that mothers exclusively breast-feed for the first six
months and continue breast-feeding, supplemented by solid foods, until their babies are 2
years old.
The International Code of Marketing of Breast-Milk Substitutes, sponsored by the
World Health Organization and UNICEF, is not legally binding. It is up to individual
countries to implement the code by enacting their own laws.

The Philippine study wanted to examine if marketing for breast milk substitutes
was to blame for a drop in breast-feeding in the Southeast Asian country, one of several
where multinational companies fought a legal battle for the right to aggressively sell baby
formulas.
When the Philippine government tried to tighten its advertising laws for milk
products, the companies took it to court.
The Supreme Court ruling in October 2007 upheld the Department of Healths
mandate to regulate advertising of breast milk substitutes. It prohibited all health and
nutrition claims but failed to support a full advertising ban, citing freedom of speech.
WHO data show exclusive breast-feeding rates for Filipino babies up to four
months old dropped from 47.3 percent in 1998 to 40.1 percent in 2008.
Four of the six authors of the study are from the WHO, led by the organizations
medical officer Howard Sobel. They conducted a household survey between April and
December 2006 and focus groups in April-May 2007.
According to their findings, 59.1 percent of the mothers recalled an infant formula
advertisement message and one-sixth reported a doctor recommended using formula.
Those who recalled an ad message were twice as likely to feed their babies infant
formula, while whos advised by a doctor where four times as likely to do so.
Despite poverty and extra strain on household income associated with formula
use, 41.1 percent of the infants and young children were fed formula, the authors said.
The WHO says addition of formula leads to decreased stimulation from suckling
and its reflex for breast milk production. Not breast-feeding also was associated with a

5.8 times increased risk of all-cause deaths in the first two months of life, with risks
elevated up to the second year, it says.
The authors said that despite the WHOs adoption in 1981 of the International
Code of Marketing Breast Milk Substitutes to curtail unethical marketing promotions,
few countries have fully implemented the codes ban on advertising or other forms of
promotion.
Alex V. Castro III, executive director of the Infant Pediatric Nutrition Association
of the Philippines that groups infant formula makers, said the association fully supports
breast-feeding.
He said their members have been diligently complying with the Philippines
adaptation of the WHOs milk code, including prohibitions in advertising. He said no
advertisement has been allowed without approval of an interagency headed by the
Department of Health.

Synthesis
The World Health Organization published an International Code for Marketing
Breast Milk Substitute to protect the promotion of breast feeding and limit the usage of
substitutes to provide adequate nutrition to the Philippines to comply with the
International code President Corazon Aquino signed the Milk Code, which is a law that
ensures safe and adequate nutrition for infants through the promotion of breastfeeding
and the regulation of promotion, distribution, selling, advertising, product public
relations, and information services artificial milk formulas and other covered products,
under the international code of the WHO entitled as The International Code for
Marketing breastmilk substitute cited on (E.O 51, 2015)
There`s various aspects that can affect the application of Milk Code among staff
nurses in some hospitals including their level of awareness, compliance and practices.
These aspects have highest influenced among nurses in the hospital in applying the law,
WHO data show exclusive breast-feeding rates for Filipino babies up to four months old
dropped from 47.3 percent in 1998 to 40.1 percent in 2008.According to their findings,
59.1 percent of the mothers recalled an infant formula advertisement message and onesixth reported a doctor recommended using formula. Those who recalled an ad message
were twice as likely to feed their babies infant formula, while whos advised by a doctor
where four times as likely to do so.Despite of poverty and extra strain on household

income associated with formula use, 41.1 percent of the infants and young children were
fed formula,
The researchers also found a study that Filipino mothers who have been
influenced by advertisements or their doctors to use infant formula are two to four times
more likely to feed their babies with those products, it signifies the breaching of law by
personnel who actually prefer to promote the Milk Code in the health institutions.
The foreign and local literatures cited and noted have eloquently benefit the
researchers ideas in obtaining better understanding of the sole concept of the study. The
review is integral in determining then direction and interpretation of data will be
collected. Themes from various studies has been applied in research tool development to
make a content more reliable.

CHAPTER III
METHODOLOGY
This chapter presents the method done by the researchers. Composed of research
design, locale, instrumentation, data gathering procedure, population and sampling and
statistical plan to fully extrapolate the research to be done.
Research Design
The researchers utilized the descriptive correlational study which may be defined
that researchers were interested in describing relationships among variables, without
seeking to establish casual connections. The purpose of descriptive studies is to observe,
describe and document aspects of a situation. In a descriptive study, researchers observe,
count, delineate, elucidate and classify quantitative description focuses on the prevalence,
incidence, size and measurable attributes of a phenomenon. (Polit and Beck, 2011) This
will help the researchers to determine the level of awareness and compliance of the Milk
Code among nurses in a tertiary hospital in Manila.
Research Locale
The study was conducted in a tertiary hospital in the city of Manila. The
hospitalcaters manila residents without fee, is a 300 bed non-profit tertiary, general and
training hospital located in Quirino, Manila this institution has composed of Out-patient
department, Emergency department, Ears Eyes Nose Throat Department, Obstetrics and
Gynecology

department,

Pediatric

department,

Medicine

department,

Surgery

department. As hospital operated and maintained through taxes paid by Manila residents.
The hospital has for its primary concern the admission and treatment of patients who are
bona fide residents of the city. Furthermore, it is responsible for the provision of an
integrated community health program and in the promotion of scientific excellence
through research activities.
Population and Sampling Technique
The sampling technique that the researchers used in this study is non-probability
sampling which is rarely representative of the target population. The method of nonprobability sampling used was purposive sampling. Purposive sampling is based on the
belief that researchers knowledge about the population can be used to hand pick the
cases to be included in the sample. Researchers might decide purposely to select the
widest possible variety of respondents or might choose subjects who are judged to be
typical of the population in question or particularly knowledgeable about the issues under
the study. The respondents of the questionnaire are 50 nurses in tertiary hospital that is
included in the study, staff nurses that has at least1-year hospital experience and above.
Nurses who will answer the questionnaire are those assigned in Obstetric Outpatient
department, Obstetrics Emergency Room, Pediatric Ward, Obstetric Ward, Neonatal
Intensive Care Unit, and Pediatric Intensive Care Unit.who cares infants and
breastfeeding babies. Researchers pick staff nurses who have least1-yearof experience
because after at least 1 year of experience in that certain wards they have the complete
concept of breast feeding, researchers wanted to know if 1-year hospital experience is
enough for them to have a complete application of the milk code. Researchers also

wanted to know if nurses who have greater length of experience is more familiar in
application of the Milk Code.

Research Instrumentation
The instrument used for this study is a self-made questionnaire which is a method
of a data collection that asks respondents to give feedback to a written set of questions. A
4. (four-point) scale is used to gather information. The respondents answered a
questionnaire that is utilize and patterned to Likert Scale. The questionnaire consists of an
item that is to determine the awareness and compliance of nurses on the Milk Code. The
first part of the questionnaire deals with the respondents demographic profile such as
gender and length of experience. Part two is a self-structured questionnaire. It is
composed of ten (10) items. The questionnaire is answerable by the following Likert-type
rating scale: (4) extremely aware (3) moderately aware (2) slightly aware (1) not aware at
all; use to measure the level of awareness of the nurse about the milk code. The last part
determines the compliance of nurses about the implementation of the milk code and is
answerable by following rating scale: (4) always (3) seldom (2) rarely (1) never.
The researchers made a questionnaire design to gather responses from the
respondents that can be analyzed and gather data relevant to the topic under study. Upon
constructing the questionnaire, it was subjected for validation by three experts for content
validity. Three medical professionals were sought, these includes the chief nurse,
Obstetric

supervisor

and

Manila

Health

Department

head.

Suggestions

and

recommendation were integrated in the questionnaire. After validation, pilot testing was
conducted to 10 nurses who fits the criteria. The result of the pilot testing was tabulated
for statistical treatment and subjected for Cronbach alpha for the instruments validity and
reliability. The test result yields 0.741 for awarenessand 0.718 for compliance
respectively. Result more than (>) 0.7 is considered valid and reliable.
Data Gathering Procedures
The researcher pursued the study with detailed sequential plan. The data for this
research were collected using a survey questionnaire. The survey was created using a
suitable questions modified from related research and individual questions formed by the
researcher the survey was comprised of 15 questions, which were related to the
participants perception regarding Milk Code. Upon validation of the questionnaires,
revisions were made based on the recommendations of the selected experts. The
researchers seek a permission letter and signed by the dean of the Department of Nursing
together with the advisers approval so that they can start the study. This was followed by
a letter seeking approval from the hospital director to allow us to administer the survey
questionnaire to conduct survey to the tertiary hospital. After the approval the researcher
will go to the different wards composed of Obstetric Outpatient department, Obstetrics
Emergency Room, Pediatric Ward, Obstetric Ward, Neonatal Intensive Care Unit, and
Pediatric Intensive Care Unit. Ask the nurses or the respondents permission if they may
answer the survey questionnaires, then researchers distributed the questionnaires to the
target population and spent some time with the respondents to facilitate the test. Further,
the researchers oriented the respondents about the purpose and mechanics of the study.

The respondents answer without time pressure and were assured of their privacy and
confidentiality regarding their personal information. The information collected were not
made available to others without the consent of the respondents to observe strict
confidentiality. The data were collated, tabulated and analyzed accordingly the result of
the tally, treatment of statistical treatment and survey questionnaire of the study.
Statistical Treatment
To answer question number 1 which is the demographic data of the respondents in
terms ofgender and length of experience, frequency and percentage distribution was
utilized. The sum of number in the frequency column must equal the sample size. In less
verbal terms, f= N, (which means the sum of signified by the Greek letter sigma, ) the
frequencies (f) equals the sample size (N) just as the sum of all frequencies should equal
N, the sum of all percentage should equal 100.
Researchers applied general weighted mean to answer question number 2 and 3
which is the level of awareness and the compliance of the respondents. It constitutes a
hierarchy, with ratio scales at the top and nominal measurement at the base. Moving from
a higher to a lower level of measurement results in an information loss.
Level of awareness and compliance score were represented with the following
qualitative interpretation.
Table1. level of awareness scale category
Scale

Qualitative Interpretation

4.00-3.25

Highly Aware

3.24-2.50

Moderately Aware

2.49-1.75

Slightly Aware

1.74-1.00

Not Aware

Table 2. Compliance Scale Category

Scale
4.00-3.25

Qualitative Interpretation
Highly Compliant

3.24-2.50

Moderately Compliant

2.49-1.75

Slightly Compliant

1.74-1.00

Not Compliant

Pearson correlation coefficient was used to answer question number 4 which is

the difference between the level of awareness and the compliance of the respondents in
milk code. It is a good idea to conduct a Pearson correlation coefficient value to
determine just how strong that relationship is between those two variables. The
coefficient value can range between -1.00 and 1.00. if the coefficient value is in the
negative range, then that means the relationship between two variables is negatively
correlated, or as one value increases, the other decreases. If the value is in the positive
range, then that means that the relationship between the variables are positively
correlated, or both value increase or decrease together.

Nxy (x)(y)
R=

[Nx2 (x)2 ][Ny2 (y)2]

Where:
N = Number of pairs of scores
xy = Sum of the products of paired scores
x = Sum of x scores
y = Sum of y scores
x2 = Sum of squared x scores
y2 = Sum of squared y scores

CHAPTER IV
PRESENTATION, ANALYSIS AND INTERPRETATION OF DATA
This chapter focuses on the presentation of data, statistical analysis, interpretation,
and regarding the relationship between level of awareness and compliance of nurses on
Milk Code. The data collected were subsequently summarized, analyzed and interpreted
with the use of appropriate statistical treatments. The data were presented in figures and
tables to further illustrate the results.

I.
A.

DEMOGRAPHIC DATA

Gender
Male; 26%

Male
Female

Female; 74%

Gender
Figure 2.1: Demographic Profile of the Respondents in terms of Gender
The graph above represents the demographic profile of the Nurses in terms of
gender. As seen in this data, women had seventy-four percent (74%) of the sample size

compare to men, with only twenty-six percent (26%).It indicates that female nurses are
more likely assigned in areas where milk code was implemented.
Nursing is one of the highest demanded and fastest growing profession in the
United States. Over 2,881,595 nurses population working in the United States, females
are dominant than males in relation of nursing profession. Women got the ninety-four
point two percent (94.2%) and men obtained five point eight percent (5.8%) (Okla,
Payton et. Al., 2012).

It is not so common to have a male nurse or midwife in obstetrics and

gynecology area. This might be due to rejectionduring maternity rotations in the
institution, genderdiscrimination, poor networking, or just a lack of interesting in this
area. Male nurses have been practicing for a longtime in neonatal intensive care
units, but when they wantto practice in obstetrics and gynecology, even if they
arequalified, they are barred due to gender bias (Cud & Winfrey, 2007).

B. Length of Experience

Length of Experience
1 year; 8%
1-2 years; 14%
3 years above; 46%

1 year
1-2 years
2-3 years

2-3 years; 32%

3 years above

Figure 2.2: Demographic Data of the Respondents in terms of Length of Experience

The graph above represents the demographic data of the respondents in terms of length of
experience. It indicates that majority of the respondents who were exposed in areas where
milk code was implemented had an experience of 3 years and above with a percentage of

forty-six (46%). Then Followed by the thirty-two (32%) study participants who had a 2-3
years length of experience. Respondents who had 1-2 years length of experience had
fourteen (14%). The least percentage of respondents had eight (8%) which is nurses who
had 1-year length of experience.
According to Scand (2009), clinical experience plays an important role in the
development of expertise, particularly when coupled with reflection on practice. There is
debate, however, regarding the amount of clinical experience that is required to become
an expert. Various lengths of practice have been suggested as suitable for determining
expertise, ranging from three (3) years to ten (10) years. Further, experience and
judgmental performance has found no association based on a study.
II.

Level of Awareness

Table 4. Level of Awareness of Nurses in terms of Law and Implementation of Milk Code
INDICATORS
1. The Milk Code is a law.
2. The benefits of implementing Milk Code.

WEIGHTED
MEAN
3.74
3.71

VERBAL
INTERPRETATION
Highly Aware
Highly Aware

Weighted Mean of Law and Implementation: 3.73 (Highly Aware)

The table 4 illustrates that the respondents are highly aware in terms of the law
and the benefits of implementation of the Milk Code with a weighted mean of 3.73. It can
be inferred that the respondents are aware that milk code is a law and that they are
knowledgeable aboutthe benefits of implementing it. The Philippines adopted the code by
executive order into a law in 1986. To support breast feeding, in 1992 Pres. Corazon C.
Aquino signed the Republic Act 7600 and supported by Pres. Gloria Macapagal Arroyo in

the year 2010. It was implemented since 1986 which ensures the protection of breast
feeding. However, in the Philippines it was institutionalized by the International Code of
Marketing of Breastmilk Substitute which is a World Health Organization (WHO)
resolution passed in 1981.

INDICATORS
3. The advertising, promotion, and other
marketing materials that are not approved
by the IAC (Inter-Agency Committee) of
Milk Code are prohibited.
4. Giving of samples and supplies of covered
products to any member of the general
public, hospitals, health facilities, personnel
within the healthcare system, and members
of their families are prohibited.

WEIGHTED
MEAN
3.44

VERBAL
INTERPRETATION
Highly Aware

3.58

Highly Aware

5. The direct or indirect promotion of covered

3.52
Highly Aware
products to mothers of infants are
prohibited.
6. The display of products covered by the Milk
3.5
Highly Aware
Code or placards and posters concerning
such products in a healthcare facility are
prohibited.
7. The assistance, logistics, or training,
3.54
Highly Aware
financial or material incentives, or gifts of
any sort from milk companies to health
workers are prohibited.
8. The texts, pictures, illustrations, or
3.46
Highly Aware
information that discourages or seemingly
undermines the benefits or superiority of
breastfeeding, or that idealize the use of
breast
milk
substitutes
and
milk
supplements are prohibited.
Table 5. Level of Awareness of Nurses in terms of Prohibitions of Milk Code
Weighted Mean of Prohibitions: 3.50 (Highly Aware)

The table 5 shows that the respondents are highly aware regarding the
prohibitions of Milk Code with a weighted mean of 3.50. These prohibitions are about
advertising, promotion and other marketing materials that are not approved by the Milk
Code sector, giving samples and supplies, direct or indirect promotion, display of
materials, programs and benefits from milk companies and information that discourages
or seemingly undermines the benefits or superiority of breastfeeding, and idealize the use
of breast milk substitutes and milk supplements. While there is no total ban on the
advertising and promotion of breast milk substitutes, the DOH was given power to
regulate, screen, and decide on the advertising and promotional materials of these
products alongside a committee. They also insisted that the milk industry will not be part
of this policy and regulating body.
INDICATORS
9. The sanction for Milk Code Violators will be
imprisonment of two months to one year.
10. The punishment for Milk Code violators will
be a fine of not less than ONE THOUSAND
PESOS (P1,000.00) and not more than
THIRTY THOUSAND PESOS (P30,000.00),
orsuspension or revocation of license.

WEIGHTED
MEAN
3.14
3.1

VERBAL
INTERPRETATION
Moderately
Aware
Moderately
Aware

Table 6. Level of awareness of Nurses in terms of Sanctions of Milk Code

Weighted Mean of Sanction: 3.12 (Moderately Aware)
The table 6 describes that the respondents are moderately aware when it comes to
sanctions with a weighted mean of 3.12. which reveals that the respondents were not well
informed with regards to the sanctions of the said law. Despite of being a law, blatant
violations are still committed by various institutions. The prompted Health Secretary

Francisco Duque issues the revised rules and regulations to put more teeth to the Milk
Code. Meanwhile, no violator of the milk code has been convicted.

III.

Level of Compliance

Table 7: Level of Compliance of nurses in milk code in terms of facility.

INDICATORS

WEIGHTED
MEAN
3.52

VERBAL
INTERPRETATION
Highly Compliant

1. Do you use breastfeeding room in your

hospital?
7. does your hospital practice Rooming - in
3.6
Highly Compliant
immediately after birth?
8. Do mothers with Caesarean or other
3.68
Highly Compliant
procedure with general anesthesia perform
rooming in as soon as they able to respond
to their babys needs?
Weighted mean of Compliance in terms of Facility: 3.6 (Highly compliant)

The Table 7 illustrates that the majority of the respondents are highly compliant about the
Milk Code in terms of facility with a weighted mean of 3.60. It can be concluded that the
respondents are complying as regards to Rooming in Act where in hospitals must have
a breastfeeding room for mothers. The nurses also practiced rooming-in where you placed
the newborn in the same room as the mother right after delivery up to discharge to
facilitate mother infant bonding and to initiate breastfeeding.

Table 8: Level of Compliance of Nurses in Milk Code in terms of Promotion.

INDICATORS

WEIGHTE
D MEAN
2.46

VERBAL
INTERPRETATION
Slightly Compliant

2. Does your hospital accept samples and

supplies of milk formula from any
supplier?
3. Does your hospital post pictures,
2.66
Moderately Compliant
illustrations or information about breast
milk substitute and milk supplements
that discourages the benefits and
superiority of breastfeeding?
4. Does your hospital post pictures,
2.7
Slightly Compliant
illustrations or information about the
benefit of breastfeeding?
5. Does your hospital prohibit all
3.4
Highly Compliant
promotion of breastmilk substitutes and
feeding bottles?
6. Does the hospital have a monitor
3.7
Highly Compliant
breastfeeding policy that addresses the
10 steps to successful breastfeeding?
Weighted mean of Compliance in terms of Promotion: 2.98 (Moderately compliant)
The Table 8 shows that the respondents are moderately compliant about the Milk Code
with regards to breastfeeding promotion which is supported by a weighted mean of 2.98.
The respondents garnered moderate level of compliance in question number three (3),
which indicate that they are not following the milk code in terms of promoting the milk
substitute or milk supplements by posting pictures, illustrations of information that
discourages the benefits and superiority of breastfeeding. Furthermore, some of the
respondents got a low level of compliance in question number two (2) and number four

(4) with regards to accepting samples and supplies of milk formula from any supplier and
posting pictures, illustrations or information about the benefit of breastfeeding. In the
other hand, some of the respondents are highly compliant when it comes to prohibition of
all promotion of breastmilk substitutes and feeding bottles (Question 5) and monitoring
the policy that addresses the 10 steps of successful breastfeeding (Question 6). This can
be inferred that the respondents are complying with regards to the hospital policy in
promoting and monitoring breastfeeding.
Table 9: Level of Compliance of Nurses in Milk Code in terms of Health Teachings.
INDICATORS

WEIGHTE
D MEAN
3.68

VERBAL
INTERPRETATION
Highly Compliant

9. Do you teach mothers about the maternal

nutrition and the preparation for and
maintenance of breastfeeding?
10. Do you teach mothers about the negative
3.38
Highly Compliant
effect on breastfeeding of introducing
partial breastfeeding?
11. Do you orient mothers about the milk
3.56
Highly Compliant
code?
12. Do you check the baby bag of the
3.32
Highly Compliant
mothers if they bring a bottle feeding
materials?
13. Do you teach mothers about proper
3.88
Highly Compliant
handling of baby when breastfeeding?
14. Do you teach mothers about hand
3.7
Highly Compliant
hygiene and how to clean their breast
prior/after breastfeeding?
15. Do
you
help
mothers
initiate
3.78
Highly Compliant
breastfeeding?
Weighted mean of Compliance in terms of Health Teachings: 3.61 (Highly compliant)
The Table 9 signifies that the respondents are highly compliant in terms of health
teachings with a weighted mean of 3.61. It implies that the respondents are strictly
ensuing and conducting health teachings about the milk code such as orienting mothers

about the significance of maternal nutrition and positive effect of breastfeeding and the
negative effects of milk substitute. The nurses also demonstrate the proper handling of
baby when breast-feeding and the importance of having a good hygiene prior to
breastfeeding. It can be concluded that the respondents are strictly imposing the milk
code as regards to health teaching
Pearson r Relationship Result: Level of Awareness and Compliance
Pearson correlational coefficient, also known as Pearson r test was utilized to
measure the correlation value between awareness and compliance on the Milk Code. The
statistical yield rendered a 0.128 correlation which is interpreted as no or negligible
relationship.
According to crude's estimates, which is used for interpreting strengths of correlations, a
0.128 correlation between awareness and compliance shows negligible relationship. The
relationship between the level of awareness and compliance garnered a positive value
which means that it is positively correlated, but still it is very weak and considered
negligible.
The United States of breastfeeding council has developed core competencies that
detail the knowledge, skills, and attitudes that health professionals should possess in
order to help women prepare for, initiate, and sustain breastfeeding (USBC, 2010).
Academic education programs for all health care professionals should include content on
lactation. Professional ethics refers to the use of logical and consistent communication,
knowledge, clinical skills, emotions and values in nursing practice. After encoding and

classifying the data, five major categories were identified: individual character and
responsibility, communication challenges, organizational preconditions, support systems,
educational and cultural development (Dehghani and Mosalanejad, 2015).
It can be inferred that there may be other factors that affects the strict practice of
the nurses on the Milk Code. Researchers recommend a future study about the factors
affecting nurse's compliance on the Milk Code.

CHAPTER V
SUMMARY, CONCLUSION AND RECOMMENDATION

This chapter portrays the summary of findings and the conclusions gathered from
the results. Recommendations will follow on the next subsection to address the reality of
the study.
Summary
The Milk Code or Executive Order No. 51, signed by President Corazon Aquino
in 1986, is the law that promotes breastfeeding in the Philippines. The aim of the Code is
to contribute to the provision of safe and adequate nutrition for infants by the protection
and promotion of breast feeding and by ensuring the proper use of breast milk substitutes
and breast milk supplements when these are necessary, on the basis of adequate
information and through appropriate marketing and distribution.
This study assessed if there is a significant relationship between awareness and
compliance of the respondents regarding the milk code in a selected public tertiary
hospital in the city of Manila.A descriptive-correlational research design was utilized to
determine the level of awareness and compliance of the respondents towards milk code.
Administrative approvals were sought from the Dean of the College of Health Sciences,
the Chief Nurse and the Director of the selected government tertiary hospital in Manila.

After which, an extensive review was done by expert panel to ensure content validity. A
pilot test was then conducted and Cronbach Alpha was computed to assess internal
consistency of the instrument. Minimal revisions were made based on the suggestions of
the experts. Data gathering followed through survey questionnaires that were distributed
to the fifty (50) registered nurses of the selected tertiary hospital. The respondents were
particularly assigned to Obstetric Outpatient department, Obstetrics Emergency Room,
Pediatric Ward, Obstetric Ward, Neonatal Intensive Care Unit, and Pediatric Intensive
Care Unit. The questionnaires were comprised of the demographic profile tool and twopart survey forms namely Awareness and Compliance Assessment Questionnaires.
Qualitative analyses were achieved through the use of statistical applications.
Frequency distributions and percentage were used to treat the demographic profile of the
respondents grouped according to gender and length of experience. Weighted mean was
utilized to determine the level of awareness which was sub groupedinto three (law,
prohibition, and promotion) and level of compliance which was sub grouped into three
(promotion, facilities, and health teaching) of the respondents towards milk code while
Pearson r was applied to assess the correlational value between awareness and
compliance.
Findings
The findings of this study provide a perception into nursing as it pertains to
awareness and compliance in promoting, protecting and supporting breastfeeding
specifically how Milk Code is very important to perform as the health promoter and
secure the safe and adequate nutrition for infants.

The frequency distribution of the respondents in terms of gender data revealedthat

most of the nurses in areas where Milk Code was implemented are women obtaining
thepercentage of seventy-four (74%) surpassinglyto men with only twenty-six percent
(26%) clearly states that most of the promoterof the said law in the tertiary hospitalare
women.
Majority of the respondents in terms of the length of experience are nurses with
hospital experience of three years (3 years) and above that had the forty-six percent
(46%)of the total sample size,second to that is two to three years (2-3 years) with thirtytwo percent (32%) followed by one to two years (1-2 years) experience with fourteen
percent (14%) and the least percentage of the study participantswith one-year (1 year)
length of experience got an eight percent (8%).
The respondents collectively exemplified a high level of awareness in terms of
law and the benefits of implementing the Milk Code as statistically supported by a
weighted mean of 3.73. Respondents were highly aware regarding Milk Code in terms of
prohibition with a weighted mean of 3.50. Milk code in terms of sanctions revealed that
respondents were moderately compliant with a weighted mean of 3.12.This result will
serve as a basis for the researches to focus on the said sanctions of the Milk Code, for
them to develop an educated campaign programs intended to enhance the knowledge
level of the respondents in terms of sanctions.
With respect to the assessed level of compliance, the respondents showed strict
compliance in terms of facility with a weighted mean of 3.50 and 3.61 in terms of health
teachings. The respondents garnered a moderate level of compliance in terms of

promotion which indicates that they are not following some of the aspects of the Milk
Code specifically in terms of promotion.
The essence implied by the study reveals that the relationship between awareness
and compliance regarding Milk Code rendered a result of 0.128 which means that it is in
the positive range. Therefore, the relationship between awareness and compliance is
positively correlated which indicates that as awareness increases, compliance tend to
increase as well.
The result support the need to promote the Milk Code through education.
Enhancement information packet is an educational learning package in the form of flyer
fan to increase or enhance the respondents level of awareness and compliance. The goal
is to develop a positive attitude and encourage the promotion toward Milk Code.
Conclusions
The findings of this study revealed the level of awareness and compliance of nurses on
the Milk Code. Upon comprehensive analysis of the result, researchers were able to draw
the following conclusions:
1. The demographic profile of the respondents in terms of gender revealed that
nurses who were assigned in areas where milk code was implemented were
female. Majority of the study participants had a clinical experience of 3 years and
above with a frequency distribution of 46% as shown in the result.

2. Respondents were highly aware regarding to the milk code in terms of the general
information and prohibitions while respondents showed moderate level of
awareness in terms of sanctions.
3. The level of compliance of the respondents regarding the Milk Code in terms of
facilities and health teachings were highly compliant however, in terms of
breastmilk promotion, the respondents showed a moderate level of compliance.
4. The level of awareness and compliance shows no or negligible relationship.
Correlation value between awareness and compliance is in the positive range,
which means that the relationship between awareness and compliance were
positively correlated which indicates that when awareness increases, compliance
score also increases but still, it is negligible in nature. This signifies that, there is
no significant relationship between the level of awareness and compliance of the
respondents on the Milk Code. Therefore, the null hypothesis is accepted.
5. Despite of the very weak relationship between level of awareness and compliance,
which is considered to be negligible, the researchers developed anenhancement
information packet in the form of a fan. The fan contains information about the
Milk Code. It focuses on the aspects that the respondents showed a moderate and
slight level of awareness and compliance, specifically in terms of sanctions and
promotion. By way of this information, it may possibly increase the awareness
and compliance of the nurses towards the Milk Code.

Recommendations

1. To the mothers, that she should participate in the efforts to promote, protect and
support breastfeeding as the cultural norm. Educate mothers that Infants should be fed
breast milk exclusively for the first 6 months of life. Exclusive breastfeeding means
that the infant does not receive any additional foods. Mother should continue
breastfeeding while gradually introducing solid foods to the infant until the infant is 1
year old.
2. To the hospital, they should create a positive and supportive environment at the health
care settings such as displaying breastfeeding posters in public areas; providing a
private space for breastfeeding clients as required. All general acute care hospitals
and special hospitals that has a perinatal unit shall implement initiation of
breastfeeding within the first hour after the birth and should have an infant-feeding
policy that utilizes guidance provided by the Baby-Friendly Hospital Initiative or the
State Department of Public Health Model Hospital Policy Recommendations. Educate
and monitor the nurses in perinatal unit if they are aware and complying the milk
code.
3. To the DOH, they should continue to monitor and required general hospitals and
special hospitals providing maternity care to make available breast feeding
consultation or alternatively. Maternity care hospitals must have breastfeeding
consultation or information. Enhance their program to provide more information to
the mothers.
4. To the student nurses, they should encourage breastfeeding as the preferred method of
infant feeding. Educate mothers that breastfeeding has an extraordinary range of
benefits. It has profound impact on a childs survival, health, nutrition and
development. Breast milk provides all of the nutrients, vitamins and minerals an

infant need for growth for the first six months, and no other liquids or food are
needed. Teach mothers proper positioning and also supporting breastfeeding mothers
if they encountered difficulties.
5. To the nurses, they should be aware about the sanctions for Milk Code because if they
violated they will be imprisonment for two months to one year and the punishment
for Milk Code violators will be a fine of not less than one thousand pesos (P1,000.00)
and not more than thirty thousand pesos(P30,000.00), or suspension or revocation of
license.
6. This study may use as a reference for further exploration or to replicate studies on the
Milk Code. Larger sample size, sampling design and selection of criteria should be
utilized to achieve randomness to prevent systematic evaluation that might introduce
bias. All methods will yield to a more conclusive and generalized result. Future study
may want to focus on individual character and responsibility, communication
challenges, organizational preconditions, support systems, educational and cultural
development.

Abstract
Milk Code or Executive Order No. 51 is a law that protects and promotes breastfeeding in
the Philippines. The aim of the Code is to contribute to the provision of safe and adequate
nutrition for infants by the protection and promotion of breast feeding and by ensuring
the proper use of breast milk substitutes and breast milk supplements when these are
necessary, on the basis of adequate information and through appropriate marketing and
distribution.
This study assessed if there is significant relationship exists between the
awareness and the compliance of the respondents regarding Milk Code in the selected
tertiary hospital in the City of Manila. It is a hospital-based where purposive sampling
was used. Self-made questionnaires were employed to gather data among 50 nurses who
has at least one (1) year of hospital experience and is assigned in different wards who
cares infants and breastfeeding babies such as, Obstetric ward, Neonatal Intensive Care
Unit, Pediatric ward, Outpatient department, Obstetrics Emergency Room, and Pediatric

Intensive Care Unit. A descriptive-correlational research design was used as the

framework.
The dominant characteristics of the respondents in gender which is female with
seventy-four percent (74%) compare to men who has twenty-six percent (26%). Most of
them has a length of experience of three years and above (3years) with forty -six percent
(46%). Followed by two to three years (2-3 years) with a percentage of thirty-two percent
(32%). One to two years (1-2 years) experience has a least percentage of fourteen percent
(14%) followed by one-year (1year) length of experience got an eight in percentage (8%).
The respondents collectively exemplified a high level of awareness in terms of
law and implementation of milk code as statistically supported by a weighted mean of
3.73.the awareness of the respondents in prohibitions of milk code were highly aware
with a weighted mean of 3.50 interms of violations on the Milk Code, the respondents
were moderately aware(weighted mean of 3.12). This result will serve as a basis for the
researchers to focus on the said violations in milk code, for them to develop an educated
campaign programs intended to enhance the knowledge level of the respondents in terms
of violation. The assessed level of compliance, on the other hand, is generally positive.
The respondents showed strict compliance in terms of facility with weighted mean of 3.5
and in health teaching (weighted mean of 3.61). In contrast, there is marked deviation in
terms of promotion where the respondents demonstrated moderate level of compliance
with weighted mean of 2.98. This result will serve as a basis on the said promotions in
milk code, for them to develop a campaign that will increase the promotion towards
breastfeeding.

The findings indicated a positively correlational but still it is negligible. The

statistical yield is 0.128 using a P value of 0.5 level with the extent interpreted has no
relationship.
The result support the need to promote the milk code through education.
Enhancement Information Packet (TIP) is an educational learning package in the form of
flyer fan to increase or enhance the respondents level of awareness and compliance. The
goal is to develop a positive attitude and encourage the promotion towards Milk Code.