Thursday, 16 January 2014

Congo Brazzaville: Low Breastfeeding and High Infant Mortality Rates

The Republic of Congo Brazzaville presented its consolidated 2nd to 4th periodic reports on the situation of the implementation of the Convention on the Rights of the Child in the country.  The government delegation was composed of 12 members and one of them was representing the Ministry of Health. The head of the delegation was the Minister of Social Affairs Humanitarian Action and Solidarity, Ms Emilienne Raoul, who directly responded to most of the questions from the Committee on the Rights of the Child (CRC Committee).

IBFAN presented an alternative report to inform the CRC Committee on Congo’s situation of infant and young child feeding.

General overview of breastfeeding in Congo Brazzaville

The alternative report shows that breastfeeding rates are still insufficient: for the period 2007-2010, only 19% of infants were exclusively breastfed during the first 6 months and only 21% of the children were still breastfed at the age of 2. Early initiation of breastfeeding is also worryingly low (39%) while at least one child out of three is fed with other food than human milk during the 3 first days of their life. These bad figures are the result of a lack of adequate information and inadequate traditional practices on infant and young child feeding. The alternative report highlights the crucial role of health workers for dissemination of correct information, and calls for adequate training of these professionals. Currently, none of the hospitals of the country meets the requirements of the Baby-friendly Hospital Initiative (BFHI).

Inadequate infant and young child feeding practices contribute to the very high child and maternal mortality rates in Congo, where 61 children out of 1000 born die before their first year of age. Stunting is another main concern: it increases considerably after the first 6 months to reach 21% at the age of 9-11 months with a peak of 37% at the age of 18-23 months, coinciding with the time breastfeeding is stopped and replaced with other foods.

No measures have been taken so far from the government to regulate the marketing of breastmilk substitutes. Although Congo has adopted the Global Strategy on Infant and Young Child Feeding Breastfeeding, the International Code of Marketing of Breastmilk Substitutes  has not been implemented through a national legislation. A national law has been drafted to this end in the 1990’s and since then it’s still waiting to be considered by the government.

Maternity protection at work is also a challenge for Congo, where maternity leave is as short as 15 weeks, 9 of which should be taken after birth. Moreover, a very small fraction of active women are employed in the formal sector, while a large majority of them are working in the informal sector and therefore does not benefit from the maternity leave legislation.

Discussion on infant and young child feeding

During the interactive dialogue between the CRC Committee and the Congolese delegation, the issue of breastfeeding was addressed in the context of health care. Committee members asked whether a programme to promote good nutrition and breastfeeding has been implemented. Details concerning the number of hospitals that meet the requirements of the BFHI criteria have been requested. Finally, the question of the monitoring of marketing of breastmilk substitutes has been asked.

On these points, the head of Congolese delegation asserted that more than 90% of Congolese mothers breastfeed since birth, but the rate decreases to 36% after 6 months. She pointed to a Knowledge, Attitudes and Practice (KAP) study that has been realised in order to identify the causes and determinants of the health situation observed in the population. Identification of these determinants is crucial to develop a strategy to improve the health practices, including breastfeeding.

Unfortunately, issues related to the implementation of the International Code, the need to improve the knowledge of health workers, to promote early and exclusive breastfeeding as well as appropriate complementary feeding, maternity protection for women employed in all sectors were not addressed by the government delegation.

Other issues debated at the session included a wide range of topics: child adoption and alternative care, juvenile justice and incarcerated children, respect of the child’s rights by transnational companies, birth registration, violence and sexual abuses against children, female genital mutilations, child labour, children in street situation, children refugees, education, child marriage, children with disabilities, etc…

The Committee welcomed the progress that have been made by Congo so far, while being well aware of Congo shortcomings in realizing children’s rights in the country; however it stressed that many improvements are still to be made in order to ensure that the rights of the child are fully respected, promoted and protected.

CRC Committee's Concluding Observations

In its Concluding Observations, the CRC Committee directly addressed the issue of breastfeeding (para 59; 67), as well as the relation between child rights and the business sector (para 27), data collection (para 19) and mother-to-child HIV/AIDS transmission (para 61).

The CRC 2013 General Comment N° 15 on the right of the child to the enjoyment of the highest attainable standard of health (art. 24) explicitly recognizes the importance of breastfeeding for the achievement of the right of the child to health. It urges States, in the effort of diminishing infant and child mortality, to devote particular attention to neonatal mortality and suggests, inter alia, to “pay particular attention to ensuring full protection and promotion of breastfeeding practices”. Moreover, “exclusive breastfeeding for infants up to 6 months should be protected and promoted and breastfeeding should continue together with appropriate complementary foods preferably until two years of age as feasible. States’ obligations in this area are defined in the “protect, promote and support framework”, adopted unanimously by the World Health Assembly in its 2002 Global Strategy for Infant and Young Child Feeding". Regarding Health and health services, the Committee urged Congo to pay "attention to its general comment No. 15 [...]. It recalls its recommendation to the State party to overcome the constraints preventing the implementation of existing strategies including, inter alia, by: (a) Ensuring the provision of primary health care services for all pregnant women and children, focusing on the development of accessible health care services with trained health care providers, interventions to reduce preventable and other diseases, particularly diarrhoeas, acute respiratory infections, and undernutrition. Health services should include access to sanitation and clean drinking water; (b) Strengthen and expand access to preventive health care, and therapeutic services for all pregnant women and children, particularly infants and children under five years old. These should include universal immunization services, oral rehydration therapy, treatment for acute respiratory infections, promotion of infant and young child feeding practices, particularly breast milk and infant food based on local foods, and prevention of malaria through use of impregnated bed nets. This must also include the effective implementation of the WHO/UNICEF International Code on the Marketing and Distribution of Artificial Infant Formula and a monitoring system to ensure the enforcement of regulations; (c) Increasing efforts to implement the strategies seeking to reduce maternal mortality throughout the country, including for trained care at home, in maternal and child health clinics, and emergency obstetric care; [...] (e) Continuing the dissemination of health information and promotion of health education, particularly on the use of latrines and hand washing to all segments of the society, and provide safe water to all segments of society; (f) Increasing the quality and coverage of training to staff at socio-health units and ensuring that these units are adequately staffed and have the essential facilities, including obstetric supplies and emergency medicines for children and pregnant women".

The CRC Committee, in its 2013 General Comment N° 16 on State obligations regarding the impact of the business sector on children’s rights, specifically calls on States “to implement and enforce internationally agreed standards concerning children’s rights, health and business including the [...] International Code of Marketing of Breast-milk Substitutes and relevant subsequent World Health Assembly resolutions”. In the section Children's right and the business sector, the Committee draws Congo's "attention to its general comment No. 16 [and] recommends that the State party establish and implement regulations to ensure that the business sector complies with international and national human rights, labour, environment and other standards, particularly with regard to children’s rights [...]. In particular, it recommends that the State party: (a) Establish a clear regulatory framework for the industries operating in the State party to ensure that their activities do not negatively affect human rights or endanger environmental and other standards, especially those relating to children’s and women’s rights; (b) Ensure effective implementation by companies, especially industrial companies, of international and national environmental and health standards, effective monitoring of implementation of these standards and appropriately sanctioning and providing remedies when violations occur, as well as ensure that appropriate international certification is sought; [...] (f) Be guided by the United Nations “Protect, Respect and Remedy” Framework, accepted unanimously in 2008 by the Human Rights Council, while implementing these recommendations."
The CRC Committee also urged Congo to improve its data collection system. The data should be disaggregated, among other criteria, by age, sex and socioeconomic background. These data could then be used to monitor breastfeeding rates in the country, providing thus an important tool to improve breastfeeding policies and practices.
In addition, Congo is requested to "adopt a holistic early childhood development (ECD) strategy and invest in the training of ECD teachers and provision of integrated formal and community-based programmes involving parents and covering healthcare, nutrition and breastfeeding, early stimulation and early learning for children from birth to the first year of school". Finally, the CRC Committee recommended to "ensure the implementation of effective HIV/AIDS preventive measures", including measures to prevent-mother-to-child transmission (like early diagnosis and immediate initiation of treatment).