Switzerland at the CRC : Lack of Political Will and Financial Means to Ensure Protection, Promotion and Support of Breastfeeding

On January 21st and 22nd, 2015, the Committee on the Rights of the Child considered the combined second to fourth periodic report of Switzerland on the situation of the implementation of the Convention on the Rights of the Child in the country. The delegation of Switzerland was led by Ambassador Stéphane Cueni and Mrs. Anne-Claude Demierre, State Counsellor of the canton of Fribourg.

On this occasion, IBFAN presented an alternative report to inform the CRC Committee on the situation of infant and young child feeding in Switzerland. IN addition, as a member of the Swiss NGO Child Rights Network Switzerland, IBFAN-GIFA also contributed to the joint report of the network.

General overview of breastfeeding in Switzerland

IBFAN report highlighted that Switzerland does not have a comprehensive national strategy on protection, promotion and support to infant and young child feeding in line with the Global strategy for infant and young child feeding adopted at WHA in 2002. The Swiss national strategy to promote healthy diets initiated in 2008 includes promotion of breastfeeding, and there is a national foundation tasked with breastfeeding promotion, but only a few cantons are funding small-scale breastfeeding promotion activities as part of their obesity prevention programs. Overall, political will and national planning and resources are insufficient to create a favorable environment for mothers and parents to make informed decisions and put them into practice. Although more than half of Swiss babies are born in baby-friendly hospitals, scarce international indicators reveal poor breastfeeding practices (rate of exclusive breastfeeding under 6 months: 14%, rate of early initiation of breastfeeding: 66% and no data on continued breastfeeding at 1 or 2 years). The rate of C-sections, a barrier to early initiation, is very high (33%).

In addition, protection of breastfeeding is insufficient. Indeed, the Swiss law does not cover all provisions of the International Code of Marketing of Breastmilk Substitutes and applies only to infant formula until 6 months; what is more, monitoring at national level is not independent, as the panel responsible is jointly composed of experts and members of the baby food industry. In consequence, as an example, mothers of 4 month year old babies receive gift packages at home containing samples of follow-on formula and complementary foods marketed for infants from 4 months. Parents often receive conflicting information, including from health professionals who lack appropriate independent training and are faced with potential conflicts of interest induced by financial ties between their professional associations and the baby food industry.

On a more positive note, IBFAN noted that Switzerland ratified the ILO Convention 183 on maternity protection, by revising their legislation to ensure that all working mothers are granted paid breastfeeding breaks until their child is one year of age.

Discussion on infant and young child feeding

The Committee expressed concern about the increase of obesity in children. Mentioning specifically breastfeeding, the Committee noted that even though breastfeeding is officially recommended, the efforts to promote optimal breastfeeding practices are yet not satisfactory: there is a lack of training aimed at health professionals, no national strategy on breastfeeding and only very little funds allocated to breastfeeding promotion.

Regarding obesity, the delegation explained that Switzerland has adopted a 2013-2016 Nutrition Strategy based on the 6^th Swiss Nutrition report, the European White Paper and the WHA Strategy for diet, physical activity and health. A National Plan of Action has also been put in place and is coordinated by Promotion Santé Suisse in 20 cantons. On the issue of breastfeeding, the delegation answered that much attention is paid to the health of mothers and children within the above-mentioned National Nutrition Strategy and that Federal Food Safety and Veterinary Office supports and promotes breastfeeding through the Swiss Foundation for the Promotion of Breastfeeding. In the last years, two important steps have been taken in relation with breastfeeding: 1/ a new legislation on maternity protection has been implemented, which provides paid breastfeeding breaks to working mothers, and the ILO Convention 183 has been subsequently ratified; 2/ a new ordinance has been adopted in 2008, which limits the marketing of infant formula until 6 months of age.

The Committee then raised follow-up questions on the protection of breastfeeding, emphasizing the lack of implementation of the International Code and relevant subsequent WHA resolutions into the Swiss legislation and asking if there was any immediate plan to strengthen the national legislation implementing the Code and to set up an independent monitoring mechanism. In addition, the Committee asked if, considering the need for 6 months of exclusive breastfeeding, Switzerland was planning to extend the duration of the maternity leave accordingly.

The delegation could not answer on the question on breastfeeding protection and the International Code because of lack of information. On the issue of maternity leave, it explained that the government is not considering an extension of the duration of 14 weeks, which comply with European standards, but is now working on strengthening the paternity leave.

The Committee again referred to breastfeeding and asked if there was any intention to increase to rate of hospitals certified as “baby-friendly” (about 55%).

The delegation answered that some hospitals are indeed certified, but that some others have refused to enter into the process. Currently, there is no government plan to extend the number of certified health facilities. The delegation added that a canton express concern about the fact that women were being pressured to breastfeed and said that some degree of freedom should be allowed. Mothers should be able to choose to breastfeed or not. The delegation further stated that there shouldn’t be a state plan on this issue.

The Committee finally noted that breastfeeding is also crucial for emotional bonding and attachment between the mother and her child and that Switzerland should reconsider its approach related to the Baby-Friendly Hospital Initiative. Noting that nowadays, two incomes are often necessary to support a family and that most of women no longer stay at home to take care of their children, the Committee invited Switzerland to extend the maternity leave, because it is the only way to enable women to breastfeed exclusively for 6 months.

Concluding Observations

In its Concluding Observations, the Committee referred indirectly and directly to infant and young child feeding. Regarding promotion of breastfeeding, the Committee recommended Switzerland to “strengthen its efforts to promote exclusive and continued breastfeeding by providing access to materials, and raising awareness concerning the importance of breastfeeding and the risks of formula feeding” (§ 59a). Regarding support to breastfeeding, the Committee stressed the need to “review and strengthen training for health professionals on the importance of exclusive breastfeeding, and to “further increase the number of hospitals certified as baby-friendly” (§ 59b-c). Moreover, Switzerland was urged to “develop a comprehensive national strategy on infant and young children feeding practices” and to make sure that the national recommendations on breastfeeding comply with the relevant WHO recommendations (§ 59d-e). Finally, the Committe recommended to “ensure that the International Code of Marketing of Breastmilk Substitutes is strictly enforced” and to “consider extending maternity leave to minimum six months” (§ 59f-g).

Iraq at the CRC: High Prevalence of Infections and Chronic Undernutrition among Children

On January 21^th, 2015, the Committee on the Rights of the Child considered the combined second to fourth periodic report of Iraq on the situation of the implementation of the Convention on the Rights of the Child in the country. The delegation of Iraq was led by H.E. Mohammed Mahdi Ameen Al-Bayati, Minister of Human Rights.

On this occasion, IBFAN presented an alternative report to inform the CRC Committee on the situation of infant and young child feeding in Iraq.

General overview of breastfeeding in Iraq

The rate of early initiation of breastfeeding passed from 25.1% in 2006 to 43% in 2011. While representing a significant increase, this means that almost 6 children out of 10 are still not receiving any breastmilk during their first hour of life, even though delayed breastfeeding is proven to have a negative impact on neonatal mortality. Additionally, the rate of exclusive breastfeeding under 6 months was only 20% in 2011, and there are no recent data on its progress, while the rate of continued breastfeeding at 2 years dropped from 35.7% in 2006 to 23% in 2011. Such poor breastfeeding records show a lack of general information on optimal breastfeeding practices, from the mothers’ side as well as from the health professionals, who lack the resources and capacity to proper inform pregnant women about their nursing role. Moreover, such rates are also the result of the distribution of free infant formula to all infants, as part of Iraq’s Public Distribution System for food rations.

The draft National Strategy for Infant and Young Child Feeding was prepared in 2005 and was aimed at raising awareness on infant and child feeding problems and practices. However, it is not unknown whether this strategy has been implemented so far. The draft National Strategy provides for specific training to health professionals on HIV and infant feeding issues, and thus it is not clear whether the provision of the strategy is implemented, as well as the whole strategy itself.

Regarding protection of breastfeeding, only voluntary provisions exist in Iraq to implement the International Code of Marketing of Breastmilk Substitutes. A draft law was prepared in 2011, with the goal of transposing into law most provisions of the International Code, but to date there is no information available on its adoption and implementation. The coverage rate of the Baby-Friendly Hospital Initiative (BFHI) in the hospitals and maternities in Iraq was 59% in 2009/2010, but there are no recent data on the current number of hospitals certified as “Baby-Friendly” and on whether these institutions still respect the criteria of the BFHI.

Maternity protection is not adequate, considering that the paid maternity leave duration is only 62 days. Finally, no information is available on the provision of a strategic plan to protect and promote breastfeeding in case of emergencies.

Discussion on infant and young child feeding

The CRC Committee commended the delegation of Iraq about the progress made on immunization and on institutional deliveries, highlighting that this is a very positive result considering the difficult context Iraq is in. However, it observed that there is still a high rate of preventable infections among children, such as diarrhea, and asked for comments on that as well as on the issue of chronic undernutrition. Moreover, the CRC Committee asked what efforts are being made at the health care system level in order to reduce the number of preventable maternal deaths.

The delegation of Iraq did not provide answers on the topics that have been touched related to health, justifying this with the absence of the representative of the Ministry of Health, who could not participate to the session due to budget issues.

Concluding Observations

In its Concluding Observations, the Committee made several recommendations indirectly related to infant and young child. After expressing concerns on the high rate of under-five mortality and the high prevalence of chronic under-nutrition and maternal mortality, the Committee highlighted also that “while the armed conflict is having a devastating impact on the availability and quality of healthcare, the State party devotes a low percentage of the federal budget to its healthcare system” (§ 60).

The Committee thus recommended Iraq to “reduce maternal mortality by providing access to emergency obstetric care and ensuring access to trained delivery care at home, services at maternal and child health clinics with trained health care providers” and to “allocate all necessary human, technical and financial resources for interventions aimed at reducing preventable and other diseases, particularly diarrhoea, acute respiratory infections and under nutrition” (§ 61a-b). Finally, the Committee also recommended that Iraq to “take all necessary measures to sufficiently equip hospitals as a matter of priority” (§ 61c).

Colombia at the CRC: Concerns about Declining Breastfeeding Rates and Lack of Breastfeeding Promotion

On January 20^th and 21^st, 2015, the Committee on the Rights of the Child considered the combined fourth and fifth periodic reports of Colombia on the situation of the implementation of the Convention on the Rights of the Child in the country. The Colombian delegation was led by Mrs. Cristina Plazas Michelsen Costa, Director of the Colombian Institute of Family Wellbeing.

On this occasion, IBFAN presented an alternative report to inform the CRC Committee on the situation of infant and young child feeding in Colombia.

General overview of breastfeeding in Colombia

The report highlighted that despite a high rate of institutional delivery (95%), the rate of early initiation to breastfeeding is low (57%) and has recently declined, which indicates that health professionals are not enabled to ensure optimal breastfeeding practices within hospitals. Besides, the rate of exclusive breastfeeding under 6 months has decreased since 2004 and currently, almost 6 children out of 10 are not exclusively breastfed until 6 months of age. The Colombian National Demographic and Health Survey 2010 has also shown that on average, babies are given other liquids than breastmilk at 2.7 months and that the practice of bottle feeding, which is common during the first year of life, has increased in the last decade. This situation is closely connected with the lack of promotion strategy on optimal breastfeeding practices and aimed at mothers, caregivers and community through media.

Regarding protection of breastfeeding, IBFAN noted that the International Code of Marketing of Breastmilk Substitutes and its subsequent relevant World Health Assembly resolutions are still not fully implemented into legislation and that violations of the Code, including donations of infant formula to health institutions and delivering of gifts to mothers through health workers, are common.

The report also flagged the very low rate of implementation of the Baby-friendly Hospital Initiative in the country. The latest statistic, dating back to 2009, shows that only 0.06% of the total number of health facilities of the country are certified as “baby-friendly”. In addition, there is no monitoring of this accreditation process at the country level.

Finally, IBFAN expressed concern about the lack of maternity protection for women working in the informal sector as well as the lack of any national plan to ensure protection and support of breastfeeding in case of emergencies.

Discussion on infant and young child feeding

During its discussion with Colombia, the CRC Committee addressed specifically the issue of breastfeeding. It mentioned the low breastfeeding rates and noted with particular concern the decline of the rate of exclusive breastfeeding under 6 months. It asked which efforts have been made to ensure that health professionals are properly trained on optimal breastfeeding practices and that mothers are aware of the importance of breastfeeding their child.                                                                                                               

The Colombian delegation answered that the decline of the rate of exclusive breastfeeding is a concern for the government and states the importance of taking action on this regard. It noted that a national breastfeeding plan is in place and that breastfeeding is closely connected with the employment condition of mothers. As part of the gender equality governmental project, the length of the maternity leave has recently been increased to 14 weeks, and the legislation also entitles working fathers to 1 week of paternal leave. In addition, the delegation added that some 17 human milk banks have been implemented throughout the territory in order to make it easier for every child to have access to breastmilk, and that breastfeeding-friendly rooms have been settled in employment areas in order to support working mothers to breastfeed. Finally, regarding the specific problem of teenage pregnancies, the delegation assured the Committee that special facilities have been put in place to ensure that young mothers are able to continue to go to school while breastfeeding their child.

Concluding Observations

In its Concluding Observations, the Committee made several indirect and direct recommendations to Colombia in relation with infant and young child feeding.

Regarding health and health services, the Committee recommended Colombia to “ensure the availability and accessibility of health services for all children […] by allocating adequate resources and monitoring the implementation of relevant policies” (§ 40a). In particular, the Committee highlighted the child and maternal mortality rates which continue to be very high (§ 39f), and thus recommended the State party to “increase its efforts to reduce maternal and child mortality, including by implementing the OHCHR Technical guidance on child mortality” (§ 40c) which includes specific recommendations on breastfeeding protection (including the implementation of the International Code) and promotion. It is to be noted that this technical guidance includes specific recommendations on breastfeeding protection (including the implementation of the International Code) and promotion

Referring specifically to breastfeeding, the CRC Committee expressed its concerns on the decline of exclusive maternal breastfeeding in 2010 and on the persistence of inadequate baby feeding practices. It recommended Colombia to “strengthen efforts to promote breastfeeding through educational campaigns and training to professionals, adequately implement the International Code of Marketing of Breast-Milk Substitutes and the Child-Friendly Hospital initiative [sic]” (§ 40h).

Uruguay at the CRC: Lack of Monitoring of the Legislation Implementing the Code

On January 19th and 20th, 2015, the Committee on the Rights of the Child considered the combined third to fifth periodic report of Uruguay on the situation of the implementation of the Convention on the Rights of the Child in the country. The Uruguayan delegation was led by Mrs. Alejandra Costa, Director for Human Rights and Humanitarian Law at the Ministry of Foreign Affairs.

On this occasion, IBFAN presented an alternative report to inform the CRC Committee on the situation of infant and young child feeding in Uruguay.

General overview of breastfeeding in Uruguay

The report outlined that although the rate of exclusive breastfeeding under 6 months is high (65%), some 4 children out of 10 are not breastfed within an hour after birth, which questions the quality of the counselling and support received by mothers in maternities. Besides, more than 7 children out of 10 are not breastfed until the age of 2 years, despite the recommendations of the World Health Organization.

Regarding protection and support of breastfeeding, IBFAN noted that the National Breastfeeding Standard (NNLM) is not fully implemented as many health workers are not trained on its content, including on the InternationalCode on Marketing of Breastmilk Substitutes and the guidelines “Buenas Practicas de Alimentacion del lactante y del nino pequeño”. In addition, there is no monitoring mechanism of the legislation implementing the International Code.

The IBFAN report also highlighted that in 2009-2010, only 35% of the maternities of the country were certified as “baby-friendly” and that the Human Milk Bank receives in-kind donations from Nestlé, which can lead to situations of conflict of interest.

Finally, the report noted that the maternity leave does not allow mothers to breastfeed exclusively for 6 months, and that mothers working in the informal sector are not covered. There are no training courses on HIV and infant feeding for health professionals and there is no national plan to protect and support breastfeeding in case of emergencies.

Discussion on infant and young child feeding

Questioned on the issue of maternal mortality, the Uruguayan delegation responded that measures are taken to ensure that all pregnant women have access to health and that early checkups are carried out. Majority of deliveries occur in institutions and the government has taken action to prevent avoidable maternal deaths within the current national action plan. The next action plan should also cover the issue of nutrition of pregnant women, which is not included in the current action plan.

On the issue of breastfeeding, the Committee first congratulated Uruguay for the implementation of the International Code of Marketing of Breastmilk Substitutes. However, it noted that the International Code is not yet fully implemented and that no monitoring mechanism is in place. It also asked for more information on the training of health professionals regarding optimal breastfeeding practices. It expressed concern about Nestlé’s donations received by Human Milk Bank and deplored the fact that only 35% of the maternities of the country are complying with the requirements of the Baby-friendly Hospital Initiative. Finally, the Committee regretted that women working in the informal sector are not allowed to maternity leave benefits and it stressed the need for Uruguay to adopt a plan to protect and support breastfeeding in case of emergencies.

The Uruguayan delegation answered that the maternity leave has been recently extended to 14 weeks and that after the third month of leave, parents can decide whether the father will take up the leave. However, the delegation admitted that informal workers are not allowed to these benefits. Regarding monitoring of the legislation implementing the International Code, the delegation explained that the government is currently working with UNICEF to develop such a monitoring mechanism. In regard to the implementation, the delegation noted that an initiative called “Good eating habits during breastfeeding” has been developed, as well as a strategy, and stressed the fact that breastfeeding rates have been improved (from 20% in the 1990s to 65% today). 

After follow-up questions from the Committee, the delegation again stressed that monitoring of the legislation implementing the Code is the main challenge for the government regarding breastfeeding. The delegation also admitted that the Human Milk Bank, which is under supervision of the Ministry of Health, has received glass jars to store the breastmilk from Nestlé and that these jars, which cannot be bought on the national market, are free from any advertisement. No funds from the industry are accepted. The delegation added that Uruguay has developed a joint network of human milk banks with Brazil in order to ensure that all children, especially underweight children, have access to breastmilk.

Concluding Observations

In its Concluding Observations, the Committee made recommendations indirectly related to infant and young child feeding, however it did not refer specifically to breastfeeding. Regarding health and health services, the Committee urged Uruguay to “strengthen its efforts to ensure access to quality health services by all children, particularly children living in the most disadvantaged and remote areas of the country”, as well as to “develop policies and programmes to address chronic malnutrition and anaemia” (§ 46).

Jamaica at the CRC: Low Breastfeeding Records and Insufficient Maternity Leave

On January 19^th and 20^th, 2015, the Committee on the Rights of the Child considered the combined Third and Fourth Periodic Report of Jamaica on the situation of the implementation of the Convention on the Rights of the Child in the country. The delegation of Jamaica was led by M.P. Honorable Lisa Hanna, Minister of Youth and Culture.

 

On this occasion, IBFAN presented an alternative report to inform the CRC Committee on the situation of infant and young child feeding in Jamaica.

General overview of breastfeeding in Jamaica

Despite the high rate of skilled attendance at birth (98.3%) and institutional delivery (97.1%), optimal breastfeeding practices are still not widespread in Jamaica. This is confirmed by the low rates of early initiation of breastfeeding (62.3%), exclusive breastfeeding under 6 months (23.8%) and continued breastfeeding ate at 2 years of age (31.2%). These figures show a lack of knowledge on the importance of the early initiation of breastfeeding among the health care workers assisting deliveries and, at the same time, constitute an evidence of non-compliance with the step 4 of the Baby-Friendly Hospital Initiative (BFHI). Another alarming fact relates to the median duration of exclusive breastfeeding, which is only three weeks for the average Jamaican mother.

The draft National Infant and Young Child Policy, revised in 2014, states important goals related to supporting breastfeeding in communities and the workplace, spreading the BFHI in all institutions, improving the data collection system, building capacity within all relevant agencies and at different levels of the health system, among others. However, to date, this draft has not yet been accepted and thus, the activities carried out by the National Infant and Young Child Feeding Committee remain unclear. Breastfeeding and HIV-related strategies are mentioned in the draft Policy, and thus, have not been endorsed yet. The same applies to infant and child feeding in emergencies, which has been addressed in the draft Policy in the form of specific provisions, but there is no information available on its concrete application.

Regarding protection of breastfeeding, only voluntary measures are in place to implement the International Code of Marketing of Breastmilk Substitutes and there is no enforcement mechanism. 

The Jamaican legislation does not provide for an adequate duration of maternity leave (12 weeks) and for proper relevant benefit coverage (only 8 weeks). Furthermore, employers are not required to provide breaks for nursing mothers and fathers are not entitled to any paternity leave.

Discussion on infant and young child feeding

The CRC Committee addressed specifically the issue of breastfeeding in Jamaica, asking the reasons behind such low breastfeeding rates in the country, despite the tremendous positive developments Jamaica has presented in many other areas of the Convention. It was also asked whether there could be a link between the low breastfeeding indicators and the fact that the legislation does not provide for employers to allow breastfeeding breaks to nursing mothers. The delegation replied mentioning that Jamaica was one of the first countries in the world to adopt in the 1970s an act on the maternity leave which gives women the right to a paid 3-month leave. The delegation also highlighted that Jamaica has a matriarchal society for which many mothers are working and that they do breastfeed their children up to 6 months of age. Pointing out that breastfeeding is encouraged in hospitals, the Head of Delegation described the personal experience of going to the hospital to deliver her baby and being told not to bring any bottles because that was a breastfeeding-policy hospital. 

The CRC Committee commented that, however, it is important to provide that the maternity leave is long enough and guarantees that mothers can breastfeed their children up to 6 months exclusively, reminding that this is also a very strong WHO recommendation. Maternity leave becomes thus an essential point when discussing measures aimed at encouraging women to breastfeed their children, if not up to 2 years, up to 6 months at least. The Committee then added that the positive outcomes of breastfeeding are seen later, in the better health status of children and, but not only, in the emotional bonding, which is also essential.

Concluding Observations

The Committee issued both indirect and direct recommendations related to infant and young child feeding to Jamaica (see the Concluding Observations).

After commending the State party for the decrease in infant mortality rates, the Committee expressed concerns over the “perinatal mortality levels, the increase in maternal mortality, the persistent levels of undernourishment among the poorest children, the general shortage of health care providers and access by children to quality health care, the low levels of breastfeeding and the high rate of children classified as overweight and obese” (§ 44).

Therefore, the Committee recommended Jamaica to ensure adequate provision of prenatal and post natal care, as well as to address the increase in maternal mortality (§ 45a) and to increase the number and coverage of health care professionals for an improved children’s access to health care services (§ 45c). Regarding nutrition, the Committee urged Jamaica to “introduce targeted action to prevent the undernourishment of children, including the promotion of proper infant and young child feeding practices” (§ 45b). On children obesity in particular, the Committee recommended to intensify measures to raise awareness of healthy nutrition among parents, children and the public in general, and to promote healthy eating habits (§ 45f).

With regard to breastfeeding, the Committee specifically recommended Jamaica to “take action to improve the practice of exclusive breastfeeding for the first six months, through awareness-raising measures, including campaigns, providing information and training to relevant officials, particularly staff working in maternity units, and parents” (§ 45d). Finally, the Committee recommended the State party to regulate the marketing of breastmilk substitutes (§ 45e).