Timor-Leste at the CRC: Low Coverage of Skilled Attendance at Birth and High Prevalence of Acute Malnutrition

On September 25, the Committee on the Rights of the Child considered the combined 2^nd to 3^rd periodic report of Timor-Leste on the situation of the implementation of the Convention on the Rights of the Child in the country.

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

General overview of breastfeeding in Timor-Leste

Timor-Leste is characterized by high rates of child stunting (50%), underweight (about 38%) and moderate or severe malnutrition (about 11%), associated with low delivery care coverage and evidences of inappropriate feeding practices. Almost 30% of babies are born without the assistance of a skilled attendant, while only 22% of mothers give birth at health facilities. Additionally, the median duration of breastfeeding had decreased from 17.7 months in 2003 to 17.5 months in 2009/10 and less than 20% of children aged 6-23 months receive timely and appropriate complementary feeding.

IBFAN further noted the absence of a National Breastfeeding Committee and the lack of national guidelines for Infant and Young Child Feeding (IYCF). Breastfeeding indicators are not regularly and systematically monitored and the new legislation implementing the International Code of Marketing of Breast-milk Substitutes (hereafter: the Code) has not yet been endorsed by the Ministry of Health and is thus not enforced.  

The lack of appropriate pre- and in-service training programmes on infant and young child feeding is also of concern, as well as the lack of standards and guidelines for mother-friendly childbirth.

The report also flagged the low number of hospitals that are certified as “Baby Friendly” (2 out of 6 hospitals, i.e. 33.3%).

IBFAN further stressed the insufficient duration of the maternity leave (12 weeks) and the absence of legal provision allocating breastfeeding breaks. Finally, it noted that no specific programmes on IYCF and HIV/AIDS have been developed.

Discussion on infant and young child feeding

In its preliminary statement, the delegation began by mentioning the implementation of the integrated community health services through the SISCa programme. The programme is implemented in 13 districts, 65 Sub-Districts, and 442 villages. The delegation also mentioned the health promotion programmes aimed at pregnant women and granting them prenatal care and counseling. Finally, the delegation underlined the launch of the National Commission on Child rights in 2014, which is mandated to promote, defend and monitor children’s enjoyment of their rights.

The CRC Committee highlighted the most important problems in the country, such as the high rates of poverty, hunger, child malnutrition, stunting and wasting as well as the huge differences between rural and urban areas in terms of enjoyment of equal services and possibilities. It noted with concern the inconsistent data collection, as ministers do not use similar indicators, and the lack of regulation to control business sector activities that could affect children and their families. More specifically, the Committee noted that about 7 out of 10 children are not breastfeed until 2 years of age and asked what is done to encourage mothers to breastfeed. It also pointed out the insufficient duration of the maternity leave as well as the absence of provision allowing working women to take breastfeeding breaks.

The delegation of Timor-Leste recognized that malnutrition constitutes a major challenge for the country. Consequently, some programmes and measures have been put in place to remedy the situation, such as the promotion of appropriate infant feeding practices (exclusive breastfeeding under 6 months, adequate introduction of complementary food for children between 6-23 months, continued breastfeeding until 2 years or beyond, appropriate feeding for infants born from HIV-infected mothers). Regarding maternity protection, the delegation explained that working women are entitled to 90 days of maternity leave and once they return to their workplace, they are allowed to take 3 hours per day to breastfeed.

In its follow-up questions, the Committee emphasized breastfeeding as being the best nutrition for infants and asked whether the Ministry of Health was planning to ratify the law implementing the International Code of Marketing of Breastmilk Substitutes. The Committee also stressed the low number of hospitals certified as “Baby-Friendly” and asked how many hospitals have currently complied with the Ten Steps to Successful Breastfeeding.

The delegation referred to the 2013 Demographic Health Survey whereby the following results were established: early initiation of breastfeeding=93%, exclusive breastfeeding at 3 months=63%, breastfeeding between 12-15 months=75% and  continued breastfeeding 20-23 months=39%. Moreover, the delegation explained that 5 hospitals and 65 different health centers were complying with the Baby-Friendly Hospital Initiative.  The delegation added that the Prime Minister decided until November 28, 2016, all families should be visited by healthcare professionals. A programme of medical training has been set up in partnership with the Cuban government in order to increase the number of doctors. In the future, each of the 200 villages should be attributed 1 doctor and 2 nurses.

Concluding Observations

The Concluding Observations have not yet been released. This article will be updated following their publication.

Brazil at the CRC: Need of Regulatory Decree to Enforce the Code

On September 21 and 22, the Committee on the Rights of the Child considered the combined 2^nd to 4^th periodic report of Brazil on the situation of the implementation of the Convention on the Rights of the Child in the country. 

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

General overview of breastfeeding in Brazil

IBFAN highlighted that high rate of maternal mortality in Brazil, while the rates of exclusive breastfeeding and continued breastfeeding at 2 years are low. Besides, IBFAN expressed concern about the lack of systematic and regular monitoring of breastfeeding indicators.

Besides, the pre-service training curricula should be reviewed and updated according to the scientific evidence and WHO recommendations. In addition, the practical teaching of clinical management of breastfeeding and healthy complementary feeding should be improved, and health professionals should be properly trained on implementation and enforcement of the International Code of Marketing of Breastmilk Substitutes (hereafter: the Code).

IBFAN also noted that the protection of breastfeeding is insufficient due to the lack of enforcement of the Law 11-265 of 2006 implementing the Code. Therefore, the adoption of a regulatory decree is needed. 

IBFAN further highlighted that women working in the informal sector are not cover by the maternity leave. It also emphasized the small number of "baby-friendly" hospitals (about 9% of all health facilities) of which less than 50% showed to comply with the UNICEF 10 Steps to Successful Breastfeeding and the International Code of Marketing of Breastmilk Substitutes. Only 30% of children are born in an accredited Baby-Friendly Hospital.

Finally, there is no dialogue within the Ministry of Health between the department in charge of Children’s Health and Nutrition and the department in charge of HIV/AIDS, and there is no strategic action plan on infant and child feeding in emergencies.

Discussion on infant and young child feeding

The CRC Committee began by congratulating the state party on the progress achieved in terms of basic health services, but it noted that progress tis still to be made, in particular by improving the access to health services in rural areas. It highlighted that 10% of children have stunted growth and that child obesity rate has increased. The Committee also questioned the number of health personnel in hospitals and the quality of their training. It also mentioned the long queues of patients waiting to access hospital services and the medical errors that occurred in emergency departments. The Committee finally expressed concerns about the high rates of maternal and child mortality as well as about the rate of caesarean sections.

Regarding basic health care services, the Brazilian delegation answered that despite 40,000 basic health care units providing health services for free, the number of doctors is still insufficient. Therefore, the government launched the "More Doctors" programme and hired Cuban physicians to reinforce basic health care units. In addition, the delegation noted that child malnutrition decreased from 14% in 1990 to 1.7% in 2012. However, there is still a significant number of cases of malnutrition, especially among indigenous children. Indigenous population also shows higher child mortality rates than in the average population. For these reasons, the government has allocated more doctors in indigenous areas. 

In its follow-up questions, the Committee noted that Brazil has not yet ratified the ILO Convention No. 183 and asked whether the government plans to ratify it. Indeed, the Committee highlighted that such ratification could help improving the situation of working women, allowing them to continue breastfeeding. The Committee mentioned the Brazilian exemplary Law 11-265 of 2006 implementing the Code. However, it noted with concern the lack of a regulatory decree to enforce the law. Finally, the Committee asked how many hospitals comply with the UNICEF 10 Steps to Successful Breastfeeding.

The delegation admitted that 51% of the population is overweight (35% of boys and 32% of girls) and ensured the Committee that measures have been adopted to tackle this issue, including measures to promote breastfeeding and healthy eating habits for pregnant mothers and mothers of children under 5 years. A guide which focuses on healthy eating habits has been issued and updated in 2014. Besides, a regulatory decree enforcing the Law 11-265 of 2006 is to be signed in order to regulate the marketing of breastmilk substitutes. The decree is to be launched on the 12 October at the occasion of Children’s Day.

The Committee further asked the delegation to what is done to inform HIV-infected mothers about infant and young child feeding and especially breastfeeding. The delegation answered that the national policy on HIV/AIDS and breastfeeding provides that infected women should refrain from breastfeeding. Therefore, the government allocates them financial support to buy infant formula.

Concluding Observations

In its Concluding Observations, the Committee made both indirect and direct recommendations related with infant and young child feeding. It first recommended Brazil to increase investment in existing programmes aimed at improving the reach and quality of health services in order to ensure access to quality health services, particularly for indigenous children, Afro-Brazilian children and children living in rural and marginalized areas (§54) and to strengthen its efforts to ensure that Family Health Support Units (NASF) are accessible for indigenous children was also required (§56b). The Committee also urged the country to provide the Special Secretariat for Indigenous Health (SESAI) with adequate human, technical and resources to guarantee access to quality services for all indigenous population (§56a).

With regard to nutrition, the Committee recommended Brazil to allocate adequate human, technical and financial resources to the Indigenous Nutritional Supervision System (SISVAN) to ensure that children affected by malnutrition receive adequate food and safe drinking water (§56c).

After expressing concerns on the high level of obesity and vulnerability of children to unregulated advertising promoting unhealthy food (§57), the Committee thus recommended the State party to take all necessary measures to address obesity, promote healthy lifestyles, raise awareness of health nutrition and establish a regulatory framework from advertising in order to control misleading advertising (§58).

The Committee also highlighted the increase in new HIV infections among adolescents (§61), recommending Brazil to improve access to quality, age appropriate HIV/AIDS, sexual and reproductive health services (§62a). With regard to children and business sector, the Committee specifically recommended Brazil to establish a regulatory framework for the impact of business sector on children’s right particularly the mining and construction sector, agribusinesses, food enterprises to ensure that their activities do not affect human rights (§22a). Likewise, it recommended the state party to ensure effective implementation by companies of international and national environment and health standards and appropriate sanctions or remedies when violations occur (§22b) as well as full disclosure of the environmental, health and human rights impacts of company’s business activities and their plans to address such impacts (§22c).

With reference to environmental health, the Committee recommended the state party to ensure the enforcement of existing laws and regulations concerning the use of agrochemicals (§66a) and improvement of water supply infrastructure (§66b), and to raise awareness programmes for communities living in affected areas to minimize the risks of being exposed to contaminated water and food (§66d).

Finally, regarding breastfeeding promotion, the Committee urged Brazil to improve the practice of exclusive breastfeeding for the first six months of age through awareness-raising measures including campaigns, information and training  for relevant officials, in particular staff working in maternity units and parents as well as to strengthen the monitoring of existing marketing regulations relating to breast milk substitutes (§68). 

Update 4 November 2015: The President of Brazil signed the regulatory decree related to the Law 11-265 of 2006 and thus, allowed full enforcement of the law implementing the Code.

Bangladesh at the CRC: Concerns about Declining of Exclusive Breastfeeding Rates and Low Coverage of Skilled attendance at Birth

On September 15^th and 16^th, the Committee on the Rights of the Child considered the 5^th periodic report of Bangladesh on the situation of the implementation of the Convention on the Rights of the Child in the country. 

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

General overview of breastfeeding in Bangladesh

IBFAN pointed out the low coverage of skilled attendance at birth, especially in rural and urban regions (28% and 55% respectively). Moreover, IBFAN also noted with great concern a declining trend in exclusive breastfeeding rates under 6 months between 2012 (64%) and 2014 (55%). Such situation reveals a lack of knowledge and awareness on Infant and Young Child Feeding (IYCF).

Even though the median duration of continued breastfeeding is estimated at 32.8 months, the complementary foods are introduced at an early age, resulting in a low median duration of exclusive breastfeeding, estimated at 1.8 months.

IBFAN also highlighted the absence of a National Breastfeeding Committee that would monitor the implementation of the National IYCF policy. The lack of systematic monitoring of breastfeeding indicators is also of concern. Besides, there is also a failure to enforce the International Code of Marketing of Breastmilk Substitutes and no sanction mechanism is in place to punish Code violations.

The report also flagged the importance to increase the number of Baby-Friendly certified health facilities and monitor their compliance with Ten Steps to Successful Breastfeeding, as 23% of hospitals are still not certified as “baby-friendly”.

Regarding maternity protection, IBFAN noted that women working in the informal sector are not covered by the maternity leave legislation and that there is neither paternity leave nor legal provision entitling working mothers to take breastfeeding breaks.

On a more positive note, IBFAN noted that Bangladesh infant and young child feeding curricula or session plans are adequate, as well as the development of standards and guidelines for mother-friendly childbirth procedures and support. In addition, all pregnant women have access to community-based support systems and services on infant and young child feeding and health workers are receiving adequate training in counseling and listening skills for IYCF.

Discussion on infant and young child feeding

The delegation first highlighted the decrease of maternal mortality rates from 335 (per 100,000 live births) in 2001 to 194 in 2010. Infant mortality rates have also reduced from 45 to 33 per 100,000 live births. The delegation also explained the existence of childcare centers across the country in order to support working mothers through the provision of baby-sitting services. Through the establishment of community clinics and hospitals, nutritional support is granted to mothers and children from the beginning of the pregnancy until the newborn reaches the age of 2 years. These measures are implemented in the framework of a “1,000 days” programme.

The CRC Committee congratulated Bangladesh for the adoption of the Children Act in 2013 and the law regulating the marketing of breast milk substitutes. However, the Committee expressed concern about the decline trend in exclusive breastfeeding rates under 6 months between 2012 (64%) and 2014 (55%), noting that 26% of children age between 4-5 months are bottle fed.

Moreover, the Committee considered that the low exclusive breastfeeding rates couple with the low coverage of skilled attendance at birth, reveal a low level of knowledge and awareness on Infant and Young Child Feeding (IYCF). Thus, it invited the state party to implement measures to ensure that all deliveries would be attended by skilled personnel. It also urged Bangladesh to take measures in order to increase the percentage of institutional deliveries and to monitor breastfeeding key indicators on a regular basis.

The Bangladeshi delegation answered that in 1995 the rate of neonatal mortality was very high (54 deaths per 1,000 live births) and that it came down to less than 30% in 2014 (Bangladesh Health Survey). However, the delegation admitted that this still constitutes a challenging issue for the country. The delegation added that the rate of institutional deliveries increased from 5% in 1990 to more than 35% in 2014. Regarding exclusive breastfeeding until the age of 6 months, the delegation stated that the rate increased from 42% in 2004 to 64% in 2011. [Note from IBFAN: Its is of concern that this rate again went down to 55% in 2014.]

In its follow-up questions, the Committee noted that there is no information available on the creation of the National Breastfeeding Committee and stressed that the International Code of Marketing of Breastmilk Substitutes is only partially implemented in the country. The Committee expressed concern about the partial implementation of the Baby-Friendly Hospital Initiative throughout the country and emphasized the insufficient monitoring of the Ten Steps to Successful Breastfeeding in the certified facilities. The Committee regretted that women working in the informal sector are not granted maternity leave and noted the absence of paternity leave. The CRC Committee finally added that child underweight has still to be tackled in the country.

The delegation replied mentioning that maternity leave has been increased from 4 months to 6 months. However, it admitted that the adverse effect of this legislation is that private employers are discouraged to hire women. In addition, the delegation noted that the law implementing the Code does not allow media advertising for breastmilk substitutes as well as the promotion of breastmilk substitutes in hospitals and clinics.

Moreover, the delegation noted that there is a National Breastfeeding Committee headed by the Ministry of Health and Welfare. This Committee is in charge of implementing the IYCF strategy. The delegation also explained that at every level of the health care system, there are trained gynecologists in charge of performing cesarean sections with the assistance of an anesthesiologist. Finally, the delegation agreed that further measures are to be taken in order to reduce the rate of underweight.

Concluding Observations

In its Concluding Observations, the Committee made several indirect recommendations to Bangladesh in relation with infant and young child feeding. However, it did not refer specifically to breastfeeding.

Regarding health resources and budget, the Committee urged Bangladesh to allocate sufficient financial and human resources to health services in all regions and upazilas to eliminate regional disparities in the provision of health services (§55a)

Referring to health and health services, the Committee recommended the state party to implement and apply the OHCHR Technical Guidance on child mortality (A/HRC/27/31), which includes specific recommendations on breastfeeding protection (including the implementation of the International Code of Breastmilk Substitutes) and promotion (§55b).

In particular, the Committee further highlighted that only one third of women deliver with a support of a skilled attendant and the regional disparities regarding the provision of health services (§54) and thus recommended the State party to develop and implement policies to improve health infrastructures and intensify training programmes for all health professionals (§55c).

Moreover, the Committee expressed its concerns about the 25 percent rise in the number of new infections with HIV/AIDS between 2001 and 2011 (§62). Therefore, it urged Bangladesh to promote the measures in place to prevent mother-to-child transmission of HIV/AIDS and develop a roadmap to ensure the effective implementation of preventive measures (§63a) as well as the improvement of the follow-up treatment for HIV/AIDS infected mothers and their infants (§63b). Make progress in the access and coverage on antiretroviral therapy and prophylaxis for HIV infected pregnant women is also requested by the Committee (§63c).

Finally, in relation with breastfeeding protection, the Committee congratulated Bangladesh on the adoption of a new law on banning of marketing of breastmilk substitutes (§54).