Ethiopia at the CRC: Very Low Rate of Skilled Attendance at Birth Compromises Neonatal and Maternal Health as well as Early Initiation of Breastfeeding

On May 22th, 2015, the Committee on the Rights of the Child considered the combined third to fifth periodic report of Ethiopia on the situation of the implementation of the Convention on the Rights of the Child in the country. The delegation of Ethiopia was led by H.E. Mrs. Zenebu Tadesse Woldetsadik, Head of delegation and Ministry of the Minister of Women, Children and Youth Affairs and H.E.Mr. Almaw Mengist Ambaye, State Minister of the Ministry of the Women, Children and Youth Affairs.   

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

General overview of breastfeeding in Ethiopia

Ethiopia presents high maternal and infant mortality rates and very low rates of skilled attendance at birth (10%). In such a context, IBFAN is particularly concerned about the low rates of exclusive breastfeeding within one hour after birth (51%). In addition, data show that exclusive breastfeeding is interrupted much too early (median duration of exclusive breastfeeding: 2.3 months).

IBFAN is also worried by the lack of systematic monitoring of breastfeeding indicators and the absence of information available on the results of the national policies and strategies related to infant and young child feeding, such as the National Nutrition Programme2013-2015 and the National Strategy for Child Survival.

In Ethiopia, only few provisions of the International Code of Marketing of Breastmilk Substitutes have been implemented and there is no information available on the National Breastfeeding Committee and on its activities. Besides, the Baby-Friendly Hospital Initiative is poorly implemented throughout the country, while the maternity leave is too short to enable working mothers to breastfeed exclusively up to 6 months. In addition, nursing mothers are not entitled to breastfeeding breaks.

 Finally, it is of concern that the 2013 Policy and Strategy on Disaster Risk Management does include measures to protect and support breastfeeding in emergencies, despite the fact that this topic is addressed in the 2004 National Nutrition Strategy for Infant and Young Child Feeding.

Discussion on infant and young child feeding

The CRC Committee highlighted that the breastfeeding rates are low in the country and pointed out the short median duration of breastfeeding. In addition, the Committee expressed concern about the partial implementation of the International Code and the lack of medical assistance during childbirth.

The Ethiopian delegation stated that the reduction of child mortality it is a top priority for the government and that new programmes focused on newborn health have been recently developed. The delegation also affirmed that increased financial support has been allocated to child health and that 30,000 health care workers have received specific training on newborn care.

In relation to nutrition, the delegation explained that the National Malnutrion Task Force is working in collaboration with the Breastfeeding Committee to coordinate all measures related to the 2004 National Nutrition Strategy for Infant and Young Child Feeding. The measures taken have led a reduction of the rates of stunting, underweight and child mortality under 5 years.

Regarding breastfeeding, the delegation highlighted that 52% of infants are exclusively breastfed until 6 months of age, while 98% are ever breastfed. The delegation explained that there are cultural beliefs that compromise the practice of exclusive breastfeeding (e.g. the belief that infants need to receive water). Therefore, the government implemented campaigns and activities to promote breastfeeding among mothers. Finally, the delegation noted that information on the International Code is delivered to health professionals during their pre- and in-service training.

Concluding observations

In its Concluding Observations, the Committee referred indirectly and directly to infant and young child feeding. 

After having welcomed the reduction of maternal, infant and under-five mortality rates, and the extension of immunization coverage and breastfeeding, the Committee expressed concerns about the very low per capita spending on basic health. It also deeply regretted the persistence of regional disparities in the provision of health services, and that malnutrition, infant, under-five and maternal mortality rates remain high (§55). Therefore, the Committee recommended Ethiopia to increase the annual expenditure per capita on health and eliminate disparities in the provision of health services as well as prenatal and postnatal care and immunization coverage (§56a). Moreover, Ethiopia was urged to implement the OHCHR Technical Guidance on child mortality (A/HRC/27/31), paying particular attention to rural and remote areas (§56b). Finally the Committee stressed the need to develop and implement policies to improve health infrastructures, and intensify training programmes for all health professionals, including the pastoralist health extension workers (§56d). 

With regard to the HIV/AIDS pandemic, the Committee urged Ethiopia to consider taking measures in order to eliminate geographical disparities regarding HIV and access to treatment, by enhancing free access to neonatal care and prevention of mother-to-child transmission (§58a). It also called for the improvement of the access to quality, age-appropriate HIV/AIDS, sexual and reproductive health services (§58d).

The Committee also made direct reference to breastfeeding, calling on Ethiopia to effectively address malnutrition in terms of stunting, wasting and low weight, particularly in rural and remote areas and develop public awareness programmes on food diversity consumption of nutritious food and on the benefits of breastfeeding in collaboration with the WHO and the UNICEF (§56c).

Turkmenistan at the CRC: Constructive Dialogue on Breastfeeding between the CRC Committee and the Turkmen Delegation

On January 13^th and 14^th, 2015, the Committee on the Rights of the Child considered the combined second to fourth periodic report of Turkmenistan on the situation of the implementation of the Convention on the Rights of the Child in the country. The Turkmen delegation was led by Mrs. Lyudmila Amanniyazova, Deputy Head of the State Statistics Committee and H.E. Mr. Atageldi Haljanov, Permanent Representative of Turkmenistan to the United Nations Office at Geneva.

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

General overview of breastfeeding in Turkmenistan

Breastfeeding rates are low in Turkmenistan: nine children out of 10 are not exclusively breastfed under 6 months of age and less than 4 children out of 10 receive continued breastfeeding until 2 years of age. The rate of early initiation of breastfeeding  is also very low (59.8%) while neonatal, infant and under-5 mortality rates are still high in the country.

In 2009, Turkmenistan adopted the Law on Protection and Promotion of Breastfeeding and Requirements for Infant Feeding Products, amended in 2013, which determines the main public policies on child nutrition and regulates the distribution and marketing of safe baby foods. However, this law implements only partially the International Code of Marketing of Breastmilk Substitutes and there is no clarity on its implementation or on any monitoring mechanism.

Besides, there is no recent data on the implementation of the Baby-Friendly Hospitals Initiative in the country. In 2009-2010, 81% of the maternity facilities were certified as ‘baby-friendly’. Finally, no comprehensive information on maternity protection, HIV and breastfeeding and infant feeding in emergnecies is available.

Discussion on infant and young child feeding

The CRC Committee specifically addressed the issue of breastfeeding and the lack of breastfeeding-related information. After welcoming the adoption of the 2009 law(see above)and its 2013 amendments, the Committee expressed concern for the low exclusive breastfeeding rate under 6 months and asked about the root causes of this drop as well as about the measures taken to tackle it.

Additional questions were made on the number of Baby-Friendly hospitals in the country and on the training available for expecting mothers and fathers on parenthood and breastfeeding practices. The CRC Committee also raised the issue of the training provided to health professionals on breastfeeding, the duration of the maternity leave and the existence of a paternity leave. It also highlighted that information on mother-to-child HIV transmission and on HIV and breastfeeding was missing.

The Turkmen delegation specified that according the 2009 law prohibits the distribution of samples of infant formula to families, in line with the International Code. It mentioned that currently, some 95% of hospitals and maternities are certified as “Baby-Friendly”, that expecting mothers learn about breastfeeding as part of their preparation to motherhood, and that about 2,000 parents have been given training on child care. Thanks to the measures undertaken, the rate of children ever breastfed increased  from 41% in 2008 to 61% in 2014. A study conducted in two regions of the country showed that 59% of children aged 0-5 months were exclusively breastfed. Lastly, a study assessed that doctors and nurses have good knowledge on breastfeeding.

Concerning maternity protection, the delegation explained that there are 3 types of State maternity allowances for child care, given respectively before delivery, at delivery and after deliver. It also mentioned that the maternity leave should not be less than 190 days, according to the Turkmen legislation, which also provides for a paternity leave. The delegation stated that legislation provides breastfeeding breaks of 30 minutes every three hours, available for lactating mothers with children up to 1 year and a half of age. The duration of the breastfeeding breaks can change depending on the number of children and it is considered as working time, thus not deducted from the salary.

Additional information was given on the network of health care centres that is being developed and empowered throughout the country, in order to provide coverage of maternal and children’s health services in the main cities as well as in the rural areas. No information was given on HIV and breastfeeding.

Concluding Observations

In its Concluding Observations, the Committee made several recommendations directly related to breastfeeding.

With regard to breastfeeding protection, the Committee urged Turkmenistan to “enact legislation implementing all the provisions of the International Code of Marketing of Breast-Milk Substitutes” (§ 49b), as well as to “ensure that working mothers have the practical possibility to breastfeed, including by developing breastfeeding-friendly workplaces and child care centres at work” (§ 49e). Concerning the promotion of breastfeeding, the Committee recommended the country to enhance its efforts to promote exclusive breastfeeding practices (§ 49a) and to raise awareness about optimal breastfeeding practices among the population (§ 49c). Finally, on data collection, the Committee urged Turkmenistan to “ensure systematic collection of data on infant and young child feeding” (§ 49d).

The Dominican Republic at the CRC: High Rate of Maternal Mortality and Low Rates of Breastfeeding

On January 12^th and 13^th, 2015, the Committee on the Rights of the Child considered the combined third to fifth periodic report of the Dominican Republic on the situation of the implementation of the Convention on the Rights of the Child in the country. The delegation of the Dominican Republic was led by Mr. Gertrudis Alberto Padilla Vicioso, responsible for the Public Policies Department of the National Council on the Child, Mrs. Brígida Sabino Pozo, responsible for the Late Registration Central Unit of the Central Electoral Board, and Mrs. Khaterine Urbáez Martínez, Minister Counselor for Human Rights to the Permanent Mission of the Dominican Republic to the United Nations Office at Geneva.

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

General overview of breastfeeding in the Dominican Republic

The Dominican Republic presents low rates of early initiation to breastfeeding (65%), exclusive breastfeeding under 6 months (6.7%) and continued breastfeeding at 2 years of age (25%). Such performance is alarming and questions the quality of the information received by mothers in health care facilities, considering that almost high rate of institutional delivery in the country 98%). It is also of concern that the use of infant formula is widespread among the population and that more than half of the newborns are fed with food other than breastmilk even before being breastfed at all.

In addition, the National Breastfeeding Commission lacks funds to implement the National Strategic Plan for Maternal and Infant Mortality Reduction and to perform its monitoring function on the application of Ley 8-95 implementing the International Code of Marketing of Breastmilk Substitutes, which leads to frequent Code violations.

Besides, only 6% of the hospitals and maternities were ever certified as “Baby-Friendly” and thre is no follow-up of the BFHI requirements in the certified facilities. IBFAN’s alternative report also stressed the lack of regular training of health professionals on HIV and infant feeding.

The scarce maternity protection at work is another factor which could explain the low breastfeeding rates in the Dominican Republic. Finally, the Guidelines for Infant Feeding in Emergencies were issued in 2010 but are not effectively implemented and, consequently, the baby-food industry keeps distributing and donating its products during emergencies.

Discussion on infant and young child feeding

The Committee specifically addressed the issue of neonatal and maternal mortality, and the low rate of exclusive breastfeeding in the Dominican Republic. It highlighted that although 80% of the maternal deaths are preventable, the rate of maternal mortality is still high, which seems difficult to understand in regard to the high percentage of institutional deliveries (97%). The Committee also expressed concerns about the low rate of exclusive breastfeeding rate under 6 months (8%) as well as about the early introduction of solid and semi-solid food which can lead to chronic malnutrition.

The Dominican delegation provided some data related to the implementation of the Strategic Plan for Maternal and Infant Mortality Reduction and mentioned the recent creation of a human milk bank as activities by the government in order to promote breastfeeding.

The Committee reminded the delegation that when given adequate pre- and perinatal support, nearly 100% of mothers can breastfeed their baby. The Committee welcomed the existence of human milk bank, but clearly stated that breastfeeding support is even more important.

The Dominican delegation pointed out that the low rate of exclusive breastfeeding is one of the main concerns of the Dominican health system and that the implementation of the Strategic Plan for Maternal and Infant Mortality Reduction will hopefully lead to its improvement as well as to the improvement of the rates of neonatal and maternal mortality. Regarding HIV and infant feeding, the head of the delegation mentioned that 95% of the children living with HIV have been infected through mother-to-child transmission and that services are being put in place in order to stop mother-to-child transmission of HIV in newborns.

Finally, the Dominican delegation expressed the commitment of the government to collect data on breastfeeding (including on the rate of exclusive breastfeeding under 6 months) in a more comprehensive way in view of the next review by the CRC Committee.

Concluding Observations

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

Concerning health and health services, the Dominican Republic was asked to strengthen efforts to reduce child and maternal mortality by taking into account the OHCHR Technical guidance on child mortality(§ 50b) which includes specific recommendations on breastfeeding protection (including the implementation of the International Code) and promotion. It was also urged to establish and independent mechanism for investigating cases of child and maternal mortality and to apply legal sanctions whenever such cases are due to health personnel negligence (§ 50c), as well as to undertake all necessary measures to ensure that adequate safe water and sanitation are available, especially in hospitals (§ 50f).

Specifically referring to breastfeeding, the Committee expressed its concerns about the low rate of exclusive breastfeeding under 6 months (6.7% in 2013), the early introduction of other foods, as well as the frequent recommendations of breastmilk substitutes by the health personnel. Therefore, it urged the Dominican Republic to increase efforts to eliminate child malnutrition (§50d) and to promote breastfeeding through educational campaigns. It also requested the State party to adequately implement the Strategic Plan on Breastfeeding (2012-2016), the International Code of Marketing of Breast-Milk Substitutes and the Child-Friendly Hospital initiative [...], and to strengthen maternity protection (§ 50e).

Inadequate Infant Feeding Practices in Indonesia (CESCR)

On the 1^st of May 2014, the Committee on Economic, Social and Cultural Rights concluded its consideration of the initial report of Indonesia on the implementation of the International Covenant on Economic, Social and Cultural Rights.

IBFAN presented an alternative report to inform the CESCR Committee on the situation on the issue of infant and young child feeding.

General overview of breastfeeding

IBFAN’s alternative report highlighted that inadequate infant feeding practices co-exist with high rates of child mortality in Indonesia. Indeed, the rate of early breastfeeding initiation is low (less then 30 %) and more than half of the children are not breastfed until 6 months of age, while a third of the children under five years old are stunted. Besides, complementary foods are introduced too early to almost 45% of the children. The lack of any policy or programme on infant and young child feeding has also been emphasized, as well as an absence of sanctions in case of violations of the International Code ofMarketing of Breastmilk Substitutes, despite the implementation of many provisions of this Code into national legislation. The absence of data on the number and quality of Baby-friendly hospitals has also been shown as problematic. Finally, the absence of maternity protection for women working in the informal sector, as well as the lack of public awareness about HIV/AIDS and infant feeding, have been emphasized. 

Discussion on infant and young child feeding

The Committee has not discussed the issue of infant and young child feeding.  However, the delegation has pointed out that Indonesia’s efforts were raised on improvements of healthcare services and maternal mortality rate.

CECSR Concluding Observations

In its Concluding Observations, the Committee expresses concern about the increase of the maternal mortality rate in Indonesia due, among others, to insufficient sexual and reproductive health services The Committee calls on Indonesia to address disparities in the availability and quality of maternal health care services. Moreover, the Committee urges the State to ensure access to sexual and reproductive health services to unmarried women and teenagers as well as to married women without the consent of their spouses (para 32).  

Yemen still faces Challenges regarding Protection and Promotion of Breastfeeding

The Republic of Yemen presented its consolidated 4th periodic report on the situation of the implementation of the Convention on the Rights of the Child in the country.

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

General overview of breastfeeding in Yemen

With a low rate of children initiated to early breastfeeding (30%) and insufficient rates of exclusive breastfeeding till 6 months (12%), Yemen still has a lot to do in order to protect and promote breastfeeding among the population. Bad feeding practices, such as the habit of giving other liquids than human milk to babies and premature introduction of complementary foods are common, leading to high stunting and infant mortality rates. More than 53% of the children under  6 months are stunted and 57 children die before the age of 1 for every 1000 live births. Although the International Code of Marketing of Breastmilk Substitutes has been partially translated into law in 2002, its effective enforcement and monitoring has not been ensured. Moreover, there are no baby-friendly hospitals in Yemen.

Discussion on infant and young child feeding

During the presentation of its report, the Yemeni delegation has admitted that malnutrition is a crucial problem for Yemen, causing almost half of child mortality in the country. In 2012, some 58% of children were stunted, while 15% of them were in danger of death. Together with various international and national partners, the delegation reported that the Ministry of Health has launched different programmes addressing this important issue. An academic conference on malnutrition has recently been held and this topic is to be included in each curriculum for health professionals.  Other programmes have been launched, with focus on prevention and identification of solutions to improve nutrition for children and women, especially mothers. In addition, the government is currently developing a programme to raise awareness about breastfeeding among the population. Finally, a campaign focusing on nutrition in remote areas, targeting mothers and children, has started in 2013. 

CRC Committee members asked further clarifications on the information provided by the delegation. They addressed issues related to breastfeeding, such as the enforcement and monitoring of the 2002 law to protect breastfeeding and implement the International Code of Marketing of Breastmilk Substitutes, and the concrete efforts made to increase the rate of exclusive breastfeeding until 6 months. CRC Committee members also asked whether Yemen has the intention to increase its budget line for health in general, and what is the budgetary allowance allocated to tackle malnutrition. Finally, a question on the way to measure the results of the awareness raising campaigns on malnutrition has been posed.

The Yemeni delegation responded that in 2006, 11% of children under 6 months received exclusive breastfeeding, a percentage which the government is currently trying to increase to 20% by 2015. Besides, the project entitled “Programme for advice regarding nutrition of infants” provides a training module aimed at health professionals to increase awareness about breastfeeding. Regarding the budgetary allocations, the delegation explained that even though the Ministry of Health has no specific budget line for nutrition, 3.5% of its budget is devoted to fight malnutrition. For instance, the Ministry of Health is currently trying to address nutrition and hygiene issues through a national educational TV channel, where information is regularly transmitted. The government claimed its intention to increase the budget for health. Apart from its own budget, Yemen has received funds from international donors, such as UNICEF, World Bank, World Food Programme and International Medical Call, in order to tackle malnutrition through different programmes. According to the delegation, results of such programmes can be measured after 30-40 years only, depending on the issue tackled. The reduction of stunting and wasting among the population will be seen long time after measures have been taken, although field indicators show an improvement of nutrition status.

Finally, the delegation explained that since the law to protect breastfeeding and implement the International Code was adopted in 2002, the marketing of infant formulas is strictly regulated and infant formulas producers are allowed to advertise their products only if their allegations are based on scientifically verified measures. According to Yemen, the marketing of infant formulas within hospitals and clinics, such as free samples distribution, is currently prohibited. However, the issue of the monitoring and enforcement of the 2002 law remained unanswered.

CRC Committee's Concluding Observations

In its Concluding Observations, the CRC Committee made recommendations on the importance of data collection (para 18), on the right of the child to the highest attainable standard of health, mentioning the necessity to promote breastfeeding and implement the International Code of Marketing of Breastmilk Substitutes (para 56), and on HIV/AIDS programmes (para 64).

The CRC reminded Yemen its 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, Yemen is required to pay attention to CRC General Comment N° 15 on the right of the child to the enjoyment of the highest attainable standard of health (art. 24) and to “(a) ensure that appropriate resources be allocated to the health sector, with particular attention to specific maternal and child health care and develop and implement comprehensive policies and programmes to improve the health situation of children, in particular to respond to high rates of malnutrition and diarrhoea infections; (c) ensure access to safe water and sanitation services in rural and poorest areas [...]; (d) enhance efforts to promote exclusive breastfeeding practices, by ensuring the implementation and compliance with the International Code of Marketing of Breast-milk Substitutes, and establish a monitoring and reporting system to identify violations of the Code. This includes the establishment of baby-friendly hospitals with the promotion of breastfeeding from birth”.

The CRC Committee also stressed the importance of collecting disaggregated data on a comprehensive scale and therefore, urges Yemen to expeditiously improve its data collection system.

In addition, the Committee expressed its concern about the scarcity of information provided with respect to the implementation of the National HIV/AIDS Prevention and Control Programme, as well as about the limited provision of antiretroviral prophylaxis to prevent mother-to-child transmission and general stigmatization of HIV/AIDS within the Yemeni society.  Therefore, it urged the government to expand the coverage of the national HIV programme and to ensure universal coverage for HIV testing and free antiretroviral drug provision.