67th Session of the CRC Committee: Recommendations Related to Breastfeeding

The 67th Session of the Committee on the Rights of the Child (CRC Committee) took place in Geneva from 1st September to 19th September 2014. The Committee reviewed the progress of the implementation of the Convention on the Rights of the Child in 5 countries: Croatia, Fiji, Hungary, Morocco, and Venezuela. IBFAN submitted alternative reports on the situation of infant and young child feeding for each of the reviewed countries. The reports on Croatia and Venezuela were prepared by the IBFAN groups in those countries. 

In its Concluding Observations, the CRC Committee referred specifically to breastfeeding in 4 out of 5 countries under review (Croatia, Fiji, Hungary and Venezuela). Morocco did not receive any direct recommendation on breastfeeding, albeit it was addressed several recommendations on various topics indirectly related to breastfeeding.

General measures of implementation 

The CRC Committee called for the timely adoption of a comprehensive policy covering all areas of children’s rights under the Convention in 4 out 5 countries and for the improvement of its implementation in Morocco. 

Furthermore, it recommended that all countries under review take all necessary steps to collect disaggregated data that should cover all areas of the Convention.

Health resources and budget 

The Committee also called for the strengthening of resources allocated to health, by urging Croatia to allocate adequate human resources to maintain the quality of health care and by requesting more generally Venezuela and Morocco to allocate sufficient human, technical and financial resources to the health sector and to effectively used them.

Preventive health

The importance of preventive health has been highlighted in several recommendations.

Morocco and Venezuela were asked to reduce child and maternal mortality. Fiji was specifically requested to reduce under-5 and infant mortality rate, especially by focusing on preventive measures and treatment, including immunization, improved nutrition and sanitary conditions, in particular in remote areas as well as to further reduce maternal mortality, by ensuring the generalization of specific actions to prevent post-partum bleeding and other major causes of maternal death. 

The Committee also recommended that Fiji enforce its efforts to improve prenatal care, including by increasing the training of midwiwes. 

Children’s access to health care was also addressed by the CRC Committee, especially with regard to rural areas. Indeed, Croatia was called to strengthen its efforts to ensure that all children enjoy equal access to health services with particular emphasis on children in rural areas and from minority groups. Hungary was instead requested to take measures to ensure that health care facilities and practitioners, including paediatric and specialized care practitioners, are available throughout the country including in rural areas.

Finally, the Committee showed concern about the lack of specific data in Venezuela. Therefore, it asked Venezuela to collect disaggregated data on children’s health related issues, in particular on child mortality, including under-5 mortality, maternal mortality, vaccination coverage, nutrition and breastfeeding.

Malnutrition

The Committee asked Morocco to take more effective measures to address the nutrition status of young children, while Hungary was requested to provide access to education on nutrition as well as nutritious food to all children in the country. 

The Committee also urged Venezuela to continue its efforts to reduce malnutrition and increase vaccination coverage.

HIV/AIDS

The Committee addressed the issue of mother-to-child transmission, by requesting Venezuela to collect disaggregated data on the number of cases of mother-to-child transmissions and the number of children and pregnant women under treatment. It also urged Venezuela to address the sporadic shortages of antiretroviral drugs and ensure that all HIV/AIDS positive pregnant women receive adequate treatment.

In this regard, the Committee asked Fiji to improve follow-up treatment for HIV/AIDS-infected mothers and their infants to ensure early diagnosis and early initiation of treatment.

Breastfeeding protection 

Full implementation of the International Code on Marketing of Breast-Milk Substitutes has proven to be an effective intervention to protect breastfeeding and to ensure that mothers are provided with adequate information on the best way to feed their infants and young children.

Therefore, the Committee urged Hungary to fully implement the provisions of the International Code and recommends that Fiji as well as Venezuela ensure that every hospital with a new-born nursery is regularly monitored on adequate implementation of the International Code. The Committee specifically asked Croatia to take all necessary legislative and structural measures, including monitoring, to control the marketing of breast-milk substitutes. 

More generally, in light of the CRC General Comment No. 16 on State obligations regarding the impact of the business sector on children’s rights, Morocco was asked to examine and adapt its legislative framework concerning legal accountability of business enterprises and their subsidiaries operating in or managed from the Morocco’s territory. The Committee also requested Morocco to establish monitoring mechanisms for the investigations and redress of violations of children’s rights with a view to improving accountability and transparency. 

Breastfeeding promotion 

The Committee expressed concern over the lack of awareness of the benefits of exclusive breastfeeding and risks of formula feeding in Croatia and Fiji. It also showed concern with regard to the high number of children aged up to 6 months who are not being exclusively breastfed in Fiji and the lack of information on this rate in Hungary. Finally, it expressed concern over the low number of baby friendly hospitals in Hungary. 

Therefore, it asked Fiji to raise awareness on the importance of breastfeeding and on the risks of formula feeding. Fiji was also urged to promote proper breastfeeding practices, as well as develop a policy on infant and young child feeding practices, which includes infant feeding and HIV. 

The same kind of recommendations was addressed to Croatia and Venezuela. Croatia was indeed requested to take action to improve the practice of exclusive breastfeeding, through awareness-raising measures, the provision of information and training to relevant officials, particularly staff working in maternity units, and parents. Venezuela was instead called to increase its efforts to promote breastfeeding by developing a comprehensive programme of action to promote exclusive breastfeeding, including for staff in hospital maternity wards, and to develop awareness raising campaigns. 

Finally, the CRC Committee recommended that Hungary specifically encourage exclusive breastfeeding of infants until 6 months of age, provide data on the rate of breastfeeding as well as increase the number of baby friendly hospitals. 

Breastfeeding support 

No specific recommendation on breastfeeding support (e.g. inclusion of knowledge on optimal breastfeeding practices in health curricula) has been issued by the CRC Committee following its 67th Session.

Table 1. CRC Committee - Session 67 / 2014 - Summary of Concluding Observations on IYCF

Country		IBFAN report	Summary of specific recommendations on IYCF
1	Croatia (3rd-4th periodic report)	yes	Indirect – General measures of implementation (§ 9, 15): adoption of the new National Strategy for Protection and Promotion of the Rights of the Child from 2014-2020 and ensure that it includes concrete goals and measures with clear indication of the roles and responsibilities of relevant bodies at all levels; expeditiously improve its data collection system. Health (§45): ensure that all children enjoy equal access to health services; allocate adequate human resources to maintain the quality of health care.  Direct (§49): improve the practice of exclusive breastfeeding, through awareness-raising measures, the provision of information and training to relevant officials, particularly staff working in maternity units, and parents; take all the necessary legislative and structural measures, including monitoring, to control the marketing of breast-milk substitutes.
2	Fiji (2nd-4th periodic report)	yes	Indirect – General measures of implementation (§§ 9, 15): take all necessary steps to provide for a timely adoption of a national comprehensive policy and strategy for children; establish a comprehensive data collection system. Health (§42): reduce the under-5 and infant mortality rate, especially by focusing on preventive measures and treatment, including immunization, improved nutrition and sanitary conditions, in particular in remote areas; improve prenatal care and further reduce maternal mortality, including by increasing the training of midwives and ensuring the generalization of specific actions to prevent post-partum bleeding and other major causes of maternal death.  Direct (§54): ensure that every hospital with a new-born nursery is regularly monitored on adequate implementation of the International Code of Marketing of Breast-milk Substitutes; raise awareness on the importance of breastfeeding and on the risks of formula feeding; promote proper breastfeeding practices, as well as develop a policy on infant and young child feeding practices, which includes infant feeding and HIV.
3	Hungary (4th-5th periodic report)	yes	Indirect – General measures of implementation (§§ 8, 10): improve the collection of data; adopt a comprehensive policy covering all areas of children’s rights under the Convention and ensure that its strategies and action plans are provided with necessary human, technical and financial resources for their effective implementation; Health (§47): ensure that health care facilities and practitioners, including paediatric and specialized care practitioners, are available throughout the country; provide access to education on nutrition.  Direct (§§ 50-51): encourage exclusive breastfeeding of infants until 6 months of age and provide data on the rate of breastfeeding; increase the number of baby friendly hospitals and take measures to fully implement the provisions of the International Code of Marketing of Breast-milk Substitutes.
4	Morocco (3rd-4th periodic report)	no	Indirect – General measures of implementation (§§ 7, 13, 23(a)): address previous recommendations related to data collection; ensure that the Integrated Policy on Children encompasses child protection and covers all areas under the Convention and all children; the Committee draws the State party’s attention to its general comment No. 16 (2013) on State obligations regarding the impact of the business sector on children’s rights and especially recommends that the State party examine and adapt its legislative framework concerning legal accountability of business enterprises and their subsidiaries operating in or managed from the State party´s territory. Health (§55(a)(b)): sufficient resources must be allocated for the health sector and effectively used; develop and implement comprehensive policies and programmes for improving the health situation of children and facilitating a greater and equal access to quality primary health services by mothers and children in all areas; take more effective measures to address maternal and infant mortality and the nutritional status of young children.
5	Venezuela (3rd-5th periodic report)	yes	Indirect – General measures of implementation (§§ 11; 20): finalize the design of the National Plan of Action for Children and Adolescents; expeditiously complete and implement the data collection system. Health (§§ 53(a)(b)(c)(d); 61(a)(c)): collect disaggregated data on children’s health related issues, in particular on child mortality, including under five mortality, maternal mortality, vaccination coverage and nutrition; allocate adequate human, technical and financial resources to the national public health system; building on data related to the causes, design a strategy to reduce child and maternal mortality, which includes the implementation of the two existing protocols on maternal and neonatal mortality; reduce malnutrition; collect disaggregated data on HIV/AIDS related issues, in particular on [...] number of cases of mother-to-child transmissions, [...] and number of children and pregnant women under treatment; ensure that all HIV/AIDS positive pregnant women receive adequate treatment.  Direct (§53(a);(e)): collect disaggregated data on breastfeeding; promote breastfeeding by developing a comprehensive programme of action to promote exclusive breastfeeding, including training for staff in hospital maternity wards, closely monitor the implementation of the International Code of Marketing of Breast-milk Substitutes and develop awareness raising campaigns.

Croatia at the CRC: Job Insecurity for Working Mothers and Low Rate of Exclusive Breastfeeding

On the 15th September 2014, the Committee on the Rights of the Child considered the combined Third and Fourth Periodic Report of the Republic of Croatia on the situation of the implementation of the Convention on the Rights of the Child in the country. The delegation of Croatia was led by the Assistant Minister for Social Policy, Strategy and Youth, Ministry of Social Policy and Youth, Mr. Hrvoje Sararić and includes the Senior Expert Advisor, Service for Children and Family, Ministry of Social Policy and Youth, Ms. Sabina Morosini Turčinović.

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

General overview of breastfeeding in Croatia

Information related to breastfeeding is not part of the national data collection survey. Such data are instead based on reports prepared by individual institutions or researchers.

In Croatia breastfeeding is generally considered the appropriate and desirable way to feed a newborn baby. Indeed, the rate of early initiation of breastfeeding is high (98%-99% in 2008-2009 and 91%-94% in 2011). However, there is a lack of awareness of the benefits of exclusive breastfeeding and the risks associated to formula feeding. This leads to premature cessation of breastfeeding. Indeed, the rate of exclusive breastfeeding at 6 months is very low (14.8%). Finally, Croatia lacks also of human milk banks, as there are none in the country.

In 2006 a National Breastfeeding Committee (NBC) was established by the Ministry of Health. In 2007 the National Program for Breastfeeding Protection and Promotion was completed by the NBC. However, such Program has not been implemented yet.

The Ordinance on Baby Foods for Infants and Young Children and Processed Cereal-Based Foods for Infants and Young Children (OJ 74/08) transposes the International Code of Marketing of Breastmilk Substitutes for the first time into a national legal measure. However, an appropriate monitoring system is missing.

It is worthwhile to mention that numerous courses on breastfeeding are available for health professionals in Croatia, albeit on a voluntary basis. However, the knowledge, attitudes and practices of most health professionals are still deficient.

The Baby-Friendly Hospital Initiative (BFHI) was successfully revived by UNICEF Croatia in 2006. As a consequence, 30 out of 31 maternity facilities are currently designated as ‘Baby-Friendly’. However, there has been a rapid drop in ‘Baby-Friendly’ standards following the BFHI designation.

Croatian job market (in both private and public sectors) discriminates against women. In particular, contracts are often terminated when the woman becomes pregnant or gives birth. By contrast, different kinds of maternity leave are available. Moreover, during the first 12 months after the child’s birth, mothers who are breastfeeding are entitled to two hours absence from work.

Plans of action and accompanying materials need to be prepared and finalised by the NBC and the Ministry of Health in order to be capable of coping with future emergencies.

Discussion on infant and young child feeding

The Committee specifically addressed the issue of breastfeeding. It welcomed the increase of mothers who choose to breastfeed (95%). However, it expressed concern with regard to baby food companies’ marketing and advertising concerning formulas and breastmilk substitutes.

The Delegation of Croatia pointed out the adoption in 2012 of a specific program aiming at promoting breastfeeding as the best practice and encouraging women to breastfeed. It also stressed the existence of a Committee for the Promotion and Protection of Breastfeeding.

Croatia expressed satisfaction with regard to the results brought by such a Program, especially in relation to breastfeeding in the first 3 months of life. Indeed, according to the Delegation, in the 3-year period of implementation of such Program, exclusive breastfeeding have increased dramatically. 95% of women exclusively breastfeed during the first days, whilst this rate decreases with time going by. In particular, 40% of women exclusively breastfeed after six months.

By addressing a specific concern of the Committee, the Delegation clarified that children can stay day and night with mothers who breastfeed while in hospitals.

The Delegation highlighted then the existence of a group for support led by nurses which gathers women and advised them in relation to breastfeeding. Furthermore, 8 counselling teams exist, which are well-recognised also outside the country.

It was acknowledged that until 2007, women in hospitals used to receive the so-called “happy baby” package, which contained advertisement for baby formulas. However, in 2007, a guideline was adopted prohibiting this package as well as other kind of advertisement in hospitals. Nonetheless, in the knowledge of the Delegation, this kind of advertisement is currently made in pharmacies, shopping malls and other places. Croatia declared its willingness to persist with the above-mentioned Program and continue to encourage breastfeeding. It also asserted that aggressive advertising will be prohibited, even outside the hospital system.

Furthermore, the Committee asked more generally for further information with regard to children’s rights and the business sector. Mr. Sararić, the Head of the Delegation, acknowledged that a balance between personal and working life is difficult in Croatia. However, the Croatian Government is endeavouring to better tackle this issue through the National Family Policy which is still under progress. Relevant measures need to be identified yet. In particular, Mr. Sararić mentioned the necessity to raise awareness about the strong need of family-working life balance within the business sector.

Concluding Observations

In its Concluding Observations, the Committee made several indirect recommendations. With regard to the general measures of implementation, it urged Croatia to “expedite the adoption of the new National Strategy for Protection and Promotion of the Rights of the Child for 2014-2020 and ensure that it includes concrete goals and measures” (§9) and “to expeditiously improve its data collection system” (§15).

Regarding health issues, the Committee recommended that Croatia “strengthen its efforts to ensure that all children enjoy equal access to health services” as well as “allocate adequate human resources to maintain the quality of health care”.

Additionally, the Committee issued direct recommendations related to infant and young child feeding (§ 49). It requested Croatia to “take action to improve the practice of exclusive breastfeeding, through awareness-raising measures, the provision of information and training to relevant officials, particularly staff working in maternity units, and parents”. It also recommends that the Government “take all the necessary legislative and structural measures, including monitoring, to control the marketing of breast-milk substitutes”.