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.

Fiji at the CRC: BFHI Implemented, but Still to Be Strengthened

On the 4th and 5th September 2014, the Committee on the Rights of the Child considered the combined Second to Fourth Periodic Report of Fiji 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 Fiji.

General overview of breastfeeding in Fiji

The alternative report showed that 39.8% of infants aged six months or less are exclusively breastfed. Furthermore, a large proportion of children aged 6 months or less are given water (79.6%) as well as sweetened drinks. These data reveal therefore a lack of knowledge about optimal breastfeeding practices.

According to the 2011 World Breastfeeding Trends initiative (WBTi) report on Fiji, a national Infant and Young Child Feeding/Breastfeeding policy was adopted by the Government. Such a policy provided a National Breastfeeding Committee that is however now defunct. Moreover, the WBTi report stresses that “Information, Education and Communication” materials are available only in English.

The Government of Fiji has fully implemented the International Code of Marketing of Breastmilk Substitutes (the Code) in its entirety. However, an informal monitoring in a supermarket in November 2011 highlighted that complementary food labelling the product as suitable for age 4-6 months has been only partially obscured, which constitutes a violation of the Code.

The report highlighted that Fiji has established a national Baby-Friendly Hospital Initiative (BFHI) coordinator. By the beginning of 2009, all its 12 public hospitals were certified as “baby-friendly”. Nevertheless, two main problems have been encountered in its implementation. Firstly, hospitals fail to refresh BFHI courses every two years (as the WHO recommends) and, secondly, mothers are not provided for contacts of health care persons.

According to a study conducted by the Fiji Journal of Public Health, 57% of women who do not exclusively breastfeed pinpoint work as the obstacle to exclusively breastfeeding. The Fijian legislation provides indeed only 84 consecutive (12 weeks) days as maternity leave entitlement. For the first three births, such a leave is paid at the normal remuneration rate, whilst from the fourth child, the mother is entitled to only half the normal salary. Additionally, it is worth noting that there are no provisions concerning paid or unpaid breaks during work hours.

As far as HIV and infant feeding is concerned, it must be noted that a comprehensive policy on infant and young child feeding that includes infant feeding and HIV is lacking.

In coordination with UNICEF and WHO, Fiji developed a flyer on infant feeding during emergencies. However, neither a national plan nor a focus person has been identified to coordinate activities.

Discussion on infant and young child feeding

The Fijian Delegation first stated that the infant mortality rate in Fiji is of 13.7 per 1,000 live births and that perinatal mortality represents an important component of the mortality of children under 5 years old. Regarding maternal health, the Delegation indicated that last year, 4 maternal deaths have been registered in the country. The family health units deal particularly with women’s health, children health (including immunization) and reproductive health as well as with the fight against HIV. The Delegation also indicated that according an immunization state study, the immunization coverage rate is of 84.9%. It further stated that in 2014, collaborative, comprehensive guidelines on child protection aimed at health workers have been issued and that trainings of health professionals on this issue have been organized. Community health trainings are supported by family health units and include training of health professionals on issues related with neonatal intensive care units.

The Committee asked how many women breastfeed their child, by emphasizing that breastfeeding ties very closely with child’s health as well as whether the National Breastfeeding Committee is still operational.

The Delegation noted that suboptimal breastfeeding practices in Fiji contribute to increase the burden of Non-Communicable Diseases (NCDs). Therefore, breastfeeding and infant and young child feeding are part of the National Strategic Plan for NCDs. The Delegation also indicated that during the first decade of 20th century, Fiji has developed the implementation of the BFHI; during this period, the 3 main hospitals of the countries have been certified as “baby-friendly”. However, there is a current decline in the implementation of the BFHI. The Delegation further emphasized Fiji’s endorsement of the International Code on Marketing of Breastmilk Substitutes and informed the Committee that the National Breastfeeding Committee’s plans to hold a meeting on the 24th September 2014. Finally, the Delegation indicated that “Information, Education and Communication” materials are now available in Ataque language but have not been translated into other languages yet.

The Committee expressed further its concern about the current decline of Code implementation. It also highlighted that regular monitoring of the national legislation implementing the Code through an effective monitoring mechanism is crucial. With regard to the implementation of the BFHI and the Ten Steps to successful breastfeeding, the Committee noted that the training of health professionals and the monitoring of these trainings are very important. Finally, the Committee insisted on the importance of monitoring the marketing practices that occur in hospitals in order to make sure that Code policies are followed.

Concluding Observations

In the Concluding Observations, several indirect recommendations were made by the Committee. With regard to the general measures of implementation, it urged Fiji “to take all necessary steps to provide for a timely adoption of [a national comprehensive policy and strategy for children], and to ensure that sufficient human, technical and financial resources are allocated to facilitate its implementation" (§9). It also recommended that Fiji “take all necessary efforts to establish a comprehensive data collection system” (§15). 

Concerning health issues, the Committee recommended that Fiji “strengthen its efforts to further 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”. It also requested the Government to “enforce its efforts to 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” (§ 42).

Furthermore, the Committee issued direct recommendations related to infant and young child feeding (§54). It recommended that Fiji “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. It also urged Fiji to “raise awareness on the importance of breastfeeding and on the risks of formula feeding” and to “promote proper breastfeeding practices, as well as develop a policy on infant and young child feeding practices, which includes infant feeding and HIV".