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.

Hungary at the CRC: Lack of Data, but Willingness to Further Consider Breastfeeding

On the 9th and 10th September 2014, the Committee on the Rights of the Child considered the combined third to fifth periodic reports of Hungary on the situation of the implementation of the Convention on the Rights of the Child in the country. The delegation of Hungary was led by the Deputy State Secretary, Ms. Tünde Fürész and it includes a desk officer of the Department of Health Policy, Ms. Gabriella Kissné Erdélyi as well as the Acting Head of Department of the General Directorate of Social Affairs and Child Protection, Gulyásné dr. Kovács Erzsébet.

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

General overview of breastfeeding in Hungary 

Hungary shows a high rate of caesarean sections (30.8%) which might have a negative impact on the rate of early initiation of breastfeeding. However, the latter information is not available. Moreover, there is no available data on exclusive breastfeeding in the first 6 months for the recent years. The most recent data show a low rate of exclusive breastfeeding at the age of 6 months (±42%).

Generally, Hungary shows a poor monitoring of key breastfeeding as well as infant and young child feeding (IYCF) indicators. Furthermore, since 2002, there is neither information on courses on breastfeeding nor on others efforts to promote breastfeeding in the country. There is also a lack of information concerning the past and current activities conducted by the National Committee on Breastfeeding.

According to our IBFAN International Code Documentation Centre, only few provisions of the International Code of Marketing of Breastmilk Substitutes have been fully implemented into the national legislation. Moreover, the national Baby-Friendly Hospital Initiative (BFHI) coordinator, Dr. Cholnoky, also emphasized that baby food companies systematically violate the International Code by providing free sample and promotional materials to mothers.

In 2002, Dr. Cholnoky deplored that the BFHI was not followed by the medical professionals. At that time, the lack of knowledge about breastfeeding practices was identified as the main barrier to the widespread of the BFHI. However, the practice of ‘rooming-in’ (allowing mothers and infants to remain together) was common. Currently, out of 119 hospitals, there are 17 hospitals certified as “baby-friendly” in the country.

Hungary shows low fertility and female employment rates that are largely explained by insufficient support for parents to reconcile work and care commitments. Maternity leave lasts 24 weeks and the amount of maternity leave benefits is of 70% of the daily average gross earnings of the previous year. However, mothers working within the informal sector are not entitled to maternity leave benefits.

Data shows that in Hungary the number of pregnant women living with HIV who received antiretroviral medicaments for preventing mother-to-child transmission were of 5 in 2010 compared to 9 in 2009.

Finally, there is no information available on any emergency preparedness plan which may ensure an integrated response capable of protecting and supporting breastfeeding in case of emergencies.

Discussion on infant and young child feeding

The Committee showed particular interest in health issues and asked the Delegation to provide information about actions taken in this regard, especially to tackle deficiencies within the health system which affect children. A lack of well-trained health professional on pre-natal period was highlighted. The Committee mentioned the WHO and UNICEF recommendations related to children’s right to health as the correct path to follow.

In this framework, breastfeeding was specifically addressed and given particular attention. The Committee expressed concern in relation to the very low rate of infant early initiation of breastfeeding which is caused among others by aggressive marketing policies consisting in the distribution of free sample in maternity wards. In this regard, the Delegation clarified that every single formula given in hospital contains a clear notice affirming that breastfeeding is the best practice. Furthermore, it stressed that marketing in hospitals is prohibited.

The Committee also asked for further explanations with regard to the hospital rule preventing mothers from keeping their children with them while in hospital. The Delegation asserted instead that children must stay with mothers in hospital, unless mothers ask to put children in another room. The Delegation is therefore willing to promote further the “rooming-in” practice as well as breastfeeding. In particular, Hungary aims at introducing the so-called “kangaroo mother care” system.

The Delegation of Hungary pointed out the existence of a National Committee on Breastfeeding, whose main task is to assess the quality of hospitals as “baby-friendly”. Moreover, the Delegation repeatedly stressed their leader position in Europe in breastfeeding rates. According to the Delegation, the global average is of 4 women who exclusively breastfeed in the first 6 months out of 10 (40%). In Hungary, 36% of women exclusively breastfeed in the first six months.

The Committee solicited further the Delegation for obtaining information about work-family life balance and maternity leave in the informal sector. The Delegation answered by mentioning the Hungarian Labour Act, according to which women must be given the opportunity to breastfeed during working hours.

Finally, the Committee highlighted the high rate of C-section cases, which have an impact on early initiation breastfeeding. The Delegation acknowledged that in the period 2008-2012 the rate of induced births was indeed quite high, thereby stressing the willingness to consider the issue further.

Concluding Observations 

In its Concluding Observations, the Committee made few indirect recommendations. At the level of general measures of implementation, it urged Hungary to “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” (§10).

With regard to health issues, the Committee recommended that Hungary “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” and that the Government “take measures to provide access to education on nutrition” (§47). 

In addition, the Committee issued direct recommendations related to infant and young child feeding (§51). It recommended that Hungary “take all necessary measures to encourage exclusive breastfeeding of infants until 6 months of age and provide data on the rate of breastfeeding in its next periodic report. The Committee also recommends that the State party 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”.