Recommendations related to breastfeeding by the 66th Committee on the Rights of the Child

The 66^th Session of the Committee on the Rights of the Child (CRC Committee) took place in Geneva from 26 May to 13 June 2014. The Committee reviewed the progress of the implementation of the Convention on the Rights of the Child in 5 countries: India, Indonesia, Jordan, Kyrgyzstan and Saint Lucia. IBFAN submitted alternative reports on the situation of infant and young child feeding for each of the reviewed countries. The reports on India and Indonesia were written in collaboration with IBFAN groups in the countries. In its Concluding Observations, the CRC Committee referred specifically to breastfeeding in only 3 out of the 5 countries (India, Indonesia and Kyrgyzstan). Jordan and Saint Lucia did not receive any direct recommendation on breastfeeding, although they received recommendations on various topics indirectly related to breastfeeding.

General measures of implementation

The Committee has put an emphasis on the improvement of the data collection system in all of the 5 countries under review (India, Indonesia, Jordan and Kyrgyzstan), stressing the importance of collecting disaggregated data for the formulation, evaluation and monitoring of policies, programmes and projects for the effective implementation of the Convention.

The Committee also called for the development of a national plan for action in India and Saint Lucia, and insisted on the necessity to include time-bound and measurable goals and targets to effectively monitor progress in the implementation of child’s rights at national level (Saint Lucia).

Health resources and budget

The Committee also called for strengthening of resources allocated to health by urging Indonesia to substantially increase its allocations in the area of health to adequate levels and by recommending India to ensure that appropriate resources be allocated to health sector in order to improve the health situation of children, in particular to respond to high rates of acute respiratory infections, malnutrition and diarrhoea.

Besides, the Committee urged India to provide all professionals working with children, including health workers, with adequate and systematic training in children’s rights.

Preventive health

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

Indonesia has been requested to ensure provision of postnatal care for all women with the focus of reducing preventable and other diseases, particularly diarrhoea, acute respiratory infections and undernutrition, and to promote good infant and young child feeding practices. It has also been requested to strengthen and expand access to preventive health for all pregnant women and children, and to take all necessary efforts to reduce maternal mortality.

Kyrgyzstan has been asked to take measures to prevent deaths of children as a result of preventable and curable diseases.

Saint Lucia has been recommended to ensure adequate provision of postnatal care, as well as address the issues of low birth weight, increasing infant mortality rate, and obesity among children through awareness-raising efforts, and to continue dissemination of health information and the promotion of health education regarding basic child health to all segments of society.

Malnutrition

While India has been urged to ensure effective implementation of its National Security Food Act (2013) which contains provisions aiming at combating children’s undernourishment, Jordan has been asked to address child malnutrition and infectious diseases and Kyrgyzstan has been recommended to ensure that no child in the country is undernourished and that all children have access to adequate and sufficient food.

HIV/AIDS

The Committee has issued specific recommendations on the prevention of mother-to-child HIV/AIDS transmission (India, Indonesia) as well as a recommendation on antiretroviral therapy and prophylaxis for HIV-infected pregnant women and children (India).

In addition, general recommendations on the prevention of HIV/AIDS transmission by raising awareness of the public have been issued (Jordan, Kyrgyzstan).

Breastfeeding protection

Full implementation of the International Code on Marketing of Breastmilk 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 has insisted on the need for Indonesia and Kyrgyzstan to adopt the Code, and has requested India to ensure effective implementation of, and compliance with, the Code, as well as establish a monitoring and reporting system to identify Code violations and implement stringent measures against identified violators.

More generally, in the light of the CRC General Comment No. 16 on State obligations regarding the impact of the business sector on children’s rights, India has been requested to establish a clear regulatory framework for the industries to ensure that their activities do not negatively affect human rights, especially in relation to children’s rights. Yet, it is of serious concern that despite the systematic infringements of the Code committed by baby food companies in India, the Committee urged the country to implement more partnerships with the private sector with focus on health. According to IBFAN-GIFA, this call for an increase in number and thus importance of health projects and programmes modeled as “public-private partnerships”, is likely to lead to risks of conflicts of interest in both policy-making sphere as well as in programme implementation and, most importantly, may undermine the existing legally binding instruments and threaten development of clear and comprehensive regulatory framework.  Therefore, the recommendations of the Committee regarding the role of the private sector can be seen as conflicting.

Breastfeeding promotion

The Committee expressed concern over the insufficient rates of exclusive breastfeeding in India and Indonesia, and the poor implementation of the law on the promotion of breastfeeding in Kyrgyzstan, leading to inadequate information as well as free samples of baby food products provided to mothers.

Therefore, India has been specifically requested to promote exclusive breastfeeding practices, including the promotion of breastfeeding from birth, complementary feeding strategies with or without provision of food supplements as well as micronutrient interventions for mothers. Meanwhile, Indonesia has been urged to strengthen the promotion of breastfeeding, including by establishing a specific programme on the topic. Finally, Kyrgyzstan has been recommended to implement its legislation on the promotion of breastfeeding practices and ensure that mothers receive adequate information on the benefits of their breastmilk.

Breastfeeding support

However, no specific recommendation on breastfeeding support (e.g. inclusion of knowledge on optimal breastfeeding practices in health curricula) has been issued by the Committee following its 66th session.

Table 1. CRC Committee - Session 66 / 2014 -Summary of Concluding Observations on IYCF

Country		IBFAN report	Summary of specific recommendations on IYCF
7	India (3rd-4th periodic report)	yes	Indirect – General measures of implementation (para 14 (a); 20; 26; 30 (a)): prioritize the development of the National Plan of Action to implement the 2013 National Policy for Children; expeditiously improve its data collection system; provide all professionals working for and with children with adequate and systematic training in children’s rights. This includes in particular […] health workers […]; establish a clear regulatory framework for the industries operating in the State party to ensure that their activities do not negatively affect human rights or endanger […] other standards, especially those relating to children’s rights. Health (para 63; 64; 68): strengthen its efforts to address […] the existing disparities in access to and quality of health services, including by establishing partnerships with the private sector […]; ensure that appropriate resources be allocated to the health sector, with particular attention to specific maternal and child health care policies, programmes and schemes to improve the health situation of children, in particular to respond to high rates of acute respiratory infections, malnutrition and diarrhoea; ensure the effective implementation of the National Food Security Act. Direct (para 54): enhance efforts to promote exclusive breastfeeding practices, including the promotion of breastfeeding from birth, complementary feeding strategies with or without provision of food supplements as well as micronutrient interventions for mothers; ensure the effective implementation of, and compliance with, the International Code of Marketing of Breast-milk Substitutes, and establishment of a monitoring and reporting system to identify violations of the Code, as well as of stringent measures in all situations of violations of the Code. Violations include the promotion and distribution of samples and promotional materials by the private sector institutions involved in the Infant Formula marketing and distribution.
8	Indonesia (3rd-4th periodic report)	yes	Indirect – General measures of implementation (para 7): continue to upgrade its system of data collection to cover all areas of the Convention; ensure that all data and indicators are used for the formulation, monitoring and evaluation of policies, programmes and projects for the effective implementation of the Convention. Health (para 48; 52): increase its health budget and expand access to primary health-care services across all provinces; ensure the provision of primary health-care services for all pregnant women, including […]  postnatal care, and children, focusing on interventions to reduce preventable and other diseases, particularly diarrhoea, acute respiratory infections and undernutrition, as well as promote good infant and young child feeding practices; strengthen and expand access to preventive health care […] for all pregnant women and children, particularly infants and children under the age of 5; take all necessary efforts, including emergency obstetric care, to reduce maternal mortality; sustain the measures in place to prevent mother-to-child transmission of HIV/AIDS as well as provide for counselling and improve follow-up treatment for HIV/AIDS-infected mothers and their infants. Direct (para 54): strengthen the promotion of breastfeeding, including by establishing a programme to promote and enable all mothers to successfully breastfeed exclusively for the first six months of the infant’s life; adopt the International Code of Marketing of Breast Milk Substitutes.
9	Jordan (4th-5th periodic report)	no	Indirect – General measures of implementation (para 8 (b)): strengthen its mechanisms for data collection by establishing a central database on children and ensure that data are collected on all areas of the Convention and disaggregated. Health (para 44; 48): ensure equal access to quality health services by all children […] by addressing child malnutrition and infectious disease; improve access to quality, age-appropriate HIV/AIDS, sexual and reproductive health information and services.
10	Kyrgyzstan (3rd-4th periodic report)	yes	Indirect – General measures of implementation (para 7 (b)): develop a comprehensive system for collecting disaggregated data to cover all those under the age of 18 years. Health (para 48; 50): take measures to prevent deaths of children as a result of preventable and curable diseases, by educating parents and providing easy access to early medical intervention; take measures to ensure that no child in the country is undernourished and that all children have access to adequate and sufficient nutritious food; take all necessary measures to prevent transmission of HIV/AIDS by raising awareness of the public. Direct (para 54): take all necessary measures to implement its legislation promoting breastfeeding practices and ensure that all mothers receive adequate information on the benefits of their breast-milk;  adopt the International Code for Marketing of Breast-Milk Substitutes.
11	Saint Lucia (2nd-4th periodic report)	no	Indirect – General measures of implementation (para 11; 13; 17): develop and implement a comprehensive national plan of action for the full implementation of the Convention; to establish the Central Database Registry […] ensuring a comprehensive and integrated data collection system on children. Health (para 43(a) and (b)): ensure adequate provision of prenatal and post natal care, as well as address the increasing number of children born with low birth weight, the increasing infant mortality rate, and obesity among children, through awareness-raising efforts, and the reasons for these trends; dissemination of health information and the promotion of health education regarding basic child health to all segments of society.

Inadequate Infant Feeding Practices in Indonesia (CRC)

On the 5th of June 2014, the Committee on the Rights of the Child completed its consideration of the combined 3rd and 4th periodic reports of Indonesia on the implementation of the provisions of the Convention on the Rights of the Child in the country. 

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

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 of Marketing 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 noted that while in the 1990s, Indonesia had made progress in reducing neonatal and infant mortality, this advancement had slowed down in recent years. In addition, in regard to the high infant mortality rate in certain provinces, the expert has asked about the implementation of the Baby-friendly Hospital Initiative in Indonesia. In general, the expert has asked about the actions taken by State party to promote breastfeeding.

The Indonesian delegation responded by stating that there had been a national breastfeeding programme in place since 1990 promoting breastfeeding up until six months of age.  Nevertheless, the delegation admitted that the rate of early breastfeeding in Indonesia still remains low, and added that the provision of lactation rooms for breastfeeding mothers is scheduled in the government agenda.  

Concluding Observations

In its Concluding Observations, regarding the general implementation of the Convention, the Committee urged Indonesia to upgrade its system of data collection (para 7 (a)).

Regarding the issue of health, the Committee specifically requested the country to substantially increase the allocations in the area of health to adequate levels and to expand access to primary health-care services across all provinces (para 16 (a) and 48). It also emphasized the need to “ensure the provision of primary health-care services for all pregnant women, including access to postnatal care, and children, focusing on interventions to reduce preventable and other diseases, particularly diarrhoea, acute respiratory infections and undernutrition”, and called for the promotion of good infant and young child feeding practices (para 48 (a)). In addition, Indonesia has been urged to “strengthen and expand access to preventive health care for all pregnant women and children, particularly infants and children under the age of 5”. They should include preventive health interventions such as universal immunization services, oral rehydration therapy and treatment for acute respiratory infections (para 48 (b)). According to the Committee, the country should also “take all necessary efforts […] to reduce maternal mortality” (para 48 (c)). Regarding the issue of HIV/AIDS, the government was requested to “sustain the measures in place to prevent mother-to-child transmission as well as provide for counselling and improve follow-up treatment for HIV/AIDS-infected mothers and their infants to ensure early diagnosis and early initiation of treatment” (para 52).

Besides, the Committee emphasized the low rate of exclusive breastfeeding in the country and issued direct recommendations related to infant and young child feeding: it recommended Indonesia to “strengthen the promotion of breastfeeding, including by establishing a programme to promote and enable all mothers to successfully breastfeed exclusively for the first six months of the infant’s life” and to “adopt the International Code of Marketing of Breast Milk Substitutes” (para 56).

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).