Morocco at the CRC: Important Decline of the Exclusive Breastfeeding Rate

On the 3rd September 2014, on the occasion of the review of Morocco’s combined third and fourth periodic reports 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 Committee on the Rights of the Child about the situation of infant and young child feeding in the Kingdom.

General overview of breastfeeding in Morocco

The report highlighted the decline of exclusive breastfeeding of 23.3% between 1992 and 2011 (51% in 1992 and 27.8% in 2011). In 2005, the Ministry of Health has even declared that the decline of breastfeeding constitutes a concern of public health. An overall lack of knowledge about optimal breastfeeding practices has also been pointed out; indeed, more than 2 infants out of 3 are not breastfed within one hour after delivery, while the rate of predominant breastfeeding under 6 months of age is higher (45.5%) than the rate of exclusive breastfeeding, notwithstanding that predominant breastfeeding has been associated with an increased risk of diarrhoea. The addition of sugar in infants’ meals has also been highlighted as problematic. Finally, regional disparities have addressed: in rural areas, mothers are more likely to breastfeed, while in urban areas, breastfeeding rates are lower and bottle-feeding is more common.

In Morocco, only few provisions of the International Code on the Marketing of Breastmilk Substitutes have been implemented into law, despite the prohibition of the distribution of free baby food samples since 1992. Furthermore, some 43% of the hospitals and maternities of the country are certified as “baby-friendly” (43 out of 112). In addition, the report reflected the concern raised by the initiative “Rising to the Challenge” (convened by WHO, UNICEF and UNFPA in collaboration with other partners) about the lack of commitment of medical and paramedical institutions in raising awareness of the health professionals on the public health approaches and on the Ministry of Health primary health care guidelines in a sustainable manner and with a good standard of quality.

Finally, the report pointed out some others concerns related to infant and young children feeding: the absence of maternity leave for women working in the informal sector, the lack of knowledge on different ways of mother-to-child transmission of HIV as well as the lack of information on the current status of the 2008 pilot programme “Prevention of mother-to-child transmission of HIV”, and the absence of information on any emergency preparedness plan to ensure integrated response to protect and support breastfeeding in case of emergencies.

Discussion on infant and young child feeding

The Committee expressed concerns about the fact that only 43 hospitals out of 112 are certified as "baby-friendly" as well as about the fast decrease of the exclusive breastfeeding rate in the country. The Committee emphasized the emotional attachment between mothers and their child thrived through nursing and asked what are the measures set up by the government in order to support young mothers to breastfeed. In addition, the Committee highlighted the fact that in Morocco, only few provisions of the Code have been implemented into national legislation.

The Moroccan Delegation first stated that there are persisting differences between rural and urban areas in terms of access to reproductive health services. The government has therefore developed an action plan to improve health care provision in remote areas through hospitals and mobile health care services. The aim is to reach the ratio of 95% of skilled attendant present at birth. In terms of reproductive health, the government has implemented a national strategy and a booklet on this issue has been published in collaboration with the WHO. Regarding breastfeeding, the Delegation indicated that the 2011-2019 national strategy on nutrition focuses among other things on strengthening the nutrition of infants. In addition, the Delegation mentioned the existence of the national plan to encourage breastfeeding. It further stated that a bill aimed at encouraging breastfeeding has been prepared in the framework of the 2012-2016 national plan of action for child health. 

The Committee further asked what is done against companies that advertise their products in hospitals and if there is a national law implementing the Code and protecting breastfeeding against aggressive marketing of breastmilk substitutes.

The Delegation answered that breastfeeding is promoted within health facilities throughout the country.

Concluding Observations

In its Concluding Observations, the Committee made several indirect recommendations. With regard to the general measures of implementation, it urged Morocco “to take all necessary measures to address those recommendations that have not been implemented or not sufficiently implemented and, in particular, those related to data collection” (§7). It also asked Morocco to “ensure that the Integrated Policy on Children encompasses child protection and covers all areas under the Convention and all children” (§13).

Additionally, the Committee draws Morocco’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” (§23(a)).

With regard to health issues, the Committee recommended that Morocco “ensure that sufficient resources are allocated for the health sector and effectively used, and 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 of the country”. It also called the Government to “take more effective measures to address maternal and infant mortality and the nutritional status of young children” (§55 (a)(b)).

However, the Committee did not issued any direct recommendation related to breastfeeding.

Why non-binding international regulatory instruments do not work: A case study on breastfeeding protection

In 1981, the World Health Assembly (WHA) adopted the International Code of Marketing of Breastmilk Substitutes (the Code), to date completed and extended by fifteen subsequent relevant WHA resolutions forming integral part of it. The Code aims to ensure that parents can make fully informed decisions about infant and young child feeding by banning marketing practices that undermine breastfeeding. The Code thus contributes to safeguarding the health of infants and young children. In 1989, the Convention on the Rights of the Child (CRC) has enshrined breastfeeding protection, promotion and support in its article 24, which articulates the right of the child to the enjoyment of the ‘highest attainable standard of health’. The CRC’s General Comment No. 15 (2013), which interprets this right, specifies that besides States’ obligation to implement and enforce the Code (para 44), baby food companies have the direct obligation to comply with it in all contexts (para 81, emphasis added).

Notwithstanding this obligation, since 1981, baby food companies have systematically violated the Code provisions by malevolent marketing practices and tactics that mislead consumers and health professionals. The latest monitoring report Breaking the Rules 2014 published by the IBFAN’s International Code Documentation Centre covers 27 companies and presents 813 violations in 81 countries. It reminds the world that breastfeeding rates will continue to decline with the inevitable consequence of increased mortality and morbidity in infants and young children as long as corporate strategies that violate the Code continue. At present, there is no effective global mechanism that would ensure accountability of baby food companies which all seem prone to evade their human rights obligations in the absence of an effective sanction mechanism. Relying on implementation of the Code at country level has proven to be an unsatisfactory solution as all over the globe, baby food companies systematically resisted these efforts. Even in the minority of countries that have been successful and adopted adequate laws to regulate marketing of breastmilk substitutes, these companies, using their political influence and economic power, directly challenged the domestic law (e.g. in India) or resisted the adoption of enforcement mechanisms (e.g. in the Philippines).

The 33-year experience of Code implementation provides a strong argument to illustrate the necessity of a binding treaty on obligations of TNCs under human rights, a crucial step to the fulfilment of human rights of every human being, in this particular case of every child. Non-binding international recommendations, such as the Code, or “voluntary” corporate social responsibility measures, such as those indicated in the UN Guiding Principles, have failed to make TNCs liable for their human rights violations. Were a binding treaty on TNCs’ obligations adopted, violations of child rights caused by baby food companies would no doubt diminish, and those identified could be prosecuted and firmly sanctioned by an independent international judicial body. The treaty would help ensure the right of children to adequate food and nutrition as well as to health through the respect of the Code at global scale.

Portugal and the Issue of Breastfeeding in the Perspective of Child's Rights

Portugal presented its consolidated 3^rd and 4^th periodic report on the situation of the implementation of the Convention on the Rights of the Child (CRC) in the country.

IBFAN presented to the Committee an alternative report and an annex showing examples of violations of the International Code on the Marketing of Breastmilk Substitutes that were noted in the country.

General overview of breastfeeding in Portugal

The alternative report presented by Portugal states that in 2012, 78.9 % of mothers of the country have initiated their child to breastfeeding within the first hour of delivery. However, statistics show that exclusive breastfeeding starts to decrease after 5 to 6 weeks to reach a low rate of 22.4% at 5/6 months. Furthermore, use of follow on formulas and toddler milks is recommended by health professional after 6 months in Portugal, regardless of the WHO’s statement of the 17^th July 2013 that states: “ […] as well as being unnecessary, follow-up formula is unsuitable when used as a breast-milk replacement from six months of age onwards.” In addition, although Portugal has implemented the EU Directive 2006/141/EC on infant formulae and follow-on formulae, which is weaker than the International Code, through the adoption of a law (Decreto-Lei 217/2008), this law has not been monitored yet. Besides, there are no enforcement mechanisms in place either. Thus, industries are not sanctioned when they violate the International Code. The advertisement of breastmilk substitutes is widespread: for example, free samples of infant formulas are distributed through the health care system. Although a government body has been established with a mandate to report such violations, no monitoring of the law is done at a national level.

Breastfeeding courses are then mainly provided by NGO’s. Concerning the Baby-Friendly Hospital Initiative (BFHI), only 10 hospitals out of the 40 maternity wards have been certified as “baby-friendly”.

Discussion on infant and young child feeding

During the interactive dialogue between the CRC Committee and the delegation of Portugal, the issue of breastfeeding was tackled in the context of health care. The members of the Committee addressed their concerns about the health budget allocation and the lack of coordination within the different bodies of the government.

The Portuguese delegation confirmed that Portugal had received a recommendation to improve the coordination between the different bodies of the government by the UPR, as it had been reviewed during its 6^th session in 2009. . The delegation also highlighted the difficulties to increase the health budget allocation due to the economical crisis that lasts since 2009. The health budget allocation decreased in 2013 from 11 Mio to 7 Mio Euro. However, the government managed to increase the budget allocation to 9 Mio Euro for 2014. Besides, the government works closely with NGOs to guarantee to all children the right to health care.

The Committee then raised questions about breastfeeding, especially the implementation of the International Code and the training of health professionals on breastfeeding issues. 

The Portuguese delegation first acknowledged the WHO recommendation for exclusive breastfeeding until 6 months and then continued breastfeeding until 2 years or more. It stated that the government officially recommends exclusive breastfeeding until 6 months. On the question of health professionals, the delegation asserted that they are aware of the crucial role of breastfeeding in regard of infant and young child nutrition and that they are called to respect WHO resolutions, particularly the International Code. The delegation then mentioned the monitoring activity of the association Mama Mater that is collecting data about breastfeeding. These data should be further analyzed in order to understand the rates of exclusive breastfeeding after 6 weeks. About BFHI, the delegation stated that 11 maternity wards are currently certified as "baby-friendly", but the government intends to increase this number in the coming years. It then explained that “breastfeeding corners” (Cantinhos de Amamentação) are disseminated among the hospitals of the country, allowing mothers to receive advice regarding breastfeeding even after they will have left hospital. The delegation noted the engagement of several NGOs in peer counseling on breastfeeding. The government finally expresses its will to inform the population about the benefits of breastfeeding through a national youth health programme.

The members of the Committee also raised issues about corporal punishment, juvenile justice, integration of migrants, road traffic injuries and drowning, participation of children in bull fighting, child trafficking, education, children with disabilities, adoption and family support.

CRC Committee's Concluding Observations

In its Concluding Observations, the CRC Committee made recommendations on the importance of collecting data on children (para 18), on the right of the child to the highest attainable standard of health, mentioning the negative impact of budget restrictions on health care (para 48), and on the necessity to promote and support breastfeeding practices and to regulate the marketing of infant formulas (para 56).

First, the CRC Committee emphasized the importance of establishing a more comprehensive and integrated data collection system on children.

Then, the Committee drew Portugal’s attention to its 2013 General Comment N°15 on the right of the child to the enjoyment of the highest attainable standard of health (art. 24), which explicitly recognises the importance of breastfeeding for the achievement of the right of the child to health. The General Comment N° 15 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, Portugal is specifically demanded to “minimize the impact of financial restrictions in the area of health care, and further recommends that austerity measures in the area of health should be evaluated on the basis of a child’s right’s impact assessment to ensure that such measures do not have a negative impact on child health and well-being.”

Lastly, despite all measures taken to encourage breastfeeding, the Committee expressed its concern about the decline of exclusive breastfeeding rates between four and six months of age, and the practice of providing complementary foods to infants from the age of four months in Portugal. It therefore recommended the State Party to “improve the practice of exclusive breastfeeding for the first six months, through awareness-raising measures including campaigns, information and training for relevant officials, particularly staff working in maternity units, and parents”. Portugal is also demanded to “strengthen the monitoring of existing marketing regulations relating to breast milk substitutes”.

General Comments on the right to health and on business and child rights

The CRC Committee issued two new General Comments in April 2013: General Comment No. 15 on ‘the right of the child to the enjoyment of the highest attainable standard of health (art. 24)’ and General Comment No. 16 on ‘State obligations regarding the impact of the business sector on children’s rights’. These are two very important documents which frame the importance of breastfeeding within the right of the child to health and to adequate food and nutrition as well as to survival, growth and development identifying both Sates’ obligations but also business sector’s responsibilities.

General Comment 15 urges States, in the effort of diminishing infant and child mortality, to devote particular attention to neonatal mortality and are suggested, 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 the Global Strategy for Infant and Young Child Feeding.

In order to prevent negative impact of marketing on children’s right to health, survival and development, States are required adopt preventive measures including appropriate and effective regulation and monitoring of advertising and marketing industries. The General Comment 16 specifically calls on States “to implement and enforce internationally agreed standards concerning children’s rights, health and business including the [...] International Code of Marketing of Breast-milk Substitutes and relevant subsequent World Health Assembly resolutions”.

Read the full General Comments here.

Human rights recommendations on breastfeeding by the Committee on the Rights of the Child (64th session)

The 64^th session of the Committee on the Rights of the Child (CRC Committee) took place in Geneva from 16 September to 4 October 2013. The Committee reviewed the progress of the implementation of the Convention on the Rights of the Child in 7 countries: China, Kuwait, Lithuania, Luxembourg, Monaco Sao Tome and Principe and Tuvalu.

IBFAN submitted 4 alternative reports on the situation of infant and young child feeding for China, Kuwait, Lithuania and Luxembourg. The reports were written in collaboration with IBFAN groups in the countries.

We regret to see that in its concluding observations, the CRC Committee referred specifically to breastfeeding in only 2 out of the 7 countries (China and Tuvalu). In the case of Luxembourg, even if breastfeeding was largely mentioned in the discussion between the CRC Committee and the government delegation, Luxembourg did not receive any recommendation concerning breastfeeding.

Some of the recommendations on health care and on the business sector and its impact on child rights are of relevance for infant and young child feeding and are reported below.

The CRC Committee recommended China and Tuvalu to promote exclusive breastfeeding. It has also stressed the need to establish Baby-Friendly Hospitals (China) and to adopt the International Code of Marketing of Breastmilk Substitutes and resolutions (China, Tuvalu). It also urged Tuvalu to provide training to all health workers about breastfeeding.

The Committee particularly addressed the issue of children affected by contaminated formula in China and recommended the government to strengthen its legislative framework on food and health standard and ensure sanctions and remedies in cases of violation.

An Emphasis has been put on the importance of respecting the right of the child to the enjoyment of the highest standard of health (China, Lithuania, Monaco, Sao Tome and Principe). Countries have been reminded to pay attention to the 2013 General Comment 15 on the right of the child to health, which 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 the Global Strategy for Infant and Young Child Feeding.

Some of the countries are recommended to provide quality training for the health care personnel (and to increase the budget for health programs in general. China is urged to improve health infrastructure as well as availability and accessibility to emergency obstetric and neonatal care, especially in rural and poor areas, in order to prevent child and maternal mortality. Sao Tome and Principe is recommended to undertake surveys in order to understand the causes of maternal mortality and to intensify its efforts to improve access to safe drinking water and sanitation. Lithuania is demanded to ensure maternal care for women who choose to deliver at home and finally, it recommended Monaco to ensure that all children, including non-nationals, enjoy the same access and quality to health services.

A great focus was placed on the need to regulate the impact of the business sector on children’s rights. The CRC Committee drew attention to the 2013 General Comment 16, which specifically calls on States “to implement and enforce internationally agreed standards concerning children’s rights, health and business including the [...] International Code of Marketing of Breast-milk Substitutes and relevant subsequent World Health Assembly resolutions”.

 Countries are recommended to ensure the implementation by companies of both international and national environment and health standards and ensure appropriate sanctions in cases of violations. Countries are also recommended to require companies to undertake assessments of the environmental health-related and human rights impact of their business activities The CRC Committee also focused on the need to prevent mother-to-child HIV/AIDS transmission by improving access to treatment, follow-up treatments and by ensuring early diagnosis, as well as early initiation of treatment.

Direct link to our website: http://ibfan.org/reports-on-the-un-committee-on-the-rights-of-the-child/118

Kuwait to regulate business activities in child rights

Kuwait presented its 2^nd periodic report on the situation of the implementation of the Convention on the Rights of the Child. The next consolidated 3^rd to 6^th periodic report is expected by November 2018. The Kuwaiti delegation was composed of 19 members headed by H.E. Dhara Abdul Razzak Razzooqi, Ambassador, Permanent Representative of the State of Kuwait in Geneva.

IBFAN presented an alternative report on the situation of infant and young child feeding in Kuwait. The report, prepared by IBFAN Kuwait, shows that there are very low exclusive breastfeeding rates. This is due to insufficient coverage and low quality of antenatal education about breastfeeding management, weak support for the baby-friendly hospital initiative (BFHI) as well as lack of timely follow-up and competent support for mothers after hospital discharge. Concerning maternity at work, the duration of maternity leave is shorter than the ILO recommendation of 18 weeks, and women working in the informal sector do not enjoy the same rights as those in the formal sector.

Discussion on health care

The delegation of Kuwait informed the CRC Committee that particular attention was being paid to the social and health aspects of the life of the child, which has led, among other things, to reduce mortality rate. The government allocated a considerable budget to health care.

The issue of breastfeeding and infant and young child feeding has not been directly addressed in the dialogue between the CRC Committee and the government delegation.

The Kuwaiti delegation also specified that specialized centres had been established for HIV and AIDS tests and other sexually transmitted diseases. To date, there is in Kuwait a very limited number of HIV-positive cases thank to the effective programme established by the Government.

Concluding Observations

Kuwait did not receive any direct recommendations on breastfeeding in the Concluding Observations of the CRC Committee.

However, the CRC Committee has addressed to Kuwait recommendations on the impact of the business sector on child rights.

The CRC Committee recalled Kuwait the content of the General Comment no. 16 (2013) on State obligations in regard to the importance of the impact of the business sector on child rights. It recommended to Kuwait to establish and implement regulations in order to ensure that the business sector respects the international and national human rights and complies with labour, environment and specifically with children’s rights.

The CRC Committee therefore recommended Kuwait to: “(a) Ensure effective implementation by companies, especially industrial companies, of international and national environment and health standards; set up effective monitoring of implementation of these standards and appropriate sanctioning and providing remedies when violations occur, as well as ensure that appropriate international certification is sought; (b) Require companies to undertake assessments, consultations, and full public disclosure of the environmental, health-related and child rights impacts of their business activities and their plans to address such impacts”.

The Committee also mentioned the importance of respecting the environment in order not to contaminate water. It urged Kuwait to: “(c) Take immediate measures to relocate all families and children subjected to pollution that endanger their life and health status; and (d)  Be guided by the United Nations “Protect, Respect and Remedy” Framework, accepted unanimously in 2008 by the Human Rights Council, while implementing these recommendations” (para 23-24).