Recommendations related to Breastfeeding by the 65th Committee on the Rights of the Child

The 65^th Session of the Committee on the Rights of the Child (CRC Committee) took place in Geneva from 13 to 31 January 2014. The Committee reviewed the progress of the implementation of the Convention on the Rights of the Child in 6 countries: Congo Brazzaville, Germany, Holy See, Portugal, Russian Federation and Yemen. IBFAN submitted 5 alternative reports on the situation of infant and young child feeding for Congo, Germany, Portugal, Russian Federation and Yemen. The reports were written in collaboration with IBFAN groups in the countries. In its Concluding Observations, the CRC Committee referred specifically to breastfeeding in only 4 out of the 6 countries (Congo, Germany, Portugal and Yemen). The Holy See and the Russian Federation did not receive any direct recommendation on breastfeeding.

The right of the child to health

A particular emphasis has been put on the importance of respecting the right of the child to the enjoyment of the highest attainable standard of health. The CRC Committee referred to its 2013 General Comment N° 15 on the right to health (art. 24) in its recommendations to all reviewed countries, including the Holy See. The General Comment N° 15 explicitly recognizes the importance of breastfeeding for the achievement this right. This General Comment urges States, to devote particular attention to neonatal mortality in their effort to diminish infant and child 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. The Global Strategy calls, among other, for the improvement of the quality and availability of sex-disaggregated data, an issue that has been included in recommendations to Congo, Germany, Portugal and Yemen.

Protect

A great focus was placed on the need to regulate the impact of the business sector on children’s rights. In its recommendations to Congo, Germany and the Russian Federation, the CRC Committee expressly drew attention to its 2013 General Comment N° 16 on State obligations regarding the impact of the business sector on children’s rights, which specifically calls on States Parties 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” (hereafter referred as “the International Code”). Therefore, these three reviewed countries are recommended to ensure the compliance by companies of both international and national health and environmental standards and ensure appropriate sanctions in cases of violations. Congo and the Russian Federation are also recommended to require companies to undertake assessments of the environmental health-related and human rights impact of their business activities.

In addition, the CRC Committee expressly urged Germany to take every necessary measure to ensure the access to breastfeeding through the control of infant formula. More specifically, the CRC Committee urged Yemen, Congo and Germany to respectively implement and strictly enforce the International Code, while Portugal is asked to strengthen the monitoring of its marketing regulations related to breastmilk substitutes.

Promote

In the case of Congo, the CRC Committee stressed that preventable diseases, including diarrhoea, continue to impact negatively on child mortality rate. Thus, it urged the government to promote infant and young child feeding practices, in particular breast milk, and to adopt a holistic early childhood development strategy covering healthcare, nutrition and breastfeeding.

Furthermore, the CRC Committee raised the issue of new morbidity related to attachment disorders in Germany, which could be related to declines in exclusive breastfeeding practices. It underlined the decline of exclusive breastfeeding rates of children between four and six months and the aggressive marketing of breastmilk substitutes in Portugal. In the case of Yemen, it showed concern about the high rates of chronic malnutrition (stunting), acute malnutrition (wasting) and communicable diseases, especially diarrhoea, among children, linked to the lack of awareness about exclusive breastfeeding practices. Accordingly, the CRC Committee recommended Germany, Portugal and Yemen to promote exclusive breastfeeding.

In regard of General Comment N°15, Germany is specifically requested to better promote healthy eating habits and to pay special attention to children in vulnerable situations.

Support

Congo is urged to ensure provision of primary health care services for all pregnant women and children within accessible health care service with trained health care providers. It is specifically recommended to increase the quality and coverage of training to staff at socio-health units.

The CRC Committee also stressed the need for Yemen to establish baby-friendly hospitals.

The CRC Committee also focused on the need to prevent mother-to-child HIV/AIDS transmission by ensuring the implementation of effective HIV/AIDS preventive measures (Congo), by expanding the coverage of the National HIV/AIDS Prevention and Control Programme (Yemen) and by providing sufficient amount of breastmilk substitutes and anti-retroviral drugs in all regions (Russia).
                                                                                    

Table 1. CRC Committee - Session 65 / 2014 -Summary of Concluding Observations on IYCF

Country		IBFAN report	Summary of specific recommendations on IYCF
1	Congo (2nd to 4th periodic report)	yes	Indirect – Data collection (para 19): improve data collection system. The data should cover all areas of the Convention and should be disaggregated by age, sex, geographic location, ethnic and national origin and socioeconomic background in order to facilitate analysis on the situation of all children, particularly those in situations of vulnerability. Children’s rights and the business sector (para 27): establish a clear regulatory framework for the industries operating in the State party to ensure that their activities do not negatively affect human rights, especially those relating to children’s and women’s rights; ensure effective implementation by companies, especially industrial companies, of international and national environmental [...]  health standards, effective monitoring of implementation of these standards and appropriately sanctioning and providing remedies when violations occur; require companies to undertake assessments, consultations, and full public disclosure of the environmental, health-related and human rights impacts of their business activities and their plans to address such impact; be guided by the United Nations “Protect, Respect and Remedy” Framework. Health care (para 59 a): ensure provision of primary health care services for all pregnant women and children with focus on development of accessible health care services with trained health care providers, intervention to reduce preventable and other diseases, particularly diarrhoeas, acute respiratory infections and undernutrition; strengthen and expand access to preventive health care, and therapeutic services for all pregnant women and children, particularly infants and young children under five years old; continue to disseminate health information and promotion of health education; increase quality and coverage of training to staff at socio-health units and ensure units are adequately staffed and have essential facilities, including obstetric supplies and emergency medicines for children and pregnant women; sustain the measures in place to prevent mother-to-child transmission of HIV. Direct (para 59 b; 66 b): promote IYCF practices, particularly breast milk and infant food based on local foods; adopt a holistic early childhood development (ECD) strategy and invest in the training of ECD teachers and provision of integrated formal and community-based programmes involving parents and covering healthcare, nutrition and breastfeeding, early stimulation and early learning for children for birth to the first year of school.
2	Germany (3rd and 4th periodic report)	yes	Indirect – Data collection (para 16): establish a comprehensive and integrated data collection system on children covering all Länder and the entire period of childhood up to the age of 18, and to introduce indicators on children’s rights on which progress in the realization of those rights could be analysed and assessed. The data should be disaggregated by age, sex, disability, geographical location, ethnicity, migration status and socio-economic background. Children’s rights and the business sector (para 23): establish a clear regulatory framework for the industries operating in the State party to ensure that their activities do not negatively affect human rights [...], especially those relating to children’s rights; examine and adapt its legislative framework (civil, criminal and administrative) to ensure the legal accountability of business enterprises and their subsidiaries operating in or managed from the State party’s territory, regarding violations of child and human rights; comply with international and domestic standards on business and human rights with a view to protecting local communities, particularly children, from any adverse effects resulting from business operations, in line with the UN “Protect, Respect and Remedy” Framework and the Guiding Principles on Business and Human Rights and by the Committee’s own general comment N° 16. Health care (para 57): advocate and raise awareness through programmes targeting schools and families, emphasizing [...] healthy eating habits. Direct (para 57; 63): [in regard of General Comment 16] take every necessary legislative and structural measure to ensure that every child within the State party has access to breastfeeding through the control of infant formula which will promote better bonding between infants and mother; strengthen efforts to promote exclusive and continued breastfeeding by providing access to materials, and educating and raising awareness of the public on the importance of breastfeeding and the risks of formula feeding; strictly enforce the International Code of Marketing of Breast-milk Substitutes.
3	Holy See (2nd periodic report)	no	none
4	Portugal (3rd and 4th  periodic report)	yes	Indirect – Data collection (para 18): establish a more comprehensive and integrated data collection system on children covering the entire period of childhood up to age 18, and to introduce indicators on children’s rights on which progress in the realization of those rights could be analysed and assessed. The data should be disaggregated by age, sex, geographic location, ethnicity, migration status and socio-economic background to facilitate the determination of the overall situation of children. Health care (para 48): [in regard to General Comment 15] minimize the impact of financial restrictions in the area of health care; 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. Direct (para 56): take action 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; strengthen the monitoring of existing marketing regulations relating to breast milk substitutes.
5	Russian Federation (4th and 5th  periodic report)	no	Indirect - Children’s rights and the business sector (para 21): pray attention to General Comment 16 on State obligations regarding the impact of the business sector on children’s rights and recommends that the State party establish and implement regulations to ensure that the business sector complies with international and national human rights, particularly with regard to children’s rights; ensure effective implementation by companies, especially industrial companies, of international and national health standards, effective monitoring of the implementation of these standards and appropriately sanctioning and providing remedies when violations occur, as well as ensure that appropriate international certification is sought; require companies to undertake assessments, consultations, and full public disclosure of the environmental, health-related and human rights impacts of their business activities and their plans to address such impact; be guided by the United Nations “Protect, Respect and Remedy” Framework. Health care (para 52; 54): pray attention to General Comment 15 on the right of the child to the enjoyment of the highest attainable standard of health, and recommends that the State party take measures to regularly assess the health conditions of children deprived of parental care and children in difficult situations in order to prevent irreparable damage to their health;; take all necessary measures to prevent mother to child transmission of HIV/AIDS throughout the country by providing sufficient amount of breast milk substitutes and anti-retroviral drugs in all regions, irrespective of their legal status in the country.
6	Yemen (4th periodic report)	yes	Indirect – Data collection (para 18): improve its data collection system. The data should cover all areas of the Convention and should be disaggregated by age, sex, geographic location, ethnic and national origin and socioeconomic background in order to facilitate analysis on the situation of all children, particularly those in situations of vulnerability. Health care (para 16; 56; 64): establish a budgeting process, which includes child rights perspective and specifies clear allocations to children in the relevant sectors and agencies, including specific indicators and a tracking system; increase substantially the allocations in the areas of health and education; ensure that appropriate resources be allocated to the health sector, with particular attention to specific maternal and child health care and develop and implement comprehensive policies and programmes to improve the health situation of children, in particular to respond to high rates of malnutrition and diarrhoea infections; expedite the process to join as a full member the Scale Up Nutrition Initiative (SUN) and to take effective measures to address the widespread and serious undernourishment affecting children; strengthen its efforts to develop outreach services, including a network of mobile health-care facilities in conflict-affected areas, particularly targeting children and pregnant women, as an interim measure, and ensure that health-care facilities are rehabilitated and not re-occupied for military purposes by either the armed forces or non-State armed groups; ensure universal coverage for HIV testing and free antiretroviral drug provision; pay particular attention to pregnant adolescents in rural areas, pregnant mothers with HIV and children born to mothers with HIV. Direct (para 56): enhance efforts to promote exclusive breastfeeding practices, by ensuring the implementation and compliance with the International Code of Marketing of Breast-milk Substitutes, and establish a monitoring and reporting system to identify violations of the Code. This includes the establishment of baby-friendly hospitals with the promotion of breastfeeding from birth.

Congo Brazzaville: Low Breastfeeding and High Infant Mortality Rates

The Republic of Congo Brazzaville presented its consolidated 2^nd to 4^th periodic reports on the situation of the implementation of the Convention on the Rights of the Child in the country.  The government delegation was composed of 12 members and one of them was representing the Ministry of Health. The head of the delegation was the Minister of Social Affairs Humanitarian Action and Solidarity, Ms Emilienne Raoul, who directly responded to most of the questions from the Committee on the Rights of the Child (CRC Committee).

IBFAN presented an alternative report to inform the CRC Committee on Congo’s situation of infant and young child feeding.

General overview of breastfeeding in Congo Brazzaville

The alternative report shows that breastfeeding rates are still insufficient: for the period 2007-2010, only 19% of infants were exclusively breastfed during the first 6 months and only 21% of the children were still breastfed at the age of 2. Early initiation of breastfeeding is also worryingly low (39%) while at least one child out of three is fed with other food than human milk during the 3 first days of their life. These bad figures are the result of a lack of adequate information and inadequate traditional practices on infant and young child feeding. The alternative report highlights the crucial role of health workers for dissemination of correct information, and calls for adequate training of these professionals. Currently, none of the hospitals of the country meets the requirements of the Baby-friendly Hospital Initiative (BFHI).

Inadequate infant and young child feeding practices contribute to the very high child and maternal mortality rates in Congo, where 61 children out of 1000 born die before their first year of age. Stunting is another main concern: it increases considerably after the first 6 months to reach 21% at the age of 9-11 months with a peak of 37% at the age of 18-23 months, coinciding with the time breastfeeding is stopped and replaced with other foods.

No measures have been taken so far from the government to regulate the marketing of breastmilk substitutes. Although Congo has adopted the Global Strategy on Infant and Young Child Feeding Breastfeeding, the International Code of Marketing of Breastmilk Substitutes  has not been implemented through a national legislation. A national law has been drafted to this end in the 1990’s and since then it’s still waiting to be considered by the government.

Maternity protection at work is also a challenge for Congo, where maternity leave is as short as 15 weeks, 9 of which should be taken after birth. Moreover, a very small fraction of active women are employed in the formal sector, while a large majority of them are working in the informal sector and therefore does not benefit from the maternity leave legislation.

Discussion on infant and young child feeding

During the interactive dialogue between the CRC Committee and the Congolese delegation, the issue of breastfeeding was addressed in the context of health care. Committee members asked whether a programme to promote good nutrition and breastfeeding has been implemented. Details concerning the number of hospitals that meet the requirements of the BFHI criteria have been requested. Finally, the question of the monitoring of marketing of breastmilk substitutes has been asked.

On these points, the head of Congolese delegation asserted that more than 90% of Congolese mothers breastfeed since birth, but the rate decreases to 36% after 6 months. She pointed to a Knowledge, Attitudes and Practice (KAP) study that has been realised in order to identify the causes and determinants of the health situation observed in the population. Identification of these determinants is crucial to develop a strategy to improve the health practices, including breastfeeding.

Unfortunately, issues related to the implementation of the International Code, the need to improve the knowledge of health workers, to promote early and exclusive breastfeeding as well as appropriate complementary feeding, maternity protection for women employed in all sectors were not addressed by the government delegation.

Other issues debated at the session included a wide range of topics: child adoption and alternative care, juvenile justice and incarcerated children, respect of the child’s rights by transnational companies, birth registration, violence and sexual abuses against children, female genital mutilations, child labour, children in street situation, children refugees, education, child marriage, children with disabilities, etc…

The Committee welcomed the progress that have been made by Congo so far, while being well aware of Congo shortcomings in realizing children’s rights in the country; however it stressed that many improvements are still to be made in order to ensure that the rights of the child are fully respected, promoted and protected.

CRC Committee's Concluding Observations

In its Concluding Observations, the CRC Committee directly addressed the issue of breastfeeding (para 59; 67), as well as the relation between child rights and the business sector (para 27), data collection (para 19) and mother-to-child HIV/AIDS transmission (para 61).

The CRC 2013 General Comment N° 15 on the right of the child to the enjoyment of the highest attainable standard of health (art. 24) 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 its 2002 Global Strategy for Infant and Young Child Feeding". Regarding Health and health services, the Committee urged Congo to pay "attention to its general comment No. 15 [...]. It recalls its recommendation to the State party to overcome the constraints preventing the implementation of existing strategies including, inter alia, by: (a) Ensuring the provision of primary health care services for all pregnant women and children, focusing on the development of accessible health care services with trained health care providers, interventions to reduce preventable and other diseases, particularly diarrhoeas, acute respiratory infections, and undernutrition. Health services should include access to sanitation and clean drinking water; (b) Strengthen and expand access to preventive health care, and therapeutic services for all pregnant women and children, particularly infants and children under five years old. These should include universal immunization services, oral rehydration therapy, treatment for acute respiratory infections, promotion of infant and young child feeding practices, particularly breast milk and infant food based on local foods, and prevention of malaria through use of impregnated bed nets. This must also include the effective implementation of the WHO/UNICEF International Code on the Marketing and Distribution of Artificial Infant Formula and a monitoring system to ensure the enforcement of regulations; (c) Increasing efforts to implement the strategies seeking to reduce maternal mortality throughout the country, including for trained care at home, in maternal and child health clinics, and emergency obstetric care; [...] (e) Continuing the dissemination of health information and promotion of health education, particularly on the use of latrines and hand washing to all segments of the society, and provide safe water to all segments of society; (f) Increasing the quality and coverage of training to staff at socio-health units and ensuring that these units are adequately staffed and have the essential facilities, including obstetric supplies and emergency medicines for children and pregnant women".

The CRC Committee, in its 2013 General Comment N° 16 on State obligations regarding the impact of the business sector on children’s rights, 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”. In the section Children's right and the business sector, the Committee draws Congo's "attention to its general comment No. 16 [and] recommends that the State party establish and implement regulations to ensure that the business sector complies with international and national human rights, labour, environment and other standards, particularly with regard to children’s rights [...]. In particular, it recommends that the State party: (a) 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 environmental and other standards, especially those relating to children’s and women’s rights; (b) Ensure effective implementation by companies, especially industrial companies, of international and national environmental and health standards, effective monitoring of implementation of these standards and appropriately sanctioning and providing remedies when violations occur, as well as ensure that appropriate international certification is sought; [...] (f) Be guided by the United Nations “Protect, Respect and Remedy” Framework, accepted unanimously in 2008 by the Human Rights Council, while implementing these recommendations."

The CRC Committee also urged Congo to improve its data collection system. The data should be disaggregated, among other criteria, by age, sex and socioeconomic background. These data could then be used to monitor breastfeeding rates in the country, providing thus an important tool to improve breastfeeding policies and practices.

In addition, Congo is requested to "adopt a holistic early childhood development (ECD) strategy and invest in the training of ECD teachers and provision of integrated formal and community-based programmes involving parents and covering healthcare, nutrition and breastfeeding, early stimulation and early learning for children from birth to the first year of school". Finally, the CRC Committee recommended to "ensure the implementation of effective HIV/AIDS preventive measures", including measures to prevent-mother-to-child transmission (like early diagnosis and immediate initiation of treatment).