The Dominican Republic at the CRC: High Rate of Maternal Mortality and Low Rates of Breastfeeding

On January 12^th and 13^th, 2015, the Committee on the Rights of the Child considered the combined third to fifth periodic report of the Dominican Republic on the situation of the implementation of the Convention on the Rights of the Child in the country. The delegation of the Dominican Republic was led by Mr. Gertrudis Alberto Padilla Vicioso, responsible for the Public Policies Department of the National Council on the Child, Mrs. Brígida Sabino Pozo, responsible for the Late Registration Central Unit of the Central Electoral Board, and Mrs. Khaterine Urbáez Martínez, Minister Counselor for Human Rights to the Permanent Mission of the Dominican Republic to the United Nations Office at Geneva.

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

General overview of breastfeeding in the Dominican Republic

The Dominican Republic presents low rates of early initiation to breastfeeding (65%), exclusive breastfeeding under 6 months (6.7%) and continued breastfeeding at 2 years of age (25%). Such performance is alarming and questions the quality of the information received by mothers in health care facilities, considering that almost high rate of institutional delivery in the country 98%). It is also of concern that the use of infant formula is widespread among the population and that more than half of the newborns are fed with food other than breastmilk even before being breastfed at all.

In addition, the National Breastfeeding Commission lacks funds to implement the National Strategic Plan for Maternal and Infant Mortality Reduction and to perform its monitoring function on the application of Ley 8-95 implementing the International Code of Marketing of Breastmilk Substitutes, which leads to frequent Code violations.

Besides, only 6% of the hospitals and maternities were ever certified as “Baby-Friendly” and thre is no follow-up of the BFHI requirements in the certified facilities. IBFAN’s alternative report also stressed the lack of regular training of health professionals on HIV and infant feeding.

The scarce maternity protection at work is another factor which could explain the low breastfeeding rates in the Dominican Republic. Finally, the Guidelines for Infant Feeding in Emergencies were issued in 2010 but are not effectively implemented and, consequently, the baby-food industry keeps distributing and donating its products during emergencies.

Discussion on infant and young child feeding

The Committee specifically addressed the issue of neonatal and maternal mortality, and the low rate of exclusive breastfeeding in the Dominican Republic. It highlighted that although 80% of the maternal deaths are preventable, the rate of maternal mortality is still high, which seems difficult to understand in regard to the high percentage of institutional deliveries (97%). The Committee also expressed concerns about the low rate of exclusive breastfeeding rate under 6 months (8%) as well as about the early introduction of solid and semi-solid food which can lead to chronic malnutrition.

The Dominican delegation provided some data related to the implementation of the Strategic Plan for Maternal and Infant Mortality Reduction and mentioned the recent creation of a human milk bank as activities by the government in order to promote breastfeeding.

The Committee reminded the delegation that when given adequate pre- and perinatal support, nearly 100% of mothers can breastfeed their baby. The Committee welcomed the existence of human milk bank, but clearly stated that breastfeeding support is even more important.

The Dominican delegation pointed out that the low rate of exclusive breastfeeding is one of the main concerns of the Dominican health system and that the implementation of the Strategic Plan for Maternal and Infant Mortality Reduction will hopefully lead to its improvement as well as to the improvement of the rates of neonatal and maternal mortality. Regarding HIV and infant feeding, the head of the delegation mentioned that 95% of the children living with HIV have been infected through mother-to-child transmission and that services are being put in place in order to stop mother-to-child transmission of HIV in newborns.

Finally, the Dominican delegation expressed the commitment of the government to collect data on breastfeeding (including on the rate of exclusive breastfeeding under 6 months) in a more comprehensive way in view of the next review by the CRC Committee.

Concluding Observations

In relation with infant and young child feeding, the Committee made several indirect and direct recommendations to the Dominican Republic in its Concluding Observations.

Concerning health and health services, the Dominican Republic was asked to strengthen efforts to reduce child and maternal mortality by taking into account the OHCHR Technical guidance on child mortality(§ 50b) which includes specific recommendations on breastfeeding protection (including the implementation of the International Code) and promotion. It was also urged to establish and independent mechanism for investigating cases of child and maternal mortality and to apply legal sanctions whenever such cases are due to health personnel negligence (§ 50c), as well as to undertake all necessary measures to ensure that adequate safe water and sanitation are available, especially in hospitals (§ 50f).

Specifically referring to breastfeeding, the Committee expressed its concerns about the low rate of exclusive breastfeeding under 6 months (6.7% in 2013), the early introduction of other foods, as well as the frequent recommendations of breastmilk substitutes by the health personnel. Therefore, it urged the Dominican Republic to increase efforts to eliminate child malnutrition (§50d) and to promote breastfeeding through educational campaigns. It also requested the State party to adequately implement the Strategic Plan on Breastfeeding (2012-2016), the International Code of Marketing of Breast-Milk Substitutes and the Child-Friendly Hospital initiative [...], and to strengthen maternity protection (§ 50e).

Breastfeeding Challenges in India (CRC)

On the 3^rd of June 2014, the Committee on the Rights of the Child completed its consideration of the combined 3rd and 4th periodic report of India 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 India.

General overview of breastfeeding in India

About 26 million babies are annually delivered in India. According to the National Family Health Survey-3 (NFHS-3) data, 20 million are not able to receive exclusive breastfeeding for the first six months of their life and about 13 million do not get good timely and appropriate complementary feeding after six months along with continued breastfeeding. The rate of early initiation of breastfeeding within one hour following the delivery is of only 23.4% and exclusive breastfeeding up to the age of six months is of 46.3%. 

However, the national legislation implementing the International Code of Marketing of Breastmilk Substitutes, called the Infant Milk Substitute Act, is still not effectively enforced. Therefore, an effective monitoring mechanism is required at state and district level. In addition, there is no comprehensive adequate training of health professionals done by the government, even though BPNI/IBFAN India has developed a training course and trained more than 15'000 health workers since 2004. Besides, the alternative report emphasized that an increasing number of institutional deliveries occur without adequate space, staff or infrastructure. The Baby-friendly Hospital Initiative (BFHI), launched in the country in 1993, has not been properly revived since then. 

Finally, it has been noted that he national legislation on maternity protection does not cover women working in private and informal sector. Clearly, the support to working mothers needs to be extended to women in the unorganized sector as they form the major part (almost 90%) of working women. Lastly, the alternative report states that the national guidelines on Infant Feeding and HIV have not yet been made into policy, and that there is no policy on infant feeding in case of emergency.

Discussion on infant and young child feeding

The Committee raised the issue of maternal malnutrition and child stunting, and asked if there is any programme to address mother malnutrition. Furthermore, the Committee insisted on optimal infant and young children feeding practices, especially breastfeeding, to combat children malnutrition, which is proven to affect, inter alia, children’s learning capacities. The Committee highlighted the decline in breastfeeding rates in recent years and asked whether there were any programmes in place to remedy this situation. The issue of regional disparities  in breastfeeding rates has also been raised, as well as the promotion of infant formula, despite the implementation of the IMS Act. The Committee showed concern for the Code violations that occur in India and wondered if they are the consequences of a lack of monitoring of the national legislation. It finally asked if there was any implementation of the BFHI at national level and if there were any national guidelines or policy on HIV and infant feeding.

The delegation of India responded that the exclusive breastfeeding rate in India is about 40%, which is relatively high compared to other countries.  It added that the high rate of institutional delivery (78%) gives the country a great opportunity to promote optimal breastfeeding practices to young mothers, and that dedicated breastfeeding counsellors are deployed in maternity wards throughout the country.  The delegation expressed the hope that the actions taken would lead to an increase in breastfeeding rates. It admitted that India had been slow to implement the International Code of Marketing of Breastmilk Substitutes, but it stated that government is currently awareness-raising on the IMS Act among the district health officers. Regarding the issue of HIV and infant feeding, the delegation answered that the existing national guidelines do provide the appropriate guidance to the population.

Concluding Observations

In its Concluding Observations, the CRC Committee made a wide range of indirect recommendations related to infant and young child feeding. At the level of general implementation, the Committee urged India to prioritize the development of the National Plan of Action to implement the 2013 National Policy for Children (para 14 (a)). It requested also the country to expeditiously improve its data collection system (para 20), and to provide all professionals working for and with children with adequate and systematic training in children’s rights, which includes in particular health workers (para 26). In the light of the CRC General Comment No. 16 on State obligations regarding the impact of the business sector on children’s rights, the Committee also insisted on the need to 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 (para 30 (a)).

Regarding health issues, the Committee requested India to increase the resources allocated to the health sector and to ensure that they are appropriate (para 18(a) and 64 (b)), 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”. The Committee also called for to the “effective implementation of the National Food Security Act (2013) which contains provisions aiming at combating children’s undernourishment” (para 64 (d)). The Committee also addressed the issue of HIV/AIDS mother-to child transmission by urging the government to “sustain the measures in place to prevent mother-to-child transmission of HIV/AIDS and develop a roadmap to ensure the implementation of effective preventive measures” and “improve access and coverage of antiretroviral therapy and prophylaxis for HIV-infected pregnant women […]” (para 68 (b) and (e)).

In addition, the Committee issued direct recommendations related to infant and young child feeding (para 64 (d)). It urged India to “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” and called for 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. The Committee thus specified that “violations include the promotion and distribution of samples and promotional materials by the private sector institutions involved in the Infant Formula marketing and distribution”.

Nonetheless, it is of serious concern that despite the systematic infringements of the Code committed by baby food companies, the Committee recommended India to “strengthen its efforts to address the existing disparities in access to and quality of health services, including by establishing partnerships with the private sector […]” (para 64 (a)).

Low Breastfeeding Rates in Jordan (CRC)

On the 26^th of May 2014, the Committee on the Rights of the Child considered the combined fourth to fifth periodic reports of Jordan on the situation of the implementation of the Convention on the Rights of the Child (CRC) in the country.

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

General overview of breastfeeding in Jordan

In Jordan, the rate of early initiation of breastfeeding is low (38.8%) what, compared to the very high rate of institutional delivery (almost 99%), questions the quality of the training provided to health professionals. Furthermore, almost four children out of five are not exclusively breastfed until 6 months of age, while more than 45% of the infants under 1 month of age are fed with infant formula and some 24% of the children of 4-5 months of age are weaned prematurely. These data should be assessed in close conjunction with the high stunting rate of the children under 5 years of age are stunted (8%). The country has implemented most, but not all, of the provisions of the International Code of Marketing of Breastmilk Substitutes as legally enforceable measures.

A general lack of data on “baby-friendly” hospitals also has been observed. Similarly, a lack of data on HIV/AIDS and infant feeding has been noted. This is especially concerning given that the latter infection is still stigmatized and the population does not receive adequate and comprehensive information about it.

Besides, the alternative report emphasized that not all working women are benefiting from maternity protection and many women still experience occupational segregation.

Finally, it has been highlighted that, despite a national policy and training programme on infant and young child feeding in emergencies, support to optimal breastfeeding practices in refugees’ camps is not ensured and refugee women often face difficulties to access to health care facilities.

Discussion on infant and young child feeding

The CRC Committee pointed out that the rate of exclusive breastfeeding is low and asked if there was any national campaign to encourage mothers to breastfeed for a longer period. 

The delegation of Jordan answered that Jordan has implemented a law prohibiting the marketing of breastmilk substitutes. It stated that awareness-raising campaigns to promote breastfeeding have been launched and information on the best way to incorporate breastfeeding within the family routine has been disseminated.  The delegation also explained that there is a national guidance for medical professionals on the circumstances in which powdered milk should be recommended.

In addition, the delegation also explained that Jordan has the lowest rate of HIV/AIDS in the Arab region and that the national HIV/AIDS strategy includes reintegration measures for infected persons and awareness-raising campaigns on the transmission of the virus.

Concluding Observations

In its Concluding Observations, the CRC Committee recommended Jordan to strengthen its mechanisms for data collection (para 8 (b)). Regarding health issues, it urged the country to “ensure equal access to quality health services by all children, through the adoption of measures aimed at prioritizing children in the most disadvantaged and marginalized situations, especially child refugees, and by addressing child malnutrition and infectious diseases” (para 44). The Committee also emphasized the necessity to “improve access to quality, age-appropriate HIV/AIDS, sexual and reproductive health information and services” (para 48).

However, the Committee issued no direct recommendations related to infant and young child feeding. 

Lack of Code Implementation in Ukraine (CESCR)

On the 29^th of April 2014, the Committee on Economic, Social and Cultural Rights considered the sixth periodic report of Ukraine on how the country is implementing the provisions 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

The alternative report has highlighted the lack of availability, collection, analysis and reliability of data related to breastfeeding in Ukraine. In addition, the lack of funding for public awareness on infant feeding issues has been noted. The International Code of Marketing of Breastmilk Substitutes has not been implemented through national legislation and there is no systematic monitoring on Code violations, which is one of the reasons for violations by stakeholders. The extended Baby-friendly Hospital Initiative (BFHI) (mother- and family-friendly health services) is not included in training programmes for health professionals, either at regional or national level, and there is lack of attention of medical staff on the essential elements of the extended BFHI. Besides, efforts of medical staff to support BFHI are not compensated financially. 

Discussion on infant and young child feeding

Infant and young child feeding issue has not been specifically addressed. However, a Member of the Committee noted that in 2006, infant and maternal mortality was still high, and life expectancy at birth was relatively low. He then asked what measures were taken Ukraine to tackle these issues.

The delegation responded by stating that the Government had improved maternal healthcare. By 2012, the number of natural births increased to 70%, which reduced the number of birth complications and therefore, halved the maternal mortality rate to approximately 12.5 of 100,000 live births.  It then added that there has been a 2/3 decrease in the number of still births, and a marked decrease in the mortality rate of children under five years of age to 11 for every 100,000 live births, thanks to the implementation of best practice and new technology. Moreover, the delegation emphasized that child health facilities throughout the country were being reviewed, and that the United Nations Children’s Fund (UNICEF) was advising on a strategy to provide primary medical care to children. 

CECSR Concluding Observations

In its Concluding Observations,  the Committee shows its concern that, despite the progress made in decreasing the infant, child and maternity mortality rates, they still remain high (art. 12). It recommends that Ukraine step up its efforts with a view to further reducing the high rate of infant, child and maternal mortality, including by improving the quality, availability and accessibility of medical assistance throughout the country (para. 20). 

Breastfeeding Practices in the Russian Federation

The Russian Federation presented its consolidated 4^th and 5^th periodic report on the situation of the implementation of the Convention on the Rights of the Child (CRC) in the country.

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

General overview of breastfeeding in the Russian Federation

The alternative report highlighted several obstacles to breastfeeding practices in Russia. First, in 2002, UNICEF listed only 12 maternity wards as meeting the requirements of the Baby-friendly Hospital Initiative (BFHI) out of the 277 hospitals in the country. However, exclusive breastfeeding rate is higher in baby-friendly hospitals (88.9%) than in other health facilities (32.6%), and breastfeeding initiation takes place in a median time during the two first hours in baby-friendly hospitals, whereas in other structures, breastfeeding initiation happens only during the 12 first hours. In addition, the report highlighted the lack of public policies and programmes to protect, promote and support breastfeeding and infant and young child feeding, the absence of systematic data about breastfeeding and no action on implementation of the International Code of Marketing of Breastmilk Substitutes in Russia. Thus, there are no legal provisions to regulate the advertisement and marketing of breastmilk substitutes. IBFAN’s report also stressed that, despite the good maternity protection legislation, there is employment discrimination of women. Besides, the occupational segregation in the low-level jobs lead to insufficient maternity protection for the women concerned. Finally, the report pointed out that only 9 regions out of 83 were providing support to prevent mother-to-child HIV transmission.

Discussion on infant and young child feeding

During the discussion between the members of the CRC Committee and the State Party, the question of Russia’s implementation of the International Code has been raised. The Committee also addressed the issue of breastfeeding practices and asked whether any governmental support is provided to working women in order to help them combine their work with breastfeeding. Finally, the Committee enquired about the existence of a national programme which aims to prevent mother-to-child transmission of HIV and the kind of support provided to HIV-positive mothers and children. None of these issues has received response from the Russian delegation.

CRC Committee's Concluding Observations

In its Concluding Observations, the CRC Committee made recommendations on the importance of respecting child rights in relation to the business sector (para 21), on the right of the child to health (para 52) and on the necessary measures to prevent mother-to-child HIV/AIDS transmission (para 54). However, no specific recommendation on breastfeeding has been made to the Russian Federation delegation.

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 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 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 urges the State party to: [...] (d) Ensure effective implementation by companies, especially industrial companies, of international and national environment and 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;(e) 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 impacts; and (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 2013 General Comment N°15 on the right of the child to the enjoyment of the highest attainable standard of health (art. 24) explicitly recognises 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 Russian Federation is requested to pay "attention to CRC general comment No. 15 (2013) 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. The Committee also recommends that the State party take measures to provide all children, irrespective of their legal status in the country with access to medical assistance, in particular preventive health care and emergency assistance, without any discrimination."

Finally, as the Russia Federation seems to have opted for a policy which recommends HIV-positive mothers to avoid all breastfeeding, the Committee in order to address inequalities recommends to "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, using, inter alia, mobile medical personnel."