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.

Assemblée Générale de Nestlé - Intervention d'IBFAN-GIFA

10 avril 2014 - Lausanne

Chers Membres du Conseil d’administration, chers actionnaires,

Mon nom est Camille Selleger, je suis juriste et je m’exprime au nom de la Geneva Infant Feeding Association, membre suisse du réseau IBFAN. Vous vous demandez sans doute ce que j’ai d’important à vous dire. En fait, j’ai une simple question à vous poser : Pensez-vous que tous les enfants ont les mêmes droits ?

Pensez-vous que vos enfants, vos petits-enfants, ont moins de droits que les enfants des pays défavorisés?

Je crois que chacun d’entre nous connaît la réponse à ces questions. Les droits des enfants sont universels. Chaque enfant de cette planète a le droit à la vie, à jouir d’une bonne santé et d’une alimentation adéquate. A ce propos, l’année dernière, le Code international de commercialisation des substituts de lait maternel, mis en place pour protéger l’alimentation des nourrissons et des jeunes enfants des pressions commerciales, a été officiellement intégré à la Convention sur les droits de l’enfant. Le Code international est donc lui aussi plus que jamais universel. Le Comité sur les droits de l’enfant précise même que (je cite) « […] dans tous les contextes, les entreprises privées devraient s’y conformer... » C’est clair et limpide comme de l’eau de roche.

Cependant, le Conseil d’administration veut vous faire croire qu’il y a 2 poids 2 mesures, et que ce qui vaut pour les enfants défavorisés ne vaut pas pour les enfants d’ici. Nestlé dit qu’il faut respecter le Code international dans les pays pauvres, mais qu’ici cela ne vaut pas la peine. Selon Nestlé, nos enfants n’ont pas le droit à cette protection pourtant universelle, inconditionnelle et prévue noir sur blanc dans le droit international. Malgré ces évidences, le Conseil d’administration a la gentillesse nous faire rêver avec de jolis rapports pleins de photos attendrissantes, où l’on peut lire que Nestlé s’engage pour les droits humains. Comment peut-on affirmer qu’on respecte les droits humains alors qu’on ne respecte pas les droits des enfants ?

Vous savez, quand je pense à tout ça, j’ai un mot qui me vient en tête (et je pense que vous aussi): cynisme. Je sais que les affaires sont les affaires, mais pas à n’importe quel prix. Pas en se moquant du droit des enfants. Je suis une vraie Suisse, j’ai grandi ici et je sais combien Nestlé fait partie de notre patrimoine. Pour cette raison, la firme doit montrer l’exemple, pas seulement dans ses déclarations et dans ses jolis rapports, mais aussi et surtout dans ses actes. Faire des bénéfices, oui, mais avec conscience et respect. Et sans cynisme.

Ma question est la suivante : Le Conseil d’administration s’engage-t-il à ce que Nestlé respecte strictement le Code international et les résolutions postérieures qui s’y rapportent dans tous les pays du monde et sans distinction ?

Merci de votre attention.

Breastfeeding and child rights in Luxembourg

Luxembourg 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 in the country. The combined 5^th to 6^th periodic report is expected by October 2019.

IBFAN submitted an alternative report on the situation of infant and young child feeding in Luxembourg. The report highlights the fact that breastfeeding rates are insufficient. Only 6% of infants are exclusively breastfeeding during the first 6 months; this rate has indeed decreased since 2001. In 2005, the government of Luxembourg assured it will establish a national plan for promoting and protecting breastfeeding. Until now two plans have been adopted, one between 2006 and 2010 and the other between 2011 and 2015. Unfortunately, the action plan has not been backed with sufficient budget, leading to restricted implementation. More and more women stop breastfeeding their children before they reach 6 months. The report also underlines the fact that only half of the four maternity hospitals are baby-friendly, while there is a lack of information to mothers about breastfeeding from midwives and breastfeeding counselors. The report states that the implementation of the International Code of Marketing of Breastmilk Substitutes and resolutions is weak as it conforms to the EU Directive 2006/141/EC and not to the WHO Code. Concerning maternity protection at work, breastfeeding breaks are paid by the employer and women need to present a medical certificate for the whole duration of breastfeeding. This may lead certain women to feel pressured not to ask for the break or not taking them for the entire breastfeeding period, which in turn could explain the decreasing rate of exclusive breastfeeding at 6 months.

Discussion on infant and young child feeding

During the dialogue with the government delegation, CRC Committee has raised questions on breastfeeding. The Committee members pointed to the fact that exclusive breastfeeding is practiced by always fewer women. They asked whether health professionals receive training on breastfeeding, and on the impact of cesarean section on breastfeeding rates. The Committee members asked whether promotion of breastmilk substitutes is authorized in hospitals. They highlighted the fact that the promotion of infant formula in hospitals, and lack of regulation of their marketing together with a lack of support to understand the importance of exclusive breastfeeding up to 6 months, can undermine the successful breastfeeding by mothers, and recommended to Luxembourg to have strong regulations on the marketing of breastmilk substitutes coupled with a good monitoring of the Code and resolutions, as well as adequate maternity protection for working women so that mothers are really supported to breastfeed. The Committee also addressed the need to turn all four hospitals into baby-friendly.

The Luxembourg delegation reported that concerning the decreasing rate of exclusive breastfeeding, it is mainly women of low social and economical background who stop more and more breastfeeding their children after 6 months. The government of Luxembourg highlighted the fact that it is currently working in collaboration with international partners on the project to change the image of breastfeeding in order to convince mothers to continue breastfeeding their child until 6 months.

Concerning the Baby-Friendly Hospital Initiative, the delegation of Luxembourg said that one of the objectives of the national programme is to put BFHI in the national criteria for maternity units.

Concluding Observations

Although issue related to breastfeeding such as the BFHI, the marketing breastmilk substitutes, adequate budgeting of the national action plan and maternity protection were tackled during the Committee, we regret to see that no recommendations on this issue in the Concluding Observations were given to Luxembourg. 

For more information on breastfeeding in Luxembourg please see http://www.liewensufank.lu/fr

China to strengthen legislation on food safety and the International Code

China 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. The next consolidated 5^th to 6^th periodic report is expected by March 2019. The Chinese delegation was composed of 44 members headed by H.E. Mr. Guide Jia, Deputy Director-General at the Department of Treaty and Law and Ministry of Foreign Affairs.

In view of the session, IBFAN presented an alternative report on the situation of infant and young child feeding in China, prepared by IBFAN East-Asia. The report shows that in China breastfeeding declined rapidly during the 1980s due to the promotion of breastmilk substitutes and inappropriate medical practices. With the implementation of BFHI since 1992 and of national regulation on the marketing of breastmilk substitutes (China’s Regulation) since 1995, breastfeeding’s superiority has been recognized and mothers are encouraged and supported to breastfeed their infants. However, breastfeeding promotion in community and work place has not yet received enough attention. One of the challenges regards the popularity of formula feeding and persistence of inadequate feeding practices related to giving water to infants 0-5 months. Another challenge is how to ban the marketing promotion of infant formula which undermines mothers’ confidence on successful breastfeeding. It is difficult for health authorities to supervise, conduct training and reassessments of the baby-friendly health facilities in China given the great number of concerned facilities (over 60 thousands). Finally, it is hard to ensure mothers’ entitlement to paid maternal leave and breastfeeding facilities, especially during the rapid social and live style charging in China.

Discussion on infant and young child feeding

During the dialogue with the government delegation, issues related to breastfeeding and infant and young child feeding have been raised by the CRC Committee, in particular relation to breastfeeding programmes and the baby-friendly hospital initiative (BFHI). The delegation of China did not address these issues in its responses. The Committee pointed out that the exclusive breastfeeding rate is falling, claiming that this is due to incidents of contaminated milk. The Committee insisted on the importance of establishing and reinforcing breastfeeding programmes, as well as promoting the Baby-Friendly Hospital Initiative. The Chinese delegation did not address these issues.

With regards to HIV and AIDS, the CRC Committee asked if there is any programme protecting young people and mothers.

The Chinese delegation answered that the government had implemented a project of HIV prevention and that to date, around 90,000 HIV-positive pregnant women have accessed appropriate services. This has led to a decrease of mother-to-child transmission rate.

Concluding Observations

In its Concluding Observations, the CRC Committee made recommendations on promoting exclusive breastfeeding, BFHI and on adopting the International Code of Marketing of Breastmilk Substitutes. The Committee also mentioned the importance of respecting child rights in relation to the business sector.

Regarding breastfeeding in particular, the CRC Committee was concerned “about the decrease in the exclusive breastfeeding and the incidents of contaminated infant formula in mainland China” (para 64). It strongly recommended that the government of mainland China: “(a) Intensify its efforts to reform laws and strengthen implementation of regulations on food and health safety standards, including for business sector and ensure that any officials or companies violating international and national environment and health standards are appropriately sanctioned and remedies provided when violations occur; (b) Collects systematic data on children affected and take all measures to ensure that all children and their families have access to effective redress, including free medical treatment and adequate compensation; (d) Promote exclusive breastfeeding and the establishment of Baby-Friendly Hospitals and adopt a Code of Marketing of Breast-Milk Substitutes with appropriate controls on the marketing of artificial infant formula” (para 64-65)

In relation to Health and health services, the Committee recommends that “mainland China strengthen its efforts to address, as matter of urgency, the existing disparities in health outcomes and resource allocations in order to ensure that all children enjoy the same access to and quality of health services, paying special attention to children in vulnerable situations, especially children living in poverty and rural areas and children of migrant workers. In particular, it recommends that mainland China take all measures to eliminate child and maternal mortality, including by improving health infrastructure and the availability and accessibility to emergency obstetric and neonatal care and skilled birth attendants at primarily health facilities in rural and poor areas.” (para 62)

The CRC Committee, in its General Comment 16 (2013), 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”.

The Committee drew attention of China to its general comment no. 16 in the recommendations related to Child Rights and the business sector. It recommended to mainland China to strengthen the implementation of regulations in order to ensure that the business sector respects international and national human rights and complies with labour, environment and with child rights in particular. The CRC Committee therefore recommended that mainland China: “(c) Establish monitoring requirements for all industries 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 (d) Investigate and hold accountable government officials, including local officials, suspected of failing to uphold environmental regulations or preventing people from accessing information or medical care, and ensure that children and their families have immediate and full access to effective and medically approved treatment and long-term remedies, including rehabilitation services and compensation” (para 22-23).

Lithuania's lack of support for breastfeeding programme implementation

Lithuania presented its consolidated 3^rd and 4^th periodic reports on the situation of the implementation of the Convention on the Rights of the Child in the country. The consolidated 5^th to 6^th periodic report is expected by November 2018.

The IBFAN alternative report of Lithuania was prepared by the Initiative group of breastfeeding mothers and breastfeeding promoters of NGO "Pradžių pradžia" (IBFAN Lithuania). The report reflected the ‘Declaration on Breastfeeding Support and Relate Issues in Lithuania’ which was addressed to the highest authorities such as the Ministry of Health and Ministry of Education of the Republic of Lithuania, and was also shared with all universities and medical colleges and faculties of the country during the World Breastfeeding Week in 2011.

The report shows that in Lithuania, executive health policy does not direct any attention towards an integral programme on protection, support and promotion of breastfeeding. Dissemination of evidence-unbased information and misleading advertising is the key reason for refraining from breastfeeding or choosing a comparatively short period of breastfeeding. Article 24 of the Convention of the Rights of the Child is not appropriately respected and no mechanisms exist for control of its implementation: a comparatively large number of mothers continue refraining from or choose especially short periods of breastfeeding[1]. Thus, responsible state bodies that do not take action to encourage mothers to feed infants in a natural way, fail implementing public health strengthening actions based on disease prevention, which results in increased personal health care costs and sickness benefits. Currently, no substantial actions are taken to upgrade breastfeeding-related qualifications of health care specialists. Certain seminars on nutrition of infants and children for health care specialists are supported and organized by companies distributing breastmilk substitutes which violate the International Code of Marketing of Breastmilk Substitute and resolutions. What is more, accessibility to personal health care services for breastfeeding women is not sufficiently communicated and organized. There are very few baby-friendly hospitals and in other health care institutions, the quality of services is very low or services that ensure successful breastfeeding are nonexistent. Consequently, a birth-giving mother, limited by time and distance, cannot freely choose a health care institution. Mothers and newborns experience discrimination as they end up in a hospital without the BFHI status.

During the discussion between the government delegation and the CRC Committee, issues related to breastfeeding were not discussed.

Concluding Observations

We regret that the CRC Committee has made no specific recommendation on infant and young child feeding to the government of Lithuania in its Concluding observations.

In par. 39 and 40 regarding health care and services, the Committee regretted the decreasing budget allocations to maternal and child health care programmes. It reminded Lithuania to pay attention to its General Comment no. 15 (2013), which insists 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 increase its budget allocations for maternal and child health programs. The Committee also recommends that the State party ensure maternal care for women who choose to deliver at home by providing access to emergency obstetric care, trained care at delivery, and post partum care.”

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[1] Statistical data of research made at Health authority of Lithuania show that: just 30% of infant are breastfeed more than 0,5 year. For more see: http://www.tavovaikas.lt/kudikis/mityba-ir-sveikata/isaiskejo-kiek-sutaupo-seima-per-metus-maitinant-kudiki-krutimi.d?id=62015889

Sao Tome and Principe to address maternal deaths and business impact on child rights

Sao Tome and Principe 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 5^th and 6^th periodic reports are expected by June 2018.

IBFAN did not present any alternative report.

Discussion on infant and young child feeding

The Committee did not address issues related to breastfeeding. However, it tackled the question of maternal mortality in relation to HIV/AIDS infections. The delegation of Sao Tome and Principe explained that it is currently taking steps to eradicate these infections by 2015. Counseling centers for sexual health have been established in schools and awareness-raising activities are being organized for young persons.

Concluding Observations

No recommendation specifically refers to breastfeeding in the Concluding Observations. The CRC Committee instead mentioned the importance of a good health care system. It drew attention to its General Comment no. 15 (2013) on the right of the child to enjoy the highest attainable standard of health. It therefore recommended Sao Tome and Principe to: “(a) allocate adequate human, technical and financial resources to improve the quality of health care and provide quality training for the health care personnel, particularly at local levels; (b) Undertake surveys and studies on the extent and root causes of maternal mortality throughout the country and apply the findings therein for formulating and implementing comprehensive programmes for addressing maternal deaths: and, (c) Seek financial and technical assistance from UNICEF and the World Health Organization (WHO), among others, in this regard” (para 48-49).

The CRC Committee also insisted on improving the access to safe drinking water. It recommended the State party to: “(a) intensify its efforts to improve access to safe drinking water and sanitation, and in doing so pay particular attention to rural and outlying areas” (Para 54-55).

Another paragraph was dedicated to HIV/AIDS. The Committee recognized the efforts of Sao Tome and Principe to decrease the mother-to-child transmission of HIV/AIDS rate by spreading HIV/AIDS testing for pregnant women. However, the Committee noticed that regular follow-up on infected mothers and children remain inadequate and that the access to antiretroviral treatment limited. Therefore, the CRC Committee recommends Sao Tome and Principe to: “(a) Sustain the measures in place to prevent the Mother-to-Child transmission of HIV/AIDS and develop a roadmap to ensure the implementation of effective preventive measures; (b) Improve follow-up treatment for HIV/AIDS-infected mothers and their exposed infants[...] and (d) Improve access and coverage of Antiretroviral Therapy and Antiretroviral prophylaxis for HIV infected pregnant women. In doing so, the Committee recommends that the State party seek technical assistance from, inter alia, the United Nations Joint Programme on HIV/AIDS (UNAIDS) and UNICEF” (para 52-53).

Finally, the CRC Committee drew Sao Tome and Principe’s attention to the General Comment No. 16 (2013) on State obligations regarding the impact of the business sector on children’s rights and recommended Sao Tome and Principe to have a clear regulatory framework and effective implementation and monitoring mechanisms to ensure that business activities do not negatively affect the rights of the child. Concerning that issue, the Committee recommended in particular Sao Tome and Principe to: “(b) Ensure effective implementation by companies, especially those of the extractive industries, of international and national environment 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; (c) 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, (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).

Breastfeeding at the Committee on Economic Social and Cultural Rights.

In 2013, IBFAN submitted to the CESCR five alternative reports on the situation of infant and young child feeding in Azerbaijan, Denmark (50th session),Austria, Belarus and Egypt (51st pre-session). The reports aim at sensitizing the Committee on the issue of infant and young child feeding and its importance for the full implementation of the rights enshrined in the International Covenant, in particular the right to health and food. The IBFAN-GIFA team presented the reports orally at a meetings of the CESCR with NGOs.

Read the post-session report
More information

Breastfeeding situation in Slovenia

The situation of the implementation of the Convention on the Rights of the Child in Slovenia has been reviewed at the 63^rd session of the Committee on the Right of the Child (CRC Committee), on Wednesday 6^th June.

IBFAN presented its alternative report where it highlighted that Slovenia has only few provisions of law implementing the International Code of Marketing of Breastmilk Substitutes.

The issue of breastfeeding has been touched upon during the interactive dialogue between the CRC Committee and the country delegation.

Slovenian delegation reported that their country puts a special emphasis on breastfeeding, in laws, policies and guidelines (e.g. in the ‘Guidelines on Healthy Diet for Young Children’), where it has pledged to increase exclusive breastfeeding for the period 0-6 months of the baby’s life.

According to the delegation, breastfeeding rates are high in Slovenia, with 97% of breastfed babies up to 3 months and 2/3 exclusively breastfed in 2010.

Slovenia has also adopted a ban on marketing of breastmilk substitutes, while many maternity clinics are mother-friendly hospitals.

Breastfeeding is included in labour legislation according to which mothers have the right to breastfeed breaks until the baby is 18 months of age, without loss of payment.

The problem of high incidence of obesity in the country was also addressed by the delegation. In a US-EU countries ranking on obesity, Slovenia falls in the first third with the most obese population. Obesity is a complex issue and it is mentioned in several policies: on physical activity, on nutrition, etc. Vending machines have been abolished in schools and a policy on healthy diet in schools is subsidized by the State.

WHA Resolution Tackles Conflicts of Interest

The 65^th World Health Assembly (WHA) took place in Geneva in May and discussed an Implementation plan on infant and young child feeding. 

Proposed by Canada, UK, Swaziland and Mexico, the WHA adopted a new resolution WHA 65.6 on Maternal, infant and young child nutrition . 

It calls on governments to strengthen controls on the marketing of breastmilk substitutes and to establish “adequate mechanisms” to deal with conflicts of interest. 

The Resolution will be especially important in relation to the new partnerships and “multi-stakeholder” arrangements that are springing up to tackle poor nutrition - many of which are pushing fortified processed baby foods and fuelling the multi-billion “business of malnutrition”.

WHA 65.6 also mandates WHO "to provide clarification and guidance on the inappropriate promotion of foods for infants and young children".

More on this on IBFAN website