Sweden at the CRC: Significant Decrease of the Rate of Exclusive Breastfeeding

On January 13^th and 14^th, 2015, the Committee on the Rights of the Child considered the fifth periodic report of Sweden on the situation of the implementation of the Convention on the Rights of theChild (CRC) in the country. The Swedish delegation was led by Mrs. Pernilla Baralt, State secretary at the Ministry of Health and Social Affairs.

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

General overview of breastfeeding in Sweden

The report pointed out the lack of tracking of key breastfeeding indicators (especially related to early initiation of breastfeeding and to continued breastfeeding at the age of 2 years). It also emphasized the significant decrease of the rate of exclusive breastfeeding until 6 months that happened between 2000 (33.4%) and 2012 (14.5%).

Regarding the promotion of optimal breastfeeding practices, it is of serious concern that the official Swedish publications, such as the ones accessible from the National Food Agency portale, are not in line with the official recommendations on infant and young child feeding issued by the World Health Organization. In addition, the protection of breastfeeding is still insufficient in Sweden. The International Code of Marketing of Breastmilk Substitutes and the relevant subsequent World Health Assembly resolutions have been only partially implemented through national legislation and although a voluntary policy on the marketing of breastmilk substitutes has been adopted, it is not enough to ensure that parents and caregivers are not facing undue commercial pressure from the baby food industry.

In addition, the quality of the training courses of health professionals on optimal breastfeeding practices, considered as ‘too basic’ in a 2008 report, should be put into question and improved, and the consistency of information provided to mothers in maternity wards of the country should be regularly monitored.

Finally, mother-to-child HIV transmission rate should be monitored and information on the implementation of any specific policy on infant feeding in emergencies should be provided.

Discussion on infant and young children feeding

The Committee raised concern about the lack of implementation of the International Code into national legislation and about the issues related to the marketing of infant formula in the country. It noted that the rate of exclusive breastfeeding is very low and asked if there is an explanation about it. The Committee further emphasized the link between suboptimal breastfeeding practices and the growing trend of obesity and overweight within the Swedish population. It then requested the delegation to provide clarification on the activities that are lead by the government with aim to promote breastfeeding.

The delegation answered that in Sweden, the cultural environment is generally favourable to breastfeeding. It also noted that the decrease of the rate of exclusive breastfeeding is not so important for children born since 2011 and that in 2009, a national breastfeeding committee has been formed in order to promote, protect and support breastfeeding. Besides, it highlighted that a 2013-2016 Strategic Plan for Coordination on Breastfeeding Health has been adopted and is structured around 5 main objectives (1/development of a national knowledge on breastfeeding, 2/ training on breastfeeding aimed at health professionals, 3/ information of health professionals and policy-makers about the WHO recommendations on breastfeeding, that have been translated in Swedish 4/ official recommendations on breastfeeding should be consistent with the WHO recommendations and 5/ the EU directive on infant formulae and follow-up formulae should be implemented through national legislation and monitored).

The Committee thanked the delegation for its clarifications. It however insisted on several unanswered questions: Is there a Swedish comprehensive database tracking the breastfeeding indicators (especially the early initiation of breastfeeding and the continued breastfeeding until the age of 2 years)? Is the International Code fully implemented and monitored? What explains the decrease of the rate of exclusive breastfeeding considering the very high rate of institutional deliveries? Which measures are take to tackle the obvious lack of adequate training of health professionals regarding breastfeeding? Is there any plan implemented to protect and support breastfeeding in emergencies?

Concluding Observations

In its Concluding Observations, the Committee did not make any recommendation directly or indirectly related to infant and young child feeding. A general recommendation related to health and health services called for strengthening “efforts to improve the health status of children from disadvantaged and marginalized groups and allocate sufficient financial, human and technical resources to ensure their right to health without discrimination” (§ 41).

Turkmenistan at the CRC: Constructive Dialogue on Breastfeeding between the CRC Committee and the Turkmen Delegation

On January 13^th and 14^th, 2015, the Committee on the Rights of the Child considered the combined second to fourth periodic report of Turkmenistan on the situation of the implementation of the Convention on the Rights of the Child in the country. The Turkmen delegation was led by Mrs. Lyudmila Amanniyazova, Deputy Head of the State Statistics Committee and H.E. Mr. Atageldi Haljanov, Permanent Representative of Turkmenistan 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 Turkmenistan.

General overview of breastfeeding in Turkmenistan

Breastfeeding rates are low in Turkmenistan: nine children out of 10 are not exclusively breastfed under 6 months of age and less than 4 children out of 10 receive continued breastfeeding until 2 years of age. The rate of early initiation of breastfeeding  is also very low (59.8%) while neonatal, infant and under-5 mortality rates are still high in the country.

In 2009, Turkmenistan adopted the Law on Protection and Promotion of Breastfeeding and Requirements for Infant Feeding Products, amended in 2013, which determines the main public policies on child nutrition and regulates the distribution and marketing of safe baby foods. However, this law implements only partially the International Code of Marketing of Breastmilk Substitutes and there is no clarity on its implementation or on any monitoring mechanism.

Besides, there is no recent data on the implementation of the Baby-Friendly Hospitals Initiative in the country. In 2009-2010, 81% of the maternity facilities were certified as ‘baby-friendly’. Finally, no comprehensive information on maternity protection, HIV and breastfeeding and infant feeding in emergnecies is available.

Discussion on infant and young child feeding

The CRC Committee specifically addressed the issue of breastfeeding and the lack of breastfeeding-related information. After welcoming the adoption of the 2009 law(see above)and its 2013 amendments, the Committee expressed concern for the low exclusive breastfeeding rate under 6 months and asked about the root causes of this drop as well as about the measures taken to tackle it.

Additional questions were made on the number of Baby-Friendly hospitals in the country and on the training available for expecting mothers and fathers on parenthood and breastfeeding practices. The CRC Committee also raised the issue of the training provided to health professionals on breastfeeding, the duration of the maternity leave and the existence of a paternity leave. It also highlighted that information on mother-to-child HIV transmission and on HIV and breastfeeding was missing.

The Turkmen delegation specified that according the 2009 law prohibits the distribution of samples of infant formula to families, in line with the International Code. It mentioned that currently, some 95% of hospitals and maternities are certified as “Baby-Friendly”, that expecting mothers learn about breastfeeding as part of their preparation to motherhood, and that about 2,000 parents have been given training on child care. Thanks to the measures undertaken, the rate of children ever breastfed increased  from 41% in 2008 to 61% in 2014. A study conducted in two regions of the country showed that 59% of children aged 0-5 months were exclusively breastfed. Lastly, a study assessed that doctors and nurses have good knowledge on breastfeeding.

Concerning maternity protection, the delegation explained that there are 3 types of State maternity allowances for child care, given respectively before delivery, at delivery and after deliver. It also mentioned that the maternity leave should not be less than 190 days, according to the Turkmen legislation, which also provides for a paternity leave. The delegation stated that legislation provides breastfeeding breaks of 30 minutes every three hours, available for lactating mothers with children up to 1 year and a half of age. The duration of the breastfeeding breaks can change depending on the number of children and it is considered as working time, thus not deducted from the salary.

Additional information was given on the network of health care centres that is being developed and empowered throughout the country, in order to provide coverage of maternal and children’s health services in the main cities as well as in the rural areas. No information was given on HIV and breastfeeding.

Concluding Observations

In its Concluding Observations, the Committee made several recommendations directly related to breastfeeding.

With regard to breastfeeding protection, the Committee urged Turkmenistan to “enact legislation implementing all the provisions of the International Code of Marketing of Breast-Milk Substitutes” (§ 49b), as well as to “ensure that working mothers have the practical possibility to breastfeed, including by developing breastfeeding-friendly workplaces and child care centres at work” (§ 49e). Concerning the promotion of breastfeeding, the Committee recommended the country to enhance its efforts to promote exclusive breastfeeding practices (§ 49a) and to raise awareness about optimal breastfeeding practices among the population (§ 49c). Finally, on data collection, the Committee urged Turkmenistan to “ensure systematic collection of data on infant and young child feeding” (§ 49d).

Fiji at the CRC: BFHI Implemented, but Still to Be Strengthened

On the 4th and 5th September 2014, the Committee on the Rights of the Child considered the combined Second to Fourth Periodic Report of Fiji on the situation of the implementation of the Convention on the Rights of the Child in the country.

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

General overview of breastfeeding in Fiji

The alternative report showed that 39.8% of infants aged six months or less are exclusively breastfed. Furthermore, a large proportion of children aged 6 months or less are given water (79.6%) as well as sweetened drinks. These data reveal therefore a lack of knowledge about optimal breastfeeding practices.

According to the 2011 World Breastfeeding Trends initiative (WBTi) report on Fiji, a national Infant and Young Child Feeding/Breastfeeding policy was adopted by the Government. Such a policy provided a National Breastfeeding Committee that is however now defunct. Moreover, the WBTi report stresses that “Information, Education and Communication” materials are available only in English.

The Government of Fiji has fully implemented the International Code of Marketing of Breastmilk Substitutes (the Code) in its entirety. However, an informal monitoring in a supermarket in November 2011 highlighted that complementary food labelling the product as suitable for age 4-6 months has been only partially obscured, which constitutes a violation of the Code.

The report highlighted that Fiji has established a national Baby-Friendly Hospital Initiative (BFHI) coordinator. By the beginning of 2009, all its 12 public hospitals were certified as “baby-friendly”. Nevertheless, two main problems have been encountered in its implementation. Firstly, hospitals fail to refresh BFHI courses every two years (as the WHO recommends) and, secondly, mothers are not provided for contacts of health care persons.

According to a study conducted by the Fiji Journal of Public Health, 57% of women who do not exclusively breastfeed pinpoint work as the obstacle to exclusively breastfeeding. The Fijian legislation provides indeed only 84 consecutive (12 weeks) days as maternity leave entitlement. For the first three births, such a leave is paid at the normal remuneration rate, whilst from the fourth child, the mother is entitled to only half the normal salary. Additionally, it is worth noting that there are no provisions concerning paid or unpaid breaks during work hours.

As far as HIV and infant feeding is concerned, it must be noted that a comprehensive policy on infant and young child feeding that includes infant feeding and HIV is lacking.

In coordination with UNICEF and WHO, Fiji developed a flyer on infant feeding during emergencies. However, neither a national plan nor a focus person has been identified to coordinate activities.

Discussion on infant and young child feeding

The Fijian Delegation first stated that the infant mortality rate in Fiji is of 13.7 per 1,000 live births and that perinatal mortality represents an important component of the mortality of children under 5 years old. Regarding maternal health, the Delegation indicated that last year, 4 maternal deaths have been registered in the country. The family health units deal particularly with women’s health, children health (including immunization) and reproductive health as well as with the fight against HIV. The Delegation also indicated that according an immunization state study, the immunization coverage rate is of 84.9%. It further stated that in 2014, collaborative, comprehensive guidelines on child protection aimed at health workers have been issued and that trainings of health professionals on this issue have been organized. Community health trainings are supported by family health units and include training of health professionals on issues related with neonatal intensive care units.

The Committee asked how many women breastfeed their child, by emphasizing that breastfeeding ties very closely with child’s health as well as whether the National Breastfeeding Committee is still operational.

The Delegation noted that suboptimal breastfeeding practices in Fiji contribute to increase the burden of Non-Communicable Diseases (NCDs). Therefore, breastfeeding and infant and young child feeding are part of the National Strategic Plan for NCDs. The Delegation also indicated that during the first decade of 20th century, Fiji has developed the implementation of the BFHI; during this period, the 3 main hospitals of the countries have been certified as “baby-friendly”. However, there is a current decline in the implementation of the BFHI. The Delegation further emphasized Fiji’s endorsement of the International Code on Marketing of Breastmilk Substitutes and informed the Committee that the National Breastfeeding Committee’s plans to hold a meeting on the 24th September 2014. Finally, the Delegation indicated that “Information, Education and Communication” materials are now available in Ataque language but have not been translated into other languages yet.

The Committee expressed further its concern about the current decline of Code implementation. It also highlighted that regular monitoring of the national legislation implementing the Code through an effective monitoring mechanism is crucial. With regard to the implementation of the BFHI and the Ten Steps to successful breastfeeding, the Committee noted that the training of health professionals and the monitoring of these trainings are very important. Finally, the Committee insisted on the importance of monitoring the marketing practices that occur in hospitals in order to make sure that Code policies are followed.

Concluding Observations

In the Concluding Observations, several indirect recommendations were made by the Committee. With regard to the general measures of implementation, it urged Fiji “to take all necessary steps to provide for a timely adoption of [a national comprehensive policy and strategy for children], and to ensure that sufficient human, technical and financial resources are allocated to facilitate its implementation" (§9). It also recommended that Fiji “take all necessary efforts to establish a comprehensive data collection system” (§15). 

Concerning health issues, the Committee recommended that Fiji “strengthen its efforts to further reduce the under-5 and infant mortality rate, especially by focusing on preventive measures and treatment, including immunization, improved nutrition and sanitary conditions, in particular in remote areas”. It also requested the Government to “enforce its efforts to improve prenatal care and further reduce maternal mortality, including by increasing the training of midwives and ensuring the generalization of specific actions to prevent post-partum bleeding and other major causes of maternal death” (§ 42).

Furthermore, the Committee issued direct recommendations related to infant and young child feeding (§54). It recommended that Fiji “ensure that every hospital with a new-born nursery is regularly monitored on adequate implementation of the International Code of Marketing of Breast-milk Substitutes. It also urged Fiji to “raise awareness on the importance of breastfeeding and on the risks of formula feeding” and to “promote proper breastfeeding practices, as well as develop a policy on infant and young child feeding practices, which includes infant feeding and HIV".

Venezuela at the CRC: Strong Legislation but Lack of Data

On the 1^st and 2^nd September 2014, the Committee on the Rights of the Child considered the combined third to fifth periodic reports of Venezuela on the situation of the implementation of the Convention on the Rights of the Child in the country. The Delegation of Venezuela, led by the Minister of Popular Power for Women and Gender Equality (Ministerio del Poder Popular para la Salud, MPPS), Ms. Andreina Tarazón, was constituted of 31 members, including the General Director of the Health Committee of the Ministry of Popular Power for Education, Ms. Asia Yadira Acosta.

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

General overview of breastfeeding in Venezuela

The report highlighted a significant deficit in data collection on infant and young child feeding (IYCF). The available data on IYCF are from 2008 and show that more than 70% of children are not exclusively breastfed until 6 months of age while almost 13% are predominantly breastfed until 6 months of age, although it is considered as an inadequate practice. Some 75% of the children are introduced to complementary food before the recommended age of 6 months. In addition, when bottle feeding, the dilution of the powder milk or formula has shown to be inadequate in more than 70% of cases.

Nonetheless, the Government of Venezuela has shown its will to encourage breastfeeding. Firstly, one of the goals set in the “Plan de la Patria Socialista de la Nación 2013-2019” is to increase exclusive breastfeeding by 70%. Secondly, breastfeeding is promoted as a priority by the MPPS and is referred to in the Organic Law on Children and Adolescents Protection (Ley Orgánica para la Protección de Niños y Adolescentes, LOPNA). Thirdly, the International Code of Marketing of Breastmilk Substitutes, as well as the Baby-Friendly Hospital Initiative (BFHI), were formally implemented into national legislation through two ministerial decisions in 2004. However, in 2010, only 17 out of 204 hospitals were certified as ‘baby-friendly’ and violations of the Code can still be detected, such as the use of health claims, promotion of ‘baby competitions’, corporate sponsoring of  medical events.

Regarding training of health professionals, courses on breastfeeding are organized jointly by the Childcare and Paediatricians Venezuelan Society and the UNICEF. Besides, a course on breastfeeding counselling is organized at national level; since its launch, more than 3,000 accredited breastfeeding counsellors have been trained. Finally, the GALACM-UCV breastfeeding support group also gives training courses on breastfeeding. Nevertheless, in 2009, it is of concern that about 35% of surveyed mothers did not receive information on breastfeeding during pregnancy.

In Venezuela, mothers are entitled to a maternity leave that has been increased from 12 to 20 weeks in 2012. Yet, IBFAN report calls for the extension of the maternity leave up to 40 weeks of corrected age for mothers with premature babies.

Regarding IYCF and VIH/AIDS, a programme on the prevention of vertical transmission is carried out in order to ensure the supply of infant formula during the first year of life for children of HIV-positive mothers. Finally, the national legislation states that breastfeeding should be protected in case of emergencies.

Discussion on infant and young child feeding

The Delegation of Venezuela affirmed that a humanist approach is taken in the field of reproductive health and that the government guarantee the provisions of medical services in this field through the programme Barrio Adentro. A specific programme entitled Misión niño Jesús aimed at pregnant women has been implemented.  In addition, the Delegation stated that the government provides support to improve the nutrition of mothers and children, especially by timely supplementation. Finally, it highlighted that 8 human milk banks have been implemented in  the country.

Concluding Observations

In its Concluding Observations, the Committee made several indirect recommendations. With regard to general measures of implementation, it urged Venezuela “to finalize the design of the National Plan of Action for Children and Adolescents (2015-2019)” (§11) as well as “to expeditiously complete and implement its data collection system” (§20).

As far as health issues are concerned, it recommended that Venezuela “collect disaggregated data on children’s health related issues, in particular on child mortality, including under five mortality, maternal mortality, vaccination coverage, nutrition and breastfeeding; allocate adequate human, technical and financial resources to the national public health system; building on data related to the causes, design a strategy to reduce child and maternal mortality, which includes the implementation of the two existing protocols on maternal and neonatal mortality and continue its efforts to reduce malnutrition and increase vaccination coverage” (§53 (a)-(d)). Furthermore, The Committee also addressed the issue of HIV/AIDS mother-to child transmission by requesting the government to “collect disaggregated data on HIV/AIDS related issues, in particular on [...] number of cases of mother-to-child transmissions, [...] and number of children and pregnant women under treatment” and “ensure that all HIV/AIDS positive pregnant women receive adequate treatment” (§61(a),(c)).

The Committee also issued direct recommendations related to infant and young child feeding (§53(e)). It recommended that Venezuela “increase its efforts to promote breastfeeding by developing a comprehensive programme of action to promote exclusive breastfeeding, including training for staff in hospital maternity wards, closely monitor the implementation of the International Code of Marketing of Breast-milk Substitutes and develop awareness raising campaigns”.