Mexico at the CRC: Steep Decline of Breastfeeding Practices

On May 19 and 20, 2015, the Committee on the Rights of the Child considered the combined fourth and fifth periodic report of Mexico 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 Mexico.

General overview of breastfeeding in Mexico

In its alternative report, IBFAN insisted on the high rates of child overweight and obesity as well as on the lack of drinking water and the widespread sale of soft drinks in schools. In 2006, child obesity rose to 36.9% while deaths caused by diabetes progressively increased. 

The report also emphasized the high infant mortality rate (7 per 1, 000 live births for 2012-2013) that even reaches 23.89 per 1,000 live births in remote regions like Chiapas. 

In such a context, it is of concern that breastfeeding rates are low. The 2012 National Health and Nutrition Survey showed that the median duration of breastfeeding was of 10 months only. It also reveals a steep decline of exclusive breastfeeding rates between 2006 and 2012. Regarding the enforcement of the International Code of Marketing of Breastmilk Substitutes, IBFAN report flagged the lack of monitoring and sanctioning mechanism, leading to Code violations within the National Health System. 

IBFAN also denounced the adverse impacts of national nutrition programmes. For example, the programme “Prospera”, Mexico’s largest programme of food assistance, includes distribution of a ready-to-use food supplement, contravening the international recommendations on infant and young child feeding. The Programme Cruzada Contra el Hambre is led in partnership with corporations that violate the International Code and the distribution of Tarjetas Sin Hambre allows poor families to access to a list of 15 subsidized products that includes unhealthy foods such as instant sugar-added coffee (Nescafé Dolca), instant oat cereal Powder milk (Nestlé’s Nido and others) and instant chocolate powder.

IBFAN also noted the Mexico did not ratify the ILO Convention 183 (2000) on Maternity Protection and needs to extend maternity protection to the growing number of women working in the informal sector. 

Finally, IBFAN stressed the need to adopt and implement the Operational Guidance on Infant and Young Child Feeding in Emergencies in order to protect breastfeeding during disasters.

Discussion on infant and young child feeding

The CRC Committee expressed concerns about the high rate of child mortality in indigenous areas. It also raised the issues of child obesity and teenage pregnancies. 

More specifically, the CRC Committee noted the decline of breastfeeding rates and the fact that many mothers receive promotional gifts from baby food companies within hospitals and maternities. It highlighted the lack of enforcement of regulations related to the marketing of breastmilk substitutes and asked which actions are by the government in this regard

The Mexican delegation answered that the mortality rate is currently following a downward trend in Mexico, and that many policies and programmes have been implemented in this regard. The government also mentioned their programmes “Prospera” and “Cruzada Contra el Hambre”, noting that they cover large portions of indigenous regions. For example, some 25% of the beneficiaries of the Prospera programme are from indigenous communities. In addition, the delegation noted that more than 700,000 families have beneficied of the programme “Tarjetas Sin Hambre”. 

In relation with infant and young child feeding, the delegation responded that as part of a national strategy for breastfeeding a new programme on breastfeeding promotion has been launched. It also affirmed that the Ten Steps to Successful Breastfeeding of the Baby-Friendly Initiative are being implemented throughout the country and that several human milk banks have been set up. 

Regarding obesity, the delegation mentioned the national comprehensive strategy for tackling overweight and obesity, which is based on 3 pillars: 1) taxes 2) legal reform and 3) promotion of physical activity. Likewise, a special tax on sugary drink has been implemented as part of this strategy. In relation with the legal reform, the delegation mentioned the integration of a constitutional article prohibiting the sale of sugary drinks in schools, as well as federal legal provisions limiting the advertisement of unhealthy foods on TV during programmes aimed at children and in cinemas. It affirmed that the government carries out awareness-raising activities such as campaigns to measuring waist and promote physical activity and it made reference to the national council on NCDs. The delegation also mentioned the implementation of water fountain in every school as part of the legal undertaken.

Finally, regarding maternal mortality, the delegation noted that several campaigns aiming at tackling teenage pregnancies have been launched. As a result, a drop of 15% of such pregnancies is expected. It also affirmed that teenage mothers are allowed to deliver in any health service of the country.

Concluding observations 

In its Concluding Observations, the Committee issued both indirect and direct recommendations related to infant and young child feeding to Mexico. 

Addressing specifically infant and young child feeding, the Committee expressed concerns the decline of exclusive breastfeeding (§47d) and recommended Mexico to strengthen the efforts to “promote breastfeeding through educational campaigns and training to professionals” and “adequately implement the International Code of Marketing of Breast-Milk Substitutes and the Child-Friendly Hospital Initiative”(§48d).

Highlighting the persistent child chronic malnutrition in rural and indigenous areas (§47c) and the increasing of overweight and obesity among children (§47e), the Committee also recommended Mexico to draft a national strategy on nutrition that would ensure food security, especially in rural and indigenous areas (§48c), as well as to continue raising awareness on the impact of processed food including and strengthen the regulations restricting the advertising and marketing of junk, salty, sugary and fatty foods and their availability for children (§48e).

Regarding, health services, the Committee stressed the need to ensure the availability and accessibility of quality health services, in particular rural and indigenous children, including by allocation adequate resources (§48a). 

The Committee also expressed concerns over the high child and maternal mortality rates (§47b), recommending the State party to strengthen and reduce maternal and child mortality, including by implementing the OHCHR Technical Guidance on child mortality (A/HRC/27/31).

Finally, regarding environmental health, the Committee expressed concern about the insufficient measures taken by Mexico to address air, water, soil and electromagnetic pollution, which gravely impact on children and maternal health. It thus recommended the State party to assess theses impacts on children and maternal health as a basis to design a well-resourced strategy to remedy the situation, prohibit the import and use of pesticides or chemicals that are banned or restricted for use in exporting countries and examine and adapt its legislative framework to ensure the legal accountability of business enterprises involved in activities having a negative impact on the environment in the light of its General Comment No 16 (2013) on State obligations regarding the impact of the business sector on children’s rights (§51-52a-c).

[Note: Click here to access to a discussion paper prepared by IBFAN Mexico which provides an interpretation of what should be an "adequate" implementation of the International Code of Marketing of Breast-milk Substitutes.]

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).

67th Session of the CRC Committee: Recommendations Related to Breastfeeding

The 67th Session of the Committee on the Rights of the Child (CRC Committee) took place in Geneva from 1st September to 19th September 2014. The Committee reviewed the progress of the implementation of the Convention on the Rights of the Child in 5 countries: Croatia, Fiji, Hungary, Morocco, and Venezuela. IBFAN submitted alternative reports on the situation of infant and young child feeding for each of the reviewed countries. The reports on Croatia and Venezuela were prepared by the IBFAN groups in those countries. 

In its Concluding Observations, the CRC Committee referred specifically to breastfeeding in 4 out of 5 countries under review (Croatia, Fiji, Hungary and Venezuela). Morocco did not receive any direct recommendation on breastfeeding, albeit it was addressed several recommendations on various topics indirectly related to breastfeeding.

General measures of implementation 

The CRC Committee called for the timely adoption of a comprehensive policy covering all areas of children’s rights under the Convention in 4 out 5 countries and for the improvement of its implementation in Morocco. 

Furthermore, it recommended that all countries under review take all necessary steps to collect disaggregated data that should cover all areas of the Convention.

Health resources and budget 

The Committee also called for the strengthening of resources allocated to health, by urging Croatia to allocate adequate human resources to maintain the quality of health care and by requesting more generally Venezuela and Morocco to allocate sufficient human, technical and financial resources to the health sector and to effectively used them.

Preventive health

The importance of preventive health has been highlighted in several recommendations.

Morocco and Venezuela were asked to reduce child and maternal mortality. Fiji was specifically requested to reduce 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 as well as to further reduce maternal mortality, by ensuring the generalization of specific actions to prevent post-partum bleeding and other major causes of maternal death. 

The Committee also recommended that Fiji enforce its efforts to improve prenatal care, including by increasing the training of midwiwes. 

Children’s access to health care was also addressed by the CRC Committee, especially with regard to rural areas. Indeed, Croatia was called to strengthen its efforts to ensure that all children enjoy equal access to health services with particular emphasis on children in rural areas and from minority groups. Hungary was instead requested to take measures to ensure that health care facilities and practitioners, including paediatric and specialized care practitioners, are available throughout the country including in rural areas.

Finally, the Committee showed concern about the lack of specific data in Venezuela. Therefore, it asked Venezuela to collect disaggregated data on children’s health related issues, in particular on child mortality, including under-5 mortality, maternal mortality, vaccination coverage, nutrition and breastfeeding.

Malnutrition

The Committee asked Morocco to take more effective measures to address the nutrition status of young children, while Hungary was requested to provide access to education on nutrition as well as nutritious food to all children in the country. 

The Committee also urged Venezuela to continue its efforts to reduce malnutrition and increase vaccination coverage.

HIV/AIDS

The Committee addressed the issue of mother-to-child transmission, by requesting Venezuela to collect disaggregated data on the number of cases of mother-to-child transmissions and the number of children and pregnant women under treatment. It also urged Venezuela to address the sporadic shortages of antiretroviral drugs and ensure that all HIV/AIDS positive pregnant women receive adequate treatment.

In this regard, the Committee asked Fiji to improve follow-up treatment for HIV/AIDS-infected mothers and their infants to ensure early diagnosis and early initiation of treatment.

Breastfeeding protection 

Full implementation of the International Code on Marketing of Breast-Milk Substitutes has proven to be an effective intervention to protect breastfeeding and to ensure that mothers are provided with adequate information on the best way to feed their infants and young children.

Therefore, the Committee urged Hungary to fully implement the provisions of the International Code and recommends that Fiji as well as Venezuela ensure that every hospital with a new-born nursery is regularly monitored on adequate implementation of the International Code. The Committee specifically asked Croatia to take all necessary legislative and structural measures, including monitoring, to control the marketing of breast-milk substitutes. 

More generally, in light of the CRC General Comment No. 16 on State obligations regarding the impact of the business sector on children’s rights, Morocco was asked to examine and adapt its legislative framework concerning legal accountability of business enterprises and their subsidiaries operating in or managed from the Morocco’s territory. The Committee also requested Morocco to establish monitoring mechanisms for the investigations and redress of violations of children’s rights with a view to improving accountability and transparency. 

Breastfeeding promotion 

The Committee expressed concern over the lack of awareness of the benefits of exclusive breastfeeding and risks of formula feeding in Croatia and Fiji. It also showed concern with regard to the high number of children aged up to 6 months who are not being exclusively breastfed in Fiji and the lack of information on this rate in Hungary. Finally, it expressed concern over the low number of baby friendly hospitals in Hungary. 

Therefore, it asked Fiji to raise awareness on the importance of breastfeeding and on the risks of formula feeding. Fiji was also urged to promote proper breastfeeding practices, as well as develop a policy on infant and young child feeding practices, which includes infant feeding and HIV. 

The same kind of recommendations was addressed to Croatia and Venezuela. Croatia was indeed requested to take action to improve the practice of exclusive breastfeeding, through awareness-raising measures, the provision of information and training to relevant officials, particularly staff working in maternity units, and parents. Venezuela was instead called to increase its efforts to promote breastfeeding by developing a comprehensive programme of action to promote exclusive breastfeeding, including for staff in hospital maternity wards, and to develop awareness raising campaigns. 

Finally, the CRC Committee recommended that Hungary specifically encourage exclusive breastfeeding of infants until 6 months of age, provide data on the rate of breastfeeding as well as increase the number of baby friendly hospitals. 

Breastfeeding support 

No specific recommendation on breastfeeding support (e.g. inclusion of knowledge on optimal breastfeeding practices in health curricula) has been issued by the CRC Committee following its 67th Session.

Table 1. CRC Committee - Session 67 / 2014 - Summary of Concluding Observations on IYCF

Country		IBFAN report	Summary of specific recommendations on IYCF
1	Croatia (3rd-4th periodic report)	yes	Indirect – General measures of implementation (§ 9, 15): adoption of the new National Strategy for Protection and Promotion of the Rights of the Child from 2014-2020 and ensure that it includes concrete goals and measures with clear indication of the roles and responsibilities of relevant bodies at all levels; expeditiously improve its data collection system. Health (§45): ensure that all children enjoy equal access to health services; allocate adequate human resources to maintain the quality of health care.  Direct (§49): improve the practice of exclusive breastfeeding, through awareness-raising measures, the provision of information and training to relevant officials, particularly staff working in maternity units, and parents; take all the necessary legislative and structural measures, including monitoring, to control the marketing of breast-milk substitutes.
2	Fiji (2nd-4th periodic report)	yes	Indirect – General measures of implementation (§§ 9, 15): take all necessary steps to provide for a timely adoption of a national comprehensive policy and strategy for children; establish a comprehensive data collection system. Health (§42): 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; 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.  Direct (§54): 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; raise awareness on the importance of breastfeeding and on the risks of formula feeding; promote proper breastfeeding practices, as well as develop a policy on infant and young child feeding practices, which includes infant feeding and HIV.
3	Hungary (4th-5th periodic report)	yes	Indirect – General measures of implementation (§§ 8, 10): improve the collection of data; adopt a comprehensive policy covering all areas of children’s rights under the Convention and ensure that its strategies and action plans are provided with necessary human, technical and financial resources for their effective implementation; Health (§47): ensure that health care facilities and practitioners, including paediatric and specialized care practitioners, are available throughout the country; provide access to education on nutrition.  Direct (§§ 50-51): encourage exclusive breastfeeding of infants until 6 months of age and provide data on the rate of breastfeeding; increase the number of baby friendly hospitals and take measures to fully implement the provisions of the International Code of Marketing of Breast-milk Substitutes.
4	Morocco (3rd-4th periodic report)	no	Indirect – General measures of implementation (§§ 7, 13, 23(a)): address previous recommendations related to data collection; ensure that the Integrated Policy on Children encompasses child protection and covers all areas under the Convention and all children; 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 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. Health (§55(a)(b)): sufficient resources must be allocated for the health sector and effectively used; 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; take more effective measures to address maternal and infant mortality and the nutritional status of young children.
5	Venezuela (3rd-5th periodic report)	yes	Indirect – General measures of implementation (§§ 11; 20): finalize the design of the National Plan of Action for Children and Adolescents; expeditiously complete and implement the data collection system. Health (§§ 53(a)(b)(c)(d); 61(a)(c)): collect disaggregated data on children’s health related issues, in particular on child mortality, including under five mortality, maternal mortality, vaccination coverage and nutrition; 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; reduce malnutrition; 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; ensure that all HIV/AIDS positive pregnant women receive adequate treatment.  Direct (§53(a);(e)): collect disaggregated data on breastfeeding; 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.