Ghana at the CRC: Concerns about the Decline of Exclusive Breastfeeding and the High Rate of Neotoal Mortality

On May 21 and 22, 2015, the Committee on the Rights of the Child considered the combined third to fifth periodic report of Ghana on the situation of the implementation of the Convention on the Rights of the Child in the country. The delegation of Ghana was led by Hon.Nana Oye Lithur, Minister of Gender, Children and Social Protection, and Ms. Laadi Ayamba, Chair person, Parliamentary Select Committee.

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

General overview of breastfeeding in Ghana

IBFAN report highlighted the declining trend in breastfeeding rates, particularly the exclusive breastfeeding rate under 6 months (63% in 2008 to 45.7% in 2011) and early initiation of breastfeeding (52% in 2008 to 45.9% in 2011). This situation is closely connected with the inadequate funding to implement the policies and actions plans on Child Health and Nutrition.

In Ghana, the InternationalCode of Marketing of Breastmilk Substitutes is fully implemented through the BreastfeedingPromotion Regulation 2000 (BPR 2000). However, the Committee in charge of monitoring its implementation was found inactive due to the lack of commitment from the Food and Drugs Authority which results in systematic violations.

In  addition, despite the pre- and in-service training programs aimed at health workers and courses provided by the Ghana Health Service with the support of UNICEF, WHO and other partners, the need for more trained counsellors in health facilities was underlined.

The report finally flagged the short duration of the maternity leave which does not cover women working in the informal sector. Finally, the lack of emergency preparedness plan with specific guidelines to ensure protection and support of breastfeeding in emergencies was pointed out.

Discussion on infant and young child feeding

During its discussion with Ghana, the CRC Committee addressed specifically the issue of breastfeeding. It expressed concerned about the high neonatal mortality rate and the decline of exclusive breastfeeding due to the insufficient monitoring on the implementation of the BPR 2000 and the subsequent violations of the International Code. It asked which measures will be taken to this particular issue and asked for more information on breastfeeding promotion to mothers as well as on the implementation of an adequate monitoring and sanction mechanism to enforce the BPR 2000.

First of all, the delegation admitted the lack of financial resources allocated to health. Regarding neonatal mortality, the delegation stated that a new Sub-Committee composed of government representatives, medical staff, technicians and community health workers has been established in 2012. It aims to design and launch a national action plan for the period 2014 to 2018.   In addition, a national meeting on neonatal mortality will be held in July 2015, bringing together all relevant partners at national level, including community health workers.

In relation to the persistent high maternal mortality rates, the delegation highlighted the implementation of a policy on free antenatal and delivery care for all women. As a result, the latest demographical and health survey showed that 97% of pregnant women receive antenatal care and 74% of births are attended by a skilled health professional. Besides, specific trainings are delivered so that midwives are enabled to deliver services at community level, especially in the most remote areas, and physicians as well as technicians are enabled to deal with perinatal conditions such as post-partum hemorrhage. The government recently started a pilot project to provide women delivering at home (30% of pregnant women), a tablet of misoprostol to prevent hemorrhages. The delegation also explained that pregnant teenage girls are granted with free access to antenatal care, although they still sometimes face discrimination on the ground.

Besides, the delegation admitted that the rate of exclusive breastfeeding under 6 months declined between 2008 and 2011. To remedy this situation, the government took measure to increase awareness of health workers through specific trainings. The government also stressed its commitment to strengthen the implementation of the Baby-Friendly Hospital Initiative as well as to enforce the BPR 2000, resulting in the slow rise of the rate of exclusive breastfeeding.

Finally, the delegation declared that misleading advertisements have been reduced since the entering into force of the BPR 200. However, it admitted that baby food manufacturers are still trying to influence health professionals through sponsorship of seminars and conferences.

Concluding observations

In its Concluding Observations, the Committee referred directly and indirectly to infant and young child feeding. 

The Committee first recommended Ghana to improve its data collection system (§16). Then, referring to its General Comment No 16 (2013) on State obligations regarding the impact of the business sector on children’s rights, the Committee urged the State party to establish clear regulations and a nation-wide legislative framework requiring companies operating in the State party to adopt measures to prevent and mitigate their adverse child impact of their operations in the country (§20a) and to 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 (§20b).

Regarding health, the Committee expressed concerns about the insufficient funding allocated to health, the low number of qualified and experienced health provider staff as well as an inequitable provision of health services (§49 a-b). Therefore, it called for the allocation of sufficient financial and human resources, particularly to child health and nutrition, providing effecting access to trained and qualified health care (§50a). 

The Committee also highlighted the continuous high maternal and neonatal mortality rates in the State (§49f), stressing AIDS as one of the causes of child mortality (§53c). Thus, it recommended Ghana to reduce mortality rates by improving parental care (§50c) and by providing access to antiretroviral therapy and followed-up treatment for HIV/AIDS infected mothers and their children (§54b, d). It also urged the State party to finalize the National Newborn Strategy and Action Plan (§50b), to improve prenatal care, to prevent communicable diseases (§50c), to implement the OHCHR Technical guidance on child mortality (A/HRC/27/31) (§50h) and to expedite the approval of the National Nutritional policy (§50f). 

Regarding breastfeeding, the Committee expressed specific concerns about the decline of breastfeeding rates between 2008 and 2011 and the inadequate monitoring of the BPR 2000 (§49d). It thus recommended Ghana to “continue the promotion of exclusive breastfeeding for six months with appropriate introduction of infant and diet thereafter, aimed at reducing neonatal as under-five mortality” (§50d) and strengthen the monitoring of implementation of the BPR by implementing a deterrent sanctioning system and ensuring that the Food and Drug Authority is committed to enforce the BPR (§50e).

Uruguay at the CRC: Lack of Monitoring of the Legislation Implementing the Code

On January 19th and 20th, 2015, the Committee on the Rights of the Child considered the combined third to fifth periodic report of Uruguay on the situation of the implementation of the Convention on the Rights of the Child in the country. The Uruguayan delegation was led by Mrs. Alejandra Costa, Director for Human Rights and Humanitarian Law at the Ministry of Foreign Affairs.

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

General overview of breastfeeding in Uruguay

The report outlined that although the rate of exclusive breastfeeding under 6 months is high (65%), some 4 children out of 10 are not breastfed within an hour after birth, which questions the quality of the counselling and support received by mothers in maternities. Besides, more than 7 children out of 10 are not breastfed until the age of 2 years, despite the recommendations of the World Health Organization.

Regarding protection and support of breastfeeding, IBFAN noted that the National Breastfeeding Standard (NNLM) is not fully implemented as many health workers are not trained on its content, including on the InternationalCode on Marketing of Breastmilk Substitutes and the guidelines “Buenas Practicas de Alimentacion del lactante y del nino pequeño”. In addition, there is no monitoring mechanism of the legislation implementing the International Code.

The IBFAN report also highlighted that in 2009-2010, only 35% of the maternities of the country were certified as “baby-friendly” and that the Human Milk Bank receives in-kind donations from Nestlé, which can lead to situations of conflict of interest.

Finally, the report noted that the maternity leave does not allow mothers to breastfeed exclusively for 6 months, and that mothers working in the informal sector are not covered. There are no training courses on HIV and infant feeding for health professionals and there is no national plan to protect and support breastfeeding in case of emergencies.

Discussion on infant and young child feeding

Questioned on the issue of maternal mortality, the Uruguayan delegation responded that measures are taken to ensure that all pregnant women have access to health and that early checkups are carried out. Majority of deliveries occur in institutions and the government has taken action to prevent avoidable maternal deaths within the current national action plan. The next action plan should also cover the issue of nutrition of pregnant women, which is not included in the current action plan.

On the issue of breastfeeding, the Committee first congratulated Uruguay for the implementation of the International Code of Marketing of Breastmilk Substitutes. However, it noted that the International Code is not yet fully implemented and that no monitoring mechanism is in place. It also asked for more information on the training of health professionals regarding optimal breastfeeding practices. It expressed concern about Nestlé’s donations received by Human Milk Bank and deplored the fact that only 35% of the maternities of the country are complying with the requirements of the Baby-friendly Hospital Initiative. Finally, the Committee regretted that women working in the informal sector are not allowed to maternity leave benefits and it stressed the need for Uruguay to adopt a plan to protect and support breastfeeding in case of emergencies.

The Uruguayan delegation answered that the maternity leave has been recently extended to 14 weeks and that after the third month of leave, parents can decide whether the father will take up the leave. However, the delegation admitted that informal workers are not allowed to these benefits. Regarding monitoring of the legislation implementing the International Code, the delegation explained that the government is currently working with UNICEF to develop such a monitoring mechanism. In regard to the implementation, the delegation noted that an initiative called “Good eating habits during breastfeeding” has been developed, as well as a strategy, and stressed the fact that breastfeeding rates have been improved (from 20% in the 1990s to 65% today). 

After follow-up questions from the Committee, the delegation again stressed that monitoring of the legislation implementing the Code is the main challenge for the government regarding breastfeeding. The delegation also admitted that the Human Milk Bank, which is under supervision of the Ministry of Health, has received glass jars to store the breastmilk from Nestlé and that these jars, which cannot be bought on the national market, are free from any advertisement. No funds from the industry are accepted. The delegation added that Uruguay has developed a joint network of human milk banks with Brazil in order to ensure that all children, especially underweight children, have access to breastmilk.

Concluding Observations

In its Concluding Observations, the Committee made recommendations indirectly related to infant and young child feeding, however it did not refer specifically to breastfeeding. Regarding health and health services, the Committee urged Uruguay to “strengthen its efforts to ensure access to quality health services by all children, particularly children living in the most disadvantaged and remote areas of the country”, as well as to “develop policies and programmes to address chronic malnutrition and anaemia” (§ 46).

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).

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.