Bangladesh at the CRC: Concerns about Declining of Exclusive Breastfeeding Rates and Low Coverage of Skilled attendance at Birth

On September 15^th and 16^th, the Committee on the Rights of the Child considered the 5^th periodic report of Bangladesh 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 Bangladesh.

General overview of breastfeeding in Bangladesh

IBFAN pointed out the low coverage of skilled attendance at birth, especially in rural and urban regions (28% and 55% respectively). Moreover, IBFAN also noted with great concern a declining trend in exclusive breastfeeding rates under 6 months between 2012 (64%) and 2014 (55%). Such situation reveals a lack of knowledge and awareness on Infant and Young Child Feeding (IYCF).

Even though the median duration of continued breastfeeding is estimated at 32.8 months, the complementary foods are introduced at an early age, resulting in a low median duration of exclusive breastfeeding, estimated at 1.8 months.

IBFAN also highlighted the absence of a National Breastfeeding Committee that would monitor the implementation of the National IYCF policy. The lack of systematic monitoring of breastfeeding indicators is also of concern. Besides, there is also a failure to enforce the International Code of Marketing of Breastmilk Substitutes and no sanction mechanism is in place to punish Code violations.

The report also flagged the importance to increase the number of Baby-Friendly certified health facilities and monitor their compliance with Ten Steps to Successful Breastfeeding, as 23% of hospitals are still not certified as “baby-friendly”.

Regarding maternity protection, IBFAN noted that women working in the informal sector are not covered by the maternity leave legislation and that there is neither paternity leave nor legal provision entitling working mothers to take breastfeeding breaks.

On a more positive note, IBFAN noted that Bangladesh infant and young child feeding curricula or session plans are adequate, as well as the development of standards and guidelines for mother-friendly childbirth procedures and support. In addition, all pregnant women have access to community-based support systems and services on infant and young child feeding and health workers are receiving adequate training in counseling and listening skills for IYCF.

Discussion on infant and young child feeding

The delegation first highlighted the decrease of maternal mortality rates from 335 (per 100,000 live births) in 2001 to 194 in 2010. Infant mortality rates have also reduced from 45 to 33 per 100,000 live births. The delegation also explained the existence of childcare centers across the country in order to support working mothers through the provision of baby-sitting services. Through the establishment of community clinics and hospitals, nutritional support is granted to mothers and children from the beginning of the pregnancy until the newborn reaches the age of 2 years. These measures are implemented in the framework of a “1,000 days” programme.

The CRC Committee congratulated Bangladesh for the adoption of the Children Act in 2013 and the law regulating the marketing of breast milk substitutes. However, the Committee expressed concern about the decline trend in exclusive breastfeeding rates under 6 months between 2012 (64%) and 2014 (55%), noting that 26% of children age between 4-5 months are bottle fed.

Moreover, the Committee considered that the low exclusive breastfeeding rates couple with the low coverage of skilled attendance at birth, reveal a low level of knowledge and awareness on Infant and Young Child Feeding (IYCF). Thus, it invited the state party to implement measures to ensure that all deliveries would be attended by skilled personnel. It also urged Bangladesh to take measures in order to increase the percentage of institutional deliveries and to monitor breastfeeding key indicators on a regular basis.

The Bangladeshi delegation answered that in 1995 the rate of neonatal mortality was very high (54 deaths per 1,000 live births) and that it came down to less than 30% in 2014 (Bangladesh Health Survey). However, the delegation admitted that this still constitutes a challenging issue for the country. The delegation added that the rate of institutional deliveries increased from 5% in 1990 to more than 35% in 2014. Regarding exclusive breastfeeding until the age of 6 months, the delegation stated that the rate increased from 42% in 2004 to 64% in 2011. [Note from IBFAN: Its is of concern that this rate again went down to 55% in 2014.]

In its follow-up questions, the Committee noted that there is no information available on the creation of the National Breastfeeding Committee and stressed that the International Code of Marketing of Breastmilk Substitutes is only partially implemented in the country. The Committee expressed concern about the partial implementation of the Baby-Friendly Hospital Initiative throughout the country and emphasized the insufficient monitoring of the Ten Steps to Successful Breastfeeding in the certified facilities. The Committee regretted that women working in the informal sector are not granted maternity leave and noted the absence of paternity leave. The CRC Committee finally added that child underweight has still to be tackled in the country.

The delegation replied mentioning that maternity leave has been increased from 4 months to 6 months. However, it admitted that the adverse effect of this legislation is that private employers are discouraged to hire women. In addition, the delegation noted that the law implementing the Code does not allow media advertising for breastmilk substitutes as well as the promotion of breastmilk substitutes in hospitals and clinics.

Moreover, the delegation noted that there is a National Breastfeeding Committee headed by the Ministry of Health and Welfare. This Committee is in charge of implementing the IYCF strategy. The delegation also explained that at every level of the health care system, there are trained gynecologists in charge of performing cesarean sections with the assistance of an anesthesiologist. Finally, the delegation agreed that further measures are to be taken in order to reduce the rate of underweight.

Concluding Observations

In its Concluding Observations, the Committee made several indirect recommendations to Bangladesh in relation with infant and young child feeding. However, it did not refer specifically to breastfeeding.

Regarding health resources and budget, the Committee urged Bangladesh to allocate sufficient financial and human resources to health services in all regions and upazilas to eliminate regional disparities in the provision of health services (§55a)

Referring to health and health services, the Committee recommended the state party to implement and apply the OHCHR Technical Guidance on child mortality (A/HRC/27/31), which includes specific recommendations on breastfeeding protection (including the implementation of the International Code of Breastmilk Substitutes) and promotion (§55b).

In particular, the Committee further highlighted that only one third of women deliver with a support of a skilled attendant and the regional disparities regarding the provision of health services (§54) and thus recommended the State party to develop and implement policies to improve health infrastructures and intensify training programmes for all health professionals (§55c).

Moreover, the Committee expressed its concerns about the 25 percent rise in the number of new infections with HIV/AIDS between 2001 and 2011 (§62). Therefore, it urged Bangladesh to promote the measures in place to prevent mother-to-child transmission of HIV/AIDS and develop a roadmap to ensure the effective implementation of preventive measures (§63a) as well as the improvement of the follow-up treatment for HIV/AIDS infected mothers and their infants (§63b). Make progress in the access and coverage on antiretroviral therapy and prophylaxis for HIV infected pregnant women is also requested by the Committee (§63c).

Finally, in relation with breastfeeding protection, the Committee congratulated Bangladesh on the adoption of a new law on banning of marketing of breastmilk substitutes (§54).  

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).