Ethiopia at the CRC: Very Low Rate of Skilled Attendance at Birth Compromises Neonatal and Maternal Health as well as Early Initiation of Breastfeeding

On May 22th, 2015, the Committee on the Rights of the Child considered the combined third to fifth periodic report of Ethiopia on the situation of the implementation of the Convention on the Rights of the Child in the country. The delegation of Ethiopia was led by H.E. Mrs. Zenebu Tadesse Woldetsadik, Head of delegation and Ministry of the Minister of Women, Children and Youth Affairs and H.E.Mr. Almaw Mengist Ambaye, State Minister of the Ministry of the Women, Children and Youth Affairs.   

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

General overview of breastfeeding in Ethiopia

Ethiopia presents high maternal and infant mortality rates and very low rates of skilled attendance at birth (10%). In such a context, IBFAN is particularly concerned about the low rates of exclusive breastfeeding within one hour after birth (51%). In addition, data show that exclusive breastfeeding is interrupted much too early (median duration of exclusive breastfeeding: 2.3 months).

IBFAN is also worried by the lack of systematic monitoring of breastfeeding indicators and the absence of information available on the results of the national policies and strategies related to infant and young child feeding, such as the National Nutrition Programme2013-2015 and the National Strategy for Child Survival.

In Ethiopia, only few provisions of the International Code of Marketing of Breastmilk Substitutes have been implemented and there is no information available on the National Breastfeeding Committee and on its activities. Besides, the Baby-Friendly Hospital Initiative is poorly implemented throughout the country, while the maternity leave is too short to enable working mothers to breastfeed exclusively up to 6 months. In addition, nursing mothers are not entitled to breastfeeding breaks.

 Finally, it is of concern that the 2013 Policy and Strategy on Disaster Risk Management does include measures to protect and support breastfeeding in emergencies, despite the fact that this topic is addressed in the 2004 National Nutrition Strategy for Infant and Young Child Feeding.

Discussion on infant and young child feeding

The CRC Committee highlighted that the breastfeeding rates are low in the country and pointed out the short median duration of breastfeeding. In addition, the Committee expressed concern about the partial implementation of the International Code and the lack of medical assistance during childbirth.

The Ethiopian delegation stated that the reduction of child mortality it is a top priority for the government and that new programmes focused on newborn health have been recently developed. The delegation also affirmed that increased financial support has been allocated to child health and that 30,000 health care workers have received specific training on newborn care.

In relation to nutrition, the delegation explained that the National Malnutrion Task Force is working in collaboration with the Breastfeeding Committee to coordinate all measures related to the 2004 National Nutrition Strategy for Infant and Young Child Feeding. The measures taken have led a reduction of the rates of stunting, underweight and child mortality under 5 years.

Regarding breastfeeding, the delegation highlighted that 52% of infants are exclusively breastfed until 6 months of age, while 98% are ever breastfed. The delegation explained that there are cultural beliefs that compromise the practice of exclusive breastfeeding (e.g. the belief that infants need to receive water). Therefore, the government implemented campaigns and activities to promote breastfeeding among mothers. Finally, the delegation noted that information on the International Code is delivered to health professionals during their pre- and in-service training.

Concluding observations

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

After having welcomed the reduction of maternal, infant and under-five mortality rates, and the extension of immunization coverage and breastfeeding, the Committee expressed concerns about the very low per capita spending on basic health. It also deeply regretted the persistence of regional disparities in the provision of health services, and that malnutrition, infant, under-five and maternal mortality rates remain high (§55). Therefore, the Committee recommended Ethiopia to increase the annual expenditure per capita on health and eliminate disparities in the provision of health services as well as prenatal and postnatal care and immunization coverage (§56a). Moreover, Ethiopia was urged to implement the OHCHR Technical Guidance on child mortality (A/HRC/27/31), paying particular attention to rural and remote areas (§56b). Finally the Committee stressed the need to develop and implement policies to improve health infrastructures, and intensify training programmes for all health professionals, including the pastoralist health extension workers (§56d). 

With regard to the HIV/AIDS pandemic, the Committee urged Ethiopia to consider taking measures in order to eliminate geographical disparities regarding HIV and access to treatment, by enhancing free access to neonatal care and prevention of mother-to-child transmission (§58a). It also called for the improvement of the access to quality, age-appropriate HIV/AIDS, sexual and reproductive health services (§58d).

The Committee also made direct reference to breastfeeding, calling on Ethiopia to effectively address malnutrition in terms of stunting, wasting and low weight, particularly in rural and remote areas and develop public awareness programmes on food diversity consumption of nutritious food and on the benefits of breastfeeding in collaboration with the WHO and the UNICEF (§56c).

The Gambia at the CRC Committee: Cultural Beliefs against Optimal Breastfeeding Practices

On January 15^th, 2015, the Committee on the Rights of the Child considered the combined second and third periodic report of the Gambia on the situation of the implementation of the Convention on the Rights of the Child in the country. The delegation of The Gambia was led by Ms. Fanta Bai Secka, Director of Social Welfare, Mr. Baba Samateh, Director of Social Statistics at the Gambia Bureau of Statistics, and Ms. Bafou Jeng, State Counsel at the Ministry of Justice, Child’s Rights Unit.

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

General overview of breastfeeding in the Gambia

The Gambia is characterized by high neonatal, infant, under-five and maternal mortality rates, associated to little delivery care coverage and low breastfeeding rates. Almost one baby out of two is born without the assistance of a skilled attendant and a same proportion of newborns are not breastfed within one hour from birth, while seven children out of ten are not exclusively breastfed until 6 months of age. Additionally, the most recent data on breastfeeding in the Gambia date back to 2010, showing an irregular and insufficient data collection system regarding breastfeeding. The UNICEF highlighted the existence of cultural beliefs against exclusive breastfeeding among the population, with a general traditional mindset asserting that colostrum is not good for the baby.

Although National Nutrition Policy 2010-2020 dedicates a full section to the promotion of optimal infant and child feeding practices, including a list of specific strategies, there is no clarity on their implementation. In addition, there is neither National Breastfeeding Committee and Coordinator nor information available on future plans of creating one.

On a positive note, the Gambia adopted a strong law on the marketing of breastmilk substitutes, implementing most of the International Code of Marketing of Breastmilk Substitutes. In 2008, the Baby-Friendly Hospitals Initiative criteria were respected in over 20 health care facilities, but there are no recent data on its current implementation and monitoring mechanism.

Finally, the legislation on maternity protection does not cover all women working in all sectors. There are no figures on the exact number of children under 15 living with HIV in the Gambia and no strategic action plan on infant and child feeding in emergencies.

Discussion on infant and young child feeding

The CRC Committee questioned the delegation of the Gambia on the causes of such a low profile of breastfeeding in the country, mentioning specifically that the exclusive breastfeeding rate under 6 months could and should be improved, observing that it is the most natural way of feeding children and that should be promoted also because of the emotional needs of children. The Committee asked also what measures are being taken in order to encourage women to breastfeed and whether these measures are put in place at a prenatal care level or through the media.

The Gambian delegation stated that breastfeeding was an issue in the past, and that is does not constitute an issue anymore. Continuous campaigns on the radio, on TV and in the communities are supporting breastfeeding and encouraging exclusive breastfeeding until 6 months. Additionally, the delegation affirmed that since the enactment of an act in 2010, women are entitled to 6 months of paid maternity leave, as a further proof of the efforts the government is making to promote and support breastfeeding.

The Committee then addressed the fact that the Gambia’s legislation on maternity protection does not cover all sectors, and the delegation assured that it actually does, adding that there is all the political will to promote and raise the breastfeeding rates, confirmed by a statement made by the President of the nation. Regarding HIV and breastfeeding, the Committee asked what support system is provided to the mothers living with HIV, and the delegation mentioned the existence of a system of monthly food rations including supplement milk provided to women living with HIV.

Concluding Observations

In its Concluding Observations, the Committee made both indirect and direct recommendations related with infant and young child feeding. It first recommended to ensure the allocation of sufficient resources for the health sector and to facilitate a greater and equal access to quality primary health services by mothers and children in all areas (§ 61a). Effective measures were also required to “increase the number of trained medical and other health personnel, including traditional healers”, and “facilitate cooperation between trained medical personnel and traditional healers, especially midwives” (§ 61b). The Committee also urged to improve access to maternal care services through improved health infrastructure and to increase availability and accessibility of emergency obstetric and neonatal care and skilled birth attendants at lower- and district-level health facilities (§ 61c).

With regard to nutrition, the Committee recommended the Gambia to “strengthen its efforts to address malnutrition and diseases of children, including by strengthening educational programmes, campaigns to inform parents about basic child health and nutrition [...]” (§ 61d), and to “strengthen its efforts to increase address to safe drinking water and sanitation” (§ 61e).

Finally, specifically referring to breastfeeding, the Committee urged the State party to “ensure the effective implementation of the 2010-2020 National Nutrition Policy, strengthen its awareness-raising efforts on the importance of breastfeeding and promote exclusive breastfeeding of children up to the age of six months”. It also recommended to “establish a National Breastfeeding Committee, systematically collect data on breastfeeding practices, ensure the enforcement of the International Code of Marketing of Breast-milk Substitutes, include breastfeeding in the training of nurses, and provide maternity leave to all working mothers, including domestic workers” (§ 65).