IBFAN's contribution to the OHCHR consultation on the mortality and morbidity of children under 5 years of age (HRC Resolution 24/11)

About the International Baby Food Action Network (IBFAN) 

A world-wide network. IBFAN is a 35-year old coalition of more than 273 not-for-profit non-governmental organizations in more than 168 developing and industrialised nations. The network works for better child health and nutrition through the protection, promotion and support of breastfeeding and the elimination of irresponsible marketing of breastmilk substitutes.

Our commitment. IBFAN is committed to the Global Strategy on Infant and Young Child Feeding (2002) – and thus to assisting governments in implementation of the International Code of Marketing of Breastmilk Substitutes (International Code) and its relevant resolutions of the World Health Assembly (WHA) to the fullest extent, and to ensuring that corporations are held accountable for their International Code violations. In 1998, IBFAN received the alternative Nobel Prize, called the Right Livelihood Award, “for its committed and effective campaigning for the rights of mothers to choose to breastfeed their babies, in the full knowledge of the health benefits of breastmilk, and free from commercial pressure and misinformation with which companies promote breastmilk substitutes”.

A crucial underlying determinant to prevent child mortality and morbidity

Breastfeeding, the most effective intervention to save children lives. Breastfeeding is a key element to combat mortality and morbidity of children under 5 years of age; it is the single most effective intervention for saving lives.[1] Optimal breastfeeding practices, including exclusive breastfeeding for the 6 first months, have proven to reduce infant and child mortality while sub-optimal breastfeeding practices significantly increase sanitary risks for the child, including infections, diarrhoea and pneumonia, the three major killers of infants and children.[2] Colostrum, the mother’s milk during the first post-partum days, provides protective antibodies and indispensable nutrients, essentially acting as a first immunisation for newborns, strengthening their immune system and reducing the chances of death in the neonatal period. Breastmilk alone is the ideal nourishment for infants for the first six months of life, providing them all of the nutrients they need, which means that no other liquid or food is required. Furthermore, continued breastfeeding beyond six months, accompanied by adequate complementary foods, ensures growing children a good nutritional status and protects them against illnesses.[3] In addition, breastmilk is a low-cost, high quality and locally produced food and thus, ensures food security from the start of the life.[4] Therefore, the World Health Organisation (WHO) recommends exclusive breastfeeding until 6 months of age and then, complementary breastfeeding until 2 years of age or further. Despite these recommendations, approximately 1.4 million children under five die each year because they haven’t been properly breastfed, 830 000 of which could have been prevented if the infant had been breastfed within the first hour after birth.[5]

Early cessation of breastfeeding and the impact of infant formula on child health. While the crucial role of breastfeeding in fighting child mortality and morbidity is widely recognised, early cessation of breastfeeding in favour of industrial breastmilk substitutes as well as needless supplementation and poorly timed introduction of complementary foods are far too common. Currently, only 39% of the 134.6 million infants born worldwide are exclusively breastfed in the first 6 months. This leaves almost 85 million of babies whose right to health, adequate food and nutrition is compromised by early cessation of breastfeeding. Moreover, only 58% of children are still breastfed at 2 years.[6] These low breastfeeding rates are due to several combined factors related to the lack of integrated programmes at scale for the protection, promotion and support of optimal infant and young child feeding, including lack of protection from unethical marketing of breastmilk substitutes, bottles and teats, lack of promotion and support in the health care system and lack of support for breastfeeding women in their workplace.[7] As a result, numbers of babies are fed with breastmilk substitutes, what denies the child the positive effects of breastfeeding highlighted above and increases the risks of exposing the child to pathogenic organisms and substances. The harmful pathogens that may contaminate the powdered formulas can cause serious illnesses and even lead to death.[8] Lastly, the presence of bisphenol A, a chemical component of most plastic bottles and teats, may present danger for child health and therefore, increase the risks associated with artificial feeding.[9]

IBFAN’s action to reduce under-five child mortality and morbidity by advocating for breastfeeding with regard to human rights standards and principles

Breastfeeding and the baby food industry. The misconduct of baby food companies continues to be a key cause for poor breastfeeding practices, as these companies reap profits from promotion of their products which directly compete with breastfeeding. They too often undermine breastfeeding by making unethical and unfounded claims about their products and by marketing them in deceptive ways. These commercial malpractices have a negative impact on the realisation of the right of children to health and to adequate food and nutrition, and thus affect directly child mortality and morbidity rates. Indeed, studies have shown that promotion of breastmilk substitutes has a negative influence on breastfeeding rates.[10] Besides, the increasing undue influence of companies, including baby food companies, on policy-makers and key institutions constitutes a threat to the independence of public health institutions. Therefore, it risks affecting their ability to work in the public interest in a transparent and accountable way. For these reasons, IBFAN promotes the accountability of the business sector by engaging in a critical debate about the role and the human rights obligations of commercial actors. Therefore, we work towards the implementation of the Maastricht Principles on Extraterritorial Obligations of States in the area of Economic, Social and Cultural Rights[11]. In addition, IBFAN advocates for the adoption of legal safeguards against the impact of conflicts of interest within the process of policy-making at both international and national levels, for example within the framework of the WHO reform.

The International Code of Marketing of Breast-milk Substitutes. IBFAN is committed to the Global Strategy on Infant and Young Child Feeding, adopted by WHO in 2002.[12] Hence, we are assisting governments in implementation of the International Code of Marketing of Breastmilk Substitutes and its subsequent WHA resolutions to the fullest extent, and ensuring that corporations are held accountable for their International Code violations. Companies have an obligation to comply with the International Code regardless of any government action, yet monitoring by civil society shows that none of the large multinational companies live up to this obligation. A crucial contribution of IBFAN is the preparation of global monitoring reports that continuously show the extent to which the baby food industry violates the International Code. The latest 2014 report details global marketing trends by baby food manufacturers and exposes violations of the International Code and its subsequent resolutions.[13] IBFAN has also been assisting governments since 1981 with their implementation of the International Code; much of the success to date can be attributed to our efforts and those of UNICEF (and to some degree WHO). However, the level of progress in International Code implementation cannot be regarded as satisfactory. The grossly inadequate resources invested in breastfeeding and optimal infant and young child feeding, particularly in the International Code implementation and monitoring, are one of the causes.

The Convention on the Rights of the Child. Since 1989, the Convention on the Rights of the Child (CRC) has placed breastfeeding on the child rights agenda, particularly in regard to its Article 24, which enshrines the right of the child to the enjoyment of the highest attainable standard of health. The CRC Committee, in its General Comments 15 and 16, further elaborated on government and non-state actors’ obligations to ensure that the International Code is implemented and enforced, and that optimal breastfeeding practices of are adequately protected, promoted and supported by States Parties. Moreover, the CRC Committee recognises that implementation of the International Code by States Parties as a concrete measure towards the realisation of parents’ right to objective information on the advantages of breastfeeding and thus, to fulfilling the obligations of the Article 24 of the Convention.[14] It has also regularly recommended governments to adopt additional policies, programmes and initiatives to protect, promote and support breastfeeding.[15] Since 1998, IBFAN collaborates with the CRC Committee and submits alternative reports on the state of infant and young child feeding, including breastfeeding practices, in the reviewed countries. In 2013 alone, a total of 17 countries were reviewed by the Committee on the Rights of the Child (CRC Committee). IBFAN submitted alternative reports on the situation of IYCF for 13 of them: China, Kuwait, Lithuania, Luxembourg, Malta, Guinea, Niue, Armenia, Guinea Bissau, Israel, Rwanda, Slovenia and Uzbekistan.[16] In addition, IBFAN contributed to the consultation processes on the right of the child to the enjoyment of the highest attainable standard of health (Article 24),[17] that lead to the adoption of CRC General Comment 15, and on child rights and the business sector,[18] that lead to the adoption of CRC General Comment 16.

Women’s rights to reproductive health and maternity protection. Human rights for women and children were largely developed separately within the human rights framework and the complex inter-connectedness of mother and child in pregnancy, infancy and breastfeeding has not yet been adequately addressed. Breastfeeding has not been properly recognised by the international community as an essential part of human rights, including as women's sexual and reproductive right, and it is constantly undervalued and threatened because of misinformation and commercial pressures. Furthermore, the maternal practice is seen by some as being incompatible with other roles that women have, in particular their occupational role. Dominant social values, structures and institutions, which are rapidly spreading across the globe, often exploit and undervalue women's physical needs and both their productive and reproductive contributions. Many countries, industrialised and developing alike, lack adequate maternity protection in the workplace to protect breastfeeding practices. Currently, there is no comprehensive framework or convention tackling the rights, needs and capability of both mother and child during this critical period of biological, emotional, social and legal interconnectedness. For this reason, in 2014, IBFAN will advocate for women’s rights to reproductive health as well as maternity protection within the framework of the Convention on the Elimination of Discrimination against Women (CEDAW) by submitting regularly alternative reports to the CEDAW Committee and sharing CRC Committee’s Concluding Observations to promote harmonisation of work of these two treaty bodies.

Contribution to international consultation processes. IBFAN takes part in human rights bodies’ topical discussion days, providing its expertise on issues such as the rights of children of incarcerated parents,[19] and attempts to raise the profile of safe food and adequate nutrition for infants and young children, i.e. breastfeeding and optimal infant feeding practices, in relevant international and national policies in the context of Post-2015 Millennium Development Goals agenda.[20] In addition, IBFAN will take part in the upcoming 2nd International Conference on Nutrition.

[1] Bhutta et al., What works? Interventions for maternal and child undernutrition and survival, The Lancet, 2008, 371 (9610) : 417-440. http://www.who.int/nutrition/topics/Lancetseries_Undernutrition3.pdf.
[2] Arifeen S. et al., Exclusive breastfeeding reduces acute respiratory infection and diarrhea deaths among infants in Dhaka slums. Pediatrics, 2001, 108(4): 67. http://pediatrics.aappublications.org/content/108/4/e67.full?sid=832a7273-16cf-4a41-a87d-bda69505da92.; 

Chantry C.J. et al., Full Breastfeeding Duration and Associated Decrease in Respiratory Tract Infection in US Children. Pediatrics, 2006, 117( 2) : 425 -432. http://pediatrics.aappublications.org/content/117/2/425.full.;
Duijts L. et al., Prolonged and Exclusive Breastfeeding Reduces the Risk of Infectious Diseases in Infancy. Pediatrics, 2010, 126 (1) : 18 -25. http://pediatrics.aappublications.org/content/126/1/e18.full.
UNICEF, Pneumonia and diarrhoea : How to tackle the deadliest diseases for world’s poorest children. June 2012. http://www.unicef.org/media/files/UNICEF_P_D_complete_0604.pdf.
[3] Singh K. and Srivastava P, The effect of colostrums on infant mortality: urban rural differentials. Health and Population, 1992, 15(3&4): 94-100. http://nihfw.org/Publications/material/J294.pdf.
[4] IBFAN, Food and nutrition security from the start of the life, Submission to the E-Consultation on Hunger, Food and Nutrition Security. http://www.fao.org/fsnforum/post2015/sites/post2015/files/resources/post%202015_08%2001%202012_IBFAN%20input%20(2).pdf.
[5] Save the Children, Superfood for babies: How overcoming barriers to breastfeeding will save children’s lives, 2013. http://www.savethechildren.org/atf/cf/%7B9def2ebe-10ae-432c-9bd0-df91d2eba74a%7D/SUPERFOOD%20FOR%20BABIES%20ASIA%20LOW%20RES%282%29.PDF.
[6] Childinfo / UNICEF, Child nutrition – Statistics by area : Infant and young child feeding. http://www.childinfo.org/breastfeeding_iycf.php. (accessed 7 February 2014)
[7] UNICEF / IBFAN, Challenges to Breastfeeding and State Parties’ Obligations, Oral Presentation to the CRC Committee, 21st January 2014, Geneva.
[8] FAO / WHO, Enterobacter sakazakii and other microorganisms in powdered infant formula, Meeting Report, WHO Microbiological Risk Assessment Series, 2004, 6. http://www.fao.org/docrep/007/y5502e/y5502e00.htm.
IBFAN, Infant and Young Child Feeding and Chemical Residues, 2013. http://ibfan.org/ips/IBFAN-Statement-on-Infant-and-Young-Child-Feeding-and-Chemical-Residues.pdf.
[9] Braun J.M. and Hauser R., Bisphenol A and children's health. Current Opininion in Pediatrics, 2011, 23 (2): 233-239. http://www.ncbi.nlm.nih.gov/pubmed/21293273.
Braun J.M. et al., Impact of Early-Life Bisphenol A Exposure on Behavior and Executive Function in Children. Pediatrics, 2011, 24: 873-882. http://pediatrics.aappublications.org/content/126/1/e18.full.pdf+html.
Donna S. et al., Bisphenol A and Chronic Disease Risk Factors in US Children. Pediatrics, 2013, 19: e637-e645. http://pediatrics.aappublications.org/content/early/2013/08/13/peds.2013-0106.full.pdf+html.
[10] US Government Accountability Office, Some Strategies Used to Market Infant Formula May Discourage Breastfeeding; State Contracts Should Better Protect against Misuse of WIC Name, February 2006. http://www.gao.gov/new.items/d06282.pdf.
Foss K.A. and Southwell B.G., Infant feeding and the media: the relationship betweenParents' Magazine content and breastfeeding, 1972–2000. International Breastfeeding Journal, 2006 (1): 10. http://www.internationalbreastfeedingjournal.com/content/pdf/1746-4358-1-10.pdf.
[11] Maastricht Principles on Extraterritorial Obligations of States in the area of Economic, Social and Cultural Rights. http://www.etoconsortium.org/nc/en/library/maastricht-principles/?tx_drblob_pi1[downloadUid]=23.
[12] WHO, Global Strategy for Infant and Young Child Feeding, 2002. http://whqlibdoc.who.int/publications/2003/9241562218.pdf?ua=1.
[13] ICDC, Legal Update, January 2014. http://www.ibfan-icdc.org/files/Jan_2014.pdf.
[14] UNICEF, Implementation Hanbook for the Convention on the Rights of the Child, 3rd edition, 2007 : 360. http://www.unicef.org/publications/files/Implementation_Handbook_for_the_Convention_on_the_Rights_of_the_Child_Part_2_of_3.pdf.
[15] In 2013, out of the 17 States Parties reviewed under the Convention, the CRC Committee made recommendations on the implementation of the International Code to 9 countries and recommendations on the protection, promotion and support of breastfeeding to 10 countries.
[16] These reports can be found online on IBFAN’s website: http://ibfan.org/reports-on-the-un-committee-on-the-rights-of-the-child.
[17] IBFAN, Breastfeeding and the right of the child to the enjoyment of the highest attainable standard of health. Contribution to the General Comment on the Child’s Right to Health. http://www2.ohchr.org/english/bodies/crc/docs/CallSubmissions_Art24/InternationalBabyFoodActionNetwork.pdf.
[18] IBFAN / FIAN, Submission to the General Comment on Child Rights and the Business Sector. http://www2.ohchr.org/english/bodies/crc/docs/CallSubmissionBusinessSector/IBFAN_FIAN_JointSubmission.pdf.
[19] IBFAN, Children of Incarcerated Parents: Considerations on Infant and Young Child Feeding, 2011. http://ibfan.org/upload/files/children-inc_parents_IBFAN%20subsmission.pdf.
[20] IBFAN, Food and nutrition security from the start of the life, Submission to the E-Consultation on Hunger, Food and Nutrition Security. http://www.fao.org/fsnforum/post2015/sites/post2015/files/resources/post%202015_08%2001%202012_IBFAN%20input%20(2).pdf.

Breastfeeding Practices in the Russian Federation

The Russian Federation presented its consolidated 4^th and 5^th periodic report on the situation of the implementation of the Convention on the Rights of the Child (CRC) in the country.

IBFAN presented an alternative report to inform the CRC Committee on Russia’s situation on the issue of infant and young child feeding.

General overview of breastfeeding in the Russian Federation

The alternative report highlighted several obstacles to breastfeeding practices in Russia. First, in 2002, UNICEF listed only 12 maternity wards as meeting the requirements of the Baby-friendly Hospital Initiative (BFHI) out of the 277 hospitals in the country. However, exclusive breastfeeding rate is higher in baby-friendly hospitals (88.9%) than in other health facilities (32.6%), and breastfeeding initiation takes place in a median time during the two first hours in baby-friendly hospitals, whereas in other structures, breastfeeding initiation happens only during the 12 first hours. In addition, the report highlighted the lack of public policies and programmes to protect, promote and support breastfeeding and infant and young child feeding, the absence of systematic data about breastfeeding and no action on implementation of the International Code of Marketing of Breastmilk Substitutes in Russia. Thus, there are no legal provisions to regulate the advertisement and marketing of breastmilk substitutes. IBFAN’s report also stressed that, despite the good maternity protection legislation, there is employment discrimination of women. Besides, the occupational segregation in the low-level jobs lead to insufficient maternity protection for the women concerned. Finally, the report pointed out that only 9 regions out of 83 were providing support to prevent mother-to-child HIV transmission.

Discussion on infant and young child feeding

During the discussion between the members of the CRC Committee and the State Party, the question of Russia’s implementation of the International Code has been raised. The Committee also addressed the issue of breastfeeding practices and asked whether any governmental support is provided to working women in order to help them combine their work with breastfeeding. Finally, the Committee enquired about the existence of a national programme which aims to prevent mother-to-child transmission of HIV and the kind of support provided to HIV-positive mothers and children. None of these issues has received response from the Russian delegation.

CRC Committee's Concluding Observations

In its Concluding Observations, the CRC Committee made recommendations on the importance of respecting child rights in relation to the business sector (para 21), on the right of the child to health (para 52) and on the necessary measures to prevent mother-to-child HIV/AIDS transmission (para 54). However, no specific recommendation on breastfeeding has been made to the Russian Federation delegation.

The CRC Committee, in its 2013 General Comment N° 16 on State obligations regarding the impact of the business sector on children’s rights, specifically calls on States “to implement and enforce internationally agreed standards concerning children’s rights, health and business including the [...] International Code of Marketing of Breast-milk Substitutes and relevant subsequent World Health Assembly resolutions”. In the section Children's right and the business sector, 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 recommends that the State party establish and implement regulations to ensure that the business sector complies with international and national human rights, labour, environment and other standards, particularly with regard to children’s rights [...]. In particular, it urges the State party to: [...] (d) Ensure effective implementation by companies, especially industrial companies, of international and national environment and health standards, effective monitoring of the implementation of these standards and appropriately sanctioning and providing remedies when violations occur, as well as ensure that appropriate international certification is sought;(e) 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; and (f) Be guided by the United Nations “Protect, Respect and Remedy” Framework, accepted unanimously in 2008 by the Human Rights Council, while implementing these recommendations."

The CRC 2013 General Comment N°15 on the right of the child to the enjoyment of the highest attainable standard of health (art. 24) explicitly recognises the importance of breastfeeding for the achievement of the right of the child to health. It urges States, in the effort of diminishing infant and child mortality, to devote particular attention to neonatal mortality and suggests, inter alia, to “pay particular attention to ensuring full protection and promotion of breastfeeding practices”. Moreover, “exclusive breastfeeding for infants up to 6 months should be protected and promoted and breastfeeding should continue together with appropriate complementary foods preferably until two years of age as feasible. States’ obligations in this area are defined in the “protect, promote and support framework”, adopted unanimously by the World Health Assembly in its 2002 Global Strategy for Infant and Young Child Feeding". Regarding Health and health services, the Russian Federation is requested to pay "attention to CRC general comment No. 15 (2013) on the right of the child to the enjoyment of the highest attainable standard of health, and recommends that the State party take measures to regularly assess the health conditions of children deprived of parental care and children in difficult situations in order to prevent irreparable damage to their health. The Committee also recommends that the State party take measures to provide all children, irrespective of their legal status in the country with access to medical assistance, in particular preventive health care and emergency assistance, without any discrimination."

Finally, as the Russia Federation seems to have opted for a policy which recommends HIV-positive mothers to avoid all breastfeeding, the Committee in order to address inequalities recommends to "take all necessary measures to prevent mother to child transmission of HIV/AIDS throughout the country by providing sufficient amount of breast milk substitutes and anti-retroviral drugs in all regions, using, inter alia, mobile medical personnel."

Germany, Breastfeeding and Attachment Disorders between Mother and Child

Germany presented its consolidated 3^rd and 4^th periodic report on the situation of the implementation of the Convention on the Rights of the Child (CRC) in the country.

IBFAN presented an alternative report and an annex to inform the CRC Committee on Germany’s situation on the issue of infant and young child feeding.

General overview of breastfeeding in German

The alternative report insists on the lack of up-to-date information concerning breastfeeding practices. Indeed, there is only one national  survey with data on breastfeeding practices and this data go back to 2005, assessing that initiation of breastfeeding was of 81.5% and that children were exclusively breastfed during a mean duration of 4 to 6 months, while WHO recommends exclusive breastfeeding to 6 months. The report highlights that in the most vulnerable social classes, breastfeeding is less practiced. Another discrepancy in practices has also been found between the different Länder. Regarding the implementation of the International Code, Germany has adopted the EU Directive 2006/141/EC on infant formulae and follow-on formulae, which is weaker than the Code. However, even this legislation is neither monitored nor enforced. The marketing of breastmilk substitutes is aggressive and “gifts”, among other things, are provided to patients by doctors and nurses. Hipp provides, for example, a special programme that gives the attendants credits for their obligatory continued education. In addition, Germany faces another issue related to conflicts of interest: some scientists are paid by baby food industry to carry out studies on breastfeeding. As demonstrated in the literature, such business interests may seriously affect the results of these studies and thus influence the reliability of the data and ultimately lead to distortion of policy decisions. Finally, only 78 out of about 800 hospitals complied with the requirements of the WHO/UNICEF Baby-friendly Hospital Initiative (BFHI). Furthermore, due to economic pressure on hospitals to work profitably and more workload for less staff, baby-friendly hospitals face difficulties to keep up their standards. The national health insurance does not consider their services as a quality standard and therefore, does not get any extra payment and support.

Discussion on infant and young child feeding

The CRC Committee asked if Germany implemented the International Code. The issue of maternity protection rules, especially maternity leave, has also been discussed, as well as the  existence of any potential barriers to breastfeeding in public. The Committee then raised its concern about the increasing rate of attachment disorders between the mothers and their children in Germany, stressing the importance of breastfeeding to build attachment in the early stage of life. The German delegation did not address in their response any of these issues.

A wide range of other topics related to the rights of the child were tackled during the session: the impact of the business sector on children’s rights, children with disabilities, children from ethnical and social minorities, birth registration, corporal punishment, help lines for children, juvenile justice, education, harmful practices on children, children in institutions and baby-boxes.

CRC Committee's Concluding Observations

In its Concluding Observations, the CRC Committee recommended Germany to establish a comprehensive data collection system (para 16), to respect children’s rights in relation to the business sector (para 23), to raise awareness about healthy eating habits (para 57) and to promote breastfeeding while informing the public on the risks of formula feeding (para 63).

In the first instance, the CRC Committee requested the State Party to “establish a comprehensive and integrated data collection system on children covering all Länder and the entire period of childhood up to the age of 18, and to introduce indicators on children’s rights on which progress in the realization of those rights could be analysed and assessed.

Further, the Committee recalled its 2013 General Comment N° 16 on State obligations regarding the impact of the business sector on children’s rights, that specifically calls on States “to implement and enforce internationally agreed standards concerning children’s rights, health and business including the [...] International Code of Marketing of Breast-milk Substitutes and relevant subsequent World Health Assembly resolutions”. In the section Children's right and the business sector, the Committee recommended Germany to “(a) Establish a clear regulatory framework for the industries operating in the State party to ensure that their activities do not negatively affect human rights or endanger environmental and other standards, especially those relating to children’s rights; (b) Take into consideration the best interests of the child when adopting budgetary measures such as subsidies for business affecting children rights; (c) Examine and adapt its legislative framework (civil, criminal and administrative) to ensure the legal accountability of business enterprises and their subsidiaries operating in or managed from the State party’s territory, regarding violations of child and human rights.”

The CRC 2013 General Comment N°15 on the right of the child to the enjoyment of the highest attainable standard of health (art. 24) explicitly recognises the importance of breastfeeding for the achievement of the right of the child to health. It urges States, in the effort of diminishing infant and child mortality, to devote particular attention to neonatal mortality and suggests, inter alia, to “pay particular attention to ensuring full protection and promotion of breastfeeding practices”. Moreover, “exclusive breastfeeding for infants up to 6 months should be protected and promoted and breastfeeding should continue together with appropriate complementary foods preferably until two years of age as feasible. States’ obligations in this area are defined in the “protect, promote and support framework”, adopted unanimously by the World Health Assembly in its 2002 Global Strategy for Infant and Young Child Feeding". Regarding Health and health services, Germany is urged to pay attention to the General Comment N° 15 and to “undertake advocacy and awareness-raising programmes targeting schools and families, emphasizing the importance of physical exercise, healthy eating habits and lifestyles, as well as take all necessary efforts to address the existing disparities in health outcomes. Special attention should be paid to children and young people in vulnerable situations, especially those from socially disadvantaged or migration backgrounds”. The Committee furthermore recommended the State Party to “take every necessary legislative and structural measure to ensure that every child within the State party has access to breastfeeding through the control of infant formula which will promote better bonding between infants and mother."

Last but not least, as the Committee noted with concern that breastfeeding rates were declining in Germany, it recommended the government to “strengthen its efforts to promote exclusive and continued breastfeeding by providing access to materials, and educating and raising awareness of the public on the importance of breastfeeding and the risks of formula feeding. The Committee urges the State party to strictly enforce the International Code of Marketing of Breast-milk Substitutes.”

Portugal and the Issue of Breastfeeding in the Perspective of Child's Rights

Portugal presented its consolidated 3^rd and 4^th periodic report on the situation of the implementation of the Convention on the Rights of the Child (CRC) in the country.

IBFAN presented to the Committee an alternative report and an annex showing examples of violations of the International Code on the Marketing of Breastmilk Substitutes that were noted in the country.

General overview of breastfeeding in Portugal

The alternative report presented by Portugal states that in 2012, 78.9 % of mothers of the country have initiated their child to breastfeeding within the first hour of delivery. However, statistics show that exclusive breastfeeding starts to decrease after 5 to 6 weeks to reach a low rate of 22.4% at 5/6 months. Furthermore, use of follow on formulas and toddler milks is recommended by health professional after 6 months in Portugal, regardless of the WHO’s statement of the 17^th July 2013 that states: “ […] as well as being unnecessary, follow-up formula is unsuitable when used as a breast-milk replacement from six months of age onwards.” In addition, although Portugal has implemented the EU Directive 2006/141/EC on infant formulae and follow-on formulae, which is weaker than the International Code, through the adoption of a law (Decreto-Lei 217/2008), this law has not been monitored yet. Besides, there are no enforcement mechanisms in place either. Thus, industries are not sanctioned when they violate the International Code. The advertisement of breastmilk substitutes is widespread: for example, free samples of infant formulas are distributed through the health care system. Although a government body has been established with a mandate to report such violations, no monitoring of the law is done at a national level.

Breastfeeding courses are then mainly provided by NGO’s. Concerning the Baby-Friendly Hospital Initiative (BFHI), only 10 hospitals out of the 40 maternity wards have been certified as “baby-friendly”.

Discussion on infant and young child feeding

During the interactive dialogue between the CRC Committee and the delegation of Portugal, the issue of breastfeeding was tackled in the context of health care. The members of the Committee addressed their concerns about the health budget allocation and the lack of coordination within the different bodies of the government.

The Portuguese delegation confirmed that Portugal had received a recommendation to improve the coordination between the different bodies of the government by the UPR, as it had been reviewed during its 6^th session in 2009. . The delegation also highlighted the difficulties to increase the health budget allocation due to the economical crisis that lasts since 2009. The health budget allocation decreased in 2013 from 11 Mio to 7 Mio Euro. However, the government managed to increase the budget allocation to 9 Mio Euro for 2014. Besides, the government works closely with NGOs to guarantee to all children the right to health care.

The Committee then raised questions about breastfeeding, especially the implementation of the International Code and the training of health professionals on breastfeeding issues. 

The Portuguese delegation first acknowledged the WHO recommendation for exclusive breastfeeding until 6 months and then continued breastfeeding until 2 years or more. It stated that the government officially recommends exclusive breastfeeding until 6 months. On the question of health professionals, the delegation asserted that they are aware of the crucial role of breastfeeding in regard of infant and young child nutrition and that they are called to respect WHO resolutions, particularly the International Code. The delegation then mentioned the monitoring activity of the association Mama Mater that is collecting data about breastfeeding. These data should be further analyzed in order to understand the rates of exclusive breastfeeding after 6 weeks. About BFHI, the delegation stated that 11 maternity wards are currently certified as "baby-friendly", but the government intends to increase this number in the coming years. It then explained that “breastfeeding corners” (Cantinhos de Amamentação) are disseminated among the hospitals of the country, allowing mothers to receive advice regarding breastfeeding even after they will have left hospital. The delegation noted the engagement of several NGOs in peer counseling on breastfeeding. The government finally expresses its will to inform the population about the benefits of breastfeeding through a national youth health programme.

The members of the Committee also raised issues about corporal punishment, juvenile justice, integration of migrants, road traffic injuries and drowning, participation of children in bull fighting, child trafficking, education, children with disabilities, adoption and family support.

CRC Committee's Concluding Observations

In its Concluding Observations, the CRC Committee made recommendations on the importance of collecting data on children (para 18), on the right of the child to the highest attainable standard of health, mentioning the negative impact of budget restrictions on health care (para 48), and on the necessity to promote and support breastfeeding practices and to regulate the marketing of infant formulas (para 56).

First, the CRC Committee emphasized the importance of establishing a more comprehensive and integrated data collection system on children.

Then, the Committee drew Portugal’s attention to its 2013 General Comment N°15 on the right of the child to the enjoyment of the highest attainable standard of health (art. 24), which explicitly recognises the importance of breastfeeding for the achievement of the right of the child to health. The General Comment N° 15 urges States, in the effort of diminishing infant and child mortality, to devote particular attention to neonatal mortality and suggests, inter alia, to “pay particular attention to ensuring full protection and promotion of breastfeeding practices”. Moreover, “exclusive breastfeeding for infants up to 6 months should be protected and promoted and breastfeeding should continue together with appropriate complementary foods preferably until two years of age as feasible. States’ obligations in this area are defined in the “protect, promote and support framework”, adopted unanimously by the World Health Assembly in its 2002 Global Strategy for Infant and Young Child Feeding". Regarding Health and health services, Portugal is specifically demanded to “minimize the impact of financial restrictions in the area of health care, and further recommends that austerity measures in the area of health should be evaluated on the basis of a child’s right’s impact assessment to ensure that such measures do not have a negative impact on child health and well-being.”

Lastly, despite all measures taken to encourage breastfeeding, the Committee expressed its concern about the decline of exclusive breastfeeding rates between four and six months of age, and the practice of providing complementary foods to infants from the age of four months in Portugal. It therefore recommended the State Party to “improve the practice of exclusive breastfeeding for the first six months, through awareness-raising measures including campaigns, information and training for relevant officials, particularly staff working in maternity units, and parents”. Portugal is also demanded to “strengthen the monitoring of existing marketing regulations relating to breast milk substitutes”.

Yemen still faces Challenges regarding Protection and Promotion of Breastfeeding

The Republic of Yemen presented its consolidated 4th periodic report on the situation of the implementation of the Convention on the Rights of the Child in the country.

IBFAN presented an alternative report to inform the CRC Committee on Yemen’s situation on the issue of infant and young child feeding.

General overview of breastfeeding in Yemen

With a low rate of children initiated to early breastfeeding (30%) and insufficient rates of exclusive breastfeeding till 6 months (12%), Yemen still has a lot to do in order to protect and promote breastfeeding among the population. Bad feeding practices, such as the habit of giving other liquids than human milk to babies and premature introduction of complementary foods are common, leading to high stunting and infant mortality rates. More than 53% of the children under  6 months are stunted and 57 children die before the age of 1 for every 1000 live births. Although the International Code of Marketing of Breastmilk Substitutes has been partially translated into law in 2002, its effective enforcement and monitoring has not been ensured. Moreover, there are no baby-friendly hospitals in Yemen.

Discussion on infant and young child feeding

During the presentation of its report, the Yemeni delegation has admitted that malnutrition is a crucial problem for Yemen, causing almost half of child mortality in the country. In 2012, some 58% of children were stunted, while 15% of them were in danger of death. Together with various international and national partners, the delegation reported that the Ministry of Health has launched different programmes addressing this important issue. An academic conference on malnutrition has recently been held and this topic is to be included in each curriculum for health professionals.  Other programmes have been launched, with focus on prevention and identification of solutions to improve nutrition for children and women, especially mothers. In addition, the government is currently developing a programme to raise awareness about breastfeeding among the population. Finally, a campaign focusing on nutrition in remote areas, targeting mothers and children, has started in 2013. 

CRC Committee members asked further clarifications on the information provided by the delegation. They addressed issues related to breastfeeding, such as the enforcement and monitoring of the 2002 law to protect breastfeeding and implement the International Code of Marketing of Breastmilk Substitutes, and the concrete efforts made to increase the rate of exclusive breastfeeding until 6 months. CRC Committee members also asked whether Yemen has the intention to increase its budget line for health in general, and what is the budgetary allowance allocated to tackle malnutrition. Finally, a question on the way to measure the results of the awareness raising campaigns on malnutrition has been posed.

The Yemeni delegation responded that in 2006, 11% of children under 6 months received exclusive breastfeeding, a percentage which the government is currently trying to increase to 20% by 2015. Besides, the project entitled “Programme for advice regarding nutrition of infants” provides a training module aimed at health professionals to increase awareness about breastfeeding. Regarding the budgetary allocations, the delegation explained that even though the Ministry of Health has no specific budget line for nutrition, 3.5% of its budget is devoted to fight malnutrition. For instance, the Ministry of Health is currently trying to address nutrition and hygiene issues through a national educational TV channel, where information is regularly transmitted. The government claimed its intention to increase the budget for health. Apart from its own budget, Yemen has received funds from international donors, such as UNICEF, World Bank, World Food Programme and International Medical Call, in order to tackle malnutrition through different programmes. According to the delegation, results of such programmes can be measured after 30-40 years only, depending on the issue tackled. The reduction of stunting and wasting among the population will be seen long time after measures have been taken, although field indicators show an improvement of nutrition status.

Finally, the delegation explained that since the law to protect breastfeeding and implement the International Code was adopted in 2002, the marketing of infant formulas is strictly regulated and infant formulas producers are allowed to advertise their products only if their allegations are based on scientifically verified measures. According to Yemen, the marketing of infant formulas within hospitals and clinics, such as free samples distribution, is currently prohibited. However, the issue of the monitoring and enforcement of the 2002 law remained unanswered.

CRC Committee's Concluding Observations

In its Concluding Observations, the CRC Committee made recommendations on the importance of data collection (para 18), on the right of the child to the highest attainable standard of health, mentioning the necessity to promote breastfeeding and implement the International Code of Marketing of Breastmilk Substitutes (para 56), and on HIV/AIDS programmes (para 64).

The CRC reminded Yemen its 2013 General Comment N°15 on the right of the child to the enjoyment of the highest attainable standard of health (art. 24) explicitly recognizes the importance of breastfeeding for the achievement of the right of the child to health. It urges States, in the effort of diminishing infant and child mortality, to devote particular attention to neonatal mortality and suggests, inter alia, to “pay particular attention to ensuring full protection and promotion of breastfeeding practices”. Moreover, “exclusive breastfeeding for infants up to 6 months should be protected and promoted and breastfeeding should continue together with appropriate complementary foods preferably until two years of age as feasible. States’ obligations in this area are defined in the “protect, promote and support framework”, adopted unanimously by the World Health Assembly in its 2002 Global Strategy for Infant and Young Child Feeding". Regarding Health and health services, Yemen is required to pay attention to CRC General Comment N° 15 on the right of the child to the enjoyment of the highest attainable standard of health (art. 24) and to “(a) ensure that appropriate resources be allocated to the health sector, with particular attention to specific maternal and child health care and develop and implement comprehensive policies and programmes to improve the health situation of children, in particular to respond to high rates of malnutrition and diarrhoea infections; (c) ensure access to safe water and sanitation services in rural and poorest areas [...]; (d) enhance efforts to promote exclusive breastfeeding practices, by ensuring the implementation and compliance with the International Code of Marketing of Breast-milk Substitutes, and establish a monitoring and reporting system to identify violations of the Code. This includes the establishment of baby-friendly hospitals with the promotion of breastfeeding from birth”.

The CRC Committee also stressed the importance of collecting disaggregated data on a comprehensive scale and therefore, urges Yemen to expeditiously improve its data collection system.

In addition, the Committee expressed its concern about the scarcity of information provided with respect to the implementation of the National HIV/AIDS Prevention and Control Programme, as well as about the limited provision of antiretroviral prophylaxis to prevent mother-to-child transmission and general stigmatization of HIV/AIDS within the Yemeni society.  Therefore, it urged the government to expand the coverage of the national HIV programme and to ensure universal coverage for HIV testing and free antiretroviral drug provision.