Recommendations related to breastfeeding by the 66th Committee on the Rights of the Child

The 66^th Session of the Committee on the Rights of the Child (CRC Committee) took place in Geneva from 26 May to 13 June 2014. The Committee reviewed the progress of the implementation of the Convention on the Rights of the Child in 5 countries: India, Indonesia, Jordan, Kyrgyzstan and Saint Lucia. IBFAN submitted alternative reports on the situation of infant and young child feeding for each of the reviewed countries. The reports on India and Indonesia were written in collaboration with IBFAN groups in the countries. In its Concluding Observations, the CRC Committee referred specifically to breastfeeding in only 3 out of the 5 countries (India, Indonesia and Kyrgyzstan). Jordan and Saint Lucia did not receive any direct recommendation on breastfeeding, although they received recommendations on various topics indirectly related to breastfeeding.

General measures of implementation

The Committee has put an emphasis on the improvement of the data collection system in all of the 5 countries under review (India, Indonesia, Jordan and Kyrgyzstan), stressing the importance of collecting disaggregated data for the formulation, evaluation and monitoring of policies, programmes and projects for the effective implementation of the Convention.

The Committee also called for the development of a national plan for action in India and Saint Lucia, and insisted on the necessity to include time-bound and measurable goals and targets to effectively monitor progress in the implementation of child’s rights at national level (Saint Lucia).

Health resources and budget

The Committee also called for strengthening of resources allocated to health by urging Indonesia to substantially increase its allocations in the area of health to adequate levels and by recommending India to ensure that appropriate resources be allocated to health sector in order to improve the health situation of children, in particular to respond to high rates of acute respiratory infections, malnutrition and diarrhoea.

Besides, the Committee urged India to provide all professionals working with children, including health workers, with adequate and systematic training in children’s rights.

Preventive health

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

Indonesia has been requested to ensure provision of postnatal care for all women with the focus of reducing preventable and other diseases, particularly diarrhoea, acute respiratory infections and undernutrition, and to promote good infant and young child feeding practices. It has also been requested to strengthen and expand access to preventive health for all pregnant women and children, and to take all necessary efforts to reduce maternal mortality.

Kyrgyzstan has been asked to take measures to prevent deaths of children as a result of preventable and curable diseases.

Saint Lucia has been recommended to ensure adequate provision of postnatal care, as well as address the issues of low birth weight, increasing infant mortality rate, and obesity among children through awareness-raising efforts, and to continue dissemination of health information and the promotion of health education regarding basic child health to all segments of society.

Malnutrition

While India has been urged to ensure effective implementation of its National Security Food Act (2013) which contains provisions aiming at combating children’s undernourishment, Jordan has been asked to address child malnutrition and infectious diseases and Kyrgyzstan has been recommended to ensure that no child in the country is undernourished and that all children have access to adequate and sufficient food.

HIV/AIDS

The Committee has issued specific recommendations on the prevention of mother-to-child HIV/AIDS transmission (India, Indonesia) as well as a recommendation on antiretroviral therapy and prophylaxis for HIV-infected pregnant women and children (India).

In addition, general recommendations on the prevention of HIV/AIDS transmission by raising awareness of the public have been issued (Jordan, Kyrgyzstan).

Breastfeeding protection

Full implementation of the International Code on Marketing of Breastmilk 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 has insisted on the need for Indonesia and Kyrgyzstan to adopt the Code, and has requested India to ensure effective implementation of, and compliance with, the Code, as well as establish a monitoring and reporting system to identify Code violations and implement stringent measures against identified violators.

More generally, in the light of the CRC General Comment No. 16 on State obligations regarding the impact of the business sector on children’s rights, India has been requested to establish a clear regulatory framework for the industries to ensure that their activities do not negatively affect human rights, especially in relation to children’s rights. Yet, it is of serious concern that despite the systematic infringements of the Code committed by baby food companies in India, the Committee urged the country to implement more partnerships with the private sector with focus on health. According to IBFAN-GIFA, this call for an increase in number and thus importance of health projects and programmes modeled as “public-private partnerships”, is likely to lead to risks of conflicts of interest in both policy-making sphere as well as in programme implementation and, most importantly, may undermine the existing legally binding instruments and threaten development of clear and comprehensive regulatory framework.  Therefore, the recommendations of the Committee regarding the role of the private sector can be seen as conflicting.

Breastfeeding promotion

The Committee expressed concern over the insufficient rates of exclusive breastfeeding in India and Indonesia, and the poor implementation of the law on the promotion of breastfeeding in Kyrgyzstan, leading to inadequate information as well as free samples of baby food products provided to mothers.

Therefore, India has been specifically requested to promote exclusive breastfeeding practices, including the promotion of breastfeeding from birth, complementary feeding strategies with or without provision of food supplements as well as micronutrient interventions for mothers. Meanwhile, Indonesia has been urged to strengthen the promotion of breastfeeding, including by establishing a specific programme on the topic. Finally, Kyrgyzstan has been recommended to implement its legislation on the promotion of breastfeeding practices and ensure that mothers receive adequate information on the benefits of their breastmilk.

Breastfeeding support

However, no specific recommendation on breastfeeding support (e.g. inclusion of knowledge on optimal breastfeeding practices in health curricula) has been issued by the Committee following its 66th session.

Table 1. CRC Committee - Session 66 / 2014 -Summary of Concluding Observations on IYCF

Country		IBFAN report	Summary of specific recommendations on IYCF
7	India (3rd-4th periodic report)	yes	Indirect – General measures of implementation (para 14 (a); 20; 26; 30 (a)): prioritize the development of the National Plan of Action to implement the 2013 National Policy for Children; expeditiously improve its data collection system; provide all professionals working for and with children with adequate and systematic training in children’s rights. This includes in particular […] health workers […]; 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 […] other standards, especially those relating to children’s rights. Health (para 63; 64; 68): strengthen its efforts to address […] the existing disparities in access to and quality of health services, including by establishing partnerships with the private sector […]; ensure that appropriate resources be allocated to the health sector, with particular attention to specific maternal and child health care policies, programmes and schemes to improve the health situation of children, in particular to respond to high rates of acute respiratory infections, malnutrition and diarrhoea; ensure the effective implementation of the National Food Security Act. Direct (para 54): enhance efforts to promote exclusive breastfeeding practices, including the promotion of breastfeeding from birth, complementary feeding strategies with or without provision of food supplements as well as micronutrient interventions for mothers; ensure the effective implementation of, and compliance with, the International Code of Marketing of Breast-milk Substitutes, and establishment of a monitoring and reporting system to identify violations of the Code, as well as of stringent measures in all situations of violations of the Code. Violations include the promotion and distribution of samples and promotional materials by the private sector institutions involved in the Infant Formula marketing and distribution.
8	Indonesia (3rd-4th periodic report)	yes	Indirect – General measures of implementation (para 7): continue to upgrade its system of data collection to cover all areas of the Convention; ensure that all data and indicators are used for the formulation, monitoring and evaluation of policies, programmes and projects for the effective implementation of the Convention. Health (para 48; 52): increase its health budget and expand access to primary health-care services across all provinces; ensure the provision of primary health-care services for all pregnant women, including […]  postnatal care, and children, focusing on interventions to reduce preventable and other diseases, particularly diarrhoea, acute respiratory infections and undernutrition, as well as promote good infant and young child feeding practices; strengthen and expand access to preventive health care […] for all pregnant women and children, particularly infants and children under the age of 5; take all necessary efforts, including emergency obstetric care, to reduce maternal mortality; sustain the measures in place to prevent mother-to-child transmission of HIV/AIDS as well as provide for counselling and improve follow-up treatment for HIV/AIDS-infected mothers and their infants. Direct (para 54): strengthen the promotion of breastfeeding, including by establishing a programme to promote and enable all mothers to successfully breastfeed exclusively for the first six months of the infant’s life; adopt the International Code of Marketing of Breast Milk Substitutes.
9	Jordan (4th-5th periodic report)	no	Indirect – General measures of implementation (para 8 (b)): strengthen its mechanisms for data collection by establishing a central database on children and ensure that data are collected on all areas of the Convention and disaggregated. Health (para 44; 48): ensure equal access to quality health services by all children […] by addressing child malnutrition and infectious disease; improve access to quality, age-appropriate HIV/AIDS, sexual and reproductive health information and services.
10	Kyrgyzstan (3rd-4th periodic report)	yes	Indirect – General measures of implementation (para 7 (b)): develop a comprehensive system for collecting disaggregated data to cover all those under the age of 18 years. Health (para 48; 50): take measures to prevent deaths of children as a result of preventable and curable diseases, by educating parents and providing easy access to early medical intervention; take measures to ensure that no child in the country is undernourished and that all children have access to adequate and sufficient nutritious food; take all necessary measures to prevent transmission of HIV/AIDS by raising awareness of the public. Direct (para 54): take all necessary measures to implement its legislation promoting breastfeeding practices and ensure that all mothers receive adequate information on the benefits of their breast-milk;  adopt the International Code for Marketing of Breast-Milk Substitutes.
11	Saint Lucia (2nd-4th periodic report)	no	Indirect – General measures of implementation (para 11; 13; 17): develop and implement a comprehensive national plan of action for the full implementation of the Convention; to establish the Central Database Registry […] ensuring a comprehensive and integrated data collection system on children. Health (para 43(a) and (b)): ensure adequate provision of prenatal and post natal care, as well as address the increasing number of children born with low birth weight, the increasing infant mortality rate, and obesity among children, through awareness-raising efforts, and the reasons for these trends; dissemination of health information and the promotion of health education regarding basic child health to all segments of society.

Why non-binding international regulatory instruments do not work: A case study on breastfeeding protection

In 1981, the World Health Assembly (WHA) adopted the International Code of Marketing of Breastmilk Substitutes (the Code), to date completed and extended by fifteen subsequent relevant WHA resolutions forming integral part of it. The Code aims to ensure that parents can make fully informed decisions about infant and young child feeding by banning marketing practices that undermine breastfeeding. The Code thus contributes to safeguarding the health of infants and young children. In 1989, the Convention on the Rights of the Child (CRC) has enshrined breastfeeding protection, promotion and support in its article 24, which articulates the right of the child to the enjoyment of the ‘highest attainable standard of health’. The CRC’s General Comment No. 15 (2013), which interprets this right, specifies that besides States’ obligation to implement and enforce the Code (para 44), baby food companies have the direct obligation to comply with it in all contexts (para 81, emphasis added).

Notwithstanding this obligation, since 1981, baby food companies have systematically violated the Code provisions by malevolent marketing practices and tactics that mislead consumers and health professionals. The latest monitoring report Breaking the Rules 2014 published by the IBFAN’s International Code Documentation Centre covers 27 companies and presents 813 violations in 81 countries. It reminds the world that breastfeeding rates will continue to decline with the inevitable consequence of increased mortality and morbidity in infants and young children as long as corporate strategies that violate the Code continue. At present, there is no effective global mechanism that would ensure accountability of baby food companies which all seem prone to evade their human rights obligations in the absence of an effective sanction mechanism. Relying on implementation of the Code at country level has proven to be an unsatisfactory solution as all over the globe, baby food companies systematically resisted these efforts. Even in the minority of countries that have been successful and adopted adequate laws to regulate marketing of breastmilk substitutes, these companies, using their political influence and economic power, directly challenged the domestic law (e.g. in India) or resisted the adoption of enforcement mechanisms (e.g. in the Philippines).

The 33-year experience of Code implementation provides a strong argument to illustrate the necessity of a binding treaty on obligations of TNCs under human rights, a crucial step to the fulfilment of human rights of every human being, in this particular case of every child. Non-binding international recommendations, such as the Code, or “voluntary” corporate social responsibility measures, such as those indicated in the UN Guiding Principles, have failed to make TNCs liable for their human rights violations. Were a binding treaty on TNCs’ obligations adopted, violations of child rights caused by baby food companies would no doubt diminish, and those identified could be prosecuted and firmly sanctioned by an independent international judicial body. The treaty would help ensure the right of children to adequate food and nutrition as well as to health through the respect of the Code at global scale.

Lack of Breastfeeding Promotion, Protection and Support in Saint Lucia (CRC)

On the 6^th of June 2014, the Committee on the Rights of the Child considered the combined second to fourth periodic reports of Saint Lucia 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 Saint Lucia's situation on the issue of infant and young child feeding.

General overview of breastfeeding in Saint Lucia

The alternative report highlighted the lack of tracking of key breastfeeding indicators as well as the absence of infant and young child policies and programmes at national level. It has shown that some 20% of caregivers do not know how to prevent diarrhoea, reported to be the one of the main causes of infant and child mortality in the country, while breastfeeding has proven to be one of the most effective intervention to prevent accute diarrhoea. 

Regarding the implementation of the International Code of Marketing of Breastmilk Substitutes, a recent report issued by IBFAN’s International Code Documentation Centre showed that only some provisions of the Code have been implemented on a voluntary basis.

IBFAN's report also raised concerns about the fact that in 2011, UNICEF recorded that no single hospital registered as “baby-friendly” in the country. Finally, the lack of information available on the prevention of HIV/AIDS mother-to-child transmission and on an emergency preparedness plan to ensure integrated response to protect and support breastfeeding in case of emergencies have been emphasized.

Concluding Observations

In its Concluding Observations, regarding the general implementation of the Convention, the Committee urged Saint Lucia to strengthen its efforts to develop and implement a comprehensive national plan of action  […], including specific time-bound and measurable goals and targets to effectively monitor progress in the implementation of child’s rights throughout the country (para 11). The Committee also recalled its previous recommendation about the implementation of a comprehensive and integrated data collection system on children, covering the entire period of childhood up to the age of 18 (para 17).

Regarding health issues, the Committee requested Saint Lucia to continue to strengthen efforts to ensure adequate provision of prenatal and post natal care, as well as address the increasing number of children born with low birth weight, the increasing infant mortality rate, and obesity among children, through awareness-raising efforts, and the reasons for these trends, and to continue the dissemination of health information and the promotion of health education regarding basic child health to all segments of society (para 43).

However, the Committee issued no direct recommendations related to infant and young child feeding. 

Inadequate Infant Feeding Practices in Indonesia (CRC)

On the 5th of June 2014, the Committee on the Rights of the Child completed its consideration of the combined 3rd and 4th periodic reports of Indonesia on the implementation of the provisions of the Convention on the Rights of the Child in the country. 

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

General overview of breastfeeding

IBFAN’s alternative report highlighted that inadequate infant feeding practices co-exist with high rates of child mortality in Indonesia. Indeed, the rate of early breastfeeding initiation is low (less then 30 %) and more than half of the children are not breastfed until 6 months of age, while a third of the children under five years old are stunted. Besides, complementary foods are introduced too early to almost 45% of the children. The lack of any policy or programme on infant and young child feeding has also been emphasized, as well as an absence of sanctions in case of violations of the International Code of Marketing of Breastmilk Substitutes, despite the implementation of many provisions of this Code into national legislation. The absence of data on the number and quality of Baby-friendly hospitals has also been shown as problematic. Finally, the absence of maternity protection for women working in the informal sector, as well as the lack of public awareness about HIV/AIDS and infant feeding, have been emphasized.

Discussion on infant and young child feeding

The Committee noted that while in the 1990s, Indonesia had made progress in reducing neonatal and infant mortality, this advancement had slowed down in recent years. In addition, in regard to the high infant mortality rate in certain provinces, the expert has asked about the implementation of the Baby-friendly Hospital Initiative in Indonesia. In general, the expert has asked about the actions taken by State party to promote breastfeeding.

The Indonesian delegation responded by stating that there had been a national breastfeeding programme in place since 1990 promoting breastfeeding up until six months of age.  Nevertheless, the delegation admitted that the rate of early breastfeeding in Indonesia still remains low, and added that the provision of lactation rooms for breastfeeding mothers is scheduled in the government agenda.  

Concluding Observations

In its Concluding Observations, regarding the general implementation of the Convention, the Committee urged Indonesia to upgrade its system of data collection (para 7 (a)).

Regarding the issue of health, the Committee specifically requested the country to substantially increase the allocations in the area of health to adequate levels and to expand access to primary health-care services across all provinces (para 16 (a) and 48). It also emphasized the need to “ensure the provision of primary health-care services for all pregnant women, including access to postnatal care, and children, focusing on interventions to reduce preventable and other diseases, particularly diarrhoea, acute respiratory infections and undernutrition”, and called for the promotion of good infant and young child feeding practices (para 48 (a)). In addition, Indonesia has been urged to “strengthen and expand access to preventive health care for all pregnant women and children, particularly infants and children under the age of 5”. They should include preventive health interventions such as universal immunization services, oral rehydration therapy and treatment for acute respiratory infections (para 48 (b)). According to the Committee, the country should also “take all necessary efforts […] to reduce maternal mortality” (para 48 (c)). Regarding the issue of HIV/AIDS, the government was requested to “sustain the measures in place to prevent mother-to-child transmission as well as provide for counselling and improve follow-up treatment for HIV/AIDS-infected mothers and their infants to ensure early diagnosis and early initiation of treatment” (para 52).

Besides, the Committee emphasized the low rate of exclusive breastfeeding in the country and issued direct recommendations related to infant and young child feeding: it recommended Indonesia to “strengthen the promotion of breastfeeding, including by establishing a programme to promote and enable all mothers to successfully breastfeed exclusively for the first six months of the infant’s life” and to “adopt the International Code of Marketing of Breast Milk Substitutes” (para 56).

Breastfeeding Challenges in India (CRC)

On the 3^rd of June 2014, the Committee on the Rights of the Child completed its consideration of the combined 3rd and 4th periodic report of India on the implementation of the provisions of the Convention on the Rights of the Child in the country. 

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

General overview of breastfeeding in India

About 26 million babies are annually delivered in India. According to the National Family Health Survey-3 (NFHS-3) data, 20 million are not able to receive exclusive breastfeeding for the first six months of their life and about 13 million do not get good timely and appropriate complementary feeding after six months along with continued breastfeeding. The rate of early initiation of breastfeeding within one hour following the delivery is of only 23.4% and exclusive breastfeeding up to the age of six months is of 46.3%. 

However, the national legislation implementing the International Code of Marketing of Breastmilk Substitutes, called the Infant Milk Substitute Act, is still not effectively enforced. Therefore, an effective monitoring mechanism is required at state and district level. In addition, there is no comprehensive adequate training of health professionals done by the government, even though BPNI/IBFAN India has developed a training course and trained more than 15'000 health workers since 2004. Besides, the alternative report emphasized that an increasing number of institutional deliveries occur without adequate space, staff or infrastructure. The Baby-friendly Hospital Initiative (BFHI), launched in the country in 1993, has not been properly revived since then. 

Finally, it has been noted that he national legislation on maternity protection does not cover women working in private and informal sector. Clearly, the support to working mothers needs to be extended to women in the unorganized sector as they form the major part (almost 90%) of working women. Lastly, the alternative report states that the national guidelines on Infant Feeding and HIV have not yet been made into policy, and that there is no policy on infant feeding in case of emergency.

Discussion on infant and young child feeding

The Committee raised the issue of maternal malnutrition and child stunting, and asked if there is any programme to address mother malnutrition. Furthermore, the Committee insisted on optimal infant and young children feeding practices, especially breastfeeding, to combat children malnutrition, which is proven to affect, inter alia, children’s learning capacities. The Committee highlighted the decline in breastfeeding rates in recent years and asked whether there were any programmes in place to remedy this situation. The issue of regional disparities  in breastfeeding rates has also been raised, as well as the promotion of infant formula, despite the implementation of the IMS Act. The Committee showed concern for the Code violations that occur in India and wondered if they are the consequences of a lack of monitoring of the national legislation. It finally asked if there was any implementation of the BFHI at national level and if there were any national guidelines or policy on HIV and infant feeding.

The delegation of India responded that the exclusive breastfeeding rate in India is about 40%, which is relatively high compared to other countries.  It added that the high rate of institutional delivery (78%) gives the country a great opportunity to promote optimal breastfeeding practices to young mothers, and that dedicated breastfeeding counsellors are deployed in maternity wards throughout the country.  The delegation expressed the hope that the actions taken would lead to an increase in breastfeeding rates. It admitted that India had been slow to implement the International Code of Marketing of Breastmilk Substitutes, but it stated that government is currently awareness-raising on the IMS Act among the district health officers. Regarding the issue of HIV and infant feeding, the delegation answered that the existing national guidelines do provide the appropriate guidance to the population.

Concluding Observations

In its Concluding Observations, the CRC Committee made a wide range of indirect recommendations related to infant and young child feeding. At the level of general implementation, the Committee urged India to prioritize the development of the National Plan of Action to implement the 2013 National Policy for Children (para 14 (a)). It requested also the country to expeditiously improve its data collection system (para 20), and to provide all professionals working for and with children with adequate and systematic training in children’s rights, which includes in particular health workers (para 26). In the light of the CRC General Comment No. 16 on State obligations regarding the impact of the business sector on children’s rights, the Committee also insisted on the need to 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 other standards, especially those relating to children’s rights (para 30 (a)).

Regarding health issues, the Committee requested India to increase the resources allocated to the health sector and to ensure that they are appropriate (para 18(a) and 64 (b)), with “particular attention to specific maternal and child health care policies, programmes and schemes to improve the health situation of children, in particular to respond to high rates of acute respiratory infections, malnutrition and diarrhoea”. The Committee also called for to the “effective implementation of the National Food Security Act (2013) which contains provisions aiming at combating children’s undernourishment” (para 64 (d)). The Committee also addressed the issue of HIV/AIDS mother-to child transmission by urging the government to “sustain the measures in place to prevent mother-to-child transmission of HIV/AIDS and develop a roadmap to ensure the implementation of effective preventive measures” and “improve access and coverage of antiretroviral therapy and prophylaxis for HIV-infected pregnant women […]” (para 68 (b) and (e)).

In addition, the Committee issued direct recommendations related to infant and young child feeding (para 64 (d)). It urged India to “enhance efforts to promote exclusive breastfeeding practices, including the promotion of breastfeeding from birth, complementary feeding strategies with or without provision of food supplements as well as micronutrient interventions for mothers” and called for the “effective implementation of, and compliance with, the International Code of Marketing of Breast-milk Substitutes”, and establishment of a “monitoring and reporting system to identify violations of the Code”, as well as of “stringent measures” in all situations of violations of the Code. The Committee thus specified that “violations include the promotion and distribution of samples and promotional materials by the private sector institutions involved in the Infant Formula marketing and distribution”.

Nonetheless, it is of serious concern that despite the systematic infringements of the Code committed by baby food companies, the Committee recommended India to “strengthen its efforts to address the existing disparities in access to and quality of health services, including by establishing partnerships with the private sector […]” (para 64 (a)).