Sweden at the CRC: Significant Decrease of the Rate of Exclusive Breastfeeding

On January 13^th and 14^th, 2015, the Committee on the Rights of the Child considered the fifth periodic report of Sweden on the situation of the implementation of the Convention on the Rights of theChild (CRC) in the country. The Swedish delegation was led by Mrs. Pernilla Baralt, State secretary at the Ministry of Health and Social Affairs.

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

General overview of breastfeeding in Sweden

The report pointed out the lack of tracking of key breastfeeding indicators (especially related to early initiation of breastfeeding and to continued breastfeeding at the age of 2 years). It also emphasized the significant decrease of the rate of exclusive breastfeeding until 6 months that happened between 2000 (33.4%) and 2012 (14.5%).

Regarding the promotion of optimal breastfeeding practices, it is of serious concern that the official Swedish publications, such as the ones accessible from the National Food Agency portale, are not in line with the official recommendations on infant and young child feeding issued by the World Health Organization. In addition, the protection of breastfeeding is still insufficient in Sweden. The International Code of Marketing of Breastmilk Substitutes and the relevant subsequent World Health Assembly resolutions have been only partially implemented through national legislation and although a voluntary policy on the marketing of breastmilk substitutes has been adopted, it is not enough to ensure that parents and caregivers are not facing undue commercial pressure from the baby food industry.

In addition, the quality of the training courses of health professionals on optimal breastfeeding practices, considered as ‘too basic’ in a 2008 report, should be put into question and improved, and the consistency of information provided to mothers in maternity wards of the country should be regularly monitored.

Finally, mother-to-child HIV transmission rate should be monitored and information on the implementation of any specific policy on infant feeding in emergencies should be provided.

Discussion on infant and young children feeding

The Committee raised concern about the lack of implementation of the International Code into national legislation and about the issues related to the marketing of infant formula in the country. It noted that the rate of exclusive breastfeeding is very low and asked if there is an explanation about it. The Committee further emphasized the link between suboptimal breastfeeding practices and the growing trend of obesity and overweight within the Swedish population. It then requested the delegation to provide clarification on the activities that are lead by the government with aim to promote breastfeeding.

The delegation answered that in Sweden, the cultural environment is generally favourable to breastfeeding. It also noted that the decrease of the rate of exclusive breastfeeding is not so important for children born since 2011 and that in 2009, a national breastfeeding committee has been formed in order to promote, protect and support breastfeeding. Besides, it highlighted that a 2013-2016 Strategic Plan for Coordination on Breastfeeding Health has been adopted and is structured around 5 main objectives (1/development of a national knowledge on breastfeeding, 2/ training on breastfeeding aimed at health professionals, 3/ information of health professionals and policy-makers about the WHO recommendations on breastfeeding, that have been translated in Swedish 4/ official recommendations on breastfeeding should be consistent with the WHO recommendations and 5/ the EU directive on infant formulae and follow-up formulae should be implemented through national legislation and monitored).

The Committee thanked the delegation for its clarifications. It however insisted on several unanswered questions: Is there a Swedish comprehensive database tracking the breastfeeding indicators (especially the early initiation of breastfeeding and the continued breastfeeding until the age of 2 years)? Is the International Code fully implemented and monitored? What explains the decrease of the rate of exclusive breastfeeding considering the very high rate of institutional deliveries? Which measures are take to tackle the obvious lack of adequate training of health professionals regarding breastfeeding? Is there any plan implemented to protect and support breastfeeding in emergencies?

Concluding Observations

In its Concluding Observations, the Committee did not make any recommendation directly or indirectly related to infant and young child feeding. A general recommendation related to health and health services called for strengthening “efforts to improve the health status of children from disadvantaged and marginalized groups and allocate sufficient financial, human and technical resources to ensure their right to health without discrimination” (§ 41).

Turkmenistan at the CRC: Constructive Dialogue on Breastfeeding between the CRC Committee and the Turkmen Delegation

On January 13^th and 14^th, 2015, the Committee on the Rights of the Child considered the combined second to fourth periodic report of Turkmenistan on the situation of the implementation of the Convention on the Rights of the Child in the country. The Turkmen delegation was led by Mrs. Lyudmila Amanniyazova, Deputy Head of the State Statistics Committee and H.E. Mr. Atageldi Haljanov, Permanent Representative of Turkmenistan to the United Nations Office at Geneva.

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

General overview of breastfeeding in Turkmenistan

Breastfeeding rates are low in Turkmenistan: nine children out of 10 are not exclusively breastfed under 6 months of age and less than 4 children out of 10 receive continued breastfeeding until 2 years of age. The rate of early initiation of breastfeeding  is also very low (59.8%) while neonatal, infant and under-5 mortality rates are still high in the country.

In 2009, Turkmenistan adopted the Law on Protection and Promotion of Breastfeeding and Requirements for Infant Feeding Products, amended in 2013, which determines the main public policies on child nutrition and regulates the distribution and marketing of safe baby foods. However, this law implements only partially the International Code of Marketing of Breastmilk Substitutes and there is no clarity on its implementation or on any monitoring mechanism.

Besides, there is no recent data on the implementation of the Baby-Friendly Hospitals Initiative in the country. In 2009-2010, 81% of the maternity facilities were certified as ‘baby-friendly’. Finally, no comprehensive information on maternity protection, HIV and breastfeeding and infant feeding in emergnecies is available.

Discussion on infant and young child feeding

The CRC Committee specifically addressed the issue of breastfeeding and the lack of breastfeeding-related information. After welcoming the adoption of the 2009 law(see above)and its 2013 amendments, the Committee expressed concern for the low exclusive breastfeeding rate under 6 months and asked about the root causes of this drop as well as about the measures taken to tackle it.

Additional questions were made on the number of Baby-Friendly hospitals in the country and on the training available for expecting mothers and fathers on parenthood and breastfeeding practices. The CRC Committee also raised the issue of the training provided to health professionals on breastfeeding, the duration of the maternity leave and the existence of a paternity leave. It also highlighted that information on mother-to-child HIV transmission and on HIV and breastfeeding was missing.

The Turkmen delegation specified that according the 2009 law prohibits the distribution of samples of infant formula to families, in line with the International Code. It mentioned that currently, some 95% of hospitals and maternities are certified as “Baby-Friendly”, that expecting mothers learn about breastfeeding as part of their preparation to motherhood, and that about 2,000 parents have been given training on child care. Thanks to the measures undertaken, the rate of children ever breastfed increased  from 41% in 2008 to 61% in 2014. A study conducted in two regions of the country showed that 59% of children aged 0-5 months were exclusively breastfed. Lastly, a study assessed that doctors and nurses have good knowledge on breastfeeding.

Concerning maternity protection, the delegation explained that there are 3 types of State maternity allowances for child care, given respectively before delivery, at delivery and after deliver. It also mentioned that the maternity leave should not be less than 190 days, according to the Turkmen legislation, which also provides for a paternity leave. The delegation stated that legislation provides breastfeeding breaks of 30 minutes every three hours, available for lactating mothers with children up to 1 year and a half of age. The duration of the breastfeeding breaks can change depending on the number of children and it is considered as working time, thus not deducted from the salary.

Additional information was given on the network of health care centres that is being developed and empowered throughout the country, in order to provide coverage of maternal and children’s health services in the main cities as well as in the rural areas. No information was given on HIV and breastfeeding.

Concluding Observations

In its Concluding Observations, the Committee made several recommendations directly related to breastfeeding.

With regard to breastfeeding protection, the Committee urged Turkmenistan to “enact legislation implementing all the provisions of the International Code of Marketing of Breast-Milk Substitutes” (§ 49b), as well as to “ensure that working mothers have the practical possibility to breastfeed, including by developing breastfeeding-friendly workplaces and child care centres at work” (§ 49e). Concerning the promotion of breastfeeding, the Committee recommended the country to enhance its efforts to promote exclusive breastfeeding practices (§ 49a) and to raise awareness about optimal breastfeeding practices among the population (§ 49c). Finally, on data collection, the Committee urged Turkmenistan to “ensure systematic collection of data on infant and young child feeding” (§ 49d).

The Dominican Republic at the CRC: High Rate of Maternal Mortality and Low Rates of Breastfeeding

On January 12^th and 13^th, 2015, the Committee on the Rights of the Child considered the combined third to fifth periodic report of the Dominican Republic on the situation of the implementation of the Convention on the Rights of the Child in the country. The delegation of the Dominican Republic was led by Mr. Gertrudis Alberto Padilla Vicioso, responsible for the Public Policies Department of the National Council on the Child, Mrs. Brígida Sabino Pozo, responsible for the Late Registration Central Unit of the Central Electoral Board, and Mrs. Khaterine Urbáez Martínez, Minister Counselor for Human Rights to the Permanent Mission of the Dominican Republic to the United Nations Office at Geneva.

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

General overview of breastfeeding in the Dominican Republic

The Dominican Republic presents low rates of early initiation to breastfeeding (65%), exclusive breastfeeding under 6 months (6.7%) and continued breastfeeding at 2 years of age (25%). Such performance is alarming and questions the quality of the information received by mothers in health care facilities, considering that almost high rate of institutional delivery in the country 98%). It is also of concern that the use of infant formula is widespread among the population and that more than half of the newborns are fed with food other than breastmilk even before being breastfed at all.

In addition, the National Breastfeeding Commission lacks funds to implement the National Strategic Plan for Maternal and Infant Mortality Reduction and to perform its monitoring function on the application of Ley 8-95 implementing the International Code of Marketing of Breastmilk Substitutes, which leads to frequent Code violations.

Besides, only 6% of the hospitals and maternities were ever certified as “Baby-Friendly” and thre is no follow-up of the BFHI requirements in the certified facilities. IBFAN’s alternative report also stressed the lack of regular training of health professionals on HIV and infant feeding.

The scarce maternity protection at work is another factor which could explain the low breastfeeding rates in the Dominican Republic. Finally, the Guidelines for Infant Feeding in Emergencies were issued in 2010 but are not effectively implemented and, consequently, the baby-food industry keeps distributing and donating its products during emergencies.

Discussion on infant and young child feeding

The Committee specifically addressed the issue of neonatal and maternal mortality, and the low rate of exclusive breastfeeding in the Dominican Republic. It highlighted that although 80% of the maternal deaths are preventable, the rate of maternal mortality is still high, which seems difficult to understand in regard to the high percentage of institutional deliveries (97%). The Committee also expressed concerns about the low rate of exclusive breastfeeding rate under 6 months (8%) as well as about the early introduction of solid and semi-solid food which can lead to chronic malnutrition.

The Dominican delegation provided some data related to the implementation of the Strategic Plan for Maternal and Infant Mortality Reduction and mentioned the recent creation of a human milk bank as activities by the government in order to promote breastfeeding.

The Committee reminded the delegation that when given adequate pre- and perinatal support, nearly 100% of mothers can breastfeed their baby. The Committee welcomed the existence of human milk bank, but clearly stated that breastfeeding support is even more important.

The Dominican delegation pointed out that the low rate of exclusive breastfeeding is one of the main concerns of the Dominican health system and that the implementation of the Strategic Plan for Maternal and Infant Mortality Reduction will hopefully lead to its improvement as well as to the improvement of the rates of neonatal and maternal mortality. Regarding HIV and infant feeding, the head of the delegation mentioned that 95% of the children living with HIV have been infected through mother-to-child transmission and that services are being put in place in order to stop mother-to-child transmission of HIV in newborns.

Finally, the Dominican delegation expressed the commitment of the government to collect data on breastfeeding (including on the rate of exclusive breastfeeding under 6 months) in a more comprehensive way in view of the next review by the CRC Committee.

Concluding Observations

In relation with infant and young child feeding, the Committee made several indirect and direct recommendations to the Dominican Republic in its Concluding Observations.

Concerning health and health services, the Dominican Republic was asked to strengthen efforts to reduce child and maternal mortality by taking into account the OHCHR Technical guidance on child mortality(§ 50b) which includes specific recommendations on breastfeeding protection (including the implementation of the International Code) and promotion. It was also urged to establish and independent mechanism for investigating cases of child and maternal mortality and to apply legal sanctions whenever such cases are due to health personnel negligence (§ 50c), as well as to undertake all necessary measures to ensure that adequate safe water and sanitation are available, especially in hospitals (§ 50f).

Specifically referring to breastfeeding, the Committee expressed its concerns about the low rate of exclusive breastfeeding under 6 months (6.7% in 2013), the early introduction of other foods, as well as the frequent recommendations of breastmilk substitutes by the health personnel. Therefore, it urged the Dominican Republic to increase efforts to eliminate child malnutrition (§50d) and to promote breastfeeding through educational campaigns. It also requested the State party to adequately implement the Strategic Plan on Breastfeeding (2012-2016), the International Code of Marketing of Breast-Milk Substitutes and the Child-Friendly Hospital initiative [...], and to strengthen maternity protection (§ 50e).

IBFAN Statement on the occasion of the 25th Anniversary of the Convention on the Rights of the Child

On the occasion of the 25th Anniversary of the United Nations Convention on the Rights of the Child, IBFAN would like to congratulate the States parties as well as the Committee on the Rights of the Child for the work that they have achieved with the aim of realizing children’s rights at global scale. For more than 10 years now, IBFAN has been collaborating with the Committee and sending regular alternative reports and contributions on the issue of infant and young child feeding, channeling information from its global grassroots network to the international policy-making scene.

Breastfeeding constitutes one of the single most effective interventions in order to fulfill the child’s rights to life and to the enjoyment of the highest attainable standard of health. Article 24 of the Convention specifically mentions the importance of providing parents with education and support related to breastfeeding and the CRC General Comment No. 15 stresses the obligation for States to protect, promote and support breastfeeding through the implementation of the World Health Assembly Global Strategy for Infant and Young Child Feeding.

However, breastfeeding continues to face tremendous commercial pressures from the baby food industry. To date, only 37 countries have enacted a law including all the provisions of the International Code of Marketing of Breastmilk Substitutes and the enforcement of such laws is often problematic. The influence of the baby food industry on parents’ feeding choices through misleading marketing campaigns remains substantial and more than one child out of two is not exclusively breastfed until 6 months of age, despite the official recommendations of the World Health Organization.

Addressing this crucial issue, the Committee has repeatedly re-affirmed the necessity for States to promote and support breastfeeding as well as to implement and enforce the International Code and its relevant subsequent World Health Assembly resolutions. This last recommendation has also been highlighted in two General Comments issued by the Committee in 2013: the General Comment No. 15 on the right of the child to the enjoyment of the highest attainable standard of health and the General Comment No. 16 on State obligations regarding the impact of the business sector on children’s rights.

Protecting the right of every infant and young child to benefit from the most adequate food possible and creating an enabling environment for breastfeeding remain at the core of IBFAN’s engagement and we stay committed to work alongside the Committee of the Rights of the Child in the future. IBFAN will continue to provide information to the Committee and to support the effective implementation of its Concluding Observations in reviewed countries, in particular through the World Breastfeeding Trends Initiative. 

67th Session of the CRC Committee: Recommendations Related to Breastfeeding

The 67th Session of the Committee on the Rights of the Child (CRC Committee) took place in Geneva from 1st September to 19th September 2014. The Committee reviewed the progress of the implementation of the Convention on the Rights of the Child in 5 countries: Croatia, Fiji, Hungary, Morocco, and Venezuela. IBFAN submitted alternative reports on the situation of infant and young child feeding for each of the reviewed countries. The reports on Croatia and Venezuela were prepared by the IBFAN groups in those countries. 

In its Concluding Observations, the CRC Committee referred specifically to breastfeeding in 4 out of 5 countries under review (Croatia, Fiji, Hungary and Venezuela). Morocco did not receive any direct recommendation on breastfeeding, albeit it was addressed several recommendations on various topics indirectly related to breastfeeding.

General measures of implementation 

The CRC Committee called for the timely adoption of a comprehensive policy covering all areas of children’s rights under the Convention in 4 out 5 countries and for the improvement of its implementation in Morocco. 

Furthermore, it recommended that all countries under review take all necessary steps to collect disaggregated data that should cover all areas of the Convention.

Health resources and budget 

The Committee also called for the strengthening of resources allocated to health, by urging Croatia to allocate adequate human resources to maintain the quality of health care and by requesting more generally Venezuela and Morocco to allocate sufficient human, technical and financial resources to the health sector and to effectively used them.

Preventive health

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

Morocco and Venezuela were asked to reduce child and maternal mortality. Fiji was specifically requested to reduce under-5 and infant mortality rate, especially by focusing on preventive measures and treatment, including immunization, improved nutrition and sanitary conditions, in particular in remote areas as well as to further reduce maternal mortality, by ensuring the generalization of specific actions to prevent post-partum bleeding and other major causes of maternal death. 

The Committee also recommended that Fiji enforce its efforts to improve prenatal care, including by increasing the training of midwiwes. 

Children’s access to health care was also addressed by the CRC Committee, especially with regard to rural areas. Indeed, Croatia was called to strengthen its efforts to ensure that all children enjoy equal access to health services with particular emphasis on children in rural areas and from minority groups. Hungary was instead requested to take measures to ensure that health care facilities and practitioners, including paediatric and specialized care practitioners, are available throughout the country including in rural areas.

Finally, the Committee showed concern about the lack of specific data in Venezuela. Therefore, it asked Venezuela to collect disaggregated data on children’s health related issues, in particular on child mortality, including under-5 mortality, maternal mortality, vaccination coverage, nutrition and breastfeeding.

Malnutrition

The Committee asked Morocco to take more effective measures to address the nutrition status of young children, while Hungary was requested to provide access to education on nutrition as well as nutritious food to all children in the country. 

The Committee also urged Venezuela to continue its efforts to reduce malnutrition and increase vaccination coverage.

HIV/AIDS

The Committee addressed the issue of mother-to-child transmission, by requesting Venezuela to collect disaggregated data on the number of cases of mother-to-child transmissions and the number of children and pregnant women under treatment. It also urged Venezuela to address the sporadic shortages of antiretroviral drugs and ensure that all HIV/AIDS positive pregnant women receive adequate treatment.

In this regard, the Committee asked Fiji to improve follow-up treatment for HIV/AIDS-infected mothers and their infants to ensure early diagnosis and early initiation of treatment.

Breastfeeding protection 

Full implementation of the International Code on Marketing of Breast-Milk Substitutes has proven to be an effective intervention to protect breastfeeding and to ensure that mothers are provided with adequate information on the best way to feed their infants and young children.

Therefore, the Committee urged Hungary to fully implement the provisions of the International Code and recommends that Fiji as well as Venezuela ensure that every hospital with a new-born nursery is regularly monitored on adequate implementation of the International Code. The Committee specifically asked Croatia to take all necessary legislative and structural measures, including monitoring, to control the marketing of breast-milk substitutes. 

More generally, in light of the CRC General Comment No. 16 on State obligations regarding the impact of the business sector on children’s rights, Morocco was asked to examine and adapt its legislative framework concerning legal accountability of business enterprises and their subsidiaries operating in or managed from the Morocco’s territory. The Committee also requested Morocco to establish monitoring mechanisms for the investigations and redress of violations of children’s rights with a view to improving accountability and transparency. 

Breastfeeding promotion 

The Committee expressed concern over the lack of awareness of the benefits of exclusive breastfeeding and risks of formula feeding in Croatia and Fiji. It also showed concern with regard to the high number of children aged up to 6 months who are not being exclusively breastfed in Fiji and the lack of information on this rate in Hungary. Finally, it expressed concern over the low number of baby friendly hospitals in Hungary. 

Therefore, it asked Fiji to raise awareness on the importance of breastfeeding and on the risks of formula feeding. Fiji was also urged to promote proper breastfeeding practices, as well as develop a policy on infant and young child feeding practices, which includes infant feeding and HIV. 

The same kind of recommendations was addressed to Croatia and Venezuela. Croatia was indeed requested to take action to improve the practice of exclusive breastfeeding, through awareness-raising measures, the provision of information and training to relevant officials, particularly staff working in maternity units, and parents. Venezuela was instead called to increase its efforts to promote breastfeeding by developing a comprehensive programme of action to promote exclusive breastfeeding, including for staff in hospital maternity wards, and to develop awareness raising campaigns. 

Finally, the CRC Committee recommended that Hungary specifically encourage exclusive breastfeeding of infants until 6 months of age, provide data on the rate of breastfeeding as well as increase the number of baby friendly hospitals. 

Breastfeeding support 

No specific recommendation on breastfeeding support (e.g. inclusion of knowledge on optimal breastfeeding practices in health curricula) has been issued by the CRC Committee following its 67th Session.

Table 1. CRC Committee - Session 67 / 2014 - Summary of Concluding Observations on IYCF

Country		IBFAN report	Summary of specific recommendations on IYCF
1	Croatia (3rd-4th periodic report)	yes	Indirect – General measures of implementation (§ 9, 15): adoption of the new National Strategy for Protection and Promotion of the Rights of the Child from 2014-2020 and ensure that it includes concrete goals and measures with clear indication of the roles and responsibilities of relevant bodies at all levels; expeditiously improve its data collection system. Health (§45): ensure that all children enjoy equal access to health services; allocate adequate human resources to maintain the quality of health care.  Direct (§49): improve the practice of exclusive breastfeeding, through awareness-raising measures, the provision of information and training to relevant officials, particularly staff working in maternity units, and parents; take all the necessary legislative and structural measures, including monitoring, to control the marketing of breast-milk substitutes.
2	Fiji (2nd-4th periodic report)	yes	Indirect – General measures of implementation (§§ 9, 15): take all necessary steps to provide for a timely adoption of a national comprehensive policy and strategy for children; establish a comprehensive data collection system. Health (§42): reduce the under-5 and infant mortality rate, especially by focusing on preventive measures and treatment, including immunization, improved nutrition and sanitary conditions, in particular in remote areas; improve prenatal care and further reduce maternal mortality, including by increasing the training of midwives and ensuring the generalization of specific actions to prevent post-partum bleeding and other major causes of maternal death.  Direct (§54): ensure that every hospital with a new-born nursery is regularly monitored on adequate implementation of the International Code of Marketing of Breast-milk Substitutes; raise awareness on the importance of breastfeeding and on the risks of formula feeding; promote proper breastfeeding practices, as well as develop a policy on infant and young child feeding practices, which includes infant feeding and HIV.
3	Hungary (4th-5th periodic report)	yes	Indirect – General measures of implementation (§§ 8, 10): improve the collection of data; adopt a comprehensive policy covering all areas of children’s rights under the Convention and ensure that its strategies and action plans are provided with necessary human, technical and financial resources for their effective implementation; Health (§47): ensure that health care facilities and practitioners, including paediatric and specialized care practitioners, are available throughout the country; provide access to education on nutrition.  Direct (§§ 50-51): encourage exclusive breastfeeding of infants until 6 months of age and provide data on the rate of breastfeeding; increase the number of baby friendly hospitals and take measures to fully implement the provisions of the International Code of Marketing of Breast-milk Substitutes.
4	Morocco (3rd-4th periodic report)	no	Indirect – General measures of implementation (§§ 7, 13, 23(a)): address previous recommendations related to data collection; ensure that the Integrated Policy on Children encompasses child protection and covers all areas under the Convention and all children; the Committee draws the State party’s attention to its general comment No. 16 (2013) on State obligations regarding the impact of the business sector on children’s rights and especially recommends that the State party examine and adapt its legislative framework concerning legal accountability of business enterprises and their subsidiaries operating in or managed from the State party´s territory. Health (§55(a)(b)): sufficient resources must be allocated for the health sector and effectively used; develop and implement comprehensive policies and programmes for improving the health situation of children and facilitating a greater and equal access to quality primary health services by mothers and children in all areas; take more effective measures to address maternal and infant mortality and the nutritional status of young children.
5	Venezuela (3rd-5th periodic report)	yes	Indirect – General measures of implementation (§§ 11; 20): finalize the design of the National Plan of Action for Children and Adolescents; expeditiously complete and implement the data collection system. Health (§§ 53(a)(b)(c)(d); 61(a)(c)): collect disaggregated data on children’s health related issues, in particular on child mortality, including under five mortality, maternal mortality, vaccination coverage and nutrition; allocate adequate human, technical and financial resources to the national public health system; building on data related to the causes, design a strategy to reduce child and maternal mortality, which includes the implementation of the two existing protocols on maternal and neonatal mortality; reduce malnutrition; collect disaggregated data on HIV/AIDS related issues, in particular on [...] number of cases of mother-to-child transmissions, [...] and number of children and pregnant women under treatment; ensure that all HIV/AIDS positive pregnant women receive adequate treatment.  Direct (§53(a);(e)): collect disaggregated data on breastfeeding; promote breastfeeding by developing a comprehensive programme of action to promote exclusive breastfeeding, including training for staff in hospital maternity wards, closely monitor the implementation of the International Code of Marketing of Breast-milk Substitutes and develop awareness raising campaigns.