Colombia at the CRC: Concerns about Declining Breastfeeding Rates and Lack of Breastfeeding Promotion

On January 20^th and 21^st, 2015, the Committee on the Rights of the Child considered the combined fourth and fifth periodic reports of Colombia on the situation of the implementation of the Convention on the Rights of the Child in the country. The Colombian delegation was led by Mrs. Cristina Plazas Michelsen Costa, Director of the Colombian Institute of Family Wellbeing.

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

General overview of breastfeeding in Colombia

The report highlighted that despite a high rate of institutional delivery (95%), the rate of early initiation to breastfeeding is low (57%) and has recently declined, which indicates that health professionals are not enabled to ensure optimal breastfeeding practices within hospitals. Besides, the rate of exclusive breastfeeding under 6 months has decreased since 2004 and currently, almost 6 children out of 10 are not exclusively breastfed until 6 months of age. The Colombian National Demographic and Health Survey 2010 has also shown that on average, babies are given other liquids than breastmilk at 2.7 months and that the practice of bottle feeding, which is common during the first year of life, has increased in the last decade. This situation is closely connected with the lack of promotion strategy on optimal breastfeeding practices and aimed at mothers, caregivers and community through media.

Regarding protection of breastfeeding, IBFAN noted that the International Code of Marketing of Breastmilk Substitutes and its subsequent relevant World Health Assembly resolutions are still not fully implemented into legislation and that violations of the Code, including donations of infant formula to health institutions and delivering of gifts to mothers through health workers, are common.

The report also flagged the very low rate of implementation of the Baby-friendly Hospital Initiative in the country. The latest statistic, dating back to 2009, shows that only 0.06% of the total number of health facilities of the country are certified as “baby-friendly”. In addition, there is no monitoring of this accreditation process at the country level.

Finally, IBFAN expressed concern about the lack of maternity protection for women working in the informal sector as well as the lack of any national plan to ensure protection and support of breastfeeding in case of emergencies.

Discussion on infant and young child feeding

During its discussion with Colombia, the CRC Committee addressed specifically the issue of breastfeeding. It mentioned the low breastfeeding rates and noted with particular concern the decline of the rate of exclusive breastfeeding under 6 months. It asked which efforts have been made to ensure that health professionals are properly trained on optimal breastfeeding practices and that mothers are aware of the importance of breastfeeding their child.                                                                                                               

The Colombian delegation answered that the decline of the rate of exclusive breastfeeding is a concern for the government and states the importance of taking action on this regard. It noted that a national breastfeeding plan is in place and that breastfeeding is closely connected with the employment condition of mothers. As part of the gender equality governmental project, the length of the maternity leave has recently been increased to 14 weeks, and the legislation also entitles working fathers to 1 week of paternal leave. In addition, the delegation added that some 17 human milk banks have been implemented throughout the territory in order to make it easier for every child to have access to breastmilk, and that breastfeeding-friendly rooms have been settled in employment areas in order to support working mothers to breastfeed. Finally, regarding the specific problem of teenage pregnancies, the delegation assured the Committee that special facilities have been put in place to ensure that young mothers are able to continue to go to school while breastfeeding their child.

Concluding Observations

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

Regarding health and health services, the Committee recommended Colombia to “ensure the availability and accessibility of health services for all children […] by allocating adequate resources and monitoring the implementation of relevant policies” (§ 40a). In particular, the Committee highlighted the child and maternal mortality rates which continue to be very high (§ 39f), and thus recommended the State party to “increase its efforts to reduce maternal and child mortality, including by implementing the OHCHR Technical guidance on child mortality” (§ 40c) which includes specific recommendations on breastfeeding protection (including the implementation of the International Code) and promotion. It is to be noted that this technical guidance includes specific recommendations on breastfeeding protection (including the implementation of the International Code) and promotion

Referring specifically to breastfeeding, the CRC Committee expressed its concerns on the decline of exclusive maternal breastfeeding in 2010 and on the persistence of inadequate baby feeding practices. It recommended Colombia to “strengthen efforts to promote breastfeeding through educational campaigns and training to professionals, adequately implement the International Code of Marketing of Breast-Milk Substitutes and the Child-Friendly Hospital initiative [sic]” (§ 40h).

Uruguay at the CRC: Lack of Monitoring of the Legislation Implementing the Code

On January 19th and 20th, 2015, the Committee on the Rights of the Child considered the combined third to fifth periodic report of Uruguay on the situation of the implementation of the Convention on the Rights of the Child in the country. The Uruguayan delegation was led by Mrs. Alejandra Costa, Director for Human Rights and Humanitarian Law at the Ministry of Foreign Affairs.

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

General overview of breastfeeding in Uruguay

The report outlined that although the rate of exclusive breastfeeding under 6 months is high (65%), some 4 children out of 10 are not breastfed within an hour after birth, which questions the quality of the counselling and support received by mothers in maternities. Besides, more than 7 children out of 10 are not breastfed until the age of 2 years, despite the recommendations of the World Health Organization.

Regarding protection and support of breastfeeding, IBFAN noted that the National Breastfeeding Standard (NNLM) is not fully implemented as many health workers are not trained on its content, including on the InternationalCode on Marketing of Breastmilk Substitutes and the guidelines “Buenas Practicas de Alimentacion del lactante y del nino pequeño”. In addition, there is no monitoring mechanism of the legislation implementing the International Code.

The IBFAN report also highlighted that in 2009-2010, only 35% of the maternities of the country were certified as “baby-friendly” and that the Human Milk Bank receives in-kind donations from Nestlé, which can lead to situations of conflict of interest.

Finally, the report noted that the maternity leave does not allow mothers to breastfeed exclusively for 6 months, and that mothers working in the informal sector are not covered. There are no training courses on HIV and infant feeding for health professionals and there is no national plan to protect and support breastfeeding in case of emergencies.

Discussion on infant and young child feeding

Questioned on the issue of maternal mortality, the Uruguayan delegation responded that measures are taken to ensure that all pregnant women have access to health and that early checkups are carried out. Majority of deliveries occur in institutions and the government has taken action to prevent avoidable maternal deaths within the current national action plan. The next action plan should also cover the issue of nutrition of pregnant women, which is not included in the current action plan.

On the issue of breastfeeding, the Committee first congratulated Uruguay for the implementation of the International Code of Marketing of Breastmilk Substitutes. However, it noted that the International Code is not yet fully implemented and that no monitoring mechanism is in place. It also asked for more information on the training of health professionals regarding optimal breastfeeding practices. It expressed concern about Nestlé’s donations received by Human Milk Bank and deplored the fact that only 35% of the maternities of the country are complying with the requirements of the Baby-friendly Hospital Initiative. Finally, the Committee regretted that women working in the informal sector are not allowed to maternity leave benefits and it stressed the need for Uruguay to adopt a plan to protect and support breastfeeding in case of emergencies.

The Uruguayan delegation answered that the maternity leave has been recently extended to 14 weeks and that after the third month of leave, parents can decide whether the father will take up the leave. However, the delegation admitted that informal workers are not allowed to these benefits. Regarding monitoring of the legislation implementing the International Code, the delegation explained that the government is currently working with UNICEF to develop such a monitoring mechanism. In regard to the implementation, the delegation noted that an initiative called “Good eating habits during breastfeeding” has been developed, as well as a strategy, and stressed the fact that breastfeeding rates have been improved (from 20% in the 1990s to 65% today). 

After follow-up questions from the Committee, the delegation again stressed that monitoring of the legislation implementing the Code is the main challenge for the government regarding breastfeeding. The delegation also admitted that the Human Milk Bank, which is under supervision of the Ministry of Health, has received glass jars to store the breastmilk from Nestlé and that these jars, which cannot be bought on the national market, are free from any advertisement. No funds from the industry are accepted. The delegation added that Uruguay has developed a joint network of human milk banks with Brazil in order to ensure that all children, especially underweight children, have access to breastmilk.

Concluding Observations

In its Concluding Observations, the Committee made recommendations indirectly related to infant and young child feeding, however it did not refer specifically to breastfeeding. Regarding health and health services, the Committee urged Uruguay to “strengthen its efforts to ensure access to quality health services by all children, particularly children living in the most disadvantaged and remote areas of the country”, as well as to “develop policies and programmes to address chronic malnutrition and anaemia” (§ 46).

Jamaica at the CRC: Low Breastfeeding Records and Insufficient Maternity Leave

On January 19^th and 20^th, 2015, the Committee on the Rights of the Child considered the combined Third and Fourth Periodic Report of Jamaica on the situation of the implementation of the Convention on the Rights of the Child in the country. The delegation of Jamaica was led by M.P. Honorable Lisa Hanna, Minister of Youth and Culture.

 

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

General overview of breastfeeding in Jamaica

Despite the high rate of skilled attendance at birth (98.3%) and institutional delivery (97.1%), optimal breastfeeding practices are still not widespread in Jamaica. This is confirmed by the low rates of early initiation of breastfeeding (62.3%), exclusive breastfeeding under 6 months (23.8%) and continued breastfeeding ate at 2 years of age (31.2%). These figures show a lack of knowledge on the importance of the early initiation of breastfeeding among the health care workers assisting deliveries and, at the same time, constitute an evidence of non-compliance with the step 4 of the Baby-Friendly Hospital Initiative (BFHI). Another alarming fact relates to the median duration of exclusive breastfeeding, which is only three weeks for the average Jamaican mother.

The draft National Infant and Young Child Policy, revised in 2014, states important goals related to supporting breastfeeding in communities and the workplace, spreading the BFHI in all institutions, improving the data collection system, building capacity within all relevant agencies and at different levels of the health system, among others. However, to date, this draft has not yet been accepted and thus, the activities carried out by the National Infant and Young Child Feeding Committee remain unclear. Breastfeeding and HIV-related strategies are mentioned in the draft Policy, and thus, have not been endorsed yet. The same applies to infant and child feeding in emergencies, which has been addressed in the draft Policy in the form of specific provisions, but there is no information available on its concrete application.

Regarding protection of breastfeeding, only voluntary measures are in place to implement the International Code of Marketing of Breastmilk Substitutes and there is no enforcement mechanism. 

The Jamaican legislation does not provide for an adequate duration of maternity leave (12 weeks) and for proper relevant benefit coverage (only 8 weeks). Furthermore, employers are not required to provide breaks for nursing mothers and fathers are not entitled to any paternity leave.

Discussion on infant and young child feeding

The CRC Committee addressed specifically the issue of breastfeeding in Jamaica, asking the reasons behind such low breastfeeding rates in the country, despite the tremendous positive developments Jamaica has presented in many other areas of the Convention. It was also asked whether there could be a link between the low breastfeeding indicators and the fact that the legislation does not provide for employers to allow breastfeeding breaks to nursing mothers. The delegation replied mentioning that Jamaica was one of the first countries in the world to adopt in the 1970s an act on the maternity leave which gives women the right to a paid 3-month leave. The delegation also highlighted that Jamaica has a matriarchal society for which many mothers are working and that they do breastfeed their children up to 6 months of age. Pointing out that breastfeeding is encouraged in hospitals, the Head of Delegation described the personal experience of going to the hospital to deliver her baby and being told not to bring any bottles because that was a breastfeeding-policy hospital. 

The CRC Committee commented that, however, it is important to provide that the maternity leave is long enough and guarantees that mothers can breastfeed their children up to 6 months exclusively, reminding that this is also a very strong WHO recommendation. Maternity leave becomes thus an essential point when discussing measures aimed at encouraging women to breastfeed their children, if not up to 2 years, up to 6 months at least. The Committee then added that the positive outcomes of breastfeeding are seen later, in the better health status of children and, but not only, in the emotional bonding, which is also essential.

Concluding Observations

The Committee issued both indirect and direct recommendations related to infant and young child feeding to Jamaica (see the Concluding Observations).

After commending the State party for the decrease in infant mortality rates, the Committee expressed concerns over the “perinatal mortality levels, the increase in maternal mortality, the persistent levels of undernourishment among the poorest children, the general shortage of health care providers and access by children to quality health care, the low levels of breastfeeding and the high rate of children classified as overweight and obese” (§ 44).

Therefore, the Committee recommended Jamaica to ensure adequate provision of prenatal and post natal care, as well as to address the increase in maternal mortality (§ 45a) and to increase the number and coverage of health care professionals for an improved children’s access to health care services (§ 45c). Regarding nutrition, the Committee urged Jamaica to “introduce targeted action to prevent the undernourishment of children, including the promotion of proper infant and young child feeding practices” (§ 45b). On children obesity in particular, the Committee recommended to intensify measures to raise awareness of healthy nutrition among parents, children and the public in general, and to promote healthy eating habits (§ 45f).

With regard to breastfeeding, the Committee specifically recommended Jamaica to “take action to improve the practice of exclusive breastfeeding for the first six months, through awareness-raising measures, including campaigns, providing information and training to relevant officials, particularly staff working in maternity units, and parents” (§ 45d). Finally, the Committee recommended the State party to regulate the marketing of breastmilk substitutes (§ 45e).

Tanzania at the CRC: Suboptimal Breastfeeding Practices and Low Rate of Institutional Delivery

On January 15^th and 16^th, 2015, the Committee on the Rights of the Child considered the combined third to fifth periodic reports of the United Republic of Tanzania on the situation of the implementation of the Convention on the Rights of the Child in the country. The Tanzanian delegation was led by Mrs. Sophia Simba, Minister for Community Development, Gender and Children.

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

General overview of breastfeeding in the United Republic of Tanzania

In Tanzania, high rates of neonatal, infant, under-5 and maternal mortality coexist with a low rate of skilled attendant at birth (49%). Suboptimal breastfeeding practices are widespread: some 1 child out of 2 is neither breastfed during the first hour after delivery nor exclusively breastfed until 6 months of age. In addition, early introduction of complementary food is a recurring problem and vast majority of babies under 3 months old are fed with water, juice, porridge or other foods, increasing the risk of infections and malnutrition. There is also a cultural belief that the colostrums is dirty and should be discarded.

Although the 1992 Food and Nutrition Policy pointing out the high rate of malnutrition among children linked with inadequate breastfeeding and weaning is still in place, as well as the National Nutrition Strategy 2011/12-2015/16 and the 2004 National Strategy on Infant and Young Child Nutrition, several problems persist in the country regarding promotion and support of breastfeeding. First, information on the activities undertaken to promote breastfeeding is lacking, as well as information on specific trainings or courses on optimal breastfeeding practices aimed at health professionals. The High Level Steering Committee on Nutrition, created in 2011, in charge to coordinate multi-sectorial interventions to reduce child malnutrition and promote optimal breastfeeding. However, it has only a coordinating role and does not carry out any monitoring activity. Finally, there is no information on the existence of a specific National Breastfeeding Committee or Coordinator.

Regarding protection of breastfeeding, in 1994, Tanzania has adopted a National Regulation for Marketing of Breastmilk Substitutes and Designated Products. However, its revision has not been endorsed yet and there is very poor awareness of its content at all levels and in most sectors.

In addition, in 2010, only 37% of the hospitals in the country were certified as “baby-friendly" and maternity leave is only available every 3 years and does not cover women in the informal sector. Even though 9 women out of 10 know that HIV can be transmitted through breastfeeding, the estimated rate of mother-to-child transmission in 2013 was 15.8%. Last but not least, the country does not have any plan to protect and support breastfeeding in case of emergencies.

Discussion on infant and young child feeding

The CRC Committee first noted that in the last years, the overall budget allocated to health has decreased and that the country shows high rates of maternal, neonatal and infant mortality. It asked the delegation if there is any initiative or measure in place to address the issue of the very high maternal mortality, which has a direct impact on child survival. 

The Committee also raised specific questions on breastfeeding. It asked for further clarifications on the activities to promote breastfeeding in relation with the National Breastfeeding Week. Regarding the High Level Steering Committee on Nutrition, it asked which is its role regarding breastfeeding promotion in the country, especially within hospitals facilities.

The Tanzanian delegation answered that during the National Breastfeeding Week, awareness-raising activities such as seminars, distribution of ICT materials, workshops on importance of breastfeeding, trainers’ training on breastfeeding and HIV, information on the International Code and on optimal breastfeeding practices have been organized and a promotional campaign on exclusive breastfeeding until 6 months of age has been launched. The delegation added that the High Level Steering Committee on Nutrition is in charge to ensure that proper resources are allocated to provide good nutrition to the population including through fortification of oil, wheat and maize.

The Committee expressed further concern about the very low rate of institutional delivery and asked how, in this conditions, does the government ensure that all mothers have access to correct information about the best way to feed their child. Besides, it emphasized that almost half of the mothers do not breastfeed until 6 months and asked what measures are taken to tackle this issue. It also asked what kind of regulations of the marketing of breastmilk substitutes are in place in order to allow mothers to make the correct information, and noted that guaranteeing that mothers are enable to optimally  breastfeed leads to huge public savings and places children in the best situation to start their life.

In a follow-up question, the Committee noted that the rate of early initiation of breastfeeding is very low in the country and emphasized its crucial importance for the baby’s as well as for the mother’s health. The Committee also asked if there is any programme to help mothers in terms of lactation, noting that the rate of continued breastfeeding until 2 years is particularly low. Regarding breastfeeding protection, supposedly ensured by the implementation of the Baby-friendly Hospital Initiative, it asked if there is any regulation regarding baby foods advertisements in hospitals. On the access to emergency obstetric care, the Committee asked what is the coverage of skilled attendants at birth and if there are trainings for traditional birth attendants. Regarding the large number of young mothers, it asked if there are any family planning services in the country.

The delegation highlighted the importance of breastfeeding in the first months of life for the healthy development of brain. It explained that breastfeeding importance is raised in one of the guidelines on IMCI (Integrated Management of Child Illnesses) and also through parenting education. Promotion of breastfeeding is also done through dissemination of ICT materials in health centers, hospitals and schools. The delegation further noted that the Tanzania Food and Drugs Authority has implemented regulations on the marketing of breastmilk substitutes and is providing information through national media on the best use of breastfeeding instead of formula feeding. Besides, the Tanzania Bureau of Standards is in charge of controlling the food standards and making screens.

Concluding Observations

In its Concluding Observations, the Committee issued recommendations indirectly related to infant and young child feeding. With regard to health and health services, the Committee stated its concerns over the persistent high maternal mortality and morbidity rates, the limited access to health care services to children poverty and remote and rural areas, and the prevalence of chronic malnutrition, leading to stunting and the limited access to safe drinking water and sanitation (§ 53).

Therefore, the Committee urged Tanzania to allocate sufficient financial and human resources to health services, particularly mentioning the trained care at delivery as well as improved care for new-borns and during the neonatal period, antenatal care and services for infants and preschool children at primary health centres (§ 54a). It also requested Tanzania to “establish more child and maternal health clinics and access to safe and trained delivery [...]” (§ 54b).

Specifically addressing the issue of children nutrition, the Committee recommended Tanzania to “strengthen national strategies to address the critical nutritional needs of children, particularly among the most vulnerable groups, through targeted interventions” and to “improve access to safe drinking water and adequate sanitation facilities and ensure sustainability, availability, sufficiency and affordability to all, particularly children” (§ 53c-d).

Finally, the Committee urged the country to implement the OHCHR Technical guidance child mortality (A/HRC/27/31) (§ 54 e) which includes specific recommendations on breastfeeding protection (including the implementation of the International Code) and promotion.

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

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

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

General overview of breastfeeding in the Gambia

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

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

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

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

Discussion on infant and young child feeding

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

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

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

Concluding Observations

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

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

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