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).

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).