United Nations System
Standing Committee on Nutrition

Report of the Meeting of the Working Group on Breastfeeding and Complementary Feeding

Saturday 11 April 1999 (7:00 – 10:30 p.m.) UNHCHR, Geneva
Chair: Lida Lhotska, UNICEF
Rapporteur: Felicity Savage, WHO

1. A rights based approach to infant feeding and care

David Clark of UNICEF explained how a rights-based approach to programming differs from a needs-based approach, focusing on basic principles of universally recognised human rights. Although many rights are needs based, a rights based approach means that the needs of every single woman and child must be fulfilled. Programmes which set targets aiming to reach only a certain percentage of the population are no longer acceptable. A rights-based approach provides three additional considerations:

• The notion of legal and moral obligation and accountability of the State
• The affirmation that women and children are rights holders
• The principle that benevolent and charitable actions are insufficient

Women’s and children’s rights are human rights, and the CRC and CEDAW did not invent any special rights for them. These instruments recognise that women and children have special needs that must be met in order to protect, respect, facilitate and fulfill their basic human rights.

The Universal Declaration of Human Rights, the International Covenant of Civil and Political Rights, and the CRC all recognise the right to life and the right to health. Member states are under an obligation to ensure the survival and development of the child, including the right to the highest attainable standard of health. The CRC specifically recognises breastfeeding as a component in assuring the child’s enjoyment of those rights, and governments can be reminded of their obligations to take appropriate measures, such as implementation of the International Code of Marketing of Breast-milk Substitutes, the BFHI, and the enactment of imaginative maternity legislation.

Marcus Stahlhofer, WHO, explained that the Department of Child and Adolescent Health and Development (CAH) is exploring ways to bring a rights approach to its work. While the emphasis in the past has been on the protection of the older child, little attention has been paid to the health of young children. CAH is trying to redress this imbalance by having health issues included in the reporting process of the CRC, and by acting as a channel for high level advocacy for improved child health programmes, and to assist countries by following up on recommendations of the CRC and providing practical assistance for implementation.

Discussion focussed on whether there was an incompatibility between the rights of women to choose whether or not to breastfeed, and of the child to be breastfed. It was noted that the CRC places an obligation on governments to create an environment that is supportive to breastfeeding, and to enable women to make a fully informed decision. It was also noted that the issue of whether or not a child has the right to breastfeed still presents difficulties.

Recommendation:

All implementing agencies should adopt a rights based approach to all their infant feeding programmes.

2. Updates on 1998 Working Group Recommendations.

Maternity Legislation

Ted Greiner, Sida, warned the group that the recently published report on maternity protection published by the ILO as a step towards the re-negotiation of the 1952 Maternity Protection Convention, indicated that there could be a reduction in levels of protection for working mothers. The report is based on responses to a questionnaire sent to all Ministries of Labour, employers and Trade Unions. The questionnaire revealed that ILO’s primary concern is with employment issues, not with health issues. By placing the question on nursing breaks in the section of the questionnaire dealing with non-mandatory recommendations, rather than in the section on issues to be dealt with under the revised convention, the ILO secretariat has effectively removed nursing breaks from the draft revised convention. It is likely that the respondents were unaware of this change, and its significance, and it is clear that the health and developmental implications of making it difficult for women to breastfeed optimally had not been taken into account. There is no proposed increase in the length of maternity leave (12 weeks in the convention, and 14 under the recommendation) and it is proposed to remove any compulsory element, meaning that women could be put under pressure to "voluntarily" relinquish their maternity entitlement and return to work early.

The human rights implications of creating obstacles to working mothers’ ability to breastfeed their infants and separating mother and child at too early an age cannot be overlooked, and must be communicate to the ILO and the tripartite delegations to the upcoming International Labour Conference.

Recommendation:

The Working Group requests the SCN Secretariat to utilise its good offices to approach the new Director General of ILO and express concern over the process towards the re-negotiation of the Maternity Protection Convention. In particular, the question should be raised as to whether the rights of working mothers and the importance of exclusive breastfeeding in assuring the child’s right to the highest attainable standard of health have been duly considered by the ILO Secretariat in the drafting of the questionnaire and subsequent report to be considered by the International Labour Conference.

The Care Approach – Early Childhood Care for Survival, Growth and Development (ECC/SGD)

Lida Lhotska, UNICEF, explained that building upon the Care for Nutrition approach, UNICEF is now moving towards a broader strategy: Early Childhood Care for Survival, Growth and Development (ECC/SGD). The strategy focuses on the antenatal period and the 0-8 year age group, with a special emphasis on 0-3 years. ECC/SGD addresses the need to move away from vertical programming, and has three main components: nutrition, health and psycho-social and cognitive development. The area of care for nutrition has been well developed and its six key elements, care for women, breastfeeding and complementary feeding, psycho-social stimulation food preparation, hygiene and home health care practices, are increasingly recognised. In the health area, the Integrated Management of Childhood Illness (IMCI) initiative has been seen as an important building block in developing community-based approaches to young child health needs. The least developed is the psycho-social component, and consensus on a number of issues in this area needs to be sought urgently. However, current knowledge is sufficient to launch this integrated rights-based approach. UNICEF is working intensively with a number of countries that are interested in integrated programming. A training manual on ECC/SGD is being developed and will be field-tested in a six-country workshop in the Eastern and Southern Africa Region in June 1999.

In the following discussion, the need to refine indicators that could be used for situation analysis and monitoring was emphasised.

Recommendation:

An intersectoral rights-based approach to child survival growth and development should be adopted by all implementing bodies.

Complementary feeding

Graeme Clugston, WHO, presented the state-of-the-art review of Complementary Feeding in Developing Countries (exact title) developed collaboratively by WHO, UNICEF, UC Davis and ORSTOM. He mentioned that work is being done with the London School of Hygiene to translate the conclusions of the review into guidelines for health workers.

There was discussion of the possible usefulness of commercially processed complementary foods, including those that are locally developed and manufactured. It was mentioned that experience using such foods in emergency situations should be utilised, especially in view of the HIV situation. However, in non-emergency situations, the cost of processed foods often makes them unobtainable by those who are most in need of them, and they do not necessarily help to solve the problem of malnutrition.

Felicity Savage, WHO, presented recent experience of training health workers to counsel mothers on complementary feeding as part of the IMCI initiative. A randomised controlled study implemented in the urban areas of Pelotas, Brazil, has shown significant differences in the weight-for-age of children treated by IMCI trained health workers compared to untrained health workers. Implementation of the Breastfeeding Counselling (BFC) training course, which has now been introduced into 46 countries, was briefly reviewed. An additional module on complementary feeding is being developed, following the successful model of the nutrition component of the IMCI course.

Discussion centred on the question: why is there not a larger number of countries implementing the BFC course particularly in the Eastern and Southern African Region? There is a need to expand this training rapidly, since now there are so many threats to breastfeeding. The difference between this course, with its special emphasis on development of clinical and counselling skills, and other lactation management training courses was explained.

Wilma Freire, PAHO, and Mary Ruel informed the group of the recent interagency meeting in Washington organised by PAHO and several international organisations (USAID, UNICEF, Linkages, IFPRI, INCAP among others) on processed complementary foods in Latin America. Representatives from several countries presented information on national experiences with the use of processed complementary foods, especially in urban areas.

Aileen Robertson, WHO/EURO, provided information on the development of a policy on complementary feeding in the European Region. This had become an imperative, as new initiatives could result in reinforcement of existing poor practices if up-to-date recommendations and guidelines are not introduced. Therefore WHO/EURO has developed such recommendations now available in draft and welcomes comments on them.

Recommendations:

The Breastfeeding Counselling training course and its complementary feeding component needs to be more widely implemented, particularly in countries affected by the HIV epidemic to counter the tendency to abandon breastfeeding protection, promotion and support.

International Code of Marketing of Breast-milk Substitutes

David Clark UNICEF reported that compared with 11 countries that fully implemented the Code in 1994, there are now 20 countries with strong legislation that regulates promotion of breast-milk substitutes, bottles and teats. Despite this progress, it was recognised that in the presence of HIV, Code implementation has to be strengthened to prevent abandonment of efforts to control the promotion of products that compete with breastfeeding. Code implementation is more important than ever, when the use of breast-milk substitutes is being considered for interventions to reduce mother-to-child transmission (MTCT) of HIV.

Recommendation:

In the context of MTCT of HIV, global implementation of the International Code of Marketing of Breast-milk Substitutes and subsequent relevant WHA resolutions needs to be accelerated and strengthened.

Baby Friendly Hospital Initiative

Lida Lhotska, UNICEF, reported that there are now 14,546 hospitals that achieved baby friendly status. She introduced a new UNICEF publication of six country case studies that illustrates the impact of the initiative on children’s and mothers health, and demonstrates the cost saving effect of the intervention. She also emphasised the need to strengthen BFHI implementation in the context of HIV, since the initiative creates a supportive environment for both breastfeeding and artificially feeding mothers.

Recommendation:

Implementation of BFHI needs to continue and be strengthened.

Economic value of breastfeeding

Jay Ross of Linkages reported that the model for assessing the economic value of breastfeeding which he presented to the Working Group in 1998 had been used in Bolivia, El Salvador, Ghana, Mali, showing significant potential savings as a percentage of GNP. This information is used to help launch breastfeeding campaigns in those countries. Country applications are being planned for other countries – Benin and Madagascar. Regional training workshops are planned for the Greater Horn of Africa, and the Eastern, Central and southern Africa region. A regional training workshop was held in West Africa in December for 9 Francophone W. African countries.

Recommendation:

The Benefits of Breastfeeding Model for assessing the economic value of breastfeeding (BOB) should be used more widely to advocate for the introduction and strengthening of breastfeeding policies and programmes.

HIV and infant feeding

Felicity Savage, WHO, reported on the field test of a course on HIV and Infant Feeding Counselling, prepared collaboratively by WHO, UNICEF with support from UNAIDS, following a recommendation of the Technical Consultation on HIV and Infant Feeding held in April 1998. The field test was held in Zimbabwe, March 1999, and will be introduced initially as part of the Prevention of Mother to Child Transmission (PMTCT) pilot projects. The course takes three days and is designed to be used following the Breastfeeding Counselling training, using the same format. Trainers for the BFC course are particularly well suited to implement the HIV and infant feeding counselling course. It is expected that the revised version of the training materials will become available in the third quarter of 1999, and it is proposed to introduce the course in the Eastern and Southern African Region, involving participants from all PMTCT pilot countries. Meantime countries that wish to use the training need to be urged to strengthen the BFHI, Code implementation and breastfeeding counselling training, to ensure that suitable trainers will be available.

Lida Lhotska, UNICEF, provided additional information about UNICEF’s efforts to secure generic infant formula as well as a micronutrient mix to be used with home prepared formula, for pilot site countries. She said that UNICEF is funding a study that looks at how to make expressed breast-milk from HIV positive mothers safer. She emphasized the need for operational research to test the feasibility of all proposed alternative feeding options; also, if a proposed intervention is potentially harmful, rigorous monitoring will be imperative.

Discussion focused on growing concerns that some governments are questioning the continued relevance of the International Code, particularly to the extent that it prohibits the donation of free and low cost supplies of infant formula to the health care system. It was explained that the prohibition remains an important one to prevent spillover, but that alternative means of distribution were permitted by the Code, such as through pharmacies on prescription. A clear distinction was made between provision of supplies to an institution or facility and giving formula free of charge to mothers.

Recommendations

• UNICEF should prepare a briefing note explaining the continued relevance of the Code in the context of prevention of mother-to-child transmission (MTCT) of HIV, explaining particularly the provisions concerning free and low cost supplies.

• Additional research is needed on the relative safety of exclusive breastfeeding.

• More research is urgently needed into the effects of the alternative feeding options proposed in connection with MTCT of HIV on children’s health and family wellbeing; and on how mothers cope in practice with using various feeding options.

• In all PMTCT initiatives, infant feeding practices and their effects on children’s health need to be more closely monitored.