WORLD HEALTH ORGANIZATION
ORGANISATION MONDIALE DE LA SANTE
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
REGIONAL COMMITIEE Forty-eighth session Sydney 22-26 September 1997 Provisional agenda item 16
WPRlRC48/12 24 June 1997
ORIGINAL: ENGLISH
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INFANT AND YOUNG CHILD NUTRITION AND IMPLEMENTATION OF THE INTERNATIONAL CODE OF MARKETING OF BREAST-MILK SUBSTITUTES
This two-yearly progress report has been prepared in compliance with Regional Committee resolution WPRlRC36.R 15, which. infer alia, "urges Member States: (I) to intensify national efforts directed towards the improvement of infant and young child nutriticn, including the adoption of suitable measures to give effect to the International Code of Marketing of Breast-milk Substitutes; (2) to report at regular intervals on the
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progress made in their national efforts". Based on the reports received from Member States at the request of the Regional Director, this document provides a summary of the status of breast-feeding, and complementary feeding and weaning practices in countries and areas of the Region, and describes government actions taken in the implementation of the International Code of Marketing of Breast-milk Substitutes and the Baby-friendly Hospital Initiative. The Regional Committee is asked to take note of the findings of this progress report. Member States are requested to continue actions to improve infant and young child nutrition, to implement the International Code of Marketing of Breast-milk Substitutes and to support the Baby-friendly Hospital Initiative.
WPRlRC481l2 page 2
l. INTRODUCTION
This two-yearly progress report is submitted to the Regional Committee in compliance with resolution WPRJRC36.R 15. As of 6 June 1997. 29 countries and areas had returned a revised
questionnaire to the Regional Office. They reported on the following five areas: available baseline data on breast-feeding; national measures and community support for breast-feeding; activities in breast-feeding promotion and the Baby-friendly Hospital Initiative; complementary feeding; and implementation of the International Code of Marketing of Breast-milk Substitutes. The diversity of the geographical. cultural and socioeconomic conditions in the Region is retlected in the infant feed\l1g practices followed. In many cases these do not follow recommended guidelines and result in undernutrition during infants' first months. Exclusive breast-feeding. started immediately after birth and continued until the child is four to six months of age. provides infants with the necessary nutrients and protects them against infectious diseases and allergies. Breast-feeding should be continued. up to two years of age or Support from the
,/1
beyond. while appropriate and adequate complementary foods are introduced.
health care system. the workplace and the community are necessary for mothers to be able to make the right choice on infant feeding. Inappropriate weaning is acknowledged as the major cause of infant malnutrition. Complementary foods are often introduced either too early or too late, following too short a period of breast-feeding. Contaminated foods and inappropriate weaning foods add to the young child's health problems. In order to contribute to the provision of safe and adequate nutrition for infants, the World Health Assembly in 1981 adopted the International Code of Marketing of Breast-milk Substitutes. The International Code aims to protect and promote breast-feeding, and recommends further actions to ensure proper use of breast-milk substitutes when these are necessary. The Innocenti Declaration on the Protection, Promotion and Support of Breast-feeding was adopted at a WHO/UNICEF meeting in 1990 and welcomed by the World Health Assembly in resolution WHA44.33. It includes four operational targets for governments: the appointment of national breast-feeding coordinators and multisectoral national committees; making maternity \..,
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WPRlRC48112 page 3
services baby-friendly; implementation of the International Code; and enactment of legislation protecting the breast-feeding rights of women. The Baby-friendly Hospital Initiative. targeted at maternity services. is a joint
UNICEF/WHO strategy. Hospitals are awarded "baby-friendly" status if they follow the "ten steps for successful breast-feeding". The Initiative has been functioning as a mobilization programme for breast-feeding promotion. In the Region. WHO cooperates with other United Nations agencies. particularly with UNICEF. and with governments and nongovernmental organizations to promote breast-feeding and improve the health of infants and young children. Breast-feeding promotion is an important element of national plans of action for nutrition drawn up by Member States following the International Conference on Nutrition in 1992. WHO emphasizes training of health workers who provide care to mothers. infants and young children. It also provides technical guidance to country activities. Such initiatives are in harmony with the approach advocated in the regional document New horizons in
health.
2. CURRENT SITUATION
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Of the 29 countries and areas in the Region which reported data on the prevalence of breastfeeding. 15 reported that more than 90% of women start breast-feeding soon after delivery. The percentage of women starting breast-feeding soon after delivery increased in ten countries and areas, and decreased in three as compared to previous country reports. However, many mothers were still not breast-feeding exclusively or predominantly up to four to six months after giving birth, as recommended. In ten countries and areas, less than 50% of mothers who started breast-feeding after birth continued exclusive breast-feeding for four months. Altogether 16 countries and areas reported that less than 75% of women practise exclusive breast-feeding. Although proper comparison with previously reported data is difficult, it is clear that exclusive breast-feeding during the first four months of life declined in at least six countries and areas and increased in another six.
WPRlRC48/12 page 4
Data indicate that a considerable proportion of women opted for early weaning
111
eight
countries and areas. Data received on complementary foods given to infants aged six to nine months are incomplete. It is worth noting, however. that 17 countries and areas indicated that they had national recommendations on weaning. In eight countries such recommendations did not exist. The data show that weaning practices were still inappropriate or not well known in many of the countries and areas of the Region.
3. IMPROVING INFANT FEEDING
Measures to promote breast-feeding were taken in almost all countries. as recommended by the Innocenti Declaration. The promotion of breast-feeding was covered in national policies of 22
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countries and areas. National breast-feeding committees were established in 18 countries and areas. With regard to the International Code of Marketing of Breast-milk Substitutes, national legislation reflecting its aims was enacted in II countries and areas. most recently in China and the Lao People's Democratic Republic in 1995. Of the 29 countries which returned questionnaires, 22 had produced national policy documents which promoted the aims of the International Code. while in a further six countries such documents were in preparation. In New Zealand voluntary measures were in operation. Despite the increased concern of governments to adopt national measures in support of the objectives of the International Code. implementation still needs to be strengthened. Marketing of breast-milk substitutes to the general public in violation of the International Code was still common in 11 countries and areas and increases in the nlllnber of violations compared to two years ago were reported by five countries. Companies marketing and distributing breast-milk substitutes donated educational materials and equipment in ten countries and areas. With regard to article 7 of the
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International Code, which covers health workers, it was reported that, particularly in private hospitals, health workers were offered samples of breast-milk substitutes or other inducements in 11 countries and areas. Violations of this article had increased in French Polynesia, Hong Kong and Malaysia as compared to two years ago. Free and low-cost supply of breast-milk substitutes through the health care system still reached mothers in the hospitals of Guam, Hong Kong and Viet Nam.
.,
WPR/RC48/12 page 5
Implementation of national regulations through collaborative efforts involving governments, nongovernmental organizations, professional organizations and manufacturers and distributors of breast-milk substitutes were reported by seven countries and areas. Table I gives details of national measures and implementation of the different articles of the International Code. The Baby-friendly Hospital Initiative was being pursued in a growing number of countries. Action plans have been drawn up in 15 countries and areas. Minimum training on breast-feeding in the form of the WHO/UNICEF 18-hour course and/or the WHO/UNICEF 40-hour counselling course
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were initiated in 19 countries (see Table 2).
It was reported that there were 5785 baby-friendly
hospitals in 11 countries and areas of the Region. a considerable increase over the 1300 hospitals in ten countries reported in 1995. New plans were reported to expand the initiative. In the Philippines. mothers were included in a new drive to create Mother-baby Friendly Hospitals. China expanded the initiative to COUll ties
and Illunicipalities and has broadened the criteria to include assessing support
systems at the workplace and in the community. Preservice and inservice training for health workers on breast-feeding was revised in 18 countries. In seven countries the training also included doctors. Maternity leave varied from a low of zero to a high of 104 weeks for government workers. Maternity leave was treated as sick leave in a few countries. Maternity leave of at least 12 weeks was available for the female workforce in only 12 countries. Additional national measures such as the establishment of child care facilities near the workplace were reported from six countries and areas.
4, CONCLUSION
The country reports showed that the rate of breast-feeding has not improved greatly since 1995, despite more active government programmes such as the Baby-friendly Hospital Initiative. Measures such as the adoption of national guidelines and measures to promote breast-feeding have not been able to reverse this trend. All health workers working with mothers and children need to be better motivated and trained. They should be provided with sufficient information and skills to
WPRlRC481l2 page 6
support mothers not only in hospitals, but also through community health services. Emphasis should not only be placed on breast-feeding for four to six months after birth, but also on a proper weaning period. with the cOlltinuation of breast-feeding for up to two years of age or beyond while appropriate and adequate complementary foods are introducec. It is hoped that governments will take an active role to ensure that national regulations for the sale of breast-milk substitutes are in place and strictly implemented. This will necessitate increased resource mobilization if such measures are to be In addition, measures to grant
monitored. Collaboration with all parties concerned is essential.
working women at least 12 weeks maternity leave and to encourage additional measures to facilitate breast-feeding at the workplace need to be developed.
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WPRlRC48/12 page 7
Table I. Implementation of the International Code of Marketing of Breast-milk Substitutes in selected countries and areas of the Western Pacific Region Country/area American Samoa Australia Cambodia China Cook Islands Fiji French Polynesia Guam Hong Kong japan Kiribati Lao P.D.R. Malaysia Mariana Islands Marshall Islands. Micronesia F.S. Mongolia New Zealand Niue Palau Papua New Guinea Philippines Republic of Korea Samoa Singapore Solomon Islands Tonga Vanuatu Viet Nam Article 2 Article 4 Article 5 Article 6 Article 7 Article 9 Article II National measures covering the scope of the Code Legislation In preparation Legislation National measures Awaiting legislation Legislation Partial law National hreast-feeding policy Decision Legislation Awaiting legislation National poitey in preparation Voluntary National policy in preparation Awaiting legislation Legislation Legislation Partial law Legislation National hrea,t-fceding policy National measures
2 ...
4 +++ ++ +++ ++ ++ ++ ++ + ++ + +++ ++ +++ ++ +++ +++ + ++ +++ + ++
+++ ... +++ + +++ +++ + ++ +++ +++ + +++ +++ +++ +++ +++ +++
5 +++ + ... ++ + ++ +++ + +++ +++ +++ ++ +++ + ...
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+++ + +++ +++ + +
+++ +++ ++ +++
Legislation
+ ++ +++ ++ ++ +
... + +++ +++ + +++ +
Article 6 ++ ++ ... ++ ++ ++ ++ + ... + + + ++ + + ++ + +++ ++ +++ ++ +++ ... ++ + ++ + ++ +
7 ++ +++ ... ++ ++ + + + + +++ ++ ++ + + +++ + + +++ ++ ++ + +++ ... + +++ ++ + +++ +
9 + +++ ...
II + +++ ... + ++ +++ ++ +++ + ...
++ ++ +++ +++ ++ +++ ++ ...
++ +++ +++ ...
+.. +++
+ ... ++ + +++ + + ... ...
+++ + +++ +++ + ++ +++ ... + +++ ... + + +
... ++ +++ + + ...
+
Scope of the Code Infomlation and education The general public and mothers Health care systems Health workers Labelling Implementation and monitoring
+
++ +++ Note:
minor or no implementation Partial implementation Full implementation Data collected from ofticial government reports and other publications. No Code implementation (or no data available) in countries not included in the table.
WPRlRC481l2 page 8
"
Table 2. National measures to meet the Innocenti Declaration targets and the implementation status of the Baby-friendly Hospital Initiative in selected countries and areas of the Western Pacific Region Maternily l'OlJritry!areu
NallOnal breast·fecding committee -
National hreasHceding policy
leave at \cast 12 wceks
Bahy·lhendly I""pital initiali\"c actiun plan + t
Minimum ,") breasl·feeding training provided 10 health workers -
Baby·friendly hospitals ("')I largeled hospilals 01 () 1/30 II ... ( I ) 4740/7800 01 I 21 10 (4) 0/0 01 I ...
Public health education programme
American Samoa Australia Camhodia China Cook Islands Fiji French Polynesia l,uam llong Kong Japan Kiribati Lao I'.D.R. \1aJaysia Mariana Islands Mar>hall Islands 1'.licroncsia. F.S. ~\'tongolia
-I') -I') +
+
+ + +
+
+
+ + -
+ -
+ + +
+ -.
+ -
+ -
-.
+
-
+ -
+ + + +
+ -
+ + + +
+
+
+ + -
-
+
0 01 I (I)
+ + +
+
-
+ t
+ +
+ + + -
Ncw Cakdonia New Zealand Niul! Palau Papua New Guinea Philippines
+ + + t
"
+
+ + + +
+ +
+ + -
2/8(14) 32i 118 (10) 01 I 0/2 0/4(4) 59/ 250
+ + +
+ + t
+
+
-
0/0
... + + +
-
--(')
• +
+ -. t
+ + +
+ +
+ t t -
+
.
-
Samoa Singapore Solomon Islands Tonga Vanuatu
+ +
+ +
+ .-
+ -
+
_.
+ +
Viet Nam
•
+ +
+ + + + + -
+
II I 0/ I 4/19 920/1748 0/0 011 017 0/4 0/2 23/ ... (30)
+ + + -
+
+ + +
-
(') Breast-feeding covered hy other national policies andlor guidelines. (") WHOIUNICEF IS-hour hreasl-tCeding management course andlor WIIO/UNICEF 40-hour breast·feeding counselling: a training
course. ("') The numbers in brackets sho" Ihe hospitals" hich have recci"cd a certificate of commilmenl. + ytS
no no dala