WORLD HEALTH ORGANIZATION
REGIONAL OFFICE FOR
•
ORGANISATION MONDIALE DE LA SANTE
THE WESTERN PACIFIC
BUREAU RrolONAL DU PACIFIQUE OCCIDENTAL
REGIONAL COMMITTEE Thirty-sixth session Manila 16-20 September 1985 Provisional agenda item 17
WPR/RC36/ 12 9 July 1985 ORIGINAL: ENGLISH
INFANT AND YOUNG CHILD NUTRITION AND IMPLEMENTATION OF THE INTERNATIONAL CODE OF MARKETING OF BREAST-MILK SUBSTITUTES Report by the Regional Director
The Regional Committee is expected to follow up and review the implementation of the operative paragraphs of resolutions WHA33.32, WHA34.22, WHA35.26, WPR/RC32.Rll, WPR/RC33.R16 and WPR/RC34.R18. Operative paragraph 6(7) of resolution WHA33.32 calls for a report on the action of WHO and Member States regarding the promotion of breast-feeding and infant and young chlld feeding to the World Health Assembly in even-numbered years; and Article 11.7 of the International Code of Marketing of Breast-milk Substitutes calls for a report on the status of implementation of the International Code, also in even-numbered years. Those reports are to be made up of information provided by Member States through the regional committees in odd-numbered years. The present report, therefore, represents the routine biennial report to the Regional Committee in odd-numbered years. It should be seen as complementary to the progress report presented to the Regional Committee at its thirty-fourth session in September 1983. It summarizes the information available concerning activities in the field of infant and young child nutrition and provides information on the status of implementation of the International Code of Marketing of Breast-mi!k Substitutes. It also provides some information on trends observed in the Region.
WPR/RC36/12 page 2
1. INTRODUCTION
At its thirty-third session in September 1982, the Regional Committee for the Western Pacific adopted resolution WPR/RC33.Rl6, which requested Member States to report annually to the Regional Director on both infant and young child feeding and implementation of the International Code of Marketing of Breast-milk Substitutes, the material submitted to be used by the Regional Director at his discretion and as required by Articles 1 1.6 and 11.7 of the International Code and resolutions of the World Health Assembly) In the Regional Committee resolution, note was also taken of World Health Assembly resolutions WHA33.32 on infant and young child feeding, and WHA34.22 and WHA35.26 on the International Code of Marketing of Breast-milk Substitutes, as well as the previous Regional Committee resolution WPR/RC32.R11 on infant and young child feeding. In compliance with these resolutions, the routine biennial report to be submitted to the Regional Committee in odd-numbered years was presented to the thirty-fourth session of the Regional Committee in September 1983. The present report sets out the information available concerning action taken under the regular programme of activities in the field of infant and young child nutrition and as a follow-up to the World Health Assembly and Regional Committee resolutions. The majority of Member States have used the Guiding Principles2 set out to facilitate reporting on action taken in the field of infant and young child feeding. The information is based on the five main themes used during the Joint WHO/UNICEF Meeting on Infant and Young Child Feeding, held in Geneva in October 1979, namely: the encouragement and support of breast-feeding; the promotion and support of appropriate and timely complementary feeding (weaning) practices with the use of local food resources; the strengthening of education, training and information on infant and young child feeding; the development of support for the improved health and social status of women in relation to infant and young child feeding; the appropriate marketing and distribution of breast-milk substitutes.
1See resolution WPR/R C33.R 16. Handbook of Resolutions and Decisions of the WHO Regional Committee for the Western Pacific, Vol. II, 4th ed., 1984, page 68.
2Guiding principles for facilitating reporting by Member States on action taken in the field of infant and young child feeding (document WHO/GP/81/Rev.l).
WPRJRC:36j12 page 3
Most of the activities have been carried out as part of a comprehensive programme on maternal and child health and nutrition, which are essential elements of the strategy for health for all by the year 2000. The information on measures taken by Member States with cooperation from WHO is presented within the broader context of primary health care and the health-for-aU strategies. This report is complementary to the progress report presented to the Regional Committee in September 1983.1
2. SUMMARY OF ACTIVITIES
Australia In Australia, the reported levels of breast-feeding among Australian women has been maintained. The national average of breast-feeding at the time of discharge from hospital is 85%, and at the age of three months 56%. All State and Territory health authorities have policies to encourage and support breast-feeding and provide training for health workers. Guidelines have been developed by a working party of the National Health and Medical Research Council to promote breast-feeding. It is reported that health care practices which influence breast-feeding have been reviewed by health authorities in all States and Territories. Rooming-in is the norm in most of the maternity hospitals and efforts to eJiminate inappropriate feeding practices have been intensified. Since March 1979, the Australian Conciliation and Arbitration Commission has been granting a minimum of six weeks' compulsory unpaid maternity leave for aJJ female employees under federal awards together with optional leave of up to twelve months, including the compulsory period. Since 1985, additional provisions for parental leave for those who are not eligible for Australian Public Service maternity leave are being implemented. Child care services for places of work and work-related day-care facilities are eligible for funding through the Children's Services Programme. With respect to appropriate weaning practices, no national problem exists in Australia. Mothers are encouraged to use suitable modifications of family foods for weaning. Problems associated with the weaning period among aboriginal groups are being dealt with by the health authorities in the States concerned. Infant and young child nutrition and feeding are receiving renewed attention in the curricula developed for various categories of health workers in teaching institutions in all States and Territories. A number of nongovernmental organizations provide education and information programmes with some government support.
loocuments WPRJRC34jll, Add.l, Corr.J and Corr.2.
WPR/RC36/12 page 4
The Industry Code of Practice for the Marketing of Infant Formulas, which was accepted by the Government in May 1983, has had the desired effect of curbing inappropriate marketing and distribution practices. The Industry Code of Practice is being reviewed in 19&5. New orders of the Export Control Act have taken into account the relevant articles of the International Code of Marketing of Breast-milk Substitutes and have ensured both quality and appropriate labeJling of all products leaving Australia. The International Code has been brought to the attention of all State and Territory health authorities. The Commonwealth Department of Health has the responsibility of monitoring implementation of the International Code at the national level while the State health authorities have to require compliance within their jurisdiction. With respect to quality of products, no problem exists in Australia and the National Health and Medical Research Council Food Standards Committee maintains close monitoring. China Since the 1982 national workshop on breast-feeding held in Shanghai, the promotion of breast-feeding and the increase in the level of breast-feeding in some areas of the country has been one of the main tasks of the maternal and child health services. A national coordinating group on the scientific study on breast-feeding has been established under the Ministry of Public Health and a research programme on breast-feeding for 1983-1985 has been mapped out. A survey covering 100 000 infants from birth to six months of age in two provinces has been conducted. It is noted that the general trend is for levels of breast-feeding to be lower in cities than in the rural areas and lower in large cities than in medium-sized or smaller towns. The national workshop held in Shanghai developed a unified methodology for the evaluation and analysis of data collected from various sources. Two national meetings, one in the northern part and one in the southern part of China, held during the third quarter of 1984, made proposals for furthering the promotion of breast-feeding. A number of studies were carried out on the effects of early and prolonged mother /child contact and the frequency of feeding on the secretion of breast-milk. Rooming-in, provision of guidance, etc. resulted in an improvement in the levels of breast-feeding in specific cities. A widespread publicity campaign on the advantages of breast-feeding has been launched in various parts of the country using films, video tapes, mass media, health talks, etc. The target for the specific areas is that, by the end of 1985, 80% of infants should be completely breast-fed for the first four months. Cook Islands The Ministry of Health has given emphasis to breast-feeding; information on the importance of breast-feeding is provided during the holding of maternal and child health clinics as well as through press and radio. Promotion of sound nutritional practices during pregnancy and lactation periods is also encouraged.
WPR/RC36/1 2 page 5
With respect to breast-milk supplements or weaning foods, encouragement is being given to locally prepared foods whose preparation is demonstrated by health staff. A total of 97% of infants are breast-fed at the time of hospital discharge in the main island of Rarotonga, and 85% continue to be breast-fed at six weeks. Not more than 5% are on breast-milk substitutes and on the average 6.5%-70% maintain breast-feeding at the age of three months. Maternity leave with pay for a period of six weeks has been approved by the Government since 1982. The Government, through the Ministry of Health, has supported the implementation of the International Code of Marketing of Breast-milk Substitutes in its entirety since 1982. As all breast-milk substitutes are imported from New Zealand, which keeps a strict control on compliance with the International Code, Cook Islands does not have problems regarding quality control or labeJling compliance.
Following the disbanding of the first working group, a second working group has been formed with the mandate to develop strategies for the implementation of the Code and its amendments. The working group has submitted the necessary proposed amendments for the Pure Food Act to the Central Board of Health. With regard to maternal rights, the proposed amendments have been presented to both employee and employer groups for their appropriate joint action. Workshops have been organized at three major hospitals in order to obtain feedback on hospital practices which would encourage breast-feeding. It is hoped that, in the near future, the results of the working group, tabled at the National Food and Nutrition Committee, will be submitted to the Cabinet. Hong Kong Planning is in hand to expand the establishment of the Health Education Unit of the Family Health Services in order to provide health education to expectant mothers at the newly estabiished Prince of Wales Hospital.
Since January 1985, the Health Education Unit of the Family Health Services of the Medical and Health Department has been participating in a regular television programme for the promotion of family health, including promotion of breast-feeding. The information booklet produced in this context and distributed to expectant mothers provides a good coverage of the importance, advantages and techniques of breast-feeding. Malaysia Emphasis on breast-feeding education and promotion has been strengthened in both urban and rural areas through the involvement of all categories of government and private health personnel. Voluntary agencies are also involved - in promoting breast-feeding through education, motivation and provision of mother-to-mother support. In April 1984, a foHow-up seminar on breast-feeding was organized by the Ministry of Health in collaboration with the National Council of Child Welfare.
WPR/RC36/12 page 6
The 1979 Code of Ethics for Infant Formulae, which was revised in 1983, was further revised in 1984 and 1985 based on comments and complaints received during the period. The last revised edition will be implemented later this year. Monitoring and evaluation committees have been formed both at national and state levels to monitor the implementation of the Code of Ethics. A Vetting Committee consisting of representatives of the Ministry of Health, paediatricians and obstetricians and the University, together with the Ministry of Information, continues to vet alJ materials on infant formula for print or media. Since its establishment, this Committee has approved 356 materials and rejected 196. Malaysia proposes to continue to promote breast-feeding and infant feeding through its own code and has no plans at present to adopt legislation in this regard. New Zealand Since the announcement by the Prime Minister of New Zealand regarding adoption of the International Code in its entirety, a monitoring committee has been established to carry out the functions in Article 11.2 of the International Code, in particular with respect to investigation of complaints relating to possible breaches of the Code and making recommendations to the Minister of Health on the workings of the Code. Possible breaches of the International Code have been investigated by the Committee and appropriate action taken. The number of informations of possible breaches of the provisions of the International Code have decreased in recent months. In response to the Committee's recommendation in August 1984 that non-complying labels should not be used in the manufacturing process after 31 December 1984, the Committee was advised that all breast-milk substitute products at retail outlets should have a complying label after September 1985. Infant and young child feeding, especially promotion of breast-feeding, is an important activity of the Ministry of Health. The Food Act 1981 and Food Regulations 1984 regulate the production standards and composition of foods suitable for young infants. Republic of Korea The main emphasis of activities in infant and young child feeding has been on information, education and communication through the use of television, posters and other media, and on strengthening of training of health personnel. In addition, all medical facilities have received guidelines on encouraging the practice of rooming-in, prohibiting bottle-feeding without a doctor's prescription, establishing maternal and child health clinics, and prohibiting the sales promotion tactics of milk manufacturing companies. Guidelines have also been issued for monitoring the growth and development of children from birth. Efforts are being made to issue guidelines for breast-milk s~bstitute production and marketing. Inter-agency collaboration with other governmental ministries and nongovernmental organizations has included breast-feeding campaigns and school health education.
WPR/RC36/l2 page 7
Research activities are being conducted on infant and young child feeding as well as on a comprehensive public nutrition improvement programme. Collaboration has been extended to the women's associations and other economic groups for the promotion of breast-feeding. Collaboration is also being provided with respect to prenatal and postnatal leave for women employees and the operation of day-care centres and feeding rooms for nursing employees. A breast-feeding campaign has also been initiated by consumer groups. Singapore Since 1982, the Ministry of Health has intensified its activities for the promotion of breast-feeding through health education programmes, educational talks and routine demonstrations in the maternal and child health centres. Breast-feeding has also been promoted through government hospitals. The Ministry of Health has started screening of video shows in various places as part of its overall health education strategy and this will be extended to all clinics by next year. Singapore is continuing to apply its local Code of Ethics on the Sale of Infant Formula Products. The monitoring authority, the Sale of Infant Food Ethics Committee, vets all promotional and educational materials put out by milk and infant food distributors. Samoa Samoa supports the International Code of Marketing of Breast-milk Substitutes and is trying its best to encourage and support breast-feeding through education, training and information on infant and young child feeding. Breast-feeding is encouraged in hospitals as well as by birth attendants when home deliveries take place. Earlier surveys have shown that 92%-94.5% of mothers breast-feed, the average duration being up . to 11.6 months. District nurses in particular advise mothers on all matters related to breast-feeding as well as on infant and young child feeding. The nutritionists of the Health Department continue to give demonstrations on appropriate feeding methods. Follow-up clinics are held fortnightly for mothers whose children are admitted for malnutrition. Nutrition lectures in support of infant and young child feeding are given to nurse trainees, health inspectors and school lecturers. The Health Education Unit has started a programme for men in urban and rural areas on maternal and child health and nutrition; health educators in outer districts give talks and demonstrations to women's committees. Companies which market breast-milk substitutes in Samoa are cooperating with the provisions of the Code. It is proposed that a National Food and Nutrition Committee be formed to plan nutrition policies for the country in the future. Solomon Islands The Government reports that, in compliance with resolution WPR/RC33.R 16, it gives unequivocal support to breast-feeding. Ninety-nine per cent. of infants in Solomon Islands are breast-fed and those that require feeding with breast-milk substitutes are fed by cup and spoon.
WPRJRC36fl2 page 8
Tonga Although 95% of all Tongan women breast-feed their infants, the duration of breast-feeding is often only four to six months, while only 15%-20% of women breast-feed for over twelve months. Around 40% of babies are given a bottle as supplemental feed by the fourth month and 50% by the sixth month. Children born to Tongan couples Jiving abroad but left to the care of other family members in Tonga are invariably bottle-fed, which frequently results in the use of inappropriate breast-milk substitutes. There is less concern about complementary foods, which consist of foods that are not processed but locally available. The decline in the incidence and severity of diarrhoeal diseases continues. Institutional practices favour the promotion of breast-feeding, with commencement of breast-feeding immediately after delivery, rooming-in, and demand feeding. The Ministry of Health together with the National Food and Nutrition Committee have taken positive steps towards the implementation of the International Code, which was officiaHy adopted in 1984. Vanuatu The Department of Health strongly promotes the traditional practice of breast-feeding. Promotional efforts are made through various media and at antenatal and maternal and child health clinics. The Vanuatu Labour Act supports breast-feeding by aHowing twelve weeks' maternity leave and two 30-minute breaks per day for working mothers. Hospital and home delivery practices encourage the commencement of breast-feeding immediately after delivery, as well as rooming-in. In 1984, two large hospitals in Vanuatu reported that virtually aU babies were being breast-fed at the time of hospital discharge. In the rural areas, breast-feeding continues up to eighteen months; in the urban areas there is a higher percentage of bottle-feeding with 22% of infants receiving bottle-feeds. The International Code is fully endorsed by the Department of Health; the National Food and Nutrition Committee has recommended its official adoption by the Government. At present, there is no advertising of breast-milk samples are given. Supplementary foods are introduced at using traditional staples. The incidence of malnutrition is between 1 and 2 years of age. Nutrition education is now supplementary foods. substitutes and no free the age of four months highest among children emphasizing appropriate
Nutritional anaemia among pregnant women .is common and efforts are being made to reduce its incidence. Protection and promotion of breast-feeding is recognized as an important aspectof primary health care.
WPR/RC.36/l2 page 9
VietNam A national workshop on breast-feeding was held in south Viet Nam and, as recommended by the workshop, maternity leave is being increased from two and a half months to six months. Two courses on nutrition in primary health care with emphasis on infant and young child feeding have been conducted in north and south Viet Nam, respectively. Education of young mothers and girls before marriage consisting of practical lessons on nutrition is being promoted throughout the country. Soya milk is being introduced as a supplementary food in creches in the country.
3. TRENDS IN THE REGION
The information provided by Member States, which is summarized above, complements the previous progress reports presented to the Regional Committee in 1982 and 1983. These reports provided evidence of comprehensive maternal and child nutrition activities which specificaJJy emphasize breast-feeding and implementation of the International Code. Only fourteen countries or areas have submitted reports in 1985. It is hoped that in future all countries wiU endeavour to send in their reports on time for subsequent use both in the Regional Committee and the World Health Assembly. Efforts at the national level show an increasing awareness of the need and a desire to promote breast-feeding and provide appropriate supplementation to infants and young children. Although in some countries the threat to breast-feeding is minimal and the importation and distribution of milk substitutes are subject to direct state control, a close watch needs to be kept in order to ensure that policies do not result in any deterioration in breast-feeding practices. In conclusion, in the light of the replies received from countries or areas, the response of Member States to the resolutions of the World Health Assembly and the Regional Committee has been satisfactory. WHO wiH continue to support Member States in their efforts to improve infant and young chHd nutrition as weH as in measures that are consistent with the letter and spirit of the International Code.