Archive site - new site at www.babymilkaction.org

If you agree that breastfeeding should be specifically mentioned in the next Millennium Development Goals please make a submission - however short - to  an online consultation that ends  10th January.  Follow this link  Contributions can be posted on the consultation website(www.fao.org/fsnforum/post-2015) or sent to fsn-moderator@fao.org and are welcome in English, French, Spanish, Arabic, Russian and Chinese.

IBFAN's submission is HERE

I raised our concerns about breastfeeding and the risks of public private  partnerships in health policy setting at a Civil Society meeting in London (2nd November) where  we had an opportunity to meet 8 of the 27 members of the Post2015  High Level Team (appointed by the UN Secretary General) http://www.beyond2015.org/un-high-level-panel  We were not invited to the  separate meeting with the Private Sector. 

Contributions can be posted on the consultation website (www.fao.org/fsnforum/post-2015) or sent to fsn-moderator@fao.org and are welcome in English, French, Spanish, Arabic, Russian and Chinese.

Here is the main text of the IBFAN submission that you can use in your submission.  The submission with charts etc is HERE

FOOD AND NUTRITION SECURITY FROM THE START OF LIFE

Submission to the E-Consultation on Hunger, Food and Nutrition Security

There is growing concern today about the increasing global burden of malnutrition – both under nutrition and obesity – with health consequences throughout the life course. Malnutrition is a major factor in child health and survival; it has been estimated to be an underlying cause of up to 50–60 percent of under-five deaths . Today, almost a quarter of the world’s children, especially in Africa and Asia do not get adequate food . At the same time, there is a rising incidence of nutrition related noncommunicable diseases including diabetes, cardiovascular diseases and cancer. 

Malnutrition – both under- and over – sets in during the first two years of life, mostly during infancy . Food and nutrition security during this period means ensuring early and exclusive breastfeeding during the first six months, followed by introduction of complementary foods along with continued breastfeeding up to two years.  A growing body of evidence points to the key role of infant and young child feeding practices, especially early and exclusive breastfeeding, in mitigating both forms of malnutrition and in the prevention of child mortality. Nonetheless interventions that address these practices have not received adequate attention during the MDGs era, and thus there is an unused potential for achieving progress in food and nutrition security in the childhood but also in the adulthood. The post-MDGs development agenda should bridge this gap and make a priority of such interventions. 

1. Breastfeeding contribution to the Millennium Development Goals (MDGs)

The key building block for child survival, growth and healthy development is provided by early initiation of breastfeeding and exclusive breastfeeding for six months, with continued breastfeeding for up to two years or beyond with the addition of safe  and nutritionally adequate complementary foods. These optimal feeding practices constitute a public health recommendation by the World Health Organisation (WHO) for normal growth, health and development. 

As defined in the Global Strategy for Infant and Young Child Feeding, they provide the foundations for the achievement of the health-related Millennium Development Goal (MDG) and contribute to the achievement of all the other MDGs.

Breastfeeding and complementary feeding are key to child survival and health. Scientific research has shown that breastfeeding is good for mothers, babies and societies.  In conditions of poverty and in emergency situations, breastfeeding is a real lifeline and artificial feeding is a huge risk to infant survival. Exclusive breastfeeding in the first six months of life has also been associated with decreased infant deaths in HIV-exposed infants when compared with mixed feeding and exclusively replacement feeding . For all babies, breastfeeding enhances neurological, visual and motor development and reduces incidence and severity of diarrhoeal and respiratory diseases.

Sub optimal breastfeeding  increases newborn infections by six times, diarrhoea by 3 times and pneumonia by 2.5 times. These three are major killers of infants before they reach their first birthday. 

Complementary feeding of infants and young children older than 6 months in addition to continued breastfeeding is also key to survival. Growth reference analyses for developing countries  has consistently shown falling off after the early months, while research has shown that little can be done for growth recovery after the first two to three years.

Breastfeeding tops the list of effective preventive interventions for child survival. Together with appropriate complementary feeding these two have more impact even than immunisation, safe water and sanitation .

Breastfeeding reinforces immunization. Breastfeeding provides the baby with anti-bacterial, anti-viral and anti-parasitic agents and strengthens the infant's developing immune system to fight off disease . Breastfeeding confers active and passive immunity; it primes the infant's immune system and improves the "take up" or antibody response to vaccines. Colostrum is so rich in antibodies and so high in anti-infective properties that it has been called "the first immunisation".  

Breastfeeding enhances neurological, visual and motor development; it protects against obesity, respiratory infections and diarrhoea, and against allergies, skin disease and asthma. In this way, breastfeeding complements other key interventions to improve child health. 

The effect of continued breastfeeding is sustainable: it does not require booster shots.  

Breastfeeding is one of the most cost-effective nutrition interventions, as stated by the World Bank in 2006. The beneficial nutrition interventions with the lowest unit cost were salt iodization at $ 0.20 to $0.50 unit cost per participant and breastfeeding promotion in hospitals at $0.30 to $0.40, if infant formula was removed from maternity wards. However if infant formula is not removed from maternity wards, the report indicates that the unit cost increases to $ 2 to $ 3 per infant . This increase shows the high cost to health care systems and governments incurred by importing or purchasing expensive breastmilk substitutes. 

Early and exclusive breastfeeding contribute to improving women’s health in the period following childbirth and in later life. Breastfeeding benefits for maternal health include improved postpartum recovery, reduced iron loss, delayed fertility return, decreased breast and ovarian cancers and reduced bone loss with aging. 

Breaking the inter-generational circle of malnutrition. For mothers to breastfeed their babies optimally, they need skilled support and access to adequate nutrition in their own right to deliver this crucial intervention. The lifecycle approach is key to breaking the intergenerational vicious circle of malnutrition in girls/women. 

Breastfeeding and child spacing. "More births are probably prevented world-wide each year by breastfeeding than by all other contraceptive methods combined" . In the 21st century, 200 million women who want to limit their childbearing have no access to contraception or family planning services (ref. see Gay Palmer page 133 and 396).  In Africa, it is estimated that in 2009, only 28% of married women use contraceptives .  In some African countries, births might increase by 50% if breastfeeding stopped.

Moreover, women who artificially feed risk becoming pregnant again too soon; closely spaced pregnancies damage the health and endanger the lives of both mothers and children. Women are able to raise healthier children by spacing births using the Lactation Amenorrhea Method (LAM). LAM provides a method of birth spacing that women themselves can control, independently of pressures from their husbands and relatives.

Breastfeeding and Gender Equality. Women’s unique roles of child bearing and breastfeeding place them in vulnerable positions, socially, economically and nutritionally. Globally, women are disproportionately affected by poverty, illiteracy, discrimination and violence. Women’s reproductive rights and productive roles require adequate support to ensure that they obtain equality at all levels of society.

The persistent injustices and discrimination experienced by women around the world led the UN to adopt the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) in 1979. This document specifically states that maternity is a social function, that women should benefit from appropriate medical services in connection with pregnancy and lactation, and that there should be support to enable parents to balance family and work responsibilities including participation in public life. This last point is also underlined in Article 18 of the Convention on the Rights of the Child (CRC).

Breastfeeding is an integral part of women’s reproductive health and as such, represents a right for women. However, women can only enjoy the full health benefits of breastfeeding when they receive accurate information to make an informed choice about infant feeding, are able to exercise their right to breastfeed without coercion and pressure, and when governments, communities, health professionals and families protect this right.

Goal 1 Eradicate extreme poverty and hunger Breastfeeding significantly reduces early childhood feeding costs, and exclusive breastfeeding halves the cost of breastfeeding 1. Exclusive breastfeeding and continued breastfeeding for two years is associated with reduction in underweight 2 and is an excellent source of high quality calories for energy. By reducing fertility, exclusive breastfeeding reduces reproductive stress. Breastfeeding provides breast milk, serving as low-cost, high quality, locally produced food and sustainable food security for the child.

Goal 2 Achieve universal primary 

education Breastfeeding and adequate complementary feeding are prerequisites for readiness to learn 3. Breastfeeding and quality complementary foods significantly contribute to cognitive development and capacity. In addition to the balance of long chain fatty acids in breast milk which support neurological development, initial exclusive breastfeeding and complementary feeding address micronutrient and iron deficiency needs and, hence, support appropriate neurological development and enhance later school performance.

Goal 3 Promote gender equality and empower women

 Breastfeeding is the great equalizer, giving every child a fair start on life. Most differences in growth between sexes begin as complementary foods are added into the diet, and gender preference begins to act on feeding decisions. Breastfeeding also empowers women:

• increased birth spacing secondary to breastfeeding helps prevents maternal depletion from short birth intervals,

• only women can provide it, enhancing women’s capacity to feed children

• increases focus on need for women’s nutrition to be considered

Goal 4 Reduce  child  mortality

 By reducing infectious disease incidence and severity, breastfeeding could readily reduce child mortality by about 13%, and improved complementary feeding would reduce child mortality by about 6% 4. In addition, about 50-60% of under-5 mortality is caused by malnutrition due to inadequate complementary foods and feeding following on poor breastfeeding practices 5 and, also, to low birth weight. The impact is increased in unhygienic settings. The micronutrient content of breastmilk, especially during exclusive breastfeeding, and from complementary feeding can provide essential micronutrients in adequate quantities, as well as necessary levels of protein and carbohydrates.

Goal 5 Improve  maternal  health

The activities called for in the Global Strategy include increased attention to support for the mother's nutritional and social needs. In addition, breastfeeding is associated with decreased maternal postpartum blood loss, breast cancer, ovarian cancer, and endometrial cancer, as well as the probability of decreased bone loss post-menopause. Breastfeeding also contributes to the duration of birth intervals, reducing maternal risks of pregnancy too close together, including lessening risk of maternal nutritional depletion from repeated, closely-spaced pregnancies. Breastfeeding promotes return of the mother’s body to pre-pregnancy status, including more rapid involution of the uterus and postpartum weight loss (obesity prevention).

Goal 6 Combat HIV/AIDS, malaria,  and other  diseases

 Based on extrapolation from the published literature on the impact of exclusive breastfeeding on MTCT, exclusive breastfeeding in a population of untested breastfeeding HIV-infected population could be associated with a significant and measurable reduction in MTCT.

Goal 7 Ensure environmental sustainability

 Breastfeeding is associated with decreased milk industry waste, pharmaceutical waste, plastics and aluminium tin waste, and decreased use of firewood/fossil fuels for alternative feeding preparation 6, less CO2 emission as a result of fossil fuels, and less emissions from transport vehicles as breastmilk is locally produced.

Goal 8 Develop a  global  partnership  for  development

 The Global Strategy for Infant and Young Child Feeding fosters multi-sectoral collaboration, and can build upon the existant partnerships for support of development through breastfeeding and complementary feeding. In terms of future economic productivity, optimal infant feeding has major implications.

1 Bhatnagar, S., Jain, N. P. & Tiwari, V. K. Cost of infant feeding in exclusive and partially breastfed infants. Indian Pediatr. 33, 655-658 (1996). 

2 Dewey, K. G. Cross-cultural patterns of growth and nutritional status of breast-fed infants. Am. J. Clin. Nutr. 67, 10-7 (1998). 

3 Anderson, J. W., Johnstone, B. M. & Remley, D. T. Breast-feeding and cognitive development: a meta-analysis. Am. J. Clin. Nutr. 70, 525-35 (1990). 

4 Jones, G. et al. How many child deaths can we prevent this year? Lancet 362, 65-71 (2003). 

5 Pelletier, D. & Frongillo, E. Changes in child survival are strongly associated with changes in malnutrition in developing countries. J. Nutr. 133, 107-119 (2003) 

6 Labbok M. Breastfeeding as a women's issue: conclusions and consensus, complementary concerns, and next actions. IJGO 1994; 47(Suppl):S55-S61

2. Challenges and opportunities

Barriers to optimal infant and young child feeding contribute to 1.4 million preventable deaths annually in children under five, the majority of whom are dying already during the first month of life. 

Initiating breastfeeding within the first hour of birth can reduce neonatal mortality by 20%, but shockingly, more than half the world’s newborns are not breastfeed within an hour of birth. Exclusive breastfeeding for six months and continued breastfeeding for 12 months may prevent under five child deaths by 13%, complementary feeding may contribute to reduce 6% child deaths (Lancet 2003). Globally only around 37% % of infants under six months are exclusively breastfed. Infants need continued breastfeeding along with adequate amounts of complementary foods after they are six months old and continued breastfeeding for two years or beyond. Yet, only a minority of children continue breastfeeding until the age of two.

Status of policy and programmes to improve breastfeeding and complementary feeding practices

The latest Countdown to 2015  report on maternal, newborn and child survival analyzed the progress in 68 priority countries, in the period 1990-2010 of key interventions that contribute to achieving the MDGs for child mortality and maternal health. Early initiation of and exclusive breastfeeding as well as complementary feeding are again listed among the most effective interventions. Nonetheless, the report points to insufficient coverage of effective maternal, newborn and child interventions. Among these early initiation of breastfeeding has a median coverage of 48%, exclusive breastfeeding of 34% and complementary feeding (6-9) months of 66% (see Figure 1).

Figure 1: Median coverage for effective maternal, newborn and child interventions in 68 Countdown countries. Source: Countdown to 2015 decade report (2000—10): taking stock of maternal, newborn, and child survival. The Lancet 2010. 

The report also reviews the adoption of evidence-based policies that contribute to maternal, newborn and child health. The enactment of the International Code of Marketing of Breastmilk Substitutes and the adoption of a maternity protection policy in line with ILO recommendations have been implemented in only 22 and 1 country respectively (see Figure 2). Assessment of the implementationof the 2002 the Global Strategy for Infant and Young Child Feeding using the World Breastfeeding Trends Initiative (WBTi) in 51 countries has shown that most countries are lagging in having policies and programmes in all 10 indicators .

Figure 2: Status for adoption of evidence-based policies related to maternal, newborn and child health in 68 countries. Source:  Countdown to 2015 decade report (2000—10): taking stock of maternal, newborn, and child survival. The Lancet 2010. 

The two figures clearly demonstrate that breastfeeding and infant and young child feeding interventions do not receive adequate attention. Despite the well-established importance of breastfeeding and complementary feeding in early period of life, little international funding is provided for interventions to enhance these practices . Furthermore, an analysis by Action Against Hunger (ACF) shows that breastfeeding is the 3rd least popular intervention in terms of funding and that product-based micronutrient interventions are now dominating the nutrition scene . 

Challenges

Some of the main challenges that hamper the achievement of optimal infant and young child feeding practices are listed below. 

• Implementation of the International Code of Marketing of Breastmilk Substitutes

Protecting breastfeeding and adequate complementary feeding is essential. Promotion of breastfeeding alone is not sufficient. The negative impact of inappropriate promotion of breastmilk substitutes must continue to be challenged. Companies too often undermine breastfeeding by making unethical and unfounded claims about their products and by marketing them in coercive and deceptive ways, in violation of the International Code. 

The Code, adopted by the World Health Assembly (WHA) in 1981 and followed by numerous resolutions, is a minimum global standard, aiming to promote appropriate infant and young child feeding by protecting it from commercial malpractice. Even if countries have adopted many or at least some provisions of the Code in national legislation, Code violations continue as enforcement is inadequate.  

Companies are obliged to comply with the Code regardless of any government action, yet monitoring by civil society shows that none of the large multinational companies live up to this obligation.  Independent monitoring of commercial practices and exposing Code violations must be expanded.

• Correct and unbiased information

Information available to people regarding exclusive breastfeeding and other optimal infant feeding practices is grossly inadequate, often biased due to commercial interference. There is a poor understanding of the fact that breastfeeding should be regarded as a norm and artificial feeding as a substitute that can never be equal to the norm. The level of support a mother needs to succeed in practicing exclusive breastfeeding for the first six months and to continue for 2 years or beyond is underestimated and few resources have been spent in this area.

• Maternity protection

Breastfeeding is that aspect of nurturing that covers both child feeding and child care, requiring mothers and babies to be together. More and more women work and often far from home and in the informal sector. It is necessary to make adjustments in the workload of mothers of young children so that they may find the time and energy for breastfeeding; this should not be considered the mother’s responsibility, but rather a collective responsibility.  It is important to note that the main reason given by majority of working mothers for ceasing breastfeeding is their return to work [following maternity leave]. The challenge in terms of breastfeeding protection is the adoption and the monitoring of an adequate policy of maternity entitlements that facilitate six months of exclusive breastfeeding for women employed in all sectors, with urgent attention to the non-formal sector.

• Supportive health care system

Obstacles to optimal breastfeeding practices are created by the continuing pressures exerted by the baby food manufacturers, either directly on parents and caregivers, or indirectly through the health care system and health care providers. Baby Friendly Hospital Initiative (BFHI), the backbone of which is formed by the ‘Ten steps for successful breastfeeding’, is a key initiative to ensure breastfeeding protection and support within the health care system. Revitalization of the Baby-friendly Hospital Initiative (BFHI) and its expansion is a key strategy to implement.  

• The challenge of rising public-private partnerships (PPPs)

The sponsorship and funding  of health workers, researchers, NGOs and policy makers has been a key strategy of the baby food industry and food industry in general that opens the door to undue influence on scientific bodies, policy makers and governance mechanisms that promote voluntary approaches rather than effective regulation.

The public private partnerships and alliances between businesses,  NGOs and the UN that are being set up to conquer child malnutrition and deal with the challenge of NCDs, increase these risks as adequate safeguards to deal with conflicts of interest are neglected, and “trust” and “mutual benefits” prevail as guiding principles. Industry funded foundations also influence policies promoting business friendly policies and programmes 

Several WHA Resolutions have highlighted these risks and have called for 'governance' in  health policy and programme setting to be protected from the undue influence of those who stand to gain financially from decisions.

Industry involvement at a core strategic level can also favour market-led responses to infant and young feeding that sideline the critical role of breastfeeding and appropriate complementary feeding that the Countdown report demonstrates.  Malnutrition is now seen as a  profitable business that will assist business’ ‘top strategic priority' which is to change traditional food patterns and cultures, extend the bottle-feeding period,  encourage snacking on highly processed imported products. 

• Trade related challenges

Multilateral and bilateral trade and investment agreements that countries have entered into or are currently being negotiated are formalising a supra-national system of binding global governance that provides multinational corporations new rights. Many of these agreements contain investment chapters or clauses which allow investors to sue governments directly at an international arbitration tribunal for measures put in place for the protection of the public welfare but which an investor sees as having infringed upon an investment or on expected profits. Such agreements could impact on the sovereignty and ability of governments to make and implement policies, laws, regulations or programmes in the public interest and could undermine wide swaths of domestic consumer, environmental, workplace and other vital safeguards. 

Any initiative to eradicate hunger, food insecurity and malnutrition should include checks and balances to counter such agreements. The texts and all relevant documents relating to such agreements should be open to public scrutiny and negotiations suspended while comprehensive cost-and-benefit analysis is carried out and all detrimental clauses removed. The safeguards contained in human rights conventions do take precedence over multilateral and bilateral trade and investment agreements and WHA resolutions relating to public health which are set by the world’s highest health policy setting body should also take precedence.  

3. Directions for the future

In December 2012, the World Breastfeeding Conference took place in New Delhi bringing together more than 800 representatives of civil society, governments, international organisations, breastfeeding groups, social movements and individuals from 82 countries, all concerned about the continuing inequality in health and nutrition and the dismal situation of food security and malnutrition worldwide. 

The 2012 World Breastfeeding Conference Declaration and Call to Action   called on all concerned parties to accelerate action for the protection, promotion and support of breastfeeding and infant and young child feeding as a human right which should be entrenched in policies and programmes as a necessary condition. This Call to Action comes in timely with the new consultations on the post 2015 development agenda, and thus we would like to propose some of the fundamental actions to the attention of this discussion. 

In order to achieve food and nutrition security from the start of life, the post 2015 development agenda should prioritize interventions that empower mothers to provide optimal infant and young child feeding to their infants and young children. In particular, the following actions should be taken: 

1. Adopting a human right-based approach to the protection, promotion and support of breastfeeding and infant and young child feeding at international, national, sub-national and community levels. 

2. Establishing institutional mechanisms to avoid and manage conflicts of interest in health and nutrition decision-making and programme implementation.

3. Supporting all women with a comprehensive system of maternity protection at work, including the non-formal sector, with a provision of financing.

4. Ensuring appropriate and adequate education and training of all health care professionals and allied health and community workers both in pre-service and in-service, and in all sectors, to counter widespread ignorance and to provide skilled support to lactating women. 

5. Establishing clear budget lines for breastfeeding and infant and young child feeding policy and programme interventions to ensure adequate human and financial resources in order to enhance optimal practices.

6. Investing in the Baby Friendly Hospital Initiative including mother friendly practices and link it to community initiatives. Further this should be rooted in all maternal and neonatal health programmes, and with due attention to low birth weight babies. 

7. Publicising widely the multiple risks of artificial feeding, bottles and teats as well as early complementary feeding through all kinds of media campaigns.

8. Ensuring universal access to accurate information and counselling on breastfeeding and infant and young child feeding to all mothers, and to do that provide skilled counsellors in the health facilities and in the community so that they are available for any situation.

9. Monitoring and track the Global Strategy for Infant and Young Child Feeding in every country using World Breastfeeding Trends Initiative (WBTi) and advocate to bridge the gaps. 

10. Protecting breastfeeding from commercial sector, by strictly enforcing the International Code of Marketing of Breastmilk Substitutes and subsequent related World Health Assembly Resolutions and prohibit all kinds of promotion of commercial foods for children for two years or beyond.

11. Promoting the use of affordable and diverse, locally grown, indigenous foods for timely and appropriate complementary feeding after six- months along with continued breastfeeding.

12. Enhancing and supporting breastfeeding related research with public funding. 

CLICK here for the Miriam Labbock's summary, made when she was Infant feeding advisor for UNICEF on how Breastfeeding contributes in some way to all the current MDGs. 

CLICK HERE  for the background paper