9.1.1. Convention on the Rights of the Child

The CRC is an instrument for protecting and fulfilling the rights of children (6). It was adopted by United Nations member states almost universally in November 1989, and countries which have agreed to it (also referred to as States Parties) are required to report regularly to the United Nations about progress in implementation.

Article 24 of the CRC addresses child health and nutrition, and some quotations are particularly relevant. States Parties agree to “take appropriate measures to diminish infant and child mortality”, and “to combat disease and malnutrition … through the provision of adequate nutritious foods and clean drinking water”; and to “ensure that all segments of society, particularly parents and children, are informed, have access to education and are supported in the use of basic knowledge of child health and nutrition, and the advantages of breastfeeding”. The CRC is an important tool to hold governments to account on progress in the area of infant and young child feeding. The periodic review and reporting process also provides an entry point for making recommendations to strengthen national plans and actions in the area of infant and young child feeding.

9.1.2. International Code of Marketing of Breast-milk Substitutes and subsequent relevant Health Assembly resolutions – the Code

The Code was adopted by WHO Member States in 1981 in response to the realization that wide-spread marketing of breast-milk substitutes was leading to adverse health outcomes in infant and young children all over the world (4). Progress in the implementation of the Code is reported every alternate year in the World Health Assembly (WHA), and through this process, a series of resolutions to further clarify the Code have been adopted by WHO Member States.

Manufacturers of infant formula often promote and market their products in ways which encourage mothers and health workers to believe that breastfeeding and artificial feeding are equivalent. This undermines mothers' confidence in breast milk and in their ability to breastfeed according to global recommendations. The Code seeks to regulate the marketing of breast-milk substitutes, including infant formula and other milk products, foods and drinks, and bottle-fed complementary foods, when they are presented as replacements for breast milk. The Code also seeks to regulate the marketing of feeding bottles and teats.

The Code addresses the quality and availability of the products, and information concerning their use. It provides recommendations concerning the marketing of industrially-prepared complementary foods, encouraging the use of locally-available foods. Thus the Code does not seek to ban products, but to control promotion that may influence families to use them when they are not needed.

Health workers have important responsibilities to comply with the provisions of the Code (7). For example, health care facilities should not be used for the purpose of promoting or displaying infant formula or other products within the scope of the Code. If preparation of formula feeds has to be demonstrated, this should be done only by trained health workers and only to mothers or family members who need to use formula, or who have made an informed decision to do so. Health workers should explain clearly the dangers of using the products.

Health facility administrators and staff need to understand and fulfil their responsibilities under the Code. These include:

• to encourage and protect breastfeeding;
• not to accept financial or material inducements to promote these products;
• not to give samples of infant formula to pregnant women, mothers of infants and young children, or members of their families.

The fact that HIV can be transmitted through breast milk should not undermine efforts to implement the Code. HIV-positive mothers, as all women, need to be protected from commercial promotion of infant formula and other products, and to remain free to make an informed decision regarding infant feeding. The Code fully covers their needs.

9.1.3. ILO Maternity Protection Convention, 2000 (No. 183)

Maternity protection at work is essential for safeguarding the health and economic security of women and their children. This consensus is reflected in the international labour standards of the ILO, which set out basic requirements of maternity protection at work. ILO Maternity Protection Convention No. 183, adopted by ILO Member States in 2000 (5), covers:

• 14 weeks of maternity leave, including 6 weeks of compulsory postnatal leave;
• cash benefits during leave of at least two thirds of previous or insured earnings;
• access to medical care, including prenatal, childbirth and postnatal care, as well as hospitalization when necessary;
• health protection: the right of pregnant and nursing women not to perform work prejudicial to their health or that of their child;
• breastfeeding: minimum one daily break, with pay;
• employment protection and non-discrimination.

Few countries have ratified this Convention, although many countries have adopted some provisions through ratification of previous ILO maternity protection conventions. Health professionals have an important role to advocate for good legislation on maternity protection, and hospitals and other health facilities should offer maternity leave and breastfeeding support for their own personnel.

9.2.1. Integrated Management of Childhood Illnesses

WHO and UNICEF developed the IMCI strategy to reduce child mortality and promote the healthy growth and development of children (8). The IMCI strategy combines preventive and curative interventions to combat the major causes of child mortality. It promotes a continuum of care by focusing on actions in the health system and at the family and community levels.

IMCI includes the promotion of appropriate feeding practices among both healthy and sick children. In countries where IMCI has been evaluated, feeding practices improved, and children showed less growth faltering (9,10). IMCI is an important delivery strategy for infant and young child feeding interventions through which many children can be reached and coverage improved.

9.2.2. Essential Nutrition Actions

While IMCI focuses on child health services, the Essential Nutrition Actions (ENA) approach promotes integration of concise nutrition messages and interventions into multiple entry points in the health care system (11).

The ENA approach promotes seven essential nutrition actions:

• exclusive breastfeeding from birth to 6 months;
• appropriate complementary feeding from 6 months with continued breastfeeding up to 24 months or beyond;
• appropriate feeding of infants and young children during and after illness;
• adequate nutrition of women;
• control of vitamin A deficiency;
• control of anaemia through iron supplementation and de-worming of women and children;
• control of iodine deficiency disorders.

These actions should be implemented at all critical times when mothers and children have contact with health services, including during:

• antenatal care;
• labour, delivery and immediate post-partum care;
• postnatal care and family planning;
• immunization;
• growth monitoring and promotion;
• well-baby and sick child visits.

The ENA approach is a useful complement to IMCI and may guide programme planning and management for infant and young child feeding at various levels.

9.3.1. Behaviour change communication

Mothers do not make infant or young child feeding decisions alone. Other people in the family and community influence them. To improve practices, a communication strategy must address the beliefs of these other people, so that there is a change in family and community norms.

When developing a communication strategy, it is useful to understand the stages of an individual person's change. A person often moves from pre-awareness of a recommended practice to awareness, contemplation of trying the new practice, trial of the practice, adoption of the practice, maintenance, and finally advocacy of the new practice (13).

When communicators understand this process, they can identify the stage of their target group, and then can design a strategy to move them to the next stage. For someone in the “pre-awareness” stage, the most important need is information. If a person is contemplating trying out what he or she has learned, it is useful to encourage him or her, and to provide opportunities to try it. If a person is already trying a new practice, the health workers should emphasise the benefits and help him or her to overcome resistance from family or community, through home visits and support groups.

Moving from one stage of change to another requires a mixture of communication approaches, including mass, electronic and print media; community advocacy and events; and interpersonal communication (community groups, individual counselling, mother-to-mother support groups and home visits). These approaches need to be directed towards mothers and family members, community leaders, and others who are influential in the community.

9.3.2. Training and support of community health workers

Community health workers can be important agents of change in a community and provide services to support infant and young child feeding (14). However, to do so effectively they need to be trained in the requisite knowledge and skills, and be supported by supervisors and more highly-skilled health workers to practise accordingly. WHO and UNICEF have developed several courses that can be used for such training (15,16). Research shows that infant and young child feeding counselling provided by community health workers can improve caregiver knowledge and practices and lead to improved health outcomes including child growth.

9.3.3. Training and support of lay and peer counsellors

Health workers often do not have enough time to provide all the help that mothers and families need. Peer and lay counsellors can extend the reach of health services, and provide more easily-accessible infant and young child feeding counselling (17). Peer counsellors have a similar background to those whom they help; they typically are women who have given birth to at least one child and breastfed successfully. Lay counsellors may not have so much in common with those whom they help, and may not have breastfeeding experience. However, both can be effective if committed and well trained. They may provide individual counselling, visit the homes of pregnant or breastfeeding women, lead support groups, give talks to community groups, or work alongside a community health worker in a health facility.

Peer and lay counsellors can be trained in necessary skills using local adaptations of the courses developed for health workers (18). They need an on-going connection to someone who can support them to sustain their efforts, and to whom they can refer difficult cases. This support may be a health worker or a health facility, or a NGO.

9.3.4. Fostering breastfeeding support groups

Breastfeeding support groups, or mother-to-mother support groups, enable mothers to encourage and assist each other to establish and sustain breastfeeding (19). They can also support appropriate complementary feeding. A hospital that is designated Baby-friendly is required, when discharging a mother, to refer her to a breastfeeding support group, if there is one nearby, and to foster and promote the establishment of such groups (see Step 10 in Session 4.7).

Group meetings are led by members with experience and some training, but depend on a sense of equality and acceptance, which encourages mothers to share experiences, ask questions and help each other in a familiar, non-threatening community setting. Breastfeeding support groups can be initiated by health workers from primary and referral level facilities, community health workers, or lay or peer counsellors.

9.3.5. Health workers' roles in supporting community-based approaches

Involvement of the health sector is necessary for community-based approaches to succeed (12). Health workers' supporting roles include:

• Helping with the training of lay or peer counsellors;
• Providing feedback to lay or peer counsellors when they refer infants with feeding difficulties;
• Initiating and participating in breastfeeding support group meetings to provide information and discuss appropriate feeding practices;
• Encouraging women's groups formed for other reasons, such as micro-enterprise, community service, or for economic, social, political or religious reasons, to include support for optimal infant and young child feeding in their activities;
• Participating in other community activities where appropriate infant feeding can be promoted (such as health fairs, community meetings and radio programmes);
• Protecting, promoting and supporting appropriate feeding practices whenever they are in contact with mothers, caregivers or families.