X-f. Infants
There is a clear consensus in the international community on the importance of breastfeeding in infant feeding, expressed in many different ways. The major international initiatives, in chronological order, have been the following:
- In response to concerns about inappropriate marketing and promotion, the International Code of Marketing of Breastmilk Substitutes was adopted by the World Health Assembly (WHA) in 1981. It was supported by a vote of 118 to 1, with only the United States voting against it. The WHA has approved a series of resolutions in subsequent years to further clarify and strengthen the code.
- On August 1, 1990 the Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding was adopted by participants at a meeting on Breastfeeding in the 1990s held at the International Child Development Centre in Florence, Italy. The declaration stated a variety of specific global goals, including the goal that "all women should be enabled to practice exclusive breastfeeding and all infants should be fed exclusively on breast-milk from birth to 4-6 months of age". In 1991 the UNICEF Executive Board passed a resolution (1991/22) saying that the Innocenti Declaration would serve as the "basis for UNICEF policies and actions in support of infant and young child feeding". In May 1996 the World Health Assembly passed a resolution on Infant and Young Child Nutrition (WHA49.15) in which it confirmed its support for the Innocenti Declaration.
- At the World Summit for Children held in September 1990, the overall target in relation to nutrition was: "Between 1990 and the year 2000, reduction of severe and moderate malnutrition among under-5 children by half." The targets set in 1990 included a number of supporting elements related to reduction of the incidence of low birth weight, elimination of iron deficiency anemia, elimination of iodine deficiency disorders, etc. One target called for "Empowerment of all women to breast-feed their children exclusively for four to six months and to continue breastfeeding, with complementary food, well into the second year." These goals were adopted at the summit by most countries of the world.
- On March 15, 1991 the European Union adopted a Directive on Infant Formulae and Follow-Up Formulae which member countries were to implement through their national laws by June 1994. However, this EU directive is weaker than the International Code of Marketing of Breastmilk Substitutes.
- In 1992, the World Declaration and Plan of Action for Nutrition, agreed upon at the conclusion of the International Conference on Nutrition in Rome, made several explicit references to breastfeeding. One of its pledges was to "to reduce substantially within this decade . . . social and other impediments to optimal breastfeeding". The Plan of Action asserted, in article 30, that "Breastfeeding is the most secure means of assuring the food security of infants and should be promoted and protected through appropriate policies and programmes." Article 33 stated that "Governments, in cooperation with all concerned parties, should . . . prevent food-borne and water-borne diseases and other infections in infants and young children by encouraging and enabling women to breast-feed exclusively during the first four to six months of their children’s lives." Article 34 provides a detailed call for action on promoting breastfeeding.
- In 1994 in Cairo the International Conference on Population and Development concluded with a Programme of Action in which breastfeeding was advocated as an important child survival strategy. It also called for policies that would allow working women to breastfeed, for those in the informal (unsalaried) sector as well as those in the formal sector.
- In 1995 the Platform for Action that came out of the Fourth World Conference on Women in Beijing called for promoting public information on the benefits of breastfeeding, implementing the International Code of Marketing of Breastmilk Substitutes, and facilitating breastfeeding by working women.
- In 1995 and 1996 groups associated with the South Asian Association for Regional Cooperation prepared a SAARC Model Code for the Protection of Breastfeeding and Young Child Nutrition, comparable to the International Code of Marketing of Breastmilk Substitutes. It was adopted at the 3rd SAARC Ministerial Conference on Children of South Asia held in Rawalpindi, Pakistan in August 1996.
The efforts at the international level have led to several major streams of action, including the work underway on the marketing code, the baby-friendly hospital initiative, and maternity legislation. Details on these initiatives are provided in other Links. To see how they can be fit into the human rights perspective, it is important to consider a major dilemma relating to breastfeeding rights. How do the woman’s rights relate to the infant’s rights?
In clarifying the law regarding nutrition rights, there is a knotty issue relating to breastfeeding that must be addressed. Infant care and feeding is affected by many different parties, including the infant, the parents, siblings, the extended family, the community, health professionals, employers, formula makers, local government, national government, and others. These are all different parties, each with its own interests and its own capacities to press for outcomes preferable to itself. At times infants are not nurtured properly because of the pull of others’ interests. They are all concerned, more or less, with the infant’s health, but they also have other interests such as profits, increased leisure time, and having opportunities to do other things. Where these parties do not all have preferred outcomes that are consistent with one another, there is conflict among them.
At times the woman and the infant may have conflicting interests. The conflict is raised in clear relief when it is argued that the infant has a right not only to be well nourished but, more specifically, that the infant has a right to be breastfed. Such a right could clash with the woman’s right to choose how to feed her infant.
Article 3 of the Convention on the Rights of the Child says that in all actions concerning children, "the best interests of the child shall be a primary consideration. It is assumed that normally the parents judge what is in the child’s best interests. The state should interfere in the parent-child relationship only in extraordinary situations, when there is extremely compelling evidence that the parents are acting contrary to the best interests of the child.
The infant has great interests at stake, but few resources to be used to press for preferred outcomes. Given the infant’s powerlessness, it is sensible to use the law to help assure that the best interests of the infant are served. However, while it is surely appropriate to use the law to protect the infant from outsiders with conflicting interests, it is not reasonable to use the law to compel an unwilling mother to breastfeed. Thus, for the purposes of framing appropriate law, the woman and infant can be viewed as generally having a shared interest in the infant’s well being. From the human rights perspective, the major concern is with protecting the woman-infant unit from outside interference.
Some individuals feel that women should be obligated to breastfeed their infants, but that appears to be a minority view, one that is not supported by international human rights law. The prevailing view is that women must remain free to feed their infants as they wish, presumably in consultation with other family members, and that outsiders are obligated to refrain from doing anything that might interfere with a freely made, informed decision. Rather than have the state make decisions for them, citizens in a democracy prefer assurances that nothing impedes them from making good decisions. To the extent possible we should be free to choose, and that includes being free to make what others might regard as unwise decisions.
These considerations may be summarized in a number of fundamental principles regarding the nutrition rights of infants:
Principle 1 is derived from article 3 of the Convention on the Rights of the Child. Principle 2 is based on the International Covenant on Economic, Social and Cultural Rights, article 11, and the Convention on the Rights of the Child, article 24, paragraph 1. In Principle 6, the obligation to fulfill does not apply because only the mother or another woman can adequately provide for infants’ nutritional needs. The state is not equipped to fulfill infants’ needs directly. Principle 7 derives directly from the Convention on the Rights of the Child, article 24, paragraph 2e.
In general, the state is obligated to take action to respect, protect, fulfil (facilitate), and fulfil (provide) human rights. In relation to breastfeeding, the state cannot provide directly, but it can respect, protect, and facilitate. Respect means that the government will not itself do anything that interferes with breastfeeding. This has been an issue where, for example, women in the armed services have been denied the opportunity to breastfeed their infants. Protect means that the state will stop others from interfering directly with breastfeeding. This has been an issue where, for example, some localities have passed laws prohibiting breastfeeding in public places. Higher courts have consistently found these laws unacceptable.
The major work, however, is in the area of facilitation through overcoming obstacles to breastfeeding. There are four major arenas in which obstacles must be addressed.
First, there is the issue of the medicalization of infant feeding. In many cases, health professionals and health institutions treat infant feeding as if it were like delivering medicine. In response, the Baby Friendly Hospital Initiative and a number of baby-friendly educational programs are helping to help to promote breastfeeding.
Second, there is the aggressive marketing of infant formula by major manufacturers, both to parents directly and to governments that provide subsidized formula. This is being countered by the International Code of Marketing of Breastmilk Substitutes of 1981 and the effective work of several nongovernmental organizations in promoting the implementation of the code. There are now strong indications that the manufacturers are trying to use exaggerated fear of transmission of HIV through breastfeeding as a new opportunity to promote their products.
Third, there is the problem of facilitating breastfeeding by working women, whether self employed (e.g., in farming) or salaried. Many positive initiatives have been taken, including legislation to insure paid maternity leave and breastfeeding breaks; support of adequate maternity protection; and equal opportunities and equal wages.
Fourth, there is the need to assure community support to initiate, sustain, and maintain breastfeeding. Nongovernmental organizations have frequently taken the lead to establish supportive settings in schools, work places, the media, and public places generally. Governments should provide more vigorous backing for the different forms of community support for breastfeeding.
All of us—parents, families, local communities, governments, etc.—have moral responsibilities for looking after infants. Beyond these moral obligations, however, we also have legal obligations because infants, like others, have specific human rights, plainly established in international law. The ten principles enumerated here summarize the nutrition rights of infants in relation to breastfeeding. There is still much work to be done to assure that these rights are fully realized everywhere.
Continue to X-g. Infants of HIV Positive Mothers
Subsection X-f last updated on September 26, 1999