GENDER RESPONSIVE BUDGETING AND THE AUSTRALIAN NATIONAL

BREASTFEEDING STRATEGYInfant and Young Child Feeding in

Emergencies (IYCF-E)

BACKGROUND PAPER

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Table of ContentsAcronyms..................................................................................................................................2

1. Context.............................................................................................................................4

The way forward for Australia is clear and urgent action is needed.....................................6

2. Introduction......................................................................................................................7

3. Human Rights Instruments and International Guidance.................................................10

Breastfeeding protection, promotion and support, public health, and the World Trade Organization agreements...................................................................................................11

Global health guidance...........................................................................................................11

4. The World Breastfeeding Trends Initiative (WBTi) and the World Breastfeeding Costing Initiative (WBCi)......................................................................................................................15

5. Human rights, gender budgeting and progressing breastfeeding in 2020......................18

Participation..............................................................................................................21

Resources...................................................................................................................21

6. IYCF-E workshop – discussions and areas for development...........................................22

7 Conclusion and recommendations: Key actions needed for advancing breastfeeding protection, promotion, and support in Australia....................................................................24

Recommendations for WBTi action in this area..................................................................24

The jurisdiction emergency management preparedness and response plan (federal/state/local)........................................................................................................24

Cross sectoral work for IYCF-E........................................................................................24

Protecting breastfeeding and reducing risk of formula feeding in emergencies............25

Next steps for WBTi Australia advocacy and action - monitoring and evaluating ANBS implementation on IYCF-E..............................................................................................29

References .............................................................................................................................32

Annex 1. Human Rights Instruments and International Guidance..........................................35

Breastfeeding protection, promotion and support and human rights instruments............35

Breastfeeding protection, promotion and support, public health, and the World Trade Organization agreements...................................................................................................37

Global health guidance.......................................................................................................38

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Acronyms ABA: Australian Breastfeeding Association AIDR Australian Institute for Disaster ResilienceANBS: Australian National Breastfeeding StrategyANU: Australian National UniversityBAA Breastfeeding Advocacy AustralianBFCI: Baby Friendly Community Initiative BFHI: Baby Friendly Hospital Initiative BMS: Breast Milk SubstitutesCESCR: Covenant on Economic, Social and Cultural RightsCEDAW: Convention on the Elimination of All Forms of Discrimination Against WomenCIP: Comprehensive Implementation Plan CRC: Convention of the Rights of the Child DOH: Department of Health FSANZ: Food Standards Australia New ZealandGSIYCF: Global Strategy for Infant and Young Child Feeding GNI: Gross National IncomeIBFAN: International Baby Foods Action NetworkIBLC: International Board-Certified Lactation Consultant IFE: Infant Feeding in Emergencies IYCF: Infant and Young Child FeedingIYCF-E: Infant and Young Child Feeding in Emergencies LCANZ Lactation Consultant Association of Australia and New ZealandMCH Maternal, Child Health NGO: Non-Governmental OrganizationNHMRC: National Health and Medical ResearchOECD: Organisation for Economic Co-operation and DevelopmentOG-IFE: Infant and Young Child Feeding in Emergencies Operational GuidancePHAA Public Health Association of AustraliaSDG: Sustainable Development GoalTRIPS: Trade-Related Aspects of Intellectual Property Rights WBTi: World Breastfeeding Trends InitiativeWBCi: World Breastfeeding Costing InitiativeWHA: World Health AssemblyWHO: World Health OrganizationWTO: World Trade OrganizationUNICEF: United Nations Children’s Fund

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Executive summaryOver 300,000 babies are born in Australia each year, and the recent disasters have heightened public awareness of the need for emergency planning and preparation to keep infants and young children safe. From late 2019, bushfires, air pollution and floods generated disruption, displacement and widespread necessity for emergency and disaster responses in Australian jurisdictions. During the response to the current COVID 19 pandemic, concerns at disruptions to health services including to maternity care practices and breastfeeding support have also come to the fore.

In the 2019 Australian National Breastfeeding Strategy (ANBS), all Australian governments agreed that developing a national policy on Infant and Young Child Feeding in Emergencies (IYCF-E) was a national priority, as was ensuring that skilled breastfeeding and lactation support was available during emergencies and disasters (Department of Health Australia, 2019).

Emergencies and disasters shift all infants and young children and their caregivers into an “at risk” category by heightening the danger that breastfeeding will be reduced or ceased, and by the increased risk that environmental conditions associated with emergencies and disasters pose to infants and young children who are not breastfed. Experiences around the world confirm the reality that breastfeeding is reduced during disasters and evacuations, and maternal and child health can be severely compromised as a result.

Nevertheless, emergency management, health workers, nutrition experts and protection workers can support families to mitigate such adverse impacts.

This document sets out the context and issues for implementation of IYCF-E in Australia. It arises from a 2020 webinar series and workshop at ANU and partnership with NGOs, notably IBFAN/WBTi Australia and Save the Children, and individuals motivated to implement policies which better enable women to breastfeed their babies during emergency and disaster situations in Australia. During April through July 2020 a series of webinars and online workshops were organized and facilitated by prominent public health and gender experts on ‘Gender Budgeting and Breastfeeding’ to galvanise action on breastfeeding protection, promotion and support in Australia. Webinar presentations highlighted key policy, programme and resources gaps including related to breastfeeding protection, promotion and support in emergencies and disasters. Experiences from countries around the world were also shared to stimulate ideas and initiatives for Australia.

Information presented during the webinars then informed two IYCF-E workshops. Workshop participants recommended WBTi Australia develop a strong position paper on IYCF-E to support advocacy, including for an urgent national consultation meeting of all relevant national and state

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level stakeholders on improving Australia’s IYCF-E preparedness and response. Other concrete recommendations were made, linked to relevant action areas of the ANBS. Participants agreed to ensure close monitoring and tracking of progress in advancing the IYCF-E agenda in line with monitoring tools and timeline endorsed by Australian Governments in the ANBS.

To provide a background for WBTi Australia’s future work, this paper outlines international policies and guidance on IYCF-E, including the human rights context. It also describes Australian experience and policy

context on IYCF-E, and the gaps and challenges and recommendations for policy action and financing identified by the 2018 WBTi Australia Assessment Report. Finally, it sets out the key ANBS action areas related to IYCF-E, with a focus on the areas related to emergency planning, and on ensuring access to skilled support, but also identifying other relevant action areas of the ANBS such as the Baby Friendly Hospital Initiative (BFHI) and the WHO Code, donor human milk banking, and the NHMRC Dietary Guidelines and Infant Feeding Guidelines for Health Workers.

Progressing breastfeeding policy in Australia: Infant and Young Child Feeding in Emergencies

1. Context

Over 300,000 babies are born in Australia each year, and the recent disasters have heightened public awareness of the need for emergency planning and preparation to keep infants and young children safe. From late 2019, bushfires, air pollution and floods generated disruption, displacement and widespread necessity for emergency and disaster responses in Australian jurisdictions. During the emergency response to the current COVID 19 pandemic, concerns at disruptions to health services including to maternity care practices and breastfeeding support have also come to the fore.

It is well known that gender1 affects vulnerability (Parkinson et al., 2018), and inadequate planning and emergency responses can worsen the impacts of disasters. In early 2018 a rapid 1 Gender: Gender refers to the roles, behaviors, activities, attributes, and opportunities that any society considers appropriate for girls and boys, and women and men. Gender interacts with, but is different from, the binary categories of biological sex. From WHO: https://www.who.int/health-topics/gender

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“We were so overwhelmed by everything that was happening that we weren't aware that our baby wasn't getting enough breast milk at first, and then people didn't have enough time or energy to offer advice and help with possible alternatives to breastfeeding. I

“We lost power and were told not to use the water. We were also unable to get to shops, chemists etc. We had purchased bottled water prior to the flood but my biggest concern was running out of formula. It was also quite difficult sterilising bottles without power. “*

review of evidence commissioned to inform development of the ANBS had already identified infant and young child feeding in emergencies and disasters (IYCF-E) as an area requiring attention in Australia (Smith et al., 2018). This is despite the fact that emergencies commonly disrupt breastfeeding, even though emergency circumstances increase the importance of breastfeeding.

The evidence review focused on disasters in OECD and high-income country settings, and concluded that implementing specific measures to protect, support and promote recommended breastfeeding can prevent disruption to IYCF during and after emergencies.

A subsequent policy assessment by WBTi Australia (Hull, Smith, Peterson, & Hocking, 2018; World Breastfeeding Trends Initiative Australia et al., 2018), and a related audit of emergency planning documents in Australian jurisdictions (Gribble, Peterson, & Brown, 2019) revealed significant ongoing gaps in Australia’s planning for IYCF-E.

Reports of infants being wet nursed in evacuation centres as a last option rather than as implementation of best practice guidance, illustrate the lack of planning and guidance for those supporting IYCF-E in Australia (Gribble, 2017, 2020). Experience during the COVID-19 pandemic has reinforced concerns at emergency planning in health services including in Australia (Gribble, 2020; Hull, Kam, & Gribble, 2020).

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“We were so overwhelmed by everything that was happening that we weren't aware that our baby wasn't getting enough breast milk at first, and then people didn't have enough time or energy to offer advice and help with possible alternatives to breastfeeding. I

The way forward for Australia is clear and urgent action is needed

The Australian National Breastfeeding Strategy (ANBS) released in June 2019 noted that:

‘Breastfeeding provides a safe and reliable method of infant feeding in emergencies, providing a consistent source of adequate nutrition and protection against

infections’ (Australia. Department of Health, 2019) .

In the ANBS, Australian governments agreed that developing a national policy on infant and young child feeding in emergencies (IYCF-E) was a national priority, as was ensuring that skilled breastfeeding and lactation support was available during emergencies and disasters (Australia. Department of Health, 2019). As at mid-2020, no progress was reported on this Priority Action area by the federal Department of Health or relevant state health or emergency management service agencies.

Emergencies and disasters shift all infants and young children and their caregivers into an “at risk” category by heightening the danger that breastfeeding will be reduced or ceased, and by the increased risk that environmental conditions associated with emergencies and disasters pose to infants and young children who are not breastfed.

Breastfeeding is one of the most cost-effective interventions to reduce infant mortality or morbidity and ensure appropriate growth and overall wellbeing, in all contexts and even more during emergencies. Without early initiation of breastfeeding, and ongoing exclusive breastfeeding infants and young children are at a higher risk in the short term of acquiring infections and of acquiring non-communicable diseases later in life (Horta, Bahl, Martines, & Victora, 2007). Breastfeeding supports normal cognitive development and children who were not breastfed are found to perform poorer on intelligence tests, have lower school attendance and a lower income in adult life (Jones, Steketee, Black, Bhutta, & Morris; Victora et al., 2016). Longer duration of breastfeeding also contributes to the health and wellbeing of the mothers, including reducing the risk of ovarian and breast cancers and helping to space pregnancies.

The economic consequences of insufficient breastfeeding are substantial, with reduced cognitive development, higher health costs and deaths, estimated to amount to $302 billion annually, or 0·49% of world GNI (Rollins et al.). Investing in breastfeeding programmes is a sound and fair investment as it protects the right of women and their children to breastfeed and is the safest and most reliable source of food for infants during emergencies.

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“It was comforting to know that as long as I was with my baby, she would get what she needed. I felt sorry for women who did not breastfeed because it would have been difficult to bottle or formula feed during the floods.” *

In disasters, families living in disadvantaged communities are often of lower socio-economic status and particularly hard hit, with more exposure to harm, and less access to resources to help them cope.

Experience in the past 12 months has amply demonstrated that there is a critical gap in emergency planning and the need for urgent action by Australian governments on IYCF-E.

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2. Introduction

Infants and young children who are not optimally breastfed are at a higher risk of acquiring infections and of acquiring non-communicable diseases later in life (Horta et al., 2007). Breastfeeding supports normal cognitive development and children who were not breastfed are found to perform poorer on intelligence tests, have lower school attendance and a lower income in adult life (Jones et al.; Victora et al., 2016). Longer duration of breastfeeding also contributes to the health and wellbeing of the mothers, including reducing the risk of ovarian and breast cancers and helping to space pregnancies. The economic consequences are likely to be substantial, with reduced cognitive development, higher health costs and deaths, estimated to amount to $302 billion annually, or 0·49% of world GNI (Rollins et al., 2016).

Breastfeeding is the recommended way to feed human infants, and underpins appropriate development including of immune responses (Hanson, 2004). Breastfeeding is well known to provide immune protection and prevent various diseases in the perinatal period, studies have shown that exclusively breastfeeding infants develop a stronger immune system (Jackson & Nazar, 2006). During an emergency, breastfeeding is the recommended and safe way to feed infants and underpins

resilience in disaster-affected populations.

Breastfeeding remains the recommended way of feeding infants also in the context of HIV and other infectious diseases like Hepatitis B, Tuberculosis and influenza. Recommendations are that HIV positive or suspected women should be encouraged and supported to breastfeed their infants, to prevent all the risks of not breastfeeding (World Health Organization (WHO), 2016).

The COVID 19 pandemic, a global health emergency of unprecedented nature, affecting more than 200 countries in the world, highlighted once again that breastfeeding protection, promotion and support is of paramount importance in all contexts. WHO recommendations reiterate that women for whom COVID 19 is suspected or confirmed can breastfeed their infants, as any minimal risk of transmission is outweighed by the various benefits brought by breastfeeding and human milk feeding (World Health Organization (WHO), 2020a, 2020b). The same recommendations emphasize that even when the mother is too ill to breastfeed or provide expressed milk, wet nursing or donor human milk feeding are preferred options.

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WHO recommendations reiterate that women for whom COVID 19 is suspected or confirmed can breastfeed their infants, as any minimal risk of transmission is outweighed by the various benefits of breastfeeding. Even a mother with confirmed/suspected COVID-19 is not able to breastfeed or to express breastmilk, wet nursing or donor human milk feeding can be options.

During a disaster, stress and fear may affect a caregiver’s capacity to care for their children if they are not supported. At the same time, food and water supplies may be insecure and health infrastructure damaged. Yet protecting safe infant feeding is often an afterthought in emergency preparedness and response.

Member States have through the years have endorsed evidence-based protocols and guidance that calls for the protection, promotion, and support of breastfeeding even during emergencies (World Health Assembly (WHA), 2010). Global recommendations have emphasized the role that wet nursing and donor human milk share may have in emergencies context, as a safer alternative when breastfeeding from the biological mother is not possible, even in contexts of high HIV prevalence (World Health Assembly (WHA), 2016)(IFE Core Group, 2017; World Health Organization (WHO), 2004).

Experiences around the world show that breastfeeding is reduced during disasters and evacuations and maternal and child health can be severely compromised. Nevertheless, emergency management, health workers, nutrition experts and protection workers can support families to mitigate such adverse impacts.

This document sets out the context and issues for implementation in Australia of IYCF-E.

The paper arises from a 2017 workshop at ANU and partnership with NGOs notably IBFAN and Save the Children, and individuals motivated to implement policies which protect, promote and support women to breastfeed their babies in Australia also during emergencies situations.

Section 1 outlines the international policies and guidance on IYCF-E, including the human rights context. It introduces the Global Strategy on Infant and Young Child Feeding (GSIYCF) and the Infant and Young Child Feeding in Emergencies (IYCF-E) Operational Guidance, and other relevant international guidance and standards.

Section 2 brings in the Australian experience and policy context. This section describes the performance of Australian policy World Breastfeeding Trends Initiative (WBTi) report in 2018, and general achievements since then. It does so against the background of evidence that the funding and implementation of breastfeeding policies, especially on IYCF-E, have been very poor globally. The report presents the gaps and challenges identified by the Australia WBTi report, including in IYCF-E, and summarises its recommendations for policy action and financing.

Section 3 outlines the international policies and guidance on IYCF-E, including the human rights context. It introduces the Global Strategy on Infant and Young Child Feeding (GSIYCF) and the Infant and Young Child Feeding in Emergencies (IYCF-E) Operational Guidance, and other relevant international guidance and standards.

Section 4 illustrates the Australian experience and policy context. This section describes the performance of Australian policy World

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Breastfeeding Trends Initiative (WBTi) report in 2018, and general achievements since then. It does so against the background of evidence that the funding and implementation of breastfeeding policies, especially on IYCF-E, have been very poor globally. The report presents the gaps and challenges identified by the Australia WBTi report, including in IYCF-E, and summarises its recommendations for policy action and financing.

This section also introduces the Australian National Breastfeeding Strategy (ANBS), 2019, and the process of its development. It briefly outlines ANBS key action areas of most relevance to this background paper. These actions are the focus of the Australian governments’ agreed Priority Actions on emergency planning and ensuring access to skilled support, for example health professional (HP) education and training. IYCF-E action in Australia is also required in other ANBS policy areas in particular, implementation of the WHO Code and the Baby Friendly Hospital Initiative (BFHI), donor human milk banking, and updating of IYCF-E content in the NHMRC Dietary Guidelines and Infant Feeding Guidelines for Health Workers.

Section 5 summarises the ‘Gender Budgeting and Breastfeeding Webinar series, which aimed to galvanise action on breastfeeding protection and support in Australia and including workshops which aimed to build capacity and guide efforts to achieve this.

Section 6 provide a snapshot of the discussions facilitated during the IYCF-E workshops to sets goals to galvanise effective action on IYCF-E in Australia, to ensure national implementation of IYCF-E at all levels of government and for all families in Australia.

Section 7 presents the conclusion from the IYCF-E workshop, with a series of concrete recommendations that will need to be implemented to be able to operationalize the actions of the ANBS linked with IYCF-E. It makes recommendations for IYCF-E advocacy and policy progress based on the international and Australian policy context, and through the strategies and pathways identified through the WBTi Australia and related processes.

Section 8 summarises the ANBS tools, timetable and relevant monitoring framework for the monitoring and tracking of the progress of the implementation of the ANBS.

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3. Human Rights Instruments and International Guidance

The Covenant on Economic, Social and Cultural Rights (CESCR), the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW), and the Convention on the Rights of the Child (CRC)

Global guidance and recommendations for IYCF-E are upheld by several human rights treaties to which Australia is committed. These commitments are covered by treaties such as the Covenant on Economic, Social and Cultural Rights (CESCR), the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW), and the Convention on the Rights of the Child (CRC).These are summarised below, with further detail in Annex 1.

IMPORTANT NOTE: The Government of Australia is a State Party to all three treaties mentioned below:CESCR: ratified in 1980CEDAW: ratified in 1983CRC: ratified in 1990

Linkages between breastfeeding protection, promotion, and support and the CESCR

The International Covenant on Economic, Social and Cultural Rights (CESCR) recognizes the right to enjoy "the highest attainable standard of physical and mental health", including the reduction of infant mortality and the healthy development of the child (Article 12).

Linkages between breastfeeding protection, promotion, and support - the CEDAW

Article 10 of CEDAW protects access to information to ensure the health and well-being of families.

Article 11 confers the right to health "including the safeguarding of the function of reproduction", while Article 12 assures "adequate nutrition during pregnancy and lactation", thus recognizing the importance of breastfeeding.

Linkages between breastfeeding protection, promotion, and support - the CRC

The Convention on the Rights of the Child (CRC 1989) provides the most comprehensive international human rights framework for facilitating enhanced Code implementation and monitoring. The CRC recognizes that all children have the right to the highest attainable standard of health, specifically the right to good nutrition (Art.24), including breastfeeding. This principle addresses unfairness, or social inequities in infant feeding in Australia unequal access to breastfeeding support and protection, which result in differences in vulnerability and resilience to disasters across the Australian population.

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Article 24 requires the Government and other duty bearers (including the private sector) to take all necessary measures (including the adoption of all relevant legislation, policies and programmes) to ensure that all sectors of society, particularly parents, "have access to education and are supported in the use of basic knowledge of child health and nutrition, the advantages of breastfeeding..."

As a State Party to the CRC, the Government of Australia is legally bound by the CRC provisions, and is required to bring national laws and policies in line with the CRC.

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Breastfeeding protection, promotion and support, public health, and the World Trade Organization agreements

WTO agreements and Public Health: a joint study by the WHO and the WTO Secretariat (2002)

The endorsement by the international community of the Doha Declaration on the Trade-Related Aspects of Intellectual Property Rights (TRIPS) Agreement and Public Health is a very visible expression of governments' commitment to ensuring that the rules-based trading system is compatible with public health interests.

In 2020 WHO and UNICEF issued an information brief on the implication of trade agreements for domestic implementation of the Code for policy makers, regulators, and other relevant officials (World Health Organization (WHO) & UNICEF, 2020).

The brief conclusions highlight that:“States have obligations to protect, respect and fulfil the right to health under international human rights law, including an obligation to protect and support breastfeeding under Article 24 of the Convention on the Rights of the Child (CRC). “

Global health guidance

World Health Organization (WHO) International Code of Marketing of Breastmilk Substitutes

The WHO International Code of Marketing of Breastmilk Substitutes was agreed by governments in 1981 at the World Health Assembly to stop the harmful promotion of commercial breastmilk substitutes while making them available when needed. Australia has endorsed the Code.

The Code was adopted as a "minimum requirement", it sets the floor for acceptable standards rather than the ceiling. Such flexibility in standard setting is particularly important for policies that deal with marketing practices and products, as marketing practices and product

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MINISTERIAL CONFERENCE Declaration on The Trips Agreement and Public Health“Art. 4 We agree that the TRIPS agreement does not and should not prevent Members from taking measures to protect public health. Accordingly, while reiterating our commitment to the TRIPS Agreement, we affirm that the Agreement can and should be implemented in a manner supportive of WTO

lines change in response to market conditions also during emergencies situations. Figure 1 presents a ten-point summary of the Code, scope, coverage, and main recommendations.

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Figure 1 The Code: A 10-point summary

Subsequent WHA resolutions

Subsequent Resolutions have clarified articles in the Code considering ongoing scientific investigation and to address questions of interpretation. While these resolutions do not formally amend the Code, they nevertheless convey the collective views of WHO Member States on the subject. Thus, when Member States seek to develop policies in this area, they may well choose to refer not only to the Code itself but also to subsequent relevant WHA Resolutions.

For example, in May 2016, the WHA recommended Member States implement measures that would prevent the inappropriate promotion of foods for infants and young children (World Health Assembly (WHA), 2016).

IMPORTANT NOTE: Under Article 18 of the WHO Constitution, such Resolutions of the WHA have the same status as the Code.

The Innocenti Declaration and the Global Strategy for Infant and Young Child FeedingThe Innocenti Declaration (which was updated in 2005) identified the need for a government structure and system for the management and support of breastfeeding programmes, including during emergencies (World Health Organization (WHO) & UNICEF, 1990). It recommended that all health facilities with maternity services implement the Ten Steps

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for Successful Breastfeeding, leading to the WHO/UNICEF Baby Friendly Hospital Initiative (BFHI) (World Health Organization (WHO), 2018). It also reiterated the importance of implementing the Code and the passage of legislation, in favour of maternity protection in the workplace (paid maternity leave for at least 18 weeks, paid breastfeeding breaks, and where possible creches).

Recognising that women’s individual breastfeeding decisions were influenced by the wider cultural and social environment, the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) endorsed the Global Strategy for Infant and Young Child Feeding (World Health Organization/UNICEF (WHO/UNICEF), 2003).

This recommends breastfeeding to be optimal infant and young child feeding as in Table 1.

Table 1: WHO/UNICEF optimal Infant and Young Child Feeding recommendations

World Health Organization (WHO) Guiding Principles for Feeding Infants and Young Children During Emergencies

There has been global guidance on infant and young child feeding in emergencies since 2004, when WHO issued Guiding Principles for Feeding Infants and Young Children During Emergencies (World Health Organization (WHO), 2004). These policy principles reaffirm the importance of protecting, promoting, and supporting breastfeeding during calamities, while limiting and strictly controlling the use of breast milk substitutes, and the role of complementary feeding. In 2007, the Infant Feeding in Emergencies (IFE) Core Group, built on WHO’s guiding principles by issuing Operational Guidance on IYCF in Emergencies.

In 2010, the WHA Resolution 63.23 urged that interventions to improve infant and young child nutrition be scaled up and integrated as core interventions with the protection, promotion, and support of breastfeeding and timely, safe, and appropriate complementary feeding.

Through the 2015 Sustainable Development Goals (SDGs), all countries, including high income countries, committed to mobilize efforts to end all forms of poverty by 2030 and improve access to reproductive health services, as well as to increase exclusive breastfeeding rates to 70% by 2030 (United Nations (UN), 2015). Breastfeeding is central to SDG “nutrition” and health goals, as well as other SDG goals (UNICEF, 2018).

Reflecting the May 2016 Resolution by the WHA on preventing inappropriate promotion of foods for infants and young children, in 2017,

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Recommended Infant and Young Child Feeding practices (including during emergencies)Initiate breastfeeding immediately after birth (within the 1st hour)Exclusive breastfeeding for the first 6 monthsComplementary feeding:

timely (introduced at 6 months or 180 days)‐ adequate (energy and nutrients)‐ safe (hygienically prepared, stored, used)‐ appropriate (frequency, feeding method, active feeding)‐

Continued breastfeeding from six months up to 24 months or beyond

the updated Operation Guidance was released by the IFE Core Group (OG-IFE) (Version 3.0), increasing its emphasis on the needs of the non-breastfed children, the importance of appropriate and timely complementary feeding and foods2, and re affirming the six multi-sectoral actions needed to ensure the protection, promotion and support of infant and young child feeding in emergencies (IFE Core Group, 2017).

In 2018, the WHA endorsed WHA Resolution 71.9 affirming that “recognizing that appropriate evidence-based and timely support of infant and young child feeding in emergencies save lives, protects child nutrition, health and development, and benefits mothers and families”. It urged Member States to: “take all necessary measures to ensure evidence-based and appropriate infant and young child feeding during emergencies, including through preparedness plans, capacity-building of personnel working in emergency situations, and coordination of intersectoral operations”.

All humanitarian workers and agencies are required to: “Uphold the provisions of the Operational Guidance on infant feeding in emergencies (IFE) and the International Code of Marketing of Breastmilk Substitutes and subsequent relevant World Health Assembly (WHA) resolutions (collectively known as the Code)” in line with the 2018 Sphere Standards (The Sphere Project, 2018).

Globally, little progress has been made on policy for IYCF in emergencies. Work by IBFAN using the WBTi tool shows that maternal nutrition, breastfeeding, and complementary feeding practices remain poorly addressed by policymakers, despite almost 40 years since endorsing the Code, and then the Innocenti Declaration, the BFHI, the GSIYCF, the IYCF-E Operational Guidance, other relevant recommendations and 20 World Health Assembly Resolutions (Gupta, Suri, Dadhich, Trejos, & Nalubanga, 2019).

The WBTI analysis shows that countries with the worst implementation of policy areas for IYCF in general have the greatest gaps in policy for infant feeding in emergencies.

2 WHO (Complementary feeding is defined as the process starting when breast milk alone is no longer sufficient to meet the nutritional requirements of infants, and therefore other foods and liquids are needed, along with breast milk. The transition from exclusive breastfeeding to family foods – referred to as complementary feeding – typically covers the period from 6–24 months of age, even though breastfeeding may continue to two years of age and beyond. https://www.who.int/elena/titles/complementary_feeding/en/ accessed on July 1,2020

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Countries’ actions to improve the situation lag even more on infant feeding in emergencies and disasters.

4. The World Breastfeeding Trends Initiative (WBTi) and the World Breastfeeding Costing Initiative (WBCi)

The World Breastfeeding Trends Initiative (WBTi), was developed to measure progress. (International Baby Food Action Network (IBFAN)). The tool helps identify gaps in existing policies and programs and enables advocacy. The tool uses a set of fifteen indicators, ten indicators looking at different policy areas and 5 indicators looking at infant feeding practices. Each indicator receives a grade out of ten, and overall, the country will have a score out of 150. The assessment process enables collaboration between various actors, such as clinicians, academics, policy advisors, and relevant organisations.

WBTi in AustraliaWBTi was implemented in Australia in 2017 by a WBTi Australian core group following the a ‘Gender Responsive Budgeting and Breastfeeding’ workshop at the Australian National University (ANU)

This event was motivated by other country’s WBTi assessment results that showed that many policies for breastfeeding were rarely funded enough to be effective. It was hoped that a gender perspective in this process would be beneficial. No other nations had completed the assessment with a gender lens prior to the Australian assessment.

IBFAN representative Dr Shoba Suri provided training and a core group of eleven individuals was formed that included representatives from the Australian Breastfeeding Association (ABA), Breastfeeding Advocacy Australia (BAA), the Lactation Consultant Association of Australia and New Zealand (LCANZ), and the Public Health Association of Australia.

A broader reference group included organisations such as UNICEF Australia, Breastfeeding Coalition of Tasmania, Childbirth and Parenting Educators of Australia and the South East Queensland Breastfeeding Coalition (Hull, 2018).

The indicator that specifically looks at IYCF-E is Indicator 9. The analysis found a lack of national policy/guidelines in Australia that contain even basic elements of the OG-IFE on management and preparedness for infants and young children in an emergency. There is an absence of co-ordination of those responsible for IYCF-E and no emergency response and preparedness education of health professionals that are aligned with IYCF-E principles. Australia scored a total of 0.5/10 for this Indicator (Gupta, 2019).

The report showed poor performance in areas necessary for infant feeding in emergencies namely, inadequate national coordination, health professional breastfeeding education and monitoring of infant feeding. Australia scored well for maternity protection (indicator 4) due to

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The Australian government and health system did not perform well in policy areas for infant feeding in an emergency (or pandemic), and that is the focus of this document.

parental leave policies, anti-discrimination legislation, and baby-friendly health accreditation. Consequently, Australia’s WBTi score was 25.5/150. This placed Australia third from the bottom of a table of 97 countries globally (Gupta, 2019).

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WBTi Australia Report Recommendations on ICYF-E

The following key recommendations in the WBTi Australia Report were also the basis for its submission to the Royal Commission into Natural Disaster Arrangements in 2020.

1. Federal Department of Health to be designated in the COMDISPLAN as the resource agency providing advice and expertise on IYCF-E.

2. Federal Department of Health to convene and appropriately fund a national advisory committee on IYCF-E with the purpose of incorporating the needs of mothers, infants and young children into emergency management planning at all levels of government, and to ensure that appropriate agencies take responsibility for IYCF-E. This committee must include a broad range of stakeholders from all levels of government, health organisations and emergency management organisations.

3. Indicators related to IYCF-E to be included in the National Breastfeeding Strategy.

4. Australian Institute for Disaster Resilience to produce a Disaster Resilience Handbook on IYCF-E and integrate cross-cutting IYCF-E issues into other Handbooks (e.g. Disaster Health, Planning for Spontaneous Volunteers, Evacuation Planning).

5. Orientation and training on IYCF-E to be required for Defence personnel involved in emergency management and response.

6. Existing Australian education and training on IYCF-E (e.g. ABA and National Critical Care and Trauma Centre, Darwin) to be made available to all relevant health and emergency workers.

Impact and successes of WBTi Australia.

A unique strength of WBTi is that the process is participatory and designed to galvanise advocacy and action. Our WBTi assessment report is the first in the world to embed an explicit gender analysis. IBFAN is moving to incorporate the gender budgeting approach pioneered by our team to assist policy and program costing, and advocacy for adequate funding.In Australia, the WBTi Report and related processes and follow up has influenced awareness, advocacy, and action through our ‘triple A’ approach (Awareness, Advocacy and Action).Firstly, team activities have raised Awareness of the problem, among health workers, policy decisionmakers and the public:

Communication via WBTi and other online blogs, social media, relevant newsletters, and academic journal publications;

Via health conferences and workshop presentations such as to expert meetings on the ANBS. The WBTi Australia team won an

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award for best paper in the Advocacy and Leadership category at the National Public Health Association of Australia 2018 conference;

And also, through meetings with Ministers and public health officials about the Australia’s score.

Secondly it has stimulated Advocacy: Advocacy to government, involving discussions or meetings with

several federal and state Ministers and departments of healthThirdly, it has generated capacity and Action, initiating constructive engagement with health policy makers, services, and professional organisations.The WBTi Australia Report Card has been embedded as ‘international benchmarking’ within the Australian National Breastfeeding Strategy 2019, and reproduced in the 2019   Children’s Rights report published by the Australian Human Rights Commission.The World Breastfeeding Costing Initiative (WBCi) and Gender Responsive BudgetingAlongside policy assessment is a need for financial resources, gender sensitive budgets for women and children and IYCF (Gupta, 2019).The WBCi Financial Planning Tool assists countries plan and budget their strategies for implementing GSIYCF and follows the principles and structure of the World Breastfeeding Trends Initiative (WBTi) (IBFAN Asia). The main purpose of the tool is to assist national program managers, partners, government, donor, policy makers for financial planning of IYCF policy and programmes.

The WBCi tool is excel based, flexible, user friendly and countries can easily customize it to meet their needs and generate annual as well as multiyear estimates for IYCF. It is intended for programme managers and partners to initiate advocacy with national govt. and donors and can be used by planners, MCH/nutrition coordinators, public health practitioners, and finance personnel in developing budgetThe tool assists in planning and budgeting for women and children.

Training in the WBCi was provided in 2017 to the WBTi Core Team Australia, and this was updated in the 2020 webinar series on Gender Responsive Budgeting and Progressing Breastfeeding Policy in 2020 and Beyond’.

7.

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5. Human rights, gender budgeting and progressing breastfeeding in 2020

Between April and end July 2020, there were 6 webinars hosted by the ANU Crawford School of Public Policy in the ‘Gender Responsive Budgeting and Progressing Breastfeeding Policy in 2020 and Beyond’ series. These were organised in partnership with Save the Children and IBFAN/WBTi Australia.

The 2020 program follows up the highly successful ‘Gender Budgeting and Breastfeeding’ event held at ANU in 2017 at which WBTi Australia was cofounded by Associate Professor Julie Smith and Naomi Hull. The World Breastfeeding Trends Initiative (WBTi) is an innovative initiative of BPNI/IBFAN Asia, which aims at strengthening and stimulating action to protect, promote and support breastfeeding worldwide’.

The forums aimed to galvanize efforts to improve breastfeeding policies and funding in national budgets.

These webinars aimed to galvanize efforts to improve breastfeeding policies and funding in Australian governments’ budgets. The program was initially organised as a 3-day forum and workshop from 7-9 April 2020 but reconfigured into an online series due to the COVID 19 pandemic lockdown announced in mid-March,2020.

The Human rights, gender budgeting and progressing breastfeeding policy in Australia webinar program project has been a highly innovative and adaptive element of cutting edge and high impact research activity at the ANU on the economics of breastfeeding and gender responsive budgeting. It is advancing in partnership with leading national and international health and women’s NGOs such as WBTi Australia, International Baby Food Action (IBFAN), the Lactation Consultants Association of Australia (LCANZ) and the Save the Children, as well as strengthening academic collaborations .

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Gender Responsive Budgeting and Progressing Breastfeeding Policy in 2020 and Beyond’The introductory webinar ‘Gender Responsive Budgeting and Progressing Breastfeeding Policy in 2020 and Beyond’ was held on Monday 6 April. This webinar introduced the concepts and tools for a gender analysis of budgeting for breastfeeding. Speakers outlined how to apply gender analysis including to government budgeting, and the usefulness of using the WBTi tool to assess country policies and budgeting for breastfeeding. Participants were shown how the WBCi tool could be used for advocacy with an example of budgeting for policy development and WHO Code implementation in the Philippines. A presentation by officials from the federal Department of Health provided a summary of the 2019 Australian National Breastfeeding Strategy, including how it was developed, and the key action areas. The key topics covered during the webinar were the following:

1. Introduction to Gender Budgeting - Miranda Stewart, ANU and Melbourne Law School.

2. Measuring implementation, the WBTi experience - JP Dadhich, IBFAN Asia.

3. Budgeting and advocacy using WBCi tool - Alessandro Iellamo, Save the Children

4. The Australian National Breastfeeding Strategy- Alice Knight, Australian Department of Health

WBTi Australia had identified that in Australia as well as in other countries, the IYCF-E component of the Global Strategy is particularly poorly implemented. In times of health crisis and emergency, including COVID-19, the implementation of the WHO/UNICEF Global Strategy for Infant and Young Child Feeding and the Operational Guidance for Infant and Young Child Feeding in Emergencies (OG-IFE) is more important than ever, but it is hindered by lack of investment in breastfeeding policies and plans nationally that includes emergency preparedness and response.

Emergency and pandemic preparedness and response planning in Australia

Hence, two webinars focussed on IYCF-E. On 20 April, a webinar focussed on Health and Disaster Management for Mothers and their Babies from 20 April. Experts in gender and emergencies, infant and young child feeding in emergencies, Australian breastfeeding policy, and experiences of disasters drew on global experience including from Japan, New Zealand, Italy and Australia.

The following topics were covered during the webinar:

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These webinars raised questions about how to apply the tools of gender analysis and budgeting to inform our advocacy (and recover from any backward steps during COVID 19 pandemic), to secure the resources for breastfeeding protection, promotion and support in Australia.

1. Gender Emergency Management - Debra Parkinson, Monash University

2. Global IYCF-E guidance and recommendations - Alessandro Iellamo, Save the Children

3. WBTi’s Australia IYCF-E findings - Naomi Hull, WBTi Australia4. Emergency response and required actions on IYCF-E 2020 -

Karleen Gribble, Western Sydney University

Progressing Australia’s policy, planning and protocols for mothers and babies in health disastersA further webinar on 4 May provided opportunities for experts to share with Australians some lessons learned, and experiences related to infant and young child feeding in emergencies and infant feeding in the context of COVID 19, in high- and middle-income countries. Experts from across the world presented how their countries are working towards better plans and policies to protect women and children in times of emergencies and in pandemic situations.

This webinar covered the following topics:

1. The IYCF-E in New Zealand, experience in Christchurch experience- Carole Bartle, NZ College of Midwives

2. Philippines experience power of relactation and wetnursing - Innes Fernandez, Arugaan Phillipines

3. The role of NGOs in addressing Japans IYCF-E challenges and policy gaps - Hiroko Hongo, Infant and Young Child Feeding Support Network in Japan

4. IFE preparedness and response in a devolved health system, Italian experience - Angela Giusti, Italian National Institute for Health and Julia Bomben, Pedagogist, formerly BFHI Italy.

‘Protecting women’s reproductive rights in policy and resourcing decisions – the need for ‘data and dollars’

A webinar ‘Protecting women’s reproductive rights in policy and resourcing decisions – the need for ‘data and dollars’ was held on Monday 18 May which came back to how a gender budgeting lens can contribute to gender equality, including by identifying what is needed in the way of data and dollars to protect, promote and support breastfeeding in Australia, and by looking across various components of government budgets. Presentations also covered how economic statistics are biased in their view of economic activity, looking only at the icing on the cake, not its foundational ingredients and layers of care work. Time use data is crucial so we can see and value the unpaid work that households, mainly women do, and so too is good data needed to make breastfeeding visible and policy well informed in Australia. The webinar covered the following topics:

1. Data, dollars, and democratic deficits – prioritizing women’s concerns in Australian fiscal decision making - Marian Sawer, ANU

2. Gender budgeting for breastfeeding – Addressing and prioritizing the invisible IYCF economy in economic statistics and budget policy making Julie Smith, ANU

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3. Back to work, time for a time survey that accurately counts women’s ‘work productivity’ amidst the COVID 19 pandemic disruption- Lyn Craig, University of Melbourne

4. Breastfeeding data for policy visibility, implementation, and accountability - Lisa Amir, La Trobe University.

Advancing women’s and children’s health rights, gender responsive budgeting and progressing the Australian National Breastfeeding Strategy in maternity care The fifth webinar was held on 29 June and focussed on advancing women’s and children’s health rights, gender responsive budgeting and progressing the Australian National Breastfeeding Strategy in maternity care.

Experts from Australia, Thailand, and the United States presented on aspects of protecting, promoting and supporting breastfeeding in maternity care services, including through WHO Code implementation and quality maternity care.

This webinar covered the following topics:

1. Opening remarks - Michael Moore, formerly World Federation of Public Health Associations and ACT Health Minister

2. Global progress and problems in BFHI implementation – health and welfare systems as marketing channels - Rachel Pickel Legal Consultant, UNICEF East Asia and Pacific Regional Office

3. Can gender-responsive budgeting contribute to better maternity care in Australia’s federal system? Empowering civil society to get data, decisions and dollars for baby friendly hospitals and skilled breastfeeding support Julie Smith ANU, Naomi Hull WBTi Australia, Alessandro Iellamo Save the Children.

4. Managing media and post COVID 19 advocacies for women’s health rights in Australian maternity care, Hannah Dahlen, Western Sydney University

5. Progressing policy and regulation of milk banking and milk sharing – ANBS actions - Libby Salmon, ANU

6. Advancing the rights of incarcerated mothers, and their infants and young children - Karleen Gribble, Western Sydney University

7. Progress on BFHI and the Ten Steps in US maternity care settings, Melissa Bartick, Harvard University

‘Back to work’ or ‘babysitting the economy’? – Advancing public health and productive work through investments in maternity protection and childcare The sixth webinar was held on 27 July and focussed on advancing public health and productive work through investments in maternity protection and childcare.

Experts presented on the political economy of ‘first food systems’, how paid maternity leave affected breastfeeding and health in Australia, dependency and its implications for gender economic equality, and what is needed for addressing the dependency and separation through breastfeeding friendly workplaces and childcare.

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This webinar covered the following topics:

1. Ultra-processed foods, first-food systems and corporate power', Phil Baker, Deakin University

2. Paid maternity leave: how it enables breastfeeding and improves women’s health in Australia, Lyndall Strazdins, Australian National University

3. Making care work count: Gender-responsive budgeting (GRB) including cost analyses of policy inaction as strategy for linking gender equality policy to public budgets, Siobhan Austin, Curtin University

4. The origins and future of the Australian Breastfeeding Association’s breastfeeding friendly workplace (BFW) accreditation program – making every job ‘breastfeeding friendly’, Sally Eldridge, Australian Breastfeeding Association

5. What do we know about human rights and breastfeeding friendly childcare? The ANBS and public investments in quality care for infants and young children, Julie Smith, Australian National University and Julie McGuire, Queensland University of Technology

6. ‘How is ‘work from home’ and ‘childcare’ changing for families with infants and young children. Policy directions for breastfeeding friendly care infrastructure for our COVID 19 new normal’, Emma Woolley, NSW Health

ParticipationMore than 430 individuals registered for these online events, many attending all or most of the 6 webinars. In total there were 748 registrations for the events. People from a great diversity of sectors, affiliations and geographic locations participated. Some of those attending were health workers, others worked in the NGO sector. Policymakers in health and emergency services, and academic experts in gender analysis and breastfeeding also participated. The reach of the webinars based on registrations is summarised in the Box. Around 70-80 people participated in each webinar, and a total of around 30 people in the two IYCF-E workshops.

Resources The webinars were recorded and along with copies of the PowerPoint presentations, were uploaded on the website of the ANU Crawford School as follows:

1. Gender Responsive Budgeting and Progressing Breastfeeding Policy in 2020 and Beyond – Introductory Webinar (6 April) https://crawford.anu.edu.au/news-events/events/16383/gender-responsive-budgeting-and-progressing-breastfeeding-policy-2020-and

2. Breastfeeding policy in 2020 and beyond – Emergency and pandemic preparedness and response planning in Australia (20 April) https://taxpolicy.crawford.anu.edu.au/news-events/events/16419/breastfeeding-policy-2020-and-beyond-emergency-and-pandemic-preparedness

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3. Progressing Australia’s policies and plans for mothers and babies in disasters and pandemics: experiences from high- and middle-income countries (4 May) https://taxpolicy.crawford.anu.edu.au/news-events/events/16471/progressing-australias-policies-and-plans-mothers-and-babies-disasters-and

4. Protecting women’s reproductive rights in policy and resourcing decisions – the need for ‘data and dollars’ (18 May) https://crawford.anu.edu.au/news-events/events/16582/protecting-womens-reproductive-rights-policy-and-resourcing-decisions-need

5. Advancing women’s and children’s health rights, gender responsive budgeting and progressing the Australian National Breastfeeding Strategy in maternity care https://crawford.anu.edu.au/news-events/events/16978/advancing-womens-and-childrens-health-rights-gender-responsive-budgeting

6. ‘Back to work’ or ‘babysitting the economy’? - Advancing public health and productive work through investments in maternity protection and childcare ‘https://taxpolicy.crawford.anu.edu.au/news-events/events/17185/back-work-or-babysitting-economy-advancing-public-health-and-productive

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6. IYCF-E workshop – discussions and areas for development

Building from the IYCF-E webinars held on April 20 and May 4, 2020, the team began a process to develop a WBTi Australia position paper on implementing IYCF-E.

The process was designed to:1. Share and learn from experiences and data, to identify gaps,

threats, and opportunities to progress in Australian policy and practice for IYCF-E and use a gender lens to policy and budgeting, and.

2. Draft a proposal to support Priority Actions. to ensure skilled breastfeeding and lactation support are available during emergencies and disasters, and develop a national policy on IYCF-E, as agreed by the Council of Australian Governments (COAG) in the Australian National Breastfeeding Strategy (ANBS)

The aim was to build consensus among key stakeholders on concrete next steps to ensure firstly, that appropriate capacity for IYCF-E is in place; secondly that women can access the necessary support during emergencies and thirdly, that the national and state levels preparedness and response plans includes best practice, relevant and related IYCF-E actions and budgets that are gender sensitive.

A first workshop organized was “Workshop: Informing the development of a position paper of the World Breastfeeding Trends Initiatives Infant and Young Child Feeding in Emergencies: The case for Australia”.

The main objective was to share experiences, ideas, and recommendations to address the current policies, protocols, data and capacity gaps regarding emergency preparedness and response on support to women and their children during an emergency.

Three groups addressed:1. Jurisdiction emergency management preparedness and response

plan (federal/state/local)2. Cross sectoral capacity building (health, nutrition, and emergency

services)3. IYCF-E protection, promotion and support including minimizing the

risk of artificial feeding

Table 2 Guide questions

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Guide questions used for the group discussions:1. What are the human rights instruments relevant to this Action Area? How

are these given effect (eg through laws, policies or programs) in Australia?2. What were the key gaps in legislation, policies and programs that WBTi Aus

identified? 3. What concrete actions would you recommend addressing the gaps in

policies and programmes for this specific area. What mechanisms and links need to be in place? To address those gaps?

4. How would you see the use of the WBCi to estimate the cost of such actions? Are there available resources for this area? What resources could we tap? What resources need to be allocated by all level of governments?

5. How are we going to monitor the progress made in relation to those actions?

The guide questions were used in each of the three groups, and the facilitators were asked to ensure that the following conceptual framework was used to orient the discussion. The questions were meant to help each group to consider and reflect on the specific domain but using overarching elements, a) human rights n) gender responsive budget and resource allocations c) the WBTi and the WBCi approach vs. the ANBS action areas and 4) the Monitoring and Evaluation aspects.

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Table 3:Workshop discussion framework

The workshop provided a time to think and work on what Australia’s governments and relevant organizations and agencies can do to ensure that all women and infants affected by a disaster will be supported, and appropriate and timely IYCF support provided.

On May 27, a second workshop was held, and 17 participants attended. The workshop was facilitated by the coordinator of WBTi Australia and had as an objective the one to review and ensure consensus around the key actions and way forward recommended during the group work in the first workshop.

The workshops were characterized by vibrant and highly participatory discussion. Participants had all registered for at least one of the webinars and had responded to a targeted invitation to contribute their expertise and experience to the development of the WBTi document. There was representation from many countries and sectors, by people with diverse experience, expertise, and qualifications relevant to the topic.

The review of the recommendations from the first workshop, helped build consensus on key actions that are cross cutting/overarching the three domains. At the same specific actions and recommendations were revisited, updated, and endorsed by the whole group (Table 4).

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7 Conclusion and recommendations: Key actions needed for advancing breastfeeding protection, promotion, and support in Australia

Recommendations for WBTi action in this area

Important considerations and reflections across the three dimensions are set out below.

The jurisdiction emergency management preparedness and response plan (federal/state/local)

One group focussed on issues for IYCF-E of interjurisdictional emergency management preparedness and response planning. This group discussion was facilitated by Mary Peterson, with Alex Iellamo as observer. Participants included people with experience on supporting families during emergencies in Australia, health professionals, and policymakers with specific expertise and experience in Australian emergency management and planning.

Australian policy implementation in this area needs to include federal, state, and local governments.

Discussions focussed on the need to: Constitute an emergency planning coordination and capacity building

committee to develop a plan like the one that has been prepared for disabilities (Villeneuve, 2006).

Consider the possibility of organizing a workshop among key stakeholders (government and non government) to review the progress, identify the issues and agree on a way forward

Build partnerships with relevant government and non-government (e.g. dept of health, foreign affairs, agriculture, home affairs) organizations

Engage local agencies and state level agencies to ensure that the right guidance is in place

Advocate for more resources for funding to deliver services  Invest in health professional education around breastfeeding and

breastfeeding counselling, also during emergencies Advocate to the government to invest in a marketing campaign for

breastfeeding promotion, protection and support Update and improve the Emergency shelter guidelines with provisions

for mothers and young children (breastfeeding and not breastfeeding) Work with recognized emergency agencies like the Red Cross to

integrate IYCF-E in their materials, programmes and initiatives Advocate and engage the Department of Health for the development of

the national IYCF-E policy Collaborate with the national Australian Institute for Disaster

Resilience (AIDR): part of their role is to educate and link to resources, this is an opportunity

o Ensuring that relevant specialists from the WBTi and this group will be engaged in a national forum that will work on the policy for example

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Cross sectoral work for IYCF-E

A second group focussed on issues for IYCF-E of cross-sectoral coordination.

This group discussion was facilitated by Karleen Gribble, with Naomi Hull as observer. Participants included people with experience on supporting families during emergencies in Australia, health professionals, and people with specific NGO and other sectoral expertise and experience in Australian emergency management and planning.

Focus on the importance of the global human rights and international recommendations like the Code, the CEDAW, the CRC and the CESCR

At the same time the group stressed the importance of the Universal Declaration of Human Rights

The group also acknolwedged the importance of the OG-IFE and the Sphere Standards

There was a strong recommendation from the group to ensure that the welfare agencies in Australia are sensitised and engaged more on the issues, concerns and needs around IYCF-E, the health system seems to be more advanced on that, more needs to be done with the welfare groups

An important proposition from the group is the urgent need to call on a multistakeholder forum where all the relevant and interested agencies can meet and discuss what are the needs for Australia

Review, adapt and localise the international guidance and recommendations to meet the needs and priorities

Ensure a collaboration of health and welfare agencies to work together towards the different priorities and needs and work on more cross sectoral isseus and concerns.

Protecting breastfeeding and reducing risk of formula feeding in emergencies

The third group focussed on issues of how to protect breastfeeding in emergencies including through implementation of the WHO Code, and donor human milk sharing.

This group discussion was facilitated by Libby Salmon, with Julie Smith as observer. Participants included people with academic or other professional experience of policy development in Australia, expertise on milk banking, and NHMRC guideline development, and health professionals, including people with experience in health professional education and training, and the Baby Friendly Hospital Initiative in Australia. Discussions on actions focussed around:

● The need to advocate for adoption of relevant international guidance and instruments that protect breastfeeding (WHO Code and WHO guidance of Inappropriate Promotion of Foods for IYC, the Innocenti Declaration and the Convention on the Rights of the Child and CEDAW).

○ Form alliances with the Obesity Coalition● How to define an emergency in the light of the ongoing disaster of

infant feeding, in Indigenous communities and other risk populations

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● The ANBS had many great ideas to protect breastfeeding, through health professional education, school education, and in emergencies.

○ Participants expressed frustration at the lack of political commitment at national and state/territory levels to implement the WHO Code and the NHMRC Infant Feeding Guidelines.

○ Participants attributed the lack of progress to the powerful influence of the industries covered by the Code and allergy specialists on government agencies like NHMRC and FSANZ. ○ Ensure National Breastfeeding Committee is independent

and has no formula industry members ● The lack of resources and budgets to update and implement NHMRC

Dietary and Infant Feeding Guidelines for Health Workers○ This includes a lack of breastfeeding promotion, protection, and

support programs with Indigenous communities.○ Budgets are needed to communicate the NHMRC Dietary and

IF Guidelines to clinical health workers. WBTi could develop a communications strategy and social media tools for this.

● The urgent need to advocate for:a. Implementation of current NHMRC guidelines b. Updated and expanded content on IYCF-E standards and

recommendations in NHMRC Guidelines: ○ Revise IYCF-E strategies in NHMRC dietary guidelines to

include milk banks, relactation, and continue breastfeeding beyond 2 years instead of 12 months. This might assist advocacy to align NHRMC guidelines with WHO recommendations.

○ To have influence, input into NHMRC dietary guidelines needs expertise and professional presentation (e.g. from health professional organisations, possibly LCANZ and researchers)

● Action on drafting and advocacy tasks requires a coalition e.g. WBTi bringing in ABA and LCANZ, organizations with no Conflict of Interest

● Need for a joint advocacy campaign by health professional bodies and at the grass roots that requires advocacy for:

○ Support for ABA to utilising ABA capability for strategic resource mobilisation and on health and emergency worker education and training

○ Resources for LCANZ○ Medicare rebates for IBCLCs

When there is consistent description, training, and practical testing of clinical competencies

○ Control of marketing of toddler formulas through the current national review of advertising of food and beverages to children.

After the plenary workshop, held on May 27, the group agreed on the following recommendations and actions that will inform the WBTi Position Paper on IYCF-E (Table 4).

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Table 4. IYCF-E Background Paper WBTi Australia June 10, Workshop

Areas/Domains The jurisdiction emergency management preparedness and response plan

Cross sectoral work for IYCF-E Protecting breastfeeding and reducing risk of formula feeding in emergencies

Overarching themes/recommendations:

IYCF-E is based on the implementation of global human rights and international recommendations like the Code, CEDAW, CRC and the CESCR, Declaration of Human Rights IYCF-E and skilled support in emergencies requires the ANBS to be funded and implemented WBTi Aus R3)IFYE policy development and implementation requires: Multi-sectoral stakeholders’ engagement through workshops and round table discussion Building partnerships across government and non-governmental organizations Building IYCF-E capacity through expanded education and training for defence, health, welfare, emergency workers (WBTi Aus R5 and R6)From WBTi Australia, the themes were:Design and roll out an advocacy strategy targeting different IYCF-E stakeholders and focus on the adoption of relevant international instruments and recommendations (e.g. Code etc) and for their promotion and implementation Design and roll out a comprehensive communication strategy raising awareness on need for protection, promotion, and support of breastfeeding in emergencies (targeting families, communities, and others) Establish an IFE coordination core group (coalition, collective group working on and advocating for the implementation of key recommendations) (WBTi Aus R1, R4, R2 - DOH in COMDISPAN and National IYCF-E advisory committee, AIDR Handbook and IYCF-E and cross reference)

Specific themes/recommendations

Engage local agencies and state level agencies to ensure that the right guidance is in place Advocate for more resources for funding to deliver services 

The group also acknowledged the importance of the OG-IFE and the Sphere Standards Welfare agencies in Australia are sensitised and engaged more on the issues,

Define an emergency in the light of the ongoing disaster of infant feeding, in Indigenous communities.The ANBS had many great ideas to protect breastfeeding, through health professional education, school education, and in emergencies.

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Areas/Domains The jurisdiction emergency management preparedness and response plan

Cross sectoral work for IYCF-E Protecting breastfeeding and reducing risk of formula feeding in emergencies

Invest in health professional education around breastfeeding and breastfeeding counselling, also during emergencies – free from industry influence/WHO Code compliant and appropriate clinical skills.Update and improve the Emergency shelter guidelines with provisions for mothers and young children (breastfeeding and not breastfeeding)Work with recognized emergency agencies like the Red Cross to integrate IYCF-E in their materials, programmes, and initiativesAdvocate and engage the Department of Health for the development of the national IYCFE policy Collaborate with the

concerns, and needs around IYCF-E, the health system seems to be more advanced on that, more needs to be done with the welfare groupsReview, adapt and localise the international guidance and recommendations to meet the needs and priorities Ensure a collaboration Health and Welfare agencies to work together towards the different priorities and needs and work on more cross sectoral issues and concerns

Participants expressed frustration at the lack of political commitment at national and state/territory levels to implement/legislate the WHO Code and the NHMRC Infant Feeding Guidelines. Participants attributed the lack of progress to the powerful influence of the formula industry and allergy specialists on government agencies like NHMRC and FSANZ. The lack of resources and budgets to update and implement NHMRC Dietary and Infant Feeding Guidelines for Health WorkersThis includes a lack of breastfeeding promotion, protection, and support programs with Indigenous communities.Budgets are needed to communicate the NHMRC Dietary and IF Guidelines to clinical health workers. WBTi could develop a communications strategy and social media tools for this.The urgent need to advocate for:Implementation of current NHMRC guidelines IYCF-E standards and recommendations in NHMRC guidelines: Revise IYCF-E strategies in NHMRC dietary guidelines to include milk banks,

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Areas/Domains The jurisdiction emergency management preparedness and response plan

Cross sectoral work for IYCF-E Protecting breastfeeding and reducing risk of formula feeding in emergencies

national Australian Emergency Institute: part of their role is to educate and link to resources, this is an opportunityEnsuring that relevant specialists from the WBTi and this group will be engaged in a national forum that will work on the policy for example

relactation, and continue breastfeeding beyond 2 years instead of 12 months, as in current NHMRC guidelines. The latter might assist advocacy to align NHRMC guidelines with WHO recommendations.Important that health professional organisations and other relevant organisations are recruited to make evidence-based submissions to the DOH/NHMRC/FSANZ prior to ANBS review of the Infant Feeding Guidelines.BFHI/BFCI – Through national hospital accreditation system

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Next steps for WBTi Australia advocacy and action - monitoring and evaluating ANBS implementation on IYCF-E

The WBTi Australia report forms the international benchmarking for the ANBS. The group is planning its next WBTi Assessment and expects to begin the second assessment in 2021. For this purpose, the group is gathering data and forming strategies to stimulate action on ANBS implementation, monitor and assess progress, and inform its future assessment.

Key timelines for the WBTi Australia work in the IYCF-E area are:

June-July 2020Establishment of the WBTi Aus IYCF-E SubgroupFinalization of the background paper Preparation of the WBTi Aus Position Statement

August-September 2020 Finalization and endorsement of the WBTi Aus Position Statement by the WBTi Core GroupLaunch of the WBTi Aus Position Statement

October 2020 Engagement with relevant stakeholders using Triple A and Gender Budgeting approaches

End year

Given the recent natural disasters, disease emergencies and economic hardship for families in Australia, the focus of this work and advocacy is the following areas of the ANBS which progress action on IYCF-E.

As shown above, IYCF-E policy and capacity requires progress in other key areas of the ANBS. The following section lists specific IYCF-E outcomes in ANBS action areas that enable breastfeeding at the level of the individual, settings, and structural environment.

ANBS Priority 3 - Individual enablersOne of the three Priorities of the ANBS is enabling individual mothers to breastfeed. Priority Action area 3.2 of the ANBS is ‘to provide breastfeeding and lactation support and maternal health care to families in exceptionally difficult circumstances. Detailed actions included ‘ensuring skilled breastfeeding support is available, including during emergencies and disasters’, and ‘develop a national policy on infant and young child feeding in emergencies.

These are the responsibility of the Commonwealth, States and Territories, and agencies in several fields particularly health services and emergency management services.

ANBS Priority 2 - Settings that enable breastfeeding

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The second Priority in the ANBS is focussed on settings that enable breastfeeding. This includes actions such as health professional education and training (ANBS Action area 2.2).

In the context of the Australian emergency response to COVID 19 pandemic, it is also important to draw attention to other settings which enable breastfeeding - the Baby Friendly Health Initiative with its Ten Steps to Successful Breastfeeding (Action area 2.1) and milk banking (Action area 2.4).

ANBS Priority 1 - Structural enablers - An enabling environment for decisions on breastfeeding

An enabling environment for decisions on breastfeeding includes ANBS Priority Action area 1.2, to preventing appropriate marketing of breastmilk substitutes. This requires an independent review of regulatory arrangements for restricting the marketing of breastmilk substitutes and raising the awareness of the MAIF Agreement in the community. These are both Commonwealth responsibilities for implementation.

The ANBS also relevantly includes Priority Action area (1.4) on reviewing and updating dietary and infant feeding guidelines and raising awareness of these among health professionals, parents, and families. This is the responsibility of the Commonwealth, the NHMRC and Commonwealth and states and territories. Health professional associations also have a responsibility for raising awareness of the dietary and infant feeding guidelines.

Currently the NHMRC dietary guidelines include some information on breastfeeding in specific situations such as emergencies (under ‘6. Breastfeeding in specific situations’, particularly 6.4 ‘Breastfeeding in emergency situations’, and ‘8.8 Formula feeding in emergency situations’).

However, these lack detail and do not reflect current, updated knowledge and experience.For example, 6.4 refers to breastfeeding women ‘needing nutritional support and supplies of clean water to enable continued breastfeeding’, while 8.8 refers to the requirements for supplies of infant formula, sterile water and feeding containers for infants being formula fed. This also states that ‘there are important health and ethical issues associated with distribution of infant formula in disaster situations’, and that ‘the preparation of any disaster plan should include discussion of these issues.

Monitoring, evaluation, and accountability: How will we know if the ANBS is implemented, fully resourced, and working?

The ANBS sets out an evaluation plan with key data collection, monitoring and reporting timetable. The ANBS also sets out the questions, criteria for measuring success, and data which can be collected for evaluating success.

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These can be used to guide WBTi advocacy and motivate action and accountability of governments and other stakeholders. For example, in the IYCF-E area, evaluation of the Strategy could involve:

Evaluation questions To what extent are systemic and structural changes improving the

enabling environment for optimal breastfeeding? Is there equitable access to breastfeeding initiatives for all mothers? And does the Strategy continue to reflect best practice global standards and approaches?

Success criteria Actual achievement of planned implementation, reduced gap

between mothers intentions and decisions to breastfeed, improved access and better outcomes for priority populations, alignment with WHO guidelines and other international authorities on breastfeeding

Indicative data sources Initiative and strategy monitoriing reports, routine data analysis

and qualitative data collection and experience/satisfaction surveys

ANBS monitoring, evaluation, and reporting timetable

Assisting the evaluation of progress and outcomes of the strategy is the reporting and evaluation schedule for the ANBS. This sets out the key timelines and reporting accountabilities.

For example, a baseline evaluation is to be completed by end June 2020, with a formative and summative evaluation by 30 June 2025. Evaluation findings and reports will be prepared by the Assistant Secretary of the preventative health policy branch of the Australian Department of Health and provided to the Australian Health Ministers Advisory Council and the public, via the Department of Health website.

The ANBS also includes a reporting tool for regular updating of progress by jurisdictions. This may be useful for WBTi Australia to collect data on implementation progress.

For example, it includes data collection for each Priority area and Action area on ‘activities funded’, the amounts of ‘funding committed’, ‘key outputs’, ‘progress on key indicators’, ‘implementation issues and risk’, and ‘action planned for the next 12 months. It also includes an overall progress rating (none, little, fair, good or very good).

WBTi Australia will make use of these ANBS timelines and monitoring and evaluation commitments - that have been agreed by all Australian governments - in its advocacy to galvanise action on implementing the ANBS Priority Action areas on IYCF-E.

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References Australia. Department of Health. (2019, June 2019). Australian National

Breastfeeding Strategy 2019 and Beyond Retrieved from https://www.coaghealthcouncil.gov.au/Portals/0/Australian%20National%20Breastfeeding%20Strategy%20-%20Final.pdf

Gribble, K. (2017). Supporting the Most Vulnerable Through Appropriate Infant and Young Child Feeding in Emergencies. Journal of Human Lactation, 0(0), 0890334417741469. doi:10.1177/0890334417741469

Gribble, K. (2020). Is emergency planning for infants and young children adequate? Australian Journal of Emergency Management.

Gribble, K., Peterson, M., & Brown, D. (2019). Emergency preparedness for infant and young child feeding in emergencies (IYCF-E): an Australian audit of emergency plans and guidance. BMC Public Health, 19(1), 1278. doi:10.1186/s12889-019-7528-0

Gupta, A., Suri, S., Dadhich, J. P., Trejos, M., & Nalubanga, B. (2019). The World Breastfeeding Trends Initiative: Implementation of the Global Strategy for Infant and Young Child Feeding in 84 countries. J Public Health Policy, 40(1), 35-65. doi:10.1057/s41271-018-0153-9

Hanson, L. A. (2004). Immunobiology of human milk: how breastfeeding protects babies: Pharmasoft Pub.

Horta, B. L., Bahl, R., Martines, J. C., & Victora, C. G. (2007). Evidence on the long-term effects of breastfeeding: systematic reviews and meta-analysis. Geneva: World Health Organization.

Hull, N., Kam, R. L., & Gribble, K. D. (2020). Providing breastfeeding support during the COVID-19 pandemic: Concerns of mothers who contacted the Australian Breastfeeding Association. Breastfeeding Review Vol. 28, No. 3, Nov 2020: 25-35. Availability: <https://search.informit.com.au/documentSummary;dn=480749310059270;res=IELHEA>   ISSN: 0729-2759. [cited 05 Nov 20].

Hull, N., Smith, J., Peterson, M., & Hocking, J. (2018). Putting Australia to the test — The World Breastfeeding Trends Initiative. Breastfeeding Review 26(2), 7-15.

IFE Core Group. (2017). Infant and Young Child Feeding in Emergencies: Operational Guidance for Emergency Relief Staff and Program Managers, Version 3. Oxford: Emergency Nutrition Network.

Jackson, K. M., & Nazar, A. M. (2006). Breastfeeding, the immune response, and long-term health. The Journal of the American Osteopathic Association, 106(4), 203-207.

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Jones, G., Steketee, R. W., Black, R. E., Bhutta, Z. A., & Morris, S. S. (2003). How many child deaths can we prevent this year? Lancet, 362. doi:10.1016/s0140-6736(03)13811-1

Parkinson, D., Duncan, A., Joyce, K., Jeffrey, J., Archer, F., Weiss, C., . . . Dominey-Howes, D. (2018). Gender and Emergency Management (GEM) guidelines A literature review. Retrieved from https://knowledge.aidr.org.au/media/5373/gem-literature-review.pdf

Rollins, N. C., Bhandari, N., Hajeebhoy, N., Horton, S., Lutter, C. K., Martines, J. C., . . . Lancet Breastfeeding Series, G. (2016). Why invest, and what it will take to improve breastfeeding practices? Lancet, 387(10017), 491-504. doi:10.1016/S0140-6736(15)01044-2

Smith, J. P., Cattaneo, A., Iellamo, A., Javanparast, S., Atchan, M., Hartmann, B., . . . Hull, N. (2018). Review of effective strategies to promote breastfeeding: an Evidence Check rapid review brokered by the Sax Institute (www.saxinstitute.org.au) for the Australian Department of Health. Retrieved from Canberra, Australia:

The Sphere Project. (2018). The Sphere Handbook: Humanitarian Charter and Minimum Standards in Disaster Response. Geneva: The Sphere Project.

UNICEF. (2018). BREASTFEEDING A Mother’s Gift, for Every Child. Retrieved from New York: https://www.unicef.org/publications/index_102824.html

United Nations (UN). (2015). The Sustainable Development Agenda. Retrieved from Geneva: http://www.un.org/sustainabledevelopment/development-agenda/,

Victora, C. G., Bahl, R., Barros, A. J., Franca, G. V., Horton, S., Krasevec, J., . . . Lancet Breastfeeding Series, G. (2016). Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet, 387(10017), 475-490. doi:10.1016/S0140-6736(15)01024-7

Villeneuve, M., Sterman, J., & Llewellyn, G.L. (2018). . (2006). Person-Centred Emergency Preparedness: A process tool and framework for enabling disaster preparedness with people with chronic health conditions and disability. Retrieved from Sydney: http://sydney.edu.au/health-sciences/cdrp/projects/UOS_PrepareNSW_user_guide_FINAL_v2.pdf?

World Breastfeeding Trends Initiative Australia, Hull, N., Smith, J. P., Hocking, J., Peterson, M., Salmon, L., . . . Sheridan, D. (2018). World Breastfeeding Trends Initiative Assessment Report: Australia Retrieved from New Delhi: http://worldbreastfeedingtrends.org/country-report-wbti/

Resolution 63.23 Infant and young child nutrition, WHA63.23 C.F.R. (2010).

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Resolution WHA 69.9 Ending inappropriate promotion of foods for infants and young child

Agenda item 12.1, (2016).

World Health Organization (WHO). (2018). Implementation Guidance. Protecting, promoting and supporting Breastfeeding in facilities providing maternity and newborn services: the revised Baby-Friendly Hospital Initiative. Retrieved from Geneva:

World Health Organization (WHO), & UNICEF. (2020). WHO policy brief on international trade agreements and implementation of the International Code of Marketing of Breast-milk Substitutes Retrieved from

World Health Organization (WHO). (2004). Guiding principles for feeding infants and young children during emergencies. Retrieved from https://apps.who.int/iris/bitstream/handle/10665/42710/9241546069.pdf?ua=1

World Health Organization (WHO). (2016). Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV Infection: What's new. . Retrieved from Geneva, Switzerland.: http://www.who.int/hiv/pub/guidelines/arv2013/en/

World Health Organization (WHO). (2020a). Clinical management of COVID-19 interim guidance 27 May Retrieved from Geneva: https://apps.who.int/iris/handle/10665/332196

World Health Organization (WHO). (2020b). Frequently asked questions: Breastfeeding and COVID-19 For health care workers (7 May 2020). Retrieved from Geneva: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/q-a-on-covid-19-and-breastfeeding

World Health Organization (WHO), & UNICEF. (1990). Innocenti Declaration on the protection, promotion and support of Breastfeeding. Retrieved from Florence, Italy:

World Health Organization/UNICEF (WHO/UNICEF). (2003). Global strategy for infant and young child feeding. Retrieved from Geneva, Switzerland: https://www.who.int/nutrition/publications/infantfeeding/9241562218/en/

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Annex 1. Human Rights Instruments and International Guidance

Breastfeeding protection, promotion and support and human rights instruments The Covenant on Economic, Social and Cultural Rights (CESCR), the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW), and the Convention on the Rights of the Child (CRC)

Several human rights treaties contain relevant rights on breastfeeding, including the Covenant on Economic, Social and Cultural Rights (CESCR), the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW), and the Convention on the Rights of the Child (CRC).

IMPORTANT NOTE: The Government of Australia is a State Party to all three treaties mentioned below:CESCR: ratified in 1980CEDAW: ratified in 1983CRC: ratified in 1990

Linking the Government's efforts to ensure effective and sustained breastfeeding programme and Code implementation through national law and regulations can be considerably strengthened by linking such efforts with the Government's legal obligations under the relevant human rights treaties and measures taken to fulfil said obligations.

Linkages between breastfeeding protection, promotion, and support and the CESCR

The International Covenant on Economic, Social and Cultural Rights (CESCR) recognizes the right to enjoy "the highest attainable standard of physical and mental health", including the reduction of infant mortality and the healthy development of the child (Article 12).

This Article is elaborated upon in the Preamble of the Code: "inappropriate feeding practices lead to infant malnutrition, morbidity and mortality in all countries, and improper practices in the marketing of breastmilk substitutes and related products can contribute to these major public health problems." As part of its obligation as State Party to CESCR, the Government of Australia must submit periodic reports to the United Nations Committee on Economic, Social and Cultural Rights on measures taken and obstacles encountered in the implementation of CESCR. The reports must include data on infant mortality rates in the country, including causes of mortality, as well as other information concerning newborn and child health. The Government must also describe the measures taken to reduce the infant mortality and to provide for the healthy development of the child.

Linkages between breastfeeding protection, promotion, and support - the CEDAW

Article 10 of CEDAW protects access to information to ensure the health and well-being of families.

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Article 11 confers the right to health "including the safeguarding of the function of reproduction", while Article 12 assures "adequate nutrition during pregnancy and lactation", thus recognizing the importance of breastfeeding.

The Code has specific provisions, which address these concerns, based on the fundamental principle that breastmilk substitutes "should not be marketed or distributed in ways that may interfere with the protection and promotion of breastfeeding." As stated previously, specific articles are designed to ensure that information and education on infant feeding are not tainted with a commercial sales message, overt or subtle.Linkages between breastfeeding protection, promotion and support - the CRC

The Convention on the Rights of the Child (CRC 1989) provides the most comprehensive international human rights framework for facilitating enhanced Code implementation and monitoring. The CRC recognizes that all children have the right to the highest attainable standard of health, specifically the right to good nutrition (Art.24), including breastfeeding.

All but one government have ratified the CRC. Governments, as State Parties are legally bound by the CRC, and are required to bring national laws and policies in line with its provisions. Australia ratified the CRC in December 1990 and is thus obliged to protect the rights enshrined in the Convention, including protection of its citizens from unlawful infringement on such rights by third parties, including the private sector. Additionally, governments are accountable at both national and international levels. This includes regular reporting to the United Nations Committee on the Rights of the Child, on progress made in implementing the CRC.

The protection, promotion and support of breastfeeding at all times and in all contexts attempts to protect some fundamental human rights, children’s rights to life, survival and development, the right to health, the rights to safe and adequate food and nutrition, and the right of women to full and accurate information on which to base decisions affecting their children’s health as well as the right to receive all the needed support and access the needed resources.

Numerous articles of the CRC are supportive of the intent of the Code, particularly the right of children to the highest attainable standard of health, and adequate food and nutrition, by, inter alia, reducing infant mortality, and promoting breastfeeding.

As a State Party to the CRC, the Government of Australia is legally bound by the CRC provisions, and is required to bring national laws and policies in line with the CRC. Furthermore, it must regularly report to the United Nations Committee on the Rights of the Child on progress made in the effective implementation of the CRC (namely the International Code of Marketing of Breastmilk Substitutes and its subsequent related 20 World Health Assembly (WHA) resolutions, the Baby-Friendly Hospital Initiative (BFHI), and the Global Strategy for Infant and Young Child Feeding (IYCF).

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and should be implemented in a manner supportive of WTO

Likewise, as part of its obligation to protect the rights enshrined in the CRC, the Government must ensure that its citizens, including all children and mothers, are protected from any unlawful infringement on such rights by third parties, including the private sector.

The CRC reflects the legal obligations of the Government to all children and mothers under its jurisdiction, and provides legal and normative guidance on protecting, promoting, and supporting infant and young child feeding at all times, applies during emergencies..Article 24 requires the Government and other duty bearers (including the private sector) to take all necessary measures (including the adoption of all relevant legislation, policies and programmes) to ensure that all sectors of society, particularly parents, "have access to education and are supported in the use of basic knowledge of child health and nutrition, the advantages of breastfeeding..." It also requires the Government and other duty bearers to ensure parents can act upon the information provided.

Breastfeeding protection, promotion and support, public health, and the World Trade Organization agreements

WTO agreements and Public Health: a joint study by the WHO and the WTO Secretariat (2002)

The endorsement by the international community of the Doha Declaration on the Trade-Related Aspects of Intellectual Property Rights (TRIPS) Agreement and Public Health is a very visible expression of governments' commitment to ensuring that the rules-based trading system is compatible with public health interests.

In 2020 WHO and UNICEF issued an information brief that aims at describing the implication of trade agreements for domestic implementation of the Code for policy makers, regulators, and other relevant officials (WHO, 2020).

The brief conclusions highlight that:“States have obligations to protect, respect and fulfil the right to health under international human rights law, including an obligation to protect and support breastfeeding under Article 24 of the Convention on the Rights of the Child (CRC). “

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and should be implemented in a manner supportive of WTO

- “International trade agreements, including WTO agreements, recognize the right of States to regulate (including to protect health).”

- “Although most of countries worldwide (136) have implemented the Code through some form of legislation, some of which is more stringent than the Code itself, there has never been a formal legal dispute concerning domestic implementation of the Code under an international trade agreement.”

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Global health guidance

World Health Organization (WHO) International Code of Marketing of Breastmilk Substitutes

In 1981, the 34th World Health Assembly (WHA) adopted the International Code of Marketing of Breastmilk Substitutes in the form of a Recommendation which urged all Member States among other things to translate the Code into national legislation, regulations or other suitable measures; to involve all concerned parties in its implementation; and to monitor compliance with it.

The Code’s position is that commercial products should be available when needed but should not be promoted.

While the Code is not a legally binding instrument as such, it nevertheless represents an expression of the collective will of the membership of WHO, which has been formally subscribed to by a large number of its Member States, international and regional bodies, nongovernmental organizations and others as a 'minimum requirement' to be adopted by 'all member states...in its entirety'.

Resolution WHA34.22 by which the WHA adopted the Code stressed that adherence to it "is a minimum requirement and only one of several important actions required in order to protect healthy practices in respect of infant and young child feeding" in all contexts. The implication is that governments, acting individually, are not only permitted to adopt additional, possibly more stringent, measures than those set out in the Code; they are, in effect, actively encouraged to do so.

Because the Code was adopted as a "minimum requirement", it sets the floor for acceptable standards rather than the ceiling. Such flexibility in standard setting is particularly important for policies that deal with marketing practices and products, as marketing practices and product lines change in response to market conditions also during emergencies situations. Figure 1 presents a ten-point summary of the Code, scope, coverage, and main recommendations.

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Figure 2 The Code: A 10 point summary

Subsequent WHA resolutions

Subsequent Resolutions have clarified articles in the Code considering ongoing scientific investigation and to address questions of interpretation. While these resolutions do not formally amend the Code, they nevertheless convey the collective views of WHO Member States on the subject. Thus, when Member States seek to develop policies in this area, they may well choose to refer not only to the Code itself but also to subsequent relevant WHA Resolutions.

IMPORTANT NOTE: Under Article 18 of the WHO Constitution, such Resolutions of the WHA have the same status as the Code.

The Innocenti Declaration (1990, updated in 2005) identified the need for a government structure and system for the management and support of breastfeeding programmes, including during emergencies. It

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recommended that all health facilities with maternity services implement the Ten Steps for Successful Breastfeeding, and reiterated the importance of implementing the Code and the passage of legislation, in favour of maternity protection in the workplace (paid maternity leave for at least 18 weeks, paid breastfeeding breaks, and where possible creches).

In 2002, the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) endorsed the Global Strategy for Infant and Young Child Feeding,7 that recommends optimal infant and young child feeding as in Table 1.

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Table 5: WHO/UNICEF optimal Infant and Young Child Feeding recommendations

World Health Organization (WHO) Guiding Principles for Feeding Infants and Young Children During Emergencies

There has been global guidance on infant and young child feeding in emergencies since 2004, when WHO issued Guiding Principles for Feeding Infants and Young Children During Emergencies (WHO, 2004). The principles reaffirm the importance of protecting, promoting, and supporting breastfeeding during calamities, while limiting and strictly controlling the use of breast milk substitutes, and the role of complementary feeding. In 2007, the Infant Feeding in Emergencies (IFE) Core Group, whose members include UNICEF and WHO, built on WHO’s guiding principles by issuing Operational Guidance on IYCF in Emergencies (WHO,2004; IFE Core Group, 2017). The Operational Guidance asserts the importance of supporting breastfeeding in the difficult situations associated with emergencies. Other global guidance relevant to IYCF-E has built on these foundations.

In 2010, the WHA endorsed Resolution 63.23 which urges governments, inter alia, to scale up interventions to improve infant and young child nutrition in an integrated manner with the protection, promotion, and support of breastfeeding and timely, safe, and appropriate complementary feeding as core interventions. Two years later, in 2012, the WHA (WHA 65.6) endorsed the Comprehensive Implementation Plan for Maternal, Infant, and Young Child Nutrition (CIP).8 It has six (6) goals that all countries must contribute to by year 2025:

1. Forty percent reduction of the global number of children under five who are stunted.

2. Fifty percent reduction of anaemia in women of reproductive age.3. Thirty percent reduction of low birth weight.4. No increase in overweight children.5. Increase the rate of exclusive breastfeeding in the first six months

to at least fifty percent. 6. Reduce and maintain childhood wasting to less than 5%.

In September 2015, world leaders adopted 17 Sustainable Development Goals (SDGs). By the year 2030, all countries aim to mobilize efforts to end all forms of poverty (United Nations (UN), 2015). “Nutrition” appears as a free-standing element of SDG # 2 (“End hunger, achieve food security and improved nutrition, and promote sustainable agriculture”), but also SDG # 3, calls to ensure healthy lives and to promote wellbeing for all, at all ages.

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Recommended Infant and Young Child Feeding practices (including during emergencies)Initiate breastfeeding immediately after birth (within the 1st hour)Exclusive breastfeeding for the first 6 monthsComplementary feeding:

timely (introduced at 6 months or 180 days)‐ adequate (energy and nutrients)‐ safe (hygienically prepared, stored, used)‐ appropriate (frequency, feeding method, active feeding)‐

Continued breastfeeding from six months up to 24 months or beyond

In May 2016, the WHA recommended Member States implement measures that would prevent the inappropriate promotion of foods for infants and young children (World Health Assembly (WHA), 2016). The following year, in 2017, the updated Operation Guidance was released by the IFE Core Group (OG-IFE) (Version 3.0), increasing its emphasis on the needs of the non-breastfed children, the importance of appropriate and timely complementary feeding and foods3, and re affirming the six multi-sectoral actions needed to ensure the protection, promotion and support of infant and young child feeding in emergencies (IFE Core Group, 2017).

In 2018, the WHA endorsed WHA Resolution 71.9 affirming that “recognizing that appropriate evidence-based and timely support of infant and young child feeding in emergencies save lives, protects child nutrition, health and development, and benefits mothers and families”. It urged Member States to: “take all necessary measures to ensure evidence-based and appropriate infant and young child feeding during emergencies, including through preparedness plans, capacity-building of personnel working in emergency situations, and coordination of intersectoral operations”.

All humanitarian workers and agencies are required to: “Uphold the provisions of the Operational Guidance on infant feeding in emergencies (IFE) and the International Code of Marketing of Breastmilk Substitutes and subsequent relevant World Health Assembly (WHA) resolutions (collectively known as the Code)” in line with current Sphere Standards (The Sphere Project, 2018).

Work by IBFAN using the WBTi tool shows that almost 40 years after endorsing the Code, with the Innocenti Declaration, BFHI, the GSIYCF, the IYCF-E Operational Guidance, other relevant recommendations and 20 World Health Assembly Resolutions, maternal nutrition, breastfeeding, and complementary feeding practices remain poorly addressed by policymakers (Gupta et al.).

The WBTI analysis shows that countries with the worst implementation of policy areas for IYCF in general have the greatest gaps in policy for infant feeding in emergencies.

3 WHO (Complementary feeding is defined as the process starting when breast milk alone is no longer sufficient to meet the nutritional requirements of infants, and therefore other foods and liquids are needed, along with breast milk. The transition from exclusive breastfeeding to family foods – referred to as complementary feeding – typically covers the period from 6–24 months of age, even though breastfeeding may continue to two years of age and beyond. https://www.who.int/elena/titles/complementary_feeding/en/ accessed on July 1,2020

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Countries’ actions to improve the situation lag even more on infant feeding in emergencies and disasters.