INTRODUCTION

The BFHI and BFCI must receive a greater attention in all countries if breastfeeding, and exclusive breastfeeding for 6 months have to be achieved. Exclusive breastfeeding highly contributes to reduce mortality in all children. Improved overall IYCF will greatly contribute to the achievement of the MDG 4 as over 60% of child mortality is attributable to inadequate infant and young child nutrition.

The objectives of the Conference were to:

1. To update participants on current issues/developments on infant and young child nutrition

2. To discuss the New WHO/UNICEF BFHI training and assessment tools

3. To review progress made in BFHI and community support, and share best practices

4. To consolidate lessons from IBFAN Africa Capacity Project in 5 countries to increase visibility of IBFAN at the national level.

5. To come up with strategies for scaling up implementation of BFHI in the region tapping on best practices Major issues covered during the conference include:

1. Nutrition of Children Under Fives

2. Breastfeeding in the context of HIV, including the WHO Consensus Statement on HIV and Infant Feeding

3. Lessons from ESAR selected Countries in Strengthening the IYCF Components of PMTCT programmes

4. The Code of Marketing

5. Infant Feeding in Emergencies

6. AU and NEPAD Commitment to Maternal, Infant and Young Child Nutrition;

7. Child Survival and Partnership for Maternal, Neonatal and Child Health programmes

8. Evidence for BFHI and new BFHI training tools

9. Gender Mainstreaming, Men and Youth involvement

10. IBFAN visibility-Lessons ON CB PROJECT in 5 Countries

11. Country Progress Reports with Emphasis to (BFCI)

12. Network Sustainability

DISCUSSION

1. Malnutrition has not improved in the region and in Sub-Sahara there are countries where it is increasing-the role of exclusive breastfeeding was well recognized

2. IYCF components of the PMTCT programmes were on the whole very weak as observed from the WHO/UNICEF IATT reviews in 9 countries

3. The WHO Consensus Statement is not yet well understood and the information needs to be widely disseminated
4. Some current studies such as the Mitra Plus Study that provided triple ARV to HIV+ mothers who are breastfeeding for 6 months further reduce the risk of HIV transmission for babies. Rates of transmission of around 1% were observed in exclusively Bf infants in a study by Augustine Massawe in Tanzania.

5. The involvement of civil society was seen as critical in sustaining BFHI and IYCF. In countries where IBFAN NGOS are well involved, sustainability seemed better

COUNTRY PROGRESS REPORTS ON BFH

1. Countries have done better in developing national strategies and policies or guidelines but implementation remains low in all countries for all aspects of the IYCF including BFHI;

2. Country reports indicated serious decline in BFHI, though much commitment is shown for reactivation in all countries;

3. Most BFHI training is still centrally conducted and has low staff coverage which affects qualityhowever, a few best examples of facility based training were reported in a few countries;

4. In countries where large numbers of mothers deliver outside health facilities (60-90%) Somalia, Gambia, Rwanda, Sudan there are better community based initiatives (BFCI);

5. Many countries have not yet adopted the New BFHI Training Tool-countries are adopting the tools at national level and developing integrated minimum training packages;

6. In-service training of health workers is proving very expensive and participants called for urgent efforts to integrate IYCF in pre-service training;

7. In countries where large numbers of mothers deliver outside health facilities (60-90%) Somalia, Gambia, Rwanda, Sudan there are better community based initiatives (BFCI);

8. Many countries have draft Codes and are committed to speed up Code enactment process but COUNTRIES report subtle company tactics that undermine this process - e.g. companies calling for Code reviews that have no meaning;

9. There is little monitoring of the Code by countries apart from that supported by IBFAN Africa-many countries request for training in this area;

10. Nurses and doctors are not the only target by baby milk companies, nutritionists are also being targeted and tend to work for companies- hence the need to target training on the Code to all cadres; and

11. Companies were shown to be taking advantage of emergency situations-the need to monitor the Code in any food aid projects.

CHALLENGES

1. Implementation of new training tools needs extra resources-funding and staff time and facilitators;
2. High staff turnover;
3. Difficulty of including medical doctors in training;
4. Quality of training;
5. Local companies are becoming code violators-Mauritius, Zambia, Swaziland
6. National Nutrition Institute in Southern Africa is offering health professional training in many countries in Africa misleading them in the guise of HIV; and
7. NGO collaboration with governments and in some countries WHO poses major challenges.

RECOMMENDATIONS
1. There are too many training tools, there is a need for an integrated training tool, making it a single package;
2. Regional partners to develop self teaching modules since governments are reluctant to release staff for training;
3. IBFAN Africa to develop a training module and assessment indicators for community support;
4. WHO and UNICEF to support Integration into pre-service training Curriculum;
5. The BFHI training modules on the Code and HIV and infant feeding should not be optional in African countries;
6. There is need for a coordinated regional response to scaling up of BFHI and other IYCF;
7. Regional partners to mobilise resources including facilitators for scale up of national integrated packages;
8. Regional bodies to increase advocacy for implementation of the Code and resource allocation to IYCF-ex-IBFAN Africa visits to countries made major impact in the 5 CB project countries; and
9. IBFAN to increase advocacy to WHO for support with advocacy to governments on the need for Code enactment.

COMMITMENT Countries are committed to:
1. Scale up BFHI using the new training tools and incorporating the modules on the Code of Marketing and HIV/infant feeding

2. Each country thought that exclusive breastfeeding cannot be achieved without community support-called for support for exchange visits to countries with successful community initiatives so that each country can initiate effective community support

3. Stepping up multi-sectoral approach and active involvement of civil society

4. Use youth groups to improve Code monitoring and for wider information dissemination

5. More training on Code monitoring for cadres targeted by the companies

6. Self training as well as spread out training that avoids high costs and formal timing

The more than 137 participants all left the meeting very motivated. Prototype of feeding cup developed by the Health Department in the Republic of South Africa were distributed to encourage cup feeding.
DAY ONE, MONDAY 13TH AUGUST 2007. FIRST SESSION:OFFICIAL OPENING The Regional Conference began with a welcome song sung by members of REENCONTRO, which is one of the IBFAN Mozambique groups at 8.40 am followed by a big welcome to the participants by Mrs Rufaro Madzima the IBFAN board chairperson. She went to introduced all those sitting at the top table; Dr , the deputy minister for health, Mozambique, Dr D Travoada, WHO, Mozambique, Dr S Mebrahtu, UNICEF, ESAR, Mrs P Kisanga, IBFAN, Africa and Dr M Kyenkya, the Key note address speaker. After a short prayer, Mrs Morewane, the board member for South Africa, coordinated the self introduction by all the participants. Mrs Kisanga then welcomed the participants to Pestania Rovuma Hotel, Maputo and read out the conference objectives and gave the overview of the programme for the next 5 days. She thanked UNICEF and WHO regional offices, WHO Mozambique for their participation; the government of Mozambique, the Ministry of Health, Mozambique for their support; the local organizing committee members for their hard work, youth group, Mozambique (also young IBFANERS); participants and the governments for releasing their staff to participate in this important meeting; the donors- SIDA, Dutch government, ICCO, UNICEF, WHO Mozambique; facilitators, regional youth group and the IBFAN staff. The coordinator continued further to give background of the meeting. She mentioned that such a meeting is held every 3 years and the current was the 7th one. The conference aimed to provide a forum for sharing of experiences and information, enrich and update participants on new knowledge and developments, create consensus on some issues, formulate the next 3 year action plan and goals, and elect a new advisory board. She also mentioned that there were about 100 participants from 24 out of 32 countries. The theme of the 7th regional conference was 7th Regional Conference is Revitalization of the Mother and Baby Friendly Health Facility and Community Initiative in Africa: Successes, Challenges and Forging Ahead. Most important aspect of the conference would be to update members on IYCF with relation to HIV. This was a confusing in the past, but now the role of exclusive breast feeding and counseling is more clear (WHO Statement). Each participating country would present an overview on the implementation of BFHI and BFCI, and capacity building. This followed the launching of IBFAN Mozambique and regional Youth network. Certificates of appreciation were awarded to groups and individuals in recognition of their dedication and devotion to the work of IBFAN. Dr Margaret Kyenkya, the first regional coordinators informed the participants about the beginning of IBFAN Africa almost 25 years ago and how we have come a long way. However, the question is do African leaders knw what we have. We recognize the hard work and efforts of Pauline and her staff. She concluded by saying,we need to stay strong and keep working. Dr S Mebrahtu, expressed her thanks for the inviting UNICEF to participate in this important event. She noted that the theme of the current 7th Regional ConferenceRevitalization of the Mother and Baby Friendly Health Facility and Community Initiative in Africa: Successes, Challenges and Forging Ahead. Was timely and relevant to the on going efforts to improve maternal nutrition and health and optimal infant and child feeding practices, hence enhance child survival growth and development. As well, the importance of tackling some of the main serious challenges affecting infant and young child nutrition one of which has been the HIV pandemic remains a global challenge. She went on to say that the Food Security and Nutrition is Key to Africa Achievement to 6 of the Millennium Development Goals: During the launching of IBFAN Mozambique, Orinda said that working alone doe not have much impact and hence the reason for forming the net work. We will be working closely with the Ministry of Health and membership is open to all. Vulie, during the launching of the youth net work, insisted on their involvement in everything including seeking for representation on the IBFAN advisory board. OPENING REMARKS BY WHO .DR TROVODADA (Armanda to summarize) Discurso da abertura da Organização Mundial de Saúde Em nome do escritório regional da OMS quero agradecer o convite e dizer que estamos honrados em participar neste encontro cujo o tema é revitalização do hospital amigo da mãe e da criança e iniciativas comunitárias. Desde que foi lançado a iniciativa hospital amigo da criança pela OMS e UNICEF em 1991 após a declaração de Innocenti de 1990, progressos notáveis foram realizados através o mundo para melhorar as praticas de alimentação infantil, embora permanecem grandes desafios nomeadamente no nosso continente. • 1 em cada 2 crianças com desnutrição severa morre durante o seu tratamento no hospital devido a cuidados inadequados. • 1 em cada 4 crianças de idade escolar sofre de carências nutricionais que podem afectar o seu desenvolvimento psíquico e mental assim como o seu desenvolvimento físico. • A malnutrição nas gravidas faz com que 1 em cada 6 recém nascido nasça com baixo peso. • Praticas inadequadas de alimentação infantil são responsáveis por 1/3 das causas de malnutrição Meus senhores e senhoras num mundo em que mais de 10 milhões de crianças morre antes do seu quinto aniversario, de doenças preveniveis e onde a malnutrição esta associada a mais de 50% desta mortes temos que agir com urgencia. O lema da semana mundial do aleitamento materno este ano que éiniciando o aleitamento materno dentro da primeira hora de vida para salvar a vida das crianças esta em linha com as recomendações da Organização Mundial da Saúde, e surge num momento particularmente oportuno em que estamos todos unindo os nossos esforço para atingir os ODM e que a comunidade internacional esta mobilizando-se para combater a malnutrição e promover a sobrevivência infantil. O colostro é tudo o que um bebé precisa. É como se fosse receber sua primeira vacina, protegendo-o de doenças infecciosas principalmente das diarréias e infecções respiratórias. A OMS colocou entre os 6 pontos da sua agenda, ênfase nos cuidados de saúde primários como abordagem para reforçar os sistemas de saúde providenciando o acesso ás intervenções essenciais. Reforçar os laços entre o sistema de saúde e a comunidade representa o mais importante e eficiente meio de tratar a malnutrição. A promoção do aleitamento precoce dentro da primeira hora e do aleitamento materno exclusivo nos 6 primeiros meses de vida nas unidades sanitárias e a nível das comunidades são intervenções chaves para redução da mortalidade neonatal e infantil. Resultados de um estudo conduzido no Ghana mostra que 16% das mortes neonatais poderiam ser prevenidas dando o leite do peito as crianças logo quando nascem, e que este numero aumenta até 22% se a amamentação iniciar dentro da primeira hora. Recomendações especificas as mães infectadas pelo vírus HIV para a prevenção da transmissão vertical do vírus foram feitas como vem refletido no consenso adoptado em outubro de 2006; o aleitamento materno é mais seguro do que o aleitamento misto, e é a opção a mais apropriada para muitas das mães que não conseguem reunir as condições para substituir o leite do peito como é o caso em muitos dos nossos países. Pois nos primeiros 2 meses de vida um criança que toma o biberão tem 6 vezes mais probabilidade de morrer de diarréia ou outra doença do que uma criança que toma o leite do peito. A Estratégia Mundial da alimentação do lactente e da criança pequena reúne todas as acções necessárias para facilitar o acesso a essas intervenções. A iniciativa hospital amigo da criança é o instrumento para implementar essas praticas, A OMS reitera o seu apoio continuo aos governos para que o aleitamento materno precoce e exclusivo nos 6 primeiros meses de vida seja uma realidade para todas as crianças africanas. Vamos agir todos unidos e a todos os niveis envolvendo a comunidade, os jovens e os homens para melhorar as praticas de alimentação infantil Muito obrigada pela vossa atenção! Opening speech by the dep MOH (Armandato summarize)
KEYNOTE ADDRESS: THE MILLENIUM DEVELOPMENT GOALS AND RELEVANCE OF BREASTFEEDING AND OPTIMAL INFANT AND YOUNG CHILD FEEDING IN ACHIEVING MDG 4 IN SUB-SAHARAN AFRICA. THE ROLE OF THE BFHI: By Dr Margaret Kyenkya KEYNOTE ADDRESS HIGHLIGHTS Dr Kyenkya started by congratulating for reaching the ripe age of 25 years. She said this is something IBFAN needs to be proud of having grown from 5 participants from 3 countries at the first IBFAN regional conference in 1982 to 100 sitting in this room in the year 2007. Her key note address speech provided a thrilling detailed historical perspective on the beginning of the IBFAN and the Baby friendly hospital initiative. She talked at length on the benefits of early initiation of breast feeding and exclusive breast feeding. She informed the participants that at the time of Milennium summit in September 2000, she had never doubted that the the strategy for the promotion, protection and support of breastfeeding, and optimal infant and young child feeding is not only essential for attaining children right to optimal health and nutrition. BUT that without it, without its implementation AFRICA has little hope of making a dent in the Millennium Development Goals by 2015. For example, she continued, in Mali, if human milk was given a market value of $1 per liter, its GDP would go up 5%; and that with current breastfeeding rates. One of the ECA papers exploring how Africa can achieve targets MDGs, argues that African countries need to attain a 6% growth to reach the targets. The Baby Friendly Hospital Initiative has an important role to restore the confidence of millions of women around the world in their own capabilities to have faith in breast feeding. BFHI should recreate an environment that removes obstacles and re-empowers woman with the knowledge, skills and space to transit from pregnancy/childbirth with her capacity to make the miracle of breastfeeding work totally intact. Empowered so this woman will pass her knowledge and skills to her children and others and in this way the bottle feeding culture will disappear. and we shall resort of this miracle that in a single shot (act) will deliver nutrients (food), pharmacology to boost the immune system of the consumer and cover our humanity. She commended the IBFAN movement (donors, individuals, government partners, member groups for having earned its place at the table because over the last 30 years, IBFANers have not only halted the decline in breastfeeding but have actually reversed it. For example the 2006 DHS of Uganda puts the exclusive breastfeeding rate at 63% In Sept of 2000, World leaders gathered at the UN headquarters in New York and once again, riled against global poverty and economic injustice. This meeting was however, a milestone in that for the first time, all countries accepted that poverty and injustice anywhere is a collective problem that demands a collective response. They agreed on a common vision for a better future that would have less poverty, less hunger, equal opportunities for women, universal access to education and better access to health services. They signed to a set of measurable targets that each country would achieve by 2015, fifteen years later. The UN and its member states have been keeping a tap on progress and half ay through have produced detailed reports of how each country is doing and what it will take to achieve the MDGs. Collectively the work of the women movement, of the environment movement, of the youth movement, and above all, of the human rights movement are all supposed and expected to make a contribution for the world towards the 8 MDGs. She questioned how the Africa region is doing? According to the 2007 progress report towards the MDGs , very few African countries are expected to reach these goals in the current environment and this knowledge can really get you down. Between 1990 and 2015, the following are to be achieved these targets movements are expected to help: 1. Eradicate extreme poverty and hunger (halve $1 a day income earners). Already 18 yrs ago in 1989, UNICEF and IBFAN worked out that the cost of replacing breastfeeding at family level for one year would be the same as feeding a family of 6 on fish, cassava, and vegetables for the same. Why then is there reluctance to give human milk a market value and then invest in its protection, promotion and support? Norway did in the early 1990s and a result was extensive maternity and paternity leave. Many countries have followed suit since then. Achieve Universal Primary Education for every girl and boy 2. Promote Gender Equality and Empower Women 3. Reduce child mortality by two thirds 4. Reduce maternal mortality ratio by three quarters: A woman who does not become pregnant cannot die of pregnancy related cause. Half of the worlds pop do not have access to contraceptives because of logistical. Financial and cultural and religious limitations. Breastfeeding is still preventing more births than all the available contraceptives combined. In addition it reduces iron deficient anemia in both infants and women. 5. Combat HIV/AIDS, Malaria and other diseases by haltering the diseases by 2015 and reversing the spread of HIV 6. Ensure environment sustainability. In 1991, Bradford calculated that for every 3 m children fed on formula, there would be 450tins of formula, 70,000 of unrecycleable metal discarded. 7. Develop Global Partnership for development The environment is favourable. The UNDP in 2006 reported that a number of countries in Southern Africa (Botswana, Lesotho, South Africa, Swaziland, Zambia, and Zimbabwe) experienced reversals in human development since the 1990s. Over one-third of the population is living on less than $1 a day. Countries like Lesotho and Zimbabwe had actually attained the status of medium development but have since slipped. We know the problems. We live with them. We are all affected by HIV and what it has done to our economies and to our caring capacity. It is stated that if the current trend were to continue, we might hope to achieve the MDGs in 2050. The African leaders are concentrating on how to get money to finance the attainment of the goals. Some estimates put the amount needed to achieve the first goal at US$17.6 billion and for the other seven 10.5b. Yet this SA region alone is said to be indebted to the tune of US$78.1billion and spends about $6.8b annually servicing this debt. Some countries are exporting more dollars than they get in. So the argument (half way through mind you) is that external partners need to offer steep front loaded debt relief and at the same time increase external funding without politicking it. Wisdom indicates, rapid progress is tough in African region with famines and wars and all their consequences, diseases everywhere and Violence in the homes and so on. When we achieve these goals, we would have made a move towards, development in the world and for the people in sub-saharan Africa. We also hope that whatever we do, will have been implemented in such a way that it moves us closer to the attainment of basic human rights, including the right of women to breastfeed and the rights of children to adequate nutrition and health. The most recent meeting of the Sub-Committee on Nutrition, (the SCN is a UN inter-agency working group that provide technical pronouncements on issues to do with nutrition) has documented how breastfeeding can contribute to the reduction of CMR and Maternal Mortality as follows: About 50-60% of under-5 mortality is caused by malnutrition and this malnutrition is due to poor breastfeeding and complementary feeding practices. The Infant and Young Child feeding strategy seeks to put into place practices that increase the nutrition status of infants and young children. It is complete, it is backed by good rationalization and the tools are well developed. All that is needed is to make it work! To make it happen. And if we succeed in increasing breastfeeding rates and in improving complementary feeding practices, malnutrition will drop and so will child mortality. By reducing infectious disease incident and severity (pneumonia, diarrhea, etc), breastfeeding could readily reduce child mortality by about 13%. Improved complementary feeding would reduce child mortality by about 6%. So those are the facts as we know them today. Breastfeeding saves lives. The lead WBW poster screams saving one million lives through For example, one MDG strategy to reduce CM is through increased immunization coverage. But everywhere, immunisable diseases keep reemerging because the service delivery system has broken down due to war or other disturbance or government do not have money to deliver adequate vaccines to the points where they are needed or bad governance makes the resource for their purchase disappear. And yet again, the absence of health workers due to brain drain, robs communities of this service. But, it is important to note that the mother is the first immunizer and her capacity to produce the combined therapy of food, vaccine and immune booster and medication has to be protected at all costs. That combined therapy is breastfeeding and infant and young child feeding Will that make breastfeeding work? No. Breastfeeding is an intimate process between two very vulnerable people: A newborn mother child dyad. BF and IFYC feeding are relevant to the MDGs but it is the relevance of the organization behind the breastfeeding movement that I would like to focus us on. Take into account that the quality of life in many countries has actually declined. Access to clean water is not better, More people are poorer. What would be the IMR if BF had not been promoted, protected and supported? In less than 30 years, we have reversed the declining trend of breastfeeding recorded in the 70s to a stable situation in the 90s, and to amazing increases in exclusive breastfeeding rates in the 2000s. For example the Uganda Demographic and Health Survey recently reported that exclusive breastfeeding rate to be 60%. In 1981, the 5 yearly DHS did not even measure exclusive breastfeeding. The term did not even exist because the value of breastfeeding was not known or documented. The lead WABA poster for WBW 2007 proclaims ‘Early Initiation and Exclusive breastfeeding can save more than one million lives babies’. Now we have high powered consultants, economists documenting how breastfeeding contributes. What exactly have we done?
We have promoted and protected breast feeding in all situations including in emergencies and in the era of HIV infections.

We have kept up to date with developments and brought these to the attention of those who need to know. In the mid-1990s, the HIV scare could have destroyed the breastfeeding movement if it were not for the constant monitoring of the first Australian infants that were said to be infected with HIV through breastfeeding and progressive documentation of how BF was better for a child whose mother was HIV positive. AFASS would not have been if it were not for IBFAN.
We have protected. There is no other single movement in the last 50 years that has kept the baby food industry on their toes as the Nestle Boycott and IBFANs work as coordinated through the International Code Documentation Centre.

Not only have our governments protected this but actions have spilled off to uncover substandard milks, baby foods and feeding utensils whose use would have contributed to pneumonias, diarrhea, childhood cancers, inadequate micronutrient intake, and indeed vulnerability to viral infections such as HIV. All these illnesses contribute to the burden of disease; to malnutrition, to increased child mortality. We have supported early initiation and made it fashionable. MDGs are an arm of Human Rights. Reduction of infant and child mortality being an arm of the Convention on the Rights of the Child and Maternal Mortality as arm of CEDAW. There are 20,000 BFHIs around the world and about 5900 in Sub-Saharan Africa. and health workers handled mothers just prior to, during and immediately after birth? Because it is the heart of success; it is the heart of getting those exclusive breastfeeding rates up and it is the heart of reductions, not just in child mortality or infant mortality BUT of neonatal mortality! If any of your countries is working on a road map to the reduction of newborn and maternal mortality, do whatever needs to be done to hand them the BFHI strategy. The roadmap something that heads of states have committed to and I am afraid they are not even considering BFHI. From the start, I have focused not so much on the well documented role of BF to the reduction of Child and Maternal Mortality but on what the IBFAN Network is and will continue to contribute. The BFHI story demonstrates that you can have well written technical reports and documentation but they do not necessarily move the world until someone becomes creative in using those documents, those facts to move the world. WABA is networking with every one and you are the WABA link in the region. It is very tempting to get buried in the day to day routines, office work, especially when you become an organisation and establish a beauracracy. What IBFAN does best is network. We cannot afford to be complacent or assume that everyone knows. We need to speak up and speak out because we have skills that have worked and we have wisdom to share. The tendencies to be overly sensitive and protective of knowledge is creeping in. We need to avoid that. Think of our role for the MDGs as a relay. We catch and pass the torch as rapidly as possible. DAY ONE, MONDAY 13TH AUGUST 2007. SECOND SESSION: OBJECTIV 1. UPDATES ON CURRENT ISSUES AND DEVELOPMENTS ON INFANT AND YOUNG CHIDL NUTRITION NUTRTION OF CHILDREN UNDER FIVE IN SUB SAHARAN AFRICA: OVERVIEW AND CURRENT TRENDS. By Saba Mebrantu Dr Mebrantu began her presentation by citing the following quotes:
“Adequate food is a human right
“Good nutrition is essential to achieve the aims of the Millennium Declaration, including those expressed by the Millennium Development Goals The World Bank, 2006

She reviewed the nutrition status of children under five years of age at global level with relation to MDG goals. Over 1/3 all children in Sub-Saharan Africa are underweight (more than 15 million children in ESA alone). Undernutrition, she continued, is associated with the increased risk of morbidity and mortality, damage to cognitive development, less productive in their adulthood, thus impacting upon economic development. About 60% of the total deaths in the underfives are associated with undernutrition. The data she presented on global trends in child underweight from 1990-2005, indicated that the situation in Africa has remained static over this period as compared with other countries and at global level. She then dwelt on the effects of infant feeding practices on under five mortality. Of all the interventions, exclusive breast feeding had the highest impact followed by the impregnated mosquito notes and complimentary feeding with continued breast feeding. With relation to the rates of exclusive breast feeding up to 6 months in sub Saharan Africa, she noted that the increase has been significant from 990 to 2004. In West and Central Africa, the increase has been by 450% and by 41% in East and Southern Africa. The countries which have done very well include Ethiopia, Uganda, Burundi, Madgascar and Rwanda. Countries which still need strengthening include Malawi, Zimbabwe, Mozambique, Zambia and Botswana. Kenya, South Africa, Somali, Angola and Swaziland require renewed focus, revision of strategies and activities and national commitment for improving EBF and at scale Finally she recommended immediate steps which need to be taken within the sub-saharan African countries to promote and improve IYCF - Disseminate of documentation of IYCF best practices and lessons learned, including HIV+ context - Address scale-up issues- explore including in national nutrition plans with national budget allocation (SWAPS, PRSPs) - Advocacy to firmly place IYCF into the MDGs/Survival and Development and HIV agenda - Support scale-up implementation with more holistic approach such that IYCF can contribute to the general development
BREAST FEEDING: WHAT DOES NEW RESEARCH SAY INCLUDING THE CONTEXT OF HIV. By J Mareverwa

SUMMARY/HIGHLIGHTS OF PRESENTATION
1. 2 million child deaths could be averted every year through effective breast feeding in Africa
2. Counselling on breast feeding leads to improved feeding practices, improved intakes of milk and growth AND reduces the incidence of diarrhoea
3. Malnutrition contributes to +/- ½ of the <5 mortality. A 1/3 of this is due to faulty feeding practices
4. The nutrition and antibodies that b/milk provides are so crucial to young children that they outweigh the small risk of transmitting HIV calculated at +/- 1%/month of breast feeding
5. The risk of postnatal HIV transmission by 6/12 of age in exclusively b/fed infants who were HIV negative at 4 to 8 wks was 4.04%. Replacement feeding was associated with an increased mortality compared with EBF(15.12% vs. 6.13% at 3/12)
6. Exclusively breast fed infants have at least 2.5 times fewer illness episodes than those on formula. Infants are as much as 25 times more likely to die in the 1st 6/12 of life if not exclusively breast fed.

7. Infants <1yr are 3 times more likely to die from respiratory infections if not b/fed than EBF ones ( 8. Infants EBF for 4/12+ have ½ the mean number of acute otitis media episodes of those who never breast fed. 9. Putting mothers on effective combination of ARVs also dramatically cuts the risk of HIV transmission through b/feeding to<2%. Where mothers are being encouraged to b/feed exclusively ARVs for B/feeding mothers could spare thousands of children from HIV infection 10. Breast fed children were observed to have higher intelligent quotient (IQ) than those fed on artificial formula.
HIV AND INFANT FEEDING UPDATE: THE WHO CONSENSUS STATEMENT ON HIV AND INFANT FEEDING. By Dr Daisy Trovoada
n Reunião de consulta reuniu vários especialista da área HIV/PTV, saúde infantil, Nutrição, saúde reprodutiva/ Maternidade segura, etc das NU,OMS AFRO e OMS/Sede e o grupo IATT (interagency task team on prevention of HIV infections in pregnant women, mothers and theit infants.
n Revisão das novas evidencias e experiências sobre HIV e alimentação do lactente existentes desde 2000.
n Estabelecer/esclarecer e rever as orientações das NU sobre alimentação infantil e HIV
Transmissão do HIV através do leite do peito Novas evidências
n Decréscimo de 3-4 vezes no risco de transmissão do HIV associado ao aleitamento materno exclusivo os 6 primeiros meses de vida, comparado com o aleitamento não exclusivo (Costa do Marfim, Zimbabwe e RSA).
n Nível baixo de CD4 materno, carga víral elevada no sangue e no leite do peito, a seroconversão materna durante o aleitamento materno e a duração do próprio aleitamento materno são factores de risco importantes para a transmissão do vírus e na mortalidade infantil.
n Há indicações do que TARV nas mães eligiveis para o tratamento poderia reduzir a transmissão pós-natal do HIV (dados de Botswana, Mozambique e Uganda)
Morbilidade & Mortalidade: Novas evidências
n No sítios onde a profilaxia ARV e o leite artificial foi providenciado o risco combinado de contrair a infecção e morrer aos 18 meses foi semelhante para os lactentes ao biberão e os que tomaram leite do peito durante 3 a 6 meses (Botswana e Costa de Marfim).
n O desmame precoce (< 6 meses) foi associado a um elevado risco de morbilidade (diarreia) e mortalidade nas crianças HIV expostas (Malawi, Kenya, Uganda e Zambia).
n O desmame precoce aos 4 meses foi associado a uma redução da transmissão do virus mas também a um aumento da mortalidade infantil dos 4 aos 24 meses (dados preliminarios da Zambia).
n O aleitamento materno além dos 6 meses nas crianças infectadas pelo HIV foi associado a uma melhoria da sobrevivencia em comparação com os que tiveram desmame mais cedo.
Melhorando as praticas de amamentação
n Mensagens consistentes, repetidas/frequentes e o aconselhamento de qualidade melhoraram aderência e a duração do aleitamento materno exclusivo até aos 6 meses (Zambia, Zimbabwe e Africa do sul).
Situação actual
n Orientação das NU sobre HIV e alimentação do lactente: disponível e incorporada nos documentos de política nacional mas o desafio resta sua implementação.
n A cobertura e a qualidade das intervenções para PTV incluindo o aconselhamento e o apoio para o aleitamento muito fraca.
n A fraca organização dos serviços de saúde afecta o apoio e a qualidade do aconselhamento opções de alimentação inadequada tanto para as mães HIV+/HIV-.
n Intensificar a qualidade das intervenções para o aconselhamento e apoio a alimentação infantil necessita um compromisso forte e sustentável e apoio por parte das agencias internacionais e doadores trabalhando em concerto com os ministérios de saúde.
n Necessidade de um seguimento apropriado para todas as crianças sobretudo para aquelas que tomam o biberão.
n O aumento do acesso ao teste precoce no primeiro mês de vida, e ao TARV oferece novas oportunidade para avaliação pós natal da alimentação, aconselhamento e apoio nutricional.
n Pesquisas ainda são necessárias para identificar os assuntos prioritários incluindo para achar as melhores opções de alimentação segura para a criança exposta ao HIV
Recomendações
n A opção do aleitamento infantil a mais apropriada para uma mãe HIV+ deve continuar a depender das suas circunstancias individual (estado de saúde) mas deve tomar em consideração a disponibilidade dos serviços de saúde e serviços de aconselhamento e apoio que ela poderá receber.
n O aleitamento materno exclusivo é recomendado as mães HIV+ durante os 6 primeiros meses a não ser que ela reúne as condições para substituir o leite do peito e que seja aceitável, viável, acessível, sustentável e seguro (AVASS) para ela e seus filhos antes do tempo.
n Se alimentação substituta for aceitável, viável, acessível, sustentável e segura recomenda-se então a interrupção total e completa do leite do peito.
n Aos 6 meses se as condições para a substituição do leite do peito não estão reunidas recomenda-se continuar o aleitamento materno e recomenda-se a introdução de alimentos complementar, a mãe e seu filho deverão continuar a serem avaliados regularmente.
n Logo que uma dieta adequada, equilibrada e segura dpv nutricional pode ser providenciada recomenda-se a cessação imediata do aleitamento materno.
n qualquer que seja a opção de alimentação escolhida pela mãe, os serviços de saúde deve fazer o seguimento de todas as crianças e providenciar aconselhamento e apoio continuo, particularmente nos momentos chave em que necessidade de reconsiderar a escolha alimentar (diagnostico precoce e no 6º mês)
n As mães lactantes HIV+ cujo os filhos são HIV+ devem ser fortemente encorajadas a continuar o aleitamento materno.
n Os governos e outros intervenientes devem revitalizar acções com vista a protecção, promoção e apoio ao aleitamento materno, na população em geral.
n Os programas nacionais devem providenciar a todas crianças expostas ao HIV e suas mães um pacote integrado de intervenções de saúde em prol da sobrevivência infantil e materna.
n Os governos devem assegurar que o pacote de intervenções acima referido bem como as novas orientações dadas sejam disponiveis antes de considerar qualquer distribuição gratuita de leite artificial.
n Os governos e os doadores devem aumentar o seu compromisso e os recursos para implementar a Estratégia Mundial de alimentação para o lactente e criança pequena assim como as acções prioritárias do quadro de implementação da orientação sobre HIV e alimentação infantil, com vista a prevenir a infecção pós natal, melhorar a sobrevivência sem HIV e atingir os objectivos do UNGASS
INFANT FEEDING IN THE CONTEXT OF HIV By J Mareverewa
SUMMARY
Dr Mareverwa reviewed the WHO recommendations for appropriate feeding of infants born to HIV infected mothers.
As in WHO 2006 statement, she recalled evidence and observations from studies in Botswana, Mozambique, Uganda, Cote d’Ivoire, Malawi, Zimbabwe and South Africa on breast feeding practices and duration of breast feeding in post natal HIV transmission
• New evidence on Morbidity and Mortality in settings where ARV prophylaxis and free formula were provided the combined risk of HIV infection and death by 18 months was similar in infants on exclusive formula feeds and infants breastfed for 3-6 months (Botswana and Cote d’lvoire)
Ø Early cessation of breastfeeding (<6/12) was associated with increased risk of morbidity (especially diarrhea) and mortality in HIV exposed children in Malawi, Kenya, Uganda and Zimbabwe
Ø Early breastfeeding cessation at 4/12 was associated with reduced HIV transmission but also with increased child mortality from 4-24 months
Ø Breastfeeding of HIV infected infants beyond 6/12 months was associated with improved survival compared to stopping breastfeeding (Botswana and Zambia)
Ø Improved adherence and larger duration of exclusive breastfeeding up to 6 months were achieved in HIV infected and HIV uninfected mothers when they were provided with consistent messages and frequent high counseling in South Africa, Zambia and Zimbabwe
Ø Weak and poorly organized health services affect the quality of infant feeding counseling and support
Ø Inaccurate, insufficient or non-existent infant feeding counseling has led to inappropriate feeding choices by both HIV positive and HIV negative women
Ø Increasing access to early infant diagnosis in the first months of life and to pediatric ARV Rx provides new opportunities for post-natal infant feeding assessment counseling and follow-up nutritional support
Recommendations
Ø The most appropriate infant feeding option for an HIV infected mother should continue to depend on her individual circumstances
Ø Exclusive breastfeeding is recommended for HIV infected women for the first 6 months of life unless replacement feeding is AFASS for them and their infants before that time
Ø When replacement feeding is AFASS, avoidance of all breastfeeding by HIV positive is recommended
Ø At 6 months, if replacement feeding is still NOT AFASS continuation of breastfeeding with additional complementary foods is recommended, while the mother and baby continue to be regularly assessed
Ø All breastfeeding should stop once a nutritionally adequate and safe diet without breast milk can be provided
Ø Breastfeeding mothers of infants and young children who are known to be HIV infected should be strongly encouraged to continue breastfeeding

HIV AND INFANT FEEDING: LESSONS FROM ESAR SELECTED COUNTRIES IN STREGHTHENING THE IYCF COMPONENTS AND THE ROLE OF REVISED BFHI, MATERIALS IN THE HIV CONTEXT,IN THE SCALING UP OF PMTCT PROGRAMMES: By Saba Mebrantu
Saba presented the finding of the recent joint IATT country missions on IF and BFHI in: Botswana, Lesotho, Swaziland and and Tanzania.
The objectives were to review the status of implementation of PMTCT programs, paediatric CST and five priorities areas of action of UN HIV and infant feeding frame work and then and make recommendations for improving coverage and effectiveness and access of children to services.
The overall goal was to provide TA to support the acceleration of PMTCT scale up and the integration of pediatric care into national ART programs
The joint mission comprised of UNICEF, WHO, UNAIDS, UNFPA, CDC, EGPAF, Baylor College and Clinton Foundation
Key findings

Strengths
• Infant and young child feeding policy, strategy and guidelines are in place or under-development in all 4 countries.
• Code of marketing of breast milk substitutes exists (Botswana and Tanzania) or is under endorsement (Lesotho and Swaziland)
• IF and Nutrition is increasingly being recognized as an important component of PMTCT and Paediatric Aids (Botswana, Lesotho and Swaziland)
• Monthly child monitoring (Botswana, Lesotho and Swaziland) an important opportunity to identify and manage early growth faltering
• Support to BF and IYCF/BFHI is being revitalized or accelerated in the countries surveyed
Weaknesses
• Capacity of health workers on HIV and infant feeding counseling is weak (Botswana, Lesotho and Swaziland) or is un-harmonized among key partners (Tanzania). IF components of PMTCT plans and resources allocated to this are limited
• There is limited capacity for nutrition in the Ministry of Health - nutrition is consistently under-funded (Botswana, Swaziland and Lesotho)
• Exclusive BF rates are low and infant and neonatal mortality rates associated with HIV and replacement feeding are on the increase (Botswana and Swaziland)
• There is little support for women beyond IF counseling in ANC and maternity settings (no support groups, no community involvement)
• Understanding and applicability of the AFASS concept is disturbingly low
• Weak supply chain management of infant formula and non-optimal use (Botswana)
• Replacement feeding is not feasible for the majority of women (Tanzania, Swaziland and Lesotho: Reasons noted were poor social economic status, stigma and failure to disclose to partner, Unreliable supplies
Recommendations
• Greater involvement nutrition departments in:
the national PMTCT working/coordinating groups
Development of national PMTCT scale up plans and
Resource mobilization and allocation
• Strengthen current IF training with the 40-hour integrated course and ensure it is linked with PMTCT training
• Strengthen counseling for mothers, through:
Reactivation of BFHI (with a strong step 10)
Supervision and mentoring of counselors
Support for women at community level: NGO, FBO, support groups…
• Up-date IYCF guidelines for HIV context and ensure these are harmonized with PMTCT, IMCI and other related guidelines (Tanzania, Botswana, Lesotho, Swaziland)
• Undertake in-depth review of Infant Formula Supply Chain Management to assure adequate supply (Botswana)
• Revise and realign HIV and IF training with WHO integrated course (Botswana, Lesotho, and Swaziland)
• Guidelines and protocol on management of acute malnutrition with links to Paed Care and Treatment (Botswana, Lesotho and Swaziland)

DISCUSSION
* The most recent initiative of Focus Antenatal Care provides opportunity for nutrition and infant feeding counseling, this should be part of FAC package. This is beginning in Kenya
* Training materials, Not easy to review materials with a large group. So aim is to highlight the materials and then the details can be discussed in groups.

Many countries are not even using them.
* The current training materials and many, big and hence very intimidating.
* IF counseling strongly focused within PMTCT in Kenya but needs to be strengthened. Post natal follow up also needs to be strengthened. Universal access targets for HIV and advocacy for IF and BF needs so be positioned and monitoring and evaluation mechanism needs to be established.
* BFHI/HIV should be included in policies and strategies, there is still room for advocacy
* There should be mother and child joint services and not a separate one. Mother should be given ARV and at the same time exclusive breast feeding should be emphasized.
* What are the reasons for mixed feeding? Is it stigma? Then the community support is important. Communities are not always aware of this model, community participation should be encouraged.
* We have to improve lobbying and advocacy at policy makers. Advocacy should empower women. We need to recognize, after the birth the child, there are 2 individuals, mother and a child. We want the best for the child and the mother. So what is in it for the mother
* The key note address was informative. How best can we influence policy makers and how do we lobby for the necessary resources? On the issue of neo natal mortality rate and maternal mortality, traditionally, the post natal visit to the health facility is 6weeks after delivery, There is a need to review this. It would be better after 3-7 days. How do we influence the mothers.
* DHS data: the figures for exclusive breast feeding 0-6 months seem to be higher than what has been observed in some countries.
* Counseling for the prevention of HIV, we tend to focus on the life of a mother, it is important to include the child as well
* In Ghana, the road mapping of MDG goals left out BFHI. So we need to fight and work harder at lobbying. Research figures are encouraging and West Africa needs to do the same.
* Saba showed the rates of exclusive breast feeding in different countries. At what age exclusive breast feeding was stopped. The issue is in case of HIV infected mother, if she continues to breast feed, the baby is sure to get infected. According the available information, one out of ten mothers are infected. Health workers do not have enough idea about the BFHI. Also it is important to inform the rest of the family members.
* With regard to HIV, BFHI has to be strengthened. Health workers and families do not know enough.
* In most countries, IYCF does not focus on PRSP which is food security focused. Breast milk adds to food security in family. Take advantage in formulating messages.
* In Mozambique most of us are not aware of HIV/AIDS. Women are illiterate and have misconceptions and wrong beliefs about the anatomy of breast and reproductive system. So we need to know how we can help this mothers so as to improve breast feeding practices. How can we inform these mothers better?
* Quality Research is necessary to influence policy makers. Therefore it important to use tools which define the issues well.
* Communities and families have a lot to do. How confident are the counselors? Do they feel capable to inform and convince the mothers?
* It is important to identify the gaps for research.
* Post and pre natal care: It is important to teach about exclusive breast feeding at ante natal level. However, post natal care is forgotten. In Gambia we are still at 6 weeks but then this is still a burden on midwives and nurses. Also effect of EBF on survival of low birth weight babies should be emphasized.

HIV positive mothers may choose to EBF for 6 months but then go into mixed feeding as the issue is the availability of sustainable replacement feeds. There are cultural and stigma problems which the health workers and community workers find difficult to deal with.
* In Tanzania, PMTCT link between the antenatal care, labour ward and post natal care is weak or does not exist so not easy to know what mother is up to once she is discharged from ante natal care. BFHI is mostly hospital based and nutrition studies in some rural areas indicate that Exclusive breast feeding up to 6 months is as low as less than 5%. Women like to deliver at a health facility but distance and the cost of transport are main obstacles
* As regards EBF, there are conflicting messages. At one time it was within the first ½ hour, then 1 hour, then for the first 3 moths, then 4 months and now 6 months. Sometimes, husband do not want their wives to breast feed. Women also fear that EBF for 6 months would have negative impact on the bonding between her and her husband. So we should not talk about just mother to child bonding. Many women deliver at home and therefore more counseling should be done at ante natal level
* Sometimes health service system should be blamed for excluding men from all the services. There was a time when the health workers gave glucose water to the baby and taught mothers to use it at home.
* Identifying the key indicators in IYCF is a big challenge as information is not collected routinely. DHS information is appropriate for evaluation and trends but not for routine monitoring

CHALLENGES FACED BY BREASTFEEDING MOTHERS OPTING FOR EXCLUSIVE BREASTFEEDING IN THE ERA OF HIV: THE CASE OF MANZINI, SWAZILAND. By Ms L Mamba and Dr Sibiya A study looking at the challenges faced by breastfeeding mothers opting for exclusive breastfeeding was conducted in Swaziland. The objectives of the study were to:
* determine infant feeding practices for children 0-6 months in the context of HIV and possible reasons for introducing mixed feeding.
* determine possible factors that influence failure to exclusively breastfeed, in the context of HIV document possible challenges for exclusive breastfeeding.
* recommend possible actions to improve exclusive breastfeeding.

Method: Currently 40 nursing, unemployed mothers having infants of less than 6 months living in the rural areas of the Manzini region were purposively selected. Mothers were visited at their respective homes and face to face interviews were conducted by the researcher, reading questions to the respondents and recording responses. Data from this study was analysed using Statistical Package for Social Sciences. Key findings
* The analysed data indicated that most mothers shared skin-to-skin mother-baby contact and initiated breast milk within the first hour of delivery.
* Where breastfeeding was not possible for one reason or another, mothers still provided skin to skin mother-child contact.
* Mothers introduced mixed feed as early as birth; only 30% of the infants studied were exclusively breastfeeding at the time of interview.

· From the 30% only less than a third were planning to introduce mixed feed at 6 months the majority were planning to do so as early as 3 months. Reasons given for mixed feed before the age 6 months were:. - The baby crying soon after breastfeeding and therefore the mother-in-law complaining that baby is not satisfied only with breastmilk - The baby suckle hands and imitates suckling - The family complains that the baby is not only satisfied with breastmilk, so forced by family to introduce emasi (sour milk) - The nursing mother feels breastmilk is not enough. - The mother has only one functioning breast - The mother is busy with house chores - Baby has a navel and assumption that this means that the baby cannot be -satisfied with breastmilk alone. - The baby sweats a lot - Mixed feed introduced for the baby to grow These results indicate that modification of breastmilk will be an acceptable replacement option for infant feeding in context to HIV and AIDS. INFANT AND YOUNG CHILD FEEDING IN THE HIV ERA: A CASE STUDY FROM TANZANIA: By Z. Lukmanji The presentation discussed the factors which determine the choice of infant feeding options by the HIV infected mothers with children under five. Information was collected through 4 case studies involving HIV infected women and their children below 5 years, currently enrolled in an ongoing study of ARV and mother to child infection. All 4 women were between 31 and 36 years old. Three were married and one had widowed recently (husband died of HIV). The children were between 10 and 25 months old. Of the 4, three were exclusively breast fed for 3 months and 1 continued until 6 months. All tested HIV positive during their last pregnancy, having no idea who might have infected who (was it the husband or was she already positive before getting married) The reasons for stopping EBF at 3 months were:
1. The child was too demanding and was tiring her out. the child did not like artificial formula and was fed on cow milk. By 5 months, the child was having all the adult foods. The weight gain and nutrition status was normal
2. Initially had decided to EBF for 6 months but stopped at 3 months as the child started showing signs of wanting to eat other foods so she feared the mother in law would do just that. The mother worked and left the child with the neighbour and had no idea what the child ate during her absence. Weight gain and nutrition status normal.
3. Never breast fed. Sister bought the milk initially and now the husband pays for it. The husband does not know of her status as he might not accept it and therefore would not give money to buy the milk. No relatively her seriously questioned her not breast feeding. Child at all the foods by the age of 4 months. Weight gain and nutrition status normal.
4. Exclusively breast fed for 6 months as could not afford the artificial or replacement feeding. Both her and husband are unemployed and lived with her parents. Initially husband did not accept her HIV status and so left her. But then got himself tested and went back to her. The child being fed on porridge and family meal. Weight gain unsteady and moderately underweight.

IBFAN COMMITMENT TO THE CODE:25 YEARS OF THE INTERNATIONAL CODE OF MARKETING OF BREASTMILK SUBSTITUES: By R Maseko IBFAN was founded on 12 October 1979 by six international NGOs, helped to develop the International Code of Marketing of Breastmilk Substitutes. IBFAN now counts over 150 groups in over 90 countries around the world. The network is committed to seeing marketing practices of breast milk substitutes everywhere change accordingly and globally has successfully used boycotts and adverse publicity to press companies into more ethical behavior.
The International Code of Marketing of Breastmilk Substitute was adopted by the World Health Assembly (WHA) in 1981 as an international recommendation and a minimum universal requirement to protect the health of infants and young children.
IBFAN Africa has worked hard in the past 25 years to sensitize National Governments and lobby policy makers about the Code and relevant WHA resolutions, and how they can translate them into enforceable national legislation.
SCOPE OF THE CODE
The Code applies to breastmilk substitutes, when marketed or otherwise represented as a partial or total replacement for breast milk. These include beverages such as: infant formulae, other milk products, cereals, vegetable mixes, juices, baby teas and follow up milk. The Code also applies to feeding bottles and teats.
With the collaboration of ICDC Penang, and support from UNICEF/WHO and National Governments, IBFAN Africa has trained people in almost all the countries that have groups that are members or affiliates of IBFAN Africa. Twelve countries in Africa have good National laws and 7 countries with many provisions of the Law.
Since 2000, the regional office with collaboration of ICDC Penang, UNICEF & WHO has conducted trainings on how to Monitor The Code using very simple forms- SIM.
Violations of the Code
It may seem Code Violations by Industry is reduced. On the contrary, there is a lot. Industry has gone back to using Health workers to promote their products.
In some places, industry enforce Economic threats to force governments to weaken National Laws where they exist, or offer to pay for writing National Laws.
In some countries, industry ignore the International Code and engage in promotion of their products.
Monitoring The Code During the past several years, IBFAN has engaged in several monitoring activities, either working with ICDC in conducting the Global Code Monitoring, IMP, or supporting countries by providing both technical and financial support to carry out monitoring at country level.
Continuous Monitoring:
IBFAN Africa has been encouraging countries to be always on the look out for Code Violations by Industry. Very simple forms have been developed to encourage monitoring, but still with no great success. The Regional Office of IBFAN Africa would like to see more countries coming up with National Laws to ensure, protection and promotion of optimal Infant and Young Child Feeding.

CODEX ALIMENTARIUS AND THE INTERNATIONAL CODE OF MARKETING OF BREASTMILK SUBSTITUTES: By H.H.T.Tarimo

SUMMARY AND HIGHLIGHTS Mr Tarimo introduced the Codex Alimentarius and discussed how the BMS CODE is linked to The Codex Alimentarius. The Codex Alimentarius Commission (or Codex) was established in 1961 by FAO and WHO to develop international food standards, guidelines and recommendations to protect the health of consumers and to ensure fair practices in the food trade.
IBFAN International Codex Working group formed in 1996 with the main task of fighting to get some of the provisions of the International Code and Subsequent WHA resolutions incorporated into Codex standards. One of the achievements of this Working group has been the successful alliances built with like minded stakeholders globally.

The activities of the working group have been the preparation of IBFAN positions and defending them in Codex sessions. To-date this endeavour has been a resounding success particularly with regard to the revision of the Codex standards for infant formula, cereal based complementary foods, food labelling and the codes of hygienic practices for baby foods To complement the work of the international working group IBFAN Africa Code/ Codex Working group was formed in 2004/5 and IBFAN Africa has managed to mobilize resources to promote participation of some delegates from Africa to critical Codex sessions with a mission to defend IBFAN/ Africa positions. The link between the Code and Codex Alimentarius Article 10 of the CODE: Codex Alimentarius is referenced in Article 10- (Quality) of the Code with states that: Food products within the scope of the Code should, when sold or otherwise distributed, meet applicable standards recommended by the Codex Alimentarius Commission and also the Codex Code of Hygienic Practice for Foods for Infants and children. Article 9 (labelling) of the Code have a lot to do with quality and safety of baby foods for infants and young children. Resolution WHA 34.22 of 1981: requests the Codex Alimentarius Commission to give full consideration within the framework of its operational mandates to improve the quality standards of baby foods and to support and promote the implementation of the International Code. Resolution WHA 55.25 of 2002: Requests the Codex Alimentarius Commission to continue to give full consideration, within the framework of its operational mandate, to improve the quality standards of processed foods for infants and young children and to promote their safe and proper use at an appropriate age, including though adequate labelling, consistent with the policy of WHO, in particular the International Code of Marketing of breastmilk substitutes, resolution WHA 54.2 and other relevant resolutions of the Health Assembly
Resolution WHA 58.32 of 2005 requested the Codex
• To continue to give full consideration, when elaborating standards, guidelines and recommendations, to those resolutions of the Health Assembly that are relevant in the framework of its operational mandate.
• To establish standards, guidelines and recommendations on food for infants and young children formulated in a manner that insures the development of safe and appropriately labelled products that meet their own nutritional and safety needs.
• To complete work of addressing the risk of microbiological contamination of powdered infant formula and establish appropriate microbiological criteria or
• standards related to Enterobacter sakazakii and other relevant microorganisms in powdered infant formula, and to provide guidance on safe handling and on warning messages on product packaging.
INFANT FEEDING IN EMERGENCIES: PROGRESS AND CURRENT DEVELOPMENTS: By Dr L Fidalgo
SUMMARY AND HIGHLIGHTS
In emergency situation it is believed that the malnourished mothers cannot breast feed and foods should go to the lactating mothers so that they can feed their babies and maintain strength ot care for the older children.
Dr Fidalgo advised the participants to be aware of existing materials and guidelines on infant feeding in emergencies and the programmes one can support to protect, support and promote breast feeding. If any observed violation of the international code should be reported to the emergency coordinator or the IBFAN office.
Since 1999, IBFAN has been working in the field of infant feeding during the emergency situation. IBFAN launched the policy statement in IFE in 1999 and the in the year 2000, IBFAN emergency technical working group was established. Since then, IBFAN has developed manuals, guidelines and a tool for monitoring compliance of the international code in collaboration with UNICEF, WHO and Linkages.
It has conducted training of professionals on infant feeding in emergency situation and in monitoring and evaluation of IFE of the IBFAN country members.
Materials and manuals available for infant feeding in emergency situation have been developed for the emergency relief staff, health and nutrition workers and program mangers. IBFAN AFRICA has developed a tool for Monitoring Compliance to the International Code of Marketing in Emergencies in Africa.

Cameroon shared its experiences in dealing with infant feeding in emergencies. It has a multi-sectorial committee which coordinates and evaluates the situation. The committee ensures that no trade mark is used in the products and in most emergency areas there are food stores. However, some manufacturers and companies take advantage of emergencies, hence people need to be alert and ensure effective coordination.
MATERNITY PROTECTION FOR WORKING WOMEN: IMPORTANCE, REGIONAL PROGRESS AND NEW DEVELOPMENTS: By D Aphane

SUMMARY AND HIGHLIGHTS
Ms Aphane enlightened the participants on the situation regarding the maternity leave and protection for the working mothers within East, Central and Southern Africa. The issue is still not regularized at most governments level despite ILO Commitment to Maternity Protection since its inceptin in 1919. She gave an overview of the thorough analysis she had carried out on the available instruments to effect laws and legislations regarding the maternity protection and breast feeding.
She observed that several international and regional instruments are in concert in supporting a woman right to breastfeeding and a child right to nutrition. The instruments go to different lengths in making linkages and supporting breast feeding in the context of employment and it is important understand that before provisions under regional and or international instruments can be enjoyed by the citizenry, they need to be ratified and domesticated, that is, going through a process of making them part of national legislation.
Maternity protection and promotion in the twenty first century is taking place under a fragile landscape for women in the region, whether in East, Central or Southern Africa.
The aim of maternity protection is to safeguard the health of the mother and child. Other types of related leave such as parental or so called paternity leave are meant to safeguard the health of the child, unlike maternity leave they have a single purpose. Additionally, maternity protection also seeks to safeguard the mother job and benefits.
Research has established that all societies in both East, Central and Southern Africa traditionally had and continue to have their ways of protecting maternity, amidst challenges of break down of family structures through migration, modernisation and the money economy. These safety nets have been weakened.
In conclusion, a lot has been said about maternity leave but it remains elusive and a preserve of a few women. We need to roll out access, I mean dish it out so that mothers out there can have a taste of it. In turn our breastfeeding advocacy will pay blue chip dividends. Let us not allow governments and employers to privatise maternity protection, it is for child bearing mothers out there.

Gender Mainstreaming in IBFAN Africa
Origins of gender mainstreaming
n The idea of mainstreaming surfaced during the Women in Development (WID) period in the 1970s when development workers were concerned about the lagging behind of women in the development process and non recognition of women role as producers..
Gender mainstreaming defined
n The ‘Beijing Platform for action’ articulated gender mainstreaming in the following terms:
n … government and other actors should promote an active and visible policy of mainstreaming a gender perspective in all policies and programmes so that, before decisions are taken an analysis is made o f the effects on women and men respectively. (United Nations, 1996, p11).
The development of Gender and Development
n After the failure of WID, development practitioners sought to move women issues into the mainstream of development. Thus the concept of Gender and Development (GAD) evolved. This concept was popularized in 1985 and intensified at the 1995 Beijing conference. The GAD approach emphasized a focus on women, men, girls, and boys, male and female adults.
BREASTFEEDING AND WID
n It can be safely said that the WID perspective also contributed to the decline in exclusive breastfeeding, increase in mixed feeding and introduction of formula feeding.
n Clear reasons for the above being that women were introduced an additional burden of income generation without easing their work load, breast feeding became the casualty.
IBFAN’S Rational for Gender Mainstreaming Reproductive health &breastfeeding
n IBFAN is mainstreaming gender in a bid to find a holistic way of dealing with reproductive health, infant and young child feeding.
n By adopting a gender perspective, IBFAN will be bring to the fore, the centre, removing from the periphery concerns on breastfeeding which have hitherto, been borne by women.
n Similarly, to the general concern of gender mainstreaming, the core of gender mainstreaming in IBFAN work, is the need or the process by which men and the youth are are removed from the periphery and brought to the centre of breastfeeding and reproductive health. Gender mainstreaming in reproductive health and breastfeeding is concerned with positive change be it at political, policy, legislative, community, organisational and family level.
n Men meaningful involvement in a systematic fashion will positively impact on IBFAN work on promoting and protecting breastfeeding.
n In the process of gender mainstreaming, IBFAN should have the UN bodies as one of its allies and strategically place itself to get some of its funds from various UN agencies UNICEF,UNDP ,UNIFEM and possibly FAO.
n
n Finally, IBFAN should leave no stone unturned in mainstreaming gender in reproductive health and promotion of breastfeeding.
n IBFAN advocacy and lobbying component should identify for strategic partnerships which will enhance its influence socially, economically, politically, legally and culturally.
n Without men involvement, IBFAN work in promoting and protecting breastfeeding might produce limping results.
n IBFAN should go all the way to mainstreaming gender in its work.
AU-NEPAD Commitment to Nutrition: Maternal, infant and young childAchieving MDGs 4 & 5 : By B D Giyose
Africa is not a hopeless and lost continent! In Fact it is the Last Eden!
Ms Giyose began her session with 10 very pertinent and practical questions to the participants.

1. How many are participants are from agriculture, science and technology, infrastructure, education, finance, industry and health? (All from health!!) 2. 7th Ibfan conference. How well have you as the breast feeding and nutrition community networked? 3. 10-20-30 years later, what have really achieved? What have you done different? (Time to take stock) 4. Are we asking the right questions? Have you set yourselves the right targets? 5. How practical or realistic are the messages or advice we give? Is it too idealistic/utopian? 6. How well are we utilizing research for policy and programme reengineering (does not have to be perfect science and P value oriented) 7. How do we reach out to the policy makers? 8. Are we effectively using media (is media well represented in this conference?) 9. What is stopping us doing cost analysis or cost benefit analysis of breast feeding and infant and child feeding, maternal and child nutrition in general? 10. After this, so what, what next?
NEPAD, she began, is an African Initiative Programme of African Union Mandate by the OAU, adopted in 2001. Its goals and objectives are to:
• To eradicate poverty, [reduce hunger and malnutrition]
• To encourage sustainable growth and development
• To halt the marginalization of Africa, enhance participation in the global economy
• To accelerate the empowerment of women NEPAD main priorities are to o establish conditions for sustainable development and encourage policy reforms which would lead to increased investment in priority sectors (agriculture, health, education, infrastructure etc.) and finally to mobilize resources.
Africa with 53 countries is extremely diverse and cultures and traditions vary. The level of development, economies, education, perception, expectations vary amongst the countries and priority and the Governance issues are different and challenging.
Available statistics indicate that 337 Africans consume less than 2,100KCal per day and 12 deaths per minute occur due to hunger and malnutrition and 5 million die of hunger annually. 200 million Africans are chronically malnourished; 126 million children underweight and about 50% children stunted. 25 million live with HIV/AIDS. The prevalence of acute malnutrition ranges from 2 25 % and stunting among the children below five years of age is 10 - > 50%. Iron deficiency anaemia among the underfives is 40%, pregnant women 80%, and 40% in general population. 60% general population is vitamin A and 5% are iodine deficient (MI, FAO, WFP, ECSA, UNICEF)
Activities of AU and NEPAD are planned as different sector initiative with a focus on women, infants and young children. Therefore, for each initiative, strategies have been formulated and hence programmes to fulfill those strategies. The strategies are:
• Agriculture Comprehensive African Agriculture Development Programme (CAADP) 2003
• Health Strategy 2003 & Africa Regional Nutrition Strategy (ARNS) 2005
• Gender, Youth and Civil Society Strategy 2005
• Science and Technology Consolidated Plan of Action 2006
• Infrastructure spatial development

As regards the implementation activities at country level, this is coordinated through SADC, COMESA, AMU, ECAS and ECOWAS. Programmes within CAADP focus for example on the promotion of nutrient dense foods; fortification including Bio-fortification; policy review and advocacy; capacity Development and so on. Activities organized include Pan African Nutrition Initiative (Nutrition Lens) 2005, Abuja Food Security Summit 2006, food Security framework for Africa and Africa Ten Year Strategy for VMD reduction 2006 WIP, Lancet series on Maternal and Nutrition Series to be launched in October 2007
Within the health sector, food and nutrition initiatives have included, Africa Regional Nutrition Strategy 2005, its implementation framework 2006, HIV and AIDS programme, and activities to reduce conditions associated with pregnancy and childbirth.
Food and nutrition initiatives within science and technology sector are concerned with the dissemination of biodiversity, biotechnology and indigenous knowledge, energy, water and desertification, material sciences,manufacturing and laser, post-harvest
information and communication technologies. Activities within the gender and youth and civil society have been formulation of protocol to the African Charter on human and people rights on the rights of women in Africa 2004; Solemn Declaration on Gender Equality 2004; Parliament initiatives (PAP, SADC etc.) ; NEPAD Gender Task Force 2005; and policy review and gender mainstreaming
In conclusion Ms Giyose assured the participants that the AU and NEPAD is fully committed to achieving all MDGs, continuing to build stronger ties with RECs and development partners, strengthening cross sectoral linkages, mobilizing resources, building capacity, fully respecting the African Agenda. She ended her review by leaving behind some food for thought for the participants
Some Thoughts - the big five!
• How can we make Breastfeeding fashionable and sexy?
• How do we attract the full attention of our governments?
• How do we harness our indigenous knowledge systems for optimum impact?
• How do we ensure that research done in Africa is relevant and owned by Africans?
• How do we get the Private Sector to support our cause?

PARTNERSHIP FOR MATERNAL, NEONATAL AND CHILD HEALTH (MNCH). By Pauline Kisanga
Mrs Kisanga informed the participants of a new global health Partnership for Maternal, Newborn & Child Health launched in Delhi in September 2005 to accelerate efforts towards achieving Millennium Development Goals (MDGs) 4 and 5.
The partnership which aimss to intensify and harmonize national, regional and global action to improve maternal, newborn and child health is the result of a merger of three existing partnerships:
the Partnership for Safe Motherhood and Newborn Health (2003 by WHO),
the Child Survival Partnership (2004 by UNICEF NY) and
the Healthy Newborn Partnership (2000 by SCF USA). Pauline then went on to discuss the benefits and advantages of the new partnership, conceptual framework, goals and priorities of the parternship, principles governing partnership interventions, goals and priorities of the partnership, principles governing partnership interventions, partnership 10 year plan and governance.
The partnership aim is to achieve universal coverage of interventions throughout the continuum of care reflecting cross cutting issues-gender, human rights, education, nutrition, family planning, access to affordable-safe services.
The major goal of the partnership is to enable nations achieve the MDG 4 &5. Finally Pauline explained what partnership would mean to IBFAN.
PARTNERSHIP: IMPLICATIONS FOR IBFAN
l IBFAN members need to be alert to ensure that through public private partnerships, the Partnership does not get infiltrated by the BM companies
l There is a need for Alignment of IBFAN work with that of the partnership to attract more resources towards infant and young child nutrition interventions
l Communication with and belonging to the WG and different constituency groups will improve our chances for IYCF issues into the 10 year plan
l As a source of funding: The major entry point for funding, I think, is the national level although the different constituencies are also preparing project proposals

DISCUSSION: HIGHLIGHTS
* CODE: labeling of some products in the market: one might find formula with misleading labels such as :for dietary use or misleading scientific names such as thelactose free formula but are not scientific. We need to be careful with the genetically modified products being heavily used for products heavily marketed in developing countries.
* Sometimes, it may not be Nestle who violets the code as in Mauritius where the major companies MILUPA and IBL own a chain of supermarkets, transshipping and travel agencies. The discussant urged participants to strengthen links with consumer protective groups to prevent violation of such big companies.
* South Africa was requested to enforce the CODE so as to safeguard the infiltration of their products into the neighbouring countries.
* A concern was raised over the implementation of the CODE not mandated to

regulate marketing of BMS. The situation would be challenging as the priorities would be different. As well, the companies can always find a way round promoting their products.
* Although international code has existed for 25 years, less than 40% of the countries have managed to enact it to the national laws. This indicates a big challenge. She proposed that UNICEF and WHO should advocate the minister as some of the IBFANers are unable to discuss such issues at higher level. Alternatively, the countries need to change their approach.
* Nutritionists should be looking at the care providers being targeted by the manufacturers of BMS. IBFAN may be requested to assist identify loopholes in the CODE which allow the companies to abuse it and address accordingly.
* The new maternal and child health partnership should be integrated into other programmes as otherwise it would imply more resources and manpower.
* How does NEDPA enter countries?. The response was that the entry point is at the ministerial level.
* With reference to NEPAD, participants were requested to strengthen coordination in what they are doing and link with other partners and disciplines such as agriculture, water and sanitation, science and technology and so on as the team work ensures holistic approach for addressing various issues.
* In Nigeria, IMCI activities are there but IMCI does not think of BFHI. When we started BFHI in paediatrics, but it was not possible for PMTCT and obstetricians to accept EBF in HIV easily. It was difficult to convinces the mothers and colleagues. Therefore the information from the research is very useful. Some have been presented but then one cannot be sure of the methodologies. Why don’t we invite more researchers to attend IBFAN conference?
* This conference should interpret research and practice and formulate guidelines
* IBFAN does not do research but relies on the results of any operational research.

IBFAN has become more and more scientific but still action oriented. They used recommendations and statements from reliable organization for actions. At the same time anecdotal evidence and case studies should not be ignored.
* Working women office space is not designed for women. If BF introduced at work place, is there a place where they can do it? Are women bosses friends or enemies and are they tougher than men? Can we look inward. How can we change our own attitude as women?
* Men should be mainstreamed. Young fathers should be involved. What do

the men have to lose when women BF. Men gain more than they loose
* Maternity leave demands for 6 months. Is it feasible for all the employers? Besides what is the point of giving a woman 6 months maternity leave if she is not going to breast feed?
* In emergency situation, what might be prepared and planned in advance might be different from what happens in the field. Therefore, it is important to have very strong coordination established to prevent the companies violation
* Are WFP involved in IFE? Yes they are close partners of IFE. It is important to be aware of the activities being carried out in emergencies and coordinate well inorder to use the available resources effectively and avoid duplications
* Are the orphans taken care of in emergencies. The issue of orphans is inadequately addressed in IFE. There are WHO guidelines on how they may be handled.
* Response from Mr Tarimo: Abusing the CODE can imply penalties and there should be a legislation in the law as given in the CODE handbook. Other punishments may be imprisonement, suspension of licence, payment for the damage and so on
* Response from B Giyose: NEPAD is a non-political body which gets funding from the African Union and contributions from developing partners for specific projects. In some countries there is a NEPAD contact/focal person. NEPAD has more than 10 sectors and operates across sectors. Futhermore, the youth and civil society are taken on board. Breast feeding issues are addressed within the health and agriculture sectors.