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Report
28 October 2020
Protecting young children from vaccine-preventable diseases
https://www.unicef.org/eca/reports/protecting-young-children-vaccine-preventable-diseases
PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES MODULE 22 Disclaimer: The resource modules were authored by the individuals under the guidance of the UNICEF Regional Office for Europe and Central Asia. The text is presented in draft format and it is expected that it will be adapted and contextualized for use by interested countries. The material has not been edited to official publication standards. UNICEF accepts no responsibility for errors. The designations in this publication do not imply an opinion on legal status of any country or territory, or of its authorities, or the delimitation of frontiers. Coordination and Editing: Aleksandra Jovic, UNICEF, Early Childhood Development Specialist Lead Author: Bettina Schwethelm, Young Child Health and Development Specialist, Director, MCH-ECD Co-authors: Svetlana Stefanet, UNICEF, Immunization Specialist Sergiu Tomsa, UNICEF, Communication for Development Specialist Contributors: Silvia Sanchez R., UNICEF, Knowledge Management Consultant Viviane Bianco, UNICEF, Communication for Development Consultant UNICEF/ Krepkih Andrey TABLE OF CONTENTS Key Messages Why is this Topic Important to you? ..................................................................................6 Learning Outcomes ....................................................................................................................................6 Pre-Test for this Module ...............................................................................................................................7 Glossary and Definitions ............................................................................................................................10 I. Introduction ..................................................................................................................................111. Nurturing Care A Holistic Approach to Young Child Health, Development and Wellbeing ................................112. Vaccination Trends Globally and in Europe ...........................................................................................................143. Working with Families to Protect Young Children from Vaccine-Preventable Diseases Module Overview and Summary ..........................................................................................................................15 II. Immunization and Vaccine Preventable Diseases A Major Public Health Achievement ...................161. Childhood Immunization .......................................................................................................................................162. How Vaccines Work .............................................................................................................................................173. The Benefits of Vaccination to the Individual Child and Society ...........................................................................204. Vaccine Safety and Side Effects ...........................................................................................................................225. Family-Held Vaccination Records ..........................................................................................................................23 III. Understanding Barriers to Vaccination ...............................................................................................241. Caregivers Along the Continuum of Vaccine Acceptance, Hesitancy, and Rejection ...........................................242. Understanding how Individuals Make Behavioural Choices .................................................................................26 a. The Behaviour Change Journey ........................................................................................................................26b. Factors Influencing Caregiver Decisions ...........................................................................................................27c. Perception Biases, Beliefs, and Myths About Vaccines The Internet and Social Media ................................31d. The Role of Health Workers ..............................................................................................................................34 IV. Communication Skills and Tools to Support Vaccine Acceptance by Caregiver .................................371. Active Listening Skills ...........................................................................................................................................37 a. Verbal Communication ......................................................................................................................................37b. Non-Verbal Communication ..............................................................................................................................38c. Empathy ............................................................................................................................................................39 2. Working with Caregivers Along the Continuum of Vaccine Hesitancy .................................................................39a. Vaccine-Accepting Families ...............................................................................................................................40b. Vaccine-Hesitant Caregivers .............................................................................................................................41c. Vaccine Refusers and Anti-Vaccine Advocates .................................................................................................44 3. Helping Caregivers Overcome Barriers to Vaccination .........................................................................................46a. Preparing Caregivers for Vaccination and Helping Them Manage Mild Side-Effects ........................................46b. Helping Caregivers Problem-Solve ....................................................................................................................46c. Addressing Rumours in the Community ...........................................................................................................47 V. Summary of Key Points and Post-Test .................................................................................................481. Summary of Key Points ......................................................................................................................................482. Post-Test with Answers ......................................................................................................................................49 VI. Websites And Video Clips .....................................................................................................................531. Websites .............................................................................................................................................................532. Relevant Video Clips ...........................................................................................................................................53 Annexes: Information Cards ........................................................................................................................55Information Card 1 - Common Vaccine-Preventable Diseases ...........................................................................................55Information Card 2 - Frequently Asked Questions (FAQS) About Childhood Vaccinations .................................................58Information Card 3 - Simple Ways to Show Empathy ........................................................................................................62Information Card 4 - Responses that Encourage Communication ......................................................................................63Information Card 5 - Roadblocks to Communication ..........................................................................................................64Information Card 6 - Practical Communication Skills Case Study ....................................................................................65Information Card 7 - The CASE Approach ...........................................................................................................................66Information Card 8 - Steps to Address Negative Rumours in the Community ...................................................................67Information Card 9 - Reducing Pain ....................................................................................................................................68Information Card 10 - What is Community or Herd Immunity and Why is it Important? ....................................................70 Worksheets................ ..................................................................................................................................71 References................. ..................................................................................................................................73 6 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES KEY MESSAGES Why is this topic important to you? Vaccination is one of the worlds safest and most cost-effective public health interventions. Yet growing distrust in science, coupled with misinformation, means that vaccination coverage rates are declining in some countries and communities, resulting in an upsurge of vaccine-preventable diseases. The routine vaccination schedule brings families into frequent contact with the healthcare system, providing opportunities to reach children with life-saving vaccines and other crucial services for children and their families. Research shows that those caring for children tend to trust the advice of their health workers when it comes to vaccination, despite conflicting and often misleading information from other sources. That is why your role is so important: poor or disrespectful responses to caregivers and their concerns, coupled with a lack of uptake of vaccines (whether at a clinic or during a home visit), can have a strong and negative impact not only on their future demand for vaccination, but also for a whole range of other health services. As a professional who is trusted by the families you serve, you have a unique opportunity to identify vaccine-hesitant caregivers; understand their fears, dilemmas and choices; provide them with relevant information; help them overcome their vaccination hesitancy; strengthen their confidence in vaccines and immunization, and, in some instances, vaccinate their children. Using your communication skills and your knowledge about how individuals make behavioural choices, you can influence and guide parents to make decisions in the best interests of their children by listening to and understanding their concerns, providing answers to their questions, and helping them make the best choice for their child and their community. LEARNING OUTCOMES Once you have completed this module you will: Have a good understanding of vaccine-preventable diseases and the importance of immunization. Understand the role of health workers particularly home visitors in guiding families in their decisions to have their children protected against vaccine-preventable illnesses. Understand the importance of checking the immunization status of the child during each relevant visit and reminding caregivers about upcoming vaccination appointments. Understand that the views of caregivers range across a continuum from vaccine acceptance, to hesitancy and rejection, and that tailored approaches and actions are required from you to ensure that as many infants and children are protected against vaccine-preventable diseases as possible. Be able to apply evidence-based techniques and approaches to address hesitancy and influence caregivers decisions and behaviours. When checking a childs records, know how to give their caregivers the space to voice concerns and ask questions so that you can provide facts about vaccination benefits and address rumours and misinformation. Know how to identify caregivers who are hesitant about vaccines and respond to their questions and concerns with facts and empathy to help them make informed decisions and move towards vaccination. Communicate with caregivers who are rejecting vaccines in a respectful and empathetic way, reminding them that vaccines are safe, advising them of the dangers and symptoms of vaccine-preventable diseases, and reinforcing their responsibilities, as caregivers, to inform health workers if their child has not been vaccinated. Show your appreciation and validation of families that have accepted vaccination and that might be willing to become vaccine advocates in your community. Be able to advise parents on how to deal with the possible common side effects of vaccination. 7 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES PRE-TEST FOR THIS MODULE Some of these questions may refer to topics that are unfamiliar to you at this early stage, but do not worry. The module will cover all of these issues and features a post-test (with answers) at the end so that you can assess your own progress. 1. Costing studies have shown that childhood vaccinations constitute one of the most cost-effective public health interventions. True False 2. The number of parents refusing vaccinations for their infants and young children is increasing. This group should, therefore, be the main target for education by home visitors. True False 3. Increasing herd/community immunity is not a good argument for increased support for immunization programmes. True False 4. Several countries in Europe have had a high number of measles cases. Some of the reasons for this include (please mark all answers that apply): a. Shortages of measles vaccine in these countriesb. Caregivers who are complacent, because they do not know that measles is a dangerous and very infectious diseasec. Researchers who have been unable to dis-prove the myth that measles vaccine causes autismd. Measles brought in by travellers from poor, under-developed countriese. Falling immunization coverage. 5. The reason for vaccine hesitancy is simple: caregivers just lack the evidence about the benefits of vaccines. True False 6. Some of the strategies to overcome vaccine hesitancy among parents include (please mark all answers you consider correct):a. Improving the interpersonal and communication skills of health workersb. Listening to the concerns of caregivers and showing empathyc. Understanding how behaviour change takes place and using a solid behaviour-change approachd. Ensuring that health workers welcome caregivers who may feel socially excluded and stigmatizede. Telling caregivers that health professionals know best and that they should not question immunization, as they are not expertsf. Improving the quality of health services. 7. Some of the challenges to the achievement of high immunization coverage rates for measles and rubella coverage (please circle the answers you consider correct)a. The rejection of vaccines by some families in small communities and urban areas creates pools of unprotected children, increasing the risks of the rapid spread of epidemicsb. Measles vaccine is routinely provided to children when they are one year of age: a time when some caregivers may feel that their young children have already received enough vaccines to be protected MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 8 c. Lack of trust in vaccine safetyd. Shortage of vaccines in some countries as a result of recent epidemics. 8. Home visitors should be prepared to respond flexibly to the concerns of parents about vaccinations, with brief, tailored and fact-based elevator speeches (short enough to be presented during an elevator ride of just a few floors). True False 9. Polio has been eradicated and will soon be removed from all immunization schedules. True False 10. Arrange the following stages into the correct sequence for an expanded behaviour-change model: 11. List some non-verbal communication features you can use to make caregivers feel more comfortable: 12. Giving young infants multiple vaccines at the same time can overwhelm their immune system. True False 13. Naturally acquired immunity works better and is safer than vaccine-acquired immunity. True False 14. The following approaches need to be avoided when addressing the concerns of caregivers about vaccines (mark all that apply): a. Reflective listeningb. Solving any problems the caregiver has in getting to the clinicc. Empathy for their concerns about whether they are making the best decision for their childd. Praising them by telling them that they are your best parents and that you are so proud of theme. Rebuking caregivers for missing vaccination appointmentsf. Reminding caregivers that they are not experts and should not question immunization. Stages Step Decision Advocacy Pre-contemplation Maintenance Preparation Contemplation Trigger Fine-tuning Trial 9 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 9 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 15. Caregivers who refuse vaccines are likely to include individuals with some of the following characteristics (mark all that apply)a. They are from marginalized populationsb. They question science and are often highly educated c. They come from poor and uneducated families in urban areasd. They dont trust their health care system or health workers. 16. The three Cs are (mark all that apply) Complacency Concern Convenience Confidence. 17. Vaccination programmes are expensive because of the costs of vaccines, cold-chains and the salaries needed to deliver so many vaccines to so many children. It is an important public health intervention, but not very cost-effective. True False 18. 18. Measles is so dangerous because (mark all that apply)a. The disease kills most unvaccinated children because the vaccine only starts working when a child is around two years oldb. It is so infectious that herd community cannot be achievedc. It can wipe out much of the immune memory that a young child had acquired before contracting measlesd. Survivors of measles have an increased likelihood of death in the 2-3 years after contracting the diseasee. The infection spreads rapidly when a group of unvaccinated individuals is exposed to a case of measles. 19. There are no good sources of credible information about vaccines and vaccine safety. True False 20. Vaccine rejectors have a responsibility to inform health workers that their child has not been protected against vaccine-preventable diseases and should know about the signs and symptoms of these diseases. True False 21. While vaccination contributes primarily to Sustainable Development Goal 3 (SDG 3) on good health and wellbeing by reducing the number of vaccine-preventable deaths, it also contributes indirectly to many other SDGs. True False 10 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 10 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES GLOSSARY AND DEFINITIONS Caregiver. The parent or primary guardian of the child. This module uses the terms parent and caregiver interchangeably, recognizing that while most children are cared for by their parents, this is not always the case. For the purposes of this module, the terms parent or caregiver refer to the adults responsible for children and who make critical decisions on their behalf around immunization. Closed questions. Questions that are generally answered with a simple yes or no, in contrast to open-ended questions that encourage the other person to elaborate on their answer and encourage a genuine, two-way dialogue. Empathy. The capacity to understand or feel what another person is experiencing from their point of view, i.e. putting yourself in their shoes. This contrasts with sympathy, which often conveys pity for someone else, but not necessarily an understanding of their situation. European Centre for Disease Prevention and Control (ECDC). EU agency aimed at strengthening Europes defenses against infectious diseases. The core functions cover a wide spectrum of activities: surveillance, epidemic intelligence, response, scientific advice, microbiology, preparedness, public health training, international relations, health communication, and the scientific journal Eurosurveillance.1 Herd/community immunity. It is achieved when the vast majority of a population (at least 95% of children for childhood vaccination) is vaccinated, ensuring the protection of the whole community, including individuals who have not been vaccinated. Immunization. The process by which a person develops resistance to an infectious illness, usually through the application of a vaccine. Interpersonal communication. The exchange of information, thoughts, and feelings both verbal and non-verbal between two or more people that leads to dialogue, mutual understanding, respect for different perspectives and positions and immediate feedback. It can take place in a face-to-face setting or via video or audio settings by phone or Internet. MMR. Measles-mumps-rubella vaccine. Vaccination. Act of introducing a vaccine into the body to produce immunity to a disease. Vaccine hesitancy (WHO, 2019). The reluctance or refusal to vaccinate despite the availability of vaccines. Vaccine hesitancy is complex and context-specific, varying across time, place and vaccines, and is influenced by multiple factors, such as complacency, convenience and confidence. 1 European Centre for Disease Prevention and Control. https://www.ecdc.europa.eu/en/about-ecdc https://www.ecdc.europa.eu/en/about-ecdc 11 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES IINTRODUCTION 1. Nurturing Care A Holistic Approach to Young Child Health, Development and Wellbeing Recent decades have seen a surge of research on neuroscience and child development that has identified what newborns and young children need to survive, thrive, and lead healthy and productive lives. In May 2018, this critical body of scientific knowledge was brought together and used to create the Nurturing Care Framework by the World Health Organization (WHO), UNICEF, the World Bank and other partners. Compelling and robust scientific evidence was translated into five easily understandable and mutually supporting components that are essential for children to thrive (also shown in Figure 1): Good health Adequate nutrition Opportunities for early learning Responsive caregiving, and Security and safety. G OOD HEAL TH ADEQUATE NUTRITION G O PP UR TU NIT IES FO R E ARLY LEARN ING SECURITY AND SAFET Y R ESPO NSIV E C AR EG IVIN G Components of nurturing care Figure 1. The Nurturing Care: five interconnected components UNICEF/Kudravtsev 12 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES To survive, thrive and reach their full developmental potential, infants and young children need all five components of the Nurturing Care wheel. The components are not stand-alone, nor do they work as additions to each other: they are indivisible and synergistic. Responsive caregiving, for example, creates an enabling environment that can safeguard the other components: that is, a caregiver who is responsive to a child will be able to detect early signs that the child is feeling ill, tired, overwhelmed, anxious or threatened and will be able to respond in a way that protects the childs wellbeing. Similarly, a responsive caregiver is sensitive to the signs that a child is feeling well, alert, and ready to play and explore, and will be able to respond with appropriate activities. While parenting is perhaps the most challenging task for any adult, measures and support to prepare people for parenthood and education in parenting are more often available in high-and middle-income countries. Where such support is available in low-income countries, it tends to be accessed most frequently by high- and middle-income families. Families in many countries in the Europe and Central Asia region are fortunate to benefit from universal health care and home-visiting services provided by the public sector during the critical times of pregnancy and the first few years of a childs life. While the number of visits provided to all families is often limited, home visiting can be an effective entry point and opportunity to provide reliable and valid information and advice on child development, child rearing and parenting. Universal home-visiting services can also be used to identify families that are vulnerable or that need additional and targeted services. Providing all families with trusted and evidence-based information and advice and identifying the families with additional needs require knowledge and special skills in working with families from all walks of life to build a genuine and supportive partnership. About the resource package for home visitors and its modules The resource package for home visitors Supporting Families for Nurturing Care is a growing set of training modules (see Figure 2). It aims to strengthen the knowledge of home visitors on the key components of Nurturing Care, and enhance their skills in working with families to enable and empower them to provide the best start to their children. While targeting home visitors, many of these modules are also suitable for other health and non-health professionals who interact with pregnant women and the families of young children. Each of the modules responds to one or more components of Nurturing Care and builds capacity and skills needed by the home visitor to provide supportive home visits. In addition, each module aims to help home visitors reflect on professional attitudes and strengthen practices to engage inclusively and respectfully families that are diverse and face different needs and challenges. The modules have been developed by well-known experts and can be translated and adapted to different country contexts. In some countries, the modules have already become a mainstay of lifelong learning and continuing professional development for health workers and social-service providers engaged in promoting the comprehensive wellbeing of young children and their families. You can find hard copies of all modules on the International Step by Step Association (ISSA) website at https://www.issa.nl/modules_home_visitors and on UNICEF Agora. UNICEF/Voronin https://www.issa.nl/modules_home_visitors 13 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES Knowledge Module 1: The Early Childhood Years - A Time of Endless Opportunities Module 7: Parental Wellbeing Module 11: Working against Stigma and Discrimination - Promoting Equity, Inclusion and Respect for Diversity Module 12: Children Who Develop Differently - Children with Disabilities or Developmental Difficulties Module 18: Gender Socialisation and Gender Dynamics in Families - The New Role of the Home Visitor Skills Module 2: The New Role of the Home Visitor Module 10: Caring and Empowering - Enhancing Communication Skills for Home Visitors Module 13: Developmental Monitoring and Screening Module 15: Working with Other Services Module 17: Supervision - Supporting Professionals and Enhancing Service Quality Module 22: Protecting Young Children from Vaccine-Preventable Diseases Figure 2. The Supporting Families for Nurturing Care resource package and its modules (asterisks indicate complementary pre-existing training packages) Components of nurturing care Thinking Healthy*Care for Child Development*Module 4: Falling in Love - Promoting Parent-Child AttachmentModule 5: Engaging Fathers Module 8: Common Parenting Concerns Integrated Management of Childhood Illnesses (IMCI)*Module 20: Healthy Weight, Physical Activity, Sleep and Sedentary TimeModule 21: The Care of Small and Sick NewbornsModule 22: Protecting Young Children from Vaccine-Preventable Diseases Module 6: The Art of Parenting - Love, Talk, Play, ReadModule 19: Early Childhood Education Programmmes Module 9: Home Environment and SafetyModule 14: Keeping Young Children Free from Violence, Abuse and Neglect Infant and Young Child Feeding (IYCF)*Baby-friendly Hospital Initiative (BFHI)Module 16: Responsive Feeding G OOD HEALT H ADEQUATE NUTRITIO NG OPP UR TU NIT IES FO R E ARLY LEARN ING SECURITY AND SAFET Y RE SPO NS IVE C AR EG IVIN G 14 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 2. Vaccination Trends Globally and in EuropeSince the development of the first vaccination against smallpox more than a century ago, vaccine programmes for children have become an integral component of preventive primary health care in every country on earth. Vaccination programmes prevent between 2 and 3 million deaths globally each year (WHO, 6.12.2019). In 2019, about 86 per cent of infants worldwide (116.3 million infants) received 3 doses of diphtheria- tetanus-pertussis (DTP3) vaccine, protecting them against infectious diseases that can cause serious illness, disability or death. Individuals and governments benefit from vast cost-savings as a result of the prevention of illness (EU and WHO, 2019). Based on the costs of illnesses, including treatment costs and productivity losses, that have been averted, every dollar invested in vaccines during the Decade of Vaccines (2011-2020) is estimated to have yielded a net return of about $16 (Ozawa et al., 2020). Two of the three strains of wild polio virus strains have been eradicated. A growing number of countries have achieved disease-free certifications (i.e. the European region has sustained its polio free status since 2002). The growing number of combination vaccines (i.e. the child is vaccinated against several diseases with one injection) is reducing the number of injections needed. In recent years, however, vaccination programmes have become victims of their own hard-earned success: few caregivers remember epidemics of polio, measles, pertussis or chickenpox that took the lives of many children, left many more with disabilities, and undermined their health and development. They may be unaware that measles is one of the worlds most contagious diseases, and that its transmission can only be halted if at least 95 per cent of the population is protected by immunization. In addition, misinformation that links vaccines to autism is easy to find and continues to circulate through social media and on websites, despite being discredited repeatedly, including by large-scale population studies (Hviid et al., 2019). Misinformation is sometimes disseminated deliberately to contradict (and appear alongside) evidence-based information about the benefits of vaccination. As a result of such challenges, countries around the world, and particularly in the Europe and Central Asia Region, have seen a resurgence of measles as the number of unprotected children and adults has grown. Measles cases have reached their highest level in Europe in 20 years (The Guardian, 21.12.2018). In total, 49 of the 53 countries in WHO European Region reported more than 192,943 measles cases and more than 100 measles-related deaths between 1 January 2018 and 31 December 2019, with a regional coverage with 2 doses of measles vaccination of only 91 per cent for the two doses of measles vaccination, which is too low to ensure herd immunity. Large disparities at the local level persist: some communities report over 95% coverage, and others below 70%. Several countries in the region Albania, the Czech Republic, Greece and the UK have recently lost their measles free certification. In the absence of disease, fear of disease has been replaced by fear of vaccines for some people (WHO, 2017). UNICEF/Bershadskyy Yuriy Immunization is one of the most cost-effective ways to save lives and promote good health and well-being. Every year, vaccines save 2-3 million lives, and millions more are protected from disease and disability. It routinely reaches more households than any other health service and brings communities into regular contact with the health system. This provides an effective platform to deliver other primary health care services and upon which to build universal health coverage. (Gavi The Vaccine Alliance, 2019) 15 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 3. Working with Families to Protect Young Children from Vaccine-Preventable Diseases Module Overview and Summary UNICEF/ Krepkih Andrey Because of the frequency of the contact required with families, especially during the early months of a childs life, the quality of immunization services can either enhance or endanger the trust families place in health care services and professionals. As a health visitor for families with young children, you are in a unique position to educate the families you meet on the importance of vaccines and the vaccination schedule and identify caregivers who have some concerns or who may even reject vaccines. In their own home, and when talking to someone the family trusts their home visitor caregivers may feel more comfortable asking questions and voicing fears that have not been addressed during crowded vaccination sessions or in a busy doctors office. Your knowledge of the benefits and safety of vaccines, your communication skills and empathy for families, and your understanding of their concerns are your major tools for the promotion of this crucial health intervention. Once you have completed this module, you will be able to answer questions and provide practical tips to caregivers on how to support their child while they are being vaccinated and help them deal with common side effects. You will also be able to provide evidence-based information to counter any misinformation that might be spreading through the caregivers network or social media. Because you have the information about the childs vaccination status, you can tailor your response and refer families to other experts and specialists where necessary. The quality of your support is vital. It may influence whether caregivers complete the vaccination schedule for their children, and the way in which they engage with health services in the future. You may never know for sure, but you may have saved a childs life, while protecting other young children who cannot be vaccinated because of counter-indications, as well as infants who have not yet received their first vaccines! MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 16 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES IIIMMUNIZATION AND VACCINE PREVENTABLE DISEASES A MAJOR PUBLIC HEALTH ACHIEVEMENT 1. Childhood Immunization In its listing of 100 objects that have shaped public health, Global Health NOW of the Johns Hopkins Bloomberg School of Public Health called immunization one of the most important public health achievements in human history.2 The development of vaccines has accelerated since the first use of a smallpox vaccine in 1798, and particularly since the middle of the 20th century. Today more than 30 infectious diseases can be prevented with vaccines (see Information Card 1 in annexes for information about common vaccine-preventable childhood diseases). Even though the worlds population has grown by almost 70 per cent, Gavi The Vaccine Alliance reports that cases of common vaccine preventable diseases have fallen by around 90 per cent (Gavi, 29.01.2019). Smallpox has been eradicated, as well as two of the three wild polio strains (WHO, 24.10.2019), and a number of countries have achieved measles-free status. Today, WHO recommends 10 vaccines during infancy and the early childhood years, plus one (for HPV) during adolescence recommendations that apply to every country (WHO, April 2019). Bacillus Calmette Guerin (BCG) (1 dose protects against tuberculosis) DTP-containing vaccine (3 doses protects against Diphtheria, Tetanus, and Pertussis Td (Tetanus and Diphtheria) booster at 9-15 yrs Hepatitis B (34 doses - protects against hepatitis type B) Hib (3 doses - prevents Haemophilus influenzae type b) Pneumococcal (3 doses - protects against pneumococcal disease) Polio (OPV and/or IPV, 34 doses - protects against poliomyelites) Rotavirus (23 doses - protects against rotavirus disease) Measles (2 doses - protects against measles) Rubella (1 dose - protects against rubella) HPV (2 doses - protects against human papilloma virus that can cause cervical and other types of cancer) (adolescent girls) Most of the countries in the ECA region use the MMR vaccine, a combined vaccine against measles, mumps and rubella. WHO recommends vaccination against mumps in high performing immunization programmes with the capacity to maintain coverage over 80% and where mumps reduction is a public health priority. Unfortunately, there has been a 30 per cent increase in cases of measles globally, and many countries in Europe and Central Asia have reported falling immunization coverage: half of the countries in the Region have DTP3 and MCV1 coverage below the 95 per cent minimum needed to ensure herd immunity. In 2019 WHO declared vaccine hesitancy as one out of 10 threats to global health. As we will discuss in more detail below, the WHO Vaccines Advisory Group has attributed this to the three Cs: Complacency, in-Convenience, and lack of Confidence, which contribute to vaccine hesitancy among parents and caregivers. Health workers, especially home visitors who work closely with their communities, have a critical role to play, as their advice is trusted by parents and can influence decisions around vaccination. To fulfil this role, however, home visitors need clear, factual information on vaccines, as well as communication tools to tackle the global threat to health posed by vaccine hesitancy (WHO, 2019). 2 Global Health NOW. One hundred objects that shaped public health. Retrieved from https://www.globalhealthnow.org/object/vaccines https://www.globalhealthnow.org/object/vaccines 17 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 17 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 2. How Vaccines WorkAs a home visitor, you often have very little time to cover a large range of relevant topics with the families you visit. That is why you need to be able to explain, in concise and understandable terms, how vaccines work and why it is important to vaccinate all children. To be efficient, apply the Elevator speech approach (Karam et al., 2019a, b) to make your most important points in the time that it would take for a ride in an elevator. It is important to tailor your messages to each family, taking into account their existing level of knowledge, as well as their concerns and attitudes around vaccination. Visuals can often be very powerful, helping you to make a point quickly and convincingly. Reflection and discussion There are many reasons why children are not vaccinated or vaccinated incompletely, but the following four steps can help you prepare short, clear responses to families that have concerns. First write down some of the questions and concerns you and your colleagues have heard from the caregivers you visit. Then choose several questions related to how vaccines work and develop brief elevator speeches with your colleagues or on your own. For your responses, use simple language, avoid jargon and technical terms; use analogies or simple examples and comparisons. Then try out your elevator speeches on others (family, caregivers, etc.) Finally, compare your responses to those provided by experts from WHO and the European Centre for Disease Prevention and Control (ECDC) and modify your elevator speeches as needed. Here are your practice questions: the kind of questions you may well be asked by the families you visit. Look through them and prepare some answers. When you have finished, compare your answers to the information provided in Box 1 below: How do vaccines work? Why it is better to be vaccinated than to acquire natural immunity (have the child fight the disease on his/her own)? Are the vaccines, especially multiple doses, too strong for a small fragile baby to handle? Can vaccines cause the infection they are supposed to prevent? What happens when a child has been sick with a vaccine-preventable disease? Doesnt this make them more resistant and stronger in fighting new diseases? I have heard that vaccinating my child also protects other children. What is community/ herd immunity and why is it important? UNICEF/Krepkih Andrey MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 18 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES How do vaccines work? Vaccines contain either a much-weakened form of the virus or bacterium that causes a disease, or a small part of it. When the body detects the contents of the vaccine, its immune system will produce the antibodies required to fight off infection and eliminate the disease-causing virus or bacterium. When a person later comes into contact with the virus or bacterium, the immune system will recognize it and protect the person by producing the right antibodies before any disease can be caused. (ECDC, Questions and answers about childhood vaccinations) Why it is better to be vaccinated than to acquire natural immunity (have the child fight the disease on his/her own)? Infants and young children are vaccinated in controlled settings (doctors offices or clinics), and parents are informed about possible side effects, how to manage these, and when to seek additional advice. With vaccines, the immune system is stimulated to develop protection without infection, hence it is more effective (WHO, 2017). The only way a child can acquire natural immunity is to become sick with the disease itself. Even when the impact on the child is mild, it may mean additional caregiving and expenses for some families. But the disease could also result in complications, long-term illness, disability and even death, and many other children may become exposed in the process. For measles, the Center for Disease Control and Prevention (CDC) has reported complications with 30 per cent of measles cases, most commonly diarrhoea, ear infections and pneumonia. For every 1,000 cases of measles, one child may also be affected by encephalitis and two may die. Whats more, the measles infection can destroy much of the wider immunity a child has built up, increasing their risk of contracting other diseases. Are the vaccines, especially multiple doses, too strong for a small fragile baby to handle? Newborns commonly manage many challenges to their immune systems at the same time. The mothers womb is free from bacteria and viruses, so newborns immediately face a host of different challenges to their immune systems. From the moment of birth, thousands of different bacteria start to live on the surface of the intestines. By quickly making immune responses to these bacteria, babies keep them from invading the bloodstream and causing serious diseases. In fact, babies are capable of responding to millions of different viruses and bacteria because they have billions of immunological cells circulating in their bodies. Therefore, vaccines given in the first two years of life are a drop in the ocean of what an infants immune system successfully encounters and manages every day. (ECDC. Questions and answers about childhood vaccinations) Can vaccines cause the infection they are supposed to prevent? Inactivated vaccines do not have live germs and cannot cause infections. Live vaccines have weakened germs that are unable to cause disease in healthy people. Rarely a mild form of infection may occur. (WHO, 2017) What happens when a child has been sick with a vaccine-preventable disease? Doesnt this make them more resistant and stronger in fighting new diseases? The defences of children who have survived a vaccine preventable-disease are not necessarily stronger. On the contrary, the disease tends to make the child weaker and more vulnerable. Recent research on measles has shown that having suffered and survived this deadly disease may make it harder for a child to fight other infections for years to come. It has been known for some time that children who had measles were 2-3 times more likely to die from pneumonia, diarrhoea or other conditions in subsequent years. Now, we have learned that the measles virus infects and destroys memory B-cells. These are the cells where the immune system stores information about past Box 1. How vaccines work https://www.cdc.gov/vaccines/pubs/pinkbook/meas.html https://www.ecdc.europa.eu/en/immunisation-vaccines/childhood-vaccination/faq?pdf=yes&preview=yes 19 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 19 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES infections that can help it in fighting new infections. In addition, the measles virus also reduces the ability of the immune system to respond to new and dangerous pathogens. It now seems possible that there could be actually five times more indirect deaths from immune amnesia (caused by the measles virus) than the initial infection caused. (Gallagher, 2019) I have heard that vaccinating my child also protects other children. What is community/herd immunity and why is it important? Vaccination protects you and your family, and it also helps protect others. It contributes to community immunity. This is achieved when enough people in a population are immune to an infectious disease (through vaccination and/or prior illness) so that it is unlikely to spread from person to person. Even those who cannot be vaccinated because they are too young, are allergic to vaccine components, or vaccination is contraindicated for them, are offered some protection because the disease cannot spread in the community and infect them. This is also known as herd or community immunity. When more than 95% of population is (blue dots) in a community they can protect those who are not yet vaccinated (yellow dots) from those who are infectious (red dots) When groups of unvaccinated people build up and are in close proximity, community immunity doesnt work and the disease spreads. For additional brief answers to common questions and concerns (developed by WHO and ECDC communication experts), check Information Card 2 Frequently Asked Questions (FAQs) about Childhood Vaccinations (in annexes), which also includes links to additional information. However, keep in mind that you will have to tailor your answers to the needs of individual families, their attitudes towards vaccination, and level of knowledge, so just learning some standardized answers by heart is not enough. 20 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 20 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 3. The Benefits of Vaccination to the Individual Child and Society NOPOVERTY AFFORDABLE ANDCLEAN ENERGY CLIMATEACTION LIFE BELOWWATER LIFE ON LAND PARTNERSHIPSFOR THE GOALS DECENT WORK ANDECONOMIC GROWTH SUSTAINABLE CITIESAND COMMUNITIES ZEROHUNGER EDUCATIONQUALITY EQUALITYGENDER AND SANITATIONCLEAN WATER PEACE, JUSTICEAnd STRONG INSTITUTIONS RESPONSIBLECONSUMPTIONAND PRODUCTION GOOD HEALTHAND WELL-BEING INDUSTRY, INNOVATIONAND INFRASTRUCTURE REDUCED INEQUALITIES GLO BA L S TRA TEGY FOR WOME NS, CHILDRENS AND ADO LESCEN TS HEA LTH SU RVIV E TH RIV E TRANSFORM Figure 3. Sustainable Development Goals (SDGs) Reflection and discussion Immunization for vaccine-preventable diseases provides one of the strongest financial returns of any public health intervention, but its benefits go far beyond the health sector alone. Take a look at Figure 3, which sets out all of the Sustainable Development Goals. Can you list ways in which the benefits of immunization can be felt across all of these goals? To help you, the potential links between immunization and the SDGs are set out in Table 1: perhaps you can think of others! When you see how vaccination supports the achievement of the SDGs, you can feel confident and proud in promoting such a cost-effective and safe service to your community and to the families you serve. Immunizing children is one of public healths best buys. Vaccines are relatively easy to deliver and, in most cases, provide lifelong protection. They boost development both through direct medical savings and indirect economic benefits such as cognitive development, educational attainment, labour productivity, income, savings and investment (Gavi The Vaccine Alliance, 2019) https://www.gavi.org/vaccineswork/value-vaccination https://www.gavi.org/vaccineswork/value-vaccination 21 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES Sustainable Development Goal Vaccination programmes 1. No povertyPrevent expensive illnesses and associated health-care costs, reducing the number of people forced into poverty. 2. Zero hungerProtect childrens nutritional status, because illness impairs absorption of essential nutrients. Malnourished children are also at a higher risk of death from vaccine-preventable diseases. 3. Good health and wellbeing Reduce mortality and morbidity and provide the platform for the delivery of other health services. 4. Quality educationVaccinated children have better nutrition and health status, and have, therefore, better chances to learn and achieve. 5. Gender equalityGlobally, this is a gender-equal intervention, with similar rates of vaccination for girls and boys 6. Clean water and sanitation (WASH) Prevent diarrhoeal diseases, alongside WASH programming. 8. Decent work and economic growth Contribute to the growth of healthy children who attain education and become a productive workforce. Caregivers are more likely to be able to work when children are not affected by vaccine-preventable diseases. 10. Reduce inequalityProtect all communities and children, including the most marginalized, those living in rural areas and in conflict zones, which can be further devastated by epidemics of infectious disease. 11. Healthy citiesProtect children from increased risk of exposure to vaccine-preventable diseases in cities where infections are more able to spread quickly. 16. Peace, justice and strong institution Contribute to equity and strong health services. Table 1. Vaccination and the achievement of the Sustainable Development Goals (SDGs) Source: Gavi, 2019 UNICEF/ Krepkih Andrey 4. Vaccine Safety and Side Effects Before you respond to concerns about the safety of vaccines in general
News note
11 February 2021
UNICEF signs supply agreement for Pfizer/BioNTech COVID-19 vaccine
https://www.unicef.org/eca/press-releases/unicef-signs-supply-agreement-pfizerbiontech-covid-19-vaccine
NEW YORK, 11 February 2021: UNICEF announced today the signing of an agreement with Pfizer on behalf of the COVAX Facility for the supply of the Pfizer-BioNTech COVID-19 Vaccine through 2021.  Deliveries of the vaccine are anticipated to start as early as the first quarter of 2021, once the countries that were allocated Pfizer-BioNTech vaccine…
News note
16 June 2021
UNICEF signs supply agreement for Sputnik V COVID-19 vaccine
https://www.unicef.org/eca/press-releases/unicef-signs-supply-agreement-sputnik-v-covid-19-vaccine
NEW YORK/COPENHAGEN, 27 May 2021 -  UNICEF and Human Vaccine (Limited Liability Company), a wholly-owned subsidiary of the Russian Direct Investment Fund (RDIF), today announced a long-term agreement (LTA) for the supply of the Sputnik V COVID-19 vaccine. This is the fourth long-term supply agreement UNICEF has signed with a COVID-19 vaccine manufacturer. So far this year, UNICEF has signed such agreements with the Serum Institute of India, Pfizer and AstraZeneca. Procurement by UNICEF under this agreement is conditional on the product achieving an Emergency Use Listing from WHO, to confirm the quality, safety and efficacy of the vaccine.  In addition, an Advance Purchase Agreement (APA) with Gavi, the Vaccine Alliance, will also be needed for procurement to begin on behalf of the COVAX Facility. Should the COVAX Facility decide to enter into an advance purchase agreement for the supply of the Sputnik V vaccine, UNICEF will be ready to deliver as soon as regulatory milestones have been met. At this point, UNICEF through this LTA, stands ready to access up to 220 million doses of the vaccine available for supply in 2021, to meet country demand.  The Sputnik V vaccine consists of two different components of the vaccine to be administered 21 days apart. An exact delivery schedule will be determined in collaboration with the manufacturer. UNICEF’s priority is to make sure that all countries have safe, fast and equitable access to COVID-19 vaccine and to help them prepare for the rollout of immunization.  The best way to bring the pandemic under control is to ensure that safe and effective vaccines are made available as widely as possible and as quickly as possible, reducing inequity by ensuring that no country or territory is left behind due to its economic status. On 24 February 2021, COVID-19 vaccine vials are produced for the COVAX facility at a manufacturer in Pune, a city located in the western Indian state of Maharashtra. UNICEF/UN0421679?Singh
News note
31 July 2019
Why family-friendly policies are critical to increasing breastfeeding rates worldwide - UNICEF
https://www.unicef.org/eca/press-releases/why-family-friendly-policies-are-critical-increasing-breastfeeding-rates-worldwide
NEW YORK, 1 August 2019 – From supporting healthy brain development in babies and young children, protecting infants against infection, decreasing the risk of obesity and disease, reducing healthcare costs, and protecting nursing mothers against ovarian cancer and breast cancer, the benefits of breastfeeding for children and mothers are wide spread. Yet, policies that support breastfeeding – such as paid parental leave and breastfeeding breaks – are not yet available to most mothers worldwide. “The health, social and economic benefits of breastfeeding – for mother and child – are well-established and accepted throughout the world. Yet, nearly 60 per cent of the world’s infants are missing out on the recommended six months of exclusive breastfeeding,” said UNICEF Executive Director Henrietta Fore. “In spite of the benefits of breastfeeding, workplaces worldwide are denying mothers much needed support. We need to far greater investment in paid parental leave and breastfeeding support across all workplaces to increase breastfeeding rates globally.” Only 4 out of 10 babies are exclusively breastfed: Only 41 per cent of babies were exclusively breastfed in the first six months of life in 2018, as recommended. In comparison, these rates were more than half – 50.8 per cent – in the least developed countries. The highest rates were found in Rwanda (86.9 per cent), Burundi (82.3 per cent), Sri Lanka (82 percent), Solomon Islands (76.2 percent) and Vanuatu (72.6 percent). Research also shows that infants in rural areas have higher levels of exclusive breastfeeding than urban babies. Upper-middle-income countries have the lowest breastfeeding rates: In upper-middle-income countries, exclusive breastfeeding rates were the lowest at 23.9 per cent, having decreased from 28.7 per cent in 2012. Breastfeeding at work works: Regular lactation breaks during working hours to accommodate breastfeeding or the expression of breastmilk, and a supportive breastfeeding environment including adequate facilities enable mothers to continue exclusive breastfeeding for six months, followed by age-appropriate complementary breastfeeding. Working women do not get enough support to continue breastfeeding: Worldwide, only 40 per cent of women with newborns have even the most basic maternity benefits at their workplace. This disparity widens among countries in Africa, where only 15 per cent of women with newborns have any benefits at all to support the continuation of breastfeeding. Too few countries provide paid parental leave: The International Labour Organization (ILO) Maternity Protection Convention 2000 (no. 183) standards include at least 14 weeks of paid maternity leave, and countries are recommended to provide at least 18 weeks as well as workplace support for breastfeeding families. Yet, only 12 per cent of countries worldwide provide adequate paid maternity leave. UNICEF’s latest policy brief on family-friendly policy brief recommends at least six months of paid leave for all parents combined, of which 18 weeks of paid leave should be reserved for mothers. Governments and businesses should strive for at least 9 months of combined paid leave. Availability of longer maternity leave means higher chances of breastfeeding: A recent study found that women with six months or more maternity leave were at least 30 per cent more likely to maintain any breastfeeding for at least the first six months. Breastfeeding makes sense for both babies and their mothers: Increasing breastfeeding could prevent 823,000 annual deaths in children under five and 20,000 annual deaths from breast cancer. Not enough babies breastfed in the first hour: In 2018, less than half of babies worldwide – 43 per cent – were breastfed within the first hour of life. Immediate skin-to skin contact and starting breastfeeding early keeps a baby warm, builds his or her immune system, promotes bonding, boosts a mother’s milk supply and increases the chances that she will be able to continue exclusive breastfeeding. Breastmilk is more than just food for babies – it is also a potent medicine for disease prevention that is tailored to the needs of each child. The ‘first milk’ – or colostrum – is rich in antibodies to protect babies from disease and death. The investment case for breastfeeding: If optimal breastfeeding is achieved, there would be an estimated reduction in global healthcare costs of USD 300 billion. ### Notes to Editors: About World Breastfeeding Week World Breastfeeding Week is marked annually from 1 to 7 August to highlight the critical importance of breastfeeding for children across the globe. Breastfeeding gives children the healthiest start in life and is one of the simplest, smartest and most cost-effective ways we have of ensuring that all children survive and thrive. This fact sheet – marking World Breastfeeding Week – features new data from the 2019 Global Breastfeeding Scorecard, and the latest available evidence on coverage, access to family-friendly policies, and the health and economic benefits of breastfeeding. Mother and father with new born baby UNICEF/UN0206267/Pirozzi
Photo Essay
10 May 2018
Breastfeeding: the best gift a mother can give her child
https://www.unicef.org/eca/stories/breastfeeding-best-gift-mother-can-give-her-child
Breastmilk saves lives, protects babies and mothers against deadly diseases, and leads to better IQ and educational outcomes, yet rates of breastfeeding in Europe and Central Asia are low, with only 23 percent of the wealthiest families and 31 percent of the poorest breastfeeding up to the recommended age of two. Empowering and enabling women to breastfeed  needs to be at the heart of countries’ efforts to keep every child alive and to build healthy, smart and productive societies. “Breastfeeding is the best gift a mother, rich or poor, can give her child, as well as herself,” said Shahida Azfar, UNICEF’s Deputy Executive Director. “We must give the world’s mothers the support they need to breastfeed.” A mother breasfeeds her baby at a maternity centre in Tashkent region, Uzbekistan. A mother breasfeeds her baby at a maternity centre in Tashkent region, Uzbekistan.  The early initiation of breastfeeding – putting newborns to the breast within the first hour of life – safeguards infants from dying during the most vulnerable time in their lives.  Immediate skin-to skin contact and starting breastfeeding early keeps a baby warm, builds his or her immune system, promotes bonding, boosts a mother’s milk supply and increases the chances that she will be able to continue exclusive breastfeeding.   A mother learns to breastfeed her baby at a maternity hospital in Fergana, Uzbekistan. A mother learns to breastfeed her baby at a maternity hospital in Fergana, Uzbekistan. Breastmilk is safe as it is the right temperature, requires no preparation, and is available even in environments with poor sanitation and unsafe drinking water. It’s also more than just food for babies – breastmilk is a potent medicine for disease prevention that is tailored to the needs of each child. The ‘first milk’ – or colostrum – is rich in antibodies to protect babies from disease and death.   A patronage nurse teachers a mother how to breastfeed in Kyzylorda city, Kazakhstan. A patronage nurse teachers a mother how to breastfeed in Kyzylorda city, Kazakhstan.  In Kazakhstan, UNICEF has been working with patronage nurses to support mothers to breastfeed their children. The project has been running for several years and includes two visits during pregnancy and nine visits until the child reaches the age of three. As a result, there was a 14 percent increase in the number of children who were exclusively breastfed in the pilot region. A patronage nurse visits a family in Kyzylorda city, Kazakhstan. A patronage nurse visits a family in Kyzylorda city, Kazakhstan.  There are several reasons why a mother may not be able to breastfeed, or does not wish to do so. Reasons include low awareness of the importance of breastfeeding and long-term impacts, as well as not knowing how to breastfeed properly which can subsequently cause the mother a lot of pain. Patronage nurses work with mothers to try to overcome these obstacles.    A mother breastfeeds her baby, while the father and the older son support them. Mother Jovana breastfeeds her son Aleksa (two-months-old) while older son Ognjen (18-months-old) and husband Nikola support her at a clinic in Serbia.  Breastfeeding is not a one-woman job. Women who choose to breastfeed need support from their governments, health systems, workplaces, communities and families to make it work.  UNICEF urges governments, the private sector and civil society to create more enabling environments for breastfeeding mothers including arming mothers with the knowledge to make informed decisions, and providing them with the support they need from their families, communities, workplaces and healthcare systems to make exclusive breastfeeding for the first six months happen. Smiling parents watch as their baby breastfeeds at a maternity unit in Armenia. Smiling parents watch as their baby breastfeeds at a maternity unit in Armenia. In Armenia, UNICEF, together with the ministry of health and local health authorities, have created a sustainable parental education system at maternity and primary health-care facilities across the country to encourage breastfeeding and provide support to parents. In a UNICEF-supported space for refugee and migrant families, two mothers breastfeed their babies. In a UNICEF-supported space for refugee and migrant families in Serbia, two mothers breastfeed their babies.  During the refugee and migrant crisis in Europe, UNICEF stepped in to provide support for children and mothers. Support included providing private spaces for breastfeeding mothers, nutritional guidance and breastfeeding support. UNICEF supports action to improve infant and young child nutrition across Europe and Central Asia, aiming to ensure that every child has the best possible nutritional start in life. Through its global campaign, Every Child ALIVE , which demands solutions on behalf of the world’s newborns, UNICEF urges governments, the private sector and civil society to:   Increase funding and awareness to raise breastfeeding rates from birth through the age of two.  Put in place strong legal measures to regulate the marketing of infant formula and other breastmilk substitutes as well as bottles and teats.   Enact paid family leave and put in place workplace breastfeeding policies, including paid breastfeeding breaks.  Implement the ten steps to successful breastfeeding in maternity facilities, and provide breastmilk for sick newborns.  Ensure that mothers receive skilled breastfeeding counselling at health facilities and in the first week after delivery.  Strengthen links between health facilities and communities, so that mothers are ensured of continued support for breastfeeding.  Improve monitoring systems to track improvements in breastfeeding policies, programmes and practices.     
Report
07 June 2021
From Faith to Action: Inter-Religious Action to Protect the Rights of Children Affected by Migration
https://www.unicef.org/eca/reports/faith-action-inter-religious-action-protect-rights-children-affected-migration
FROM FAITH TO ACTION: INTER-RELIGIOUS ACTION TO PROTECT THE RIGHTS OF CHILDREN AFFECTED BY MIGRATION WITH A FOCUS ON EUROPE AND CENTRAL ASIA ii Authors: Susanna Trotta (Joint Learning Initiative on Faith & Local Communities [JLI]), Christine Fashugba (UNICEF), Johanne Kjaersgaard (UNICEF/Princeton), Mario Mosquera (UNICEF), Olivia Wilkinson (JLI). Reviewers: Kerida McDonald (UNICEF), Anna Knutzen (UNICEF), Seforosa Carroll (WCC), Frederique Seidel (WCC), Jean Duff (JLI). Suggested Citation: Trotta, S., Fashugba, C., Kjaersgaard, J., Mosquera, M., Wilkinson, O., (2021). From Faith to Action: Inter-religious action to protect the rights of children affected by migration with a focus on Europe and Central Asia. UNICEF Europe and Central Asia Regional Office and Joint Learning Initiative on Faith & Local Communities: Geneva and Washington DC. Project Leads: Mario Mosquera (UNICEF), Olivia Wilkinson (JLI). Cover photo credit: UNICEF/UN012796/Georgiev Acknowledgements This publication is part of a collaboration between the United Nations Childrens Fund (UNICEF), the World Council of Churches (WCC), and the Joint Learning Initiative on Faith and Local Communities (JLI). We are grateful for the contribution of the three case study organizations highlighted in this publication, Apostoli, Ecumenical Humanitarian Organization, and Zentralrat der Muslime in Deutschland. iv list of Acronyms CCME Churches Commission for Migration in Europe ECARO Europe and Central Asia Regional Office EHO Ecumenical Humanitarian Organization in Serbia FBO faith-based organization ICMC International Catholic Migration Commission JLI Joint Learning Initiative on Faith & Local Communities NGO non-governmental organization SAR search and rescue UASC unaccompanied and separated children UNICEF United Nations Childrens Fund WCC World Council of Churches ZMD Zentralrat der Muslime in Deutschland list of boxes Box 1 - The Humanitarian Corridors Initiative, Italy Box 2 - The Vaiz, Turkey Box 3 - Learning to Live Together: Arigatou Foundation, Interfaith Council on Ethics Education for Children, and Global Network of Religions for Children Box 4 - Refugees Hosting Refugees Box 5 - Ecumenical assistance for asylum seekers: Oekumenischer Seelsorgedienst fr Asylsuchende, Switzerland Box 6 - Search for Common Ground against violent extremism among young returnees, Kyrgyzstan Box 7 - Goda Grannar (Good Neighbours), Sweden Box 8 - Faith Over Fear movement supported by UNICEF and Religions for Peace From Faith to Action v contents Acknowledgements iii List of acronyms iv List of boxes iv Executive Summary 1 Introduction 2 Situation Analysis Summary 3 Faith Activities to Support Children on the Move 5 Promising Practice Case Study #1: Ecumenical Humanitarian Organization, Serbia 12 Promising Practice Case Study #2: Apostoli, Greece 16 Promising Practice Case Study #3: Central Council of Muslims, Germany 20 Glossary 24 Annex 1 - Legal and Political Framework 25 Annex 2 - Country-specific information 28 Endnotes 33 UNICEF/UNI197534/Gilbertson VII Photo From Faith to Action 1 executive summAry Five main areas in which faith actors have a positive impact on children on the move in Europe and Central Asia1. Providing assistance for children on the move along safe and unsafe migration routes, and when they arrive. For example, faith actors perform or fund search and rescue (SAR) operations, establish safe and legal routes for children to travel (e.g., humanitarian corridors), and provide shelter, food, and legal advice and other essential services for children and their families. 2. Facilitating integration and social inclusion by enhancing access to social services (particularly education) and bringing host communities and newcomers closer together by fostering empathy, cultivating welcoming practices, and identifying shared spaces. 3. Offering spiritual and psychosocial support that can enhance resilience, sustain a sense of belonging, and facilitate the process of migration and integration. 4. Fostering social cohesion, combating xenophobia and discrimination, promoting inter-religious dialogue, speaking out for peaceful coexistence, and addressing the root causes of conflict that have forcibly displaced children and families. 5. Advocacy to influence decision-makers towards more inclusive approaches in response to the displacement of children and families. Strategies include building inter-religious coalitions for advocacy, using their influence to speak to policymakers on migration, and advocating for the rights of children and for governments and communities to welcome refugees and migrants. This publication aims to highlight the actual and potential roles of faith actors in contributing towards an effective and holistic response to child displacement in Europe and Central Asia. These roles range from providing shelter and other material support to fostering psychosocial and spiritual wellbeing, speaking out against xenophobia, promoting peaceful coexistence, and influencing policymakers to protect the rights of children on the move. While it must be recognised that faith actors have also played negative roles, this publication aims primarily to serve as a useful tool to improve cooperation between faith actors and other stakeholders, such as UNICEF and national authorities, in the protection of children and youth on the move. This publication aims to highlight the actual and potential roles of faith actors in contributing towards an effective and holistic response to child displacement in Europe and Central Asia. We developed this publication through an extensive review of academic articles, research reports, conference reports, and other documents focusing on key issues affecting young refugee and migrants and on the roles of faith actors in supporting children on the move. This publication is organized into an introductory section, a central section underlining different areas in which faith actors are engaged with some remarks on challenges and opportunities, and a final section highlighting three case studies with faith-based organizations (FBOs) working with children and youth on the move in Germany, Greece, and Serbia. This publication illustrates a plurality of ways in which faith actors actively support children and youth on the move, namely, by ensuring their protection and social inclusion, providing spiritual and psychosocial support, countering xenophobia and discrimination, and advocating for policy changes. 2 introduction This publication emerges from discussions in Europe and Central Asia about the role of faith actors in protecting children on the move. The content was developed in preparation for the conference From Faith to Action: Inter-religious action to protect the rights of children affected by migration with a focus on Europe and Central Asia held online on 10-11 December 2020. The primary topics include the need to safeguard and protect children, the realities of migration and forced displacement, inter-religious cooperation and the roles of faith actors, and how these threads intersect in the Europe and Central Asia region. The publication starts with some key facts and figures on the current situation of migrants and children on the move in Europe and Central Asia. We have also included information on the impact of COVID-19 in the region. The first section ends with an overview of key issues affecting children on the move and their families. The second section presents an overview of faith-based engagements with children on the move in Europe and Central Asia. It is structured in five subsections: Faith actors support to provide protection for children on the move. Social inclusion and access to social services. Spiritual and psychosocial support for children on the move. Faith actors efforts to combat xenophobia and foster peaceful societies. The role of faith actors in policy and advocacy. These subsections build on previous work, including the Faith Action for Children on the Move forum held in Rome in 20181 and the Faith and Positive Change for Children, Families and Communities Initiative (FPCC)2, a collaboration between UNICEF, the Joint Learning Initiative on Faith & Local Communities (JLI), and Religions for Peace. The From Faith to Action initiative is built on the principle that a child is a child, and reinforces the principle of the best interest of the child. The next section highlights challenges and opportunities for discussion during the conference, and focuses on the five main thematic areas indicated. The publication also includes a glossary and annexes citing relevant legal and policy documents and country-specific information. The final section includes three case studies. The first one, developed with the Ecumenical Humanitarian Organization, focuses on their work in providing material and psychosocial support to children on the move in Serbia. The second one, developed with Apostoli, illustrates their engagements towards the inclusion of youth on the move in Greece. The last one, developed with the Central Council of Muslims in Germany, describes their activities, including policy and advocacy efforts, to foster social cohesion and mutual support between established communities and newcomers. From Faith to Action 3 situAtion AnAlysis summAry in family incomes. Cuts in remittances may cause children and youth to drop out of school and seek work, migrate, or put them at risk of child marriage or trafficking.7 Social distancing restrictions may further impede the limited education opportunities that may be available to most displaced children.8 The lack of devices or stable internet access can be a barrier to online learning. 9 As governments tighten border controls and impose stricter health requirements on new arrivals, some have been criticized for using COVID-19 as an excuse to toughen immigration policies, suspend asylum procedures, and retreat from international legal obligations to rescue and provide safety as has been the case for many refugee and migrants crossing the Mediterranean.10 Some nationalist and populist voices see refugees as transmission threats and push for hard-line immigration policies, feeding into populist rhetoric in fear of the other.11 At the same time, responses to COVID-19 have also played unifying role. Advocacy and humanitarian organizations continue to push for a narrative that sees the pandemic as an opportunity to expand health care and social protections for refugees and migrants.12 Multilingual information dissemination, including health and public safety instruction, has become common practice in several European countries.13 Key issues faced by children on the move and their familiesExploitation (including online exploitation), smuggling and trafficking Children on the move are exposed to great risks and are vulnerable to trafficking, smuggling and various forms of exploitation.14 Around 75% of 14 to 17-year-old refugees and migrants crossing the Mediterranean from North Africa to Italy experience exploitative practices such as arbitrary detention or forced labour.15 Since digital tools are especially important for children who travel unaccompanied or separated from family, they are at high risk of online exploitation.16 In 2020, an estimated 94,800 refugees and migrants arrived Europe from countries as diverse as Afghanistan, Algeria, Bangladesh, Morocco, Tunisia, and Syria. Nearly one in every five (18.5%)1, was a child. At the end of 2020, there were some 60,000 refugee and migrant children in Bosnia and Herzegovina, Bulgaria, Greece, Italy, Montenegro, and Serbia. Among them were 12,000 unaccompanied and separated children (UASC) whose lives depended on humanitarian assistance. UNICEF and partners worked tirelessly to reach approximately 51,000 refugee and migrant children with a range of support2 to protect their health and well-being. The COVID-19 pandemic certainly affected the influx of refugees and migrants into Europe. UNICEF and humanitarian partners had to adapt quickly to the fast-moving situation across the Europe and Central Asia region, and ensure that children were prioritized in procedures related to disembarkation and accommodation. The European Union (EU) registered a 33% overall decrease in the number asylum applications. However, the decrease was not evenly spread across Europe, and many local communities received unexpectedly large surges of new arrivals3. The pandemic raised many additional concerns about the health and safety of children and families. Refugee and migrants living close together have often faced a double lockdown with additional restrictions imposed on their confinement in settlements and camps, that compounded their stress and isolation. As classroom learning adapted to online modalities, a major challenge was connecting refugee and migrant children to education opportunities when access to Internet technology and digital devices was very difficult. The impact of COVID-19 The COVID-19 pandemic has created additional stress on humanitarian supply chains3 and heightened risks faced by displaced populations. Children and families often live in overcrowded settings4 with limited access to clean water, hygiene and other basic services,5 and are often excluded from access to information.6 Displaced children and youth are witnessing a decline 1 UNHCR data for Italy, Greece, Bulgaria, Spain as of 31 December 2020. Operational Portal Refugee Situations: Mediterranean situation, 2 UNICEF Refugee and Migrant Response in Europe Humanitarian Situation Report 2020 No. 38 3 https://ec.europa.eu/info/strategy/priorities-2019-2024/promoting-our-european-way-life/statistics-migration-europe_en Of the 94,800 refugees and migrants who arrived in Europe in 2020, nearly one in five was a child. 4 Obstacles to family reunificationUnaccompanied and separated children (UASC) form a significant percentage of children on the move.17 Although all children have the right to be with their families or guardians, obstacles to family reunification are common.18 Family reunification processes may impose, for example, increased income requirements, expensive medical tests, restrictions on who can apply, and long waits under the Dublin regulations.19 Detention of refugee and migrant childrenEnding detention of refugee and migrant children is one of the priorities of the international community.20 However, in there was an increase in the number of immigration detentions of children arriving in Europe.21 Urgent measures that are being called for include scaling up of efforts to end new detentions, the release of child detainees into non-custodial and community-based alternatives, and the improvement of conditions in detention centres where alternative measures are not possible.22 Access to healthcare Children need to live in a safe environment and should have continuous access to quality healthcare. In unsafe and overcrowded living conditions, children are often exposed to heightened risks of contracting COVID-19 or the inability to access health services such as vaccination.23 Access to educationA quarter of children who arrived in Europe through the Central or the Eastern Mediterranean routes in 2017 had not completed any formal education, while a further 33% had only attended primary school.24 For children on the move, access to education is crucial to overcome cultural and linguistic barriers. However, most reception centres often do not have learning facilities or teaching personnel. Discrimination and xenophobiaNationalistic, xenophobic, misogynistic, and explicitly anti-human rights agendas of many populist political leaders have required human rights proponents to rethink many longstanding assumptions. Highly politicised narratives that support pushback operations and restrictive policies fuel xenophobic sentiments, putting children at risk of experiencing violence and discrimination.25 Preventing and combating xenophobia and discrimination against young refugees and migrants is crucial in efforts aimed at protecting their rights, fostering their livelihoods, ensuring access to health and education services26 and overcoming language barriers that severely affect their social inclusion.27 UNICEF/UNI309268/Onat From Faith to Action 5 fAith Activities to support children on the move Given this framework of compassion and a history of providing front-line support to vulnerable communities, it is no surprise that many governments, as well as local, national and international organizations have chosen to engage with faith actors as key partners in responding to the refugee and migration crisis in Europe and elsewhere in the world. In this section, we explore some of the ways in which religious leaders, faith communities, and FBOs are providing protection and spiritual support for children on the move, combatting xenophobia, helping to build peaceful societies and advocate for the rights of young refugees and migrants. i. Faith actors support to provide protection for children on the moveFaith actors contribute to enhancing child protection in multiple ways. In this section, they are outlined according to migration stages, i.e., along migration There is a consensus across religious traditions about the dignity of every child.28 The fundamental principle of respect for human life is found in religions that believe all human beings, including children, deserve to be respected and treated with dignity, and forms the basis of faith-based motivations to support children on the move.29 Religious groups, institutions and practitioners have a long and proud history of protecting vulnerable migrants and families, persecuted individuals, and unaccompanied children. Under Canon Law in Medieval times, anyone who feared for their life could find sanctuary in the closest church.30 In Europe, Belgian nuns rescued young Jews from the Nazis in the World War II,31 and Hungarian refugees found shelter and assistance in churches in Austria and elsewhere during and after the 1956-57 crisis.32 UNICEF/UN020042/Gilbertson VII Photo 6 routes and after arrival. Overall, safe and legal routes for displaced people, including children, are narrowing. For a long time, faith actors have been involved in campaigning for, organizing, and implementing sponsorship programmes for refugees. In Canada, FBOs have been a strongly involved in the private sponsorship system,33 and similar initiatives have been established in other countries. In 2016, an ecumenical initiative in Italy (see box 1) worked in collaboration with the government to grant a number of exceptional humanitarian visas to create a humanitarian corridor for refugees stranded in Lebanon and other countries to come to Italy. This initiative expanded to other European countries such as France, Belgium and Andorra.34 Recently, the Community of SantEgidio signed an agreement with the German government to transfer refugee and migrant families from the Greek island of Samos to Germany35 and inaugurated a new corridor from Lesvos to Italyprioritising families and unaccompanied minors.36 Box 1 - The Humanitarian Corridors Initiative, Italy37 Humanitarian Corridors is a small-scale initiative run by the Federation of Evangelical Churches in Italy (FCEI), the Tavola Valdese of the Waldensian Church and the Community of SantEgidio in cooperation with the Ministries of the Interior and of Foreign Affairs in Italy. The FBOs and the Government define the programme as establishing a legal and safe alternative to deadly sea routes, smuggling, and trafficking. Over a two-year period, the initiative enabled 1,000 visas to be granted to refugees who qualified as being in particularly vulnerable conditions. Among them were babies as young as five days old.38 Authorities have afforded FBOs with flexibility in the selection of the programmes beneficiaries while meeting government security requirements. Beneficiaries were selected independently from their ethnicity or religion. FBOs provided funding for accommodation and services for the reception of refugees during their initial period of permanent settlement in Italy. Additionally, in instances where the timeframe for the application for international protection was potentially very tight, FBOs negotiated with the state to obtain extensions. Through this initiative FBOs have, arguably, created privileged channels within the asylum application in Italy, that favours asylum seekers who have access to the programme. However, this privileged position also works as an avenue for lobbying towards the improvement of the Italian asylum system in general. Displaced people are often exposed to hardship along migration routes. Faith communities and FBOs are among the first to provide assistance, from the distribution of food to the provision of shelter and legal advice, especially to vulnerable groups like children. All faiths share a tradition of providing sanctuary and assistance to strangers. This tradition lives in multiple forms today,39 and is often characterised by a multi-religious configuration, as in the case of the City of Sanctuary UK movement.40 In Germany, Kirchenasyl, a highly organized network of churches41, is ready to host refugees and migrants who risk of being deported. However, in recent years, this network has been under pressure from the German government with ongoing legal challenges, and shrinking numbers of people who have access to church asylum.42 All faiths share a tradition of providing sanctuary and assistance to strangers. In Hungary, Catholic and Lutheran Bishops mobilised against the anti-refugee narrative by hosting families and individuals on the move, and providing legal advice, translation services, and assistance in finding work.43 However, this help has been curtailed since Hungary passed a law in favour of detaining asylum seekers while their status is being determined.44 ii. Social inclusion and access to social servicesEducation is key to building peaceful societies. Faith actors play a significant role in education globally,45 including providing education to children on the move in formal and informal contexts. Catch-up classes, language classes, and activities supported by volunteers from the faith community are often key to social inclusion and integration.46 Faith actors, at times, associate schooling with peace building and with the prevention of trafficking and exploitation of children.47 Jesuit Relief Services have highlighted the importance of providing education for refugee girls.48 However, there is also evidence that education from religious institutions has sometimes been influenced by politicisation and securitisation, and this highlights the need for teachers to receive training and support on issues such as countering extremism.49 Since the onset of the pandemic, online education and increased dependence on digital technologies by children have heightened the risk of online exploitation. Religions for Peace and ECPAT International have issued guidance for religious leaders on how to protect children from online sexual exploitation.50 From Faith to Action 7 Faith and Positive Change for Children offers guidance documents for religious leaders, faith communities and FBOs to help address challenges in the times of COVID-19 for example, adapting rituals, helping those at risk, and combating misinformation.51 The World Council of Churches has issued guidance52 that gives practical advice encouraging members to trust evidence-based guidance on COVID-19 safety, for example, following physical distancing and using technology to conduct religious services. Box 2 - The Vaiz of Bursa, Turkey53 Turkey hosts 3.6 million refugees the highest number of any country worldwide.54 In Bursa, the government mobilises the Vaiz, a network of state preachers, to support displaced people. The Vaiz provides direct services, delivers welcoming messages to positively influence the local faith community, advocates with the Government to to let Syrians refugees access healthcare, school, and other social services,55 and sponsors refugee children and youth events in the local community.56 More significantly, the state preachers have also used their influence to overcome bureaucratic and legal hurdles to the issuing of birth certificates and wedding registrations for displaced people who do not have the necessary paperwork.57 May countries had to divert and prioritise healthcare staff and resources to treat the sick and fight the spread of COVID-19. As a result, basic health services, including routine childhood immunization, were often temporarily suspended.58 As these services resume, faith actors can play crucial roles in supporting immunization uptake and countering anti-vaccination narratives, including religious objections, as illustrated by numerous studies.59 Religious beliefs and practices can foster wellbeing and support the integration of refugee and migrant children on the move. A recent study found that young Coptic Christians in Italy highly valued their sense of belonging to their faith community, both in terms of the religious freedom in Italy and as cultural and religious identity.60 Similarly, a study conducted in Germany, the Netherlands and the UK explained how religion can be beneficial to the social integration of Muslim migrants with their own faith/ethnic community and does not hamper integration with broader society.61 A survey conducted among churches in 19 European countries in 2014-2015 revealed that one-third had between one in 20 and one in five young members with a migration background.62 Box 3 - Learning to Live Together: Arigatou Foundation, Interfaith Council on Ethics Education for Children, and Global Network of Religions for Children63 The Global Network of Religions for Children, the Arigatou Foundation and the Interfaith Council on Ethics Education for Children in collaboration with UNICEF, UNESCO, and education professionals and academics, including those from different religious traditions, developed a methodology to foster peaceful coexistence and mutual respect in interfaith and intercultural contexts. The methodology is used in both formal (e.g., schools) and informal (e.g., refugee camps) contexts and includes activities, interfaith prayers for peace, feedback mechanisms and learning modules on different themes. In Greece, a similar programme named Learning to Play Together64 has been developed using physical education and sports to engage young refugees and migrants who come from different geographic, cultural, religious and linguistic contexts. iii. Spiritual and psychosocial support for children on the moveResearch indicates how spirituality can contribute to the resilience of children during and after their displacement.66 Fostering resilience is particularly important for children who experience and are exposed to stress, risks and violence during their migration processit includes developing a sense of belonging, acknowledging the importance of education and schooling, and connecting with the community.67 Faith actors support this resilience through the provision of community, space, and resources for sustained and holistic care. Often, these spaces are designed to aid children in finding their place in society and their identity within the faith communities by offering them psychosocial and spiritual support. Another component in the building of childrens identities is the ongoing incorporation of faith into psychosocial and resilience programs,68 which provide coping strategies for children on the move.69 8 Box 4 - Refugees Hosting Refugees Recent research has focused on hosts, refugees and refugee hosts (i.e., refugees hosting other refugees). Research from University College London65 examines the roles that members of local faith communities, faith leaders and FBOs can play in promoting social justice and social integration for refugees living in Cameroon, Greece, Malaysia, Mexico, and Lebanon. The study found that in Greece, members of refugee communities collect and distribute material support for other refugees, including baskets to break the fast during the holy month of Ramadan. Box 5 - Ecumenical assistance for asylum seekers: Oekumenischer Seelsorgedienst fr Asylsuchende (OeSA), Switzerland70 OeSA is an ecumenical organization reflecting a collaboration between the Methodist Church, the Reformed Church and the Catholic Church in Basel, Switzerland. OeSA offers several services to asylum seekers of any (or no) faith and any country of origin, including psychosocial and spiritual support during Refugee Status Determination (RSD). OeSA is also a place where asylum seekers can meet, take German lessons, attend music workshops, and where their children can attend activities organized twice a week.71 Volunteers working for this initiative are also of different religious and cultural backgrounds [who can] easily share the motivating vision and the working style of the organization.72 The sensitivity of OeSA workers towards faith-related issues has allowed them, for instance, to negotiate extra permits for Muslim asylum seekers who are staying in Registration and Procedure Centres (RPCs)73 to stay in the mosque longer during Ramadan. Working with the childrens faith communities can help achieve integration and long-term wellbeing.74 When building resilience and providing comprehensive psychological support for children on the move, it may be necessary for faith-based organizations and local faith communities to provide support to parents, caregivers and other adults in the childrens lives. This is fundamental when responding to the needs of traumatised children. iv. Faith actors efforts to combat xenophobia and discrimination and to foster peaceful coexistenceThe role of faith actors in the Global Compact for Refugees has been recognized within the plans of several anti-discrimination, xenophobia and intolerance measures and programs. Peer-to-peer workshops that bring together a particular group, for example, young people, new arrivals, or members of a faith community with a similar migration background can be used to strengthen such initiatives. In this way, relationships of trust create a safe environment to address issues such as religious prejudice, discrimination, and extremismfaith actors often become the main points of reference for displaced minors.75 Multi-religious initiatives can play a pivotal role in integration processes in countries of arrivals. The European Council of Religious Leaders and University of Winchester Centre of Religion, Reconciliation and Peace analysed case studies featuring the cooperation of at least two organizations belonging to different religious traditions in Germany, Poland, Sweden (see box 8), and the UK. 83 The study counters the idea that faith actors only support communities of their own religious tradition, and outlines potential benefits of multi-religious cooperation in integration processes by achieving shared objectives through enhanced dialogue, and combating racism and radicalisation.84 UNICEF/UN0354305/Canaj/Magnum Photos From Faith to Action 9 Box 6 - The work of Search for Common Ground against violent extremism among young returnees, Kyrgyzstan76 In Kyrgyzstan, youth radicalisation,77 especially among labour migrants and returnees, is a key issue.78 Search for Common Ground has been engaged in several programmes to prevent and combat violent extremism in the country. In 2016-2017, in partnership with the State Commission on Religious Affairsm (SCRA), the group implemented a project that used social media as a tool for deradicalization targeted and included young people, including returnees from Syria. An evaluation of the project suggested that, as a result, youth participants, as well as grant recipients, expanded their knowledge about radicalisation, extremism, and fanaticism, and gained skills in critical thinking and problem-solving.79 In 2018, the youth-led project called #JashStan80, supported by the United Nations Peacebuilding Fund, produced a reality television series turning violent and radical discourse into tolerance and peaceful coexistence. In July 2020, Search for Common Ground announced that the European Union Instrument Contributing to Stability and Peace (EUIcSP) would support a two-year project,81 which will draw on its research on the risks of radicalisation and violent extremism among Central Asian migrant workers in Russia. The project will engage religious and traditional leaders and include psychosocial support.82 Xenophobia and discrimination against refugees based on religion, nationality and ethnicity are on the rise across the region.89 To combat stigma and discrimination, faith actors promote sensitisation and advocate against xenophobic mind-sets, as well as working to protect refugees directly from discriminatory experiences and attacks.90 Public condemnation of xenophobic threats or attacks by religious leaders can have significant effects on faith communities and support efforts to eradicate, or, create further partnerships to counter the violence.91 Faith communities, particularly those that participate in interfaith initiatives can also be instrumental in reconciliation and healing following a conflict.92 Local faith actors and interfaith councils can provide expertise within countries of origin to address root causes of conflict and displacement. They can help remove obstacles to return and address issues of reintegration in the country of originespecially when tensions among religious and ethnic groups are still present.93 Box 7 - Goda Grannar (Good Neighbours), Sweden This multi-religious collaboration between the Stockholm Mosque, the Katarina parish and Islamic Relief started in 2015, as a makeshift shelter for transit migrants. It later became a much more multifaceted initiative, offering asylum seekers a wide range of services, from language cafs to counselling on issues such as employment, education and healthcare.85 In particular, they support newly arrived families with young children to find preschool and activities to help them create a network in their new community. After initial scepticism shown by some members of the local faith communities,86 the collaboration has proved to be successful and has grown in numbers and even expanded to other districts and faith actors, such as the Syrian Orthodox Church and the Negashi Mosque.87 In addition to the more practical work on integration, members of different faith communities have started a dialogue about their religious beliefs, traditions and values through this project, which has led to improved social relationships.88 v. Faith actors and policy/advocacyFaith actors are often part of networked organizations that allow them to have a strong impact within the international arena. For instance, Eurodiaconia is a European network of 52 churches and Christian NGOs94 who are active in many areas, including migration and forced displacement. The network organizes events at the European level, and recently, published the report, Fostering Cooperation Between Local Authorities and Civil Society Actors in the Integration and Social Inclusion of Migrants and Refugees,95 on the European Commissions European Web Site on Integration (EWSI), which consolidates information and good practices. Eurodiaconia recommends strengthening multi-stakeholder platforms and using transparent monitoring and evaluation mechanisms. It also suggests promoting mutual knowledge exchange among all stakeholders involved, including migrants. In April 2020, 67 NGOs and FBOs (including the International Catholic Migration Commission (ICMC), Caritas, and HIAS Greece) signed a letter, urgently requesting the relocation of displaced children stranded in Greece to other EU member states.96 In September 2020, a wide alliance (including Caritas Europe, the Churches Commission for Migrants in Europe (CCME), the European Council on Refugees and 10 Exiles, the ICMC, the International Rescue Committee, the Red Cross, and the SHARE Network) released an advocacy statement to the European Commission on the situation of migrants and refugees in Europe.97 The alliance asked for a more equitable sharing of responsibility in responding to the needs of people on the move and for safe and legal passages to Europe.98 Faith actors, at times, have been excluded from decision-making processes on migration at the policy level. Recently, however, governments and international organizations are more aware of the roles that faith actors play in responding to migration and forced displacement. In the 2018 Global Compacts on Refugees and on Safe, Orderly and Regular Migration faith actors were included as relevant stakeholders. Box 8 - Faith Over Fear movement supported by UNICEF and Religions for Peace109 UNICEF and Religions for Peace in 2017, launched the movement, Faith Over Feara global multi-religious advocacy initiative. Its aim is to spread positive messages about migration and faith to promote a welcoming culture towards displaced people among faith communities. One example from Germany (provided by the WCCs Churches Commitments to Children for this campaign) is a video110 telling the story of a Christian retired couple from Bonn who met two Syrian Muslim refugees at a local church. As their friendship became stronger, the German couple decided to host the Syrians, several weeks before they had their first child. They ended up living together for over eight months and now feel that they belong to the same extended family, celebrating Ramadan and Christmas together.111 The campaign also features a social media toolkit112 to facilitate the engagement of religious leaders and faith communities who are willing to share their stories of choosing faith over fear. A number of faith actors made recommendations during the development of the Compacts. The Interfaith Conference on the Global Compacts on Migration and Refugees brought together faith actors and policymakers and called for a greater acknowledgement of the roles played by FBOs.99 The JLI published a policy brief100 on Faith Actors and the Implementation of the Global Compact on Refugees, outlining issues, examples and recommendations of burden and responsibility sharing, reception and admission, meeting needs and supporting communities, and durable solutions. Faith actors are often part of networks making a strong impact in the international arena. Since the Global Compacts were adopted, faith actors have released statements on the importance of following their principles and guidelines, and faith communities have been urged to act to assist migrants and refugees accordingly.101 The 2019 Local Humanitarian Leadership forum in Beirut, Lebanon, emphasized that engaging local faith actors is in line with the commitments of the Global Compacts on Migration and on Refugees.102 The forum emphasized the need to localize assistance to migrants and refugees by effectively engaging local faith actors.103 Faith actors are often involved in advocacy efforts on issues affecting children on the move. They organize themselves in coalitions and take part in multi-religious campaigns, such as campaigning against the detention of children due to their immigration status104 or family separation,105 and support the right to birth registration.106 Faith actors use their influence to foster peaceful coexistence and combat violence in the name of religion through advocacy initiatives. They use statements to declare unity and speak out against xenophobia, such as the Athens Declaration, United Against Violence in the Name of ReligionSupporting the Citizenship Rights of Christians, Muslims and Other Religious and Ethnic Groups in the Middle East. 107 During the 2015-2016 refugee and migrant crisis in Europe, many religious leaders, faith actors and multi-faith alliances mobilised to push for a welcoming response and to fight against hostile populist reactions. For instance, in the UK, a multi-religious coalition of over 200 Christian, Jewish, Muslim, Sikh, Buddhist and Hindu religious leaders reacted to the refugee and migrant crisis by issuing an open letter108 to the then Prime Minister, Theresa May. They urged the government to establish legal routes for refugees from Syria and other countries, especially for those who had family in the UK. The study Faith and Childrens Rights, conducted by Arigatou International in collaboration with the International Dialogue Centre (KAICIID) and World Vision International, collected recommendations for action from religious leaders, child rights advocates, and children themselves. Participants demonstrated that the deepening of faith actors understanding of childrens rights may help communities to see the common ground between rights and religion, leading to the formation of fruitful partnerships. Such ideas can be incorporated into sermons and activities in religious communities. Faith actors can refer to legal agreements such as the Convention on the Rights of From Faith to Action 11 the Child and use the power of its mandate as a tool to advance initiatives that support children and families in their communities.113 The expertise of faith actors can significantly strengthen policy concerning the criteria for resettlement and engagement with host communities to guarantee welcome and protection of unaccompanied or separated children. This will also ensure to put in place special measures to counter risky transit and post-arrival integration, including education and trauma healing. Such endeavours can assist in counteracting negative responses to resettlement and ensuring effective integration processes.114 Opportunities and ChallengesAs this publication illustrates, engaging faith actors can result in more effective responses to the vulnerabilities of displaced children. To summarise, faith actors can contribute to: Assisting children on the move along migration routes. This includes performing or funding SAR operations, engaging in the creation and implementation of safe and legal routes, and providing basic services such as shelter, food and legal advice to children on the move and their families after arrival. Offering spiritual and psychosocial support that can enhance childrens resilience to sustain their sense of belonging and support them through their migration process. Facilitating integration and social inclusion by enhancing access to social services (in particular education) and promoting empathy, welcoming practices and shared space between the host community and the newcomers. Fostering social cohesion and inter-religious dialogue to combat xenophobia and discrimination. Advocating for and influencing policy makers towards more inclusive response approaches to displaced children and their families. Some challenges have also emerged from this review of faith actors engagements in response to the displacement of children and their families. In particular: Faith actors support can be hampered by legal challenges. For example, the legal cases against Kirchenasyl (church asylum) in Germany and the increasing detention of asylum seekers in Hungary. They require help to combat the criminalisation of migrants support. Faith actors, especially faith communities, are often heterogeneous and complex entities, which can have internal tensions and challenges. These need to be identified, and, if possible, addressed through dialogue. Recognition of the plurality and nuanced nature of faith actors is critical to avoid stereotyping. Some faith actors might lack institutional capacity required by common humanitarian standards to implement large-scale refugee response projects. When collaboration is established between international organizations and local and national faith actors that there can be opportunities for enhanced visibility, mutual understanding, finding points of complementarity, and capacity sharing. Faith actors and their activities are not exempt from politicisation. For example, they can fuel anti-migrant sentiments to ensure the support of political actors. Their engagement can also be instrumental in achieving other actors political agenda. To establish a long-term relationship of trust with key local faith actors, these factors need to be taken into consideration and addressed through in-depth knowledge of the local political context and trust building in the partnership. Recognition of the plurality and nuanced nature of faith actors is critical. 12 promising prActice cAse study #1: ecumenicAl humAnitAriAn orgAnizAtion, serbiA EHOs work in Serbia is multifaceted. It ranges from fostering the inclusion and empowerment of marginalised groups such as the Roma community116 and supporting children and the elderly117 to peacebuilding work with young people from different ethnic and faith communities.118 Since 2015, EHO has been assisting migrants and refugees in transit through Serbia.119 Part of this engagement focused on children on the move and access to education in particular. A previous project120 on social inclusion, now concluded, specifically addressed the needs of children on the move by supporting their inclusion in local schools through training local teachers in intercultural work to promote welcoming approaches and counter prejudice and discrimination. This previous project focussing on inclusion was financially supported by Swiss Church Aid (HEKS/EPER)121 and implemented in partnership with the local government. Building on it, EHO started a new project in 2019 called Empowerment of Refugee 1. The Ecumenical Humanitarian Organizations work with children and women on the move in SerbiaThe Ecumenical Humanitarian Organization (EHO) is a development organization guided by Christian ethical values. A member of Act Alliance,115 it was founded in 1993 in Novi Sad, Serbia, on the initiative of the World Council of Churches (WCC). The founding churches are the Slovak Evangelical A.B. church in Serbia, the Serbian Reformed Christian church, the Apostolic Exarchate for Greek Catholics in Serbia and Montenegro and the Evangelic Christian A.B. church in Serbia-Vojvodina. The ecumenical nature of the organization is unique in Serbia. It contributes to the expansion of its engagement, both in terms of areas and type of intervention as well as in geographical terms within Serbia. For EHO, respect for human rights and the dignity of all people is a core value. UNICEF/UNI220347/Pancic From Faith to Action 13 Women and Children, financially supported by the Evangelical Lutheran Church in America (ELCA), which is the main focus of his case study. 2. The context: Children and youth on the move in SerbiaUNHCR data on Serbia reflecting mixed migration movements from January until 27 September 2020 shows that, after a sharp drop in arrivals between April and the beginning of June, the number of arrivals rose considerably. During the whole period, 1,129 unaccompanied minorsaround 84% of which were maleentered the territory.122 According to the latest data (September 2020) from UNHCR and the Serbian Commissariat for Refugees and Migration (hereinafter Commissariat),123 Serbia currently hosts almost 26,000 refugees, 197,000 IDPs, and around 1,900 people at risk of statelessness. The number of people living in some of the Asylum Centres (AC) and Reception and Transit Centres (RTC) around the country has been growing in the last months. For example, a UNHCR assessment of the sites from August 2020 reported that the Sombor RTC was operating at full capacity with 753 people (of which 10% were children).124 The numbers rose to 854 by the end of August and to 1,141 at the end of September.125 Serbia is one of the countries in the Balkan region where the effects of restrictive policies on border crossings are more visible. In September 2020, the number of migrants and refugees who were pushed back from neighbouring states (3,115) was more significant than the number of arrivals, and the highest since UNHCR started monitoring them in 2016.126 In September, the total number of migrants and refugees hosted in RTCs or ACs in the country was 5,064526 were children, including 174 unaccompanied minors.127 Numerous sources have identified a significant increase in violent border enforcement practices and pushback operations in the areas close to the borders to Hungary and Croatia, where EHO operates.128 Since the onset of the COVID-19 pandemic until the beginning of November, Serbia had 55,676 confirmed cases and 861 deaths.129 The COVID-19 crisis worsened the situation for many refugees and migrants. A 2020 report by Save the Children highlighted how physical distancing is virtually impossible in often overcrowded transit centres in the Western Balkans.130 Due to further restrictions on freedom of movement, only a few NGOs were allowed to keep working inside RTCs and ACs.131 New rules on sanitization and the use of masks were introduced in all centres.132 Children on the move, and especially unaccompanied minors, have faced and continue to face several obstacles to their right to educationfrom language barriers and lack of documents necessary for enrolment to adequately trained teachers.133 However, in the last years, several efforts have been made to ensure access to education for children in RTCs and ACs centres in Serbia.134 For instance, a transportation service for children living in a reception centre and attending a local school was organized by IOM Serbia in collaboration with the Commissariat and funded by the EU Regional Trust Fund in Response to the Syrian Crisis and the MADAD Fund.135 Moreover, before the second lockdown began, several children living in RTCs and ACswith the support of UNCHR Serbiahad either started going to school or received vouchers for the purchase of books and other school materials.136 3. EHOs Empowerment of Refugee Women and Children ProgramBuilding on the social inclusion project described in Section 1, the program Empowerment of Refugee Women and Children137 is currently implemented by EHO in the RTCs of id, near the border to Croatia and Bosnia-Herzegovina, and Sombor, near the border to Hungary. The geographical position of both camps plays an important
Programme
18 October 2017
Refugee and migrant children in Europe
https://www.unicef.org/eca/refugee-and-migrant-children
People have always migrated to flee from trouble or to find better opportunities. Today, more people are on the move than ever, trying to escape from climate change, poverty and conflict, and aided as never before by digital technologies. Children make up one-third of the world’s population, but almost half of the world’s refugees: nearly 50 million children have migrated or been displaced across borders.   We work to prevent the causes that uproot children from their homes While working to safeguard refugee and migrant children in Europe, UNICEF is also working on the ground in their countries of origin to ease the impact of the poverty, lack of education, conflict and insecurity that fuel global refugee and migrant movements. In every country, from Morocco to Afghanistan, and from Nigeria to Iraq, we strive to ensure all children are safe, healthy, educated and protected.  This work accelerates and expands when countries descend into crisis. In Syria, for example, UNICEF has been working to ease the impact of the country’s conflict on children since it began in 2011. We are committed to delivering essential services for Syrian families and to prevent Syria's children from becoming a ‘ lost generation ’. We support life-saving areas of health , nutrition , immunization , water and sanitation, as well as education and child protection . We also work in neighbouring countries to support Syrian refugee families and the host communities in which they have settled.   
Report
30 July 2018
Capture the moment
https://www.unicef.org/eca/reports/capture-moment
CAPTURE THE MOMENT: EARLY INITIATION OF BREASTFEEDING 1 CAPTURETHE MOMENT Early initiation of breastfeeding: The best start for every newborn 2 CAPTURE THE MOMENT: EARLY INITIATION OF BREASTFEEDING United Nations Childrens Fund (UNICEF) July 2018 Permission is required to reproduce any part of this publication. Permissions will be freely granted to educational or non-profit organizations. Please contact: UNICEF Nutrition Section, Programme Division andData, Analytics and Innovation, Division of Data, Research and Policy3 United Nations PlazaNew York, NY 10017, USA email: nutrition@unicef.org At WHO contact: nutrition@who.int ISBN: 978-92-806-4976-5 For the latest data, please visit:https://data.unicef.org/topic/nutrition/infant-and-young-child-feeding/ Suggested citation:UNICEF, WHO. Capture the Moment Early initiation of breastfeeding: The best start for every newborn. New York: UNICEF; 2018 Notes on the maps in this publication: This map is stylized and not to scale. It does not reflect a position by UNICEF on the legal status of any country or territory or the delimitation of any frontiers. The dotted line represents approximately the Line of Control in Jammu and Kashmir agreed upon by India and Pakistan. The final status of Jammu and Kashmir has not yet been agreed upon by the parties. In addition, the final boundary between the Sudan and South Sudan has not yet been determined, and the final status of the Abyei area has not yet been determined. Photo credits: On the cover: UNICEF/UNI114722/Pirozzi; page 6: UNICEF/UNI95002/Pirozzi; page 12: UNICEF/UNI11851/Pirozzi; page15: UNICEF/UNI164740/Noorani; page 19: UNICEF/UN0156444/Voronin; page20: UNICEF/UNI94993/Pirozzi; page 23: UNICEF/UN0159224/Naftalin; page 26: UNICEF/UNI180267/Viet Hung; page 29: UNICEF/UNI38775/Pirozzi CAPTURE THEMOMENT Early initiation of breastfeeding: The best start for every newborn 4 CAPTURE THE MOMENT: EARLY INITIATION OF BREASTFEEDING AcknowledgementsThis report was prepared by UNICEFs Nutrition Section (Programme Division), the Data and Analytics Section (Division of Data, Research and Policy) and the Division of Communication, in collaboration with WHOs Department of Nutrition for Health and Development and the Department of Maternal, Newborn, Child and Adolescent Health. Report team UNICEF, Programme Division: Maaike Arts, France Bgin, Willibald Zeck, Carole Leach-Lemens and Victor M. Aguayo. UNICEF, Division of Data, Research and Policy: Vrinda Mehra, Julia Krasevec, Liliana Carvajal-Aguirre, Tyler A. Porth, Chika Hayashi and MarkHereward. WHO: Laurence Grummer-Strawn, Nigel Rollins, and Francesco Branca. Communication teamUNICEF: Julia DAloisio (editing), Yasmine Hage and Xinyi Ge (fact checking), Nona Reuter (design), Irum Taqi, Guy Taylor and Shushan Mebrahtu (advocacy), Kurtis Cooper and Sabrina Sidhu (media). UNICEF gratefully acknowledges the support of the Bill & Melinda Gates Foundation, UNICEF USA and the Government of the Netherlands. UNICEF and WHO would like to extend special thanks to their partners in the Global Breastfeeding Collective for their breastfeeding advocacy efforts. List of abbreviationsBFHI Baby-friendly Hospital Initiative CHW Community health worker DHS Demographic and Health Survey MICS Multiple Indicator Cluster Survey UNICEF United Nations Childrens Fund WHA World Health Assembly WHO World Health Organization CAPTURE THE MOMENT: EARLY INITIATION OF BREASTFEEDING 5 Contents Starting out right 7 Why an early start to breastfeeding matters 8 Early initiation in numbers 10 What the global and regional data tellus 10 Barriers and missed opportunities 13 Skilled birth attendants 13 Institutional deliveries 14 Caesarean sections 16 Supplemental foods or liquids 18 Clearing the path for breastfeeding 21 Lessons from countries 24 What needs to be done? 27 Annexes 29 Annex 1. Countries with largest changes in prevalence of early initiation of breastfeeding between 2005 and 2017 30 Annex 2. Overview of early initiation of breastfeeding rates by country 31 Annex 3. Notes on the data 39 Endnotes 41 6 CAPTURE THE MOMENT: EARLY INITIATION OF BREASTFEEDING6 CAPTURE THE MOMENT: EARLY INITIATION OF BREASTFEEDING 7 Starting out right Whether delivery takes place in a hut in a rural village or a hospital in a major city, putting newborns to the breast within the first hour after birth gives them the best chance to survive, grow and develop to their full potential. These benefits make the early initiation of breastfeeding a key measure of essential newborn carein the Every Newborn Action Plan.1 The World Health Organization (WHO) and the United Nations Childrens Fund (UNICEF) recommend that children initiate breastfeeding within the first hour of birth and be exclusively breastfed for the first six months of life meaning no other foods or liquids are provided, including water. From the age of 6 months, children should begin eating safe and adequate complementary foods while continuing to breastfeed for up to two years and beyond.2,3 The early initiation of breastfeeding putting newborns to the breast within the first hour of life is critical to newborn survival and to establishing breastfeeding over the long term. When breastfeeding is delayed after birth, the consequences can be life-threatening and the longer newborns are left waiting, the greater the risk. Improving breastfeeding practices could save the lives of more than 800,000 children under 5 every year, the vast majority of whom are under six months of age. Beyond survival, there is growing evidence that breastfeeding boosts childrens brain development and provides protection against overweight and obesity. Mothers also reap important health benefits from breastfeeding, including a lower risk of breast cancer, ovarian cancer and type 2 diabetes.4 The life-saving protection of breastfeeding is particularly important in humanitarian settings, where access to clean water, adequate sanitation and basic services is often limited. This report presents the global situation of early initiation of breastfeeding and describes trends over the past ten years. Drawing from an analysis of early initiation rates among babies delivered by skilled birth attendants, the report describes key findings and examines the factors that both help and hinder an early start to breastfeeding. The report outlines key learnings from countries where rates of early initiation have improved or deteriorated and concludes with recommendations for policy and programmatic action. No matter where a newborn takes his or her first breath, the desire to give that baby the best start in life is universal. The first hours and days after birth are one of the riskiest periods of a childs life but getting an early start to breastfeeding offers a powerful line ofdefense. 8 CAPTURE THE MOMENT: EARLY INITIATION OF BREASTFEEDING Why an early start to breastfeeding matters When it comes to breastfeeding, timing is everything. Newborns who are put to their mothers breast within the first hour of life are more likely to survive, while those left waiting face life-threatening consequences. Indeed, the longer newborns wait for the first critical contact with their mother, the greater their risk ofdeath. According to a recent meta-analysis of five studies from four countries, including more than 130,000 breastfed newborns, those who began breastfeeding between 2 and 23 hours after birth had a 33 per cent greater risk of dying compared with those who began breastfeeding within one hour of birth. Among newborns who started breastfeeding 24 hours or more after birth, the risk was more than twice as high (see Figure 1).5 The protective effect of early breastfeeding existed independently of whether or not the children were exclusively breastfed. Children who are not put to the breast within the first hour of life also face a higher risk of common infections. In a study of more than 4,000 children in Tanzania, the delayed initiation of breastfeeding was associated with an increased risk of cough and an almost 50 per cent increased risk of breathing difficulties in the first six months of life, compared with newborns who began breastfeeding within the first hour of birth.6 Babies are born ready to breastfeed. The newborn suckling reflex allows infants to suck, swallow and feed immediately after birth. Putting newborns to the breast necessitates skin-to-skin contact, and this closeness between mother and baby in the moments after delivery provides both short- and long-term benefits. Immediate skin-to-skin contact helps regulate newborns body temperature and allows their bodies to be populated with beneficial bacteria from their mothers skin. These good bacteria provide protection from infectious diseases and help build babies immune systems.7 Suckling at the breast triggers the release of prolactin in the mother, an important hormone that stimulates milk production and helps ensure a continuous food supply for the infant.8 The breastmilk consumed by newborns during the first few days called colostrum is extremely rich in nutrients and antibodies and acts as a childs first vaccine, providing a vital shield of protection against disease and death. Skin-to-skin contact immediately after birth until the end of the first breastfeeding has been shown to extend the duration of breastfeeding, improve the likelihood of babies being breastfed at all in the first months of life, and may also contribute to an increase in exclusive breastfeeding.9 Initiating breastfeeding within the first hour of life is no easy feat: mothers cannot be expected to do it alone. They require adequate support and guidance on positioning and feeding their newborns. The appropriate care of both newborn and mother in the moments after birth is critical to ensuring that breastfeeding not only begins but continues successfully. While a small proportion of women cannot breastfeed for medical reasons, most mothers simply need the right support at the right time to ensure that breastfeeding gets an early start. CAPTURE THE MOMENT: EARLY INITIATION OF BREASTFEEDING 9 <1 hour is optimal For newborns, every minute counts Risk of infection and death increases the lo nger th e del ay Breastfeeding <1 hour after birth saves lives and provides benefits that last a lifetime. Waiting 1 day or more increases their risk of death* by more than 2 times. Waiting 2-23 hours increases their risk of death* by 1.3 times. The longer babies need to wait, the greater the risk. 24h2-23h<1h *Risk of death is presented for the first 28 days of life and in comparison to those who initiated in <1 hour. Figure 1. Visualization of the evidence about the importance of initiating breastfeeding within the first hour of life.Source: Smith Emily R, et al. Delayed breastfeeding initiation and infant survival: A systematic review and meta-analysis. PLoS ONE, vol, 12, no. 7, 25 July 2017. 10 CAPTURE THE MOMENT: EARLY INITIATION OF BREASTFEEDING Early initiation in numbersWhat the global and regional data tellus Most of the worlds newborns are left waiting too long to begin breastfeeding. In 2017 alone, an estimated 78 million newborns had to wait more than one hour to be put to the breast. This means that only about two in five children (42 per cent), the majority born in low- and middle-income countries, were put to the breast within the first hour of life. While this is a slight improvement from 37 per cent in 2005, progress is slow. Early initiation rates vary widely across regions from 35 per cent in the Middle East and North Africa to 65 per cent in Eastern and Southern Africa (see Figure 2). Estimates are not available for any countries in North America or Western Europe (see box 1), highlighting the concerning data gap in many high-income countries. While early initiation rates vary widely across regions, there are no notable differences globally in rates of initiation by the sex of the child, place of residence (rural or urban) or household wealth. <20% 20-39% 40-59% 60-79% 80 No current data No data Country with datafrom 2005-2012 56% 52% 65% 40% 35% 40% 32% 42% Eastern andSouthern Africa Eastern Europeand Central Asia* West andCentral Africa Middle Eastand North Africa* SouthAsia East Asia andthe Pacific Latin America andthe Caribbean* World CAPTURE THE MOMENT: EARLY INITIATION OF BREASTFEEDING 11 <20% 20-39% 40-59% 60-79% 80 No current data No data Country with datafrom 2005-2012 56% 52% 65% 40% 35% 40% 32% 42% Eastern andSouthern Africa Eastern Europeand Central Asia* West andCentral Africa Middle Eastand North Africa* SouthAsia East Asia andthe Pacific Latin America andthe Caribbean* World Globally, only two out of five newborns are put to the breast within the first hour of life Figure 2. Per cent of newborns put to the breast within one hour of birth, by country and region, 2017.Source: UNICEF global databases, 2018. For notes on the data, see Annex 3. BOX 1 Breastfeeding initiation in high-income countries The early initiation of breastfeeding benefits every newborn no matter where they live. Yet many high-income countries are failing to track this important indicator of child nutrition. Globally, rates of early initiation of breastfeeding are tracked using data from household surveys, such as Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS). These large-scale surveys assess initiation rates by asking mothers of children under age 2 whether their youngest child was put to the breast within the first hour of life or later. Many low- and middle-income countries undertake such household surveys every four to five years. While many high-income countries track breastfeeding through hospital registries or other data systems, these data are not collected using standard global indicators (such as breastfeeding initiation within the first hour of life) and are therefore not internationally comparable. While it is not possible to report on early initiation rates for the majority of high-income countries, we can report on the number of children who have never been breastfed. In high-income countries, 21 per cent of children are never breastfed, compared with only 4 per cent of children who are never breastfed in low- and middle-income countries.10 This wide gap means that 2.6 million children in high-income countries are missing out completely on the benefits of breastfeeding. 12 CAPTURE THE MOMENT: EARLY INITIATION OF BREASTFEEDING 13 Globally, the proportion of deliveries assisted by a skilled birth attendant has increased from just over 60 per cent in 2000 to nearly 80 per cent in 2016.12 Despite the potential for skilled birth attendants to support breastfeeding initiation, this is not always the case in practice. UNICEFs 2016 report, From the First Hour of Life, showed that the presence of a medical doctor, nurse or midwife did not support the early initiation of breastfeeding in many low- and middle-income countries. In Europe and Central Asia, for example, where almost all births are attended by skilled providers, only 65 per cent of infants delivered by a skilled health provider began breastfeeding within the first hour of life. And in South Asia, the early initiation rate in the presence of a skilled provider was much lower, at 34 per cent.13 According to findings from a review of the latest data between 2010 and 2017 on birth assistance and the timing of breastfeeding initiation in 74 countries, early initiation rates were found to be somewhat similar whether the newborn was delivered with the support of a skilled or unskilled provider. Only 48 per cent of newborns delivered by a skilled birth attendant and 44 per cent of newborns delivered by an unskilled attendant began breastfeeding within the first hour of birth. These findings tell a story of missed opportunities. There is great potential for skilled birth attendants to support mothers in initiating breastfeeding immediately after birth; but better training and support are needed to help them seize these critical moments. Barriers and missed opportunities Why are newborns missing out on breastfeeding in the first hour of life and what obstacles stand in their way? In some cases, outdated practices in health facilities mean that mothers and babies are separated immediately after birth and support and guidance on optimal breastfeeding is limited. In others, the lack of knowledge about breastfeeding after a caesarean section, or cultural practices that involve feeding newborns supplemental foods or drinks, candelay newborns first critical contact withtheir mother.11 In the context of public health and nutrition programmes, missed opportunities refer to moments where mothers and children fail to receive key life-saving interventions, despite having contact with a health provider. Today, more births take place in health institutions with skilled providers than ever before. Yet, most newborns are still not being put to the breast within the first hour of life. These low global rates of early initiation of breastfeeding are evidence of a massive missed opportunityworldwide. Skilled birth attendants Having a skilled attendant present at birth is crucial for the survival and well-being of mother and baby and a measure of the quality of care received. A mothers contact with skilled providers during pregnancy and delivery can provide her with the support needed to carry out the recommended breastfeeding practices, including initiation of breastfeeding within the first hour after birth. 14 CAPTURE THE MOMENT: EARLY INITIATION OF BREASTFEEDING Figure 3. Trends in per cent of infants put to the breast within one hour of birth, by change in institutional delivery rate, 2005 and 2017. The lines on the bars represent confidence intervals. Source: UNICEF Global databases 2018. For notes on the data, see Annex 3. Institutional deliveries Over the past decade, the global rate of institutional deliveries has been rising, with three quarters of all deliveries (75 per cent) now occurring in health facilities. Institutional deliveries take place in a health facility, such as a maternity clinic or a hospital, and are usually performed under the supervision of a skilled birth attendant, suggesting a certain standard of care. However, supporting mothers to bring babies to the breast is not always a routine intervention after birth, and the increase in institutional deliveries has not always translated into improvements in the rate of early initiation of breastfeeding. In a subset of 58 countries with trend data available for both the place of delivery and the rate of early initiation of breastfeeding, the increase in institutional deliveries (from 53 per cent in 2005 to 71 per cent in 2017) is greater than the rise in early initiation rates over the same period (from 45 per cent to 51 per cent). These figures reflect a missed opportunity to support mothers and newborns in initiating breastfeeding immediately after birth. The only significant improvement in early initiation rates since 2005 can be seen among the group of countries where institutional deliveries increased by more than 20 percentage points (see Figure 3). The rise in breastfeeding initiation rates among this group of countries is primarily driven by low-income countries, where early initiation rates increased by 15 percentage points, compared with an increase of 8 percentage points in lower- middle-income countries. While this increase in early initiation rates is 2017 2005Per cent of newborns put to the breast within one hour of birth Change in institutional delivery rate, 20052017 Minimal/No increase<10 percentage point Moderate increase10 to 19 percentage point Large increase20 percentage point 0 10 20 30 40 50 60Percentage Early initiation rates have only improved significantly among the group of countries with a large increase in institutional deliveries 15 16 CAPTURE THE MOMENT: EARLY INITIATION OF BREASTFEEDING important, the rate of early initiation in countries with rising numbers of institutional deliveries is still discouragingly low, with only half of newborns being put to breast in the first hour of life. The effect of increasing institutional delivery rates on early initiation of breastfeeding depends on national and facility-based policies on the care of mothers and newborns, as well as the skills and commitment of the health professionals working in these facilities. An increase in institutional deliveries can improve early initiation rates when national or facility-based policies emphasize immediate skin-to-skin contact and provide staff trained to support. However, an increase in institutional deliveries can also negatively influence rates of early initiation if staff members are not appropriately trained and facilities maintain outdated policies and practices that create barriers for breastfeeding such as separating newborns and mothers without medical justification or routinely providing liquids or foods to the newborn.14 Caesarean sections Globally, caesarean sections have increased from an average of 13 per cent in 2005 to more than 20 per cent in 2017. All regions have witnessed a large increase in rates of caesarean sections, apart from Sub-Saharan Africa, where rates have remained somewhat unchanged.15 Access to surgical deliveries, where medically needed, is a critical part of ensuring safer deliveries for newborns and their mothers. Yet the rising rates of elective caesarean section worldwide have had consequences on the early initiation of breastfeeding. Several studies show that surgical deliveries can reduce the likelihood of immediate skin-to-skin contact and the early initiation of breastfeeding.16,17,18 In one study, women who ultimately delivered by caesarean section after an unsuccessful trial of labour were more likely to initiate breastfeeding within the first hour after birth than women with a scheduled repeat caesarean section.*,19 An analysis of key factors linked to early initiation rates among babies delivered by a skilled birth attendant showed that the type of delivery can significantly affect when the newborn is put to the breast. Consistently, across all 51 countries studied, early initiation rates among newborns delivered by vaginal birth were more than twice as high as early initiation rates among newborns delivered by caesarean section (see Figure 4). A statistically significant difference was seen in all but 4 of the 51 countries studied. These findings are concerning because immediate skin-to-skin contact and the initiation of breastfeeding are especially important for babies born by caesarean section. The close contact between mother and baby protects newborns with good bacteria from their mothers body a critical step in developing the babys gut health and immune system.20 With a vaginal delivery, this process likely occurs in the birth canal. There is some evidence that immediate or early skin-to-skin contact after a caesarean section can help increase early breastfeeding initiation and decrease the time to the first breastfeed.21 * Repeat caesarean section refers to a caesarean section in a woman whose previous delivery was via caesarean section. MalawiRwanda KyrgyzstanMozambique NamibiaBurundi HondurasMyanmar ZimbabweZambiaTurkeyNiger LesothoTogo CambodiaPeru KenyaLiberiaGhana United Republic of TanzaniaDominican Republic NepalEthiopiaUganda BeninDemocratic Republic of the Congo BangladeshPhilippines YemenTajikistanIndonesia AngolaSierra Leone HaitiGambia IndiaMexico Burkina FasoCameroon AfghanistanNigeria ArmeniaEgypt ComorosGabon Cte d'IvoireSenegal CongoJordan PakistanGuinea Percentage Caesarean sectionVaginal delivery 0 20 40 60 80 100 Figure 4. Per cent of newborns put to the breast within one hour of birth, by type of delivery (vaginal delivery or caesarean section), by country, 2017.Source: UNICEF Global databases 2018. For notes on the data, see Annex 3. In nearly every country, early initiation rates are significantly lower among newborns delivered by caesarean section 17 18 CAPTURE THE MOMENT: EARLY INITIATION OF BREASTFEEDING With the right support, most newborns delivered by caesarean section can be put to the breast within the first hour after birth. However, in practice, women who deliver by caesarean section often face important challenges in initiating breastfeeding, such as managing the effects of anesthesia, recovering from surgery and finding help to hold the baby safely. Key actions to facilitate skin-to-skin contact and initiation of breastfeeding immediately after birth include having an appropriate policy and protocol in the maternity facility, building the skills of staff and involving fathers in breastfeeding support.22 Figure 5. Per cent of newborns put to the breast within one hour of birth, by type of supplemental feeding in the first three days of life, by World Bank country-income grouping, 2017.Source: UNICEF Global databases 2018. For notes on the data, see Annex 3. Breastmilk only Non-milk-based (e.g., water, sugar water, tea, honey) Milk-based (e.g., infant formula, animal milk) 0 10 20 30 40 50 60 70 80 Low-incomecountries Lower-middleincome countries Upper-middleincome countries Allcountries n=18 n=21 n=6 n=45 Perc enta geSupplemental foods or liquids Giving newborns foods or drinks in the first days of life is common in many parts of the world and is often linked to cultural norms, family practices and health system policies and procedures that are not based on scientific evidence. These practices and procedures vary by country and may include discarding colostrum or having an elder family member give the newborn a specific food or liquid, such as honey, or having a health professional routinely give the newborn a specific liquid, such as sugar water or infant formula. These practices can delay a newborns first critical contact with his or her mother.23, 24 ,25 Early initiation rates are nearly twice as high among newborns whoreceive only breastmilk, compared with newborns who receive milk-based supplemental feeds in the first three days of life CAPTURE THE MOMENT: EARLY INITIATION OF BREASTFEEDING 19 Figure 5 shows that among newborns who received milk-based liquids in the first three days after birth, nearly two in three babies waited one hour or longer to be put to the breast. This finding is based on an analysis of 51 countries with available data on the timing of initiation and the receipt of liquids and foods other than breastmilk. Conversely, close to 60 per cent of newborns receiving only breastmilk in their first days of life were put to the breast within the first hour. The rates of early initiation were slightly better among newborns receiving water-based supplementary feeds than among newborns receiving other supplementary feeds, but still significantly lower than among newborns receiving only breastmilk. 20 CAPTURE THE MOMENT: EARLY INITIATION OF BREASTFEEDING 21 programme and policy-related factors that improve the chances of optimal breastfeeding practices, including starting breastfeeding in the first hour of life.27 The analysis found that a combination of interventions had the greatest impact on the early initiation of breastfeeding, leading to a significant 85 per cent increase in rates. These interventions comprised the home and family environment (peer support, one-to-one counselling, home visits or telephone and home support by father or grandparent) and health systems and services (including the BFHI). Access to antenatal care, where mothers are counselled about the initiation of breastfeeding, also has a positive effect on its practice.28, 29, 30, 31 The more antenatal visits and professional antenatal care a mother receives, the greater the probability that she will initiate breastfeeding within the first hour of her childs life. There is a need to better institutionalize the protection, promotion and support of breastfeeding in maternity facilities, particularly in the first days of life. A systematic review of the Baby-friendly Hospital Initiative (BFHI) in 19 countries showed that facilities adherence to the BFHIs Ten Steps to Successful Breastfeeding can increase breastfeeding rates, including theearly initiation of breastfeeding (see box 2). Efforts to avoid supplementing newborns with liquids or foods other than breast milk (step 6) were crucial to successful breastfeeding outcomes. This may be because of the detrimental impact of supplements on breastfeeding success, or because carrying out this step requires other steps to be in place, including having a policy to support breastfeeding and putting the newborn to the mothers breast in the first hour of life.26 Breastfeeding can be challenging to learn, particularly in the first moments after birth. But having the right policies, programmes and people in place provides a strong support network for mothers. A systematic review and meta-analysis conducted in 2015 identified Clearing the path for breastfeeding 22 CAPTURE THE MOMENT: EARLY INITIATION OF BREASTFEEDING The Baby-friendly Hospital Initiative, launched in 1991 and updated in 2018, ensures adequate protection, promotion and support for breastfeeding in facilities providing maternity and newborn care. The BFHIs Ten Steps to Successful Breastfeeding are key to improving the early initiation of breastfeeding and to supporting optimal breastfeeding practices more generally. The updated BFHI guidance emphasizes the importance of integrating the Ten Steps into other initiatives to improve the quality of care around birth and encourages countries to achieve sustainable, universal coverage of breastfeeding interventions. Critical management procedures 1a. Comply fully with the International Code of Marketing of Breast-milk Substitutes and relevant World Health Assembly (WHA) resolutions (the Code). 1b. Have a written infant feeding policy that is routinely communicated to staff and parents. 1c. Establish ongoing monitoring and data management systems. 2. Ensure staff has sufficient knowledge, competence and skills to support breastfeeding. Key clinical practices 3. Discuss the importance and management of breastfeeding with pregnant women and their families. 4. Facilitate immediate and uninterrupted skin-to-skin contact and support mothers to initiate breastfeeding as soon as possible after birth. 5. Support mothers to initiate and maintain breastfeeding and manage common difficulties. 6. Do not provide breastfed newborns any food or fluids other than breast milk, unless medically indicated. 7. Enable mothers and their infants to remain together and to practise rooming-in 24 hours a day. 8. Support mothers to recognize and respond to their infants cues for feeding. 9. Counsel mothers on the drawbacks of feeding bottles, teats and pacifiers. 10. Coordinate discharge so that parents and their infants have timely access to ongoing support and care. BOX 2 The Baby-friendly Hospital Initiative Ten Steps to Successful Breastfeeding(revised 2018) 23 24 CAPTURE THE MOMENT: EARLY INITIATION OF BREASTFEEDING Tracking the performance of breastfeeding programmes at country level provides evidence of successes and challenges in improving the early initiation of breastfeeding. The examples below, drawn from the experiences of UNICEF country offices, offer important learnings for countries. In Cambodia, an increase in the rates of early initiation of breastfeeding from 6 per cent in 1998 to 63 per cent in 2014 appears to be the result of awareness raising and promotional campaigns in communities, along with investments in improved quality of care around the time of delivery. The percentage of deliveries by a skilled birth attendant increased from 44 per cent in 2005 to 89 per cent in 2014, while institutional deliveries increased from 22 per cent to 83 per cent during the same period. Between 2000 and 2010, the use of supplements in the first three days after birth decreased considerably from 93 per cent to 15 per cent in public facilities, from 91 per cent in 2000 to 34 per cent in 2010 in private facilities and from 94 per cent to 21 per cent for home deliveries.32 In the Dominican Republic, while caesarean section rates almost doubled, increasing from 31 per cent in 2002 to 58 per cent in 2014, the rate of early initiation of breastfeeding decreased from 62 per cent to 38 per cent during the same period. Since 2014, the Ministry of Health and its partners have increased support for the Mothers and Newborns in Good Care initiative, which integrates the promotion, protection and support of breastfeeding as a part of the evidence-based interventions to reduce preventable maternal and newborn deaths. Monitoring the BFHI standards and the Code remains a challenge, particularly in private facilities, where about 40 per cent of deliveries take place, and where 86 per cent of deliveries take place via caesarean section. In Egypt, caesarean section rates more than doubled between 2005 and 2014, increasing from 20 per cent to 52 per cent. During the same period, rates of early initiation of breastfeeding decreased from 40 per cent in 2005 to 27 per cent in 2014. While support for the early initiation of breastfeeding is available in facilities implementing the BFHI where staff are trained and practices are monitored, there are many facilities that are not baby-friendly and lack trained staff and adequate monitoringsystems. In Montenegro, standard postdelivery practices include a two-hour observation period during which breastfeeding is not usually initiated. While the rate of caesarean sections increased from 12 per cent in 200733 to 20 per cent in 2013,34 the rates of early initiation of breastfeeding decreased from 25 per cent in 2005 to 14 per cent in 2013.35 Lessons from countries CAPTURE THE MOMENT: EARLY INITIATION OF BREASTFEEDING 25 The government and its partners are currently working to build the capacities of health professionals, with a focus on breastfeeding. The promotion of breastfeeding and baby-friendly hospitals is also done though social media.Plans are underway for a national BFHI programme to be initiated shortly in all maternity wards of the country. In Rwanda, the proportion of deliveries with skilled birth attendants increased from 39 per cent in 2005 to 91 per cent in 2014, with nearly all births in health facilities being assisted by skilled birth attendants. At the same time, the country implemented an intensive and sustained communication campaign on feeding practices, including early initiation of breastfeeding and the BFHI. This resulted in increased awareness about breastfeeding among decision-makers, leaders and communities, and increased investments in building the capacities of community health workers to support breastfeeding. Rwanda now has 45,000 community health workers who counsel mothers about adequate feeding practices and safe deliveries. The rates of early initiation of breastfeeding also increased from 64 per cent in 2005 to 81 per cent in 2014. Between 2010 and 2013, the rate of caesarean sections nearly doubled from 7 per cent to 15 per cent, yet this jump did not impact early initiation. This finding reveals the power of establishing a cadre of well-trained health professionals to support early initiation. In Serbia, there was a steady decline in early initiation rates from 17 per cent in 2005 to just under 8 per cent in 2010. Based on these findings, the government took measures to improve the quality of care around birth and the Ministry of Health and its partners increased support to the BFHI, engaged neonatologists in discussions about improving the BFHI, organized events for pediatricians and other specialists and collaborated with mother support groups. By 2014, the rate of early initiation of breastfeeding had increased to 51 per cent in the country. By 2017, Serbia had integrated the BFHI criteria into its hospital accreditation standards, making the programme more sustainable and easier to scale-up to universal coverage. In Viet Nam, the rate of early initiation of breastfeeding decreased from 44 per cent in 2006 to 27 per cent in 2014, in the context of near universal institutional deliveries (which reached 94 per cent in 2014, while caesarean section rates rose from 10 per cent in 2002 to 28 per cent in 2014). In response, the Ministry of Health approved national Guidelines for essential care of the mother and newborn during and immediately after a caesarean section in November 2016.36 The guidelines emphasize skin-to-skin contact immediately after birth and support for the initiation of breastfeeding within the first hour after birth. 26 CAPTURE THE MOMENT: EARLY INITIATION OF BREASTFEEDING 27 What needs to be done? Too many newborns are not put to the breast in the first hour of life. While access to maternity facilities and skilled birth attendants at delivery have the potential to improve childrens and mothers chances of survival and wellbeing, the quality of care provided is often inadequate and missed opportunities leave far too many newborns waiting for the first critical contact with their mother. The early introduction of supplementary foods and liquids and non-indicated caesarean sections are inappropriate practices that may neglect or disrupt support for the early initiation of breastfeeding. National and facility policies to support breastfeeding around the time of birth are inadequate and the capacities of skilled birth attendants are often insufficient. The following recommendations for action, applicable in development and humanitarian settings, are based on the Global Breastfeeding Collectives framework of key policy actions for improving breastfeeding:37 1) Increase funding to strengthen the protection, promotion and support of breastfeeding programmes, including for interventions impacting the early initiation of breastfeeding. 2) Fully implement the International Code of Marketing of Breast-milk Substitutes and relevant World Health Assembly Resolutions through strong legal measures that are enforced and independently monitored by organizations free from conflicts of interest. This includes monitoring the compliance of health professionals and health facilities. 3) Enhance the quality of care in facilities by establishing policies on immediate skin-to-skin contact and early initiation of breastfeeding after birth as part of national policies on maternal and newborn care, along with other evidence-based recommendations, including those in the WHO/UNICEF Ten Steps to Successful Breastfeeding.38,39, 40,41 Support for the early initiation of breastfeeding should be reflected in all newborn care policies and cover all situations, including caesarean sections and small and pre-term newborns. National policies should discourage the provision of foods or liquids to breastfed newborns in the first days of life, unless such items are needed for medical reasons. Governments and health professionals need to work together to reduce unnecessary caesarean sections through a combination of improved policies and appropriate incentive schemes. Giving all newborns an early start to breastfeeding requires action on the part of multiple actors particularly governments, health care institutions and health care workers. 28 CAPTURE THE MOMENT: EARLY INITIATION OF BREASTFEEDING Support for skin-to-skin contact and early initiation of breastfeeding should be integrated into the pre-service training of health care workers, including those targeting physicians, nurses, midwives and other birth attendants. In-service capacity building to bridge knowledge and skills gaps needs to be supported where needed. 4) Improve access to skilled breastfeeding counselling for all mothers, wherever they deliver their babies. Health professionals should prepare and counsel women undergoing a caesarean section on initiating breastfeeding. 5) Strengthen links between health facilities and communities, and encourage community networks that protect, promote and support breastfeeding. Through behaviour change strategies, encourage mothers and families to demand support for the early initiation of breastfeeding from birth attendants through behavioural change communication strategies. Establish and support social accountability systems in which mothers and families can provide feedback about the quality of care and hold providers accountable. 6) Develop monitoring systems that track the progress of policies, programmes and funding towards improving early initiation of breastfeeding. This includes both ensuring the availability of country level data on early initiation of breastfeeding and data on enabling factors, such as the number of maternity facilities implementing the Ten Steps. Facilities should monitor their own practices in this area as part of quality improvement approach. Support for improving the early initiation of breastfeeding is a life-saving intervention, with the power to protect newborns when they are most vulnerable. Mothers and newborns who get an early start to breastfeeding are more likely to continue breastfeeding, paving the way for a successful breastfeeding relationship throughout the critical first years of a childslife. Governments, policy makers and health providers must together do much more to protect, promote and support the early initiation of breastfeeding. By strengthening the capacities of health workers, adopting protective policies and making mothers and newborns a priority, we can capture the moment and give every newborn the best startto life. Annexes 30 CAPTURE THE MOMENT: EARLY INITIATION OF BREASTFEEDING Perc enta ge Countries where prevalence ofearly intiation has gone up Countries where prevalence ofearly intiation has gone down 68.7 36.6 53.0 41.6 50.8 21.117.5 19.6 60.5 38.1 44.0 26.5 37.2 18.6 25.0 14.4 0 10 20 30 40 50 60 70 Baseline estimate Latest estimate MontenegroJordanViet NamDominicanRepublic BurkinaFaso SerbiaBelarusGeorgia ANNEX 1.Countries with largest changes in prevalence of early initiation of breastfeeding between 2005 and 2017 Trends in per cent of newborns put to the breast within one hour of birth, by country, around 2005 and around 2017.Source: UNICEF Global databases 2018. For notes on the data, see Annex 3. CAPTURE THE MOMENT: EARLY INITIATION OF BREASTFEEDING 31 Countries and territoriesLatest estimatei Baseline estimate for trend ii Trendiii CategoryYear Early initiation of breastfeeding (%) Rank iv Year Early initiation of breastfeeding (%) Afghanistan 2015 40.9 57 Albania 2008 43.4 Algeria 2012 35.7 2006 49.5 Andorra no data Angola 2015 48.3 50 2007 54.9 Anguilla no data Antigua and Barbuda no data Argentina 2011 52.7 Armenia 2015 40.9 58 2005 32.2 Australia no data Austria no data Azerbaijan 2013 19.7 74 2006 30.7 Bahamas no data Legend for categories: Increase: 8 percentage point increase Minimal/no change: <8 percentage point change Decrease: 8 percentage point decrease ANNEX 2.Overview of early initiation of breastfeeding rates by country i Latest estimate refers to the most recent estimate from 2000 onwards availale in the UNICEF global database. Regional aggregates and rank were based on countries with recent estimates (2013-2018) only. Trends were presented if a baseline point between 2003 and 2008 was available in addition to a recent (2012-2018) estimate. ii A baseline estimate is presented if the latest estimate was between 2012 and 2018 and if a point between 2003 and 2008 was also available; else blank. iii Trends are presented for a subset of 77 countries with a recent (2012-2018) latest estimate and where a baseline (2003-2008) was also available. iv Rank based on a subset of 76 countries with recent (2013-2018) data. 32 CAPTURE THE MOMENT: EARLY INITIATION OF BREASTFEEDING Countries and territoriesLatest estimatei Baseline estimate for trend ii Trendiii CategoryYear Early initiation of breastfeeding (%) Rank iv Year Early initiation of breastfeeding (%) Bahrain no data Bangladesh 2014 50.8 43 2006 35.6 Barbados 2012 40.3 Belarus 2012 53.0 2005 21.1 Belgium no data Belize 2015 68.3 20 2006 50.4 Benin 2014 46.6 53 2006 54.1 Bhutan 2015 77.9 9 Bolivia (Plurinational State of) 2016 55.0 33 2008 62.8 Bosnia and Herzegovina 2011 42.3 Botswana 2007 40.0 Brazil 2006 42.9 British Virgin Islands no data Brunei Darussalam no data Bulgaria no data Burkina Faso 2014 41.6 55 2006 19.6 Burundi 2016 85.0 3 Cabo Verde 2005 72.7 Cambodia 2014 62.6 26 2005 35.5 Cameroon 2014 31.2 67 2006 19.6 Canada no data Central African Republic 2010 43.5 Chad 2014 23.0 73 2004 32.4 Chile no data China 2013 26.4 71 2008 41.0 Colombia 2009 63.4 CAPTURE THE MOMENT: EARLY INITIATION OF BREASTFEEDING 33 Countries and territoriesLatest estimatei Baseline estimate for trend ii Trendiii CategoryYear Early initiation of breastfeeding (%) Rank iv Year Early initiation of breastfeeding (%) Comoros 2012 33.7 Congo 2014 25.3 72 2005 34.4 Cook Islands no data Costa Rica 2011 59.6 Cte dIvoire 2016 36.6 63 2006 24.9 Croatia no data Cuba 2014 47.9 51 2006 70.2 Cyprus no data Czechia no data Democratic Peoples Republic of Korea 2012 28.1 Democratic Republic of the Congo 2013 51.9 39 2007 48.0 Denmark no data Djibouti 2012 52.0 Dominica no data Dominican Republic 2014 38.1 62 2007 60.5 Ecuador 2012 54.6 Egypt 2014 27.1 69 2005 40.1 El Salvador 2014 42.0 54 2008 32.8 Equatorial Guinea no data Eritrea 2010 93.1 Estonia no data Eswatini 2014 48.3 49 2006 59.1 Ethiopia 2016 73.3 14 2005 66.2 Fiji 2004 57.3 Finland no data France no data Gabon 2012 32.3 34 CAPTURE THE MOMENT: EARLY INITIATION OF BREASTFEEDING Countries and territoriesLatest estimatei Baseline estimate for trend ii Trendiii CategoryYear Early initiation of breastfeeding (%) Rank iv Year Early initiation of breastfeeding (%) Gambia 2013 51.5 40 2005 47.7 Georgia 2012 68.7 2005 36.6 Germany no data Ghana 2014 55.6 32 2006 35.2 Greece no data Grenada no data Guatemala 2014 63.1 25 2008 55.5 Guinea 2016 33.9 64 2005 37.9 Guinea-Bissau 2014 33.7 65 2006 22.6 Guyana 2014 49.2 48 2006 43.1 Haiti 2012 46.7 2005 42.9 Holy See no data Honduras 2011 63.8 Hungary no data Iceland no data India 2015 41.5 56 2005 23.1 Indonesia 2012 49.3 2007 40.2 Iran (Islamic Republic of) 2010 68.7 Iraq 2011 42.8 Ireland no data Israel no data Italy no data Jamaica 2011 64.7 Japan no data Jordan 2012 18.6 2007 37.2 Kazakhstan 2015 83.3 4 2006 64.2 Kenya 2014 62.2 27 2003 49.6 CAPTURE THE MOMENT: EARLY INITIATION OF BREASTFEEDING 35 Countries and territoriesLatest estimatei Baseline estimate for trend ii Trendiii CategoryYear Early initiation of breastfeeding (%) Rank iv Year Early initiation of breastfeeding (%) Kiribati no data Kuwait no data Kyrgyzstan 2014 82.5 5 2005 64.7 Lao Peoples Democratic Republic 2011 39.1 Latvia no data Lebanon 2004 41.3 Lesotho 2014 65.3 24 2004 56.8 Liberia 2013 61.2 29 2006 66.2 Libya no data Liechtenstein no data Lithuania no data Luxembourg no data Madagascar 2012 65.8 2003 60.6 Malawi 2015 76.2 11 2006 58.3 Malaysia no data Maldives 2009 60.5 Mali 2015 53.2 37 2006 44.4 Malta no data Marshall Islands 2007 72.5 Mauritania 2015 61.8 28 2007 44.3 Mauritius no data Mexico 2015 51.0 42 Micronesia (Federated States of) no data Monaco no data Mongolia 2013 71.1 16 2005 77.5 Montenegro 2013 14.4 76 2005 25.0 Montserrat no data 36 CAPTURE THE MOMENT: EARLY INITIATION OF BREASTFEEDING Countries and territoriesLatest estimatei Baseline estimate for trend ii Trendiii CategoryYear Early initiation of breastfeeding (%) Rank iv Year Early initiation of breastfeeding (%) Morocco 2010 26.8 Mozambique 2013 69.0 18 2003 63.8 Myanmar 2015 66.8 21 Namibia 2013 71.2 15 2006 67.3 Nauru 2007 76.4 Nepal 2016 54.9 34 2006 35.5 Netherlands no data New Zealand no data Nicaragua 2011 54.4 Niger 2012 52.9 2006 46.6 Nigeria 2016 32.8 66 2007 29.9 Niue no data Norway no data Oman 2014 71.1 17 Pakistan 2013 18.0 75 2006 25.9 Palau no data Panama 2013 47.0 52 Papua New Guinea no data Paraguay 2016 49.5 47 2008 47.1 Peru 2016 54.8 35 2003 47.4 Philippines 2013 49.7 46 2003 46.0 Poland no data Portugal no data Qatar 2012 33.5 Republic of Korea no data Republic of Moldova 2012 60.9 2005 66.6 Romania 2004 57.7 CAPTURE THE MOMENT: EARLY INITIATION OF BREASTFEEDING 37 Countries and territoriesLatest estimatei Baseline estimate for trend ii Trendiii CategoryYear Early initiation of breastfeeding (%) Rank iv Year Early initiation of breastfeeding (%) Russian Federation 2011 25.0 Rwanda 2014 80.5 7 2005 63.9 Saint Kitts and Nevis no data Saint Lucia 2012 49.6 Saint Vincent and the Grenadines no data Samoa 2014 81.4 6 San Marino no data Sao Tome and Principe 2014 38.3 61 2006 35.3 Saudi Arabia no data Senegal 2016 29.4 68 2005 22.6 Serbia 2014 50.8 44 2005 17.5 Seychelles no data Sierra Leone 2013 53.8 36 2005 33.1 Singapore no data Slovakia no data Slovenia no data Solomon Islands 2015 78.9 8 2006 75.0 Somalia 2009 23.4 South Africa 2003 61.1 South Sudan 2010 50.5 Spain no data Sri Lanka 2016 90.3 1 2006 79.9 State of Palestine 2014 40.8 59 2006 64.6 Sudan 2014 68.7 19 Suriname 2010 44.7 Sweden no data Switzerland no data 38 CAPTURE THE MOMENT: EARLY INITIATION OF BREASTFEEDING Countries and territoriesLatest estimatei Baseline estimate for trend ii Trendiii CategoryYear Early initiation of breastfeeding (%) Rank iv Year Early initiation of breastfeeding (%) Syrian Arab Republic 2009 45.5 Tajikistan 2012 49.6 2005 60.9 Thailand 2015 39.9 60 2005 49.6The former Yugoslav Republic of Macedonia 2011 21.0 Timor-Leste 2016 75.2 12 2003 46.9 Togo 2013 60.6 30 2006 35.8 Tokelau no data Tonga 2012 79.1 Trinidad and Tobago 2006 41.2 Tunisia 2011 39.9 Turkey 2013 49.9 45 2003 52.3 Turkmenistan 2015 73.4 13 2006 59.8 Turks and Caicos Islands no data Tuvalu 2007 15.0 Uganda 2016 66.1 22 2006 41.8 Ukraine 2012 65.7 2005 35.9 United Arab Emirates no data United Kingdom no data United Republic of Tanzania 2015 51.3 41 2004 57.6 United States no data Uruguay 2013 76.5 10 Uzbekistan 2006 67.1 Vanuatu 2013 85.4 2 2007 71.9 Venezuela (Bolivarian Republic of) no data Viet Nam 2013 26.5 70 2006 44.0 Yemen 2013 52.7 38 2006 29.6 Zambia 2013 65.8 23 2007 55.6 Zimbabwe 2015 57.6 31 2005 68.2 CAPTURE THE MOMENT: EARLY INITIATION OF BREASTFEEDING 39 ANNEX 3.Notes on the data A. General Notes A.1 Early Initiation of Breastfeeding: Indicator DefinitionNumerator:

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