1. March 2017

2. Rafael Pérez-Escamilla, PhD Katie Doucet
Professor of Epidemiology & Public Health, Yale School of Public Health
Katie Doucet
Research Coordinator, Yale School of Public Health
Project funding provided by: Yale University with an unrestricted grant from
The Family Larsson-Rosenquist Foundation

3. Becoming Breastfeeding Friendly
Introduction
Project Vision & values
BBF Framework: Themes and Gears
BBF index
BBF process
Maternal-child health session in Maikunkele village, Nigeria. © 2013 Adrian Brooks, Courtesy of Photoshare

4. Introduction
Breastfeeding has proven, natural benefits to mother and child
Exclusively breastfed child 14 times less likely to die in the first 6 months than a non-breastfed child
Prevalence of breastfeeding is low globally (Lancet, 2016)
37% of children < 6 months in LMIC exclusively breastfed
58% of children between months in LMIC still breastfed
Scaling up breastfeeding universally can prevent over 800,000 deaths among children < 5 years (Lancet, 2016)

5. BBF Project Vision
Create an evidence-based measurement and toolbox to help guide development and tracking of large-scale, well-coordinated, multi-sector, national breastfeeding promotion programmes
BBF will not only assess and measure, but also support countries to scale- up breastfeeding programmes through step-by-step evidence-based criteria

6. BBF Project Vision
Empower countries to assess their current readiness for scale-up
Identify key areas for improvement
Act upon them using an evidence-based approach
Monitor progress of scaling-up breastfeeding protection, promotion and support programmes

7. BBF values Country capacity building In-country support
Professional development opportunities at Yale
Country data ownership without restrictions
Decision making
Conference presentations & publications

8. BBF Framework: Breastfeeding Gear Model
The Breastfeeding Gear Model (BFGM)a: robust framework serves as foundation for BBF
BFGM: eight ‘gears’ at work and in harmony for large-scale improvement in a country’s national breastfeeding program
Evidence-based ‘Becoming Breastfeeding Friendly Index’ (BBFI) consists of these eight gears
a Pérez-Escamilla et al. Adv Nutr 2012

9. BBF Index BBFI developed by Technical Advisory Group (TAG):
UNICEF- New York: France Begin
WHO- Geneva- Larry Grummer-Strawn
Gates Foundation- Ellen Piwoz
Alive & Thrive- Nemat Hajeebhoy (replaced by Roger Mathisen)
PAHO- Chessa Lutter
WHO Consultant- Rukhsana Haider
GAIN- Alison Tumilowicz
The Manoff Group – Marcia Griffiths
Academic scholars from Mexico, Ghana, UK, Brazil, Canada, US

10. BBF Index: Themes and Gears
Measures presence and degree of advocacy to protect, promote, and support breastfeeding scaling-up efforts:
Public attention (1 benchmark)
Individual and group champions (1 benchmark)
Social Cohesion/Mobilization (2 benchmarks)

11. BBF Index: Themes and Gears
Evaluates level of expressed commitment policymakers have made towards scaling-up breastfeeding:
Expressed commitment (3 Benchmarks)

12. BBF Index: Themes and Gears
Assesses adoption and quality of key breastfeeding legislation and policies (including maternity laws)
Assesses integration into health care system
Addresses enforcement of breastfeeding legislation and policies:
National Breastfeeding Policy
(2 benchmarks)
BFHI/Ten Steps (1 benchmark)
International Code of Marketing of
Breastmilk Substitutes (2 benchmarks)
National Maternity Protection Legislation (5 benchmarks)

13. BBF Index: Themes and Gears
Measure budgetary and human resources commitment, including adequacy of resources to achieve breastfeeding targets:
Government budgetary commitment (4 benchmarks)

14. BBF Index: Themes and Gears
TRAINING: Measure presence, quality, and adequacy of curriculum, ensuring coverage of essential breastfeeding topics:
Pre-service training for health care providers (1 benchmark)
In-service training for facility-based health care providers (2 benchmarks)
In-service training for community-based health care providers (2 benchmarks)
In-service training for community health workers (2 benchmarks)
Train the trainers (1 benchmark)
Coordination and integration of breastfeeding training programs (2 benchmarks)
PROGRAM DELIVERY: Assesses existence and quality of BF promotion programs and coverage and integration with other existing health programs:
Facility-based delivery (5 benchmarks)
Community-based delivery (1 benchmark)
Supervision (1 benchmark)

15. BBF Index: Themes and Gears
Measures existence, quality and coverage of national promotion strategy and actions undertaken by either government or civic societies to raise awareness:
National Breastfeeding Promotion Strategy (2 benchmarks)
Government or civic breastfeeding promotion (1 benchmark)

16. BBF Index: Themes and Gears
Evaluates presence, quality, and adequacy of a multi-level Monitoring & Evaluation system that decision makers use to direct investments into breastfeeding programmes efficiently:
BF Outcomes (5 benchmarks)
Monitoring Process Indicators (5 benchmarks)

17. BBF Index: Themes and Gears
Evaluates presence, quality, and adequacy of coordination system, including use of data in decision making and advocacy:
Breastfeeding Committee (3 benchmarks)

18. BBF Scoring BBFI Metric scoring process Benchmarks Individual gears
Final overall score
Consensus must be reached on each benchmark score before recording

19. Moderate Gear Strength
BBF Scoring
Gear scores show strength of each gear to enable scaling up
Gear Total Score
Interpretation
Gear not present
0.1 to 1.0
Weak Gear Strength
1.1 to 2.0
Moderate Gear Strength
2.1 to 3.0
Strong Gear Strength

20. MEXICO BBF RESULTS Mexico final score: 1.44 - Moderate Environment
Advocacy
"Civil society organizations have the ability to position the subject on the political agenda, as well as to activate the decision-makers for the development of actions and policies in relation to breastfeeding".
MEXICO BBF RESULTS
Coordination and Monitoring
"For a national policy on breastfeeding, it is necessary to have a strategic framework that includes an actor who has the capacity to follow the lines of action and who has the capacity to make informed decisions."
Political Will
"Keeping breastfeeding on the public agenda requires the sustained support of high-level public officials."
Research and Evaluation
"Any health system that intends to make decisions on breastfeeding, based on scientific evidence and valid information from the relevant groups, should have comprehensive surveys and information systems"
Legislation and Policies
"Regulatory instruments should limit the interests of other sectors that may put the protection, promotion and support of breastfeeding at risk."
Promotion
"It is necessary to have strategies of promotion, protection and support of the breastfeeding, articulated by the government, that reach the entire population."
Funding and Resources
"To plan short-term and long-term training , promotion, research, monitoring and evaluation of the protection, promotion and support of breastfeeding, it is necessary to have financial and human resources labeled for this purpose”
Training
"Breastfeeding policies and actions require trained personnel who can implement them”

21. BBF: Current Developments
Phase III: rolling out
Manual and technical information
Website
Studies