Rafael Pérez-Escamilla, Prof, PhD
Expected Learning Outcomes
Definition of scaling-up breastfeeding programmes
Essential components for success in breastfeeding programmes scale-up
The importance of implementation science initiatives to enable scaling-up breastfeeding promotion, protection and support programmes
Infant and Young Child Feeding (IYCF) practices have a great impact on the nutrition status of children under two years of age as well as on their risk for infectious diseases and mortality . The World Health Organization (WHO) recommends breastfeeding to be initiated within one hour after birth, to be practiced exclusively for the first six months of life followed by the introduction of safe nutritious complementary foods, and to continue breastfeeding until the child is at least two years old . These WHO guidelines are backed by a robust body of evidence indicating that optimal breastfeeding behaviours are strongly associated with lower incidence of gastrointestinal and respiratory tract infections as well as with child survival . Furthermore, breastfeeding may protect children against otitis media , malocclusions , dental caries , obesity and type 2 diabetes  and has been consistently associated with improved cognitive development . Benefits of breastfeeding to the mother include prolonged lactational amenorrhea and a reduced risk of postpartum haemorrhage, ovarian and breast cancer, and type 2 diabetes . Thus, it is not surprising that the WHO Global Strategy on Infant and Young Child Nutrition specifically calls for strong government commitment to protecting, promoting, and supporting breastfeeding , and continues to be firmly endorsed by public health authorities. Indeed, the 2015–2030 Sustainable Development Goals identify increasing the prevalence of exclusive breastfeeding (EBF) in the first six months to at least 50% as a key global nutrition target .
Even though the goal to improve the rates of EBF for six months has been in place for almost 15 years globally, and has been strongly endorsed by international organisations and governments worldwide, less than 40% of infants younger than six months are exclusively breastfed, with wider variation within than across world regions (▶Fig. 22.1). Based on nationally representative surveys collected between 2008 and 2014, EBF prevalence among children younger than six months ranges from 27% in West and Central Africa to 56% in Eastern and Southern Africa .
The variation in EBF prevalence across countries is indeed remarkable; survey data collected between 2000 and 2014 in 128 countries indicates that at a country level EBF rates vary widely, from 1% in Djibouti to 87% in Rwanda . Thus, an important question is why is there so much global variability in EBF practice across countries? Is it because we simply don’t have the know-how on what is needed to support EBF effectively? Or are there major bottle necks preventing the translation of scientific knowledge into practice? , .
The lack of progress at increasing EBF rates globally to the recommended levels is perplexing as evidence-based hospital and community-based initiatives that have been shown to be efficacious at improving EBF have been in place for decades, and case studies in a few countries have shown major improvements in EBF rates relatively soon after those initiatives are scaled-up , , . Although some have attributed this lack of progress simply to lack of political will, it has recently become increasingly clear that the answer is much more complicated due to the numerous interrelated factors that need to interact in complex ways to make EBF scaling-up efforts successful , .
The objective of this chapter is to identify the key components that countries need to have in place for effectively scaling-up their EBF programmes. This has important implications for maternal-child health and wellbeing globally. Improving EBF rates has been estimated to save millions of lives and dollars , , , . Colchero, et al. recently estimated the costs in Mexico of inadequate breastfeeding associated with paediatric respiratory infections, otitis media, gastroenteritis, necrotising enterocolitis (NEC), and sudden infant death syndrome (SIDS) to range between US $745.6 million and US$2.4 billion, with the costs of infant formula accounting for 11–38% of the total costs . The economic costs of inadequate breastfeeding were estimated based on the direct health care costs associated with the increased risk of disease when infants under 6 months are nonEBF or are not breastfed from ages 6 to under 11 months, lost future earnings due to premature infant death, and the costs of purchasing infant formula. The annual number of disease cases attributed to inadequate infant breastfeeding practices ranged from 1.1 to 3.8 million and the number of infant deaths from 933 to 5796 per year, altogether representing nearly 27% of the absolute number of episodes of the diseases examined .
Bartick & Reinhold recently estimated that if 90% of families in the United States were to comply with recommendations to breastfeed exclusively for 6 months, savings to the United States would amount to $13 billion per year and prevent an excess 911 deaths, the vast majority being infants . The authors based their cost estimates on NEC, otitis media, gastroenteritis, hospitalisation for lower respiratory tract infections, atopic dermatitis, SIDS, childhood asthma, childhood leukaemia, type 1 diabetes mellitus, and childhood obesity . Bartick, et al. also recently estimated the cost of suboptimal breastfeeding in the United States with regard to suboptimal maternal health . At current breastfeeding rates in the United States, their analysis indicated that suboptimal breastfeeding resulted in 4,981 excess cases of breast cancer, 53,847 cases of hypertension, and 13,946 cases of myocardial infarction compared with women who optimally breastfed. Additionally, suboptimal breastfeeding incurred a total cost of $17.4 billion to society resulting from premature death (95% confidence interval [CI], $4.4– 24.7 billion), $733.7 million in direct costs (95% CI, $612.9–859.7 million), and $126.1 million in indirect morbidity costs (95% CI, $99.00–153.22 million) .
Given the urgency to address the global suboptimal prevalence of EBF and that we do have the know-how about how best to support women EBF , the primary objective of this chapter is to present the required key elements for the successful scaling-up of breastfeeding programmes. The chapter introduces and defines key concepts and frameworks, followed by specific descriptions of key components identified as essential for successful scaling-up. The chapter then presents approaches and tools available for policy makers to guide their scaling-up efforts and concludes with reflections on the required improvements in policy tools and future directions for the field.
There is strong international consensus that global scaling-up of breastfeeding protection, promotion, and support should be guided by the principles outlined in the Global Strategy for Infant and Young Child Feeding (IYCF) . The Global Strategy is based on nine operational targets related to both breastfeeding and complementary feeding. The first four are drawn from the operational targets of the 1990 Innocenti Declaration on the Protection, Promotion, and Support of Breastfeeding . The principles outlined in this declaration are very relevant as they were adopted by the World Health Assembly (WHA) in 1991 through resolution WHA44.33 as “a basis for international health policy and action” regarding the implementation of recommended IYCF practices. These four principles directly address scaling-up of national breastfeeding programmes as they call for:
Appointing a national breastfeeding coordinator and establishing a multi-sectoral national breastfeeding committee
Ensuring that every facility providing maternity services fully practices all the “Ten steps to successful breastfeeding”
Implementation and enforcement of the International Code of Marketing of Breast-milk Substitutes (the WHO Code) 
Enacting legislation to protect the breastfeeding rights of working women
The second set of five indicators of the Global Strategy addresses issues relates to both breastfeeding and complementary feeding, including actions needed for addressing the special needs of highly vulnerable children and their families (e.g., those affected by human immunodeficiency virus and humanitarian emergencies). The principles underlying these five indicators call for:
Developing, implementing, monitoring, and evaluating a comprehensive policy on infant and young child feeding
Ensuring that the health and other relevant sectors protect, promote, and support EBF for 6 months and continued breastfeeding up to 2 years of age or beyond
Promoting timely, adequate, safe, and appropriate complementary feeding with continued breastfeeding
Providing guidance on feeding infants and young children in exceptionally difficult circumstances and
Considering new legislation or other measures to operationalise the principles and aim of the WHO Code
Relevant to this chapter it is important to underscore that the Innocenti Declaration also called upon international organisations to:
Draw up action strategies for protecting, promoting, and supporting breastfeeding, including global monitoring and evaluation of their strategies
Support national situation analyses and surveys and the development of national goals and targets for action
Encourage and support national authorities in planning, implementing, monitoring, and evaluating their breastfeeding policies 
These recommended actions have been proven over time indeed to be key for the successful scaling-up of breastfeeding programmes, although the focus has now shifted more for countries to establish ownership of these and not rely so much on foreign assistance to conduct them .
The global experience unequivocally indicates that optimal breastfeeding practices are the result of strong coordination between breastfeeding protection, promotion, and support activities , , , , . Protection refers to policies that allow women to exercise their right to breastfeed their infants if they chose to do so. Protection policies include enforcing the WHO Code for the Ethical Marketing of Breast Milk Substitutes , adequate paid maternity leave legislation, nursing breaks during work hours  and protection against harassment while nursing in public spaces. Promotion refers to activities undertaken to foster or “sell” the benefits of breastfeeding through social marketing approaches including World Breastfeeding Week, the use of mass media including social media outlets (e.g., Facebook, Twitter, Web blogs), and behaviour change communication campaigns . Support is a term used to describe actions taken to empower women to implement their decision to breastfeed. Support is needed across multiple domains including qualified lactation management as well as family and other sources of social support .
Scaling-up of effective health interventions was a central theme for the Millennium Development Goals and it has now become even more central to the successful achievement of the Sustainable Development Goals agenda. From the health sector perspective, la raison d’être of scaling-up is for benefits resulting from new technologies and innovations to have a major and rapid impact at improving health on a large scale . Although there isn’t a single consensus definition of “scaling-up”, a central theme to this concept is the expansion of access of quality programmes to large segments of the target population(s). Scaling-up has several dimensions, including programme demand and supply as well as impacts . Scaling requires strong intention, guided by a strategic plan behind the type of scaling-up being sought, including expansion or replication of a programme into other geographical areas or target populations (i.e., horizontal scaling-up); policy, political, legal or institutional scaling-up that occurs when governments make the decision to implement a programme at the national or subnational level (vertical scaling-up); and/or diversification to add evidence based components to existing scaled-up “packages” (functional scaling-up) . Sustainability of scaled-up programmes is usually the result of successful integration of vertical and horizontal scaling-up processes with the capacity to incorporate diversification or adaptation as needed.
Here we define scaling-up as “a process aimed at maximising the reach and effectiveness of a range of actions, leading to sustained impact on outcomes”, as recently proposed by Gillespie, et al. in the field of nutrition . Based on a peer reviewed and grey literature review, Gillespie, et al.  identified nine elements that are central to successful scaling-up of nutrition programmes:
Having a clear vision or goal for impact
An enabling organisational context for scaling up
Establishing drivers such as catalysts, champions, system-wide ownership, and incentives
Choosing contextually relevant strategies and pathways for scaling-up
Building operational and strategic capacities
Ensuring adequacy, stability, and flexibility of financing
Ensuring adequate governance structures and systems
Embedding mechanisms for monitoring, learning, and accountability
Having a clear goal for impact calls for having clarity from the beginning as to what type and level of impact is expected, accompanied by appropriate metrics and a compelling justification of why the impact goal is important and how it can be achieved. The intervention characteristics element calls for stakeholders to have clarity on what exactly is to be scaled up to achieve large-scale impact; for example, this could be a technology, a process, and/or an innovative approach . Scaling-up impact requires an enabling environment in the context of where the scaling-up process is to take place. The enabling environment is strongly driven by political and policy factors and structural factors specific to health care and community organisation systems. Launching and sustaining a successful scaling-up agenda requires the presence of champions, identifying the right mix of incentives, having a strong governance structure, and local ownership of the scaled-up programme.
A sound scaling-up strategy is needed to operationalise clearly what will be scaled-up and how. This key element is crucial for identifying adequate context specific pathways and corresponding processes to be followed to attain sustained high coverage and quality implementation of the programme or intervention being scaled-up. Building operational and strategic capacities is needed for successful scaling-up to occur. The type of capacities needed are multi-level (individual, organisational, systemic) and include the capacity to plan, implement, and sustain the scaling-up process . Attaining these capacities requires stable financial commitment. According to Gillespie, et al., ‘the governance of scaling-up encompasses the structures and systems that underpin and support all stages of the scale-up process’ . Governance goes to the heart of the decision-making process as well as of the oversight and accountability of the resources being used for scaling-up. Governance requires a good understanding of the intersection between vertical (from national to local level) and horizontal (inter-sectoral coordination) governance structures. Finally, sound monitoring and evaluation systems are needed to steer the scaling-up process in the right direction and for the scaled-up programme or intervention to become sustainable with regards to high levels of coverage and quality.
According to the USA National Institutes of Health (NIH) implementation science is ‘the study of methods to promote the integration of research findings and evidence into healthcare policy and practice’ . A key goal of implementation science research is to identify and address major bottlenecks (e.g., social, behavioural, economic management) that prevent effective implementation of programmes in the “real world”. A second key goal of implementation science is to find out whether the programmes being implemented are having the intended impact or not and why . To achieve this goal, implementation science also seeks to understand the behaviour of healthcare professionals and other stakeholders to understand the sustainable uptake, adoption, and implementation of evidence-based interventions .
A recent major development in the field of nutrition is the increasing recognition that implementation science research can benefit greatly from the Complex Adaptive Systems (CAS) framework developed over the years by researchers of health care systems and defined as a “multi-disciplinary approach to understanding the behaviour of diverse, interconnected agents and processes from a system-wide perspective” . The CAS health framework is well suited for guiding scaling-up of breastfeeding programmes as it is based on multi-disciplinary approaches to understanding the behaviour of diverse, interconnected agents, and processes from a non-linear system wide perspective , , . The CAS framework acknowledges that programmes are formed by many moving parts that have the capacity to self-organise and adapt as required by circumstances and learning by experience , . CAS constructs include feedback loops, emergent behaviour, interdependence, scale-free networks, and path dependence, all of which can help understand the sustainability of implementation of programmes implemented at scale (▶Fig. 22.2).
Feedback loops occur when an output of a process within the system is fed back as an input into the same system. For example, a central feature of successful national breastfeeding programmes is their ability to coordinate hospital-based with community-based efforts with both serving as referral and counter-referral systems . Indeed, randomised controlled trials conducted in Brazil and Belarus have shown that strong implementation of step 10 of the Baby Friendly Hospital Initiative (BFHI), which represents the link between facility and community efforts, is crucial for sustaining positive breastfeeding impacts in the long term. The concept of Scale-free Networks refers to structures that are dominated by a few focal points or hubs with an unlimited number of links, following a power-law distribution (▶Fig. 22.2).
Social network analysis is a powerful tool that can be used to model the “contagion” of health-related behaviours . Breastfeeding “contagion” may be strongly facilitated through the endorsement of highly visible individuals or role models that others seek to emulate. For example, successful breastfeeding mass media campaigns have often featured famous actresses, sports stars, or other celebrities. Obstetricians and paediatricians have also been very influential forces behind successful national breastfeeding programmes.
Phase transitions occur when radical changes take place in the features of system parameters as they reach certain critical or tipping points (▶Fig. 22.2). For example, it took several years after it started for the Brazilian National Breastfeeding Programme to detect substantive impacts in breastfeeding behaviours. In this instance, the initial foundation years involved strong evidence based advocacy efforts to create the right conditions for the programme to emerge. The construct of Path Dependence indicates that processes that have similar starting points may end up leading to different outcomes because of bifurcations and choices made along the way (▶Fig. 22.2). Path dependence explains why national breastfeeding programmes need to be adapted to the local contexts.
Emergent behaviour refers to the spontaneous creation of order from “chaos”, which appears when smaller entities on their own jointly contribute to organised behaviours as a collective. The global experience indicates that successful scalingup emerges from the coming together of key actors and processes at the right time and place following a “perfect storm”-like scenario .
The Assessing, Innovating, Developing, Engaging and Devolving (AIDED) framework is an example of a CAS scaling-up framework recently developed for understanding how best to scale-up family health interventions including breastfeeding . AIDED involves five key steps involving assessment, design and package of an innovation, and development of strategy, where it is crucial to identify resistance to scaling-up effort, engage key stakeholders, and to devolve to a sustainable position. AIDED is non-linear, comprises multiple feedback loops, and allows for countries to begin the process of scaling-up at different starting points (▶Fig. 22.3).
Assessing the landscape involves obtaining a precise understanding of the receptivity of the user groups and of the environmental context of the user groups for programme implementation. It also involves examining environmental factors that may facilitate or prevent up-take of the programme.
Innovating to fit with user receptivity involves adapting the programme to local context and preferences so that receptive users would perceive the programme as being beneficial in their specific context. Adaptation assumes that it is feasible to make changes to the design and packaging of the programme to meet the needs of the local context.
Developing support refers to sensitising the environment to be supportive of increased use of the programme. Developing support involves enhancing education as well as identifying and addressing resistance to the innovation. Legal and regulatory actions as well as economic incentives are important for fostering an enabling environment.
Engaging with user groups needs to occur throughout the scale-up process and involves several key steps: (1) introduction of the innovation from outside the user group to inside the user group via boundary spanners; (2) translation of the innovation so that user groups could assimilate the new information; and (3) integration of the innovation into the routine practices and social norms of the user group. Introduction of the innovation, the first part of the engage component, refers to giving information about the innovation to the user group.
Devolving efforts for spreading the innovation is based on user groups releasing and spreading the innovation for its re-introduction in new user groups within their peer networks so that the spread and scaling-up of the programme takes a life of its own.
An in-depth analysis of the Loving Support breastfeeding campaign in the United States provides important insights into the definition of social marketing and how this framework can be applied to protect, promote, and support breastfeeding . Social marketing involves the application of commercial marketing principles to advance the public good  A social marketing campaign starts with the identification of a benefit (e.g., breastfeeding) and how the target audience perceives this benefit (▶Table 22.1).
Developing effective social marketing campaigns requires in-depth understanding of the determinants of the behaviour in the different contexts where it will take place and the perceived consequences of performing the behaviour or not. This understanding allows for the initial development of the campaign’s brand, relevance, and positioning through an evidence-based marketing mix following the “4Ps” (product, price, place, promotion). The marketing mix is designed to maximise use of the product (e.g., breast pump), services (e.g., peer counsellors) or activities (e.g., breastfeeding support group), while taking into account consumers’ perceptions about the price or sacrifices they will need to make to follow the target behaviour. For example, employed women may be very resistant to consider EBF if sacrificing their jobs is what it would take for them to be able to do so. Also, spouses may not be supportive of EBF if they are afraid their wives are going to be harassed when they breastfeed in public places . The third component of the marketing mix involves providing access to a product or service via strategic placement through opportunity points (e.g., Baby-Friendly Hospitals, peer counselling programmes). Lastly, the product or service needs to be promoted through innovative communication campaigns and experienced by the target population . Effective breastfeeding social marketing campaigns need to be developed based on mixed methods formative research that incorporates effective process and outcome evaluation systems , .
Key term / concept
Application of marketing principles and techniques to foster social change or improvement
Social marketing is based on four inter-related tasks: audience benefit; target behaviour; essence; and marketing mix
Perceived benefit of behaviour change by target audience
At the centre of the social marketing construct. e.g., How do women and society at large perceive the benefit of BF? How soon are benefits from BF to be expected?
Behaviour(s) that may change as a result of production adoption and use, accessing services, and/or adopting healthy behaviours
Social marketing focuses on population-based behaviour change. e.g., What are the determinants, context, and consequences of changing or not changing infant feeding behaviours from the perspective of the target audience?
Identifying behaviours, products, and services essential for marketing desired behavioural change
Branding, relevance, and positioning strategies based on target audience preferences, e.g., What type of BF messages currently resonate with WIC women? What type of infrastructure (e.g., Baby-Friendly Hospital Initiative) services (peer counselling), activities (BF support groups); and products (e.g., breast pumps) need to be made available? How relevant are these to the needs and wants of the target population segments? Where and how can these be accessed by the target audiences? Are there policy and legislation changes needed for improving breastfeeding behaviours?
Specific design and features of campaign products, services, and activities
Referred to as the “4Ps”; refers to product, price, place, and promotion strategies for campaign implementation. Reaching this point requires having completed the audience benefit, target behaviour and essence steps based on solid formative evaluation work with target consumers. e.g., Is BF marketing mix relevant to the life circumstances of WIC participants? Do WIC participants identify well with campaign brand?
Incentives and costs involved with behavioural change as perceived by target audiences
Price concept in social marketing goes well beyond monetary cost and includes the psycho-social “costs” perceived by consumers. e.g., Do WIC women perceive that they would need to sacrifice their jobs in order to breastfed exclusively for 6 months? Do women perceive that they can afford to “pay” the social stigma “price” associated with BF in public? Are WIC participants willing to go to a clinic to receive peer counselling services? Or do they strongly prefer to receive them at home? Are there enough electric breast pumps available to lend out or will women be asked to purchase their own? Do WIC women perceive the free formula to be a powerful disincentive to choose exclusive BF?
Location where there is an opportunity for target audience to access the campaign products, services and activities
Consumers need to have access to the necessary tools to enact behavioural changes sought out by campaign. Crucial for the campaign to create spaces and opportunities for consumers to access, practice, and sustain healthy behaviours. e.g., Are BF promotion programs available in communities where WIC participants live? Are BF support social media and mobile technologies, and BF support efforts well adapted to the health literacy and cultural norms of different WIC population segments?
Communication efforts to disseminate campaign behaviours, products, services, incentives and priorities among different stakeholders
Health communication is a component of social marketing that in and by itself may not be able to elicit behaviour change. Promotion need to work in an integrated way with the other three components of the social marketing model for behavioural change campaigns to be effective. Information is needed to make informed decisions regarding target behavioural change in places, points in time, and ways that are literacy and culturally appropriate, e.g., is the campaign’s communication strategy taking into account the two-way communication information technologies preferred by WIC participants or is it still all based on old fashion linear (oneway) communication systems?
Adapted from Lefebvre  and Institute of Medicine  Source: Pérez-Escamilla , reproduced with permission. BF = breastfeeding, WIC = Supplemental Nutritional Program for women, infants, and children.
Pérez-Escamilla, et al. recently conducted a systematic review of the peer reviewed and grey literature to identify the key barriers and facilitators for scaling-up effective breastfeeding programmes and to map them into the AIDED framework . The data extraction process identified 22 enabling factors and 15 barriers for dissemination, diffusion, and scale-up and/or sustainability that were then mapped into the five AIDED components (▶Table 22.2, ▶Table 22.3).
Mapping of facilitators and barriers into the AIDED framework components led to the following classification:
Assess The empirical evidence indicates that successful dissemination, diffusion, and scaling-up of breastfeeding promotion programmes has relied heavily on baseline facility and community needs assessments, as well as operational (formative) research/pilot studies. These efforts have been particularly successful when needs assessments are conducted with the scale-up of breastfeeding promotion in mind and take into account input from key stakeholders working in different sectors.
Innovate Three innovations that have been key for effectively fitting and packaging of breastfeeding promotion programmes, resulting in successful scale-up, are: (1) communications and mass media campaigns that set the stage for the introduction of a breastfeeding promotion programme in target areas; (2) facility-based delivery systems (e.g., BFHI ; (3) community-based EBF promotion and support programmes that include peer counsellors, community health workers, mother-to-mother support groups, and visible community events (e.g., World Breastfeeding Week).
Develop Global breastfeeding promotion efforts have been built upon the foundation established by evidence-based international consensus meetings/declarations and global infant feeding recommendations issued by the United Nations International Children’s Fund (UNICEF) and WHO. Translating this support into action has greatly benefited from the efforts of international advocacy groups (e.g., International Baby Food Action Network [IBFAN], World Alliance for Breastfeeding Action [WABA]) and local advocacy groups, as well as coalition building with various stakeholders including public opinion leaders. Before scale-up can proceed, it is crucial to elicit will and long-term commitment for scale-up from policy makers through political sensitisation based on cost/savings analyses, and civil society mobilisation and engagement. Maternity leave and work place legislation, as well as the enforcement of the WHO International Code of Marketing of Breast Milk Substitutes (WHO Code), are key for attaining the supportive environment needed for EBF promotion to succeed on a large scale. Indeed, the frequent violation of the WHO Code has been consistently identified as a major barrier for breastfeeding promotion. Key to sustainable large-scale breastfeeding protection, promotion, and support programmes is the training of administrators, health professionals, and paraprofessionals, a process that can be facilitated by improvements in medical/nursing school curricula. The physical infrastructure for the delivery of breastfeeding support at the facility and community level needs to be in place for successful large scale-up to occur. For example, a major barrier for the initial implementation of BFHI in many countries was that maternity wards were not designed to accommodate rooming-in. Lack of community-level infrastructure for lactation management support continues to be a major barrier for EBF promotion globally.
AIDED framework components mapped to factor
International advocacy groups: IBFAN, WABA
Evidence-based recommendations: timely initiation of BF; EBF for 6 months (WHO)
International consensus meetings/declarations: Bellagio and beyond
Local advocacy & coalition building, including public opinion leaders
Civil society mobilisation and engagement
Long-term commitment to scaling-up
Process and sustainability facilitators
Research and evaluation
Baseline facility and community needs assessments
Operational (formative) research/pilot studies
Facility-based delivery system, e.g., BFHI
Innovate, Develop, Engage, Devolve
Community-based EBF promotion and support: baby-friendly primary health care units, peer counsellors, community health workers, mother-to-mother support groups
Innovate, Develop, Engage, Devolve
Communications/mass media campaigns; targeting opinion leaders, policy makers, mothers; simple and double messages; celebrities
Innovate, Develop, Engage
Visible community events: world breastfeeding week, other
Innovate, Develop, Engage
Programme delivery through other existing programmes: immunisations, diarrhoeal control, family planning, and other programmes
Innovate, Develop, Engage, Devolve
Training: administrators, health professionals, and paraprofessionals
Endorsement from medical societies
Medical/nursing school curricula
Legislation: maternity leave, work place, WHO Code
Programme coordination and quality control
Intersectoral coordination: government, civil society (NGOs, philanthropists), medical societies, academic researchers, mass media
Develop, Engage, Devolve
Monitoring and evaluation, low-cost, rapid response
Adapted from Pérez-Escamilla, et al. . BF = breastfeeding, BFHI = Baby-Friendly Hospital Initiative, EBF = exclusive breastfeeding, IBFAN = International Baby Food Action Network, NGO = non-government organisation, WABA = World Alliance for Breastfeeding Action, WHO = World Health Organization
Number of sources citing factor
AIDED framework component(s) mapped to factor
Unethical marketing of infant formula
Develop, Engage, Devolve
Unsustainable workforce development system (affects sustainability)
Overburdened staff in medical facilities and in community health settings
CHW investment just to promote breastfeeding difficult to justify
Strong dependency on international aid (affects sustainability)
Weak M&E systems
Assess, Develop, Devolve
Prolonged lag time before impacts can be detected
Lack of community-level breastfeeding promotion and support
Develop, Engage, Devolve
Unpaid “volunteers”: high turnover
Cultural beliefs: “insufficient” milk, other
Lack of multilevel incentives
Lack of referral system for lactation management problems
Poor interpersonal communication skills among peer counsellors/community health workers
Assess, Develop, Engage
Adapted from Pérez-Escamilla, et al. . CHW, community health workers; M&E, monitoring and evaluation.
Engage Breastfeeding promotion programmes ultimately seek to engage the mother in considering practicing optimal infant feeding behaviours, including EBF. There are many factors that influence a mother’s infant feeding decisions, including the advice from health care providers, family, neighbours, friends, media, and others. Small trials have shown that women across cultures are significantly more likely to practice EBF when they are presented with innovative approaches that take into account the contexts in which they live. The key for the success of these interventions has been addressing cultural beliefs surrounding their infant feeding choices, such as the often unfounded belief that a high proportion of women are not able to produce enough milk for EBF their infants . This pervasive belief has consistently been identified as one of the strongest risk factors for the early introduction of replacement infant feedings including infant formula. Once infant formula is introduced, the likelihood that the mother will revert to EBF is exceedingly low, and breastfeeding duration becomes shortened as a result. Hence, it is crucial to understand the roots of this pervasive belief in different cultures to address it effectively. A key barrier for the scale-up of breastfeeding protection, promotion, and support programmes is the lack of adequate communication skills among health care providers and peer counsellors/community health workers. Thus, developing a workforce that is well trained on the technical aspects of lactation management and breastfeeding promotion is essential, but not a sufficient condition for successful scale-up. Scale-up requires developing the communication, and counselling non-judgmental skills of individuals providing breastfeeding support to women. Good receptivity is most likely when women and individuals in their circle of influence fully engage in the decision-making process; otherwise, efforts to engage target individuals successfully are compromised and scaleup eventually fails. Innovative facility and community-based breastfeeding promotion and support approaches delivered through, for example, peer counsellors, community health workers, or mother-to-mother support groups are indeed crucial for proper engagement of target individuals.
Devolve Once a comprehensive breastfeeding programme has been successfully scaled-up and EBF uptake is widespread among the initial users, efforts to devolve for continued spread among the next generation of “users” are critical for sustaining the initial scale-up phase. For this to happen, six conditions need to be met:
Effective sustainable lactation management and communication/counselling through train-the-trainer programmes need to be in place
A sustainable workforce development pipeline, including medical, nursing, and technical schools, needs to be developed
National intersectoral breastfeeding coordination with adequate budget allocation should not rely heavily on foreign aid and it should be highly decentralised, as in the case of Brazil. Key sectors or stakeholders involved should be target women and communities, government, civil society (e.g., Non-Governmental Organisations [NGOs], women’s organisations, unions, and philanthropists), international agencies, medical societies, academic researchers, and mass media
Systems to avoid redundancies by incorporating breastfeeding promotion through existing programmes, such as diarrhoea, immunisations, family planning, and growth monitoring, must be in place
Facility and community based infrastructure needed for effective breastfeeding promotion must also be available
There must be monitoring and evaluation systems that include low-cost rapid-response management information systems to facilitate local decentralised management of breastfeeding promotion efforts
Scaling-up experiences have also identified specific barriers for devolving, including lack of proper staff incentives, “programme fatigue”, draining of trained workforce members from the initial user groups, and attempting to devolve through staff who are already overburdened with other duties . Programme fatigue has been identified to be one of the reasons for the decline in BFHI quality in several countries where BFHI was launched over a decade ago. It is apparent that fidelity to the “package” of steps has declined with time, especially once initial certification and recognition is obtained.
Using the above classification of mapping of facilitators and barriers, the AIDED mapping was then translated into the pragmatic Breastfeeding Gear Model (BFGM) targeting decision makers (▶Fig. 22.4).
Analogous to a well-oiled engine, the BFGM indicates the need for several key “gears” to be working in synchrony and coordination for delivering effective breastfeeding protection, promotion, and support at scale. Evidence-based advocacy is needed to generate the necessary political will to enact legislation and policies to protect, promote, and support breastfeeding at the hospital and community level. This political-policy axis in turn drives the resources needed to support workforce development, programme delivery, and promotion. Research and evaluation are needed to sustain the decentralised programme’s coordination “gear” required for goal setting and system feedback. The BFGM has strong construct validity and has helped explain the different levels of performance in national breastfeeding outcomes in Mexico and Brazil (▶Fig. 22.5) .
The BFGM is indeed a specific CAS scaling-up model. The non-linear BFGM provides a good illustration of the CAS “perfect storm” that is needed for national breastfeeding programmes to successfully emerge. According to the BFGM, national breastfeeding programmes behave like an engine, requiring different intersectoral and interlocked gears coordinated by a master gear that utilises feedback loops to ensure the engine is properly functioning. The BFGM fully recognises the need to include influential champions and leaders to create strong demand and acceptance of the programme services (scale-free networks). It also includes an evidence-based advocacy gear, which is often the first to be organised, to create the conditions for the whole machine to be assembled and before substantial impacts in breastfeeding behaviours are actually observed (phase transitions). Finally, while the BFGM posits that the gears are likely to be the same across countries, it fully recognises that the nuts and bolts needed to make each gear function are context specific (path dependent) .
The construct validity of the BFGM has been assessed through extensive peer review, confirming that it was able to identify key breastfeeding protection, promotion, and support components as well as the key elements of the policy heuristic model, which calls for agenda setting (i.e., generate attention to problem), policy formulation and adoption, effective policy implementation through diverse programmes or interventions, and programme monitoring and evaluation . It also strongly emphasises the need for champions and visionary leaders to carry the policy process forward .
Although currently there are no policy tool boxes to assist policy makers with the scaling-up process of breastfeeding programmes following CAS action-oriented conceptual frameworks such as the BFGM, there are two important initiatives that have sought to develop indicators that can help inform the scaling-up process. These initiatives are the WHO’s Infant and Young Child Feeding: A Tool for Assessing National Practices, Policies and Programmes launched in 2003 , and IBFANs World Breastfeeding Trends Initiative (WBTi) launched in 2004  heavily building upon the WHO tool. Both initiatives seek to involve stakeholders in assessing IYCF outcomes, activities, and processes with the goal of empowering countries to identify IYCF gaps that need to be addressed.
The specific goal of the WHO tool is to help countries ‘assess the strengths and weaknesses of policies and programmes for protecting, promoting and supporting optimal feeding practices, and determine where improvements may be needed to meet the aim and objectives of the Global Strategy for Infant and Young Child Feeding’ . The tool is recommended to be used every several years to document indicators trends, identify gaps, and assist countries with the planning process. The tool specifically targets teams formed by key national policymakers, programme managers/staff, and NGO leaders.
The tool which is strongly driven by the Innocenti Declaration (1990) and related IYCF global strategy (WHO/UNICEF 2003) is divided into three major areas:
National IYCF policies and targets
National IYCF programme
At the heart of the tool are the criteria that are needed to score and/or rank each indicator within each of the three areas. The manual contains specific instructions on how to assess each indicator including:
Key question to be answered
Background on why the practice, policy or programme is important
Possible sources of information
Interpretation criteria to identify successes and challenges that need to be addressed
For assessing the prevalence of IYCF practices, the tool recommends using random household surveys representative of the level at which assessment is being conducted (from national to local) (▶Table 22.4). Each IYCF behaviour indicator is finally rated as “poor”, “fair”, “good”, or “very good” based on prevalence and evidence-based cut-off points.
For assessing IYCF policies and targets, each of the six indicators is scored through weighted scores for each criterion, percentage coverage (i.e., percentage facilities with BFHI accreditation), or compliance with implementation, monitoring and enforcement of policy components (i.e., WHO Code). For each indicator the scores can range from 0 to 10 (▶Table 22.5) (except for percentage facilities with BFHI accreditation where scores can range from 0 to 100%) and each is finally rated as “poor”, “fair”, “good”, and “very good”, based on pre-established cut-off points.
For the IYCF programme, each of the 12 indicators is rated as being “unmet”, “partially met”, or “fully met“, with a weighted score corresponding to each response option (▶Table 22.6). The score for each indicator can range from 0 to 10 and each indicator is then ranked as “poor”, “fair”, “good”, or “very good”, based on pre-established cut-offs. Because the programme indicators are often difficult to score quantitatively, an alternative qualitative scoring system is allowed to rank the criteria as either “low-”, “medium-”, or “high-” level of achievement . Based on pre-testing in nine countries, the following recommendations emerged for optimal tool implementation: (1) identification of a key coordinator and the key support needed; (2) identification of an assessment team; and (3) plan and implement assessment based on operating rules established a priori .
Infant feeding behaviour
Initiation of breastfeeding
% of babies breastfed within one hour of birth
% of babies 0 to < 6 months of age exclusively breastfed in the last 24 hours
Duration of breastfeeding
Median duration in months of breastfeeding of children under three years of age
% of breastfed babies 0 to < 12 months of age fed from bottles in the last 24 hours
% of breastfed babies 6 to < 10 or 7 to < 10 months of age who received complementary foods in the last 24 hours
World Health Organization (WHO). Infant and young child feeding. A tool for assessing national practices, policies and programmes, 2003. Available at: http://www.who.int/nutrition/publications/inf_assess_nnpp_eng.pdf
Policies and targets
National infant and young child feeding policies
Based on Global Strategy on Infant and Young Child Feeding
National coordinators and committees
Baby-Friendly Hospital Initiative achievements
% facilities accredited as Baby-Friendly Hospital Initiative achievements
International Code of Marketing of Breast-milk Substitutes
Code implementation and monitoring
Legislation protecting and supporting breastfeeding among working mothers
Adoption and implementation of ILO Maternity Protection Conventions
Operational targets of the Global Strategy
Action plan implementation
ILO = International Labour Organization World Health Organization (WHO). Infant and young child feeding. A tool for assessing national practices, policies and programmes, 2003. Available at: http://www.who.int/nutrition/publications/inf_assess_nnpp_eng.pdf
National infant and young child feeding programme
Multisectoral-funded programme in place
An active and sustainable Baby-Friendly Hospital Initiative
Resources, infrastructure, and national coordination
Mother-Friendly childbirth strategies
Mother-friendly child birth procedures
Health care provider (pre-service) education
Medical, nursing, and midwifery schools, nutrition and public health academic programmes
In-service training for health care providers
Curriculum content, knowledge, and skills among professionals and paraprofessionals
Community outreach and support
Includes non-health organisations
Information, education and communication
Comprehensive evidence-based internal communication (IC) strategy
Contraceptive support for breastfeeding women
Lactational Amenorrhoea Method (LAM)
HIV and infant feeding
Voluntary counselling and testing (VCT) and follow-up support
Infant and young child feeding in emergencies
Coordination among government, international agencies, and other and non-government actors; adequate training
Research for decision making
Translational research and evaluation for decision making
Monitoring and evaluation
Adequate management information systems (MIS) useful to decision makers
World Health Organization (WHO). Infant and young child feeding. A tool for assessing national practices, policies and programmes, 2003. Available at: http://www.who.int/nutrition/publications/inf_assess_nnpp_eng.pdf
Building heavily upon the WHO tool and the World Alliance for Breastfeeding Action (WABA) Global Participatory Action Research (GLOPAR), WBTi was launched by IBFAN Asia as a tool for tracking, assessing, and monitoring the IYCF Global Strategy worldwide using a web-based tool kit . The WBTi methodology involves scoring 15 indicators, 10 of which deal with policies and programmes, and five of which deal with infant feeding practices (▶Table 22.7).
Specific criteria are outlined for scoring each indicator . Each criterion for each of the 10 policies and programme indicators is assigned a score that can range from 0 to 3 with each indicator having a possible score ranging from 0 to 10; thus, each country can attain a maximum score of 150 points. Each indicator is then colour coded as red (score: 0 to 3.5), yellow (4 to 6.5), blue (7 to 9), or green (> 9) for easy visualisation. As in the WHO tool, the ranking of the five infant feeding indicators is based on their actual prevalence in relationship to international recommendations and are colour coded as red, yellow, blue and green. Consistent with the WHO tool, WBTi recommends for each country to form its own multi-stakeholder group to conduct the WBTi indicators assessment, using existing data and/or by conducting interviews with key informants. All data are entered into the user-friendly WBTi webpage, which allows for graphical representation of findings that can be used for evidence-informed advocacy purposes. The expectation is for this participatory process not only to lead to the identification of gaps but also to actual implementation of the changes needed to fill those gaps. The WBTi process is recommended to be repeated every 3 to 5 years. There is limited published evidence to support changes in national breastfeeding programmes as a result of the WBTi process. However, a study by Lutter & Morrow did document a positive association between the WBTi score and EBF . They specifically found that among 22 countries in Africa, Asia, the Middle East, and Latin America with at least two assessments between 1986 and 2010, the median annual increase in EBF was 1.0% in countries in the upper 50th percentile of WBTi scores, in comparison to only 0.2% in countries with the lowest WBTi scores (p=0.01).
Policies and programmes
Infant feeding practices
National Policy, Programme and Coordination
Percentage of babies breastfed within one hour of birth
Baby-Friendly Hospital Initiative
Percentage of babies < 6 months of age exclusively breastfed in the last 24 hours
Implementation of the International Code of Marketing of Breastmilk Substitutes
Babies are breastfed for a median duration of how many months
Percentage of breastfed babies less than 6 months old receiving other foods or drink from bottles
Health and Nutrition Care System (in support of breastfeeding and IYCF)
Percentage of breast-fed babies receiving complementary foods at 6–9 months of age
Mother Support and Community Outreach (community-based support for the pregnant and breastfeeding woman)
Infant Feeding and HIV
Infant Feeding During Emergencies
Mechanism of Monitoring and Evaluation Systems
Note: Background information on Millennium Development Goals (MDG) 1 (extreme poverty and hunger), 4 (child mortality) and 5 (maternal health) is collected but is not scored, colour-rated or graded. It can be used to provide a better understanding of the health, nutritional and socioeconomic context which influences infant and young child feeding (IYCF) practices and programmes. World Breastfeeding Trends Initiative (WBTi). WBTi Guide Book. Available at: http://worldbreastfeedingtrends.org/wpcontent/uploads/2015/03/docs/WBTi-Guide-Book-2014.pdf
The individual and societal benefits that can be derived from improved protection, promoting, and support of optimal breastfeeding practices has been well established . Likewise, the key ingredients for effectively scaling-up of national breastfeeding programmes have been identified to a large extent . In spite of this vast amount of knowledge, relatively little progress has been made over the past decade at improving key breastfeeding outcomes such as early initiation of breastfeeding and EBF for six months. The global cost of this inaction or of a lack of adequate translation of knowledge into practice is in the order of hundreds of millions of dollars annually and is a matter that must be addressed .
An important step in changing the status quo has been development of indicators to capture the enabling environment and progress with key elements needed for scaling-up breastfeeding programmes to the national level. However, these efforts need to be improved by basing this approach in conceptual frameworks and models that capture the complex non-linear relationships among all key elements that need to be in place for the scale-up of effective breastfeeding protection, promotion, and support programmes . This chapter offers the AIDED framework and related BFGM as powerful conceptual models to take the enabling environment assessments and subsequent monitoring of scaling-up to the next level. For this to happen, however, it is crucial that prospective scaling-up CAS research is embedded in existing assessment tools as well as in CAS-based policymaker friendly tools currently under development. The goal of these tools should continue not only to be the collection of data per se but to ensure that the assessment process generates the required evidence for decision makers to call for the necessary investments and actions to address poor breastfeeding performance worldwide. Regarding decision making, one of the key pieces of missing evidence is the costing of key elements needed for successful scaling-up of breastfeeding programmes. For example, it is important to empower countries to find out how much it costs their country to have all the gears of the BFGM solidly in place and working as a harmonious system. Without this information it becomes practically impossible for the Ministry of Finance to be able to allocate an itemised budget for the Ministry of Health to run an effective national breastfeeding programme. Although there are ongoing efforts to cost the activities needed to protect, support, and promote breastfeeding at scale , , there is much work that lies ahead to be able to empower decision makers to make sound evidence-based investment decisions for their programmes. How decisions are made as part of a successful scaling up process of national breastfeeding programmes is indeed a very high priority area of implementation science research that can benefit many other maternal-child health and nutrition domains.
In conclusion, improving the uptake and scaling-up of effective national breastfeeding programmes should be a top priority for all countries. CAS research is needed to empower decision makers to achieve this goal through well-validated participatory decision making tools to help their countries assess baseline needs (including costs) as well as progress with their scaling-up efforts , . Robust systems thinking frameworks and scaling-up models are now available to guide fruitful efforts, enabling their replication with appropriate adaptations across countries . It is expected that this process can help reverse the declines in investments in breastfeeding protection, promotion, and support in diverse world regions , . This is likely to increase health equity  that is a key principle behind the Sustainable Development Goals.
Scaling-up refers to the expansion of access to quality programmes that result from new technologies and interventions aimed at having a major and rapid impact on improving health in large sections of the target population. Breastfeeding is one such intervention that can have substantial positive short- and long-term impact on mothers, infants and society
Successful scaling-up of breastfeeding programmes requires to have strong coordination between breastfeeding protection, promotion and support activities and at the same time requires multi-level, multidisciplinary teams and stable financial commitment
Implementation research is necessary to develop effective large scale programmes and how to best monitor them. This needs to include an understanding of all stakeholders as well as the complex interrelations necessary for successful programmes
There are several existing tools to assist in the development of successful breastfeeding scale-up programmes with “Becoming Breastfeeding Friendly” being the newest most comprehensive framework launched in 2017 (http://bbf.yale.edu/)