World Breastfeeding Week 2012

Understanding the Past – Planning the Future

Celebrating 10 years of WHO/UNICEF’s Global Strategy

for Infant and Young Child Feeding

Meeting in Florence, Italy, in July 1990, government policy makers from more than 30 countries adopted the Innocenti Declaration. e 44th World Health Assembly, in

1991, welcomed the Declaration as “a basis for international health policy and action” and requested the Director-General to monitor achievement of its targets (resolution

WHA44.33).

Introduction

e 10

anniversary of the Global Strategy for Infant and

Young Child Feeding provides an opportunity to assess the

progress towards implementation by WHO Member States in

Latin America and the Caribbean. It also provides an oppor-

tunity to examine countries’ breastfeeding and complemen-

tary feeding practices. is policy brief, which analyzes eﬀects

of the policies and programs on breastfeeding practices, shows

that implementation of the Global Strategy is associated with

positive trends in exclusive breastfeeding over the past 10 to

20 years. e results are clear: investing in protecting, pro-

moting and supporting breastfeeding though implementa-

tion of the Global Strategy may lead to increases in exclu-

sive breastfeeding!

Adopted by the World Health Assembly and the UNICEF

Executive Board in 2002, the Global Strategy recognized that

“Malnutrition has been responsible directly or indirectly for 60%

of the 10.9 million deaths annually among children under ﬁve.

Well over two-thirds of these deaths, which are often associated

with inappropriate feeding practices, occur during the ﬁrst year

of life. No more than 35% of infants worldwide are exclusively

breastfed for the ﬁrst four months of life; complementary feed-

ing frequently begins too early or too late, and foods are often

nutritionally inadequate or unsafe. Malnourished children who

survive are more often sick and suﬀer life-long consequences of

impaired development. Because poor feeding practices are a major

threat to social and economic development, they are among the

most serious obstacles to attain and maintain health that face this

age group.”(1)

To address these problems, the Global Strategy set forth nine

operational targets related to both breastfeeding and comple-

mentary feeding. e ﬁrst four targets reaﬃrm the relevance

of the operational targets of the Innocenti Declaration on the

Protection, Promotion and Support of Breastfeeding

• Appointanationalbreastfeedingcoordinatorandestablish

a multisectoral national breastfeeding committee.

• Ensurethateveryfacilityprovidingmaternityservicesfully

practices all the “Ten steps to successful breastfeeding.”

• GiveeecttotheprinciplesandaimoftheInternational

Code of Marketing of Breast-milk Substitutes and related

World Health Assembly resolutions (Code).

• Enactimaginativelegislationtoprotectthe breastfeeding

rights of working women.

e second ﬁve targets more broadly address breastfeeding,

complementary feeding and feeding in diﬃcult circumstances

such as during emergencies or in the context of HIV/AIDS.

World Breastfeeding Week 2012 - Understanding the Past – Planning the Future

• Develop,implement,monitorandevaluateacomprehen-

sive policy on infant and young child feeding.

• Ensure that the health and other relevant sectors pro-

tect, promote and support exclusive breastfeeding for six

months and continued breastfeeding up to 2 years of age or

beyond.

• Promote timely, adequate, safe and appropriate comple-

mentary feeding with continued breastfeeding.

• Provideguidanceonfeedinginfantsandyoungchildrenin

exceptionally diﬃcult circumstances.

• Considernewlegislationorothermeasurestogiveeectto

the principles and aim of the Code.

Assessing implementation progress

To assess progress in the implementation of the Global Strat-

egy, the WHO developed a tool for assessing national practic-

es, policies and programs in support of infant and young child

feeding (2). It is designed to help users assess the strengths and

weaknesses of policies and programs for protecting, promoting

and supporting optimal feeding practices in their local setting

and determine where improvements may be needed to meet

the aims and objectives of the Global Strategy. Inspired by this

tool, the International Baby Food Action Network (IBFAN)

of Asia developed the World Breastfeeding Trends Initiative

(WBTi) to track, assess and monitor infant and young child

feeding practices, policies and programs worldwide in sup-

port of breastfeeding and complementary feeding (3, 4). e

WBTi focuses on a set of 15 indicators. e ﬁrst 10 address

the general infant and young child feeding environment, fo-

cusing largely on the breastfeeding environment. e second

ﬁve address infant and young child feeding practices (Box).

For each indicator, a list of key criteria and a subset of ques-

tions to consider in assessing implementation progress and

to assign a score is deﬁned. e maximum score for each in-

dicator is 10 points, for a possible total score of 150 points;

100 for indicators related to the general environment for in-

fant and young child feeding and 50 for indicators related to

breastfeeding and complementary feeding practices.

To date, WBTi has been carried out in 12 countries in Latin

America: Argentina, Bolivia, Brazil, Colombia, Costa Rica,

Dominican Republic, Ecuador, Guatemala, Mexico, Nicara-

gua, Peru and Uruguay. (For the full reports see www.ibfan-

alc.org/WBTi/index.html) Adjusted WBTi scores based on the

10 indicators related to policies and programs range from 31

to 76 (Table 1). For these 12 countries, the lowest average

scores are for the indicators of feeding and HIV (3.6) and

World Breastfeeding Trends Initiative (WBTi) indicators

1. National Policy, Program and Coordination

2. Baby Friendly Hospital Initiative (Ten Steps to Successful Breastfeeding)

3. Implementation of the International Code of Marketing of Breast-milk Substitutes and relevant WHA resolutions

4. Maternity Protection

5. Health and Nutrition Care System (in support of breastfeeding and infant and young child feeding)

6. Mother Support and Community Outreach-Community-based support for the pregnant and breastfeeding mother

7. Information Support

8. Infant Feeding and HIV

9. Infant Feeding During Emergencies

10. Mechanisms of Monitoring and Evaluation Systems

11. Percentage of babies’ breastfed within one hour of birth

12. Percentage of babies less than 6 months of age exclusively breastfed in the last 24 hours

13. Babies are breastfed for a median duration of how many months

14. Percentage of breastfed babies less than 6 months old receiving other foods or drink from bottles

15. Percentage of breastfed babies receiving complementary foods at 6 to 9 months of age

Celebrating 10 years of WHO/UNICEF’s Global Strategy for Infant and Young Child Feeding

Table 1. World Breastfeeding Trends Initiative (WBTi) policy and program indicators

Country Indicator Adjusted

score

(1-10)

1 2 3 4 5 6 7 8 9 10

Policies and

programs

BFHI Code Maternity

protection

Health system

support

Community

support

Information

support

Feeding

and HIV

Feeding during

emergencies

Monitoring and

evaluation

Argentina 4 6.5 8 4 7.5 4 8 2 3 4 51.0

Bolivia 10 4 8 3 6 6 4 1.5 0 9 51.5

Brazil 9 2.5 10 7.5 5 1 8 5 0 5 53.0

Colombia 5.5 5.5 7 4 9.5 5 8 3.5 0 2 50.0

Costa Rica 10 7.5 10 9 6.5 9 9 4 4 7 76.0

Dominican

Republic

3 6.5 10 2.5 5 3 3 2.5 0 2 37.5

Ecuador 5 6.5 7 6 5 4 5 3 2 4 47.5

Guatemala 7 5 8 3 4 3 6 2.5 1 6 45.5

Mexico 2 5 7 3.5 5 4 1 3.5 0 0 31.0

Nicaragua 9 8.8 7 7 9 8 8 5.5 7 6 75.0

Peru 5 6 8 4.5 4.5 2 2 3.5 2 5 42.5

Uruguay 6.5 7.5 4 5 6 6 5 6.5 0 6 52.5

Figure 1. Points for each indicator of the World Breastfeeding Trends Initiative (WBTi)

for 12 Latin American countries, 2008-2010

6.3

5.9

7.8

4.9

6.1

4.6

5.6

3.6

1.6

4.7

Policies and

programs

BFHI Code Maternity

protection

Health system

support

Community

support

Information

support

Feeding and

HIV

Feeding

during

emergencies

Monitoring

and evaluation

Points

World Breastfeeding Week 2012 - Understanding the Past – Planning the Future

feeding during emergencies (1.6). e three highest average

scores are for the Code (7.8), policies and programs (6.3) and

health system support (6.1) (Figure 1).

Globally, a total of 40 countries have carried out a WBTi.

Among these, 25 also have nationally representative data on

trends in exclusive breastfeeding and breastfeeding duration

over a 10 to 20 year period, including eight countries in Af-

rica, seven in Asia, nine in Latin America (Bolivia, Brazil, Co-

lombia, Dominican Republic, Ecuador, Guatemala, Mexico,

Nicaragua, and Peru) and one in the Middle East.

Assessing global changes in breastfeeding

practices

Data from these 25 countries show that while breastfeeding

duration at the ﬁrst survey largely explains breastfeeding du-

ration at the last survey (Figure 2), there are a few notable

exceptions. One of these is Brazil, where the median dura-

Figure 2. Correlation between breastfeeding duration

(months) at rst and last survey

Colombia 1986-2010

Brazil 1986-2006

Reference line

Regression line

10 15 20 25

Breastfeeding 2

Breastfeeding 1

30 35

Linear = 0.811

Figure 3. Median breastfeeding duration (months) and global and national breastfeeding activities: Brazil 1974-2002

Campaigns

Social Mobilization

IBFAN

HMB

BF Conferences

Years

Code Monitoring

BFHI Revitalized

Planning

Code Revised

Code Training

Trainings:

- Materials

- Post Service

- Firemen

Code Revised

BFHI

WBW

BF Conference

IBFAN

Code Training

Policies:

- Code

- HMB

- Maternity Leave

IBFAN

Months

1974

1975

1976

1977

1978

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

Code

Wellstart

WHA Resolution

IGAB

10 Steps

Innocenti

BFHI+ICDC

WBW

18 hr/80 hr Courses

BF Counseling Courses

BF Course for

Managers

HIV + IF

Course

Global Strategy:

6 months EBF

Translated into English from Rea MF. A review of breastfeeding in Brazil and how the country has reached 10 months’ breastfeeding duration. Cad Saude Publica. 2003;19

Suppl 1:S37-45.

Celebrating 10 years of WHO/UNICEF’s Global Strategy for Infant and Young Child Feeding

tion of breastfeeding increased from 5.2 months in 1986

to 14 months in 2006. During this same period, exclusive

breastfeeding increased from 2.5% to 38.6%. is remarkable

increase coincides with new policies and programs put into

place during the period with (Figure 3). Another standout is

Colombia, where breastfeeding duration increased from 8.5

months to 14.9 months between 1986 and 2010, and exclu-

sive breastfeeding increased from 15.4% to 46.8%.

e progress in breastfeeding practices in Brazil and Colom-

bia contrasts sharply with several other countries in Latin

America where, over a similar period of time, little progress

has been made (Figure 4). In the Dominican Republic, ex-

clusive breastfeeding increased only 0.7 percentage points,

from 7% to 7.8%, over a 16-year period. During the same

period, breastfeeding duration declined from 9.3 months to

7.1 months. In Mexico, breastfeeding duration Orly increased

from 9.5 months to 10.4 months between 1987-1988 and

2006. Nevertheless, the large gains observed in many other

countries are impressive given the concurrent increase in ur-

banization, female education and employment, which are tra-

ditionally associated with less breastfeeding (5).

In contrast to the strong correlation between initial and later

breastfeeding duration, there is only a weak correlation (0.09)

between initial and later exclusive breastfeeding (Figure 5).

is suggests that, between the ﬁrst and last surveys, changes

occurred in social or cultural factors and/or in policies and

programs that led to changes in exclusive breastfeeding prac-

tices. One possible explanation is that policies and programs

have focused on exclusive breastfeeding, which public health

oﬃcials prioritize in promotion eﬀorts because of its very large

eﬀect on infant morbidity and mortality (6).

Assessing the relationship between imple-

mentation of the Global Strategy and

global changes in breastfeeding practices

Regression analysis using an adjusted WBTi, score, which sums

the ﬁrst eight indicators, shows that current exclusive breast-

feeding is signiﬁcantly associated with initial exclusive breast-

feeding

. It is also signiﬁcantly associated with the adjusted

WBTi score using a one-sided t value, but not with other fac-

tors commonly associated with exclusive breastfeeding, such as

place of residence, maternal employment, maternal education

or gross national income price parity per capita (Table 2) (7).

e analysis shows that for each change of 10 points in a WBTi

score, an increase in exclusive breastfeeding of 6% would be ex-

pected. It is important to note that because the data are obser-

vational the analysis reﬂects only an association between trends

in exclusive breastfeeding and the breastfeeding environment as

measured by WBTi. Also, data on both exclusive breastfeeding

trends and WBTi are only available for a limited number of

countries, though they are fairly evenly distributed across Af-

rica, Asia and Latin America. Nevertheless, this analysis is the

ﬁrst quantitative assessment of the relationship between poli-

cies and programs in support of breastfeeding and changes in

breastfeeding practices. Strengthened by case studies (7), it sug-

gests that the association between breastfeeding promotion and

improved exclusive breastfeeding may be causal.

Figure 4. Changes in breastfeeding duration (months) among Brazil, Colombia, Mexico and the Dominican Republic

0102-600288-6891

Months

Brazil Colomb ia Mexico Dominican Republic

e ﬁrst eight WBTi indicators were used because implementation of the last two, infant feeding and HIV and infant feeding during emergencies that they did not contribute

to the predicted change in exclusive breastfeeding.

World Breastfeeding Week 2012 - Understanding the Past – Planning the Future

Factors for successful breastfeeding promotion policies and

programs are well documented. ey include implementation

of the International Code of Marketing of Breast-milk Substi-

tutes, the Baby Friendly Hospital Initiative, advocacy, training

and education, community-based promotion and support, ma-

ternity legislation and workplace support, and communication

and support for infant feeding in diﬃcult circumstances (8).

Current breastfeeding and complementary

feeding practices

Despite signiﬁcant improvements in breastfeeding practices

in many countries of Latin America and the Caribbean, a big

gap still separates current practices from accepted breastfeed-

ing recommendations (Table 3). Although early initiation

could prevent about one-ﬁfth of neonatal deaths (9), in only

eight of the 14 countries with data are 50% or more of new-

borns put to the breast within one hour of birth. Although

WHO recommends six months of exclusive breastfeeding,

only in ﬁve of 19 countries does this apply to over half of

infants. Few countries track bottle feeding, and of those that

do, several show that the majority of children under 2 years of

age received a bottle the previous day.

In general, complementary feeding has received far less atten-

tion than breastfeeding. Although only ﬁve countries in the

region (Bolivia, Colombia, the Dominican Republic, Haiti,

Honduras and Peru) have data on the new WHO/UNICEF

indicators for assessing infant and young child feeding prac-

tices, they show a large gap between recommended and actual

practices (10, 11) (Figure 6). Although most children received

solid, semi solid or soft foods between 6.0 and 8.9 months of

age, on average 18% did not. Minimum dietary diversity, de-

ﬁned as the proportion of children 6.0 to 24 months of age who

received foods from four or more food groups during the previ-

ous day, ranged from 28% in Haiti to 81% in Peru. Minimum

meal frequency, deﬁned as two or more meals for breastfed in-

fants 6.0 to 8.9 months and three or more meals for breastfed

children 9.0 to 23.9 months of age or four meals or more for

non breastfed children 6.0 to 23.9 months of age, ranged from

46% in Haiti to 78% in Peru. Lastly, minimum acceptable diet

for breastfeed children, deﬁned as the proportion of children

6.0 to 23.9 months of age who had at least the minimum di-

etary diversity and the minimum meal frequency the previous

day ranged from only 16% in Haiti to 66% in Peru.

Regarding complementary feeding, Peru had the best in-

dicators, while Haiti had the worst. Nonetheless, given the

importance of complementary feeding between 6.0 and 24

months for healthy growth and prevention of undernutrition,

the few countries with this information show a gap between

actual and ideal practices. So few countries in the region have

information on complementary feeding makes it diﬃcult to

develop sound policies and programs and track progress.

Figure 5. Correlation between exclusive breastfeeding

duration (%) at rst and last survey

Reference line

Regression line

20 40

Exclusive Breastfeeding 2

Exclusive Breastfeeding 1

60 80

Linear = 0.091

Table 2. Predictors of current exclusive breastfeeding

by initial exclusive breastfeeding

Model Unstandardized

coecients

Standard-

ized coef-

cients

Signi-

cance

B Standard

error

Beta t

(Constant) -15.035 31.173 -.430 .673

Initial exclusive

breastfeeding (%)

.615 .260 .725 2.366 .029

WBTi adjusted (1-8) .973 .525 .595 1.853 .080*

Residence (urban,

rural)

0.15 .321 .019 .048 .962

Paid maternal em-

ployment (yes, not)

-.335 .196 -.454 -1.713 .104

Maternal education

(% with secondary

level)

-.034 .205 .038 -.168 .869

Gross national

income price parity

per capita ($)

.002 .002 -.444 .973 .344

Dependent variable: Current exclusive breastfeeding; R square = 0.34; adjusted R

square 0.12 *One-sided t test <0.05

Celebrating 10 years of WHO/UNICEF’s Global Strategy for Infant and Young Child Feeding

e deﬁnition for the new indicator for complementary feeding by WHO and partners (9) diﬀers from that used in the WBIi reports and is only available for the countries listed.

Not available.

Estimated.

Source of data other than that of complementary feeding: OPS. Situación actual y tendencia de la lactancia materna en America Latina y el Caribe: Implicaciones políticas y

programáticas. En preparación. 2012.

Table 3. Breastfeeding and complementary feeding practices in Latin America and the Caribbean

Country Indicator

1 2 3 4 5

Early initiation (%) Exclusive breastfeeding < 6

months (%)

Breastfeeding duration

(months)

Bottle feeding < 23 months

(%)

Complementary feeding 6-8

months (%)

Argentina, 2010 NA

55 NA NA NA

Bolivia, 2008 63.8 60.4 18.8 35.3 75.4 (2003)

Brazil, 2006 42.9 38.6 14.0 58.3 NA

Chile, 2008-10 NA 43.5 NA NA NA

Colombia, 2010 56.6 42.8 14.9 40.4 NA

Costa Rica, 2006-08 NA 53.1 14.0 86.4 NA

Cuba, 2006 70.2 26.4 NA NA NA

Dominican Republic, 2007 65.2 7.7 (E)

7.1 84.9 (E) 81.1

Ecuador, 2004 26.4 39.6 14.7 NA NA

El Salvador, 2008 32.8 31.4 18.7 20.6 NA

Guatemala, 2008-09 55.5 49.6 21.0 38.5 NA

Guyana, 2009 63.9 33.2 19.1 NA NA

Haiti, 2005-06 44.3 40.7 18.8 20.3 87.4

Honduras, 2005-06 78.6 29.7 19.2 48.6 (E) 84.0

Mexico, 2006 NA 22.3 10.4 NA NA

Nicaragua, 2006-07 54.0 30.6 (E) 18.4 NA NA

Panama, 2009 NA 27.5 6.3 NA NA

Paraguay, 2008 47.1 24.4 11.0 NA NA

Peru, 2010 51.3 68.3 21.7 42.4 81.4 (2004-06)

Uruguay, 2006-07 60.0 57.1 7.1 NA NA

Venezuela, 2006-08 NA 27.9 7.5 62.3 NA

Figure 6. Complementary feeding practices in selected Latin American and Caribbean countries, 2003-2007

100

Bolivia 2003 Co lombia

2005

Do minican

Re public

2007

Ha iti 2006-06 Honduras

2006-06

Pe ru 2004-06

continuous

In troduction of solid semi solid or soft foods Mi nimum dietary diversity (all children)

Mi nimu m me al frequency (breastfed children) Mi nimum acceptable diet (breastf ed children)

World Breastfeeding Week 2012 - Understanding the Past – Planning the Future

Conclusion

Although countries in Latin America have make remarkable

progress in implementing the Global Strategy over the past

10 years, more needs to be done to ensure that all infants and

young children beneﬁt from optimal breastfeeding and comple-

mentary feeding. is year’s World Breastfeeding Week cam-

paign, whose slogan is “Understanding the Past – Planning

the Future” celebrates the 10th anniversary of the Global

Strategy for Infant and Young Child Feeding. is is the

perfect opportunity to reinvigorate eﬀorts to fully imple-

ment all the Strategy’s operational targets so that all infants

and young children beneﬁt from optimal breastfeeding and

complementary feeding practices.

References

1. WHO. Global Strategy for Infant and Young Child Feeding. Geneva:

World Health Organization; 2003.

2. WHO. Infant and Young Child Feeding: A tool for assessing national

practices, policies and programmes. Geneva: World Health Organiza-

tion; 2003.

3. International Baby Food Action Network (IBFAN), Asia. World

Breastfeeding Trends Initiative (WBTi). India: IBFAN; 2011.

4. Gupta R, Holla R, Dadhich JP, Suri S, Trejos M, Chanetsa J. e status of

policy and programmes on infant and young child feeding in 40 countries.

Health Policy and Planning 2012;doi:10.1093/heapol/czs061:1-20.

5. Chaparro CM, Lutter CK. Increases in breastfeeding duration observed in

Latin America and the Caribbean and the role of maternal, demographic

and healthcare characteristics. Food Nutr Bull. 2010;31:S117-27.

6. Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS, Bellagio

Child Survival Study Group. How many child deaths can we prevent

this year? Lancet. 2003;362:65-71.

7. Lutter CK, Morrow AL. Global trends in breastfeeding and implica-

tions for policy and programs. In preparation. 2012.

8. WHO, UNICEF, Academy for Educational Development, USAID, Af-

rica’s Health in 2010. Learning from large-scale community-based pro-

grammes to improve breastfeeding practices. Geneva: WHO; 2008.

9. Edmond KM, Zandoh C, Quigley MA, Amenga-Etego S, Owusu-

Agyei S, Kirkwood BR. Delayed breastfeeding initiation increases risk

of neonatal mortality. Pediatrics. 2006;117:380-6.

10. WHO and partners. Indicators for assessing infant and young child

feeding practices. Part 1 Deﬁnitions. Geneva: World Health Organiza-

tion; 2008.

11. WHO and partners. Indicators for assessing infant and young child

feeding practices. Part 3: Country proﬁles. Geneva: World Health Or-

ganization; 2010.

For more information, please contact:

Project on Healthy Life Course

Pan American Health Organization

525 23rd Street, NW

Washington D.C. 20037

Website: www.paho.org

Telephone: (202) 974-3871

[email protected]

Acknowledgments

is policy brief was written for World Breastfeeding Week 2012 by Dr. Chessa Lutter, Senior Advisor Food and Nutrition, Pan

American Health Organization. It is also available in French, Portuguese and Spanish. is brief and other material on infant

and young child feeding are available at: www.paho.org/alimentacioninfantil.