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Professor Rafael Pérez-Escamilla
Yale School of Public Health, Principal Investigator, Becoming Breastfeeding Friendly (BBF): A Guide to Global Scale Up
How does integrating BBF in the operationalization approach being testing in Ghana extend its potential?
This is the crux – different groups of researchers, program evaluators doing work in silos will never be as effective as when key stakeholders discuss together and integrate their knowhow into smart platforms that can avoid redundancies and bring a lot of benefit to countries and families that we all want to receive better breastfeeding protection, promotion and support.
BBF started as a bird’s eye view for policies. The original idea was that the world would be much more effective at advancing policies and programs if we understand the policy gaps that need to be addressed to enable the environments that families and women need to implement their right to breastfeed when they choose to do so.
What I really like that is now happening in Ghana is this very innovative initiative called Breastfeeding for Life (BFL) that strongly complements BBF. It seeks to pick up where BBF ends. Once countries have done their breastfeeding trends, policies and programs landscape analysis, identified key systems level policy recommendations that need to be implemented to advance breastfeeding outcomes, then the key question is: How do we translate these policy recommendations into specific programs, interventions?
This has been an enormous gap, not only in the field of breastfeeding, but across maternal, infant and young child feeding programs. In some instances, it can take 20 years to translate policy recommendations into evidence-based program and interventions. What BFL is trying to do is analogous to how we are empowering decisionmakers, governments with a policy toolbox to identify policy priorities. BFL will allow the policy and program implementors to identify the best evidence-based programs and interventions for their context.
There is a very large literature on breastfeeding interventions. We have a good idea of which ones are effective and which ones not. Because BFL will be mapping out these interventions across countries with contrasting settings, it can help to build an important database that eventually, in my view with support from artificial intelligence, can help decisionmakers understand their particular context to select the best way to proceed with say, training required by the Baby-Friendly Hospital Initiative (BFHI), to provide a cash transfer to women working in the informal economy, as it often happens in lower income countries, to have better regulation based on the International Code of Marketing of Breastmilk Substitutes (The Code).
The holistic approach that integration of BBF with BFL will bring about solutions from the systems to the program and interventions levels to improve multi-sectoral coordination to substantially improve the effectiveness of breastfeeding protection, promotion, and support globally. This is why I am very excited to continue working with the Foundation on this enterprise.
Breastfeeding rates are not rising rapidly enough to meet the World Health Assembly goals. What keeps you optimistic?
I was very engaged in the 2023 Lancet Series on Breastfeeding. The bottom line is that it takes a whole of society approach to make breastfeeding work for families and moms who choose to do so. We like to think of the social-ecological model because it is very practical, and easy to visualize. That model has several concentric circles. At the center is the household where the mom and the baby are interacting. The next layer is the community. If a society does not support breastfeeding in public, it is not going to be easy for a mom who wants to breastfeed to be able to implement her right to do so when she goes to the market or is using the mass transit system.
The community layer of the socio-ecological model represents the access, or lack of access, to maternity facilities that are baby friendly, and to primary healthcare centers that provide community-based breastfeeding peer counseling. It also represents the work environments and how breastfeeding friendly they are or not to facilitate the ability for the mom to follow through her decision to breastfeed the baby for as long as she wants.
Communities are surrounded by policies that sit at the outer layer of the social-ecological model. Social protection policies are crucial for communities and families to have breastfeeding support when the mother works for income outside of the household. There are also healthcare and education policies. If medical students and nurses are not trained on breastfeeding as is very common across countries, then there is not going to be a qualified workforce to deliver the high-quality breastfeeding counseling and support that women need to make breastfeeding work.
Trade and regulatory policies are in that outer layer as well. If there are constant Code violations, infant feeding products imported into countries that don't respect the Code, commercial milk formula companies sponsoring pediatric conferences and no enforcement of Code regulation, then guess what's going to happen? When moms go to see their pediatricians, the pediatricians have already been visited by infant formula company representatives. If they are not well trained in breastfeeding and conflict of interest specifically, they may get persuaded that every single baby needs not only infant formula, but very expensive, specialized infant formula said to make them sleep better or not develop allergies when there is zero scientific evidence to support that. These companies also have major funding to sponsor infant feeding conferences all over all over the world. When I go to many pediatric association meetings, they indeed look like commercial milk formula markets.
This lack of regulatory policies also explains why supermarkets or pharmacies visibly display very nice-looking commercial milk formula products with packaging loaded with Code violations including misleading health messages. They offer discounts – two for one, three for one, which is another Code violation. It's also no surprise that women get targeted through Twitter, Facebook, Instagram. Through artificial intelligence, formula companies have developed sophisticated algorithms to target different moms. They know if a mom is pregnant, about to deliver, if she has delivered, if she has a six-month-old.
At the end of the day BBF helps by identifying those massive policy gaps across systems, including the marketing systems in the outer layers of the social-ecological model. What BFL will do is to translate these policies into specific programs and interventions that are cost effective and appropriate for the local context in which they are going to operate.
How can BBF support the very personal decision to breastfeed?
As a scientist, as a professional with over three decades of experience co-designing, implementing, evaluating infant feeding programs on a large scale, I am optimistic that we have the knowhow to make breastfeeding work for all. That’s why I really love working in the area of breastfeeding.
When I meet with the president of a country, a secretary of health, a mayor of a city, or healthcare providers in a municipality, I feel very comfortable saying: If all these layers of the social-ecological model are addressed through policy changes to enable environments for breastfeeding in communities and empowering moms and families to breastfeed through evidence-based interventions such as the BFHI, breastfeeding peer counseling, maternity leave and so on, you will see major improvements in exclusive breastfeeding (EBF) outcomes within a very reasonable amount of time.
Having said that, what The Lancet 2023 Breastfeeding Series exposes is how sophisticated and well-funded is the marketing playbook from the commercial milk formula industry to undermine and create smokescreens at every layer, for every policy, program and intervention that we know works, and that combined, have led a good number of countries to improve their EBF outcomes – even with imperfect investments or the lack of a well-coordinated, national multi-level strategy.
In countries like Ghana that have had relatively high rates of EBF, very elegant research including randomized controlled trials, have shown that home-based breastfeeding counseling was able to strongly improve EBF rates even though they were already quite high to begin with. Unfortunately, nowadays EBF rates have come down in Ghana as a result of urbanization combined with stronger marketing by the commercial milk formula industry in the low- and middle- income countries markets, as markets in higher income countries have become fairly saturated for their products.
There is indeed cause for optimism, but the missing link is to have in place much more innovative and evidence-based advocacy with decision makers, and at counteracting the algorithms from commercial milk formula companies to send accurate breastfeeding messages to moms that are being provided with misinformation. In my view, how much progress we make over the next decade is going to be a function of how much we can strengthen the policy layer of the social-ecological model, because it reflects the political will needed to effectively implement, scale up and sustain multi-sectoral programs driven by the massive knowhow that we have in place in the area of breastfeeding.
How does collaborating with the Foundation enable you to develop BBF and bring scientific knowledge to practical application?
My formal collaboration started in 2017, following two years of conversations about developing BBF, based on the Breastfeeding Gear Model (BFGM) – an engine-like model with eight gears (evidence-based advocacy, political will, policy development, legislation, funding and resources, training and program delivery, combined with behavior change, communication campaigns, evaluation, and at the center, the master gear that reflects setting goals, monitoring and coordination of activities in a decentralized way, from the national to municipal level) – and based on the experiences of countries that had been successful at improving breastfeeding outcomes. BBF became the translation of the BFGM into a policy toolbox to allow countries to assess by themselves the strengths and weaknesses of each gear and the whole “breastfeeding engine” using evidence-based benchmarks, and to make policy recommendations based on the scores and consensus discussion by the BBF committee members.
After doing a massive search of the literature and interviews with informants, I was approached at a conference about developing indicators for each of the gears and a policy toolbox. That planted the seed for BBF being one of the first projects that was funded by the foundation. In many ways BBF reflected the goal of the Foundation to move the science in our field into knowledge translation. It was very clear its vision was to see major improvements in EBF around the world. The Foundation has made major commitments also to basic, clinical, and epidemiology projects in the field of breastfeeding, human milk, and lactation, as long as there is a clear understanding of how the projects will help improve breastfeeding outcomes globally.
I have been extremely comfortable working with the Foundation in terms of my scientific independence. It is very unusual for a foundation to be so arm’s length to the work that we are doing. My team has benefitted a lot from Foundation participation in several of our meetings, and from its constructive feedback, always allowing my team at Yale to be in the driver’s seat and make final decisions. This is an example of how foundations can support innovative research to move a field forward while respecting the independence of researchers.
As a result, we are thrilled to be working with the Foundation on merging BBF with BFL into a unique dynamic platform, that will constantly be updated with new evidence. The goal is to work intensively with countries selected as knowledge hubs across different regions to support their neighboring countries. This way the Foundation will be contributing to self-driven capacity-building efforts in the countries themselves, instead of people from the countries having to be trained at Yale University or Harvard, or at other institutions located in high income countries. This is totally consistent with the philosophy of BBF which since day one has been to find out how can we empower countries to oversee their own breastfeeding destinies.
BBF has been implemented in 8 countries and counting – what’s next?
Our approach is not to try to convince governments that don’t want to support breastfeeding that they should support it. That is the role for evidence-based advocacy. BBF and BFL are for countries that have already decided that they want to scale up effective programs but need a roadmap to undertake this complex task.
I am very satisfied across the board with the original eight BBF countries, and it’s very gratifying to see that additional countries have approached us to train them on how to implement BBF using their own funds. BBF has indeed been proven to be feasible across very diverse settings with governments owning the process and taking very specific policy actions in response to the process, regardless of the level of economic development of the country.
For example, In Germany, the new national breastfeeding strategy is heavily based on the BBF process. In Mexico, they are about to start the fourth application of BBF because of how useful it has been to advance the breastfeeding national agenda.
Is there anything that you would like to add?
In the past, I have been criticized very harshly by groups that claim that my work is seeking to force women who don't want to breastfeed to do so, or to ask society to shame women that don’t breastfeed. I want to say that is the farthest from the truth.
The reality is that the great majority of women in the world are choosing to breastfeed. The second reality is, that among those who choose to breastfeed, very few end up meeting their breastfeeding goals. The evidence unequivocally says that this is because of major structural barriers that are discriminatory against the right that women have to breastfeed their babies for as long as they wish. And that's the group of people that every day I wake up to work for.
I want to say very clearly that I respect 100% the right that women have to choose how to feed their babies. I think what is very important is for them to make that decision based on sound evidence and not on misinformation. At the end of the day a woman should be supported in the infant feeding choice she makes. If she chooses to formula feed (or even if she didn’t, but that’s what she ended up having to do), she should be supported.
This is about allowing people to make informed decisions on a level playing field, no matter what their decision is, and it applies to breastfeeding, formula feeding and mixed feeding. Now it is far from being an even playing field, it is biased and tilted towards misinformation, making it very difficult for women who want to breastfeed to be able to do so for as long as they as they wish.
I never condone shaming people for decisions they make. People want the best for their infants, for their children. Instead of shaming them, we should shame the systems that are failing them. That’s what The 2023 Lancet Series on Breastfeeding is exposing – that a lot of people want access to the services and the policies needed to be successful with one of the most cost-effective interventions every known to humankind, which is breastfeeding, just don’t have access to them because of major social, economic, political and health care systems structural barriers.
That’s where I’m optimistic that we are entering a new phase. I hope that the work we have been engaged with on The Lancet Series, together with BBF, BFL, and other work that the Foundation is funding, collectively will end up taking the breastfeeding world to the next levels.