How do global organisations work best to influence political commitment at country level to protect and promote breastfeeding and support women to breastfeed?

Whether they live in low, middle or high income countries, many women encounter barriers to breastfeeding. Worldwide, fewer than 40% of infants under six months old are breastfed exclusively and more than half of newborns are not breastfed within the first hour of life (UNICEF Global Databases 2014). Many of the barriers to breastfeeding are socio-cultural, economic or relate to the lack of support from health services (Save the Children 2013). Socio-cultural barriers include societal norms for infant feeding, inappropriate advice from family and friends, lack of acceptability of breastfeeding in public spaces, and cultural beliefs e.g. that breastmilk alone is inadequate to meet the nutritional needs of babies. Economic barriers include the need for women to engage in paid employment soon after birth and the influence of commercial interests e.g. lobbying and advertising by breast-milk substitutes companies. Health service barriers include lack of skilled practitioners and lack of breastfeeding support programmes in hospitals and communities. The evidence for what enables women to breastfeeding highlights the importance of factors such as mother-to-mother support/peer counselling and initiatives such as the UNICEF Baby Friendly Initiative (Renfrew et al 2012), adequate paid maternity leave, legislation to support breastfeeding mothers in the workplace, and implementation and monitoring of the WHO Code of Marketing of Breastmilk Substitutes. Previous studies have highlighted that global and national organisations are key to protecting, promoting breastfeeding, and supporting women to breastfeed but their efforts are not always harmonised or effective (UNICEF 2013). This study aimed to explore the role of global and national organisations in influencing political will to protect, promote and support breastfeeding. The objectives were to: highlight examples of good practice where global and national organisations have successfully influenced national political commitment to breastfeeding; identify barriers that prevent global and national organisations from influencing national governments to prioritise breastfeeding; and make recommendations for how global organisations can more effectively influence political commitment to breastfeeding. .We conducted case studies of six countries: Bangladesh, Brazil, Indonesia, Nigeria, the Philippines and the United Kingdom. The countries were selected to represent different geographical regions, income levels and a range of experiences and achievements in protecting and promoting breastfeeding, and supporting women to breastfeed. Each case study comprised:1. a desk-based review of published and grey literature; 2.telephone interviews with 23 key informants from 19 global organisations across the six countries (an additional 16 informants from 10 global organisations provided written responses to the interview questions)3.an online survey of national organisations to which 20 organisations responded. Data were collected during November and December 2014. The research material was analysed and triangulated under key themes. Each case study was written up following a structured template and reviewed by respondents from global organisations who had participated in the study for accuracy and clarification.The findings of the case studies identified that global and national organisations were most effective when they worked collaboratively using strong, unified and consistent breastfeeding messages such as the Common Narrative approach used in Bangladesh. Our study highlighted four components that coalitions of global, national and government partners need to incorporate in their plans to successfully improve breastfeeding practices at scale. These are: creating an enabling environment for breastfeeding through implementing the International Code of Marketing of Breastmilk Substitutes (the Code) and maternity protection legislation; implementing infant and young child feeding programmes that focus on health facilities and community support, and include individual counselling; raising community awareness of the importance of breastfeeding using mass media such as television, radio and social media; and equipping all health workers with the knowledge and skills to support women to breastfeed. According to our study, the most common barrier to governments’ commitment to breastfeeding is inadequate implementation of the Code and the negative influence of representatives of BMS companies. Other barriers include a lack of effective global leadership for breastfeeding, lack of knowledge, capacity and staff turnover at national government level, lack of accurate data and lack of resources for breastfeeding programmes. Our study culminated in four over-arching recommendations:1.Enhance and strengthen international leadership on breastfeeding2.Facilitate and support national government ownership of breastfeeding-focussed initiatives, policies, plans and programmes3.Initiate improved collaboration and coordination among global and national organisations operating at the national level4.At both international and national levels, enhance breastfeeding advocacy and communications through the identification of breastfeeding champions, including pregnant women, breastfeeding mothers and families, and fathers, as well as the provision of consistent breastfeeding messages.ReferencesUNICEF Global Databases (2014). Infant and Young Child Feeding. Available at www.data.unicef.org/nutrition/iycfSave the Children (2013). Superfood for babies: how overcoming barriers to breastfeeding will save babies lives. London: Save the Children Renfrew MJ, McCormick FM, Wade A, Quinn B, Dowswell T. (2012) Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database of Systematic Reviews, 5: DOI: 10.1002/14651858.CD001141.pub4.UNICEF (2014) Breastfeeding on the worldwide agenda: findings from a landscape analysis on political commitment for programmes to protect, promote and support breastfeeding. New York: United Nations Children’s FundThe study was funded by Save the Children UK and supported by a Project Advisory Group with representation from Alive & Thrive, Helen Keller Institute, MAINN, UNICEF IYCF Group and WHO. The full report is available at: http://www.savethechildren.org.uk/resources/online-library/breastfeeding-policy-matters