Becoming Baby Friendly: A Complex Adaptive Systems Toolbox for Scaling up Breastfeeding Programs Globally
Authors: Perez‐Escamilla Rafael , Hromi‐Fiedler Amber , Gubert Muriel 
Published: November 2023

Metrics exist to assist committed countries with measuring their existing environments for scaling up breastfeeding programs. Yet, no evidence‐based toolboxes exist to help countries to both assess as well as guide the development of national breastfeeding programs and their scaling‐up. The Becoming Breastfeeding Friendly (BBF)Toolbox provides an evidence‐based index (BBFI) as well as case studies designed to guide the development and tracking of large scale well‐coordinated multi‐sector national breastfeeding promotion programs that can be uniformly translated for use in low, middle, and high income countries worldwide Grounded in the evidence‐based Breastfeeding Gear Model (BFGM) complex adaptive systems framework, the BBFI was developed between August 2015 and January 2016 by Yale University researchers in collaboration with a 13‐member Technical Advisory Committee (TAG) comprised of academic (Bangladesh, Brazil, Canada, Ghana, Mexico, UK, USA), international agencies (WHO, UNICEF, PAHO), philanthropic organizations (Bill and Melinda Gates Foundation, Alive & Thrive), and policy experts in breastfeeding as well as members with expertise in metric development relevant to scaling up of health and nutrition programs. First, a review of the academic and grey literature was conducted by the BBF steering committee to identify metrics to assess country‐level readiness to scale up health initiatives within the areas of infant and young child feeding, food and nutrition, and newborn survival. The steering committee met regularly to develop and reach agreement on the key benchmarks and definitions for the BBFI, which were then proposed to the TAG. TAG members participated in the progressive assessment and revision of the BBFI following a Delphi consensus methodology. As part of this process, the TAG was convened for a three day highly intensive participatory meeting to discuss and reach initial consensus on the definitions and benchmarks for the metric. Following this meeting, TAG members continued to provide their expertise with the refinement of the BBFI, including weighting the benchmarks to help develop the BBF scoring algorithm. The resulting BBFI consists of eight gears that correspond to the BFGM: Advocacy (4 benchmarks); Political Will (3 benchmarks); Legislation & Policy (10 benchmarks); Funding & Resources (4 benchmarks); Training & Program Delivery (17 benchmarks); Promotion (3 benchmarks); Research & Evaluation (10 benchmarks); and Coordination, Goals, & Monitoring (3 benchmarks). Each gear contains gear‐related themes and associated benchmarks. A global BBFI total score as well as sub‐scores for each of the eight gears can be calculated from the benchmarks. The country environment as BBF is ranked as weak, moderate, strong and outstanding according global BBFI result. To aid countries in how to use their baseline enabling environment assessment to advocate for policy and program changes, the toolbox includes eighty‐seven case studies illustrating data‐driven decision making along with their references. The BBF toolbox is currently in the final stages of validation in Mexico and Ghana. Findings thus far indicate that BBF has a strong potential to influence effective scaling up of breastfeeding protection, promotion and support worldwide.Support or Funding InformationFunded by the Family Larsson‐Rosenquist Foundation.