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December 13, 2017
by Jenny Blair

Working around the world, a Yale School of Public Health researcher seeks to increase breastfeeding one baby at a time.

Breast milk: it’s liquid gold. For the vast majority of babies and mothers, breastfeeding is a safe, free and healthful choice, one that saves countless lives.

Yet relatively few mothers breastfeed for long. Many of them add or substitute with formula long before the baby has fully benefited from breast milk. Completing the recommended six months of exclusive breastfeeding (EBF) after birth—the single most powerful way to reduce infant mortality—is uncommon. In low- and middle-income countries, only 37 percent of babies receive EBF for the first six months of life. The United States’ rate is 27 percent. In the United Kingdom, it’s less than 1 percent.

Professor Rafael Pérez-Escamilla, Ph.D., director of the Global Health Concentration at the Yale School of Public Health, is working to change those numbers one country at a time. He’s devised an evidence-based process that helps countries create a customized program to boost and sustain their breastfeeding rates. The Becoming Breastfeeding Friendly (BBF) process, now under way in Mexico and Ghana, is about to launch in three more countries. It’s the culmination of Pérez-Escamilla’s decades-long concern with infant nutrition. “Very early on, I became convinced that the earlier in life that we start, the more successful we are going to be with health promotion and disease prevention,” Pérez-Escamilla said. “The human race exists in large measure because of breastfeeding. What could be more important than that?”


Study after study shows how important breastfeeding is for both mothers and their children. A 2016 analysis in The Lancet estimated that universal EBF would prevent 20,000 annual maternal deaths from breast cancer alone, in addition to averting 823,000 child deaths. Breastfed babies suffer fewer bouts of diarrhea and fewer respiratory infections, they are less likely to become obese and they score higher on intelligence tests. Nursing mothers gain a natural, temporary form of birth control, and they enjoy a lower risk of diabetes and breast and ovarian cancers. Not to mention all that bonding time.

But as many mothers can attest, it’s not always easy to breastfeed. And telling people “breast is best” is nowhere near enough. “In many countries, the vast majority of women already know that,” Pérez-Escamilla said.

One problem is a lack of expert help. Breastfeeding is a skill both mother and baby must learn. Assistance from a lactation counselor in the baby’s first month can be invaluable—a successful first few weeks can ensure smooth sailing afterward. Learning how to breastfeed is just the start, though. All over the world, finding the time and a safe, clean and private place to nurse can be prohibitive. Work environments can be hostile to nursing mothers, and women have been harassed for nursing in public. Inadequate maternity leave and the difficulties of pumping do not help. The problem can be worse for women who earn a living in the informal sector, such as by selling produce at a public market. Add to that the pressure exerted by companies that sell baby formula. Marketing can be intense, including offers of free or discounted formula and promotion of the idea that the breast won’t give babies enough nutrition. Though the World Health Organization issued an ethical code concerning the marketing of baby formula back in 1981, it’s not often enforced. “For example, in Mexico [these companies] are totally out of control,” Pérez-Escamilla said. “It is absolutely difficult to try to promote breastfeeding in that context.”


Addressing all these factors was his aim when, in 2012, supported by the Bill & Melinda Gates Foundation, Pérez- Escamilla and his team sat down to study peer-reviewed and “gray” (derived from reports from international agencies) literature to learn what has and hasn’t worked in breastfeeding programs. The team then mapped out a group of interlocking processes, or “gears,” that are necessary to the “machine” needed to scale up breastfeeding rates and keep them high. The team dubbed this approach the breastfeeding gear model. These gears include advocacy, political will and funding for program implementation; pro-breastfeeding legislation and policies relating to, for example, paid maternity leave; training of lactation professionals; social marketing based on a sound understanding of a community’s unique needs; research and evaluation; and intersectoral coordination and monitoring of ongoing programs.

Then, thanks to a 2015 grant from the breastfeeding-focused Family Larsson-Rosenquist Foundation, Pérez- Escamilla’s group devised the two-step BBF initiative.

Step one is a months-long assessment of 54 benchmarks around the country to generate a score on the BBF Coun- try Index created by Pérez-Escamilla’s team and a group of breastfeeding policy experts, including representatives from the World Health Organization, UNICEF and the Gates Foundation.
Each benchmark corresponds to a gear in the breast- feeding gear model. Countries with too many low bench- mark scores and inadequate gears might fund and launch unfocused programs without seeing their EBF rates budge. So assessing what is and isn’t in place is crucial.

In step two, the committee shows decision makers their “BBF report card” and issues recommendations. As of spring 2017, the BBF process was complete—and is expected to soon lead to implementation of new policies to protect, promote and support breastfeeding—in its first two pilot countries, Mexico and Ghana.

In the early 1990s, surveys in Ghana revealed a shockingly low 2 percent EBF rate. After the country passed new laws, including one mandating 12 weeks’ paid maternity leave, the rate climbed to 63 percent in 2008. But then it began to fall. By 2011, the rate was 46 percent. Ghana’s goal: 85 percent.With its Breastfeeding Friendly Country Index scores in hand, Pérez-Escamilla flew to Ghana in February to present encouraging results. Ghana already has all eight gears in place, with four rated “strong” and the others of “moderate strength.” The team recommended that lawmakers increase maternity leave, train breastfeeding advocates and partner with media.

In Mexico, Pérez-Escamilla’s birthplace, the challenge is steeper and the goal more modest. With an EBF rate of only 15 percent, the country’s goal is to double that rate within 5 years. The committee suggested paid maternity leave, the expansion of hospital policies that promote nursing and the prevention of unethical marketing of infant formula, among other measures.

By 2019, scale-up in Ghana and Mexico should be complete. In the meantime, three new countries—Myanmar, Germany and Samoa—are beginning the benchmarking process. In an ideal world, all newborns would benefit from a full course of human milk. That’s the goal of the Family Larsson-Rosenquist Foundation. The World Health Organization aims for 50 percent EBF by 2025. As for Pérez-Escamilla, his goal is simply to work with each country to help it reach its own goals.

“All we need is political will and a relatively small investment to improve breastfeeding globally,” he said. “It will be, perhaps, very surprising how soon after you start investing in these recommendations you can start seeing improvement.”

Read the latest Yale Public Health magazine for insights on global childhood health.

Submitted by Elisabeth Reitman on December 11, 2017