Research and Evaluation

Scaling-up of breastfeeding programs and initiatives cannot be effective without decision makers having access to useful process and impact evaluations in a timely manner. For that to happen, a sound multi-level monitoring and evaluation system:

• Systematically and routinely collects data on process indicators, to ensure the effectiveness and quality of breastfeeding programs;
• Identifies ineffective or poor quality programs and rectifies them;
• Allows for information sharing from the local to the national level, in a timely fashion;
• Enables decision makers to directly invest in breastfeeding programs in efficient ways; and
• Enables investment in operational evaluation/research seeking to understand and continuously improve the quality of the national breastfeeding program.

This gear evaluates:

• Availability, integration, and monitoring of key breastfeeding practices
• Availability of monitoring systems to track implementation of activities essential to the scaling up of breastfeeding

The two themes for this gear

• Breastfeeding Outcomes (Benchmarks REG1, REG2, REG3, REG4, REG5)
• Monitoring Process Indicators (Benchmarks REG6, REG7, REG8, REG9, REG10)

All benchmarks are referenced to “the past year” unless otherwise noted.

Description: Indicators of key breastfeeding practices are vital to understanding the current state of breastfeeding, trends in breastfeeding practices, and identifying where improvements need to be made.
Key breastfeeding practices:

• Children ever breastfed
• Early initiation of skin-to-skin/breastfeeding
• Exclusive breastfeeding under 6 months
• Continued breastfeeding at 1 year
• Continued breastfeeding at 2 years

This benchmark assesses if indicators of these key breastfeeding practices are included in national surveys on a routine basis at least once every 5 years.

Possible data sources: These breastfeeding practices are typically obtained from nationally representative Demographic and Health Surveys (Demographic and Health Surveys may be available through https://www.dhsprogram.com/) or equivalent surveys as well as “rapid” large scale surveys applied during immunization campaigns.

How to score: The scoring reflects the frequency at which key breastfeeding practices are included in national surveys and the frequency at which those national surveys are administered.

☐ No progress: Indicators of key breastfeeding practices are not routinely included in periodic national surveys.

☐ Minimal progress: Indicators of key breastfeeding practices are routinely included in periodic national surveys and this data are updated at least once every 10 years.

☐ Partial progress: Indicators of key breastfeeding practices are routinely included in periodic national surveys and this data are renewed at least once every 5 years.

☐ Major progress: Indicators of key breastfeeding practices are routinely included in periodic national surveys and this data are renewed more than once every 5 years.

Description:
According to the WHO, health information systems have four key functions:

• data generation;
• compilation;
• analysis and synthesis; and
• communication and use

Monitoring key breastfeeding practices in routine health information systems serves to update decision makers on current breastfeeding status nationally and help them decide when to intervene.

This benchmark assesses if key breastfeeding practices are monitored in routine health information systems and gauges coverage and if key indicators have been publicly reported. Key breastfeeding practices:

• Children ever breastfed
• Early initiation of skin-to-skin/breastfeeding
• Exclusive breastfeeding under 6 months
• Continued breastfeeding at 1 year
• Continued breastfeeding at 2 years

Possible data sources: Interviews with health officials from the MOH, UNICEF and WHO can help identify if the country has an active health information system available, its usage, and its coverage. Examining the health information system data will be needed to corroborate key informants’ reports and confirm which, if any, key breastfeeding practices are monitored.

How to score: The scoring for this benchmark reflects if:

a) key breastfeeding practices are monitored in routine health information systems,
b) systems have full coverage (i.e. national, subnational and local coverage), and
c) key breastfeeding indicators are publicly reported.

☐ No progress: Key breastfeeding practices are not monitored in routine health information systems.

☐ Minimal progress: Key breastfeeding practices are monitored in routine health information systems, but the systems are not electronic nor have key indicators been publicly reported.

☐ Partial progress: Key breastfeeding practices are monitored in routine health information electronic systems, but the systems do not have full coverage (i.e. national, subnational and local coverage) nor have key indicators been publicly reported.

☐ Major progress: Key breastfeeding practices are monitored in routine health information electronic systems, have full coverage (i.e. national, subnational, and local level) and key indicators have been publicly reported.

Description: National surveys must be able to stratify data to these different levels with reasonable representation. Data that should be available on key breastfeeding practices:

• Children ever breastfed
• Early initiation of skin-to-skin/breastfeeding
• Exclusive breastfeeding under 6 months
• Continued breastfeeding at 1 year
• Continued breastfeeding at 2 years

This benchmark assesses if data on key breastfeeding practices are available and the regional levels of this availability.

Possible data sources: National survey data from national health surveys administered by the government or through organizations, such as the Demographic and Health Survey, should be examined to assess the availability of key breastfeeding practices and the level of stratification. Interviews with health officials from MOH may help identify other data sources and whether data is collected at various levels (national and sub-national including local/municipal levels). Reports derived from those alternative data sources should be assessed for understanding the quality of data at the different levels, including the local/municipal level.

How to score: The scoring reflects availability of key breastfeeding data at various levels.

☐ No progress: Data on key breastfeeding practices are not available at all levels: national, subnational and local/municipal.

☐ Minimal progress: Data on key breastfeeding practices are only available at the national level.

☐ Partial progress: Data on key breastfeeding practices are available at the national level and subnational levels.

☐ Major progress: Data on key breastfeeding practices are available at the national, subnational and local/municipal levels.

Description: Understanding breastfeeding practices of key vulnerable groups aids in decision making and advocacy. Key breastfeeding practices:

• Children ever breastfed
• Early initiation of skin-to-skin/breastfeeding
• Exclusive breastfeeding under 6 months
• Continued breastfeeding at 1 year
• Continued breastfeeding at 2 years

Vulnerable groups refers to populations at risk due to social, economic, cultural or biomedical circumstances. These can include indigenous populations, internally displaced populations, refugees, orphans, and HIV infected mothers and children. Countries can choose to include more vulnerable groups, if desired.

Possible data sources: Data from national health surveys administered by the government or through organizations, such as the Demographic and Health Survey, should be examined to assess the availability of key breastfeeding practices on vulnerable groups. Interviews with health officials from MOH, as well as the national breastfeeding coordinator, may help identify other data sources and whether data is collected on vulnerable groups. If so, it is important to corroborate the availability of such data.

How to score: The scoring for this benchmark reflects the availability and representativeness of key breastfeeding practice data for key vulnerable groups.

☐ No progress: Data on key breastfeeding practices are not representative of vulnerable groups.

☐ Minimal progress: Data on key breastfeeding practices are representative of vulnerable groups at the national level.

☐ Partial progress: Data on key breastfeeding practices are representative of vulnerable groups at the national and subnational levels.

☐ Major progress: Data on key breastfeeding practices are representative of vulnerable groups at the national, subnational and local/municipal levels.

Description: This benchmark assesses whether indicators of key breastfeeding practices are placed in the public domain and the frequency that this is done.

Public domain:

• making information/results about key breastfeeding practices available and accessible to all individuals using a publicly available method, such as published reports, media coverage, social media sites accessible to the public, etc.; and
• making the databases available and accessible to researchers as well as the general public.

Key breastfeeding practices:

• Children ever breastfed
• Early initiation of skin-to-skin/breastfeeding
• Exclusive breastfeeding under 6 months
• Continued breastfeeding at 1 year
• Continued breastfeeding at 2 years

Possible data sources: Interviews with health officials from MOH, UNICEF, and WHO, and the national breastfeeding coordinator, may help identify data on indicators of key breastfeeding practices placed in the public domain and how often. Media sources, infant feeding and/or breastfeeding reports from organizations can also be resources. All efforts should be made to access the public domain information to corroborate reports from key informants.

How to score: The scoring for this benchmark reflects the frequency at which the themes of key breastfeeding practices are placed in the public domain.

☐ No progress: Key breastfeeding practices (i.e. reports, breastfeeding databases, etc) are not placed in the public domain.

☐ Minimal progress: Key breastfeeding practices (i.e. reports, breastfeeding databases, etc) are placed in the public domain less than once every two years.

☐ Partial progress: Key breastfeeding practices (i.e. reports, breastfeeding databases, etc) are placed in the public domain every two years.

☐ Major progress: Key breastfeeding practices (i.e. reports, breastfeeding databases, etc) are placed in the public domain annually.

Description: This benchmark assesses whether there is a monitoring system in place to track implementation of the Code. According to the WHO, monitoring mechanisms need to have the following criteria to ensure efficiency of implementation of the Code:

• Independence and transparency;
• Freedom from commercial influence;
• Empowerment to investigate code violations;
• Empowerment to impose legal sanctions. ¹

Process indicators that track implementation of the Code include:

• Prohibition of advertising and sales promotions of breast milk substitutes;
• Prohibition of free or low-cost supplies of breast milk substitutes and materials/gifts to health workers and health facilities;
• Requiring appropriate labeling with message of superiority of breastfeeding.

Possible data sources: Interviews with high level staff at the MOH, UNICEF, FDA and WHO should reveal if there is a monitoring system to track implementation of the code. Reports from WHO and UNICEF regarding country implementation of the Code are also good resources. Every effort should be made to access the monitoring system to corroborate key informant’s feedback and official reports.

How to score: The scoring for this benchmark includes the: a) presence/absence of a monitoring system to track implementation of the Code; b) if present, it is operational (i.e. used to track and enforce violators of the code by those implementing the code) and c) process indicators are periodically publicly reported for decision-making.

☐ No progress: There is no monitoring system in place to track implementation of the Code.

☐ Minimal progress: A monitoring system in place to track implementation of the Code but it is not operational nor are process indicators publicly reported.

☐ Partial progress: A monitoring system in place to track implementation of the Code and it is operational or process indicators are publicly reported.

☐ Major progress: A monitoring system in place to track implementation of the Code and it is operational and process indicators are publicly reported.

¹World Health Organization. Country Implementation of the International Code of Marketing of Breast-Milk Substitutes: Status Report 2011. 2013.

Description: This benchmark assesses the presence of a monitoring system to track enforcement of maternity protection legislation. Monitoring systems systematically and routinely collect data on process indicators in order to track progress of program or initiatives to ensure implementation and effectiveness.

Possible data sources: Interviews with government staff at the MOH, Ministry of Employment and Labour, UNICEF and WHO should reveal the presence of a monitoring system to track enforcement of maternity protection legislation. Reports from WBTi regarding enforcement of maternity protection legislation are also good resources. Every effort should be made to access the monitoring system to corroborate key informant’s feedback and official reports.

How to score: The scoring for this benchmark includes:

• Presence/absence of a monitoring system to track enforcement of maternity protection legislation;
• If present, it is operational (i.e. used to track and enforce violators of the maternity protection legislation); and
• Process indicators are periodically publicly reported for decision-making.
  
  

☐ No progress: There is no monitoring system in place to enforce maternity protection legislation.

☐ Minimal progress: A monitoring system in place to enforce maternity protection legislation but it is not operational nor are process indicators publicly reported.

☐ Partial progress: A monitoring system in place to enforce maternity protection legislation and it is operational

or process indicators are publicly reported.

☐ Major progress: A monitoring system in place to enforce maternity protection legislation and it is operational and process indicators are publicly reported.

Description: A national monitoring system that tracks the provision of lactation counseling/management and support can ensure that these services are available and provided countrywide. Monitoring systems systematically and routinely collect data on process indicators in order to track progress of program or initiatives to ensure implementation and effectiveness.

Possible data sources: Interviews with government staff at the MOH, UNICEF and WHO, and the national breastfeeding coordinator should reveal the presence of a monitoring system to track enforcement of maternity protection legislation. Every effort should be made to access the monitoring system to corroborate key informant’s feedback and official reports.

How to score: The scoring for this benchmark includes

a) Presence/absence of a monitoring system to track the provision of lactation counseling/management and support;

b) If present, it is operational (i.e. used to track the provision of lactation counseling/management and support; and

c) Process indicators are periodically publicly reported for decision-making.

☐ No progress: There is no monitoring system in place to track provision of lactation counseling/management and support.

☐ Minimal progress: A monitoring system in place to track provision of lactation counseling/management and support but it is not operational nor are process indicators publicly reported.

☐ Partial progress: A monitoring system in place to track provision of lactation counseling/management and support and it is operational or process indicators are publicly reported.

☐ Major progress: A monitoring system in place to track provision of lactation counseling/management and support and it is operational and process indicators are publicly reported.

Description: This benchmark assesses the presence of a monitoring system to track implementation of BFHI/Ten Steps. Monitoring systems systematically and routinely collect data on process indicators in order to track progress of program or initiatives to ensure implementation and effectiveness.

Possible data sources: Interviews with government staff at the MOH, UNICEF and WHO, and the national breastfeeding coordinator should reveal the presence of a monitoring system to track implementation of the BFHI/Ten Steps. Every effort should be made to access the monitoring system to corroborate key informant’s feedback and official reports.

How to score: The scoring for this benchmark includes:

a) Presence/absence of a monitoring system to track the implementation of the BFHI/Ten Steps;

b) If present, it is operational (i.e. used to track the compliance of BFHI/Ten Steps);and

c) Process indicators that measure implementation activities of the BFHI/Ten Steps are periodically publicly reported for decision-making.

☐ No progress: There is no monitoring system in place to track implementation of BFHI/Ten Steps.

☐ Minimal progress: A monitoring system in place to track implementation of BFHI/Ten Steps but it is not operational nor are process indicators publicly reported.

☐ Partial progress: A monitoring system in place to track implementation of BFHI/Ten Steps and it is operational or process indicators are publicly reported.

☐ Major progress: A monitoring system in place to track implementation of BFHI/Ten Steps and it is operational and process indicators are publicly reported.

Description: Monitoring systems systematically and routinely collect data on process indicators in order to track progress of program or initiatives to ensure implementation and effectiveness.

• Number of communication channels used;
• Number of breastfeeding BCC messages delivered;
• Proportion of country reached by breastfeeding BCC messages; and
• Proportion of households with knowledge of breastfeeding BCC messages.

Possible data sources: Interviews with government staff at the MOH, UNICEF and WHO, and the national breastfeeding coordinator should reveal the presence of a monitoring system to track behavior change communication activities. Whenever possible a review of documents describing monitoring system structure and activities should be undertaken to corroborate the information provided by the key informants.

How to score: The scoring for this benchmark includes:

• Presence/absence of a monitoring system to track the BCC activities;
• If present, it is operational (i.e. used to track BCC activities); and
• Process indicators are periodically publicly reported for decision-making.

☐ No progress: There is no monitoring system in place to track behavior change communication activities.

☐ Minimal progress: A monitoring system in place to track BCC activities but it is not operational nor are process indicators publicly reported.

☐ Partial progress: A monitoring system in place to track BCC activities and it is operational or process indicators are publicly reported.

☐ Major progress: A monitoring system in place to track BCC activities and it is operational and process indicators are publicly reported.

• Research and Evaluation Gear
• Research and Evaluation Gear Scoring Table