Pilot testing of the Becoming Breastfeeding Friendly toolbox in Ghana

Background Ghana has achieved significant progress in breastfeeding practices in the past two decades. Further progress is, however, limited by insufficient government funding and declining donor support for breastfeeding programs. The current study pretested feasibility of the Becoming Breastfeeding Friendly (BBF) toolbox in Ghana, to assess the existing enabling environment and gaps for scaling-up effective actions. Methods Between June 2016 and April 2017, a 15-person expert country committee drawn from government and non-government agencies was established to implement the BBF toolbox. The committee used the BBF index (BBFI), comprising of 54 benchmarks and eight gears of the Breastfeeding Gear Model (advocacy; political will; legislation and policy; funding and resources; training and program delivery; promotion; research and evaluation; and coordination, goals and monitoring). Available evidence (document reviews, and key informant interviews) was used to arrive at consensus-scoring of benchmarks. Benchmark scores ranged between 0 (no progress) and 3 (major progress). Scores for each gear were averaged to estimate the Gear Total Score (GTS), ranging from 0 (least) to 3.0 (strong). GTS’s were aggregated as a weighted average to estimate the BBFI which ranged from 0 (weak) to 3.0 (outstanding). Gaps in policy and program implementation and recommendations were proposed for decision-making. Results The BBFI score was 2.0, indicating a moderate scaling-up environment for breastfeeding in Ghana. Four gears recorded strong gear strength: advocacy (2.3); political will (2.3); legislation and policy (2.3); and coordination, goals and monitoring (2.7). The remaining four gears had moderate gear strength: funding and resources (1.3); training and program delivery (1.9); promotion (2.0); and research and evaluation (1.3). Key policy and program gaps identified by the committee included sub-optimal coordination across partners, inadequate coverage and quality of services, insufficient government funding, sub-optimal enforcement of policies, and inadequate monitoring of existing initiatives. Prioritized recommendations from the process were: 1) strengthen advocacy and empower breastfeeding champions, 2) strengthen breastfeeding regulations, including maternity protection, 3) strengthen capacity for providing breastfeeding services, and 4) expand and sustain breastfeeding awareness initiatives. Conclusions The moderate environment for scaling-up breastfeeding in Ghana can be further strengthened by addressing identified gaps in policy and programs. Electronic supplementary material The online version of this article (10.1186/s13006-018-0172-y) contains supplementary material, which is available to authorized users.


Background
Breast milk provides all of the essential nutrients, minerals, and vitamins an infant requires for growth in their first months of life. It also contains antibodies that help combat disease and build the child's immunity at the most vulnerable part of his or her life. During the first six months, an exclusively breastfed child (given only breast milk) is 14 times less likely to die than a non-breastfed child.
Early initiation and exclusive breastfeeding of young children are essential components of Ghana's child health Strategy. However, only 56% of Ghanaian infants are put to the breast within one hour of delivery, as recommended. Further, only 52% of infants younger than 6 months are exclusively breastfed compared to 63% in 2008. Indeed, the median duration of exclusive breastfeeding has been progressively declining over the past decade and is now at only 2.5 months.
To contribute to addressing these adverse outcomes, the Becoming Breastfeeding Friendly (BBF) process used the Breastfeeding Gear Model (BGM) 1 to assess country readiness to scale up various components of breastfeeding services in Ghana (programs, initiatives, policy environment, etc). The BBF will also help countries use evidence to scale up breastfeeding support services. The BGM uses available contextual evidence to score country breastfeeding performance based on 8 'Gears':

Policy Brief
Janauary 2017 In consultation with the Ghana Health Service, a 12-member committee with membership from government, United Nations agencies, civil societies, bilateral donor organizations, and academia was established to implement the process, in collaboration with the Ghana Health Service and under the leadership of the University of Ghana. The committee held four meetings between June and December 2016. Using a rigorous scoring process, the committee scored the national breastfeeding program performance, by consensus, on the 8 gears using best available evidence. The figure below is color-coded and shows the outcome of the readiness assessment for each of the 8 gears. Overall, the country score was 1.99 out of a maximum of 3.0. This means the country has a moderate strength environment for scaling up breastfeeding impact.
Following the assessment, the committee also proposed recommendations for action based on the BBF findings. Subsequently in January 2017, a call to action meeting, attended by a cross-section of stakeholders, enabled sharing, discussion, and prioritization of the key recommendations. Below are a list of the key recommendations and priority actions for the consideration of decision makers and breastfeeding champions.

Annex: Full list of recommendations
Advocacy Gear:  Implement training (e.g. seminars) for media personnel across the country on breastfeeding issues to build their knowledge and capacity to advocate for breastfeeding interventions through the Ghana Journalist Association and the Editors Forum.  Enlist new/Engage existing champions and provide materials on breastfeeding for them to use for advocacy  Actively promote breastfeeding through existing scientific meetings of the professional associations/societies e.g. medical association, nutrition association, etc.  Actively engage persons identified as breastfeeding champions and also professional societies (including GINAN) and build their capacity for effective advocacy; motivate them with system of recognition, e.g. as part of annual reviews  Revise and update breastfeeding-relevant policies and strategies, and scale up implementation of such policies country-wide  Provide guidelines for setting realistic targets for breastfeeding at national level  Ensure the 'Ten Steps to successful breastfeeding' are explicitly indicated in key documents on newborn and child health  Revise LI 1667 (breastfeeding promotion Law) to allow more stringent penalties for Code violations and also incorporate recent World Health Assembly resolutions  Strengthen implementation and dissemination of the Code of marketing of breast milk substitutes.  Advocate for ratification of the ILO Maternity Protection Convention, 2000, No. 183.  Facilitate adoption of at least 14 weeks maternity leave.  Facilitate amendment of LI 1667 (breastfeeding promotion Law) to require onsite accommodations for breastfeeding in government and private work places  Establish monitoring system regarding employment protection and discrimination relating to breastfeeding and maternity; will require gathering data on violations, particularly in the private sector.  Maternity protection at workplace should be incorporated into trade union collective bargaining agreements.  Strengthen enforcement of code of marketing of breast milk substitutes

Funding & Resources Gear:
 Review budget line indicators for reporting and tracking breastfeeding  Breastfeeding should be adequately budgeted for in integrated annual work plans  Analyze and report breastfeeding data in district-level health information management system (during annual reviews) for program improvement Training & Program Delivery Gear: Curricula  Champion and implement updated breastfeeding training curricular of Nurses and Midwives Council in pre-service training institutions.  Harmonize training curricula used by government health service agencies and also nongovernment partners; eliminate contradictions, ensure it contains key competencies (knowledge and skills aspects) necessary for optimal practice.  Update Community Infant and Young Child Feeding (IYCF) training package to include health worker responsibilities under the Code  Strengthen practical component of training using 'qualified trainers'

M & E
 Establish decentralized harmonized database of in-service training (+ trainers) to ensure adequate information on existing capacity and gaps.  Assess content of breastfeeding training programs to identify gaps.  Establish capacity need for breastfeeding  Establish/strengthen monitoring system for monitoring BFHI re-assessment-together with an alert system that kicks in prior to the time for reassessment; strengthen decentralization of BFHI reassessment

Job aids and resources
 Ensure timely dissemination of training documentation to all stakeholders; keep records of institutions which have received the documents.

Training programs
 Scale up community health workers and volunteers training in breastfeeding  Target training and service delivery resources to districts which are resource constrained  Operationalize process to certify lactation management specialists/consultants Promotion Gear: b corn q b. ec:st' ed1n 1 fr E'"d y  Scale up dissemination/implementation of existing policies and programs on breastfeeding  Increased budget for implementation of social behaviour change communication campaigns  Engage retired health staff (as complement to staff in service) and also volunteers to support breastfeeding promotion  Report breastfeeding programming activities (including promotion activities) at decentralized levels  Develop program for breastfeeding promotion all year round in partnership with media  Use maternity promotion as a tool for breastfeeding promotion  Awareness creation among workers concerning existing maternity protection should be implemented

Research & Evaluation Gear:
 Operationalize annual breastfeeding surveillance system  Identify groups with elevated vulnerability regarding successful breastfeeding and establish breastfeeding protection, promotion and support criteria for these vulnerable groups  Ensure wide dissemination of national survey data on breastfeeding  Decentralize monitoring of Code implementation  Develop simplified template for collation of reports on lactation counselling/support to be reported at regional level  Create access to BFHI/Ten Steps implementation tracking data on Ghana Health Service (GHS) website  Include behaviour change communication tracking data in district-level health information management system

Coordination, Goals, & Monitoring Gear:
 Ensure regular scheduled meetings of BFHI/IYCF committees are implemented; limit adhoc meetings  Develop a workplan for action b corn q b. ec:st' ed1n 1 fr E'"d y