cross-sectoralimplementation guidance

Cross-Sectoral Implementation Guidance

ADS Chapter 212:

Breastfeeding Promotion Policy

AcknowledgementsThis document was prepared using a vetting process over the period of time from June 2000 - October 2001.

Initial drafts were prepared by the Agency Breastfeeding Committee (ABC) members Kristen Marsh, MiriamLabbok, and Beth Drabant, then reviewed with representatives from each sector in an interview/interactiveprocess.

The authors wish to thank Karen Lombardi of the Monitoring, Evaluation and Design (!VIEDS) project, therest of the ABC (Shirley Coly, Mihira Karra, Jennifer Notkin, Rachel Herr, and Jyoti Schlesinger) and themany USAID staff who participated in this process. The contribution of Linkages to this document isgratefully acknowledged.

I. GIPHN Senior ManagementDuff Gillespie, Director GIPHN

Ray Kirkland, Deputy Director, GIPHN

Margaret Neuse, Director, Office of Population

Sigrid Anderson, Chief, Division of Family Planning

Ellen Starbird, Chief, Division of Policy & Evaluation

Jeff Spieler, Chief, Research Division

Maria Busquets, Acting Chief, Communication, Management & Training

Joy Riggs-Perla, Director, Office of HealthlNutrition

Irene Koek, Director, Division of Environmental Health

Richard Greene, Director, Child Survival Division

Bob Emrey, Director, Health Policy Reform Division

Paul Delay, Director, mV/AiDS Division

Paul Hartenberger, Director, Office of FieldlProgram Support

II. SO Team LeadersSO1 - Ellen Starbird

S02 - Mary Ellen Stanton

S03 - AI Bartlett

S04 - Paul Delay

S05 - Irene Koek

III. Other GlBureau CentersCenter for Economic Growth and Agricultural Development (GIEGAD) Emmy Simmons, Rob Bertramand Steve Hadley

Center for Human Capacity Development (GIRCD) Emily Vargas-Barone

IV. Regional BureausAFRISDIHRDD - Hope Sukin

ANElSEAlSPA -Gary Cook

E&EIEESTIHRHA - Mary Ann MickaIMJ Lazear

LACIRSD-PHN - Carol Dabbs

V. Other OfficesBureau for Humanitarian Response (BHR) Len Rogers

BHRlOFDA - Peter Morris

BHR- Tom Marchione

Office of Private and Voluntary Cooperation (BHRlPVC) Ann Hirschey

Office of Food for Peace (BHRIFFP) Rene Berger

Bureau for Legislative and Public Affairs (LPA) Barbara Bennett

Office of Women in Development (GIWID) (refused interview)

Office of Administrative Services - Betsy Brown, Martha Rees, and Steve Callahan

Bureau for Policy and Program Coordination (PPCIPDA) Joyce Holfeld

Final revisions were completed by Rachel Herr and Amanda Huber in October, 2001.

Cross-Sectoral Implementation GuidanceADS Chapter 212: Breastfeedin Prombtlon Policy

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Table of Contents

Acronynts v

Introduction 7

Child Health and Infectious Diseases •••••••••••••••••••••••••••••••••.••••••••••••••••.••• 9

Maternal and Neonatal Health •.•••••••••••••••••••••••••••••••••••••.•••••••.•••••••••••11

HIV/AIDS •••••••••••••••••••••••••••••••••••••••••.•••••••••••••••••••••••••.•••••••13

Population and Family Planning ••••••••••••••.••••••••••••••••••.•••••••••••••••••••••••15

Nutrition, Agriculture, and Food Security •••.••••••••••••••••••••••••••••••••••.•••••••••••17

Gender and WOlDen's Rights 19

Education and Human Capacity Development ••••••••••••••••••••••••••••••••••••••••••••••21

Economic Development, Environment, and the Private Sector •••••••••••••••••••••••••••••••••23

Disasters and Emergenies •••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••25

Appendices:

Appendix A: International Code of Marketing of Breastmilk Substitutes ••••••••••••••••••••••••29

Appendix B: Definitions and Suggested Breastfeeding Indicators ••••••••••••••••••••••••••••••35

Appendix C: Functional Series 200 - Programming Policy Chapter 212 -Breastfeeding Promotion Policy ••••••••••••••••••••••••••••••••••••••••••••••39

See Also Companion Document:

Background Paper

ADS Chapter 212: Breastfeeding Promotion Policy

Cross-Sectoral Implementation Guidance,ADS Chapter 212: Breastfeeding Promotion Policy

Acronyms

ACC/SCN

ADS

BFHI

DHS

EBR

FP

FYGHHIV/AIDS

LAM

LURMCH

MDB

MTCT

PPCIPDC

RF

UN

UNICEF

USAID

veT

Administrative Committee on Coordination, Sub-Committee on Nutrition

Automated Directive Systems

Baby Friendly Hospital Initiative

Department of Human Services

Exclusive Breastfeeding Rate

Family Planning

Fiscal Year

Bureau for Global Health

Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome

Lactational Amenorrhea Method

Lactational User Rate

Maternal/Child Health

Median Duration of Breastfeeding

Mother-to-Child Transmission

Bureau for Policy and Program Coordination, Office of Policy Development and Coordination

Replacement Feeding

United Nations

United Nations Children's Fund

United States Agency for International Development

Voluntary Counseling and Testing

Cross-Sectoral Implementation Guid~nce

ADS Cha ter 212: Breastfe~ding Promotion Policy

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Introduction

Implementing ADS Chapter 212:Breastfeeding Promotion Policy

This cross-sectoral guidance is designed to assist inthe implementation of the new ADS Chapter 212, across-sectoral approach to protection, promotion, andsupport of breastfeeding. Each page addresses onearea of United States Agency for InternationalDevelopment (USAID) programming; it brieflyreviews the importance of breastfeeding to the sectorand suggests modifications for data gathering as wellas breastfeeding promotion policy implementation.

Why Do We Need New Policy andImplementation Guidance Now?

Breastfeeding is a unique behavior and life-savingintervention that is cost-effective and doable.Breastfeeding provides low-cost, high-quality food forinfants and young children, improves their health,increases infant survival sixfold, lowers family expenditures for food and health care, improves nutrientstatus thus increasing productivity, contributes to fertility reduction, and is the safest form of young childfeeding in emergency and disaster situations.Breastfeeding is also environmentally friendly, reducing need for frrewood and reducing pharmaceutical,plastics, and dairy industry waste. Both workplaceefficiency and productivity benefit in that there is lessabsence due to family illness when children are breastfed, and breastfed children demonstrate more rapidcognitive development in the early months and years.

Breastfeeding protection, promotion, and support arenow approved written policy for the entire Agency.Due to improvements in data collection, we can nowsay that these interventions have a proven track recordand are within the Agency's interest. Today withincreasing attention to emerging infectious diseases,food security, and economic growth, the need to maintain breastfeeding support is increasingly important.Nonetheless, many USAID technical staff remain poorly informed on the potential benefits of breastfeeding,and still fewer have the skills necessary to implementbreastfeeding-supportive policy and programs.

The advances of the 1990s are at risk. Breastfeedinghas not as yet been fully integrated into food and disaster relief programming, nutrition efforts, workplace

approaches, nor child survival programming. Itsimpact on micronutrient levels, on fertility, on familyhealth and productivity, and in reducing infectiousdiseases has not been mainstreamed into the relevantstrategic approaches and activities. In addition, misunderstandings concerning the impact of breastfeedingon the spread of human immunodeficiencyvirus/acquired immunodeficiency syndrome(HIV/AIDS) has created an unwitting backlash,threatening to undo the progress of the last decade.

Advances and Trends:Breastfeeding Protection,Promotion, and SupportAchieve Results

Over the last 10 to 15 years, following aCongressional mandate for action, USAID-initiatedprogramming has turned around the decline in breastfeeding worldwide noted in the 1960s and 1970s. Thelast Agency strategy development in this area wascompleted in 1990, and, in less than a decade, countries with USAID programming saw a nearly 20percentage point increase in infants exclusivelybreastfed and experienced a median duration ofbreastfeeding of nearly two months. While thereremains much to be done to achieve optimal breastfeeding with appropriate complementary feeding forall, these achievements are real, measurable, and significant, and provide a good base for implementationof ADS Chapter 212: Breastfeeding Promotion Policy.

Cross-Sectoral Implementation GuidanceADS Chapter 212: Breastfeeding Promotion Polij:y

Child Health and Infectious Diseases

Importance to sector

Increased Child Survival

• Infant mortality remains a major reason for loweredlife expectancy and human suffering worldwide;breastfeeding currently prevents about 5-6 milliondeaths per year, and could prevent an additional 1-2million. Hence, breastfeeding may be considered themortality-preventive intervention with the greatestimpact.

• Immediate breastfeeding at birth helps avoidhypothermia, a major threat to neonatal survival.

Decreased Morbidity

• Breastfeeding reduces the incidence of pneumonia,diarrhea, reported illness in general, ear infections,juvenile diabetes, colitis, and childhood cancers.

• Breastfeeding continues to confer antibodies fromthe mother's immune system to the child as long asbreastfeeding continues, for two years or longer.

• Recently, breastfeeding has been found to causeimproved cognitive development.

• Breastfeeding is associated with reduced incidenceof later infectious disease and chronic diseases suchas diabetes and cancers.

Program Issues

• Cost-effective: Breastfeeding is rated one of themost cost-effective child survival interventionsaccording to a World Bank report on child survivalinterventions.

• Nearly universally doable: Even maternal infectious illness is not a contraindication; the risk ofpassage generally is more than balanced by the protective effects of breastfeeding.

• mY/AIDS is a special issue (See HIV sector).

• Implement program and demographic data collection for monitoring, evaluation and planning purposes.


Promote optimal breastfeeding in all programs:

• Program breastfeeding skills supportfor optimal breastfeeding (exclusivefor six months followed by slowweaning for two years or more) in allchild survival programs.

• Include breastfeeding in the recovery protocol for all infant and youngchild illness.

• Support the Baby Friendly HospitalInitiative (BFHI), which includes earlyinitiation and exclusive breastfeedingand linkage to community support foroptimal breastfeeding.

• Support optimal breastfeeding forits contribution to child spacing.

Ensure compliance with the Code ofMarketing ofBreastmilk Substitutes (seeappendix A).

Do not purchase or distribute breastmilksubstitutes unless it has been determinedthat they are necessary to increase child survival, or are for research and comply withthe USAID policy on human subjectsresearch (see section 212.4.2(a) of appendixC, Internal Mandatory References,"Guidelines for Documenting Exceptions toADS Chapter 212.3.2"). Substitutes may

.only be used in a context of optimal breast-feeding support, when steps are taken to .ensure that they are used safely, and whenuse is in compliance with the Code ofMarketing of Breastmilk Substitutes.

Cross-Sectoral Implementation GuidanceADS Chapter 212: Breastfeeding Prom,otion.~olicy , .

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Maternal and Neonatal Health


Increased Maternal Survival

• Breastfeeding is associated with improvedpostpartum uterine involution (contraction) andless blood loss.

Decreased Risk of Cancer and Osteoporosis

• Women who breastfeed have lower risk ofbreast, ovarian,· and endometrial cancer in lateryears. There is some evidence that breastfeedingmay also help prevent osteoporosis.

Delayed Menses

• Breastfeeding delays the return of menses,which increases child spacing, allowing more timefor the mother to recover between pregnancies.Amenorrhea also reduces the risk of anemia.

Increased Neonatal Survival

• Immediate postpartum skin-to-skin and breastattachment combats hypothermia (loss of bodyheat) and hypoglycemia (low blood sugar) whichcan result from the stress.

• Immediate breastfeeding can help avoid theuse of dangerous traditional prelacteal feedswhen full information is shared with the familyand community.


Promote optimal breastfeeding in programsthat "address health and nutrition," "targetinfants and young children and/or wonlen ofreproductive age," or "influence maternal andchild behaviors."

• Train birth attendants in the skills ofimmediate postpartum breastfeeding toavoid potentially deadly hypoglycemiaand hypothermia.

• Support breastfeeding skills for optimal breastfeeding (exclusive for sixmonths followed by slow weaning fortwo years or more) for all mothers.

• Include nutrition counseling in allpregnancy outcome efforts to help themother maintain adequate stores forbreastfeeding and ensure her ownhealth.

• Implement program and demographicdata collection for monitoring, evaluation, and planning purposes.

Ensure compliance with the Code ofMarketing ofBreashnilk Substitutes (seeappendix A).

Do not purchase or distribute breashnilksubstitutes unless it has been determined thatthey are necessary to increase child survival,or are for research and comply with theUSAID policy on human subjects research(see section 212.4.2(a) of appendix C, InternalMandatory References, "Guidelines forDocumenting Exceptions to ADS Chapter212.3.2"). Substitutes may only be used in acontext of optimal breastfeeding support,when steps are taken to ensure that they areused safely, and when use is in compliancewith the Code of Marketing of BreastmilkSubstitutes.

Cross-Sectoral Implementation GuidanceADS Chapter 212: Breastfeeding Promotion Policy.

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HIV/AIDS


Mixed or Partial Breastfeeding Carries IncreasedRisk of Transmission

• With existing practices in endemic areas,10-20 percent of infants will contract HIVthrough breastfeeding.

• Factors associated with the higher risks oftransmission include nonexclusive breastfeeding, poor breast health (mastitis, crackednipples, other), high maternal viral load orAIDS, duration of breastfeeding, and poornutritional status.

Exclusive and Healthy Breastfeeding Can ReduceTransmission

• Exclusive breastfeeding and breast healthlower mother-to-child transmission (MTCT)risk, perhaps to a level comparable to replacement feeding.

• Rapid weaning is probably associated withincreased transmission and should be discouraged.

Breastfeeding Lowers Child Mortality in General

• Breastfeeding is associated with a loweroverall mortality risk than nonbreastfeeding inmost HIV endemic areas, due to the highprevalence of infectious diseases.

• The immunity conferred through breastmilk,especially in the first six months, protectsagainst opportunistic infections in HIV-positive infants.


Promote optimal breastfeeding in all programs:

• Include breastfeeding skills for optimal breastfeeding (exclusive for sixmonths followed by slow weaning fortwo years or more) for all mothers whocome for voluntary counseling and testing (VCT).

• If diagnosed HIV-positive, counsel onthe risks and benefits of all feedingapproaches.

• Recognize that deCisions on infantfeeding must be based on local circumstances, including mv prevalence andmortality from other disease, and withinthe framework of informed choice andconfidentiality.

• Discourage rapid or abrupt weaning.

• Encourage integration of VCT andother HIVIAIDS programs into antenatal,maternity, BFHI, and reproductive healthservices for consistent messages andcomprehensive breastfeeding support.



Do notpurchase or distribute breastmilk substitutes unless it has been determined that theyare necessary to increase child survival, or arefor research and comply with the USAID policy on human subjects research (see section212.4.2(a) of appendix C, Internal MandatoryReferences, "Guidelines for DocumentingExceptions to ADS Chapter 212.3.2").Substitutes may only be used in a context ofoptimal breastfeeding support, when steps aretaken to ensure that they are used safely, andwhen use is in compliance with the Code ofMarketing of Breastmilk Substitutes.

Cross-Sectoral Implementation GuidanceADS Chapter 212: Breastfeeding PromotIon Policy

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Population and Family Planning


Slowed Population Growth

• Breastfeeding is a major determinant of fertility.

• Delayed fertility return allows the womanand/or couple the time needed to consider allmethods and save resources if necessary to usethe method.

Increased Birth Intervals

• In many developing countries, breastfeedinghas more impact on birth intervals than contraceptive use.

• If breastfeeding were to deteriorate, contraceptive use would have to double and triple in somecountries just to keep fertility stable at the current high levels.

Natural Birth Control

• There· is ,a method of child spacing that promotes optimal breastfeeding, appropriate andtimely introduction of family planning (FP) during breastfeeding, and adequate child spacing:the Lactational Amenqrrhea Method, or LAM.


Promote optimal breastfeeding in programsthat "address health and nutrition," "targetinfants and young children and/or women ofreproductive age," or "influence maternal andchild behaviors." Since the target populationfor FP and breastfeeding support are nearlyidentical:

• Program breastfeeding skills supportfor optimal breastfeeding (exclusive forsix months followed by slow weaningfor two years or more).

• Include counseling on breastfeedingmaintenance while using FP in all FPprograms.

• Include LAM in counseling on FPoptions in every FP and maternal/childhealth (MeR) program.

• Support BFHI which include supportand early initiation of breastfeeding.


Ensure compliance with the Code ofMarketing ofBreashnilk Substitutes (seeappendix A).

Cross-Sectoral Implementation GuidanceADS Chapter 212: Breastfeeding Promotion Polie . ,

Nutrition, Agriculture, and Food Security

Importance to Sector

Micronutrients

• Breastfeeding is the major sourceof micronutrients in early life and isan essential part of any micronutrient or vitamin A intervention effort.

OtherNutrition and Food Security

• Breastmilk provides total foodsecurity for infants up to 6 monthsof age and continues to be a criticalsource of essential nutrients for twoyears and beyond.

• Lactational infertility caused bybreastfeeding can help ensure household and community food security byincreasing child spacing, slowingpopulation growth, and reducingpressures on the food supply.

Cost-Effective

• Breastmilk is cheaper, safer, morenutritious, and less expensive toproduce in terms of household foodresources, and safer to store in itsoriginal container than other infantfood.

• Breastfeeding reduces the burdenon household family food budget byensuring that family resources andtime are not used to purchase formula, bottles, extra firewood, andextra clean water.

Implementing ADS Chapter 212: BreastfeedingPromotion Policy

Promote optimal breastfeeding in programs that "addresshealth and nutrition," "target infants and young childrenand/or women ofreproductive age," or "influence maternaland child behaviors."

• Support programs to provide breastfeeding skillsfor optimal breastfeeding (exclusive for six monthsfollowed by slow weaning for two years or more) forall mothers.

• Include promotion of breastfeeding in food securityplans. Review strategies and programs to create andstrengthen linkages between agriculture, health, andnutrition programs.

• Promote improved infant feeding practices andmaternal dietary practices as part of agricultural andagro-forestry extension services as well as at othergroup meetings (e.g., marketing associations, dairyprocessing cooperatives, microfillance clubs, etc.).

• Develop labor-saving technology to allow womentime to care for children (e.g., lower maintenancecrops, faster preparation foods, etc.).

• Target mothers and children from birth up to 3years of age in Title IT Food programs for correct andlocally appropriate breastfeeding messages.

• Implement program and demographic data collectionfor monitoring, evaluation, and planning purposes.

Ensure compliance with the Code ofMarketing ofBreastmilk Substitutes (see appendix A).

Do not purchase or distribute breastmilk substitutes unlessit has been determined that they are necessary to increasechild survival, or are for research and comply with theUSAID policy on human subjects research (see section212.4.2(a) of appendix C, Internal Mandatory References,"Guidelines for Documenting Exceptions to ADS Chapter212.3.2"). Substitutes may only be used in a context of optimal breastfeeding support, when steps are taken to ensurethat they are used safely, and when use is in compliancewith the Code of Marketing of Breastmilk Substitutes.

Cross-Sectoral Implementation Guidancl!ADS Chapter 212: Breastfeeding PrqmotlonPolicy'

Gender and Women's Rights


Empowerment

• Breastfeeding empowers a woman byenabling her to feel confident in herability to provide the best in infantnutrition and to exercise preventivehealth care for herself and her child.

• Breastfeeding helps women controltheir fertility and support the survival oftheir children.

Cost-Effective

• The cost of making maternal milk (i.e.,food for the mother, time off from work,etc.) is much less than the cost of formulain most developing country settings.

Work Productivity

• Breastfed infants are less often ill,demanding less maternal absence fromwork.

• Exclusive breastfeeding provides allnecessary nutrition for brain growth anddevelopment in the early months.

Attention to Conducive Environments

• Breastfeeding focuses attention on theneed for mother-friendly workplaces,childcare, and gender equality in distribution of food and other resourceswithin the household and community.


Promote optimal breastfeeding in programs that"address health and nutrition," "target infants andyoung children and/or women of reproductive age,"or "influence maternal and child behaviors."

• Support breastfeeding in all national andinternational workplace discussions.

• Support the recommendations from the recentInternational Labor Organization conventionencouraging policies that allow women to workand breastfeed.

• Incorporate family health and breastfeedinginto agricultural and job programs.

• Advocate for women's access to correctinformation on feeding choices, FP, and breastfeeding support.

• Support mother-ta-mother support groups andprenatal discussions, which help women establish good breastfeeding skills and support eachother in an atmosphere of trust and respect.

• Enable women to make and act upon theirown infant feeding decisions by providing themwith correct information and counseling.

• Implement program and demographic datacollection for monitoring, evaluation, and planning purposes.


Do not purchase or provide breastmilk substitutesunless it has been determined that they are necessaryto increase child survival, or are for research andcomply with the USAID policy on human subjectsresearch (see section 212.4.2(a) of appendix C,Internal Mandatory References, "Guidelines forDocumenting Exceptions to ADS Chapter 21~.3.2").

Cross-Sectoral Implementation Guidance.ADS Chapter 212: Breastfeeding Promotion Policy

Education and Human Capacity Development


Early Childhood Development

• Mother-infant interaction encourageschild development.

• Breastfeeding and weaning behaviors arean essential part of building educationalcapacity and development.

• Breastfeeding provides frequent interaction between mother and infant, fosteringbonding, a sense of security, and ageappropriate stimuli.

Cognitive Development

• Scientific evidence shows that breastfeeding enhances brain development andlearning readiness. Breastfeeding protectsbabies from illnesses that can cause malnutrition, hearing problems, and learningdifficulties. Breastmilk is a rich source ofvitamin A, which reduces the risk of eyeproblems, growth failure, and illness.

Implementing ADS 212: BreastfeedingPromotion Policy

Promote optimal breastfeeding in programs that"address health and nutrition," "target infants andyoung children and/or women of reproductive age,"or "influence maternal and child behaviors."

• Incorporate breastfeeding and care into formal and nonformal education curriculaincluding higher education training.

• Incorporate breastfeeding into children'sprograms, educational materials, toys, andbooks.

• Ensure access to correct information onnutrition, family planning, reproductivehealth, and breastfeeding for women, men,youth, and school-aged children.

• Implement p~ogram and demographic datacollection for monitoring, evaluation, andplanning purposes.


Cross-Sectoral Implementation Guid~n~eADS Chapter 212: Breastfeeding Promo~ioi1 Policy

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Economic Development, Environment, and the Private Sector

Importa.nce to Sector

Reduced Household Costs

• In many countries, the cost of purchasing formula may be equal to the average wage.Breastfeeding is the cheapest and most efficientfood.

National Savings with Breastfeeding

• Breastmilk production is a major contributor tothe nation's economy, not just by preventing costlyillnesses and reducing the economic burdencaused by large populations, but also in the savingof precious import dollars on formula and relatedproducts.

Slower Population Growth

• Breastfeeding increases birth spacing, slowingpopulation growth, thus reducing the economicburden on the social sector and other societalresources.

Decreased Health Care and Labor Costs

• Breastmilk prevents many illnesses in infants,young children, and mothers, decreasing the burden of disease and related health care costs.

• With healthier children, parents are less oftenabsent from work due to care of a sick child.

Less Environmental Burden

• Breastfeeding reduces environmental pollutionfrom plastics and dairy herds (methane).

• Preparation of breastmilk substitutes involvesuse of fIrewood, contributing to deforestation andindoor air pollution.

• Breastfeeding does not waste scarce naturalresources and is the world's most energy-efficientfood production system.


Promote optimal breastfeeding in programsthat "address health and nutrition," "targetinfants and young children andlor·women ofreproductive age," or "influence maternaland child behaviors."

• Calculate the economic value ofbreastfeeding and use in strategicplanning and policy and advocacydiscussions.

• Support and create incentive forwork arrangements that allow womento be gainfully employed and to breastfeed, in both public and private sectors.

• Incorporate promotion of improvedinfant feeding and maternal dietarypractices in microenterprise activities.

• Ensure access to accurate information on breastfeeding andbreastfeeding choices (includingaccurate information on environmental toxins).

• Implement program and demographic data collection for monitoring,evaluation and planning purposes.


Cross-Sectoral Implementation GuidanceADS Chapter 212: Breastfeeding Promotion Policy'"

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Disasters and Emergencies


Ellsures Illfallt Survival

• During a disaster, whether natural or manmade, the breastfed child is the most likelychild to survive.

• Breastmilk offers increased protectionagainst many infectious diseases and is a reliable therapy against diarrhea and othercommon illnesses.

Food Security

• Breastmilk is a safe, sure food and the onlyreliable food for infant food security, evenwhere reliable water, fuel, and sanitary facilities are scarce.

• Breastmilk is less susceptible to seasonalitythan other foods.

Cost-Effective

• Breastfeeding saves millions of dollars indisaster relief annually.


Promote optimal breastfeedillg in programs that"address health and nutrition," "target infants andyoung children and/or women of reproductiveage," or "influence maternal and child behaviors."

• Develop and implement appropriateinteragency policies and guidelines oninfant feeding in emergencies.

• Prepare humanitarian staff to supportmothers and caregivers to appropriatelyfeed their infants in an emergency situation.

• Monitor infant feeding practices in emergencies.

• Incorporate breastfeeding education inTitle II programs.

• Target pre-pregnant, pregnant, and lactating women with nutritious foods.

• Ensure that health care services in emergency or refugee situations are"baby-friendly," encourage early initiation,and optimal breastfeeding (exclusive for sixmonths, continued for two years).

• Implement program and demographicdata collection for monitoring, evaluation,and planning purposes.

Ellsure compliallce with the Code ofMarketillgofBreastmilk Substitutes (see appendix A).

Do Ilot purchase or distribute breastmilk substitutes unless it has been determined that they arenecessary to increase child survival, or are forresearch and comply with the USAID policy onhuman subjects research (see section 212.4.2(a)of appendix C, Internal Mandatory References,"Guidelines for Documenting Exceptions to ADSChapter 212.3.2"). Substitutes may only be usedin a context of optimal breastfeeding support,when steps are taken to ensure that they are usedsafely, and when use is in compliance with theCode of Marketillg of Breastmilk Substitutes.

Cross-Sectoral Implementation GuidanceADS Chapter 212: Breastfeeding Promotion Poli~y

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Appendices

Appendix A - International Code ofMarketing ofBreastmilk Substitutes

Appendix B - Definitions and SuggestedBreastfeeding Indicators

Appendix C - Functional Series 200 Programming Policy Chapter 212 - BreastfeedingPromotion Policy

Cross-Sectoral Implementation Guidanc~ADS Chapter 212: Breastfeedin Promotio,.fPolicy

APPENDIX A: InternationalCode of Marketing ofBreastmilk Substitutes

Art. 1. Aim of the Code

Art. 2. Scope of the Code

Art. 3. Definitions

Art. 4. Information and education

Art. 5. The general public and mothers

Art. 6. Health care systems

Art. 7. Health workers

Art. 8. Persons employed by manufacturers anddistributors

Art. 9. Labeling

Art. 10. Quality

Art. 11. Implementation and monitoring

The Member States of the World Health Organisation:

Aflinning the right of every child and everypregnant and lactating woman to be adequatelynourished as a means of attaining and maintaininghealth;

Recognising that infant malnutrition is part of thewider problems of lack of education, poverty, andsocial injustice;

Recognising that the health of infants and youngchildren cannot be isolated from the health andnutrition of women, their socio-economic statusand their roles as mothers;

Conscious that breastfeeding is an unequalledway of providing ideal food for the healthygrowth and development of infants; that it formsa unique biological and emotional basis for thehealth of both mother and child; that the antiinfective properties of breast milk help to protectinfants against disease; and that there is animportant relationship between breastfeeding andchild spacing;

Recognising that the encouragement and protection of breastfeeding is an important part of thehealth, nutrition and other social measuresrequired to promote healthy growth and develop-

ment of infants and young children; and thatbreastfeeding is an important aspect of primaryhealth care;

Considering that when mothers do not breastfeed, or only do so partially, there is a legitimatemarket for infant formula and for suitable ingredients from which to prepare it; that all theseproducts should accordingly be made accessibleto those who need them through commercial ornoncommercial distribution systems; and that theyshould not be marketed or distributed in ways thatmay interfere with the protection and promotionof breastfeeding;

Recognising further that inappropriate feedingpractices lead to infant malnutrition, morbidityand mortality in all countries, and that improperpractices in the marketing of breastmilk substitutes and related products can contribute to thesemajor public health problems;

Convinced that it is important for infants toreceive appropriate complementary foods, usuallywhen the infant reaches four to six months of age,and that every effort should be made to use locally available foods; and convinced, nevertheless,that such complementary foods should not beused as breastmilk substitutes;

Appreciating that there are a number of socialand economic factors affecting breastfeeding,and that, accordingly, governments shoulddevelop social support systems to protect, facilitate and encourage it, and that they shouldcreate an environment that fosters breastfeeding,provides appropriate family and communitysupport, and protects mothers from factors thatinhibit breastfeeding;

Affirming that health care systems, and thehealth professionals and other health workersserving in them, have an essential role to play inguiding infant feeding practices, encouragingand facilitating breastfeeding, and providingobjective and consistent advice to mothers andfamilies about the superior value of breastfeeding, or, where needed, on the proper use ofinfant formula, whether manufactured industrially or home prepared;

Affirming further that educational systems andother social services should be involved in theprotection and promotion of breastfeeding, and inthe appropriate use of complementary foods;

Cross-Sectoral Implementation GuidanceADS Chapter 212: Breastfeeding Promotion Policy

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Aware that families, communities, women'sorganisations and other nongovernmental organisations have a special role to play in theprotection and promotion of breastfeeding and inensuring the support needed by pregnant womenand mothers of infants and young children,whether breastfeeding or not;

Affirming the need for governments, organisations of the United Nations system,nongovernmental organisations, experts in variousrelated disciplines, consumer groups and industryto cooperate in activities aimed at the improvement of maternal, infant and young child healthand nutrition;

Recognising that governments should undertake avariety of health, nutrition and other social measures to promote healthy growth and developmentof infants and young children, and that this Codeconcerns only one aspect of these measures;

Considering that manufacturers and distributorsof breastmilk substitutes have an important andconstructive role to play in relation to infant feeding, and in the promotion of the aim of this Codeand its proper implementation;

Affirming that governments are called upon totake action appropriate to their social and legislative framework and their overall developmentobjectives to give effect to the principles and aimof this Code, including the enactment of legislation, regulations or other suitable measures;

Believing that, in the light of the foregoing considerations, and in view of the vulnerability ofinfants in the early months of life and the risksinvolved in inappropriate feeding practices,including the unnecessary and improper use ofbreastmilk substitutes, the marketing of breastmilk substitutes requires special treatment, whichmakes usual marketing practices unsuitable forthese products;

THEREFORE:

The Member States hereby agree the following articles which are recommended as a basis for action.

Article 1. Aim of the Code

The aim of this Code is to contribute to the provision of safe and adequate nutrition for infants, bythe protection and promotion of breastfeeding, andby ensuring the proper use of breastmilk substi-

tutes, when these are necessary, on the basis ofadequate information and through appropriate marketing and distribution.

Article 2. Scope of the Code

The Code applies to the marketing, and practicesrelated thereto, of the following products: breastmilksubstitutes, including infant formula; other milk products, foods and beverages, including bottle-fedcomplementary foods, when marketed or otherwiserepresented to be suitable, with or without modification, for use as a partial or total replacement ofbreast-milk; feeding bottles and teats. It also appliesto their quality and availability, and to informationconcerning their use.

Article 3. Definitions

For the purposes of this Code:

"Breastmilk substitute" means any food being marketed or otherwise represented as a partial or totalreplacement for breast milk, whether or not suitablefor that purpose.

"Complementary food" means any food, whether manufactured or locally prepared, suitable as acomplement to breast milk or to infant formula, wheneither becomes insufficient to satisfy the nutritionalrequirements of the infant. Such food is also commonly called "weaning food" or "breastmilk supplement".

"Container" means any form of packaging of productsfor sale as a normal retail unit, including wrappers.

"Distributor" means a'person, corporation or anyother entity in the public or private sector engaged inthe business (whether directly or indirectly) of marketing at the wholesale or retail level a product withinthe scope of this Code. A "primary distributor" is amanufacturer's sales agent, representative, nationaldistributor or broker.

"Health care system" means governmental, nongovernmental or private institutions or organisationsengaged, directly or indirectly, in health care formothers, infants and pregnant women; and nurseriesor childcare institutions. It also includes health workers in private practice. For the purposes of this Code,the health care system does not include pharmacies orother established sales outlets.

"Health worker" means a person working in a component of such a health care system, whetherprofessional or nonprofessional, including yoluntary,unpaid workers.

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"Infant formula" means a breastmilk substitute formulated industrially in accordance with applicable CodexAlimentarius standards, to satisfy the normal nutritional requirements of infants up to between four andsix months of age, and adapted to their physiologicalcharacteristics. Infant formula may also be prepared athome, in which case it is described as "home prepared."

"Label" means any tag, brand, mark, pictorial or otherdescriptive matter, written, printed, stencilled,marked, embossed or impressed on, or attached to, acontainer (see above) of any products within thescope of this Code.

"Manufacturer" means a corporation or other entityin the public or private sector engaged in the businessor function (whether directly or through an agent orthrough an entity controlled by or under contract withit) of manufacturing a product within the scope ofthis Code.

"Marketing" means product promotion, distribution,selling, advertising, product public relations, andinformation services.

"Marketing personnel" means any persons whosefunctions involve the marketing of a product or products coming within the scope of this Code.

"Samples" means single or small quantities of a product provided without cost.

"Supplies" means quantities of a product provided foruse over an extended period, free or at a low price, forsocial purposes, including those provided to familiesin need.

Article 4. Information and education

4.1 Governments should have the responsibility toensure that objective and consistent information isprovided on infant and young child feeding for use byfamilies and those involved in the field of infant andyoung child nutrition. This responsibility should covereither the planning, provision, design and dissemination of information, or their control.

4.2 Informational and educational materials, whetherwritten, audio, or visual, dealing with the feeding ofinfants and intended to reach pregnant women andmothers of infants and young children, should includeclear information on all the following points:

1. the benefits and superiority of breastfeeding;

2. maternal nutrition, and the preparation for andmaintenance of breastfeeding;

3. the negative effect on breastfeeding of introducing partial bottle feeding;

4. the difficulty of reversing the decision not tobreastfeed; and

5. where needed, the proper use of infant formula,whether manufactured industrially or home prepared.

When such materials contain information about theuse of infant formula, they should include the socialand financial implications of its use; the health hazards of inappropriate foods or feeding methods; and,in particular, the health hazards of unnecessary orimproper use of infant formula and other breastmilksubstitutes. Such materials should not use any picturesor text which may idealise the use of breastmilk substitutes.

4.3 Donations of informational or educational equipment or materials by manufacturers or distributorsshould be made only at the request and with the written approval of the appropriate government authorityor within guidelines given by governments for thispurpose. Such equipment or materials may bear thedonating company's name or logo, but should notrefer to a proprietary product that is within the scopeof this Code, and should be distributed only throughthe health care system.

Article 5. The general public and mothers

5.1 There should be no advertising or other form ofpromotion to the general public of products within thescope of this Code.

5.2 Manufacturers and distributors should not provide,directly or indirectly, to pregnant women, mothers ormernbers of their families, samples of products withinthe scope of this Code.

5.3 In conformity with paragraphs 1 and 2 of thisArticle, there should be no point-of-sale advertising,giving of samples, or any other promotion device toinduce sales directly to the consumer at the retaillevel, such as special displays, discount coupons, premiums, special sales, loss leaders and tie-in .sales, forproducts within the scope of this Code. This provisionshould not restrict the establishment of pricing policies and practices intended to provide products atlower prices on a long-term basis.

Cross-Sectoral Implementation GuidallceADS Chapter 212: Breastfeedin9 Promotion Pollc'y'

5.4 Manufacturers and distributors should not distribute to pregnant women or mothers of infants andyoung children any gifts of articles or utensils whichmay promote the use of breastmilk substitutes or bottle feeding.

5.5 Marketing personnel, in their business capacity,should not seek direct or indirect contact of any kindwith pregnant women or with mothers of infants andyoung children.

Article 6. Health care systems

6.1 The health authorities in Member States shouldtake appropriate measures to encourage and protectbreastfeeding and promote the principles of this Code,and should give appropriate information and advice tohealth workers in regard to their responsibilities,including the information specified in Article 4.2.

6.2 No facility of a health care system should be used.for the purpose of promoting infant formula or otherproducts within the scope of this Code.

This Code does not, however, preclude the dissemination of information to health professionals as providedin Article 7.2.

6.3 Facilities of health care systems should not beused for the display of products within the scope ofthis Code, for placards or posters concerning suchproducts, or for the distribution of material providedby a manufacturer or distributor other than that specified in Article 4.

6.4 The use·by the health care system of "professionalservice representatives", "mothercraft nurses" or similar personnel, provided or·paid for by manufacturersor distributors, should not be permitted.

6.5 Feeding with infant fonnula, whether manufactured orhome prepared, should be demonstrated only by health wolkers, or other community wolkers ifnecessmy; and only to themothers or family members who need to use it; and the information given should include a clear explanation of thehazards of inlproper use.

6.6 Donations or low-price sales to institutions ororganisations of supplies of infant formula or otherproducts within the scope of this Code, whether foruse in the institutions or for distribution outside them,may be made.

Such supplies should only be used or distributed forinfants who have to be fed on breastmilk substitutes.If these supplies are distributed for use outside the

Cross-Seetorallmplementation Guidance ,ADS Chapter 212: Breastfeedin Promotion Polie:

institutions, this should be done only by the institutions or organisations concerned. Such donations orlow-price sales should not be used by manufacturersor distributors as a sales inducement.

6.7 Where donated supplies of infant formula or otherproducts within the scope of this Code are distributedoutside an institution, the institution or organisationshould take steps to ensure that supplies can be continued as long as the infants concerned need them.Donors, as well as institutions or organisations concerned, should bear in mind this responsibility.

6.8 Equipment and materials, in addition to thosereferred to in Article 4.3, donated to a health care system may·bear a company's name or logo, but shouldnot refer to any proprietary product within the scopeof this Code.

Article 7. Health workers

7.1 Health workers should encourage and protectbreastfeeding; and those who are concerned in particular with maternal and infant nutrition should makethemselves familiar with their responsibilities underthis Code, including the information specified inArticle 4.2.

7.2 Information provided by manufacturers and distributors to health professionals regarding productswithin the scope of this Code should be restricted toscientific and factual matters, and such informationshould notimply or create a belief that bottle feedingis equivalent or superior to breastfeeding. It shouldalso include the information specified in Article 4.2.

7.3 No financial or material inducements to promoteproducts within the scope of this Code should beoffered by manufacturers or distributors to healthworkers or members of their families, nor shouldthese be accepted by health workers or members oftheir families.

7.4 Samples of infant fonnula or other products within thescope of this Code, or ofequipment or utensils for theirpreparation or use, should not be provided to health wolkersexcept when necessary for the purpose ofprofessional evaluation or research at the institutional level. Health wolkersshould not give samples of infant formula to pregnantwomen, mothers of infants and young children, or membersof their families.

7.5 Manufacturers and distributors of products withinthe scope of this Code should disclose to the institution to which a recipient health worker is affiliated

any contribution made to him or on his behalf for fellowships, study tours, research grants, attendance atprofessional conferences, or the like. Similar disclosures should be made by the recipient.

Article 8. Persons employed by manufacturers anddistributors

8.1 In systems of sales incentives for marketing personnel, the volume of sales of products within thescope of this Code should not be included in the calculation of bonuses, nor should quotas be setspecifically for sales of these products. This shouldnot be understood to prevent the payment of bonusesbased on the overall sales by a company of otherproducts marketed by it.

8.2 Personnel employed in marketing products withinthe scope of this Code should not, as part of their jobresponsibilities, perform educational functions in relation to pregnant women or mothers of infants andyoung children. This should not be understood as preventing such personnel from being used for otherfunctions by the health care system at the request andwith the written approval of the appropriate authorityof the government concerned.

Article 9. Labelling

9.1 Labels should be designed to provide the necessary information about the appropriate use of theproduct, and so as not to discourage breastfeeding.

9.2 Manufacturers and distributors of infant formulashould ensure that each container has a clear, conspicuous, and easily readable and understandable messageprinted on it, or on a label which cannot readilybecome separated from it, in an appropriate language,which includes all the following points:

1. the w9rds "Important Notice" or their equivalent;

2. a statement of the superiority of breastfeeding;

3. a statement that the product should be usedonly on the advice of a health worker as to theneed for its use and the proper method of use; and

4. instructions for appropriate preparation, and awarning against the health hazards of inappropriate preparation.

Neither the container nor the label should have pictures of infants, nor should they have other pictures ortext which may idealise the use of infant formula.They may, however, have graphics for easy identifica-

tion of the product as a breastmilk substitute and forillustrating methods of preparation. The terms"humanised," "maternalised" or similar terms shouldnot be used. Inserts giving additional informationabout the product and its proper use, subject to theabove conditions, may be included in the package orretail unit. When labels give instructions for modifyinga product into infant formula, the above should apply.

9.3 Food products within the scope of this Code, marketed for infant feeding, which do not meet all therequirements of an infant formula, but which can bemodified to do so, should carry on the label a warningthat the unmodified product should not be the solesource of nourishment of an infant. Since sweetenedcondensed milk is not suitable for infant feeding, norfor use as a main ingredient of infant formula, itslabel should not contain purported instructions onhow to modify it for that purpose.

9.4 The label of food products within the scope of thisCode should also state all the following points:

1. the ingredients used;

2. the composition/analysis of the product;

3. the storage conditions required; and

4. the batch number and the date before whichthe product is to be consumed, taking intoaccount the climatic and storage conditions ofthe country concerned.

Article 10. Quality

10.1 The quality of products is an essential elementfor the protection of thehealth of infants and thereforeshould be of a high recognised standard.

10.2 Food products within the scope of this Codeshould, when sold or otherwise distributed, meet applicable standards recommended by the CodexAlimentarius Commission and also the Codex Code ofHygienic Practice for Foods for Infants and Children.

Article 11. Implementation and monitoring

11.1 Governments should take action to give effectto the principles and aim of this Code, as appropriate to their social and legislative framework,including the adoption of national legislation, regulations or other suitable measures. For this purpose,governments should seek, when necessary, the cooperation of WHO, UNICEF and other agencies of theUnited Nations system. National policies and meas-

Cross-Sectoral Implementation Guidanc~.

ADS Chapter 212: Breastfeeding PromotionPoUcy

ures, including laws and regulations, which areadopted to give effect to the principles and aim ofthis Code should be publicly stated, and shouldapply on the same basis to all those involved in themanufacture and marketing of products within thescope of this Code.

11.2 Monitoring the application of this Code lies withgovernments acting individually, and collectivelythrough the World Health- Organisation as provided inparagraphs 6 and 7 of this Article. The manufacturersand distributors of products within the scope of thisCode, and appropriate nongovernmental organisations, professional groups, and consumerorganisations should collaborate with governments tothis end.

11.3 Independently of any other measures taken forimplementation of this Code, manufacturers and distributors of products within the scope of this Codeshould regard themselves as responsible for monitoringtheir marketing practices according to the principlesand aim of this Code, and for taking steps to ensurethat their conduct at every level conforms to them.

11.4 Nongovernmental organisations, professionalgroups, institutions, and individuals. concerned shouldhave the responsibility of drawing the attention ofmanufacturers or distributors to activities which areincompatible with the pril).ciples and aim of this Code,so that appropriate action can be taken. The appropriate governmental authority should also be informed.

11.5 Manufacturers and primary distributors of productswithin the scope of this Code should apprise eachmember of their marketing personnel of the Code andof their responsibilities under it.

11.6 In accordance with Article 62 of the Constitutionof the World Health Organisation, Member Statesshall communicate annually to the Director Generalinformation on action taken to give effect to the principles and aim of this Code.

11.7 The Director General shall report in even yearsto the World Health Assembly on the status of implementation of the Code; and shall, on request, providetechnical support to Member States preparing nationallegislation or regulations, or taking other appropriatemeasures in implementation and furtherance of theprinciples and aim of this Code.

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APPENDIX B: Definitions andSuggested BreastfeedingIndicators

Modified from Bertrand, J. Indicators for Monitoring andEvaluation of Reproductive Health and Child Survival Programs,Measure Project, 2001, and from USAID ADS Chapter 212.

DEFINITIONS:

Optimal Breastfeeding: Exclusivebreastfeeding forthe fITst six months of life, with continued breastfeeding and appropriate complementary feeding for twoyears or more. Breastfeeding should be initiated immediately postpartum. (Support of adequate maternalnutrition is an important part of breastfeeding support.)

Exclusive breastfeeding: the infant has received onlybreastmilk from his/her mother, and no other liquidsor solids with the exception of drops or syrups consisting of vitamins, mineral supplements or medicines.

Exclusive breastmilk feeding: May receiveexpressed breastmilk, in addition to breastfeeding.

Complementary Feeding: The appropriate additionof other foods while continuing breastfeeding, starting at about· age 6 months. (N.B. Other foods givenduring breastfeeding prior to this time are considered"supplementary.")

Breastmilk Substitutes: Foods or liquids used assubstitutes for breastfeeding, including use of powdered or liquid milks or formula, wet-nurses, etc. Thisdoes not include therapeutic formulas used undermedical supervision.

Replacement Feeding (RF): Breastmilk substitutesthat provide all the nutrients the child needs. Thisdoes not include breastmilk substitutes such as powdered milks or animal milks.

INDICATORS:

TIMELY INITIATION OF BREASTFEEDING:PERCENT OF INFANTS 0 • < 12 MONTHSWHO WERE PUT TO THE BREAST WITHIN ONE HOUR OF DELIVERY

Definition

This indicator measures the timely initiation of breastfeeding. It is calculated as:

# of infants 0<12 months put to breast w/in one hourx100

Total # of infants 0<12 months

Data Requirements

Recall data from mothers with infants less than 12months old.

Data Source(s)

Population-based surveys employing representativesamples. The Demographic and Health Survey (DHS)reports the initiation of breastfeeding within one hourfor those countries in which the breastfeeding/infant-feeding module is included in the DHS.

Program records may be used to track trends inbreastfeeding initiation among clients, but not tomeasure the impact of program interventions onwomen with infants in the population of thecatchment area.

Purpose and Issues

Mothers are more likely to successfully initiate lactation, encounter fewer problems breastfeeding, andmaintain optimal breastfeeding behaviors if they initiate breastfeeding shortly after birth.

Breastfeeding should begin no later than one hour afterthe delivery of the infant. Colostrum, the thick yellowish milk produced in the fITst few days after birth, isnutritious and helps to protect the infant against common infections. Thus, breastmilk is the infant's fITst"immunization" against common illnesses.

A mother may have difficulty remembering for aslong as 12 months when she initiated breastfeedingfor her youngest infant, and thus this indicator is subject to potential recall bias. This bias is likely to beeven greater in populations that are not accustomed toremembering and conceptualizing time. However,

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because this particular type of bias (toward a longeror shorter period than actually occurred) is assumed tobe randomly distributed across a population, thepotential bias should not skew the data to misrepresent the population's general behavior related tobreastfeeding initiation.

EXCLUSIVE BREASTFEEDING RATE(EBR): PERCENT OF INFANTS < 6MONTHS OF AGE WHO ARE EXCLUSIVE·LY BREASTFED

, Definition

Exclusive breastfeeding is defined as those infantswho receive only breastmilk directly from the breast,and no other liquids or solids including water. Infants,are, however, allowed to have drops of vitamins/minerals/medicines. This definition is often modified toinclude exclusive breast-milk feeding, which includesfeeding of expressed milk.

EBR can be calculated using the following equation:

# of infants O-<six months exclusively breastfed x 100

Total # of infants O-<six months

Data Requirements

A 24-hour recall of food consumption of infants lessthan six months of age.

Data Source(s)

Population-based surveys employing representativesamples (e.g., the DHS). Program records of EBR (totrack trends but not impact). The DHS country reportsand Nutrition Reports both present the EBR forinfants 0-<4 months of age. However, EBR for infantsO-<six months can be calculated using DHS data.

Purpose and Issues

It is important to note that even in hot, dry climates,breastmilk contains sufficient water for an infant'sneeds. Additional water or sugary drinks are not needed to quench the infant's thirst, and they can also beharmful. If the infant is also given water, or drinksmade with water, then the risk of diarrhea and otherillnesses increases.

Indicators of current breastfeeding practices can berelatively easily measured and are sensitive tochanges resulting from program activities. Using a24-hour recall period to measure current status maycause the proportion of exclusively breast-fed infants

to be overestimated, since some infants who are givenother feeding irregularly may not have received themin the 24 hours before the survey.

The best estimates of exclusive breastfeeding areobtained from current status data in cross-section surveys. The advantage of this approach is that it is notsubject to recall error. The measure should be interpreted as the percent of infants who "are currentlybeing exclusively breastfed," rather than the percentthat have been exclusively breastfed since birth.

MEDIAN DURATION OF BREASTFEEDIN~

(MOB): DURATION OF BREASTFEEDIN(:;"

Definition

Breastfeeding is defined as those infants who receiveany breastmilk directly from the breast. This definition is often modified to include breast-milk feeding,which includes feeding of expressed milk.

MDB can be calculated using the following calculation:

50th percentile duration of breastfeeding among durations reported by mothers whose infants are 3-4 yearsof age.

Data Requirements

Recall data on breastfeeding duration from motherswho have weaned.

Data Source(s)

Population-based surveys employing representativesamples ·(e.g., the DHS). Program records of breastfeeding duration (rare).

Purpose and Issues

Breastfeeding continues to be an important nutritionstaple and continues to provide immunological disease fighting factors as long as breastfeedingcontinues. It also contains factors that help theimmune system mature.

Indicators of current breastfeeding practices can berelatively easily measured and are sensitive tochanges resulting from program activities. Using arecall period maycause the duration of breastfeedingto be over- or under-estimated.

The best estimates are obtained from current statusdata in cross-section surveys. However, there could beconsiderable truncation of data if all currently breastfed children were included. A possible advantage ofusing recall among only one age group would be

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decreased variance in recall. This approach is subjectto recall error.

LACTATIONAL AMENORRHEA METHOD(LAM) USER RATE (LUR): PERCENT OFELIGIBLE WOMEN WHO USE LAM

Definition

Percent of eligible women using the lactational amenorrhea method (LAM) as their contraceptive method,at a given point in time (e.g., at the time of the survey), or from reproductive calendar data. Thisindicator can be calculated as:

# women with infants < 6 months of age using LAMas an FP m~thod x 100

# women with infants < 6 months of age

Data Requirements

The total number of married women within 6 monthspostpartum, and of these, the number who are usingLAM as their method of FP.

Data Source(s)

Population-based surveys employing representativesamples (e.g., the DHS); or FP service statistics.

Purpose and Issues

This indicator measures the percent of eligible womenof reproductive age in a given population using theLAM method. Ideally, the LUR is measured in thecontext of a population-based representative survey, bycurrent status. However, recall data may also be usedif available. It can be also measured using service statistics, but this is less than ideal, since the findings willnot be generalizable to the larger population.

The LUR does not measure the use of LAM in relation to other contraceptive methods.

Cross-Sectoral Implementation GuidanceADS Chapter 212: Breastfeeding PromotionPplicy

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APPENDIX C: FunctionalSeries 200 - ProgrammingPolicy Chapter 212 •Breastfeeding PromotionPolicy*This is a new ADS chapter.

Section

212.1 ••••••••Overview

212.2 ..••.•••Primary Responsibilities

212.3 ••••••••Policy and Procedures

212.3.1 ••••.•Current Accepted NormsConcerning optimal Breastfeeding

212.3.2 ••••••Agency Policies

212.4 ••••••••Mandatory References

212.4.1 ••••••External mandatory References

212.4.2 ••••••Internal mandatory References

212.5 •••••.••Additional Help

212.6 ••.••.••Definitions

Chapter 212 -.Breastfeeding PromotionPolicy

*This is a new ADS chapter.

212.1 OVERVIEW

Effective Date: 01/04/2002

a. Objective

The objectives of this chapter are to

• Define USAID policy and responsibilitiesrelated to breastfeeding,

• Provide references to updated guidance onbest breastfeeding practices and breastfeedingprogram support approaches for USAID strategic objective areas, and

• Address breastfeeding programming as relat-

ed to mother-to-child transmission (MTCT) ofHIV/AIDS and other infectious disease.

b. Overview

The goal of USAID-supported breastfeeding activitiesis to increase the percentage of infants that are immediately and exclusively breastfed, that receiveappropriate complementary foods in addition tobreastfeeding from age 6 months, and that continuebreastfeeding for two years or longer.

In 1990, the United States recognized the importanceof breastfeeding by signing the InnocentiDeclaration on the Protection, Promotion, andSupport of Breastfeeding. The Innocenti Declarationcalls on all governments to implement the WorldHealth Organization (WHO) International Code ofMarketing of Breastmilk Substitutes adopted in1981 by the World Health Assembly.

Research has conclusively documented the very positive and cost-effective impact of breastfeeding onchild survival, birth spacing, and aspects of maternal

( health. Breastfeeding provides low-cost, high-qualityfood for infants and young children and improvestheir health, immune system, and nutritional status,resulting in a multifold increase in survival.Breastfeeding lowers family expenditures for foodand health care; improves micronutrient andprotein/energy status, thus increasing productivity;contributes to fertility reduction; and is the safestform of young child feeding in emergency and disaster situations. Breastfeeding also is environmentallyfriendly, reducing the need for firewood to preparebreastmilk substitutes, as well as reducing pharmaceutical, plastics, and dairy industry waste. Theworkplace benefits because there are fewer absencesdue to family illness when children are breastfed.

212.2 PRIMARY RESPONSIBILITIES


a. Program managers in all sectors of USAIDIWand in field missions are responsible for integrating breastfeeding promotion into broaderhealth and related strategies as appropriate.

b.The USAID Mission Director is responsiblefor ensuring that the programs implementedthrough his/her mission conform to USAID'spolicy on breastfeeding.

c. The Bureau for Policy and Program

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Coordination, Office of Policy Developmentand Coordination (PPCIPDC) is responsible foroverall compliance and reporting as needed.

d.The Bureau for Global Health, Office ofHealth and Nutrition breastfeeding experts areresponsible for providing detailed guidance,technical assistance, and field support toMissions and other Bureaus as needed to reinforce the support, promotion, and protection ofoptimal breastfeeding.

212.3 POLICY DIRECTIVES ANDREQUIRED PROCEDURES


212.3.1 Current Accepted NormsConcerning.·Optimal Breastfeeding


The pattern of breastfeeding that is associated withthe best health outcomes is exclusive breastfeedingfor the fIrst six months of life, with continued breastfeeding and appropriate complementary feeding fortwo years or more. Adequate maternal nutrition isnecessary to support breastfeeding. Breastfeedingshould be initiated immediately postpartum. This pattern is sometimes referred to as optimal infantfeeding, or the "Gold Standard."

Due to its nutritional value and immune-system boosting properties, USAID supports breastfeeding as thebest staple in infant and young child feeding, especially in countries where infectious diseases continueto be the leading cause of mortality among childrenunder 5 years of age.

The risk of MTCT of HIV/AIDS must be weighedagainst the risk of increased death and illness thatoccurs in the absence of breastfeeding. Of childrenborn to HIV-positive mothers, 14-36 percent will beinfected with HIV - approximately 20 percentthrough pregnancy and delivery, and 14 percentthrough breastfeeding. In some settings, non-HIVinfant mortality will be 10-20 percent if the mother<toes NOT breastfeed. Therefore, decisions on infantfeeding must be based on local circumstances, withinthe framework. of informed choice and confidentiality.

Recent international conferences, including the WHOTechnical Consultation in Geneva in October 2000 andthe 28th session of the UN Administrative Committeeon Coordination Sub-committee on Nutrition

Cross-Sectorallmplem~ntation .Guidance .. _~ : ".' ....ADS Chapter 212: Breastfeedin Promotior'lpolicy.:

(ACC/SCN), have concluded that breastfeedingremains the best source of nutrition for the greatmajority of infants and should continue to be promotedand supported among mothers who are not known tobe HIV-infected. They have also recommended that,when considering infant feeding options for motherswho test positive for HIV, replacement feeding (RF)(nutritionally complete breastmilk substitutes) shouldbe considered only if acceptable, feasible, affordable,sustainable, and safe. Other international health documents stress that, in areas of high infectious diseaseburden, the accessibility, affordability, and services ofthe health care systems must be of sufficient quality toadequately address the increase in disease associatedwith less-than-optimal breastfeeding.

212.3.2 Agency Policies


a. USAID promotes optimal breastfeeding inprograms that

• Address health and nutrition;

• Include MTCT, especially those that includevoluntary counseling and testing (VCT), oroffer counseling that includes other feedingoptions;

• Target infants and young children and/orwomen of reproductive age; and

• Might influence maternal and child behaviors.

b.ln general practice, no USAID funds will beused to purchase or transport breastmilk substitutes or related materials such as baby bottles ornipples/teats.

c. If an exception is deemed necessary toincrease child survival, or to support researchthat conforms with USAID policy on humansubjec,ts research (22 CFR 225 as implemented), the USAID unit that agrees to fund thepurchase or transport of breastmilk substitutes,replacement foods, and related materials must

(1) Offer them in a context in which optimal breastfeeding is also supported (see Definitions,212.6),

(2) Notify PPCIPDC that an exception is necessary(see Mandatory Reference Guidelines forDocumenting Exceptions),

(3) Document and keep on file

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(a)The basis of the detennination that the useof replacements could result in increasedoverall child survival,

(b)Steps taken to comply with the WHOInternational Code of Marketing of Breastmilk Substitutes as outlined in the AdditionalHelp document, Cross-SectoralImplementation Guidance for ADSChapter 212: "Breastfeeding PromotionPolicy," and

(c)Steps taken to ensure that breastmilksubstitutes can be used safely, that preparation is affordable, and that substitutes will beproperly prepared and given.

(4) If there is evidence of noncompliancewith the above policies, both notify PPCIPDCand seek technical input from GH, or terminate funding.

212.4 MANDATORY REFERENCES


[All Mandatory References are accessible viathe Web site:http://www.usaid.gov/pubs/adsl200/chapt2b.html]

212.4.1 External Mandatory References


a.22 CFR 225, as implemented,Protection of Human Subjects

212.4.2 Internal Mandatory References


a. Guidelines for Documenting Exceptions toADS Chapter 212.3.2

212.5 ADDITIONAL HELP


[Unless otherwise indicated, documents notedin this section are accessible via the Web site:http://www.usaid.gov/pubs/adsI200/chapt2b.html]

a. Breastfeeding - USAID Background Paper,2001

b.USAID Commodity Reference Guide, 1998Edition, Guidelines for the Office of Food forPeace

c. Cross-Sectoral Implementation Guidancefor ADS Chapter 212: "BreastfeedingPromotion Policy", 2001, developed by theBureau for Global Health (USAID/GH)http://www.usaid.gov/pubslads/200/212.pdf

d. Innocenti Declaration on the Protection,Promotion, and Support of Breastfeeding,1990

e. Internet Web sites of USAID, World HealthOrganization (WHO), and UNICEF

f. Ten Steps to Successful Breastfeeding

g. UNAIDSIWHOIUNICEF HIV and InfantFeeding: Guidelines for Decision-Makers,.1998, "WHO Technical Consultation, NewData on the Prevention of MTCT of HIVand the Policy Implications: Conclusionsand Recommendations, Geneva 11-13October 2000" or update

h.World Health Organization (WHO)International Code of Marketing of Breastmilk Substitutes

212.6 DEFINITIONS


The tenns and defmitions listed below havebeen incorporated into the ADS Glossary. Seethe ADS Glossary Word I PDF I HTML forall ADS terms and definitions.

Breastmilk Substitutes: Foods or liquids used assubstitutes for breastfeeding, including use of powdered or liquid milks or fonnula, wet-nurses, etc. Thisdoes not include therapeutic formulas used undermedical supervision. (Chapter 212)

Complementary Feeding: The appropriate additionof other foods while continuing breastfeeding, startingat about 6 months. (Note: Other foods given duringbreastfeeding prior to this time are considered "supplementary.") (Chapter 212)

Exclusive Breastfeeding: The infant has receivedonly breastmilk from his/her mother, and no other liquids or solids with the exception of drops or syrupsconsisting of vitamins, mineral supplements, or medicines. (Chapter 212)

Exclusive Breastmilk Feeding: May receive

Cross-Sectoral Implementation GuidanceADS Chapter 212: Breastfeeding PromotioflPollcy'

expressed breastmilk, in addition to breastfeeding.(Chapter 212)

Optimal Breastfeeding: Exclusive breastfeeding forthe fIrst six months of life, with continued breastfeeding and appropriate complementary feeding for twoyears or more. Breastfeeding should be. initiatedimmediately postpartum. (Support of adequate maternal nutrition is an important part of breastfeedingsupport.) (Chapter 212)

ReplacementFeeding (RF): Breastmilk substitutesthat provide all the nutrients the child needs. Thiswould not include breastmilk substitutes such as powdered milks or animal milks. (Chapter 212)

Cross-Seetorallmplementation ~.uida"ce .. ,.' .ADS Chapter 212: Breastfeedin~fPromotion PoUcy

This document is the result of a group effort coordinated and facilitated by staff of the MEDS (Monitoring,Evaluation and Design Support) project, with funding from the USAID Bureau for Global Programs, FieldSupport and Research. MEDS staff acknowledges and thanks the contributions of all those involved in

its research, development, and review. The MEDS project is funded by the U.S. Agency for InternationalDevelopment under contract no. HRN-I-02-99-0002-00, task order no. 02. LTG Associates, Inc., and TvT

Associates, Inc., implement the project.

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