Research and Evaluation

Breastfeeding Outcomes Theme

In Peru, the Continuous DHS provides annual data on initiation of breastfeeding, exclusive breastfeeding under six months, solids food introduction and median breastfeeding duration at the national and urban-rural levels. 

The need for a continuous survey was two-fold. Firstly, to facilitate the capacity of in-country teams to carry out the surveys. By undertaking the exercise annually, Peru was able to build up their own expertise through regular practice despite staff turnover. Secondly, there was a need to have data available more frequently than every five years in order to better monitor health and population programs. Peru was decentralizing their government functions and transitioning to results-based budgeting, which required timely health and population information.

Critical to the success of the Peru program was establishing a permanent DHS unit within the national statistics agency (INEI) from the beginning of the project. This reduced staff turnover because there were long-term job prospects, in contrast to hiring and training new staff every five years for the DHS.  Additionally, permanent staff led to better data quality from the field and allowed for more close supervision of performance due to having smaller teams compared to a standard DHS team. (It should be noted that the INEI already had adequate government funding to support its staff and to carry regular DHS surveys.) Over time, the external staff trained the Peruvian staff allowing for a gradual transfer of responsibilities. The survey is now wholly funded by the Peruvian government, with virtually no external technical assistance.

Another successful aspect of the program was managing the expectations of stakeholders. Continuous Survey data differs from the standard DHS measures, especially where there is pooled data from multiple cycles (see below for description). It means initial results will take a while to come through and they may look unfamiliar. The project team developed more user-friendly reports and data files, ran seminars for policy makers, and data analysis workshops to help stakeholders read and interpret the results. Given the amount of data continuous surveying generates, it is key that countries have systems in place to effectively disseminate and utilize the information. 

One of the challenges they faced were the resources available to foster greater understanding and use of the data at a regional level and to improve the level of analysis undertaken. Also, using information from one or two cycles of data collection (in Peru, the cycles are six monthly) to understand annual trends had some limitations and they found that they needed to pool many cycles of data to get reliable information, usually 2 to 3 years worth. This was especially the case at the sub-national level and with certain health indicators that have a slow pace of change. In response to this, in 2008 they expanded the sample size from 6,300 to 23,000 households and then increased to 29,000 in subsequent cycles. In 2015 the number jumped to 35,000 households, about six times the original annual sample size. The demand for solid annual data, led to increased sample sizes and, in turn, increased costs.

The Peruvian government now relies on the continuous survey data, which they use to help decide health program budget allocations for Peru’s 24 regional departments.

Reference:

  1. Rutstein, Shea O., Way, Ann. (2014). The Peru Continuous DHS Experience. DHS Occasional Papers No. 8. Rockville, Maryland, USA.

The Health Data Collaborative is a joint effort by multiple global health partners to work alongside countries to improve the availability, quality and use of data for local decision-making and tracking progress toward the health-related Sustainable Development Goals (SDGs).  The Health Data Collaborative addresses the challenges of fragmented and piecemeal data by getting global health partners to align their financial and technical resources around a common agenda for measurement and accountability.

When the Health Data Collaborative team is asked by a country to help improve their health data systems, they work with the existing data collecting monitoring and analyzing systems rather than introducing new ones. They will establish working groups, based around specific technical issues, and comprised of experts from partner organizations. The working groups will focus on the following:

  • Strengthening national health-related data systems and capabilities
  • Increasing efficiencies of investments in health information systems
  • Aligning ad hoc donor funding to national plans and facilitating coordination of donor support for health information systems
  • Improving harmonization of data collection, sharing and use
  • Ensuring international standards and methodologies
  • Establishing open data platforms for rapid sharing and analysis of quality-assured health data
  • Using new technologies to fill data gaps and harness the data revolution
  • Engaging a wider set of players, from the private sector, academia and civil society
  • Cooperating with existing initiatives designed to improve the use of data
  • Learning and sharing lessons and best practices
  • Tracking progress in country capacity to monitor the health-related SDGs

The Health Data Collaborative aims to have 60 low-income and lower-middle income countries, and supporting donors, “using common investment plans to strengthen health data systems” by 2024. This will also necessarily involve donor organizations moving away from funding program-specific monitoring and evaluation systems to country-wide systems, aligned to the SDGs. By 2030, countries will shift to independently running their newly strengthened health data systems.

Exclusive breastfeeding rates 0–5 months of age and early initiation of breastfeeding are two of the indicators on the Global Reference List of 100 Core Health Indicators- a standard set of 100 indicators prioritized by the global community to provide concise, real-time information on the health situation and trends.

Under development is a one-stop shop for health information system standards that will include:

  • Guidelines for designing measurement and evaluation systems within national health sector plans
  • A package of recommended indicators, data quality metrics and dashboards for collecting and analyzing data at health facilities and in communities
  • Standards for integrating outbreak surveillance into routine health information systems
  • Harmonized set of survey tools for collecting comprehensive household health data
  • Resource kit to improve birth and death registration
  • Core health workforce metrics
  • Guidelines on designing health systems that talk to each other and policies for sharing data

Kenya's Health Data Collaborative Roadmap is the first example of a strategic plan to improve monitoring and evaluations systems through a partnership with the Health Data Collaborative.  Kenya is now moving towards one monitoring and evaluation system for all health-related data.

“WHO is proud of having joined with key partners and stakeholders to launch this initiative,” said Dr Nathan Bakyaita, Officer-in-charge of WHO’s country office in Kenya. “The strong collaboration and presence of our key partners at the meeting is testimony of our commitment to a harmonised approach to health sector M&E in Kenya.”

Countries wishing to participate in the Health Data Collaborative should contact them through the website - http://www.healthdatacollaborative.org/contact-us/.

References:

  1. Health Data Collaborative.
  2. World Health Organization. (2016). Kenya takes steps to save mothers’ lives, showing why better data matters.

In Brazil, the Information System for Primary Care (SIAB) collects continuous data on the prevalence of exclusive breastfeeding and breastfeeding for all health care users under 4 months of age.

Community Health Agents, through home visits, register families, identify the situation of sanitation and housing and undertake the monthly monitoring of the health status of families, including number of exclusively breastfed children under four months. Based on this information and other procedures carried out by the Family Health Teams in the Basic Health Unit or at home, the Primary Care Municipal Coordination team consolidate their data monthly and send them to the Health Districts. The state figures are sent monthly to Datasus, the Health Informatics Department which processes all healthcare data in the country.

References:

  1. Ministry of Health, Brazil. Information System for Primary Care.  
  2. Szwarcwald, C. L., Escalante, J. J. C., Neto, R., de Lyra, D., Souza Junior, P. R. B. d., & Victora, C. G. (2014). Estimation of maternal mortality rates in Brazil, 2008-2011.Cadernos de Saúde Pública, 30, S71-S83.

Within the United States, the Joint Commission, an independent non-profit organization, accredits and certifies nearly 21,000 health care organizations and programs in the United States. Accreditation is not always required by state laws but maintaining accreditation from the Joint Commission fulfills many statutory obligations and insurance company rules about eligibility for insurance reimbursement. Joint Commission-accredited hospitals must report their performance measurements on a minimum of six measure sets, however, the Perinatal Care core measures (see below) are mandatory where a facility has 300 or more live births per year.  The other measure sets include topics such as asthma care, stroke care and immunizations.

The data collected are publicly reported on the Joint Commission website at Quality Check®, www.qualitycheck.org. Providing public access to performance measures on specific medical topics ensures people can compare hospitals in their area.

Hospitals and maternity facilities wishing to achieve or maintain their Joint Commission accreditation must collect and report on the Perinatal Care core measures. These serve as a national, standardized performance measurement system providing assessments of care delivered in 5 focus areas: elective delivery, Cesarean section, antenatal steroids, health care-associated bloodstream infections in newborns, and exclusive breast milk feeding.

To aid hospitals and maternity facilities in the accurate collection of the exclusive breast milk feeding core measure (# of exclusively breast milk-fed non-NICU term infants, including those supplemented with human milk), a toolkit was published by the United States Breastfeeding Committee (USBC).

Part 1 of the toolkit provides guidance for data collection which includes real-life samples of charts, from baby friendly hospitals in the US, to help facilities in assessing their current charting tools and consider potential adjustments (See Appendix 1 of the USBC toolkit).

Part 2 covers implementing practices to improve exclusive breastfeeding rates.  There are many evidence-based interventions suggested, the majority of which are drawn from the Ten Steps.  For example, the guidance to perform Apgar assessments and other procedures which may be painful (heel-sticks, medication administration) while mother and baby are skin-to-skin or breastfeeding, helps to avoid mother-baby separation, thereby reducing newborn stress and the risk of neonatal hypothermia and hypoglycemia. (See Appendix 2 of the USBC toolkit for resources aligned to the interventions.)

Reference:

  1. United States Breastfeeding Committee. (2010). Implementing The Joint Commission Perinatal Care Core Measure on Exclusive Breast Milk Feeding.

In Peru, the Continuous DHS provides annual data on initiation of breastfeeding, exclusive breastfeeding under six months, solids food introduction and median breastfeeding duration. Following the decentralization of government functions, in 2009 the continuous survey started collecting and analyzing data for each of the country’s 24 departments (regions).  The survey then breaks down the data further into four levels of conurbations- large cities, small cities and towns, semi-urban areas, and rural areas. Additionally, the data from the larger cities are further disaggregated by wealth using census data.

24 of the 27 field teams are based in the capital of each of the departments outside Lima. Three other teams are responsible for metropolitan Lima and its suburbs. During each six-month cycle of the continuous survey, fieldwork is split in half, using a representative sample for each half. 

Reference:

  1. Rutstein, Shea O., Way, Ann. (2014). The Peru Continuous DHS Experience. DHS Occasional Papers No. 8. Rockville, Maryland, USA.

In Brazil, the SISVAN (Food and Nutrition Surveillance System) provides monthly data of breastfeeding (exclusive and not exclusive) at the national, regional, state and county level (including municipalities). The reports are public and available online.

Reference:

  1. Ministry of Health, Brazil.  SISVAN (Food and Nutrition Surveillance System).  

In the U.S., the Centers for Disease Control and Prevention (CDC) publishes a bi-annual national Breastfeeding Report Card, which is also disaggregated to state level through on the Nutrition, Physical Activity and Obesity: Data, Trends and Maps.  This online tool can search for and view indicators related to nutrition, physical activity and obesity, either on the basis of a specific location or by indicator. See REG 5 for more details.

The CDC Maternity Practices in Infant Nutrition and Care (mPINC) Survey is a unique system in that it’s used for both surveillance and intervention. The CDC collects breastfeeding data using mPINC, which is a national survey administered every two years to every facility in the U.S. that routinely provides maternity care services. A key informant on behalf of his or her institution in their capacity as the person most knowledgeable about the relevant practices completes the survey and returns it to the CDC.  These practices include early initiation of skin to skin contact and breastfeeding, children ever breastfed, and numbers of children breastfed at one year. The CDC then calculates 7 subscores corresponding to the maternity care practice domains for each facility resulting in a total facility mPINC score. The maternity care practice domains are: Labor and Delivery Care, Postpartum Care, Feeding of Breastfed Infants, Breastfeeding Assistance, Contact Between Mother and Infant, Facility Discharge Care, Staff Training and Structural and Organizational Aspects of Care Delivery. Each facility receives an annotated individualized score report, which contains: a) that facility’s mPINC subscores; b) that facility’s total mPINC score.  Within the report, the facility subscores and total score are benchmarked to all hospitals nationwide, all other hospitals nationwide of similar size, and all hospitals in their own state. Hospital staff can use this information to advocate for improvements in maternity services within the hospital hierarchy.

See Reference #2 for a sample report and the scoring algorithm.

Every two years, aggregated national mPINC data by state, facility type, facility birth size, NICU level, and region are published on the CDC website-http://www.cdc.gov/breastfeeding/data/mpinc/state_reports.html
http://www.cdc.gov/breastfeeding/data/mpinc/results-tables.html
 
The data is broken down further by theme, including Indicators on the Ten Steps to Successful Breastfeeding, breastfeeding assistance and feeding of breastfed infant.

References:

  1. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion, Division of Nutrition, Physical Activity and Obesity. (2015). Breastfeeding Report Cards.  Atlanta, GA.
  2. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion, Division of Nutrition, Physical Activity and Obesity. (2013). Maternity Practices in Infant Nutrition & Care (mPINC) Survey.  Atlanta, Georgia.

Breastfeeding Report Cards

In the U.S., the Centers for Disease Control and Prevention (CDC) undertook a number of surveys on breastfeeding practices and rates (outlined below).  These data sources are analyzed and published in a bi-annual national Breastfeeding Report Card, which is also disaggregated at the state level through the Nutrition, Physical Activity and Obesity: Data, Trends and Maps.  This online tool can search for and view indicators related to nutrition, physical activity and obesity, either on the basis of a specific location or by indicator. Data and standard reports on breastfeeding practices are publicly available on the CDC website, including the results of the mPINC surveys (bi-annual) (see REG3 for more details), National Immunization Surveys (annual), and the PRAMS surveillance (annual) (See REG4 for more details).  The CDC strategically publishes data when breastfeeding is expected to gain major media attention, for instance releasing breastfeeding rates from the National Immunization Surveys just prior to World Breastfeeding Week.  The CDC “Vital Signs” publication (a glossy fact sheet issued monthly from the head of the agency), has published breastfeeding statistics/trends twice, in August 2011 and October 2015. (available at: http://www.cdc.gov/vitalsigns/Breastfeeding/index.html, http://www.cdc.gov/vitalsigns/breastfeeding2015/index.html)

The Global Nutrition Report 2016: From Promise to Impact: Ending Malnutrition by 2030 referenced the report cards as an example of strategic data collecting to measure coverage of BFHI, which the report found to be a key aspect of sustaining BFHI. The Report Card and data map indicators measure types of support in key community settings:

  • Average mPINC Score (see below)
  • Number of IBCLC's per 1,000 live births
  • Number of CLC’s per 1,000 live births
  • % of live births at Baby Friendly facilities
  • Number of La Leche leaders per 1,000 live births
  • State's care regulations support on-site breastfeeding
  • Key breastfeeding practices –
    • children ever breastfed,
    • breastfeeding at 6 months,
    • breastfeeding at 12 months, 
    • exclusive breastfeeding at 3 months and
    • exclusive breastfeeding at 6 months,
    • % of infants receiving formula before 2 days old

CDC Data sources:
Breastfeeding Rates – CDC National Immunization Surveys (NIS):

The NIS site explains the survey methods used - http://www.cdc.gov/breastfeeding/data/nis_data/survey_methods.htm. See Other Resources for more detail.

Breastfeeding support indicators - Average mPINC score: CDC Maternity Practices in Infant Nutrition and Care (mPINC) Survey. http://www.cdc.gov/breastfeeding/data/mpinc/results.htm

  1. % of live births at facilities designated as Baby Friendly (BFHI): Baby Friendly USA. Baby-Friendly Hospitals and Birth Centers. Available at http://www.babyfriendlyusa.org*
  1. % of breastfed infants receiving formula before 2days of age: CDC National Immunization Surveys  http://www.cdc.gov/breastfeeding/data/NIS_data/index.htm
  1. Number of La Leche League Leaders per 1,000 live births: La Leche League International database of accredited LLL Leaders, obtained through correspondence with La Leche League Representative to US Breastfeeding Committee
  1. Number of CLC’s per 1,000 live births: The Academy of Lactation Policy and Practice http://talpp.org/findlc.cfm -obtained through correspondence Director of Operations at Healthy Children Project, Inc.
  1. Number of IBCLCs per 1,000 live births: International Board of Lactation Consultant Examiners http://uslca.org/wp-content/uploads/2013/02/
  1. States child care regulation fully supports onsite breastfeeding: National Resource Center for Health and Safety in Child Care and Early Education, Achieving a state of healthy weight: 2013 update. Aurora, CO: University of Colorado Denver.
  1. Number of Live Births by state: National Vital Statistics Reports; vol 63 no 2. Hyattsville, MD: National Center for Health Statistics. 2014. Available at http://www.cdc.gov/nchs/data/nvsr/nvsr63/nvsr63_02.pdf

References:

  1. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion, Division of Nutrition, Physical Activity and Obesity. (2015). Breastfeeding Report Cards. Atlanta, GA.
  2. International Food Policy Research Institute. (2016). Global Nutrition Report 2016: From Promise to Impact: Ending Malnutrition by 2030.  Washington, DC.
  3. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion, Division of Nutrition, Physical Activity and Obesity. (2015). Nutrition, Physical Activity and Obesity Data, Trends and Maps web site.  Atlanta, GA.
  4. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health. Pregnancy Risk Assessment Monitoring System. Atlanta, GA.

In Brazil, the SISVAN (Food and Nutrition Surveillance System) provides monthly data of BF (exclusive and not exclusive) for national and subnational level (including municipalities). The reports are public and available online. The definition of vulnerable groups can change for each country. In Brazil these groups include that ones that are quilombo’s people descendants (quilombolas), riverside population (ribeirinhos), black and brown people. The SISVAN (Food and Nutrition Surveillance System) provides monthly data of BF (exclusive and not exclusive) for each one of these vulnerable groups.

Reference:

  1. Ministry of Health, Brazil.  SISVAN (Food and Nutrition Surveillance System).  

PRAMS, the Pregnancy Risk Assessment Monitoring System, is a surveillance project of the Centers for Disease Control and Prevention (CDC) and state health departments. Developed in 1987, PRAMS collects state-specific, population-based data on maternal attitudes and experiences before, during, and shortly after pregnancy. PRAMS surveillance currently covers about 78% of all U.S. births. The data allows for identifying groups of women and infants at high risk for health problems, to monitor changes in health status, and to measure progress towards goals in improving the health of mothers and infants. PRAMS data are used by researchers to investigate emerging issues in the field of reproductive health and by state and local governments to plan and review programs and policies aimed at reducing health problems among mothers and babies.
PRAMS has two sections: one is a set of core questions that all states/regions must ask and the other is a set of pre-tested standard questions that each geographic area chooses from, depending on their research needs.  This enables states to identify vulnerable groups with respect to key breastfeeding practices.  This does mean that each state’s questionnaire is unique to them, so information at a national level or comparisons across states is only possible where states use the same standard questions. 
The core questions about breastfeeding include:

  • During any of your prenatal care visits, did a doctor, nurse, or other health care worker talk with you about breastfeeding your baby?
  • Did you ever breastfeed or pump breast milk to feed your new baby, even for a short period of time?
  • Are you currently breastfeeding or feeding pumped milk to your new baby?
  • How many weeks or months did you breastfeed or pump milk to feed your baby?

Standard questions include:

  • What were your reasons for not breastfeeding your new baby?
  • What were your reasons for stopping breastfeeding?
  • Things that may have happened at the hospital where a new baby was born:
    • hospital staff gave information about breastfeeding
    • the baby stayed in the same room as the mother
    • hospital staff helped mother learn how to breastfeed
    • mother breastfed in the first hour after the baby was born
    • baby was breastfed in the hospital
    • baby was fed only breast milk at the hospital
    • hospital staff told mother to breastfeed whenever the baby wanted
    • the hospital provided a breast pump
    • the hospital gave a gift pack with formula
    • the hospital gave a telephone number to call for help with breastfeeding
    • hospital staff gave the baby a pacifier
  • During most recent pregnancy, what did you think about breastfeeding your new baby?
  • Did anyone suggest that you not breastfeed your new baby?
  • Who suggested that you not breastfeed your new baby?
  • When you went for WIC (a federal assistance program for healthcare and nutrition of low-income pregnant women, breastfeeding women, and infants and children under the age of five) visits during your most recent pregnancy, did you receive information on breastfeeding?
  • During your most recent pregnancy, when you went for your WIC visits, did you speak with a breastfeeding peer counselor or another WIC staff person about breastfeeding?
  • Before your new baby was born, did any of the following things happen:
    • Someone answered questions about breastfeeding
    • offered a class on breastfeeding
    • attended a class on breastfeeding
    • decided or planned to feed only breast milk to baby
    • discussed feeding only breast milk to baby with family
    • discussed feeding only breast milk to baby with health care worker
    • planned to breastfeed within the first hour after giving birth
  • How old was your new baby the first time he or she drank liquids other than breast milk (such as formula, water, juice, tea, or cow’s milk)?

Data on the following is collected: barriers to and content of prenatal care (including access to state/federally funded health care programs), obstetric history (including health behaviors-i.e. visiting a dentist, exercising etc), maternal use of alcohol and cigarettes, physical abuse, contraception, economic status, maternal stress, and early infant development and health status. 

PRAMStat is an online data platform developed to provide public access to over 250 maternal and child health indicators from PRAMS. Users can view and interact with PRAMS visualizations, such as maps and charts, and save visualizations for use in creating fact sheets and presentations.  With PRAMStat, a user can explore PRAMS data from 2000 through 2011 from a single state or select a topic and allows for comparisons across states because the same data collection methods are used in all states  (http://www.cdc.gov/prams/pramstat/index.html). For breastfeeding, PRAMStat provides data on these key practices: Ever Breastfed, Breastfeeding @ 4 weeks and Breastfeeding @ 8 wks, and this can be disaggregated into categories such as, adequacy of pre-natal care, income, marital status, race/ethnicity, age, education, or WIC participant.

An example of how the PRAMS data can be used to examine key breastfeeding practices among vulnerable groups is provided by the state of Rhode Island. The Rhode Island Department of Health and its partners developed a strategic plan to protect, promote, and support breastfeeding statewide.  This strategy is the state's response to the U.S. Surgeon General’s Call to Action to Support Breastfeeding and the objectives are based on Healthy People 2020, a 10-year national health agenda set by the United States Department of Health and Human Services.
 
Figures 1 and 2 on page 6-7 of the plan give a state and regional breakdown of key breastfeeding practices for vulnerable groups in Rhode Island.  These groups are mothers who are younger than age 20, unmarried, and who have 12 years of education or less. They were identified as vulnerable through data monitoring by the Rhode Island Department of Health using the PRAMS Data Book and the Rhode Island Department of Health, KIDSNET Database (a confidential, computerized child health information system).

References:

  1. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health. Pregnancy Risk Assessment Monitoring System.  Atlanta, GA.
  2. Rhode Island Department of Health. (2015).  Rhode Island Breastfeeding Strategic Plan 2015-2020.

Each year, CDC’s National Center for Immunizations and Respiratory Diseases (NCIRD), in partnership with the National Center for Health Statistics, conducts the National Immunization Survey (NIS). The NIS uses random-digit dialing to survey households with children aged 19–35 months. A more detailed description of the methods can be found at the National Immunization Survey Web site http://www.cdc.gov/vaccines/imz-managers/nis/index.html.

Reference:

  1. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion, Division of Nutrition, Physical Activity, and Obesity. NIS Survey Methods.  Atlanta, GA.

Monitoring Process Indicators

WHO and UNICEF have established a global network of civil society organizations and experts from several countries to provide technical support to countries in improving their efforts to monitor and enforce Code implementation – known as, the NET CODE: Network for Global Monitoring and Support for Implementation of the International Code of Marketing of Breast-milk Substitutes and subsequent relevant World Health Assembly Resolutions. A monitoring protocol is available which provides countries with assistance in setting up a monitoring system - to detect, investigate and act on alleged violations of national measures and the Code (Chapter 2) -and to set up an assessment system - to verify the level of adherence with national measures and the Code and to identify gaps and issues (Chapter 3).

Reference:

  1. World Health Organization. (2015). Net Code Protocol: Protocol for The Assessment and Monitoring of “The Code” and Relevant National Measures.

In Viet Nam, Alive & Thrive developed a set of tools to document compliance with restrictions on the marketing of breastmilk substitutes.  It includes monitoring forms for interviewing mothers, providers, and sales personnel and for assessing labels (infant milk products, bottles, and nipples), point-of-purchase materials, and information materials (for health workers and mothers). These forms were developed in 2004 by the International Baby Food Action Network.

Reference:

  1. Alive and Thrive. (2015).Monitoring Tools to Support Compliance with Decree 21 in Viet Nam.

In New Zealand, the Ministry of Health (MoH) is responsible for monitoring the NZ Code of Practice, however, there is no monitoring system for systematically and routinely collecting data. The process followed is the MoH receives a complaint about a potential breach of the Code. If the issue is not resolved to the complainant’s satisfaction through the natural justice process, it will be submitted to a Compliance Panel for a decision. There is an appeal process, presided over by an adjudicator, for complaints unresolved by the Compliance Panel.

Reference:

Ministry of Health, New Zealand. (2007).  Implementing and Monitoring the International Code of Marketing of Breast-milk Substitutes in New Zealand: The Code in New Zealand.

In 2011, the Australian Government implemented the Paid Parental Leave (PPL) scheme to provide eligible working parents with up to 18 weeks of Government‑funded time off from work to care for a newborn or recently adopted child. In addition to an extensive evaluation process of the scheme (including measuring breastfeeding rates before and after the introduction of PPL), the Department of Social Services (DSS) collects and publicly reports performance indicators measuring usage on a rolling three-year basis:

  • Percentage and number of mothers for whom PLP has been paid as a proportion of all mothers in the same year
  • Percentage and number of parents paid government-funded PLP by employers
  • Percentage and number of families who have taken the full 18 weeks of PLP

References:

  1. Institute for Social Science Research, The University of Queensland. (2014). PPL Evaluation: Final Report.
  2. Department of Social Services, Australia. (2015).  Department of Social Services Annual Report 2014–15.

This Philippine WBTi report and Call to Action paper documents the WBTi assessment process and accompanying advocacy efforts to secure improved Maternity Leave legislation.  This assessment took place shortly after Senator Cayetano’s speeches calling for extended maternity leave legislation and her sponsored bill. The World Breastfeeding Week theme in 2015 was working women who breastfeed and so this advocacy/legislative push was well timed.

The WBTi assessment involved intensive workshops with multi sector participants - members of the House of Representative, Chiefs of Staff of elected politicians, Government representatives from Health and Nutrition, Trade Unions, Breastfeeding advocacy groups, mother support groups, NGOs, and medical and justice professionals.  The report is very clear in its aim for this process to galvanize improvements in Maternity Leave.

The paper also illustrates some of the ways advocacy groups publicized their "Call to Action".  The Philippine Pediatric Society organized an International Breastfeeding Conference and 1000 breastfeeding women attended The Big Latch On/Hakab Na event, with another 73,000 participating on line. As noted above, the Government committee, Women, Children, Family Relations and Gender Equality, chaired by Sen Cayetano, played a critical role in pushing this issue at the national government level.  The public hearing in November 2015 was well attended by breastfeeding advocacy and mother support groups. In February 2016, the Senate passed legislation for 100 days paid Maternity Leave and the President at the time signed into law before his term ended in May 2016.

Reference:

  1. International Baby Food Action Network. (2015).  Philippine-WBTi Report and Call to Action.

The CDC publishes a bi-annual national Breastfeeding Report Card, which is also disaggregated to state level. The Report Card indicators measure types of support in key community settings, including the number of Certified Lactation Consultants (CLC)’s and IBCLC's per 1,000 live births and % of live births at Baby Friendly facilities.  (See REG5 for more details)

Reference:

  1. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion, Division of Nutrition, Physical Activity and Obesity. (2015). Breastfeeding Report Cards.  Atlanta, GA.

Alive & Thrive operated one-on-one and group counseling for pregnant women and mothers with children under 2 years with trained, certified counselors in Viet Nam.  Each franchise completes a Monthly Report Form (PB) including information about the number of counseling contacts for exclusive breastfeeding (EBF) promotion, EBF support and management, and complementary feeding education, and management. The monitoring system provides an easy and streamlined program that allows for sharing data in a timely manner to facilitate evidence-based decision-making and improve program quality. The design of this system took into account the existing infrastructure of the health care system.  The document below includes useful examples of monitoring forms used for this intervention.

Reference:

  1. Alive and Thrive. (2014).  Franchise Monitoring Manual.

In the U.S., Baby Friendly USA Inc is the accrediting body and the national authority for the Baby-Friendly Hospital Initiative in the United States.  Their website tracks the hospitals and birthing centers that hold the Baby-Friendly designation.

Reference:

  1. Baby Friendly USA.

The CDC Maternity Practices in Infant Nutrition and Care (mPINC) Survey is a national survey, administered every two years to every facility in the U.S. that routinely provides maternity care services, and is completed by a key informant on behalf of his or her institution in their capacity as the person most knowledgeable about the relevant practices. These surveys monitor and examine changes in practices over time. This is an ongoing, national system to monitor and evaluate hospital practices related to breastfeeding among all facilities that routinely provide intrapartum care in the U.S. The data is presented by facility type, size, NICU level, region and state. The survey monitors the following:

Labor and delivery:

  • Skin-to-skin contact
  • Early initiation of breastfeeding,
  • Performance of routine procedures while skin-to-skin

Feeding of breastfed infant

  • Initial feeding received after birth
  • Supplementary feedings

Breastfeeding assistance

  • Documentation of feeding decision
  • Breastfeeding advice and counseling
  • Assessment and observation of breastfeeding
  • Pacifier use

Mother/infant contact

  • Separation of mother and newborn during transition to receiving patient care units
  • Patient rooming-in
  • Instances of mother infant separation throughout the intrapartum stay

Discharge care

  • Assurance of ambulatory breastfeeding support
  • Distribution of “discharge packs” containing infant formula

Staff training

  • Preparation of new staff
  • Continuing education
  • Competency assessment

Structural & Organizational Aspects

  • Breastfeeding policy
  • Communication of breastfeeding policy
  • Infant feeding documentation policy
  • Employee breastfeeding support
  • Facility receipt of free infant formula
  • Prenatal breastfeeding instruction
  • Coordination of lactation care

Indicators on the Ten Steps to Successful Breastfeeding

  • Percent of hospitals with recommended policies and practices consistent with the Ten Steps to Successful Breastfeeding
  • Percent of hospitals by number of recommended policies and practices

The CDC calculates Facility mPINC Subscores across 7 maternity care practice domains, which contribute to each facility’s Total Facility mPINC Score.  Each facility receives an annotated individualized score report, the Facility mPINC Subscores and Total Facility mPINC Score, benchmarked to all hospitals nationwide, all other hospitals nationwide of similar size, and all hospitals in their own state. Samples of the report and the scoring algorithm are on the website.

Reference:

Alive and Thrive (A&T) evaluates and monitors its breastfeeding media campaign in Viet Nam to understand the reach of the key messages and resulting changes in beliefs and behaviors.  Two years into the campaign, four of every five pregnant women or mothers with children under two years old, in the catchment areas, received personal IYCF counselling services. The monitoring system operates within the public health system at five levels: village, commune, district, province, A&T regional offices and A&T central office in Hanoi.  At the village and commune levels, paper forms are used and all other levels use electronic forms. Data is submitted monthly and are then checked, collated, and analyzed to generate a report for each province and an overall report for the 15 provinces. The data are then shared back with regional and provincial teams and discussed at the Province Management Board meetings by the 20th of the month. The reports are produced on a rolling quarterly basis. These data include:

  • Coverage (%): Total number of registered children divided by the total children in the catchment area   
  • Volume: Total number of counseling contacts
  • Service Utilization: % of mother-child pairs that received full counseling packages 
  • Quality: Repeat clients (proxy for quality)

Besides the data on quantity, data on quality was also collected through the supportive supervision visits. Supervisors fill out a checklist at each visit, and this allows them to rank the quality of the franchise based on:

  • Status of the facility and staff
  • Quality of the counseling service
  • Quality of recording and reporting data

See Reference #2 for more detail on the forms, who completes them and when, sample forms, and how the monitoring information was used. 

References:

  1. Tuan, N. T., Alayon, S., Do, T. T., Ngan, T. T., & Hajeebhoy, N. (2015). Integrating a project monitoring system into a public health network: experiences from Alive & Thrive Vietnam.Glob Public Health, 10 Supppl 1, S40-55. doi:10.1080/17441692.2014.980836
  2. Tuan NT, D. T., Ngan TT, Kiem TT, Hajeebhoy N, Alayón S. (2014). Viet Nam Franchise Monitoring Manual. Washington, DC: Alive & Thrive