Program Delivery Benchmarks

Facility-Based Delivery Theme

Breastfeeding promotion and support standards and guidelines need to be developed and disseminated to ensure delivery of high quality breastfeeding care within facilities providing maternity and newborn care. Breastfeeding standards and guidelines can be developed and disseminated as an individual guideline or can also be included in maternity and/or child health materials (for example, young child feeding guidelines, child health guidelines). This benchmark measures the availability and coverage of breastfeeding promotion and support standards and guidelines. 

Possible data sources : Interviews with government officials within the area of infant/young child feeding and health provide evidence of the availability and coverage of breastfeeding promotion and support standards and guidelines for program delivery.

The scoring reflects the:

a) Development of standards and guidelines for breastfeeding promotion and support; and 
b) Level of dissemination to facilities and personnel.

How to score

☐ No progress: Standards and guidelines for breastfeeding promotion and support have not been developed.

☐ Minimal progress: Standards and guidelines have been developed but they have not been disseminated to any facilities and personnel providing maternity care. 

☐ Partial progress: Standards and guidelines have been developed and disseminated to some facilities and personnel providing maternity care. 

☐ Major progress: Standards and guidelines have been developed and disseminated to all facilities and personnel providing maternity care.


Example: The Brazilian Ministry of Health has issued and disseminated a series of guidelines to standardize and ensure high-quality breastfeeding care. This series includes: 

• Newborn health care: a guide for health professionals (4 volumes)

• Child health: growth and development (Primary Healthcare Book 33)

• Child health: breastfeeding and complementary feeding (Primary Healthcare Book 23)

• Ten Steps for a Healthy Feeding: feeding guide for child under two years - a guide for the Professional in the Primary Health Care

• Breastfeeding and the use of medicines and other substances

• Legislation and marketing of products that interfere with breastfeeding: a health professionals guide

• Breastfeeding. Distribution of Milk and Infant Formulas in Health Establishments and Legislation

• Essentials of breastfeeding for working woman

Humanized Care Low Birth Weight: Kangaroo Method: technical manual

• Manual for Kangaroo Method: shared follow-up between Hospital Care and Primary Care. 

These materials are the standard national guidelines to promote, protect and support breastfeeding and complementary food and are disseminated within all facilities providing maternity and newborn care (including hospitals, clinics, and primary health care/community services). 

Score: Major Progress

Domain- Existence: Yes

Domain- Coverage: Standards and guidelines for breastfeeding promotion and support have been developed and disseminated nationally to all facilities and personnel providing maternity care.

This benchmark measures if assessment systems are in place for designating facilities as BFHI/Ten Steps. Designating facilities as BFHI/Ten Steps certifies that these facilities have completed the steps required to become “Baby-Friendly”, indicating that those facilities protect, promote and support breastfeeding following the Ten Steps. These assessment systems must be based on the same criteria as the BFHI UNICEF/WHO global criteria and must be incorporated into the national plan to have maximum effectiveness.

Possible data sources : Interviews with government officials within the area of infant/young child feeding and health provide evidence of the existence of assessment systems for designating facilities as BFHI/Ten Steps.  A review of the assessment systems protocols and the National Breastfeeding Plan are needed to understand the quality and content of the assessment systems. 

The scoring of this benchmark reflects the:

a) Existence of assessment systems for designating BFHI/Ten Steps facilities; 
b) Quality of the assessment system; and 
c) Level of incorporation of the assessment systems into the National Breastfeeding Plan.

How to score:  

☐ No progress: No assessment systems exist for designating BFHI/Ten Steps facilities. 

☐ Minimal progress: Assessment systems exist but they are not based on the BFHI UNICEF/WHO global criteria nor are they incorporated into the National Breastfeeding Plan. 

☐ Partial progress: Assessment systems exist and are based on the BFHI UNICEF/WHO global criteria but they are not incorporated into the National Breastfeeding Plan. 

☐ Major progress: Assessment systems exist and they are based on the BFHI UNICEF/WHO global criteria and they are incorporated into the National Breastfeeding Plan.


Example: The New Zealand Breastfeeding Alliance (NZBA) is a coalition of 30 breastfeeding stakeholder organizations and is funded by the Ministry of Health to manage and assess the BFHI/BBF initiatives.

Score: Major Progress

Domain- Existence: Yes

Domain- Quality: Based on the BFHI UNICEF/WHO global criteria

Domain- Effective: National Strategic Plan of Action for Breastfeeding 2008–2012 has a goal of all District Health Boards achieving and maintaining Baby Friendly Hospital accreditation


Having a reassessment system designed to determine if hospital or maternity services continue to adhere to the Baby-Friendly/Ten Steps criteria is necessary to continue to support breastfeeding programs.  Without a reassessment system, hospitals or maternity services would not be held accountable for not continuing to meet the Baby-Friendly/Ten Steps standards required for BFHI/Ten Steps accreditation.  This benchmark assesses if there is a reassessment system(s) in place for reevaluating designated Baby-Friendly/Ten Steps facilities.

Possible data sources : Interviews with government officials within the area of infant/young child feeding and health provide evidence of the existence of reassessment systems for reevaluating designated Baby-Friendly/Ten Steps facilities.  A review of the reassessment systems protocol and the National Breastfeeding Plan are needed to understand the quality and content of the reassessment systems. 

The scoring for this benchmark reflects the:

a) Existence of reassessment systems to reevaluate Baby-Friendly/Ten Steps facilities; 
b) Incorporation into the National Breastfeeding Plan; and 
c) Presence/absence of time bound implementation.

How to score

☐ No progress: No reassessment systems exist for reevaluating designated Baby-Friendly/Ten Steps facilities. 

☐ Minimal progress: Reassessment systems exist- not been incorporated in the National Breastfeeding Plan with a time bound implementation plan. 

☐ Partial progress: Reassessment systems exist - incorporated in the National Breastfeeding Plan but no time bound implementation plan. 

☐ Major progress: Reassessment systems exist - incorporated in the National Breastfeeding Plan and have a time bound implementation plan.

Example : The New Zealand Breastfeeding Alliance (NZBA), which is a coalition of 30 breastfeeding stakeholder organizations and is funded by the Ministry of Health to manage and assess the BFHI/BBF initiatives, also reassesses maternity facilities to determine if they continue to adhere to the Baby-Friendly/Ten Steps criteria. 

Score : Major Progress

Domain- Existence: Yes

Domain- Quality: National Strategic Plan of Action set a timeframe for all District Health Boards achieving and maintaining Baby Friendly Hospital accreditation as a priority area for 2008-2010

It is important to understand if the percent of public and private hospitals and maternity facilities designated or reassessed as baby-friendly is increasing, decreasing, or remaining the same. This benchmark assesses the proportion of deliveries that take place within hospitals and maternity facilities that have been designated or recertified as baby-friendly over the past 5 years. The following questions from the WHO Global Nutrition Policy Review module on the Baby-friendly Hospital Initiative can be used to help assess how many healthcare facilities (pubic and private) have ever been designated Baby-Friendly:

  • How many of these have been designated or re-assessed as Baby-Friendly in the past 5 years?
  • What is the total number of births per year in the facilities that were designated or re-assessed as Baby-Friendly in the past 5 years?
Possible data sources : Reviews of reports on the status of the BFHI in the country including Ministry of Health (MOH) (including the National Breastfeeding/Infant and Young Child Feeding committee), UNICEF, etc.  Conduct interviews with government officials in the MOH and experts working in-country with UNICEF, Pan American Health Organization (PAHO) or WHO that are familiar with BFHI within the country.

Scoring reflects the coverage of BFHI in-country. 

How to score

☐ No progress: No maternity facilities have been designated or reassessed as “Baby-Friendly” in the last 5 years.

☐ Minimal progress: Less than or equal to 33.3% of deliveries take place in hospitals and maternity facilities designated or reassessed as “Baby-Friendly” in the last 5 years. 

☐ Partial progress: Between 33.3% and 66.6% of deliveries take place in hospitals and maternity facilities designated or reassessed as “Baby-Friendly” in the last 5 years.

☐ Major progress: More than 66.6% of deliveries take place in hospitals and maternity facilities designated or reassessed as “Baby-Friendly” in the last 5 years.

Example : Between 2011 and 2014, Uruguay stands out as having made dramatic progress on the BFHI. Fifty-two out of a total of 64 hospitals providing delivery-care services were certified or recertified. 

For calculating the number of deliveries within BFHI facilities the following information was used: 

(1) the annual number of birth (2010-2013) was 49,000; 

(2) deliveries occurring in health facilities (2010-2013) 99.5%; 

(3) health facilities that have been certified or recertified as baby-friendly since 2008 54/64 (84.4%); and 

(4) health facility deliveries occurring in facilities certified/recertified since 2008, 75.2%.  

Score : Major Progress

Domain- Coverage: More than 66.6% of deliveries took place in hospitals and maternity facilities designated or reassessed as “Baby-Friendly” in the last 5 years. 

Description : Healthcare facilities should be providing community outreach and support activities for breastfeeding.   

Community breastfeeding outreach to promote breastfeeding:

  • Community health fairs
  • Disseminate educational materials in community settings or via media
  • Continuous activities - breastfeeding educational sessions for pregnant and postpartum women in community settings

 Breastfeeding support activities:

  • In-person (outpatient), on-line, or phone access to professional breastfeeding support
  • Provide individual and group breastfeeding counseling

This benchmark assesses if health facilities are implementing breastfeeding related community outreach and support activities and how well it links with existing community-based breastfeeding/nutrition programs.

Possible data sources : Interviews can be conducted with government officials within the MOH, the national and local breastfeeding coordinators, representatives of NGOs involved in health or breastfeeding; health facility officials, representatives of organizations involved with mother-to-mother support groups. If available, the National Breastfeeding Plan can be reviewed to understand the specific health-facility based community outreach and support activities and the coverage reached.   

The scoring reflects the: 

a) Level and quality of implementation of health facility-based community outreach and support activities; and 
b) Level and quality of linkages with community breastfeeding/nutrition programs.  

How to score

☐ No progress: No health facility-based community outreach and support activities related to breastfeeding are being implemented and linkages with community breastfeeding/nutrition programs are not in place. 

☐ Minimal progress: Health facility-based community outreach and support activities are minimally implemented -local level only- or limited linkages with community breastfeeding/nutrition programs are in place. 

☐ Partial progress: Health facility-based community outreach and support activities are effectively implemented -national, subnational, and local level- or effective linkages with community breastfeeding/nutrition programs are in place. 

☐ Major progress: Health facility-based community outreach and support activities are effectively implemented and effective linkages with community breastfeeding/nutrition programs are in place.

Example: Sri Lanka's Lactation Management Centres are run out of specialist hospitals.  The service is run by Nursing Officers who are available seven days a week from 7 am – 5 pm, via in-patient care, out-patient visits and telephone hotlines.  Any mother with breastfeeding problems may use the center for free, without referral letters or appointments. In addition, they speak at ante-natal health educational classes, take part in special day/half-day programmes organized to educate nursing officers staff on other wards, and run lecture/clinical sessions for nursing students and midwifery students.

Score : Minimal Progress

Domain- Existence: Yes

Domain- Quality: Lactation Centers are implemented in specialist hospitals only so there is not national coverage

Domain- Effective: Not enough information to assess linkages with community programs

Community-Based (i.e. Non-Health Care Facilities Delivery) Theme

This benchmark assesses if non-health care facilities, such as community organizations, have conducted breastfeeding outreach and support activities and, if so, have they achieved national coverage.  This benchmark assesses if community-based breastfeeding outreach and support activities are being implemented and, if so, the coverage of those activities.

Community based outreach: Home visits, mother-to-mother support groups, providing hands-on assistance and breastfeeding guidance beyond the hospital walls.

Possible data sources :  Interviews can be conducted with government officials within the MOH, the national and local breastfeeding coordinators, representatives of NGOs involved in health or breastfeeding; health facility officials, representatives of organizations involved with mother-to-mother support groups. If available, the National Breastfeeding Plan can be reviewed to understand the specific community-based outreach and support activities and the coverage reached. 

The scoring for this benchmark reflects the availability and coverage of community-based breastfeeding outreach and support activities. Full national coverage refers to the fact that all activities are being implemented to cover all the specific target population. For example, if a community-based breastfeeding initiative is designed to reach an indigenous/ethnic population that only lives within a certain geographical area within the entire country, coverage would be considered national if the program activities reach the entire target population.  

How to score

☐ No progress: No community-based breastfeeding outreach and support activities. 

☐ Minimal progress: Community-based breastfeeding outreach and support activities have minimal coverage - at the local level only. 

☐ Partial progress: Community-based breastfeeding outreach and support activities have partial coverage - local and subnational level only. 

☐ Major progress: Community-based breastfeeding outreach and support activities have full national coverage.

Example : The LINKAGES Project in Bolivia, a community based behavioral change project, reached one million people, and covered eight of nine departments, three eco-regions, 155 municipalities, and 2,389 communities.  The purpose was to increase timely initiation of breastfeeding and the rate of exclusive breastfeeding through BCC, training, and community activities using the existing network of CHWs. 

Score: Partial Progress

Domain- Existence: Yes

Domain- Coverage: Extensive but not national

Supervision Theme

Description : Supportive supervision refers to a non-authoritarian method of monitoring and evaluating staff performance. 

Supervisors :

  • Serve as mentors
  • Encourage two-way communication
  • Facilitate team building
  • Encourage problem solving
  • Monitor performance towards goals
  • Maintain regular follow-ups with staff

This benchmark assesses if there are trained and certified lactation management specialists available to provide supportive supervision for breastfeeding program delivery and, if so, the coverage of that type of supervision.

Possible data sources : Interviews can be conducted with the national breastfeeding coordinator and representatives of NGOs involved in health or breastfeeding. If available, MOH documents specifying the parameters and registries reporting on coverage attained with supportive supervision should be reviewed to corroborate the key informants’ reports.

The scoring for this benchmark assesses the availability and coverage of trained and certified lactation management specialists available to provide supportive supervision for breastfeeding program delivery. 

How to score

☐ No progress: No trained and certified lactation management specialists available to provide supportive supervision for breastfeeding program delivery at either the facility or community level. 

☐ Minimal progress: Trained and certified lactation management specialists available at the facility and/or community level with sub-national/local coverage

☐ Partial progress: Trained and certified lactation management specialists available at the facility and community level reaching partial national coverage

☐ Major progress: Trained and certified lactation management specialists at the facility and community level reaching full national coverage.


Example : In Indonesia, to become a breastfeeding counselor, the WHO/UNICEF’s breastfeeding counseling training module is required (a total of 40 hours). There is no education prerequisite for the training and after completing the training, one counseling assignment must take place within the month to obtain the certificate. Breastfeeding counselors do not have a clear mechanism for starting a practice, so they can practice anywhere without supervision. Other than this, there is no other regulation regarding breastfeeding counseling, including what types of services may be performed or any obligation to comply with the code of ethics.

There is an official association for breastfeeding counselors, the Indonesian Breastfeeding Counselors Association, with approximately 200 members. If a breastfeeding counselor wants to become a member, he or she will be given an ethics code of conduct to follow. This association also offers supervision that standardizes care among their members. There is no obligation for a breastfeeding counselor or specialist to become a member. Coordination to issue a national license needs to be establish as well as to standardize care and increase coverage nationally.

Score: Minimal Progress

Domain- Existence:  Yes

Domain- Coverage:  Local coverage only

Breastfeeding support, Raichur, India

A technology enhanced campaign uses laptops to support breastfeeding among women in a rural area in Raichur, India. © 2013 Dr Abhay Mane/ Smt. Kashibai Navale Medical College, Courtesy of Photoshare