Training Benchmarks

Pre-Service Training for Health Care Providers Theme

This benchmark assesses if the curricula of health provider schools (i.e. medical schools, nursing schools, midwifery schools, nutrition programs etc.) and pre-service education programs, specifically for health care professionals that will care for mothers, infants and young children, includes breastfeeding. The essential breastfeeding topics required for pre-service curriculum are described in Annex 4

Possible data sources : Consult expert(s) in higher education, who know the content and quality of pre-service health care professional curriculums, should be able to provide a level of assessment on the quality and coverage of the breastfeeding topics within pre-service programs. This assessment(s) should be corroborated against recent surveys that have probed for this information or conduct a review of the training program curricula.

The scoring for this benchmark reflects:

a) Existence of breastfeeding pre-service training for health care professionals; 
b) Degree of inclusion of essential breastfeeding topics (see Annex 4) in the pre-service curriculum; and 
c) Level of coverage across pre-service programs. 

How to score

☐ No progress: Breastfeeding curricula do not exist in pre-service programs for health care professionals that will care for mothers, infants and young children. 

☐ Minimal progress:  Breastfeeding curricula exist in pre-service programs but the curricula do not cover all essential breastfeeding topics and they are not integrated within all pre-service programs. 

☐ Partial progress: Breastfeeding curricula exist in pre-service programs and the curricula cover all essential breastfeeding topics or they are integrated within all pre-service programs. 

☐ Major progress: Breastfeeding curricula exist in pre-service programs and the curricula cover all essential breastfeeding topics and are integrated within all pre-service programs.


Example: Little data exists about the presence and quality of breastfeeding within medical pre-service education curriculums in the US.  A seminal study in the US in 1995 on residency training for physicians caring for mothers, infants, and young children found that residents within all areas didn’t demonstrate effective breastfeeding management and care.  Since then, the studies that have emerged in this area have shown that pre-service breastfeeding training for residents hasn’t significantly improved. The American Academy of Pediatrics (AAP) have developed a Breastfeeding Residency Curriculum and set of curriculum tools for residents (pre-service training) but these have not been adopted by all the institutions providing pre service training for health professionals.

Score: Minimal Progress 

Domain- Existence: Yes

Domain- Coverage: Breastfeeding curriculum is not integrated within all pre-service programs.

Domain- Quality: Curriculum does not cover all the essential topics in Annex 4.


In-Service Training for Facility-Based Health Care Providers Theme

Facility-based health care professionals who care for mothers, infants and young children should receive in-service instructional training on breastfeeding to improve their breastfeeding knowledge so they can effectively educate and care for mothers during pregnancy and the postpartum period.  

This benchmark assesses whether facility-based health care professionals who care for mothers, infants and young children are receiving instructional in-service training on breastfeeding. If so, it assesses the quality of the training against specific breastfeeding topics (see the list in Annex 4) and the integration of breastfeeding training across all facility-based in-service programs.

Possible data sources: Expert(s) in higher education who know the content and quality of in-service health care professional curriculums would be best to consult. They should be able to provide a level of assessment on the quality and coverage of the breastfeeding topics within facility-based in-service programs. Ideally this assessment from expert(s) should be corroborated against specific surveys that have recently probed for this information, if available at all.  Alternatively, a review of training program curricula can be conducted.

Facility-based health care professionals : Prenatal care, maternity care and pediatric staff based in clinics or hospitals that work with pregnant and postpartum women, infants and young children. 


The scoring for this benchmark reflects:

a) Existence of breastfeeding in-service training for facility-based health care professionals who care for mothers, infants and young children;

b) Degree of inclusion of essential breastfeeding topics (see Annex 4) in the facility-based in-service curriculum;

c) Level of integration of breastfeeding training in facility-based in-service programs for those who care for mothers, infants and young children


How to score:

    ☐ No progress: Breastfeeding training does not exist in in-service programs for facility-based health care professionals   
    ☐ Minimal progress: Breastfeeding training exists in in-service programs for facility-based health care professionals but the curricula are not integrated within all in-service facility-based programs     
    ☐ Partial progress: Breastfeeding training exists in in-service programs for facility-based health care professionals and the curricula cover all essential breastfeeding topics or are integrated within all     in-service facility-based programs     
    ☐ Major progress:
Breastfeeding training exists in in-service programs for facility-based health care professionals and the curricula cover all essential breastfeeding topics and are integrated within all     in-service facility-based programs    


Example: The Ministry of Health of Viet Nam developed their IYCF training program based on WHO, UNICEF and Alive & Thrive training material. The 40 sessions, including 25 theory sessions and 15 practicals are focused on breastfeeding and complementary feeding. All the essential topics in Annex 4 are included in this training manual, with the exception of contraception. 

Score: Partial Progress 

Domain- Existence: Yes

Domain- Quality: All topics in Annex 4 (with the one exception of contraception) are included.

Domain- Effective: Not enough information to assess the level of integration of breastfeeding training into the curricula of all facility-based in-service programs.

Facility-based health care professionals who care for mothers, infants and young children should also receive hand-on training in counseling and support skills specific to breastfeeding so they can provide effective counseling and support to breastfeeding women.  

This benchmark assesses whether facility-based health care professionals who care for mothers, infants and young children are receiving hands-on breastfeeding counseling and support skills training. If so, it assesses the quality against specific breastfeeding topics (see list in emptyAnnex 5) and the integration of breastfeeding training across all facility-based in-service programs.

Possible data sources: Expert(s) in higher education who know the content and quality of in-service health care professional curriculums, including the hands-on trainings, would be best to consult.  They should be able to provide a level of assessment on the quality and coverage of the breastfeeding topics for counseling and support skills within facility-based in-service programs. Ideally this assessment from expert(s) should be corroborated against specific surveys that have recently probed for this information, if available at all.  Alternatively, a review of training program curricula can be conducted.

Facility-based health care professionals: Prenatal care, maternity care and pediatric staff based in clinics or hospitals that work with pregnant and postpartum women, infants and young children.

The scoring for this benchmark reflects:

a) Existence of hands-on in-service training in breastfeeding counseling and support skills for facility-based health care professionals who care for mothers, infants and young children;
b) Degree of inclusion of the essential breastfeeding counseling and support skill topics (see Annex 5) in the facility-based in-service curriculum; and
c) Level of coverage/integration of breastfeeding counseling and support skills training into the curricula across facility-based in-service programs

How to score:

☐ No progress: Hands-on breastfeeding training does not exist in in-service programs for facility-based health care professionals who care for mothers, infants and young children. 

☐ Minimal progress: Hands-on breastfeeding training exists in in-service programs for facility-based health care professionals but the curricula do not cover all essential breastfeeding counseling and support skills topics and breastfeeding curricula are not integrated within all in-service facility-based programs. 

☐ Partial progress: Hands-on breastfeeding training exists in in-service programs for facility-based health care professionals and the curricula cover all essential breastfeeding topics or breastfeeding curricula are integrated within all facility-based in-service programs.

☐ Major progress: Hands-on breastfeeding training exists in in-service programs for facility-based health care professionals and the curricula cover all essential breastfeeding topics and breastfeeding curricula are integrated within all facility-based in-service programs.

Example: The Ministry of Health of Viet Nam developed their IYCF training program based on WHO, UNICEF and Alive & Thrive training material. The 40 sessions, including 25 theory sessions and 15 practicals are focused on breastfeeding and complementary feeding. All the essential topics in Annex 5 are included in this training manual, with the exception of contraception. 

Score: Partial Progress 

Domain: Existence: Yes

Domain: Quality: All topics in Annex 5 (with the one exception of contraception) are covered.

Domain- Effective: Not enough information to assess the level of integration of breastfeeding training into the curricula of all facility-based in-service programs.


In-Service Training for Community-Based Health Care Providers Theme

Community-based health care professionals who care for mothers, infants and young children should receive in-service instructional training in breastfeeding to improve their breastfeeding knowledge so they can effectively educate and care for mothers during pregnancy and the postpartum period.

This benchmark assesses whether community-based health care professionals who care for mothers, infants and young children are receiving in-service instructional training on breastfeeding. If so, it assesses the quality of the training against specific breastfeeding topics (see the list in Annex 4) and the integration of breastfeeding training across all facility-based in-service programs. 

Possible data sources: Expert(s) in higher education who know the content and quality of in-service health care professional curriculums, including the hands-on trainings, would be best to consult.  They should be able to provide a level of assessment on the quality and coverage of the breastfeeding topics within community-based in-service programs. Ideally this assessment from expert(s) should be corroborated against specific surveys that have recently probed for this information, if available at all.  Alternatively, a review of training program curricula can be conducted.

Community-based health care professionals : Staff based in primary health care clinics that work with pregnant and postpartum women, infants and young children. 


The scoring for this benchmark reflects:

a) Existence of breastfeeding in-service training for community-based health care professionals who care for mothers, infants and young children; 
b) Degree of inclusion of essential breastfeeding topics (see Annex 4) in the community-based in-service curriculum; and 
c) Level of integration of breastfeeding training into the curricula in community-based in-service training.

How to score

☐ No progress: Breastfeeding training does not exist in in-service programs for community-based health care professionals who care for mothers, infants and young children. 

☐ Minimal progress: Breastfeeding training exists in in-service programs for community-based health care professionals but the curricula do not cover all essential breastfeeding topics and the curricula are not integrated within all in-service community-based programs.

☐ Partial progress: Breastfeeding training exists in in-service programs for community-based health care professionals and the curricula cover all essential breastfeeding topics or the curricula are integrated within all in-service community-based programs.

☐ Major progress: Breastfeeding training exists in in-service programs for community-based health care professionals and the curricula cover all essential breastfeeding topics and the curricula are integrated within all in-service community-based programs.


Example: In Sri Lanka, grass-roots level maternal and child health care delivery is done by Public Health Midwives. They provide antenatal education and postnatal counseling, including improving breastfeeding skills, problem identification, intervention and referral.  They receive the WHO/UNICEF 40 hour breastfeeding counseling training.  

Score: Partial Progress 

Domain: Existence: Yes

Domain: Quality: Course follows WHO curriculum, which includes all the essential topics in Annex 4.

Domain- Effective: Not enough information to assess the level of integration of breastfeeding training into the curricula of all facility-based in-service programs.

Community-based health care professionals who care for mothers, infants and young children should also receive hand-on training in counseling and support skills specific to breastfeeding so they can provide effective counseling and support to breastfeeding women.  

This benchmark assesses whether community-based health care professionals who care for mothers, infants and young children are receiving hand-on breastfeeding counseling and support skills training. If so, it assesses the quality against specific breastfeeding topics (see list in Annex 5) and the integration of breastfeeding training across all facility-based in-service programs.

Possible data sources: Expert(s) in higher education who know the content and quality of in-service health care professional curriculums, including the hands-on trainings, would be best to consult.  They should be able to provide a level of assessment on the quality and coverage of the breastfeeding topics within community-based in-service programs. Ideally this assessment from expert(s) should be corroborated against specific surveys that have recently probed for this information, if available at all. Alternatively, a review of training program curricula can be conducted.

Community-based health care professionals: Staff based in primary health care clinics that work with pregnant and postpartum women, infants and young children.

The scoring for this benchmark reflects:

a) Existence of hands-on in-service training in breastfeeding counseling and support skills for community-based health care professionals who care for mothers, infants and young children; 
b) Degree of inclusion of the essential breastfeeding counseling and support skill topics (see Annex 5) in the community-based in-service curriculum; and 
c) Level of coverage/integration of breastfeeding counseling and support skills training into the curricula across community-based in-service programs.  


How to score

☐ No progress: Hands-on breastfeeding training does not exist in in-service programs for community-based health care professionals who care for mothers, infants and young children. 

☐ Minimal progress: Hands-on breastfeeding training exists in in-service programs for community-based health care professionals but the curricula do not cover all essential breastfeeding counseling and support skills topics and breastfeeding curricula are not integrated within all in-service community-based programs.   

☐ Partial progress: Hands-on breastfeeding training exists in in-service programs for community-based health care professionals and the curricula cover all essential breastfeeding topics or breastfeeding curricula are integrated within all in-service community-based programs.  

☐ Major progress: Hands-on breastfeeding training exists in in-service programs for community-based health care professionals and the curricula cover all essential breastfeeding topics and  breastfeeding curricula are integrated within all in-service community-based programs. 


Example: In Sri Lanka, grass-roots level maternal and child health care delivery is done by Public Health Midwives. They provide antenatal education and postnatal counseling, including improving breastfeeding skills, problem identification, intervention and referral.  They receive the WHO/UNICEF 40-hour breastfeeding counseling training.  

Score: Partial Progress 

Domain- Existence: Yes

Domain- Quality: Course follows WHO curriculum, which includes all the essential topics in Annex 5.

Domain- Effective: Not enough information to assess the level of integration of breastfeeding training into the curricula of all facility-based in-service programs.

In-Service Training for Community Health Workers and Volunteers Theme

Community health workers and volunteers that work with mothers, infants and young children should receive instructional training on breastfeeding within their in-service curriculum so they can effectively educate and care for mothers during pregnancy and the postpartum period. 

This benchmark assesses whether community health workers and volunteers that work with mothers, infants and young children are receiving in-service instructional training on breastfeeding. If so, it assesses the quality against specific breastfeeding topics (see the list in Annex 4) and the integration of breastfeeding training across all facility-based in-service programs.

Possible data sources: Expert(s) with the government, NGOs and/or community-based organizations who would know the content and quality of community health worker in-service training curriculums would be best to consult.  They should be able to provide a level of assessment on the quality and coverage of the breastfeeding topics within community- health worker in-service programs. Ideally this assessment from expert(s) should be corroborated against specific surveys that have recently probed for this information, if available at all.  Alternatively, a review of training program curricula can be conducted.

Community health workers : Para-professionals that are trained to deliver education and provide peer support within the community to mothers, their infants and young children.

Volunteers : People that provide breastfeeding counselling and support but are not paid for providing that service.  

The scoring for this benchmark reflects:

a) Existence of breastfeeding in-service training for community health workers and volunteers who care for mothers, infants and young children; 
b) Degree of inclusion of essential breastfeeding topics (see Annex 4) in the community health worker and volunteer in-service curriculum; and 
c) Level of coverage/integration of breastfeeding training across community health worker and volunteer in-service programs for those who care for mothers, infants and young children. 

How to score

☐ No progress: Breastfeeding training does not exist in in-service programs for community health workers (or volunteers) who care for mothers, infants and young children. 

☐ Minimal progress: Breastfeeding training exists in in-service programs for community health workers but the curricula do not cover all essential breastfeeding topics and breastfeeding curricula are not integrated within all in-service programs.  

☐ Partial progress: Breastfeeding training exists in in-service programs for community health workers and the curricula cover all essential breastfeeding topics or breastfeeding curricula are integrated within all in-service programs.  

☐ Major progress: Breastfeeding training exists in in-service programs for community health workers and the curricula cover all essential breastfeeding topics and breastfeeding curricula are integrated within all in-service programs.  

Example: The Institute of Public Health Nutrition in Bangladesh developed their IYCF training program in consultation with key NGOs and based it on the results of surveys and formative research undertaken. The course content is also drawn from the WHO/PAHO Guiding Principles for Complementary Feeding of the Breastfed Child (2003), WHO’s Infant and Young Child Feeding Counseling: An Integrated Course (2006), and Academy for Educational Development’s Essential Nutrition Actions training module. The audience is all health workers involved with infant and young child feeding in Bangladesh and it was used to train BRAC’s existing cadre of CHWs - 11,000 frontline workers and supervisors - by integrating into their systems.  The language is purposefully easy to understand and accessible to all level of professionals and workers.  The training sessions involve brain storming, discussion, demonstration, case study, role play, question-answer, group work, group discussion etc. CHWs also undergo 1-3 days of field practice, supervised by a trainer who observes the trainees counseling a mother on breastfeeding, negotiating with mothers around 2-3 key practices, and demonstrating recommended practices. This training covers all the essential breastfeeding topics in Annex 4 except contraception and maternal absence.

Score: Partial Progress

Domain- Existence: Yes

Domain- Quality: Course covers most of the essential breastfeeding topics in Annex 4, with the exception of contraception and maternal absence.

Domain- Effective: Not enough information to assess the level of integration of breastfeeding training into the curricula of all facility-based in-service programs.

Community health workers and volunteers who care for mothers, infants and young children should also receive hands-on training in counseling and support skills specific to breastfeeding so they can provide effective counseling and support to breastfeeding women.  

This benchmark assesses whether community health workers and volunteers who care for mothers, infants and young children are receiving hands-on breastfeeding counseling and support skills training. If so, it assesses the quality against specific breastfeeding topics (see list in Annex 5) and the integration of breastfeeding training across all in-service programs.

Possible data sources: Expert(s) with the government, NGOs and/or community-based organizations who would know the content and quality of community health worker in-service training curriculums would be best to consult.  They should be able to provide a level of assessment on the quality and coverage of the breastfeeding counseling and support skills topics within community health worker in-service programs. Ideally this assessment from expert(s) should be corroborated against specific surveys that have recently probed for this information, if available at all. Alternatively, a review of training program curricula can be conducted.

Community health workers:  Para-professionals that are trained to deliver education and provide peer support within the community to mothers, their infants and young children. 

Volunteers:  People that provide breastfeeding counselling and support but are not paid for providing that service.   

The scoring for this benchmark reflects:

a) Existence of hands-on in-service training in breastfeeding counseling and support skills for community health workers and volunteers who care for mothers, infants and young children; 
b) Degree of inclusion of the essential breastfeeding counseling and support skill topics (see Annex 5) in the community health worker in-service curriculum; and 
c) Level of coverage/integration of breastfeeding counseling and support skills training into the curricula across in-service programs.  

How to score :  

☐ No progress: Hands-on breastfeeding training does not exist in in-service programs for community health workers (or volunteers) who care for mothers, infants and young children.

☐ Minimal progress: Hands-on breastfeeding training exists in in-service programs for community health workers but the curricula do not cover all essential breastfeeding counseling and breastfeeding curricula are not integrated within all in-service programs.  

☐ Partial progress: Hands-on breastfeeding training exists in in-service programs for community health workers and the curricula cover all essential breastfeeding topics or breastfeeding curricula are integrated within all in-service programs.  

☐ Major progress: Hands-on breastfeeding training exists in in-service programs for community health workers and the curricula cover all essential breastfeeding topics and breastfeeding curricula are integrated within all in-service programs.  

Example: The Institute of Public Health Nutrition in Bangladesh developed their IYCF training program in consultation with key NGOs and based it on the results of surveys and formative research undertaken. The course content is also drawn from the WHO/PAHO Guiding Principles for Complementary Feeding of the Breastfed Child (2003), WHO’s Infant and Young Child Feeding Counseling: An Integrated Course (2006), and Academy for Educational Development’s Essential Nutrition Actions training module. The audience is all health workers involved with infant and young child feeding in Bangladesh and it was used to train BRAC’s existing cadre of CHWs - 11,000 frontline workers and supervisors - by integrating into their systems.  The language is purposefully easy to understand and accessible to all level of professionals and workers.  The training sessions involve brain storming, discussion, demonstration, case study, role play, question-answer, group work, group discussion etc. CHWs also undergo 1-3 days of field practice, supervised by a trainer who observes the trainees counseling a mother on breastfeeding, negotiating with mothers around 2-3 key practices, and demonstrating recommended practices. This training covers all the essential breastfeeding topics in Annex 5 (including Code implementation) except contraception and maternal absence.

Score: Partial Progress 

Domain- Existence: Yes

Domain- Quality: Course covers most of the essential breastfeeding topics in Annex 5, with the exception of contraception and maternal absence.

Domain- Effective: Not enough information to assess the level of integration of breastfeeding training into the curricula of all facility-based in-service programs.

Train the Trainers Theme

Master trainers in breastfeeding are qualified through national or international certification as breastfeeding specialists or lactation consultants to train and support facility-based and community-based health care professionals and community health workers. They are a key resource for ensuring the quality and coverage of breastfeeding training to these groups. They can provide support by:

a) Serving as a primary resource to health care providers and community health workers for breastfeeding-related questions and problems (including those of a clinical nature);
b) Providing breastfeeding related materials as needed; and
c) Maintaining quality and standardization of breastfeeding services through on-site visits.

Possible data sources :  In depth interviews with national level government officials within the area of infant/young child health, NGOs and organizations working on infant nutrition to identify the existence and level of coverage of master trainers within the country.  Expert assessment(s) should be corroborated against specific surveys.

The scoring for this benchmark reflects the existence and coverage of master trainers. 

How to score :  

☐ No progress: No master trainers in breastfeeding in the country. 

☐ Minimal progress: Master trainers in breastfeeding- only at national level

☐ Partial progress: Master trainers in breastfeeding- at national and subnational level throughout the country. 

☐ Major progress: Master trainers in breastfeeding- at national, subnational, and local levels through the country.

Example: In Mexico, all the states have at least one qualified person to replicate training with other health professionals.  

Score: Partial Progress 

Domain- Existence: yes

Domain- Coverage: national and subnational level but not local level

Coordination and Integration of Breastfeeding Training Programs Theme

Breastfeeding training programs can be delivered through different entities using different modalities, such as face-to-face “classroom” programs or on-line breastfeeding tutorial and courses.   It is essential that the breastfeeding training programs are coordinated to prevent redundancies and ensure the quality of the overall national training for breastfeeding. These courses can be completed by different entities, however, they should be integrated, registered, evaluated and/or certified in order to be coordinated. This benchmark assesses the level of coordination of all breastfeeding training programs within the country.

Possible data sources : In depth interviews with national level government officials within the area of infant/young child health, NGOs and organizations working on infant nutrition identify the level of coordination of breastfeeding trainings within the country. Expert assessment(s) should be corroborated against specific surveys and country-specific documentation.

The scoring for this benchmark reflects the level of coordination among breastfeeding training programs. 

How to score:

☐ No progress: No evidence of coordination. 

☐ Minimal progress: Some coordination but the majority of breastfeeding training programs are not included. 

☐ Partial progress: Between half and 75% of breastfeeding training programs are coordinated. 

☐ Major progress: Great majority (> 75%) of breastfeeding training programs are coordinated.

Example: 

In Ghana, there are multiple programs and institutions that conduct training. However, there is no single institution to coordinate breastfeeding training and the situation is fragmented. 

Score: Minimal Progress

Domain- Existence: Yes

Domain- Coverage: some level of coordination

The integration of breastfeeding information and skills into training programs for health care providers working in related areas of maternal and child health is crucial to the scaling up of breastfeeding. Health care providers working in related programs (e.g. maternal and child health; Integrated Management of Childhood Illness (IMCI); Ten Steps; the Supplemental Nutrition Program for Women, Infants, and Children (WIC)) should also be skilled in breastfeeding to facilitate provision of support and education to their clients as needed. This benchmark assesses whether breastfeeding information and skills are integrated into related training programs and, if so, the breadth of coverage of that integration.  

Possible data sources :  In depth interviews with national level government officials and local health service coordinators within the area of infant/young child health, NGOs and organizations working on infant nutrition identify if breastfeeding information and skills are integrated into related training programs and the level of that integration. Expert assessment(s) should be corroborated against specific surveys and country-specific documentation.

The scoring for this benchmark reflects the level of integration of breastfeeding information and skills into related training programs. 

How to score

☐ No progress: Breastfeeding information/topics and skills are not integrated into related training programs. 

☐ Minimal progress: Breastfeeding information/topics and skills are integrated into some - less than 50%- related training programs. 

☐ Partial progress: Breastfeeding information/topics and skills are integrated into most- between 50% and 99%- related training programs. 

☐ Major progress: Breastfeeding information/topics and skills are integrated into all related training programs.

Example: 

In Ghana, interviews with Program Managers in Reproductive Health and Child Health, Nutrition and reviewing the Ghana Health Service’s training courses and manuals (e.g. Safe Motherhood Protocol, Essential Care for Every Newborn, Helping Babies Breath, IMNCI, Essential Nutrition Actions, Community Management of Acute Malnutrition) demonstrated that breastfeeding is integrated into all the relevant training programs.

Score: Major Progress

Domain- Existence: Yes

Domain- Coverage: Breastfeeding skills and topics fully integrated into all related training programs. 

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