Marketing of commercial milk formula: a system to capture parents, communities, science, and policy.

Despite proven benefits, less than half of infants and young children globally are breastfed in accordance with the recommendations of WHO. In comparison, commercial milk formula (CMF) sales have increased to about US$55 billion annually, with more infants and young children receiving formula products than ever. This Series paper describes the CMF marketing playbook and its influence on families, health professionals, science, and policy processes, drawing on national survey data, company reports, case studies, methodical scoping reviews, and two multicountry research studies. We report how CMF sales are driven by multifaceted, well resourced marketing strategies that portray CMF products, with little or no supporting evidence, as solutions to common infant health and developmental challenges in ways that systematically undermine breastfeeding. Digital platforms substantially extend the reach and influence of marketing while circumventing the International Code of Marketing of Breast-milk Substitutes. Creating an enabling policy environment for breastfeeding that is free from commercial influence requires greater political commitment, financial investment, CMF industry transparency, and sustained advocacy. A framework convention on the commercial marketing of food products for infants and children is needed to end CMF marketing.

The political economy of infant and young child feeding: confronting corporate power, overcoming structural barriers, and accelerating progress.

Despite increasing evidence about the value and importance of breastfeeding, less than half of the world's infants and young children (aged 0-36 months) are breastfed as recommended. This Series paper examines the social, political, and economic reasons for this problem. First, this paper highlights the power of the commercial milk formula (CMF) industry to commodify the feeding of infants and young children; influence policy at both national and international levels in ways that grow and sustain CMF markets; and externalise the social, environmental, and economic costs of CMF. Second, this paper examines how breastfeeding is undermined by economic policies and systems that ignore the value of care work by women, including breastfeeding, and by the inadequacy of maternity rights protection across the world, especially for poorer women. Third, this paper presents three reasons why health systems often do not provide adequate breastfeeding protection, promotion, and support. These reasons are the gendered and biomedical power systems that deny women-centred and culturally appropriate care; the economic and ideological factors that accept, and even encourage, commercial influence and conflicts of interest; and the fiscal and economic policies that leave governments with insufficient funds to adequately protect, promote, and support breastfeeding. We outline six sets of wide-ranging social, political, and economic reforms required to overcome these deeply embedded commercial and structural barriers to breastfeeding.

An educational intervention to update health workers about HIV and infant feeding.

Clinical guidelines are used to translate research findings into evidence-based clinical practice but are frequently not comprehensively adopted by health workers (HWs). HIV and infant feeding guidelines were revised by the World Health Organization to align feeding advice for HIV-exposed and unexposed infants, and these were adopted in South Africa in 2017. We describe an innovative, team-based, mentoring programme developed to update HWs on these guidelines. The intervention was underpinned by strong theoretical frameworks and aimed to improve HWs' attitudes, knowledge, confidence, and skills about breastfeeding in the context of HIV. On-site workshops and clinical mentoring used interactive participatory methods and a simple low-tech approach, guided by participants' self-reported knowledge gaps. Workshops were conducted at 24 participating clinics over three sessions, each lasting 1-2 hr. Evaluation data were collected using a self-administered questionnaire. Of 303 participating HWs, 249/303 (82.2%) attended all workshops. Achieving high workshop attendance was challenging and "catch-up" sessions were required to achieve good coverage. Common knowledge gaps identified included antiretroviral therapy adherence monitoring during breastfeeding and management of viral load results (173 participants), management of breast conditions (79), and advice about expressing and storing breastmilk (64). Most participants reported all their knowledge gaps were addressed and anticipated that their practice would change. We describe a feasible, sustainable approach to updating HWs on HIV and infant feeding guidelines and improving skills in breastfeeding counselling in resource-constrained settings. This approach could be adapted to other topics and, with further evaluation, implemented at scale using existing resources.

Clan-involved approaches to increasing antenatal care use in a rural minority area of China: implementation research.

AIM: This study aimed to test a model which involved clans and health providers to increase antenatal care attendance in rural minority areas of China with high HIV prevalence. METHODS: Formative research was conducted to determine barriers and facilitators to antenatal care use. A strategy involving clans in addressing the barriers identified was developed. Implementation of the new strategy was done through three plan-do-study-act (PDSA) cycles, lasting four months each. RESULTS: Awareness and uptake of antenatal care increased significantly after the intervention. The proportion of post-partum women who used any antenatal care increased from 21.3% to 64.5% (p < 0.001), and the proportion who knew that antenatal care is necessary increased from 77.8% to 89.8% (p < 0.001). The proportion of pregnant women who attended antenatal care (p < 0.001) and the proportion of pregnant women who went for a first antenatal care visit in early pregnancy (p < 0.001) all showed increasing trends during the study period. CONCLUSION: Involving clans in antenatal care programmes in rural minority areas of China had an impact on antenatal care use. A quality improvement approach incorporating PDSA cycles can help local health authorities make context-specific, evidence-informed decisions to improve uptake of health services.

A continuous quality improvement intervention to improve the effectiveness of community health workers providing care to mothers and children: a cluster randomised controlled trial in South Africa.

BACKGROUND: Community health workers (CHWs) play key roles in delivering health programmes in many countries worldwide. CHW programmes can improve coverage of maternal and child health services for the most disadvantaged and remote communities, leading to substantial benefits for mothers and children. However, there is limited evidence of effective mentoring and supervision approaches for CHWs. METHODS: This is a cluster randomised controlled trial to investigate the effectiveness of a continuous quality improvement (CQI) intervention amongst CHWs providing home-based education and support to pregnant women and mothers. Thirty CHW supervisors were randomly allocated to intervention (n = 15) and control (n = 15) arms. Four CHWs were randomly selected from those routinely supported by each supervisor (n = 60 per arm). In the intervention arm, these four CHWs and their supervisor formed a quality improvement team. Intervention CHWs received a 2-week training in WHO Community Case Management followed by CQI mentoring for 12 months (preceded by 3 months lead-in to establish QI processes). Baseline and follow-up surveys were conducted with mothers of infants <12 months old living in households served by participating CHWs. RESULTS: Interviews were conducted with 736 and 606 mothers at baseline and follow-up respectively; socio-demographic characteristics were similar in both study arms and at each time point. At follow-up, compared to mothers served by control CHWs, mothers served by intervention CHWs were more likely to have received a CHW visit during pregnancy (75.7 vs 29.0%, p < 0.0001) and the postnatal period (72.6 vs 30.3%, p < 0.0001). Intervention mothers had higher maternal and child health knowledge scores (49 vs 43%, p = 0.02) and reported higher exclusive breastfeeding rates to 6 weeks (76.7 vs 65.1%, p = 0.02). HIV-positive mothers served by intervention CHWs were more likely to have disclosed their HIV status to the CHW (78.7 vs 50.0%, p = 0.007). Uptake of facility-based interventions were not significantly different. CONCLUSIONS: Improved training and CQI-based mentoring of CHWs can improve quantity and quality of CHW-mother interactions at household level, leading to improvements in mothers' knowledge and infant feeding practices. TRIAL REGISTRATION: ClinicalTrials.Gov NCT01774136.

A public health approach for deciding policy on infant feeding and mother-infant contact in the context of COVID-19.

The COVID-19 pandemic has raised concern about the possibility and effects of mother-infant transmission of SARS-CoV-2 through breastfeeding and close contact. The insufficient available evidence has resulted in differing recommendations by health professional associations and national health authorities. We present an approach for deciding public health policy on infant feeding and mother-infant contact in the context of COVID-19, or for future emerging viruses, that balances the risks that are associated with viral infection against child survival, lifelong health, and development, and also maternal health. Using the Lives Saved Tool, we used available data to show how different public health approaches might affect infant mortality. Based on existing evidence, including population and survival estimates, the number of infant deaths in low-income and middle-income countries due to COVID-19 (2020-21) might range between 1800 and 2800. By contrast, if mothers with confirmed SARS-CoV-2 infection are recommended to separate from their newborn babies and avoid or stop breastfeeding, additional deaths among infants would range between 188 000 and 273 000.

Introducing INSPIRE: an implementation research collaboration between the Department of Foreign Affairs, Trade and Development Canada and the World Health Organization.

The government of Canada, through the Department of Foreign Affairs, Trade and Development (DFATD) has supported global efforts to reduce the impact of the HIV pandemic. In 2012, WHO and DFATD launched an implementation research initiative to increase access to interventions that were known to be effective in the prevention of mother-to-child transmission of HIV and to learn how these could be successfully integrated with other essential services for mothers and children. In addition to facilitating the implementation research projects, DFATD and WHO promoted four approaches: (1) Country-specific implementation research prioritization exercises, (2) Ministry of Health involvement, (3) Country-led, innovative, high-quality research, and (4) Leveraging regional networks and learning opportunities. While no single aspect of INSPIRE is unique, the process endeavors to promote and support high-quality, rigorous, locally-led implementation research that will have a substantial impact on the health and survival of HIV-infected women and their children.

Prioritizing the PMTCT implementation research agenda in 3 African countries: INtegrating and Scaling up PMTCT through Implementation REsearch (INSPIRE).

Countries with high HIV prevalence face the challenge of achieving high coverage of antiretroviral drug regimens interventions including for the prevention of mother-to-child transmission of HIV (PMTCT). In 2011, the World Health Organization and the Department of Foreign Affairs, Trade and Development, Canada, launched a joint implementation research (IR) initiative to increase access to effective PMTCT interventions. Here, we describe the process used for prioritizing PMTCT IR questions in Malawi, Nigeria, and Zimbabwe. Policy makers, district health workers, academics, implementing partners, and persons living with HIV were invited to 2-day workshops in each country. Between 42 and 70 representatives attended each workshop. Using the Child Health Nutrition Research Initiative process, stakeholder groups systematically identified programmatic barriers and formulated IR questions that addressed these challenges. IR questions were scored by individual participants according to 6 criteria: (1) answerable by research, (2) likely to reduce pediatric HIV infections, (3) addresses main barriers to scaling-up, (4) innovation and originality, (5) improves equity among underserved populations, and (6) likely value to policy makers. Highest scoring IR questions included health system approaches for integrating and decentralization services, ways of improving retention-in-care, bridging gaps between health facilities and communities, and increasing male partner involvement. The prioritized questions reflect the diversity of health care settings, competing health challenges and local and national context. The differing perspectives of policy makers, researchers, and implementers illustrate the value of inclusive research partnerships. The participatory Child Health Nutrition Research Initiative approach effectively set national PMTCT IR priorities, promoted country ownership, and strategically allocated research resources.

Breastfeeding and HIV transmission in the developing world: past, present, future.

PURPOSE OF REVIEW: In the past 5 years, research has identified antiretroviral drug interventions that significantly reduce HIV transmission through breastfeeding. This evidence is reflected in WHO guidelines that now recommend national health authorities to adopt a public health approach for HIV and infant feeding, namely to promote and support a single infant feeding practice to all HIV-infected mothers. In most developing countries where diarrhoea, pneumonia and malnutrition are common causes of infant mortality, this means breastfeeding and providing antiretroviral drugs. Scaling-up these approaches is essential to eliminate new paediatric infections and to improve maternal health. The review examined knowledge and implementation of these interventions, and considered areas for future research. RECENT FINDINGS: Most recent reports focus on approaches for resolving implementation challenges rather than investigating new clinical interventions. Wherever WHO guidelines have been implemented, significant reductions in HIV transmission and improved survival are reported. Health system inefficiencies and social barriers continue to impede progress. A limited number of studies examined mechanisms of transmission and how breastmilk and viral factors influence these processes. SUMMARY: The findings of recent research should give confidence to health workers and policy makers that major improvements in HIV-related child and maternal mortality are attainable and justify intensified efforts.

Using a campaign approach among health workers to increase access to antiretroviral therapy for pregnant HIV-infected women in South Africa.

BACKGROUND: In 2010, WHO guidelines modified eligibility criteria for persons living with HIV to start on lifelong antiretroviral therapy. Pregnant HIV-infected women were identified as a priority group. Yet, despite the availability of key resources and medications, antiretroviral treatment rates for pregnant women in South Africa remained low. METHODS: A prospective, nonrandomized, controlled study to evaluate the impact of a campaign approach among health workers to improve referral and initiation rates of antiretroviral therapy for eligible pregnant HIV-infected women in 2 matched districts in KwaZulu-Natal Province. RESULTS: The average number of referrals of pregnant women for antiretroviral therapy increased from 79 per month (95% confidence interval [CI]: 69 to 89) at baseline to 188 per month (95% CI: 167 to 209) 6 months after the intervention (P < 0.001). Similarly, the number of pregnant women initiated on antiretroviral therapy increased from 21 per month (95% CI: 2 to 40) at baseline to 124 per month (95% CI: 108 to 140) after the intervention (P < 0.001). Unlike in the control district, where no improvements were seen, the intervention district showed a greater than 4-fold increase in women initiated on antiretroviral therapy. CONCLUSION: A targeted campaign among health workers can accelerate access to antiretroviral therapy for pregnant HIV-infected women.

Por que investir e o que será necessário para melhorar as práticas de amamentação? / Why invest, and what it will take to improve breastfeeding practices?

Apesar de seus benefícios estabelecidos, a amamentação não é mais uma norma em muitas comunidades. Os determinantes multifatoriais da amamentação necessitam de medidas de suporte em diversos níveis, de legislações e políticas a atitudes e valores sociais, condições de trabalho e emprego para mulheres, e serviços de saúde para possibilitar que as mulheres amamentem. Quando intervenções relevantes são oferecidas adequadamente, as práticas de amamentação são responsivas e podem melhorar rapidamente. Os melhores resultados são obtidos quando intervenções são implementadas concomitantemente por diversos canais. A propaganda de substitutos ao leite materno afeta negativamente a amamentação: as vendas em todo o mundo em 2014 de 44,8 bilhões de dólares demonstram a grande ambição competitiva da indústria com a alimentação infantil. Não amamentar está associado com menor inteligência e perdas econômicas de aproximadamente 302 bilhões de dólares anualmente ou 0,49% do produto nacional bruto mundial. A amamentação fornece, em curto e longo prazos, vantagens para a saúde, econômicas e ambientais para as crianças, mulheres e para a sociedade. Para alcançar estes ganhos, suporte político e investimento financeiro são necessários para proteger, promover e dar suporte à amamentação.

Scaling-up exclusive breastfeeding support programmes: the example of KwaZulu-Natal.

BACKGROUND: Exclusive breastfeeding (EBF) for six months is the mainstay of global child health and the preferred feeding option for HIV-infected mothers for whom replacement feeding is inappropriate. Promotion of community-level EBF requires effective personnel and management to ensure quality counselling and support for women. We present a costing and cost effectiveness analysis of a successful intervention to promote EBF in high HIV prevalence area in South Africa, and implications for scale-up in the province of KwaZulu-Natal. METHODS AND FINDINGS: The costing of the intervention as implemented was calculated, in addition to the modelling of the costs and outcomes associated with running the intervention at provincial level under three different scenarios: full intervention (per protocol), simplified version (half the number of visits compared to the full intervention; more clinic compared to home visits) and basic version (one third the number of visits compared to the full intervention; all clinic and no home visits). Implementation of the full scenario costs R95 million ($14 million) per annum; the simplified version R47 million ($7 million) and the basic version R4 million ($2 million). Although the cost of the basic scenario is less than one tenth of the cost of the simplified scenario, modelled effectiveness of the full and simplified versions suggest they would be 10 times more effective compared to the basic intervention. A further analysis modelled the costs per increased month of EBF due to each intervention: R337 ($48), R206 ($29), and R616 ($88) for the full, simplified and basic scenarios respectively. In addition to the average cost effectiveness the incremental cost effectiveness ratios associated with moving from the less effective scenarios to the more effective scenarios were calculated and reported: Nothing-Basic R616 ($88), Basic-Simplified R162 ($23) and Simplified-Full R879 ($126). CONCLUSIONS: The simplified scenario, with a combination of clinic and home visits, is the most efficient in terms of cost per increased month of EBF and has the lowest incremental cost effectiveness ratio.