A proposal to recognize investment in breastfeeding as a carbon offset.

Policy-makers need to rethink the connections between the economy and health. The World Health Organization Council on the Economics of Health for All has called for human and planetary health and well-being to be moved to the core of decision-making to build economies for health. Doing so involves valuing and measuring what matters, more and better health financing, innovation for the common good and rebuilding public sector capacity. We build on this thinking to argue that breastfeeding should be recognized in food and well-being statistics, while investments in breastfeeding should be considered a carbon offset in global financing arrangements for sustainable food, health and economic systems. Breastfeeding women nourish half the world's infants and young children with immense quantities of a highly valuable milk. This care work is not counted in gross domestic product or national food balance sheets, and yet ever-increasing commercial milk formula sales are counted. Achieving global nutrition targets for breastfeeding would realize far greater reductions in greenhouse gas emissions than decarbonizing commercial milk formula manufacturing. New metrics and financing mechanisms are needed to achieve the health, sustainability and equity gains from more optimal infant and young child feeding. Properly valuing crucial care and environmental resources in global and national measurement systems would redirect international financial resources away from expanding carbon-emitting activities, and towards what really matters, that is, health for all. Doing so should start with considering breastfeeding as the highest quality, local, sustainable first-food system for generations to come.

Les responsables politiques doivent repenser les liens entre économie et santé. Le Conseil de l'Organisation mondiale de la Santé sur l'économie de la santé pour tous a demandé que le bien-être et la santé, aussi bien de l'humain que de la planète, soient désormais au cœur du processus de prise de décisions afin de créer des économies au service de la santé. Il est donc impératif d'identifier et de valoriser ce qui compte, d'accroître et d'optimiser le financement de la santé, d'innover pour le bien commun et de renforcer les capacités du secteur public. En partant de cette réflexion, nous plaidons pour une reconnaissance de l'allaitement dans les statistiques relatives à l'alimentation et au bien-être, et estimons que tout investissement réalisé dans ce domaine devrait être considéré comme un crédit-carbone dans le cadre des modalités financières mondiales liées aux systèmes économiques et sanitaires ainsi qu'à une alimentation durable. Les femmes allaitantes nourrissent la moitié des enfants en bas âge dans le monde avec d'immenses quantités de lait extrêmement précieux. Ces activités de soins ne sont pas comptabilisées dans le produit intérieur brut ou les bilans alimentaires nationaux, contrairement aux ventes de lait maternisé en constante progression. Atteindre les cibles mondiales de nutrition pour l'allaitement contribuerait davantage à réduire les émissions de gaz à effet de serre que décarboner la production de lait maternisé. De nouveaux paramètres et mécanismes de financement sont nécessaires pour bénéficier des avantages en matière de santé, de durabilité et d'équité qui découlent d'une meilleure alimentation des nourrissons et jeunes enfants. Valoriser correctement les principales ressources consacrées à l'environnement et aux soins dans les systèmes de mesure nationaux et mondiaux permettrait de détourner les moyens financiers internationaux du développement d'activités à fort taux d'émissions pour les rediriger vers ce qui compte vraiment, c'est-à-dire la santé pour tous. Et pour y parvenir, la première étape consisterait à reconnaître l'allaitement comme l'aliment de base, local, durable et de qualité pour les générations futures.

Los responsables de formular las políticas deben volver a plantearse las conexiones entre la economía y la salud. El Consejo sobre la Economía de la Salud para Todos de la Organización Mundial de la Salud ha pedido que la salud y el bienestar humanos y del planeta se sitúen en el centro de la toma de decisiones a fin de desarrollar economías para la salud. Esto requiere valorar y medir lo que importa, más y mejor financiación sanitaria, innovación para el bien común y reconstrucción de la capacidad del sector público. Nos basamos en este pensamiento para argumentar que la lactancia materna debería reconocerse en las estadísticas de alimentación y bienestar, mientras que las inversiones en lactancia materna deberían considerarse como una compensación de emisiones de carbono en los acuerdos globales de financiación para sistemas alimentarios, sanitarios y económicos sostenibles. Las mujeres lactantes alimentan a la mitad de los bebés y niños pequeños del mundo con inmensas cantidades de una leche muy valiosa. Este trabajo de cuidados no se contabiliza en el producto interior bruto ni en los balances alimentarios nacionales y, sin embargo, sí se contabilizan las ventas cada vez mayores de leche de fórmula comercial. Alcanzar los objetivos mundiales de nutrición para la lactancia materna supondría una reducción mucho mayor de las emisiones de gases de efecto invernadero que descarbonizar la fabricación de leche de fórmula comercial. Se necesitan nuevas métricas y mecanismos de financiación para lograr los beneficios en materia de salud, sostenibilidad y equidad de una alimentación más óptima de los bebés y los niños pequeños. Una valoración adecuada de los cuidados esenciales y de los recursos medioambientales en los sistemas de medición globales y nacionales redirigiría los recursos financieros internacionales lejos de la expansión de las actividades que emiten carbono, y hacia lo que realmente importa, es decir, la salud para todos. En este contexto, habría que empezar por considerar la lactancia materna como el sistema de primera alimentación de mayor calidad, local y sostenible para las generaciones futuras.

Global evidence of persistent violations of the International Code of Marketing of Breast-milk Substitutes: A systematic scoping review.

The influence of marketing on infant and young child feeding and health is well recognized, and an International Code was adopted by the World Health Assembly (WHA) in 1981 to reduce inappropriate marketing and protect breastfeeding. Yet the marketing and influencing continue. This scoping review systematically examined the published research evidence on the nature and extent of exposure to International Code violations from 1981 to August 2021. We used several search strategies involving multi-language databases, organization websites, citation tracking, and expert consultation, to find research items meeting our inclusion criteria. We evaluated 657 items and retained 153 studies from at least 95 countries in the review. The majority of the studies (n = 113) documenting exposure to inappropriate marketing were published since 2010. Studies reported a broad range of marketing violations targeting mothers and families, health workers, and the general public. Marketing via digital platforms and brand extension has become more frequent. The evidence shows the use of misleading and inaccurate labeling and health and nutrition claims in breach of the Code. Our review confirms that violations of the Code have not ceased and calls for renewed attention from the WHA and national governments to protect the health of children and their mothers.

The financing need of equitable provision of paid maternal leave in the informal sector in Indonesia: a comparison of estimation methods.

BACKGROUND: Providing an enabling environment for breastfeeding is hampered by the inequitable implementation of paid maternity leave, primarily due to perceived or actual financial costs. To estimate the real cost of paid maternity leave requires using reliable methods. We compared methods utilized in two recent studies in Indonesia. Study A estimated the financial need of providing paid maternity leave in the formal sector with a 10-year forecast at 21% coverage of eligible mothers, while study B estimated similar costs for the informal sector at 100% coverage annually. Results are critical for guiding future application of either method to inform paid maternity leave policies. METHODS: We compared number of covered mothers working informally, total annual cost, and cost per mother. We modified some parameters used in study A (method A) to be similar to study B (method B) for comparison, namely the period of estimate (annual), coverage (100%), estimate of women potentially breastfeeding, exchange rate, female labor force participation rate, the percentage of women working in the informal sector, and adding administration cost. RESULTS: The methods differ in determining the number of mothers working in the informal sector who gave birth, the minimum wage as unit cost, and administrative cost. Both studies estimated the cost at various lengths of leave period. Method A requires more macro (e.g. national/regional) level data, while method B involves (e.g. individual) micro level data. We compared the results of method A with method B, respectively: 1) number of covered mothers working informally were 1,425,589 vs. 1,147,204; 2) total annual costs including administrative costs were US$650,230,167 vs. US$633,942,726, and; 3) cost/mother was US$456 vs US$553. CONCLUSION: Certain flexibilities can be applied to both methods, namely using parameters specific to respective regions (e.g. provincial level parameters), flexible period of analysis, and the use of administrative cost. In a setting where micro data is scarce and not easily accessible, method A provides a feasible approach, while method B will be most appropriate if suitable micro data is available. Future comparison studies in other settings are needed to provide further evidence on the strengths and weaknesses of both methods.

Community support model on breastfeeding and complementary feeding practices in remote areas in Vietnam: implementation, cost, and effectiveness.

BACKGROUND: Poor access to healthcare facilities and consequently nutrition counseling services hinders the uptake of recommended infant and young child feeding (IYCF) practices. To address these barriers and improve IYCF practices, Alive & Thrive (A&T) initiated community support groups in remote villages across nine provinces in Vietnam. OBJECTIVE: This study examines the effectiveness of the support group model and related project costs for reaching underserved areas to improve IYCF practices. METHODS: To evaluate the model's implementation and project costs, we reviewed implementation guidelines, expenditure and coverage reports, monitoring data, and budgets for the nine provinces. To evaluate the model's effectiveness, we used a 3-stage sampling method to conduct a cross-sectional survey from April to May 2014 in three provinces entailing interviewing mothers of children aged 0-23 months in communes with (intervention; n = 551) and without support groups (comparison; n = 559). FINDINGS: Coverage: From November 2011 to November 2014, in partnership with the government, A&T supported training for 1513 facilitators and the establishing 801 IYCF support groups in 267 villages across nine provinces. During this period, facilitators provided ~ 166,000 meeting/support contacts with ~ 33,000 pregnant women and mothers with children aged 0-23 months in intervention villages. COSTS: The average project costs for supporting the meetings, compensating village collaborators, and providing supportive supervision through staff in commune health stations were USD 5 per client and USD 1 per contact. After adding expenditures for training, supportive supervision, and additional administrative costs at central and provincial levels, the average project cost was USD 15 per client and USD 3 per contact. Effectiveness: Survey participants in intervention and comparison communes had similar maternal, child, and household characteristics. Multiple logistic regression models showed that living in intervention communes was associated with higher odds of early initiation of breastfeeding (OR: 1.7; 95% CI: 1.1, 2.7), exclusive breastfeeding from 0 to 5 months (OR: 12.5; 95% CI: 6.7, 23.4), no bottle feeding (OR: 2.69; 95% CI: 1.82, 3.99), and minimum acceptable diet (OR: 1.51; 95% CI: 0.98, 2.33) compared to those living in comparison communes. CONCLUSION: The IYCF support group model was effective in reaching populations residing in remote areas and likely contributed to improved IYCF practices. The study suggests that the model could be scaled up to promote equity in breastfeeding support.

Breastfeeding, first-food systems and corporate power: a case study on the market and political practices of the transnational baby food industry and public health resistance in the Philippines.

BACKGROUND: The aggressive marketing of breastmilk substitutes (BMS) reduces breastfeeding, and harms child and maternal health globally. Yet forty years after the World Health Assembly adopted the International Code of Marketing of Breast-milk Substitutes (The Code), many countries are still to fully implement its provisions into national law. Furthermore, despite The Code, commercial milk formula (CMF) markets have markedly expanded. In this paper, we adopt the Philippines as a case study to understand the battle for national Code implementation. In particular, we investigate the market and political strategies used by the baby food industry to shape the country's 'first-food system', and in doing so, promote and sustain CMF consumption. We further investigate how breastfeeding coalitions and advocates have resisted these strategies, and generated political commitment for a world-leading breastfeeding policy framework and protection law (the 'Milk Code'). We used a case study design and process tracing method, drawing from documentary and interview data. RESULTS: The decline in breastfeeding in the Philippines in the mid-twentieth Century associated with intensive BMS marketing via health systems and consumer advertising. As regulations tightened, the industry more aggressively promoted CMFs for older infants and young children, thereby 'marketing around' the Milk Code. It established front groups to implement political strategies intended to weaken the country's breastfeeding policy framework while also fostering a favourable image. This included lobbying government officials and international organizations, emphasising its economic importance and threats to foreign investment and trade, direct litigation against the government, messaging that framed marketing in terms of women's choice and empowerment, and forging partnerships. A resurgence in breastfeeding from the mid-1980s onwards reflected strengthening political commitment for a national breastfeeding policy framework and Milk Code, resulting in-turn, from collective actions by breastfeeding coalitions, advocates and mothers. CONCLUSION: The Philippines illustrates the continuing battle for worldwide Code implementation, and in particular, how the baby food industry uses and adapts its market and political practices to promote and sustain CMF markets. Our results demonstrate that this industry's political practices require much greater scrutiny. Furthermore, that mobilizing breastfeeding coalitions, advocacy groups and mothers is crucial to continually strengthen and protect national breastfeeding policy frameworks and Code implementation.

Advice to use infant formula and free samples are common in both urban and rural areas in China: a cross-sectional survey.

OBJECTIVE: To examine the association between the place of residence and receiving free samples and advice to feed the baby with infant formula. DESIGN: A cross-sectional study. SETTING: The current study covered twelve counties/districts in China. PARTICIPANTS: 5112 mothers with infants aged 0-5·9 months. RESULTS: About 16 % of the mothers received free samples of infant formula. During pregnancy, this likelihood was higher among mothers in small and medium cities (OR: 1·96; 95 % CI 1·14, 3·38) and non-poor rural counties (OR: 4·65; 95 % CI 1·65, 13·14) compared with mothers in big cities. During the hospital stay, it was lower in big cities. After discharge, it was lower in poor rural counties (OR: 0·14; 95 % CI 0·05, 0·41). About 26 % of the mothers were advised to feed their infants with infant formula. The likelihood of receiving advice to feed the baby with infant formula from hospitals was lower in non-poor (OR: 0·37; 95 % CI 0·21, 0·66) and poor rural counties (OR: 0·35; 95 % CI 0·13, 0·91) than in big cities. Mothers in non-poor rural counties were less likely to receive advice from traditional mass media (OR: 0·17; 95 % CI 0·06, 0·48), while mothers in small and medium cities were more likely to receive advice from modern mass media (OR: 1·84; 95 % CI 1·20, 2·80) compared with mothers in big cities. CONCLUSIONS: The promotion strategy of infant formula varies from different places of residence in China. The study suggests the need to strengthen enforcement of relevant regulations, especially within health facilities and through modern mass media.

The financing need for expanding paid maternity leave to support breastfeeding in the informal sector in the Philippines.

In low- and middle-income countries, almost three-fourths of women in the labour force lack maternity protection. In the Philippines, current laws do not guarantee paid maternity leave to workers in the informal economy. A non-contributory maternity cash transfer to informal sector workers could be used to promote social equity and economic productivity and could provide health benefits by helping mothers meet their breastfeeding goals. The objective of the study is to provide a realistic cost estimate and to assess the financial feasibility of implementing a publicly financed, non-contributory maternity cash transfer programme to the informal sector in the Philippines. Using a costing framework developed in Mexico, the study estimated the annual cost of a maternity cash transfer programme. The methodology estimated the unit cost of the programme, the incremental coverage of maternity leave and expected number of enrollees. Different unit and incremental costs assumptions were used to provide a range of scenarios. Administrative costs for running the programme were included in the analysis. The annual financing need of implementing maternity cash transfer programme in the Philippines ranges from a minimum scenario of USD42 million (14-week maternity cash transfer) to a more ideal scenario of USD309 million (26-week maternity cash transfer). The latter is financially feasible as it is equivalent to less than 0.1% of the country's gross domestic product substantially lower than the share cost of not breastfeeding (0.7%). The annual cost of the programme is only 10% of the total cost of the largest conditional cash transfer programme.

Health staff experiences with the implementation of early essential newborn care guidelines in Da Nang municipality and Quang Nam province in Viet Nam.

BACKGROUND: The World Health Organization (WHO) recommends early essential newborn care (EENC) - The First Embrace - as a simple lifesaving procedure for newborns. The successful implementation of EENC at scale requires an understanding of health staff experiences, including facilitators, barriers, and local adaptations of EENC. This study aims to gain insight into health staff experiences with implementation of EENC guidelines after participation in training and coaching initiatives in Da Nang municipality and Quang Nam province in Viet Nam. METHODS: In each province/municipality, we randomly selected one hospital from the following categories: public provincial/municipal hospital, public district hospital, and private hospital. We conducted in-depth interviews with 19 hospital staff (11 midwives, 5 doctors and 3 health managers) and two trainers during 7 days between September and October 2017. We used deductive/inductive thematic analysis to generate themes. RESULTS: The health staff reported improved staff and mother satisfaction, and health benefits for both mothers and newborns after implementing EENC. Facilitators to successful implementation were management support for resource allocation and collaboration across departments, and creative demand generation. Barriers included staff shortage, skepticism about the new protocols and practices and challenges translating knowledge and skills from trainings and coaching into practice. CONCLUSIONS: After implementing EENC, through training and coaching using the WHO approach, health staff reported improved staff and mother satisfaction as well as health benefits for both mothers and newborns. An approach to develop competencies, with a focus on practical training and coaching, should be promoted to form, reinforce and sustain recommended EENC practices among health staff.

Breastfeeding practices and associated factors at the individual, family, health facility and environmental levels in China.

We examined the association between breastfeeding practices and associated factors using cross-sectional data from face-to-face interviews with 9,745 mother-child dyads in China. The study collected information on breastfeeding practices and potential associated factors at the individual, family, health facility and environmental levels in China. We used survey commands in Stata to consider sampling weight and survey design effects. Although breastfeeding was the norm (97.4% ever breastfed), the prevalence of early initiation of breastfeeding (EIBF) in 0-11 months old was 8.2%, exclusive breastfeeding (EBF) in 0-5 months old was 27.8% and breastfeeding on the previous day in 6-11 months old was 77.5%. The prevalence of EIBF was lower for caesarean delivery and among mothers belonging to ethnic minority groups. The prevalence of EBF was higher among mothers who practiced EIBF, received information that encouraged breastfeeding and knew that a baby should be breastfed on demand and exclusively. By contrast, the prevalence of EBF was lower in mothers who received infant formula advice or felt uneasy breastfeeding in public places. The prevalence of breastfeeding on the previous day was higher among mothers whose partners supported breastfeeding and who knew about timing of colostrum production, EBF for 6 months, and to nurse more to stimulate milk production. The prevalence of breastfeeding on the previous day was lower in mothers who received infant formula advice or felt uneasy breastfeeding in public places. In conclusion, we found that the prevalence of EIBF and EBF practices in China was low and associated with factors at individual, family, health facility and environmental levels.

National nutrition strategies that focus on maternal, infant, and young child nutrition in Southeast Asia do not consistently align with regional and international recommendations.

We examined the consistency of national nutrition strategies and action plans (NNS) focusing on maternal, infant, and young child nutrition in Southeast Asia with regional and international recommendations. Between July and December 2017, we identified and extracted information on context, objectives, interventions, indicators, strategies, and coordination mechanisms from the most recent NNS in nine Southeast Asian countries. All NNS described context, objectives, and the following interventions: antenatal care, micronutrient supplementation during pregnancy, breastfeeding promotion, improved complementary feeding, nutrition in emergencies, and food fortification or dietary diversity. Micronutrient supplementation for young children was included in eight NNS; breastfeeding promotion during pregnancy and support at birth in seven; and school feeding, deworming, and treatment of severe acute malnutrition in six. All NNS contained programme monitoring and evaluation plans with measurable indicators and targets. Not all NNS covered wasting, exclusive breastfeeding, low birthweight, and childhood overweight. Strategies for achieving NNS goals and objectives were health system strengthening (nine), social and behaviour change communication (nine), targeting vulnerable groups (eight), and social or community mobilization (four). All addressed involvement, roles and responsibilities, and collaboration mechanisms among sectors and stakeholders. There was a delay in releasing NNS in Indonesia, Myanmar, and the Philippines. In conclusion, although Southeast Asian NNS have similarities in structure and contents, some interventions and indicators vary by country and do not consistently align with regional and international recommendations. A database with regularly updated information on NNS components would facilitate cross-checking completeness within a country, comparison across countries, and knowledge sharing and learning.

Enhancing governance and strengthening advocacy for policy change of large Collective Impact initiatives.

Nutrition issues are increasingly being addressed through global partnerships and multi-sectoral initiatives. Ensuring effective governance of these initiatives is instrumental for achieving large-scale impact. The Collective Impact (CI) approach is an insightful framework that can be used to guide and assess the effectiveness of this governance. Despite the utility and widespread use of this approach, two gaps are identified: a limited understanding of the implications of expansion for an initiative operating under the conditions of CI and a lack of attention to advocacy for policy change in CI initiatives. In this paper, a case study was undertaken in which the CI lens was applied to the advocacy efforts of Alive & Thrive (A&T), UNICEF and partners. The initiative expanded into a regional movement and achieved meaningful policy changes in infant and young child feeding policies in seven countries in Southeast Asia. These efforts are examined in order to address the two gaps identified in the CI approach. The objectives of the paper are (a) to examine the governance of this initiative and the process of expansion from a national to a regional, multilayered initiative, with attention to challenges, adaptations, and key elements, and (b) to compare advocacy in the A&T-UNICEF initiative and in typical CI initiatives and gain insight into how the practice of advocacy for policy change can be strengthened in CI initiatives.

Media audit reveals inappropriate promotion of products under the scope of the International Code of Marketing of Breast-milk Substitutes in South-East Asia.

OBJECTIVE: To review regulations and to perform a media audit of promotion of products under the scope of the International Code of Marketing of Breast-milk Substitutes ('the Code') in South-East Asia. DESIGN: We reviewed national regulations relating to the Code and 800 clips of editorial content, 387 advertisements and 217 Facebook posts from January 2015 to January 2016. We explored the ecological association between regulations and market size, and between the number of advertisements and market size and growth of milk formula. SETTING: Cambodia, Indonesia, Myanmar, Thailand and Vietnam. RESULTS: Regulations on the child's age for inappropriate marketing of products are all below the Code's updated recommendation of 36 months (i.e. 12 months in Thailand and Indonesia; 24 months in the other three countries) and are voluntary in Thailand. Although the advertisements complied with the national regulations on the age limit, they had content (e.g. stages of milk formula; messages about the benefit; pictures of a child) that confused audiences. Market size and growth of milk formula were positively associated with the number of newborns and the number of advertisements, and were not affected by the current level of implementation of breast-milk substitute laws and regulations. CONCLUSIONS: The present media audit reveals inappropriate promotion and insufficient national regulation of products under the scope of the Code in South-East Asia. Strengthened implementation of regulations aligned with the Code's updated recommendation should be part of comprehensive strategies to minimize the harmful effects of advertisements of breast-milk substitutes on maternal and child nutrition and health.

The Rise and Fall of Universal Salt Iodization in Vietnam: Lessons Learned for Designing Sustainable Food Fortification Programs With a Public Health Impact.

BACKGROUND: In 2005, more than 90% of Vietnamese households were using adequately iodized salt, and urinary iodine concentration among women of reproductive age was in the optimal range. However, household coverage declined thereafter to 45% in 2011, and urinary iodine concentration levels indicated inadequate iodine intake. OBJECTIVE: To review the strengths and weaknesses of the Vietnamese universal salt iodization program from its inception to the current day and to discuss why achievements made by 2005 were not sustained. METHODS: Qualitative review of program documents and semistructured interviews with national stakeholders. RESULTS: National legislation for mandatory salt iodization was revoked in 2005, and the political importance of the program was downgraded with consequential effects on budget, staff, and authority. CONCLUSIONS: The Vietnamese salt iodization program, as it was initially designed and implemented, was unsustainable, as salt iodization was not practiced as an industry norm but as a government-funded activity. An effective and sustainable salt iodization program needs to be reestablished for the long-term elimination of iodine deficiency, building upon lessons learned from the past and programs in neighboring countries. The new program will need to include mandatory legislation, including salt for food processing; industry responsibility for the cost of fortificant; government commitment for enforcement through routine food control systems and monitoring of iodine status through existing health/nutrition assessments; and intersectoral collaboration and management of the program. Many of the lessons would apply equally to universal salt iodization programs in other countries and indeed to food fortification programs in general.

Development and implementation of a locally produced ready-to-use therapeutic food (RUTF) in Vietnam.

BACKGROUND: In Vietnam, malnutrition remains a public health problem, even though much progress has been made in the last decades. The number of cases of severe acute malnutrition (SAM) is more than 200,000 per year. To accelerate the treatment of SAM, community-based treatment with ready-to-use-therapeutic foods (RUTFs) is preferred. However, a locally available and acceptable RUTF for the treatment of SAM was lacking. OBJECTIVE: In a joint effort by the National Institute of Nutrition, UNICEF, and the Institut de Recherche pour le Développement, a local RUTF was developed and tested. METHODS: The product was optimalized for impact and acceptability. At the same time, capacity for the Integrated Management of Acute Malnutrition (IMAM) was developed. RESULTS: The local product was found to be highly acceptable and effective. After training of health staff the product could be introduced in the IMAM program. CONCLUSIONS: The IMAM program was highly successful in treating children with SAM, with more than 90% of the children recovering. Production capacity of the factory is currently being increased to enable up-scaling of the IMAM program and potential export of the product to countries in the region.

Estimating carbon and water footprints associated with commercial milk formula production and use: development and implications of the Green Feeding Climate Action Tool.

Carbon offset frameworks like the UN Clean Development Mechanism (CDM) have largely overlooked interventions involving food, health, and care systems, including breastfeeding. The innovative Green Feeding Climate Action Tool (GFT) assesses the environmental impact of commercial milk formula (CMF) use, and advocates for breastfeeding support interventions as legitimate carbon offsets. This paper provides an overview of the GFT's development, key features, and potential uses. The offline and online GFT were developed using the DMADV methodology (Define, Measure, Analyze, Design, Verify). The GFT reveals that the production and use of CMF by infants under 6 months results in annual global greenhouse gas (GHG) emissions of between 5.9 and 7.5 billion kg CO2 eq. and consumes 2,562.5 billion liters of water. As a national example, in India, one of the world's most populous countries, CMF consumption requires 250.6 billion liters of water and results in GHG emissions ranging from 579 to 737 million kg CO2 eq. annually, despite the country's high breastfeeding prevalence among infants under 6 months. The GFT mainly draws on data for low- and middle-income countries (LMICs), as many high-income countries (HICs) do not collect suitable data for such calculations. Despite poor official data on breastfeeding practices in HICs, GFT users can input their own data from smaller-scale surveys or their best estimates. The GFT also offers the capability to estimate and compare baseline with counterfactual scenarios, such as for interventions or policy changes that improve breastfeeding practices. In conclusion, the GFT is an important innovation to quantify CMF's environmental impact and highlight the significance of breastfeeding for planetary as well as human health. Women's contributions to environmental preservation through breastfeeding should be recognized, and breastfeeding interventions and policies should be funded as legitimate carbon offsets. The GFT quantifies CMF's carbon and water footprints and facilitates financing breastfeeding support as a carbon offset initiative under CDM funding facilities.

Cost analysis of establishing and operating the first human milk bank at Da Nang Hospital for Women and Children in Vietnam: an activity-based costing ingredients study.

BACKGROUND: Breastfeeding is the biological norm for feeding infants and young children. When mothers' breastmilk is unavailable, donor human milk (DHM) from a human milk bank (HMB) becomes the next option for small vulnerable newborns. A comprehensive cost analysis is essential for understanding the investments needed to establish, operate, and scale up HMBs. This study aims to estimate and analyze such costs at the first facility established in Vietnam. METHODS: An activity-based costing ingredients (ABC-I) approach was employed, with the cost perspective from service provision agencies (specifically, the project conducted at Da Nang Hospital for Women and Children and Development Partners). Estimated financial costs, based on actual expenditures, were measured in 2023 local currency and then converted to 2023 US dollars (USD). We examined three scenarios: 1) direct start-up costs + indirect start-up costs + implementation costs, 2) direct start-up costs + implementation costs, and 3) capital costs + implementation costs over the 6.5 years of operation. RESULTS: The total start-up cost was USD 616,263, with total expenditure on direct activities at USD 228,131 and indirect activities at USD 388,132. Investment in equipment accounted for the largest proportion (USD 84,213). The monthly costs of Da Nang HMB were USD 25,217, 14,565, and 9,326, corresponding to scenarios 1, 2, and 3, respectively. Over HMB's 6.5 years of operation, on average, the unit costs were USD 166, USD 96, and USD 62 for DHM received and USD 201, USD 116, and USD 74 for pasteurized DHM meeting specified criteria in the corresponding scenarios. Unit costs were highest in the initial six months, decreased, and reached their lowest levels after a year. Then, the unit costs experienced an increase in late 2020 and early 2021. CONCLUSION: Although the unit cost of DHM in Da Nang HMB is comparable to that in certain neighboring countries, intentional measures to reduce disposal rates, improve HMB efficiency, motivate more community-based donors, and establish an HMB service network should be implemented to lower costs.

Acceptability and impact on anthropometry of a locally developed ready-to-use therapeutic food in pre-school children in Vietnam.

BACKGROUND: In South East Asia, concerns exist about the acceptability of peanut-based Ready-to-Use-Therapeutic-Foods (RUTF) for the treatment of severe acute malnutrition (SAM). Therefore, an alternative, culturally acceptable RUTF made from locally available ingredients and complying with local food traditions and preferences was developed. The current study evaluated its acceptability and impact on anthropometry. METHODS: The study was a randomized, two-arm, cross-over intervention trial to test the acceptability of the local product (bar) against a commercially available, peanut-based RUTF paste (Plumpy'nut®). Children (n = 67) from two kindergartens in a rural area of North Vietnam were recruited. The age of the children was between 3 and 5 years. RESULTS: The Vietnamese RUTF was well-accepted, although overall acceptability was less than of Plumpy'nut®, with the latter scoring higher on palatability (P < 0.05). In contrast, reluctance to eat Plumpy'nut® was higher than for the Vietnamese RUTF (P < 0.05). Impact on anthropmetrical indices was similar for both RUTF. The nutritional status of the children who consumed the two RUTF over a 4 week period improved significantly, with a mean weight gain of 0.64 (SD 0.27) Kg, and increases in WHZ and HAZ z-scores of 0.48 (SD 0.30) and 0.05 (SD 0.13) respectively (P < 0.01 both). Weight gain was similar between the 2 products (0.32 kg per 2 weeks for both). CONCLUSIONS: Both the commercial Plumpy'nut® and the local produced RUTF were accepted although the harder consistency of the local product might have caused the lower overall acceptance. The promising increase in nutritional status needs to be confirmed in a controlled trial in children with SAM.

The volume and monetary value of human milk produced by the world's breastfeeding mothers: Results from a new tool.

The Mothers' Milk Tool was developed to make more visible the economic value contributed to society by women's unpaid care work through breastfeeding infants and young children. This manuscript describes the development and display key features of the tool, and reports results for selected countries. For the development, we used five steps: (1) defining the tool by reviewing existing tools and scholarly literature to identify uses, approaches, design features, and required data characteristics for a suitable product; (2) specifying the best open-access data available for measurement and easy updating; (3) analyzing development options; (4) testing predictive models to fill identified breastfeeding data gaps; and (5) validating the tool with prospective users and against previous research. We developed an Excel-based tool that allows working offline, displaying preloaded data, imputing data, and inputting users' data. It calculates annual quantities of milk produced by breastfeeding women for children aged 0-35.9 months, and the quantities lost compared to a defined biologically feasible level. It supports calculations for an individual mother, for countries, and global level. Breastfeeding women globally produce around 35.6 billion liters of milk annually, but 38.2% is currently "lost" due to cultural barriers and structural impediments to breastfeeding. The tool can also attribute a monetary value to the production. In conclusion, the Mothers' Milk Tool shows what is at risk economically if women's important capacity for breastfeeding is not protected, promoted, and supported by effective national policies, programs, and investments. The tool is of value to food and health policymakers, public officials, advocates, researchers, national accountants and statisticians, and individual mother/baby dyads, and will assist consideration of breastfeeding in food balance sheets and economic production statistics. The tool supports the 2015 Call to Action by the Global Breastfeeding Collective by facilitating the tracking of progress on breastfeeding targets.

Corrigendum: First do no harm overlooked: Analysis of COVID-19 clinical guidance for maternal and newborn care from 101 countries shows breastfeeding widely undermined.

[This corrects the article DOI: 10.3389/fnut.2022.1049610.].