Breastfeeding among women employed in Mexico's informal sector: strategies to overcome key barriers.

BACKGROUND: Rates of exclusive breastfeeding fall below recommended levels, particularly among women in paid employment. In Mexico, more than half of women are in informal employment, meaning they lack many of the protections that may support breastfeeding. METHODS: In-depth interviews with 15 key informants representing government agencies (n = 6 organizations), NGOs (n = 4), international organizations (n = 2), and academia (n = 2) in Mexico. Interviews were conducted between March and June 2023. To understand and describe barriers to breastfeeding among informally employed women in Mexico according to key informants and the current and potential policies to address these barriers, we conducted a qualitative thematic analysis. RESULTS: Current policies to promote, protect, and support breastfeeding predominantly apply to all employed women, but respondents expressed concern that they did not provide adequate protection for women in informal employment. Additional themes concerned the need for relevant programs to be institutionalized and coordinated, discussions of breastfeeding as a right, and the legal equivalence (whether true in practice or not) of formal and informal workers. CONCLUSIONS: Women employed in Mexico's informal sector face a dearth of maternity protections. According to key informants, few policies exist to promote, protect, and support breastfeeding among employed women, in general, but the economic vulnerability and challenging working conditions of women in informal employment exacerbates their situation. The lack of access to formal labor protections, such as paid maternity leave, creates a significant barrier to breastfeeding for women in the informal sector. Recommendations include short-term policies to fill gaps in social protection for informally employed women, as well as longer-term solutions such as the development of universal social protection programs and supporting formalization.

Adaptation of a community health outreach model during the COVID-19 pandemic: the case of the Mexican consulates in the United States of America.

The Ventanillas de Salud (VDS - "Health Windows") are a culturally sensitive outreach program within the 49 Mexican Consulates in the United States that provides information and health care navigation support to underserved and uninsured Mexican immigrants. During the COVID-19 pandemic the VDS rapidly transitioned to remote operations adding new services. Based on the EquIR implementation framework, this qualitative study investigates how adaptations to improve emergency preparedness were performed. We conducted motivational interviews with three actors - six VDS coordinators, eight partner organizations, and ten VDS users- in two VDS, Los Angeles and New York, to document specific needs of the target population and identify implementation processes to adapt and continue operating. The VDS adapted their model by adding new services for emerging needs, by switching service provision modalities, and by expanding the network of partner organizations. According to the VDS staff, these adaptations increased their topics, depth, reach, and diversified their users. Users had mostly positive opinions about the VDS adaptation, although they highlighted some heterogeneity across service provision. The VDS is a public health intervention able to serve a marginalized population and its implementation offers valuable lessons to complement health systems and to improve preparedness and resiliency for future crises.

Barriers to COVID-19 vaccination among older adults in Mexico City.

Vaccines are effective to reduce COVID-19 related outcomes, but universal vaccination campaigns can reveal within-country access inequities. Mexico City has had high rates of COVID-19 related morbidity and mortality and a population survey warned that vaccine acceptance was lowest in older adults. Since February 2021, Mexico started a universal and free vaccination campaign prioritizing older adults. By April 17, every older adult in Mexico City had been eligible to receive the first dose. A week later, we conducted a telephone survey representative of older adults residing in Mexico City (n = 503). We asked if they received their first dose and, if they haven't, we followed-up with an open question to register their reasons. In addition to sociodemographic characteristics and food insecurity, we also inquired about vaccine hesitancy, health concerns related to COVID-19, self-rated health, comorbidities, frailty, and depression. The objective of the study was to identify the main barriers to receive the first dose of the vaccine. We estimated descriptive statistics and logistic regression models. Results show that 7.6% of older adults in Mexico City did not receive their first dose. Barriers for not receiving it were vaccine hesitancy (60.4%), not having COVID-19 health concerns (46.4%), poor self-rated health (46.7%), a previous diagnosis of depression (35.7%), low socioeconomic status (65.4%), and household food insecurity (59.8%). Responses to the open question clustered in four themes: misinformation about the process (30%), distrust of the vaccine (24%), personal health problems (24%), and difficulties to get an appointment (22%). Logistic regression models adjusted for vaccine hesitancy and revealed two distinct reasons for not having their first dose: 1) vaccine hesitancy and misinformation on COVID-19, and 2) household food insecurity. Reaching these two groups requires active and differentiated public-health measures; the first with additional information from trusted sources, and the second by facilitating vaccination in neighborhoods with high levels of food insecurity and informal labor, where missing a day's work is a strong disincentive. Vaccination campaigns need an equity lens to reach universal coverage; ensuring full access demands thorough and carefully tailored new interventions.

Estimating the costs for implementing a maternity leave cash transfer program for women employed in the informal sector in Brazil and Ghana.

BACKGROUND: Maternity leave policies are designed to protect gender equality and the health of mothers in the workforce and their children. However, maternity leave schemes are often linked to jobs in the formal sector economy. In low- and middle-income countries a large share of women work in the informal sector, and are not eligible to such benefit. This is worrisome from a social justice and a policy perspective and suggests the need for intervening. Costing the implementation of potential interventions is needed for facilitating informed decisions by policy makers. METHODS: We developed and applied a costing methodology to assess the cost of a maternity leave cash transfer to be operated in the informal sector of the economy in Brazil and Ghana, two countries with very different employment structures and socioeconomic contexts. We conducted sensitivity analysis by modeling different numbers of weeks covered. RESULTS: In Brazil, the cost of the maternity cash transfer would be between 0.004% and 0.02% of the GDP, while in Ghana it would range between 0.076% and 0.28% of the GDP. The relative cost of rolling out a maternity intervention in Brazil is between 2.2 to 3.2 times the cost in Ghana depending on the benchmark used to assess the welfare measure. The differences in costs between countries was related to differences in labor market structure as well as demographic characteristics. CONCLUSIONS: Findings show how a standard methodology that relies on routinely available information is feasible and could assist policymakers in estimating the costs of supporting a maternity cash transfer for women employed in the informal sector, such intervention is expected to contribute to social justice, gender equity, and health trajectories.

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Aproximación al consumo de alimentos recomendables y no recomendables en la primera ola de la pandemia por Covid-19 en México.

OBJETIVO: Estimar la frecuencia con la que se consumen algunos alimentos recomendables y no recomendables du-rante la pandemia por Covid-19 en México, y su asociación con características sociodemográficas y seguridad alimentaria. Material y métodos. Se analizó la Encuesta de Seguimien-to de los Efectos del Covid en el Bienestar de los Hogares Mexicanos (Encovid-19). Se identificaron cuatro grupos con información de la frecuencia de su consumo y se estimaron modelos de regresión logística ajustando por características sociodemográficas y seguridad alimentaria. RESULTADOS: Los niveles socioeconómicos más altos A/B y C se asociaron con una mayor frecuencia de consumo de alimentos recomenda-bles y no recomendables. La inseguridad leve se asoció con un menor consumo de alimentos recomendables, y la inseguridad moderada y severa se asociaron con un menor consumo de todos los grupos estudiados. CONCLUSIONES: Comprender la experiencia de la inseguridad alimentaria durante una cri-sis como la pandemia puede indicar la necesidad de incluir grupos de población tradicionalmente no considerados en los programas de apoyo.

Follow-up and growing-up formula promotion among Mexican pregnant women and mothers of children under 18 months old.

Milk formula sales have grown globally, particularly through follow-up formulas (FUF) and growing-up milks (GUM). Marketing strategies and weak regulatory and institutional arrangements are important contributors to caregivers' decisions about child feeding choices. This study describes maternal awareness, beliefs, and normative referents of FUFs and GUMs among Mexican pregnant women and mothers of children 0-18 months (n = 1044) through the lens of the theory of reasoned action (TRA). A cross-sectional survey was undertaken in two large metropolitan areas of Mexico. Descriptive analyses were conducted following the constructs of the TRA. One-third of the participants had heard about FUFs, mainly through health professionals (51.1%) and family (22.2%). Once they had heard about FUFs, the majority (80%) believed older infants needed this product due to its benefits (hunger satisfaction, brain development, and allergy management). One quarter of the participants were already using or intended to use FUFs; the majority had received this recommendation from doctors (74.6%) and mothers/mothers-in-law (25%). Similarly, 19% of the women had heard about GUMs. The pattern for the rest of TRA constructs for GUMs was similar to FUFs. Mexican women are exposed to FUFs and GUMs, once women know about them, the majority believe older infant and young children need these products, stating perceived benefits that match the poorly substantiated marketing claims of breast-milk substitutes. Health professionals, particularly doctors, act as marketing channels for FUFs and GUMs. Marketing of FUFs and GUMs represents a threat to breastfeeding in Mexico and a more protective regulatory and institutional environment is needed.

Impact of prelacteal feeds and neonatal introduction of breast milk substitutes on breastfeeding outcomes: A systematic review and meta-analysis.

The introduction of fluids other than breast milk during the first few days of life or later neonatal period has been identified as a risk factor for suboptimal breastfeeding (BF) outcomes in numerous studies using varying study designs. However, the relationship between early introduction of fluids other than breast milk and BF outcomes has not been systematically assessed using only prospective studies that can establish temporality, which is critical for determining whether observed associations are causal. We conducted a systematic review and meta-analysis of prospective studies to assess if there is a difference in BF outcomes as a result of the introduction of: (a) milk-based prelacteals, (b) water-based prelacteals and (c) breast milk substitutes (BMS) between 4 days and 4 weeks postpartum. We searched PubMed, Lilacs, Web of Science and other repositories for original research investigating the relationship between early introduction of prelacteals and/or BMS and BF outcomes. Forty-eight studies met the inclusion criteria for the systematic review. Of the 39 prelacteal feeding studies, 27 had the prerequisite statistical information for inclusion in the meta-analysis. Findings from the meta-analysis showed a relationship between prelacteals and exclusive BF cessation (RR 1.44; 1.29-1.60) and any BF cessation (2.23; 1.63-3.06) among infants under 6 months old. Nine studies focusing on the introduction of BMS during the neonatal period identified this practice as a statistically significant risk factor for a shorter BF duration. Effective interventions are needed to prevent the introduction of unnecessary milk-based prelacteals and BMS during the perinatal and neonatal periods to improve BF outcomes.

Impact of baby behaviour on caregiver's infant feeding decisions during the first 6 months of life: A systematic review.

Caregivers are often concerned about baby behaviours. Without adequate counselling, parental response can lead to altering infant feeding and jeopardizing breastfeeding. We conducted a systematic review to assess the evidence about the influence of baby behaviours perceived as problematic (crying, sleep waking and posseting) on infant feeding decisions during the first 6 months of life (self-reported milk insufficiency, breastfeeding duration and introduction of formula). The review focused on quantitative studies published in English, Portuguese or Spanish without date restriction. The search was designed with the support of a medical librarian and conducted in seven databases. Data were managed in Covidence and risk of bias was assessed through the Johanna Briggs Institute critical appraisal checklists. Synthesis of the literature was guided by a conceptual model of the impact of baby behaviours on caregivers feeding practices. We retrieved and reviewed 4312 titles/abstracts and selected 22 for review; 10 were purely descriptive and 12 were cross-sectional, prospective and quasi-experimental studies. Although studies from diverse regions were included in the review, more than half were from high-income countries. All studies reported that baby behaviours affect feeding decisions, the most common baby behaviours studied were crying and fussiness, and the studies suggested relationships with lactation problems and reports of milk insufficiency, maternal breastfeeding confidence, breastfeeding duration and discontinuation, and introduction of formula. There are many factors that lead to perceiving baby behaviours as problematic and there is a need to provide anticipatory guidance to parents and caregivers, starting in pregnancy and counselling through well-trained health providers.

Risk factors for self-reported insufficient milk during the first 6 months of life: A systematic review.

The objective of this systematic review was to identify multifactorial risk factors for self-reported insufficient milk (SRIM) and delayed onset of lactation (DOL). The review protocol was registered a priori in PROSPERO (ID# CDR42021240413). Of the 120 studies included (98 on SRIM, 18 on DOL, and 4 both), 37 (31%) studies were conducted in North America, followed by 26 (21.6%) in Europe, 25 (21%) in East Asia, and Pacific, 15 (12.5%) in Latin America and the Caribbean, 7 (6%) in the Middle East and North Africa, 5 (4%) in South Asia, 3 (2.5%) in Sub-Saharan Africa, and 2 (1.7%) included multiple countries. A total of 79 studies were from high-income countries, 30 from upper-middle-income, 10 from low-middle-income countries, and one study was conducted in a high-income and an upper-middle-income country. Findings indicated that DOL increased the risk of SRIM. Protective factors identified for DOL and SRIM were hospital practices, such as timely breastfeeding (BF) initiation, avoiding in-hospital commercial milk formula supplementation, and BF counselling/support. By contrast, maternal overweight/obesity, caesarean section, and poor maternal physical and mental health were risk factors for DOL and SRIM. SRIM was associated with primiparity, the mother's interpretation of the baby's fussiness or crying, and low maternal BF self-efficacy. Biomedical factors including epidural anaesthesia and prolonged stage II labour were associated with DOL. Thus, to protect against SRIM and DOL it is key to prevent unnecessary caesarean sections, implement the Baby-Friendly Ten Steps at maternity facilities, and provide BF counselling that includes baby behaviours.

Breastfeeding inequities in South Africa: Can enforcement of the WHO Code help address them? - A systematic scoping review.

INTRODUCTION: Suboptimal breastfeeding rates in South Africa have been attributed to the relatively easy access that women and families have had to infant formula, in part as a result of programs to prevent maternal-to-child transmission (MTCT) of HIV. This policy may have had an undesirable spill-over effect on HIV-negative women as well. Thus, the aims of this scoping review were to: (a) describe EBF practices in South Africa, (b) determine how EBF has been affected by the WHO HIV infant feeding policies followed since 2006, and (c) assess if the renewed interest in The Code has had any impact on breastfeeding practices in South Africa. METHODS: We applied the Joanna Briggs Institute guidelines for scoping reviews and reported our work in compliance with the PRISMA Extension (PRISMA-ScR). Twelve databases and platforms were searched. We included all study designs (no language restrictions) from South Africa published between 2006 and 2020. Eligible participants were women in South Africa who delivered a healthy live newborn who was between birth and 24 months of age at the time of study, and with known infant feeding practices. RESULTS: A total of 5431 citations were retrieved. Duplicates were removed in EndNote and by Covidence. Of the 1588 unique records processed in Covidence, 179 records met the criteria for full-text screening and 83 were included in the review. It was common for HIV-positive women who initiated breastfeeding to stop doing so prior to 6 months after birth (1-3 months). EBF rates rapidly declined after birth. School and work commitments were also reasons for discontinuation of EBF. HIV-positive women expressed fear of HIV MTCT transmission as a reason for not breastfeeding. CONCLUSION: The Review found that while enforcing the most recent WHO HIV infant feeding guidelines and the WHO Code may be necessary to improve breastfeeding outcomes in South Africa, they may not be sufficient because there are additional barriers that impact breastfeeding outcomes. Mixed-methods research, including in-depth interviews with key informants representing different government sectors and civil society is needed to prioritize actions and strategies to improve breastfeeding outcomes in South Africa.

Breastfeeding at the workplace: a systematic review of interventions to improve workplace environments to facilitate breastfeeding among working women.

BACKGROUND: Breastfeeding can be affected by maternal employment. This is important considering that in 2019, 47.1% of women globally participated in the labor force. The aim of this study was to review workplace interventions to promote, protect and support breastfeeding practices among working mothers globally. METHODS: A systematic review was conducted following the guidance of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Observational, experimental and qualitative peer-reviewed studies in English and Spanish, published between 2008 and 2019 were included. The review focused on working women who were pregnant, breastfeeding or who recently had a child, and women's working environments. The outcomes of interest included breastfeeding intentions, initiation, exclusivity and duration, confidence in breastfeeding or breastmilk extraction, and perceived support at workplace. Quality was assessed according to National Institute for Health and Care Excellence (NICE) checklist for systematic reviews. It was registered on PROSPERO (#140624). RESULTS: Data was extracted from 28 quantitative and 9 qualitative studies. The most common interventions were designated spaces for breastfeeding or breastmilk extraction (n = 24), and the support from co-workers (n = 20). The least common interventions were providing breast pumps (n = 4) and giving mothers the flexibility to work from home (n = 3). Studies explored how interventions affected different breastfeeding outcomes including breastfeeding duration, breastfeeding exclusivity, confidence in breastmilk expression, and breastfeeding support. The evidence suggests that workplace interventions help increase the duration of breastfeeding and prevent early introduction of breastmilk substitutes. Having a lactation space, breastmilk extraction breaks, and organizational policies are key strategies. However, to achieve equitable working conditions for breastfeeding mothers, organizational and interpersonal changes need to occur as well. CONCLUSIONS: The systematic review revealed that interventions at the workplace are important in protecting, promoting and supporting breastfeeding among working mothers. To achieve equitable work environments and fair nutritional opportunities for infants of working mothers, interventions should focus at the three ecological layers - individual, interpersonal, and organizational. The quality of studies can be improved. There is a need for studies assessing impacts of workplace interventions on infant feeding practices, mothers' self-esteem and outcomes such productivity and abstentionism.

Urban poverty and nutrition challenges associated with accessibility to a healthy diet: a global systematic literature review.

BACKGROUND: There is an increasing global trend towards urbanization. In general, there are less food access issues in urban than rural areas, but this "urban advantage" does not benefit the poorest who face disproportionate barriers to accessing healthy food and have an increased risk of malnutrition. OBJECTIVES: This systematic literature review aimed to assess urban poverty as a determinant of access to a healthy diet, and to examine the contribution of urban poverty to the nutritional status of individuals. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) methodology, our review included quantitative and qualitative studies published in English or in Spanish between 2000 and 2019. The articles were eligible if they focused on nutrition access (i.e. access to a healthy diet) or nutrition outcomes (i.e., anemia, overweight and obesity, micronutrient deficiency, micronutrient malnutrition) among urban poor populations. Articles were excluded if they did not meet pre-established criteria. The quality of the quantitative studies was assessed by applying Khan et al.'s methodology. Similarly, we assessed the quality of qualitative articles through an adapted version of the National Institute for Health and Care Excellence (NICE) methodology checklist. Finally, we systematically analyzed all papers that met the inclusion criteria based on a qualitative content and thematic analysis. RESULTS: Of the 68 papers included in the systematic review, 55 used quantitative and 13 used qualitative methods. Through the analysis of the literature we found four key themes: (i) elements that affect access to healthy eating in individuals in urban poverty, (ii) food insecurity and urban poverty, (iii) risk factors for the nutritional status of urban poor and (iv) coping strategies to limited access to food. Based on the systematization of the literature on these themes, we then proposed a conceptual framework of urban poverty and nutrition. CONCLUSIONS: This systematic review identified distinct barriers posed by urban poverty in accessing healthy diets and its association with poorer nutrition outcomes, hence, questioning the "urban advantage". A conceptual framework emerging from the existing literature is proposed to guide future studies and policies. SYSTEMATIC REVIEW REGISTRATION: PROSPERO Registration number: CRD42018089788 .

Food insecurity measurement and prevalence estimates during the COVID-19 pandemic in a repeated cross-sectional survey in Mexico.

OBJECTIVE: To validate the telephone modality of the Latin American and Caribbean Food Security Scale (ELCSA) included in three waves of a phone survey to estimate the monthly household food insecurity prevalence during the COVID-19 pandemic in Mexico. DESIGN: We examined the reliability and internal validity of the ELCSA scale in three repeated waves of cross-sectional surveys with Rasch models. We estimated the monthly prevalence of food insecurity in the general population and in households with and without children and compared them with a national 2018 survey. We tested concurrent validity by testing associations of food insecurity with socio-economic status and anxiety. SETTING: ENCOVID-19 is a monthly telephone cross-sectional survey collecting information on the well-being of Mexican households during the pandemic lockdown. Surveys used probabilistic samples, and we used data from April (n 833), May (n 850) and June 2020 (n 1674). PARTICIPANTS: Mexicans 18 years or older who had a mobile telephone. RESULTS: ELCSA had an adequate model fit and food insecurity was associated, within each wave, with more poverty and anxiety. The COVID-19 lockdown was associated with an important reduction in food security, decreasing stepwise from 38·9 % in 2018 to 24·9 % in June 2020 in households with children. CONCLUSIONS: Telephone surveys were a feasible strategy to monitor reductions in food security during the COVID-19 lockdown.

Barriers and enablers of breast-feeding protection and support after the 2017 earthquakes in Mexico.

OBJECTIVE: To study the barriers and enablers of breast-feeding protection and support after the 2017 earthquakes in Mexico. DESIGN: A qualitative study using a phenomenological approach to analyse data collected from in-depth interviews, virtual ethnography and documentary analysis of newspapers. SETTING: Data were collected after the September 2017 earthquakes in Mexico (from 8 September 2017 to 15 May 2018). PARTICIPANTS: The participants included key informants (n 13) from different sectors. Postings retrieved from forty-two Facebook and forty-seven Twitter accounts and a WhatsApp group informed the virtual ethnography analysis. Newspaper material covering the 2017 earthquakes in Mexico (seven newspapers) was retrieved for the documentary analysis. RESULTS: Interviews with key informants revealed a lack of knowledge, unclear institutional protocols during emergencies and lack of enforcement of existing international frameworks. The virtual ethnography uncovered a strong call for donations in the immediate aftermath of the earthquakes, and generalized donations of formula revealed a tense relationship between actions taken by breast-feeding experts and the negative reactions from the government and citizens. This analysis highlights the relevance of pre-existing networks of experts in protecting and supporting breast-feeding. From the newspaper documentary analysis, similar themes emerged. CONCLUSIONS: This study identified key barriers and enablers in the protection and support of breast-feeding during the 2017 earthquakes in Mexico. Relevant actors should embrace the lessons highlighted in this study because countries such as Mexico are likely to experience other emergencies in the near future.

[Monthly prevalence of generalized anxiety disorder during the Covid-19 pandemic in Mexico]. / Prevalencia mensual de trastorno de ansiedad generalizada durante la pandemia por Covid-19 en México.

Objective. Estimate the prevalence of generalized anxiety disorder (GAD) from April to June 2020. Materials and methods. Repeated cross-sections design based in the Encovid-19, a series of monthly mobile surveys with representative samples of Mexico (N= 833-1 674). The questionnaire includes the GAD-2 scale, and, in July, the GAD-7 scale was added; we examined its internal validity with confirmatory factor analysis and its concurrent validity with sociodemographic variables. Using GAD-7 as criterion, we analyzed the predictive validity of the GAD-2. We estimated the monthly prevalence with the GAD-2. Results. The GAD-7 and the GAD-2 are reliable and valid. The GAD-2 has a sensitivity of 0.87 and a specificity of 0.90. The monthly prevalence remains high and stable, between 30.7 and 32.6%. GAD concentrated in women, unemployed and persons with low socioeconomic status. Conclusions. GAD is a public health problem that worsened during the Covid-19 pandemic.

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.

Costs of maternity leave to support breastfeeding; Brazil, Ghana and Mexico.

OBJECTIVE: To develop a method to assess the cost of extending the duration of maternity leave for formally-employed women at the national level and apply it in Brazil, Ghana and Mexico. METHODS: We adapted a World Bank costing method into a five-step method to estimate the costs of extending the length of maternity leave mandates. Our method used the unit cost of maternity leave based on working women's weekly wages; the number of additional weeks of maternity leave to be analysed for a given year; and the weighted population of women of reproductive and legal working age in a given country in that year. We weighted the population by the probability of having a baby that year among women in formal employment, according to individual characteristics. We applied nationally representative cross-sectional data from fertility, employment and population surveys to estimate the costs of maternity leave for mothers employed in the formal sector in Brazil, Ghana and Mexico for periods from 12 weeks up to 26 weeks, the WHO target for exclusive breastfeeding. FINDINGS: We estimated that 640 742 women in Brazil, 33 869 in Ghana and 288 655 in Mexico would require formal maternity leave annually. The median weekly cost of extending maternity leave for formally working women was purchasing power parity international dollars (PPP$) 195.07 per woman in Brazil, PPP$ 109.68 in Ghana and PPP$ 168.83 in Mexico. CONCLUSION: Our costing method could facilitate evidence-based policy decisions across countries to improve maternity protection benefits and support breastfeeding.

Costing of actions to safeguard vulnerable Mexican households with young children from the consequences of COVID-19 social distancing measures.

COVID-19 has imposed unprecedented challenges to society. As the pandemic evolves, the social distancing measures that have been globally enforced, while essential, are having undesirable socioeconomic side effects particularly among vulnerable populations. In Mexico, families who depend upon informal employment face increased threats to their wellbeing, and households who in addition have young children may face long-term consequences. The Mexican government has not yet taken actions, but a coalition of non-governmental organizations is advocating in partnership with academic institutions for social protection actions such as a cash transfer and basic services subsidies for families with young children, subsisting from the informal sector economy. To facilitate governmental action, we estimated the costs for implementation of these recommendations. The methodology used could be replicated in other countries facing similar challenges.

How do context variables affect food insecurity in Mexico? Implications for policy and governance.

OBJECTIVE: To assess, from a systems perspective, how climate vulnerability and socio-economic and political differences at the municipal and state levels explain food insecurity in Mexico. DESIGN: Using a cross-sectional design with official secondary data, we estimated three-level multinomial hierarchical linear models. SETTING: The study setting is Mexico's states and municipalities in 2014. PARTICIPANTS: Heads of households in a representative sample of the general population. RESULTS: At the municipal level, vulnerability to climate disasters and a poverty index were significant predictors of food insecurity after adjusting for household-level variables. At the state level, gross domestic product and the number of nutrition programmes helped explain different levels of food insecurity but change in political party did not. Predictors varied in strength and significance according to the level of food insecurity. CONCLUSIONS: Findings evidence that, beyond food assistance programmes and household characteristics, multiple variables operating at different levels - like climate vulnerability and poverty - contribute to explain the degree of food insecurity. Food security governance is a well-suited multisectoral approach to address the complex challenge of hunger and access to a nutritious diet.