How Does "Becoming Breastfeeding Friendly" Work? A Programme Impact Pathways Analysis

Becoming Breastfeeding Friendly (BBF) is an initiative designed to track country readiness and progress to effectively scale up breastfeeding programmes. BBF includes a policy toolbox that has three components: the BBF Index (BBFI), case studies, and a five-meeting process. Mapping pathways of how BBF was implemented and utilized enables contextually grounded interpretation of its impact on breastfeeding outcomes. We conducted a programme impact pathways (PIP) analysis to identify pathways and critical quality control points (CCPs) by which BBF can enable changes in policy, legislation, and implementation of breastfeeding programmes. A BBF PIP diagram was developed, and CCPs were identified through a literature review and an iterative interviewing process with BBF investigators. The PIP was revised after feedback from BBF's Technical Advisory Group. BBF pretesting in Ghana and Mexico informed the formative evaluation of the PIP. PIP analysis identified relevant pathways between BBF activities and outcomes. Eight CCPs that could facilitate or attenuate BBF to fully impact the scaling up of the breastfeeding programmes were identified: (a) committee formed and trained; (b) committee understands BBF and BBFI; (c) committee's ability to acquire data; (d) BBFI scores; (e) criteria used for prioritizing recommendations; (f) dissemination of recommendations; (g) policymaker's reactions and media coverage; (h) committee's motivation and effective teamwork throughout BBF. Ghana and Mexico's pretesting of BBF confirmed the CCPs and provided valuable insights on potential mechanisms of BBF impacts at the country level. To further validate the PIP, a policy analysis framework is being tested in Ghana and Mexico.