Infant feeding policies and monitoring systems: A qualitative study of European Countries.

Implementation of the Global Strategy for Infant and Young Child Feeding varies widely among countries. Policymakers would benefit from insights into obstacles and enablers. Our aim was to explore the processes behind the development and implementation of national infant and young child feeding policies and monitoring systems in Europe. A qualitative study design was employed to analyze open text responses from six European countries (Croatia, Germany, Lithuania, Spain, Turkey and Ukraine) using inductive thematic analysis. Countries were selected based on their World Breastfeeding Trends Initiative scores on national policy and monitoring systems. The 33-item online questionnaire was distributed to country representatives and completed by country teams. Key enablers and strengths included strong and continuous government commitment to infant and young child feeding, an operational national breastfeeding authority, a national and active monitoring and evaluation system, implementation of the International Code of Marketing of Breastmilk Substitutes in national legislation, the integration of skilled breastfeeding supporters, the implementation of the Baby-friendly Hospital Initiative, and positive cultural norms and traditions supporting optimal infant and young child feeding. In some countries, UNICEF played a key role in funding and designing policies and monitoring systems. Weak government leadership, the strong influence of the industry, lack of adequate national legislation on the International Code and cultural norms which devalued breastfeeding were particularly noted as obstacles. Government commitment, funding and protection of optimal infant and young child feeding are essential to the implementation of strong national policies and monitoring systems.

INTRODUCTION

Optimal breastfeeding practices have long been identified as crucial for infant survival and maternal and infant health (Victora et al., 2016). UN experts outline that all countries have a responsibility to protect breastfeeding as a human right (United Nations, 2016). To aid countries in protecting and supporting breastfeeding, the World Health Assembly (WHA) adopted in 2002 the Global Strategy for Infant and Young Child Feeding (hereafter Global Strategy; WHO, 2002). WHO further developed a technical tool to support countries to evaluate their own implementation of the Global Strategy (WHO & LINKAGES, 2003)‎. The Breastfeeding Promotion Network of India and the International Baby Food Action Network (IBFAN) built upon this tool to create the World Breastfeeding Trends initiative (WBTi), a simplified assessment tool which incorporated a more participatory approach, producing a user‐friendly, colour‐coded online report and report card for each country (Gupta et al., 2019). The aim of the WBTi is twofold: to help countries monitor their progress in the implementation of the Global Strategy and to generate recommendations for action. This is done by a multi‐sectoral core country team, free of conflict of interest, using the WBTi assessment tool. The tool focuses on indicators for Infant and young child feeding (IYCF) policies, programs and practices (Table 1). These are based on WHO variables and definitions (WHO & UNICEF, 2021). The Global Breastfeeding Collective, a partnership of international agencies led by WHO and UNICEF which works to support governments to fund and implement effective strategies to support breastfeeding, recommend that countries conduct a WBTi assessment every 5 years (Global Breastfeeding Collective, 2020).

Table 1

The 15 indicators of the World Breastfeeding Trends initiative

Part I: Policy and programs (Indicator 1–10)	Part II: Infant feeding practices (Indicator 11–15)
1. National Policy, Programme and Coordination 2. Baby‐friendly Hospital Initiative 3. Implementation of the International Code of Marketing of Breastmilk Substitutes 4. Maternity Protection 5. Health and Nutrition Care Systems 6. Mother Support and Community Outreach 7. Information Support 8. Infant Feeding and HIV 9. Infant Feeding During Emergencies 10. Monitoring and Evaluation	11. Early Initiation of Breastfeeding 12. Exclusive Breastfeeding 13. Median Duration of Breastfeeding 14. Bottle Feeding 15. Complementary Feeding

Other global benchmarking efforts to monitor IYCF include UNICEF's earlier reports on IYCF programs, based on their own IYCF assessment matrix (UNICEF, 2011), their series of reports on The State of the World's Children (UNICEF, 2019) and the Global Nutrition Reports (https://globalnutritionreport.org). A principal difference in these assessments is that they are conducted by external agencies, whereas the WBTi has been designed to be participatory, based on the example of the Global Participatory Action Research Project (Cadwell & White, 1995). This draws on the experience of local groups and individuals involved in breastfeeding protection, promotion and support. All participants in the research are seen as equal partners in developing, creating, analysing and disseminating the research findings.

More recently, another benchmarking assessment tool has been launched, the Becoming Breastfeeding Friendly (BBF) initiative (Pérez‐Escamilla et al., 2018). This uses a gear model to illustrate the interconnectedness of key policies, with 54 criteria across eight gears. Many of the areas overlap with the 77 items assessed in the WBTi tool, as both are based on WHO's own assessment tool (WHO & LINKAGES, 2003). The indicators or gears assessed are similar except in a few areas: BBF includes a gear assessing the state of research, while WBTi includes two indicators on breastfeeding in complex circumstances: infant feeding with HIV and IYCF in emergencies. Despite large differences in methods, the BBF findings and recommendations have been shown to be consistent with those of the WBTi in two countries where both the WBTi and the BBF were conducted within a few years of each other. In Scotland, both assessments highlighted similar strengths, such as government policies, implementation of the BFHI and community‐based support, and similar gaps in relation to maternity protection, information support, and implementation of the International Code of Marketing of Breastmilk Substitutes and subsequent relevant WHA Resolutions (hereafter referred to together as ‘the International Code’) (McFadden et al., 2022; WBTi UK Core Group, 2016; https://www.who.int/teams/nutrition-and-food-safety/food-and-nutrition-actions-in-health-systems/netcode/code-and-subsequent-resolutions). In Germany, BBF produced several recommendations consistent with those of the WBTi assessment, for example, with respect to policy development. However, WBTi considered the lack of International Code implementation to be one of the major obstacles to the protection, promotion and support of breastfeeding, while BBF did not identify this as a major problem. The implementation of BFHI as a quality standard for obstetric institutions was also not considered as important by BBF as it was by WBTi. Since the period under assessment by the WBTi and BBF, these evaluations were followed by the development of a new German policy and strategy for the promotion of breastfeeding; this was published in 2021, based on mutual cooperation among WBTi, BBF and other stakeholders in a participatory process (Federal Ministry of Food and Agriculture Germany, 2021).

So far, the BBF has been carried out in eight countries (https://ysph.yale.edu/bfci/). The WBTi has been carried out in 98 countries to date, with numerous countries carrying out reassessments every 3–5 years. Repeated WBTi reassessments have been associated with positive changes in policies, programs and breastfeeding practices (Gupta et al., 2019, 2020). An earlier analysis of WBTi scores, in 22 countries across Africa, Asia, Latin America and the Middle East, showed a significant association between WBTi policy and programme scores and increased rates of exclusive breastfeeding over time (Lutter & Morrow, 2013). The current war in Ukraine, the COVID‐19 pandemic and other emergencies will undoubtedly influence the maintenance and progress of WBTi and other strategic initiatives related to IYCF.

In the European region, the WBTi assessment has been completed by 19 countries so far. A 2020 overview of 18 WBTi country reports showed that European governments are not doing enough to protect, promote and support optimal IYCF practices (Zakarija‐Grković et al., 2020). None of the 18 countries had fully implemented the Global Strategy, with the production of a national IYCF policy, and the protection of infant feeding in emergencies, receiving the lowest scores. Despite the open access to the WBTi reports, which provide detailed information on policies and programs across many countries, very few researchers have taken the opportunity to use these data. This paper seeks to remedy that gap.

A deeper understanding of why some countries achieved high scores, while others scored very low, might help policy‐makers identify action that may lead to stronger policies and programs, and consequently better infant feeding practices. Robust monitoring and evaluation (M&E) systems ensure effective implementation and regular improvement of national policies and programs. Our aim was to explore the processes behind the development and implementation of national IYCF policies and monitoring systems in Europe, and to identify key obstacles and enablers, along with strengths, weaknesses, opportunities and threats (SWOT). This information will be useful to other countries working to implement the Global Strategy.

METHODS

Design

This study adopted a cross‐sectional, descriptive qualitative design, using an online survey with open questions, to explore the critical moments and processes undertaken by six European countries (Croatia, Germany, Lithuania, Spain, Turkey and Ukraine) in implementing the Global Strategy.

Setting and relevant context

The countries chosen for this study were European countries who had published a WBTi report in which they had received a high score for both indicators 1 and 10 (Turkey, Ukraine and Croatia), as well as those countries that had received a low score for both indicators 1 and 10 (Germany, Spain and Lithuania). The three cases at each extreme were chosen to show the greatest distinction between enablers and obstacles (Patton, 2002), as the remaining countries had more heterogeneous outcomes (Table 2).

Table 2

WBTi scores (0–10) for Indicators 1 and 10 in 18 European countries

Country	Indicator 1: National policy, programme and coordination	Indicator 10: Monitoring and evaluation
Turkey	10	10
Ukraine	9.5	9
Croatia	9.5	8
Malta	8	5
North Macedonia	6	5
Moldova	5	7
Armenia	4	8
Belgium	4	4
Georgia	4	9
Bosnia and Herzegovina	3	5
France	2	5
Italy	2	5
United Kingdom	1	5
Austria	0.5	5
Portugal	0	9
Lithuania	2	2
Germany	1	2
Spain	0	0

Eligibility criteria were developed independently of the composition of the research team. Coincidentally, two members of the research team were also the WBTi Coordinators for countries that met the eligibility criteria. To reduce potential bias, they involved additional members of their original WBTi country teams to produce a joint response to the questionnaire. In addition, their countries were analysed by other members of the research team, who also read their original WBTi country reports as a means of strengthening the validity of the findings.

The six countries in this study have a range of systems of government, from strong national coordination to federal or similar systems, for instance, those of Spain and Germany. Some countries (Croatia, Lithuania and Ukraine) have undergone fairly recent significant political changes. Croatia and Ukraine have suffered from wars; the resulting devastating impact on maternal and infant health has led to strong UNICEF programme activity. In Turkey, one of the aims of the UNICEF Baby‐Friendly Hospital Initiative (BFHI) is to reduce morbidity and mortality in infants and children by preventing malnutrition. In the other European countries, UNICEF has no field/country offices to deliver national services, only national committees whose task is mainly fundraising.

Sample

A purposive sampling approach (Green & Thorogood, 2018) was used. The WBTi Country Coordinators for the six eligible countries were contacted and all agreed to participate in the study, with most Coordinators involving other WBTi country team members in the process of completing the questionnaire. A total of 19 people, distributed unevenly across the six study countries, contributed information, some of whom chose to remain anonymous. Respondents included a coordinator of the National Breastfeeding Committee (NBC), BFHI coordinators, paediatricians, International Board Certified Lactation Consultants (IBCLCs), breastfeeding counsellors, public health specialists and officials from the Ministries of Health (MoH).

The WBTi method is designed to be participatory and local: it brings together a multi‐sectoral group of partners within each country, including both governmental and nongovernmental organizations (NGOs), to work together to identify gaps and make recommendations for action (IBFAN, 2019). While this brings more potential for bias than an assessment by an external agency, it also provides accountability and a deeper stake in implementing the recommendations. The sample of participants in our study echoed this multi‐sectoral approach, providing perspectives from different agencies and local actors.

All members of the research team had been involved in evaluating Global Strategy implementation in their own countries; hence, they had attended training sessions with other country WBTi Coordinators, leading to familiarity with the process and with each other, including some of the study participants.

Data collection

Data collection took place from July to August 2021, using email with a link to an online questionnaire (see Supporting Information) accessible only to invited participants. Participants were informed that the information provided would be published in a peer‐reviewed journal and were offered the option of responding anonymously, or having their names included in the Acknowledgments. To enhance the credibility of the findings, a final draft of the manuscript was sent to participants for a stakeholder check, and for consent to publish. Feedback, including clarification of some quotes, was incorporated into the final version.

An online survey format was chosen for ease, speed, and low cost (Ball, 2019). Follow‐up calls were made to reduce nonresponse errors (Ponto, 2015), but it was not possible to obtain detailed responses from all countries. In some cases, this was because the activity in question simply did not exist in that country; in other cases, it is likely that lack of fluency in English led to shorter responses. The questionnaire was in English, as are all the WBTi country reports. The potential of online surveys for sample bias was addressed by the purposive sampling method. The online survey was designed using the Standards for Reporting Qualitative Research guidelines (O'Brien et al., 2014), and aligned with the Checklist for Reporting Results of Internet E‐Surveys (Eysenbach, 2004). The three‐part questionnaire contained 33 questions of which 25 were open‐ended. The open‐ended questions focused on the specific historical, cultural and political settings that led to the country score. Part one explored changes in national IYCF policy and monitoring systems that occurred since the WBTi report was published. Part two explored the IYCF policy and monitoring processes that contributed to the country's score. Part three consisted of a SWOT analysis of the process used in developing and implementing an IYCF policy and monitoring system.

We used an iterative process to refine the survey questions, requiring several rounds of discussion among research team members before the final version was agreed upon. We submitted the questionnaire to academic colleagues with experience in qualitative research for comments and piloted the survey among a small group of WBTi coordinators for usability and technical functionality. Based on this feedback, we shortened the survey and clarified some questions. We strove to use clear, consistent, plain language given the fact that most participants were not native English speakers. Short follow‐up interviews were conducted via email or phone calls for credibility checks and to clarify responses as needed. The survey was created on Google Forms, and responses were automatically downloaded into a spreadsheet.

All eight members of the research team were WBTi Country Coordinators. WBTi Coordinators are content experts in IYCF and have insight into the multifactorial nature of IYCF policies, programs and practices. Throughout the data analysis process, research team members reflected upon and acknowledged potential personal biases in relation to the line of enquiry and their professional and personal experiences (Mitchell et al., 2018).

Data analysis

Qualitative data were analysed using Braun and Clarke's (2006) six‐phase guide to performing thematic analysis. First, we familiarized ourselves with the data by becoming immersed in the participants' responses, reading and rereading responses several times. Next, a general inductive method was used for the coding process, following the approach outlined by Thomas (2003).

These codes were then revised iteratively. First, they were discussed and refined by a small team of four, to create the list of common codes and definitions that became the code book. Next, themes were constructed using the codes as building blocks, to create coherent clusters of meaning (Table 3). The themes were further refined by the two researchers who are native English speakers.

Table 3

Data analysis structure and definitions

Themes	Definitions
The role of government support	Strong ongoing commitment to IYCF programs, with adequate funding
The role of National Breastfeeding Committee	Interdisciplinary National Breastfeeding (or IYCF) Committee coordinates multi‐sectoral action
The importance of M&E of IYCF programs and practices	M&E integrated into periodic national surveys, with results used to improve policy and programs
Compliance with the International Code	International Code implemented in national laws, with monitoring and enforcement of compliance, despite resistance by industry
Role of professional and volunteer breastfeeding supporters	Involvement of professional and lay breastfeeding supporters in policy development and programme implementation
UNICEF and the BFHI	Involvement of UNICEF in policy development and/or implementation of Baby‐friendly Initiative
Impact of culture on IYCF	Local practices, attitudes and media which impact IYCF

Abbreviations: BFHI, Baby‐friendly Hospital Initiative; IYCF, infant and young child feeding; M&E, monitoring & evaluation; UNICEF, United Nations International Children's Emergency Fund.

Thomas' (2003) methods were also used to increase trustworthiness: first, the response from each country was coded independently by two members of the research team, capturing evidence for codes with quotes from the text. The pair of researchers then met via video call to discuss and resolve discrepancies. Next, each country's original WBTi report (http://www.worldbreastfeedingtrends.org) was consulted for a triangulation check. Finally, the draft report was shared with the respondents for a stakeholder check, to strengthen the credibility of the findings.

Participants' responses to the SWOT questions on national policies and M&E systems were entered in a spreadsheet. A balanced selection of responses was chosen to reflect the most common SWOTs in participating countries (Chermack & Kasshanna, 2007).

Ethics

Institutional Review Board approval was obtained from the University of Split School of Medicine on 13th July 2021 (No. 2181‐198‐03‐04‐21‐0074). Data were anonymized and stored on a secure institutional server. Participants were offered the option of responding anonymously, thereby providing autonomy. All respondents were volunteers on their country's WBTi teams and were under no obligation to take part in our research (Varkey, 2021).

RESULTS

Characteristics of participants

Six WBTi country representatives were contacted and all six participated (100% response). Most involved other members of their WBTi national team, resulting in the following number of participants from each country: Croatia/n = 4, Germany/n = 2, Lithuania/n = 2, Spain/n = 4, Turkey/n = 5 and Ukraine/n = 2, resulting in a total of 19 participants contributing information to the questionnaire responses. Based on participant responses, major themes were created and are described below. Their definitions are shown in Table 3.

The role of government support

The importance of government commitment was a significant theme that ran through every response and was also reflected in the SWOT analysis (Tables 4 and 5). Government support for IYCF policy and programs ranged from strong to weak or nonexistent, with funding of programs as an indicator of the level of commitment.

Table 4

Policies and programs: Strengths, weaknesses, opportunities and threats

Strengths	Weaknesses
Multi‐sectoral collaboration ‘The coordination between all the provinces [sic] in the country’. (Spain) ‘Close collaboration of the NBC with UNICEF’. (Croatia)	Segmented and chaotic coordination ‘There is no National Breastfeeding Committee’ (Ukraine) ‘First of all, there is no IYCF policy, no set criteria to achieve certain goals, so, there is no plan of actions and all the work continues to be segmental and chaotic’. (Lithuania) ‘Lack of coordination from the Health Ministry’. (Spain)
Government plays an active role ‘There is a national [IYCF] policy… supported by government programs’. (Ukraine) ‘Government directed development, implementation and funding of our IYCF policy’. (Turkey)	IYCF seen as low priority ‘There is a widespread attitude that breastfeeding is nice to have but not really important, so little effort is put in protection, promotion and support of breastfeeding’. (Germany)
NGOs/volunteers spearhead IYCF programs ‘We have many committed volunteers organized in NGOs who work hard for progress and do cooperate’. (Germany) ‘The nongovernmental sector is active in strengthening the legal framework and changing practices’. (Lithuania)	International Code not integrated into legislation ‘Lack of a legal advisor within the NBC, i.e., an expert to assist with incorporating the Code and subsequent Resolutions into the legislature’. (Croatia)
Avoiding conflicts of interests ‘We have…competent and code‐compliant educational institutions’. (Germany) ‘Having dedicated, hard‐working, ambitious members of the NBC, knowledgeable about IYCF and without conflict of interests’. (Croatia)
Opportunities	Threats
Involvement in international networks sets standards and spurs progress	Lack of Code legislation/strong formula industry influence
‘Active involvement in the BFHI Network and the involvement of Croatia in the WBTi’ [led to success in producing and implementing an IYCF policy] (Croatia)	‘There is no national legislation [of the Code]… which creates conditions for its violation’ (Ukraine) ‘Too much influence of the industry … Competent people are not being paid nor put in key positions, industry‐influenced persons are put in key positions. Industrial influence in all institutions. No commitment, only profit commitment’. (Germany)
Prestigious awards encourage healthy competition
‘Baby‐Friendly and Mother‐Friendly certifications still remain very prestigious awards for our healthcare facilities’. (Turkey)
Involvement of IBCLCs improves the quality of policies and programs	Contradictory health professional recommendations
‘The inclusion of IBCLCs in the work of the NBC, and recognising their leading role in IYCF protection, promotion, support and education’. [contributed to success in producing and implementing an IYCF policy] (Croatia)	‘Some regional scientific reports on IYCF in recent years (ESPGHAN, EFSA)’ [undermine WHO recommendations] (Turkey)
Missed opportunities ‘After the first initiative to found an NBC, this was not followed up with strong political support’. (Germany) ‘The MOH prepared a draft Feeding programme with detailed objectives and actions to improve the situation for the new current Government. However, the approved Government's programme remained only very generalized’. (Lithuania)	Resistance to change ‘Resistance to change among healthcare professionals and health professional organizations’. (Turkey) Poorly supported breastfeeding champions/volunteers ‘No real support for midwives and IBCLCs’. (Germany)
	Changing governments/priorities ‘Lack of Consistency in Healthy Priorities with Changing Governments. Nutrition and the IYCF have never been priority areas for health…’. (Lithuania)

Abbreviations: BFHI, Baby‐friendly Hospital Initiative; EFSA, European Food Safety Authority; ESPGHAN, European Society for Paediatric Gastroenterology Hepatology and Nutrition; IBCLC, International Board Certified Lactation Consultant; IYCF, infant and young child feeding; MOH, Ministry of Health; NBC, National Breastfeeding Committee; NGO, nongovernmental organization; UNICEF, United Nations International Children's Emergency Fund; WBTi, World Breastfeeding Trend Initiative; WHO, World Health Organization.

Table 5

Monitoring and evaluation systems: Strengths, weaknesses, opportunities and threats

Strengths	Weaknesses
Active IYCF committees are essential ‘A functional NBC, that meets regularly and monitors breastfeeding programs’. (Croatia)	Without a national M&E system there are no incentives for data collection ‘No strategy, no planning, no criteria and targets to achieve’. (Lithuania) ‘We have not started any process to establish this process. Perhaps the greatest weakness is this difficulty in started it’. (Spain)
A national IYCF policy that mandates monitoring systems ‘Establishment of national strategic targets for breastfeeding and IYCF’. (Turkey) ‘Policy implementation is monitored at the state level. There is a state interest in quality implementation’. (Ukraine)	Data are only partially collected/evaluated ‘…only in healthcare facilities certified for compliance with the status BFHI or on a voluntary basis by NGOs’. (Ukraine) ‘…further quantitative and qualitative monitoring studies are needed by different institutions to obtain more in‐depth information’. (Turkey)
WHO/UNICEF standards and definitions strengthen the monitoring framework ‘Available WHO/UNICEF guidelines, standards and indicators facilitate the monitoring and evaluation’. (Turkey)	Data often inaccurate due to nonstandardized methods or inadequate training ‘Insufficient training in monitoring and evaluation among health professionals leads to inaccurate and non‐standardized data collection… plus IYCF practice indicators to be collected have not been agreed upon’. (Croatia)
NGOs play a key role ‘Over the decades there have always been dedicated persons in the NBC, at BFHI and at other places who persevered and kept bringing the subject up’. (Germany)

Abbreviations: BFHI, Baby‐friendly Hospital Initiative; IYCF, infant and young child feeding; M&E, monitoring and evaluation; NBC, National Breastfeeding Committee; NGO, nongovernmental organization; UNICEF, United Nations International Children's Emergency Fund; WHO, World Health Organization.

Multi‐sectoral involvement led to success

‘Stakeholder institutions such as universities, professional associations, National Evaluation Team members working voluntarily for IYCF monitoring and evaluation systems’. (Turkey)

IYCF M&E low on the government's priority list

‘The attitude of politicians and government and the absence of an issue on the list of priorities’. (Lithuania)

‘The State statistics do not cover all indicators recommended by WHO/UNICEF for the BFHI’. (Ukraine)

Missed opportunity—lack of involvement of media and the public

‘The media were not sufficiently involved; hence, the public were not informed of the process – they could have served as a quality‐check’. (Croatia)

Economic pressures and other priorities

‘There was no commercial advantage to reap from this process…’ (Germany)

Lack of staff for data collection

‘Chronic shortage of health workers, makes it difficult imposing data collection upon them’. (Croatia)

In higher scoring countries like Croatia, the government was ‘willing to establish an NBC; willing to adopt the NBP [National Breastfeeding Programme]; willing to fund NBP activities’. However, in all three low‐scoring countries, the lack of government commitment to IYCF was clear, from ‘no policy, no programme, no funding’ (Lithuania) to ‘lip service yes, but no measures that would make substantial changes’ (Germany). Meanwhile in Spain, ‘there are other priorities’ for the government. Continuous and long‐term government commitment led to strong and sustained policies; Croatia listed a series of government IYCF policies dating back to 2006.

The fragmented or weak government commitment was reflected in poor scores on policy. In Spain, policies were not formulated: ‘we have not started any process to establish this process. Perhaps the greatest weakness is this difficulty in started it [sic]’; whereas in Germany, they were not sustained: ‘after the first initiative to found an NBC, this was not followed up with strong political support’. Another cause of fragmented support was when the government itself was frequently changing and could not sustain a commitment to IYCF policies and programs: ‘there is no state systemic approach and strategic planning in this area. Often changing governments of different political orientations set different priorities’ (Lithuania). Even in Turkey, where government commitment to IYCF was strong, ‘bureaucratic hurdles’ could slow progress. Fragmented government support also led to lost opportunities: ‘the MoH prepared a draft Feeding programme with detailed objectives and actions to improve the situation for the new current Government. However, the approved Governments programme remained only very generalized’ (Lithuania; Table 4).

Adequate and sustained funding is perhaps the most tangible evidence of a government's commitment to IYCF policy and programs (Table 4). In all three of the highest scoring countries, central funding underlay the establishment of national policies and programs including M&E; in Croatia and Ukraine, the initial funding came from UNICEF. Some countries reported only partial funding, reflecting the government's lack of commitment to IYCF. ‘All these initiatives were barely funded … They surely had some impact, but remained ineffective with regard to public health, since they were prevented from spreading Germany‐wide by neither funding nor supporting them sufficiently’.

The role of NBCs

A key theme, repeated in the SWOT analysis (Tables 4 and 5), was the crucial role of national IYCF authorities, commonly called NBC, in producing policies and coordinating their implementation. Analysis of the data revealed the following attributes of productive NBCs: coordination, long‐term commitment and interdisciplinary/multi‐sectoral collaboration.

Coordination was reported as effective in both Turkey and Croatia. In Turkey, ‘our IYCF policies are put on the agenda at the Scientific Committee and NBC meetings, evaluated and revised through joint work then submitted to the approval of the Ministry officials. This process is often effective’. In Croatia, regular NBC meetings facilitated effective coordination. The response from Spain noted that the Ministry of Health did support the dissemination of best practices, including those in breastfeeding, but did not coordinate a national breastfeeding strategy or programme. Effective coordination could also be challenging where there were a ‘large number of health facilities and difficulties in their continuous supervision’ (Turkey). All top‐scoring countries had long‐standing NBCs. In Croatia, it was founded in 2007, and ‘the Coordinating Council of the Ministry of Health of Ukraine for the implementation of BFHI has been established and is operating on a permanent basis’.

Effective NBCs included strong interdisciplinary and multi‐sectoral collaboration; this was also emphasized in the SWOT analysis (Table 4). Participants reported that having ‘a multidisciplinary team of individuals representing mothers, midwives, community nurses, general practitioners, paediatricians, the MoH, UNICEF and IBCLCs, all actively involved in the protection, promotion and support of breastfeeding’ (Croatia) strengthened the work of the NBC. Involving government representatives, alongside IYCF experts, was key: ‘The ministry of health, ministries of education, researchers, hospitals, health workers were involved in the process. Their collaboration was efficient and productive’ (Ukraine); they were felt to be ‘able to coordinate action to inform policy and decision makers’. When this was lacking, the NBC was seen as ineffective. Collaboration with UNICEF was highlighted by several participants as being key to progress, with UNICEF often responsible for establishing IYCF programs (see Section 3.7). Regional collaboration was also highlighted as a strength in Spain (Table 4).

The importance of M&E of IYCF programs and practices

The responses on M&E showed great variation among the participants in both survey responses and the SWOT analysis (Table 5). In several countries, IYCF questions were not included in the national data collection system, and data on IYCF programs and practices were often incomplete or inconsistent. Interestingly, although Spain does not have a dedicated monitoring system for IYCF, they have proposed a potential new direction for M&E: ‘the prevalence of breastfeeding has been included as a selected indicator in the proposal of the working group for the surveillance of equity and social determinants of health that is currently being worked on’.

M&E is strongest in countries where IYCF practices are integrated into national and periodic health surveys. Ukraine was an example of an IYCF M&E system which is part of the national health information system, and the importance of the ‘state interest in quality implementation’ was mentioned in the SWOT analysis (Table 5). Even in low‐scoring Spain, some ‘questions specific on breastfeeding’ were included in their 5 yearly National Health Survey, which had the ‘positive value of being a robust monitoring source that allows to see trends and the impact in Spain of the strategies developed since 2008’.

In five countries, the collection of IYCF data was either incomplete or was not used to evaluate or improve services (Table 5). Lithuania only had ad hoc monitoring work, and ‘in practice, those data are not critically analysed, not used to plan improvements’ resulting in fragmented M&E systems. Germany's lack of monitoring system was attributed to the low priority placed on IYCF, and to conflicts of interests: ‘no monitoring system was established because no interest in breastfeeding protection and promotion, industry, lobbyism’. In contrast, the importance of evaluating data and using it to improve services was illustrated in Turkey: ‘the information/data on the implementation process of the IYCF programs is used by officials to make decisions in resource allocation and to lead planning’. Inconsistency in the use of WHO/UNICEF definitions and standards for monitoring was repeatedly raised as an issue (Table 5).

Compliance with the International Code

Gaps in the national legislation of the International Code were considered a major obstacle for the development and implementation of IYCF policies and programs by all respondents (Table 4). In Ukraine, there is no relevant legislation; consequently, the responsibility to comply with the International Code lies with each individual and institutional actor within healthcare services. In Turkey, the International Code is not fully enacted in the legislation and the surveillance system is ineffective; consequently, ‘the formula industry uses aggressive marketing methods and applies subtle methods (cross‐promotion, covert advertising and improper health claims, etc.) to bypass the already few regulation [sic]’. In the four countries belonging to the European Union (EU), the legislation is weak, reflecting gaps in EU regulation.

Violations of the International Code are reported in all countries, but monitoring of compliance is inadequate everywhere and is often delegated to NGOs (Table 5). Without direct government involvement, enforcement is unlikely to occur. ‘In many countries, industry undermines attempts to develop and implement IYCF policies’. In Lithuania, ‘the links between some health authorities and the baby food industry, including breastmilk substitutes, create an ambiguous situation [so] that [it] is not possible to formally oppose their authority and at the same time make appropriate changes’. Conflicts of interest are a widespread threat reported in all countries, contributing to delays and derailments in policy making, and undue influence in health professional education. In Germany, ‘conflicts of interests are one of the main reasons for the failure of policies and monitoring of breastfeeding’. Moreover, in Spain, the steps to prevent conflicts of interests have not even begun: ‘we don't work the subject of conflicts of interests because that is a second step. First, we need to get the national policy’.

Role of professional and volunteer breastfeeding supporters

All participants described the importance of having a competent, skilled and highly motivated breastfeeding support workforce, consisting of both professionals and volunteers. This committed workforce brings about change and drives improvement. In Lithuania, ‘the nongovernmental sector is active in strengthening the legal framework and changing practices’. Croatia highlights ‘the inclusion of IBCLCs in the work of the NBC, and recognizing their leading role in IYCF protection, promotion, support and education’ (Table 4), and notes that successful implementation of BFHI ‘was facilitated by a team of dedicated health professionals who had an interest in breastfeeding’. Breastfeeding champions appeared to have a great impact in several countries, while their efforts were less effective in others.

The voluntary workforce was considered a valuable component of successful IYCF programme implementation (Table 4). Reliance on a voluntary workforce brought both risks and benefits. On the one hand, highly motivated volunteers initiated and implemented IYCF activities: ‘field evaluation and follow‐up studies are realized by the National Evaluation Teams consisting of volunteer health workers’ (Turkey). On the other hand, relying on volunteers risked being unsustainable if unsupported by government: ‘for decades the committed volunteers' work was torpedoed and rendered ineffective by lobbyism of the industry, and lack of governmental support, political will and funding’ (Germany).

Several respondents reported an underutilised skilled breastfeeding workforce since ‘competent people are not being paid nor put in key positions’, while ‘industry influenced persons are put in key positions and there is no real support for midwives and IBCLCs’ (Germany; Table 4). Another obstacle to optimal breastfeeding support is ‘The heavy workload of healthcare professionals and the fact that infant feeding may not be a priority in daily practices’ (Turkey). In Lithuania, ‘a large part lacks the knowledge of staff and the general public’, indicating a need for training of staff to provide effective breastfeeding support.

The role of UNICEF and the BFHI

The role of UNICEF as a key driver in initiating, implementing and monitoring IYCF policies and programs, and the importance of the BFHI, are highlighted across the responses. In Croatia ‘The BFHI assessment programme was funded from the outset [from 1993] by the Office for UNICEF’. In Turkey, ‘WHO/UNICEF guidelines facilitate IYCF implementation’ and ‘In the first years of the programme, evaluation and follow‐up components were added to IYCF activities and programme in collaboration with the MoH and UNICEF’. In Ukraine, ‘great support’ was provided in setting up the initial national breastfeeding programme and BFHI. Support continued in the form of funding for conducting trainings, assessments and attending BFHI meetings, as well as providing expertise in producing teaching resources and promoting IYCF activities. Importantly, UNICEF also supported the development of a Ukrainian legislative initiative on the International Code. The BFHI framework and standards have been instrumental in transforming maternity services since 1991. Turkey reports that ‘Baby‐friendly and Mother‐friendly certifications still remain very prestigious awards for our healthcare facilities’ (Table 4). Croatia credits ‘active involvement in the BFHI Network for up‐to‐date information/research’. BFHI also contributes to basic monitoring and data collection in Spain, where ‘only the hospitals in the BFHI programme have a system of indicators and monitoring’. On the other hand, among low‐scoring countries, Germany reports that ‘BFHI was implemented on a voluntary basis only, by an NGO, without any official support. … BFHI in Germany was never integrated into national healthcare quality standards and has to fend for itself as an association’.

Impact of culture on IYCF

Cultural norms influence priorities and IYCF decisions throughout all of society, impacting everyone from parents to healthcare professionals to policymakers. Societal traditions are reflected in the importance of support offered by family members and society, as highlighted in Turkey: ‘our culture norm and family members support breastfeeding and IYCF’. In contrast, in Germany, there is ‘a sociocultural phenomenon: the high appreciation of technology and “progress,” in line with “mastering nature”; and the low appreciation of all care work, not only with respect to breastfeeding’, in particular women's work, due to ‘changing understanding of the roles of men and women’. Cultural norms also impacted medical practices: Turkey reports ‘high caesarean delivery rates’ which can be an obstacle to the initiation of breastfeeding.

DISCUSSION

In this qualitative study, key obstacles and enablers, along with strengths, weaknesses, opportunities and threats contributing to the implementation of strong national IYCF policies and monitoring systems were identified, both by inductive thematic and SWOT analysis. Strong government will is essential, leading to effective policy making and implementation, adequate funding and appropriate legislation protecting breastfeeding. Lack of government leadership was especially seen in countries with devolved or federal systems, or unstable governments, and opportunities were missed. Some countries received UNICEF funding and programme support to establish strong IYCF policies and programs after experiencing severe adversity. Cultural norms also had an impact on the prioritization of IYCF. The influence of the baby feeding industries proved to be a threat in all countries, delaying and undermining policy and programs and influencing health professional training in IYCF.

In 2013, the global lack of political prioritization of IYCF was highlighted in UNICEF's landscape analysis (UNICEF, 2013). This was echoed by Save the Children in their Breastfeeding: Policy matters report, which found that ‘political commitment is fundamental to improving breastfeeding practices’ (McFadden et al., 2015).

The Global Strategy calls upon governments to produce, and adequately fund, a national IYCF policy and programme, and this has been reiterated by the Global Breastfeeding Collective (2018). In practice, it is impossible to have strong national policies and programs without government commitment. Low‐ranking countries emphasized lack of government support and funding as the main obstacle. This was perceived to result from industry influence and changing government priorities. The threat posed by industry influence is well illustrated in Germany's own WBTi report (http://www.worldbreastfeedingtrends.org). The Global Strategy further specifies that the production and implementation of IYCF policies should be coordinated by a national IYCF authority that meets regularly and links effectively with relevant sectors. Top ranking countries had long‐standing, multidisciplinary NBC, free of conflicts of interest, run in close collaboration with the MoH and country UNICEF office. In some instances, strong policy and NBC were opportunities that sprang from adversities, including war (Croatia and Ukraine) (Grgurić et al., 2016), whereas in others they reflected cultural norms (Turkey).

The rationale for M&E of health programs is to measure effectiveness and efficiency and to plan improvements. A continuous system of monitoring or periodic surveys were identified both by SWOT and inductive thematic analysis as the strength of countries with high scores, identifying gaps, informing changes and justifying investments in IYCF programming. The use of WHO standards and definitions contributed to the quality of monitoring (WHO & UNICEF, 2021).

The low performance of all six countries on the International Code has already been reported (WHO, 2020b). Our study identifies this as a factor associated with inadequate and/or delayed IYCF policies and programs. To overcome this obstacle, two important factors should be addressed. First, for EU countries, the updating of the EU regulation to include all the provisions of the International Code and subsequent relevant resolutions, as urged and instructed by the WHA in 2016 (World Health Assembly, 2016). Second, the prevention and control of conflicts of interests that threaten policy setting and programme implementation, especially with regard to health professional education (Grummer‐Strawn et al., 2019). This would be part of a wider strategy aiming at reducing the influence of the transnational formula industry on public policies and programs (Baker et al., 2021). Finally, systematic monitoring of compliance with the International Code, and subsequent enforcement of legal measures, should be the responsibility of MoH.

The Global Strategy calls on governments to provide skilled breastfeeding support. The 2018 WHO Guideline: Counselling of Women to Improve Breastfeeding Practices aims to provide global, evidence‐informed recommendations on breastfeeding counselling, as a public health intervention (WHO, 2018). To support this, the WHO produced a new Competency Verification Toolkit to improve the skills of health workers (WHO, 2020a). In addition, WHO has produced a model medical textbook chapter on breastfeeding, which is currently under revision (WHO, 2009). The European Commission's Blueprint for Action recommends that relevant health workers acquire the IBCLC certification, shown to meet best practice criteria for competence in providing skilled breastfeeding support (Cattaneo, 2005). Meta‐analyses have shown that interventions at every level are the most effective way to structure breastfeeding support services and improve outcomes (Sinha et al., 2015). Integrated care coordinates support networks, in maternity services and at the community level, including peer support groups and access to skilled and specialist lactation support (Rosin & Zakarija‐Grković, 2016). Healthcare systems would benefit from employing certified lactation consultants and should refer mothers and families to both professional and skilled voluntary support providers. A Cochrane systematic review provided evidence for the vital role of both voluntary and professional breastfeeding counsellors in providing effective breastfeeding support (McFadden et al., 2017). Breastfeeding support in the community has often been based on the work of volunteers (e.g., La Leche League), IBCLCs and others, in many cases unsupported by governments. Government support for the existing breastfeeding workforce is needed everywhere, to better enable mothers to breastfeed.

Cultural traditions and medical practices can influence family decisions to breastfeed and impact the rates of breastfeeding, as well as decisions at the policy level. Research has shown that where breastfeeding is the cultural norm, mothers are more likely to decide to breastfeed (Bień et al., 2016), and policymakers consider breastfeeding a national priority, as demonstrated in Turkey. Cultural norms also influence healthcare practices. According to WHO, Caesarean sections should be based on medical indications, but Gedefaw et al. (2020) found that in some countries it has become the norm. Training of healthcare professionals on managing birth interventions is often insufficient (Radzyminski & Callister, 2015). Birth practices have been found to affect breastfeeding (Pilla & Kitsantas, 2017). More education of health professionals on the impact of birth practices on breastfeeding is needed.

Limitations

The questionnaire and responses were all in English, but this was not the native language of the respondents or of most of the researchers. These factors meant that there may have been gaps in the collection and interpretation of data. Time and funding constraints limited the possible types of data collection. The fact that both researchers and respondents were WBTi coordinators gave the researchers a deeper understanding of the context of responses, but also introduced potential bias, which was managed by ensuring that every step of the analysis process involved multiple researchers.

CONCLUSIONS

Our study identified several key obstacles and enablers to the establishment and implementation of strong IYCF policies and monitoring systems, but further research would be valuable to determine how exactly the process could be more successful on a wider basis. Government commitment, funding, and protection of optimal IYCF are essential to the implementation of national policies and M&E systems. In some countries, UNICEF played a pivotal role in establishing national IYCF leadership, and the BFHI was an important intervention everywhere. The ubiquitous influence of the formula industry hinders strong policies, high‐quality health professional training, and investment in durable programs.

AUTHOR CONTRIBUTIONS

All authors contributed to the design of the research study, performed the research and analysed the data. Each author contributed to the writing of the paper and all authors have read and approved the final manuscript.

CONFLICTS OF INTEREST

All authors are WBTi country coordinators. In addition, I. Z. G. and S. R. were study participants.

Supplementary information.

Click here for additional data file.