"Stronger With Breastmilk Only" Initiative: Evaluation in Four Countries in West and Central Africa and at Regional Level

"Advances on policy and programmatic environment for breastfeeding have been achieved and the work needs to continue towards the implementation of the SWBO Initiative!"

In November 2019, a regional initiative called Stronger with Breastmilk Only (SWBO) was launched to support countries in West and Central Africa to strengthen, promote, and support exclusive breastfeeding (EBF)and achieve the World Health Assembly target of 50%. Conducted by the Society for Implementation Science in Nutrition (SISN), this evaluation examined how the initiative was set up and/or implemented and how it contributed to strengthening the policy and programmatic environment for breastfeeding in 4 countries: the Democratic Republic of Congo (DRC), Senegal, Sierra Leone, and Chad.

Developed by the United Nations Children's Fund (UNICEF), Alive & Thrive (A&T), and the World Health Organization (WHO), SWBO (detailed at Related Summaries, below) encourages the development of evidence-based social and behaviour change communication (SBCC) campaigns and strategic policy advocacy to promote the provision of breastmilk only - without water, other liquids, or foods - to infants during the first 6 months of life. It also encourages countries to strengthen their health system for optimal breastfeeding counseling during antenatal care, postnatal care, and other well-child visits. Governments and partners were invited to adapt the initiative to their national context and integrate it into existing nutrition programmes and platforms to facilitate scaling up and sustainability. A regional team developed numerous resources and tools to assist them in this task.

In 2022, SISN partnered with A&T and UNICEF to carry out an evaluation approach called Outcome Harvesting, which involves identifying changes and then looking back to determine if and how a project or an intervention contributed to those changes. They applied the Breastfeeding Gear Model (BFGM) as an analytical lens to provide insight into countries' advances in relation to the policy and programmatic environment for breastfeeding. They also examined the support for country actors provided by at the regional level - e.g., a blended learning programme on SBCC provided by the regional team to strengthen the capacity and work of countries - to identify what had most helped actors.

Published by SISN, the final report presents a series of case studies summarising the results of this evaluation. With the support of the regional team, which took different forms, the 4 participating countries made significant progress in the setting up of the initiative. SWBO has generally helped to reinvigorate or galvanise country efforts around EBF, and several notable advances in the policy and programmatic environment around breastfeeding have been observed in each country. For example:

• In DRC, the First Lady was mobilised in favour of nutrition. During World Breastfeeding Week 2021, and after receiving the title of "ambassador for the fight against malnutrition", the First Lady launched the SWBO initiative. She also recorded messages that were broadcast on four channels over two months for the awareness campaign.
• In Senegal, SWBO has revitalised the infant and young child feeding (IYCF) committee and brought together many stakeholders.
• In Sierra Leone, high-level decision-makers participated in major events such as the National Stakeholder Consultative Meeting of SWBO Stakeholders and a ceremony to recognise nutrition champions. Parliamentarians, already involved in the past, took a more active role, and religious networks were engaged in discussions to integrate breastfeeding promotion messages into their religious activities. The media has been involved in participating in and covering major events. Communities were engaged by mobilising community leaders and groups, such as mother and father support groups, to promote and protect EBF.
• In Chad, SWBO has allowed revisiting and galvanising work on the Code of Marketing of Breastmilk Substitutes (the Code).

The evaluation notes that although several laws or policies, national strategies, or budgeted operational plans were developed, validated, and approved, there is a danger of assuming that their existence will necessarily lead to their implementation. As many of them now find themselves in the implementation phase of the initiative, they look forward to continued support from the regional team to maintain their momentum. However, the evaluation also found that it is not necessary to have a large, locally based team available on a consistent basis to be able to support country teams in their efforts. The UNICEF and WHO teams that remain on the ground in those countries can play a significant role in continuing to catalyse these efforts in the region, which is essential considering the aggressiveness of the marketing by the breastmilk substitute (BMS) industry.

Top takeaways include:

1. The SWBO initiative has allowed countries to "re-invigorate" the EBF work by giving it a fresh touch.
2. The countries embarked on SWBO's journey with great enthusiasm and appreciated it.
3. As a whole, the SWBO initiative has taken several steps toward strengthening the programmatic and policy environment for breastfeeding in the region.
4. SWBO has made some policy progress, particularly with respect to the Code, but work on maternity leave has been limited.
5. The commitment to the initiative and the work for its setting up is considerable, but there is still work to be done.

In conclusion: "Maintaining momentum and keeping breastfeeding and IYCF at the agenda is therefore crucial for the continuation of the work undertaken." About 20 other countries in the region have committed to carry out the SWBO initiative in their context.

Click here for the 24-page report in PDF format in French.