TABLE 5.

Illustration of progress regarding the gears in the context of the SWBO initiative

Gears	Examples
Advocacy	In Sierra Leone, the initiative has strengthened BF advocacy efforts by engaging diverse groups of actors in a wide range of activities. High-level decision-makers participated in major events such as 1) the national stakeholder consultative meeting of SWBO stakeholders and 2) the ceremony to recognize nutrition champions appointed to use their voices and networks to raise awareness about the importance of EBF. Parliamentarians, already engaged in the past, took a more active role for the Code. In DRC, it was the first time that the First Lady was mobilized in favor of nutrition. During the 2021 WBW, after receiving the title of “Ambassador for the fight against malnutrition”, she launched the SWBO initiative. Later, messages featuring her were also broadcast on 4 channels over 2 mo for the awareness campaign.
Political will	In Senegal, the Minister of Health and Social Action was the signatory of 1) the National Strategy as well as 2) a letter sent to the 14 regions to encourage them to develop their regional operational plans. In Burkina Faso, during the implementation process of the initiative, a new Minister of Health was appointed. An advocacy meeting was scheduled to brief him on the initiative and on the development of the National Strategy. He pledged to follow in the footsteps of his predecessor and his subsequent presence at several events related to the initiative demonstrated his commitment.
Legislation and policies	In DRC, the initiative reactivated the work on the Code. The latter had been formalized in 2006 in the form of an order signed by the Minister of Health. However, its implementation had lagged behind and it was still unknown within the Government and among the many health partners. The approach taken to resume the work on the Code was to organize awareness sessions on the Congolese Code. In Sierra Leone, the initiative has built on the longstanding work around the Code that led to the enactment of the Breastmilk Substitute (BMS) Act in July 2021 and its signing by the President in August 2021. Close engagement with parliamentarians and technical legislative support (UNICEF and WHO) were particularly helpful in achieving enactment of the BMS law. The SWBO initiative provided a real momentum to this work.
Funding and resources	In Burkina Faso, the PRSS, a government program funded by the Global Financing Facility through the World Bank, represented an opportunity for the Ministry of Health to fund the SWBO initiative. Over time and with support from A&T and UNICEF, the DN worked to successfully mobilize the necessary funds. In Chad, the initiative allowed to redirect funding to carry out activities related to BF. In a country context characterized with a high prevalence of emergency situations, donors prioritize emergencies and the management of undernutrition to the detriment of prevention activities. Hence, although BF is part of the Infant and Young Child Feeding in emergencies (IYCF-E), it is not always a priority. Thus, by strengthening BF activities in other existing maternal and child health care programs and helping to scale up IYCF activities, this has helped to mobilize additional funds for BF.
Training and program delivery	In Chad, by 2020, a toolbox with visual teaching aids had been produced in collaboration with the Directorate of Nutrition and Food Technology to support child health outreach and was made available to various partners for their fieldwork. The toolbox was revised in 2021 and, as part of the SWBO initiative, 2 key messages were added to emphasize IYCF, EBF ≤6 mo and complementary foods from 6 mo. The content of this toolbox was used in health centers to conduct awareness sessions with health personnel (doctors, nurses, midwives, and technical health workers) to reinforce the implementation of the BFHI and the awareness raising about the Code. In Burkina Faso, at the time of the assessment, a cascade training was planned (from the central to the community level) and a pilot phase had started. A scaling-up phase was then planned in the rest of the health districts.
Breastfeeding promotion	In Chad, substantial effort was invested in a mass media campaign (television, community radio, and large posters) to raise awareness among the population. Two cell phone companies also committed to broadcasting free awareness messages to their subscribers, reaching nearly 5 million subscribers. - In DRC, a second launch of the "SWBO promotion campaign" was done in 2021. It culminated in the posting of large publicity boards in 4 strategic locations in Kinshasa for 2 mo, reaching a large pool of people. This was accompanied by a full media launch where journalists and reporters from different communication platforms (radio, television, print and online) were also informed and mobilized to convey messages in favor of EBF.
Research and evaluation	In Burkina Faso, IYCF indicators were integrated into the health information system to track or monitor progress of interventions (e.g., information on BF counseling into routine and supervisory data), and questions were also integrated into the national nutrition survey to track women’s exposure to the SWBO messages. In DRC, the technical committee responsible for the implementation of the SWBO initiative was planning to set up a mechanism to monitor violations of the Code using the Kobo Collect application. Country actors had already started discussing forms for recording Code violations.
Coordination, goals, and monitoring	In Senegal, the initiative revitalized the IYCF committee and brought together many stakeholders. This committee had been created in the years 2013–2014, and its actions had been somewhat scattered; however, the initiative allowed the work to be done in unison and thus favored the coordination of the actions of the different partners. In DRC, work on IYCF was already a priority, but the country remained plagued by numerous emergencies, including armed conflict with displaced populations and Ebola outbreaks. Nutrition actors at the national level were therefore frequently called upon for these emergencies, making it more difficult to develop plans and strategies. In such a context, the SWBO initiative provided an enabling space for the development of a budgeted operational plan for EBF and complementary feeding, as well as a useful support, which helped them to coordinate their efforts.

Abbreviations: A&T, Alive & Thrive; BF, breastfeeding; BFHI, Baby-Friendly Hospital Initiative; BMS, breastmilk substitute; DN, Directorate of Nutrition; DRC, Democratic Republic of the Congo; EBF, exclusive breastfeeding; IYCF, Infant and Young Child Feeding; IYCF-E, Infant and Young Child Feeding in emergencies; PRSS, Projet de renforcement des services de santé; SWBO, Stronger With Breastmilk Only; WBW, World Breastfeeding Week.