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. 2019 Jan 29;15(3):e12766. doi: 10.1111/mcn.12766

Table 2.

Process evaluation of “real‐world” pretesting of BBF implementation in Ghana and Mexico, 2016

Country context prior to BBF Ghana Mexico
Country environment a , b , c , d
Economic and region Low‐middle income country located in West Africa. Upper‐middle income country located in Latin America and Caribbean region.
Political system Ghana is a unitary republic with an executive presidency and a multiparty political system. Administratively, Ghana is divided into 10 regions with 216 districts. Each region has a regional coordinating council headed by a regional minister appointed by the president who coordinates the activities of districts under their jurisdiction. The United Mexican States are a federation whose government is representative, democratic and republican based on a presidential system. The constitution establishes three levels of government: The federal union, the state governments and the municipal governments.
Health system structure Ghana has a universal health‐care system strictly designated for Ghanaian nationals, National Health Insurance Scheme (NHIS). All Ghanaian citizens have the right to access primary health care. State‐funded institutions such as Mexican Social Security Institute (IMSS) and the Institute for Social Security and Services for State Workers (ISSSTE) play a major role in health and social security. Private health services are also very important and account for 13% of all medical units in the country.
Demographic As of 2016, Ghana had a population of 28,206,728 with approximately 460,000 births per year. As of 2015, Mexico had a population of 119,938,473 with 2,293,708 births per year.
Infant mortality Infant mortality prevalence under 5 years is 58.8 deaths/1,000 live births. Infant mortality prevalence under 5 years is 14.6 deaths/1,000 live births.
Enabling environment for breastfeeding (BF) e
Exclusive breastfeeding (EBF) rates From 2008 to 2014 EBF rates declined from 63% to 52%. From 2006 to 2012 EBF rates declined from 22.3% to 14.4% especially in rural areas (36.9% to 18.5%).
Amount of donor funding for BF $2 was allocated per child by donor funding in 2013. $0 was allocated per child by donor funding in 2013.
Status of ten steps of BF No official data on % of births occur in baby friendly hospitals and maternities. 3.5% of births occur in baby friendly hospitals and maternities.
Status of code implementation in legislation Full provisions in law: Countries have enacted legislation or adopted regulations, decrees or other legally binding measures encompassing all or nearly all provisions of the code and subsequent WHA resolutions. Many provisions in law: Countries have enacted legislation or adopted regulations, decrees or other legally binding measures encompassing many provisions of the code and subsequent WHA resolutions.
Status of paid maternity leave Legislation mandates 12 weeks of maternity leave with 100% of previous earnings paid for by employer funds. Legislation mandates 12 weeks of maternity leave with 100% of previous earnings paid for by social funds.
Percent of primary health‐care facilities offering individual IYCF counselling 100% of primary health‐care facilities offer individual IYCF counselling. No data available of proportion of primary health‐care facilities that offer individual IYCF counselling.
Percent of districts offering community BF programmes 100% of districts implement community‐based nutrition, health, or other programmes with IYCF counselling. No data available on districts implementing community‐based nutrition, health, or other programmes with IYCF counselling.
PIP components for implementing BBF f
Country's commitment
Process of commitment to BBF Director introduced BBF to Ghana Health Services through multiple meetings. Both partnered to select BBF committee members. Director was historically engaged with multiple BF activities within the country. The director introduced BBF to the National BF Forum (a group of key stakeholders including other academics, civil society and government) who supported the implementation of BBF.
Time to initiate first meeting (months) 11 months 10 months
Country director and coordination team
Sector of the director profile and number of hours per week devoted to BBF Director is from academia and has devoted approximately 12‐hours per week to implement BBF. Director is from academia and devoted approximately 2‐hours per week to implement BBF.
Motivation to engage on BBF Member of technical advisory group of BBFI development Member of technical advisory group of BBFI development
Paid human resources involved in implementing BBFg A research assistant devoted 30 hours per week and an administrative assistant dedicated 5 hours per week. A project coordinator devoted 40 hours per week and a research assistant dedicated 40 hours per week.
Committee selection
Composition of committee 12‐member (three academics, six government, and three international organizations such as UNICEF, USAID, and WHO) 11‐member (two academics, two academics advisors to government, three government, three civil society, and one international organization, i.e., Save the Children)
Starting conditions Consultation with the Ghana health service under the leadership of the University of Ghana. Consultation with BF experts in Mexico under the leadership of the Universidad Iberoamericana.
Committee formed and trained
Training Training on BBF scoring process at first meeting by director. Training on BBF scoring process at first meeting by director, coordinator and BBF staff as technical assistance.
Technical assistance to BBF director
Provider of technical assistance Senior researcher involved in developing BBF programme followed up the whole implementation with two sites visits, real‐time guidance, providing tools and templates and a technical manual. Senior researcher involved in developing BBF programme followed up the whole implementation with two sites visits, real‐time guidance, providing tools and templates and a technical manual.
Case studies
Usefulness of case‐studies Not fully used by committee members Not fully used by committee members
Informing decision makers throughout BBF process
Strategies used to engage stakeholders Consultation visits to key decision makers (UNICEF: country director; WHO: country representative; Ghana Health Service: director of family health) Face to face meetings were conducted by the coordination team with key stakeholders (UNICEF: country director)
Complete five‐meeting process
Time to complete (months) May 2016 to February 2017 June 2016 to April 2017
BBFI
BBF Total score Moderate‐to‐strong environment for scaling up BF programmes (2.0 out of a maximum of 3.0). Weak‐to‐moderate environment for scaling up BF programmes (1.4 out of a maximum of 3.0).
Informed and prioritized recommendations
Prioritization of BBF recommendations Director led the prioritization process with the input from the committee, reaching consensus on recommendations via email between the fourth and fifth meeting Mexico committee reached face‐to‐face consensus at the fourth meeting on priorities recommendations
Key recommendations

1. Strengthen advocacy by enlisting more BF champions (high level and visible individuals); engage with existing champions and build their capacity

2. Ratify and adopt provisions of ILO Maternity Protection Convention, 2000, No. 183

3. Harmonize, strengthen, and monitor preservice and in‐service training of health staff and volunteers providing BF services

4. Scale up dissemination of accurate information on BF practice using multiple channels of communication at all levels

1. Motivate decision‐makers to develop effective breast‐ feeding programmes and policies through civil society advocacy

2. Advocate with high‐level public officials to keep BF in public agenda

3. Use regulatory instruments to limit risk to breast‐ feeding protection, promotion and support

4. Identify and support financial and human resources train on BF protection, promotion, and support, and research, monitoring and evaluation

5. Implement BF policies and actions via trained personnel

6. Reach entire population including women employed in informal economy

7. Implement comprehensive surveys and health‐care information systems

8. Develop strategy for implementing the national policy on BF
Dissemination of recommendation
Strategies used to disseminate BBF recommendations Ghana held a fifth and sixth meetings for disseminating the key recommendations, one with a technical staff and another with high level decision makers. In both meetings, there was strong media coverage. Specific materials were produced for dissemination (e.g., policy briefs, infographic) Mexico held a fifth call to action with strong involvement from civil society and media coverage. Specific materials were produced for dissemination (e.g., policy briefs, infographic)
Committee builds partnerships and develops collective agenda and ideas
Examples of activities emerging after BBF A social media campaign prototype was subsequently developed in response to recommendations. Messages were developed and translated into visual format with input from the BBF committee. The materials informed the development of Breastfeed4Ghana, a social media campaign in Ghana aimed to strengthen breastfeeding support through advocacy, harness support for maternity protection laws, and implement more effective dissemination of accurate actionable information about breastfeeding across Ghana through cost‐effective and innovate social media platforms. In response to a major earthquakes in Mexico of September 2017, the BBF committee members lead a task force to promote, protect and support breastfeeding. Multiple coordinated activities were developed including advocacy against formula donation, and free support from lactation consultants through WhatsApp. Evaluation of these activities was conducted to inform the development of an action plan to protect breastfeeding in future emergency situations.

Data sources:

b

Ghana Statistical Services. Available at: http://www.statsghana.gov.gh/pop_stats.html

c

Mexico National Institute of Geography and Demography. Available at: http://en.www.inegi.org.mx/

d

Global Health Observatory data. Infant Mortality. Available at: http://www.who.int/gho/child_health/mortality/neonatal_infant_text/en/

f

BBF documentation.

g

The hours per week devoted are an estimation based on the report from BBF Director in Ghana and BBF project coordinator in Mexico.