Led by Yale School of Public Health Professor Rafael Pérez-Escamilla, Becoming Breastfeeding Friendly (BBF): A Guide to Global Scale-Up was created to increase breastfeeding rates around the world. The Family Larsson-Rosenquist Foundation contributed over USD 2 million to support the programme.

The BBF process was pre-tested in Mexico and Ghana in 2015 and has since been implemented again in these two countries and in six additional countries: England, Scotland, Wales, Germany, Myanmar and Samoa. BBF is expected to continue expanding to other countries, such as China and Mozambique.

“The human race exists in large measure because of breastfeeding. What could be more important than that?” – Rafael Pérez-Escamilla, PhD, Professor of Public Health, Yale School of Public Health; Director, Becoming Breastfeeding Friendly; Director, Office of Public Health Practice; Director, Global Health Concentration

Professor Pérez-Escamilla’s core team at the Yale School of Public Health has included:
• Amber J. Hromi-Fiedler, PhD, MHP (BBF co-Director)
• Cara Brooks Safon
• Gabriela Buccini, PhD, MPH
• Grace Jane Carroll, MPH
• Kassandra Harding
• Katie Doucet

As the name suggests, BBF is a process that helps countries make sustainable improvements to their breastfeeding outcomes based on the Breastfeeding Gear Model developed by Professor Pérez-Escamilla’s team. First, participating countries are invited to assess eight simultaneous key components, called gears:

• Advocacy
• Political Will
• Legislation and Policies
• Funding and Resources
• Training and Program Delivery
• Promotion
• Research and Evaluation
• Coordination, Goals and Monitoring

The gears are measured with 54 corresponding benchmarks – which can provide valuable data for identifying specific gaps where action is needed – and then scored. The individual gear scores show the strength of a country’s current environment for scaling up breastfeeding protection, promotion and support programmes and initiatives. The eight gear scores are then used to calculate a BBF Total Score: the strength of a country’s current national enabling environment as a whole to scale up breastfeeding programmes and initiatives.

The BBF assessment takes approximately nine months to one year to complete. Detailed how-to recommendations and case studies with best practices from numerous countries, across multiple sectors, are available to help countries conduct their assessments.

Once complete, countries can draw on a suite of BBF evidence-based support tools – from how to develop communications materials to methods of conducting qualitative interviews – to help them achieve their breastfeeding objectives.

Further reading

Siregar AYM, Pitriyan P, Hardiawan D, Zambrano P, Vilar-Compte M, Belismelis GMT, et al. The yearly financing need of providing paid maternity leave in the informal sector in Indonesia. Int Breastfeed J. 2021;16(1):17. DOI: 10.1186/s13006-021-00363-7

Ulep VG, Zambrano P, Datu-Sanguyo J, Vilar-Compte M, Belismelis GMT, Pérez-Escamilla R, et al. The financing need for expanding paid maternity leave to support breastfeeding in the informal sector in the Philippines. Matern Child Nutr. 2021;17(2):e13098. DOI: 10.1111/mcn.13098

Soti-Ulberg C, Hromi-Fiedler A, Hawley NL, Naseri T, Manuele-Magele A, Ah-Ching J, et al. Scaling up breastfeeding policy and programs in Samoa: application of the Becoming Breastfeeding Friendly initiative. Int Breastfeed J. 2020;15(1):1. DOI: 10.1186/s13006-019-0245-6

Pérez-Escamilla R. Breastfeeding in the 21st century: How we can make it work. Soc Sci Med. 2020;244(112331):112331. DOI: 10.1016/j.socscimed.2019.05.036

Aryeetey R, Harding K, Hromi-Fiedler A, Pérez-Escamilla R. Analysis of stakeholder networks for breastfeeding policies and programs in Ghana. Int Breastfeed J. 2020;15(1):74. DOI: 10.1186/s13006-020-00311-x

Vilar-Compte M, Teruel GM, Flores-Peregrina D, Carroll GJ, Buccini GS, Perez-Escamilla R. Costs of maternity leave to support breastfeeding; Brazil, Ghana and Mexico. Bull World Health Organ. 2020;98(6):382–93. DOI: 10.2471/BLT.19.22989

Than MK, Nyi SN, Hlaing LM, Mar SL, Thwin T, Cashin J, et al. Scaling up breastfeeding in Myanmar through the Becoming Breastfeeding Friendly Initiative. Curr Dev Nutr. 2019;3(8):nzz078. DOI: 10.1093/cdn/nzz078

Carroll G, Atuobi-Yeboah A, Hromi-Fiedler A, Aryeetey R, Safon C, Pérez-Escamilla R. Factors influencing the implementation of the Becoming Breastfeeding Friendly initiative in Ghana. Matern Child Nutr. 2019;15(3):e12787. DOI: 10.1111/mcn.12787

Buccini G, Harding KL, Hromi-Fiedler A, Pérez-Escamilla R. How does “Becoming Breastfeeding Friendly” work? A Programme Impact Pathways Analysis. Matern Child Nutr. 2019;15(3):e12766. DOI: 10.1111/mcn.12766

Hromi-Fiedler AJ, Dos Santos Buccini G, Gubert MB, Doucet K, Pérez-Escamilla R. Development and pretesting of “Becoming Breastfeeding Friendly”: Empowering governments for global scaling up of breastfeeding programmes. Matern Child Nutr. 2019;15(1):e12659. DOI: 10.1111/mcn.12659

Vilar-Compte M, Teruel G, Flores D, Carroll GJ, Buccini GS, Pérez-Escamilla R. Costing a maternity leave cash transfer to support breastfeeding among informally employed Mexican women. Food Nutr Bull. 2019 Jun;40(2):171-181. DOI: 10.1177/0379572119836582. Epub 2019 Apr 29.

Carroll GJ, Buccini GS, Pérez-Escamilla R. Perspective: What will it cost to scale-up breastfeeding programs? A comparison of current global costing methodologies. Adv Nutr. 2018 Sep 1;9(5):572-580. DOI: 10.1093/advances/nmy041.

Safon C, Buccini G, Ferré I, de Cosío TG, Pérez-Escamilla R. Can “Becoming Breastfeeding Friendly” impact breastfeeding protection, promotion, and support in Mexico? A qualitative study. Food Nutr Bull. 2018 Sep;39(3):393-405. DOI: 10.1177/0379572118789772. Epub 2018 Aug 15.

Flothkötter M, Kunath J, Lücke S, Reiss K, Menzel J, Weikert C. Becoming breastfeeding friendly in Germany – an international research project to assess the readiness to scale up breastfeeding. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2018 Aug;61(8):1012-1021. DOI: 10.1007/s00103-018-2784-1.

Aryeetey R, Hromi-Fiedler A, Adu-Afarwuah S, Amoaful E, Ampah G, Gatiba M et al. Ghana Becoming Breastfeeding Friendly Committee. Pérez-Escamilla R, Hromi-Fiedler AJ, Gubert MB, Doucet K, Meyers S, Dos Santos Buccini G. Becoming Breastfeeding Friendly Index: Development and application for scaling-up breastfeeding programmes globally. Matern Child Nutr. 2018 Jul;14(3):e12596. DOI: 10.1111/mcn.12596. Epub 2018 Feb 22.

Pilot testing of the Becoming Breastfeeding Friendly toolbox in Ghana. Int Breastfeed J. 2018 Jul 11;13:30. DOI: 10.1186/s13006-018-0172-y. eCollection 2018.

González de Cosío T, Ferré I, Mazariegos M, Pérez-Escamilla R; BBF Mexico Committee. Scaling up breastfeeding programs in Mexico: Lessons learned from the “Becoming Breastfeeding Friendly” initiative. Curr Dev Nutr. 2018 Apr 25;2(6):nzy018. DOI: 10.1093/cdn/nzy018. eCollection 2018 Jun.

Pérez-Escamilla R, Curry L, Minhas D, Taylor L, Bradley E. Scaling up of breastfeeding promotion programs in low- and middle-income countries: the “breastfeeding gear” model. Adv Nutr. 2012 Nov 1;3(6):790-800. DOI: 10.3945/an.112.002873. Epub 2018 Feb 22.