Developing a National Report Card on Breastfeeding

This Activity Sheet is a special issue produced by Andrew Chetley,
project consultant, in conjunction with the launch of Phase II of
the Global Participatory Action Research Project (GLOPAR) this
July 1995. (See back page for description of GLOPAR Project.)

41-50 marks Excellent
36-40 marks Very Good
31-35 marks Good
26-30 marks Average
21-25 marks Poor
16-20 marks Bad
11-15 marks Very Bad
0 -10 marks Terrible

A National Report Card can be a powerful tool to draw attention to the state of breastfeeding in any country. It can provide a very visual and easy to understand summary that should help to stimulate a campaign for action.

There are five key indicators that can be used in every country to
develop such a Report Card.

These are:

1. the exclusive breastfeeding rate;and the four targets set by the
Innocenti Declaration;
2. a national breastfeeding committee and coordinator;
3. all maternity facilities implementing all Ten Steps to Successful Breastfeeding;
4. action to implement the International Code of Marketing of Breastmilk Substitutes; and
5. appropriate legislation to provide adequate maternity leave for breastfeeding mothers.

Each of these can be given a score out of 10, as indicated in the
detailed explanations below, and the country can then be rated
according to its performance on breastfeeding. The scale for ranking
a country is as follows:

With each of the sections on the report card, you should fill in the
appropriate information in a single, powerful sentence and then add
some additional information which helps to explain the context of the
remark, or indicates what the appropriate standard should be. Additional
information can also be included as a note. (See the example: Report
Card for India).

You should put all the five statements on one side of the sheet, with
ideas for action, how to get involved, your organisation's address and
the notes on the reverse side.

Question 1: How long are babies exclusively breastfed?
The statement to answer this question should refer to a study carried
out in the country within the past five years. Ideally, it should be a
national study, although this may not always be possible. If it is a
recent study of a reasonable size, you can still use the results, and
include a note that it is based on one region, one city, one hospital,
or whatever.

Getting data on exclusive breastfeeding is not easy. To be exclusive,
no other food or liquid, not even water, should be given. Researchers
sometimes do not specify if they mean exclusive breastfeeding when they talk about the breastfeeding rate in a country. Nevertheless, if you
can get an exclusive breastfeeding statistic, you can score it
according to the following scale:

Marks for Exclusive Breastfeeding according to % of babies breastfed and age of babies

% 6 5 4 3 2 1
100 10 8 7 5 3 2
90 9 7 6 5 3 2
80 8 7 5 4 2 1
70 7 6 5 4 2 1
60 6 5 4 3 2 1
50 5 4 3 3 2 1
40 4 3 3 2 1 1
30 3 2 2 2 1 1
20 2 2 1 1 1 1
10 1 1 1 1 1 1
0 0 0 0 0 0 0

So, if the study shows that 50% of babies of 4 months of age are
exclusively breastfed, the mark is 3; if 100% are exclusively breastfed
at 3 months, the mark is 5.

In the additional information you include with the statement answering
the question, you should include the justification for looking at
exclusive breastfeeding, which is:

The World Health Organization (WHO) recommends exclusive breastfeeding for all children until about 6 months of age.(1)

Give the reference for this statement in the Notes. You can also put
additional information in the Notes about the factors that could be
obstacles to exclusive breastfeeding in your country, such as: there is
more exclusive breastfeeding in rural areas; the education level of
mothers is a factor in how long babies are exclusively breastfed; new
commercial promotion of infant drinks is interfering with exclusive
breastfeeding, and so on.

Question 2: Is there a national breastfeeding policy and a national
committee and coordinator to encourage its implementation?

This is a set of simple yes/no questions. The scoring for them is very
easy:

Is there a national policy? Yes = 3; No = 0
Is there a national coordinator?
Yes = 2; No = 0
Is there a national committee?
Yes = 3; No = 0
Does the committee include at least: government, non-government
and health worker representatives? Yes = 2; No = 0

In the additional information with the statement answering the
questions, you can give the justification for having a committee
and a policy, which is the Innocenti Declaration:

The Innocenti Declaration, confirmed by 139 governments at the 1990
World Summit for Children, called on all governments to establish, by
1995, a national breastfeeding committee and a national breastfeeding
coordinator. The World Health Organization recommends that a national
breastfeeding policy should be developed in every country.(2)

You might also want to include some comments about the implementation
of the policy or the effectiveness of the committee: has it met? Is it
involved in World Breastfeeding Week? Is it fully representative?

Question 3: What percentage of facilities that provide maternity
facilities fully practise all Ten Steps to Successful Breastfeeding and are considered "Baby-Friendly"?

If your country has a national Baby-Friendly Hospital programme, this information should be readily available.The scoring is simple. The number of hospitals that has been targeted to become baby friendly is compared to the actual number that have received a certificate that they have achieved this status. The resulting percentage is then divided by 10 and rounded to the nearest whole number. So, if 22% of hospitals are baby friendly, the score is 2; if 78% are baby friendly, the score is 8.

In the additional information, you can include the justification for this indicator.

The Innocenti Declaration called for all facilities offering maternity care to meet these 10 Steps by 1995.(3)

You might also want to include further information  here about what is happening in your country, or put this in the Notes. For example, you might be able to identify which of the 10 Steps are more difficult to implement and why.

Question 4: Is the International Code of Marketing of Breastmilk
Substitutes in effect?

At first glance, this is a simple yes/no question; however, it is a  little more complex. There are various ways of putting the International Code into practice, so the scale of marks is as follows:

Code in force in full as a law 10
Some parts of the code as a law 9
Code as a voluntary measure 8
Some parts of the code as a
voluntary measure 7
Law drafted, awaiting final approval 5
The best approach is being studied 3
Industry code 1
No action taken/planned or
no information 0

In addition to the statement on the code, you can include the justification for looking at this issue:

The Innocenti Declaration called for all governments to take action to implement the International Code and supplementary resolutions approved by the World Health Assembly.(4)

You might also want to include some information about what the government has done on this and when. Also, you might include some
notes about how effective the Code/law has been in practice, whether
there is a monitoring committee, whether there are new marketing practices that need to be addressed.

Question 5: Is there legislation to provide adequate maternity leave
for breastfeeding mothers?

This appears to be a simple yes/no question; however, it is also quite complex. The International Labour Organisation (ILO) laid down some standards that should be met:

12 weeks maternity leave (six weeks before and six weeks
after birth) with a salary of at least two-thirds of regular
earnings;
no dismissal during maternity leave;
two half-hour breastfeeding breaks during each working day.

These are important, although not sufficient to provide the necessary support that breastfeeding women require. The best support would be six months leave after birth and six weeks before birth, together with the other measures. Also, such measures should apply to both the government and private sectors. Accordingly, a maximum of 10 points can be awarded by adding together the following elements:

ILO conventions in place: 3
Maternity legislation applied to all sectors:
add 3
Maternity leave of 4 months after birth: add 1
of 5 months after birth: add 1
of 6 months after birth: add 1
Other measures to protect women not covered by formal sector
legislation: add 1

You can include the justification for this section:
The Innocenti Declaration called for the provision of imaginative
legislation to protect the breastfeeding rights of working women.
It also said that "obstacles to breastfeeding within the health
system, the workplace and the community must be eliminated".(5)

Other indicators you could use

In addition to the five main questions that are used to provide your country's breastfeeding score, there are other powerful statements that you may be able to make about the situation in your country. These could include answers to the following questions:

Do health workers receive adequate training about breastfeeding?
Do textbooks and other training materials provide accurate information about breastfeeding?
How many mother-to-mother support groups are there in your country? Is this enough?
Are there any popular education or social mobilisation activities about breastfeeding in your country?
n Does your country take part in World Breastfeeding Week?

Some of these questions may require very detailed answers that are difficult to rank or score easily. In some cases, the answer may appear to be a subjective one, and could vary according to who makes the judgement, unless you are able to develop very clear criteria. Nonetheless, you could develop a small point system for all of these. It might be something as simple as deducting a point from the total country score for negative answers.

Two other questions which you could include in your country report card are often very difficult to find answers for, and are also almost impossible to score or rank. Nonetheless, if you do have this information, it would make a powerful additional argument for the reasons why more efforts should be made to encourage breastfeeding. One of the questions concerns health, the other economics. They are:
n What is the rate of infant malnutrition/infant or childhood diarrhoea/child acute respiratory infections according to the type of infant feeding?
The justification for this is that: bottle-fed infants younger than 2 months are up to 25 times more likely to die from diarrhoeal disease than breastfed infants and three times more likely to die from acute respiratory infections. The overall risk of death from all causes for non-breastfed infants is approximately double that for infants who have been exclusively breastfed.(6)

If you do have this information available, you may be able to calculate the number of deaths that could be prevented if breastfeeding was encouraged.

How much is spent on artificial baby milks?

The justification for this is that it is unnecessary expenditure in most cases and that the money could be better spent. For example, in Nigeria in 1990, the 40 kilograms of infant milk powder needed to adequately feed an infant through the first year of life cost more than 2.5 times the annual minimum wage. In the Philippines, one hospital that put into practice the Ten Steps to Successful Breastfeeding was able to save 8% of its annual budget.(7)

Time for Action!
Having worked out the score for your country and the statements, now is the time to suggest some ideas for action (What Needs to be Done?). You can suggest these according to the problems identified by the Report Card. For example, if there is no national committee, you could call for the government to set one up. Four or five action ideas should be sufficient -- enough so that they are likely to appeal to several different audiences; not so many that it seems like an impossible task to achieve change.

There should also be a section on what the reader of the Report Card can do (What Can You Do?). One major action is to get in touch with your organisation and join it and the campaign. You might want to include the name and address of other organisations that people can contact, especially if it is a large country or if different organisations work on different aspects of the issue. You can also include a few other ideas such as writing to government representatives, organisation a small talk or workshop about the subject, calling a local radio or television studio to encourage coverage of the story, writing to local newspapers or magazines about the problem.

Notes
The Notes given below are the standard references for the justifications that have been provided throughout this guide. If you use any of the justifications, you should also use the relevant Note. You can also include additional information in the Notes about the situation in your country, or further references.

• The WHO statement comes from a World Health Assembly resolution (WHA 47.5) approved by all WHO's Member States in 1994.
• The WHO statement originated in a 1990 WHO/UNICEF Technical Meeting and is reproduced in: Saadeh, R. (ed.), Breastfeeding: The technical basis and recommendations for action, Geneva: WHO, 1993.
• The Ten Steps to Successful Breastfeeding were first elaborated in the 1989 WHO/UNICEF publication: Protecting, Promoting and Supporting Breastfeeding.
• WHO, International Code of Marketing of Breastmilk Substitutes, Geneva, 1991; IBFAN, Protecting Infant Health: A Health Workers' Guide to the International Code of Marketing of Breastmilk Substitutes, (7th edition) Penang, 1993.
• The International Labour Office (ILO) set basic standards as long ago as 1919, which were revised in 1952 (Reference: ILO Convention No 3 and Convention No 103). However, these now need to be updated. In many countries, campaigns are now underway to push for maternity leave of at least 6 months after birth and 6 weeks before birth. Such provisions should always apply to both the private and the public sector. Women working in the informal sector, often the majority in many countries, are not affected by such legislation; they need more imaginative solutions to enable them to continue to breastfeed.
• Victora, C.G. et al. (1987). Evidence for protection by breastfeeding against infant deaths from infectious diseases in Brazil, Lancet, 2:319-22; UNICEF, Children and Development in the 1990s, New York, 1990
• UNICEF, Children and Development in the 1990s, New York, 1990; UNICEF, The State of the World's Children 1993, New York: Oxford University Press, 1992

The WABA Link
Finally, it is useful to include a short paragraph which shows that the National Report Card and the work of your group is part of a larger global effort to improve breastfeeding practices. You can use a section such as the one given below, and add another line or two to mention that your organisation is a participant in the WABA network and is involved in the GLOPAR Project.

The information summarised in this National Report Card was collected as part of the Global Participatory Action Research Project (GLOPAR) of the World Alliance for Breastfeeding Action (WABA). WABA is a global network of organisations and individuals who believe breastfeeding is the right of all children and mothers and who dedicate themselves to protect, promote and support this right.

Other ideas for using report cards

Although the basic Report Card is meant to show the national situation, there are other uses for this idea. These include:

. . . using the Report Card at a local level
You could survey a city, or a region of a country, or even a small community to find out whether the policies which should be in place nationally are known about at the local level (and whether they are acted upon). You will probably need to adapt the questions on the Report Card to compre the situations.

. . . using the Report Card to compare the situation in different parts of the country
You could see whether the score for rural areas differs from urban areas; whether there are differences according to income levels of different parts of country; or whether there are other regional differences. If such differences do exist, then you can use the different report cards to show this dramatically and to ask why.

. . . using the Report Card to assess
different viewpoints
You could ask individuals or organisations representing five or six different viewpoints -- government, health workers, mothers, non-governmental organisations, women's groups, the infant food industry -- to give their assessment of the national situation, using blank Report Cards. Then you could organise a public meeting to discuss any differences in the marks being awarded. (This could also take place on a television or radio programme.)

Finally, remember that the Report Card (see page 6 and 7) is a powerful visual tool. Encourage the media to reproduce it. Use it in displays and exhibitions. Make an overhead transparency or a slide of it for use at talks, workshops and seminars.

Model Format

NATIONAL REPORT CARD

[COUNTRY NAME]: [SCORE] MARKS out of 50 -- [RATING]

[GOOD/AVERAGE/POOR/BAD]
Marks for Breastfeeding

Q.1 How long are babies exclusively breastfed? The World Health Organization (WHO) recommends exclusive breastfeeding for all children until about 6 months of age.(1)
[YOU CAN PROVIDE ADDITIONAL INFORMATION HERE]

Q.2 Is there a national breastfeeding policy and a national committee and coordinator to encourage its implementation?
The Innocenti Declaration, confirmed by 139 governments at the 1990 World Summit for Children, called on all governments to establish, by 1995, a national breastfeedingcommittee and a national breastfeeding coordinator. (2)
[YOU CAN PROVIDE ADDITIONAL INFORMATION HERE]

Q.3 What percentage of facilities that provide maternity facilities fully practise all Ten Steps to Successful Breastfeeding and are considered “Baby-Friendly”?
The Innocenti Declaration called for all facilities offering maternity care to meet these Ten Steps by 1995.
[YOU CAN PROVIDE ADDITIONAL INFORMATION HERE]

Q.4 Is the International Code of Marketing of Breastmilk Substitutes in effect?
The Innocenti Declaration called for all governments to take
action to implement the International Code and supplementary resolutions approved by the World Health Assembly.(4)
[YOU CAN PROVIDE ADDITIONAL INFORMATION HERE]

Q.5 Only government sector employees qualify for maternity leave and it is not long enough to ensure that mothers can exclusively breastfeed for six months.
The Innocenti Declaration called for the provision of imaginative legislation to protect the breastfeeding rights of working women.
It also said that "obstacles to breastfeeding within the heath system, the workplace and the community must be eliminated". (5)
[YOU CAN PROVIDE ADDITIONAL INFORMATION HERE]

Model Format

[NAME OF COUNTRY] REPORT CARD

WHAT NEEDS TO BE DONE?
[FILL IN FOUR OR FIVE SUGGESTIONS FOR NATIONAL ACTION.]
•
•
•
•

WHAT CAN YOU DO?
Join the [NAME OF THE NATIONAL GROUP] and become involved in this campaign to protect, promote and support breastfeeding.
[NAME OF THE GROUP
Address
Phone/fax/email]

[You might want to include the name and address of several organisations if it is a
large country, or if they work on different aspects of the issue.]

[ADD ONE OR TWO OTHER IDEAS]
•
•

Notes
1. The WHO statement comes from a World Health Assembly resolution (WHA 47.5) approved by all WHO's Member States in 1994. [YOU CAN ADD ADDITIONAL INFORMATION ABOUT YOUR NATIONAL SITUATION.]
2.The WHO statement originated in a 1990 WHO/UNICEF Technical Meeting and is reproduced in: Saadeh, R. (ed.), Breastfeeding: The technical basis and recommendations for action,Geneva:WHO,1993 [YOU CAN ADD ADDITIONAL INFORMATION ABOUT YOUR NATIONAL SITUATION.]
3. The Ten Steps to Successful Breastfeeding were first elaborated in the 1989 WHO/UNICEF were first elaborated in the 1989 WHO/UNICEF publication Protecting, Promoting and Supporting Breastfeeding [YOU CAN ADD ADDITIONAL INFORMATION ABOUT YOUR NATIONAL SITUATION.]
4. WHO, International Code of Marketing of Breastmilk Substitutes, Geneva, 1991; IBFAN, Protecting Infant Health: A Health Workers' Guide to the International Code of Marketing of Breastmilk Substitutes, (7th edn.), Penang, 1993. [YOU CAN ADD ADDITIONAL INFORMATION ABOUT YOUR NATIONAL SITUATION.]
5. The International Labour Office (ILO) set basic
standards as long ago as 1919, which were revised in 1952
(Reference: ILO Convention No 3 and onvention No 103). However, these now need to be updated. In many Countries, campaigns are now underway to push for maternity leave of at least 6 months after birth and 6 weeks before birth. Such provisions should always apply to both the private and the public sector. Women working in the informal sector, often the majority in many countries, are not affected by such legislation; they need more imaginative solutions to enable them to continue to breastfeed. [YOU CAN ADD ADDITIONAL INFORMATION ABOUT YOUR NATIONAL SITUATION.]
6. Victora, C.G. et al. (1987). Evidence for protection by breastfeeding against infant deaths from infectious diseases in Brazil, Lancet, 2:319-22; UNICEF, Children and Development in the 1990s, New York, 1990. [YOU CAN ADD ADDITIONAL INFORMATION ABOUT YOUR NATIONAL SITUATION.]
7. UNICEF, Children and Development in the 1990s, New York, 1990; UNICEF, The State of the World's Children 1993, New York: Oxford University Press, 1992. [YOU CAN ADD ADDITIONAL INFORMATION ABOUT YOUR NATIONAL SITUATION.]

The information summarised in this National Report Card was collected as part of the Global Participatory Action Research Project (GLOPAR) of the World Alliance for Breastfeeding Action (WABA). WABA is a global network of organisations and individuals who believe breastfeeding is the right of all children and mothers who dedicate themselves to protect, promote and support this right. The [NAME OF NATIONAL GROUP] is a participant in the WABA network and partner in WABA's GLOPAR project. [ORGANISATION/ ADDRESS/ PHONE/ FAX/ E-MAIL]

About GLOPAR

The Global Participatory Action Research (GLOPAR) Project was conceived by the World Alliance for Breastfeeding Action (WABA) in 1993 as part of a long-term effort to mobilise groups and individuals around the world to protect, promote and support breastfeeding.

The philosophy is, in many ways, encapsulated in the title:
Global Participatory Action Research Project.

Global
The project is meant, over time, to look at the situation of breastfeeding in all countries, while recognising that it is not possible to do everything at once. Although global in scope, the foundation for the work is the national-level analysis. The global picture is to be built up from the national findings.

Participatory
The project is meant to involve local groups and individuals, particularly those who are most involved in breastfeeding protection, promotion and support, in assessing the impact of policies and practices, and in offering suggestions for future directions. It is meant to be participatory as well by encouraging the use of networking skills, investigative techniques and monitoring methods that would be directly relevant to the investigators.

Action
The project is designed to stimulate action, not simply to collect information. Having more information about a subject is not helpful unless there are also some suggestions about how to translate the information into tools for change, and how to improve the situation.

Research
The project is designed to stimulate research, or as the title of the guidebook (Investigating Breastfeeding) prepared for the project suggests, to investigate, to ask questions, to find out why breastfeeding does or does not occur. The research, the investigation, is to be participatory — not done by external researchers, but by people in each country — and is meant to lead to useful analysis that could stimulate action for change.

Project
Finally, this whole exercise is a project — an experiment — to see if it is possible to use these methods of investigation to stimulate the mobilisation of larger networks of groups and individuals and to see if, in the words of the guidebook, “simply asking a few questions” would “start a process of change for the better”.

You can be a project partner too... If you are interested to begin a rapid assessment of the state of breastfeeding in your country, write for a copy of the GLOPAR guidebook, Investigating Breastfeeding: question, ideas and issues to explore... which contains model questionnaires for national surveys. The guidebook is also available in Spanish.
Also available from the WABA Secretariat are outputs from this project, WABA Global Participatory Action Research Project: Report on Phase I , reproduced in WABA Link, Issue 11, June 1995, and a model format, National Report Card on the State of Breastfeeding in India.


The World Alliance for Breastfeeding Action (WABA) is a global people's initiative to protect, promote and support breastfeeding. WABA works on the Innocenti Declaration and in close liaison with the United Nations Children's Fund (UNICEF).

Report: Andrew Chetley Design: Susan Siew
WABA, PO Box 1200, 10850 Penang, Malaysia Tel: 60-4-6584 816 Fax: 60-4-6572 655