Becoming Breastfeeding Friendly Index: Development and application for scaling-up breastfeeding programmes globally.

Global efforts to further improve exclusive breastfeeding rates have not been successful, in part because effective scaling-up frameworks and roadmaps have not been developed. The Becoming Breastfeeding Friendly (BBF) toolbox includes an evidence-based index, the BBF Index (BBFI), to guide the development and tracking of large scale, well-coordinated, multisector national breastfeeding promotion programmes. This paper describes the development of the BBFI, which is grounded in the Breastfeeding Gear Model complex adaptive systems framework. The BBFI was developed by the BBF Steering Committee in collaboration with a high-level Technical Advisory Group following the Delphi consensus methodology. Key benchmarks and definitions were informed by evidence-based health, nutrition, and newborn survival initiatives identified from the academic and grey literature. The BBFI consists of 8 gears (54 benchmarks): Advocacy (4); Political Will (3); Legislation and Policies (10); Funding and Resources (4); Training and Program Delivery (17); Promotion (3); Research and Evaluation (10); and Coordination, Goals, and Monitoring (3). Scores are generated for 8 gear scores plus a total country score to gauge the scaling-up enabling environment. The BBFI provides an evidence-based index to assist countries in (a) assessing their readiness to scale up breastfeeding programmes and (b) tracking scaling-up progress.