2019: A Year in Research

The 2010’s are over – but data-driven innovations from the last decade will continue to drive improvements in MIYCN for healthier families, communities, and nations. In 2019, A&T continued support research in a variety of areas.

“The rigorous research that A&T supports fills data gaps and documents improvements in maternal, child, and infant nutrition (MIYCN) at scale, in both policies and programs,” explains Joy Del Rosso, Director of Knowledge, Leadership and Learning for Alive & Thrive. “The A&T initiative continues to expand global knowledge on maternal nutrition, breastfeeding, and complementary feeding in its effort to improve nutrition outcomes around the world.”

Policy Advocacy

A billion dollars and two thousand lives, every day. This impactful study, which is the foundation for Alive and Thrive’s online tool, examines the human and economic costs of not breastfeeding. Each year, $340 billion in unnecessary healthcare costs and cognitive losses, as well as 700,000 lives of mothers and infants are lost due to inadequate breastfeeding. This data calls for scaling up financing and implementation of policies, programs and interventions worldwide to create enabling environments that support breastfeeding mothers.
Indonesia would reap significant economic benefits from expanding maternity protection programs, according to this study that explored the potential financial cost to optimizing paid maternity protection programs. The costs of implementing maternity benefits are far less than the significant economic profits and health benefits Indonesia would gain as a result of expanding maternity protection, such as increasing maternity leave from three to six months and incorporating lactation rooms in medium and large firms.
This supplement, comprising three papers, addresses gaps in policy advocacy to create supportive environments for optimal breastfeeding and infant and young child feeding (IYCF). While policy advocacy is nearly universal, few studies in this field directly evaluate advocacy strategies and document their effects. The supplement serves as a guide for future IYCF policy enhancement, identifying the drivers and triggers of policy change and providing evidence that Alive & Thrive, UNICEF, and partners enhanced policies in Southeast Asia.
The International Code of Marketing of Breast-Milk Substitutes (the Code) is intended to prevent inappropriate marketing of breastmilk substitutes, but these practices persist around the world. Creating a strategic group and implementing 15 critical tasks are the key drivers of advocacy efforts necessary to translate the Code into national legislation, according to this real-time analysis of A&T advocacy efforts undertaken with UNICEF in seven Southeast Asian countries.
The advocacy efforts of Alive & Thrive, UNICEF and partners have made progress in improving IYCF policies, according to a study that used contribution analysis (CA), a recent advance in the field of evaluation. CA is a six‐step approach that can help explore attribution in complex environments. Complemented with developmental evaluation, CA showed that advocacy efforts did in fact improve IYCF policies in the seven countries where Alive & Thrive and UNICEF implemented a four-part process for policy change.
Large initiatives should adopt an explicit advocacy approach, create a strategic group of actors, and realize 15 critical tasks to enhance their effectiveness in advocacy for policy change, specifically related to implementation of the Code, according to this real-time analysis of advocacy efforts.
In this case study of the collective impact (CI) approach, researchers conclude that an Alive & Thrive-UNICEF advocacy effort was effective because it met conditions for an effective CI initiative: 1) an independently funded staff dedicated to the initiative provided ongoing support; 2) participants shared a vision for change that included a common understanding of the problem and a joint approach to solving the problem through agreed‐upon actions; 3) a diverse set of stakeholders, across sectors, coordinated a set of differentiated activities through a mutually reinforcing plan; 4) all players engaged in frequent and structured open communication to build trust, assure mutual objectives, and create common motivation; and 5) all participating organizations agreed on the ways success would be measured and reported.
The 2019 Nobel Prize in Economics recognized the importance of using experimental research – namely randomized control trials – to identify solutions to development problems. Alive & Thrive has used cluster-randomized evaluations, with other methods, to generate lessons about infant and young child nutrition behavior change at scale in Bangladesh, Vietnam, and Ethiopia. After testing adaptations in other countries, this body of evidence now informs the shaping of nutrition behavior-change strategies around the world, benefitting millions of women, children, and their communities.

Nutrition Systems Strengthening

Alive & Thrive-supported training, supervision and mass media activities improved front-line health workers’ (FLW) delivery of nutrition services, according to a study in Bangladesh and Viet Nam. Interventions were significantly associated with at-scale service delivery improvements, indicating these strategies should be considered when designing future interventions.
A study of caregivers in Bangladesh concluded that health workers who comply with evidence-based practices positively influence their clients’ IYCF behaviors. The study documented the relationship between providers’ compliance with evidence-based practices during counseling and clients’ IYCF behavior change, such as reported increases in exclusive breastfeeding. While behavior change is multifactorial, improvements to technical quality of care may contribute to desired health outcomes.


A multi-dimensional intervention using interpersonal communication and community mobilization activities, delivered at scale in Burkina Faso, increased mothers’ optimal breastfeeding knowledge, breastfeeding beliefs and breastfeeding practices. Women in the intervention areas were more likely to exclusively breastfeed, initiate breastfeeding within an hour of birth and avoid giving their infants pre-lacteal feeds.
Multilevel support for breastfeeding could increase early initiation of breastfeeding by 25%, reduce prelacteal feeding by 25%, and increase exclusive breastfeeding by 25%, according to this study in Uttar Pradesh. Breastfeeding is not a one-woman job – fathers, grandmothers, health workers, and communities play a part in child feeding. A cross-sectional survey conducted among new mothers, husbands, and mothers-in-law in Uttar Pradesh, examined determinants of breastfeeding practices and potential strategies for improvement. A multifactorial approach, including strategies such as health services and family and community level interventions, has the potential to improve practices, the study found.
The Becoming Breastfeeding Friendly (BBF) initiative provides a guide for countries to assess the enabling environment for breastfeeding policies, programs and scale-up. This study documents the BBF process and outcomes in Myanmar, revealing the initiative was successfully conducted and the environment for scale-up was moderate. Nine recommendations are discussed to strengthen the enabling environment, prioritizing a National Infant and Young Child Feeding Alliance. Lessons are noted to inform considerations for other countries committing to the BBF initiative.

Maternal Nutrition 

Maternal behavioral characteristics (such as knowledge, beliefs and self‐efficacy), followed by support from family members, community factors and adequate health services access, were significantly associated with key maternal nutrition practice, according to this study conducted in Uttar Pradesh, India. The study found that while strengthening existing program operations could result in large improvements, maternal nutrition determinants are multifactorial, and strengthening operations may not be sufficient to meet WHO-recommended levels without creating an enabling environment.
Participation in nutrition-focused antenatal care can reduce food insecurity during pregnancy and the postpartum period, according to this study conducted in Bangladesh. Integrating social and behavior change interventions to improve nutrition knowledge of pregnant and lactating women in populations where resources can be directed towards accessing adequate and appropriate foods can provide a potentially effective means to reduce food insecurity, without incurring high costs of providing supplemental food, the study found.
The provision of intensive counseling and micronutrient supplements led to lower overall complications among recently delivered women in Bangladesh, according to this study. The study suggests that maternal nutrition interventions may reduce pregnancy complications or impact women’s ability to accurately recognize complications.

Complementary Feeding 

Delivery of social and behavior change interventions using multiple platforms was feasible and effective, resulting in improvements in complementary feeding practices and child stunting within a two-year period, this study in Ethiopia concluded. The study evaluated the impact of the A&T intensive complementary feeding interventions compared to standard interventions on knowledges, practices and child growth.
Breastfeeding, dietary diversity, complementary feeding and malnourishment as a health hazard are not understood, and women experience a lack of health-related autonomy, this study involving mothers of malnourished children found. Given that malnutrition has roots in infancy, the study’s results underscore an urgent need to create community awareness about infant feeding practices, using innovative behavior change strategies.
Mothers in the rural Boucle de Mouhoun Region of Burkina Faso had low levels of knowledge of IYCF and practices, according to this study: 60% of children had the minimum meal frequency, while only 18% benefited from the minimum dietary diversity and 13% received minimum acceptable diet. Mothers’ perceived self-efficacy to provide children with these food groups was low. The results highlight the need to improve mothers’ IYCF knowledge and practices in the region.
Interaction within mothers’ social networks, reinforced by promoting positive social norms for appropriate behaviors, can affect IYCF practices, according to this study in Bangladesh. The study used household surveys to trace the paths of exposure to interventions like interpersonal counseling, community mobilization and mass media. Findings conclude that through networks, diffusion and norms, exposure to large-scale social and behavior change interventions will contribute to sustained positive changes in IYCF.

Highlights from World Breastfeeding Week 2019

Alive & Thrive celebrated World Breastfeeding Week 2019 in collaboration with partners and communities around the globe. From August 1-7, A&T planned and participated in events honoring the theme, “Empower Parents, Enable Breastfeeding,” to raise awareness about breastfeeding’s benefits and the need for supportive, enabling environments for mothers and families.

Check out some of the highlights of #WBW2019 around the world!


In July, A&T launched our Cost of Not Breastfeeding Tool, which quantifies the preventable losses of life, cognition, and health system costs in countries around the world due to inadequate breastfeeding. This video, published during WBW, illustrates the importance of the new tool.


The WBW inauguration ceremony, where A&T was presented with an award for contributions to IYCF practices in the country.

The Bangladesh National Nutrition Service presented A&T with an award during the WBW inauguration ceremony, recognizing our achievements in infant and young child feeding (IYCF) practices in the country. “Alive & Thrive is providing technical assistance and support to the Government of Bangladesh, strengthening nutrition services through the health system,” explains Zeba Mahmud, Country Director of A&T in Bangladesh. The award serves to recognize A&T’s varied work in the country –  since 2010, A&T has helped develop guidelines and strategies to promote breastfeeding and complementary feeding, assisting to raise exclusive breastfeeding rates. Collaborating with INGO and government partners, A&T has reached 126 million people in Bangladesh with mass media and interpersonal communications campaigns, and will continue to provide technical assistance to the Government of Bangladesh in implementing the Breastmilk Substitutes Act and its bylaws.


In Cambodia, A&T along with the Cambodia Center for Independent Media and SUN Cambodia hosted a media workshop to educate journalists on the importance of breastfeeding and breastfeeding policies in the nation. The participants developed practical tools to increase media coverage of breastfeeding, pledging to use their influence to build supportive environments and policies for nutrition. Following the workshop, the journalists joined visits to WBW celebrations in Siem Reap and rural areas. Check out the first article published about the workshop, advocating for enforcement of marketing regulations for breastmilk substitutes.

Hon Kroeun, Deputy Country Director of Helen Keller International Cambodia and Coordinator of the SUN CSA Cambodia, speaks with local journalists at the media orientation workshop, hosted by A&T and Cambodia Center for Independent Media in Phnom Penh.
Parents and children attend the World Breastfeeding Week launch event hosted by the Ministry of Health in Siem Reap, Cambodia. Participants in the media orientation attended the launch, interviewing stakeholders and providing media coverage.


To improve the quality and safety of human milk banks (HMBs) in Myanmar, A&T and UNICEF held trainings for hospital staff at Central Women’s Hospital and Yankin Children’s Hospital. Staff learned about new guidelines for the HMB process as well as strategies for breastfeeding counselling. For infants unable to receive breastmilk from their mothers, HMBs serve a vital role, giving vulnerable infants access to the benefits of breastmilk when they need it most.

Staff are trained on best practices for human milk banks at Central Women’s Hospital and Yankin Children’s Hospital.


Mothers in the Philippines simultaneously latch their babies as they take to social media to advocate for the normalization and support of breastfeeding.

The photographer Giacomo Pirozzi visited the Philippines to document breastfeeding practices and challenges. In alignment with the week’s theme “Empower Parents, Enable Breastfeeding,” his photographs focused on workplace lactation in both the formal and informal sectors, drawing attention to enabling environments for breastfeeding for working mothers. August 18th, he photographed Hakab Na! (Big Latch On), the biggest breastfeeding event in the Philippines, hosted by Breastfeeding Pinays, an online forum of over 270,000 breastfeeding families where thousands of mothers simultaneously latched their babies around the country.


In an important milestone for the Center of Excellence (CoE) for Breastfeeding initiative in Vietnam, two designation ceremonies were conducted, following a decision on August 6 from the Ministry of Health, approving a legal foundation to expand the CoE approach nationwide. The potential for impact is widespread.

“The designation of the first hospital in Ca Mau as a Center of Excellence gives us motivation to replicate the model towards building a brea

A&T Southeast Asia Regional Director Roger Mathisen with staff at Tran Van Thoi CoE designation ceremony.

stfeeding-friendly province,” said  Nguyen Van Dung, the Acting Director of the Department of Health in Ca Mau.

To receive the CoE designation, multiple groups evaluate the hospital, including mothers who have recently given birth in the facility; the MOH or DOH then determines which hospitals qualify. Hospitals recognized as a CoE serve as best practice models for the promotion of breastfeeding and receive media attention to help pregnant women and their families make informed choices about their birth facilities. “The CoE initiative is a practically significant intervention to create and maintain a breastfeeding-friendly environment… and can bring great impact on ensuring nutrition and sustainable development of children,” said Nguyen Viet Tien, Deputy Minister of Health at the CoE ceremony.

Vietnam Television produced two videos, looking at the CoE approach and its impact for WBW.


A&T supported the Federal Government of Nigeria to launch the Start Strong/Zero Water Breastfeeding Campaign and unveiled the National Maternity Entitlement Assessment Report to mark the start of WBW. Start Strong/Zero Water is a major mass communication campaign designed to raise awareness of the importance of exclusive breastfeeding for infants in their first 6 months and early initiation of breastfeeding. With only one in three Nigerian children exclusively breastfed, the National Maternity Entitlement Assessment Report presentation highlighted that mothers were often not granted adequate time to breastfeed during work hours.

Dr. Mairo Al-Makura (2nd from right), a representative for Nigeria’s first lady, unveiled the Start Strong/Zero Water campaign logo at the WBW launch.

Kaduna State, Nigeria

Nutrition is crucial in Kaduna state – after the high level of malnourished children in the area prompted a state of emergency in malnutrition, exclusive breastfeeding has been prioritized. Hajiya Aisha Umma Garba El’Rufai, the First Lady of Kaduna State and chairperson of the Kaduna Emergency Nutrition Action Plan, held a parade in Kaduna as well as a panel dialogue called “Breastfeeding: Family friendly policies are key to enabling exclusive breastfeeding.” The panel focused on the need for community support towards nursing mothers to reduce child mortality through exclusive breastfeeding, while the parade raised awareness about exclusive breastfeeding and celebrated the recent legislation passed in the state guaranteeing six months maternity leave.

Her Excellency Hajiya Aisha Ummi Garba El’Rufai wife of the Governor of Kaduna State addressing onlookers during the fun parade.

Watch Madame El Rufai in this Facebook Live interview with A&T’s technical advisor Chinweuba Ezeigwe. 

Lagos, Nigeria

In Lagos, a baby show was held, in recognition of mothers who practice exclusive breastfeeding. The Alive & Thrive team, along with 112 other stakeholders, including representatives from the Lagos State Ministry of Health, the Primary Health Care Board, Traditional Medicine Board, implementing partners, health workers, and breastfeeding mothers from A&T supported public health facilities in Lagos participated in the event. The babies, presented by their mothers, were assigned points based on their health behaviors, encouraging stakeholders in Lagos to adopt best practices in infant health. Judges evaluated factors such as early initiation of breastfeeding; exclusive breastfeeding for babies under 6 months; weight, as a measure of proper nutrition; and adherence to immunization schedule. While only one baby was named the winner, entire communities benefit from raising awareness about the importance of breastfeeding and engaging stakeholders to prioritize infant health.

Winners of the baby show activity at the Lagos Mainland Local Government Area pose with their gifts.


On August 5th, A&T held a panel in India to raise commitment to the creation of enabling environments for breastfeeding, in public and in private. Under the leadership of the Ministry of Health and Family Welfare (MoHFW) and in collaboration with the Indian Academy of Pediatrics and Centre for Advocacy and Research, the panel also informed the development of a guidance note for health facilities to improve adherence to the Infant Milk Substitutes Act, which bans the promotion of milk substitutes to encourage optimal breastfeeding.

Dr. Khera, from the MoHFW, delivering the keynote address at the panel to promote optimal breastfeeding.


A&T in Ethiopia collaborated with partners to organize events at national and regional levels to raise awareness about gender-equitable parenting and social protections to support breastfeeding. Nationally, together with the Ethiopia Federal Ministry of Health, the Ethiopia National Nutrition Program (NNP), and media agencies, A&T helped orchestrate a week of activities raising awareness for breastfeeding, including a press conference, features on national TV programs, and community engagement in health facilities. The breastfeeding promotion extended to regional levels; in Amhara, Tigray, SNNP, Afar, and Somali, A&T provided technical guidance to TV roundtable discussions, radio programs, and communications materials. In each regional city, panel discussions were organized with representatives from NNP, religious leaders, hospitals, implementing partners and breastfeeding mothers, to advocate for optimal breastfeeding strategies and environments in Ethiopia.

Breastfeeding mothers supporting breastfeeding-friendly policies at a regional panel in Ethiopia.

What are Centers of Excellence for Breastfeeding?

In Vietnam, 94% of births take place in the hospital, but not every facility prioritizes breastfeeding in its early newborn care. This video shows how the Center of Excellence for Breastfeeding approach in Vietnam can help families to employ breastfeeding best practices for improved health and nutrition outcomes.