Table 1 The Breastfeeding Gear Model

The evidence-based Breastfeeding Gear Model (BFGM) posits that the engine needed by countries to successfully scale up and sustain breastfeeding programs at the national level includes 7 peripheral gears and a master coordinating gear [31]. Evidence-informed advocacy is needed to generate the political will that results in legislation leading to policies with earmarked resources for the effective protection, promotion and support of breastfeeding. These resources are essential for building and sustaining the workforce capacity through sound education and training and for the proper implementation of facility (e.g., Baby Friendly Hospitals) and community based (e.g. breastfeeding counseling) programs (training and implementation gear). Social marketing through behavior change communication campaigns that address society at large are needed to educate and elicit support for breastfeeding mothers including family members, friends, health care providers, and decision makers. Implementation research and evaluation is needed to ensure that scaling up bottle neck are identified and addressed on time for long term success and sustainability. The central master or coordination gear is typically conformed by a national breastfeeding coordinating entity that needs to be well funded and empowered to monitor goals and lead the intersectoral coordination needed to ensure that the complex breastfeeding system work.

The BFGM has been operationalized into the Becoming Breastfeeding Friendly initiative (BBF), a policy tool-box for decision makers interested in scaling up their breastfeeding programs at the national level using evidence of strengths and weaknesses in each of the gears of the BFGM. BBF includes metrics and how to set up a policy development process through an intersectoral committee where civil society organization and international agencies are also represented [123, 124]. BBF has now been successfully applied in 8 countries across 5 world regions; Germany, Ghana, England, Mexico, Myanmar, Samoa, Scotland, and Wales (Pérez-Escamilla R. Becoming Breastfeeding Friendly, Yale School of Public Health. www.bbf.yale.edu (accessed October 27, 2020).