FACTS Spotlight: National Breastfeeding Month


August 9, 2021

By Natasha Scaria, MD

Key Factors in Breastfeeding Promotion: A Review of Research

Editor’s Note: Earlier this month, we posted a synopsis of a systematic review published in 2016 analyzing the literature on the effectiveness of interventions to increase exclusive breastfeeding. The research[i] article summarized below involves a systematic review that became the foundation to create a framework for scaling up breastfeeding promotion programs in low- and middle-income countries. The article is titled, “Scaling Up of Breastfeeding Promotion Programs in Low- and Middle-Income Countries: the ‘Breastfeeding Gear’ Model.” The compelling study was published by Pérez-Escamilla et al in 2012. Dr. Natasha Scaria wrote this brief summary while on the FACTS fertility awareness elective.


Large-scale promotion of breastfeeding could prevent an estimated 11.6% of infant deaths and significantly improve maternal and child health globally.[i] Despite their potential impact and cost-effectiveness, there have not been many studies to promote these programs. Pérez-Escamilla et al assessed a number of breastfeeding programs to identify enabling factors and barriers to implementing breastfeeding promotion programs around the world, and specifically in low- and middle-income countries. Their systematic review was then used to create the breastfeeding gear model (BFGM) to show which factors need to be in place for these breastfeeding programs to work effectively.

The researchers developed a framework to look at factors that support or hinder an increase of exclusive breastfeeding in communities around the world. The factors included in this framework are summarized with the acronym, AIDEDi:

Assess the landscape

Innovate to fit user receptivity

Develop support

Engage user groups

Devolve efforts for spreading innovation

This system is important to maximize the fit of a program according to the community it serves. Research found that when key groups adopt these breastfeeding programs, their use spreads to other communities through the passage of information to other social groups. 


A systematic review was done of the literature on the knowledge sharing and sizing up of exclusive breastfeeding programs in low- and middle-income countries. This research specifically evaluated breastfeeding programs that used the 1-6-24 model (i.e., programs in which breastfeeding started within 1 hour of birth, exclusive breastfeeding took place for 6 months, and those in which breastfeeding continued for 24 months).


Researchers identified 17 sources that fit their search criteria, with 28 countries represented. Regarding access, researchers were looking at what people in a community wanted or needed as well as the social, political, technological, legal, and economic conditions within the community’s environment. Based on information from needs assessments as well as pilot studies, successful spreading of ideas throughout a community was a key factor that enabled these programs to succeed.

Regarding innovation, researchers sought ways to design the breastfeeding programs to make them viewed as acceptable and helpful to the community they served. Key factors supporting innovation included communications and mass media campaigns that promote breastfeeding as well as facility and community-based exclusive breastfeeding promotions that use peer counselors, community health workers, and support groups to promote the different programs.

Regarding development, enabling factors include the evidence from international consensus as well as feeding recommendations from UNICEF and the World Health Organization. Breastfeeding programs cannot be scaled up without commitment from policymakers. Other key factors include the provision of maternity leave as well as workplace legislation.

Engagement with these programs requires the crossing of barriers through translation of the innovation so users can assimilate and integrate new ideas into their routines. To increase engagement, programs also need to consider the mother’s cultural beliefs.

Obstacles to engagement, innovation, and development were also identified. Poor communication between healthcare professionals and community health workers creates a large barrier to upscaling breastfeeding programs. Regarding devolving, there needs to be sustainable lactation management and communication/counseling, workplace development, and a national budget and support. Barriers can also include a lack of proper incentives for the program staff as well as staff fatigue.[ii]


It is clear that the first essential factor to scale up breastfeeding promotion is the need for evidence-based advocacy. Such advocacy may lead to legislative action as well as policies to boost the use of breastfeeding at the hospital and community level. Exclusive breastfeeding is recommended, at minimum, for the first 6 months of life with continued breastfeeding for at least 24 months. However, in many places around the world, this is not the case.

Breastfeeding promotion programs can be scaled up quickly and efficiently using the AIDED framework. These scaling procedures require effective health communication strategies as well as staff training and education. Government support needs to be present both at the local and national level.

Large scale studies are needed to optimize procedures to establish government coordination of new programs and promote breastfeeding using existing programs. Grassroots, community-based breastfeeding programs need to be the focus to create sustainable breastfeeding programs. When women hear about the benefits of long-term breastfeeding from their peers, they are much more likely to try these methods because the information is coming from their community.

Optimizing Peer-to-Peer Influence

Throughout the FACTS elective, students have the opportunity to sit in on numerous sessions where women share their fertility experiences with their peers. This shared experience proved incredibly beneficial to disseminate knowledge. It is not surprising that the same type of peer-to-peer discussion would prove effective to scale up breastfeeding programs. When people know they have support from others, they are better able to handle the challenges they face.

Creating a space for women to discuss the benefits of breastfeeding with their peers, as suggested by this article, will help engage them and increase the likelihood that these women will try to breastfeed longer. Future research could assess programs that incorporate health outreach workers into their breastfeeding programs and compare their engagement level to programs without this type of peer facilitation. Based on the study by Pérez-Escamilla et al, programs using this model would likely have much better long-term breastfeeding engagement.

Editor’s Note: When women breastfeed exclusively for six months without a return of their menses, they are effectively using the lactational amenorrhea method (LAM) to prevent pregnancy. This is another benefit and one more compelling reason to actively promote breastfeeding, particularly in lower income countries.


[i] Bhutta ZA, Ahmed T, Black RE, Cousens S, Dewey K, Giugliani E, Haider BA, Kirkwood B, Morris SS, Sachdev HP, et al. Maternal and Child Undernutrition Study Group What works? Interventions for maternal and child undernutrition and survival. Lancet. 2008;371:417–40.

[ii] Bhandari N, Kabir AK, Salam MA. Mainstreaming nutrition into maternal and child health programmes: scaling up of exclusive breastfeeding. Matern Child Nutr. 2008;4: Suppl 1:5–23.

About the Author

Natasha Scaria, MD

Natasha Scaria, MD earned her medical degree at Chicago Medical School at Rosalind Franklin University. She is currently a family medicine resident at Advocate Christ Hospital in Chicago. She wrote this review of research while on the FACTS fertility awareness elective. She is interested in women’s health and community medicine.


The FACTS CME Course is HERE!

The FACTS 4-part CME Course – Fertility Awareness Based Methods (FABMs) for Family Planning and Restorative Reproductive Women’s Healthcare prepares you as a medical professional to present more comprehensive options for family planning and women’s health monitoring and management of a range of reproductive health concerns. Through online lectures, live case study discussions, and readings, this course will explore the broad applications of modern Fertility Awareness-Based Methods (FABMs) and their role in pregnancy prevention, infertility, and women’s health.

The course is divided into four parts; you may elect to do any or all of them and they may be completed in any order. Each part is worth up to 14 AAFP-approved CME credits.

• Part A, An Introduction to Modern FABMs for Family Planning
• Part B, Special Topics in FABMs for Helping Couples Achieve or Avoid Pregnancy
• Part C, FABMs for Restorative Reproductive Medicine and at Various Stages of Life
• Part D, Medical Applications of FABMs

Click here to download the full lesson schedule for the course. 

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