Informal consultation with Member States and United Nations agencies

on a proposed set of indicators for the Global Monitoring Framework

for Maternal, Infant and Young Child Nutrition

International Labour Organization

Geneva, Switzerland

16 to 17 April 2015

Indicators for the Global Monitoring Framework on

Maternal, Infant and Young Child Nutrition

(30 March 2015)

1

I. Background and purpose

In May 2012, the Sixty-fifth World Health Assembly approved a Comprehensive implementation plan on

maternal, infant and young child nutrition (1). This plan established six global targets to be achieved by

2025.

The Comprehensive implementation plan on maternal, infant and young child nutrition proposes actions to

support the achievement of the global targets. Action 5 calls for a well-defined framework that would allow

a harmonized and internationally accepted approach to monitoring of progress towards nutrition targets at

both the national and global levels, as well as on the actions taken to put the Comprehensive implementation

plan into practice.

A draft Global Monitoring Framework was first presented on 6 September 2013 and discussed in an

informal consultation with Member States and United Nations agencies that was held from 30 September to

1 October 2013 in Geneva, Switzerland. In May 2014, the 67th World Health Assembly (WHA) approved

the outcome indicators corresponding to the six global targets (2).

At the request of Member States, the Secretariat further analysed “… tracer indicators for policy and

programme implementation in health and other sectors relevant to the achievement of global nutrition

targets”, and developed “… an extended set of indicators to track processes that have an impact on global

targets in specific country settings for consideration by Member States at the 68th WHA”.

In January 2015, the 136th Executive Board discussed a report by the Secretariat presenting 14 additional

core indicators, including five intermediate outcome indicators, monitoring conditions on the causal

pathways to the targets; six process indicators, monitoring programmes and situation-specific progress; and

three policy, environment and capacity indicators, measuring political commitment (3). The report was

supported by a background paper that included an extended list of 16 indicators relevant to specific settings,

an analysis of the links between the indicators and the targets, the evidence base for the proposed indicators,

and practical considerations on the implementation of the framework (4).

During the discussion of the Secretariat report, Member States requested clarification on the standard

definitions of the indicators, the current availability of data, and the operational aspects of data collection.

The present paper addresses such requests for the proposed set of core indicators.

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II. Proposed core indicators

II.1. Intermediate outcome indicators

Indicator name Short definition

IO1 Diarrhoea in children Prevalence of diarrhoea in children under 5 years of age

IO2 Underweight in women of

reproductive age

Proportion of women aged 15–49 years with low body mass index

(BMI <18.5 kg/m2)

IO3 Adolescent fertility Number of births during a given reference period to women aged

15–19 years /1000 women aged 15–19 years

IO4 Overweight or obesity in

women

Proportion of overweight and obese women, 18+

(BMI ≥ 25 kg/m2)

IO5 Overweight in school-age

children and adolescents

Proportion of overweight in school-age children and adolescents

5–18 years [sex-specific BMI-for-age > +1 standard deviation

(SD)]

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IO1 Diarrhoea in children

Definition

The prevalence of diarrhoea in children under 5 years of age is defined as the percentage of children aged

under 5 years who had diarrhoea in the 2 weeks preceding the survey.

Diarrhoea is defined as the passage of three or more loose or liquid stools per day (or more frequent passage

than is normal for the individual). Frequent passing of formed stools is not diarrhoea, nor is the passing of

loose, “pasty” stools by breastfed babies (5).

Diarrhoea has a direct impact on mortality, through stunting (6).

This indicator is calculated as:

Number of children under 5 years in the samplewho had diarrhoea in the 2 weeks preceding the survey

Total number of children under 5 years in the sample∗ 100%

Stratifiers

This indicator is further disaggregated into all or some of the following background characteristics: age (in

months), sex, source of drinking water, toilet facility, residence, region, mother’s education, and wealth

quintile.

Data requirements

The following question is put to the caregiver: “Has [NAME] had diarrhoea in the last 2 weeks?”

Data sources

Population-based household surveys (e.g. demographic and health surveys [DHS], multiple indicator cluster

surveys [MICS]).

Issues

Although diarrhoea has a low prevalence in high-income countries, it can occur in vulnerable populations

anywhere. Given that it is commonly assessed, it could also be easily reported. There are limitations in this

measure of prevalence: it is a 2-week prevalence measure, does not take into account seasonality and is self-

reported (recall bias).

Data availability

Data were identified for 100 countries with surveys from 2005 (Maternal, Newborn, Child and Adolescent

Health database – not yet widely available). The United Nations Children’s Fund (UNICEF) Global

Databases provide data on a different indicator, i.e. children with diarrhoea receiving treatment with oral

rehydration salts, and 115 countries present data collected since 2000. The data source for both indicators is

probably the same.

Note: this indicator is not part of the Global reference list of 100 core health indicators (7).

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IO2 Underweight in women of reproductive age

Definition

The prevalence of underweight in women of reproductive age is defined as the percentage of women aged

15–49 years with BMI lower than 18.5 kg/m².

Women who are underweight tend to have increased risk of intrauterine growth restriction, which increases

the risk of neonatal mortality and future stunting in their offspring (8). Maternal malnutrition is a key

contributor to poor fetal growth and low birth weight, as well as short- and long-term infant morbidity and

mortality (9).

This indicator is calculated as:

Number of women aged 15– 49 years in the sample with BMI < 18.5 kg/m²

Total number of women aged 15– 49 years in the sample ∗ 100%

Stratifiers

Results can be presented by age and relevant sociodemographic stratifiers.

Data requirements

Weight and height of women, measured with standardized equipment.

Data sources

Population-based (preferably nationally representative) household surveys in which height and weight were

measured (e.g. DHS, MICS).

Issues

Potential limitations include measurement error and representativeness of the sample.

Data availability

Data are available for 109 countries since 2000 (Noncommunicable Disease Risk Factor Collaboration

[NCD-RisC] collaborating group).

Note: this indicator is part of the additional indicators in the Global reference list of 100 core health

indicators (7).

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IO3 Adolescent fertility (adolescent birth rate)

Definition

The adolescent birth rate measures the annual number of births to women aged 15–19 years, per 1000

women in that age group. It represents the risk of childbearing among adolescent women aged 15–19 years.

It is also referred to as the age-specific fertility rate for women aged 15–19 years (10).

This indicator is calculated as:

Number of live births to women aged 15– 19 years in a year

Total number of women aged 15– 19 years in a year∗ 1000‰

The numerator is the number of live births to women aged 15–19 years and the denominator is an estimate

of exposure to childbearing by women aged 15–19 years. The numerator and the denominator are calculated

differently for civil registration, survey and census data (11,12):

In the case of civil registration, the numerator is the registered number of live births born to women

aged 15–19 years during a given year, and the denominator is the estimated or enumerated

population of women aged 15–19 years;

in the case of survey data, the adolescent birth rate is generally computed based on retrospective

birth histories. The numerator refers to births to women that were 15–19 years of age at the time of

the birth during a reference period before the interview, and the denominator refers to person-years

lived between the ages of 15 and 19 years by the interviewed women during the same reference

period. Whenever possible, the reference period corresponds to the 5 years preceding the survey. The

reported observation year corresponds to the middle of the reference period;

in the case of census data, the adolescent birth rate is generally computed based on the date of last

birth or the number of births in the 12 months preceding the enumeration. The census provides both

the numerator and the denominator for the rates.

Stratifiers

Results may be presented by relevant sociodemographic stratifiers (e.g urban/rural, wealth quintile,

education level).

Data requirements

For civil registration data, data on births or the adolescent birth rate are obtained from country-

reported data from the United Nations Statistics Division, or regional statistics divisions or statistical

units. The population figures are obtained from the last revision of the United Nations Population

Division World Population Prospects and only exceptionally from other sources.

For survey data, the data are obtained from surveys such as (DHS, the United States’ Centers for

Disease Control and Prevention – assisted Reproductive Health Surveys, MICS and other nationally

sponsored surveys. Whenever the estimates are available in the survey report, they are directly taken

from it. In other cases, if microdata are available, estimates are produced by the United Nations

Population Division, based on national data.

For census data, the estimates are preferably directly obtained from census reports. In such cases,

adjusted rates are only used when reported by the national statistical office. In other cases, the

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adolescent birth rate is computed from tables on births in the preceding 12 months, by age of mother,

and census population distribution by sex and age.

Data sources

Estimates are produced by the United Nations Population Division at the beginning of every year, for the

Millennium Development Goals database.

Data are available on the United Nations website (13) and for annual data dating back to 1960 on the World

Bank website (14).

Issues

There are a number of limitations in the estimates:

for civil registration, rates are subject to limitations that depend on the completeness of birth

registration, the treatment of infants born alive but dead before registration or within the first 24

hours of life, the quality of the reported information relating to age of the mother, and the inclusion

of births from previous periods. The population estimates may suffer from limitations connected to

age misreporting and coverage;

for survey and census data, both the numerator and denominator come from the same population.

The main limitations concern age misreporting, birth omissions, misreporting the date of birth of the

child, and sampling variability in the case of surveys.

The adolescent birth rate is commonly reported as the age-specific fertility rate for ages 15 to 19 in the

context of calculation of total fertility estimates. It has also been called adolescent fertility rate. A related

measure is the proportion of adolescent fertility measured as the percentage of total fertility contributed by

women aged 15–19 years.

The World Health Organization (WHO) encourages inclusion of ages 10–14 years in countries with a high

number of adolescent births. Even though the number is likely to be small, the risks to mothers and infants

are serious.

Data availability

Data could be identified for 184 countries for the year 2012 (United Nations Population Division, World

Bank development indicators database).

Note: this indicator is part of the Global reference list of 100 core health indicators (7).

7

IO4 Overweight or obesity in women

Definition

The prevalence of overweight in women is defined as the percentage of women aged 18+ years with BMI

≥25 kg/m². The prevalence of obesity is defined as the percentage of women aged 18+ years with BMI

≥30 kg/m².

Maternal overweight and obesity result in increased maternal morbidity and infant mortality (15). Maternal

overweight is associated with overweight and metabolic syndrome in children (16–18).

This indicator is calculated as:

Number of women aged 18 + years in the sample with BMI ≥ 25 kg/m²

Total number of women aged 18 + years in the sample∗ 100%

Stratifiers

Results may be presented by age and relevant sociodemographic stratifiers where available.

Data requirements

Weight and height of women, measured with standardized equipment.

Data sources

Population-based (preferably nationally representative) household surveys in which height and weight were

measured (e.g. DHS, MICS).

Issues

Potential limitations include measurement error and representativeness of the sample.

Data availability

Data have been collected for this indicator for 124 countries since 2000 (NCD-RisC collaborating group).

Note: This indicator is part of the WHO NCD Global Monitoring Framework (19) and of the Global

reference list of 100 core health indicators (7).

8

IO5 Overweight in school-age children and adolescents

Definition

The prevalence of overweight in school-age children and adolescents is defined as the percentage of children

aged 5–18 years with sex-specific BMI-for-age above +1 SD from the WHO 2007 reference median.

This indicator is calculated as:

Number of school– age children and adolescent in the sample with BMI– for– age > +1 SD of the WHO 2007 reference

Total number of school– age children and adolescent in the sample ∗ 100%

Stratifiers

Results may be presented by age and relevant sociodemographic stratifiers.

Data requirements

Weight and height of school-age children and adolescent (5–18 years), measured with standardized

equipment.

Data sources

School-based or population-based (preferably nationally representative) surveys in which height and weight

were measured.

Issues

Potential limitations include measurement error and representativeness of the sample.

Data availability

Data have been collected for this indicator for 24 countries since 2000, covering the age range 5–18 years.

When restricting the age range to between 12 and 18 years, the same data source indicates data collection for

55 countries (NCD-RisC collaborating group). Therefore, most of the age groups that are not covered are

between 5 and 12 years.

Note: this indicator is part of the WHO NCD Global Monitoring Framework (19) and of the Global

reference list of 100 core health indicators (7).

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II.2. Process indicators

Indicator name Short definition

PR1 Minimum acceptable diet Proportion of children aged 6–23 months who receive a minimal

acceptable diet

PR2 Safely managed drinking water

services

Proportion of population using a safely managed drinking water

services

PR3 Safely managed sanitation

services

Proportion of population using a safely managed sanitation

services

PR4 Iron and folic acid

supplementation

Proportion of pregnant women receiving iron and folic acid

supplements

PR5 Births in baby-friendly hospitals Percentage of births in baby-friendly facilities

PR6 Breastfeeding counselling

Proportion of mothers of children 0–23 months who have

received counselling, support or messages on optimal

breastfeeding at least once in the last year

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PR1 Minimum acceptable diet

Definition

This indicator measures the proportion of children aged 6–23 months who receive a minimum acceptable

diet (MAD), apart from breast milk.

Complementary feeding interventions are most efficient in reducing malnutrition and promoting adequate

growth and development (20). Without adequate diversity and meal frequency, infants and young children

are vulnerable to malnutrition, especially stunting and micronutrient deficiencies, and to increased morbidity

and mortality.

The MAD considers both the minimum feeding frequency and the minimum dietary diversity, as appropriate

for various age groups. If a child meets the minimum feeding frequency and minimum dietary diversity for

his or her age group and breastfeeding status, then he or she is considered to receive a MAD.

The minimum daily meal frequency is defined as:

twice for breastfed infants aged 6–8 months;

three times for breastfed children aged 9–23 months;

four times for non-breastfed children aged 6–23 months.1

The minimum dietary diversity is achieved when the diet contains four or more of the following food groups:

grains, roots and tubers;

legumes and nuts;

dairy products (milk, yogurt, cheese);

flesh foods (meat, fish, poultry, liver or other organs);

eggs;

vitamin A-rich fruits and vegetables;

other fruits and vegetables.

This indicator is calculated as:

Number of breastfed children aged 6– 23 months in the sample who had at least the minimum

dietary diversity and the minimum meal frequency during the previous day +

Number of non– breastfed children aged 6– 23 months in the sample who received at least 2 milk feedings and had at least

the minimum dietary diversity not including milk feeds and the minimum meal frequency during the previous day

Total number of children aged 6– 23 months in the sample with MAD component data ∗ 100%

Stratifiers

Results may be presented by relevant sociodemographic stratifiers where available (e.g. urban/rural, wealth

quintile, mother’s education).

1 The minimum meal frequency for non-breastfed children is defined as four or more feedings of solid, semi-solid, soft food, or milk feeds for children aged 6–

23 months. At least two of these feedings must be milk feed.

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Data requirements

Data on breastfeeding, dietary diversity (food group variables), number of semi-solid/solid feeds and

number of milk feeds collected for children aged 6–23 months the day preceding the survey.

Data sources

Population-based household surveys (e.g. DHS and MICS).

Issues

This indicator is of global importance and aims to further encourage implementation of appropriate

programmes that inform mothers and caregivers about the WHO recommendations for continued

breastfeeding (21) and complementary feeding (22).

The United States Agency for International Development (USAID) programme Feed the future recommends

this indicator be collected approximately every 2 years (23).

Data availability

Data have been compiled into a database since 2014 for 44 countries (Global databases, UNICEF). Prior to

data-collection efforts starting around 2010, data were not aligned with the indicator definition; this explains

the small number of countries currently in the database, which will increase in the next year with many new

surveys becoming available.

Note: this indicator is part of the additional indicators in the Global reference list of 100 core health

indicators (7).

12

PR2 Safely managed drinking water services

Definition

This indicator measures the proportion of a population using a basic drinking water source that is located on

their premises and available when needed; the water is free of faecal (and priority chemical) contamination

and/or regulated by a competent authority.

Basic drinking water sources include the following types: piped water into a dwelling, yard or plot; public

taps or standpipes; boreholes or tube wells; protected dug wells; protected springs; and rainwater. Packaged

drinking water is considered as a basic source if households use a basic water source for other domestic

purposes.

Improved, safe drinking services that include a household connection as well as covered wells and bore

holes can have an impact on preventing the incidence of diarrhoea, which can have an impact on stunting

(24).

This indicator is calculated as:

Number of households (or population) with safely managed drinking water services

Total number of households (or population) ∗ 100%

Stratifiers

Results may be stratified by urban/rural and wealth quintiles.

Data requirements

Information on the number of households with a basic drinking water source that is located on the premises

and available when needed, with a certification by a competent authority that it is free of faecal (and priority

chemical) contamination.

Data sources

Household surveys can provide data on basic water on premises as well as availability when needed, and

free from contamination, via direct water quality testing. Administrative sources can provide data on

freedom from contamination, regulation of water safety and risk management. Elements from household

surveys can be reported immediately.

Issues

Most household surveys and censuses in the WHO/UNICEF Joint Monitoring Programme (JMP) for Water

Supply and Sanitation database do not include a separate stratum for informal urban settlements or slums,

which may fall outside official enumeration areas used by household surveys and censuses. Monitoring of

disadvantaged groups is difficult when they form a small proportion of the population, and therefore are

difficult to reach through conventional household surveys. In such cases, alternative survey instruments or

mechanisms, such as rapid assessment-type surveys that could lead to more efficiency in gaining

information on target subpopulations; citizens’ networks; or crowd-sourced data, could be explored as an

alternate measure.

13

In the household surveys and censuses that form the majority of JMP data, most survey responses are made

at the level of the household, and it is therefore impossible to accurately measure intra-household

inequalities such as sex, age or disability.

Data availability

Since 2000, data have been collected on this indicator for 192 countries (WHO/UNICEF JMP for Water

Supply and Sanitation).

Note: this indicator is part of the Global reference list of 100 core health indicators (7).

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PR3 Safely managed sanitation services

Definition

This indicator measures the proportion of population using a basic sanitation facility that is not shared with

other households and where excreta are safely disposed in situ or transported to a designated place for safe

disposal or treatment.

Basic sanitation facilities include flush or pour-flush toilets to sewer systems, septic tanks or pit latrines,

ventilated improved pit latrines, pit latrines with a slab, and composting toilets.

Improved sanitation and hygienic practices have an impact on preventing the incidence of diarrhoea, which

can have an impact on stunting (24). A systematic analysis also showed that improvements in water,

sanitation and hygiene (WASH) have also been seen to have mild impacts on stunting (25).

This indicator is calculated as:

Number of households (or population) with safely managed sanitation services

Total number of households (or population) ∗ 100%

Stratifiers

Results may be stratified by urban/rural and wealth quintiles.

Data requirements

Information on the number of households with a basic sanitation facility that is not shared with other

households and where excreta are safely disposed in situ or transported to a designated place for safe

disposal or treatment.

Data sources

Household surveys can provide information on types of sanitation facilities and disposal in situ.

Administrative, population and environmental data can be used to estimate safe disposal/transport of

excreta, when no country data are available.

Issues

Most household surveys and censuses in the WHO/UNICEF JMP for Water Supply and Sanitation database

do not include a separate stratum for informal urban settlements or slums, which may fall outside official

enumeration areas used by household surveys and censuses. In such cases, alternative survey instruments or

mechanisms like rapid assessment-type surveys could lead to more efficiency in gaining information on

target subpopulations. Citizens’ networks, or crowd-sourced data could be explored as an alternate measure.

In the household surveys and censuses that form the majority of JMP data, most survey responses are made

at the level of the household, and it is therefore impossible to accurately measure intra-household

inequalities such as sex, age or disability.

15

Data availability

Since 2000, data have been collected on this indicator for 192 countries (WHO/UNICEF JMP for Water

Supply and Sanitation).

Note: this indicator is part of the Global reference list of 100 core health indicators (7).

16

PR4 Iron and folic acid supplementation

Definition

This indicator is defined as the proportion of women with a birth in the last 2 years who received or bought

iron and folic acid supplements for at least 6 months during their last pregnancy, in amounts that were in

accordance with recommended protocols.

Iron and folic acid supplementation can decrease the risk of maternal anaemia and neural tube defects in

offspring.

This indicator is calculated as:

Number of pregnant women in the sample who received or purchased the recommended number of iron/folic acid tablets during last pregnancy

Total number of pregnant women in the sample with a birth in the last 2 years∗ 100%

WHO recommends that all pregnant women consume daily tablets containing 30–60 mg of elemental iron

and 400 µg (0.4 mg) folic acid, beginning as soon as possible during gestation and no later than the third

month (26, 27).

Stratifiers

Results may be presented by source of supplements (i.e. provided by the health system/care organization or

purchased), by relevant sociodemographic stratifiers where available (e.g. urban/rural, wealth quintile,

mother’s education) and other social determinants (e.g. distance to nearest care facility).

Data requirements

Information on the number of pregnant women who were given or who purchased iron/folate tablets during

their last pregnancy; the number of tablets received or purchased; and the total number of women who gave

birth in the reference period.

Data sources

Health facility and antenatal care clinic records; population-based household surveys (e.g. DHS,

reproductive health surveys and MICS)

Issues

This indicator captures the distribution of iron and folic acid supplements, but not the actual consumption.

Women must receive appropriate counselling on why and how to take iron and folic acid supplements. This

indicator is primarily intended to measure supplementation during the last two trimesters of pregnancy.

Accurate reporting of the numbers of supplements received or purchased by women is problematic, even

when measured specifically for the second and third trimesters of pregnancy. Heath-facility patient records

may not be consistently accurate. Some women may be purchasing supplements from community-based

pharmacies and other sources and their recall of the amounts purchased may be subject to error (28).

17

After the first trimester of pregnancy, some women may be receiving or purchasing iron supplementation

alone (without folic acid or other micronutrients), or some women may be taking a formulation that contains

multiple micronutrients (including iron and folic acid). Restricting this indicator to tablets containing only

iron and folic acid may not capture all women who are receiving or purchasing iron supplementation.

Additionally, the indicator refers only to daily provision and may exclude supplements containing other

vitamins and minerals in addition to iron and folic acid (i.e. multiple micronutrient supplements) (27).

Data availability

Since 1999, 61 countries have collected data on the number of tablets taken during pregnancy (DHS).

Although the DHS questionnaire only asks about iron supplementation, the responses of women cover folic

acid as well when the supplements given in countries include both iron and folic acid. On the request of

countries, the question is sometimes modified to include both iron and folic acid.

Note: this indicator is not part of the Global reference list of 100 core health indicators (7).

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PR5 Births in baby-friendly hospitals

Definition

This indicator measures the percentage of babies born in facilities that have been designated as “baby-

friendly”.

Babies born in baby-friendly facilities have an increased breastfeeding initiation, particularly among

mothers with lower education. The baby-friendly hospital initiative (BFHI) accreditation also increased

exclusive breast-feeding for ≥4 weeks by 4.5% among mothers with lower education who delivered in BFHI

facilities (29).

This indicator is calculated as

Number of births that took place in facilities

currently designated as “baby– friendly” in the calendar year

Total number of births in the calendar year ∗ 100%

Stratifiers

Results may be presented by urban/rural stratification.

Data requirements

• Census information on the annual number of births in the country.

• Counts of the number of births in facilities designated as “baby-friendly”.

Data sources

Census and birth facilities registry systems.

Issues

The Ten steps to successful breastfeeding (30) describe the key policies and procedures necessary to

breastfeeding support. Maternity facilities that have implemented the “Ten steps” – with the addition of

relevant parts of the International Code of Marketing of Breast-milk Substitutes (31) – can be designated as

“baby-friendly”. Adherence to the “Ten steps” dramatically improves rates of exclusive breastfeeding. In

one randomized controlled trial, the difference in exclusive breastfeeding rates at 3 months between the

BFHI intervention groups and the control hospitals was almost 7-fold.

Global information on implementation of the BFHI has not been updated since the Global nutrition policy

review in 2009–2010 (32). Multiple surveys have been used since to update the information in a subset of

countries. WHO intends to survey BFHI national coordinators in 2015.

Data availability

Data are available in the following reports:

BFHI report for industrialized countries 2014 (32 countries) (33)

19

Global nutrition policy review (WHO, 2013; 35 countries) (32)

Pan American Health Organization survey on BFHI implementation in Latin America 2014 (34)

UNICEF Nutridash survey 2013 (UNICEF, 2014; 38 countries) (35)

World Breastfeeding Trends Initiative (WBTi) 2014 (92 countries) (36)

Note: this indicator is not part of the Global reference list of 100 core health indicators (7).

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PR6 Breastfeeding counselling

Definition

This indicator is defined as the proportion of mothers of children aged 0–23 months who have received

counselling, support or messages on optimal breastfeeding by trained health-system personnel or volunteers

at least once in the last year.

Studies have shown that educating mothers on appropriate complementary feeding can improve child

growth, in families that are food secure (37).

This indicator is calculated as:

Number of mothers of children aged 0– 23 months in the sample who have received counselling, support or messages on optimal breastfeeding

by health − system personnel or volunteers at least once in the last year

Total number of mothers of children aged 0– 23 months in the sample∗ 100%

Stratifiers

Women with children aged 0–11 months and 12–23 months may be reported separately, and by type of

provider (e.g. paid/unpaid). Other stratifiers may be sociodemographic (e.g. urban/rural, wealth quintile,

mother’s education, distance to nearest care facility).

Data requirements

Data would be required on the following parameters: the date of birth of the women’s children; whether they

received any counselling/support/messages on optimal breastfeeding in the last year; (if yes) who they

received such messages from – based on a pre-categorized list.

Data sources

Currently the data on this indicator are not collected but their inclusion in population-based household

surveys such as MICS and DHS is under discussion. Standard modules and adaptation instructions to

facilitate inclusion of this indicator in household surveys need to be developed.

Issues

Persons providing the counselling/support/messages can either be paid (e.g. medical doctors, nurses,

community health workers, health extension workers and others) or unpaid (e.g. peer support counsellor,

mother support group leader) but would need to have been trained on the national standards for providing

such counselling/support/messages.

The country would need to come up with a list of such categories of people who provide training on national

standards, and customize the survey instrument to include only those persons, taking the following into

account:

recognizable and specific names: in order to facilitate the respondent’s recall, each country should

develop a complete and thorough list of all persons who are trained and have this role – using

21

specific and recognizable names for the types of persons (e.g. “local government area peer support

counsellor”, “village health volunteer”) and customize the survey instrument with the appropriate

persons in their country;

regular updates for new surveys: as categories of people that would have such a function can change

over time, care would be needed to ensure every survey reconsiders the categories prior to finalizing

questionnaires and other related materials. In other words, old lists from a 2015 survey should not be

used without first reviewing and updating, if necessary, ahead of a survey in 2018.

Limitations of the indicator include:

it assumes all persons in the selected categories were trained as per the national standards: the

assumption would be that all of the people in the categories the country selects as being appropriate

may or may not have been trained. In an ideal situation, all paid and unpaid persons fitting the above

categories would have received the required refresher training at specified intervals, and any newly

paid or unpaid persons would be trained prior to starting activities. However, this may not be the

case in all countries, but is probably a bias that cannot be avoided. Additional information at the

input level, such as records related to all persons (paid and unpaid) that would have this function, and

their training status (date of full training on national breastfeeding standards and dates of refresher

trainings), would be useful information in this regard;

it assumes all trained persons are providing optimal messages: while the optimal situation would be

that all trained persons were able to give optimal advice, all training and trainees are not equal.

Therefore, an assumption is being made that optimal counselling/support/messages are provided.

Additional information related to the capacity of trained persons (even if just following the training

session, as a post-test – both written and oral, as oral skills are important for delivery of counselling

and support), and/or data from supportive supervision visits on a small sample of sites, could be

useful to indicate whether the messages reaching the target women are optimal.

Data availability

This is a new indicator and thus no standard data following this definition are yet available, to our

knowledge, and a global database is yet to be developed.

Note: this indicator is not part of the Global reference list of 100 core health indicators (7).

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II.3. Policy, environment and capacity indicators

Indicator name Short definition

PE1 Trained nutrition

professionals Number of trained nutrition professionals /100 000 population

PE2

Regulation of

marketing of breast-

milk substitutes

Country has legislation /regulations fully implementing the International

Code of Marketing of Breast-milk Substitutes (resolution WHA34.22) (31,

38) and subsequent relevant resolutions adopted by the Health Assembly

PE3 Maternity protection Country has maternity protection laws or regulations in place in line with

the ILO Maternity Protection Convention 183 and Recommendation 191

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PE1 Trained nutrition professionals

Definition

This indicator is defined as the number of health personnel trained to respond to nutrition challenges and

implement nutrition-related interventions and programmes at each service delivery level (e.g. management

of malnutrition) per 100 000 population.

There is increasing evidence of a strong correlation between the density of human resources for health in a

country and population health outcomes. This indicator is based on the same principle and concept applied

to human resources for implementing nutrition actions in a country, and population nutrition outcomes.

This indicator is calculated as:

Number of health personneltrained to respond and implement nutrition interventions

total population ∗ 100 000

Stratifiers

Results may be presented by urban/rural stratification.

Data requirements

Data would be required on the training received by health personnel and on their capacity to handle nutrition

programmes, usually obtained through ad hoc surveys.

Data sources

This indicator is maintained in the Nutrition Landscape Information System, to encourage countries to

collect and compile data in order to assess their national capacity for implementing nutrition interventions

and scaling up action in nutrition. At present, data are not available for all countries.

Issues

Although the commitment of national governments for improving maternal, infant and young child nutrition

has increased, owing to various global movement and initiatives, service delivery remains a challenge.

Therefore, it is important to strengthen and monitor the capacity to deliver nutrition interventions, not only

at the central government level, but also at local governmental levels.

An alternative proxy indicator for the country’s “capacity” to deliver nutrition interventions would be simply

the density of nursing and midwifery personnel.

Data availability

Data are not readily available yet for this indicator, but the data are available at country level through some

in-depth review, as evidenced by the in-depth Landscape Analysis country assessment conducted in a

number of countries. It was considered important to monitor, in order to truly assess countries’ potential

capacity to scale up action in nutrition

24

If “nursing and midwifery personnel density per 10 000 population” will be used as a proxy indicator for

country’s “capacity” to deliver nutrition interventions, the number of countries collecting information on the

number of nursing and midwifery personnel (year 2000 onwards) is 186. The data on “nursing and

midwifery personnel density per 10 000 population” are available in the Global Health Observatory.

Note: this indicator is not part of the Global reference list of 100 core health indicators (7).

25

PE2 Regulation of marketing of breast-milk substitutes

Definition

This indicator is defined as whether the government has adopted comprehensive legislation (law, regulation,

decree, etc.) for national implementation of the International Code of Marketing of Breast-milk Substitutes

(resolution WHA 34.22) (31, 38) and relevant subsequent resolutions adopted by the WHA (39).

Little progress in increasing breastfeeding rates is seen in the absence of provisions of the International

Code of Marketing of Breast-milk Substitutes (31, 40). However, the establishment of legislation is not

sufficient and should be complemented by adequate implementation and monitoring mechanisms (41).

This indicator is calculated as:

The country has adopted comprehensive legislation (law, regulation, decree, etc.) for national

implementation of the International Code of Marketing of Breast-milk Substitutes (resolution WHA 34.22)

(31, 38) and relevant subsequent WHA resolutions (Yes/No).

Stratifiers

Not relevant.

Data requirements

Access to national legislative document(s). Translation into United Nations language, where necessary.

Data sources

WHO Code Survey 2014–2015

WHO Global database on the Implementation of Nutrition Action (GINA)

WHO Status report on country implementation of the International Code of Marketing of Breast-milk

Substitutes (2013) (42)

Relevant partner databases (e.g. UNICEF, International Code Documentation Centre (ICDC))

Issues

This indicator assesses the presence of the legislation, but not its actual implementation, i.e. it does not cover

actions taken by governments to enforce the legislation, such as monitoring marketing in different settings

and channels, as well as sanctioning and documenting violations.

Improper marketing and promotion of food or drink products that compete with breastfeeding often

negatively affect the choice and ability of a mother to breastfeed her infant optimally. The Code adopted

through WHA resolution 34.22 (38), was formulated in response to the realization that such marketing

resulted in poor infant feeding practices, which negatively affect the growth, health and development of

children and are a major cause of mortality in infants and young children.

The Code (31, 38) is a set of recommendations to regulate the marketing of breast-milk substitutes, feeding

bottles and teats. It is an expression of the collective will of the highest global authority on health, and

26

carries substantial political and moral weight, The Code aims to contribute “to the provision of safe and

adequate nutrition for infants, by the protection and promotion of breastfeeding, and by ensuring the proper

use of breast-milk substitutes, when these are necessary, on the basis of adequate information and through

appropriate marketing and distribution” (Code, Article 1) (31).

Subsequent to the adoption of WHA resolution 34.22 (38), numerous additional WHA resolutions that have

been adopted provide clear guidance and directives on key issues, such as the recommendation for the

duration of exclusive breastfeeding and concerns over intrinsic contamination of powdered infant formula;

the need to ensure that micronutrient interventions do not undermine breastfeeding and optimal

complementary feeding; and the need to avoid conflicts of interest in the funding of monitoring and infant

and young child feeding programmes.

An alternative form of expressing this indicator would be to measure the strength of legislation for national

implementation of the International Code of Marketing of Breast-milk Substitutes (resolution WHA34.22)

(31, 38) and subsequent relevant resolutions adopted by the WHA. The strength of the legislation would be

assessed based on the extent to which it covers key provisions of the Code, including appropriate scope,

information and education materials; promotion to the general public and to health workers; labelling of

designated products; and provisions for the establishment of monitoring mechanisms, among others, and to

what extent it takes into consideration subsequent relevant WHA resolutions. Criteria for categorizing

overall strength is currently being developed in consultation with UNICEF, as part of harmonization of

indicators under the NetCode project.

Data availability

A total of 107 countries have information on national legislation related to the International Code of

Marketing of Breast-milk Substitutes (GINA) (31).

Note: this indicator is not part of the Global reference list of 100 core health indicators (7).

27

PE3 Maternity protection

Definition

This indicator is defined as whether the country has adopted legislation (law, regulation, decree, etc.) for

national implementation of maternity and paternity protection in line with International Labour Organization

(ILO) guidance.

Returning to work after maternity leave has been identified as a significant cause for stopping or never

starting breastfeeding (43–46). In most low- and middle-income countries, maternity leave is limited to

formal sector employment or is not always provided in practice (47–49).

This indicator is calculated as:

The country has adopted legislation (law, regulation, decree, etc.) for national implementation of maternity

and paternity protection in line with ILO guidance (Yes/No).

Stratifiers

Not relevant.

Data requirements

Access to national legislative document(s). Translation into United Nations language, where necessary.

Data sources

ILO maintains the TRAVAIL Database of Conditions of Work and Employment Laws, which provides a

picture of the regulatory environment of working time, minimum wages and maternity protection, including

paternity leave, in more than 100 countries around the world. It contains comprehensive legal information,

which allows customized research on a specific country, comparison of the legislation of several countries or

regions on a particular subject, and searches by text. ILO also periodically publishes reviews of national

legislation related to maternity protection at work (see for example the recent ILO report Maternity and

paternity at work: law and practice across the world (50).

WHO has included information on maternity protection legislation in GINA.

Issues

This indicator assesses the presence of the legislation, but not its strength or actual implementation (i.e. it

does not cover actions taken by governments to enforce the legislation, such as monitoring and

enforcement).

Maternity protection at work is an essential element in equality of opportunity, treatment and health

protection. It seeks to enable women to combine their reproductive and productive roles successfully, and to

prevent unequal treatment in employment due to women’s reproductive role. Maternity protection is

important for nutrition, in terms of achieving good birth outcomes and enabling breastfeeding. Increasingly,

legislation on paternity protection is being developed as a means to provide fathers with security in their

parenting role and to reinforce maternity protection via supporting those women who have a male partner.

28

An alternative form of expressing this indicator would be to measure the strength of national maternity

protection laws or regulations. The strength of the legislation is assessed based on the extent it covers key

provisions of the ILO Maternity Protection Convention No. 183 and the accompanying ILO Maternity

Protection Recommendation No. 191, including appropriate duration of leave, amount of maternity leave

benefits, source of cash benefits, breastfeeding breaks, remuneration of nursing breaks, nursing facilities,

and coverage of law, among others. Criteria for determining overall strength are currently being developed

in consultation with ILO.

Data availability

A total of 178 countries have information on national legislation on maternity protection (50).

Note : this indicator is not part of the Global reference list of 100 core health indicators (7).

29

III. Final considerations

The intermediate, process and policy indicators presented are proposed for a core set of indicators that

would allow a broad understanding of policies and programmes that are conducive to improving nutrition.

Reporting on the entire core set would greatly enhance countries’ capacity to implement and track the

Comprehensive implementation plan on maternal, infant and young child nutrition (1) and respond to the

global need for more and improved nutritional data.

However, the analysis presented by this paper shows that while some indicators are already broadly and

systematically collected, others are instead collected only by some countries or have been recently

developed and are at an early stage of implementation.

The proposed core set could be considered a template on which countries may adapt or build their nutrition

monitoring systems. The implementation of this framework may be progressive, taking into account the

need to avoid overwhelming personnel, programmes and surveillance systems.

30

References

1. Comprehensive implementation plan on maternal, infant and young child nutrition. In: Sixty-fifth

World Health Assembly, Geneva, 21–26 May 2012. Resolutions and decisions, annexes. Geneva:

World Health Organization; 2012: 55–68 (A65/11 – 26 April 2012 and A65/11 Corr.1 – 11 May 2012

(http://www.who.int/nutrition/topics/WHA65.6_annex2_en.pdf, accessed 1 April 2015).

2. Resolution WHA67(9). Maternal, infant and young child nutrition. In: Sixty-seventh World Health

Assembly, Geneva, 19–24 May 2014. Resolutions and decisions, annexes. Geneva: World Health

Organization; 2014: 62 (http://apps.who.int/gb/ebwha/pdf_files/WHA67-REC1/A67_2014_REC1-

en.pdf#page=25, accessed 1 April 2015).

3. Maternal, infant and young child nutrition: development of the core set of indicators. Report by the

Secretariat. Geneva: World Health Organization; 2014 (EB136/9;

http://apps.who.int/gb/ebwha/pdf_files/EB136/B136_9-en.pdf, accessed 1 April 2015).

4. Indicators for the Global Monitoring Framework on Maternal, Infant and Young Child Nutrition.

Geneva: World Health Organization; 2014

(http://www.who.int/nutrition/topics/indicators_monitoringframework_miycn_background.pdf?ua=1,

accessed 1 April 2015).

5. Diarrhoeal disease. Geneva: World Health Organization; 2012 (Fact sheet no 330;

http://www.who.int/mediacentre/factsheets/fs330/en/, accessed 1 April 2015).

6. Checkley W, Buckley G, Gilman RH, Assis AM, Guerrant RL, Morris SS et al; Childhood

Malnutrition and Infection Network. Multi-country analysis of the effects of diarrhoea on childhood

stunting. Int J Epidemiol 2008;37(4):816–30. doi:10.1093/ije/dyn099.

7. Global reference list of 100 core health indicators Working version 5. Geneva: World Health

Organization; 2014

(http://www.internationalhealthpartnership.net/fileadmin/uploads/ihp/Documents/Key_Issues/One_M_

E_Platform/Global_RefList_Core_Indicators_V5_17Nov2014_WithoutAnnexes.pdf, accessed 1 April

2015).

8. Black RE, Allen LH, Bhutta ZA, Caulfield LE, de Onis M, Ezzati M et al., Maternal and Child

Undernutrition Study Group. Maternal and child undernutrition: global and regional exposures and

health consequences. Lancet 2008;371(9608):243–60. doi:10.1016/S0140-6736(07)61690-0.

9. Imdad A, Bhutta ZA. Maternal nutrition and birth outcomes: effect of balanced protein-energy

supplementation. Paediatr Perinat Epidemiol 2012;26(s1):178–90. doi:10.1111/j.1365-

3016.2012.01308.x.

10. United Nations Statistics Division. Millennium Development Goals Indicators

(http://mdgs.un.org/unsd/mdg/Metadata.aspx?IndicatorId=0&SeriesId=761, accessed 1 April 2015).

11. Handbook on the collection of fertility and mortality data. New York: United Nations; 2004

(ST/ESA/STAT/SER.F/92; http://unstats.un.org/unsd/publication/SeriesF/SeriesF_92E.pdf, accessed 1

April 2015).

12. United Nations, Department of Economic and Social Affairs, Population Division. Manual X: indirect

techniques for demographic estimation. New York: United Nations; 1983

(http://www.un.org/esa/population/publications/Manual_X/Manual_X.htm, accessed 1 April 2015.

13. United Nations. Department of Economic and Social Affairs. Population Division. 2013 update for the

MDG database. New York: United Nations; 2013 (POP/DB/Fert/A/MDG2013;

http://www.un.org/en/development/desa/population/publications/dataset/fertility/data/2013_Update_M

DG(5.4)_ABR.xls, accessed 1 April 2015).

14. Adolescent fertility rate. Births per 1,000 women ages 15–19. Geneva: World Bank; 2015;

http://data.worldbank.org/indicator/SP.ADO.TFRT, accessed 1 April 2015).

31

15. Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M et al.; Maternal and Child

Nutrition Study Group. Maternal and child undernutrition and overweight in low-income and middle-

income countries. Lancet 2013; 382(9890):427–51. doi:10.1016/S0140-6736(13)60937-X. Erratum in:

Lancet 2013;382(9890):396.

16. Gulati S, Misra A, Colles SL, Kondal D, Gupta N, Goel K et al. Dietary intakes and familial correlates

of overweight/ obesity: a four-cities study in India. Ann Nutr Metab 2013;62(4):279–90.

doi:10.1159/000346554.

17. Yajnik CS. The lifecycle effects of nutrition and body size on adult adiposity, diabetes and

cardiovascular disease. Obes Rev 2002; 3(3):217-24.

18. Boney CM, Verma A, Tucker R, Vohr BR. Metabolic syndrome in childhood: association with birth

weight, maternal obesity, and gestational diabetes mellitus. Pediatrics 2005;115(3):e290–6.

19. World Health Organization. NCD Global Monitoring Framework

(http://www.who.int/nmh/global_monitoring_framework/en/, accessed 1 April 2015).

20. Informal meeting to review and develop indicators for complementary feeding. report, 3–5 December

2002, Washington, DC. Geneva: World Health Organization; 2002

(http://www.who.int/nutrition/publications/infantfeeding/a91059/en/, accessed 1 April 2015).

21. World Health Organization. E-Library of Evidence for Nutrition Actions (eLENA). Continued

breastfeeding (http://www.who.int/elena/titles/continued_breastfeeding/en/, accessed 1 April 2015).

22. World Health Organization. E-Library of Evidence for Nutrition Actions (eLENA). Complementary

feeding (http://www.who.int/elena/titles/complementary_feeding/en/, accessed 1 April 2015).

23. Feed the future indicator handbook. New York: United States Agency for International Development;

2014

(http://www.feedthefuture.gov/sites/default/files/resource/files/ftf_handbook_indicators_october2014.

pdf, accessed 1 April 2015).

24. Cairncross S, Hunt C, Boisson S, Bostoen K, Curtis V, Fung IC et al. Water, sanitation and hygiene

for the prevention of diarrhoea. Int J Epidemiol 2010;39(Suppl. 1):i193–205. doi:10.1093/ije/dyq035.

25. Dangour AD, Watson L, Cumming O, Boisson S, Che Y, Velleman Y et al. Interventions to improve

water quality and supply, sanitation and hygiene practices, and their effects on the nutritional status of

children. Cochrane Database Syst Rev 2013;8:CD009382. doi:10.1002/14651858.CD009382.pub2.

26. Nutrition Landscape Information System (NLIS). Country profile indicators: interpretation guide.

Geneva: World Health Organization; 2010

(http://whqlibdoc.who.int/publications/2010/9789241599955_eng.pdf, accessed 1 April 2015).

27. Guideline: Daily iron and folic acid supplementation in pregnant women. Geneva: World Health

Organization; 2012 (http://apps.who.int/iris/bitstream/10665/77770/1/9789241501996_eng.pdf,

accessed 1 April 2015).

28. Measure Evaluation PRH. Family Planning and Reproductive Health Database. Percent of pregnant

women who receive the recommended number of iron/folate supplements during pregnancy

(http://www.cpc.unc.edu/measure/prh/rh_indicators/specific/womens-nutrition/percent-of-pregnant-

women-who-receive-the, accessed 1 April 2015).

29. Hawkins SS, Stern AD, Baum CF, Gillman MW. Evaluating the impact of the Baby-Friendly Hospital

Initiative on breast-feeding rates: a multi-state analysis. Public Health Nutr 2014; 14:1–9. [Epub ahead

of print].

30. World Health Organization, UNICEF. Baby-Friendly Hospital Initiative: Revised, updated and

expanded for integrated care. Geneva: World Health Organization, UNICEF and Wellstart

International; 2009 (http://www.who.int/nutrition/publications/infantfeeding/bfhi_trainingcourse/en/,

accessed 1 April 2015)

32

31. International Code of Marketing of Breast-milk Substitutes. Geneva: World Health Organization; 1981

(http://whqlibdoc.who.int/publications/9241541601.pdf?ua=1&ua=1, accessed 1 April 2015).

32. Global nutrition policy review. What does it take to scale up nutrition action? Geneva: World Health

Organization; 2013 (http://apps.who.int/iris/bitstream/10665/84408/1/9789241505529_eng.pdf?ua=1,

accessed 1 April 2015).

33. Industrialized countries, Esastern Europe and the Commonwealth of Independent States. Country

report collection presented on the Eighth Meeting of BFHI Coordinators, Vilnius, Lithuania, June 6-8

2014 (unpublished material).

34. PAHO survey on BFHI implementation in Latin America, 2015, ahead of publication (personal

communication by Chessa Lutter).

35. Nutridash 2013. Global report of the pilot year. New York: United Nations Children’s Fund; 2014

(http://www.sightandlife.org/fileadmin/data/News/2015/2_Feb/UNICEF_Global_NutriDash_report_2

013.pdf, accessed 1 April 2014).

36. World Breastfeeding Trends Initiative (WBTi). (http://worldbreastfeedingtrends.org/, accessed 2 April

2015).

37. Imdad A, Yakoob MY, Bhutta ZA. Impact of maternal education about complementary feeding and

provision of complementary foods on child growth in developing countries. BMC Public Health

2011;11(Suppl. 3):S25. doi:10.1186/1471-2458-11-S3-S25.

38. Resolution WHA34.22. International Code of Marketing of Breast-Milk Substitutes. In: Thirty-fourth

World Health Assembly, Geneva, 21 May 1981. Resolutions and decisions, annexes. Geneva: World

Health Organization; 1981 (http://www.who.int/nutrition/topics/WHA34.22_iycn_en.pdf, accessed 1

April 2015).

39. World Health Organization. E-Library of Evidence for Nutrition Actions (eLENA). Regulation of

marketing breast-milk substitutes (http://www.who.int/elena/titles/regulation_breast-

milk_substitutes/en/, accessed 1 April 2015).

40. Cattaneo A, Burmaz T, Arendt M, Nilsson I, Mikiel-Kostyra K, Kondrate I et al.; ‘Promotion of

Breastfeeding in Europe: Pilot Testing the Blueprint for Action’ Project. Protection, promotion and

support of breast-feeding in Europe: progress from 2002 to 2007. Public Health Nutr 2010;3(6):751–9.

doi:10.1017/S1368980009991844.

41. Lutter CK. The International Code of Marketing of Breast-milk Substitutes: lessons learned and

implications for the regulation of marketing of foods and beverages to children. Public Health Nutr

2013;16(10):1879–84. doi:10.1017/S1368980012004235.

42. Country implementation of the International Code of Marketing of Breast-milk Substitutes. Status

report 2011. Geneva: World Health Organization; 2013

(http://apps.who.int/iris/bitstream/10665/85621/1/9789241505987_eng.pdf, accessed 1 April 2015).

43. Bick DE, MacArthur C, Lancashire RJ. What influences the uptake and early cessation of breast

feeding? Midwifery 1998;14(4):242–7.

44. Baker M1, Milligan K. Maternal employment, breastfeeding, and health: evidence from maternity

leave mandates. J Health Econ 2008;27(4):871–87. doi:10.1016/j.jhealeco.2008.02.006.

45. Agunbiade OM1, Ogunleye OV. Constraints to exclusive breastfeeding practice among breastfeeding

mothers in Southwest Nigeria: implications for scaling up. Int Breastfeed J 2012;7:5.

doi:10.1186/1746-4358-7-5.

46. Perera PJ, Ranathunga N, Fernando MP, Sampath W, Samaranayake GB. Actual exclusive

breastfeeding rates and determinants among a cohort of children living in Gampaha district Sri Lanka:

a prospective observational study. Int Breastfeed J 2012;7(1):21. doi:10.1186/1746-4358-7-21.

33

47. Koujianou Goldberg P, Pavcnik N. The response of the informal sector to trade liberalization. J Dev

Econ 2003;72(2):463–96.

48. Ogbuanu C, Glover S, Probst J, Liu J, Hussey J. The effect of maternity leave length and time of

return to work on breastfeeding. Pediatrics 2011;127(6):e1414–27. doi:10.1542/peds.2010-0459.

49. Ruhm CJ. Policies to assist parents with young children. Future Child. 2011;21(2):37–68.

50. Maternity and paternity at work: law and practice across the world. Geneva: International Labour

Organization; 2014 (http://www.ilo.org/wcmsp5/groups/public/---dgreports/---dcomm/---

publ/documents/publication/wcms_242615.pdf, accessed 1 April 2014).