The WBTi has identified 15 indicators in two parts, each indicator having specific significance.

1.   Part-I deals with infant feeding practices (indicator 1-5)
2.   Part -II deals with policy and programmes (indicator 6-15)

Once assessment of gaps is carried out, the data on 15 indicators is fed into the questionnaire using the WBTi web based toolkit© which is specifically designed to meet this need. The toolkit objectively quantifies the data to provide a colour- coded Rating in Red, Yellow, Blue or Green representing grade 'D' to grade 'A' state. The toolkit has the capacity to generate visual maps or graphic charts to assist in advocacy at all levels e.g. national, regional and international.

In Part I ask for specific numerical data on each infant and young child feeding practice. Those involved in this assessment are advised to use data from a random household survey that is national in scope . The data thus collected is entered into the web- based toolkit. The achievement on the particular target indicator is then rated and graded i.e. Red or grade 'D', Yellow or grade 'C', Blue or grade 'B' and Green or grade 'A'. The cut off points for each of these levels of achievement were selected systematically, based on an analysis of past achievements on these indicators in developing countries . These are incorporated from the WHO's tool.

Many mothers, in the world, deliver their babies at home particularly in the developing countries and more so in the rural areas. Breastfeeding is started late in many of these settings due to cultural or other beliefs. Ideally it should start within first half an hour of birth according to the guidelines in Baby Friendly Hospital Initiative (BFHI) "Step" 3 of the Ten Steps to Successful Breastfeeding, which says, "Start breastfeeding within the first half an hour of birth". The baby should be placed "skin-to-skin" with the mother in the first half an hour following delivery and offered the breast within the first hour in all normal deliveries. If the mother has had a cesarean section the baby should be offered breast when she is able to respond and it happens within few hours of the general anesthesia also. Mothers who have undergone cesarean sections need extra help with breastfeeding otherwise they initiate breastfeeding much later. Optimally, the baby should start to breastfeed before any routine procedure (such as bathing, weighing, umbilical cord care, administration of eye medications) is performed. Early breastfeeding helps better temperature control of the newborn baby, enhances bonding between the mother and the baby, and also increases chances of establishing exclusive breastfeeding early and its success.

1.   Use a study carried out in the country in the last five years.

2.   When you are using for the web-based toolkit WBTi for the country, ideally, it should be a study, which has a national scope. You can also use the UNICEF's Multiple Indicator Cluster Survey (MICS)

www.childinfo.org (5) when available and the WHO Global Data Bank on Breastfeeding (6) www.who.int/wormcontrol/databank/en. You can also consider using data from the Demographic and Health Survey (DHS) (4), from the "Breastfeeding Initiation" table in the chapter on "Infant Feeding and Maternal and Child Nutrition". (See the DHS website at http://www.measuredhs.com. Select survey, Select Indicators, Maternal and Child Nutrition, Initial BF, and Started within one hour)

Exclusive breastfeeding for the first six months is very crucial for survival, growth and development of infant and young children. It lowers the risk of illness, particularly from diarrheal diseases (8). It also prolongs lactation amenorrhea in mothers who breastfeed frequently (8). The WHO commissioned a systematic review of the published scientific literature and the findings were submitted for technical review and scrutiny during an Expert Consultation in March 2001. This Expert Consultation recommended a change to "exclusive breastfeeding for 6 months (8). The World Health Assembly (WHA) in May 2001 formally adopted this recommendation through a Resolution 54.2 /2001. The World Health Assembly in 2002 approved another resolution 55.25 that adopted the Global Strategy for Infant and Young Child Feeding. Later the UNICEF Executive Board also adopted this resolution and the Global Strategy for Infant and Young Child Feeding in September 2002, bringing a unique consensus on this health recommendation. Further, in areas with high HIV prevalence there is evidence that exclusive breastfeeding is more protective than "mixed feeding" for risks of HIV transmission through breastmilk (9, 10).

1.  Use a study carried out in the region/country in the last five years.

2.   When you are using for the country, Ideally, it should be a study, which has a national scope. You can also use the UNICEF's Multiple Indicator Cluster Survey (MICS) (5)
www.childinfo.org (5) when available and the WHO Global Data Bank on Breastfeeding (6) http://www.who.int/wormcontrol/databank/en/

3.When available, consider using data from the Demographic and Health Survey (DHS) (4), from the "24 hour recall" question presented in the table on "Breastfeeding Status" in the chapter on "Infant Feeding and Maternal and Child Nutrition". (See the DHS website at (http://www.measuredhs.com. Select survey, Select Indicators, Maternal and Child Nutrition, Breastfeeding Status, Exclusive Breastfeeding, (currently listed by 2-month increments)) (See Annex-1)

It is recognized that 24-hour recall may not capture the true breastfeeding patterns since birth. Unfortunately, reliable and valid data on the long-term patterns are not widely available yet. Data may not be available for this indicator because it is relatively new recommendation. Find out what data is there for the period of 0-3 and 4-6 months and average could be taken for 0-6 months. Or if data is available for each month, a calculator to find out the data for 0-6 months is provided for use in MS Excel (See Annex-1)

The additional information here would provide some degree of understanding of exclusive breastfeeding patterns below and after 3 months of age. If your area has new information on exclusive breastfeeding since birth it would make a useful addition to data.

The "Innocenti Declaration" (3) and the Global Strategy for Infant and Young Child Feeding recommends that babies continue to be breastfed for two years of age or beyond along with adequate and appropriate complementary foods starting after six months of age. Breastmilk continues to be an important source of nutrition and fluids and immunological protection for the infant and the young child. The continued closeness between mother and child provided by breastfeeding helps in optimal development of the infant and young child.

1.    Use a study carried out in the region/country in the last five years.

2.   When you are using for the country, Ideally, it should be a study, which has a national scope. You can also use the UNICEF's Multiple Indicator Cluster Survey (MICS)(5)

www.childinfo.org when available and the WHO Global Data Bank on Breastfeeding (6) http://www.who.int/wormcontrol/databank/en/

3. When available, consider using data from the Demographic and Health Survey (DHS) (4), from the table on "Median duration and frequency of breastfeeding" in the chapter on "Infant Feeding and Maternal and Child Nutrition". The DHS measures the median duration of breastfeeding among children less than 3 years of age, based on current status. (See the DHS website athttp://www.measuredhs.com" Select Surveys, Select Indicators, Maternal and Child Nutrition, Median duration of BF, Median BF duration, any breastfeeding)

Babies should be breastfed exclusively for first 6 months of age and they need not be given any other fluids, fresh or tinned milk formulas as this would cause more harm to babies and replace precious breastmilk. Similarly after six months babies should ideally receive mother's milk plus solid complementary foods. If a baby cannot be fed the breastmilk from its mother's breast, it should be fed with a cup. (If unable to swallow, breastmilk can be provided by means of an infant feeding tube.) After 6 months of age, any liquids given should be fed by cup, rather than by bottle. Feeding bottles with artificial nipples and pacifiers (teats or dummies) may cause 'nipple confusion' and infants' refusal of the breast after their use. Feeding bottles are more difficult to keep clean than cups and the ingestion of pathogens can lead to illness and even death (11). Pacifiers also can easily become contaminated and cause illness.

1.   Use a study carried out in the region/country in the last five years.

2.   When you are using for the country, Ideally, it should be a study, which has a national scope. You can also use the UNICEF's Multiple Indicator Cluster Survey (MICS)(5)

www.childinfo.org when available and the WHO Global Data Bank on Breastfeeding (6) http://www.who.int/wormcontrol/databank/en/

3.When available, consider using data from the Demographic and Health Survey (DHS) (4), from the table on "Types of Food Received by Children in the Preceding 24 Hours" in the chapter on "Infant Feeding and Maternal and Child Nutrition" or the DHS website atwww.measuredhs.com. However, in both sources, data is only listed by 2 or 3 month increments) See DHS Comparative Study No. 30 (12) for data reported for 0< 12 months.

Babies should be breastfed exclusively for first 6 months of age and they need not be given any other fluids, fresh or tinned milk formulas as this would cause more harm to babies and replace precious breastmilk. Similarly after six months babies should ideally receive mother's milk plus solid complementary foods. If a baby cannot be fed the breastmilk from its mother's breast, it should be fed with a cup. (If unable to swallow, breastmilk can be provided by means of an infant feeding tube.) After 6 months of age, any liquids given should be fed by cup, rather than by bottle. Feeding bottles with artificial nipples and pacifiers (teats or dummies) may cause 'nipple confusion' and infants' refusal of the breast after their use. Feeding bottles are more difficult to keep clean than cups and the ingestion of pathogens can lead to illness and even death (11). Pacifiers also can easily become contaminated and cause illness.

As babies grow continuously and need additional nutrition along with continued breastfeeding, after they are 6 months of age, complementary feeding should begin with locally available indigenous foods being affordable and sustainable. They should be offered soft or mashed foods in small quantities, 3-5 times a day. Complementary feeding should gradually increase in amount and frequency as the baby grows (13, 14). Breastfeeding, on demand, should continue for 2 years or beyond. Complementary feeding is also important from the care point of view, the caregiver should continuously interact with the baby and take care of hygiene to keep it safe.

The indicator proposed here measures only whether complementary foods are provided in a timely manner, after 6 months of age along with breastfeeding. Complementary feeds should also be adequate, safe and appropriately fed, but indicators for these criteria are not included because data on these aspects of complementary feeding are not yet available in many countries. It is useful to know the median age for introduction of complementary foods, what percentage of babies are not breastfeeding at 6-9 months and also how many non-breast-feeding babies are receiving replacement foods in a timely manner. These figures can help in determining whether it is important to promote longer breastfeeding and/or later or earlier introduction of complementary foods. This information should be noted, if available, although it is not scored. It is also possible to generate more information as additional and help guide local program.

1.    Use a study carried out in the region/country in the last five years.

2.   When you are using for the country, Ideally, it should be a study, which has a national scope. You can also use the UNICEF's Multiple Indicator Cluster Survey (MICS)(5)

www.childinfo.org when available and the WHO Global Data Bank on Breastfeeding (6) http://www.who.int/wormcontrol/databank/en/

3.   When available, consider using data from the Demographic and Health Survey (DHS) (4) from the table on "Breastfeeding Status" in the chapter on "Infant Feeding and Maternal and Child Nutrition" which has data for 6-9 months of age. (See the DHS website at http://www.measuredhs.com, Select Surveys, Select Indicators, Maternal and Child Nutrition, BF status, BF and supplements, 7-9 months.)

In this summary sheet analysis is done based on what are the SCORES and where your country or region stands in terms of Infant and young child feeding practices individually or combined. It is good to analyze this with team of stakeholders. Find out reasons and draw a list of recommendations for your health and nutrition managers and policy makers.

In Part II a set of criteria has been developed for each target based on the Innocenti and beyond, i.e. considering most of the targets of the Global Strategy. For each indicator there is a sub set of questions leading to key achievement, indicating how a country is doing in a particular area. Each question has possible score of 0-3 and the indicator has a maximum score of 10.Once information about the indicators is entered, The achievement on the particular target indicator is then rated and graded i.e. Red or grade 'D', Yellow or grade 'C', Blue or grade 'B' and Green or grade 'A'

The Global Strategy for Infant and Young Child Feeding, adopted by the World Health Assembly in May 2002 and the UNICEF Executive Board in September 2002 reaffirms the Innocenti Declaration and lays additional emphasis on some other key aspects of infant and young child feeding. The Global Strategy for IYCF calls for Revitalization of the Innocenti Goals as well sets additional targets.

1.   National Commitment in the development of a National Multicultural Authority, responsive to international guidelines to set policy.
2.  Establish and enforce theCode of Marketing of Breastmilk Substitutes and subsequent WHA Resolutions.
3.  Renew efforts to assess and reassess Baby-friendly Hospitals; and ensure quality through training inputs.
4.  Institute Maternity protection for working women.

1.  Ensure that relevant sectors protect, promote and support exclusive breastfeeding for first six months and continued breastfeeding for up to two years or beyond while providing women the support and access they need at family, community and workplace.
2.  Support for timely and appropriate complementary feeding.
3.  Initiate communications and advocacy for these issues.
4.  Community based initiatives to support women's care and nutrition and optimal infant and young child feeding.
5.  Additional attention to infant feeding and HIV
6.  Additional attention to Infant feeding during emergencies.

This part of the Toolkit will cover "Innocenti and beyond" targets looking at policies and programmes. The Score will be assigned again as a color-coded rating for easy understanding of the current situation with regard to the Global Strategy for Infant and Young Child Feeding.

The "Innocenti Declaration" (3) was confirmed by 139 governments in 1990. It recommended all governments to have national breastfeeding committees and coordinators as established mechanisms to protect, promote and support breastfeeding in the country. World Summit for Children recommends, "All governments should develop national breastfeeding policies. The Global Strategy for Infant and Young Child Feeding calls for an urgent action form all Member States to develop, implement, monitor and evaluate a comprehensive policy on IYCF.

Most countries would have their National Plans of Action on Nutrition, National Plan of Action for the Child as a follow up to the UN Summit for Children. Apart from this National Nutrition Policies and National Health Policies that could accommodate infant and young child feeding. Many countries have taken action and already have national breastfeeding committees,The plan has been implemented to some extent in the last 12 months,Over 50% of funds have been utilised at the end of the last financial year ; minutes of this committee as well terms of reference of these would be quite useful. The documents could give possible source for detailed information on this particular section.

Discussions on implementation of the Global Strategy for Infant and Young Child Feeding can be held at national level with the National Breastfeeding Coordinator, officials from the Ministries of Health, Planning, and/or Labor, government regulatory representatives, WHO, UNICEF, and country breastfeeding promotion groups like IBFAN. Find out and get written copies of whatever national policies cover infant and young child feeding.

Other sources could be BFHI policy and programme, national legislation as a follow up to the International Code of Marketing of Breastmilk Substitutes (The Code) and its implementation process, and reports of community based organizations on nutrition and health.

The Innocenti Declaration (3) calls for that all maternity services fully practice all the Ten Steps to Successful Breastfeeding set out in Protecting, promoting and supporting breastfeeding: the special role of maternity services, a Joint WHO/UNICEF Statement (15). UNICEF's 1999 Progress Report on BFHI (16) lists the total number of hospitals/maternities in each country and the total number designated "Baby Friendly". According to the Step 2 of ten steps all staff in maternity services should be trained in lactation management. UNICEF and WHO recommend that all staff should receive at least 18 hours of training and higher level of training is more desirable. Several countries initiated action on BFHI and progress made so far has been in numbers mostly and reports suggest that fall back happens if the skills of health workers are not sufficiently enhanced. The Global Strategy for Infant and Young Child Feeding indicates that revitalization of BFHI is necessary and its assessment is also carried out periodically to sustain this programme and contribute to increase in exclusive breastfeeding.

The Toolkit will focuses on quantitative and qualitative aspects both. It looks at the percentages of hospitals and maternity facilities designated BFHI and also at the programme quality e.g. skilled training inputs in BFHI, which is key to sustaining it, and how it is monitored and evaluated.

Interviews can be held with the national Baby Friendly Hospital Initiative (BFHI) committee members in the Ministry of Health, and UNICEF and WHO officials. Review any summary reports on the status of the BFHI, numbers (and percentages) of hospitals declared Baby Friendly, etc. Refer to the latest status report on BFHI prepared by UNICEF/NY for official figures reported by the country. Find out from the IBFAN/other breastfeeding groups in the country on such information on quantity and quality of BFHI. Find out how many hospitals that are certified BFHI have trained their staff with minimum level of training of 18 hours recommended. To find out the quality of services, interviews of mothers may be recorded. Information Sources Used:

The "Innocenti Declaration" calls for all governments to take action to implement all the articles of the International Code of Marketing of Breastmilk Substitutes (17) and the subsequent World Health Assembly resolutions. The aim of the Code is 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 breastmilk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution. The "State of the Code by Country" by the ICDC on countries' progress in implementing the Code provides sufficient information on the action taken.

Nations are supposed to enact legislations as a follow-up to this. Several relevant subsequent World Health Assembly resolutions, which strengthen the International Code of Marketing of Breastmilk Substitutes have been adopted since then and have the same status as the Code and should also be considered. The Global Strategy for infant and young child feeding calls for heightened action on this target. According to WHO 162 out of 191 Member States have taken action to give effect to it but the ICDC's report brings out the fact that only 27 countries have so far brought national legislations that fully covers the Code. The ICDC uses criteria to evaluate the type of action. The same criteria will be used for this section

Current data on Code implementation by country can be obtained from the International Code Documentation Centre (ICDC) of the International Baby Food Action Network (IBFAN), which publishes the "State of the Code by Country" report periodically (18) www.ibfan.org/english/pdfs/btr04/soccountry04.pdf, the local Breastfeeding groups /IBFAN Focal Points' office, or other groups that have conducted national surveys on Code compliance. Other key informants may include MOH, WHO and UNICEF officials.

The "Innocenti Declaration" and Global Strategy for IYCF call for provision of imaginative legislation to protect the breastfeeding rights of working women and further monitoring of its application in consistency with ILO Maternity Protection Convention and recommendations. The ILO's Maternity Protection Convention (MPC) 183 (19,20,21) specifies that women should receive:

1.  At least 14 weeks of paid maternity leave to all women workers
2.  One or more paid breastfeeding breaks daily or daily reduction of hours of work to breastfeed
3.   Job protection and non-discrimination for breastfeeding workers

Interviews can be held with officials of the Ministry of Health, Labor, Welfare, or Women's Affairs and staff of NGOs such as IBFAN. Data on the ILO conventions and progress in ratifying them in various countries can be requested from the ILO. WABA also documents a country profile on the status of Maternity Protection based on this recommendationwww.waba.org.my/womenwork/mpc19nov04.pdf and it lists the length of maternity leave and paternity leave as well as who pays for these, breastfeeding breaks provided or not and if these are paid or unpaid. WABA used GLOPAR tools to measure it more simply based on the maternity leave entitlements and scoring accordingly. In here we measure this target covering all type of work including the unorganized sector.