Marketing of commercial milk formula: a system to capture parents, communities, science, and policy.

Despite proven benefits, less than half of infants and young children globally are breastfed in accordance with the recommendations of WHO. In comparison, commercial milk formula (CMF) sales have increased to about US$55 billion annually, with more infants and young children receiving formula products than ever. This Series paper describes the CMF marketing playbook and its influence on families, health professionals, science, and policy processes, drawing on national survey data, company reports, case studies, methodical scoping reviews, and two multicountry research studies. We report how CMF sales are driven by multifaceted, well resourced marketing strategies that portray CMF products, with little or no supporting evidence, as solutions to common infant health and developmental challenges in ways that systematically undermine breastfeeding. Digital platforms substantially extend the reach and influence of marketing while circumventing the International Code of Marketing of Breast-milk Substitutes. Creating an enabling policy environment for breastfeeding that is free from commercial influence requires greater political commitment, financial investment, CMF industry transparency, and sustained advocacy. A framework convention on the commercial marketing of food products for infants and children is needed to end CMF marketing.

The political economy of infant and young child feeding: confronting corporate power, overcoming structural barriers, and accelerating progress.

Despite increasing evidence about the value and importance of breastfeeding, less than half of the world's infants and young children (aged 0-36 months) are breastfed as recommended. This Series paper examines the social, political, and economic reasons for this problem. First, this paper highlights the power of the commercial milk formula (CMF) industry to commodify the feeding of infants and young children; influence policy at both national and international levels in ways that grow and sustain CMF markets; and externalise the social, environmental, and economic costs of CMF. Second, this paper examines how breastfeeding is undermined by economic policies and systems that ignore the value of care work by women, including breastfeeding, and by the inadequacy of maternity rights protection across the world, especially for poorer women. Third, this paper presents three reasons why health systems often do not provide adequate breastfeeding protection, promotion, and support. These reasons are the gendered and biomedical power systems that deny women-centred and culturally appropriate care; the economic and ideological factors that accept, and even encourage, commercial influence and conflicts of interest; and the fiscal and economic policies that leave governments with insufficient funds to adequately protect, promote, and support breastfeeding. We outline six sets of wide-ranging social, political, and economic reforms required to overcome these deeply embedded commercial and structural barriers to breastfeeding.

A summative content analysis of how programmes to improve the right to sexual and reproductive health address power.

INTRODUCTION: Power shapes all aspects of global health. The concept of power is not only useful in understanding the current situation, but it is also regularly mobilised in programmatic efforts that seek to change power relations. This paper uses summative content analysis to describe how sexual and reproductive health (SRH) programmes in low-income and middle-income countries explicitly and implicitly aim to alter relations of power. METHODS: Content analysis is a qualitative approach to analysing textual data; in our analysis, peer-reviewed articles that describe programmes aiming to alter power relations to improve SRH constituted the data. We searched three databases, ultimately including 108 articles. We extracted the articles into a spreadsheet that included basic details about the paper and the programme, including what level of the social ecological model programme activities addressed. RESULTS: The programmes reviewed reflect a diversity of priorities and approaches to addressing power, though most papers were largely based in a biomedical framework. Most programmes intervened at multiple levels simultaneously; some of these were 'structural' programmes that explicitly aimed to shift power relations, others addressed multiple levels using a more typical programme theory that sought to change individual behaviours and proximate drivers. This prevailing focus on proximate behaviours is somewhat mismatched with the broader literature on the power-related drivers of SRH health inequities, which explores the role of embedded norms and structures. CONCLUSION: This paper adds value by summarising what the academic public health community has chosen to test and research in terms of power relations and SRH, and by raising questions about how this corresponds to the significant task of effecting change in power relations to improve the right to SRH.

A scoping review of the impact of organisational factors on providers and related interventions in LMICs: Implications for respectful maternity care.

We have limited understanding of the organisational issues at the health facility-level that impact providers and care as it relates to mistreatment in childbirth, especially in low- and middle-income countries (LMICs). By extension, it is not clear what types of facility-level organisational changes or changes in working environments in LMICs could support and enable respectful maternity care (RMC). While there has been relatively more attention to health system pressures related to shortages of staff and other resources as key barriers, other organisational challenges may be less explored in the context of RMC. This scoping review aims to consolidate evidence to address these gaps. We searched literature published in English between 2000-2021 within Scopus, PubMed, Google Scholar and ScienceDirect databases. Study selection was two-fold. Maternal health articles articulating an organisational issue at the facility- level and impact on providers and/or care in an LMIC setting were included. We also searched for literature on interventions but due to the limited number of related intervention studies in maternity care specifically, we expanded intervention study criteria to include all medical disciplines. Organisational issues captured from the non-intervention, maternal health studies, and solutions offered by intervention studies across disciplines were organised thematically and to establish linkages between problems and solutions. Of 5677 hits, 54 articles were included: 41 non-intervention maternal healthcare studies and 13 intervention studies across all medical disciplines. Key organisational challenges relate to high workload, unbalanced division of work, lack of professional autonomy, low pay, inadequate training, poor feedback and supervision, and workplace violence, and these were differentially influenced by resource shortages. Interventions that respond to these challenges focus on leadership, supportive supervision, peer support, mitigating workplace violence, and planning for shortages. While many of these issues were worsened by resource shortages, medical and professional hierarchies also strongly underpinned a number of organisational problems. Frontline providers, particularly midwives and nurses, suffer disproportionately and need greater attention. Transforming institutional leadership and approaches to supervision may be particularly useful to tackle existing power hierarchies that could in turn support a culture of respectful care.

ASHA Kirana: when digital technology empowered front-line health workers.

This practice paper describes our experience of implementing accredited social health activists (ASHA) Kirana, a digital technology-enabled Maternal Clinical Assessment Tool (M-CAT) and how the ASHAs felt empowered in the process. M-CAT aimed to train ASHAs to collect data that assists doctors in identifying maternal risks, in Karnataka, India. Systematic clinical assessment is not common in rural public health institutions. High caseloads, a tendency to 'normalise' maternal risks, varied competence of doctors and task shifting to insufficiently trained cadres may be some contributing factors. M-CAT was a response to this challenge. ASHAs asked a set symptom-cluster-based questions during home visits that were analysed by software algorithms to generate reports for doctors. M-CAT was implemented in one primary health centre with a group of 14 ASHAs, 2 auxiliary nurse midwives and 349 pregnant and postpartum women over 4 months. Our team worked with the ASHAs to refine the tool and supported them with training, hands-on assistance and regular debrief meetings. By learning how to collect individual-level data that they could interpret and act on, the ASHAs felt empowered with new knowledge on maternal risks. Their perfunctory data collection at home visits changed to substantive interactions with women and families, during which they captured pertinent qualitative information. The information asymmetry between doctors and ASHAs reduced. ASHAs started taking proactive steps on early indications of maternal risks. They changed from being mere transmitters of information to active users of it. Thus, technology-driven initiatives that include empowerment as an objective can strengthen the role of front-line workers in health systems.

When accountability meets power: realizing sexual and reproductive health and rights.

This paper addresses a critical concern in realizing sexual and reproductive health and rights through policies and programs - the relationship between power and accountability. We examine accountability strategies for sexual and reproductive health and rights through the lens of power so that we might better understand and assess their actual working. Power often derives from deep structural inequalities, but also seeps into norms and beliefs, into what we 'know' as truth, and what we believe about the world and about ourselves within it. Power legitimizes hierarchy and authority, and manufactures consent. Its capillary action causes it to spread into every corner and social extremity, but also sets up the possibility of challenge and contestation.Using illustrative examples, we show that in some contexts accountability strategies may confront and transform adverse power relationships. In other contexts, power relations may be more resistant to change, giving rise to contestation, accommodation, negotiation or even subversion of the goals of accountability strategies. This raises an important question about measurement. How is one to assess the achievements of accountability strategies, given the shifting sands on which they are implemented?We argue that power-focused realist evaluations are needed that address four sets of questions about: i) the dimensions and sources of power that an accountability strategy confronts; ii) how power is built into the artefacts of the strategy - its objectives, rules, procedures, financing methods inter alia; iii) what incentives, disincentives and norms for behavior are set up by the interplay of the above; and iv) their consequences for the outcomes of the accountability strategy. We illustrate this approach through examples of performance, social and legal accountability strategies.

Beyond measurement: the drivers of disrespect and abuse in obstetric care.

Concerns about disrespect and abuse (D&A) experienced by women during institutional birth have become critical to the discourse on maternal health. The rapid growth of the field from diverse points of origin has given rise to multiple and, at times, confusing interpretations of D&A, pointing to the need for greater clarity in the concepts themselves. Furthermore, attention to measurement of the problem has been excessive when viewed in relation to the small amount of work on critical drivers of disrespect and abuse. This paper raises some key issues of conceptualisation and measurement for the field, puts forward a working definition, and explores two critical drivers of D&A - intersecting social and economic inequality, and the institutional structures and processes that frame the practice of obstetric care. By identifying gaps and raising questions about the deeper causes of D&A, we point to potentially fruitful directions for research and action.

Adapting maternal health practice to co-morbidities and social inequality: A systematic approach.

The process of adapting universal guidelines to local institutional and cultural settings is recognized as important to their implementation and uptake. However, clarity on what, why and how to adapt in an evidence-based manner is still somewhat elusive. Health providers in low and middle income country contexts often have to deal with widely present co-morbidities and social inequalities among pregnant women. Since neither of these problems finds adequate discussion within the usual guidelines, and given the continual pressures posed by resource scarcity, health providers respond through ad hoc adaptations inimical to maternal safety and equity. We argue for, and describe, a grounded process of systematic adaptation of available guidelines through the example of a handbook on maternal risks for primary care doctors and staff nurses. The systematic adaptation in this practical, action-oriented handbook builds on research for a long-standing community-based project on maternal safety and rights. It takes a case-based problem-solving approach. Reiterating guidelines and best practices in diagnostic decision-making and risk management, it indicates how these can respond to co-morbidities and social inequality via complex clinical cases and new social science information.

Advancing sexual and reproductive health and rights in low- and middle-income countries: implications for the post-2015 global development agenda.

The papers and commentaries in this special issue illuminate progress made by low- and middle-income countries towards implementation of the Programme of Action (PoA) agreed by 179 countries during the International Conference on Population and Development in Cairo in 1994. The PoA presents a path-breaking sexual and reproductive health and rights (SRHR) framework for global and national population and health policies. While progress towards implementation has been made at global, regional and national levels, continuing and new challenges require that high priority be given to SRHR for all, particularly women and girls, during the remaining months of the millennium development goals and in the United Nations post-2015 development agenda. This paper highlights three critical gaps, raised in other papers: inequalities in access to sexual and reproductive health (SRH) information and services; the widespread need to improve SRH services to meet public health, human rights and medical ethics standards for quality of care; and the absence or inadequate use of accountability mechanisms to track and remedy the other two. We discuss priority actions to achieve equality, quality and accountability in SRHR policies, programmes and services, especially those that should be included in the post-2015 development agenda.

Sexual and reproductive health and rights in changing health systems.

Sexual and reproductive health and rights (SRHR) are centrally important to health. However, there have been significant shortcomings in implementing SRHR to date. In the context of health systems reform and universal health coverage/care (UHC), this paper explores the following questions. What do these changes in health systems thinking mean for SRHR and gender equity in health in the context of renewed calls for increased investments in the health of women and girls? Can SRHR be integrated usefully into the call for UHC, and if so how? Can health systems reforms address the continuing sexual and reproductive ill health and violations of sexual and reproductive rights (SRR)? Conversely, can the attention to individual human rights that is intrinsic to the SRHR agenda and its continuing concerns about equality, quality and accountability provide impetus for strengthening the health system? The paper argues that achieving equity on the UHC path will require a combination of system improvements and services that benefit all, together with special attention to those whose needs are great and who are likely to fall behind in the politics of choice and voice (i.e., progressive universalism paying particular attention to gender inequalities).

Sexual and reproductive health and rights in the post-2015 development agenda.

Women's health is currently shaped by the confluence of two important policy trends - the evolution of health system reform policies and from the early 1990s onwards, a strong articulation of a human rights-based approach to health that has emphasised laws and policies to advance gender equality and sexual and reproductive health and rights (SRHR). The drive for sexual and reproductive rights represents an inclusive trend towards human rights to health that goes beyond the right to health services, directing attention to girls' and women's rights to bodily autonomy, integrity and choice in relation to sexuality and reproduction. Such an expanded concept of the right to health is essential if laws, policies and programmes are to respect, protect and fulfil the health of girls and women. However, this expanded understanding has been ghettoised from the more mainstream debates on the right to health and was only partially included in the Millennium Development Goals. The paper argues in favour of a twofold approach in placing SRHR effectively in the context of the post-2015 development agenda: first, firmly ground it in an inclusive approach to the right to health; and second, drawing on two decades of national-level implementation, propose a forward-looking agenda focusing on quality, equality and accountability in policies and in programmes. This can build on good practice while addressing critical challenges central to the development framework itself.