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The Issues
The Australian Government has consistently recognised the value of breastfeeding to the health and well being of the Australian community. The first dietary guideline for Children and Adolescents is "Encourage and support breastfeeding" 1
The National Better Health Targets for the year 2000 are that 80% of infants are exclusively breastfed at three months and 60% exclusively breastfed at six months. There have been a number of initiatives to help meet these targets but there is still some way to go.
It is difficult to accurately assess the breastfeeding rates throughout Australia, as there is no national collection of the statistics. However, from various State based research it would appear that 84% of babies are breastfed on hospital discharge, 61% breastfed at three months and 49% at six months. 2
Australian breastfeeding rates have remained static for the last 12 years and there is some concern that they may follow overseas trends and start to decline. Breastfeeding, rather than formula feeding, promotes good health and dramatically lowers the incidence of a number of illnesses, so saving health care costs.
Increasing the breastfeeding rates in Australia has the potential to improve the health status of Australia's future population and thus make significant savings to the Government health expenditure. 3
The Government has made a start in the area of breastfeeding by committing $2Million to the National Breastfeeding Stategy. A number of projects have been undertaken with this money and it is important that the area continues to receive significant funding so the impetus is not lost.
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The Problems
- While the initiation rates in Australia are reasonable the failure to continue is marked. 84.6% are breastfeeding when they are discharged from hospital, only 61.2% are feeding at 10 weeks and 48.4% at 24 weeks.4 There is a very steep decline in the number of breastfed infants between 2 and 6 weeks.
- Breastfeeding rates among some groups are very low eg teenage mothers, Indigenous communities and some ethnic groups. A number of strategies have begun to target these groups but more needs to be done.
- Although many in the community recognise the benefits of breastfeeding, the superiority of breastmilk over substitutes and the benefits of exclusive breastfeeding are still not widely recognised.
- Legislation in Australia is not particularly supportive of breastfeeding. There is no legislation to give mothers in the paid workforce the legal right to breastfeeding breaks as set down by the ILO Convention No 103 (Maternity Protection), nor is there uniform national laws entrenching the legal right of mothers to breastfeed their baby in public places.
- All women are not entitled to adequate paid maternity leave for at least the 12 weeks that it takes to establish breastfeeding properly.
- There is poor implementation of the World Health Organisations Code on the Marketing of Breastmilk substitutes. The code in Australia has only been adopted by manufacturers on a voluntary basis. There is no code for retailers or for bottles and teats. Free and subsidised supplies of breastmilk substitutes are not banned.
- Nationally there is no breastfeeding coordinator or national body overseeing the promotion and protection of breastfeeding. Policies and implementation varies from State to State and policies between Government departments are not always in harmony eg promoting breastfeeding vs no support for lactation breaks.
- There is no ongoing routine national collection of breastfeeding rates.
- The value of breastmilk is not recognised in the National Food Accounts; consequently breastfeeding is not given recognition for its economic value or importance in the community. The current structure of the National Food Accounts shows an improvement in economic value with decreases in breastfeeding, as cow's milk is included in the accounts while breastmilk is not.
- Very few hospitals have gained Baby Friendly Hospital Initiative accreditation.5
- There is no consistent education for health professionals in the area of lactation and many professional bodies do not consider breastfeeding as an important area for on-going education or accreditation.
- There appears to be no allowance made for conflict of interests by representatives of baby food related industries serving on government committees concerned with infant feeding issues. (An increase in initiation and duration of breastfeeding may lead to decreased sale of formula and other baby food related products)
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Yr 1: Establishing Infrastructures and removing barriers
Aims
- Value breastfeeding as an important pubic health measure
- Collect national data on a regular basis to determine the initiation and duration of breastfeeding in Australia
- Incorporate increased breastfeeding initiation and duration into the relevant National Health Priority Areas (specifically cardiovascular disease, cancer control, diabetes mellitus and asthma)
- Implement appropriate strategies to overcome structural barriers to breastfeeding
- Establish national policies supportive of breastfeeding
- Value the economic contribution of breastfeeding
Strategies
- National collection of statistics
- develop suitable national classification standards for breastfeeding statistics
- encourage and collate state based collection of statistics (this would require a standardisation of the questions) or
- Use the National Health Surveys to collate statistics. This is only a sample as opposed to a census in the option above.
- National Health Priorities
- disseminate information about the relationship between breastfeeding and the Health Priority Target Areas of cardiovascular disease, cancer control, diabetes mellitus and asthma
- encourage partnerships between breastfeeding organisations and organisations concerned with the Health Priority Targets Areas
- ensure that breastfeeding is discussed in relation to these areas in reports, including the biennial report on Australia's Health by the Australian Institute of Health and Welfare (ref AIHW 1998)
- Establishment of a National Panel and/or Coordinator to promote and protect breastfeeding
- Public policies and breastfeeding:
- Ensure that the impact on breastfeeding is considered when developing and implementing policies
- Ensure that conflict of interests by representatives of baby food related industries serving on government committees concerned with infant feeding issues are identified and controlled for. (An increase in initiation and duration of breastfeeding may lead to decreased sale of formula and other baby food related products)
- Establish policies that are supportive of breastfeeding
- Evaluate the implementation of the recommendations of the March 1985 Report of the Working Party on Implementation of the WHO International Code of Marketing of Breast-milk Substitutes
- Examine appropriate standards and laws to determine where they need to be strengthened or augmented. Areas should include:
- marketing of infant formulas - manufacturers code, retailers code, standards on bottles and teats etc
- legislation and systems needed to stop discrimination in all areas of society
- Child care centres
- encouraging more BFHI hospitals
- maternity leave provisions
- Improving attitudes in private businesses
- overcoming barriers in the workplace (building on the Women in Work project)
- extension of the Mother Friendly Workplace Award and Baby Care room initiatives
- Retailers campaign - 'Breastfeeding mothers welcome here' stickers on Family Friendly businesses
- Media campaign on breastfeeding in public (building on the Family Project)
- translation of more materials into languages other than English
- education in all forms of media
- Inclusion of breastmilk in the National Food Accounts
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Years 2 & 3: Antenatal
Aims
- Provide targeted information to prospective and new parents about the benefits of breastfeeding and management techniques
- Provide information, support and resources to health professionals to ensure they are aware of breastfeeding management issues
- Ensure that breastfeeding is portrayed as the cultural norm
Strategies
- Media campaigns
- targeting the benefits of breastfeeding over substitutes
- targeting the risks of using substitutes
- building on the work done in the Family Project
- School programs
- develop materials for all levels of education from pre to secondary on a state by state basis
- encourage implementation of the materials
- Breastfeeding education classes
- every pregnant woman to have access to affordable breastfeeding education classes
- ensuring that existing services are adequately resourced
- identify gaps in the education system and develop initiatives to fill them
- Indigenous education
- building on the best practice models
- research into current rates, attitudes and beliefs
- providing resources to indigenous communities
- Health Professional education (at all levels) and including domiciliary midwives
- follow up the work done on the Antenatal tender
- working with tertiary institutions to develop appropriate curriculums for breastfeeding education
- developing resources as needed
- Working with professional associations eg to ensure appropriate professional development opportunities for their members in relation to breastfeeding management
- Education in the workplace tying in the education from other areas
- building on the work of the Women and Work tender
- Training of peer support workers and/or Breastfeeding Counsellors for traditional "hard to reach" sectors eg mothers with languages other than English, Indigenous mothers, teenage mothers and mothers from lower socio-economic backgrounds
- identifying and training appropriate groups of workers
- developing resources for peer support workers
- support systems in place for the peer support workers
- Media campaign targeting the benefits of breastfeeding
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Years 4 & 5: Postnatal
Aims
- Provide information to new and prospective parents on the benefits of breastfeeding and breastfeeding management issues
- Increase the duration of breastfeeding through media education
- Increase the duration of breastfeeding through provision of support services
Strategies
- Media campaign targeted at longer duration of exclusive breastfeeding
- Benefits of exclusive breastfeeding till 6 months
- Management of longer exclusive breastfeeding
- Initiatives to encourage maternity hospitals to attain Baby Friendly Hospital Accreditation
- Identify barriers
- Providing resources and encouragement to attain the accreditation
- Resources to encourage women to sustain exclusive breastfeeding for longer periods
- accurate information made readily available to mothers and health professional about the risks of early introduction of solids
- monitor marketing strategies of manufacturers, distributors and retailers of infant formula, other baby foods and baby food related products
- ensure marketing strategies of manufacturers, distributors and retailers of infant formula, other baby foods and baby food related products are consistent with WHO Code
- encourage private health insurers include ABA membership as a claimable expense
- Provide telephone support to all families for the cost of a local call
- identify gaps in current resources
- providing services to fill the gaps
- Home visiting support program
- every family receives at least one home visit if wanted
- Developing Internet resources to provide information and support for families
- Strengthen peer support programs
- continuation of this program as outlined in Years 2 & 3: Antenatal
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Rationale
Range of strategies
In accordance with Australia's adoption of the strategies of the Ottawa Charter of Health Promotion and the Jakarta Declaration on Health Promotion in the 21st Century, a range of strategies has been used in this 5-Year Plan. These strategies encompass the areas of: strengthening community action; developing personal skills; reorienting health services; building healthy public policy; and creating supportive environments. 6
National Collection of Breastfeeding Statistics
It is essential that we have accurate and regular collection of breastfeeding statistics. Without these it is not possible to determine the effectiveness or otherwise of strategies. The statistics can either be collated from individual States (it should be noted that not all States currently collect breastfeeding statistics) or collected nationally through a vehicle such as the National Health Survey.
The statistics will help guide present and future Australian policy makers
They will also provide a background to better deal with the pluralistic and complex nature of the National Health Priorities. The AIHW can incorporate these breastfeeding statistics into national data sets and use them to prepare reports on National Health Priorities.
The Australian Bureau of Statistics decision in 1998 to review its health survey strategy provides a good opportunity to improve the collection of breastfeeding statistics.
National Panel and/or Coordinator to promote and protect breastfeeding
The government has established specific national bodies to co-ordinate information and advice for a number of major problems. The area of breastfeeding would benefit from such national co-ordination and direction.
The Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding has the establishment of a national breastfeeding coordinator and a multisectorial national breastfeeding committee composed of representatives from relevant government departments, non-government organisations, and health professional associations and its first operational target.
Without a national panel in place to actively promote breastfeeding it is possible for breastfeeding to have its priority set by political convenience.
Legislation on the Marketing of Infant formulas and implementation of the full Code
In May 1981, Australia was among 118 countries at the World Health Assembly which voted overwhelmingly in favour of the resolution (WHA 34.22) adopting the International Code of Marketing of Breast-milk Substitutes. In 1992 manufacturers and importers of infant formula signed the Marketing in Australia of Infant Formula (MAIF) Agreement. However this agreement is only voluntary and does not include a code for retailers or bottle and teats. While these areas remain outside the MAIF agreement, breastfeeding is being undermined.
"In 1996, infant formula sales in Australia were reported to be worth $100 million divided approximately between pharmacy and grocery outlets. As companies jostle for market share in this competitive market, their activities inevitably impact on breastfeeding mothers. It is virtually impossible to target marketing so it will impact on mothers already using formula, encouraging them to switch brands. There are still common reports of breastfeeding mothers being given free samples of infant formula, undermining their confidence and, inevitably, their breastfeeding. Many health workers have come to believe that formula is so close to breastmilk that 'putting the baby on the bottle' doesn't really matter." 7
Governments have to take the initiative in this area, as it is not possible to rely on the conscience of companies that need to make profits from the sale of breastmilk substitutes.
Numerous studies have shown that free or subsidised supply in hospitals and community health centres lead to a decline in breastfeeding. 8
Improving attitudes in Private Businesses
Employers, mothers, families, baby and government all benefit from mothers continuing to breastfeed when they return to work. 9
Australia currently has no legislation that guarantees a mother paid maternity leave. This often means that mothers are returning to work quickly after the birth of their baby, and see working and breastfeeding as mutually exclusive.
Breastfeeding is more common among higher socio-economic groups where the mother can often afford to stay at home. Many mothers in lower socio-economic groups would choose to breastfeed if offered the incentive or opportunity to breastfeed. 10
Four factors have been identified as assisting women to successfully combine working and breastfeeding
- Lactation breaks
- Clean, hygienic and private facilities for women to express breastmilk at work along with somewhere to store the milk
- Flexible work options which can include telecommuting, job sharing, permanent part-time and flexible starting and finishing times.
- Support from employers and colleagues 11
Education in the workplace is necessary to achieve the last of these.
Baby Care Rooms and Breastfeeding Mothers Welcome Here campaigns
In today's society it is not possible or desirable for mothers to stay at home while ever they are breastfeeding their babies. The Baby Care Room Awards and Breastfeeding Mothers Welcome Here Stickers are two initiatives that facilitate mothers taking their breastfed babies out in public.
Baby Care Room Awards indicate that baby care rooms meet an acceptable standard for mothers or fathers to use. There are a number of criteria that have been developed jointly by the Nursing Mothers' Association of Australia and Parents Magazine.
In a number of regions in Australia e.g. Forbes in central NSW, a project has been undertaken in conjunction with local businesses to identify those businesses that are happy to have families and breastfeeding mothers in their establishments. Usually stickers are applied to front windows and an advertising campaign is undertaken.
Any initiatives such as the two above need to be done simultaneously with a media campaign.
Inclusion of Breastmilk in the National Food Accounts
"Estimates of the current value of human milk production in Australia show breastfeeding is a major economic issue, as well as being significant to public health. Current milk production is 33 million kg, or $2.2 billion a year" 12
In these days of economic rationalism it is important that the value of breastmilk is recognised for it own value and because it values the work of women.
Strategies for Indigenous Communities
There are a number of barriers for indigenous mothers to overcome in order to breastfeed successfully. They include poor maternal health during pregnancy, early introduction of food, smoking and alcohol abuse. Culturally sensitive and appropriate education programs are needed to make mothers aware of these issues and their consequences. 13
Health Professionals need to be trained how to prevent and best treat breastfeeding problems. Aboriginal and Torres Strait Islander Health workers with special training in lactation should be resourced to provide information and support on infant feeding matters. A supportive breastfeeding culture needs to be developed and maintained. 14
Research is needed into the breastfeeding rates of indigenous communities in all parts of Australia, attitudes to breastfeeding, especially among indigenous fathers and the educational needs of mothers.
Media Campaign
While most people will acknowledge the superiority of breastmilk, a number of barriers have been identified, that prevents breastfeeding being initiated or continued. These include behavioural barriers such as a perception that breastfeeding in public is embarrassing or, difficulty making sense of conflicting information about infant feeding. Social barriers such as the loss of women's collective wisdom about breastfeeding following the generations of bottle-feeding, portrayal through media advertisements that bottle-feeding is the cultural norm, structural barriers such as few suitable places to breastfeed comfortably outside the home, breastfeeding outside the home not sufficiently protected by antidiscrimination legislation and poor management of many breastfeeding situations by health professionals are other situations that need addressing. 15
"The need for a multi-strategy approach to the promotion of breastfeeding, including some type of public education or mass media component, has been asserted frequently." 16
Advertising is very visible and reaches large numbers of people. Each year about 125,000 women become mothers for the first time. Every year the range of educative strategies and support services needs to be there for a new target audience. The advertising needs to be consistent over a number of years to keep breastfeeding in the public eye and to reach new families.
Advertising may need to move beyond the traditional breastfeeding messages to include different perspectives. " Traditionally the benefits of breastfeeding have been promoted rather than the risks of not breastfeeding. This perspective is unusual when compared to other public health messages, for example the public are often told of the risks associated with smoking, alcohol abuse, speeding, drink-driving, unprotected sex.
The media campaigns have to be highly visible to counteract the highly visible products associated with bottle-feeding. A visual alternative needs to be provided, especially in the context of breastfeeding in public places. A range of media could be used including cinema advertising, billboards, buses and Internet web sites.
The media campaign should aim to
- Create a positive social environment for breastfeeding
- Provide support and advice to nursing mothers
- Support and strengthen other interventions
- Reach audiences beyond mothers, including policy makers, hospital directors and others whose support is vital.17
Evaluate the Implementation of the WHO Code
Nearly 15 years has passed since the 'Report of the Working Party on
Implementation of the WHO International Code of Marketing of Breast-milk
Substitutes' was published. Sufficient time has elapsed to allow the
recommendations to have been implemented. It is now important to evaluate
the success of these recommended strategies, and to identify any barriers
to implementation of strategy or achievement of goals 18
Schools Programs
The success of programs such as the anti-tobacco, anti-discrimination and green campaigns show the value of education at school level. Although education programs are developed on a state basis, generic materials could be developed for incorporation into state curricula.
There is a growing awareness that it is best not to confine learning about health to one time and one subject area, but rather involve links across subject areas and school years. 19
Breastfeeding is well suited to this ecological approach. It has links with a number of curriculum areas, such as biology, international economics, politics, child studies and health, and can be integrated into subjects at all stages of school
Breastfeeding Education Classes
Interactive breastfeeding education classes have been shown to increase the confidence levels associated with breastfeeding, and to be associated with longer breastfeeding duration 20
Baby Friendly Hospital Initiative (BFHI)
"The BFHI addresses a major factor which has contributed to the erosion of breastfeeding - that is, health care practices which interfere with breastfeeding. Until practices improve, attempts to promote breastfeeding outside the health service will be impeded. Although inappropriate maternity care cannot be held solely responsible for low exclusive breastfeeding rates, appropriate care may be a prerequisite for raising them." 21
BFHI in Australia has had a number of setbacks including a period of inactivity during the changeover from UNICEF to the Australian College of Midwives Inc (ACMI) as the governing body. As there are currently only 17 accredited hospitals in Australia it is important that this initiative be given a boost to encourage more hospitals to seek accreditation. This could include funding the National Advisory Council and specific funding incentives to hospitals that gain the award.
Health Professional Education
Health professional breastfeeding education has been identified by a number of studies as an important strategy to improve breastfeeding management "Ongoing education of midwives is required to ensure that consistent and up-to-date information and support is given to breastfeeding mothers". 22
Mothers identify conflicting advice about breastfeeding as being negative for breastfeeding 23
Training Peer Support Workers
At an International Breastfeeding Workshop in 1988 it was stressed that women from all cultures learn best from their own people. Following this, in the 1980's, ABA ran Thallikool outreach projects for indigenous women who do not usually make use of ABA services. As it was found to be an important community perception that Aboriginal Outreach Workers were paid for their work these projects were funded by the NSW State Government. 24
The Strong Babies Strong Culture program in the Northern Territory is an aimed at restoring the role of support for Aboriginal mothers to older women and grandmothers in the community. 25
Following their involvement in a ABA Group especially for Vietnamese speaking mothers, a number of the women expressed an interest in training to become breastfeeding Counsellors and/or community educators.26 Completion of the training will enable them to become peer support Counsellors for their Vietnamese community.
These projects can be used as a framework for future programs aimed at supporting communities that are traditionally hard to reach.
Resources to encourage women to sustain exclusive breastfeeding for longer periods
A range of strategies aimed at: lessening the pressure for early introduction of commercially profitable foods to the baby's diet; promoting a 'culture of breastfeeding'; correcting misinformation about breastfeeding in the community; and providing support for a 'healthy choice is an easy choice' are needed to encourage women to sustain exclusive breastfeeding for longer.
Provide Telephone Support to all Families for the cost of a Local Call
The Nursing Mothers' Association of Australia currently receives 275,000 counseling contacts each year, a number of which are STD calls. All mothers should have access to breastfeeding information for the cost of a local call regardless of the area in which they live. This is especially applicable for those mothers in rural and remote areas who may not have access to traditional forms of support.
Home Visiting Program
Correct positioning and attachment of the baby at the breast are vital aspects of breastfeeding management. Checking and correcting the baby's positioning and attachment is greatly facilitated by a face-to face visit. The logistics of leaving the house with a new baby to seek help with establishing breastfeeding or for help with breastfeeding problems can be difficult for mothers, especially those with other children and/or those relying on public transport. Having a home visiting program would be beneficial for breastfeeding mothers to allow easier access to appropriate help. This is especially important as many mothers leave hospital before breastfeeding is established, and therefore need one-to-one contact within the first two weeks of the birth.
Developing Internet Resources
The Department of Health already has a number of pages with breastfeeding material from the Family Project and the Health Professional Project. ABA also has quite a significant amount of information available at their web site, as well as email counseling. These sorts of services can be expanded so that more information and help is accessible to parents and health professionals in this rapidly expanding medium.
Providing ongoing support to the partners of the recently launched HealthInsite web page is important.
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References:
- Australian Dietary Guidelines for Children and Adolescents, NHMRC, 1995
- Scott JA, Binns CW, Aroni RA, Infant Feeding practices in Perth and Melbourne - Report 1, 1995 p72
- ABA Budget Submission 96/97
- Scott, Binns & Aroni, Infant Feeding Practices in Perth and Melbourne - 1993, Report 2, 1997
- There are 17 hospitals Australia wide currently with this accreditation
- World Health Organisation, Health and Welfare Canada, Canadian Public Health Association 1986, Ottawa Charter for Health Promotion. Statement from the International Conference on Health Promotion, November 17-21, 1986, Ottawa, Ontario, Canada.
World Health Organisation 1997, The Jakarta Declaration on Health Promotion in the 21st Century, Jakarta.
- Brodribb, Breastfeeding Management in Australia, 1997, p371
- Evidence for the 10 Steps to Successful Breastfeeding, WHO, 1998, p52
- Mother Friendly Workplace Information Sheet, Nursing Mothers Association of Australia
- Brodribb, Breastfeeding Management in Australia, 1997, p358
- Mother Friendly Workplace Information Sheet, Nursing Mothers Association of Australia
- Smith, J., Ingham L., The Economic Value of Breastfeeding in Australia, Breastfeeding - the Natural Advantage, 1997
- Gabriel, R, Promoting Breastfeeding among Aboriginal and Torres Strait Islander Women, Breastfeeding the Natural Advantage, 1997, p77
- Gabriel, R, Promoting Breastfeeding among Aboriginal and Torres Strait Islander Women, Breastfeeding the Natural Advantage, 1997, p77
- McIntyre, E, Determinants of Infant Feeding Patterns: An analysis of focus group discussions, Breastfeeding - the Natural Advantage, 1997, p 145
- Strategies to Promote Breastfeeding - An overview, NSW Health Dept, 1995, p56
- Strategies to Promote Breastfeeding - An overview, NSW Health Dept, 1995, p56
- National Health and Medical Research Council, 1985, Report of the Working Party on Implementation of the WHO International Code of Marketing of Breast-milk Substitutes, Australian Government Publishing Services, Canberra.
- Ackermann. A 1997, Defining the health promoting school, in D. Coloquhoun, K. Goltz and M. Sheehan eds, The Health Promoting School, Harcourt Brace, Sydney
- Cox S. and Turnball C. 1998 Devleoping effective interactions to improve breastfeeding outcomes. Part 2 Antenatal Empowerment of mothers for postnatal success in breastfeeding. Breastfeeding Review, vol 6, no2, pp17-21.
- Evidence for the 10 Steps to Successful Breastfeeding, WHO, 1998, p1
- Fetherston C 1995 Factors Influencing Breastfeeding Initiation and Duration in a Private Western Australian Maternity Hospital, Breastfeeding Review, vol 3, no1, pp9-14
- Vogel A. and Edwin A, 1998 The Establishment and duration of breastfeeding. Part 1: Hospital Influences. Breastfeeding Review, vol 6 no 1 pp5-9.
- Gabriel R. Promoting Breastfeeding among Aboriginal and Torres Strait Islander Women, Breastfeeding the Natural Advantage. ABA International Conference, October 1997, Sydney.
- Yunupingu, B 1997 Strong Women, Strong Babies, Strong Culture Breastfeeding the Natural Advantage. ABA International Conference, October 1997, Sydney.
- Dell, K 1997 Hospitals and Community Groups - Embracing the 'Tenth Step' to Meet the Needs of Non-English Speaking Mothers. Breastfeeding the Natural Advantage. ABA International Conference, October 1997, Sydney
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