A few blogs ago I said I would share some of the essays I write as part of my post graduate study in Child Health.
I failed my first essay, in the main for not writing it in an academic style (which requires writing in third person; using evidence from the literature; NOT using personal experience, anecdotes or opinions unless you can reference them from the literature). Nevertheless, the issue is close to my heart so I have edited the referencing system to make it more readable, and I think it passes in blog form for anyone interested in the subject of breastfeeding, which is surprisingly fraught with political and economic agendas.
A couple of points before sharing the essay:
I shared the following story about my friend’s experience in a maternity clinic in Cambodia 3 years ago, with another Cambodian friend recently. He stated that the public health system in Cambodia do promote breastfeeding and do not supply milk substitutes near their maternity wards or services. Nevertheless my observation at a private maternity clinic is worth sharing, with attention to the fact that it is not necessarily “the norm”.
When I visited <friend’s> wife in the maternity hospital (private) I was shocked to see baby formula and bottled water for sale inside the hospital. You cannot do that here because the health system want to encourage breastfeeding and will not support formula company marketing as a matter of professional ethics. When I tried to find out the name of the formula company owner, it seemed that it is a French company, with a very high profit margin.
At the time of the baby’s birth my friend rang me. He was holding a very distressed baby and I suggested the baby was hungry. He agreed but the hospital staff shut the baby outside with Dad and Grandmother, to “check Mum”. The baby cried for an excessive period of time and they were denied access to Mum. Eventually Grandmother surrendered and bought formula and bottled water at the shop downstairs. It appeared to my outsider eyes, as a deliberate tactic.
While exclusive breastfeeding for the first six months of a baby’s life is the optimal practice for multiple health reasons, mothers who do not or cannot sustain this should not be judged and their babies can still lead healthy lives. I am aware that many mothers have felt unreasonable pressure to exclusively breastfeed, and then guilty when they have been unable or chosen not to. It is not my intent to make anyone feel guilty because of their choices or individual circumstances.
Critical Analysis of a National Health Promotion Program
Baby Friendly Health Initiative
More recently named the Baby Friendly Health Initiative (BFHI), I first learned about the Baby Friendly Hospital Initiative during my Public Health studies over 17 years ago. In 1991, World Health Organisation and UNICEF introduced the BFHI, “to protect, promote and support breastfeeding in all birth settings”1. The initiative was introduced in Australia in 1993 and has been governed by the Australian College of Midwives since 19952. The Australian Breastfeeding Association3 state that the BFHI project “aims to give every baby the best start in life by creating health care environments where breastfeeding is the norm and practices known to promote the health and wellbeing of all women and babies are followed”.
As outlined by the Australian College of Midwives2, BFHI accreditation is awarded to hospitals which meet certain standards relating to consistent and accurate information and support to mothers as they establish feeding. A critical component of these standards is the WHO International Code of Marketing of Breast-milk Substitutes (“The Code”). The Code comprises ten main points requiring that facilities in no way display, advertise, promote, provide products or otherwise engage with companies who sell infant milk substitutes, bottles and teats. In Australia The Code is applied in part by the Marketing in Australia of Infant Formula (MAIF) Agreement, in which manufacturers and importers have voluntarily signed a self-regulatory code of conduct4.
Aware of The Code as a global initiative 17 years ago, I assumed effective global implementation was in place. However in recent years I have spent time in Cambodia, where I learned that in those countries without strong health systems, who are in most need of protective policies such as Baby Friendly Health Initiatives, practices violate recommended guidelines. Through many friends and colleagues in Cambodia, I have observed that the marketing of infant milk substitutes is blatantly immersed in maternal and child health care provision. Milk substitutes, bottled water, bottles, teats and other related paraphernalia are stocked and sold inside private maternity clinics. Established practices appear to discourage exclusive breastfeeding in favour of either adding or replacing with milk substitutes, generating a profit to providers. It seems the milk substitute scandal that rocked the world in the early 1970s5, when it was disclosed that milk substitute companies were marketing their products aggressively and unethically in poor countries, leading to untold infant disease and mortality, continues today in many vulnerable places. My personal observations are supported by Ellis-Petersen H6 who confirms that health providers from some of the world’s poorest countries are given financial and other incentives by milk substitute manufacturers, to promote their products at the expense of breastfeeding.
According to the Department of Health’s Australian National Breastfeeding Strategy : 2017 and Beyond7, who recommend exclusive breastfeeding to around 6 months of age, “Evidence shows that breastfed babies are less likely to suffer from necrotising enterocolitis, diarrhoea, respiratory illness, middle ear infection, type 1 diabetes and childhood leukaemia. Available evidence also shows that breastfed babies have enhanced cognitive development. Breastfeeding also benefits mothers by promoting faster recovery from childbirth, reducing the risks of breast and ovarian cancers in later life, and reduced maternal depression”. Referring to this page on the DOH website, it is possible to locate information on the Baby Friendly Health Initiative, but it is mentioned only briefly and near the bottom of the page. The Department of Health also state that in Australia, 90% of children are initiated on exclusive breastfeeding, but only 15.4% of babies are exclusively breastfed to 5 months of age7.
The gap between what we know (exclusive breastfeeding to 6 months of age is optimal) and what happens in Australia (only 15.4% of children come near this target), suggests that improvements are needed in our breastfeeding health promotion strategies. The fact that 90% of Australian mothers initiate exclusive breastfeeding suggests that sufficient information is available and intent exists in the baby’s first hours, days or weeks. Something changes beyond that which needs to be addressed.
Holowko N et al8 found that breastfeeding rates in Australia have not increased substantially since 2001, although more infants are now breastfed for the minimum recommended six months. They also found a correlation between women who have a low education or a low-educated parent, and lower rates of initiating breastfeeding, or maintaining breastfeeding to the recommended six months. This evidence suggests a socio-economic link, identifying a possible target population for whom health promotion activities should focus.
With only 15.4% of Australian infants exclusively breastfed to the recommended six months of age, Hauck YL et al9 investigated the categories women listed as supporting their breastfeeding capacity, in an international study including women from Australia, Sweden and Ireland. The categories are listed here in ranking of importance as outlined by the 449 Australian women in the study: breastfeeding was going well; maternal knowledge of health benefits; health professional support; informal face to face support; maternal self-determination; partner support; maternal knowledge of psychological benefits; cultural norm; work environment; informal online support. This study outlines some possibilities for health promotion in encouraging breastfeeding in the Australian population. It could be possible that the most important category for Australian women (breastfeeding was going well) is in fact influenced by other categories given less importance, such as partner support, cultural norm and work environment. Some influences may even be unidentified, for example the comparison between Australia where The Code prevents marketing of infant milk substitutes in or near maternal and child health facilities and Cambodia where such marketing is highly visible.
Given the (often negative) attention that breastfeeding receives in the Australian media, it is probably necessary for health promotion to target not just young, antenatal or breastfeeding women, but also the general population. Anecdotal evidence suggests some stigma attached to what is and is not appropriate in relation to breastfeeding infants in public places. The Australian Breastfeeding Project, started in 2015, aims to reduce stigma and keep mothers breastfeeding for longer, with a group of breastfeeding women giving mixed reports around the issue of stigma attached to breastfeeding in Australia10.
In April and May 2017 the Australian Health Ministers’ Advisory Council held a series of stakeholder consultation workshops as part of the implementation of the Australian National Breastfeeding Strategy : 2017 and Beyond7. As per Fact Sheet 2 in the reference, participants recommended a national campaign, identifying that mothers cannot be the only target population in any health promotion campaign, and that mothers, partners, families, the health system, governments and the community at large have a shared responsibility to make breastfeeding a biological and cultural norm. I would argue that while the community at large have a shared interest in ensuring our future generations have the best start possible in life, without appropriate awareness campaigns their responsibility relating specifically to breastfeeding is limited. Participants also recommended strengthened implementation of The Code on Marketing of Breastmilk Substitutes; increased support and funding for the BFHI, such as making BFHI a requirement of accreditation; research to understand the barriers and allow better targeting of priority groups; as well as other recommendations which can be found in the reference.
A 2012 opinion piece by Barker R11 states that very few women in Australia deliberately choose to abandon breastfeeding, and that it is the circumstances around breastfeeding that lead women to stop breastfeeding early. These circumstances are listed as including the commercialization of readily available breastmilk substitutes with manufacturers exploiting a loophole in the MAIF Agreement ; unresolved breastfeeding problems met with conflicting advice; early return to paid work requiring some form of supplementation; and lack of family and community support. Barker offers a number of solutions including one year of paid maternity leave; allocation of funding to research breastfeeding problems and how to manage them; defragmentation of perinatal care; end milk substitute manufacturers’ exploitation of a loophole in the MAIF agreement which allows for certain milk substitute advertising; plain packaging of infant milk substitutes; and all milk substitutes in the first six months to be available by prescription only. This piece is written by a retired Midwife and Child and Family Health Nurse with 30+ years of experience, however it remains an opinion piece and further study is needed to provide objective information on the reasons and solutions for early breastfeeding abandonment.
The Baby Friendly Health Initiative is clearly successful at promoting breastfeeding initiation in Australian women but it falls short in promoting appropriate duration of breastfeeding. The initiative is directly linked to the Australian College of Midwives, whose role starts in the antenatal period and normally ends with domiciliary care termination at around six weeks of age, when Child and Family Health Nurses assume responsibility. Better integration of services between Midwifery care and Child and Family Health Nurse care could potentially be required, as mentioned in some of the literature about fragmented care and conflicting advice. I suggest that the BFHI should be part of a more comprehensive program connecting to services beyond Midwifery and Child and Family Health, to capture the attention of a broad range of service providers, consumers and the general community.
Only targeting young women and mothers designates the issue of breastfeeding as a female / mother-specific concern, ignoring the investment needed from partners, families, the health system and the wider community. BFHI is specific to maternal and child health care facilities, which may be too narrow a focus for a successful breastfeeding health promotion campaign? However, aspects to maternal and child care obviously do need improvement, such as providing more specialized support via lactation consultants, research into the problems women experience with breastfeeding and a more consistent approach between health professionals regarding appropriate advice and support for solutions. Establishing the BFHI as a requirement for hospital and health facility accreditation will also bring the issue to the forefront of all health services, not only those who already have a breastfeeding focus. The Department of Health’s Breastfeeding website page only mentions BFHI briefly, with the Australian College of Midwives and Australian Breastfeeding Association – two non governmental agencies – being the initiative’s main representatives and advocates. I suggest that the DoH need to give a more significant priority to BFHI, to highlight it as an important intervention embraced across government and non-government agencies.
As a privileged and developed nation geographically positioned so close to some of the world’s least privileged nations, Australia also has a more global role to play. While various infant milk substitute companies are signatory to the MAIF Agreement here in Australia, those same companies are not only exploiting loopholes in the Australian agreement they have signed, but they are clearly exploiting vulnerable populations in our region and beyond, whose children most need the protection breastfeeding offers. Australia are already building partnerships in places like Cambodia, for example the WHO Collaborating Centre at the University of Technology Sydney, who this year launched a Bachelor of Science in Midwifery Bridging Course at the University of Health Sciences in Phnom Penh in collaboration with UNFPA12. The aim of this partnership is to reduce maternal and neonatal mortality in Cambodia. Partnerships such as this are well positioned to advocate for the implementation of Baby Friendly Health Initiatives in some of the world’s most vulnerable places, making Australia a potential leader of the Baby Friendly Health Initiative on a global scale.
As a health promotion program the BFHI has an imperative role in promoting breastfeeding as a culturally normal, biologically desirable start to life for all Australian children. There are successes worth celebrating since the BFHI was introduced to Australia 25 years ago, but there are also gaps in the program which need to be strengthened to improve our national breastfeeding outcomes. Australia’s strong and functional health system also has a role to play beyond our national borders for the good of the world’s most vulnerable populations.
- World Health Organisation (n.d.), Baby-friendly Hospital Initiative, http://www.who.int/nutrition/topics/bfhi/en/
- Australian College of Midwives (undated), What is the WHO Code?, https://www.midwives.org.au/what-who-code
- Australian Breastfeeding Association (undated), Is Your Hospital Baby Friendly?, https://www.breastfeeding.asn.au/bf-info/your-baby-arrives/your-hospital-baby-friendly
- Department of Health (March 2005), Marketing in Australia of Infant Formulas: Manufacturers and Importers Agreement – the MAIF Agreement, http://www.health.gov.au/internet/main/publishing.nsf/Content/health-pubhlth-publicat-document-brfeed-maif_agreement.htm
- Muller, M (1974), ‘The Baby Killer’, War on Want, https://waronwant.org/sites/default/files/THE%20BABY%20KILLER%201974.pdf
- Ellis-Petersen Hannah (27 February 2018), ‘How formula milk firms target mothers who can least afford it’, The Guardian https://www.theguardian.com/lifeandstyle/2018/feb/27/formula-milk-companies-target-poor-mothers-breastfeeding?CMP=share_btn_fb
- Department of Health (November 2017) Australian National Breastfeeding Strategy : 2017 and Beyond, http://www.health.gov.au/breastfeeding
- Holowko N, Jones M, Koupil I, Tooth L, Mishra G (2015), ‘High education and increased parity are associated with breastfeeding initiation and duration among Australian women’, Public Health Nutrition Vol 19(14), pp 2551-2561
- Hauck YL, Blixt I, Hildingsson I, Gallagher L, Rubertsson C, Thomson B, Lewis L (2016) ‘Australian, Irish and Swedish women’s perceptions of what assisted them to breastfeed for six months: exploratory design using critical incident technique’, BMC Public Health Vol 16:1067 https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-016-3740-3
- Tovey A 2015 ‘Breastfeeding photo project helps reduce stigma and keeps mothers feeding for longer’, ABC News online 15 March 2018, http://www.abc.net.au/news/2018-03-15/photo-project-to-reduce-stigma-around-breastfeeding-in-public/9544616
- Barker R 2012 ‘Duration not initiation is the real breastfeeding battle’, ABC News online 5 November 2012, http://www.abc.net.au/news/2012-11-05/barker-breastfeeding-battle/4352172
- University of Technology Sydney (3 April 2018), ‘New partnership to boost midwifery education in Cambodia’, https://www.uts.edu.au/about/faculty-health/news/new-partnership-boost-midwifery-education-cambodia