Breastfeeding in NSW: Promotion, Protection and Support

Transcription

1 Policy Directive Department of Health, NSW 73 Miller Street North Sydney NSW 2060 Locked Mail Bag 961 North Sydney NSW 2059 Telephone (02) Fax (02) Breastfeeding in NSW: Promotion, Protection and Support Document Number PD2006_012 Publication date 19-Apr-2006 Functional Sub group Clinical/ Patient Services - Baby and child Clinical/ Patient Services - Maternity Clinical/ Patient Services - Nursing Population Health - Health Promotion Personnel/Workforce - Conditions of employment space space space Summary This policy provides direction for the Department and Area Health Services on how to progress NSW Health's commitment to promote, protect and support breastfeeding in the community and amongst staff. A 6 page summary "Policy at a Glance" is provided and followed by the full Policy Directive. Replaces Doc. No. Breast Milk [PD2005_063] Gift Bags Provided to Mothers of New Born Babies [PD2005_252] Author Branch Centre for Chronic Disease Prevention and Health Advancement Branch contact Edwina Macoun Applies to Area Health Services/Chief Executive Governed Statutory Health Corporation, Community Health Centres, NSW Dept of Health, Public Health Units, Public Hospitals Audience Health Promotion Units, all staff Distributed to Public Health System, Community Health Centres, Divisions of General Practice, NSW Ambulance Service, NSW Department of Health, Public Health Units, Public Hospitals, Private Hospitals and Day Procedure Centres, Tertiary Education Institutes Review date 19-Apr-2011 File No. Status Active Director-General space Compliance with this policy directive is mandatory.

2 policy at a glance Breastfeeding in NSW: Promotion Protection AND Support Breastfeeding rates are strongly influenced by the way health services are organised and by health service policies and practices. There has already been a great deal of important work done by individual health professionals and service managers to promote, protect and support breastfeeding in NSW. However, there is considerable scope to increase the current suboptimal breastfeeding rates in NSW, through enhanced, coordinated, systemic action, particularly with regard to duration and exclusivity.

3 2 The need and basis for a policy Breastfeeding in NSW: Promotion, Protection and Support is the first comprehensive breastfeeding policy for NSW Health. This Policy is designed to demonstrate NSW Health s commitment towards improved population breastfeeding practices and guide action. The Policy is based on the following considerations: The many health benefits of breastfeeding for mothers and infants. The revised National Health and Medical Research Council s Infant Feeding Guidelines for Health Workers (NHMRC, 2003). A demonstrated need to improve NSW breastfeeding rates; and Recent systematic reviews of the evidence on effective interventions by health services. The health advantages of breastfeeding There is good evidence that breastfeeding has a wide range of health benefits for infants, children and mothers. The list of health advantages continues to grow. See Table 1. NHMRC Infant Feeding Guidelines for Health Workers In 2003 the National Health and Medical Research Council (NHMRC) published revised Infant Feeding Guidelines for Health Workers. Some key recommendations include: Early initiation of breastfeeding (within the first hour of birth), rooming in and frequent, on-demand feeding of newborns. Exclusive breastfeeding until about 6-months of age. Breastfeeding complemented with appropriate, hygienically prepared food from about 6-months; and Continued breastfeeding until 12-months of age or beyond, while receiving appropriate complementary foods. Table 1: Health advantages of breastfeeding for infants and mothers Mother Promotion of maternal recovery from childbirth accelerated uterine involution and reduced risk of haemorrhaging (thus reducing maternal mortality) and preservation of maternal haemoglobin stores through reduced blood loss, leading to improved iron status Possible improved bone mineralisation and thereby decreased risk of post-menopausal hip fracture Prolonged period of post-partum infertility, leading to increased spacing between pregnancies Possible accelerated weight loss and return to pre-pregnancy body weight Reduced risk of pre-menopausal breast cancer Possible reduced risk of ovarian cancer Infant Reduced incidence and duration of diarrhoeal illnesses Protection against respiratory infection and reduced prevalence of asthma Reduced occurrence of otitis media and recurrent otitis media Possible protection against neonatal necrotizing enterocolitis, bacteraemia, meningitis, botulism and urinary tract infection Possible reduced risk of auto-immune disease, such as type 1 diabetes and inflammatory bowel disease Possible reduced risk of developing cow s milk allergy Possible reduced risk of adiposity later in childhood Improved visual acuity and psychomotor development, which may be caused by polyunsaturated fatty acids in the milk, particularly decosahexaenoic acid Higher IQ scores, which may be the result of factors present in the milk and/or of greater stimulation Reduced malocclusion as a result of optimal/correct jaw shape development Source: Dietary Guidelines for Children and Adolescents in Australia, NHMRC 2003

4 3 Need to improve population breastfeeding rates Breastfeeding is a public health issue for New South Wales. Despite the clear health benefits, data from the NSW Population Health Survey indicated that many mothers in NSW are not breastfeeding in line with NHMRC recommendations. For example while initiation rates were fairly good, only slightly more than half of all the infants were exclusively breastfed at 3 months (until about 6 months is recommended) and less than one third of mothers continued any breastfeeding to 12 months. Table 2 shows that over the past decade improvement in population practices concerning duration and exclusive breastfeeding have been small and initiation rates may have slightly decreased. The 2001 Child Health Survey showed that around half of infants were receiving solid foods by 4-months and just less than half were receiving breastmilk substitutes by 4-months. Action is needed to disseminate the revised NHMRC recommendation of exclusive breastfeeding to about six-months of age. Evidence for effective interventions The Policy draws on three recent reports prepared for NSW Health by the NSW Centre for Public Health Nutrition. These reports provide data on breastfeeding rates in NSW 1, an overview of systematic reviews of relevant interventions and strategies 2, and promising case studies on promoting, protecting and supporting breastfeeding relevant to the NSW context 3. Who is the target audience for the Policy? The Policy will be for all NSW Health personnel who are responsible for policies, services and practices which relate to the promotion, protection and support of breastfeeding. This includes personnel in: Senior management, who play a fundamental role by providing the necessary organisational support. Maternity, child and family health, paediatric and neonatal services. Other NSW Health services which come into contact with pregnant women, mothers and their infants such as hospital departments, outpatient clinics, parenting education services, community health, family and youth support services, nutrition services, oral health programs and NSW Health child care centres. Employee relations, because the policy addresses issues associated with combining breastfeeding and work. Workforce development. Health promotion, particularly with regard to facilitating collaborative action with service providers and external groups. The Policy acknowledges the important role of other stakeholders outside the NSW Health system. Collaboration is encouraged between NSW Health and tertiary institutions, private hospitals, Divisions of General Practice, professional representative bodies, research organisations, local government, the Australian Breastfeeding Association, Aboriginal Community Controlled Health Services, consumer organizations (such as playgroups) and other key groups. Table 2: Rates of breastfeeding in NSW in 1995 (National Health Survey, NSW sub-sample a ), 2001 (NSW Child Health Survey a ) and 2004 (NSW Population Health Survey) BREASTFEEDING PRACTICE (%) Full b Any Full b Any Exclusive Full Any Initiation ( ever breastfed ) At hospital discharge 78.4 At 3 months At 6 months At 12 months 21.2 c a Both surveys used similar questions to determine breastfeeding practices. b Exclusive breastfeeding could not be determined from the 1995 and 2001 surveys as questions were not asked concerning consumption of water and juice by infants full breastfeeding is used as a surrogate for exclusive breastfeeding. c Data for Australia, not NSW, as data for breastfeeding at 12 months not available for NSW (data showed overall breastfeeding practices were very similar for NSW and Australia) 1 Hector D, Webb K, Lymer S (2004) State of Food and Nutrition in NSW series: Report on breastfeeding in NSW CPHN/NSW Health Department: Sydney. 2 Hector D, King L, Webb K. (2004) Overview of recent reviews of interventions to promote and support breastfeeding. CPHN/NSW Health Department: Sydney. 3 King L, Hector D, Webb K.(2005) Promoting and supporting breastfeeding in NSW: Case studies. CPHN/NSW Health Department: Sydney.

5 4 Policy Statement Breastfeeding is the biological norm and most beneficial method for feeding infants with immediate and long-term health outcomes for mother and infant and is to be actively promoted, protected and supported by the NSW Health system. NSW Health endorses the: National Health and Medical Research Council s (NHMRC) Dietary Guidelines for Children and Adolescents incorporating the Infant Feeding Guidelines for Health Workers as the basis for practice and policy. World Health Organization (WHO) s International Code of Marketing of Breastmilk Substitutes and Marketing in Australia of Infant Formulas: Manufacturers and Importers Agreement (MAIF Agreement). WHO and UNICEF s Baby Friendly Hospital Initiative and the notion of integrating a Baby Friendly approach through hospital and community services. WHO and UNICEF s Global Strategy for Infant and Young Child Feeding. NSW Health acknowledges that: Virtually all women can breastfeed providing they have appropriate support and accurate information from their families, communities and health services. Breastfeeding is the most ecologically sustainable way to feed infants and provides substantial cost savings to families, the health care system, employers and government. Health workers have an obligation to promote, protect and support breastfeeding and to ensure that best practice in breastfeeding is followed. All parents should receive accurate information about breastfeeding and skilled support if they experience difficulties. An integrated, organisational response is needed to address the decline in breastfeeding rates that occur throughout the first year of life, especially in the early months after birth. There is a substantial body of evidence that provides direction for effective programs and practices to promote, protect and support breastfeeding in NSW Health services and this should be the basis for action. Health services have an obligation to address the special needs of groups at risk of low breastfeeding rates. NSW Health workplaces play an important, exemplary role in supporting exclusivity and duration of breastfeeding, given the high proportion of women who return to the workforce after child birth. Monitoring of population breastfeeding rates should be ongoing and should adopt the WHO standard terms and nationally recommended indicators. Further research is needed to clarify the relative importance of the many determinants of breastfeeding and identify effective strategies to address them, including successful approaches for those groups at risk of low breastfeeding rates. Policy Goals and Strategic Areas Goals While it is acknowledged that there are many factors that influence breastfeeding rates, this Policy aims to contribute to the following broad population goals in NSW: To at least maintain the current proportion of infants who are ever breastfed. To increase the proportion of infants exclusively breastfed to 6 months. To increase the duration of breastfeeding. Strategic Areas The Policy nominates 5 key strategic areas for action by NSW Health: Organisational support for an enhanced, coordinated effort across the NSW health sector. Workforce development and provision of breastfeeding friendly workplaces. Provision of evidence-based health services. Intersectoral collaboration with organisations outside the NSW Health system; and Monitoring and reporting of breastfeeding rates.

6 Areas of Responsibility Table 3 indicates the strategies under five areas of responsibility that are required to be implemented by the Department and Chief Executives of Area Health Services. Table 3: NSW Department of Health and Area Health Service responsibilities NSW DEPARTMENT OF HEALTH STRATEGIES AREA HEALTH SERVICE STRATEGIES Organisational support for an enhanced, coordinated NSW Health effort Oversee the statewide implementation and evaluation of this policy. Oversee policy implementation and provision of Area Health Service leadership and direction in promoting, protecting and supporting breastfeeding. Workforce development and provision of breastfeeding friendly workplaces Collaborate with pre-service training organisations, credentialing bodies and employers to enhance workforce knowledge and skills to promote, protect and support breastfeeding. Support NSW Department of Health employees to combine breastfeeding and work. Enhance the knowledge, attitude and skills of the workforce to promote, protect and support breastfeeding. Support Area Health Service employees to combine breastfeeding and work. Provision of evidence-based health services Encourage Area Health Services to implement the Baby Friendly Initiative. Assist Area Health Services to comply with responsibilities under the WHO International Code of Marketing of Breastmilk Substitutes and the Marketing in Australia of Infant Formulas: Manufacturers and Importers (MAIF) Agreement. Implement the Baby Friendly Initiative across the Area Health Service. Comply with responsibilities under the WHO International Code of Marketing of Breastmilk Substitutes and the Marketing in Australia of Infant Formula: Manufacturers and Importers (MAIF) Agreement. Incorporate breastfeeding education and referral into routine antenatal care. Incorporate breastfeeding education and support services into routine hospital maternity care. Encourage and support research into the promotion, protection and support of breastfeeding. Incorporate breastfeeding education and support into routine child and family health services. Incorporate breastfeeding support into routine paediatric services. Provide breastfeeding support for mothers who access any health services. Identify and provide specific breastfeeding education and support interventions to women who are at risk of low breastfeeding rates. Intersectoral collaboration with organisations outside the NSW Health system Work collaboratively with key health and non-health sectors to promote, protect and support breastfeeding. Work collaboratively with key health and non-health sectors to promote, protect and support breastfeeding. Monitoring and reporting of breastfeeding rates. Assist the NSW Department of Health in state monitoring Monitor and report on population breastfeeding rates. initiatives.

7 6 Policy implementation time frame The review date for the Policy Directive is Chief Executives are required to provide a policy implementation progress report by June Policy Implementation The Policy is accompanied by recommended actions for the Department and for Area Health Service (AHS)s. The Department will contribute a range of measures to assist AHSs in policy implementation. These include: Customised AHS policy implementation planning days. Consultancy from planning and content experts to assist AHSs in refining their policy implementation plans. Funding of the Australian Breastfeeding Association (NSW Branch) to provide peer support services for breastfeeding mothers and to advise on provision of breastfeeding-friendly work places. Statewide dissemination of a NSW Health consumer publication on introducing solids. Revision of the Sydney South West AHS Caring for Infants manual for statewide distribution to child care centres. A multilingual consumer resource called Breastfeeding: Best for Babies and Mothers on the NSW Health website through the Multicultural Health Communication Service. A breastfeeding component targeting parents and health professionals on the new Healthy Kids website. Breastfeeding reports on population data, interventions and promising areas for applied research and special issue of the Public Health Bulletin (prepared by the NSW Centre for Public Health Nutrition on behalf of the Department) on the NSW Health and CPHN websites. Collaboration with midwifery and child and family health nurse organisations to develop workforce competency standards and assessments for breastfeeding. Analysis and reporting on population breastfeeding rates in line with WHO definitions. Who has been involved in developing the policy? Key stakeholders have been involved and consulted throughout the policy development process. They include key branches of the Department, Area Health Services, the NSW Centre for Public Health Nutrition, the NSW Maternal and Perinatal Committee, health professional bodies (including the Australian Lactation Consultants Association, Child and Family Nurses Association, Dietitians Association of Australia, NSW Lactation College, NSW Midwives Association, Pharmacy Guild of Australia), front-line service managers from maternity units and child and family health services, the Aboriginal Health and Medical Research Council, the Multicultural Health Communications Service, the Australian Breastfeeding Association (NSW Branch) and population health experts. Policy monitoring and evaluation The Department has undertaken independent research to establish baseline information on current practices in Area Health Services relevant to the Policy. This information will assist in tracking impacts of the Policy and making decisions about future policy implementation. To download a full copy of Breastfeeding in NSW: Promotion, Protection and Support with accompanying strategies, actions and evidence go to For additional printed copies of the Policy contact the Better Health Centre: Ph: Fax: For More Information: NSW Centre for Public Health Nutrition website Healthy Kids website Multicultural Health Communication Service April Hyde or Edwina Macoun at the Department Ph: NSW Health gratefully acknowledges the Australian Breastfeeding Association for permission to use many of their photos. Published April 2006.

8 Breastfeeding in NSW: Promotion Protection AND Support

9 Breastfeeding in NSW: Promotion, Protection and Support This work is copyright. It may not be reproduced in whole or part for study training purposes subject to the inclusion of an acknowledgement of the source and no commercial usage or sale. NSW Department of Health 2006 PD 2006_012 SHPN (NPA) ISBN For further copies contact the NSW Better Health Centre: Tel. (02) Fax. (02) Full and summary copies of this policy can be downloaded from the NSW Health website: NSW Health gratefully acknowledges the Australian Breastfeeding Association for permission to use many of their photos. April 2006

10 Breastfeeding in NSW: promotion, protection and support ii Breastfeeding in NSW: Promotion, Protection and Support Background NSW Health has developed the Policy Directive in NSW: Promotion, Protection and Support to assist personnel to increase support for breastfeeding within the NSW Health system and thereby contribute to improved population breastfeeding rates. Table 1 (page v) outlines strategies that are required to be implemented by the Department and Chief Executives of Area Health Services. The Policy provides a response to the National Health and Medical Research Council s (NHMRC) revised Dietary Guidelines for Children and Adolescents in Australia 1 and Infant Feeding Guidelines for Health Workers 2. It draws on three reports and a NSW Public Health Bulletin 3 which provide data on breastfeeding rates in NSW 4, recent reviews of breastfeeding interventions 5 and case studies of interventions (GL ) 6 prepared for NSW Health. These reports and articles provide data on recent research, policies and programs related to the public health challenge of promoting, protecting and supporting breastfeeding in NSW by the public health service. These and other resource materials for this policy are available on the NSW Health website ( Population breastfeeding rates are strongly influenced by the way health services are organised and by health service policies and practices. The critical role of the health sector is supported by an increasing body of evidence concerning effective health service strategies to promote, protect and support breastfeeding. While there has already been a great deal of important work undertaken by individual health professionals and service managers to promote, protect and support breastfeeding in NSW, there is considerable scope to increase suboptimal breastfeeding rates through enhanced, coordinated systemic action. Indeed, recent consultations with a broad range of NSW Health staff and key partners consistently and strongly indicated the need for greater organisational support for breastfeeding as a public health issue 7. The purpose of the Policy is to increase support for breastfeeding by the NSW Health system. The focus recognises the critical role of the health sector in promoting breastfeeding as well as the increased body of evidence concerning breastfeeding interventions. Breastfeeding in NSW: Promotion, Protection and Support lists five strategic areas for action for the Department and Area Health Services that will contribute towards improving the suboptimal rates of breastfeeding in NSW, particularly with regard to exclusivity and duration. The strategic areas are: (1) Organisational support for an enhanced, coordinated NSW Health effort; (2) Workforce development and provision of breastfeeding-friendly workplaces; (3) Provision of evidence-based health services; (4) Intersectoral collaboration with organisations outside the NSW Health system; and (5) Monitoring and reporting of breastfeeding rates. The Policy encourages collaboration with key groups outside the NSW Health system including tertiary institutions, private hospitals, Divisions of General Practice and general practitioners, professional representative bodies, research organisations, local government, the Australian Breastfeeding Association, Aboriginal Community Controlled Health Services and consumer organisations (such as playgroups) and other key groups.

11 iii policy statement Breastfeeding is the biological norm and most beneficial method for feeding infants with immediate and long-term health outcomes for mother and infant and is to be actively promoted, protected and supported by the NSW Health system. NSW Health endorses the: NHMRC Dietary Guidelines for Children and Adolescents 1 and the Infant Feeding Guidelines for Health Workers 2 as the basis for practice and policy. World Health Organization s International Code of Marketing of Breastmilk Substitutes 8 and Marketing in Australia of Infant Formulas: Manufacturers and Importers Agreement (MAIF Agreement) 50. Baby Friendly Hospital Initiative 9 and the notion of integrating a Baby Friendly approach through hospital and community services. World Health Organization and UNICEF s Global Strategy for Infant and Young Child Feeding 10. NSW Health acknowledges that: Virtually all women can breastfeed providing they have appropriate support and accurate information from their families, communities and health services. Breastfeeding is the most ecologically sustainable way to feed infants and provides substantial cost savings to families, the health care system, employers and government. Health workers have an obligation to promote, protect and support breastfeeding and to ensure that best practice in breastfeeding is followed. An integrated, organisational response is needed to address the decline in breastfeeding rates that occur throughout the first year of life, especially in the early months after birth. There is a substantial body of evidence that provides direction for effective programs and practices to promote, protect and support breastfeeding in NSW Health services and this should be the basis for action. Health services have an obligation to address the special needs of groups at risk of low breastfeeding rates. NSW Health workplaces play an important, exemplary role in supporting exclusivity and duration of breastfeeding, given the high proportion of women who return to the workforce after child birth. Monitoring of population breastfeeding rates should be ongoing and should adopt the WHO standard terms and nationally recommended indicators. Further research is needed to clarify the relative importance of the many determinants of breastfeeding and identify effective strategies to address them, including successful approaches for those groups at risk of low breastfeeding rates. all parents should receive accurate information about breastfeeding and skilled support if they experience difficulties.

12 Breastfeeding in NSW: promotion, protection and support iv Policy Goals and Strategic Areas Goals While it is acknowledged that there are many factors that influence breastfeeding rates, this policy, and its subsequent implementation, aims to contribute to the following broad population goals in NSW: to at least maintain the current proportion of infants who are ever breastfed. to increase the proportion of infants exclusively breastfed to 6 months; and to increase the duration of breastfeeding. Strategic Areas NSW Health is well placed to protect, promote and support breastfeeding through the following important strategic areas: organisational support for an enhanced, coordinated effort across the NSW health sector. Workforce development and provision of breastfeeding friendly workplaces. provision of evidence-based health services. intersectoral collaboration with organisations outside the NSW Health system; and monitoring and reporting of breastfeeding rates. Policy Implementation Time Frame Chief Executives are required to provide a policy implementation progress report by June 2008.

13 v Areas of Responsibility Table 1 indicates the strategies under five areas of responsibility that are required to be implemented by the Department and Chief Executives of Area Health Services. Table 1: NSW Department of Health and Area Health Service responsibilities NSW DEPARTMENT OF HEALTH STRATEGIES AREA HEALTH SERVICE STRATEGIES Organisational support for an enhanced, coordinated NSW Health effort Oversee the statewide implementation and evaluation of this policy. Oversee policy implementation and provision of Area Health Service leadership and direction in promoting, protecting and supporting breastfeeding. Workforce development and provision of breastfeeding friendly workplaces Collaborate with pre-service training organisations, credentialing bodies and employers to enhance workforce knowledge and skills to promote, protect and support breastfeeding. Support NSW Department of Health employees to combine breastfeeding and work. Enhance the knowledge, attitude and skills of the workforce to promote, protect and support breastfeeding. Support Area Health Service employees to combine breastfeeding and work. Provision of evidence-based health services Encourage Area Health Services to implement the Baby Friendly Initiative. Assist Area Health Services to comply with responsibilities under the WHO International Code of Marketing of Breastmilk Substitutes and the Marketing in Australia of Infant Formulas: Manufacturers and Importers (MAIF) Agreement. Implement the Baby Friendly Initiative across the Area Health Service. Comply with responsibilities under the WHO International Code of Marketing of Breastmilk Substitutes and the Marketing in Australia of Infant Formula: Manufacturers and Importers (MAIF) Agreement. Incorporate breastfeeding education and referral into routine antenatal care. Incorporate breastfeeding education and support services into routine hospital maternity care. Encourage and support research into the promotion, protection and support of breastfeeding. Incorporate breastfeeding education and support into routine child and family health services. Incorporate breastfeeding support into routine paediatric services. Provide breastfeeding support for mothers who access any health services. Identify and provide specific breastfeeding education and support interventions to women who are at risk of low breastfeeding rates. Intersectoral collaboration with organisations outside the NSW Health system Work collaboratively with key health and non-health sectors to promote, protect and support breastfeeding. Work collaboratively with key health and non-health sectors to promote, protect and support breastfeeding. Monitoring and reporting of breastfeeding rates Monitor and report on population breastfeeding rates. Assist the NSW Department of Health in state monitoring initiatives.

14 STRATEGIES, ACTIONS AND EVIDENCE Contents 1. strategies And Actions 1 For Nsw Health Department of Health 1 Area Health Services 4 2. evidence For Policy, 9 Strategies And Actions 3. Abbreviations Glossary 22 Appendix 1: 23 Baby Friendly Initiative Appendix 2: 26 Workplace Breastfeeding Support Programs References 27

15 1 STRATEGIES AND ACTIONS FOR NSW HEALTH: NSW DEPARTMENT OF HEALTH 1. STRATEGIES AND ACTIONS FOR NSW HEALTH This provides recommended actions corresponding to strategies (as shown in Table 1) for implementation by the Department and Area Health Services. NSW Department of Health NSW Department of Health Organisational Support Strategies and Actions 1 Oversee the statewide implementation and evaluation of this policy 5,10,11,12,13,14,15,16,17 Actions 1.1 Establish and maintain a NSW Breastfeeding Reference Committee as required with membership from key stakeholders to support policy implementation and to encourage collaboration and coordination of effort. 1.2 Take appropriate measures to aid effective policy coordination to: Disseminate the policy and resource materials to health professionals*; Assist AHSs to implement the policy; and Evaluate policy implementation and impacts. 1.3 Facilitate a consistent approach to breastfeeding services within NSW, through: Development/review and dissemination of breastfeeding practice guidelines; and Review and dissemination of information about best-practice in breastfeeding promotion, support, and protection interventions and their evaluation (including those that meet the needs of groups at risk of low breastfeeding rates). 1.4 Establish and maintain a NSW Health Breastfeeding information and resource website. 1.5 Oversee the review/development and dissemination of NSW Health-endorsed consumer resources (including multicultural and culturally appropriate resources) for breastfeeding. 1.6 Provide members of the Aboriginal Maternal and Infant Health Strategy network with guidance on evidence-based breastfeeding support programs. 1.7 Contribute to national approaches to breastfeeding through leadership and communication. NSW Department of Health Workforce Development and Breastfeeding-Friendly Workplaces Strategies and Actions 2 Collaborate with pre-service training organisations, credentialing bodies and employers to enhance workforce knowledge and skills to promote, protect and support breastfeeding 5,10,14,15,18,19,20,52 Actions 2.1 Encourage pre-service training organisations to review breastfeeding and infant nutrition course curricula for health professionals and provide information as required to assist this process, eg tertiary institutions courses for health professionals, courses for child care workers, etc. 2.2 Develop and disseminate specific breastfeeding component for orientation programs for health professionals. 2.3 Work with health organisations to develop and disseminate breastfeeding competency standards and assessments for health professionals. 2.4 Encourage and support professional development to enhance health and other key social/welfare professionals breastfeeding knowledge, attitudes and skills. For example, social workers, welfare workers, child care workers, Aboriginal health workers. 2.5 Facilitate relevant health professionals breastfeeding education in line with Families First aims. 2.6 Incorporate breastfeeding promotion, protection and support into the standards review framework for Child and Family Health Nurses. 2.7 Include breastfeeding education for midwives in Birthrate Plus (midwifery workforce calculation tool) (if approved following pilot studies). *For the purpose of this document, health professionals include Midwives and Obstetricians, Child and Family Health Nurses, Neonatal Intensive Care Nurses, Paediatric Nurses and Paediatricians, Dietitian/Nutritionists, Pharmacists, Lactation Consultants, Medical Practitioners, relevant maternity and community health managers and administrators.

16 Breastfeeding in NSW: promotion, protection and support Encourage inclusion of breastfeeding promotion, protection and support content in courses accredited by the NSW Nurses and Midwives Board NSW, Institute of Medical Education and Training and the NSW Medical Board. 3 Support NSW Department of Health employees to combine breastfeeding and work 4,5,10,11,12,17,18,21,22,23,24,25,26,27,28,29,30,31,32,33 Actions 3.1 Develop Policy Directive that promotes the principles of a Breastfeeding Friendly workplace for NSW Department of Health and Area Health Services. 3.2 Review/revise relevant NSW Department of Health policies to encourage continued breastfeeding when returning to work. 3.3 Provide appropriate working conditions and facilities for NSW Department of Health employees who wish to breastfeed on returning to work. For example, lactation breaks, expressing facilities, flexible work times, access to breastfeeding consultation. See Appendix Inform all NSW Department of Health employees, particularly pregnant women, of policies and facilities available to support employees who wish to breastfeed on returning to work, eg in employee orientation programs, on application for maternity leave and returning to work from maternity leave. NSW Department of Health Evidence-Based Services Strategies and Actions Strategies 4 Encourage Area Health Services to implement 1,2,5, 9,10,11,12,18,34,35,36,37,38, the Baby Friendly Initiative Actions 39,40,41,42,43,44,45,46,47, Disseminate information to AHS to assist with the implementation of Baby Friendly steps in maternity, child and family and paediatric services and achievement of Baby Friendly Hospital Initiative accreditation in maternity hospitals. 4.2 Participate in NSW Baby Friendly Initiatives to: Seek representation on the NSW Baby Friendly Initiative Committee. Support the development of accreditation for community services. Advocate the extension of accreditation to paediatric services; and Provide web link from the NSW Health Breastfeeding website to the Australian Baby Friendly Initiative website. 4.3 Approach the National Accreditation Standards body for Maternal and Infant Care Services to assess the feasibility of including BFHI standards in ACHS EQuIP Accreditation. Assist AHS to comply with responsibilities 5 under the WHO International Code of Marketing of Breastmilk Substitutes and the Marketing in Australia of Infant Formulas: Manufacturers and Importers (MAIF) Agreement 1,2,8,10,12,13,18,49,50,51 Actions 5.1 Inform health service employees of their responsibilities under the WHO Code and the MAIF Agreement and support them in meeting these responsibilities, including reporting of breaches. Encourage and support research into the 6 promotion, protection and support of 1,4,5,10, 12,14,52,53,54 breastfeeding Actions 6.1 Champion research into: The relative importance of breastfeeding determinants, particularly social and environmental factors. The effectiveness of breastfeeding activities and promising areas of intervention, particularly for groups at risk of low breastfeeding rates. The role of the media in breastfeeding; and Breastfeeding economic assessments.

17 3 STRATEGIES AND ACTIONS FOR NSW HEALTH: NSW DEPARTMENT OF HEALTH NSW Department of Health Intersectoral Collaboration Strategies and Actions 7 Work collaboratively with key health and non-health sectors to promote, protect and support breastfeeding 5,10,11,14,17,18,52,55 Actions 7.1 Seek and encourage the support of the education sector to provide information to include breastfeeding in appropriate components of: Primary and secondary school curricula; and TAFE courses, eg Child Care and Welfare courses 7.2 Encourage Local Government and Shires Association of NSW to advocate for local councils to provide appropriate parenting facilities, eg discreet breastfeeding areas and messages, eg signage, for breastfeeding in public places. 7.3 Disseminate this policy to key health groups external to NSW Health and to key community organisations to encourage collaborative action in the implementation of this policy, eg professional bodies, Divisions of General Practice, Australian Breastfeeding Association and Aboriginal Community Controlled Health Services. 7.4 Review the policies of other key organisations, eg Royal Australian College of Physicians, as a step towards further collaborative action, including the promotion of consistent information and advice. NSW Department of Health Monitoring and Reporting Strategies and Actions 8 Monitor and report on population breastfeeding rates 1,2,4,11,12,16,52,56,57 Actions 8.1 Adopt the WHO standardised breastfeeding definitions and indicators for monitoring and reporting on population breastfeeding rates in all breastfeeding data collections. 8.2 Use nationally recommended questions and indicators for monitoring and reporting in all breastfeeding data collections. 8.3 Monitor breastfeeding rates in NSW, with analysis and reporting on these rates at least every two years through the NSW Health Survey. 8.4 Facilitate a coordinated approach to data collections relevant to breastfeeding. 8.5 Revise and contribute to the Midwifery Data Collection form to include key items on breastfeeding. 8.6 Seek development of a breastfeeding dashboard indicator and encourage its inclusion in relevant performance measurement tools at the state and local level. 8.7 Explore methods to monitor breastfeeding rates and practices in Aboriginal and Torres Strait Islander population.

18 Breastfeeding in NSW: promotion, protection and support 4 Area Health Services Area Health Services Organisational Support Strategies and Actions 9 Oversee policy implementation and provision of Area Health Service leadership and direction in promoting, protecting and supporting breastfeeding 5,10,11,12,16,52,58 Actions 9.1 Establish and maintain an AHS Breastfeeding Network with membership from a range of key services, eg antenatal, postnatal, maternity, child and family health, health promotion, relevant allied health groups including general practitioners, the Australian Breastfeeding Association, Aboriginal Community Controlled Health Services and other Aboriginal health stakeholders, Nutrition Network, Paediatric groups and community organisations, to facilitate policy implementation through: Coordination of initiatives. Identification and elimination of inefficiencies. Communication and collaboration between stakeholders; and Maximising the efficient use of available resources. 9.2 In addition to establishing and maintaining an AHS Breastfeeding Network, take appropriate measures to aid effective policy coordination, eg breastfeeding service contact, designated breastfeeding coordinator on a permanent or rotational basis, integrated breastfeeding service plan, breastfeeding group to: Disseminate the policy and resource materials to AHS health professionals. Facilitate policy implementation; and Strengthen sustainability of the policy elements in the AHS. 9.3 Adopt a consistent and integrated approach to breastfeeding services within the AHS through: Implementing the NHMRC Infant Feeding Guidelines for Health Workers. Application of best-practice in breastfeeding promotion, protection and support interventions and their evaluation; and Ensuring that the needs of groups at risk of low breastfeeding rates are addressed in service provision. 9.4 Enhance communication and referral pathways between maternity services, transitional community midwifery programs, child and family health services, paediatric services and general practitioners. 9.5 Participate in the statewide Breastfeeding Reference Committee as required. 9.6 Provide access to NSW Department of Health endorsed professional and consumer resources (including multicultural resources) for breastfeeding. 9.7 Include implementation of Breastfeeding Policy in Clinical Streams for Child and Youth and Aboriginal Health services. Area Health Services Workforce Development and Breastfeeding Friendly Workplaces Strategies and Actions 10 Enhance the knowledge, attitude and skills of the workforce to promote, protect and 5,10,11,12,12, 14,16,18,20,38,52,57 support breastfeeding Actions 10.1 Include Breastfeeding Support Skills/ Competencies in staff selection criteria for maternity, neonatal nurseries, paediatric and child and family health settings Encourage and support external professional development opportunities, eg through financial assistance, study leave, staff relief, etc, and provide in-service training programs to enhance breastfeeding knowledge, attitudes and skills of all staff caring for pregnant women, mothers and infants Use relevant competency standards to assess staff breastfeeding knowledge, attitudes and skills Implement a specific breastfeeding component for health professionals orientation programs.

19 5 STRATEGIES AND ACTIONS FOR NSW HEALTH: AREA HEALTH SERVICES 10.5 Provide opportunities for networking, collaboration, sharing knowledge and transfer of management practice skills across service boundaries. Such opportunities may include shared education forums, secondment opportunities and shared venues that provide support services to women and families Facilitate relevant health professionals breastfeeding education to be consistent with Families First aims. 11 Actions Support Area Health Service employees to combine breastfeeding and work 4,5,10,11, 12,16,18,26,27,28,29,30,31,32,33, Review/revise relevant AHS policies to encourage and support continued breastfeeding when returning to work Inform all AHS employees, particularly pregnant women, of policies and facilities available to support employees who wish to breastfeed on returning to work, eg in employee orientation programs, on application for maternity leave and returning to work from maternity leave Provide appropriate working conditions and facilities for AHS employees who wish to breastfeed on returning to work. For example, lactation breaks, expressing facilities, flexible work times, breastfeeding consultations. See Appendix 2. Area Health Services Evidence-Based Services Strategies and Actions 12 Actions Implement the Baby Friendly Initiative across the Area Health 1,2,5,10,11,12,13,18,40,41,42,43,44,45, 46,47,48,59,60 Service 12.1 Adopt an integrated approach to the application of the Baby Friendly Initiative in maternity, paediatric and community health services across the Area. 13 Actions Comply with responsibilities under the WHO International Code of Marketing of Breastmilk Substitutes and the Marketing in Australia of Infant Formula: Manufacturers and Importers (MAIF) Agreement 1,2,8,10,12,18, Inform AHS employees of their responsibilities under the WHO Code and the MAIF Agreement and support them in meeting these responsibilities, including reporting of breaches. Incorporate breastfeeding education and 14 referral into routine antenatal care 1,5,6,10,52,58,61 Actions 14.1 Provide antenatal breastfeeding assessment and education, consistent with the Infant Feeding Guidelines for Health Workers that includes a variety of formats (eg face-to-face, small groups) for all pregnant women Implement protocol identifying and actively addressing skill and support needs of mothers who have previously had breastfeeding difficulties and/or unsatisfying breastfeeding experiences Utilise up-to-date information on effective practice to inform antenatal breastfeeding education, eg Breastfeeding and You: A handbook and video for antenatal educators Cease the distribution of commercial gift packs in any NSW Health service facility. Incorporate breastfeeding education 15 and support services into routine hospital maternity care 1,2,5,10,12,14,15,18,39,52,55, Actions 58,62,63,64,65,66,67,68, Adopt the WHO/UNICEF Ten Steps to Successful Breastfeeding in maternity services Pursue Baby Friendly Hospital Initiative (BFHI) accreditation in maternity services. See Appendix Maintain and sustain Baby Friendly Hospital Initiative (BFHI) accreditation in maternity services Cease the distribution of commercial gift packs in any NSW Health service facility.

20 Breastfeeding in NSW: promotion, protection and support Cease offering complementary and/or supplementary feeds to breastfeeding infants, unless medically indicated or requested by the mother, after advice that this may effect breastfeeding outcomes Implement protocol whereby a mother s written permission is obtained, and discussion with an appropriate health professional occurs, prior to giving complementary feeds to her infant. Consultation with the attending medical officer is indicated in situations of doubt Provide in-hospital postnatal breastfeeding education and support programs, consistent with the Infant Feeding Guidelines for Health Workers, for mothers initiating breastfeeding Provide specialist breastfeeding support services, eg access to lactation consultants, breastfeeding support units/clinics for mothers experiencing breastfeeding establishment difficulties including: Caesarean section births. Premature and/or sick infants; and Maternal illness Provide an effective referral system from maternity, neonatal and paediatric units to community services, which prioritises referrals of mothers who are experiencing breastfeeding difficulties and provide appropriate specialist support services. 16 Actions Incorporate breastfeeding education and support into routine child and family health 6,10,11,12,14,15,18,52,55,62,64,67,68, 70 services 16.4 Review age appropriate parenting and infant management advice so that it protects and supports a mother s ability to continue breastfeeding. For example the use of pacifiers (dummies) and complimentary infant formula feeding, infant settling and sleep training techniques, parenting styles and introduction of solids. 17 Actions Incorporate breastfeeding support into routine paediatric services 1,2,6,10,11,12,18,44,45, Adopt Baby Friendly Paediatric Steps to Successful Breastfeeding in NSW paediatric services. See Appendix Support continued breastfeeding among infants and children attending paediatric services by providing facilities and breastfeeding advice to mothers. Provide breastfeeding support for 18 mothers who access any health Actions 1,2,5,10,13,14, 16,18,27,34,59,60,72,73,74 service 18.1 Support women to continue breastfeeding when they, or their infant, are utilising any NSW health service, including accident and emergency and surgical wards Admit breastfeeding infants whilst their mother is in hospital to permit breastfeeding to continue Provide positive messages (eg signage) and suitable breastfeeding and expressing facilities for visitors to AHS buildings Adopt the Baby Friendly Seven Point Plan for Community Health Services in NSW child and family health services. See Appendix Review organisational barriers and implement strategies to provide breastfeeding support and education services for mothers within the first few months Review organisational barriers and implement strategies to provide services for mothers experiencing breastfeeding difficulties and require acute breastfeeding management.

21 7 STRATEGIES AND ACTIONS FOR NSW HEALTH: AREA HEALTH SERVICES Identify and provide specific breastfeeding 19 education and support interventions to women who are at risk of lower breastfeeding rates 1,2,4,5,10,11,14,15,18,55,75 Actions 19.1 Identify groups within local communities at risk of lower breastfeeding rates* and conduct specific breastfeeding support for these groups by: Collaboration with current services that have established links with these groups, eg Aboriginal Health Services, Multicultural Health Services, Community Groups, Youth Services. Identification of instances where current breastfeeding support services fail to meet the needs of these groups; and Identification, development and implementation of evidence-based interventions that promote and support breastfeeding in these groups, eg peer support, culturally specific programs. Area Health Services Intersectoral Collaboration Strategies and Actions Work collaboratively with key health 20 and non-health sectors to promote, protect and support 5,10,14,16,18, 18,20,52,55 breastfeeding Actions 20.4 Foster collaboration with Aboriginal Community Controlled Health Services to improve communication pathways to provide consistent, evidence-based breastfeeding information to families Work with Families First regional groups for breastfeeding promotion, protection and support through Families First regional plans, communication and coordination systems. Area Health Services Monitoring and Reporting Strategies and Actions Assist the NSW Department 21 of Health in state monitoring Actions 1,2,4,6,10,11,12 14,16,32,55,54 initiatives 21.1 Where appropriate, contribute to state breastfeeding monitoring activities Apply WHO standardised breastfeeding definitions and indicators, developed for statewide population level monitoring and reporting, in records and local breastfeeding data collections Assist with the dissemination of state breastfeeding reports within AHS Foster collaboration with Local Governments to provide appropriate parenting facilities (eg discreet breastfeeding areas) and positive messages (eg signage) for breastfeeding in public places, taking into consideration community cultural composition Work with community breastfeeding groups (eg The Australian Breastfeeding Association) to provide peer support to mothers and to foster appropriate links between peer support and professional support services Foster collaboration with General Practitioners to improve referral pathways and to provide consistent, evidence-based breastfeeding information to families. *women who are less than 25 years, women who have less than a tertiary education, Aboriginal and Torres Strait Islander women, women of the most disadvantaged SEIFA quintile.

22

23 9 EVIDENCE FOR POLICY, STRATEGIES AND ACTIONS 2. EVIDENCE FOR POLICY, STRATEGIES AND ACTIONS Breastfeeding and Breastmilk Breastfeeding is the biological norm and most beneficial method for feeding infants. It is a natural act, but also a learned behaviour that sometimes requires effort and assistance to establish. Breastfeeding is influenced not only by the knowledge, attitudes and skills of the mother but also by the extent to which she is supported by a range of institutions, community groups and structures including hospitals and community services, home and family, the workplace, the community, economic structures and policies, and underlying cultural and societal norms. Almost all mothers are capable of breastfeeding. If appropriate advice and support are not provided, a mother may choose not to breastfeed or cease breastfeeding prematurely. Breastmilk meets an infant s nutritional needs for about the first 6-months of life and contributes substantially to nutritional needs during the second 6-months of life and beyond. The composition of breastmilk changes over time so that it is uniquely suited to the needs of the growing infant. Breastmilk contains protective immunological components, growth hormones and other anti-infective properties which cannot be replicated. In the early days and weeks following birth, exclusive breastfeeding to the baby s need is important to the establishment of an ongoing, adequate supply of breastmilk. Health Impacts of Breastfeeding Breastfeeding provides many short- and longterm health benefits for mothers and infants 77 and is universally recommended by authoritative organisations such as the World Health Organization 10 (WHO), the Royal Australasian College of Physicians 59 (RACP), the Royal Australian College of General Practitioners 60 (RACGP), The Australian Medical Association 78 (AMA), the American Academy of Pediatrics 34 (AAP), the Pharmaceutical Society of Australia 73, and Australia s National Health and Medical Research Council (NHMRC). There are very few contraindications to breastfeeding. 2,79,80,81 Breastfeeding is associated with optimal health and immunity, physical growth and development, and cognitive development. A summary of the health advantages of breastfeeding is provided in Table 2 (NHMRC 2003). More recent systematic reviews and meta-analyses support and extend this summary and provide unequivocal evidence that breastmilk is protective against a large number of adverse health outcomes for infants and mothers. 77 Abundant and convincing evidence exists showing that breastfeeding (particularly exclusive breastfeeding up to 6-months and breastfeeding for a longer duration), is protective against gastrointestinal illnesses, otitis media and respiratory tract infections in infants up to two years and beyond. 77,82,83 A recent meta-analysis of studies conducted in developed countries only, indicated severe respiratory tract illnesses more than tripled (resulting in hospitalisations) in their first year for formula-fed infants compared with infants who were exclusively breastfed for at least 4-months. 84 The immunological properties of breastmilk are notable in relation to pre-term and very-low-birthweight infants, with evidence of breastmilk offering protection against respiratory infections and necrotising enterocolitis. 2,77 Benefits are also seen in these groups of infants, and in full-term infants, in relation to neurological development. 2,77 Most studies have found that breastfeeding is protective against asthma and atopy 2,77 with breastfeeding being recommended by The Australasian Society of Clinical Immunology and Allergy. 85 Evidence is also accumulating of the protective effect of breastmilk for a number of chronic diseases and their risk factors. Recent meta-analyses and research findings show an association between breastfeeding and a reduced risk of obesity in childhood and in later life 86,87 with the most recent meta-analysis 88 finding a clear dose-response relationship ie the longer the duration of breastfeeding, the lower the risk of obesity in later life. A number of recent single studies have shown that breastfeeding is protective against several chronic diseases and associated risk factors: inflammatory bowel disease; insulin response; lipoprotein profile associated with reduced risk of atherosclerosis; ischaemic heart disease; diastolic blood pressure. 77, 89,90,91,92,93,94 Most recently a study has shown

24 Breastfeeding in NSW: promotion, protection and support 10 that exclusive breastfeeding to 6-months and longerterm breastfeeding reduces systolic blood pressure in children aged 9 to 15 years. 95 The magnitude of the effect was comparable to the published effects of salt restriction and physical activity on blood pressure in adult populations. The public health significance of just this single health outcome is of importance. There is substantial evidence of multiple health benefits of breastfeeding for mothers 77. Breastfeeding leads to improved recovery from childbirth as well as protection against premenopausal breast cancer, and probably postmenopausal breast cancer and ovarian cancer. 77,96 There is clear dose response relationship between premenopausal breast cancer and breastfeeding. 97 A dose response relationship has also been shown for a number of other health outcomes in mothers who breastfed, such as rheumatoid arthritis. 98,99 It is clear that breastfeeding and breastmilk are protective against a large range of immediate and longer-term health outcomes that pose a significant burden to individuals, the health system and society as a whole. Economic Costs of Not Breastfeeding Breastfeeding yields cost savings for families, the health care system, employers and government. 100,101 Those illnesses for which there is convincing and abundant evidence of a protective effect of breastfeeding are among the major health problems in Australia and contribute significantly to the health burden 77. To date, most economic analyses of the benefits of breastfeeding to the health system have concentrated on just a few infant illnesses and on direct health care costs only. For example, Smith (2002) 102 estimated the cost of weaning to infant formula before 3-months of age was $290 million per year in Australia, for five infant illnesses. Estimates of economic benefits that can be apportioned to improved breastfeeding practices and rates will have been considerably underestimated as they focus on the infant period only, they exclude the protective effect against a large number of infant and maternal illnesses, and they do not include the indirect and outof-hospital health care costs of poor health outcomes associated with not breastfeeding. Importantly, they do not account for the costs of a number of costly chronic diseases, including obesity that are associated with formula feeding. Direct expenses for families using Table 2: Health advantages of breastfeeding for infants and mothers Mother Promotion of maternal recovery from childbirth accelerated uterine involution and reduced risk of haemorrhaging (thus reducing maternal mortality) and preservation of maternal haemoglobin stores through reduced blood loss, leading to improved iron status Possible improved bone mineralisation and thereby decreased risk of post-menopausal hip fracture Prolonged period of post-partum infertility, leading to increased spacing between pregnancies Possible accelerated weight loss and return to pre-pregnancy body weight Reduced risk of pre-menopausal breast cancer Possible reduced risk of ovarian cancer Infant Reduced incidence and duration of diarrhoeal illnesses Protection against respiratory infection and reduced prevalence of asthma Reduced occurrence of otitis media and recurrent otitis media Possible protection against neonatal necrotizing enterocolitis, bacteraemia, meningitis, botulism and urinary tract infection Possible reduced risk of auto-immune disease, such as type 1 diabetes and inflammatory bowel disease Possible reduced risk of developing cow s milk allergy Possible reduced risk of adiposity later in childhood Improved visual acuity and psychomotor development, which may be caused by polyunsaturated fatty acids in the milk, particularly decosahexaenoic acid Higher IQ scores, which may be the result of factors present in the milk and/or of greater stimulation Reduced malocclusion as a result of optimal/correct jaw shape development Source: Dietary Guidelines for Children and Adolescents in Australia, NHMRC 2003

25 11 EVIDENCE FOR POLICY, STRATEGIES AND ACTIONS infant formula include the costs of the infant formula and equipment, medical care for illnesses, and lost working days for parental infant care. There are some costs associated with breastfeeding, such as breast pumps, work breaks for expressing, marginally increased maternal food costs, and maternal leave payments if leave is extended in order to continue breastfeeding. However, these are outweighed by the numerous and abundant costs associated with formula feeding. An alternative way of looking at the economics of breastfeeding has been to assess breastmilk as part of the food supply. Such an analysis in , including adjustment for a small increase in maternal food consumption, estimated the net benefit of breastfeeding to be at least $2.2 billion per year in Australia. Environmental Impact of Not Breastfeeding The alternative to breastfeeding, ie the use of infant formula, incurs substantial environmental costs. These include deforestation, soil erosion, pollution, climatic changes, wasted resources and overpopulation. 104,105 For every million bottle-fed babies, 150 million tins of formula are consumed. 106 The cost to the environment of producing this amount of formula includes the direct waste, energy consumption and pollution from the production, packaging, transport and disposal of formula containers, bottles, teats and sterilising equipment. 104,105,106,107 Manufacturing of bottles, teats, and other feeding equipment uses large amounts of plastic, rubber, silicon, and glass. Plastic feeding bottles, teats, and pacifiers take hundreds of years to break down when disposed in landfill sites. 106 The production of infant formula consumes energy as heat-treated cows milk is converted to powder, and during transportation of raw materials and the finished product. 104,105,106, 107,108 The large number of grazing cows required for the production of cows milk infant formula impacts negatively on the environment 108,109 through land cleared for pasture 110,111, production of large quantities of methane gas 112,113, and pollution of rivers and groundwater from sewage and fertilizers used for pasture. 114,115,116,117,118 Summary Breastfeeding and breastmilk are important public health issues. There is strong, convincing and abundant evidence that breastfeeding is protective against a large range of immediate health outcomes (such as respiratory illness and otitis media) and longer term health outcomes (including breast cancer, obesity and chronic disease). Low rates of breastfeeding therefore put large numbers of infants and mothers at increased risk of ill health. These health risks, together with the negative environmental impacts of formula feeding, result in considerable costs to individuals, the health system, government and society. Substantial costs could be saved through effective promotion, protection and support of breastfeeding. Recommended Breastfeeding Practices For NSW In 2003 the National Health and Medical Research Council published revised Infant Feeding Guidelines for Health Workers. 2 Some key recommendations include: Early initiation of breastfeeding (within the first hour of birth) and frequent, on-demand feeding of newborns and rooming-in. Exclusive breastfeeding until about 6-months of age. Breastfeeding complemented with appropriate, hygienically prepared food from 6-months; and Continued breastfeeding until 12-months of age or beyond, while receiving appropriate complementary foods. It is important to note that these NHMRC Guidelines do not recommend 12-months as an end point and that breastfeeding should be encouraged and supported for longer if both mother and infant wish. In this vein, NSW Health acknowledges the World Health Organization recommendations that breastfeeding continues for up to 2-years and beyond with the introduction of appropriate complementary foods 10 and that breastmilk can continue to meet half of an infant s nutritional needs during the second half of the first year of life, and up to one-third during the second year of life.

26 Breastfeeding in NSW: promotion, protection and support 12 Breastfeeding Practices In NSW Three major surveys in the recent years, the National Health Survey 1995: NSW Sub-sample 119 and the NSW Child Health Survey and the ongoing NSW Population Health Survey ( data) have provided data on the prevalence of particular breastfeeding practices at the population level in NSW (Table 3). The rate of initiation of breastfeeding in NSW in 2001 (90.2%) was reasonably high and compared favourably with a number of other countries (e.g. Ireland 34% in 2000, UK 69% in , USA 71% in ) 120. However, it was lower than the rates achieved in Norway and Sweden (97-99%) 120,123. The initiation rate was slightly less in 2004 (87%). While there are some small increases in breastfeeding duration towards the recommended 12 months or beyond since 1995, Table 3 shows that the prevalence of any breastfeeding continued to drop to about half of infants at 6 months of age and to less than a third of infants at 12 months of age in The recommendation for introduction of solids in 1995 and 2001 was between 4 and 6-months so the low percentage of NSW infants fully breastfed to 6-months in 1995 (17%) and in 2001 (15%) is somewhat expected. 4 This percentage did increase to 25% in 2004 but is still low. Also, in 2001, 13% and 53% of infants were receiving solid foods and 46% and 47% of infants were receiving breastmilk substitutes, by their third and fourth months respectively. 4 Rates of full breastfeeding (no breastmilk substitutes or solid foods; an approximation to exclusive breastfeeding) were low in the 1995 and 2001 surveys ie 57% and 53% respectively. Similarly, according to data from the NSW Population Health Survey, only slightly more than half of infants were exclusively breastfed at 3 months of age. Hence, there appears to be a persisting gap between the NHMRC recommendation to breastfeed exclusively to about 6 months and population practice. Table 3: Rates of breastfeeding in NSW in 1995 (National Health Survey, NSW sub-sample a ), 2001 (NSW Child Health Survey a ) and 2004 (NSW Population Health Survey) BREASTFEEDING PRACTICE (%) Full b Any Full b Any Exclusive Full Any Initiation ( ever breastfed ) At hospital discharge 78.4 At 3 months At 6 months At 12 months 21.2 c a Both surveys used similar questions to determine breastfeeding practices b Exclusive breastfeeding could not be determined from the 1995 and 2001 surveys as questions were not asked concerning consumption of water and juice by infants full breastfeeding is used as a surrogate for exclusive breastfeeding c Data for Australia, not NSW, as data for breastfeeding at 12 months not available for NSW (data showed overall breastfeeding practices were very similar for NSW and Australia) The majority of the information in this section is derived from the NSW Centre for Public Health Nutrition, for NSW Health: Report on Breastfeeding in NSW, 2004 (Hector et al 2004, revised 2005)

27 13 EVIDENCE FOR POLICY, STRATEGIES AND ACTIONS Policy Context Two previous NSW Department of Health publications included breastfeeding policies - Maternity Services in NSW: Final report of the Ministerial Task Force on Obstetric Services 14 and Maternal and Perinatal Care in New South Wales: Since then, there have been NSW Health circulars relating to infant feeding practices 62,63 but no updated comprehensive breastfeeding policy or service framework. More recently, three reports 4,5,6 and a special edition of the NSW Public Health Bulletin 3 have been prepared for NSW Health. These provide data on breastfeeding rates in NSW, recent reviews of interventions and case studies of recent research, policies and programs related to the public health challenge of promoting, protecting and supporting breastfeeding in NSW by the public health service. NSW Health s commitment to the goals of fairer access and healthier people provides an important policy context. 124 In all Fairness 125 provides an explicit statement of NSW Health s commitment to reduce health inequities through the following areas of priority action: Strong beginnings-investing in the early years of life, greater participation-engaging communities for better health, a stronger primary health care system, regional planning and inter-sectoral action-working better together, organisational development and resources. In recognition of the diverse needs and cultural consideration of Aboriginal people Ensuring Progress in Aboriginal Health: a Policy for the NSW Health System 126 describes five Aboriginal health principles that must be applied in all relevant NSW Health policy initiatives: Whole-of-life view of health, holistic approach to health, practical implementation of self-determination and self management, working in partnership and cultural respect. Also with regard to indigenous health, the importance of breastfeeding is emphasised in the NSW Health Aboriginal Health Strategic Plan 127 and the NSW Otitis Media Strategic Plan for Aboriginal Children. 128 The NSW Premiers Department released Employer Sponsored Childcare Policy and Guidelines. 28 This recommends that lactation breaks, expressing facilities, breastmilk storage and access to breastfeeding consultation services are included in enterprise agreements and award provisions for the benefit of breastfeeding employees of government agencies. To date this Policy has not been issued to the Department or Area Health Services. The Department has, however, addressed the need for expressing facilities through the Work and Family Room Policy (PD2005_310). The Families First Initiative is committed to improving breastfeeding rates in NSW. The Families First Outcomes Evaluation Framework 20 includes breastfeeding as one of five indicators for child physical development by setting a goal to increase the proportion of infants exclusively breastfed. The Initiative seeks to achieve this through its aims 129, which are: Healthier children and parents and better functioning families. Children better prepared to learn when they start at school. Reductions in conditions that lead to mental health problems in children. Improved recognition and early intervention for post natal depression and other mental health issues in parents with new babies. Greater parental participation in education and training. Communities in which people interact and are friendly places to bring up children. Reductions in conditions that lead to child abuse and neglect; and Reduction in juvenile and adult crime. In 2003, the National Health and Medical Research Council released the revised Dietary Guidelines for Children and Adolescents in Australia 1 incorporating the revised Infant Feeding Guidelines for Health Workers. 2 These guidelines renewed Australia s commitment to encourage and support breastfeeding and provide information to enable health professionals to implement this commitment.

28 Breastfeeding in NSW: promotion, protection and support 14 From 1996 to 2001 the Australian Government funded the National Breastfeeding Strategy. 55 The Strategy includes family education, accreditation standards for maternal and infant care services, workplace breastfeeding, health professional education (for general practitioners, pharmacy assistants, child and family health nurses and other community based health professionals), indigenous health, data collection and antenatal education. More recently, the Commonwealth Department of Health and Aged Care funded the Australian Food and Nutrition Monitoring Unit (AFNMU) to coordinate the second phase of a national food and nutrition monitoring and surveillance system for Australia. 57 As part of their work, AFNMU prepared a discussion paper and recommendations for a national system for monitoring breastfeeding, including recommendations for population indicators, definitions and next steps. 53,54 Working at national and local levels, the Australian Breastfeeding Association (ABA) is well known for its contribution to breastfeeding policy, its telephone counselling services and peer support for new mothers and for providing a comprehensive range of breastfeeding resources for consumers and health professionals. 12 ABA s core business now covers a much broader ambit including environmental support strategies such as programs to accredit breastfeedingfriendly baby care rooms and workplaces for breastfeeding mothers. 31 See Appendix 2. Internationally, the most significant policy development in recent years has been the launch of the Global Strategy for Infant and Young Child Feeding in 2003, by the World Health Organization (WHO) and the United Nations Children s Fund (UNICEF). 10 This strategy calls on all governments to promote and protect breastfeeding through policy development and implementation, coordination of effort, monitoring and evaluation, and provision of adequate resources. The document strongly encourages intersectoral action consistent with the Baby Friendly Hospital Initiative (BFHI) 9, the International Code of Marketing of Breastmilk Substitutes 8 and the Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding. 13 It emphasises the central role of health services and the wisdom of using existing health and intersectoral structures to implement breastfeeding policy initiatives. The Commonwealth Government supports the Australian College of Midwives (ACMI) to lead implementation of the Baby Friendly Hospital Initiative in Australia. 37 The BFHI identifies ten key steps for implementation within the hospital setting and includes a proposal to extend the initiative into the community setting. Accreditation for maternity services is available. In the UK and Canada, steps for community and paediatric services have also been developed. Although many hospitals in NSW now practice elements of the BFHI Ten Steps, only two NSW hospitals have formalised their breastfeeding support activities by receiving BFHI accreditation. 36,37 In 1981, Australia voted to adopt the WHO International Code of Marketing of Breastmilk Substitutes (WHO Code). 8,51 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 larger Australian infant formula manufacturers have signed a voluntary agreement to conform to the WHO Code the Marketing in Australia of Infant Formulas: Manufacturers and Importers Agreement (MAIF Agreement). 50,51 However, the MAIF Agreement does not cover infant formula distributors, retailers, feeding bottles and teats, or health care systems and workers. Although the MAIF Agreement does not formally cover health workers, the National Health and Medical Research Council (NHMRC) has interpreted the WHO Code, for health workers in Australia, through the Infant Feeding Guidelines for Health Workers. 2 An Advisory Panel on the Marketing in Australia of Infant Formula (APMAIF) receives and investigates complaints about the marketing of infant formula in Australia. Health workers are encouraged to report breaches of the WHO Code to the APMAIF committee. Although some of these complaints may be outside the APMAIF terms of reference, each complaint is documented. Details of how to report a breach in the MAIF Agreement can be found in the annual APMAIF reports. 50,51

29 15 EVIDENCE FOR POLICY, STRATEGIES AND ACTIONS Need For Organisational Approach A large number of factors affect breastfeeding practices. 17 The main determinants of breastfeeding that are amenable to intervention have been grouped into six categories. 17 Health service organisation, policies and practices. Aspects of feeding practices. Mothers knowledge, attitude and skills. Health status of the mother and her infant. Structural and social support; and Socio-cultural, economic and environmental factors. These categories have been further extended to a conceptual framework of factors affecting breastfeeding showing three levels of factors that influence breastfeeding practices: individual, group and society. 17 The way health services are organised, their policies and practices have a direct and crucial influence on infant feeding practices at individual and group level. The broad range of determinants involved and the many stakeholders within and external to the health system play a part, make collaborative, intersectoral, multi-faceted action a necessity in the promotion, protection and support of breastfeeding. 131 Key policy documents have called for a collaborative, coordinated effort. 5,6,10,16 In addition, consultations conducted in the preparation of this Policy clearly identified the need for greater organisational support, for breastfeeding as a public health issue. 7 Health Service Consultation A Consultation Survey 7 was conducted with health professionals and key stakeholders across the NSW health system in late This survey explored breastfeeding service issues and the feasibility of implementing a range of evidence-based interventions to promote, protect and support breastfeeding. Main Findings There is considerable variation in breastfeeding services provided by Area Health Services. For example, some Areas offer comprehensive antenatal breastfeeding education programs including specific cultural, adolescent and special needs programs, while others offer no programs at all. Services for postnatal support in maternity units are also varied. Some services provide facilities for infants to room-in with their mothers, while others do not. The Baby Friendly Hospital Initiative principles were generally regarded as desirable and feasible, with the majority of maternity services already working towards achieving the Ten Steps to Successful Breastfeeding (Appendix 1). Similarly, Baby Friendly models adapted for community and paediatric services are supported as being feasible for implementation within NSW Health. However, the process for gaining BFHI accreditation is perceived as difficult by clinicians mainly due to lack of organisational support, eg lack of the leadership and the modest resources required to pursue BFHI accreditation. Child and Family Health Nurses frequently indicated a need for organisational support to reduce waiting times between hospital discharge and their first appointments with new mothers. Similarly, a need for more timely access to health professionals by mothers experiencing breastfeeding problems, especially in rural areas, was identified. There is a varied knowledge and skills base amongst health professionals, and varying levels of support for professional development in relation to breastfeeding. Some Area Health Services provide local in-service programs, but in many Areas staff feel under-skilled and lack support for professional development in breastfeeding issues. Nearly all health professionals are required to self-fund any external breastfeeding education they undertake to support their work (such as conferences or courses). Both maternity and child and family health professionals identified a need for standardised consumer information and resources within the health services and across the state.

30 Breastfeeding in NSW: promotion, protection and support 16 Evidence-base for action There is a substantial body of strong and consistent evidence which provides a sound basis for adopting programs and services to promote, protect and support breastfeeding within the NSW Health system. Two major reports inform this evidence base: In 1995, the NSW Department of Health produced a report describing a range of public health interventions that could be used to promote breastfeeding, Strategies to Promote Breastfeeding: An overview. 16 A subsequent report, published in 2004, Overview of recent reviews of interventions to promote and support breastfeeding 5, identified, appraised and summarised the evidence available from systematic reviews and meta-analyses published since These reviews emphasise the key role of health services and identify a broad, multi-faceted portfolio of interventions as the most powerful approach for improving breastfeeding outcomes. Notably the Overview report concluded that: There is a substantial body of consistent evidence that provides a sound basis to proceed with evidencebased programs and practices in a number of areas, particularly those areas addressed by mainstream health services. These action areas comprise the organisation of hospital services, and prenatal and postnatal community-based education and support services for women. Information most relevant to this policy from these reviews is summarised on the following page. Health services policies, practices and training There is strong evidence that specific hospital practices can improve breastfeeding initiation and short-term duration of breastfeeding (to 3-months). Practices such as early skin-to-skin contact 65 and rooming-in 38, and not using commercial hospital discharge packs 66, have been shown to be particularly effective. These practices are included in the Ten Steps to Successful Breastfeeding, that form the basis of the Baby Friendly Hospital Initiative for maternity services. 38 Evidence also indicates that health service policy and professional training (also components of the BFHI Ten Steps ) are important in enabling the consistent and integrated implementation of such practices and that these are essential components of the overall strategy mix. Commercial Discharge Packs Commercial hospital discharge or gift packs containing an assortment of commercial products, educational and promotional materials and samples, are currently distributed within NSW Health facilities. There are at least four reasons for abolition of this practice (Action 15.4): There is convincing evidence that the giving of a commercial hospital discharge pack containing either samples of formula or a pack without formula samples but which advertises formula feeding materials ie branded information, teats, and bottles, is detrimental to exclusive breastfeeding in the first three months postpartum (twice as likely to stop exclusive breastfeeding before 2 weeks and 1.25 times more likely to stop exclusive breastfeeding between 3 and 6 weeks postpartum). These findings are from a Cochrane meta-analysis 66 of nine goodquality studies examining the impact of such packs on breastfeeding practices of mothers from a diversity of socio-demographic backgrounds in the US and Canada. Two of the review studies 66,67, where the commencement of solids was measured, found that solids were introduced earlier when commercial discharge packs relating to formula feeding were provided. The information in this section is derived from the NSW Centre for Public Health Nutrition, for NSW Health Overview of Recent Reviews of Interventions to Promote and Support Breastfeeding (Hector et al 2004).

31 17 EVIDENCE FOR POLICY, STRATEGIES AND ACTIONS The provision of commercial samples and product information within NSW Health facilities could be construed as an endorsement of those products by the facility and NSW Health; and The provision of commercial discharge packs which commonly advertise formula feeding materials such as teats and bottles, contravenes Step 9 of the Baby Friendly Hospital Initiative s Ten Steps to Successful Breastfeeding which states Give no artificial teats or pacifiers to breastfeeding infants. Education and support Support provided by health professionals has been shown to significantly increase breastfeeding initiation and duration. 67 Findings of systematic reviews and meta-analyses indicate that well conducted educational and support interventions have substantial and significant effects on breastfeeding initiation and duration. Education of mothers before and immediately after birth is effective in improving breastfeeding initiation and duration rates while the isolated use of written materials has been shown to be ineffective. Sessions spanning both prenatal and postnatal periods are most effective. One-to-one educational programs and/or small group programs in an informal environment have been shown to be optimal, particularly when combined with postnatal home visits. Content should include: benefits of breastfeeding, principles of lactation, myths (eg insufficient milk, breastfeeding is easy), common problems and solutions, and skills training. Postnatal support alone increases breastfeeding duration. Both professional and lay (including peer) support strategies have been shown to have a significant impact on short-term duration (to 3-months) and exclusivity of breastfeeding. Postnatal support also increases breastfeeding duration up to 6-months. Peer support may be particularly effective in reaching and influencing low income and more disadvantaged groups A mix of prenatal and postnatal support is probably most effective, particularly if postnatal home visits are included. Combined educational and support interventions that were long-term, intensive and generally comprised of face-to-face information, guidance, and support were found to be effective. Table 4 (page 19) summarises the evidence of interventions to promote and support breastfeeding from a synthesis of findings of systematic reviews. These findings highlight a key role for health professionals in providing education and support in the antenatal, perinatal and postnatal periods. Coordination of services to ensure consistency of advice and development of stronger links between health professional services and peer support (such as the Australian Breastfeeding Association) is likely to improve rates of longer breastfeeding duration. Additional Evidence The systematic reviews and meta-analyses included in the Overview of Breastfeeding Interventions 5 report only included studies published up to Research on the determinants of breastfeeding 17 confirms the importance of interventions in other areas, particularly of interest for NSW Health, such as the workplace environment. The evidence of effectiveness of such interventions is accumulating. Example: Baby Friendly Hospital Initiative (BFHI) At the time of the systematic reviews there were no good quality studies showing the effectiveness of the BFHI in its entirety (although conclusive evidence for some of the components of the BFHI had been identified, see section above). Since these systematic reviews, a substantial number of studies have shown the BFHI increases the rates of initiation and duration of breastfeeding 36. This evidence originates from diverse countries such as Scotland, the United Kingdom, Republic of Belarus, the United States, Switzerland and Brazil. 40,41,42,43,44,45,46,47,48,69

32 Breastfeeding in NSW: promotion, protection and support 18 Example: Workplace Support Given that 25% of mothers in Australia return to the workforce before their infant is 6-months old (and around 40% by 12-months), workplaces have an important role to play in encouraging and assisting breastfeeding exclusivity and duration 74. Return to work is frequently cited by mothers as a primary reason for early weaning. 32 Working mothers who have convenient access to their infant during the working day breastfeed for longer than women who are separated from their infants. 21 Similarly, women who express breastmilk at work breastfeed for longer than mothers who do not express at work. 22 Supportive workplace policies and programs have been shown to increase breastfeeding duration among working mothers. 23,24,25,26,27 Workplace strategies involve a mix of organisational policies and provisions including maternity leave, flexible employment practices, lactation breaks for breastfeeding and expressing and physical facilities such as private rooms for expressing and refrigeration for breastmilk storage. Informing employees of their workplace policies and provisions is also a key element of workplace support for breastfeeding. 17,28,31,32,33 Case Studies A recent CPHN report, Promoting and Supporting Breastfeeding in NSW: Case Studies 6 (GL ), extends our knowledge about appropriate interventions. The report provides more detailed descriptions of specific strategies found to be effective in recent systematic reviews, as well as a range of promising initiatives not covered in the systematic reviews. The absence of particular types of interventions not covered in systematic reviews and/ or meta-analyses does not necessarily mean that such interventions are not effective. It could be that these types of interventions have not been extensively and/or adequately (methodologically) researched. The Case Studies report covers three broad areas: education and support; health service policies and practices; and mass media, advocacy and healthy public policy. The case studies in this report have been used to guide some of the actions indicated in this Policy. As a large employer of women in their childbearing years, NSW Health has a responsibility to model exemplary policies and provisions for working mothers to support their efforts to combine breastfeeding and work (refer to Appendix 2: Workplace Breastfeeding Support Programs for further detail on workplace programs).

33 19 EVIDENCE FOR POLICY, STRATEGIES AND ACTIONS Table 4: Interventions to Promote and Support Breastfeeding: Conclusions from a synthesis of findings of systematic reviews. EDUCATION HEALTH SERVICE POLICY AND PROGRAMS Education alone is effective in increasing rates of breastfeeding initiation and short-term duration Content should include: benefits of breastfeeding, principles of lactation, myths, common problems and solutions, and skills training Formats most effective are one-to-one educational programs and/or small group programmes in an informal environment together with postnatal home visits Sessions spanning prenatal and postnatal periods are most effective Explicit health service policies that outline appropriate health service practices are beneficial Specific in-hospital practices that support breastfeeding are: early skin-to-skin contact between the baby and mother, rooming-in, not giving commercial hospital discharge packs, not using supplemental feeds, and not using artificial teats and pacifiers A Cochrane review 11 indicated that WHO/UNICEF training courses for in-hospital health professionals increased the likelihood of prolonged exclusive breastfeeding by 30% The combination of policy, in-hospital practices and professional training is effective in improving breastfeeding practices Support Multifaceted interventions Increases the longer-term duration and exclusivity of breastfeeding Particularly effective in settings where there are high rates of breastfeeding initiation Must include face-to-face contact Effectiveness is enhanced by home visits Peer support increases both rates of breastfeeding initiation (among women who intend to breastfeed) and the duration of exclusive breastfeeding Multifaceted interventions have been shown to be effective at increasing the initiation and, in most cases, duration of breastfeeding in developed countries The optimal mix of interventions will depend on the setting, however packages including two or more of the following have been shown to be effective in improving breastfeeding practices: education of mothers, peer support, changes to hospital practices such as rooming-in and early skin-to-skin contact, staff training, development and implementation of hospital policy, media campaigns/programmes, paid maternity leave Peer support is particularly effective among socioeconomically disadvantaged women Peer counsellors are more successful if they are culturally and socially similar to mothers, available to advise on problems and answer questions, and contact is frequent Postnatal support alone increases breastfeeding duration Combination of Education and Support Face-to-face education and peer counselling is particularly effective Source: Hector D and King L. (2005) Interventions to Encourage and Support Breastfeeding. NSW Public Health Bulletin 16(3-4):56-61

34

35 21 ABBREVIATIONS AND GLOSSARY 3. ABBREVIATIONS ABA ABS ACHS AFNMU AHS AIHW AMIHS ANMC APMAIF BFHI BSP CIAP CNC CNS CPHN EquIP IBCLC MAIF NHMRC NGO NSW SEIFA SIDS UNICEF WHO WHO Code Australian Breastfeeding Association australian Bureau of Statistics Australian Council of Healthcare Standards Australian Food and Nutrition Monitoring Unit Area Health Service Australian Institute of Health and Welfare Aboriginal Maternal and Infant Health Strategy Australian Nursing and Midwifery Council Advisory Panel on the Marketing in Australia of Infant Formula Baby Friendly Hospital Initiative Breastfeeding Services Plan Clinical Information Access Project Clinical Nurse Consultant Clinical Nurse Specialist NSW Centre for Public Health Nutrition Evaluation and Quality Improvement Program of ACHS International Board Certified Lactation Consultant Marketing in Australia of Infant Formulas: Manufacturers and Importers Agreement National Health and Medical Research Council Non Government Organisations New South Wales Socio-Economic Indexes for Areas Sudden Infant Death Syndrome United Nations Children s Fund World Health Organization International Code of Marketing of Breastmilk Substitutes

36 Breastfeeding in NSW: promotion, protection and support GLOSSARY Antenatal Services Area Health Services Attending Medical Officer Breastfeeding Breastfeeding duration Breastmilk Breastmilk substitute Community Services Complementary feeding Exclusively breastfed Ever breastfed Fully breastfed Infant Formula Lactation Consultant Maternity Services Neonatal Services NSW Department of Health NSW Health Paediatric Services Peer Support Predominant breastfeeding services provided during pregnancy. nsw Health administrative regions incorporating Northern Sydney/Central Coast, South Eastern Sydney/Illawarra, Sydney South West, Sydney West, Greater Southern, Greater Western Hunter/New England and North Coast Area Health Services and the Children s Hospital at Westmead. medical Officer in charge of infants healthcare. the child receives some breastmilk but can also receive any food or liquid including non-human milk. the total length of time an infant received any breastmilk at all from initiation until weaning is complete. Human milk, including colostrum. any milk, other than breastmilk, or food based fluid used in infant feeding as a replacement for breastmilk, whether or not it is suitable for that purpose (commonly includes infant formula, cows milk, and other milk fed to infants). services based in the community. the child has received both breastmilk and solid or semi-solid food (this may include any food or liquid containing non-human milk). an infant has received only breastmilk from his/her mother or a wet nurse, or expressed breastmilk, and no other liquids or solids with the exception of drops or syrups consisting of vitamins, mineral supplements or medicines. an infant has been put to the breast, if only once and/or an infant has received expressed breastmilk but has never been put to the breast. an infant is fully breastfed if he/she has receives breastmilk as the main source of nourishment, but can take some other liquids such as water, water-based drinks, fruit juices, oral rehydration solutions, ritual fluids, and drops or syrups. It excludes breastmilk substitutes or solids. It embraces the WHO terms exclusive breastfeeding and predominant breastfeeding. any food being marketed or otherwise represented as a partial or total replacement from breastmilk, whether or not suitable for that purpose (see also Breastmilk Substitute). international Board Certified Lactation Consultant (IBCLC). services providing antenatal, birth and postnatal care. services providing care for newborn infants. central administrative office of NSW Health. Also known as the Department. the NSW Department of Health and Area Health Services. services providing care for infants and children. support by those who have increased their knowledge and skills as a result of dedicated training outside a professional capacity. Typically, the support is provided on a voluntary basis. an infant s predominant source of nourishment is breastmilk but may also receive water and water-based drinks ie sweetened and flavoured water, teas, infusions etc., fruit juice, oral rehydration solutions, drops and syrup forms of vitamins, minerals and medicines, ritual fluids (limited quantities).

37 23 APPENDIX 1: BABY FRIENDLY INITIATIVE APPENDIX 1: BABY FRIENDLY INITIATIVE The Baby Friendly Hospital Initiative 9 (BFHI) was developed and launched, in 1991, jointly by WHO and UNICEF. It is a global initiative to protect breastfeeding and aims to give every baby the best start in life by creating a health care environment where breastfeeding is the norm thus helping to reduce the levels of infant morbidity and mortality in each country. The objectives are to: Enable mothers to make an informed choice about how to feed their newborns. Support early initiation of breastfeeding. Promote exclusive breastfeeding for the first 6 months. Ensure the cessation of free and low cost infant formula supply to hospitals; and include, possibly at a later stage and where needed, other mother and infant health care issues. BFHI aims to foster an environment that will enable women who choose to breastfeed, not only initiate breastfeeding but to also exclusively breastfeed until about 6-months of age and continue breastfeeding for up to 2-years of age. The initiative does this by being an assessment and accreditation program of maternity services that adopt the Ten Steps to Successful Breastfeeding policies. A Baby Friendly hospital is one where mothers have an informed choice about infant feeding which is supported, respected and encouraged. Baby Friendly accreditation is a quality improvement measure. Becoming accredited demonstrates that a hospital offers a higher standard of care to all mothers and babies. Attaining accreditation reflects the commitment of all hospital administrators, managers and staff. To achieve the standard, midwives and other carers obtain an increased knowledge of breastfeeding support and greater skills and commitment to facilitate breastfeeding. This engenders an environment that encourages best practice, improving the health of new generations.

38 Breastfeeding in NSW: promotion, protection and support 24 Ten Steps to Successful Breastfeeding In 1989, the Ten Steps to Successful Breastfeeding was developed and published as a joint statement by WHO and UNICEF as a response of concern that maternity services were not providing a breastfeeding culture. Promoting, Protecting and Supporting Breastfeeding: The Special Role of Maternity Services A Joint WHO/UNICEF Statement, (1989). The Statement was prepared to increase awareness of the critical role that health services play in promoting breastfeeding, and to describe what should be done to provide mothers with appropriate information and support. It is intended for adaptation to suit local circumstances by policy-makers and managers as well as clinicians. Focusing on the brief period of prenatal, delivery and postnatal care provide by maternity services, the Statement encourages those concerned with maternity services to review policies and practices that affect breastfeeding. Maternity Services Ten Steps to Successful Breastfeeding Every facility providing maternity services and care for newborn infants should: 1. Have a written breastfeeding policy that is routinely communicated to all health care staff. 2. Train all health care staff in skills necessary to implement this policy. 3. Inform all pregnant women about the benefits and management of breastfeeding. 4. Help mothers initiate breastfeeding within half an hour of birth. 5. Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants. 6. Give newborn infants no food or drink other than breastmilk, unless medically indicated. 7. Practise rooming-in - that is, allow mothers and infants to remain together - 24 hours a day. 8. Encourage breastfeeding on demand. 9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants. 10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.