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Submission no.108 AUTHORISED: 28/3/07 SUBMISSION TO THE FEDERAL INQUIRY INTO BREASTFEEDING The House of Representatives Standing Committee on Health and Ageing FEBRUARY 2007 REBECCA FERLUGA Submission to the Inquiry into Breastfeeding, February 2007 Rebecca Ferluga SUBMISSION T O THE INQUIRY INTO BREASTFEEDING, FEBRUARY 2007 Introduction: 1 am the Mother of three children, aged (R) 7 years, (A) 4.5 years and (M) 16 months.
Breastfeeding is the biologically normal way for me t o feed my babies from birth into early childhood.

The duration of breastfeeding for each child has been (R) 2 years 5 months, (A) 2 years I I months, and (M) happily ongoing!

Breastfeeding has been a daily part of my life as mother for over seven years, with just a few months' gap between babies.

Breastfeeding my children has not been without some challenges, but on the whole has been very positive, for our family as well as myself.
What follows in this submission are some of the positive and negative experiences, as well as the support (or otherwise) that I have found during this time.
My submission broadly addresses these points of reference: a. the extent of the health benefits of breastfeeding; b. evaluate the impact of marketing of breast milk substitutes on breastfeeding rates and, in particular, in disadvantaged, Indigenous and remote communities; d. initiatives t o encourage breastfeeding; e. examine the effectiveness of current measures t o promote breastfeeding.
My Breastfeeding Story - positive experiences and helpful support: * Midwife-based care for my pregnancies, births and postnatal period after each baby; including domiciliary visits aker early discharge, These skilled practitioners (women and one man) educated me and encouraged me t o trust in my own ability t o nurture, birth and nourish my babies.
* Breastfeedinn s u ~ p o r t clinic, provided by the hospital, where I attended a day-stay session with an International Board Certified Lactation Consultant (IBCLC).

My daughter was just a few weeks old.

Note, however, that my appointment was almost three weeks after self-referral; I was very fortunate t o get an earlier place after another mother's cancellation.

I could not have afforded a private lactation consultant, had I even known they existed at that time.
* The Australian Breastfeeding Association's Breastfeedinn Counsellors; information and suggestions obtained by email, telephone and face-to-face contact with trained volunteers - all of which has been without cost and readily available t o me.
* Accurate, researched, UD-to-date breastfeedinn information; obtained by reading books, booklet series, leaflets, handouts, internet articles, Essence magazine subscription, Most were obtained directly from the Australian Breastfeeding Association (purchased, borrowed from the local group's library, o r received free of charge).

Other titles were obtained elsewhere after reading critical reviews by the Association's voluntary publication review panel or Lactation Resource Centre.
* Peer s u ~ ~ o r t from other breastfeedinn mothers; notably from other mothers who were members of my local Australian Breastfeeding Association groupfs.

It was often lacking from playgroup and 'new mothers group' mainly because so few continued t o breastfeed their baby beyond the first few months, and the culture in both groups was almost competitive at times.

The support I gained from other ABA members was varied and included: 'survival support' - e.g.
home-cooked meals o r babysitting my older childfren while I cared for my newborn baby; Submission to the inquiry into Breastfeeding, February 2007 Rebecca Feriuga learning more about how breastfeeding works through guided discussions; and learning about breastfeeding and mothering from the women with older babieslchildren.

They have 'been there' and were always eager to share their insight with other newer mums.
In particular, this role modelling by breastfeeding mothers can not be overestimated in its value!

It is a rare commodity today in Australia, given the very poor breastfeeding rates beyond the first few months.

* Family history: I am fortunate t o have been breastfed as a baby, and t o have been old enough t o still remember my youngest two siblings being breastfed by our mother.
She has also been of constant practical help since I became a mum myself; having successfully breastfed her four children she can understand what I am doing and why.

Few in my generation (born in the 1970s) have such support from their own mothers, this understanding and practical skill to help their daughters t o breastfeed.

These mothers simply do not have the personal knowledge of successful breastfeeding t o pass on t o their daughters.
* Domestic helD arranged by the hospital - but only available following the birth of my second child, due t o some concerns about my health following the birth, and because my husband was living away from home for study at the time, The social worker arranged this help for a period of six weeks; a carer came twice a week at first then later once a week, t o help with heavy chores that I was advised t o avoid.
I was able t o leave these t o her, while I took the extra time t o rest o r breastfeed my baby or care for my toddler.

T o be able t o relax for a short while was immensely helpful, both emotionally and physically.

After the period of care came t o an end, I tried t o find out how it might continue; I was not permitted t o continue with this firm privately, and could not afford any other.
I was not eligible for support as 'just a new mother' via any local agencies, such as Council or other care services, so the home help ceased.

My husband's absence for training continued until our son was three months old, and I continued t o visit the hospital physiotherapists for several more months.

Clearly my need for practical home support was ongoing, as it would be for many other mothers.
* Maternal & Child Health (M&CH) Nurses who were well-informed about normal breastfeeding, the information and normal growth, normal behaviour and breastfed babies.

I valued understanding shown by many (but sadly not all) of our M&CHNs and especially valued those who were accepting of the decisions I made regarding my children.

They were not judgemental o r prescriptive.


As a first-time mum this can be hard to find, but by the second and third babies, it is noticeable how much more at ease the nurses are t o let you do your own thing.

* The Australian Breastfeedine Association has ~ l a y e d a huge part in mv success as a breastfeeding mother!

It is no coincidence then that I have been a member continuously since 2001.

After a time I volunteered as a Community Educator with my local group.
I spent time explaining breastfeeding and breastmilk t o local groups, such as kindergarten, primary and secondary school classes, as well as postnatal mothers groups, the two local maternity hospitals, and the broader community at public events.

Two and a half years ago I began training t o become a Breastfeeding Counsellor, and just last week I achieved this goal.
All the women who trained me are volunteers, too, and their time and expertise would be completely out of my reach if I were t o have paid money for this training.

N o w I plan t o repay the efforts of the many counsellors and members who helped me t o successfully breastfeed my three children, by supporting, empowering and educating other mothers in my own community in the same way.
Submission to the Inquiry into Breastfeeding, February 2007 Rebecca Ferluga My Breastfeeding Story - negative experiences and unhelpful interference * Postnatal home visits hMaternal & Child Health /M&CH) Nurses were too late and too few; waiting for up to one week after discharge was terribly distressing, particularly after 'early discharge', when the breastmilk had begun t o 'come in' at home with a bountiful vengeance.
The only home visit with my first child took place when she was 10 days old, My second child was seven days and my third was eight days old at the time of each home visit.

I do not recall if a second home visit was offered before having t o get the baby and myself t o the clinic for appointments instead; this was very hard to manage, especially later with both a young toddler and pre-schooler in tow.
I was recovering from heavy postpartum haemorrhaging after each of the three births, yet it seemed t o make little difference to the protocol.

A lack of resources?

* Inaccurate information from health professionals.

This has happened several times.


Here are just two examples: (i) In extremely hot weather the M&CH Nurse advised me t o give my then three-week-old baby cooled, boiled water by bottle or spoon "to make sure she is not dehydrated and t o make sure she gets 'proper' feeds" - apparently I was feeding my baby far too often and for too short a duration each time, and so she was not getting a full feed of milk.

Yet in hot weather this is exactly the right thing t o do!
By responding t o my baby with short frequent feeds, I was allowing her t o increase her fluid intake, building up my supply and still providing her with valuable nutrients.

I did try the advice, because I 'had to' - once.

My baby hated it.

I decided t o trust my instinct that filling her with water would reduce her appetite for breastmilk and therefore limit her growth, rather than help her.
And I realised that she was happier to take longer 'full' feeds at night when the air was cooler and she was more comfortable t o be held.

1 learnt later that these were precisely the right approaches!

(ii) Different baby, different service and practitioner, in October 2005 ...

I was given a copy of a booklet produced in-house by the service, Breastfeeding Information for New Parents.
Much of it was helpful, However there was an emphasis on scheduling and limiting breastfeeds (although these terms were not used) and an expectation that mothers should work on reducing night feeds.

Remember, this was handed out at the first visit; such advice is highly inappropriate at this age!

Quote: "As a general rule, a healthy thriving full term baby should be able to space feeds to 3 to 4 hourly by day and eventually longer at night.
This is approximately 6 to 8 feeds in 24 hou rs... To encourage reduction in night feeds we recommend you do not allow your baby to go longer than 4 hours between feeds during the day.

If your baby is feeding under 3 hours helshe may be snack feeding which can lead to reduction in breast milk as the baby isn't efectively emptying the breast."

How very confusing, restrictive and inaccurate!


Supply will match demand if the baby is given ready access t o the breast; whatever mill< they remove will be replaced.

My young babies all fed much more frequently than this advice stated, and continued night feeds until weaned (youngest is ongoing); all three grew consistently well above average, have been extremely healthy and have reached developmental milestones such as speech, crawling and walking earlier than expected.
Yet I could so easily have found myself following this poor advice, leading t o low milk supply, failed breastfeeding, early weaning, and very different outcomes for my children.

With advice handed out such as in these examples, in the early years I found myself 'fudging' the answers t o the questions "How many feeds is shelhe having now?"

and "He's not still waking for night feeds is shelhe?

You poor thing", no matter how well-intentioned the nurse asking them.
f know other mothers feel this expectation t o meet the implied standards, too; however if none of us tell the truth then the nurses, the service and the statistics will never change!
Submfssion to the Inlnqu~ty ~nto Breastfeeding, February 2007 Rebecca Ferluga There is a recurring theme - we mustn't feed our babies too often 1 too long I too quicl<ly I at night 1 for comfort ... yet so many mothers are told "you haven't got enough milk t o feed your baby properly, see how fussy he is / how little weight he has put on".

Little wonder, with so many restrictions and inappropriate expectations forced upon us.
Why does it take so long for 'front line' health professionals to learn about the norms of breastfed infants?

Information such as the Australian research, that shows young babies feed between 8 t o 17 times across 24 hours, averaging I I feeds; o r that it is important for the milk supply and a mother's comfort that some of these feeds be at night, when the relevant mill<- producing hormones are at their peak?
Mothers need accurate information, not outdated and rash advice which risks their ability t o breastfeed and adequately nourish their babies.

* Publications and handout literature: (i) Poor quality or out-of-date: The titles I found available in bool<stores o r from local libraries varied enormously in accuracy, reliability, local content and - in the libraries - were often many years old.
I learned over time t o be selective, generally only trusting in Australian titles, andlor editions that were less than five years old.

There seems t o be no system of approval or review in place, particularly of items made available t o the general public by the local library corporations I have used.

How would a mother know that the 10 year old video o r 1% year old book she has borrowed is now considered t o be inaccurate and out-of-date?
(ii) Lack of breastfeeding resources at health services: Health professionals and facilities I have visited, such as antenatal clinics, pharmacies and GPs, generally had very few handouts o r literature on offer, unless it happened t o have been supplied gratis (by the local ABA group, for example) o r was supplied by commercial interests such as "Bounty" and the like, paid for by companies not really so interested in breastfeeding.
Maternal & Child Health Clinics varied immensely in the amount of resources and space they offered t o breastfeeding education.

I saw this variation between individual clinics and across municipal areas, both as a mum using the services and as a volunteer Community Educator with the Australian Breastfeeding Association (ABA) while visiting new mothers groups.
Again, the resources offered t o new mums were generally supplemented by those made available by local ABA groups, o r the rather dubious 'informative brochures' written by artificial baby milk manufacturers.

It is possible for health professionals t o access education resources (usually at low cost) from the ABA's Lactation Resource Centre, yet this was not widespread in the services that I have used.

* Marketing - .
* Marketing - .

by manufacturers of artificial baby milk products: (i) Direct promotion sent to Maternal & Child Health Nurses, from manufacturers; for example I have seen marketing material presented in the form of a magazine, which I was told "has some interesting stuff about skin care and eczema" as though that made up for the source behind it.

This person was clearly uncomfortable that I had seen it, and she was right.
I felt that it might provide credibility t o the company and its products, if not in her mind, perhaps in the mind of any parent she might loan this 'interesting' magazine to.

As a commercial entity, any 'education' in these items provided by a manufacturer must surely be viewed with distrust?

It is not in their interest for mothers t o breastfeed successfully.
These nurses do provide good practical support t o breastfeeding mothers and are happy t o display some educational literature I posters, however it is not appropriate for material from manufacturers to be sent t o any health professionals whether as so-called education o r outright advertising.
It would cost $75 for this M&CH service t o receive a 'facility subscription' t o the Submission to the Inquiry into Breastfeeding, February 2007 Rebecca Ferluga Australian Breastfeeding Association, providing 10 copies of the bimonthly magazine for a year; more than enough t o loan out from the four clinics it operates.

The promotional material sent from the manufacturers costs the service nothing.

This is not a level playing field, and must be addressed.
(ii) Advertising of artificial milk products for children over twelve months of age, in retail outlets, on television and in print media.

My children have benefited from breastmilk well into their second and third years, the eldest two weaning by their own accord.

It is sometimes very difficult for me t o explain t o others why I have 'allowed' this t o go on for so long, when they are all too aware of products t o "give fussy toddlers all the golden goodness they need".
These supplements are openly promoted by our supermarkets and pharmacies, and in magazine and television advertisements.

This undermines any mother who wishes t o breastfeed and be seen as 'normal', no matter what the age of her child.

By breastfeeding my walking, talking, adventurous toddler, I am ensuring he IS getting all the goodness he needs, no matter how fussy an eater he is!
Numerous times I have been able t o comfort my children by breastfeeding them when sick and unable to eat o r drink other foods (even providing the older children with my expressed breastmilk), thus saving them from becoming dehydrated and needing medical attention.

Where are the slick advertising campaigns t o say that it's good for both me and my child t o keep breastfeeding well past six monthslone year?!
The risks t o my health and that of my children by N O T breastfeeding at all o r for their first two years of life are great, and well-supported by research.

Yet so few in our community are aware of these risks from artificial feeding.

Again, the competition is too fierce, unless the Government steps in and changes the situation with ongoing community education campaigns and by preventing the marketing of artificial milk products.
Breastfeeding support services - a rural perspective on the difference between life in the country and the city Eight months ago we moved from the inner urban fringe of Melbourne t o a small rural town in the far western district of Victoria, and I have gained some perspective of the differences that exist in terms of available support and services for breastfeeding mothers.
Edenhope is located close t o the SA-Vic border, half way between Adelaide and Melbourne, with the nearest large regional centre 100 km away, Horsham.

The West Wimmera Shire covers an area of approximately 9000 km2.

Issues faced by mothers with young children in the Edenhope area include: * Lack of health care o ~ t i o n s and fewer ~rofessional breastfeedinn support services available.

.

'Choice' is not an option for mothers in our local towns as it is in metropolitan areas.
Where a medical clinic or M&CHC exists in a town, it is most likely the only one available in the district and operated on limited days by just one or two practitioners (in fact the whole Shire is covered by one M&CH Nurse).

There are certainly no 24 hour, seven day, clinics or pharmacies t o be found.
Lactation support is a specialist service, based in Horsham and staffed part-time by one IBCLC; telephone contact is the main service offered t o rural mothers, with a day-stay at an outpost only if necessary (the IBCLC will travel t o the small hospital here).

From my experience, breastfeeding support services and qualified practitioners are not adequately promoted or widely publicised in this area of Victoria.
As a new resident I have found it very difficult t o locate these skilled people, and only recently been made aware of a small number of.

IBCLCs and the Lactation Support Service in the regional centre, by word-of-mouth.

Submission to the Inquiry into Breastfeeding, February 2007 Rebecca Ferluga This i s unsatisfactory and only serves t o frustrate and fail breastfeeding mothers looking for timely professional support.
* Distance: Alternatives t o these services for families here in the Edenhope district involve travelling to Narracoorte, Horsham o r even Mount Gambier, distances ranging from 110 km t o 300 km return.

It is not difficult t o imagine a mother deciding it i s all too much when faced with a breastfeeding crisis, so far out of reach of professional support.
Other mothers have told me they had to 'tough it out' the best they could, when faced with no choice 'after hours' o r unable t o travel; somehow they managed t o keep breastfeeding, for a short time.

Telephone call charges also have an impact outside metro areas on the amount of access mothers have to breastfeeding information.
Calling the ABA Victorian Helpline, for example, requires making at least two calls, the first t o Melbourne; after taking down the telephone numbers of the counsellors on roster, it is very unlikely that the list would include any numbers local t o our exchange and so STD rates would also apply t o the second call.

It is not unusual for a mother t o need t o call on the Helpline counsellors several times over the course of dealing with a complex issue.

These costs do add up.


* Isolation and lack of communit~ breastfeeding support: Mothers are often reluctant to be involved with 'new mothers groups', primarily due t o the large distances involved.

It is not practical or affordable t o travel from one town t o another where the M&CH Nurse might arrange a group, particularly in the heat we experience here.
Local contact with other mothers can be limited, too, when there is no regular social network for mothers with young children, as is the case in many small towns - I no longer take the availability of Playgroup or Library Storytimes for granted!
The Australian Breastfeeding Association covers this area with one geographically vast group - approximately 150 km by 200 km, from the SA border across to towns north and east of Horsham, but essentially based in that centre - whose volunteers and members meet once o r twice a month, trying to include outreach visits to the furthest towns were possible every few months.

This is for many women like myself the best opportunity we have t o gain mother-to- mother support and breastfeeding information.
Without these volunteers, willing t o travel large distances at their own expense, the opportunity for mothers t o access face-to-face breastfeeding counselling and t o meet other mothers who are breastfeeding is very limited.

And life in the city?


In contrast, within a two kilometre radius from my previous home in Melbourne, I had a choice of t w o major public hospitals (one of them maternity, where my last child was born); eight pharmacies; six medical clinics with numerous practitioners and allied services; two maternal and child health clinics operated by three nurses, six days a week; and access t o breast pump hire or purchase through retail outlets and the extensive ABA hire system.
Within a fifteen minute drive I had access t o a public breastfeeding support clinic and a number of IBC Lactation Consultants.

If I wanted I could also pick up any parenting magazine and call several parenting support consultants, who could visit me about breastfeeding, sleeping or parenting issues.
I had access t o a vibrant, active local ABA group with around 85 members and six o r seven counsellors; gatherings were scheduled almost every week for us t o meet other mums and learn about breastfeeding from the counsellors.

I had a vast range of choices for accessing breastfeeding support, as do many other city mothers.

Luxury that I only now appreciate fully.
Submission to the inquiry into Breastfeeding, February 2007 Rebecca Ferluga Extra focus on rural women and increasing access to breastfeeding support By making these comparisons, I am not asking to replicate access t o all these services in rural Victoria, rather asking that the Government in this review acknowledge: that there is a lack of support which must be impacting on breastfeeding rates in rural communities; that there is not a 'one-size-fits-all solution' across city and country; and that we need specific solutions and increased Government support t o fill the gaps so rural mums and babies don't miss out on the professional and community breastfeeding support they need.
What can be done?

By detailing some of the ways I have gained positive breastfeeding support, I hope t o provide this lnquiry some ideas of what might be implemented to help other mothers; my negative experiences are included t o illustrate areas which need to be targeted for improvement by the Government.
In summary, to protect and encourage breastfeeding the Commonwealth Government must: campaign and educate t o create community awareness of breastfeeding as normal for babies and children in accordance with the World Health Organisation's Guidelines legislate t o protect breastfeeding and fully embrace the W H O Guidelines increase financial and practical assistance for volunteers, organisations and health professionals who are working t o educate parents and help them succeed at breastfeeding * promote breastfeeding services and resources such as the Australian Breastfeeding Association and IBCLCs t o all parents and the wider community make community breastfeeding assistance available t o all parents via a national free-call Breastfeeding He1 pl ine, 24 hours 1 seven days encourage health services t o use the Lactation Resource Centre, t o be able t o provide the best educational literature t o parents and t o access extensive breastfeeding research provide widespread practical support, postnatally in the home, for longer periods provide rural communities with practical and financial assistance t o foster local breastfeeding support services and peer networks for mothers with young children support research into breastfeeding and improved ongoing education of health professionals prohibit manufacturers and retailers of artificial baby milks from marketing these products (including 'follow-on' supplements); prohibit the supply of samples and promotional materials, and the sponsorship of education for parents and health professionals by these companies Thank you for the opportunity t o present this submission t o the lnquiry into Breastfeeding.
Mrs Rebecca Ferluga 24 February 2007 Submission to the inquiry into Breasffeeding, February 2007 Rebecca Ferfuga