Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1694819441242.pdf (Australia)
Hon John Hiii MP 06MHE/3864 Hon Alex Somlyay MP Chairman Standing Committee on Health and Ageing Parliament House CANBERRA ACT 2600 Submission no.

274 AUTHORISED: 17/4/07 roll?

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Government of South Australia Minister for Health Minister for the Southern Suburbs Minister Assisting the Premier in the Arts Level 9 11 Hindmarsh Square Adelaide SA 5000 GPO Box 2555 Adelaide SA 5001 DX 243 Telephone (08) 8463 6270 (08) 8463 6277 Facsimile Minister.Health@heaith.sa.gov.au Dear Mr Somlyay Thank you for your letter of 7 December 2006 to Hon Mike Rann MP, Premier of South Australia, inviting a submission from South Australia to the Commonwealth Parliamentary Inquiry into the health benefits of breastfeeding.
As this matter falls within the health portfolio, Premier Rann asked me to respond on his behalf.

The Government of South Australia is pleased to provide a response to the Inquiry, as breastfeeding is seen by our Government as both a public health strategy and an effective early intervention response for the health of infants.

A detailed response to the inquiry and its terms of reference is attached for your consideration.

I would be happy to provide any additional information to assist the committee.
Yours sincerely JOHN HILL Date: I B ~^ Printed on recycled paper using soy based inks ATTACHMENT 1 SOUTH AUSTRALIAN GOVERNMENT'S SUBMISSION TO THE HOUSE OF REPRESENTATIVES STANDING COMMITTEE ON HEALTH AND AGEING INQUIRY INTO BREASTFEEDING.
STANDING COMMITTEE ON HEALTH AND AGEING Parliament House, Canberra ACT26O0 | Phone: (02) 6277 4145 | Fax; (02) 6277 4844 | Email; haa.reps@aph.gov.au Terms of Reference Inquiry into the health benefits of breastfeeding The House of Representatives Standing Committee on Health and Ageing has reviewed the 2005-2006 annual report of the Department of Health and Ageing and resolved to conduct an inquiry.
"The Committee shall inquire into and report on how the Commonwealth government can take a lead role to improve the health of the Australian population through support for breastfeeding.
The Committee shall give particular consideration to: (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; (c) the potential short and long term impact on the health of Australians of increasing the rate of breastfeeding; (d) initiatives to encourage breastfeeding; (e) examine the effectiveness of current measures to promote breastfeeding; and (f) the impact of breastfeeding on the long term sustainability of Australia's health system."
(29 November 2006) SA Government Submission to the House of Representatives Standing Committee on Health and Ageing Inquiry into the health benefits of Breastfeeding T:\Cablneft2007\Pink Notes\Flnal\06MHE-3864 - Commonwealth Parliamentary Inquiry Into the Health Benefits of breastfeedlnoAOSMHE 3864 bf submission 7 feb 07 IM.doc The South Australian Government welcomes the inquiry into the health benefits of breastfeeding.
The South Australian Government demonstrates its commitment to breastfeeding by identifying breastfeeding as an indicator in South Australia's Strategic Plan and relevant to several targets (see box below).

!

1 So^th Australia's S:-3tea;c Plan 2C07 OojGCii\.e 2: Improving Wellbeing Healthy Weight Target 2.2 Target: increase the proportion of South Australians 18 arid over with healchy weight ty 10 percentage points by 2014.
Supplementary measures - percentage of 4 year old South Australians who are oveiweight or obese.

Abo-la ns heal'^y i *'e expectancy Target 2.5 Target' lower the morbidity and mortality rates of Aboriginal South Australians.
Objective 6: Expanding Opportunity Aboriginal Wellbeing Target 6.1 Target: improve the overall wellbe'ng of Aboriginal South Australians Ea-;\ childhood-girth //eight Target 5 3 Target: Reduce the proportion of low birth weight babies » Supplementary measures - percentage of mothers who breastfeed their infants for at least 6 months.
:* Number of participants in parenting courses Promoting breastfeeding is a child health and well being priority in South Australia and is identified in Eat Well South Australia1 (the state nutrition strategy) and the Eat Well Be Active Healthy Weight Strategy2.

Children, Youth and Women's Health Service (CYWHS) is leading the development and implementation of a state plan to achieve improved breastfeeding rates.

Current breastfeeding rates are well below those recommended nationally and internationally.
The breastfeeding initiation and duration rates in South Australia are reflective of rates across Australia.

Breastfeeding initiation rates are moderately high in hospital but decrease rapidly as the baby ages, and by three months fall well below the recommendations of the National Health and Medical Research Council (NHMRC)3.
The 2001 National Health Survey conducted in Australia showed breastfeeding initiation rates begin well in hospital with approximately 83% of babies being breastfed upon discharge from hospital.
Unfortunately, those rates decrease as the baby's age increases, with the number of fully breastfed babies at three months decreased to approximately 57%, and at six months, SA Government Submission to the House of Representatives Standing Committee on Health and Ageing Inquiry into the health benefits of Breastfeeding T:\Cabinet\2007\Plnk Notes\Hnal\06MHE-3864 - Commonwealth Parliamentary Inquiry Into the Health Benefits of breastfeedlng\06MHE 3864 bf submission 7 feb 07 IM.doc decreased again to approximately 18% being fully breastfed.
Finally, at one year of age there are only 23% of babies still receiving any breast milk as part of their normal diet.1'4 The NHMRC Dietary Guidelines for Children and Adolescents suggests a goal of initiation rates in excess of 90%.

Norway for example has 92% of mothers' breastfeeding their child at three months.
In order to address this problem a comprehensive range of strategies needs to be implemented underpinned by partnerships between state, territory and the Australian governments, the business and community sector and Australian women and their families.
Success requires sufficient intensity of effort across Australia supporting all women to breastfeed but paying particular attention to the needs of women with low breastfeeding rates including Aboriginal women, young women, disadvantaged women and those from culturally and linguistically diverse backgrounds.

This needs to be backed up by supportive policy directions and underpinned by good monitoring systems, appropriate research and an informed and supportive workforce.
As with many preventive health programs a sufficiently coordinated national approach is needed with an adequate level of resources and sufficient evaluation across Australia to have a significant impact on increasing rates.
National policy to support the importance of breastfeeding already exists in both the NHMRC Dietary Guidelines for Children and Adolescents in Australia (DGCAA)5 and also the national nutrition strategy, Eat Well Australia (EWA) and its Aboriginal component, the National Aboriginal and Torres Strait Islander Nutrition Strategy and Action Plan (NATSINSAP)6.

They are underpinned by strong evidence about the multiple benefits of breastfeeding.
The DGCAA recommends exclusive breastfeeding for six months, continuation of breastfeeding for one year and beyond as desired by mother and child.

The national nutrition strategy, EWA including NATSINSAP identifies promoting breastfeeding and improving infant nutrition as a key national priority and sets out an agenda for action listing objectives, proposed actions, target groups and potential partners.
The objectives and proposed actions are listed below and are clearly relevant to a number of the terms of reference of the Inquiry into the health benefits of breastfeeding.

EWA prioritises breastfeeding due to its importance to health and Australia's low breastfeeding rates.

Evidence shows that breast milk is the best food for babies.
The priority for research should therefore be about ways to improve breastfeeding rates rather than building further evidence for breastfeeding 1 For monitoring purposes a fuliy breastfed infant is defined as one who receives breast milk as the main source of nourishment.

That is, the infant is exclusively breastfed with no other liquid or solids or Is predominantly breastfed and may receive water and/or juice, but no solids or formula.
[Exclusive breastfeeding means breast milk, vitamins, minerals, medicine} SA Government Submission to the House of Representatives Standing Committee on Health and Ageing inquiry into the health benefits of Breastfeeding.
T:\Cabinet\2007\Pink Notes\Final\06MHE-3864 - C o m m o n w e a l th Parliamentary Inquiry into the Health Benefits of breastfeeding\06MHE 3864 bf submission 7 feb 07 IM.doc From the National nutrition strategy, Eat Well Australia - improving breastfeeding Objectives • • • • Increase the proportion of mothers who breastfeed to at least six months of age by reducing cultural, structural and economic barriers to breastfeeding; Increase the proportion of mothers who introduce solid foods consistent with NHMRC Infant feeding guidelines; Increase health system policies that encourage and support breastfeeding to at least six months; Introduce, implement, maintain and monitor policies, practices and facilities in the community that encourage mothers to decide to breastfeed and support breastfeeding to at least six months.
Proposed actions • Evaluate and expand effective National Breastfeeding Strategy activities; • Review policies and practices that influence breastfeeding decisions and make practices/policies more supportive; • Review progress and identify ways to accelerate the uptake of the Baby-friendly Hospital initiative in all maternity hospitals; » Review the current status of Australia's implementation of the WHO Code of Marketing of breast-milk substitutes; • Reach consensus on standard methods for measuring duration and initiation rates of breastfeeding; • Review and recommend growth standards for use in assessment of breastfed babies; • Review previous strategies (across sectors) for disseminating information on nutrition, first foods, social aspects and active lifestyles for children in early life to parents and other caregivers and recommend future directions.
The national breastfeeding strategy is now out of date.

The South Australian Government recommends that a jiew national breastfeeding strategy be developed building on the previous plan and consistent with the objectives and priority actions outlined in EWA and other key documents, eg Healthy Weight 2008.

Targets should be set defining initiation rates, duration rates and rates of exclusive breastfeeding and monitoring is essential.
The Plan of Action should support a nationally coordinated approach in order to maximise the effectiveness of promoting breastfeeding by building on the existing policy and various programs in jurisdictions.

The Plan will require an adequate level of investment in tested strategies if Australia is to increase rates.

Evaluation will also need to be a key component.

Results will not be achieved unless appropriate strategies are implemented in sufficient "dose" over an adequate amount of time.
If rates can be improved, as they are in other countries such as Norway, where 92% of mothers are breastfeeding their child at three months, it is likely that this will result in improved health outcomes and savings to the cost of health care in the future.

SA Government Submission to the House of Representatives Standing Committee on Health and Ageing inquiry into the health benefits of Breastfeeding.
T:\Cabinet\2007\Pink Notes\Final\06MHE-3864 - Commonwealth Parliamentary Inquiry into the Health Benefits of breastfeeding\O6MHE 3864 bf submission 7 feb 07 IM.doc The roles and responsibilities of the Commonwealth Government and State and Territory governments should be detailed in the Plan.
Activities that would be best done nationally by the Commonwealth would include: • Comprehensive social marketing programs (mass media), with states and territories supporting community level activities to complement the social marketing.

• Monitoring breastfeeding initiation, intensity and duration rates.
» Identification of best practice programs to increase breastfeeding rates, including those in population groups less likely to breastfeed, like young women, those with low levels of schooling, lower incomes and those of Aboriginal background and some other ethnic backgrounds.

• Regulations related to removing the promotion of breast milk substitutes.

• Monitoring and enforcement of the Advisory Panel on the Marketing in Australia of Infant Formula (APMAIF) agreement.
• Providing leadership by encouraging and supporting Australian Government Departments to adopt breastfeeding friendly workplace policies, as can state and territory governments.
• Supporting private hospitals to be accredited under the Baby Friendly Health Initiative Activities that would be best done by the States and Territories would include: • Supporting public hospitals to be accredited under the Baby Friendly Health Initiative • Support for social marketing programs; « Ensuring adoption of breastfeeding friendly policies in workplaces, especially in the public sector, public places and community organisations; » Support for women through health services.
Activities that would be shared by Commonwealth, State and Territory governments would be the assessment of regulatory measures and incentives that would make it easier for women to breastfeed such as: « building regulations that provides parenting space; « length of paid maternity leave (to cover the minimum 6 months of exclusive breastfeeding); • enacting and enforcing of regulations to protect women's right to breastfeed in public; • mechanisms to encourage employers to support women to breastfeed at work.
SA Government Submission to the House of Representatives Standing Committee on Health and Ageing Inquiry into the health benefits of Breastfeeding.

T:\Cabinet\2007\Pink Notes\Final\06MHE-3864 - Commonwealth Parliamentary inquiry into the Health Benefits of breastfeeding\06MHE 3864 bf submission 7 feb 07 IM.doc Addressing the terms of reference a) The extent of the health benefits of breastfeeding Breastfeeding has immediate and long term effects on health across the life span.
Breastfeeding is a major determinant of infant health.

Breastfeeding provides health protection for both mothers and babies.

Breastfeeding has a positive impact on the incidence of gastrointestinal and respiratory illnesses which can affect a baby's ability to thrive.

Whilst protection against disease is most important in developing countries there are also a wide range of benefits for developed countries.
Breastfeeding offers immunological protection and is particularly important for pre-term and low birth weight babies offering protection for these vulnerable infants7.

A report8 in South Australia in 2004 showed that 7% of babies born were of low birth weight (<2500g) with 1.6% being of very low birth weight (<1500g).

Low birth weight can be linked with infant morbidity and mortality8.
Salient point for Aboriginal women Perinatal mortality is a key indicator of population health status9 and the perinatal mortality rate for births to Aboriginal mothers is much higher than that of births to non-Aboriginal mothers (16.9/1000 births and 9.7/1000 births respectively)8.

The low birth weight experienced by many Aboriginal babies has contributed extensively to the incidence of chronic disease as they develop through childhood into adulthood 8.
Predominant breastfeeding by Aboriginal women for an extended period up to 2 years, together with the introduction to babies of complementary semi-solid foods on an individual basis according to their growth, development and need, may contribute significantly to reducing chronic disease rates.
Generally breastfeeding has been identified as a positive indicator for reducing the incidence of overweight and obesity in children and research has shown obesity levels appear to be lower (up to 30%) in children who have been breastfed1011.

A meta- analysis cited in the American Journal of Epidemiology highlighted that the longer the duration of breastfeeding, the greater the decrease in risk of becoming overweight12.
This is supported by a study in Australia which showed children between the ages of one and eight years who were breastfed for less than four months appear to be at greatest risk of becoming overweight.13 Obesity levels are on the rise in children and a cause for concern for future population health.

Overweight and obesity have become a significant health issue, as highlighted in the South Australia Strategic Plan.
The Plan which aims to increase the proportion of South Australians 18 and over with healthy weight by 10 percentage points by 2014 (Target 2.2).

SA Government Submission to the House of Representatives Standing Committee on Health and Ageing Inquiry into the health benefits of Breastfeeding.
T:\Cabinet\2007\Pink Notes\Final\06MHE-3864 - Commonwealth Parliamentary Inquiry into the Health Benefits of breastfeeding\06MHE 3864 bf submission 7 feb 07 IM.doc Data collected on four year olds in South Australia showed approximately 21.5% of girls and 18.4% of boys were classified as overweight or obese14.

The percentage of four year old South Australians who are overweight or obese will be a supplementary measure of meeting Target 2.2.
Several studies15 have shown women who breastfeed are protected against premenopausal and possibly post-menopausal breast cancer as well as ovarian cancer and rheumatoid arthritis.

Studies have also indicated an association between breastfeeding and postpartum weight loss and a decrease in maternal depression 15.
In regard to the first term of reference the South Australian Government recommends that breastfeeding is acknowledged as an important public health strategy and supported by INNOCENTI the appointment of a National Breastfeeding Coordinator DECLARATION on the Protection, Promotion and Support of Breastfeeding global goal).

(UNICEF, b) Evaluate the impact of marketing of breast milk substitutes on breastfeeding rates and, in particular, in disadvantaged, Indigenous and remote communities.
It is likely that the marketing of breast milk substitutes has a negative impact on breastfeeding rates by projecting the theory that breast milk substitutes cause no harm to babies because they are as nutritious as breast milk.
Salient points for Aboriginal women Some Aboriginal women are part of a larger group of women who are less likely to breastfeed than others, for example: • • those of low socioeconomic status;16'17 young mothers; Studies conducted in several different states of Australia have shown breastfeeding prevalence by Aboriginal women decreases by increasing proximity to urban areas and are similar to women of low socio-economic background 19 18 Breastfeeding has been a normal part of Aboriginal culture and mature Aboriginal women living in remote and rural parts of Australia tend to follow more traditional lifestyles and breastfeed more often and for longer.
Aboriginal women also tend to be younger mothers than non-Aboriginal women and adolescent Aboriginal mothers may be less inclined to breastfeed their first child as breastfeeding impacts on their freedom, body image, social interaction, education and lifestyle choices.

SA Government Submission to the House of Representatives Standing Committee on Health and Ageing Inquiry into the health benefits of Breastfeeding.
T:\Cabinet\2007\Pink Notes\Final\O6MHE-3864 - Commonwealth Parliamentary Inquiry into the Health Benefits of breastfeeding\06MHE 3864 bf submission 7 feb 07 IM.doc Barriers to breastfeeding for Aboriginal women documented in the literature47 include: • • • • • • • embarrassment of feeding in public (shame) thoughts that feeding formula is as good as breast milk cracked and sore nipples thoughts that breastfeeding was painful as well as inconvenient tiredness and poor milk supply contributing factors of lack of support, confidence and low self esteem lack of knowledge about the physiology of breastfeeding.
Breastfeeding has also been reported by some women as a cause of interpersonal violence by some young Aboriginal men20.

Other reasons for low rates of breastfeeding may include general ill health and lack of access to healthy food.

Maternal depression has been seen to escalate in some instances with pregnancy and following delivery.
In South Australia in 2002, a statewide Aboriginal breastfeeding forum21 identified specific strategies to support Aboriginal women to breastfeed - organizational support from health services, home visiting by midwives and advocating for increased attendance at antenatal classes.

Breast milk substitute (formula) promotion There are an increasing number of new formula companies and marketing initiatives.
There are many formula company websites and information on these websites is biased towards the product.

This promotes the 'convenience' aspect of formula.

Formula companies vigorously market their products to new mothers and sample bags provided to women antenatally and postnatally require close scrutinizing to ensure that they meet the World Health Organisation (WHO) Baby Friendly Health Initiative principles (no promotion of formula or dummies).
One particular concern that has been raised is the need to strengthen restrictions on the marketing of infant formulas.

There is a need to fully implement the WHO code on marketing of infant formulas.

At present, for example, retailers (eg supermarket chains) can advertise infant formulas.
The Advisory Panel on the Marketing in Australia of Infant Formula (APMAIF) was established to monitor compliance with and advise the Government on the Marketing in Australia of Infant Formula: Manufacturers and Importers (MAIF) Agreement.48 The Australian Marketing Agreement voluntarily supports the WHO International Code on the Marketing of Infant Formula but it is not enforced in law.
Complaints by members of the public of alleged breaches of the MAIF agreement to the Advisory Panel for the Marketing of Infant Formula (APMAIF) dropped from 189 in 2002/03 to 80 in 2003/04.

SA Government Submission to the House of Representatives Standing Committee on Health and Ageing Inquiry into the health benefits of Breastfeeding.
T:\Cabinet\2007\Pink Notes\Finai\08MHE-3864 - Commonwealth Parliamentary Inquiry into the Health Benefits of breasffeedtng\06MHE 3864 bf submission 7 feb 07 IM.doc In regard 1o the second 'erm of reference recomme-ics that: the South Australian Government • Further research be conducted into the attitudes, behaviours, knowledge and social determinants influencing breastfeeding in Aboriginal communities.
1 Legislation is exacted to require all infant fon-nu'a manufacturers :o be signator'es to the Marketing Agreement rather than being a voluntary act. '

• Breaches of the Marketing Agieemenl be monitored and the deterrents to treaches be strengthened.

c) The potential short and long term impact on the health of Australians of increasing the rate of breastfeeding Breastfeeding provides many health benefits to women and babies at different stages of life.
Breastfeeding has been shown to protect babies against many childhood illnesses and infections.
The following infant and childhood illnesses for example, have evidence for either a convincing, probable or possible protective effect from breastfeeding: Convincing • gastrointestinal illnesses • otitis media • respiratory tract infections Probable Possible • asthma • cognitive ability 1 urinary tract infection » coeliac disease • sudden infant death « insulin dependent diabetes • obesity • meningitis22 • neonatal necrotising syndrome enterocolitis For women breastfeeding provides protection against: Convincing Probable Possible • premenopausal breast • postmenopausal breast cancer recovery from childbirth • cancer • ovarian cancer rheumatoid arthritis • maternal depression • endometrial cancer • post-partum weight loss 22 SA Government Submission to the House of Representatives Standing Committee on Health and Ageing inquiry into the health benefits of Breastfeeding.
T:\Cabinet\2007\Pink Notes\Final\O6MHE-3864 - Commonwealth Parliamentary Inquiry into the Health Benefits of breastfeeding\06MHE 3864 bf submission 7 feb 07 IM.doc Breastfeeding has the potential to increase the physical, mental and emotional health of women and children.

In the short term breastfeeding can decrease hospital admissions and in the long term have an impact on the reduction of chronic disease.
Salient points for Aboriginal women The South Australian 'Our Culture Our Babies Our Future Framework'23 will improve access to culturally appropriate perinatal care and develop sustainable perinatal services that take into account the social determinants of health.

It will also provide alternative birthing services for Aboriginal and Torres Strait Islander women and increase the Aboriginal workforce specifically related to perinatal care.
The key strategies of this framework and program are: • Making healthy pregnancy and birthing a focus • Providing best practice models for maternal and infant care « Developing mechanisms to engage Aboriginal and Torres Strait Islander (ATSI) community participation and partnership Increasing the ATSI maternity care workforce and developing career pathways • • Addressing the challenges of teenage pregnancy and pregnancy and birth in remote settings » Providing accountability, evaluation and monitoring to determine the most effective outcomes for Aboriginal women and their babies.
i In regard 10 the third term of reference the South Australian Government recommends the further monitoring be undertaken on the impact of breastfeeding on that development of cnronic disease.

d) Initiatives to encourage breastfeeding In South Australia there are a number of different breastfeeding initiatives in place.
Examples of some of the services provided are listed below: Baby Friendly Health Initiative Hospitals accredited under this initiative include Flinders Medical Centre Crystal Brook District Hospital, Loxton Hospital Complex Inc., Millicent and District Health Service, Mt Barker and District Soldiers Memorial Hospital, Tanunda Hospital, Kapunda Hospital, Waikerie Hospital and Victor Harbour Hospital The Women's and Children's Hospital and Child and Family Health Division are working towards becoming the first community organisation in Australia to be accredited Antenatal and postnatal education and support This support is provided by Midwifery Group Practices and numerous metropolitan and regional hospital and health services SA Government Submission to the House of Representatives Standing Committee on Health and Ageing inquiry into the health benefits of Breastfeeding.
T:\Cabinet\2O07\Pink Notes\Final\06MHE-3864 - Commonwealth Parliamentary Inquiry into the Health Benefits of breastfeeding\06MHE 3864 bf submission 7 feb 01 IM.doc 10 Specific breastfeeding education programs These education programs at run at various metropolitan hospitals and a specific program for teenagers is run at the Waikerie and Loxton hospitals Postnatal breastfeeding support This support is provided at various hospitals and Torrens House, which is a residential facility.
Post natal support in the home This service is provided by volunteers in a number of health services including specific programs such as the Domiciliary Midwifery Home Visiting program.
Antenatal and postnatal support for Aboriginal women There are various support programs provided specifically for Aboriginal women in both the metropolitan and regional areas of South Australia including Aboriginal Health liaison officers, Aboriginal Health units and support groups and programs such as the Family Anangu Bibi Birthing program.
Telephone support services This includes the 24 hour parent help line provided by the Children Youth and Women's Health Service, a medicines information service and telephone support services provided by various hospitals and health services.

Breastfeeding friendly workplace policies The Government of South Australia encourages all of its workplaces to develop breastfeeding friendly workplace polices and this policy has been implemented in the SA Department of Health.
In addition to the above, the Department of Health is promoting breastfeeding through its policy development and funding of a range of healthy weight and nutrition initiatives, including those which are part of the Australian Better Health Initiative.
The initiatives listed above are consistent with the multi-faceted, long-term interventions that include promotion, education and policy approaches that have been shown to be the most successful in having an impact on increasing breastfeeding rates.24 Research shows personal skills, the environment and health services can have a significant impact on a woman's decision to breastfeed and the duration of the breastfeeding.
The impact of these is demonstrated in more detail below: SA Government Submission to the House of Representatives Standing Committee on Health and Ageing Inquiry into the health benefits of Breastfeeding.
T:\Cabinet\2007\Pink Notes\Finaft06MHE-3864 - Commonwealth Parliamentary Inquiry into the Health Benefits of breastfeeding\O6MHE 3864 bf submission 7 feb 07 IM.doc 11 Developing personal skills Health education programs (in conjunction with other strategies) have been shown to have an effect on the initiation and short-term duration of breastfeeding.25 Pre and post natal support by health professionals and/or peer counsellors is the most effective strategy for influencing initiation and duration rates.26'27'28'29 There is clear value in providing peer support for women to breastfeed and a variety of programs may be needed if they are to meet the needs of women in general and the needs of disadvantaged women (particularly women on low incomes)29 with low feeding rates.
It is unlikely that one model will suit all.

is a need for sustainable There independent community groups who support breastfeeding and raise the profile in the community, with women and the health role system.

The Australian Breastfeeding Association successfully but there may also be a need for groups for Indigenous women for example and for other specific programs.
(ABA) undertakes this Initiatives to encourage breastfeeding need to be underpinned by a robust national breastfeeding monitoring strategy.

National data collection needs to be strengthened, ideally with sufficient data for states and territories to be able to reliably extract their rates.

South Australia is aware of the consultation on establishing a national food and nutrition monitoring system and recommend that this include a focus on breastfeeding and related data (eg introduction of solids).
There is an urgent need to advance planning of this initiative.

South Australia is establishing a system to monitor breastfeeding rates through its monthly computer assisted telephone information (CATI) monitoring system as well as using data collected by CYWHS nurses as part of regular child health checks.

Nationally agreed data is important.


A complementary issue is the need for a nationally consistent approach to the way infant growth is measured with everyone using the same charts across Australia in both the public and private sectors.

This is flagged in Eat Well Australia 'review and recommend growth standards for use in assessment of breastfed babies'.49 The Food Standards Code related to minimum age labelling requirements for infant foods is currently being addressed.
Food Standards Australia New Zealand (FSANZ) expects to send the Final Assessment Report of the Proposal, P274 - Labelling Minimum Age for Infant Foods - to the FSANZ Board in early March 2007, followed by consideration by The Australia and New Zealand Food Regulation Ministerial Council (ANZFRMC) and if no review is requested, gazettal will follow in mid-2007 to amend the Australia New Zealand Food Standards Code.
It is important that the option to change the labelling so it indicates that these foods are suitable for children from the age of around six months is approved.

This brings it in line with government recommendations that exclusive breastfeeding should be until six months 2001 NHS were that solids were being offered regularly to 15.2% of infants at SA Government Submission to the House of Representatives Standing Committee on Health and Ageing inquiry into the health benefits of Breastfeeding.
T:\Cabinet\2007\Pink Notes\Final\O6MHE-3864 - Commonwealth Parliamentary Inquiry into the Health Benefits of breastfeeding\06MHE 3864 bf submission 7 feb 07 IM.doo Comment [PCI]: G ':, £••-,-••: f-r: Z-:-z" 12 13 weeks of age and 88% at 26 weeks.
Findings of the 2001 National Health Survey (NHS) showed that solid food was being offered regularly to 15.2% of infants at 13 weeks of age and 88.0% at 26 weeks (NHMRC recommends solids at around 26 In regard 10 the fourth term of reference the South Australian Government recommends thai: • - • A review of education curricula for schools and relevant health science tertiary cou'ses ('nciuding cursing, ADongmal Health Workers, mia.vifery, dietician, medicine, pharmacology etc) is conducted, and that curricula must include brsastfeed.ng information .f not already comamed v.ithm course ,nformat,on.
Funding is increased to the ABA as the leading breastfeeding community organisation to continue to provide and to expand pre- and post-natal peer support for women to breastfeed.

The workforce is developed to increase the number of health workers in Aboriginal Health Servces to sucpot Aboriginal worsen to breastfeed :r remote community.

• Health promotion programs are introduced specifically for Aboriginal women both anle-a:a!

y and postnatal.
y and postnatal.

'* to promote breasifeea.ng supported in human resources with additional Midwives to reflect 'Aboriginal culture keeping us strong' A future national food and nutrition monitoring system include a focus on breastfeeding and related data (eg introduction of solids) to ensure the collection of agreed nationa.

dara.
dara.

Re-orientating health services The Baby Friendly Health Service (BFHI) is a World Health Organisation initiative to protect and promote breastfeeding, when a birthing hospital is accredited as a BFHI this ensures the 'Ten Steps to Successful Breastfeeding1 are implemented by the hospital.
Step 2 of the initiative is to ensure information and advice given by health professionals in the hospital is consistent and accurate, which contributes to a positive birthing environment.31'32 Most women consult a General Practitioner (GP) either in the pre-natal or post-natal period and some studies have shown that the GP can have a significant influence on a woman's decision to breastfeed.
The GP can also advise and support women in the post-natal period with any problems she may be experiencing or can refer the woman on to a lactation consultant.

The training of GPs in breastfeeding practice contributes to improving breastfeeding outcomes.33'34 SA Government Submission to the House of Representatives Standing Committee on Health and Ageing Inquiry Into the health benefits of Breastfeeding.
T:\Cabinet\2007\Pink Notes\FinarVO6MHE-3864 - Commonwealth Parliamentary Inquiry into the Health Benefits of breastfeeding\06MHE 3864 bf submission 7 feb 07 IM.doo 13 fourth term of reference the South Australian Government in regard recommends that: to the • " - • • • As many Australian hospitals as possible become BFHI accredited.

Breastfeeding expertise is available in community settings including in rural and renoie areas Access to Lactation Consultants is made easier for finandaUy disadvantaged women.
improved facilities are provided for oreastfeeding motners across socio-economic groups to support them to breastfeed in public There is further development and diffusion of models for antenatal and postnatal care *'or Aborginai women, (eg Anangu B.DI which is a successful Soutn Australian program for Aboriginal women) There is further development of antenatal and postnatal support programs for all rural and remote women.'
Supportive environments Social factors have a large influence on a woman's decision to breastfeed and also on the length of time she breastfeeds her child.

A supportive community can make breastfeeding easier for women, and therefore the community needs to be aware of the important health benefits of breastfeeding to mother, baby and the community.
Social marketing through media campaigns has the ability to raise awareness about the advantages of breastfeeding amongst the population, thus impacting on breastfeeding attitudes and insight, and increasing acceptance of breastfeeding amongst the community.36' • Workplaces that support breastfeeding or the expression of breast milk by employees while at work, enables women to continue breastfeeding after their return to work from maternity leave.
Workplaces are important settings to consider when attempting to create supportive environments for breastfeeding women37 • Public places need to be breastfeeding friendly to enable women to breastfeed in comfortable surroundings while enjoying social interaction38.

• Workplaces that support breastfeeding or the expression of breast milk by employees while at work, enables women to continue breastfeeding after their return to work from maternity leave.
Workplaces are important settings to consider when attempting to create supportive environments for breastfeeding women.39 « Public places need to be breastfeeding friendly to enable women to breastfeed in comfortable surroundings while enjoying social interaction.40 The revisions of the SA Government Submission to the House of Representatives Standing Committee on Health and Ageing inquiry into the health benefits of Breastfeeding.
T:\Cabinet\2007\Pink Notes\Fina!\O6MHE-3864 - Commonwealth Parliamentary Inquiry into the Health Benefits of breastfeeding\06MHE 3864 bf submission 7 feb 07 IM.doo 14 South Australian Equal Opportunity Act are aimed at ensuring that women breastfeeding in public places in South Australia are not discriminating against, but this is not uniform in all States.
In regard to the fourth term of reference the South Australian Government recommends that: * National social marketing campaigns which raise community awareness about the - ; • positives of breastfeeding are conducted.

• Both State and Territory Governments and the Australian Government ensure that government departments are accredited as Breastfeeding Friendly Workplaces.

* • The Australian Government encourages and promotes ABA Breastfeeding Friendly - Workplace accreditation as a quality measure.
• • • All State and Territory Governments and the Australian Government enact legislation to prevent discrimination against breastfeeding women in public places and enforce breaches to the legislation.

Socially inclusive facilities for breastfeeding women be created (particularly in regional locations) to allow breastfeeding and associated activities to take place.

Both State and Territory Governments and the Australian Government legislate for appropriate paid maternity leave.
• ABA counsellors receive additional training to enable them to effectively support , Aboriginal women and other disadvantaged groups in the community to breastfeed.

* « The Australian Government provides additional funds to provide for more Lactation Consultants in hospitals and community settings including rural and remote communities.

» The Australian Government address the gaps in the availability of support for breastfeeding and associated problems post-discharge from hospital.
Community organisations such as the ABA provide a valuable service to the community and are able to access women who may not utilise mainstream services.

The ABA is an integral part of promoting breastfeeding in South Australia.

The influences on a woman's decision to breastfeed are complex and interwoven.
Her level of personal skills, her environment and experiences with health professionals can all have an impact on a woman's decision to breastfeed and her ability to sustain breastfeeding as demonstrated in the diagram on the next page.

SA Government Submission to the House of Representatives Standing Committee on Health and Ageing inquiry into the health benefits of Breastfeeding.
T:\Cabinet\2007\Pink Notes\Final\06MHE-3864 - Commonwealth Parliamentary Inquiry into the Health Benefits of breastfeedlng\06MHE 3864 bf submission 7 feb 07 IM.doc 15 INFLUENCES on breastfeeding I |iiSii|ii:illi^Nwtp|Mll!iSli • Media, marketing « Aboriginal Health Workers • Hospitals • Policy • Awareness • Employers • Home visits • Legislation • Social support 1 Hlllljll «amwBiimiiuiiii»iiiiiwji^^uiwiiiiMHMi^Mirimim*MM» • Breastfeeding friendly locations • Lactation consultants • Attitudes • Peers • Work place • Partners • Peer Counsellors • Family • Friends « Services • GPs • Motivation • Attitude • Knowledge • Support • Education • Support • Skills SA Government Submission to the House of Representatives Standing Committee on Heaith and Ageing Inquiry into the health benefits of Breastfeeding.
T:\Cabinet\2007\Pink Notes\Final\O6MHE-3864 - Commonwealth Parliamentary Inquiry into the Health Benefits of breastfeeding\06MHE 3864 bf submission 7 feb 07 IM.doc 16 e) Examine the effectiveness of current measures to promote breastfeeding The breastfeeding initiation and duration rates in South Australia are reflective of rates across Australia.
The 2001 National Health Survey4 conducted in Australia showed breastfeeding initiation rates begin moderately well in hospital with approximately 83% of babies being breastfed upon discharge from hospital.

Those rates decrease as the baby's age increases, with the number of fully breastfed babies at three months decreased to approximately 57%, and at six months, decreased again to approximately 18% being fully breastfed.
Finally, at one year of age there are only 23% of babies still receiving any breast milk as part of their normal diet.

"'4 Fully breastfeeding rates (which include exclusive breastfeeding) in Australia are lower than the NHMRC's exclusive breastfeeding recommendations.

In Australia, the NHMRC recommends babies be exclusively breastfed until six months of age and continue to be breastfed until 12 months of age and beyond if desired.
The NHMRC indicates that an initiation rate in excess of 90%, with 80% of babies still being breastfed at six months is achievable and would have a positive effect on long-term health outcomes.

There has been little change in overall breastfeeding rates in Australia between the two National Health Surveys conducted in 1995 and 20014.
This would indicate that current strategies to promote breastfeeding are maintaining breastfeeding rates but not having an impact on increasing rates in a community where breastfeeding reflects cultural and socio-economic factors.

South Australia recognises that there is value in ongoing assessment of the evidence for the benefits of breastfeeding as well as the evidence for effectiveness in polices and programs to support women to breastfeed in line with recommendations.
The evidence needs to be synthesised, disseminated and promoted to relevant groups.

At the moment there is no coordinated way this is done, and a risk of wasted effort as various groups try to do this.
In South Australia, the Children, Youth and Women's Health Service undertook a consultation in February 2006 with breastfeeding experts and stakeholders representing non-Government organisations, community organisations, Department of Health, metropolitan and country hospitals, regional health services, universities and professional organisations.

The consultation was used to identify the best strategies to have a positive effect on breastfeeding rates.
The consultation identified the first four weeks of baby's life as a key time period for women to stop breastfeeding, and support provided at this stage could see an improvement in the number of women who continue to breastfeed.

with no other liquid or soiids or is predominantly breastfed and may receive water and/or juice, but no solids or formula.
Exclusive breastfeeding - breast milk, vitamins, minerals, medicine SA Government Submission to the House of Representatives Standing Committee on Health and Ageing Inquiry into the health benefits of Breastfeeding.
T:\Cabinet\2007\Pink Notes\Rnal\O8MHE-3864 - Commonwealth Parliamentary Inquiry into the Health Benefits of breastfeeding\06MHE 3864 bf submission 7 feb 07 IM.doc 17 Very broadly, community attitudes that breastfeeding in Australia becomes a cultural 'norm', and women need support post- natally to enable them to continue breastfeeding.

to breastfeeding need to change so Much information is provided to women explaining the benefits of breastfeeding but still many women do not breastfeed.
Perhaps more emphasis should be placed on the disadvantages of artificial feeding.

More research being conducted into why women choose to formula feed when they have been well informed of the advantages of breastfeeding would be useful for future planning.
The currently established 2001 indicators for monitoring Australian breastfeeding41 rates following the WHO guidelines for population indicators determine the: • exclusive breastfeeding rate (allows drops and syrups of vitamins minerals or medicines only) measured to six months • predominant breastfeeding rate, mainly source of nourishment is breastfeeding with other fluids such as water and juice allowed rate of breastfeeding at each month up to 12 months, (continued) • • percentage of mothers who report that they ever breastfed • median duration of breast feeding, determining the average time spent breast feeding.
However, these indicators do not presently monitor 'complementary feeding', that is a combination of breast feeding being the main source of nutrition with the inclusion of semi solids, water and juice till two years of age.

This indicator would identify many mothers who are presently undertaking this approach.
Salient points for Aboriginal women The WHO guidelines on breastfeeding that promote 'exclusively breastfeeding,' that is, nothing but breast milk till the age of six months, does not necessarily meet the reality of many Aboriginal women as new mothers.

Research into the breastfeeding support needs of Aboriginal mothers is needed, to determine how to support breastfeeding initiation, continuation and introduction of solids.
Aboriginal Primary Health Care guidelines suggest a theoretical risk that breast milk may be insufficient beyond four months of age for Aboriginal infants and this requires further investigation42.

While breastfeeding and appropriate introduction of solids is important in reducing the gap in healthy life expectancy for Aboriginal and Torres Strait Islanders, Aboriginal mothers often find it difficult to comply with the rigid expectations of the current health system.
Their often small for gestational age babies may become failure to thrive infants who then are significantly disadvantaged as they become at higher risk for debilitating childhood diseases and prone to the chronic cardiovascular, renal and endocrine diseases (including type 2 diabetes) in adulthood.43 44 SA Government Submission to the House of Representatives Standing Committee on Health and Ageing Inquiry into the heaith benefits of Breastfeeding.
T:\Cabinef\20u7\Pink Notes\Final\O6MHE-3864 - Commonwealth Parliamentary Inquiry into the Health Benefits of breastfeeding\06MHE 3864 bf submission 7 feb 07 IM.doc 18 In regard to the fifth term of references the South Australian Government recommends that: » The National Health and Medical Research Council Food for Health Dietary Guidelines for Children and Adolescents in Australia Inccrfjorsung the Infant Feeding Guidelines for Health Workers policy recommendations and implementation ae reviewed to ers-jre they a:e reflective of the breastfeeding practices of Aboriginal and Tories Strait Islander women.
.

• A national system for monitoring breastfeeding in Australia be reflective of the i breastfeeding practices of Aboriginal and Torres Strait Islander women.

It is important to increase the capacity of hospitals, health services, health professionals and volunteer organisations to provide evidence-based best practice, accurate, comprehensive, culturally appropriate breastfeeding services to women as and when they are needed.
The Baby Friendly Health Initiative (BFHI), 'Ten Steps to Successful Breastfeeding' accreditation works across health service settings to ensure consistency of evidence- based breastfeeding practices, This includes referral to community support services.

Breastfeeding rates start to drop immediately post discharge, from a high initiation rate in hospitals, and continue to fall as the baby ages.
However, the adoption of BFHI practices in hospital appears to positively influence breastfeeding initiation and duration rates right through to six months of age.45 Health professionals who provide support to breastfeeding women need to have undertaken breastfeeding education so they are providing evidence-based current information to women.

This could be done by including breastfeeding education in the curricula of primary and secondary schools as well as universities.
Many women have decided about breastfeeding before giving birth, based on the norms within their social groups.

These social groups are broad and include partners, families and friends.

It is important to influence cultural norms about breastfeeding.

A social marketing campaign raising awareness of the benefits of breastfeeding would be helpful in affecting community attitudes.
n regard to the fifih t e rn of reference the South Australian Government recommends the development of early intervention strategies in the critical period of the first few after baay's omh to support continued breastfeeding.

SA Government Submission to the House of Representatives Standing Committee on Health and Ageing Inquiry into the health benefits of Breastfeeding.
T:\Cabinet\2007\Pink Notes\Final\06MHE-3864 - Commonwealth Parliamentary Inquiry into the Health Benefits of breastfeeding\06MHE 3864 bf submission 7 feb 07 IM.doo 19 f) The impact of breastfeeding on the long term sustainabiiity of Australia's health system Very little research has been done into the cost benefits of breastfeeding in Australia.
However, a study done in the Australian Capital Territory (ACT) did show early weaning attributes to the $1-2 million annual hospitalisation costs for common childhood illnesses, against which breastfeeding offers some protection.

The ACT has quite a positive breastfeeding rate compared to other states in Australia (90% of babies' breastfed at discharge from hospital and 63% still being exclusively breastfed at 13 weeks versus the national figure of 8 1% and 57% respectively).
Therefore, it could be assumed that if the breastfeeding rates increased in other states the savings to those hospital systems would be similar to the saving the ACT has estimated.

| Several countries nave estimated the costs to their nealth system of early weaning, i.e.
: • The US found SUS3 6 bill'on cou'd be saved annually f infants \vere exck sively I i j • The UK found that an increase of I0--' in the number of babies'breastfed to three breastfed to six months, rrontns of age •,vouia save more tnan £500,000 per year.
• Yugoslavia found SUS40 million could be saved on hospilal admissions if the 30% of infants oartiaiiv breastfed at four months was inceased io 70°/-, Alternatively, if breastfeeding were considered part of the Gross Domestic Product (as a food commodity) the net economic benefit would be a minimum of $2.2billion/per year.

The ABA estimates $100 million was spent on the purchase of infant formulas in 1996.
Women from low socio-economic groups are less likely to breastfeed than women from higher socio-economic groups and therefore families least able to afford the cost of infant formula are the ones making the purchases.46 Breastfeeding's many protective factors can help reduce hospital admissions reducing demand on the system and thereby having a positive effect on the long term sustainabiiity of the health system.
In regard to the sixth term of reference the South Australian Government recommends that the Australian Government recognises that breastfeeding is a socio-economic issue and that it needs to provide additional support to health professionals and community organisations to increase breastfeeding rates which will reduce the demand on the health system and increase the population .of healthier productive people.
SA Government Submission to the House of Representatives Standing Committee on Health and Ageing Inquiry into the health benefits of Breastfeeding.
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