Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1694819140387.pdf (Australia)
Submission no.
302 AUTHORISED: 17/4/07 National Aboriginal and Torres Strait Islander Nutrition Strategy and Action Plan (NATSINSAP) Submission to the House of Representatives Breastfeeding Inquiry from Selected Members of the NATSINSAP Steering Committee March 2007 Breastfeeding submission from the State, Territory and Non- Government Members of the NATSINSAP Steering Committee The steering committee for the National Aboriginal and Torres Strait Islander Nutrition Strategy and Action Plan (NATSINSAP) acknowledges and supports the current parliamentary inquiry into the health benefits of breastfeeding.
This submission has been prepared by the NATSINSAP National Senior Project Officer, with input and authorisation provided by the state-wide public health nutritionists or equivalent level positions from the following member jurisdictions which are represented on the NATSINSAP steering committee: Northern Territory Department of Health and Community Services Queensland Health South Australia Department of Health Department of Health Western Australia Victorian Department of Human Services NSW Health National Heart Foundation of Australia (Note that the Australian Government Department of Health and Ageing is not party to this submission.
The Australian Government Department of Health and Ageing is providing its own submission to the inquiry).

The NATSINSAP has been developed as a key component of Eat Well Australia 2000-2010; a national framework for population based action in public health nutrition for all Australians (SIGNAL 2001a).
The NATSINSAP was endorsed by the Australian Health Ministers Conference in August 2001 and was designed to provide national coordination and cooperation across the country to improve the nutritional status of Aboriginal and Torres Strait Islander people (SIGNAL 2001b).

The poor health status of Aboriginal and Torres Strait Islander people indicates that they are the most disadvantaged population group in Australia (SIGNAL 2001b).

The origins of poor health can in part be traced to early life.
Poor nutrition during pregnancy and childhood is a determinant of poor health and social outcomes in adulthood, including chronic disease, poor school attendance and reduced learning.

Low birth weight, growth failure and iron deficiency are indicators of poor nutritional status which have shown little improvement over the past decade.

They are a salient reminder of the increasing health disparity between Aboriginal and non-Aboriginal populations.
Address to the Terms of Reference "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; The health benefits of breastfeeding are widely reported.
Eat Well Australia 2000- 2010 identifies breastfeeding as a priority area for national action (SIGNAL 2001a) and the Dietary Guidelines for Children and Adolescents in Australia nominate 'Encourage and support breastfeeding' as the first dietary guideline (NHMRC 2003).

The NHMRC has set targets for Australia to increase breastfeeding initiation rates to in excess of 90 per cent and to increase the proportion still breastfeeding at 6 months to 80 per cent (NHMRC 2003).
In conjunction with this, the NATSINSAP identifies 'Family focussed nutrition promotion, resourcing programs, disseminating and communicating good practice' as a key national action area (SIGNAL 2001b).

It is well known that improving infant feeding practices which includes encouraging and promoting breastfeeding is one of the most cost effective public health interventions.

The poor health status of many Indigenous infants is linked to recurrent infection, under nutrition and increasingly over nutrition.
Breastfeeding responds to all of these factors by providing protection against infection and optimum nutrition for growth and development.

The benefit of breastfeeding is greatest in the first six months of life (Binns 2002).

Research shows that breastfed infants have a lower incidence of, and/or reduced severity of gastrointestinal disease.

Studies suggest that this protection may also be extended to reducing the incidence and severity of respiratory, ear and other infections (Kramer & Kakuma 2003).
The magnitude of the effects is large, with significant implications for Aboriginal and Torres Strait Islander communities.

For example, a recent meta-analysis of studies conducted in developed countries demonstrated more than a tripling of severe respiratory illnesses requiring hospitalisation for formula fed infants compared with those exclusively breastfed for a least four months (Bachrach et al 2003).

Breastfeeding is also associated with reduced infant and child mortality (Jain 1996).
Under nutrition and poor growth among Aboriginal infants is well reported within remote communities (Rousham & Gracey 1997).

Despite widespread and prolonged breastfeeding by Aboriginal mothers in remote areas, their infants have poor growth patterns after six months (NHMRC, 2000) and recurrent infections.
In October 2005 rates of underweight children under the age of 5 years in remote communities across the Northern Territory (NT) were reported to be between 8% and 18% (compared to an expected rate of 3%).

Across the NT, 9% of children were recorded as wasted, with some regions recording rates of up to 14% (GAA, 2005).

It has been said that international relief agencies regard a prevalence of wasting of children more than 8% as a nutritional emergency (Ruben 1995).
While the Northern Territory is the only jurisdiction to have in place a comprehensive growth monitoring program, poor growth is a serous problem among Aboriginal infants in remote communities across Australia.

Within this context breastfeeding provides protection against infections and the cycle of growth faltering.

However, the importance of appropriate solids introduced at an appropriate time to complement breast feeding should not be overlooked (SIGNAL 2001b).
Although breast-feeding helps to protect against infection such as gastro enteritis, it cannot be expected to completely prevent such infections in the context of poor living conditions and food insecurity.

Continued breastfeeding is beneficial for Aboriginal infants and their health would probably be much worse if they were bottle fed (on infant formula) in unhygienic living conditions (NHMRC, 2000).
Conversely, there is emerging evidence of an inter-relationship between over nutrition in early life and chronic disease in adult life.

Given that breastfeeding is inversely associated with childhood obesity it is likely to be an important protective factor in longer term chronic disease prevention (Mayer-Davis 2006).
Among Torres Strait Islander communities adult obesity is three times more prevalent and diabetes is six times more prevalent than for the general Australian population (Leonard et al, 2002).

A study of an Indigenous population overseas with similarly high prevalence rates found that people who were exclusively breastfed had significantly lower rates of Type 2 diabetes than those who were exclusively bottle fed with infant formula (Pettitt et al 1997).
Type 2 diabetes has been diagnosed in primary school aged children in the Torres Strait in recent years (Leonard et al, 2002).
b. evaluate the impact of marketing of breast milk substitutes on breastfeeding rates and, in particular, in disadvantaged, Indigenous and remote communities; The NATSINSAP steering committee members that have contributed to this submission are not aware of any research on the impact of marketing of breast milk substitutes on the breastfeeding rates of Australian Indigenous communities specifically.
However international experience indicates the potentially dangerous Impact of these practices when coupled with poor education standards, poverty and the poor living conditions prevalent in many Australian Indigenous communities.

It is therefore considered to be an area requiring preventative action and close scrutiny.

Anecdotal evidence from the Northern Territory provides cause for concern.
At the NT Aboriginal Nutrition and Physical Activity Forum held in Alice Springs in 2004, a large group of women shared their concerns in relation to infant feeding.

Of relevance, these women were concerned about breast feeding rates reducing over time, particularly for young women and the inappropriate choices for feeding young infants (NAPA 2004a).
Further anecdotal evidence collected during an NT Infant Feeding Guidelines project (2005) undertaken on behalf of the Northern Territory Department of Health and Community Services indicated that the use of infant formula in remote communities was becoming more common, particularly amongst young mothers (NT DHCS 2005).
During the consultation in Alice Springs it was reported that the number of non breast fed Indigenous infants admitted to the paediatric wards in Alice Springs was increasing and was at times as high as 20% of all infants.

In response to these concerns and to inquiries from remote store managers and health centre staff, the project developed a set of guidelines for selling infant formula in remote stores in the NT.
The guidelines suggest that stores do not promote infant formula and bottles and stock only one type of both.

Stores are encouraged to stock and promote a range of infant feeding cups (NT DHCS 2005).

At a national level, Australia voted in support of the World Health Organisation International Code of Marketing of Breastmilk Substitutes (WHO Code) in 1981.
The aim of the Code is to contribute to the provision of safe and adequate nutrition of 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 WHO code seeks to ensure that infant formula is not marketed or distributed in ways that may undermine breastfeeding.
Implementation of the WHO Code in Australia must be done in the context of Australian laws, in particular the Trade Practices Act 1974.

In 1992 Australian manufacturers and importers of infant formula signed the Marketing in Australia of Infant Formula: Manufacturers and Importers (MAIF) Agreement.

The MAIF Agreement is however limited to extent it is a voluntary industry Agreement and as such not all infant formula manufacturers and importers have signed this Agreement in Australia.
Furthermore, several aspects of the WHO Code are not part of the MAIF agreement and have not been implemented in Australia.

The WHO Code applies to all agencies involved in the marketing and promotion practices related to breastmilk substitutes and other products.

The MAIF Agreement applies only to manufacturers and importers of infant formula.

It does not cover retailers such as supermarkets, pharmacies or chemist shops.
It is also notable that the MAIF Agreement applies only to the marketing and promotion of infant formula up to 12 months of age, and does not cover'weaning foods', bottle-fed complementary foods, toddler formulas, feeding bottles, teats and pacifiers.

This limitation has been frequently exploited over recent years through the marketing of Toddler' formula on television and in magazines.
Recommendations • That the Australian Government legislate that the MAIF Agreement is mandatory and that it is expanded to include retailers of all infant formula, toddler formula and related products.

• A system to monitor the sale and promotion of infant formula in rural and remote Aboriginal and Torres Strait Islander communities.

• That the Australian Government supports the monitoring and enforcement of breaches of an expanded MAIF Agreement.
c. the potential short and long term impact on the health of Australians of increasing the rate of breastfeeding; It is difficult to accurately assess the potential short and long term impact on the health of Australians in the absence of a national breastfeeding monitoring program inclusive of Aboriginal and Torres Strait Islander people in urban, rural and remote communities.
A national monitoring program would document the extent to which breastfeeding practices are consistent with national dietary guidelines and to determine how these practices are changing.

This information could be used to assess health impacts and identify areas of further policy refinement and implementation (Webb et al 2001).

Breastfeeding studies which are currently available are difficult to compare given variations in data collection methodology and in breastfeeding definitions.
Despite such inconsistencies, a snapshot of breastfeeding rates reported for Indigenous Australians are identified below.

The Dietary Guidelines for Children and Adolescents in Australia reports the target for increasing the prevalence of breastfeeding at hospital discharge to in excess of 90 per cent and increasing the proportion still breastfeeding at 6 months to 80 per cent (NHMRC 2003).

It is clear that non-Indigenous and Indigenous Australians still fall well short of these goals.
In 2004-05, the Australian Bureau of Statistics reported that 66% of Indigenous children 0-3 years had been breastfed compared with 72% of non-Indigenous children.

This gap halved for those breastfeeding past 6 months of age.

Indigenous women living in remote areas were more likely to have breastfed their children than those in non-remote areas (ABS 2004-05).
Northern Territory In the Northern Territory a chart audit undertaken in 2003 (n=780) indicated that the rate of any breastfeeding (exclusive, fully or partial) at hospital discharge for Indigenous infants from rural areas was reported to be 98%.

This compared to the reported rate for Indigenous infants from urban areas which was 84.1% (NPAP 2004b).
Victoria In Victoria, select studies have identified that approximately 85% of Victorian Aboriginal mothers' breastfed their babies initially and only about 50% continue to breastfeed at 12 weeks (DHS 2004).

This compares poorly with data collected in Victoria across the mainstream population which showed that at 12 weeks 59% of babies across Victoria were partially or fully breastfed (Adams 2006).
Perceived low quantity of milk was reported as the most common reason for breastfeeding cessation and low levels of support for Aboriginal mothers in urban settings has been suggested as a reason for early cessation of breastfeeding and early introduction of solids (Adams 2006).

Western Australia Based on a number of studies in Aboriginal communities in Western Australia it has been reported that breastfeeding rates decline in groups who live closer to urban areas (Binns 2006).
A study conducted during 2001-02 of 425 Aboriginal mothers residing in the Perth metropolitan area found that breastfeeding initiation rates for urban Aboriginal women were quite high at almost 90%.

However there was a decline to about 59% at 24 weeks, with only 31.5% being exclusively breastfed at this time.
When compared with non-Aboriginal mothers, the Aboriginal breastfeeding rates were higher than the non-Aboriginal average breastfeeding rates, but lower than the highest socioeconomic groups (Binns 2006).
Overall, concerns relating to breastfeeding and infant nutrition for Aboriginal and Torres Strait Islander groups are, in part related to: • A possible trend for urban and young mothers to stop breast feeding early (Groos et al,1997); • The associated introduction of inappropriate foods to infants at an early stage (Groos et al, 1997); • Delayed introduction of additional solid food to infants in other areas where prolonged breastfeeding is still common and/or mothers may be malnourished (Groos et al 1997); and Ensuring that breastfeeding rates within remote Aboriginal and Torres Strait Islander remain high.
Recommendations • An identified priority area within the NATSINSAP is development of a national food and nutrition information system.

As a key part of this broader program, it is recommended that the Australian Government develop a national system for monitoring breastfeeding in Australia with standardised data collection on breastfeeding rates and standardised definitions for measuring breastfeeding practices.
d. initiatives to encourage breastfeeding; The NATSINSAP was designed to provide national coordination and cooperation across the country and to build on existing efforts to improve nutrition (including breastfeeding) and food security across jurisdictions for Aboriginal and Torres Strait Islander people.

Despite being approved and endorsed in 2001, dedicated resourcing was not forthcoming until the appointment of a national project officer in August 2004.
In 2006 the Office of Aboriginal and Torres Strait Islander Health (OATSIH) within the Australian Government Department of Health and Ageing committed further funding to this position until October 2008, under the guidance of a national steering committee and reference group.

Over this period there have been significant achievements within two of the seven identified NATSINSAP priority areas: 1.

Food supply in remote and rural communities 2.


Aboriginal and Torres Strait Islander nutrition workforce Of greatest relevance to breastfeeding promotion is the progress achieved within 'workforce' development.
In a review undertaken in 1998 of training in breastfeeding support and infant nutrition it was noted that the existing Aboriginal Health Worker units relating to maternal and child health and nutrition were all optional, and as such the qualification did not result in a minimum level of expertise in this area (Groos et al, 1997).
A significant achievement of the NATSINSAP has been the inclusion of 'nutrition' as a core unit in the new national Aboriginal and Torres Strait Islander Health Worker competencies which form part of the Health Training Package, HTL07 and were released in February 2007.

This means every Health Worker undertaking the 'practice' stream at a Certificate IV level around Australia will study nutrition as part of their training.
There will also now be the opportunity for Health Workers to specialise in nutrition within the new national competencies at the Certificate IV and Diploma levels.

Whilst units in maternal and child health within the new national Aboriginal and Torres Strait remain optional, some jurisdictions, particularly the Northern Territory and Queensland have significantly increased the number of specialist Indigenous focussed maternal and child health positions.
In 2002, the Northern Territory government funded an additional 25 Islander Health Worker competencies new positions with a focus on regional and remote areas.

In Queensland 61 new positions in Indigenous children's health have been funded from 2002 to 2009 to focus on the 0-5 age group.
Queensland Health, through the development of the 'Growing Strong' program has taken the lead in supporting breastfeeding and infant nutrition education within both state based accredited training programs for Aboriginal and Torres Strait Islander Health Workers as well a state-wide 'in-service' program to up-skill existing Health Workers (QLD Health 2006).
'Growing Strong' resources provide The information about nutrition during pregnancy and early childhood, with a specific focus promoting breastfeeding and supporting mothers with common breastfeeding in-service training targeting community based Aboriginal and Torres Strait Islander Health Workers is delivered by Nutritionists in partnership with Aboriginal Nutrition Promotion Officers.
A state-wide process evaluation undertaken from 1998-2005 of the 'Growing Strong' program identified that 38 training in-services had been conducted across Queensland that were attended by more than 323 Aboriginal Health Workers.

Seventy six percent of respondents referred to the 'Growing Strong' resources for information on maternal and infant nutrition (QLD Health 2006).

issues.
issues.

Regular In South Australia, the Queensland 'Growing Strong' training program, has also been delivered for Aboriginal Health Workers across the state.

This has complimented a range of initiatives undertaken in South Australia to promote breastfeeding, with a focus on Aboriginal communities.

Increasing and supporting breastfeeding is a priority highlighted in both the South Australia Strategic plan for 2007 and within Eat Well South Australia, the state nutrition strategy.
In 2002, a state-wide Aboriginal breastfeeding forum identified specific strategies to support Aboriginal women to breastfeed, including organisational support from health services, home visiting by midwives and engaging Aboriginal women to attend antenatal classes (Gov.

SA 2002).

The 'Family Anangu Bibi Birthing program' based in Port Augusta has been reportedly successful in engaging Aboriginal mothers with increased ante-natal visits and an increased opportunity to breastfeed.
Through a partnership between an Aboriginal Maternal Infant Care Workers and a midwife, community based care is provided through pregnancy, birth and the post partum period.

The evaluation report suggests further expansion of the initiative to other areas of South Australia.

In the Northern Territory a process was undertaken in 2006 to review the NT feeding guidelines.
This included a Territory wide training program and the development of resources for urban and remote settings (http://www.nt.gov.au/health/docs/ifg_flipchart.pdf).

Other initiatives across Australia generally target breastfeeding as a part of community focussed Maternal and Child Health programs.
However, in a review undertaken by the Australian government of community based Aboriginal and Torres Strait Islander Health service providers it was identified that not all providers perceive breastfeeding and infant nutrition as a priority within their populations (Engeler et al.

1997).
1997).

In 2006 the $102.4 million Healthy for Life program was funded by the Australian Government Department of Health and Ageing to enhance the capacity of primary care services to improve the quality of Aboriginal and Torres Strait Islander child and maternal health services and chronic disease care, and to improve the capacity of the Indigenous health workforce.

Eighty primary health care services are now participating in the program through 53 sites.
An evaluation of the Healthy for Life program will commence in 2007.

At this stage it is not known the degree to which the Healthy for Life program will actively support breastfeeding and the many factors leading to early weaning and poor child growth.

Reducing the rates of low birth weight have been identified as a key health outcome, however support to improve breastfeeding rates or infant growth have not been specifically identified as a medium or longer term outcome for the program (AGDHA 2006).
Recommendations • Nationally consistent training and support materials in nutrition and maternal & child health are developed to support state based Registered Training Organisations to deliver specialist training for Aboriginal and Torres Strait Islander Health Workers; aligned to the new Aboriginal and Torres Strait Islander Primary Health Care qualification.
• Strengthen the role of Aboriginal and Torres Strait Islander Health workers and other Health Care professionals in providing advice, care and support to breastfeeding mothers to increase the capacity of community based services to provide good primary health care in the areas of maternal and child health and in nutrition.
• Expand support for the implementation of the NATSINSAP as a mechanism to provide coordination across Australia for the development and delivery of in-service packages in nutrition for Aboriginal and Torres Strait Islander Health Workers, to facilitate rapid and culturally appropriate training for all groups involved in providing breastfeeding and infant nutrition advice to women, families and communities.
e. examine the effectiveness of current measures to promote breastfeeding Mainstream health service delivery and health promotion programs have not had the same effect in Aboriginal and Torres Strait Islander maternal and child health as they have in the non-Indigenous Australian population.
Effective strategies to improve the health of Aboriginal and Torres Strait Islander women, pregnant women, babies and young children could be the adaptation of mainstream models, delivered in a more culturally and socially acceptable way (Herceg, 2005).

There is however limited high quality information on successful interventions in Aboriginal and Torres Strait Islander maternal and child health; including programs to support breastfeeding.
In a literature review reported in 2005, a number of programs were identified which described improved impacts.

All of these programs had multiple components and success could not be attributed to any one component or a particular combination of these components.
However a number of common features were identified: Integration with other services (eg hospital liaison, shared care) • Community based and/or community controlled services • A specific service location intended for women and children • Providing continuity of care and a broad spectrum of services • • Outreach services • Home visiting • Welcoming and safe service environments • Flexibility in service delivery and appointment times • A focus on communication , relationship building and development of trust • Respect for Aboriginal and Torres Strait Islander people and their culture • Having an appropriately trained workforce • Valuing Aboriginal and Torres Strait Islander staff and female staff • Provision of transport; and • Provision of childcare or playgroups (Herceg, 2005) However an earlier review of breastfeeding interventions in Aboriginal communities found many Aboriginal specific services did not prioritise breastfeeding, focussing instead on other health issues (Adams, 2006).
To specifically encourage continued breastfeeding and the appropriate introduction of complementary food to Aboriginal and Torres Strait Islander infants, the following elements have been considered important: • Antenatal and postnatal care and advice in supporting women in their infant feeding choices as well as preparing them for common breastfeeding problems (Groos, 1997).
Emphasis; should be given to appropriate support structures, including peer support and home visiting as well as referral to specialised health care professionals to assist mothers to maintain breastfeeding in the community; • Nutrition, growth and development of infants and young children should be related to advice on feeding choices.
In particular the benefits of breastfeeding for low birth weight babies and those born to mothers with gestational diabetes should be emphasised (Groos, 1997); and • Training opportunities and resources should take into account issues surrounding the introduction of first foods for toddlers and be amended to take account of the NHMRC Dietary Guidelines for Children and Adolescents (Groos, 1997).
The NATSINSAP identifies strategies for promoting effective breastfeeding programs within the key action area: "Family focussed nutrition promotion, resourcing programs, disseminating and communicating 'good practice'.
In this context 'good practice' as defined by the community and health professionals, includes understanding community priorities, family, culture, preferred methods of communication and learning, in addition to an up-to-date knowledge of the prevention and management of diet related disease (SIGNAL 2001b).

However across Australia identification and dissemination of'good practice' nutrition and breastfeeding information currently occurs in an ad hoc manner.
Resources to implement this important area within the NATSINSAP have so far been limited.

Recommendations • Development of a maternal and child health policy framework with goals and targets pertaining to Indigenous Australians which includes a focus on the initiation and maintenance of breastfeeding, the appropriate introduction of solids at the appropriate time and strategies to address poor childhood growth.
• Expand support for the implementation of NATSINSAP to provide coordination in the transfer of'good practice' in breastfeeding and infant nutrition promotion to avoid duplication of effort across sectors.

• Continue to support the evaluation of current efforts to promote breastfeeding within appropriate and supportive environments as essential for improved nutrition of Aboriginal and Torres Strait Islander infants.

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