Evaluation Toolkit for Breastfeeding Programs and Projects

June 2012

Appendix A - Policy context

Page last updated: 04 November 2013

Policy context

The Australian National Breastfeeding Strategy 2010-2015 was endorsed by the Australian Health Ministers’ Conference (AHMC) on 13 November 2009. The aim of the Strategy is to contribute to improving the health, nutrition and wellbeing of infants and young children and the health and wellbeing of mothers, by protecting, promoting, supporting and monitoring breastfeeding. AHMC (now known as the Standing Committee on Health or SCoH) brings together the Commonwealth Minister for Health and Ministers for Health from respective state and territory government jurisdictions. The Strategy and a range of other relevant publications are available from the Australian Department of Health and Ageing’s website.
The Strategy outlines a series of strategic goals across the breastfeeding continuum of ‘ages and stages’, underpinned by key objectives and an evidence-base of ‘what works best’. The goals are as follows:
  • increase community acceptance of breastfeeding as a cultural and social norm
  • mothers feel comfortable and supported in their breastfeeding relationship
  • breastfeeding friendly communities, public spaces, workplaces and child care environments empower mothers to continue breastfeeding
  • community leaders and role models value and enable breastfeeding and are supported to breastfeed
  • improve the availability and access to antenatal education with information on the value of breastfeeding
  • pregnant women establish breastfeeding support networks and are linked to support groups in the community
  • improve breastfeeding initiation rates
  • improve the consistency of breastfeeding advice provided by health professionals
  • increase the number of birthing services with documented breastfeeding policies and workplace supports
  • improve breastfeeding training for health professionals
  • improve continuity of care between birthing and health and community services, and breastfeeding support services and networks. Ensure mothers and their families know what breastfeeding support services are available and how to access them
  • ensure mothers receive appropriate breastfeeding supports and referrals, including access to trained peer breastfeeding counsellors
  • increase the percentage of babies who are fully breastfed from birth to six months and continue breastfeeding with complementary foods to 12 months and beyond
  • increase the access to parental leave
  • increase the number of model breastfeeding friendly workplaces, services and environments (p 34-37).
The commitment to develop the Australian National Breastfeeding Strategy was a key element of the Australian Government’s (2008) response to The Best Start: Report on the inquiry into the health benefits of breastfeeding conducted by the House of Representatives Standing Committee on Health and Ageing (2007). That Inquiry, which reported in 2007, identified a range of key issues and complexities associated with the health benefits of breastfeeding.
  • Only a small proportion of mothers are exclusively breastfeeding their babies for the first six months of life, as recommended by the WHO and the NHMRC.
  • There is no national breastfeeding data collection system and there is a lack of quality data on the effectiveness of measures to promote breastfeeding and improve initiation and duration of breastfeeding.
  • Multifaceted influences on breastfeeding practices create challenges in researching and distinguishing the impact of particular interventions or programs.
  • While successful strategies for promoting and supporting breastfeeding exist, lack of coordination can be an issue in terms of policies and procedures. Barriers to initiating and continuing successful breastfeeding were identified as including cultural perceptions and practices; low levels of education or literacy; low socioeconomic status; lack of ongoing support or access to support and lack of appropriate education and ongoing advice.
In recommendations particular to the preparation of this evaluation toolkit, the Inquiry proposed Australian Government leadership in the coordination and oversight of a national strategy to promote and support breastfeeding; in monitoring, education and coordination; in specific strategies to improve baby-friendly health initiatives across the health system and in the monitoring, surveillance and evaluation of breastfeeding rates and practices in Indigenous communities (p xvii-xx).

The Australian Government Response to the House of Representative’s Inquiry was provided in December 2008. Importantly, this included a commitment to the development and implementation of a National Breastfeeding Strategy (2009), with state and territory governments, through AHMC (p 4).

The Response included other comments with implications for this Toolkit. For example, in relation to Recommendation 2, it noted the work being undertaken by the Department of Health and Ageing with stakeholders to update the breastfeeding data indicators recommended in the 2001 report Towards a national system for monitoring breastfeeding in Australia, using new research and guidelines from Australia and international sources, including the World Health Organization and support for a basic set of indicators in the context of developing a National Breastfeeding Strategy (2009, p 4). This work has progressed, and in 2011 the AIHW published the National Breastfeeding Indicators Workshop Report and the Australian National Infant Feeding Survey: Indicator Results.

In relation to recommendations 3, 4 and 9, the Australian Government priority to evaluate the impact and effectiveness of programs intended to increase breastfeeding rates was noted, along with the intention to canvass priorities for evaluating best practice programs with state and territory governments as part of the National Breastfeeding Strategy (2009, p 5). The Toolkit is intended to contribute to these outcomes.

In relation to recommendation 19, the Australian Government reported inclusion of a measure of breastfeeding practices, under the Aboriginal and Torres Strait Islander Health Performance Framework, as one way of providing leadership in the monitoring, surveillance and evaluation of breastfeeding rates and practices in Indigenous populations in both remote and other areas (p 10). The 2010 Australian National Infant Feeding Survey: Indicator Results includes breastfeeding rates reported by Aboriginal and Torres Strait Islander mothers or carers.

Indicators and national statistics

In an article on complexities in measuring and reporting on breastfeeding in the International Breastfeeding Journal, Hector (2011) notes that simple, valid and reliable indicators are critical in public health monitoring to describe progress toward a goal.

As described in the previous section, an update of indicators was proposed as part of the Australian Government response to the 2007 Parliamentary inquiry into breastfeeding. A national workshop was convened by the Australian Institute of Health and Welfare (AIHW) in December 2010, designed to make decisions on a set of breastfeeding indicators with the purpose of ‘supporting the reporting of national breastfeeding trends, and thereby the evaluation of the Australian National Breastfeeding Strategy 2010-2015 (2009) and related policies and programs’ (p v). The Workshop report notes that the following draft set of indicators was agreed in principle:
  • proportion of children ever breastfed (for children aged 0-24 months)
  • proportion of children breastfed at each month of age, 0-24 months
  • proportion of children exclusively breastfed to each month of age, 0-6 months
  • proportion of children predominantly breastfed to each month of age, 0-6 months
  • proportion of children receiving soft/semi-solid/solid food at each month of age, 0-12 months
  • proportion of children receiving non-human milk or formula at each month of age, 0-12 months (p 12).
It is worth noting that the workshop report defines ‘aged x months’ as being in the x +1 month of life (e.g. a child aged 6 months has lived 6 complete months and is in the 7th month of life). However, the potential for misinterpretation of this indicator both at the application and analysis stages remains. Similarly, there is a view that indicators should be broadly consistent with standards, recommendations and practice and in this regard it has been pointed out that the National Health and Medical Research Council (NHMRC) guidelines (2012) related to breastfeeding recommend ‘that infants are exclusively breastfed until around 6 months of age when solid foods are introduced’. As Hector (2011) indicates, this is likely to create some problems in indicator development as the timing issues are juxtaposed.

These issues also suggest there is likely to be a need for ongoing guidance around the use of indicators relating to the goals of ‘exclusively’ and ‘predominantly’ breastfed.

The AIHW 2010 Australian National Infant Feeding Survey: Indicator Results (2011) utilises the national workshop indicators as part of a baseline national survey on estimates of prevalence and duration of breastfeeding as well as exploring barriers to initiating and continuing breastfeeding, using a sample drawn from the Medicare enrolment database. An initial sample of 52,000 was used and a response rate of 56% achieved. The report also highlights the definitional difficulties referred to above, in relation to current age of child and descriptions of selected infant feeding practices (p 2-4). These are addressed by use of a ‘time to event’ analysis technique as well as by strict adherence to the use of ‘exclusively breastfed’ and ‘predominantly breastfed’ definitions in the survey process. Other limitations of the data included estimates based on the recall of infant feeding practices and sample size issues for subpopulations (p 56).

The report’s main findings are as follows:
  • Breastfeeding was initiated for 96% of children aged 0-2 years (p 7).
  • Approximately 69% of infants received some breastmilk at 4 months of age, although only 39% were exclusively breastfed to less than 4 months and approximately 60% were receiving some breastmilk at 6 months, but only 15% were exclusively breastfed to less than 6 months (p 7,8).
  • 47% of infants were predominantly breastfed to less than 4 months and 21% were predominantly breastfed to less than 6 months (p 10).
  • Less than 1% of children aged 1 month received soft/semi-solid or solid food, rising to 35% of infants aged 4 months, 92% of infants aged 6 months and 95% of children aged 12 months (p 11).
  • Approximately 40% of infants aged 1 month received non-human milk or infant formula, with a gradual rise in this rate to 55% at 6 months. Nearly 80% of children aged 12 months received non-human milk or infant formula (p 12).
  • Higher initiation rates and intensity of feeding for longer periods were associated with older mothers/carers, mothers/carers with tertiary education and with higher gross household incomes and infants who did not regularly use a dummy (p 14, 18, 22, 26).
  • Similar associations were made for these groups in relation to lower and later rates of introduction of non-human milk and soft/semi-solid/solid foods (p 30, 34).
  • The reasons most cited in the report for giving the child breastmilk were: healthier for child (94%), convenient (64%) and helps with mother-child bonding (64%) (p 38).
  • Reasons most cited for not breastfeeding (amongst the 4% who never breastfed) were: previously unsuccessful experience (38%), to enable partner to share feeding (29%) and infant formula as good as breastmilk (26%) (p 39).
The report (2011) highlights the lack of consistency in data collected and indicators reported for breastfeeding rates and duration between different jurisdictions and surveys.

National Women’s Health Policy 2010

The National Women’s Health Policy (2010) provides an overarching policy framework for the improvement of the health and wellbeing of all women in Australia, in particular those at greatest risk. It includes the health priority area of sexual and reproductive health, including the importance of the health of mothers prior to conception, during pregnancy and in the post-natal period in terms of profound and long-term effects on their own health and that of their children.

The National Women’s Health Policy (2010) acknowledges breastfeeding as a key protective factor for both maternal and infant health in terms of the best nutritional start and immunological protection for infants, the promotion of infant bonding and attachment and other maternal health benefits such as promotion of recovery from childbirth and reduced risks for breast and ovarian cancer. The policy recognises the Australian dietary guidelines recommendation for exclusive breastfeeding for infants until six months of age and quotes the Australian Institute of Family Studies report with breastfeeding initiation rates at 92 per cent in 2004, declining to 56 per cent of infants fully breastfed at three months and 14 per cent at six months. The policy also notes that younger, less educated and more socioeconomically disadvantaged Australian women are less likely to breastfeed (p 62).

State and territory policies

Most state and territory jurisdictions have breastfeeding policies or frameworks and operate a range of programs and projects which are either specific to breastfeeding or focused on generic health objectives (for example maternal and infant health, nutrition, obesity etc.). These activities are variously delivered through health and other government agencies, non-government organisations or jointly.

Other relevant documents

A qualitative research report developed by Woolcott Research for the Department of Health and Ageing in 2009 (Exploratory Research Regarding Infant Feeding Attitudes and Behaviours) found that breastfeeding rates are affected by women’s changing and evolving attitudes, expectations and experiences from pregnancy until the time the child is around six months of age (p 3). The report observed that “more committed breastfeeders were likely to be slightly older, have achieved higher levels of education, and from higher socio-economic areas” (p 6). This finding is broadly consistent with the AIHW 2010 Australian National Infant Feeding Survey results.

The Woolcott report (2009) also found a lack of awareness among mothers and partners about breastfeeding guidelines; variation in the types of information, advice and support available to women and a range of involvement by and accessibility to health professionals with regard to infant feeding (p 7-10). It recommended implementation of social marketing activities to ‘normalise’ breastfeeding, improved information for mothers, partners and family members; promotion of the importance of exclusive breastfeeding; conduct of an audit of breastfeeding-related education and training to professionals and the conduct of further research on specific culturally and linguistically diverse groups’ awareness and attitudes regarding breastfeeding (p 11-13).

The NHMRC Infant Feeding Guidelines: Information for Health Workers (2012) documents the evidence base and provides Australian recommendations on breastfeeding and infant feeding practices. This in turn further informs the policy, programs, research, indicators and evaluation used to protect, promote, support and monitor breastfeeding in Australia.

References

Australian Government 2008, Response to The Best Start: report on the inquiry into the health benefits of breastfeeding, Commonwealth Government of Australia, viewed June 2012,

Australian Health Ministers’ Conference 2009, The Australian National Breastfeeding Strategy 2010-2015. Australian Government Department of Health and Ageing, Canberra, viewed May 2012,

Australian Institute of Health and Welfare 2011, National breastfeeding indicators: workshop report, AIHW, viewed May 2012,

Australian Institute of Health and Welfare 2011, 2010 Australian national infant feeding survey: indicator results, AIHW, viewed May 2012,

House of Representatives Standing Committee on Health and Ageing, The Best Start: report on the inquiry into the health benefits of breastfeeding, Commonwealth of Australia 2007, viewed May 2012,

Commonwealth of Australia 2010, National Women’s Health Policy 2010, Commonwealth Department of Health and Ageing, viewed May 2012,

Hector, DJ 2011, “Complexities and subtleties in the measurement and reporting of breastfeeding practices”, International Breastfeeding Journal vol 6, viewed May 2012.

Osborne, D, Economus, L, Sparham, L 2009, Exploratory Research Regarding Infant Feeding Attitudes and Behaviours, Woolcott Research for the Commonwealth Department of Health and Ageing, viewed May 2012, www.health.gov.au/internet/main/publishing.nsf/Content/B4D6F3BD03FE218ECA2576BA001CC322/$File/FINAL%20Infant%20Feeding%20Report%20-%2016.06.09.pdf (This website link was valid at the time of submission)

National Health and Medical Research Council 2012, Infant Feeding Guidelines: Information for health workers, Canberra, National Health and Medical Research Council. For more information please visit Australian Dietary Guidelines.

Webb, K, Marks, GC, Lund-Adams, M, Rutishauser IHE, Abramah, B 2001, Towards a national system for monitoring breastfeeding in Australia: recommendations for population indicators, definitions and next steps, Australian Food and Nutrition Monitoring Unit, viewed May 2012.

World Health Organization, LINKAGES 2003, Infant and young child feeding: a tool for assessing national practices, policies and programmes, World Health Organisation, viewed May 2012, For more information please visit WHO website.