The professionalising of breast feeding—Where are we a decade on?

Midwifery 28 (2012) 281–290

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Commentary

The professionalising of breast feeding—Where are we a decade on? Lesley Barclay, RM, PhD (Director)a,n, Jo Longman, MPH, PhD (Research Fellow)a, Virginia Schmied, RN, RM, PhD (Professor of Maternal and Infant Health)b, Athena Sheehan, RM, MN, PhD (Senior Lecturer)c, Margaret Rolfe, MStat, PhD (Biostatician)a, Elaine Burns, RM, PhD (Lecturer in Midwifery)b, Jennifer Fenwick, RM, PhD (Professor of Midwifery)d a

University Centre for Rural Health—North Coast, University of Sydney, PO Box 3074, Lismore, NSW 2477, Australia School of Nursing and Midwifery, University of Western Sydney, Locked Bag 1797, Penrith, NSW 2751, Australia c Faculty of Nursing and Health, Avondale College, 185 Fox Valley Road, Wahroonga, NSW 2076, Australia d Griffith University, Logan Campus, University Drive, Meadowbrook QLD 4131, Australia b

a r t i c l e i n f o

Keywords: Breast feeding Health policy Health services

abstract This paper is an empirically informed opinion piece revisiting an argument published in Midwifery 10 years ago, that the increasing professionalisation of breast feeding was not supporting women in Australia in sustaining breast feeding. We present the last 10 years of primary research on the topic, explore major policy initiatives and the establishment and growth of lactation consultants in Australia to see if this has made a difference to sustained rates of breast feeding. We present an analysis of the only consistently collected national statistics on breast feeding and compare this with national and state level government data collections from the last decade. We have found that the considerable effort invested in trying to improve duration of breast feeding amongst women in Australia appears to have failed to improve sustained breast-feeding rates. We argue that this situation might be related to losing sight of the embodied nature of breast feeding and the relationships that must exist between the mother and baby, the knowledge and skills women quickly develop, and a loss of woman to woman support. We conclude that midwives have a major role in avoiding us reproducing similar, unintended, negative consequences to those resulting from increasing obstetrician managed normal birth. These include midwifery scrutiny and involvement in policy development and institutional practices and the design of services. & 2012 Elsevier Ltd. All rights reserved.

Introduction A woman’s decision to breast feed, and the support required to sustain breast feeding, is dependent on a wide range of factors. These include cultural and social circumstance, family support, her baby’s health and her employment plans. Some but not many of these factors are potentially modifiable by health systems, institutional policy and practice. There is strong evidence, for example, that medications around the time of birth can affect the initial breast-feeding experience for both mother and baby (Australian Health Ministers’ Conference, 2009; Thompson et al., 2011). Furthermore preventing advertising or free product distribution in hospitals to newly birthed women increases initiation of breast feeding. For example Beake et al.’s (2011) systematic

n

Corresponding author. E-mail addresses: [email protected], [email protected] (L. Barclay), [email protected] (J. Longman), [email protected] (V. Schmied), [email protected] (A. Sheehan), [email protected] (M. Rolfe), [email protected] (E. Burns), j.fenwick@griffith.edu.au (J. Fenwick). 0266-6138/$ - see front matter & 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.midw.2011.12.011

review of structured programs such as the Baby Friendly Health Initiative (BFHI) reports evidence of an increase in initiation and short-term duration from structured programs. This evidence however shows rates still falling short of levels recommended by WHO, and is primarily from countries with a low baseline of breast-feeding rates. The last decade has seen concentrated efforts to improve duration of breast feeding amongst women both in Australia and globally. This is generally expressed as increased professional support for breast-feeding women, education of these professionals, public health promotion campaigns and broader policy implementation such as the BFHI. Walsh et al. (2010) report that in Australia 21% (66/317) of hospitals have been accredited as Baby Friendly. Whilst BFHI has had positive impact, such as the removal of infant artificial milk direct marketing to women in hospitals there is a lack of evidence that BFHI is having a positive influence on the duration of breast feeding (Bartington et al., 2006). Benefits of such programs to breast feeding at 6 months are less clear (Beake et al., 2011). Further research is required to assess the impact of structured programs on breast feeding to 6 months. At the same time as policies have been developed to support breast feeding, such as BFHI, there has been an exponential

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growth of professional skills around breast feeding. The development of a culture valuing credentialing of skills and services around breast feeding has been evident in the establishment, in 1984, of the Australian Lactation Consultants Association (ALCA – now Lactation Consultants of Australia and New Zealand Ltd, LCANZ), and the growing emphasis on technical expertise. We suggest this could be at the expense of a social orientation and support. Lactation Consultants (LCs) pass an examination and are able to operate as a business, charging a fee (often around $100) for their services. The first lactation consultants were certified in 1985 (Karolyn Vaughan—International Board of Lactation Consultant Examiners, 2010). The vast majority of LCs are also qualified as midwives and/or child and family health nurses. For example, of the 170 newly qualified LCs in 2010, 164 selfreported they were registered nurses, 141 of them were also registered midwives and 56 also had Child and Family Health nurse qualifications (Karolyn Vaughan—International Board of Lactation Consultant Examiners, 2010). It is not possible to tell how many of these work privately as an LC or are salaried members of the health service. The International Board of Lactation Consultant Examiners (IBLCE) serves over 21,000 certificants internationally. The exam has been translated into 20 different languages and is administered in over 80 countries (IBLCE). It consists of 174 questions taken over two 2.5 hrs sessions (IBLCE, 2010a). The statistical report for the IBLCE shows that the number of candidates for the 2010 exam was the highest it has ever been in the exam’s history. Australia fielded the third highest number of candidates globally (after the US and Korea); some of these candidates will have been for recertification (Gross, 2010). In the Asia Pacific region there are 4,754 International Board Certified Lactation Consultants (IBCLCs), 2,208 (47%) of whom are in Australia (IBLCE, 2010b). Germany has the largest number of IBCLCs in Europe at 1,240, with the UK reporting 298 (IBLCE, 2010c). Although the US has the largest total number of IBCLCs at 10,249, in terms of population, Australia has by far the highest rate of IBCLCs at nearly 10 per 100,000 population compared to 3 per 100,000 in the US. This occurs alongside a universal and free child and family health service that operates in Australia; with no comparable universal service in the US. The Nursing Mothers Association Australia, a socially oriented movement, was founded in 1964, with a main aim to ‘yencourage and provide support and information to mothers who want to breastfeed’ (Australian Breastfeeding Association, 2005). Its approach to achieving these aims was based on mother-to-mother support for breast feeding. These mothers did not claim ‘expert’ status, and gave their time voluntarily. This was not a business nor was this conducted within a professional or expert model. Womanto-woman learning was based on role modelling, with the intention of increasing women’s confidence in breast feeding and capacity to make decisions based on their own sense of what might be right. This is a very different proposition to women being guided by the knowledge and technical skills of an expert. Despite these initiatives, problems around breast feeding seem also to be increasing. A number of papers over a decade or so describe the problematic and distressing nature of breast feeding for large numbers of women (Schmied, 1998; Dykes and Williams, 1999; Binns and Scott, 2002; Kelleher, 2006; Cooke et al., 2007; Hegney et al., 2008; Hauck et al., 2011). A recent metasynthesis confirms these findings (Burns et al., 2010). Breast-feeding issues are reported to constitute half of the 60 or so calls a day to the new national Pregnancy, Birth and Baby helpline (May, 2010). A number of commentators including the authors of this paper have suggested the lack of progress in managing breast-feeding difficulties, and improving sustained breast feeding might be related to the lack of attention given to the embodied nature of breast feeding and the relationships that exist between mother and baby. Policy

initiatives and increasing the professionals involved in breast feeding advice have occurred within a changed context. This is an ideology of breast feeding not simply having become more acceptable, but a ‘prescribed practice’ for good mothering (Murphy, 1999; Schmied and Barclay, 1999; Stearns, 2010; Sheehan and Schmied, 2011). A diminishment of value for woman to woman support in policies and practices, particularly in Australia and the US, may also be a contributing factor to distress and lack of confidence in women. That despite a changed policy environment, increased professional knowledge and skills and increased value attached to breast feeding; the rates of women still ‘fully’ breast feeding at 3 and 6 months appear to have remained stubbornly static at best, and gradually declining at worst. We argue that a focus on institutional regulations and narrowly based external technical skills potentially reduces self-confidence in women themselves. We revisit others’ work to see if an ‘authentic presence’ (Schmied et al., 2011a) and facilitative supportive relationships that women require to enhance breast feeding might suffer in this policy driven professionalised environment and try to explain why this is so. The health system’s preoccupation with a therapeutic approach and organisational strictures not only do not appear to address the conceptualisation of breast feeding developed from increasing numbers of empirical studies, but also exacerbate a reductionist approach resulting in disconnected encounters (Dykes, 2005; Schmied et al., 2011a). As in normal birth there are now economic drivers of a new profession that continue to reframe breast feeding as expert territory and appear to be contributing to an iatrogenesis that distresses women and infants and is becoming costly to the community. Our goal therefore in this empirically informed commentary is to revisit arguments, which three of the authors made 10 years ago in the light of more recent research. The paper revisits our decade old argument about the potential negative effects of over professionalising breast feeding and illuminates this with a range of more recent research. We undertake a new analysis of the first nationally consistent Australian data set with questions about the breast-feeding practices of Australian women. This work enables us to assess the consequences of a decade of increasing policy and professional activity around breast feeding on duration of breast feeding in Australia.

How did we do this work? To assess the impact of a range of initiatives on rates of breast feeding we used PubMed, Medline and Embase to identify papers published where breast feeding and rate appeared in the title, and/or (from reading the abstract) where breast-feeding rates were a key part of the paper. We also explored national or state-wide Australian Government data collections and health websites to identify reports on breast-feeding rates. We also sourced published papers and read and reread recent studies on breast feeding and critiques of breastfeeding interventions using conventional searching techniques supplemented by experts to help find additional works. We relied on understandings derived from, and sources used in recent metasynthesis (Schmied et al., 2011a). We used generously contributed information and individual sources to help us identify the function and impact of organisations such as the Australian Breast Feeding Association and LCANZ when this was not readily available in published form. Analyses on breast-feeding rates The list of papers identified was reviewed by experts in the field and additional papers and reports that had not been identified by our search were added. The 15 papers identified

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283

Table 1 Sources of national and state government data collections on breastfeeding rates in Australia. Authors

Publications

Amir L.H. and Donath S.M.

Socioeconomic status and rates of breastfeeding in Australia: evidence from three recent national health surveys. Med J Aust. 2008;189(5):254–6 Breastfeeding in Australia, 2001; 2003; Cat. no. 4810.0.55.001 [cited 2011 June 21]; Available from http://www.abs.gov. au/ausstats/[email protected]/mf/4810.0.55.001 Growing up in Australia: Longitudinal study of Australian children annual report 2006-7 [breastfeeding section]. Australian Institute of Family Studies; 2007 [cited 2010 December 10]; Available from: http://www.aifs.gov.au/ growingup/pubs/ar/ar200607/breastfeeding.html Annual Report Archive. Melbourne: Dept of Education and Early Childhood Development; [cited 2011 25 September]; Available from: http://www.education.vic.gov.au/ecsmanagement/matchildhealth/annualdata/archive.htm Rates of breastfeeding in Australia by State and socio-economic status: Evidence from the 1995 National Health Survey. J Paediatr Child Health. 2000;36:164–8. New South Wales Child Health Survey 2001. NSW Public Health Bull 2002;13.(S-4) 2003–2004 Report on Child Health from the New South Wales Population Health Survey. Sydney: NSW Department of Health, 2006 2005–2006 Report on Child Health from the New South Wales Population Health Survey. Sydney: NSW Department of Health, 2008 New South Wales Mothers and Babies 2006 NSW Public Health Bulletin Supplement 2009 20:S-1 New South Wales Mothers and Babies 2007 NSW Public Health Bulletin Supplement 2010, 21:S-1 2007–2008 Report on Child Health from the New South Wales Population Health Survey. Sydney: NSW Department of Health, 2010 New South Wales Mothers and Babies 2008 NSW Public Health Bulletin Supplement 2010, 21:S-1 2 Infant and Child Nutrition in Queensland 2003. Brisbane: 2005 Infant Nutrition Project 2006–7: measurement of exclusive breastfeeding. Brisbane: 2007 The Health of Queenslanders 2010. Third Report of the Chief Health Officer Queensland. Brisbane: 2010

Australian Bureau of Statistics Baxter J.

Dept of Education and Early Childhood Development Victoria Donath S. and Amir L. NSW Centre for Epidemiology and Research NSW Centre for Epidemiology and Research NSW Centre for Epidemiology and Research NSW Centre for Epidemiology and Research NSW Centre for Epidemiology and Research NSW Centre for Epidemiology and Research NSW Centre for Epidemiology and Research Queensland Health Queensland Health Queensland Health

which report rates from Australian Government data collections are presented in Table 1. Each study was explored thoroughly (including some discussion with those involved in the data collection and analysis on occasions) to understand how the data were collected and analysed, and how breast feeding was defined. The data have then been presented for different time points and definitions of breast feeding in a way to aid comparison. Using LSAC to explore national and state level breast-feeding rates To add rigour and ensure conclusions on rates were comparable nationally, we analysed data from the Longitudinal Study of Australia’s Children (LSAC) to obtain proportions of infants being breast fed. Previously it has only been possible to aggregate data Australian states collect themselves. This is highly problematic when definitions and questions are not the same. LSAC is a national survey of infants and children using interviews and standardised survey questions collected across all jurisdictions. The sample is selected from the Australian national medical insurance system’s enrolment database, with questionnaires and interviews distributed to a selectively stratified population. The sample is weighted to account for the probability of selecting each child in the study, and to adjust for non-response. To our knowledge the LSAC data have not previously been analysed to report and compare breast-feeding rates across jurisdictions. The LSAC study asks a number of questions about breast feeding. Wave 1 of the survey was distributed to selected families with an infant child (B cohort) in the period 2003 to 2004. The ages of these children ranged from 3 to 19 months at the time of the Wave 1 survey. The Wave 2 survey was used to follow up these same children 2 years later in 2005 to 2006. The determination of a child’s breast-feeding activity at 6 and 12 months of age required information from both Waves 1 and 2. The proportion of infants breast feeding at 6 or 12 months was therefore reported for the period 2003–2005. The data are not representative of lower socio-economic status groups (Donath and Amir, 2008) or younger mothers, and the reported proportion of women breast feeding is therefore likely to be an overestimation.

What did we find when revisiting the original argument? What women want The latest Cochrane review on breast-feeding support (Britton et al., 2009) confirms that women benefit from both peer support or peer and professional support in combination rather than professional support alone. Furthermore the recent metasynthesis led by Schmied et al. (2011a), emphasises that: ‘ysupport for breastfeeding occurs along a continuum from authentic presence at one end, perceived as effective support, to disconnected encounters at the other. The latter is perceived as ineffective or even discouraging and counterproductive.’ (Schmied et al., 2011a, p. 5). Research shows that women experience styles of support as either facilitative or reductionist in approach. Table 2 summarises the work led by Schmied et al. (2011a) and uses terms identified by others (Varcoe et al., 2003; Dykes, 2005) in a compilation of this work. The classifications offered in Table 2 can be further developed as crucial to successful sustained breast feeding; that is authentic presence; facilitative style; avoiding a reductionist approach and minimising disconnected encounters. Work by Sheehan (Sheehan and Schmied, 2011) and others report that many women, in Australia at least, do not receive the authentic presence from the staff employed to provide care. These are not the characteristics of care received by most Australian women, as only a minority of Australian women receive continuity of midwifery care models. We assume and would argue that women in continuity of care models have been shown to do better, at least on breast-feeding initiation (Hatem et al., 2008).

Historical breast-feeding rates (Victoria only) The Maternal and Child Health Service (MCHS) in Victoria is the only collection of annual data reporting breast feeding back as far as the 1930s. Data from 1950 to 2009 are shown in Fig. 1 describing ‘fully’ breast feeding at 6 months.

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Table 2 The continuum of support for breast feeding: from Authentic Presence to Disconnected Encounters. Authentic presence

Facilitative style

Reductionist approach

Disconnected encounters

Found to be supportive

Enabling women to learn for themselves ‘Realistic information’ including challenges Accurate, detailed information Practical and encouraging tips

Information given in a ‘dogmatic’ way Information/advice is conflicting

Undermining and blaming

Reflects trust and connectedness between the parties ‘Being there for me’ Empathetic Positive approach Took time, touched base–more evident in peer support than professional Reassurance and encouragement Responsive (tailored to woman), not ‘telling’ Shared experience Supporter shows interest in that individual woman Relationship built up over time

Care fragmented Information standardised and not appropriate to specific situations

Not pressurising Based on interaction and discussion – two way learning Offering practical help

Critical manner

Practical hands-on can be ‘intrusive and rough’ (woman as milk machine) and based on telling Pressurising Staff too busy

No relationship

Fig. 1. Breast feeding in Victoria 1950–2010 (NB data are missing from 1992–1993 to 1999–2000).

The Victorian data show that the establishment of the Nursing Mothers Association in 1964 (NMAA), a peer to peer support network, appeared to coincide with a change to the downward trend of breast-feeding rates. Over the subsequent decades the decline was reversed with a steady increase in rates. It could be argued that the woman to woman support that the NMAA was built on helped to reverse what in our experience suggests was professional inadequacy and misinformation rampant in the 1960s and 1970s. The data however, also show fairly static rates over the past two decades. Breast-feeding rates: national level data There is little national information. The papers on breastfeeding rates that we identified revealed considerable variation in definition, data collection methods, timing and analysis. The

National Health Survey (NHS) in 1995 and again in 2001 included breast feeding but the 2007 survey did not. In 2010 the Australian National Infant Feeding Survey was conducted on behalf of the Australian Government Department of Health and Ageing and results are expected at the end of 2011 (see Addendum). A summary of findings from available national data is presented in Table 3. Initiation of breast feeding or ever having breast fed seems to have increased a little over time. ‘Any at discharge’, and ‘any’ and ‘fully’ breast feeding at 3 months appears relatively constant. ‘Any’ breast feeding at 6 months seems to show a slight increase over time with ‘any’ breast feeding at 12 months being moderately consistent apart from the 2004-6 LSAC data. Information on ‘fully’ breast feeding at 6 months is sufficiently scant and varied to prohibit any general comment on trends.

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285

Table 3 National breast-feeding rates 1992–2006. Year

Initiated or ever (%)

Any at hospital discharge (%)

Any at 3 months (%)

‘fully’ at 3 months (%)

Any at 6 months (%)

‘fully’ at 6 months (%)

81.8

62.6

57.1

46.2

18.6

1992–5 1995

86

82

63.1

2001

87

83

64.3

54

48.9

32

53.3

51.0

13.0

2003/5

90.7

67.2

2004/5

87.9

64.4

2003/5

92

Any at 12 months (%)

NHS (Donath and Amir, 2000)

46.6

21.3

NHS 1995 (Australian Bureau of Statistics, 2003; Amir and Donath, 2008)

23 24.8

50.4 56

Source

NHS 2001 (Australian Bureau of Statistics, 2003; Amir and Donath, 2008)

24.9

Our weighted analysis of LSAC B cohort Wave 1 and 2

23.3

NHS 2004–5 (Amir and Donath, 2008)

28

LSAC B cohort unweighted (Australian Institute of Family Studies, 2007)

14

100 90

Percentage of cohort

80 70 60 50 40 30 20 10 0 Birth

1

2

3

4

6 7 5 Months of age

8

9

10

11

12

Fig. 2. Breast feeding: the first 12 months, B cohort (from Baxter, 2007). Source: Growing Up in Australia, Waves 1 and 2.

Generally, there was a pattern of decline in full breast feeding over the first few weeks of babies’ lives. The LSAC findings illustrate this, describing Australian National initiation rates of 90% reducing to 14% at 6 months (Baxter, 2007) (see Fig. 2). Our analyses of the LSAC data determined a child’s breastfeeding status for initiation and at 3, 6 and 12 months of age (‘fully’, ‘partially’, or ‘any’) from (1) LSAC Wave 1 data for children 12 months or older at the time of Wave 1 interview or (2) Wave 1 and Wave 2 data for children aged less than 12 months at Wave 1. The Wave 1 and 2 interview questions used for determining breast-feeding status were as follows: Waves 1 and 2 Wave 1 Waves 1 and 2 Wave 1

Was the child ever breast feed? Is the child still being breast fed? How old was the child when he/she completely stopped being breast fed? How old was the child when he/she had and milk or food other than breast milk?

Waves 1 and 2

Wave 2

How old was the child when he/she was first given infant artificial milk or other nonbreast milk regularly? How old was the child when he/she first regularly had solid food?

To calculate National and State breast-feeding rates (presented in Table 4 and in Fig. 3) we used the LSAC data which provided survey weightings to produce unbiased estimates of population parameters for geographic areas (Soloff et al., 2006; Australian Institute Of Family Studies, 2010) with the frequencies and crosstabulation procedures from IBM SPSS version19 statistical software. Similar unweighted analyses were also performed in order to compare with rates presented by Baxter (2007) who had not used any weighting (personal communication). Our analyses of the unadjusted rates for LSAC data are consistent with National findings reported by Baxter (Baxter, 2007; Baxter et al., 2009).

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Table 4 LSAC results—National and State breast-feeding rates. Year National NSW Victoria Queensland South Australia Western Australia

Initiated or ever (%)

Any at 3 months (%)

‘fully’ at 3 months (%)

Any at 6 months (%)

‘fully’ at 6 months (%)

Any at 12 months (%)

90.7 90.1 91.2 89.7 89.7 94.3

67.2 64.7 69.2 67.4 61.5 69.4

53.3 51.2 54.5 52.9 51.0 55.2

51.0 47.6 52.7 50.8 46.5 55.5

13.0 13.2 12.5 10.9 10.1 17.6

24.9 22.8 25.9 24.5 22.6 26.7

95% confidence intervals are available on request.

Ever breastfed

Any 6 mths

Fully 6 mths

100 90

Percentage of cohort

80 70 60 50 40 30 20 10 0

National

NSW

VIC

QLD

SA

WA

Fig. 3. Breast feeding by State from LSAC data 2003/4 for ‘ever breast fed’, ‘any’ breast feeding at 6 months and ‘fully’ breast feeding at 6 months.

Breast-feeding rates: state level data LSAC data were analysed on a state by state basis, which facilitated a comparison with the Victorian data shown in Fig. 1. Results are shown in Table 4. We used sample weighted logistic regression analyses, to compare the breast-feeding (Yes/No) response for at discharge, 3, 6 and 12 months amongst the five Australian mainland states NSW, QLD, VIC, SA and WA. The data in Table 4 show higher rates of breast feeding across all time points in Western Australia, lower rates in South Australia, with Queensland, Victoria and NSW being moderately similar. Significant differences between states occurred only for full breast feeding at 6 months (p ¼0.001) where Western Australia rates were significantly higher than all other states (NSW p¼ 0.011; Vic p ¼0.006; Qld p ¼0.000; SA p ¼0.002). Borderline differences between states occurred for ‘any breast feeding’ at 3 months (p ¼0.066) and ‘any breast feeding’ at 6 months (p¼0.052) from sample weighted logistic regression analyses, with WA again having the highest rate. As seen in Table 5, at state level, the NSW Midwives Data Collection reports some stability around any breast feeding at discharge, 86.7% in 2006, 86.8% in 2007 and 87.4% in 2008 (Centre for Epidemiology and Research, 2009, 2010a, b). These rates have been calculated with the denominator excluding respondents who did not report breast-feeding status. Although the earlier NSW Mothers and Babies 2005 Report (Centre for Epidemiology and Research, 2007) was very comprehensive, breast-feeding rates were not reported. The NSW Population

Health Survey provides data every 2 years from 2003 onwards and this shows some stability of full breast feeding at 6 months over this period of 25–27%. The Queensland perinatal data collection shows the same proportion breast feeding at hospital discharge for 2000–2004, which then gradually increases over time to 90% in 2008. Victoria’s MCHS Annual Reports consistently show a high proportion (around 38%) of full breast feeding at 6 months relative to the other States, and much higher than our analysis of the LSAC data for Victoria (12.5%). In contrast, the Victorian MCHS figure for partial breast feeding at 6 months is very low (a mean of 6.9% over the years from 2000/1 to 2009/10), compared to the LSAC state data which range from 34.4% for NSW to 39.9% for QLD with Victoria the highest at 40.2% (not shown here). Not all the MCHS data are puzzling however. For example the rates of ‘any’ breast milk at 3 months and ‘any’ breast milk at 6 months are similar to other reported rates. In addition to rates reported in Table 5, data from the MCHS in Victoria include interesting data showing that between 2000 and 2009 the ‘fully’ breast-feeding rate at hospital discharge has decreased from 79% to 73.1% and the rate for ‘partially’ breast feeding on discharge has increased from 4.6% to 13.5%, suggesting that women are breast feeding their babies in hospital, but increasing numbers are not ‘fully’ breast feeding in hospital. Whilst there are considerable inconsistencies in the data presented here, generally we are in agreement with the assessment of the Health Ministers’ Conference from 2009 that ‘Breastfeeding experts consider that breastfeeding rates have remained fairly static over the last ten years’ (Australian Health Ministers’ Conference, 2009, p. 9).

Discussion National data on breast-feeding rates are hard to compare either over time or from study to study, and it therefore remains surprisingly difficult to state breast-feeding rates in Australia with any certainty. Reliable national level time trend data and even comparisons between jurisdictions for Australian breastfeeding rates are not available due to the inconsistent use of definitions and methodological differences between surveys (AIHW 2009) (Australian Health Ministers’ Conference, 2009) p. 9. In Australia there remains no national monitoring of breast feeding, and therefore continued taxonomic challenges in tracking trends over time (and difficulties in appraising the impact of policy and increasing professional support for breast feeding), despite the publication in 2001 of recommended indicators (Webb et al., 2001). Hector (2011) provides a useful discussion of the difficulties of definition, and contributed to a National Breastfeeding Indicators Workshop (Canberra, December 2010) when the Australian Institute for Health and Welfare and the Department of Health and Ageing

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287

Table 5 State-wide breastfeeding rates over time. State Year data collected

Any breast- feeding at Discharge

NSW 1992–5 2001 2001–2 2003–4 2003–5 2005–6 2006 2007 2007–8 2008

78.4

Qld

1992–5 2000 2001 2002 2003 2003 2003–5 2004 2005 2006 2007 2008

84.1 86.3 86.1 86.7 86.6 82.6

1992–5 2000/1 2001/2 2002/3 2003/4 2003–5 2004/5 2005/6 2006/7 2007/8 2008/9 2009/10

82.2 83.6 83.4 83.6 83.9

Vic

Initiated or ever

Any at 3 months

‘fully’ at 3 months

Any at 6 months

‘fully’ at 6 months

Any at 12 months

89.8

60.0 60.5

56.6 52.7

44.2 42.6

87.1 90.1 91.1

69.1 64.7 68.1

64.1 51.2 58.8

53.9 47.6 54.5

17.2 15.1 14.2 24.7 13.2 27.0

28.5 22.8 27.8

89.8

69.0

58.8

54.8

26.3

28.3

63.8

56.3

47.7

19.2

52.9

57.0 50.8

17.9

86.7 86.8 87.4

86.8 87.0 87.3 89.5 89.6

93.7 91.7 89.7

95.3

91.2 84.2 85.3 85.3 86.1 85.8 86.6

69.1 67.4

10.9

59.7 61.7 59.2 58.6 57.6 57.7 69.2 58.8 60.1 60.4 61.2 60.5 61.0

56.0

54.5

45.0 45.2 44.1 43.1 43.9 52.7 46.7 45.9 46.0 46.9 45.6 45.6

31.9 32.0 24.5

33.3 18.3 40.0 38.8 37.9 38.2 12.5 37.0 38.7 38.0 38.9 37.9 36.9

25.9

Source

a b bb bb L bb bbb bbb bb bbb a c c c c cc L c c c c c/cc a d d d d L d d d d d d

Reference codes a NHS 1995 (Donath and Amir, 2000). b NSW Child Health Survey 2001 (Centre for Epidemiology and Research, 2002). bb NSW Population Health Survey (Centre for Epidemiology and Research, 2006, 2008, 2010a). bbb NSW Mothers and Babies 2006, 2007, 2008 excluding respondents who did not report breastfeeding status (Centre for Epidemiology and Research, 2009, 2010b, 2010c). c Queensland perinatal data collection (Queensland Health, 2010). cc Queensland Health (2005, 2007, 2010). d Victorian MCHS (Deptartment of Education and Early Childhood Development Victoria). L From our own analysis of LSAC data B cohort wave1 (2003–4) wave 2 (2005–6).

discussed what the appropriate indicators might be. The findings from this workshop were published in July 2011 (Australian Institute Of Health And Welfare, 2011) and include draft national indicators, definitions, calculations and point of measurement. This progress may lead to a more satisfactory national situation in the future. It is difficult to account for disparities in the Victorian data and this example illustrates the practical challenges of collecting and analysing these data, exacerbated by the complexities of definition. This is an area worthy of further investigation, however, as are the rates for Western Australia. If rates in these states are actually higher, there may be important lessons to learn. With these caveats, our assessment of existing data collections suggest that there has been no improvement in sustained full breast-feeding rates (at 3 or 6 months) in recent years, and possibly (looking at the Victorian local data collection) a slight fall in the proportion of women ‘fully’ breast feeding at 6 months. In understanding this we need to revisit the use of policy and professional support for women wanting to breast feed and rebalance this with understanding the assertion that: breastfeeding is more than the simple transfer of nutrients from mother to

child; it is, we argue, a socially constructed practice (Burns et al., 2010, p. 202). The history of support for women who want to breast feed In 2001 the NMAA became the Australian Breastfeeding Association with the purpose of being ‘ythe recognised Australian authority for breastfeeding information and support’ (Australian Breastfeeding Association, 2005). This goal appears to reflect a different orientation of the organisation. While justifiable, given the still poor breast-feeding rates, this public discourse suggests a culture of expertness conveyed by the organisation; with an authoritative expert stance becoming evident. Arguably 40 years of working with and learning from women builds expertness however the intimate and unique wisdom of breast-feeding mothers appears to be less valued in the public discourse. Of course this is possibly overstating a shift in orientation, but it is worth considering what might have been lost as well as gained by the public face of a stronger more authoritative organisation. The increasing numbers of highly qualified professionals specifically focused on supporting breast feeding in Australia is

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in addition to a universal, free service provided both in hospital and in the community. The development of a professional culture and credentials around breast feeding is demonstrated by the almost exponential growth of a new profession and association; the LCANZ. We argue that while well intentioned, this discourse demonstrates a growing emphasis on technical expertise supported by an examination structure rather than a social orientation or measures of social skills. Australia’s participation rates in this process of professionalising breast feeding are very high given we have universal, free services both postnatally and in the community. We have professionals educated in breast feeding who have this as a key role. Recent research shows, despite this, our routine performance as professionals can be poor and does not necessarily meet women’s needs (Dykes 2006; Sheehan et al., 2009). Perhaps the rise of LCs is a response to poorly designed institutions and fragmented services received by the majority of women, and staff who are subject to this. Implementing the BFHI policies in such institutions however is not likely to help practitioners who work in a non-authentic way and who are already exhibiting disconnected encounters though the design of services (Schmied et al., 2011a, p. 5). While breast-feeding expertise and consultants clearly remain an important source of support for women in specific situations such as a baby born with a cleft palette, prematurely, or twins for example, this expertise has become the mainstream. As a result, more and more healthy women with infants without health problems are being referred to lactation consultants while still in hospital or upon discharge. This, together with staff shortages and workload pressures, has led to the deskilling, and undervaluing of midwives and child and family health nurses who are not qualified as LCs and further devalued mother to mother support. More importantly it has contributed to an ever-increasing sense that breast feeding is technically challenging, that it is too hard to do without professional help. This is reflected in women’s anticipation that breast feeding is going to be problematic (Maclean, 1990; Schmied, 1998). We wonder what has happened to women’s confidence in themselves and their capacity in relation to this overwhelming barrage of professional help and institutional strictures that are increasingly put in front of them. These concerns have underpinned some further useful work over this last decade (Sheehan et al., 2009; Burns et al., 2010). What appears to be happening is that structural and professional reform might actually have the effect of diminishing self-reliance and excluding social peers who might actually be helpful to breast-feeding women. The Baby Friendly Health Initiative Australia has worked hard to try to increase the numbers of hospitals accredited as Baby Friendly (Walsh et al., 2010). Our analysis suggests that while some aspects of BFHI have been positive such as the stopping of direct marketing of infant artificial milk to women in hospital, the results are less than we would hope given the effort expended most particularly in the duration of breast feeding. Further any activity that institutionalises a social process and surrounds it with rules that diminish women’s own wisdom and confidence is problematic. As Walsh et al. (2011, p. 604) state we need to reduce the challenges for staff in aiming for BFHI accreditation, including a ‘discord between ‘informed choice’ and ‘mother’s choice’’. Time poor staff and poorly designed routinised services make authentic presence difficult to achieve. Given the empirical evidence that person to person support works (Schmied et al., 2011a), it is possible that midwifery led models of care, which have been shown to increase breast-feeding initiation (Hatem

et al., 2008), are more successful than the rigid application of BFHI. Policies such as BFHI imposed by managers can be perceived by staff as requiring them to take an over-zealous or rigid approach to the application of some of the 10 steps (Schmied et al., 2011b). Arguably this is less likely in women centred services such as case load midwifery. Bilson and Dykes have been critical of the top-down (‘scientificbureaucratic’) approaches to policy implementation and managing and producing organisational cultural change, which disregards that cultures are ‘ylocally accomplished and reproduced and can sustain practicesy’ p. 34 and are based on ‘yemotional, verbal and non-verbal’ (p. 34) interactions. They also suggest that underneath top-down approaches lies an assumption about causality, which does not reflect real-world environments where causality is complex and circular rather than linear. As a result, these authors argue for the implementation of BFHI to be approached in a way which is flexible, reflexive (including allowing for critical reflection) and emotionally engaged, with an emphasis on the people in the process not the rules. They propose that: ‘yattempts to implement BFHI will need to promote responsibility and vision of staff and parents rather than compliance with rigid procedures and practicesy’ (Bilson and Dykes, 2009, p. 39). We do not take issue with the 10 steps. The extension of BFHI accreditation however and expanding this to community settings is arguable. The more important factor seems to be redesigning services to put women at the centre and give staff time to assist women (Schmied et al., 2011b) through establishing professional relationships based on continuity and the capacity to develop facilitative rather than disconnected encounters. Research shows that:

 both peer and professional support are important for the

  

success of breast feeding and peer supporters are powerful role models, although there is also evidence that antenatal peer support with trained peers does not increase initiation of breast feeding compared to usual care (MacArthur et al., 2009); women expect support for breast feeding in the early postpartum period, and regard breast feeding as a skill, as something to be learned; health professionals often fail to provide the support that women need; previous studies have not been able to show which are the effective components of interventions, or to report women’s views adequately.

The recent metasynthesis also demonstrated that the most important elements of support comprise realistic emotional, alongside practical and informational, support (Schmied et al., 2011a). A qualitative synthesis by Mcinnes and Chambers (2008) suggests women have a preference for social or volunteer support networks and that emotional support is as important as practical and ‘informational’ support. Schmied et al.’s (2011a) metasynthesis confirms that women commonly report that health professionals have too little time to spend with them actively supporting breast feeding. The time is not available for them to build the kinds of relationships and ways of interacting that women report works best for them. Part of this picture might also include the pervasive idea of linear time on a postnatal ward, which clashes with the cyclical time that establishing breast feeding might require (Dykes, 2005) and can be provided in midwifery case load models. This is also seen in our own BFHI study of staff perceptions (Schmied et al., 2011b). The professional emphasis on policy such as BFHI and expert skills allows these barriers to go unrecognised or be missed.

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The professionalising of breast feeding—where are we a decade on? In 2001, a paper was published in which authors hypothesised that the increasing ‘professionalising’ (as they termed it) of breast feeding may have been having negative consequences for breast-feeding women. Further, that breast feeding was not a purely physiological process but a ‘ysocial, emotional or embodied experience where difficulties with breast feeding cannot always be resolved through clinical management that in the main, focuses on physiology.’ (Schmied et al., 2001 p. 48). Schmied’s (1998) work in the late 1990s identified that there was a fundamental paradox between her research findings of an identity as a ‘good’ mother linked to breast feeding, and contemporary models of womanhood linked to rational behaviour and autonomy including control over one’s body. This observation has been repeated by others including Stearns (2010, p. 21) who suggests that ‘ybreastmilk is, in fact, a commodity with high value in the construction of the good mother’, and Campo (2010, p. 61) who describes how ‘‘The requisites for subjectivity as they are defined and valued in contemporary society, such as autonomy and individualism, are at odds with the subjectivity of breastfeeding women’’. Schmied et al. (2001) argued, alongside others more recently, that breast feeding is a highly complex and uncertain phenomenon and is experienced by women in a wide range of ways. It was also suggested that the gradual co-opting of what was essentially an emotional and social relationship/experience by ‘experts’ appeared to be making breast feeding more difficult for women. Undervaluing ‘non-expert’ help and support from family members, friends and other breast-feeding women was professionalising a social experience and likely to result in iatrogenisis or medically induced problems. This is perhaps now exemplified in the title of a relatively new journal ‘Breastfeeding Medicine’, which exacerbates the ever-increasing notion of technical expertness. Most importantly it was argued that both women and professionals needed to find a new way to talk about breast feeding. For example for women to be able to express the harmonious, connected relationship that some experience and for others to be able to articulate the challenges to the known embodied self that breast feeding presented. A decade later we can now be more precise. An increase in empirical studies and publications, both by our team and others, allows us to revisit these propositions. Through an examination of subsequent evidence and nationally consistent data, we can suggest, albeit tentatively, that a professionalised approach may be counterproductive to increasing confident and sustained breast feeding. Conversely the woman to woman support network established by NMAA in the 1960s seemed to reverse a decline as might midwifery continuity models of care. We need to therefore understand the nuances that result from further rigorous institutionalising of breast feeding and increasing professionalising care and not assume this to be a good thing. The comparisons with increasing obstetric management of normal birth in Australia and elsewhere are insightful here. We create a ‘market’ and allow business opportunity in. Despite poorer results and an ever-increasing caesarean rate it is now difficult to contain costs and morbidity attached to the obstetric domination of normal birth. Similarly, paying for another professional to support breast feeding in normal circumstances, rather than relying on woman to woman support enhanced by one to one continuity of care midwifery, appears to add cost without increasing duration.

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Conclusion Our analysis of data from existing government collections, and the LSAC data has drawn into sharp focus the difficulties of sensibly interpreting national and state level data on breastfeeding rates. This then impacts on our capacity to assess the impact of efforts to improve sustained breast-feeding rates amongst Australian women. In the future Australia may benefit from consistency in definition, data collection and analysis approaches. At present however, it remains impossible to say with any confidence that the increased activity to support breast feeding is having a positive impact on duration of breast feeding amongst Australian women. It appears to us this might be related to losing sight of the embodied nature of breast feeding and the relationships that must exist between the mother and baby, the knowledge and skills women quickly develop, and a loss of woman to woman support. Replacing this with institutional regulations and limiting opportunities to develop authentic presence and facilitative relationships between caregivers, family and friends exacerbate this loss of recognition of breast feeding as a social/emotional/ embodied practice. Of considerable interest in Australia is that none of the points raised in our original article and subsequent publications led by Schmied following her research and more recently by Sheehan, appear to be adequately reflected in the new National Breastfeeding Strategy 2010–2015 (Australian Health Ministers’ Conference, 2009). If we continue to fail to make an impact on sustained breastfeeding rates then we are in danger of reproducing similar, unintended, negative consequences to those resulting from increasing obstetrician managed normal birth. Midwives, child and family health nurses, health visitors and others need to work with developing policy, institutional practices and service design that maximise positive outcomes for women and their infant feeding. We must be aware of risks repeating the experience of creating a plethora of highly trained professionals who actually increased morbidity in women and turned childbirth into a technically challenging and expensive event.

Conflict of interest The authors declare that they have no competing interests.

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