RECOMMENDATIONS ON BREASTFEEDING PROMOTION

A REPORT ON CONSULTATIONS CONDUCTED

with

PROFESSIONAL AND CONSUMER GROUPS AND INDIVIDUALS

Barbara Lusk with Maraea Rakuraku and Lina Samu

for the

Health Funding Authority

May 2000

ACKNOWLEDGEMENTS

My thanks are extended to the many people who willingly gave me time during this consultation. I wasconstantly impressed by the concern you expressed about the well being of mothers and babies and thepassion you had for trying to improve mothers' breastfeeding experiences. It was clear that the work youdo is more than a job. It is a calling and a commitment to those women and families you work with.

Barbara Lusk

He mihi nunui ki a koutou mo o koutou whakaaro, korero e pa ana ki tenei mahi, Ko Te Puna Hauora o teraki Paewhenua, Dr Jan Bryant, Judyth Hilton, Helen Bryant, Becky Fox, Riripeti Haretuku, HauoraWhanui, Te Hauora o te Hiku o te ika Trust, Maori team Child and Family Service ki Tamaki Makurau, TeKaha o te Rangatahi,

Ki nga wahine ma ko Jackie, Jocelyn, raua ko Becky Kia ora ra

Ki nga mema o Nga Maia o Aotearoa me Te Waipounamu, kia ora koutou mo o koutou korero whakaaro meo koutou awhina.

He mihi atu ahau ki toku whanaunga Harangi Biddle mo o whakaaro, tautoko ana ki tenei mahi.

Kia ora koutou katoaNa

Maraea Rakuraku

Thank you to all the Pacific people whom participated in this study

Malo fakaue lahi, Malo 'aupito, Vinaka, Meitaki ma'ata, Fa'afetai,Fa'ainalo fa'afetai tele lava.

Lina Samu

CONTENTS

1. BACKGROUND TO THIS REPORT

1.1Breastfeeding rates in New Zealand

1.2Parameters of this report

2. CONSULTATION PROCESS

2.1Questionnaire on Michele Lennan's recommendations

2.2Consultations with health professionals

2.3Format of interviews with health professionals

2.4Community focus groups

3. FINDINGS

3.1Responses specific to different ethnicities3.1.1 Pacific Islands3.1.2 European3.1.3 Chinese

CONSULTATIONS WITH MAORI: Findings and discussions

(Separate report with own page numbers inserted here)

3.2Regional and socioeconomic differences

3.3Identified barriers to breastfeeding

3.4Findings related to service specifications3.4.1 Consultation with key stakeholders to confirm

or amend Michele Lennan's recommendations3.4.2 Resources on breastfeeding3.4.3 Ante-natal classes3.4.4 Post-natal classes and support3.4.5 Professional training in breastfeeding theory

and practice3.4.6 Breastfeeding and employment

4. DISCUSSION

4.1The overlap between "public health" and "personal health"

4.2 Most women want to breastfeed

4.3Confirmation or amendment of Michele Len nan'srecommendations

4.4Ante-natal classes

4.5Professional training

4.6Breastfeeding and employment

5. RESOURCES AND STRATEGIES GAP ANALYSIS

5.1Provision of post-natal support5.1.1 Provision of free post-natal education5.1.2 A centre in the community for women to

access advice and education5.1.3 Closer liaison between professionals

5.2Identified resources and strategies• Resource on breastfeeding techniques with photos• Resource for women wanting to return to work• Printed resource for Chinese women and their families• Resource and radio campaign to promote theimportance of breastfeeding to family members• Resource and radio campaign to promote the nurturingof a new mother by friends and family• Creation of breastfeeding culture in Northland andAuckland• Creation of breastfeeding health promotion positions

6. RECOMMENDATIONS

BREASTFEEDING PROMOTION

1. BACKGROUND TO THIS REPORT

The main body of the report has been written by Barbara Lusk with the sections specific to Maoriand Pacific Islands being written by Maraea Rakuraku and Lina Samu respectively. While this hascreated three different styles within the one report we decided that this method would result infindings being presented in ways which were as true as possible to the kaupapa of the people wetalked with.

To show the reader who contributed which sections, we have used different fonts.

• General material including recommendations is in Anal.• Barbara's material on her consultations is in Anal• Lina's is in Courier New• Maraea's report is in Times new Roman and is presented as a whole, as she requested (between pages 10

and 11 of the larger report).

1.1 Breastfeeding rates in New ZealandIn 1994 the Public Health Commission documents recommended the following as New Zealandbreastfeeding targets:

"To increase breastfeeding at three months from 60% (1991) to 70% by 1997, and74% by the year 2000.

To increase breastfeeding (full or partial) at six months from 55% (1991) to 70% by1997, and 75% by the year 2000"

The 1998 Ministry of Health document, "Progress on Heath Targets" shows that thesebreastfeeding rates were not achieved. Plunket data for breastfeeding rates in Northland andAuckland over 1997,1998 and 1999, while not covering 100% of new mothers and their babiesand using different definitions from those in the Ministry of Health data, indicate that rates havepossibly not increased.

The Health Funding Authority has two contracts with providers with the objective of increasingbreastfeeding rates:

a) in Auckland and Northlandb) in New Zealand

These are summarised in the following section.

1.2 Parameters of this reportThe writing of the report was part of a contract on Breastfeeding Promotion between the HealthFunding Authority and Barbara Lusk Consultancy. The Service Objectives of this contract were:

1. To recommend and develop resources and strategies to promote breastfeeding in the Northernregion

2. To assess the barriers and opportunities for the promotion of breastfeeding friendly workplacesand public places.

The key tasks of the first stage of the contract were:

1. To consult with key stakeholders (i.e. regional Maori and Pacific providers, consumer groups,the Breastfeeding Authority and HHS Maternity managers) to confirm or amend therecommendations of the 1997 "Breastfeeding Scoping Project" prepared for the North Health(now the Health Funding Authority) by Michele Lennan (Appendix 1)

2. To determine what resources on breastfeeding already exist, to assess their acceptability andusefulness and identify any gaps

3. To assess what information is disseminated through ante-natal classes, the effectiveness ofthis and to identify gaps

4. To identify how teaching related to breastfeeding is included in the curricula of nursing andmedical schools

5. To consult key people in key government and non - government organisations to identifycurrent policies and conditions regarding breastfeeding and the workplace and makerecommendations re strategies to promote breastfeeding friendly workplaces and public places

6. To make recommendations about strategies to support and encourage an increase inbreastfeeding in the Northern region.

This report presents the findings from a series of consultations around these tasks carried out inMarch, April and May 2000 by Barbara, Maraea and Lina.

The next stage of the contract which follows after this initial consultation process is to develop andproduce key information or resources needed to promote breastfeeding to Maori, Pacific Islands,Asian and other women.

Prior to this, in 1999, the Health Funding Authority gave a public health contract to the NewZealand Breastfeeding Authority (NZBA) to advance the Baby Friendly Hospital Initiative (BFHI)(Appendix 2) The two main goals of BFHI are:

• To transform facilities providing maternity services and care or newborn infants throughimplementation of the ten steps to successful breastfeeding

• To end the practice of distribution of free and low cost supplies of breast milk substitutes tohospitals and health care facilities.

The two contracts are complementary in that the purpose of both is to increase breastfeedingrates.

2. CONSULTATION PROCESS

This report brings together the experiences and ideas from many people working in the maternityfield or having specific interests around related interests. In general comments are not sourced toparticular individuals or organisations, as this was not an audit but a process to gain an overviewof issues which impinge on breastfeeding rates in Northland and Auckland. Where relevant to thediscussion, organisations have been named.

The methods used to elicit information were varied. They included a questionnaire, meetings withhealth professionals and consumer groups and focus groups with women who had recently hadbabies.

2.1 Questionnaire on Michele Lennan's recommendations

Questionnaires asking for feedback on Michele Lennan's recommendations were sent by mail to30 key stakeholders in the NZBA using a list provided by the convenor of NZBA, Julie Stufkens.Some recipients took the opportunity offered in the accompanying letter to contact the writer withfurther comments. These have been added to the findings from the consultation.

Copies of the questionnaire were sent or given to Maori and Pacific Islands providers and HHSmaternity managers we visited.

10 questionnaires were returned by mail with a small number of other responses being returnedfollowing interviews.

2.2 Consultations with health professionalsThese consultations were carried out in a variety of ways. Appendix 3 has the names of thoseconsulted.

Maraea Rakuraku conducted interviews with Auckland and Northland Maori providers andidentified individuals. Lina Samu who is Samoan did the same within the Pacific Islandscommunities in Auckland.

The Pacific professionals consulted were from the Pasifika Healthcare Fono's Community HealthServices Team. Other Pacific providers were contacted but, although wanting to provide feedback,were unable to give time to meet with Lina because of their workload.

Interviews with mainstream providers and pakeha individuals were carried out by Barbara whoalso interviewed Chinese health professionals.

At the beginning of the consultation process Barbara attended the Lactation ConsultantsConference in Rotorua and spoke informally to participants about the ideas presented to theconference by the keynote speaker, Molly Pessl, President of the International Board of LactationConsultants and by other speakers.

Group meetings were held with managers and staff from several organisations.

Barbara and Maraea spent three days in Northland meeting with Maori Providers in Kawakawaand Kaitaia, Whangarei Hospital Maternity Unit staff, the Kerikeri Plunket nurse, Hokianga Healthstaff and a midwife from the Kawakawa Maternity Unit.

Some meetings with individuals were face to face while many of the interviews were done byphone.

Four people provided written comments and suggestions.

2.3 Format of interviews with health professionalsIn most cases a summary of the contract was faxed or emailed prior to the interview taking place.

An explanation was provided at the beginning of the interview about this contract being aboutpublic and not personal health issues. An explanation was given on what public health initiativescould include.

In many group and individual interviews the format was unstructured as the interviewees camefrom a wide range of involvement and experiences and it was found to be more productive to dothis than to keep to a predetermined structure.

Specific questions were asked on the issues to be covered with that group or individual as per thecontract clauses. eg childbirth educators were asked about qualifications of facilitators, length of

antenatal course, demographics of who attended, attendance of partners and others, thebreastfeeding content of their courses and how the messages were conveyed.

The interviews often covered more than one topic as the service specifications specified that wehad to consult the same people over different issues.

As well as specific questions relevant to their roles, everyone was asked what they thought wouldpromote breastfeeding and what they saw as the barriers to women successfully establishingbreastfeeding. They were also asked for suggestions on resources and strategies which theythought would promote breastfeeding successfully.

2.4 Community focus groupsFocus groups with new mothers in Auckland were facilitated by Maraea (two groups of Maoriwomen) and Lina (two groups of Pacific women). Karen Browne held a focus group interview withMaori mothers in Rawene. There were five participants in each group.

The women in Lina's groups identified as being Samoan (5), Tongan (3), Niuean (I), Tuvalu (1).Nine were breastfeeding and one had just stopped. Amongst the respondents there were twenty-five children who were breastfed exclusively on average to the age of 4-5 months. Children werebreastfed to an average of 10 months before the mothers relied on giving them formula and solidfood.

A structured instrument was used for these groups. (Appendix 4)

The sessions were two hours long. Kai was provided and participants were each given $20 inappreciation of their involvement.

3. FINDINGS

These have been presented under four main headings

1. Responses specific to different ethnicities2. Regional and socioeconomic differences3. Identified barriers to breastfeeding4. Key tasks as specified in the Health Funding Authority contract service descriptions.

3.1 Responses specific to different ethnicitiesAuckland is a multicultural society with marked cultural differences in patterns and practices ofparenting young babies. In Northland the population is largely bicultural. There are markeddifferences in the breastfeeding patterns between the two cultures.

Maori, Chinese, European and Pacific Islands health professionals and community women wereinterviewed. The following sections show the marked differences in breastfeeding beliefs andpractices which need to be recognised when making decisions about strategies and resources.

3.1.1 Pacific IslandsPacific women agreed that in their societies and amongst their families,they are used to seeing women breastfeed in their families as a naturalpart of life and have no qualms about breastfeeding their babies inpublic or wherever they need to be fed.

"There are ways to do things discreetly I mean I don't care Iused to be shy but my baby's needs come first!"

The Pacific women interviewed-said that the primary motivational factorsfor breast feeding their babies were:

• The message from the health professionals that "Breast is best". Thismessage which was found to be consistent by Pacific women amongst thehealth professionals and carried much persuasive power

• Breastfeeding is far less expensive and was the only option as mostwomen and their families struggled financially with more than onechild. This is a very important factor because several women citedthat their breast feeding experiences especially with their firstbabies was excruciatingly painful, however they had no alternative butto breastfeed their children because of their tight budgets

• Breastfeeding their babies, was more convenient than the "hassles" ofbottle feeding preparation

• Breastfeeding was crucial in building a stronger mother child bond inthe view of all the mother participants

• Breastfeeding was seen as "natural" and very much a link to culturalheritage.

"It was natural I saw my mother, my sisters, my extendedfamily back just pull out the susu (breast) in public andfeed the baby."

Pacific women do not use colostrum for their babies. This is expressedand discarded.

The main barriers identified to breastfeeding for the Pacific womeninterviewed were:

• The need to return to work because of financial pressure• The influence of family members such as mothers, mothers-in-law,aunts, friends to stop breastfeeding to free mothers up to earn moneyor to go and "enjoy life" and not be tied down by breastfeeding

• The lack of proper training and guidance given initially makingbreastfeeding experiences negative.

Some Pacific health professionals talked about how in the Pacificislands the whole family and village creates a totally supportiveenvironment for a mother who has just given birth. This is done by wayof providing meals and making sure that she does no strenuous work butjust focuses on producing the best breast milk she can for her baby.

It was recognised with the different lifestyles now in New Zealand andthe extended kinship links not being in force as much as they are in theislands that it is difficult to practise this support and so mothers areoften compelled to opt for bottle feeding. The cost of living andfinancial commitments such as mortgage/rent, food, clothing, power,phone, family, church and cultural obligations and other expenses oftenmeans that mothers have to return to work before they would prefer.

Women indicated that if they could have breastfed for longer they wouldbut financial pressure forces many Pacific women like themselves to re-enter the workforce. Many of those interviewed were homemakers and didtell that although they felt great about being able to stay in the homeand breastfeed their babies, they felt the stress of living on oneincome.

There was also mention of the gap in New Zealand's legislation in termsof providing paid parental leave

"I mean it's in the best interests of the economy to paymothers parental leave because we women are the backbone ofthe economy. The government should allow us as muchopportunity to care for and nurture our children withoutbecoming stressed and therefore stressing out our children,in turn making them and ourselves sick too."

On the whole breastfeeding was seen as best for first the baby and alsobeneficial for the mother in terms of:

• Helping to better help mothers' wombs heal and "get back into place"after giving birth as well as being a way for a mother to regain herfigure

• Breastfeeding was also seen as a natural contraceptive for many of thewomen.

Mothers consciously watched what they ate and drank and were careful notto take in things harmful to their children.

Several women noticed the marked difference in the health of theirchildren. Those who were breastfed seemed to be healthier than theirbottle fed children.

None of the women interviewed have or would have thought about feedingtheir children exclusively with breast milk mainly because of:

• Cultural conditioning i.e. our Pacific babies are bigger thereforeneed more food

• They felt that the messages coming from the health professionals isbreastfeed until 4-5 months old

Most Pacific mothers indicated that they are starting to feed theirbabies solids by four months because of the encouragement from healthprofessionals such as Plunket to start feeding solids around the 4-5month old age. There was also the belief that:

"Pacific Island babies are much more bigger than Palagi(Pakeha) babies and need that extra nourishment or elsethey'll go hungry!"

Pacific women found that often professionals advice and those fromfamily members and friends often conflicted but there was a tendency tolean more towards the professionals' advice because they "know whatthey're talking about." This is an indication of how many Pacificpeople place high value on the advice given by health professionals inpreference to that from significant others.

Changes in breastfeeding patterns are happening in Pacific Islandscommunities. Pacific professionals found that although the messages topromote and encourage breastfeeding on the whole were very positive,there was a noticeable trend in mothers who were born in New Zealand andexposed to the lifestyle here to bottle feed their babies.

The "show me how" face-to-face education is the way Pacific peopleprefer to receive information. Contrary to popular belief that Pacific

people will not read pamphlets, most do take notice of a leaflet if itis in a Pacific language and if it goes hand in hand with personalinteraction, messages will be effectively communicated.

3.1.2 EuropeanThe mothers of many New Zealand born "European" women of childbearing age were notencouraged to breastfeed because the thinking of the period when they had babies was thatbottle-feeding was better. It was easier to regulate the babies' feeding times and you could seehow much they were getting. So many European women do not have the experience of seeingfamily members breastfeeding. Many come from families with only two or three children and so donot have the experience of seeing their mother feeding younger siblings. These women have notbeen brought up in a culture where breastfeeding is the norm as have many Maori and PacificIslands women.

It appears there are differences in the patterns of breastfeeding amongst European womendepending upon factors such as economic status, education level, family experience ofbreastfeeding, concern about body shape and employment opportunities. A home birth midwifesaid that all women she delivered breastfed. Not explored in this consultation were thebreastfeeding practices of women from countries such as Holland and Germany who have settledin New Zealand.

The comment was made that many women who had very low incomes and were seen to be on orclose to the poverty level were the ones who tended to bottle-feed even although it cost aconsiderable amount. One respondent thought that women with higher incomes were more likelyto breastfeed even if they returned to work as they were more likely to be able to negotiatebreastfeeding or expressing arrangements. Some would also be able to take more unpaid time offwork although this was possibly not the norm.

Several midwives commented that they had delivered women who had made the decision thatthey would not breastfeed because they were concerned that their breasts would sag and be lessattractive.

3.1.3 ChineseVery few Chinese women breastfeed exclusively although some do mixed feeding. What happensdepends upon their country of origin. In China in the rural areas women will breastfeed. But in thecities the practice is to bottle-feed. The same holds for women from Hong Kong, Taiwan,Singapore and Malaysia. Negative beliefs about breastfeeding come from people's experience intheir country of origin.

Many beliefs and influencing factors responsible for the low rate of breastfeeding by Chinesewomen were identified:

• In the countries of origin a mother is allowed to rest for a month. Her baby will be taken fromher after birth so she can sleep. The practice is to discard the colostrum

• It is seen as too much trouble - especially in the establishment stage• The baby will wake up every hour whereas with a bottle it will sleep longer• Breast milk is too thin - it looks watery• You will have trouble weaning the baby• Families do not understand demand feeding and growth spurts• You have to stay home if you are going to breastfeed as it is embarrassing to breastfeed in

public• Grandmothers control what happens with a new baby and they tell the new mother to bottle fed• It is considered that some of the main foods used in Chinese cuisine can't be eaten if you are

breastfeeding eg cabbage, onions, broccoli• Many mothers go back to work very early leaving their baby with grandparents

. Chinese doctors recommend that women bottle feed.

The biggest barrier identified by the three Chinese respondents was that Chinese have the beliefthat if something is expensive it must be good. Formula is expensive whereas there is no cost tobreast milk. Also formula is considered superior because it has added vitamins and iron.

The Chinese health professionals spoken to were frustrated by their inability to change theirclients' beliefs and practices. They were hopeful that recommendations to the Health FundingAuthority would lead to resources in Chinese, which addressed the existing beliefs aboutbreastfeeding.

He mihi nunui ki a koutou mo o koutou whakaaro, korero e pa ana ki tenei mahi, Ko Te PunaHauora o te raki Paewhenua, Dr Jan Bryant, Judyth Hilton, Helen Bryant, Becky Fox, RiripetiHaretuku, Hauora Whanui, Te Hauora o te Hiku o te ika Trust, Maori team Child and FamilyService ki Tamaki Makurau, Te Kaha o te Rangatahi,

Ki nga wahine ma ko Jackie, Jocelyn, raua ko Becky Kia ora ra

Ki nga mema o Nga Maia o Aotearoa me Te Waipounamu, kia ora koutou mo o koutou korerowhakaaro me o koutou awhina.

He mihi atu ahau ki toku whanaunga Harangi Biddle mo o whakaaro, tautoko ana ki tenei mahi.

Kia ora koutou katoa

Na

Maraea Rakuraku

There is a whakatauki that translates into english as,

"when looking towards the future look into the past"

This whakatauki can take on a number of interpretations but in essence it means to striveconfidently into the future one must continually be guided and understand what has taken place inthe past. By doing so the repetition of mistakes is lessened and the future can be viewed withouthesitation and with optimism.

During the consultation process that took place in Auckland and Northland often I was reminded ofthis whakatauki, by those I spoke to. They spoke of needing the past to be acknowledged. Therewas a sense of wanting to place in context why behaviour today continues to be determined bywhat happened in the past. As one person stated,

"There needs to be a base knowledge of where we (Maori) have come fromto understand where we are heading. Why we are heading there and whatmakes us want to go there?"

The report itself was to be undertaken in a certain manner and adopt a particular format. Duringthe process of writing the report it became apparent to me in order to remain true to the findings ofthe consultation I must report all aspects of the consultation. Therefore eliminating any potentialmisunderstanding as to the context in which the findings were reported.

Reaction to consultation

There was a sense of frustration coupled with cynicism that yet another consulting process wastaking place,

"Here we go... another this is how we interpret what you say to make whatwe think you need in the first place"

Yet its value was recognised as being significant and vital in terms of ensuring the maintenance ofa healthy Treaty partnership.

All acknowledged the resources need updating. Ideas were brainstormed as people becameenergised. However, all consulted wanted it to be reported that pouring more funding intodeveloping resources was not necessarily going to improve or maintain breastfeeding rates forMaori. There existed more important institutional and pragmatic issues as recognised by therecommendations in Michelle Lennans 1997 Scoping report specific to Maori that needed to beaddressed.

This report may seem to deal primarily with personal health issues yet the point is for Maori thereare no differences between what is termed personal and public health.

The report is formattel in a way that seeks to acknowledge this whakatauki and pay tribute notonly to Nga wahine ma who contributed their time and whakaaro to this process but also to thosewhanau who have supported and encouraged their wahine to breastfeed despite a history of activepolicy dissuading Maori from doing so.

Format of the Report

The report is separated into two sections. The first section deals with the past the second sectionlooks at the present and concludes with what could be afuture.

Section 1 begins with is an outline of what occurred traditionally in terms of the birthing processfor Maori women. This is then followed by a brief overview of the effects of colonising policieson the well being of Maori and consequently breastfeeding.

Section 2 of the report then looks at the findings of the consultation. Michelle Lennansrecommendations are discussed separately followed by recommendations and conclusion.

SECTION

Nga Wa o mua

He wahine, he oneone, I ngaro ai te tangata

For women, for land, men die

The above pepeha illustrates the manner in which women were viewed. Survival of the collectivewas paramount. This survival was dependent on the nurturing and welfare of land and of women.Land provided the basic needs of sustenance in the form of food and shelter whilst the survival ofan Iwi was dependent on a woman and her ability to have children. Women at times were referredto as Te Whare Tan gata, which literally translates into, the house of man.

Traditional Birthing Te Kohanga Reo

As the birthing period drew near pregnant women were housed in a purpose built temporaryconstruction known as Te Whare Kohanga' some distance from the general population. The Wharekohanga then become the delivery suite and home for the mother, baby and attendants for a coupleof weeks preceding and following the birth.

As baby was being born a tohunga (expert) would be present at the birth reciting a karakia andwhakapapa of the child. Following the birth the whenua (placenta) would be retained and buried ina place significant to the whanau of the newborn.

The postpartum period was particularly important in the development of the relationship betweenthe new born and mother. Time away from the collective ensured the mother could focus on thewellbeing of herself and the baby whilst supported by attendants.

The final stage, was a formal welcome by the rest of the kainga to welcome the mother and newaddition back into the community.

The dynamics of Tapu and Noa2 governed the overall process.

According to Ranginui Walker,

"The power of tapu to control behaviour derived from spiritual beliefsconcerning human nature"3

As explained by Dune the balance between Tapu and Noa

"..dictated the limits for personal and community activities" 4

'Dune, M Whaiora Maori Health Development1994 Oxford University Press, Oxford2 Ibid

Walker, Ranginui Ka whawhai tonu matou Struggle without end1990 Penguin Books, Auckland

The Purpose

The underlying threat of sickness and disease was reiterated in the construction of other temporaryshelters in response to specific events eg the building of Whare mate, to accommodate dying ordead people again built some distance from the living quarters of the village. All were destroyedfollowing completion of their purpose. Again, the welfare of the collective dictated actions.

Through the processes of colonisation these practices were replaced by the practices of anotherculture and consequently this level of care within a Maori cultural context was removed.

B reastfeed ing

Breastfeeding was viewed as imperative in maintaining and sustaining a child's development andwellbeing. A well fed and looked after child was reflective of the health status of the hapu,whanau and Iwi. Because whakapapa is such an imperative component to the psyche of Maori ahealthy child ensured the continuance of generations.

Breastfeeding was such a valued practice its benefits were recognised in the social acceptance ofwet nursing.

COLONISATION

Two government Acts in particular had a direct impact on breastfeeding for Maori women. TheSuppression of Tohunga Act 1907 and the Native Health Act 1909.

Suppression of Tohunga Act 1907

This Act outlawed Tohunga, Maori experts. It prevented tohunga from practising in their areas ofexpertise ranging from knowledge of medicines to cure illness to knowledge of birthingtechniques. The passing of this act ensured that,

"...health care would be firmly based on Western concepts and methods."5

Native Health Act 1909

Maori women were forbidden from breastfeeding in public except for wet nursing non Maoribabies. According to Harangi Biddle the reason behind this Act was the 'offensive' bared breastand definitions of what determined 'modest' behaviour. Victorian based sensibilites and tikangaMaori were colliding head on.

The whole birthing process for Maori women was affected by the passing of these Acts and thesimultaneous attack on Maori social structures. Te Whare Kohanga were discouraged, tohungawere forbidden from practising and forced underground. Traditional practices were replaced.Maori women were placed in hospital for the period of their confinement no longer supported bywhanau or nurtured during the post natal period. Even the manner in which women gave birth was

4 Dune p9

subject to victorian beliefs namely being placed on their backs to give birth, some forcibly, ratherthan in the squatting position.

SUMMARY

The psychological damage was immediate as to the physical and emotional effects. Repercussionson the health and wellbeing of Maori women and their whanau continues to be felt today. Theaftermath has been no less than devastating. On close investigation of 'whanau' practicessurrounding breastfeeding some found their beliefs were based as a response to colonisedmethodology. The following is one such story, Because the 1909 Act outlawed breastfeeding forMaori women Maori mothers were encouraged to feed their babies a mixture of flour and water ina bottle. The reasoning, it looked like milk!! Through the following generations this practice wasaccepted. The reasoning became distorted resulting in the belief the mixture was given because itwas good for the baby!!

Nevertheless in spite of stories like the one above and the violent, consistent imposition ofcolonisation some Maori whanau survived the onslaught and have long histories of successfulbre astfeeding.

The advancement of diseases and consequently the fear of HIV, Hepatitis has further discouragedthe use of wet nurses within the Maori community.

The breakdown of Maori social structures has ensured whanau relationships are no longer there tosupport and encourage a breast feeding mother positively.

SECTION 2

Public Health and Private Health

During the consultation Maori were stating the realms of Public Health and Personal Health asdefined by the Health Funding Authority are too restrictive in terms of what Maori define as healthand wellbeing.

Within these definitions there is no acknowledgement of the model of health known as Te wharetapa wha6, a holistic model portraying health as the four walls of a house. The dynamics of Tapuand Noa are overlooked. Instead Maori interpretations of health are distorted to fit into a westernstructured model.

On another level the way in which programmes are funded has resulted in a very competitiveenvironment where providers are vying for the same contract. This is recognised by both providersand consumers as contributing to a hostile environment for consumers.

Providers feel this places them as Maori in a reactive rather than participatory position. Reactive tohostility created by the competitiveness, reactive to a system that confines Maori definitions ofhealth within a mono cultural framework and reactive to the situations of consumers.

Therefore the findings of the consultation cross over into what is defined as personal health. Thisis but a reflection of the environment in which the consultation was taking place.

More often than not Maori Health professionals would find themselves working within thepersonal health field with little financial recognition.

"The work is there and it has to be done, in the end the money does notmatter when you see these mothers.. .and the difficulties they are having"

Maori under the public system are subjected to questionable continuance of quality care. Thisseems to apply more generically to the Auckland region rather than the Northland areas. As oneHealth professional noted

Continuity of care from the LMC which more often than not tends to be theMidwife..........to whomever is required.

Consumers require and deserve clarity of post natal service provision.

However, providers agreed financial support and resources needed to be placed into existingservices rather than re-creating a service.

Success Stories

The vast geographical areas, limited access to shops to purchase formula and consistent serviceprovision is credited for the high rates of breastfeeding in the Hokianga, namely Rawene andsurrounding areas. Hauora Hokianga is the sole provider of maternity services in the area andconsumers feedback was positive and complimentary. The one negative experience of hospitalservices happened outside the area.

6 Ibid

Opinions of Health Professionals

Some professionals believe there is an unreal expectation placed on Midwives that they will teachBreastfeeding. Breast feeding is a time consuming activity with no financial incentive orrecognition of time spent in follow up.

"It is not logistically feasible for them to go to a lot of women and spendquality time showing them what to do"

However there is a recognition that midwives do the best they can within an under resourced, overworked environment. Maori midwives tend to spend a lot of their personal time in follow up. Partof the frustration felt by mothers with their midwives derives from a model of care that does notencompass breastfeeding education. By the time other services picked up the mother and babyproblems regarding breastfeeding had escalated and mother was formula feeding. Maori womenwho worked for Plunket and Maori health workers agreed that by the time they picked up a motherand her baby patterns had already being established dependent on the level of service receivedfrom the LMC. Many expressed dissatisfaction at this happening especially if the baby had healthproblems and was not being breastfed.

CONSUMER AND HEALTH PROVIDER FEEDBACK

Ante natal services

Within some areas of Northland attendance was low. Transport, cost of classes, vast geographicalareas were identified as contributing factors. Within Auckland social reasons were identifiedrather than financial reasons for non attendance by Maori.

There were suggestions the classes need to be more inclusive of variants on the definition of'partner'. The assumption the father of the baby will be involved places pressure on the pregnantwoman and consequently attendance of Maori at mainstream classes is low. Many wished toattend classes but found the atmosphere intimidating and non approving. A whanau oriented classwas preferred.

On Health professionals

Conflicting technical advice often without explanation eg latching techniques,

"I was told by my midwife to do it this way and by the nurses in hospital todo it another way"

Often the advice though positive was coupled with confusing behaviour.

One Maori mother shared her experience.

"My son was premature and I had made a conscious decision to Breastfeedwhile I was pregnant, I told all the nurses in SCBU (Special Care Baby Unit)that I did not want my son to receive anything but breast milk. In fact theyencourage you to Breast feed as the milk is so good for baby. One day Ireturned from a walk to find a nurse about to give my baby a bottle offormula!!"

Sharing Stories! wananga

As stated by a participant

Sharing stories about Breastfeeding is fine as long as the stories are positive

It was suggested that support be provided for those women who are bombarded by the negativestories..

Maori respond positively to the 'hands on' approach within a 'wananga' type setting whether it isconducted on a Marae or the rooms of a local hail. Wananga not only encompasses a temporaryphysical setting but also a Maori specific way of teaching. One professional suggested she wouldlike to see Dr Rose Pere's Te Wheke 7 model used. Maori teaching techniques and demonstrationsappropriate to a Maori audience was viewed as an effective, and preferred method ofcommunication.8

Timing

Rose Pere created a model of education known as Te Wheke.In 1999 Pehiaweri Marae, Whangarei conducted a wananga about Breastfeeding which involved kuia sharing stories and demonstrations of breastfeeding

Not only is it about producing resources but timing when they are introduced to the pregnantwoman. A consumer (Rawene) stated

HJ would have liked to have seen a video the day after the birth aboutBreastfeeding techniques?!

Many others suggested post natal mothers who are breastfeeding visit a day or so after the deliveryto talk through with the women issues and show them the different techniques. . It was suggestedby one Health Provider that the information is delivered within the school setting so by the timewomen start having babies they are already aware of the benefits and physiological changes thatoccur. Technique showing would not be necessary until after the birth. According to one providertoo often mothers are aware of the benefits but it is the education regarding technique and lack ofon call advice that will result in formula feeding.

Still according to one midwife an assumption is made that women are aware of the benefits.Women must be educated early on in their pregnancy as to the benefits of breastfeeding on a moreholistic level encompassing Te Whare Tapa Wha. Merely saying 'breast is best' creates pressureand unfulfilled expectations when a mother has sore nipples due to incorrect latching. Theliterature suggest decisions made during the first trimester dictate behaviour adopted by a postnatal mother. For Maori the impact of colonising policies need to be considered andacknowledged as contributing to the decision making process.

The Workplace

No provision was made for Breastfeeding women to express milk in privacy. One Maori womenshared her story regarding a work colleague

"The only place we could go to during our break was into the locker room.X would have to sit down one end of the locker room with her back to usexpressing milk while we all sat down the other end. I used to feel sorry forher"

There was also a reluctance to tell potential employees at job interviews that you had a young babyand that you were nursing. One woman recalls

"I used to advertise the fact I had a baby in my CV but I took it out as all thejob interviews I went to all the focus would be on how old the baby was, wasI breastfeeding ....1 never got the jobs, I guess they thought I would not be areliable employee because I had a baby"

Post natal support service

Services like La Leche were found to be supportive but identified as very monocultural and gearedmore for white, middle class women. Yet despite this one Maori woman expressed how thoughshe was taken aback by some of the 'cultural' practices she always felt welcome and validated inher decisions regarding breastfeeding. She was able to receive practical advice in a supportiveenvironment. One La Leche woman gave her a contact number she could ring any time if she washaving any difficulties.

La Leche featured predominantly in the conversations with urban based women. Cultural andsocial differences were viewed as major obstacles in terms of rural women accessing La Lecheservices

RECOMMENDATIONS

If resources are to be developed targetting Maori they must encompass the following aspects

Whanau wellbeing

Ko te kaunoti kei te wahine, engari te hika kei te tane tera

The receiving piece is with the woman but the fire-causing piece is with theman

The above illustrates that though female and male domains are separate. For the survival andmaintenance of the whanau co-operation between the two is required. The campaign must focus onthe whanau and particularly the benefits breastfeeding has on the health and well being of thewhanau, hapu and iwi. A material driven society and the effects of colonisation contributes to theneeds of a mother being overlooked.

• Education of the wider whanau is required of how to best support the mother. It isnot necessarily by removing baby from the household to give mum a rest but byallowing the mother time with the baby whilst household chores are undertaken.

• Education of the wider whanau will aid in the restoration of care towards Maoriwomen that existed before the imposition of colonialist laws. One healthprofessional explained colonisation was responsible for the removal of motivationfrom Maori. That, on one level education is required addressing the motivation tobreastfeed and parent successfully.

• Support a service that is inclusive of the father/ partner and the role he is to playin breastfeeding.

Tikanga Maori

There must be acknowledgement of Tapu/Noa, he whare tangata and all resources must bepresented and supported in a culturally appropriate manner.

All longterm strategies must involve continual and regular consultation withMaori

Consistent information across services

The resource must be consistent with information promoted by other services eg SIDS messages,Smokefree campaigns.

The Maori view of health is supported by the manner in which campaigns cross over eg SIDSvideo includes detailed advice on Breastfeeding.

CHOICES AVAILABLE

A number of proposals were made ranging from who should develop the resources to what thatresources should be. One suggestion was that,

• Funding is directed to Maori providers already working within the field. A numberof advantages exist in doing so. The resource is developed by and with the people it willdirectly impact upon therefore establishing 'ownership' of a resource.

• Promote and direct funding into supporting an existing resource.

EXISTING SERVICES FOR MAORI

In the course of the research I became aware of a belief/ technique being utilised resulting insuccessful breastfeeding rates and improving the health of Maori babies.

Whangai u

"Healthy baby, happy mother, happy father"

Whangai u is breastfeeding knowledge and a breastfeeding technique. It is part of the renaissanceguiding Maori to return to traditional modes of care specific to birthing.

Whangai u translates into english as the feeding breast. Whangai means to feed whilst II is a termfor breast. Whangai u encompasses a traditional Maori approach with practical knowledge andtechnique of breastfeeding. The appeal of whangai u lies in it's simplicity and approach. Maoribeliefs of hauora and wellbeing are incorporated, acknowledged and demonstrated practically.Whangai u transcends the barriers colonisation has created in terms of cross generationalknowledge of tikanga Maori. Maori women who have utilised Whangai u have reported bothphysical, emotional and spiritual benefits not only to themselves and the breastfeeding child(ren)but to the wider whanau. Empowerment on an individual and collective has taken place.

Background

The name was gifted by a Tuhoe kuia and owes its revival to the perseverance of Harangi Biddle.Biddle first received the knowledge from her kuia and has spent the past 10 years developing apackage and promoting its benefits. More recently Biddle gifted the package to Nga Maia oAotearoa me Te Waipounamu to be used by Maori midwives with knowledge of tikanga Maori in amanner appropriate to Maori.

Response to whangai u has been overwhelmingly positive. It offers a practice which encompassesMaori cultural beliefs in a manner significant and relevant to Maori women. As one womanrecalled,

"If only I had known this information 7 babies ago. Whangai u is the way togo"

Nga Maia o Aotearoa me te Waipounamu

A collective of Maori midwives formed in 1994 for purposes of professional development andcultural support. Nga Maia operates within a tikanga Maori framework advocating Maoridelivering services in a manner appropriate to Maori. Part of Nga Maia's commitment to Maori

and to the provision of an accountable service to Maori involves adopting Whangai U as apractice/ technique/belief into its structure.

Mothers who have had contact with midwives of Nga Maia utilising Whangai u have reported verypositive outcomes.

"Its like everything clicked with them... .I'd had Maori midwives before andpakeha ones but Nga Maia and whangai u works, it really works"

UPDATE OF MICHELLE LENNANS RECOMMENDATIONS

When discussing the recommendations with Providers all confirmed that since the report 'babysteps' had been taken.

Recommendation 2

Consultation with Maori is required,

"...to ensure that Maori are fairly represented and the views, the kaupapaaround Breast feeding are seen and known"

Recommendation 3

Within a kaupapa Maori research framework

Recommendation 4

Must take place within a Kaupapa Maori research framework

Recommendation 5

Within a kaupapa Maori Research framework

Recommendation 7

The media must be lobbied to prevent the portrayal of dummies and bottles

as the 'baby' article identifier. Continuing to do so contravenes the WHO code.

Could be aided by messages regarding breast feeding in public places for example Shopping Malls,Restaurants. The Public needs to be educated not to stare.

Mothers rooms must be removed from the toilet. This effects Maori in a particular as the eating offood in an area used for excrement contravenes beliefs of Tapu and Noa.

Recommendation 8

No provision within the workplace for breastfeeding mothers. Whether it is a comfortable roomand privacy to express milk or having a 10-15 minute break every 3-4 hours to express

Recommendation 9

Teaching Institutions require a regular update of knowledge so,

"The message and practice is consistent and congruent"

It is essential a Lead Maternity Carer has a certain level of Cultural Safety and the ability to applyit practically and proficiently within a Maori setting.

Upskill Midwives and those LMC's who require an update on BF knowledge

IDEAS FOR RESOURCES

POSTERS

Use whanau oriented pictures eg a father and children watching and cuddling mum whilst shebreastfeeds.

Or

A similar scene but in a public place eg a shopping mall.

Technical advice

Pictures showing babies mouths open. .the way they are open before latching

Or

A foldout chart with latching steps/how to hold the breast while feeding

TELEVISION ADVERTISEMENT

A group of men talking with pride about how their wife/girlfriend/ partner breastfeed/breastfed.

VIDEOS• Northlandlocal identities breastfeeding on location sharing breastfeeding

stories.• A group of kuia sharing stories about breastfeeding• Different generations of Maori women sharing stories about breastfeeding

CONCLUSION

Even though this consultation started off with very clear outlines of method and reporting as in anyinteraction involving people it has evolved into something unexpected and unique.

Consultation with Maori must always take so much more into account yet always results in a veryMaori interpretation. Boundaries set are redefined and readjusted to accommodate the distinctview Maori.

This exercise would truly have been beneficial and empowering to all concerned if the followingcomment by researcher Fiona Cram is considered.

"A question and answer that is imposed on a community is unlikely to leadto change whereas a question and answer that evolves in collaboration with acommunity might well be beneficial"9

Cram, F Ethics and Cross-cultural Research1995, Department of Psychology, University of Auckland

GLOSSARY

Hapu to be pregnant

Kainga village

Pepeha proverb,, moral

WhakataukiProverb

WhanauFamily

The quotes are from those who participated in the consultation.

Neither macrons or double vowels have been used in the writing of Te Reo Maori

3.2 Regional and socioeconomic differencesEven within cultures there are differences in breastfeeding patterns in different geographic areasand socioeconomic groupings. For example we heard feedback that many European women inlower socioeconomic groups bottle feed whereas European women with higher levels of educationand higher incomes had higher rates of breastfeeding.

Maori breastfeeding rates are considered to be higher in rural areas in Northland than those inSouth Auckland.

3.3 Identified barriers to breastfeeding"Most women want to breastfeed but things get in the way."

"Women stop when they don't want to because of problems."

There were several themes about barriers to breastfeeding which came consistently through thequestionnaire responses, interviews with health professionals and the community focus groups.They were common to responses from people of all ethnicities. The feedback from people aboutthe barriers to breastfeeding provides a guide to possible key interventions.

These problems or barriers were identified as:

Fragmentation of the maternity servicesEarly discharge of women from hospitalLack of support for women immediately postpartum to establish breastfeedingConflicting advice from the health professionals they meet with over the period in hospital andin the period followingSome LMCs not being proactive about promoting breastfeedingAntenatal classes not being appropriate for many womenThe isolation of many new mothers when they return homeLack of understanding and support from family membersThe influence of family members who recommend bottle feeding to the new motherA national culture which is not supportive of breastfeedingEarly return to work and workplaces which are not baby friendly.

Fragmentation of maternity servicesEarly discharge of women from hospitalLack of support for women immediately postpartum to establish breastfeeding

Although explanations were given at the beginning of each interview of the difference betweenIt health initiatives" and "public health initiatives", most people interviewed talked aboutthe Lead Maternity Carer (LMC) structure and its influence on breastfeeding rates. In fact it wasoften the first thing people wanted to talk about - and this without prompting. The constantfeedback from the range of people interviewed was that the current system combined with shorthospital stays means that many women lack the support in the weeks following birth to establishbreastfeeding successfully.

The following are just a small number of comments on the current situation. They come frommidwives, lactation consultants, private childbirth educators, Parents Centre educators, La LecheLeague leaders, Maori and Pacific providers, Plunket staff, maternity staff in HHSs, tutors intertiary education institutions, paediatricians and GPs. They reflect major concern with the currentmaternity system, not just for breastfeeding, but for the health of the mother and the baby.

"Post-natal care has got worse, not better, under the LMC"

"LMC system is a matter of luck. Whether a woman gets support depends on her LMC"

"LMC has not enhanced maternity."

"Continuity of care is important and it is not there."

"Variation in the contracts is a real problem......This is a national issue"

Concern was expressed time after time about the lack of support for women once they left thematernity unit. Many leave hospital as their breast milk is coming in which is seen as the timewhen they need support to establish breastfeeding.

"The first two weeks are especially crucial but six weeks are also crucial"

"Women continue to be short changed on the care and support they need."

"It's support, support, support, support that women need in those first few weeks.And for many women it's not there."

For Pacific women the advice to breastfeed was there but not the followup support to establish breastfeeding. All the women were encouragedstrongly to breast feed by their midwives, their Plunket nurses andtheir doctors. But most women in the focus groups felt that they werenot shown how to breast-feed properly which would have made thebreastfeeding experience more positive for them.

Most of the women interviewed had bad first time breastfeedingexperiences. Many talked about being determined to breastfeed whether ithurt or not because of the financial need to do so. They spoke ofstruggling for months with sore and bleeding nipples.

Most admitted that they felt like failures as mothers because

". you know I thought as a Polynesian woman thatbreastfeeding would just come naturally. I didn't realisethat you had to learn about it!"

A few of them were made to feel like failures in the hospital when theirbabies could not latch on to their nipples properly for feeding.

Most of the women had the feeling that hospitals, each time they wentgive birth to their children, tried to get rid of them much faster thanwhen their last child born. This was very apparent across the board -from a few mothers who had a large gap age difference between theirsecond to last child and their new baby, as well as the mothers who hadchildren one or two years apart.

"How are we meant to get the training and the advice we needto help us out when they kick us out too quickly!"

Mothers said they wanted to stay in hospital longer but were not giventhe opportunity.

Several people commented that it is not the early discharge which is problematic but thefragmentation of the services which leave many women unsupported.

"The short stay in hospital is not important. It's the team approach - everyonehaving consistent messages and style."

"Hospitals are inappropriate for many women but more intensive support isneeded."

Two examples of consistency of care resulting in high breastfeeding rates were discussed.

The midwifery practice associated with the AUT midwifery course has data which shows the clientbreastfeeding rate at 6 weeks is 97.5%. Midwives from this practice put this down to consistencyof care and a team approach where each midwife gives consistent advice about breastfeeding.They also make an average of nine postnatal visits to women.

There was a success story from the Hokianga which was confirmed by the Maori woman in thefocus group in Rawene. In the Hokianga, staff from Hokianga Health are also able to provideconsistency of care during a woman's pregnancy, hospital stay, postnatally till six weeks andthrough to Well Child care. Another family member is booked in with the woman when she comesfor delivery and this family member stays with the woman the whole time she is in hospital. In thisway there is whanau support for the woman when she leaves.

Many people were critical of the LMC services offered to women postnatally. It was reported byseveral respondents that they know of women who had only two postnatal visits from their LMC.One respondent talked of a woman who had had only one post-natal visit.

"There are access problems for women. We get women who are desperate - theyring their LMC and get no help."

"Some of the women who ring me only get 2 visits from the LMC. They come outof hospital and have problems with breastfeeding and say, "What's wrong withme." So many give up at two weeks. They struggle. Many feel their LMC is notbeing supportive enough. Visits are only 10 to 15 minutes."

"In one weekend we had three phone calls from desperate women who had justcome home and whose LMC had said to them on the Friday that she was goingaway for the long weekend and would be back on Tuesday."

There was a realisation by many respondents of the stresses on individual LMCs

"There is a lack of good post natal care. The pay is poor for postnatal care.Midwives are undervalued."

"A lot of midwives are suffering from burn out"

"It is difficult for a LMC midwife to watch a full feed because of funding so theyrefer them on to a Family Centre."

"Section 51 is severely underfunded for post natal."

There was general agreement by those who work with women antenatally that most women wantto breastfeed.

"If women have personal support in the first six weeks then they will feed."

Unfortunately many people reported that many women who expressed their intention tobreastfeed changed to formula feeding very quickly after going home.

"We have breasifeeding starting postpartum but dropping off very quickly. At sixmonths the rates are pathetic." (Paediatrician)

"We see high initiation rates and dramatic drop offs." (HHS Maternity Manager)

Plunket staff told of their frustration at seeing women for the first time when they were alreadyexperiencing breastfeeding problems.

"By the time we see them to give them messages about breastfeeding it is toolate."

"There is a gap between LMC and Well Child - this is the problem."

A former community nurse who is now the manager of a Maori provider expressed her frustration.

"When you got to the mothers very early there was a good breastfeeding rate.Now we see them at six weeks and it's too late. We used to be able to supportthem."

Concern was expressed by many people that unless the structural issues could be resolved, therewas limited benefit in general promotion of breastfeeding.

"Breastfeeding promotion on its own is not enough. Promotion of breastfeedingwithout support can lead to failure and disillusionment with breastfeeding."

"Knowledge alone is not enough. Women need support to be available"

"There could be posters and TV adverts to promote the idea of breastfeeding butsupport is needed for women once the child is born."

• Conflicting advice from health professionalsThis was mentioned by almost all respondents.

"The women in my antenatal classes always have a lunch after their babies areborn. The main complaint they have is about the conflicting advice they get aboutbreastfeeding."

"The greatest barriers to breastfeeding are staff ignorance, inconsistency of adviceand no real commitment to breastfeeding."

"Women see too many people around breastfeeding."

The mothers we spoke to were adamant that this was a major problem for them.

One woman spoke of going to the lounge area in her ward and finding a young woman in tears.

"She had been determined to breastfeed but the nurses on the ward had told herto give up trying and to bottle feed. She didn't know that there was a lactationconsultant available but when I told her this she contacted her and was able tobreastfeed."

From comments made by respondents it seems that this inconsistency in advice can result fromthe differences in breastfeeding policies and practices in New Zealand over the last forty years.

There are staff in all organisations who received their training several years ago when differentbreastfeeding practices were in vogue - or when bottle feeding was the norm.

"Many health professionals probably don't believe in breastfeeding."

"Some LMCs are lukewarm about breastfeeding."

Another reason was seen as the fact that in a maternity unit a woman can see several differenthospital staff in the two or three days they may spend in the unit. While a women with anindependent LMC may get good advice from her/him, they are likely to experience inconsistentadvice during their time in hospital.

From the other perspective, in the meetings with HHS staff we heard of the difficulty of monitoringthe practices - including the breastfeeding advice they give - of GPs and independent midwivesunder the shared care arrangements.

Assessment and/or supervision of all staff in an organisation was seen to be a necessary adjunctto inservice training. It was felt by several people that advice given on breastfeeding was not seento be as important as some other protocols and practices in a hospital.

"Compared with other medical techniques you seem to be able to do anything youbloody like with breastfeeding."

"If a nurse or midwife gives out inappropriate advice why are they not taken totask? They would be if they gave out the wrong drug."

There is recognition of the problem in the HHSs. They are putting in place several strategies toaddress these issues such as team care, orientation of staff when they join the Unit, compulsoryinservice days each year on breastfeeding and producing breastfeeding best practice guidelines.

Plunket has made breastfeeding a priority, providing regular inservice sessions on breastfeedingand auditing advice staff give on breastfeeding.

• Some staff and LMCs not being proactive about promoting breastfeedingMany women spoke about the LMC postnatal visits being short and the LMC seeming not to havethe time to help them. These comments were endorsed by several health professionals.

"Women speak of midwives not having time to teach breastfeeding. This is notappropriate."

While this is seen as not the universal experience it was identified by many of the respondents asbeing an issue of concern. Respondents recognised that it is not always possible for a LMC totime a home visit when a baby is about to feed.

Another issue identified by several respondents was that some LMCs did not ask women howtheir breastfeeding was going. They felt that this proactive approach should always be taken.

A similar comment was made about some staff in maternity units. Childbirth educators reportedthat some women talked of feeling that they shouldn't worry them as they always seemed to haveso much to do.

This is recognised by staff in hospitals as a difficulty. Time and time again the comment wasmade that to teach a women to breastfeed it is necessary to spend the whole feeding period withher and that time is not often available to them.

The lactation consultant positions in hospitals were set up to provide teaching opportunities forstaff but several people commented that a large part of their time was taken up with working withwomen in crisis with breastfeeding. This was seen by some as the ambulance at the bottom ofthe cliff whereas if time could be spent with each woman when it was needed man y of the crisissituations would not arise.

"The lactation role has changed. It started out as teaching health professionals.There was resistance to this. It has become damage control - to assist midwives."

Representatives from both Plunket and La Leche League spoke of the experiences of bothorganisations. Where previously their services were focussed on keeping breastfeeding going,now they deal with crises.

This was seen as a factor in the difficulty the Pacific women spoken tohad in establishing breastfeeding. Health professionals also talked ofseeing health professionals such as Plunket and their hard work formothers and home visits. Most saw weaknesses in terms of the messages ofthe benefits of breastfeeding getting out too late to mothers.

Several people made the suggestion that it would be useful for community educators/healthworkers to be able to visit women in the days they were in hospital to help with establishing arelationship. There was a recurring suggestion that lay people could be trained to give advice onbreastfeeding - that a clinician was not needed unless there were problems.

• Antenatal classes not being seen as appropriate for many womenIt was difficult to learn what percentage of women attend antenatal classes as they are offered bya range of organisations - both private and public. The publicly funded ones are run by hospitals,Plunket and Parents'Centre and Pacific providers. Private ones run by childbirth educators chargeparticipants fees.

Apart from classes provided by Pacific providers, in general, it is mainly white middle class womenwho attend ante-natal classes. Child birth educators and HHS staff spoken to said Maori andAsian women generally do not attend although one Parent Centre /Plunket educator spoke of themulticultural groups who attended her sessions and the language difficulties she encounters.

A suggestion made by several respondents was that many Maori and Pacific women trapped intopoverty, were facing a daily struggle to get through each day providing food and shelter - Maslow'stheory of hierarchy was mentioned several times as being a key factor in non-attendance.

It was posited by a respondent who works with many Maori and Pacific Islands women is that theconcept of "class" is too associated with school and lack of success for them to want to attend.

Some LMCs had single women who didn't attend antenatal classes as they saw the classes beingfor partnered women. Some hospitals recognise this as a problem and run classes for singlewomen.

There was a recognition by several respondents that pregnant adolescents need separate classeswhich are not always available.

• The isolation of many new mothers when they return homeWhen women live in an extended family situation this is not a problem. But there is a significantnumber of mothers returning home after discharge from a maternity unit who are alone in thehouse with a new baby. They may have other children to look after.

"Many don't have partners or if they do they are either at the pub, working orwatching sport."

In poorer socioeconomic areas they may have no phone or means of transport. Where visits bythe LMC are minimal and/or of short duration people were concerned that there is not the supportgiven to help women establish breastfeeding.

The Plunket Line restarted a 24 hour phone service recently and the HHSs offer a 24 hour servicealso. Some breastfeeding problems can be dealt with over the phone but we were assured thatmany women require practical help in person especially if they have left it for some time beforeasking for help.

Several respondents from La Leche League, Parents Centre, Plunket and lactation consultantstalked of how they would visit women in their homes after receiving tearful panic calls. This wasdone in a voluntary capacity. Several took prepared meals with them knowing how stressed themother would be.

• Lack of understanding and support from family membersOne of the recurring themes in the responses was the seeming lack of understanding of the needa new mother has for nurturing and help. Many women return home after a birth and are expectedto pick up the reins of running the house from the minute she walks in the door.

This is not the same in all cultures. In Chinese families everything is done for a new mother for thefirst month.

Good support from family members is given to Pacific mothers in thefirst month after birth.

• The influence of family members who recommend bottle feeding to the new motherThis was identified as a major factor by many of the people consulted. In some situations it maybe supplementary bottlefeeding, in others it will be the suggestion that she gives up breastfeedingtotally.

Several reasons were identified:

• The partner or other family members want to have the experience of feeding the baby

The baby is crying and the suggestion is made that the mother does not have enough milk

• Family members had the experience of being told that bottlefeeding was better thanbreastfeeding when they had their own babies

• The mother wants to go out socially or to shop

• The mother is tired and other family members tell her to rest and they will feed the baby

Pacific women interviewed felt that their families and friends oftentried to influence them not to breastfeed.

Grandmothers were keen to look after their grandbabies and send themothers out to work to provide a more comfortable living for the familyand also "breastfeeding cuts into your time you could be out doingbetter things."

A few of the reasons cited were based on ignorance for example a coupleof women had been told by aunts or mothers that they should stopbreastfeeding their babies after a certain age because it would

interfere in the sexual relationships with their husbands! partners.Another participant was told by a church friend who is a teacher that:

only those who can't afford formula and bottlesbreast feed."

Two participants who fed their babies up to two years were made to feelshamed by family members.

• A national culture which is not supportive of breastfeeding"As a result of social change, breastfeeding is not seen as important."

This lack of support for breastfeeding was seen to be shown in sometimes subtle ways. Baby-feeding rooms in public places have the graphic of a baby with a bottle on their doors - not abreastfeeding woman and baby. They are usually situated adjacent to toilets.

"We should be saying to councils and shopping mall management, "Would you liketo eat your lunch in the toilet?"

All of the women felt that although it was positive that majorsupermarket malls were making and effort to provide rooms for mothers tonurse and change their babies. However many said it was repulsive tohave these important facilities located in the toilets of the malls.

Women reported being given odd looks when they breastfeed in public places. While somewomen are prepared to put up with this behaviour from strangers, others find it puts them offfeeding their baby where others can see them.

Generally Pacific respondents found that messages from society on thewhole were supportive of breastfeeding, however there was mention of theway that mothers are sometimes made to feel ashamed of breastfeedingtheir babies in public.

A few felt that civil rights of mothers were violated if they wererefused permission to breastfeed their babies in some businesses andwere quite offended

"I mean what harm is it doing them! And this is the problemin New Zealand when there is so much shame surroundingwomen's bodies something like breastfeeding which is naturaland vital to a baby's health is turned into somethingshameful!"

Concern was expressed by several people that there is nothing about breastfeeding in the schoolhealth curriculum. Pacific Islands women who were consulted echoed this concern.

Some of the women felt that it was important that young women hear aboutthe benefits of breastfeeding when they are at school as many PacificIslands women have babies when they are young.

Some women are given packs from hospitals containing information on bottle-feeding. Some ofthis material is from commercial companies.

• Early return to workThe fact that only a few workplaces are baby-friendly and mother-friendly is another indication thatwe do not live in a breastfeeding culture.

A few women told of how relatives would bring the babies to theirworkplaces at lunch times to feed and how they would express milk beforework and at work for their children. One mother felt that their workenvironment was not a place where they could comfortably "look after aninfant".

"At church I can sit out in the hail and breastfeed but notin the hail at work. At work there isn't a place where I canlook after my baby to change him to feed him ..."

If a woman has not already given up breastfeeding prior to returning to work she may do so whenshe re-enters the workforce. The large number of mothers of young babies returning to work soonafter birth is a recent phenomena and indicates a major social shift which needs to be consideredwhen planning strategies to ensure that breastfeeding rates increase.

Several reasons were identified for the increase in women returning to work soon after givingbirth:

• Many women return because there is a financial imperative to do so. In some families thewoman is the only wage earner

• For some it is a lifestyle choice. They want to maintain the lifestyle which they had while therewere two incomes

• There is external pressure on many women to return to work as soon as possible. Thispressure can because they feel their career will suffer if they are away from their job for toolong.

• Some women in low paid positions fear they will lose their jobs if they stay away from work toolong.

One respondent reported that her experience is that women feel pressured to return to paidemployment by comments from others such as, "You must be bored being at home all the time."

3.4 FINDINGS RELATED TO KEY TASKS AS SPECIFIED IN SERVICE SPECIFICATIONS

3.4.1 Consultation with key stakeholders to confirm or amend the recommendations madeby Michele Lennan in the Breastfeeding Scoping Report (1998)There was endorsement of all the recommendations by everyone who responded.

Most comments made under each question are included in relevant sections in this report exceptwhere they are outside the scope of the consultation. These comments are:

Recommendation 1. BFHI status"That HHS Managers work with NZBA to have strategies for working towards BFHIin New Zealand and that there is assured ongoing funding to achieve this"

Recommendation 3. National data collection to monitor breastfeedin q rates"Data collection alignment could be promoted so all organisations collect the same -same definition of breastfeeding, ages of infants, ethnicity and location. Plunket hasexcellent data."

Recommendation 5. Database of current research"In one part of the country, they are unaware of the research and data in anotherpart which leads to constant "reinventing the wheel" and therefore wastedresources."

"The database of current research should include the tools, resources and trainingprovided for those working with breastfeeding women so that audited best practicesmay be used in other areas"

"The proposed database be "plugged into" other databases eg La Leche League,Centre for Breastfeeding Information, Lactation Research Centre and NMOA"

3. 4.2 Resources on breastfeedingResources were collected from the A+ Resource Centre, La Leche League, Plunket, HHSs.

A request was made to Public Health staff in other Health Funding Authority offices to send anyresources that they were aware of.

Most written resources collected were in English with few graphics and large blocks of writing. Theonly resource in another language was a hand-written and photocopied sheet in Chinese fromNational Women's.

We collected two Pacific Islands posters showing pictures of women and babies but withoutspecific messages about breastfeed ing.

The Ministry of Health have produced postcards and posters about breast being best and fastfood - once again with no specific message about breastfeeding.

The HHSs have developed their own handouts for clients with some also using the Public HealthCommission booklets, "Breastfeeding, Giving your baby the best you've got" (1994) and "HealthyEating for Babies and Toddlers" (1995)

La Leche League has a comprehensive supply of resources to cover breastfeeding issues. Theyare detailed and based on up to date knowledge of the theory and practice of breastfeeding.While not in an appropriate format for other than women who are fluent readers, they provide anexcellent source of information.

Plunket provides the booklet, "Thriving under five " to mothers, which has comprehensiveinformation for mothers on breastfeeding.

The Well Child/Tamariki Ora Health book which each mother should receive has a small sectionon breastfeeding.

All the resources mentioned above have blocks of words and few photos or graphics. As such itwould be difficult for many women to access the information in them.

All Pacific educators felt that the resources to teach breastfeedingwere inadequate and outdated. Resources such as posters, leaflets andvideos were used but they have become outmoded. One person said,

"Look we're working with copies of copies"

Pacific people need things to interact and learn with which would bemore effective. Although Pacific people are not really readers ofpamphlets most do take notice of a pamphlet if it is in a Pacificlanguage.

The respondents felt that a resource that was professionally andartistically presented would make a huge impact on Pacific people.

Maori providers we interviewed in Northland have produced their own resources for use by theirstaff. They used pictures and ideas from books and journals and then photocopied and/orlaminated them. Staff talked of having to fit the development of these into their other workbecause they were desperate for material and nothing suitable was available. They argued verystrongly that they be given the funds to develop their own resources because of their knowledgeof the local issues and what their clients respond to.

The gap analysis has identified the following areas of need:

• Information on breastfeeding techniques for low literacy women, in different languages• Information in different languages for women returning to work• Resource or strategy to promote breastfeeding to family members• Resource or strategy to promote the nurturing of new mothers• Information for Chinese mothers and families in Chinese about the benefits of breastfeeding.

More detailed recommendations follow later in the report after taking into consideration responsesto other sections of the consultations as these have a bearing on the recommendations.

3.4.3 Antenatal classes"Ante-natal classes provide support groups. We feed information aboutbreastfeeding all through them. Meetings afterwards show that 90% arebreastfeeding."

Antenatal classes are provided by a range of providers, Plunket, Parents Centre, HHSs, Pacificproviders, private obstetric practices and independent childbirth educators. In different geographicareas who the main providers are differs eg in South Auckland Plunket does not have antenatalclasses while they run classes in the North Shore and West Auckland. In Whangarei the HHS runclasses in the Plunket rooms and Parent Centre offers classes also. In Kaitaia there appear to beno classes provided.

Not all ante-natal education is done in ante-natal classes. In Kerikeri, Plunket run classes whichare attended by European women. Maori women in general do not attend the classes but thePlunket nurse visits them, often in their own homes. The reasons for non-attendance includes thatmany live out of the main centres of population in that area and may not have the money for petrol- or for warrants or registration and will not bring a car into town because they fear getting a ticketand having their car confiscated.

In Hokianga the midwives also do much of their ante-natal education with Maori women one-to-one in the women's own homes for the same reasons.

The pattern of who attends ante-natal classes differs considerably with the different HHSs.

National Women's Hospital runs ante-natal classes which are attended mainly by the clients ofother LMCs. Only some of their own clients attend classes. Staff felt this was because themidwives spent time at each consultation talking the woman through the birth process anddiscussing breastfeeding.

In Whangarei 40% of the births are to Maori women but only 20% of these attend the HHS ante-natal classes.

Some Pacific women spoke of attending classes run by their maternityunit. Pacific providers in a Auckland have been funded to provide ante-natal classes and find that women do attend - often with husbands orother family members.

The team of nurses at Pasifika Healthcare runs classes once a week inthe GP & nursing services. This differs from other ante-natal classeswhere educators - who may be midwives or nurses - facilitate the groups.The reason for nurses taking the classes is that there is the mindset ofmany Pacific people that doctors and nurses are still the "authority"when it comes to health issues. There may often therefore be resistanceto community health teams of educators in their experience. The classesare well attended by pregnant women and their partners or other supportpeople.

A team of community educators who work in their owrcommunity requests and conduct education sessionscommunity groups and church groups. They find thatmore and are more receptive to the message whenlanguage but they still encounter those who thinkmore valid if delivered by a palagi person.

languages respond toon breast feeding forPacific people relaxit is in their ownthe message would be

The staff at two HHS maternity units spoke of the difficulty they have with not knowing who hasattended an ante-natal class and who has not. They will know this for their own clients but not forthose clients with other LMCs. They see that attendance at an ante-natal class makesconsiderable difference to the readiness of women when they come into hospital for the birth. OneHHS manager expressed concern about women who delivered in their facilities who had no ante-natal education.

One HHS manager expressed frustration.

"Hospitals don't get paid if women don't attend. We are getting out of it. We aresubsidising our ante-natal classes from our other maternity services."

Many ante-natal classes are facilitated by women with training in facilitation techniques. Severalspoken to had done a course from Aoraki Polytechnic in Timaru and had obtained a Certificate inChildbirth Education. This comprehensive course provides training in facilitation and learningstyles as well as factual maternity related information including breastfeeding. The cost isconsiderable - $2,500 plus travel costs.

Pacific clinical professionals from Pasifika Healthcare have receivedindepth professional development training from professional experts i.e.lactation consultants and specialists in breastfeeding and other areas.The community health workers and educators have no formal education assuch but are given once again indepth inhouse training to work amongsttheir Pacific communities.

La Leche League leaders do comprehensive training at their own expense to gain La LecheLeague Leader Accreditation. They have to buy their own resource manuals.

Some facilitators from mainstream organisations are midwives and some are not. Several peoplemade the comment that facilitators needed the ability to work with groups effectively - being amidwife was not sufficient. The thought was expressed by several people interviewed that thefacilitator needed to have experience of breastfeeding their own children.

Some classes are held in hospitals, some in Plunket rooms, Parents Centre rooms, communityhouses and some in private homes. Hospitals are considering or are already taking the classesout into the community, using GP rooms and community houses in an attempt to make them moreaccessible to women.

Partners or another family member are encouraged to come with the woman and most women docome with a support person.

Most ante-natal programmes are six, two hour sessions. Breastfeeding information is always acomponent. This subject is usually given about 1.5 to 2 hours. The timing of it varies from at thebeginning of the course to towards the end.

There were differing opinions on where it should be placed to make the greatest impact. Somerespondents, not childbirth educators, felt that, ante-natally, women are focussed on the birthingprocess and are not interested in breastfeeding however this opinion was not supported by mostrespondents.

The information is given to women in different ways - by lecture, video, question and answeractivities, the use of dolls for women to practice positioning of the baby during breastfeeding.Resources were available for women to take home.

The educators at Pasifika Healthcare were proactive in promoting the"breastfeeding is best" message. In terms of the recommendation forpromotion of exclusive breastfeeding to mothers encouragingbreastfeeding only to up to six months, it was felt that this was arecommendation appropriate to the needs of non-Pacific babies as Pacificbabies were much more bigger in size.

Their main message is to promote breastfeeding as the most beneficialand cheapest option for Pacific mothers, families and their babies. Alsoto breastfeed for as long as they can.

They teach healthy eating and sleeping for mother, correct positioning,attachment and latching, how to take care of cracked nipples, expressingmilk, when to feed baby, reading baby signs, feeding on each side.

Several women attended antenatal classes with their husbands and saidthat the use of baby dolls was very helpful in teaching them the skillsof positioning the baby for feeding.

Most childbirth educators spoken to said they thread ideas about breastfeeding throughout thesessions. If a woman wanted information about bottlefeeding it was not provided during the classbut afterwards on a one-to-one basis. Posters or information on bottle-feeding were not displayedalthough material was available for women who wanted information on this.

One respondent felt there was opportunity for people from other organisations e.g. Plunket and LaLeche League, to be invited to speak to the groups to explain the services they offer women post-natally and to provide a link between maternity care and Well Child.

Very few used the idea of peer education where a breastfeeding woman feeds her baby andanswers questions. La Leche League do not run ante-natal classes as such but pregnant womenattend La Leche League sessions with mothers who are breastfeeding. La Leche League leadersfeel that this type of peer education is the best way of encouraging and supporting a woman whohas not breastfeed before.

"Pregnant women and women with babies - this is a critical factor. This is a modelwhich we use which could be used more widely."

Many other respondents reinforced this idea of women teaching women. If a woman can see apositive breastfeeding experience it encourages them to breastfeed.

"It is the idea of an old-fashioned apprenticeship - this idea of an ante-natalwoman learning from a post-natal woman."

"Women learn from other women. It's recreating the biological environment whichis the normal way for women to learn."

Many people interviewed about ante-natal classes talked about the changes in society meaningthat many European women had not had the experience of holding a baby or of seeing anotherwoman breastfeeding.

"If they have never held a baby before it is very difficult. Tackle this duringpregnancy. Have one to one matching with a mother who has a baby."

Another issue which many respondents referred to in connection with ante-natal education wasthat it was important not to present just the romantic view of breastfeeding but to give a realisticpicture of the difficulties that can happen. This is done in most classes. A childbirth educatorbelieves that the facilitator needs to be able to problem solve.

"Breastfeeding is a process. It takes time to persevere."

South Auckland is looking at setting up small ante-natal groups just on breastfeeding. A group ofobstetricians whose clients go to ante-natal classes provided by other providers offers clients asession on breastfeeding run by lactation consultants.

Waitemata Health provides classes for men run by a man at a cost to the men.

Respondents who had contact with women who attended ante-natal classes saw the classes asan important component of the preparation a woman has before birth and mothering.

3.4.4 Post natal classes and supportFeedback from many people was that it would be useful to have more education aboutbreastfeeding post-natally.

While not a requirement of this contract, questions were asked respondents about what servicesthey offered post-natal groups.

Molly Pessi, the keynote speaker at the Lactation Conference gave information about the post-natal support they provide for mothers at her facility, Evergreen Hospital. Washington, USA. Onday 4, 99% of mothers come back for a head to toe examination of the baby. One day a week 300mothers and babies come back to the hospital for post-natal education groups. These continue fora year and most mothers and other family members, continue to attend weekly. A range of topicsare discussed including child development, infant feeding, parenting, relationships with partnerand other family members. Continuation of breastfeeding is constantly promoted and the groupssessions are used to discuss and resolve problems.

"Mothers need support for breastfeeding and they need it often."

She reported the breastfeeding rates for her hospital as being 90% at three months, 84% at sixmonths and 76% at 12 months. The breastfeeding rate on discharge from her Baby FriendlyHospital is almost 100%. She attributes the continuing high breastfeeding rates to the post-nataleducation groups.

La Leche League sessions provide education and support groups for post-natal women. They arefacilitated by La Leche League leaders who train and work voluntarily. In addition coffee morningsare held and leaders provide a 24 hour phone service. Breastfeeding rates of women who attendare very high.

Several Pacific women in the focus groups had very positive and helpfulexperiences of seeking advice from La Leche League helpline when theyhad no-one else to turn to in the middle of the night.

La Leche League is finding that, with changing social patterns, there are fewer women available totrain and work as leaders. This is limiting the number of women they are able to assist withbreastfeeding.

HHSs offer post-natal group sessions for which the women have to pay as the Health FundingAuthority does not fund these. Numbers for these are generally low.

Twice a week Waitemata Health provides sessions on breastfeeding taken by a lactationconsultant for women while they are in hospital. Women who are not in hospital over that timemiss out.

Parents Centres offer a six week post-natal course which women pay for as they are only partiallysubsidised. They start at three weeks and by then many of the women are struggling withbreastfeeding. These women are referred to La Leche League and to Plunket Family Centres.

Plunket Family Centres are often used by women with breastfeeding problems for one to oneconsultations. Plunket is not funded for this service until three weeks or later - depending on thearrangement they have with the LMCs. They are constantly faced with the dilemma of meetingrequests for service for which they are not funded. This is not just the situation in Northland andAuckland. Maureen Easterbrook, a Plunket nurse from Thames Valley gave a presentation at theLactation Consultants conference outlining Plunket's role in breastfeeding.

"Plunket is generally funded to care for babies from 6 weeks of age. We are oftenfaced with the quandary of a first visit where a mother has either abandoned theirbreastfeeding or has established inappropriate patterns which will hinder thecontinuation of breastfeeding."

3.4.5 Professional training in breastfeeding theory and practiceKey staff in the following tertiary institutions were consulted:

• Auckland University of Technology• Manukau Institute of Technology• UNITEC• Northland Polytech• Auckland School of Medicine

Discussions were also held with the Plunket National Clinical Educator responsible for the trainingof new Plunket nurses.

• Preservice training for midwivesMidwifery training is done at AUT. An independent midwifery practice operates from the AUTNorth Shore campus and students spend time with the practice midwives throughout the course.

In year two there is a comprehensive section on breastfeeding - 40 hours of classroom work, 70hours of self directed learning and 40 hours of practice - a total of 150 hours. The module focuseson the physiology of lactation and establishment of breastfeeding. The history and politics relatedto breastfeeding are addressed. A section on infant formula is included in the module.

Considerable time is spent during the course gaining clinical experience. This includes practicalwork with breastfeeding mothers.

• Inservice training for independent midwivesMany independent midwives do the Lactation Consultant qualification or access update coursesoffered by polytechs. It seems that there is no requirement for specified inservice training inbreastfeeding or other clinical subjects for independent midwives.

"People have to be motivated to go to do something."

• Preservice training for nursesTutors spoken to from the four organisations which provide degrees in nursing felt that, while theycovered breastfeeding in their courses, not enough time was able to be spent on the topicbecause of pressures within the curriculum.

•AUTThe breastfeeding component of the course is in year three and consists of one and a halfhours on the physiology of breastfeeding, one and a half hours on the application of thetheory including safe methods of breastfeeding. The participate in a debate on"Breastfeeding is best". Breastfeeding is discussed in the section on the immune systemand developmental physiology when the advantages of breastfeeding are covered.

• Northland PolytechThe course at Northland Polytech is the same as that offered by AUT with some variations.The theoretical subject is taught at year 3 with students doing a case study on a pregnantwoman. They look at the birth plans and then follow her through her pregnancy, birth andpost-natally. They are buddied with a midwife either in the hospital or independent. Theyspend time with Plunket nurses.

• Manukau Institute of TechnologyThree hours is spent on breastfeeding theory in year three which is seen as far fromadequate. The ideal is considered to be six to eight hours. 37% of the students arebetween 40 and 45. Many have preconceived ideas on breastfeeding and time is needed toexpose them to evidence based research.

It is considered that students have sufficient practical experience in situations wherebreastfeeding is covered. They have 20 days of clinical practice at one of the localmaternity units or with a Plunket nurse. This will include time working with post-natalwomen.

• UNITECSpecific theoretical content relating to breastfeeding consists of a one hour lecture and twohours tutorial in second year. Students are required to complete a study guide which coversissues of breastfeeding such as benefits for mother and child, benefits of colostrum, basicprinciples of breastfeeding, community resources available to women, expressing. Topicson infant milk formula feeding is also included in the study guide. This includes theWHO/UNICEF international code on marketing breast milk substitutes, reasons whywomen don't breastfeed and composition of formulas.

Each student relates theory to practice by "walking through a pregnancy with a woman."There may be some students whose woman does not breastfeed.

• Inservice training for staff in maternity unitsBecause of concern about conflicting/inconsistent breastfeeding advice mothers receive, HHS5are providing annual compulsory inservice on breastfeeding for staff who work with new mothersand their babies.

At National Women's Hospital the Breastfeeding Support Module consists of a study day,completion of a workbook and a clinical audit.

• Certification of Lactation ConsultantsMany Plunket nurses and midwives are choosing to become IBLCE accredited. This requiresthem to complete 30 hours of breastfeeding related education plus practical experience withwomen and babies.

• Plunket nurse preservice trainingPlunket nurses complete a Graduate Diploma in Community Child and Family Health Promotion.This is a 40 week level 6 course combining practical experience with distance learning and ninedays of residential group learning. There are 12 learning modules with breastfeeding being amajor component throughout. Part of the formative assessment for candidates involves clinicalassessments including home visits and clinic situation. It has been calculated that in all there are320 hours of the course which involve breastfeeding theory or practice in some way.

Plunket nurses are registered nurses who do advanced training. All do an eight weeks orientationwith an experienced Plunket nurse before coming on the course.

Many are Maori and Pacific Islands who see this role as being one which gives them theopportunity of working in the community rather than in a hospital.

Staff from other providers attend the course and gain the Diploma. There is significant cost to thisfor the providers

• Inservice training for Plunket nursesEach Plunket nurse attends four days of inservice training annually with breastfeeding updatebeing a major part of this.

• Medical training

• Auckland School of MedicineIn the 0 &G, neonatal programme, 5th year students have a teaching session onbreastfeeding. The theoretical teaching is done in tutorial groups of approximately 25students. The Lactation Consultant from National Women's Hospital has half an hourlecture to cover the topic. Handouts are provided.

Students spend times on the wards. A very small number have chosen to go with theLactation Consultant as she meets with women on the wards.

Senior House Officers at National Women's Hospital attend an hour lecture once a weekon different topics. The lecture presented by the Lactation Consultant covers historicaltrends in breastfeeding, the debate on identifying the trigger for natural weaning, newresearch on breast development and discussion of practical steps to overcome perceivedor actual breastfeeding problems.

Registrars do not receive formal training in breastfeeding apart from what they receive onthe wards.

Very few GPs now are involved in maternity services. This is reflected in the small numberwho enrol into the Diploma of Obstetrics course offered by the School of Medicinecompared to pre the LMC changes. 80% of people attending are from overseas and will notbe practising in New Zealand.

• Other medical education

The Goodfellow Unit at Auckland School of Medicine has traditionally provided ContinuingMedical Education (CME) for GPs but now does minimal education as IPAs have nowtaken over this role. From discussions with GPs it appears that, because of the non-involvement of GPs in maternity care, courses in breastfeeding are not being offered.

Several people said that it was probably more important to offer breastfeeding courses topractice nurses.

3.4.6 Breastfeeding and employment issuesWith many women returning to work within the first months after birth, the issue of being able tocontinue breastfeeding while working was identified by many of the respondents as a key issue.One respondent referred to research which suggests that breastfeeding is not truly establisheduntil five to six months and that women who return to work earlier than this may have their abilityto maintain breastfeeding compromised..

"A lot of the problem with trying to improve breastfeeding rates is to do withbreastfeeding falling apart when she goes back to work. It is overwhelming."

Those few Pacific mothers in the two focus groups who did have theexperience of working and trying to breastfeed found that theirfamilies', work place's and colleagues' support was vital in helpingthem to continue their choice to breastfeed their babies.

Paid parental leave was seen by many respondents as being a key issue in women being able tocontinue to breastfeed. As many women return to work quickly because of economic necessity, itwill assist these women to remain at home for a longer period.

Information from the Minister of Women's Affairs was that paid parental leave legislation shouldbe in the House in the first half of the current term.

Information from the Ministry of Women's Affairs was that paid parental leave is an Alliancepriority but the issue, is very complex and decisions will not be made quickly. Negotiations aretaking place with several Ministers. These Ministers are consulting widely with a wide range ofemployers.

There are some baby-friendly workplaces in New Zealand but the vast number of womenreturning to work would find it difficult to continue to exclusively breasifeed because the facilities inthe workplace for feeding or expressing and the time to do so are not available to them.

To explore this issue further the following organisations were contacted:

• EEO Trust• Human Rights Commission• Department of Labour• Ministry of Women's Affairs• Employers and Manufacturers Association• Industrial Relationship Services• Shell• PriceWaterhouse-Coopers• Westpac

TO Bevan whose Masters thesis (University of Otago) was on the economics of breastfeedinggave input to the consultation.

• Department of Labour

Material sent from the Department of Labour gave a summary of the existing labour marketpolicies relevant to women who want to breastfeed on return to work. (Appendix 5)

The advice from the Department of Labour follows:

"Government employers are required by the State Sector Act to be good employers and developan EEO programme, which seeks to achieve the following three conditions:

1. Inclusive, respectful, and responsive organisational cultures which enable access to work,equitable career opportunities, and maximum participation for members of designated groupsand all employees;

2. Procedural fairness as a feature of all human resource strategies, systems, and practices; and3. Employment of EEO groups at all levels in the workplace.

EEO initiatives have, since 1990, largely involved the promotion of the benefits of voluntaryemployer provision of family-friendly policies. The Government has recently indicated that it willconsider options related to providing some legislative framework related to EEO obligations in thenear future.

The Department recommends strategies to promote breastfeeding friendly workplaces and publicplaces. They suggest that a key element to maximising the effectiveness of strategies to promotebreastfeeding friendly workplaces is ensuring that this information is available through locationsthat are most likely to reach all employers as well as employees who are likely to be breastfeedingin the near future. For example, key locations for delivering this material would include the officesof health providers such as doctors and midwives. Any material promoting breastfeeding friendlyworkplaces should discuss the benefits of such workplaces to both employees and employers, aswell as practical advice on delivering breastfeeding friendly workplaces.

The Department also suggests that it is important that information be provided to a range ofemployees. The Department is aware of anecdotal evidence that claims that low levels ofbreastfeeding amongst Maori and Pacific women are affected by these groups returning to workrelatively earlier than other groups. For these employees it may be particularly relevant thatinformation about the benefits of combining breastfeeding with a return to work be provided.

• Ministry of Women's AffairsThe Ministry supports the ILO Convention 103 on Maternity Protection and Recommendations.New Zealand is unable to ratify this Convention as it includes criteria on breastfeeding breaks.New Zealand can meet some criteria in the Convention but not the paid breastfeeding breaks. 1.5hours a day was the recommendation for this.

(There is a move to remove these paid breastfeeding breaks from "Recommendations" into the"Optional Recommendations" which is seen by many breastfeeding groups as a backward step.Many organisations and individuals have already written to government on this.)

The Ministry is not focussing on progressing this at the moment, as it is seen as not as urgent asthe issue of paid parental leave.

• Human Rights CommissionThere is nothing in Human Rights legislation about women's rights to breastfeed or express in theworkplace. It is, however, an issue which is coming up for the Commission increasingly often.They can only act if there is a complaint. The EEO search revealed only one case which was todo with a woman requesting permission to work at home part-time for a three-month period so shecould breastfeed her baby. She lost her case. Complaints Division report said that, "while thisrefusal could in some circumstances amount to indirect discrimination, in this case the employerhad established "good reason" for the refusal."

"Often businesses think it is too hard so don't start."

Another was doubtful whether a requirement for an employer to provide breastfeeding facilitiesand flexibility for women would have positive outcomes. She felt that women would suffer. Whilerecognising that breastfeeding does decrease on return to work, she wonders whether theemployment issue is the problem.

"It is a minor factor. If a woman is enjoying breastfeeding it is amazing what shewill do to get around barriers."

One respondent suggested writing information for employers as this is where the power lies.

4. DISCUSSION

4.1 The overlap between "public health" and "personal health"The consultations brought into prominence the overlapping of the two types of service and how, ifthey are seen as separate, problems are created.

The split between personal and public health was seen as the biggestbarrier in the system.

Situations which illustrate this are included throughout the discussions.

4.2 Most women want to breastfeedThere was agreement from antenatal educators that most women decide early on in pregnancythat they will breastfeed. It is concerning therefore to find that so many of them turn to bottle-feeding within a short period.

"Women get a bad start and it gets worse."

"Women feel a sense of loss when they stop"

This consultation process has identified several areas where interventions could be made toincrease breastfeeding rates and duration. This section of the report discusses these. It is basedon the sequence of the Health Funding Authority contract Service Descriptions apart from thesection on the gap analysis which is given a chapter of its own as it sums up the discussions.

4.3 Confirmation or amendment of Michele Lennan's recommendationsThere was a low response rate to the questionnaire. One can only speculate that people wouldhave responded if they had concerns.

From the feedback given, it would appear that people feel that the recommendations are still valid.Suggestions from responses have been included in the body of the "Findings" section of thisreport.

4.4 Ante-natal classesIt would be difficult to determine whether attendance at these classes and especially the sessionon breastfeeding results in a higher probability of a woman establishing and maintainingbreastfeeding. There are other important factors which influence a woman's breastfeedingdecision.

Breastfeeding is covered in all the ones discussed with respondents although almost none hadbreastfeeding women to talk about the positive things and the difficulties about breastfeeding andto show the participants how they breastfeed their babies. It would give participants the

The Human Rights Commission are producing a pamphlet on pregnancy and maternity leave. Itappears there is nothing in this on breastfeeding.

• EEO TrustThe EEO Trust hold a wealth of material on employment and breastfeeding and were particularlyuseful in sourcing overseas and New Zealand material. They act as an information disseminator.Their newsletter, "Work and Family File" goes to 250 companies and would provide a means toget information to these employers.

The advice from the Trust was to target employers and women simultaneously with information.The messages for each would be different but would be useful in making it more possible forbreastfeeding women to return to work. If the decision is made by the Health Funding Authority toproduce information for employers, the EEO Trust would give feedback during the development ofthe material, circulate it, put it on the website and profile it in the resource catalogue.

The Trust has no policy statement on breastfeeding as such. Their focus is rather on promotingfamily friendly workplaces. It has annual awards for organisations who provide family friendlyworkplaces. Three of these organisations were contacted (see below).

The Trust's advice, also, was to target employers and women at the same time with any resourceor strategy.

• Shell New ZealandShell based their decision to provide places where a woman can breastfeed or express oneconomic reasons. Staff retention and attraction was the driving force behind the policy. The costof providing a space, a small frig and a lazyboy chair is nothing compared to the cost of employinga replacement and training them. It is considered that the cost of time the woman may take toexpress or breastfeed is not significant.

Shell have now built in values about a family friendly workplace into performance appraisals.

• PriceWaterhouse-CoopersThey have a group called, "Progressing Women" which looks at what can be done to retain andattract women in the organisation. As a result of their efforts, family friendly facilities include aroom for breastfeeding and expressing and designated car spaces. Within their own offices thisworks well but there are difficulties for women who go out into other client companies to work."Clients don't like it."

• WestpacWestpac has policies about family friendly workplaces. While practices and facilities to makebreastfeeding or expressing possible, are operating well in the corporate offices, they are notalways implemented at the branches. With a staff of 6,500 across New Zealand this can be aproblem. Many branches do not have a suitable room and some managers are more supportivethan others.

These three organisations see themselves as values based organisations which work towardsproviding a balance for their employees between work and family. They also know that thesepolicies make financial sense.

• Other responsesThere was a suggestion that EEO legislation is coming for private employers. One respondentsuggested that most employers don't want to think about breastfeeding She felt that one of thebiggest issues, especially for small businesses will be the facility needed for this.

opportunity to talk to the "peer educators" about the emotional feelings associated withbreastfeeding as well as the practical aspects. We recommend that this practice is incorporatedinto each class. A lactation consultant who monitors research identified three recent studies whichshow that this is an effective intervention.

There is an opportunity to encourage, not only partners but also other family members to attendthe breastfeeding session. A constant theme from midwives, Pacific Islands providers and Plunketis that family members often make the decisions - overtly or subtly - about giving the baby a bottle.If these members attended at least the session on breastfeeding it may go some way towardsresolving this factor - at least for the women who attend ante-natal classes.

Several people suggested that the Health Funding Authority specifications for ante-natal classesbe revised to allow for more breastfeeding promotion. Others felt that the classes needed to beaudited before contracts were renewed.

"There is vety little evaluation or supervision. If audited it would provide somequality control."

There are many women who don't attend these sessions. The challenge is to get more womenattending.

Taking the classes out to maraes, churches and involving the communities in a whanauexperience is recommended to increase participation by Maori.

"Use the marae approach. Kuia who bottle fed can say, "I did that with my kids butI know there is a better way." Older women can talk about traditional practices."

Pacific providers already take the classes into the community. They alsorecommend a family approach to education.

4.5 Professional training• MidwivesMidwives, more than any other professional group see women in the period immediately afterbirth. Their expertise in breastfeeding management needs to be of the highest standard.

The AUT midwifery course appears to be giving students a good theoretical backgroundcombined with the important practical component.

There were many comments that people had concerns about the advice some midwives gave.This was put down to the information about breastfeeding they got when training being no longerappropriate. The fact that their practice was not always audited was seen to compound theproblem.

"Upskilling is needed about not giving personal opinions."

"Some midwives are not keeping up to date. I've heard midwives telling women togo "cold turkey."

Suggestions for addressing this issue included the Health Funding Authority having recertificationrequirements for LMCs which included update training in the theory and practice of breastfeeding.

"The training of midwives needs to be standardised to retain registration."

The suggestion of one respondent that this training should have a component on motivationalfactors around breastfeeding is worth serious consideration.

"This could include how to increase a woman's confidence and motivation tobreastfeed - how to provide effective support. Practitioners also need to know howto do motivational interviewing for women who haven't considered breastfeeding."

• NursesThe teaching on breastfeeding in general nursing courses is seen by tutors to be insufficient forstudents to be excellent breastfeeding practitioners. However an undergraduate course makesstudents aware of many health issues without the expectation they will be experts in any particularfield.

• Staff in Maternity UnitsWhile HHS5 are implementing inservice breastfeeding update sessions and auditing of staffbreastfeeding practices, one anecdotal comment suggested that these were not alwaysimplemented. It is possible the introduction of BFHI assessments will ensure that they are infuture.

• Doctors"A GP has huge power. What they say is seen as important."

Very few GPs are now involved in the provision of maternity services and yet women do go tothem with problems postnatally. Evidently they don't often present with a breastfeeding problemalthough this may underlie the presenting problem.

Many people spoken too were concerned that the advice women were getting from their GP wasnot always accurate or helpful.

"The knowledge of GPs is abysmal"

"There are GPs who say, "Just give her a bottle."

A respondent from within the medical profession felt that the problem was with the practicalaspects rather than the theory.

"Levels of information about practical aspects of breastfeeding is grossly weak.They have the theory but not the practice."

The GPs I spoke to expressed concern that members of their profession were not up to date intheir knowledge of breastfeeding. They acknowledged that there was not the motivation for themto attend breastfeeding updates and that the IPAs were not likely to provide a course unless therewas a demand for it from practitioners.

One solution offered was that the Health Funding Authority stipulate that GPs have to attend asession on breastfeeding and other aspects of infant care.

"There is a small amount of valuable information on breastfeeding that doctorsneed to know and it needs to be imbedded in a wider range of information aboutbabies such as a crying or unsettled baby."

For women who do attend a general practice for advice on breastfeeding, it was considered bysome that courses on breastfeeding for practice nurses may offer a more effective way to addressthis problem. If the Health Funding Authority is to explore the issue of professional training thismay be worth considering.

• Plunket

Plunket has a strong commitment to regularly updating and auditing staff on breastfeeding theoryand practice. While there may be some Plunket nurses who do not provide appropriate advice totheir clients, it is likely that procedures Plunket has in place should be sufficient to address this.

4.6 Breastfeeding and employmentThere are several possible actions the Health Funding Authority could pursue under this heading.Two which have been recommended are:

• Provide material for women giving guidance on how to continue to breastfeed while working• Provide information for employers promoting the idea of family friendly workplaces

There is plenty of research data and practical information available from a range of sources todevelop any of these resources. The issues are known and the needs are there.

Changing employment legislation and practices is a major long term challenge which is best takenup by government and non-government organisations. While several people recommended thatemployers be targeted with information about the requirements breastfeeding women have, thisseems to be a low priority compared to other identified needs. It may be better for a breastfeedinghealth promoter (see below) to liaise with relevant organisations such as the EEO Trust and theMinistry of Women's Affairs to encourage them to work on this issue.

Health Funding Authority funding could be also put towards providing information to breastfeedingwomen who were considering returning to work. This could include information on working andbreastfeeding and also information on their rights as workers. It could be given to the woman bythe health professional who was working with her soon after birth - a Maori or Pacific provider, theLMC or the Plunket nurse.

La Leche League has a printed resource on expressing and storing milk for a woman who returnsto work and there is other printed material available on this. However a gap has been identified fora low literacy resource in different languages on returning to work.

"A good resource is on hand expressing is needed - give it to Plunket - tie it in withgoing back to work."

"This needs to include information for the woman that it is not a good idea to weanyour baby at the same time you leave her to go back to work. She then has twomajor things to deal with - you leaving her and being put on the bottle"

With many Chinese women returning to work very soon after the birth of their baby, it was felt thata Chinese version of this resource would be very useful.

"We need a pamphlet in Chinese on this with lots of pictures."

5. RESOURCES AND STRATEGIES GAP ANALYSIS

5.1 Provision of post-natal supportAs described above, there was almost universal concern that, for many women, support in the firstweeks after delivery was inadequate. Respondents identified that, under the current system, thereis a gap between when a women leaves hospital and when the Well Child provider takes over thecare of the child.

"There is no clear definition between the roles of different people in the system."

"Funding lines break down. There is lack of support for women."

"Women need post-natal support. Plunket starts at six weeks but some are notbreastfeeding by then."

Three initiatives were identified as needed to provide women with the post-natal support. Theywere:

• The provision of free post-natal classes• A centre in the community where women can go for advice, support and education• The requirement that all providers who work with women over this period meet and co-ordinate

services.

It is realised that some of the above suggestions would need to be funded from the personalheath purse and not the public health one. As respondents constantly stressed, there are largeareas of overlap and the two sections need to work together if there is to be positive change forwomen and their babies.

5.1.1 Provision of free post-natal educationThe call for post-natal education groups was seen by the large majority of people questioned asbeing a way in which this lack of support could be addressed. Some HHSs already provide thisservice for a fee but generally numbers attending are small.

Many respondents gave strong support for funding to be put into existing organisations such asPlunket, Parent's Centre and Maori and Pacific Islands providers to provide this post-nataleducation.

"Mothers could be trained under the Tamariki Ora scheme to become educators."

These sessions would provide group education for women - and families - during the post-natalperiod. If they were included under Tamariki Ora contracts, there could be ongoing sessions whichcover areas of infant nutrition and parenting as well as breastfeeding.

A whanau approach could be used. This would help address the two issues of family membersnot being supportive of the new mother and of them encouraging a mother to bottle feed.

Providers spoken to in Northland were adamant that they would be able to provide this services ifthey were given funding to put more community workers into the community.

"What we need is more people - not more posters or pamphlets."

"Pacific Island people are hands on learners you know wecan't just look at pictures in pamphlets and tell that thisis how you're meant to feed the baby because the way in thepicture may not be the right way for us and our own baby asshown in the drawing!

Many respondents suggested that post-natal educators did not have to be health professionals.They could be women from the community who have the ability to work with other women.Women with similar life background, experiences and ethnicity as the women themselves wouldbe appropriate.

Plunket is increasingly employing Maori and Pacific Islands clinical staff and they see clients ofmany different ethnicities. Plunket already runs a kaiawhina scheme where Maori women aretrained to become support people for mothers and whanau. This could be extended to includetraining in facilitation so that they were able to run education sessions in the community.

Ringa Atawhai are the first point of contact for many families in Northland and already do healthpromotion work. This is another existing organisation which could be funded to provide services.They already see women who have breastfeeding problems, referring them on to healthprofessionals.

Parents Centre has expertise in this area also and experienced and well trained educators. Theirservices could be expended if more funding was available.

While La Leche League has voluntary leaders, funding could be provided for resources and officeadministration to support their work.

The idea recommended by several Pacific and European respondents that educators fromexisting organisations be allowed to visit women while they were in hospital to help them with theestablishment of breastfeeding and to provide continuity from the ante-natal to the post-natalperiod is worth pursuing. These visits could take the form of group education sessions for women,their babies and family members.

The suggestion put strongly by several respondents that current providers such as Maori andPacific providers and Plunket be funded to provide this post-natal service.

5.1.2 A centre in the community for women to access advice and educationThe majority of respondents working with women suggested that Plunket Family Centres could begiven funding to extend their services significantly. These centres currently provide a place forwomen to go to from three to four weeks post-natally. However funding difficulties mean that theservices they can offer are limited by the staffing level they are able to maintain.

It was felt that centres needed to provide a 24 hour a day service and that staffing could includePlunket nurses, community workers, educators and a lactation consultant. In larger centres apaediatrician could be available at certain times. Such a centre would provide a place for womento go to for education group sessions, a place to catch up on sleep or to get advice from anappropriate health professional. Such a centre could be available to women immediately after theyleave hospital.

In some communities there may be another provider who is the appropriate organisation to fund torun a similar centre.

In rural Northland areas this may not be the appropriate response. A better option may be to funda community educator to visit rural areas and work with women and families post-natally.

5.1.3 Closer liaison between health professionals"Bring everyone together to find out what is happening"

The staff from a Northland Well Child provider spoke of not knowing the staff at the local maternityunit and of being concerned that they and the midwives were giving conflicting advice.

It is possible that misunderstandings exist and gaps in service occur between LMCs and WellChild providers which could be resolved if the interested parties were to meet together on aregular basis. This could become a requirement of the Health Funding Authority. If this idea is tobe implemented, funding for someone to organise and facilitate the meetings would be required.

One HHS manager felt that the crisis work lactation consultants now do would not be needed ifthere were no problems in the first place. She made the suggestion that it would be useful to setup a pilot in one geographic area with all the providers and community groups working together.Baseline data would be needed to compare changes during and after the pilot period.

5.2 Identified resources and strategies• Resource on breastfeeding techniques with photosA gap analysis shows that there is a need for a resource with simple instructions in English andother languages on breastfeeding techniques with accompanying photos.

An Australian booklet of photos and simple advice on breastfeeding for "low literacy women" wassent by Anne Vickars from Wellington School of Medicine. We showed this to as many people aspossible. The response was very positive with the proviso that the photographs show women ofdifferent ethnicities and that the breasts and nipples in the photographs show a range of sizes andtypes. Another recommendation was that the photos should include one showing a man beingsupportive.

This resource could be given to women by their LMC post-natally.

Translations of this resource into Maori, Chinese, Samoan, Tongan and Tuvaluan are needed. Adecision will need to be made once costings are established as whether these are inserts ordifferent language versions of the resource.

An alternative suggestion made by one midwife was to have a fold out chart showing latchingtechniques and how to hold the breast while the baby is feeding.

• Resource for women wanting to return to workThis resource also needs to be in the different languages. It needs to have photos showingexpressing techniques, practical advice on how to combine work and breastfeeding andinformation about their rights in the work place.

• A printed resource for Chinese women and their familiesCurrently there is no resource which addresses the issues specific to Chinese families. It isconsidered unlikely that they would respond with behaviour change to generic resources orstrategies because the issues underlying the low rates of breastfeeding in Chinese populationsare different to those of other ethnic groups.

The Chinese health professionals we spoke to suggested the use of Chinese radio andnewspapers to promote messages about the benefits of breastfeeding.

• Resource and radio campaign to promote the importance of breastfeeding to familymembers

A poster for display in community houses, marae, doctor's surgeries, shopping malls and otherplaces where it would be seen by family members would be useful if it did not stand alone but wassupported by other health promotion activities. The messages in the poster need to be specificaround the message to support the baby and mother by encouraging her to breastfeed and not togive bottles.

In addition to this, a radio campaign to promote the same messages is recommended. Pacific andMaori put great store in radio and the cost may be no more than printed resources.

Run a breastfeeding campaign through Pacific Islands media for a wholeweek for example on Radio 531 P1, newspapers and television in their ownlanguages. As this involves so much expense focus on the radio which haslanguage networks to cater for all the Pacific groups.

• Resource and radio campaign to promote the nurturing of a new mother by friends andfamily

A media campaign in different languages, perhaps based around Mothers Day or BreastfeedingWeek, provides one way to get messages into the general population. The cheapest option ispossibly the use of local radio ensuring that appropriate stations were chosen for different ethnicand age groups. Talk back sessions with health professionals could be arranged to support thepromotional spots. By using radio the messages could be tailored to the different ethnicities. Itcould be repeated each year based around an annual event such as Mothers' Day if ongoingfunding was available.

Articles in magazines identified as reaching different ethnic groups could support this initiative.

Messages would include the need a woman has for support and sleep in the weeks after birth andways to nurture her - cooking meals, hanging out washing, doing housework, caring for otherchildren.

Posters in different languages and photos of people of that ethnicity with the same messages asthe media campaign would strengthen the promotion.

• Creation of a breastfeeding culture in Northland and AucklandThis is a big ask especially as there has been very little public health promotion on breastfeedingin recent years.

Some of the strategies and resources suggested above will help towards achieving the goal ofestablishing a breastfeeding culture in society. There are other strategies which would assist indeveloping such a culture.

• Most people we spoke to suggested television advertising of positive messages about thebenefits of breastfeeding. One suggestion was to involve as models public figures such as LucyLawless who are known to have breastfed or local heroes from within local communities. InNorthland these would be Maori who have status in their communities.

Television advertisements would be an expensive option but may be possible if free airtime wasavailable on television channels.

• Another regular suggestion was that someone is needed to work with popular programmessuch as Shortland St to ensure that any baby is shown as being breastfed and not bottle-fed.

Hokianga respondents suggested that a video be made using the facilities of the local polytechand showing local identities breastfeeding and/or sharing breastfeeding stories. This couldinclude a group of kuia and women of different generations sharing their stories.

• Creation of breastfeeding health promotion positionsWe see that to create a breastfeeding culture it is necessary to work on several strategies at once.Funded breastfeeding advocate positions in both Auckland and Northland would enable the co-ordination of breastfeeding promotion initiatives such as working with mayors, councillors andcouncil staff, shopping mall management, working with employment related agencies, liaising withtelevision producers, arranging magazines interviews and talkback sessions on radio. This personcould also be responsible for arranging and facilitating co-ordination meetings of providers whichwe have recommended.

Each position could be based in an existing provider organisation.

• Resources not considered necessary1. An information booklet on breastfeeding for doctors was prepared by Michele Lennan and is

with the Health Funding Authority. However a resource for GPs was not seen as a priority bydoctors.

"GPs don't see many babies now. The money could be used in better ways."

2. Waitemata Maternity Unit has prepared a Best Practice guideline booklet for staff. Whileuseful, this may be something that could be done by NZBA.

6. RECOMMENDATIONS

"A health dollar spent in the first year of life has more value than a dollar spent atany other time.

We consider that one activity by itself is not likely to result in significant change in breastfeedingrates. We recommend that several strategies are initiated to complement each other taking intoaccount that the preferred way of learning for many Maori and Pacific Islands people is by face toface interaction and not through printed resources.

These recommendations acknowledge the clear differences between cultures and that there needto be specific strategies and resources to meet the identified factors in different ethnicities. Whileinitial breastfeeding rates in Pacific communities are currently good, changes are occurring withNew Zealand born women which suggest that resources and strategies are needed in Pacificlanguages and media.

The following are the recommendations for strategies and resources based on the advice gainedfrom our consultations. No costing of them has been prepared. As not all of them will be possibleunder the funding available, decisions will need to be made as to which ones to run with.

• Breastfeeding education for women and their whanau1. Provision of free post-natal classes for women and their support people/whanau facilitated by

community educators from existing organisations. The educators should be women who havebreastfed and who share the same life experience and are of the same culture as the womenwho attend. This recommendation includes sessions for women while still in hospital.

2. Requirement of the Health Funding Authority for ante-natal classes to include the teaching ofbreastfeeding to pregnant women by breastfeeding women who demonstrate techniques anddiscuss their personal experiences of breastfeeding.

3. Requirement of the Health Funding Authority that facilitators of ante-natal classes encouragegrandparents and other family members involved in supporting the mother post-natally toattend ante-natal classes especially the session on breastfeeding.

• Professional standards1. Requirement by the Health Funding Authority for midwives to undertake regular updating

education on breastfeeding including auditing of their breastfeeding practices.

2. Requirement by the Health Funding Authority that LMCs and Well Child providers in definedgeographic areas meet on a regular basis to co-ordinate services and establish agreed on bestpractices.

3. Requirement by the Health Funding Authority for IPAs to offer CME sessions to GPs and/orpractice nurses on the care of the newborn including sessions on breastfeeding practice andtheory. Requirement for GPs or their Practice Nurses to attend these sessions to gain credits.

• Social environment strategies

1. The establishment of breastfeeding promotion positions in Auckland and in parts of Northland.These could be fulitime or parttime depending on the size of the population. The people inthese positions would be responsible for promotingbreastfeeding and for co-ordinatingmeetings of all those who work with mothers antenatally and postnatally in their area.

2. Production of posters and media campaign promoting the importance of breastfeeding to familymembers.

3. Production of posters and a media campaign promoting the nurturing of a new mother and theimportance of breastfeeding.

4. Television advertisement aimed at changing public support for breastfeeding.

• Resources1. Production of a resource for women wanting to return to work.

2. Production of a resource for Chinese women and their families.

3. Production of a resource on breastfeeding techniques with photos.

• Staffing1. Increased funding of existing Plunket Family Centres to enable them to extend their post-natal

services to women including post-natal education groups. Where appropriate, funding could begiven to Maori or Pacific providers to provide this service.

2. Funding of community health positions in rural areas to reach women and their whanau pre andpostnatally to ensure they have access to education about breastfeeding and other maternityrelated issues.

Appendix I

KEY RECOMMENDATIONS OF MICHELE LENNAN'S SCOPING REPORT

That North Health (now Health Funding Authority Northern Region)

1. Supports and works with the CHEs (now HHSs) to work towards achieving Baby FriendlyHospital Initiative (BFHI) status

(The Breastfeeding Authority (BFA) has been set up to work towards this)

2. Promotes a meeting of all groups interested in breastfeeding to work through breastfeedingpromotion strategies eg BFHI

(The BFA held two meetings last year with representatives from many organisations attending)

3. Works with other divisions of the HFA to encourage and support the Ministry of Health to set upa national data collection system to monitor breastfeeding rates

4. Encourages the HFA to initiate a nation-wide longitudinal survey of current breastfeedingpractices in conjunction with the (hoped for) Ministry of Health's data collection system. Thisstudy would also include an ethnographic component

5. Encourages the Health Funding Authority to set up a data base of current research onbreastfeeding

6. Working with the CHEs and CENZ, initiates an evaluation of childbirth education classes

7. Initiates a media promotion in different languages which sends positive messages about breastfeeding

8. Works in conjunction with the EEO Trust (if they are interested) to promote breast feedingfriendly workplaces through strategies aimed at employers

9. Liaises with all teaching institutions to discuss the way in which breastfeeding could be includedin their curriculum

10. Initiates an evaluation of:a) available breastfeeding material to see what the messages are being conveyed - are theypositive or negative?b) any promotional programme which North health may initiate

Appendix 2

DEFINITION OF A BABY FRIENDLY HOSPITAL INITIATIVE (BFHI)

A baby friendly hospital (BFH) is a health care facility where the practitioners who provide care forwomen and/or children adopt practices that aim to protect, promote and support exclusivebreastfeeding from birth. At the same time, Baby Friendly facilities ensure that women whochoose not to breastfeed are supported in their decision and provided with unbiased informationand advice.

UNICEF/WHO have established the following Ten Steps to define a BFH.

"Ten Steps to Successful Breastfeeding"

The baby friendly health facility should:

1.Have a written breastfeeding policy that is routinely communicated to all health care staff

11.Train all health care staff in skills necessary to implement this policy

Ill. Inform all pregnant women about the benefits and management of breastfeeding

1V.Help mothers initiate breastfeeding within half-hour of birth

V.Show mothers how to breastfeed and how to maintain lactation even if they should beseparated from their infants

Vi.Give new-born infants of breastfeeding mothers no food or drink other than breast milkunless medically indicated

VII. Practice rooming-in - allow mothers and infants to remain together 24 hours a day

VIII. Encourage breastfeeding on demand

IX. Give no artificial teats or dummies to breastfeeding infants

X. Foster the establishment of breastfeeding support groups and refer mother to them ondischarge from hospital.

From

"Baby Friendly Hospital Initiative: Aotearoa New Zealand Action Plan 2000 - 2002"Prepared for New Zealand Breastfeeding Authority Incorporated by the

Implementation Advisory Group of the NZBA

Appendix 3

Individual consultations

• Queenie Ballance - National Council of Women - Auckland Branch• Tui Bevan - researcher, Dunedin• Erin Brenford - Lactation consultant, Auckland• Leo Buchanan - Paediatrician, Hutt Valley• Anna Caird - Shell New Zealand head office, Wellington• Moh Lee Cheok - Plunket Nurse, Pakuranga• Jennie Collard-Scruby - Lactation Consultant, Plunket Nurse, Hunters Corner• PriceWaterhouse-Coopers - Human Resources• Stephanie Cowan - SIDS and Director of Education for Change Ltd, Christcurch• Elizabeth Coverley - Lactation Consultant, Middlemore Hospital• Diane Edwards - Parents' Centre Childbirth Educator• Lesley Eiseg - National Council of Women, Karitane Nurse and Nanny, Auckland• Jill Evans - Midwife, Kawakawa Hospital• Colleen Fakalogotoa - Acting Northern Region Manager, Royal New Zealand Plunket• William Ferguson - Kumeu GP and spokesperson on Maternity services, New Zealand College

of General Practice• Tanya Fong - Human Resources, Westpac Bank, Wellington• Richard Fox - Goodfellow Unit• Rosemary Gordon, Director, La Leche League New Zealand, Taupo• Sandy Grey, President, New Zealand College of Midwives, Auckland• Jacqul Gunn - HOD Nursing - Auckland University of Technology• Julie Anne Hall - nursing tutor - Auckland University of Technology• Marion Heeney - Manager Maternity Services, Middlemore Hospital• Gary Henry - Manager, National Women's Hospital• Paul Herbert - Advisor in Health Education, Auckland Education Advisory Service• Anne Heritage - Immediate Past Director, La Leche League New Zealand, Auckland• Carol Howard - Private Childbirth educator, North Shore• Trish Jackson-Potter - Acting Regional Nurse Specialist, Plunket, Auckland• Rachel Kempon - EEO Trust, Auckland• Shane kinley - Department of Labour, Wellington• Diane Lawson - Manager, Te Ha 0 Te Oranga, Dargaville• Lesley McCowan - Associate Professor, Maternal and Foetal Medicine, Auckland School of

Medicine• Heather McDonald - for Laila Harre - Minister of Women's Affairs• Linda Mackay - Home Birth Association and Women's Health Council, Auckland• Queenie Mahanga - Tapuhi, Hauora Whanui, Kawakawa• Lyvia Marsden - Manager, Te Puna Hauora 0 Te Raki Paewhenua• Sue Matthews - Co-ordinator of Training, Plunket, Te Puke• Sarah Matthewson - Information Manager - EEO Trust, Auckland• Helen May - School of Nursing - Manukau Institute of Technology• Mary Munn - Manager Northland Plunket, Whangarel• Pauline Penney - Plunket Childbirth educator, Auckland• Tuella Percival - South Seas Healthcare, Auckland• Beverley Pownall - Lactation consultant, Auckland• Kathy Reay - Lactation consultant, breastfeeding educator, Auckland Obstetric Centre• Helen Roberts - Senior lecturer in Women's Health, Auckland School of Medicine• Marcia Roberts - Lactation consultant, National Women's Hospital• Tina Stiffe - Plunket nurse, Kerikeri

• Judy Strid - Manager - National Women's Hospital Information Centre• Julie Stufkens - Co-ordinator, New Zealand Breastfeeding Authority, Christchurch• Lana Tai - Midwife, Botany Downs Maternity Unit• Barbara Taunton-Smith - Lactation consultant and Birthcare Childbirth Educator• Maisie Taylor - Ringa Atawhai, Northland• Tessa Turnbull - Katikati GP and President, New Zealand College of General Practice• Judith Turner - Health Tutor, Northland Polytech• Adrian Trenhoim - Paediatrician, Middlemore• Diana Vellenoweth - Midwife, Kawakawa Maternity Unit• Anne Viccars - Junior Research Fellow, Wellington School of Medicine• Alison Vogel - Paediatrician, Middlemore• Linda Williams - convenor - Maternity Services Consumer Council and Women's Action

Coalition, Auckland• Human Rights Commission, Auckland• Trish Warder - Lactation consultant Waitakere and North Shore Hospitals and private Childbirth

educator, Auckland• Angela Wilson - Midwife and Antenatal educator, National Women's Hospital• Lorna Wong - Plunket Chinese Unit, Mt Albert• Angela Yeoman - Ministry of Women's Affairs, Wellington

• Harangi Biddle - Te Waimana Kaaku, Bay of Plenty• Rangimarie Hohaia - Te Awamutu• Atawhai Benefield - Te Puna Hauora o te Raki Paewhenua• Riripeti Haretuku - Maori SIDS Programme, University of Auckland• Dr David Tipene Leach - University of Auckland• Jocelyn Rakuraku - Manurewa• Judyth Hilton - Putea 0 Pua Trust, Otahuhu• Becky Fox - Plunket National Maori Advisor, Wellington• Helen and Jan Bryant - Birkenhead• Ngaurere Maiava - A+ Child and Community Health, Auckland

Group meetings• AUT Midwife Practice

Dawn Holland - ManagerMidwives: Kate Mills, Kathy Pankhurst, Ingrid Struik, Jac Tourell

• Auckland Lactation Consultants monthly meeting - 20 participants

• Hokianga HealthBarbara Walker - Manager Community ServicesSally van Rooyen - PHNRobin Hauraki - PHNLiz Bowker and Ingrid Ouwerkerk - MidwivesKathrin Clarke - Health promotion

• Maternity Services Consumer Council monthly meetingLynda Wiliams - MSCC co-ordinatorLesley Eiseg and Alison Whitburn - National Council of WomenMarilyn Manukia - Pacific Islands Health and Welfare CommitteeDee Podevin and Jill Leach-Jones - Postnatal Psychosis Support GroupKarin Rothville - West Auckland Parents Centre, Childbirth Education NZBrenda Hinton - Home Birth Association

• National Women's HospitalMaternity Manager - Sandra BuddMidwives: Carol Hall, Liz Reed, Lesley McLennanMarcia Roberts - Lactation Consultant

• Northland HealthMaternity Manager - Jim GreenChristine Read - Maternity Services Co-ordinatorLynda King - Midwife and Ante-natal classes Co-ordinator

North Shore HospitalBarry Twydle - Maternity ManagerMidwives: Ginny Smith, Trish Warder,Tanya Paterson, Jan Henderson, Nicole Toxopeus,

Fiona Mellis, Barbara Brinsden, Margaret Njovu, Gaylene Mathias, Judy Cartmill

South Auckland HealthMarian Heeney - Group Manager Women's HealthJenny Woodley - Charge Midwife/ManagerRuth Murdoch - Project Co-ordinator Women's Health

Te Hauora 0 Te Hiku 0 te IkaMaureen Allen - ManagerDebbie Poananga - Community Health EducatorTangi Henare Davan - It It

Waireti Walters - it 94

Louise - THOTT and independent midwifePhyllis Turea - Whakawhitiora PaiAda Wedding - Plunket nurse

Wiri Plunket Family CentreIrish Jackson-Potter - Acting Regional Nurse SpecialistLouise Troy - Plunket NurseAnne Wilde -

UNITEC School of NursingShirin Caldwell - TutorKate Barry - Tutor

• Pasifika Healthcare Fono's Community Health Services Team.Annie Titonekeare - Team Leader - Cook Island,Annette Schwalger - Samoan educatorHaren Makaea - Niuean educatorDoreen Yandall - Fijian educatorTe TJru McQuarrie - Cook Island educator

• Waikato PolytechnicEstelle MarmentKaren Peters

• Te Kaha o te Rangatahi - Papatoetoe

Appendix 4

COMMUNITY CONSULTATION INSTRUMENT

• Introductions*Introduce of self*Purpose of the project*Confidentiality , ethics*Note taking*Breaks*Access to a copy of the project findings

• Invite participants to introduce the person they are sitting next to*where they are from, (Auckland)*number of babies*where babies were born and how far apart.

Questions

1. What kind of messages do you think are out there (society) regarding Breast feeding? (Covermessages from health professionals, society, employment.)

2. Could you share your experiences of breastfeeding? past, present

3. How will these experiences impact on future breastfeeding?

4. Are you currently breastfeeding?

5. How long have you been breastfeeding?

6. What led to you making the decision to breastfeed?

7. Why do you continue to breastfeed? What factors contribute to you maintaining that decision?

8. When will you stop breastfeeding? (When baby is a certain age?) Why?

9. If you have you recently stopped breastfeeding, for what period did you breastfeed?

10. What made you stop breastfeeding? What factors led to you making that decision?

11. In your opinion what could make the breastfeeding experience more positive?

(2 hours)

Appendix 5

DEPARTMENT OF LABOUR COMMENTS

Existing labour market policies relevant to women who want to breastfeed on return towork

The Equal Employment Opportunities Contestable Fund (EEO Fund) provides funding forinitiatives in the workplace that, amongst other things, encourage family friendly policies. TheEEO Fund has previously funded a number of directly relevant initiatives:

• In 1991/1992, the New Zealand Distribution Workers Federation completed a project entitled'Friendly to Families';

• In 1993/1994, the Legal Resources Trust completed a 'Family Friendly' video resource;• In 1994/1995, Metropolitan Lifecare Group Ltd and the Service Workers Union worked together

on a project which developed family friendly policies at nine workplaces;• In 1994/95, the Ministry of Women's Affairs and the New Zealand Employers Federation

worked together with the EEO Trust, to initiate the Work and Family Directions Project.Following this project the EEO Trust established the Work and Family Network; and

• In 1998/1999, Athena Research completed a project that addressed the organisational costsand benefits of employer provided dependant care facilities.

• The Joint Equal Employment Opportunities Trust also promotes EEO programmes andpractices in private sector workplaces.

Government employers are required by the State Sector Act to be good employers and developan EEO programme, which seeks to achieve the following three conditions:

1. Inclusive, respectful, and responsive organisational cultures which enable access to work,equitable career opportunities, and maximum participation for members of designated groupsand all employees;

2. Procedural fairness as a feature of all human resource strategies, systems, and practices; and3. Employment of EEO groups at all levels in the workplace.

EEO initiatives have, since 1990, largely involved the promotion of the benefits of voluntaryemployer provision of family-friendly policies. The Government has recently indicated that it willconsider options related to providing some legislative framework related to EEO obligations in thenear future.