Babies Are Beautiful

My latest Child Health essay was about Attachment.  It may sound boring but in fact, it’s an intriguing subject worth sharing.  We were all once in need of attachment to someone and for all of us, it played out in an imperfect way, affecting who we are today.

Assignment 3: Principles and application of attachment theory

Scenario Three: During a health check for six-month-old Phoebe you notice a mild delay in her motor skills. Her mother speaks of her with a sense of frustration, indicating that Phoebe is so dependent on her, that she is bored and feels isolated compared to her lifestyle before the pregnancy. You are aware that this mother had a difficult labour, that resulted in a caesarean section delivery.

Healthy development, crucial to an infant’s life-long cognitive, socio-emotional and physical health outcomes, is intrinsically linked to the quality of the infant’s attachment with a primary caregiver4, 18.  The infant brain grows most rapidly and is in its most pliable state from the prenatal period into the first three years, when the foundations of neurobiological architecture and processes are being laid6, 20.  Healthy growth and development relies on the timing, nature and patterns of external experiences26, which impact on a child’s social, emotional and academic success throughout life27.

Sensitive and consistent caregiver interactions are required for healthy psychological and physical development6, but infant attachment to the primary caregiver occurs regardless of the quality of care, including when neglect or abuse are involved30.  Positive early caregiving experiences promote healthy brain development while negative early experiences that may be threatening, uncertain, neglectful or abusive, over-activate the stress response system, affecting neurobiological processes and causing a disruption to development which can result in lifelong negative emotional and cognitive outcomes17, 30.

Factors that play a role in the caregiver-infant attachment process include but are not limited to genetics, family income, family size, parental age, education and mental health, marital relationships, social support systems, life stressors and social adversity14.  The impact that early years experiences have on the developing infant’s quality of attachment and the implications for Maternal Child and Family Health (MCaFH) Nurse practice will be discussed herein with a focus on Scenario 3.

John Bowlby formulated the first comprehensive theories of attachment in the late 1950s and early 1960s and his work was built upon by a number of others, notably Mary Ainsworth and John Robertson31.   Apart from physical attachment via the umbilical cord, newborn babies are unattached but physically dependent for all of their needs24.  There is a biological predisposition to form emotional attachments11 which become established during the first two years of life through a number of phases16.

Referencing Mary Ainsworth’s Strange Situation Procedure, Mares et al18 describe the four different attachment behaviours which manifest in children when faced with a specific range of stressors.  These attachment patterns are categorized as “secure” (seen in children who have experienced consistent and predictable caregiving); “insecure/avoidant” and “insecure/ambivalent” (both considered normal variants and seen in children who have anxieties about the availability of their caregiver); and “disorganized” (considered pathological and seen in children who have experienced distress and/or fear from their primary caregiver).  Children with secure attachment are considered most likely to have positive long-term outcomes in terms of social, emotional and cognitive wellbeing18, while children with disorganized attachment are more likely to experience negative long-term outcomes30, 11.

Individual children will present with different attachment patterns based on interrelating factors such as genetic predisposition, specific external experiences, age at which and frequency with which the experiences occur26, 6, 27, 25.  Appendix 1 provides a diagrammatic overview of the Circle of Security8 showing the characteristics of secure attachment whereby an infant experiences a safe haven (comforting caregiving responses); secure base (reliable and consistent caregiver); proximity maintenance (the caregiver is nearby while the child explores his/her world); and separation anxiety (the child expresses sorrow when separated from the caregiver)5.

As argued by Staples29, evidence about the impact that caregiving attachment has on long-term outcomes for infants highlights the need for early assessment and multidisciplinary intervention with appropriate support, care and education being a crucial role of the MCaFH Nurse.  Effective communication, establishing and maintaining respectful, professional, therapeutic relationships with children, caregivers and families using a strengths-based approach are included in the required standards of practice for the MCaFH Nurses in Australia15.

The role of the MCaFH Nurse is complex but Fraser et al13 identified key practice areas as being: “child growth and development; maternal mental health; information provision to support behaviour/attitudinal change; and building parent capacity”, by establishing therapeutic relationships with clients, utilizing skills including enhanced communication, reflective practice, emotional intelligence and empathy.

Appendix 227 provides a diagrammatic view of age-dependent functional development of different parts of a human infant’s brain, showing that this infant with delayed motor skills may have some disruption of cerebellar development.  MCaFH Nurse practice includes the use of “standardized, evidence-based assessment tools3.  An example of this is the NT Government Department of Health Child and Family Health Clinical Practice Manual (2016) (see Appendix 3a).  To ensure appropriate assessment and diagnosis, a full physical assessment, growth monitoring, physical development monitoring, sleep, nutrition and toileting patterns and/or concerns should be undertaken.  Socioemotional and cognitive assessment are also required, and referral to other services as appropriate3.

Early intervention is imperative to positively alter the infant’s developmental course and enhance her long-term outcomes22.  The NT Government Department of Health Child and Family Health Clinical Practice Manual (2016) outlines legislation requiring that MCaFH Nurses obtain informed consent from the child’s legal guardian before making a referral to another service (see Appendix 3b).  In this scenario a referral to Occupational Therapy is recommended for specialized early intervention of the infant’s motor skills delay23.  Using a reference tool such as the Ages and Stages Questionnaire, described in Appendix 41, or the Red Flags Early Identification Guide7 will assist the MCaFH Nurse to facilitate discussion with the mother (and father or other caregivers as appropriate), to ensure informed consent and participation in all recommended interventions including referral to other services.

As recommended by the Australian Health Minister’s Advisory Council2, during individual consultation with the infant and her mother, the MCaFH Nurse should offer health education, anticipatory guidance and information for parental skill development based on their individual assessment and needs.  This includes advice, support and referral for both the infant and the mother’s needs.  Zanardo et al31 found a significant correlation between emergency caesarian section delivery and negatively altered mother-infant bonding experiences, which will be a significant consideration in this scenario.  Women commonly feel unprepared for their transition to motherhood, lack confidence in parental skills and experience stress, distress and postnatal depression2.  As discussed above, these factors may all affect the infant’s healthy development and indicate a need for early intervention.  Providing a safe place for this mother to express her feelings and using a standardized assessment tool such as the Edinburgh Postnatal Depression Scale (EPDS)8 will allow the MCaFH Nurse to assess the mother’s needs, offer advice and guidance in a non-judgmental and supportive environment, and consider options for appropriate follow up and/or referral.

Depending on the EPDS score, it may be appropriate to refer the mother to a General Practitioner for further mental health care.  There is mixed evidence of the effectiveness of home visits to children and families at risk10.  However, Center on the Developing Child5 recommend coaching of parents should take place in a wide variety of settings, including home visits.  The Australian Health Minister’s Advisory Council2 describe intuitive and anecdotal evidence that the MCaFH Nurse could provide support to this family in their home for a more complete assessment of the situation and perhaps more contextualized advice and support, involving the father, extended family or other caregivers and support people.

In this scenario the MCaFH Nurse must make an assessment of mother-infant interactions, to ensure appropriate interventions are based on individual circumstance and need.  Intervention should involve promoting age-appropriate play and communication to encourage sensitive and nurturing responses of the mother to her child’s needs, not only improving the child’s external experiences but also the mother’s mental health, leading to an improved dyadic relationship9.  An example of standardized resources available for use in this scenario is the Ages and Stages tool which offers age-specific developmental information and ideas for activities to promote development in communication, fine and gross motor skills, problem solving and personal/social skills (see Appendix 4)1.

Encouraging involvement of the father or other caregivers is an important part of the process, as evidence shows infants have better cognitive outcomes when their fathers are actively involved27.  Linking the family into support systems such as play groups, Circle of Security sessions18 or Families as First Teachers20, would give the infant opportunities for stimulation and the mother a chance for social contact with others experiencing similar transitions to parenthood, as well as a range of useful information to implement on a practical level to improve the attachment process.  It may also be appropriate to provide links to relevant websites offering practical and supportive information, such as

The common connection throughout the interventions discussed in this scenario is a MCaFH Nurse service that is able to establish and maintain a therapeutic relationship with the family.  This requires a range of specialized skills to promote parental skill and confidence, support the needs of both mother and infant, ensure timely intervention for optimum long-term outcomes, and collaborate with a multi-disciplinary team of specialists and allied health professionals.


  1. Australian Government Department of Health (updated 20 May 2013). National Framework For Universal Child and Family Health Services, Appendix 3: Tools to assist in health surveillance and monitoring.  Retrieved from
  2. Australian Health Minister’s Advisory Council (2011). National Framework for Universal Child and Family Health Services.  Retrieved from$File/NFUCFHS.PDF
  3. Barker, D, Barker, M, Fleming, T, Lampl, M (11 December 2013). Developmental biology: Support mothers to secure future public health, Nature International weekly journal of science, Vol. 504, Issue 7479, p. 209
  4. Bowlby, J (1982). Attachment and Loss, Volume 1 Attachment, Second Edition, Basic Books, New York.  Retrieved from
  5. Center on the Developing Child (2007). The Impact of Early Adversity on Child Development (In Brief).  Retrieved from
  6. Child Development Program and Brisbane North Primary Health Network (July 2016). Red Flags Early Identification Guide for children aged birth to five years, Second Edition.  Retrieved from
  7. Circle of Security Network (2013). Circle of Security®: Parent Attending to Child’s Needs.  Retrieved from
  8. Cox, JL, Holden, JM, Sagovsky, R (June 1987). Detection of postnatal depression.  Development of the 10-item Edinburgh Postnatal Depression Scale, British Journal of Psychiatry, Vol. 150, pp. 782-786.  Retrieved from
  9. Daelmans, B, Black, M, Lombardi, J, Lucas, J, Richter, L, Silver, K, Britto, P, Yoshikawa, H, Perez-Escamilla, R, Macmillan, H, Dua, T, Bouhouch, R, Bhutta, Z, Darmstadt, G L & Rao, N (14 September 2015). Effective interventions and strategies for improving early child development, British Medical Journal, Vol. 351. pp. 23-26
  10. Doyle, C, Cicchetti, D (June 2017). From the Cradle to the Grave: The Effect of Adverse Caregiving Environments on Attachment and Relationships Throughout the Lifespan, Clinical Psychology Science and Practice, Vol.24, No.2
  11. Doyle, O (July 2017). The First 2,000 Days and Child Skills: Evidence from a Randomised Experiment of Home Visiting, Life Course Centre Working Paper Series, No. 2017-13.  Retrieved from
  12. Fraser, S, Grant, J, Mannix, T (December 2016). Maternal Child and Family Health Nurses: Delivering a Unique Nursing Speciality, Maternal and Child Health Journal, Vol. 20, Issue 12, pp 2557-2564
  13. Gervai, J (2009). Environmental and genetic influences on early attachment, Child and Adolescent Psychiatry and Mental Health, Vol. 3, No. 25.  Retrieved from
  14. Grant, L, Mitchell, C, Cuthbertson, L (2017). National Standards of Practice for Maternal, Child and Family Health Nurses in Australia, Adelaide, Flinders Press
  15. Institute for Learning and Brain Sciences (2012). Phases of Attachment Development, University of Washington.  Retrieved from
  16. Jordan, B (August 2014). An overview of attachment theory, Community Paediatric Review, Current issues in children’s health and development, The Royal Chlidren’s Hospital Melbourne.  Retrieved from
  17. Mares, S, Newman, L, Warren, B (2011). Clinical Skills in Infant Mental Health: The First Three Years.  Retrieved from;dn=283546165841039;res=IELHEA
  18. Mercer, J (2015). Examining Circle of SecurityTM: A Review of Research and Theory, Research on Social Work Practice, Vol 25, No. 3, pp 382-392.  Retrieved from
  19. Newman, L, Judd, F, Olsson, CA, Castle, D, Bousman, C, Sheehan, P, Pantelis, C, Craig, JM, Komiti, A, Everall, I (2016). Early origins of mental disorder – risk factors in the perinatal and infant period, BMC Psychiatry, Vol. 16, No. 270.  Retrieved from
  20. NT Government Department of Education (last updated November 2017). Families as First Teachers.  Retrieved from
  21. Oberklaid, F, Drever, K (September 2011). Is my child normal?  Milestones and red flags for referral, Australian Family Physician, Vol. 40, No. 9.  Retrieved from
  22. Occupational Therapy Australia (2016). Occupational Therapy Guide to Good Practice: Working with Children.  Retrieved from[may2016]-finalweb.pdf
  23. Perry, B (October 2001). Keep the Cool in School: Attachment – The First Core Strength, Early Childhood Today.  Retrieved from
  24. Perry, B, Szalavitz, M (2007). The Boy Who Was Raised as a Dog And Other Stories From a Child Psychiatrist’s Notebook, Basic Books, New York
  25. Perry, B, Szalavitz, M (March 2010). Born For Love, HarperCollins e-books
  26. Rowley, S, Williams, J (2015). Research Review Educational Series, Multi-sensory stimulation and infant development.  Retrieved from
  27. Sethna, V, Perry, E, Domoney, J, Iles, J, Psychogiou, L, Rowbotham, NEL, Stein, A, Murray, L, Ramchandani, PG (May-June, 2017). Father-child interactions at 3 months and 24 months: Contributions to children’s cognitive development at 24 months, Infant Mental Health Journal, Vol. 38, Issue 3, pp. 378-390
  28. Staples, J (June 2016). Neuroscience research into infant mental health: the impact on child and family health nursing policy and practice, Australian Journal of Child and Family Health Nursing, Vol. 13, Issue 1
  29. Sullivan, RM (August 2012). The Neurobiology of Attachment to Nurturing and Abusive Caregivers, The Hastings Law Journal, Vol. 63, No. 6, pp 1553-1570
  30. Van der Horst, FCP (2011). John Bowlby – From Psychoanalysis to Ethology, Unraveling the Roots of Attachment Theory, Wiley-Blackwell
  31. Zanardo, V, Soldera, G, Volpe, F, Giliberti, L, Parotto, M, Giustardi, A, Straface, G (24 May, 2016). Influence of elective and emergency cesarean delivery on mother emotion and bonding, Early Human Development, Vol. 99

Appendix One: Circle of Security

Circle of Security

Circle of Security Network 2013

Appendix Two: Age-Dependent Brain Development

Brain Areas Pic

Rowley and Williams (2015)



Pessimism and Privilege

Pessimism and Privilege

Partners in Health was formed by Dr Paul Farmer and some peers including Roald Dahl’s daughter Ophelia, in the late 1980s after Farmer became determined to make a difference to the people he met in Haiti as a medical student.

The success of Partners in Health in places as far flung as Haiti, Russia and Rwanda, is proof that optimism combined with love, focus and action, makes incredible difference.

Global health statistics available through many organisations such as The Gates Foundation and UNICEF confirm that to be on the right side of history, you really need to take an optimistic and informed view of what is actually happening in this era of progress.

The same can be said for indigenous health here in Australia.  When a colleague said recently “what is the point of what we do because nothing is changing”, I was surprised and a little disturbed, as I pondered on the information available to us through many sources that in fact, as difficult as things continue to be, strides of improvement are well documented, well known and deserve to be celebrated.

If you’re privileged enough to express pessimism about the point of helping others, you’re privileged enough to access the plethora of information that justifies optimism.

This I Believe – Dr Paul Farmer:

I believe that health care is a human right.

I have worked as a doctor in many places and I have seen where to be poor means to be bereft of rights.

I saw early on, still just a medical student, the panicky dead-end faced by so many of the destitute sick.  A young woman dying in childbirth.  A child writhing in the spasms of a terrible disease for which a vaccine has existed for more than a century.  A friend whose guts were irreparably shredded by bacteria from impure water.  An 8 year old caught in crossfire.

“What a stupid death”, goes one Haitian response.

Fighting such stupid deaths is never the work of one, or even of a small group.  I’ve had the privilege of joining many others providing medical care to people who would otherwise not be able to get it.  The number of those eager to serve is impressive and so is the amount that can be accomplished.

I believe that stupid deaths can be averted.  We’ve done it again and again.  But this hard and painful work has never yet been an urgent, global priority.  The fight for health as a human right, a fight with real promise, has so far been plagued by failures.

Failure because we’re chronically short of resources.

Failure because we’re too often at the mercy of those with the power and money to decide the fates of hundreds of millions.

Failure because ill health, as we’ve learned again and again, is more often than not, a symptom of poverty and violence and inequality.  And we do little to fight those when we provide just vaccines, or only treatment for one disease or another.

Every premature death, and there are millions of these each year, should be considered a rebuke. 

I know it’s not enough to attend only to the immediate needs of the patient in front of me.  We must also call attention to the failures and inadequacy of our own best efforts.  The goal of preventing human suffering must be linked to the task of bringing others, many others, into a movement for basic rights.

The most vulnerable; those whose rights are trampled; those rarely invited to summarise their convictions for a radio audience, still believe in human rights, in spite of or perhaps because of, their own troubles.

Seeing this in Haiti and elsewhere has moved me deeply and taught me a great deal.  I move uneasily between the obligation to intervene and the troubling knowledge that much of the work we do, praised as humanitarian or charitable, does not always lead us closer to our goal.  That goal is nothing less than the refashioning of our world into one in which noone starves, drinks impure water, lives in fear of the powerful and violent, or dies ill and unattended.

Of course such a world is a utopia and most of us know that we live in a dystopia.  But all of us carry somewhere within us, the belief that moving away from dystopia moves us towards something better and more humane.

I still believe this.


My Privilege

This working week while visiting Baby 1 at his home, it transpired that another baby (Baby 2) who I had been looking for without success, was known to Baby 1’s family.  When I explained that I’d been reliably informed that Baby 2 is not in town, Mum 1 argued with me.  Amusingly in hindsight, I argued back a few times before Mum 1 suggested that she take me to Baby 2.  With the baby seat sorted, Baby 1 excitedly let me strap him in, his long black eyelashes open wide, laughing excitedly when the car started to move as Mum explained to me “He really love to cruise around”!  We drove through town, onto and along a dirt track, up a hillside through scrub and over dry rocky streams.

Above town, sitting in the dirt near an open fire beside a group of rusty tin sheds with doors but no windows, I finally met Baby 2 and her mother.  I never would have located them without Mum 1’s generous guidance.  With children running about our ankles, Mum 2 explained why she could not come with me immediately as other Mums asked did I also need to see their children?  There is no electricity and no water supply at these tin sheds they call home, and Mum 2 needed to visit a shelter in town to shower first.  This year I am working in Australia, not in Cambodia, in case this story is disorienting.

Working with indigenous people has always been an honour to me, for a number of reasons including the generosity I regularly encounter despite such marginalisation and hardship; and working with another culture where values of sharing and participation quite foreign to my own dominate strongly.  It is not too far removed from similar experiences in Cambodia.

These experiences never fail to remind me of my own privileges and how important it is to me, to use my privilege in useful ways.  Recently someone suggested to me that actually my life has not been very privileged and I shouldn’t suggest that it has been.  But referring to my privilege does not mean I am unrealistically optimistic.  I belong to the working class and grew up with various challenges that will always walk with me.  Yet compared to many, I do have privileges, that I recognise and appreciate.

Jerin Arifa is a young Bangladeshi woman described in one website as “an award winning trailblazer in women’s rights”.  Now an American citizen, she grew up in Bangladesh where her activism began in childhood.  Amidst protests from neighbours who profited from cheap child labor, Jerin and some other young people taught reading and writing to homeless youth in a park.  I can’t find how or why she made her way to America but she was an undocumented immigrant for some years, during which time she won a number of impressive academic awards.

A few years ago I first heard the term “intersectionality”.  Today I heard Jerin Arifa speak on the subject in simple and easily-understood terms.  Working with other cultures and societies, I often reflect on the social injustices I witness and am even a part of because of the systems that I belong to.  Hearing Erin speak today, intersectionality seems an articulate and essential philosophy to share.  It describes the ways in which oppressive attitudes and systems of power such as xenophobia, sexism and homophobia are inextricably linked.

Intersectionality has its roots in the feminist movement.  When the suffragettes fought for equal political rights, black women (in fact, black people), were not represented.  As one example, women in South Australia gained the right to vote in 1895, yet indigenous Australians only earned the right to vote in 1962.  Historically, intersectionality disputed the idea that gender is the only thing to determine a woman’s fate in male dominated society.  For example, women of colour, different religion, different sexual orientation, living in poverty or with disability, are not represented by the same inequalities that white women living in the mainstream middle class may experience.  The philosophy has since evolved to include inequalities and injustices beyond only those endured by women.

Jerin Arifa talks about the issue eloquently in this four minute video.

Jerin Arifa Talks Privilege and Justice

On Breastfeeding

A few blogs ago I said I would share some of the essays I write as part of my post graduate study in Child Health.

I failed my first essay, in the main for not writing it in an academic style (which requires writing in third person; using evidence from the literature; NOT using personal experience, anecdotes or opinions unless you can reference them from the literature).  Nevertheless, the issue is close to my heart so I have edited the referencing system to make it more readable, and I think it passes in blog form for anyone interested in the subject of breastfeeding, which is surprisingly fraught with political and economic agendas.

A couple of points before sharing the essay:


I shared the following story about my friend’s experience in a maternity clinic in Cambodia 3 years ago, with another Cambodian friend recently.  He stated that the public health system in Cambodia do promote breastfeeding and do not supply milk substitutes near their maternity wards or services.  Nevertheless my observation at a private maternity clinic is worth sharing, with attention to the fact that it is not necessarily “the norm”.

When I visited <friend’s> wife in the maternity hospital (private) I was shocked to see baby formula and bottled water for sale inside the hospital.  You cannot do that here because the health system want to encourage breastfeeding and will not support formula company marketing as a matter of professional ethics.  When I tried to find out the name of the formula company owner, it seemed that it is a French company, with a very high profit margin.

At the time of the baby’s birth my friend rang me.  He was holding a very distressed baby and I suggested the baby was hungry.  He agreed but the hospital staff shut the baby outside with Dad and Grandmother, to “check Mum”. The baby cried for an excessive period of time and they were denied access to Mum.  Eventually Grandmother surrendered and bought formula and bottled water at the shop downstairs. It appeared to my outsider eyes, as a deliberate tactic.


While exclusive breastfeeding for the first six months of a baby’s life is the optimal practice for multiple health reasons, mothers who do not or cannot sustain this should not be judged and their babies can still lead healthy lives.  I am aware that many mothers have felt unreasonable pressure to exclusively breastfeed, and then guilty when they have been unable or chosen not to.  It is not my intent to make anyone feel guilty because of their choices or individual circumstances.

Critical Analysis of a National Health Promotion Program
Baby Friendly Health Initiative

More recently named the Baby Friendly Health Initiative (BFHI), I first learned about the Baby Friendly Hospital Initiative during my Public Health studies over 17 years ago.  In 1991, World Health Organisation and UNICEF introduced the BFHI, “to protect, promote and support breastfeeding in all birth settings”1.  The initiative was introduced in Australia in 1993 and has been governed by the Australian College of Midwives since 19952.  The Australian Breastfeeding Association3 state that the BFHI project “aims to give every baby the best start in life by creating health care environments where breastfeeding is the norm and practices known to promote the health and wellbeing of all women and babies are followed”.

As outlined by the Australian College of Midwives2, BFHI accreditation is awarded to hospitals which meet certain standards relating to consistent and accurate information and support to mothers as they establish feeding.  A critical component of these standards is the WHO International Code of Marketing of Breast-milk Substitutes (“The Code”).  The Code comprises ten main points requiring that facilities in no way display, advertise, promote, provide products or otherwise engage with companies who sell infant milk substitutes, bottles and teats.  In Australia The Code is applied in part by the Marketing in Australia of Infant Formula (MAIF) Agreement, in which manufacturers and importers have voluntarily signed a self-regulatory code of conduct4.

Aware of The Code as a global initiative 17 years ago, I assumed effective global implementation was in place.  However in recent years I have spent time in Cambodia, where I learned that in those countries without strong health systems, who are in most need of protective policies such as Baby Friendly Health Initiatives, practices violate recommended guidelines.  Through many friends and colleagues in Cambodia, I have observed that the marketing of infant milk substitutes is blatantly immersed in maternal and child health care provision.  Milk substitutes, bottled water, bottles, teats and other related paraphernalia are stocked and sold inside private maternity clinics.  Established practices appear to discourage exclusive breastfeeding in favour of either adding or replacing with milk substitutes, generating a profit to providers.  It seems the milk substitute scandal that rocked the world in the early 1970s5, when it was disclosed that milk substitute companies were marketing their products aggressively and unethically in poor countries, leading to untold infant disease and mortality, continues today in many vulnerable places.  My personal observations are supported by Ellis-Petersen H6 who confirms that health providers from some of the world’s poorest countries are given financial and other incentives by milk substitute manufacturers, to promote their products at the expense of breastfeeding.

According to the Department of Health’s Australian National Breastfeeding Strategy : 2017 and Beyond7, who recommend exclusive breastfeeding to around 6 months of age, “Evidence shows that breastfed babies are less likely to suffer from necrotising enterocolitis, diarrhoea, respiratory illness, middle ear infection, type 1 diabetes and childhood leukaemia.  Available evidence also shows that breastfed babies have enhanced cognitive development.  Breastfeeding also benefits mothers by promoting faster recovery from childbirth, reducing the risks of breast and ovarian cancers in later life, and reduced maternal depression”.  Referring to this page on the DOH website, it is possible to locate information on the Baby Friendly Health Initiative, but it is mentioned only briefly and near the bottom of the page.  The Department of Health also state that in Australia, 90% of children are initiated on exclusive breastfeeding, but only 15.4% of babies are exclusively breastfed to 5 months of age7.

The gap between what we know (exclusive breastfeeding to 6 months of age is optimal) and what happens in Australia (only 15.4% of children come near this target), suggests that improvements are needed in our breastfeeding health promotion strategies.  The fact that 90% of Australian mothers initiate exclusive breastfeeding suggests that sufficient information is available and intent exists in the baby’s first hours, days or weeks.  Something changes beyond that which needs to be addressed.

Holowko N et al8 found that breastfeeding rates in Australia have not increased substantially since 2001, although more infants are now breastfed for the minimum recommended six months.  They also found a correlation between women who have a low education or a low-educated parent, and lower rates of initiating breastfeeding, or maintaining breastfeeding to the recommended six months.  This evidence suggests a socio-economic link, identifying a possible target population for whom health promotion activities should focus.

With only 15.4% of Australian infants exclusively breastfed to the recommended six months of age, Hauck YL et al9 investigated the categories women listed as supporting their breastfeeding capacity, in an international study including women from Australia, Sweden and Ireland.  The categories are listed here in ranking of importance as outlined by the 449 Australian women in the study: breastfeeding was going well; maternal knowledge of health benefits; health professional support; informal face to face support; maternal self-determination; partner support; maternal knowledge of psychological benefits; cultural norm; work environment; informal online support.  This study outlines some possibilities for health promotion in encouraging breastfeeding in the Australian population.  It could be possible that the most important category for Australian women (breastfeeding was going well) is in fact influenced by other categories given less importance, such as partner support, cultural norm and work environment.  Some influences may even be unidentified, for example the comparison between Australia where The Code prevents marketing of infant milk substitutes in or near maternal and child health facilities and Cambodia where such marketing is highly visible.

Given the (often negative) attention that breastfeeding receives in the Australian media, it is probably necessary for health promotion to target not just young, antenatal or breastfeeding women, but also the general population.  Anecdotal evidence suggests some stigma attached to what is and is not appropriate in relation to breastfeeding infants in public places.  The Australian Breastfeeding Project, started in 2015, aims to reduce stigma and keep mothers breastfeeding for longer, with a group of breastfeeding women giving mixed reports around the issue of stigma attached to breastfeeding in Australia10.

In April and May 2017 the Australian Health Ministers’ Advisory Council held a series of stakeholder consultation workshops as part of the implementation of the Australian National Breastfeeding Strategy : 2017 and Beyond7.  As per Fact Sheet 2 in the reference, participants recommended a national campaign, identifying that mothers cannot be the only target population in any health promotion campaign, and that mothers, partners, families, the health system, governments and the community at large have a shared responsibility to make breastfeeding a biological and cultural norm.  I would argue that while the community at large have a shared interest in ensuring our future generations have the best start possible in life, without appropriate awareness campaigns their responsibility relating specifically to breastfeeding is limited.  Participants also recommended strengthened implementation of The Code on Marketing of Breastmilk Substitutes; increased support and funding for the BFHI, such as making BFHI a requirement of accreditation; research to understand the barriers and allow better targeting of priority groups; as well as other recommendations which can be found in the reference.

A 2012 opinion piece by Barker R11 states that very few women in Australia deliberately choose to abandon breastfeeding, and that it is the circumstances around breastfeeding that lead women to stop breastfeeding early.  These circumstances are listed as including the commercialization of readily available breastmilk substitutes with manufacturers exploiting a loophole in the MAIF Agreement ; unresolved breastfeeding problems met with conflicting advice; early return to paid work requiring some form of supplementation; and lack of family and community support.  Barker offers a number of solutions including one year of paid maternity leave; allocation of funding to research breastfeeding problems and how to manage them; defragmentation of perinatal care; end milk substitute manufacturers’ exploitation of a loophole in the MAIF agreement which allows for certain milk substitute advertising; plain packaging of infant milk substitutes; and all milk substitutes in the first six months to be available by prescription only.  This piece is written by a retired Midwife and Child and Family Health Nurse with 30+ years of experience, however it remains an opinion piece and further study is needed to provide objective information on the reasons and solutions for early breastfeeding abandonment.

The Baby Friendly Health Initiative is clearly successful at promoting breastfeeding initiation in Australian women but it falls short in promoting appropriate duration of breastfeeding.  The initiative is directly linked to the Australian College of Midwives, whose role starts in the antenatal period and normally ends with domiciliary care termination at around six weeks of age, when Child and Family Health Nurses assume responsibility.  Better integration of services between Midwifery care and Child and Family Health Nurse care could potentially be required, as mentioned in some of the literature about fragmented care and conflicting advice.  I suggest that the BFHI should be part of a more comprehensive program connecting to services beyond Midwifery and Child and Family Health, to capture the attention of a broad range of service providers, consumers and the general community.

Only targeting young women and mothers designates the issue of breastfeeding as a female / mother-specific concern, ignoring the investment needed from partners, families, the health system and the wider community.  BFHI is specific to maternal and child health care facilities, which may be too narrow a focus for a successful breastfeeding health promotion campaign?  However, aspects to maternal and child care obviously do need improvement, such as providing more specialized support via lactation consultants, research into the problems women experience with breastfeeding and a more consistent approach between health professionals regarding appropriate advice and support for solutions.  Establishing the BFHI as a requirement for hospital and health facility accreditation will also bring the issue to the forefront of all health services, not only those who already have a breastfeeding focus.  The Department of Health’s Breastfeeding website page only mentions BFHI briefly, with the Australian College of Midwives and Australian Breastfeeding Association – two non governmental agencies – being the initiative’s main representatives and advocates.  I suggest that the DoH need to give a more significant priority to BFHI, to highlight it as an important intervention embraced across government and non-government agencies.

As a privileged and developed nation geographically positioned so close to some of the world’s least privileged nations, Australia also has a more global role to play.  While various infant milk substitute companies are signatory to the MAIF Agreement here in Australia, those same companies are not only exploiting loopholes in the Australian agreement they have signed, but they are clearly exploiting vulnerable populations in our region and beyond, whose children most need the protection breastfeeding offers.  Australia are already building partnerships in places like Cambodia, for example the WHO Collaborating Centre at the University of Technology Sydney, who this year launched a Bachelor of Science in Midwifery Bridging Course at the University of Health Sciences in Phnom Penh in collaboration with UNFPA12.  The aim of this partnership is to reduce maternal and neonatal mortality in Cambodia.  Partnerships such as this are well positioned to advocate for the implementation of Baby Friendly Health Initiatives in some of the world’s most vulnerable places, making Australia a potential leader of the Baby Friendly Health Initiative on a global scale.

As a health promotion program the BFHI has an imperative role in promoting breastfeeding as a culturally normal, biologically desirable start to life for all Australian children.  There are successes worth celebrating since the BFHI was introduced to Australia 25 years ago, but there are also gaps in the program which need to be strengthened to improve our national breastfeeding outcomes.  Australia’s strong and functional health system also has a role to play beyond our national borders for the good of the world’s most vulnerable populations.


  1. World Health Organisation (n.d.), Baby-friendly Hospital Initiative,
  2. Australian College of Midwives (undated), What is the WHO Code?,
  3. Australian Breastfeeding Association (undated), Is Your Hospital Baby Friendly?,
  4. Department of Health (March 2005), Marketing in Australia of Infant Formulas: Manufacturers and Importers Agreement – the MAIF Agreement,
  5. Muller, M (1974), ‘The Baby Killer’, War on Want,
  6. Ellis-Petersen Hannah (27 February 2018), ‘How formula milk firms target mothers who can least afford it’, The Guardian
  7. Department of Health (November 2017) Australian National Breastfeeding Strategy : 2017 and Beyond,
  8. Holowko N, Jones M, Koupil I, Tooth L, Mishra G (2015), ‘High education and increased parity are associated with breastfeeding initiation and duration among Australian women’, Public Health Nutrition Vol 19(14), pp 2551-2561
  9. Hauck YL, Blixt I, Hildingsson I, Gallagher L, Rubertsson C, Thomson B, Lewis L (2016) ‘Australian, Irish and Swedish women’s perceptions of what assisted them to breastfeed for six months: exploratory design using critical incident technique’, BMC Public Health Vol 16:1067
  10. Tovey A 2015 ‘Breastfeeding photo project helps reduce stigma and keeps mothers feeding for longer’, ABC News online 15 March 2018,
  11. Barker R 2012 ‘Duration not initiation is the real breastfeeding battle’, ABC News online 5 November 2012,
  12. University of Technology Sydney (3 April 2018), ‘New partnership to boost midwifery education in Cambodia’,