Innocenti Declaration on the Protection, Promotion and Support of

This latest WHO/UNICEF initiative led to a meeting, titled "Breastfeeding in the 1 990's: A global initiative", at the international assembly of August 1 990, during

which the Innocenti Declaration on the Protection, Promotion and Support of

Breastfeeding was designed (World Health Organisation & UNICEF, 1 990). The

declaration states that breastfeeding provides infants with the ideal food needed for growth and development, reduces the incidence of infant morbidity and mortality, results in enhanced health for women, and is economically beneficial.

It stipulates that the minimum age that all infants should be exclusively ,

breastfed is four to six months, and that breastfeeding should continue for at least the first two years of age. The declaration also states that "all women should be enabled to practice exclusive breastfeeding" (World Health Organisation & UNICEF, 1 990, p. 1 ).

The declaration also outlines targets for individual countries to achieve, including the appointment of a national breastfeeding coordinator, the establishment of a multi-sector national breastfeeding committee, ensuring hospitals support the 'Ten steps to successful breastfeeding', compliance with the Code, and legislation to protect breastfeeding women. It was hoped that the Innocenti Declaration would pressure governments to implement policies that would support women to breastfeed.

In 1 990 the New Zealand Department of Health signalled their support for the Innocenti Declaration. Responding to pressure from professional groups such as The Lactation Consultants Association (Vogel & Mitchell, 1 998c) and lay groups including La Leche League (Gordon, 1 998), the Department of Health convened a meeting in 1 99 1 to re-consider the Code's place within New

Zealand. In 1 992, the department developed a 'breastfeeding kit' to educate health care professionals working for the Royal New Zealand Plunket Society, and within the hospital system, about the Code and the Innocent; Declaration.

However, a national breastfeeding coordinator has never been appointed. Furthermore, legislative policy requiring companies to comply with the Code has not been developed and, to date, compliance with the Code remains voluntary. A committee to monitor the implementation of the Code was eventually

established in 1 998; however, as was the case with the 1 983 Breast Milk Substitutes Monitoring committee, it lacks the authority to enforce the Code. New Zealand has had only limited success with the Innocenti Declaration, which has been attributed to the lack of a co-ordinated effort on its behalf (Beasley &

Trlin, 1 998). It has also been suggested that there has been a lack of

commitment to, and financial support for, implementation of the Code in New Zealand ( Dignam, 2001 ).

However, it became evident early on that New Zealand was not the only country having difficulty ensuring that the Code and the Innocenti Declaration were adhered to. This prompted a group of 1 7 international organisations to form the World Alliance for Breastfeeding Action (WABA) in 1 99 1 (Baumslag & Michels,

1 995). WABA supports breastfeeding through World Breastfeeding Week, which is held each year a nd through collaboration with UNICEF. In 1 992, the theme for World Breastfeeding Week was the Baby Friendly Hospital Initiative

(BFHI). New Zealand took part in celebrating the 2002 World Breastfeeding Week, which assisted in raiSing the profile of both breastfeeding and the BFHI i n this country (Heritage, 2003).

2.7.2 The Baby Friendly Hospital Initiative

The fact that most women give birth to their babies within a hospital setting led the WHO and UN ICEF to develop guidelines for encouraging breastfeeding in maternity facilities, resulting in the Ten steps to successful breastfeeding (World Health Organisation & UNICEF, 1 989). These steps outline how health care professionals should go a bout ensuring that breastfeeding is protected and promoted within the hospital setting. Each of the ten steps is supported by

research that highlights how it can support women to breastfeed2. It was hoped that the implementation of these steps would revolutionize practices, especially in m aternity hospitals and associated facilities.

The g uidelines form the basis of the Baby Friendly Hospital Initiative (BFHI ), which was launched in 1 991 by the WHO and UNICEF. The BFHI was established with the aim of empowering women throughout the world to breastfeed, and eliminating the provision of artificial formula within the hospital setting. The New Zealand College of Midwives included the Ten steps to successful breastfeeding in their publication Protecting, promoting and supporting breastfeeding (New Zealand College of Midwives, 1 992). The Ten steps to successful breastfeeding was also adopted by the Royal New Zealand Plunket Society, which, in 1 996, published their own breastfeeding policy, adapting the document to better fit the services offered by the community-based organisation.

By the mid-1 990s, New Zealand government agencies were beginning to respond to pressure from lobby groups, and in 1 994 the Ministry of Health convened a meeting of interested parties to discuss how the BFHI might be implemented. It was concluded that the BFHI should serve as a vehicle through which to increase breastfeeding rates in New Zealand (Vogel & Mitchell, 1 998c). The Ministry oversaw the formation of the BFHI taskforce, which became known as the New Zealand Breastfeeding Initiative Taskforce (NZBIT), and reported to the Ministry as well as to the Public Health Commission.

That year the Public Health Commission acknowledged the importance of breastfeeding, and outlined targets for breastfeeding rates, which included increasing the number of exclusively breastfed infants at three months of age to 75% (Public Health Commission, 1 994). In 1 995, the Public Health Commission also specifically mentioned the BFHI in the publications Food and nutrition 2 For further information about the research that formed the basis for the Ten Steps to Successful Breastfeeding please refer to the following authors: Step one (Ellis, 1 992); Step two (Auerbach, 1988; Becker, 1 992); Step three ( Rentschler, 1 991 ); Step four

(Kuriniji & Shiono, 1 991 ); Step five (Slavin & Harvey, 1 98 1 ); Step six (Glover &

Sandilands, 1 990); Step seven ( Keefe, 1 986); Step eight ( De Carvalho, Robertson, Friedman, & Klaus, 1 983); Step n ine ( N ewman, 1 990); Step ten ( Kyenkya-Isabirye &

guidelines· for healthy infants and toddlers (Public Health Commission, 1 995a; 1 995b), and Food and nutrition guidelines for healthy breastfeeding women (Public Health Commission, 1 995a; 1 995b). However, no funding was m ade available for the operation of the NZBIT (New Zealand Breastfeeding Authority, 2000; Vogel & Mitchell, 1 998c). Following the 1 997 New Zealand Lactation Consultants Association Conference, the Lactation Consultants' Association, La Leche League New Zealand, and the College of Midwives joined forces to submit a proposal to the Health Funding Authority to implement BFHI (Vogel & Mitchell, 1 998c). Their proposal was not funded.

In 1 998, the Ministry of Health published Progress on Health Targets, which noted that the goals set for breastfeeding rates had not been achieved (Ministry of Health, 1 998). The report highlighted changes to global policy as

implemented by the WHO (World Health Organisation & UNICEF, 1 990), and offered an assessment of why the goals had not been met; however, this discussion was limited because of a lack of available research that explored the reasons why women were not breastfeeding, with only one study being cited by way of explanation (Basire, Pullon, & McLeod, 1 997).

That same year saw the establishment of the New Zealand Breastfeeding Authority (NZBA), a coalition of 30 stake holder organisations that included midwives, La Leche League representatives, medical practitioners, dieticians, and representatives from the Royal New Zealand Plunket Society. The NZBA was granted funding in 1 999 by the Health Funding Authority to establish the

BFHI within New Zealand. The funding contract provided for the establishment of structures to support the implementation of BFHI within New Zealand, and initiate training for BFHI assessors (New Zealand Breastfeeding Authority, 2000).

It became evident when assessing breastfeeding rates that there was a need to streamline the manner in which national health targets for breastfeeding were measured. Therefore, the Ministry of Health commissioned a document that reviewed, and provided recommendations for, national breastfeeding definitions (Coubrough, 1 999). The report compiled research and expert opinion on how breastfeeding rates could be measured against precise definitions, for the purpose of accurately assessing New Zealand's success at meeting its targets.

The year 2000 saw the establishment of a NZBA Committee and an

Implementation Advisory Group to oversee implementation of the BFHI in New Zealand. A national co-ordinator was appointed to manage the initiative and, by the end of the year, 1 7 trainers had completed the NZBA's BFHI training course (Stufkins, 2000).

A survey of New Zealand hospitals was undertaken in 2000 to assess compliance with the Ten steps to successful breastfeeding (Pownall, 2000).

The results demonstrated that few hospitals had an organisation-wide

breastfeeding policy, and it was noted that few hospitals actually had education programmes that informed staff about breastfeeding. The study also highlighted that hospitals were struggling to comply with the BFHI because of the inflexible nature of the ten steps, the inconsistencies inherent in the assessment process, and the financial commitment needed to the meet the initiative requirements. Probably the most significant difficulty for hospitals wishing to implement the BFHI was that independent maternity care providers did not have reporting mechanisms by which their practice could be monitored.

In 2001 the Ministry of Health released a tool kit for the District Health Boards (DHBs), called Improve Nutrition (Ministry of Health, 200 1 ). The tool kit directs DHBs to support their maternity facilities to attain BFHI accreditation; however, the way in which this is achieved is left to the discretion of the DHBs.

2.7.3 2002-2003

In 2002, the World Health Assembly convened in Geneva with the goal of formulating a global strategy for infant and young child nutrition and feeding. The Assembly adopted a resolution stating that infants should be exclusively breastfed for six months, with continued breastfeeding for up to two years or beyond (World Health Organization, 2002). As a matter of urgency, the Assembly called for governments to "formulate, implement, monitor, and evaluate a comprehensive policy on infant and young child feeding" (World Health Organization, 2002, p. 1 3). The World Health Assembly

recommendation was endorsed by the WHO, which has since adopted the global strategy.

The New Zealand Ministry of Health has yet to establish a policy to implement the World Health Assembly's resolution (Ministry of Health, 2002), although it has published Breastfeeding: A guide to action in 2002. This document highlights that there have been no significant changes to breastfeeding rates in New Zealand over the past ten years, and presents a plan to increase these rates in 2002/2003. It specifies seven goals, which include the establishment of a national breastfeeding coordinator, the achievement of Baby Friendly

Hospitals throughout New Zealand, an increased focus on rendering culturally­ appropriate breastfeeding support, enhanced support of breastfeeding

promotion, improved access to antenatal education, and the provision of quality care during the postpartum period (Ministry of Health, 2002).

At the time of writing, some 1 3 years since the inception of the BFHI , only six of New Zealand's 85 maternity facilities have attained 'Baby Friendly Hospital Status' (Heritage, 2003). This contrasts sharply with the success of many developing nations such as Kenya, which has 232 facilities with BFHI status, Nigeria with 1 1 47, and the Philippines with 1 047 (UNICEF, 2002). Although its not clear what breastfeeding definitions have been employed, nor how strict the assessment processes and criteria for approval are, the number of approved hospitals in these developing countries does play to the spirit of the BFHI concept. The New Zealand Government has been hesitant to make the necessary changes at a policy level and pursue strategies to support breastfeeding women. Strategies that have been suggested have been primarily population-based, without emphasis on understanding the personal meaning of breastfeeding for breastfeeding women.

In 2002, Minister of Health Annette King noted that a woman's decision to breastfeed is influenced by "social norms and by the beliefs and values of women and their Significant others" (Ministry of Health, 2002, p. iii). The goals recommended to increase breastfeeding rates take into account a woman's need for support from SOciety in the form of BFHI and community strategies. However, until these societal factors and women's beliefs and values regarding breastfeeding are addressed, the suggested strategies will not alter the current demographic trends.