applying gender-responsive budgeting and the wbci …...underpinned by mother nature and the...

Applying gender-responsive budgeting and the WBCi tool to maternity care in Australia’s federal system

• Honorary Associate Professor Julie Smith

• Research School of Population Health (RSPH), ANU

• Naomi Hull, WBTi Australia• Alessandro Iellamo, Save the Children

PresenterPresentation Notes .

Overview – using human rights and gender budgeting for advocacy on maternity care • Introductory gender analysis on implementing the WHO Code in

health care systems and the Ten Steps within maternity facilities.

• Uses gender budgeting approach to describe key policies and help identify key actors and avenues for advocacy.

• Shows that effective Code regulation of marketing in health channels and mandating BFHI criteria in Australia’s hospital accreditation would – better enable breastfeeding, – be cost saving for budgets, and – advance gender equality.

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PresenterPresentation NotesUsing a human rights framework and gender budgeting for effective advocacy on ANBS maternity care policy actionsThis presentation is about how we can use a human rights framework and a gender budgeting approach and tools to more effectively advocate for resourcing and implementation of ANBS actions on maternity care. It provides an introductory gender analysis which highlights the significance of implementing the WHO Code in health care systems and of the Ten Steps within maternity facilities.It uses a gender budgeting approach to describe key policies and identify key actors and avenues for advocacy. We conclude that effective Code regulation of marketing in health channels and mandating BFHI criteria in Australia’s hospital accreditation would better enable breastfeeding, be cost saving for budgets, and advance gender equality.

Breastfeeding support as a reproductive health right

Galtry J. Strengthening the human rights framework to protect breastfeeding: a focus on CEDAW. International Breastfeeding Journal 2015;10(1):1.Jonsson U. Breastfeeding a human rights perspective. The 6th Nordic Breastfeeding Conference. Frösundavik, Sweden; 2015.Meier BM, Labbok M. From the Bottle to the Grave: Realizing a Human Right to Breastfeeding through Global Health Policy. Case W. Res. L. Rev. 2009;60:1073.Van Esterik, P. (1994). Breastfeeding and feminism. International Journal of Gynaecology and Obstetrics, 47 Suppl, S41-50; discussion S50-44. doi:10.1016/0020-7292(94)02233-o

PresenterPresentation NotesHuman rights and resources for realising themBreastfeeding is a human right of both women and young children. The rights of women in maternity care have suffered even more ‘egregious breaches’ during COVID 19.Governments have endorsed human rights treaties which declare their commitment to human rights, and have a duty to their citizens to implement measures to advance those rights, as far as feasible. Feminists have identified the obligations for governments to invest ‘maximum feasible resources’ towards realising human rights. Breastfeeding advocates have identified that governments do not provide the necessary resources for implementing policies that would enable more women and children to breastfeed.Human rights experts point out that rights holders need data and information, and pathways for redress and action to demand and claim their rights from duty bearers, such as parliaments, governments and companies.Gender equality is not that ‘women should be like men’. Inequality can arise from structural barriers and indirect discrimination. This means that different treatment might be needed to achieve equality in practice, and that it may need transformation of institutions. A central concept is investing in capabilities, in particular, ‘a good society must arrange to provide care for those in a condition of extreme dependency, without exploiting women as they have traditionally been exploited, and thus depriving them of other important capabilities.(Martha Nussbaum 2009)Regarding the breastfeeding relationship, this means we need to focus on the capabilities of individuals, and over their life course, and consider how to achieve more equal distribution of the cost and burden of care, as well as provide for specific capabilities for material wellbeing of women, for example, income, leisure, health on an equal basis.

Gender responsive budgeting improves budgeting

Source: Henderson (1982) in Sharp (2017) GRB with special reference to the unpaid economy, University of South Australia

• Human rights and maximum feasible resources

• The economy includes and is underpinned by mother nature and the unmonetized (unpaid) sector

• Take account of different situations of women and men

• Gender responsive budgeting - a tool for gender equality; more effective and efficient resource use; quality of decision-making, accountability and transparency

• Analyse gender impact of processes and policies to develop policies to promote equality between men and women

Gender Analysis to unpack gender differentiated direct and indirect impacts of budget and policies on the paid and unpaid spheres of the economy.

Actions to change budgetary decision-making processes and priorities that bring about spending and taxation changes that promote gender equality.

Describe situation, assess policy, scrutinise resourcing, monitor trends, evaluate results

Stewart, M., & Costa, M. (2020). Gender-responsive budgeting and breastfeeding, Gender Responsive Budgeting and Progressing Breastfeeding Policy in 2020 and Beyond http://genderinstitute.anu.edu.au/gender-responsive-budgeting-and-progressing-breastfeeding-policy-2020-and-beyond-introductory.Stewart, M., Smith, J. P., & Guzman, M. S. (2019). Submission to Victorian Parliament Public Accounts and Estimates Committee Inquiry into Gender Responsive Budgeting

PresenterPresentation NotesGender budgeting – budgets are not gender neutralGender budgeting originated in Australia and a central concept is to challenge the idea that government spending and revenue raising affect men and women the same. Instead, it is argued, women and mean are situated differently in society and the economy, so fiscal policies affect women and men differently.The budgeting process and gender outcomes are not always transparent or evident because of who is or are not represented in decisionmaking, and what outcomes are measuredHowever the different situation of men and women in the process and in how they are affected influences the effectiveness and efficiency of policies and programs as well as gender equality.Gender budgeting is a structured approach to analysing decisionmaking, resource allocations and inputs from a gender perspective – gives new insights into where rights are not being spoken for, or resourced and realised and avenues for addressing that. It includes analysis to unpack the gender differentiated impacts, and actions to change budgetary decision-making processes and priorities to bring about budgeting changes that promote gender equality.It can be viewed as an accountability tool linking governments’ budget interventions with its commitments and recognition of women’s needs and rights (Costa et al 2019)Gender budgeting promotes good budgeting, by Better collection of data and analysisImproved budget decisionmakingIncreased resourcing of areas that reduce inequality in economic and social areas between men and womenIt sets out a five step approach of describing the situation, assessing policy, scrutinising resourcing, monitoring trends and evaluating results. To do this it categorises programs into three types of programs. It analyses the gender impact of mainstream programs as well as women specific programs and agency internal programs because there are important differential impacts in mainstream programs which are the biggest part of budgets. For example where does BFHI fit? Delivered by states but funded via federal state health agreements. Where does WHO Code implementation occur? Can include human rights offices, as we as programs.It also highlights that advocacy actions need to apply at different stages of the budget cycleFormulationExecutionImplementation Evaluation and audit

http://genderinstitute.anu.edu.au/gender-responsive-budgeting-and-progressing-breastfeeding-policy-2020-and-beyond-introductory

The importance of accounting for the non-market household economy

Source: UN Women/Neelabh Banerjee

Develop a Breastfeeding Budget through:

• “Dialogue between gender budget analysts and breastfeeding advocates.

• Endorsing and implementing the GSIYCF.

• Implementing and monitoring the International Code

• Integrating breastfeeding into discussions about care work.

• Counting the value of human milk and breastfeeding in GDP.

• Highlighting national breastfeeding rates along with other measures of women’s empowerment.”

Building ‘Breastfeeding Budgets’ … for economic efficiency andgender equity

PresenterPresentation NotesGender budgeting makes visible the non market economy.Policymakers for example competition or trade regulators often neglect to consider the non market economy. The non market economy includes unpaid household production but also other ‘women’s work’ such as nursing or childcare. It also includes volunteer breastfeeding counsellors. In 2008, the Breastfeeding Advocacy Team (UNBAT) which comprises Non- Governmental Organizations that focus on breastfeeding, proposed a Breastfeeding Budget (page 2) and suggested the need to ‘begin a dialogue between gender budget analysts and breastfeeding advocates’.Breastfeeding is a good case study for gender analysis because it exemplifies the care economy. ‘Extreme care’, can place considerable demands on women, has costs for womenOften viewed as free, natural, unskilled, undemanding …Influenced by both biology and social norms and institutionsInteracts with market economy, has economic valueMay be shifted/compete such as cutbacks to childcare services, marketing of BMS

https://www.facebook.com/unwomen?group_id=0

Gender, babies and breastfeeding

Mulford C. Is breastfeeding really invisible, or did the health care system just choose not to notice it? International Breastfeeding Journal 2008.Mulford C. Are we there yet? Breastfeeding as a gauge of carework by mothers. In: Smith PH, Hausman B, Labbok M, editors. Beyond Health, Beyond Choice: Breastfeeding Constraints and Realities: Rutgers University Press; 2012. p. 123-132.

Breastfeeding as archetypal example of careworkand structural determinants of health

Components of an enabling environment for breastfeeding —a conceptual model

Rollins NC, Bhandari N, Hajeebhoy N, et al. Why invest and what it will take to improve breastfeeding practices. The Lancet 2016; Vol 387 January 30, 2016:491–504

PresenterPresentation NotesThe components of an enabling environment for breastfeeding—a conceptual modelIt is now recognised that an enabling environment is needed for breastfeeding, it is not just an individual level decision. Structural factors are important. While the whole population is exposed to a range of social and cultural factors relevant to breastfeeding, pregnant and breastfeeding women may be affected in more direct and personalised ways.

Figure 1

The Lancet 2016 387, 491-504DOI: (10.1016/S0140-6736(15)01044-2)

Linking human rights and gender budgeting to breastfeeding policies and programs?

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What Australian government policies intersect to affect breastfeeding, at what level?

Direct/targeted policies that affect breastfeeding

‐Identify level of government, and goal /metrics of policy, time period, etc‐Identify budget allocation (and revenues needed)‐Ensure budget execution is done properly, tracked, monitored‐Evaluation and renewal/retargeting

Indirect/general policies that affect breastfeeding

‐Require mass/systemic change‐Engaging both market/care economy‐Engaging federal/mass policy, tax, transfer, work systems

Stewart, M., & Costa, M. (2020). Gender-responsive budgeting and breastfeeding, Gender Responsive Budgeting and Progressing Breastfeeding Policy in 2020 and Beyond http://genderinstitute.anu.edu.au/gender-responsive-budgeting-and-progressing-breastfeeding-policy-2020-and-beyond-introductory.Smith, J. P. (2020). Addressing and prioritising the invisible IYCF economy in economic statistics and budget policymaking. Gender Responsive Budgeting and Progressing Breastfeeding Policy in 2020 and Beyond. http://genderinstitute.anu.edu.au/protecting-women%E2%80%99s-reproductive-rights-policy-and-resourcing-decisions-%E2%80%93-need-%E2%80%98data-and-dollars%E2%80%99Stewart, M., Smith, J. P., & Guzman, M. S. (2019). Submission to Victorian Parliament Public Accounts and Estimates Committee Inquiry into Gender Responsive Budgeting.

PresenterPresentation NotesSo how does gender budgeting link to governments fiscal policies “Gender budgeting would ensure that the health of women and children and gender equality are addressed by adequate fiscal policies and federal-state agreements on public contributions to these agreed actions” (Stewart, Smith 2019)

– Describing the infant and young child food economy– Assessing policies - maternity services as a key marketing

channel– Scrutinising budgets and resources revealing

underinvestment in breastfeeding and lactation support

Gender responsive budgeting and maternity care

Smith, J. P. (2020). Addressing and prioritising the invisible IYCF economy in economic statistics and budget policymaking. Paper presented at the Gender Responsive Budgeting and Progressing Breastfeeding Policy in 2020 and Beyond Australia. http://genderinstitute.anu.edu.au/protecting-women%E2%80%99s-reproductive-rights-policy-and-resourcing-decisions-%E2%80%93-need-%E2%80%98data-and-dollars%E2%80%99

Describing the infant and young child (IYC) food economy

Smith, J. P. (2004). Mothers' milk and markets. Australian Feminist Studies, 19(45, November), 369. Smith, J. P. (2015). Markets, breastfeeding and trade in mothers' milk. International Breastfeeding Journal, 10( ), 9. doi:10.1186/s13006-015-0034-9

PresenterPresentation NotesDescribing and assessing the infant and young child (IYC) food economy A gender analysis of the infant and young child economy highlights the invisibility of women’s paid and unpaid work including breastfeeding and breastfeeding support. Although breastfeeding in Australia has been valued at around $4 billion a year, compared to half a billion of commercial baby food sold, it is rarely considered as part of the productive economy. This also influences the position of workers in related areas of the market economy, where care work is poorly paid and not valued. Skills and qualifications of such health workers are discounted, and women are poorly represented in decisionmaking. Milk banks have trouble getting funded.ACCC Determination 15 July 2016

Assessing policies: Competitive marketing pressures harm women & children, and the economy

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‘Manufacturers invest in a broad range of marketing activities to expose their brands to consumers, communicate the benefits of their products and encourage early adoption (i.e. lock-in) and/or switching by a minority of consumers at the margins.

In this regard, CCS notes that marketing expenditure by manufacturers increased significantly over the period of study. In particular, the hospital channel receives a significantly higher share of marketing expenditure compared to its share of total revenue.

Manufacturers provide sponsorship and/or payments to the private hospitals for participation in their milk rotation systems.

Given that majority of parents who use Formula Milk in hospitals do not have a preferred brand and tend not to switch brands of Formula Milk after leaving the hospital, manufacturers have invested significant efforts and resources into the marketing activities in the hospital channel to gain a ‘first-mover’ advantage .

PresenterPresentation NotesAssessing policies – competitive marketing harms women and babies, reduces breastfeeding and the IYC food economy and adds to health costsIt has long been recognised that competitive marketing pressures harm women and babies. The WHO International Code recognises that women and babies are uniquely vulnerable to marketing hence ‘usual marketing practices are unsuitable or these products’. The Code provisions addressing marketing practices in health channels recognise that manufacturers invest heavily in marketing through hospitals so as create dependency on formula. This is a valuable distribution network, hence companies will pay to be in it, or give free or low cost supplies and other benefits such as education events.Without Code implementation to protect mothers, markets will be bigger but mothers and babies more vulnerable.

Health care systems as distribution channel for formula

Hospital based systems of maternity care have provided a system through which formula feeding can be systematically and aggressively marketed to all women.

PresenterPresentation NotesHealth care systems as distribution channel for formulaLow-priced formula to health providers adds to risk of conflict of interest for health care workers and health care institutions created through other interactions offered by major formula manufacturers. These include industry-provided training and education activities, or sponsorship and travel support, which work against professional motivations to better support breastfeeding and obtain relevant education and training from sources independent of the commercial baby food industry. Hence, allowing marketing through low cost supplies of infant formula to the health sector is detrimental to dynamic efficiency as it reduces innovation and undermines sound ethics and business practice in the health care sector.Free or low cost supplies of formula to health services is commercially advantageous, but economically inefficient as it competes with breastfeeding and breastmilk provisionProfitability and viability of enterprises that support breastfeeding are undermined Incentives for innovative care models are reduced.

‘Ten Steps to Unsuccessful Breastfeeding’

‘Ten Steps to Unsuccessful Breastfeeding (Evidence based ways to prevent breastfeeding):

1. medicated birth2. separation of mother and infant3. routine supplementation with formula or other fluids4. dummies5. scheduled feeds6. restricted number and duration of feeds7. test weighing8. early introduction of solids and juices9. weight charts based on formula fed infants10. lack of skilled, sensitive support

WHO. Division of Child Health and Development. Evidence for the Ten Steps to Successful Breastfeeding. Vol. WHO/CHD/98.9. Geneva: World Health Organisation, 1998.Enkin MW, Keirse MJ, et al. A guide to effective care in pregnancy and childbirth. Oxford: OUP, 1995.

‘The baby-friendly approach is effective in increasing exclusive breastfeeding rates. Evidence exists for the effectiveness of individual steps, but even more so for full implementation of all steps together.’

WHO 2009

PresenterPresentation NotesTen steps to unsuccessful breastfeeding Code and BFHI is about reversing this

Health facility/institutional incentives result in economic inefficiencies by undermining BF

Low cost supplies or company education etc can reduce institutional incentives for health care providers to introduce efficient quality care models to protect breastfeeding, for example;

• milk expressing

• donor milk banking

• lactation consultants

• staff education and training

PresenterPresentation NotesHealth facility/institutional incentives result in economic inefficiencies by undermining BFAlso marketing practices will shape how maternity services operate and where they allocate resources. For example, if formula is readily available and cheap in maternity facilities, then health workers with skills or qualifications in breastfeeding support or lactation management will not be powerful or valued. Lactation consultants will find less employment opportunities. Professional education will be more available to pediatricians expert in formula. Milk banks will be less viable because formula is cheap and supporting breastfeeding takes up staff time. Services will be lower quality and less innovative than other health services with less powerful commercial interests involved.

Results of health channel marketing in Australia

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Smith J: The contribution of infant food marketing to the obesogenic environment in Australia. Breastfeed Rev 2007, 15(1):23-35.Smith J. Formula for fatness: infant food marketing in Australia. In: Dixon J, Broom D, eds. The seven deadly sins of obesity. Sydney: University of New South Wales Press, 2007.

Infant formula milk sales

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PresenterPresentation NotesResults of health channel marketing in AustraliaAustralian Medical Journal advertising Increased milk formula salesDecreased breastfeeding

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74.0672263014

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87.6476010711

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88.0897696152

96.5015026907

103.0082991876

95.3927212248

97.1642705594

85.488718357

82.0289867155

90.0405580589

94.0963639471

103.6210468398

PublicationYear

infant formulamilk


1904

1910

1915

1920

1925

1030

1935

1940

1945

195050

1955100

1960126

1965159

1970516

197503

198000

198570


infant formulamilk


1905-09

1910-14

1915-19

1920-24

1925-29

1930-34

1935-39

1940-44

1945-49

1950-5401

1955-5920

1960-6411

1965-6916

1970-7445

1975-7930

198000

198500

























1904

1905

1906

1907

1908

1909

1910

1911

1912

1913

1914

1915

1916

1917

1918

1919

1920

1921

1922

1923

1924

1925

1926

1927

1928

1929

1930

1931

1932

1933

1934

1935

1936

1937

1938

193924

1940

1941

1942

1943

1944

1945

1946

1947

19489

194924

195023

195135

195265

195328

195438

195538

195651

195739

195846

195942

196057

196150

196249

196355

196460

196570

196674

196786

196855

196960

197056

197143

197269

197346

197482

1975126

197688

197785

197880

197970

198074

198161

198280

198375

198477

198563

198695

198764

198888

198997

1990103

199195

199297

199385

199482

199590

199694

1997104

1998

1999

2000
























111111111111

#REF!

#REF!

#REF!

kg per capita, pa


Chart23

190419040.9346991037

190519050.9374570447

190619060.9572580645

190719070.9599056604

190819080.9642553191

190919090.9882397572

191019100.9912400766

191119110.9909833756

191219120.9539052497

191319130.9689025957

191419140.97649717510.920.3207243916

19151915

19161916

19171917

19181918

19191919

192019200.940.327696661

19211921

19221922

19231923

192419240.940.327696661

19251925

192619260.950.3311827957

19271927

192819280.930.55

192919290.51

193019300.930.45

193119310.52

193219320.5

193319330.51

193419340.48

193519350.49

193619360.48

193719370.49

193819380.47

193919390.460.9

194019400.480.88

194119410.460.88

194219420.460.88

194319430.950.470.88

194419440.88

194519450.88

194619460.89

194719470.89

194819480.89

194919490.89

195019500.71250.9

195119510.9

195219520.9

195319530.9

195419540.9

195519550.9

195619560.9

195719570.9

195819580.9

195919590.9

196019600.82

196119610.82

196219620.82

196319630.82

196419640.82

196519650.75

196619660.75

196719670.75

196819680.75

196919690.75

197019700.7

197119710.7

197219720.7

197319730.7

197419740.7

197519750.7

197619760.77

19771977

19781978

19791979

19801980

19811981

19821982

19831983

19841984

19851985

19861986

19871987

19881988

19891989

19901990

19911991

19921992

199319930.772

19941994

199519950.747

199619960.746

199719970.7744

199819980.764

199919990.8173

200020000.8164

initiation

9 months

3 months

6 months

VIC 3 months, fully'breastfed'

VIC 6 months, fully 'breastfed'

NSW 1 month

VIC initiation

VIC 9 months, 'breastfed'

QLD initiating any breastfeeding

year

Breastfeeding rates

0.6197894737

0.4198573854

0.6332631579

0.4289847199

0.6332631579

0.4289847199

0.64

0.4335483871

0.864

0.63

0.804

0.56

0.792

0.55

0.756

0.53

0.64

0.53

0.55

0.42

0.52

0.42

0.48

0.39

0.47

0.38

0.49

0.38

0.47

0.37

0.46

0.35

0.46

0.33

0.43

0.31

0.4

0.29

0.42

0.27

0.37

0.25

0.36

0.23

0.31

0.22

0.33

0.19

0.33

0.17

0.29

0.15

0.28

0.13

0.27

0.13

0.25

0.12

0.24

0.11

0.22

0.1

0.21

0.1

0.21

0.09

0.22

0.11

0.25

0.13

0.28

0.15

0.31

0.18

0.34

0.21

0.38

0.24

0.41

0.27

0.45

0.3

0.46

0.31

0.47

0.32

0.49

0.33

0.49

0.31

0.504

0.356

0.52

0.371

0.523

0.374

0.528

0.386

0.535

0.388

0.532

0.384

0.537

0.387

0.533

0.39

0.532

0.387

0.527

0.39

0.535

0.393

0.539

0.4

0.527

0.391

0.526

0.393

0.527

0.3979

0.524

0.4007

0.523

0.3992

charts

AWW

MJA

charts

1900

1904

1910

1915

1920

1925

1030

1935

1940

1945

19500

19550

19606

19659

197016

19753

19800

19850

infant formula

year



5

10

12

15

5

0

0

7

advertising

1900-041900-04

1905-091905-09

1910-141910-14

1915-191915-19

1920-241920-24

1925-291925-29

1930-341930-34

1935-391935-39

1940-441940-44

1945-491945-49

1950-541950-54

1955-591955-59

1960-641960-64

1965-691965-69

1970-741970-74

1975-791975-79

19801980

19851985

infant formula

milk

year



0

1

2

0

1

1

1

6

4

5

3

0

0

0

0

0

annual milk sales

1904

1905

1906

1907

1908

1909

1910

1911

1912

1913

1914

1915

1916

1917

1918

1919

1920

1921

1922

1923

1924

1925

1926

1927

1928

1929

1930

1931

1932

1933

1934

1935

1936

1937

1938

1939

1940

1941

1942

1943

1944

1945

1946

1947

1948

1949

1950

1951

1952

1953

1954

1955

1956

1957

1958

1959

1960

1961

1962

1963

1964

1965

1966

1967

1968

1969

1970

1971

1972

1973

1974

1975

1976

1977

1978

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000


kg per live birth


24.411877192

8.5259774062

24.2743888647

22.8234044833

34.5406841317

65.2168001088

28.0121257847

38.0125092186

38.4815937031

50.5489328591

39.4806222953

45.9195804236

42.2952206401

57.0971915543

49.5297709571

49.0699313192

54.5103244995

60.0392560468

69.9060313464

74.0672263014

86.4716911905

55.0095432752

59.6553033116

56.3207497536

43.0594654837

69.4420856779

46.0289901886

81.8673856031

125.6287229842

87.6476010711

85.1293246307

80.4439270054

70.0312375352

74.3636016974

60.5956530219

80.2991208947

75.172048703

77.1228371467

62.5794591981

95.2676706836

63.5465167172

88.0897696152

96.5015026907

103.0082991876

95.3927212248

97.1642705594

85.488718357

82.0289867155

90.0405580589

94.0963639471

103.6210468398

breastfeeding rates

190419040.9346991037

190519050.9374570447

190619060.9572580645

190719070.9599056604

190819080.9642553191

190919090.9882397572

191019100.9912400766

191119110.9909833756

191219120.9539052497

191319130.9689025957

191419140.97649717510.920.3207243916

19151915

19161916

19171917

19181918

19191919

192019200.940.327696661

19211921

19221922

19231923

192419240.940.327696661

19251925

192619260.950.3311827957

19271927

192819280.930.55

192919290.51

193019300.930.45

193119310.52

193219320.5

193319330.51

193419340.48

193519350.49

193619360.48

193719370.49

193819380.47

193919390.460.9

194019400.480.88

194119410.460.88

194219420.460.88

194319430.950.470.88

194419440.88

194519450.88

194619460.89

194719470.89

194819480.89

194919490.89

195019500.71250.9

195119510.9

195219520.9

195319530.9

195419540.9

195519550.9

195619560.9

195719570.9

195819580.9

195919590.9

196019600.82

196119610.82

196219620.82

196319630.82

196419640.82

196519650.75

196619660.75

196719670.75

196819680.75

196919690.75

197019700.7

197119710.7

197219720.7

197319730.7

197419740.7

197519750.7

197619760.77

19771977

19781978

19791979

19801980

19811981

19821982

19831983

19841984

19851985

19861986

19871987

19881988

19891989

19901990

19911991

19921992

199319930.772

19941994

199519950.747

199619960.746

199719970.7744

199819980.764

199919990.8173

200020000.8164

&A

Page &P

initiation

9 months

3 months

6 months

VIC 3 months, fully'breastfed'

VIC 6 months, fully 'breastfed'

NSW 1 month

VIC initiation

VIC 9 months, 'breastfed'

QLD initiating any breastfeeding

year

Breastfeeding rates

0.6197894737

0.4198573854

0.6332631579

0.4289847199

0.6332631579

0.4289847199

0.64

0.4335483871

0.864

0.63

0.804

0.56

0.792

0.55

0.756

0.53

0.64

0.53

0.55

0.42

0.52

0.42

0.48

0.39

0.47

0.38

0.49

0.38

0.47

0.37

0.46

0.35

0.46

0.33

0.43

0.31

0.4

0.29

0.42

0.27

0.37

0.25

0.36

0.23

0.31

0.22

0.33

0.19

0.33

0.17

0.29

0.15

0.28

0.13

0.27

0.13

0.25

0.12

0.24

0.11

0.22

0.1

0.21

0.1

0.21

0.09

0.22

0.11

0.25

0.13

0.28

0.15

0.31

0.18

0.34

0.21

0.38

0.24

0.41

0.27

0.45

0.3

0.46

0.31

0.47

0.32

0.49

0.33

0.49

0.31

0.504

0.356

0.52

0.371

0.523

0.374

0.528

0.386

0.535

0.388

0.532

0.384

0.537

0.387

0.533

0.39

0.532

0.387

0.527

0.39

0.535

0.393

0.539

0.4

0.527

0.391

0.526

0.393

0.527

0.3979

0.524

0.4007

0.523

0.3992

1948

1949

1950

1951

1952

1953

1954

1955

1956

1957

1958

1959

1960

1961

1962

1963

1964

1965

1966

1967

1968

1969

1970

1971

1972

1973

1974

1975

1976

1977

1978

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

infants and invalids food


8.5259774062

24.2743888647

22.8234044833

34.5406841317

65.2168001088

28.0121257847

38.0125092186

38.4815937031

50.5489328591

39.4806222953

45.9195804236

42.2952206401

57.0971915543

49.5297709571

49.0699313192

54.5103244995

60.0392560468

69.9060313464

74.0672263014

86.4716911905

55.0095432752

59.6553033116

56.3207497536

43.0594654837

69.4420856779

46.0289901886

81.8673856031

87.6476010711

85.1293246307

80.4439270054

70.0312375352

74.3636016974

60.5956530219

80.2991208947

75.172048703

77.1228371467

62.5794591981

95.2676706836

63.5465167172

88.0897696152

96.5015026907

103.0082991876

95.3927212248

97.1642705594

85.488718357

82.0289867155

90.0405580589

94.0963639471

103.6210468398

PublicationYear

infant formulamilk


1904

1910

1915

1920

1925

1030

1935

1940

1945

195050

1955100

1960126

1965159

1970516

197503

198000

198570


infant formulamilk


1905-09

1910-14

1915-19

1920-24

1925-29

1930-34

1935-39

1940-44

1945-49

1950-5401

1955-5920

1960-6411

1965-6916

1970-7445

1975-7930

198000

198500

























1904

1905

1906

1907

1908

1909

1910

1911

1912

1913

1914

1915

1916

1917

1918

1919

1920

1921

1922

1923

1924

1925

1926

1927

1928

1929

1930

1931

1932

1933

1934

1935

1936

1937

1938

193924

1940

1941

1942

1943

1944

1945

1946

1947

19489

194924

195023

195135

195265

195328

195438

195538

195651

195739

195846

195942

196057

196150

196249

196355

196460

196570

196674

196786

196855

196960

197056

197143

197269

197346

197482

1975126

197688

197785

197880

197970

198074

198161

198280

198375

198477

198563

198695

198764

198888

198997

1990103

199195

199297

199385

199482

199590

199694

1997104

1998

1999

2000
























111111111111

#REF!

#REF!

#REF!

kg per capita, pa


Year ending JuneVictoriaNSWQldTasmania

infants and invalids foodVIC initiationVIC 3 months, any breastfeedingVIC 3 months, fully'breastfed'VIC 6 months, any breastfeedingVIC 6 months, fully 'breastfed'VIC 9 months, any breastfeedingVIC 9 months, 'breastfed'NSW 1 monthNSW 1 month ('entirely breastfed')NSW 3 months any breastfedingNSW 3 months fully breastfedNSW 6 months any breastfedingNSW 6 months fully breastfedNSW 9 months any breastfedingQLD initiating fully breastfeedingQLD initiating any breastfeedingQLD 3 months any breastfedingQLD 3 months fully breastfedQLD 6 months any breastfeedingQLD 6 months fully breastfedTAS initiatingTAS initiating fully breastfedTAS 3 months any breastfeedingTAS 3 months fully breastfeedingTAS 6 months any breastfeedingTAS 6 months fully breastfeedingTAS 12 months any breastfeedingTAS 12 months fully breastfeedingSA initiatingSA initiating fully breastfedSA 3 months any breastfeedingSA 3 months fully breastfeedingSA 6 months any breastfeedingSA 6 months fully breastfeedingWA, initiating any breastfeedingWA initiating fully breastfeedingWA, 3 months any breastfeedingWA 3 months fully breastfeedingWA, 6 months any breastfeedingWA, 6 months fully breastfeedingWA, 12 months any breastfeedingWA, 12 months fully breastfeeding

190493%72%

190594%77%

190696%79%

190796%80%

190896%82%

190999%83%

191099%84%

191199%85%

191295%86%

191397%91%

191492%62%42%32%98%94%

1915

1916

1917

1918

1919

192094%63%43%33%

1921

1922

1923

192494%63%43%33%

1925

192695%64%43%33%

1927

192893%102%86%95%63%72%55%

192969%51%

193063%45%93%87%75%68%

193171%52%

193268%50%

193368%51%

193467%48%

193566%49%

193666%48%

193765%49%

193864%47%

193963%46%0.9

194096%80%85%56%63%48%0.88

194196%79%83%55%60%46%0.88

194292%76%82%53%61%46%0.88

194395%92%64%80%53%61%47%0.88

194470%55%54%42%0.88

194566%52%54%42%0.88

19460.89

19470.89

919480.89

2419490.89

23195071%48%39%0.9

35195147%38%0.9

65195249%38%0.968%62%55%44%33%25%

28195347%37%0.9

38195446%35%0.9

38195546%33%0.9

51195643%31%Apparent annual consumption of infants and invalids food per live birth0.9

39195740%29%0.9

46195842%27%0.9

42195937%25%0.9

57196036%23%0.82

50196131%22%0.82

49196233%19%0.82

55196333%17%0.82

60196435%29%15%0.82

70196528%13%0.75

74196627%13%0.75

86196725%12%0.75

55196824%11%0.75

60196922%10%0.7559%53%23%17%

56197021%10%0.741%

43197121%9%0.7

69197222%11%0.744%18%7%

46197325%13%0.749%22%10%

82197428%15%0.764%57%29%23%58%25%15%

197531%18%0.757%58%30%18%

88197634%21%0.7762%35%18%

85197738%24%66%39%27%

80197841%27%70%44%35%

70197945%30%72%66%44%41%29%71%49%36%

74198046%31%86%52%38%

61198147%32%

80198249%33%

75198349%31%75%40%38%30%28%

77198454%50%36%81%77%60%51%45%39%20%12%82%78%53%49%34%86%84%62%53%45%41%13%11%

63198555%52%37%80%77%52%48%36%33%

95198656%52%37%80%78%50%46%36%32%

64198756%53%39%

88198857%54%39%

97198957%53%38%

103199058%54%39%

95199155%53%39%

97199258%53%39%

85199377%58%53%39%

82199454%39%

90199575%62%54%45%40%78%60%57%44%17%84%64%56%48%19%78%63%60%44%22%82%50%46%46%18%87%69%63%51%22%13%11%

94199675%53%39%48%

104199777%53%39%

199876%53%40%83%85%

199982%58%52%40%

200082%58%52%40%

u1473103:Source: ABA 2001Coy et al 1976, reported in Manderson, 1985p. 164 Includes infants on mixed regimes

u1473103:Source: ABA 2001Coy et al 1976, reported in Manderson, 1985p. 164

u1473103:Source: Newton 1976, reported in Manderson, 1985p. 164

u1473103:Source: Armstrong 1939City and suburbs of Sydney

u1473103:Source Mein Smith 1991figures before 1943-44 are for 'up to 3, 6, and 9 months, not 'at' 3,6,9 monthsfigure is for total minus artificially fed

u1473103:Source Mein Smith 1991figures before 1943-44 are for 'up to 3, 6, and 9 months, not 'at' 3,6,9 months






u1473103:Source Mein Smith 1991figures before 1943-44 are for 'up to 3, 6, and 9 months, not 'at' 3,6,9 monthsfigures are breastfed not inc partially breastfed








u1473103:NHS for Victoria 56.0


u1473103:Source: ABA 2001 breastfeedingpartly and fully on discharge




u1473103:Source: ABA 2001 breastfeedingfully on discharge



u1473103:Source: ABA 2001

u1473103:NHS 43.9

u1473103:NHS

















u1473103:NHS

u1473103:Mein Smith 1990

u1473103:Source: Mein Smith 1990

u1473103:Mein Smith thesis p. 279





&A

Page &P


kg per live birth

&A

Page &P


Industry approach to avoiding restraint on advertising

Adaptive marketing strategies – market segmentation and disease mongering to ‘avoid regulation’ and ‘focus on marketing through doctors and nurses’

PresenterPresentation NotesAdaptive marketing strategies over time – market segmentation and disease mongering to avoid regulationTrust, safety, scientific, expertsWhere mother can’t BF…Now, marketing to mothers fears and frustrations about normal infant behaviour? ‘Special people needing special care’ColicDigestive problems Weight gain/impaired fat absorptionSensitivity or lactose intoleranceContemporary marketing strategiesProduct segmentation to avoid regulationSpecialised formulasFocus on marketing through doctors and nursesMarketing toddler formulas to parents through pediatricians

WHO International Code vs MAIF – who is enabled and involved in decisionmaking about budgets?

PresenterPresentation NotesAs those affected are not in the room when budgeting decisions are made, women may lose out as maternity care consumers and as health workers. The Code will not be implemented and BFHI will not be resourced.

Scrutinising budgets and resources: the WHO International Code and BFHI

PresenterPresentation NotesScrutinising budgets and resources, monitoring and evaluating…As those affected are not in the room when budgeting decisions are made, women may lose out as maternity care consumers and as health workers. The Code will not be implemented and BFHI will not be resourced.The 2020 WHO Code report noted that ‘Protection of breastfeeding is especially important in health care’. WHO emphasises preventing inappropriate promotion of foods for infants and young children – both companies responsibilities and health worker responsibilitiesWHO has also revised the BFHI which remains poorly implemented worldwide

– International Code– BFHI – Health and nutrition care systems

Policy assessments and recommendations: the Best Start Inquiry and WBTi Australia report

CODE Best Start Report 2007 recommendations to the Australian Department of Health

WBTi Australia 2018 Recommendations

WBTi Indicator 3 Implementation of the International Code of Marketing of Breast-milk Substitutes

That the Department of Health and Ageing adopt the World Health Organization's International Code of Marketing of Breast-milk Substitutes and subsequent World Health Assembly resolutions

The Australian Government should meet its obligations to enact legislation or other effective measures to implement the WHO Code and subsequent WHA resolutions in full, with appropriate enforcements. • FSANZ regulation of marketing of food for 0-36 months• MAIF scope of products, retailing, compulsory membership• NHMRC Infant Feeding Guidelines

That Food Standards Australia New Zealand change the labelling requirements for foods for infants under Standard 2.9.2 of the Food Standards Code to align with the NHMRC Dietary Guidelines recommendation that a baby should be exclusively breastfed for the first six months

All health worker organisations and government programs should include WHO Code compliance as part of their professional ethical standards. Government funding should be linked to Code compliance.

Monitoring and effective sanctions for breaches written into legislation and a process described.

Australian policy development and assessment

PresenterPresentation NotesBest Start inquiry called for full implementation of the Code, and aligning FSANZ labelling with NHMRC dietary guidelinesWBTi Australia assessment incorporated gender analysis – taking account of women’s different position including in decision-making to indicate different impacts of policy and budgets on women, and how to make policy more effective equitable and transparentCalled for full implementation of the Code, legislation for Code monitoring and sanctions, WHO code compliance under health worker organisation ethical standards, and government funding linked to Code compliance

BFHI Best Start Report 2007 recommendations to the Australian Department of Health


WBTiIndicator 2 -BFHI Baby

Friendly Hospital

Initiative (Ten Steps to

Successful Breastfeeding)

Work with the Australian Council on Healthcare Standards (and/or equivalent accreditation organisation) towards including Baby Friendly Health status as part of the accreditation process.

That the Commonwealth Government task and adequately fund a National IYCF Advisory Committee to establish a working group to develop and implement a strategy to incorporate all global BFHI criteria into existing national quality improvement standards

That the Department of Health and Ageing fund the Australian College of Midwives to run the Baby Friendly Hospital Initiative in Australia, to facilitate the accreditation of all maternity hospitals

That the Commonwealth Government task and fund a National IYCF Advisory Committee to establish an independent, WHO Code-compliant body to administer, maintain, monitor and expand BFHI as required by Australia’s obligations under WHO Code Article 6 Health Care Systems and Article 7 Health Workers

That the Commonwealth Government, when negotiating future Australian Health Care Agreements, require state and territory governments to report on the number of maternity wards in public hospitals that have been accredited under the BFHI

That the Commonwealth government enact legislation with policy guidance and when negotiating Australian Health Care Agreements require state and territory government to report on the number of maternity wards in public hospitals that have been accredited under the BFHI to enable the recommendations

That the Department of Health and Ageing fund a feasibility study for a network of milk banks in Australia including the development of a national regulatory and

That the Commonwealth Government task and adequately fund the National IYCF Advisory Committee to develop and implement a time-bound program to increase the number of BFHI institutions in the country.

PresenterPresentation NotesBest Start Inquiry recommended making BFHI part of Australian Healthcare Standards (ACHS), funding ACM to facilitate accrediting all maternity hospitals, and mandatory state and territory reporting on BFHI via Australian Health Care Agreements. It also recommended a feasibility study for milk banking including a regulatory and quality framework.WBTi Australia similarly called for BFHI criteria to be incorporated into existing hospital standards, and Commonwealth funding for maternity hospitals to be linked to reporting on BFHI implementation by states and territories. Reflecting a gender analysis of BFHI decision-making, it recommended an independent WHO Code compliant body be funded to run it.

SKILLED SUPPORT

Best Start Report 2007 recommendations to the Australian Department of Health


WBTiIndicator 5 -Health and

Nutrition Care Systems (in support of

breastfeeding & IYCF)

That the Minister for Health and Ageing provide Medicare provider/registration numbers to International Board Certified Lactation Consultants (IBCLC) as allied health professionals

All health professionals likely to come into contact with breastfeeding mothers or infants/young children in their clinical practice must receive and be assessed as competent on basic breastfeeding content in their pre-registration training. The Australian healthcare professional regulation body needs to provide leadership in this area. Specialist professions need to gain expertise in the provision of breastfeeding support in line with their level of practice.

The crucial contribution of women’s skills, knowledge and experience of mother to mother support for breastfeeding and lactation should be endorsed, recognized and adequately resourced including by health policymakers and health systems such as though health policies and via Step 10 of BFHI. Women should be more fully resourced by governments and health and education agencies to invest in enhancing their knowledge, skills and qualifications for delivering breastfeeding and lactation support

That the Department of Health and Ageing fund research into best practice in programs that encourage breastfeeding, including education programs, and the coordination of these programs

Widespread education is needed on mother-friendly practices and the role these play in supporting breastfeeding practice. National government prioritisation of keeping breastfeeding dyads together when either is hospitalised is needed. The Royal Australian and New Zealand College of Psychiatry have provided an excellent precedent for this in their policy statement.

That the Treasurer move to exempt lactation aids such as breast-pumps, nipple shields and supply lines from the Goods and Services Tax

Health policy and practice throughout Australia need to have IYCF principles interwoven at every level. As an essential part of this, there must be a recognition that the requirements of the WHO Code form a minimum standard for ethical practice in areas related to infant formula or other breastmilk substitutes. This would also include a commitment to ongoing professional in-service education about breastfeeding for all healthcare professionals in regular contact with breastfeeding mothers or infants and children.

PresenterPresentation NotesSkilled Support The Best Start inquiry recommended IBCLCs be Medicare providers, and there be funding of education programs. WBTi Australia called for Australian healthcare professional regulatory bodies to show leadership on breastfeeding management competency requirements, and for women’s skills, knowledge and experience to be recognised and resourced, and funded to enhance their qualifications for delivering breastfeeding and lactation support. Also for all health professionals coming into contact with breastfeeding mothers or infants/young children to be required to be competent in their preregistration training, and for WHO Code requirements being a minimum standard for ethical practice.

International Code and BFHIHealth professional education and trainingMilk banksPriority groups

Action and advancing the ANBS – show me the money!

Enabling women’s breastfeeding decisions ANBS action areas on maternity care

1.2 WHO International Code

2.1 BFHI

2.1 HP education and training

PresenterPresentation NotesAlso 2.4 Milk banks3.2 Incarcerated mothers and their children

Review regulatory arrangements forrestricting the marketing of breastmilk substitutes and raise awareness of the MAIF in the communityImplement the BFHI in a higher proportion of hospitals and community health services and integrate the BFHI in national accreditationProvide and support access to education and training in breastfeeding for all health professional who care for women and children and support development of clinical care tools for primary health care services

The ANBS includes a set of evaluation criteria for improved accountability Does the awareness campaign promoting MAIF increase awareness and public’s willingness to report breaches, and reduce inappropriate promotionHas the strategy increased the number of BFHI facilities and to what extent has including BFHI accreditation in national standards contributed to thatTo what extent have HPs increased their knowledge and skills to provide consistent, timely and evidence based information and support and mothers and families feel supported in all settings across the continuum

Also milk banks and priority groups

The WHO/UNICEF Global StrategyGender Budgeting and the WBCiUsing the WBCi for advocacy and action and accountability in Australia

Investing in breastfeeding

What needs to be done: global costings

Action Area USD (in billions)

Maternity Entitlement 12.6BFHI Implementation 2.0

Community support/HW training

1.6

International Code Implementation

0.5

Media Promotion 0.7

Sharing the care burden – calculating the cost

PresenterPresentation NotesSharing the care burden – calculating the cost

The World Bank report t ‘Scaling Up Nutrition – What will it Cost estimated USD 2 Billion for Behavior change intervention in 36 high burden countries, but includes only ‘Breastfeeding promotion’. It does not spell out estimates for interventions for protecting and supporting breastfeeding. As improving breastfeeding rates requires a holostic, coordinates action, these estimates are grossly inadequate to improve breastfeeding practices. Our report investing in babies contains a holistic estimation of investment in all the required interventions for implementing the GSIYCF in its entirety. which includes (read the list).

Action AreaUSD in billions)Maternity Entitlement 12.6BFHI Implementation 2.0Community support/HW training 1.6International Code Implementation 0.5Media Promotion 0.7

Applying the WBCi tool to maternity care

Australia – BFHI as a case study, incorporating Code as a case study

PresenterPresentation NotesApplying the WBCi tool to maternity careAustralia – BFHI and Code as a case study

Estimated cost to implement key IYCF interventions in Australia

Key areas of intervention Total estimate in USDDevelopment/updates of policies and guidelines

1,211,696

Legislating the Code (one time) 1,105,672

Implementing the BFHI 4,510,538Training of health workers on IYCF and BF counselling

563,438

Media Support 1,620,643Monitoring 181,754Total cost estimate (USD)* 11,034,024Total cost estimate (AUD) 16,110,775

PresenterPresentation NotesEstimated cost to implement key IYCF interventions in AustraliaAnnual cost $16 million (2012 dollars)Annual savings $60-100 million (2002 dollars)

28

Effective WHO International Code implementation works

Source: Data from Euromonitor International Passport Global Market Information database

0

5

10

15

20

25

30

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Reta

il sale

s (kg

) per

infa

nt/ch

ild (0

-36m

o.)

Year

China India

0

5

10

15

20

25

30

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Ret

ail s

ales

(kg)

per

infa

nt/c

hild

(0-3

6mo.

)

Year

Indonesia Philippines

PresenterPresentation NotesCountries which have more effectively implemented the WHO International Code such as through legislation have experienced slower sales growth during a period in which the Asia Pacific region experienced a milk formula sales boom.

Implementing the ‘Ten Steps’ reshapes maternity care, enables more women to breastfeed and is cost saving

BFHI status has consistent positive effects on BF, and the more steps implemented the more effective – a ‘dose response’

Better enabling women to breastfeed reduces health and economic costs now and in future

International Code helps motivate innovation for quality care in BFHI hospitals, and advances gender equality in the health workforce

Improving coverage of BFHI and Ten Steps advances social and gender equity in access to quality healthcare standards, and health workforce opportunities

Smith, J. P., Cattaneo, A., Iellamo, A., Javanparast, S., Atchan, M., Hartmann, B., . . . Hull, N. (2018). Review of effective strategies to promote breastfeeding: an Evidence Check rapid review brokered by the Sax Institute (www.saxinstitute.org.au) for the Australian Department of Health. Retrieved from Canberra, Australia: Smith, J. P. (2018). Presentation: Valuing women's lactation work. Paper presented at the Telethon Kids Institute, Perth Smith, J. P., Thompson, J. F., & Ellwood, D. A. (2002). Hospital system costs of artificial infant feeding: estimates for the Australian Capital Territory. Australian and New Zealand Journal of Public Health, 26(6), 543-551. Retrieved from ://WOS:000225980600011

PresenterPresentation NotesCompliance with The Code is required for health facilities to achieve Baby-friendly status. Full Code compliance is proposed as one of four ‘critical management procedures’ the revised 2017 draft) WHO operational guidance for implementing the BFHI in facilities providing maternity and newborn services.From WHO 2009 model chapter in medical text: “Hospitals become baby-friendly by implementing the Ten Steps to Successful Breastfeeding, summarized in Box 5 (2), and complying with relevant sections of the International Code of Marketing of Breast-milk Substitutes and subsequent relevant Health Assembly resolutions (collectively referred to as the Code)1 (3).From UNICEF WHO 2009 section 1 : Supplies of breast-milk substitutesResearch has provided evidence that clearly shows that breast-milk substitute marketing practices influence health workers’ and mothers’ behaviours related to infant feeding. Marketing practices prohibited by The International Code of Marketing of Breast-milk Substitutes (the Code) have been shown to be harmful to infants, increasing the likelihood that they will be given formula and other items under the scope of The Code and decreasing optimal feeding practices. The 1991 UNICEF Executive Board called for the ending of free and low-cost supplies of formula to all hospitals and maternity wards by the end of 1992. ‘Global Criteria’ for the 10 Steps and other componentsThe criteria listed below for each of the Ten Steps and the Code are the minimum global criteria for baby-friendly designation. A review of the breastfeeding or infant feeding policy indicates that it upholds the Code and subsequent WHA resolutions by prohibiting:Distribution of samples or gift packs with breast-milk substitutes, bottles or teats or of marketing materials for these products to pregnant women or mothers or members of their families.Acceptance of free gifts (including food), literature, materials or equipment, money or support for in-service education or events from these manufacturers or distributors by the hospital.Acceptance of free or low cost breast-milk substitutes or supplies.“A review of records and receipts indicates that any breast-milk substitutes, including special formulas and other supplies, are purchased by the health care facility for the wholesale price or more.”

Conclusion

A gender budgeting approach gives us new analysis tools which can empower us in our advocacy and action for relevant decision-making and resourcing o

applying gender-responsive budgeting and the wbci …...underpinned by mother nature and the...

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