Breastfeeding

Introduction

Breastfeeding promotes the healthy growth and development of infants and young children. In Australia, The National Health and Medical Research Council (NHMRC) publishes infant feeding guidelines recommending that infants be exclusively breastfed (Box 1) until around 6 months of age when solid food are introduced. The guidelines also recommend that breastfeeding be continued until 12 months of age and beyond, 'for as long as the mother and child desire' (NHMRC 2015).

There are a range of factors which can influence breastfeeding related to the individual and the environment (Boones et al. 2019; Izumi et al. 2024), and it is important to acknowledge that not every mother chooses to, or is able to, breastfeed.

Benefits for mother and child

Breastfeeding provides many benefits for both mother and child. Breastfeeding promotes the healthy growth and development of infants and young children, with benefits extending into adult life (WHO 2017).

Breastfeeding provides infants with a nutrition source that is easy for their digestive systems to absorb, and changes composition over months and years to meet the child’s nutritional, immunological and developmental needs (Kim and Yi 2020). In infants, breastfeeding is also reported as being protective against infections of the ear, respiratory tract and gastrointestinal system, and of sudden infant death syndrome (SIDS) (Masi and Stewart 2024).

In adolescence and adulthood, breastfeeding has been associated with improved cognitive development and a reduction in the risk of living with overweight and obesity and chronic conditions such as diabetes and asthma (Pereyra-Elías et al. 2022; Lefebvre and John 2013; Morris 2018; Miliku and Azad 2018).

Important short- and long-term health benefits have also been seen for mothers (Prentice 2022). Possible immediate maternal benefits of breastfeeding include reduced bleeding after birth, assistance with spacing between pregnancies, maintenance of a healthy weight and enhanced mental health and wellbeing (Hady et al. 2023; Modak et al. 2023; Prentice 2022). Breastfeeding is also associated with many long-term benefits such as reduced risk of Type 2 diabetes, cardiovascular disease, breast and ovarian cancer (Prentice 2022).

Economic benefits

Breastfeeding can have economic benefits at the family level as well as for broader society. For example, families may have no or reduced costs to buy infant formula for the first years after birth (Perez-Escamilla and Segura-Perez 2023). Higher breastfeeding rates lead to lower healthcare costs as breastfeeding protects against a range of diseases.

According to a 2002 study, early weaning was estimated to add around $60 million to $120 million to annual hospitalisation costs for gastrointestinal illnesses, respiratory and ear infection, eczema, and neonatal necrotising enterocolitis in Australian hospitals (Smith et al. 2002).

Environmental benefits

Evidence indicates that feeding with infant formula had almost twice the carbon footprint of breastmilk (Andresen et al. 2022). Infant formulas can negatively impact the environment through production processes related to cattle farming, deforestation, packaging and transportation (Becker and Ryan-Fogarty et al. 2019; Smith 2019). In comparison, breastfeeding uses fewer resources and produces minimal or no waste.

Barriers and enablers for breastfeeding

There are multiple barriers and enablers that influence breastfeeding practices including biological factors, attitudes, and support.

Demographic factors can influence breastfeeding practices. For example, mothers aged 25 and under were less likely to exclusively breastfeed to 4 months, and more likely to introduce infant formula earlier than mothers aged 35 and older (AIHW 2011).

Additionally, the 2010 Australian National Infant Feeding Survey (ANIFS) showed mothers with lower levels of education, income and socioeconomic area had lower rates of breastfeeding initiation and shorter breastfeeding duration (AIHW 2011).

Mothers with tertiary education qualifications and higher socioeconomic areas were more receptive to beneficial health behaviours – such as breastfeeding – and were more likely to seek out support networks (Neves et al. 2021; Boone et al. 2019). These mothers may be more likely to have a supportive workplace and/or home environments for breastfeeding and access to external support systems for breastfeeding issues.

Culturally and linguistically diverse mothers had higher rates of exclusive breastfeeding cessation within 6 months according to the 2010 ANIFS. Research has shown that some migrant women experience challenges with exclusive breastfeeding and adjusting to life with a baby in a new country (Izumi et al. 2024). Furthermore, many migrant women recognise that exclusive breastfeeding is the healthiest option, but face barriers and a lack of support when navigating a new country’s postpartum and breastfeeding norms (Izumi et al. 2024). Migrant women also have difficulty in accessing culturally appropriate information and support services (Dennis et al. 2018)

Breastfeeding rates are lower among mothers who were living with obesity (body mass index (BMI) of 30 or higher) compared to those within the healthy range (BMI between 18.5 and 24.9) (Hashemi-Nazari et al. 2020). This may be due to a multitude of reasons such as delayed ability to secrete breast milk (Hashemi-Nazari et al. 2020).

Mothers may also cease breastfeeding due to low breast milk supply related to postpartum haemorrhage, mastitis and taking oral contraceptive pills containing oestrogen (Thompson et al. 2010; Pevzner and Dahan 2020). In rare cases, this may be due to the breasts not having enough glandular tissue, which is responsible for producing breast milk (Spatz and Miller 2020).

Research has found that having a baby that was born pre-term or small for gestational age was also associated with lower breastfeeding rates (Lutsiv et al. 2013; Nejsum et al. 2023). These babies potentially have reduced energy and may breastfeed less vigorously and effectively, leading to subsequent weight loss, which negatively impacts the mother’s confidence with breastfeeding (Dooks et al. 2020). Additionally, these babies are taken to neonatal intensive care units (NICU) for observation and treatment which may adversely impact the establishment of breastfeeding due to the introduction of formula at an earlier age (Nejsum et al. 2023). This could lead to higher rates of breastfeeding cessation or formula use.

Women who received any form of support were less likely to stop exclusive breastfeeding before five months than women who did not (Babakazo et al. 2015). Support can take various forms including home visits from trained breastfeeding support providers, helplines, online peer support groups, as well as encouragement from partners, family and friends (Babakazo et al. 2015). Having a supportive partner, family and friends can have a positive influence on initiating and sustaining breastfeeding (Snyder et al. 2021).

Access to supportive environments for breastfeeding, particularly workplaces, are an important indicator of continued exclusive breastfeeding (Bradford et al. 2017). Women who had access to working from home, flexible working hours, private space for expressing milk, and paid maternal and paternal leave were more likely to breastfeed for a longer duration (Vilar-Compte et al. 2021).

Breastfeeding strategies and resources

The Australian National Breastfeeding Strategy: 2019 and beyond (the Strategy) recognises breastfeeding is not only an individual woman's issue and aims to provide a framework for integrated, coordinated action to guide Commonwealth, state, territory and local government programs and policies to support mothers, partners, and their infants throughout their breastfeeding journey (CHC 2019).

The key goal of this strategy is to meet the WHO global nutrition target by raising the rate of exclusive breastfeeding in the first 6 months up to at least 50% by 2025 (note the latest data available is for 2022, as shown below).

The Strategy outlines three priority areas to better enable and support breastfeeding. These are:

• structural enablers
• settings than enable breastfeeding (for example, breastfeeding-friendly environments which support breastfeeding in the workplace)
• individual enablers (for example, universal access to breastfeeding support services, particularly for priority groups).

Each of the priority areas are supported by action such as:

• community education and awareness – ensuring clinical care services, support and education are readily available
• increasing the number of settings that are conducive to breastfeeding, such as programs and initiatives that support breastfeeding in the workplace
• a review of regulatory arrangements for restricting the marketing of infant formula products
• increasing health professionals’ education and training surrounding breastfeeding
• universal access to breastfeeding support services, such as antenatal education about the importance of breastfeeding, and enhanced post-natal support for breastfeeding.

Breastfeeding in Australia

This section will discuss the prevalence of breastfeeding in Australia, focusing on breastfeeding duration and breastfeeding by state or territory, remoteness area and among First Nations mothers.

The NHMRC recommends that infants be exclusively breastfed until 6 months of age and then continued breastfeeding alongside suitable complementary foods until 12 months of age and beyond (NHMRC 2015).

According to the 2022 National Health Survey (NHS), based on self-reported data, an estimated 91% of infants aged between 0–3 years were breastfed at least once (ever breastfed) (ABS 2023a).

The survey showed that breastfeeding declined with increasing age of the infants, an estimated:

• 71% of infants received breast milk at 4 months
• 63% received breast milk at 6 months
• 33% received breast milk at 12 months (ABS 2023c).

The data visualisation (Figure 1) presents data on the proportion of infants aged 0–3 years who ever received breast milk for 4, 6, and 12 months of age, in 2022.

Exclusive breastfeeding

In 2022, based on self-reported data from the NHS, more than 3 in 5 (64%) infants aged 0–3 years were exclusively breastfed at 4 months, and nearly 2 in 5 (38%) at 6 months (ABS 2023a).

The following data visualisation (Figure 2) presents data on the proportion of infants aged 0–3 years by exclusive breastfeeding status for at least 6 months, and state or territory or remoteness area of participant’s residence, in 2022.

Based on self-reported data, in 2022:

• rates of exclusive breastfeeding ranged across states and territories from 44% in Victoria to 21% in South Australia
• exclusive breastfeeding rates also varied across remoteness areas from 50% in Remote areas to 30% in Outer regional areas (AIHW analysis of ABS 2023b).

The NHS also estimated that in Australia the proportion of infants (0–3 years) who were:

• exclusively breastfed for at least 6 months and continued to breastfeed to 12 months was 26%
• exclusively breastfed for at least 6 months but less than 12 months was 13%
• not exclusively breastfed for at least 6 months was 62% (AIHW analysis of ABS 2023b).

Introduction to soft, semi-solid or solid foods

The current recommendation is to introduce solids at around 6 months, so that infants can receive nutrients that are essential for growth and development (NHMRC 2015). Introducing solids also helps infants learn how to eat and gives them an experience of new tastes and textures, while developing their teeth and jaw (Borowitz 2021).

Based on self-reported data, the introduction to soft, semi-solid or solid food varied depending on the age of the infant with an estimated 3.3% being introduced at less than 4 months. This increased to 95% at 4 months and decreased to 64% at 6 months or later (ABS 2023c).

Reasons for introduction of food and/or drink other than breast milk

The NHS estimated that the most common reasons for the introduction of food and/or drink other than breast milk were that:

• the infant was ready to have other foods (60%)
• there was not enough breast milk (18%)
• the infant was old enough to stop (6.9%)
• the infant was not attaching properly (4.9%) (ABS 2023c).

The following data visualisation (Figure 3) presents the proportion of common reasons for the introduction of food and/or drink other than breast milk, in 2022.

Breastfeeding among First Nations mothers

Breastfeeding practices among First Nations communities have been disrupted by colonisation, prior to which First Nations mothers routinely breastfed their infants, usually for two to four years (Mitchell et al. 2023).

The reduced transmission of cultural breastfeeding practices – and the introduction of non-Indigenous practices such as bottle feeding and the use of infant formula – contribute to the lower breastfeeding rates among First Nations women, especially in urban areas (Springall et al. 2022).

According to the 2022–23 National Aboriginal and Torres Strait Islander Health Survey (NATSIHS), an estimated 83% of First Nations infants aged 0–3 years had ever breastfed (AIHW analysis of ABS 2024).

The NATSIHS estimated that the rates of ever breastfed varied:

• across states and territories from 91% in South Australia to 80% in Queensland
• across remoteness areas from 87% in Inner regional areas to 73% in Very remote areas (AIHW analysis of ABS 2024).

The following data visualisation (Figure 4) presents the proportion of First Nations infants aged 0–3 years who were ever breastfed by state or territory and remoteness area, in 2022–23.

Exclusive breastfeeding among First Nations mothers

The NATSIHS estimated that rates of exclusive breastfeeding for at least 6 months differed:

• across states and territories from 44% in the Northern Territory to 22% in New South Wales
• across remoteness areas from 40% of infants in Remote areas to 21% in Outer regional areas (AIHW analysis of ABS 2024).

The following data visualisation (Figure 5) presents data on the proportion of First Nations infants aged 0–3 years by exclusive breastfeeding status for at least 6 months, and state or territory or remoteness area of participant’s residence, in 2022–23.

The NATSIHS also estimated that the proportion of First Nations infants (0–3 years) who were:

• exclusively breastfed to 6 months and continued to breastfeed to 12 months was 17%
• exclusively breastfed for at least 6 months but less than 12 months was 11%
• not exclusively breastfed for at least 6 months was 73% (AIHW analysis of ABS 2024).

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