Breastfeeding indicatoors for use in population surveys in Australia: have we reached consensus?
Health status indicators (Research)
|Publication:||Name: Breastfeeding Review Publisher: Australian Breastfeeding Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 Australian Breastfeeding Association ISSN: 0729-2759|
|Issue:||Date: Nov, 2011 Source Volume: 19 Source Issue: 3|
|Topic:||Event Code: 310 Science & research|
|Geographic:||Geographic Scope: Australia Geographic Code: 8AUST Australia|
An indicator is described by the World Health Organization as 'a variable with characteristics of quality, quantity and time used to measure, directly or indirectly, changes in a situation and to appreciate the progress made in addressing it. It also provides a basis for developing adequate plans for improvement' (WHO 2001). Simple, valid indicators are crucial to track progress and guide investment to improve nutrition and health during the first 2 years of life. Indicators that assess breastfeeding are useful to monitor trends, to develop and evaluate [policies and] programs, and for advocacy (Arimond et al 2008). Without an accurate national picture of breastfeeding practices and how these are changing over time, it is difficult to make rational decisions about the need for additional/ more effective programs and interventions to achieve policy goals (Webb et al 2001, p13).
Breastfeeding indicators are underpinned by definitions of various breastfeeding practices, relating to the initiation, duration and intensity of breastfeeding. Development of definitions around breastfeeding began in the late 1980s. In 1988, a meeting sponsored by the Interagency Group for Action on Breastfeeding (IGAB), an ad hoc working group of representatives from UNICEF, the United States Agency for International Development (USAID), the Swedish International Development Agency (SIDA) and the World Health Organization (WHO), led to the publication of the first schema to categorise breastfeeding practices (Labbok & Krasovec 1990). The meeting was organised to agree upon a set of definitions that could be used as standardised terminology for the collection and description of cross-sectional information on breastfeeding behaviour. This schema and framework: (1) acknowledged that the term 'breastfeeding' alone is insufficient to describe the numerous types of breastfeeding behaviour, (2) distinguished full from partial breastfeeding, (3) subdivided full breastfeeding into categories of exclusive and almost exclusive breastfeeding, (4) differentiated among levels of partial breastfeeding and (5) recognised that there can be token breastfeeding with little to no nutritional impact. The breastfeeding definitions used in this schema are summarised in Table 1.
Another meeting was held, in Geneva in June 1991, again with representatives from WHO, UNICEF, USAID, as well as the Demographic Health Surveys Program of the Institute for Resource Development/Macro International Inc. The purpose of this meeting included standardisation of breastfeeding/ infant feeding definitions but was particularly aimed at reaching consensus on the definitions of key infant feeding indicators and specific methodologies for their measurement: to have a common set of measures to assess breastfeedingpractices and evaluate the progress of promotional programmes. Indicators should be limited in number, relatively easy to measure and interpret, and operationally useful. The focus of the indicators should be on intra-country comparison, although the degree of comparability between countries is also of interest. This meeting resulted in a set of infant feeding definitions (Table 1) and indicators (WHO 1991), as well as direction for measurement of the indicators. Labbok (2000) has critiqued the WHO definitions and indicators as being designed only to study what enters the infant's mouth (a nutrition-focused approach) and not examining the impact of direct breastfeeding compared to indirect breastmilk-feeding. In Australia, Thorley (2011) has recently highlighted the importance of differentiating between breastfeeding and breastmilk-feeding.
Efforts to reach consensus on breastfeeding indicators for use in Australia were first formally documented in 2001 by members of the National Food and Nutrition Monitoring and Surveillance Project, funded by the Commonwealth Department of Health and Aged Care (Webb et al 2001). Webb et al indicated that surveys prior to 2001 had comprised a lack of consistent definitions, that studies were conducted for different purposes and with different methodologies, with different infant age groups, and different reporting periods; rendering reliability and meaningfulness low. The 2001 Report, Towards a national system for monitoring breastfeeding in Australia: Recommendations for population indicators and next steps, aimed to develop national breastfeeding indicators to provide a common set of measures for use by those that collect data (a) on nationally representative samples, and (b) others who wish to compare their sample data with national data about breastfeeding. However, although the focus was largely national comparisons, one of the key selection criteria was that the indicators be 'consistent with WHO wherever possible to meet international reporting obligations'. Other criteria used in selecting indicators included: relevance to key policy recommendations, consistency with previous indicators/data collected in Australia so that trends may be documented, feasibility/ease of collecting the required information on a nationally representative sample and measurable and valid for detecting the direction and magnitude of changes over time and differences between population subgroups. The set of indicators proposed for use in Australia were derived through extensive stakeholder consultation and expert consensus. These indicators were described in full including description of the rationale or purpose of each indicator, how it should be calculated, measurement issues and data requirements. The breastfeeding definitions underpinning these indicators are summarised in Table 1 and the indicators are listed in Table 2. The indicators related to intensity of breastfeeding are determined using 24-hour recall methods (see below).
The 2001 indicators were not formally tested nor adopted in Australia. In 2008 the Department of Health and Ageing commissioned a review and update of the indicators described by Webb et al. Extensive stakeholder consultations during this 2008 review were conducted mainly by email and, although considerable progress was made, full consensus was not reached at the end of the consultation period. A main recommendation to government in the consultation final report (Hector 2008, unpublished) was that a round-table discussion be held to try and reach consensus on breastfeeding indicators. A workshop was subsequently held, in December 2010, attended by some of those who had participated in the 2008 review; federal, state and territory government employees working in nutrition, epidemiology/health data and maternal health areas; and academics and researchers in child health. A set of proposed core indicators were brought to the workshop by the Australian Institute of Health and Welfare (AIHW). Criteria for indicator selection included supporting the reporting of breastfeeding trends in Australia, especially in terms of evaluating the Australian National Breastfeeding Strategy 2010-2015 ('the Strategy', Australian Health Ministers' Conference 2009). The indicators were discussed for suitability, stability, simplicity and measurability resulting in final agreement to a set of six core indicators. The workshop Report (AIHW 2011) provides some of the history, process, discussion points and decisions regarding these core indicators. Naturally, there was debate at the workshop concerning a number of the indicators but agreement ('no workshop attendee had any major issues with') was reached. The agreed core indicators (AIHW 2011) are summarised in Table 1, compared to the 2001 indicators.
The 1991 WHO Infant and Young Child Feeding Indicators have also been reviewed and updated 'to reflect developments in infant and young child feeding recommendations and scientific knowledge about what constitutes optimal breastfeeding and complementary feeding practices' (WHO 2008), for example to reflect the Global Strategy to exclusively breastfeed for the first 6 months of life (WHO/UNICEF 2003). The WHO (2008) emphasises, as in 1991, that the indicators are mainly designed for use in large-scale surveys or national programs. The indicators for breastfeeding are not vastly different to those in 1991; most of the indicators, except 'children ever breastfed' and 'early initiation of breastfeeding', are based on current status/24-hour recall data (see below); a number of new indicators were incorporated to reflect timely, adequate and appropriate complementary feeding.
Comparison of Australian Breastfeeding Indicators: 2001 and 2011
First glance would suggest that these two sets of indicators are very similar and indeed they are. There is broad agreement as to what breastfeeding/infant feeding practices need to be measured and reported. However, there are a number of obvious and less obvious differences between the sets of indicators. Two main differences between 2011 and 2001 are: (1) Use of preposition: Indicators related to breastfeeding intensity, ie exclusive and predominant/full breastfeeding, involve the preposition 'to' rather than 'at'. Choice of preposition was extensively discussed in the 2008 Review (also in Hector 2011) and during the 2010 workshop (AIHW 2011); where it was decided that concepts that involve not having an attribute are best expressed using the preposition 'to'. For example, 'exclusive breastfeeding' is defined as not having anything other than breastmilk (eg exclusively breastfed to 6 months). Use of 'to' accurately reflects infant feeding recommendations to exclusively breastfeed 'to' 6 months (rather than 'at' 6 months which is not a useful indicator; Hector 2011); plus the 'to' implies from birth to the month of age when exclusive breastfeeding ceases (whether 'first' or 'regular' is used to signify deviation from exclusive breastfeeding; Hector 2011). 'To' could be replaced with 'for', 'until' or 'through'--the latter used in the United States Breastfeeding Report (although the term 'through' is used interchangeably with the preposition 'at'; CDC National Immunization Survey; CDC 2011); and, (2) Non-use of the 24-hour period of recall: It was decided, conversely, that concepts which involve having an attribute are best expressed using 'at' (eg receiving soft/semi-soft/solid food ('solids') at 'x' months or receiving breastmilk at 'x' months). For solid foods this reflects the currently recommended practice (NHMRC 2003; currently under revision) to introduce solids at (around) 6 months. Use of the preposition 'at' in these instances is congruent with expression of the indicators in 2001. However, in 2001 indicators related to breastfeeding intensity were described according to practices during the previous 24-hours, ie using recall survey methods (Table 1). This method of measurement is known to produce misclassification errors for breastfeeding practices and does not measure practices since birth (Binns et al 2009; Hector 2011). The 24-hour recall method was chosen by Webb et al (2001) for greater accuracy. Although an earlier options paper had recommended that rates be measured and reported by 24-hour recall and longer-term recalled practice (the two methods are debated fully by Hector 2011; the systematic overestimation of exclusive breastfeeding using longer-term recall methods (retrospective assessment) has been recently reported from recall as short as 9 months (Agampodi et al 2011). Use of the 24-hour recall method was not preferred by stakeholders in the 2008 review or during the 2010 workshop. Regardless, the indicators were not determined at the workshop in relation to likely survey method or data availability. The AIHW considered that the survey method would not be incorporated into or be 'defined' in association with the indicators. Nevertheless, some indication of the survey methods is given in the 2011 Workshop Report (Table 2, AIHW 2011) and this creates some perplexities.
These and other perplexities, discrepancies and details are discussed below in relation to each of the newly agreed indicators in comparison to 2001 and the revised WHO indicators:
Proportion of children ever breastfed: (a) Reducing the recall period from 4 years to 2 years will increase validity; (b) Also, trends over time are easier to report, without having to do complex analyses (Smith et al 2006); (c) This is an optional WHO Indicator (2008; no. 9), although on a minor point of difference, the WHO uses 0-23.9 months, ie does not include recalled practice of mothers of infants aged 24 (24.0-24.9) months.
Proportion breastfed at each month of age, 0-24 months: (a) Extension of reporting of this indicator from 12 to 24 months reflects the WHO recommendation to breastfeed for up to 2 years, or longer; (b) The indicated denominator in the Workshop Report should include those infants/children aged 'x months or older at the time of the survey, if longer-term recall data are used.
Median duration of breastfeeding: (a) Discarded as not pertinent, nor well-understood and communicated. (b) Remains an optional indicator (no. 13) in the WHO 2008 Indicators (0-35.9 months).
Proportion exclusively breastfed to each month, 0-6 months: (a) Use of the preposition 'to' rather than 'at' is described above. (b) The report indicates 7 data points however 6 data points is correct--'to 1 month', 'to 2 months', 'to 3 months', 'to 4 months', 'to 5 months', 'to 6 months'. If using the proposition 'at' (eg if using 24-hour recall data) then there are still 6 data points: 'at <1 month', 'at 1 month', 'at 2 months', 'at 3 months', 'at 4 months', 'at 5 months'; not at 6 months as it is recommended to exclusively breastfeed to 6 months, not at 6 months, when complementary foods are recommended.
Proportion predominantly (fully) breastfed to each month, 0-6 months: (a) The WHO neither uses nor defines the term 'fully' breastfeeding/breastfed in either of their 'indicators' documents (WHO 1991, 2008). This term was used in the 2001 Report, following Cattaneo et al (2000), to be the sum of exclusive and predominant breastfeeding. However in the Strategy and the 2011 Workshop Report it is indicated that 'predominant' breastfeeding is equivalent to 'fully' breastfeeding. Equating 'predominant' and 'fully' is in accordance with the WHO definition of predominant breastfeeding in that 'predominant' requires that the infant receive breastmilk and allows but doesn't require the infant to receive water and other watery drinks, including juice (Table 2). This means that exclusive breastfeeding is then a 'subset' of predominant breastfeeding and predominant breastfeeding is not a distinct breastfeeding practice as interpreted by Webb et al (2001) and Cattaneo (2000). Possibly the 'confusion' has arisen from the terms used by Labbok & Krasovec (1990) where 'full breastfeeding' was defined as the sum of 'exclusive' and 'almost exclusive', where 'almost exclusive' breastfeeding is distinct from exclusive breastfeeding (Table 2). However, confusion persists. Although the WHO measurement guide (WHO 2010) clearly indicates which questions and therefore infant feeding practices are to be used to determine predominant breastfeeding, ie to include those infants who are receiving breast milk as the sole source of nourishment and those who are also receiving water or watery drinks/juice; some researchers are still interpreting predominant breastfeeding as distinct from exclusive breastfeeding using the WHO methods (eg Hanif 2011); (b) It is worth mentioning here the main objective of the Strategy: 'to increase the percentage of babies who are fully breastfed from birth to 6 months of age, with continued breastfeeding and complementary foods to twelve months and beyond'. It would have been preferable for the Strategy to have 'exclusive' rather than 'full breastfeeding to 6 months' as the core objective/indicator to measure progress as this is the recommended practice for optimal infant health; (c) The specifications for this indicator in the report indicate that it would be calculated using survival analysis; but the impression from the workshop was that all of the indicators would be determined using longer-term recall/retrospective assessment and therefore survival analysis (no specification was given for exclusive breastfeeding; also see next two indicators).
Receiving soft/semi-solid/solid foods (solids) at each month, 0-12 months: (a) 'Soft' is now included in the definition of 'solids' (WHO 2008, AIHW 2011); (b) It is indicated that this (and the next) indicator be determined from 24-hour recall data, but this is likely an inaccuracy in the report. If 'complementary' feeding (ie introduction of solids) gives the deviation from exclusive breastfeeding according to recommendations, ie to exclusively breastfeed from birth to 6 months and then continue breastfeeding while introducing solids, then it makes sense to use the same survey questions and analytical methods to report against both indicators, exclusive breastfeeding and timing of introduction of solids; (c) In the report 'complementary feeding' should be changed to 'require that the infant receive soft, solid or semi-solid food' to be consistent with the Strategy and WHO; (d) Additionally, the Strategy and the Report indicate that 'partial' breastfeeding is equivalent to 'complementary'. However partially breastfed infants are not necessarily receiving solids in addition to breastmilk (more than 'token' but not as much as fully, Labbok & Krasovec 1990; partial breastfeeding is defined within WHO 1991, 2008); they could be receiving non-human milk or formula, or watery liquids, as well as breastmilk. Complementary foods are any food suitable to be fed to infants as a complement to breastmilk or to infant formula when milk alone becomes insufficient to meet the nutritional needs of the infant. Partial breastfeeding has been incorrectly defined as being when the infant receives breastmilk in addition to complementary foods in other studies (eg Mirshahi et al 2008). Often the terms 'complementary' and 'supplementary' are incorrectly used interchangeably; supplementary feeds are classified as fluids other than breastmilk, such as artificial formula or water, which could be given to a baby after a breastfeed or instead of a breastfeed. The WHO (2009) only uses complementary feeding to relate to appropriate feeding practices in breastfed children aged 6-23 months and has replaced the 1991 indicator 'timely complementary feeding rate' with the indicator 'introduction of solid, semi-solid or soft foods', which is a measure of a single feeding practice.
Proportion receiving non-human milk or formula at each month, 0-12 months: (a) As per the previous indicator, this would best be determined using the same methods as for exclusive breastfeeding, ie longer-term recall; and, (b) 'Non-human milk or formula' is now used instead of 'breastmilk substitutes'.
The above narrative, including the differences among breastfeeding and infant feeding definitions and indicators shown in Table 1 and Table 2, provides insight into some of the intricacies of measuring and reporting on breastfeeding practices in cross-sectional population level surveys. The variations in indicators and definitions for describing breastfeeding arise and continue despite each group of definitions and indicators being determined with similar aims and objectives and by consensus-forming processes.
The AIHW have decided not to prescribe how the data is to be collected, analysed and interpreted in order to report on the indicators. However, the critical need to work towards harmonisation of methodologies for measuring indicators has been stressed by the WHO (2008) and has resulted in the publication of their detailed measurement guide (WHO 2010). Attention to correct use of preposition ('to' or 'at') within indicator phrasing in accurate reflection of the data collected will increase comparability of indicators between surveys. However, differences in survey questions, survey and analytical methods and interpretation of the data, including the boundary points (Hector 2011), renders comparisons often dubious at best. Indicators such as 'proportion exclusively breastfeeding in the previous 24 hours at 'x' months of age' (eg Webb et al 2001), 'exclusive breastfeeding from birth to '6' months' and/or breastfeeding definitions which reflect the period over which exclusive breastfeeding is measured, eg total breastfeeding = exclusively breastfed in the previous 7 days (but not since birth necessarily) (Breastfeeding Committee for Canada 2006), have the potential to provide more accurate comparisons across surveys; however, such indicators are not as 'simple' as those currently agreed upon.
The upcoming report on the recent National Infant Feeding Survey of over 50,000 Australian infants aged 0-2 years (AIHW, October 2010) will provide insight into the success of the agreed indicators. Comparisons of the survey questions, methods and indicators with those used in ongoing population health surveys in the jurisdictions--particularly in Queensland and New South Wales--may support further indicator refinement. Indeed, the AIHW (2011) stresses that indicator development is a cycle, and that application of the indicators to current and future data collections including the recent Australian National Infant Feeding Survey, may lead to refinement of the indicators and/ or improved data collections as resources permit. The report also indicates that it will be important to standardise the indicator definitions under appropriate governance arrangements; and that the AIHW and the Australian Department of Health and Ageing have initiated a project to formalise the specifications for the indicators. This is occurring as part of a broad government effort to improve the comparability, consistency and relevance of national information on the health and wellbeing of Australians. For example, a set of indicators for children's health--the Children's Headline Indicators--exist in Australia. These are a set of 19 indicators designed to focus policy attention on priorities for children's health, development and wellbeing, one of which is for breastfeeding: 'proportion of infants exclusively breastfed at 4 months of age'.
Indicators must be broadly consistent with standards, recommendations and best practice. The draft report of the updated Infant Feeding Guidelines for Health Workers has been released for public consultation (NHMRC 2011) and included in these draft Guidelines is the main recommended practice: In Australia, it is recommended that as many infants as possible be exclusively breastfed until around six months of age (22-26 weeks) when spoon foods are introduced. This recommendation, if accepted post-consultation, will mean that a single indicator 'percentage of infants exclusively breastfed until/to 6 months of age' will no longer be useful, as solid foods will be introduced once the infant has turned 5 months of age, assuming a proxy of 5 months is used for '22-26 weeks'; technically 22 weeks is equal to 5 months plus 1 week if a month has an average of 4.33 weeks. A single indicator relating to the recommendation about exclusive breastfeeding would then be 'percentage of infants exclusively breastfed until/ to 5 months of age' or if using the preposition 'at' then the useful single indicator would be 'exclusive breastfeeding at 4 months' (as per the current headline indicator). Similarly 'introduction of solid foods before 5 months' would be the corresponding single indicator in order to show adherence to recommended practice.
Stakeholders in the 2008 Review and subsequent workshop, as reflected in the 2011 Report, highlighted the desirability of collecting indicators from maternity services in a nationally standardised manner. Many hospitals are not accredited as 'Baby-Friendly' in Australia, yet may implement several or many of the component Ten Steps. Australia could implement routine data collection of hospital practices which support breastfeeding ie 24-hour rooming-in and early skin-to-skin contact or undermine breastfeeding, ie supplementation in hospital. Such a system could possibly also report on exclusive breastfeeding during the hospital period, although it is important that any such system does not necessitate health professionals making 'judgements' on the category of breastfeeding but that the questions enable later categorisation of breastfeeding practices.
There was agreement at the workshop that further attention needs to be given to devise and implement appropriate data collection methods that better capture information from population sub-groups, such as those residing in remote areas, indigenous Australians, those from culturally diverse groups and those from low socio-economic groups.
Breastfeeding indicators for population monitoring have been developed over time, nationally and internationally, using consensus-forming processes. However, there are subtle and palpable differences between the various sets of indicators as well as the underpinning breastfeeding definitions.
Provision of a set of nationally agreed indicators does not mean that the same survey questions and survey, analytical and interpretive methods, are used to report against the indicators across different surveys, hence comparisons (eg across jurisdictions or with international data) should be made cautiously.
A set of indicators has been agreed for use nationally in Australia (AIHW 2011) for which indicator specification is occurring. Indicator definitions will be standardised under appropriate governance arrangements according to a broader government effort to improve the comparability, consistency, and relevance of national information on the health and wellbeing of Australians.
Reporting of particular indicators may need to be revised in accordance with changing recommended practices.
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Debra J Hector PhD, MPH Senior Research Fellow, Prevention Research Collaboration, School of Public Health, University of Sydney NSW 2006
Table 1: Comparison of 'consensus' definitions of breastfeeding Labbok & WHO (1991) Krasovec (1990) Exclusive Requires: Requires: breastfeeding breastmilk from breastmilk the breast (including milk expressed or Allows: nothing from a wet else nurse) Allows: drops or syrups consisting of vitamins, mineral supplements or medicines Almost exclusive Vitamins, minerals, water, juice, and ritualistic fluids given infrequently in addition to breastfeeds Predominant Breastmilk breastfeeding (including milk expressed or from a wet nurse) as the predominant source of nourishment Allows: liquids (water, water- based drinks, juice, ORS), ritual fluids, drops or syrups (vitamins, minerals, medicines) Full breastfeeding Exclusive Breastfeeding plus Almost Exclusive breastfeeding Partial Breastfeeding breastfeeding at high, medium, or low intensity Distinct from 'full breastfeeding' (see above) and from 'token breastfeeding' which relates to minimal, occasional, irregular breastfeeds Complementary Requires that breastfeeding the infant receives breast milk and solids or semi-solid foods Allows: any food or liquid including non- human milk Webb et al WHO (2008) (2001) Exclusive Requires: Requires: breastfeeding breastmilk breastmilk (including (including milk colostrum, milk expressed or expressed or from a wet from a wet nurse) nurse) Allows: drops, Allows: ORS, syrups drops, syrups (vitamins, (vitamins, minerals, minerals, medicines) medicines) Almost exclusive Predominant An infant's Requires: breastfeeding predominant breastmilk source of (including nutrition has expressed been breastmilk breast milk or but may also from a wet have received nurse) as the water and predominant water-based source of nutrition drinks Allows: certain (sweetened and liquids (water flavoured and water- water, teas, based drinks, infusions, fruit juice), etc); fruit ritual fluids juice; ORS; and ORS, drops drops and or syrups syrups in (vitamins, limited minerals, quantities medicines) Note--this is the definition in the glossary not as used within the indicator definitions Full breastfeeding Exclusive Breastfeeding plus Predominant Breastfeeding (in glossary and indicator definitions) Partial breastfeeding Complementary Receives: Requires: breastfeeding breastmilk and breastmilk solid or semi- (including milk solid food expressed or from a wet Allows: 'this nurse) and may include any solid or semi- food or liquid solid foods including non- human milk' Allows: any food or liquid including non- human milk and formula Used to describe infant feeding 6-23 months National Breastfeeding Breastfeeding Indicators Strategy (2009) Workshop Report (2011) Exclusive Requires: Requires: breastfeeding breastmilk breastmilk (including (including expressed expressed breastmilk) and breastmilk) medicines Allows: ORS, (including ORS, drops, syrups vitamins, (vitamins, minerals) minerals, medicines) Almost exclusive Predominant Receives: Receives: breastfeeding breastmilk and breastmilk medicines (including Allows: water, expressed water-based breastmilk) as drinks, tea or the predominant fruit juice source of (which is not nourishment recommended for babies) Allows: certain liquids (water, water-based drinks, fruit juice1), ritual fluids, ORS, drops or syrups (vitamins, minerals, medicines) Full breastfeeding Same as Same as Predominant Predominant Breastfeeding Breastfeeding Partial Requires: solid Receives: breastfeeding or semi-solid breastmilk food plus (including breastmilk expressed (including breastmilk) expressed Allows: any breastmilk) food or liquid Allows: any including non- food or liquid human milk and including non- formula [same human milk and as formula [same complementary] as complementary] Complementary Requires: Receives: breastfeeding breastmilk breastmilk (including (including expressed expressed breastmilk) breastmilk) plus solid or Allows: any semi-solid food food or liquid Allows: any including non- food or liquid human milk and including non- formula [same human milk and as partial] formula [same as partial] (1) Of concern to some workshop participants (as reflected in the review , Hector 2008, unpublished) was the inclusion of fruit juice as allowable for predominant/full breastfeeding; the debate is partly about when it is appropriate to introduce juice (AIHW 2011) Table 2: Comparison of breastfeeding indictors developed for population monitoring in Australia in 2001 and 2011 Webb et al (2001) AIHW (2011) Comments Per cent ever Proportion of Shorter recall breastfed (1) children ever period will provide breastfed (2) more valid data Also can identify trends over time without having to do complex analyses (age-period cohort analyses to determine year of breastfeeding practice according to age of child at time of survey) Per cent breastfed Proportion of The denominator AT each completed children breastfed indicated in the month of age to 12 AT each month of age AIHW report is: months (1) to 24 months (2) number of children aged x months--this should include the number of children aged x months or older at time of survef if longer- term recalled practices are included Median duration of Not included in AIHW breastfeeding among indicators (not 'ever breastfed' often used nor well children (1) understood (2008 review)) Per cent exclusively Proportion of Changed from 24- breastfeeding in the children exclusively hour recall to previous 24 hours breastfed TOb each include recalled among infants AT month of age, 0-6 practices (where each completed month months (2) recall period is up of age to 6 months to 2 years) (3) Denominator should include number of children aged x months or older at the time of the survey (as per above (a)) Report indicates 7 data points (0-6 months); but should be 6 (b) Per cent fully Proportion of Issues with breastfeeding in the children differences in previous 24 hours predominantly interpretation of among infants AT breastfed TO (b) WHO definitions of each completed month each month of age, predominant of age to 6 months 0-6 months (2) breastfeeding (3) between the two reports--in AIHW 'fully ' is equivalent to predominant whereas in Webb et al 'fully ' equals the sum of predominant plus exclusive Changed from 24- hour recall to include longer-term recalled practices (where recall period is up to 2 years) Report indicates 7 data points (0-6 months); but should be 6 (b) Per cent receiving Proportion of Relates to single solid foods in the children receiving infant feeding previous 24 hours soft-semi-solid- recommendation about among infants AT solid food AT (a) age of introduction each completed month each month of age, of solids Could be of age to 6 months 0-12 months expressed according (3) to those giving- not-giving breast milk at the time of solids introduction (nearly all data collections would allow this sub- analysis) Determine using survival analysis as per other indicators; not as indicated in the Report which is on 24-hour recall basis? Per cent receiving Proportion of 'Breast milk breast milk children receiving substitutes' and substitutes in the non-human milk or 'non-human milk or previous 24 hours formula At (a) each formula' are among infants AT month of age, 0-12 equivalent--non- each completed month months human milk was of age to 6 months majority decision in (3) December meeting Determine using survival analysis as per other indicators; not as indicated in the Report which is on 24-hour recall basis? (1) Based on maternal recall among children aged 0-47 months (2) Based on maternal recall among children aged 0-24 months [point estimates for various indicators includes longer-term recalled practice as well as current practice in survival analysis (eg the estimate of the per cent breastfeeding at each month of age includes both those currently breastfeeding (censored) and those that have ceased (uncensored)] (3) Based on 24-hour recall (current practice) (a) If the Indicator is expressed on an 'AT' basis then the data points refer to 'at <1 month, at 1 month, at 2 months, at 3 months etc (b) If the indicator is expressed on a 'TO' basis then the data points refer to 'to 1 month, to 2 months, to 3 months etc
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