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Establishing a National Women's Health Strategy for 2020 to 2030 – Australian College of Midwives’ Response

5th November 2018

Section A: Demographics

Name Hilary Karry

Where are you based? South Australia

Are you replying on behalf of an organisation? Yes, The Australian College of Midwives

Email address Hilary.Karry@miwives.org.au

Organisation’s area of expertise Professional College

Are you a providing a response as: Health Professional / Professional College

Do you identify as an Aboriginal or Torres Strait Islander person?

No

Do you identify as a person from one of the priority populations identified in the Strategy?

No

Does your organisation represent one of the Yes, our organisation represents midwives – over 98% of midwives are women, and

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priority population groups?

comprise members of the population priority groups below (1):

• Aboriginal and Torres Strait Islander women

• Pregnant women and their children

• Culturally and linguistically diverse women

• Members of the LGBTIQ community

• Women from low socio-economic backgrounds • Women from from rural and remote areas

• Women living with a disability and their carers

• Women affected by the criminal justice system 1. Australian Institute of Health and Welfare [AIHW] (2016), Nursing and midwifery workforce 2015, Australian Government, viewed 5th November 2018, <https://www.aihw.gov.au/reports/workforce/nursing-and-midwifery-workforce-2015/data >.

In which country were you born? Canada

Section B: The Structure of the Strategy

Is the overall structure of the Strategy appropriate and easy to follow? (relates to the entire Strategy).

Yes

Please provide comments about the overall structure of the strategy (200 words)

The structure of the overall strategy is generally easy to follow, and introduces and frames the strategy well. It is missing a monitoring and implementation framework – it is difficult to judge the

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success of a strategy without SMART goals (specific, measurable, achievable, time-bound).

Do the sections:

• About the Strategy, • The Strategy in context,

• Women’s health at a glance,

• Priority Populations,

• Life course approach and

• What we want to achieve Provide adequate context and background for the Strategy?

No

Is anything missing from context and background? (400 words)

The Strategy in Context: Missing the following documents:

• National Mental Health Care in the Perinatal Period (2017) • National Strategic Approach to Maternity Services (in consultation)

• Australian National Breastfeeding Strategy (in consultation) The National Men’s Health Strategy 2020-2030 is included despite being under consultation, therefore being under consultation should not preclude inclusion or consideration in the Strategy. It is vital that we consider how the Strategy aligns with the National Strategic Approach to Maternity Services, as there will likely be significant overlap. The Australian National Breastfeeding Strategy must be included here, as part of the strategy is looking at an awareness of the public health impact of breastfeeding and its role

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in disease prevention. Women’s health at a glance There is no causal evidence to support statement that maternal age and obesity lead to increased caesarean sections. If this is included – please provide the relevant research evidence. While obese women tend to have a higher cesarean section rate, research suggests it is due to health professionals’ biases and not their intrinsic ability to birth vaginally (1, 2). Women of advanced maternal age are also more likely to experience intervention, though this again is likely due to health practitioners’ perception of increased risk as opposed to actual risks posed by advanced maternal age (3). Research in this area is vital to reduce the multiple harms caused by unnecessary inductions, caesarean sections and obstetric interventions in general (4). This issue has been explored in the most recent Lancet series “Optimising caesarean section use”. The high (and rising) caesarean section rate in Australia should be a focus of this document, as a modifiable factor which can cause significant morbidity and mortality to women and their babies, as well as lead to long-term intergenerational health impacts. This should be two separate sections – one discussing obesity. Another discussing the increase in caesarean sections and unnecessary medical interventions. Discrimination women face around pregnancy, maternity leave, breastfeeding and parenting is missing. There is also no reference to the health impacts of intergenerational

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caring (except for an excerpt later in the document). This could be explored for women caring for young children and ageing parents, women caring for grandchildren and women caring for a family member or spouse and children/grandchildren/parents. Priority Populations Gender is a social construct, while sex is biologically determined by reproductive structures and organs. Life course approach Breastfeeding is a key modifiable risk factor for girls’ and women’s long term health and is absent from these sections. Breastfeeding is a normal, healthy activity for women and the fact that so few Australian women achieve their breastfeeding goals is a marker for barriers to optimizing women’s health (5). 1. Ellekjaer KL, Bergholt T and Løkkegaard E (2017). ‘Maternal obesity and its effect on labour duration in nulliparous women: a retrospective observational cohort study’. BMC Pregnancy and Childbirth. 17:222. DOI: 10.1186/s12884-017-1413-6 2. Hollowell, J, Pillas, D, Rowe, R, Linsell, L, Knight, M, Brocklehurst, P (2014), ‘The impact of maternal obesity on intrapartum outcomes in otherwise low risk women: secondary analysis of the Birthplace national prospective cohort study’. British Journal of Obstetrics and Gynaecology, vol. 121, no. 3, DOI: 10.1111/1471-0528.12437. 3. Li, Y, Townend, J, Rowe, R, Knight, M, Brocklehurst, P, Lollowell, J (2014). ‘The effect of maternal age and planned place of birth on intrapartum outcomes in healthy women with straightforward pregnancies: secondary analysis of the Birthplace national prospective cohort study’. BMJ Open 2014;4:e004026. doi: 10.1136/bmjopen-2013-004026 4. Sandall, J, Tribe, RM, Avery, L, Mola, G, Visser GHA, Homer, CSE, Gibbons, D, Kelly, NM, Kennedy, HP, Kidanto, H, Taylor, P, Temmerman, M (2018), ‘Short-term and long-term effects of

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caesarean section on the health of women and children’, The Lancet, vol. 392, no. 10155, DOI: https://doi.org/10.1016/S0140-6736(18)31930-5 5. Victora, C. G., Bahl, R., Barros, A. J., França, G. V., Horton, S., Krasevec, J., ... & Group, T. L. B. S. (2016). Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. The Lancet, 387(10017), 475–490

Do the sections:

• Strategy blueprint,

• Policy principles and • Strategy objectives

adequately frame the approach for, and the intent of, the Strategy?

No

If no was selected, please provide your comments and explain your selection (400 words)

The term ‘gender’ is used, instead of the appropriate term ‘sex’. Women experience inequality because they are female (their biological sex). Gender is a social construct. It is vital that documents such as this use the correct terms when addressing sex-based inequality and oppression. This must be consistent through-out this strategy, as well as the National Men’s Health Strategy. Also note that ‘gender’ is not assigned at birth, sex is. Occasionally a person is intersex. Otherwise the sections frame the approach and intent of the Strategy relatively well.

Section C: Priority Areas

Do you agree with the priority areas identified for the Strategy?

Yes

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Priority Areas Priority Area 1 – Mental health and wellbeing Priority Area 2 – Chronic disease and preventive health Priority Area 3 – Sexual and reproductive health Priority Area 4 – Conditions where women are overrepresented Priority Area 5 – Healthy Ageing

If no was selected, please provide comments

and explain your selection The priorities are generally good. Priority Area 3: Sexual and reproductive health is an appropriate topic, but it is imperative that healthy childbearing is explicit within that priority, and the health needs of women and their children are not lost in this document. Some of the “actions” are not actions (e.g. Recognise we don’t have early detection for some cancers). This is an issue, an action must be what we will do to address this issue. The strategy aims to work in a model that is not strictly medical, perhaps it would benefit from a Priority area: Social determinants of health.

Do the priorities and actions specified for No

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Priority area 1: Mental health and wellbeing adequately address the specific health needs of women and girls in Australia?

With regard to Priority area 1, is anything missing or should anything be changed? (400 words)

1.1 Nil. 1.2 Awareness and education was discussed in the previous point, but we need an action to address and reduce bullying, especially in the age of social media. There is limited data into the effect of midwifery-led continuity of care models on postpartum depression and perinatal mental health (1). However a study by Marks, Siddle and Warwick (2) found that high-risk women were more likely to disclose and engage in mental health referral services when receiving maternity care in a midwifery-led continuity of care model. Pregnancy is an opportunistic time to screen, identify and refer women to appropriate services, including for mental health disorders. This is facilitated in a model of care where women experience care with a trusted, known midwife across the entire perinatal period. Earlier identification of birth trauma is vital to provide appropriate, timely treatment to women. 1.3

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Expand existing services for longer prevalence high impact conditions – this must include puerperal psychosis as well as significant perinatal depression. It is imperative that we increase the number of publicly funded beds in mother-baby units. Mother’s hospitalised for postnatal mental health issues must not be separated from their babies. There is inadequate mention of mothers, motherhood, families and infant care in this section. Motherhood is a specific and significant transition that most Australian women find extremely challenging. Breastfeeding is protective of women’s mental health but lack of understanding and resources to support the conflict between mother’s stress and overwhelm and infant feeding in the early weeks means that women are frequently given unhelpful messages. Creating additional career pathways for midwives to specialist in mental health (a model working well in the UK), would give women in the perinatal period greater access to specialist mental health professionals. Include Centre for Perinatal Excellence (COPE) Standards for Perinatal Mental Health Training. http://cope.org.au/ . Increased training for mental health practitioners in mental health to support the mother and father from preconception through to extended postnatal period. 1. Sandall, J., Soltani, H., Gates, S., Shennan, A. and Devane, D., 2016. Midwife-led continuity models of care compared with other models of care for women during pregnancy, birth and early

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parenting. Cochrane Database of Systematic Reviews. 2. Marks, M.N., Siddle, K. and Warwick, C., 2003. Can we prevent postnatal depression? A randomized controlled trial to assess the effect of continuity of midwifery care on rates of postnatal depression in high-risk women. The Journal of Maternal-Fetal & Neonatal Medicine, 13(2), pp.119-127.

Do the priorities and actions specified for Priority area 2: Chronic disease and preventive health adequately address the specific health needs of women and girls in Australia?

No

With regard to Priority area 2, is anything missing or should anything be changed? (400 words)

1. Increase awareness of chronic disease symptoms and risk factors for women and embed a prevention-focused life course approach in policy and practice.

2. Tailor health services to meet the needs of women and girls

This section does not recognise breastfeeding as a key modifiable risk factor for poor health. Suboptimal breastfeeding is an independent risk factor for non-communicable diseases such as breast cancer, ovarian cancer, endometrial cancer, heart disease and diabetes (1, 2). Any amount of breastfeeding reduces a woman’s risk of stroke by 23% (3), hypertension and cardiovascular disease by 20–30% (4) and diabetes by 25% (5). Breastfeeding significantly reduces a woman’s risk of ovarian cancer (6) and breast cancer (7, 8). Girls who were breastfed as babies have lower rates of sudden and unexpected death in infancy (SUDI)(9), obesity (10), diabetes (11) and breast cancer (12). A recent analysis concluded that 14% to 20% of all childhood leukaemia cases could be prevented by breastfeeding for 6 months or more (13). Having been breastfed is associated with a reduced risk of developing autistic traits (14) and being breastfed for 4 months or more

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3. Invest in targeted prevention and management of chronic conditions affecting women and girls

has been shown to have long-term protective effects against social, attention and aggression problems in adolescence (15, 16, 17). It is therefore imperative to address barriers to breastfeeding for mothers, and look at implementation of specific strategies such as the National Breastfeeding Strategy (in consultation) as well as mandating programs such as the Baby Friendly Health Initiative (BFHI). Strategies need to be put in place to educate women, and girls about the protective effects and health promoting effects of breastfeeding. These women need appropriate breastfeeding support in the postnatal period by a known midwife, lactation consultant or community nurse. Midwifery continuity of care models have been shown to be an effective (and cost-effective) intervention to increase breastfeeding rates of women (18). 1. Victora, C. G., Bahl, R., Barros, A. J., França, G. V., Horton, S., Krasevec, J., ... & Group, T. L. B. S. (2016). Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. The Lancet, 387(10017), 475–490. 2. Groer, M.W.K.-T.K. Clinics in human lactation. How breastfeeding protects women’s health throughout the lifespan: the psychoneuroimmunology of lactation. Amarillo, TX: Hale Publishing; 2011. 3. Jacobson, L. T., Hade, E. M., Collins, T. C., Margolis, K. L., Waring, M. E., Van Horn, L. V., ... & Wambach, K. (2018). Breastfeeding History and Risk of Stroke Among Parous Postmenopausal Women in the Women's Health Initiative. Journal of the American Heart Association, 7(17), e008739.

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4. Kirkegaard, H., Bliddal, M., Støvring, H., Rasmussen, K. M., Gunderson, E. P., Køber, L., ... & Nohr, E. A. (2018). Breastfeeding and later maternal risk of hypertension and cardiovascular disease–The role of overall and abdominal obesity. Preventive medicine, 114, 140–148. 5. Gunderson, E. P., Lewis, C. E., Lin, Y., Sorel, M., Gross, M., Sidney, S., ... & Quesenberry, C. P. (2018). Lactation duration and progression to diabetes in women across the childbearing years: the 30-year CARDIA study. JAMA Internal Medicine, 178(3), 328–337. 6. Gaitskell, K., Green, J., Pirie, K., Barnes, I., Hermon, C., Reeves, G. K., ... & Million Women Study Collaborators. (2018). Histological subtypes of ovarian cancer associated with parity and breastfeeding in the prospective Million Women Study. International Journal of Cancer, 142(2), 281–289. 7. Zhou, Y., Chen, J., Li, Q., Huang, W., Lan, H., & Jiang, H. (2015). Association between breastfeeding and breast cancer risk: evidence from a meta-analysis. Breastfeeding Medicine, 10(3), 175–182. 8. Bartick, M. C., Schwarz, E. B., Green, B. D., Jegier, B. J., Reinhold, A. G., Colaizy, T. T., ... & Stuebe, A. M. (2017). Suboptimal breastfeeding in the United States: Maternal and pediatric health outcomes and costs. Maternal & Child nutrition, 13(1), e12366. 9. Thompson, J. M., Tanabe, K., Moon, R. Y., Mitchell, E. A., McGarvey, C., Tappin, D., ... & Hauck, F. R. (2017). Duration of breastfeeding and risk of SIDS: an individual participant data meta-analysis. Pediatrics, 140(5), e20171324. 10. Modrek, S., Basu, S., Harding, M., White, J. S., Bartick, M. C., Rodriguez, E., & Rosenberg, K. D. (2017). Does breastfeeding duration decrease child obesity? An instrumental variables analysis. Pediatric Obesity, 12(4), 304-311. 11. Martens, P. J., Shafer, L. A., Dean, H. J., Sellers, E. A., Yamamoto, J., Ludwig, S., ... & McGavock, J. (2016). Breastfeeding initiation associated with reduced incidence of diabetes in mothers and offspring. Obstetrics & Gynecology, 128(5), 1095–1104. 12. Michels, K. B., Trichopoulos, D., Rosner, B. A., Hunter, D. J., Colditz, G. A.,

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Hankinson, S. E., ... & Willett, W. C. (2001). Being breastfed in infancy and breast cancer incidence in adult life: results from the two nurses' health studies. American Journal of Epidemiology, 153(3), 275–283. 13. Amitay, E. L., & Keinan-Boker, L. (2015). Breastfeeding and childhood leukemia incidence: a meta-analysis and systematic review. JAMA pediatrics, 169(6), e151025–e151025. 14. Boucher, O., Julvez, J., Guxens, M., Arranz, E., Ibarluzea, J., de Miguel, M. S., ... & O’Connor, G. (2017). Association between breastfeeding duration and cognitive development, autistic traits and ADHD symptoms: a multicenter study in Spain. Pediatric Research, 81(3), 434. 15. Hayatbakhsh, M. R., O'Callaghan, M. J., Bor, W., Williams, G. M., & Najman, J. M. (2012). Association of breastfeeding and adolescents' psychopathology: a large prospective study. Breastfeeding Medicine, 7(6), 480–486. 16. Poton, W. L., Soares, A. L. G., Oliveira, E. R. A. D., & Gonçalves, H. (2018). Breastfeeding and behavior disorders among children and adolescents: a systematic review. Revista de Saude Publica, 52, 9. 17. Oddy, W. H., Kendall, G. E., Li, J., Jacoby, P., Robinson, M., De Klerk, N. H., ... & Stanley, F. J. (2010). The long-term effects of breastfeeding on child and adolescent mental health: a pregnancy cohort study followed for 14 years. The Journal of Pediatrics, 156(4), 568–574. 18. Victorian perinatal services performance indicators 2013−14 18. Sandall, J., Soltani, H., Gates, S., Shennan, A. and Devane, D., 2016. Midwife-led continuity models of care compared with other models of care for women during pregnancy, birth and early parenting. Cochrane Database of Systematic Reviews.

Do the priorities and actions specified for Priority area 3: Sexual and reproductive health adequately address the specific health needs of women and girls in Australia?

No

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With regard to Priority area 3, is anything missing or should anything be changed? (400 words)

Missing a priority in this section: Increase health promotion of women and babies in the preconception, and perinatal period. This document is lacking actions around health promotion in this time. Also needs to address risk factors for ill health in this period, including:

- Overmedicalisation of pregnancy and childbirth - Overuse of screenings/tests - High caesarean section rate - High induction rate - Suboptimal breastfeeding rates - Use of prophylactic antibiotics

These are risk factors for significant morbidity and mortality for women, as well as long-term health consequences for girls born to these mothers. Midwifery-led continuity of care models have proven cost-effective, as well as beneficial at reducing rates of caesarean section, increasing breastfeeding rates, and increasing maternal satisfaction. This model empowers women, who leave midwifery care as capable, confident mother. As stated earlier, obesity and advanced maternal age are not causes of caesarean section. There is no evidence to support that these factors impede a woman’s innate ability to labour and birth her baby. Doctors and midwives give these women less time to labour, are more likely to offer induction and elective casesarean, and are more quick to intervene than in women of “normal” age and BMI. It is important to not propagate non-evidence

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based stereotypes, which further perpetuate misconceptions. This will only increase the rate of unnecessary caesarean sections and interventions. 3.2 Suggested action: increase access to midwifery-led, continuity of care models for women in their community. These should be accessible regardless of risk, and geography. It is acknowledged that the perinatal period is time of greater vulnerability - and yet no strategies focus on raising of children and supports, education and health promotion to support these women. Please note that the definition used for perinatal period (to end of first year, page 19) is not consistent with the AIWH definition for perinatal period; the AIWH definition is 'the perinatal period commences at 20 completed weeks (140 days) of gestation and ends 28 completed days after birth.” Please specify which guidelines this document will align with in terms of defining the postnatal period. Involve the work of the Centre of Perinatal Excellence (COPE) (www.cope.org.au) As discussed in the response for Priority 2 – this is another area where the benefits of breastfeeding to women and their children should be revisited as protective against long-term health issues (e.g. obesity, breast and cervical cancer, asthma). The postnatal period

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is where women report the least amount of support in standard maternity care paths (private obstetric, pubic tertiary). Women need access to breastfeeding and parenting support in the postnatal period, in order to support them in this vulnerable period.

Do the priorities and actions specified for Priority area 4: Conditions where women are overrepresented adequately address the specific health needs of women and girls in Australia?

Yes

With regard to Priority area 4, is anything missing or should anything be changed? (400 words)

This priority area is quite broad, and could benefit from being more specific. The point about pregnant women being overrepresented in intimate family violence could be explored more, none of the actions or details address how to identify and assist pregnant women specifically. Screening at the booking visit and at subsequent antenatal and postnatal visits should become part of National and State Best Practice Guidelines. Priority 4.2 is appropriate, promotion of positive relationships for girls and boys is a great way to address issues of intimate partner violence.

Do the priorities and actions specified for Yes

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Priority area 5: Healthy ageing adequately address the specific health needs of women and girls in Australia?

With regard to Priority area 5, is anything missing or should anything be changed?

5.1 Promote the benefits on breastfeeding on healthy ageing The impacts of women having less superannuation due to decreased work during childraising years impacts on healthy aging. There could be a broader focus on intergenerational caring. This can include a woman caring for children and aging parents, grandchildren, grandchildren and aging parents/spouse, or ill spouse/family member and children. This significantly affects the physical and mental health of women, their ability to work and thus their superannuation. It is largely unspoken and expected of women, and needs further study and investigation.

Section D: Research, partnerships and progress

Do the actions specified for Investing in research, adequately address the specific research needs to improve health outcomes for women and girls in Australia?

No

With regard to Investing in research, is anything missing or should anything be changed?

This document purports to be focused on a model of health that is not simply medical, but more holistic. However, the research is focusing on the biomedical model – ignoring research needed into breastfeeding and human lactation. This entire document is also ignoring the vast amount of research supporting the benefits of midwifery continuity-of-

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care to the health and wellbeing of mothers and their children (1). This solution is not discussed at all in this document. Create a Centre for Research Excellence for Human Lactation. As a women's health issue breastfeeding is vastly under researched and funding is extremely hard to obtain because lactation is not seen as an important issue for women. Yet the majority of women have breastfeeding difficulties, half stop breastfeeding before they want to and only 20% breastfeeding for 12 months, to the detriment of their own health and their infant's. Around of fifth of breastfeeding experience mastitis and 5% of those women go on to develop an abscess. Australian breastfeeding rates for premature babies are extremely low and this is an area where human milk feeding is critical. Research should focus on prevention and primary health care actions to promote health, rather than managing symptoms and diseases. 1. Sandall, J., Soltani, H., Gates, S., Shennan, A. and Devane, D., 2016. Midwife-led continuity models of care compared with other models of care for women during pregnancy, birth and early parenting. Cochrane Database of Systematic Reviews.

Does the section: Strengthening partnerships adequately outline that strong partnerships between government, patients, advocates, healthcare professionals and industry are necessary to implement the

Yes

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actions identified in the Strategy?

Please provide your comments and explain your selection (200 words)

This section is generally good. However, the final paragraph should be the first. “Above all, action must be driven and owned by women”. This cannot simply be lip service to women, women must be considered and included at every step of this Strategy, at times throughout this document, women and girls are not front and centre.

What specific targets and measures should be used in this Strategy to determine progress towards achieving the overall purpose of the Strategy to: ‘improve the health and wellbeing of all women and girls in Australia, providing appropriate, accessible and equitable care, especially for those at greatest risk of poor health’? (400 words)

Increase access to midwifery-led continuity of care models from pre-conception to 6 weeks postnatal in women’s communities. Consideration of the development and validation of long term outcome 'measures' that are important to women (ie consideration of women's experiences of care that goes beyond simply collecting clinical outcome measures). Increase in rate of exclusive breastfeeding, as well as increase in rate of any breastfeeding by 1 month, 6 months, etc… Breastfeeding outcomes need to be not only recorded but the data linked back across maternity services. Increased accessibility of postnatal education and support around breastfeeding and early parenting. Early detection and referral of mental health issues in the perinatal period.

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Opportunistic screening for other risk factors and problems (psychosocial, medical, mental health) in perinatal period. Womens’ mental health disorders will decrease significantly. Womens’ prevalence of cardiovascular disease will reduce substantially. Aboriginal & Torres Strait Islander womens comorbidities will decrease to bring the figure closer to Non-Indigenous womens’ rates. Womens’ mortality rates will be reduced by half due to intimate partner violence due to education and ability for women to access help and resources more readily. Eating disorders will be reduced in young women. Women who are pregnant will experience less anxiety and depression due to better access to resources and education and screening prenatally. Women who identify as LGBTIQ will experience less anxiety, depression and affective disorders. Women living in rural and remote areas will experience better health outcomes.

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Women who are socioeconomically disadvantaged will experience lower rates of being overweight and obesity. Women will experience lower levels of dementia due to increased screening by GP’s and targeting of reduced areas of cognition earlier in the woman’s life. Women will be more likely to receive appropriate treatment for a heart attack. Womens’ incidence of lung cancer will be reduced. Womens’ incidence of chronic disease will be reduced. Women from culturally and linguistically diverse backgrounds will have better access to services and interpreters to reduce comorbidities in this group, especially mental health. Women in the criminal justice system will have lower rates of alcohol and substance abuse and experience lower rates of family violence. Womens’ incidence of suicide will be reduced.

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Primary Health Networks will be better equipped to coordinate workforce strategies to address and treat mental health disorders. Availability of free digital and phone app services for women contemplating suicide. De-stigmatising language surrounding mental health issues. Include more questions on health determinants in the Australian Bureau of Statistic survey. Or incorporate them as a national survey under Myhealthrecord platform. Infant mortality is a key indicator that measures population health; and access to quality maternity care and services. Stillbirth is specifically mentioned however infant loss / mortality post birth deserves a mention also given it has far reaching effects and association with poor health outcomes, lower socioeconomic determinants of health, poor mental health.

Overall comments

Do you have any additional comments? Consider how primary health models (such as midwifery-led continuity of care models) can work to prevent illness and promote wellness. Despite moving towards a model of health which is not simply medical, this document still has a way to go to address the health and wellness of women and girls (mentally, physically, spiritually, holistically, emotionally,

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culturally). I encourage you to continue to collaborate with women and members of the identified Priority Populations – to make sure the voice and needs of women and girls aren’t lost as this Strategy is implemented and monitored. I strongly encourage the Strategy to address the harms of the rising rate of caesarean sections on mothers and their children, as well as the benefits to mothers, babies and society of supporting strategies to increase the rate of breastfeeding in Australia. This is well within the scope of this document.