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Item Resisting stigma: the role of online communities in young mothers' successful breastfeeding.(BioMed Central Ltd, 2024-03-06) Severinsen C; Neely E; Hutson RBACKGROUND: Breastfeeding initiation and continuation rates are shaped by complex and interrelated determinants across individual, interpersonal, community, organisational, and policy spheres. Young mothers, however, face a double burden of stigma, being perceived as immature and incompetent in their mothering and breastfeeding abilities. In this study, we aimed to understand the experiences of young mothers who exclusively breastfed for six months and beyond and explore their experiences of stigma and active resistance through social media. METHODS: In 2020, in-depth telephone interviews about breastfeeding experiences were conducted with 44 young mothers under age 25 in Aotearoa New Zealand who breastfed for six months or longer. Participants were recruited via social media. Interviews were audio-recorded, transcribed and analysed thematically. RESULTS: Analysis yielded four themes on young mothers' negotiation of breastfeeding and support. The first three themes revealed young mothers' encounters with socio-cultural contexts. They faced negative judgments about maturity and competence, adverse guidance to supplement or cease breastfeeding, and an undermining of their breastfeeding efforts. The fourth theme showed how young mothers sought alternative support in online environments to avoid negative interactions. Online spaces provided anonymity, convenience, experiential knowledge and social connections with shared values. This facilitated identity strengthening, empowerment and stigma resistance. CONCLUSION: Our research highlights the importance of online communities as a tool for young mothers to navigate and resist the societal stigmas surrounding breastfeeding. Online spaces can provide a unique structure that can help counteract the adverse effects of social and historical determinants on breastfeeding rates by fostering a sense of inclusion and support. These findings have implications for the development of breastfeeding promotion strategies for young mothers and highlight the potential of peer support in counteracting the negative impacts of stigma. The research also sheds light on the experiences of young mothers within the health professional relationship and the effects of stigma and cultural health capital on their engagement and withdrawal from services. Further research should examine how sociocultural barriers to breastfeeding stigmatise and marginalise young mothers and continue to reflect on their socio-political and economic positioning and how it can exacerbate inequities.Item Feeding and dietary practices of New Zealand infants : an observational study : a thesis presented in the partial fulfilment of the requirements for the degree of Doctor of Philosophy in Nutritional Science at Massey University, Albany, New Zealand(Massey University, 2023) Brown, Kimberley JaneBackground: Nutrition and early-life feeding practices have short and long-term impacts on the quality and longevity of life. The importance of optimal nutrition during infancy is recognised worldwide and evidence-based infant feeding recommendations have been developed to promote infant health, growth, development, and the establishment of healthy eating behaviours. Currently, there is limited evidence on infant nutrition and feeding practices in New Zealand (NZ), with gaps in our knowledge about what infants are being fed, adherence to the Ministry of Health (MoH) ‘Healthy Eating Guidelines for New Zealand Babies and Toddlers (0–2 years old)’, and the prevalence of concerning feeding behaviours (CFB). Aim: To 1) investigate the contributions that key foods and food groups make to the dietary intake of NZ infants, 2) investigate infant adherence to key dietary indicators as recommended by the MoH’s ‘Healthy Eating Guidelines for New Zealand Babies and Toddlers (0–2 years old)’, and 3) determine the prevalence of parent-reported concerning infant feeding behaviours and associated demographic characteristics and feeding practices of NZ infants between 7.0 and 10.0 months of age. Methods: The observational First Foods NZ (FFNZ) study recruited 625 ethnically diverse infants (aged 7.0 to 10.0 months) living in Auckland and Dunedin between July 2020 and February 2022. Caregivers who were 16 years or older, spoke English, and had not recently participated in a nutritional intervention that may have influenced their infant’s diet were invited to attend two study visits. Appointments were conducted in the participant’s home, available research centre, or via Zoom (during Covid19 restrictions for second appointment only) and included two 24-hour diet recalls and demographic and feeding questionnaires. Diet recall data were analysed through FoodWorks (Version 10, Xyris Software, Australia) using the NZ Food Composition Database FOODfiles™ 2018 Version 01, and foods were allocated food and food group codes using the FFNZ coding system. Counts of foods and food groups consumed were analysed for at least one and both diet recall days, where available. Key indicators from the MoH’s ‘Healthy Eating Guidelines for New Zealand Babies and Toddlers (0–2 years old)’ that were measurable from FFNZ data and applied to those aged 7.0 to 10.0 months were extracted from questionnaire data, or where stated from 24-hour recalls. Recommendations analysed included exclusive breastfeeding to ‘around’ six months of age (defined as ‘5 months’ or ‘6 months’, being the age when something other than breast milk, i.e. either another drink, or solid foods, was first introduced); current breastfeeding; the introduction of solid foods ‘around’ six months of age” (defined as ‘5 months’ or ‘6 months’ when the first solid food was introduced); the introduction of puréed foods and spoon-feeding when starting solid foods; offering of iron-rich foods (meat, poultry, fish, seafood, and iron fortified infant cereals), vegetables, and fruit as first foods; the daily offering of MoH food groups (24-hour recall data; vegetables, fruit, grain foods, milk and milk products, and meat and protein-rich foods); no salt and sugar added to meals (specific 24-hour recall question); avoidance of inappropriate drinks (specific 24-hour recall question; beverages other than breast milk, formula, or water such as cow’s milk as a drink, other milk, juice, soft drinks, tea, and alcohol); and use of self-feeding when developmentally appropriate. Logistic regression was then used to estimate odds ratios, 95% confidence intervals, and p-values for associated sociodemographic characteristics and key indicators. After their second appointment, caregivers were emailed a final questionnaire, which included the Paediatric Eating Assessment Tool (PediEAT). Feeding behaviours were categorised according to the total PediEAT and subscale scores (physiologic symptoms, problematic mealtime behaviours, selective/restrictive eating, and oral processing). Scores were categorised as ‘concern’ and ‘no concern’ using the PediEAT scoring system. Unpaired t-tests and the chi-squared tests determined associations between PediEAT scores and infant and caregiver sociodemographic characteristics. Logistic regression, adjusted by infant age and deprivation, determined associations between PediEAT scores and food groups consumed during both diet recalls. Data were analysed using Stata software (StataCorp, Texas) and Microsoft Excel (version 16.66). Results: Written consent was obtained from 625 caregivers. Data from the demographic and feeding questionnaire were available from all infants (n=625). All caregivers completed at least one diet recall. A second diet recall was available from 614 infants. PediEAT results were available for 554 term infants. Most infants consumed vegetables (96.2% of infants), fruit (91.8%), grain foods (90.4%), milk and milk products (64.0%), and meat and protein-rich foods (84.3%) at least once during the two 24-hour diet recall days. Commercial infant foods (CIF) were consumed by 78.1% and discretionary foods by 56.3% of infants at least once. The proportion of infants who consumed vegetables (63.2%), fruit (53.9%), grain foods (49.5%), milk and milk products (38.6%), meat and protein-rich foods (31.8%), CIF (41.8%), and discretionary foods (16.1%) on both diet recall days was lower. Overall, only 6.5% of infants met guidelines for the daily consumption of the MoH food groups. The ten most common foods consumed were carrot, banana, bread, brassicas, kumara, extruded commercial infant snacks, pumpkin, apple, potato, and commercial infant pouches. Breastfeeding was initiated by 97.2% of mothers, and 37.8% of infants were exclusively breastfed to around six months. At the time of participation, 66.2% of infants were breastfed. Most infants met guidelines for introducing solid foods, including the age of introduction (75.4%), offering iron-rich foods as first foods (88.3%), providing puréed textures (80.3%) and spoon-feeding (74.1%). Self-feeding at the time of participation was common (86.9%). Most met guidelines for avoiding inappropriate beverages (93.9%) and adding salt (76.5%) and sugar (90.6%) to foods. Typically, infants with caregivers who were younger, higher educated, not currently working, primiparous, and living in low deprivation were more likely to meet the guidelines. Feeding behaviour scores were higher than PediEAT norm-reference values and 17.3% of infants were categorised with ‘concern’ feeding behaviours. ‘Concern’ scores were highest for selective/restrictive eating (29.2%), problematic mealtime behaviours (21.5%), and physiologic symptoms (13.7%) subscales. Mothers who were primiparous and highly educated caregivers were more likely to report ‘concern’ total PediEAT scores. Primiparous mothers and caregivers with higher education, that did not use early child education centres, and had infants of NZ Asian infant ethnicity were more likely to report problematic mealtime behaviours. Infants characterised as of ‘concern’ had significantly lower odds of consuming ‘vegetables’ and ‘meat and protein-rich foods’ and were more likely to consume ‘CIF’. Infants with problematic mealtime behaviours had a lower odds of consuming ‘discretionary foods’ and were more likely to be still breastfeeding. Conclusion: This research provides evidence on infant food and food group intake, adherence to key MoH infant feeding guidelines, and the prevalence of parent-reported infant feeding behaviours and associated demographic characteristics and feeding practices from an ethnically diverse group of NZ infants from Auckland and Dunedin. Infants were shown to consume a range of foods within the MoH food groups at least once during the study. However, only 6.5% of infants consumed all five food groups during both recalls. Grain foods, milk and milk products, and meat and protein-rich foods were the least commonly consumed food groups when investigating those consumed on both recall days, increasing the risk of nutritional deficiencies. Most infants met guidelines for introducing solid foods and avoiding inappropriate beverages and adding salt and sugar to meals, although the prevalence of exclusive breastfeeding to ‘around’ six months, however, continues to be low, particularly for first-time mothers. As seen previously, sociodemographic characteristics were also associated with adherence, identifying key groups (primiparous mothers, lower educated caregivers, those living with multiple children, and those living in areas of high deprivation) that require additional support. Finally, CFB were prevalent in our study, with higher scores reported by primiparous mothers and caregivers who were highly educated. Infants with CFB were less likely to meet recommendations for ‘vegetables’ and ‘meat and protein-rich foods’ and were more likely to consume ‘CIF’. Further investigation is required to understand parental perceptions of feeding behaviours and the nutritional implications of CFB. Further research will determine the nutritional implications of not meeting the MoH food group guidelines during complementary feeding, investigate what support parents need in NZ to improve adherence to the MoH breastfeeding and food group recommendations, and the impact of CFB on nutrient intake.Item Being the 'good' mother : a discursive study of breastfeeding women's experiences of accessing early childhood education in New Zealand : a thesis presented in partial fulfilment of the requirements for the degree of Master of Science in Psychology (Endorsement in Health Psychology) at Massey University, Auckland, Aotearoa New Zealand(2019) Henderson, Kaitlin ChristinaA majority of women in New Zealand will attempt breastfeeding, return to employment, and access early childhood education (ECE) care within the first year of their child’s life. There is a great interest in promoting and increasing national breastfeeding rates, yet little research exploring how normative ideals of motherhood influence breastfeeding women once they return to employment. Psychological studies that explore breastfeeding and employment often locate the issue at an individual level, constructing breastfeeding as a personal ‘choice’. Such research ignores the significant influence that structural barriers and societal pressures have on breastfeeding women’s ability to freely choose an infant feeding method. This research seeks to remedy this limited focus. In the current study, I was interested in examining how discursive constructions of breastfeeding shape women’s subjectivities as mothers, and the ways in which these subjectivities enable or constrain women’s ability to breastfeed. I utilised a poststructuralist approach to highlight how women’s constructions of breastfeeding influenced their accounts of infant feeding in ECE and workplace settings. I conducted qualitative interviews with seven women living in Auckland who had experienced combining breastfeeding with employment and I applied a Foucauldian discourse analysis to make sense of the data collected. Through my analysis I discovered that the participants worked to align themselves with the subject position of ‘good’ mother. Participant’s discursive constructions of breastfeeding worked to strengthen their subjectivities as ‘good’ mothers through three primary discourses; breastfeeding as best for the child, a natural and easy part of motherhood, and a difficult journey. The subjectivity of the ‘good’ mother had significant implications for how women navigated ECE and workplace settings. Participants often placed themselves under considerable stress to ensure they continued breastfeeding, despite structural difficulties. In the workplace the ‘good’ mother had to manage disruptions caused by breastfeeding, navigate poor management, and mitigate stigma. In ECE settings women had to manage tensions between public and private spheres and deal with low structural support. Women’s ability to uphold their status as ‘good’ mother in these contexts was often dependent on the level of privilege each participant held. Western constructions of motherhood compel women to be ‘good’ mothers regardless of the strain introduced. Therefore, I argue that by unpacking women’s constructions of breastfeeding and motherhood, in relation to ECE care and employment, the negative impacts of such discourses are highlighted and avenues to address these can become apparent.Item Perceived insufficient milk supply in New Zealand mothers during the first-year postpartum : this thesis presented in partial fulfilment of the requirements for the degree of Master of Science in Nutrition and Dietetics at Massey University, Albany, New Zealand(Massey University, 2019) Hintz, MicahBackground: Mothers rarely achieve breastfeeding (BF) recommendations and there are numerous reasons that may lead to early cessation. However, insufficient milk supply is a frequently reported cause. Current research on perceived insufficient milk supply (PIM) itself is limited. Numerous factors are suggested to play a part in the occurrence of PIM, including: demographic, psychological as well as feeding practices and management factors. Aim. To determine the factors associated with PIM and the impact that this has on BF practices. Methods: Secondary analysis of the data collected from Manawatu Mother and Baby Study. Sixty-one women were included. Interviews about maternal demographics, obstetric characteristics and BF practices were conducted on women approximately 2 weeks postpartum, then at 2 weekly intervals throughout the first three months, and finally once per month until the infants first birthday. Bivariate associations and logistic regression analyses were conducted to determine the relation of PIM with variables, as well as with BF duration. Results: PIM was reported by 44% of the participants and was the main reason for introduction of infant formula. Formula use was a significant predictor for PIM (R2=0.22) and was explained by formula being used in response to PIM. We found that PIM was a significant predictor of BF duration (any BF 5 months R2=0.44, full BF 5 months R2=0.13, any BF 12 months R2=0.32). Additionally, maternal importance of BF at 4 weeks can also predict the duration of BF. Conclusion: PIM plays a significant role in the introduction of infant formula and BF cessation. However, the absence of a significant relationship between PIM and demographic variables makes it difficult to identify mothers who may be at risk of PIM. Further research is required to try identify mothers at risk of PIM, in order to help prevent or resolve it.Item Determinants of successful breastfeeding by young mothers in New Zealand : a thesis presented in partial fulfillment of the requirements for the degree of Masters in Science in Nutrition and Dietetics at Massey University, Albany, New Zealand(Massey University, 2017) Polglaze, Rebekah LeighBackground: International research has shown that younger mothers are less likely to initiate/maintain breastfeeding (BF) than older women. Optimising BF maintenance in young mothers is important because early cessation of BF has been associated with negative health outcomes for the infant, which may extend beyond infancy into adulthood. Despite this, little is known about the facilitators of successful BF in this group. Therefore, the purpose of this study was to investigate the factors that enabled a group of mothers who gave birth at a young age to successfully breastfeed for at least 4 months. Objective: To gain an in-depth understanding of the factors that led to a successful breastfeeding experience in mothers who gave birth at a young age. Methods: Seventeen positive deviants were identified. These were mothers who gave birth under the age of 25 years, who had successfully BF for at least 4 months. Participants were recruited through various support groups and breastfeeding networks. Semi-structured in-depth interviews were conducted in person or over the phone with each of the seventeen mothers. The interviews were recorded and transcribed, which enabled theme identification. Demographic information was also collected using a short questionnaire. A thematic analysis was used to analyse the qualitative data obtained from each mother’s breastfeeding experiences. Interpretative phenomenology was used to extract themes from the transcripts, these were then double-checked by two researchers in the research team. Results: Participants were located throughout the North Island of New Zealand (NZ). Eleven mothers identified themselves as NZ European, three mothers identified as NZ European and Māori, and one mother identified as NZ European and Hawaiian. The mothers had given birth between the age of 15 through to 24 years and these births occurred between 2004 and 2017. Despite purposive sampling, of mothers who had successfully BF, participants identified core barriers to BF. These barriers were explored in depth before enablers of BF could be identified and examined. The key barriers include lack of breastfeeding knowledge, expectations, which differed from the lived experience, the quality of the initial support for BF, lack of ongoing support for BF and initial difficulties with the practice BF. Once the core barriers to BF had been fully explored, it was possible to identify and examine the enablers of successful BF. It became evident through the data analysis that the mothers found alternative solutions to overcome these barriers. These solutions were categorised into three key enablers, resilience in the face of adversity, a positive breastfeeding culture and the economy of BF. These factors facilitated the mothers to overcome the barriers they were faced with, which enabled them to successfully breastfeed. Conclusion: Intrinsic motivation amongst positive deviants appears to be a driver of information and support seeking behaviour, which enhances self-efficacy and breastfeeding resilience amongst young mothers.Item Key determinants of breastfeeding success in infants born before 30 weeks gestation : a thesis presented in partial fulfilment of the requirements for the degree of Master of Philosophy at Massey University, Auckland, New Zealand(Massey University, 2005) Thomas, Carol LesleyBreastfeeding is promoted at a public health level by many agencies internationally and nationally. While there is an abundance of literature to guide practice regarding breastfeeding term healthy infants, there is little regarding premature infants, particularly those born before 30 weeks gestation. Data on breastfeeding outcomes in this population is limited in the New Zealand literature. The aims of the study were to identify the breastfeeding outcomes of premature infants born before 30 weeks gestation: to identify key determinants that may contribute to the success of breastfeeding outcomes; and to describe the feeding practices of this population during hospitalisation and post-discharge. This audit used a non-experimental, cross-sectional, descriptive, correlational design using pre-existing medical records, to obtain variables of interest. Independent variables included maternal and infant characteristic and infant feeding characteristic. Key determinant variables were identified as maternal support, maternal milk supply, kangaroo care and bottle use. Feeding problems and growth were also considered as independent variables. Breastfeeding outcomes are comparable to the New Zealand population of breastfed infants in duration but not intensity of breast milk received. Maori and Polynesian infants have poorer breastfeeding outcomes compared to Caucasian and Asian infants and have higher rates of feeding problems. Further research is required to identify the cause of increased feeding problems in these cultures.Item Six months exclusive breastfeeding : a relational behaviour influenced by actual and virtual social networks : a thesis presented in fulfilment of the requirements for the degree Doctor of philosophy in Midwifery, Massey University, Manawatu, New Zealand(Massey University, 2017) Alianmoghaddam, NargesDespite widespread consensus regarding the health benefits of six months exclusive breastfeeding for mothers and infants, the prevalence of six months exclusive breastfeeding is very low in developed countries including New Zealand. This research contributes to the literature nationally and internationally through documenting influencing factors among New Zealand women and their family that relate to the practise of six months exclusive breastfeeding. This research is a qualitative study involving face to face postpartum interviews with 30 mothers who prior to the birth of their infants were characterised as highly motivated to breastfeed exclusively for six months. The research participants were recruited from the lower North Island of New Zealand. Initial data were collected using a short questionnaire administered before the birth to record demographic information and to establish an antenatal intention to breastfeed exclusively. An initial postpartum face to face interview was conducted at around six weeks. Each participant was then followed via short monthly audio-recorded telephone interviews until giving up exclusive breastfeeding or until six months after the birth. Social construction is was used as the epistemological framework underpinning the research. A range of social theories, linked to the central theory of social constructionism, were used to highlight the importance of social relationships, social interactions and social support. The theory of “planned behaviour” proposed by Icek Ajzen (1991), the theory of stress, coping strategies and social support proposed by Thoits (1995), theories of “governmentality” and “biopower” developed by Michel Foucault (1972), arguments about the "strength of weak ties” proposed by Mark Granovetter (1973) and theories related to “landscapes of care” suggested by Milligan and Wiles (2010), were used in this thesis to illuminate the findings that resulted from the thematic analysis of the qualitative data. The research was reviewed and approved by the Massey University Human Ethics Committee. The central finding of this research is that six months exclusive breastfeeding practice is not limited to the intentions or actions of the mother-infant dyad; it is socially constructed by actual and virtual social networks around the mother as well as the other relational influences such as historical, geographic, socioeconomic and social contexts of the mother’s life. Additional findings of this research related to the quality of breastfeeding support through social media such as Facebook, Skype and smartphone apps, makes a significant contribution to the New Zealand and international literature in this area.Item The reasons why women with small for gestational age babies stop breastfeeding : a thesis presented in partial fulfilment of the requirements for the Master of Arts in Midwifery at Massey University(Massey University, 2000) Hutchings, Sarah LouiseThere has been a multitude of research literature on breastfeeding benefits, incidence and duration of breastfeeding, characteristics of women who breastfeed and formula feed, and variables associated with breastfeeding initiation and success in the 'general' breastfeeding population. Unfortunately there has been very little written about breastfeeding in women who deliver small for gestational age (SGA) babies. The literature has demonstrated that women with SGA babies have different characteristics to women in the general breastfeeding population as illustrated in the adjacent literature review. The literature review, which accompanies this thesis, has highlighted the multiple advantages associated with breastfeeding, which may be particularly beneficial for SGA babies. Whether women delivering SGA babies have different breastfeeding experiences, or reasons for discontinuing breastfeeding, however has never been investigated. The research presented in this thesis is part of a randomised-controlled trial entitled "The effect of educational information on the duration of breastfeeding in small for gestational age babies". Only one arm of this larger study has been analysed due to the restraints of a 75-point thesis. The full program of study is in progress. The primary aim of this arm was to determine why women with small for gestation age babies stop breastfeeding. Other influences on breastfeeding success were also investigated to determine if these external influences were statistically significant. The findings from this research project have demonstrated that women with SGA babies have the same breastfeeding concerns as women in the general breastfeeding population. The most commonly cited reason for stopping breastfeeding were concerns about 'not enough milk'. Forty four percent of the women cited the midwife as being the most 'valuable' support with their breastfeeding experience. Overall the women with SGA babies had very good breastfeeding rates at 3 and 6 months postnatally compared with the general breastfeeding population statistics. This is a credit to the midwives caring for these women and babies and may also be related to the fact that term SGA babies have been undernourished in utero and can often be hungry babies with 'catching up' to do. These research findings also support the idea that the introduction of supplementary bottles administered on the postnatal wards can have a detrimental effect on future breastfeeding success. However, small for gestational age infants are at increased risk of hypoglycaemia and supplemental feeding may be necessary if the infant is feeding poorly or shows evidence of hypoglycaemia. Any strategies that can improve the breastfeeding duration for SGA infants can result in a wide range of health benefits. The adjacent literature review demonstrates that breastfeeding is the best form of infant feeding and may be even more so for small term babies.Item Birth and breastfeeding events : the influence of birth on breastfeeding duration : an exploratory research study : a thesis presented in partial fulfilment of the requirements for the degree of Master of Philosophy in Midwifery, Massey University(Massey University, 2004) Hagan, Annette ElsieA retrospective exploratory methodology was used to examine the influence perinatal events had on breastfeeding duration measured at four months postpartum. A self-reporting questionnaire and examination of obstetric records provided the quantitative data for 68 normal vaginal birth women and 85 Caesarean section women. Nonparametric Pearson's Chi-square goodness of fit test was used to measure statistical significance. Almost 88% (87.6%) of the respondents were breastfeeding four months following birth. This was 86.8% of normal birth women and 88.2% of Caesarean section women. Sixty-four percent of infants were exclusively breastfeeding and 11% fully breastfeeding four months after birth. Prior breastfeeding was the only event or experience found to be significantly statistically associated with type of birth and breastfeeding duration. A marginally significant statistical relationship was found between type of Caesarean section and breastfeeding at four months postpartum. Highly significant statistical relationships were identified between type of birth and: time of first cuddle, concomitant skin-to-skin contact, time of first breastfeed, supplementary feeding in hospital, and receiving help in hospital. A significant statistical relationship was identified between type of birth and having a breastfeeding problem in hospital, and a marginally significant statistical relationship between type of birth and 'rooming in'. Other events that were expected and identified as highly significant statistically were: multiparity and having breastfed before, having a breastfeeding problem in hospital and receiving help, type of birth and time in hospital, and breastfeeding at four months postpartum and satisfaction. There was a marginally significant statistical relationship between breastfeeding at four months postpartum and type of caesarean section. This studies finding that there was no difference in breastfeeding rates at four months for either sub-sample of women warrants further exploration.Item The baby friendly hospital initiative : level of implementation in ten New Zealand hospitals : a thesis submitted in partial fulfilment of requirements for the degree of Master of Philosophy in Midwifery at Massey University(Massey University, 2000) Pownall, Beverly MargaretThe potential benefits of breastfeeding are well documented. These include benefits for the infant which may extend into adult life, as well as benefits for the mother, the family, the economy, and the environment. Yet despite this, breastfeeding rates in New Zealand are not improving, and there is evidence of practices in New Zealand hospitals which have a negative influence on breastfeeding. One possible solution to this is to try to improve hospital policies and practices through implementation of the Global Baby Friendly Hospital Initiative (WHO/UNICEF, 1989). The purpose of this study was to ascertain the level of implementation of BFHI related policies and practices in New Zealand hospitals which provide maternity services. A descriptive survey utilizing face to face interviews of groups of 2-6 participants was undertaken in ten hospitals located in the North Island of New Zealand. Respondents included midwifery managers, lactation consultants, midwives, and nurses, familiar with their hospital's breastfeeding policy and practices. An adapted questionnaire and classification system developed by Kovach (1995) classified hospitals within four levels of implementation ranging from high, moderately high, partial, and low. Most of the hospitals were implementing six of the Ten Steps. The majority were not fully implementing Steps 1 and 2, and some hospitals had insufficient knowledge of current practices to be able to demonstrate implementation of Steps 3 and 5. The area identified as needing the greatest attention by hospitals is staff education on breastfeeding. Overall, five hospitals were classified as high implementers and five as moderately high, however no hospital was considered to be fully implementing BFHI. The study identified four main findings: a lack of consistent breastfeeding definitions and insufficient knowledge of exclusive breastfeeding rates; current difficulties in obtaining data, particularly about self-employed Lead Maternity Carer (LMC) practices; a lack of staff knowledge and misperceptions about the BFHI; and a gap between recommended evidence-based practices and reported breastfeeding practices in the surveyed hospitals.