The present results need to be considered in light of limitations. Although a thirty-percent response rate is acceptable for an anonymous postal survey it could be that midwives most interested in breastfeeding promotion responded and their views may differ from non-respondents. Self-report instruments about practice highlight what respondents say they do but may not reflect actual practice. We attempted to minimise this risk by assuring anonymity and requesting complete honesty, but future research should include an observation study of practice. The three instruments were separated in the survey form but may have engendered a certain response set. Different responses may have been achieved if the instruments had been distributed individually. To confirm validity, the instruments need to be tested with other health professional populations.
This study provides initial support for the reliability and validity of the NFA and BIP scales. Factor analysis of the revised BKQ confirmed its focus on knowledge and practice and will enhance its use in health professional education and practice. Unlike previous measures, the NFA assesses in-depth knowledge with regards to benefits of continuous skin-to-skin contact between mother and baby for physiological stability and coordinated attachment. The BIP assesses practice for breastfeeding initiation. Accurate assessment of health professional knowledge and practice for the initiation of breastfeeding using standardised measures can help to identify learning deficits, inform the content of educational interventions and enhance the likelihood of best practice in the workplace [5, 6, 8, 49]. The development of accurate assessment tools is important in light of on-going concerns about health professional breastfeeding knowledge and practice [1, 6, 18, 24, 25, 27, 28, 50, 51].
Further testing and refinement of the NFA and BIP is warranted. We recommend the inclusion of more items on assessment of milk transfer and assessing effective breastfeeding to enhance internal reliability of that subscale. Items regarding the effects of analgesia on newborn feeding ability need to be increased in number and refined. Emphasizing the adverse effects of narcotic analgesia administered to the mother during birth on newborn feeding abilities may influence midwives' knowledge of these which in turn can impact on practice and outcomes for mothers and babies. Perhaps further items regarding knowledge of suckling ability of premature and the 'near term infant' could be expanded in future questionnaires to enhance content.
Associations between midwives' characteristics, knowledge and reported practice were interesting. Midwives with 11 to 15 years clinical experience scored more highly in both general breastfeeding (BKQ) and in-depth (NFA) knowledge than colleagues with less than six years experience. Although not significant, groups with 6 – 10 years and over 15 years clinical experience also scored less than the group with 11 to 15 years experience. However, significantly higher practice scores were reported by groups with over 15 years and 11 to 15 years of clinical experience compared with groups with at least 10 years experience. A decrease in breastfeeding knowledge amongst health professionals including midwives with advancing years since their initial education has been reported previously . As suggested by Lowe , the comparative decline in knowledge of health professionals with more years of clinical experience could be attributed to a lack of participation in breastfeeding education as part of their continuing professional development. This rationale is highly probable considering recent interest and discussions regarding ongoing difficulties to improve the uptake of available lactation and infant feeding professional development education and resources for midwives and other health professionals . In Australia, continuing education specifically to update breastfeeding knowledge is mainly taken up by those hospitals moving toward BFHI accreditation.
Higher practice scores demonstrated by more experienced midwives could be a result of those midwives understanding what works well in practice without knowing the scientific basis of continuous skin-to-skin contact and newborn innate feeding abilities. On the other hand, midwives with more experience may be committed to professional development. For instance, almost half the midwives with International Board Certified Lactation Consultant (IBCLC) certification, participating in the study reported over 15 years of clinical midwifery experience. The potential incongruence between knowledge and practice needs further investigation. Consumers consistently report conflicting advice by health professionals with regards to breastfeeding issues higlighting the need for efficient assessment of learning needs and education [12, 18, 53, 54]. Greater emphasis on the practical application of breastfeeding knowledge amongst midwives to enhance consistency of breastfeeding advice and support to mothers has been recommended [5, 7, 8, 10].
The tools used in the present study focus on a specialised area of knowledge and could be used to identify knowledge and practice deficits in the area of newborn feeding behavior for breastfeeding initiation. This was not an included area of knowledge on a recent education needs analysis conducted by Wallace and Kosmala-Anderson  but could be added as an important area of knowledge for inclusion in education programs on lactation and infant feeding.
As expected, midwives who were committed to their own professional development scored highly on both measures of breastfeeding knowledge and practice. Results of the present study indicate that midwives who keep abreast of advancing knowledge have a better understanding and application of research evidence than those who do not access such resources. Hospitals need to make research-based resources readily available, encourage a learning culture, and provide easily accessible learning programs including computer based learning to refresh knowledge and inform practice [4, 5].
Practice standards recommend that all health professionals providing care to mothers and/or infants complete at least 18 hours of education on human lactation and infant feeding . Although there are a range of BFHI-based courses available  not all are used to meet the education needs of qualified practitioners. More efficient, cost-effective education methods need to be sought to enable employees to take professional responsibility for maintaining and improving their knowledge and practice [1, 4, 6, 8].
Few studies have measured the influence of personal breastfeeding experience on knowledge and practice even though it is often suggested that health professionals rely on personal experience to inform practice [23, 25, 26, 30, 50, 51]. In the present study, midwives with personal breastfeeding experience of more than three months scored higher across all measures than midwives with less or no breastfeeding experience. Lowe  reported that midwives who had difficult personal breastfeeding experiences were less knowledgeable about lactation and infant feeding matters. It could be that midwives with previous successful breastfeeding experience take a keen interest in supporting other women to breastfeed and keep their knowledge and practice updated.
While midwives' education can positively affect their personal breastfeeding experience , it cannot be assumed that personal breastfeeding experience provides sufficient knowledge in a professional capacity to adequately inform and support mothers [6, 51, 56]. Likewise midwifery colleagues cannot assume that professional education and experience is adequate for personal breastfeeding success . It is up to midwives, other health professionals and education providers to ensure information from evidence based research is implemented for the care of women and their families at the time of breastfeeding initiation [6, 10].
NFA scores demonstrated moderate predictive validity for practice. Continuing professional education activities should aim to address knowledge deficits and also measure practice outcomes. Maintaining the knowledge base of a high proportion of staff (80%) is essential for Baby Friendly Hospital accreditation [2, 57]. The NFA and BIP could be useful tools in accreditation processes to assess knowledge and practice, inform the content and scope of continuing professional education activities, provide evidence of competence, and offer cost efficiencies by targeting specific deficits rather than offering lengthy, broad program content.