Challenging Dogma

...Using social sciences to improve the practice of public health

Friday, April 20, 2007

Breastfeed or Else: How The National Breastfeeding Awareness Campaign’s Goals Are Thwarted - Katrina Wilcox Hagberg

The National Breastfeeding Awareness Campaign (NBAC) was designed and implemented by the Health and Human Services Office of Womens’ Health in 2003 to promote breastfeeding among first-time parents. The goal of the NBAC was to increase the proportion of mothers whom breastfeed their babies, both in the early postpartum period and at six months postpartum, with focus on exclusive breastfeeding for six months after birth. Campaign results published on the NBAC website tout that significantly more women surveyed had breastfed a child since the campaign’s conclusion, however the results did not indicate how long women were able to continue breastfeeding (1). The goal of the NBAC is not in question by any authority, as many studies have indicated that numerous childhood diseases can be prevented or limited in severity by prolonged breastfeeding. Duration of breastfeeding is as important as initiation as many benefits of breastfeeding appear to be dose-dependent. However, the HHS’s choice in theoretical basis on which the NBAC was designed lacks sensitivity to sociocultural and economic variables that significantly impact a woman’s ability and willingness to exclusively breastfeed for six months postpartum. In addition, the NBAC message and promotional materials were negatively framed, portraying formula feeding as a risky behavior, but did not provide alternative options for women who were unable to breastfeed and ignores women’s own stated drivers of and barriers to successful breastfeeding.

Reliance on the Health Belief Model
The NBAC appears to be designed using the Health Belief Model, as its primary goal is to make women aware that their infants are highly susceptible to various diseases, such as ear infections, respiratory illnesses, and childhood obesity, and that failure to breastfeed will cause harm to their baby. The Health Belief Model assumes that all health behaviors are rational, and as such, internalization of potential susceptibility and severity should lead to the intention to adopt the health behavior (2). The Health Belief Model presumes that barriers to a health behavior are minimal, and therefore should easily be outweighed by the perceived benefits of the health behavior. The Health Belief Model is focused on the individual and therefore does not take into account the sociocultural and economic factors that are barriers to the integration of health behavior. As the Health Belief Model does not account for these factors, these variables are not included in the NBAC design, which has greatly constrained the campaign’s impact.

NBAC’s Failure to Account for Sociocultural and Economic Variables
There are many social, cultural, and economic variables that impact breastfeeding initiation and duration. Historical campaigns on proper infant feeding have led to our society’s current ambivalence about breastfeeding. As early as the 1880’s, campaigns encouraged introducing cow’s milk into the diet of infants, either exclusively or in supplementation to breast milk. Formula was developed after it became apparent that cow’s milk negatively affected the health of infants and that return to breastfeeding would not occur due to societal acceptance of bottle-feeding (3). Even today, the impact of historical events on rates of breastfeeding is still apparent. As of 1998, 64 percent of U.S. mothers initiated breastfeeding in the hospital, while only 29 percent reported feeding any breast milk to their baby at six months postpartum. These rates are still lower for infants born to black women: 45 percent of black women initiated breastfeeding and 19 percent were still breastfeeding at six months (4). Breastfeeding initiation and duration rates are influenced by the medical community’s perception of what constitutes appropriate infant care, economic variables impacting women in the workforce, and societal framing of the female body.

The medical community has not embraced breastfeeding as the standard of care, instead breastfeeding has been framed as the ‘ideal’ and formula feeding is considered the ‘norm’. One study reported that a majority of pediatricians either agreed or had neutral opinion about the statement that breastfeeding and formula feeding are equally acceptable methods for feeding infants (5). Several studies have found that pediatricians lack knowledge and training on breastfeeding topics. One study reported that 65 percent of doctors recommended exclusive breastfeeding for the first month after birth and 37 percent recommended extended duration of breastfeeding (5). Training on breastfeeding topics in medical school, residency programs, and continuing educational programs does not adequately prepare practitioners for their role in breastfeeding support and promotion (5, 6). One step to increasing rates of breastfeeding is to incorporate the teaching of lactation, breastfeeding management, and the relationship between human milk and human health into medical and nursing school curriculums to improve the state of knowledge among healthcare providers and to prepare them for their role in promoting breastfeeding to new mothers.

Changes in the delivery of healthcare, including shorter postpartum hospital stays, further limit the breastfeeding education and support available to new mothers. The Baby-Friendly Hospital Initiative was launched to enhance successful initiation of breastfeeding worldwide. Hospitals with the Baby-Friendly designation have demonstrated compliance with standards and guidelines relating to hospital policy, training for staff, initiation of breastfeeding within an hour of birth, and a hospital environment that supports breastfeeding. It has been reported that breastfeeding initiation rates at Baby-Friendly Hospitals, at 85 percent, is elevated compared to national levels (7). However, there are only 54 hospitals with the baby-friendly designation in the U.S. Baby-friendly hospitals are also not evenly distributed across the nation; instead, these hospitals are located in regions that traditionally have high rates of breastfeeding. For example, 21 baby-friendly hospitals are located in the Pacific coast states, which typically have the highest breastfeeding rates, whereas only 4 baby-friendly hospitals are located in the southern states, which have the lowest rates (8, 9). Breastfeeding is a practical skill that mothers may require help to learn. The assistance of health practitioners is an essential component to the acquirement of the skill of breastfeeding and encouragement for continuing breastfeeding beyond the hospital walls. Although the NBAC provided limited ‘how-to’ information on breastfeeding on its website, it did not improve the education of the healthcare providers who are directly involved with new mothers.

While advice of healthcare providers is an important indicator of breastfeeding initiation, economic forces have been a primary force around infant feeding habits of working class mothers. Women are thwarted in their ability to breastfeed by demands of work outside the home. Breastfeeding duration is decidedly influenced by full-time maternal employment. In the U.S., one-third of mothers return to work within three months of giving birth and two-thirds return within six months (10). Studies indicate that continuation of breastfeeding to six months is shortened by full-time employment (11, 12, 13). The Family and Medical Leave Act mandates only 12 weeks of unpaid maternal leave (14). The likelihood that a mother will continue to breastfeed after returning to work is therefore dependent on the mother’s occupation and socioeconomic status. Women employed as professionals may have more flexibility in their schedules and support of their place of employment to meet both the needs of the job and their infants. However, the majority of women in the United States (63 percent) have hourly shift, minimum wage positions (10), which may not offer the flexibility or facilities necessary to facilitate continuation of breastfeeding. The NBAC did not address employment barriers to breastfeeding. Instead, due to its reliance on the Health Belief Model, it focused on educating individual women on the health risks associated with not breastfeeding and assumed that barriers of employment would not be a significant obstacle for women to conquer.

Upon returning to work, space and time for pumping, as well as support from employers and coworkers, are additional obstacles to mothers. The NBAC provided minimal information to support women in this transition on their website, focusing on pumping and neglecting how to deal with attitudes of employers and coworkers and constraints of the job. Positive results from providing lactation programs at the workplace include lower absenteeism, higher productivity, greater morale and company loyalty, and lower health care costs (15, 16). However, lactation programs are not widely available, even at the professional level, and are especially lacking at the minimum wage level. Nursing and pumping are time consuming activities, and the combination of breastfeeding and employment requires major work and lifestyle changes on the part of the woman. In addition employer and coworker acceptance and support of the woman to allow her the time and space to pump is essential for continuing breastfeeding after returning to work. As this is not typically the case, it’s not surprising that mothers cite “going back to work” as one of the most important reasons a mother would chose not to breastfeed (17). Support of nursing mothers from the business community, at all employment levels, is necessary to increase the rates of breastfeeding. The design of the NBAC did not consider how economic factors act as a barrier to breastfeeding and therefore neglected to create initiatives directed at improving maternal leave policies and access to at work lactation programs to assist women in reaching the goal of breastfeeding for six months postpartum.

Even as breastfeeding gains greater support from the medical community and government, breastfeeding incites reactions in the broader society. Breastfeeding is a culturally mediated behavior. Non-US born mothers are more likely to breastfeed, despite financial and practical barriers, than U.S. born women (18). In addition, U.S. acculturation reduces the odds of a mother breastfeeding (19). In other cultures, breastfeeding is seen as a natural process and women openly breastfeed in public places, a behavior supported by the partner, family, and others around the mother. However, in the U.S. the female body, specifically the breasts, are largely viewed in a sexual context. Breastfeeding in public is seen as a “lewd” and inappropriate act. A recent national survey for the Centers of Disease Control and Prevention reported that 52 percent of responders were either uncomfortable with or undecided about breastfeeding in public (20). A survey published by the American Dietetic Association reported that only 43 percent of respondents thought that women should have the right to breastfeed in public places (21). Although breastfeeding is not outlawed in any state, only 36 states have laws specifically allowing women to breastfeed in any public or private location (22). However, mothers who choose to breastfeed in public may receive negative reactions, which may lead to feelings of shame and embarrassment and they may be less likely to breastfeed in public in the future. Negative reactions to nursing mothers occur even among mothers themselves. A 2006 cover of Babytalk magazine, whose readership is overwhelmingly mothers of babies, pictured a nursing baby with a portion of a woman’s breast. In a poll of its readers, a quarter of the responses were negative, calling the photo inappropriate (23). A lack of societal acceptance, as a whole, is undermining breastfeeding initiation and duration and must be considered in the design of campaigns, such as the NBAC, and initiatives intended to improve breastfeeding rates.

Framing of the NBAC Promotional Materials
Much of the responsibility for breastfeeding is placed on the mother, however support of those people around the mother is an important factor that determines breastfeeding initiation and duration. As the responsibility is placed exclusively on the mother, the risk of not breastfeeding also lies on the mother. Mothers are pressured to optimize every dimension of their child’s lives, resulting in a tradeoff between the child’s needs and the mothers’ needs and wants. The promotional materials used by the NBAC were focused on the risk of not breastfeeding instead of the positive health benefits of breastfeeding for both mother and infant. Risk-based advertisements, framing formula feeding as risky, creates negative emotion in order to persuade women determined to be “at risk” to adopt the recommended behavior. In the NBAC television advertisements, not breastfeeding was portrayed as comparably dangerous as a pregnant women log rolling or riding a mechanical bull. In using a risk-based approach focused exclusively on infants, the mothers themselves become an obstacle to their baby’s good health. For women who cannot breastfeed, who find the demands of breastfeeding overwhelming, who cannot merge breastfeeding and employment, or who simply choose not to breastfeed, formula feeding is the less risky option. One study examining women’s perspectives on the information, advice, and support they received while breastfeeding indicated that women found pressure to breastfeed and being made to feel guilty the least helpful, and possibly counterproductive, to their breastfeeding efforts (24). However, the NBAC chose to do just that: the campaign played off of fear and a mother’s sense of responsibility for her infant in attempt to change breastfeeding behavior.

The NBAC radio advertisements also did not take into consideration what would be a supportive approach to encourage women to attempt and continue to breastfeed. The radio advertisements featured voices of men educating their partners about the benefits of breastfeeding, however women’s voices were noticeably lacking. This tactic flies in the face of one of the NBAC’s stated goals: to give women the sense that they have what it takes to successfully breastfeed. One study examining women’s perspectives on the information, advice, and support they received while breastfeeding indicated that women found advice for specific concerns, encouragement to keep going, and reassurance that what they were going through was normal the most helpful in initiation and continuation of breastfeeding (24). Had the NBAC radio spots featured a mother’s perspective, assuring women that what their experiences with breastfeeding are normal, woman may have felt that they had the ability to breastfeed and taken action.

The NBAC also used print media to help disseminate the message about the benefits of breastfeeding. The print media used the illusion of breasts as the substance to communicate the benefits of breastfeeding on the baby’s health. The choice may have been an attention grabber, but the message may have instead been interpreted in a sexual manner. The illusion of breasts used in the NBAC print media did not advance society’s views as breasts as functional anatomy to society; instead it fed off the current societal views of breasts as sexual objects to garner attention to the campaign’s message.

Through the NBAC, the HHS had the opportunity to improve the health of considerably more infants, through improvements in the rates of breastfeeding initiation and duration, than it actually achieved. The impact of the NBAC was thwarted by its reliance on the Health Belief Model, and therefore did not acknowledge sociocultural and economic barriers to breastfeeding behavior. Revision of the campaign’s design through use of other behavioral models other than the Health Belief Model, such as social factors and attitudes that comprise the Theory of Reasoned Action and Bandura’s concept of self efficacy (25) would make a more powerful resource and means for affecting changes in breastfeeding behavior. Inclusion of factors that recognize and transform the sociocultural attitudes and economic barriers to breastfeeding, such as the medical perspective on appropriate infant care, the impact of employment, and societal views of breasts and breastfeeding, are essential for improving breastfeeding rates in the U.S. In addition, providing women the support and encouragement necessary to have them understand that they can be successful breast feeders is indispensable. Advances in breastfeeding behavior must be achieved, but not at the detriment of formula feeding. Adjusting the risk-based messages, patronizing voice, and use of sensational images in the NBAC promotional materials would make the breastfeeding messages and behavior modifications more approachable and achievable to women. If these modifications can be made, the NBAC or future breastfeeding campaigns have a chance to make significant advances on breastfeeding behavior.

1 The Federal Government’s Source for Women’s Health Information, National Breastfeeding Awareness Campaign. Presentation on Breastfeeding Campaign with Campaign Research Findings (8/1/2005). Washington, DC; U.S. Health and Human Services Office on Women’s Health.
2 Rosenstock IM. Historical origins of the health belief model. Health Education Monographs 1974;2:328-335.
3 Wolf JH. Low breastfeeding rates and public health in the United States. American Journal of Public Health 2003;93(12):2000-2010.
4 US Department of Health and Human Services. HHS Blueprint for Action on Breastfeeding. Washington DC: US Department of Health and Human Services, Office of Women’s Health;2000.
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20 Centers for Disease Control and Prevention. Health Styles Survey – Breastfeeding Practices 2003. Washington DC: Centers for Disease Control and Prevention.
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22 National Conference of State Legislatures. 50 State Summary of Breastfeeding Laws. Washington DC: National Conference of State Legislatures.
23 SFGate. ‘Breast’ cover gets mixed reaction. SFGate.
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25 Salazar MK. Comparison of four behavioral theories. American Association of Occupational Health Nurses Journal 1991;39:128-135.

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