Challenging Dogma

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

Sunday, April 22, 2007

The Breastfeeding Campaign: Questioning the Language of “Informed Choice”—Jo Hunter

The National American breastfeeding Awareness campaign began in 2004 under the auspices of the U.S. Department of Health and Human Services Office on Women’s health (1). The campaign targets a general population. In this paper, I will focus on the TV advertising campaign, and the article in the New York Times that resulted from these two advertisements (2). Although these advertisements was by no means the only part of the campaign, neither to they represent its main sentiment, I focus on these advertisements because they became the most publicized part of the campaign.

The World Health Organization recommends breast-feeding for the first six months of a child’s life. Many countries have adopted this standard and promoted breast-feeding as the only right decision. As evidence in favor of breast-milk becomes increasingly incontrovertible, intervention becomes more single-minded in attempting to increase the percentage of women who breastfeed. Although breastfeeding does benefit many babies, the premise of the American breastfeeding campaign seems to be that informed choice involves weighing risks and benefits and inevitably coming to the same conclusion as the public health community, a premise rooted in the health belief model. I argue that informed choice could lead to more than one decision. It may also be alienating, misleading and paternalistic to compare not breastfeeding to risky behaviors, as the American breastfeeding campaign has done.

So, while breastfeeding may be ideal for the health of the baby it may not be the “right” decision for the mother. The context, barriers and decisions that lead women not to breastfeed need to be considered. This critique will also look at the campaign in terms of the applicability of the health belief model, theories of self-efficacy, and use feminist critique to question the notion of a woman’s duty to her child.

Limited Comparisons: Drawing False Parallels
Given the proven nutritional benefits to a baby’s health, the goal of an intervention seemed apparent: increase the rates of breastfeeding women, and increase the length of time women spent breastfeeding. In July of 2006 the New York Times ran an article titled “Breast feed or Else” (3) in response to the Breastfeeding Campaign’s television advertising campaign. This menacing phrase seemed to encapsulate the message that the public health community was putting forward in its breastfeeding campaign. In the article the authors described some of the evidence presented by the breastfeeding campaign in favor of breastfeeding; the evidence presented seemed to focus on the linear relationship between breastfeeding and a baby’s health.
However, breastfeeding is not only related to the good nutrition of a baby, nor is it a behavior that exists in a vacuum. Breastfeeding is a behavioral decision that is made in relation to many other choices. These other choices also impact the health of the baby, and may even make breastfeeding a ‘bad’ choice for some women. For example, if a mother is tired, emotionally distraught, or working in a job where she cannot breastfeed on site, the nutritional benefits of breastfeeding to the baby may seem to be outweighed by other long-term costs to income, self-esteem or family stability.

Breastfeeding campaign advertisements showed a pregnant woman being thrown off a mechanical bull. The implication was that taking part in this high-risk behavior while pregnant is comparable to failing to breastfeed after the infant is born. Another message put forth by the campaign equated smoking during pregnancy with failing to breastfeed. Although smoking or riding a mechanical bull while pregnant are related to a baby’s health, they are not similar to breastfeeding.

Nonchalantly engaging in dangerous behavior for the sake of fun or entertainment—such as riding a mechanical bull—is different from making a difficult and deliberate choice whether or not to breastfeed. Mothers in the midst of this decision are alienated by the representation. Equating the risk of failing to breastfeed with the risk due to smoking during pregnancy is an even less accurate analogy. Smoking during pregnancy has been shown to have a profound impact on the fetus, whereas the relationship between breastfeeding and infant health is real but far less profound (4).

For several generations, many women believed that formula was a good choice for their baby. The medical establishment backed this claim. To equate formula with behaviors that are considered flippant or socially irresponsible is not constructive or accurate. In the next sections I will explore how this type of message is also not effective.

The Breastfeeding Campaign and the Health Belief Model
The health belief model appears to motivate and underscore much of the breastfeeding campaign. In particular, not breastfeeding is expressed in terms of risk. There is a risk associated with failing to breastfeed and a benefit associated with breastfeeding. Understanding breastfeeding in these simplistic terms, it seems natural and logical that public health professionals would have a clear set of goals that are designed to increase rates of breastfeeding. The advertising campaign was built on the premise that if women stood up and took note of the dangers of not breastfeeding, they would weigh the risks and benefits, and begin to breastfeed.
However, in this age, breastfeeding is not only an issue of nutrition or the health of a baby. The current upsurge in interest and intervention around breastfeeding arrives in the context of several generations of working women in the United States. Here and across the world, the act of breastfeeding is intimately tied to feminism, culture, politics and economics. When no allowances were made for childbirth and childrearing in the early years of women entering the workforce, formula made it possible women to return to work more quickly after giving birth (5). The decline in breastfeeding is an intimate part of improving women’s status in America, as formula continues to make it possible for women to fulfill their professional goals (6). Breastfeeding is also tied to the economic and work status of women. Women who have fewer years of education and are working in lower-income jobs are less likely to breastfeed. This is the result of barriers and cultural norms that are not addressed in the television advertisements.

In addition, a culture’s lack of support of public breastfeeding impacts women’s ability to do so, and also their personal perceptions and valuation of breastfeeding. As such, when women decide whether or not to breastfeed their infant, they are responding and acting on complex combination of policies, feelings, beliefs and knowledge. This context needs to be considered and addressed when we respond to women’s desire to breastfeed. The reality that breastfeeding helps to provide a basis for a baby’s good health is not the only relevant reality.

The weighing of the risks and benefits of breastfeeding also tends to neglect the reality that the risks and benefits of breastfeeding connect two separate people. The physical and social benefits that have driven the breastfeeding campaign are largely enjoyed by the baby. As such, a mother is weighing the costs and risks to herself against the benefits to her child. These costs include discomfort, being extremely tired from expressing milk or being unable to work due to the demands of breastfeeding. Although mothers tend to be remarkably sacrificial when it comes to their children, it is inappropriate to use of the health belief model’s cost-benefit approach to convince women to take risks to benefit another entity.

Finally, the health belief model does not consider the reasons that women may not be able to breastfeed. Is lack of knowledge around the risks and benefits of this behavior the fundamental reason that women are not breastfeeding? The focus on individual knowledge may neglect the reality that many women are not able to breastfeed despite wanting to do so. The campaign should address what prevents women from breastfeeding, such as lack of privacy, lack of time, or cultural perceptions of breastfeeding in public. That is, it should make breastfeeding a collective responsibility, where the decision of the individual is understood and respected, and the obligations to create a good environment for breastfeeding lay on the shoulders of the community, and not only on an individual mother.

In summary, there are at least three reasons that the health belief model may not guide the best possible intervention around breastfeeding. Firstly, it fails to recognize that women’s attitudes and beliefs around breastfeeding are related to relationships between breastfeeding and the economic, political and cultural foundations of a society. These things affect a women’s desire to breastfeed. Secondly, it fails to recognize that a woman is not weighing her individual risk and benefit, but a potential risk to her without personal benefit. Again, this impacts her desire to breastfeed. Finally, there are physical barriers that make it impossible to breastfeed. For example, a job, a limited supply of breast milk, or a lack of family support for breastfeeding may all create barriers that are largely independent of a women’s desire to breastfeed. Due to these three limitations the health belief model based program that focuses only on the individual decision to breastfeed will fall short of its goal.

Theories of Self-Efficacy
The breastfeeding campaign also fails to consider theories of self-efficacy. That is, when a person believes a task is manageable, they are more likely to attempt that task or take that action (7). To an extent, the breastfeeding campaign does this by saying that women should breastfeed and that they have different options available. They provide information about expressing milk, for example.

However, by implying that all women should find breastfeeding a natural choice, it minimizes and ignores the very real challenges facing women. Women feel as though they should feel comfortable with this life event. When they don’t, they may feel unable to fit the mold they are presented with by the campaign. According to Bandura, people’s “level of motivation, affective states, and actions are based more on what they believe than what is objectively true.” (8) Faced with an image that is so different from their daily reality, even a small change towards breastfeeding becomes daunting and overwhelming.

According to social cognitive theory, a woman should be affirmed in her attempts to breastfeed in order to feel more able to do so. However, the television ad campaign fails to affirm women’s attempts or encourage them to confront problems. Rather, it presents information in such a way that women are made to feel irresponsible, careless and ultimately bad mothers, if they fail to breastfeed. By presenting an image of risk, women’s fears and realities are not recognized or affirmed. Rather, women are being given the message that they are engaging in risky behavior—placing their newborn at risk—even to the point of implying irresponsibility on the part of mothers. This message implies that genuine fears and limitations that are preventing women from breastfeeding should disappear in light of the risks of not breastfeeding.

Instead, the breastfeeding campaign could affirm and address these fears in a genuine way, with the recognition that it may lead some women to decide that breastfeeding is not the right decision for them or their child. In this light, women may feel supported to feel their fears and address them. They may also feel able to take small life changes if breastfeeding was not represented in an absolute way. This does not mean that the intervention should dumb down or deemphasize evidence in favor of breastfeeding. Rather, this evidence should be framed in such a way that recognizes women’s experiences. In this light, they may be free to recognize their limits, and attempt to stretch those limits to the extent they feel comfortable.

New mothers are able to make the correct decision for themselves and their infants; a campaign should recognize this acknowledgement of agency would help women feel able to make this decision rather than undermining a women’s sense of self-efficacy by putting forward absolute notions of right and wrong that may conflict with a women’s own beliefs and context.

A Feminist Perspective
The feminist perspective on breastfeeding is by no means unitary. Breastfeeding may be empowering (9). However, this television campaign, by taking a moral tone of risk, the national breastfeeding campaign implies that women have an absolute duty to their babies. It ignores her personal experiences of pain and her own sources of fulfillment. For some, breastfeeding may not be the best option, both for the mother and for the baby. In other cases, breastfeeding may be a good and healthy option for the baby, and yet have a potentially detrimental effect on a mother. Although a woman may voluntarily take on a certain level of responsibility so not to cause harm to her fetus or infant, her body should not be conflated with her child’s body. A women’s duty to her child is not absolute, particularly where her own life and health is in question.

An intervention that creates guilt around the autonomy of a woman’s body should be questioned. It is paternalistic to put forward images of irresponsibility around a complex choice like breastfeeding. Beyond the question whether the intervention is effective, it is important to question whether it is effective in a broader sense—does the intervention improve the target audience’s mental and physical well-being? For mothers who cannot breastfeed, receiving the message that they are behaving in an irresponsible way generates pain and guilt. This pain and guilt does not necessarily result in the desired action, breastfeeding.

Presenting the benefits of breastfeeding in terms of the risks caused by failing to breastfeed is accompanied by an implied duty that imposes directives not only about what a women is bound to do with her body if she has a baby, but also the optimum length of time that that action is needed. However, there are many choices that can be beneficial to a young child that are not imposed on a family because they are recognized as unreasonable. Similarly, a breastfeeding campaign should recognize that breastfeeding takes a significant toll on a woman. Recognition of this fact means acknowledging that women are not only mothers or suppliers of milk. This may not change the goal of the campaign, however, it will change the way in which its message is presented.

The advertising campaign may not be effective because it stimulates guilt, feelings of inadequacy and irresponsibility. It does not empower or recognize the challenges facing mothers. It also imposes a duty on mothers that may not be realistic given economic and cultural factors.

How could the campaign be improved? The unequivocal message that failure to breastfeed means taking a significant risk on your child’s behalf should have been shifted from the centre of the campaign. The campaign could instead focus on the reasons women fail to breastfeed. It should recognize that a woman does not have an absolute duty to her child. By acknowledging the decision-making power and autonomy of mothers, women could be empowered to make a decision that is both informed and supported.

(1) Center for Disease Control and Prevention. Breastfeeding: Promotion and Support. Atlanta GA: Center for Disease Control.
(2) New York Times. Breastfeed or Else June 13 2006
(3) New York Times. Breastfeed or Else June 13 2006
(4) Center for Disease Control and Prevention. Atlanta GA: Center for Disease Control. (5) Blue Cross of California. Women’s Health Newsletter California: Blue Cross of California. 2003
(6) Tenner, Edward. Our Own Devices: The Past and Future of Body Technology.
(7) Pajares, Frank. (2002) Overview of Social Cognitive Theory and of Self-Efficacy. Emory University.
(8) p2. Bandura, A. (1997) Self Efficacy: The Exercise of Control. New York: Freeman.
(9) Van Esterik, Penny. Breastfeeding: A Feminist Issue

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