Challenging Dogma

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

Wednesday, April 25, 2007

Breastfeeding Promotions: Educational and Informative, But No One Is Listening-- Elena Tovar

Breastfeeding is the best form of nutrition that a mother can provide for her infant (1-3). The American Dietetics Association states that exclusive breastfeeding for the first 6 months of life and breastfeeding with complementary foods for at least 12 months provides not only optimal nutrition, but health protection as well(14). It is considered a public health strategy, in itself, for “improving infant and child health survival, improving maternal morbidity, controlling health care costs, and conserving natural resources” (4). Further studies have shown that breastfeeding promotes uterine involution, better cognitive development in children, lower incidence of pre-menopausal breast cancer in the infant, lower incidence of pre-menopausal ovarian cancer in the infant, and lower incidence of maternal osteoporosis (3). In fact, according to the World Health Organization, there are very few situations in which breastfeeding is totally contraindicated. They include instances where the mother is HIV positive, has active tuberculosis, or is drug/alcohol dependant (5). With all of the empirical evidence that supports breastfeeding and has existed for years, what are the obstacles that keep public health promotions from being more influential in the U.S.? And, more importantly, what needs to change to allow these breastfeeding promotions to better adjust to these obstacles?

The failure of health campaigns’ efforts to increase the prevalence of breastfeeding can be attributed to the fact that they are most often directed toward the education of medical and other health professionals, rather than those who are actually involved in the decision to breastfeed. Further, because these misdirected campaigns, such as the Breastfeeding Promotion in Physicians’ Office Practices (which will later be described), rely on the Health Belief Model, certain factors beyond the mother’s control, mainly the social stigma toward breastfeeding in public and a social support system (or lack of one), are not addressed. Research shows that the taboo on public breastfeeding and an un-indoctrinated social support system are key determinants in a woman’s decision to breastfeed (6-9).

There is, of course, truth to the idea that the increase in medical and other health professional education would result in some increase in the amount of breastfeeding education delivered to patients. However, this fact cannot be the basis of a health movement because there are too many uncontrolled variables. Which patients will receive the proper information? If breastfeeding education seminars are not mandated, how can the cooperation of medical and other health professionals truly be controlled? The average amount of interaction time between a patient and general practitioner in the U.S. is 10 to 20 min (15). Does a pediatrician being educated in the concepts of breastfeeding guarantee that he will be capable of influencing such a personal decision within a 10 to 20 minute appointment? Health practitioners do have the responsibility of effectively communicating with their patients. Relying on them to “sell” or promote a concept such as breastfeeding, however, is simply unrealistic. Doing this allows public health practitioners to evade their responsibility to change a public health behavior on a community level by assuming medical professionals can change it on an individual level.

Perhaps the most important reason for the failure of so many breastfeeding campaigns is the most obvious-- they do not directly involve the mothers, mothers-to-be, or any other key figures playing a role in the decision to breastfeed. At face value, interventions that require only the education of a small group, who are then responsible for the amplification of that information in a sort of “trickle-down” process, sound very appealing. They require little more than attendance at seminars and the distribution of pamphlets and/or publication of journal articles. But interventions such as these are ineffective because they fail to focus on the major players in the issue-- nursing mothers and potentially nursing mothers. In the last two years, the American Academy of Pediatrics (AAP), the Maternal and Child Health Bureau (MCHB), public health professionals, and numerous other maternal and pediatric health professionals and programs have teamed up to strengthen and promote an already existing, large scale program called Breastfeeding Promotion in Physicians’ Office Practices (BPPOP III). The theory behind the program is similar to most-- educate and promote breastfeeding amongst medical professionals who will, in turn, educate and promote breastfeeding amongst their patients. Their program goals include (10):

“Educate and support pediatric, obstetric, and family medicine residents; practicing physicians; and other health care professionals in effective breastfeeding promotion and management in racially and ethnically diverse populations”

“Develop strategies to bring together health professional, public health, and breastfeeding support organizations to increase the incidence and duration of breastfeeding and decrease racial and ethnic disparities”

“Deliver focused, culturally effective training in breastfeeding promotion and effective maternal support to 30 practices or 100 individuals in the BPPOP III program through Web cast/teleconferencing technology”

Not one of these objectives (and very few of their other five) mentions the mothers who will be nursing nor do they mention the role of the family. By identifying only family physicians and their knowledge of breastfeeding promotion as the key determinants in a woman’s decision to breastfeed, not only have the AAP and MCHB greatly overlooked numerous other factors involved in that decision, but the U.S. Preventive Services Task Force (USPSTF) (11) and various state programs have done the same in similar programs.

The model that these programs have been based upon is the Health Belief Model. The idea that perceived susceptibility and severity will lead to intention and, eventually, behavior, is the backbone of the model. If that model was reliable and productive in the case of breastfeeding promotion, then physicians educating their patients would be a sufficient means of promotion. Mothers would be made aware by their physicians of the severity and susceptibility that could come with the decision not to breastfeed an infant; hence, they would intend to breastfeed, and they would breastfeed for at least 12 postnatal months. However, a recent study conducted by the United Nations Children’s Fund (UNICEF) in the United Kingdom shows that each year, 75,000 mothers stop breastfeeding within the first postnatal week, but only 1% of those women had intended to do so (12). This is the major weakness of the Health Belief Model and, therefore, the breastfeeding programs that are based on it-- intention does not necessarily lead to a behavior.

The beliefs and opinions of family members and friends, particularly the husbands and mothers of the mothers-to-be, are very often overlooked as determinants in the decision to breastfeed (7). Not only has support from “informal social network members (male partner, mother, family/friends)” been shown to increase breastfeeding, but negative social support has been shown to decrease breastfeeding as well (7). One study in Australia showed that the father’s influence is not only important in the decision to breastfeed but is also correlated with the length of time of that a mother continues to breastfeed (5). Yet even with the vast amount of literature supporting the role of social network member support in the decision to breastfeed, promotions and programs such as BPPOP III underestimate that role. Even a similar promotion based on the professional education of health professionals that may put more emphasis on the role of family and friend support has no reliable means of extending the scope of those promotions to family members or loved ones. If the playing field of such promotions is a physician’s office and/or a hospital, the only people that can be affected by the promotion are those present at the office or hospital. Assuming that a father-to-be or any other members of the family or social network attend the prenatal appointments (or even the childbirth itself) is an unrealistic and irresponsible assumption to make. Without that attendance, primary-care based interventions are severely restricted.

Let us assume, still, that the education of family members along with the mother is as simple as BPPOP III program objective makes it sound. Assume that simply including the father-to-be, grandmother-to-be, or any other loved one taking part in the decision to breastfeed in a 15 minute discussion is enough to alter any misconceptions and convince all of those present that breastfeeding is a necessary behavior. Based on the Health Belief Model, this step would reduce the perceived barriers to the intention of a woman to breastfeed. The problem, however, is that Americans no longer live in a traditional, family-based culture. The opinions and experiences of the grandmother and father are not the only ones being considered by pregnant women in the United States. More and more women are planning pregnancies as single mothers. The opinions of the father and/or grandmother may not be as highly regarded by some women as the opinions and experiences of friends who have had their own children. Interventions focused on professional education, and typically based upon the Health Belief Model, have no way of tackling these perceived barriers because these interventions focus and depend on the medical professional/patient interactions.

Numerous studies have identified embarrassment of public breastfeeding as a major determinant in the decision to breastfeed (9, 13). For a woman who is active and not staying home for the first year after giving birth, breastfeeding a baby 10 to 12 times a day means, at some point, probably having to breastfeed in public. This necessity clashes with the taboo on breastfeeding outside of the home or a public bathroom that is so common in American culture. Because women’s breasts in modern American culture are viewed as sexual, there is a natural inclination to view public breastfeeding as a form of indecent exposure. A major component in a breastfeeding promotion campaign must involve attacking this stigma. In dealing with this obstacle, breastfeeding promotions like BPPOP III are the least successful. Breastfeeding promotions that are based on professional education work to augment breastfeeding at an individual level. They have no means of combating social norms or taboos. Medical and health professionals being better educated in the methods of breastfeeding promotion will do very little at a societal level. Studies show that embarrassment of public breastfeeding can affect not only a woman, but her male counterpart as well, further persuading a woman to bottle feed instead (13).

The Health Belief Model fails most in dealing with societal pressures, norms, and taboos. Breastfeeding promotions based on the Health Belief Model rely on only individual intention and rationality to result in a health behavior. This is why basing an entire public health campaign on education and communication between a medical or other health professional and his or her patient fails. Educating a patient and using certain techniques of promotion may be beneficial and may even lead to intent. However, if feelings of stress and embarrassment exist when faced with the need to breastfeed in public, intent may no longer lead to a behavior. Furthermore, stress and embarrassment are common causes of poor let down, making breastfeeding in public even more difficult for a woman (14). In fact, in some areas where bottle-feeding is the norm (i.e. specific socioeconomic or ethnic groups that dominate a particular demographic), women who do decide to breastfeed have reported going to “great lengths to avoid having to breastfeed in public” (9). It is one thing to intend to breastfeed after being spoken to by a health professional; it is another thing to maintain that behavior when dealing with unforeseen feelings of embarrassment that American culture can create.

Finally, I would even go so far as to say that breastfeeding promotions should bypass the formal medical establishment. Formal medicine is not capable of being solely responsible for the movements that are seen as socially controversial. It lacks the ability of attacking a problem or group of problems from different angles because the only angle it can control is that of the doctor/patient interaction. When doctors started to advise their patients to stop smoking in the 1960’s, only a small percentage of the population responded. Even as medical evidence on the dangers of smoking accumulated, the public response was minimal (E Tovar MD, personal communication, April 2, 2007). Doctors would tell patients why they should not smoke, what would happen to their bodies if they continued to smoke, and may have even offered suggestions on how to smoke. Patients would say, “Okay, I’ll quit, doctor,” walk out the door, and light up. Similar to breastfeeding, the public viewed cigarette smoking as something that was a personal choice-- a concept Americans highly regard. It was not until public health took over with multiple advertising campaigns and the lobbying for anti-smoking legislation that people started to grasp the urgency of the issue. In the same way, breastfeeding must be moved to the arena of public health so that people may be indoctrinated to understand that breastfeeding is not just a personal choice but a necessity with very few contraindications.

There are certainly some less traditional promotions taking place that seem to be much more effective than those discussed in this paper. What seems to set these promotions apart from the rest is that they take a multi-level approach in promoting breastfeeding-- one that addresses the individual players involved in making the decision to breastfeed and one that addresses society as a whole. ProMoM, Inc. is a prime example of such a promotion. Rather than solely educating the public about the benefits of breastfeeding, ProMoM has organized annual national “Nurse Outs,” an online Breastfeeding Activism discussion forum, and a program called “The 3 minute Activist” that combats the media or any organization for the negative portrayal of breastfeeding (16). Promotions and interventions, such as this one, that incorporate theories aimed at a larger audience base, such as Advertising Theory and Agenda Setting Theory, will be more successful than those based on the Health Belief Model. Though education is a key component in most public health interventions, it may not always be the most effective in swaying the opinions and beliefs of a community. Advertising Theory and Agenda Setting Theory, as well as other theories of marketing and mass communication, focus on bringing an issue into the public eye, allowing public opinion to be swayed, and eventually changing individual behaviors.

Too many breastfeeding promotions are impersonal and assume that a middleman (a medical or other health professional) is needed in order to get a point across. Not targeting the women making the decision to breastfeed and the social network that supports them is a mistake that leads to the failure of so many campaigns. Not targeting the population as a whole and breaking down the social stigma toward breastfeeding is a mistake that inhibits the spread of those same campaigns. It is not that physicians and health practitioners are incapable of educating the people that they work with; they simply lack the resources to do so on a large scale. As representatives of modern medicine, they are restricted to the tactics of the Health Belief Model-- a model that may work in some cases, but not in the more controversial ones. Medical/health professionals may continuously educate and provide empirical evidence on the benefits of breastfeeding to their patients-- but what can it accomplish if no one is listening?


1. Lawrence RA, Lawrence RM. Breastfeeding: a guide for the medical profession. 5th ed. St. Louis: Mosby, 1999.

2. Riordan J, Auerbach KG. Breastfeeding and human lactation. 2nd ed. Sudbury, Mass.: Jones and Bartlett, 1999.

3. Moreland J, Coombs J. Promoting and Supporting Breastfeeding. American Family Physician 2000; 61: 2093-2100.

4. American Dietetic Association. Promoting and Supporting Breastfeeding 2005; 105: 810-818; American Dietetics Association.

5. New South Wales Department of Health. Eat Well NSW: Strategic directions for public health nutrition. North Sydney, NSW: NSW Department of Health, 2004.

6. Sciacca JP, Dube DA, Phipps BL, Ratliff M. A breast feeding education and promotional program: Effects on knowledge, attitudes, and support for breast feeding. Journal of Community Health 1995; 20(6): 473-490.

7. Raj VK, Plichta SB. The Role of Social Support in Breastfeeding Promotion: A Literature Review. Journal of Human Lactation 1998; 14(1):41-45.

8. Pisacane A, Continisio GI, Aldinucci M, D’Amora S, Continisio P. A Controlled Trial in the Father’s Role in Breastfeeding Promotion. Pediatrics 2005; 116(4):494-498.

9. Scott JA, Mostyn T. Women’s Experiences of Breastfeeding in a Bottle-Feeding Culture. Journal of Human Lactation 2003; 19(3):270-277.

10. American Academy of Pediatrics. Breastfeeding Initiatives: Breastfeeding Promotion in Physicians’ Office Practices (BPPOP III) Program. Elk Grove Village, IL: American Academy of Pediatrics, 2006.

11. United States Preventative Services Task Force. Behavioral Interventions to Promote Breastfeeding: Recommendations and Rationale. Annals of Family Medicine 2003; 1(2):79-80.

12. United Nations Children’s Fund. Breastfeeding. United Kingdom: United Nations Children’s Fund.

13. Shepherd CK, Nursing D, Power KG, Carter H. Examining the correspondence of breastfeeding and bottle-feeding couples' infant feeding attitudes. Journal of Advanced Nursing 2000; 31(3): 651–660.

14. Staniec M. (2007, March). Lactation. Presented in classroom lecture at Boston University, Boston, MA.

15. Dugdale DC, Epstein R, Pantilat SZ. Time and the Patient-Physician Relationship. Journal of General Internal Medicine 1999; 14(s1):34-40.

16. Promotion of Mother’s Milk, Inc. New York City, New York: Promotion of Mother’s Milk.

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