Challenging Dogma


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

Sunday, April 22, 2007

The CDC Breastfeeding Campaign: How An Ineffective and Narrow Approach Inadvertently Alienates Women Subgroups in America—Katherine Ogando

The CDC Breastfeeding Campaign
Breastfeeding, a fairly controversial subject, is an unpopular option for many North American women even though it has proven health benefits for both the infant and the mother. As such, increasing the practice of breastfeeding has become a public health concern of the Centers for Disease Control and Prevention (CDC). The intervention to promote breastfeeding in the United States has been ineffective in part because the campaign has a strong focus on censoring the advertisement of Breast Milk Substitutes (BMS) instead of marketing a constructive view of breastfeeding in the United States. The approach of the campaign is also narrow because the advertisements utilize the Health Belief Model, a simplistic behavioral model that does not reliably address the issues impeding the success of the intervention. Lastly, the distribution of information via advertisements is circulated exclusively to the pregnant woman population when the opinion of husbands, partners, and other members of the mother’s social circle greatly influence the decision of the mother with regards to breastfeeding. Ultimately, the current breastfeeding campaign does not create a change in the societal view of breastfeeding, which is necessary to achieve change in the target population.

The CDC, in conjunction with other prominent women’s health organizations, launched the Breastfeeding Campaign as part of the Healthy People 2010 goals. According to the HHS Blueprint for Action on Breastfeeding, one of the aims in the US strategic plan for breastfeeding is to promote it as the normal and preferred method of feeding infants and young children by “supporting breastfeeding in the family, through places of work, among health care providers, in the community, and throughout society.”[1] The strategy, although it did not quite meet the expectations of increasing the rate of women breastfeeding in early postpartum period to 75%, 50% at six months, and 25% at one year postpartum [2], made some progress over the previous attempt at making breastfeeding appealing to the population. To illustrate, in 1998 no group of women reached the target for 5-6 months postpartum. In fact, according to the CDC Pediatric Nutrition Surveillance, the percentage of mothers who breastfed in early postpartum, six months, and one year were 64%, 29%, and16%, respectively [3]. In 2005, the figures were more promising as 21 states achieved the 75% goal in early postpartum, and five states achieved all three Healthy People 2010 objectives [2]. Still, the latest figures leave more to be desired, as there is still a sociodemographic discrepancy in the subgroups with the lowest breastfeeding rates: data shows that non-Hispanic black women and populations with low socioeconomic status have markedly lower breastfeeding rates [2].

Breast-milk Substitutes
One of the campaign’s more subtle approaches to increase the number of women who breastfeed has been to discourage the use of BMS. BMS include any replacement of breast milk, including solids and infant formula, and items that facilitate use of breast milk replacement, such as baby bottles [1]. The campaign targets marketing of commercial competitors through the WHO International Code of Marketing of Breast-milk Substitutes, a set of guidelines to promote the consumption of breast milk over infant formula [4]. The Code opposes advertisement of BMS to the public, promotion of products in health care facilities, and dissemination of free samples of products to mothers. In addition, it calls for a description of the health benefits of breastfeeding and the risks involved in artificial nutrition in the BMS product label [5].

The countermarketing strategy of BMS is one of the most significant efforts to promote breastfeeding with the intent to curtail business-selling tactics in an aggressively capitalistic country such as the United States. It is reminiscent of the war against Big Tobacco in the level of censorship as we notice that baby formula or baby bottle advertisements are notably discreet in their claims on television commercials [6]. In fact, the warning labels on cigarette packets detailing the dangers of smoking are comparable to the labels on baby formula containers [7]. The censorship of the claimed benefits of formula feeding in general advertisements also resemble the restrictions placed on tobacco companies when cigarette ads had not yet been completely banned [7]. But in seeing the similarities between the two campaigns, it would seem that the two products being regulated promote comparable health hazards. Because formula feeding may not be a result of irresponsible parenting, it is inappropriate to compare tobacco use, a lifestyle choice, to an alternative mode of feeding an infant—even if it is unequal in quality to breastfeeding. So what is the unintended message the Breastfeeding Campaign is sending?

The BMS curtailing strategy does not consider the effect it has in women to whom breastfeeding is not recommended. Despite the fact that the estimated number of women who cannot physiologically breastfeed because of minimal or lack of milk production is low [8], there are a number of women who have introduced toxins in their bodies because of medication regimens or lifestyle decisions, as well as having diseases transferable through breast milk. Rather than promoting a positive impression of breastfeeding in the United States, the strategy alienates women who cannot or consciously choose not to breastfeed by inducing feelings of shame and guilt of bad mothering [9].

Why has the Breastfeeding Campaign not been more successful?
Like so many other public health interventions, perhaps the reason the breastfeeding campaign has not met expectations lies in its fundamental flaw. The approach follows the psychosocial principles of the Health Belief Model, which posits that an individual is moved to take action when perceived threats and perceived benefits outweigh the perceived barriers to taking action [10]. These premises are clearly depicted in the breastfeeding promotion effort’s adjunct advertisement campaign in 2002. The campaign slogan was “Babies were born to be breastfed,” and broadcasted commercials in which pregnant women engaged in physically dangerous activities. In one commercial, a woman in late-stage pregnancy is riding a mechanical bull and falls off the bull as the text “You wouldn’t take risks before your baby is born. Why start after?” appears on the screen. A voiceover citing some health benefits of breastfeeding concludes the commercial [11]. The advertisement likens the risks of providing artificial nutrition to physical harm, thus seeking to increase the perceived threat and highlighting the perceived benefits with the voiceover at the end of the commercial.

The shortcomings of the Health Belief Model begin with the supposition that intention to act automatically leads to behavioral change. In fact, the Health Belief Model was originally structured to accurately predict a short-term change, such as individual tuberculosis screenings, as opposed to long-term behavioral change [10], as is at least six months of exclusive breastfeeding. Long-term behavioral changes are influenced by more complex psychosocial variables that interact between and throughout ecological spheres.

Institutional Barriers
The Health Belief Model would not predict behavior effectively in a situation where, for example, there are institutional barriers not readily perceived by the population at hand. In the case of women of low SES, recipients of welfare in the form of Transitional Aid for families with dependent children receive time-limited monetary benefits [12], forcing working mothers to return to their place of employment sooner after giving birth. Places of employment are not typically flexible enough to offer facilities where women can safely and privately breastfeed or pump breast milk for their infants, as it may cause an increase in the direct and indirect costs of running a business. It is also uncommon for businesses to allow mothers to take time off from work several times a day to feed their infants. It is rare even among major corporations, as only one third of large corporations provide accommodations for mothers to breastfeed at work [9].
The institutional barrier is seen through racial discrepancies as well. African American women, the racial group with the lowest breastfeeding rates, tend to return to work postpartum 2 months earlier than other races [13]. In situations such as these, artificial infant nutrition seems a more viable option for low-income women to feed their infants. In addition to barriers at work, women of low SES and African American women receive provisions of free infant formula from healthcare facilities, and are more likely to be offered advice from healthcare professionals promoting BMS than information about breastfeeding.

An additional force that influences breastfeeding behavior is the woman’s involvement in the WIC program. WIC is a federal supplemental nutrition program for low-income women, infants, and children up to five years old [14]. The WIC programs offers vouchers for baby formula and nutritional education at specialized clinics. Unfortunately, WIC educators disseminate nutritional information disproportionately in this population since African American women receive less information and guidance from physicians and WIC counselors to breastfeed than white women [13]. This discrepancy is especially influential in the case of African American women, who account for 22% of WIC program participants [13]. Isn’t the Breastfeeding Campaign alienating women who choose to follow the advice of their physician? Even the forgers of the Breastfeeding Campaign acknowledge this fact in the HHS Blueprint for Action on Breastfeeding:
Breastfeeding is not viewed positively among African American women. Furthermore, it has been difficult for African American women to receive information and education about breastfeeding, to have breastfeeding initiated in the hospital, to continue breastfeeding in the early days in the home setting, and to continue breastfeeding for an extended period [1].

Clearly, merely informing the public that breastfeeding is beneficial for the baby’s health will not lead to a rational change in breastfeeding behavior in a society that makes it impractical and improbable that a woman would adhere to the recommendations of the Breastfeeding Campaign. The approach should be modified, not only into a more ecologically aware construct to better analyze the obstacles that affect individual attitudes and perceptions towards breastfeeding, but also into an intervention that empowers women that can make the decision to breastfeed their infant. To accomplish this successfully, the understanding that the intervention should not only target pregnant women is crucial.

The Scope of the Intervention
The Breastfeeding Campaign fails to effectively address the institutional barriers the target population is facing, but its true weakness is overcoming the challenge to change societal perspective. Women are a subgroup within a population that does not widely endorse the practice of breastfeeding in public. If the campaign seeks to reach women, it would benefit from understanding those groups that are closest to women as well. The failure to consider the role of the community and its influence on the individual results in the practice of cultural encapsulation, described as a disregard of “cultural variation in a dogmatic adherence to some universal notion of truth,” [15]. Indeed, the architects of the Breastfeeding Campaign, as well as the supporters of the Health Belief Model, operate under the assumption that individuals are autonomous, independent beings. Counter to this belief is the reality that American women are strongly influenced by the infant feeding preferences of their significant other [17], particularly those of the baby’s father and the baby’s grandmother [16]. This is not to suggest that women are incapable of making decisions on their own, and it is important to note that one of the main determinants of breastfeeding is the woman’s attitude towards it [17]. Nevertheless, the Breastfeeding Campaign does not take into account that women are more likely to breastfeed if their significant others are supportive of this action [17] as is clear from their one-track television and print advertisements.

Implications of the Breastfeeding Campaign
What breastfeeding means to a married, educated, middle class mother is different than what it means to a low-income, young, single mother with very little social support. In the end, a woman may not relate to the message of the Breastfeeding Campaign as she may feel it does not apply to her situation. What the campaign is succeeding in is sending a message that vilifies women who do not breastfeed, alienating those who believe they do not have that alternative. The perception of threat being exhibited in the ad campaign, portraying options other than breastfeeding as irresponsible, only serves the opposite of the intended behavior: it antagonizes women to the cause. The messages of the Breastfeeding Campaign should be more positive, more inclusive, and most importantly, more sensitive to the social and political atmosphere faced exclusively by mothers by virtue of simply being a woman. The response to the campaign is summarized by the commentary on Respectful of Otters, where the author mentions many areas that the Campaign could address. It concludes with truth in biting sarcasm:
Hahahahahahahaha! No. They're pushing an extensive PR campaign to make formula-feeding mothers feel guilty. Because who needs all that other stuff, when we could focus on personal responsibility?[18]

REFERENCES
1. Department of Health and Human Services. HHS Blueprint for Action On Breastfeeding. Washington, DC. US Department of Health and Human Services, Office on Women’s Health, 2000.
2. Centers for Disease Control and Prevention. Breastfeeding Practices: Results from the 2005 National Immunization Survey. Atlanta, GA. Department of Health and Human Services,
Centers for Disease Control and Prevention. http://www.cdc.gov/breastfeeding/data/NIS_data/data_2005.htm.
3. U.S. Department of Health and Human Services. CDC Pediatric Nutrition Surveillance. Atlanta, GA. US Department of Health and Human Services, Centers for Disease Control and Prevention, 2000.
4. Shealy KR, Li R, Benton-Davis S, Grummer-Strawn LM. The CDC Guide to Breastfeeding Interventions. Atlanta, GA. US Department of Health and Human Services, Centers for Disease Control and Prevention, 2005.
5. World Health Organization. International Code of Marketing of Breast-milk Substitutes. Geneva: World Health Organization, 1981, pp. 5-7,
6. Edwards J. Abbot Labs Wails About Ruling on Baby Formula Ads. New York, NY. Brandweek.
http://www.brandweek.com/bw/news/recent_display.jsp?vnu_content_id=1001480464
7. Schaffer Library of Drug Policy. History of Tobacco Regulation. National Commission on Marihuana and Drug Abuse. http://www.druglibrary.org/schaffer/LIBRARY/studies/nc/nc2b.htm
8. Olson B. Breastfeeding: New Health Benefits. Michigan State University Extension. 2003; 1:1-4.
9. Rabin R. Breast-feed or else. New York Times, June 13, 2006
10. Rosenstock IM. The Health Belief Model: Explaining health behavior through expectancies (pp.39-62). In: Glanz K, Rimer B, Lewis F, eds. Health Behavior and Health Education: Theory, Research and Practice. San Francisco, CA: Jossey-Bass; 1990.
11. AdCouncil. Breastfeeding Awareness Campaign. Washington, DC. AdCouncil. http://adcouncil.org/campaigns/breastfeeding.
12. Health and Human Services. Transitional Aid to Families with Dependent Children. Boston, MA. Office of Health and Human Services.
http://www.mass.gov/?pageID=eohhs2modulechunk&L=4&L0=Home&L1=Government&L2=Departments+and+Divisions&L3=Department+of+Transitional+Assistance&sid=Eeohhs2&b=terminalcontent&f=dta_c_finassist_tafdc&csid=Eeohhs2
13. Oyeku, S. A closer look at racial/ethnic disparities in breastfeeding. Public Health Reports. 2003; 118: 377-378
14. Food and Nutrition Service. WIC at a Glance. Washington, DC. United States Department of Agriculture. http://www.fns.usda.gov/wic/aboutwic/wicataglance.htm
15. Sue, DW, Sue D. The Politics of Counseling and Psychotherapy (pp. 33-62). In: Counseling the Culturally Diverse: Theory and Practice. New York, NY: John Wiley & Sons, 2003.
16. Bentley ME, Dee DL, Jensen JL. Breastfeeding among Low Income African American women: Power, beliefs, and decision making. Journal of Nutrition. 2003; 133: 305S-309S.
17. Kessler LA, Gielen AC, Diener-West M, Paige DM. The Effect of a Woman’s Significant Other On Her Breastfeeding Decision. Journal of Human Lactation. 1995; 11: 103-109.
18. Lactation or bust. Respectful of Otters (blog). June 13, 2006. Available at http://respectfulofotters.blogspot.com/2006_06_01_respectfulofotters_archive.html#115025468686313265.

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