Challenging Dogma

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

Sunday, April 22, 2007

The National Breastfeeding Awareness Campaign: Empowering Whom? Intervention Fails to Address Key Barriers for Women-Shaula Forsythe

The US Department of Health and Human Service’s Office of Women’s Health, together with the Ad Council, developed a national breastfeeding awareness campaign, “Babies were born to be breastfed”, to promote breastfeeding. Their goal was to empower first-time mothers to initiate breastfeeding and exclusively breastfeed for six months, as recommended by the American Academy of Pediatrics (1,2). Exclusive breastfeeding is defined as feeding a baby only breastmilk without supplementation. In the United States, the rate of women who initiate breastfeeding and continue for six months is far below the Healthy People 2010 goal, which aims for 75% of women to initiate breastfeeding and 50% to breastfeed exclusively for six months (3). According to the National Immunization Survey conducted in 2005, 73% of women with a new baby had ever breastfed, 39% were breastfeeding with supplementation at six months, and only 14% of women were exclusively breastfeeding at six months (2).

The Office of Women’s Health (OWH) breastfeeding awareness campaign, which ran from June 2004 to 2006, listed child health problems mothers could reduce in their children by breastfeeding. This message relied on numerous research studies which showed that children who were breastfed had a lower risk for developing obesity, ear infections, and asthma (1). The OWH campaign used the tag line, “Babies were born to be breastfed” and the message, “Breastfeed exclusively for six months” in order to reduce your child’s risk of developing asthma, obesity, and ear infections (1). Print materials ran these messages alongside photographs of items like ice cream scoops made to resemble breasts in order to illustrate the child obesity message. Radio and television ads conveyed the same message but with different scenarios.

The health benefits of breastfeeding to mom, baby, and even society have been well-established (5). There is a strong need for the breastfeeding awareness campaign, especially in light of the low national breastfeeding rates. Yet, the OWH breastfeeding campaign message depended solely on the health belief model. According to this model, by making women more aware of the childhood illnesses linked to not breastfeeding, women will be more likely to weigh their perceived susceptibility and severity of these child diseases over their perceived barriers to breastfeeding and thus make the decision to breastfeed (4). Yet, this campaign was ineffective because it failed to address major factors that women identify as influential in their decision to breastfeed. One study showed that many women knew that breastfeeding was the best way to feed their baby, yet they still did not breastfeed. Thus, there must be other factors that influence women’s behavior (10). These additional factors are not included in the health belief model’s perceived barriers, but are better addressed in other behavior change models. The breastfeeding campaign also neglects key barriers that exist for women who intend to breastfeed to actually do so.

In addition, significant disparities exist in breastfeeding rates between sociodemographic groups of women. The breastfeeding campaign failed to target its message to reach any of these groups. In 2005, only 65% of women with a high school education had ever breastfed their new baby, compared to 85% of women with a college education. At 6 months, 29.3% (10.2% exclusively) of women of low education were breastfeeding compared to 53% (19% exclusively) of college educated women (2). Another disparity exists between racial groups of women. In 2005, only 27% of black women were still breastfeeding at 6 months out of 60% that initiated, compared to 42% of white women at 6 months from 76% that initiated it (2). Finally, women that worked after giving birth compared to women who were unemployed initiated breastfeeding at the same rate. Yet, at 6 months only 10% of full-time mothers were exclusively breastfeeding compared to 24% of women were unemployed (2).

To better understand the nature of these disparities, studies have identified some key reasons for disparities in breastfeeding rates among high-risk groups of women. These factors are beyond the scope of the health belief model, including social factors that influence a woman’s intent as well as actual environmental barriers which prevent a woman from fulfilling her intent. These factors include little access to information and support resources, low social pressure and support networks to breastfeed, and workplace and hospital policies that do not support breastfeeding (6). While all women are affected by these factors, those populations of women who are most at-risk for not breastfeeding are most affected by them. It is these target groups and the barriers they face that the national breastfeeding campaign failed to address using the health belief model.

Health belief model fails to acknowledge how a mother’s education level influences her ability to weigh perceived severity, susceptibility
The breastfeeding awareness campaign chose to inform women of the diseases that are more likely to afflict children who are not breastfed. Yet, this message assumed a certain level of background knowledge about asthma, obesity, and ear infections. Those women with a lower education level were less likely to know how prevalent obesity was among children and the negative health effects this could have on a child. These women were less likely to understand the perceived benefits to herself and her child by avoiding these illnesses. Benefits included such things as cost and time for medical treatment as well as lost quality of life for her child and family. According to the health belief model, a woman’s perceived susceptibility and severity of these childhood diseases must outweigh her perceived barriers to breastfeeding in order to change her decision to breastfeed (4). Yet, if a woman is not informed about these diseases, this message may not be enough to influence her decision. The health belief model fails to take into account how education level and knowledge affect a mother’s ability to understand her child’s susceptibility and the severity of these health problems associated with not breastfeeding.

Lower education level, which correlates with low health literacy, also relates to a decreased access to breastfeeding information resources. Access to health information may improve a mother’s attitudes towards breastfeeding and her confidence to successfully breastfeed. A more highly educated woman may feel more capable to find resources to make a decision regarding breastfeeding and improve her ability to seek help if necessary. Many women feel they cannot produce enough milk to feed their baby, but many times this is a misperception. It usually originated from the experiences of other women they know or their own low self esteem (6). According to the theory of reasoned action, the increased support and positive attitude towards breastfeeding among highly educated women predicts increased intention and breastfeeding behavior (7,8). Supporting evidence has shown that the lack of confidence to breastfeed by women led to early termination of breastfeeding behavior (9).

The OWH breastfeeding campaign posted their print materials in public places, such as on billboards and in magazines and newspapers. Yet, they did not post these ads in places where women could be immediately provided with more information about the message they display. These places could have included physician’s offices, hospitals, or WIC offices. Because the campaign did not include information about the diseases they list, women who see a poster at a bus stop may not be in a position to seek out more information about these diseases. One goal of the breastfeeding campaign was to initiate a dialogue between mothers and their medical providers, but with such a disconnect between the placement of the message and a provider visit, this was unlikely to happen. It may be weeks between the time a woman sees the breastfeeding message and the time she sees her medical provider. Thus, this campaign did not target the important role medical providers play to provide information and breastfeeding support to at-risk women.

Breastfeeding awareness campaign focuses on individual-level decision making but fails to address social norms and social support that affect a woman’s decision to breastfeed
Another way in which the breastfeeding awareness campaign failed to reach women was the reliance solely on individual-level factors that affect breastfeeding. There are other important social factors which the health belief model does not include that need to be considered. The national breastfeeding awareness campaign did not consider how social factors influence breastfeeding among racial and ethic groups. Therefore, they ignored the unique barriers each group faces. By examining the history of breastfeeding among black women, we can see the effect of social norms and support on breastfeeding rates (11).

Black mothers have the lowest breastfeeding rates of all racial and ethnic groups. This is a trend which has persisted in this group for well over 40 years (11). Generations of black women did not breastfeed and were not breastfed. One reason is that first-time black mothers felt less social pressure to breastfeed. Mothers provide the primary support, together with a partner, family, and friends. This support has been reported by women as a major factor in their fulfillment to breastfeed (11). The Theory of Reasoned Action contends that the support women receive, attitudes towards breastfeeding, and their perceptions of social norms determine their intention and behavior to breastfeed (8). Thus, the lack of social pressure and lack of maternal support helps to explain the low breastfeeding rates among black women by this behavior model. Engaging generations of black women to learn about breastfeeding could increase the support to new mothers and increase breastfeeding rates (12).

Hispanic women have relatively high breastfeeding rates, but the campaign was simply translated into Spanish, rather than identifying particular barriers to breastfeeding in this group (2). Like black women, social support from family is very important to their behavior. This population struggles with unique issues, such as accessing information because of language barriers as well as obtaining support services from the medical community due to health insurance and immigration status. Thus, the breastfeeding awareness campaign failed to tailor its campaign to target these at-risk groups by addressing their particular barriers to breastfeeding.

Breastfeeding awareness campaign failed to target actual environmental and social barriers that exist for mothers to breastfeed
Finally, the breastfeeding awareness campaign’s use of the health belief model follows the assumption that intention leads to behavior (4). Yet, this model failed to take into account the actual environmental and social barriers which exist to breastfeed. Mothers report one major barrier to breastfeeding as the return to work after giving birth or after maternity leave (5). Of course, this is most challenging for women with less economic resources who must return to work shortly after giving birth. Large differences also exist between workplaces and workplace policies on breast-pumping for new mothers. Issues that mothers face in the workplace involve finding time to pump breastmilk 2-3 times per day, having a cold place to store milk, and finding a comfortable place to pump (13). Further, social barriers exist, such as co-workers’ acceptance of this behavior. Some women experience embarrassment and harassment at their workplace when they try to pump (13). Any one of these factors impose actual, rather than perceived barriers to breastfeeding, which can prevent a woman who intends to breastfeed from being able to do it.

The breastfeeding awareness campaign failed to inform women of policies that exist for their protection to breastfeed in public or at their workplace (5). Even so, many of these policies are merely symbolic; a woman may be given breaks at work to pump, but not a place to do so, which limits her ability to actually pump. This is an important issue that cannot be ignored if the Office of Women’s Health wants to increase breastfeeding rates. The structure of the workplace and the workday is a historical construct that does not take into account the unique needs of new mothers. Introducing more flexibility in a work day or maternity leave to better accommodate new mothers is not easily introduced into such an ingrained system. Looking at this issue from the Critical Feminist Perspective opens one’s eyes to the historical context and structure that discourages breastfeeding, especially in the workplace (12). Males hold many very powerful positions and the breastfeeding issue may make them feel uncomfortable. Men may be less aware of the positives of breastfeeding that may concern them, such as being financially positive for a workplace in terms of health insurance and missed work days. This is another very important group target for breastfeeding awareness in order to initiate change in the workplace for women.

Other environmental barriers to breastfeeding exist which many women may not even realize. One such place includes the hospital labor and delivery rooms, many of which do not facilitate breastfeeding initiation or continuation (14). The designation of baby-friendly hospitals arose from the movement to encourage and support breastfeeding from the first minute a baby is born (15). Hospital practices that pose challenges to breastfeeding include providing formula samples, keeping baby in a nursery away from its mother, not placing baby in mother’s arms right after birth and not facilitating feeding shortly thereafter (15). Many hospitals also do not provide education and support to mothers, in the form of lactation consultants and breastfeeding lessons, to make sure that women who want to breastfeed have successfully initiated it by the time they leave the hospital. Research has shown that when some of these hospital barriers to breastfeeding were removed, rates of breastfeeding among women giving birth at these hospitals increased (14). This proved that there were women who intended to breastfeed, but faced barriers in the hospital to initiating the behavior. When such barriers were removed, more women were able to fulfill their intention.

In conclusion, the OWH breastfeeding awareness campaign chose a message that relied on the health belief model to change a mother’s breastfeeding behavior. Yet, this model failed to take into account so many issues that strongly affect those women who are least likely to breastfeed. With such a large difference in breastfeeding rates among education level, race, and occupation, it is important to target those women with the lowest breastfeeding rates to make the strongest impact. Yet, this awareness campaign neglected the individual and social influences that affect a woman’s decision to breastfeed. The message also failed to address the actual environmental barriers women face who may have the intention to breastfeed but cannot actually do so. Because of these important aspects that affect behavior choice, this was an ineffective public health campaign to increase breastfeeding rates.

The breastfeeding campaign aimed to empower women to breastfeed, but relied solely on avoiding disease. Women that experienced actual barriers to fulfilling their breastfeeding intention may have merely felt increased guilt and frustration by their inability to breastfeed. This campaign did not empower women because it did not provide any tools or solutions to overcome breastfeeding barriers. Some women may have even felt more helpless after reading the message about the increased health problems that her baby may face because she could not breastfeed. Truly empowering women means showing them and those around them the positive attributes of breastfeeding and helping women reach their intentions through better access to support resources while minimizing obstacles in hospitals and workplaces. An improved OWH national breastfeeding campaign should use a combination of behavior change models to address the major barriers for women to breastfeed in order to produce significant and long-lasting change.

1.The National Women’s Health Information Center..National Breastfeeding Awareness Campaign- Babies Were Born to be Breastfed. Washington, DC: U.S. Department of Health and Human Services, Office on Women’s Health.
2.US Department of Health and Human Services. Breastfeeding Practices-Results from the 2005 National Immunization Survey. Washington, DC: Centers for Disease Control and Prevention.
3.US Department of Health and Human Services. Healthy People 2010. Washington, DC.
4.Rosenstock I. Historical Origins of the Health Belief Model. Health Education Monographs 1974; 2: 298-305.
5.Porter D. Breastfeeding: Impact on Health, Employment, and Society. July 18, 2003. Congressional Research Service Report for Congress.
6.Bryant C, Coreil J, D'Angelo S, Bailey D, Lazarov M. A strategy for promoting breastfeeding among economically disadvantaged women and adolescents. NAACOG's Clinical Issues. 1992: 3: 723-730.
7. Bandura A. Social cognitive theory: An agentic perspective. Annual Review of Psychology 2001; 52: 1-26.
8.Salazar MK. Comparison of Four Behavioral Theories: A Literature Review. AAOHN Journal 1991; 39: 128-135.
9.Ertem I, Votto N, and Leventhal J. The timing and predictors of the early termination of breastfeeding. Pediatrics 2001: 107: 543-548.
10. Zimmerman D, Guttman N. Mothers who formula feed do know that “breast is best'”: education is not enough. Archives of Pediatric Adolescent Medicine 1996: 150: 68.
11.Arlotti J, Cottrell B, Lee S, Curtin J. Breastfeeding Among Low-Income Women With and Without Peer Support. Journal of Community Health Nursing 1998; 15: 163-178.
12.Thomas L. A Critical Feminist Perspective of the Health Belief Model: Implications for Nursing Theory, Research, Practice, and Education. Journal of Professional Nursing 1995; 11: 246-252.
13.Kantor J. On the Job, Nursing Mothers Find a 2-Class System. The New York Times. September 1, 2006.
14.Komara C, Simpson D, Teasdale C, Whalen G, Bell S, Giavanetto L. Intervening to Promote Early Initiation of Breastfeeding in the LDR. MCN American Journal of Maternal and Child Nursing 2007; 32: 117-123.
15.Baby Friendly-USA. Implementing the Baby Friendly Hospital Initiative in USA. E. Sandwich, MA.

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