Challenging Dogma

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

Tuesday, April 24, 2007

National Breastfeeding Awareness Campaign: Failure to Create Change - Eva Mui

In 2002, the Office on Women's Health (OWH) implemented The National Breastfeeding Awareness Campaign, “Babies were Born to be Breastfed,” in response to suboptimal breastfeeding rates in the United States. The postpartum breastfeeding rate of 69% and rate of exclusive breastfeeding until 6 months, then at 33%, were both shy of the Healthy People 2010 Goals set forth by the Department of Health and Human Services (1). This was a concern since breastfeeding provides an endless list of health benefits. Breast milk is recognized as the ideal mode of feeding infants because it is nutritionally superior to all other types of nutrition; in addition to other physiologic and psychological benefits, it contains anti-infectious agents which promote immunity (2).

The overall goal of this campaign was to increase the proportion of mothers who breastfed their babies in the early postpartum period to 75% and to increase the proportion of women practicing exclusive breastfeeding until six months to 50% by the year 2010 (1). Other important goals identified by the campaign were to empower women to breastfeed and to recast breastfeeding as having greater perceived consequences (1). The campaign intended to increase these perceived consequences of breastfeeding by highlighting new research that showed babies who are exclusively breastfed for 6 months are less likely to develop ear infections, diarrhea, respiratory illnesses, and may be less likely to develop childhood obesity (1).

The Campaign

The “Babies were Born to be Breastfed” campaign was made up of local community projects and a media outreach component. At the local level, sixteen community based demonstration projects, made up of breastfeeding coalitions, hospitals, and universities, worked with OWH and the Ad Council to offer breastfeeding services, train healthcare providers on breastfeeding, implement the media aspects of the campaign, and track breastfeeding rates in their communities. The second component, a media outreach campaign, delivered breastfeeding messages through television, radio, newspapers, magazines, mass transit shelters, billboards, and Internet ads, targeting first time mothers and fathers who would not normally breastfeed their infants.

Perhaps their most publicized outreach was a series of television commercials that aired as a collaborative public service advertising effort with the Advertising Council. In the “Ladies' Night” commercial one woman, near term, is seen riding a mechanical bull. She is having a blast and the crowd cheers her on. She falls off the bull, but she picks herself right up and takes a bow for the crowd. In another, the “Log Rolling” commercial, two pregnant women are seen dueling it out as they balance on river logs. Both the commercials culminated with the message: "You wouldn't take risks before your baby is born, why start after?" These commercials quickly became controversial, labeled by critics, such as Judith Werner for the New York Times, as a negative campaign which “bullied mothers into breastfeeding and vilified those who don’t, but did not offer any social support to make breastfeeding feasible for today's mom” (3).

Results of the campaign show that awareness of breastfeeding messages increased from 28% pre-campaign to 38% post-campaign, and the percentage of women who had at some point breastfed their infant increased from 63% to 73% (1). Although surveys have shown some benefit stemming from the campaign, mainly in raising awareness, the United States is still far from reaching its original goal: to increase the length of time mothers adhere to breastfeeding, ideally six months.

"Babies Are Born to be Breastfed" was not effective at reaching its goal for two main reasons. First, not only did it fail to provide the social support needed for mothers adopt breastfeeding, but second, it also took one step backwards by blaming mothers who did not or could not make the change. Taking a deeper look into the fundamental causes of why some women did not breastfed will illuminate why it was critical to provide social support and why blaming moms was not an effective strategy. Pivotal barriers to change which public health did not acknowledge include the increased role of today’s working mother in society, the lack of social acceptance for breastfeeding in the U.S., and psychological barriers such as lack of self-efficacy.

Analysis of the campaign’s behavior change model, the Health Belief Model, makes it evident that the program’s creators did not consider any of these fundamental obstacles to change. This model states that when an individual perceives susceptibility to a problem, then they will weigh their barriers to change against consequences of making no change. In this case, a barrier to 6 months of exclusive breastfeeding may be return to work and the consequence of not breastfeeding would be an increased risk of future illness for the baby. If the consequences are worse than the barriers, then the individual will intend to change in order to avoid those consequences. The model, however, is erroneously based on the assumption that an individual’s intention to act, alone, will lead to that action. A goal of the campaign was to warn women of consequences of not breastfeeding their babies, specifically increased susceptibility to ear infections, diarrhea, respiratory illnesses, and childhood obesity. It then expected that mothers would correct their behaviors when informed of the possible health outcomes. The campaign assumed that mothers were all independently capable of change and willingly choose whether or not to breastfeed.

Mothers have multiple and demanding roles in society

If program planners take into consideration the fact that mothers have increasingly demanding roles in today’s society, then they might not be blaming mothers for being unable to breastfeed their babies. Instead, they might realize that they could instead offer new mothers with much needed social support. More and more now, women are spending longer hours at work and are responsible for earning an income (4). Statistics show that one third of mothers are now returning to work within three months of giving birth and two-thirds are returning within six months (4). When women return to work, their roles as mothers remain intact. This creates a dilemma because women are not physically able to be in two places at once! And so, mothers may not have enough time to nurse their infants exclusively for six months. This new role for mothers is an important factor to be considered since employment status is found to be the second strongest negative determinant of breastfeeding in the U.S. (4). In fact, full time working moms are twice as likely to have weaned their babies at six months than moms who do not work at all (4).

Even if a working mom decides that she would like to try to continue breastfeeding her child, she faces time constraints and requires major lifestyle changes. Acknowledging these constraints can lead to solutions such as workplace programs which encourage nursing (4). Programs, which allow break time and rooms for expression of milk, provide mothers with the time and place to continue breastfeeding (5). Because the volume of milk production is directly related to frequency of breastfeeding, allowing mothers to express milk at the workplace prevents premature weaning (5). In recent years, continued nursing past six months has increased along with the appearance of such workplace programs, suggesting they are possibly effective in promoting continued breastfeeding (4). Also observed is that in states which implement laws that accommodate for breastfeeding, such as Minnesota, women are generally more comfortable with nursing (4, 5). This finding suggests that implementation of such a program would ameliorate other barriers to change such as lack of social acceptance for breastfeeding. These institutional and legislative changes seem promising.

Breastfeeding is not socially accepted in the U.S.

In order to create a successful campaign, lack of social acceptance in the U.S. for breastfeeding must also be addressed. The act of breastfeeding babies in public is still not socially accepted in the US and there are few designated places a mother could go to nurse her baby (5, 6). For example, onlookers may not react well if they see a mother nursing her baby at a public park or at a mall. This does not leave a mother many alternatives. She could breastfeed her baby in the women’s restroom, but this is unsanitary. Mothers are given conflicting messages when, on one hand, they are told to nurse their infants, but on the other, they are shunned when they do so in public. This not only creates difficulties for a mother to nurse her infant, but leaves a negative impression on her. She is made to feel like the only acceptable place to nurse a baby is behind the closed doors of her home. It is no wonder why women feel uncomfortable and feel the need to resort to bottle feeding prematurely. Indeed, a mother’s perception of social norm is a predictor of whether or not she breastfeeds her baby (6). That is, women who felt confident in public and who felt that breastfeeding was the social norm, were much more likely to nurse their infants (6).

To illustrate social influence on breastfeeding, one study found that mothers who lived with family or friends generally breastfed their infants for a shorter duration of time than mothers who lived alone or with just a spouse (7). Mothers who live with family or friends do not enjoy the same privacy as mothers living alone. A mother may be living in more crowded conditions, which increases the likelihood that she will not be able to find a comfortable place or some quiet time to nurse her infant. These moms may have felt that bottle feeding was more convenient, since privacy is not an issue when bottle feeding.

Psychological Barriers to Breastfeeding

Finally, the intervention’s failure to take psychological barriers into consideration was a significant omission. A major mistake in the “Babies Were Born to be Breastfed” campaign was the use of guilt tactics, which is not an effective way to promote change. In the “Log Rolling” and “Ladies' Night” public service announcements, pregnant women are depicted as putting their babies in immediate danger. The ads may make mothers feel guilty by implying that they deliberately chose to put their child in harm’s way. It is easy to see how such a negative message might bring down a mother’s level of self-efficacy. A new mother may be stressed out as it is, adjusting to the responsibilities of motherhood and dealing with her own insecurities about whether or not she is performing her best as a mother. She does not need the added message that she may be subjecting her baby to harm. This message may satisfy one campaign goal, increasing perceived consequences of breastfeeding, but defeats the purpose of another goal: empowering women to breastfeed. The campaign should, instead of making mothers feel guilty, motivate moms to change by targeting self-efficacy. Because self-efficacy is a strong predictor of a mother’s success in nursing her infant, encouraging moms that they can succeed will be more effective than telling them they are bad mothers, which exacerbates the problem (7).

Factors such lack of support from medical professionals, and personal feelings of discomfort and self-consciousness are other common psychological barriers to breastfeeding (8), all of which can be improved upon with thoughtful programming. For example, when surveyed about why breastfeeding was discontinued, women most commonly reported the reason as insufficient milk supply (8). Many mothers, especially in Western culture, rely on numbers such as on a baby bottle as guideline for how much to feed their babies (8). They are unaccustomed to physical cues indicating that their baby is full and so often perceive an insufficient milk supply even when it is actually enough (8). A mother's insecurity about her ability to supply enough nutrition can be ameliorated by support from lactation consultants or nurses. These professional resources have proved to be very beneficial to mothers; those who had assistance from lactation consultants or nurses practiced longer breastfeeding duration than those who didn’t receive help (8). The problem is that while 92% of mothers receive lactation assistance while in hospital, only 55% receive help at home (8). Future action should be directed towards increasing the availability of lactation consultants to women after they leave the hospital. If coached, new moms may be more able to cope with psychological barriers, which will prevent unnecessary early cessation.

Future Directions

The "Babies were Born to be Breastfed" campaign was erroneously based on the Health Belief Model. The program aimed to increase perceived susceptibility to health risks when not breastfeeding, but failed to recognize significant barriers to behavior change. Because the intervention did not address the causes of this problem, it was not effective in resolving it. Addressing the practical, social barriers to change will enable public health programmers to create more effective behavioral change programs.

In this analysis, women’s increased roles in today’s society, lack of social acceptance of breastfeeding in public, and psychological barriers such as low self-efficacy, are all obstacles to realizing an increase in breastfeeding. Analyzing these factors has provided some insight to why it is not easy for women to exclusively breastfeed their infants during the first six months or longer. Not only did the campaign fail to provide proper social support, but it also brought moms' self-efficacy down with negative commercial advertisements. Instead of making mothers feel inadequate, confidence should be instilled in mothers.

An alternative approach to this campaign uses principles from the Social Cognitive Theory. This model is based on the concept of self-efficacy; if one believes they can succeed at something, then they can. A campaign based on this model would first require a change in the environment, especially at work, by providing social support in a society that is not breastfeeding-friendly. Such a program would empower women to change by bringing out positive feelings and helping out struggling mothers. Only then can exclusive breastfeeding for a longer duration be more plausible. There also needs to be acceptance for the fact that some women may still not be able to breastfeed their infants.

This is not to say that the Health Belief Model is useless. The Health Belief Model was successful in creating awareness, but it must be supplemented by additional models in order to create change. Empowerment will set moms up to succeed. When moms are prepared to succeed, implementing breastfeeding programs will provide the support needed to make the change.


1. US Department of Health and Human Services. National Breastfeeding Awareness Campaign Results. Office on Women's Health, 2005.

2. Mahan, K. and Escott-Stump, S. Krause's Food, Nutrition, & Diet Therapy. Philadelphia, PA: Saunders, 2004.

3. Werner, J. New York Times. June 23, 2006.

4. Ryan, A., Zhou, W., and Arsenberg, M. The effect of employment status on breastfeeding in the United States. Women's Health Issues 2006; 16; 243-251.

5. La Leche League International. Working it out: Breastfeeding at work.

6. Kools, E., Thijs, C., Kester, A., and Vries, Hein. The motivational determinants of breastfeeding; Predictors for the coninuation of breast-feeding. Preventative Medicine 2006; 43; 394-401.

7. Baghurst, P., Pincombe, J., Peat, B., Reddin, E., and Antoniou, G. Breast feeding self-efficacy and other determinants of the duration of breast feeding in a cohort of first-time mothers in Adelaide, Australia. Midwifery 2006; article in press.

8. Lewallen, L., Dick, M., Flowers, J., Powell, W., Zickefoose, K., Wall, Y., and Price, Z. Breastfeeding support and early cessation. Journal of Obstetric, Gynecologic, and Neonatal Nursing 2006; 35: 166-173.

9. Centers for Disease Control and Prevention. CDC’s Breastfeeding National Immunization Data.

10. Hauck, Y., Hall, W., and Jones, C. Prevalence, self-efficacy and perceptions of conflicting advice and self-management: Effects of a breastfeeding journal. Journal of Advanced Nursing 2007; 57(3), 306-317.

11. Ingram, J., Rosser, J., and Jackson, D. Breastfeeding peer supporters and a community support group: Evaluating their effectiveness. Maternal and Child Nutrition 2004; 1, 111-118.

12. Johnston, M. and Esposito, N. Barriers and facilitators for breastfeeding among working women in the United States. Journal of Obstetric, Gynecologic, and Neonatal Nursing 2007; 36(1), 9-20.

13. Kruske, S., Schmied, V., and Cook, M. The ‘Earlybird’ gers the breastmilk: Findings from an evaluation of combined professional and peer support groups to improve breastfeeding duration in the first eight weeks after birth. Maternal and Child Nutrition 2007; 3(2), 108-119.

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