Introduction to Breastfeeding
As An Important Public Health Issue
Breastfeeding is becoming an increasingly
important public health issue. The American Academy of Pediatrics recommends
that women breastfeed their infants for at least 6 months, citing both short-
and long-term medical and emotional benefits for mom and baby.(1) Research shows that, in addition to
other benefits, breastfed infants have lower rates of ear infections and
diarrhea,(2), respiratory illness,(3), and obesity,(4) while women have lower rates of breast
and ovarian cancer.(5,6) However, according to the 2013 CDC
Breastfeeding Report Card, only 49% of women are still nursing at 6 months, of
which 16.4% are doing so exclusively (without formula supplementation).(7) As such, improving breastfeeding rates
and duration are important public health goals for women, babies, and society
overall.
Introduction To The National Breastfeeding Awareness
Campaign
Recognizing the need to address
breastfeeding as a public health imperative, The National Breastfeeding
Awareness Campaign (NBAC) was launched in 2004 by the United States Department
of Health and Human Services’ Office on Women’s Health (OWH).(8) The campaign sought to achieve two main
goals: first, increase the proportion of mothers who exclusively breastfeed
their babies (from 69% to 75% during months 0-6 and from 33% to 50% during
months 6-12) and second, increase general awareness of breastfeeding and its
benefits.(8)
The campaign had both media and community
outreach components. For its media component, the OWH collaborated with the Ad
Council to develop materials for television, radio, newspapers, magazines, mass
transit shelters, billboards, and Internet. Their intended target audience was
first-time mothers and fathers who have no experience with breastfeeding. The
OWH website publishes several of the materials used in their media campaign including
links to print, radio, and television segments.(8)
Print Ads
The OWH website publishes three versions
of their print ads. All are depictions of breasts using non-breast materials.
In the first, there are two dandelions with pink centers used in association
with the message “Breastfeed for 6 months. Help reduce your child’s risk for
respiratory illness;” in the second, two otoscopes are used in conjunction with
the message “Breastfeed for 6 months. Help reduce your child’s risk of ear
infections;” and in the third, there are two scoops of ice cream, each with its
own bright red cherry, and the message “Breastfeed for 6 months. Help reduce
your child’s risk for childhood obesity.”(8)
Television Ads
The website also publishes two television
ads, one featuring a very pregnant woman riding a bull and one featuring two very pregnant women participating in
a log roll. “You
wouldn’t take risks before your baby is born,” they say. “Why start after?”(8)
Radio Ads
Finally, the website publishes two radio
ads. One is an R&B song in which the risks of not breastfeeding
are soulfully swooned. The refrain, which repeats several times, is “you got to
know the facts, lady.” The other is a country song, which sings “when it came to increasin'
disease resistance, that woman could lactate like nobody's business,” in
reference to the country singer’s “mama.”
Despite its best intentions to
increase breastfeeding rates in new mothers, NBAC’s method of doing so was
deeply flawed. With messages like “You wouldn’t take risks before your baby is
born—why start after?” and “Help reduce your child’s risk of disease X,” NBAC
highlights the bad things that can happen to babies who are not breastfed and
places the burden on women to fix them. These messages are a textbook
representation of a campaign based on the Health Belief Model (HBM).(9) The HBM suggests that a person’s
likelihood to adopt a new health behavior depends on two factors: first, the
individual’s belief in a personal (or in this case, her child’s) threat of
disease or illness; and second, an individual’s belief that the new health
behavior will actually make a difference. As such, NBAC seeks to convince new
mothers not only that their children are at risk for developing countless
numbers of terrible diseases (e.g. obesity, diabetes, asthma, and ear
infections), but also that breastfeeding will miraculously make these things go
away.
NBAC plays to several strengths of the
HBM, most notably in its use of “perceived susceptibility,” “perceived
severity,” and “perceived benefits” to convince mothers that breastfeeding will
help reduce the likelihood of serious illness in their children. However, there
are also many weaknesses to using this model, both in terms of its application
to this particular campaign and because of weaknesses inherent to the model
itself.
In this paper, I will identify three
major flaws of the NBAC because of its use of the Heath Belief Model: first, I
will critique its failure to account for individual attitudes and beliefs that
may influence a woman’s decision to breastfeed; second, I will critique its
exclusion of non-health related reasons, in particular social barriers, for not
breastfeeding; and third, I will critique its exclusion of environmental and
economic factors that prohibit breastfeeding success. Following the critique, I
will present features of an alternative campaign that may be better tailored to
the diverse needs of new moms learning to breastfeed in the United States.
Critique #1. The NBAC Fails
To Account For Individual Beliefs and Attitudes That May Be Barriers To
Breastfeeding Success
Ask
any woman who has attempted to breastfeed her infant and she will tell you that
it is hard work. Despite its being a
“natural” behavior, breastfeeding is rarely a naturally innate skill.
Nevertheless, this campaign addresses neither the challenges that individual
women face with breastfeeding (10) or the feelings that many women
experience when they struggle to succeed.(11) It wrongly assumes that breastfeeding
success is independent of a woman’s personal experience, beliefs about
breastfeeding, self-perception of success, or self-confidence in adequately
nourishing her child. This assumption is problematic for several reasons.
First, according to Ruowei Li et al.
in their article “Why Mothers Stop Breastfeeding: mothers’ self-reported
reasons for stopping during the first year,” the number one reason why women
stop breastfeeding is the perception that their infant is not satisfied by
breast milk alone.(12) As a result, many women introduce
formula or food within the first few months because they are worried that their
child is hungry. The earlier these supplements are introduced, the more likely
a woman’s breast milk supply will suffer as her baby’s demand, supplanted by
other sources of nutrition, will decrease.
Second, Li et al. point out that
Hispanic mothers and mothers with annual incomes <350% of the federal
poverty line are among the more likely to stop breastfeeding before their
peers.(12) While there are certainly environmental
and economic factors for this discrepancy that are addressed later in this
paper, these research findings support the campaign’s lack of emphasis on the
individual beliefs and attitudes of populations needing the most help. For
example, NBAC claims that they are targeting African-American mothers, a
population with comparatively low breastfeeding rates,(7) through their use of a black woman on
the mechanical bull and the “soul music” radio segment.(8) However, their efforts are misguided.
“Deploying black women and symbols likely to resonate with African Americans
represent a use rather than an understanding of cultural
particularity,” writes Joan Wolf in her paper, “Is Breast Really Best? Risk and
Total Motherhood in the National Breastfeeding Awareness Campaign.” “It was the
outcome of market research (focus groups) that sought to determine how best to
sell a product (breast-feeding) more than an effort to understand the ‘diverse
values, beliefs, and cultures in the community.’”(13)
Ultimately, perhaps in a
well-intentioned effort to make its ads as broadly appealing as possible, the
NBAC fails to account for the fact that women have deeply unique breastfeeding
experiences that are highly informed by individual beliefs and attitudes. While
this variation may be due to a variety of factors, addressing the individual
needs of cultural groups needing the most support would be a good place to
start.
Critique #2. The NBAC Fails
To Account For Social Barriers To Breastfeeding
Despite
the fact that breastfeeding is becoming a more socially acceptable activity,
women perpetually face societal barriers that hinder their breastfeeding
success. Among these are negative reactions to public breastfeeding,(14) resistance to accommodating women’s
nursing needs in the workplace,(15) hyper-“sexualization” of female breasts,(16) and male reactions to breastfeeding.(17) The NBAC avoids the social context of
nursing entirely in its print and television ads, and touches upon it only
briefly in its radio segments. Excluding any discussion of the social barriers
that women face while attempting breastfeeding is a major flaw in the NBAC
overall.
The NBAC puts a lot of pressure on
individual women to make the right choice for their babies, but no pressure on
society to support them in this endeavor. They compare the health implications
of not breastfeeding to that of riding a mechanical bull or log-rolling while
heavily pregnant. This is not only an unfair comparison (there is no comparable
danger in giving infants formula), but also one in which women are expected to
succeed against all odds. It fails to account for the fact that unlike the
woman who chooses to mount the bull, a woman most likely chooses not to
breastfeed because of obstacles that are likely completely out of her control.
Two of the most significant obstacles that NBAC excludes are societal reactions
to women who breastfeed in public and lack of accommodations for nursing women
in the workplace.
In their paper “Men and Infant Feeding:
Perceptions of Embarrassment, Sexuality, and Social Conduct in White Low-Income
British Men,”(Henderson
et al., 2011) Henderson et al. observe that
“perceptions of breastfeeding as a sexual activity and the dominant mass media
emphasis on breasts as a sexual site may present additional obstacles to
breastfeeding.” While this study was conducted in Britain, it is definitely
applicable to similar obstacles that women face in this country. Whether it
intends to or not, NBAC does address some of the prevailing male perceptions of
breastfeeding by using male vocalists in both of its radio ads. Both the
country and soul segments feature male vocalists singing the praises of the
breastfeeding women in their lives: the country song says, “Mamma's nursin'
helped raise a healthy family. There's nothin' she wouldn't do, she helped us kids
get through, with less risk for ear infections and respiratory illnesses,”
while the soul song says, “wonderful woman, if you do breastfeed, our little
baby will be at less risk of respiratory illnesses.” It is refreshing to hear a
male not only profess his understanding of breastfeeding’s benefits, but also
express gratitude for the work women do for their children.
While this is certainly a strong
first-step, NBAC’s message is likely far too subtle to inspire real social
change. Henderson et al. assert that for real changes in perception to happen,
both pre- and peri-natal education should target men directly. Only then can
many of the deeply entrenched problems generated by historical views of sexuality
and masculinity be addressed.
Critique #3. The NBAC Fails
To Account for Economic and Environmental Barriers to Breastfeeding
There is a wide variation in
breastfeeding rates between racial and socioeconomic groups in this country.(18) Much of this variation can be attributed
to discrepancies between levels of social support, healthcare provider
guidance, quality of maternity- and postpartum-care, and hospital engagement in
breastfeeding (e.g. breastfeeding initiation delays, provision of pacifiers,
promotion of formula, etc.).(18) These discrepancies are especially
pronounced when comparing resources available to different racial groups and to
populations in poorer or wealthier parts of the country. Therefore, for many
women attempting to breastfeed, there can be any number of insurmountable
economic and environmental barriers to success.
Recognizing that African-American
women have some of the lower breastfeeding rates in this country, the NBAC
tailored part of its campaign for this audience. Nevertheless, as noted above,
its methods for doing so fall short of reaching not only African-Americans, but
also many of the other most vulnerable populations at risk for breastfeeding
failure. The CDC recommends that public health measures to promote
breastfeeding target black mothers in rural areas, mothers younger than 20
years old or who have not completed high school, and enrollees in the WIC
program. In addition, they emphasize the importance of supporting women’s
efforts not only to initiate breastfeeding, but also to continue for as long as
possible.(18)
Dr. Miriam Labbok, Professor of
Maternal and Child Health at the University of North Carolina and Director of
the Carolina Global Breastfeeding Institute points out that women who receive
WIC are at a particular disadvantage because they are recipients of free
formula for 3 out of 4 weeks each month.(19) In an interview I conducted with her on
March 3, 2014, she said, “WIC really threw out a wrench by giving out free
formula.”(20) She argues that this money could be much
better spent on counseling and supporting new moms who otherwise have very
little economic, community or social encouragement. WIC, she says, is doing the
poorest women in this country a huge disservice. The NBAC fails to account for
the vulnerabilities of this population and others facing similar economic and
environmental burdens. Relying too heavily on the tenets of the HBM, its ads do
not address the needs or concerns of women facing some of the most substantial
barriers in this country.
Introduction To An
Alternative To The National Breastfeeding
Awareness Campaign
Based
on the above critique, the NBAC could improve its impact by changing the content,
target audiences, and method of delivery of its messages. Of the many
improvements it might pursue, there are three in particular on which I would
like to focus. While I do not expect any of these suggestions to fix the
campaign or universally increase breastfeeding rates in this country, I do hope
that they will offer alternatives for targeting some of the root causes of the
breastfeeding problem. First, NBAC should further investigate the individual
beliefs and attitudes that hinder women’s breastfeeding success and address
some of these sentiments in their ads. These individual beliefs should be
addressed not only in the context of the obstacles women “in general”
encounter, but also in terms of the obstacles that specific socioeconomic and
racial groups encounter. Second, NBAC should contextualize its ads in
contemporary society and address some of the social barriers that women face.
To do this, NBAC must address sexuality, male-female dynamics, public
breastfeeding, and workplace accommodations. Third, NBAC should design its
campaign to focus not only on generating passive awareness, but also encouraging
active participation via social networks.
Intervention #1.
Acknowledgement And Incorporation Of The Diversity Of Breastfeeding Experiences
Into The NBAC Campaign
As
detailed above, the NBAC assumes that when given the right information, women
will make the right choice. Armed only with the knowledge that breastfeeding
will decrease the likelihood of ear infections, respiratory illnesses, and
childhood obesity, women are expected to just pick up their babies, put them on
their breasts, and go. This is an unreasonable expectation given the many
physical, emotional, personal, environmental, and economic challenges that
women face. The NBAC can do a better job of addressing these individual beliefs
and attitudes in two ways. First, I think NBAC and women would be well-served
by acknowledging that breastfeeding is hard work for everyone. It is a skill
that needs to be learned, despite the
assumption that it is “natural” and therefore “second-nature.” One Canadian breast-feeding ad(21) treats this issue particularly well.
Showing a woman struggling to learn a new language, it says “it takes time…to
learn a new language. Why would breastfeeding be any different?” This ad is
particularly powerful in the way that it normalizes the feelings of uncertainty
and frustration many women experience when first starting to breastfeed their
baby. Whether discouraged by pain, fearful that they are not providing adequate
nutrition, or confused about the lactation process in general, women need to be
encouraged by the fact that they do not struggle alone. The success of this ad
is predicated on The Social Norms Theory(22), which states that correcting
misperceptions will result in an increase in the desired behavior. In this way,
this ad can be used to establish the social expectation that breastfeeding is
challenging for everyone.
This message would be further bolstered by
tailoring the ads to specific populations so that the message is broadened to
say not only “we are all in this together,” but also that “breastfeeding is
hard for people like you and me.” This could be achieved using
African-American, Hispanic, and visibly poor women in these ads, as opposed to
the obviously white, affluent woman sitting in a café in Nova Scotia in the
Canadian ad above.
Intervention #2.
Incorporation Of The Social Context Of Breastfeeding Into The NBAC Campaign
The
NBAC is also undermined by its trying to advocate for breastfeeding in a social
vacuum. Ironically, none of the ads shows a woman actually breastfeeding her
baby, but more importantly for this argument, there are no ads featuring women
breastfeeding in a park, or in a mall, or at a restaurant—all images that could
potentially inspire not only more breastfeeding in public, but also social
acceptance of women who choose to do so. In keeping with the Social Norms
theory again, this breastfeeding flashmob(23) video clip from the show, The New Normal, humorously addresses
this issue. It features a woman at a restaurant who, in the process of
breastfeeding her baby, is challenged by a male employee. He is reproached by a
large group of women who parade around the restaurant with their babies. While
promotion of breastfeeding as a socially normal activity is an imperative for
improving breastfeeding rates in this country, one of the risks of the Social
Norms approach is using sources that are either unreliable or lacking
credibility. Therefore, any use of humor for the purposes of advancing awareness
should be used judiciously.
As discussed above, another social
barrier that many breastfeeding women encounter are negative reactions from
men.(17) As such, media campaigns that target men
and their relationships with breastfeeding women are an important step in advancing
breastfeeding as a social norm. Despite listing it as one of its goals, the
NBAC does not make a deliberate effort to deliver its message to men aside from
using male vocalists in its songs. However, if men don’t support breastfeeding
women, societal change will continue to be slow. One campaign, Project Breastfeeding(24) is trying to address this issue
directly. The project has created a photographic series of men, many of them
shirtless, holding babies and children in the breastfeeding position and the
underlying message, “I would if I could.” The project slogan states: “Destigmatize
public breastfeeding. Educating Men. Empowering Women. Our goal and mission
statement is simple, we need to normalize breastfeeding once again.” In this
way, this project is targeting men and encouraging their participation in
support of breastfeeding woman. While in many ways, this campaign is a
beautiful application of the Social Norms theory, some men may react poorly to
such an alternative message, particularly as it blurs the line between typical
gender roles and responsibilities.
Intervention #3. Using
Social Networks to Increasing NBAC’s Impact
Finally,
in addition to modifying the content of its ads, the NBAC could be strengthened
through application of the Social Network theory to its intervention. Research
such as that performed by Drs. Nicholas Kristakis and James Fowler at Harvard
Medical School supports that groups of interconnected people can have either
positive or negative effects on individual health.(25) The impact of these networks on
breastfeeding women has also been demonstrated in research citing “new moms
groups” and the effect of family members, friends, co-workers, and partners as
important factors for whether a new mother succeeds with breastfeeding.(26,27) With the growing influence of social
networks such as Facebook, more and more people are seeking “community” on the
Internet and new mothers—tired, anxious, and isolated at home—are certainly
among those who do.
The First 6 Weeks
is a breastfeeding
organization in Canada that has recognized this fact. As part of its campaign,
it has assembled a collection of stories about women’s breastfeeding
experiences during the first 6 weeks of their babies’ lives. The stories range
from “Breastfeeding is the most amazing thing that ever happened to me,” to “I
tried and failed.” Not only is this campaign reaching out to women during the
time they are most likely to quit, they have created a collection of stories
that brings women together in this shared experience. In keeping with the
tenets of the Social Network theory, I think that both of these campaigns, NBAC
and First 6 Weeks, would be additionally strengthened by directing women to online
support groups and chat rooms where they could discuss their experiences in
real time.
Conclusion
According
to NBAC, its campaign did not “fail.” Awareness about breastfeeding and its
health benefits definitely increased (28); however, there are no data to show
either that more women are actually breastfeeding or that these breastfeeding
efforts will be sustained. In order for these changes to happen, a different
approach needs to be taken. Yes, women are the only people who have the physical
means to breastfeed, but they can’t do it alone. Until society embraces
breastfeeding not only as a public health imperative, but also as a social
norm, there will always be opportunities for improvement.
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