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)
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)
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)
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.
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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