Challenging Dogma - Fall 2007

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

Tuesday, December 11, 2007

“The Fear Factor”, How The Breastfeeding Advocacy Campaign Failed Through Manipulation – Regina Njoroge

In June 2004, the U.S. Department of Health and Human services Office on Women’s Health and the Ad Council launched a national campaign encouraging first time mothers to breastfeed exclusively for six months. The campaign’s tagline was “Babies were born to be breastfed.” The overall goal of the campaign was to increase the proportion of mothers who breastfeed their babies exclusively in the early postpartum period to 75% and those within 6 months postpartum to 50% by the year 2010 (1-2). Exclusive breastfeeding according to the World Health Organizations (WHO) definition is feeding an infant only breast milk without any additional food or drink (3). Besides trying to raise breastfeeding initiation rates, the campaign stressed the negative effects of not breastfeeding such as lower respiratory tract infections, middle ear infections, eczema, childhood obesity and Type 2 diabetes among others.

The main theme of DHHS campaign was to focus on the consequences of not breastfeeding rather than on the benefits. This was based on the assumption that, once the mothers know the risk they are taking by not breastfeeding, they will automatically take action and chose to breastfeed. However, results from the National Immunization Survey (NIS) show that the strategy has failed. An August 2007, MMWR report shows that while more women are choosing to initiate breastfeeding, the percentage of those who continue to breastfeed exclusively for three months is very low. Rates for exclusive breastfeeding through ages 3 months and 6 months among infants born in 2004 were 30.5% and 11.3%, respectively, below target (4). Based on this data one can conclude that The DHHS “babies were born to be breastfed” campaign is a flawed public health intervention.

The campaign fails to address the social perception of the act of breastfeeding in the general public
The campaign assumes that knowledge of the risk factors associated with not breastfeeding will lead to behavior change. It fails to acknowledge the subjective norm principle of the Theory of Planned Behavior (TPB). The subjective norm is the belief that others expect one to perform or not to perform a behavior, and the motivation to comply with these expectations. According to the TPB, if people evaluated a suggested behavior as positive (attitude), and if they think their significant others wanted them to perform the behavior (subjective norm), this results in a higher intention (motivation) and they are more likely to perform the behavior (5).

The “Babies were born to breastfeed” campaign fails to recognize that there are many prevailing social and cultural norms that contribute to a woman’s choice on whether to breastfeed or not. Research has shown that infant feeding decisions are most often made prior to pregnancy or during the first trimester. The decision is based more on the socio-cultural environment that the woman is in other than on individual choice or preference (6-7). Similarly, a woman’s social network can significantly contribute to either making breastfeeding successful or difficult. Studies on women who initiate breastfeeding at birth have shown that encouragement from parents and relatives is significantly associated with breastfeeding patterns of mothers (8-9). The campaign addresses the issue of breastfeeding as an individual decision that a mother has to make and fails to consider the social network that surrounds the pregnant woman, such as husbands, parents, grandparents, friends and employers among others.

The campaign does not try to improve the social acceptability of breastfeeding in public. The sexual perception of breastfeeding in the United States also plays a prominent roll in a woman’s decision to breastfeed. While the act of breastfeeding was once a natural biological act, in today’s society particularly in the US, the social and sexual significance of the female breast rivals, if not exceeds, its biological significance (10. In North America and in many other westernized countries woman's breasts are a taboo; they are supposed to be hidden. Exposing a woman's breasts in public is considered shameful and inappropriate ("indecent exposure") even while breastfeeding (11-12). As a result women have been thrown out of restaurants, airplanes and business premises and accused of indecent exposure because they were nursing their babies. Such incidences indicates that some people still perceive breastfeeding as an indecent, disgusting, animalistic, sexual, and possibly even perverse act (10). Such incidences have a very strong impact on a woman’s decision to breastfeed, because they send the message that women who chose to breastfeed in public risk facing discrimination or evoking negative emotional reactions. As a result, even women who breastfeed may have difficulties doing it exclusively because of other people's attitudes towards them.

Another issue that the DHHS campaign fails to address is the social obstacles that women face when they go back to work. In the united State, women are entitled to only 3 months of unpaid maternity leave. Studies show that one third of women return to work within three months, while two-thirds return within six months of having a baby. Many of these women are forced to return to work because they are unable to go without the additional income (13). The decision to work while breastfeeding is a complex one, according to Dr. Frances Biagioli of Oregon Health and Science University, new mothers must negotiate the emotional distress of leaving a baby behind, social aspects such as a fear of leaking, lack of an appropriate space to pump (other than a bathroom stall), finding time for breaks and fatigue (14). Consequently, breastfeeding is discontinued. The campaign approach was unfair to women who choose to or have to go back to work by suggesting that they are putting their child in danger by not breastfeeding when it's so difficult to breastfeed exclusively and work. There should have been more focus on working with employers to provide more work place support to breastfeeding mothers such as, paid maternity leaves, lactation rooms and flexible schedules.

The Media Ads were contradictory to the campaign slogan
The television ads failed to address why breastfeeding is important and what its benefits are for the baby and the mother. One television ad has a scene at a ladies nightspot, with music playing in the background and a crowd cheering as a pregnant woman rides on a mechanical bull. As she is thrown off the bull, a message appears on the screen “you wouldn’t take the risk before your baby is born, why start after?” A second advertisement shows two women competing in a log rolling game. As one of the women plunges into the water, again the message appears on the screen “you wouldn’t take the risk before your baby is born, why start after?” Both ads conclude with a voice- over quickly stating, “Recent studies show babies who are breastfed are less likely to develop ear infections respiratory illnesses and diarrhea; Babies were born to be breastfed” (15). According to the Ad council, these new Public Service Announcements (PSAs) should speak to parents clearly about the consequences of not breastfeeding, which may help encourage more mothers to initiate and continue to breastfeed exclusively for six months. This effort fails to effectively apply the power of persuasion in changing behavior. According to researcher Ruth Faden of John Hopkins University “persuasion succeeds by improving and not by undermining a person’s understanding of her situation”. Faden notes that public health uses communication of information to mold behavior for the purpose of promoting social and individual welfare. She proposes that information must be packaged to enhance rather than cripple understanding (16). The DHHS TV ads serve to mislead women about the true risk of not breastfeeding by setting up inappropriate comparisons. The suggestion that mechanical bull riding while pregnant is comparable to not breastfeeding your child during the first six months is misleading. The idea of a pregnant woman going out on a ladies night and riding a mechanical bull portrays an irresponsible woman who would take risk to harm her child in order to pursue her own pleasure. Comparing the danger of riding a mechanical bull to formula feeding grossly misrepresents non-breastfeeding women as equally negligent and irresponsible.

The ads also portray women’s failure to breastfeed not only as an extremely risky choice, but also as a completely voluntary individual choice, similar to log rolling or mechanical bull riding. The message ignores the fact that there are women who may not have a choice to breastfeed, such as women with HIV infection, women on interacting medication, or women who might risk domestic violence. Telling these women that they are harming their child by not breastfeeding feeding leaves them with feelings of failure, shame, self-blame.

The fear appeal message failed to promote self-efficacy in pregnant women and new mothers
Based on The Social Cognitive Theory, a person’s decision to engage in a particular behavior is highly influenced by his or her self-efficacy; the belief in one's capabilities to organize and execute the courses of action required to produce given attainments, or the extent to which a person believes they can master or be successful in performing a task (17). Generally, people with a high level of self-efficacy are more likely to expend more effort, and persist longer in a task than those with low efficacy (18). Even though the DHHS acknowledges that women already know the benefit of breastfeeding, it fails to acknowledge that most women perceive breastfeeding as a difficult task. Hence, they lack the confidence that they can actually do it successfully. Knowing that breastfeeding a baby reduces the risk for several diseases might motivate one to initiate breastfeeding. However, for women to maintain breastfeeding practices, they need to feel that they can actually be successful in doing it. Studies have shown that lack of confidence is associated with a shortened duration of breastfeeding (8). The campaign could have focused more on how to breastfeed successfully rather than focusing exclusively on the harms of not breastfeeding.

Additionally, focusing on the harms of not breastfeeding could serve as a turn-off to low-income and minority women, who are the very group that the campaign was trying to target. According to the MMWR report, low breastfeeding rates persist among mothers who are low income, black, young or with low education (19). It is important to note that this group has in many cases been labeled for making bad health choices such as smoking while pregnant, use of illicit drugs, and poor diet. Hence, a fear appeal message could actually do more harm than good by decreasing their sense of self-efficacy to breastfeed. The fear appeal theory postulates that utilizing a message that instills a sense of fear and dread in the audience has the exact opposite effect that it intends. That is, it completely turns the recipient off, not only to hearing the message, but also to heading the content or advice contained within that message (20). Targeting this group of women calls for a more positive message, that would improve and not undermine self-efficacy.

The DHHS breastfeeding promotion campaign should start by acknowledging that most women are aware of the benefits of breastfeeding. However, the decision to breastfeed has many intertwined layers of emotional, social, economic factors that need to be addressed. The campaign should adjust the content of the promotional materials to take into consideration social issues such as support from family and friends, the acceptability of breastfeeding in public places and employer support. Additionally, the content, manner, and tone in which the promotional messages are conveyed should be positive and seek to empower pregnant women and new mothers. If these issues are not addressed with a positive tone, the DHHS campaign is unlikely to substantially increase breastfeeding rates. The current approach is more likely to instill fear and guilt other than change behavior.


1. US Department of Health and Human Services: HHS blueprint for action on breastfeeding. Office on Women's Health, 2000.
2. US Department of Health and Human Services. Healthy People 2010 midcourse review. Washington, DC: 2005. Available at
3. World Health Organization. Promoting proper feeding for infants and young children. Geneva. 2004. Available at
4. Centers for Disease Control and Prevention. Breastfeeding Trends and Updated National Health Objectives for Exclusive Breastfeeding: United States, Birth Years 2000—2004. Atlanta, GA: Mortality and Morbidity Weekly Report, 2007.
5. Ajzen, I. From intentions to actions: A theory of planned behavior (pp. 11-39). In Kuhl, J.& Beckman, J. n ed. Action-control: From cognition to behavior. New York: Springer-Verlag, 1985.
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11. Dettwyler, K. "Beauty and the Breast: The Cultural Context of Breastfeeding in the United States." Sexuality and Breastfeeding. Journal of Human Lactation 1995; 11: 263
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13. Ryan, A. et al. The Effect of Employment Status on Breastfeeding in the United States. Women’s Health Issues 2006. 16: 243-251.
14. Bhatia, J. Breastfeeding Push Turns to Workplace Obstacles. Women’s eNews, New York: 07/13/2006.
15. US Department of Health and Human Services: National Breastfeeding awareness Campaign-Babies were born to be breastfed. Washington, DC: Office on Women's Health, 2000. Available at
16. Faden, Ruth R. Ethical issues in government-sponsored public health campaigns. Health Education Quarterly 1987: 14: 27–37.
17. Wikipedia. Self-efficacy. Wikipedia Foundation Inc.
18. Schunk, D.H. Goal setting and self-efficacy during self-regulated learning. Educational Psychologist 1990. 25: 71-86
19. Centers for Disease Control and Prevention. Racial and socioeconomic disparities in breastfeeding in the U.S. Atlanta GA: MMWR 2006.
20. Ruiter A.C. The Role of Coping Appraisal in Reactions to Fear Appeals: Do We Need Threat Information? Journal Health Psychology 2003; 8: 465-474

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