Challenging Dogma - Fall 2007

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

Wednesday, December 12, 2007

Got Fear?: The Failures of The Health and Human Services Campaign to Overcome the Barriers to Breastfeeding – Elmy Trevejo

The benefits of breastfeeding have been well documented for years. It is believed that breastfeeding saves 5-6 million children’s lives annually. According to the Lancet Child Survival Series, it is estimated that 1.3 million additional lives could be saved annually if women were enabled to achieve six months exclusive breastfeeding with continued breastfeeding thereafter (6). Infants that are not breastfed have decreased survival rates due to physical conditions such as NEC (necrotizing enterocolitis), diarrhea, respiratory illnesses, sepsis, and pneumonia. Bottle fed infants are more likely to suffer from otitis media, atopic dermatitis, gastroenteritis, and asthma (5,6,11). Other studies have found that infants that are bottle-fed may be more susceptible to increased cardiac risk factors such as obesity, diabetes and childhood leukemia (6). The benefits to the mother are quite substantial as well, and include decreased risk of breast cancer, ovarian cancer, and type two diabetes mellitus. There is also an association between breastfeeding and decreased cases of post partum depression (6, 12).
“ ...[Breastfeeding] represents the normal and expected way to feed infants and young children, yet continues to suffer from cultural and commercial barriers that make it difficult for mothers to adhere to the medical recommendations to breastfeed exclusively for six months, and to continue breastfeeding with appropriate complementary foods for one year and beyond (15, p. 552).”

Breastfeeding rates in the United States are considerably lower than in other parts of the world. The American Academy of Pediatrics recommends that women breastfeed for >12 months, and thereafter for as long as mutually desired (13). The latest data compiled by the Center for Disease control states that in 2004, the rates for breastfeeding early postpartum, at six months, and at twelve months was 73.8, 41.5, and 20.9, respectively. US Healthy People 2010 target is to increase the proportion that breastfeed their babies at birth to 75% and for six months to 50% (12). As a public health initiative the Department for Health and Human Services developed a marketing campaign to address this growing public health crisis.

The campaign featured two television ads, radio spotlights, and print media coverage. The commercials, which aired from June of 2004 to December of 2005, became the center for significant controversy due to the manner in which HHS targeted the audience. The first commercial shows two women, late in their pregnancies, in a logrolling competition. A message is briefly displayed on the screen that states, “You wouldn’t take risks with your baby before their born. Why start after?” The logrolling women are then back on the screen, and a voiceover states that studies show that babies that are breastfed for six months are less likely to develop ear infections, respiratory illnesses, and diarrhea. The end of the commercial shows the final message, “Babies were born to be breastfed.” The second commercial that HHS created depicted a woman in her third trimester being helped on top of a mechanical bull, and riding it until she falls off. The same message is displayed, “You wouldn’t take risks with your baby before their born. Why start after?” The same voice over is heard that quickly states some of the benefits of breastfeeding. In this paper, I am going to discuss the reasons that the HHS campaign for breastfeeding failed to be an effective public health initiative. The Health and Human Services campaign failed to be an effective public health initiative because it 1) uses a scare tactic/bullying approach, 2) fails to address the barriers that new mothers face that may hinder their compliance, and finally 3) the campaign fails to address the growing duality that exists between women and their bodies in American culture.

The Health and Human Services campaign uses a scare tactic approach towards breastfeeding
This tactic is discussed in the Protection Motivation Theory developed by Rogers in 1983. Protection motivation theory was first developed within the framework of fear-arousing communication. As stated by Boer and Seydel, protection motivation is the result of the threat appraisal and the coping appraisal. The appraisal of the health threat and the appraisal of the coping responses result in the intention to perform adaptive responses (protection motivation) or may lead to maladaptive responses. Protection motivation is a mediating variable whose function is to arouse, sustain and direct protective health behavior. It facilitates the adoption of adaptive behaviors and can best be measured by behavioral intentions (2). The HHS campaign uses this tactic in order to “frighten” their audience. The assumption is made that if knowing that one is causing harm to their child, mothers will be more apt to adopting breastfeeding practices. This is the major flaw in the campaign. The campaign uses callous blaming in order to get the audience’s attention. The message that is portrayed is that women who choose not to breastfeed are essentially harming their children, and goes as far as to compare it to dangerous activities such as mechanical bull riding, and logrolling. Although the message is supposed to be humorous, the underlying message is riddled with blame and has a tone of judgment that is not effective.

The campaign, in essence, labels women that bottle-feed as “bad mothers” or mothers that do not care about the well being of their children. The strategy used was designed to notify the public that on all counts breastfeeding is better for infants. The problem is that the campaign assumes that people are unaware of this. Studies have shown that when asked, non breastfeeding mothers state that they are aware that breastfeeding is superior to bottle-feeding, but the barriers that they faced to breastfeed outweighed the potential benefits. As stated by the HHS in June of 2004, “Research has shown that many women know that breastfeeding is the best nutrition for babies. This knowledge has not translated into changed behaviors, and breastfeeding rates have hit a plateau.” Pregnancy and birth are highly stressful and anxiety provoking events for most women, and instead of trying to empower and encourage women to embrace breastfeeding for the numerous benefits that it has, the HHS campaign bullies women into feeling like “incompetent mothers,” if they choose not to breastfeed.

The Campaign fails to address professional and social barriers
Another issue that I have with the HHS campaign is that it fails to address any of the barriers that women face when making the decision to breastfeed or bottlefeed. One of the biggest barriers that women face is related to lack of support in the workplace, and shortened maternity leave. One third of mothers return to work within three months of having a baby, and two thirds return within six months from birth (14). As stated by C. Barona-Vilar, “Among employed women, structural support linked to working conditions has a decisive role on breast-feeding election and duration. Duration of breastfeeding tends to be longer when maternity leave is longer, especially among women with higher professional qualifications and permanent contracts. Among women with lower professional qualifications, and women whose high level of precarious work and low income converges, breast-feeding duration is substantially reduced (1)” The United States guarantees three months of unpaid maternity leave. When compared to other countries, this is appalling. In Norway, more than 97% of women breast-feed their infants during the immediate postpartum period, 80% continue at 3 months, 20% breast-feed beyond 12 months. Women can take maternity leave for 42 weeks with full pay or for 52 weeks with 80% pay. After returning to work, they are entitled to 1-1 ½ hour breaks each day to feed their infant (13). Many women are forced back into the workplace early because they are unable to go without the additional income, adding another layer of complexity to breastfeeding their infants.

Another complaint that new mothers have is regarding the stigmas regarding workplace pumping. As suggested by Caroline Jane Gatrell, “mothers face hostility if they breastfeed infants, or express milk, within workplace spaces. Consequently, shortened breastfeeding duration rates among employed mothers have attributed to organizational discouragement (3). It was originally suggested by Witters-Green that even where employers are aware of the issues, they fail to offer suitable spaces for breastfeeding. This is partly for cost-related reasons but also because employers are ‘discomfitted’ and ‘offended’ by the idea of breastfeeding mothers (14). There are false perceptions regarding breastfeeding in the workplace. Women often choose not to continue breastfeeding after returning to work, because of the way they feel their coworkers will react (8). In this country, breastfeeding has become something that should be hidden and done discretely, in order to keep everyone comfortable, instead of acknowledging it as a natural and biological necessity. Some women even feel that if they were to breast feed or expel milk at work, their professional life would suffer from negative consequences. Without addressing these concerns, the message of the HHS campaign is useless. It is easy for the campaign to blame women for their inability to care for their infants appropriately, but we as a society need to change policy and the workplace environment to assist and encourage women to feel that breastfeeding is socially acceptable.

The Campaign fails to acknowledge the dichotomy between breastfeeding and sexuality
It is well known that in Western cultures, breasts have become increasingly oversexualized. The social norm has changed the focus of the breast from its biological function to a sexual male fetish. As stated by Iris Young in her essay, Breasted Experience, “To be understood as sexual, the feeding function of the breasts must be suppressed, and when the breasts are nursing they are desexualized. A great many women in this culture that fetishizes breasts are reluctant to breastfeed because they perceive that they will lose their sexuality. They believe that nursing will alter their breasts and make them ugly and undesirable (17, p. 199).” This process may contribute to the reason women choose not to breastfeed. If women are afraid that by breastfeeding they are in essence “desexualizing” themselves, they are less likely to adopt the behavior. They are more likely to view the behavior in a negative way. The dichotomy that prevails creates a disassociation for most women. Although they want to do their best by providing nutrients for their infant, it puts their own sexual identity at risk.

According to Dettwyler, a well-known breastfeeding advocate, she states that the sexualization of women’s breasts underlies the taboo against breastfeeding in public. “It is ironic that breastfeeding an infant in public is still widely frowned upon, denying the natural function of the breasts at the same time as objectifying them for the sexual gratification of men” (3, p. 204). Women are concerned that they will no longer be considered attractive to their male partners. A survey conducted by Ward in December 2006, found that men were more likely to endorse traditional gender ideologies that portray men as sexually driven, and women as objects of sexual desire. It was difficult for men to accept the duality of female sexuality, and the biological need to provide nutrition for their infants. “These findings support the notion that traditional masculine ideation focuses on the sexual aspect of women’s breasts and bodies, thereby making it more difficult for men to embrace the reproductive functions (16).”

The failure of the HHS campaign is that it does not acknowledge that this duality exists. As long as women’s bodies are objectified to the degree seen now, it will be extremely difficult to change breastfeeding compliance rates without addressing the root issue. In our society, we do not object to media shots of women in skimpy outfits that accentuate their breasts, but we become very uncomfortable with the image of a woman nursing. Western culture continues to see the breast as an object for sexual gratification, and has made any other views of the breast perverse. The Health and Human Services campaign fails to broach the social stigma that our culture has towards a “desexualized” breast. It fails to acknowledge the dichotomy, and therefore cannot be effective in persuading mothers to breastfeed.

In conclusion, the Department of Health and Human Services breastfeeding campaign fails to be effective due to its judgmental and “bullying” strategy. To combat this public health issue, we cannot alienate and label women as inadequate mothers without addressing the social and professional reasons that contribute to the decision making process. The fire and brimstone campaign approach to breastfeeding is insulting and fails to encourage women to adopt the behavior. Instead of focusing on changing policy and also trying to address the manner in which women now objectify themselves, the health and human services campaign puts the blame and focus on the individual mother. It is obvious that this issue is multi-layered, and must be addressed in that manner, as well.

1. Barona-Vilar, C., et al., A Qualitative Approach to Social Support and Breast-feeding decisions, Midwifery (2007) 1:1-8.
2. Boer, H., Seydel, E. Protection Motivation Theory. (95-120) In M. Connor and P. Norman (Eds.) Predicting Health Behavior. Buckingham: Open University Press, 1996.
3. Dettwyler, K., Biocultural Perspectives. Beauty and the Breast: The Cultural Context of Breastfeeding in the United States (1995) 167-216.
4. Gatrell, Caroline. Secrets and lies: Breastfeeding and professional paid work. Social Science and Medicine (2007) 65:393-404.
5. Jacknowitz, A., Increasing Breastfeeding Rates: Do Changing Demographics Explain Them?. Women’s Health Issues (2007) 17: 84-92.
6. Johnston-Robledo, Ingrid. Indecent Exposure: Self-objectification and Young Women’s Attitudes Toward Breastfeeding. Sex Roles: A Journal of Research (2007) 56: 429-437.
7. Labbok, M. Breastfeeding: A woman’s reproductive right. International Journal of Gynecology and Obstetrics (2006) 94: 277-286.
8. Khoury, A., Moazzem, S., Jarjoura, C., et al. Breast-Feeding Initiation in Low-Income Women: Role of Attitudes, Support, and Perceived Control. Women’s Health Issues (2005) 15: 64-72.
9. Kukla, R., Ethics and Ideology in Breastfeeding Advocacy Campaigns. Hypatia (2006) 21: 157-180.
10. Li, R., Fridinger, F., Grummer-Strawn, L. Public Perceptions on Breastfeeding Constraints. Journal of Human Lactation (2002) 18(3): 227-235.
11. Marshall, J., Godfrey, M., Renfrew, M. Being a ‘good mother’: Managing breastfeeding and merging identities. Social Science & Medicine (2007) 65: 2147-2159.
12. Miracle, D., Fredland, V. Provider Encouragement of Breastfeeding: Efficacy and Ethics. Journal of Midwifery & Women’s Health (2007) 52(6): 545-548.
13. Raju, Tonse. Continued Barriers for Breast-Feeding in Public and the Workplace. The Journal of Pediatrics (2006) 148: 677-679.
14. Ryan, A., Zhou, W., Arensberg, M. The Effect of Employment Status on Breastfeeding in the United States. Women’s Health Issues 2006; 16:243-251.
15. Walker, M., International Breastfeeding Initiatives and their Relevance to the Current State of Breastfeeding in the United States. Journal of Midwifery & Women’s Health (2007) 52: 549-555.
16. Ward, L. Breasts Are for Men: Media, Masculinity Ideologies, and Men’s Beliefs About Women’s Bodies., Sex Roles (2006) 55: 703-714.
17. Young,I. Breasted Experience: The Look and the Feeling (189-209). In: Throwing Like a Girl and Other Essays in Feminist Philosophy and Social Theory. Indianapolis, IN: Indiana University Press (1990).

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  • At December 13, 2007 at 7:43 AM , Anonymous Meg Gavaghan said...

    Elmy -- I thought your evidence regarding the sexualization of breasts in society and its link to reduced breatfeeding was interesting and not one I had thought about before. Great job!


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