Challenging Dogma - Fall 2007

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

Tuesday, December 11, 2007

The National Breastfeeding Awareness Campaign: How it Fails Both Mother and Baby – Erin Whitney Evans

According to the American Academy of Pediatrics (AAP), breastfeeding is the preferred method of infant feeding due to its numerous health benefits, which include reduced incidence of infectious disease, diarrhea, type I and type II diabetes mellitus, asthma, overweight, and obesity (1). Accordingly, the AAP recommends that women exclusively breastfeed their infants for the first six months of life (1). While early postpartum breastfeeding rates in the United States have risen in recent years, research shows that by five to six months of age, breastfeeding rates significantly decline for infants of all races (2). To address this disparity, goal 16-9 in Healthy People 2010 aims to increase the proportion of mothers who breastfeed in the early postpartum period to 75% and those who continue to breastfeed until six months postpartum to 50% (2). In effort to reach this goal, in 2003, the United States Department of Health and Human Service’s Office on Women’s Health (OWH) was awarded funds to design and implement a public health campaign to increase the proportion of mothers who breastfeed for six months postpartum and to encourage first time mothers to commit to breastfeeding (3).

The campaign, whose primary component is a media outreach program, launched two television ads and four print ads in June 2004, which promote the benefits of exclusively breastfeeding for six months postpartum. The television ads use images of pregnant mothers performing a log roll and a pregnant mother riding a mechanical bull and the tagline “You wouldn’t take risks before your baby was born. Why start after? Babies were born to be breastfed” to promote breastfeeding (3). These television ads suggest that by not breastfeeding, mothers put their baby’s health at risk. The print ads also include the tagline “Babies were born to be breastfed”; however, they publicize the health benefits of breastfeeding, specifically decreased risk for respiratory infections, ear infections, overweight and obesity (3). Despite its good intentions, the National Breastfeeding Awareness Campaign will be ineffective because it’s ad campaign is based on the flawed health belief model, it fails to increase the breastfeeding self-efficacy of mothers and it does not attempt to increase the social acceptance of breastfeeding.

The Flawed Health Belief Model: Intention to breastfeed is not the only mitigating factor

As aforementioned, the National Breastfeeding Awareness Campaign exclusively relies on its television and print ads to educate mothers on the benefits of breastfeeding and the risks of not breastfeeding. It’s design is therefore consistent with the health belief model, in that it assumes that educating first time mothers on the risks of not breastfeeding through the television ads and the benefits of breastfeeding through the print ads, mothers will change their intention to breastfeed; and, therefore, the rates of mothers who breastfeed their babies will increase. The campaign’s reliance on the health belief model will cause it to fail, because this approach assumes that the intention to breastfeed is the only factor that influences whether or not a woman breastfeeds her baby. This rationale neglects to address other mitigating factors that affect a woman’s decision to breastfeed such as familial support and returning to work.

The health belief model states that an individual’s behavior is dictated by their intention, and that intention is determined by four factors: perceived susceptibility, perceived severity, perceived benefits of an action, and perceived barriers to taking that action (4). In other words, the health belief model states that if the benefits of carrying out a behavior outweigh the barriers to taking action, an individual will intend to perform a behavior and therefore do so (4). The health belief model is flawed, however, because it fails to address environmental and social factors that affect behaviors (5). The failure of the health belief model to accurately predict behavior is supported by the findings of a recent study, which showed that “successfully changing intention only engenders a small change in behavior” (6, p. 260). Accordingly, by simply increasing a mother’s knowledge of the benefits of breastfeeding and the risks of not breastfeeding, and failing to address other factors that affect her decision to breastfeed, it is unlikely that this campaign will lead to significant increases in breastfeeding rates.

One of the social factors that this campaign fails to address is the role familial support plays in a mother’s decision to breastfeed. Research shows that familial support greatly impacts whether a mother breastfeeds as well as the duration for which she does so (7-9). According to a recent study examining the predictors of breastfeeding in low-income women, Arlotti et al. found that women who participated in a peer counselor group and received social support for breastfeeding had much higher rates of exclusive breastfeeding than those without a peer counselor (7). Similarly, Giugliani et al. concluded that women whose partners favored breastfeeding were 32 times more likely to breastfeed, as compared to women whose partners either preferred formula or were ambivalent about feeding methods (8). Further, Kaufman and colleagues found that women with no sources of social support were six times more likely to cease lactation than women with social support (9). These studies suggest that the National Breastfeeding Awareness Campaign should have addressed increasing familial and social support of breastfeeding in order to increase breastfeeding rates.

If and when a mother returns to work is also an important mitigating factor in whether she chooses to breastfeed her baby and for how long (10-14). This is an especially relevant issue in today’s society as 71% of mothers were part of the American workforce in 2006 (10). Currently, American mothers are legally given only 12 weeks of unpaid maternity leave (11). Therefore, it is argued that significant policy and structural barriers to breastfeeding exist in the workplace such that mothers who want to breastfeed and return to work have almost no sources of support (12). This argument is supported by a study done by Scott et al, which found that breastfeeding duration is negatively associated with an early return to work (13). Further, in a study of low-income Mexican mothers, Scrimshaw and colleagues found that the intention to be employed postpartum was associated with not initiating breastfeeding (14). In a similar low-income population, Arlotti et al found that mothers who intended to return to work, attend school, or both postpartum, breastfed their babies for six to nine weeks less than participants who intended to stay home (7). This research suggests that mothers who return to work postpartum either discontinue breastfeeding early or do not even attempt to initiate it because they face or anticipate facing considerable challenges to breastfeeding in the workplace. Accordingly, the National Breastfeeding Awareness Campaign will fail because in its reliance on the health belief model, it simply teaches mothers the benefits of breastfeeding and the risks of not breastfeeding without attempting to increase familial or social support or improve workplace policies and barriers to breastfeeding.

Failure to address the concept of self-efficacy

Mothers face many challenges when breastfeeding their infants such poor milk supply, pain, time commitment, and return to work. Research has shown that a significant predictor of breastfeeding duration, or how effectively a mother faces these challenges, depends on her confidence in her ability to breastfeed (15). Despite these findings, in its current form, the National Breastfeeding Awareness Campaign does not provide mothers with the tools needed to increase self-efficacy and or to assist them in overcoming the challenges they face while breastfeeding. Therefore, the National Breastfeeding Awareness Campaign will not effectively increase breastfeeding rates.

Self-efficacy is defined as an individual’s beliefs regarding their capability to perform a behavior and often determines how people think, self motivate, and behave (16). Several individual health behavior theories include the concept of self-efficacy such the social cognitive theory, which suggests that if a person does not believe they can perform a behavior successfully, they will not attempt it (16). Based on this rationale, if a mother has low confidence in her ability to breastfeed for six months, she may not attempt breastfeeding. Accordingly, for the National Breastfeeding Awareness Campaign to succeed, it should have addressed the challenges mothers may face and provided them with the support to face and successfully overcome these challenges.

Several recent research studies have shown how vital self-efficacy is to successful breastfeeding. Mitra et al. identified the barriers to breastfeeding in a cohort of 694 low-income pregnant women in Mississippi. They concluded that low self-efficacy negatively impacts breastfeeding rates (17). Similarly, Blyth et al. found that mothers with high breastfeeding self-efficacy were significantly more likely to be exclusively breastfeeding at four months postpartum as compared to mothers with low breastfeeding self-efficacy (18). Lastly, Scott et al. argue that mothers need to be provided with anticipatory guidance on how to prevent or manage common breastfeeding difficulties in order to increase duration of breastfeeding (13). Considering these studies, as well as the central role of self-efficacy in behavioral theories, the National Breastfeeding Awareness Campaign will be ineffective as it does not attempt to increase mother’s breastfeeding self-efficacy.

Failure to increase the social acceptance of breastfeeding

Thirty-nine of the 50 states in the U.S. have laws that specifically allow women to breastfeed in any public or private location (19). Accordingly, if laws are in place to protect a woman’s right to breastfeed in public, one would think that breastfeeding is socially acceptable and publicly supported in the U.S. However, in their policy statement, the American Academy of Pediatrics (AAP) suggests that exclusive breastfeeding rates are low in the U.S., in part, because mothers are turned off from breastfeeding due to lack of broad societal support, media portrayal of bottle-feeding as normative, and lack of encouragement from health care professionals (1). These findings suggest that breastfeeding is not a social norm in the United States. According to the framing theory, the best way to change an individual’s behavior is to change social norms, or customary codes of behavior in a group or culture that guide how to behave or not to behave (4). Using the rationale of the framing theory, it follows that more mothers would breastfeed if breastfeeding became the social norm. Although, as aforementioned, both the print and television ads of the National Breastfeeding Awareness Campaign solely focus on disseminating the benefits of breastfeeding and the risks of not breastfeeding. As a result, the National Breastfeeding Awareness Campaign will fail because it does not attempt to increase societal acceptance of breastfeeding and make it a social norm.

Several recent studies show that American adults do not view breastfeeding as a social norm or customary behavior. In one study of 2,369 American adults, Li and colleagues found that 27% of their cohort considered breastfeeding in public embarrassing (20). Similarly, the 2004 Health Styles survey, done by the Centers for Disease Control and Prevention (CDC), revealed that 37% of adult respondents agree with the statement that “mothers who breastfeed should do so in private places only” (21). Further, McIntyre et al. interviewed 66 restaurant and 29 shopping center managers and found that two-thirds of the restaurant managers and half of shopping center managers either discourage breastfeeding anywhere in their facility or suggest mothers move to a more secluded area if they want to breastfeed (22). The CDC’s Guide to Breastfeeding Interventions echoes these findings and cites anecdotal evidence that women throughout the U.S. are commonly asked to leave public locations when breastfeeding (23). These findings suggest that breastfeeding, while supported by legislation, is not considered a social norm in the U.S. nor supported by the American public. Therefore, these findings highlight the need for a campaign that addresses the social acceptance of breastfeeding.

Perhaps the most telling evidence that social acceptability of breastfeeding needs to be addressed is the finding that public perception of breastfeeding negatively impacts a mother’s decision to breastfeed. As aforementioned, the AAP reports lack of societal support or acceptance of breastfeeding negatively affects breastfeeding initiation rates in the U.S. (1). Further, according to a recent study by Guttman et al., low-income women’s perceptions of social disproval of breastfeeding in public and reports of ridicule from friends discouraged them from breastfeeding (24). Consequently, because the National Breastfeeding Awareness Campaign does nothing to increase the acceptability of public breastfeeding, public perception will continue to negatively influence women’s decision to breastfeed; and therefore, this campaign will fail to increase breastfeeding rates.

How to design a successful breastfeeding awareness campaign

The evidence that breastfeeding is the best route of infant feeding is unequivocal; however, in order to increase breastfeeding rates in the United States, a campaign that addresses more than just the medical benefits of breastfeeding is needed. A successful campaign must address the challenges that mothers face when breastfeeding and provide them with the tools to face and overcome these challenges. First, using a rational-empirical approach, a campaign should include an educational component that focuses on educating mothers of all races and levels of income on the benefits of breastfeeding for both mother and baby as well as how to face the challenges of breastfeeding. Second, a campaign should take a normative-re-educative approach to persuade the public that breastfeeding is the best form of infant feeding and should be supported. Lastly, using a power-coercive approach, a campaign should be directed at increasing the length of maternity leave. A campaign that used this combination of approaches would be in the position to increase women’s breastfeeding self-efficacy by increasing their social support, make breastfeeding the social norm, and lengthen maternity leave, and would therefore likely increase breastfeeding rates in the United States.

Conclusions

In response to the Healthy People 2010 goals, the National Breastfeeding Awareness Campaign was designed to increase the proportion of mothers who breastfeed their babies in the United States by the year 2010. However, the campaign will be ineffective because its media campaign is based on the flawed health belief model. The campaign assumes that educating women on the benefits of breastfeeding and risks of not breastfeeding will lead to increased rates of breastfeeding; yet, it fails address the other mitigating factors, such as familial support and return to work, that impact a mother’s decision to breastfeed and the duration for which she does so. Additionally, the campaign will fail because it does not attempt to increase mother’s breastfeeding self-efficacy, which has been shown to greatly impact breastfeeding initiation and duration. Lastly, the National Breastfeeding Awareness Campaign will fail because it does not attempt to increase public acceptance of breastfeeding. Breastfeeding is undoubtedly the best method of infant feeding; and, therefore, a revised campaign that addresses each of these components is needed in order to increase initiation and duration of breastfeeding in the United States.

REFERENCES

1. American Academy of Pediatrics Work Group on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 205;115:496-506.

2. US Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington, DC: US Government Printing Office, November, 2000.

3. US Department of Health and Human Services. Office on Women’s Health. “National Breastfeeding Awareness Campaign: Babies were born to be breastfed.” Washington, DC. Accessed on October 24, 2007 from www.4women.gov/breastfeeding/index.cfm?page=campaign

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19. National Conference of State Legislatures. 50 State Summary of Breastfeeding Laws. Accessed on November 28, 2007 from www.ncsl.org/programs/health/breast50.htm

20. Li R, Fridinger F, Grummer-Strawn L. Public perceptions on breastfeeding constraints. Journal of Human Lactation. 2002;18:227-235.

21. Centers for Disease Control and Prevention. Health Styles Survey - Breastfeeding Practices: 2004. Atlanta, GA: U.S. Department of Health and Human Services, Center for Disease Control and Prevention, 2004. Accessed on November 28, 2007 from www.cdc.gov/breastfeeding/data/healthstyles_survey/survey_2004.htm#2004

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24. Guttman N, Zimmerman DR. Low-income mothers’ view on breastfeeding. Soc Sci Med. 2000; 50:1457-73.

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