The National Breastfeeding Awareness Campaign: A Frame That Ignores Potential Barriers and Alienates Women- Nicole Santomauro

Introduction

The current health recommendation is that all mothers breastfeed their child exclusively for the first 6 months of their baby’s life, and continue to breastfeed for at least the first 1-2 years. Breastfed babies have a decreased risk of death during the first year of life, diabetes, ear infections, obesity, and hospitalization from asthma or pneumonia. Mothers who breastfeed also have a decreased risk of breast cancer, ovarian cancer and type II diabetes (11). The federal government’s Healthy People 2010 and 2020 guidelines both include an objective to increase the proportion of mothers who breastfeed their babies (13).

In 2004, a two-year National Breastfeeding Awareness Campaign (NBAC) became the first multi-media campaign to promote breastfeeding for the recommended 6 months among first-time parents who would not normally breastfeed their baby (7). The overall goal of the campaign was to increase the proportion of mothers who breastfeed in the early postpartum period to 75% and those within 6 months postpartum to 50% by 2010 (13). The campaign consisted of both media outreach and community based demonstration projects. The media aspect of the NBAC will be specifically analyzed in this paper. The media campaign was launched in June 2004 and consisted of television commercials, magazine advertisements, and radio promotions (14).

Critique 1: The NBAC assumes rational behavior

The NBAC follows the Health Belief Model (HBM). This model describes health behavior as motivated by the perceived susceptibility and perceived severity to a poor health outcome balanced with the perceived benefits and perceived barriers to the health behavior in question. This theory states that a person will perform the health behavior of interest if they believe that they are susceptible to the poor health outcome, this outcome will have severe consequences on their life, there is a benefit to performing the health behavior in question and the barriers to performing this action are relatively low. The individual’s behavior is also affected by a cue to action (usually the intervention itself) and the individual’s self efficacy or the belief that they are capable of changing their health behavior (5).

The problem with a public health campaign based on the HBM is that it assumes rational behavior and that perceived susceptibility, severity, benefits and barriers are all equally weighed and used to rationally come to a planned decision about behavior. This is not usually the case and the HBM (and therefore the NBAC) does not take into account spontaneous, unplanned activity that characterizes most human behavior and decision making (18). The NBAC specifically emphasizes the perceived benefits of breastfeeding in order to lead woman to rationally decide to breastfeed. However, barriers and self efficacy may deter behavior and are not appropriately addressed. Research has shown that many women know that breastfeeding is the best nutrition for their babies, but this knowledge doesn’t translate to an increase in breastfeeding rates (22). This proves that women are not behaving rationally and high perceived benefits do not lead to an increase in behavior.

Also notable, the NBAC initially focused on their slogan with the goal to develop one that more adequately portrays that breastfeeding in a benefit (the previous initiative slogan was “Breast is Best”). The final slogan, “Babies Were Born to be Breastfed”, continued to focus on portraying an increased benefit to breastfeeding even though it had already been proven that humans are not rational and a high perceived benefit does not necessarily lead to an increase in behavior. The campaign fails to examine possible reasons for the gap between message and behavior and maintains the assumption that health behaviors are a result of thoughtful analysis and rational conclusions (10). Fundamentally, the campaign assumes that an increase in education will result in an increase in breastfeeding rates, which does not seem to be the case. Just because a public health campaign explains the benefits of an action does not mean the person will necessarily perform said action, and the barriers to action need to be adequately addressed.

Critique 2- The NBAC ignores barriers to breastfeeding

There are many cultural differences in breastfeeding practices. For example, African Americans tend to emphasize the whole family rather than bonding exclusively with the newborn. Bottle feeding will involve the whole family in taking care of the infant and African Americans often believe it is better to return to work quickly in order to support the family, rather than nurse (22). There is also sometimes a historical aversion to breastfeeding since black woman were sometimes forced to wet nurse -breastfeeding a child who is not a woman’s own- white women’s children during slavery in the south (2).

Sexual abuse survivors have a particularly difficult time breastfeeding since breastfeeding can trigger abuse memories and post-traumatic stress episodes (9). Also, women who are uncomfortable with their body, specifically women with eating disorders and other kinds of dysmorphia and obsessive-compulsive disorder, are much less likely to breastfeed (17). Also, almost all women represented breastfeeding are white, in great shape, conventionally pretty, thin, and have normal size and shaped breasts (10). The NBAC doesn’t take any of the cultural, racial, class or ethnic differences into account. This can leave many mothers feeling alienated or inadequate making them less likely to choose to breastfeed.

The societal link of breastfeeding to sexuality is a major barrier for new mothers. Breasts are often associated with sexuality rather than function and breastfeeding is often viewed as something embarrassing, shameful and offensive, especially if in public (16). There have been many examples of breastfeeding making others feel uncomfortable. Women are often told to “go somewhere more private” while breastfeeding, that their actions constitute indecent exposure, or to “cover up” so that children can’t see (12). The NBAC, rather than fighting the stigma that breastfeeding is something inappropriate, actually reinforces this belief. Specifically, a radio promotion entitled “soul song” which was supposed to be targeted specifically at African American women, features a man speaking over 70s style seduction music:

“Oooh—Hello special lady. It's time for a little one-on-one conversation. I’m talking 'bout rrvy baby, baby. Not you baby—our baby, baby, and recent scientific studies on lactation… .Magical lady, gonna get down to business, gonna turn the lights down reeeaaal low…For a slide show on childhood disease resistance. Wonderful woman, if you do breastfeed, our little baby will be at less risk for respiratory illness. Hey, just talkin’ about breastfeedin’ … educate your sweet self at 800–994-WOMAN or get down to http://www.4women.gov, or talk to your health-care provider. Babies were born to be breastfed, exclusively for 6 months, baby” (10).

This radio promotion clearly equates breastfeeding with sexual seduction which reinforces the incorrect perception that makes up a major barrier for many women to breastfeed.

The societal image of a woman breastfeeding is of a very young infant being held in their mother’s arms while she sits in a rocking chair, staring at her child as he eats. This corresponds to the idea that breastfeeding is not something that is done at work, in public, while multitasking, or with an older baby (10). This societal impression dissuades women from breastfeeding even if they otherwise want to. Many women need to return to work early in their baby’s life. In one study, only 10.6% of mothers continued to breastfeed after returning to work, even with the provisions of breast pumping breaks and lactation rooms. This is strikingly low, especially considering that those in lower income jobs may not even have these provisions available (3). Also, breastfeeding can be extremely painful for some women to the point where they simply can not do physically do it. These barriers to breastfeeding are generally ignored by the NBAC producing a campaign that frames the choice to breastfeed in an incorrect and even harmful way.

Critique 3- The NBAC uses poor framing

The NBAC is framed to portray mothers who do not choose to breastfeed as doing so for selfish reasons. Rather than directly discussing the benefits of breastfeeding, there is a strong emphasis on avoiding the harm of not breastfeeding. This negative focus portrays mothers who do not breastfeed as making a bad and selfish choice and that they are knowingly harming their child. This is especially significant because of its effect on women who try to breastfeed and are unable to, resulting in a sense of guilt and inadequacy as a mother (10). Also, most of the women who the NBAC is targeting are low income and minority women. These women regularly experience discrimination and are already more likely to be perceived by society to harm their children through other “bad choices” (10). Internalized racism, “the acceptance by members of the stigmatized races of negative messages about their own abilities and intrinsic worth” (8), may result in women who are more likely not to breastfeed if they have internalized the stigma that they are more likely to make poor maternal choices. The frame of the NBAC stigmatizes these women even more than they already are and reinforces their internalized racism.

The incorrect frame that breastfeeding is a choice made by the mother and unaffected by anything other than the mother’s free will results in the NBAC targeting the mothers alone. This means that fathers, grandparents, employers and the general public are all untargeted and outside of the campaign, but they all contribute to making breastfeeding difficult for new mothers. The NBAC website’s “questions and answers about breastfeeding” page doesn’t at all answer questions that women may have; it instead provides reasons to breastfeed and a list of benefits (10). This suggests that there shouldn’t be any question as to the decision to breastfeed and holds the woman morally responsible if she chooses not to or is unable to breastfeed.

The commercials specifically used exaggeration as a framing technique. Bottle feeding at any point before 6 months is equated to diabetes in one commercial (a nipple is placed over an insulin bottle). In another commercial, not breastfeeding is equated with mechanical bull riding at a bar while very pregnant. This analogy not only portrays the woman as doing something risky, but mechanical bull riding (or log rolling as shown in yet another commercial) is a voluntary activity that is clearly being performed for no purpose and just for fun. The frame portrays choosing not to breastfeed as risky, but also irresponsible and a poor moral choice, similar to drinking alcohol and partying at ladies night while pregnant (10). Comparing voluntary personal choices like these to the reasons that a woman might not breastfeed (as explained above) undermines these real concerns and doesn’t address these important barriers to action. Although these extreme analogies are meant for dramatic effect, they misinform the viewer in terms of the actual risks and benefits and make the campaign laughable while undermining its credibility (22).

Critique Summary

The NBAC presents information using the Health Belief Model (HBM) and is thus subject to all of the issues that go along with the model itself. First, the HBM assumes rational and planned behavior and that health decisions are based on a careful weighing of the benefits and barriers of action compared to the severity and susceptibility of the individual to the poor health outcome. In reality, humans are much more spontaneous than the HBM allows and so education on these four characteristics does not always result in changed behavior. The HBM is also an individual level model and doesn’t consider environmental or societal effects on behavior. The HBM may therefore be more useful for one time decision making, but is probably inadequate in terms of health behaviors that require continuous action, such as breastfeeding for at least 6 months (19).

The NBAC also ignores the many legitimate barriers that women face in trying to breastfeed their baby. Ignoring barriers not only leaves these women with a multitude of unanswered questions, but allows the barriers to be the end of their consideration to act since the campaign does not provide any suggestions or alternatives. It frames breastfeeding as something that is easy and natural (“babies were born to be breastfed”) and so makes it seem (unrightfully so) that complications in what is framed as a simple decision to breastfeed must be the exception and out of the ordinary. Knowledge of modifiable barriers towards breastfeeding can guide the development of interventions to change behavior. Barriers should be the very basis of the intervention and the NBAC makes the mistake of ignoring them completely instead.

Lastly, the emphasis of the NBAC is focused entirely on the risks of not breastfeeding, rather than the benefits of breastfeeding. This negative focus, as well as the lack of acknowledgement to any barriers women may face, frames the issue of breastfeeding as a voluntary choice unaffected by environmental or societal influences. The result of this frame is the misperception that women who do not breastfeed are doing so for selfish, personal reasons (10). Framing women who do not breastfeed in a negative light makes women experiencing even modifiable barriers, as well as minority or marginalized women, even less likely to choose to breastfed not only because their barriers to action are not acknowledged and discussed with appropriate interventions, but also because they may internalize this belief and be overwhelmed with feelings of guilt and inadequacy as a mother.

Proposed Intervention

Intervention 1- Use of Social Norms/Social Network Theory

Social learning theory describes how people observe others behavior within their society and then adopt these behaviors in their own life. This mimicked behavior, coupled with reinforcement that increases the likelihood of the person repeating said behavior, results in behavior change and the person adopting the observed behavior (4). In other words, people are more likely to behave similarly to those around them, specifically to those within their social network. Decisions to take up a behavior are not made by rational, planned individual weighing of pros and cons. Instead, behavior changes are much more likely to reflect choices made by groups of people all at once who form a social network (4). This influence could be used as an intervention to promote breastfeeding.

The primary determinant of behavior is the social norm. This is clearly seen in the analysis of the NBAC since education did nothing to affect the norms of society and so there was no change in breastfeeding rates. In order to change breastfeeding behavior, an intervention must change the social norms in society on a large level (20). The best way to implement this intervention is through public policy. Policy changes will change the social norms, which will result in a change in behavior. A great start is HR2819, the Breastfeeding Promotion Act of 2009. This legislation would protect breastfeeding women from discrimination in the workplace and include pumping in the definition of lactation. It would also give employers a tax credit of up to $10,000 a year if they provide employees with access to qualified breast pumps, lactation consulting services, and dedicated lactation space. Tax breaks will also be created for women who purchase qualified breast pumps or lactation consulting services. Performance standards for breast pumps will be established and the Department of Health and Human Services would produce a breast pump guide for these evaluated pumps (6). However, this bill is still in committee so an appropriate advocacy campaign could be extremely effective in getting the bill passed and beginning the process of changing social norms. Other legislation could improve maternal leave policies allowing more time to breastfeed at home, as well as enforce the laws that already exist in most states allowing and protecting the rights of women to breastfeed in public.

Massachusetts is currently one of only three states without any breastfeeding legislation (11). Passing appropriate legislation that will encourage breastfeeding and eliminate some of the institutional barriers will be an important step in changing the social norm in favor of breastfeeding. Breastfeeding will then rapidly spread through social networks since individuals will do what their friends and family are also doing. Eventually this network spread will result in breastfeeding becoming the social norm.

Intervention 2- Empower women

One of the major critiques of the NBAC was that it framed women who do not breastfeed in a very negative light. According to the Theory of Gender and Power, this negative framing will make the woman even less likely to breastfeed, even if she is presented with a solution to modifiable barriers. This theory can also be applied to consider the particular implications for women in general and an appropriate intervention for any women’s health issue should take the issues presented by this theory into account.

The Theory of Gender and Power discusses the relationship between the sexual division of labor, the sexual division of power, and cathexis or the affective and social exposures. The sexual division of labor portrays women as less likely to work and more likely to stay at home and take care of their families. If a woman needs to work in order to support her family, this sexual division can be interpreted as taking her away from motherhood and breastfeeding. This can result in the woman feeling like a bad mother or that she is not fulfilling her motherly duties. The sexual division of power represents that unequal balance of power and control between the two genders. If a woman feels powerless then they may be unmotivated to breastfeed. Also the power divide between men and women may make the decision to breastfeed highly influenced by the male preference without much say from the mother. Lastly, cathexis or affective and social exposures are gender based exposures and barriers to breastfeeding because of society’s gender roles. This is clearly seen in the issue of breastfeeding promotion since the social norm is that women should not express their sexuality. This belief coupled with the sexualized societal perception of breasts may greatly affect a woman’s decision to breastfeed. Gender norms interact with cultural norms to influence the woman’s decision to act (21).

The Theory of Gender and Power can be applied to a breastfeeding campaign to better understand the risk factors that affect women’s health. Interventions for women will not be effective if they ignore the social environment (21). Women’s lack of power can influence her health behavior choices and interventions should be based around these identified risk factors with the goal of empowering women, rather than work against them as seen in the NBAC.

Intervention 3- Address and work to eliminate barriers

The typical barriers to breastfeeding can be divided into institutional barriers, societal barriers, personal barriers and cultural barriers. Intervention 1 deals with changing the social norms and affecting policy changes which should help to address and eliminate institutional barriers such as a lack of time and space to pump at work. Intervention 2 deals with the societal implications for women and should help to address societal barriers such as the image of a woman breastfeeding being viewed as “inappropriate”. Additional interventions are required to specifically address and help eliminate personal and cultural barriers. When women discover these perceived barriers to breastfeeding, interventions need to be provided that can help eliminate the barriers and increase self-efficacy.

Self- efficacy is the belief that one has the capability to undertake the actions needed to bring about particular outcomes. A person can experience an increase in self-efficacy either by experiencing success at the behavior or by observing others succeed at the behavior (15). Therefore, a rather simple intervention to increase self-efficacy can be to make the presentation of successful breastfeeding more identifiable to a variety of different races, ethnicities, and body types. The NBAC used only one African American woman in their ads (and she was portrayed as irresponsible for mechanical bull riding in a bar while pregnant). Breastfeeding women should be presented in a large variety of races, different levels of society’s view of attractiveness, more normally sized and with varying size and shaped breasts. This will make the women presented in the media identifiable to many more women which will increase women’s self efficacy in that they can successfully breastfeed.

The NBAC simply ignored barriers altogether resulting in the misperception that any barrier that does arise is both rare and not able to be modified. Personal barriers include pain, embarrassment, discomfort with their own body, and problems with breastfeeding in specific populations such as sexual abuse survivors or those with psychological disorders. Cultural barriers include differences in breastfeeding practices between those of varying cultures, race, ethnicity, or social class. A different informational campaign could have included information on how to use breast pumps, provide access to lactation consultation services, and answered common breastfeeding questions (10). There is a solution or an alternative to many of the personal and cultural barriers and a good intervention needs to provide support and options by specifically addressing common issues and making this information readily available.

More personalized support not only at birth, but into the first year of the infant’s life could be offered to help deal with individual issues and difficulties. In one study that looked at the effect of breastfeeding support for obese women (another subpopulation who have additional difficulties with breastfeeding) on breastfeeding retention rates, peer counseling was found to substantially improve breastfeeding success. Those who received additional support had an increase in breastfeeding retention by 9% after two weeks and by 13% after eight weeks compared to the control group (1). This personalized support intervention could be provided to all women in order to deal with any possible barriers as soon as they come up.

Conclusion

An alternative intervention to the NBAC would incorporate three important characteristics. First, Social Norms Theory and Social Networks Theory could be used to influence breastfeeding behavior on a community level. People are more likely to act in accordance with personal connections within their social networks and are likely to do as their peers do. These actions are likely to follow the social norm since humans generally conform (20). Advocating for important breastfeeding legislation that will provide protection and support of breastfeeding women, as well as eliminate institutional barriers to breastfeeding will go a long way in changing the social norms around breastfeeding behavior.

Second, breastfeeding as a women’s health issue must take into account the issues surrounding the female gender and their relationship to society as a whole. The Theory of Gender and Power can be used to identify social barriers unique to women. These social barriers must be appropriately addressed for the success of any women’s health intervention. Interventions can then be used to empower women, thus increasing their ability to breastfeed as well as their self-efficacy.

Lastly, personal and cultural barriers must be addressed by providing support and answers to common breastfeeding questions and making this information readily available. Women portrayed breastfeeding should be made identifiable to a larger variety of women by presenting women of varying races, ethnicities, shapes and sizes. Personal support should be given in order to address specific issues beyond the general information and common questions.

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